www.mddus.com


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CANCER


oral epithelial dysplasia (i.e. leukoplakia or eythroplakia) and later OSCC, regardless of the type of OLP or how it has been managed. Similarly, about four per cent of patients with oral submucous fibrosis (OSMF; caused by exposure to a variety of agents, particularly arecoline in areca nut) will develop OSCC, while around a quarter will have leukoplakia. This disorder causes thinning, fibrosis and grey pigmentation of the oral mucosa, particularly of the buccal mucosa (main picture). Other potentially malignant disorders of the mouth include


scleroderma, chronic mucocutaneous candidiasis (and perhaps chronic hyperplastic candidiasis), rare instances of gross deficiency of iron, vitamin B12 and/or folic acid and some genetic disorders. Warts of the mouth are not caused by oncogenic types of HPV and thus are not considered potentially malignant.


The role of the GDP A quick diagnosis is key and the box on the right provides some simple advice. If the clinical picture has significantly improved following removal of any likely local traumatic causes then generally this means the lesion was not cancer. However if there is no substantial improvement, or concerns remain, then specialist referral is warranted. Patients should be informed of the possibility of a malignant lesion


or disorder and the importance of attending the specialist appointment. It may also be appropriate to urge caution in googling symptoms as information found on the internet will often be inaccurate, alarming, biased and/or difficult to understand. Contemporaneous notes should be recorded that provide an


accurate indication of what the clinician observed, thought and actioned, as well as indicating that the patient was made aware of the possible diagnosis and was agreeable to the way forward. Simply writing “possible cancer, patient reassured” is inappropriate and opens the door to criticism.


Conclusion Any solitary, odd and/or destructive lesion that has no obvious local cause and/or is present in a background of disease known to be potentially malignant should be considered as cancer until proven otherwise. Healthcare providers should inform patients of their thoughts, arrange timely and appropriate referral to a specialist, as well as maintain accurate and contemporaneous records.


Professor Stephen Porter is institute director and professor of oral medicine at UCL Eastman Dental Institute


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Simple steps for diagnosis and management of oral cancer


• Assume all solitary persistent lesions without an obvious cause are suspicious.


• Remove all potential sources of local trauma and review (e.g. within two to three weeks). If the lesion has not reduced significantly within this time, regard it as suspicious and refer appropriately.


• Do not assume that a patient who does not smoke tobacco or drink alcohol cannot have oral cancer.


• Tell the patient of your clinical judgment and decision to seek specialist advice.


• Refer patients with lesions that are suspicious and have not responded to removal of likely local causes - but be sensible (multiple superficial ulcers are very unlikely to be cancer). Refer patients with non-healing extraction sockets.


• Ensure all relevant details are included in the referral and ensure it is marked urgent.


• When oral cancer is not in doubt, call the nearest appropriate specialist to gauge their thoughts and wishes.


• Referrals can be emailed provided principles of GDPR/Caldicott are followed.


• Keep accurate, contemporaneous and legible clinical notes (including a record of any correspondence with patients, relatives and specialists). If possible, keep clinical images of the lesions.


• Keep contact details of local specialists up-to-date.


• Know the wishes of local specialists regarding the early management of potential malignancy.


• Ensure staff are up-to-date with significant trends in the diagnosis of malignant/potentially malignant disease.


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