Journal of Oral and Maxillofacial Pathology

: 2007  |  Volume : 11  |  Issue : 2  |  Page : 86--88

Proceedings of the panel discussion on 'Standardized Reporting of Oral Epithelial Dysplasia'

Vinay Hazarey1, Dinesh Daftary2, Alka Kale3, Saman Warnakulasuriya4,  
1 Department of Oral Pathology, Government Dental College Nagpur, India
2 Formerly Oral Pathologist, Tata Institute of Fundamental Research, Bombay, India
3 Department of Oral Pathology, J N Dental College, Belgaum, India
4 Department of Oral Medicine, King's College, London, Dental Institute at Guy's, King's & St. Thomas' Hospitals, London and World Health Organization (WHO) Collaborating Centre for Oral Cancer/Precancer, London, United Kingdom

Correspondence Address:
Vinay Hazarey
Department of Oral Pathology, Government Dental College Nagpur

How to cite this article:
Hazarey V, Daftary D, Kale A, Warnakulasuriya S. Proceedings of the panel discussion on 'Standardized Reporting of Oral Epithelial Dysplasia'.J Oral Maxillofac Pathol 2007;11:86-88

How to cite this URL:
Hazarey V, Daftary D, Kale A, Warnakulasuriya S. Proceedings of the panel discussion on 'Standardized Reporting of Oral Epithelial Dysplasia'. J Oral Maxillofac Pathol [serial online] 2007 [cited 2022 Jul 1 ];11:86-88
Available from:

Full Text

Reporting of dysplasia along with clinical presentation and patient-related factors helps in determining the risk status of potentially malignant oral lesions. However, there is still a lack of uniformity among oral pathologists in reporting oral epithelial dysplasia (OED). In this background, a panel of specialists discussed 'Standardised Reporting of Oral Epithelial Dysplasia' at the 15 th annual meeting of the Indian Association of Oral and Maxillofacial Pathologists (IAOMFP) held at Chennai in December 2006. This project was facilitated by the World Health Organization (WHO) Collaborating Centre for Oral Cancer and Precancer, UK, an organization committed to the clinical calibration of potentially malignant disorders [1] as well as the histopathological calibration of oral epithelial dysplasia. [2]

The panelists were Dr. Vinay Hazarey (VH), Department of Oral Pathology, Government Dental College, Nagpur, India; Dr. Dinesh Daftary (DD) oral Pathologist, Formerly with the Tata Institute of Fundamental Research (TIFR), Bombay, India; Dr. Alka Kale (AK), Department of Oral Pathology, JN Dental College, Belgaum, India and Dr. Saman Warnakulasuriya (SW), Department of Oral Medicine, King's College, London, UK, Dental Institute at Guy's, King's and St. Thomas' Hospitals, London, UK and WHO Collaborating Centre for Oral Cancer/Precancer, London, UK.

DD: Recognition of precancerous potentiality of certain oral lesions came into existence based on clinical and statistical considerations. Dysplasia being a prognostic evaluation could be regarded a seemingly abnormal island in an ocean of normality. In the broadest sense, the question raised was "Why is dysplasia feared the world over?" One could make the assumption that if an epithelium shows two or more features of the histological criteria of malignancy and is consequently followed for a sufficient amount of time, it would show the remaining characteristics, by which time, it shall be termed as a carcinoma. Even though some oral keratoses could transform into malignancy in the absence of dysplasia, dysplasia still remains the most common pathway to malignancy. So, it pays to expect and suspect OED in potentially malignant disorders and if present, confirm and treat any dysplasia if possible. The recording of oral dysplasia is both a science and art in its own right. Quantification of the microscopic features allows grading of dysplasias as 'mild', 'moderate' or 'severe'. DD described the various stages of dysplasia as varying moods of OED i.e progressive, static, regressive and carcinomatous. From the follow-up studies conducted by the TIFR group, dysplastic lesions appear to have 15 times greater malignant transformation risk than nondysplastic lesions [Table 1]. Dysplasia is probable in the absence of an irritant, could be associated with habits and due to the presence of inflammation in the lamina propria. Another confounding factor is the presence of Candida spp. on the epithelium. Considering the interplay of such factors in reporting dysplasia, there is a crying need to evolve a consensus of principles and practice.

VH: The question is 'Does the Ljubljana classification used for grading laryngeal dysplasia [3] work for oral dysplasias?' This classification attempts to provide distinction between abnormal hyperplasia which does not require treatment and atypical (risky) hyperplasia which needs to be carefully monitored. Categories recognized in grading the pathology of squamous intraepithelial lesions (SILs) are simple hyperplasia, atypical hyperplasia and carcinoma in situ .

AK: A pilot study was carried out by five oral pathology centers on the consensus of reporting on a set of precirculated pathology slides. This study sought to achieve external quality assurance and to plan a way forward for the academy to set up and uniformly monitor calibration by oral epithelial dysplasia oral pathologists and particularly trainees. For this exercise, the Smith and Pindborg's grading system [4] was used. The results of the study highlighted the areas of agreement or disagreement while scoring atypia using this system. Interobserver variations were noted necessitating further research to minimize such variations in pathology reporting by reaching a consensus n criteria used for scoring.

SW: The various assumptions made by oral pathologists in interpreting dysplasia reports are that dysplasia is related to progression to cancer, dysplasia is due to mutations and that greater the dysplasia, greater is the risk for transformation. Thus, dysplasia is only a surrogate for predicting risk but is still relevant and it is only one part of the assessment of precursor lesions.

The demerits of the Smith and Pindborg atypia scoring system such as scores for categories being allocated subjectively by authors and the difficulty in obtaining the Smith and Pindborg monograph, necessitated a standardized system that improves consistency of interpretation of cellular atypia. This is presented in the new WHO system of classification [5] published in 2005.

The epithelium of precursor lesions may be thick but is often atrophic in the mouth. By definition, there is no evidence of invasion. The magnitude of surface kerataosis is of no importance in dysplasia assessment. Allocation to categories within each of the classifications requires consideration firstly of architectural features and then of cytology.

Dysplasia: The term "dysplasia" applies when an architectural disturbance is accompanied by cytologic atypia (variations in the size and shape of the keratinocytes). Criteria used for diagnosing oral epithelial dysplasia are listed in [Table 1]. These features could be broadly categorized as changes to the architecture (strata) of the epithelium and those that manifest as cellular atypia. [6] The concept that "the more prominent or numerous they are, the more severe the grade of dysplasia" was stressed by a series of photomicrographs.

Conventionally, dysplasia is divided into grades of mild, moderate and severe. However, dysplasia as a concept represents a spectrum of change rather than discrete identifiable stages. It seems probable that the lack of guidelines in interpretation contribute to the inconsistent assessments.

The first question to be addressed when dysplasia is present is "when do overall changes in cellular compartments such as hyperplasia or atrophy progress to dysplasia"? Next, pathologists need some guidelines to improve consistency in interpreting transitions in the grades of severity of dysplasia.

 Grades of Dysplasia

Mild dysplasia: Disturbance in architecture limited to the lower third of the epithelium, accompanied by minimal cytological atypia.

Moderate dysplasia: Disturbance in architecture extending upto the middle third of the epithelium is the initial criterion. Consideration is further given to the degree of cytological atypia. The presence of marked atypia may indicate that a lesion should be categorized as severe dysplasia despite not extending into the upper third of the epithelium. Alternatively, lesions with mild atypical features extending into the middle third of the epithelium may merit being graded as mild dysplasia.

Severe dysplasia: Recognition of severe dysplasia starts with greater than two thirds of the epithelium showing disturbance in architecture with associated cytologic atypia. However, as noted before, disturbance in architecture extending into the middle third of the epithelium with sufficient cytologic atypia is graded as severe rather than moderate dysplasia.

This concept of giving priority to the disturbance in architecture followed by the degree of cytological atypia to score the overall dysplasia, is illustrated in [Table 2].

There are few longitudinal studies that examine the cancer risk in different grades of dysplasias. However, there is agreement that the status of dysplasia does provide a useful predictive marker for the management of these potentially malignant disorders.

The assessment of precursor lesions remains a difficult area for the histopathologist. Much of this reporting is subjective and external quality assurance is of value. This workshop has attempted to update our thinking with regards to morphological interpretation of precursor lesions and to establish a means of standardizing the reporting on OED by oral pathologists in India. There is no doubt that the largest pool of oral precancers being investigated at a given time in India is due to high-risk chewing and tobacco habits in the population. It is therefore proposed that the academy will set up and monitor calibration of oral pathologists and particularly the trainees in a uniform way to report on oral epithelial dysplasia in the future.


1Warnakulasuriya S, Johnson NW, van der Wall I. Nomenclature and classification of potentially malignant disorders of the oral mucosa. J Oral Pathol Med 2007;36:575-80.
2Warnakulasuriya S, Reibel J, Bouquot J, Dabelsteen E. Oral epithelial dysplasia classification systems: Predictive value: Utility, weaknesses and scope for improvement. J Oral Pathol Med 2007;36.
3Gale N, Kambic V, Michaels L, Cardesa A, Hellquist H, Zidar N, et al. The Ljubljana classification: A practical strategy for the diagnosis of laryngeal precancerous lesions. Adv Anat Pathol 2000;7:240-51.
4Smith CJ, Pindborg JJ. Histological grading of oral epithelial atypia by the use of photographic standards. Copenhagen: C. Hamburgers Bogtrykkeri; 1969.
5World Health Organization. Classification of Tumours. Pathology and Genetics. Head and Neck Tumours. International Agency for Research on Cancer (IARC). In : Barnes L, Eveson JW, Reichart P, Sidransky D, editors. IARC Press: Lyon; 2005. p. 177-80.
6Speight P, Farthing PM, Bouquot JE. The pathology of oral cancer and precancer. Curr Diagn Pathol 1996;3:165-76.