November/December 2011, Volume 32, Issue 4
Published by AEGIS Communications
Enhanced Screening Technologies: Vital Tools for Oral Healthcare
One of the most important functions of dental care is a thorough assessment and evaluation of patients’ oral and related systemic health. Many patients feel that that the primary purpose of a preventive dental/hygiene appointment is to prevent decay, check for “cavities and gum disease,” and maintain a beautiful smile. Unfortunately, they are misunderstanding the true benefit of a thorough oral health examination and comprehensive dental care, as well as the value it brings to overall health and wellness. As oral healthcare moves into the medical model of prevention and healing, the role and focus of the dentist becomes more of a diagnostician versus that of a procedure-based clinical technician.
As a diagnostician, the proper incorporation and utilization of appropriate enhanced screening technologies is essential in obtaining improved outcomes. As patients’ systemic and dental health management is becoming increasingly more complex, with an increased number of medications, the need to use advanced technologies to assist in the diagnostic process has never been greater. Today these diagnostic technologies range from computerized databases, to multi-spectrum visualization tools, to DNA, cellular, and tissue collection techniques.
However, it is imperative that clinicians remember that all of these technologies are adjunctive screening devices that are used to complement a comprehensive review of the patient’s health and pharmacological status, along with a thorough visual and tactile examination. The role of adjunctive screening technologies is to provide additional information to supplement the information obtained during the routine evaluation process. No single device can deliver 100% accuracy or effectiveness in detecting any or all conditions. Detection and diagnosis is accomplished with the accumulation of data from multiple sources and modalities. The real goal of the enhanced examination is to confirm health and to discover any abnormality, no matter what it may be, as early in the disease process as possible.
The diagnostic process involves three distinct steps that often get blurred together, especially when evaluating diagnostic devices. The first step in the process is screening and detection, the objective of which is determining if any abnormal process or disease condition is present. The second step is the assessment of the condition, which is to characterize the situation. One of the primary goals of the assessment process is to determine what other screening and examination techniques should be performed. The third step is diagnosis—compiling all the information available from multiple sources and assessment techniques to arrive at a consensus decision regarding the abnormality. This is referred to as the working or provisional diagnosis.
The foundation of all healthcare is knowledge of the patient health history and present status. Being able to accurately obtain, evaluate, and share this knowledge is crucial in the diagnostic process. A multitude of situations and medications have a major impact on the health of the oral cavity. Hundreds of medications are known to have a xerostomic effect.1 Others cause gingival inflammation or affect coagulation and healing responses, and still others affect the balance of the flora of the oral cavity.
Dental Practice Management Systems
There are now dental practice management systems, such as ICE Dental Systems (www.icehealthsystems.com), that are recognizing the importance of the patient’s overall health status and are making it the foundation of patient care and management. These systems are integrating Internet knowledge-based platforms, such as Lexi-Comp OnlineTM (Lexi-Comp, Inc., www.lexi.com), that assess clinical and medication information with user-friendly interfaces. These systems help practitioners to simplify the identification, recording, and interactions of prescribed and over-the-counter medications and treatments that their patients are using. With more than 400 drug formulary changes weekly,1 it is virtually impossible for a clinician to stay current without computerized assistance.
This collection of interactive databases and reference manuals is continually updated as the FDA and drug manufacturers announce changes to their drug information and systemic conditions with a specialized focus on their relationship to dentistry. These programs assist clinicians with faster and safer point-of-care decisions, enabling better diagnosis and case management. Decision support software can alert the practitioner to the potential effects the patient’s medications and treatments may have on the oral cavity. It can also guide clinicians regarding what dental treatments and pharmacology may be the most appropriate for the patient’s care by considering their interaction with the patient’s other health circumstances and concerns.
These databases are designed to allow dental professionals to access critical information quickly and simply. They include information on drug interactions that influence oral conditions, and are oriented to dental-specific applications to help ensure that correct diagnosis and appropriate care is rendered for each patient. Once a clinical working diagnosis has been attained, suggestions are provided for possible treatment and management.
Salivary diagnostics has become a reality, and it is being used in dental offices today. Patients simply rinse with specialized solutions and expectorate into a funneled collection tube, which is processed and analyzed at the laboratory. The collected saliva can be evaluated at the laboratory for its status and susceptibility to both oral and systemic conditions. OralDNA® Labs Inc. (www.oraldna.com) has developed a salivary test called MyPerioID® PST® to identify the patients’ genetic susceptibility and inherent risk to periodontal disease by evaluating their interleukin-1 (IL-1) gene cluster. The test enables the clinician to establish which patients are at increased risk for more severe periodontal infections due to an exaggerated immune response. This lab has another salivary test, MyPerioPath®, that identifies the type and concentration of 13 pathogenic bacteria that are known to cause periodontal disease, and also assists in the diagnosis and management of the condition.
Studies have identified several high-risk strains of human papilloma virus (HPV), especially the variants HPV-16 and -18, as potential etiologic agents in the development of squamous cell carcinoma of the head and neck (SCCHN).2,3 The OraRisk® HPV test by OralDNA Labs is another noninvasive, salivary screening tool to help identify patients that might be at increased risk for this type of cancer. It also assists in developing the appropriate referral and surveillance recommendations.
Any modality that improves the ability to achieve early detection of soft-tissue abnormalities, especially those that are neoplastic in nature, is an invaluable asset to a clinician’s diagnostic armamentarium. Visual enhancement devices can be used in combination with a conventional visual oral mucosal examination to improve the evaluation, identification, and monitoring of oral mucosa and abnormalities. Imaging modalities available include the use of reflectance and fluorescence technology to evaluate tissue under various illumination (lighting) conditions. Fluorescence technology, in particular, enables the visualization of the chemical and morphology variations of the tissues and substances within the oral cavity. This visualization, which can be either direct (viewed directly by the eye) or indirect (viewed on a monitor or screen), gives the clinician additional information to aid in the assessment of the status and health of the oral cavity.
Fluorescence can aid in the evaluation of both the hard- and soft-tissue structures, as well as the biological activity of the flora and other microbial activity. Fluorescent technologies do not require the use of mouth rinses or stains; the process simply repeats the visual exam with the aid of the device(s). Fluorescent technologies can be used both in the role of a field of view screening technology to assess a wide area or region, and as a site-specific technology to closely evaluate a smaller area when an irregularity has been detected.
Examples of caries detection devices that function by using light energy that is free from ultraviolet or ionizing radiation include DIAGNOdent® (KaVo Dental, www.kavo.com), Spectra™Caries Detection Aid (Air Techniques, Inc., www.airtechniques.com), and the SOPRO Light Induced Fluorescence Evaluator or SOPROLIFE® (Acteon Group, www.acteongroup.com). They use visible light fluorescence technology to differentiate between healthy tooth structures and areas of carious activity. These noninvasive fluorescence technologies function by emitting light energy that is absorbed into metabolites of cariogenic bacteria and material called porphyrins.
The battery handheld VELscope® VxTM (LED-Dental Inc., www.velscope.com) enables clinicians to visually scan the entire oral cavity, looking for changes in the fluorescence pattern of tissue, which may indicate an area of concern. This area can then be more closely evaluated to determine an appropriate course of action. A unique feature of this device is the ability to attach an inexpensive camera system to easily photo-document any area that has been detected. These images can assist in the monitoring, referral, and educational process, as well as in attaining improved care, management, and outcomes.
The DentLight Oral Exam System (Dent-Light, Inc., www.dentlight.com) uses a battery handheld light source to stimulate a fluorescence response that is emitted from the tissue. The clinician views the tissue that is being stimulated with this specialized light through specific filters that are attached to the magnification optics of their loupes. If an area of concern is detected, the area can be photographed with a standard handheld digital camera with the supplied filter that can be attached to a lens filter adapter.
The Identafi® (DentalEZ® Group, www.dentalez.com) uses a multi-spectral fluorescence and reflectance technology to enhance visualization of mucosal abnormalities. The small, cordless, handheld device uses a three-wavelength optical illumination and visualization system that allows dental professionals to identify oral mucosal abnormalities. A disposable mirror attachment also assists in visualizing the area in an indirect manner.
ViziLite® Plus with TBlue® (Zila, Inc., a Tolmar Company, www.zila.com) is a disposable handheld device that produces a diffuse light created by a chemiluminescent light stick that is also used as a tissue retraction device. After the conventional visual and tactile exam, the patient rinses with a flavored 1% acetic acid prerinse solution and then expectorates it. The tissue is then re-examined using the disposable chemiluminescent light source in a dim environment. If an area of concern is detected, it is marked with the supplied TBlue® swab to help further visualize and document the area.
It is important to remember that a surgical biopsy with a microscopic examination is the only accepted method of diagnosing cancer and many other mucosal conditions. The role of a biopsy is to rule out a malignancy and to establish the appropriate diagnosis for the patient’s condition. All other modalities, including cytology, are adjunctive procedures to aid in determining if and where a surgical biopsy would be appropriate and most beneficial. Cytology is not a substitute for the traditional surgical biopsy technique that removes architecturally intact tissue. In the majority of cases, a lesion that is worthy of a cytology procedure is better served by a surgical biopsy that will render a diagnosis.
Brush cytology is another adjunctive screening procedure that involves a minimally invasive collection of transepithelial mucosa cells with minimal or no discomfort to the patient. The technique involves the collection of disaggregated epithelial cells by vigorous brushing of the oral lesion with a sterile nylon bristle brush. It is primarily used to screen a suspicious leukoplakia or erythroplakia of the mouth in order to help determine the presence or lack of potentially malignant dysplastic change. The OralCDx® Brush Test® (OralCDx Laboratories, Inc., www.sopreventable.com) is an effective system for ruling out the presence of abnormal, atypical, and dysplastic cells. The areas have to be properly brushed, then the cells are placed and fixed on a glass slide.
Liquid-based cytology of the oral cavity is a relatively new screening technique that has also been effective. The tissue is brushed and the cells are transferred from the brush into a special liquid preservative/fixative bottled solution. Other oral conditions such as herpes simplex infection and candidiasis can be diagnosed by this procedure. Both cytology methods may aid the clinician in determining if the lesion detected should be observed or if it should have an immediate invasive full thickness biopsy procedure with intact architecture performed.
The entire dental team plays a strategic role in the data collection, discovery, and diagnostic process. From the patient’s very first contact with the dental office, whether it is on the phone, over the practice’s Internet portals, or in person, the importance of a consistent message on the value and necessity of an enhanced oral examination cannot be overstated. Proper communication is critical in the examination process. Education and training must encompass the entire team. Remember that the first place most patients turn to for advice and comforting on any procedure is the office’s staff.
It is imperative to understand and properly communicate the comprehensive benefit that an enhanced exam and other diagnostic procedures will have for the patient. The screening and diagnostic processes discussed have the common goal of providing practitioners with quality information to enhance and facilitate best practices in diagnostic decisions. Many of these new diagnostic devices may require additional ongoing research, and it is important to remember that they are all adjunctive devices to be used in addition to standard examination techniques. Patients and clinicians must understand the limitations of each diagnostic modality. Diagnosis is a decision made by a healthcare professional after evaluating and compiling all information available, from multiple sources and assessment techniques, and not by a device.
1. Lexi-Comp drug interaction database. Lexi-Comp, Inc. http://online.lexi.com. subscription required to view.
2. D’Souza G, Kreimer AR, Viscidi R, et al. Case–Control Study of Human Papillomavirus and Oropharyngeal Cancer. N Eng J Med. 2007;356:1944-1956.
3. Kahn MA. The emerging role of human papillomavirus in oropharyngeal squamous cell carcinoma. Compend Contin Educ Dent. 2011;32(special issue 2):1-7.
About the Author
Scott D. Benjamin, DDS
Sidney, New York