Early detection of oral premalignant disease and oral cancer: refining the process.

Abstract

In a recent editorial1Gould AR. The American Dental Association's oral cancer campaign-an opportunity to make a difference.Oral Surg Oral Med Oral Pathal Oral Radial Endod. 2002; 93: 377-378Abstract Full Text Full Text PDF Scopus (2) Google Scholar I attempted to suggest a strategy by which dental professional organizations could augment their oral cancer educational programs for health care providers and the public. A desired outcome of these efforts would be increased effectiveness of the oral health care delivery system in the detection of oral premalignant disease and oral cancer (referred to hereafter as oral disease). This outcome hopefully would be achieved, in part, by raising professional and public awareness of oral cancer and by delineating the threat that this disease poses to general public's well-being. In this editorial, I would like to discuss the current techniques employed by individual health care providers in the early detection of oral disease and the opportunities that remain for refinement of these methods. Periodic clinical inspection of patients has long been the mainstay for detection of oral disease, including oral cancer. Components of such evaluation include direct visual examination, palpation, assessment of function, and analysis of patient signs and symptoms. Pertinent aspects of the patient history, including exposure to tobacco products and alcohol, are also factored into this diagnostic activity. It is a method that has found widespread acceptance in the dental profession and one whose effectiveness is generally deemed validated both by the aggregate experience of numerous oral health care professionals and by the scientific literature. This notwithstanding, we should question whether the efficacy of standard clinical methods for early oral disease detection has actually been confirmed through outcomes-based scientific investigation or, alternatively, to what degree these procedures are merely assumed effective on the basis of prevailing “standards of care” and professional decision making. The Institute of Medicine report on the future of dentistry (IOM Report) calls attention to this dilemma, stating that “[m]any clinical interventions in dentistry—as well in medicine—have never been subjected to rigorous scientific investigation. Their effectiveness has been assumed on the basis of experience, indirect scientific evidence, and judgment.”2Dental education at the crossroads: challenges and change. : National Academy Press, Washington DC1995: 6Google Scholar Unresolved issues regarding clinical oral examination for early preneoplastic and neoplastic diseases include (1) proper frequency of clinical examination, both in the presence and absence of risk factors (eg, tobacco and alcohol exposure); (2) criteria for a decision to perform a biopsy; (3) criteria for identification of biopsy sites, including selection of sites likely to yield diagnostically significant information; and (4) appropriate management of patients with persistent or recurrent clinically suspicious disease which, on biopsy, is found to demonstrate only nonspecific epithelial alterations (eg, hyperparakeratosis, acanthosis). The unrelenting emergence of new technologies applicable to early detection of oral disease lends an additional layer of complexity to this issue. Consider intraoral photography. Although long used in documenting oral lesion appearance, the advent of digital imaging and computer technologies expands opportunities for longitudinal patient evaluation, creating the potential for computer-assisted analysis of sequential images for detection of subtle early oral disease. OralCDX® and ViziLite® technologies offer additional alternatives for patient evaluation. Application of so-called artificial intelligence programs and expert systems provides entirely new opportunities for the collection, analysis, and application of clinically significant data. A major challenge for the profession will be to determine the most appropriate integration of these and other new technologies with standard examination techniques in order to formulate an optimum method of patient examination for oral disease. The IOM Report squarely faces this issue, calling on the profession to “improve our knowledge of what works and what does not work to prevent or treat oral health problems.”2Dental education at the crossroads: challenges and change. : National Academy Press, Washington DC1995: 6Google Scholar Perhaps the dental diagnostic specialties can offer a proactive influence on research in this domain. Through consensus building, important questions worthy of focused research effort may be identified to enhance the effectiveness (patient benefit and cost) of the oral clinical examination. Professional organizations can also take a role in obtaining funding sources for research support. Through the development of suitable professional meeting agendas and awards programs, oral health investigators may be encouraged to address these issues to help refine the process of oral disease detection. In this manner, the dental diagnostic specialties may contribute to efforts to “develop and implement a systematic research agenda to evaluate the outcomes of alternative methods of preventing, diagnosing, and treating oral health problems….”2Dental education at the crossroads: challenges and change. : National Academy Press, Washington DC1995: 6Google Scholar