Is early diagnosis of oral cancer a feasible objective? Who is to blame for diagnostic delay?

Worldwide, oral cancer has one of the lowest survival rates and poor prognosis remains unaffected despite recent therapeutic advances. Reducing diagnostic delay to achieve earlier detection is a cornerstone to improve survival. Thus, intervention strategies to minimize diagnostic delays resulting from patient factors and to identify groups at risk in different geographical areas seem to be necessary. The identification of a 'scheduling delay' in oral cancer justifies the introduction of additional educational interventions aimed at the whole health care team at dental and medical practices. The access to and the kind of healthcare system in a particular country are also relevant in this context, particularly the referral system. The design of a simple, clear, fail-safe, fast-track referral scheme for those suspected with cancer may diminish greatly the length of the delay. Moreover, there is a need for future investigations, which are methodologically adequate, that consider cultural and geographical aspects and use patient survival as the final outcome, that are able to recognize the agents/factors responsible for diagnostic delay by patients as well as healthcare providers and those attributable to the healthcare systems.

[Professional burnout in dentists and stomatologists of the Galician Health Service]. / Desgaste profesional entre los odontólogos y estomatólogos del Servicio Gallego de Salud.

AIM: To analyse the degree of professional burnout in primary care dentists of the Galician Health Service (GHS). DESIGN: Descriptive, cross-sectional study. SETTING: Dental care units of the GHS primary care network. SUBJECTS: All primary care dentists of the new primary care model of the GHS (N=79). Response rate: 50% (N=35). MEASUREMENTS: Anonymous self-applied questionnaire: the Maslach Burnout Inventory, that evaluates emotional exhaustion, depersonalization, and personal achievements; a social and personal questionnaire. Student's t test, ANOVA, 2 or Fisher's exact test were used. MAIN RESULTS: Mean age: 46.58+/-9.47; sex: 74.3% males; temporary job: 82.9%; years in the GHS: 15.25+/-8.34. High values were detected in: emotional exhaustion 54.3%; depersonalization 55.6%; personal achievements 6.9%. No statistically significant differences were identified in terms of age, sex, marital status, type of contract, rural vs urban areas, number of patients treated, or years in the GHS, apart from the "personal achievements" subscale, that was rated, significantly higher (P=.046) by those who had shorter experience at for the GHS. CONCLUSION: GHS dentists show a degree of professional burnout close to the one described for family doctors at the Spanish National Health System.

Artefacts in oral incisional biopsies in general dental practice: a pathology audit.

OBJECTIVES: To investigate the artefacts in oral biopsies taken by general dental practitioners (GDP) and oral and maxillofacial surgeons (O&MF) and to assess the concordance of clinical and pathological diagnoses. DESIGN: Cross-sectional investigation. SETTING: Primary care and hospital practice. MATERIAL AND METHODS: A total of 354 randomly selected oral biopsy samples studied by the same pathologist. MAIN OUTCOME MEASURES: Clinical and pathological diagnoses - prevalence and location of surgical handling artefacts: crush, splits, haemorrhage and fragmentation. RESULTS: Artefacts identified in GDPs biopsies: crush 27.1%; haemorrhage 19.8%; splits 11.3%; and fragmentation 6.2%. O&MSs biopsies showed: crush 10.2%; splits 13%; fragmentation 2.3%; and haemorrhage 8.5%. No differences in split or fragmentation were identified between GDPs and O&MSs. Crush (chi2 = 16.76; P = 0.000) and haemorrhage (chi2 = 9.31; P = 0.003) were more frequently identified in GDPs biopsies. Concordance between clinical and pathological diagnoses was excellent ( > 0.75) for both groups in all disorders considered. CONCLUSIONS: The elicited clinical knowledge, the quality of the samples sent to the pathologists seem to suggest the advisability for the GDPs to perform diagnostic biopsies.

Oral mucosa: variations from normalcy, part II.

This is the second article in a 2-part series on the variations of oral mucosa. We describe the following 5 conditions that deviate from normalcy: lateral soft palate fistulas, double lip, fissured tongue, racial gingival pigmentation, and geographic tongue.

Oral mucosa: variations from normalcy, part I.

Many lesions can be identified in the oral mucosa. Some are indicative of pathologic conditions restricted to the oral cavity, whereas others are signs of systemic disorders. A third group of alterations is not severe enough to be considered pathologic; however, knowledge of this group is mandatory for a correct differential diagnosis to be established. This is the first article in a 2-part series concerning all of these pseudopathologic conditions.

Survival to oral cancer. A study of clinical risk markers with independent prognostic value.

BACKGROUND: The aims of this study have been to describe survival to oral cancer and to identify clinical variables with independent influence on its prognosis before treatment. METHODS: 94 oral cancer patients treated during 1991-99 entered the study. The variables considered were: age, sex, location of the lesion, clinical presentation, symptoms, TNM classification, months elapsed since treatment and ploidy pattern. A descriptive study of the data was performed, along with a survival analysis using Kaplan-Meier curves (log rank test for comparison among curves) and single and multivariate Cox regression. RESULTS: Multivariate analysis recognized a prognostic value for the age of the patient (OR = 1.06; CI95%: 1.02-1.09) and also for tumour size. Tumour stage resulted also selected, but its predictive value was lower than size's, so it was excluded from the predictive model. No statistically significant differences in terms of survival were identified on the rest of variables considered in the study. CONCLUSIONS: This study suggests the need for considering age and tumour size as the most relevant clinical variables for predicting survival to oral cancer at the time of diagnosis.

Experimental intervention study about recognition of erythroplakia by undergraduate dental students.

The aim of this study was to assess the efficacy of an examiners' training programme applied to identification of erythroplakia, which undergraduate dental students have found particularly difficult. An experimental group of 5th year undergraduate dental students received a pictorial handout with diagnostic criteria for oral red lesions and two, one hour-long diagnostic seminars in which oral erythroplakia was discussed, together with other red lesions with similar clinical appearance. Three months later a set of 16 photographic slides depicting previously pathologically diagnosed red lesions were projected. Sensitivity, specificity and agreement were all higher for the experimental group compared to a control group. It is suggested that teaching procedures using slides could be useful for training future examiners at recognizing oral erythroplakias.

Flow cytometric DNA ploidy analysis of oral cancer comparison with histologic grading.

It has been reported that DNA content analysis provides prognostic information eliminating the subjective component involved in routine microscopic decision making. In an attempt to establish a relationship between pathological findings and flow cytometric analysis, 36 formalin-fixed, paraffin-embedded tumour tissue samples were prepared according to Hedley's method and analysed by means of an Epics Profile II flow cytometer. DNA aneuploidy was observed in 15 tumours (41%). A statistically significant correlation was identified between DNA index and mitoses, cellular response and degree of differentiation, but not the ploidy status. It was not possible to identify a significant association of sex, age, and site of the tumour to DNA index. We found a strong correlation between histologic malignancy and DNA index; an increase in DNA index as malignancy score increases was noted. It was concluded that DNA index shows a good correlation with the histologic features of oral cancer, being a complement of differentiation and histologic grading analysis. The use of DNA analysis as a complement to pathological studies would help to diminish the subjective component of assessment of head and neck cancers. Ploidy status was not statistically associated with the differentiation of tumours.

Dark oral lesions: differential diagnosis with oral melanoma.

Oral melanoma is a neoplasm with a poor prognosis; its premature diagnosis is of foremost importance. We review here pathologic situations to be considered in the clinical differential diagnosis: tattoos, melanotic macules, Laugier's disease, melanocytic nevus, drug intake, some vascular lesions, and oral pigmented lesions associated with endocrine disorders or with different syndromes.

Flow cytometric analysis of nuclear DNA content in oral leukoplakia.

DNA ploidy has been studied in 31 paraffin-embedded specimens of oral leukoplakia and in 10 specimens of oral leukoplakia that have undergone malignant transformation after a 5-year observation period. Three out of 31 specimens (9.7%) showed an aneuploid DNA pattern, with DNA indices of 1.17, 1.28 and 1.32. It was not possible to establish a statistically significant difference of DNA ploidy related to the presence or absence of dysplasia. One out of the 10 oral leukoplakias that underwent malignant transformations had a multiploid pattern with DNA indices of 1.44 and 2.37. In this study the DNA index has not proved to be of value in the identification of dysplastic leukoplakia among the non-dysplastic ones.

Assessment of dental students' ability to recognise precancerous lesions and conditions.

The role of dentists in both primary (promoting a healthier lifestyle) and secondary (early diagnosis) prevention of oral cancer is undeniable, and becomes particularly important as oral cancer is thought to be preceded by premalignant lesions or conditions in about one half of the cases. In these situations, there is the possibility for an early diagnosis which will definitively influence the survival rate. Thus, it is an undergraduate educational objective related to secondary prevention of oral cancer to increase the efficacy of screening of precancerous lesions/conditions. A questionnaire with 38 clinical cases including 16 benign lesions, 9 malignant lesions and 13 precancerous lesions or conditions was applied voluntarily to 3rd, 4th and 5th year University of Santiago de Compostela dental students on April 1996. The participation rate was 90% of the 3rd-year students, 60% in 4th-year class, and 50% of the 5th-year group. The agreement in the diagnosis with a panel of experts reached 81.45% for 5th-year students. Students of 3rd- and 4th-year scored lower percentages, probably due to the rarity of some of the conditions in our area. 5th-year students scored significantly higher values than 3rd- and 4th-year students.