Philip Lewis outlines the vital knowledge needed for early mouth cancer detection.

We are privileged to be members of a regulated profession. The efforts we have made to obtain professional qualifications allow us to carry out an array of marvellous things others are not permitted to do. As a result, we have gained the confidence of the public who trust us to look after them.

Dental teams are instrumental in maintaining oral health. We have the ability to relieve pain and prevent emergencies. We can help people in their control of other medical conditions like diabetes and heart disease and we can improve their smiles, leading to enhanced self-confidence and self- esteem. We can do much more than that. We can save people’s lives.

The incidence of mouth cancer has increased by over a third during the last ten years. The most recent figures report 8,846 new cases in 2022. 3,034 people lost their lives because of the disease. Survival rates are generally dependent on how early the cancer is discovered. The earlier the diagnosis the better the outcome.

The diagnosis of mouth cancer is made by specialists working in secondary care, usually from the results of a biopsy. Those of us working in primary care can assist in this process by gathering information gained by observation and examination.

What is mouth cancer?

The term describes a range of conditions. Cancer can arise from a variety of tissues but the type we will most commonly see is squamous cell carcinoma (SCC) which accounts for more than 80 per cent of tumours within the mouth.

Squamous cell carcinoma on the side of the tongue.

What are we looking for?

Essentially we’re looking for anything unusual which can’t easily be explained. This may include:

• Red or white patches on the mucosa.
• Ulcers that don’t heal within three weeks.
• Lumps on the tissues or under the skin.
• Bleeding or tooth mobility in the apparent absence of periodontal disease.
• Unexplained weight loss.
• Changes to the voice.
• Numbness or altered sensation.
• A feeling of something stuck in the throat.
• Suspicious skin blemishes.

During an early detection examination, we’re not only looking inside the mouth but also looking at the lips, the skin of the face neck and scalp when possible. We should feel for lumps and note changes in symmetry. We should also listen for changes in the voice and note comments patients make about their general health or health concerns that they may have. This really is a team effort where both clinical and non-clinical team members have an important role to play.

Abnormalities on the skin of the face, neck and scalp should also be closely examined. Sometimes patients will attempt to conceal unsightly blemishes with make-up. If this is suspected, pass the patient a wipe so that a more thorough examination can be carried out.

How is the examination carried out?

Input from both clinical and non-clinical team members is vital to establish an efficient early detection protocol. Again, the whole team is involved with this. Everyone has a role to play. The practice receptionist can explain the details and importance of the examination to patients, increase their awareness of the condition and give simple counselling so they will not be alarmed if, for example, they are subsequently referred for a second opinion.

Every team member can use their eyes and report anything unusual to colleagues. This might include lumps, spots, skin abnormalities or swellings. The more eyes the better! It’s very easy for a single individual to miss something another may well notice. The clinician needs to carry out a thorough examination, first taking a careful medical history to identify pre-existing conditions that may cause changes in the mouth, or medicines that might cause oral abnormalities or ulceration. A social history looking at things like smoking and drinking habits may alert the clinician to suspect the patient could fall into a high-risk group.

Factors that increase risk include:

• Gender. Men are more than twice as likely than women to develop the disease.
• Age. Most cases occur in people over the age of 50, however, recent years have seen an increasing incidence among the young.
• The use of tobacco. Tobacco in all its forms is still the major identifiable risk factor. There is no ‘safe’ tobacco. Smokeless tobacco, snuff, chewing tobacco and water pipes are equally dangerous. The incidence of mouth cancer is especially high in countries where betel quid chewing is popular. In parts of India and Asia mouth cancer accounts for more than 40 per cent of all cancers and this high incidence is attributed to the widespread use of Paan.
• Regular alcohol, especially spirits. Alcohol is a carcinogen in its own right. It also makes mucous membranes more permeable allowing toxins of high molecular weight to breach the mucosa. The use of alcohol and tobacco together increases the risk of developing mouth cancer about 40 fold for this reason.
• Sexual behaviour. Infection with some strains of the human papillomavirus (HPV) greatly increases risk. It is believed that within 10 years HPV will be the major risk factor for mouth cancer, overtaking the use of tobacco. HPV probably accounts for most of the recent increase in case among women and younger individuals.
• Social deprivation. Lack of essential vitamins, minerals and antioxidants associated with a poor diet is believed to increase risk.
• Additional factors. These include diabetes, obesity, sun exposure, diseases which suppress the immune system, air pollution, radiation exposure, exposure to carcinogenic chemicals, changes in hormone levels, some inherited genetic conditions and some viral and bacterial infections.

Palpation of the lymph chains of the face and neck

Palpation should be explained to the patient before the procedure is carried out as some patients may never have had this sort of examination in a general dental practice.

Use the pads of the fingers to palpate. ‘Walk’ the fingers gently but firmly along the chains of lymph nodes checking for enlargement and texture. The most common reason for enlargement is infection. Such nodes will be warm and tender to the touch. Nodes enlarged due to cancer tend to be cool, non-tender and ‘fixed’ to the underlying tissues. Carefully checking the skin of the face, the appearance and texture of the lips and all the internal surfaces of the mouth including the tissues under the tongue and in the visible areas of the throat. Palpation of the tongue and floor of the mouth adds further valuable information. Grasping the tip of the tongue with a piece of gauze makes its manipulation much easier. The floor of the mouth and sides of the tongue are high-risk areas for mouth cancer and need careful scrutiny. Any unusual findings are carefully recorded in the patient’s notes and clinical photographs are taken whenever possible. With practice a full intra-oral and extra-oral examination can be completed in two minutes or less.

Check the appearance and texture of the lips. Be aware that dermal fillers can initially make the lips feel lumpy. Ask if this procedure has recently been carried out.

What next?

If it is suspected that an abnormality has an innocent cause review the patient two to three weeks later to confirm healing. Remember to ask how long the abnormality has already been present. All innocent ulcers should heal within three weeks so if the patient tells you it has already been present for longer than that it should arouse your serious concern.

If in doubt refer immediately using your local rapid referral pathway.

Regular examinations in dental practices are important but as we all know access to treatment is generally becoming more difficult. In addition, mouth cancer can develop quickly. For these reasons, the Mouth Cancer Foundation recommends frequent self-examination at home. Full details are available on the website: www.mouthcancerfoundation.org/self-examination

A self check leaflet for patients.

It is easy to miss a timely diagnosis. For example, colleagues were alerted to this abnormality which resembled a cold sore by a dental nurse who had noticed it at a previous hygiene visit more than a month before.

It turned out to be an invasive basal cell carcinoma which required a wide incision to remove. Had it been missed again subsequent treatment would have been even more invasive.

There may not be many opportunities to save lives in general dental practice but early detection of mouth cancer certainly counts as one.

To summarise:

• Look. Every team member can use their eyes and report suspicions to others.
• Inspect. Observe the face and neck carefully for swellings, blemishes and suspected abnormalities.
• Feel. Palpate lymph chains and other tissues.
• Examine. Scrutinise all the surfaces of the mouth and throat and record any unusual findings.

Yes, the first letters spell LIFE. Both life itself and the quality of life for the patient and those around them. That’s exactly the gift you could offer in just a couple of minutes. They may well be the most important two minutes of your day!

Author: Philip Lewis.