A comparison of the management of potentially malignant oral mucosal lesions by oral medicine practitioners and oral & maxillofacial surgeons in the UK

Oral leukoplakia diagnosis and treatment in Europe and Australia: Oral Medicine Practitioners' attitudes and practice

The management of oral potentially malignant disorders (OPMD) including oral leukoplakia (OL) is not currently structured according to agreed guidelines. The current report presents survey data gathered from Oral Medicine Practitioners (OMPs) in Europe and Australia and is aimed to investigate attitudes and practice in the diagnosis, risk stratification and treatment of OL. In the presence of a clinical provisional diagnosis of OL, respondents reported always undertaking biopsy in 83% of cases, with most OMPs also relying on diagnostic adjuncts. The potential for malignant transformation is almost invariably assessed through epithelial dysplasia status, with other biomarkers described in the literature used less often. Active treatment of OL was considered mandatory by 20% of OMPs, while others reserve treatment for selected cases only. OMPs are mostly driven to active treatment by lesion-related features which are frequently jointly considered including lesion site, clinical appearance and dysplasia status. Inconsistent assessment was observed regarding mild dysplasia, lesion size, presence of unavoidable trauma, exposure to tobacco and patient age. Frequently observed geographical variations were seldom statistically significant. In agreement with previous surveys, a lack of consensus around the management of OL was observed, supporting claims from learned academies and societies for treatment guidelines aiming to reduce inter-practitioner variability.

Clinical photography: attitudes of practitioners specialized in oral mucosal diseases

Introduction: Clinical photography is an important tool for clinical practice, training and research frequently used across medical specialties. It may provide snapshot images of evolving clinical situations. The aim of this work was to record its contribution in the management of oral mucosal diseases and, to identify the methods of using this tool by carrying out a survey with practitioners specialized in oral pathologies. This allowed us to make recommendations for appropriate use of this tool. Material and methods: An online anonymous questionnaire was sent via email, to practitioners who were member of two associations of French specialists. Results: 51 oral medicine specialists completed the survey. Among them, 48 (94%) used photography in their daily practice. Lack of time or interest was the reasons given by the 3 practitioners who did not use photography. Pictures were mostly taken with smartphones, which provide precise and accurate images, and stored on personal or professional computers. Sharing of images was performed mostly by secured professional or personal email addresses. Consent was obtained verbally in most cases. Conclusion: Photography could be a valuable asset in the practice of oral medicine. However, recommendations for the safety of patient personal data are not always followed.

Management of Oral Potentially Malignant Disorders

Patients with oral potentially malignant disorders (OPMDs), including oral leukoplakia and erythroplakia, proliferative verrucous leukoplakia, oral submucous fibrosis, and oral lichen planus/lichenoid lesions can be challenging to manage. A small proportion will undergo cancer development and determining a patient's cancer risk is key to making management decisions. Yet, our understanding of the natural history of OPMDs has not been fully elucidated, and a precision approach based on the integration of numerous predictive markers has not been validated by prospective studies. Evidence-based health promotion by clinicians and healthcare systems is not embraced universally. Medical and surgical interventions evaluated by rigorous research measuring important endpoints, such as cancer development, mortality, or survival are difficult and expensive to run. Most of these studies employ non-ideal surrogate endpoints and have deep methodologic flaws. Diagnostic criteria for enrolling research subjects are not uniform, and patients with the highest risk for cancer development comprise small proportions of those enrolled. Few studies explore quality of life and patient preferences. It is time to rethink how we approach the management of these patients, across each OPMD, and considering the healthcare infrastructure and cost effectiveness. Global networks with well-characterized patient populations with OPMDs and well-designed interventional trials using validated outcome measures are needed.

Clinical photography: Attitudes among dental students in two dental institutions

INTRODUCTION

Clinical photography is an important tool in teaching, clinical practice and academia especially for mucosal pathologies. Our aim was to examine differences in attitude towards clinical photography for mucosal pathologies among students.

METHODS

Questionnaires about clinical photography were completed by students in dental teaching hospitals in Birmingham (UK) and in Israel (ISR). The questionnaires focussed on the perceived value of clinical photography for a number of purposes and also explored perceived barriers to clinical photography and technology in general. The two departments have different access to clinical photography; in the United Kingdom a separate dedicated photography unit takes all the photographs, whereas in ISR the clinicians take their own photographs. Pearson Chi-squared tests determined statistical significance between categorical variables (P < 0.05).

RESULTS

Among the 163 respondents, there were no significant differences in the value of photography between countries or genders. The participants felt that the aims of photography included: teaching (99.4%), monitoring premalignancy (97.6%) and clinician communication (95.8%). More than 90% thought photography should be used for dysplasia and erosive lichen planus cases. Respondents from ISR were more in favour of photographing pathologies including simple leukoplakia, reticular lichen planus, vesiculobullous or pigmented lesions (P < 0.001 compared to the UK). Overall, the main reasons for not using photography were time constraints (25.5%) and access (21.8%).

CONCLUSIONS

This study highlights a favourable attitude towards clinical photography for various teaching and clinical indications thereby demonstrating its importance. In order to maximise the benefits of clinical photography, access should be simplified.

To treat...or not to treat? Clinicians' views on the management of oral potentially malignant disorders

Oral potentially malignant disorders (PMD) are recognisable mucosal conditions that have a variable and unpredictable risk of transformation to invasive squamous cell carcinoma (SCC). Modern management relies initially on clinical recognition of suspicious lesions and histopathological assessment and grading after incisional biopsy. However, it then varies from wide excision to observation and review, and depends not only on the severity of dysplasia but also on the clinician's preference as there is no high-level evidence to support best practice. We invited clinicians from oral and maxillofacial surgery, oral medicine, ear, nose, and throat (ENT), and plastic surgery, to complete an online questionnaire on current practice, which included 3 fictitious cases, to ascertain their views on the management of PMD and to find out whether they would be interested in becoming involved in a proposed future randomised controlled trial (RCT). Of the 251 who replied, 178 (71%) were oral and maxillofacial surgeons, and 99 (39%) expressed an interest in participating in a future RCT. Most respondents (n=164 or 99%) would always treat severely dysplastic lesions by excision or laser ablation, whereas only 8% (n=13) would always excise mild dysplasia. The greatest equipoise among those interested in taking part in a RCT was found in the case of moderate dysplasia for which 27% (n=27) favoured observation compared with surgical excision or laser ablation. This study shows that there is support for a multicentre, prospective RCT that compares observation with resection and laser ablation in patients with moderate dysplasia.

Oral premalignancy: the roles of early detection and chemoprevention

Premalignancy and chemoprevention studies in head and neck cancer typically focus on the oral cavity. Avoiding or cessation of alcohol and smoking, early detection of potentially malignant disorders or cancer, and early detection of recurrent and/or second primary tumor form the basis of prevention of oral cancer. Analysis of tissue prospectively collected in evaluation of retinoids for chemoprevention trials allowed identification of molecular biomarkers of risk to develop oral cancer, loss of heterozygosity being the most validated one. Improving risk assessment and identification of new targets for chemoprevention represent the main challenges in this field.

White lesions

Increased thickness of the epithelium imparts a white appearance to the oral mucosa by increasing the distance to the underlying blood vessels. Usually this thickening is a result of the increased formation of keratin. Some other less common causes of white lesions are acanthosis or a thickening of the spinous cell layer, edema of the epithelium, or increased fibrosis of the connective tissue thereby reducing blood vessels. Occasionally the surface of an ulcer may appear white, due to collection of fibrin on the surface. In this article the authors discuss white lesions based on putative etiology, that is, hereditary, reactive, inflammation related, immunologic, traumatic, infection related, and idiopathic.

Management of potentially malignant disorders: evidence and critique

At a workshop coordinated by the WHO Collaborating Centre of Oral Cancer and Precancer in the United Kingdom, issues related to management of patients affected by oral leukoplakia were discussed by an expert group. The consensus views of the working group are presented here. Although removal of a lesion still seems to be the predominant method of treatment by the majority of relevant health care professionals, no randomized controlled trials have been undertaken to test the hypothesis that excision either by scalpel or laser greatly influences the potential for later malignant transformation within the oral mucosa of an affected individual. Results of observational studies indicate that, although surgery may have a beneficial effect, this is not likely to reduce the risk of later recurrence nor malignant transformation at the same or another site. Medical measures that lessen the size, extent or histopathological features of dysplasia within leukoplakia likewise presently do not seem to be of particular promise, as relapse or later malignant transformation can occur, and there is a risk of adverse effects, particularly with systemic agents (which themselves may be contra-indicated in some individuals). While the risk of malignant transformation, and the development of further potentially malignant disease may theoretically be reduced by cessation of risk activities, such as tobacco usage and alcohol consumption, there remain no good studies that demonstrate that such measures significantly reduce such events.

Cancerisation within the oral cavity: the use of 'field mapping biopsies' in clinical management

Field cancerisation within the oral cavity risks multiple primary tumour development. Whilst multi-focal disease may ultimately affect up to 24% of oral cancer patients, a particular management problem is encountered with those patients presenting with pan-oral dysplasia. In an attempt to characterise the extent of dysplasia and to quantify the risk of malignant change, examination under anaesthesia (EUA) and multiple, 'field mapping biopsies' were carried out for 16 consecutive patients presenting with pan-oral disease. Seventy lesions, predominantly homogenous leukoplakias, were biopsied primarily showing hyperkeratosis or mild dysplasia histologically. More significant dysplasia was seen to affect the faucial pillars, floor of mouth and ventral tongue. Interventional CO(2) laser surgery was used to excise 11 severely dysplastic lesions in six patients. Field mapping appears effective in the initial identification and treatment of the most significant areas of dysplasia in patients with multi-focal precancer. Longitudinal, multi-centre trials are now required.

Effective management of smoking in an oral dysplasia clinic in London

BACKGROUND

Precancerous lesions precede the development of oral cancer; of several clinical types the most common is leukoplakia. The risk factors include tobacco and excess alcohol use and diets low in antioxidants. Studies concerning the management of risk factors related to oral precancer are meager.

OBJECTIVES

We investigated the effectiveness of smoking cessation at a dysplasia clinic among patients followed up for at least for 12 months.

METHODS

Data from case notes relating to 180 patients with white and red patches of oral mucosa (excluding other benign disorders confirmed by biopsy findings) attending a dysplasia clinic at a teaching hospital in London and seen by one consultant between 1993 and 2003 were transcribed. Effect of referring to a smoker's clinic to receive specialist help was evaluated against brief advice given at the dysplasia clinic +/- medications.

RESULTS

The mean age at the first visit was 48.5 years (+/-12.5), 65% were male, and 88% were white European. One hundred and sixty-two patients (90%) had used tobacco and 83% were current smokers. Of the smokers 95% had smoked over 10 years, the majority smoking over 10 cigarettes per day. Nine were alcohol misusers including two binge drinkers. One hundred and forty-six were diagnosed with oral leukoplakia, 16 with non-homogeneous types (speckled or nodular). Three patients were diagnosed with an erythroplakia. Nineteen per cent exhibited the presence of dysplasia and one subject had in situ carcinoma. Five patients in the sample quit smoking prior to arrival in the dysplasia clinic. Twenty-seven cases (20%) with oral leukoplakia quit smoking while registered as a patient at the dysplasia clinic: 17 of 100 subjects quit with brief advice +/- medications and 10 of 30 following referral to the smoker's clinic. The difference between the two groups was significant for point prevalence abstinence at the last visit to the clinic (minimum 12 months follow up). Out of a total of 180 precancer cases managed in the dysplasia clinic (mean follow up 4.2 years) three patients subsequently developed invasive carcinoma during follow up.

CONCLUSIONS

Smoking cessation needs to be an integral component of management of cases attending a dysplasia clinic and referring to smoker's clinics could help to improve the effectiveness of managing patients with oral precancer to quit smoking.

Interventional laser surgery: an effective surgical and diagnostic tool in oral precancer management

Invasive oral squamous cell carcinomas (OSCCs) are often preceded by precancerous lesions, the management of which remains controversial, polarized between active surgical excision to try to prevent malignant change or more conservative, medical or observational techniques. In order to determine the efficacy of interventional CO2 laser surgery in oral precancer management, the records of 57 consecutive laser-treated patients presenting over a 4-year period, with histologically confirmed dysplastic lesions, were reviewed. Leukoplakias were the commonest clinical lesions (69%), whilst the floor of the mouth was the most frequent anatomical site (42%). Laser surgery successfully excised 55 precancerous lesions, 11 of which exhibited more severe dysplasia or neoplasia compared with initial biopsy. Postoperative scarring and morbidity were minimal. After surgery, patients were followed for between 1 and 44 months (mean 18 months). Of these patients, 76% remained disease-free, whilst 24% developed new dysplastic lesions at distinct or multiple sites, often exhibiting increased dysplasia. Of the patients experiencing recurrence, 7% developed OSCC, whilst a further 3.5% presented with other aerodigestive tract cancers. Neither initial lesion appearance nor histological diagnosis predicted clinical behaviour. Interventional laser surgery is thus advised, in contradistinction to conservative management of oral precancers, to facilitate efficacious, low-morbidity treatment and to establish definitive histological diagnosis. As a consequence of field change carcinogenesis, regular follow up of treated precancer patients is mandatory for effective tertiary prevention.

Bcl-2 expression in sequential biopsies of potentially malignant oral mucosal lesions assessed by immunocytochemistry

OBJECTIVE

To examine, for the first time Bcl-2 expression in sequential (autogenous) oral mucosal biopsies taken from the same sites in a gender, risk-factor matched, Caucasoid sample, over a 21-year period.

DESIGN

Retrospective immunocytochemical longitudinal study of archival serial biopsies.

MATERIALS AND METHODS

Computer records were used to identify biopsy specimens derived from 12 patients. These were divided into four groups: (1) Histologically innocuous lesions which remained histologically innocuous. (2) Dysplastic lesions which remained dysplastic. (3) Histologically innocuous lesions which later progressed to squamous cell carcinoma (SCC). (4) Dysplastic lesions which later progressed to SCC. This represented 65 biopsies in total. Bcl-2 expression was studied using mouse antihuman BCL-2 oncoprotein clone 124 (Dako, Denmark).

RESULTS

Generally, there was a lack of Bcl-2 immunoreactivity in the epithelium, with one exception in dysplastic epithelium from a group (3) patient.

CONCLUSION

These findings suggest that in our series, Bcl-2 is not expressed early in oral premalignant lesions and appears to contradict previous reports. Possible explanations for this disparity are considered.