Received Date : 26-Aug-2016

Revised Date : 30-Sep-2016

Accepted Article
Accepted Date : 19-Oct-2016

Article type : Original Article

Title: WhatsApp is an effective tool for obtaining second opinion in oral pathology
practice

Running head: WhatsApp and Oral Pathology

Sachin C Sarode1 (BDS, MDS, PhD), Gargi S Sarode1 (BDS, MDS, PhD), Rahul Anand1
(BDS, MDS), Shankargouda Patil2 (BDS, MDS), Hemant Unadkat3 (BDS, MS, PhD)

1 Department of Oral Pathology and Microbiology

Dr. D.Y. Patil Dental College and Hospital
Dr. D.Y. Patil Vidyapeeth,
Sant-Tukaram Nagar, Pimpri
Pune: 411018

2 Department of Maxillofacial Surgery and Diagnostic Sciences,

Division of Oral Pathology
College of Dentistry,
Jazan University,
Jazan, Kingdom of Saudi Arabia.

3
Clinician Scientist and Principal Investigator
National Dental Centre of Singapore
5 Second Hospital Avenue,
Singapore 168938

Corresponding author:
Prof. Dr. Sachin Sarode
Department of Oral Pathology and Microbiology
Dr. D.Y. Patil Dental College and Hospital
This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jop.12515
This article is protected by copyright. All rights reserved.
 Dr. D.Y. Patil Vidyapeeth,
Sant-Tukaram Nagar, Pimpri
Pune: 411018
Accepted Article
Mob. No: 9922491465
Email: drsachinsarode@gmail.com

Conflict of interest: None declared

Funding source: Nil

Title: WhatsApp is an effective tool for obtaining second opinion in oral pathology
practice

Abstract:

Background: The aim of the present study was to find out the efficacy of WhatsApp
application for obtaining second opinion on histopathological diagnosis in oral
pathology practice.

Methods: A total of 247 cases comprising of 34 different oral pathologies were

photomicrographed using smartphone cameras through compound microscopes and
sent for second opinion diagnosis (SOD) to 20 different oral pathologists using
WhatsApp.

Results: Out of 4795 (97.06%) total second opinion received, correct SOD was received
for 4710 (98.22%) cases. 100 % times correct SOD was received for lesions including
adenomatoid odontogenic tumor, keratinizing cystic odontogenic tumor, odontome,
dentigerous cyst, etc. Lesions such as myoepithelial carcinoma, osteosarcoma,
fibrosarcoma and intravascular papillary endothelial hyperplasia received less
percentage of correct SOD (85.71 to 75.75%). Correct SOD was obtained for variants of
ameloblastoma (99.01%), grading of epithelial dysplasia (87.54%) and squamous cell
carcinoma (95.26%). A positive correlation was observed between correct SOD and age
(p = 0.0143) and experience (p = 0.0189) of the pathologist. The time taken for giving
second opinion by the pathologists ranged from 81.98 ± 32.89 minutes to 90.72 ± 38.88
minutes.

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 Conclusion: Smartphone camera is a handy and efficient tool in capturing
photomicrographs from the compound microscope. Transfer of such photomicrograph
via WhatsApp is an effective and convenient approach in procuring second opinion on
Accepted Article
histopathological diagnosis of oral pathologies.

Keywords: Oral pathology; Smartphone; Photomicrograph; Second opinion; WhatsApp

Introduction:

Histopathology is a specialized branch of medicine, which deals with the diagnosis of

lesions based on their microscopic examination. One needs to have systematic
knowledge, training and expertise to reach to a correct diagnosis. However, it is truly
said that ‘pathologies do not read books before manifesting themselves’ and hence
exceptions are inevitable on histopathological grounds as well. Under such
circumstances, in quest of accurate diagnosis, one has to consider consulting the other
pathologists for second opinion diagnosis (SOD) where diagnostic challenges persist.

SOD has become a crucial aspect of day-to-day practice for histopathologists worldwide.
Usually the slides and tissue blocks are exchanged for second opinion as the pathologist
prefers to view the slides in real time. However, such practice often leads to diagnostic
delay, which could prove critical in cases of malignant lesions. It has been reported that
diagnostic delay is often associated with poor prognosis in cases of malignant
disorders.1,2

Increased use of smartphones and the endless application possibilities that have
augmented with the software applications has created a new era in clinical data
exchange among clinicians.3 WhatsApp Messenger is a cross-platform mobile messaging
application that allows the exchange of text messages, images, audio, and video
messages using the internet connection.4 A popular feature of ‘group chat’, allows
people to communicate, share images and videos over a common interface.5 Its efficacy
and utility has been demonstrated in various clinical settings. For instance, in
traumatology cases, WhatsApp has been used to establish an initial diagnosis and

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 classification of tibial plateau fractures during emergency surgery so as to instantly and
adequately seek advice regarding plastic and reconstructive surgery.6-8
Accepted Article
The configuration of smartphone camera (megapixel, resolution and zoom) varies
depending upon the brand and the model of the phone. Today, the minimum
configurations and facilities available in any smartphone camera are 5 megapixel lens,
640 x 960 pixels resolution, 5x zoom, HDR facility and autofocus. With these settings, it
is feasible to capture decent images from any binocular compound microscope. Most
importantly, many health care professionals have access to high-speed 3G or 4G
internet facility from different service providers that aid in immediate exchange of
images. With this view in mind, the present study was designed to find out the
effectiveness of WhatsApp application in the field of oral pathology for obtaining second
opinion on histopathological diagnosis.

Materials and methods:

The present study was carried out in the department of oral pathology and
microbiology at Dr. D.Y. Patil Dental College and Hospital, Pimpri, Pune, India. The
institution’s scientific and ethics committee approved the study.

WhatsApp platform: WhatsApp© (WhatsApp Inc. California, USA) is an instant

messaging application for smartphones that uses internet to share text messages,
images, video, user location, and audio messages. The version employed in this study
was 2.10 or higher.

Smartphones: 8 megapixel lens, 3x zoom and 640 x 960 pixels resolution, HDR and
autofocus facility were the minimum camera specifications available in the
smartphones used. These specifications are sufficient to capture microscopic images
from the binocular compound microscope.
Study groups: Total 30 oral pathologists participated in the present study from all over
India. All oral pathologists had Dental Council of India recognized ‘Masters in Oral
Pathology and Microbiology’ degree with a 10 years of academic experience in various

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 recognized dental colleges in India. Group A (n=10) pathologists were assigned the
work of capturing representative images from the binocular compound microscope and
sending them to pathologists from group B (n = 20). The second opinion diagnoses
Accepted Article
obtained from Group B pathologists were compared with the original final diagnoses of
the cases.

Photomicrograph
A total of six photomicrographs were taken for each case/slide: 1 scanner view (X50), 2
low power (X100) and 3 high power magnification (X400). However, for smaller tissues,
less than six photomicrographs were selected. The allotted pathologist from Group A
solely had selected the representative area from the slides for photomicrography. Each
captured image went through a quick screening by the designated pathologist for its
clarity. The final images were then sent to group B pathologists only after obtaining
satisfactory clear images of the slides.

Broadcast facility: In Broadcast facility, recipients receive the broadcast message like a
regular message i.e. directly in the individual chat.9 In the present study, broadcast list
was prepared which included 20 participating oral pathologists from group B. The
images and clinical information was shared via broadcast facility of WhatsApp.

Case selection:
We identified a total of 247 cases/slides of 34 oral pathologies for inclusion in the
present study. The pathologies selected were odontogenic tumors (52), odontogenic
cysts (28), malignant epithelial tumors (45), oral potentially malignant disorders (40),
salivary gland neoplasms (15), fibro-osseous lesions (8), malignant connective tissue
neoplasms (5), benign connective tissue neoplasms (8) and others (46) (Table 1).
Twenty four to twenty five cases of each lesion were randomly allotted to 10 different
pathologists from group A. Each pathologist was asked to acquire six photomicrographs
of each slide/case on his/her smartphone as described above. All the captured
photomicrographs by group A pathologists were sent to group B pathologists using
Broadcast facility of WhatsApp. The photomicrographs were accompanied by a brief
clinical and demographic description of the patient such as age, sex, site, clinical
presentation, duration etc. In cases of leukoplakia and oral squamous cell carcinoma,

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 along with the SOD, pathologists were requested to do additional histopathological
grading of the lesions. In the end, each pathologist from group B received 247 cases for
SOD.
Accepted Article
Time period
The precise time of uploading of photomicrographs and the message received for
second opinion was noted. The time interval between the two was considered as the
time required for obtaining the second opinion (Figure 1 and 2). The photomicrographs
of the selected cases were shared with the pathologists for SOD over a period of 2
months.

Statistical analysis:
The comparison of mean time required for SOD between different oral pathologies was
done using ANOVA and unpaired ‘t’ test. Pearson Correlation Coefficient test was used
to study the correlation between correct SOD and experience/age of the oral
pathologists. All statistical analysis was done using GraphPad Prism 7 and p < 0.05 was
considered as statistically significant.

Results and observations:

Demographic data of the pathologists

Out of total 30 pathologists, 21 were male and 9 were female (M: F = 1: 0.4). In group A,
the age ranged from 38 to 45 years, with a mean of 40.4 ± 2.22 years. While in group B,
age ranged from 30 to 50 years, with a mean age of 41.05 ± 4.46 years. There was no
statistically significant difference between the mean age of group A and group B
pathologists (p = 0.334). In group A, the total experience of the pathologists ranged
from 10 years to 17 years with a mean of 12.7± 2.16 years. Similarly, in group B, the
total experience ranged from 10 to 20 years with a mean of 13 ± 3.17 years. There was
statistically no significant difference between the mean age of group A and group B
pathologists (p = 0.395).

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 Comparison of diagnostic outcome
There were a total of 247 slides selected for SOD, which were sent to 20 different oral
pathologists. Total 4940 (247 x 20) of SOD requests were sent, out of which 4795
Accepted Article
(97.06%) opinions were received. Hundred percent of SOD were received for
ameloblastic fibroma, dentigerous cyst, radicular cyst, melanoma, oral submucous
fibrosis, Warthins tumor, adenoid cystic carcinoma, fibrosarcoma, hemangioma,
lymphangioma, squamous papilloma and mucocele. Least percentage of SOD were
received for osteosarcoma (75%) and myoepithelial carcinoma (70%). Out of 4795
(97.06%) of SOD received, 4710 (98.22%) were found to be correct SODs. The number
was significantly higher than that of wrong SOD which was just 85 (1.77%). 100%
correct SOD were received for adenomatoid odontogenic tumor, keratinizing cystic
odontogenic tumor, odontome, dentigerous cyst, melanoma, leukoplakia, oral
submucous fibrosis, lichen planus, Warthins tumor, myoepithelial carcinoma and
psammomatoid ossifying fibroma. Comparatively, lesions like myoepithelial carcinoma,
osteosarcoma, fibrosarcoma and intravascular papillary endothelial hyperplasia
received less percentage of correct SOD (85.71% - 75.75%). (Table 1) All the correct
SOD received for ameloblastoma cases, 402 (99.01%) were able to correctly identify the
histopathological variants. (Table 2) However, incorrect histopathological variant was
diagnosed for unicystic and desmoplastic ameloblastoma in 2.77% and 5.12% cases
respectively.

In cases of leukoplakia, out of 297 SOD received, 260 (87.54%) were correct for grading
of dysplasia. Most accurate SOD for grading of dysplasia was discerned for mild
dysplasia (94.20%) followed by moderate (84.03%) and severe (75%). Similarly, in case
of oral squamous cell carcinoma, out of 613 SOD received, 584 (95.26%) correct SOD
were received in accordance with the histopathological grading. Most accurate SOD for
grading of oral squamous cell carcinoma was for well differentiated (98.74%) followed
by moderately differentiated (94.46%) and poorly differentiated (80%). (Table 3)

Time period for second opinion

For total 247 cases, the time required for SOD ranged from 7 to 478 minutes with a
mean of 83.06 minutes. Maximum time was required for the SOD of odontogenic tumors
(102.2 ± 54.62 minutes) followed by malignant connective tissue tumors (89.9 ± 28.27

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 minutes), salivary gland neoplasms (86.11 ± 54.6227.65 minutes), fibro-osseous lesions
(85.56 ± 26.71 minutes), malignant epithelial tumors (83.7 ± 42.04 minutes) and oral
potentially malignant disorders (82.38 ± 28.82 minutes). Minimum time was required
Accepted Article
for the SOD of other pathologies’ group (79.59 ± 24.75 minutes) and odontogenic cysts
(81.72 ± 38.65 minutes).

Mean time required for the SOD of odontogenic tumor showed statistically significant
difference with the odontogenic cysts (p < 0.0001), malignant epithelial tumors (p <
0.0001), oral potentially malignant disorders (p < 0.0001), salivary gland tumors (p <
0.0001), fibro-osseous lesions (p = 0.0004), malignant connective tissue tumors (p =
0.0426), benign connective tissue tumors (p = 0.0014) and other pathologies (p <
0.0001).
The mean time required for the SOD of odontogenic cysts showed statistically
significant difference with the odontogenic tumors (p<0.0001). However, no significant
difference was observed with other groups of pathologies. In case of malignant
epithelial tumors, comparison with odontogenic tumors (p < 0.0001) and other
pathologies (p = 0.0116) showed statistically significant differences. Oral potentially
malignant disorders showed statistically significant results when compared with
odontogenic tumors (p<0.0001), malignant connective tissue tumors (p=0.0158),
benign connective tissue tumors (p=0.0214), salivary gland tumors (p=0.0318) and
other pathologies (p=0.0267) while the comparison with other pathologies was
statistically insignificant. Salivary gland tumors showed significant statistical difference
when compared with odontogenic tumors (p<0.0001) and other pathologies
(p<0.0001). Mean time utilized by benign connective tissue neoplasms for second
opinion showed significant results when compared to odontogenic tumors (p=0.0014),
oral potentially malignant disorders (p=0.0214) and other pathologies (p=0.0002). For
fibro-osseous lesions statistically significant results were found when compared with
odontogenic tumors’ group (p=0.0014) and other pathologies’ group (p=0.0086).

Oral pathologists and second opinion

All the pathologists were able to give correct SOD for more than 96% of second opinion
cases. More than 99% of correct SOD was received from 3 pathologists (99.18% -
100%). The lowest percentage of correct SOD was 96.69%.

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 The percentage of correct SOD received was correlated with the age and experience of
the pathologists. A strong positive correlation was observed between correct SOD and
age of the pathologists (R = 0.538; p = 0.0143). However, moderate positive correlation
Accepted Article
was observed with the experience of pathologists (R = 0.5193; p = 0.0189).
Mean time taken for SOD by any individual pathologist ranged from 81.98 ± 32.89 to
90.72 ± 38.88. No statistically significant correlation of time taken by individual
pathologist was observed when compared with his/her age (R = 0.129; p = 0.415),
experience (R = 0.1819; p = 0.442) and percentage of correct SOD (R = 0.207; p = 0.379).

Discussion
Smartphones have emerged as essential tools providing assistance in patient care,
monitoring, rehabilitation, communication, diagnosis, teaching, research and
reference.10 Recently, few attempts have been made to study the usefulness of
WhatsApp technology in dental clinics. Petruzzi et al.11 studied the use of WhatsApp as a
telemedicine platform for facilitating remote oral medicine consultation and improving
clinical examination. Clinical images and related questions were submitted by general
dentists, physicians, dental hygienists and patients to the authors via WhatsApp. Zotti et
al.12 studied the usefulness of WhatsApp in improving oral hygiene compliance in
adolescent orthodontic patients.

None of the pathologists asked for additional photomicrographs for second opinion.
However, in actual practice numerous photomicrographs of various magnifications can
be captured and exchanged for obtaining SOD. In the present study, for smaller tissue
samples (especially mucosal pathologies like leukoplakia), it was possible to cover the
complete tissue area in scanner and low power magnifications.

All the SOD requests were sent using the Broadcast Facility of WhatsApp.7 We also had
the option of creating a ‘WhatsApp Group’ for 20 oral pathologists in which the message
would be visible to all the pathologists present in the group but that would have steered
into bias influencing the diagnosis. As majority of the pathologists from group B (14)
were comfortable in receiving the second opinion request privately in their chats, we
opted for the ‘Broadcast’ facility available on WhatsApp for the present study.

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 Total 4940 number of SOD request were sent, out of which 4795 (97.06%) replies were
received. The reason for abstinence to reply (2.93%) were non-availability, technical
problem, insufficient clinical information, unsatisfactory photograph quality and
Accepted Article
diagnostic uncertainty. 100% of SOD were received for ameloblastic fibroma,
dentigerous cyst, radicular cyst, melanoma, oral submucous fibrosis, Warthins tumor,
adenoid cystic carcinoma, fibrosarcoma, hemangioma, lymphangioma, squamous
papilloma and mucocele. (Table 1) Histopathological pathognomonic appearances seen
in these lesions could be one of the reasons for 100% reply for SOD. In contrast, least
percentage of SOD was received for osteosarcoma (75%) and myoepithelial carcinoma
(70%). (Table 1) Fewer number of replies in these cases could be attributed to the
lesions’ complex histopathology and rarity in their occurrences.

In the present study, out of 4795 (97.06%) total SOD received, number of correct SOD
i.e. 4710 (98.22%) was significantly higher as compared to incorrect opinions i.e. 85
(1.77%). Every time (100%) correct SOD was received for adenomatoid odontogenic
tumor, keratinizing cystic odontogenic tumor, odontome, dentigerous cyst, melanoma,
etc. (Table 1) As these pathologies are easy to diagnose because of their pathognomonic
histopathological appearances, accurate diagnoses were received consistently.
Comparatively, lesions like myoepithelial carcinoma, osteosarcoma, fibrosarcoma and
intravascular papillary endothelial hyperplasia received less percentage of correct SOD
(85.71%-75.75%). (Table 1) These lesions are difficult to diagnose because of their
rarity and confusing histopathological appearances. In actual practice, these are the
lesions, which require SOD more often than usual. Nevertheless, WhatsApp has
facilitated acquisition of fairly good percentage of correct SOD for such cases.

Out of 406 (96.66%) SOD received for ameloblastoma, 402 (99.01%) SOD were able to
identify histopathological variants correctly. (Table 2) The inaccurate histopathological
variants were diagnosed for unicystic and desmoplastic ameloblastoma in 2.77% and
5.12% respectively. These results suggested that microscopic images captured through
smartphones cameras were sharp enough to pick up the squamous and granular
metaplasia of the stellate reticulum like cells of ameloblastoma thus aiding the accurate
identification of histopathological variant of ameloblastoma.

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 Out of 297 SOD received for leukoplakia, 260 (87.54%) SOD accurately graded epithelial
dysplasia. Most accurate SOD for grading was obtained for mild dysplasia followed by
moderate and severe. Similarly, in cases of oral squamous cell carcinoma, out of 613
Accepted Article
SOD received, 584 (95.26%) correct SOD were received for histopathological grading.
Most accurate SOD for grading of oral squamous cell carcinoma was for well-
differentiated followed by moderately differentiated and poorly differentiated. (Table 3)
Although there is a lot of subjectivity associated with grading of epithelial dysplasia and
oral squamous cell carcinoma, significantly good number of pathologists was able to
identify it precisely in the present study. The mucosal biopsies of the oral cavity
especially for leukoplakia and oral squamous cell carcinoma were small in size. Hence, it
was possible to cover all the areas of the tissue section in photomicrograph with
scanner, low power and high power magnification. Thus, pathologists from group B got
a complete view of the section for arriving at an accurate histopathological grading of
leukoplakia and oral squamous cell carcinoma.

For total 247 cases, the time required for SOD ranged from 7 to 478 minutes with a
mean of 83.8 ± 39.08 minutes. Time required for conventional method for obtaining
SOD depends upon the availability, appointment and location of the consultant
pathologist. If the consultant is based in another city or state, it usually takes more time
for obtaining the SOD. Present study demonstrated the efficacy of WhatsApp in
obtaining SOD in the field of oral pathology within the shortest period of time. It is also
possible to obtain general pathology SOD from experts who are based in other cities,
state or country in a brief period of time.

It is known that WhatsApp application depresses the resolution of the image before
transmitting them to other users. In the present study, most pathologists did not find
any difficulty in the interpretation of the photomicrographs, however, in 12 (8.27%)
cases of second opinion (out of 145 non-reply), pathologists mentioned about the clarity
of the photomicrographs. We recommend that, WhatsApp should come up with the
option where in the sender has the liberty of selecting the image quality so that original
size and quality image can be shared with the receiver, which can facilitate more
accurate SOD.

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 In conclusion, present study proves the effectiveness of WhatsApp application in
obtaining the second opinion on histopathological diagnosis. Time frame required for
obtaining second opinion was minute as compared to conventional method and thus
Accepted Article
could be helpful in reducing diagnostic delay. We recommend similar studies on large
‘diagnostically difficult’ sample size, as they frequently need SOD from experts.
‘WhatsApp based SOD’ cannot match with the conventional actual slide viewing by the
pathologists. We believe that future smartphones will be equipped with more
sophisticated version of cameras that can capture morphological features with great
details thus facilitating more accurate diagnosis on the second opinion, thus totally
eliminating the conventional slide viewing modus operandi.

Conflict of interest: None declared.

Funding source: Nil.

Acknowledgement: We would like to thank all the oral pathologists who have actively
and wholeheartedly participated in the present study.

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messenger is useful and reproducible in the assessment of tibial plateau fractures:

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 Inter- and intra-observer agreement study. Int J Med Inform 2015; 84: 141-8.
7. Johnston MJ, King D, Arora S, Behar N, Athanasiou T, Sevdalis N, Darzi A. Smartphones
let surgeons know WhatsApp: an analysis of communication in emergency surgical
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teams. Am J Surg 2015; 209: 45-51.
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amongst staff members at plastic and reconstructive surgery section using
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10. WhatsApp FAQ (2016). WhatsApp.
https://www.whatsapp.com/faq/en/general/23741782 Accessed 22 March 2016.
11. Petruzzi M, De Benedittis M. WhatsApp: A telemedicine platform for facilitating
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Usefulness of an app in improving oral hygiene compliance in adolescent orthodontic
patients. The Angle Orthodont 2015; 86; 101-7.

Figure captions:
Figure 1: Second opinion request sent on broadcast facility of WhatsApp.
Figure 2: Second opinion reply from pathologist of group B (pathologist 15). The time
taken for second opinion in this case was 22 minutes.

Table captions:
Table 1: Pathologies selected for second opinion and their second opinion responses.
Table 2: Second opinions received on different histological variants of ameloblastoma.
Table 3: Second opinion on histopathological grading of dysplasia and oral squamous cell
carcinoma.

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ccepted Articl
Table 1: Pathologies selected for second opinion and their second opinion response.

Sr. Pathology Number Number Number of Correct Wrong Pathology mentioned Time taken
No. of cases of second second second second in wrong diagnosis for second
opinion opinion opinion opinion opinion
requested received (min)

Odontogenic tumors

1 Ameloblastoma 21 420 406 (96.66%) 402 (99.01%) 4 (0.98%) Details in table 2 124.12±63.56

2 Adenomatoid odontogenic tumor 3 60 58 (96.66%) 58 (100%) 0 - 83.88±51.43

3 Calcifying epithelial odontogenic 3 60 59 (98.33%) 56 (94.91%) 3 (5.08%) Primary intra-osseous 79.95±41.95

tumor carcinoma (3)

4 Keratocystic odontogenic tumor 10 200 190 (95%) 190 (100%) 0 - 82.85±38.02

5 Ameloblastic fibroma 2 40 40 (100%) 39 (97.5%) 1 (2.5%) Ameloblastoma (1) 76.25±35.21

6 Odontome 13 260 253 (97.03%) 253 (100%) 0 - 95.06±41.40

Odontogenic cysts

7 Dentigerous cyst 8 160 160 (100%) 160 (100%) 0 - 82.74±35.07

8 Radicular cyst 17 340 340 (100%) 338 (99.41%) 2 (0.58%) Unicystic ameloblastoma 82.40±39.32
(2)

9 Calcifying epithelial odontogenic 3 60 59 (98.33%) 56 (94.91%) 3 (5.08%) Unicystic ameloblastoma 75.08±40.43

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ccepted Articl cyst (3)

Malignant epithelial tumors

10 Micro-invasive squamous cell 5 100 89 (89%) 84 (94.38%) 5 (5.61%) Carcinoma in situ (4), 95.96±46.59
carcinoma Pseudo-epitheliomatous
hyperplasia (1)

11 Verrucous carcinoma 7 140 130 (92.85%) 128 (98.46%) 2 (1.53%) Verrucous hyperplasia (1), 100.56±55.9
Proliferative verrucous 1
leukoplakia (1)

12 Oral Squamous cell carcinoma 31 620 613 (98.87%) 613 (100%) 0 - 77.54±36.11

13 Melanoma 2 40 40 (100%) 40 (100%) 0 - 81.17±26.97

Oral Potentially malignant disorders

14 Leukoplakia 15 300 297 (99%) 297 (100%) 0 - 83.27±28.07

15 Oral submucous fibrosis 10 200 200 (100%) 200 (100%) 0 - 81.60±25.32

16 Lichen planus 15 300 295 (98.33%) 295 (100%) 0 - 82.01±26.60

Salivary gland neoplasms

17 Pleomorphic adenoma 5 100 91 (91%) 89 (97.8%) 2 (2.91%) Adenocarcinoma NOS (2) 88.83±26.12

18 Warthins tumor 2 40 40 (100%) 40 (100%) 0 - 85.8±27.41

19 Mucoepidermoid carcinoma 4 80 77 (96.25%) 72 (93.5%) 5 (6.49%) Adenocarcinoma NOS (4), 84.15±26.39

Salivary duct carcinoma

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ccepted Articl
20 Adenoid cystic carcinoma 2 40 40 (100%) 38 (95%) 2 (5%)
(1)

Salivary duct carcinoma 79.92±30.29

(1), polymorphous low
grade adenocarcinoma (1)

21 Myoepitheial carcinoma 2 40 28 (70%) 24 (85.71%) 4 (14.28%) Fibrosarcoma (3), 97.36±33.46

Myoepithelioma (1)

Fibro-osseous lesions

22 Fibrous dysplasia 2 40 37 (92.5%) 33 (89.18%) 4 Ossifying fibroma (4) 85.75±25.74

(10.81%)

23 Ossifying fibroma 4 80 71 (88.75%) 70 (98.59%) 1 (1.4%) Fibrous dysplasia (1) 84.02±26.53

24 Psammomatoid ossifying fibroma 2 40 33 (82.5%) 33 (100%) 0 - 88.63±28.62

Malignant connective tissue neoplasms

25 Osteosarcoma 2 40 30 (75%) 25 (83.33%) 5 (16.66%) Ossifying fibroma (3), 91.9±26.10

osteoblastoma (2)

26 Fibrosarcoma 1 20 20 (100%) 17 (85%) 3 (15%) Fibroma (3) 95.45±30.22

27 Lymphoma 2 40 33 (82.5%) 30 (90.90%) 3 (0.09%) Chronic inflammation (3) 84.72±28.95

Benign connective tissue neoplasms

28 Hemangioma 4 80 80 (100%) 75 (93.75%) 5 (6.25%) Pyogenic granuloma (5) 87.01±26.52

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ccepted Articl
29 Lymphangioma 2 40 40 (100%) 37 (92.5%) 3 (7.5%) Hemangioma (3)

Pyogenic granuloma (5),

88.15±27.48

30 Intra-vascular papillary endothelial 2 40 33 (82.5%) 25 (75.75%) 8 (24.24%) 89.39±25.60

hyperplasia fibroma (2),
hemangioendothelioma (1)

Other pathologies

31 Pyogenic granuloma 18 360 355 (98.61%) 353 (99.43%) 2 (0.56%) Hemangioma (1), fibroma 78.38±23.68
(1)

32 Squamous Papilloma 10 200 200 (100%) 195 (97.5%) 5 (2.5%) Verrucous hyperplasia (3), 79.59±23.86
verruciform xanthoma (2)

33 Mucocele 15 300 300 (100%) 300 (100%) 0 - 80.10±25.78

34 Verruciform xanthoma 3 60 58 (96.66%) 45 (77.58%) 13 Papilloma (13) 84.58±30.30

(22.41%)

Total 247 4940 4795 4710 85 (1.77%) 83.8 ±

(97.06%) (98.22%) 39.08

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ccepted Articl
Table 2. Second opinions received on different histological variants of ameloblastoma.

Sr. Pathology Total Total number of Total number of Correct Wrong Pathology mentioned
No. number of second opinion second opinion second second in wrong diagnosis
cases requested received opinion opinion

1 Follicular Ameloblastoma 8 160 158 (98.75%) 158 (100%) 0 -

2 Plexiform Ameloblastoma 3 60 59 (98.33%) 59 (100%) 0 -

3 Acanthomatous Ameloblastoma 2 40 40 (100%) 40 (100%) 0 -

4 Granular cell ameloblastoma 2 40 38 (95%) 38 (100%) 0 -

5 Unicystic ameloblastoma 4 80 72 (90%) 70 (97.22%) 2 (2.77%) Radicular cyst (1),

Dentigerous cyst (1)

6 Desmoplastic ameloblastoma 2 40 39 (97.5%) 37 (94.87%) 2 (5.12%) Squamous odontogenic

tumor (1), Primary intra-
osseous carcinoma (1)

Total 21 420 406 (96.66%) 402 (99.01%) 4 (0.98%)

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ccepted Articl
Table 3. Second opinion on histopathological grading of dysplasia and oral squamous cell carcinoma

Sr. Category Number Number of Number of Correct Wrong Type of Wrong grade given
No. of cases second second grading grading
opinion opinion
requested received

1 Leukoplakia

Mild 7 140 138 (98.57%) 130 (94.20%) 8 (5.79%) No dysplasia (5), Moderate (3)

Moderate 6 120 119 (99.16%) 100 (84.03%) 19 (15.96%) No dysplasia (3), mild (12), severe (4)

Severe 2 40 40 (100%) 30 (75%) 10 (25%) mild (1), moderate (9)

Total 15 300 297 (99%) 260 (87.54%) 37 (12.45%)

2 Oral squamous cell carcinoma

Well 16 320 318 (99.37%) 314 (98.74%) 4 (1.25%) Moderate (4)

Moderate 12 240 235 (97.91%) 222 (94.46%) 13 (5.53%) Well (11), poor (2)

Poor 3 60 60 (100%) 48 (80%) 12 (20%) Moderate (12)

Total 31 620 613 (98.87%) 584 (95.26%) 29 (4.73%)

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Accepted Article

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Accepted Article

This article is protected by copyright. All rights reserved.