DT News - UK - Interview: “An oral cancer exam should be part of a dental check-up”

Brendan Day, DTI

Wed. 22 August 2018

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Though oral cancer is a condition rarely seen in the dental practice, the combination of its increasing incidence and relatively poor five-year survival rate make it a growing area of concern. To discuss this topic, Dental Tribune International spoke with Prof. David Conway, Professor of Dental Public Health at the University of Glasgow’s School of Medicine, Dentistry and Nursing in Scotland and co-author of a recent study on oral cancer detection in Scottish dental practices.

Prof. Conway, in your study, you write that anecdotal evidence says that dentists might only see one or two cases of oral cancer in their practising careers. Is this infrequency purely due to the low incidence rates or could it also be due to unfamiliarity with correctly identifying oral cancer?
Well that’s the old adage; oral cancer is not particularly common and is not something a dentist would see every week. We wanted to assess whether this was true by analysing the robust national level data we have in Scotland from dental services and the cancer registry. One of our hypotheses was that there could be practices—particularly those located in deprived communities, where the burden of oral cancer is greatest—where the likelihood might be much greater.

We found that oral cancer is a rare condition. In our estimate calculations, a dentist could expect to see one patient with oral cancer every ten years or four in his or her practising career—so, a very rare event indeed. But even more concerning was that for those patients who were actually diagnosed with oral cancer in Scotland, we found that just over 50 per cent of them had not attended an NHS dentist in the previous two years.

Two key messages arise from our study. Firstly, our efforts to improve prevention and early detection in dental practice settings need to fully recognise the rarity of the condition. This may include aspects of training or systems such as IT decision support or prompts in dental practices. Secondly, and perhaps more importantly, we need to reach out to those patients at highest risk of oral cancer who are not attending their dentist regularly. They have not accessed or had the opportunity for early detection by the dentist. This is important because we know early detection of oral cancer will improve prognosis and outcomes.

So what is it that prevents half of these high-risk patients from going to the dentist? Is it perhaps financial reasons, time constraints, a fear of the dentist, or something entirely different?
Well in some ways Scotland has the advantage that there is good coverage of dental practices. There’s good coverage in deprived communities in particular, as well as in urban centres. There may be some access issues in rural and remote areas, but for the majority of the population, there is good coverage in terms of physical access to dental services.

When you look at the published rates of registration with NHS dentists, over 90 per cent of the population is registered. However, that doesn’t mean that they attend regularly, with seven out of ten attending in the previous two years. So, approximately half of those at highest risk are in the non-attending group.

In terms of barriers, there could be multiple. While an NHS dental check-up is free in Scotland, costs or fear of costs could remain a barrier. Other possible barriers include the inability to get time away from work, competing priorities, and general fear or anxiety. It would be worthwhile exploring in-depth the barriers to and facilitators for regularly attending dental care for those patients and communities at highest risk.

One of the greatest risk factors for oral cancer is smoking, a habit that is seeing decreasing popularity throughout the developed world, including in Scotland. Why then do the incidence rates of oral cancer continue to rise?
Well in terms of risk factors for oral cancer, smoking and alcohol consumption are the two major risk factors. While smoking rates have gone down in Scotland and the rest of the UK, inequalities in smoking prevalence remain, with far more smokers from deprived communities relative to more affluent areas.

However, it is really the combination of smoking and alcohol consumption that is most dangerous. You don’t even have to have a high level of alcohol consumption—moderate alcohol consumption, combined with smoking—to substantially increase your risk of developing oral cancer.

It’s important to also understand that there are now considered to be two distinct types of oral cancer: cancer of the oral cavity, or mouth cancer; and oropharyngeal cancer, or throat cancer. For both oral cavity and oropharynx cancers, smoking and alcohol are important risk factors, but for oropharyngeal cancer, the human papillomavirus [HPV] comes into play, which is a whole different discussion, particularly in terms of prevention.

Regardless, the risk profile that we see across oral cancer is that it is typically males, over 60–65 years, and living in socio-economically deprived communities. The increase in incidence rates in the last decade has been driven largely by increases in oropharyngeal cancer diagnoses, which is in turn driven by HPV. Even with the recently announced introduction of the HPV vaccination programme for adolescent boys, there will still be adult cohorts in the decades to come who are at risk and won’t be covered by this programme, and for whom we will need to develop other prevention and early detection strategies.

Should oral cancer examinations be part of a regular dental check-up?
Yes, that’s essentially what we’re arguing for. Most dentists recognise that an oral cancer exam should be part of a dental check-up.

As well as a comprehensive intra- and extra-oral clinical examination, symptom and sign checklists could be considered, including for example persistent sore throat, difficulty swallowing, hoarseness and lumps in the neck—things that might not necessarily be at the fore of one’s mind when seeing a patient for a dental check-up or treatment.

Hopefully, this paper can start a discussion about the potential role for dentists in prevention and early detection of oral cancer, but a discussion that also recognises the difficulty of these efforts. This is a needle in the haystack type of problem, but it’s a really important needle to find. Oral cancer is a horrific disease with poor survival rates—only around 50 per cent of those diagnosed are alive five years later. It is an in-your-face, no-hiding, disfiguring disease, and the treatment can be very protracted, complex and costly. The earlier it is detected, however, the better the outcome can be, so it is essential that dentists are supported to detect oral cancer earlier and that patients at higher risk are supported to attend dental practices regularly for this opportunity.

Thank you very much for the interview.

Editorial note: Prof. Conway’s article, titled “Is detecting oral cancer in general dental practices a realistic expectation? A population-based study using population linked data in Scotland”, was published online in the British Dental Journal on 10 August 2018 and can be found here.

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