• 1/10/2006
  • Tallahassee, FL
  • Cliff Rapp, LHRM
  • First Professionals Insurance Co.

Every year, oral cancer kills more people in the United States than cervical cancer, malignant melanoma or Hodgkin’s disease. Ninety percent of all oral cancers are squamous cell carcinoma, and oral cancer has one of the lowest five-year survival rates of all major cancers.

Malpractice claims alleging “failure to diagnose oral cancer” often are the most difficult to defend and are the most expensive of all dental claims.

An analysis of Physician Insurer’s Association of America (PIAA) closed-claim data reveals oral cancer claims are on the rise nationwide. Indefensible cases fall into three categories: failure to follow up on a lesion with marginal clinical suspicion (most often a failure to biopsy); failure to re-examine a lesion and the patient’s medical history; and office-systems failure, allowing a patient or diagnostic reports to slip through the cracks.

Dentists should view all lesions, lumps and bumps as possible cancer. Although most lesions are benign, squamous cell carcinoma often is found on the mucosa – facilitating the argument that diagnostic measures are readily available. Closely monitor patients who have suspicious lesions until a definitive diagnosis is made.

Thoroughly document possible traumatic origin of a lesion. When patients explain a suspicious clinical sign or symptom, get “ proof” and consider a biopsy. Institute a fail-safe follow-up system. Refer patients to a specialist for further diagnostic workup or care, and send a consultation request to promptly facilitate the referral. Include the referral process in your follow-up system to ensure receipt of the consultant’s written report of findings.

Documentation, Early Detection Are Crucial

With cancer, as with many diseases, early detection is the key to long-term survival. Patients who receive regular medical and dental care assume they are being routinely and adequately screened for all types of disease – especially oral cancer.

Document all routine oral cancer screenings and update the patient’s medical history accordingly. Identify and counsel patients who are at risk for oral cancer, and follow them regularly. Document all missed appointments and no-shows.

Accurately document a lesion’s clinical presentation on all visits. Carefully document all conversations and warnings about the importance of long-term observation, as well as all recommendations for consultations with specialists. Document the patient’s response to your discussions.

If a patient refuses treatment, explain the potential consequences and note the record. Send the patient a certified letter confirming your discussion, his or her refusal of treatment and the potential consequences. For high-risk patients, instruct your staff to document all efforts at recall and send a certified letter. When possible, obtain an “Informed Refusal of Treatment” form from the patient.

Resist the temptation to “abandon” noncompliant patients. Consider withdrawing as their dentist, providing adequate written notice of your intention to withdraw, and affording ample opportunity to transfer their care. Send the letter by certified mail, and again urge compliance.

Juries view oral cancer screening as non-invasive, easy to perform and relatively inexpensive. Defensible treatment records should clearly show you offered treatment choices; made a mutual decision with the patient; properly documented discussions; and performed regular follow-up.

Cliff Rapp is vice president of risk management for First Professionals Insurance Company (FPIC), a leading provider of professional liability insurance for physicians, dentists and other health-care providers in Florida, Georgia and Arkansas.

Information in this article does not establish a standard of care, nor is it a substitute for legal advice. The information and suggestions contained here are generalized and may not apply to all practice situations. FPIC recommends you obtain legal advice from a qualified attorney for a more specific application to your practice. This information should be used as a reference guide only.