Stacey L. Simmons, DDS
“You want me to stick my tongue out at you?” Yup. That’s exactly what I said, and it’s probably the only time you can do that without getting in trouble too.
“Why are you checking my neck and under my chin—this is a dental checkup!”
“What’s that fancy flashlight for, and why do you have those glasses on?”
“Oh, that crack in my lip has been there for the last four months; it doesn’t seem to go away, but the weather is cold and dry so I’m not worried.”
These are some of the questions and comments I get when I do my patient exams, which, to some extent, surprises me. Why? Because screening for cancer—whether it’s oral or head/neck—is something we should all be doing at every single patient visit. It takes seconds and can literally save a life.
During my 15 years of private practice, I’ve had numerous patients come in with suspicious lumps, lesions, and not-quite-so-right-looking tissues that are just begging for a biopsy or at least a follow-up. For the most part, fortunately, these are benign,
nonpathological areas of concern that typically run their course and are part of the tissue diversity. However, when I do refer a patient for a biopsy and it comes back positive for cancer, the whirlwind of events that subsequently follows is quite daunting for the patient, especially when there was a lack of symptoms that might indicate the “C” word.
Early detection of neoplastic changes in the oral cavity is the best method to improve patient survival rates;1 however, visual examination of the oral cavity relies heavily on clinical expertise in recognizing early neoplastic changes, which can be difficult even for experienced practitioners.1 With available technology, we are able to detect premalignant and malignant lesions sooner than with just the naked eye. If cancer is caught in the early stages, it can make all the difference in treatment options and, ultimately, outcomes. Management of these patients can be simple to complex with issues ranging from speech, swallowing, and chewing—not to mention self-esteem issues and social anxieties.
Let’s look at some staggering statistics from the American Cancer Society and Oral Cancer Foundation:
• The estimated number of patients who will be diagnosed with oral or oropharyngeal cancer in 2019 is approximately 53,000. Approximately 72% of those cases will be male.2
• Just under 11,000 of those cases will result in death.2
• HPV is the leading cause of oropharyngeal cancers, which is the fastest growing oral cancer population under the age of 45.3
Technology has become such an integral part of our everyday lives that it would be almost imprudent not to maximize the tools at our disposal to aid us in oral cancer detection and diagnosis. Options vary from tissue staining (Toluidine blue), brush biopsies (OralCDx BrushTest), and light-based techniques, including chemiluminescence (ViziLite, Microlux) and autofluorescence imaging (VELscope, OralID), which work on the assumption that neoplastic and preneoplastic tissues that have undergone abnormal metabolic or structural changes have different absorbance and reflectance properties when exposed to specific wavelengths of light.1
With so many possibilities, each presenting with pros and cons, here’s a checklist of what to look for when deciding which device is best for you:
• Safe, simple, and quick to use
• Not messy or painful
• FDA-cleared medical device
• Photo documentation, ease of use
• Customer support, team training
• Up-front cost and subsequent per-patient cost
I’ve tried staining, and I’m not a fan because it’s messy and patients really don’t like it. Brush biopsies are simple, but they can be technique sensitive with an unwanted turnaround time. My go-to that meets all of the above criteria is the OralID. Simplicity is the ultimate sophistication, and this device is definitely simple. With a fancy pair of glasses (or “spy” glasses as my 9-year-old says) and a flashlight that emits a fluorescent light, you can check a patient’s tissue in under one minute.
If the tissue appears dysplastic, then you can send it out for a tissue biopsy. What’s more, you can easily take pictures of the lesion with your phone using the SmartFilterID cover, which clips right over the camera lens. Documentation is so vital, and when patients can actually see what you see . . . well, a picture is worth a thousand words. Your cost is an up-front purchase and an occasional battery change. Plus, you can bill it under the code D0431.
As dentists, we have the advantage over our medical colleagues, because we typically see our patients more than once a year, even up to four times a year if they are on a shorter recall program. This increased frequency gives us the opportunity to detect early neoplastic changes in the oral cavity—what an incredible service to the patients under our care. We would be doing our patients a disservice if we didn’t screen for potentially cancerous lesions, especially in high-risk patients—tobacco/alcohol users and smokers, etc. OralID is ideal in these situations.
Probably one of the biggest thought processes that we have to overcome in medicine is that the absence of pain doesn’t necessarily mean that all is well. High blood pressure doesn’t hurt, and when carious lesions start forming, they don’t hurt either. Cancer is the same way. Initially it doesn’t hurt, but if left unchecked with free rein, management often becomes expensive, emotional, and emergency based.
So, when my patients ask what I’m doing when I have them stick their tongue out at me so I can shine my OralID light into their mouths, I’ll just tell them my cool spy glasses are searching for the bad guys . . . because we all know that adding a bit of humor into the mix is healthy, too, right?
1. Nagi R, Reddy-Kantharaj YB, Rakesh N, Janardhan-Reddy S, Sahu S. Efficacy of light based detection systems for early detection of oral cancer and oral potentially malignant disorders: Systematic review. Med Oral Patol Oral Cir Bucal. 2016;21(4):e447-e455. doi: 10.4317/medoral.21104.
2. Oral cavity and pharynx. Cancer Statistics Center. American Cancer Society website. https://cancerstatisticscenter.cancer.org/?_ga=2.219641433.171251318.1548706753-1286212010.1548706753#!/cancer-site/Oral%20cavity%20and%20pharynx. Accessed January 28, 2019.
3. HPV/oral cancer facts. The Oral Cancer Foundation website. https://oralcancerfoundation.org/understanding/hpv/hpv-oral-cancer-facts/. Updated February 1, 2019. Accessed February 8, 2019.
Stacey L. Simmons, DDS, a graduate of Marquette University School of Dentistry, is in private practice in Hamilton, Montana. She is a guest lecturer at the University of Montana in the anatomy and physiology department. Dr. Simmons is the editorial director of PennWell’s clinical dental specialties e-newsletter, Breakthrough Clinical, and a contributing author for DentistryIQ, Perio-Implant Advisory, and Dental Economics. She also serves on the Dental Economics editorial advisory board. You may contact her at firstname.lastname@example.org.