Are you testing for oral cancer?

By Mary Govoni, CDA, RDA, RDH, MBA

Afriend of mine recently had a small cancerous lesion removed from his tongue. While he is very grateful to his dentist and dental hygienist for finding this lesion and referring him for diagnosis and treatment, he also seemed surprised that the lesion was discovered in the dental office. His surprise triggered a host of questions in my mind. Does he think dentistry is only about teeth and gums? If so, is it his perception, or does his dental team not take enough time to educate him? Does his dental team discuss its findings with him at his visits where exams — including oral cancer exams — are performed? In other words, if oral cancer screenings are routinely performed, are the patients told that the findings are negative when no suspicious areas are noted, or are patients only told when something suspicious is found? My point is that if we don't let the patients know our findings each time we perform such an examination, they don't necessarily know that we've performed this vital service for them; therefore, it doesn't have value for them. If we don't consistently inform our patients about all the valuable services that we routinely provide for them, how will they know?

Of all the health professions, dentistry is in the best position to make early diagnoses for patients. To that end, the American Dental Association began an oral cancer awareness campaign in 2001. In its current phase that runs through January 2004, the focus is on practicing dentists and helping them to be more aware of the risks of oral cancer. Oral cancer strikes people of all ages. Although people who use tobacco products and consume immoderate amounts of alcohol are at the greatest risk, 25 percent of oral cancers occur in people who do not have these risk factors, according to the National Cancer Institute. Editor's note: For additional information about the ADA campaign, additional facts about oral cancer, and to learn about ADA-sponsored educational activities at the national, state, and local level, go to www.ada.org.

Learning more about oral cancers is a very important step we can take as dental professionals. Included in that learning is the knowledge that we have diagnostic tools available that can aid in early diagnosis of precancerous and cancerous lesions. These tools can and should be used in addition to visual and manual examination.

ViziLite™ from Zila, Inc., distributed by Patterson Dental (see chart on previous page) — A ViziLite™ examination is a painless, non-invasive test that makes abnormal lesions — that may not be detectible on visual examination with normal light — visible. The ViziLite™ is a single-use examination kit that includes a flavored acetic acid solution used as a rinse by the patient and a light capsule that is activated and used to illuminate the oral tissues. Abnormal lesions will appear white. According to the manufacturer, the test can be performed in two minutes, making it a time-efficient diagnostic tool. The test kit also includes a graphic clinical chart on which the examination findings can be recorded. For additional information about the ViziLite™ exam kit, go to www.zila.com.

OralCDx™ from CDx Laboratories, distributed by Sullivan-Schein Dental (see chart on previous page) — This computer-assisted brush biopsy was introduced several years ago and can be performed painlessly on suspicious lesions. The test is appropriate for white, red, mixed red and white, and ulcerated lesions. The OralCDx™ kit contains a sterile biopsy brush, a bar-coded specimen slide, fixative, slide holder, requisition form, instructions for performing the test, postage-paid mailing box to send the specimen slide, and instructions for billing patients and insurance companies.

No anesthetic is used when the test is performed. The brush is specially designed to penetrate all three layers (superficial, intermediate, and basal) of the epithelial tissue. The brush technique is explained in great detail in the instructions included with the kit. The specimen slides are sent to OralScan Laboratories for analysis. If the results are positive, an additional scalpel biopsy may be required, and the patient may be referred to a specialist for additional treatment. For additional information, including education programs, go to www.oralcdx. com.

If your practice is not routinely performing oral cancer exams on all patients, this protocol should be implemented as soon as possible. Also, talk to the patients about the risks of oral cancer. The ADA and other organizations have information available that you can provide to your patients. Investigate and consider using both of these valuable diagnostic test kits to enhance your screening procedures. Most important of all, if you do use, or decide to use ViziLite™ or OralCDx™, let your patients know that you are providing state-of-the-art screening procedures for them so they will truly value your care and expertise.

About the ViziLite™ Oral Examination Device

Indications — Used in conjunction with a conventional visual oral mucosal examination to improve the identification, evaluation, and monitoring of oral mucosal abnormalities in those at increased risk for oral cancer.

Packaging — The ViziLite Test Kit includes a handheld disposable chemiluminescent light and a 1% acetic acid mouth rinse that work together to help dental professionals detect abnormalities in the oral cavity that might not be visible to the unaided eye.

Instructions for performing a ViziLite exam —

1. Perform a routine exam of the oral cavity, noting the presence of any lesions in any of the following locations — attached gingiva, buccal mucosa, floor of mouth, hard and soft palate, dorsal, lateral, and ventral tongue.
2. Instruct patient to rinse mouth with 1% w/w acetic acid solution for up to one minute and expectorate.
3. Activate the ViziLite capsule and assemble with ViziLite retractor as follows:
   * Bend flexible outer capsule, breaking brittle inner vial.
   * Shake to mix contents of the ViziLite Capsule.
   * Insert illuminated capsule into open piece of ViziLite retractor and assemble the two pieces of ViziLite retractor.
4. Dim ambient room lights.
5. Repeat exam of oral cavity using illumination from ViziLite device.
6. Look for acetowhite lesion(s) and document site of any identified areas in any of the following locations — attached gingiva, buccal mucosa, floor of mouth, hard and soft palate, dorsal, lateral, and ventral tongue.
7. Discard ViziLite device.
8. Take appropriate clinical-management option, such as performing biopsy of identified acetowhite lesion; referring patient to oral surgeon for possible biopsy or counseling patient that lesion should be followed and schedule future appointment; and documenting absence of acetowhite lesions.

About OralCDx

Indications — The OralCDx® Computer-assisted, Oral Brush Biopsy Analysis Method is accepted as an effective adjunct to the oral cavity examination in the early detection of precancerous and cancerous oral lesions. All OralCDx® "atypical" and "positive" results must be confirmed by incisional biopsy and histology to completely characterize the lesion. Persistent lesions, even with negative results, must receive adequate follow-up evaluations. — Council on Scientific Affairs, American Dental Association.

Packaging — An introductory package contains an instructional video, sample practice materials, a laminated clinical guide to lesions, and three OralCDx test kits.

Instructions for performing an OralCDx exam —

1. Brush biopsy of the lesion — No topical or local anesthetic is needed. Slightly moisten the biopsy brush with the patient's saliva if the lesion is dry. Press the biopsy brush firmly against the lesion. Rotate 10 or more times (depending on the thickness of the lesion) until pink tissue or pinpoint microbleeding is observed.
2. Preparing the specimen — Spread the cellular sample from the brush onto the glass slide. Rotate and drag the brush lengthwise, transferring as much material from the brush to the slide as possible.
3. Fixative — Quickly squeeze the entire contents of one fixative package onto the glass slide, flooding the slide. Set the slide aside to dry for 15 minutes, then place it in the slide holder. After completing the test requisition form, you are ready to send the specimen to OralScan Laboratories in the postage-paid box provided.
4. Results — Dentists are faxed an OralCDx report usually within three days after the specimen is received by the laboratory. For lesions with "positive" or "atypical" OralCDx results, a summary screen containing representative cellular abnormalities is printed and, together with a pathologist's explanatory report, is mailed to the dentist. These images enable the dentist to explain the abnormal test results to the patient and substantiate the need for further evaluation of the lesion.

Mary Govoni is a Certified and Registered Dental Assistant and a Registered Dental Hygienist, with over 28 years of experience in the dental profession as a chairside assistant, office administrator, clinical hygienist, educator, consultant, and speaker. She is the owner of Clinical Dynamics, a consulting company dedicated to the enhancement of the clinical and communication skills of dental teams. She can be reached at [email protected].