Avoiding misdiagnosis of oral cancer

November sees two events intended to raise public awareness of mouth cancer: the British Dental Health Foundation’s Mouth Cancer Action Month and the Mouth Cancer Foundations’ Mouth Cancer Awareness Week (10th to 16th November). It’s an important opportunity to raise the profile of this devastating disease because, worryingly, rates of oral cancer continue to rise.

According to the BDHF's latest statistics there were 7,698 new cases in 2011, a rise of 50% since 2000. Deaths from mouth cancer approached 2,500 in 2011. 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.

Dental professionals are 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.

The DDU opened 63 files in the five years between 2008 and 2012 which related to oral cancer, including 29 claims. In 53 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 four cases, the patient died from the disease.

Of the 29 claims, four have been settled and 12 closed with no payment while 13 remain active. Of the settled claims, the largest award of over £40,000 plus legal costs was made to the family of an elderly patient who died from oral cancer after a delay in diagnosis. As well as the claims, there were 31 complaints and six dental professionals were investigated by the GDC.

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 they know how to spot the possible signs and respond appropriately. The DDU has 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 if the patient does not want to discuss the subject, don’t insist.
  • Even though you will routinely examine patients for malignancy as part of routine dental examinations, it's important to ensure that your skills are in line with current teaching and practice. The GDC now recommends all 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 if negative, in the clinical notes, making a careful note of suspicious lesions or swellings along with your treatment plan and advice. The use of mouth maps and photographs may be helpful.
  • Dental professionals who suspect an abnormality might be cancerous 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.
  • Chase up oral cancer referrals to ensure they have been received and that the patient has been sent a consultation appointment.

This guidance was correct at publication 08/11/2013. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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Avoiding misdiagnosis of oral cancer

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