A digital manual for the early diagnosis of oral neoplasia
Introduction
The oral cavity is the hollow part of the mouth, which can be accessed and examined easily. A thorough physical examination of the oral cavity provides valuable insight into a person’s overall health in general and their oral health in particular. An extraoral head and neck physical examination is an integral component of assessment of oral health. Although a comprehensive examination of the oral cavity is an essential component of any general physical examination, it often receives minimal attention in routine practice. A careful history and oral examination leads to clinical suspicion of infection, trauma, reactive or neoplastic processes localized in the oral cavity and of oral manifestations of systemic diseases, thereby providing valuable diagnostic leads. Careful history, clinical examination and microscopic findings from a biopsy can lead to the early diagnosis of a vast majority of oral lesions.
The objective of this digital manual is to provide a clinical manual to assist providers in its early clinical diagnosis of oral precancers and preclinical invasive oral cancers leading to prompt referral for appropriate care, and in the recognition and diagnosis of common anatomic variations and other intraoral lesions relevant in the differential diagnosis. The goal of this manual is to provide and reinforce the clinical skills of doctors, nurses, health workers and students in examining the oral cavity in a systematic and consistent manner and in diagnosing commonly observed lesions of the oral cavity. We provide a brief description of the steps to take in the examination of the oral cavity followed by a description of lesions and conditions illustrated in the digital manual. The images in this digital manual have been predominantly obtained from participants in the Trivandrum oral cancer screening (TOCS) project, a large community-based cluster randomized controlled trial conducted in Trivandrum district, Kerala State, India .
We have developed a clinical algorithm based on our own experience in the TOCS project, which we believe provides a useful approach for examination of the oral mucosa and subsequent clinical categorization of the findings with as little ambiguity as possible. This digital manual is expected to fulfil the need for a ready reference to help in the early clinical diagnosis of oral precancers and cancers. This manual is by no means an exhaustive compendium of images and descriptions, representing the whole range of oral lesions and conditions, particularly the rare manifestations, but it is a repository of oral precancers, cancers and common anatomical variations and other intraoral lesions that may appear as oral neoplasia.
The vast majority of patients with oral cancer present in advanced stages, which necessitates expensive and aggressive combined modality treatment, leading to low cure rates, severe morbidity and poor quality of life. In early stages, before the involvement of neck nodes such as stage I disease, the treatment is simple, affordable, cosmetically more acceptable and more effective with survival rates exceeding 90% at 5 years. Early detection and evaluation of oral pre-cancers will be useful in preventing invasive oral cancer, in identifying underlying occult malignancy and early changes of malignant transformation as well as in detecting oral neoplasia in pre-invasive, or early preclinical invasive stages, before the occurrence of regional node metastasis. In the TOCS project, oral visual screening and subsequent evaluation and treatment of the oral lesions resulted in a 34% reduction in oral cancer mortality among tobacco and/or alcohol users .
Since oral visual inspection is an integral part of any physical examination during routine health care interactions, visual screening for oral neoplasia can be easily, effectively and universally integrated in routine primary care. This manual is expected to fulfil the need for a ready reference manual to assist oral visual screening in such contexts.
Even though the manual is intended to help in the early detection of oral precancers and asymptomatic early cancers, the importance of primary prevention cannot be emphasized enough in oral cancer prevention and control. Not initiating or quitting of tobacco use in any form and alcohol drinking and practicing a healthy lifestyle play the most important and indisputable role in reducing the risk from oral cancer, given that almost 90% of these cancers are caused by tobacco and/or alcohol use. Early detection and prompt treatment of early lesions has an important complimentary role along with primary prevention. The advances in surgery, radiotherapy and chemotherapy have been notably ineffective in curing and preventing death from advanced oral cancer. In this context this manual will play an important role in identifying oral neoplasia in pre-invasive or early stages, thereby contributing to successful control of this major cancer in several regions of the world.
