J Dent Educ. 70(8): 820-824 2006
© 2006 American Dental Education Association
Milieu in Dental School and Practice |
Oral Brush Biopsy Technique Instruction Outcomes for Senior Dental Students
David L. Hall, D.D.S.
Key words: oral brush biopsy, dental student technique instruction/competency outcomes
Submitted for publication 01/12/06;
accepted 04/03/06
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Abstract
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Computerized oral brush biopsy became commercially available in 1999. The objectives of this study were to provide senior dental students with the clinical competency to perform oral brush biopsy and to evaluate the extent to which students used this technique and the outcomes of their biopsy techniques. During the 2004–05 academic year, 114 senior dental students at The Ohio State University College of Dentistry participated in a brush biopsy instructional program. Brush biopsy training was part of their outreach and engagement experience. Technique instruction included 1) completion of thirteen interactive online educational modules, 2) discussion of a written protocol including clinical photographs and an oral pathology position paper, and 3) performance of a trial demonstration brush biopsy on each other. Eighty-one students submitted brush biopsies on clinical patients. Lesions were found in approximately one out of every twenty patients. Seventy-four biopsy results (91 percent) were diagnostic although seventeen (21 percent) were limited by suboptimal cellular representation and seven (9 percent) were inadequate. The high percentage (71 percent) of students who actually applied their training in a true clinical setting indicates that the program was successful in providing dental students the information necessary to perform this procedure on their own. However, the number of incomplete specimens suggests the need for technique refinement and additional clinical experience.
Oral brush biopsy is a noninvasive method of evaluating oral mucosal lesions for cellular atypia. It is a three-layer transepithelial exfoliative cytology technique. Computerized brush biopsy analysis (Oral CDx®) became commercially available in 1999.1 Previous authors have discussed the sensitivity,2–4 specificity,3,4 and overall efficacy4–6 of this technique. My research did not identify any studies in the literature that have evaluated the outcomes of brush biopsy training programs. The purpose of this convenience data study was to evaluate an oral brush biopsy technique training program for senior dental students. The objectives of this instructional program were to provide senior dental students with the clinical competency to perform oral brush biopsy and to evaluate the outcomes of their efforts to use this technique on their own.
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Methods
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During the 2004–05 academic year, 114 senior dental students at The Ohio State University College of Dentistry participated in a brush biopsy instructional program. Oral brush biopsy training and clinical application were supervised by faculty from the section of primary care and geriatric dentistry. Brush biopsy technique instruction included 1) completion of interactive online educational modules (www.oralcdx.com/store/minimodules.aspx), 2) discussion of a written protocol including sample clinical photographs and an oral pathology position paper, and 3) performance of a trial demonstration brush biopsy on each other. Oral CDx (Suffern, NY, USA) provided trial demonstration and patient clinical kits. The Oral CDx online educational modules included an oral cancer overview, clinical indications for brush biopsy, patient screening recommendations, patient presentation strategies, practice management suggestions, litigation considerations, brush biopsy technique instructions, and guidelines for interpretation of brush biopsy results.
Following completion of their training, all students participated in a two-week extramural outreach and engagement clinical experience. Outreach and engagement provided mobile comprehensive dental care to thirteen area long-term care facilities and numerous community-based health care centers. During this program, each student performed head and neck examinations including oral soft tissue screening on ten to twenty-five patients. Brush biopsies were performed by students and submitted to Oral CDx for computer evaluation. All biopsies were completed according to the established written protocol (see Figure 1
) and Oral CDx guidelines. Students were instructed to brush approximately five to ten times using enough pressure to bend the brush handle and bristles. The clinical sampling endpoint was the appearance of pink microhemorrhage. Samples were immediately spread onto supplied glass slides. Alcohol/wax fixative was liberally applied and allowed to dry for fifteen minutes. Glass slides were then placed in the plastic containers provided. Standard brush biopsy computerized test requisition forms were completed and mailed to Oral CDx (see Figure 2).
Brush biopsy results were then reviewed with students and evaluated, applying 95 percent confidence intervals to the numbers of diagnostic versus suboptimal specimens that lacked adequate basal cells. Lesion colors, locations, appearances, symptoms, duration, ulcerations, size, and students’ gender were also compared with the occurrence of suboptimal specimens using logistic regression analysis and p<0.05 considered significant. Lesion colors were red, white, and mixed. Lesion locations were combined and grouped as follows: 1) palate and oropharynx, 2) buccal, labial, and alveolar mucosa, 3) ventral, lateral, and dorsal tongue, and 4) floor of mouth and retromolar trigone. Lesion appearances were classified as flat, plaque-like, and verrucous. Lesion symptoms were none, pain, and bleeding. Lesion durations were less than six months, six months to one year, and greater than one year. Ulceration was either present or absent. Lesion sizes were less than five millimeters, five to ten millimeters, ten to twenty millimeters, and more than twenty millimeters. The total number of patients was tabulated and patient ages recorded so that the overall incidence of atypia could be calculated. Patient ages were compared to the incidence of atypia using logistic regression analysis with p<0.05 significant.
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Results
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Eighty-one of 114 senior dental students performed brush biopsy on clinical patients. Student training sessions, clinical experiences, and brush biopsy submissions were evenly distributed over the four quarters of the senior academic year. Brushable lesions were sampled in approximately one of every twenty patients (5 percent lesion selection rate). Seventy-four Oral CDx results (91 percent) were diagnostic, while seventeen (21 percent) were limited by suboptimal cellular representation and seven (9 percent) were inadequate, requiring repeat testing. The number of suboptimal specimens was statistically significant (95% CI:12.7–31.5%). Atypia was detected in sixteen of eighty-one (20 percent atypia detection rate) specimens selected from 1,650 total patients (1.5 percent overall incidence rate). The average age of the total patient population was fifty-seven years with a range of fifteen to eighty-five years. The average age of patients providing brush biopsy specimens was seventy-four years. There was a positive relationship between increasing age and an increased incidence of atypical results (p=0.0017). Lesion colors, locations, appearances, symptoms, duration, ulcerations, size, and students’ gender did not affect the occurrence of suboptimal specimens.
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Discussion
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The high percentage (71 percent) of students who applied their training in a true clinical setting indicates that the program was successful in providing the information necessary to allow students to perform the procedure on their own. This percentage is comparable to clinical technique competency training outcomes discussed by numerous authors.7–10
The significant number of suboptimal specimens (21 percent) and inadequate specimens (9 percent) suggests the need for technique refinement and additional clinical experience. In all specimens that were either suboptimal (seventeen) or inadequate (seven), basal cells were not completely represented. The percentage of suboptimal specimens in this study was approximately twice the amount reported in one previous investigation2 whose brush biopsies were performed by experienced oral histopathologists.11,12 Average insufficient specimen cell counts of 7 percent have been noted in additional studies1,3 performed by practiced clinicians. The most likely explanation for these differences is that 30 percent of dental students simply didn’t brush hard enough to obtain an optimal complete (three cell layers) sample.13
Lesion selection results (5 percent lesion selection rate) were at the low end of the manufacturer’s suggested range (5–10 percent). Atypia results (20 percent atypia detection rate and 1.5 percent overall incidence rate) were slightly higher compared to previous publications.1–4 Lower lesion selection, higher atypia detection, and higher overall incidence rates could be due to inexperienced observers, variation between observers, stricter determination of brushable lesions, and/or the advanced average age of the patient population.
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Conclusions
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The results of this study indicate that oral brush biopsy technique training can be successfully integrated into ongoing clinical educational programs for dental students. During training, special emphasis should be placed on brushing hard enough to sample three layers of cells. Collaboration with oral pathology specialists might improve results, decrease selection rates, and provide more in-depth detailed knowledge and understanding.
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Footnotes
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Dr. Hall is an Associate Professor, Section of Primary Care, The Ohio State University College of Dentistry. Direct correspondence and requests for reprints to him at OSU College of Dentistry, 305 W. 12th Avenue #186, Columbus, OH 43218; 614-292-3592 phone; 614-292-8013 fax; hall.611{at}osu.edu. This author has no financial interest in Oral CDx. Trial demonstration and patient clinical brush Bx kits were provided by Oral CDx.
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