Description
My mother complained that she thought she had a swelling on her palate. It was pain free. She was told to ‘see her son who does good root fillings’. The complaint was left to lapse – for a very long time. Some many months later she mentioned it to me whilst at dinner in a restaurant. I took a peek and had her booked into see me the following morning. I saw her and referred her that afternoon to a maxillofacial surgeon. Routine tests and biopsy undertaken that week proved it to be a mucoepidermoid carcinoma some 2 cm by one centimetre (Figure 1).
How were we to treat it? I took opinions from oncologists, maxillofacial surgeons, general practitioners, the internet and family.
She was a young sixty, former Secretary to a Minister in Government, loved dialogue, enjoyed food, thrived on company, entertained frequently and was currently coordinating a multicultural concert in London with artists from the UK, Australia, India and Ceylon. Facing life with a deformity was the last option. Balancing risks with quality of life was the issue. ‘I have had a great life and I have no regrets’ she said. ‘But at least leave me with my smile’.
We found a surgeon with delicate hands and determined skills. He diligently dissected away the lesion down to the palatal bone, cauterised the palatine nerves and left the lesion to heal under an acrylic plate.
Despite excluding cancers of the salivary glands and nasopharynx, about 3000 new cases of oral cancers present themselves in the United Kingdom every year. Of these, about 1600 patients will die. It has a high mortality and morbidity and the ratio of deaths to registrations is higher than that for invasive cancer of the uterine cervix, breast and malignant melanoma. New cases are about 45 per one million per year in England and twice that in Scotland.
One of the very first patient’s to visit me at the first practice I bought in Wimbledon came cheerily in and said, ‘Doc, can I have some Bonjela?’ (Figure 2). He said he had an ulcer under his denture and the previous practitioner had supplied him with a free sample. I took one look at his lesion, rang Queen Mary’s Roehampton, arranged for him to be seen that afternoon and paid for the cab that took him in. His wife came by some several months later to thank me, but to also inform me that his funeral was just over.
The raìson dêtre of dentistry is no longer the mere relief of pain, but the saving of a life.
The poor survival rate is due partly to the late presentation of cases, with some 60% presenting with lesions over 2cm in diameter. The main source of screening is the general dental practitioner and studies have not been encouraging about their ability to detect oral cancers early.
Hence not recording soft tissue screening is not negotiable. On average, the five year survival rate is anticipated to rise from the current 40% to 80 % when the oral cancer is detected early.
About 95% of all oral cancers present as squamous cell carcinomas.
The general site distributions are:
Tongue 28.8%; Oropharynx 14.9%; Floor of mouth 13.4%; Lip 11.3%; Gum 5.3%; Ill defined sites 7.8%; Unspecified 18.4%.
Some potentially malignant lesions are:
Leukoplakia, Erythroplakia, Chronic iron deficiency anaemia, Lichen planus, Submucous fibrosis, Lupus erythematosus, Actinic keratosis and Tertiary syphilis.
Cancer may present in the mouth as:
• Ulcer, wound or tooth socket which does not heal
• Induration of any mucosal lesion
• Tooth mobility without apparent cause
• White/red patches
• Pain/parasthesia with no apparent cause
• Fixation of mucosa to underlying tissue with loss of mobility
• Fungation/growth to produce elevated, cauliflower surface
• Dsyphagia without other reason
Those most at risk are:
• Men (2x that of women – but decreasing)
• Over forty years of age
• Smokers and other tobacco users
• Heavy alcohol drinkers
• Those who have had oral, lung or throat cancer before
• The immunocompromised
• Fair skinned people (lip cancer)
• Betel quid chewers
• Diet – high fat, low Vitamin A, iron deficiency
• Combination of the above
Screening should take at least 3 minutes, be systematic and cover lips, lower and upper labial sulci and mucosa, labial commissures, buccal mucosa, buccal sulci, alveolar ridges and gingiva, tongue, floor of mouth, hard and soft palate, facial tissues and submandibular and cervical lymph nodes.
This profession should subscribe to any standard which has the potential to help patients reduce their risk of oral cancer and to sign up to any protocol which will help detect cancer early. We are, after all, health care professionals first and dentists as part of that concept. Detecting oral cancer early saves lives.
What of my mother? Despite the surgery, she carried on stoically with the concert. Everyone bought tickets, more as a tribute to her perseverance than the concert. The concert, nevertheless, was packed out and a huge success. She loved the fuss and continues to heal.
Should we have been so conservative in our approach? Only time will tell, but whenever she goes she will still have that beautiful smile on her face.
