Public description of a proper exam
As lay people we really do not always know what the doctor is doing, looking at, or thinking as they examine our mouths. Are they going to recognize the early signs of cancer? Are they looking where it routinely occurs? Are they using all the tools available to them when they are examining our mouths? Most of us would never know. But there are some things that will indicate to you whether your professional is doing a thorough job or not. Clearly we all wish to just feel comfortable trusting our medical and dental professionals to do things well and correctly. In the real world that is not always possible or the case. Understanding the process helps you evaluate if you are in good hands; ones worthy of trusting your life to. Sounds severe, even harsh? You bet. But being informed is the first step in taking good care of yourself, choosing competent care, and recognizing potential problems early enough to have them caught at a survivable state. When it comes to a medical or dental professional who may save your life by catching dangerous diseases at the earliest possible time, you need to be concerned with more than a great personality and chairside manner. So here is what to expect. Remember that any one of the signs and symptoms we mention here by itself could be something benign and non related to oral cancer.
Preparing for the exam: If you have dentures (plates) or partials, you will be asked to remove them. No one can see all the soft tissue areas of the mouth with any appliances in place.
Part of a comprehensive exam is asking a patient important questions. These reveal things to the examiner that may augment their decision making after the physical exam, or direct them to explore a particular area in greater detail. Obviously the first thing they want to know is if YOU have experienced any problems or have noticed any changes yourself. Be candid. This verbal history taking part of the process is very important. With some of the new causes of oral and oropharyngeal cancers the signs and symptoms are VERY subtle. In disease caused by the HPV virus, the oral environment may be completely normal in appearance and the oral history is crucial. Questions you should expect to hear are; (1) Have you noticed any changes in swallowing? Do things seem to stick or catch in your throat when you swallow? This sensation usually is not painful, but something that subtly gets more noticeable over time. Most people, men in particular, have a tendency to ignore things like this, especially if they are not painful. But this one question can be a red flag for the development of a base of tongue oral cancer caused by the virus. (2) Have you had any chronic hoarseness? Here a condition that has lasted for over two weeks is what is important. Less than that and it could be any transient infection. Persistence over a protracted period of time is the indicator of something more dangerous. (3) Have you noticed/felt any small lumps when feeling the side of your neck putting on makeup or shaving? They are interested in things which are painless. Again something that people will ignore, these can be the metastasis of an oropharyngeal cancer away from the inside of your mouth out into the lymph nodes of your neck. Painful swollen nodes are usually a sign of an infection not cancer. The painless ones are the red flags. (4) Have you had any ear aches that seem to persist, particularly unilateral (only on one side)? (5) Have you or any of your friends noticed a change in your voice? Again, similar to hoarseness which not only will you feel, but others can hear, there may be changes in how your tongue moves and helps you form certain sounds when you speak. Oral cancers that impact the nerves that control the movement of your tongue can be painless, and alter your speech in very subtle ways or even your ability to stick it straight out of your mouth without it consistently veering to one side when you try to. All these questions help your professional examiner come to good conclusions about your health, and potential need for examinations beyond the simple screening that you are there to receive on that day.
Your healthcare provider will inspect your face, neck, lips, and mouth to look for any signs of cancer. Clearly a sore on your lip will be obvious to everyone, even you. But some of what they are looking for is more subtle. Is there a nice symmetry to your features, or does part of your external mouth not move well, or possibly droop? Some doctors are looking at these things when you first approach and sit in the chair, and it may not be apparent to you that their observations are actually taking place. But a good practitioner is sensitive to these small give-aways... a slur in your speech, a corner of the mouth that does not seem to move well in concert with everything else, a subtle swelling on one side of your face causing asymmetry. By themselves, these are not areas of specific oral cancer concern, but they are all part of putting together the puzzle of different signs, which may indicate you are worthy of referral to a specialist, or to have further diagnostic procedures.
In the old days before the common use of rubber gloves, a manual palpation of the oral cavity was called a "wet finger" exam. Manual palpation is a very important part of the examination. If you are approached with two wooden tongue blades, or with only a mouth mirror to do the screening, the examiner is missing valuable opportunities to detect important things. With both hands, he or she will feel the external area under your jaw and the outside of your neck, checking for lumps (enlarged lymph nodes) that may suggest inflammation or more. Many times if these nodes are painless but hard and enlarged, and feel like they are fixated in position, it can be a sign of cancer. When feeling the floor of your mouth (bi-manually palpating it), a finger is placed under your tongue and the fingers of the other hand placed under your chin. Rolling the soft tissues of the floor of your mouth between the two, they can detect enlarged nodes or other hard spots called indurations that may be an area of concern. Anyone not using their fingers to examine you, and only looking with a mirror, or worse using just a pair of wooden tongue blades, is going to miss things. Touch is important. He or she will then look at and feel the insides of your lips and cheeks to check for possible signs of cancer, or pre-cancerous tissue changes, such as red and/or white patches, or thickened areas.
Your provider will have you stick out your tongue so it can be checked for swelling or abnormal color or texture. They will be watching to see if as you extend it, it deviates to one side or the other, a possible sign that something is affecting the nerves which control its movement. Then, using a small piece of gauze, he or she will gently pull your tongue to one side, then the other to fully visualize its edges, a common location for lesions to occur. They will likely feel the boarders of the tongue (again for hard spots) at the same time. A common site for oral cancer to occur is the base of the tongue where it begins to curve down your throat. This area cannot be visualized well unless the tongue is pulled forward, and the gauze is necessary to do this. The forward pull on your tongue to roll that portion of it up into a more visible position may be a little uncomfortable, but not painful. If they did not do this, they have missed an important location to examine. ENT doctors are very good at quickly running a gloved finger across the part of your tongue that is more in the throat, feeling for the roughness that indicates a base of tongue cancer is developing. They do this quickly so that it does not elicit a gag reflex in you. We feel this is a very important part of the tactile exam, and wish that dentists would also do this more. The underside of your tongue will also be checked. When considering this thorough tongue palpation, no one forgets if their examiner pulled their tongue firmly out of their mouth to see everything.
Additionally, the screener will visually examine the roof and floor of your mouth, as well as the back of your throat and the tonsillar pillars on each side. When viewed directly from the front, the opening to the back of your mouth and throat should appear symmetrical and not swollen on either side. This triangular shape, formed by the tonsillar pillars on each side and the tongue on the bottom, is referred to as the trigome. It is very symmetrical in shape in most people, but if one side is enlarged, distorting that symmetry, (a tonsil swollen on that side), and that swelling is also painless, that could be the indication of a beginning tonsillar cancer. This is also a very common viral caused cancer particularly in non smokers.
Please note that for the most part, those who do the examination with wooden tongue blades to hold your tongue down are doing two things incorrectly in our opinion. (This is more commonly done in medical environments than dental.) First, a proper exam is partially tactile. They need to feel parts of your tongue, and mouth as we have previously described. They cannot do this with a wooden tongue blade. Secondly, many times they are actually putting the tongue blade right onto an area that needs to be visualized as they move your tongue left and right.
A good oral cancer exam is visual AND tactile. It takes eyes trained in what and where to look for things, and gloved fingers to feel particular areas as well. These are some of the things that you should expect. Some doctors will use additional devices to do the exam. These might be different kinds of lights and pre-examination rinses that help them visualize areas of suspicion, or they may even use a dye on an area of suspect tissue. Rest assured that while these add to the thoroughness of the exam, a well-done visual and tactile examination with the eyes and fingers only, when conducted by a trained professional, will do a good job of finding oral cancer early if it is done properly.
Some professionals are beginning to use adjunctive devices to assist them in doing a thorough screening. We believe that this is fine AS LONG AS A PROPER VISUAL AND TACTILE SCREENING IS DONE FIRST. These devices which include various lights, dyes, and even tissue collection brushes, may add to the process, but they are NOT a substitute for a correctly done, white light, visual and tactile screening.
This is not a postponable elective procedure to have your professionals do. Annual opportunistic oral cancer exams are a must. When you get home after your examination, take a few minutes to take a good look inside your mouth with a hand mirror. Obtaining a small interior mouth mirror from your dentist or the drug store would be useful to have at home. You could also ask the doctor to walk you on a "guided tour" through this self exam while you are in the office. When you are aware of what your NORMAL mouth looks like, regular monthly exams that you do at home by yourself will allow you to recognize any changes that are taking place. These home examinations are particularly important if you are engaged in any known risk factors for developing the disease such as smoking or using smokeless tobacco. When you go in for your next exam, remember to bring to the examiners attention any area of concern that you may have felt or noticed. While it may be nothing, there is no harm in ensuring that your concerns have been explored carefully and the doctor has an opportunity to evaluate what you have noticed. Early detection of oral cancers by your professional examiner or yourself is the key to survival of this disease.
The visual and tactile exam is not a guarantee that every cancer or precancer will be caught, especially in those that rise from HPV viral infections. While no screening technique for any cancer is 100% effective, this exam is painless, inexpensive or often free, non invasive, involves no exposure to anything which has long-term harm like radiation exposure, and can be accomplished quickly in just a few minutes - often while you are at your dental professional for other purposes anyway. If your professional does not do this screening automatically, ASK FOR IT. If you are told that because you are young, a non smoker, or for other reasons you do not need screening, you are talking to someone who is not current in their knowledge. The fastest growing segment of the oral cancer population are young, non smoking individuals who come to the disease from the HPV16 virus which also causes cervical cancers. Since it is the most common sexually transferred infection in the US, the CDC has said that between 50-80 % of the entire US population will have an HPV infection at some point in their lifetime. People with infections have no symptoms, so you will never know that you have been exposed or that your body has cleared it. Therefore, if you are old enough to have engaged in sexual contact, you are old enough to require an oral cancer examination regularly. It is your health and your life that is being protected by being proactive.