Mouth cancer

More defensive dentistry

Sir, I note, with concern, the observations raised by Bradley, Barratt et al.1 regarding the inappropriate referral of suspected oral malignancies, and the proposed reasons for such a pattern developing.

I speak as a GDP with hospital experience and an interest in the subject, and would note that the sentiments expressed are commonly voiced by surgical colleagues who find their departments swamped with common, benign conditions which have been fast-tracked with all the attendant worries, fears and inconvenience that this engenders.

My view is simple: what else could we possibly expect? The much-publicised antics of the GDC and the medical negligence lawyers have created a climate of fear and defensive dentistry of unprecedented proportions. No-one dares run the risk of missing a malignancy, the consequences for all involved can be disastrous. There has been a tendency for postgraduate courses to stress the need for immediate referral of any white patch as it could be a deadly cancer. This, coupled with the comparative paucity of oral medicine training in an increasingly crowded undergraduate curriculum, means that younger colleagues have, quite literally, never seen any of the common oral lesions, or had any experience in their management.

I would note that there is a world of difference between an 80-year-old, non-smoking, teetotal lady with bilateral reticular LP and a firm white patch in the sublingual pouch of a 50-year-old alcoholic, but, in the utter chaos of regulations, compliance, protocols, endless, mindless templates, threats and fears, the finer points are lost. Refer, stat; it's safer; you've Done Your Bit. It is also far easier to hit the refer button than invest the effort and clinical time taken to fully assess a suspect lesion, when the NHS is only interested in targets. A referral takes one time unit, a full evaluation plus biopsy may take several.

I feel that this pattern will continue to evolve to a point where any and all slight variations from the absolutely normal will be referred on to secondary care. The only way to circumvent this inevitability is a fundamental change in the system. Mentoring by experienced colleagues, roving senior colleagues to observe and advise practices which have a high referral base, not with the aggressive, punitive approach of the GDC, but a trusted helper who can really guide those starting out on their professional journey, would be one idea. Electronic referral and not the unwieldy and clumsy Rego, with a dedicated assessment and two-way communication, is another. This will mean a move away from this infernal target-based mentality, which is, perhaps, a step too far for the current establishment. It could all be so different, but, with the current adversarial set-up, things can only get worse. And who can blame them?


  1. 1.

    Bradley H, Barratt O, Simms M L, Atkin P A. Inappropriate referrals. Br Dent J 2020; 228: 906.

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Correspondence to R. Bate.

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Bate, R. More defensive dentistry. Br Dent J 229, 637 (2020).

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