SAN FRANCISCO - Enhanced oral cancer detection can help general practitioners save patients' lives while protecting dentists from malpractice lawsuits, according to a presentation by Dr. Jonathan Bregman at this week's California Dental Association's CDA Presents 2015 meeting.
The early detection of oral cancer, which has been aided by new high-tech screening devices, was the focus of Dr. Bregman's session. He stressed the importance of creating an effective protocol that practices should use, including assessing risk factors and being aware of the changing demographics of the disease.
Once a disease that was mostly limited to older white men who smoked and drank alcohol, the number of oral cancer cases among young people who don't have the usual risk factors has shown alarming growth in the past few years.
"I've been in dentistry 40 years and never have I ever heard of people in their late 20s and 30s having oral cancer," Dr. Bregman told DrBicuspid.com in an interview. "It just didn't exist; the age has trended way, way down. It's truly an epidemic that's flying below radar of most people. The critical part is getting people to be aware of their mouth and the risk factors to help bring down the horrible and growing number of deaths from oral cancer."
Establishing oral cancer protocols
Dr. Bregman stressed the importance of basic exams, record keeping, and effective communication to reduce patients' risk of the disease. A basic part of the protocol includes establishing and documenting a two- to three-week waiting period to re-evaluate areas of concern to see if they have changed, gotten bigger, or disappeared. If the area persists beyond that period, dentists should refer such patients for follow-up and biopsies, he advised.
"However, the vast, vast majority of all these areas go away in two to three weeks," he said.
Detecting oral cancer in the early stages is now easier, especially with the advent of a variety of new high-tech screening devices available, Dr. Bregman said.
"It's not so difficult, but there has to be consistency within our profession and the medical profession about what to look for and what these kinds of changes can mean, as well as to help our patients be able to do a self-exam to understand what's normal in their mouths. Tell them what you're doing and what you're looking for -- help them understand," he said.
The problem is that oral cancer survival rates haven't changed in last 40 to 50 years, and the survival rate is only about 50% after five years.
"The critical point, the reason why survival rates of these cancers is so bad, is that most cases aren't caught until later stages," Dr. Bregman said. "The goal has to be early detection, when surgical treatment offers much, much better chances for survival."
Educating patients about HPV
Dr. Bregman noted the worrisome increase in oral cancers related to human papillomavirus (HPV) in the last few years, stressing the importance of oral cancer screening for patients starting at age 16.
"You have people who are carriers and don't know it, and they pass it along," he said. "And the more sexual contacts you have, the greater chance your body won't be able to clear the cancer-producing virus."
Just as dentists have learned to ask about patients' HIV status on health forms, they should now query them about HPV, he advised.
"Don't just put that question on the health form," Dr. Bregman said. "You have to have every person on your team come together and talk about why we're putting this on the form."
Dentists should also ask parents if they've gotten their children the HPV vaccine, "because there's a direct correlation between HPV and oral cancer," he said. "Get them educated -- talk about it every single time."
Often parents put their heads in the sand, said Dr. Bregman, noting that oral sexual activity can begin at age 13, and teens sometimes think oral sex is better because they won't get pregnant.
"I think that's a place where we're failing in dentistry, and we need to get on track with the overall education of our patients," he said.
Avoiding malpractice claims
While most dentists are aware of the importance of oral cancer screening, some still don't do it, Dr. Bregman acknowledged.
"Unfortunately, I'm fearful that many, many dentists don't [screen], and there's no reason for it," he said.
When dentists are asked why they don't screen for oral cancer, they respond that it takes too much time, Dr. Bregman said.
"But it doesn't," he asserted. "More importantly, we're putting ourselves at tremendous risk for malpractice claims."
Malpractice claims resulting from dentists failing to detect oral cancer are skyrocketing, according to Dr. Bregman. He recalled discussing the issue with an insurance carrier agent who told him there are more claims and complaints regarding the lack of detection and late detection of oral cancer than ever before.
"She said it's becoming the biggest reason for malpractice lawsuits compared to other claims against dentists," he said.
High-tech detection devices
The first oral cancer detection devices used rinses and special lights, but the big improvement was the advent of fluorescence technology, Dr. Bregman said.
"That really changed everything," he said. "Now can see more under the oral mucosal tissues to detect things that you can't see otherwise. As fluorescence technology has developed, it has dramatically improved what kind of early detection can take place," Dr. Bregman said. "I think the advent of fluorescence technology has really made a huge difference as far as saving lives through early detection."
There has been a lot of good research using new technology to spot oral cancer early, and it's becoming more powerful, he said.
"If you use something beyond the basic exam, you are helping with early detection, no matter which one you use," Dr. Bregman noted.