Patients' Perceptions of Oral Cancer Screening in Dental Practice

A Cross-Sectional Study

Oluwatunmise Awojobi; Suzanne E Scott; Tim Newton


BMC Oral Health. 2012;12(55) 

In This Article


Oral cancer refers to cancers affecting the mouth, lip and oral cavity. The Tumour-Node-Metastasis (TNM) staging system for Head and Neck Cancers is employed to describe how advanced the cancer is, depending on the size of the tumour, whether regional lymph nodes have been affected or the cancer has spread to a different part of the body (metastasis). The stage at which oral cancer is diagnosed is a major determinant of mortality and morbidity following treatment.[1] For instance, Stage 1 (early disease) has an 80% 5-year survival rate whereas for Stage 4 (advanced) disease the 5 year survival rate can be as low as 20%.[2] The most recent statistics shows that worldwide there were 263, 900 new cases and 128,000 deaths in 2008 and the incidence of oral cancer is on the increase across the world in both developed and developing countries and regions including Melanesia, South-Central Asia and Eastern Europe.[3] In the United Kingdom, the latest yearly incidence of oral cancer had risen to 6,236 cases as of 2009 with a mortality rate of 1985 across the country in 2010.[4] Detecting oral cancer at an early stage is the most effective means of improving survival and reducing morbidity from the disease.[5]

The two major known risk factors for oral cancer are alcohol and tobacco. These factors have a synergistic effect so people who both drink and use tobacco have a much higher risk of oral cancer than those using only alcohol or tobacco.[6] Other factors that have been implicated in the development of oral cancer include poor diet and nutrition, sun exposure and the human papilloma virus.[7] Oral cancer is most common in males, lower socioeconomic groups and in ethnic minority groups[8] although rates in females are on the rise with an average increase of 3% each year since 1989.[4] The majority of oral cancers are diagnosed in patients over 40 years of age.[9]

Early diagnosis is ensured by the prompt response of patients and healthcare professionals to early signs and symptoms in order to facilitate diagnosis and treatment before the disease becomes advanced. However, approximately 30% of patients wait more than three months before consulting a healthcare professional about signs of oral cancer.[10] Delayed presentation has been found to be influenced by the process of symptom interpretation, knowledge of oral cancer, coping responses and barriers to seeking help such as problems with access and their social circumstances and responsibilities.[11] However, lack of awareness leading to misattribution of symptoms, has been reported as the most common reason for delay in seeking help for oral cancer signs and symptoms.[12] This lack of awareness about oral cancer in the UK has been reported by Warnakulasuriya[13] and awareness of the early signs of the disease was found to be low (except for persistent ulcers).[14] Furthermore, awareness has been found to be lower in individuals at higher risk.[15]

Early diagnosis of oral cancer could be aided by opportunistic screening for signs and symptoms among patients attending for routine dental care in primary care settings. In the UK, Speight et al.[16] and Johnson et al.[17] propose that targeted opportunistic oral cancer screening of high risk individuals attending a General Dental Practice may be the most cost-effective option for oral cancer screening. Such screening involves a simple systematic visual examination of the oral cavity and includes palpation of the head, neck and soft tissues.[18] During a dental check-up, it is routine practice for a soft tissue examination to be carried out for all patients, when the oral mucosa is inspected and oral tissues are palpated (preferably including lymph nodes). As this is the case for all patients, it is assumed that screening for oral cancer is also done routinely when high risk patients attend the dental practice.

Informing high risk patients that they are being checked for early signs of oral cancer during a routine examination could present a prime opportunity to provide this group with information about the existence of oral cancer and advice surrounding prevention and early detection (which includes interpretation of signs, symptoms and prompt help-seeking). The British Dental Association (BDA) does advise that patients should normally be told that an oral cancer check is being carried out.[16] However, patients are often unaware that they have been screened for signs of oral cancer.[19] Data from the U.S indicates that General Dental Practitioners (GDPs) are reluctant to tell their patients they are performing an oral mucosal examination and often avoid using the word 'cancer' altogether as they are concerned about alarming patients.[20] GDPs in the U.S. have also suggested that patients may not be receptive to information about oral cancer; however, patients appear to be in favour of discussing oral cancer with their Dentists.[20]

In order to explore the extent of the missed opportunity for increasing oral cancer awareness in dental practices, this study surveyed a sample of adults attending two General Dental Practices in South East London. The aims were to explore patients' awareness of oral cancer and oral cancer examination experiences including whether such screening or results of the screening were discussed with them. In addition, this study compared knowledge of the signs of oral cancer, anticipated help-seeking behaviours and oral cancer examination experiences between those who are at low and high risk of developing oral cancer.