Oral Cancer Screening Exam

Oral Cancer Screening Exam


In the following video you’ll learn the
basics of an oral cancer screening examination. The purpose of this exam is
to detect cancer early or better yet before it happens. If you
can catch cancer early the patient has a much greater chance of
a cure and of living a normal life. Every patient at any age can develop oral
cancer but the highest risk patient is generally older and male. Ask whether the
patient is a smoker or ex-smoker. Other risk factors include alcohol, meal nut
products, poor diet and previous head and neck cancer. Human papilloma virus may also be
a risk especially for tonsil cancer. Ask the patient about unusual changes in
their mouth and listen for changes in their voice. Start by examining the head,
neck and face for changes in color, contour, consistency, and function. First
look then palpate. Explain what you’re doing and why. You may see irregular
pigmentation and premature wrinkling, this can signal sun damage and the risk
of skin cancers. You can use the American Cancer Society’s ABCDE rule to assess
for melanoma risk in pigmented lesions. Look for asymmetry, border irregularity,
color variation, diameter larger than six millimeters, and evolution over time.
Inspect and palpate the ears including the pinna, lobe, oracle, invisible portions
of the external auditory canal. The sclera of the eye should be white – yellow
may indicate jaundice and liver disease, hematomas might indicate a blood
disorder. The eyes should be able to follow your finger. There should be no
enlargement of the lacrimal glands, no swelling, and no drainage. Assess function
of facial muscles and the cranial nerves. If you see any deficit figure out which
nerve is affected. Palpate firmly enough to feel the sub epithelial
structures but not hard enough to hurt your patient, alternating between
observation and palpation allows you to understand the structures, shape, and size.
It also helps you avoid surprising the patient and yourself by suddenly
palpating a painful structure and it keeps you from altering a lesion
by palpation before you get a chance to see it. Palpate the nose and peek up the
anterior portion of the Nerys for abnormalities. Examine the neck lymph
nodes next. Palpate the spinal accessory nodes moving the tissues across the
trapezius muscle to aid detection. If a lymph node is palpable
note its size and whether it’s hard or soft, painless are painful, freely movable
or fixed. It should move freely. Manually palpate the neck,
comparing right and left sides for asymmetry looking for enlarged painless
lymph nodes and other abnormal masses. If an abnormal finding is present for more
than two weeks consider appropriate referral. The patient should relax her
head against the headrest and if she gently droops her head forward it might
help you palpate more easily. Palpate the jugular chains using deeply placed
fingers on either side of the sternocleidomastoid muscle all the way
from its origin at the clavicle to its insertion at the mastoid process
including the retro auricular nodes behind the ear. Include the anterior
scalene and supraclavicular nodes above the clavicles and the Delphian nodes
near the inferior midline of the neck. Examine the front of the neck
next. The butterfly shaped thyroid gland should have no nodules or masses. Palpate
the larynx for enlargement or immobility. Listen for hoarseness. Watch the
patient’s swallow, structures should move freely up and down, and the large carotid
bifurcation feels different from a lymph node – it has a pronounced pulse.
Palpate the submandibular and sublingual nodes extra orally between the fingers
and the lingual aspect of the mandible and later as part of the intraoral
examination. View and feel the parotid gland including its tail below the angle
of the mandible along with the pre irregular lymph nodes.
Make sure you compare right and left sides. Evaluate the lips both open and
closed taking a close look at the Vermilion border , commissures, and mucosa. The
patient should remove her lipstick before this
portion of the examination. The color of the lip Vermillion should be uniform in
pink, the junction between the Vermillion and skin should be crisp,
there should be no cracking at the comma sure’s which might indicate a candida or
bacterial infection also associated with anemia, and drooping at the corners of
the mouth. Palpate the lips between the thumb and fingers – it’s normal to feel
minor salivary glands but they should be all approximately the same in size. You
often see dysplastic changes on the lips of sun-exposed adults such as this 90-year-old in the form of actinic colitis. The Vermilion border becomes blurred and
ill-defined with rough, scaly, white and red zones. Persistent ulceration or induration may signal the onset of squamous cell carcinoma. Council these
patients to avoid the sun, use sun blocks, and have regular skin examinations. Ask
the patient to remove all appliances and prosthesis before continuing the
examination into the oral cavity. View the entire buccal mucosa by retracting
the tissues. Bilateral Linea Alba as seen in this case are normal, as is the
prominent Stenson’s parotid duct. Compare the results of your inspection and
palpation between right and left. You should feel some small uniform salivary
glands. The most common submucosal masses are salivary gland tumors,
enlarged lymph nodes, or lipomas. Smooth surface exophytic masses are usually
focal fibrous hyperplasia. If the buccal mucosa is diffusely white
stretch the cheek, if it disappears it’s probably lucu edema. Lacey white
lines, if multifocal and bilateral, may be like annoyed drug reaction, contact
allergy, or occasionally lichen planus. A malignancy in this region is usually
indurated and red. When in doubt check it out. Next take a close look at the color, contour, consistency, and function of the
alveolar processes and gingiva. As you look at the midline of this patient
you’ll see a maxillary freedom tag which is not pathology but in developmental
conditions stable once formed. You may see occasionally a discrete gingival
mass often called an epulis. This umbrella term includes gingival fibroma,
pyogenic granuloma, peripheral giant cell granuloma,
peripheral ossifying fibroma, and other conditions.
Bolle contour changes may also be present. One sign of oral cancer that’s
sometimes overlooked is a tooth with bone loss out of proportion to the rest
of the arch with no definite ideology such as a crack root. Be very suspicious
of such a situation. Another is a poorly healing extraction site. Bony tori are
usually stable and bilateral. Odontogenic cysts and tumors can cause unilateral
alveolar expansion. It’s easier to inspect the edentulous ridges, as you can
see in this elderly patient, if there’s a lot of ridge resorption the metal nerve
may be located close to the alveolar crest and may develop a painful nodule
called a traumatic neuroma. The denture patient may be prone to other lesions,
such as denture stomatitis, epulis fissuratom – a fissured mass at the
dentures edge – palatal papillomatosis – multiple nodules on the palate – and
candidiasis which can be pseudomembranous where the white wipes
off, atrophic where the tissues are fire-engine red, or hyper plastic where
the epithelium is white, rough, and the white doesn’t rub off. Identify and try
to explain any submucosal swellings. The hard pallet’s the most common intraoral
site for minor salivary gland tumors which could be benign or malignant and
is also a site where lymphoma can occur. Smokers may have nicotinic stomatitis, a
white, wrinkled palate with red dots but this can also occasionally be seen in
patients who drink very hot beverages. Torus palatinus is located on the
midline and is stable once formed and the size of canal cyst is located in the
anterior midline and might leak a salty fluid. A good view of the soft palate,
uvula, and tonsillar pillars is worth the effort as tumors here often go
undetected. Try to view this area when the patient says ‘ahh’, you may need a
tongue depressor or a mirror. A last resort is to watch the area closely as
the patient gags. In this patient you see multiple small, red, benign lymphoid
nodules which should be transient. Palpate as much as you can,
certainly the soft palate and the uvula. If needed, palpate the tonsil from the
side. Squamous cell carcinoma and lymphoma are the most common malignancies of this
area. Unexplained earache can be associated with pharyngeal cancers.
Palpate the base of the tongue behind the circumvallate papillae using a sweep
of the finger, this area is hard to see without special equipment. Pull the
tongue forward gently getting a firm grip with gauze in order to view the
entire dorsal tongue. Wipe away any debris. Closely inspect the lateral and
ventral tongue along its entire length, this is where half of all oral cancers
arise. In this patient the red nodules bilaterally on the posterior lateral
tongue are foliate papillae corresponding with the nodules seen in
the pharynx. Their bilateral, further assurance that they’re benign. Reactive
lymphoid tissues such as this should become less apparent once the stimulus,
like an infection, resolves. Make sure to complete this step by thoroughly
palpating the tongue, careful attention to this very important area of the mouth
could make a significant impact on early detection of oral cancer. Finally the
floor of the mouth needs to be inspected and palpated. About a third of intraoral
cancers occur here. Ask the patient to raise her tongue to the floor of her
mouth so you can see well. The floor of the mouth is an unusual site for trauma
or infection so if you see any red or white lesion think carefully about the
need for biopsy, especially if it’s indurated. Use two hands to palpate this
area, one inside the mouth, and one below the chin. Also assess the sublingual and
submandibular glands at the same time. Oral cancer strikes over 35,000
Americans a year and kills about 8,000. Dentistry’s best current hope for
improving the sad statistic rests in your hands and eyes. Do a thorough oral
cancer screening exam on every patient, every year, looking for changes in color,
contour, consistency, and function.

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