In this article, Nicki Rowland, owner of Practices Made Perfect and The Exceptional Leadership Academy, discusses the importance of raising awareness of mouth cancer not just within our patient cohorts but also within our local communities. As an ex-practice owner, Nicki embraced Mouth Cancer Action Month each year and not only boosted her practice’s profile and turnover but also gained much media attention by using a systematic approach to help save lives.

The Issue

With a 97% escalation in oral cancer across the UK in the past 20 years and patients slipping through the net during the Covid-19 crisis, it is more important than ever before that as a profession we play our part in educating the world about oral cancer. We have a professional obligation to do so and are perfectly positioned to spread the word about this silent killer.

So, why are we seeing an escalating trend in mouth cancer? Well, the problem is that it is not being detected early enough. Early detection is key to saving lives. In 2011, the BDA stated:-

“A major problem is that more than half of all oral cancer cases have already metastasized to regional or distant structures at the time of detection which decreases the 5 year survival rate to less than 50% for tongue and floor of mouth cancers”.

Also, in May 2015, an article in the British Dental Journal highlighted that despite being aware of their professional duty of care to check for oral cancer, clinicians said that time constraints and a lack of experience, knowledge and confidence were barriers to mouth cancer checks and talking to patients about cancer. The study also reflected on the point that the whole dental team is often not trained in the early detection of oral cancer in general practice as access to CPD, time and funding are also standing in the way.

Outside of the dental world, there is no Government initiative to tackle oral cancer. Youngsters in secondary schools are not being educated about the risk factors as they start to experiment with lifestyle choices that increase their risk of developing the disease e.g. exposure to HPV through oral sex. This lack of education is worrying as more and more young people are dying from oral cancer. Only when patient and public awareness is boosted will symptoms for oral cancer begin to present earlier in general practice.

So, What Can We Do in Our Dental Practices?

We can make a huge difference in raising oral cancer awareness and detecting it earlier in general dental practice by taking some key steps and implementing a systematic approach to the problem. In my practice, we took a 10 step approach:-

• Step 1 - Have a Management Strategy for Oral Cancer in Your Practice.

The objectives laid out in your strategy should include robust mouth cancer check for every patient, talking to and educating your patients about the disease and training your team to deliver an oral cancer service. The end goal is that every team member is confident in their role within your oral cancer service, that your patients can see that you are safeguarding their oral and systemic health and very importantly that you are meeting your duty of care to do so.

 

• Step 2 - Clarifying Each Team Member’s Role and Responsibilities  

Every member of your dental team has a role to play in the early detection of oral cancer in your practice. From triaging on reception to a robust intra and extra-oral mouth cancer check in surgery, everyone needs to sign up to their responsibilities. Decide what each person's role should be and build these responsibilities into their job description.  When signing a contract of employment, an individual is agreeing to the details of their job description and has a legal obligation to carry out the tasks listed. As with any other strategic plan, every team member needs to buy into achieving the objectives. If one link in the chain is broken, the strategy is likely to fail.

 

• Step 3 - Train All Staff to Talk About the 'C' Word. 

Do you talk to your patients about ‘oral cancer' when you are checking them for it? Do your reception team know how to answer questions sensitively and appropriately if patients ask about oral cancer? And do your dental nurses know how to support a patient if a referral is made for suspected oral cancer? If the answer to any of these questions is 'No' then I would suggest training your team to talk about oral cancer.

The results of a survey highlighted by the Oral Health Foundation estimates that 90% of dentists check for oral cancer but only a small percentage discuss what they are doing with patients. The survey also showed that 9 in 10 patients would like to be checked for the disease, however, only 14% indicated that their dentist had discussed what they were doing during a mouth cancer check.

So as a profession, why do we still avoid the 'C' word? It appears that we are the ones afraid to use the word not our patients. Is this due to our fear of litigious activity if the patients knows too much? Or is it because dentists lack knowledge, confidence and experience in dealing with oral cancer management? Either way, training the team to talk about cancer in a confident, knowledgeable and appropriate way will alleviate whatever it is holding us back from these essential communications. Raising awareness and teaching patients to self-check will also help to save lives.  

 The GDC advises that oral cancer management CPD is delivered as a core topic for dental clinicians. However, my recommendation is that your administration team should be included in the training. Which practice wants to miss an oral cancer at the first port of call on reception and be sued as a result? 

 

• Step 4 – Triage Every Patient

Every patient should be triaged for oral cancer by the reception team when booking an appointment, particularly if they are a new patient. Train your reception team to ask the correct and appropriate questions when booking an appointment to ensure that a lesion, that could be potentially suspicious, is not missed. Cold sores are an area for concern as many people do not associate them with being a symptom of oral cancer. Some practices choose not to see patients with cold sores for fear of bringing Herpes Simplex onto the premises. However, a triage system that picks up early signs of oral cancer, including cold sores, and drives appropriate and timely intervention by a clinician, can avoid litigation and save lives.

 

 

• Step 5 – Check Thoroughly

I spend much time observing mouth cancer checks in practice and often see the extra-oral component totally missing. In many cases, a lesion is not visible intra-orally but can be detected extra-orally through palpation of the cervical chain of lymph nodes. Oral cancer lesions are synonymous with an 'iceberg'. Often, what is visible on the surface is insignificant but what lies beneath is the killer. A full 50:50 intra:extra mouth cancer check takes between 90 secs to 2 minutes to perform and may save someone's life and avoid you being faced with a litigious situation. 

 

• Step 6 - Educate Your Patients About Oral Cancer and Self-Checking 

Dental professionals in general practice are perfectly positioned to educate their patients and the public about oral cancer. As there is currently no Government initiative to tackle the escalating problem that this hidden killer presents, it is our professional obligation to do something about it. To combat oral cancer, people firstly need to know about it! So, talk to your patients about oral cancer whilst you are conducting your check and educate and advise them to self-check on a monthly basis. Advice leaflets and posters in your waiting areas are essential to getting the ball rolling and instigating conversations about oral cancer and mouth cancer checks.

Publicise your oral cancer management system on your website and use social media to blog about oral cancer and get the message out there. The only way we will make a difference and save lives is to tell the public what we are doing to safeguard people's health and educate them to avoid and detect this little known cancer themselves.

 

• Step 7 - Offer Free Mouth Cancer Check Days and Support Mouth Cancer Action Month 

In these challenging days of derogatory 'Which?' reports and OFT statements, why not give something back to the community? Dentistry is rarely portrayed in a favourable light and our public persona often reflects a money generating ethos. This may be true of a few clinicians but in general our professional is genuinely endeavouring to deliver good quality dentistry despite the heavy hand of Government policy and the restrictions imposed by Covid-19. So why not show the public what we are really all about and invite people in for a free oral cancer check? 

Showing that your practice is going the extra mile to secure people's oral and systemic health builds trust and nurtures lasting relationships between your patients, your community and your dental team. Delivered well, free mouth cancer check days for none-patients have resulted in conversion rates of up to 60% in my practice. Rarely have I seen many initiatives in practice that have achieved these stunning figures! Word of mouth referrals also increase when individuals relay their experience of thorough mouth cancer check and what the dentist taught them about self-checking. Education is paramount as patients often do not realise that you are carrying out a potentially life-saving process! 

 

• Step 8 - Use PR to Promote Your Oral Cancer Event

When running a free mouth cancer check day or oral cancer open day, be sure to let the media know about it!

Local newspapers, radio stations and even TV channels are happy to support dental practices that have a robust social responsibility policy particularly if raising funds for charity. Mouth Cancer Action Month is a perfect opportunity to spread the word about your oral cancer event and raise public awareness of this hidden killer. Supporting a charity like the Oral Health Foundation offsets the commercial element which often deters the media from promoting a practice event. Ensure that you send out a press release with an eye-catching headline a couple of weeks before the event. It is often worth following up an e-mail with a phone call as I have often seen a personal call result in a photographer or film crew attending on the big day!

• Step 9 – Have a Clear Referral Pathway

Good communication between healthcare professionals is essential. This is particularly important when making a referral for a head or neck cancer to avoid a delay in diagnosis and appropriate intervention. NICE guidelines should be followed every step of the way to ensure an appropriate and timely referral and support for the patient and family.

The Department of Health requires that the dental team adopts a care pathway approach. I would urge you to be clear on the care pathway pertaining to your specialist centre and be up to speed on the 'fast track' service for immediate referrals as this is a topic that CQC will quiz you on in an inspection. In addition, building rapport and communicating directly with your specialist team is key to avoiding delays and ensuring an early diagnosis.

 

• Step 10 – Use a Systematic Approach

Does your practice want to know if it making a difference by checking thoroughly for oral cancer? Well, the only way to be sure, is to run reports and audit your activity. To ensure that variables are minimised, a systematic approach needs to be taken, that is, the examination needs to be done in exactly the same way every time. I would advise using oral cancer custom screens on your software package in surgery. They are usually laid out in a tick box fashion and it is then simply a case of the dental nurse calling out the area to be examined and the dentist giving a response to be recorded. This method also ensures that nothing is missed and a 50:50 intra:extra oral exam is always done too.

 If you don't have custom screens but have a maintenance package with your software provider, the company will normally install one for you. Otherwise, for a small fee, companies will build one in for you.

Custom screens - a simple tool for saving lives!

My ‘Take Home’ Message.

Within the CQC’s Key Lines of Enquiry, inspectors are now looking for evidence that our teams care about safeguarding patients against oral cancer. Not only does an oral cancer management system in practice safeguard your patients’ oral and systemic health but also assists in meeting our professional obligation to do so. My take home message is definitely “Learn, check, talk and educate”.

A Word from Nicki

If any reader needs any help to integrate the above steps into their practice, please contact me at [email protected]. I would be very happy to help!