In this episode of PodMD, Oral and Maxillofacial surgeon Dr Felix Sim will be discussing the topic of potentially malignant disorders of the oral cavity, including the types of conditions that are potentially malignant, how a patient would typically present, recent trials and developments, when a dentist or GP should refer and more. This is the first podcast in a two-part series. The next podcast will focus on oral cancer.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Felix Sim
Dr Felix Sim is an Australian trained Oral and Maxillofacial surgeon, with a special interest in head and neck cancer and complex dental implants and dental rehabilitation.
Felix Sim obtained his undergraduate dental qualification at the University of Sydney in 2001 and medical degree at the University of Melbourne in 2009. He then undertook and completed his specialist training in Victoria in 2015. Following his specialist qualification, Felix was selected to a two-year sub-specialty training in head & neck oncology and microvascular reconstruction in Portland, Oregon, USA.
Aside from his private practice in Glen Iris, Springvale and Werribee, Felix holds public hospital appointments at Monash Hospital, Geelong Hospital and Royal Melbourne Hospital where he is supervisor of registrar training.
Today, we’ll be discussing the topic of potentially malignant disorders of the oral cavity, which is a two part podcast series. The next podcast will focus on oral cancer.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Felix, thanks for talking with us on Pod MD today.
Felix: Thank you for having me.It’s a real great pleasure.
The topic of today’s discussion is potentially malignant disorders of the oral cavity. Felix, can you describe for our listeners what potentially malignant disorders of the oral cavity are?
Felix: Potentially malignant conditions of the Oral cavity are essentially precancerous conditions. Anything that ranges from what we call leukoplakia, which is white patches in the mouth, erythroplakia, which is red patches in the mouth, erythroleukoplakia which is red and white patches in the mouth there’s other conditions like lichen planus and oral submucous fibrosis, which is not so common in Australia and oral dysplasia, all of which have some form of malignant transformation potential in varying capacities.
How would a patient with a potentially malignant condition of the oral cavity typically present?
Felix: So the typical patient would usually present to a dental practice. It could be your standard routine, general checkups that you have every six months, and a patient would present with a new red patch, tongue, cheek, inner aspect of the cheek or maybe even the floor of mouth, they’re the high-risk factors, but remember I mentioned that there’s different forms of precancerous conditions. I’m going to call it precancerous conditions, just so that it’s not as a mouthful rather than saying potentially malignant oral conditions of the oral cavity each time.
So I’m going to go through each part. Like you know, there’s leukoplakia. So leukoplakia, essentially white patches that occur in the mouth and leukoplakia themselves that commonly occur in the tongue, cheek, and occasionally floor mouth. They usually asymptomatic or meaning that they don’t cause any pain, but they could be their longstanding. Leukoplakia itself doesn’t necessarily mean that it’s all going to lead to cancer, but it could be good differentiation of what are the nasty, more sinister ones versus the non-sinister ones.
Erythroplakia patches are red patches in the mouth. They also commonly occur in the tongue, the cheek and the floor of mouth. Sometimes they can be symptomatic, and sometimes it can be painful, however not all the time. Lichen planus is a condition that’s an autoimmune condition, for patients I usually describe that is like a condition similar to psoriasis or eczema, so it’s an autoimmune condition. There’s various varying types of lichen planus and lichen planus I have to emphasise has a very low rate of malignant transformation. Typically lichen planus presents as having the white reticular striations usually on the inner cheek, sometimes the gums, and/ore the tongue. The conditions of lichen planus would often cause some discomfort and that discomfort could vary from other burning sensation, stinging sensation usually triggered by citric or acidic food, sometimes toothpastes as well.
Submucous fibrosis, now oral submucous fibrosis as I mentioned is not a common condition that we see or encounter very much here in Australia, because the main risk factors for developing submucous fibrosis is betel nut chewing and in the subcontinent of India, Sri Lanka, Pakistan where a lot of people would actually chew betel nut as on a daily habit. They would then present more often with submucous fibrosis. Now submucous fibrosis is a condition that mainly usually affects the buckle mucosa, where you have fibrous banding of the buccal mucosa, which often leads to restriction or mouth opening in severe cases because of this fibre expanding that develops.
Oral dysplasia is a generic term that we ascribe to essentially any lesions that has a histological confirmation that there’s been some dysplasia. Dysplasia itself can be graded as mild, moderate, or severe.But how would an old dysplasia present? Well an oral displeasure, will present in various forms. Again, it could be a white patch, it could be a small superficial red patch, so that’s why those generic terms of leukoplakia, erythroplakia and erythroleukoplakia are clinical terms and oral dysplastic lesion is usually described once there’s a histological confirmation dysplasia.
Another type of precancerous condition, that is commonly seen in women is a proliferative verrucous leukoplakia, so they affect the gums, the buckle mucousa, alveolar ridges and tongue. They’re also asymptomatic, but they often present with like a white plaque with kind of verrucous keratotic surface, and it happens in widespread regions of the gums, sometimes a cheek so often it makes it difficult to treat because you cannot really excise the whole thing without causing significant morbidity.
What are the risks of the condition?
Felix: So I guess we’re all worried that precancerous conditions can lead to cancer itself, and with all the different conditions that I mentioned, every one of those conditions have a slightly different prevalence of malignant transformation. So we start with leukoplakia like you know whether be homogeneous or non-homogeneous when its mixed with a red patch, typically, homogeneous leukoplakia have a low rate of transformation of malignancy, roughly in the vicinity of maybe .02%. Other conditions, like Erythroplakia have a slightly higher risk of malignant transformation from .02 to 1%, and it typically affects adults like you know all these conditions we need to look at not just the actual condition themselves, but the actual population group that’s affected, so I’ll go through that a bit more maybe perhaps in the actual what to do in a step by step in the clinical practice.
Lichen planus, as I mentioned lichen planus has a very low rate of malignant transformation. Again under 1% maybe .05% to 0.5%. But that’s also depending on the variation in the type of lichen planus, because you’ve got the typical reticular form, you’ve got the discriminative which is more erosive lichen planus that has a slightly increased risk of malignant transformation. Submucous fibrosis, by far has the highest risk of malignant transformation. And that’s up to 5% in population groups. And then finally, I think there’s one condition that probably should be mentioned that is, that commonly occurs in elderly females. Is the verrucas leukoplakia, so they’re the ones that you would see have this thick and white plot along the gums and that usually has a risk of malignant transformation up to 2% of the time.
What are the treatment options?
Felix: Treatment options for precancerous condition is all about early recognition and diagnosis because the main aim of treating precancerous conditions is to prevent or minimise the risk of malignant transformation, and if it does turn malignant, that we identify it earl,y because the key factor to detect such cases at an early stage is actually recognition and improvement of the awareness in the primary care level. So how do we do that? Well, this is part of the reason of the podcast is so that people can identify the risk factors, identify the lesions that have higher malignant transformation rates, so that that early referrals can be given to patients so that they can actually be then and diagnosed. So what are the actual key steps for it? Well, what are the treatments? Well often treatments, I think the gold standard of treatment at this stage for precancerous conditions, or especially dysplasia, is excision.
Have there been any developments in treatment in the last years or are there any in trials or development now?
Felix: Currently the gold standard for the diagnosis for religion is the visual exploration of the oral cavity and tissue biopsy. So we need to have histological confirmation as the gold standard. In developments and in some clinical practise as well, other adjunctive techniques have been looked at, and that includes oral cytology saliva retests looking at biomarkers, light-based techniques which includes auto fluorescence chemiluminescence, and that’s essentially putting a chemical compound along the mucosal lining of the mouth that lights up at different wavelengths when the light is shown throughout that shows differentiates what dysplasia dysplastic tissue would look like and what not what non dysplastic tissue would look like? Some examples of those kind of chemicals can use is lugols iodine, just a straightforward iodine.
Now because the other thing that is actually a problem with potential malignant oral conditions is that often there’s field change that affects widespread areas and some people, some groups have looked at systemic treatment looking at anti-inflammatory drugs or drugs targeting P53 Mutation, which we know is a tumour suppressor or antioxidants to look at and if they can actually use that as a as a systemic treatment to treat widespread oral field change. However, all these studies have only really looked at them on a trial, clinical trial basis, and none of them have actually gained enough evidence to be really implemented in day-to-day clinical practise. So inmy clinical practise I certainly do not prescribe or advocate for any systemic treatment for precancerous conditions of the mouth.
Are there any warning signs a GP or dentist or their patient can look out for?
Felix: Absolutely there is. The warning signs of any potentially malignant conditions of the oral cavity and the precancerous conditions is usually number one is abnormality of the mucosa. So dentists are probably the most key team members of the primary care, because they would look at patients mouths, oral cavity on a regular basis every 6 to 12 months and they would be usually the first ones that pick up changes within the actual oral cavity, so the warning signs would be any changes that was not noted on previous exam, a red patch, awhite patch, an ulcer. An ulcer would typically heal and resolve after about two weeks, but if you have ulcers that persist beyond two weeks beyond three weeks, don’t ignore them.
The most common type of presentation that we get for patients with early stage oral cancer is usually a non-healing ulcer and I’ll explore that more like sort of probably the second podcast that we’ll be doing, but essentially people, we would often find GPs would treat these oral cancers and reasonably so, with a trial of antifungals. Well, I think it’s important to review them after two weeks, and if the ulcer still persist to have an early referral.In summary, I think warning signs for things to look for is number one and non-healing ulcer.
Number two, a new lesion, whether it be red patch, white patch of the oral cavity that was not there in previous times, and if it still persists beyond two to four weeks for at least referral. All in all, you one would need to combine this with the demographics of the patient identifying risk factors or the patient themselves, because if you have a white patch on a 21 year old who does not smoke and is often stressed and bites their cheek then, well, it’s likely to be probably hyperkeratosis of traumatic keratosis, but if you have a white patch on a heavy lifelong smoker who’s 55-60 years old that was not there in previous examination, and that would certainly be something that would require urgent attention review and possible referral for biopsy.
What is the likelihood of recurrence of the condition?
Felix: Well, unfortunately with dysplastic lesions of the oral cavity, or proliferative verrucous leukoplakia, any of these conditions have a tendency to recur. Surgical excision will only treat what we see as surgeons or specialists as macroscopically abnormal. We can only identify what it is abnormal and try and excise that, but histologically once we get these reports, quite often we would find that along the Histology report that even despite excising what appears to be abnormal macroscopical, that we would still find under the microscope that there is still dysplasia along the periphery of the margins and because of that, recurrence is certainly possible and therefore one would still need to have a close surveillance in each patients depending what’s found on Histology and risk factors as well.
When should a GP or dentist refer?
Felix: Well, a GP and dentist should refer when again, as I mentioned, there’s persistent abnormality of the mucosa or the lining of their or cavity that persists beyond two weeks, four weeks if there is high risk factors of developing malignancy, and they’re the smokers the heavy drinkers, the elderly and if there is actually any changes to the surface texture. So when you have an ulcer, it is very important to actually palpate the ulcer itself. If the ulcer feels smooth and it does not feel any different to the surrounding tissue, then that’s quite superficial. But if the ulcer, if the white patch, if the red patch has some form of induration, induration meaning thickening, that feels different to the adjacent tissue, that’s also a red flag, and you should also refer them.
What role does the GP or dentist play in the treatment of the condition?
Felix: Well, I think the role of the GP is crucial as a primary health care provider, so whether it be GPs and dentists will always be the first port of call for patients to see when they present with such a condition. They play a significant role in the detection, recognition, which will hopefully lead to an early diagnosis of these precancerous conditions. So I think in summary, precancerous conditions of the oral cavaity is a relatively common condition that deserves good awareness and recognition from all Gps and dentists that would see patients on a daily basis so that early referral, early recognition of the actual high-risk lesions can be made. So that if it is malignant, then we know that early treatment of malignant conditions of the oral cavity or oral cancer also leads to improved success and outcomes of these patients.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on potentially malignant disorders of the oral cavity.
Felix: The take home message is number one. Identify those patients who have higher risk potential of developing precancerous or cancerous conditions of the oral cavity. Traditionally they are the heavy smokers and heavy drinkers.
Number two in those patient groups, if they come to you with an ulcer in the mouth or a new red patch of white patch in the mouth of the lips that was not there in previous examination times when you’ve seen them, do not ignore them. Do not just assume that it’s a fungal infection and treat it with antifungals and never see them again. Do please review them 2-3 weeks after you initially prescribed the medication and if the lesion is still persistent to refer early, so that a tissue diagnosis can be obtained via biopsy.
Number 3, for those patients who have high risk factors, never forget the value of smoking cessation advice or any advice that you could partake as a Primary Health care provider to reduce their risk factors, I always tell my patients it’s never too late to stop smoking. It’s never too late to stop excessive consumption of alcohol because all these factors are cumulative and they will eventually lead to potential problems sometime along their lifespan.
Thanks for your time and the insights you’ve provided.
Felix: Thank you, great to be here