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Deviation From Normal

Sol Silverman, Jr, MA, DDS, talks about normal/benign lesions and how to know when they need more serious attention.

Q. What is the protocol for a lesion that appears in the mouth that is not overtly malignant or benign?

A. With a lesion that appears to have a precancerous risk and a diagnosis has not been established, then a biopsy or a referral is in order. Many oral cancers can mimic benign lesions, particularly those with a white, red, or red and white appearance. The principle is that any deviation from normal in the mouth (a lesion) where a definitive diagnosis has not been made and the change has been present or at least noticed for more than 3 weeks, a biopsy and/or referral should be considered in order to appropriately advise the patient and establish a treatment plan.

MAKING THE DETERMINATION

Q. Should the decision on whether lesions are benign or malignant be determined in the general dental office?

A. Not unless the diagnosis is obvious or certain. For example, cheek biting and canker sores are usually clearly apparent from history and clinical characteristics, even though they have a range of appearances. However, if there’s any degree of uncertainty, a biopsy/referral is in order. Other common benign conditions that are usually obviously benign include Fordyce’s granules, geographic tongue, ethnic pigmentation, and fibromas.

Q. Are adjunctive techniques useful in helping determine if a lesion is normal or something more serious?

A. When a deviation from normal is noted, adjunctive techniques can help determine whether the lesion might be benign, should be followed closely, or biopsied immediately. Remember, biopsy is the gold standard for establishing a definitive diagnosis.

Approved adjunctive techniques include brush biopsy, toluidine blue staining, and chemiluminescence/fluorescence (see “Detection and Diagnosis” from the June 2007 issue of Dimensions for more information on adjunctive techniques). These approaches help identity abnormalities, thus accelerating the biopsy or at least referral for further evaluation. Many continuing education courses are available on using adjunctive techniques in detecting oral cancer and I recommend that all dental professionals become familiar with these devices/techniques to determine the utility in their practice.

Q. Do other risk factors, like smoking, come into play when determining whether a lesion may be caused by trauma or is something more serious?

A. Any other type of risk factors that patients may have, whether it be immuno-suppression, smoking, drinking, or another factor, always add to the risk.

The bottom line is if you don’t know what a lesion is and it’s been there for more than 3 weeks, then a more definitive course of action should be taken.

DURATION OF LESION

Q. If a patient comes in with a lesion that has been there for 3 days, do you advise the patient to return for another appointment?

A. Always. The time that a lesion has been present is one certainty that can make a determination between benign and something more serious. If the lesion or deviation from normal disappears, then it’s not cancer or precancerous. This working diagnosis requires the patient to return to the dental office to see if the lesion has disappeared. With a very reliable patient for whom it’s not convenient to return to the office, the dental professional can advise him or her to monitor the signs and symptoms of the lesion to determine the need for a follow-up observation. This course of action should be noted on the patient’s chart.

Q. Can a patient make this determination on his or her own?

A. This requires the dental professional to use his or her experience with the patient. The best course of action is to have the patient return for another appointment. Unfortunately, sometimes patients refuse return appointments because of the inconvenience. As health care professionals, we need to emphasize to patients the importance of sharing responsibility in their own health. A return appointment should be encouraged. With 34,000 new cases of oral and pharyngeal cancers diagnosed each year and with approximately 9,000 deaths, patients need to understand the importance of following up, the need for appropriate treatment, and the importance of early diagnosis.1

REFERENCE

1. Jemal A, Siegel R, Ward, et al. Cancer statistics, 2006. CA Cancer J Clin. 2006;56:106-130.

From Dimensions of Dental Hygiene. September 2007;5(9): 28-29.

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