By Shirley Gutkowski
A rat in the house might eat the ice cream. That's a pretty long mnemonic for a simple word — arithmetic. I've used that mnemonic my entire writing life, probably since about third grade. Although that mnemonic is a lot longer than the word "arithmetic," somehow it works.
Simple arithmetic is something that we don't use often enough in our profession. We think back at the math we had to take in school and the gigantic equations — full of letters, numbers, and symbols. Most of the math we need to do in clinical practice is really very simple. For instance, up to 80 percent of the population is afflicted with periodontal disease. Certainly, a large percentage of our daily patient base should be some type of periodontal patient. Simple, right?
Another simple arithmetic problem relates to the number of biopsies referred from an office on a weekly basis. Let's look at the numbers carefully. Suppose an average dental practice with one doctor and one hygienist has about 3,000 active patients.
According to information from nearly every article written on oral cancer in the last 10 years, 3 percent of all cancers are oral cancers. Oral cancer affects about 30,000 people per year. The population of the United States is about 300 million; so about 0.1 percent of the total population of the United States is diagnosed with oral cancer every year. Of those, 50 percent will die an agonizing death. There are very few cancers that have such a high death rate. It's widely thought that the reason for such a dismal survival rate is due to late diagnosis.
So, then, we have 0.1 percent of the population diagnosed with oral cancer every year. Translate that to our fictitious dental office of 3,000 active patients, and we discover that three of those patients in that practice have oral cancer. Those are the raw numbers — basic arithmetic. (Decimal points and percent signs are not advanced math, I swear.)
OK, you're swallowing hard now. Some of you reading this may be thinking, "Yeah, but..." Everyone reading this magazine works in an upscale office with no one in their practice having any risk factors for oral cancer. One of the cancer facts that you may not know, though, is that 25 percent of oral cancer victims have no risk factors. They don't smoke, drink, or chew spit tobacco. They are the innocents. They trust us to save them from decay and oral cancer.
For the sake of continuing the illustration, mitigating factors must be tossed into the mix. With periodontal disease, certainly there are practices that see only 50 percent of their practice in poor periodontal health. There are a certain percentage of patients who will not agree to treatment. Perhaps the hygienist visits the patients at home every night to floss for them, dramatically reducing the incidence of periodontal disease at that office. Oral cancer numbers in a practice are subject to mitigating factors too.
Possibly the office entertains a greater proportion of children than the office down the street. Maybe it's a specialty office — orthodontics, endodontics, or cosmetic. It may be that the office is located in Utopia. We'll take into consideration that the specialists' offices that cater to children are the least likely type of office to have patients with oral cancer. This concession just means that the numbers behind the cancer risks in general offices has just increased. The thinking now is to biopsy everything that isn't pale pink.
That's a lot of biopsies. That's a lot of upset to our patients — much of which may be needless. Biopsies are like X-rays; we don't know that we don't need them until after we've taken them. Upsetting patients is something oral health care providers have been trained to be sensitive to. The line between upsetting patients diplomatically and scaring them is a wide one.
As professionals, we must not dance on that line; we must tread on it.
According to an article in JADA about two years ago, dentists admitted to being uncomfortable discussing oral cancer with their patients. They even hesitated to use the term "oral cancer exam," opting instead for phrases such as "looking for lumps or bumps." A separate issue of JADA contained a paper about patients' knowledge of oral cancer. The majority of patients reported never having had an oral cancer exam. The question then becomes, one or two biopsies per week, or over treatment or under treatment?
Consider this list provided by the ADA Web site, describing oral cancer signs and symptoms:
1. A color change
2. A lump, thickening, rough spot, crust, or small eroded area
3. A sore that bleeds easily or does not heal
4. Pain, tenderness, or numbness anywhere in the mouth or lips
5. Difficulty chewing, swallowing, speaking, or moving the jaw or tongue
6. Changes in the voice
7. A change in the way the teeth fit together
8. Systemic changes (drastic weight loss; a lump or mass in the neck)
I believe that anything after number two is not to be considered early diagnosis. Anything from number three to number eight is too late. Maybe it's time to integrate some of the newer detection techniques into the practice. Brush biopsies are a simple way to detect abnormalities at the first sign on the ADA list. We don't need a mnemonic to remind us early oral cancer screening is a simple way to decrease oral cancer deaths.
We all understand the correlation between certain risk factors and oral cancer. The two main risk factors are tobacco use and alcohol use, with a synergistic relationship between the two. Diet and lifestyle are two risk factors that are not considered very often, and they are not as obvious. People who work out in the sun or are sun worshipers live life on the edge of cancer of the lip, not just skin cancer. Sexual practices have also recently been determined as risk factors for oral cancer. Human papilloma virus has been associated with cervical cancer for decades. It now seems to be showing up in lingual and palatine tonsil squamous cell carcinomas.
Certainly, a good health history interview can uncover instances where oral cancer risks may be identified; however, a question about oral sex may never find its way into many dental health histories or interviews. Using the simple arithmetic outlined above incorporates all of that. If you find that your practice only biopsies spots or lesions once a month or less, maybe it's time for a refresher course in oral pathology. Maybe it's time to incorporate some of the newer detection techniques into the practice. Brush biopsies are a simple way to incorporate value-added benefits for your patients.
In March 2002, JADA reported on a study of oral lesions in dentists and dental hygienists. The study was done over two years, with volunteer dentists and dental hygienists who stopped by a booth at a dental convention for an exam and brush biopsy of benign-looking spots. Ten percent had atypical cells in the computer-assisted analysis; one person had a positive result. No one is immune, and without the aid of a microscope and a trained eye, early cancerous lesions are impossible to detect.
The simple facts are oral cancers are still detected in stages too advanced for good outcomes and, secondly, things need to change. Applying simple arithmetic should transform those problems. If nothing else motivates oral health care providers, the fact that most oral cancers are diagnosed by physicians ought to.
• JADA, November 2001 Supplement, Combatting oral cancer.
• JADA, March 2002, pgs 357-362, Computer-assisted analysis of oral brush biopsies at an oral cancer screening program.
Shirley Gutkowski, RDH, BSDH, has been a full time practicing dental hygienist in Madison, Wis., since 1986. Ms. Gutkowski is published in print and on Internet sites, and speaks to groups through Cross Links Presentations. She can be contacted at [email protected].