Paul Lambden highlights the importance of early diagnosis and management of oral lesions.
As an indemnity provider, there has recently been a significant increase in the number of cases of oral cancer where the diagnosis has been delayed.
It is not common, but about one in every 50 cancers is a primary mouth tumour. Over 60% develop in people over 55 and it is more common in men.
Mouth cancer can develop in any area of the mouth. Recent cases have presented as persistent tongue ulceration, swelling of the tonsil and anterior pillar of fauces, and an enlarging mass in the floor of the mouth.
The ulcerated tongue case was not diagnosed in a timely manner. The patient attended the practice with an ulcer on the left lateral border of the tongue, which, he said, had been present for four weeks.
During the dental examination, the dentist identified a sharp lingual cusp on a lower second molar, which she stoned and smoothed.
She reassured the patient that: ‘It would be alright’. She asked the patient to book an appointment for a check-up, which he did for some eight weeks later.
When he returned the ulcer was still present, larger, and the patient pointed out that he had a small swelling in the neck on the same side. The dentist adjusted the lower molar further and prescribed a course of penicillin.
The patient returned the following week because the ulcer was bleeding intermittently.
The dentist became concerned. She referred the patient to the local maxillofacial department. They diagnosed a malignant ulcer with spread to lymph nodes.
The patient received surgery, chemotherapy and radiotherapy. However, the matter is now the subject of a claim.
During a dental examination or if a patient attends with any oral lesion, the dentist must:
- Take a history including smoking and alcohol usage
- Ask specifically about duration, pain, bleeding and any other related symptoms
- Examine the lesion carefully for any sinister features of appearance and the presence of any associated lymph gland enlargement
- If it is an ulcer, and you believe trauma is the cause, ensure that the patient fully understands that it is essential to see a dentist after a maximum of seven days to ensure healing. If it is not healing or if the ulcer has been present for three weeks, an urgent two-week referral to the hospital should be actioned.
It is also important that previously diagnosed lesions with malignant potential, such as leukoplakia, are regularly monitored and any changes should be carefully assessed and referred on the urgent two-week pathway.
The site of the tumour determines treatment of oral cancer. It also depends on early diagnosis. If diagnosed early, up to nine out of 10 cases are curable by surgery alone.
Delay results in a worsening prognosis and overall about 60% of patients live for five years after diagnosis.
In summary, diagnose and manage any oral lesion. If it persists or has any associated sinister features, clinicians should undertake an early referral using a two-week rule.