Oral cancer is a problem begging for a solution. That solution, Chris Sheedy discovers, is dentists
Of the almost 5,000 people presenting with head and neck cancers each year in Australia, over 50 per cent have intra-oral cancers. If diagnosed early enough, the individual has a very good chance of full recovery and survival. The solution may be as simple as the removal of a small area of gum tissue. But as soon as the cancer spreads to other parts of the head and neck, it is a very different story indeed.
“If it progresses to local nymph nodes, the patient may end up needing a neck dissection, sometimes they lose half the tongue, and you can get metastatic spread,” says Dr Peter Foltyn, consulting dentist at Sydney’s St Vincent’s Hospital. “Once it proceeds beyond a small size, which is regarded as Grade 1, you go to something that invades bone in the upper and lower jaw. Once it reaches Grade 4, you go from an 80 per cent survival rate in five years to a 20 per cent survival rate. Oral cancers kill.”
The problem with oral cancer is that—unlike with breast and skin cancers—there is no public-awareness program that can help with self-assessment. Plus, there has been little in the way of education about the importance of being checked regularly by a medical professional, in the same way there has been for bowel and cervical cancers.
In fact, there is no reliable, regular screening method at all for oral cancers, Dr Foltyn says. “If you read the peer-reviewed journals, mainly from the USA, they say that for 90 per cent of mouth cancers or intra-oral cancers, it is the individual’s dentist who is in the position to diagnose them. By ‘dentist’, I’m also including the oral health therapist and the dental hygienist.”
Dr Phillip Palmer, founder and chairman of Prime Practice, strongly agrees that dentists need to play a more active role in screening patients for oral cancers. He says a GP does not see inside anywhere near the number of mouths as a dentist, and is also not as knowledgeable about the oral cavity.
“When I was a clinician, I certainly did a very thorough visual and digital examination of the patient to assess if they had oral cancer,” Dr Palmer says. “I always explained this to the patient and interestingly, a couple of times when I had patients who left me when they moved out of the area, they would come back and say they had returned because their new dentist ‘didn’t do that thing you do with the oral cancer’.”
Over the last few years, Dr Palmer says, he has been asking dentists whether they perform oral cancer screenings on their patients and the responses have been mixed. Most say they do it if they remember, or if the patient meets what they believe is the risk profile: over 50 and a smoker and/or heavy drinker. But oral cancers can present in anybody: young or old, smoker or non-smoker, male or female.
All dentists, our experts agree, should be conducting oral cancer screenings. And it is not only for the good of the patient.
The legal issue
In 2015 a woman formerly from Cairns, Queensland, was awarded $6.7 million by the Queensland Court of Appeal after a missed diagnosis of cryptococcal meningitis left her deaf and blind.
What does this have to do with dentists? Plenty, Dr Foltyn says.
“Once it proceeds beyond a small size, which is regarded as Grade 1, you go to something that invades bone in the upper and lower jaw. Once it reaches Grade 4, you go from an 80 per cent survival rate in five years to a 20 per cent survival rate. Oral cancers kill.”—Dr Peter Foltyn, St Vincent’s Hospital, Sydney
“Going blind is terrible, but she still has the rest of her life to live,” he says. “If dentists fail to pick up on an oral cancer and it progresses to the point where the patient loses half their jaw, it’s very different to going blind. They can’t speak, they can’t eat, their appearance is gone and their job prospects are diminished. If it’s Grade 2 or Grade 3 there’s a 30 per cent or 40 per cent chance you’re going to be dead in five years. From that perspective, I think that court case from last year should leave dentists quite concerned.”
The current knowledge of growth rates of oral cancers makes it hard for dentists to get away with failing to identify a cancer if they only saw the patient a few months ago. Dentists could also be liable if their employees, such as dental hygienists and oral health therapists, did not spot the issue.
“At some point in time, data will be used to say, ‘If you had a check-up four months ago and your cancer now is 3.2 centimetres in diameter, this would have been here at the time you had the examination.’ It’s a look back, and this is where dentists can be caught out,” Dr Foltyn says.
“Dentists have got that responsibility because we’re doctors of the mouth. Our medical colleagues really don’t understand teeth and gums. We can’t expect them to identify the nuances. It’s our responsibility, especially with patients over the age of 40, to ensure that we have a look around.”
The silver lining
A story about cancer and legal issues need not be all bad news. If dentists begin screening every patient thoroughly, they are offering a powerful service to society as well as protecting themselves from potential legal action. At the same time the profession is becoming more relevant in a different way.
“Dentists are always looking for how can they add value,” Dr Palmer says. “We all know that patients should come in regularly for a check-up but we struggle with explaining convincingly why. But frankly, for the same reason that not many women would miss out on
their Pap smear, I don’t think many people would miss out on their oral cancer screening if they saw the same value in it. It could almost be that the check of the teeth and gums is secondary to the importance of the oral cancer screening.”
What does a dentist do when they identify a suspicious indicator? “If in doubt, biopsy,” Dr Foltyn advises. “One of the problems with this is that it’s not a technique that most general dentists are familiar with, so a lot of dentists refer off to specialist oral surgeons or periodontists. That just throws more delay into the equation.
“It’s easy enough to learn to do excisional or punch biopsies, and if more dentists were able to do that, it would mean that the patient would have a result within a day. If there is a positive result of the biopsy, treatment can be started much quicker.”