 |
QUESTION
|
|---|
There has been a great deal of attention to the need for dentists to provide oral cancer screenings as part of their routine clinical examinations. What are a dentist’s responsibilities regarding the diagnosis of oral lesions and what is the diagnostic protocol that should be followed?
|
ANSWER
|
|---|
The simplest and most direct answer to the first half of this question is that dentists are responsible for periodically, and thoroughly, examining their patients’ faces, necks and oral cavities for the presence of lesions and diseases.
While dentists need not possess extraordinary abilities and knowledge, they are held to a standard of care in the eyes of the law, based on current, accepted treatment protocols. Of course, this may vary based on geographic location and other factors as well as over time, so the standard of care referred to in this article may or may not apply in a particular circumstance.
Dentists are taught in dental school, and it is reinforced in continuing education courses, how to examine the orofacial region and become familiar with the manifestations of the diseases that affect it. Most dental schools place a distinct emphasis on the diagnosis of oral cancer. In this day and age, it would likely not be acceptable for dentists to be unaware that they are responsible for periodically examining their patients of record for oral cancer. A patient may sucessfully sue for malpractice if a dentist does not satisfy the standard of care, including the failure to use reasonable care or judgment in the management of a patient, and that patient is harmed as a direct result. Specifically, negligence could be constituted if a dentist notices a lesion and neither attempts to diagnose the problem or refer the patient to a specialist for diagnosis or unreasonably delays the diagnosis, thereby compromising the patient’s health.
|
DIAGNOSTIC PROTOCOL
|
|---|
The protocol for diagnosing oral lesions (for example, oral cancer) is part of the overall process of taking a personal, medical and habit history and performing a clinical oral examination for each patient.1 Characteristics in the personal history, such as age, sex, ethnic background and occupation, are important considerations in assessing risk factors for oral cancer. For example, fair-skinned people who spend considerable time outdoors are at much higher risk of developing facial and labial cancer than are other patients. A history of habitual use of any form of tobacco, alcohol or both can be critical.
The medical history should include questions about systemic diseases that may predispose a patient to develop oral cancer. A short list of diseases would include anemia, liver disease, human immunodeficiency virus positivity and previous malignancy. Dentists should note that periodic oral updates of all histories are also standard procedure.
The clinical oral examination is by far the dentist’s most potent tool for discovering oral lesions. This procedure often takes only 30 to 120 seconds and should be performed at the initial visit and at each recall appointment. The dentist should begin by observing the face, head and neck, with particular emphasis placed on the vermillion of the lips. The systematic intraoral examination should include all mucous membrane and gingival surfaces, with emphasis placed on the lateral border of the tongue, floor of the mouth, and pharynx, which are prime sites for oral cancer. The dentist then should perform bimanual, digital palpation to determine if there are any abnormal enlargements of facial or cervical lymph nodes or of salivary glands.
The systematic intraoral examination should emphasize the lateral border of the tongue, floor of the mouth, and pharynx.
|
FOLLOW-UP
|
|---|
If the dentist observes a suspicious area, he or she should document it thoroughly in the patient’s dental record with regard to size, shape, consistency, color and duration. If possible, a photograph also should be taken to provide a baseline record of the lesion from which changes can be noted. The dentist must then decide who is best suited to diagnose and, if necessary, treat the observed lesion. It is important to keep in mind that any delay in the diagnosis and treatment of premalignant or frank malignant lesions could seriously compromise the patient’s health; therefore, a timely and decisive response is important. Dentists should not think that referral of a patient for diagnosis implies incompetence. Rather, patients genuinely appreciate dentists’ concern for their health.
If the examination reveals a malignant lesion, then—absent unusual circumstances—the patient should be so informed. Treatment, or referral for treatment, then follows. Premalignant lesions with low transformation potential (as documented by a biopsy) may be treated locally or observed for changes at appropriate intervals, usually no greater than six months. If the dentist opts to observe the patient, he or she should note any ominous clinical changes in the lesion and perform another biopsy. In addition, the patient should be apprised of, and agree to, the attendant risks of such treatment or observation.
TOP
QUESTION
ANSWER
