Oral Cancer Screening Consent Form

Our practice continually looks for advances to ensure that we are providing the optimum level in oral health care to our patients.  We are concerned about oral cancer and look for it in every patient regardless of history or habits.

One American dies every hour from oral cancer.  Late detection of oral cancer is the primary cause that both the incidence and mortality rates of oral cancer continue to increase.  As with most cancers, age is the primary risk factor for oral cancer.  Tobacco and alcohol use are other major predisposing risk factors but more than 25% of oral cancer victims have no such lifestyle risk factors.  Oral cancer risk by patient profile is as follows:


Increased Risk:  patients ages 18-39

High Risk:  patients age 40 and older; tobacco users (any age, any type within 10 years)

Highest Risk:  patients age 40 and older with lifestyle risk factors (tobacco and/or alcohol users with previous history of oral cancer.


We have incorporated an early detection oral cancer screening into our standard of care.  We find that using this method allows us to identify suspicious areas at their earliest stage, sometimes even before they are visible in the mouth.  This method is similar to proven early detection procedures for other cancers. It is a simple and painless examination that gives the best chance to find and oral abnormalities at the earliest stage.  Early detection of pre-cancerous tissue can minimize or eliminate the potentially disfiguring effects of oral cancer and possible save your life.  This screening will be offered to you and your family once per year starting at the age of 18.

This enhanced examination is recognized by the American Dental Association code revision committee as CDT-5 procedure code D0431: however, this exam may not be covered by your insurance.