Management Strategies for Oral

Potentially Malignant Disorders

Oral Potentially Malignant Disorders

Oral potentially malignant disorders (OPMDs) include oral leukoplakia

(OL), oral erythroplakia, oral submucous fibrosis, oral lichen planus,
proliferative verrucous leukoplakia, and actinic keratosis. Once an OPMD
has been clinically diagnosed, execution of management strategy is critical.
When formulating the strategy, healthcare providers should consider
histopathology, lesion characteristics (ie, surface texture, unifocal,
multifocal), lesion location in the mouth (ie, tongue, floor of mouth), patient
risk factor assessment, and a detailed medical/cancer history.

In this newly published article, Nadeau and Kerr[1] detail various parameters
surrounding evaluation and management of OPMDs. The authors make it
clear that OPMDs are challenging, each with their own nuances regarding
risk for malignant transformation. For example, when OL is unifocal,
nonhomogeneous, nodular, or verrucous, there is a much higher chance of
the OL becoming dysplastic (12.63-fold) or demonstrating a focus of
carcinoma (8.9-fold) when compared with homogeneous types of OLs.[1]

Provider knowledge of these variables is critical when counseling patients

about their diagnosis and management options and when selecting
interventions along with follow-up care. Although progression to malignancy
is difficult to predict with OPMDs, clinicians can account for multiple risk
factors such as smoking/alcohol status, high-risk location in the oral cavity,
and size of lesion (>200 mm2) to help formulate a tailored management plan
for each patient. Consultation with an oral pathologist to discuss the
histologic appearance in the context of specific patient history and lesion
characteristics can provide additional perspective and/or recommendations.

Modifiable oral cavity cancer risks related to tobacco and heavy alcohol use
should be communicated to patients with OPMDs so that they are able to
make changes that may lead to regression/disappearance of certain lesions
such as OL. Providers confronted with patients who use tobacco and/or
heavy alcohol can integrate recommendations for cessation of tobacco[2] and
alcohol[3] because they are both established, independent, causative agents
for oral cavity cancer and OPMDs.

Available treatment strategies for OPMDs include surgical removal/ablation,

photodynamic therapy, and surveillance. The authors make a clear point
with supportive studies that traditional surgical excision of dysplastic
OPMDs may decrease malignant transformation (MT) risk, yet it does not
fully eliminate that risk and, in some instances, has not changed the MT risk
when compared with surveillance alone. Appropriate surgical margin
identification for OPMDs is clinically challenging. The authors note that
smaller excisional margin sizes (1-2 mm) without marginal histologic
assessment are common surgical management goals for OPMDs.[

1]

Viewpoint

Nadeau and Kerr carefully outline updated considerations for all OPMDs.
Healthcare providers involved in screening, diagnosing, referring, and/or
managing patients with OPMDs should be well versed in standards of care,
including baseline biopsy goals, tobacco/alcohol cessation, currently
available interventions, and surveillance care.
Clinicians should also develop a local team of practitioners who are experts
in diagnosis and management of OPMDs to help patients obtain the best
opportunity for positive outcomes. I encourage readers with interest to
retrieve and review the full article by Nadeau and Kerr as a strategy to update
your knowledge base and to continue to improve overall morbidity,
mortality, and survival rates related to OPMDs.