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Every clinician should be proficient in performing an oral, head, and neck examination.

When this technique is performed consistently, the time it takes to perform the exam decreases and thetime it takes to perform the exam decreases and the ability to detect abnormalities increases.

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This presentation will discuss the oral cancerThis presentation will discuss the oral cancer examination and will be divided into the extraoral exam and the intraoral exam.

The extraoral exam involves a complete assessment of the skin, face, and neck including palpation of the extraoral structures.

The intraoral exam involves a complete assessment of the entire mucosal coverage of the mouth and throat, including palpation of these structures.

Most oral cancers are detected under the tongue.

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The exam requires an external light source (preferably not a penlight) allowing both hands to be free.

The use of a mirror gauze and/or tongue blades toThe use of a mirror, gauze, and/or tongue blades to retract the lips, cheeks, and tongue allows complete visualization of these areas.

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The extraoral examination begins with a visual assessment for asymmetry, masses, and discoloration.

Palpation is important to evaluate the subcutaneous structures and to assess any visible abnormalitiesstructures and to assess any visible abnormalities.

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Visual inspection should include all areas of skin of the scalp, face, and neck.

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Any abnormalities that are noted can be marked and documented on a screening form such as shown here.1

This Form is located in the supplemental WordThis Form is located in the supplemental Word documents.

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Any abnormalities that are noted can be marked and documented on a screening form such as shown here.

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During the extraoral examination one should look forDuring the extraoral examination, one should look for any obvious abnormalities or growths on the skin.

The most common form of skin cancer is basal cell carcinoma, although other malignancies including squamous cell carcinoma and melanoma are not infrequent. Basal cell carcinoma classically presents as a slow-growing, pearl-like papule or nodule, which develops central ulceration as it enlarges. Fine telangiectatic blood vessels are often observed on the surface as seen heresurface, as seen here.

This basal cell carcinoma occurred on the forehead, although these tumors can develop on other sun-exposed areas of the face and neck.

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After the visual examination the extraoral tissuesAfter the visual examination, the extraoral tissues should be examined by palpation.

Both hands can be used to assess the parotid glands, cheeks, and facial region.

Lymph nodes in the facial occipital and preauricularLymph nodes in the facial, occipital, and preauricular areas may be abnormally enlarged and should be examined.

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The cervical lymph nodes are divided into levels oneThe cervical lymph nodes are divided into levels one through six.

Level one includes the submental and submandibular area.

Level two through four follows the jugular vein deepLevel two through four follows the jugular vein deep to the sternocleidomastoid muscle.

Level five is behind the sternocleidomastoid and in front of the trapezius muscle.

Level six is in the paratracheal region including theLevel six is in the paratracheal region including the thyroid glands.

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Examination of the neck includes palpation of the level one lymph nodes in the submental and submandibular region.

In addition the submandibular glands should beIn addition, the submandibular glands should be palpated bilaterally. When the glands are compressed, clear saliva may be observed intraorally flowing from Wharton’s ducts in the floor of mouth.

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This swelling below the angle of the mandible could represent a tumor or infection in either the submandibular gland or in a submandibular lymph node.

Such patients should be referred for further evaluation and diagnosis.

In this case, the swelling proved to be a benign tumor in the submandibular gland (pleomorphic adenoma).

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The jugular chain lymph nodes are classified into levels two through four from superior to inferior. These can be palpated deep to the sternocleidomastoid muscle.

The level five lymph nodes lie behind the sternocleidomastoid muscle and in front of the trapezius muscle.

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Relaxation of the sternocleidomastoid muscle will aid in the palpation of the jugular lymph nodes. Turning the head to the side being palpated will allow separation of the muscle from the lymph nodes.

The lymph nodes should be assessed for mobility, tenderness, and size.

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Palpation of the midline structures from the mandible to the sternal notch allows examination of the hyoid bone, thyroid cartilage, cricoid cartilage, trachea, thyroid gland, and paratracheal lymph nodes.

Palpation during swallowing may also assist the examiner in distinguishing masses from normal structures.

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The intraoral examination also requires visualThe intraoral examination also requires visual inspection and palpation for a full assessment of the mouth.

The most common form of oral cancer is squamous cell carcinoma, which arises from the mucosal lining epithelium and accounts for 90% of all intraoral malignancies.

Although these tumors are usually associated with risk factors such as tobacco and alcohol use, oral

i l i i i di id l ith tcarcinomas can also arise in individuals without known risk factors.

Therefore, all patients should receive a complete examination.

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Using a systematic and consistent technique for each patient, the clinician should perform a thorough assessment of all intraoral structures during each exam.

Areas suspicious for malignancy include red, white, or speckled lesions, non-healing ulcers, or tissue masses. Any abnormalities should be noted and considered for biopsy or referral.

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The intraoral examination usually begins with a visual inspection of the tissues external to the teeth. These areas can be examined in a clockwise fashion, beginning at the 12:00 position.

The inner aspect of the upper lip requires that the examiner gently grasp the upper lip between the thumb and index fingers.

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Moving in a systematic clockwise manner, the tissues of the left buccal mucosa can be examined.

Retraction of the cheek will allow better visualization of these areas A good external light source isof these areas. A good external light source is essential to illuminate the intraoral structures.

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Moving to the 6:00 o’clock position, the lower lip is retracted to allow examination of the labial mucosa and gingival tissues.

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The vermilion border of the lower lip is a common site for oral cancer, especially in individuals with great amounts of sun exposure.

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Completing the clockwise cycle, the tissues of the right side of the mouth are examined (8:00 and 10:00 positions).

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During the clockwise examination, the gingival tissues should also be examined.

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Following examination of the tissues external to the teeth, the tissues inner to the teeth should be inspected.

The floor of the mouth can be visualized by having theThe floor of the mouth can be visualized by having the patient lift the tongue. Because the floor of mouth is a common site for oral cancer, careful inspection of this site is important.

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Pre-malignant alterations of the oral mucosa often present as white patches (leukoplakia), red patches (erythroplakia), or speckled (mixed red and white) lesions.

If any suspicious areas are discovered, the patient can be referred for further evaluation and biopsy.

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With the aid of a good external light source, the hard palate can be examined for any mass, ulceration, or other mucosal alterations.

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To visualize the soft palate and oropharynx, depress the tongue with a mouth mirror or tongue blade.

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When the patient says “Ahhhh,” the soft palate will elevate and allow better examination of the oropharynx.

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Oral cancer may begin as a white patch (leukoplakia), red patch (erythroplakia), or as a granular area of ulceration, as seen here.

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Examination of the tongue is an important part of the total oral examination.

By having the patient stick out the tongue, the dorsal aspect can be examinedaspect can be examined.

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The most common site for oral cancer is the lateral/ventral surface of the tongue. Therefore, careful inspection of these areas is critical when performing an oral examination.

Grasping the tongue with a cotton gauze, pull the tongue out to each side. Slight rotation of the tongue will lift it up and permit easier examination of the posterior tongue and floor of mouth.

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This small “speckled” leukoplakia of the lateral tongue is asymptomatic, and it would not have been discovered without a good oral examination.

If the tumor is discovered at this early stage theIf the tumor is discovered at this early stage, the prognosis for the patient would be excellent.

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After the visual examination, the intraoral tissue can be examined via palpation.

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Feel the lips and cheeks for any masses that may be present.

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Palpation of these tissues can be done bi-digitally (using two fingers from the same hand) or bimanually (using fingers from both hands).

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Using bi-manual palpation, the floor of mouth and submandibular glands can be examined for any masses.

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The palatal tissues and tongue can be palpated using a single digit.

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Oral Cancer Screening

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MOUTH CANCER EDUCATION FORM

Date _______________ Location_____________________ Please check all that apply.

SITE NORMAL ABNORMAL (Please circle – See

Legend)

NOT

EVALUATED

COMMENTS

Skin

_________

R W F E T

__________

________________

Nose

_________

R W F E T

__________

________________

Ears

_________

R W F E T

__________

________________

Lips

_________

__________

________________

Upper

_________

R W F E T

__________

________________

Lower

_________

R W F E T

__________

________________

Oral Cavity

_________

__________

________________

Tongue

_________

R W F E T

__________

________________

Floor of Mouth

_________

R W F E T

__________

________________

Other sites

_________

R W F E T

__________

________________

Oropharynx

_________

R W F E T

__________

________________

Salivary Glands

_________

R W F E T

__________

________________

Lymph Nodes

_________

R W F E T

__________

________________

Legend: R = Red, W = White, F = Firm, E = Elevated (raised), T = Tender (painful)

Oral Cancer Screening

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REFERENCES

1. Neville BW, Damm DD, Allen CM, Bouquot JE: Oral and Maxillofacial Pathology, ed. 2, St. Louis, 2002, W. B. Saunders Company.

RELATED REFERENCES Ahluwalia KP, Yellowitz JA, Goodman HS, Horowitz AM. An assessment of oral cancer prevention curricula in US medical schools. J Cancer Educ. 1998;13:90-95. American Cancer Society. Update January 1992: the American Cancer Society guidelines for the cancer-related checkup. CA Cancer J Clin 1992;42:44-5. Anonymous. Perform a death-defying act. The 90-second oral cancer examination. J Am Dent Assoc 2001;132 Suppl:36S-40S. Axéll T. The professional role of the dentist under the aspects of pre-cancer and cancer diagnosis and management. Int J Dent 1993;6:609-611. Centers for Disease Control and Prevention. Preventing and Controlling oral and pharyngeal cancer. Recommendations from a national strategic planning conference. MMWR 1998;47(no. RR-14) Day TA, Davis BK, Gillespie MB, Joe JK, Kibbey M, Martin-Harris B, Neville B, Richardson MS, Rosenzweig S, Sharma AK, Smith MM, Stewart S, Stuart RK. Oral cancer treatment. Curr Treat Options Oncol, 2003. 4(1):27-41. Day TA, Chi A, Neville B, Hebert JR. Prevention of head and neck cancer. Curr Oncol Rep, 2005. 7(2):145-53. Downer MC. Moles DR. Palmer S. Speight PM. A systematic review of test performance in screening for oral cancer and precancer. Oral Oncol. 2004;40(3):264-73. Epstein JB, Scully C. Assessing the patient at risk for oral squamous cell carcinoma. Spec Care Dent 1997;17:1208. Gillison, M.L D.R. Lowy, A causal role for human papillomavirus in head and neck cancer. Lancet, 2004. 363: 1488-9. Guggenheimer J, Verbin RS, Johnson JT, Horkowitz CA, and Myers EN: Factors delaying the diagnosis of oral and oropharyngeal carcinomas. Cancer 1989; 64:932-935.

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Hay JL. Ostroff JS. Cruz GD. LeGeros RZ. Kenigsberg H. Franklin DM. Oral cancer risk perception among participants in an oral cancer screening program. Cancer Epidemiol Biomark Prev. 2002;11(2):155-8. Healthy People 2010 Website: http://www.health.gov/healthypeople Hollows P, McAndrew PG, and Perini MG. Delays in the referral and treatment of oral squamous cell carcinoma. Br Dent J 188(5):262-5, 2000. Horowitz AM, Goodman HS, Yellowitz JA, Nourjah PA. The need for health promotion in oral cancer prevention and early detection. J Public Health Dent. 1996;56:319-330. Horowitz AM, Nourjah P, Gift HC. U.S. Adult knowledge of risk factors and signs of oral cancers: 1990. J Am Dent Assoc 1995;127:39-45. Horowitz AM, Nourjah PA. Factors associated with having oral cancer examinations among US adults 40 years of age or older. J Public Health Dent 1996;56:331-5. Jullien JA, Downer MC, Speight PM, Zakrzewsak JM. Evaluation of health care workers’ accuracy in recognizing oral cancer and pre-cancer. Int Dent J. 1996;46:334-9. MacFarlane GJ. Boyle P. Evstifeeva TV. Robertson C. Scully C. Rising trends of oral cancer mortality among males worldwide: the return of an old public health problem. Cancer Causes & Control 1994;5(3):259-65. Mathew B. Sankaranarayanan R. Wesley R. Nair MK. Evaluation of mouth self-examination in the control of oral cancer. Brit J Cancer. 1995;71(2):397-9. McCunniff MD, Barker GJ, Barker BE, Williams K. Health professionals’ baseline knowledge of oral/pharyngeal cancers. J Cancer Educ. 15(2):79-81, 2000. Melrose RJ, Abrams AM. Experience with a self-instructional oral cancer course in continuing education. J Dent Educ 1976;40:150-3. Mignogna MD, Fedele S. Oral cancer screening: 5 minutes to save a life. Lancet 2005; 365: 1905-6. National Institute of Dental and Craniofacial Research. Perform a death-defying act. The 90-second oral cancer examination. J Am Dent Assoc 2001; 132:36S-40S. Neville BW, Day TA, Oral cancer and precancerous lesions. CA Cancer J Clin, 2002. 52(4): p. 195-215. Oral & Head and Neck Cancer Awareness Week: The Yul Brynner Head and Neck Cancer Foundation, Inc. www.headandneck.org

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Rankin KV, Burzynski NJ, Silverman S, Scheetz JP: Cancer curricula in US Dental Schools. J Cancer Educ 1999;14:8-12. Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, and Edwards BK: SEER Cancer Statistics Review, 1993-1997, National Cancer Institute. Bethesda, MD, 2000. Sankaranarayanan R, Ramadas K, Thomas G, Muwonge R, Thara S, Mathew B, Rajan B. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial. Lancet, 2005. 365: 1927-33. Silverman S Jr. Demographics and occurrence of oral and pharyngeal cancers. The outcomes, the trends, the challenge. J Am Dent Assoc. 2001;132 Suppl:7S-11S. Silverman S Jr. Gorsky M. Lozada F. Oral leukoplakia and malignant transformation. A follow-up study of 257 patients. Cancer. 1984;53(3):563-8. Tomar S, Silverman S Jr, Carpenter W. Oral cancer education: a comparison of self-study and didactic methods. J Cancer Educ. 1998;13:141-4. US Department of Health and Human Services. Health People 2010 (Conference Edition, in Two Volumes) Washington, DC: January 2000. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD. US Department of Health and Human Services. National Institute of Dental and Craniofacial Research. National Institutes of Health, 2000. Walton L, Silverman S, Ramos D, Costa CR. Dental student education in oncology: design and assessment of an undergraduate course. J Cancer Educ 1992;7:221-5. Winn DM, Blot WJ, Shy CM, Pickle LW, Toledo A, and Fraumeni JF: Snuff dipping and oral cancer among women in the southern United States. N Engl J Med 1981; 304:745-749. Winn DM, Ziegler RG, Pickle LW, Gridley G, Blot WJ, and Hoover RN: Diet in the etiology of oral and pharyngeal cancer among women from the southern United States. Cancer Res 1984; 44:1216-22. Yellowitz JA, Goodman HS. Assessing physicians’ and dentists’ oral cancer knowledge, opinions and practices. J Am Dent Assoc 1995;126:53-9. Yellowitz JA, Horowitz AM, Drury TF, Goodman HS. Survey of U.S. dentists’ knowledge and opinions about oral pharyngeal cancer. J Am Dent Assoc 2000;131: 653-61.

1-30-07 EMF

ORAL CANCER SCREENING TRAINING EVALUATION

Training Title: Training date(s): Presenter(s): Sponsoring Agency: A. Please check the appropriate boxes

Excellent/ High

Good Average Fair Poor/ Low

1. How closely did this training meet your learning needs?

2. How useful will the material be to you?

3. Overall, how would you rate the quality of this training?

B. How will you use the information presented in this training? (Check all that apply). I will perform an oral cancer screening on all patients age 40 years and older. I will perform an oral cancer screening on all patients that smoke or chew tobacco. I will NOT perform an oral cancer screening on my patients. C. How likely are you to conduct an oral cancer screening with the routine physical exam?

____Very likely ____likely ___Not Likely D. Do you have any suggestions as how this specific program could be improved? (For

example, content, presenter, A/V materials, handouts, format, length, etc.)

Please give the completed form to the presenter

Thank-you for attending the training and completing this form