Incorporating More Oral Pathology in Your Dental Practice

Episode #418 with Dr. Ashley Clark

Survival rates for oral cancers are not great. So, the best thing to do is to actively prevent them.  And today, Kirk Behrendt brings in Dr. Ashley Clark, Division Chief of Oral Pathology at the University of Kentucky College of Dentistry, to share the importance of early detection, the steps to take when you come across a case, and how to communicate your findings without terrifying your patients. Screening every patient, every time, can help save a life! To learn more, listen to Episode 418 of The Best Practices Show!

Main Takeaways:

Early detection is critical to preventing oral cancers.

Screen every patient, every time, for oral cancer.

Adequately train team members to look for signs.

Never ignore leukoplakia. It can become cancerous.

Communicate clearly without scaring your patients.

Quotes:

“Oral cancer is probably the biggest thing we deal with — the most important thing that we deal with, specifically squamous cell carcinoma — and survival rates aren't getting any better. They really haven't significantly improved. So, my passion is to get the information out there, catch it before it turns into cancer. That's my main goal, is to educate as many general dentists, specifically, as possible on how to find leukoplakia, what it looks like, what it can mimic, and what to do about it so we can hopefully prevent these oral squamous cell carcinomas from happening.” (2:25—3:02)

“The five-year survival rate for oral cancer that is HPV-negative is 45% to 50%, overall. And that doesn't include the fact that they're going to have a pretty disfiguring surgery to try to get the cancer out, plus or minus radiation where they might lose saliva and have to deal with those quality-of-life issues. So, if we can catch leukoplakia as it’s in its dysplastic phase, surgically removing it lowers that risk of that patient having oral cancer by 50%. So, that's where we are. I will say that the rates of HPV-negative oral cancer have declined, and that correlates with the decline in smoking. But the survival rates still aren't great.” (3:14—4:04)

“[The decline in HPV-negative oral cancer risk] directly correlates with the decline in smoking. About 80% of patients with HPV-negative oral cancer are pretty heavy smokers — or people who smoke pretty heavily, I'd rather say. But one interesting thing that’s happening is between the ages of 18 and 44, there's been this cohort of young women who have been getting tongue cancers without any risk factors — no HPV, no tobacco, no alcohol. So, that's another thing I like to get out. Don't ignore your 30-year-old female patient who has a white tongue lesion, because incidents have grown 0.06% every year for like 20 years. So, that's another group that might be getting overlooked.” (4:09—4:56)

“I think other healthcare professionals who are focusing on the teeth might forget to look at the soft tissue. That's not a value judgment — I did it myself several times when I was in charge of looking at teeth. I forgot, or I was focused in on that pathology. So, I think it could be really easy to focus in on the crown you're doing and forget about doing an oral cancer screening. So, I think doing them every patient, every time, is one thing upon which we could improve.” (5:34—5:57)

“Another [important] thing is to not ignore leukoplakia, especially if it’s on the gingiva. Sometimes, leukoplakia doesn't really look that scary — especially proliferative verrucous leukoplakia. Initially, it doesn't look that scary. But if it’s left untreated, nearly 100% will eventually turn into cancer. So, don't ignore things that could come down the road.” (6:04—6:26)

“I train a lot of dental hygienists. And they actually find a ton of lesions, in my experience. They might not always know what they are as well as a doctor who might have a little bit more training does. But the hygienists have been great at screening and finding them. I think that one of the issues is we don't see it every day. And I always tell my former students, ‘Don't feel bad that you don't remember what this is. Just see it, and then know what to do about it.’” (7:03—7:38)

“I understand if you haven't seen a lot of this pathology, you might say, ‘I know this isn't right, but I'm not quite sure what it is.’ And as long as you say, ‘I know this isn't right. I'm going to get it to someone who does know what to do about it,’ then you've done your job.” (7:50—8:04)

“There's really not a whole lot of data on the best way to communicate with your patients. And something that I found surprising is that communication does not reliably improve with experience. So, just because you've been telling people something for 10 years doesn't necessarily mean that you're doing it the proper way. So, communication is very important. And also, patients will judge your competence based on your communication skills. So, the communication piece is important.” (8:45—9:14)

“What is trending upward is HPV-driven cancer. So, now, more men will get HPV-driven oropharyngeal carcinoma — HPV-driven throat cancer — than women will get HPV-driven cervical cancer. So, it’s really an epidemic that is happening with HPV-driven cancers. About 16,000 men will get HPV throat cancer. About 10,000 women will get cervical cancer. So, another thing I really push is the Gardasil 9 vaccine. I think most people know about Gardasil. But they might not know about Gardasil 9, which is one that came out relatively a long time ago, about 2014. But as of 2018, it was available for anyone ages nine to 45. Whereas before, it was only open to age 26 for women, 21 for men. So, that's really exciting.” (9:50—10:51)

“The interesting thing is people don't know that more men get HPV cancer than women do. Because when you think of HPV cancer, you think of women — cervical cancer. And physicians think that too. So, more women are actually protected with the vaccine than men. So, it really should be reversed, at this point.” (11:05—11:26)

“Starting next week, it takes a very small amount of time, make sure you're looking at all the soft tissue. Every patient, every time, is the Ashley Clark motto, I like to say. So, leukoplakia tends to happen before these HPV-negative cancers. So, that's sort of the good thing about these oral cavity proper oral cancers, is that we can see them before they turn outright malignant. So, our goal is to catch them in that dysplastic phase.” (12:34—13:06)

“Assistants, I don't know how well they're trained in catching anomalies. But I'm sure if they’ve been doing it for a long time, they know exactly what a weird-looking thing looks like. So, lateral and ventral, tongue, floor, mouth, and gingiva. Those are the most common places that we get cancers. And the gingival ones are tricky because they tend to look like other things. So, my advice is, always treat it like you've diagnosed it. If you think it’s periodontal disease, treat it like that. Common things occur commonly. Periodontal disease is more common than gingival squamous cell. But if it’s not responding appropriately to your treatment plan, let's go back to your original diagnosis and rethink it.” (13:15—13:56)

“For me, if I was a general dentist, I would say, ‘Hey, I see this white thing here. I don't know what it is. Doesn’t look like cancer to me, but I can't promise that it’s not something that might turn into cancer. So, I'm going to give you a referral. We’re going to get it taken care of before it turns into anything bad, hopefully.’ So, you don't want to panic these patients, but you want to add some degree of urgency, especially if you really don't think it’s cancer. But it is a flat, white lesion that you can't explain. So, that needs a biopsy. And preferably, a scalpel biopsy, not a brush biopsy.” (14:28—15:03)

“We don't want to scare [patients], but we want to say, ‘I can't promise you that this isn't a form of precancer, and we just want to rule that out. So, that's why it’s important that you go get your biopsy.’” (15:15—15:27)

“I would recommend referring to oral surgery or a periodontist, especially if it’s on the gingiva, because periodontists do surgeries too. So, we don't want to forget about that specialty. But usually, oral surgery, there are insurance implications here. Sometimes, oral surgery can take medical insurance. I guess perio can too, but I tend to find out surgery takes medical more than perio. But that just might be my bias. So, refer to one of those two.” (15:44—16:17)

“[After referring a patient,] what they will do is take a biopsy, send it to me or another pathologist, and get a report back. And then, hopefully, the surgeon will, including the periodontist, send that report back to the general dentist. So, if you have a patient with leukoplakia, and let's say I call it hyperkeratosis. That's totally benign. Let's say it comes back as hyperkeratosis on the lateral tongue. It’s benign. It doesn't need to come out. But you need to watch it. And the literature says you have to watch that spot every six months for 20 years. And if it changes in any way, you have to rebiopsy it. So, I don't want people to miss that second part, the follow-up part. Like, ‘We’ve caught this white lesion. Oh, it was hyperkeratosis. Well, now, we still have to watch it.’ Because if it changes, then the diagnosis has changed.” (16:18—17:18)

Snippets:

0:00 Introduction.

1:13 Dr. Clark’s background.

1:53 Why Dr. Clark is passionate about this topic.

3:07 Recent data on oral cancers.

4:58 What the dental profession gets wrong about oral pathology.

6:27 Have adequate training for early detection.

8:04 The importance of communicating with patients.

9:35 Trends in this space.

11:26 Where to start with treatment planning.

14:04 How to have the conversation with patients.

15:27 Who to refer cases to.

17:19 The importance of early detection.

18:32 Myths around piercings and squamous cell carcinoma.

20:12 The future of oral pathology.

22:42 Dr. Clark’s contact information.

23:29 Last thoughts on oral pathology.

Reach Out to Dr. Clark:

Dr. Clark’s Facebook: https://www.facebook.com/ashley.neuman.39

Dr. Clark’s Facebook: https://www.facebook.com/OralPathologySpeaker/services

Dr. Clark’s email: ashley.clark.dds@uky.edu 

Dr. Ashley Clark Bio:

Dr. Ashley Nicole Clark, DDS, is an Associate Professor and Division Chief of Oral Pathology at the University of Kentucky College of Dentistry. She earned a DDS from Indiana University and a certificate in Oral and Maxillofacial Pathology from the University of Florida.

Dr. Clark has earned the John H. Freeman Award in the Scholarship of Teaching. She serves as a councilor for the American Academy of Oral and Maxillofacial Pathology and is on the review committee for oral pathology for the Commission on Dental Accreditation. Dr. Clark is on the professional board for Digital Dental Notes and Oral Cancer Cause, is a member of OKU, and is a Fellow in the American College of Dentists. Dr. Clark has published over 40 papers and abstracts, two book chapters, and has authored the oral pathology sections of the Dental Decks.