First Impressions Magazine

First Line of Defense
In spite of growing awareness of oral cancer, some still fear the screening rate is low
By Laura Thill

Your customers can’t treat what they don’t see. Indeed, the first step in detecting oral cancer is a thorough visual checkup, according to experts. "Unless dentists pull the patient’s tongue forward and use their fingers to palpate the neck and inside of the mouth, [they’re not providing] a thorough screening," says Brian Hill, executive director, Oral Cancer Foundation (Newport Beach, Calif.).

Over 34,000 Americans are diagnosed with oral or pharyngeal cancer each year, and only half are expected to live beyond five years, largely because it often is discovered late in its development, according to the Oral Cancer Foundation. Dentists need to be custodians of the mouth, says Hill. And, now more than ever, distributor reps should be informing their customers of the prevalence of oral cancer and the tools available to screen their patients.

In spite of the growing awareness of oral cancer among dentists and their patients, Hill says that data from the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) suggest that in two-thirds of the cases, oral cancer is not discovered until it has progressed to stage 3 or 4. "If more dentists and doctors were screening their patients for oral cancer, we would be discovering the disease as early as stage 1 or 2, and that’s just not happening," he says. "The Foundation’s feeling is that only about 25 percent of dentists are really involved in opportunistic screening of their patients. And, dentists should screen 100 percent of their patient population that is old enough to be engaged in sexual activity."

However, dentists who do play a role in oral cancer screening take it very seriously. "We give our patients a thorough oral screening in the office twice a year," says Brent Agran, DDS, a dentist at a Chicago area-based practice. For Agran, a typical dental checkup includes examining the patient’s head and neck/lymph nodes, tongue, oral cavity, palate and the back of the throat, he explains. "As dentists, we try to detect cancer early. The earlier we can catch it, the bigger a difference we can make in someone’s life." And, while he believes more dentists are adhering to screening protocols, he thinks sales reps can help by addressing the importance to their dental customers.

The signs of oral cancer
The risk of oral cancer has been associated with the use of products such as chewing tobacco. Also, recent research has linked the human papillomavirus, particularly versions 16 and 18 (HPV16 and HPV18) – a common sexually transmitted virus – to oral cancer as well, especially in the back of the mouth. Although oral cancer tends to affect more men than women, and more African-Americans than Caucasians, researchers believe this is due to differences in lifestyle rather than gender or race.

Oral cancer begins as a pre-cancerous dysplasia. There are three stages of dysplasia: mild, moderate and severe. By detecting abnormal tissue in the mild dysplasia stage, the dentist has a good chance of preventing it from developing into cancer.

Oral cancer often is painless in its early stages, with few or subtle signs of physical change. However, knowledgeable dentists usually can see and feel precursor tissue changes. As a rule, they should advise patients to come in for screening when certain conditions, such as the following, persist longer than two weeks:

Sores, irritations, lumps or thick patches in the mouth, on the lips or in the throat.
Red or white spots or a patch in the mouth. (Only 25 percent of white spots progress to dysplasia. Red spots are generally more dangerous.)
A feeling that something is caught in the throat.
Difficulty chewing or swallowing.
Difficulty moving the jaw or tongue.
Numbness on the tongue or in other areas of the mouth.
Swelling of the jaw, causing dentures to fit poorly or become uncomfortable.
Pain in one ear that persists without hearing loss.

"Cells in the mouth are replaced very rapidly through the normal process of programmed cell death and replacement, known as apoptosis," says Hill. So, if a patient has persistent abnormal tissue or symptoms, the dentist should refer [him or her] to an oral surgeon for a second opinion and a biopsy if warranted."

Adjunct devices
In addition to visual screenings, adjunct technologies, such as autofluorescence devices, are available to dentists to help them do their job, says Hill. While he supports the use of these tools, he emphasizes that a dentist must first perform a conventional visual and tactile exam in order to know what he or she is looking for. "Using an adjunctive screening device is a good add-on to help in the discovery process and to avoid missing anything," he points out. "These technologies are not necessarily specific to a particular disease. But, they help find cells that are damaged. The dentist must then determine through referral and biopsy whether these cells are damaged due to cancer."

One such device, the VELscope system, is based on the direct visualization of tissue fluorescence and the change in fluorescence, which occurs when abnormalities are present. The system emits a blue light into the oral cavity, which stimulates tissue, from the epithelium layer to the lower basement membrane and into the stroma. This causes all three layers to fluoresce, enabling the dentist to differentiate between normal and abnormal tissue.

By looking through the VELscope handpiece and its filter system, the dentist sees layers of tissue awash in a shade of candy apple green. Abnormal tissue appears dark and irregular, and contrasts with the green fluorescence pattern of surrounding healthy tissue. "That doesn’t necessarily mean the tissue is cancerous," says John Pohl, president, 14th Floor Solutions (Lake Forest, Ill.), a marketing agency for the VELscope® screening system (LED Dental Inc., White Rock, British Columbia). "It could be damaged from a burn or a bite. Or, a bilateral congenital condition (e.g., the exact same formation on both sides of the mouth), likely has been present since birth and does not suggest cancer. But, if an abnormal looking spot in the oral cavity has not improved within two or three weeks, the dentist should refer the patient to an oral surgeon for a biopsy," Pohl says.

While autofluorescence devices, such as the VELscope, may provide dentists with additional information, permitting them to make the best clinical decision, the first step in an oral screening exam is a visual exam by the hygienist or dentist, says Pohl. "Typically, the hygienist does the oral exam and points out any issues to the dentist who can check further. Then, the next step is to use the VELscope.

"Dentists tell us that about 5 percent of their patients who have had the VELscope exam show something [suspicious] and are asked to return," he continues. "Of those patients who return, only 5 percent (or 0.25 percent of the total) later require a biopsy. In other words, for every 800 patients, about 40 will have to return [for a follow-up screening], and about two of those will require a biopsy. The dentist finds something in a very small percentage of patients, but [he or she] catches it early on."

While some dentists may object to the cost of purchasing a VELscope (just under $5,000 for the device and another $2 per patient exam for consumables), sales reps should remind their customers that the exam provides additional patient care while generating revenue for the practice. "Most insurance companies still don’t cover the exam with a VELscope," says Pohl. "Still, most dentists only charge the patient about $30 or $35." So, it’s added peace-of-mind at a minimal cost for the patient, he points out. "And, if the dentist performs 800 exams each year, [he or she] makes $24,000." In 2 ½ months, the dentist can pay for the device, which typically lasts about five or six years, he adds. And, while some practices may opt to carry two or three units, many have one, which they park in a central location.

"Sales reps should let their dental customers know they have a device that is easy to incorporate into their practice and can help them with the oral cancer screening process," Pohl continues. Reps should tell their customers the VELscope exam is completely non-invasive, doesn’t require a bad-tasting rinse and provides immediate results, he notes. "Dentists won’t need to call their patients back for a follow-up exam. Also, it enhances the image of the practice to carry [advanced] technology."

Pohl adds that the VELscope is backed by in-depth clinical research, which reps should provide for their customers. "Autofluorescence technology has been around for decades," he says. "VELscope was just the first to apply it to the oral cavity."

The role of HPV testing
For some dentists, the more information they can offer their patients, the more satisfied they are that they are providing the best possible care. It follows, then, that more dentists are conducting Human papillomavirus (HPV) testing at their practices. HPV is one of the most common virus groups affecting the skin and mucosal areas of the body, according to experts. While over 120 different types of HPV have been identified, HPV16, HPV18 as well as additional genotypes have been linked to oral cancer.

These HPV viruses tend to manifest themselves in posterior regions of the oral cavity, such as the base of the tongue, the oropharynx or back of the throat, the tonsils and the tonsillar pillars. HPV-positive tumors reportedly occur in non-smokers and are more frequently discovered in younger populations than tobacco-related malignancies. In spite of this, about 98 percent of people in the United States have never visited an otolayrngologist, says Robert Walker, vice president and general manager of OralDNA® Labs (Brentwood, Tenn.).

OralDNA Labs, a clinical lab-testing manufacturer, offers the OraRisk (sm) HPV Test, which is distributed through Henry Schein Dental. The non-invasive screening tool is designed to identify oral HPV viruses, enabling the dentist to determine which patients are at higher risk for oral cancer and refer them for appropriate follow-up evaluation by an oral pathologist. As with autofluorescence testing, oral HPV testing is an adjunct screening to accompany a thorough visual exam.

Candidates for HPV testing include patients who are:

Sexually active.
Have a family history of oral cancer.
Have signs or symptoms of oral cancer.
Demonstrate traditional risk factors for oral cancer.
Have suspicious oral lesions.

OralDNA Labs provides dentists with a patient questionnaire to address the above issues. "We find that patients are asking for the test," says Walker. "It’s the dentists and hygienists (both of whom can administer the test) who we must educate.

"Just because patients are oral HPV-positive, doesn’t mean they will develop oral cancer," he continues. By educating them, dentists can put them at ease that they are healthy, he notes. "A positive test result tells us we need to be more diligent about checkups and follow-ups in order to catch something early on. This is another step toward blending dental and medical care." Patients testing positive who have no other signs or symptoms of oral cancer may be retested one year later to see if their immune system has rid the body of the HPV viruses.

The cost of the OraRisk HPV to the dentist is $70 per test, although on average dentists charge patients between $85 and $90 for the exam, according to Walker. A mid-size practice likely will use between 24 and 36 tests in a year. The test is reimbursable, but because it is new, OralDNA Lab is unsure how many insurance companies will recognize the test. "In the future, we expect to see reimbursement 65 percent of the time or more," says Walker. "I think the dental community has come a long way in terms of understanding oral cancer and the role dentists can play," he points out, adding that dentists who do not provide good screening programs will not be as competitive as those who do.

Getting past the reservations
Given how simple it is for dentists to perform a visual oral cancer screening or follow up with an adjunctive screening device or test, why do some lag behind when it comes to providing this service to their patients? "Some dentists are concerned that screening for oral cancer (and possibly detecting a positive sign) will increase their practice liability," says Pohl. "They are worried that if they miss a diagnosis of oral cancer, they will be sued."

However, dentists are not expected to diagnose oral cancer, says Hill. "We don’t expect dentists to be diagnosticians. We only expect them to discover abnormal tissue. We want them to provide the first line of defense and find things that may be suspicious. From hygienists to dentists to oral surgeons to pathologists, suspect tissue can be detected early, offering the patient the best possible opportunity for a life-saving diagnosis."

"The only person who can say [a finding] is oral cancer is the pathologist who is looking at cells under a microscope," says Hill. "We are just looking to dentists to do their part. If everyone does their part, patients won’t fall through the cracks [so easily]." Sales reps can help by convincing their dental customers of the importance of oral cancer screening, he adds.