Light My Fire

Oct. 1, 2009
We do initial and periodic exams several times a day.

by Paul Feuerstein, DMD

For more on this topic, go to and search using the following key words: initial and periodic oral exam, diagnostic tools, perio charting, Dr. Paul Feuerstein.

We do Initial and periodic exams several times a day. Sometimes an exam takes minutes while other times it may last an hour. Everyone seems to have his or her protocol and order for this procedure. For an initial exam, many dentists include dental and perio charting, intra– and extraoral photos, a medical history, and an oral cancer screening.

As most hygienists will lament, the doctor's periodic exam fluctuates based on the time he or she has at that moment, respect for the hygiene schedule (and the patient's time), and the time available on the schedule. But the fee remains a constant.

We now have more diagnostic tools available for this exam. For instance, we use caries detection systems. This takes additional time and includes equipment that costs anywhere from $2,500 to $12,000. Do we charge extra for a caries exam that utilizes these detection systems?

There are new digital perio charting systems such as the Florida Probe (, Dental RAT (, or voice–activated systems such as PerioPal ( How about charging for full–mouth perio charting or perhaps the photo series? Some offices do charge for these while others live in the world of “Does my insurance cover that?” You have invested time, and in the case with some of these devices, money. This is especially true if there are per–use or disposable charges.

The soft–tissue exam is just as important. We have been trained in school and continuing education on what to look for regarding normal and abnormal. Most pathology courses give an encyclopedia of lesions, tell us how to recognize them when small and large, and hopefully guide us in the course of treatment. There are simple rules for this exam including proper lighting. Only relying on the overhead light requires the patient or examiner to move in to positions that could require chiropractic intervention.

Many of us use headlights, and the new array of LED units make them simple and lightweight. Still, a good look at the hard and soft palate almost requires doing the twist. A few diagnostic lights have appeared in the past few years.

Although marketed as “oral cancer screening” devices, they are actually soft–tissue illumination devices that also give insight into some subepithelial, precancerous areas. There has been controversy about these lights, but without getting into a histological discussion, suffice it to say that you will do a better oral exam with these illumination concepts.

A visible lesion can be excised, biopsied, or tested physically by getting a sample of some cells. One of the products available, Oral CDx, has the practitioner use a stiff brush, capture some cells, fix them, and send them to their labs. If you want to be amazed by some technology, check out the company's Web site to see the methods they use for analysis. A battery of computers read and analyze the cells with processes that look like the CSI labs on the TV show. Check it out at

For the not–so–visible lesions, Zila started the process with the ViziLite, now ViziLite PLUS. Using a bluish glow stick after the patient has rinsed with a solution (mainly acetic acid), tissue areas glow to indicate possible subepithelial cell changes that could be precancerous. These areas also can be stained for further identification with the company's “T–Blue” solution. Complete information is on Zila's Web site at The cost per exam kit is less than $30.

VELscope at uses a different light frequency and intensity. With no rinse, it highlights suspicious subepithelial areas. Although there is an initial investment in the light, the only cost per use is the disposable shield. VELscope has partnered with camera companies PhotoMed and Dental Learning Center to allow easy imaging of these lesions for documentation. They also recently made a retrofit device that works with the Sapphire light from Den–Mat.

Trimira ( took a slightly different approach. The company has three different lights in one unit at different frequencies and intensities. The Identafi 3000 allows similar views to ViziLite and VELscope but added a bright, full–spectrum white light that illuminates oral tissues better than overhead lights or headlights. This is especially useful in simpler diagnostic situations such as identifying denture sore spots, canker sores, and other lesions that are not easily visible when a patient complains.

The point here is to spend a little more time on the soft– tissue exam, and take a look at some aids that will help you and your patients. Still, as with all technology, use your clinical knowledge to make decisions.

Dr. Paul Feuerstein installed one of dentistry's first computers in 1978. For more than 20 years, he has taught technology courses. A mainstay at technology sessions, Dr. Feuerstein is an ADA seminar series speaker. A general practitioner in North Billerica, Mass., since 1973, Dr. Feuerstein maintains a Web site ( and can be reached by e–mail at [email protected].

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