'Let's just watch that ...'
I've been a dental hygienist for 17 years. One thing I take professional pride in is that I perform a very thorough intraoral exam.
by Dianne Glasscoe
I've been a dental hygienist for 17 years. One thing I take professional pride in is that I perform a very thorough intraoral exam. Over the years, I have identified various lesions, and a few have been cancerous.
Melanoma misdianosed as an amalgam tattoo
Recently, a patient presented with an ulcerated lesion on the ventral surface of her tongue. I discovered it when I lifted her tongue with gauze to do her oral cancer exam. The patient did not know the lesion was there and stated it had caused no discomfort. It was about 3 mm in diameter, and the center of the lesion was indurated.
Melanoma misdiagnosed as a "melanotic macule"
When the doctor came to check my patient, I described the lesion and pointed out the location. I was shocked when he said, "I think it's OK. Let's just watch it." He did not recommend a follow-up visit or even a referral to an oral surgeon. I could not believe my ears!
I think the patient was beginning to be concerned, and she asked me if I thought it would be OK. I told her that I did not know what kind of lesion it was, and she should keep a close check on it. I knew this would be difficult, because the lesion was located at the area adjacent to #32. That seems a bit far back for a patient to see easily.
My question is this: Should I have recommended she return in a couple of weeks for a check to see if the lesion was still there? I know I'm not supposed to override my doctor on diagnoses, but if this had been me, I would have wanted a referral. What should I have done?
Not Sleeping Well in Washington
Dear Not Sleeping,
Your doctor must have been running on "auto pilot" that day. Most conscientious clinicians would not be so cavalier about a potential oral cancer.
Once I had a patient in my chair that had broken a tooth. (I had a cancellation, so my chair was open.) This patient was a smoker and used alcohol regularly. I took an X-ray of the area, and the patient asked me, "Am I going to see the doctor today? I have this little sore under my tongue that I'd like for him to look at." I took gauze and pulled the tip of his tongue to the side so I could see what he was talking about.
The lesion was not like anything I had ever seen before. It was very ulcerated, diffuse, and about 6 mm in length. The patient stated that he had shown the lesion to his general surgeon about six months earlier while preparing for surgery to repair a herniated disk in his back. According to the patient, the surgeon replied, "That little bump is not nearly as important as fixing your back."
After my boss took a look at the lesion and without saying a word, he turned and quickly left the operatory for his private office. He closed the door behind him. His quick departure created an awkward moment for the patient and me. The patient asked me what that was about, I replied that I was unsure, but I knew he would be back. My unspoken guess that he was calling the local oral surgeon was confirmed when he re-entered my operatory and said, "Mr. Jones, I don't know for sure, but I think that sore under your tongue is a cancer. I have called the oral surgeon, and they want you to come right now. Is there any reason you cannot go now?" The patient responded that he would go.
The diagnosis was invasive squamous cell carcinoma. The patient underwent a partial glossectomy, partial mandiblectomy, chemotherapy, and radiation treatment. He died one and a half years later. The most unnerving aspect of this case was the ultra-cavalier attitude of the general surgeon. If he had acted before the cancer metastasized, the patient's chances of survival would have increased greatly.
It is true that some oral lesions (probably most) are benign and will resolve with time and correct medications. However, given the unusual shape of the lesion and its position in the oral cavity, it is obvious to me that, at the very least, this patient should have been asked to return in one to two weeks to see if the lesion had resolved. How can a patient be expected to monitor something she can hardly see?
An even better choice would have been to do a brush biopsy (oralcdx.com) on the lesion to see if any atypical cells were present. This is an easy way to find out if further referral is warranted. The code is "D7287 - cytology sample collection" in the CDT-4 codes. I understand that some third party payers recognize that this is a valuable diagnostic tool and will reimburse according to their plan.
There is a compelling story of a dental hygienist who was diagnosed with oral squamous cell carcinoma. The early atypical cells were identified with a brush biopsy. You can read her story at http://www.oralcdx.com, and click on the section under "Dentists and Medical Professionals."
Actually, you did well to maintain your composure although you were feeling at odds with your doctor's assessment. However, I recommend that you have a private talk with your doctor about this case. Let him know of your uneasiness in merely "watching" something that could be a potential cancer. Gather some data on the brush biopsy and present it to him for future use. It is a wonderful tool for those very early lesions that may appear insidious at first. The earlier a neoplastic lesion is intercepted, the better the outcome for the patient. Treatment for oral carcinomas that are given time to metastasize can be very disfiguring and traumatic, and a significant number of afflicted people do not survive.
Also, your boss should be aware that his inaction could be viewed as negligence, especially if the lesion turned out to be malignant. Again, early detection is so important, and dental hygienists can play an important role in detecting even subtle changes in the oral cavity.
According to the Centers for Disease Control, oral cancer incidence is on the rise. All hygienists need to be diligent in performing thorough intraoral and extraoral examinations on every patient. It is the standard of care.
Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe for speaking or consulting, call (301) 874-5240 or email firstname.lastname@example.org. Visit her Web site at www.pro fessionaldentalmgmt.com.