The Oral Cancer Exam and Biopsy: Clinical Tips from an Expert

You remember those old denture marking sticks you would use to mark denture sores? Well, those are great little things. You're looking at the lesion, you have the goggles on, you can see where the margins are, and you take these little denture sore spot marking pencils and you draw a line around where the margins are. Makes it very, very simple. Then you take your 12B blade or 15 blade or whatever, you remove it, you're all set. Simple, easy, no big deal. Welcome to the Phil Klein Dental Podcast. Oral cancer is often silent, showing little to no symptoms until it's too late. According to the stats, 12,000 people die each year from oral cancer in the United States alone. But here's the good news. General dentists are in a unique position to be the first line of defense. With a thorough oral cancer exam, we have the opportunity and ability to catch suspect lesions early. before they progress into life-threatening malignancies. Simply put, early detection saves lives. Joining us today is a general dentist who has performed thousands of oral cancer exams and hundreds of biopsies. He will share his approach to screening, his clinical insights, and some valuable tips that can dramatically improve our ability to detect potentially malignant lesions. And the idea, of course, is to do this at its earliest, most treatable stages. So if you're looking to enhance your clinical skills and make a real difference in your patients' lives, stay tuned, because this episode could change the way you approach oral cancer detection in your practice. Our guest is Dr. Robert Convissar, a world-renowned lecturer on oral cancer diagnosis and biopsy technique. He has close to four decades of clinical experience and has authored over 20 peer-reviewed papers and seven laser textbooks. He has delivered close to 400 continuing education programs worldwide. So we're certainly happy to have him on the show. Dr. Convissar, welcome to the show. Thank you. We're certainly happy to have you on, Dr. Convissar. You've been a great contributor to Viva Learning over the years, specifically in oral cancer and biopsy. To begin this episode, give us an idea of how common oral cancer is. Oral cancer? is the sixth leading cause of deaths in men in the United States. I'll ask you a question. What time did you wake up this morning? 7, 7 a.m. What time is it now where you are? 4 p.m. Central. Okay, nine hours. How many people in the United States died of oral cancer since you got up this morning nine hours ago? The answer is 1.3 people every hour of every day die of oral cancer. So since you got up this morning, A dozen people in the United States died of oral cancer. So that's pretty significant. Over 58,000 diagnoses in the United States every year. Well over 12,000 deaths every year. More people die of oral cancer than of pancreatic cancer, which gets a lot more play in the news, or cervical cancer, which gets a lot more play in the news. People don't realize... How many famous people have died or even have survived from oral cancer? It's a huge deal. So 1,000 a month are dying from this? More than 1,000 a month, yes. So what percentage of that 12,000, I know you don't have an exact number, but approximately, could have been saved by an early detection exam? Virtually all of them. The problem with dentistry is that we are afraid to look or we're afraid to deal with cancer. or we put our heads in the sand, or we try to ignore it, or we try to belittle it. Let's talk about two people in particular. Stanley Tucci, very, very famous actor. He's a good actor. I like him. Great. Conclave, the recent movie, The Devil Wears Prada, The Hunger Games. He's been in plenty of movies. Stanley Tucci survived stage four tongue cancer. He was out of commission for a very, very long time. For those of you that like cooking shows, watch Top Chef and things like that, Shirley Chung is a very, very famous chef. Stage four tongue cancer. And of course, you can go down the whole list. Babe Ruth, oral cancer. Sigmund Freud, you always see pictures of him with cigars in his mouth. He died of oral cancer. Michael Douglas had oral cancer. Michael Douglas had oral cancer. Exactly. He survived. I think that was related to HPV. Related to HPV. Now, HPV is highly... with cervical cancer. It's also highly associated with oral cancer. Pharyngeal. Exactly, or pharyngeal cancer. The good news about HPV-induced oral cancer, if you can ever say there's good news about cancer, is that HPV-induced oral cancers are more amenable to treatment than other cancers of the mouth that are not caused by HPV. So, Michael. Michael Douglas is a survivor. Lots of people have survived, but a lot of people have passed away from it. Yeah, now oral pharyngeal cancer, which is, as we just mentioned, is very much related to HPV, can be tested in the dental office with a long swab that goes down to the pharyngeal tissue and sent to a lab. When you test for the HPV, if it continually shows up positive over multiple tests, then you become very high risk. So that puts you in a category where you're being treated differently as far as the potential of getting that cancer, and that could save your life. So it's really the HPV, and there's a certain strain of HPV, I believe, that is particularly dangerous when it comes to oropharyngeal cancer. Yes, it's like women go for their pap smears all the time as a preventative measure. the population in general, it wouldn't be a bad idea to have the pharyngeal swab to test for HPV. So let me ask you this. I'd love your opinion on this, Dr. Commissar. Are dentists any less liable by not doing an oral cancer exam versus doing an exam and missing something? If you don't do an oral cancer exam, but the patient develops oral cancer, you're liable simply because Part of an everyday exam on every patient is looking at the cheeks, looking at the lips, looking at the tongue, looking at the soft tissue, looking at the soft palate, the hard palate, and on and on and on. So an average exam, D0150, new patient, D0120, periodic exam, all of those exams technically include an oral cancer exam. So if you're doing an exam on any patient, if you look... to any patient and you miss something, you're liable. If you do an oral cancer screening with a specific device and you miss it, you're also liable. Now, dentists don't like to get involved with cancer. They don't like to get involved with biopsies because they're worried and they shouldn't be because there are four possible outcomes. Let's say it's benign and you got it all. Well, congratulations. Are you done? No, absolutely not. You follow up the patient to make sure it doesn't recur. It's benign and you didn't get it all. Are you done? No, you watch the patient periodically to make sure it doesn't enlarge. It's malignant and you got it all. Well, congratulations. Are you done? No, you refer the patient to a head and neck surgeon for further evaluation. It's malignant and you didn't get it all. Well, you refer the patient to a head and neck surgeon. So no matter... what the biopsy results are, you have no liability. The liability occurs when you don't look, when you put your your head in the sand when you don't know how to do a competent oral cancer screening. That's the problem. Now, when you're talking about getting it all, you're talking about the perimeters of the biopsy being clean? Yes, yes. I'm talking about clean margins. Okay, clean margins. And in order to get those clean margins, is there any particular biopsy technique that you recommend? It depends on the size of the lesion. It depends on the shape of the lesion. Lesions are... If they're benign, they're relatively discreet. You know there's a beginning and an end. You know there's a definitive margin. Something that's malignant, you can't tell where it begins and ends. It just blends into the surrounding tissue. So there are many lesions you can do with a punch biopsy. There are plenty of lesions that you can do the old-fashioned way with a scalpel. Scalpels work beautifully. If you're well-trained, you can do them with radiosurgery and electrosurgery. Just take a slightly wider margin so there's no effect on the tissue. I've been using lasers for biopsies for over three decades. And if you know the tool that you're using, a laser, radiosurge, electrosurge, whatever, you should have no problem whatsoever doing a biopsy correctly. It's training and using the tool correctly more than anything else. So what do you recommend, Dr. Commissar, to a doctor who doesn't do biopsies, they don't feel comfortable doing biopsies, but they consistently on every patient perform an oral cancer exam? And if they see something suspicious, they send it out. Is that removing the liability on that dentist? Because they did the exam and then they referred it to a specialist. The second part of that question is, is there any protocol associated with not doing a biopsy and just referring these patients out? Yes and no as far as liability. First of all, documentation is everything in any malpractice case. Document, document, document. Make absolutely certain that you documented, you discovered a lesion, where the lesion is, and you referred the patient to Dr. X oral maxillofacial surgeon. As long as you write down you have made the referral, you are fine. The other thing, of course, is the most wonderful, magnificent, perfect tool in the history of dentistry is your smartphone. Just take a picture of the lesion and put it in the patient's file so you have documented, you saw the lesion, this is what the lesion looks like, and you send a copy of that to the oral surgeon. What I have done in the past when there were lesions that were suspicious that I didn't want to get involved with is I would take the patient, walk the patient over to the front desk. have my people at the front desk call the oral surgeon right then and there with the patient standing there, and the patient would make the appointment to see the oral surgeon right in front of me. So I knew that that patient was going to follow up. When you give a patient bad news, oh, there may be some cancer or there's something we need to biopsy, very often they'll put their heads in the sand. But if you walk them, you make certain that the phone call is made, you have no liability whatsoever. The liability is when you see something and you don't make certain that they are referred to the correct specialist. So what do you recommend, Dr. Commissar, as far as the armamentarium needed in a typical general practice to do a thorough oral cancer exam? What kind of tools do we need? The best tools are a piece of gauze, your eyeballs, your thumb and index finger. to palpate tissue and i prefer to use a fluorescence visualization device and there are a whole bunch of devices out there on the market one of which is something called goccles which look like protective curing light glasses and as a matter of fact it's special lenses in these glasses that filter out certain wavelengths and you can actually use your curing light with these special glasses to see if there is something worth biopsying or not. The important thing to understand, whether you're talking about any of these different devices, is that they do not diagnose cancer. They diagnose that there is something worth evaluating. They diagnose something that's worth looking into. You don't take a goggles and look at something and say, oh, that's cancer. You say there's something there. It needs to be evaluated further. Here's the oral. surgeon's number, and let's make an appointment. And these things are invaluable. And it's not just from the point of view of dentists thinking it's invaluable. It's the Journal of the American Medical Association published an article not too long ago about how invaluable these are for use in surgery, that when somebody comes in with a lesion, the goggles and other similar devices are able to delineate. the margins of the lesion much, much better than if you just use your own eyeballs. These things are really invaluable. And in the simplest terms, the way this thing works is that if it's green, the tissue is emitting a green fluorescent color that indicates healthy tissue. And when it's dark, then there's something going on. It could be dysplastic. There could be some... unhealthy activity going on at the tissue level. Is that correct? Is that right? Exactly. It gives you an idea that something's going on. It doesn't tell you it's cancer. It usually implies that that tissue is more mitotically active. And we know that cancers grow faster and cancers are more mitotically active. If you cut yourself. and the cut is healing. You take a look at the cut through goggles or something similar 24 hours after you cut yourself. It will look a little different than the surrounding tissue because as that area heals, it's more mitotically active. So that's basically how it works. It'll fluoresce differently. You'll see a tremendous difference in color. Take a picture. Send the picture to the oral surgeon. This is what I saw. and take it from there. So you do a lot of biopsies when you need to. You've been doing this a long time. Now, you're not an oral surgeon. You're a general dentist, right? Just a plain old vanilla general practitioner. Where did you get the confidence in doing the biopsy? Because again, it's not only just the cutting and the removal of the tissue, it's also deciding when not to touch something, like something that's going to bleed forever. So tell us about that. Well, when I graduated from dental school, I did a one-year GPR, general practice residency, which in the state of New York these days is mandatory to get a license, which I think is a wonderful thing. I learned more in my one-year GPR than I did in four years of dental school. I'm a big advocate for general practice residencies. or aegds so i did a lot of everything and once i got into private practice uh i continued doing oral cancer screenings my residency was in a va hospital uh 1980 to 1981 and in the va hospital what did we have in those days we had alcoholic drug abusing tobacco smoking uh patients and all of those things are risk factors for all cancer smokers get oral cancer Alcoholics get oral cancer. Alcoholic smokers have a 30 times greater incidence of oral cancer because of the synergy between the alcohol and tobacco. So I saw a ton of oral cancer. And the first time I was in an OR and saw a hemiglasectomy, have a guy have half of his tongue removed, I knew that I was going to make certain nobody was ever going to die in my office on my watch. So I took plenty of continuing education. I learned how to... finesse my biopsy technique. I learned how to do a competent oral cancer screening, and I just took it from there. It's not difficult. I would rather do a simple soft tissue biopsy than... a class two restoration MOD on a second molar where you have to worry about the mesial marginal ridge height and the distal marginal ridge height and the proximal box curing correctly and the occlusion and the color and all of that stuff. Biopsy is a very simple procedure to do. It sounds like you should have been an oral surgeon. Well, I did plenty of surgery in my day. Now, was your mentor in your general practice residency an oral surgeon? Yes. Okay, so that explains it. The hospital that I trained at, the oral maxillofacial surgeon was a brilliant oral surgeon who was trained during the Korean War. And he was actually in a MASH unit, and he put people's faces together when they were blown apart during the Korean War. So he was eminently trained, and he was just a great, wonderful instructor. And like I said, Performing a biopsy is not a big deal at all. It doesn't take a ton of training. So we've talked offline about this, Dr. Commissar. You have a mnemonic device that you use to teach, and it basically helps us identify lesions that could be malignant. Tell us about that. Okay. So when I developed this technique for oral cancer screening, I was trying to think of a mnemonic device because Like you and many of our colleagues out there, how did we learn gross anatomy? A lot of mnemonic devices, the 12 cranial nerves, the five branches of the facial nerve, and on and on and on. And I couldn't think of a great mnemonic device, but I came up with FIGRUB, F-I-G-R-U-B, FIGRUB. And that gives us six characteristics that would make you think that it's probably malignant, not benign. F for fixed. If it's fixed to the tissue. Rather than wobbly, it's probably malignant. I, indurated. If it's hard, it's probably cancer because benign things are relatively sore. G, growth. If it grows quickly, that's a warning sign. If it grows slowly, not too bad. R, red. If it's red or white, or red and white, that's a warning sign. U, ulcerated. Cancers usually, but not always, have an ulcerated border. B, bleeding. If it bleeds easily, if it bleeds spontaneously, it's probably something that's malignant. Now, you have to use that with a little bit of common sense. I'm taking a look at a patient's palate, and I see something that is fixed and indurated and ulcerated. What is it? It's just a... maxillary torus, a palatal torus, and he had pizza and he has a pizza burn. That's why it's ulcerated. So a little bit of common sense when you use F-I-G-R-U-B, and you should have confidence in being able to figure out if you're looking at something benign or malignant. So of course, it's important to document the size of the lesion when you identify something, and you can do that through photographs. So you take a picture with the perioprobe horizontally and vertically. Because that will tell you that it's three millimeters by four millimeters. You come back two weeks later to the patient and you're standing a foot closer to the patient. Well, it's going to look bigger. Or you're standing a foot further away from the patient. Well, it's going to look smaller. If you have a periodontal probe in the photo, you know that the size is exactly what it is. So that's a good little tip. So you talked about what we need to have in the office as far as the exam. which every office has. And then, of course, something like Goccels is another addition, which should really help. What about the actual biopsy? What do we need as far as armamentarium to do the biopsy itself? And let me add a second part of that question. What do you do when the biopsy comes back malignant? Okay, first let's do if it comes back malignant. The first thing you do is you get the pathology report. It says malignant. You discuss it with the patient. And you send that patient right to whoever you feel like, either an oral maxillofacial surgeon or a head and neck surgeon, whoever you have confidence in. And you have the surgeon take it from there. That's happened plenty of times in my lifetime. You just make certain they make the appointment and they go. As far as special equipment, there is no special equipment. Everything you need to perform a biopsy is in your office. A 15 blade. a needle holder, a pair of scissors to cut the sutures, some sort of suture material, any suture material. You want to use silk, you want to use gut, you want to use nylon, you want to use vicryl, who cares? Whatever you're comfortable with. Cotton forceps, cotton pliers, and that's basically it. Something that would be optional but highly recommended. You remember those old denture marking sticks you would use to mark denture sores? Well, those are great little things. You're looking at the lesion. You have the goggles on. You can see where the margins are. And you take these little denture sore spot marking pencils and you draw a line around where the margins are. Makes it very, very simple. Then you take your 12B blade or 15 blade or whatever. You remove it. You're all set. Simple, easy, no big deal. Once the biopsy is completed for healing purposes, do you typically suture or do you often rely on secondary intention for healing? And I assume this is related to the size of the biopsy itself. Depending on the size of the lesion, because I use a laser most of the time, I rarely... rarely suture. And in the past, when I used the blade, same thing. Most of the time, you just let it granulate in by secondary intent. It's easy. It's simple. The only time I would suture is if it's in an area of cosmetics. If I'm doing a mucous seal on the lip or something that's in a visible area or the upper anterior or lower anterior gingiva and the patient has a wide smile, I would suture. But otherwise, just... Let it heal by secondary intent. That'll be absolutely fine. Have you had situations where you've done a biopsy and you really were challenged as far as stopping the bleeding? No. There are a couple of good little hints aside from gauze and pressure. Something that I always keep in my office all the time is a little bottle of nasal spray. Oxymedazoline, it's sold as Afrin and plenty of other things. Those are very, very potent vasoconstrictors. So if you have a little problem with bleeding, you take a little bit of Afrin, a drop or two of Afrin on a cotton pledget, hold it with pressure on the bleeding site, and it should usually stop it. Very, very quickly. Any recommendations, Dr. Commissar, on a good video to watch as a refresher for our listeners to take just to make sure they're doing the latest and the greatest with their oral cancer exams? The American Dental Association has a very nice oral cancer screening video. You can watch it on YouTube. for free uh just google on youtube american dental association oral cancer screening and and the video will pop up of course there are continuing education courses um personally I give CE courses on oral cancer detection, on biopsy technique. We also give hands-on courses, what to do, how to do it. We work on pig mandibles, so everybody gets a chance to perform biopsies. And once again, a biopsy is not a difficult procedure, much simpler than doing a quadrant of periosurgery, much simpler than placing an implant. And these are things that GPs do. GPs place millions of implants a year. To do a biopsy is much, much, much simpler. I know you're a big fan of lasers. You teach lasers, Dr. Commissar. What kind of laser is typically used in your office for a biopsy procedure? What kind of laser I'm using is a little difficult. I've been using lasers for 30 plus years. I've been lecturing and teaching lasers for decades. I've written seven laser textbooks. So I have about a dozen lasers in my office. My preference is a carbon dioxide laser for a whole host of reasons. But once again, you don't need a laser. A laser is a tool. If you're trained well using the tool, you'll get a great result. I could give you the best laser in the world and no training and you'll mess up terribly. I could give you a terrible laser, but give you great training and you'll get good results. So whether you use a laser or a scalpel or an electro surge or a punch or anything else, the important thing is, the important things, there are three things that are critical. Number one is training. Number two is training. And number three is training. Once you're well-trained using the device, you should have no trouble whatsoever. So we haven't talked about the actual part where you actually remove the specimen. What do you do with it and how is it handled? Is that typically handled by your staff? That's something that I do. As soon as I have the biopsy. removed from the tissue. The biopsy jar is on my bracket table. I just drop it in the biopsy jar, fill out the form and send it out. And the biopsy jar and all the instructions and all the paperwork you get for free from the biopsy service. So you don't have to go out and buy anything. You call the local oral pathologist and you say, hey, I want to start doing biopsies. They will send you the FedEx label or the postage paid label. They'll send you the jar. They'll send you the paperwork. You just do the biopsy, throw it in the jar, you're all set. No big deal. Yeah, and it certainly is a lifesaver to do this. And I encourage every general dentist in the world who's listening to this podcast to get the training that Dr. Commissar is alluding to so that you have the confidence in doing these because how many lives do you think you have saved in your career? Plenty, plenty, at least a dozen easily. My oral pathology professor at NYU. Always started off as oral pathology lectures every morning by saying, good morning, ladies and gentlemen. If you practice as a dentist for 25 years full time and you never see a case of oral cancer, you killed somebody by missing it. And that was a... really profound statement. And that made a tremendous impression on me. So then I went to the VA hospital and saw a lot of oral cancer. So if you've been practicing a long time and haven't seen an oral cancer, there's a good chance that you missed one. So it's critically important. And if anybody has any questions, wants to contact me about trainings or anything, may I give my email address? Absolutely, please, please do. Because I use a laser, my email address is so ridiculous, you'll never forget it. I use a laser. My name is Bob and I'm a DDS. So my email address is, ready for this, laserbobdds, L-A-S-E-R-B-O-B-D-D-S, laserbobdds at Gmail. And if you need training on biopsy technique, on lasers, on working on one week old babies, which is another. topic for another day, just shoot me an email and I'll make certain you get the best training in the world. Very good. Thank you very much, Dr. Convissar. Always a pleasure to have you on the show. And thanks for your contributions over the years to Viva Learning. Have a great evening. Thanks for having me. It's been a pleasure.