A new chairside diagnostic procedure for dentists?

[Smilemaker100]

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At the recent "Annual Scientific Assembly of the American College of Chest Physicians" held in Montreal this October, new studies have revealed that swabs of a patient's buccal mucosal cells may help diagnose lung cancer with an accuracy of 50%. There is a significant association between global DNA
methylation in buccal mucosal cells and malignant tissues of the lung (certain methylation patterns of DNA can lead to expression of oncogenes).

"The human lung is inaccessible for direct examination. Buccal cells lining the inner cheek of tobacco smokers are carcinogen- and oxidant-exposed, easily accessible, and potentially valuable surrogates for lung tissue. Lung cancer susceptibility phenotyping might include carcinogen-metabolism and oxidant-metabolism gene expression assayed in buccal cells."

I wouldn't be surprised if dentists get more involved in chairside diagnostic procedures for other illnesses in the future (ie.more oral medicine/oral pathology). As we begin to observe a trend of more and more patients with caries-free mouths, dentists will have to find other procedures to do in the oral cavity.

Comments?

 

[DrJeff]

At the recent "Annual Scientific Assembly of the American College of Chest Physicians" held in Montreal this October, new studies have revealed that swabs of a patient's buccal mucosal cells may help diagnose lung cancer with an accuracy of 50%. There is a significant association between global DNA
methylation in buccal mucosal cells and malignant tissues of the lung (certain methylation patterns of DNA can lead to expression of oncogenes).

"The human lung is inaccessible for direct examination. Buccal cells lining the inner cheek of tobacco smokers are carcinogen- and oxidant-exposed, easily accessible, and potentially valuable surrogates for lung tissue. Lung cancer susceptibility phenotyping might include carcinogen-metabolism and oxidant-metabolism gene expression assayed in buccal cells."

I wouldn't be surprised if dentists get more involved in chairside diagnostic procedures for other illnesses in the future (ie.more oral medicine/oral pathology). As we begin to observe a trend of more and more patients with caries-free mouths, dentists will have to find other procedures to do in the oral cavity.

Comments?

While the concept of dental providing widespread medical screening is interesting, I'd be a bit concerned over its use with respect to maintaining our relative dental autonomy from managed healthcare (I realize you "canucks" have it a bit different 😉 😀 ).

I could see the insurance companies potentially using this as a means to get managed dental care into our offices, and thus decrease our ability to set our own fees (see the HMO'ing of medical fees and what it's done to our medical colleagues) 😱

 

[OffAngleHatchet]

I could see the insurance companies potentially using this as a means to get managed dental care into our offices, and thus decrease our ability to set our own fees (see the HMO'ing of medical fees and what it's done to our medical colleagues) 😱

Could you explain this a bit more? I can see how a buccal mucosa swab/test sort of blurs the line between medicine and dentistry, but I fail to see how it can be a wedge for managed care.

 

[Smilemaker100]

Could you explain this a bit more? I can see how a buccal mucosa swab/test sort of blurs the line between medicine and dentistry, but I fail to see how it can be a wedge for managed care.

That's the attitude which really irritates me! 😡 The head & neck area as well as the oral cavity are obviously the aspects which interests us as dentists but it is NOT separate from the rest of the body. Dentistry is becoming more and more medically oriented than it has in the past. In case you aren't aware, there are a number of dental schools in which dental students are enrolled in medical school curriculums for the first year or so. There is a reason why!!!!!!

I don't know how far along you are in your dental education, but in case you aren't aware , there are over 200 systemic diseases (including diabetes, metastases, AIDS related conditions and many more) which are manifested in the mouth which go undetected by family physicians and are detected by dentists.

 

[DrJeff]

Could you explain this a bit more? I can see how a buccal mucosa swab/test sort of blurs the line between medicine and dentistry, but I fail to see how it can be a wedge for managed care.

First off, with respect to insurance companies, you have to remember they are a FOR PROFIT(their profits, not yours 😱 ) company, and while your patients might think that they are a great thing, you as a business person dealing with them will soon realize the amount of headaches and red tape they'll cause you are vast and ever increasing(but thats a monsterous additonal thread topic on its own)

Now, if you're doing an intra-oral swab to detect the chances of lung cancer, that's going to be billed via medical insurance(a bit of an assumption on my part, but I feel that its a safe assumption) not dental. When you enroll with an insurnace companies plan, in most cases you have to enroll with all of their plans and then the wording of the contract states that the fees that you accept from them will be the lowest that you charge (i.e. if the fee that insurance company A pays you for a procedure is $100, and company B pays $90 for the same procedure, then per the contract, comapny A will only reimburse you the $90 that comapny B pays you). Medical and dental insurance are 2 seperate items(for now) and while a smaller segement of insurance company cash outlaws, they're always looking for ways to lower costs. If you were to do/bill this oral swab under an HMO pro rated fee schedule, it wouldn't take an insurance company too long to bundle/morph this HMO medical fee schedule to dentistry.

You have to remember that from a business side, dental insurance companies want to see your patients loose all their teeth and have dentures made since long term that is much more cost effective to their bottom lines.

 

[Smilemaker100]

While the concept of dental providing widespread medical screening is interesting, I'd be a bit concerned over its use with respect to maintaining our relative dental autonomy from managed healthcare (I realize you "canucks" have it a bit different 😉 😀 ).

I could see the insurance companies potentially using this as a means to get managed dental care into our offices, and thus decrease our ability to set our own fees (see the HMO'ing of medical fees and what it's done to our medical colleagues) 😱

There is a lot of debate going on in the medicare system in Canada at the moment, especially on the political platform when elections come around. 🙄

The socialized medical system is deteriorating especially with about 10 million Canadian baby boomers who are afflicted with a number of chronic conditions and are relying on the system more and more as time rolls on. It appears that a little above 50 % of the population are in favor of more privatization of certain services.

In Canada, we are leaning more and more to a "two-tiered" medicare system. This is especially more evident in the Western provinces where there is a lot of privatization in the works ,especially for orthopedic procedures, cataracts surgery and open heart surgery. As a matter of fact, these private clinics are attracting a lot of non residents (foreigners) hailing from the U.S and other countries because of the "under-pricing". For instance, surgeons' fees in Canada are 10 to 20 % of those in the U.S 😱

It looks like Canada will be keeping its current medical system while continuing to expand the parallel private system. A number of politicians are insinuating that a number of people (hospital workers such as nurses, doctors and hospital managers) can reap the benefits from this expansion. They have also argued that the private sector can even save medicare.

I can discuss this subject in more length but that is beyond the realm of this thread. But I just wanted to give you an insight, Dr Jeff, that there is a lot more privatization going on in Canada than most Americans are aware of.

 

[Smilemaker100]

First off, with respect to insurance companies, you have to remember they are a FOR PROFIT(their profits, not yours 😱 ) company, and while your patients might think that they are a great thing, you as a business person dealing with them will soon realize the amount of headaches and red tape they'll cause you are vast and ever increasing(but thats a monsterous additonal thread topic on its own)

Now, if you're doing an intra-oral swab to detect the chances of lung cancer, that's going to be billed via medical insurance(a bit of an assumption on my part, but I feel that its a safe assumption) not dental. When you enroll with an insurnace companies plan, in most cases you have to enroll with all of their plans and then the wording of the contract states that the fees that you accept from them will be the lowest that you charge (i.e. if the fee that insurance company A pays you for a procedure is $100, and company B pays $90 for the same procedure, then per the contract, comapny A will only reimburse you the $90 that comapny B pays you). Medical and dental insurance are 2 seperate items(for now) and while a smaller segement of insurance company cash outlaws, they're always looking for ways to lower costs. If you were to do/bill this oral swab under an HMO pro rated fee schedule, it wouldn't take an insurance company too long to bundle/morph this HMO medical fee schedule to dentistry.

You have to remember that from a business side, dental insurance companies want to see your patients loose all their teeth and have dentures made since long term that is much more cost effective to their bottom lines.

It will definitely be interesting to see how this evolves. But you can't deny that at some point in the future, this subject may be debated.

 

[Doggie]

At the recent "Annual Scientific Assembly of the American College of Chest Physicians" held in Montreal this October, new studies have revealed that swabs of a patient's buccal mucosal cells may help diagnose lung cancer with an accuracy of 50%. There is a significant association between global DNA
methylation in buccal mucosal cells and malignant tissues of the lung (certain methylation patterns of DNA can lead to expression of oncogenes).

"The human lung is inaccessible for direct examination. Buccal cells lining the inner cheek of tobacco smokers are carcinogen- and oxidant-exposed, easily accessible, and potentially valuable surrogates for lung tissue. Lung cancer susceptibility phenotyping might include carcinogen-metabolism and oxidant-metabolism gene expression assayed in buccal cells."

I wouldn't be surprised if dentists get more involved in chairside diagnostic procedures for other illnesses in the future (ie.more oral medicine/oral pathology). As we begin to observe a trend of more and more patients with caries-free mouths, dentists will have to find other procedures to do in the oral cavity.

Comments?

Maybe it's just me, but I think a diagnostic test that only gives you a 50% guess at whether or not you have a disease is of no diagnostic value at all. Might as well have a long term smoker flip a coin and use that as a diagnostic test.

 

[Smilemaker100]

Maybe it's just me, but I think a diagnostic test that only gives you a 50% guess at whether or not you have a disease is of no diagnostic value at all. Might as well have a long term smoker flip a coin and use that as a diagnostic test.

Sure, but that's not the point. My point was I foresee a number of diagnostic procedures being undertaken by dentists in the future as well as an increased "medicalization" direction in our field and wanted to see what others views were on this.

 

[Smilemaker100]

Maybe it's just me, but I think a diagnostic test that only gives you a 50% guess at whether or not you have a disease is of no diagnostic value at all. Might as well have a long term smoker flip a coin and use that as a diagnostic test.

There was an error in my original post, it is MORE than 50%. I reread the data from the unpublished abstract which I got from a doctor-friend of mine.

 

[OffAngleHatchet]

That's the attitude which really irritates me! 😡 The head & neck area as well as the oral cavity are obviously the aspects which interests us as dentists but it is NOT separate from the rest of the body. Dentistry is becoming more and more medically oriented than it has in the past. In case you aren't aware, there are a number of dental schools in which dental students are enrolled in medical school curriculums for the first year or so. There is a reason why!!!!!! I don't know how far along you are in your dental education, but in case you aren't aware , there are over 200 systemic diseases (including diabetes, metastases, AIDS related conditions and many more) which are manifested in the mouth which go undetected by family physicians and are detected by dentists.

I'm sorry if I didn't frame my response the way you'd like to hear it, but I find that most lay people divide the dental vs. medical profession by what tasks each practitioner performs.

And for me, being only slightly more enlightened than your average joe (I just started dschool this year), the "blurring the line" phrase made sense in my mind because I was thinking about who does testing and who does treatment. For operative procedures in dentistry, at least, the person making the discovery of decay is the same one executing the treatment. Likewise, the family doctor requesting the blood test is the same one prescribing antibiotics.

This new test is an intraoral exam that can be delivered by a dentist... but the person who would actually treat the cancer would be an oncologist (medical doctor). Hence, the "blurring the line".

Most people outside of our tiny world of dental practices and dental schools still think that the mouth is just there to hold teeth so you can chew; that tooth decay is just 'normal wear and tear' (and not a bacterial infection); and that Novocaine is still our local anesthetic of choice.

Yes, I am aware that there are a ton of diseases that show up in the oral cavity first - we're learning about them now. And, I'm currently learning how abnormal physiology affects the oral cavity. Please remember that you had to learn new things yourself before you got to where you are now. I'll get there eventually, so cut me some slack. I hope for your sake that you don't blow your top every time a patient comes to you and doesn't quite see eye to eye with you on whatever it is you're talking about. I'm hoping you'd probably talk to them in such a way that they don't feel stupid - that you'd probably try to shift their thinking, calmly. At least I hope so. If that's not the case, well, good luck to you then.

 

[OffAngleHatchet]

<snip>

Thanks for that explanation. That makes more sense to me now.