If your patient has any history of a malignancy, you need to be on the lookout for the signs and symptoms of metastatic disease to the oral cavity. Every year, case reports of breast cancer, lung cancer, renal cell cancer, lymphoma, and other malignancies spreading to the jaws are published.
Thankfully, this is a relatively rare occurrence, with approximately 1% of head and neck cancers representing metastatic disease dental equipment. Nevertheless, they can be challenging to diagnose due to a lack of a visible lesion and the fact that the dental practitioner often is not thinking about this as a possibility.3
An example of this might be refractory temporomandibular joint (TMJ) disease in a patient with a history of breast cancer. While TMJ arthritis would be the most common diagnosis, metastatic breast cancer to the TMJ is another possibility to be considered.4
Reading the History, But Missing the Point
Almost every dental practitioner I know has an excellent form or other way for capturing the patient’s medical history. But after the data is captured, there is often a failure to interpret it or recognize its importance. While smoking and alcohol history are widely recognized as risk factors for oral cancer, other conditions may increase the risk such as:
Transplant patients (due to immunosuppression)
Other immune-suppressed populations (HIV, hepatitis C)
Inflammatory bowel disease (Crohn’s, ulcerative colitis)
Chronic candidiasis infection
Lichen planus (relatively low transformation rate of approximately 1% to 3%)
Autoimmune diseases (systemic lupus erythematosus, rheumatoid arthritis), which may be associated with the diseases or treatment of these diseases
Practitioners should have a lower threshold to biopsy suspicious lesions in patients with these conditions.
You Made the Diagnosis But It Was the Wrong One!
Trust your judgment, but do not trust your initial diagnosis. I follow this in my own practice. Often once an initial workup, biopsy, or culture has been sent, the diagnosis is “made” and you move on with your busy day. But beware. Just because you made a diagnosis, it does not always mean you made an accurate diagnosis. For example, traumatic tongue ulcers might actually be early tongue cancers.5
I have had cancer patients referred after a practitioner tried several different treatments for a lesion after a diagnosis, only to discover that the diagnosis was wrong. Often this occurs because the patient is young or doesn’t have obvious risk factors for oral cancer, or the initial biopsy was “benign vacuum forming machine dental.”
The key to avoiding this pitfall is that if the clinical picture does not follow the natural history of your initial diagnosis or respond to therapy, your first thought should be “I made the wrong diagnosis” instead of “I am going to change the management strategy.” This will avoid circular thinking, and it will get you to consider other alternatives when things are not progressing the way you expect.
My hope is that awareness of these common errors may help avoid potential diagnostic mistakes. Instead of someone saying “you missed it,” you can happily say to yourself, “I nailed it!” dental implant machine