Farah Elnaqa, a foundation dentist, describes her first encounter of oral cancer in a patient.

figure 1

©metamorworks/iStock/Getty Images Plus

One of the first and most important things we were taught at university is how to recognise oral cancer: the areas where it's most commonly found, the clinical signs to look for and how and when to refer a suspicious lesion. But never did I think that just a few months into my foundation training, I would be urgently referring one of my patients for a suspected oral squamous cell carcinoma (OSCC).

It was a Thursday afternoon and I was about to see my final patient of the day. I had a quick look through the notes and saw that he was a regular attender of the practice for almost ten years. He was a non-smoker, non-drinker, periodontally stable and generally had good oral health.

'Just a quick check-up and I'll be done,' I thought to myself. Little did I know this would not be the case.

'So, how can I help? Have you had any problems since your last check up?' I said.

'No complaints doctor, one of my back bottom teeth is just a little sharp and it's causing a bit of discomfort to my tongue. I was hoping you could just smooth it down a bit for me,' said the patient.

My initial thought was that I'd need to smooth it a little with a white stone, or worst case, the patient might need to be booked in for a filling. Either way, I assumed, pretty quick and straightforward. I looked into his mouth, and as I expected, I could clearly see a sharp lingual edge on the lower right 6. But what I wasn't prepared for, was what I was about to find next.

There it was on the lateral border of the tongue: a large, irregular, speckled ulcer with rolled margins.

While I was thinking about options of how best to get my patient out of discomfort today, I thought to have a look at the soft tissues. And there it was on the lateral border of the tongue: textbook description OSCC - a large, irregular, speckled ulcer with rolled margins. Although I had never seen an OSCC in real life, I instinctively knew that something was not quite right. I asked my patient if he was aware that he had quite a large ulcer on the side of his tongue.

'I've not really noticed to be honest, I don't really look at my tongue. I just assumed it was sore because my tooth was sharp.'

So, I did what we had been taught to do at university: I took a thorough history, photographs, and recorded a detailed description of the ulcer's appearance in my notes. I also placed a temporary filling on the tooth in question - to ensure my patient was comfortable and just in case it may have been the causative factor of the ulcer. As per the NICE guidelines,1 I booked my patient to come back in a few weeks and I hoped that there would be a chance at some resolution. Unfortunately, when I saw him again, there the ulcer still was, and I knew what I needed to do. It was a difficult conversation to have, especially so early on in my career.

'What do you think it is? Is it cancer?' asked the patient.

'I can't rule it out completely,' I said. 'There can be many causes for ulcers, but the best thing I can do for you, is to refer you to the experts that can find out.'

I tried to offer as much reassurance as I could, but it is much easier said than done to tell someone to try not to worry.

The latest figures from The State of Mouth Cancer UK Report2 show that one person every hour is diagnosed with mouth cancer in the UK. Last year 8,722 people in the UK were diagnosed with oral cancer and around 2,702 people lost their life to it. That's seven people every day. Recognising oral cancer early is crucial in beating the disease as early detection boosts the chances of survival from 50% to 90%.2 Unfortunately, there seems to be little education about oral cancer. The majority (80%) of the population cannot recall ever seeing any public health messages around oral cancer and only around one-in-seven (15%) recall being exposed to information about the disease in the last year.2 As dental professionals, it is our responsibility to educate the public and help make them aware of oral cancer. Most importantly, we should know the signs to look for and when to be concerned. Hopefully by doing this, we can reduce the number of lives lost each year to oral cancer.

How can we better educate our patients? Studies show that simple and specific instructions are better recalled than general statements. Patients can be helped to remember medical information by use of explicit categorisation techniques. Written or visual materials should also be used to support spoken information,3 such as by providing information leaflets.

So, what is the key information that we should provide to our patients? Firstly, it is important to make patients aware that they should regularly be checking their mouth, in order to be able to recognise when something new or unusual has appeared. Patients should be made aware of the two main causes of oral cancer: smoking or chewing tobacco and drinking large amounts of alcohol,4 followed by signposting them to services to help them quit. The six key signs that patients should be asked to look out for in the head and neck region are:5

  • An ulcer or sore on the mouth or lip that does not heal in three weeks

  • White patches or red patches that do not go away

  • A lump or thickening in the mouth or lip

  • Difficulty or pain with chewing, swallowing or speaking

  • Bleeding or numbness in the mouth

  • A lump in the neck.

This experience has had a great impact on me, both on a professional and personal level. It has highlighted to me the importance of our role as healthcare providers and also as educators. It is a common misconception that dental professionals only treat teeth, but this experience has shown me that ultimately, we could be the reason someone's life is saved.

Thankfully for my patient, the cancer was detected early, before there was any lymph node involvement. It has successfully been excised, but the patient has yet to undergo radiotherapy. The journey is not yet over, but I am glad I that I will be there along the way to offer my support.

Although my patient tells me that he is eternally grateful to me for helping recognise his cancer early, it is I who is eternally grateful to him. This experience of truly being able to make a difference to someone's life has been one of the most rewarding and fulfilling experiences of my life.