A seven-week ulcer found during a scale and polish
Mr R, 59, is a kaumātua who attends your clinic for a scale and polish, his first in four years. He smokes 25 cigarettes a day, drinks six to eight beers at weekends, and has a Community Services Card. He mentions a sore spot on the left side of his tongue that he thinks he bit seven weeks ago. On examination there is a 15 × 12 mm ulcerated, indurated area on the left lateral border of the tongue, fixed to the underlying tissue, with rolled everted margins; it is not tender to light palpation. He has a firm, non-tender 1.5 cm submandibular lymph node and no trismus. He has come 90 minutes by bus, is keen to be cleaned up, and asks you for antibiotics because the doctor has been giving him some for his chest. You are the only clinician on site; the dentist covers the clinic one morning a week and is not due until Thursday.
1. What have you found, what are the red flags, and what must you do - and not do - today?
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What you are looking at. A 15 × 12 mm ulcer present for seven weeks, indurated, fixed to underlying tissue, with rolled everted margins, on the lateral border of the tongue, in a heavy smoker and drinker, with a firm submandibular node. Those are the classic red flags for oral squamous cell carcinoma. Duration beyond three weeks, induration, fixity and a painless ulcer are the features that most reliably separate malignancy from a traumatic ulcer, and the lateral tongue is a high-risk site. Differentials include a traumatic or major aphthous ulcer, tuberculosis, syphilis, a salivary gland malignancy and lymphoma - none of which changes what you do next.
What not to do. Do not prescribe antibiotics: there is no evidence of infection and antibiotics will delay diagnosis. Do not biopsy, scrape or cauterise the lesion - it is outside your scope and can distort the tissue. Do not scale over it.
What to do. Refer urgently, today. In New Zealand the route is an urgent referral on the high-suspicion-of-cancer pathway to oral and maxillofacial surgery at the regional hospital, or to his GP to make that referral if that is the local arrangement. The Faster Cancer Treatment programme expects a first specialist assessment within about 14 days for high suspicion and a treatment decision within 62 days of referral. The fact that the dentist is not in until Thursday is irrelevant to the urgency of the referral.
Communication. Tell him what you have found and what you cannot tell: 'I can't diagnose this, but it needs to be looked at by a specialist within days, not months.' Give written information, confirm his contact details, and check how he will get to the hospital. Document the size, site, duration, texture, node, risk factors, who you spoke to and when the referral was sent.
2. He says he will sort it out after the tangi and asks you again for antibiotics. How do you handle informed refusal while keeping him engaged?
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Explore before persuading. 'Tell me about the tangi - when is it, and what is worrying you about getting seen?' If the barrier is time, make the appointment for after it; if it is transport, look for a Kaupapa Māori health navigator, whanau support or a telehealth first contact; if it is fear, name it gently.
Informed refusal. He is entitled to refuse (right 7). That entitlement only means something if he understands what he is declining: this could be a cancer, and delay can change the treatment and the outcome. Explain it in plain language, check his understanding back, and avoid both minimisation and scare tactics.
Antibiotics. Repeat plainly that antibiotics will not fix this and may mask the problem. Do not prescribe to keep the peace; that is a decision that can cost him his life.
Document. Record what you told him, what he said, the alternatives you offered, and the safety-net advice: if the ulcer grows, bleeds, becomes painful or the neck lump enlarges, contact the clinic or the hospital immediately.
Widen the circle, with consent. Ask whether he would like a whanau member or kaumātua support person in the conversation. The hui process - mihimihi and whakawhanaungatanga before the kaupapa - is not a delay, it is what makes the conversation possible.
Leave the door open. Make a follow-up call in a week, send a text reminder, and offer to make the hospital appointment yourself so all he has to do is turn up. Keep the relationship intact: a patient who feels judged does not come back, and the second chance is often the one that is lost.
3. What is your scope of practice here, and what exactly would you record and follow up?
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Scope. Your role is recognition, communication and referral - not definitive diagnosis, biopsy or prescribing. The dental hygienist scope covers assessment, preventive care and referral within a collaborative model; suspecting malignancy and escalating it sits squarely inside that, and failing to escalate is a professional failure, not a matter of being 'only the hygienist'. The dentist's weekly visit is a rota issue, not a reason to wait.
Record contemporaneously. Date and time; site and size with a diagram or photograph; duration and the patient's own explanation; texture (indurated, fixed, rolled margins); tenderness; lymph node findings; risk factors (25 cigarettes a day, six to eight beers at weekends); the referral destination and method; what you told the patient and how he responded.
Language matters. Say 'this needs to be checked by a specialist', not 'this is cancer' - but do not soften it into 'just a sore spot'. That is exactly how delays happen.
Follow up. Confirm the referral was received, confirm he was offered an appointment, and ring the hospital if nothing has happened within the expected timeframe, documenting that you did. Non-attendance and lost referrals are common causes of late diagnosis, and a follow-up call is part of the referral, not an extra.
Look after yourself. Finding a suspected cancer is stressful. Debrief with a colleague, and write your reasoning down, because you may be asked to account for it months later.