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The Intraoral and Extraoral Exam

COURSE NUMBER: 337

Credit Hours:

3 Hour(s)

This continuing education course will introduce the protocol for a complete oral cancer examination with proper techniques for both the intraoral and extraoral exam; provide patient education information, as well as information on some adju...

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Overview

This continuing education course will introduce the protocol for a complete oral cancer examination with proper techniques for both the intraoral and extraoral exam; provide patient education information, as well as information on some adjunct devices and materials that may be utilized in lesion detection and lastly, to emphasize that all patients be told they are receiving a complete oral cancer examination.


Between 2007 and 2011, according to the American Cancer Society (ACS), the incidence or number of new oropharyngeal cancer cases increased in white males, held steady in white females and decreased in black males and females. The ACS reports the increase in incidence in white males is due to an increase in cancers of the base of the tongue and tonsils associated with human papillomavirus (HPV) infections.1 Studies have shown that visual and tactile examination of the structures of the head, neck and oral cavity are effective in detecting abnormalities occurring within these structures. Therefore, procedures such as the head and neck and intraoral examinations, often referred to as an oral cancer examination or oral cancer screening, are important elements of a complete patient assessment. These examinations should be performed on a routine basis for every patient, not just new patients or those with known risk factors such as the use of tobacco or alcohol, increasing age, or + HPV status.


It is important to diagnose lesions in a pre-malignant or early stage while still confined to the epithelial layers. Growing awareness of the importance of diagnosing oral cancer early is demonstrated by the inclusion of a specific objective (OH-6) in Healthy People 2020. The goal of which is to increase the proportion of oral and pharyngeal cancers detected at the earliest stage from 32.5% in 2007 to 35.8% in 2020.2 Early treatment normally results in less surgery, less radiation and chemotherapy, and a better quality of life. Treatment for oral, oropharyngeal and other head and neck cancers diagnosed at later stages is usually associated with more extensive dysfunction and disfigurement than treatment for those same cancers diagnosed in earlier stages. Complications associated with therapy for oral, oropharyngeal and other head and neck cancers include: altered eating and swallowing patterns, salivary gland dysfunction, and loss of hard and soft oral tissues such as teeth, bone, and parts of the tongue, among others. In a 2010 study, Rethman et al. reported there was sufficient evidence-based information to support oral cancer screening by visual and tactile methods as a means to detect cancer in the early stages.3 In 2009 Watson et al. looked at a group of patients already diagnosed with oral or pharyngeal cancer to determine if oral/pharyngeal cancer screening examinations done in the general dental office were associated with early detection. The researchers found those patients who had a screening examination within the last year were significantly more likely to have an early stage cancer than those who did not have the examination.4


In March of 2013, Consumer Reports published an article entitled “The cancer tests you need and those you don’t.”5 This article reported oral cancer screening, “A visual exam of the mouth by a dentist or other health-care provider,” as one of the eight screening tests to avoid. The reason given was “Most people don’t need the test unless they are at high risk, because the cancer is relatively uncommon.”5 The article states the recommendation was based on a review of the effectiveness of oral cancer screening by the United States Preventive Services Task Force (USPSTF) which “…found inadequate evidence on the diagnostic accuracy, benefits, and harms of screening for oral cancer. Therefore, the USPSTF cannot determine the balance of benefits and harms of screening for oral cancer in asymptomatic adults.”6An article, by Burkhart, 2013, addressed the Consumer Reports article. The USPSTF published another version of its recommendation online in Annals of Internal Medicine in November 2013 stating clearly that “This recommendation focuses on screening of the oral cavity performed by primary care providers and not dental providers or otolaryngologists.”7 The ACS and the American Dental Association among others continue to recommend oral cancer examinations as a vital element of routine dental examinations.8,9


The length of time between a patient’s initial consultation with a healthcare provider and a diagnosis of cancer is termed “professional delay.”10 Professional delay may be caused by inadequate clinical skills and knowledge, a low threshold of suspicion, lack of experience, and the presence of non-specific signs/symptoms. Studies by Yu found a delay of as much as 6 months, much longer than expected, from the time of the initial examination to the diagnosis/treatment.11 In addition to professional delay, patients may delay seeking care for many reasons. The most common reasons are lack of knowledge of the signs and symptoms of oral cancer leading to a low level of suspicion, no pain, and fear of the dentist, among others.12,13 Cancer progression is relatively rapid in the oral tissues, and as one would expect, professional and or patient delay results in more late stage diagnoses, more extensive surgery and more radiation and chemotherapy for the patient.


A complete head and neck and intraoral examination is not only important for the early detection of cancer but also for accomplishing a comprehensive assessment of the patient prior to providing dental treatment (Table 1).

  • Intended Audience:

    Dental Assistants, Dental Hygiene Students, Dental Hygienists, Dental Students, Dentists, Dental Assistant Students

  • Date Course Online:

    Feb 19, 2009

  • Last Revision Date:

    Dec 5, 2015

  • Course Expiration Date:

    Dec 4, 2018

  • Cost:

    Free

  • Method:

    Self-instructional

  • AGD Subject Code(s):

Learning Objectives

Upon completion of this course, the dental professional should be able to:


  • State eight objectives of the intraoral and head and neck examinations.    
    
  • List the sequence of performing a total oral cancer examination.    
    
  • List prime areas for the development of oral cancer.    
    
  • Describe four adjunct tests or devices and procedures that may be performed in conjunction with the oral cancer examination.    
    
  • Discuss reasons for using an adjunct device when performing an oral cancer examination.    
    
  • List five descriptors important for accurately documenting oral lesions.    
    
  • List four risk factors for the development of oral cancer.    
    
  • Define the term “professional delay.”    
    
  • Identify and define the three general classification categories most examination findings can be placed into.
    

Disclaimers

Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy. Note:  Registration is required to take test.

Author(s)

Conflict of Interest Disclosure Statement

- The authors report no conflicts of interest associated with this course.

Submission Information

Recognition

AGD Pace Logo

Approved PACE Program Provider

THE PROCTER & GAMBLE COMPANY


Nationally Approved PACE Program Provider for FAGD/MAGD credit.

Approval does not imply acceptance by any regulatory authority or AGD endorsement.


8/1/2021 to 7/31/2027

Provider ID# 211886