Screen and Hygiene: A 21st Century Approach to Shining a Light on Oral Cancer

What dental professionals can accomplish by screening for oral cancers is profound. According to the Oral Cancer Foundation, there are over 100,000 dentists in the United States, both specialists and generalists, and each sees between five and 15 patients per day on average; importantly, this number does not include patients who go into the dental office only to see the hygienist.² Likewise, the Centers for Disease Control and Prevention (CDC) report that approximately 60% of the US population sees a dentist every year.³ However, the literature shows that only 15% to 25% of those who visit a dentist regularly report having had an oral cancer screening.² Taken in sum, these statistics represent a tremendous opportunity for dentists and hygienists alike to complete oral cancer screenings on this population each year. Awareness, routine clinical screening processes, and an understanding of technologically advanced, yet cost-efficient diagnostic tools will undoubtedly increase the percentage of dental patients who receive screenings.

The goal of oral cancer screening is twofold:
1. Education on the risk factors;
2. Identifying pathologies early, greatly increasing the chance for a cure.⁴

The first goal is educating patients on the risk factors and why they need to come back for regular screenings. A systematic approach to reviewing medical history and risk factors with the patient is essential. Individuals with risk factors such as tobacco use, alcohol use, previous oral cancer or pathology diagnosis, HPV16 virus, history of sun exposures, and other concerns need to be educated on oral cancer risk reduction. The dentist and hygienist can participate in screening for risk factors. In turn, the patient can modify habits, such as smoking, after education. The Oral Cancer Foundation states that historically 75% of oral, head, and neck cancers are related to tobacco and alcohol use. Also, as HPV positive disease becomes more prevalent, younger men and women in their 20s and 30s have an increased incidence of oral cancers.⁵ By sitting down with patients and reviewing their medical history in depth, practitioners can determine if they require further education on habit or health modification.

The second goal of oral cancer screening is detection at an early stage at which lesions may be precancerous. This is when the visual examination and use of diagnostic tools are appropriate. At this point, the lesions are easier to remove, and there is a higher chance of a full recovery.

The dentist and hygienist are a team in the detection and diagnosis of oral cancer. The registered dental hygienist (RDH) is qualified to complete oral cancer screenings and bring areas that appear abnormal to the attention of the dentist for further examination and diagnostic procedures. Many patients see the hygienist on a more regular basis than the dentist, which makes it vital that the RDH conduct oral cancer screenings. The ADA Current Dental Terminology (CDT) code D0120 for “periodic oral examination” includes “an oral cancer evaluation…where indicated.” In addition, the CDT code D0150 for “comprehensive oral examination” also includes “an evaluation for oral cancer where indicated.”⁶ The National Institute for Dental and Craniofacial Research (NIDCR) provides visual/tactile examination procedures in poster form to ensure dental providers follow a consistent screening process.⁷ The oral cancer screening should be completed as a routine part of every periodic exam and can be easily incorporated into a hygienist’s routine.

Several tools have emerged as robust detection technologies that can be used in addition to the visual/tactile screening. The VELscope® (LED Dental, leddental.com) is a frequently used tool which incorporates fluorescence visualization to detect oral disease. The VELscope’s blue light excites natural “fluorophores” in mucosal tissues, and its proprietary filter helps enhance the contrast between healthy and abnormal tissue.⁸ In addition, it is non-invasive, with no unpleasant rinses or stains required.⁹ It is important to note that not all the tissue changes discovered will be cancer; however, often times the adjunctive technologies are helpful in the detection of abnormal pathologies as a whole.

OralID™ (Forward Science, forwardscience.com) is a fluorescence oral screening device that advertises no per-patient costs.⁹ OralID’s fluorescence technology uses a blue light, and when the light shines on healthy tissue, it fluoresces green. When it shines on abnormal tissue, the light appears dark, signifying a lack of fluorescence. The operatory room light needs to be turned off to perform the screening; complete darkness is not required as the OralID light intensity is sufficient.¹⁰

Identafi® (DentalEZ, dentalez.com) uses three wavelengths of light, revealing mucosal abnormalities.⁹ White light is used to illuminate the tissue for conventional/visual examination. Violet light enhances fluorescence of healthy tissue; tissue with loss of fluorescence could signify tissue abnormality. Green-amber light is a narrow band reflectance that helps a provider differentiate between abnormal and normal vasculature.¹¹ It is recommended to turn off the room light to maximize visualization.

The DOE SE Oral Exam System (Dentlight, dentlight.com) uses patent-pending LED Beam technology and a high-contrast fluorescence viewer that enables both intra and extra oral access to improve detection.⁹ DOE promotes long-range illuminations to the back of the throat, and its small size improves access to the back of the throat for detection. Furthermore, the system suppresses ambient light, so the room light does not need to be turned off.¹²

These are only a sample of the tools available for oral cancer screening in the dental office. Each has its individual benefits, and choosing a tool ultimately comes down to personal preference. Insurance code D0431 “adjunctive exams” was approved by the ADA in 2005 and can be used for oral cancer detection tools. Not all insurances accept/reimburse for the advanced screening techniques, but even so, on average, these exams cost patients an additional $35 annually.¹³ Early cancer detection would be worth that amount to many patients.

A common question that arises is when the hygienist or dentist should choose to use an advanced screening tool. Although the decision is the provider’s, a common rule of thumb is to consider using the screening tools if risk factors are present such as tobacco and alcohol use, HPV, age over 40 years, frequent sun exposure, and/or poor diet.⁷ Another technique is to use advanced screening tools at every other periodic exam if the patient exhibits normal risk factors and is visiting the practice every 6 months.

If abnormal tissue is detected during an exam, biopsy including excision and incisional techniques along with exfoliative cytology and cell staining with toluidine blue can be performed. Most of the time, if there is suspicion of oral cancer by the dentist or hygienist, proper referral should be initiated to the oral surgeon for care.

In a recent case, a hygienist was performing scaling and root planing for a new female patient in a Texas clinic and noticed the tissue under her tongue looked irregular. After evaluation with the VELscope and a biopsy, the oral surgeon determined the patient had Stage 1 oral cancer. She has since had three surgeries to remove this lesion. Because of the hygienist’s diligent approach, the team’s excellence in screening, the use of technology, and proper referral, the patient’s life was saved by the frontline defenders in the dental office.

As oral healthcare providers, the dental team is the best chance patients have for detecting oral cancer early enough for a full recovery. A team-based approach of analyzing health history, visual/tactile exams augmented by screening tools, and referral to the appropriate specialist can lead to the greatest opportunity to achieve optimal outcomes for patients.

Cynthia Blendermann Perone, DDS
Private Practice
Coral Springs Modern Dentistry
Coral Springs, Florida