Introduction

Squamous cell carcinoma of the oral cavity and pharynx accounts for over 48,250 cases per year in the United States with approximately 9,575 deaths per year(1,2). Unfortunately, the diagnosis continues to rely on patient presentation and physical examination with biopsy confirmation. This may result in delay in diagnosis accounting for the fact that the majority of these cancers are diagnosed at a late stage (1, 3-5). Studies confirm that survival does correlate with stage, making early diagnosis and treatment optimal for this disease (1). Despite advances in surgical techniques, radiation therapy technology, and the addition of combined chemotherapy and radiation therapy to the treatment regimen, survival data has not shown appreciable change in decades (1,6,7). Five-year survival data reveal overall disease specific survival rates of less than 60% although those that do survive often endure major functional, cosmetic, and psychological burden due to dysfunction of the ability to speak, swallow, breathe, and chew. Seventy-five percent of all head and neck cancers begin in the oral cavity. According to the National Cancer Institute’s Surveillance, Epidemiology, and Ends Results (SEER) program, 30 percent of oral cancers originate in the tongue, 17 percent in the lip, and 14 percent in the floor of the mouth (11). Many other studies support this finding that oral cancers appear most often on the tongue, and floor of the mouth (12,13).  New data related to the HPV16 virus may indicate that these trends are changing with the poster mouth including the tonsils, tonsillar pillar and crypt, the base of the tongue, and the oropharynx increasing rapidly in incidence rates. A thorough, systematic examination of the mouth and neck need only take a few minutes and can detect these cancers at an early and curable, stage. Our goal is to discover oral, head and neck cancers early, before patients present complaining of pain, a mass, bleeding, otalgia, or dysphagia. Errors in diagnosis are most often ones of omission, and therefore the importance of a systematic approach to the oral, head and neck cancer examination cannot be overstated.

History

Although this report is based on examination technique, it is critical to remember that any person with a history of tobacco and alcohol use or prior head and neck malignancy has a significant risk of developing an oral, head and neck cancer. In fact historically 75 percent of these cancers are related to alcohol and tobacco use (10). These individuals may deserve more frequent examinations as described to follow. Bear in mind that 1 out of 4 oral, head and neck cancers particularly in patients over the age of 50 are detected in patients who do not smoke or drink alcohol; obviously all patients, regardless of their history, need to be screened at least once a year by their physician or dentist. Current research indicates that HPV positive disease is rapidly changing these ratios and age groups. Younger, non smoking patients under the age of 50 are the fastest growing segment of the oral cancer population. Unfortunately, this increase in the number or oral, head and neck cancers found in men and women in their 20’s and 30’s is rapidly replacing those caused by tobacco since the use of tobacco products has declined in the US every year for more than a decade. During this same period of time the incidence rate of OSCC has actually increased. This HPV 16-18 presence, makes determination of at risk populations much more difficult, and opportunistic screening of ALL patients must become the norm if the death rate is to be reduced. As in many cancers, the symptoms and history will often lead the dentist/physician to not only the presence of a cancer but also the likely site of the lesion. Tobacco/alcohol lesions tend to favor the anterior tongue and mouth, and HPV positive lesions tend to favor the posterior oral cavity.

Application

This examination protocol has been developed for use by both dental and medical professionals. The different environments of practice will dictate obvious differences in the equipment and manner in which the examination is conducted. However all aspects of this thorough examination are applicable to both types of practitioners to ensure that a complete assessment of the patient has been accomplished.

Instruments Used For Oral, Head and Neck Cancer Examination

Clinicians need certain instruments and supplies in order to conduct a thorough and time efficient examination. Suggested tools for the oral, head and neck cancer exam include: an adequate light source, mirrors (laryngeal and nasopharyngeal), gloves, tongue blades, 2×2 gauze pads, anesthetic nasal spray, flexible nasopharyngolaryngoscope, otoscope, and nasal speculum.

General Examination

A thorough oral, head and neck cancer examination can easily be completed in less than 5 minutes. It primarily consists of inspection and palpation. Once good rapport has been established with the patient, the clinician is ready to begin the exam. It is important to explain to the patient exactly what you are doing before doing it. Not only will this help put the patient at ease, but it also gives you the opportunity to educate your patient about the signs and symptoms of oral, head and neck cancer and how to detect it at an early stage. It is important for clinicians to understand the complex systemic effects of malignancy on the body. Commonly changes noticed in a person’s face and body pertaining to weight loss, anorexia and/or fatigue, may be the first sign of a malignancy. The initial physical evaluation of a patient actually begins as soon as you meet the patient. While taking the patient’s history it is helpful to note any facial asymmetry, masses, skin lesions, facial paralysis, swelling or temporal wasting. Inspection of the lips, both moving and at rest, can also be performed while first meeting the patient. Again, look for any asymmetry or gross lesions on the lips. Listening in an important part of this examination. The sound of one’s voice and speech are important in considerat