Utilization of COVID-19 testing for opportunistic screening of oral cancer.

Dear Editor,

On March 11, 2020, the world health organization (WHO) declared COVID-19 a pandemic as the world faces unprecedented global health crisis. COVID-19 has severely impacted public life and the global economy [1]. In response, governments aiming to minimize community spread adopted preventive strategies like closing schools and enforcing social distancing. Such measures resulted in suspension of all elective dental care services and limited practice to emergency cases only; this also meant that oral cancer screening has almost entirely stopped. In this letter, we would like to make a case for conducting oral cancer screening when individuals are tested for COVID-19, which, if given careful consideration, would likely improve population health on the long-run.

Oral cancer is considered a major global health burden. Over 354,000 new cases and 177,000 associated deaths have been reported in 2018 [2], mostly in low- and middle-income countries and among low socioeconomic groups [2], [3]. Up to 30% of the global burden of oral cancer is reported in the Indian subcontinent where it ranks first among all cancers [3]. This could be attributed to wide use of major risk factors like tobacco, alcohol, and areca nut [3], [4]. Unfortunately, more than half of oral cancer cases –especially in developing countries- are diagnosed in late stages, which translates to high mortality and morbidity. Even in developed countries like the United States, five-year survival is no more than 65% [4].

Oral cancer is often preceded by visible oral changes known as “oral potentially malignant disorders” (OPMDs), which can be visually detected and put under surveillance [5]. Basic screening with visual inspection remains the best method to detect visible cancerous or OPMDs, possibility reaching 74% sensitivity and 99% specificity [6]. As mentioned previously, the suspension of dental practice negatively affects the role of dental practitioners in prevention and early detection of oral cancer and OPMDs. To overcome such issues, oral health professionals should come up with alternative and innovative approaches.

It is known that community-based screening of oral cancer is costly and needs plenty of resources and workforce; however, health decision makers can benefit from mass COVID-19 screening in early detection of oral cancer. Hundreds of thousands or even millions of people all around the world are screened for COVID-19 daily. We therefore suggest deploying dentists, hygienists, and dental students in COVID-19 testing centers and adopting “opportunistic screening” of oral cancer side by side with COVID-19 testing. This is particularly important for high-risk individuals with history of tobacco or alcohol use. To test for COVID-19, swabs are taken from oro- or nasopharyngeal mucosa often with the mouth wide open. Visual inspection of the oral cavity for the purpose of screening oral cancer and OPMDs can be done quickly and is unlikely to be a major inconvenience. The examination can be done using headlight and disposable dental examination instruments, and a well-trained dental practitioner will not take more than two minutes to finish the exam [7]. Accordingly, we expect individuals coming for COVID-19 testing will mostly agree to oral cancer screening if given the option.

To help achieve this goal, interns and senior dental students can be trained on conducting visual inspection and examination of the oral cavity for oral cancer and OPMDs. The suggested “opportunistic screening” can be applied in similar circumstances, other than COVID-19, where large number of people attend medical centers, or can be approached elsewhere via medical teams. Dental societies and professional organizations have to coordinate with health policy makers in order to adopt the strategy of opportunistic screening, and to train and involve dental practitioners, interns and senior dental students in such a strategy. We have seen many dental students and practitioners show great solidarity as they volunteered to help during the pandemic in hospitals and senior citizen centers, so we believe many are willing to volunteer with enthusiasm in an activity that is relevant to their area of practice. Oral cancer researchers pin hopes on opportunistic screening to reduce the incidence of late stage diagnosis and hence improving the outcomes [7].

Opportunistic screening for oral cancer is a cost-effective and feasible approach during the COVID-19 pandemic that will prove to be beneficial for population health in the future. However, such effort requires a well-developed system for preparedness, training, coordination, follow-up and referral.

Declaration of Competing Interest

The authors declared that there is no conflict of interest.