Guide to epidemiology and diagnosis
of oral mucosal diseases and conditions
W O R L D HEALTH ORGANIZATION*
INTRODUCTION
The Oral Health Surveys Manual (OHS) (5) and
the International Classification of Diseases: Appli-
cation to Dentistry and Stomatology (ICD-DA) (1)
have been developed in the epidemiology
subprogramme of WHO's Oial Health Unit to
provide respectively:
(i) a systematic appioach to the collection and
reporting of comparable data on the most common
oral diseases and conditions for use in planning and
evaluating otal health programmes and in identi-
fying importani research potentials,
(ii) a basis for standard, detailed classification
and coding of all oral conditions and diseases,
irrespective of their rare or frequent occurrence.
The first of these, on basic methods that were
recommended for ttse in oral health surveys, was
published in 1971. In this manual emphasis was
placed on the assessment of the two most prevalent
oral diseases: caries and gingival or periodontal
disease. In addition, some guidance was given on
the recognition and recording of certain dento-
iacial anomalies and of a few diseases of the oral
mucosa. This manual was updated in 1977.
A complementary manual, the Guide to Oral
Health Epidemiological Investigations, provides
methods for use in situations where more detailed
information on a condition or disease is required,
than can be collected using the methodology of the
basic manual.
As a companion to the ICD-DA, the objective of
the present guide is to provide a standard system for
the examination, identification and recording ofa
wider range of oral mucosal conditions: in partic-
ular, those that have significant implications in
* This guide was prepared by Professor I. R. H. Kramer,
Eastman Dental Hospital, London; Professor J. J. Pindborg,
Royal Dental College, Copenhagen; and V. Bezioukov and
J. Sardo Inlirri of the Oral Health, WHO, Geneva.
0301-5661/80/010001-26S02.50/0© 1980 Munksgaard, Copenhagen
relation to urgent needs for treatment or for
prevention. Some other, less important, conditions
are referred to where there is relevance for differ-
ential diagnosis.
The Guide is intended for dentists and physicians
who may need to conduct such surveys and who are
not specialists in oral diagnosis or epidemiology.
Those who aie already fully experienced in the
diagnosis of lesions of the oral mucosa may find
useful the recommendations relating to systernatic
examination, topography and recording.
It is accepted that accutate diagnosis cannot be
fully achieved on the basis of clinical examination
alone: commonly, laboratory investigations such as
examination ofa smear, cytology or a biopsy would
be desirable in order to confirm a clinical diagnosis.
However, for survey purposes, clinical examination
may be all that is possible, and lesions that conform
closely to the criteria outlined in this manual are
very likely to belong to the indicated diagnostic
category.
The specific aims of this manual are:
(1) to provide a systematic approach to the
collection and reporting of data on oral mucosal
lesions;
(2) to encourage dental health personnel in all
countries to perform systematic epidemiological
assessment of oral mucosal diseases as a basis for
planning and evaluating oral health programmes
and especially for the prevention and earlier diag-
nosis of pi-ecancerous lesions and oral cancer.
To achieve these aims the manual provides:
(l) a description of standard survey procedures
for the diseases and conditions described in the
manual including guidance on survey planning
and detet-mination of sample size;
(ii) concise descriptions of the main clinical
features of each condition dealt with by the manu-
al, as classified in the ICD-DA;
 WORLD HEALTH ORGANIZATION
(iii) a standardized topography of the oral cavity
with associated definitions of boundaries and struc-
tures and standard procedures for examination and
recording;
(iv) recommendations for post survey actioti and
reporting the results.
SURVEY PLANNING
DETERMINATION OF OBJECTIVES
The objectives of a study determine the kinds of
data that will be needed and the form in which they
should be collected.
The final objectives must be kept clearly in mind
while selecting oral health assessments for inclusion
in a study to ensure that each piece of information is
definitely necessary for planning, evaluation or
research purposes.
The methods described in this manual can be
used to obtain data for the following purposes:
(1) estimating the prevalence of specific oral
mucosal diseases and conditions and identifying
variations in local, regional or national groups;
(2) supplying data which can assist public health
authorities to determine priorities with respect to:
(a) health education, preventive and treatment
services;
(b) the groups in most urgent need of treatment
(oral precaneerous conditions and cancer);
(,3) evaluating possible etiological factors in the
development of oral mucosal cancer.
SELECTING THE SAMPLE
To obtain valid data on oral mucosal diseases and
conditions it may be possible to examine the entire
adult population of a certain area. However,
normally this is not possible and the data will
have to be based on a sample. In this case care
should be taken to include sufficient subjects in the
sample according, to a carefully designed plan, to
ensure that the sample is representative of the
population being studied and that the results are
free from avoidable bias. Investigators are caution-
ed that in some populations there is a tendency for
patients with some severe conditions to withdraw
from the community. It is therefore important to
collect information about each group or com-
munity to be included in the survey to ensure that
such subjects will not be excluded from the sample.
However, there will be some situations in which
neither examination of the entire population is
possible nor will a sample provide valid data
because occurrence of a disease or condition is so
rare that it is unlikely that a survey would ever
include a single case. In such cases the only feasible
solution is to maintain a clinical recording system
within the general health care system.
In order to decide how many and which people
or groups to include in the sample, it is very useful to
discuss the survey planning with a health statistician, if
possible the one who will be responsible for the
analysis of the results. If adequate statistical help is
not available, assistance may be requested from the
Oral Health Unit of the World Health Organiza-
tion. The checklist for survey planning (see Annex
1, page 26) obtainable from WHO, should be
completed and sent to the Oral Health Unit of the
World Health Organization when requesting as-
sistance (see p. 7).
The determination of the sample size for an
investigation will depend on the exact objectives of
the survey. A 'prevalence' survey of a population
which includes many ethnic, dietary or geographi-
cal groups usually requires a rather large sample of
the order of 5000 - 10000 subjects including
sufficient numbers of individuals from each of the
relevant subgroups of the population. An investiga-
tion of the influence of one or two factors of diet or
of an oral habit previously identified as relevant, in
a defined population, may require relatively small
numbers, perhaps between 200 and 300 carefully
selected srtbjccts.
This section discusses the general factors in-
volved in determining the sample size and the
constraints imposed upon the investigator by these
factors and others such as finance and availability
of personnel: examples of sample size determina-
tion for given precision and confidence levels are
included.
GENERAL INFORMATION NEEDED FOR THE
CALCULATION OF SAMPLE SIZE FOR ESTIMATING
PREVALENCE
The basic information required for calculating the
necessary sample size, in addition to the objectives
of the study, is:
(a) the expected prevalence of the condition(s)
being surveyed;
(b) an estimation of the amount of heterogeneity
in the population;
(c) the required precision of the results;

(d) the necessary confidence level,
(a) The expected prevalence ofa lesion or condition
m a y be estimated using data from previous studies
or from studies in other similar countries.
(b) The heterogeneity within the population - Factors
such as urban or rural environment, religious
practices, dietary habits and occupation may in-
fluence the prevalence of diseases and demand for
services. In addition it has been demonstrated that
some oral habits (e.g. smoking and pan* or tobacco
chewing) have an important influence on preval-
ence of oial mucosal diseases. As there are some-
times considerable differences between communi-
ties or groups in their exposure to some of these
factors, the usual practice in simple prevalence
surveys is to stratify the population according to the
groups considered most important and to sample
numbers of subjects proportionate to the size of
eaeh stratum. The results should then be weighted
using census figures when these are available and
recent; or the results reported as a proportion, i.e.
number of cases per 1000 subjects examined, for
each important sub-group of the population. In
contrast to dental caries or periodontal diseases, for
which there is only a small difference in disease
prevalence between the sexes, there may be con-
siderable differences between the sexes in exposure
to different factors such as occupational hazards or
oral habils and it is thereibi-e essential to record the
sex of each subject and to survey approximately
equal numbers ofeach.
(c) The precision required of the results - M e a n scoresigative follow-up as a certain percentage progress
or averages based on observations of a sample are
only estimates of the true population values. They
really indicate to an investigator that the true
population mean or average is likely to lie between
certain limits on either side of the estimate. These
limits can be calculated by statistical procedures.
In general the narrower the limits required, (i.e. the
higher the precision) the larger the sample will
need to be.
The acceptable or recjuired precision levels in
dental epidemiological investigations range be-
tween 5% and 20% of the prevalenee found,
depending on the survey objectives, methods and
on the actual disease pi'evalence. For the rather low
prevalence rates of the more important oral lesions
* A preparation of betel {Areca catechu) nut and lime rolled in
betel leaf.
Guide to epidemiology
(e.g. leukoplakia, range 3-8%) a precision of± 10%
would be the most practical size acceptable. For
conditions like oral cancer that occur with a
prevalence of 0.01 to 0.05 per hundred (i,e, 10-50
cases per 100000 population), the same level of
precision would be unattainable from a survey
approach. In fact, to obtain data on oral cancer
with this level of precision the only feasible solution
is to maintain an accurate recording system, based
on the ICD-DA, within a national health service, as
the sample size needed to estimate prevalences of
this order to an accuracy of + 1 0 % is approximately
2 million persons. When a recording system for
these diseases is to be instituted at national or
provincial level, simple recording forms for routine
registration of oral diseases should be designed so
that computer sutnmarization is possible, using
either local or external facilities.
(d) The confidence level is an estimate oi the
reliability of the survey results and is the percentage
of titnes that the investigator may expect to find
that the true mean lies between the stated limits if
the survey were repeated a large number of times.
In most prevalence surveys a 95% confidence level
is appropriate. However, there may be very speeial
occasions, for example, when comparisons between
groups are being made, that a higher degree of
precision might be required.
The following examples of the determination of
sample sizes are for surveys estimating leukoplakia,
this being one of the lesions whieh requires invest-
to oral cancer. Surveys of oral mucosal conditions
will normally include a range of different lesions,
each with a dilferent prevalence, and it is conve-
nient to use the estimated or expected prevalenee oi
leukoplakia to determine the overall sample size for
a general pt evalence study. The sample size chosen
will then give valid figures for conditions as com-
mon as leukoplakia, or more common. It will then
be necessary to calculate precision and confidence
levels for the other conditions measured in the
survey. However, it must be remembered that for
lesions as rare as oral cancer no statistically valid
figure can be obtained from a survey approach.
As can be seen from Tables 1 (A) and (B), the
sample sizes for the different prevalence figures
vary considerably according to the specified preci-
sion and confidence levels. Note the very large,
virtually prohibitive, numbers of subjeets necessary
 WORLD HEALTH ORGANIZATION

Table 1(A)*. Sample sizes for diflerent prevalence rates at at the 95 % confidence level (see T a b l e 1 A). If in fact
fwo precision levels±5% and + 10% for 95% confidence level the survey d e m o n s t r a t e d that the prevalence was
Estimated prevalen- Precision + 5% Precision+!0% 8%, then the level of precision a t t a i n e d would be
ee in population m u e h higher; the actual level of precision can be
2% 80000 20000 determined from s t a n d a r d tables of confidence
3% 45000 10000 intervals for binomial proportions. In the e x a m p l e
4% 35000 9000 of 8% prevalenee, it is in faet e q u a l to a preeision
5% 30000 7000
6% o f + 6 . 2 % . If, on the other h a n d , he assumed a
25000 6000
7% 20000 5000 r a t h e r high level (e.g. 8%) using the same preeision
8% 20000 4500 a n d confidence levels, a sample of 4500 persons
9% 15000 4000 would be sufficient. However, if the survey d e m o n -
0% 15000 4000
strated that the true level was only 2%, the s t a n d a r d
Table 1(B). Sample sizes lor dilferent prevalence rates at two tables for eonfidenee intervals indicate that the
precision levels±5% and±10% for 99% confidence level level of precision is o n l y ± 2 0 % . For d a t a sum-
Estimated prevalen- Preeision±5% Preeisioni 10% marized at W H O the precision level of each
ce in population condition or disease will be calculated a n d included
2% 90000 30000 in the s u m m a r y tables. T h e investigator should err
3% 90000 20000 on the side of caution a n d underestimate the
4% 60000 15 000 prevalence expected; this may, however, lead to the
5% 50000 10000
45000 10000 examination of a larger sample t h a n is strictly
6%
7% 35000 9000 necessary. T h e investigator should also consider the
8% 30000 8000 facilities a n d resources that he has at his disposal
9% 30000 7000 when deciding upon the type of survey a n d the
10% 30000 7000
n u m b e r oi subjeets it will be feasible to include in
* The Tables 1A & IB assume that a simple random sample the sample.
of individuals {not clusters such as households or villages) can be
taken.
DESIGNING THE SAMPLING PLAN
H a v i n g decided on the sample size recjuired, the
if a precision level o f + 5 % at the 9 5 % or 99% investigator needs to decide on the m e t h o d of
eonfidence level is speeified. sampling a p p r o p r i a t e to the p o p u l a t i o n being
For most studies a precision o f + 1 0 % is sufficient, surveyed a n d the resources in terms of finance a n d
especially if d a t a will be gathered in a field survey personnel available.
without the facilities of a laboratory to assist Several examples of different sampling plans are
diagnosis. In such cases the diagnosis error m a y be now diseussed.
larger t h a n the desired preeision figure so that a 1. In a small country for which comprehensive
larger sample to obtain that precision figure would d e m o g r a p h i e d a t a are available, a survey of oral
be wasteful. Thus, the likely diagnostie error is a mucosal lesions could be a r r a n g e d at the same time
useful guide to a reasonable level of precision a n d a as a national general health survey a n d the sample
good reason w h y + 1 0 % is usually acceptable. selected for the general survey could be ttsed for the
For a simple prevalenee survey of a population oral survey. Obviously a r a n d o m sample of the
that has not been previously surveyed, the 95% population of a small country would be quite
eonfidence level would usually be a p p r o p r i a t e . T h e feasible in terms of cost of travelling to the various
investigator, on the basis of his knowledge of the examination centres. In addition, subjects might be
population, will then have to estimate whether the examined in hospital clinics where good facilities
prevalence of the lesion of interest is likely to be for diagnosis are available.
high or low. If he assumes the level to be r a t h e r low, In a large country such a survey may be possible,
for example 3%, a sample size of 10000 persons b u t the resources required would be very m u c h
(divided between the i m p o r t a n t sub-groups in the greater because of the a m o u n t of travel involved.
population for which the precision levels would be In any type of survey there will always be a
wider) would be necessary for a precision o f + 10% certain percentage of contacted subjects w h o will

n o t respond, or who will refuse an examination. It is
essential that this group of'refusers' be investigated
t o determine the reasons for refusal and whether
they are in fact substantially different from the rest
of the population, partieularly with respect to the
condition being surveyed. This part of the investi-
gation is time-consuming and costly, but is essential
i n order to make some assessment of the validity of
t h e sample.
2. If a preselected random sample is not readily
obtainable*, it will be necessary to design some
type of stratified sampling plan. Different ap-
proaehes are often used for urban and non-urban
areas. Within cities the various soeioeconomic
levels are usually the most important subdivisions;
'where there are marked differences in dietary or
religious habits, those groups may be the most
important subgroups. It is occasionally necessary
to further subdivide the main groupings and
include, for example, different socioeconomic divi-
sions within ethnic groups, or ethnic subdivisions
'within a group having a particular habit.
For a non-urban population cluster sampling is
usually the most satisfactory method of obtaining a
reasonably unbiased sample. The following ex-
ample illustrates one of the ways in which this
method may be applied. As part of a regional oral
mucosal disease survey a sample of 5000 persons is
to be examined in a large rural area containing a
population of approximately 160000 persons. It is
deeided that 10 primary sampling loeations will be
used within the area.
A list of all rural eommunities with population
estimates and cumulative population total is then
prepared, e.g.
Cumulative
Population total
Village A 2000 2000
Village B 8000 10000
Village C 7000 17000
Village D 10000 27000
Village E 5000 32000
Village F 8000 40000
Village G 3 000 43 000
Village X 10000 160000
National sampling survey organization frames are often
available but usually pose special problems in their use.
Guide to epidemiology 5
160000 persons divided by 10 sites gives 16000
persons for each sampling subdivision. A random
number between 1 and 16000 is selected to be the
starting point and the cumulative list is then
checked at multiples of 16000. The village corre-
sponding to each check point of 16000 on the list is
used as the cluster sampling site, i.e. if the random
number chosen was 60, A, C and F would be
chosen, plus 7 other villages and 500 persons would
be examined at each of the chosen villages.
3. For surveys designed to compare the preval-
ence ofa lesion in two or more groups with different
habits, in order to elucidate possible etiological
factors, care should be taken to ensure that the two
groups are as similar as possible with respect to all
factors exeept those being investigated: for ex-
ample, if pan chewing is only common in rural
areas, it will be necessary to compare the rural
chewers with a group of rural non-chewers. The
total sample size in sueh an investigation will
depend on the different prevalences expected in the
two groups and no specific guidance on sample
design and size for this type of survey is possible
beyond applying what has already been said.
It is important to remember that sample design
must be tailored to the objeetives ofa study and that
a particular design will probably not be suitable for
the examination of alternative objeetives. Let us
eonsider a survey to determine the overall preval-
ence of certain oral conditions in a population,
assuming that a sample size of at least 6000 persons
with the various subgroups in the population
represented in the sample according to their rela-
tive sizes has been ehosen as appropriate. The
results may indieate that several habit groups
appear to have a higher prevalence than the t est of
the population. However, because the survey was
designed as an overall prevalence survey, the results
obtained for each subgroup will have wider preeision
levels than the total survey sample and may not
allow statistically significant conclusions to be
drawn from the differences in prevalence found. It
would then be necessary to conduct a further
investigation to determine whether the apparent
differences were in fact significant.
Age groupings - Beeause the prevalenee of most of
the serious oral mucosal diseases is extretnely low
below the age of adolescenee, it is usual to restrict
the survey to ages over 15 years. However, presen-
tation ol the findings by age is very important; the
 WORLD HEALTH ORGANIZATION
results should be reported for 5 year intervals from
the age of 15 to 34, i.e. 15-19, 20-24, ete., and
thereafter 10 year intervals are standard, i.e. 35-44,
45-54, etc.
Approval and scheduling - Usually permission to
examine population groups must be obtained from
some local, regional or national authority. It is
important to acquaint the dental and medical
professions and administrators in the area with the
details of the survey.
In the case ofa survey of oral mucosal conditions,
it is very important to have a good contact with
local or central hospitals or special clinics. For
example, if oral cancer is suspected, the patient
should be referred immediately to a hospital for
detailed examination and treatment.
One of the important aspeets of planning a
survey is the preparation of an orderly schedule for
data eollection and intervening travel to ensure
that the survey is conducted as economically as
possible and the time spent waiting for transport or
patients is as short as possible,
TRAINING AND GALIBRATING THE EXAMINERS
Epidemiology is concerned with the study of factors
that affect the health of groups of people. Thus,
while examiners may differ slightly in their assess-
ments of the oral health status of individuals, it is
important that they be in close agreement in their
assessments of the status of groups.
Whenever an epidemiological survey is under-
taken, it is essential for the participating examiners
to be trained to make eonsistent clinical judge-
ments. Otherwise eaeh examiner will interpret and
apply written instructions in his own way and will
deviate even from his own average, from time to
time, in his assessment of clinical conditions. The
objectives of standardization and calibration are:
i) to ensure uniform interpretation, understand-
ing and application of the criteria for the various
diseases and conditions to be observed and re-
corded;
ii) to ensure that each examiner can examine to a
consistent standard and that variation among
different examiners is minimized.
The Guide is designed to facifitate the aehieve-
ment of the first objective by defining criteria in
clear and precise terms.
In preparation for field surveys of common
diseases, it is usual for the observers to undergo a
period of training and caHbration so that each
member of the team will use the same assessment
criteria and will use them with a high degree of
aeeuraey. Such a period of training would involve
the members of the team in the examination of
selected groups of patients showing the various
conditions that are to be recorded and the re-
examination oi these patients after an interval to
determine the extent to whieh each observer varies
in his assessment of those cases.
However, for most of the conditions described in
this Guide, it would rarely be possible for any
substantial group of eases to be assembled so that
the team of observers could undergo the desired
training and calibration. Furthermore, for certain
of these conditions the final diagnosis could only be
established with eonfidenee if clinical examination
were supplemented by laboratory tests. Beeause of
these diffieulties and because appropriate labora-
tory tests may not be available, some other training
and calibration procedures must be devised.
It would be ideal if all the observers were
individuals with long training and experience in
the diagnosis of lesions of the oral mucosa. If this is
not possible, then suitable clinical photographs
may be of some asssistance in the period of
preparation for the field survey. For this purpose
the Oral Health Unit of the World Health Organi-
zation is prepared to make available on loan and
without charge 35 mm transparencies, together
with sets of explanatory notes. This training mate-
rial will only be made available if W H O is satisfied
that the instructional sessions will be in the charge
ofa member of the team who is already experienced
in this field of elinieal diagnosis.
ORGANISING THE SURVEY
GENERAL
The person in charge of the survey will need to
contact such people as factory personnel officers, ;
trade unions and local authority officials to ensure
that the population is aware of the survey. These
persons may also be able to assist the organizers by
providing examining areas in town and village
sehools, or commercial buildings, or factories.
If the primary sampling unit consists of some
kind of cluster of houses, i.e. a village or section ofa
village or town, an enumeration prior to the survey
should be made, A few days before the survey the

investigator should ensure that each household is
visited and that information about the names, age
and sex of the people living in each house is noted.
A serial number should be allotted to each house-
hold and a rough map of the area showing the
location ofeach house should be prepared. Finally,
a n alphabetic list of the names, age and sex, and
household numbeis of all individuals to be exa-
mined should be completed. When conducting the
survey, as each individual is examined, his or her
name should be ehecked against the list. Examina-
tion of every individual on the list should be
attempted. This is, however, not usually possible
and a note should be made of the reason why an
individual is not examined. This procedure is
indispensable, especially if a follow-up survey is
intended at a later date.
The examiner should reeord in a diary the
location of eaeh day's examinations, the identifiea-
tion number of all persons examined during that
day and any unusual findings or happenings.
Occasionally, observations are made and impres-
sions are formed that have an important beai^ingon
later assessment of survey results. If these are not
described clearly at the tim.e they are observed,
they will either be forgotten or beeome confused
with other impressions or happenings during the
survey,
II is very importani ihat Ihe examiner also reviews each Mouth mirrors are needed to retract the cheeks
day's reeord forms that same evening for completeness and and tongue. A dental or laryngeal mirror is needed
accuracy of recording, so that any recording errors can to visualize some areas of the oral cavity and
be corrected and missing information collected
before the examining team moves to the next
survey site.
SURVEY PERSONNEL
Each examiner should be assisted by a recording
clerk who is alert, cooperative, able to follow
instructions explicitly and who ean print and
record numerals clearly as prescribed. The exa-
miner should give the clerk clear instructions about
recording the data on the survey form. The clerk
should be told the meaning of the terms that will be
used and instrueted in the coding systems so that,
with practice, he can recognize obvious mistakes
made by the examiner.
It is also desirable to have an organizing clerk at
each examination site to maintain a flow of subjects
to the examiner(s) and to enter the general descrip-
tive information on the record form. The organi-
Guide to epidemiology
zing clerk should also scan the finished records for
accuracy and completeness so that missing infor-
mation may be obtained before the survey team
moves to another location.
For surveys in rural areas a local guide will be
needed in each village. A good local guide can
facilitate the work and substantially reduce the
time required to eomplete the village. A villager
who is comparatively educated and held in respeet
by other villagers should be ehosen if possible, A
schoolmaster, councillor or village policeman may
be suitable. Besides identifying the villagers the
village guide can be helpful in persuading un-
cooperative villagers to cooperate and in gathering
necessary information about individuals and the
village.
If possible, a person should be available to
sterilize and maintain an adequate supply of
instruments for the examiner,
INSTRUMENTS AND SUPPLIES
Adequate examination of the oral eavity does not
require mueh equipment. However, good lighting
is of the greatest importance. A dental light, a
headlight or a head mitTor are adequate and a
torch is least satisfactory. However, use of the
headlight or mirror may not be practical in some
situations as it may frighten away the subjects.
nasopharynx.
If the appropriate equipment for intraoral pho-
tography is available, photographs should be made
of all intet-esting oral conditions encountered du-
ring the survey. These are valuable in cases of
doubtful diagnosis and are also useful as ti'aining
material. A library of photographs illustrating the
diffez'ent conditions in the local popuiation is a
valuable addition to the usual teaching materials
which are in the main prepared in other eountries,
ASSISTANGE FROM WHO
Investigators planning a survey of oral mucosal
conditions and diseases may request assistance from
W^HO* in the planning of the study, in particular
Requests should be addressed to: The Oral Health Unit,
WHO, Avenue Appia, 1211 Geneva 27, Switzerland.
8 WORLD HEALTH ORGANIZATION
the design of the sampling plan and size of the
sample (see Annex I, p. 26),
For surveys of populations, especially those for
which no information is available about the preval-
ence of oral preeancerous lesions and cancer, WHO
is also willing to provide the following assistance:
i) a supply of standard recording forms;
ii) summarization of the results - provided that
the standard form has been used and that W H O
has been involved from the beginning in the design
and organization of the study;
iii) a set of colour transparencies, on loan, illu-
strating the lesions of interest and importance as
well as conditions which are of relevance in the
differential diagnosis of those lesions. This material
is designed expressly for the training of examiners.
The colour photographs in this publieation should
be used as reference standards during the survey.
EXAMINATION OF THE ORAL
MUCOSA
1. EXAMINATION PROCEDURE
A thorough methodical procedure for the oral
examination should be carefully learned and not
varied. Two mouth mirrors are recommended for
the examination. Whilst digital palpation of the
mucosa would be ideal, for praetieal reasons mouth
mirrors may be used to gain an idea of the texture of
the tissues. Digital palpation, using any necessary
precautions, may then be reserved for the examina-
tion of particular lesions. Dentures should be
removed before starting the examination. The
following procedure is recommended:
The lips should be examined with the mouth
closed and open. Note the colour, texttire and any
surface abnormalities of the vermilion border.
Lower labial mueosa and sulcus. Examine visually
the mandibular vestibule with the mouth partially
open. Observe the colour and any swelling of the
vestibular mucosa and gingiva.
Upper labial mucosa and sulcus. Visually examine
the maxillary vestibule and frenulum with the
mouth partially open.
Commissures, bueeal mucosa, buccal sulcus (upper and
lower). Using the mouth mirrors as retraetors and
with the mouth wide open, examine the entire
buccal mucosa extending from the commissures
and back to the anterior tonsillar pillar. Note any
change in pigmentation, colour, texture and mobil-
ity of the mucosa, make sure that the commissures
are examined earefully and are not eovered by the
mouth mirrors during retraction of the cheek.
Alveolar ridges (processes). Check from all sides
(buccally, palatally, lingually).
Tongue, With the tongue at rest and mouth
partially open inspect the dorsum of the tongue for
any swelling, uleeration, coating or variation in
size, colour or texture. Also note any change in the
pattern of the papillae eovering the surfaee of the
tongue. The patient should then protrude the
tongue and the examiner should note any abnor-
mality of mobility. With the aid of mouth mirrors,
inspeet the margins of the tongue. Then observe the
ventral surface.
If adequate preeautions ean be taken by the
examiner, the tongue ean be examined more
effieiently by grasping the tip with a piece of gauze
to assist full protrusion and to aid examination of
the margins.
Floor of the moulh. With the tongue still elevated
inspect the fioor of the mouth for swellings or other
abnormalities.
Hard and soft palate. With the mouth wide open
and the subject's head tilted backwards, gently
depress the base of the tongue with a mouth mirror.
First inspect the hard and then the soft palate.
Mucosal or facial tissues that seem to be abnor-
mal, as well as the submandibular and eervieal
lymph nodes, should be palpated.
2. TOPOGRAPHICAL CLASSIFICATION OF ORAL
MUCOSA
A systematic and standard approach system for recording of
different conditions of the oral mucosa is very importani. The
classification proposed by ROED PETERSON & RENSTRLIP (3) is
convenient for this purpose and is used in this Guide.
The numbers for loeations refer to the drawing in Fig. 25v
The same numbers are used for eoding locations of lesions on
page 2 of the survey form.
Vermilion border - upper (13), lower (14)
The 'lipstick' area between the labial mucosa and the skin ol
the lip. I
Labial commissures - right (15), left (16) ?
A square of approximately 1.5 em of mucous membranf
extending about 1.5 cm distally from the corner of the mouth
(angula oris).
Labial mucosa - upper (17), lower (18)
A rectangular area extending from the vermilion border to 1
em from the deepest part of the labial sulcus, and laterally toJ
line drawn veriically from the angles of ihe mouth.
Labial sulci - upper (21), lower (22) s
A rectangular area mesial to the distal surfaces of thf

upper/lower canines and extending Irom the mucogingival
reflexion to the deepest parl of the suleus and then approxim-
ately 1 cm towards the mucosa of the lip.
Cheek (buccal mucosa) - right (19), left (20)
Lies between the upper and lower buecal sulci, and extends
forwards to a line drawn vertically from the angles of the
mouth. The areas defined as labial commissures are excluded.
Buccal sulcus - right upper (23) lower (24)
Buccal sulcus - left upper (25) lower (26)
A rectangular area posterior to the regions of the distal
surfaces of the canines, back to the anterior tonsillar pillar and
extending from the mucogingival reflexion to the deepest part
of the sulcus and then approximately 1 cm towards the mucosa
of the cheek.
Postenor gingiva and alveolar ridge (process) Buccally
Upper gingiva or edentulous alveolar ridge buccally - right
(27), left (28)
Lower gingiva or edentulous alveolar ridge buccally - right
(29), left (30)
A rectangular area posterior Co the regions of the distal
surfaces of the canines extending to the anterior tonsillar pillar
and from the free margin of the gingiva or the top of the
edentulous alveolar ridge (process) to the upper/Jower muco-
gingival reflexion.
Anterior gingiva and alveolar ridge (process) labiaity:
Upper anterior gingiva or edentulous alveolar ridge labially
(31) Lower anterior gingiva or edentulous ridge labially (32)
A rectangular area between the regions of the di.stal surfaces
of the eanines and extending from the free margin of the
gingiva or the top of the edel^tulous alveolar ridge to the
mueogingival reflexion.
Fosterior gingiva and alveolar ridge (process) palatally
linguatly
Upper gingiva or edentulous alveolar ridge palatally - right
(33), left (34)
Lower gingiva or edentulous alveolar ridge lingually - right
(35), left (36)
A rectangular area posterior to the regions oi: the distal
surfaces of the canines extending to the anterior tonsiliar pillar
and lying between the free margin of the gingiva or the
edentulous alveolar ridge and the junction between ihe
horizontal and vertical part of the palate, or the lingual
mueogingival reflexion.
Anterior gingiva and alveolar ridge {process) palatally and lingually
Anterior gingiva or edentulous ridge palatally (37) and
lingually (38)
A rectangular area between the regions of the distal surlaces
of the canines and from the margin of the gingiva or edentulous
ridge to the palatal rugae (plicae palatinae transversae) or the
lingual mueogingival reflexion.
Dorsum of the tongue - right (39), left (40)
A triangular ai'ea posterior to the tip (as defined in 43) back
to the terminal sulcus and between the margin (as defmed in 44
and 45) and the midline.
Base of the tongue - right (41), left (42)
A rectangular area posterior to the terminal suleus and
between the two anterior tonsillar pillars.
Tip of the tongue (43)
A circular area with a radius of 1 cm with the centre at the
tip of the tongue.
Guide to epidemiology
Margin of the tongue - right (44), left (45)
A rectangular area starting 1 cm posteiuor to the tip of the
tongue, extending back to the anterior tonsillar pillar and
covering J cm of the dorsal and ventral edge oi ihe tongue.
Ventral (inferior) surface of Ike tongue - right (46), left (47)
A triangular area from the reflexion of the tongue following
the midline lo 1 cm posterior to the tip of the tongue and
following an imaginary line lying 1 cm from the edge of the
tongue.
Floor of the moulh
Frontal (48)
A triangular area between lines drawn from the regions oi
the distal surlaces of the lower canines to the lingual frenulum
and the anterior lower alveolar ridge (proeess) iingually.
Floor of llie mouth
Lateral - right (49), left (50)
Triangular areas posterior to area (48) between the lingual
mucogingival reflexion and the rellexion of the tongue.
Hard palate - right (51), left (52)
A ti'iangular area between the upper alveolar ridge (process)
palatally, the midline and the junction of the hard and soft
palates.
Soft palate - right (53), left (54)
A reetangular area posterior to the junction of the hard and
soft palate and between the anterior tonsillar pillar and the
midline, and including half the uvula..
Anterior tonsiltar pillar - right (55), left (56)
The fold of tissue that forms the margin of the tonsillar fossa.
3. DESCRIPTION OF LESIONS
and Target conditions
The eonditions recorded will refleet the range of
conditions and diseases found in the survey popula-
tion as well as the particular interests of those
conducting the survey and may also be influenced
by the supplementary methods of investigation that
are available.
In this guide a limited range of 'target condi-
tions' has been selected for description. These
comprise oral carcinoma, together with certain
mucosal lesions that are known or believed to be
precaneerous, relatively common conditions that
enter into the differential diagnosis of these lesions,
and certain infections that are capable of being
diagnosed with a high degree of confidence under
field survey conditions.
In most surveys it will be desirable to record only
lesions present at the time of examination, but in
some surveys an alternative approach may be
preferred for certain conditions. For example,
recurrent aphthae may be reeorded only if present
on the day the individual is examined, or it may be
deeided to record whether the individual has
suffered an attack during a defined period of time.
Whichever approach is adopted, the rules must be
10 WORLD HEALTH ORGANIZATION
clearly defined and understood by all survey
personnel.
Carcinoma (140-149 of ICD-DA)
The most important oral mueosal lesion is the
carcinoma, in most cases a squamous cell car-
cinoma, because it may cause death if not treated at
an early stage. The location of an oral carcinoma is
often associated with various smoking and/or che-
wing habits involving tobacco and/or areca (betel)
nut. Depending upon where the quid is kept, the
carcinoma may be located in a buccal or labial
sulcus. Reverse smoking is associated with car-
cinoma of the palate and posterior part of the
dorsum of the tongue.
The carcinoma may develop in a white patch
(an area of leukoplakia) or in a red area (an
erythroplakia) but many carcinomas arise in an
area of mucosa that previously appeared normal.
Despite the serious nature of the lesion, there
may be little or no pain.
Except in some early and small lesions, there is
usually induration - the tissue feels firm and
thickened - either throughout the lesion, or at the
margins if there is ulcet-ation. Where the tumour
occurs on a mobile part of the mucosa, there may be
fixation and loss of mobility beeause the tumour has
involved the deeper tissues.
The appearanee oi the surface of the tumour is
very variable: it may be relatively smooth and
white or red, but commonly the surface is nodular
(Fig. 1) or uleerated (Fig. 2) and the ulcer may have
a raised rolled margin. In the later stages there may
be a soft fungating mass (Fig. 3) that bleeds readily.
If the carcinoma arises on the lip, where the surface
can become dry, there is often a crusted or scaly
appearance or the surface can appear warty.
One variety of oral scjuamous eell earcinoma, the
verrucous carcinoma, tends to grow slowly and to
involve the deeper tissues at a relatively late stage.
The verrucous carcinoma is a predominantly exo-
phytic growth, and presents as a painless warty
mass that usually has a white nodular surface.
For complete eonfidenee in diagnosis, scjuamous
eell carcinoma requires histological examination.
However, if this is not possible a provisional
diagnosis has to be made on the basis of the clinical
findings described above: associated with these
findings at the site of the primary lesion there may
be involvement of the lymph nodes draining the
area, and the affeeted nodes feel enlarged, firm or
hard, and they may be tender. However, it will
be remembered that inflammatory enlargement of
lymph nodes oecurs in association with oral ulcers
other than carcinoma.
Occasionally, a patient may have more than one
carcinoma in the mouth at the same time, but
usually the earcinoma is a solitary lesion.
It is also important to distinguish between a
carcinoma of the mucosa and mucosal ulceration
caused by a neoplasm arising in the deeper tissues.
Leukoplakia (528.6X, 523.84) :;
For the purpose of this guide, leukoplakia is defined
as a white patch, or plaque, that cannot be
characterized clinically or pathologically as any
other disease.
It may, therefore, be desirable to create one or
more speeial categories in the survey for lesions of
this type; the eriteria for reeording lesions in these
eategories should be carefully defined.
These lesions are characterized by the presence
ofa white patch anywhere on the oral mucosa; they
may vary from a quite small and circumscribed
area to an extensive lesion involving a large area of
mucosa. The appearance is variable; the surface
may be smooth or wrinkled and sometimes smooth-
surfaeed lesions my be traversed by small eracks or
fissures giving an appearanee aptly likened to
cracked mud (Fig. 4). Lesions may be white,
whitish-yellow or grey and some appear homo-
geneous (Fig. 5), while others are nodular, showing
white areas intermingled with red zones; this is
often called a nodular (speckled) leukoplakia (Fig,
6). In those lesions in which there is much epithelial
hyperplasia, the affected mucosa may lose some of
its normal softness and ffexibility.
Before reaching a diagnosis of leukoplakia, it is
important to consider whether the whiteness of the
mucosa could be due to leukoedema (a relatively
common appearance that is often regarded as a
normal variation). Leukoedema is seen typically on
the buccal mucosa and has been described as
resembling an ill-defined 'grey veil' lying on the
mucosa (Fig. 7). The affected area appears slightly
more grey or white than the rest of the mucosa, but
when the area is gently scraped with the blunt edge
of a mouth mirror, the greyness diminishes or
disappears.
If the eonditions of the survey permit, it is
 Guide to epidemiology 11

Fig. 1. Carcinoma ol labial commissure. Fig, 2. Carcinoma oi palate. Fig. 3. Carcinoma of border of tongue. Fig. 4. Leukoplakia ol
buccal mucosa. Fig. 5. Homogeneous leukoplakia of lloor of mouth and ventral surface of tongue. Fig. 6. Nodular (speckled)
leukoplakia of labial commissure and buecal mucosa.
12 WORLD HEALTH ORGANIZATION

Fig. 7. Leukoedema of buccal mucosa. Fig. 8. Erylhroplakia of buccal mueosa. Fig. 9. Leukokeratosis nicotina palati. Fig. 10.
Lichen planus: reticular type with some papules on buccal mucosa. Fig. IL Plaque form of lichen planus on buccal mucosa.
Fig. 12. Erosive lichen planus on tongue.
 Guide to epidemiology 13

Fig, 13. Submucous librosis wilh fibrous bands. Fig. 14. Submucous fibrosis of tongue. M§. 75. Herpetic gingivostomatitis affecting
labial mucosa and vermilion border. Fig. 16. Herpetic gingivostomatitis of palate. Fig. 17. Acute necrotizing gingi\'itis. Fig. IS.
Cancrum oris.
14 WORLD HEALTH ORGANIZATION

Fig. 19. Acute pseudomembranous candidiasis of palatal mucosa. Fig. 20, Chronic candidiasis of tongue. Fig. 21. Cronic hyper-
plastic candidiasis of labial commissure. Fig. 22. Recurrent aphthous ulceration of labial mucosa. Fig. 23. Major aphthae of palate.
Ing, 24. Herpetiform ulceralions of labial mucosa.

desirable to record separately the various forms of
leukoplakia, and for this purpose the following
subdivisions are recommended:
a) Homogeneous Lesions that are uniformly
white
b) Non-homogeneous Lesions in which part of the
lesions is white and
appears reddened.
Alternatively, a more elaborate subdivision may
be used, sueh as:
1, Homogeneous a) smooth
b) furrowed (fissured)
c) ulcerated
2. Non-homogeneous nodulo-speckled (well-
demareated raised white
; areas, interspersed with
reddened areas).
When recording leukoplakia, space has been allow-
ed in the reeording form for three different subdivi-
sions:
1. Homogeneous smooth and fissured
2. Homogeneous uleerated
3. Non-homogeneous nodulo-speckled
In 3-5% of patients, a leukoplakia will turn
malignant and the risk is greater with the non-
homogeneous lesions. It is therefore desirable,
wherever possible, that patients should be re-
examined at regular intervals.
Erythroplakia (528.70)
Whilst leukoplakia is a relatively eommon condi-
tion, erythroplakia is rare. In contrast to leuko-
plakia, erythroplakia is almost always assoeiated
with premalignant changes histologically and is
therefore a most important precaneerous lesion.
The term 'erythroplakia' is used analogously to
leukoplakia to designate lesions of the oral mucosa
that present as bright red velvety plaques which
cannot be eharaeterized elinieally or pathologie-
ally as due to any other condition. Just as there are
many oral lesions that present elinieally as white
patehes on the mucosa, so there are a number of
conditions that appear as ted areas. These include
some dermatoses, inflammatory conditions due to
Guide to epidemiology 15
local infection, or a more general subacute or
chronic stomatitis associated with the presence of
dentures, tuberculosis, fungus infections and other
conditions. Some red plaques prove to be early
squamous cell carcinomas. The red patches that
cannot be classified in any of these eategories fall
into the grotip of erythroplakias.
The lesions of erythroplakia are usually irregular
in outline though well defined and have a bright
red velvety surface (Fig. 8). Oeeasionally the
surface is granular. If red areas are intermingled
with white, the lesion should be elassified under
leukoplakia.
For those particularly interested in the oral
preeaneerous lesions, a more detailed deseription,
ineluding histopathological features, ean be found
in the W H O Report on Oral Preeaneerous Le-
sions (4),
Leukokeratosis nicotina palati (528.72)
In addition to the leukoplakic patches that may
develop anywhere in the oral mucosa in tobacco
users, a specific lesion may occur in the palate of
heavy pipe and cigar smokers, partieularly the
former. These changes do not occur in those areas
of the palate that are shielded from the tobacco
smoke, as by a denture.
In the early stages the mueosa is reddened, but
soon becomes gixyish-white and may present a
wrinkled appearance. Later it becomes thickened
and white umbilicated nodules with red centres
appear, partieularly in the posterior part of the
palate (Fig. 9). Caneer rarely develops in leuko-
keratosis nieotina palati, exeept in reverse smokers.
Lichen planus (697.00-697.09)
This disease eommonly affects the oral mueosa and
lesions may occur in the mouth in the absence
of skin lesions. Whilst a number of reports have
referred to caneer arising in the oral lesions of
lichen planus, espeeially of the erosive or atrophic
types, there remains considerable uncertainty
about the risk of this occurrence.
Oral mucosal lesions are usually multiple and
often have a symmetrieal distribution. They eom-
monly take the form of minute white papules that
gradually enlarge and coalesce to form a retieular
(Fig. 10), annular or plaque pattern. A eharacter-
stic feature is the presence of slender white lines
(Wickham's striae) radiating from the papules. In
16 WORLD HEALTH ORGANIZATION
the reticular form there is a lace-like network
of slightly raised grey-white lines, often inter-
spersed with papules or rings. The plaque form
(Fig. 11) may be difficult to distinguish from
leukoplakia, but in lichen planus'there is usually no
change in the flexibility of the affected mucosa. In
some patients the lesions are atrophic, with or
without erosions (Fig. 12). Oral lesions of lichen
planus may also include buUae, but these are rare.
When the tongue is affected, the white patches
rarely display a reticular pattern and the margins
of the patches appear diffuse.
Oral submucous fibrosis (528.80)
This condition, which is found almost exclusively
among Indians and Pakistanis, is a slowly progres-
sive disease of unknown etiology. There are several
indications that oral submucous fibrosis predis-
poses to cancer; superimposed leukoplakias, occa-
sionally of the speckled type, are often present and a
considerable number of submucous fibrosis cases
are associated with epithelial dysplasia.
The disease is characterized by the presence of
palpable fibrous bands in the oral mucosa (Fig. 13),
ultimately leading to severe restriction of the
movements of the mouth, ineluding that of the
tongue. On clinical examination, limitation of
opening of the mouth may be obvious. In addition,
the tongue may be small and exhibit very limited
mobility and show a marked loss of papillae (Fig.
14), In the earlier stages of the disease it will usually
be possible to detect vertical fibrous bands in the
cheek, which can be felt by running the blunt edge
of the mouth mirror backwards and forwards along
the cheek mucosa. The palate may appear abnor-
mally pale and the uvula may be shrunken. Other
characteristic elinical features of submucous fib-
rosis are loss of normal oral pigmentation and, as
previously noted, there may be areas of leuko-
plakia.
Acute herpetic gingivostomatitis (054,20)
This condition is caused by the herpes simplex virus
and it is more common in ehildren than in adults.
Unlike herpes labialis (which is caused by the same
virus), herpetic stomatitis is rarely recurrent.
Especially in children, acute herpetic gingivosto-
matitis may cause a marked constitutional distur-
bance (malaise, high fever), together with regional
lymphadenopathy, flushing and profuse salivation.
The initial oral lesions are small vesieles, which
occur on any part of the oral mueosa, particularly
on the labial mueosa (Fig. 15), but also ineluding
the tongue and the palate, and the vesicles may be
very numerous. Both sides of the mouth are affected
(whereas in herpes zoster the lesions are almost
always unilateral).
The vesieles rupture within 12-24 hours, produ-
cing small painful shallow ulcers that tend to
coalesce to form compound ulcers. The ulcers
usually heal within two weeks and do not cause
scarring.
Gingival lesions commonly accompany the le-
sions in other parts of the mouth (Fig. 16). The
gingiva may be bright red, but without ulceration,
or there may be extensive gingival ulceration.
However, unlike the ulceration of acute necrotising
gingivitis, the gingival ulceration of acute herpetic
gingivostomatitis has no special predeliction for the
tips of the interdental papillae.
Acute neerolizing gingivitis (stomatitis) (lOl.XO)
Acute necrotizing gingivitis is known under many
other names, the foremost being Vincent's gingi-
vitis, but terms like "ulceromembranous gingivitis"
and "fusospirochaetal gingivitis" are frequently
used. It is well known that epidemics of acute
necrotizing gingivitis often are observed among
troops. In the western part of the world the disease
usually affects adults and is very rare among
children, whereas it is observed quite often among
children in some developing countries. The exact
etiology is obscure, although it usually is considered
as a fusospirochaetal lesion. The patients may suffer
from regional lymphadenopathy, increased saliva-
tion and elevated temperature. ""' ..
The oral lesions are eharaeterized by a necrosis
at the tips of the interdental papillae and along the
marginal gingivae (Fig. 17), or at the edge of the
mucosa ffap over an erupting molar. The uleers are
covered by a greyish-yellow pseudomembrane.
The lesions are tender and bleed when touched
lightly. There is a characteristic oral fetor.
Cancrum oris (528. IX)
Under the names "noma" and "gangrenous stoma-
titis" , cancrum oris has been known for hundreds of
years in various parts of the world. Today the
disease is mostly confined to some of the developing
areas of Africa, Asia and South America. The

etiology is unknown, but the bacteriological and
histologieal findings are like those in acute neeroti-
zing gingivitis. However, canerum oris is not
confined to the gingiva: the neerosis is relentlessly
progressive and ultimately there may be massive
destruction of the mouth, jaws and face (Fig. 18).
Diseases such as measles, smallpox, malaria,
acute herpetic gingivostomatitis and protein mal-
nutrition may be associated or predisposing factors.
Cancrum oris, which is commonly preceded by
an acute necrotizing gingivitis, begins as an ulcera-
tion of the oral mucous membrane which extends
outwards and eauses a well demarcated necrosis of
the overlying skin. The neerotie area may beeome
large, the gangrenous tissue separates and may
expose neerotie bone. Later, the dead bone and the
associated teeth may sequestrate,
Gandidiasis {112.00-09)
In several populations it has been found that about
50% of normal individuals are carriers of Candida.
A variety of oral lesions are eaused by the fungus
Candida albicans. The term "candidiasis" is used
when lesions are present. The disease is also known
as "moniliasis" and "eandidosis". Acute candidiasis
may be pseudomembranous or atrophic. The for-
mer, also known as thrush, consists of ereamy,
pearly-white (Fig. 19) or bluish-white patches
whieh can be removed by gentle scraping. Thrush
may occur in all areas of the oral mucosa, although
the sites of predeliction are the buccal mucosa,
palate and tongue. The atrophic variety, a red and
painful lesion, may oecur during treatment with
antibiotics. Chronic candidiasis may manifest itself
in several forms. As persistent angular eheilitis, as
denture stomatitis, as a median rhomboid glossitis-
like lesion (Fig, 20) and as a retroeommissural
hyperplastie lesion (Fig. 21). The latter may often
resemble a leukoplakia.
Recurrent oral aphthae (528.20)
Apart from gingivitis, the most prevalent oral
mueosal lesions are ulcerations of the types known
as "canker sore" and "aphthous ulcerations", with a
prevalence ranging from 10% to 607o in various
population samples. The etiology is unknown, but
there is evidence of an autoimmune factor. The
clinical picture of recurrent aphthae shows great
variation. Recurrences may take place at intervals
of several years, or the patient may have many
Guide to epidemiology 17
attacks eaeh year. .
Three main clinical patterns may be reeognized.
In the most eommon (minor aphthae, Mikulicz
aphthae) there are typically 1-4 ulcers in each
attack. These are usually confined to the non-
keratinized parts of the mueosa (Fig. 22) and
therefore do not involve the hard palate or the
gingiva. Eaeh uleer reaches a diameter of 1 -2 cm
over a period of about a week and is usually healed
by the end of the seeond week from onset. The
ulcers are shallow, but painful, and they do not
cause searring.
In the second and less common' type (major
aphthae, Suttons aphthae, periadenitis mucosa
neerotiea reeurrens) there are usually no more than
one or two lesions in each attack. These occur
anywhete on the mueosa or fauces and in some
patients the tongue is the site of predelietion. Eaeh
lesion exhibits marked induration and the ulcer is
relatively deep and destructive. Healing may take
many weeks and is followed by scarring (Fig, 23).
In the third type (herpetiform ulceration, stoma-
titis herpetiformis) there is a large number of small
shallow ulcers in each attack and these ulcers oecur
on any or all parts of the oral mucosa, including the
palate, tongue and gingiva. The uleers may num-
ber 50 or more, and although each individual uJcer
rarely exceeds 2 mm in diameter, groups of ulcers
may coalesce to form compound ulcers with irre-
gular outlines (Fig, 24). Thus the clinical' ap-
pearances are very like those of true herpetic lesions
of the oral mucosa, but stomatitis herpetiformis is
not due to the herpes virus, and stomatitis herpeti-
formis is recurrent whilst true herpes infections
rarely produce recurrent intraoral lesions.
Some types of recurrent oral uleeration that may
closely resemble the aphthae described below, are
associated with certain deficiency states (such as
iblic acid deficieney), or with gluten intolerance.
Differential diagnosis
When the lesion (or lesions) is a white patch it should
be kept in mind that the following diseases are also
characterized by being white or whitish: leukoe-
dema (528.71), cheek biting (528,93), white sponge
naevus (750.26), syphilitic papules (091.20), or
discoid lupus erythematosus (695.40), Fordyce
spots (heterotropie sebaceous glands) (750,25) are
usually of a yellowish colour, .: v , '
18 WORLD HEALTH ORGANIZATION
Fig. 25. Topography of the oral mucosa modified after ROED.PETERSF.N & RENSTRUP (3).
An elevated, pale, soft or firm and well demar-
cated mass is most often a fibroepithelial polyp
(fibroepithelial hyperplasia), but focal epithelial
hyperplasia (mostly occurring among Indians in
Latin America and Eskimos) may present a similar
appearance: however, the lesions of focal epithelial
hyperplasia are commonly multiple whereas fi-
broepithelial polyp is usually solitary.
The majority of ulcerations to be found in the
oral mucosa are of traumatic origin and should
disappear one to two weeks after appropriate
treatment. If not, a biopsy should be done. If the
uleerations are crateriform and lead to scar forma-
tion, the diagnosis of major aphthae (syn, periade-
nitis mueosa neerotiea reeurrens) should be con-
sidered.
Several diseases of the oral mucosa which are
systemic in nature are associated with the forma-
tion oi bullae. Often the oral bullae are the first sign
\ Date (year) (6)
Registration number (8) (12)
of the systemic disease, especially in pemphigus and
benign mucous membrane pemphigoid. Another
buUa-forming disease affecting the mouth is ery-
thema multiforme.
Some oral diseases are eharaeterized hy pigrnented
areas, usually ofa brownish type. When evaluating
a presumed pathologieal pigmented spot, it should
always be kept in mind that many individuals and
especially those with dark skin will have a physiolo-
gically pigmented oral mucosa. If this possibility
ean be ruled out, one should also consider the
following lesions: amalgam tattoo, various types of
naevi, melanoma and Addison's disease,
4. WHO STANDARD RECORDING FORM FOR ORAL
MUCOSAL DISEASES
A form for the recording of information on oral
mucosal diseases and oral habits is reproduced in
Fig. 26. The form consists of four parts, an
 Guide to epidemiology 19

WHO ASSESSMENT FORM FOR ORAL MUCOSAL DISEASES

Registration
(1) T t (5) Date . (6) (7) No, (8) J(12)

PERSONAL AND DEMOGRAPHIC INFORMATION

Sex M = 1, F = 2 (13) D Name

family other

AgG in years (14) (15) Address.

Ettinic group ; (16)

Religion (17)

Occupation (18) | | Geographic location ... .(20) I 1 I (21)

Diet (19) I I Examiner .(22) L J
SMOKING HABITS If no habit present - leave box blank
1 = occasionally
2 = regularly Number per day Duration years

Cigarettes (23) D (24) (26) _

Cigars (28) (29) (31)L

Others (specify) (33)1 I (3411 I I (36) [in

Graais per week

European pipe (38)1 I (39). (41)

Water pipe (43)1 I (44). (46)

Others (specify) (48)1 I (49) L (51)

CI.-WtNG AND
OTHER HABITS 1 = Occasionally
2 = Regularly Location of quid
1 = left side
Number per day Duration years 2 = right side
3 = both sides
Areca nut, lime
and leaf (53)1 I (54)1 \ I •^fi) .n
(58)L 4 = others(specify)

(59)1 I iRnil I I (R?) (64) D

Tobacco chewing (65) D (66) (68) (70)

- •
grams per week

Other habits (specify) ,

(71)L (72) (74) (76)

.... (77) D (78)

Card No. (80)

WHO 5394.1 ORH (12/79) - 20000

Fig. 26. W H O assessment form for oral mucosal diseases (page 2 of form on next page).
20 WORLD HEALTH ORGANIZATION

WHO ASSESSWIEIMT FORM FOR ORAL MUCOSAL DISEASES

CODES If no disease or condition present - leave box blank.

Loca tion Leuko. Erythro Lichen Submucous Candid-

Carcinoma 1 = present Carcinoma
CO Je plakia plakia pianus fibrosis iasis
Leukoplakia 1 = smooth & fissured
2 = ulcerated
3 = nodulo.speckled
13) 20)
Erythroplakia 1 = present
(21) :28)
Lichen planus 1 = atrophic or (29) (36)
ulceratiue
2 = other types (37) (44)
Submucous 1 = present (45) (52)
fibrosis
(53 (60)
Candidiasis 1 = acute pseudo-
membraneous (61 (68)
2 = other types

Leukokeratosis nicotina palatini (69) L I

Herpetic gingivostomatitis (70)1 I

Acute necrotizing gingivitis (71)1 I
Cancrum oris (72)1 I
Recurrent aphthae (73)1 I
Other specify (74)1 I
(75)0

PREVIOUS TREATIVIEi\IT

0 =unknown 1 = yes (76)

Biopsy 1= punch, 2 = incisional (77) •

Photograph 1 = yes (78)1 I

TREATMEIMT REOUIREMENTS

0= none

1 =; oral hygiene instruction oniy (79) D

2 = recommended change of habit and follow-up

3 = treatment needed

4 = urgent treatment needed with referral

Card No. (801L


identification section 'where personal and demo-
graphic information can be coded, a section for the
recording of habits on page 1; on page 2 a section
for recording the nature and location of lesions in
the mouth and a section where various information
on treatment provided and needed can be collec-
ted. It should be noted that some additional condi-
tions of importance to particular populations can
be included. To avoid loss of data during transport
and processing, it is recommended that forms be
made in duplicate so that the investigator may
retain a copy of all records.
The form is designed to facilitate subsequent
computer processing of the results and 'whenever
possible recording codes are shown near the appro-
priate boxes.
Investigators should make arrangements to re-
produce the required number of forms for their
survey. However, if this is impossible, W H O may
be able to assist with providing the forms.
Identification section of the form
Boxes 3, 4 and 5 are reserved for the W H O code for
the country in which the survey was conducted and
should be left blank. This will be coded automatic-
ally at WHO. The name of the country should be
written in bold letters on the first page ofeach batch
of forms sent to W H O for processing.
Date of examination
The day, month and year should be written in
block letters at the time of the examination.
Usually, only the year will be entered into the
computer. The year should be entered in boxes 6
and 7, e.g. 78.
Recording the day and month will make it
possible to refer later to any day's examinations
which may need to be reviewed in relation to
survey notes.
Registration number
Each subject, beginning with the first to be exa-
mined, should be given a registration number. This
number should always have the same number of
digits as the total to be examined. Thus, if it is
intended to examine some 9000 subjects, the first
subject should be numbered 0001, These numerals
should be entered in boxes 8 through 12.
If possible the registration numbers should be
written on the forms prior to the commencement of
Guide to epidemiology 21
any day's survey. It is essential to repeat the
registration number on the second page and to
label biopsy material with ihc same nunihcr. Il is
important to ensure that each registration number
is used only once. Cross checks are necessary when
more than one examiner participates in the survey.
For example, if a total of 10000 subjects is to be
surveyed by two examiners, examiner 1 should use
numbers 0001 to 5000 and examiner 2 should use
500] to 10000.
Sex
This information should be recorded at the time of
the examination, because it is not always possible to
tell a person's sex from the name. The appropriate
code (1 for male, 2 for female) should be entered in
box 13. . , ,
Age
Age should be recorded as age at last birthday. It
may not always be possible to obtain this informa-
tion where a register of births is not maintained.
When the subject's age is not known precisely, it
may be necessary to estimate it on the basis of
physical development, stage of tooth eruption,
tooth wear, or by questioning the subject on histori-
cal events in his community. Local residents may
provide invaluable assistance with this latter ap-
proach. Age should be expressed in the internatio-
nally conventional manner whereby age at birth is
zero years. In communities where age is normally
expressed in some other way, a conversion must be
made.
Name
The name of the subject should be written in block
letters, beginning with the family name.
Ethnic group, religion, occupation and diet
In different countries ethnic and other groups are
frequently identified in various ways, e.g, by area
or country of origin, race, colour, language, reli-
gion or tribal membership. There are as yet no
internationally accepted criteria. Local health and
education authorities should be consulted before
deciding which ethnic or religious groups should be
recorded. When this decision has been reached, a
coding system should be devised in consultation
with the survey statistician. Because it is not always
possible to identify a person's ethnic group or
22 WORLD HEALTH ORGANIZATION
religion from his name alone, this information must
be recorded at the time of the examination and
coded in boxes 16 and 17.
There is an international classification of occu-
pations* but the designated groups are not suitable
for studies of this type. Therefore, national govern-
ment or local authorities should be consulted before
specifying the occupation groups to be recorded.
When this has been done, a coding system should
be devised in consultation with the survey statisti-
cian. Occupation should be written in block letters
at the time of the examination and the appropriate
code entered in box 18.
Similarly a system for coding information on
dietary habits should be devised in consultation
with local personnel and entered in box 19 on the
form at the time of examination.
Geographical location
The site where the examination is conducted may,
if desired, be written in block letters in the space
provided, or a code may be used. Since more than
nine locations may be included in one survey two
boxes are provided for coding location. The appro-
priate code number should be entered in boxes 20
and 21.
Examiner
If more than one examiner is participating in the
survey each examiner should be allotted a code
number. The appropriate examiner's code number
should be entered in box 22 on all forms.
Oral habits
The first page of the Assessment Form provides for
the detailed recording of oral habits. If no habit or
disease is present the record box should be left
blank. This section is divided into two parts: one for
smoking and another for chewing and other habits.
In each subdivision there is space for the inclusion
of habits of particular local interest. This informa-
tion has to be collected by carefully questioning the
subjects, as some estimate of duration and intensity
of habit is required.
Diagnosis and location of lesions
Page 2 of the form provides for the recording of type
* International Standard Classification ol' Occupations. In-
ternational Labotir Ofilice (Revised edition 1968) Geneva
1969.
and location of six important lesions. If no lesion or
disease is present the record box should be left
blank. Several location code spaces should be used
to record lesions which extend over more than one
site. The code numbers (13-56) for topographical
locations of the oral mucosa, specified in the section
on Topographical Classification, should be used for
the recording of locations of lesions. The code
numbers used refer to Fig. 25, There is also space
for the recording of the presence of seven other
lesions without a specific code for location.
Previous treatment and treatment need
Information on previous treatment (box 76), biop-
sies (box 77) and photographs (box 78), may be
recorded where necessary.
Treatment needs according to the following
criteria should be coded in box 79.
Code Criteria
0 None, no treatment required.
1 Oral hygiene instruction - this may be
necessary for some specific conditions,
2 Suggestion for a change of habit and follow- |
up - for subjects for whom precaneerous I
lesions and apparently associated habits
have been found.
3 Treatment needed - use this code for chro-
nic conditions of oral mucosa which do not
require urgent treatment, , i i
4 Urgent treatment needed with referral -
this code is recorded when a life-threatening
condition or disease, for example oral can-
cer or cancrum oris, has been identified,
POST SURVEY ACTION AND
REPORTING THE RESULTS
When the survey has been completed, the principal
investigator should ensure that all forms are sorted
in numerical order by registration number as this
arrangement facilitates the checking of the forms. If
the summarization of the survey data is to be
performed by computer, either at W H O or else-
where, there is no need to sort the forms by location
or age grouping as this will be done by the
computer. The forms should then be tied in bundles
of about 100 and each bundle should be clearly
labelled with the name of the country in which the

survey was done. The Survey Summary Shed
provided by WHO (see Annex 3) should be
completed in duplicate, one copy to be retained by
the investigator and the other including in the
package of forms being despatched for processing.
It is also important that authorities giving per-
mission for the survey should be informed of the
results and, in particular, findings that call for
treatment, • Personnel and physical arrangements - It is desirable
PREPARATION OF SURVEY REPORTS
A Guide to Oral Health Epidemiological Investi-
gations (1979) (6) and the FDI Commission on
Classification and Statistics for Oral Conditions
(1962) (2) have made specific recommendations
concerning the preparation of survey reports. In
order to facilitate comparisons with other surveys,
it is recommended that reports conform as closely
as possible with the general principles set out in
these publications.
The amount of detail to be included in a report
will depend upon the requirements of the agency
for which the survey is being conducted. If the
report is to be written for publication in a scientific
journal, it will be much briefer than if it is to be
published as a monograph. However, in both cases
the general form of the report will be similar and
should include some or all of the following informa-
tion:
1. Statement of the purposes of the survey
This statement should include a succinct and clear
description of the aims of the survey and the
expected ways in which the results will be used.
2. Materials and methods
Under this heading it is customary to include:
A general description of the survey - A general
description of the geographic region and of the
people examined and of oral habits practised in the
region.
The nature of the information collected - This should
be reported in some detail and should include a
description of the general data and the specific
diseases or conditions recorded.
Method of collecting data - A description of the
methods used to collect data, e.g. by questionnaire,
interview, or clinical examination. Reference to
this guide may be ineluded.
Sampling method - An explanation should be given
Guide to epidemiology 23
of the type of sampling that was used, the size of the
sample, the proportion it formed of the population
from which it was drawn, and the extent to which it
is considered representative of the parent popula-
tion. The number and description of persons 'who
were selected for the sample but who were not
examined, and any sampling problems should also
be reported.
to give a brief account of the physical arrangements
of the examination site, the equipment used (inclu-
ding detailed description of method of oral exami-
nation) and the organization, previotts tt^aining,
and experience of the personnel employed in
collecting, processing and tabulating the primary
data.
Statistical analysis and computational procedure - T h e
statistical methods followed in compiling the final
summary tables from the raw data should be
referenced or briefiy described. If unusual statisti-
cal analyses have been made of the results pres-
ented in the final summary tables, adequate textual
reference or, in certain cases, a description of the
analyses should be given.
If the survey forms are sent to WHO, the data
will be processed by computer and summarized in
tables. Examples of the kind of tables that can be
obtained are described in Annex 2.
Cost analysis - Information on survey expenses is
of considerable interest. In a detailed report (for
publication in a scientific journal) it is desirable to
recot-d costs for the following activities: planning,
pilot survey calibration trials, field work, supervi-
sion, statistical analysis, salaries and overheads.
This information facilitates the critical evaluation
of survey methods and provides economic data for
health surveys in general,
3. Results
There are several ways in which the results may be
presented. If brevity in the main report is impor-
tant, the text should contain a written description
of only the more important results. Summary tables
may be included in the text, or in an appendix if
they are numerous, or they may even be repro-
duced separately and made available, on request,
to those who are interested. Illustrations such as
graphs, histograms, or scatter diagrams may be
used to illustrate points that are neither easily
explained in the text nor easily visualized from
24 WORLD HEALTH ORGANIZATION

tables. A cardinal rule for both figures and tables is
that they should be labelled clearly so that they are
readily comprehensible without reference to the
text.
Acknowledgements - We wish to thank the reviewers of the
Guide for their valuable suggestions for improvements. The
assistanee of the members of the WHO/FDI joint working
group and all reviewers is gratefully acknowledged.

4. Discussion and conclusion

The purpose of the discussion is to explain the
extent to which the survey met the objectives for
which it was designed, to highlight results of
particular interest, to discuss their significance and
to compare the results of the survey with relevant
published information. The conclusion might also
suggest further work that is required, either for
planning needed services or for elucidating some
interesting findings, , World Health Organization, Geneva 1978.
5. Summary
A precis of the report, ofa length suitable for use as
an abstract, is required. Objectives of the study
should be stated, the number of people examined
and the most important results should be given.
Any unusual or unexpected results should be noted,
6. References
A list of all publications referred to in the report
should be included.
REFERENCES
1. APPLICATION OF THK INTERNATIONAL CLASSITICATION OF DI-
SEASES I'o DENTISTRY AND STOMATOLOGY (ICD-DA). 2nd ed.
2. FfiDERATioN DENTAIRE INTERNATIONALE: General principles
concerning the international standardization of dental
caries statistics. Int. Dent. J. 1962: 12: 65-75.
3. ROED-PE'1'ERSEN. B. & RENS'IRI^P. G.: A topographical
classification of the oral mucosa suitable for electronic data
processing: its application to 560 leukoplakias. Ada Odonlol.
Scand, 1969: 27: 681-695.
4. WHO GOLLABORATING GENIRI: FOR ORAL PRECANGI:ROUS LE-
siONS: Definition of leukoplakia and related lesions: an aid to
studies on oral precancer. Oral Surg. 1978: 46: 518-539.
5. WORLD HICAL'I'H ORGANI/.A'IION: Oral health surveys - Basic
melhods. 2nd ed. WHO, Geneva 1977.
6. WORLD HICALIII ORGANI/.A'I'ION; A guide to oral health epidemi
logicat investigations. WHO, Geneva 1979. Annex I: 37.

Request for reprints:

Oral Health Unit
World Health Organization
1211 Geneva 27
Switzerland
 Guide to epidemiology 25

ANNEX I

Check list of data for survey planning and sampling design

Country:
Principal investigator:
Address:

Area(s) or region(s) to be surveyed:

Population of area (estimate):

Population over 15 years of age (estimate):

Planning data available

Census figures (date):

Best information or estimate of levels of oral mucosal diseases in population.

Important subgroups or subdivision of population.

1, Urban - rural:
2, Ethnic or tribal:
3, Religion:
4, Dietary Regimes: .
5, Habits: - Betel:
Smoking:
Chewing:
Other: _
6, Socioeconomic levels:
Approximate number of subjects it is intended to survey:

Do you wish to make duplicate recordings?

ANNEX 2

•("• Tables available foi- the standaid WHO programme

Tables will be produced for each ethnic, dietary, religious, occupation group and for geographic location, subdivided by sex and
standard age groups for each table, . . : :
1, Iriforrnation on habits (for each hab-it)
N and % with regular ' mean frequency mean duration
habils , per day or week in years
N and % occasional .; ^ . • mean frequency " mean duration
habits per day or week in years
2, Information oti lesions . i .
N and % wilh each lesion ':- prevalence per ' precision levels ' "-
100000 persons
3, Cross tabulation showing habits and lesions for each habit and type of lesion: correlation coefficients between habits and lesions
for the whole population and for only those with habit, . .

Cross tabulation relating location of quid in regular habit groups and location and type oflesion for the following lesions and
subdivisions within lesion type: carcinoma, leukoplakia, erythroplakia, lichen planus, submucous fibrosis, candidiasis,

4, Summary of diOerent treatment requirements, . . . . . . . . .

26 WORLD HEALTH ORGANIZATION

ANNEX 3
Survey Summary Sheet - WHO oral tntteosal diseases assessment

Country: Dale-
Principal investigator:
Address:

Registration numbers used: lo

to
to
Age ranges examined:

Elhnie group Religion : Occupation

(Box 16) Code (Box 17) Code (Box 18) Code

1 1
2 2 2
3 3 3
4 4 4
5 5 5
6 6 6
7 7 7
8 8 8
9 9 9
0 0 0
Dietary group Geographic loealion Examiner
(Box 19) Code Code (Boxes 20 and 21) Code (Box 22) Code
. 1 01 . 1
. 2 02 9
. 3 03 . 3
. 4 04 _ 4
. 5 05 5
. 6 Ofi _ 6
- 7 07 .. 7
. 8 08 _ 8
- 9 09 . 9
- 0 10 _ 0

Additional habits reeorded page 1

Box 33-36
Box 48-51
Box 71-76
Box 77-79
Additional lesions reeorded page 2
Box 74
Box 75
Comments or other relevant information regarding survey data