First Impressions Magazine

Doctors of the mouth
Distributor reps play key role in advocating oral cancer screening among dentists.
by Laura Thill

Over 34,000 Americans are diagnosed with oral or pharyngeal cancer each year, and only half are expected to live beyond five years, according to the Oral Cancer Foundation (Newport Beach, Calif.). That’s not because oral cancer is difficult to detect, but because it often is discovered late in its development. If more dentists performed regular oral cancer screenings on their patients, these figures could greatly improve, experts believe. "In 1948, cervical cancer was the biggest killer among women," says Brian Hill, executive director, Oral Cancer Foundation. "Then, in 1958, there was a 20 percent drop. What happened? Women began getting regular check-ups by their OB/GYNs. The same thing can happen in the dental industry if dentists begin providing regular screenings for oral cancer.

"Dentists have been behind the curve and need to be educated," he continues. "Dental distributor reps should recognize this opportunity." Indeed, 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.

"Dentists need to be doctors of the mouth," says Hill. As more patients become aware of the availability of oral cancer screening, they will begin to discriminate between those dentists who do – and don’t – provide screening. "If a dentist does not screen, [his or her] patients should find a new one," he adds. "Dentists who don’t screen for oral cancer will [no longer] get referrals.

"In the past, dentists have not screened their patients for oral cancer because they haven’t always known what to look for, and insurance companies [don’t always] cover this," he continues. "But, it is quite easy to detect abnormal-looking tissue and refer a patient to an oral surgeon for follow-up."

The signs of oral cancer
Historically, the majority of people diagnosed with oral cancer were 40 years and older, according to the Oral Cancer Foundation. But, that’s changing. The use of products such as chewing tobacco can lead to oral cancer at any age. Also, recent research has linked the human papilloma virus, particularly version 16 (HPV16) – 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 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:

Sore, irritation, lumps or thick patch in the mouth, on the lips or in the throat.
Red or white spots or a patch in the mouth. (Only 20 percent of white spots become malignant. 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, without hearing loss.

"Cells in the mouth are replaced every 14 days," says Hill. So, if a patient has abnormal tissue or symptoms after that period, the dentist should refer [him or her] to an oral surgeon."

Detecting oral cancer
Oral cancer screening is not a new concept, according to John Pohl, president, 14th Floor Solutions (Lake Forest, Ill.), a marketing agency for the VELscope® screening system (LED Dental Inc., White Rock, British Columbia). "Oral cancer screening goes back decades," he says. "Dentists are supposed to provide an oral cancer screening for each patient using the naked eye and palpitation (touch)." Often referred to as the "white light" exam, the dentist relies on the overhead white or incandescent light in his or her office, and moves the patient’s tongue from side to side, feeling and looking for signs of cancer. "The white light exam can be effective, but most dentists don’t [perform one]," he adds.

In the last several years, manufacturers have produced adjunctive screening systems designed to supplement white light oral cancer screening. Two such products are the VELscope system and ViziLite Plus (Zila Pharmaceuticals Inc.). Both systems, while very different, offer dentists greater assurance of catching early signs of oral cancer. The ViziLite Plus is comprised of a chemiluminescent light source to improve the identification of lesions, and a blue phenothiazine dyento (TBlue 630) to mark the identified lesions. The patient rinses with a dilute acetic acid solution, which reportedly makes abnormal squamous epithelium tissue appear acetowhite when viewed under the ViziLite low-energy wavelength light. Normal epithelium (surface) tissue absorbs the light and appears dark.

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 fluorescent pattern of surrounding healthy tissue.

Oral cancer begins as a pre-cancerous dysplasia, notes Pohl. 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. Sometimes abnormal-looking tissue turns out to be nothing more than a sore caused by a bite or burn on the inside of the mouth, Pohl points out. "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," he says. Some dentists prefer to do their own biopsies, he adds.

There are two types of biopsies, notes Pohl. A surgical biopsy, performed by an oral surgeon, involves the removal of several layers of tissue from a small area inside the patient’s mouth. To ensure he or she removes the right area of tissue, the oral surgeon includes a 10-millimeter-wide safety margin around the abnormal tissue, says Pohl. The tissue sample is sent to an oral pathologist for analysis. However, a device such as the VELscope can help the surgeon see and remove abnormal-looking tissue, he adds, noting that the device is FDA-cleared not only for use by dentists but by oral surgeons, ENTs and other physicians.

Sometimes, dentists perform an in-office biopsy, called a brush biopsy, in which they use a specially designed brush to scrape out a tissue sample. The sample is then sent to a lab for analysis. LED Dental has teamed with a company called OralCDx Laboratories (Suffern, N.Y.), which provides the OralCDx® brush biopsy said to complement the VELscope system, according to Pohl. Dentists who use the OralCDx brush biopsy can send their tissue samples to OralCDx Laboratories for analysis. "The lab tells the dentist whether the tissue sample is normal or abnormal," he says. "If it is abnormal, the patient must see the oral surgeon for a surgical biopsy. The OralCDx is an interim step that can save the patient time and money if [he or she] doesn’t need a surgical biopsy. So, VELscope is the detection device, a surgical biopsy is a diagnostic procedure, and a brush biopsy is an interim step that tells the dentist whether the surgical biopsy is necessary."

How to sell it
"Distributor reps are looking to [make a sale], of course, but they also want to do what’s best for the dentist," says Pohl. "Every dentist in America should be screening for oral cancer. Two-thirds of the time, oral cancer is not discovered until it is in a late stage. But, if dentists can detect it early, the survival rate is 80 to 90 percent. The distributor rep needs to convey this to [his or her] dental customers." They can do so by asking several probing questions, including the following, he adds:

"Doctor, have you heard about adjunctive screening devices for oral cancer available today?"
"Did you know that these devices can help save your patients’ lives, as well as generate revenue for your practice?"
Did you know that the test adds only a few minutes to the patient exam? Patients will appreciate that it is noninvasive."

The VELscope unit costs about $5,000, notes Pohl. It includes a couple of disposable pieces (a plastic sheath and cap that cover the handpiece), which cost $2.50 each. Dentists who screen for oral cancer generally charge about $35 per screening, he points out. "Between 150 and 200 screenings should pay for the device." The ADA CDT code is D0431, and about 30 percent of insurance companies presently reimburse for VELscope screenings, he adds. "The market share is still low for VELscope. We have about 1,500 units in use across the United States. That leaves a lot of untapped market for distributor reps to cover."