Dental professionals play an important role in diagnosing and treating oral lesions. Since many oral lesions share similar clinical features, relying solely on clinical diagnosis without histopathological confirmation may lead to misdiagnosis and subsequent adverse outcomes, particularly for precancerous or cancerous lesions.1
To prevent such misdiagnosis, the American Academy of Oral and Maxillofacial Pathology (AAOMP) recommends that all “abnormal tissue be submitted promptly for microscopic evaluation and analysis,” highlighting histopathology as the gold standard for achieving a definitive diagnosis.1
Previous studies show that clinical diagnosis of oral and maxillofacial lesions is often inaccurate. One study found that nearly one-third of diagnoses made by general dental practitioners were incorrect. Research indicates that diagnostic accuracy improves when clinicians carefully examine patients, take thorough histories, and clearly describe lesions using standardized terminology. Studies comparing clinical and histopathological diagnoses report agreement rates ranging from about 50% to 81%.1
To further examine this variability, a study was conducted to measure the agreement between clinical diagnoses of oral and maxillofacial lesions and the corresponding histopathological findings in cases submitted to the Oral Pathology Central Laboratory at the King Abdulaziz University Faculty of Dentistry (KAUFD) and the University Dental Hospital (UDH). The study also sought to identify provider characteristics, such as professional rank and specialty, that may influence diagnostic accuracy.1
The Study
This descriptive, retrospective study analyzed data from 858 patients treated between 2018 and 2022. All included patients had oral or maxillofacial lesions that required biopsy and received a histopathology diagnosis. There were no age limits, and informed consent was obtained from all patients or guardians.1
Inclusion criteria required a complete clinical file, a definitive histopathologic diagnosis, and lesions confined to oral and maxillofacial tissues, including bone, connective tissue, glandular tissue, and/or mucosal tissue. Cases were excluded if the diagnosis originated from an outside institution or if the lesions were located outside the oral or maxillofacial region.1
Data collected included patient demographics, lesion characteristics, and both the clinical and histopathological diagnoses. Provider information, such as years of experience and professional rank, was also recorded.1
The Results
The primary outcome was the level of agreement between the clinical and histopathological diagnoses. The secondary outcome identified factors influencing diagnostic accuracy, including patient variables, lesion features, and provider experience.1
The largest source of referrals was consultants (59.2%), followed by postgraduate students (26.1%), residents (11.3%), and undergraduate students (3.4%). Furthermore, 58.9% of all referrals originated from dentists with 5 or more years of experience. Among specialist referrals, nearly half (45.1%) were made by oral surgeons, while endodontists accounted for approximately one quarter (22.6%).1
The patients’ mean age was 37 years, with a balanced sex distribution (approximately 50% male, 50% female). While the floor of the mouth was the least common site (0.4%), the most common lesion sites were the mandible (34.6%), the maxilla (26.2%), and the buccal mucosa (11.2%).1
The three most frequent histopathological diagnoses were cystic lesions (25.2%), inflammatory lesions (21.6%), and reactive/adaptive lesions (15%). Overall, the clinical diagnosis matched the histopathological findings in 44.1% of cases, with Cohen’s kappa analysis indicating moderate agreement between the clinicians and the pathology report. Diagnostic accuracy was highest for lesions on the ventral surface of the tongue (71.4%) and the lips (52.6%).1
Neither patient age nor sex correlated with clinical diagnostic accuracy. While years of experience had no measurable effect on success rates, diagnostic success was significantly associated with the provider’s rank and specialty. For instance, diagnoses made by oral surgeons were 1.6 times more likely to match histopathological diagnoses than those of other specialties, after adjusting for provider characteristics. Odontogenic tumors exhibited the highest diagnostic match rate at 72.7%, whereas inflammatory and miscellaneous lesions proved statistically more challenging to diagnose accurately.1
Limitations
This study has some limitations that should be considered. Its single-center focus may affect the generalizability of the findings, and, as a cross-sectional and observational study, it is subject to the biases inherent in such research designs. The cohort’s heterogeneity – including a wide range of lesion types and non-standardized biopsy methods – may also have affected diagnostic consistency. Additionally, because nearly half of the biopsies were performed by oral surgeons, the results may not fully represent cases typically encountered by general dental practitioners. Finally, some biopsies did not yield a definitive histopathological diagnosis, making it impossible to compare those cases with the clinical diagnoses.1
Conclusion
Clinical diagnoses matched histopathological findings in only 44.1% of cases, with disagreement observed in nearly 56%. This finding, which aligns with previous literature, strongly suggests that reliance on clinical diagnosis alone is insufficient. Odontogenic tumors had the highest clinical accuracy, followed by benign mesenchymal lesions, while inflammatory and miscellaneous lesions were more challenging to diagnose correctly.1
The most common biopsied sites were the mandible, maxilla, and buccal mucosa, though the floor of the mouth showed the highest disagreement rate, albeit in a small number of cases (4 out of 858). Better diagnostic agreement was observed among oral surgeons and consultants, likely due to greater exposure and specialized training. Notably, years of experience alone did not correlate with accuracy, underscoring the need for educational curricular review and the importance of continuous training.1
Ultimately, histopathological examination remains essential for accurate lesion identification. Clinical diagnosis should not be relied upon alone – especially given that 58% of malignancies were clinically misdiagnosed – as the consequences for incorrect treatment and patient outcomes could be serious. Conversely, incorrectly diagnosing a benign lesion could lead to unnecessarily invasive treatment. For example, misdiagnosis of a radicular cyst as an invasive odontogenic tumor can lead to unnecessary invasive surgery and the loss of part of the jaw or the jaw entirely.1
Minimizing misdiagnoses is not only essential for patient outcomes but could also improve cost efficiency and shorten the time to definitive treatment. To improve early detection and diagnosis, clinicians should take thorough patient histories, follow proper biopsy procedures, and consult with pathologists to avoid diagnostic errors. Diagnostic disagreement may also be reduced through standardized biopsy documentation and regular clinicopathological discussions when diagnoses differ.1
To address remaining gaps, the authors recommend additional multicenter studies to better understand the factors influencing clinical misdiagnosis. Future research should also examine how clinician training affects diagnostic accuracy and evaluate how diagnostic disagreement impacts clinical outcomes and patient quality of life.1
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Reference
1. Sindi, A.M., Aljohani, K. Agreement Between Clinical and Histopathological Diagnoses of Oral and Maxillofacial Lesions and Influencing Factors: A Five-Year Retrospective Study. Clin Cosmet Investig Dent. 2024; 16: 273-282. https://pmc.ncbi.nlm.nih.gov/articles/PMC11366236/
