Oral Cancer – The Need to Remain Vigilant

By Dr Sarah Jones – NSW Advisory Services Peer Advisor

As dentists, we have an obligation to examine all intraoral tissues, not just the teeth and gums. Oral cancer is a debilitating disease and we certainly hope that none of our patients is unfortunate enough to develop cancer. However, with an increasing incidence, there is a reasonable chance that we may be the practitioners to notice cancerous or pre-cancerous lesions first, particularly if the presentation is symptom-free. Nobody wants to be the practitioner who allows cancer to develop under his or her watch.

It is important at all times to achieve the best possible outcomes for our patients. The routine application of effective oral cancer screening will have a dual benefit: the avoidance of delayed diagnosis (and the unfavourable consequences which can flow from that) and, by extension, fewer adverse consequences for the practitioner.

Aside from the obvious sense of guilt for a patient’s poor outcome, the consequences for a practitioner can include legal action for negligence. A recent overseas study [1] reviewed cases where dental practitioners were found liable for failure to diagnose and/or refer, and the results were costly (average settlement of over $1 million US). Strong statistical evidence is difficult to source locally, but it would be reasonable to expect similar adverse findings in the NSW and ACT jurisdictions, particularly with the rise of plaintiff legal firms actively targeting adverse medical outcomes.

“Dentists tend to sit on suspicious lesions” says Dr Peter Foltyn of the Dental Department at St Vincent’s Hospital in Sydney. Dr Foltyn sees 6-10 oral cancer patients weekly in his role at the Kinghorn Cancer Centre at St Vincent’s Hospital. He recommends not ‘sitting on’ suspicious lesions. One reference [2], produced by a WHO-sponsored collaborating group, seeks to assist in classifying whether a lesion is suspicious. If an undiagnosed lesion or ulcer persists for greater than two weeks, Dr Foltyn suggests that we either biopsy or refer.  His concern arises from seeing first-hand the outcome of diagnostic delay for patients attending the Head and Neck Clinic.

Perhaps this diagnostic delay arises from the tendency of dentists to ‘watch’ other pathology, such as incipient carious lesions. However the consequences of prolonged ‘watching’ of potential malignancy are much too severe for this to be an acceptable management strategy. Failure to diagnose or refer a patient promptly allows progression of the disease. As cancer progresses, the necessary treatment becomes more extensive and debilitating, and the chance of survival diminishes. Treatment for cancers may include combinations of surgery, chemotherapy and radiotherapy. If you are worried about a patient’s lesion, it is acceptable to not know the diagnosis, so long as you refer to someone who does.

There were 3,896 head and neck cancers (not including lip and skin cancers) reported [3] in Australia in 2009, and this number appears to be rising. This represents 3.4% of all cancers. 2,037 (or 52%) of these were oral cancers. If a newly diagnosed oral cancer patient has seen a dentist in the preceding year, the question that will be asked is: “Why did the dentist not see this?”

So what do we need to do?

Examination

  • Your examination needs to be thorough and well-documented, include both extra- and intraoral components, and any abnormalities must be noted and acted upon. A history of any symptoms must also be taken;
  • All mucosal surfaces must be viewed (the lip, tongue, floor of mouth, buccal mucosa, gingivae, and palate); dentists have a tendency to jump straight to the teeth and periodontium;
  • Dr Foltyn says screening can be easily done in “less than a minute” and suggests, for example, screening while waiting for local anaesthetic to take effect;
  • Educate yourself about which lesions should raise an index of suspicion, due to a higher malignant transformation potential;
  • Remember also to ensure that you examine all patients being treated by a dental auxiliary in the context of a Structured Professional Relationship; and
  • Take a thorough history to identify any significant risk factors such as tobacco or alcohol, and educate yourself about emerging risk factors, such as HPV (human papilloma virus).

A suspicious lesion

  • If a lesion is suspicious and persistent (i.e. not reducing in size or healing), and if in any doubt as to the diagnosis, it must be biopsied or referred for diagnosis;
  • Document the lesion appropriately in your notes with a very comprehensive description of your findings. Photographic images are particularly useful;
  • Dr Foltyn encourages practitioners to become familiar with performing simple punch biopsies in appropriate circumstances, and referring when necessary;
  • Establish referral pathways for your practice, so that you have a number of dental and medical specialists to whom you can refer quickly, if necessary; and
  • Remember to ensure that the patient did in fact follow through on the referral. However, there is a fine line between making a patient unnecessarily anxious, and ensuring they understand the necessity for diagnosis of a suspicious lesion.

Summary

Screening patients for oral cancer allows us to identify cancer early, perhaps before it is even symptomatic. We have an obligation to check for any suspicious lesions, screening takes very little time, and the outcome for patients is vastly improved by early diagnosis and management.

Key points

  1. A dentist is obliged to examine all relevant extra- and intraoral tissues during examination
  2. If a lesion persists for greater than 2 weeks, and if in any doubt as to diagnosis, BIOPSY or REFER
  3. Delaying treatment allows progression of cancer
  4. Failure to diagnose and/or refer could lead to medico-legal issues

Bibliography: 

[1] Head and neck, oral, and oropharyngeal cancer: a review of medicolegal cases. Epstein JB et al, Oral Surg Oral Med Oral Pathol Oral Radiol 2015 Feb;119(2):177-8

[2] S. Warnakulasuriya et al, Nomenclature and classification of potentially malignant disorders of the oral mucosa. J Oral Pathol Med (2007) 36: 575-80

[3] Australian Institute of Health and Wealfare 2014. Head and neck cancers in Australia. Cancer series no. 83. Cat. no. CAN 80. Canberra: AIHW

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