Jaisri R. Thoppay, DDS, MBA, MS, discusses the assessment and management of oral lesions.
Q: Why is oral cancer so difficult to diagnose?
A: The impact of systemic conditions and diseases in the oral cavity is well documented and often quoted as a window to the body. The oral cavity, though easily accessible, is complex and sometimes presents enigmatic conditions. With newer medical management and advancement in clinical approaches, new oral conditions have started to present. Post-COVID-19 complications in the oral cavity presenting with a loss of taste, some neuropathic, and oral lesions are a few to mention. The peculiarity is that the oral cavity houses susceptible areas that hold hard and soft tissues that are in a constant transaction between the internal structures and external environment.
Q: What is the dentist’s role in the early diagnosis of oral cancer?
A: As dentists, we have an excellent opportunity to screen the oral cavity under magnification for any suspicious areas. The oromucosal sites present various clues of general health susceptibility. One of the critical areas that concern is that 3% to 5% of cancer worldwide is ever rising despite all the advancements that the dental field is seeing in the current era. Early diagnosis improves 5-year survival rates while minimizing post-management complications and consequences. However, the challenge in early diagnosis is that the oromucosal lesions often appear red, white, or a mixture of red and white and occasionally pigmented.
Q: After identifying a suspicious area, how do we approach such a presentation? Should we observe or treat? Can that lesion be cancerous or premalignant?
A: There are simple ways to approach these lesions. The initial step is identifying etiopathology, followed by assessing clinical appearance.
Q: What is the etiopathology?
A: Apart from known risk factors, such as smoking, alcohol, and genetics, certain factors that need to be considered are related to the general oral status. Poor oral hygiene and dry mouth may predispose such lesions to further vulnerability and magnify or alter their clinical presentation. For example, if the patient is under any autoimmune therapy, the patient may have an opportunistic candidal infection that may alter the clinical presentation of the oral lesion. When such appearance is considered exclusively as oral candidiasis and managed empirically with either an antifungal or a magic mouthwash, there is uncertainty about the resolution of such lesions. The prognosis is better when oral lesions are systematically approached, considering patients’ pre-existing medical and oral conditions. Further, it helps to advance or modify the treatment plan based on the prognosis. Also, if a lesion is chronic, a systematic approach provides a good foundation in management; if it is a premalignant condition, it helps prevent malignancy, and if it ever transforms, it can be diagnosed early.
Q: What is the clinical appearance?
A: The lesion can be a single site or multiple sites, homogenous white or red, plaque-like or smooth, and sometimes ulcerative or erosive. The lesion may appear heterogeneous with mixed manifestations. Thorough documentation of the lesion is essential.
Q: How do we get the patient on board?
A: Adjunctive devices often facilitate further guidance in managing the lesions. There are a lot of adjunctive devices on the market—some of which I have trialed and some with studies that documented their efficacy. A few to mention are vital tissue staining with toluidine blue; adjunctive visualization devices, such as ViziLite (DenMat), Microlux DL (AdDent), Orascoptic DK, VELscope (LED Dental), toluidine blue staining and ViziLite (chemoluminescent light detection system) in combination; and cytopathology (OralCDx brush test system) for the detection of oral premalignant and malignant lesions.
I use VELscope and Oral CDx in my practice based on the type of assessment and monitoring needs. The visualization devices are noninvasive and help screen the lesion multiple times as needed during the initial assessment, before biopsy, post biopsy, and active lesion-monitoring phases. There is an insurance code (D0431), but the patient should be aware that it is most often not reimbursable.
Q: When do we investigate the lesion further?
A: Any persistent lesions over an average 14-day period need a biopsy to understand the histopathology, leading to a definitive diagnosis. A biopsy can facilitate ruling out malignancy while also providing details of possible specimen architecture, providing guidance on malignant potential chronicity and risk for malignant transformation. The adjunctive visualization may facilitate spotting an ideal site for tissue sampling for the biopsy.
When a definitive diagnosis has arrived, and if the lesions are chronic, it is crucial to focus on managing the lesions appropriately and to have a key focus on preventing malignant transformation. If the diagnosis is malignant, a proper referral to the oncology team should be made for cancer staging, assessment, and management. Management of oral cancer is multidisciplinary, and post-cancer treatment may have its complications.
As an oral health provider, I find restoring a person’s smile and having an active part in minimizing the global burden of cancer rewarding.
ABOUT DR. THOPPAY
Dr. Thoppay obtained her dental degree and MBA in India and her master’s in oral biology from Augusta University in Georgia. She completed her oral medicine residency and interdisciplinary geriatric fellowship at the University of Pennsylvania in Philadelphia and her interprofessional geriatric fellowship at the Virginia Commonwealth University in Richmond. She is the president of the Center for Integrative Oral Health in Winter Park, Fla. She can be reached at email@example.com.