Dental School Biopsy Education to Promote Access to Care and Early Detection

Despite decline in traditional risk factors, oral cavity cancer incidence remains steady. The disease and its treatment are a source of significant morbidity [1]. As dentists, we typically see our patients more frequently than they see their primary physicians and are adept in routine oral examination. This places us in the ideal position for early detection via oral, head, and neck cancer screening. Moreover, oral cancer is often preceded by premalignant lesions, and direct visualization and identification is possible, unlike in other anatomic organs. Therefore, we possess the opportunity for frequent and accessible tissue screening for early detection. Holmes et al. have demonstrated that dentists diagnose oral cancers earlier and at lower stage than medical counterparts [2]. However, even more opportunity for early detection exists, as surveyed dentists and dental students lack confidence in performing biopsies [3, 4]. Treatment delays occur in patients with head and neck cancer, and delay in biopsy likely contributes. For head and neck tumors, it takes an average of 5.1 weeks from the time a referral is written for a patient to see a specialist, 5.2 additional weeks to receive surgery, and 10.3 weeks to receive radiation therapy [5]. Inherent in this is a known, long “package” time from surgery to completion of radiation which takes 6 weeks to complete. However, the delay in seeing a specialist and time to surgery could be decreased if more general providers felt prepared to perform biopsy. In addition, delays in diagnosis and treatment may result in the progression from early- to late-stage cancer, which is associated with reduced patient survival rates [6]. While dental education stresses the detection and diagnosis of lesions, there is little hands-on training provided on how to perform routine soft tissue biopsies. Surveys from Montague et al. and Shah et al. highlight this dilemma. Shah and colleagues found that while 85% of dental students deemed biopsy skills essential, 74% lacked confidence in performing them [3]. Montague reported that 83% of practicing dentists recognized the importance of biopsy training, yet only 46% were confident in performing the procedure [4]. Other than clinical outcomes, the lack of training in oral biopsies carries legal risk and ethical dilemma. Epstein et al. examined legal databases and found that verdicts with alleged failure to diagnose or treat oral cancer had malpractice settlements ranging from $50,000 to $7.7 million [7]. In some cases, merely noting a lesion and referring a patient to a specialist is not adequate—especially given the delays in specialist care [5]. Beyond medicolegal concerns, this discrepancy creates issue when discussing provider accountability and the obligation to prioritize timely diagnosis. Increasing biopsy training in dental school curricula would decrease negative patient outcomes, litigation, and importantly, align clinical decision making with patient-centered care. Fortunately, some schools have bridged this gap in biopsy confidence and performance. In a 2006 study, senior dental students at The Ohio State University College of Dentistry participated in a brush biopsy instructional program. Following this, the students performed oral brush biopsies on each other. The results were overwhelmingly positive: Around 91% of samples submitted were diagnostic, and 71% of students applied their training in clinical practice afterwards—far exceeding confidence and performance rates reported in the earlier surveys [8]. We devised a PICO question to guide our own analysis. In dental school education, does formal biopsy training improve knowledge and technical skills as compared to prior in achieving some minimal confidence to perform biopsy independently? To determine the efficacy of formal education, and using our PICO framework, we designed a pilot biopsy program for the undergraduate oral surgery honors program. Punch biopsy was selected as the biopsy modality of choice given its ability to preserve anatomic structure of the tissue as well as a low complication rate [9]. In addition, it was selected as a highly reproducible technique that was well suited for teaching students. A curriculum was devised which included an introductory lecture by senior authors with review of indications and technique for punch biopsy, providing an overview of the instrument and procedural steps. Next, students were instructed in hands-on training. Handheld punch biopsies with circular 10 mm × 4 mm wide cutting blades were selected to perform the biopsy. Determining the analogue for hands-on training was key to the success and scalability of the proposed pilot program. Oranges were selected, given the tactile sensation of the rind being similar to tense intraoral epithelium and the core to looser subepithelial tissue. Furthermore, every orange can help train multiple pre-doctoral students, with each student able to perform multiple repetitions of this procedure. Historically, fruits have been used in both dentistry and medicine to train pre-doctorates and residents on surgical techniques [10, 11]. In some studies, fruits are recommended over synthetic or porcine training models [11]. Participants were asked to take a pre- and post- training survey. This survey assessed for self-reported clinical knowledge and confidence in performing biopsy. Survey responses were tabulated as confidence and knowledge in performing biopsy where 1 = not favorable and 5 = most favorable. The results were notable Table 1. Students demonstrated significant gains in clinical confidence (M_pre = 2.3, M_post = 4.1; mean difference = 1.8; 95% CI [1.2, 2.3]; t(21) = 6.5; p < 0.001; Cohen's d = 1.40) and in clinical knowledge (M_pre = 2.8, M_post = 4.4; mean difference = 1.6; 95% CI [1.2, 2.0]; t(21) = 7.8; p < 0.001; Cohen's d = 1.66). Although biopsies may not be considered part of “core dentistry”, it should not dictate what dental students are exposed to and educated on. Drawing a comparison, dental implants were once considered specialist-level care; yet, many continuing education (CE) courses and pilot programs at select dental schools expose dentists and predoctoral students to this valued set of procedures [12]. From there, dentists and predoctoral students can continue to practice their newly acquired techniques throughout school, in residency, and beyond. Biopsy education has the added potential benefit of improving early detection and thus outcomes in oral cancer. Formal education programs such as this pilot seminar are reasonable initial goals. At our institution, we plan to expand our program into a larger biannual seminar open to third- and fourth-year students, allowing up to four opportunities for didactic and clinical exposure to soft tissue biopsy. It is our aim to provide foundational skills and knowledge through this program that could aid incorporation into practice. As shown by the OSU study, this predoctoral exposure can lead to meaningful change in dentists’ practices [8]. Such meaningful change could identify more oral precancerous and cancerous lesions at early stages, when therapies are more effective and outcomes are better. As the pilot seminar becomes a standard part of our institution's pre-doctoral education, long-term outcomes and surveys are planned to record clinical knowledge, confidence, and percent of graduates who implement biopsies into their own practice. Our goal will be to expand upon the encouraging results by the OSU study and upset historical discrepancies in clinical confidence shown by Montague et al. and Shah et al. [3, 4, 8]. Most importantly, implementation of this program will foster a new generation of graduates who are more comfortable and confident in performing biopsies, achieving patient-centered care with accountability, dignity, and an elevated repertoire of skills to practice at the highest standard of care. 1.6 95% CI [1.2, 2.0]; 1.8 95% CI [1.2, 2.3] The authors have nothing to report.