November is mouth cancer awareness month – a cancer that currently affects over 8,300 people a year in the UK, and resulted in 2,722 people in the UK losing their life in 2017. The number of people affected by mouth cancer has increased almost 50% in the last ten years.
Dentists see a large number of patients every year, and although it is unlikely that a dentist will see more than 1 or 2 cases of mouth cancer during their career, a vigilant approach should be adopted if malignancies are not to be overlooked. Unusual infections relating to retained roots or appearance of an infection adjacent to otherwise healthy teeth, unexplained mobile teeth, local osteomyelitis, swellings or discharges are signs to be wary of, and any oral and facial lumps, swellings and ulcerations that do not respond to the usual or accepted lines of treatment or do not heal in the usual way should be investigated further.
Benign conditions can sometimes be precursors of future problems and as such, they require careful monitoring and appropriate follow up. The greatest concern is the presence of malignant lesions. A carcinoma may present as an ulcer and can mimic a number of more common clinical conditions including periapical lesions, periodontal disease, natural movement or tilting/displacement of teeth or facial asymmetry.
Luckily, when patients visit the dentist for a routine examination it presents an ideal opportunity for carrying out an oral cancer screen on the oral mucosa.
Following the basic principles of a dental hard and soft tissue examination will alert dentists to the possibility of a benign or malignant lesion requiring investigation. An awareness of the risk factors and their relevance for example, age, family history, ethnicity and social habits such as smoking or alcohol consumption are all important considerations for clinicians.
A medical history can reveal a recognised risk factor for mouth cancer which may or may not be relevant to lesions seen in the mouth. For this reason, any such screening should include a lifestyle enquiry (use of tobacco, alcohol, betel nut, etc.) and a regular review of the patient's medical history. Smokers should be offered and encouraged to seek professional help with smoking cessation.
The most effective oral screening is one that follows a consistent, structured and reproducible format for each and every adult patient. Ideally this should involve a visual inspection of all areas of the mouth, including the floor of mouth, gingivae, sulci, palate, tongue and oropharynx. Any unusual lesions should be palpated and examined by touch.
A record should be made in the clinical notes of the site, size, colour and consistency of any lesion. Diagrams, photographs or intra-oral camera images can be helpful too, so future comparisons can more easily be made.
An extra-oral examination should also be performed, routinely checking the symmetry, salivary glands, lymph nodes and temporomandibular joints. A careful review of the rest of the face can reveal a variety of skin lesions, such as melanoma, basal cell and squamous cell carcinoma.
In particular, concerns about facial asymmetry, persistent unexplained swelling or bleeding, or continuous low-grade pain should cause concern. Unusual masses in the salivary glands and nodes can be detected, and an early referral made. It is entirely appropriate for a dentist to make a referral to the appropriate specialist for further investigation.
It is important to assess and document nerve function when dealing with any patient who complains of unusual or persistent facial pain. The areas of the face and mouth identified as having a change of sensation should be assessed and recorded, and it is often helpful to draw a diagram of the affected area. Motor or sensory loss, particularly when associated with pain should be referred and investigated by a Maxillofacial Surgeon or a Neurologist without delay.
Dental practitioners should be mindful that they may be the only healthcare professional who has the opportunity to see the patient and identify these conditions in time to make a difference to the prognosis.
What is normal?
Many straightforward oral conditions like white patches and ulcers have been linked with malignant change. It is crucial to assess and refer these conditions as necessary and if within your clinical capability and experience, a clinician may be able to investigate appropriately and establish the diagnosis themself. Alternatively a clinician will refer the patient to an appropriate clinician and obtain a diagnosis with the help of an expert opinion. A decision would then be made as to who will monitor and review these conditions carefully.
Part of the monitoring process is explaining to the patient what is normal and what changes to look out for. Monitoring is most successful when patients are actively involved and feel that they can easily and quickly report changes or concerns. If they do, it is imperative that these reports are taken seriously and acted upon.
If there is any doubt about an individual case, it may be possible to ask a colleague in your practice to have a look at the patient with you. Any referral to a Maxillofacial Surgeon or Oral Medicine specialist should be made with the patient's consent and this will need to include an explanation as to why a second opinion is being sought. If this is done firmly but sensitively, it need not alarm the patient. Try to avoid trivialising the matter as the patient may not appreciate the need to act upon the referral.
A referral should include a proper summary of the case, including a provisional diagnosis if one can be made and a clear statement of your concerns about the patient. It should also include all the necessary data that the specialist will require in order to determine the urgency of the referral, and a statement about the patient's relevant medical history, relevant risk factors as well as a description of the clinical findings.
Follow up and record keeping
Ensure you follow up and monitor every referral relating to oral lesions and suspected pathology. If the lesion is serious enough to merit a second opinion, it is serious enough to follow up. To suggest a referral and then to take no further interest in the outcome has, in the past, been criticised as a breach of the dentist's duty of care.
Record keeping allows the dentist to demonstrate every conversation, procedure and test that has taken place – these should include both positive and negative findings and the consent obtained from the patient.
For patients who see multiple dentists or doctors, clear and constant records are vital so that everyone who has been involved in the patients care can see the journey the patient has taken. This should include what information has been given to the patient and what advice or discussions have taken place.
In a situation where a patient alleges negligence against a practice or a clinician, but failed to attend a review, claims can be more easily refuted if the patient record clearly documents the examinations that were carried out and the appointments that were made. In addition it is often helpful to have a record of the attempts to make appointments, contact the patient or follow up on any referrals made.
The persistent problem
Any persistent symptoms and/or signs that have not responded to treatment or clinical input need to be highlighted. If a patient has cooperated with treatment and attended regularly, but there is no change to a lesion within two weeks, then they should be referred for a consultant opinion. Early referral can often assist in the screening of a patient for malignancy, and when referral is contemplated it must be done quickly.
A variety of tests and investigations are now available for primary care practitioners to investigate suspicious intra-oral lesions. The use of these products requires a degree of formal training and a clear understanding of the limitations of each investigation. Part of the training should include the interpretation of the findings of each test and a clinician should have an awareness of their own clinical limitations in carrying out tests or determining a diagnosis. The danger of a false negative creating a false sense of security could lead to inappropriate reassurance and an inevitable delay in referral.
In both a negligence and General Dental Council case, fault cannot be attributed to any particular product since clinicians must still rely on their own observations, interpretation, analysis, suspicions and clinical judgement.
Patients should be handled sensitively and carefully, and a proper explanation given of the concerns and the need for referral. A false alarm will always be preferable to a missed diagnosis, and although 'hoping for the best' is less confrontational, it may not properly discharge one's duty of care to the patient.
A late referral for a suspected malignant lesion may cause the patient unnecessary distress, pain and suffering through the delay in obtaining a diagnosis or treatment. There are many cases when some delay in referral is inevitable because of the need to eliminate the more common problems, but any delay must be justified within the records, showing a proper consideration of the history taking, assessment, investigations and appropriateness of treatment planning and monitoring decisions.
In order to ensure that any lumps, lesions, swellings, discharges or ulceration are properly assessed, it is important that dentists stay abreast of current developments in the assessment and diagnosis of these types of lesions.
The management of an oral malignancy depends on the specific diagnosis and the stage of the tumour. It is therefore crucial to refer any suspicious lesions to an experienced specialist at the earliest opportunity.
A delay in referral can have devastating consequences for the patient, leading to allegations of negligence. Effective patient management in these cases is a balance between best clinical practice, informed by regular continuing professional development and underpinned by accurate and appropriate record keeping.
This article was originally published in 2014.