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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.