Oral Cancer: Why the Biopsy is Still the Most Important Treatment to Recommend

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According to the Oral Cancer Foundation, one person in the United States dies every hour each day from oral cancer. Dental hygienists are often the first clinician to find these cancers in our patients’ mouths. The identification of suspicious lesions in the oral cavity can be tricky. However, the more familiar we become with the lesions, we will hopefully yield better outcomes for our patients.

The Oral Cancer Foundation states that, if cancers are caught early, patients may suffer few “treatment disfigurations” compared to their counterparts whose cancers are detected at a later stage. Similar to different malignancies found in other areas of the body, the prognosis for a patient can be dependent upon how early it is detected.1

Many lesions commonly found in the oral cavity are benign. However, others that we will see at some point during our careers are precancerous and even cancerous. This is why it is so imperative for us to be vigilant about recognizing suspicious lesions and educating our patients about them.

I realize it can be difficult to point things out to patients that may be worrisome. We never know how they’re going to react. Will they be angry? Scared? Confrontational? Appreciative? As health-care providers, we have an obligation to our patients. Whether I suspect a lesion is malignant or not, I educate the patient about the importance of a biopsy.

One doctor who I work with compares an oral biopsy to going to the dermatologist. If a dermatologist sees a suspicious mole or another odd skin lesion anywhere on the body, they remove it and look at it under the microscope. The same should apply for dental professionals.

While we know there are some great adjunct tools to help identify oral cancer, the gold standard for diagnosing a lesion is still a scalpel biopsy.2 One study comparing two screening tools stated, “Clinicians and patients could have a false sense of security” because both cancerous and precancerous lesions will go undetected by these tools.

A View of Danger

I have always practiced clinical hygiene with loupes and a headlight, and I feel they have been instrumental in being able to spot suspicious lesions. Intraoral cameras are also an invaluable tool for these lesions − not only to provide documentation but also for patient education.

Sometimes it’s difficult for patients to understand what we’re describing to them. Just as you show a patient decay on a radiograph, having a photo of a suspicious lesion is extremely helpful. It’s been my experience that patients can better grasp the seriousness of the situation and appreciate the need for a biopsy once they’ve seen a picture of the lesion. It is also so critical to include a detailed description in the patient’s chart. A few important things to chart are the color or colors of the lesion, if the borders are well-defined or blended, whether it is flat or raised, and the size.

Already during my short career, I have found lesions in a large number of patients. The majority of the biopsy reports I have seen come back noting nothing of concern. However, many times, the results have come back as dysplasia, which means it has the potential to turn cancerous. There have been a few instances of different oral cancers as well. Noncancerous lesions like trauma or herpes will typically have healed within two to four weeks; if a lesion has been present longer than this, a biopsy may be warranted.3

Viewing the Reports

I have the privilege to work in a specialty practice where our doctors perform a majority of their own biopsies. So I get to see the histology reports. This has helped me immensely in becoming more knowledgeable and comfortable with oral pathology. If you work in an office where biopsies are not routinely performed, requesting a copy of the report for your patients may be helpful so that you can become familiar with their condition.

The biopsy results help determine how often a patient needs to be seen for a follow-up. If a patient is on a six-month recall currently, they may need to be seen more frequently for an intraoral exam to ensure nothing has changed or progressed. It also helps determine if the patient will need to seen by another specialist, such as an oral pathologist or an ophthalmologist.

With the example of pemphigus, which is a “potentially life-threatening autoimmune disorder that causes blisters and erosions of the skin and mucous membrane,” one study concluded that 60% of pemphigus vulgaris patients develop oral lesions first before anywhere else in the body. The study went on to say, “Timely recognition and therapy of oral lesion is critical as it may prevent skin involvement.”4 That means we may be the first person to see something like this arise in our patients.

As dental hygienists, we not only play a critical role in our patients’ oral health but their systemic health as well.

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  1. Oral Cancer Facts. Oral Cancer Foundation. Retrieved from https://oralcancerfoundation.org/facts/
  2. Epstein, J.B., Silverman, S., Epstein, J.D., Lonky, S.A., Bride, M.A. Analysis of oral lesion biopsies identified and evaluated by visual examination, chemiluminescence, and toluidine blue. Erratum in Oral Oncol. 2008: Jun;44(6):615.
  3. Mehrotra, R., Singh, M., Thomas, S., Nair, P., Pandya, S., Nigam, N.S., Shukla, P. A cross-sectional study evaluating chemiluminescence and autofluorescence in the detection of clinically innocuous precancerous and cancerous oral lesions. J Am Dent Assoc. 2010 Apr: 141(4):388.
  4. Arpita, R., Monica, A., Venkatesh, N., Atul, S., Varun, M. Oral Pemphigus Vulgaris: Case Report. Ethiopian Journal of Health Science. 2015 Oct: 25(4): 367–372.