J Appl Oral Sci. 473
ABSTRACT
www.scielo.br/jaos
http://dx.doi.org/10.1590/1678-775720140254
2014;22(6):473-6
Oral pot ent ially m alignant disorders in a large
dent al populat ion
Alessandro VILLA1, Anita GOHEL2
1- Division of Oral Medicine and Dentistry, Brigham and Women’s Hospital, and Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston MA.
2- Department of General Dentistry, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, United States.
Corresponding address: Dr. Alessandro Villa - Division of Oral Medicine and Dentistry, Brigham and Women’s Hospital - 1620 Tremont Street, Suite BC-3-028 - Boston - MA 02120 - Phone: 617-732-5517 - Fax: 617-232-8970 - e-mail: avilla@partners.org
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bj ect ives: Oral cancer ( OC) m ay be preceded by clinically evident oral pot ent iallym alignant disorders ( OPMDs) . Oral carcinogenesis is a m ult ist ep process t hat begins
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m alignant phenot ypes. The aim of our st udy was t o est im at e t he prevalence of OPMDs in a large populat ion of dent al pat ient s. Met hods: Pat ient s w ere seen in t he Oral Diagnosis and Oral Medicine clinics at Bost on Universit y Henry M. Goldm an School of Dent al Medicine bet w een July 2013 and February 2014 and received a com prehensive oral exam inat ion t o ident ify any possible m ucosal lesions. Pat ient s w it h a suspect ed OPMD ( subm ucous
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t o explore t he relat ionship bet w een OPMDs and associat ed risk fact ors. Result s: A t ot al of 3,142 pat ient s received a com prehensive oral exam inat ion [ m edian age: 43 ( range: 18–97) ; 54.3% fem ales] . Am ong t hese, 4.5% had an oral m ucosal lesion w it h 0.9% being
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epit helial hyperplasia and nine w it h oral lichen planus) . Males and current sm okers w ere associat ed w it h higher odds of having OPMD ( OR 1.7, 95% CI 0.8–3.8; OR 1.9, 95% CI 0.8–4.1) . I ncreasing age was associat ed wit h having OPMDs ( p< 0.01) . Conclusion: Opt im al oral visual screening for OC rem ains a sim ple and essent ial t ool t o ident ify any suspicious
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t he im port ance of a t horough chairside screening by dent ist s and dent al st udent s t o det ect any m ucosal changes.
Ke yw or ds: Oral m ucosa. Leukoplakia. Screening.
I N TROD UCTI ON
Alm ost 263,020 oral cavit y cancers, and 127,654 oral can cer deat h s occu r w or ldw ide each y ear9. On January 1, 2010, in t he US t here were around 275,193 wom en and m en alive who had a hist ory of oral and oro- pharyngeal cancer ( 181,084 m en and 94,109 wom en)18. The 5- year survival rat e of pat ient s wit h oral cancer rem ains alm ost unchanged regardless of various t reat m ent im provem ent s in t he last t hirt y years11. I ndividuals at high risk of developing oral cancer ( OC) are m ainly older, m ales, h eav y t obacco sm ok er s an d alcoh ol u ser s, an d have a poor diet and low socioeconom ic st at us5,13.
Recent st udies have im plicat ed HPV infect ion as an in d ep en d en t r isk f act or f or or o- p h ar y n g eal cancers6,10.
J Appl Oral Sci. 474 h i st o p at h o l o g i cal st ag es f r o m h y p er k er at o si s/ h y p e r p l a si a , t o v a r i o u s d e g r e e s o f d y sp l a si a ( cat egorized by m ild, m oderat e, or severe according t o t he pr esence and sev er it y of cell at y pia and ot h er st r u ct u r al asp ect s of t h e ep it h eliu m ) , t o car cin om a i n si t u &,6 DQG ¿QDOO\ WR LQYDVLYH cancer26. Hist opat hological evaluat ion for t he grade of epit helial dysplasia is t he m ost com m on m et hod used t o ascert ain m alignant pot ent ial of individuals wit h oral pre- cancerous lesions21.
Early det ect ion for oral cancer has t he pot ent ial t o decrease t he m orbidit y and m ort alit y of t he disease, especially in high- risk individuals8. To dat e only one random ized clinical t rial evaluat ed t he effect of oral cancer screening and dem onst rat ed t hat periodic oral exam inat ion has t he pot ent ial t o reduce m ort alit y from oral cancer in high- risk individuals23. Visual and t act ile exam inat ion rem ains t he m ost com m on t ool available t o det ect any m ucosal changes and requires a 90- s ex am , yet few oral healt h car e pr ov ider s are conduct ing a t horough oral m ucosal exam . The aim of t he present st udy was t o 1) est im at e t he prevalence of OPMDs and 2) ident ify t he associat ed risk fact ors in a large dent al populat ion.
M ATERI AL AN D M ETH OD S
St u dy popu la t ion
All new pat ient s aged 18 or older, at t ending t he Oral Diagnosis Clinic in t he Depart m ent of General Dent ist ry at Bost on Universit y Henry M. Goldm an Sch ool of Den t al Med icin e f r om Ju ly 8 , 2 0 1 3 , t hrough March 8, 2014 were included in t his st udy. A writ t en consent was obt ained from each part icipant . The st udy was approved by t he Bost on Universit y Medical Cam pus I nst it ut ional Review Board. Each pat ient was asked quest ions on: socio- dem ographic inform at ion including age and gender; self- report ed m edical hist ory; fam ily hist ory of cancer; t obacco sm oking and alcohol consum pt ion; height and weight t o det erm ine body m ass index ( BMI ) . A t horough visual oral soft t issue exam inat ion was perform ed
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by an at t ending dent ist t o ident ify any OPMD or any ot her m ucosal lesion using m out h m irrors and a st er ile piece of gauze t o r et ract t he t ongue24. The diagnost ic crit eria for t he recognit ion of OPMD ( er y t h r op lak ia, leu k op lak ia, or al lich en p lan u s
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recom m endat ions12,26. Alt hough oral lichen planus
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on it s p r e- m alig n an t n at u r e1 7. On ly or al lich en planus pat ient s wit h an ulcerat ive com ponent were included in t his analysis. Pat ient s wit h leukoplast ic
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clinical diagnosis were reevaluat ed and considered f or biopsy f or diagn ost ic pu r poses ( Figu r e 1 )1 9. I ndividuals wit h OPMD were considered as cases and
t hose wit hout any OPMD as cont rols.
St a t ist ica l a n a lysis
We d e s c r i b e d t h e d i s t r i b u t i o n o f p a t i e n t charact er ist ics, including dem ographics, t obacco sm oking, and daily alcohol consum pt ion. To explore t he associat ion bet ween OPMDs and risk fact ors t hat m ight be expect ed t o be associat ed wit h OPMDs, we used logist ic regression m odels t o est im at e t he odds
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St at ist ical analyses were perform ed using STATA, version 9.2 ( St at a Corp LP, College St at ion, TX, USA) . For all analyses, a P value of < 0.05 ( 2- t ailed) was
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RESULTS
A t ot al of 3 , 1 4 2 p at ien t s ( 5 4 . 3 % , f em ales) received a com prehensive exam inat ion of t he oral cav it y ( Table 1 ) . At t h e t im e of t h e oral ex am , pat ient s ranged in age from 18 t o 97 years, wit h a m edian age of 43 years. Tobacco sm oking and alcohol consum pt ion was r epor t ed in 75.8% and 63.9% of t he individuals, respect ively. A t ot al of 142
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lesion ( 78 whit e lesions, 30 ulcerat ive lesions, 34 m ixed lesions; Figure 1) am ong t hese, 37 pat ient s ( 1.2% ) had a suspicious OPMD and r eceived an
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t hr ee w er e diagnosed w it h leukoplak ia and nine wit h oral lichen planus. None of t he pat ient s had a diagnosis of oral cancer.
Male pat ient s were associat ed wit h higher odds of having OPMD ( OR 1.7, 95% CI 0.8–3.8; p= 0.16; Table 2 ) . I n div idu als w h o w er e cu r r en t t obacco sm okers were t wice as likely t o have an OPMD ( OR 1.9, 95% CI 0.8–4.1; p= 0.12) com pared t o never
Figure 1- Oral mucosal lesions and oral potentially malignant disorders (OPMDs) in a dental population Oral potentially malignant disorders in a large dental population
J Appl Oral Sci. 475 sm okers. I ncreasing age was associat ed wit h having OPMDs ( p< 0.05) . Daily alcohol consum pt ion did not increase t he risk of having an OPMD ( OR 0.7. 95%
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associat ions for syst em ic diseases, BMI and OPMDs ( dat a not shown) .
D I SCUSSI ON
We conduct ed a large st udy in a populat ion of den t al pat ien t s an d f ou n d t h at ar ou n d 1 % h ad an OPMD u pon or al ex am in at ion ( su bsequ en t ly
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oral visual and t act ile exam inat ion rem ains a non-invasive t ool t hat can r esult in ear lier diagnosis of OPMDs, but also a large num ber of ot her oral m u cosal diseases. OPMDs w er e associat ed w it h older age and daily t obacco sm oking. Our result s are in agreem ent wit h ot her st udies on OPMDs. Li, et al.15 ( 2011) showed t hat sm oking was associat ed wit h a m ore t han t wo- fold increase in t he odds of having an OPMD ( OR 2.5, 95% CI : 1.3–4.8) . Chung, et al.3 ( 2005) report ed t hat individuals who were current sm okers had a 4.7- fold ( 95% CI : 3.2–6.8) increased risk of having an OPMD. However, when
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whereas Chung, et al.3 ( 2005) found t hat OPMDs am ong individuals report ing alcohol drinking were
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95% CI : 2.4–5.3) .
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should not be a separat e pr ocedur e rat her t hey should be part of t he com plet e dent al exam inat ion for all pat ient s7. Prim ary prevent ion of OSCC should focus on t he prevent ion of cancer by avoiding known car cinogens ( e.g., heav y t obacco consum pt ion)2. Secondary cancer prevent ion includes early det ect ion of cancer t hrough screening program s in a populat ion at r isk and asy m pt om at ic, as w ell as pr event ion of t he t ransform at ion of OPMDs25. Dent ist s and all m em bers of t he oral healt h t eam have t he unique opport unit y t o prevent sm oking upt ake and prom ot e sm oking cessat ion am ong t heir pat ient s and m ay t her efor e r educe t he pr evalence of OPMDs1 4. I n addit ion, pat ient s at high risk m ay be referred t o specialist s for behavioral counseling int ervent ions t o reduce t obacco use or heavy alcohol consum pt ion16. Oral m ucosal lesions are easily det ect ed t hrough direct visualizat ion, and so oral healt h providers, ot olar y n g olog ist s, p r im ar y car e p h y sician s an d
TOTAL OPMD
(N=3,142) (N=27)
n (%) n (%)
Age
18-30 906 (28.8) 2 (7.5)
31-50 1,134 (36.1) 12 (44.4)
50+ 1,102 (35.1) 13 (48.1)
Median (range) 43.0 (18-97) 49 (23-88)
Gender
Female 1,706 (54.3) 11 (40.7)
Male 1,436 (45.7) 16 (59.3)
Daily tobacco use
Never 2,259 (75.8) 17 (63.0)
Ever 722 (24.2) 10 (37.0)
Daily alcohol consumption
Never 1,906 (63.9) 19 (70.4)
Ever 1,078 (36.1) 8 (29.6)
OPMD: oral potentially malignant disorders Table 1- Patients characteristics
OPMD No
(N=3,115) Yes (N=27)
Odds ratio (95% CI)
p for trend
Age
18-30 904
(99.8) 2 (0.2)
1.0 <0.01
31-50 1,122
(98.9)
12 (1.1)
4.8 (1.1-21.7)
50+ 1,089
(98.8)
13 (1.2)
5.4 (1.2-24.0)
Gender
Female 1,695
(99.4)
11 (0.6)
1.0 0.16
Male 1,420
(98.9)
16 (1.1)
1.7 (0.8-3.8)
Daily tobacco use
Never 2,242
(99.3)
17 (0.7)
1.0 0.12
Ever 712
(98.6)
10 (1.4)
1.9 (0.8-4.1)
Daily alcohol consumption
No 1,887
(99.0)
19 (1.0)
1.0 0.48
Yes 1,070
(99.3) 9 (0.7)
0.7 (0.3-1.7)
OPMD: oral potentially malignant disorders
Table 2- Multivariate analysis for oral potentially malignant disorders
VILLA A, GOHEL A
J Appl Oral Sci. 476 nurse pract it ioners should be effect ively t rained t o perform a com prehensive oral m ucosal exam inat ion and ident ify abnorm al lesions1.
As in all st udies, our result s m ust be int erpret ed in t he cont ext of t he lim it at ions of t he invest igat ion.
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Lar ger st udies ar e necessar y t o fur t her ex plor e t he associat ion bet ween sm oking t obacco, alcohol consum pt ion and OPMDs. Second, our result s m ay not be generalizable t o t he populat ion at large, as only dent al pat ient s w er e included. Random ized-cont rolled t rials m ay be useful t o furt her invest igat e
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exam inat ion in t he cont ext of OPMDs.
The Com m ission on Dent al Accredit at ion ( CODA) in t he Unit ed St at es has recent ly approved a new dent al curriculum t o help dent al st udent s becom e
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General Dent ist ry, CODA 2- 23 b)4. Opt im al oral visual screening for OC rem ains a sim ple and essent ial t ool t o ident ify any suspicious lesions and pot ent ially increase survival.
CON CLUSI ON
A t hor ough v isual and t act ile ex am inat ion in dent al pat ient s, par t icular ly t hose w it h a hist or y of sm oking and elderly is warrant ed. Dent ist s and dent al st udent s should st ay alert for signs of oral pot ent ial m alignancy and counsel t heir pat ient s about risk fact ors for oral cancer. Alt hough OPMDs
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t horough chairside screening by dent ist s t o det ect any m ucosal changes.
CON FLI CT OF I N TEREST
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t o declare.
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Oral potentially malignant disorders in a large dental population
