Can dental professionals make a difference?

In spite of advancements in surgery, radiation and chemotherapy, overall five-year relative survival rates for patients with oral and pharyngeal cancers have not improved significantly for more than two decades, remaining at less than 60 percent. This survival outcome ranks as one of the lowest for all cancers. In addition to the mortality, associated morbidity has a profound effect on patients’ quality of life, family and friends—and on our health system.

Improved control involves both prevention and early detection. An impact on prevention can be achieved by tobacco-use cessation and modification of alcohol abuse. There are data indicating that diets rich in fruits and vegetables are helpful. Also, as we learn more about identifying genetic mutations and the role of viruses, further prevention guidelines will be emerging. Additionally, with an increased understanding of pre-cancerous lesions (leukoplakias) regarding recognition, diagnosis and management, further control can be gained. However, the factor most closely related to malignant transformation is aging; but longevity continues to increase, indicating another challenge for improved control.

Currently, the greatest opportunity to improve control is by early detection. At the time of diagnosis, almost two-thirds of all oropharyngeal cancers are advanced lesions (stages III and IV), requiring more aggressive treatment and still resulting in poor survival and increased morbidity. More than 80 percent of early lesions (stages I and II) can be cured with appropriate treatment.

The two featured articles in this issue address this problem. Cruz and colleagues¹ and Patton and colleagues² surveyed a randomized selection of dental professionals in New York state and North Carolina, respectively. Independently, they concluded that an optimal knowledge of prevention and early detection of oropharyngeal cancer is lacking. The New York study included both dentists and dental hygienists, recognizing the important role of the entire dental professional team in examinations and prevention counseling, with the greatest deficiencies being tobacco-use cessation and alcohol consumption. The North Carolina survey confirms a low knowledge level of risk factors as well as diagnostic approaches.

The authors of both studies conclude that education at all levels (undergraduate, postgraduate and continuing education) is essential in improving dental participation in control. A recent exit interview of graduating dental students from seven schools in California, Kentucky and Texas indicated a large number of these soon-to-be dentists had a lack of confidence, knowledge or both in recognizing and managing precancerous or malignant oral lesions.³ It reasonably may be assumed that such deficiencies probably will be carried over into their practices and services.

One limitation of such questionnaire-type studies is the response rate, which approximated 50 percent. It might be speculated that nonresponders may represent professionals who do not consider oral cancer control as a high priority, further magnifying a deficiency of knowledge, confidence and responsibility. While most dental professionals claim to do oral cancer examinations, the question remains as to the guidelines used and adequacy if the procedure is limited.

Improvement in dental professionals’ participation in oropharyngeal cancer control mandates an increased emphasis on prevention and early detection education. It must be instilled that this is a role and a responsibility of oral health care providers. Codes for reimbursement are an important incentive, as are licensure requirements.

For optimal participation, there must be a comfort zone for providers in understanding risks, signs and symptoms, and diagnostic approaches. While the highest risk group comprises smokers and drinkers older than 40 years of age, there are younger patients, who may have no risk factors, who nonetheless develop cancers. Therefore, practitioners should perform periodic oral examinations on all adult patients, and they should inform patients of this service. We also must address, through education and research, the high oral cancer occurrence and mortality rates among African-Americans.

In conclusion, these articles document a deficiency in the knowledge and participation of dental professionals in oral and pharyngeal cancer control. This implies the need for increased emphasis in not only professional education, but public education as well. There are many organizations that promote oral cancer control through various activities, such as Web sites, telephone communications, literature distributions and screenings.

The American Dental Association has recognized this important aspect of oral health care services, and the Association holds a five-year National Cancer Institute education grant to increase the role of dental professionals in prevention and early detection of oropharyngeal cancers. The program involves a series of standardized continuing education courses scheduled in the 10 public health districts in the United States. This activity entails a minimum of 15 such courses given each year with an outcome assessment component. The first five years of the grant will be completed in 2007. The evaluation should help assess the effectiveness of continuing education in behavior modification regarding early detection of oral cancer, an approach to precancerous lesions, and tobacco-use cessation. The two articles featured in this issue document the need for expanding education for improving oral cancer control.

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