Impact of COVID-19 on the early detection of oral cancer: A special emphasis on high risk populations.

Dear Editor,

The emergence of the disease caused by the novel coronavirus 2019 (COVID-19) has resulted in an unprecedented global public health crisis, prompting the world health organization (WHO) to declare it a public health emergency of international concern. The pandemic has spread exponentially and unpredictably across the world causing, along with the so mentioned health burden, devastating global economic impacts [1]. By April 25, 2020, the numbers of global COVID-19 confirmed infected cases and deaths have exceeded 2, 719, 897 and 187,705, respectively [1]. In response to the widespread of COVID-19, with the objective to minimize community spread of the disease, countries adopted many preventive strategies like social distancing, lockdowns, and quarantine of suspected cases. Owing to the transmission of COVID-19 through droplets and aerosols, which are inherent features of dental practice, most of the countries followed a strategy of suspension of all elective dental care services and reserving dental care only for emergency cases. In this brief communication, we examine the impact of closure of dental practices during COVID-19 pandemic on missing opportunities for the early detection of oral cancer and discuss approaches to minimize the risks of delayed diagnosis.

Oral and oropharyngeal cancer represents a major public health concern worldwide, accounting for 447,571 new cases and 228,389 deaths, in 2015 [2]. The major attributable fraction of the risk of oral cancer is attributed to tobacco [3], either smoked or smokeless, alcohol and betel quid use. Most of oral cancer cases occur in low- and middle-income countries and among low socioeconomic groups in a population [4]. Indeed, around 30% of the global burden of oral cancer being in the Indian subcontinent, where it ranks the first of all body cancers in men [2]. Such a high incidence of oral cancer in these countries is mainly attributable to the high prevalence of its risk factors (smoking, smokeless tobacco, and areca nut). The latter, areca nut, a well-known risk factor for oral cancer, is habitually chewed by around 600 million Asians [5]. Besides areca nut and smoking, smokeless tobacco is a common habit in South Asia and the Middle East [6], [7]. The habit of spitting in public places by tobacco and areca nut chewers can significantly contribute to the spread of the offending corona virus.

Owing to the well-known major risk factors, oral cancer is considered a preventable disease and moreover, due to easy accessibility, it can be detected in early stages. Yet, majority of oral cancer cases in the developing countries are diagnosed in advanced stages, resulting in increased morbidity and mortality of oral cancer. Generally, dentists play a pivotal role in the early detection of oral cancer through opportunistic screening when a patient presents in a dental practice for routine care and by rapid referral of suspicious lesions. In the time of COVID-19, nevertheless, the whole world being in lockdown, and dental clinics are closed. Therefore, opportunities for screening the oral cavity might be significantly disrupted, and consequently diagnosis of malignant and/or potentially malignant lesions might be delayed, a matter that inevitably leads to a missed diagnosis of oral cancer or, at best, diagnosis later on but at a late stage [8].

Another major dilemma related to confinement and stress secondary to the outbreak is the probability of the indulging in the risky habits such as smoking, smokeless tobacco, and areca nut, which further increases the risk of oral malignant and/or potentially malignant lesions. It is understandable that the current unprecedented pandemic has drawn the attention of the whole world to the control of coronavirus disease and caring for the sick, yet other important health issues such as oral cancer still need our attention and should not be ignored. In light of the fact that the outbreak, and consequently the lockdown, might continue indefinitely, oral health professionals should come up with some alternative approaches to increase public awareness on early symptoms of oral cancer.

Many patients already diagnosed with oral potentially malignant disorders (e.g. oral leukoplakia) are under surveillance by oral medicine specialists in hospitals. Due to clinic closures, the regular clinic visits for review of their conditions are also heavily disrupted putting these patients at risk. New approaches are needed for continuing care for these special groups of patients, often neglected during emergency closure of clinics.

Telemedicine for educating, interviewing and examining the patients is one of these approaches. There are a plethora of applications and/or social media that can be used for this purpose including zoom, messenger, and Facebook. Dental practitioners/oral medicine specialists can arrange virtual visits to follow up, interview, do clinical examination, and even to conduct oral habits cessation counseling for their patients [9], [10]. For their part, the patients can take various photographs of their mouths and send them to the dentists at regular intervals [9]. Another important point to be stressed upon is the virtual education of the patients and the public regarding clinical signs and risk factors of oral cancer via valid and reliable websites, mostly organization- or education-based, rather than using the currently available information in the media, where most of which could be misleading.

In summary, during a pandemic other important health issues may be neglected by the public and ignored by the health systems and the dental profession has a role to engage in managing serious health issues such as “detecting oral cancers early” as an ethical responsibility.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.