Download Oral Cancer: Prevention and Detection in Primary Dental Healthcare

ORAL MEDICINE AND PRIMARY DENTAL CARE
Oral Cancer: Prevention and Detection
in Primary Dental Healthcare
David I Conway, Lorna MD Macpherson, John Gibson and Vivian I Binnie
The incidence of oral cancer is rising
in the UK. Mortality from the disease
r e m a i n s h i g h a n d s u r v i va l h a s n o t
improved significantly in the last 30
years. The primary dental health team
has an integral role in the delivery of
oral health promotion and prevention
advice and in the early detection
o f oral malignancy and potentially
malignant lesions. Both prevention
and early detection within the general
dental practice setting have a potential impact on overall incidence, morbidity and mortality from oral cancer.
KEY WORDS: ORAL CANCER, PREVENTION, PRIMARY CARE
Introduction
Oral cancer remains an insidious
and growing problem. The most
recently available United Kingdom
data show that there are approximately 3500 newly diagnosed cases
of oral cancer per annum 1-4 with
about half of this number dying
from the disease each year.1,3,5
The incidence and mortality
rates associated with oral cancer
have generally shown little improvement over the last three
decades. 6 The five-year survival
rates for oral cancer remain poor,
with little improvement having
been observed in England and
Wales over the last three decades, 6
and survival from oral cancer in
Scotland getting worse in the same
period. 3
Oral cancer is more prevalent
in people from deprived backDI Conway BDS, FDS. Lecturer/Specialist
Registrar in Dental Public Health.
LMD Macpherson PhD, BDS, MPH, FDS,
FRCD(C). Senior Lecturer in Dental Public
Health.
J Gibson PhD, BDS, MB ChB, FDS(OM), FFD,
FDS. Senior Lecturer in Oral Medicine.
VI Binnie BDS, MPH. Lecturer in Oral Health
Promotion/Dental Public Health.
All at University of Glasgow Dental Hospital
and School, UK.
This paper details the primary dental
healthcare team’s roles in delivering
s m o k i n g c e s s a t i o n a n d a l c o h o l r eduction counselling, in the early detection by oral examination, and in the
process of prompt referral.
© PRIMARY DENTAL CARE 2002;9(4):119-123
grounds, 6 and in the older population, 7 with 98% of cases presenting
in those over 40 years of age. 7
However, there is recent evidence
to suggest that there is a rise in
younger age groups, 8 thus it is
important to recognise that oral
cancer can occur in either gender
and at almost any age.
Through regular patient contact,
general dental practitioners are in
the ideal position to examine properly the oral soft tissues thus, in
theory, promoting the early detection of oral cancer and potentially
malignant lesions. 6
Furthermore, if oral cancer is
suspected, the dental team plays a
vital role in the early management
of the patient with respect to
patient counselling and prompt
referral, thereby facilitating early
diagnosis and definitive treatment.
The primary care dental team is
therefore in the pivotal position
to speed the patient’s journey
from the community to the hospital
service.
The educational requirements of
the whole primary healthcare team
in relation to oral cancer-related
practices have been investigated
r e c e n t l y . 9 In response to these
needs a continuing educational
resource material Oral Cancer
Pr evention and Detection 10 was
developed and distributed to primary healthcare professionals in
Scotland.
Prevention
The aetiology of oral cancer is
multifactorial. There is unequivocal evidence establishing tobacco
usage and alcohol consumption as
the major risk factors in the development of oral cancer.11 Moreover,
a synergistic relationship between
tobacco and alcohol is recognised,
with a greatly increased risk if
both habits are practised together. 12
Encouraging patients to become
aware of what they can do to
prevent oral cancer is important
for all health professionals. The
general dental practice team has an
important role to play through
dissemination of oral health promotion advice.
In general, the dental team
should be seen to practise what
i t preaches: the dental practice
should aim to become a healthpromoting environment. Both staff
and patients should benefit from
measures to create a healthy
environment. The practice should
develop and adopt a no-smoking
policy, both in work areas and in
the waiting room. The most important health promotion activities in
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preventing oral cancer are smoking
cessation and sensible alcohol
consumption. Patient information
should be readily visible and available in practice waiting rooms and
at reception.
Health Promotion Departments
are an important resource, both in
terms of trained personnel and
health education materials. The
primary care dental team would
benefit from one member acting as
liaison between the local Health
Promotion Department and reporting back to the practice about
new materials and literature.
Smoking cessation and alcohol
reduction counselling
Prevention advice should begin
with recording in the case notes
the patient’s smoking/tobacco and
alcohol habits as part of the routine
history and examination of regular
attenders, as well as new patients.
Of the dentists who do ask, some
find it difficult to take this further
in those patients who are asymptomatic. Dentists are more at ease
with broaching the topic of smoking cessation if there is evidence
of tobacco-related lesions in the
mouth. 13
The 4As approach to giving
smoking cessation advice: (Ask
your patient, Advise your patient,
Assist your patient, Arrange followup for your patient) is a welldocumented approach which forms
a useful guide for dentists and
hygienists working chairside. 14 It
has recently been modified to
include a fifth ‘A’ which incorporates assessment of the patient, as it
is known that all patients are not
psychologically ready to give up,
and a modified approach known as
the 5As can be used. 15
For the ‘4/5 As’ model to be
most effective and implement
change, multidisciplinary working
across the whole of primary healthcare services is required. Thus,
guidelines for primary care members, including the dental team,
have been issued in both Scotland
and England.16,17 This should ensure
clear and consistent advice across
all team members when delivering
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smoking cessation advice.
Many quit-attempts in patients
fail due to nicotine withdrawal
and this can be addressed by the
use of nicotine replacement therapy
(NR T). Infor mation on and encouragement to use NRT is seen as
part of ‘Assist’ for patients who are
trying to quit and who wish to use
Facial
Superior
deep jugular
Submandibular
Submental
Middle
deep jugular
Inferior
deep jugular
Supraclavicular
Figure 1 Cervical lymphatic chain.
this therapy. Currently, dentists in
the UK are not able to prescribe
these products on the NHS, though
in one smoking cessation trial,
patients could opt to buy these
at cost price in the dental practice
setting. 18
With regard to alcohol reduction
in high-risk patients, dental team
members can ask and advise to
drink within accepted limits, although further counselling is seen
to be the domain of the specialist
organisations. It would therefore
be useful for information on local
referral mechanisms to be available
for staff members for use with their
high-risk patients.
Oral examination/detection
Regular check-ups by a dentist,
which include examination of the
oral mucosa, are important in the
early detection of oral cancer or
potentially malignant lesions. Additionally, contact with other primary
care dental team members—including hygienists—provides not only
an appropriate setting for preventive advice, but also a valuable
screening opportunity.
It is recognised that oral cancer
is often detectable and identifiable
early in its development. Diagnosis
and treatment at this stage is normally associated with an improved
outcome. 19 However, many patients
with oral cancer present late and
have a resulting poor prognosis. 20
Additionally, the later the detection,
the more extensive the treatment
necessary leading to increased morbidity—including loss of function,
aesthetics and mental health.
While early detection of oral
cancer should improve prognosis,
there are, however, some barriers
to this occurring. 9 Awareness of
the disease amongst the public
and some primary healthcare professionals is low, and those most
at risk (the socioeconomically deprived and the elderly 10 ) are least
Figure 2 Clinical examination sheet: oral mucosa check-list chart.
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Table 1: Oral cancer symptoms as they relate to time of presentation
Early
Later
A non-healing ulcer or sore
Difficulty chewing or swallowing
Any lump or thickening
Difficulty moving the tongue or jaw
Any white or red patch
Swelling of any part of the mouth which
may cause dentures to fit poorly or
become uncomfortable
Persistent soreness
likely to visit a dentist and are
consequently denied the benefits
of a frequent intra-oral examination. Moreover, such individuals are
more likely to present with oral discomfort to other primary healthcare
professionals eg general medical
practitioners, nurses, or community
pharmacists.
Therefore, it is important that all
members of the primary healthcare
team are aware of oral cancer, of
the importance of encouraging
regular dental attendance, and of
their role in the identification and
appropriate referral of individuals
with oral mucosal complaints
which last longer than three weeks.
Examination for
Oral Cancer
The oral mucosa is easily inspected
and, therefore, oral cancer should
be detectable at a very early
stage. 21,22 However delay often occurs between the time of onset of
signs or symptoms and diagnosis.
Whilst this is usually due to the
patient’s delay in seeking a consultation, in some cases it results
from a clinician’s failure to detect,
or suspect, the malignant nature
of a lesion. Thus, it is important
that clinicians are able to conduct a
comprehensive screening examination for oral cancer.
A thorough and methodical
inspection should include both
extra-oral and intra-oral examinations.
Examination of the lymph node
groups of the neck should be routinely performed, standing behind
the patient: palpate the neck from
the submental area under the
chin, moving posteriorly to the submandibular and then the jugulodi-
A lump in the neck
gastric regions and then down the
deep cervical chain as shown in
Figur e 1. Lymphadenopathy will
present as hard swellings or masses,
usually asymmetric and tender.
A thorough and systematic
approach is required to view the
whole oral mucosa for changes, 22
and this can be aided by the use of
a chart, with tick-boxes (Figure 2),
indicating the sites to be examined.
Figure 3 Erythroplakia affecting the palatofauceal complex.
Figure 4
Speckled patch on the left buccal
mucosa.
This can be beneficial to ensure a
thorough examination and good
record-keeping is carried out.
Demonstration of accurate recordkeeping is becoming an increasingly
important aspect of clinical governance and medicolegal defence.
The ‘danger areas’ are particularly the floor of the mouth, posterior and lateral aspects of the
tongue, and the retromolar areas.
This can be inspected by reflecting
the tongue with a dental mirror,
and asking the patient to touch the
palate with the tip of the tongue.
ET AL
The dorsal surface of the tongue
should be viewed by asking the
patient to stick the tongue out and
noting the normal anatomical
landmarks of the papillae which to
the inexperienced operator may
give rise to ‘diagnostic’ concern. To
examine the full extent of the lateral border of the tongue, the tip of
the tongue should be held in gauze
to enable it to be gently pulled,
allowing full visualisation to both
the left and right lateral borders
in turn. Finally, the hard and soft
palates and retromolar areas/pilar
of fauces areas should be viewed
in their entirety, removing any
dentures if present.
Clinical Presentation
Symptoms
Small carcinomas of the oral cavity
may be painless or associated only
with mild irritation. Such lesions
may be discovered as an incidental
finding during routine dental examinations. Most patients delay seeking professional advice for more
than three months after becoming
aware of an oral problem. 19 When
patients finally seek consultation,
the most frequent complaint is a
‘sore’ or ‘irritation’ in the mouth.
Squamous cell carcinoma of the
tongue tends to present as a nonhealing ulcer, or as an outgrowth
of tissue. Due to movement of the
tongue during speech and mastication, pain is a common presenting
symptom, but there are a number
of oral symptoms of which patients
may complain (Table 1).
Alteration in normal anatomy or
function clearly requires an explanation. Therefore, where there is
objective evidence of sensory or
motor disturbance, slurring of the
speech, or difficulty in chewing,
further investigation is warranted.
Signs
The most common presentations of
a squamous cell carcinoma of the
oral mucosa are an area of redness,
combined white/red lesion or an
indurated (hard) area of ulceration.
When such a lesion has been present for a month or more, then
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the lesion should be viewed with
suspicion.
Since oral cancers spread through
the lymphatic system, lymph nodes
in the submandibular region and
deep cervical chain may be palpable
(Figure 1). Unfortunately, this means
that the disease process has reached
a more advanced stage. Cancers of
the tongue and floor of the mouth
show a higher tendency to regional
metastasis than cancers of the lower
lip. It should be noted that cancers
may show ipsilateral, contralateral
or bilateral lymphatic spread. Oral
cancer can present in many forms.
Common presentations are an area
of redness (Figure 3), a speckled—
combined white and red—lesion
(Figure 4), a swelling (Figure 5), or
as a solitary ulcer (Figure 6).
Figure 5 Swelling on ventral surface of tongue
and floor of mouth.
Figure 6 Ulceration of left lateral border of
tongue
with
raised-rolled
borders
and
induration.
jump to any conclusions at this stage
Patient counselling
since many different conditions occur
Patients often have strong suspicions
within the mouth. That’s why seeing a
about the possibility of an abnormalspecialist is important.’
ity in their mouth being malignant,
cancer or ‘nasty’. Primary care dentists have a most important role in Referral guidelines/protocol
dealing with a patient’s concerns, The only way to obtain a definitive
taking into account their psychoso- diagnosis of an oral lesion is from a
cial, medical and family background. histopathological report of a biopsy
Counselling should be a sympa- of the suspected lesion. This should
be done in a specialist unit with a
thetic discussion, its extent dictated
by the patient who should be
allowed to express his or her
General Dental Practice
fears and concerns. The denURGENT
Date
tist should respond to direct
Oral Cancer Specialist Unit
questioning from the patient in
Dear Named Specialist
a controlled manner, but no
absolute responses can be
Re: Patient’s details: Name, Address/Postcode,
Telephone number
given without the results of the
Date of birth
histopathological investigation.
Name of patients General Medical Practitioner
The dentist who has genuine
Further to our telephone conversation I would be
concerns about a lesion being
grateful if you could see the above named patient,
malignant or premalignant has
as a matter of priority.
a responsibility in preparing
• Reasons for referral: Presenting complaint
History of presenting complaint, including
the patient for ‘bad news’ from
previous treatment
the specialist team. However, it
• Social history: Occupation, family details,
is important to leave the patient
Smoking: number per day / number of years
Alcohol: number of units / day
feeling informed and secure,
without giving misinformation,
• Medical and drug history
for example:
• Clear statement of clinical examination
Dentist: ‘I have some concerns
about what I can see in your
mouth. However, I am not completely sure and would like you
to see a specialist.’
Patient: ‘Is it serious? Is it cancer?’
Dentist: ‘I don’t think we can
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• The patient’s level of understanding and
concerns about their mucosal abnormality.
Yours sincerely,
General Dental Practitioner
Figure 7 Example of referral letter.
degree of urgency that must not
exceed a month, as outlined in the
NHS Plan.23
Members of the primary dental
health team must ensure they are
aware of the local referral arrangements for oral cancer. They should
make telephone contact with the
regional consultant in oral and
maxillofacial surgery, plastic surgery,
ENT surgery or oral medicine. Telephone discussion will allow the
referring practitioner to identify
whether or not a particular consultant deals with suspected oral
cancer. This will save unnecessary
waiting time.
It is best to establish these referral pathways before a patient with
a suspicious oral lesion is seen in
the dental practice. Local protocols
and referral arrangements for
patients with suspected oral cancer
is an advisable subject for a local
CPD/audit session, where invited
dental practitioners and primary
healthcare workers can meet with
the relevant specialists in the secondary care sector.
In some areas Rapid Access
Clinics may exist.24 Their effectiveness will only be established with
appropriate education for the whole
of the primary healthcare team
and the public, to allow them
to be used appropriately.
If a referral is to be made,
telephone contact should be
made followed-up with a formal letter of referral. The referral letter should be marked
‘URGENT’ and addressed personally to a named consultant,
and must include the details
shown in Figure 7.
The referring dentist should
be aware of the likely scenario
when the patient first attends
the specialist unit. The patient
may be advised to expect a
biopsy (usually under local
anaesthetic with or without
sutures being placed) and that
this is the only way to definitively diagnose the lesion.
Clinical photographs are usually taken for the case notes
as a matter of routine. Radiographical assessment of the
DI C ONWAY
head and neck may be performed,
and blood may also be taken for
analysis.
It is important to realise that following referral the primary dental
health team have a continuing role.
If oral cancer is diagnosed, the
patient’s life is never going to be
the same again. The dental practice
should have an ‘open door’ policy
and patients should be encouraged
to return for further discussion and
support as they feel they need. A
formal follow-up appointment is a
good way to show that they are not
being abandoned into hospital care,
without any support mechanism
in place.
Conclusions
The primary dental healthcare
practitioner and team, being in
regular contact with patients and
their families, ar e in the ideal
position to give advice on the
risk factors associated with oral
cancer and to examine for oral
cancer and potentially malignant
lesions. Prevention in the form of
smoking cessation and sensible
drinking advice should be offered.
Dentists should consider this in
terms of a common risk factor
approach: as smoking is relevant
to oral cancer, but also to periodontal disease and general health. 25
Examination of the oral mucosa
should form part of all patients’
routine check up.
Dentists have an important
initial and continuing counselling
role for patients with suspected oral
cancer and for those diagnosed.
To facilitate this, communication
pathways should be established
between primary and secondary
care and referral protocols should
be in place.
There is a need for improved
awareness of the roles of the oral
cancer specialist care team and of
the general dental practitioner by
each other, to establish a greater
integrated approach in the overall
management of patients with oral
cancer making the patient journey
smoother, more effective, and improving outcome.
Acknowledgements
We would like to acknowledge
Scottish Council for Postgraduate
Medical and Dental Education
the Health Education Board for
Scotland for providing financial
support.
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Correspondence: DI Conway,
Department of Dental Public Health,
Level 8, University of Glasgow Dental
Hospital and School, 378 Sauchiehall Street,
Glasgow G2 3JZ.
E-mail: [email protected]
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