By Kristine A. Hodsdon, RDH, BS
There have been days in clinical practice when I have felt tired and found myself just going through the motions, truly yearning for a non-fat latte vs. seating my 4 p.m. patient. Then, being a New England Patriots fan, I’d remember that we Pats fans have clearly changed the saying of, “It’s not over until the fat lady sings,” to “It’s not over until Vinatieri kicks.”
For all non-football fanatics who may be scratching their heads wondering what I’m talking about, let me explain. On December 29, 2002, kicker Adam Vinatieri made a field goal in the final seconds of the game that helped the New England Patriots defeat the Miami Dolphins 27-24. Vinatieri’s leg has provided the winning margin in New England’s three Super Bowl victories, including game-winning, last-second kicks in the 2002 and 2004 Super Bowls. Sports fans know that winning is often a result of persistence and not giving up even when against all odds. As practitioners, we can learn from the sports world when implementing new services such as oral cancer protocols and adjunctive technologies.
Pep talks and being prepared
Winning athletes know that success is not solely based on raw talent. Champions stay focused and are prepared. When putting oral cancer protocols and adjunctive technologies into practice, we need to keep our heads in the patient education game and have the foundational knowledge to communicate effortlessly to our patients.
The following is a lifesaving “game plan” for your winning team:
- Communicate to your patients that you will be performing an oral cancer assessment and why. Most adult patients are familiar with the current diagnostic protocols for breast, prostate, and cervical cancer. Use these examinations as a starting point in your patient education. When utilizing adjunctive technologies, remember to link the matching medical technologies - i.e., mammogram, PSA tests, and Pap smear - and how they correlate with the advances in dentistry.
- It is important to have annual cancer examinations. Discuss the warning signs of oral cancer and the hazards associated with tobacco and alcohol use. Let them know that if a sore or lesion appears in or around the mouth/lips, they should call your office FIRST!
- Reassure the patient that this starts out “kind of like a facial massage.” Next, revisit your clinical skills needed for a basic extra oral and intraoral assessment. It includes eyes, ears, and tactile sense:
- Using your eyes and looking for abnormal deviations.
- Using your ears, and questioning the patient concerning “tobacco use.” Listen and discover what types (cigarettes, chew, snuff, cigars, etc.), how long, how often, and if he or she has tried to quit. This will give you additional information that will help you determine the patient’s risk level and his or her willingness to begin or not begin a cessation program.
- Using your fingers, tactile sense, and palpate for anything that feels abnormal.
- Armamentarium. Conventional supplies for an oral soft-tissue examination have changed little over recent years. They include 2x2 gauzes, mouth mirror, tongue blades, incandescent patient light, magnification, air/water syringe, periodontal probe or millimeter rule, and a camera to photograph any deviation. Yet, similar to the expectations in the medical protocols, patients deserve the advance technologies that augment a manual exam.
Adjunctive technologies
The primary goal of adjunctive technologies is to accelerate a diagnosis by identifying lesions that may have previously gone undetected by conventional means. If pathology is undetected and treatment is delayed, it can increase the likelihood of “game over” for the patient. Just as sports officials use instant replay to make sure they have made the correct call, the use of adjunctive technologies enhances the win-win scenario for the practitioner and patient.
ViziLite® Plus - vizilite.com/index.asp - ViziLite Plus combines the oral screening technology of ViziLite, an advanced biophotonic light technology, with TBlue630, a marking system using Zila® Tolonium Chloride (ZTCTM), the only patented pharmaceutical-grade form of toluidine blue used in marking lesions identified during a ViziLite examination. Vizilite, manufactured by Zila Pharmaceuticals, is the only FDA-cleared adjunctive oral screening technology available to dental professionals.
In regard to the before-mentioned medical models, the FDA cleared ViziLite as an adjunctive screening tool for use in the oral cavity, based on clinical data pertaining to the use of chemilluminescence, the ViziLite technology, in the cervical cavity. This is because the squamous epithelium in the oral cavity is virtually identical to that of the cervix. Gynecologists have used chemiluminescence since 1995 as an adjunct to the Pap smear; this procedure is known as speculoscopy. The technology behind ViziLite has been evaluated in 13,000 patients and four FDA studies. Trials have been conducted with ViziLite Plus and Zila Tolonium Chloride in the oral cavity at NYU, Chicago Cancer Center, Vancouver, and UCSF. The ADA used the clinical data from all of the studies of the ViziLite technology to assign a CDT-5 code, D0431, for the procedure “adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including pre-malignant lesions, not to include cytology or biopsy.”
Vizilite produces a diffuse chemiluminescent blue/white light with an average wavelength of approximately 490-510 nanometers. The wavelengths emitted are absorbed by normal cells and reflected by abnormal cells, due to their higher nuclear/cytoplasmic ratio. As a result, atypical or dysplastic mucosal lesions containing a white component will appear “acetowhite.”
Lesions appear brighter, sharper, and the margins more distinctive. If ViziLite reveals an abnormality, TBlue630 may be used to mark suspicious lesions for further evaluation. Annual ViziLite Plus examinations, following the conventional head and neck examination, are recommended for all adult patients.
Microlux DL - www.addent.com/whatsnew.html - The Microlux DL can also be used in conjunction with a traditional visual and tactile examination. This product is a battery-operated LED light and its principal indication is as a transilluminator. Its FDA indication for examination of the oral cavity is, “following a conventional exam, this device is used as an aid to improve the visualization of oral lesions.” It illuminates the oral cavity like a flashlight would. After rinsing with the DL solution, irregular cells will take on a whitish hue, which will contrast with the surrounding tissues, making it more obvious to the examiner. To my knowledge, there are no publicly available studies regarding sensitivity of this device as an adjunctive screening technology in patients at increased risk for oral cancer.
VELscope™ Oral Cancer Screening Device - www.velscope.com - This portable handheld device will soon be introduced into the marketplace. Its indication is enhanced clinical visualization that will assist practitioners with defining the borders of a lesion in the mouth. The technology uses blue fluorescence that penetrates into the tissue. The research and clinicals have initiated at the BC Cancer Agency (Vancouver, B.C.) and developing partnerships with the British Columbia Oral Cancer Prevention Program (BCOCPP) and a series of grants from the U.S. National Institutes of Health (NIH), specifically the National Institute of Dental Craniofacial Research.
Oral CDx - Oral CDx is a system that combines a painless oral brush biopsy, which is taken in the dental office, with advanced computer analysis. The Oral CDx oral brush biopsy test was developed precisely to evaluate benign-appearing oral spots. Oral CDx oral brush biopsy has been evaluated in a multicenter clinical trial that involved 35 U.S. academic dental sites. The findings were published in the Journal of the American Dental Association (JADA) in October 1999. The test has also been reviewed by the Council on Scientific Affairs of the American Dental Association and has the Seal of Acceptance.
Post-game wrap-up
For clinicians incorporating new standards for health in their dental practices, persistence and confidence in your abilities are the skills needed to get points on the scoreboard. We may never don a Super Bowl ring or display the Stanley Cup in our operatories, however, winning the big game in dentistry is knowing that your MVPs (Most Valuable Patients) have healthy, disease-free smiles.
Kristine A. Hodsdon RDH, BS, is the director of RDH eVillage, an online newsletter from PennWell, the parent company of DE&M. She is a hygiene consultant who frequently contributes to dental and dental hygiene publications. Kristine has presented more than 200 lectures both nationally and internationally and can be reached at [email protected].
