Nexus - Spring 1999 Issue     

Oral Cancer Detection: Practicing for Life


Milton Palat, D.D.S., J.D.,
Associate Professor of Surgical Sciences (Periodontics


What is the ethical impact on society of dentists who, as dental students, provide a
complete oral cancer screening for every patient they treat, but fail to continue this life-saving practice as private practitioners? There is an implied contract between the dental professional and society: society will afford to the profession certain status and privileges such as self governance. In return, the professional will make a commitment to adhere to the highest ethical standards and work toward eradication of oral disease. Using the five ethical principles upon which the dental profession is founded -- patient autonomy, nonmaleficence, beneficence, justice, and veracity -- let us examine this contract in light of an actual case.

Case Scenario
Mr. R has come to your office for an initial examination and informs you that he is changing dentists. He had been Dr. X's patient for 15 years. Mr. R is an overweight man of 55 who admits to smoking a pack-and-a-half of cigarettes daily and consuming at least three to four beers per day. He works at his own landscaping business that requires him to be outdoors daily for long periods. You note that most of his teeth are restored by full crowns in the posterior areas and facial veneers in the anterior region. His primary concern, however, is the papillary lesion, which you determine is one to two centimeters in diameter, with irregular borders, along the buccal gingival of #19. The patient reports that this "lump" bleeds easily and has been there for several years. As is your usual custom, you do a complete cancer screening and discover the following: palpation of the left submandibular and cervical areas reveals several nodules that are not painful. His face appears slightly swollen in the area of #19, and #19 itself is depressible. Radiographs reveal that #19 has no bone around its roots and the extensive radiolucency around its roots appears diffuse and does not appear to involve #18 or #20.

The patient is extremely apprehensive and repeatedly asks, "Is this cancer?" From the patient's social history you learn that his father had suffered from alcoholism and had died from oral carcinoma. The patient has been accompanied to the office by his spouse, who has informed your receptionist of her husband's anxiety.

Since the well-being of the patient is dentistry's primary goal, we must begin with the premise that dentists should possess not only knowledge, skill, and technical competence, but also those traits that foster adherence to ethical principles. Qualities of compassion, kindness, integrity, fairness, and charity complement the ethical practice of dentistry and help to define the true professional.

Now for the application of the five ethical principles stated above.

I. Autonomy: a duty to respect the patient's rights to self determination and confidentiality.

In keeping with this principle, the dentist is obligated to involve patients in treatment decisions in a meaningful way, with due consideration being given to the patient's needs, desires, and abilities, and to safeguarding the patient's privacy.

Using this principle, let's consider the following options:
 
A.

Since the patient should become involved in treatment decisions, it would be unwise to discuss treatment until a confirmed diagnosis has been determined.
B. The findings should be held in strict confidence and only released with the patient's permission, preferably in writing.
C. Regardless of the final diagnosis, all treatment options should be discussed with Mr. R, giving the risks and benefits of each, and any alternative treatment should be made known.
D. If the doctor's skill and knowledge do not include either performing a biopsy or the surgical treatment when required, this information also should be shared with the patient.

II. Nonmaleficence: a duty to refrain from harming the patient.

Accordingly, the dentist is obligated to keep knowledge and skills current, know one's own limitations and when to refer to a specialist or other professional, and know when and under what circumstances delegation of patient care to auxiliaries is appropriate.

How does the principle of nonmaleficence relate to this case? Here are some possible ways.
 
A.

Dentists who fail to perform a complete cancer screening have in fact ignored the obligation to keep their knowledge and skills current.
B. This principle also requires the dentist never to compromise the welfare of a patient and, where necessary, to seek consultations with others considered more knowledgeable or at least provide a referral to another professional with the proper skill and knowledge. It is feasible to assume that Mr. R's original dentist either failed to recognize the potential danger of the lesion and/or to seek consultation with others.
C. Perhaps routine radiographs taken at proper intervals may have discovered the extent of the bone loss around #19 or at least uncovered the periodontal status of the lesion long before it had a chance to worsen.
D. Additionally, several risk factors for oral cancer in this case should have alerted the previous practitioner to the possibility of a serious situation. The lesion, combined with the consumption of alcohol, the use of tobacco, and the constant exposure to sunlight, should have acted as an alarm to the previous dentist.
"Dentists who fail to perform a complete cancer screening have ignored the obligation to keep their knowledge and skills current."

III. Beneficence: a duty to promote the patient's welfare.
The most important aspect of this obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs, desires, and values of the patient. The same ethical considerations apply whether the dentist engages in fee-for-service, managed care, or some other practice arrangement.
 
Dentists may choose to enter into contracts governing the provision of care to a group of patients; however, contract obligations do not excuse dentists from the ethical duty to put each individual patient's welfare first. Based on the facts provided by the patient, who happens to be a fee-for-service patient, it appears that the previous treatment did not reflect the principle of beneficence.

IV. Justice: a duty to treat people fairly.

Accordingly, the dentist is obligated to deal with people justly and deliver dental care without prejudice. In its broadest sense, this principle expresses the belief that the dental profession should actively seek allies throughout society who can help improve access to care for all.

This principle requires us to consider the idea of "appropriate criticism." This means that although dentists are expected to inform a patient of the status of his or her oral health, it should be done without disparaging the previous dentist. However, a corollary to this principle is the concept of "justifiable criticism." That is, dentists are obliged to report instances of gross or continually faulty treatment by other dentists to the appropriate reviewing agency. Does the lack of diagnosis or awareness of the patient's oral health status warrant "justifiable criticism" in this case? You make the call.

V. Veracity: This final principle holds that the dentist has a duty to communicate truthfully.

Accordingly, the dentist is obligated to respect the position of trust inherent in the dentist-patient relationship, communicating truthfully and without deception and maintaining intellectual integrity.

Having been made aware by the patient and his spouse of the patient's anxieties, please consider the following options in order to provide a proper diagnosis, via a biopsy, to this very frightened patient. Would you:
 
A.

Discuss the need for a biopsy and indicate that you cannot make a diagnosis without it? or
B. Indicate that the lesion and the radiograph and the clinical exam arouse your suspicion, but you must do a biopsy or refer the patient to someone who will? or
C. Tell the patient that you do not think it's serious (although you do) since you notice how upset he is? or
D. Discuss the situation with the patient's spouse and/or family before further decisions? Once again, you make the call.
"It is easily arguable that the single most important procedure in dentistry is an oral/pharyngeal cancer examination."

In this case, the biopsy returned a squamous cell carcinoma with regional metastasis. Each of the ethical principles discussed above must be considered in light of this new information.

This article seeks to underscore the fact that the quality of health care we deliver to our patients actually depends as much on the character of the dentist as it does on the practitioner's skill and knowledge. By the same token, if the professional relationship of dentistry with society is to improve, then each member of the profession must understand that the ethical foundation of quality health care is each member's obligation.


As Dean Michael C. Alfano has pointed out, "It is easily arguable that the single most important procedure in dentistry is an oral/pharyngeal cancer examination. Yet, tragically, most dentists do not perform a proper cancer exam (although they think they do!). This failure was underscored in an Ann Landers column in which a grateful patient wrote of being saved from throat cancer by a conscientious dentist who palpated the lymph nodes in his neck. The patient wrote further about how few of his friends have ever had their necks examined during a dental exam. Ann Landers wrote back, 'My dentist always checks my neck. You can be sure that after this column appears, thousands of dentists will be reminded by their patients to do the same. Thanks for a letter that will save lives.'"

Dean Alfano continued, "Whatever the reason for this lapse in dental practice, we must change the status quo. We can do it with your assistance in a self-help mode in which we each inspire one or more colleagues, or perhaps a local dental society, to 'get with the program.'"

References
1. Principles of Ethics and Code of Professional Conduct, American Dental Association, August 1998.
2. "The University of Kentucky's Curriculum in Professional Ethics," David A. Nash, Journal of the American College of Dentists, Spring 1996.
3. "Whither Oral Medicine . . . Enter Ann Landers!" Michael C. Alfano, Dental Abstracts Vol. 43, Issue I 1998 p. 4-5.

Oral Cancer
Fact: 30,000 Americans will be diagnosed with oral or pharyngeal cancer yearly.
Fact: 8,000 Americans die each year of these diseases.
Fact: Five-year survival rate is only half of those diagnosed.
Fact: Early detection is very possible. Tissue changes in the mouth may be seen and felt easily.

Warning Signs

Two lesions that could be precursors to cancer are
  • Leukoplakia (white lesions)
  • Erythroplakia (red lesions)

  • Possible signs/symptoms of oral cancer that patients report:
  • A lump or thickening in the oral soft tissues
  • Soreness or feeling that something is caught in the throat
  • Difficulty chewing or swallowing
  • Ear pain
  • Difficulty moving the jaw or tongue
  • Hoarseness
  • Numbness of the tongue or other areas of the mouth
  • Swelling of the jaw that causes dentures to fit poorly or become uncomfortable
  • If the above problems persist for more than two weeks, a thorough clinical examination and laboratory tests, as necessary, should be performed to obtain a definitive diagnosis.

    Risk Factors
    Tobacco/Alcohol Use Tobacco and excessive alcohol use increase the risk of oral cancer. Using both tobacco and alcohol poses a much greater risk than using either substance alone.
    Sunlight Exposure to sunlight is a risk factor for lip cancer.
    Age Oral cancer is typically a disease of older people usually because of their longer exposure to risk factors. Incidence of oral cancer rises steadily with age, reaching a peak in persons age 64-74. For African Americans, incidence peaks about 10 years earlier.
    Gender Oral cancer strikes men twice as often as it does women.
    Race Oral cancer occurs more frequently in African Americans than in whites.

    Dentist's Role
    1. Examination during each visit.
    2. History of patient's alcohol and tobacco use.
    3. Inform patient of the effects of alcohol and tobacco use as risk factors for oral cancer.
    4. Diagnostic -- perform appropriate techniques.
    5. Follow-up symptoms of oral cancer.
    6. Be knowledgeable regarding examinations; diagnosis; treatment; prevention; and side effects.
    7. Rehabilitation of the patient.