By Trish Jones, RDH, BS
As dental professionals, we sometimes take for granted what we see or what patients go through until it hits close to home, meaning one of us is the target of the nuisance. More on that in a bit.
While attending the American Academy of Cosmetic Dentistry Annual Session in Florida in 2013, I had the opportunity to hear Eva Grayzel speak. She's a nationally known storyteller and oral cancer survivor. When her oral cancer was diagnosed, she was given only a 15% chance of survival. She told her heart-wrenching story of diagnosis in 1998-an ulcer on her tongue that had become quite large and painful-when she was just 33 years old. She described how her tongue was partially reconstructed, and how she had a modified radical neck dissection and radiation therapy.
She reduced the roomful of dentists, assistants, hygienists, and guests to tears; then they were on their feet and applauding her second chance at life. She is remarkable. Her talk left quite an impact on me, and I'm sure on many others, about the importance of performing oral cancer exams on every dental patient.
According to the National Institutes of Health, oral cancer is the sixth most common cancer in the world. The disease is diagnosed in over 45,000 Americans per year, and over 8,000 of those patients die each year, a death every hour of every single day.
The 411 on oral cancer
Detecting oral cancer early can increase the survival rate to 80% to 90%. Right now the five-year survival rate of those diagnosed is approximately 65% according to the American Dental Association. Detection is crucial because even the smallest asymptomatic lesions could have significant malignant potential. In 2013, among the 42,000 people diagnosed with oral cancer in the U.S., 18,000 will not be alive in five years. Oral cancer's incidence rate has increased the last five years in a row.
Oral cancer involving the tongue accounts for approximately 20% to 25% of cases diagnosed. Cancer involving the floor of the mouth is 15%, the lips 10% to 15%, and the minor salivary glands 10% to 15%. Squamous cell carcinomas tend to spread quickly.
The tissue that lines the oral cavity is composed of squamous epithelium. Cancer that arises from these tissues can metastasize to lymph nodes and other sites. If cancer is detected late, the probability of metastasis is much greater. The earlier a cancerous lesion is detected, the less chance it has to spread.
Cancer stages determine how much of the lesion has invaded the oral cavity, and the severity and prognosis. The American Joint Committee on Cancer developed a system to stage cancer. It is called the TNM system and is based on tumor size and invasion level, the involvement of lymph nodes, and metastasis of the cancer.
Oral cancer may not be prominent in the media but it should be. We commonly hear about cervical cancer, testicular cancer, and skin cancer, although oral cancer affects more people than those types. Since oral cancer is diagnosed routinely in later stages, prognosis is grim. Patients may not notice because they feel no pain and may not recognize symptoms to be abnormal. As dental professionals, we should make our patients aware of the facts of this growing cancer.
The obvious and most recognized risk factor for oral cancer is tobacco use. Tobacco use includes cigarettes, pipe smoking, and chewing. Another risk factor is alcohol consumption, which is a contributing risk factor for a particular type of esophageal cancer called esophageal squamous cell carcinoma. In addition, people who inherit a deficiency in an enzyme that metabolizes alcohol have been found to have substantially increased risks of alcohol-related esophageal squamous cell carcinoma. Risk factors increase tremendously when both alcohol and tobacco use are combined. Oral cancer is twice as common in men than women, which is usually attributed to smoking and alcohol use.
A more recent critical risk factor for oral cancer is human papillomavirus, which has over 170 strains. The FDA estimates that 70% of HPV-16 or -18 is associated with cervical cancer. It is spread through sexual contact and accounts for 25% of the cancers of the mouth and oropharynx (upper throat). HPV is linked to the increase in oral cancer in nonsmokers. Young people are exposed to this as they become sexually active. Oral cancer due to HPV has increased 225% in the past three decades. Another risk factor is age. Those over 40 are at a higher risk for oral cancer, although the younger generation is now at a growing risk due to HPV. No one is safe.
Surprisingly, there are no mandatory universal guidelines for oral cancer screening programs in dental offices. It's up to each office to decide whether or not oral cancer screenings are performed and how they're done, whether manual exams for abnormalities, or other modalities such as cancer-screening devices or salivary tests. These screening techniques detect abnormalities in tissue that indicate whether further testing, such as a biopsy, is required for a definitive diagnosis.
It is often the office's discretion to charge for such exams. According to the Centers for Disease Control and Prevention (CDC), screenings should be performed on all patients over the age of 17. Why? Human papillomavirus (HPV) is easily spread and is the fastest growing risk factor for oral cancer.
The hygiene appointment
The dental hygiene appointment is often the best opportunity to perform an oral cancer screening exam. RDHs have been trained and educated to assess any tissue abnormalities in the head and neck region. Any suspicious areas should be brought to the dentist's attention for discussion and evaluation.
It can't be said enough-oral cancer kills one American every hour. Think of it this way: For each patient you see for an hour, another person will have passed away from oral cancer. An oral cancer screening should be a routine part of every dental exam.
There are different kinds of screenings, such as a hands-on conventional exam that includes a visual examination of the soft tissues of the mouth, a tongue exam that involves extending the tongue to the base, and manual palpation of the cheeks, lips, gums, and borders of the tongue. The lymph nodes in the head and neck should be palpated as they can be key in identifying the first signs of oral cancer.
As we now realize that many lesions are not visible to the naked eye, diagnostic aids such as oral cancer detection devices are becoming an adjunct tool for the dental professional. Light-based systems utilize tissue reflectance and fluorescence to enhance the oral screening exam. The medical applications of fluorescence technology include diagnosis of the GI tract, cervix, lung, skin, and oral mucosa. Fluorescence visualization devices are particularly sensitive to dysplasia and cancer, and can also be sensitive to vascular normal tissues. Dental professionals should be familiar with the normal appearance and patterns of oral cavity fluorescence in order for abnormal patterns to be easily detectable.
What is a suspicious lesion?
What are you looking for? As a dental professional, you are looking for any abnormal lesions such as leukoplakia or erythroplakia. Symptoms patients may bring to your attention include a sore that doesn't heal, red or white patches, or pain or tenderness in the mouth or lips. Patients may also complain of issues with their tongue regarding chewing, speaking, or moving the jaw. They may have pain or swelling in the TMJ area, or difficulty with occluding teeth together. Patients may indicate bad breath or abnormal taste, or experience numbness or unusual bleeding.
Devices fall into two categories. One uses light and dyes to assess the oral cavity; while the other uses only fluorescent light to detect abnormalities.
ViziLite Plus-This system uses Zila tolonium chloride and incandescent light as a marker for abnormal and suspicious lesions. It relies on disposable technology to eliminate cross contamination. The patient rinses with a dilute acetic acid solution, waits five minutes, and in a dimmed operatory the dental clinician then uses the ViziLite Plus to identify any suspicious areas.
Microlux/DL-This consists of a simple rinse for the mouth. A chemiluminescent light is then used to reveal any abnormal tissue before it is visible to the naked eye. Microlux/DL is similar to early detection procedures for other cancers, such as mammography and Pap smear. It is suggested that the Microlux/DL exam be performed annually.
VELscope Vx-VELscope Vx uses tissue fluorescence rather than reflectance. It is a handheld device that enhances visualization of mucosal abnormalities such as oral cancer and premalignant dysplasia. This system does not require any dyes. VELscope Vx exams are done during routine hygiene visits under normal lighting conditions. Photo documentation is easy to integrate and share with patients or other dental specialists.
OralID-This system uses fluorescence technology in the form of a blue light that allows the clinician to identify oral cancer, precancer, and other abnormal lesions at an early stage. The battery-operated, handheld oral exam light emits a visible blue light (435 nm to 460 nm) that can be shined directly into the oral cavity. Protective eyewear that enhances the visual effects of the blue light during the oral exam is included. When the blue light shines on healthy oral tissue, it fluoresces green. When it shines on abnormal tissue, it appears dark due to a lack of fluorescence.
OralID is an affordable choice with product training for the team included. OralID should be implemented properly and efficiently so it's used on every patient. OralID also has a cytology kit (brush biopsy)available for use after any suspicious areas are found. It is a brush biopsy.
Brush tests/brush biopsy-The OralCDx BrushTest is an in-office test that helps determine if white or red spots are harmless. This system consists of a specially designed brush that is used to painlessly obtain a sample of the lesion in question. The superficial, intermediate, and basal layers of the epithelium are sampled, and no anesthesia is required. The sample is sent to a special laboratory to be analyzed. It has been reported that this type of testing is highly accurate.
Salivary tests-SaliMark OSCC Salivary Diagnostic Test is indicated for use when visual exams or fluorescent device exams detect a suspicious lesion or an abnormality in the tissue. The painless test is the first commercial saliva test for early detection of oral squamous cell carcinoma. This system uses molecules or biomarkers in saliva that reflect cancer activity, and the combination of these marker levels provide the most accurate information available on the probability of cancer.
Which one to use?
Which system is right for your office? The one that you're going to use! If you're unsure which one to incorporate, contact the companies and request information or a demo. This article only mentions these products as examples.
Oral cancer detection devices are simply tools for screening and are not designed to diagnose oral cancer. They can result in false negatives if not used appropriately. The ideal screening is a conventional visual-oral tactile exam combined with an adjunct screening device.
If any abnormality is discovered, a biopsy will usually be indicated. A small sample of the tissue will be cut out or may be aspirated by a fine needle. This may require the patient being referred to a specialist if the area is deep in the throat or mouth. Once a pathologist examines the tissue, results will indicate if it is cancerous and what kind of cancer it is.
Treatment of cancerous lesions usually involves surgery, but this depends on the stage and location of the cancer. Surgery may be followed by radiation or radiation combined with chemotherapy. In advanced cases, treatment is not always successful as up to 70% of the cases relapse and can result in death.
So this is where the reality check came into play for me. At my regular dental office, the hygienist used the VELscope as a routine oral cancer exam a few months ago. It found a suspicious lesion on the left side of my soft palate. I have basically ignored it ... until now. I'm not in pain and it doesn't bother me. Do I sound like a typical patient? Why do we think something has to be painful before we do something about it? I recently had access to the OralID device, and again, it confirmed this spot on the back of my throat.
Am I scared now? Yes. The OralID comes with a yellow adapter for a smartphone so a photo can be taken with it. It provides a constant visual for me. Yes, I have an appointment to have a biopsy because I have too much life left to live. RDH
Charge for oral cancer screenings?
To charge or not to charge for oral cancer screenings? It's up to the discretion of each dentist. But if you're providing a service that may save someone's life, it might be feasible to charge for life-saving services. There are several insurance codes that can be used.
CDT D0480 is for "adjunctive prediagnostic test that aids in detection of mucosal abnormalities, including premalignant and malignant lesions, not to include cytology or biopsy procedures." Other codes are indicated for hard and soft tissue biopsies.
TMN oral cancer stages
- Lesion is less than 2 cm
- No lymph nodes involved
- Lesion is between 2 to 4 cm
- No lymph nodes involved
- Lesion is 4 cms or more/no lymph nodes involved
- Lesion is any size and one lymph node involved on same side
- Lesion has metastasized to surrounding tissues and lymph nodes may be involved
- Lesion has metastasized to more lymph nodes to either one or both sides of the neck
- Reoccurrence of cancer after treatment
Trish Jones, RDH, BS, is an international speaker and author with experience in esthetic dentistry, dental sales, and working in a dental laboratory. She is a past chair for the American Academy of Cosmetic Dentistry Charitable Foundation Give Back a Smile. She can be reached via email at [email protected]
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