How often do we operate in the “run and gun” mode and omit the most important aspect of the patient visit—so much so that we may miss something right in front of our noses? We have been taught to look, listen, and feel lesions, like little TSA agents for oral cancer, but how much time are you reserving for that exam? Jumping out of the box of dentistry opens the door to save lives, one patient at a time, by treating the entire patient. Common causes of liability for failure to diagnose or delayed diagnosis of oral cancer fall into 4 major categories:
- Errors in clinical judgment
- Failure to follow up
- Failure to screen patients appropriately
- Evaluation delays
The Death Tolls
One person dies every hour from oral cancer, but, truth be told, one person dies every hour from skin cancer as well. More than one million cases of non-melanoma skin cancer are found in the United States each year.
More than 90% of all skin cancers are caused by UV radiation,1 and 1 in 5 Americans will develop skin cancer during his or her lifetime.2 While skin cancer can occur anywhere on the body, it most commonly occurs on sun-exposed areas such as the ears, a place where sunscreen is often not applied at all. This just happens to be where our wrists lie as we ask our patients to open wide!
We are taught to recognize abnormalities in the oral cavity and bring it to the patient’s attention, but what happens when you see a mysterious mole on someone’s lip, ear, eyelid, or the tip of his or her nose? We have a brilliant opportunity and obligation to treat the entire patient, not just his or her oral cavity. Oral health matters.
What to Look For?
The most common form of skin cancer is basal cell carcinoma with an estimated 3.6 million cases per year.3 It occurs most frequently in men who spend a great deal of time outdoors and primarily produces lesions on the head and neck. An open sore that bleeds, oozes, or crusts and remains open for a few weeks only to heal up and then bleed again is a very common sign of an early basal cell carcinoma.
The second most common skin cancer is squamous cell carcinoma with more than 1.8 million new cases per year.3 It primarily affects people who sunburn easily, tan poorly, and have blue eyes and red or blonde hair. These are most commonly found in areas frequently exposed to the sun, such as the rim of the ear, lower lip, face, bald scalp, neck, hands, arms, and legs: a perfect example of where we, as dental professionals, come into play! These present like warts and sometimes appear as open sores with a raised border and a crusted surface over an elevated, pebbly base.
Malignant melanoma is the rarest form of skin cancer but is the deadliest. Melanoma accounts for less than 1% of skin cancer cases, but it causes a large majority of skin cancer deaths.4 Oral melanomas are uncommon, and, similar to their cutaneous counterparts, they are thought to arise primarily from melanocytes in the basal layer of the squamous mucosa.
The oral mucosa is primarily involved in fewer than 1% of melanomas, and the most common locations are the palate and maxillary gingiva.5 Metastatic melanoma most frequently affects the mandible, tongue, and buccal mucosa. In contrast to cutaneous melanomas, which are etiologically linked to sun exposure, risk factors for mucosal melanomas are unknown. These melanomas have no apparent relationship to chemical, thermal, or physical events (eg, smoking; alcohol intake; poor oral hygiene; irritation from teeth, dentures, or other oral appliances) to which the oral mucosa is constantly exposed.
We must visually inspect the oral cavity, obtain good clinical histories, and be willing to perform a biopsy in any condition that is not readily diagnosed. Patients with oral malignant melanoma often recall having an existing oral pigmentation for months to years before diagnosis, and the condition may even have elicited prior comment from physicians or dentists. Most people do not inspect their oral cavity closely, and melanomas are allowed to progress until significant swelling, tooth mobility, or bleeding causes them to seek care. Melanoma can happen on any tissue in the mouth, particularly inside the lips and cheeks, on the undersurface of the tongue, and on the hard palate.
Wreaking Havoc in the Oral Cavity
These patients may end up having to endure cancer therapies that can destroy their oral mucosa. It is important to recommend oral care products that can help and not exasperate the sore and damaged mucosa. A very soft toothbrush is the most important gift you can give your patient. The CS 5460 Ultrasoft Swiss-made toothbrush (Curaprox) has 5,460 end-rounded bristles that are effective, gum-friendly, and addictive to your mouth. The CUREN filaments do not absorb water like nylon bristles do, so they last much longer. For people with inflammation post radiotherapy, the CS surgical mega soft (Curaprox) has more than 12,000 ultrafine filaments that are 0.06 mm in diameter and guarantee perfect oral hygiene during special medical situations.
More importantly, using an alcohol-free mouthwash and a gentle toothpaste that does not contain sodium lauryl sulfate is a definite must with all your patients and your family. Using a toothpaste with natural enzyme activity can boost your saliva’s natural defenses and help protect your patients from high decay rates and keep their pH levels in tow.
The Nitty Gritty
This isn’t just my viewpoint here. It is very personal for me indeed. Because of my personal history with melanoma, I started looking at every single patient differently. When I was 29, I was diagnosed with malignant melanoma. My world stopped when my husband brought the lesion to my attention and, quite frankly, saved my life. I remember being nonchalant about seeing the dermatologist about it, which is possibly how our patients feel when we bring a lesion to their attention. We must be vigilant with our exams and our followup. At this point in my career and personal life, I comment on anything that looks suspicious or, as my daughter would say, “looks wrong,” even with friends at a dinner party! Never could I imagine that my cancer would open my “dental door” and have me educate clinicians on jumping out of that rectangle box that surrounds the mouth and takes one’s dental career to the next level. Every action has a reaction, and my first action was to cry and hide. But the reaction gave me the power to fight and ignite everyone’s passion to fight with me.
This brings me back to the beginning with the TSA agent: If you see something, say something. I recommend using a periodontal probe to measure the lesion and take a photo with the patient’s cell phone in addition to the photo for our chart. This is an excellent reminder to the patient when he or she gets home that we noticed something suspicious, and if it does not go away in 7 to 10 days, he or she should visit his or her dermatologist for an exam.
Jump with me out of that rectangle box of dentistry with your new perspective of taking exams to the next level. Be confident knowing that you are overprepared for your day ahead—not just to drill, fill, scale and clean but quite possibly to also save a life.
- Koh HK, Geller AC, Miller DR, et al. Prevention and early detection strategies for melanoma and skin cancer: current status. Arch Dermatol 1996; 132(4):436-442.
- Stern, RS. Prevalence of a history of skin cancer in 2007: results of an incidence-based model. Arch Dermatol 2010; 146(3):279-282.
- Our New Approach to a Challenging Skin Cancer Statistic. The Skin Cancer Foundation. Accessed April 30. https://www.skincancer.org/blog/our-new-approach-to-a-challenging-skin-cancer-statistic/
- American Cancer Society. Key Statistics for Melanoma Skin Cancer. Accessed April 30, 2021. https://www.cancer.org/cancer/melanoma-skin-cancer/about/key-statistics.html
- The Oral Cancer Foundation. Oral Malignant Melanoma. Accessed April 30, 2021. https://oralcancerfoundation.org/facts/rare/oral-malignant-melanoma/
Ms. Nanne graduated from the University of Pittsburgh School of Dental Medicine in 1994. She has served as the executive director of the Global Oral Cancer Forum in 2016 and continues to help promote the changes required for a substantial impact on incidence, morbidity, and mortality of oral cancer worldwide educating health professionals globally. She’s authored articles in several publications and is a key opinion leader for several companies. Ms. Nanne has sat on the Corporate Council for Dimensions of Dental Hygiene for almost 2 decades and has held an executive board position in the Cleveland Dental Hygiene Association for more than 15 years. She can be reached at firstname.lastname@example.org or email@example.com.
Disclosure: Ms. Nanne is the director of professional relations and education for Curaden USA but did not receive additional compensation for this article.