Dr Richard Hague 2026 - bold Richard.hague@uwa.edu.au bold - From a General Dentist perspective Oral Premalignant Conditions and Oral Cancer Presented from a General Dentist perspective by Dr. Richard Hague (2026). # Learning Outcomes \* Students will be able to: \* Describe an oral lesion \* Describe features of pre-malignancy and oral cancer \* Write a concise and impactful referral letter \* Understand management strategies post-treatment patients in General Dental Practice. By the end of this session, students will be able to: - Describe an oral lesion - Describe features of pre-malignancy and oral cancer - Write a concise and impactful referral letter - Understand management strategies for post-treatment patients in General Dental Practice.  Clinical photo of the oral cavity showing inflamed mucosa with erythematous and ulcerated areas adjacent to teeth. **How to describe lesions** • Location • Try to be as accurate as possible.  #### Precision in Documentation - Location - Try to be as accurate as possible. Labelled anatomical diagram of the oral cavity showing key structures relevant to lesion location. Labels include: Superior lip (pulled upward), Superior labial frenum, Gingivae, Palatoglossal fold, Fauces, Palatopharyngeal fold, Hard palate, Soft palate, Uvula, Cheek, Palatine tonsil, Tongue (lifted up), Molars, Premolars, Canine, Incisors, Lingual frenum, Opening of duct of submandibular gland, Inferior lip (pulled down), Vestibule, and Inferior labial frenum. **How to describe lesions** • Location • Mid-line, central hard palate Location Mid-line, central hard palate https://pocketdentistry.com/wp-content/uploads/285/c01f0011.gif  #### Palatal Findings - Location: Mid-line, central hard palate Anatomical diagram of the oral cavity with labeled structures. The image shows a superior view of the mouth with teeth, tongue, and surrounding tissues. Labels include: Superior lip (pulled upward), Superior labial frenum, Gingivae, Palatoglossal fold, Fauces, Palatopharyngeal fold, Hard palate, Soft palate, Uvula, Cheek, Palatine tonsil, Tongue (lifted up), Molars, Premolars, Canine, Incisors, Vestibule, Lingual frenum, Opening of duct of submandibular gland, Inferior gingivae, Inferior labial frenum, and Inferior lip (pulled down). A yellow circle highlights the mid-line central hard palate region, corresponding to the text description 'Location: Mid-line, central hard palate'. How to describe lesions Location - Right floor of mouth, adjacent to submandibular duct.  #### Floor of Mouth Findings - Location: Right floor of mouth, adjacent to submandibular duct. Anatomical diagram of the oral cavity with labeled structures. The image shows a mouth opened wide, revealing teeth (incisors, canines, premolars, molars), tongue, uvula, hard and soft palate, gingivae, cheeks, lips, frenums, and submandibular duct opening. A yellow dot highlights the location described in the text: 'Right floor of mouth, adjacent to submandibular duct.' Labels include Superior lip, Superior labial frenum, Gingivae, Palatoglossal fold, Fauces, Palatopharyngeal fold, Hard palate, Soft palate, Uvula, Cheek, Molars, Premolars, Canine, Incisors, Vestibule, Tongue, Lingual frenum, Opening of duct of submandibular gland, Inferior labial frenum, and Inferior lip. How to describe lesions - Location - Mid-crestal, left retromolar pad. <!-- Image (498,382,865,949) -->  #### Retromolar Findings - Location: Mid-crestal, left retromolar pad. Anatomical diagram of the oral cavity with multiple labeled structures including superior lip, gingivae, hard palate, soft palate, uvula, tongue, and various teeth types (molars, premolars, canines, incisors). A yellow highlight marks the left retromolar pad area, corresponding to the text description 'Mid-crestal, left retromolar pad' under the heading 'How to describe lesions'. # How to describe lesions ## *Location* ## *Distribution and definition* * Localised? * Single/multiple * Regular/irregular border * Poorly defined? #### Assessment Criteria - Localised? - Single/multiple - Regular/irregular border - Poorly defined?  Clinical photo showing the lateral aspect of the tongue with multiple small, raised, white-yellowish papules or nodules scattered across the surface. The lesions appear slightly erythematous and are distributed in clusters on the dorsal and lateral tongue mucosa. This presentation is consistent with conditions such as transient lingual papillitis (lie bumps) or potentially a viral exanthem affecting the oral mucosa. Rawlings N, Willis A. Oral Ulceration - Clinical Feature. JIDA. Published online April 13, 2023. doi:10.58541/001c.74191  Rawlings N, Willis A. Oral Ulceration - Clinical Feature. JIDA. Published online April 13, 2023. doi:10.58541/001c.74191 Clinical photograph showing a large oral ulcer with a yellowish-white fibrinous base and an erythematous halo. The image demonstrates the characteristic features of an oral ulcer as discussed in Rawlings N, Willis A. Oral Ulceration - Clinical Feature. JIDA. Published online April 13, 2023. # How to describe lesions - Location - Distribution and definition - Size https://www.periodontalcare.sdcep.org.uk/media/5mzlc5xz/unc-probe-combined.jpg?rmode=max&width=500  #### Clinical Parameters - Location - Distribution and definition - Size Close-up clinical photo of a periodontal probe (UNC-type) with millimeter markings along the shank. The image is included to demonstrate how to describe lesions by providing a visual reference for measuring size and distribution. # How to describe lesions * Location * Distribution and definition * Size * Shape * **Macule** * **Vesicle** * **Pustule** * **Papule** * **Nodule** * **Plaque** * **Sessile-based / pedunculate** * **Ulcers / erosions** #### Morphological Classifications - Location - Distribution and definition - Size - Shape - Macule - Vesicle - Pustule - Papule - Nodule - Plaque - Sessile-based / pedunculate - Ulcers / erosions # How to describe lesions - Location - Distribution and definition - Size - Shape - Colour - Homogenous? - Red (erythroplakia) - White (leukoplakia) #### Visual Characteristics - Location - Distribution and definition - Size - Shape - Colour - Homogenous? - Red (erythroplakia) - White (leukoplakia) - Location - Distribution and definition - Soft - Size - Hard - Fluctuant - Shape - Colour - Consistency #### Physical Properties - Location - Distribution and definition - Size - Shape - Colour - Consistency - Soft - Hard - Fluctuant # How to describe lesions * **Location** * **Distribution and definition** * **Size** * **Shape** * **Colour** * **Consistency** * **Texture** * **Smooth** * **Rough** #### Surface Quality - Location - Distribution and definition - Size - Shape - Colour - Consistency - Texture - Smooth - Rough # How to describe lesions - Location - Distribution and definition - Size - Shape - Colour - Consistency - Texture - History - When did it start? - Pain - Experience of trauma - Medication changes - Medical Hx changes #### Clinical History and Progression - Location - Distribution and definition - Size - Shape - Colour - Consistency - Texture - History - When did it start? - Pain - Experience of trauma - Medication changes - Medical Hx changes #### Surface Texture Characteristics The surface texture of a lesion provides critical diagnostic information regarding its nature and potential for malignancy: - **Smooth and Thin:** Often associated with early-stage changes or specific types of atrophy. - **Granular or Fine-Pointed:** A surface that appears composed of small, grain-like elevations. - **Verrucous or Rough:** Characterized by a jagged, wart-like, or uneven surface texture. - **Fissured or Corrugated:** Presence of deep grooves, folds, or a wrinkled appearance. - **Ulcerated:** A loss of epithelial integrity, often appearing as a crater or sore; this is a high-risk feature for malignancy. #### Clinical History and Progression Understanding the temporal behavior of a lesion is essential for accurate assessment: - **Duration:** Determine how long the lesion has been present. Chronic lesions that do not resolve within two weeks require closer scrutiny. - **Changes in Size or Appearance:** Rapid growth or changes in color and texture are significant clinical indicators. - **Associated Symptoms:** Document the presence of pain, burning sensations, numbness (paresthesia), or bleeding. - **Habits and Risk Factors:** History of tobacco use, alcohol consumption, or other local irritants that may contribute to the development of the lesion. # Surgical Sieve Surgical Sieve VITAMINS CDE VITAMINS CDE **VITAMINS CDE** * **Vascular - haemangioma, vascular malformations** * **Infective or Inflammatory - odontogenic / non-odontogenic eg tonsillitis** * **Trauma - mucocele / polyps** * **Autoimmune - pemphiugus vulgaris** * **Metabolic - hyperparathyroidism** * **Idiopathic or Iatrogenic (thermal / chemical / laceration)** * **Neoplasia - including potentially malignant disorders** * **Socio-cultural - e.g paan chewing and oral submucous fibrosis** * **Congenital - exostoses** * **Degenerative / Drug related - calcium channel blockers** * **Endocrine / Exocrine - pleomorphic adenoma** 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). https://doi.org/10.1038/s41415-021-2717-5 #### Clinical Categories and Examples - **Vascular**: Haemangioma, vascular malformations - **Infective or Inflammatory**: Odontogenic / non-odontogenic (e.g., tonsillitis) - **Trauma**: Mucocele / polyps - **Autoimmune**: Pemphigus vulgaris - **Metabolic**: Hyperparathyroidism - **Idiopathic or Iatrogenic**: Thermal / chemical / laceration - **Neoplasia**: Including potentially malignant disorders - **Socio-cultural**: e.g., paan chewing and oral submucous fibrosis - **Congenital**: Exostoses - **Degenerative / Drug related**: Calcium channel blockers - **Endocrine / Exocrine**: Pleomorphic adenoma *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 MINDS * Autoimmune * Congential * Trauma * Infection * Vascular * Endocrine * Metabolic * Inflammatory * Neoplasia * Degenerative / Drugs * Safety (Iatrogenic) #### Diagnostic Categories - Autoimmune - Congenital - Trauma - Infection - Vascular - Endocrine - Metabolic - Inflammatory - Neoplasia - Degenerative / Drugs - Safety (Iatrogenic) AM I LOSING SIGHT OF WHAT'S IMPORTANT? DO I EVEN KNOW WHAT'S IMPORTANT TO LOSE SIGHT OF? POORLY DRAWN LINES  AM I LOSING SIGHT OF WHAT'S IMPORTANT? DO I EVEN KNOW WHAT'S IMPORTANT TO LOSE SIGHT OF? POORLY DRAWN LINES Two-panel comic strip from 'Poorly Drawn Lines' featuring a grey mouse. Left panel shows the mouse sitting with a speech bubble asking 'AM I LOSING SIGHT OF WHAT'S IMPORTANT?'. Right panel shows the same mouse gesturing with arms out while asking 'DO I EVEN KNOW WHAT'S IMPORTANT TO LOSE SIGHT OF?'. The visual humor and text together form a single comparative figure illustrating existential confusion. What’s important? What’s important? The Active Minds Framework provides a structured approach to clinical assessment and decision-making regarding oral lesions. It emphasizes a systematic progression from initial observation to definitive action. #### Clinical Assessment Steps 1. **Identify the Lesion** - Locate and document the presence of any abnormal tissue or mucosal changes. 2. **Describe the Lesion** - Note the size, shape, color, and texture. - Record the specific anatomical location. - Assess the borders (e.g., well-defined vs. poorly defined). 3. **Determine the Differential Diagnosis** - List potential conditions based on clinical appearance and patient history. - Distinguish between inflammatory, traumatic, and potentially malignant etiologies. 4. **Assess Risk Factors** - Evaluate tobacco and alcohol use. - Consider age, gender, and relevant medical history. - Review duration and persistence of the lesion. 5. **Formulate a Management Plan** - Decide on the appropriate next steps: observation, referral, or biopsy. - Establish a timeline for follow-up if immediate intervention is not required. Classification (WHO 2005) - WHO classification of tumours: Pathology and Genetics of Head and neck tumours • Mild dysplasia • Moderate dysplasia • Severe Dysplasia • Carcinoma in situ • (Carcinoma) ↑ Increasing severity  The WHO classification of tumours regarding the pathology and genetics of head and neck tumours (2005) categorizes lesions by increasing severity: - Mild dysplasia - Moderate dysplasia - Severe Dysplasia - Carcinoma in situ - (Carcinoma) Diagram illustrating the WHO 2005 classification of head and neck tumours. It features a vertical white arrow pointing downwards, with the label 'Increasing severity' next to it. The diagram visually represents the progression from Mild dysplasia at the top to (Carcinoma) at the bottom. Based on the visual layout, this content is displayed as a horizontal table. <table border="1" cellpadding="8" cellspacing="0"> <tr> <th>WHO 1978 classification</th> <th>WHO 2005 classification</th> <th>WHO 2017 classification</th> <th>SIN 2005</th> <th> <br>SIN 2005 (續)</th> <th>Ljubljana classification 2003</th> <th>SIL 1988</th> <th>OIN/CIS (JSOP)system 2010</th> <th>Binary system 2006</th> </tr> <tr> <td rowspan="2">Mild dysplasia</td> <td>Squamoshyperplasia</td> <td rowspan="2">Mild dysplasia</td> <td>SIN 1</td> <td rowspan="2">Low grade dysplasia</td> <td>Squamous cell (simple) hyperplasia</td> <td>Hyperplasia/keratosis</td> <td>Reactive atypical epithelium</td> <td rowspan="3">Low risk</td> </tr> <tr> <td>Mild dysplasia</td> <td>Basal/parabasal cell hyperplasia*</td> <td>SIL I (low grade)</td> <td>Oral epithelial dysplasia</td> </tr> <tr> <td>Moderate dysplasia</td> <td>Moderate dysplasia</td> <td>Moderate dysplasia</td> <td>SIN 2</td> <td>High grade dysplasia</td> <td>Atypical hyperplasia**</td> <td>SIL II (high grade)</td> <td>OIN/CIS (JSOP)<sup>1</sup></td> <td rowspan="2">High risk</td> </tr> <tr> <td>Severe dysplasia</td> <td>Severe dysplasia</td> <td>Severe dysplasia</td> <td>SIN 3<sup>***</sup></td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td>Carcinoma <i>in situ</i></td> <td></td> <td></td> <td></td> <td>Carcinoma <i>in situ</i></td> <td></td> <td></td> <td></td> </tr> </table>  #### Comparative Classification Systems for Epithelial Dysplasia | WHO 1978 | WHO 2005 | WHO 2017 | SIN 2005 | SIN 2005 (Cont.) | Ljubljana 2003 | SIL 1988 | OIN/CIS (JSOP) 2010 | Binary 2006 | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | Mild dysplasia | Squamous hyperplasia / Mild dysplasia | Mild dysplasia | SIN 1 | Low grade dysplasia | 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 dysplasia | Atypical hyperplasia** | SIL II (high grade) | OIN/CIS (JSOP) | High risk | | Severe dysplasia | Severe dysplasia | Severe dysplasia | SIN 3*** | | | | | High risk | | | Carcinoma *in situ* | | | | Carcinoma *in situ* | | | | A comprehensive comparison table titled 'Classification' comparing various oral epithelial dysplasia systems. Columns include WHO 1978, WHO 2005, WHO 2017, SIN 2005, Ljubljana classification 2003, SIL 1988, OIN/CIS (JSOP) system 2010, and Binary system 2006. Rows categorize conditions by severity: Mild dysplasia (mapped to Low risk), Moderate dysplasia, Severe dysplasia, and Carcinoma in situ (mapped to High risk). The table aligns terms such as Squamous hyperplasia, Basal/parabasal cell hyperplasia, Atypical hyperplasia, and Reactive atypical epithelium across different classification years. # Oral pre-malignant conditions Transformation Rates - there will be variations in literature... * **Oral lichen planus - 1.4%** * **Oral Lichenoid lesions - 3.8%** 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  Transformation Rates - there will be variations in literature... - Oral lichen planus: 1.4% - Oral Lichenoid lesions: 3.8% 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 Clinical photograph of the oral cavity showing a mucosal lesion on the buccal mucosa. The image displays white, lacy, reticular striations (Wickham striae) and erythematous areas characteristic of Oral Lichen Planus or an Oral Lichenoid lesion, as referenced in the slide's text. Oral pre-malignant conditions Transformation Rates - there will be variations in literature... • Oral lichen planus - 1.4% • Oral Lichenoid lesions - 3.8% • Leukoplakia - 8.6% 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  Transformation Rates - there will be variations in literature... - 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 Clinical photo of an oral cavity showing a lesion on the tongue. The image displays the upper and lower teeth, with a white, irregularly shaped patch visible on the ventral surface of the tongue. This visual corresponds to the text 'Oral pre-malignant conditions' and is likely illustrating leukoplakia or lichenoid lesions mentioned in the context. # Oral pre-malignant conditions ## Transformation Rates - there will be variations in literature... * **Oral lichen planus - 1.4%** * **Oral Lichenoid lesions - 3.8%** * **Leukoplakia - 8.6%** * **Submucous Fibrosis - 5.2%** 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  Transformation Rates - there will be variations in literature... - Oral lichen planus: 1.4% - Oral Lichenoid lesions: 3.8% - Leukoplakia: 8.6% - Submucous Fibrosis: 5.2% 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 Clinical photo showing the oral cavity of a patient with visible signs consistent with an oral pre-malignant condition. The image displays the upper and lower teeth, gums, and inner cheek mucosa. There appears to be whitish or pale patches on the buccal mucosa (inner cheek), which may correspond to conditions like leukoplakia or lichen planus mentioned in the text. The tongue is also visible, appearing relatively normal. This visual supports the discussion of transformation rates for various oral pre-malignant conditions. Oral pre-malignant conditions Transformation Rates - there will be variations in literature… - Oral lichen planus - **1.4%** - Oral Lichenoid lesions - **3.8%** - Leukoplakia - **8.6%** - Submucous Fibrosis - **5.2%** - Erythroplakia - **33.1%** 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  Transformation Rates - there will be variations in literature... - Oral lichen planus: 1.4% - Oral Lichenoid lesions: 3.8% - Leukoplakia: 8.6% - Submucous Fibrosis: 5.2% - Erythroplakia: 33.1% 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 Clinical photo of an oral cavity showing a red lesion on the mucosa, consistent with erythroplakia. The image includes dental instruments (a wooden tongue depressor and possibly a mirror) used to retract the cheek/lip for examination. **Oral pre-malignant conditions** Transformation Rates - there will be variations in literature... * **Oral lichen planus** - 1.4% * **Oral Lichenoid lesions** - 3.8% * **Leukoplakia** - 8.6% * **Submucous Fibrosis** - 5.2% * **Erythroplakia** - 33.1% * <u>Proliferative verrucous leukoplakia</u> - 49.5% 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  Transformation Rates - there will be variations in literature... - Oral lichen planus: 1.4% - Oral Lichenoid lesions: 3.8% - Leukoplakia: 8.6% - Submucous Fibrosis: 5.2% - Erythroplakia: 33.1% - Proliferative verrucous leukoplakia: 49.5% 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 A composite clinical photograph displaying four panels (labeled A, B, C, and D) of oral mucosal lesions. Panel A shows a white plaque on the lateral tongue. Panel B displays a lesion on the buccal mucosa. Panel C features erythematous changes near the lower anterior teeth. Panel D shows another white lesion on the gingiva or alveolar ridge. - Squamous cell carcinoma - Melanoma - Others… - Squamous cell carcinoma - Melanoma - Others... You’re not a specialist - why is a differential diagnosis important? While you are not a specialist, providing a differential diagnosis is important for guiding the referral process and ensuring the specialist understands your clinical reasoning and the level of concern regarding the lesion. Referral... Referral... # Referral Process Important to make sure not wasting time or resources. - Identify which pathway the patient will need to go down: - Public - OHCWA referral? - Private - Letter - +/- phonecall It is important to ensure that time and resources are not wasted during the referral process. #### Referral Pathways Identify which pathway the patient will need to follow: - **Public Pathway** - Determine if an OHCWA (Oral Health Centre of Western Australia) referral is required. - **Private Pathway** - Prepare a formal referral letter. - Consider a supplementary phone call to the specialist if the case is complex or urgent. # OHCWA * Typically for: * Government patients * Patients seen in private practice under the government subsidy scheme. * Referral form is completed and sent in to OHCWA * Please note **URGENCY** is critical for triaging process **Referred from** ☐ ALB ☐ ARM ☐ BBY ☐ GDC ☐ GLD ☐ LDC ☐ MID ☐ MH ☐ MOR ☐ NPC ☐ RCK ☐ RNG ☐ VAS ☐ WWK Or Other ........................................................................................................................................ **REFERRING DENTIST** ............................................................ **POSITION**............................................ **PATIENT NAME** (SURNAME) ............................................ (GIVEN NAME) ............................................ **REGISTRATION NO** .................... **DATE OF BIRTH** ............................................................................ **ADDRESS** ................................................................................................................................ ................................................................................................................................ **POST CODE** .................... **TELEPHONE NO** ............................................................ **MOBILE** ............................................................ **Referred for** ☐ ENDO ☐ ORAL MED** ☐ ORAL SURG. ☐ ORTHO ☐ PAEDO ☐ PERIO ☐ SPEC. REST ☐ STUDENT ☐ OTHER________ **Urgency** ☐ HIGH ☐ MEDIUM ☐ WAITING LIST **Details** ........................................................................................................................................................................ ........................................................................................................................................................................................ ........................................................................................................................................................................................ **Relevant Medical History**........................................................................................................................................... ........................................................................................................................................................................................ ........................................................................................................................................................................................ ........................................................................................................................................................................................ <table> <tr> <th>If Oral Surgery for 8's</th> <th>Number of Teeth</th> <th>Distal Impact (Y/N)</th> </tr> <tr> <td>Upper</td> <td>............................................................</td> <td>............................................................</td> </tr> <tr> <td>Lower</td> <td>............................................................</td> <td>............................................................</td> </tr> </table> **Requires general anaesthetic?** ☐ Yes ☐ No ☐ Unsure **Why?** ............................................................................................................................................................ **Signature** ............................................................ **Date** ....................  #### OHCWA Referral Criteria - Typically utilized for government patients. - Includes patients seen in private practice under the government subsidy scheme. - A specific referral form must be completed and submitted to OHCWA. - **Urgency** is critical for the triaging process. #### Referral Form Requirements - **Originating Clinic:** Selection of referring site (e.g., ALB, ARM, BBY, GDC, GLD, LDC, MID, MH, MOR, NPC, RCK, RNG, VAS, WWK). - **Practitioner Details:** Name and position of the referring dentist. - **Patient Information:** Full name, registration number, date of birth, address, and contact telephone numbers. - **Specialty Area:** Selection of department (Endodontics, Oral Medicine, Oral Surgery, Orthodontics, Paedodontics, Periodontics, Specialist Restorative, or Student clinic). - **Triage Status:** High, Medium, or Waiting List. - **Clinical Information:** Detailed description of the condition and relevant medical history. - **Oral Surgery Specifics (for 8's):** Number of teeth and presence of distal impact. - **Anaesthetic Requirements:** Indication if general anaesthesia is required and the justification for it. A structured medical referral form for OHCWA. The table includes fields for 'Referred from' (listing various dental practice codes), patient details ('REFERRING DENTIST', 'PATIENT NAME', etc.), and the specific reason for referral ('Referred for' with checkboxes for procedures like ENDO, ORAL MED, ORAL SURG.). It also contains a section for 'Urgency' triage and a detailed data entry table at the bottom titled 'If Oral Surgery for 8's', which tracks the number of teeth and distal impact status for upper and lower sections. # How urgent? * Suspected malignancy is **urgent**. Within 2 weeks as a *maximum*. * Suspected pre-malignant may be **urgent** due to the potential that there may have already been a malignant change within the lesion. * Other conditions should be prioritised on their own merits. * If unsure: * Seek advice from a more experienced colleague in the practice * Consider calling referral practice for advice * If all else fails, send urgent referral #### Determining Urgency - **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 potential for existing malignant changes 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 or specialist for advice. - If uncertainty persists, default to sending an urgent referral. # Private 1. Decide on who the patient needs to see: 1. Do you have a preferred clinic or clinician? (Either geographical or personal preference). 2. Is this so urgent you need the patient to ring around for first available? Could the clinic reception do this? 2. Make the referral: 1. Referral pad - which needs scanning and sending via secure mail. 2. Referral web form. 3. Referral letter - which needs sending via secure mail.  #### Selecting a Clinician 1. Decide on the appropriate specialist for the patient: - Consider preferred clinics or clinicians based on geographical location or personal professional preference. - Determine if the case is so urgent that the patient or clinic reception needs to contact multiple providers to find the first available appointment. #### Submission Methods 2. Execute the referral using one of the following methods: - **Referral Pad:** Must be scanned and sent via secure mail. - **Referral Web Form:** Submitted directly through the specialist's website. - **Referral Letter:** Sent via secure mail. Text-based procedural guide outlining patient referral steps: 1. Decide on who the patient needs to see (preferred clinic/clinician, urgency), and 2. Make the referral via pad/web form/letter. **PERTH ORAL MEDICINE & DENTAL SLEEP CENTRE** **PATIENT DETAILS** Name Date of Birth Email Address Telephone (Mobile) Telephone (Home/Work) **CONSULTATION TYPE** * Orofacial Pain * Temporomandibular Disorders * Oral Mucosal Lesions * Orofacial Disorders * Oral Appliance for Snoring & Sleep Apnoea (Sleep Study required) * Other ________ **CLINICAL DETAILS** [______] Adult [______] Paediatric [text box] **REFERRING PRACTITIONER** Name Practice Telephone Email Signature Date **LOCATION** * **WEST LEEDERVILLE** Unit 6, 24 McCourt Street, West Leederville WA 6007 * **JANDAKOT** Unit 15, 233 Berrigan Drive, Jandakot WA 6164 * **PADBURY** Unit 5, 6 Blackwattle Parade, Padbury WA 6025 [Phone icon] **9376 6789** www.oralmedsleep.com.au [Envelope icon] admin@pomds.com.au | Fax: **9376 6710** Please send all correspondence to: Unit 6, 24 McCourt Street, West Leederville WA 6007 **PERTH ORAL MEDICINE & DENTAL SLEEP CENTRE** About Us | Our Team | Services | Patients | Referrers | Blog | Contact # Refer a Patient <p style="font-size: 4px">*Other clinics are available</p> #### Example Private Referral Form: Perth Oral Medicine & Dental Sleep Centre **Patient and Practitioner Information** - Patient name, DOB, email, address, and contact numbers. - Referring practitioner name, practice, telephone, email, and signature. **Consultation Categories** - Orofacial Pain - Temporomandibular Disorders - Oral Mucosal Lesions - Orofacial Disorders - Oral Appliance for Snoring & Sleep Apnoea (requires Sleep Study) **Clinical Details** - Classification (Adult or Paediatric) and descriptive clinical notes. **Clinic Locations** - **West Leederville:** Unit 6, 24 McCourt Street, West Leederville WA 6007 - **Jandakot:** Unit 15, 233 Berrigan Drive, Jandakot WA 6164 - **Padbury:** Unit 5, 6 Blackwattle Parade, Padbury WA 6025 *Note: Other clinics are available.* # Referral letter ## Best practice guidance * Your name, clinic and contact details * Patient name, patient details including contact details * Medical history * Clinical findings - description - photos if possible * Differential diagnoses (not critical but good to include) * What you want them to do #### Best Practice Guidance for Referral Letters A high-quality referral letter should include the following elements: - **Provider 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:** A detailed description of the lesion or condition, accompanied by clinical photographs if possible. - **Differential Diagnoses:** While not strictly critical, including your clinical impressions is beneficial. - **Clear Objectives:** A specific statement regarding what you want the specialist to do (e.g., assessment, biopsy, or ongoing management). A high-quality referral letter is essential for ensuring that patients with suspected oral premalignant conditions or oral cancer are triaged correctly and seen within appropriate timeframes. #### Essential Patient and Clinician Information - **Patient Details:** Full name, date of birth, gender, address, and reliable contact telephone numbers. - **Referring Clinician:** Name, practice address, and contact details (phone and email). - **General Medical Practitioner:** Name and address of the patient's GP. #### Clinical Findings and History - **Primary Reason for Referral:** A clear statement of the clinical suspicion. - **Duration and Progression:** How long the lesion or symptom has been present and whether it is changing in size, shape, or color. - **Symptoms:** Presence of pain, numbness, bleeding, or functional interference (e.g., difficulty swallowing or speaking). - **Clinical Description:** - Exact anatomical location. - Size (measured in millimeters or centimeters). - Appearance (e.g., color, texture, presence of ulceration). - Consistency (e.g., firm, indurated, or soft). - **Associated Features:** Presence of palpable neck nodes or trismus. #### Medical and Social History - **Risk Factors:** Detailed history of tobacco use (type and quantity) and alcohol consumption. - **Medical History:** Relevant systemic conditions, current medications, and known allergies. #### Supporting Documentation - **Imaging:** Include any relevant radiographs or clinical photographs if available. - **Previous Treatments:** Details of any treatments already attempted for the condition (e.g., topical agents or courses of antibiotics) and the patient's response to them. # Pre-treatment screening - Occasionally you may be asked to provide a pre-treatment screen for a patient about to undergo treatment. - If asked to perform a pre-treatment screen it is important to consider what the treatment is likely to be and what the long term effects may be. - Check for caries and apical pathology. - Important to take an OPG for screening. Can consider full mouth series of PA’s to assess. - BWs still have a place in caries diagnosis. Occasionally, you may be asked to provide a pre-treatment screen for a patient about to undergo treatment. When performing this screening, it is important to consider the nature of the proposed treatment and its likely long-term effects. #### Clinical Assessment and Imaging - Check for dental caries and apical pathology. - Take an Orthopantomogram (OPG) for initial screening. - Consider a full mouth series of periapical radiographs (PAs) for detailed assessment. - Utilize bitewing radiographs (BWs) for accurate caries diagnosis. # Treatment * Broadly treatment will fall into: * Surgical * Chemotherapy * Radiation therapy * Combination of the above Broadly, oncology treatment will fall into the following categories: - Surgical intervention - Chemotherapy - Radiation therapy - Combination of the above modalities ## Effects of treatment * **Surgical treatment may change the anatomy of the oral cavity** * **Lymph node chain removal** * **Radiation therapy:** * **Oral mucositis** * **Salivary gland dysfunction (>50Gys)** and radiation caries * **Dysphasia, dysgeusia and oral canidiasis** * **Trismus and difficulty opening** * **Osteoradionecrosis** * **Woody neck (anatomical variation)** #### Surgical Impacts - Surgical treatment may change the anatomy of the oral cavity. - Lymph node chain removal. #### Radiation Therapy Complications - Oral mucositis. - Salivary gland dysfunction (typically occurring at doses >50Gys) and subsequent radiation caries. - Dysphasia, dysgeusia, and oral candidiasis. - Trismus and difficulty opening the mouth. - Osteoradionecrosis. - Woody neck (anatomical variation). # Effects of treatment * Chemotherapy * Oral mucositis * Candidiasis and other oral infections #### Chemotherapy Side Effects - Oral mucositis. - Candidiasis and other oral infections. PHARMACY MEDICINE SORE THROAT & MOUTH SOLUTION **Difflam** **SORE THROAT & MOUTH** **SOLUTION** **anti-inflammatory** ready to use Benzaydamine FAST SOOTHING RELIEF of sore throats & mouths **500 mL | MINT FLAVOUR** **GAROLIC | SUGAR FREE** ### Long term care requirements Most oral care advice will be provided by oncology clinic • Oral discomfort - **Difflam** sore throat mouth wash (Benzydamine hydrochloride). Can be diluted 50/50 if too strong. (Oral mucositis).  Most oral care advice will be provided by the oncology clinic. #### Management of Oral Discomfort - **Difflam Sore Throat & Mouth Solution (Benzydamine hydrochloride):** - Anti-inflammatory, ready-to-use solution. - Used for fast soothing relief of sore throats and mouths, specifically for oral mucositis. - Can be diluted 50/50 with water if the solution is too strong. - Mint flavour, sugar-free. Clinical product photo of Difflam Sore Throat & Mouth Solution bottle. The label shows it is a Pharmacy Medicine containing Benzydamine (anti-inflammatory), ready to use, 500 mL mint flavour, garlic and sugar free. This visual corresponds to the text recommendation for oral discomfort/mucositis management. # Long term care requirements Most oral care advice will be provided by oncology clinic * Oral discomfort - Diffiam sore throat mouth wash (Benzydamine hydrochloride). Can be diluted 50/50 if too strong. (Oral mucositis). * Oral dryness - Biotene mouthwash, oral gels, toothpastes **** Long term care requirements Most oral care advice will be provided by oncology clinic - Oral discomfort - Difflam sore throat mouth wash (Benzydamine hydrochloride). Can be diluted 50/50 if too strong. (Oral mucositis). - Oral dryness - Biotene mouthwash, oral gels, toothpastes - Radiation caries - Neutrafluor 5000 and other topically applied fluoride products. - Consider the use of silver diamine fluoride  Clinical product photo of a NeutraFluor 5000 Plus toothpaste tube. The image displays the packaging with branding 'Colgate', dosage information 'Sodium fluoride 11.05 mg/g', and specific indications 'For individuals at high risk of caries'. This visual serves to identify the specific topical fluoride product mentioned in the text for treating radiation caries. 40% recurrence within 5 years Zhang et al. Advancements of radiotherapy for recurrent head and neck cancer in the modern era. Radiation Oncology 18, 166 (2023) [^1]: Original PDF page 1: [[L4 OPMDs.pdf#page=1|L4 OPMDs, p.1]] [^2]: Original PDF page 2: [[L4 OPMDs.pdf#page=2|L4 OPMDs, p.2]] [^3]: Original PDF page 3: [[L4 OPMDs.pdf#page=3|L4 OPMDs, p.3]] [^4]: Original PDF page 4: [[L4 OPMDs.pdf#page=4|L4 OPMDs, p.4]] [^5]: Original PDF page 5: [[L4 OPMDs.pdf#page=5|L4 OPMDs, p.5]] [^6]: Original PDF page 6: [[L4 OPMDs.pdf#page=6|L4 OPMDs, p.6]] [^7]: Original PDF page 7: [[L4 OPMDs.pdf#page=7|L4 OPMDs, p.7]] [^8]: Original PDF page 8: [[L4 OPMDs.pdf#page=8|L4 OPMDs, p.8]] [^9]: Original PDF page 9: [[L4 OPMDs.pdf#page=9|L4 OPMDs, p.9]] [^10]: Original PDF page 10: [[L4 OPMDs.pdf#page=10|L4 OPMDs, p.10]] [^11]: Original PDF page 11: [[L4 OPMDs.pdf#page=11|L4 OPMDs, p.11]] [^12]: Original PDF page 12: [[L4 OPMDs.pdf#page=12|L4 OPMDs, p.12]] [^13]: Original PDF page 13: [[L4 OPMDs.pdf#page=13|L4 OPMDs, p.13]] [^14]: Original PDF page 14: [[L4 OPMDs.pdf#page=14|L4 OPMDs, p.14]] [^15]: Original PDF page 15: [[L4 OPMDs.pdf#page=15|L4 OPMDs, p.15]] [^16]: Original PDF page 16: [[L4 OPMDs.pdf#page=16|L4 OPMDs, p.16]] [^17]: Original PDF page 17: [[L4 OPMDs.pdf#page=17|L4 OPMDs, p.17]] [^18]: Original PDF page 18: [[L4 OPMDs.pdf#page=18|L4 OPMDs, p.18]] [^19]: Original PDF page 19: [[L4 OPMDs.pdf#page=19|L4 OPMDs, p.19]] [^20]: Original PDF page 20: [[L4 OPMDs.pdf#page=20|L4 OPMDs, p.20]] [^21]: Original PDF page 21: [[L4 OPMDs.pdf#page=21|L4 OPMDs, p.21]] [^22]: Original PDF page 22: [[L4 OPMDs.pdf#page=22|L4 OPMDs, p.22]] [^23]: Original PDF page 23: [[L4 OPMDs.pdf#page=23|L4 OPMDs, p.23]] [^24]: Original PDF page 24: [[L4 OPMDs.pdf#page=24|L4 OPMDs, p.24]] [^25]: Original PDF page 25: [[L4 OPMDs.pdf#page=25|L4 OPMDs, p.25]] [^26]: Original PDF page 26: [[L4 OPMDs.pdf#page=26|L4 OPMDs, p.26]] [^27]: Original PDF page 27: [[L4 OPMDs.pdf#page=27|L4 OPMDs, p.27]] [^28]: Original PDF page 28: [[L4 OPMDs.pdf#page=28|L4 OPMDs, p.28]] [^29]: Original PDF page 29: [[L4 OPMDs.pdf#page=29|L4 OPMDs, p.29]] [^30]: Original PDF page 30: [[L4 OPMDs.pdf#page=30|L4 OPMDs, p.30]] [^31]: Original PDF page 31: [[L4 OPMDs.pdf#page=31|L4 OPMDs, p.31]] [^32]: Original PDF page 32: [[L4 OPMDs.pdf#page=32|L4 OPMDs, p.32]] [^33]: Original PDF page 33: [[L4 OPMDs.pdf#page=33|L4 OPMDs, p.33]] [^34]: Original PDF page 34: [[L4 OPMDs.pdf#page=34|L4 OPMDs, p.34]] [^35]: Original PDF page 35: [[L4 OPMDs.pdf#page=35|L4 OPMDs, p.35]] [^36]: Original PDF page 36: [[L4 OPMDs.pdf#page=36|L4 OPMDs, p.36]] [^37]: Original PDF page 37: [[L4 OPMDs.pdf#page=37|L4 OPMDs, p.37]] [^38]: Original PDF page 38: [[L4 OPMDs.pdf#page=38|L4 OPMDs, p.38]] [^39]: Original PDF page 39: [[L4 OPMDs.pdf#page=39|L4 OPMDs, p.39]] [^40]: Original PDF page 40: [[L4 OPMDs.pdf#page=40|L4 OPMDs, p.40]] [^41]: Original PDF page 41: [[L4 OPMDs.pdf#page=41|L4 OPMDs, p.41]] [^42]: Original PDF page 42: [[L4 OPMDs.pdf#page=42|L4 OPMDs, p.42]] [^43]: Original PDF page 43: [[L4 OPMDs.pdf#page=43|L4 OPMDs, p.43]] [^44]: Original PDF page 44: [[L4 OPMDs.pdf#page=44|L4 OPMDs, p.44]] [^45]: Original PDF page 45: [[L4 OPMDs.pdf#page=45|L4 OPMDs, p.45]] [^46]: Original PDF page 46: [[L4 OPMDs.pdf#page=46|L4 OPMDs, p.46]]