The Value of Oral Cancer Screening and Detection
By Mary Govoni, RDA, RDH, MBA
Chances are you or someone in your life has battled cancer. If that is the case, you may be involved with some type of activity, such as fundraising, to help support research to find a cure for that type of cancer. The prevalence of pink ribbons on many items in the marketplace is evidence of those who have been touched by breast cancer and support the cause of eliminating this insidious disease. But have you thought about taking up the cause of early detection of oral cancer? Undoubtedly you perform an oral cancer exam on all your patients, but is that examination as comprehensive as it could be? Have you reviewed the latest technology available for screening and early detection? Have you thought about instituting a multifaceted campaign to increase awareness of oral cancer in your patient family and your community? Do you know what resources are available to you and your practice to educate patients and encourage them to participate in screenings? If not, read on...
According to the American Cancer Society, 2 to 4 percent of cancers diagnosed in the United States each year occur in the oral cavity. This includes sites on the lip, tongue, floor of the mouth, gingiva, alveolar and buccal mucosa, and oropharynx. Approximately 30,000 cases of oral cancer are diagnosed annually, and approximately 8,000 deaths occur each year from oral cancer. At the time oral cancer is diagnosed, more than half of the patients have invasive or metastatic disease, which reduces long-term survival rates. Early diagnosis is believed to be critical to increasing survival rates from this deadly and potentially disfiguring disease. The Centers for Disease Control and Prevention (CDC) states that the five-year survival rate for patients with localized disease is 81 percent, however, the five-year survival rate for patients with oral cancer that has spread to other sites is only 30 percent. In addition, patients who survive a first diagnosis of oral cancer have a 20 times higher risk of developing a second cancer.
Dental professionals obviously play a key role in the early detection and diagnosis, especially since at least 50 percent of Americans see their dentist at least once a year.
Our job as dental professionals is to provide a thorough screening to those patients whom we see regularly, using the most up-to-date screening and detection tools available. Although this screening exam is extremely important, many times we tend to take it for granted, or place less emphasis on the examination than we could. A renewed emphasis, along with some new developments in early detection and screening methodologies, can help you make a true difference in the life of your patients - potentially saving their life.
In recent years, technology developments in oral cancer screening for use in dental practices has included the brush biopsy (OralCDx®), chemilumenesence (ViziLite™) and most recently the use of fluorescence (VELscope®). The brush biopsy can be utilized for initial screening of visible lesions and has been implemented successfully into many dental practices, who then refer patients to specialists for further testing and diagnosis of suspicious areas. All of these screening tools are utilized in conjunction with traditional visual and tactile (palpation) examinations.
But what about the early changes in oral tissue that may not yet be visible to the naked eye? Research has shown that abnormal epithelium will appear white when exposed to an acetic solution and then viewed under a low-energy wavelength light. Normal tissue will appear dark under the same conditions. This technology, available as the ViziLite™ and ViziLite Plus™ early detection system, provides a much-needed adjunct to the visual and tactical examination performed by the doctor or hygienist. If an abnormal area is discovered, it can be marked with a dye (toluidine blue) and the patient can be referred for evaluation and/or biopsy by a specialist. Since advanced oral cancer has such a high mortality rate, the earlier that these abnormal areas are detected, the better the patient’s chances of survival. Zila Pharmaceuticals, the manufacturer of ViziLite™, has developed excellent training materials for the dental team to learn more about oral cancer and how to use ViziLite™. They have also developed educational materials for patients in the form of brochures to be distributed in the office, as well as information that is accessible on their Web site - www.vizilite.com. This screening tool can be utilized at new patient visits as well as re-care visits. It can be done in the hygiene or the doctor’s treatment room, since no major equipment is involved. Either the hygienist or the clinical assistant can educate the patient about the procedure, have them sign the consent form and rinse with the solution, in preparation for the doctor to see the patient and evaluate the tissue.
The newest technology available for early detection and screening utilizes Direct Tissue Fluorescence Visualization Technology with VELscope® from LED Dental Inc. This examination tool helps the viewer differentiate between normal and abnormal cell activity in the oral mucosa. VELscope utilizes a safe blue light, which when shined on the oral tissues, causes the tissue to fluoresce from the outer surface (epithelium) through to the basal membrane as well as the stroma beneath. Research shows that pre-malignant changes in the tissues typically begin at the basal membrane. Typically, healthy tissue will fluoresce bright apple green, while suspicious areas may cause a loss of fluorescence and will thus appear dark. The ability to detect abnormal activity or changes, not yet visible in white light or to the naked eye, makes this another excellent early screening tool. VELscope allows for photodocumentation of suspicious areas to facilitate follow-up and further action. Identification of suspicious areas can be followed by a brush biopsy (OralCDx®). It is always important to note that none of these screening modalities provides a definitive diagnosis - only a punch or incisional biopsy and subsequent histological examination can provide that diagnosis. But these screening tools can help identify lesions that need to be evaluated by biopsy much earlier, and give the patient a chance at a better outcome if the lesion is cancerous.
Practices may choose to utilize these additional screening tools for patients at greater risk for oral cancer, or better yet, for all patients, since 27 percent of oral cancers occur in patients with no apparent risk factors. Key risk factors for oral cancer include: age (40 years or older) alcohol and tobacco use (especially in combination) and exposure to sunlight. As mentioned earlier, a previous diagnosis of oral cancer is an additional risk factor.
As of this writing, some insurance companies are beginning to cover this procedure. The ADA CDT code to use is D0431. But keep in mind that although your patients’ insurance plans may not cover the procedure, that doesn’t mean that the patients shouldn’t be informed of its availability. If the entire team is involved in building awareness of the risks of oral cancer, patients will want to have this very important screening procedure, whether insurance covers the fee or not. It is also important to keep in mind that because one insurance carrier covers the procedure, that doesn’t mean that every plan or employer that is covered by that company will have this as a covered benefit. But your patients can certainly let their employer and the insurance companies know that they believe in the value of this screening, and to consider covering it in future contracts. For some of you who have been in the profession for a while, you probably remember when sealants were not a covered benefit under any insurance plan. Demand from patients and practitioners, along with research supporting the procedure, successfully brought about changes in reimbursement. Remember, though, that it is always risky to operate as an “insurance-driven” practice. The risk is that your patients will believe that non-covered procedures are not necessary and/or valuable. Our job is to inform and educate our patients, which ultimately creates value for the patients for the care that we provide.
Now that we’ve looked at the latest, greatest technology for screening our existing patients, we need to consider the rest of the patients in our communities. I believe that we also have an obligation to make the other 50 percent of patients who don’t see a dental professional regularly aware of their potential risk for oral cancer. Perhaps making patients aware of the risk of oral cancer is a way to entice them into the practice to participate in regular dental care. There are many ways that the entire team can become involved in these efforts.
One very effective method of educating patients is on the practice Web site. Many dental practices already have sections devoted to information about oral cancer and the importance of screening and early detection. If your practice doesn’t have a Web site yet, consider developing one. Newsletters are another great way to communicate with existing patients who come in regularly and patients who have not been in the practice for some time. A well-written newsletter, with an educational component such as information on oral cancer, is something that many patients will share with their family, friends and co-workers. Consider giving presentations to groups in your community on the risks and prevalence of oral cancer. Write articles for your local newspapers and other community publications. Participate in health fairs and other community activities where you can educate the public and distribute information.
The Oral Cancer Foundation (OCF) has many ideas and resources available to assist you in developing an awareness campaign. One very effective tool that the OCF has available are buttons that can be worn by the team, with sayings such as “We look for it” and “Dental exams save lives.” For patients there are buttons that say “I had one.” You can contact the OCF at www.oralcancerfoundation.org. The American Dental Association also has numerous resources available, including fact sheets on oral cancer and a multimedia presentation about the importance of early detection. This information is available at www.ada.org.
The National Institute for Dental and Craniofacial Research (NIDCR) also has numerous educational tools available for dental professionals and patients on oral cancer. One very useful tool is a PowerPoint presentation on detecting oral cancer, which illustrates the complete cancer screening examination. This information is available on the NIDCR Web site at www.nidcr.nih.gov/HealthInformation/
DiseasesAndConditions/OralCancer/DetectingOralCancer. The presentation can be used for training for the team, as well as for presentation to other groups. In addition, your local chapter of the American Cancer Society can also provide information and resources to assist you in educating the public.
This presentation can be utilized to train your team, and can be used for presentation to outside groups.
My hope is that you are sufficiently motivated to ramp up your screening procedures, create greater awareness about oral cancer in your practice and community, and make a difference in someone’s life. It’s easier than you think, especially if the entire team becomes involved. So get started now. Feel good about your potential for saving lives!
Mary Govoni, RDA, RDH is a certified and registered dental assistant and a registered dental hygienist with more than 34 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].