Improving oral cancer diagnosis on many fronts
A comprehensive dental visit includes more than a cleaning and X-rays; well-trained dentists know they must also take a thorough look inside the oral cavity to spot any potentially unusual lesions that could signal oral cancer.
Recently, the American Dental Association (ADA) reviewed its recommendations on what dentists should do when they spot a potentially malignant lesion in the mouth. Thomas Sollecito, chair of the Department of Oral Medicine in Penn’s School of Dental Medicine and chief of the Division of Oral Medicine in the Perelman School of Medicine, was part of an expert panel charged with reviewing and updating the ADA’s guidelines regarding oral cancer diagnostics.
“Our review sought to answer the question, ‘What is the best way of evaluating potentially malignant oral disorders?’” says Sollecito. “This is set against a background of oral cavity cancer diagnoses still being made at a relatively late stage.”
The team, which included members with expertise in epidemiology, oncology, and head and neck surgery, as well as oral medicine, reviewed high-quality scientific studies to come up with their recommendation. Among the evidence they considered were studies evaluating the effectiveness of what are known as “adjuncts,” diagnostic tests that can help dentists determine whether a lesion is potentially malignant.
“These adjuncts are being marketed to dentists, and some are probably using them in their practices,” Sollecito says. “This review is intended to provide clarity to dentists as to what is the best evidence at this time for the use of adjuncts.”
Some diagnostics use biomarkers in the saliva to test for the presence of cancerous or precancerous cells. Others use a method akin to a Pap smear, where cells are lightly scraped from the oral cavity and then evaluated for signs of dysplasia or malignancy.
But after a rigorous scientific review, Sollecito and his co-panelists found that the evidence supporting the use of these adjuncts was low in quality. If a dentist spots a suspicious lesion, the panel’s recommendation remains the same as it had been at the time of their last review in 2010: to biopsy the tissue.
“The biopsy is the gold standard,” Sollecito says.
But it is invasive, especially if the same lesion must be biopsied repeatedly to test whether it has become malignant over time.
“Ultimately, we’ll have to improve our ability to determine and predict whether a lesion’s behavior over time can be obtained without re-biopsying frequently,” he adds.
The ADA review is only one way that Sollecito is trying to increase awareness of oral cancer and early detection. Along with Eric Stoopler, director of the Oral Medicine Residency Program at Penn Dental, Sollecito edited an issue of Dental Clinics of North America focused on oral cancer, with chapter contributions from other colleagues within Penn’s Dental and Medical schools.
And on Penn’s campus, Sollecito is part of an effort to grow the pool of health care providers who possess the knowledge to recognize suspicious oral lesions and perform head and neck exams. Through a partnership with the School of Nursing, nurse practitioner students are spending time in the oral diagnosis clinic at the Dental School.
“The more people who feel comfortable looking at all of the nooks and crannies of the oral cavity in a systematic fashion, as difficult as it is, will only help in detecting a potentially malignant lesion earlier,” says Sollecito.
While the Dental students help instruct the Nursing students in how to perform oral cancer screenings, the Nursing students share their expertise in looking beyond the dental and medical conditions, and understanding the psychosocial dimensions of their patients.
“I’m really excited about this partnership,” Sollecito says. “We have a robust inter-professional interaction with the Nursing School, and it’s beneficial for everyone involved.”