J Oral Maxillofac Surg

69:125-133, 2011

Concordance Between Clinical and

Histopathologic Diagnoses of Oral
Mucosal Lesions
Kush J. Patel, BDS, MDS, MBChB,*
Harsha L. De Silva, BDS, MS, FDSRCS, FFDRCS,†
Darryl C. Tong, BDS, MBChB, MSD, CertOMS, FFDRCSI, FDSRCS,‡
and Robert M. Love, BDS, MDS, PhD, FRACDS§

Purpose: To study the epidemiology of oral soft tissue lesions in New Zealand from 2002 to 2006 and
to determine the concordance between the clinical diagnosis and the definitive histopathologic diagnosis
achieved by general dental practitioners and by specialists.
Materials and Methods: The details from biopsy referrals and the corresponding histopathologic
reports of oral soft tissue lesions were recorded into a statistical software package, and the concordance
between the clinical diagnosis and histopathologic diagnosis was determined for all the lesions.
Results: Most biopsies were benign lesions, and both clinician groups achieved a high diagnostic
concordance for these lesions. However, when considering all lesion types, the overall concordance for
both groups was a moderate 50.6%, with little difference between specialists and general dental
practitioners, although specialists were more accurate in diagnosing a malignant or premalignant lesion.
Conclusions: The clinical and histopathologic concordance achieved by oral health practitioners in
New Zealand appears to be moderate.
© 2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:125-133, 2011

Oral mucosal lesions are commonly encountered in
clinical practice. A study conducted in the United
States reported that they occurred in approximately
27.9% of patients aged 17 and older1 and in 10.3% of
children aged 2 to 17 years.2 The diagnosis and treat-
ment of mucosal pathologic features is an integral
part of the delivery of oral health care. Similar to
clinical dermatology, the actual appearance of the
lesion itself often provides valuable diagnostic infor-
mation. Thus, many experienced clinicians use visual
inspection and palpation to arrive at an accurate pro-
Received from the Department of Oral Diagnostic and Surgical
Sciences, University of Otago School of Dentistry, Dunedin, New
Zealand.
*Registrar.
†Senior Lecturer.
‡Senior Lecturer.
§Professor and Head of Department.
Address correspondence and reprint requests to Professor Love:
Department of Oral Diagnostic and Surgical Sciences, University of
Otago School of Dentistry, P.O. Box 647, Dunedin, New Zealand;
e-mail: robert.love@dent.otago.ac.nz
© 2011 American Association of Oral and Maxillofacial Surgeons
0278-2391/11/6901-0018$36.00/0
doi:10.1016/j.joms.2010.07.075
visional clinical diagnosis. Tissue biopsy and histo-
logic examination are regarded the reference standard
in diagnostic oral pathology and are used to confirm
the clinical diagnosis.
Malignancies involving the oral mucosa form an im-
portant group of pathologic features encountered in the
oral cavity. For both genders combined, cancer of the
mouth and pharynx ranks sixth overall in the world,
behind lung, stomach, breast, colon and rectal, and
cervix and corpus uteri carcinoma.3 Oral malignancy
occurs in up to 30,000 Americans annually, more than
the number affected by cervical cancer or melanoma.4 It
is relatively rare in the United Kingdom, with about
2,000 cases diagnosed annually, although the preva-
lence has been increasing.5 The death registers in Spain
have shown an annual increase in oral cancer mortality
from 1975 to 1994, with a 25% increase among males
and a 9% increase among females.6 Despite the many
advances in treatment modalities, the 5-year survival rate
has not changed in the past 50 years.7 However, evi-
dence is available supporting that early detection and
treatment has a significant bearing on improvement of
the 5-year survival rate and quality of life.8
Unlike in other parts of the body, the oral cavity
allows good access for a clinical examination. Further-
more, most oral malignancies tend to pass through a

125
126
precursor stage,9 in which the pathologic changes
might still be reversible and early intervention could
avoid the development of a more serious problem.
Oral white lesions have gained much attention in
cancer detection and control. Although most white
lesions are histologically a benign hyperkeratosis, oth-
ers with a similar clinical appearance have been asso-
ciated with a continuum of features ranging from mild
to severe dysplasia to actual carcinoma. Dysplasia
signifies an increasing risk of the potential for malig-
nant transformation10 and warrants more aggressive
management.
Most patients are likely to view a biopsy procedure
with suspicion and to become anxious regarding the
impending tissue diagnosis. A recent survey examin-
ing the current approaches to the diagnosis and man-
agement of oral premalignant lesions among the Dip-
lomates of the American Board of Specialists in Oral
Medicine revealed that most of the clinicians act on
an initial clinical diagnosis before embarking on a
biopsy to establish a tissue diagnosis.11 This can be
argued to be beneficial for beginning treatment with-
out delay and also to avoid the unwanted anxiety of a
surgical procedure for the patient. However, if this
approach is to be successful, the initial clinical diag-
nosis must be accurate and should not have missed
any premalignant or malignant pathologic features.
Hence, it is important to study the accuracy level of
the clinical diagnoses made by clinicians against the
final diagnosis obtained by histopathologic examina-
tion. A paucity of data is available on the assessment
of the diagnostic concordance between the clinical
and histopathologic diagnosis of oral soft tissue le-
sions.
Dentists are trained to examine, diagnose, and man-
age oral diseases and arguably are the clinicians most
familiar with the oral environment. However, debate
exists regarding whether the diagnosis of oral soft
tissue diseases should be performed by general dental
practitioners (GDPs) or should be left to specialists.
Seoane et al12 compared the concordance between
the clinical and histopathologic diagnosis of GDPs and
specialist oral and maxillofacial surgeons and found
that the concordance between the 2 groups was sim-
ilar. Sardella et al13 reported that the accuracy of
diagnosis varied by clinician, with GDPs correct in
40% of cases and the percentage of a correct diagnosis
was less for medical-trained postgraduate students
(27%) and physicians (33%). Williams et al,14 in their
20-year study recorded an overall concordance rate of
44.6%, 53.6%, and 56.4% in 1975, 1984, and 1994,
respectively, for the GDPs. In contrast, Bornstein et
al15 reported that a specialist’s diagnosis was more
accurate than the referring clinician’s diagnosis (70%
compared with 6.6%, respectively).
DIAGNOSIS OF ORAL MUCOSAL LESIONS
Given the additional years of training and experi-
ence received by the specialist practitioners, we hy-
pothesized that specialists would achieve a high level
of accuracy in their clinical diagnosis of oral soft
tissue lesions and that the level of concordance
achieved by specialists would be significantly greater
than that achieved by GDPs.
Materials and Methods
The histopathologic reports from the oral and max-
illofacial pathology database at the University of
Otago School of Dentistry from 2002 to 2006 were
reviewed to identify those reported on oral soft tissue
lesions. The reports were generated from specimens
received nationally from registered dentists and spe-
cialists. Ethical approval was obtained for the present
retrospective analysis of patient data. The inclusion
criteria for oral mucosal lesions for the present study
were all lesions involving the soft tissues of the
mouth: tongue, gingiva, unattached mucosa, and the
lips to the vermillion-skin junction.
Data from the reports were entered into a spread-
sheet and analyzed using the Statistical Package for
Social Sciences, version 16.0 (SPSS, Chicago, IL). The
data included a unique biopsy identity number, pa-
tient age, gender, date of biopsy, clinical diagnosis (if
provided), histopathologic diagnosis, and details of
the referring clinician. No patient’s personal or iden-
tifiable information was recorded to maintain ano-
nymity.
The specialist oral pathologists performed all the
tissue diagnoses during this study period, with 2 pa-
thologists reporting on each biopsy. The clinical di-
agnosis was recorded word for word, and an interpre-
tation was made at a later stage. The agreement
between the clinical and histopathologic diagnoses
was derived for 3 groups: all clinicians, GDPs, and
dentists with registered postgraduate qualifications
(specialists). The latter group also contained postgrad-
uate trainees working under the supervision of a reg-
istered specialist.
The lesions were grouped into 4 main categories
according to structural and histologic criteria. The 4
categories were oral mucosal lesions, gingival and
periodontal lesions, salivary gland lesions, and a mis-
cellaneous group that included all other lesions not
within the structural boundaries. Furthermore, the
clinical diagnoses were recategorized into groups ex-
pressing prognostic implications, according to the
clinician’s assessment. This created 4 groups:
Malignant (M): clinical diagnosis implying possible
existence of malignancy
Premalignant (PM): clinical diagnosis implying pos-
sible existence of premalignant lesion/condition
PATEL ET AL 127

Table 1. AGE AND GENDER DISTRIBUTION OF BIOPSIES RECEIVED FROM 2002 TO 2006

Age 2002 2003 2004 2005 2006 Total

Group (yr) Male Female Male Female Male Female Male Female Male Female Male Female Total

0-9 7 3 4 5 6 6 6 8 8 12 31 34 65
10-19 16 11 27 15 15 17 16 28 40 41 114 112 226
20-29 13 9 12 17 19 30 24 42 38 30 106 128 234
30-39 24 24 21 35 23 39 34 37 42 65 144 200 344
40-49 30 42 35 61 45 59 65 75 90 86 265 323 588
50-59 57 53 38 78 46 68 68 75 78 114 287 388 675
60-69 37 50 36 47 36 49 50 76 49 106 208 328 536
70-79 16 30 22 33 24 22 23 26 27 47 112 158 270
80-89 6 12 1 9 4 14 9 17 15 17 35 69 104
90-99 0 4 1 2 0 2 1 0 0 7 2 15 17
⬎100 0 0 1 0 0 2 1 0 2 2 4 4 8
Total 206 238 198 302 218 308 297 384 389 527 1,308 1,759
Total both
genders 444 500 526 681 916 3,067 3,067
Gender not specified in 16 biopsies, and date of birth not specified in 60 biopsies.
Patel et al. Diagnosis of Oral Mucosal Lesions. J Oral Maxillofac Surg 2011.

Benign (B): clinical diagnosis implying benign le-
sion/condition
No diagnosis (N): risk not assessed because clini-
cian failed to record clinical diagnosis
The histopathologic diagnoses were graded into 3
prognostic categories:
Malignant (M): diagnosis confirmed presence of ma-
lignancy
Premalignant (PM): diagnosis recorded condition
known to have malignant transformation risk
Benign (B): diagnosis recorded completely benign
lesion/condition
The concordance between the clinical and his-
topathologic diagnosis for a case was classified as
follows:
Concordant diagnosis (C): total concordance be-
tween clinical and histopathologic diagnosis
Concordant refined (CR): concordant histologic di-
agnosis with refinement of original clinical diagnosis
(eg, clinical diagnosis of “leukoplakia” but refined by
histologic results as “epithelial hyperplasia with mild
no written provisional clinical diagnosis and/or
in which the specialist/GDP status of the refer-
ring clinician could not be determined were
regarded as “incomplete” referrals, and were
excluded from the present analysis
2. Total concordance (TC) was determined by
considering all biopsy reports (reports with
no clinical diagnosis provided were regarded
as discordant)
Concordance was expressed as TC ⫽ (C ⫹ CR) ⫻
100/(C ⫹ CR ⫹ I ⫹ N) and CC ⫽ (C ⫹ CR) ⫻ 100/(C ⫹
CR ⫹ I), where C indicates totally concordant with
histopathologic diagnosis; CR indicates concordance
with histopathologic diagnosis but refined; I indicates
discordance between clinical and histopathologic diag-
nosis; and N, no clinical diagnosis given.
Age & gender distribution of biopsies received
450
400
Number of biopsies received

dysplasia”) 350
Discordant diagnosis (I): discordance between clin- 300
ical and histopathologic diagnosis 250 M
No clinical diagnosis (N): clinician had failed to 200 F
record clinical diagnosis 150
100
An oral pathologist was consulted when confusion
50
arose because of a description discrepancy between
0
the clinical and histopathologic diagnosis. The con-
s

s
s

ar
ar

ar

ar

ar

ar

ar

ar

ar

ar

ar

cordance was calculated in 2 methods:

ye

ye
ye

ye

ye

ye

ye

ye

ye

ye

ye

0
-9

9
9

10
-1

-2

-5
-3

-4

-6

-7

-8

-9
0

>
10

20

30

50
40

60

70

80

90

Age groups
1. Clinical concordance (CC) was determined by
considering only those biopsy reports that had FIGURE 1. Age and gender of patients.
been completed in full, with a clinical diagnosis Patel et al. Diagnosis of Oral Mucosal Lesions. J Oral Maxillofac
or a differential diagnosis entered. Reports with Surg 2011.
128 DIAGNOSIS OF ORAL MUCOSAL LESIONS

Table 2. TYPE OF LESION BY YEAR AND GENDER

2002 2003 2004 2005 2006 Total

Lesion Type Male Female Male Female Male Female Male Female Male Female Male Female Total (n)

Salivary 34 34 26 44 30 42 43 49 58 76 191 245 436 (13.94)

Mucosal 129 154 121 191 140 185 204 254 254 335 848 1,119 1,967 (62.90)
Gingival 27 42 31 56 31 65 24 48 38 70 151 281 432 (13.82)
Miscellaneous 23 16 24 20 27 29 28 35 42 48 144 148 292 (9.34)
Total 213 246 202 311 228 321 299 386 392 529 1,334 1,793
Total for both
genders 459 513 549 685 921 3,127 3,127 (100)
Gender was not specified in 16 biopsies.
Patel et al. Diagnosis of Oral Mucosal Lesions. J Oral Maxillofac Surg 2011.

Results
All oral soft tissue biopsies received by the Oral and
Maxillofacial Pathology Service of the University of
Otago School of Dentistry from 2002 through 2006
were considered as the study population. A total of
3,143 biopsy specimens met the inclusion criteria,
with the exclusion of 8 biopsy specimens for which a
histopathologic diagnosis could not be established
because the tissue sample was of inadequate size or of
poor quality for processing and reporting. A progres-
sive increase in the number of biopsies was received
at the laboratory, with the data showing a twofold
increase in 2006 (Table 1). The aforementioned trend
was stronger for females. No gender was specified for
16 of the biopsy referrals. When they were excluded,
the male/female ratio was 0.74:1. An additional 60
referrals did not have the date of birth recorded for
the age determination. Only 3,067 biopsies had the
age and gender both accurately determined (Table 1).
The age range of the referrals spanned from 1 to 102
years. The sample showed a normal distribution (Fig
1), with a mean age of 49 years. The bulk of the
biopsy specimens came from middle-aged patients,
with the patients within the age range of 40 to 69
years contributing well over half the biopsies (58.2%).
Females outnumbered males in all age groups, barring
the 10- to 19-year age group and the older than 100-
year age group.
The vast majority (62.9%) of the referrals related to
biopsies performed in the nonattached oral mucosa
(Table 2). The volumes of salivary gland pathology
and gingival pathology were nearly equal and ac-
counted for 27.9% of the sample. In each different
structural category, more biopsies were performed on
females than males, although the difference was only
marginal in the miscellaneous lesion group (Table 2).
A progressive annual increase was seen in all biopsy
categories, barring a slight decline in the gingival
biopsy referrals in 2005, before recovering to record
the greatest number in 2006.
Specialist practitioners contributed more than 80%
of the samples (n ⫽ 2,558), and the GDP referrals
were approximately 17% (n ⫽ 540). The practitioner
status was obscure (eg, the practitioner status was not
mentioned in the referral and could not be verified) in
45 referrals (Table 3). A total of 626 specimens, with
no clinical diagnosis recorded, accounted for almost
20% of the sample. GDPs did not provide a provisional
diagnosis in one quarter of their referrals, and special-
ists failed to do so in 18.7% of their biopsies. The total
diagnostic concordance for all clinicians combined
was 50.6%, and the clinical concordance reached

Table 3. CONCORDANCE BETWEEN CLINICAL AND HISTOPATHOLOGIC DIAGNOSES FOR SPECIALISTS AND
GENERAL DENTAL PRACTITIONERS

Variable C CR I N Total

Specialists 1,052 (41.1) 252 (9.9) 775 (30.3) 479 (18.7) 2,558 (100)
GDPs 201 (37.2) 66 (12.2) 137 (25.4) 136 (25.2) 540 (100)
Unknown 16 (35.6) 4 (8.9) 14 (31.1) 11 (24.4) 45 (100)
Total 1,269 (40.4) 322 (10.2) 926 (29.5) 626 (19.9) 3,143 (100)
Abbreviations: C, totally concordant with histopathologic diagnosis; CR, concordant with histopathologic diagnosis but
refined; I, discordance between clinical and histopathologic diagnosis; N, no clinical diagnosis given.
Data presented as numbers, with percentages in parentheses.
Patel et al. Diagnosis of Oral Mucosal Lesions. J Oral Maxillofac Surg 2011.
PATEL ET AL 129

Concordance between clinical and histopathological

diagnoses among Specialists and GDPs Table 5. COMMON LESIONS REPORTED BY
CLINICIANS DURING 5-YEAR PERIOD AND
80 RATE OF CONCORDANCE WITH
70 62.7
66.7 HISTOPATHOLOGIC DIAGNOSIS
Rate of concordance

60
51 49.4
50
Common No
40
Specialists Lesions Concordant Discordant Diagnosis Total
30.3 GDPs
30 25.2 25.4
18.7 Fibroepithelial
20
polyp 375 (66.3) 95 (16.8) 96 (17.0) 566
10 Mucocoele 224 (83.0) 26 (9.6) 20 (7.4) 270
0 Lichen planus 163 (71.2) 31 (13.5) 35 (15.3) 229
No diagnosis Discordant Total Clinical
Concordance Concordance
Fibrous epulis 79 (43.2) 65 (35.5) 39 (21.3) 183
Epithelial
FIGURE 2. Total concordance and clinical concordance achieved keratosis 40 (24.2) 84 (50.9) 41 (24.8) 165
by specialists and general dental practitioners. Irritative
Patel et al. Diagnosis of Oral Mucosal Lesions. J Oral Maxillofac hyperplasia 102 (63.4) 27 (16.8) 32 (19.9) 161
Surg 2011.
Data presented as numbers, with percentages in parentheses.
Patel et al. Diagnosis of Oral Mucosal Lesions. J Oral Maxillofac
Surg 2011.
63.21% when the referrals with no clinical diagnosis
were omitted from the sample (Table 3). The special-
ists had a total concordance of 51%, improving to a of 86.7% and 23.2%, showed a similar trend. GDPs
clinical concordance of 62.7%; the corresponding achieved their greatest concordance for irritative hy-
percentages for GDPs were 49.4% and 66.7% (Fig 2). perplasia (78.8%) followed closely by lichen planus
The total concordance data for individual structural (77.8%); the lowest for GDPs was also for epithelial
categories of lesions varied between a high of 58.6% keratosis (Table 6).
for salivary gland pathologic findings and a low of A progressive increase was seen in the volume of
44.4% agreement for gingival lesions (Table 4). The benign and premalignant pathologic features, with an
clinical concordance for all 4 groups improved to a almost static level of malignancies evident during the
level greater than 55% when the referrals with no 5-year period (Fig 3). An overwhelming majority of
clinical diagnosis were excluded. clinical diagnoses (63.4%) and histopathologic diag-
A total of 138 different histologic diagnoses were noses (84.7%; Tables 7 and 8) indicated benign be-
made in the 5-year period (data not presented). Spe- havior. Although the clinicians considered 16.6% of
cialists sent in 131 different pathologic diagnoses, and their referrals to be premalignant or malignant le-
the GDPs sent in 56 different diagnoses. The most sions, the pathologist confirmed malignancy in 2.4%
frequently diagnosed oral pathologic diagnosis in the and identified premalignant risks in an additional
New Zealand population (Table 5) during this 5-year 12.5%. A 96.8% rate of agreement between clinicians
period was fibroepithelial polyp (n ⫽ 566), mucocele and pathologists was evident for lesions considered
(n ⫽ 270), lichen planus (n ⫽ 229), fibrous epulis clinically benign; however, the consensus decreased
(n ⫽ 183), epithelial keratosis (n ⫽ 165), and irritative to 60% and 56.6% for a clinical diagnosis of premalig-
hyperplasia (n ⫽ 161). The total concordance nancy and malignancy, respectively (Table 9). A sim-
achieved by both groups of practitioners combined ilar trend was seen for the total concordance rate
for these lesions varied between a high of 83% for achieved by the specialists (Table 10). GDPs exam-
mucoceles to a low of 24% for epithelial keratosis. ined far fewer numbers of premalignant and malig-
The specialist group, with corresponding percentages nant pathologic lesions than did the specialists.

Table 4. CONCORDANCE BETWEEN CLINICAL AND HISTOPATHOLOGIC DIAGNOSIS FOR DIFFERENT LESION TYPES

Total Clinical
Lesion Type C CR I N Total Concordance Concordance

Mucosal 779 (39.4) 226 (11.4) 555 (28.2) 415 (21.0) 1,975 (100) 50.9 64.42
Gingival 131 (30.3) 61 (14.1) 138 (32.0) 102 (23.6) 432 (100) 44.4 58.18
Salivary 251 (57.1) 7 (1.6) 129 (29.3) 53 (12.0) 440 (100) 58.6 66.67
Miscellaneous 108 (36.5) 28 (9.5) 104 (35.1) 56 (18.9) 296 (100) 45.9 56.67
Total 1,269 (40.4) 322 (10.2) 919 (29.5) 626 (19.9) 3,143 (100) 50.6 63.21
Abbreviations as in Table 3.
Patel et al. Diagnosis of Oral Mucosal Lesions. J Oral Maxillofac Surg 2011.
130 DIAGNOSIS OF ORAL MUCOSAL LESIONS

Table 6. CONCORDANCE BETWEEN CLINICAL AND HISTOPATHOLOGIC DIAGNOSIS AMONG SPECIALISTS AND
GDPs FOR COMMON ORAL SOFT TISSUE LESIONS IN NEW ZEALAND

Concordant Discordant No Diagnosis Given

Common Lesions Specialists GDPs Specialists GDPs Specialists GDPs Total

Fibroepithelial polyp 267 (70.3) 103 (57.5) 61 (16.1) 33 (18.4) 52 (13.7) 43 (24.0) 559
Mucocoele 189 (86.7) 32 (68.1) 17 (7.8) 7 (14.9) 12 (5.5) 8 (17.0) 265
Lichen planus 144 (69.9) 14 (77.8) 29 (14.1) 2 (11.1) 33 (16.0) 2 (11.1) 224
Fibrous epulis 57 (41.6) 20 (47.6) 48 (35.0) 17 (40.5) 32 (23.4) 5 (11.9) 179
Epithelial keratosis 36 (23.2) 3 (33.3) 80 (51.6) 4 (44.4) 39 (25.2) 2 (22.2) 164
Irritative hyperplasia 76 (59.4) 26 (78.8) 26 (20.3) 1 (3.0) 26 (20.3) 6 (18.2) 161
Abbreviation: GDP, general dental practitioner.
Data presented as numbers, with percentages in parentheses.
Patel et al. Diagnosis of Oral Mucosal Lesions. J Oral Maxillofac Surg 2011.

Discussion our study could be regarded as representative of the

oral pathology trends nationwide.
The importance of regular monitoring of the dis-
Most of the biopsy specimens (more than 80%)
ease incidence within a population is self-evident for
were submitted by clinicians with recognized post-
future planning and implementation of preventive
graduate training and qualifications, identified in our
and therapeutic health care services. This report is
study as specialists. GDPs referred approximately 17%
the first study of oral soft tissue lesions for a New
of the biopsies submitted for histopathologic analysis.
Zealand population composed of more than 3,000
This rate was similar to the data reported from Eu-
oral mucosal biopsy specimens during the 5-year pe-
rope, where the number of primary care dentists
riod (2002 to 2006). Clinicians from throughout New
offering biopsy was 12% in Northern Ireland,17 21% in
Zealand referred their biopsy specimens for assess-
the United Kingdom,18 and 24.5% in Spain.19 It is not
ment by the Oral and Maxillofacial Pathology Service,
surprising that most biopsy referrals were made by
because it has been the only tertiary institution of its
specialists, although some reports have suggested a
kind in New Zealand.16 Although general anatomic
change in this trend, with GDPs increasingly perform-
pathologists are available at other centers, the School
ing biopsy procedures.15,19 A study of dentists in the
of Dentistry is regarded as the national center of
Autonomous Community of Murcia (Spain) reported
excellence for oral and maxillofacial pathology and
that 32.1% of dentists offered biopsy as a diagnostic
the only one with practicing specialist pathologists.
service to their patients.20
This has been further endorsed by the progressive
The most common lesions found in New Zealand
increase seen in the volume of biopsies referred to the
were fibroepithelial polyps, mucoceles, oral lichen
School of Dentistry during the 5-year period. Hence,
planus, fibrous epulis, epithelial keratosis, and irrita-
tive hyperplasia (Table 5) and correlates well with
other published audits. Williams et al14 reported that
Number of biopsies received over the years
fibroepithelial polyps, mucous extravasation cysts
1000
(mucocele), fibrous epulis, keratosis, lichen planus,
900
and squamous cell papilloma were the most common
800
pathologic findings. The most common oral malig-
Number of biopsies

700
Benign
nancy, oral squamous cell carcinoma, accounted for
less than 2% of the histopathologic diagnoses (n ⫽ 58)
600
Premalignant
500 Malignant
No diagnosis in our study, confirming the relatively low incidence
400
Total
of this lesion seen in developed countries. Specialists
300
referred 51 of these, for a total concordance of 66.7%,
200
which increased to 79.1% for clinical concordance. It
100
might be that the GDPs were more likely to refer what
0
2002 2003 2004 2005 2006 they believed to be oral squamous cell carcinoma to a
Year specialist, without themselves venturing to biopsy the
FIGURE 3. Implied prognosis of lesions based on histopathologi-
lesion.
cal diagnosis over the period of five years. The male/female ratio was 0.74:1, with 42.7% of
Patel et al. Diagnosis of Oral Mucosal Lesions. J Oral Maxillofac the sample male and 57.3% female. The 2006 New
Surg 2011. Zealand national census reported that 4,027,947 peo-
PATEL ET AL 131

Table 7. IMPLIED PROGNOSIS OF LESIONS ACCORDING TO CLINICAL DIAGNOSIS

Year Benign Premalignant Malignant No Diagnosis Total

2002 271 (58.4) 62 (13.4) 15 (3.2) 116 (25.0) 464 (100)

2003 325 (62.9) 69 (13.3) 15 (2.9) 108 (20.9) 517 (100)
2004 371 (67.0) 77 (13.9) 18 (3.2) 88 (15.9) 554 (100)
2005 431 (62.8) 102 (14.9) 13 (1.9) 140 (20.4 ) 686 (100)
2006 596 (64.6) 130 (14.1) 22 (2.4) 174 (18.9 ) 922 (100)
Total 1,994 (63.4) 440 (14.0) 83 (2.6) 626 (19.9) 3,143 (100)
Data presented as numbers, with percentages in parentheses.
Patel et al. Diagnosis of Oral Mucosal Lesions. J Oral Maxillofac Surg 2011.

ple usually lived in New Zealand, including 1,965,618 GDPs referred only a very few malignant lesions and
males (48.8%) and 2,062,329 females (51.2%). As the data were too small for a valid comparison with
such, the representation of females was greater than the performance of the specialists group. Both groups
expected among the 3,143 biopsy specimens re- of clinicians excelled in the diagnosis of benign patho-
ceived by the School of Dentistry during the 5-year logic features and, to a lesser extent, malignancies,
period. This observation was in contrast to the data but appeared to have more difficulties in identifying
reported by Jones and Franklin.21 They reported a the premalignant risks in the clinical setting (Table
male/female ratio of 0.9:1 in their sample. However, 10). Specialists missed 16 instances of malignancy and
their sample included both soft tissue and hard tissue an additional 44 instances of premalignant risk clini-
pathologic findings. Notwithstanding, a trend seems cally, endorsing the need for a tissue diagnosis.
to be present for females to have more histologically It has been the common consensus that specialists
diagnosed oral pathologic features. Whether females are expected to perform better in the clinical identi-
have more oral lesions or are likely to be more health fication of oral pathologic features and are therefore
conscious and access oral health services for clinical expected to achieve a significantly greater degree of
examination is unclear and merits additional study. diagnostic concordance compared with their col-
When all reports were considered, the diagnostic leagues in general dental practice. The similar concor-
concordance of all clinicians combined (GDPs and dance between the GDPs and specialists in our study
specialists) in the present study was 50.6%. GDPs had might have been because GDPs only performed biop-
a concordance of 49.4%, which was slightly lower, sies on commonly found lesions, and the specialist
but not significantly different, from that of the spe- group examined a wider range of pathologic lesions,
cialists group (51%). This result was similar to that including more complex and rare cases. In the
reported by Williams et al,14 who reported a diagnos- present study, the specialists sent referrals for a wider
tic concordance of 56.4% for general practitioners. range of oral diseases (n ⫽ 138) and the GDP referrals
Similarly, Seoane et al12 found a high level of agree- were for 56 different disease entities. Second, the
ment between GDPs and oral and maxillofacial sur- specialists referred a larger number of leukoplakias,
geons in diagnosing benign and inflammatory lesions for which the diagnosis by the clinical appearance
and precancerous and cancerous lesions, with, how- alone can be difficult,22 leading to more discordant
ever, oral and maxillofacial surgeons showing superi- diagnoses. Epithelial keratosis was one of the most
ority at diagnosing oral cancer. In the present study, common lesions in New Zealand to be biopsied, but
even the specialist practitioners achieved only a low
diagnostic concordance.
Table 8. IMPLIED PROGNOSIS OF LESIONS It has been accepted that a close dialogue between
ACCORDING TO HISTOPATHOLOGIC DIAGNOSIS
the referring clinician and the reporting pathologist is
Year Benign Premalignant Malignant Total beneficial to enhance the accuracy of the histopatho-
logic diagnosis,23 such as the differentiation be-
2002 385 (83.0) 65 (14.0) 14 (3.0) 464 (100)
2003 453 (87.6) 51 (9.9) 13 (2.5) 517 (100)
tween a diagnosis of a lichenoid reaction from li-
2004 461 (83.2) 77 (13.9) 16 (2.9) 554 (100) chen planus on the basis of clinical information of
2005 571 (83.2) 102 (14.9) 13 (1.9) 686 (100) recent drug therapy.24,25 Pathologists value the clin-
2006 792 (85.9) 110 (11.9) 20 (2.2) 922 (100) ical details, and the provision of a clinical diagnosis or
Total 2,662 (84.7) 405 (12.5) 76 (2.4) 3,143 (100) a differential diagnosis provides the pathologist with a
Data presented as numbers, with percentages in parentheses. summation of the clinician’s thoughts regarding the
Patel et al. Diagnosis of Oral Mucosal Lesions. J Oral Maxillofac biopsied lesion. Furthermore, an indication from the
Surg 2011. clinician of the context of the implied prognosis of
132 DIAGNOSIS OF ORAL MUCOSAL LESIONS

Table 9. CONCORDANCE BETWEEN IMPLIED PROGNOSIS OF CLINICAL DIAGNOSIS AND HISTOPATHOLOGIC

DIAGNOSIS AS PERCEIVED BY CLINICIANS AND CONFIRMED BY PATHOLOGISTS

Implied Prognosis of Clinical Implied Prognosis of Histopathologic Diagnosis

Diagnosis Benign Premalignant Malignant Total

Benign 1,930 (96.8) 49 (2.5) 15 (0.8) 1,994 (100)

Premalignant 172 (39.1) 264 (60.0) 4 (0.9) 440 (100)
Malignant 24 (28.9) 12 (14.5) 47 (56.6) 83 (100)
No diagnosis given 536 (85.6) 80 (12.8) 10 (1.6) 626 (100)
Total 2,662 (84.7) 405 (12.9) 76 (2.4) 3,143 (100)
Data presented as numbers, with percentages in parentheses.
Patel et al. Diagnosis of Oral Mucosal Lesions. J Oral Maxillofac Surg 2011.

the lesion (ie, clinical suspicion of an existence of
malignancy or a premalignant risk) helps the pathol-
ogist to plan the sectioning of the sample in the
appropriate fashion to ensure adequate representa-
tion of the lesion for the histopathologic examination.
However, in the present study, 20% of the referrals
had not had a clinical diagnosis provided. The GDPs
omitted a clinical diagnosis more often (25.2% of
referrals) than the specialists (18.7%). In addition,
14.3% of the lesions with no clinical diagnosis in the
present study proved to be either malignant or pre-
malignant on histopathologic examination.
The diagnostic concordance in the present sample
showed a greater level of agreement for clinical con-
cordance than for total concordance. When only fully
completed biopsy reports were considered (ie, re-
ports with a clinical diagnosis), the diagnostic concor-
dance improved, with the GDPs achieving 66% and
the specialists reaching 62.7% for clinical concor-
dance. These data compare favorably with those from
the study by Sardella et al,13 who found a diagnostic
concordance with the referral letters (45% of the
sample) that included a clinical provisional diagnosis
of only 40%. However, that study had had multiple
clinician groups, including GDPs, medically trained
physicians, and general medical practitioners with a
postgraduate dental qualification, which could ex-
plain the differences observed.
Opinion appears divided regarding whether the GDPs
should be performing oral biopsies or whether it is best
left to the specialist, who is ultimately responsible for
the management of the particular ailment. Several inves-
tigators have addressed this dilemma.12,26,27 A vast ma-
jority of oral biopsy specimens are of benign lesions.
GDPs have shown skills comparable to those of special-
ists in obtaining good oral biopsy samples12 and also
appear to perform equally well13 when diagnosing be-
nign oral lesions (Table 10). Given the likelihood of the
GDP being the first health care practitioner to see the
lesion and, more importantly, the one with a closer
relationship with his or her patient, it seems logical
that the GDP should proceed to perform a simple
incision biopsy with the patient under local anesthe-
sia. Although studies have shown that dentists are
more likely to detect the early stages of oral malig-
nancy compared with their medical colleagues,28,29
GDPs should exercise caution in handling lesions
with a premalignant or malignant risk. The manage-
ment of these is more demanding and involves critical
decision-making with regard to the selection of the
biopsy site and technique. Thus, such lesions are

Table 10. CONCORDANCE RATE FOR SPECIALISTS AND GDPs FOR IMPLIED PROGNOSIS OF CLINICAL DIAGNOSIS
AGAINST HISTOPATHOLOGIC DIAGNOSIS

Implied Prognosis of Histopathologic Diagnosis

Implied Prognosis Specialist Referral GDP Referral

of Clinical Diagnosis Benign Premalignant Malignant Total Benign Premalignant Malignant Total

Benign 1,543 (96.4) 44 (2.7) 14 (0.9) 1,601 (100) 363 (98.9) 4 (1.1) 0 (0) 367 (100)
Premalignant 166 (40.9) 238 (58.6) 2 (0.5) 406 (100) 6 (20.0) 23 (76.7) 1 (3.3) 30 (100)
Malignant 20 (27.8) 10 (13.9) 42 (58.3) 72 (100) 3 (42.8) 2 (28.6) 2 (28.6) 7 (100)
No diagnosis 400 (83.5) 70 (14.6) 9 (1.9) 479 (100) 127 (93.4) 8 (5.9) 1 (0.7) 136 (100)
Total 2,129 (83.2) 362 (14.2) 67 (2.6) 2,558 (100) 499 (92.4) 37 (6.9) 4 (0.7) 540 (100)
Abbreviation: GDP, general dental practitioner.
Data presented as numbers, with percentages in parentheses.
Patel et al. Diagnosis of Oral Mucosal Lesions. J Oral Maxillofac Surg 2011.
PATEL ET AL
better diagnosed and managed by specialist practitio-
ners and preferably by multidisciplinary services.
The clinical and histopathologic concordance
achieved by oral health care practitioners in New
Zealand was moderate and endorses the need for
histopathologic assessment to complement the clini-
cal assessment in the definitive diagnosis of oral soft
tissue pathologic features.
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