Top tips on dealing with oral cancer from a DCT

Child having a dental examination

So, this my third blog for the BDA, and I hate to bring things down, but…oral cancer: it can be a real problem for both patients, and their dentists. Working as a maxillofacial dental core trainee (DCT), I’ve seen a few cases, so I hope you might find useful some of my top tips on detecting and referring oral cancer cases appropriately.

Oral cancer tends to get quite a bit of press, it’s a popular headline grabber for the tabloids and some of it is worryingly misleading. Often, the importance of the role dentists play in detecting oral cancer, is puzzlingly absent. But dentists in all setting, from the high-street to community to the hospital, can play such a key role in catching signs of oral cancer early and potentially helping to save patients’ lives.

We all know about the red flags of oral cancer which we learnt at dental school, and I’m sure you’ve heard this before, but below is some advice and top tips which are sure to have you covered.

When do you need to worry?

  • Non disappearing painless ulcers, present for more than 3 weeks – that’s an easy one, we all know how to tell the time
  • Indurated – very simple – does it feel hard – if it’s soft and squishy, then it may be something less worrisome
  • Rolled border – feel the edges of it
  • Red or “angry” looking – again this could be exacerbated by trauma, sometimes candida can look quite scary, but that is usually more diffuse
  • White patch with speckled areas, and presence of risk factors

 

Remember: sometimes a carcinoma can be painful to the patient if they’re traumatising it! Don’t relax just because the patient says it’s painful.

  1. Common things occur commonly: so most of the time, it’s probably that sharp tooth, or cheek biting, first look for simple causes. Remember: traumatic ulcers usually correspond to the site of something obvious.
  2. If it’s bilateral, think again: usually it’s unilateral when it’s something to worry about.
  3. Risk factors: we all ask about smoking, but not many people ask about alcohol. I can’t stress how important it is to ask what a patient’s average alcohol consumption is, but also if they’ve ever had a period where they’ve gone beyond limits. I’ve had so many patients who laugh at me, wink, and then tell me “they were young once”, and now they’re “fine”, and “only drink with the boys on the weekend”. Find out how many units they’re drinking with the boys, and you’ll be surprised how easy it is to be caught out.
  4. Feel the neck: I only realised the benefit of palpating the neck once I started this job – but what are you actually feeling for? Simple – a lump! Most of the time, they’re just reactive lymph nodes, but if the patient has a suspicious lesion in the mouth, with a neck lump, you may want to think about referring for further investigations, which may include CT/MRI to disclude metastases.
  5. Look at their tongue: you’d be so surprised how easy it is to miss a small ulcer right on the ventral surface of the tongue, so don’t be shy, tell that patient you’re going to steal their tongue for a quick minute, and pull that baby right out with some gauze. Get your finger and feel on the floor of the mouth – if it’s soft, then it’s usually healthy.
  6. Don’t forget to check the skin – if you see crusted lesions on the face, don’t ignore them, you could be missing a basal cell carcinoma. At the very least note it down, and get the patient’s GP to refer them, if you’re not comfortable with dealing with it. Common sites include the lip, nose, and forehead and temple regions.
  7. Communication – Most dentists won’t have the dreaded “conversation” with patients, but if you refer a patient for an ulcer, especially if it is a two-week wait, then that patient is likely to think ‘cancer’. Here are some of the things they may ask you:
    • What do you think it is? Don’t give them a diagnosis unless you’re 100% sure, e.g. it might be just be a polyp, but if it looks sinister, just let the patient know that it’s in your training to be suspicious, and you would feel more comfortable if you had a second pair of eyes on it from the specialists.
    • Do I have to be referred? Yes some patients don’t like the idea of being referred, and they will outright refuse. That’s ok, they can make their own decisions, but as long as you warn them that you can’t offer treatment, especially if it’s something sinister, unless you’re sure of the diagnosis. Make sure you document this.

  8. Have a system: If you have a routine to your examination process, I guarantee you will not forget what you’re doing. For example, when I’m feeling the neck, I start with the submental, move to the submandibular, down the sternocleidomastoids, to the clavicles, then back and behind, up the occipital, then to posterior auricular! Not to say that’s how you have to do it, but it works for me.
  9. Tell the patient what you are doing: don’t just violently attack their neck, and start working your hands down under their top to the clavicles, or they may freak out – that’s not the service they were expecting. As you’re examining, let them know you’ll be feeling around their collar bone and behind their neck for any lumps and bumps. Sometimes I tend to joke about, especially with the kids, and let them know they’re getting a free massage. Regardless what branch of dentistry you practice, rapport with patients is key.
  10. If in doubt, refer: If you don’t know what to do, don’t sit on it, and think it’ll probably go away. As DCT’s, we are here to accept referrals and believe me, it is never a wasted journey for the patient.

 

For now, that’s all from me, I hope you find it helpful.

The BDA also has a free oral cancer toolkit for dental professionals (developed with CRUK) and will be supporting World Cancer Day on 4 February, to help raise awareness – do your bit!

As always, any ideas or suggestions on topics you’d like me to cover in future posts are more than welcome!

Surina Bhola, Dental Core Trainee/SHO

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