Dental therapist Ellena Jackson offers advice on how dental professionals begin performing oral cancer screening, and how to discuss and refer suspicious cases.
‘Nobody’s ever done that before’ – I hear this phrase practically daily from patients after I palpate their lymph nodes.
Since qualifying as a dental therapist a little over six months ago, I still struggle with how to respond. Every year we see around 12,400 new head and neck cancer cases in the UK, alongside around 4,100 deaths.
Up to 88% of cases of head and neck cancers in the UK are preventable, and chance of survival is drastically greater with early diagnosis.
As DCPs we are in the ideal position to carry out head and neck examinations but reports show that many aren’t doing so. As a clinician I believe the most prominent barriers leading clinicians to forgo this crucial assessment include: lack of time; lack of knowledge; fear of difficult conversations; the belief that other colleagues have already carried it out.
This article aims to equip you with the knowledge to begin performing oral cancer screening, and advise you on how to discuss and refer suspicious cases.
Risk factors and risk assessment
With two major risk factors; smoking and alcohol, oral cancer is a largely preventable disease. The combined risk of drinking and smoking is higher than the sum of the two alone.
Other factors to consider in a risk assessment include betel nut use, age (oral cancer is more common in over 40’s), socio-economic deprivation, HPV and sun exposure (for cancer of the lip). Patients should be informed of the risks of oral cancer and their own personal risk level.
Advice should be given on how to reduce their risk, which may include smoking cessation advice or information about the HPV vaccine for themselves or their children.
The examination
A thorough oral cancer screening should form part of every routine dental examination. Each clinician will develop their own routine, however a systematic approach is fundamental.
The key areas to include are:
- Face; assessing for asymmetry, changes on the skin including crusts, fissuring, growths or colour changes.
- Palpation of lymph nodes; preauricular, submandibular, anterior cervical, posterior auricular, posterior cervical regions and supraclavicular.
- Lips, commissures, labial mucosa and sulcus; assessing colour, texture, swellings, and surface abnormalities
- Buccal mucosa and sulcus; assessing for pigmentation, colour, texture, abnormalities
- Gingiva
- Dorsal, lateral and ventral surfaces of the tongue; assessing for swelling, ulceration, coating, size, colour, texture, pattern change, abnormal positioning.
- Floor of the mouth; assessing for colour, texture, swelling or surface abnormalities
- Hard and soft palate and oropharynx; depress the base of the tongue with the mirror
- Palpate any areas of abnormality.
Signs and symptoms
In addition to the clinical examination, listen out for patient reported signs or symptoms of oral cancer:
- Lumps or thickening of the oral tissues
- A sore throat or feeling of something stuck in the throat
- Difficulty chewing, swallowing or speaking
- Ear pain
- Difficulty moving the jaw or tongue
- A hoarse voice
- Numbness of the tongue or mouth
- Swelling of the jaw
- ll-fitting dentures.
Record keeping
Where possible, photographs should be taken and the following details should be recorded in the patient’s notes:
- Site
- Size (mm)
- Shape
- Colour
- Texture
- Feel (firm or soft)
- Mobility
- Pain
- Time
- Changes
- Referral details.
Informing the patient
The outcome of the screening should always be shared with the patient. However, a conversation about a concerning lesion requires an approach that incorporates empathy, clarity and reassurance.
Some key things to remember:
- Clearly explain what you have found and why it has caught your attention. If possible, show them the area of concern
- Don’t avoid the ‘c-word’. Explain that you would like to refer them to rule out serious concerns, but that this does not mean it is cancer
- Explain the referral steps to the patient including timings and gain consent for the referral. Advise them of the steps they should take if they don’t hear back as expected
- The patient is likely to be worried. Acknowledge their concern and explain that many oral lesions turn out to be non-cancerous but it is crucial to diagnose and treat them as early as possible
- Encourage them to ask questions
- Be prepared to provide ongoing support through the referral process.
- Referrals.
Referrals
Suspicious cases should be referred to the oral surgery department of your local NHS Trust, under the suspected cancer pathway.
As per NICE guidelines, instances of a lump on the lip or in the mouth or of erythroplakia or erythroleukoplakia an urgent two-week referral should be considered.
Be sure to monitor the referral and ensure the patient hears back within the expected time-frame. Awareness There are a few steps we can all take to raise awareness of head and neck cancers:
- Inform patients of the risk factors
- Place leaflets in our waiting rooms and information on our websites
- Engage in campaigns such as Mouth Cancer Action Month (November)
- Promote the importance of oral cancer screening on social media • Share this article with colleagues.
References
- Head and neck cancers statistics (2024) Cancer Research UK. Available at: https:// www.cancerresearchuk.org/health-professional/ cancer-statistics/statistics-bycancer-type/head-and-neck-cancers# heading-Zero (Accessed: 19 March 2024)
- NICE Guideline: Suspected cancer: recognition and referral. 1.8
- Horowitz AM, Drury TF, Goodman HS, Yellowitz JA. Oral pharyngeal cancer prevention and early detection. Dentists’ opinions and practices. J Am Dent Assoc. 2000 Apr;131(4):453-62. doi: 10.14219/ jada.archive.2000.0201. PMID: 10770007.
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