An Opening for Tumor Detection

An opportunity to obtain whiter teeth at less cost saved Dave Edler much more than money. His new dentist took one look at his mouth and recognized a sore as a potential cancer. “If not for her, I’d have let it go, and it would have gotten out of hand,” says Edler, of Alton, Ill. “She was on it.”

Edler thought his dry, cracked lip resulted from motorcycle riding. His previous dentist had never said anything. But Danielle Csaszar, DMD, formerly at College Avenue Family Dentistry in Alton, recognized the need for further evaluation and treatment. A biopsy revealed oral cancer, and a plastic surgeon was able to remove the entire lesion without long-term disfigurement.

“If not for the dentist looking at it, it could have been ugly,” Edler says. “It didn’t dawn on me that this could happen.”

Similarly, Thomas Camacho Jr. of Gainesville, Fla., is grateful that William Harriett, DMD, at University Family Dentistry in Gainesville, found a suspicious sore in his mouth, allowing him to receive early treatment with radiation.

“I’m elated he found it,” says Camacho, who has been in remission for nine years. “If it hadn’t been for him, I wouldn’t have gotten it treated.”

Some 34,000 people learned they had cancer of the oral cavity or pharynx (the upper portion of the throat) last year, according to estimates by the American Cancer Society. More than 7,500 people with this type of cancer die annually, and only about 60 percent live five years or longer, the ACS reports.

“The five-year survival rate hasn’t changed in 50 years,” says Arlen D. Meyers, MD, MBA, professor of otolaryngology at the University of Colorado Denver School of Medicine. “The five-year survival has not changed because most people present with relatively advanced disease.”

The cancer may occur on the lips, tongue, gums, cheek lining, mouth or throat. But because the sore or tumor may cause no pain, the patient often remains unaware of the problem. Doctors often find oral/pharyngeal cancer after it has spread to the lymph nodes or beyond.

Men are more likely to develop oral/pharyngeal cancer than women. Traditionally, most oral cancer has occurred in people age 40 or older. But recent trends show an increase of cases in younger people.

Edler and Camacho learned about their cancers at an early stage thanks to dentists assessing for problems in the mouth, beyond just the teeth.

“Dental screening for oral cancer is critical,” says A. Ross Kerr, DDS, MSD, clinical associate professor in the department of oral and maxillofacial pathology, radiology and medicine at New York University. “The earlier you catch it, the better off you are.”

A dentist completing a screening will ask about the patient’s health history and habits such as smoking and alcohol use that could increase risk. During the physical exam, he or she will feel the neck and check for sores on the lips or skin. Then the dentist will look inside the mouth, using a regular dental light, and will check for sores and feel for bumps. The dentist should move the tongue from side to side.

“It takes less than 90 seconds to look everywhere very well,” says Gustavo D. Cruz, DMD, MPH, associate professor of epidemiology and health promotion at the New York University College of Dentistry. “It should be part of the regular examination. It’s noninvasive.”

A suspicious spot might prompt the dentist to employ additional tools, such as applying dyes and stains, collecting cells or using a special light (see sidebar, next page). For example, the dye toluidine blue might help the dentist find the best place to obtain a biopsy, Kerr explains.

Even if a supplemental tool is used, a biopsy must confirm the diagnosis, Cruz says.

Doctors often will surgically remove the tumor. They also might treat it with radiation and, for advanced cancers, chemotherapy might be added. Treatment, however, often leads to disfigurement or difficulty eating and drinking. While the use of chemotherapy and radiation may allow for less extensive surgery, long-term side effects of therapy, such as dry mouth and ongoing dental problems, can ensue.

Second primary tumors will develop in 10 percent to 40 percent of patients, according to the cancer society.

American Dental Association spokesman Sol Silverman Jr., DDS, professor of oral medicine at the University of California, San Francisco School of Dentistry, recommends that survivors of oral/pharyngeal cancer obtain close follow-up care and limit exposure to risk factors. Treatment becomes more complex for a second tumor, but is possible.

Silverman considers it essential that dentists educate patients about lowering their risks.

“Dentists and dental hygienists are part of the health team. And they have to take these things into consideration with the examination and advising [patients] about what to do and not to do,” Silverman says.

Risk factors include use of tobacco and excessive alcohol intake. Human papillomaviruses may be a factor in 20 percent to 30 percent of cases. Other factors including sun exposure, poor nutrition and a suppressed immune system also may play a role.

Unfortunately, not everyone sees a dentist regularly. And many people are not able to afford dental care.

Many patients at risk for advanced oral cancer and late diagnosis are those with low socioeconomic status. “Those are usually the people with poor access to dental care,” Cruz says.

Another challenge stems from dentists’ knowledge of and comfort levels with screening.

“Most general dentists are not adequately trained to screen, or feel uncomfortable doing it,” Meyers adds.

Newer dentists learn about the screening in school. But those practicing for more than 10 years may not be as familiar with the techniques. To address such concerns, the state of New York mandates that dentists complete a two-hour continuing education course covering oral cancer, early detection and tobacco cessation.

And while screening to find cancers early seems like a good idea, little evidence exists that it leads to improved health outcomes, according to the U.S. Preventive Services Task Force and the National Cancer Institute. The task force does not recommend for or against screening.

The American Dental Association, however, encourages dentists to perform a screening. If a dentist does not do such an exam, Silverman suggests patients inquire about it.

“Ask the dental hygienist or dentist at the next checkup to please check for oral cancer. It doesn’t cost anything,” Cruz adds. “It takes so little time, doesn’t do any harm, and it could be a perfect teaching moment for patients at risk.”

Many professionals agree that noninvasive oral screenings by dentists are a good idea. Silverman says he has no doubt about the benefit.

“If we can detect any cancer at an earlier stage,” Silverman concludes, “then the survival rate is better, the quality of life is better and the prognosis is better.”

Dental screening for oral cancer is critical. The earlier you catch it, the better off you are.