Introduction
Oral Cancer Is Dentistry’s Disease, But We Are Losing the Battle
Raymond J. Melrose, DDS
Copyright 2001 Journal of the California Dental Association.
Oral cancer is dentistry’s disease because ours is the only profession whose scope of training and clinical practice specifically encompass preservation of the health and function of the oral cavity. No group of professionals is more familiar with the normal appearance of oral tissue and is specifically educated in professional school about oral cancer. Accreditation standards for dental education include specific references to education about oral cancer.
For the most part, our profession has taken vigorous actions to protect and to improve the oral health of our patients. Fluoridation, children’s dental health, and research in periodontal diseases are but a few examples that have positively affected oral health. What about oral cancer? Oral cancer remains a disease whose victims, on average, have a 54 percent five-year survival, a figure that has not improved in 20 years. Whereas, the five-year survival rates for patients with "hidden" cancers such as those of the breast, prostate gland, and colon have all substantially improved in that period.1 Further, oral cancer is a far more prevalent disease than is appreciated by most. The American Cancer Society estimates that 30,100 new oral cancer cases will be diagnosed nationally in 2001.1 Similar data for California predict 3,370 new cases.2 Oral cancer, then, will be the ninth-most-common cancer to occur nationally and the eighth-most-common in California. Clearly, something is seriously wrong when a common disease occurring in a site readily accessible for examination by skilled health professionals is not being diagnosed early enough to effect improved survival.
Dentists are well-aware of oral cancer, know the risk factors, and know how to examine patients for the disease. They learn this material thoroughly in dental school. But something seems to happen in the day-to-day activities of practice. Motivation to perform routine oral soft tissue examination on all patients declines.3,4 Is it from lack of time? Is there a loss of confidence in skill? Poor compensation? Is there a fear of finding something? No one knows for certain, but the end result is very tragically clear. Patients suffer and die needlessly from a disease that is eminently curable when diagnosed early or, better still, when in its premalignant phase.
Our colleagues in medicine do not have the luxury of training or experience in oral cancer or in the technique of oral examination. For the most part, their examinations of oral tissue are cursory at best. The oral cavity is not their area of responsibility and, compounding the problem of late diagnosis, physicians tend to see the high-risk patients for oral cancer more frequently than dentists because these people are older and often have significant medical problems.3 A study assessing physicians’ and dentists’ oral cancer knowledge, opinions, and practices disclosed what is related above but also revealed that 37 percent of physicians and 34 percent of dentists responding to a questionnaire did not know the importance of early detection in preventing mortality, something that would seem to be intuitive.3 A later survey of dentists alone concluded that dentists are not as knowledgeable about oral cancer prevention as they could be but were interested in continuing education on the subject.4 These are very worrisome facts, but they can be addressed through professional education.
A far more difficult problem and one whose solution could be pivotal in changing the behaviors of dentists and the outcomes for oral cancer patients is the lack of an informed public. A survey of U.S. adult knowledge of risk factors and signs of oral cancers conducted in 1990 concluded that there is extensive misinformation and a general lack of knowledge on the topic.6 Nothing has been done in the interim to change this. It is very clear to me that paramount among the reasons for success in improving the survival rates for common cancers like those of the breast, colon, prostate gland, and cervix is a public informed of the risk factors, the diagnostic methods, and the relationship between early diagnosis and improved survival. Ordinary people have clamored for and gotten attention to the problems of these cancers in terms of research, better diagnostic and treatment methods, insurance coverage, and a host of other features important to quality of life. The American Cancer Society has made important measurable reductions in incidence and mortality of the major cancers the centerpiece of its goals for the year 2015. Unfortunately, oral cancer is not one of these and will not be the beneficiary of American Cancer Society national efforts.
If the major national volunteer organization dedicated to the reduction of the burden of cancer in our population is not going to act directly to reduce the incidence and prognosis of oral cancer, who should? I firmly believe that since oral cancer is dentistry’s disease that dentistry must take it upon itself to mount comprehensive national public information programs. After the impressive national conference on oral cancer hosted by the American Dental Association in August 1996 reached the same conclusion regarding the necessity for widespread public information, it was hoped that action would follow. None did. Dr. Lawrence Meskin, the editor of the Journal of the American Dental Association, wrote that dentistry should "Do It, or Lose It," meaning that dentistry should step up to the plate and take responsibility for oral cancer.7
Following the lead of Dr. Meskin’s editorial, and acting as then president of the American Academy of Oral and Maxillofacial Pathology, I wrote to the president of the ADA formally proposing that the association consider developing an annual oral cancer awareness program for professional and lay populations. I noted that the idea had received support from oral pathologists in the United States and Europe after it had been mentioned on the Internet. The idea was referred to a council that declined support for financial reasons citing that the ADA already had a national public and professional awareness program in National Children’s Dental Health Month.8
It seems to me that our profession is too shortsighted in this battle to save lives from oral cancer. Does a high-profile celebrity have to develop advanced disease while under the care of a dentist and then have his or her story related on "60 Minutes" or "Nightline," which will delight in implying that dentistry doesn’t seem to know or to care about the only disease in its purview that is likely to kill its victims? This really isn’t the case, but it would be made to seem that way; and the cost to repair the damage, if it could ever be repaired, might be more than the cost to mount an effective program first. What if a consortium of state dental associations working together with the ADA and interested groups like the Centers for Disease Control and Prevention, Oral Health America, the Academy of General Dentistry, and others were to form to develop and test even one demonstration project for patient oral cancer awareness? This might be a difficult project to pull off; but if no one is willing to take the first step, our patients and our profession will surely suffer the consequences.
Contributing Editor
Raymond J. Melrose, DDS, is a professor in and the chairman of the Department of Oral and Maxillofacial Pathology at the University of Southern California School of Dentistry. He is also president-elect of the California Division of the American Cancer Society.
References
1. Cancer Facts & Figures 2001. American Cancer Society, Atlanta, 2001.
2. California Facts & Figures 2001. American Cancer Society, California Division, Oakland, Calif, 2001.
3. Yellowitz JA, Goodman HS, Assessing physician’s and dentist’s oral cancer knowledge, opinions and practices. J Am Dent Assoc 126:53-60, 1995.
4. Horowitz AM, Drury TF, et al, Oral pharyngeal cancer prevention and early detection: Dentist’s opinions and practices. J Am Dent Assoc 131:453-62, 2000
5. Yellowitz JA, Horowitz AM, et al, Survey of U.S. dentist’s knowledge and opinions about oral pharyngeal cancer. J Am Dent Assoc 131:653-61, 2000.
6. Horowitz AM, Nourjah P, Gift HC, U.S. Adult knowledge of risk factors and signs of oral cancers: 1990. J Am Dent Assoc 126:39-45, 1995.
7. Meskin LD, Do it or lose it. J Am Dent Assoc 128:1494-7, 1997.
8. Melrose RJ. Personal correspondence.
