by John C. Comisi, DDS, MAGD
Quality care -- what is that? I've read hundreds of articles over the last 30 years that have addressed this issue. In my office, quality means the best we can offer. This includes the time I spend with patients actively and passively listening, which I believe is essential, as well as the use of the best materials, techniques, and technology that we can offer.
One of the pieces of technology that I've incorporated in my practice for the past six-and-a-half years is the VELscope® enhanced oral assessment tool. This instrument uses an enhanced light and filter system to help the clinician evaluate and screen the oral cavity, and help identify potential abnormal tissue that could otherwise be missed when viewed in normal visible light.
It has become our office's standard of care. Whether it's with the original VELscope unit or the new and lighter handheld VELscope Vx device, we screen every adult 18 years and older at each routine dental appointment. My reasoning behind this is based on several studies indicating that the incidence of oral cancer in younger, nonrisk patients is increasing.
We explain to patients -- especially new patients since our established patients know the routine -- that we are going to do an enhanced screening to detect any abnormalities of the oral tissue, which we most likely would not easily see during our usual white light oral examination. We also explain that the combined white light oral exam and tactile exam helps us provide a more comprehensive examination than can be achieved without the VELscope.
We also tell patients that we will look for everything from cheek biting to abnormalities that may need further evaluation. When patients ask if we're looking for cancer, we tell them that we have identified lesions in the past that once biopsied and examined have turned out to be cancerous. However, because we identified the lesions in the earliest stages of development, we essentially saved lives. Without this visual enhancement, it might not have been possible to identify these suspicious areas until they developed further and caused more destruction. This typically gives patients pause, and they gladly let us proceed. We explain that oral cancer is three times more likely to develop than cervical cancer, and that males have twice the probability of developing oral cancer than women.
The oral cancer exam is very quick and easy to do. Even after all these years, I'm surprised at what the device reveals with each exam that I do. I've always thought that I was pretty good at detecting abnormalities, and I've identified many fairly obvious lesions over the years prior to incorporating the VELscope into my practice. Unfortunately, since these areas were far along in development, the surgical interventions needed were quite extensive and often disfiguring. Since incorporating fluorescence visualization, we have identified many suspicious areas that, in all likelihood, we never would have detected as early as we were able to with the VELscope. Of these areas, most were dysplastic, and several were identified as squamous papilloma, caused by the human papillomavirus (HPV). One of the earliest cases we identified was published in General Dentistry in 2008. We have also discovered many inflamed areas, traumatic injuries, and other areas of the oral cavity that have been irritated by a patient. We counsel them on ways to reduce these traumatic or caustic injuries they inadvertently create, which have the potential of converting into dysplasias if they're allowed to continue to be irritated.
The acceptance of this type of examination has been relatively easy for my patients, especially with the explanations we've discussed. We explain that there is an annual fee for the exam, and that we will perform the exam at each of their hygiene visits. The once-a-year fee is submitted to their dental insurance companies using the ADA code D0431. What should the annual fee be? In our office it is slightly higher than our fee for bitewing X-rays. More insurance companies are recognizing this code and reimbursing for this service.
For those patients who initially don't want to pay for this examination -- and there have been a handful who have refused -- I tell them I'll do the first exam at no cost because I care about them and feel very strongly that it will help me be more sure there is nothing going on intraorally that could be harmful to them. "This one is on me, but next time there will be a fee," I tell them. At their next visit, each of these patients has been happy to pay the annual fee.
We have also incorporated the use of liquid cytology brush biopsy into our diagnostics. When I identify a suspicious area with the VELscope that does not resolve itself within two weeks, I use this test. The kits I use are provided by Tufts Oral Pathology Services (TOPS) and are free to clinicians from TOPS. Contact them at 617-636-6510 office, and 617-636-6780 fax.
This liquid cytology brush biopsy is a painless procedure, similar to what is done with other brush biopsy tests except it involves using a sterile, plastic-handled nylon bristle brush for collecting trans-epithelial mucosal cells. The brush is vigorously rubbed on the oral lesion and then transferred to a vial containing a special liquid preservative/fixative solution. Once in the solution, the brush is twirled to remove the collected cells from the brush, and then the whole brush is cut off and placed into the medium. The bottle is tightly sealed and labeled. The appropriate forms are filled out and sent overnight to TOPS in prepaid packaging provided by the company. A report is faxed back from the oral pathologists at Tufts within 48 hours of receipt of the specimen, which helps determine the next steps (if any) to take, including referral for excisional biopsy of the area.
We use ADA CDT code D7288 for collecting the sample, and the patient is charged an appropriate fee for the sample collection by my office. TOPS will also charge the patient for their services, and the patient can use medical insurance for this procedure. TOPS will use CPT code 88112 if billing the patient's medical insurance or CDT code D0480 if billing the patient's dental insurance.
This combination use of VELscope and liquid cytology brush biopsy has, in my opinion, helped me raise the level of care I offer my patients. I feel more confident that I'm leaving no stone unturned in caring for my patients. It's a level I would encourage all of my colleagues to attain.
References available upon request.
John C. Comisi, DDS, is a graduate of Northwestern University Dental School and has been in the private practice of general dentistry since 1983 in Ithaca, N.Y. He is a Master of the Academy of General Dentistry, a member of The Catapult Group, and he lectures on various dental topics and procedures. Reach him at firstname.lastname@example.org.
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