In this study, the rate of agreement between the two clinical and histopathological diagnoses was examined, along with the prevalence of each biopsied lesion submitted to department of Oral Pathology, Shiraz dentistry school. Accordingly, these considerations are valuable for improving the existing knowledge about the perception and behavior of dentists and dental students regarding the necessity of performing the histopathological examination.
In the present study, the rate of clinicopathological agreement was obtained as 72.2%, which is similar to those obtained in studies by Saravani et al. [10] and Emamverdizadeh et al. [8] who calculated the overall compatibility rate as 70.1% and 72.3%, respectively. However, compared to the above-mentioned rates, the rates in the studies conducted by Tatli et al. [2] and Forman et al. [11] were higher (93.3% and 94.4%, respectively). In a study by Soyele et al. [12], clinicopathological reports of 592 biopsied cases during the period of 2008–2017 were retrieved and then analyzed. Accordingly, they recorded the concordance rate as 54.6%, which was similar to results of Poudel et al.’s study [7] (54.6%). These discrepancies could be due to remarkable differences in these studies’ methodologies such as the clinicians and the pathologists’ skills, the accuracy of biopsy, sample size, and conditions under which the specimens were transferred to the laboratory.
Based on the fact that some lesions occur more frequently in one sex or at certain ages, so it can be said that age or sex can be considered as one of the influential factors on making a better differential diagnosis. However, in the present study, no significant relationship was observed between compatibility rate and sex or age. These findings are in line with those of the Saravani et al.’s study [10]. However, in Forman et al.’s research [11], age was found to be significantly associated with accuracy between clinical and histologic diagnoses. Furthermore, in the current study, the highest compatibility rate was observed in the 9th and 10th decades of life, which is almost consistent with other similar reports, demonstrating that the highest percentage of agreement rate was in the 7th decade and older age [12–16]. The reason for the greater compatibility rate between clinical and pathological diagnoses in this age group may possibly be the loss of teeth, thereby the reduced number of odontogenic lesions and irritation associated with them. Another reason might be the exclusion of lesions developing in children or young adults. Moreover, a slight increase might be found in some specific lesions such as denture-related lesions and other prevalent lesions, which consequently makes correct diagnosis of lesions easier. Despite the results of the present study, two previous studies [11, 12] have also observed a higher concordance index in women, while another study [2] has reported slightly higher discordance rates for the female patients’ lesions compared to the male patients’ ones.
Similar to the current study, Saravani et al. [10] have also found no relationship between compatibility of clinical and histopathological diagnoses and clinician’s specialty in their study. However, in the study by Foroughi et al. [17], the highest and lowest compatibility rates between clinical and pathological diagnoses were achieved by oral medicine specialists (98%) and general dentists (71%), respectively.
The current study indicated that a significant relationship exists between lesion’s site and concordance of clinical and histological diagnoses. But, no statistically significant relationship was observed between the compatibility of clinical and histopathological diagnoses of oral lesions in the Saravani et al.’s research [10]. Additionally, in the present study, mandibular bone lesions had the highest frequency of lesions and in soft tissue lesions, the highest frequency was found to be related to buccal mucosa and the lowest one was associated with ventral surface lesions of the tongue. These results are almost similar to those of the Saravani et al.’s study, indicating Mandibular bone lesions as the most frequent lesions and tongue as the least frequent one in oral cavity. In regard to agreement rate, gingival lesions and floor of mouth both had the minimum and maximum rates of compatibility in current study, respectively. Correspondingly, this finding may be due to the fact that several oral diseases have the same clinical manifestations in gingiva; for example, desquamative gingivitis can be seen in either ulcerative and vesiculobullous or white and red lesions, so it is not clinically distinguishable among these types of diseases. However, Foroughi et al. [17] and Hashemipour et al. [15] in their studies reported the most compatibility rate of clinical and histopathological diagnoses in gingiva. Furthermore, the lowest compatibility rate was observed in floor of the mouth, reported in the Hashemipour et al. and Saravani et al.’s studies. These contradictory findings in these studies may be due to variations in the sample size and the clinicians’ knowledge and experiences.
The present study is unique as it, for the first time, examined a large number of studied biopsy samples and then classified all lesions into 5 categories of ulcerative, white and red, pigmented, exophytic, and bone lesions, which include almost all types of oral lesions. While other studies have mainly focused only on few specific lesions and a specific group [18–21]. According to the results of the current study, a statistically significant relationship exists between compatibility rate of the histopathological and clinical diagnoses and the type of lesions. Accordingly, this finding is in line with the results of the study by Saravani et al. [10] who found a significant relationship between type of lesion (either neoplastic or non-neoplastic) and clinicopathological agreement.
In this study, out of 5 general categories of lesions, the highest prevalence belonged to exophytic lesions, and white and red lesions had the highest consistency rate and pigmented lesions had the lowest rate. In white and red lesions, oral liquen planus was the most commonly observed lesion and it also had the highest percentage of consistency (88.6%). Similarly, Fattahi et al. [13] in their study found the highest percentage of consistency for Lichen planus (100%), and in another study, Goyal et al. [20] found the Lichen planus as the most common lesion in oral mucosal lesions with the clinicopathological concordance rate of 91.4%.
After white and red lesions, the highest concordance rate belonged to in bone lesions, which were more frequent in cystic lesions compared to tumor lesions. In cystic bone lesions, radicular cyst was found as the most common lesion. Similarly, Fierro-Garibay et al. [22] in their research found periapical cysts as the most common lesion. Of note, the reason for the higher incidence of radicular cysts could be their origin secondary to dental caries and trauma. In the current study, in terms of compatibility rate, Nasopalatine and Aneurismal bone cysts had the highest rates of compatibility in cystic bone lesions, which may possibly be due to the less prevalence of these lesions, their specific radiological appearance, and the site of occurrence that make their diagnosis easier.
In this study, exophytic lesions were ranked in the third place in terms of consistency, in which the group of excitatory lesions with the highest frequency had the highest concordance rate. In these reactive lesions, Mucocele mostly have the highest clinical diagnosis. The reason for this high adaptation can be explained with the specific location and history presented by the patient with the filling and emptying of the mucosal lesion and the clinical picture. However, in terms of frequency, the most irritating lesions were found to be related to fibroma lesions, which is justifiable, because the oral cavity is normally subjected to numerous stimuli that can lead to the development of fibroma-irritated lesions in the oral mucosa. According to the findings of our study, squamous cell carcinoma was observed as the most malignant tumoral lesion with a concordance rate of 79%. In line with this finding, several studies have also reported this lesion as the most common form of oral malignancies in South Asia [23, 24].
In both ulcerative and vesiculobullous lesions, we found Pemphigus vulgaris as the most frequent oral condition with a concordance rate of approximately 74%. However, compared to the results of the study by Goyal et al. [20], a higher percentage of agreement exists between clinical and histopathological diagnoses of pemphigus vulgaris (as 94.%). These inconsistent findings may possibly be due to differences in subjects and the clinicians’ knowledge and experiences.
As stated earlier, several investigations conducted on the compatibility of clinical and pathological diagnoses have reported varying compatibility rates as their results. Patients may suffer from irreversible harms as results of incorrect diagnosis. For example, poor treatment of malignant tumors with clinical features that resemble benign lesions might consequently result in serious implications for the patient, including death. Since the correct clinical or pathological diagnosis of lesions is closely linked to both knowledge and educational level of clinicians, it is critical to redesign students’ educational programs totally and then improve them. In order to avoid diagnostic errors, physicians and dentists should also take thorough histories of patients and then transmit them to pathologists, besides following proper and standard procedures when taking biopsies.
Limitations
One of the limitations of this study was sampling process performed in a single pathology center. Another limitation of the study was incomplete patients’ records.