Recommending a checkup every two years is not the way to reduce growing oral cancer rates, Robert Donald says.

Government plans to extend the gap between dental checks to ‘up to every two years’ will jeopardise efforts to tackle Scotland’s fastest growing cancers.

The Scottish Government’s Oral Health Improvement Plan (OHIP) included the proposal to extend the dental recall interval for ‘low risk’ patients for up to two years. We’re often the first health professionals to detect oral cancer during routine dental checks. It now claims three times as many lives in Scotland as car accidents and we are at the forefront in a battle against some of the fastest rising cancers in Scotland.

Early detection is key, but this now risks becoming a casualty of a Government cost-cutting exercise. Extending dental checks to two years will only handicap efforts to meet a growing threat, while putting financial pressure on cancer services.

According to a parliamentary question answered by the ex-Health Minister, Shona Robison in March this year: ‘The present arrangements allow dentists to see patients with six months between courses, although patients on average receive a dental checkup once a year.’

If the message is conveyed, via the OHIP, that it is acceptable to be seen once every two years (according to NICE guidelines), then human nature kicks in. It is very likely that patients will then wait even longer before attending their dentist.

This is exacerbated by plummeting participation rates for adults, particularly in deprived areas where only 62% of registered adults have attended for a check in the last two years. Oral cancers can occur in patients with good oral health and a healthy lifestyle and not just the ‘high risk’ groups as referenced in the NICE guidelines.

Oral Cancer Action Plan

Concern over the Government’s proposals on dental checks was therefore a major driver for BDA Scotland to launch its own Oral Cancer Action Plan at the Scottish Parliament on the 13 November. The action plan was backed up by recent survey evidence, which revealed that 97% of Scottish dentists express concerns over moves to extend dental recall intervals, which could undermine detection or oral cancers – with 77% defining it as a major or severe risk.

Whilst there are some positive initiatives in the OHIP, it is alarming to think that they may be funded by cuts to six-monthly appointments for many supposedly ‘lower risk’ patients. Nearly 750 cancer cases are diagnosed every year in Scotland with survival rates improving from 50% to 90% with early detection.

Cases fuelled by the Human Papillomavirus (HPV) are increasing among younger, more affluent patients, non-smokers and moderate drinkers.

According to BDA Scotland, new analysis shows that oral cancer cases are now costing NHS Scotland up to £90,000 per patient – with an estimated annual cost of over £65 million. This is set to more than double by 2035 if the disease goes unchecked.

Scotland has also seen a 38% increase in oral cancer deaths in the last decade (521 last year). Our incidence rates are among the highest in Europe – with residents in our most deprived communities twice as likely to be diagnosed or die from the condition as those in more affluent areas.

This has led the Glasgow MSP, Anas Sarwar, to table a motion in the Scottish Parliament calling for sustainable and innovative approaches to oral cancer treatment, and expressing concern over the potential impact of the OHIP. BDA Scotland is also calling for a strategic focus on early detection, prevention and joined up services, with measures including sufficient resources for alcohol treatment and smoking cessation programmes and a catch up programme to offer 140,000 older school-aged boys access to the vaccination programme for the cancer-causing HPV.

Two oral cancer cases

I have personally referred two oral cancer cases in the last few years that simply do not fit the traditional picture of ‘high risk’ patients. I picked up a follicular lymphoma in one of my patients in January 2014. Brian had no symptoms or discomfort and was in for his six-monthly dental check.

I noted a small lump on one of his tonsils. He is a retired non-smoker and a ‘social drinker’ (he had previously been a smoker, but gave up 25 years ago). He managed to see his GP, who is also a part-time oncologist at the local hospital, the same day as my appointment and she did an urgent referral to oral max fax and treatment was commenced quickly. He wrote to me soon after the lump was removed and thanked me for my prompt intervention.

Brian went on to make a good recovery.

I also had another retired patient recently who had not been in for a dental check for over a year. He had a symptomless lump on his tongue. He had been to see his GP as he had been feeling a bit run down but his GP could not find any problems. He did not have any history of smoking or alcohol consumption.

The oral surgeon who saw him did not suspect anything sinister and wrote me a letter to this effect. However, his biopsy result revealed an aggressive cancer. The patient sent me a very nice letter before commencing treatment, thanking me for picking this up. He kept in touch with me letting me know about his progress. Unfortunately, he did not survive and died of the cancer shortly after.

These two cases highlight the importance of early detection and the need for six-monthly dental checks. Both patients did not flag up for risk factors (although the patient who survived gave up smoking 25 years earlier).

I often wonder ‘what if’. What if the second patient had come to see me sooner, perhaps I could have saved his life?

Post script

Scottish Government has now acknowledged publicly that we are right to raise our concerns on this issue. The profession will have a further period of discussion with Government to explore these concerns and hopefully come to a sensible solution that does not put our patients’ lives at risk.