Should you do an Oral CDx on everyone over 40?

In the November "Howard Speaks" column, he proposes doing an Oral CDx on every patient over 40-years old every year. He states every patient, so I would take this to mean even patients without suspicious lesions on visual examination. How would this be done? (Swab the whole mouth?) Would the results still then be reliable?
mnfulton, Official Townie

I would both agree and disagree with Howard. I've been one of the spokespersons for the Oral CDx since it was introduced. It is not a Pap smear. It harvests all layers of the epithelium. This test is so sensitive that it can find only two abnormal cells in a field of several hundred thousand. This is done with a computer (no human could be that accurate), and if the computer finds an abnormality, it alerts the pathologist and locates it for the pathologist to look at. We dentists HAVE been missing a lot of stuff for years, and because of this the survival rate has not increased in 50 years. By the time something looks suspicious AT ALL, it's often too late.

But you're right, you can't simply brush biopsy the entire mouth. You've got to have something to brush biopsy. Any surface 'red' or 'white' areas are candidates and should be brush biopsied every six months. There is no formal guideline regarding this frequency, but my feeling is six months, although Dr. Drore Eisen (the head guy at OralScan Laboratories–makers of the Oral CDx Brush Biopsy) told me that even once a year would be excellent.

So, you see a white area that does not look weird at all. In fact, it looks quite healthy other than you're not used to seeing white in this area (and this could include the not-uncommon white line along the buccal mucosa that many have). If we notice it at all, we say, "Hmm. Doesn't look suspicious to me. Certainly no reason to get out the scalpel for a biopsy. And this is PRECISELY why we miss these things.

So now we have a very easy, non-invasive test. You don't even need anesthetic. Yet, we're so used to our previous approach, dentists are still not using the brush biopsy frequently enough.

So yes, Howard's right that we need to do a TRUE cancer screening on our patients at least once a year. ANY white area needs to be brush biopsied. And believe me, if you truly look for white or red areas, you're gonna find them–a LOT.

Do your patients a favor and test these. Heck, it's not as if you're not gonna get paid for doing it. It takes maybe two minutes from start to finish–and that includes opening the kit. Now, the vast majority will come back as normal. That doesn't mean that these areas won't turn to 'atypical' or worse in six months or a year. And just because the area was caused by trauma such as cheek biting or a sharp restoration, it doesn't mean that the white area is OK.

Start really looking for white or red areas, and you'll be amazed at how many you find. I have two patients right now–one with oral cancer, and one that may have oral cancer.
Rod, Official Townie

I feel an oral cancer screen should be done on all adult patients every time they come into the office (possibly excluding emergencies). For more info, see my DT article in the August edition, page 18.

In 1988, I defended an oral cancer case involving a 39-year old man. At the second OV, the RDH found a 2 mm lesion on the right lateral border of the tongue. Nine months later, a 1.5 cm lesion was detected. The patient claimed the initial lesion grew undetected. We said the first lesion was gone (but not charted), and a second lesion appeared in the same, general area.

A hemiglossectomy was performed. The squamous cell cancer then metastasized to his liver and lungs. He died during trial (talk about the case from hell)! The jury awarded $1.1M. The Arizona Supreme Court later reversed the case on technical grounds, and we settled before a second jury trial occurred.

This lawsuit could have been avoided with a single entry on the following OV: "Check visually and by palpation for lesion ID's on (earlier date). Resolved."

The failure to detect oral cancer is one of four cases where all DDS are at a major risk. The screen is easy, fast, and should be recorded.
jefftonner, Official Townie

The brush biopsy is very different from the other diagnostic modalities. I love the idea of testing everybody over 40, but maybe I'm missing something, because I don't understand exactly how we'd do it.

The Oral CDx is not like a Pap smear that can pick up surface cells from a wide area. The brush biopsy is designed to be very sight-specific, and the area must be rubbed until there is a little 'rawness' so that we harvest the deeper layers. Unlike exfoliative cytology (Pap smear), the OralCDx brush biopsy obtains a full transepithelial oral biopsy. The brush captures a disaggregated tissue sample of all three epithelial layers: superficial, intermediate, and basal. In fact, if you do not harvest down to the basal layer, the lab will not test the sample and will notify you to do it again.

My question would be this–in the absence of any red, white, or other unusual areas, where would we do the test? Each test is specifically for one site. Oral cancer doesn’t present itself by invading an entire mouth. Would we arbitrarily do four tests–one on each lateral border of the tongue and the right and left floor of the mouth? Or maybe six tests that would also include both right and left buccal mucosa.

But if we did that, WHERE in each of these areas would we test? The test site for a brush biopsy is about as big around as a nickle. The diagnostic test for determining elevated Prostate Specific Antigen (PSA) levels of less than, equal or greater than 4ng/ml and 10ng/ml in whole blood has a 98% accuracy. This is fabulous, but unlike the OralCDx, the PSA being a blood test, this lends itself to simple screening.

Likewise, the mammogram lends itself to routine screening (just like visual oral cancer screenings). And with a mammogram, if a suspicious area is seen, a biopsy would be done (just like if a suspicious area is seen on oral screening, a brush biopsy would be done). But you don't just start doing breast biopsies when the mammogram is negative.

The point is that oral cancer (of the type that the OralCDx can pick up) routinely presents itself with a visual: red, white, or mixed lesions (erythroplakia and leukoplakia); chronic ulcerations; lesions with unusual surface changes such as a granular appearance; mucocutaneous disorders (e.g., lichen planus) refractory to treatment; a persistent lesion despite a benign diagnosis from a previous brush or scalpel biopsy; or patients with a history of oral or other head and neck cancer, who have evidence of mucosal changes (of course, both Howard and I would recommend that ANY mucosal changes be tested regardless of history of previous cancer).

As far as colonoscopy, a TRUE oral cancer screening is analogous to colonoscopy, but WE can see in the mouth without the 'scope.' During colonoscopy, if an unusual area is seen, a biopsy is done. But if everything looks A-OK, then no biopsy is performed.

I think the problem is not that oral cancer screenings can't pick up potential pathology at an early stage, but that we dentists simply don't give a damn! It's apathy, pure and simple. We just do NOT spend the time to do it 'thoroughly'.

My point is that the OralCDx does not lend itself to routine screening of everyone. If it did, believe me, I would be the first on the bandwagon.

Here is the way the test is designed to be used–and if done this way Howard, your goal of raising the overall prognosis of oral cancer would be realized: We do a thorough (think about this word 'thorough') oral soft tissue visual screening. We look fully under the tongue and floor of the mouth. We check all other surfaces of the tongue. We check the palate and soft palate, and down in that deep dark hole (oropharynx), and even the tonsils. We check the buccal and lip mucosa. We check the attached gingiva.

And EVERY TIME we see ANYthing that is at all unusual looking (white, red, granular, ulcerated [it might NOT be a canker sore], etc.), even the smallest area, we brush biopsy it with the OralCDx. Believe me, if you do this, you'll be doing a lot of brush biopsies, and possibly save a life or two.

So Howard, I think we both passionately want the same end result. And I wish that the OralCDx could be used like a Pap smear, but it's just too different from exfoliative cytology to be used that way.

Now, if you and I could just get the dentists of the world motivated to do 'thorough' cancer screenings, and use the OralCDx immediately for the slightest visual sign of anything other than 100% normal, then we'd save lots of lives.

My approach so far in motivation of dentists is this–money motivates. I have calculated just how much the dentist should make a year if utilizing this brush biopsy. This would be close to 100% profit, because this is done during an exam visit usually. So no extra time is scheduled. Anyway, I do believe that money motivates.
Rod, Official Townie

I have done many of the brush biopsies. They are very diagnostic and do save lives. The negative side is the insurance. I met with the Delta Dental rep for AZ and at that time he stated that the insurance would pay for only one biopsy. If you find something positive and send it to the oral surgeon then the insurance will pay him to do an excisional or incisional biopsy and not pay your claim. You have to remember that brush biopsy has always given me results within two to three days so my claim has not been paid out by the time the OS submits his. The other problem we faced was that the insurances would not pay the lab bill and we had very angry patients. For cash patients willing to pay for the test go for it. Very easy and fast. We do cancer screenings on every patient and at every visit. Last year we had two patients lives saved as a result, and unfortanately two died. We see a lot of oral pathology here. My advice is to do it but realize that the insurances may not pay you.
desert rat, Official Townie

I've been doing the brush biopsy since it became available. I have not had any patients get angry about doing the biopsy even if the insurance does not pay for it. They are very appreciative to know that you are concerned and relieved you don't have to cut a piece of them to find out what they have in their mouth. I do an oral cancer screening once a year on all my patients. I don't think dentists are lazy, or even worried about not getting paid for these procedures. It is lack of education. Many of us were taught to focus on teeth. I've had the funniest responses from physicians having their initial dental exams. They do not expect us to be looking for cancer. Most people are very reluctant about following through with biopsies. This brush biopsy is a great tool for dentists. I think we need to educate our ranks. We need to establish what the standard of care is. We have no standards like the physicians do. We do not have any overall screening tool for detection.The CDx is only designed to be used on lesions. It sounds like Howard is calling for a standard test in detection. I agree. But, we need a different test. CDx is not designed for this.
Fistula, Official Townie