The Journal of the American Dental Association
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J Am Dent Assoc, Vol 139, No 10, 1338-1344.
© 2008 American Dental Association
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CLINICAL PRACTICE

Oral Lesions in Patients Participating in an Oral Examination Screening Week at an Urban Dental School

Joel B. Epstein, DMD, MSD, Dana Villines, MA, Gary Drahos, DDS, MJ, RPh, Eliezer Kaufman, DMD and Meir Gorsky, DMD


   ABSTRACT
TOP
 ABSTRACT
ORAL LESIONS
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. Dental education must emphasize early diagnosis and management of oral mucosal disease, including early detection of oral premalignant lesions and cancer. The authors evaluated clinical findings of oral screening examinations of dental patients during a one-week period in an urban dental school clinic.

Methods. Third- and fourth-year dental students conducted clinical screening examinations for all dental patients of record seen during the Yul Brynner Foundation’s Oral, Head and Neck Cancer Awareness Week in April 2006.

Results. Of 262 patients, 100 (38.2 percent) reported that they had used tobacco for a mean of 8.1 years. Most patients reported having denture or tooth and gingival problems. The dental students reported abnormal findings in 55 patients (21 percent). Two patients had suspected premalignant lesions that were diagnosed as lichen planus and traumatic keratosis.

Conclusions and Clinical Implications. The one-week screening provided an educational opportunity for the dental students, and the results demonstrate the value of having a focused week to reinforce the importance of head and neck and oral soft-tissue examination. The finding of mucosal lesions in 21 percent of patients of record reflects the fact that lesions were present but undetected. In addition, there are important implications for teaching and patient care. The screening week provided an opportunity for students to be active in a national campaign for cancer detection, and it represents an opportunity for visible community participation in the recognition of oral mucosal diseases in dental training programs and broadly for the profession.

Key Words: Oral lesions; oral premalignant lesions; oral examination; oral cancer; screening

Abbreviations: HN: Head and neck • OHANCAW: Oral Head and Neck Cancer Awareness Week • OPLs: Oral premalignant lesions • OSCC: Oral squamous cell carcinoma • UIC: University of Illinois at Chicago

Oral health care providers are responsible for the diagnosis of orofacial diseases and oral manifestations of systemic disease, as well as the medical management of patients with orofacial sensory and motor disorders. Clinicians also must recognize that the prevalence of impaired health findings in a patient’s medical history and on examination increases with age owing to use of multiple medications and comorbid conditions. In addition, more than 60 percent of drugs prescribed have orodental implications.1 Furthermore, one of 10 patients older than 35 years has at least one oral soft-tissue lesion.2 Pain is the most common reason for seeking health care.1,3 Mucocutaneous diseases and salivary gland disorders account for approximately 23 percent of all conditions treated by dentists,1 and more than 80 percent of patients receiving care from dentists have oral diseases linked to complex medical problems.4


   ORAL LESIONS
TOP
 ABSTRACT
 ORAL LESIONS
SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
In a randomly selected population in Italy (older than 40 years),5 investigators found that leukoplakia and traumatic ulcers accounted for 23 percent of all lesions, followed by candidiasis, which accounted for 7.3 percent of all lesions. According to the Third National Health and Nutrition Examination Survey, approximately one-quarter of people examined (4,801 of 17,235) had oral lesions,6 with most lesions (46.3 percent) located on the hard palate or gingiva where red-and-white lesions were most prevalent.

In a mass oral screening, Bouquot and Gorlin7 found that although the majority of lesions were benign, about 17 percent of them were oral leukoplakia, 7 percent of which represented carcinoma or severe dysplasia. On the basis of a nationwide survey of oral and maxillofacial surgeons, oral and maxillofacial pathologists and oral medicine providers, Sciubba8 reported that 12.3 percent of epithelial lesions were clinically suspicious of being dysplastic or malignant. Therefore, oral mucosal lesions are common and require recognition to allow diagnosis and appropriate management.

The American Cancer Society has estimated that approximately 30,000 cases of oral squamous cell carcinoma (OSCC) are diagnosed annually, and more than 8,000 people die of these cancers each year in the United States.9 Eighty-one percent of patients with OSCC survive for at least one year after diagnosis, and the five-year relative survival rate for all stages of the disease is approximately 50 percent,9 which has not changed significantly in the last few decades.10,11 For early-stage OSCC (stage I and II [before regional or distant spread occurs]), the five-year survival rate is approximately 80 percent, whereas in advanced-stage disease (stage III and IV), the five-year survival rate is less than 25 percent.8,10,12,13 In addition, advanced disease requires more aggressive therapy involving combined modalities that result in significant morbidity and a negative impact on patients’ quality of life, as well as a high cost of care. Therefore, early detection of mucosal disease, oral premalignant lesions (OPLs) and OSCC is of critical importance with regard to patient outcomes.

Although progress has been made with other cancers, the detection of early, localized OSCC has not improved significantly during the past three decades.14,15 The most effective approach to decreasing the morbidity and mortality associated with OSCC appears to be increasing the detection of OPLs or early detection of OSCC combined with proper treatment and follow-up. Recent reports have provided evidence that supports the utility of oral cancer screening and early detection to reduce mortality rates due to cancer.16–19

The purpose of this study was to evaluate the head and neck (HN) and oral findings and outcomes of repeated oral examinations of patients of record in an urban American dental school during a cancer screening event.


   SUBJECTS, MATERIALS AND METHODS
TOP
 ABSTRACT
 ORAL LESIONS
 SUBJECTS, MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
All patients of record in the University of Illinois at Chicago (UIC) College of Dentistry general dentistry clinic received an HN and oral examination. The examinations were conducted during the Yul Brynner Foundation’s Oral, Head and Neck Cancer Awareness Week (OHANCAW) in 2006 with the use of a standardized form (available as supplemental data to the online version of this article [found at "http://jada.ada.org"]). Third-and fourth-year dental students examined each patient for abnormal lesions during a regularly scheduled follow-up visit. A total of 262 patients signed a release-of-liability form. All dental student examiners had completed preclinical training and had been active in clinics for more than one year; they were supervised by general dental clinical faculty members.

Abstracted information included a medical history, including cancer history, and a history of alcohol and tobacco use obtained via patient self-reports on the standardized form. The students performed extraoral and intraoral examinations using standard dental instruments and a standard light source. They recorded all findings on the standardized form. The students referred patients with identified mucosal lesions for further assessment on the basis of the clinical judgment of faculty members, according to routine practice. These patients were seen by faculty members in the Department of Oral Medicine and Diagnostic Sciences or the Department of Oral and Maxillofacial Surgery, College of Dentistry, UIC, or the Department of Otolaryngology and Head and Neck Surgery, College of Medicine, UIC. After treatment, we reviewed all records retrospectively under UIC institutional review board approval. We evaluated and summarized the findings for referred patients by using statistical software (SPSS 15.0, SPSS, Chicago).


   RESULTS
TOP
 ABSTRACT
 ORAL LESIONS
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
The mean (± standard deviation) age of the 262 patients was 49.9 (± 17) years (range, 18–89 years). There were more women (n = 150, 57.3 percent) than men (n = 101, 38.5 percent) (some patients did not answer all questions). One hundred patients (38.2 percent) reported a history of tobacco use for a mean (± SD) of 8.1 (± 11.6) years (range, one to 50 years). Sixty-six patients (25.2 percent) reported that they had used alcohol for a mean (± SD) of 5.4 (± 11.3) years (range, one to 55 years). Of all patients screened, 25 (9.5 percent) reported a family history of HN cancer and 12 (4.6 percent) reported a personal history of HN cancer, including cancer of the oral cavity in two patients (0.8 percent). Twenty patients (7.6 percent) reported other malignancies, with cancers of the uterus and colon reported most frequently.

The number of subjective problems reported by patients ranged between 0 and five, with a mean (± SD) of 0.7 (± 1) for each patient. During their examinations, most of the patients reported having dental or periodontal problems and/or denture difficulties (Table 1Go). The dental students recorded abnormal HN clinical findings for 55 patients (21 percent), mainly involving the oropharynx, neck or oral cavity (35 patients [63.6 percent]). They recorded salivary gland involvement for five (9 percent) of the 55 abnormal findings (Table 2Go). The number of lesions ranged between 0 and four, with a mean (± SD) of 0.20 (± 0.54) lesions per patient.


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  		TABLE 1 Head and neck and oral symptoms reported by patients.

 

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  		TABLE 2 Sites of abnormalities.

 
Nondental-related problems. In addition to recommending follow-up visits with dental health care providers, the dental students and faculty supervisors recommended medical follow-up for nondental-related problems for 11 (20 percent) of the 55 patients with abnormal findings. Eight (14.5 percent) of these 55 patients had lesions that were not dental-related abnormalities and were not suspected of being a neoplasm.

These lesions included red changes (two patients), one on the buccal mucosa attributed to mechanical trauma and the other later diagnosed as a hemangioma of the lower lip treated via localized sclerosing-agent infiltration. One patient had ear discomfort and pain not related to dental problems and was referred to the Department of Otolaryngology and Head and Neck Surgery for diagnosis and treatment. Another patient had a history of an unspecified tumor of the mandible 14 years before the examination and was referred for follow-up. The students noted gingival swelling and bleeding in two patients, and they referred one of these patients to a physician to rule out leukemia on the basis of clinical findings; this patient was later diagnosed as having an acute periodontal infection. An oral and maxillofacial surgeon later removed a white firm lesion noted lingual to tooth no. 31 and diagnosed it as an exostosis. The students identified soft-tissue masses in two patients. One had a 5-millimeter nodule on the lower lip that had been present for several years; the students suggested further clinical evaluation. The second patient, who had advanced periodontal disease, also had a small node on the midline of the neck suspected of being a reactive lymph node; the students also recommended follow-up for this patient.

Additional evaluations. Faculty members performed additional evaluations in two (3.6 percent) of the 55 patients with abnormal HN findings that were suspected of being premalignant changes. One patient, a 68-year-old man who had smoked two packs of cigarettes per day for 10 years but had discontinued smoking 10 years earlier and had no history of HN cancer, had red-and-white striated lesions on the right buccal mucosa and an erythematous ulcerated lesion on the left lateral border of the tongue, with no history of local trauma. The dental student noted no significant findings on the HN examination. After the patient was referred to the Department of Oral Medicine and Diagnostic Sciences, the clinician noted no changes on his tongue. The clinician applied toluidine blue, which was retained on the buccal mucosa, and performed a punch biopsy at the site. The pathological diagnosis was lichen planus.

The dental students referred a 64-year-old man who had right-sided weakness following a stroke 35 years earlier to the Department of Oral Medicine and Diagnostic Sciences, where he was examined for oral changes. He had a history of having smoked five cigarettes per day for five years 40 years earlier. The examination revealed an asymptomatic 1-centimeter-diameter homogenous white lesion on the left lateral border of the tongue and on the left buccal mucosa. Toluidine blue was not retained. The clinical impression was of a reactive lesion. An incisional biopsy specimen obtained from the left buccal mucosa was diagnosed as benign keratosis and later was attributed to local mechanical trauma.


   DISCUSSION
TOP
 ABSTRACT
 ORAL LESIONS
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
Delays in diagnosis negatively affect patients’ quality of life and may have an effect on the prognosis for some oral conditions. Limited literature is available to describe the prevalence of oral lesions in general and OPLs in adults. Most studies are of subgroups such as patients undergoing immunosuppressive treatment and patients with human immunodeficiency virus infection, as well as of oral lesions associated with cancer treatment and screening for oral cancer detection.4 Table 3Go provides a summary of studies4–7,20–23 assessing the prevalence of oral mucosal lesions in various populations. A national probability sample of 17,235 adults in the United States resulted in the identification of denture-related lesions (8.4 percent of all lesions), tobacco-related lesions (4.7 percent) and frictional white lesions (2.7 percent).6 The oropharyngeal abnormalities noted in our study were comparable with those found in the national screening.6


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  		TABLE 3 Prevalence of oral lesions in population screening and survey studies.

 
The World Health Organization24 estimates that global cancer rates will increase from 10 million new cases in 2000 to 15 million in 2020 and that we have the opportunity to reduce the anticipated increase in new cancer cases by reducing tobacco use (suggesting a healthy lifestyle and diet), as well as through early detection. Brennan and colleagues25 recently reviewed the epidemiology and clinical treatment of OPLs; the results of their review indicate that continuing study is needed.

Population-based screening programs for OPLs/OSCC and other cancers such as cervical cancer are costly given the low number of lesions in the population in developed countries, as reflected in our survey. However, "opportunistic screening" during routine dental office and medical visits has been suggested and, if it is based on the patient’s history and clinical examination findings, does not add substantially to the cost of care.26 Compliance varies in different populations, and the types of settings and methods of promoting screening may be directed toward high-risk patients.27–31 Since 1998, The Yul Brynner Head and Neck Cancer Foundation, Charleston, S.C., has promoted an international effort to improve the education of the public and health care providers through an awareness week. The OHANCAW is an opportunity for community dentists and physicians to offer an examination for oral and other HN cancers ("www.headandneck.org").

Although our survey identified mucosal lesions that required diagnosis, we did not identify any malignant lesions, which is not surprising given the prevalence of the disease and the small sample size. However, the dental students did identify oral and other medical findings requiring diagnosis and treatment. A simulation model of population screening for OPLs/OSCC indicated that approximately 18,000 patients would need to be screened to save one life.32 Visual screening can reduce mortality in high-risk patients and has the potential to prevent an estimated 37,000 deaths from oral cancer per year worldwide.19

Unfortunately, people in high-risk groups often have poor health behaviors and may be less likely to participate in screening programs. A clinical examination provides valid screening, especially when it is performed by trained health care personnel with a good understanding of the presentation and natural history of OPLs/OSCC. In a study that examined the feasibility of self-examination of the oral cavity, Mathew and colleagues33 reported that of 247 patients who visited clinics, six (2.4 percent) had stage I OSCC and one was diagnosed with advanced-stage disease. The detection rate of oral cancer after self-examination compared favorably with that using trained health care workers.33 On the basis of the information available regarding the advantages of screening programs for the early detection of OPLs/OSCC, it is evident that screening must be easy to perform and of low cost.

Clinical tools. Clinical tools may assist clinicians in visualizing suspected lesions during the clinical oral examination. Toluidine blue has shown utility in identifying lesions, accelerating the clinician’s decision to perform a biopsy, guiding biopsy-site selection, and determining the extent and margins of a suspected lesion, but it does not serve as a substitute for a biopsy.34 Other approaches, including imaging techniques, are available and require further study.35–38 On the basis of clinical findings, a biopsy may be needed for diagnosis.

In this study, eight (3.1 percent) of the 262 patients had lesions that were not clinically suspected of being neoplastic. We referred these patients for further assessment. These findings in patients of record show that oral conditions may be present and not be recognized or may develop during ongoing dental care and require reexamination to be identified. These lesions represented color changes, local swellings and lymph node involvement and underwent further evaluation to rule out localized or distal neoplasm or systemic disease.39,40 Two patients were referred to rule out OPLs or OSCC. Current epidemiologic evidence shows that OSCC occurs in 1 of every 10,000 Americans and that the estimated lifetime probability of developing oral cancer is 950 for every 100,000 people.15

In our study, we also identified 12 patients with a history of HN cancer who were at an increased risk of experiencing a recurrence or developing a second primary cancer. The dental students identified 25 patients with oropharyngeal lesions that required further evaluation; some of these lesions might have been associated with a premalignant lesion or may already have represented malignant disease. Although we did not diagnose any cancer during this screening week, we did refer two patients (described earlier) who had suspicious lesions to rule out premalignant or malignant changes. Both patients had a history of tobacco use. The white striated lesion in the first patient was limited to the buccal mucosa on one side, and the results of vital staining were positive, suggesting the need for a biopsy. The second patient had a white lesion that required tissue diagnosis, even though the clinician suspected that this was a reactive lesion.

This study is based on a convenience sample of patients attending an urban dental school clinic and are not a representative group of the general population. To our knowledge, this is the first report of re-examinations of dental patients of record receiving care at a U.S. dental school. The results show that oral lesions may arise after admittance to a dental school clinic program and may not be identified during routine dental visits. Furthermore, a focused event, such as this screening week, emphasizing re-examination protocols enables clinicians to identify mucosal disease that may have been undetected.

Oral cancer screening. The oral cavity and oropharynx are accessible for inspection and palpation. A change in color, texture, size, contour, mobility and/or function of intraoral, perioral and/or extraoral tissue may be a sign of OPLs or OSCC. Continued efforts to provide health education and health promotion interventions aimed at patients and dentists invariably will result in the detection of oral cancers at early and curable stages.

The results of this study show that repeated examinations in a dental school setting provide an opportunity to identify oral changes and some potentially malignant diseases in patients of record. Furthermore, these findings suggest that oral and HN changes may develop after the patient’s initial examination and that it is important to conduct repeated examinations of the head and neck and oral cavity at various intervals during routine dental treatment.


   CONCLUSION
TOP
 ABSTRACT
 ORAL LESIONS
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
The findings of this study demonstrate the importance of having highly trained professionals examine the population for oral cancer. Left undetected and untreated, oral lesions can progress to conditions that affect patients’ quality of life and increase the cost of care and, if premalignant or malignant, could impact morbidity and mortality. The OHANCAW provides the opportunity to focus on detection and diagnosis and to emphasize the importance of oral examinations in the detection of oral mucosal conditions. The OHANCAW can provide an opportunity for annual oral screening examinations in teaching environments and in practices, allowing educators and clinicians to place increased attention on the early detection of oral mucosal disease, as well as to emphasize the recognition of the key role of oral health care providers.


   FOOTNOTES
 

Dr. Epstein is a professor, Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, and director, Interdisciplinary Program in Oral Cancer, College of Medicine, University of Illinois at Chicago, 801 S. Paulina St., Chicago, Ill. 60612-7213. Address reprint requests to Dr. Epstein.


Ms. Villines is a senior research specialist, Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, University of Illinois at Chicago.


Dr. Drahos is a clinical associate professor, Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, University of Illinois at Chicago.


Dr. Kaufman is an associate professor, Department of Oral Medicine, School of Dental Medicine, Hadassah Hebrew University, Jerusalem.


Dr. Gorsky is a professor, Department of Oral Pathology and Oral Medicine, the Maurice and Gabriella Goldschleger School of Dental Medicine, Tel Aviv University, Israel, and a visiting professor, Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, University of Illinois at Chicago.


Disclosure. None of the authors reported any disclosures.


   REFERENCES
TOP
 ABSTRACT
 ORAL LESIONS
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

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