Subject:  Oral Cancer Screening

The AAOM affirms that risk factor assessment for oral diseases including oral and oropharyngeal cancers, and a non-invasive visual and tactile oral mucosal examination is part of the standard initial and recall visit by oral health care providers and is recommended for all patients. Originator: Dr. Ross Kerr, DDS, MS

This Clinical Practice Statement was developed as an educational tool based on expert consensus of the American Academy of Oral Medicine (AAOM) leadership. Readers are encouraged to consider the recommendations in the context of their specific clinical situation, and consult, when appropriate, other sources of clinical, scientific, or regulatory information prior to making a treatment decision.  

Originator:       Dr. Ross Kerr, DDS, MS
Review:           AAOM Education Committee
Approval:         AAOM Executive Committee
Adopted:         November 19, 2014
Review Due:    November 19, 2016

Purpose

The AAOM affirms that risk factor assessment for oral diseases including oral and oropharyngeal cancers, and a non-invasive visual and tactile oral mucosal examination is part of the standard initial and recall visit by oral health care providers and is recommended for all patients.

Methods

This statement is based on a review of the current dental and medical literature related to oral cancer screening. Three recent systematic reviews provided the basis for this statement. Expert opinions and best current practices were relied upon when clinical evidence was not available.

Background

The American Cancer Society estimates that approximately 40,000 Americans will be diagnosed with oral and pharyngeal cancers in 2014, and approximately 8000 will die. The majority of these cancers are squamous cell carcinomas. Despite the relatively easy access for examination of the oral cavity and pharyngeal sites (particularly the oropharynx), less than one third of these cancers are detected in the early stages. Overall 5-year survival rates are approximately 60%, and for early stage (I & II) cancers, the 5-year survival rate increases to >80%. 

Both dental and dental hygiene curricula in the United States include training of graduates to perform a comprehensive oral soft tissue examination. In 2010, the Commission on Dental Accreditation (CODA) approved a mandatory new standard (standard 2.23 part b): “At a minimum, graduates must be competent in providing oral health care within the scope of general dentistry, as defined by the school, including screening and risk assessment for head and neck cancer.” Such a “screening” includes a visual and tactile oral mucosal examination, and dentists/dental hygienists across the United States routinely perform such examinations. Dentists and dental hygienists are not remunerated specifically for performing a standard oral cancer evaluation but rather for performing oral examinations that include an oral cancer evaluation. The American Dental Association's Code on Dental Procedures and Nomenclature (CDT) includes billing codes for oral examinations with verbiage regarding  “oral cancer evaluation”. The three main examination CDT codes are 0120 for the periodic oral evaluation of an established patient, 0150 for the comprehensive oral evaluation of a new or established patient, and 0180 for the comprehensive periodontal evaluation of a new or established patient. Each includes “oral cancer evaluation” in their descriptions. In addition to the American Academy of Oral Medicine, a number of national organizations and institutes describe such oral cancer evaluations on their websites, including the National Cancer Institute, the National Institute of Dental and Craniofacial Research, the American Cancer Society, the American Dental Association, and the Oral Cancer Foundation (see references).

Three systematic reviews are available that address the evidence supporting the practice of oral cancer screening. Each arrives at the same conclusion that there is a paucity of quality research to provide evidence to either support or refute oral cancer population-based screening. A panel convened by the American Dental Association’s Council on Scientific Affairs published a systematic review in 2010 with evidence-based recommendations regarding screening for oral cancer1. The panel suggested that “clinicians remain alert for signs of potentially malignant lesions or early-stage cancers while performing routine visual and tactile examinations in all patients, but particularly in those who use tobacco or who consume alcohol heavily.” The United States Preventive Services Task force (USPSTF) published recommendations for oral cancer screening in 20132 stating The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral cancer in asymptomatic adults. This recommendation is intended for primary care providers and does not pertain to dental providers or otolaryngologists. Dental care providers and otolaryngologists may conduct a comprehensive examination of the oral cavity and pharynx during the clinical encounter.” The Cochrane Group also published the results from their systematic review on oral cancer screening in 20133, stating that “Index tests at a prevalence reported in the population (between 1% and 5%) were better at correctly classifying the absence of PMD or oral cavity cancer in disease-free individuals than classifying the presence in diseased individuals. General dental practitioners and dental care professionals should remain vigilant for signs of PMD and oral cancer whilst performing routine oral examinations in practice.”

Clinical Practice Statement:

The AAOM recognizes that:

  1. More than 60% of oral and pharyngeal cancers are advanced stage (i.e. stage III & IV) at the time they are diagnosed.
  2. Overall, patients with oral cancer detected in the early stages have improved survival.
  3. Patients with early stage cancers generally require less aggressive treatment and therefore experience fewer complications.
  4. There is a paucity of evidence to support or refute the practice of oral cancer screening.
  5. The curricula of training programs for oral healthcare providers mandate that dentists and dental hygienists be able to competently perform screening and risk assessment for oral cavity and oropharyngeal cancer.
The AAOM thus encourages oral healthcare providers to:
  1. Perform a risk assessment for oral diseases for all patients, including an assessment for oral and oropharyngeal cancer.
  2. Perform a non-invasive visual and tactile oral mucosal examination as part of the standard initial and recall examination for all patients.
  3. Educate patients about the risk factors, provide counseling and offer treatment for avoidable risky behaviors, and promote a healthy lifestyle.   

References: 

  1. Rethman MP, Carpenter W, Cohen EE, et al. Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. J Am Dent Assoc 2010;141(5):509-20.
  2. Moyer VA. Screening for oral cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014;160(1):55-60.
  3. Walsh T, Liu JL, Brocklehurst P, et al. Clinical assessment to screen for the detection of oral cavity cancer and potentially malignant disorders in apparently healthy adults. Cochrane Database Syst Rev 2013;11:Cd010173.

Selected Websites:
www.cancer.gov/cancertopics/pdq/screening/oral/Patient/page3
www.nidcr.nih.gov/OralHealth/Topics/OralCancer/
www.mouthhealthy.org/en/az-topics/o/oral-cancer.aspx
http://oralcancerfoundation.org/diagnosis/index.htm

This Clinical Practice Statement was developed as an educational tool based on expert consensus of the American Academy of Oral Medicine (AAOM) leadership. Readers are encouraged to consider the recommendations in the context of their specific clinical situation, and consult, when appropriate, other sources of clinical, scientific, or regulatory information prior to making a treatment decision.