Is it really about time? Overcoming the real barriers to complete oral cancer screening -- part 3

By Jonathan A. Bregman, DDS, FAGD

From coast to coast the same answer

As I tour this country presenting programs on early oral cancer detection, I ask the same question of all my attendees: What do you think is the main reason that dentists give for not doing a complete oral cancer examination?

The unanimous response in more than 25 states and close to 50 locations is, “Time!” … Yes, time!

My next question is always the same: How much time does it take to do a complete extraoral and intraoral cancer examination?

The answer is always the same: “One to one-and-a-half minutes.”

Something changed somewhere along the way

Within this past year, I was made aware of a statewide study evaluating outcomes of dental school education at one particular state-supported dental school. Among the topic areas evaluated was the percent of graduates who are doing a complete extra-/intraoral cancer screening examination in their current practice setting. About 30% of respondents replied in the affirmative.

Only one-third! And that was within the first five years out of dental school. Nationwide, the percent of dental offices doing a complete screening examination is only about 20%!

My question is what happened that stopped dental professionals from doing a complete extra-/intraoral cancer screening?

What are the barriers stopping us from doing what we all know we should be doing?

Brief overview of Parts 1 and 2

In Part 1, I discussed that, in my opinion, there is a four-part “system of early oral cancer detection” for any dental office to be maximally effective:

1. The target population: Who do we examine and why?
2. The basic examination: How do we perform and record it?
3. The delivery of a difficult message: Verbal skills and seamless referrals
4. The new tools available for screening: What are they, how do they work, and when are they used?

Part 1: the first resistance factor

• Overall lack of confidence in doing the complete oral cancer screening examination. The rationale: “Not doing the exam at all puts me at less risk than doing it and missing something.”

Part 2: the second resistance factor

• Being unclear about who to examine: The changing target population.

Now, in Part 3: the third resistance factor

• Uncertainty about the complete extraoral and intraoral screening examination itself.

When every dental health-care provider had his or her respective training, the “parts and pieces” of the extraoral and intraoral oral cancer screening examination were:

• Discussed at length in the classroom setting
• Practiced (usually one student on another)
• Required to be performed and recorded for every patient evaluated as a new patient
• Required to be performed and recorded in the preventive recare clinical areas

The critical nature of this examination, the doing of it, and the recording of it were all stressed. So what happened?

It’s all there inside our heads

Besides our own books from our training, there are many books and online materials available that can serve as a refresher on how our cancer screening should be done. This “cancer screening exam” has not changed in more than 30 years.

As a prominent oral pathologist who attended a recent program of mine agreed, a squamous cell carcinoma looks the same now as it did 30, 40, or more years ago. So the majority of pathology has not changed either. To refresh what is already in our heads, we just need to take a few minutes, break out our books or our computer, and do a review. Simple, huh? So why is there resistance? Is it ego? What do you think?

Here are the facts:

1. We were taught how to do an effective cancer screening examination.
2. We have the tools at our fingertips to review what we were taught at any time we would like to do so.

If the barrier to doing a complete cancer screening examination is not being sure of what one should be doing, voila! Here is a way to easily get unstuck.

If your ego does not allow you to admit that you are rusty or unclear about what you need to be doing when performing the cancer screening exam, then you can quietly review what you need to know privately.

What about when the patient asks, “Why are you doing this cancer screening exam now when you did not do it before?”

Now that you are committed and have clarified and sharpened your skills about the complete cancer screening exam, what is your next step?

Involve the entire team!

1. Have a discussion with your team about the mission of your office as it relates to the complete cancer screening exam (see Dental Economics article by this author, December 2008. Complete buy-in is critical.
2. Write down the questions that might arise when patients experience this exam.
3. Role-play and practice the communication skills with each other that will make it comfortable and effortless to answer these questions that we all know will arise.

I am often asked to provide a scripted reply to the patient question: “Why are you doing this now?” The process of working through a response for yourself is critical to the ownership and buy-in that is required for maximum team success. So I encourage you to create your own scripts in your own words.Work through this challenge of what the “complete cancer exam” entails and how to reply to your patients’ questions about why you are doing it. Once accomplished, you will overcome another common barrier that stands in the way of performing the routine extra-/intraoral cancer screening exam that we all were taught to do and know we should be doing!In Part 4, I will be discussing the critical aspect of recordkeeping that is a key adjunct to the cancer screening exam. The confusion/lack of clarity about what this recordkeeping must entail, as well as how it must be done medicolegally, is a barrier for many dentists that is directly connected with the uncertainty about exactly how the cancer screening exam should be performed.