Oral Cancer Awareness Month Amid the COVID-19 Pandemic

Susan Cotten, BS, RDH, OMT


I always look forward to April as Oral Cancer Awareness Month with excitement. My calendar is usually filled with free screenings. Each year, I also venture to a Denver radio station to sit down with a former patient during his popular radio talk show to raise awareness about human papillomavirus (HPV), oral, and oropharyngeal cancer. 

Above all, my favorite activity is visiting local dental hygiene schools to discuss the lifesaving screenings we perform with soon-to-graduate dental hygiene students, encouraging them to never cut these screenings short since they can potentially save a life with their thoroughness.

Times Have Changed

This year is different. There will be no free oral cancer screening events. The radio interview will take place by calling in to the station. And, the dental hygiene student presentation will take place via Zoom. 

The world, our country, our lives, our families, and dentistry have been turned upside down by an unseen, highly contagious, and deadly virus. We’ve seen nothing like this in our lifetime.

Yet amid the chaos of the unknown, I see all around me acts of goodness and generosity, positivity and gratitude, hope, and love for our fellow man that hasn’t been exhibited on this grand a scale since September 11, 2001. 

It all has been brought on by an invisible virus we don’t completely understand. But as a country, we have come together to do all we can to raise awareness, stop its transmission, and save lives. Nothing is more important than a life saved. 

Listening to the daily news reports from the experts, we have at our fingertips ever-changing information about COVID-19, the numbers of real people diagnosed, its signs and symptoms, actions we can take to prevent transmission or prevent being exposed, and hopes for a vaccination to prevent infection. We hear this virus does not discriminate. And unfortunately, we hear of the many precious lives lost.

The Oral Cancer Threat 

As a science nerd and dental hygienist who is passionate about raising awareness about HPV, head and neck, and oral and oropharyngeal cancer, listening to the experts discuss the current pandemic I can’t help but relate what is occurring with COVID-19 to what we in dentistry are facing in oropharyngeal cancer. 

In dentistry, we face what some experts say is an epidemic of oropharyngeal cancer driven by an invisible, sexually transmitted virus, HPV type 16. HPV-16 is also known to cause cervical, anal, penile, and vulvar cancer.

The Centers for Disease Control and Prevention (CDC) says that more than 80% of Americans will at some point in their lifetime have an HPV infection of some type. Most won’t know they have an HPV infection, which typically does not display signs or symptoms, and most will clear the virus never knowing they were exposed.

Those with a persistent HPV infection are most at risk for cancer. Those most at risk for oropharyngeal cancer are non-smoking white males between the ages of 35 to 55, with a ratio of four to one of males to females, says the Oral Cancer Foundation.

In 2015, it was estimated that approximately 45,750 Americans would be diagnosed with oral or oropharyngeal cancer. This year, about 53,500 Americans will be diagnosed with oral or oropharyngeal cancer. That’s approximately 146 Americans diagnosed every day or six Americans every hour. Only a little more than half of those diagnosed will be alive in five years.

The experts say the data they currently have on COVID-19 is about two weeks behind. The data we have on oral and oropharyngeal cancer is four years behind. With both viruses, we must become educated, listen to the experts and their recommendations to reduce transmission, pay attention to signs and symptoms, and act accordingly when they present to ultimately save lives.

Three Steps to Saving Lives—Taken from the “Cotten Method” of Screening

We’re social distancing, providing only emergency dental treatment, and washing our hands frequently to help save lives. But what three steps can we take to increase early detection of head and neck, oral, and oropharyngeal cancer to also help save lives?

First, we can educate the entire dental team, our patients, our family and friends, and the public at large about HPV, oral, and oropharyngeal cancer, as well as the signs and symptoms, how HPV is transmitted, and what can be done to help reduce its transmission. 

Update your website with information about HPV, signs and symptoms, additional risk factors other than HPV such as tobacco and alcohol, how to perform a self-exam at home in between dental appointments, and the HPV vaccination.

Second,screen every patient, every time, including the very young beginning at their very first dental visit and elders alike. Update your medical history, asking pertinent questions relating to the potential signs, symptoms, and risk factors of oral and oropharyngeal cancer. Refer any abnormal sign or symptom that persists for two weeks. 

Third,this cancer has changed, and so have our screening techniques and processes. Educate, review, and update yourself and your team about current best practices in screening and assessing risk.

Remember, any persistent (two weeks) sign or symptom deserves a referral to a specialist for further investigation. It doesn’t mean it is cancer, however. But if it’s not right, it is wrong. 

Last September, the ADA amended its position on oral cancer to now include oropharyngeal cancer, saying all patients should receive a visual and tactile, intraoral and extraoral, oral and oropharyngeal cancer screening, not just those thought to be at risk due to tobacco and alcohol. Know how to perform a thorough oropharyngeal cancer screening, along with your oral cancer screening. They are two distinct areas in one continuous space. 

Procedure codes are an important metric in dentistry to document what we do. Currently the oral cancer evaluation is included in the DO150 Comprehensive Oral Evaluation, the D0120 Periodic Evaluation, and the DO180 Comprehensive Periodontal Evaluation. As these codes currently read, it indicates the oral cancer evaluation to be done “where indicated”.  When is this life saving procedure not indicated? 

The Beyond Oral Health Dental Codeology Consortium submitted a group CDT Code Action Request form to the Code Maintenance Committee (CMC) for a separate procedure code for oral and oropharyngeal cancer screenings. This code submission, along with others we submitted, were voted upon this past March by the CMC.

While a new code for oral and oropharyngeal cancer screenings was not the result, we were successful in having the current wording in D0150 changed, eliminating the words “where indicated” and changing the punctuation in D0120. Both changes remove the indication that oral cancer evaluations are optional. Both codes in 2021 will read differently, and the oral cancer evaluation will no longer read as to be done “where indicated.”

We have an ethical responsibility to do everything at our disposal to save lives, and at the same time reduce our liability. As an industry, let us come together to save lives.

Ms. Cotten is a speaker, consultant, author, and subject matter expert on HPV, head and neck, oral, and oropharyngeal cancer screenings. She is the owner of Oral Cancer Consulting, a regional coordinator and RDH Advisory Board member for the Oral Cancer Foundation, and a board member and oral cancer screening coordinator for Colorado Mission of Mercy. She also is the recipient of the 2018 Sunstar/RDH Award of Distinction and oral cancer screening coordinator and board member for Colorado Mission of Mercy. She is a 1994 graduate of the University of Colorado Health Sciences Center School of Dental Medicine, Department of Dental Hygiene, as well.

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