Dentistry has played an important role in directing the attention of the health profession toward the prevention of disease. Glaring by their absence have been measures that the patient might use to decrease morbidity and mortality from neoplastic diseases of the head and neck. A simplified self-examination procedure can be taught to the patient as a part of the preventive program. It is hoped that this procedure would permit earlier detection and treatm ent of both neoplastic and nonneoplastic diseases of the head and neck area.
Teaching self-examination of the head and neck: another aspect of preventive dentistry
Richard Thomas Glass, DDS, PhD, Oklahoma City Mellisia Abla, RDH Jeannie Wheatley, RDH, Tulsa, Okla
In a recent edition of t h e j o u r n a l , eight arti cles dealt in some way with the prevention of oral disease. These articles included general infor mation on patient education,1,2 the role of nutri tional counseling in the prevention of dental car ies and periodontal disease,3 the use of fluorides and sealant in dental caries prevention,4 6 the properties of mouthguard materials to prevent traumatic loss of teeth,7 and the identification of tooth crowding with emphasis on preventive orthodontics.8 This emphasis on prevention is typical of the modern dental profession and an aspect of which all dentists should feel justifiably proud. H ow ever, glaring by its absence is the emphasis on the prevention of morbidity and mortality from neoplastic diseases of the oral cavity and the remainder of the head and neck. A computer search of the literature reveals only eight recent publications that deal with the sub ject of early detection of such disease, and yet
the statistics for oral cancer dictate that this lack of emphasis should be corrected. Recent statis tics estimate that 7,500 people die of oral cancer each year. If cancer of the larynx and lymphomas is included as head and neck cancers, the estim ate is 30,350 people. For each year the incidence of new cases is 15,100 people with oral cancer and 47,000 people with cancer of the head and neck.9 For the past ten years, many physicians have been teaching breast self-examination for the de tection of cancer. H aagensen10 has pointed out that it is possibly more important to teach women how to examine their own breasts than it is to teach the technique of breast examination to physicians. His findings suggest that 90% or more of all breast malignancies are discovered by patients themselves. Thiessen11 said that al though breast self-examination should be taught to patients, there are inherent difficulties with its effectiveness caused by the “ gross physical characteristics of the organ to be examined.” In contradistinction to the breast, the oral cavity and head and neck are an easily accessible area that can be readily examined. A simplified tech nique of self-examination of the oral cavity and head and neck is presented. JADA, Vol. 90, June 1975 ■ 1265
Self-examination technique A s with other techniques taught to patients, sim plicity is the key to self-examination o f the oral cavity and head and neck. We have found it help ful to teach the procedure as a part o f the overall preventive education program. The patient is either given a hand mirror or, preferably, is seat ed in front o f a large mirror. The patient is asked to go through the technique under the watchful eye o f the instructor. The instructor continually points out normal color, texture, and anatomy as the patient examines each area. The abnor malities for which the patient is examining can be reduced to lumps and bumps, and red, white, or blue color changes in the mucosa or skin. The patient can be given a printed order o f examina tion, but an awareness of all areas to be exam ined is o f greater importance. ■ E xam ination: The self-examination proce dure is divided into eight steps. — Facial symmetry. The patient is asked to look in the mirror and, with no facial expression, to look for a balance in features and general color (Fig 1). She is asked to note and palpate any raised areas such as nevi, pimples, or scars (Fig 2).
— L ips. The patient is asked to pull the lower lip down and to note the color and texture (Fig 3). The procedure is repeated for the upper lip. — Gingiva. The patient is asked to examine the gingiva by exposing the areas (Fig 4). The normal color and stippling are pointed out to the patient. — Buccal mucosa. The patient is asked to place two fingers into the buccal vestibule and to expose the area (Fig 5), noting the color and texture. Because this area is so often involved in cheek biting, the linea alba can be pointed out as the type o f color deviation that the patient should note. The orifice of the parotid salivary gland duct also should be pointed out. —Tongue and floor o f the mouth. The patient is asked to check the mobility o f the tongue by moving it from one corner o f the mouth to the other (Fig 6). The patient is given a 2 x 2 gauge and is asked to view the lateral borders of the tongue as far back as she can see, and the floor o f the mouth. The color and areas o f vascularity are pointed out, as well as the orifice o f the sub mandibular salivary gland duct. In addition to this visual examination, the patient is asked to palpate the floor o f the mouth, and the dorsum and lateral borders o f the tongue, feeling for 1266 ■ JADA, Vol. 90, June 1975
lumps and bumps (Fig 7). — Palate. The patient is asked to examine the palate (Fig 8). She notes the color and the pres ence o f m asses. Palatal tori and rugae should be pointed out. — Lateral neck. The purpose o f this examina tion is to palpate the lymph nodes associated with the sternocleidomastoid muscle. The pa tient is asked to turn her head away from the side being examined or to grimace, making the mus cle apparent. She then palpates up and down the anterior aspect o f the muscle, feeling for lumps and bumps (Fig 9). —Trachea. The patient is asked to place her fingers around the thyroid cartilage (Adam’s apple) and m ove it from one side to the other (Fig 10). There may be crepitation associated with movement but there should be good lateral mo bility. While still grasping the cartilage, the pa tient is asked to swallow. The cartilage should m ove superiorly. After the initial examination, the patient should be aware o f what is normal for her. She then is instructed to perform the examination once a month. It should be emphasized that ab normalities will appear as raised lesions (lumps or bumps) or as changes in color (red, white, or blue). The patient is told to observe any lesion for two weeks and if healing has not occurred within this time span, to call the dentist immed iately. The patient is also told that although the instruction session consumed a fairly long time, the procedure can be performed rapidly in the patient’s own home.
Discussion H ecker12 has pointed out that symptomatic dis ease represents the tip o f an iceberg and that dec ades o f silent development o f the disease is the part below the metaphorical waterline. Those dentists who are concerned about detecting the iceberg below the surface rely on preventive measures; so it is with the early detection of head and neck malignancies. I f the example o f breast self-examination is used, it seems that the same type of early detection might be generated from oral self-examination. This in no way obviates the dentist’s responsibility for thorough clinical examination on a periodic basis with currently accepted techniques.1315 It has been pointed out repeatedly that self-examination is only an adjunct to early detection and in no way lessens
Fig 1 ■ Examination of facial symmetry.
Fig 2 ■ Palpation of face.
Fig 3 ■ Examination of lips.
Fig 5 ■ Examination of buccal mucosa.
Fig 6 ■ Examination of tongue and floor of mouth.
A Fig 4 ■ Examination of gingiva.
Fig 7 ■ Palpation of tongue.
Fig 8 ■ Examination of palate.
Fig 9 ■ Examination of lateral neck.
Fig 10 ■ Examination of trachea.
Glass—Abla—Wheatley: SELF-EXAMINATION OF HEAD, NECK ■ 1267
the importance o f periodic professional exam ination.11,16'19 T hiessen11 developed a system o f risk factors that dictates which females must be well trained in self-examination. His risk factors include the patient’s age, the anatomy o f the breast, and the familial incidence of breast cancer. Storer20 pointed out that the group of patients with the highest risk o f development o f oral cancer are those in their sixth through eighth decade o f life. H e noted that these are also the patients who tend to be edentulous and do not seek routine dental care. Oral self-examination in this group o f patients is o f greatest importance. U se o f the examples derived from the exam ination for breast cancer also will be of aid in de termining the role o f the dentist and the auxili aries in the early detection o f oral malignancies. Strax21 has pointed out that trained paramedical personnel have been used in all phases o f breast screening including interview, clinical examina tion, and teaching the technique o f self-examina tion. It seems reasonable to suggest that welltrained dental assistants or dental hygienists could be used to teach the self-examination tech nique and to do initial interviews and clinical ex amination on lesions which the patients find. Reference is made in the technique to the time period that the patient should wait after a lesion is found. The point should be emphasized that if the lesion has not completely healed within tw o w eeks, the patient should be seen by the dentist. One problem found in the breast selfexamination system has been the delay o f from an average o f eight weeks22 to 5.6 months23 be tween the finding of a lesion and the seeking of treatment. Prompt diagnosis and treatment must be sought by the patient if any self-examination system is to be effective.
Summary A technique for self-examination o f the oral cav ity and head and neck has been presented. The technique is simple in its design and yet thorough in its scope. The need for such an examination is established on the incidence o f malignancies in this area and the importance o f early detec tion, diagnosis, and treatment. The role o f dental auxiliaries and the role o f risk factors are dis cussed.
1268 ■ JADA, Vol. 90, June 1975
The authors thank Mrs. Elaine Taylor for acting as a subject for photography and Mrs. Donna Stanfield for her handling of the manuscript. Dr. Glass is chairman and associate professor of oral pathol ogy and assistant professor of pathology, Colleges of Dentistry and Medicine, University of Oklahoma, 1110 NE 12th St, Okla homa City, 73190. Miss Abla and Miss Wheatley are dental hy gienists in Tulsa, Okla. Address requests for reprints to Dr. Glass. 1. Bernhardt, M. Keeping up with prevention at the ADA. JADA 89:101 July 1974. 2. Council on Dental Health. Examples of community preven tion projects: winners of ADA Preventive Dentistry Award. JADA 89:105 July 1974. 3. McBean, L.D., and Speckmann, E.W. A review: the impor tance of nutrition in oral health. JADA 89:105 July 1974. 4. Driscoll, W.S.; Helfetz, S.B.; and Korts, D.C. Effects of acid ulated phosphate-fluoride chewable tablets on dental caries in schoolchildren: results after 30 months. JADA 89:115 July 1974. 5. Newbrun, E.; Plasschaert, A.J.M.; and König, K.G. Progress of caries in fissures of rat molars treated with occlusal sealants. JADA 89:121 July 1974. 6. Hinding, J.H., and Buonocore, M.G. The effects of varying the application protocol on the retention of pit and fissure seal ant: a two-year clinical study. JADA 89:127 July 1974. 7. Going, R.E.; Loehman, R.E.; and Chan, M.S. Mouthguard materials: their physical and mechanical properties. JADA 89:132 July 1974. 8. Van der Linden, F.P.G.M. Theoretical and practical aspects of crowding in the human dentition. JADA 89:139 July 1974. 9. Silverberg, E., and Holleg, A.I. Cancer statistics 1972. CA 22:2 Jan-Feb 1972. 10. Haagensen, C.D. Carcinoma of the breast. A monograph for the physician. American Cancer Society, 1958, p 7. 11. Thiessen, E.U. Breast self-examination in proper perspec tive. Cancer 28:1537 Dec 1971. 12. Hecker, R. The investigation of the patient. Modern devel opments including automatic multiphasic health screening and the use of computers in medicine. Med J Aust 2:492 Aug 1972. 13. Burzynski, N.J.; Moore, C.; and DeJean, E. Basic steps in mouth-throat examination for cancer detection. JADA 81:932 Oct 1970. 14. James, A.G. Systematic head and neck examination. CA 24:32 Jan-Feb 1974. 15. Jaffe, B.F. Otolaryngology for the dentist. Emphasis on the physical examination and its significance. Dent Clin North Am 18:77 Jan 1974. 16. Carryer, H.M., and others. Analysis of 2,812 examinations on 569 subjects at Mayo Clinic. Ind Med Surg 41:13 May 1972. 17. Holden, T.E. Reducing mortality in breast cancer through early detection. J Miss State Med Assoc 14:231 June 1973. 18. Gilbertsen, V.A., and Kjelsberg, M. Detection of breast cancer by periodic utilization of methods of physical diagnosis. Cancer 28:1552 Dec 1971. 19. Venet, L., and others. Adequacies and inadequacies of breast examinations by physicians in mass screening. Cancer 28:1546 Dec 1971. 20. Storer, R. Oral cancer. Lancet 1:430 Feb 1972. 21. Strax, P. New techniques in mass screening fo r breast cancer. Cancer 28:1563 Dec 1971. 22. Griep, E.A. Detection of breast cancer. A review of the registry from Blessing Hospital, Quincy. Ill Med J 144:480 Nov 1973. 23. Melamed, M.R.; Robbins, G.F.; and Foote, F.W., Jr. Prog nostic significance of gelatinous mammary carcinoma. Cancer 14:699 July-Aug 1961.