by Scott D. Benjamin, DDS
The most important function of dental care is a thorough
assessment and evaluation of the patient's oral and related systemic
health. An exam should never be focused on just one condition,
and that includes cancer. One of the biggest mistakes
that clinicians make is understating the true value of an oral
screening for a multitude of conditions and over-hyping a single
disease. The improper communication of these procedures has
greatly reduced the perception of the significance and importance
of the examination process.
It is not uncommon to see dental office promotions offering
a free exam or free consultation. These loss leaders are used to
entice patients to a practice so more profitable procedures can be
performed. These types of statements greatly misrepresent the
significant amount of knowledge, technology and expertise
required to perform these valuable procedures properly. This has
significantly and erroneously devaluated the perceived importance,
benefit and reimbursement of a complete and thorough
enhanced examination for the patients, clinicians and third-party
For the most part, patients understand that the dentist and
hygienist are comprehensively evaluating the dentition and surrounding
tissue looking for cavities and gum disease. Too often,
patients assume the primary goal is to find a problem, which they
will need to pay to have fixed. Other patients feel the importance
of a preventive dental/hygiene appointment is to prevent decay
and maintain a beautiful smile; they too have missed the real
value and true benefit of a thorough oral examination.
When we state we are going to do an "oral cancer exam," it
implies that it is the only abnormality we are looking for. The
real goal is to discover any abnormality, no matter what it might
be. Why not call it an "enhanced oral exam" rather than an "oral
cancer exam" – looking for everything from a cavity, to a cheek
bite to cancer.
Proper communication is critical in the examination process.
No matter how a practitioner presents findings after an "oral cancer
exam," it can cause undue anxiety for the patient. This is
especially true if an area has an appearance that deviates from a
completely normal healthy appearance. In these situations the
patient often perceives this abnormality to be cancer.
The entire team plays a strategic role in the data collection,
discovery and diagnostic process. From the patient's very
first contact with the dental office, whether it is on the phone,
through the practice's Internet portals or in person, the
importance of a consistent message on the value and necessity
of an enhanced oral examination cannot be overstated.
Today's advanced technologies are increasingly giving practitioners
the ability to detect and discover mucosal conditions
at their earliest stages.
No single device can deliver 100 percent accuracy or effectiveness
in detecting conditions. Detection and diagnosis is
accomplished with the accumulation of data from multiple
sources and modalities. Today's diagnostic aids can have a significant
impact on the assessment of the patient's health and
well-being. These modalities range from specialized visual
enhancement products that allow practitioners to see deeper
into soft tissue, simplified tissue and cellular sampling techniques,
to computerized databases that forewarn of possible
conditions, side effects and interactions that might be caused
by the patient's medications or conditions, especially as they
relate to the oral cavity. As our patients' systemic and dental
health situations are becoming increasingly more complex, and
with an increased number of medications, the need to use
advanced technologies to assist in the diagnostic process has
never been greater.
Computerized Pharmacology and
Medical Condition Databases
Lexi-Comp Dental Reference Library (Lexi-Comp, Inc.,
Hudson, Ohio) is an Internet-based collection of interactive databases
and reference manuals that are continually updated as the
FDA and drug manufacturers announce changes to their drug
information and systemic conditions with a specialized focus to
their relationship to dentistry. With more than 800 medications
that have a xerostomic effect and more than 400 drug formulary
changes weekly, it is impossible for a clinician to stay current
without computerized assistance. This database is designed to
allow dental professionals to access critical information on drug
interactions that influence oral conditions quickly and simply.
The database is oriented to dental-specific applications to help
ensure the correct diagnosis and the appropriate care is rendered
for each patient's situation. The complete library also includes a
reference manual for the diagnosis and management of oral soft
tissue diseases. This manual assists clinicians by providing information
on the most common oral conditions divided into sections
based on the visual appearance, provides images of the
abnormalities and assists in the establishment of the differential
diagnosis. Once a clinical working diagnosis has been attained
there are suggestions for possible treatment and management.
Salivary diagnostics are used in dental offices today by simply
having patients rinse with specialized solutions and expectorating
into a funneled collection tube that is processed and
analyzed at the lab. Due to the simplicity and non-invasive
nature of salivary collection and testing, these screening modalities
have a significant amount of appeal to clinicians. The saliva
that is collected can be evaluated at the laboratory for the status
and susceptibility to both oral and systemic conditions.
OralDNA Labs (Nashville, Tennessee) has developed a salivary
test to identify the patient's genetic susceptibility and inherent
risk to periodontal disease by evaluating his or her interleukin-1
(IL-1) gene cluster. MyPerioID PST identifies an individual's
genetic susceptibility to periodontal disease. The test enables the
clinician to establish which patients are at increased risk for
more severe periodontal infections due to an exaggerated
immune response. This lab has another salivary test
MyPerioPath that identifies the type and concentration of 13
pathogenic bacteria that are known to cause periodontal disease.
Identifying these bacteria assists in the diagnosis and management
of the condition.
Several strains of human papilloma virus (HPV), especially
types 16 and 18, have been associated with oropharyngeal cancer.
The OraRisk HPV test by OralDNA Labs is another non-invasive,
salivary screening tool to help identify patients that might be at an
increased risk for this type of cancer and assist in developing the
appropriate referral and surveillance recommendations.
Visual Enhancements for
Soft Tissue Diagnosis
Any device that improves our ability for early detection of
soft-tissue abnormalities, especially those that are neoplastic in
nature, is an invaluable asset to our diagnostic armamentarium.
Any visual enhancement is to be used in combination with a
conventional visual oral mucosal examination to improve the
evaluation, identification and monitoring of oral mucosa and
abnormalities. Imaging modalities available include the use of
reflectance and fluorescence technology to evaluate tissue under
various illumination (lighting) conditions. Fluorescence technology,
in particular, enables the chemical and morphology of
the various tissues and substances within the oral cavity. This
visualization, which can be either direct (viewed directly by the
eye) or indirect (viewed on a monitor or screen), gives the clinician
even more information to aid in the assessment of the status
and health of the oral cavity. Fluorescence can aid in the
evaluation of both the hard- and soft-tissue structures, as well as
the biological activity of the flora and other microbial activity.
The fluorescence technologies do not require the use of any
mouth rinses or stains and the process is simply repeating the
visual exam with the aid of the device(s).
The battery handheld VELscope Vx (LED Dental, Inc.,
Burnaby, British Columbia) enables clinicians to quickly visually
scan the entire oral cavity looking for changes in the fluorescence
pattern of tissue which might indicate an area of concern.
This area can then be more closely evaluated to determine an
appropriate course of action. A unique feature of this device is
the ability to attach an inexpensive camera system to easily
photo-document any area that has been detected. These images
can assist in the monitoring, referral and education process
attaining improved care, management and outcomes.
The DentLight Oral Exam Kit (DentLight, Inc., Richardson,
Texas) uses a battery handheld light source to stimulate a fluorescence
response that is emitted from the tissue. The clinician
views the tissue that is being stimulated with this specialized
light through specific filters that are attached to the magnification
optics of their loupes. If an area of concern is detected, the
area can be photographed with a standard handheld digital camera with the supplied filter that can be attached to a lens filter
The Identafi (DentalEZ Group, Malvern, Pennsylvania)
uses a multi-spectral fluorescence and reflectance technology to
enhance visualization of mucosal abnormalities. The small,
cordless, handheld device uses a three-wavelength optical illumination
and visualization system. It has a disposable mirror
attachment that also assists in visualizing the area in an indirect
ViziLite Plus with TBlue (Zila, a Tolmar Company, Fort
Collins, Colorado) is a disposable handheld device that produces
a diffused light created by a chemiluminescent light stick
that is also used as a tissue retraction device. After the conventional
visual and tactile exam, the patient rinses with a flavored
one percent acetic acid pre-rinse solution and then expectorates
it. The tissue is then dried with gentle flow of air or gauze and
is re-examined using the disposable chemiluminescent light
source in a dim environment. If an area of concern is detected it
is marked with the supplied TBlue swab to help further visualize
and document the area.
Microscopic Evaluation and Cytology
It is extremely important to remember that a surgical
biopsy with a microscopic examination is the only accepted
method of diagnosing cancer and many other mucosal conditions.
The role of a biopsy is to rule out a malignancy and
to establish the appropriate diagnosis for the patient's condition.
All other modalities, including cytology, are adjunctive
procedures to aid in the determination if and where a surgical
biopsy would be appropriate and most beneficial.
Cytology is not a substitute for the traditional, "gold standard"
surgical biopsy technique that removes architecturally
intact tissue. In the majority of cases, a lesion that is worthy
of a cytology procedure is better served by a surgical biopsy
that will render a diagnosis.
Brush cytology is a another adjunctive screening procedure
that involves a minimally invasive collection of transepithelial
mucosa cells by means of a sterile, plastic-handled nylon bristle
brush, with minimal or no discomfort to the patient. The technique
involves the collection of disaggregated epithelial cells by
vigorous brushing of the oral lesion with a sterile nylon bristle
brush. It is primarily used to screen a suspicious leukoplakia or
erythroplakia of the mouth in order to aid in the determination
of the presence or lack of premalignant dysplastic change. The
OralCDx Brush Test (OralCDx Laboratories, Inc., Suffern,
New York) is an extremely effective system for ruling out the
presence of abnormal, atypical and dysplastic cells in areas that
have been properly brushed with the cells placed and fixed on a
Liquid-based cytology of the oral cavity is a relatively new
screening technique that has also been proven very effective.
The tissue is brushed and the cells are transferred from the
brush into a special liquid preservative/fixative bottled solution
by twirling the brush in the solution to remove the collected
epithelial cells from the bristles and the nylon brush is
separated from the plastic handle and placed within the bottle.
Other oral conditions such as herpes simplex infection
and candidiasis can be diagnosed by this procedure. Liquid
cytology might also aid the clinician in determining if the
lesion detected should be observed or have an immediate
invasive full thickness biopsy procedure with intact architecture
One of the most overlooked aspects of incorporating any
new technology into a dental practice is education and training
on that specific technology and fully understanding its true role
and value, but even more importantly, its limitations. The education
and training needs to encompass the entire team. It is
important to remember that the first place most patients turn to
for advice and comfort on any procedure is the office's staff. This
aspect cannot be understated!
Many dental patients today have the unfortunate misconception
that if the dentist has not picked up a handpiece and
performed a definitive procedure that nothing has been done.
The true significance of the diagnostic process has been undervalued
by the patient and the clinician alike. As dentistry moves
forward into the medical and wellness model, this must change.
Despite the fact that there is an ADA CDT code for an "adjunctive
pre-diagnostic test," the lack of insurance coverage is one of
the greatest impediments to the adoption for many of these
advanced diagnostic technologies.
In closing, understanding and properly communicating the
true benefits of the enhanced exam and other diagnostic procedures
is imperative. Remember the goal of all health-care professionals
is to achieve better patient outcomes and to enhance and
improve patients' quality of life.