By Janet A. Yellowitz, DMD, MPH
Abstract: Although cancer is not a part of the aging process, malignant neoplasms occur primarily in older adults. As the size of the elderly population increases, there will be many more older adults at risk for oral cancer. Many older adults do not seek dental care because they do not think they need it; and, therefore, they do not receive routine oral examinations. Dental practitioners need to encourage older patients to seek dental care so they can receive oral cancer examinations.
Each year, close to 30,000 new cases of oral cancer are detected in the United States.1 As a result of this disease, nearly 9,000 deaths occur, one every hour. Most oral cancers (90 percent) are squamous cell carcinomas, begin as surface lesions, and have a highly variable presentation during their early stages. There is hardly an oral lesion that at one stage or another does not assume the same overt appearance as oral squamous cell carcinoma _ hence the concept of oral cancer as "the great mimicker."2 Detecting an oral lesion is primarily dependent upon the clinician having a high level of suspicion and providing a comprehensive oral cancer examination. For the purpose of this article, oral cancer will refer to oral squamous cell carcinoma.
Although cancer is not a part of the aging process, malignant neoplasms occur primarily in older adults. Fiftyfive percent of all cancers and 67 percent of cancer deaths occur in people age 65 and older.3
Older adults not only have a greater risk of developing cancer but are more frequently diagnosed with cancer in an advanced stage. Likewise, most oral cancers are diagnosed in a late stage, after having metastasized to the lymph nodes.
Similarly to other cancers, oral cancer is found disproportionately more often in older adults than in any other age segment. The average age at which oral cancer is diagnosed is 63, with the majority of those lesions found in those 40 years and older. The National Cancer Institutes' Surveillance, Epidemiology and End Results program found that close to half of all oral cancer cases were found in the 65andolder age group.
In another study of close to 1,000 oral cancer cases, 42 percent were in people 65 and older; 60 percent of those cases were in people age 65 to 74 and 40 percent in those 75 and older.5 For the total population, the incidence of oral cancer averages about 11 cases per 100,000, peaking at 49 cases per 100,000 people age 70 to 74. .6 The incidence rate is 30 percent higher for blacks than for whites, peaking at ages 55 to 64. Assuming these rates remain stable, as the size of the elderly population increases, there will be many more older adults at risk for oral cancer.
Today, the average life expectancy is at an alltime high. On average, females born today will live 79 years and males 73 years. Those age 65 today can anticipate an additional 17.6 years of life (19 for females arid 15.8 for males). Between the years 2010 arid 2030, when the babyboom generation reaches 65, the older population will dramatically expand. By 2030, there will be about 70 million older people, more than twice the number in 1997.
Currently, about onethird of oral cancers are diagnosed in an early, localized stage. The fiveyear survival rate for those with regional involvement is 42 percent and, for those with distant rnetastasis, 17 percent .4 Despite advances in therapy, little improvement in survival rates for oral cancer has been seen during the past several decades.
Table 1: Population at High Risk for Oral Cancer
60+ years of age
History of tobacco use
History of alcohol use
Low level of education
Occupation of lower socioeconomic category
Retired or not covered by dental insurance
Edentulous or having many nonreplaced missing teeth
Does not use preventive health measures
Risk Factors
The primary risk factors for oral cancer are tobacco use, alcohol use (current and previous), and sunlight exposure (lip cancers). Tobacco and alcohol use have been implicated in close to 75 percent of all oral cancers in the United States. Together, smoking and alcohol have a multiplicative effect on the development of oral lesions.7 The time-dose relationship of carcinogens found in tobacco and tobacco smoke is an important factor in causing oral cancer. Cigar and pipe smoking are likely to provide a greater risk than cigarette smoking, and smokeless tobaccos have been implicated in the development of cancer of the gingival and buccal mucosa. In addition, individuals having a prior oral cancer are at highest risk for developing a second lesion.
There is also growing evidence identifying the human papilloma virus and Candida albicans in the development of oral carcinoma. Although denture irritation was once thought to be a cause, it is not a risk factor for oral cancer. From a positive perspective, diets with adequate amounts of iron and vitamins A, C, and E appear to have a protective role.8,9
Although the majority of squamous cell carcinomas are associated with tobacco and/or alcohol use, not all patients with an oral cancer fit this pattern. In a recent fiveyear review of oral cancer patients treated in a metropolitan hospital, 20 percent reported no history of tobacco use, and 21 percent reported no history of alcohol use.10
One's risk of being diagnosed with an advanced oral cancer increases as one's utilization of dental services decreases. Oral cancer is often found in those least likely to seek routine oral care (Table 1).
Although most dental practices have policies to recall patients routinely, these policies apply primarily to dentate patients. In general, edentulous patients do not receive routine or preventive dental care. Often, patients wearing a complete set of dentures for many years have not seen a dentist since the dentures were delivered. Many older adults do not seek dental care because they do not think they need it. Hence, many edentulous elders do not receive routine oral examinations.
Early Lesions
Early oral cancers have numerous and variable clinical appearances. Early lesions can appear as subtle, asymptomatic red, redandwhite speckled, or white areas with subtle textural changes. Early lesions can appear as an area of induration or ulceration; can appear as a result of physical, chemical, or thermal trauma; or may resemble lichen planus.
Although oral cancer can occur anywhere in the mouth, most often it is found in cancerprone sites _ the ventral and lateral borders of the tongue, anterior floor of the mouth, and soft palate complex.
Oral Mucosa of Older Adults
The oral mucosa of older adults is often described as atrophic, thin, pale, and friable, with a decrease in capillary blood flow. Although many of these characteristics are found in an older population, these changes are not universal.
Agerelated changes of the oral mucosa have not been welldocumented or have little scientific data to support their claims. Many of the changes associated with aging were a likely result of systemic disease, poor nutrition, or medications. Aging of the oral mucosa is perhaps best described as a "postmaturational deteriorative change that, with time, leads to all increased vulnerability to challenges."11
The rate of biological aging differs both within an individual and among individuals, presenting great variability in one's tissues, including the oral mucosa. In general, muscle mass is less dense and varicosities are more frequently found in older adults. Differentiating a soft tissue change as being a result of the environment or due to intrinsic aging is often not possible. Without clear criteria, distinguishing between agerelated changes and potentially malignant changes is more difficult in older adults than in younger ones and requires the clinician to have a higher degree of suspiciousness when completing an oral cancer examination.
Practitioner Challenges
Two conditions increase the difficulty of diagnosing early lesions, the stage at which the patient has the best prognosis. First, the tissue changes common to early lesions are subtle; and, second, patients with early lesions rarely present with symptoms. Once the patient becomes symptomatic, most lesions are easily diagnosed.
Delay in Diagnosis
Oral cancer has been referred to as the "forgotten disease"12 and has frequently been a low priority of both health care providers and the public.13 Delays in diagnosis have been attributed to the attitudes of both clinicians and patients. Many health care professionals underestimate the utility of screening exams for older adults and underestimate their life expectancies. Likewise, older adults tend to be unaware of the risk of oral cancer and their need to have routine oral examinations.
For example, more than onethird of oral cancer patients in a recent study reported not seeking professional advice for more than three months after becoming aware of a lesion.14 Similarly, Prout found that oral cancer patients averaged 11 visits with medical care providers during the two years prior to their diagnosis.15 These findings suggest that:
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Patients delay seeking care after being aware of an oral change. |
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Patients do not obtain routine oral cancer examinations. |
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Patients seek the care of physicians, not dental professionals, for assessment of soft tissue changes. |
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Dentists are bestsuited to identify oral changes. |
Yet, dentists often do not detect oral lesions in their early stages due to their opinions, practices, and lack of knowledge related to oral cancer.16-18 In a recent national survey of general dentists, the vast majority reported their knowledge of oral cancer to be current, yet onethird of the dentists do not perform an oral cancer examination during a patient's initial visit, and 41 percent do not provide this examination to patients during their recall visits.19 In addition, twothirds of the dentists reported not palpating their patients' lymph nodes, which is one of the key components of an oral cancer examination. Patients treated in dental practices that do not provide comprehensive oral examinations are at an increased risk of not having an oral lesion diagnosed while it is in an early stage.
Comprehensive oral examinations are not routinely provided to all patients. Without definitive criteria to identify those most likely to have an oral carcinoma, annual oral cancer examinations are recommended for all patients. To help ensure that the components of an oral cancer examination are included in one's exarnination protocol, the oral cancer examination should be delineated as a separate service. Having the oral cancer examination itemized separately may encourage practitioners to provide it.
Starting extraorally:
1. Examine the face, head, and neck (include eyes, lips, and ears).
2. Palpate the pre and postauricular lymph nodes.
3. Palpate the occipital lymph nodes (at base of skull).
4. Palpate the superficial cervical lymph nodes (along sternocleidomastoid muscle).
5. Palpate the deep cervical lymph nodes (deep to the sternocleidomastoid muscle).
6. Palpate the supraclavicular lymph nodes.*
7. Palpate the thyroid gland.*
8. Evaluate the function of the temporomandibular joint.
Intraorally:
9. Palpate the lips.
10. Palpate the labial and alveolar mucosa and gingiva.
11. Examine the buccal mucosa.
12. Palpate and milk the parotid gland.
13. Examine the hard and soft palate and alveolar ridges.
14. Examine the oropharynx.
15. Palpate the submental and submandibular glands.
16. Palpate the tongue ** and floor of the mouth.
* Palpation of the supraclavicular lymph nodes and thyroid gland can help to the extent of invasiveness of lesions, however the connection to the oral cavity is less direct than with other nodes and glands.
**To examine the posterior part of the tongue, grasp extended tongue with gauze, distract the tongue to each side to view the opposite, exposed areas. To optimally view the floor of the mouth, gently dry tissues and apply light external pressure.
The Oral Cancer Examination
A comprehensive oral cancer examination includes the following:
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A review of the patient's medical and dental history. Wellprepared medical and dental histories provide information pertinent to the etiology of oral changes and aid in the identification of conditions that may increase the risk of disease.20 |
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Visual assessment of the head, neck and oral cavity. Visualization of the mucosal surfaces with good illumination is vital in detecting early changes, which usually have little mass and minimal depth..4 Slight drying of mucosal surfaces aids in the recognition of changes. |
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Manual palpation of regional cervical lymph nodes.21 Palpation is particularly significant when a primary lesion is not readily visible. Palpation can occur bimanually or bilaterally. The presence of a metastatic lymph node in the neck can draw attention to a potential primary site.22 |
The condition of a patient's cervical lymph nodes provides one of the most important prognostic factors in a patient with oral cancer.21 Palpable nodes are the primary sign of current or past lymph node disease and may indicate the presence of an infectious, immune, or neoplastic disease. Normal lymph nodes are not palpable on routine examination; however, small, mobile, discrete, nontender nodes are frequently found in healthy people.23 In general, tender, soft, enlarged, and freely movable nodes suggest acute infection. When unexplained, enlarged or tender nodes call for a reexamination and assessment. Hard, nontender and fixed nodes suggest a chronic infection or malignancy.
Sequence of Examination
To ensure that no area is overlooked, the clinician needs to establish a systematic routine for the oral examination. The order of the examination is a matter of individual choice to best suit one's work style. Utilizing an orderly, stepbystep protocol helps to increase efficiency and conserve time.
Table 2 identifies the components of an oral cancer examination and a recommended sequence.
Following a review of the patient's medical and dental history, ask the patient if he or she is experiencing discomfort in any areas of the mouth or neck. To reduce patient anxiety and concern about the examination and to inform the patient of the activity, explain the steps and reasons for the examination. At a minimum, patients need to be made aware of the need to bring to their dentists' attention any "lumps" and "bumps" or painful areas in their mouth, especially any change present for two weeks or longer.
Identification and Initial Management of Findings
Changes in tissue color, symmetry, texture, size, and contour need to be viewed with a higher degree of suspicion and thoroughly evaluated to rule out malignancy. Any change detected must be described in detail, providing exact location, size, color, texture, and other significant characteristics. When possible, photographic documentation is useful for followup comparisons.
When a lesion is detected, probable sources of irritation should be removed; and, when present, the use of alcohol or tobacco should be curtailed. Reevaluation of the area is needed 10 days to two weeks following the initial assessment. Traumatic lesions and areas of chronic irritation usually resolve or markedly improve within that period. Any nonhealing mucosal lesion present for 14 days should be considered suspicious for oral cancer.
When a lesion persists longer than 14 days, a diagnostic workup is required. This workup includes, but is not limited to, the use of diagnostic aids such as toluidine blue staining, cytology brushes, biopsy, and/or referral to an oral surgeon or oncology specialist. In addition, the patient needs to be made aware of the practitioner's concern and the need for immediate care.
Summary
An oral cancer examination needs to be a part of the routine (at a minimum annually) oral evaluation of all patients. As "physicians of the mouth" dentists are trained to detect changes in the oral cavity, including an asymptomatic early carcinoma. The recognition of early oral lesions requires that clinicians maintain a high index of suspiciousness of all soft tissue changes.
Providing a thorough physical examination of the head, neck, and oral cavity is essential for all dentists and any clinician involved in detecting, diagnosing, and treating oral disease. The examination assesses for manifestations of disease and presence or absence of palpable lymph nodes, and provides information critical for the development of appropriate differential diagnoses. Oral cancer must be included in the differential diagnosis for illdefined, variableappearing lesions found in older adults. With prompt action, a clinician can save lives and reduce the morbidity associated with oral cancer.
Currently, the most effective way to manage oral cancer is through early diagnosis followed by adequate treatment. If dental professionals increase their efforts to identify early lesions and increase patient awareness so that they reduce their risk behaviors, the morbidity of oral cancer will decline. However, it will take many years before real reductions in the number of cancer cases begin to occur. As more people move into the age groups of high risk for oral cancer, it is likely that the occurrence of oral cancer will increase. Thus, for older Americans, oral cancer remains a serious concern requiring constant professional attention.
Author
Janet A. Yellowitz, DMD, MPH, is an associate professor and the director of geriatric dentistry at the University of Maryland Baltimore College of Dental Surgery.
Reprinted with permission.
CDA Journal. Vol. 27, No. 9, Sept. 1999.
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