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This continuing education course is intended for general dentists, hygienists, and dental assistants. This
course will introduce the protocol for a complete oral cancer screening with proper techniques for both the
intraoral and extraoral exam; provide some patient education information, as well as information on some
adjunct considerations that may be utilized in lesion detection and lastly, to suggest that all patients be told
they are actually receiving a complete oral screening exam.
ADA CERP
Overview
According to the American Cancer Association, from 2004 to 2008 oral cancer decreased in women by
1.0% per year and remained stable in men. However, the ACS reports recent studies show that pharyngeal
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cancer related to the human papillomavirus (HPV) is continuing to increase.
Numerous studies conducted over many years have shown that visual and tactile examination of the
structures of the head, neck and oral cavity are effective in detecting abnormalities occurring within these
structures. Therefore, procedures such as the head and neck and intraoral examinations, often referred to
as oral cancer screening, are important elements of a complete patient assessment. These examinations
should be performed on a routine basis for every patient, not just new patients or those with known risk
factors such as the use of tobacco or alcohol or increasing age.
It is important to diagnose lesions in a pre-malignant or early stage while they are still confined to the
epithelial layers to not only render the most effective treatment but also to potentially limit the need for
the most invasive and disfiguring levels of treatment. Early treatment normally results in less surgery,
less radiation and chemotherapy, and a better quality of life. Treatment for oral, oropharyngeal and other
head and neck cancers diagnosed at later stages is usually associated with more extensive dysfunction
and disfigurement than treatment for those same cancers diagnosed in earlier stages. Complications
associated with therapy for oral, oropharyngeal and other head and neck cancers include: altered eating
and swallowing patterns, salivary gland dysfunction, loss of oral structures such as teeth and bone and soft
tissues such as parts of the tongue, among others. In a 2010 study, Rethman et al. reported there was
sufficient evidence-based information to support oral cancer screening by visual and tactile methods as a
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means to detect cancer in the early stages. In 2009 Watson et al. looked at a group of patients already
diagnosed with oral or pharyngeal cancer to determine if oral/pharyngeal cancer screening examinations
done in the general dental office were associated with early detection. The researchers found those
patients who had a screening examination within the last year were significantly more likely to have an
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early stage cancer than those who did not.
The length of time between a patients initial consultation with a healthcare provider and a diagnosis of
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cancer is termed professional delay. Professional delay may be caused by deficient clinical skills, a
low threshold of suspicion, non-specific signs/symptoms and lack of experience. Studies by Yu found a
delay of as much as 6 months, much longer than expected, from the time of the initial examination to the
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diagnosis/treatment. Cancer progression is relatively rapid in the oral tissues, and as one would expect,
professional delay results in more late stage diagnoses, more extensive surgery and more radiation and
chemotherapy for the patient.
A complete head and neck and intraoral examination is not only important for the early detection of cancer
but also for accomplishing a comprehensive assessment of the patient prior to providing dental treatment
(Table 1).
The head and neck examination is often overlooked by busy clinicians but it is a crucial element of the
cancer screening examination. A thorough head and neck examination is essential for detecting early
skin cancers and enlarged lymph nodes that may indicate cancer metastasis. In addition to oral cancer,
many chronic disease states may be discovered in the dental office since oral manifestations of systemic
disease may be observed during a routine dental exam and oral cancer screening. With the baby boomers
reaching retirement age, chronic disease will continue to increase. By 2030 about 20% of all Americans,
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more than 72 million people, will be older than 65 years old. Oral cancer is a disease associated with
aging; however, we have seen a continuing increase of oral cancer diagnoses in those patients under age
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40 with no known risk factors also noted in this age group is a significant increase in cancer of the tongue.
The incidence of oral cancer in Europe in people aged 20-39 years old has increased 6-fold and studies
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report increased mortality rates for the past two decades in Eastern Europe. Practitioners who focus on
patients at high risk may miss subtle changes in those patients who have no known risk factors or those
who do not fit the perceived profile of oral cancer susceptibility. With increases of oral cancer in younger
age groups, all patients, regardless of age or presence of risk factors, should be screened for oral cancer.
In general, cancer in younger populations tends to be much more aggressive and have a poorer prognosis.
Learning Objectives
Upon completion of this course, the dental professional should be able to:
State eight objectives of the intraoral and head and neck examinations.
List the sequence of performing a total oral cancer screening.
List prime areas for the development of oral cancer.
Describe four adjunct tests or devices and procedures that may be performed in conjunction with the
oral cancer screening.
Discuss reasons for using an adjunct device when performing an oral cancer screening.
List five descriptors important for accurately documenting oral lesions.
List four risk factors for the development of oral cancer.
Define the term professional delay.
Identify and define the three general classification categories most examination findings can be
placed into.
Course Contents
Attached Gingiva
Salivary Flow and Consistency
Adjuncts for the Oral Cancer Screening
Figure 1. General appraisal to obtain or update the medical and dental history
of the patient.
Cutaneous Area
As in the general appraisal, the exposed skin
of the head and neck should be examined for
Lips
The lips should be examined for symmetry and
tissue consistency and texture. Normally the lip
tissue should be resilient, smooth and have a
homogenous pink color (Figure 8). The vermillion
border should be distinct and even. Early ultra
violet damage may present as an indistinct or
broken vermillion border with color variations
or white blotches within the lip tissue. More
advanced signs of damage include induration,
pitting and ulceration of the tissues. Patients with
the very early signs of damage should be shown
the area and advised to limit exposure to the sun
and use a lip balm with a sunscreen. They should
be advised about the signs and appearance of
more serious changes. Patients should monitor
their lips for evidence of these changes. The
Lymph Nodes
The major lymph nodes of the head and neck
area should be palpated with the patient in an
upright position. Findings which should be noted
include enlarged palpable nodes, fixed nodes,
tender nodes and whether the palpable nodes
are single or present in groups. Findings which
include single or multiple, non-tender, and fixed
nodes are very suspicious for malignancy. Groups
of tender nodes usually occur in conjunction with
some type of infection. Occasionally nodes will
remain enlarged and palpable after an infection.
This is a relatively common occurrence especially
within the submandibular group of lymph
nodes. When examined, these nodes should be
small (less than 1 cm), non-tender and mobile.
Remember to correlate findings from the medical
history and general appraisal of the patient to
the observations made during the head and neck
examination. For example, a previous history
of cancer might cause the clinician to be more
suspicious of newly appearing palpable nodes
than if there is no history of cancer. If suspicious
nodes are discovered, the patient should be
referred to a physician for immediate evaluation.
Figures 11 through 12 depict the examination
techniques for the following lymph nodes.
Occipital nodes (Figure 11) Palpate the
occipital nodes about one inch above and
below the hairline.
Auricular (Figures 12 and 13) Palpate the pre
and post auricular nodes bilaterally using the
pads of the index, middle and ring fingers.
Thyroid Gland
The thyroid gland is found inferior to the larynx
and just superior to the clavicles on either side
of the trachea. It is comprised of two lobes
connected by an isthmus. Palpate the gland
using a bimanual technique where one hand
supports the tissue and the other hand palpates
the gland on one side and then the reverse is
done to examine the opposite side of the gland
(Figure 21).
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Hard Palate
The hard palate and maxillary tuberosity areas are
examined using both direct and indirect vision and
illumination. Following the visual examination the
clinician should digitally palpate the entire area
using firm non-sliding pressure against the bone
(Figure 27).
In general, the tissue is a homogenous pale pink
color, firm to palpation towards the anterior and
lateral to the midline while more compressible
towards the posterior and medial to the apices of
the teeth. The normal structures of the hard palate
should be identified:
Incisive papilla protuberance of soft tissue
lingual to the maxillary central incisors which
covers the incisive foramen and normally
appears redder than the surrounding tissues
(Figure 28)
Raphe slightly elevated line extending from the
incisive papilla to the soft palate (Figure 28)
Rugae corrugated ridges radiating laterally
from the raphe (Figure 28)
Vault relates to the depth and width of the
palate (Figure 29)
Maxillary tuberosities area distal to the last
molars (Figure 30), the tissue should be a
homogenous pink color and firm to palpation
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Buccal Mucosa
The buccal mucosa is examined using direct and
indirect vision followed by bi-digital palpation of
the entire area. Be sure to pull the tissues away
from the retromolar area and stretch the mucosa
away from the mucogingival junction (Figures 32
and 33).
Labial Mucosa
The labial mucosa is examined using direct vision
by averting the tissues over the fingers or thumbs
(Figures 37 and 38) followed by bidigital palpation
of the tissues of the lips.
Move the tissues from side to side and visualize
the frena. Normal lip tissues are a homogenous
deep pink color which changes gradually to a
deep red color with more prominent vascularity
near the mucolabial vestibule. The tissues should
be moist and have uniform consistency and
thickness when palpated (Figure 39).
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Mandible
The body of the mandible will be examined
using direct and indirect vision followed by digital
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Tongue
The tongue is examined using both direct and
indirect vision. The most common place for
cancer to occur on the tongue is the lateral border.
Grasp the tip of the tongue with a gauze square
and roll the tongue over on one side to observe
the lateral border then repeat for the other side
(Figure 48). Use the mirror to examine the
posterior lateral borders if necessary (Figure 49).
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Attached Gingiva
The attached gingiva of the maxillary and
mandibular arches is visually examined using
both direct and indirect vision. The tissues
should appear pale pink and homogenous in color
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Figure 58.
Conclusion
DentLight D.O.E.
The portable, lithium rechargeable batteryoperated handpiece emits a safe blue wavelength
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Appendix A.
Appendix A. Your Oral Cancer Screening Exam
Appendix B.
The Oral Screening Form is presented to the patient at the time of an oral cancer screening.
Appendix B. Oral Cancer Screening Form
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Appendix C.
Appendix C. Referral Form for Oral Pathologist and/or Oral Surgeon
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To receive Continuing Education credit for this course, you must complete the online test. Please go to
www.dentalcare.com and find this course in the Continuing Education section.
1.
As you examine the TM joint you notice an altered opening pathway which has its greatest
distance from the midline at maximum opening. This defines which one of the following
terms?
a. Crepitus
b. Deviation
c. Deflection
d. Subluxation
e. Derangement
2.
3.
All of the following structures would be noted when examining the oropharynx except
_______________.
a. tonsils
b. adenoids
c. tonsillar crypt
d. anterior/posterior pillars
e. posterior pharyngeal wall
4.
5.
6.
The _____________ technique would be best for palpating the hard palate.
a. digital
b. bidigital
c. bilateral
d. bimanual
e. auscultation
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7.
8.
9.
10. The _______________ technique would be appropriate for palpating the buccal and labial
mucosa.
a. digital
b. bidigital
c. bilateral
d. bimanual
e. unilateral
11. When examining the body of the mandible you would use the mouth mirror to stretch the
mucosal tissues away from the inferior border, BECAUSE you might miss a lesion which is
tucked up into a fold of tissue.
a. Both the statement and the reason are correct and related.
b. Both the statement and the reason are correct but NOT related.
c. The statement is correct but the reason is not.
d. The statement is NOT correct, but the reason is correct.
e. NEITHER the statement NOR the reason is correct.
12. All of the following are common atypical findings in the body of the mandible and the
retromolar area except _______________.
a. tori
b. scarring
c. pericoronitis
d. hyperkeratosis
e. partially erupted third molars
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13. The _______________ technique should be used when palpating the structures of the floor
of the mouth.
a. digital
b. bidigital
c. bilateral
d. bimanual
e. finger and thumb of the same hand
14. The _______________ is the most common intraoral site for oral cancer development.
a. uvula
b. tongue
c. hard palate
d. buccal mucosa
e. floor of the mouth
15. Which of the following findings associated with the tongue is caused by an error in
development?
a. Fissuring
b. Scalloping
c. Hairy tongue
d. Plica fimbriata
e. Lingual thyroid
16. Which one of the following adjunct devices might be used to help determine surgical
margins when removing or biopsying a suspicious lesion?
a. Identafi 3000 Ultra
b. OralDx Brush Test
c. ViziLite Plus with TBlue
d. VELscope
e. Liquid-Based Cytology
17. The perception of oral dryness may depend upon all of the following except the
_______________.
a. amount of saliva actually present
b. amount of serous saliva
c. amount of mucous saliva
d. salt/calcium composition of the saliva
e. consistency of the saliva
18. Which of the following examination findings would be considered atypical?
a. Stippled gingiva
b. Fordyce granules
c. Leukoedema
d. Genetic pigmentation
e. Both B and C
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19. Nutritional deficiencies, Candida albicans, human herpes virus and lesions associated with
loss of dimension are common to which one of the following structures/areas?
a. Tongue
b. Hard palate
c. Commissures
d. Floor of the mouth
e. Pharyngeal pillars
20. A symblepharon discovered during an extraoral exam would be found in the/on the
____________.
a. ear
b. nose
c. neck
d. eye
e. lip
21. If a symblepharon is discovered, the patient would need to be referred to a/an
_______________.
a. oral surgeon
b. oral pathologist
c. immunology specialist
d. ophthalmologist
e. dermatologist
22. All of the following are known risk factors for cancer. Which one cannot be eliminated by
changing behaviors or lifestyle?
a. Alcohol
b. Tobacco
c. Diet
d. Age
e. Sunlight
23. Patients with known risk factors for cancer should be screened at _______________.
a. normal maintenance visits
b. more frequent intervals
c. any time that an abnormality is noticed by the patient
d. yearly visits
e. every visit and encouraged to perform self-exams and report any abnormality
24. Which one of the following viruses is associated with a significant increase in
oropharyngeal cancers?
a. HIV
b. HPV
c. HVC
d. HVB
e. CMV
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References
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Dental Hygienist released in October 2007 through Lippincott, Williams & Wilkins. Nancy is a columnist
for RDH magazine and writes the oral case studies column. She was the 2006 recipient of the ADHA
Crest Award through Procter and Gamble. Additionally, she is a 2012 Mentor of Distinction. The award
was provided by Philips Consumer Lifestyle and Pennwell Corporation.
Email: nburkhart@bcd.tamhsc.edu
Leslie DeLong, RDH, AS, BSHS, MHA
Leslie DeLong is an Associate Professor of Dental Hygiene at the Lamar Institute of
Technology in Beaumont, Texas. She received an Associate of Science degree in
Dental Hygiene from Middlesex Community College, a Bachelor of Science degree in
Health Science from Northeastern University and a Master of Health Administration
degree from Clark University. She has been the First Year Clinic Coordinator for the
Dental Hygiene Program at Lamar since 1991. Leslie has taught Oral Pathology and
Head and Neck Anatomy and is currently teaching both clinical and didactic sections
of the Pre-Clinical Dental Hygiene and Introductory Clinic courses. Leslie co-authored Oral Exams: Are
You Performing a Complete Exam for RDH magazine. She is co-author of General and Oral Pathology
for the Dental Hygienist released in October 2007 through Lippincott, Williams & Wilkins.
Lamar Institute of Technology,
Allied Health and Sciences
Email: ladelong@lit.edu
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