Everyone has a role to play when it comes to oral cancer (2024)

It is important that every member of the dental team has an understanding of how to support and care for individuals on a cancer pathway. Whilst in the dental arena we tend to have a strong focus on head and neck cancers, a narrower focus is placed on oral cancers. Whilst this is the central focus of this article, it would be remiss to not acknowledge the impact on oral tissues as a result of undergoing treatments for other cancers.

Looking at oral cancer through the lens of a dental nurse and more specifically an oral health practitioner requires individuals to be trained, competent and confident in their work. Whilst dental nurses and oral health practitioners do not diagnose or treat oral cancers within their scope of practice, what they should be able to do is recognise any changes within the oral tissues and raise concerns with other members of the dental team.

Dental nurses and oral health practitioners must be able to deliver concise and consistent messages to patients.

Equally, dental nurses and oral health practitioners must be able to deliver concise and consistent messages to patients and where necessary, to parents, other family members and/or carers and the public, when it comes to intervention. These messages are evidence-based messages and focus typically on a number of major risk factors and are commonly identified as:

• Tobacco

• Alcohol

• Human Papilloma Virus

• Excessive exposure to ultraviolet light.

Tobacco

It is important to follow current national and local guidance when developing resources and delivering key messages relating to tobacco. Much of the current evidence relates to the smoking of tobacco as the main risk, but other forms of tobacco, such as betel quid and areca nut, are also linked to an increased risk of oral cancers.¹ The messages that dental nurses and oral health practitioners deliver should highlight the links between the duration, ie years of smoking rather than the frequency of smoking and the associated risks of oral cancers.¹

Alcohol

When it comes to alcohol, again dental nurses and oral health practitioners should be armed with those concise and consistent messages that are evidence-based. Key to the messaging is understanding the current national and local guidance when it comes to units of alcohol and sharing that there are no ‘safe lower limits',¹ as alcohol is known to increase the risk of oral cancers and especially if combined with tobacco use. Alcohol is also linked to other health conditions as noted by Lewis.²

Human Papilloma Virus

The Human Papilloma Virus (HPV) is associated with oropharyngeal cancer. The key messaging here is the importance and value of the vaccine programmes in schools and the recognition of links to sexual practices and behaviours.¹

Excessive exposure to ultraviolet light

Lip cancers are not uncommon and as with any skin cancers, the key messaging here focuses on caution relating to prolonged exposure to the sun and the use of some alternative tanning measures.³

Facts - adapted from the Mouth Cancer Foundation⁴

• Oral cancer is the sixth most common cancer worldwide

• Over 10,825 new cases of oral cancer were diagnosed last year

• One person every three hours is lost to oral cancer

• Worldwide oral cancer affects 650,000 per year

• Twice as common in men than women, although the numbers in women are increasing

• Over half of oral cancers appear on the tongue and on the tonsils

• Although oral cancers have been most common in the over 55 age group, more are being seen in the younger age groups

• The ten-year survival rate is between 18% and 57% depending on where the cancer is and how early it is diagnosed

• The incidence has risen by 49% over the past ten years

• The five-year survival rate has hardly improved in the last few decades due to late detection

• Up to 25% of oral cancer cases have no associated significant risk factors

• Oral cancers have a higher proportion of deaths than cervical and testicular cancers combined

• More deaths in the UK each year than road traffic accidents

• Awareness of the signs, symptoms, and risk factors is poor and of the major signs and symptoms and risk factors too

• It is important all patients have good access to dental care pre and post oral cancer treatment.

Figure 1 shows the Mouth Cancer Foundation's self-check sheet.

Dental nurses and oral health practitioners should encourage patients where possible to practice effective self-oral care.

Face: Check for any swellings, any changes in the appearance of the skin and any lumps

Neck: Check under the lower jaw and either side of the neck and that both sides feel the same

The tongue: look at both sides of the tongue, look for swellings, ulcers or changes in colour and check the underside of the tongue

Lips: Check the lips for any sores or changes in colour, lumps or swellings

Floor and roof of the mouth: Look for ulcers or changes in colours, changes in texture, any lumps or swellings

Tonsils and salivary glands: Look for ulcers or changes in colours, changes in texture, any lumps or swellings.

This requires similar checks to the self-care path previously mentioned and those working in secondary care may perhaps be more involved in this patient group's care. This can be a truism of the care home settings too. It is also important to foster good relationships and communication strands within these settings and with both a general dental practitioner and the general practitioner. If we then turn to oral cancer care in the older person, there are a wider number of things to perhaps navigate, not least other health conditions and co-morbidity working and access to care.

Over 78% of mouth cancers occur in the over 55s and as 58% of people in the care home setting are living with dementia this can prove challenging for the care giver when assessing the oral cavity for a mouth cancer.

The Mouth Cancer Foundation encourage care givers to adopt the Look, Listen and Observe method for screening for mouth cancers with the older person.

Look

Has there been a change in behaviour? Unexplained weight loss, difficulties with eating or drooling from the mouth?

Listen

Is there a change in the sound of the resident's voice? Have they complained of a sore throat or cough which is not clearing up? Does it sound like the resident has something stuck in their throat?

Observe

Pay particular attention to the resident's whole face and neck area. Are there any unusual lumps, bumps, or changes on the surface of the skin, red patches or white patches inside the mouth? Have their dentures suddenly become loose?

The care staff know their residents well and are well placed to notice any small changes to their resident. It is essential that an oral assessment is carried out on admission to the care home and any changes are documented clearly and escalated to the senior member of the team. Some will have in-house training on delivering effective oral care and what to look for; a number of dental nurses/oral health practitioners are involved in these training sessions. The QR code in Figure 2 takes you to the screening recommendations set out by the Mouth Cancer Foundation.

A 92-year-old female care home resident had removed her denture and had attempted to scrape off the denture fixative with her fingernail. The staff had received oral care training from the Oral Health Improvement Lead commissioned by Rochdale Borough Council, and the training had improved oral care and subsequently had become an integral part of daily personal care.

The staff noticed that an area in the patient's mouth looked abnormal and raised this with a visiting health professional who advised an urgent referral to a GP.

After much to-ing and fro-ing between the GP and dentist, a referral was made to the local Maxillofacial Department and palliative care was agreed due to the woman's age and the aggressive nature of the tumour in her mouth.

It was suggested that the resident might be tube fed, which would have meant she would have to leave her current care home and move to one with nursing support.

It was agreed with the resident, her daughter and the staff at the care home that it was in her best interests to remain where she was. It is important to remember that although residents live in a care home, this setting is their home; they are surrounded by their treasured possessions and care staff who have often become family.

The Oral Health Lead supported the staff to maintain the resident's oral care and she did pass away peacefully in her bedroom at the care home. The images in Figure 3 and Figure 4 were taken two days apart.

Taking the case study into account it is vital then that the older population are not forgotten when it comes to oral cancer care. All too often the care of the oral cavity is overlooked or sadly deemed not a priority. Many members of staff may not have been appropriately trained or have the right resources and changes in the mouth can have unintentionally been missed over the years.

None of this is helped by a lack of accessibility to NHS dental services. These issues became a driver for change when it came to some of the Society of British Dental Nurses (SBDN) special interest group, taken forward by Emma Riley and Amanda McLaughlin, who are dental nurses. They were supported by Rochdale Borough Council and developed a sustainable training oral care pack and a set of unique ‘trolley' resources. These resources provide clear and concise information on how to clean the mouth, teeth or dentures, what to look for and what to do if there are any concerns. We are delighted to share that Emma and Amanda were awarded a winner's certificate for their academic poster based on their work by the British Society of Gerodontology. The guides can be seen in Figures 5 and 6 alongside a picture of Emma and the poster (Fig. 7).

The evidence suggests that early detection increases the chances of better outcomes,² but sadly we also know that oral cancers are often more advanced before they are detected.⁵ This makes the cancer more challenging to manage. Generally, the cancer pathway begins with a referral from a dentist or doctor to the secondary care team.

From the diagnosis stage currently, the patient needs to be seen by a dentist as mentioned previously to ensure the teeth and gingival tissues are as healthy as possible before treatments can begin. The communication strands at this point with the patient are vital and dental nurses and oral health practitioners are vital.

The cancer treatment pathway is decided in the secondary care pathway and at this point, secondary care dental nurses and oral health practitioners become involved as part of a multi-disciplinary team (MDT). The MDT team will be with the patient at different parts of the journey, the dental nurse/oral health practitioner will have undertaken additional training and will be key to this journey, at the diagnosis stage, during treatment and post treatment and of course during continual care in a palliative care pathway. This could include dental nurse led clinics and planned monitoring clinics. This is explained more below.

• Surgery

• Head and neck radiotherapy or Brachytherapy

• Chemotherapy

• Cetuximab

• Photodynamic therapy.

Prior to cancer treatment commencing, it is vital that the patient has an oral health check-up with a dentist and any necessary treatment is undertaken.

• Dental treatment is avoided wherever possible during therapy

• Patients receiving radiotherapy to the head and neck area are at higher risk of dental caries, and should receive dietary advice and fluoride preparations²

• Oral mucositis may develop; manage with local guidelines

• Increased risk of fungal infections in patients receiving chemotherapy and/or radiotherapy

• Change the toothbrush regularly

• Manage the dry mouth.

The risk of osteoradionecrosis and/or medication related osteonecrosis of the jaw should always be considered. Dental extractions must be avoided where possible as patients are at risk of developing these complications.² Ongoing oral health education to the patient is essential in maintaining a healthy oral cavity.

A fluoride regime should be decided by the patient's own GP and dental hygienist.

A dry mouth is the most complained about side effect of treatment; advice must be given on how to manage the symptoms and offer products to relieve the symptoms.

A person's oral health can impact the individual both physically and emotionally. Throughout palliative care, the hope is that the ‘…patient will live till they die…'⁵ The oral cavity goes on this journey with the patient, relatives and carers and the oral cavity can often be the last area in the body that the relative can be involved in cleaning and caring for.

Dental nurses can play an active important role in raising awareness of the oral problems that can occur in palliative care.

Dental nurses can play an active important role in raising awareness of the oral problems that can occur in palliative care and work closely with other healthcare professionals, relatives and carers empowering them to ensure a clean, healthy, moist mouth for these individuals at the most important of times.

Relatives often feel redundant and helpless if their loved one is in end-of-life care. To try and ensure they still feel included and an integral part of this process a simple video has been produced by Emma Riley and Amanda McLaughlin to help relatives and carers navigate and understand the often complex and ever-changing dynamics of the oral cavity and the role they can have, if they feel they want to, in helping keeping the mouth comfortable towards the end of life (Fig. 8).

Notably, for those dental nurses with an interest in this field, a field which goes beyond the high street dental practice, working in a hospital setting will be most appropriate. The role requires a greater adoption of listening and communicative skills and being able to deliver person-centred care, whilst respecting and supporting family members. For those who become part of the survivorship population they frequently have to adapt to life as a cancer survivor and what that means for them. Those facing palliative care will need tailored support to ensure their physical and emotional needs are met.

It is so important post-surgery that those working in the high street setting understand the challenges faced by these patients, in order that they can deliver the best care; dental nurses and oral health practitioners will be vital.