The ADA recently announced an expansion to its policy on oral cancer screening recommending that dentists and dental hygienists perform routine examinations for oral cancer, including oropharyngeal cancer for all dental patients. The inclusion of oropharyngeal cancer in our screening protocol is driven by the escalating numbers of diagnosed cases of oropharyngeal cancer linked to the human papillomavirus (HPV). HPV is so common that the CDC states that almost every sexually active American adult will have an infection at some time in their lifetime. Fortunately, the vast majority of these infections will resolve on their own and will be of no consequence. A persistent infection caused by a high-risk strain has the greatest potential of transforming into an oncogenic presence. Nonetheless, it is estimated, using cancer registry data, that about 3,500 new cases of HPV-associated oropharyngeal cancers are diagnosed in women and about 15,500 are diagnosed in men each year in the United States with HPV accounting for approximately 70% of all cases.
To put it in simpler terms, HPV-related oropharyngeal cancer has risen by 225% over the past two decades, while oral cancer linked to the historical etiologic pathways of tobacco and alcohol use has declined by 50% over the same time period. HPV-related oropharyngeal cancer surpassed the incidence of HPV-related cervical cancer in 2015. The ADA’s policy also aligns with support for the HPV vaccine.
First let’s review the anatomical location. The dorsum of the tongue extends from the oral cavity into the oropharynx. The sulcus terminalus or V-shaped trough on the dorsum of the tongue separates the oral cavity from the posterior third of the tongue defining the oropharyngeal part. The areas most affected by the virus are the back of the throat, posterior base of the tongue and the tonsils.
The high-risk anatomical areas present their challenge to our profession as we possess limited visual acuity in the posterior third or oropharynx. No, we do not have an endoscope, and we are not having our patients perform a barium swallow, but what we do have are our hands, our eyes and our ears. Our hands to effectively perform an extraoral examination of lymph nodes that may be related to the presence of a tumor in the oropharynx, our eyes to evaluate asymmetry and tissue changes and ears to listen to our patient’s subjective symptoms which may lead us to making a referral. A simple change such as a patient relaying the fact that they “are having difficulty swallowing or certain foods are getting caught in their throat” may be that first symptom of a tumor at the posterior base of the tongue.
Align yourselves with organizations such as the Oral Cancer Foundation (www.oralcancer.org) to stay abreast of current knowledge, research and gain an understanding of common symptoms that may be related to both oral and oropharyngeal cancer. Provide the best possible opportunities for earlier discovery by having your entire team educated on proper screening techniques and use the current scientifically supported devices, such as the VELscope Vx, to facilitate an opportunity to see beneath the surface of the tissue where abnormal cellular differentiation typically begins.
What does this policy amendment mean to your practice and your patients? It means ‘good enough’ is not enough anymore. It means increased responsibility and the opportunity to positively impact the people who place their lives in our care. People are dying due to knowledge gaps both within society and our profession. Stand up for your patients and perform effective and opportunistic oral and oropharyngeal cancer screenings. Refer a finding that persists beyond 14 days. Don’t wait and watch. It may mean the difference between life and death. It’s that important.
Author: Jo-Anne Jones