How often have you wondered what you could do to contribute to the lives of your patients? Certainly, many of the things you do as a hygienist each day contribute to the health of your patients, but what if you actually saved their lives? How do you think that would make them feel? How do you think that would make you feel?
Early detection of oral cancer can save lives, and hygienists can play a major role in such detection. This article discusses one of the most important services you can provide your patients, a service that can literally save lives.
THE FACTS ABOUT ORAL CANCER
Oral cancer kills one person every 60 minutes in our country. It kills more people than skin cancer. It kills more people than cervical cancer. It kills our parents, our friends, and our children, and yet most dental professionals don’t take its threat seriously enough to do anything about it. It’s time to take our jobs as healthcare providers seriously, and start focusing on the health of our patients. If we don’t, the statistics show we’re going to have to start focusing on their deaths. It takes just 3 minutes to do something about this devastating health problem.
Most of us are pretty good about performing an intraoral cancer exam, but somehow after graduation and passing our boards we stopped performing our extraoral cancer exam. Maybe we forgot the importance of checking for tumors of the neck and jaw. Maybe we forgot to be checking for unusual growths extraorally that could clue us into problems intraorally. Maybe we forgot that our patients see us more often than they see their physicians, and that it would be valuable for us to check for abnormal skin lesions of the face and neck area, and lymph nodes that have been swollen for more than 2 weeks.
I have suggested to more than half a dozen patients to have a skin lesion checked by a dermatologist. Half of these have turned out to be skin cancer. Do you think these patients would ever leave our practice now to go somewhere that charges $100 less for a crown? No way! These patients are loyal because they know we care and may have saved their lives. You don’t have to be able to diagnose a thyroid problem or a basal cell carcinoma. You just need to be able to identify what is abnormal and refer your patient to the provider who can diagnose it. We all are able to do this; we may just need a short refresher course.
GET STARTED NOW
So, how do you get started? The first thing to do is get excited about doing this. There are three reasons why I am passionate about doing what I call the “Ritz Carlton” approach to extraoral cancer exams: it saves time, patients love it, and it saves lives.
It Saves Time
I found that once I started implementing this exam on a regular basis, it cut my appointment time by at least 5 to 10 minutes. The reason: patients cut down on their personal chit-chat because by performing the examination you elevated your status to healthcare professional in their mind. They got focused on the real reason they were sitting in your chair—to get healthy.
Patients Love It
Let’s face it, having your face and neck “massaged” feels great! I have never run into a situation where a patient was uncomfortable with the exam. Most of my patients ask me to keep going, and they look forward to this portion of their appointment. Plus, it instantly relaxes people. I know that a lot of patients come to the office from work and are uptight or stressed. This exam helps them focus on the appointment and not outside issues.
It Saves Lives
I have a friend who was lecturing one evening to a group of oral surgeons about oral cancer and early detection. She is not a dental professional, but she has a very personal investment in this topic that I will get into later. During the class, one of the surgeons actually discouraged general dentists and hygienists from utilizing early detection procedures. He felt there was no reason for it because if they found oral cancer the patient was just going to die anyway. In my opinion, this approach to oral cancer is why the mortality rate for it has not significantly dropped in the past 40 years. By the way, my friend who was lecturing is currently watching her mom face each day being fed through a stomach tube, not being able to swallow because her mouth has the consistency of leather after chemotherapy and radiation, and living a life devoid of many simple pleasures for the time she has left.
Why is this happening, you may ask? Her mom went in for routine surgery, and when the anesthesiologist tried to intubate her, he came up against a tumor on her soft palate. The disturbing statistic of this story is that this is how most cases of oral cancer are found. They are most likely found in the hospital, not the dental office. How can we hope to treat and cure oral cancer in its early stages when we are not detecting it early? This is why I am committed to starting every appointment with a comprehensive extraoral and intraoral cancer exam.
Once you’ve enrolled yourself and your team into doing this, you need to enroll your patients. It can be difficult initiating a new examination into your treatment sequence. Patients will notice it’s new and ask why you’re doing it now. I tell my patients the following: “We now know that oral cancer kills more people every year than skin cancer and cervical cancer, and our team is committed to seeing that number drop. So, each time you come in for your hygiene visits we will be examining for extraoral and intraoral cancer.”
When starting the exam, I tell my patient, “I am going to start off with your head and neck cancer exam. This is like a facial massage and it feels very good. What I am checking for are skin discolorations, swollen lymph nodes, and any unusual lumps and bumps.” I then proceed with these steps in my inspection:
(1) Palpate and visually inspect the skin all over the face and neck.
(2) Check for sinus congestion.
(3) Palpate the lymph nodes from the submandibular, cervical, auricular, and occipital chains.
(4) Visually inspect the patient’s neck area by having him turn his head from side to side.
(5) Palpate the entire neck region at least down to the patient’s clavicle.
(6) Visually inspect and palpate the thyroid.
(7) Have the patient swallow, and note any blockages or dysfunctional movement.
I look for anything that: (1) feels different or looks different from one side to another, (2) is sensitive or painful to the touch, or (3) has an unusual or suspicious appearance. If anything falls into these categories I will show the patient and have him feel the area. I then inform the dentist prior to the examination. The patient is then told to monitor the area for changes and see us in 2 weeks if it hasn’t gone away, or he is referred to someone who can further examine it.
Next, I move to the intra-oral cancer exam. Two important aspects to this are to:
(1) Be thorough and take your time. Most lesions get missed because we are going through the motions and not really looking.
(2) Have a routine. By having a specific sequence that you follow every time, the likelihood of missing an area is reduced. An example of a thorough sequence is:
- Palpate and visually inspect lips.
- Check labial vestibules.
- Inspect buccal mucosa.
- Inspect retromolar pads.
- Inspect hard and soft palate.
- Depress patient’s tongue and inspect tonsillar area and pharynx.
- Use a moistened 2 X 2 gauze pad to hold tongue and check lateral borders.
- Palpate tongue and check both dorsal and ventral aspects.
- Visually inspect and palpate floor of mouth.
If anything looks suspicious, inform the patient, have him look in the mirror, and alert the dentist. If the dentist feels the lesion warrants a biopsy, you can refer the patient to an oral surgeon or perform the biopsy in your office. By utilizing a brush biopsy, such as the one from Oral CDX, you can quickly and painlessly evaluate the lesion. The Oral CDX brush biopsy has been tested extensively against traditional scalpel biopsies and has proven to be 100% accurate with no false positives when used according to instructions. A kit provides all necessary items to perform the procedure. The doctor simply brushes the lesion (with no need for anesthetic) until pinpoint bleeding occurs. The auxiliary then transfers the cells from the brush onto a slide, applies a fixative, and allows the slide to dry for 15 minutes. The slide is placed into a transport case and is mailed along with a patient information sheet to the Oral CDX lab. The lab will fax you the results of the biopsy within 7 to 14 days along with a description of the cellular representation.
I highly recommend using the brush biopsy for the following reasons:
(1) Requires no anesthesia
(2) Can be done during your routine exam in just 3 minutes working time
(3) You have certainty that your patient had
the test done rather than referring him to the oral surgeon and “hoping” he made the appointment before losing his nerve.
(4) Less cost to the patient. I recommend charging about half your scalpel biopsy fee.
(5) No sutures or sustained bleeding.
MORE FRIGHTENING STATISTICS
Each year 9,000 to 10,000 people die from oral cancer in the United States, and 30,000 new cases are diagnosed. Ninety-five percent of people affected are over the age of 40, and while the two highest risk factors for oral cancer are the use of alcohol and tobacco, anyone can be affected. Other risk factors may include poorly fitting dentures, chronic irritation from jagged/decayed tooth surfaces, exposure to damaging UV light, and chewing the lips and inside of the mouth. The most common site for oral cancer is the tongue, but it can strike any part of the mouth, including the lips. If the cancer is not treated early, it can spread deep into the lymph glands of the neck.
The average 5-year survival rate for patients affected with oral cancer is poor, at only 50%, and the overall survival rate is 18% or less. Unfortunately, this is due to the lack of identification of the lesion. If the cancer is detected in its early stage, the survival rate increases to about 70% to 80%.
While erythemic and mixed erythemic/leukoplakic lesions tend to raise the most flags for practitioners, cancers of the mouth can present in many different forms. Two other lesions to be suspicious of are persistent white patches and nonhealing, ulcerative areas. I recommend spending a day with your local dental school’s oral pathology professor to gain valuable skills in the clinical detection of suspicious lesions. Another helpful tip is to request photos of cancerous lesions from such organizations as the ADA or American Cancer Society.
Dental programs in every state train their dentists and dental hygienists to detect and evaluate cancerous lesions in their earliest form, yet most cases of oral cancer are not detected by dental professionals. I propose there are a number of reasons why this unfortunate statistic is true.
Most of us are uncomfortable checking the face and neck area of our patients, especially if this is a new procedure for existing patients. When implementing any new procedure you must first ask yourself why that procedure is important. When you come from a place of certainty and the intent to enhance the health of your patients, they will embrace whatever procedure you decide to implement. Stand behind these beliefs, and know that what you are doing will benefit the life of your patient. What patient would be uncomfortable or irritated with you for checking for something that could be the cause of their death? Besides, the head and neck examination feels great! Try it out on your co-workers, and get ready for the rave reviews.
Sometimes we fail to comprehensively evaluate our patients because we can’t remember what to look for. Remember, it is not our job to diagnose the problem. It is our job to recognize the abnormal and refer to someone who can diagnose and treat the problem. Increase your clinical skills by spending time with an oral surgeon and looking at clinical photographs of abnormal lesions. Don’t let the usual become the normal. Just because you may see many leukoplakic lesions during the week, it doesn’t mean it’s normal. Studies have shown that approximately two to six patients per week in a general practice will have a lesion that needs to be biopsied.
Look at pictures of cancerous lesions. How many of those pictures did you see in your patients’ mouths last week? How many patients with early-stage cancer walked out of your door last week, completely unaware they were at risk?
One of the myths surrounding oral cancer is that it is a death sentence. This is a myth not only believed by dental professionals, but also by patients. The truth is that with early detection, oral cancer is almost always curable. The ADA has recently launched a massive campaign to increase public awareness of oral cancer and early detection. It is our responsibility to follow through with this campaign by partnering with our patients and with companies that offer early detection devices.
By conducting a thorough examination, imagine how many lives you could save. Imagine how many lesions could be detected early by taking the time to evaluate for oral cancer and by utilizing the latest technologies in diagnosis. What have you been missing by not really looking? Stop being afraid or reluctant to find oral lesions. It is our responsibility as primary oral healthcare providers to use all our knowledge and clinical skills to save the lives of our patients. One person dies every hour from oral cancer. Research shows that 70% to 80% of the people who die could have been saved through early detection. Let’s not allow one more patient to die unnecessarily because we were unwilling to perform a life-saving exam. It takes just 3 minutes.
American Cancer Society. What are the key statistics about oral cavity and oropharyngeal cancer? Available at: http://www.cancer.org. Accessed March 18, 2002.
American Dental Association Dental Newsline. The dentist’s role in spotting oral cancer. Available at: http://www.ada.org. Accessed March 18, 2002.
Cancer News on the Net. Facts about oral cancers; a review by Dr. Greg Bobier. Available at: http://cancernews.com. Accessed March 18, 2002.
Mayo Clinic Health Information. What is oral cancer? Available at: http://www.mayoclinic.com. Accessed March 18, 2002.
Oral Health Information; ADHA Online. Oral cancer facts. Available at: http://www.adha.org. Accessed March 18, 2002.
Ms. Mitchell is a full-time practicing hygienist for Dr. Michael Koczarski in Woodinville, Wash. She is a coach with Hygiene Mastery and codirects the hygiene program for PAC~live. Ms. Mitchell lectures and instructs extensively on the comprehensive assessment of dental wants and needs, treatment planning, and codiagnosis of anterior and posterior aesthetic dentistry. She can be contacted at (425) 486-2200.