Learning a valuable lesion lesson

Hygienist Hub is all about sharing professional experiences. With this being Mouth Cancer Awareness Month what better story to share the experience of former Tasmanian DHAA Director, Danielle Gibbens, that relates to finding, diagnosing and dealing with the event of cancer when treating a patient.

I have been unfortunate enough to find numerous oral cancers in my short ten year career, and I would like to thank my patient who has been kind enough to allow me to share the records and photos with you. Hopefully this will assist with prevention or early detection of this very real disease.

It was mid-2016 and I had just started at a new practice full time. Within weeks I had the pleasure of meeting a 58 year old gentleman at a regular recall appointment.

The appointment started with me introducing myself, as we had never met, followed by a verbal medical history and chief complaint which neither had changed.

Even before I got to look into the patient’s mouth I noticed a dry crusted lesion on the right-hand side of his lower lip. I asked if he knew it was there and he explained that he had similar lesions all over his body and that this had been diagnosed as a cold sore. However, despite using the cold sore cream prescribed it had not gone away.

I continued to question him; Was it sore? How long had it been there? Had the lesion gone away and returned? He explained that he had had it for nine months and it had changed shape but had never gone away completely.

Now confident that this was not a cold sore I continued to gather information to present to the dentist. It transpired that since retiring, the patient spends the majority of his time outside as he is a keen fisherman. He also disclosed that he never been a regular user of sunscreen, especially when growing up in PNG, and re-iterated he had similar spots all over his body. There was a lot of sun damage due to his time outside and a reluctance to go for regular skin checks as he preferred not to know what they were. The patient was clearly not as keen as I was to find out more about this lesion but I continued to encourage him to help us figure out what was going on – for his own benefit.

I noticed a dry crusted lesion on his lower lip. I asked if he knew it was there and he explained that he had similar lesions all over his body and that this had been diagnosed as a cold sore.

With the information gathered I got the patients permission to take clinical photos and then asked the dentist to review the lesion – it was agreed that it needed to be referred to an oral surgeon.

Fortunately, this particular practice make specialist appointments for patients, but the patient was still reluctant to commit. I resolved this by calling the oral surgeon and organising for the patient to go directly from my appointment. The patient was happy with this, kept his appointment, and a biopsy was taken.

The initial report identified a “5x10mm crusted cracked lesion on the vermillion border” and stated that, if it was anything at all, it would be a Squamous Cell Carcinoma (SCC). Subsequent reports confirmed this and recommended a wedge lip resection.

The post-surgery report explained that the surgery had included a Vermillionectomy along with the wedge excision. The histology report from pathology stated that the SCC was stage T1NoMX invading 1.9mm with the lesion being associated with multifocal SCC in situ in solar keratosis.

All this had happened within a week of the lesion being spotted at a regular hygiene appointment. At our follow-up appointment we had the chance to chat about post-surgery and the impact of the whole experience on him.

The patient reported pain for one week post treatment and an inability to touch or clean the area for up to four weeks as directed by the oral surgeon. He recalled that prior to his diagnosis, there had been three people that inform him it was a cold sore, despite never having had a cold sore prior to this. Overall he was amazed by how quickly everything had happened. The process of having the lesion identified, diagnosed and surgically removed, had taken just over a week.

Episodes such as this can effect more than just the patient, and this experience has also been very hard for his wife, who has had to sit back and watch her husband go through everything – in particular the initial phase after surgery. Time has moved on and now he is in good spirits talking about how he grows a ‘hairy lip’ and that his wife has mentioned how different it is to kiss his new lip.

Valuable lesion lessons learned

Everybody connected with this good-news story are grateful that this lesion was identified and treated so early. Tragically this is not the norm. Despite the patient’s initial reactions they always return very thankful for the early detection. A nice feeling and a reminder of why we do our job.

Danielle’s key factors that can help in the early detection of up mouth cancers

Make good notes

  • • Know the difference between ‘normal’ and ‘not normal’.
  • • Make good records by asking lots of questions.
  • • Check your medical history to check if anything has changed.
  • • Check for a history of cold sores/ulcers etc
  • • Take clinical photos – you can’t rely on your memory

Ask lots of questions

  • • Find out how long has it been there and if it comes and goes or is there all the time
  • • Has it changed in colour or consistency?
  • • Have you had anything like this before?
  • • Do you spend a lot of time in the sun?
  • • Do you wear sunscreen when out doors?

Act quickly

  • • Review lesions in an acceptable time period – some of these things can grow fast! Most things should be healed within 7-10 days so a review every two to four weeks
  • • If in doubt refer to your preferred oral surgeon or oral medicine specialist – better to get the tick of approval than to sit on it
  • • Be supportive to the patient – this is a life changing event for them, they may not behave how you imagine just be sure to be supportive