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Why hygienists must be diligent in screening new and established patients.
A patient of record today asked me if she could have two sets of vertical bitewings instead of a semi-annual scale and polish. The hygiene appointment is always anxiety-ridden for her and she insists that I hand scale instead of using my piezo ultrasonic. She could tell by the look on my face that I wasn’t going to budge, so she then asked if perhaps I could substitute two oral cancer exams for the scale and polish. Huh, I thought, but I was excited to hear she remembered that the dentist and I perform a visual and tactile extra- and intraoral soft tissue exam at every semi-annual visit.
Practicing hygienists have less time in certain practice settings to perform a thorough visual and tactile soft tissue exam, including a comprehensive patient history and oral cancer assessment. The creation of large group practices, dental service organizations (DSOs) and reimbursement problems in all dental practices have resulted in practice management challenges and the necessity of monitoring production and performance metrics. Even though the clock is king, a dedicated hygienist will continue to prioritize the soft tissue exam while telling the patient what she’s doing and why. The discussion can include telling the patient to be on the lookout for red and white patches that don’t resolve with time.1
According to a recent editorial published in the Journal of Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, the estimated annual incidence of oral cavity and pharyngeal cancer in men (37,160) and in women (14,380) in the United States has, in 2018, surpassed the number of new cases of cervical cancer in women (13,240). Many of these new oral and pharyngeal cancer cases are occurring in younger adults, the editorial says. Eleven million men and 3.2 million women in the United States now harbor human papilloma virus (HPV) in the oral cavity.1
Dental hygiene professionals can read about the impact of HPV as a risk factor for oral and pharyngeal cancer on the Oral Cancer Foundation’s website. These are topics that will light a fire under those dental hygiene professionals who truly care about early oral cancer prevention and detection. The foundation has put together an impressive array of relevant information.
One of the ancillary services that can boost dental practice revenue is HPV-linked oral cancer laboratory tests. Dental practices charge anywhere from $120-$150 for the test, and some practitioners recommend retesting again in six to 12 months. The test consists of swishing and gargling with saline for 30 seconds to collect saliva, and then spitting it back into a collection tube.
Sounds like a good idea, eh? There’s an old saying that if something sounds too good to be true, it probably is.
Commercially available oral HPV (nucleic acid DNA testing by PCR) laboratory tests are very accurate, but they’re not an accurate predictor of susceptibility to oral cancer. What does this mean?
Testing for the presence of HPV-16 was thought to be promising for the early detection of disease, but it was eventually found to have insufficient sensitivity and specificity.2 In other words, the test doesn’t identify those who will get the cancer and it’s not going to correctly identify those who will not get the cancer. Most people clear HPV-16 on their own, but it may take years to clear.2 In those individuals, the body doesn’t consider HPV-16 a threat. If the lab test for oral HPV doesn’t have any predictable value, then why do it?
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Patients with HPV-positive throat cancer have a disease-free survival rate of 85-90 percent over five years.2 This is in contrast to the traditional patient population of excessive smokers and drinkers with advanced disease who have a five- year survival rate of approximately 25-40 percent.2 These cancers rarely cause any symptoms until they’ve metastasized, but dental practitioners modify their oral cancer exams in order to look for early warning signs in susceptible individuals. The tonsil is the most commonly affected anatomical landmark, but HPV-positive oropharyngeal cancer can also be found at the base of the tongue.3
HPV can also be present in association with cancer in the oral cavity, larynx, nasopharynx, paranasal sinus and hypopharynx.3 HPV has been detected in esophageal tissue with a 3-fold greater chance of esophageal squamous cell carcinoma.3 All of the aforementioned areas are hard to visualize and there are no surface changes to observe, so a good screening will include verbal questions about symptomatology.
One of the most important aspects of oral cancer screening is palpation. The neck area is virtually ignored. Pressing down on the floor of the mouth with submandibular palpation is most important. The swelling or actual firm growths may be the first indication of cancer. The folds (crypts) in the tonsil region mask lesions. The submandibular gland may be affected. Dental offices should be using a long-handle mirror so that they can get a good view of the posterior mouth area just like ENTs do. Palpation of the cervical chain of lymph nodes in the neck region should be performed. Dental professionals seem to think that their role ends at the patient’s chin.
In 2012, the rate of oropharyngeal cancer among men was reported to be about four times that of women.4 Several studies indicate that oral HPV is likely to be sexually acquired, and HPV-positive oropharyngeal cancers are more common in younger men who don’t smoke or drink alcohol but have a history of sexual activity that could expose them to oral HPV infection, like a higher number of sex partners, lack of condom use and more frequent oral sex exposure.3 Higher risk individuals also include post-transplant immune suppression, HIV infection and smoking.3
Here are some suggested oral HPV symptomatology questions to ask the patient:
1. When you swallow, do you ever feel that something is catching or sticky in your throat?
2. Do you ever have unilateral earaches, unusual hoarseness or change in voice that’s not allergy-related?
3. Have you ever noticed that one tonsil is larger or more swollen than the other?
4. Have you ever discovered a lump in your neck or a non-healing sore on your neck?
Review the 2017 American Dental Association (ADA) YouTube video that offers guidance for evaluating adults for oral cancer during a new or routine dental exam.5 The video is based on recommendations contained in the ADA’s 2017 “Clinical Practice Guideline for the Evaluation of Potentially Malignant Disorders in the Oral Cavity.”6
There’s a sense of urgency on the part of healthcare professionals to raise awareness among younger people at risk of HPV-associated oropharyngeal cancer. Alarmingly, HPV-associated oropharyngeal cancers don’t usually cause symptoms until they’ve spread, and there’s no reliable way to screen for them like we do with a female pap smear for cervical cancer. For now, screening using a conventional visual and tactile technique is important to incorporate into new patient and recare exams, knowing that there’s insufficient evidence to determine the effect of screening on disease-specific morbidity and mortality. Adjunctive visualization systems can be added, but keep in mind that evidence to support their use is limited and conflicting.3,7 Social media is a great way to reach younger people at risk for HPV, and who better than creative RDHs to find a way to tweet for awareness.
1. Patton LL. (editorial) Oral cancer detection: what will it take? Journal. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. July 2018: 126(1): 1-3.
3. Burd EM. Human papilloma laboratory testing: the changing paradigm. Clin. Microbiol. Rev. April 2016: 29(2): 291-293.
5. American Dental Association. Instructional video. How to eval- uate for potentially malignant disorders and oral cancer; 2017. https://www.youtube.com/watch?v=7mv073MJzlg
6. Lingen MW, Abt E, Agarwal N, et al. Evidence-based clinical prac- tice guideline for the evaluation of potentially malignant disorders in the oral cavity. A report of the American Dental Association. J Am Dent Assoc. 2017;148:712-727.
7. Rethman MP. Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. J Am Dent Asso. 2010 May: 141(5):509-20.