EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for Olivia’s oral lesion?

• Prompt: How do you differentiate between benign and malignant oral lesions?
• Prompt: What red flag features would indicate an urgent referral?

Q2. What further history and investigations would be useful in this case?

• Prompt: What risk factors increase suspicion for malignancy?
• Prompt: When would you perform a biopsy or refer to a specialist?

Q3. How would you explain the diagnosis and next steps to Olivia?

• Prompt: How do you communicate the need for further assessment without causing undue distress?
• Prompt: How do you address her concerns about oral cancer?

Q4. Outline your management plan for Olivia’s oral lesion.

• Prompt: When would you refer her to an oral surgeon or ENT specialist?
• Prompt: What conservative treatments could be trialled if the lesion is benign?

Q5. What preventive strategies should Olivia follow to reduce her risk of future oral lesions?

• Prompt: How does smoking cessation impact oral health?
• Prompt: What role does regular dental screening play?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for Olivia’s oral lesion?

A structured differential diagnosis is essential to differentiate benign vs malignant causes of an oral ulcer.

• Benign Causes (More Likely):
  • Traumatic ulcer – Due to dental irritation, biting, or hot food burns; typically heals in 2–3 weeks.
  • Aphthous ulcer – Round, painful, well-demarcated, resolves within 2 weeks.
  • Oral candidiasis – White plaques that scrape off, common in immunosuppression or steroid inhaler use.
• Malignant and Pre-Malignant Conditions (Must Exclude):
  • Oral squamous cell carcinoma (SCC) – Non-healing ulcer, induration, raised edges, risk factors include smoking and alcohol.
  • Oral leukoplakia/erythroplakia – White or red patches, considered pre-malignant.
• Other Systemic Causes:
  • Lichen planus – Lacy white striations, chronic inflammation.
  • Viral infections (HSV, HPV) – Vesicular lesions or warty growths.
  • Autoimmune conditions (Behçet’s, pemphigus vulgaris) – Multiple, persistent ulcers.

A competent candidate prioritises malignancy risk while considering benign explanations.

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Q2: What further history and investigations would be useful in this case?

• Further History:
  • Duration and progression: Persistent >3 weeks is concerning.
  • Risk factors: Smoking, alcohol, HPV exposure, prior oral lesions.
  • Systemic symptoms: Weight loss, dysphagia, referred ear pain (suggest malignancy).
  • Associated conditions: GORD, immunosuppression, prior head and neck cancer.
• Investigations:
  • Oral swab – If fungal or bacterial infection suspected.
  • Punch or excisional biopsy – Gold standard for suspected malignancy.
  • Full blood count (FBC), iron studies – If nutritional deficiency suspected.
  • HPV testing – If lesion is suspicious for HPV-related oral SCC.

A competent candidate selects appropriate investigations based on clinical suspicion.

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Q3: How would you explain the diagnosis and next steps to Olivia?

1. Acknowledge concerns:
   • “I understand that having a persistent ulcer is concerning, especially given your family history.”
2. Explain findings and risks:
   • “The ulcer has been there for six weeks and has slightly indurated edges. This means we need to do further tests to rule out any serious conditions.”
3. Discuss next steps (biopsy and referral if needed):
   • “The best way to assess this is a biopsy, which will tell us if the cells are normal.”
   • “If there are concerns, I will refer you to an oral surgeon or ENT specialist.”
4. Reassure but emphasise importance of follow-up:
   • “Not all oral ulcers are cancerous, but persistent lesions should always be checked early.”

A competent candidate balances reassurance with the need for further assessment.

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Q4: Outline your management plan for Olivia’s oral lesion.

1. Referral for Biopsy and Specialist Review:
   • If ulcer persists >3 weeks or has red flag features, refer for oral biopsy.
   • Urgent ENT or oral surgeon referral if SCC is suspected.
2. Symptom Management (if benign):
   • Topical corticosteroids (triamcinolone paste) for inflammatory ulcers.
   • Chlorhexidine mouthwash for secondary infection prevention.
3. Ongoing Monitoring and Follow-Up:
   • Review in 2 weeks post-biopsy.
   • If resolved, no further action needed.
   • If persistent or worsening, escalate referral.

A competent candidate ensures timely diagnosis, appropriate referral, and symptom relief.

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Q5: What preventive strategies should Olivia follow to reduce her risk of future oral lesions?

1. Smoking Cessation:
   • “Smoking is the biggest risk factor for oral cancer. Stopping now can greatly reduce your risk.”
   • Offer nicotine replacement therapy (NRT), varenicline, or behavioural support.
2. Alcohol Reduction:
   • “Reducing alcohol intake, particularly spirits and high-proof drinks, lowers oral cancer risk.”
3. Regular Dental and GP Checks:
   • “Routine dental visits help detect any early changes.”
   • “If you notice a sore that doesn’t heal in 2–3 weeks, see a doctor promptly.”
4. Oral Hygiene and Nutrition:
   • Encourage good dental hygiene and adequate hydration.
   • Address nutritional deficiencies (iron, folate, B12) if relevant.

A competent candidate tailors prevention to modifiable risk factors and reinforces regular monitoring.

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SUMMARY OF A COMPETENT ANSWER

• Distinguishes between benign and malignant oral lesions, ensuring red flag features are addressed.
• Takes a comprehensive history, assessing risk factors such as smoking, alcohol, and family history.
• Orders appropriate investigations, prioritising biopsy for persistent or concerning lesions.
• Communicates clearly and empathetically, explaining the need for further testing while minimising anxiety.
• Implements an evidence-based management plan, including biopsy, symptom relief, and referral if required.
• Emphasises preventive strategies, particularly smoking cessation, alcohol moderation, and regular oral health checks.

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PITFALLS

• Failing to recognise red flag features, leading to delayed diagnosis of oral cancer.
• Over-reassuring the patient, dismissing the need for further investigation.
• Not ordering a biopsy, which is the gold standard for persistent lesions.
• Neglecting smoking and alcohol cessation, missing an opportunity for prevention.
• Not advising on regular oral health checks, leading to missed early interventions.

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REFERENCES

• RACGP – RACGP Guidelines on Oral Cancer Assessment
• GP Exams – Mouth/tongue/lip disease

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communicates effectively and appropriately to provide quality care.
1.3 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information effectively.
2.3 Identifies red flags and important diagnostic features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies a structured approach to making a diagnosis.
3.3 Identifies and manages urgent and serious conditions.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD