How Do I Know if It’s Oral Cancer? 5 Simple Steps

The headline news in today’s world is daunting to say the least. “The Startling Rise in Oral Cancer in Men”, “Oral Cancer Rates Rise by Two-Thirds”, “What’s Behind the Huge Rise in Oral Cancers?’ just to quote a few. What if we do find something unusual or different inside our mouth? How do I know if it’s oral cancer?

  1. The finding resolves on its own.  First rule of thumb is persistence. Anything unusual that persists beyond 14 days should always be investigated. A trip to your dentist to further evaluate a finding is critical. At that time the dentist may be able to identify the cause or may choose to evaluate further through the means of a small sampling of tissue or a biopsy. Either way, this needs to be addressed. Don’t wait!
  2. The finding is on both sides of the mouth. If the identifying lesion is present on both sides of the mouth, it is most likely part of the normal anatomical makeup. Asymmetry or presence on only one side raises more of a concern.
  3. The finding is initiated by trauma. An unusual finding may be caused by trauma; something as simple as biting your cheek or burning the palatal tissue with a slice of hot pizza can bring an area of the mouth to our attention. Again something of this nature should resolve within 7 – 10 days on its own and if it persists for more than 14 days, seek further evaluation.   
  4. The finding recurs and subsequently resolves on its own. A recurring sore that repeatedly resolves on its own is most likely initiated by trauma, stress or sometimes dietary aspects and is referred to as an aphthous ulcer or canker sore.  Typically a canker sore will last 7 – 10 days with the acute pain occurring when the lesion ulcerates. This happens in the middle of the duration of the canker sore and usually lasts 3 – 4 days.   
  5. The finding accompanies an illness and resolves on its own. There are a number of different illnesses that are accompanied by oral lesions or sores that may be found throughout the mouth. Typically the patient is experiencing general malaise, fever and would be directed to see a physician. The lesions once again resolve on their own.

Chances are if a finding meets the criteria above it is not oral cancer however there is only one way to know for sure and that is through further professional investigation. 

The point here is that in today’s world with oral, tonsillar and throat cancer on the rise, it is prudent to be knowledgeable and aware. Self examination between dental visits is vitally important as it allows for earlier discovery of anything abnormal. An oral cancer screening examination which includes checking the lymph nodes of the neck should be done on an annual basis.

Additional screening with a device such as VELscope which enables the dentist or dental hygienist to see beneath the surface where abnormal cells begin to develop provides an enhanced opportunity to again discover oral cancer in its earliest possible stage. To find a practice near you that offers the VELscope Vx examination, visit our Find a Practice Tool and enter your postal or zip code.   

Author: Jo-Anne Jones

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Is the COE Part of Your Routine?

The conventional intra and extra oral head and neck examination is taught in dental and hygiene schools to screen patients for oral cancer and other oral mucosal disease. It normally consists of a visual inspection of oral tissue, or oral mucosa, under incandescent or halogen light using the naked eye to look for suspicious lesions, as well as extra oral palpation of the face and neck to feel for suspicious lumps and intra oral palpation of the mucosa.

So why is it important? A 3-4 minute visual and palpation exam is crucial in the early detection of oral diseases. It is quick to perform, painless for the patient, and enhances the patient experience with the dental practice.

According to the Oral Cancer Foundation nearly 42,000 Americans will be diagnosed with oral or pharyngeal cancer this year. The percentage of oral cancer patients who ultimately die of the disease is higher than that of many other cancers. The key to reducing the number of lives lost to oral cancer is earlier detection of the disease, and the key to earlier detection is more frequent and more thorough intra and extra oral head and neck exams. Currently, the majority of oral cancers are detected in the later stages, when the five-year survival rate is only about 50 percent. What’s the good news? When discovered early, the survival rate leaps to around 82 percent.

There is a growing body of research available on the importance of the Clinical Oral Exam (COE) and the increased demand for comprehensive COE’s. The results from a recent independent survey have indicated that the majority of patients say they have never had an oral cancer exam. A recent UK survey found that “92% percent of respondents would like their Dentist to tell them if they were being screened for signs of oral cancer and 97% would like help from their Dentists to reduce their risk.” (1)

The take away from this study is that the majority of people are in favor of COE’s and place value in the dental health professional being involved in the oral cancer screening process. Learn how you can improve your COE. Stay ahead of the curve by screening for oral disease and oral cancer using an adjunctive device and help patient outcomes through early detection.

(1)   Oluwatunmise Awojobi*, Suzanne E Scott and Tim Newton, ‘Patients’ Perceptions of Oral Cancer Screening in Dental Practice: a Cross-sectional Study’, (BMC Oral Health 2012),

 * Tissue Fluorescence Image Courtesy of Dr. Samson Ng.

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Early Detection Can Equal Higher Survival Rates

It is a disease that we give very little thought to, but oral cancer continues to be prevalent with approximately 42,000 Americans being diagnosed with oral cancer or oral pharyngeal cancer this year. It will cause over 8,000 deaths, killing roughly 1 person every hour. Of those 42,000 newly diagnosed individuals, only slightly more than half will be alive in 5 years (Approximately 57%). This is a number which has not significantly improved in decades. Increasing oral cancer screenings can decrease the mortality rates from oral cancer. Early Detection is the key to better treatment, better outcomes and higher survival rates.

With early detection and timely treatment, deaths from oral cancer could be dramatically reduced. The 5-year survival rate for those with localized disease at diagnosis is 83 percent compared with only 32 percent for those whose cancer has spread to other parts of the body. It is important to open this discussion with patients and even if it’s not causing any pain, any discoloration, swelling, spots, ulcers or lumps that have been there for longer than two weeks should be checked out more thoroughly.

Oral cancer does not discriminate and an oral or oropharyngeal cancer can appear anywhere throughout the oral cavity, including the lips, the lining of the mouth, both under and on top of the tongue, in the back of the throat, tonsils, roof of the mouth and also within the gums, including the area behind the wisdom teeth. Regular screening and thorough documentation performs a key role in the early stages of detection and diagnosis.

The death rate from this type of cancer is high because it is often discovered late in its development, generally when it has spread to another location like the lymph nodes of the neck. At this stage the prognosis can be significantly worse. The good news is oral cancer can be readily diagnosed. In many cases cancer screening can be invasive, but unlike other forms of cancer, the oral cancer screening process is much easier and less invasive. With a comprehensive COE and good documentation it is easy to be diligent about any “area of concern” in the oral cavity.

The healthcare professional best positioned to screen for oral disease and cancer, are dentists and/or dental hygienists. Incorporating the COE into the routine dental visit seems to be the most effective way to tackle the early detection of oral disease and oral cancer. Nurse Practitioners, Physician Assistants, Primary Care or Family Physicians, Urgent Care Physicians, Otolaryngologists (ENT), Head and Neck Surgeon and Gastroenterologists are also professionals engaging in the fight against oral cancer. Make the COE discussion part of the patient relationship, it’s a great way to show that we as health care professionals truly care about our patients.

[1] National Institute of Dental and Craniofacial Research ‘Detecting Oral Cancer: A Guide for Health Care   Professionals’, (, Bethesda, MD),

Dr. John Roberson
 is  a committed professional when it comes to early detection of oral mucosal disease and oral cancer. He is an award winning Board Certified Oral & Maxillofacial Surgeon, and also has Board Certification from the National Dental Board of Anesthesiology.  He is a member of the American Association of Oral & Maxillofacial Surgeons, American College of Oral & Maxillofacial Surgeons, American Dental Association, Mississippi Dental Association, and the South Mississippi Dental Association. Learn more about his practice and dedication at


Clinical Study Concludes That VELscope™ Technology Improves Clinical Decision Making

Independent clinical study by seven researchers from the University of British Columbia, British Columbia Cancer Agency and Simon Fraser University, is the latest report to document the benefits of adjunctive oral examination technology. The lead researcher for the study was Denise M. Laronde RDH MSc, of the Department of Oral Biological and Medical Sciences, Faculty of Dentistry, at the University of British Columbia. The study concluded that integrating fluorescence visualization technology, as delivered by the VELscope® Vx, significantly improves the protocol for screening, assessing and reassessing oral lesions.

The goal of the study was to determine whether the VELscope’s fluorescence visualization (FV) technology added any value to the traditional intraoral and extraoral examination for oral cancer screening. The researchers’ questions were focused on whether positive FV results were associated with persisting lesions detected through a step-by-step procedure that included both a conventional oral examination and an adjunctive examination using VELscope® Vx technology.  The study concluded the following:  “A protocol for screening (assess risk, reassess, and refer) is recommended for the screening of abnormal intraoral lesions. Integrating FV into a process of assessing and reassessing lesions significantly improved this model.”(1)

The full article, “Influence of Fluorescence on Screening Decisions for Oral Mucosal Lesions in Community Dental Practices,” was published in the Journal of Oral Pathology & Medicine and is also available through the LED Dental website by visiting the Downloads Center.

Peter Whitehead, founder of LED Medical Diagnostics and its subsidiary, LED Dental is encouraged by the study, “Many clinicians are unaware of the significant benefits that the adjunctive use of VELscope™ can bring to the table. It is nice to see independent confirmation that the use of VELscope™ technology not only enhances early detection but also supports clinical decision making as well.”

(1)   DM Laronde, PM Williams, TG Hislop, C Poh, S Ng, C Bajdik, L Zhang, C Macaulay, MP Rosin, Influence of fluorescence on screening decisions for oral mucosal lesions in community dental practices, (Vancouver, Canada, University of British Columbia, September, 2013)

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Oral health warning

Three signs your mouth ulcer is cancerous

One of the primary symptoms of mouth cancer relates to the ulcers in the mouth. If these are painful and do not heal within several weeks, it could be a sign of mouth cancer. Furthermore, lumps that are unexplained, persistent or do not go away, are also signs of the condition say the NHS. Unexplainable loose teeth or tooth sockets that don’t heal after extractions are other symptoms of mouth cancer. Mouth cancer is one of the least common cancers in the US or UK, but it’s essential to know the symptoms.  Additionally, a person with the disease may feel a persistent numbness on the lip or tongue. Occasionally, red, or white patches may appear on the lining of the tongue or mouth in patients with mouth cancer. Read more about variables that impact your oral health.

Person smiling and mouth.

The final symptom of mouth cancer is changes in a person’s speech, such as a lisp.

Other symptoms of mouth cancer include:
• Pain or difficulty swallowing
• Bleeding or numbness in the mouth
• Difficulty moving the jaw
• Changes in the voice.

Similarly to other cancers, there are different types of mouth cancer. Each form of mouth cancer is named after the cell that the cancer starts to grow in. The most common form of mouth cancer is squamous cell carcinoma. This type of cancer makes up 90 percent of mouth cancer cases.

Squamous cell carcinoma can be found in the skin as well as inside the mouth. Other types of mouth cancer include adenocarcinoma, sarcoma, oral malignant melanoma and lymphoma. Adenocarcinoma develops inside the salivary glands. Sarcoma is a cancer that develops out of abnormalities in bone, cartilage, muscle and other tissue.

Mouth cancer infographic.

Factors that increase a person’s risk of mouth cancer and oral health include:
• Smoking
• Chewing tobacco
• Drinking alcohol
• HPV virus infection
• Unhealthy diet
• Bad oral hygiene.

Original Article

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World head and neck cancer day

Three health organisations are reminding Kiwis that head and neck cancer can be prevented.

With Wednesday marking World Head and Neck Cancer Day, the health agencies say it’s a timely opportunity to raise awareness about the devastating health impacts of head and neck cancers, including oropharyngeal – throat – cancer caused by Human Papillomavirus Virus – HPV.

Original Article

The Head and Neck Cancer Foundation Aotearoa (HNCFA), the Head and Neck Cancer Support Network (HNCSN) and the Sexually Transmitted Infections Education Foundation (STIEF) is also reminding New Zealanders that prevention is available for free in the form of the Gardasil vaccine.

This highly effective and safe vaccine prevents infection with HPV, and significantly reduces the risk of developing many different forms of cancer, including oropharyngeal cancer, cervical cancer and penile cancer.

This year, it is even more important because a significant proportion of our children have been missing out on this health prevention opportunity, due to the disruption brought by Covid-19, which is of great concern, say the health organisations.

In 2021, 53,000 fewer vaccines were delivered than in 2019, and the total reduction in doses over two years has been approximately 78,000 – that’s more than 30,000 children who have missed out.

“It was a no-brainer to vaccinate my children against HPV – they are all fully vaccinated with Gardasil. Knowing that they are protected from HPV-related cancers is one less worry on my mind,” says HPV head and neck cancer survivor, Doug Russell.

“As a parent I do not want to be in a position later in life when our children could come to us with HPV and ask why they did not get vaccinated for this entirely preventable disease.”

HPV is one of the world’s most widespread viral infections, usually resulting from direct skin-to-skin contact during intimate sexual contact with someone who has HPV. Without immunisation, around 80 per cent of people who have ever had penetrative, or non-penetrative sexual (vaginal, oral, or anal) contact will be infected by at least one type of HPV at some point in their lives. Unfortunately, condom use during sex doesn’t reliably prevent transmission of this virus.

Although there are over 150 types of HPV, only a small number of these are ‘high-risk HPV’ strains that have the potential to lead to cancerous changes in cells.

HPV is a bit of an “unlucky dip” really: in many people, HPV is naturally cleared by the body’s immune system, some people will retain the virus but have low-risk strains that may lead to genital warts, whilst others may have the high-risk strains and develop devastating cancers –  sometimes decades later – having never known about the original infection.

It isn’t possible to predict which group your child will fall into if/when exposed to HPV, but it is possible to protect them by getting them vaccinated, says the health agencies.

The virus is most commonly associated with cervical cancer, but can also cause other cancers in the genital area of people of all genders, specifically the vagina, vulva, penis, and anus.

In recent years, medical professionals have also observed a rapid rise in HPV-related oropharyngeal cancer in heterosexual people who are otherwise healthy. For this group, the main risk is oropharyngeal cancer, which affects the throat (tonsils, base of tongue and soft palate).

Although this type of cancer has traditionally been linked to smoking and heavy drinking, in recent years HPV has become the leading cause. Oropharyngeal cancers caused by HPV are rapidly rising in developed countries. In New Zealand, 95 new cases of HPV-related oropharyngeal cancer with 25 deaths were estimated for 2018. In 2020, there were 334 oropharyngeal cancer cases caused by HPV.

Doug Russell, an otherwise healthy 58-year-old, describes the lead-up to “the single toughest day” of his life in 2017.

“I had a shave one lazy Sunday morning and there was nothing wrong with me. And at lunchtime, I was sitting in the kitchen having a sandwich, and I put my hand on my throat and I said to my wife Sarah “what is that lump?”

And there was a big lump.

“So on Monday, I went to the doctor and that started this whole thing, it just appeared overnight like that.”

Doug was infected with a high-risk strain of HPV, which he had never been aware of until it led to his cancer.

“I thought I was living my life to the fullest, and I thought cancer was something that happened to other people. I really struggled, and still do struggle a little bit, to understand why this happened to me, and what the implications would be for my family.”

Doug’s experience of it happening ‘overnight’ is not uncommon. Head and neck cancers including oropharyngeal cancer are notoriously difficult to detect and, as a consequence, are often only discovered in advanced stages. Symptoms will often be very mild initially and will depend on where exactly the cancer is situated, how big it is and how far it has spread in the body.

The most common symptoms are:

•    a painless lump in the neck or in front of the ear
•    a lump or ulcer in the mouth, such as the tongue, gum, or inside the cheek
•    a persistent white or red patch in the mouth
•    a one-sided sore throat which may be associated with earache
•    pain or difficulty with swallowing
•    a hoarse voice, especially in a smoker
•    difficult or noisy breathing
•    a lump or sore on the face
•    numbness or weakness on one side of the face
•    one-sided blocked nose with bleeding
Many less serious conditions, apart from cancer, can cause these symptoms, but it is important to consult your doctor if they persist for more than three weeks.

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The Case for Having Dentists on Your Cancer Care Team

Caring for your oral health before, during, and after cancer treatment—a growing focus at NYU College of Dentistry—can minimize complications. Consider Dentists as apart of your Cancer Care.

Cancer treatment often takes a team of health professionals—oncologists, nurses, surgeons, radiologists, pathologists, and social workers—to coordinate and provide comprehensive support for patients. At NYU, dentists are increasingly being considered an important part of the cancer care team.  

Original Article

When faced with a cancer diagnosis, many patients push other health care to the side to focus on addressing the disease. But people with cancer can experience unique issues related to their oral health. For instance, radiation to the head and neck can damage the salivary glands, hurting their ability to produce saliva, which can lead to tooth decay or cavities. Radiation and chemotherapy can also cause painful mouth sores. Patients with cancer that has spread to their bones, or who are undergoing treatment that can weaken their bones, may be prescribed high doses of antiresorptive medications such as bisphosphonates. These medications can cause a rare condition called osteonecrosis of the jaw, in which the jawbone is exposed through the gums.  

Other treatments—including chemotherapy and bone marrow transplants—lower the immune system, leaving patients susceptible to infection. Infections in the mouth during cancer treatment are especially dangerous, given the immune system’s inability to fight back.

“An abscessed tooth may mean having to stop chemotherapy to treat the infection,” says Denise Trochesset, clinical professor and chair of the Department of Oral and Maxillofacial Pathology, Radiology and Medicine at NYU College of Dentistry.  

“Fortunately, intervening early to eliminate infection can minimize complications during the course of therapy,” says Dalal Alhajji, clinical instructor in the Department of Oral and Maxillofacial Pathology, Radiology and Medicine at NYU College of Dentistry.

Bridging the gap between cancer care and dental care
Many cancer centers lack services and protocols related to oral health; Trochesset and Alhajji are part of a small but growing number of oral health professionals working to change this.

Dalal Alhajji, DMD, MSD

NYU Dentistry’s Dalal Alhajji, DMD, MSD

Denise Trochesset, DDS

NYU Dentistry’s Denise Trochesset, DDS

“We need to give dentists a primary role on the cancer care team,” says Alhajji, who completed a fellowship in dental oncology and now specializes in treating cancer patients.

Over the past few years, NYU College of Dentistry has strengthened its connections with cancer providers at NYU Langone’s Perlmutter Cancer Center, particularly those treating head and neck cancers and diseases requiring bone marrow transplants. A growing number of patients with certain cancers are referred to the College of Dentistry for an exam prior to starting treatment. They’re seen at the NYU Dentistry Oral Health Center for People with Disabilities, where Alhajji oversees their care.

“We might not think of cancer patients as having a disability, but they may be medically disabled, even if for just a short period of time,” explains Trochesset.

During an exam and cleaning, Alhajji and dental students check for any signs of infection or other issues that could complicate cancer care. After the initial exam, patients can either return to their regular dentist or continue their care at the Oral Health Center for People with Disabilities, where general dentists and specialists are under one roof.

Closing this gap in care is not only transformative for patients, but for dental students as well. Because all NYU dental students rotate through the Oral Health Center for People with Disabilities during their third and fourth years of training, they now gain experience with a patient population being treated for cancer. 

“Our dental students already learn about cancer in their oral medicine and pathology courses—but now, it’s no longer just something they read about in their textbooks, which is unique for a dental school,” says Trochesset.

What cancer patients can do to keep their mouths healthy
Keeping up your oral hygiene before, during, and after cancer treatment is critical, according to Alhajji and Trochesset. They recommend that people diagnosed with cancer take the following steps to protect their oral health:

  • Visit a dentist before you begin cancer treatment for an exam, X-rays, and cleaning. The dentist may check for infections in your mouth, which can complicate cancer care that lowers your immune system. If your dentist finds an infection, they can treat it—through filling a cavity, extracting a tooth, or performing a root canal—prior to your cancer treatment.  
  • If you’ll be receiving radiation for cancer of the head or neck, Trochesset recommends asking your dentist about creating a custom mouth guard to wear during radiation treatments. A mouth guard can protect areas of your mouth from unnecessary radiation, and may be particularly useful for those with metal fillings and crowns. You may also benefit from jaw exercises or a referral to a physical therapist. 
  • Keep up your oral hygiene during cancer treatment. Alhajji recommends that you continue brushing your teeth, although you may want to switch to a very soft toothbrush. You may also need to take a break from alcohol-based mouthwash if you develop mouth sores.
  • Stay hydrated, especially if you are experiencing dry mouth.

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Dental Students Perception of HPV & Oral Cancer

Dental Students Perception of HPV & Oral Cancer

Background: Study of Dental Students Perception of HPV and Oral Cancer. Human papilloma virus (HPV) infection forms a major etiological factor for oropharyngeal cancer (OPC), which has exhibited increased global incidence.

Original Article

Aim: To compare the knowledge regarding HPV, its association with OPC, and HPV vaccine among students from different countries, years of the undergraduate program, and gender.

Methods: The current multinational cross-sectional study was conducted in 886 undergraduate dental students from Egypt, India, Pakistan, Saudi Arabia, UAE, and Sudan through Google survey forms from July 2021 to September 2021. The survey form comprised 27 items divided into four sections. The answers to the questionnaire were compared among students from different countries, different years of the undergraduate program, and males and females. Chi-square test was used to evaluate the correlation between the demographic characteristics of students and their knowledge regarding HPV and OPC.

Results: Females exhibited a better knowledge regarding knowledge and perception on HPV vaccine, whereas males exhibited a better knowledge regarding HPV and its correlation with OPC, and these differences were statistically significant (P < 0.05). The third- and fourth-year undergraduate students displayed a higher awareness of OPC and its connection with HPV than other year students, and this variance was found to be statistically significant (P < 0.001). Third-year and internship students exhibited a more positive attitude and comfort regarding the vaccine and discussing the same with patients than the other educational-level students. Students from India exhibited better knowledge about HPV and its association with OPC than the students from other countries, and this difference was statistically significant (P < 0.001).

Conclusion: Disparities in knowledge regarding HPV-related oral cancer have been detected among the female and male participants among different nations. From the entire study population, Indian students exhibited better knowledge regarding HPV. Females from all the nations exhibited a more positive attitude and comfort regarding the vaccine and discussing the same with patients than males. The results of this necessitate intervention measures including training workshops and awareness campaigns. Improving their knowledge regarding the same may increase their awareness, resulting in better patient care.

Keywords: carcinoma, squamous cell, human papillomavirus 16, oropharyngeal neoplasms, papillomavirus infections, papillomavirus vaccines, sexually transmitted diseases


Oral squamous cell carcinoma comprises a group of malignancies that manifest in various regions of the oral cavity and are the 11th most common cancer worldwide.1 The global incidence of these malignancies is 4 per 100,000 people, and they form a major economic burden.2 According to Globocan data, the 5-year prevalence of oropharyngeal cancer (OPC) globally is 2.2% in Africa, 37.6% in Asia, 16.9% in North America, 8.6% in Latin America and the Caribbean and 33.4% in Europe, respectively.3

The etiology for oral cancer is multifactorial, including exposure to ultraviolet radiation, betel or areca nut, tobacco, and alcohol.4,5 Additionally, human papilloma virus (HPV) infection forms a major etiological factor for oral cancer. The significance of this etiological factor can be ascertained from the fact that the prevalence of HPV among OPC increased from 16.3% in 1989 to 72.7% during 2000–2004.6 Currently, approximately 63% of all OPCs are attributable to HPV and may be preventable.7,8 Thus, an awareness about HPV-related OPC can facilitate the reduction in the incidence of these cancers.

OPC is associated with high mortality. The primary reason for this is the silent presentation and late diagnosis of most patients.9 Thus, diagnosis of OPC in the early stages could decrease the mortality and morbidity associated with the condition. The oral cavity is easily accessible for clinical examination, especially for dentists, who can form the frontline for the prevention of oral cancer. Thus, increasing awareness and knowledge among dental professionals and patients could improve survival among patients with oral cancer.

Several HPV-related malignancies caused due to HPV 16 and 18 such as oral and cervical cancer can be prevented through HPV vaccination.10 Although the HPV vaccine is licensed for both females and males between 9 and 26 years of age, it is recommended in 11- and 12-year-old adolescents.10 Although it is not yet approved for preventing HPV-related OPCs, molecular and epidemiological data support a contributory role for HPV in OPC, and research is being carried out to investigate the efficacy of HPV vaccines for preventing OPCs.11 It is therefore vital to target immunizable young adult college-going girls and boys, as both are part of the infection chain and at risk for HPV infection as they are growing adults with independent lifestyles but have a choice to undergo vaccination with the consent from parents and are within the age group of successful vaccination outcome.

HPV is a sexually transmitted infection. Thus, identifying the comfort of the healthcare professional to discuss these etiologies with their patients and the gaps in their knowledge regarding HPV assists in detecting early cases.

Although several studies have investigated the awareness of dentists regarding HPV vaccines, most of these studies have been limited to a single country. Thus, the present study attempted to compare the knowledge regarding HPV, its association with OPC, and HPV vaccine among students from different countries, years of the undergraduate program, and gender among dental undergraduate students from six countries, namely India, Pakistan, Saudi Arabia, Egypt, UAE, and Sudan.

Materials and Methods

Study Participants

The present cross-sectional study was conducted among 1500 dental students from six countries through Google survey forms from 5 July 2021 to 5 August 2021 after obtaining Dar al Uloom University ethical clearance. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of College of Dentistry, Dar Al Uloom University, Riyadh, KSA (COD/IRB/2020/22). Students from the third year onwards of undergraduate dental education from Egypt, India, Pakistan, Saudi Arabia, UAE, and Sudan were included in the study. Students from any other country or those not in dental undergraduate training were excluded from the study. Only these countries were included as we could get permission for the concerned academic institutions through our known contacts at respective nations to circulate the survey among their students. The survey form was provided to the students through faculty working in the academic institutions of these countries. The nature of the study was described to every subject before they participate in the survey. The response of the participants was maintained confidential, and their consent was obtained electronically by their willingness to participate in this survey by answering all the questions.

Among 1500 dental students approached, only 886 responded within the stipulated time. The sample size was selected as per reference article and taking into account the number of students in each university fitting our inclusion criteria from six different nations. Considering the proportion of 0.641 (64.1%) from the pilot study, with relative precision of 5% and 95% confidence level, the calculated sample size came up to 864. The formula for calculating the sample size is as follows:

where P = expected proportion, 1- α/2 = desired confidence level, and ε = relative precision.

Data Collection

A Google survey form was created using survey items adopted from the studies by Sallam et al and Daley et al12,13 Prior to the data collection, the questions were pretested among a group of 15 professionals to ensure the level of validity and degree of repeatability. The Google survey form was circulated by the faculty working in the academic institutions of each of the six countries through email and phone numbers. The survey took approximately 5–10 min to answer all the questions.

The survey form comprised 27 items divided into four sections (Figure 1). The first section comprised questions determining the demographics of the group, including age, sex, nationality, marital status, current level of education, and history of smoking. The second section attempted to determine the knowledge of oral cancer among the dental students and was termed as the knowledge-based questionnaire. The third section ascertained the awareness of HPV among participants and was termed as the awareness-based questionnaire. The fourth section comprised questions ascertaining the comfort of the practitioners to disseminate HPV information among patients and was termed as the attitude-based questionnaire.

Figure 1 Original survey that was circulated. Download Article to View

The aim of the study is to compare the awareness, knowledge, and perception about HPV and OPC among students from different countries, years of the undergraduate program, and gender.

Statistical Analysis

The data were collected and organized in MS-Excel. Statistical analysis was conducted using SPSS v 21 (IBM, Chicago, IL, USA). The demographic and survey data were collected as per frequency and percentage. Chi-square test was used to evaluate the correlation between the demographic characteristics of students and their knowledge regarding HPV and oral cancer. P < 0.05 was considered statistically significant.


The demographic characteristics of patients are presented in Table 1. Of the 886 participants, a majority were females (73.1%). Most participants were from India (29.3%), followed by Saudi Arabia (21.8%).

Table 1 Demographic Characteristics of Participants. Download Article to View

Tables 2 and 3 present the comparison of knowledge between on HPV and its relationship with OPC in males and females. The awareness of HPV and its association with OPC was higher in males than in females, and this difference was statistically significant (P < 0.05). On the other hand, females exhibited better knowledge and perception on HPV vaccine than males, and this difference was statistically significant (P < 0.05). Females exhibited a more positive attitude and comfort regarding the vaccine and discussing the same with patients than males, and this difference was statistically significant (P < 0.001).

Table 2 Association of Gender- with Attitude-Based Questionnaires. Download Article to View

Table 3 Comparison of Knowledge Between Males and Females. Download Article to View

Tables 4 and 5 present the comparison of knowledge on HPV and its relationship with OPC among students in different undergraduate years. Third- and fourth-year students exhibited better awareness of HPV and its association with OPC than other year students, and this difference was statistically significant (P < 0.05). The third-year and internship students exhibited a more positive attitude and comfort regarding the vaccine and discussing the same with patients than the other educational-level students, and this difference was statistically significant (P < 0.001).

Table 4 Association of Education with Awareness-Based Questionnaires. Download Article to View

Table 5 Comparison of Knowledge Between Students from Different Undergraduate Years. Download Article to View

Tables 6–8 present the comparison of knowledge on HPV and its relationship with OPC among students from different countries. Majority of Indian students exhibited better knowledge and awareness of HPV and its association with OPC than other year students, and this difference was statistically significant (P < 0.05). The Indian students exhibited better knowledge about HPV than other students from other countries, and this difference was statistically significant (P < 0.001). Indian students exhibited a more positive attitude and comfort regarding the vaccine and discussing the same with patients than students from other countries, and this difference was statistically significant (P < 0.001).

Table 6 Association of Country with Awareness-Based Questionnaires. Download Article to View

Table 7 Association of Country with Attitude-Based Questionnaires. Download Article to View

Table 8 Comparison of Knowledge Between Students from Different Countries. Download Article to View

For the knowledge-based questions like Q9, Q14 where the answers could be multiple from the options, in these questions we tried to classify the students who have opted for more than 2 options to be having good knowledge (Table 8).

For Q 15 “The spread of HPV is by?”, all the respondents who opted “through sexual contact” and for Q 16 “Most HPV infections resolve within a short time”, all the respondents who opted for option “No”, and for Q 19 “Who are eligible to take HPV vaccine?”, all the respondents who opted for “ladies and gents below 30 years” are classified as having good knowledge as they opted for the correct answers (Figure 1).

Figure 2 illustrates the varying reasons for patients not getting vaccinated. Of the various reasons, lack of knowledge of vaccine is the most common reason for not getting vaccinated.

Figure 2 Reasons for unwillingness to get vaccinated. Download Article to View


The incidence of HPV-associated OPC is increasing. Thus, awareness among healthcare professionals, especially dentists is required for the early diagnosis of this condition to reduce the associated mortality and morbidity. Thus, the present study evaluated the knowledge, attitude, and awareness of human papilloma virus and its association with oral lesions among dental undergraduate students in different nations.

The present study exhibited that males had better knowledge regarding HPV and its association with OPC, and this difference was statistically significant (P < 0.05). This finding differs from that of Reimer et al and Presto et al,14,15 who exhibited better knowledge among females. This difference may be because of the smaller sample size for males (n = 238) in the present study as compared with females (n = 648). On the other hand, females exhibited better knowledge about HPV vaccines than males, and this difference was statistically significant (P < 0.05). HPV is also responsible for cervical cancer. Cervical cancer is the third most diagnosed cancer globally and the fourth leading cause of cancer-related mortality in women.16 This cancer is preventable, and the HPV vaccine is recommended to reduce its risk. Thus, women are more aware about the vaccine. This could also explain their increased comfort level to discuss this with patients. Additionally, female students were more comfortable discussing personal health and HPV vaccines with their patients than their male counterparts, and this difference was statistically significant (p < 0.05) (Table 2). This may be because females are more emotional than males, making them more at ease with discussing personal health with their patients.

The third-year dental students exhibited better knowledge about HPV than other year students, and this difference was statistically significant (P < 0.001). Additionally, students in internship also exhibited better knowledge, awareness, and attitude than the other year students. In India, third-year students have clinical subjects such as General Medicine in their curriculum. Thus, topics on HPV and its significance may be introduced. Additionally, students in their internships would have additional practical experience with patients. This would explain their better knowledge and awareness regarding HPV. Oral microbiology is an important component in the curriculum of dentistry. Certain microorganisms including HPV dictate special focus in dentistry not only in relation to cancer but other manifestations too.

The present study exhibited that dental practitioners were able to identify the risk factors associated with oral cancer. This finding was concurrent with that of Sallam et al and Lorenzo-Pouso et al.12,17 Most dental practitioners exhibited discomfort in discussing the HPV correlation with oral cancer. This reluctance might be related to sociocultural and religious stigmas towards discussing sexually transmitted infections in these countries. It is recorded in the past that high increase in HPV-dependent OPC occurs in the United States, and other European countries and the frequency of HPV-infected OPC vary depending on geographical distribution and religious practices.18–20 HPV is regarded to be a risk factor for the development of anogenital malignancies and cervical cancers, and HPV vaccines could help in the preventing the same.20

This finding was concurrent with that of Sallam et al and Daley et al.12,13 Additionally, dentists have never been accustomed to a vaccination recommendation as the nature of their work does not include this responsibility. This may be an additional reason for the discomfort among participants.17,18 An additional reason for the discomfort may be the lack of professional guidelines for recommending the HPV vaccine as a primary prevention measure for OPC.20

In the present study, Indian students exhibited better knowledge, awareness, and attitude about HPV than other students from other countries, and this difference was statistically significant (P < 0.001). India has the highest number of oral cancers globally, with approximately 1% of the population exhibiting oral premalignant lesions.21 Thus, Indian dental students have higher clinical exposure to OPC. Moreover, the gynecologists and general hospitals usually exhibit the advertisement boards about the HPV vaccine availability and their price in India. Therefore, they are better aware of the implications of HPV in oral cancer and cervical cancer. Further, the participants were not having information about the availability of HPV vaccine in their city or surrounding hospitals in the Middle East and African countries.

Most participants expressed a desire to participate in any professional training or continuous dental education program to achieve better knowledge and understanding about HPV and its association with OPC. This could be achieved through continuing dental education programs such as workshops, awareness campaigns, and training sessions. In the present study, of the various reasons, lack of knowledge of vaccine is the most common reason for not getting vaccinated, followed by lack of information about where to get the vaccine and lack of recommendation from the doctor. This underlines the necessity to imbibe knowledge regarding HPV and its association with OPV among medical and dental students.

The principal strength of the study is the multinational nature of the study allowing the generalization of the study findings. However, this study has certain constraints. The survey design always carries the risk of bias, with participants attempting to answer as per the researcher’s expectation. Additionally, the sample size was relatively small. Furthermore, most patients (73.1%) were female. This could also influence the results. Further studies with a larger sample size and evenly matched groups would strengthen the findings of this study. Several limitations in basic knowledge about HPV was noticed among participants in the clinical group, particularly related to unawareness of the vaccine availability.


Overall knowledge about HPV, the HPV vaccine, and HPV-related OPCs is deficient among students from this sample of undergraduate dental students. Those in their third and fourth clinical years were more knowledgeable about HPV.

More than half of them reported willingness to take the vaccine. With the increasing awareness regarding HPV-related oropharyngeal cancer, dentists must be able to advice and recommend patients regarding the risk factors and preventive measures associated with this condition. To enable this, dental colleges and organizations must provide additional information on HPV and the advances in vaccines to their students and members.


The authors extend their appreciation to the Deanship of Postgraduate and Scientific Research at Dar Al Uloom University, Riyadh, KSA for supporting this work. We would like to express our gratitude to all the students from these six nations who participated in this research and the faculty who helped us in circulating the questionnaire.


The authors report no conflicts of interest in this work.

Amara Swapna Lingam,1,* Pradeep Koppolu,2,* Sara Ahmad Alhussein,1 Rawa Kamal Abdelrahim,2 Ghadah Salim Abusalim,3Sally ElHaddad,1 Sadaf Asrar,4 Mohammad Zakaria Nassani,5 Sarah Salah Gaafar,5,6 Ferdous Mohammed T Bukhary,2,7AbdulRahman Saeed AlGhamdi,8 Ali Barakat,5 Mohammed Noushad,5 Hesham Almoallim1,9

1Department of Surgical and Diagnostic Sciences, Dar Al Uloom University, Riyadh, Saudi Arabia; 2Department of Preventive Dental Sciences Dar Al Uloom University, Riyadh, Saudi Arabia; 3Department of Medical Laboratory Science, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, AlKharj, Kingdom of Saudi Arabia; 4Department Oral Biology, Liaquat college of Medicine and Dentistry, Karachi, Pakistan; 5Department of Restorative and Prosthetic Dental Sciences, College of Dentistry, Dar Al Uloom University, Riyadh, Saudi Arabia; 6Conservative Dentistry Department, Faculty of Dentistry, Alexandria University, Alexandria, Egypt; 7Department of Pediatric Dentistry and Orthodontics, King Saud University, Riyadh, Saudi Arabia; 8Dental Department, Security Forces Hospital Program, Riyadh, Kingdom of Saudi Arabia; 9Department of Oral and Maxillofacial Surgery, College of Dentistry, King Saud University, Riyadh, 11545, Saudi Arabia

*These authors contributed equally to this work

Correspondence: Amara Swapna Lingam, Department of Surgical and Diagnostic Sciences, Dar Al Uloom Univeristy, Riyadh, Saudi Arabia, Email


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2. Salehiniya H, Raei M. Oral cavity and lip cancer in the world: an epidemiological review. Vietnamese J Biomed. 2020;7(8):3898–3905.

3. Sung H, Ferlay J, Siegel RL, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209–249. doi:10.3322/caac.21660

4. Argiris A, Karamouzis MV, Raben D, Ferris RL. Head and neck cancer. Lancet. 2008;371(9625):1695–1709. doi:10.1016/S0140-6736(08)60728-X

5. Kumar M, Nanavati R, Modi TG, Dobariya C. Oral cancer: etiology and risk factors: a review. J Cancer Res Ther. 2016;12(2):458–463. doi:10.4103/0973-1482.186696

6. Chaturvedi AK. Human papillomavirus and rising oropharyngeal cancer incidence in the United States, J. Clin Oncol. 2011;29(32):4294–4301.

7. Wu X. Human papillomavirus-associated cancers-United States, 2004–2008. MMWR. 2012;61(15):258–261.

8. Gillison ML, Chaturvedi AK, Lowy DR. HPV prophylactic vaccines and the potential prevention of noncervical cancers in both men and women. Cancer. 2008;113(S10):S10:3036–3046. doi:10.1002/cncr.23764

9. Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral Oncol. 2009;45(4–5):309–316. doi:10.1016/j.oraloncology.2008.06.002

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14. Reimer RA, Schommer JA, Houlihan AE, Gerrard M. Ethnic and gender differences in HPV knowledge, awareness, and vaccine acceptability among White and Hispanic men and women. J Community Health. 2014;39(2):274–284. doi:10.1007/s10900-013-9773-y

15. Preston SM, Darrow WW. Are men being left behind (or catching up)? Differences in HPV awareness, knowledge, and attitudes between diverse college men and women. Am J Mens Health. 2019;13(6):1557988319883776. doi:10.1177/1557988319883776

16. Rashid S, Labani S, Das BC. Knowledge, awareness and attitude on HPV, HPV vaccine and cervical cancer among the college students in India. PLoS One. 2016;11:e166713.

17. Lorenzo-Pouso AI, Gándara-Vila P, Banga C, et al. Human papillomavirus-related oral cancer: knowledge and awareness among Spanish dental students. J Cancer Educ. 2019;34(4):782–788. doi:10.1007/s13187-018-1373-1

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Space between nerves and tumor cells to identify most aggressive oral cancers

Space between nerves and tumor cells to identify most aggressive oral cancers.

One of the most terrifying aspects of cancer is its unpredictability: Some cancerous tumors are cured by treatment, while others shrink with treatment only to return later. 

Original Article

Study: Spatial and Transcriptomic Analysis of Perineural Invasion in Oral Cancer

A new University of Michigan study identifies a feature in cancer that could help pinpoint treatment-resistant tumors when they are diagnosed, so oncologists know to treat aggressively from the beginning, with the hope of giving patients a better chance at survival. 

Researchers examined the role of perineural invasion––defined as when cancer invades the nerves—in oral cancer, and found that while perineural invasion is important, the distance between nerves and cancer may be as important in terms of patient outcomes. 

Broadening the definition of perineural invasion could give oral cancer patients better chances of survival with earlier, more aggressive treatment. 

“It was previously thought that cancer had to wrap around or be within the nerve to be dangerous. Our study shows that there is a distance gradient that influences the interaction and could improve treatment selection and patient survival,” said Nisha D’Silva, the Donald A. Kerr Endowed Collegiate Professor of Oral Pathology at the University of Michigan School of Dentistry. 

Microscopic image of a tongue tumor depicting cancer cells in magenta and a nerve in green. Cancer cells encircle the nerve, a feature known as perineural invasion. Image credit: D'silva lab
Microscopic image of a tongue tumor depicting cancer cells in magenta and a nerve in green. Cancer cells encircle the nerve, a feature known as perineural invasion. Image credit: D’silva lab

Although perineural invasion, or PNI, occurs frequently in oral cancer, the diagnostic criteria vary and are subjective. Moreover, the role of perineural invasion as an independent predictor of survival has not been established, D’Silva said.

To better understand the role of perineural invasion, researchers looked at tissue sections from 142 patients with PNI-positive and PNI-negative nerves. They found that perineural invasion in oral cancer is an important predictor of prognosis even before the cancer spreads, D’Silva said. Additionally, patients with nerves close to tumors had poor outcomes even if diagnosed as negative for perineural invasion using current criteria. 

Consistent with these clinical findings, analysis of nerves in sections of human tumors show a gradient of expression of stress genes that is dependent on the distance between nerves and tumors, D’Silva said. This suggests that cancer cells induce an injury response in the nerve—the closer the cancer, the greater the nerve injury and the worse the cancer behaves.

The study also showed that patients with large nerves in the tumor had poor survival rates, which suggests that even noncancerous nerves in the tumor facilitated tumor growth. Together, these findings support revising the current definition of perineural invasion to account for these nerve-cancer interactions, D’Silva said. 

Broadening the definition of perineural invasion based on nerve-tumor distance and including assessment of nerve diameter could improve treatment selection and, ultimately, reduce tumor recurrence and improve patient survival, she said.

The findings appear in Clinical Cancer Research.

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NFL Hall of Fame QB and Oral Cancer

Jim Kelly’s health remains good after beating cancer

Bills Hall of Fame quarterback had a long battle with oral cancer that gave him a bleak prognosis and required multiple surgeries on his jaw, radiation and chemotherapy. But more than three years after announcing that the cancer was gone, Kelly says there’s been no recurrence and his health is now good.

While hosting his football camp in Buffalo and throwing passes to kids, Kelly spoke with his speech only mildly affected, and said he’s healthy.


Original Article: March 6, 2018

Jim Kelly, the NFL Hall of Fame quarterback and former University of Miami football standout, announced Thursday that he will once again undergo treatment for oral cancer after recent testing indicated the cancer has returned.

Mr. Kelly, 58, was diagnosed with squamous cell carcinoma in his upper jaw in June 2013. At that time, doctors at Erie County Medical Center in Buffalo, N.Y., removed part of his upper jaw, part of the roof of his mouth and numerous teeth. He got a prosthesis to replace the teeth and bone that was removed during his surgery. Mr. Kelly, who graduated from UM in 1983, played for 11 seasons with the Buffalo Bills, leading the team to four Super Bowls.

Cancers of the oral cavity may involve bone, teeth, muscle, nerves, blood vessels, saliva glands and the inside lining of the lips and cheeks. The most common cancer of the oral cavity is squamous cell carcinoma, and it arises from the lining of the inside the mouth, the nose and the throat, according to the National Cancer Institute.

‘This can Happen to Anyone at Any Age’
“There’s a small percentage who have never smoked or drank alcohol who get cancer of the oral cavity,” says Geoffrey Young, M.D., Ph.D., FACS, chief of head and neck surgery at Miami Cancer Institute, who treats patients diagnosed with oral cancer but was not involved in Mr. Kelly’s case. “This can happen to anyone at any age so it’s always a good idea to get a yearly oral cancer screening from your dentist or primary care physician. Prevention is always better.”

Tobacco use and excessive alcohol are the main risk factors for this type of oral cancer. Mr. Kelly has said he never smoked cigarettes or chewed tobacco but smoked cigars occasionally. A small percentage of people (under 7 percent) get oral cancers from no identified cause, says the Oral Cancer Foundation. It is believed that these are likely related to some genetic predisposition, the Foundation says.

Dentists usually screen patients for oral cancer before performing regular cleanings or other procedures.  A primary care physician can also examine the oral cavity for sores or unusual growths. Before his initial diagnosis in 2013, Mr. Kelly said he suffered from pain in his jaw.

“If you have any sore or growth in the mouth that doesn’t heal within 30 days, then you should get it checked out by your dentist or primary care doctor,” Dr. Young said. “Initially, these sores may not even be painful.”

Mr. Kelly’s cancer has returned for the second time. Nine months after his first surgery in March 2014, Mr. Kelly announced the cancer had returned and aggressively spread to his brain, sinus cavity and adjacent tissues. He underwent months of treatment — including chemotherapy — that removed the cancerous cells. Before Thursday’s announcement, he had been believed to be free of cancer since September 2014. Since then, Mr. Kelly has taken part in Oral, Head & Neck Cancer Awareness campaigns, urging Americans to get screened.

Oral cancer is the largest group of the cancers that fall under the head and neck cancer category. Approximately 51,500 people in the U.S. will be newly diagnosed with oral cancer in 2018, projects the Oral Cancer Foundation. The foundation estimates that almost 10,000 people die from oral cancers every year, although not all of these cases are specifically cancers of the oral cavity.

The oral cavity includes the lips, the inside lining of the lips and cheeks (buccal mucosa), the teeth, the gums, the front two-thirds of the tongue, the floor of the mouth below the tongue and the bony roof of the mouth (hard palate). Oropharyngeal cancer starts in the oropharynx, which is the part of the throat just behind the mouth.

The human papillomavirus (HPV) has emerged in recent years as a possible leading cause of oropharyngeal (tonsil and base of tongue) cancers, particularly in non-smokers and younger age groups. Over half of tonsil and base of tongue cancers are linked to HPV. The U.S. Centers for Disease and Prevention (CDC) says that up to 70 percent of oropharyngeal cancers may be associated with HPV.

In a statement announcing that his cancer had returned, Mr. Kelly stated: “The oral cancer we hoped would be gone forever has returned. Although I was shocked and deeply saddened to receive this news, I know that God is with me. I continuously talk about the four F’s: Faith, Family, Friends and Fans. With all of you by my side, we will fight and win this battle together. Staying ‘Kelly Tough’ and trusting God will carry us through this difficult time.”

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