Part 11: Oral pathology: Keep it fresh
Oral pathology has remained relatively unchanged over the years, yet it is one area in which clinical complacency occurs.
by Tammy L. Carullo, RDH, PC, PS
Oral pathology has remained relatively unchanged over the years, yet it is one area in which clinical complacency occurs. While attending a continuing education seminar last year on this topic, I was shocked when three hygienists at my table complained that the speaker was not providing all "brand new" information. It seems general opinion is that CE is just about providing breaking news, cutting edge technology, and the latest trends.
When I asked how many of these hygienists were conducting Oral CDX biopsies on their patients, all three responded, "What's that?" Continuing education serves a much broader role than supplying only new information. In fact, many hygienists find themselves in an uphill battle to avoid clinical complacency when they believe that they do not need to revisit areas already learned. Oral pathology is one of those definitive areas that needs to be continually reviewed. If you are not presented with pathological findings on a daily basis - however common they may be - it is easy to forget what specific lesions look like to make an accurate differential diagnosis.
The true purpose for continuing education is to broaden your scope of knowledge, learn the newest information available, and comprehensively review information you may have forgotten.
One overlooked aspect of oral pathology is the need to establish a baseline evaluation. We hear about such evaluations in reference to perio. But it is equally, if not more so, critical when referring to pathological findings. If you locate a specific lesion, you should record the size, color, location, keratinization, and the course of recommendations (observations, biopsy, referrals to specialists, etc.). Then you will have a source upon which to measure subsequent appointments and you will be able to record any deviations from that baseline.
A positive outcome from an oral cancer diagnosis hinges predominantly on early detection. It falls within our responsibility not only to educate the patient, but to make the necessary documentation to track the lesions in question. With pathology examinations, three primary components of data collection are considered essential for an accurate diagnosis of a pathological finding: radiographs, extraoral and intraoral examinations, and the Oral CDX biopsy system.
During the past decade, very little has changed regarding red lesions and white lesions. But our data collection has taken an interesting turn with the inclusion of the Oral CDX biopsy system. This system is a noninvasive procedure for testing tissue cells in a suspected area within the oral cavity. The primary steps of the procedure are described below.
• Brush biopsy the lesion - No topical or local anesthetic is needed for the procedure, and patients who have previously undergone the biopsy collection have noted minor to no discomfort. If the lesion in question is dry, simply moisten the biopsy brush slightly with the patient's saliva. Press the brush firmly against the lesion, and then rotate the brush five to 10 times until pink tissue or micro-bleeding results. Depending upon the thickness and keratinization of the lesion, more rotations may needed to achieve desired results.
• Prepare the specimen - After successful collection of the specimen, spread the cellular sample from the biopsy brush onto the glass slide provided by OralScan Laboratories (makers of the Oral CDX system). Rotate and drag the brush lengthwise, transferring as much of the sample from the brush to the slide as possible.
• Submit for lab examination - Quickly squeeze the entire contents of one fixative package onto the glass slide containing the specimen, flooding the entire area. Set the slide aside to dry for 15 minutes. Then place it in the slide holder for transport. After completing the test requisition form, you are ready to send the prepared specimen to OralScan Laboratories in the provided postage-paid box.
• Receive results - Dentists receive an Oral CDX report by fax, usually within three days after the specimen is received by the laboratory. For lesions with a "positive" or "atypical" result, a summary screen containing representative cellular abnormalities is printed. The pathologist's explanatory report and conclusion are mailed to the dentist. These images enable the dentist to explain abnormal test results to the patient and substantiate the need for further evaluation of the lesion by an oral surgeon or oncologist.
In addition, remember that ViziLite (Zila Professional Pharmaceuticals) can help identify abnormalities prior to a biopsy with Oral CDX. After a 60-second rinse with a 1 percent acetic mouth rinse, the device pinpoints areas within the oral cavity that requires further investigation.
Before Oral CDX, the most common lesions often appeared too harmless for testing. Studies have shown that, every week, two to six of your patients have lesions that look "common" or "benign" either to the patient or to health-care professionals. Yet, 62 percent of these seemingly "harmless" lesions were misdiagnosed.
We often look at dental X-rays as a diagnostic tool for carious lesions or periodontal disease. But they pose a far greater benefit in diagnosing oral pathology. Advance-ments in radiography now make these seemingly difficult diagnoses a great deal easier.
Digital radiography provides a unique vantage point in diagnosing potential pathologies. The feature of magnification is helpful in detecting the early stages of disease, especially cancer. While traditional X-rays certainly are not obsolete, they do have a more limited scope than their high-tech, digital counterparts.
What specific X-rays should be taken on our patients? What about the asymptomatic lesions that may not appear upon visual examination of the oral cavity? A panoramic is often the recommended radiograph for accurately diagnosing potential pathologies of the jaw and periodontium. A much broader series, though, provides more clinical data to support potential findings. If abnormal findings are indicated upon routine radiographic examination, pursue the following options for a broadened analysis:
• Maxillary and mandibular occlusals
• CAT scan (if serious findings noted from previous)
• MRI (if serious findings noted from previous)
Extraoral examination procedure
Our instructors at dental hygiene school were absolute sticklers about correctly conducting an extraoral examination. While we may have viewed the procedure as an annoyance, there was a method to the instructor's madness. It is essential that every dentist and dental hygienist know how to precisely conduct this procedure, performing an exam on every patient.
I have heard every excuse for not doing extraorals. "The patient feels uncomfortable." "I don't have enough time." But the fact remains that there is no good excuse for being negligent. The head and neck exam falls under our jurisdiction and is our responsibility to conduct. Any patient who is uncomfortable with the procedure can be put at ease with the simple explanation that you are conducting a necessary cancer screening. The procedure takes two to five minutes, and it happens to be one of the most important services you can provide for your patients. Make the time!
If you are a veteran and have never been formally taught how to do an extraoral examination - let alone where specific lymph nodes are located - the following is a breakdown of the procedure:
• Systematically palpate with the pads of your index and middle fingers for the various lymph node groups. A slow, gentle "massaging" motion is more indicative of being able to palpate the nodes appropriately.
• Preauricular - In front of the ear
• Postauricular - Behind the ear
• Occipital - At the base of the skull
• Tonsillar - At the angle of the jaw
• Submandibular - Under the jaw on the side
• Submental - Under the jaw in the midline
• Superficial (anterior) cervical - Over and in front of the sternocleidomastoid muscle
• Supraclavicular - In the angle of the sternocleidomastoid and the clavicle
• The deep cervical chain of lymph nodes lies below the sternocleidomastoid and cannot be palpated without getting underneath the muscle:
• Inform the patient that this procedure will cause minor discomfort.
• Ask the patient to turn his or her head far to one side - toward the side you are examining - to expose the muscle.
• Hook your fingers under the anterior edge of the sternocleidomastoid muscle.
• Move the muscle backward and palpate for the deep nodes underneath.
• Note the size and location of any palpable nodes and whether they were soft or hard, nontender or tender, and mobile or fixed. Do not get frustrated if you do not feel anything. If there is an abnormality, you will feel it! There will be a pronounced swelling that you will detect upon palpation. Practice on yourself and with staff members until you feel comfortable in your ability to conduct a proper examination.
Lymph nodes can be swollen for a multitude of reasons. A simple cold or allergies could create inflammation. But if the nodes are fixed, hard, nontender, and/or greater than pea size, there may be something more serious involved. The patient should be referred to a physician immediately. Non-Hodgkins lymphoma is the number one nonoral cancer that is first detected by an oral health-care professional, but only if an extraoral examination is conducted.
Intraoral examination procedure
An intraoral examination is more than just doing a visual survey of the oral mucosa or even using a 2x2 gauze to pull the tongue from side to side. Often, pathological findings are detected only by palpation and are not easily "seen" upon visual examination. It is, therefore, critical that the following areas be thoroughly evaluated both visually and with bidigital palpation each exam (by both the hygienist and dentist): lip/mucosa, buccal mucosa, parotid gland, frenum, lingual frenum, hard palate, soft palate, uvula, floor of mouth, floor or mouth palpation, tongue, and oropharynx (tonsillar).
Oral pathology is a clear and definitive area within oral health care that requires attention to details. Keep several pathology reference books on hand in your office as quick guides. It's also essential to take an update annually. There may be a one in 100,000 chance that a particular lesion will present in your office. Staying on top of the details about all lesions provides a better perspective when differentially diagnosing the problem. The implementation of proven diagnostic examinations, as well as advancements such as the Oral CDX and digital radiography, may save a life!
Tammy L. Carullo, RDH, PC, PS, is CEO of Practice by Design, Inc. She may be contacted by e-mail at jtncar@ redrose.net or by phone at (717) 867-5325. For more information about her company, visit www.practicebydesign.com.