Oral Pathology is generally not given much of importance or attention in day to day clincial practice. Certain procedures and basic fundamental concepts of diagnosis which are so dependent on Oral Pathology and can make a tremendous impact on our clinical outcomes. These basic, yet very critical issues are highlighted in this article. - Article contributed by Dr. Avadhoot Avdhani.

What lies beneath.... Oral Pathology Unvieled

Prevalence of the oral mucosal lesions upto 41.2% has been reported in the Indian population. So every second patient visiting your clinic might be affected by them. But how many times have we looked deep into the tissues and tried to understand WHAT LIES BENEATH??? Have we lost out on something which we all are acquainted with, which is simple and contribute in a significant manner to improve the oral and general health of an individual??? We all are trained to diagnose premalignant and malignant lesions, bacterial, viral, fungal infections, and mucocutaneous lesions. We have been making these diagnoses for years. However, there has been no consensus on screening and referrals for management for these patients. We need an organized system to offer guidance and to improve access to experts in diagnosis and management of these lesions.

There is a strong demand for specialist oral pathology services in Australia. In a similar study carried out in UK it was observed that there are 43.2 % referrals from the general dental practitioners to the oral diagnosis specialist. In another study it was opined that there is an increasing demand from general dental practitioners and family physicians for a specialist unit of oral medicine and pathology and a greater recognition of the need for definitive diagnosis of oral mucosal problems. It has been found that 98% of the general histopathologists were aware of the specialty of oral pathology and 92% perceived a need for it. (I Clin Pathol 1996; 49:565-569, Journal of the Royal Society of Medicine Volume 87 July 1994: 390, Oral Diseases Volume 14 Issue 4, 367 – 375, Journal of Dental Education, Volume 71, Number 4: 487)

The branch of oral pathology deals with diagnosis, scientific study of the etiopathogenesis of the underlying condition. This knowledge is essential for the rational management and preventive programmes. The goal of oral pathology is not only to diagnose the diseases but also to transform the nature of dental education and practice in ways that will dramatically improve the way we serve our patients, & the surrounding community.

Oral pathology offers simple tips and tricks to detect and monitor bacterial, viral, fungal infections, mucocutaneous lesions, blood dyscrasias as well as potentially malignant lesions and small carcinomas. These are easy to perform, simple, cost effective and carried out within a relatively short span of time. We all have been trained in them but how many of us apply them practically??? So dear friends now is the time to revive them back and work together to make a difference.

There are numerous chair side diagnostic aids available which will help us to assess the various pathologies. These range from conventional oral examination to surgical methods. We have used them at some point or the other. But their services still remain under utilized given the advantages they offer. They have certain advantages

• These are Simple, safe and acceptable.
• They can detect the disease in its early stage. Thus early intervention in such cases will prevent subsequent progression.
• They have a high positive predictive value.

Conventional oral examination

It is the standard method most commonly used for screening of oral pathologies. This involves the clinical inspection and palpation of the oral disorders using the normal (incandescent) light. This method has a high sensitivity and specificity values as 0.85 and 0.97 respectively. This approach is used routinely in our clinics for detection and risk assessment.

Cytological methods

Cytology involves the study of cells. This can be of three types viz. exfoliative cytology, brush cytology and fine needle aspiration cytology. They have application in spectrum of conditions including premalignant lesions, malignant lesions, bacterial, viral, fungal conditions, blood dyscrasias, odontogenic cysts and tumors, salivary gland tumors…etc. The techniques are relatively painless, produce a speedy result and are inexpensive. They form an essential component of the pre operative or pre treatment assessment of the pathological processes in combination with clinical or other pre operative data. These are less demanding and can be performed as routine office procedures. Their services can be utilized in debilitated patients. The most important advantage of these techniques is that they have low degree of complications and fair degree of reliability.

Toludine blue

Toludine blue is considered as an established diagnostic adjunct. It is also known as tolunium chloride. It is a vital dye that stains nucleic acids and abnormal tissues. It has been used for decades as an aid to the identification of clinically occult mucosal abnormalities of the oral cavity. It has been valued by surgeons as a useful way of demarcating the lesion prior to excision.

Light based detection systems

These systems utilize the property of autofluoroscence of the tissues for detection of subtle changes in the tissues. They include the use of VELscope, Vizlite Plus, Microlux DL. These are useful in case of premalignant lesions and malignant lesions. They direct light of specific wavelength on the tissues. Abnormal tissues affect the scattering and absorption of light in the tissues, thus resulting in the changes in colour that can be observed visually.

Scalpel biopsy

Biopsy is indicated for the assessment of any unexplained oral mucosal abnormality that persists despite treatment or the removal of local irritants. Scalpel biopsy is recognized as a gold standard for diagnosing a condition. The definitive diagnosis can be given accurately on the basis of histopathological examination of scalpel biopsy. It can be either incisional or excisional. Generally for smaller lesions, excisional biopsy is preferred. It is confirmatory method to assess any condition and offers maximum specificity. The tissues can also be sent for advanced investigations like immunohistochemistry, polymerase chain reaction. High-resolution computer imaging systems are being applied to assess both tissue samples and exfoliated cells to reveal the features in greater detail, as well as the frequency and distribution of such changes in cells. Such imaging can identify nuclear changes in low-grade dysplasia that are associated with the presence of high-risk molecular clones and with risk of cancer formation.

Saliva samples

Though saliva lacks the drama of blood, sincerity of sweat and emotional appeal of tears, it is the most important body fluid for dental surgeons. Technologies are available enabling saliva to be used to diagnose disease and predict disease progression. It has diagnostic applications in dental caries, oral cancers, autoimmune diseases, viral diseases, fungal lesions, forensics etc. This is a promising noninvasive approach, which is still in an early stage of development.

Oral pathology is thus a specialty that should be recognized more widely as it provides a very useful diagnostic and treatment service for dental practitioners. Clinical application of the knowledge of oral pathology thus helps to develop a clear understanding of the status of oral lesions.