Is it really about time? Overcoming the real barriers to complete oral cancer screening -- part 4

By Jonathan A. Bregman, DDS, FAGD

Time ... how much time?

I ask the same question to all attendees of programs that I do across the United States: So, what do you think is the reason that dentists give for NOT doing a complete cancer screening exam?

Unanimously, the reply is, “Time.”

Which then begs the follow-up question: How much time does it really take?

The answer: “One to one-and-a-half minutes.”

I have continually thought about why more dentists do not take that small amount of time to do a complete cancer screening exam if it can save lives, reduce malpractice liability, besides being the “right way to practice dentistry.”

The answers are in this series of articles outlining the seven key barriers I have determined that stop dentists from doing a complete cancer exam.

A brief overview of Parts 1, 2, and 3

Part 1 — the overall lack of confidence in doing the complete extra-/intraoral cancer screening exam. The rationale: “Not doing the exam at all puts me in at less risk than doing it and missing something.”

Part 2 — being unclear about who to examine: the changing target population especially the influence of the human papillomavirus (HPV 16/18).

Part 3 — the uncertainties of how the complete cancer screening examination should be done, plus communicating the reasons for doing it for patients.

Now, in Part 4 — uncertainty about how to properly record my cancer screening examination

EO/IO negative ... Is that enough?

Extraoral/intraoral exam negative. That is what eo/io negative means. Is that enough record keeping to stand up in a court if a lawsuit is filed against you for delayed or lack of diagnosis of oral cancer? Interestingly, when asked this question, attendees at my courses all across the country respond with a resounding “no!” With that “no” is a very tentative “but what should it be?”

If you do not write it down, you did not do it

During my hospital-based general practice residency in dentistry, chart audits were routinely performed as they are commonly done today. The mantra was, “If you did not write it down, you did not do it.” So, when it comes to cancer screening exams, the same rule applies.

What needs to be examined and noted as having been examined?

Think about it ...

• What are all of the structures that you examine during the extraoral part of your examination? i.e., the head and neck
• What are the different structures that you examine during the intraoral part of your examination?

Need a bit of help? Dust off your textbook and take a look. You will find what you need. Here is the protocol/list that I developed with the hospital dental clinic director in my home area.

Extraoral: Head and neck --

• Symmetry
• Skin of face, nose, ears, neck, hairline
• Lips: vermillion border
• Scalp
• Parotid
• SCM
• Submandibular
• Midline
  
  • Larynx
  • Thyroid

• Submental
• Subclavian

Intraoral --

• Lips
• Cheeks
• Frenum
• Tongue: anterior, posterior, dorsal, ventral, base
• Hard palate
• Soft palate
• Floor of the mouth
• Ridges
• Oropharynx
• Tonsilar pillar
• TMJ palpation

Positive findings --

Onset, duration, number, size, texture, color, type, radiographic findings if appropriate, photo-documentation

The critical factor ... leave nothing blank

Whatever protocol you use be sure to follow these basic rules:

1. Use the same protocol for all new patients.
2. Use the same protocol for your preventive re-care (hygiene patients).
3. Be certain to have either an assistant or hygienist read off the questions or “list of structures” so that nothing is missed and the patient hears the extent of your examination.
4. Most importantly, put a notation for every blank or for every structure.
a. Normal
b. Abnormal
c. Not apply
5. If abnormal, be very specific in describing what is present.

Saving lives is up to youEarly cancer detection of the extraoral and intraoral structures is critical to enhance survival rates. When a head/neck or oral cancer is found in its earliest stage of mild dysplasia, the survival rate at five years can be more than 85% to 90%. When found at a stage when the cancer has spread to distant areas of the body, the five-year survival rate can be 20% or less. Unfortunately, over one-third of the head/neck and intraoral cancers diagnosed today are already in Stage III or IV! Effective cancer detection protocols can go a long way to change these statistics and save lives.It is up to us to properly examine and record the findings of our examination. Proper record keeping protocols are not difficult to institute. Once in place and followed regularly, you will not only greatly reduce your malpractice risk but also improve patient care by ensuring that no structure in the head/neck or intraorally is missed.Don’t let the uncertainty of proper record keeping protocols remain a barrier to performing an effective cancer screening for all of your patients. It is up to you to take the necessary steps to become a part of a nationwide effort to save lives.It’s about time!What’s coming up in the next article in this series?
Resistance factor five: concerns about differentiating normal vs. abnormal structures.