Optimizing Oral Cancer Screening

Mark C. Hutten, DDS, MS, FACP, spoke with Inside Dentistry about oral cancer signs and symptoms, the importance of developing your own consistent oral cancer screening, how HPV is affecting our patients, and more.                  

ID: What are some common oral cancer warning signs or symptoms of which general practitioners should be aware?

Dr. Hutten: As a maxillofacial prosthodontist, I recommend quite a few things for all oral health professionals and dentists to look for when it comes to oral cancer. Sometimes we dental professionals make observations in the course of a routine exam or screening, but other times patients notice problems or changes that prompt them to seek care.

·      Ulcerations. The most common symptom is an ulceration of the mouth that doesn’t heal. So, if a patient comes in with an oral ulceration, we may elect to observe it for 7 to 10 days. After that, if the lesion is still present or it’s changing in character, then it may be something we should be concerned about and biopsy. Referral to one of our surgical colleagues should be made for lesions that are more difficult to biopsy because of their location in the oral cavity, such as the base of tongue or oropharyngeal area.

·      Color changes. Dentists and prosthodontists are very good at detecting major or minor color changes in the mouth, even more so than a physician. We examine the gums, the gingiva, the tongue, and just the lining of the entire mouth and look for areas of redness, which is called erythroplakia, as well as areas of white discoloration that are not easily removed, which is called leukoplakia.

·      Condition of mucosa. We look for thickening of the mucosa, something that just doesn’t feel soft and subtle like it normally would.

·      Throat and neck problems. Patients may come in and say they have a chronic sore throat or a feeling that they have something stuck in their throat. The technical term for that is a globus sensation. Similarly, sometimes people complain about changes in their voice or lumps in their neck. As we do our exams, we should look at the neck and feel for lumps and bumps that don’t belong.

·      Occlusion/jaw problems. Sometimes patients come in and say they are having a hard time chewing, with or without pain. We should carefully look at that as a practitioner and determine if it is a simple problem with a tooth or if it is something bigger with an underlying cause because of an observed change in the occlusion of the patient. We can also look at the movement of the jaw. If a patient has a tumor in the muscles of mastication, they may present with trismus, which means they can’t open the jaw as wide. That can be a host of other things, as well, but it is a potential warning sign.

·      Changes in the tongue. Sometimes patients report changes and sensations in their tongue such as tingling. That is something that we should definitely look into and perhaps make referrals to the appropriate otolaryngologist or surgical head and neck oncologist.

·      Problems with prosthetics. Another common presenting sign is if someone comes in complaining of a denture or partial denture not fitting well. That could indicate that perhaps something is changing in the lining of the tissue, so there is a swelling underneath the removable prosthesis.

·      Loose teeth. If you have a situation where it does not appear to be the typical presentation of periodontal disease, you may start thinking about other processes such as an underlying malignancy. Clinicians should carefully diagnose the etiology of mobile or loose teeth.

·      Weight loss. This is less common, but if a patient should present with a report of significant weight loss for no apparent reason, then that should be a red flag and you may suggest that the patient have a full medical work-up with their internist as a starting point.

ID: Is a comprehensive oral cancer screening primarily for new patients?

Dr. Hutten: As a prosthodontist who has identified cancer early in multiple patients who required referral and comprehensive oncologic treatment, I think every patient should get a comprehensive oral screening and head and neck exam at least once a year. In the initial exam, it is especially critical, because you establish a baseline. When the patient should return to the office for a routine hygiene visit, the clinician should perform a complete head and neck exam at least once a year and more frequently if the patient has a previous history of a head and neck malignancy. The best complement I can get after I have done an initial exam is the patient saying, “Wow, I’ve never had anybody do a full exam like that before.” That is what we should really do as a profession. People should walk out and say, “That was the best oral exam I have ever gotten.”

ID: Can you describe an ideal oral cancer screening?

Dr. Hutten: Every practitioner is going to do an exam differently. What is critical is not performing the “ideal” exam, but developing a consistent routine—do the same thing to every patient, every time.

My preference is that I like to go back to front and inside to out. What I mean is, I look at the oropharynx. I look at the tonsils. I then work forward into the mouth checking all the tissues, checking the tongue. Then I do my extraoral exam—the neck, lymph nodes, etc. I do that same approach on every patient. It is kind of automatic.

Devices are an interesting adjunct, but I personally don’t think they replace a comprehensive visual and tactile exam. They can help show that an area looks different, but I don’t think we should use them strictly as a diagnostic tool. My concern is that we potentially have too many false positives and are having biopsies done on areas that truly don’t need biopsies.

ID: What is the role of HPV in the prevalence of oral cancer?

Dr. Hutten: The American Cancer Society stated that in 2015 about 39,500 people were going to be diagnosed with oral cavity and oropharyngealcancer. They went on to state that about 7,500 people will die a year from these diseases. These cancers are still more common in men than women at a rate of about 2:1. What was interesting to me was the rate of new cases seemed to be pretty stable in men and slightly decreasing in women. However, the number of HPV-related cancers is on the rise.The CDC stated that each year about 400 oropharyngeal cancers are possibly linked to HPV.

If you do the math between both these current statistics, it looks like around 21% of diagnosed oral cancers are HPV related. It’s quite a high number and it’s likely to keep rising. We also know that the CDC says 6.2 million new HPV infections are noted each year in the United States. What’s important to know is that in a healthy person with a healthy immune system, within 1 to 2 years these HPV infections typically go away on their own and don’t manifest into anything. The small percentage that are long lasting or in which viral proteins cause a transformation of the cellular makeup of tissue can lead to a malignancy. It’s a relatively small group in the scheme of things.

Even with a healthy patient, what we don’t know is why some healthy people are affected more than someone who is immune compromised. The immune-compromised population, the HIV population, they are much more likely to develop an HPV-related oral malignancy, but we don’t know why some people who are healthy develop this as well.

ID: What is the American College of Prosthodontists position on oral cancer screening?

Dr. Hutten: There was an initiative of the American College of Prosthodontists (ACP) to develop a series of Position Statements, one of which was on oral cancer screening, which I was asked to author. Oral cancer screening is a very important part of our practices and I feel very strongly that it needs to be completed. What we have to be careful of, though, is that we don’t over-diagnose chronic inflammation and other problems that are normally seen in the oral cavity and over-recommend biopsy, because every time you do a surgery, it carries potential problems with it. In oral cancer screening literature, there is a group of people who say oral cancer screening should never be done. I don’t agree with that at all! We have to temper our findings with what is a normal inflammation versus what is potentially malignancy. I think that is where these detection devices sometimes fail. They will light up anything that is inflamed or anything that is slightly abnormal. If you look at that one way, it’s a good thing, but if that immediately triggers a biopsy, it’s is a bad thing. The Position Statement, which was just adopted at our meeting in March, does support cancer screenings for our patients; however, we do have to temper that with what happens after a potential positive cancer screening. We also need to consider the psychological effect of telling patients that they may have oral cancer and have to get a biopsy. That carries a lot of weight on a person. When we make that recommendation, we have to be very careful. It has to be presented in a way that takes into account the psychological aspect of that term or diagnosis.

ID: How can a prosthodontist who is treating a patient who has been in treatment for cancer coordinate care and help restore function?

Dr. Hutten: As prosthodontists, we are involved in the care of patients all the way from diagnosis to their final reconstruction so we can provide function and a quality of life for them. Again, it is that early detection, early diagnosis. In fact, the ACP YouTube channel has two videos that general dentists and patients may find useful: Cancer Care and the Role of the Prosthodontist (Patient Education) and How to Do an Oral Cancer Screening (Technique). I encourage all dental professionals to take a few minutes to watch these and consider these as resources for cancer patients as well as to review their own practice of head and neck cancer screening at every recall visit. If a patient is recently diagnosed with cancer, it’s helpful to hear stories of survivors, which is featured in the first video. There is hope and we are here to help. Throughout their treatments, we are in a key role to provide care. If they have an interim prosthesis that they are wearing during chemotherapy and radiation, we have to be available to them to modify their prosthetics so they can continue to have the best quality of life during this difficult treatment. Once they have healed and recovered from their oral cancer, prosthodontists are then in a position to reconstruct these patients, whether working with a reconstructive surgeon and bone grafting, or placing implants, or making removal prosthetics to reconstruct their mouths to provide a reasonable quality of life. That’s really the key. Prosthodontists are involved all the way from initial diagnosis, through oral reconstruction and are supportive during the long-term management of the head and neck cancer patient.

Dr. Hutten received his Master’s degree in Prosthodontics and his DDS from Northwestern University Dental School, and his postgraduate education included a fellowship in Oral Oncology and a General-Practice Residency, both at Northwestern Memorial Hospital. He is a Diplomate of the American Board of Prosthodontics and a Fellow in the American College of Prosthodontists. Dr. Hutten is currently a member of the American College of Prosthodontists Board of Directors and serves as the Director of the Prosthodontic Forum. He is currently an Assistant Clinical Professor of Otolaryngology in the Feinberg School of Medicine at Northwestern University, and is Director of the General Practice Residency in Dentistry at Northwestern Memorial Hospital. Dr. Hutten is a Fellow in the International Team for Implantology, and belongs to several other major associations.