Detecting suspicious lesions: what do I say next?

mouth cancerWhen it comes to detecting suspicious lesions, Philip Lewis explains how to prepare patients for a specialist referral.

Dental team members are amazing. They put patients at their ease and provide treatment for their dental issues. They improve smiles, boost self-confidence and they save lives.

Yes, you read that right. There aren’t many opportunities for dental team members to be lifesavers. Detecting mouth cancer at an early stage is one of them. It’s an initiative for the whole dental team. Both clinical and non-clinical team members have a vital part to play. 

From a receptionist noticing changes in a patient’s voice, a practice manager spotting a swelling they haven’t seen before to a clinician picking up on a soft-tissue abnormality, we all get the chance to be pivotal in protecting a patient’s wellbeing.

Risk factors

We know there are risk factors we should be aware of: the use of tobacco in any form, regular use of alcohol, especially spirits, social deprivation with its associated problems of nutrition and vitamin deficiency. 

It is understood that increasing age is a factor and that men are more likely than women to get the disease. We appreciate the significant effects of infection that certain strains of HPV have had recently but realise how important it is to examine all adults. Many sufferers have no identifiable risk factors.

During the clinical examination, we’ll be looking for anything unusual, including: 

  • Red, white or mixed patches
  • Ulcers that don’t heal within a maximum of three weeks
  • Swellings
  • Changes to normal appearance or texture and lumps in the face or neck discovered during palpation. 

We’ll carefully check the medical history. A number of commonly-prescribed medicines can cause swellings, ulceration or other changes within the mouth. Abnormalities can also be due to formerly-diagnosed conditions like lichen planus, scar tissue following surgery or various systemic conditions.

What if we find something we think might be serious; something we feel needs a specialist opinion? It’s easy enough to send a referral, but what are we going to tell the patient?

  • There will be times when dentists want a specialist opinion

Wise words

Cancer is still a scary word. It’s reassuring to know that the vast majority of patients we send through rapid referral pathways turn out not to have mouth cancer, but some are less lucky. 

It’s essential we prepare our patients in advance for that possibility, however unlikely.

They say anything we tell a patient before an event is information, anything we tell them afterwards is an excuse. 

That’s why it’s important to give information even before the examination. Non-clinical team members can do this when properly trained.

Patients need to know an examination is going to take place, why we are doing it and precisely how the examination will be carried out. 

We can point out facts like how mouth cancer is on the increase when most other major cancers reduce in incidence each year. 

Early detection

We can explain how important early detection is. Also, how this reduces the amount of treatment needed compared to when cancer is discovered at a later stage. 

We can state how early detection vastly improves the chances of long-term survival.

We need to let our patients know the nature of the procedure; especially as it includes palpation of the face and neck, which they might otherwise find strange in a dental setting. 

We have to inform them that unusual words we might use are simply technical descriptions and do not imply problems. 

We must stress that we carry out these examinations for all our adult patients as part of the practice’s commitment to providing the best possible service for everyone. 

Remind them that we are not solely concerned with teeth, but look after everybody’s general health and wellbeing whenever possible.

As well as giving this sort of general information, we have to point out that sometimes a clinician will feel the need to take another look at an area in a few weeks’ time, or want to gain a second opinion from a specialist colleague. 

We must stress the importance of attending such a follow-up appointment and, again, impress upon the patient that we are doing this to ensure that we are serving their best interests.

The right approach

Throughout our discussions we have to maintain a supportive and sympathetic manner.

We do not wish to alarm or distress patients. However, we do need them to understand the importance of our actions and the necessity for them to comply with our recommendations. 

Trivialising the situation by making statements such as ‘it’s probably nothing’ or ‘it doesn’t look serious to me’ will not be helpful if a positive diagnosis is subsequently made and may cause a patient to lose trust in the practice. 

It is better to say: ‘There are many possible causes for what I have found. I have specialist colleagues who are extremely experienced in diagnosing the cause of this sort of thing and I think it would be wise for you to go and get a second opinion.’

Patients should always feel free to ask questions about their treatments or investigations.

A common question when we’ve found an abnormality and brought it to a patient’s attention is: ‘What do you think it is?’ 

In this event, depending on what has been discovered, we can describe a number of possible causes for what we are looking at. However, we do have to explain there is a possibility that the abnormality has been caused by cancer; indeed, some rapid referral pathways insist that this information has been given before they will accept a referral.

Human nature dictates that people will often fear the worst. Until they receive a confirmation of diagnosis, they will feel uneasy and apprehensive. 

Throughout this period, dental team members need to continue with a gentle and caring approach, promptly answering any further questions and providing more information and support.

Bottom line 

As mentioned, most suspicious cases we refer will turn out not to be mouth cancer. Those that are will set patients upon a treatment and management pathway that is a subject for other articles.

The bottom line is that early detection and timely referrals save lives. Not only lives, but also the quality of life both for sufferers and everyone around them. A few verbal skills can mean the difference between a patient accepting early treatment or not. 

With early detection, a patient’s chances of 10 year-plus survival are more than 80% compared with just 18% for late detection. 

If you or one of your team members is responsible for a patient’s early detection that potentially saves their life, you won’t only be considered their dental practice, you’ll be considered their heroes!

Oral cancer: facts and considerations

  • Alcohol is a carcinogen and combined with tobacco is especially dangerous
  • There is no safe form of tobacco
  • During the examination, look for anything unusual. The examination includes palpation of the face and neck. You need to tell patients about this prior to the procedure
  • There will be times when dentists want a specialist opinion
  • Rapid referral pathways are different in different parts of the country. Some are still paper-based while others are online. It is essential that all dental teams know how and where to refer to when a suspect abnormality has been identified
  • The Mouth Cancer Foundation offers support material for professionals and patients.

This article first appeared in Dentistry magazine. You can read the latest issue here.

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