According to the Oral Health Foundation's The State of Mouth Cancer UK Report 2019/2020, new cases of oral cancer in the UK have now reached 8,337 a year. This has increased by 64% in the last decade and by 171% compared with 20 years ago, and 2,701 UK residents died from the disease last year.
Smoking and heavy drinking are the most significant contributory factors, while the use of smokeless tobacco, chewing betal quid, HPV infection and poor diet can also increase the risk - but awareness of the main risk factors is quoted in the OHF's report as being just 21%.
Dental professionals are usually in an ideal position to spot suspicious lesions or ulcers but the aggressive nature of the disease means that missing one opportunity to make an early diagnosis or prompt referral can have serious consequences for the patient's prognosis.
Coronavirus complications
During the restrictions placed on dental practices in response to the spread of COVID-19, patient interactions were significantly reduced and general practice was restricted to telephone triage, or video consultations if available.
While it was still possible to refer patients for suspected oral cancer, the lack of examinations over this period prevented patients who were unaware of lesions to be identified, and only those patients concerned about lesions who contacted their practice are likely to have been referred. Possible delays in referrals are thought likely to be a contributory factor in delayed diagnosis that may have a significant impact on a patient's prognosis.
DDU data
The DDU opened 104 files between January 2013 and August 2020 relating to oral cancer, including 69 claims.
In 65 cases, the dental professional allegedly failed to check the patient for oral cancer during their check-up, did not diagnose a suspicious lesion, or there was a delay in referring the patient to a specialist. In at least six cases, the patient died from the disease.
Of the 69 claims, seven have been settled and seven closed with no payment, while 20 remain active. Of the settled claims, the largest award of over £13,000 plus legal costs was to a patient who presented with a large abscess in the posterior maxilla and a failure to diagnose squamous cell carcinoma was alleged.
As well as the claims, there were 35 complaints; three dental professionals were investigated by the GDC and one by the Irish Dental Council.
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Referrals
Most dental professionals are lucky enough not to see many cases of oral cancer during their career, but with the disease becoming more common it is important to know how to spot the possible signs and respond appropriately. However, Cancer Research UK have noted a significant reduction in the number of 'urgent referrals' for cancer over the period of restriction, saying, "Overall, the number of urgent referrals has dropped to around 25% of usual levels in England."
With face to face consultations returning referrals for suspected lesions are likely to begin to rise, so it is important to consider the referral pathways for your area. NICE updated their cancer referral guidance in 2015, and you should consider a suspected cancer pathway referral by the dentist (for an appointment within two weeks) for oral cancer in people when assessed by a dentist as having either:
- a lump on the lip or in the oral cavity consistent with oral cancer, or
- a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
Risk management
The DDU has also produced the following risk management advice to help members reduce the risk of delayed diagnosis.
- To know if a patient is at risk, you need to ask them about their lifestyle and record their response. Explain why your questions are relevant but don't insist if the patient doesn't want to discuss the subject.
- Even though you will routinely examine patients for malignancy as part of dental examinations, it's important to ensure that your skills are in line with current teaching and practice. The GDC now recommends that registrants complete continuing professional development in the early detection of oral cancer.
- It's advisable to have a low threshold of suspicion when it comes to any lesion or swelling, particularly when the patient is in a high risk group. If patients themselves complain of symptoms but there is no obvious problem, be prepared to seek a second opinion and investigate further if necessary.
- Record your examination findings - even negative ones - in the clinical notes, making a careful note of suspicious lesions or swellings along with your treatment plan and advice. Using mouth maps and photographs may be helpful.
- If you suspect an abnormality might be cancerous, you should make an immediate referral to an appropriate specialist for further investigation, in line with the referral guidelines produced by NICE or SIGN. Your practice should have a protocol in place to ensure referrals are made efficiently and consistently.
- Explain to the patient what you have found and what happens next. It's a good idea to tell them how long they can expect to wait before receiving an appointment and advise them to call if there is any delay.
- Follow up oral cancer referrals to make sure they have been received and that the patient has been sent a consultation appointment.
Eric Easson
Eric qualified in 2001 at Manchester University, gained the dip.MFGDP in 2006 and a Masters in Medical Law (LLM) with merit in 2015. He worked as a clinical teaching fellow at Manchester University from 2004-2020, and has worked in general practice since qualification.
He started to work for the DDU as a part-time dento-legal adviser in 2014, and is a current member of the Faculty of Forensic and Legal medicine [MFFLM], Faculty of Dental Surgery [MFDS] and College of General Dentistry [MCGDent].
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