Upon completion of this course, the dental professional will
have the ability to:
1. Recognize the incidence and current etiologic factors
related to oral and oropharyngeal cancer.
2. Identify subtle symptoms that may be suggestive of oral
and oropharyngeal cancer.
3. Perform a visual and tactile examination of high-risk
extraoral and intraoral areas.
4. Compare and contrast the value of the clinical oral
examination and adjunctive screening methods utilizing
direct fluorescence visualization.
SEER (Surveillance Epidemiology and End Results) data
demonstrates a decline in oral cancer for tobacco related sites;
however, there is a strong trend toward an increase in human
papillomavirus (HPV) implicated sites. Due to the affinity of
the virus for lymphoid tissues and posterior placement, today’s
dental professional needs to be keenly aware of the subtle symptoms that accompany this newer profile. How does this affect our
methods of screening for oral and oropharyngeal cancer, and is
the clinical oral examination predictive of histologic diagnosis
at an early stage? Two-thirds of oral squamous cell carcinomas
are discovered at an advanced stage with five-year survival rates
impeded significantly; 83.3% when the disease is discovered in
stage I or II, and only 38% when the cancer has metastasized.
This presents a call to action to elevate our knowledge regarding
examination of high-risk areas and explore adjunctive screening
methods to complement the traditional white light examination.
Incidence and Survival Rates
According to the American Cancer Society Cancer Facts and
Figures 2017, it is estimated that 49,670 men and women
( 35,720 male and 13,950 female) will be diagnosed with cancer
of the oral cavity and pharynx and 9,700 deaths are estimated.
Based on rates from 2011–2013 data, approximately 1.1% of
men and women born today will be diagnosed with cancer of
the oral cavity and pharynx at some point during their lifetime.
This number can also be expressed as 1 in 90 men and women
will be diagnosed with cancer of the oral cavity and pharynx
during their lifetime.
This is the ninth year in a row in which there has been an increase in the rate of occurrence of oral and oropharyngeal cancer.
In 2007, there was a major jump of over 11% in that single year.
In 2013, there was an estimated 300,682 people living with oral
cavity and pharynx cancer in the United States.
2 Worldwide, the
problem is far greater. Oral and oropharyngeal cancer, grouped
together, comprise the sixth most common cancer in the world.
In certain high-risk southeast Asian countries such as Sri Lanka,
India, Pakistan, and Bangladesh, oral cancer is the most common
cancer in men and may contribute up to 25% of all new cases of
3 Many different factors predispose countries such as
India to high incidence rates of oral and oropharyngeal cancer.
Risk factors in these countries include alcohol, tobacco, smoke-
less tobacco products, betel nut chewing, and the human papil-
The median age at diagnosis for both HPV6 and non-HPV7cancers of the oral cavity and oropharyngeal area is 62,
representing both primary etiologic pathways. Five-year relative survival rates for all stages of the oral cavity and pharynx
are 63% as illustrated by Table 1.
8 This represents an increase
in survival rates when compared to previous years. This is
primarily due to an increase in HPV-related cancers, which
are more sensitive and responsive to treatment, resulting in
a significant survival advantage accompanied by a profile of
otherwise healthy, young males. “Published data indicate that
tumor HPV status is a strong and consistent determinant of
superior survival, regardless of treatment strategy, with 5-year
survival rates among patients with HPV-positive tumors of approximately 75 to 80%, versus 45 to 50% among patients with
9 The subset of HPV-related cancers is
the fastest growing segment of the oral and oropharyngeal cancer population. White, nonsmoking males age 35–55 are most
at risk, with a gender predisposition of 4 to 1 over females.
The survival statistics presented in Table 2 were tabulated between 2006 and 201210 and are based on the stage of discovery
of the oral and oropharyngeal cancer.
Review of Etiologic Factors
Tobacco and tobacco products, alcohol, prolonged sun exposure,
betel nut chewing, use of areca nut, cannabis use, previous history
of oral cancer, and HIV seropositivity along with predisposing factors such as age, gender, socioeconomic status, and genetics are all
cited as risk factors for oral cancer. It is, however, the human papillomavirus (HPV) that has captured the attention of the medical and
dental communities as the fastest growing etiologic factor. “The
increase in incidence of HPV-positive OPSCC [oropharyngeal
squamous cell carcinoma] is epidemic, and OPSCC will likely soon
be the most common cancer in the United States caused by HPV as
well as the most common cancer of the upper aerodigestive tract.
Patients with HPV-positive OPSCC are more likely to be white,
middle-aged, of moderate to upper income, and to have had more
oral sexual partners.”
12 “Local-regional metastasis, but not distant
metastasis, was significantly lower for patients with HPV-positive
tumors than for those with HPV-negative tumors. In addition,
cumulative incidence of second primary tumors was significantly
lower among patients with HPV-positive tumors, largely because
of lower rates of smoking related cancer.”
The vast majority of oropharyngeal cancers are HPV-associated cancers with 60% being attributed to specific high-risk viral
strains of HPV 16 and 18. https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-fact-sheet These are the same two strains that comprise the majority
of HPV-related cervical cancers. Ninety-one percent of cervical
cancers are caused by the human papillomavirus as illustrated by
13 The remaining HPV-related oropharyngeal cancers are
attributed to viral strains 31/33/45/52/58 and other types.