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.