Update in Stomatology: Assuring Dental Student Head and Neck Cancer Screening Competency

Among the modern tendencies in dental studies, the prestigious journal "Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Oral Endodontology" from March 2011 (1) launched a smart and practical idea concerning the early diagnosis of oral and maxillofacial cancer. I bear in mind a few important issues, that both dentists and general practitioners would be appropriate to have knowledge of it.

With an annual incidence worldwide of > 500,000 cases, head and neck squamous cell carcinoma (HNSCC) is the sixth most common malignancy (2). Despite recent advantages in detection, prevention and treatment, the overall 5-year survival for HNSCC continues to be modest (3). Moreover, we are expec­ting the incidence of these diseases to grow because of the increase in drug abuse and people in high-risk groups such as smokers, plant-chewers and so on. To improve long term outcomes, effective screening, in conjunction with primary and secondary prevention strategies, is critical.

Owing to the fact that (unlike most anatomic sites) oral cavity premalignant lesions are often visible during a conventional visual and tactile examination, screening for HNSCC is thought to decrease both morbidity and mortality. This screening should be performed by different specialists: general practitioners, otolaryngologists, dermatologists and especially dentists. During university studies, all these students and doctors should be given special training in order to be able to adequa­tely recognize premalignant and malignant lesions (in their beginning). However, evidence has repeatedly demonstrated that dentists and others possess a poor working knowledge of HNSCC an often do an inadequate job of screening for the disease. Studies have also found that the majority of senior dental students expressed uncertainty or lacked the ability to adequately recognize premalignant and/or malignant lesions of the oral cavity (4). These data suggest that the challenge of ensuring adequate HNSCC screening examinations may be multifactorial. Part of the issue may be related to the development of complacency among the dentists as they move further away from their dental school education (5). In addition, new dentists may be unprepared to adequately perform thorough HNSCC screening examinations when they enter the workforce.

How can the latter be true? Preclinical training implies rather theoretical and fundamental science than practice, and students learn rather the structure than the aspect and signs of lesions. However, it is sure that the preclinical training provided at these institutions has an extensive didactic instruction regarding the pathobiology, diagnosis and treatment of diseases of the oral and maxillofacial region, including HNSCC. Despite this, it would seem that the lessons taught in these classes are quickly forgotten and/or not reinforced during the second half of dental school when the focus of training shifts to the development of the restorative skills. Some have also suggested that complacency among the clinical faculty regarding the performance of HNSCC screening has reinforced the perception among dental students that the development of excellent oral examination skills is of secondary importance. The lack of continuity between what is taught in the preclinical years and what is emphasized during the clinical years has been a longstanding issue in dental education (6). However, until now, the dichotomy between these phases of training has not been formally addressed regarding HNSCC screening.

Therefore, it is gratifying to see that the Commission of Dental Accreditation (CODA), the accrediting body chartered by the United States Department of Education, recently approved the establishment of an academic standard requiring all USA dental students to be competent in the performance of a HNSCC screening examination and risk assessment (2). The hope is that the requirement for dental students to demonstrate competency will result in the HNSCC screening examination becoming a routine component of patient management (7). Increasing this competence of dentists contributes essentially to early diagnose of these lesions, given the fact that most people go to the dentists' at least once a year.

Although it represents an excellent opportunity to increase the competency of graduating students, there are still some administrative issues to be taken into consideration in order to implement these standards: how will each university define competency? How will it be determined? How often will the competency be tested in order to ensure that doctors haven't forgotten the previously acquired information? Each of these critical issues must be addressed if this CODA standard is to have its intended effect.

Competent institutions such as AAOM (American Academy of Oral Medicine), AAOPM (American Academy of Oral and Maxillofacial Pathology) are very important be­cause they have the authority to make changes to the medical curriculum, thus contributing to the improvement and development of medicine.

Moreover, this competency should be extended to other specialties (e.g. General Practitioners, Dermatologist, ENT specialists, etc) by a special universitary and/or postuniversitary training.

That for other competent institution, such as Medical College, Ministry of Health should suggest inserting into the General Medicine or residents curricula - basic information concerning Oral Pathology (both malignancies and other general diseases of the oral cavity).

Early diagnose both in malignancies and in other systemic diseases should shorten considerably the amount of time needed in correctly identifying the affection and would quicken the prescription of an appropriate treatment.