L4 OPMDs

Oral Premalignant Conditions and Oral Cancer¹

Learning Outcomes²³

Upon completion of this session, students will be able to:

• Describe an oral lesion accurately using clinical terminology.
• Applying structured frameworks (surgical sieves) to formulate differential diagnoses
• Identify and describe the specific features associated with pre-malignancy and oral cancer.
• Compose a concise and impactful referral letter to specialists.
• Understand the appropriate management strategies for post-treatment patients within the context of a General Dental Practice.

Clinical Focus

The lecture emphasizes systematic description using standardized terminology and the long-term care requirements for patients returning to general practice after oncology treatment.


Clinical Assessment Describing Lesions⁴

To ensure a professional clinical - Right lateral border of the tongue - Left buccal mucosaassessment, descriptions of lesions should be as accurate as possible.

Importance of Systematic Description

Systematic description ensures accurate communication, particularly when photographs are unavailable. A structured approach prevents vague descriptions that could lead to missed diagnoses.


Location⁵⁶⁷⁸

Anatomical Landmarks for Reference

Oral Cavity Structures:

• Hard palate
• Soft palate
• Uvula
• Cheek
• Molars, Premolars, Canine, Incisors
• Vestibule
• Superior lip (pulled upward) and Inferior lip (pulled down)
• Superior and Inferior labial frenum
• Gingivae
• Palatoglossal fold
• Fauces
• Palatopharyngeal fold
• Palatine tonsil
• Tongue (lifted up)
• Lingual frenum
• Opening of duct of submandibular gland

Specific Site Examples

• Mid-line, central hard palate

Anatomical Reference List

• Superior lip (pulled upward)

• Superior labial frenum

• Gingivae

• Palatoglossal fold

• Fauces

• Palatopharyngeal fold

• Palatine tonsil

• Tongue (lifted up)

• Lingual frenum

• Opening of duct of submandibular gland

• Inferior labial frenum

• Inferior lip (pulled down)

• Hard palate

• Soft palate

• Uvula

• Cheek

• Molars, Premolars, Canine, Incisors

• Vestibule

• Right floor of mouth, adjacent to submandibular duct

Anatomical Reference List

• Hard palate

• Soft palate

• Uvula

• Cheek

• Molars, Premolars, Canine, Incisors

• Vestibule

• Superior lip (pulled upward)

• Superior labial frenum

• Gingivae

• Palatoglossal fold

• Fauces

• Palatopharyngeal fold

• Palatine tonsil

• Tongue (lifted up)

• Lingual frenum

• Opening of duct of submandibular gland

• Inferior labial frenum

• Inferior lip (pulled down)

• Mid-crestal, left retromolar pad

Anatomical Reference List

• Hard palate
• Soft palate
• Uvula
• Cheek
• Molars, Premolars, Canine, Incisors
• Vestibule
• Superior lip (pulled upward)
• Superior labial frenum
• Gingivae
• Palatoglossal fold
• Fauces
• Palatopharyngeal fold
• Palatine tonsil
• Tongue (lifted up)
• Lingual frenum
• Opening of duct of submandibular gland
• Inferior labial frenum
• Inferior lip (pulled down)

   

Distribution and Definition⁹¹⁰¹¹

Assessment Criteria

• Location
• Distribution and definition
  • Localised?
  • Single/multiple
  • Regular/irregular border
  • Poorly defined?
    • Diffuse, reticulated area

 

Size¹²

Assessment Criteria

• Location
• Distribution and definition
• Size (measurement using a periodontal probe)
  • Place the probe lengthways and breadthways over the lesion
  • Record dimensions in millimeters (e.g., "approximately 20mm x 20mm")


Shape¹³

Assessment Criteria

• Location
• Distribution and definition
• Size
• Shape

Morphological Classifications

• Macule
• Vesicle
• Pustule
• Papule
• Nodule
• Plaque
• Sessile-based / pedunculate
• Ulcers / erosions
  • Macule: Flat, discolored area
  • Papule: Small raised area (typically <1cm)
  • Nodule: Raised area >1cm
  • Plaque: Raised area that remains flat (not fluid-filled), representing a variation in mucosa
  • Vesicle: Small fluid-filled sac
  • Pustule: Pus-filled sac
  • Sessile: Attached base (broad attachment)
  • Pedunculated: Stalk-like attachment (e.g., fibroepithelial polyp)
  • Ulcer: Discontinuity or break in surface mucosa
  • Erosion: Superficial break

Colour¹⁴

Assessment Criteria

• Location
• Distribution and definition
• Size
• Shape
• Colour

Clinical Observations

• Homogenous?
• Red (erythroplakia)
• White (leukoplakia)
  • Homogeneous: Uniform color throughout
  • Non-homogeneous: Mixed colors or variations
  • Mixed: Red and white combinations
  • Erythroplakia is generally associated with more serious conditions

Consistency¹⁵

Assessment Criteria

• Location
• Distribution and definition
• Size
• Shape
• Colour
• Consistency

Palpation Findings

• Soft
• Hard
• Fluctuant
  • Hard/Indurated: Abnormally firm, suggesting pathological change
  • Fluctuant: "Waterbed" sensation indicating fluid content (as seen in abscesses or mucoceles)

Texture¹⁶

Assessment Criteria

• Location
• Distribution and definition
• Size
• Shape
• Colour
• Consistency
• Texture

Surface Characteristics

• Smooth
• Rough
  • Reticulated (net-like pattern)
  • Presence of edema

History¹⁷

Assessment Criteria

• Location
• Distribution and definition
• Size
• Shape
• Colour
• Consistency
• Texture
• History

Patient History Inquiries

• When did it start?
• Pain
• Experience of trauma
• Medication changes
• Medical History (Hx) changes
  • Trauma: History of biting tongue/lip, thermal burns (e.g., "pizza burn"), or chemical injury
  • Medications: Recent changes (e.g., calcium channel blockers causing gingival overgrowth)

Diagnostic Frameworks¹⁸

Vitamins Cde¹⁹²⁰

The VITAMINS CDE mnemonic serves as a structured surgical sieve to assist in the differential diagnosis of orofacial conditions.

Clinical Categories and Examples

• Vascular: Haemangioma, vascular malformations
• Infective or Inflammatory: Odontogenic or non-odontogenic conditions (e.g., tonsillitis)
• Trauma: Mucocele, polyps
• Autoimmune: Pemphigus vulgaris
  • ==Mucous membrane pemphigoid==
• Metabolic: Hyperparathyroidism
  • ==Associated with large mandibular tori==
• Idiopathic or Iatrogenic: Thermal or chemical burns, lacerations
  • ==Sodium hypochlorite extrusion during endodontics causing necrotic ulceration==
• Neoplasia: Including potentially malignant disorders
• Socio-cultural: Habits such as paan chewing and associated oral submucous fibrosis
  • ==Betel nut chewing in specific populations==
• Congenital: Exostoses
• Degenerative / Drug related: Gingival overgrowth from calcium channel blockers
• Endocrine / Exocrine: Pleomorphic adenoma

Source Reference

Adapted from: Moore, R., Dave, M., Stocker, J. et al. Simplifying differential diagnoses of orofacial conditions - a guide to surgical sieves and red flags. Br Dent J 230, 289–293 (2021).

Other Sieves Active Minds²¹

The ACTIVE MINDS mnemonic provides an alternative framework for systematic clinical assessment:

Clinical Application

The key is selecting one sieve and applying it consistently to ensure no diagnostic category is overlooked.

• Autoimmune
• Congenital
• Trauma
• Infection
• Vascular
• Endocrine
• Metabolic
• Inflammatory
• Neoplasia
• Degenerative / Drugs
• Safety (Iatrogenic)

Clinical Priorities and Red Flags²²²³²⁴

Self-Reflection on Clinical Focus

• Am I losing sight of what’s important?
• Do I even know what’s important to lose sight of?

Poorly drawn lines.

Identifying Key Clinical Factors

What’s important?

Clinical Red Flags and Indicators

• Persistent oral mucosal lesions (red or white)
• Ulcerations
  • Concerning unless definitively diagnosed as minor recurrent aphthous stomatitis
• Indurations
  • Lesions that appear soft but feel rock-hard, suggesting invasion
• Fixated to deep tissue
• Rapidly growing (excluding mealtime syndromes)
  • Suggests high metabolic rate; note Mehlum syndrome involves rapid swelling around feeding due to blocked salivary glands
• Bleeding easily (spontaneous in the absence of periodontal disease)
• Numbness (in the absence of a clear cause, e.g., M3M removal)
  • Paresthesia or anesthesia suggesting nerve fiber involvement
• Trismus
  • Difficulty opening mouth without obvious cause like pericoronitis
• Neck lumps
  • Includes palpable lymphadenopathy or thyroid nodules found during routine examination

  Case Study: Numbness of the Right Maxilla numbness affecting the right maxilla. Clinical examination revealed no obvious odontogenic cause. A CBCT scan was performed to definitively exclude hidden dental pathology. Following exclusion of dental causes, the patient was referred to neurology for investigation of potential lesions higher in the nerve pathways (e.g., intracranial pathology). This illustrates the importance of excluding dental causes before neurological referral.

  A patient presented with


Classification and Transformation Rates²⁵

WHO Classification of Tumours: Pathology and Genetics of Head and Neck Tumours (2005)

The following stages represent increasing severity of epithelial changes:

Classification²⁶²⁷

• Mild dysplasia
• Moderate dysplasia
• Severe dysplasia
• Carcinoma in situ
• (Carcinoma)

WHO 2005 Diagnostic Criteria

• Mild dysplasia: Architectural disturbances limited to the outer third of epithelium
• Moderate dysplasia: Involves the middle third
• Severe dysplasia: Extends beyond two thirds of epithelial thickness
• Carcinoma in situ: Full-thickness epithelial dysplasia without basement membrane invasion
• Carcinoma: Invasion through basement membrane

Comparative Systems for Oral Epithelial Dysplasia

Reference: Ranganathan K, Kavitha L. Oral epithelial dysplasia: Classifications and clinical relevance in risk assessment of oral potentially malignant disorders. J Oral Maxillofac Pathol. 2019 Jan-Apr;23(1):19-27.

WHO 1978	WHO 2005	WHO 2017	SIN 2005	Ljubljana (2003)	SIL 1988	OIN/CIS (JSOP) 2010	Binary (2006)
Mild dysplasia	Squamous hyperplasia; Mild dysplasia	Mild dysplasia	SIN 1 (Low grade)	Squamous cell (simple) hyperplasia; Basal/parabasal cell hyperplasia*	Hyperplasia/keratosis; SIL I (low grade)	Reactive atypical epithelium; Oral epithelial dysplasia	Low risk
Moderate dysplasia	Moderate dysplasia	Moderate dysplasia	SIN 2 (High grade)	Atypical hyperplasia**	SIL II (high grade)	OIN/CIS (JSOP)†
Severe dysplasia	Severe dysplasia; Carcinoma in situ	Severe dysplasia	SIN 3***	Carcinoma in situ			High risk

WHO 2017 Update

The 2017 update combined severe dysplasia and carcinoma in situ into a single category: severe dysplasia. When reviewing literature, verify which classification system is being used as terminology varies post-2017.

 

Oral Premalignant Conditions

Note: Transformation rates may vary across different literature sources.

Malignant Transformation Rates by Subtype

Transformation Rates^2829303132

• Oral lichen planus: 1.4%
• Oral lichenoid lesions: 3.8%
  • Reticular type: Very low transformation rate
    • Lichenoid lesions: Slightly higher risk than classic lichen planus

Reference: Iocca O, Sollecito TP, Alawi F, et al. Potentially malignant disorders of the oral cavity and oral dysplasia: A systematic review and meta-analysis of malignant transformation rate by subtype. Head & Neck. 2020; 42: 539–555

Note: Transformation rates may vary across different literature sources.

Malignant Transformation Rates by Subtype

• Oral lichen planus: 1.4%
• Oral lichenoid lesions: 3.8%
• Leukoplakia: 8.6%

Reference: Iocca O, Sollecito TP, Alawi F, et al. Potentially malignant disorders of the oral cavity and oral dysplasia: A systematic review and meta-analysis of malignant transformation rate by subtype. Head & Neck. 2020; 42: 539–555

Note: Transformation rates may vary across different literature sources.

Malignant Transformation Rates by Subtype

• Oral lichen planus: 1.4%
• Oral lichenoid lesions: 3.8%
• Leukoplakia: 8.6%
• Submucous Fibrosis: 5.2%
• Erythroplakia (red plaque): ~33% (significantly higher risk than leukoplakia)
• Proliferative Verrucous Leukoplakia (PVL): ~50% (extremely high risk)

Reference: Iocca O, Sollecito TP, Alawi F, et al. Potentially malignant disorders of the oral cavity and oral dysplasia: A systematic review and meta-analysis of malignant transformation rate by subtype. Head & Neck. 2020; 42: 539–555

Case Study: Proliferative Verrucous Leukoplakia Diagnosis

A patient presented in general practice with a lesion suspected to be standard leukoplakia. Referral to Oral Medicine and subsequent biopsy revealed Proliferative Verrucous Leukoplakia (PVL). The patient was immediately placed on three-monthly surveillance due to the ~50% transformation rate. This case highlights that clinical appearance alone cannot definitively diagnose premalignant conditions and PVL requires significantly more aggressive monitoring.

    

Referral Guidelines and Process³³³⁴

As a general practitioner rather than a specialist, establishing a differential diagnosis is a critical step in the - Eligibility includes patients with healthcare cards or pension cards. referral process to ensure appropriate urgency and specialist selection.

Importance of Differential Diagnosis³⁵

Referral…

Referral Process³⁶

It is important to ensure that time and resources are not wasted during the referral process.

Pathway Identification

Identify which pathway the patient will need to follow:

• Public
  • Oral Health Centre of Western Australia (OHCWA) referral
• Private
  • Referral letter
  • Optional phone call for coordination

Ohcwa³⁷

Eligibility and Submission

• Typically for:
  • Government patients
  • Patients seen in private practice under the government subsidy scheme
• Process:
  • Referral form is completed and sent to OHCWA
    • All referrals are triaged by specialists (e.g., Dr. Fu for Oral Surgery, Dr. Friedrich for Oral Medicine) who allocate appointments based on clinical priority and resource availability.
  • Urgency is critical for the triaging process

OHCWA Referral Form Fields

• Referred from: (Clinic codes: ALB, ARM, BBY, GDC, GLD, LDC, MID, MH, MOR, NPC, RCK, RNG, VAS, WWK, or Other)
• Referring Dentist: Name and Position
• Patient Details: Name (Surname/Given), Registration No, Date of Birth, Address, Post Code, Telephone/Mobile
• Referred for: Paedodontics, Endodontics, Periodontics, Oral Medicine, Specialist Restorative, Oral Surgery, Orthodontics, Student, or Other
• Urgency: High, Medium, or Waiting List
• Clinical Details: Space for descriptive notes
• Relevant Medical History: Space for descriptive notes

Oral Surgery Specifics (Third Molars)

• Tooth Data: Number of teeth (Upper/Lower) and Distal Impact status (Y/N)
• General Anaesthetic: Yes, No, or Unsure
• Justification: Reason for general anaesthetic requirement
• Validation: Signature and Date


How Urgent³⁸

Determining Urgency Levels

• Suspected Malignancy: Classified as urgent. The patient should be seen within a maximum of 2 weeks.
• Suspected Pre-malignant Lesions: May be classified as urgent due to the risk that malignant transformation may have already occurred within the lesion.
• Other Conditions: Should be prioritized based on their individual clinical merits.

Guidance for Uncertain Cases

If the level of urgency is unclear:

• Seek advice from a more experienced colleague within the practice.
• Consider calling the referral practice directly for advice.
• If uncertainty persists, default to sending an urgent referral.

Private³⁹

1. Clinician Selection

• Determine if there is a preferred clinic or clinician based on geographical proximity or personal professional preference.
• Assess if the case is so urgent that the patient or clinic reception needs to contact multiple providers to find the first available appointment.

2. Referral Methods

• Referral Pad: Requires scanning and sending via secure mail.
• Referral Web Form: Completed online via the specialist’s website.
• Referral Letter: Written correspondence sent via secure mail.

Referral Letter⁴⁰⁴¹

Example: Perth Oral Medicine & Dental Sleep Centre

Patient Information Required:

• Full Name, Date of Birth, Email, Address, and Contact Numbers (Mobile/Home/Work).

Consultation Categories:

• Orofacial Pain
• Temporomandibular Disorders
• Oral Mucosal Lesions
• Orofacial Disorders
• Oral Appliance for Snoring & Sleep Apnoea (requires Sleep Study)
• Adult or Paediatric status

Referring Practitioner Details:

• Name, Practice, Telephone, Email, Signature, and Date.

Clinic Locations:

• West Leederville: Unit 6, 24 McCourt Street, West Leederville WA 6007
• Jandakot: Unit 15, 323 Berrigan Drive, Jandakot WA 6164
• Padbury: Unit 5, 6 Blackwattle Parade, Padbury WA 6025

Digital Referral Options:

• Website form requires: Patient Name, DOB, Address, Email, Phone, Consultation Type, and Preferred Clinician.

*Note: Other private clinics are available for referral.

Case Study: Geographic Proximity

For a practice located in Rockingham, the closest private specialist clinic is Perth Oral Medicine and Dental Sleep Centre in Jandakot. This illustrates the practical consideration of balancing geographic proximity with specific clinician relationships when selecting private referral pathways.

Best Practice Guidance for Correspondence

A professional referral letter should include the following elements:

• Practitioner Information: Your name, clinic name, and full contact details.
• Patient Information: Full name and comprehensive contact details.
• Medical History: Relevant systemic health information.
• Clinical Findings:
  • Detailed description of the lesion or condition.
    • Use a systematic approach for descriptions, including location, size, appearance, and consistency.
  • Clinical photographs whenever possible.
• Differential Diagnoses: While not mandatory, providing your clinical impressions is highly beneficial.
• Objective: Clearly state what you are requesting the specialist to do (e.g., biopsy, management, second opinion).
  • Explicitly include the requested urgency level in your final request.


Treatment and Long Term Care

Occasionally, you may be asked to provide a pre-treatment screen for a patient about to undergo treatment for oral cancer. When performing this screen, it is essential to consider the nature of the proposed treatment and its potential long-term effects.

Pre Treatment Screening⁴²

Diagnostic Assessment and Imaging

• Check thoroughly for dental caries and apical pathology.
• Utilize appropriate imaging for comprehensive screening:
  • Orthopantomogram (OPG) is important for initial screening.
  • Consider a full mouth series of periapical radiographs (PAs) for detailed assessment.
  • Bitewing radiographs (BWs) remain necessary for accurate caries diagnosis.
    • Extraction planning: Remove hopeless teeth before radiation to prevent osteoradionecrosis

Treatment⁴³

Broadly, the treatment modalities for oral cancer include:

• Surgical intervention
• Chemotherapy
• Radiation therapy
• A combination of the above therapies

Effects of Treatment⁴⁴⁴⁵

Surgical Complications

• Surgical treatment may result in significant changes to the anatomy of the oral cavity.
• Procedures may include the removal of the lymph node chain.

Radiation Therapy Complications

• Oral Mucositis: Inflammation and ulceration of the mucous membranes.
• Salivary Gland Dysfunction: Occurs typically at doses greater than 50Gys, leading to:
  • Radiation caries
  • Dysphasia (difficulty swallowing)
  • Dysgeusia (altered sense of taste)
  • Oral candidiasis
• Trismus: Fibrosis leading to difficulty in opening the mouth.
• Osteoradionecrosis: Bone death resulting from radiation exposure - Particularly in the mandible; requires hyperbaric oxygen considerations for extractions.
• Woody Neck: Anatomical variation characterized by tissue hardness in the neck region.

Chemotherapy Complications

• Oral Mucositis: A common side effect involving painful inflammation of the oral mucosa.
• Infections: Increased susceptibility to oral health issues, including:
  • Candidiasis (fungal infection)
  • Other opportunistic oral infections

Long Term Care Requirements

Surveillance and Maintenance

Head and Neck Oncology patients have high recurrence rates and require lifelong surveillance. Patients typically undergo initial intensive review with their oncology team, then transition to shared care with general dental practice for ongoing maintenance and early detection of recurrence.

• Oral discomfort management: Difflam (benzydamine) topical anaesthetic mouth rinse (often used 50/50 dilution) to reduce mucosal pain
• Xerostomia management: Biotene products (mouth rinse, oral gels, toothpastes), saliva substitutes, and stimulants
• Caries prevention: High-fluoride protocols such as Neutrafluor 5000 (5000ppm fluoride toothpaste) and Silver diamine fluoride (SDF) for arresting caries in high-risk patients

  

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