Sir, we thank Dr Zadik for his interest (BDJ 2005; 199: 355) in our case report demonstrating a missed diagnosis of malignancy presenting in the oral cavity (BDJ 2005; 198: 341). Dr Zadik drew attention to the fact that the case report 'stated that general medical practitioners have been shown to be better at diagnosis and prompt referral of oral malignancies than their dental colleagues', although he felt that other papers came to different conclusions. We made reference to one paper1 which supported the better diagnosis and prompt referral by general medical practitioners (GMPs) when compared to general dental practitioners (GDPs).

Dr Zadik listed a number of other papers which showed either no difference or the opposite finding. In preparation for the case report we did indeed review the studies but rejected their findings in relation to comparative referral quality for a number of different reasons. One of the papers2 quoted actually showed GMPs to be slightly quicker and better at requesting urgent appointments than GDPs.

The authors of another study4 cast doubt on their findings when comparing GMPs and GDPs due to the small numbers involved. The authors of a further study5 speculated that the similar length of delays in both groups of referrers was specific to the unique way patients were referred in the country where it was carried out. It was unclear with a further study9 as to whether the physicians who were compared to GDPs included just general medical practitioners or other specialists. Other publications3,5,7 made comments which were not backed up in their results, did not look at delay in referrals,8 and had imbalances in numbers of GDPs and GMPs.9,10

Several publications3,8,10,11 referred to differences in the stage of tumours referred by both groups which is not necessarily a reflection of delayed diagnosis, but may demonstrate the differences in the kind of patients who attend both groups of referrers. None of the papers2,3,4,5,6,7,8,9,10,11,12 reported how often GDPs correctly diagnosed malignancy when compared to GMPs. The paper by Schnetler1 does show this, which is the reason it was included in our case report.

We would largely agree with the comment that 'the dental profession is the only profession capable and dedicated to the diagnosis and treatment of diseases of the oral cavity', especially as dentists are one of the few groups of health care professionals who examine the oral cavity at regular intervals. Clearly, GMPs also have a role to play in referrals, and as the references show are also responsible for a considerable number of referrals to secondary care referral centres. Improving the speed of referral by both groups of practitioners should be a priority issue.