Sir, primary care dentistry in the UK is evolving; the role of the dental hygienists and therapists (DH-Ts) has been re-defined recently. With the introduction of direct access, DH-Ts will see patients independently and provide treatment. We noted in the paper by Brocklehurst et al.1 that the performance of primary care dentists (PCDs) and DH-Ts when differentiating between mouth cancer, potentially malignant disorders and benign lesions was comparable. That said, a holistic approach is required for these diagnoses, and visual recognition of lesions is only one aspect of the diagnostic process. Two studies from Italy and Spain,2,3 countries which have had elements of direct access for over a decade, showed deficiencies in the knowledge and training of dental hygienists (DHs) regarding risk factors for oral cancer (this study did not include hygiene therapists). In addition, 57% of DHs reported a lack of confidence in their ability to diagnose oral cancer and potentially malignant diseases.

This lack of confidence was corroborated in a UK study by Turner et al.4 where the majority of participants said that they would seek a dentist's opinion of a suspicious mucosal lesion. Seeking advice is preferable to overconfidence, which could lead to mis or undiagnosed lesions but also highlights the need for further educational interventions in order to improve early detection. Brocklehurst et al's study goes further and suggests that there is an equal need for improved oral cancer education and training of PCDs and DH-Ts as although both groups were comparable, there was a wide variation within each group. DH-Ts actually missed fewer mouth cancers than PCDs.

Our experience with our recently developed nurse-led review clinics has been similar. After a period of training, specialist nurses are in a position to see and examine patients that have been diagnosed with, or treated for, head and neck cancer. They have extended skills that include interventions such as nasendoscopy. When we looked at the results comparing appropriately trained specialist nurses and experienced head and neck consultants, there was no statistical difference between the two groups. This was limited to low risk clinical groups but with continuing support and training this may be applicable to all patient groups.