VIEWPOINT – WNL: Within Normal Limits, or a Dangerous Assumption?

Written by: Jo-Anne Jones


Our professional community was rocked by the passing of a young dentist in 2021. Dr. Manu Dua woke up one morning close to his 33rd birthday with the discovery of a lesion on his tongue. He immediately thought that he had possibly bitten his tongue during sleep. He texted a picture of it to his sister, Dr. Parul Dua, a practicing dentist in New York. She pleaded with him to “get it biopsied.” The lesion persisted for months. Biopsy was delayed as Manu, like many of us in the field of dentistry, felt somewhat immune or invincible to the disease. “It can’t be cancer. I’m too young. I’m a healthy individual with no risk factors”—a dangerous assumption. Dr. Manu Dua, a young man possessing none of the typical etiologic risk factors that bring a person to oral cancer, died from metastatic squamous cell carcinoma. He was 34 years of age.1 His life and wisdom are immortalized in the publishing of his series of blogs, titled Life Interrupted: Dr. Dua’s Survival Guide.2 Manu’s story is an all-too-common event in today’s world, with many suspect lesions continuing to not be monitored or being dismissed.   

This isn’t another article focused on oral cancer statistics. This is a life-sustaining, and practice-sustaining, cautionary advisement. It is also accompanied by a strong plea from the ADA, the Oral Cancer Foundation, and countless others to ethically carry out our professional responsibilities. I challenge you to read on. Your practice may be at risk unknowingly.  

Within Normal Limits

Within normal limits is a very bold and broad sweeping statement that definitively distinguishes between health and disease and, in some cases, an outcome of life vs death. The responsibility of this statement and the onus to the patient is of grave consequence and may, in fact, be a very dangerous assumption. Any lesion and/or symptom that persists beyond 14 days always warrants a secondary evaluation, whether that is interpreted to mean re-appointing to confirm resolution or referral for further microscopic evaluation. A secondary dangerous assumption is identifying and assuming the patient in your chair to be low-risk. The unintentional exclusion of cancer evaluation in younger patients or those who do not possess typical and historical risk factors is leading to delays in diagnosis. In 2019, the ADA announced an expansion to its policy on oral cancer detection, recommending that dentists and dental hygienists perform routine examinations for oral cancer, including oropharyngeal cancer, for all patients.3 Passed by the ADA House of Delegates, this change was brought about to align with concerns from the Centers for Disease Control and Prevention (CDC) over the escalating numbers of diagnosed cases of oropharyngeal cancer linked to the human papillomavirus (HPV). The ADA’s policy also aligns with support for the HPV vaccine due to the vast majority of oropharyngeal cancers in the United States related to HPV, according to the CDC.

We now understand that there are 2 distinct etiologic pathways that bring most people to a diagnosis of oral or oropharyngeal cancer. The first pathway is through the use of tobacco and alcohol; however, this etiologic pathway has declined by 50% for more than 2 decades, with HPV-associated oropharyngeal cancer increasing by 225% over the same time period. This is the same virus that is responsible for the majority of cervical cancers in women. Oropharyngeal cancer is now considered the most common cancer caused by HPV in the United States, with nearly 81% of oropharyngeal squamous cell carcinoma (OPSCC) cases classified as HPV-associated between 2007 and 2015.4 This growth trajectory continues to escalate, occurring in epidemic proportions.5  

If your interest in reading further is dwindling, let me elaborate on how screening practices can affect your bottom line. Now we are talking about your business. Medical and dental litigation is swiftly changing. Both medical and dental malpractice insurance premiums in the United States have continued to escalate, driven by the litigious nature of our society. There has been a significant rise in failure to diagnose and failure to biopsy.6 Misdiagnosis of oral cancer is the third leading cause of malpractice in dentistry. The frank truth is that if a dentist is found guilty of malpractice for misdiagnosing or failing to diagnose oral cancer, it could lead to bankruptcy. Any clinical suspicion without substantive followup is incurring risk for the practice. The stage of disease at diagnosis also will require more extensive treatment options associated with more significant health costs as well as patient morbidity.7 It is interesting to note the amount of indemnity payment awarded in malpractice litigation correlates with the length of delay in diagnosis. This outcome strongly emphasizes the importance of thorough screening practices to rule out cancer.8 This is something to strongly consider when employing a watch and wait management pathway.   

Reviews of verdicts were analyzed between 2000 to 2010 and 2011 to 2019. The average adjusted amount awarded between 2000 to 2010 was $1,721,068 vs $3,925,504 between the years of 2011 to 2019. Failure to diagnose was the most common allegation across both decades. A 2015 review of malpractice cases in head and neck cancer reported the surge in diagnosis of and deaths from HPV oropharyngeal cancer and the inherent challenge of identifying early changes in anatomical areas with limited visual acuity. Unfortunately, with this surge, litigation has also increased, with judgments exceeding $2 million for misdiagnosing oral and oropharyngeal cancer.9   

WNL: “Within Normal Limits,” or “We Never Looked?” 

As mentioned above, litigation from a failure to diagnose has been the most common allegation throughout the years. The basic requirement for a thorough extraoral and intraoral examination, including oral cancer screening, is on an annual basis for all adults; however, it may be required more frequently due to patient-specific risk profiles. Published studies show that, currently, less than 15% to 25% of those who visit a dentist regularly report having had an oral cancer screening.10 We can interpret this data from a different perspective as well by realizing that 75% to 85% of the population are not being screened. This is simply not acceptable. We must do better.   

The examination itself takes approximately 4 minutes. There are many resources available online, including videos depicting the examination.

View the video titled “Watch the Oral Cancer Examination Video” on the YouTube channel TheCDHA with your dental team to review the steps of the extraoral and intraoral examination.

Despite our best efforts, there is also a potential role that the patient plays in delayed diagnosis. Failure to maintain appointments for followup or conduct further evaluation due to anxiety or denial can strongly influence the outcome. Thorough notation in the patient record, including action taken that is supported by extraoral and intraoral photography as applicable, reflects comprehensive recordkeeping. A thorough documentation of patient preferences and decision making should also be included.   

The Good News

Did you know that more than 90% of all future HPV-attributable cancers can be prevented?11 The 9-valent Gardasil vaccine addresses all 9 of the HPV strains that have the ability to be cancer-causing. As dental professionals, we are powerfully situated to relay this information to the public. At the present time, the vaccine is offered through a school immunization program to male and female students aged 11 and 12.    

Also, a recent and exciting announcement was made of the first-ever confirmation of a reduction in malpractice insurance made available to users of an adjunctive screening device, VELscope (LED Dental, Inc).12 This is a groundbreaking, progressive move from one of the largest insurance groups in the country, USI. USI recognizes the efforts and investment made by a dental practice to truly offer the best possible opportunities for the earliest discovery of a deadly cancer. Finally, the investment a practice has made in technology to best serve its patient base is being recognized and rewarded. VELscope employs a proprietary wavelength to enable direct fluorescence visualization beyond what can be seen with traditional white light examination at the mucosal surface. Given the fact that abnormal cellular differentiation begins at the basement membrane, with close to 70% of cancers of the oral cavity discovered in the later stages, the employment of an evidence-based technology such as VELscope holds strong value. The sensitivity and specificity of the device in identifying oral abnormalities in earlier stages led to USI’s decision to compensate dentists for being lifesaving practitioners.  

Furthermore, VELscope has taken oral cancer screening to a new level by integrating a next-generation AI platform.   

In conclusion, will this be the year you save a life? A 4-minute examination is all that is required of your time to possibly prevent a death. Just those few minutes could translate into a lifetime for one of your patients. We have the ability to make an impact on earlier discovery of oral and oropharyngeal cancer. Thank you in advance for employing thorough, opportunistic screening on all adults in your patient base. This will save lives and sustain your practice. 


  1. Makkar PD, Mohanta S. When a Dentist Dies from Oral Cancer. Dent Today. 2021.
  2. Dua A. Life Interupted: Dr. Dua’s Survival Guide. Laurel Elite Books; 2021.
  3. Versaci MB. ADA expands policy on oral cancer detection to include oropharyngeal cancer. American Dental Association. October 1, 2019.
  4. Osazuwa-Peters N, Simpson MC, Rohde RL, et al. Differences in sociodemographic correlates of human papillomavirus-associated cancer survival in the United States. Cancer Control.2021;28:10732748211041894. doi:10.1177/10732748211041894
  5. Tota JE, Best AF, Zumsteg ZS, et al. Evolution of the oropharynx cancer epidemic in the United States: Moderation of increasing incidence in younger individuals and shift in the burden to older individuals. J Clin Oncol. 2019;37(18):1538–46. doi:10.1200/JCO.19.00370
  6. Wong A, Zhu D, Tong JY, et al. The jaw-dropping costs of oral cavity cancer malpractice. Head Neck. 2021;43(10):2869–75. doi:10.1002/hed.26764
  7. Lingen MW, Abt E, Agrawal N, et al. Evidence-based clinical practice guideline for the evaluation of potentially malignant disorders in the oral cavity: A report of the American Dental Association. J Am Dent Assoc. 2017;148(10):712–27.e10. doi:10.1016/j.adaj.2017.07.032
  8. Lydiatt DD. Cancer of the oral cavity and medical malpractice. Laryngoscope. 2002;112(5):816–9. doi:10.1097/00005537-200205000-00009
  9. Epstein JB, Kish RV, Hallajian L, et al Head and neck, oral, and oropharyngeal cancer: a review of medicolegal cases. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119(2):177–86. doi:10.1016/j.oooo.2014.10.002
  10. The Oral Cancer Foundation. The role of dental and medical professionals.
  11. Centers for Disease Control and Prevention. Cancers caused by HPV are preventable.
  12. LED Dental officially partners with USI. Dent Today. 2023.


Ms. Jones is a recognized thought leader and an international, award-winning speaker who has delivered more than 1,000 presentations worldwide. She was named a 2023 Dentistry Today Leader in CE for the 13th consecutive year and is a 2021 Fellowship Award recipient with the International Academy of Facial Dental Esthetics. She partners with the Oral Cancer Foundation in conveying the urgent need for change in the way practitioners screen for oral and oropharyngeal cancer. She was instrumental in launching the international “Check Your Mouth” campaign promoting oral self-examination between professional visits. She can be reached at

Disclosure: Ms. Jones is a consultant for LED Dental, Inc. She did not receive financial compensation for this article.