Background and statistics

Oral cancer in the UK population is on the rise and is increasingly detected in young adults, some without a history of predisposing factors such as alcohol or tobacco use.

Data from Cancer Research UK indicates that rates of oral cancer have increased by 68% in the past 20 years, while data from the Oral health Foundation's State of Mouth Cancer UK Report 2020/21 also shows that the number of new oral cancer cases in the UK reached 8,337 in 2020/2021. The data also shows that in 2020, 2,702 people lost their life to oral cancer.

The ten-year oral cancer survival rate is between 18% and 57%, depending on where the cancer develops and how early it is diagnosed and treated.

The Cancer Research UK findings indicate that approximately 90% of oral cancer cases are linked to lifestyle factors and other risk factors. The data shows that smoking is the main avoidable risk factor, linked to an estimated 65% of oral cancer cases. Other risk factors include alcohol consumption, poor diets low in the amount of fruit and vegetables consumed, and human papilloma virus (HPV) infections.

Early diagnosis

Oral cancers comprise cancer of the lips, tongue, mouth (gums and palate), tonsils and the oropharynx. It can spread quickly, which is why early detection and referral is very important - early diagnosis significantly increases the five-year survival rate, and detection of lesions under 2cm is key.

There are also multiple factors that can reduce the risk of a delayed oral cancer diagnosis and any subsequent legal action. The GDC recommends that continuing professional development should include the early detection of oral cancer to ensure dentists have the requisite skills and knowledge to detect oral cancer clinically.

While primary care dentists will not see oral cancer cases all that frequently, the published data clearly indicates that the incidence of oral cancer in the population is increasing. Because of this, a high level of awareness is crucial in terms of fully considering the cause of new symptoms or suspicions lesions in a patient's mouth.

Reducing the risks of a claim

Follow-up and referrals

In order to reduce the risk of oral cancer misdiagnosis and any subsequent legal action, it is essential that the correct NICE guidelines for urgent referral are followed. It is also good practice to follow up on referrals to hospital, to make sure it has been received and is being dealt with - especially in terms of confirming that an appointment with a specialist has been arranged.

Records and reports

It's also essential to record all important clinical information. This could include palpation of the lymph nodes in the neck as part of the clinical examination, the duration of symptoms, the size, site, shape and texture in relation to the lesion, and accurately monitoring any changes by using photographs and previously recorded clinical information in relation to the lesion. Using mouth maps could also be useful.

Having detailed, accurate and contemporaneous clinical records is essential for defending clinical negligence claims, as the records can provide justification for the treatment provided and demonstrate professional reliability. In order for a claimant to succeed in a civil claim for negligence, they will have to prove there was breach of duty by the clinician, which caused injury to the claimant, so good record keeping is an important element of a successful defence.

Risk factors and advice

Recording any preventative advice given is also very important. This includes providing smoking and alcohol cessation advice, as both are significant risk factors for oral cancer.

In addition to smoking and alcohol consumption, dentists also need to be aware of other relevant risk factors, such as the use of smokeless tobacco and chewing betal quid, which have been associated with precancerous and cancerous lesions of the oral cavity. HPV infections and poor diet can also increase the risk of oral cancer development. Existing lichen planus and the presence of submucous fibrosis (from Pan chewing) are also risk factors, which can be precursors of oral cancer.

In order to establish the risk level of a patient with regards to oral cancer, questions need to be asked about their lifestyle, and the responses should be recorded accurately in the clinical records. The patient needs to be aware of the relevance of these questions in relation to the risk level for oral cancer.

If a patent is in a high-risk category for oral cancer and they have relevant symptoms, but there is no obvious problem, it would be prudent to obtain a second opinion and carry out further investigations and monitor the situation regularly, if required. Making a correct diagnosis based on clinical presentation and considering oral cancer in the range of differential diagnosis, and arranging appropriate urgent onward referral by using the two-week suspected oral cancer pathway, is essential.

Guidelines

The NICE guidelines for oral cancer referral were updated in 2015 to consider a suspected cancer pathway referral (for an appointment within two weeks) for oral cancer in patients with either:

• unexplained ulceration in the oral cavity lasting for more than three weeks, or
• a persistent and unexplained lump in the neck.

An urgent referral should be considered (for an appointment within two weeks) for assessment for possible oral cancer by a dentist in patients who have either:

• a lump on the lip or in the oral cavity, or
• a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

A dental professional should consider a suspected cancer pathway (for an appointment within two weeks) for oral cancer in patients when assessed 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

Summary

Rising rates of oral cancer over recent years indicate that it is more important than ever to identify the warning signs of oral cancer as early as possible, and to make appropriate timely referrals.

The information and advice given above highlights the importance carrying out a thorough and accurate clinical examination and keeping detailed records of their clinical findings. As well as making sure patients are cared for as thoroughly as possible, doing so can also help avoid the worry of a claim arising as a result of late or missed diagnosis.