Tuesday, 15 January 2013
AGD applauds proposed U.S. oral health initiative
AGD applauds proposed U.S. oral health initiative
May 29, 2008 -- The Academy of General Dentistry (AGD) is giving two thumbs up to the recent introduction of the Oral Health Initiative Act of 2008 by Sen. Benjamin Cardin (D-MD) and Sen. Susan Collins (R-ME). The bill, S. 3064, proposes the establishment of a multifaceted approach to oral healthcare through the creation of an expert oral health working group to assess existing U.S. oral health programs and recommend improvements.
"Dental disease presents a very serious problem for our children, particularly those from lower-income families," said AGD president Vincent Mayher, D.M.D, M.A.G.D. "This working group should look closely at all federal oral healthcare programs and make recommendations for improvement to ensure that no child is without dental care." The working group would also develop programs to improve the oral health of and prevent dental disease in children, Medicaid-eligible adults, and other vulnerable populations who are among those Americans at highest risk of dental disease.
The AGD will be issuing an action alert this week to its members, urging them to send letters to their senators asking them to support this measure, according to Janet Kopenhaver, AGD's Washington lobbyist. Cosponsorship of the bill will be a component of the AGD Scorecard of the 110th Congress, to be issued at this session's adjournment, she added.
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Saliva provides early warning signs of cancer
Saliva provides early warning signs of cancer
May 29, 2008 -- Looking inside someone's mouth may one day involve more than dental care. It could enable early diagnosis of various cancers, leading to more effective treatment outcomes and better survival rates.
According to research presented at the 2008 American Association for Cancer Research (AACR) meeting in San Diego, analyzing the DNA in saliva can provide clues about the molecular damage that can lead to cancer. In particular, the investigators found that analyzing this DNA may help detect the early signs of head and neck squamous cell cancer (HNSCC).
While this research is still in its infancy, the researchers say sampling cells in saliva could become a cancer screening method for large populations, and dentists might play an important role in such testing.
"The test is a very noninvasive one and very patient-friendly," said Seema Sethi, M.D., of Henry Ford Hospital in Detroit, the lead researcher of the study. "At the same time, it was very good at differentiating those with cancer from healthy people without the disease."
At present, more than 40,000 Americans are affected by HNSCC, and approximately 12,000 die from it each year. The development of HNSCC in people at risk, such as smokers, takes many years, and most cases are diagnosed at an advanced stage when prognosis is poor. Often, the treatment is surgery that can lead to significant disfigurement.
"Patients are sometimes unable to eat and speak afterward," Dr. Sethi said. It would be much better if clinicians could diagnose this cancer before such drastic surgery is needed, she added.
In her study, Dr. Sethi and fellow researchers took saliva samples from 27 patients with HNSCC and 10 healthy participants and extracted DNA from the samples. They then examined 82 genes with known associations to HNSCC. Eleven genes were found to have some ability to predict the presence of HNSCC in the cancer patients. Upon further assessment, the researchers found that increases in a gene called PMAIP1 alone or together with a gene called PTPN1 identified all patients with HNSCC with 96% sensitivity and 90% specificity.
While emphasizing that this research is in its early stages, Dr. Sethi hopes that it could one day be used to screen for HNSCC on a widespread basis. The noninvasive test that Dr. Sethi and fellow researchers developed could be administered by dentists, she added. So just as dentists screen for oral cancer today, they may one day screen for more pervasive cancers such as HNSCC.
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Most U.S. dental faculty like their jobs, study finds
Most U.S. dental faculty like their jobs, study finds
May 28, 2008 -- A recent study that surveyed 17% of the dental faculty in U.S. dental schools found that an overwhelming 71% are satisfied with their jobs.
Areas of high satisfaction included nature of teaching assignments and interaction with colleagues. Areas where participants showed less satisfaction included amount of time for research and the extent and quality of the faculty practice program.
"It is extremely positive to see how many current faculty are enjoying their academic careers, which sends a good message to individuals exploring academic dentistry," said ADEA President Charles N. Bertolami, D.D.S., D.Med.Sc.
However, "tenured associate professors expressed the greatest level of dissatisfaction," the study authors noted. "Opportunities for and support of professional development emerged as an area requiring substantially more attention from dental schools."
The study took into account 1,748 responses from 49 U.S. dental schools. Other findings included the following:
While 71% of the respondents were satisfied with their job, 8% expressed dissatisfaction.
73% said they were satisfied with the intellectual challenges associated with their teaching responsibilities, while 7% were dissatisfied.
18% were satisfied with the extent and quality of the intramural private practice program, while 25% were dissatisfied.
23% felt satisfied with the amount of time they have for research, while 31% were dissatisfied.
The study, "The Quality of Dental Faculty Work-Life: Report on the 2007 Dental School Faculty Work Environment Survey," was conducted through a survey developed by the Academy for Academic Leadership on behalf of the American Dental Education Association Commission on Change and Innovation in Dental Education (ADEA CCI). The results were published in the latest issue of the Journal of Dental Education (JDE, May 2008, Vol. 72:5, pp. 514-531).
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Making early detection of oral cancer a priority
Making early detection of oral cancer a priority
May 28, 2008 -- Oral cancer has a five-year survival rate of only 50%. A patient's best chance of surviving is early detection. While a number of methods and new technologies are now available to enhance early detection, the panel is still out on whether there is any one best approach for detecting oral cancer.
As we report this week, questions have been raised about the ADA's heavily promoted oral cancer campaign, which prominently features the BrushTest made by OralCDx Laboratories. Mark Lingen, D.D.S., Ph.D., a University of Chicago associate professor of pathology, has been among the most prominent critics of the campaign. So when he outlined his approach to detecting oral cancer at a recent meeting of the California Dental Association, an avid crowd showed up to listen.
"About 10% of all patients have some sort of oral mucosal abnormality," Dr. Lingen noted. Because it is extremely difficult to tell premalignant lesions apart from the harmless ones, the deadly disease often goes unnoticed until it is advanced and thus much harder to treat.
A crater-form ulcerated lesion with rolling borders that turned out to be squamous cell carcinoma.
Oral cancer is indicated through two kinds of tumors: leukoplakia (white lesions) and erythroplakia (red lesions). Five percent to 25% of leukoplakias and 90% of erythroplakias have histological evidence of premalignancy when dentists see them.
It is important to keep in mind that not all white and red lesions are premalignant, Dr. Lingen explained. And the size of the lesion won't give you a significant clue.
His take-home message: If your patient has a white or red patch and you cannot figure out why it's there, it could be precancerous or cancerous. After seeing this lesion in a patient's mouth, a dentist usually has a 10 to 14-day window to check if it has subsided. If it hasn't subsided in that time, he said, do a scalpel biopsy.
Some common areas to look for lesions are:
Floor of mouth
Ventral surface of tongue
Retromolar trigone region
Soft palate
Less common areas include:
Gingiva
Buccal mucosa
Hard palate
"I don't care how you get there -- tongue depressors, mirrors. The floor of the mouth is a very common place to get oral cancer. Examine it thoroughly," Dr. Lingen said.
Another area to check is the ventral surface of the tongue. Dr. Lingen showed a picture of a clinician using a piece of wet gauze to extend the patient's tongue.
"The most common location for oral cancer of the tongue is the posterior aspect of the anterior tongue," he said. "To get a good look at this region, you have to pull the patient's tongue out."
Another compelling reason to conduct a thorough exam is that dental-related malpractice suits associated with oral cancer are on the rise. Here are a few scenarios in which the cases are deemed indefensible:
Failure to biopsy.
Failure to re-examine a lesion. If you have a patient with a lesion, you need the patient to come back in 10 to 14 days to make sure the lesion is healing. If he or she comes back and the lesion is still there or has become worse, you need to biopsy.
Failure to follow up on diagnostic report.
Diagnostic devices
A number of devices now on the market are designed to enhance early detection of oral cancer, including:
The BrushTest (OralCDx)
Toluidine blue staining
ViziLite Plus (Zila)
Microlux (AdDent)
VELscope (LED Dental)
Here are the key advantages and disadvantages of each, according to Dr. Lingen:
The BrushTest
Dentists can use the BrushTest to collect cells from white or red lesions and send them to a lab for diagnosis. If the cells are abnormal, a biopsy will determine if the spot is potentially cancerous. You can get back three possible results: positive, negative, and atypical. If the result is atypical or positive, a scalpel biopsy is mandatory.
If the results are negative (and nothing else causes concern), then simple follow-up is probably sufficient.
Advantages:
FDA-approved.
Useful in cases in which a patient has multiple lesions throughout the oral cavity because it's painful to have multiple scalpel biopsies.
Useful for a noncompliant patient. If you see suspicious lesions and want to refer a patient for a scalpel biopsy, but are quite certain he or she won't comply, do the brush biopsy to check for positive or atypical results.
Disadvantages:
Often used inappropriately by the dentist. For example, some use it on papillomas.
Cells are seen out of context, which can result in misinterpretation. For example, if the BrushTest is used to collect cells from a patient who has lichen planus and the cells are spread out on a slide, they will be out of context and will be read as atypical.
"Don't brush biopsy everything that looks atypical," Dr. Lingen said. "You do that, and you will get back a lot of atypical results which you will then be obligated to scalpel biopsy."
Toluidine blue staining
This technology is not yet approved for use in the U.S. and is more common in Canada and the U.K. It is a liquid dye composed of tolonium chloride. Practitioners swab the blue dye onto suspicious oral lesions and look for ones that retain the blue dye, as they can be cancerous.
Advantages:
May help to better define gross extent of areas of lesions. These fields can be as large as 6 cm in diameter. If you have a patient with a field that large, but only a centimeter is clinically evident, and you excise it, you will still be left with 5.5 cm of molecularly altered tissue that has the potential to become cancerous.
Disadvantages:
Not FDA-approved.
High rates of false positives and false negatives.
Works well on erythroplakias but not on leukoplakias, which is where clinicians need more help.
May be better than visual acuity but does not identify the true margins of the field.
ViziLite Plus and Microlux
These competing technologies are similar. For the ViziLite Plus test, the patient rinses for 30 to 60 seconds with a solution that contains 1% acetic acid, and then the dentist uses a disposable light device to examine the oral mucosa. Any abnormalities will appear acetowhite. They can then be marked using the TBlue marking system.
Microlux is the same technology, except that the light device used in this system is not disposable.
Advantages:
FDA-approved.
May be better to define areas with increased amounts of DNA.
High degree of sensitivity.
Disadvantages:
Low degree of specificity. It will light up things that are not premalignant.
May be better than visual acuity but does not identify the true margins of the field.
VELscope
The VELscope is a handheld device that shines a light into the oral cavity, which excites the tissue and causes it to fluoresce. The clinician can view the different fluorescence responses to help differentiate between normal and abnormal tissue. Healthy tissue fluoresces green, while abnormal tissue does not fluoresce and may appear dark.
Advantages:
May help to better define surgical margins.
FDA-approved.
Disadvantages:
Low specificity as described for ViziLite Plus and Microlux.
May be better than visual acuity but does not identify the true margins of the field.
OralCDx wants to revise ADA-endorsed BrushTest ads
OralCDx wants to revise ADA-endorsed BrushTest ads
May 28, 2008 -- Controversial advertising in an ADA-endorsed oral cancer awareness campaign is likely to change, according to the campaign's sponsor.
The advertising, which began appearing on buses, trains, and in magazines in September 2007, has drawn criticism for two reasons. Some experts, including prominent oral pathologists, have faulted the way the nonprofit ADA is working with the for-profit OralCDx Laboratories. Others have challenged the reliability of the company's BrushTest as a means of detecting precancerous cells.
OralCDx CEO Mark Rutenberg on Tuesday released to DrBicuspid.com the draft of a new disclaimer that he hopes will clarify the relationship between the two organizations. But in an interview, he and company president Howard Kramer maintained that the test is highly accurate. And in an earlier interview, ADA president Mark Feldman, D.D.S., defended the text of the ads as they stand.
The price of promotion
Just about everyone agrees with the goal of raising awareness about oral cancer. An estimated 34,360 Americans are diagnosed with the disease each year, and on average only half of those who are diagnosed survive more than five years, according to the ADA.
And even some of the campaign's most prominent critics accept the approach of raising money from a private company. "The oral cancer campaign is important," Mark Lingen, D.D.S., Ph.D., a University of Chicago associate professor of pathology, told DrBicuspid.com. "And you have to pay for it somehow."
OralCDx is paying the entire cost of the $9.5 million, three-year campaign (something the ADA disclosed from the beginning). In fact, as Rutenberg pointed out, OralCDx isn't giving the ADA any money. "We have never given the ADA a dime," he said. "We have committed to spend $9.5 million on advertising. The ADA doesn't get that money. The ad companies get that money."
So what's the beef? In its most controversial version (click here to view the ad), the ad is labeled "IMPORTANT MESSAGE ABOUT ORAL CANCER FROM THE ADA." A headline reads, "Ask your dentist about a routine test as powerful as a Pap smear or colonoscopy." The next sentence reads, "Ask your dentist if a BrushTest can help you by accurately detecting unhealthy cells -- years before they can turn into cancer." The ad also bears the ADA's logo, and the academy's name appears in three other places.
Critics say the ads make it look as though the ADA is endorsing the BrushTest and ignoring competing tests. "I don't think it's appropriate to have a campaign that says, 'Go get this product,'" Dr. Lingen told DrBicuspid.com. "We have not had a campaign that says, 'Brush twice a day with Colgate toothpaste.'"
Dr. Lingen made that point at length in an editorial published in the April 2008 issue of Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology (OOOOE, April 2008, Vol. 105, pp. 407-409), where he serves as an editor. He's not satisfied with the fine-print disclaimer currently on the ad, which says that the ADA doesn't endorse a particular product. "One cannot have it both ways," he wrote. "You cannot develop an awareness campaign that focuses on a specific product and at the same time claim that you are not endorsing a product."
"Frankly, I agree with him on that point," Rutenberg said. He explained that people who read the ad should understand that the ADA is endorsing brush biopsy in general, not the BrushTest in particular. The current disclaimer doesn't go far enough in that direction, he added.
The current disclaimer reads, "The ADA does not endorse any specific product in connection with this awareness campaign and has no financial interest in the product featured here. For more information on oral cancer, visit www.ada.org. Part of an education campaign underwritten by OralCDx Laboratories."
The proposed new disclaimer provided to DrBicuspid.com by Rutenberg reads, "The OralCDx brand of brush test is an adjunct to the professional oral examination in the early detection of oral precancer. This test is not a substitute for a scalpel biopsy, which should continue to be utilized to evaluate suspicious oral lesions. The ADA has no financial interest in this product. This poster is part of an educational program supported by a grant from Oral Cancer Prevention International, Inc., provider of the OralCDx brand of brush test. For more information please visit www.ada.org."
Rutenberg said his company is close to agreeing with the ADA on the new draft. He also said he'd like to see less overall text on the ads, which are too "wordy."
But he didn't foresee any change in the headline that compares the brush biopsy to a Pap smear and colonoscopy. And he acknowledged that the OralCDx BrushTest dominates the market for brush biopsy tests. In fact, he said, the company's patents for the technology make it difficult for competitors to mount a challenge.
As for the ADA, Dr. Feldman defended the ads as they are. "The campaign is not product-specific at all," he told DrBicuspid.com. "The message with the ADA logo informs patients to ask their dentists about a test as powerful as a Pap smear or colonoscopy."
Tracking oral cancer
Is a brush biopsy indeed "as powerful" as a Pap smear or colonoscopy? If so, it could have great benefits. Some dentists "frequently don't examine the oral mucosa carefully and have inadequate experience in the identification of lesions," noted Martin S. Greenberg, D.D.S., oral medicine section editor at OOOOE and chair of the department of oral medicine at Penn Dental Medicine, in an OOOOE editorial. If a dentist does find something suspicious, the next step is to send the patient out to an oral surgeon or oral pathologist for a scalpel biopsy.
On the other hand, brush biopsy devices like the BrushTest let a dentist collect cells from suspicious white or red spots in the patient's mouth with much less discomfort; the sample is sent to an OralCDx laboratory for diagnosis. If the cells are abnormal, then a scalpel biopsy can confirm a potential cancer and the spot can be removed.
"The lifesaving reality and potential of the BrushTest is very obvious, and we seek to apply this in all dental offices across the country," said James Sciubba, D.M.D., Ph.D., a Johns Hopkins University pathologist, at a November ADA media briefing announcing the new oral cancer awareness campaign.
But Dr. Lingen believes that the BrushTest should not be compared to the Pap smear and colonoscopy. "Drawing analogies between these two tests and brush cytology is inaccurate," he wrote in his OOOOE editorial. For example, if there's evidence of some type of pathology during a colonoscopy, the patient receives a definitive diagnosis because the lesion is biopsied on the spot and histologically diagnosed. "Oral brush cytology never results in a definitive diagnosis," he wrote.
More to the point, should the BrushTest be your first choice? "The OralCDx procedure is neither optimum nor in the patient's best interest. Why go through the convoluted path [of BrushTest followed by a scalpel biopsy] to get definitive results?" said Dolphine Oda, B.D.S., M.Sc., a professor of oral pathology at the University of Washington.
"A scalpel biopsy is still the gold standard," said Gordon M. Rick, D.D.S., M.S., director of the Scripps Oral Pathology Service. "Why waste time and money on something else?"
To these criticisms, Rutenberg responds that a brush test saves patients the discomfort of having all their lesions tested by scalpel.
To see how Dr. Lingen thinks dentists should detect oral cancer, click here.
Rutenberg also questions the motives of some critics, who he says are afraid the BrushTest will undermine their business interests. "Some oral pathologists are concerned that the OralCDx brush biopsy is somehow competitive with the scalpel biopsy," he said, although he thinks the test will actually drive more business to practitioners of scalpel biopsy.
So far the ADA -- which stirred controversy in 2002 in a similar collaboration with OralCDx -- remains firm in its position on one side of the debate. "If research came out that said that the [BrushTest] is not accurate, then we would obviously have to shut down this campaign and remove our seal," Dr. Feldman said.
But he thinks that's unlikely. He believes the campaign will save lives by getting people into the dentists' office. "That's what this is all about," he said.
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