Ciro Gilvetti and Andrew Osafo review the signs and symptoms of mouth cancer and explain how to perform a mouth cancer examination.
November was Mouth Cancer Action Month – a campaign that aims to raise awareness of mouth cancer to enable people to become ‘mouthaware’ and save lives through prevention and early detection.
Although Mouth Cancer Action Month has passed, as dental professionals, we should be continually raising awareness of mouth cancer and are in a prime position to educate the public about this devastating condition.
Mouth cancer is a serious and debilitating disease that can devastate – and prematurely end – lives. Therefore our actions can help save lives.
Consequently the aim of this article is to review the signs and symptoms of mouth cancer and discuss how to perform a mouth cancer examination.
Mouth cancer signs and symptoms
The signs and symptoms of mouth cancer include:
Persistent pain in the mouth White or red patches in the mouth A sore or ulcer in the mouth that does not heal within three weeks Lumps and swellings in the mouth, head or neck Difficulty in chewing or moving the tongue or jaw Chronic hoarseness or sore throat that persists more than six weeks Unexplained tooth mobility.
Visual changes of the oral mucosa (Mignogna et al, 2002) precedes almost all mouth cancers. These changes are also often accompanied by a change of the texture of the oral mucosa.
According to the State of Mouth Cancer UK Report 2019/2020, 64% of British adults do not know the major signs and symptoms of mouth cancer.
Early detection and diagnosis dramatically improves survival rates and also makes treatment and rehabilitation easier.
Mouth cancer screening
The Mouth Cancer Foundation recommends dental professionals carry out a mouth cancer screening on every patient over the age of 16 at least once a year.
Dentists therefore require a pair of gloves, good lighting and gauze for a thorough, systematic mouth cancer examination. The screening is also divided into two components: extraoral and intraoral.
During the extraoral exam, the head and neck are visually inspected for any signs of asymmetry, scars or lumps or skin abnormalities (Figures 1-7).
Figures 1-7: Head and neck examination Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7
It is important to look, listen and feel every area examined.
Examine the neck one side at a time or both sides contemporary. Apply gentle pressure with two fingertips to identify any asymmetry or indurated lump.
It is generally started at the level of the submental nodes, moving to the submandibular then upper middle and lower cervical area.
Supra clavicular, posterior cervical and the parotid glands are also inspected and palpated. These areas are also referred as levels I to VI.
Remove all dentures before starting the intraoral examination. Conduct the oral cavity examination with mirrors or the clinicians’ fingers as retractors. Fingers allow the clinician to not only visualise the oral mucosa but also feel if there are any area of induration within the soft tissue or changes of texture of the mucosa.
Pull the lower lip downward and the upper lip upward and manipulate with the thumb and index finger (Figures 8-10).
Figures 8-10: Lip examination Figure 9 Figure 10
Pull the right and left buccal mucosa away one side at a time to allow the inspection of the retromolar area and the upper and lower vestibule (Figures 11 and 12).
Figures 11 and 12: Buccal mucosa, retromolar area and upper and lower vestibule Figure 12
The tongue is thoroughly inspected, as it is the most common area of mouth cancer presentation. The use of a white gauze is extremely helpful as it allows clinicians to stretch the tongue to both sides to inspect lateral borders and ventral area of the tongue (Figures 13-17).
Figures 13-18: Tongue examination – dorsum, lateral borders, ventral, tip of tongue Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 Floor of the mouth
The floor of the mouth is another area of the oral cavity at high risk of cancer presentation. Use the index finger to lift the side of the tongue and explore the muco-lingual fold and floor of the mouth.
Use one or two fingers of each hand for the bimanual palpation of the floor of the mouth, also trying to gently compress between them the floor of the mouth and the neck to look for lumps and fixed lesions.
Gingival tissues are generally inspected visually during the manipulation of the lips and inspection of the buccal mucosa.
Ask the patient to lift the tip of the tongue to allow visual inspection of the ventral area of the tongue and the roof of the mouth (Figure 18).
With a gentle yet firm pressure of one finger to the dorsum of the tongue, also ask the patient to say ‘ahhh’ to expose the posterior wall of the oropharynx and the tonsillar area for inspection (Figure 19).
Figure 19: Oropharynx and the tonsillar area
Ask the patient to lift their chin up to inspect the roof of the mouth (Figure 20). You can also use dental mirrors to inspect areas of the oral cavity that are difficult to examine directly like the lingual and the maxillary tuberosity.
Figure 20: Roof of the mouth Suspicious areas
If any unusual findings are discovered during the examination, a review appointment should be made two weeks after the initial examination.
Record the size, shape, colour, texture and the position of the suspicious areas. It is also a good idea to take clinical photographs of the area of concern.
The oral mucosa generally heals itself in two weeks. Refer the patient for further investigation if the suspicious areas are still present at the review appointment.
Refer highly suspicious lesions (Figure 21) urgently under the two weeks wait referral pathway.
Figure 21: Ulceration of tongue (left side) with raised and rolled borders
A thorough mouth cancer examination can be completed in less than five minutes. The Oral Health Foundation and Mouth Cancer Foundation therefore have produced videos that show a mouth cancer examination taking place. We encourage you to watch these videos, which can also be found on their websites (www.dentalhealth.org and www.mouthcancerfoundation.org).
It is also vital that we inform our patients of the risk factors of mouth cancer, which include tobacco use, heavy alcohol use, excessive sun exposure to lips, human papillomavirus, a history of cancer and a weakened immune system.
A number of organisations recommend self-examination for mouth cancer. The Mouth Cancer Foundation consequently launched Bite Back at Mouth Cancer, providing a head and neck cancer check that can be carried out by anyone, at any time.
Ideally, carry out the self-examination once a month.
The State of Mouth Cancer UK Report 2019/2020 revealed that 74% of British adults have never checked their mouth for signs of cancer. The report also showed that only 16% of adults conduct a check once a month.
Our goal should be to detect mouth cancers before our patients present with symptoms.
Early detection and diagnosis of mouth cancer dramatically improves survival rates and also makes treatment and rehabilitation easier. It is well documented that early detection results in a 90% survival rate, compared to 50% in late detection of mouth cancer.
Systematic and regular screenings therefore saves lives.
Mignogna MD, Fedele S, Lo Russo L, Ruoppo E, Lo Muzio L (2002) Costs and effectiveness in the care of patients with pharyngeal and mouth cancer: analysis of a paradox. Eur J Cancer Prev 11(3): 205-8
Published first in Dentistry magazine. If interested in signing up to receive Dentistry magazine, visit www.fmc.co.uk.
This article is in honour to my father, Mr Osei Osafo who recently passed away and to all those that have lost their lives to this devastating/debilitating disease.
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