Saman Warnakulasuriya

Early detection and prevention of oral cancer: the role of the dental team in saving lives

Oral cancer incidence has been increasing in Portugal in the past two decades. Many patients present for treatment at advanced stages of the disease resulting in a low life expectancy. The major risk factors for oral cancer are smoking and excess alcohol use, while a few cases are associated with HPV infection.

General dentists have an essential role to play in both early detection and prevention. This lecture aims to elucidate ways to identify patients with “high-risk” lesions by carrying out a thorough clinical oral examination with the knowledge of early signs and symptoms of oral cancer.

The evidence of the benefits of population and opportunistic screening for reduction in morbidity and mortality from oral cancer will be presented along with clinical management of cases presenting in primary care.

The limitations of commercially available diagnostic adjuncts for early detection need exploration. Late diagnosis and a slow pathway to treatment can severely limit treatment options for patients, who then face poorer survival prospects.

Dentists therefore need to familiarise with the criteria for “urgent referrals to specialists” to reduce delays often noted in a patient’s cancer journey. Primary care approaches for oral cancer prevention will be discussed with special reference to dentist’s role in smoking cession.

Oral potentially malignant disorders – challenges in diagnosis & management

Oral potentially malignant disorders (OPMDs) include oral leukoplakia, proliferative (multifocal) verrucous leukoplakia, erythroplakia, oral submucous fibrosis, oral lichen planus & lichenoid lesions, actinic cheilitis, dyskeratosis congenita, oral graft vs host disease and oral lupus erythematosus.

Differentiation of OPMDs from numerous other white and red patches that can be found in the oral cavity is a diagnostic challenge. In this diverse group of conditions, malignant transformation rates vary significantly within subtypes ranging from around 1 to 2% in oral lichen planus to over 50% in high-risk conditions such as erythroplakia and proliferative verrucous leukoplakia.

A major challenge faced by general dentists who see these conditions in primary care is to assess the risk of an individual patient and to predict who may develop a malignancy. The application of adjunctive chair-side tests is still in a development stage to identify a high-risk lesion.

The presence and severity of oral epithelial dysplasia in a biopsy is considered the gold standard for assessing the risk for malignancy development but sampling errors and the subjectivity of reporting may limit an accurate prediction. Habit interventions i.e smoking cessation, alcohol moderation and improving diet are essential elements in their management.

Dentists have a key role in long term regular follow up and periodic surveillance to detect an early carcinoma developing in an OPMD while high risk lesions may benefit from surgical intervention.

The talk will also focus on the current evidence base, research gaps, and ongoing research to address such gaps.