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Referral Controversy

Feb. 1, 2018
Dianne Watterson, RDH, advises a hygienist who was very uncomfortable when the dentist did not recommend that a patient with an oral lesion to see an oral surgeon. Could she be held liable if the patient has oral cancer?
After reporting lesion, hygienist is concerned about doctor’s response

Dianne Glasscoe Watterson, RDH, BS, MBA

Dear Dianne,

I recently had a 53-year-old woman in my chair. She related that she had never smoked and was an occasional social drinker. When I performed the oral cancer assessment, I found an odd lesion on the left lateral posterior of her tongue. The lesion was not ulcerated, but it was irregularly shaped, and 4 mm to 5 mm in size. The patient was unaware that the lesion was there and told me it had not been sore. I noted all the particulars in the chart notes, including location, size, color, and shape. I felt certain that the doctor would refer her to see an oral surgeon.

The doctor performed the periodic exam, and much to my surprise, he told the patient that he didn’t think it was anything to worry about. He ended by saying that we would check it again in six months. I was floored that he didn’t refer her for a biopsy.

After the doctor left the room, the patient asked me what I would do if that lesion was in my mouth. I had to think fast. Not wanting to contradict what the doctor had just told her, I said that she should keep an eye on the lesion and if it didn’t go away in a week or so, let us know and we’d check it again. I knew as I was saying this it would be difficult, if not impossible, for the patient to monitor the lesion since it was so far back. But in all truthfulness, if I had a lesion like that, I’d want it checked by an oral surgeon.

Now I’m worried. I keep thinking about this patient and wondering if I did the right thing. Should I have referred her anyway? Should I call her? What if the lesion is cancerous? Would I be liable even though the doctor chose not to refer?

An RDH who is losing sleep

Dear Losing Sleep,

Your educational training teaches you to identify abnormalities in the oral cavity. You may not always know what the lesion is, but you know when something is abnormal. It is the doctor’s job to decide on a course of action when something is identified, but even with their advanced training, doctors don’t always know the answers.

I can only speculate why the doctor did not refer this patient for a biopsy, but I suspect he did not wish to alarm her. Sometimes doctors use verbiage that minimizes the situation, such as calling periodontal disease “a little gum problem.”

Performing an oral cancer assessment is an important part of any preventive care visit and hygienists who omit this function are practicing in a neglectful manner.

I’m so proud of you for performing an oral cancer assessment on your patients. While hygienists know they should be doing this, too many simply omit the oral cancer exam for one reason or another. What many hygienists do not realize is that if the doctor is ever charged with failure to detect oral cancer, the hygienist who saw the patient can be named as a codefendant. Jeff Tonner, JD, told me that failure to diagnose oral cancer is a growing area of liability and can even exceed the limits of a doctor’s malpractice insurance. Since hygienists are licensees, they have a responsibility to their patients. Performing an oral cancer assessment is an important part of any preventive care visit and hygienists who omit this function are practicing in a neglectful manner.

The number of oral and oropharyngeal cancer cases grows every year. According to the Oral Cancer Foundation, 49,750 cases of oral and oropharyngeal cancer will be diagnosed in 2017. About 20% will die from this cancer.1

Let’s take a common situation in a dental office. Let’s say the hygienist finds something suspicious and the doctor refers the patient to the local oral surgeon. The hygienist walks the patient to the business desk and tells the business assistant that the patient needs to see an oral surgeon. The business assistant offers to make the call and arrange the appointment, but the patient says, “I need to think about this. I’ll make the call myself.” Then the patient exits. Out of sight, out of mind. Now there’s a problem.


The general dentist and hygienist may believe that they are off the hook if a patient does not follow their recommendations. What they may not know is that there are four subcategories in failure to detect oral cancer scenarios:

• Errors in clinical judgment—Improperly relying on a diagnostic study, such as relying solely on a negative pathology report despite the presence of a persistent oral lesion, or failure to perform the indicated diagnostic test due to inadequate suspicion of malignancy because the patient is not in a high-risk group.

• Failure to follow up—Not making sure that the next indicated clinical step is proceeding properly. Follow-up failures often result from lack of a reliable tracking system to ensure that a patient kept the appointment with the specialist or underwent the diagnostic test that was ordered.

• Failure to screen patients appropriately—Infrequently examining patients in a high-risk group, and failure to recommend routine screening examinations on patients in a risk group.

• Evaluation delay—Patients repeatedly visiting with continuing or progressive clinical findings, coupled with the practitioner’s failure to perform the indicated diagnostic tests on the patients or refer them for proper testing, or failure to request a consult.

Say the doctor recommends that the patient see the oral surgeon, but does not diagnose anything. Does anyone bother to follow up with the patient? The potential for failure to diagnose liability is possible for any of the aforementioned subcategories. This is why I recommend that any patient who is referred to an oral surgeon receive a follow-up phone call in three to four weeks, especially if there is no correspondence from the oral surgeon. Make sure that all phone calls are carefully recorded in the chart narrative.

Sometimes patients choose to delay seeing a specialist. Whatever their reasons, the delay could have disastrous outcomes and result in painful or disfiguring surgeries, or even death. Then they go through a wide range of emotions and often feel someone should pay for their suffering.

Let’s get back to your situation. I recommend that you consult with the doctor privately that you’re worried about this patient, that six months is a long time to wait for the recheck, and that you would like to bring her back for a check of the lesion right away. Any reasonable doctor should not object to a staff member having this much concern for a patient. Any suspicious lesions should be kept under a magnifying glass until (1) the lesion goes away, or (2) a definitive diagnosis is received from a specialist.

All the best,

P.S.: Here is the end of this story. When the doctor took a second look at the lesion, he indeed referred her to an oral surgeon, who performed a biopsy. The lesion was squamous cell carcinoma in situ and was subsequently removed. Had this been allowed to progress, the outcome could have been very different. This hygienist’s concern might have saved this patient’s life. Be vigilant and diligent with oral cancer assessments, always!

Dianne Glasscoe Watterson, RDH, BS, MBA, is an award-winning author, speaker, and consultant. She has published hundreds of articles, numerous textbook chapters, and two books. Dianne’s new DVD on instrument sharpening is now available on her website at under the “Products” tab. Visit her website for information about upcoming speaking engagements. Dianne may be contacted at (336) 472-3515 or by e-mail at [email protected].


1. Hill B. Oral and Oropharyngeal incidence rates for 2017. Oral Cancer Foundation website. Published January 2017. Accessed December 22, 2017.