Health literacy and the oral cancer exam

By Nancy W. Burkhart, BSDH, EdD,

Health literacy, according to the U.S. Department of Health and Human Services, is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Health literacy is dependent upon:

Communication skills of laypersons and professionals
Lay and professional knowledge of health topics
Culture
Demands of the health-care and public health systems
Demands of the situation/content

It is known that all health-care professions develop a jargon of their own that may not always translate well to disseminating needed medical or dental information. Oral cancer exams are part of the total dental treatment, as well as being a major factor in the total health of the patient. Oral cancer exams are performed at least once a year for patients of record. The failure to diagnose a disease state such as oral cancer may result in legal action by the patient against the dentist and sometimes the dental hygienist.

-------------------------------------------------------

Other articles by Burkhart

-------------------------------------------------------

Many professionals believe that the oral cancer exam should be performed on every patient at each dental visit. Some patients do not receive an oral cancer exam annually, even though the exam should be provided as a standard of care. Because of a lack of health literacy, patients may believe that they are receiving optimal care and this would include an oral cancer exam. However, unless they are told that they have received an oral cancer exam, they may not realize that they have had an exam. Some patients may not even know that they should receive an oral cancer exam as part of the standard treatment (see Figure 1).

I recently interviewed an oral cancer survivor, who had been diagnosed in 2013 with stage lll oral cancer. After listening to the patient's story, I realized that she was actually under treatment for restorative work for some time and her cancer had not been detected. This was amazing because the cancer was in the same location that the restorative work was being performed. She did not believe that she ever received an oral cancer exam by either the dentist or the hygienist.

After hearing her story, I realized that this same scenario is probably not so uncommon since oral cancer is diagnosed at late stages every single day. I know of other cases that sound almost identical to the one described. Additionally, I also thought that both the dentist and hygienist provided services for the patient. So even though the dentist is ultimately liable, the hygienist is also responsible for negligent care when such an event occurs. Hygienists are educated to recognize abnormal tissue, provide oral cancer exams, and to bring this to the attention of both the patient and the dentist. So, there is certainly some question of responsibility of both parties here as well.

Oral cancer worldwide may have many causes depending upon the practices of the population in locations throughout the world. Over 400,000 cancers are expected to occur worldwide (2013). SEER data, 2013 estimates that there will be 41,380 new cases of oral cancers in the United States alone; 7,890 deaths are estimated. Oral cancer represents 1.4% of all cancer deaths. Approximately 90% of oral cancers arise from the oral epithelium and the remaining 10% from a combination of salivary gland tumors, melanomas, sarcomas, and lymphomas or metastatic tumors from other areas of the body.

HPV-related cancers affect the base of the tongue, tonsils and other pharyngeal tissues. These types of cancers are affecting a younger population often with no history of tobacco or alcohol use. Research has shown that HPV-positive related oropharyngeal cancer has a better prognosis than cancers that are HPV-negative.

Diagnosing and treating lesions in an early stage, while still in the epithelium, is extremely important. The quality of life for the patient is greatly improved when cancer is detected at an early stage. In most cases, the patient suffers less disfigurement, will need less surgery, chemotherapy, and radiation as a part of the overall treatment for oral cancer. The quality of life is improved for the patient when there is less destruction of salivary tissue, less loss of speech function, less destruction of soft tissue/tooth structure, and less psychological trauma (see related article).

It is known that oral cancer is more likely to be detected in an early stage in the dental office than those found at a physician's office, which tend to be at a later stage. The early detection in dental offices occurs because of several reasons:

The light is focused with a very intense beam and can assist in identifying subtle changes in the tissue
The supine positioning of the patient allows high visibility
The use of a mouth mirror provides more visibility and concentrated illumination to view the oral tissues and the oropharyngeal tissues
The use of eye magnification allows the practitioner to have an enhanced view of the oral structures.

Adjunct aids, such as the direct optical fluorescence visualization, toluidine blue staining, brush biopsy, liquid-based cytology, and chemiluminescence will also provide further information into a possible etiology of questionable tissues.

Additionally, dental treatment including the oral cancer exam may occur twice a year. When the lesions are detectable to the physician, studies indicate that the cancer will be in a more advanced stage and the patient may actually be seeking treatment for oral/oropharangeal complaints when seeing a physician. An annual physical may not focus on the oral tissues, and the patient may not always schedule a physical yearly — this is especially true for younger individuals.

An additional problem may be the delays that occur before diagnosis or treatment is initiated. Yu et al. (2008) found that there is sometimes a delay in the length of time between when a patient's initial consultation with a health-care provider occurs and the ultimate diagnosis of oral cancer. This is termed "professional delay." The delay may be caused by multiple factors such as inexperience or deficient clinical skills, a low threshold of signs or symptoms on initial examination of the patient, or possibly delays because the clinician takes a "wait and see" approach.

"Patient delay" occurs when a patient fails to seek treatment and may also decide to postpone any suggested treatment. A third element may occur when the patient is delayed for reasons such as not being able to get an appointment or postponing scheduled appointments. All of these factors may cause time delays that would otherwise lead to an early diagnosis and early treatment. Yu found that a delay of as much as six months might occur. Cancer progresses rapidly in the oral tissues due to the blood supply in the area.

A study conducted in Finland by Olli-Pekka Alho et al. (2006) suggested that a crucial point in primary care was a failure to follow up with patients when the physician did not refer the patient for further evaluations and used a "wait and watch" strategy. The researchers further stated that tongue and glottic carcinomas tended to cause symptoms early, whereas pharyngeal and supraglottic tumors presented at an advanced stage. The decision not to refer or follow up was associated with a poor survival rate. As stated by van der Wal et al. (2011), a delay of six months sometimes occurs due to scheduling, work-up delay, and treatment planning. The encountered delay is because of both professional and patient factors.

Sarode et al. (2012) support an effort to teach patients self-examination. They state that no one knows your own body better than you. Learning to do a self-assessment may be a further step in early detection of oral cancer. This is especially crucial for former cancer patients and for those at higher risk for oral cancer.

The objectives of the clinical evaluation are not only crucial for detecting oral cancer but generally to determine the overall health and well-being of the patient. It is known that many disease states may be detected at an early stage in the oral tissue (see related article).

Educating the patient about dental practices and their patient rights may enhance health literacy in dentistry. Offices should inform the patient that the dental professionals will perform an oral cancer exam on each patient. The practice will also provide educational material on ways that the patient may contribute to the early detection of oral cancer and also teach preventive therapies. This process provides patient control and also ownership within their own health outcomes. Oral exams also provide valuable information about the total health of the patient. Perhaps a printed guide for the patient should be a standard part of the initial welcome package for new patients.

A continuing education course in "Promoting the Patient Oral Self-Assessment" is an excellent resource for the dental professional and can be found at dentalcare.com/en-US/dental-education/continuing-education/continuingeducation-landing.aspx. The course is #347.

The dental team can be instrumental in detecting oral disease and effective in assisting the patient in maintaining overall good health. Educating patients is the first step in early oral cancer detection.

Keep asking good questions and always listen to your patients.

Objectives for the Clinical Evaluation

Screen for oral cancer
Determine whether the patient is well enough to continue dental treatment
Enable early diagnosis of pathology
Determine possible treatment modifications
Prepare and record baseline patient assessment information
Review and update baseline assessment information
Determine whether additional diagnostic procedures are necessary

Reference: Delong L, Burkhart NW. General and oral pathology for the dental hygienist. 2013, Lippincott, Williams and Wilkins Baltimore, 6-7.

A Patient's Guide to Oral Cancer Exams

Learn to do a patient self-exam. Your dental professional can teach you the normal structures in your mouth as he/she performs your oral cancer exam and speak to any new changes that may present a concern in the future.
Ask your dental hygienist and dentist if you have been given an oral cancer exam, and also ask them to tell you what they observed. Some offices perform an oral cancer exam with each office visit. The exam is a standard of care once a year, but may be performed more often. More frequent exams are especially relevant with higher-risk patients such as those using alcohol, tobacco products, or those with a history of human papillomavirus (HPV) or previous oral cancer. An exam is warranted anytime that the patient notices a change in the oral tissues.
Ask your dental provider if you may send in a text or image via email, and will it be evaluated. You may be out of town or unable to make an office visit right away. Taking images with your cell phone usually will produce an acceptable image when an area of concern is in the anterior location of the mouth and tongue. You will be asked to appear in the office when you are able to make an appointment.
Your dentist and hygienist should use a technique during your exam that evaluates your lymph nodes in the neck region and under your chin by applying light pressure as you look to your right and left. This technique assists in evaluating any swollen lymph nodes that may indicate a disease state. Swollen nodes may be the first indication of a serious oral disease.
The oral cancer exam also includes the posterior mouth region where the tonsils are located. Some cancers are found in this region. The light sources provide illumination and allow the practitioner to assess the tissues in this region. Swelling may indicate that further evaluation may need to occur.
Ask whether the dental provider has evaluated your radiographs and any prior digital images. Ask if there was any abnormality that should be reevaluated. The written notes should indicate any areas of concern that need to be followed during future visits. This may include any cysts or tumors that have been removed in the past.
As a patient, you should be concerned if any of the following signs or symptoms appear and you should check with your health-care provider:

✓ A sore in the mouth or on the lip that does not heal (this is the most common symptom)
✓ Red or white patch on any oral tissues, tongue, tonsil, or lining of the mouth
✓ Irritation, lump, or thick patch in the mouth, neck, or throat
✓ Persistent sore throat, or a feeling that something is caught in the throat
✓ Hoarseness or change in the voice
✓ Numbness in the tongue or mouth
✓ Pain or bleeding in the mouth that does not resolve
✓ Difficulty chewing, swallowing, or moving the jaws or tongue
✓ Ear and/or jaw pain
✓ Chronic bad breath
✓ Changes in speech
✓ Loosening of teeth or toothache
✓ Dentures that no longer fit
✓ Unexplained weight loss
✓ Fatigue
✓ Fever of unknown origin, especially when prolonged
✓ Loss of appetite

NANCY W. BURKHART, BSDH, EdD, is an adjunct associate professor in the department of periodontics, Baylor College of Dentistry and the Texas A & M Health Science Center, Dallas. Dr. Burkhart is founder and cohost of the International Oral Lichen Planus Support Group (http://bcdwp.web.tamhsc.edu/iolpdallas/) and coauthor of General and Oral Pathology for the Dental Hygienist. She was a 2006 Crest/ADHA award winner. She is a 2012 Mentor of Distinction through Philips Oral Healthcare and PennWell Corp. Her website for seminars on mucosal diseases, oral cancer, and oral pathology topics is www.nancywburkhart.com.

References

1. Alho OP, Teppo H, Mantyselka P, Kantola S. Head and neck cancer in primary care: presenting symptoms and the effect of delayed diagnosis of cancer cases. CMAJ 2006; 174(6):779-84.
2. American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2012. Atlanta: American Cancer Society; 2012. American Dental Association
3. http://www.mouthhealthy.org/en/az-topics/o/oral-cancer
4. Delong L, Burkhart NW. General and oral pathology for the dental hygienist. Second edition. Lippincott Williams & Wilkins, Baltimore. 2013.
5. Holmes JD, Dierks EJ, Homer LD, Potter BE. Is detection of oral and oropharyngeal squamous cancer by a dental health care provider associated with a lower stage at diagnosis? J Oral Maxillofac Surg. 2003; 61:(3): 285-291.
6. Rethman MP, Carpenter W, Cohen EE, Epstein J, et al. American Dental Association Council on Scientific Affairs Expert Panel on Screening for Oral Squamous Cell Carcinomas. Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. J Am Dent Assoc. 2010 May; 141(5): 509-20.
7. Sarode SC, Sarode GS, Karmarkar S. Early detection of oral cancer: the detector lies within. Oral Oncology 2012;48: 193-194.
8. Van der Wal I, de Bree R, Brakenhoff R, Coebergh JW. Early diagnosis of oral cancer: is it possible? Med Oral Pathol Oral Cir bucal. 2011 May 1;16 (3):e300-5.
9. Watson JM, Logan HL, Tomar SL, Sandow P. Factors associated with early-stage diagnosis of oral and pharyngeal cancer. Community Dent Oral Epidemiol. 2009 Aug;37(4):333-41.
10. Yu T, Wood RE, Tenenbaum HC. Delays in diagnosis of head and neck cancers. J Can Dent Assoc. 2008 Feb;74(1):61.

Resources

Health Literacy
www.health.gov/communication/literacy/quickguide/Quickguide.pdf
Oral Cancer Foundation
oralcancerfoundation.org/
The ADA Practical Guide to Soft Tissue Oral Disease