Immediate Biopsy for Suspicious Oral Lesions, Says ADA

Pam Harrison

October 04, 2017

Doing an immediate biopsy in patients with a suspicious oral lesion — or referring a patient to a specialist who can — remains the single most important recommendation made by the American Dental Association (ADA) in their updated clinical practice guidelines for the evaluation of potentially malignant disorders in the oral cavity.

The clinical practice guideline was published in the October 2017 issue of the Journal of the American Dental Association. 

The last related clinical practice guideline was issued in 2010, when the ADA again emphasized the importance of doing an immediate biopsy of any suspicious oral lesion or at the very least referring patients to an appropriate specialist, such as a head and neck surgeon or an otolaryngology specialist so that patients can be more thoroughly assessed.

Often oral mucosal disease that is malignant looks very similar clinically to oral mucosal disease that is benign. Dr Thomas Sollecito


"Often oral mucosal disease that is malignant looks very similar clinically to oral mucosal disease that is benign, so it's hard to come to a definitive diagnosis based on clinical presentation alone," Thomas Sollecito, DMD, spokesperson for the ADA and professor and chairman of oral medicine at the School of Dental Medicine, University of Pennsylvania in Philadelphia, explained to Medscape Medical News.

"So taking a really thorough history and knowing, for example, that the lesion has been there for 2 months rather than 2 weeks is critical, but even with that history, oftentimes you have to confirm the diagnosis with a biopsy," he added.

The American Cancer Society estimated that there would be approximately 50,000 new cases of cancer in the oral cavity and oropharynx in 2017, over 80% of which will be oral squamous cell carcinomas (OSCCs) or oropharynx squamous cell carcinomas (OPSCCs).

Potentially malignant disorders — mucosal lesions that have an increased risk for developing into an OSCC — and OSCCs themselves are the two conditions targeted in the new clinical practice guidelines.

"These recommendations underscore the need for strong working relationships between the dental and oncology communities to provide the best possible patient care," Erich Sturgis, head and neck surgeon, MD Anderson Cancer Center in Houston, Texas, said in a statement.

Dr Sturgis and other experts at the MD Anderson Cancer Center provided input into the ADA's updated clinical practice guidelines and are working together with the ADA to improve professional and patient education about potentially malignant oral lesions.

"The American Dental Association represents something like 161,000 dentists across the country, so it's a tremendous opportunity essentially in the primary care setting to get messages out about head and neck cancer prevention," Dr Sturgis told Medscape Medical News.

Identification Challenging

Identification of early potentially malignant oral lesions can be challenging depending on whether the lesion is related to more traditional risk factors for head and neck cancer, including smoking and alcohol, or are the result of infection from the human papillomavirus (HPV), usually with the highly oncogenic HPV type 16.

"[O]ver the past 20 years HPV infection has surpassed tobacco and alcohol as a major risk factor [for head and neck cancer]," the ADA authors note, and they estimate that  HPV infection causes approximately 75% of all OPSCCs identified today. 

Thus, the ADA panel underscores that after dentists review the patient's history and look for all possible "red flag" symptoms, first and foremost they should carry out the conventional visual and tactile exam both intraorally and extraorally, paying particular attention to the lymph nodes in a patient's neck. (It's been both practitioners' experience that most patients with head and neck cancer present with late, large, or even multiple lymph node metastases in the neck, which are typically asymptomatic.)

Depending on whether a lesion is likely innocuous or suspicious, panel recommendations to perform cytologic testing vary.

For patients with a clinically evident oral mucosal lesion that seems innocuous or not likely to be malignant, "clinicians should follow up periodically" and perform biopsy or refer patients to a specialist only if the lesion does not resolve over time. For adults with no clinically evident lesions or symptoms, nothing more needs to be done.

For lesions that could be malignant or if the patient reports worrisome symptoms, "clinicians should perform a biopsy of the lesion or provide immediate referral to a specialist," the panel reaffirms.

Index tests, or what the ADA panel calls "adjuncts," are bountiful, but none of these adjuncts were felt to be accurate enough to identify target lesions in the primary care setting. "Some of these tests are simply not specific enough, meaning that you will have a significant number of false-positives just by using that adjunctive test alone, and we didn't want people to have the stress of getting a positive test result who would then require a more invasive procedure based upon a false-positive result," Dr Sollecito elaborated.

"On the other hand, it's equally obvious you don't want a test to give you a negative result, yet the patient has cancer," he added. Adjuncts that were not recommended by the ADA for the evaluation of clinically evident, innocuous, or even suspicious lesions include autofluorescence, tissue reflectance, vital staining, and salivary adjuncts.

The one situation where clinicians may reasonably resort to a cytologic adjunct is when a patient declines to have a suspicious lesion biopsied or does not want to be referred to a specialist. At this point, panel members suggest, the adjunct may help dentists further assess the suspect lesion. 

Good Opportunity

As Dr Sturgis pointed out, dentists are already examining the mouth, so they clearly have a good opportunity to evaluate patients for cancers of the oral cavity caused by traditional head and neck risk factors.

"Indeed, these lesions of the mouth are very amenable to early diagnosis, so if a dentist does a complete exam, lesions may more commonly be identified at an early stage where patients can be treated relatively simply," Dr Sturgis noted.

In contrast, both Dr Sturgis and Dr Sollecito emphasized that HPV-related cancers — cancers that occur at the back of the throat, at the base on the tongue, and in the tonsils themselves — are difficult if not impossible to visualize.  "Even when patients come to us at a cancer center when the cancer has already spread to the lymph nodes, the primary where it started is often difficult to see," Dr Sturgis said.

Dr Sollecito agreed, but he stressed that dentists are trained not only to look inside the mouth but also to assess patients for tonsillar asymmetry. If that is present, it should trigger an immediate referral to a specialist so patients can be examined more thoroughly with a scope.

Symptoms such as difficulty swallowing or a change in voice can be a sign of a hidden HPV-related cancer, and getting a good history can be key to early detection of these lesions as well, he added.

"In addition, dentists can do a head and neck exam and palpate the lymph nodes, where they might find a lymph node that is suspicious — one that is hard, one that is fixed, and one that is not tender," he explained. If such a lymph node is detected, that's another cardinal sign the patient may have an HPV-related cancer. Again, that should trigger an immediate referral.

"The more people are aware that they should talk to their dentist or their physician about something in their mouth or their neck, whether it's a symptom or an actual physical finding, will always help," Dr Sollecito stressed.

"And while dentists may not be the professional who is going to treat the cancer, they certainly are well within their realm of referring a patient to the next person who can help them," he added.

"So awareness is really important, and dentists speaking to their patients, patients speaking to their dentist, can help change some of the statistics we have around this disease and help facilitate earlier detection and earlier treatment," Dr Sollecito concluded.

Dr Sollecito and Dr Sturgis have disclosed no relevant financial relationships.

J Am Dent Assoc. 2017;148:712-727. Full text

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