Factors Affecting the Referral of Potentially Malignant Lesions from Primary Dental Care: A Pilot Study in South Yorkshire

Abstract

Early diagnosis of oral cancer is an essential element of prevention, yet many patients present late, suggesting that criteria used for referral miss the small or early-stage lesions. The aims of this study were to determine what cues are used by primary care dentists when making the decision to refer a suspicious lesion, and to investigate their recent referral behaviour. A cross-sectional study using a postal questionnaire was undertaken in a major conurbation in South Yorkshire. The questionnaire was sent to all 95 practices in the area concerned. Primary care dentists were asked to score a range of cues on a five-point scale and list their top ten. Experience of referrals made in the last 12 months was also recorded. Forty-two questionnaires were returned (44.2%). The cues that primary care dentists 'agreed' or 'strongly agreed' would initiate a referral were: 'fixed', 'smokes >20 cigarettes/day', 'indurated', 'ragged borders' and 'ulceration'. The most cited top-ten cues were 'ulcerated', 'fixed to underlying tissues', 'smoking' and 'indurated'. The median number of lesions referred was 0.77 per 1000 adult patients. Twenty-six dentists recorded their experience of 29 lesions. Of these, 17% had been found by the patient whereas 80% had been found at a routine dental examination. Seventy-nine per cent had been present for more than six weeks. Reasons for referral included atypical appearance (38%), ulceration (21%) and location (21%). Fifty-four per cent of primary care dentists described their relationship with secondary care as either 'good' or 'excellent'. The most cited cues related to established or advanced disease, not to 'red' and 'white' lesions, which the National Institute for Health and Clinical Excellence (NICE) recommend for early referral. Even allowing for the relatively poor response rate, this suggests that some small lesions of oral cancer are being missed.