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Role-substitution in oral cancer detection
Oral Medicine Role-substitution in oral cancer detection Background.—In role-substitution, one type of health care worker is replaced by another, usually when the other’s skills or professional duties have been expanded. In medicine, nurses are taking on clinical tasks formerly performed by doctors. The result of medical role-substitution has been high-quality care and good health outcomes, plus an increase in accessibility to care. Dentistry has been slower to adopt the concept. In both medicine and dentistry, the range of clinical procedures is legally defined in scope of practice documents. In the United Kingdom, the General Dental Council (GDC) defines the scope of practice and has recently made significant changes. Patients are now permitted to access dental hygienists, dental therapists, and dental hygiene-therapists (DH-Ts) without a prescription from a primary care dentist. These practitioners are allowed to examine patients, diagnose, and plan treatment within their competency. Although proponents claim these changes improve efficiency, cost-effectiveness, and access to resources, opponents counter with claims that these practitioners are delivering inherently unsafe care and often cite the possibility of missing oral malignancy as a significant problem. The most common oral malignancy is squamous cell carcinoma (SCC). The overall incidence is relatively low, but SCC carries a high mortality and morbidity. Potentially malignant disorders (PMDs) often
precede SCC; these disorders include leukoplakia, erosive leukoplakia, speckled leukoplakia, and erythroplakia. The various conditions have malignant transformation rates ranging from a low of 1% for leukoplakia to a high of 85% for erythroplakia. The diagnostic test accuracy of various dental team members when evaluating standardized photographs of mouth cancer, PMDs, and benign lesions was assessed. Methods.—Ninety-six primary care dentists (PCDs), 63 DH-Ts, 9 hospital-based dental staff, and 24 other dental professionals were asked to score 90 clinical photographs depicting various oral lesions. Participants were asked to determine if the lesion was carcinoma, a PMD (test positive), or benign (test negative). Their confidence level was then recorded on a scale from 0 to 10. The judgments were compared to the known histopathological diagnosis for each lesion, with sensitivity and specificity determined for each group of clinicians as well as each participant. Results.—The PCDs’ and DH-Ts’ age mode distribution was 40 to 49 years; that of the hospital staff dental practitioners was 30 to 39 years. Time since primary dental qualification was 10 to 19 years. All except the hospital-based dentists worked in primary care situations.
Fig 3.—Percentile of sensitivity compared across all professional groups. (Courtesy of Brocklehurst P, Pemberton MN, Macey R, et al: Comparative accuracy of different members of the dental team in detecting malignant and non-malignant oral lesions. Br Dent J 218:525-529, 2015.)
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Dental Abstracts
The median sensitivity and specificity for the PCDs and DH-Ts were comparable (Fig 3). The median sensitivity and specificity for the PCDs was marginally higher, but the DHTs missed fewer mouth cancers. At higher percentiles the DH-Ts’ sensitivity values were higher. Median sensitivity was always higher than median specificity for the groups. The implication is that when participants were uncertain about a diagnosis, they would assign the lesion as a test positive, which would prompt further testing. The result is more false positives, which reduces positive predictive values. However, it also means that when any of these professionals encountered a lesion they would only classify it as negative if they were certain of the diagnosis. Overall, however, there was considerable heterogeneity in the groups, which indicates training is an essential first step for all practitioners called upon to diagnose mouth conditions. Discussion.—The detection of mouth cancer by the PCDs and DH-Ts was comparable, indicating that DH-Ts could perform this task safely for patients in clinical situations. However, all professionals should be carefully trained in the identification of mouth lesions to ensure the best results.
Clinical Significance.—Assuming that the various levels of dental staff would perform as in this study, the result would be a higher rate of false positive results, which can be a cause of concern for patients. However, if a practitioner is unsure, it is likely that patients would prefer further testing to determine an accurate diagnosis rather than just assigning the lesion to the test negative group. Oral medicine experts advise referral when there is any doubt about a mouth lesion, so it is preferable to have more false positives than false negatives, especially in light of the serious consequences of SCC. Training to be as accurate as possible in evaluating oral lesions is essential.
Brocklehurst P, Pemberton MN, Macey R, et al: Comparative accuracy of different members of the dental team in detecting malignant and non-malignant oral lesions. Br Dent J 218:525-529, 2015 Reprints available from P Brocklehurst, School of Dentistry, The Univ of Manchester, Oxford Rd, Manchester, M13 9PL; e-mail: [email protected]
Oral Surgery Extraction or not? Background.—Treatment of maxillofacial infections most often involves surgical drainage of the affected space and antibiotic coverage. However, it is equally important to eliminate any odontogenic origin for the infection. Early management of the compromised tooth helps to resolve the infection more quickly and completely. Extraction and treatment are the options for these teeth. Changes in body temperature, white blood cell (WBC) count, fibrinogen levels, and C-reactive protein (CRP) levels were compared between cases where odontogenic infections were managed with extraction and those where treatment with no extraction was chosen. Methods.—The 179 patients were admitted to the authors’ maxillofacial unit for odontogenic infection between 2010 and 2013. They were assigned for extraction or non-extraction based on whether the causative tooth was viewed as non-restorable or restorable, respectively. Extractions were done upon admission, but the treatment protocol thereafter was the same for
both groups, including incision of the space and intravenous antibiotics. Body temperature, WBC count, fibrinogen levels, and CRP levels were measured at admission and 2 days later and changes between groups compared. Results.—For the extraction group, the mean hospital stay lasted 5.37 days, whereas it was 6.42 days for the non-extraction group. The difference was statistically significant. Mean axillary temperature, WBC count, fibrinogen level, and CRP level all had a statistically greater decline for those in the extraction group compared to those in the nonextraction group (Table 2). Discussion.—Patients having extraction of the tooth causing maxillofacial infection had a faster decline in the parameters of infection than those not having extraction. The result was a faster resolution of infection and a shorter stay in the hospital for those who had the causative tooth
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precede SCC; these disorders include leukoplakia, erosive leukoplakia, speckled leukoplakia, and erythroplakia. The various conditions have malignant transformation rates ranging from a low of 1% for leukoplakia to a high of 85% for erythroplakia. The diagnostic test accuracy of various dental team members when evaluating standardized photographs of mouth cancer, PMDs, and benign lesions was assessed. Methods.—Ninety-six primary care dentists (PCDs), 63 DH-Ts, 9 hospital-based dental staff, and 24 other dental professionals were asked to score 90 clinical photographs depicting various oral lesions. Participants were asked to determine if the lesion was carcinoma, a PMD (test positive), or benign (test negative). Their confidence level was then recorded on a scale from 0 to 10. The judgments were compared to the known histopathological diagnosis for each lesion, with sensitivity and specificity determined for each group of clinicians as well as each participant. Results.—The PCDs’ and DH-Ts’ age mode distribution was 40 to 49 years; that of the hospital staff dental practitioners was 30 to 39 years. Time since primary dental qualification was 10 to 19 years. All except the hospital-based dentists worked in primary care situations.
Fig 3.—Percentile of sensitivity compared across all professional groups. (Courtesy of Brocklehurst P, Pemberton MN, Macey R, et al: Comparative accuracy of different members of the dental team in detecting malignant and non-malignant oral lesions. Br Dent J 218:525-529, 2015.)
54
Dental Abstracts
The median sensitivity and specificity for the PCDs and DH-Ts were comparable (Fig 3). The median sensitivity and specificity for the PCDs was marginally higher, but the DHTs missed fewer mouth cancers. At higher percentiles the DH-Ts’ sensitivity values were higher. Median sensitivity was always higher than median specificity for the groups. The implication is that when participants were uncertain about a diagnosis, they would assign the lesion as a test positive, which would prompt further testing. The result is more false positives, which reduces positive predictive values. However, it also means that when any of these professionals encountered a lesion they would only classify it as negative if they were certain of the diagnosis. Overall, however, there was considerable heterogeneity in the groups, which indicates training is an essential first step for all practitioners called upon to diagnose mouth conditions. Discussion.—The detection of mouth cancer by the PCDs and DH-Ts was comparable, indicating that DH-Ts could perform this task safely for patients in clinical situations. However, all professionals should be carefully trained in the identification of mouth lesions to ensure the best results.
Clinical Significance.—Assuming that the various levels of dental staff would perform as in this study, the result would be a higher rate of false positive results, which can be a cause of concern for patients. However, if a practitioner is unsure, it is likely that patients would prefer further testing to determine an accurate diagnosis rather than just assigning the lesion to the test negative group. Oral medicine experts advise referral when there is any doubt about a mouth lesion, so it is preferable to have more false positives than false negatives, especially in light of the serious consequences of SCC. Training to be as accurate as possible in evaluating oral lesions is essential.
Brocklehurst P, Pemberton MN, Macey R, et al: Comparative accuracy of different members of the dental team in detecting malignant and non-malignant oral lesions. Br Dent J 218:525-529, 2015 Reprints available from P Brocklehurst, School of Dentistry, The Univ of Manchester, Oxford Rd, Manchester, M13 9PL; e-mail: [email protected]
Oral Surgery Extraction or not? Background.—Treatment of maxillofacial infections most often involves surgical drainage of the affected space and antibiotic coverage. However, it is equally important to eliminate any odontogenic origin for the infection. Early management of the compromised tooth helps to resolve the infection more quickly and completely. Extraction and treatment are the options for these teeth. Changes in body temperature, white blood cell (WBC) count, fibrinogen levels, and C-reactive protein (CRP) levels were compared between cases where odontogenic infections were managed with extraction and those where treatment with no extraction was chosen. Methods.—The 179 patients were admitted to the authors’ maxillofacial unit for odontogenic infection between 2010 and 2013. They were assigned for extraction or non-extraction based on whether the causative tooth was viewed as non-restorable or restorable, respectively. Extractions were done upon admission, but the treatment protocol thereafter was the same for
both groups, including incision of the space and intravenous antibiotics. Body temperature, WBC count, fibrinogen levels, and CRP levels were measured at admission and 2 days later and changes between groups compared. Results.—For the extraction group, the mean hospital stay lasted 5.37 days, whereas it was 6.42 days for the non-extraction group. The difference was statistically significant. Mean axillary temperature, WBC count, fibrinogen level, and CRP level all had a statistically greater decline for those in the extraction group compared to those in the nonextraction group (Table 2). Discussion.—Patients having extraction of the tooth causing maxillofacial infection had a faster decline in the parameters of infection than those not having extraction. The result was a faster resolution of infection and a shorter stay in the hospital for those who had the causative tooth
Volume 61
Issue 1
2016
55