Facing the facts

May 1, 2003
In my opinion, there has never been a better time to practice dental hygiene. As a profession, we are way beyond picking, polishing, and flossing. We are in the front lines of health promotion and disease prevention.

By Anne Nugent Guignon

In my opinion, there has never been a better time to practice dental hygiene. As a profession, we are way beyond picking, polishing, and flossing. We are in the front lines of health promotion and disease prevention. The systemic health connections get stronger every day. Amazing technology is now available for recognizing caries and periodontal disease before the damaging effects of these infections have had a chance to destroy sound tooth structure, bone, and soft tissue.

How can today's clinicians afford to ignore the emerging science concerning plaque biofilms? Can we close our minds to the life-saving information, new technology and equipment that aids in the diagnosis of caries and periodontal disease, as well as the treatment of these diseases? Don't we owe it to all of our patients to have the latest information about enamel remineralization, periodontal antibiotic therapies, and host modulation? Hopefully, this new information and these new tools are finding their way into more and more practices.

As much as I love waving the banner of life-saving information and tools, it is deeply disturbing that the entire dental profession is getting attacked from the rear by the alarming rate of oral cancer in this country. Thirty thousand new cases of oral cancer are diagnosed every year. The survival rate has not improved in the last five decades; the five-year survival rate is still only 50 percent. It is estimated that 10 percent of our patients have some type of oral abnormality and one quarter of these patients do not have the traditional risk factors of tobacco, age, and alcohol. Most alarming is that medical practitioners, not dental, detect a great majority of oral cancers. The ADA lists difficulty swallowing or speaking as signs and symptoms of oral cancer. Detecting carcinomas at that advanced stage is too late.

Lives are being lost. Patients are being subjected to disfiguring surgeries or the debilitating and life-altering effects of radiation. We are losing the war on oral cancer and our patients are the victims. Is it possible that dental professionals have been failing the patients who place so much trust in us?

If one considers this a war, then we need to be in the first line of defense or we will never win the battle; and we need scouts to help us plan our attack. We need scouts that are looking for the tiniest clues — things that just don't fit. Hygienists and dentists are perfect for the job. We are all trained to detect abnormalities in the oral cavity. Hygienists perform oral cancer screening exams as a regular part of the patient visit.

Imagine if we had a tool that would make our scouting mission easier and more effective. Enter the ViziLite. This simple, disposable tool can be incorporated into our patients' annual exams as a routine screening device. It can also be used to improve our chances of detecting abnormal tissue on a high-risk patient. After the patient rinses with a special solution, the room is darkened and the light activated, giving the examiner about 10 minutes to evaluate the intraoral tissues. Abnormal tissue will appear white.

While an abnormality can be something as simple as an apthous ulcer, it could also be something as serious as a squamous cell carcinoma. Certainly the ViziLite is not meant to replace a thorough visual and tactile exam, but rather give us another way to evaluate our patients' health. According to the preliminary findings, oral evaluations using the ViziLite can improve our chances of finding a suspicious lesion by as much as 30 percent.

So what happens when you spy something that just doesn't look right with either your traditional exam or the ViziLite? Do you ask your patient if they have noticed anything different, or if they know how long this sore or white patch has been in their mouth? Do you and your doctor watch it? Watch it do what?

Every one of us is trained to understand what is normal, but I doubt anyone reading this column can give a definitive diagnosis on an oral abnormality based solely on a visual evaluation. It is either arrogance or ignorance for us or our doctors to assume we are that good. We are human and we need science to help guide our patients to an appropriate decision path.

Enter Artillery Unit II, the brush biopsy called Oral CDx. Remember, we are the scouts, not the one who will fire the first round; but if we are doing our scouting jobs, then we can alert our doctors to perform a brush biopsy if our state practice act does not allow us to perform the procedure.

Research has shown that positive brush biopsy reports do detect malignant lesions. The Oral CDx test is not designed to test the most obvious, frank oral abnormalities, but rather help us aid our patients in the detection of the more subtle tissue changes that can be pre-malignant or have developed definite dysplastic changes. For whatever reason, patients may be reluctant initially to seek a more definitive evaluation of a suspicious area from either an oral surgeon or an oral pathologist. It is our responsibility to give them as much information as possible and the Oral CDx test can help us fulfill our obligation to them.

Again, the procedure is simple, painless and very inexpensive. It is much more accurate than our two well-trained eyes. A small brush is twirled on the surface of the lesion with enough pressure to create bleeding. This assures that cells from the deepest layers of the epithelium are captured in the brush, which are then transferred to a slide.

It is exactly the same procedure that gynecologists have been doing for decades in a pap smear. A special fixative coats the specimen on the slide, which is sent to the Oral CDx lab for evaluation. A positive Oral CDx test should be followed by a scalpel biopsy for a more definitive diagnosis. The company reports never having had a false positive.

The physicians have been fighting the oral cancer wars for us. Most oral cancers are found in their offices, not ours. While some may argue that these patients never enter the sacred halls of our dental offices, is this just a way to feel better about the shameful statistics? Remember, about one quarter of the oral cancers are found in patients who do not have traditional risk factors. It is impossible to believe that we cannot do a better job in the war against oral cancer, and now we have better tools than ever to help win the battles, one patient at a time.

Another even uglier war is affecting our country — missing and abducted children. While it is unthinkable that we should even have to address this issue, there are evil people with twisted minds that are intent to harm our most precious assets — our children. In addition to these tragedies, lives are lost unexpectedly in disasters like fires and plane crashes. Unfortunately, this is reality.

For years, forensic investigations have relied on dental radiographs and records to aid in identification and recovery efforts. Now that so many children and young adults are caries-free, our traditional information is no longer as valuable. Also, many investigations have been hampered when records have been difficult to obtain.

Finally, we have a way to help our law enforcement and governmental agencies more than ever before. Science tells us that we each have a unique bite and that our saliva contains precious genetic information, as well as our own unique scent. We now have the ability to record our patient's bite quickly, accurately and inexpensively with a new product called Toothprints. In addition, the bite contains enough saliva to satisfy the nose of the most discriminating bloodhound.

As soon as the rigid Toothprints wafer is softened in a container of hot water, it is ready to use. It only takes 50 seconds to obtain the Toothprints impression and a few more minutes for it to achieve final hardness. It should be stored at room temperature in a marked zip-lock bag, preferably in a safe place at the patient's home. It is advisable to put a current picture with the Toothprints record.

Toothprints should be repeated as a child's dentition changes. Valuable genetic information can also be stored on a cotton swab that has been rubbed on the patient's buccal mucosa. The swab should be placed in a marked zip-lock bag and stored in the freezer.

Finally, even though Toothprints was designed for identification of children, this same technology can be used to record adult dentition. If the impression material is too small for your adult patient, once it is flexible it can be stretched to fit a larger dentition and still capture all of the necessary information.

Some people are concerned about having fingerprints, personal records and genetic information stored in gigantic databases. Toothprints eliminates these issues. Family members can store this information at home or in a safety deposit box. Hopefully, the information will never be needed, but if so, it can be readily available for the appropriate authorities.

While I started this discussion on a very upbeat note, some of you may think it has taken a very somber or even morbid turn. Certainly that is not the intent. Our patients need us. They turn to us for help.

If we can help them discover a life-threatening condition earlier or rule out the possibility of a premalignant lesion, isn't that something to celebrate? If law enforcement officials are able to find even one child before it is too late because they have more information, isn't it worth the few minutes and few dollars it takes to get these records? If an impression helps a family receive positive identification of their loved one, we have provided a service at a time of great sorrow.

People get cancer, kids get abducted, and bodies are hard to identify. These are the facts. We can make a difference. This can be our comfort zone and it can be our patients' as well.

Anne Nugent Guignon, RDH, MPH, practices clinical dental hygiene in Houston, Texas. She writes, speaks, and presents continuing- education courses on ergonomics and advanced ultrasonic instrumentation through her company, ErgoSonics (www.ergosonics.com). She can be reached by phone at (713) 974-4540 or by e-mail at [email protected].