Cancer Screening by the GP: Key Things You Need to Know

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Identifying potentially malignant lesions before transformation into squamous cell carcinoma should be the goal of all oral healthcare professionals. Today, we'll be discussing various lesions in the mouth that could potentially become malignant and also learn about some updates on oral cancer. Our guest is Dr. Ashley Clark, an associate professor and division chief of oral pathology at the University of Kentucky College of Dentistry. She has published over 40 papers and abstracts, authored the oral pathology section of Dental Dex, and is on the professional board for digital dental notes and oral cancer cause. Her biopsy service offers free biopsy kits to dentists across the country. So if you're interested in learning more about that, you can contact Dr. Clark at ashley.clark. ashley.dds at uky.edu. Ashley is spelled A-S-H-L-E-Y. Clark is C-L-A-R-K. So that's ashley.clark.dds at uky .edu. That's a great service, Dr. Clark, and welcome to DownTalk. Thank you. Thanks for having me, Dr. Klein. I'm excited to be here. Yeah, so that's amazing. So nobody offers free anything these days that are worth something, but you offer free biopsy kits across the country. I think a lot of oral pathology labs, at least the few that I know, a lot of us do offer free biopsy kits. So our kit includes the formalin, any paperwork, and the shipping. So we pay for shipping both ways, two-day shipping. Let's begin with a simple question. What should the oral healthcare provider know about potentially malignant diseases? So what the oral healthcare provider should know is that... they can present in a variety of ways i like to focus on leukoplakia because about 85 percent of oral dysplasia presents as leukoplakia or i guess i should say a potentially malignant disorders present as leukoplakia and occasionally i see that clinicians will see leukoplakia and it doesn't look so bad you know it's thin and it's well demarcated maybe it's not in a high risk area it's on the gingiva So they watch it. And what I would like to get dentists in the rhythm of doing is biopsying it at that stage so we can diagnose it. Just make sure it's not dysplastic. Make sure it truly is just hyperkeratosis. We've done other podcasts on this. And I've asked other key opinion leaders and speakers about what a general dentist feels comfortable with. Do they feel comfortable doing that? And do they feel like if they do a biopsy and they don't do a good job and they send it out and it comes back negative and then patient, God forbid, does move to the next stage of malignancy that they're responsible? What's your feeling on that? So I think you're correct in that most general dentists don't feel comfortable doing scalpel biopsies. I have quite a few general dentists in our practice that will do laser biopsies on benign mesenchymal tumors such as fibromas. And the tissue does get burnt, but when it's a fibroma, that doesn't matter. With areas of leukoplakia, we don't want to use a laser. So we do get fewer biopsies from general dentists. But I will say... If I can do it, I would almost guarantee that any person doing general dentistry can do a biopsy. It's just a matter of getting the right tools and the comfort level of doing it. In my hands, I actually do punch biopsies myself. I actually don't do the scalpel biopsies. They're really a lot easier for me to make sure I'm getting into the connective tissue, especially on attached gingiva, because if it starts bleeding, then I know I've got the tissue I need. And also as far as when I'm preparing the specimens to look at them under the microscope, the punch biopsies tend to lay flat so I can get a nice clean cut and there's no problem with tangential sectioning. So I actually prefer punch biopsies to scalpel biopsies. So what would you suggest to a GP who doesn't do biopsies at all, or maybe did a few of them in the past? What's the best way to get a good handle on doing a biopsy and then feeling comfortable, for instance, getting your kit and and doing the biopsy and sending it back so i think i was in a in a lucky situation i did no biopsies in dental school either but when i went to university of texas i started doing biopsies on my own patients now it was easier for me because i was in a dental school and if i you know got caught where i couldn't stop bleeding or something i had an oral surgeon down the hallway so i think if i were in general dentistry i would speak to the oral surgeon to whom i normally refer those biopsies and ask if i can just come shadow for a day do it if they have a biopsy scheduled i find that most oral surgeons are really helpful when it comes to that a continuing education course would be You know, maybe helpful if you could find one in your area, but I really think getting that mentoring from a local oral surgeon would be what I would do if I was a general dentist wanting to learn how to perform my own biopsies. Now, I don't do anything crazy. I don't do soft palate biopsies because of the bleeding risk. I don't do floor of mouth biopsies just because of all the anatomy there, but I feel really comfortable doing buccal mucosa, tongue. labial mucosa, and gingival biopsies. Where you feel comfortable working is areas where you don't anticipate a lot of bleeding, which is a big, you know, not a big risk, but it is something to certainly consider when you're doing a biopsy. So as oral healthcare providers, what should we be aware of when it comes to managing areas of leukoplakia, which you mentioned is something that you want to spend particular attention to in this podcast? Yeah. So great question um what i would encourage dentists to do and what the literature says is best practices is if someone has an area of leukoplakia every single area of leukoplakia should be biopsied to establish a diagnosis because we can't tell by looking at it what the diagnosis is it could be totally benign hyperkeratosis But it might be an HPV-driven squamous cell carcinoma or intraepithelial neoplasia. We don't know. So number one would be to get your diagnosis. But the literature says long-term follow-up for 20 years. And the literature says to take every six months. So I would recommend every six months for 20 years when they come in for their hygiene checks to take a picture. I know sometimes it's hard to get all the equipment out and do stuff like that. But I think that's probably the best way to manage these areas of leukoplakia. Another thing is if you are doing your own biopsy, you do need to know how to manage what comes back as the diagnosis. So hyperkeratosis, we can just watch that. And if it changes in any way in the future, then we re-biopsy because even hyperkeratosis needs to be followed. If it's mild dysplasia or worse, I recommend to get rid of that tissue. And I don't do that myself. I send that to a surgeon. So you have to be prepared. If you do the biopsy, it comes back as moderate dysplasia that you know then that all that tissue needs to come out. The technique in which they do the biopsy, do they have to get the perimeter of the lesion all around and also get healthy tissue in that biopsy? For the initial biopsy, we recommend doing an incisional biopsy, meaning just taking a tiny piece of the tissue. And when I do... incisional biopsies on leukoplakia i don't get the border or periphery with normal tissue i actually go to where the worst looking area is and depending on the lesion that can mean different things it's usually the area that's most red Now, ulcers are a little bit different. If the leukoplakia is ulcerated, then you do want to get a rim of normal tissue on that initial biopsy. But if there's no ulceration and it's just a white or red lesion, you don't need normal. Just get the worst looking part. And then for the excision, I do recommend that a surgeon does that, someone who's used to doing those things, because what the surgeon will typically do is he or she will take a rim all the way around of normal, tag one side, and then I'll look it up in the microscope to make sure they got it all. And those patients still need follow-up after that tissue is gone because while surgical excision of potentially malignant disorders decreases risk for malignant transformation, it does not eliminate the risk because so many of them come back. So you still have to follow-up. So on the follow-up, do you recommend doing intraoral imaging using the intraoral cameras and taking the photo, putting it into the digital chart so they have a record of what it looks like and then even measuring it? always so i always take pictures at my re-evaluations every six months they get a but i get you know a big fancy extra oral camera out if you've got a wand that'll work in a pinch they don't usually get all of the anatomy surrounding it so it can be a little bit harder to tell if it's growing or changing honestly if you have a smartphone you can turn the flash on your smartphone on and the overhead light off You can snap a picture with your smartphone. Just make sure that you get it out of your phone and put it in the chart and make sure it's HIPAA compliant and all that. But those do take pretty nice pictures. And how often do you do that when you're talking about 20 years? That's a long time. It's a long time. I mean, that's a long time. Yeah. So you're going to be doing that twice a year on the patient? Twice a year. So ideally, whenever they're coming in for their hygiene checks. If it's true leukoplakia, so when I say true leukoplakia, I don't mean frictional keratosis. If they're biting on the area and some sort of trauma is causing the hyperkeratosis, that doesn't need to be followed. But if it's a lateral tongue, white lesion with sharply demarcated borders, and we don't know why it's there, and it's just hyperkeratosis, that one does need to be followed, even though there's no dysplasia in it because it's still considered a potentially malignant disorder. Okay. And are you focusing on leukoplakia in this podcast because of its prevalence? Yes. Okay. Tell us about that. What is the prevalence? So probably about one in 200 people will have it. The most common age group is men over the age of 40. And the prevalence increases with age to the point where about 10% of men ages 70 or older will have leukoplakia. Wow. So it's also the most common way in which oral potentially malignant diseases present. So my sort of career goals and aspirations are to get these cancers before they start. And the oral cavity cancers, with the exception of HPV driven cancers, they tell you before they turn to cancer. So they present with a white lesion. gradually gets thicker and then turns red and then it's cancer. So if we can catch it in those early stages and cut it out, we can decrease that risk of the patient getting cancer. Would you do really well in pathology in dental school? And that's what drove you into your interest into, I mean, that's amazing. You're division chief of oral pathology at University of Kentucky School of Dentistry. That's pretty impressive. Is that something that came from pathology in dental school? um thank god for pathology for me because uh my classmates will tell you i was not the greatest with my hand skills and i looked around after my first year and i thought oh no i'm gonna have to go to med school and so my uh second year rolls around and we're in pathology and i was like You know, sort of like the light, the room opened and the light shone down. And I marched up to the professor. His name was Nadim Islam. And I said, I want to do what you do. And he said, come to me after you've done a year of clinics. You know, you're in the worst part of dental school right now is studying and labs and you're. you know, stressed all the time. So the very last day of third year, I knocked on his door and I said, I want to do what you do. And he's been, he helped me apply for residency. And I actually went, did residency right out of dental school, which is a little unusual. So most people go practice or, you know, do a GPR or something. So yeah, I've known since the day I took the class that this, this is what I want to do. I love it. And thank goodness. That's great. No, you seem so passionate about it. And just imagine how many lives will be saved if they go along with the regimen of doing biopsies more often when they see leukoplakia. Give us some updates on oral cancer. Where are we now? So the oral cancer rates have steadily declined with a decline in smoking. So as fewer people smoke, fewer people get oral cancer. The exception is HPV-driven cancer. So while we are seeing a sort of a decline in cancer, tobacco-driven cancer, alcohol-driven cancer in the oral cavity proper, we are seeing an explosion of HPV-driven cancer in the back parts of the throat, in the oral pharynx, tonsils, etc. So there will be more men that get HPV-driven oral pharyngeal cancer. This year, then women will get HPV driven cervical cancer. So that's how prevalent it's become. The most common age group is white men ages 40 to 59. So it's affecting younger people and it develops independently of tobacco and alcohol. So you may have never smoked or you don't drink. But if you have any sort of high risk HPV that sticks around and turns into cancer. That can cause a throat cancer. And how is that discernible by general exam by a dentist? That's the scary part is it's really not. So these primary tumors are so small that you often can't see them. And they're so far in the back of the throat that you can't see them. You know, sometimes scanning won't even pick them up because they're so small. But what we can do is make sure we do extra oral tactile examinations. We feel the lymph nodes. because 80% of these cancers are caught after they've metastasized to the cervical lymph nodes. So we can make sure we check those cervical lymph nodes. The good news with these cancers is they're a lot more curable than the HPV negative cancers. So they have about an 80% five-year survival rate, even though they're caught after they've metastasized. And also, as you get older, we rely less on our lymphatics and more in our blood to remove foreign bodies. carcinogens, which is bad because that obviously drives metastasis to a greater level than if it stayed in your lymphatics. What are some of the ways in which we can prevent oral cancer as dentists, as dental professionals? So what I would recommend is every patient, every time. So that's my mantra, every patient, every time. one minute or less to do a cancer screening, you just look. So you take the overhead light and you look everywhere. I use the same pattern. You make sure you check the cervical lymph nodes and just document that. So I know a lot of people also like to use oral diagnostic aids. So one such example, let's say, would be the Gawkels that have just, it's a new product on the market. So what you do is you put these on, you use a curing light and After you've looked, after you've screened with just the light, then you can use this diagnostic aid to look again. to make sure you didn't miss anything. And a lot of people use those diagnostic aids in that way. And I think that's fine. And the science behind that device goggles, is that auto fluorescence? It's a fluorescent device. So anything that is abnormal or dysplastic should lose fluorescence or appear black. Now you have to sort of be aware of what you're doing when you're using these things, because anything with inflammation can lose fluorescence. But when you're looking at dysplasias, these have an incredibly high sensitivity rate, over 90%. This fluorescence technology has an over 90% sensitivity rate at catching these dysplasias and oral cancers. So I recommend looking with your eyes first. And then if you want to check to make sure you didn't miss anything, that's a great way. Plus, that means you're looking twice. Right. No, that's a good point. Yeah, I know gackles. I've done some reading about gackles. And what I thought was interesting about it is that... any curing light in the office works with it so you don't need a whole apparatus it has a very small footprint you can move it from operatory to operatory and then you're just putting it on and look as you said it's a second attempt to find something that's not normal and it gives you that extra screening capability by showing up a little bit darker but you know it's not 100 none of these are 100 like you said inflammatory tissue will give you a false positive their specificity rating is around 70 and this is not just goggles this is any any autofluorescent device so you have to be careful you can't which is why i said look first then screen um so i wouldn't use it as okay i see this leukoplakia on the gingiva and because you got to biopsy it. You don't have any decision to make. Leukoplakia equals biopsy. So when these tools originally came out, they were meant to assist you in, should I biopsy this or not? And I don't recommend using them in that way. If you're going to use them, I would use them as a screening device, which is how I think most people use these devices anyway. Right. So tell us about the kit that you offer. What's in the biopsy kit? and how does it work so we have a history sheet that we put in the kit we have a bottle of formalin we have all the information you could possibly need we work with a variety of insurances to keep the cost low to your patient because you don't want a patient calling you afterwards saying what's this bill for so we work with a variety of medical insurances so you want to make sure you send the medical information And then again, we do free two -day shipping. So our turnover is about 24 hours. So the cases that we received in the mail yesterday, the reports are out today. Not all of them, but for almost all the cases. I've got a metastatic lesion that I'm trying to suss out with immunohistochemistry. And that one takes a couple of days. But most of them are done in 24 hours because we don't want to keep patients waiting. The doctor can get more information about this. by emailing you directly or is there a website they can go to? So you can email me directly would be the easiest way because I can set you up with our administrative assistant, Sarah. She's fantastic and she knows all the answers to the questions that I don't even know. So that's probably the best way to do it. Or you can look us up on the internet. We have a pretty good web presence. on how you can sign up to be a contributor on the internet if you want to. And I work at University of Kentucky. That's pretty much all you have to look up. You're fully equipped to really provide a very thorough diagnosis as far as those specimens that are coming in the door. So that's, again, feel free to email Ashley Clark or the dentist who we're talking to here. Her email is Ashley, A-S-H-L-E-Y dot Clark, C-L-A-R-K dot D-D-S at U-K-Y. So if they email you, they can get a kit, and then they just need the confidence that they're identifying leukoplakia, right? Because they have to know what that looks like. Once that's identified, that's a biopsy situation, right? They have to biopsy that or refer it out. Yeah, exactly. So for me, leukoplakia is not a diagnosis, so I want to get it diagnosed. So that's why we must biopsy it because we actually don't know the diagnosis until we do or refer to a periodontist or surgeon who does biopsies. But by the way, you can email me pictures if you want to. I'm happy to do curbside consults if anybody, you know, hey, I've got this. I don't know if it's worth biopsying. I'm happy to field those questions as well. Oh, that's amazing. Yeah. This is like old time medicine where the doctor comes to your house with his little black bag and takes your temperature and you're living the life over there in Kentucky. I'm happy to do it. Yeah. No, that's great. This has been very helpful. Is there anything else that you want to share with us? So I would say the thing that I'm on to right now that I try to hammer is gingival carcinomas are really tricky. They often masquerade as other things like infection or periodontal disease. So I would suggest that anything that's not behaving the way it should with appropriate therapy, let's get a biopsy of it and make sure it's not carcinoma. Let's make sure it's not some sort of weird infection. So those gingival carcinomas are really, really tricky. And they tend to occur in women who don't smoke. They're not HPV driven. So just have a high degree of suspicion if you have a funny looking lesion on the gingiva that's not responding to appropriate therapy. Thank you, Dr. Clark, for your time today. And before we conclude this podcast. I would like to thank our sponsor, Perel Pharma. Check out their product called Gockels. That's G-O-C-C-L-E-S. It's essentially a pair of glasses that when used with any curing light helps you see abnormal tissue in the mouth. And as Dr. Clark mentioned, it's an excellent adjunct to your oral cancer exam. Thanks again, Dr. Clark, for your great insight on oral cancer. We learned a lot and we look forward to having you back again soon. Thanks for having me.