Fall/Winter 2005 Table of Contents
Oral Cancer Detection:
Dentistry at the Crossroads

The dentist thoroughly examines all sides of the tongue and the floor of the mouth.

The dentists looks at and feels the gums, the inside of the cheeks, the roof of the mouth, and the throat and tonsils.

The dentists looks at and feels the outside of the neck, face and lips.

The oral cancer brush biopsy test.

The oral cancer brush biopsy test.
By Roger P. Levin, DDS, MBA, CEO and Founder, The Levin Group

Dentistry has gone through monumental changes in the last 20 years. We have seen the introduction of composite resin, whitening products, osseointegrated implants, lasers, early caries detection devices and a host of other materials and technologies. Without question, the last two decades have been the most innovative in contemporary dentistry.

Oral cancer is one area where a minimal amount of progress has been made despite the introduction of a new early-detection diagnostic method. The mortality rate from oral cancer appears to be similar today to 20 years ago, according to the National Cancer Institute. While some other areas of cancer diagnosis and treatment have led to significant mortality rate improvements, oral cancer has remained stable. About 29,000 Americans will be diagnosed with oral cancer this year, according to the National Cancer Institute. Of those cases, 7,300 are expected to be fatal.

The future of dentistry lies at a crossroads where dentistry, medicine, and pharmacology become significantly more integrated. Even today, we are starting to see the effects of pharmacology on certain dental treatment and the relationship of oral health to systemic disease. Numerous studies today relate periodontitis to cardiovascular disease and other health problems. While this interrelationship among dentistry, medicine, and pharmacology is in its earliest stages, progress has begun and will certainly continue.

Oral Cancer Detection
Until recently, dentists relied on visual observation and scalpel biopsy to detect symptoms of oral cancer. A major problem with this diagnostic method was that detection often occurred after the cancer had spread beyond the earliest stages. Today, dentists have another tool to detect oral cancer — an oral cancer brush biopsy approved by the Federal Drug Administration that allows for the early detection of oral cancer. The earlier oral cancer is detected, the sooner it can be treated with a far better result.

As with any new technique and technology, the question arises how to implement this tool into the practice in a way that the doctor and team feel comfortable and the patient understands the need for treatment.

Challenges for doctors incorporating this technology into their practices include the following:

  1. The oral cancer brush biopsy is not typically covered by dental insurance. Although there is an opportunity for medical insurance reimbursement, most general practices are not participating members with medical insurance. Additionally, learning the administrative protocols of filing medical insurance is different from dealing with dental insurance and can often result in complications.
  2. Unlike a great deal of diagnostic dentistry, the decision to use the brush biopsy test is not always clear. Practices are instructed to use the brush on atypical red and white spots. But questions arise what is an atypical red or white spot? What spots should be tested? It is important at this point to understand that the main goal of testing with the brush biopsy is to "rule out" oral cancer and that the test is not meant to be used only when oral cancer is suspected. Similar to other medical tests, the brush biopsy is also a screening opportunity where most of the results will be negative.
  3. When results were received from the laboratory, they were initially confusing for many general dentists. There were three result categories--positive, atypical and negative. The dental profession was not completely clear as to how to respond to each of the results. Currently, the manufacturer recommends that a positive or atypical result be referred to a specialist for further diagnosis and examination, while a negative result does not need referral and can be checked again in the future. To eliminate confusion, referral recommendations are now sent along with the test results.
Oral Cancer Testing in the Practice
The key to integrating any new product or technology into the practice is a systemized approach. Each dentist should make a decision regarding treatment protocols for brush biopsy testing and then clearly educate the hygiene staff. Once the protocols are in place, patients showing certain signs or symptoms should simply be offered the test. Before implementing a new product or service, dentists need to determine an appropriate fee for the procedure. The brush biopsy requires 2-3 minutes to perform properly. The test is then sent to a laboratory that will directly charge its fees to the patient’s medical insurance. All these factors — time, labor and cost — must be considered when setting an appropriate fee.

Dental practices often experience difficulty receiving reimbursement from medical insurance companies. For this reason, it is strongly recommended that the fee simply be charged to the patient. These fees are not so high that patients cannot afford to pay for the brush biopsy, especially when they understand that the test is designed to rule out oral cancer. Some dentists feel uncomfortable because the majority of the tests come back negative. Remember, the primary focus should be on ruling out oral cancer.

Another challenge is that some dentists are hesitant to talk about oral cancer with patients. These practitioners are concerned that they are scaring patients who probably do not have the condition. One way to handle this is to use the following script:

"Mr. Jones, during your examination, I noticed a small, flat, red spot on your gum. At first glance, it appears to be an inflammatory lesion. Although I believe that you have nothing to worry about, I would like to perform a very quick, painless and simple test that will allow us to assess the cause of the lesion. The test will more than likely be negative but it's better to be sure."

Oral cancer brush biopsy will not become a major financial or productivity factor for practices. What is important is that practices focus on identifying potential precancerous or cancerous conditions as early as possible while maintaining a high level of productivity and customer service. It is also valuable for patients to understand that they will be routinely screened for oral cancer and that there is a new FDA-approved diagnostic test for suspicious spots or lesions.

Oral cancer has been a long-term problem showing very little progress for many years. Dentistry now has the best opportunity to begin making a difference in this area by using all available technologies, including the brush biopsy. By detecting pre-cancerous or cancerous cells as early as possible, dentists not only have the ability to prevent oral cancer from developing, but also the power to save lives.