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Your NHS dentistry and oral health update
Friday 7th May 2021
Stepping up the fight against mouth cancer: an update from Sara Hurley and Peter Johnson
Dear colleague,
Around 8,300 people are diagnosed with mouth cancer each year in the UK. But with by spotting mouth cancer early, a complete cure is often possible in up to 9 in 10 cases using surgery alone.
The NHS is clear - a patient with suspected mouth cancer is in urgent need and should be prioritised for a dental appointment.
We've pulled together a new NHS mouth cancer awareness leaflet so dental teams know what they need to think about when they spot the signs of mouth cancer - and when they are making sure their teams and colleagues are looking for the signs, too. In this bulletin, we've pulled together the key information you need to know. For many of you, this is common knowledge but we hope it is a useful aide that covers the basics.
We're also grateful to be so well supported in the fight against mouth cancer by our respected partners - the Mouth Cancer Foundation, the British Dental Association, the Oral Health Foundation and Cancer Research UK have all pulled together fantastic resources, from patient posters to detection toolkits which we share with you in this update and encourage you all to use.
Dental professionals are on the frontline in the fight against mouth cancer. Your clinical judgment is invaluable in spotting this disease early and so saving lives.
Thank you for continued vigilance and dedication.
Best wishes,
Sara & Peter
Sara Hurley
Chief Dental Officer England
Professor Peter Johnson
NHS National Clinical Director for Cancer
Mouth cancer awareness: key information for dental teams
We have produced a handy key information leaflet for dental teams on mouth cancer awareness, which you can print off and have to hand in your practice, or use to discuss the issue with your team and colleagues.
The leaflet can be downloaded by clicking on the image on the left.
If you are having difficulty downloading, drop the Chief Dental Officer's team a line and we will send it over to you: england.cdoexecutive@nhs.net
Detecting mouth cancer: a reminder of the key information
Symptoms of mouth cancer:
The NHS advice is for a patient to see a GP or dentist if these symptoms do not get better within 3 weeks, particularly if the patient drinks or smokes:
The most common symptoms of mouth cancer are:
- sore mouth ulcers that do not heal within several weeks
- unexplained, persistent lumps in the mouth that do not go away
- unexplained, persistent lumps in the lymph glands in the neck that do not go away
Other symptoms may include:
- pain or difficulty swallowing (dysphagia)
- changes in voice or problems with speech
- unintentional weight loss
- bleeding or numbness in the mouth
- 1 or more teeth that becomes loose for no obvious reason, or a tooth socket that does not heal after a tooth is removed (extraction)
- difficulty moving the jaw
- red or white patches on the lining of the mouth. These are common and are rarely a sign of cancer, but they can sometimes turn into cancer
Types of mouth cancer:
Mouth cancer is categorised by the type of cell the cancer (carcinoma) starts to grow in. Squamous cell carcinoma is the most common type of mouth cancer, accounting for 9 out of 10 cases. Squamous cells are found in many areas of the body, including the inside of the mouth and in the skin.
Less common types of mouth cancer include:
- adenocarcinoma, which is cancers that develop inside the salivary glands
- sarcoma, which grows from abnormalities in bone, cartilage, muscle or other tissue
- oral malignant melanoma, where cancer starts in the cells that produce skin pigment or colour (melanocytes). These appear as very dark, mottled swellings that often bleed
- lymphoma, which grows from cells usually found in lymph glands, but they can also grow in the mouth
Those more likely to be affected by mouth cancer:
More than 2 in 3 cases of mouth cancer develop in adults over the age of 55. Only 1 in 8 (12.5%) happen in people younger than 50.
Men are more likely to get mouth cancer than women. This may be because, on average, men tend to drink more alcohol than women.
The leading causes of mouth cancer in the UK are tobacco and alcohol. As cancer is sometimes linked with long-standing wounds, there's a small chance that jagged, broken teeth, which cause persistent ulcers or wounds on the tongue, can increase the chance of mouth cancer developing there.
Other risk factors for mouth cancer include:
- chewing tobacco or other smokeless tobacco products
- chewing betel nuts with or without added tobacco
- an unhealthy diet
- the human papillomavirus (HPV)
The NHS recommends regular dental check-ups if the patient smokes, drinks heavily, chews tobacco or chews betel nut (a type of nut commonly consumed in Asia).
The standard operating procedure for NHS dentistry asks practices to consider prioritising patients "with frequent recall according to NICE recall guidelines eg high oral disease risk", which includes mouth cancer.
NICE guidelines state that clinicians should "consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:
- a lump on the lip or in the oral cavity or
- a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia"
Detection kits, screening protocols and suggested dental team responsibilities
BDA and Cancer Research UK mouth cancer detection toolkit:
It is essential that dental teams continue to improve knowledge of the prevention and detection of oral cancer, including what to look out for and when and how to respond.
The British Dental Association and Cancer Research UK have produced an online toolkit that covers oral and oropharyngeal cancers including lip cancer. This practical tool illustrates the red flags which should prompt referral to secondary care via a suspected cancer pathway, lesion recognition resource and a short video demonstrating how to perform an examination.
You can access the toolkit online here.
Mouth Cancer Foundation's screening protocol and checklist of responsibilities:
The Mouth Cancer Foundation has developed a simple Mouth Cancer Screening protocol to ensure that dentists are able to standardise the process for all patients over the age of 16 years. The protocol includes advice on extra-oral and intra-oral examinations as well the use of adjunctive tools.
The Foundation has also produced a useful checklist of suggested responsibilities for all members of a dental practice team should adopt when it comes to screening patients for head and neck cancer, which we encourage you to read and adopt.
Making a referral to secondary care: guidelines and a checklist
NICE guidelines state that specialists should consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) for oral cancer in people when assessed by a dentist as having either:
- a lump on the lip or in the oral cavity consistent with oral cancer or
- a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
The Mouth Cancer Foundation has produced a useful checklist for writing a referral letter.
Helping patients spot the signs: Patient facing materials
The Oral Health Foundation produced a number of excellent patient facing materials for Mouth Cancer Action month last November. Please do continue to use them to promote the signs of mouth cancer and to urge patients to book an appointment with their dentist or GP is they suspect mouth cancer.
Further information is available online.
The Mouth Cancer Foundation has produced a useful guide for patients to do their own two minute mouth check. You can download these materials and view other resources online.
Helping patients understand the journey with mouth cancer: A Patient handbook from the Mouth Cancer Foundation
The Mouth Cancer Foundation has produced a guide for patients to to make their journey as easy as possible once diagnosed with mouth cancer. If your patient has mouth cancer or would like more information about the journey ahead of them if they are suspected of mouth cancer, please send them a link to the handbook.
The handbook can be downloaded online here.
Advice for dental teams on treating patients with mouth cancer
Patients are usually advised to contact their dentist as quickly as they can post diagnosis with head and neck cancer to arrange a thorough examination. Dentists working in community or hospital dental services will likely have experience providing care to patients with more complex medical conditions and have the more appropriate competence and experience to provide dental treatment to patients with cancer. In many cases appointments with community and hospital dentists will be organised through department.
General dental practitioners frequently receive referrals and requests from Cancer Service Consultants, GPs and patients seeking dental care aligned with individual cancer care pathways. Priority should be afforded to these patients, with timely access to assess, improve oral health and provide care as a vital element in securing better outcomes for patients. In progressing treatment planning and shared decision-making linking with the patient’s cancer care team is recommended
A UK Medicines Information (UKMi) team and the Specialist Pharmacy Service have prepared this Q&A for NHS healthcare professionals, on “How should adults with cancer be managed by general dental practitioners if they need dental treatment?”.
More widely, some key things to remember are:
- Patients will have a treatment plan with their department, dental professionals should ask about the stages of the treatment plan.
- The aim of the examination is to discover active dental disease and to assess whether any other teeth are likely to need significant treatment in the foreseeable future. Treatment for head and neck cancer can result in making further dental treatment either difficult or in some cases dangerous.
- Dentists should recommend that patients have regular appointments with the dental team for advice on tooth decay, gum disease and other conditions which can result from radiotherapy, chemotherapy and surgery.
- Dental professionals should be aware of the wider consequences of mouth cancer and the impact this can have on patients lives, including personal confidence, lifestyle choices and their mental health.
The dental oncology service, part of the Department of Sedation and Special Care Dentistry at Guys and St Thomas’ Foundation trust, has produced this leaflet for patients which explains why it is important to see a dentist before and after treatment for head and neck cancer. It also explains what patients can expect when you come to the hospital dental department before, during and after your cancer treatment.
By word of mouth ... the colleagues we're all talking about!
Dental teams from The Royal London Hospital have been using their skills to look after the mouth and teeth of patients critically ill with Covid-19 on The Queen Elizabeth Unit
Tracey Knight and Barbara Davies, dental nurses, have been awarded Year of the Nurse badges by the trust for their hard work and dedication.
Since the beginning of the pandemic much of the team’s routine dental work has been put on hold, but they and their colleagues continue to use their expertise to support staff by conducting mouth care rounds on intensive care wards.
Dental professionals across England have gone above and beyond during the pandemic and it is excellent to see not just how we can turn our hands to other tasks, but how our skills at oral health are valued and needed to care for patients that are not just in the dentist's chair.
Well done to all the Barts Health putting the mouth back in the body!
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Previous NHS dentistry and oral health updates
Previous bulletins can be accessed by clicking on the links below:
NHS primary care bulletin
The NHS primary care bulletin provides resources on health policy and practice and we encourage you to sign up for this, too. It is aimed at teams across general practice, dentistry, community pharmacy and optometry.
A reminder of the latest COVID-19 advice and guidance
NHS updates to the profession
Previous updates from the Chief Dental Officer and the NHS dentistry and oral health team are all online here.
Transition to Recovery: Dentistry's standard operating procedure
The latest version was published on Tuesday 3 February 2021 . Changes to the previous SOP are in yellow. You can read the SOP online here.
Urgent Dental Centres: Standard Operating Procedure
Changes to the previous SOP are in yellow. It was updated on Tuesday 3 February 2021 and is online here.
COVID-19: infection prevention and control dental guidance
The guidance is an appendix to and should be read in conjunction with the national guidance on infection prevention and control for COVID-19 . You can read the general guidance and the specialist dental appendix online here.
