Battling Oral Cancer

Understanding and Preventing Oral Cancer

Oral cancer can be classified into different types based on its origin, such as carcinoma, minor salivary gland cancers, melanoma, and lymphoma. The most prevalent form of oral cancer is oral squamous cell carcinoma, which accounts for approximately 90% of all oral cancer cases.⁶ Oral squamous cell carcinoma often develops from potentially malignant oral disorders, which are a group of lesions that carry a risk of cancer development in the oral cavity, whether in a clinically definable precursor lesion or in clinically normal mucosa.⁷

The primary risk factors for oral cancers are tobacco use and heavy alcohol consumption; however, other risk factors include human papillomavirus (HPV) infection, sex, excess body weight, age, poor nutrition, certain genetic syndromes, and any condition that weakens the immune system.⁸ Autoimmune diseases affect approximately 50 million Americans,⁹ and immunosuppressant medications can lower the body's ability to fight disease. "What we really need to emphasize is that anyone can develop oral cancer, and that means fighting against the stigma that it's only smokers or people with HPV who are at risk," warns Ashleigh Briody, DDS, MS, an oral pathologist who diagnoses and manages oral disease at a practice in Westerville, Ohio. "If we take a step back, we can focus on the early detection of precancerous conditions and prevention in all patients. To better serve our patients, clinicians need to know what to look for during each biannual cleaning. We aren't just looking for signs of oral cancer; we're looking for ulcers, autoimmune disease, precancerous lesions, and more."

The 5-year survival rate of oral squamous cell carcinoma is approximately 41%-a percentage that has only marginally improved during the last few years.¹⁰ However, when oral cancer is detected in the early stages, the survival rate increases to 85%¹¹ or greater, highlighting the importance of early detection and the need for early biomarkers. Unfortunately, almost half of the oral squamous cell carcinoma cases worldwide are diagnosed at later stages.^12,13 This is largely because early-stage cancers are often asymptomatic and mimic benign conditions, which reduces the likelihood that individuals will seek care.¹⁴

Screening Techniques and Tools

Dentists are playing an increasingly vital role in detecting oral cancer and precancerous lesions.¹⁵ Patients' 6-month hygiene appointments present an ideal time for regular oral cancer screenings.¹⁶ Although a visual examination and palpation of the oral cavity is a quick, painless, and noninvasive method of screening that enables the early detection of malignant and premalignant lesions, some studies have demonstrated a gap in knowledge and practice among dentists and hygienists, which suggests that comprehensive oral cancer screening in dental practices may be lacking.^17,18

Continuing education courses can help dental healthcare professionals gain confidence in recognizing the early warning signs of oral cancer. Clinicians should develop a routine, regular, and systematic approach to intraoral and extraoral assessments. The first step is to inform the patient that a screening will take place and then to obtain a comprehensive health history. Dentists are in the ideal position to correlate a patient's health history with oral conditions and provide important education throughout the examination.

There are certain features of potential malignancy that should raise a red flag during an oral screening, including the presence of leukoplakia (ie, white spots) and erythroplakia (ie, red spots), ulcers that don't heal within 2 to 3 weeks, firm or thick lesions, granular surface changes, a sharply demarcated white lesion, and/or a lesion with a central depression. Other symptoms, such as patient complaints of persistent mouth sores, pain, unusual bleeding, swelling, tooth mobility, or difficulty in swallowing or speaking are noteworthy and warrant investigation. "There are many adjuncts and screening tools, but at the end of the day, the dentist or dental hygienist really needs to feel confident and comfortable in performing an oral cancer screening and recognizing what is abnormal. It can be difficult to find good sources of information about oral disease, and although there is so much information available on social media, it is obviously only useful to those willing to access it and learn from it," says Briody, who highlights examples of suspicious features and other educational information on her Instagram.

There have been notable changes in dental education and industry trends regarding oral cancer diagnosis. "Over the past decade, there's been an increasing emphasis on early detection and risk-based screening incorporating new diagnostic technologies, such as molecular diagnostics, liquid biopsy, and adjunctive imaging tools," explains David Wong, DMD, DMSC, a professor and director of the UCLA Center for Oral/Head & Neck Oncology Research. "Salivary diagnostics, in particular liquid biopsy, have garnered strong interest as a noninvasive, chairside tool for early detection. These diagnostics have the potential to transform screening by identifying biomolecular markers of malignancy-even before clinical lesions become apparent."

"During the COVID-19 pandemic, salivary diagnostics became widely standardized and familiar to many clinicians," says Praveen Arany, BDS, MDS, MMSc, PhD, an associate professor of oral biology at the University at Buffalo School of Dental Medicine. "The best part is that they allow for kinetic readings by taking multiple samples over time. Clinical signs can be subtle and difficult to detect with precision, but change is much easier to recognize-like a bump that gradually enlarges, changes color, or starts bleeding. The same principle applies to kinetic readings. If I see a number trending in the wrong direction over time, I know I'm onto something."

As diagnostic technologies continue to evolve, clinicians are increasingly integrating multiple screening modalities to enhance early detection. "Industry-wide, we are seeing greater adoption of adjunctive screening tools, such as fluorescence visualization, brush biopsies, and molecular tests, and moving beyond reliance on the traditional visual and tactile examination alone," affirms Wong.

At the same time, advancements in artificial intelligence (AI) are opening new possibilities for improving diagnostic accuracy and treatment planning. The application of deep learning, a subset of AI, to oral cancer data may help clinicians in the diagnosis, detection, and prognostic prediction of oral cancer in clinical practice, improving early diagnosis and selection of the most appropriate treatments to increase the survival rate of patients with oral cancer.¹⁹ "Looking to the future, I do think that AI will eventually play a role, but at this point, the technology is just not there yet," says Briody. "The bottom line is: you have to learn oral pathology. There's no way around it."

Dental Management of Oral Cancer

The importance of a multidisciplinary approach to the treatment and management of oral cancer, including collaboration and excellent communication between dentists and treating medical professionals (eg, oral surgeons, oncologists, radiologists), cannot be overemphasized. "Dental professionals play a critical role not only in recognizing abnormal conditions involving the oral mucosa but also in managing patients' oral health during and after cancer treatment," notes Briody. "For those who require radiation, this would include dental clearance prior to starting radiation therapy. Ideally, all teeth with questionable long-term prognoses should be extracted prior to radiation therapy to reduce the risk of osteonecrosis." According to the literature, osteoradionecrosis is a severe side effect of radiation therapy defined as exposed irradiated bone that fails to heal over a period of 3 months without evidence of a persisting or recurrent tumor.²⁰ Generally, nonfunctional teeth or those with a poor restorative or periodontal prognosis are recommended for extraction prior to radiation therapy to decrease the risk of a tooth undergoing osteoradionecrosis.²¹

Radiation treatment can also damage salivary glands, which can result in a slew of side effects that the dental team can help manage. Posttreatment complications may include xerostomia, hampered speech, an increased risk of oral infections and dental caries, difficulty with mastication or swallowing, impaired taste, and nocturnal oral discomfort.²² "Dentists can help manage these conditions through salivary stimulants, fluoride therapy, oral appliances, and myofunctional therapy," says Wong.

One treatment that may help to minimize the side effects of oral cancer treatments, as well as assist in the management of potentially cancerous lesions, is photobiomodulation (PBM) therapy. "The use of low amounts of light in the infrared range can activate biological responses, reducing pain and inflammation while simultaneously modulating the immune system to promote tissue healing and regeneration," explains Arany. "PBM therapy should be part of clinical training for physicians, dentists, nurses, chiropractors, and physical therapists-not just taught by commercial vendors, More clinical translation research is also needed for specific diseases. A major barrier to the provision of PBM therapy is the lack of a reimbursement code, despite strong oncology evidence from controlled human clinical studies. Lastly, although the US Food and Drug Administration recognizes PBM as a distinct form of light therapy, the presence of poor-quality devices on the market continues to undermine the field, highlighting the need for quality control."

Patients who have undergone treatment for oral cancer will often need supplementary and individualized support. Therefore, the importance of regular follow-ups for any needed care and to monitor for recurrence should be emphasized.

Shifting the Narrative

As frontline providers, dentists play a critical role in identifying precancerous conditions and ensuring that patients receive timely referrals for further evaluation and treatment. By incorporating systematic screenings into routine care, adopting emerging supplemental diagnostic technologies, and fostering interdisciplinary collaboration, dental professionals can significantly impact patient outcomes. "As more targeted and immunotherapeutic treatments for oral cancer emerge, the dental team's role in preserving oral function and improving quality of life will continue to expand," suggests Wong.

Beyond the clinic, dentists have a unique opportunity to advocate for oral cancer awareness, educating patients and their communities about risk factors and the importance of early detection. Whether through patient education, community outreach, or engagement in professional organizations, dental professionals can be instrumental in shifting the narrative around oral cancer from late-stage diagnosis to proactive prevention.