By Tyler Green, DDS
In a recent article published in the Journal of the American Medical Association, 7% of Americans between the ages of 14 and 69 (roughly 16 million people) have oral HPV — a sexually transmitted virus passed through oral sex. Of these, 1% will have HPV 16, the version that has the potential for oral cancer. That translates into roughly two million Americans.
http://jama.ama-assn.org/content/early/2012/01/23/jama.2012.101.full
Odds are good that we will see some of the manifestations of this in our patients, unrelated to the traditional risk factors of smoking and drinking.
As a dentist, this hits home when I think of my patients. Who among them may have a lesion, and do I have the tools and knowledge to act if and when I see a lesion? From the cheerleader who just received her driver’s license, to the anesthesiologist who was just married at age 55, all people are at risk.
My goal is to offer patients a practice that has the latest tools and knowledge to identify possible lesions and abnormalities as soon as clinically possible, in order to minimize the impact of the horrific outcomes that often come with this disease if caught late in its presentation. The time to act is now!
I am often asked how I integrate the adjunctive technologies for oral cancer screening into my practice. The first thing I find out from a doctor is what adjunctive device he or she is now using, or what device the doctor would like to use to make oral cancer exams more effective.
In dental school we learned how to perform an oral cancer exam by using only the white overhead light. We know it is a standard of care to perform one on each patient. I become frustrated when a new patient, who has had regular exams every six months, asks me why I’m pulling on his or her tongue with gauze.
What this tells me is that dentists are not giving patients the benefits of their extensive training and are selling them short. Keeping patients healthy from preventable disease is why many dentists entered the field. Whether it is caries, perio, or other systemic disease, if it has a manifestation in the head and neck, it is within the dentist’s field of study.
I will assume that dentists know how to do basic oral cancer screening. (If not, brush up. Videos are available on YouTube.)
Imagine you are a patient in a dental office, and the staff asks if you want to have an adjunctive exam as part of your oral cancer screening. Your first question is, “Does my insurance pay for it? If not, how much will it be?”
Is it included as part of the exam fee or do you want patients to pay for this test and bill them for it separately? I tell patients that insurance may or may not pay for the exam. What do you tell patients? You need to know the answer to these questions so that your staff does not hesitate when asked.
This is a great opportunity to share with patients the benefits offered by your office. Tell them that because of your concern, your office has invested time in training and money in new equipment to provide them with the most noninvasive screening instruments to view abnormal tissues at the earliest changes.
If the doctor makes it a priority to offer this service to patients, then the staff must be trained in presentation and be familiar with the technology. An easy way for the staff to become comfortable with the device is to perform a basic exam on staff members. My office gets swamped with daily treatment, and sometimes we forget to take care of those with whom we work. So take an hour and perform an exam on each staff member. This is like a dry run before going live.
The questions that come up during this dry run will be like the ones you’ll get from patients, such as “Will my insurance cover this?” I love this question! Here is my answer. When my office started screening patients, no insurance companies paid for the screening. Now, 10 years later, many insurance companies have this as a covered benefit.
If this is not the case for a patient, my response might be, “If your insurance doesn’t cover this, I will give it to you free this time, but in the future it will cost $35.”
Patients are grateful that you give them a choice to have the adjunctive screening device used even if they decline it at this time. I always ask if I can ask them again at their next visit, and invariably they say, “Yes. It’s OK to ask me next time.”
There are three major types of adjunctive screening devices. None should be used without a white light standard oral cancer screening first. None of these devices were designed to diagnose pathology. All are screening devices used to help the dental team determine abnormal tissue and to help create a differential diagnosis if abnormal tissue is found.
The idea behind these products is to provide a contrast between normal tissue and abnormal tissue. The main ways the screening devices help to determine abnormal tissue are through fluorescence or lack of fluorescence, reflective technology, and acquiring a tissue sample through a brush biopsy.
With each of these techniques, the idea is to quickly identify abnormal tissue from normal tissue. If abnormal tissue is seen, the dentist must determine whether or not a biopsy is indicated. Do not perform a punch biopsy without a decent differential diagnosis. There are many good books that will help you come up with a differential diagnosis based on tissue color, ulceration, and other characteristics that may be observed at the exam.
I had lunch with my oral surgeon the other day and, since I had been referring patients to him for biopsies, I asked him how he was handling these patients. When a patient comes to his office with a picture of the lesion and a brief history of the differential diagnosis from the referring dentist, his discussion with the patient is quick and easy. If one of the differential diagnoses is a pathological tissue, then his biopsy decision is either incisional or excisional based on the size of the lesion. When a patient shows up at his door without a proper referral letter or photo, his job is more difficult.
Dentists need to let patients know that they have used their skill and knowledge base to identify an abnormal tissue. By sending either a mouth map or picture of the lesion, an oral surgeon or pathologist can biopsy the tissue if indicated.
The easiest way to treat patients is with a biopsy kit and pathology tube that is available from either an oral pathologist (such as JKJ Pathology in The Woodlands, Texas) or a dental school’s pathology lab.
Using an adjunctive device to aid in oral cancer screening allows you to screen many patients quicker and more thoroughly than by performing only a standard oral cancer exam. My oral surgeon said that he was seeing more oral cancer cases now than ever before. I think this is because we’re catching it earlier, and getting patients to have biopsies done sooner rather than getting so far along in the disease process that they bypass the dentist and go straight to the ENT or their physicians.
I hope this gives you some ideas on how to implement adjunctive screening devices into your standard practice model of care.
R. Tyler Green, DDS, practices in Conroe, Texas. He has a passion for oral health care and the transformational effects a great smile can have on a person’s life. Dr. Green speaks worldwide on oral cancer, magnification, illumination systems, and the use of Snap-On Smile. Reach him by email at [email protected].
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