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Today’s Advanced Diagnostic Technologies
Scott Benjamin, DDS
Dentistry is rapidly evolving from a surgical and reparative profession into a healing profession focused on overall patient wellness. The oral systematic connection has been well established, with the condition and status of the oral cavity being a great indicator of the patient’s overall health. With this, the dental practitioner’s role is progressing from that of a restorative dentist dependent on their psychomotor skills to one of a diagnostician and case manager relying on their cognitive skills. The focus is now disease prevention, early discovery, and intervention to minimize treatment, thus enabling the most desirable outcomes.
Advanced diagnostic technologies are increasingly playing a more vital role in this process, both in data collection and assessment capabilities, and the utilization of the information obtained. Diagnostic modalities available to clinicians today expand greatly on the foundation of a comprehensive visual assessment, which has been and will be the cornerstone of the diagnostic process.
The diagnostic clinician today is able to obtain a seemingly endless amount of information to assess the patient’s oral health, which in turn gives them and the patient’s other healthcare providers tremendous knowledge about the patient’s overall health and wellness. An excellent example is the advancement of radiographic imaging. The conventional 2-dimensional radiographs that have been used for more than a century have expanded to the digital imaging modalities of today. These include 3-dimensional (3-D) cone-beam computed tomography (CBCT), which provides an extremely accurate 3-D rendering of the craniofacial structures.
The 3-D CBCT images can be combined with high-precision 3-D visible light (photographic) surface images to create a virtual patient that accurately displays both hard and soft tissue structures. This multi-modal image visualization enables a treatment platform that allows assessment of the patient’s present condition, planning and simulation of treatment options, progress monitoring, and evaluation of outcomes.
Another imaging modality available includes fluorescence technology to evaluate the chemistry and morphology of various hard and soft tissues and substances within the oral cavity. This visualization, which can be either direct (ie, viewed directly by the eye) or indirect (ie, viewed on a monitor or screen), gives the clinician even more information to aid in assessing the status and health of the oral cavity. Fluorescence also can aid in the evaluation of the biological activity of the flora, as well as other microbial activity.
Salivary diagnostics has been researched and discussed for years and now has become a reality in use in dental offices today. Due to the simplicity and non-invasive nature of salivary collection and testing, these screening modalities have significant appeal to clinicians and patients alike. The saliva collected in the dental office can be evaluated at the laboratory for the status and susceptibility to both oral and systemic conditions. OralDNA® Labs has developed a salivary test, the MyPerioID® PST®, that identifies a patient’s genetic susceptibility and inherent risk to periodontal disease by evaluating their interleukin-1 (IL-1) gene cluster, and another salivary test, MyPerioPath®, that identifies the type and concentration of 13 pathogenic bacteria known to cause periodontal disease.
Presently there is no single highly accurate and successful assessment tool available for caries. However, Caries Management by Risk Assessment (CAMBRA) combines salivary evaluation with other screening modalities to correlate the caries susceptibility of a patient. The goal is to establish an appropriate methodology for obtaining the positive outcome of reducing, if not eliminating, caries for that individual. The purpose is to not only reduce the disease state at the time of examination and treatment, but also to prevent the future reoccurrence in a proactive manner.
While these salivary tests have been developed to assist the dental clinician with conditions that they are accustomed to managing on an everyday basis, other salivary tests available now, with more coming in the future, deal with situations the dentist is not as familiar or comfortable with. It has long been believed, and the scientific literature has indicated, that there is a correlation between the oncogenic genotypes (ie, strain) of the oral human papilloma virus (HPV) and oropharyngeal cancer. A “salivary” test, the OraRisksm HPV, also has been developed by OralDNA Labs to identify the presence and types of HPV in the oral cavity. Due to the higher incidence of HPV-related carcinomas in the oropharyngeal region, the patient is asked to vigorously swish and gargle with a saline solution to collect a sample from that region, which is then sent to the laboratory for analysis.
Brush cytology is another adjunctive screening procedure that involves the minimally invasive collection of disaggregated transepithelial mucosa cells using a sterile, plastic-handled nylon bristle brush, with minimal or no discomfort to the patient. The epithelial cells are collected by vigorous brushing of the oral lesion using the sterile brush. It is primarily used to screen a suspicious leukoplakia or erythroplakia of the mouth in order to aid in determining the presence or lack of premalignant dysplastic change.
Liquid-based cytology of the oral cavity is a relatively new screening technique that has been proven superior to the conventional Pap (ie, Papanicolaou) smear. Cells are transferred from the brush into a special liquid preservative/fixative bottled solution by twirling the brush in the solution to remove the collected epithelial cells from the bristles, after which the nylon brush is separated from the plastic handle and placed within the bottle. Oral conditions, such as herpes simplex infection and candidiasis, can be diagnosed by this procedure. Liquid cytology may also aid clinicians in determining if detected lesions should be observed or have an immediate invasive full-thickness biopsy procedure with intact architecture performed.
Brush cytology is not a substitute for the traditional, “gold standard” surgical biopsy technique that removes architecturally intact tissue. In the majority of cases, a lesion that is worthy of a cytology procedure is better served by a surgical biopsy that will render a diagnosis.
Despite the diagnostic aids aforementioned, it is extremely important to remember that a surgical biopsy with a microscopic examination is the only accepted method of diagnosing cancer and many other mucosal conditions. The role of a biopsy is to rule out a malignancy and establish the appropriate diagnosis for the patient’s condition. All other modalities, including liquid cytology, are adjunctive procedures to aid in determining if and where a surgical biopsy would be appropriate and most beneficial.
The most overlooked aspects of incorporating new technology into a dental practice are education and training on that specific technology and fully understanding its true role and value, but even more importantly, its limitations. This aspect cannot be overstated! Education and training should involve the entire team. It is important to remember that the first people most patients turn to for advice and comfort on any procedure is the office’s staff.
One of the greatest impediments to the adoption of many of these advanced diagnostic technologies is the lack of appropriate insurance coverage and reimbursement. Many dental patients today have the unfortunate misconception that if the dentist has not picked up a handpiece and performed a definitive procedure that nothing has been done. The true significance of the diagnostic process has been undervalued by the patient and clinician alike. As dentistry moves forward into the medical and wellness model, this thinking must change.In closing, before any diagnostic procedure is performed, it is important to have an understanding of what its true benefit is for the patient, how the information obtained will be utilized, and its effect on the patient’s outcome and quality of life.