History
The patient was told to visit the dentist by her GP. On examination, the dentist saw a large ulcer on the left side of the lateral border of the tongue. It was roughly 2 cm long, and 1 cm wide, in the region of the LL5 and LL7 (LL6 was missing).
The dentist decided that the signs and symptoms suggested that malignancy was unlikely. The patient appeared fit and well and was in her late twenties. She said the ulcer was very painful, which was uncharacteristic of cancerous ulcers, except in the final stages. She also thought it had reduced in size over the last few weeks (though she did not tell the dentist that she had been troubled with the ulcer for about a year). The dentist checked round the patient's neck to see if her lymph nodes were swollen, but they were not.
The dentist decided the ulcer was probably no more than a traumatic one. He thought the missing tooth was allowing the tongue to encroach into the space and leading to mucosal trauma. There were generalised gross deposits of sub and supra gingival calculus in the area. The dentist concluded periodontal treatment would remove the probable cause of friction and irritation. If it did not heal, a biopsy would be needed.
He reassured the patient, and performed a gross scale of the lower left quadrant. Over the next two months, the patient attended three further appointments with the practice hygienist for periodontal treatment. A fourth visit was scheduled, at which the dentist intended to review the lesion. But the patient failed to attend.
Two months later, the dentist received a letter from the hospital, informing him that a squamous cell carcinoma of the tongue had been diagnosed. The patient underwent extensive surgery, radiotherapy and chemotherapy, but she died within a year.
Negligence alleged
The patient's widower alleged that both the dentist and the GP had been negligent. He accused the dentist of failing to carry out proper investigations and failing to diagnose a cancerous growth.
Expert opinion
The GP belonged to another defence organisation, which sought the opinion of a professor in oral medicine. He said the main blame should rest with the dentist:
"The GP, in the absence of expertise, did advise the patient to visit the dentist (who) should have had the expertise to diagnose the carcinoma on presentation and take appropriate action"
But a consultant oral and maxillo-facial surgeon, who was approached by the DDU on the dentist's behalf, had a different opinion:
"I do not feel that a group of similarly trained GDPs would have been able to make the correct diagnosis with any degree of confidence in this case as:
- such tumours are rare (approximately 2,000 cases a year - a dentist may see one new case in the whole of his career), and
- it did not have the usual characteristics of a classical squamous cell carcinoma with a crater type ulcer with rolled everted edges (instead it was serpiginous in shape along the tongue border)".
The consultant also considered the rapid spread of the disease to both sides of the neck and its insensitivity to all treatments. He said this suggested that the tumour "was biologically highly malignant and arguably of very poor prognosis from the outset". He added:
"There is good evidence …that dental practitioners are not adept at making the diagnosis of squamous cell carcinoma, probably because they see many ulcers that heal spontaneously and so are tempted to wait before referring."
A body of opinion would support the dentist in assuming the patient's ulceration had spontaneously healed when she failed to attend the review appointment".
Another consultant noted that:
"Diagnosis of oral cancer may be difficult as many diseases can cause ulceration within the mouth and failure to make a correct diagnosis at first sight does occur. In particular, one form of aphthous ulceration, major aphthous ulceration, is characteristically recurrent and causes large ulcerations which are slow to heal. Also, pre-malignant lesions occur in the mouth. In general, clinicians are advised to be cautious and suspicious of any lesion which could possibly be a cancer."
Outcome
The patient's widower discontinued his action. The DDU and the GP's defence organisation agreed to meet their own costs in full.
This page was correct at publication on 09/11/2002. Any guidance 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.