You can"t find what you can"t see

June 1, 2007
This column is about GOOD NEWS and BAD NEWS. I will give you the good news first -- that is, we, the dental profession, now really have the tool to detect and identify oral cancer much earlier than ever before.

by Louis Malcmacher, DDS

This column is about GOOD NEWS and BAD NEWS. I will give you the good news first -- that is, we, the dental profession, now really have the tool to detect and identify oral cancer much earlier than ever before. You can guess the bad news -- oral cancer is one of the few cancers in the United States whose numbers have actually stayed the same or gone up over the last 30 years. Due to early screening techniques, many other cancers have actually gone down over the past 30 years. Here is another statistic that I would consider bad news -- only 15 percent of patients surveyed who go to the dentist responded that they indeed had an oral cancer examination by their dentist or hygienist! Fifteen percent! Eighty-five percent of patients surveyed said their dentist had never given them an oral cancer examination.

I speak to many dental professionals each year. I believe that most dentists and hygienists are careful to do oral cancer examinations as part of their initial patient examination and recall hygiene. The one thing we are not doing is telling patients that we are looking for oral cancer.

Defining the terms

Now let"s define our terms because many dentists I know are confused about what they may be doing in the office. There are oral cancer examinations and oral cancer screenings.

What you provide for your patient in the offi ce on a routine basis is an oral cancer examination. What is this examination? In this short column, I cannot give you the entire procedure on how to give an oral cancer exam (you can find that in textbooks and certainly on many Web sites), but basically an oral cancer examination is looking around the mouth and checking for any red or white lesions, any unusual lumps or bumps that do not look normal, and palpating the tongue and the cheeks and under the chin for any swellings or unusual anatomy. That is your basic oral cancer examination that every dentist and hygienist has been trained to do and should be doing on a regular basis.

An oral cancer screening is something entirely different. Let"s take a look at other cancer screenings that you know are given on a routine basis. A pap smear for cervical cancer, mammography for breast cancer, colonoscopy for colon cancer, and a PSA test for prostate cancer are all examples of some kind of routine screening process which the patient submits to in order to provide early detection of any kind of cancerous cells. Since they have been introduced, these cancer screenings have dramatically reduced the mortality rate for these specific cancers due to early detection and early treatment. These screenings are entirely different from your physical examination of the patient in which you can only see or feel so much, and which provides very basic oral cancer detection.

Let me define one more term for you. Biopsy is a microscopic examination of a tissue sample to see if the cells are indeed cancer cells or not. A biopsy only occurs after you have identified the lesion. Biopsy is the next step in this entire process. What I really want you to focus on is adding an oral cancer screening to your patients" examinations as they come through your office. You already do the examination and you know all about the biopsy. What we have been missing in dentistry is this screening process which can easily identify premalignant and malignant lesions before you can possibly see them. You may see them, but may not be sure if they should be biopsied.

Oral cancer screening tools

We are blessed today to have oral cancer screening tools available. A recent addition to the oral cancer screening market is a device called VELscope by LED Dental. VELscope is a device that you insert into the patient"s mouth while you do the oral examination. Through the process of autofl uorescence, it enables you to visualize abnormalities that may be clinically occult. Healthy tissue has natural fluorescence and through a VELscope, healthy tissue will take on an apple green tint and abnormal tissue stands out as irregular, dark areas. This is a fairly new device that will require a signifi cant capital investment. Therefore, long-term studies are still needed, even though it is based on some other established technologies that have not yet been used in the oral cavity. The FDA recently cleared VELscope for two critical indications, including enhancing the visualization of oral mucosal abnormalities that may not be apparent with the naked eye.

ViziLite Plus with T-Blue630 by Zila Pharmaceuticals, Inc., is the industry leader in oral cancer screening devices. It has been very well studied and should be an integral part of your dental practice. The procedure is really fairly simple. The patient rinses with a raspberry vinaigrette-tasting solution, then a special glow stick device is opened, activated, and placed in the patient"s mouth where the light will shine on the soft tissue. Through the science of chemiluminescence, any lesions will literally light up so they can be easily identified.

When you do an oral cancer examination and you are searching for lesions that may be 0.5 mm in size, it is hard to find them with a visual exam. It may be easier if you wear loupes, but I don"t know how many dentists routinely wear loupes while doing oral cancer exams ... but we certainly should. With chemiluminescence, the lesions literally light up so it is easy to see them. If a lesion is found, T-Blue630 is placed on it so that the area around it will turn blue. You can then take an intraoral photograph and send it along with the patient to an oral surgeon or keep it in your own files so that you can fi nd the lesion again in order to biopsy it.

The efficacy of chemiluminescence, the technology behind ViziLite, has been evaluated in more than 13,000 patients, including four FDA trials and in multiple published studies in peer-reviewed journals. Chemiluminescence has been widely used for more than a decade as an adjunct to the Pap smear, and has been demonstrated to significantly enhance the sensitivity of the Pap smear. There is abundant evidence-based medicine related to the effi cacy of generic toluidine blue and its demonstrated use as a preferential stain of premalignant lesions and oral cancer.

ViziLite was FDA-cleared in November 2001; the ViziLite Plus with T-blue630 Oral Lesion Identification and Marking System was FDA-cleared in February 2005. The marking system is FDA-cleared to mark suspicious lesions identifi ed during the ViziLite exam. The ViziLite Plus system is the only FDA-cleared adjunctive screening technology for the identification, evaluation, and monitoring of oral mucosal abnormalities, including premalignant lesions and oral cancer in a patient population at increased risk for oral cancer (healthy patients age 18 and older).

Much of the ViziLite Plus screening process can be delegated to assistants and hygienists. My team members prep the patient and I come in and do the screening. One of my team members also looks into the patient"s mouth and does a screening as well. It never hurts to have an extra set of eyes! It takes approximately 30 seconds of my time for each patient that goes through a ViziLite Plus screening. It is a very simple system to use, and there is no large initial capital investment in this technology. The cost per patient is approximately $19 per use, of which the patient charge for this adjunctive oral cancer screening is a very reasonable $65. Many dental and medical insurances reimburse for this procedure as well. Many dental and medical insurance pans reimburse for an oral cancer screening done with ViziLite Plus and VELscope.

Do the right thing!

I could go on in this column and try to scare you into doing an oral cancer screening because of the risk management aspects involved, but that is not the point. I could even make the case from a revenue perspective about how oral cancer screening can increase your production and cash fl ow. The practice-management benefits have been incredible. Our patients now see us in a different light -- as real physicians of the mouth who are interested in their overall health.

The real reason I want you to go ahead and institute oral cancer screening into the services your office provides is because it is simply the right thing to do. It is an enhanced standard of care. You are doing what is best for your patients who you care so much about, and we, in turn, become heroes to our patients. It is time to become the real physicians of the mouth that our patients expect us to be.

Disclosure: Dr. Malcmacher has received education grant support from Zila, Inc., for some of his lecture schedule.

Dr. Louis Malcmacher is a practicing general dentist in Bay Village, Ohio, and an international lecturer and author, known for his comprehensive and entertaining style. An evaluator for Clinical Research Associates, Dr. Malcmacher has served as a spokesman for the Academy of General Dentistry and is a consultant to the Council on Dental Practice of the American Dental Association. Contact him by e-mail at dryowza@mail. com. Sign up for his free e-mail newsletter and see Dr. Malcmacher s lecture schedule at

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