Implementation notes
Once an abnormal mucosal finding is identified in PHC, referral for further evaluation should follow clear criteria based on simple risk-stratification tools and visual assessment guidelines appropriate for PHC clinicians. The threshold for referral may be supported by telediagnosis services, which can include remote specialist consultation or image-based assessment, helping reduce unnecessary referrals in settings where specialist access is limited.
The absence of specialists within a given health service should not constitute a barrier to diagnosis. However, structural barriers such as travel distance, financial constraints, and limited appointment availability should be considered, and telediagnosis can assist in prioritizing cases and guiding referral pathways, even though it cannot fully overcome access barriers.
When biopsy is indicated, it should preferably be performed by a specialist in Oral Medicine (Stomatology) or Oral Pathology, or by a trained general dental practitioner, depending on local capacity. Histopathological diagnosis should ideally be conducted by an Oral Pathology specialist; in settings lacking laboratory capacity, telediagnosis can support case triage and linkage to reference laboratories, although it does not replace the need for histopathological processing.
Following diagnosis, referral pathways should reflect the nature of the diagnosis: confirmed cancer cases should be directed to oncology services (Head and Neck Surgery), while OPMDs require follow-up in specialized dental clinics. Clear documentation checklists, referral and counter-referral mechanisms (structured communication back to PHC regarding diagnosis and management plans), and defined time benchmarks for each phase of care are essential to minimize delays across the continuum — from detection to referral, biopsy, diagnosis, and treatment. Universities and teaching hospitals can support the development and integration of these pathways within each region or country.
