MOH/K/GIG/1.

2002 (GU)

Primary Prevention
and Early Detection of
Oral Precancer and Cancer

Oral Health Division

Ministry of Health Malaysia
October 2002

This document has been published with the assistance of

the World Health Organisation.

ii

TABLE OF CONTENTS
Primary Prevention and Early Detection of Oral Precancer and
Cancer
TITLE

Page

Table of Contents

iii

Forward by the Oral Health Director, Ministry of Health Malaysia

1.

INTRODUCTION

2.

LITERATURE REVIEW

3.

OBJECTIVES

4.

PROGRAMME TEAM

5.

METHODOLOGY

5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8

4
4
5
5
5
5
6
6

The Target Population

Sampling
Target Population for Opportunistic Screening
Standardisation of Examiners
Screening Period
Management of Programme
Oral Health Education
Forms and Recording Instructions

6.

EQUIPMENT

7.

EXAMINATION PROCEDURES

8.

AID FOR EXAMINERS

9.

DATA COLLECTION, COLLATION, PROCESSING AND ANALYSIS

9.1
9.2
9.3
9.4
9.5
9.6
9.7

Data entry diskette (Appendix 3)

Data entry diskette (Appendix 7)
Minimising data entry error
Data analysis
Data Flow from State to National Level
Data Collection and Flow at District Level
Data Collection and Flow at State Level

9
10
10
10
11
12
13

References

14

Appendices

16-47

iii

LIST OF APPENDICES
TITLE

Page

Appendix 1:

National Steering Committee 2002

Members of the Protocol Work Group

16

Appendix 2:

Flow Chart: Primary Prevention and Early Detection of

Oral Precancer and Cancer

19

Appendix 3:

Format for Screening and Case Detection of Oral

Precancer and Cancer Lesions

20

General Instructions for Appendix 3

23

Appendix 4:

Referral Letter

29

Appendix 5:

Register for Referral Cases

30

Instructions for Filling In Appendix 5

31

Appendix 6:

Flow Chart for Referral Cases

34

Appendix 7:

Data for Analysis on Referral Cases

35

Instructions for Filling In Appendix 7

36

Daily Record of Patients Examined

38

Instructions for Filling In Appendix 8

39

Appendix 9:

General Data

40

Appendix 10:

Distribution of Type of Oral Mucosal Lesions

41

Appendix 11:

Distribution of Type of Risk Habits

42

Appendix 12:

Equipment and Materials

43

Appendix 13:

TNM Classification for Lip and Oral Cavity

44

Appendix 14

Clinical Examination for Oral Mucosal Lesions

45

Appendix 15:

District Codes by State

46

Appendix 8:

iv

FOREWORD
BY THE DIRECTOR OF ORAL
HEALTH,
MINISTRY OF HEALTH MALAYSIA

In Malaysia, there are a number of unique characteristics pertaining to oral

precancer and cancer. Although prevalence is low at 0.04%, oral lesions have
been found to predominantly occur among some identified communities. The
ethnic Indian group comprise about 8% of the population, yet about 60% of oral
lesions are found among communities of ethnic Indian origin. There is also a
higher prevalence of associated precursor lesions found among Indians and the
Indigenous Groups. While ethnic origin is cited, it is acknowledged that such
communities practise risk habits found to be associated with oral lesions; namely
quid chewing, tobacco use and alcohol consumption.
Based on these factors, the Ministry of Health Malaysia has decided that a highrisk strategy aimed at members of such captive communities, augmented by
opportunistic screening of patients in dental clinics, would afford the best
approach towards reducing the incidence and prevalence of oral precancer and
cancer in the country. It is realistic to expect that early intervention through
raising awareness of such lesions coupled with concerted efforts at modifying,
reducing, or at best, stopping risk habits would also lead to a reduction of the
more invasive forms of the disease. On this rationale, the Primary Prevention and
Early Detection of Oral Precancer and Cancer Programme was launched and has
subsequently gained support from the World Health Organisation (WHO) in 2002.
The programme is a primary prevention programme aimed at captive groups. It
works towards raising awareness of known risk factors to oral lesions and of the
signs and symptoms of such lesions. Dental officers on visits to such communities
will also conduct screening sessions for early detection of oral lesions, and are
entrusted to make referrals where necessary, to oral surgeons. Referrals of cases
made through the health system must be tracked and thus oral surgeons and
pathologists play very important roles in management of cases.
There is no magic bullet in preventing and treating cancers. Gaining the support
and co-operation of estate management, village chiefs, and members of the
various communities is pivotal to the success of this programme. It is with great
hope that we undertake this programme and may our joint efforts demonstrate
the reduction in morbidity and mortality that we envisage.
On behalf of the Oral Health Division, I take this opportunity to convey our vote of
thanks to the World Health Organisation (WHO) for its support of the programme.
I also extend my heartfelt appreciation to all involved in the programme planning
and implementation.

DATIN DR. ROHANI BINTI RAMLI

1.

INTRODUCTION

The definition of oral cancers in this programme is confined to cancers of the

orofacial region affecting the oral mucosa including the tongue, lip, gingivae,
palate and alveolus. (This does not include tumours of the salivary glands or
of the oropharynx).
Oral cancer is one form of malignancy that is very easily detected through an
oral examination. Oral health personnel are in the best position to undertake
a systematic and methodical examination of the mouth and its surrounding
structures. There are well-documented risk habits associated with oral
cancers world-wide, and this is true for Malaysia as well. The presence of
precursor or precancerous lesions has also been associated with an
increased risk of oral malignancies.
In Malaysia, oral precancer and cancer lesions are very predominant among
Malaysians of Indian origin. This is borne out by records of case series since
the 1960s1-4. A more recent study5 also identified the indigenous groups of
East Malaysia as having the highest proportion of those with oral
precancerous lesions.
Accumulated records from the Ministry of Health seem to indicate high
morbidity and mortality rates associated with lip and oral cavity cancers.
In Malaysia, the characteristic features of the problem of oral cancer are :
i)

ii)
iii)

it is seen in disproportionately higher frequency in people of Indian

ethnic origin (60% of cases of oral cancer are seen in Indians4
though they comprise about 8% of the population6), and the other
Bumiputra community in Sabah and Sarawak;
it is seen in association with identifiable risk habits (tobacco, betel
quid chewing and high consumption of alcohol); and
cases seen often present late when the disease is well advanced
(Stage 3 or 4).

In the local context, oral cancer meets criteria for priority areas for
medical/health research under the category research in non-communicable
diseases for which hazardous factors are known.
The feasibility of primary prevention programme for oral cancer has been
demonstrated7,8. In view of the associated risk habits as well as the
preponderance of oral precancers and cancers found among identified ethnic
groups, theoretically, if an individual is known to have a precancerous
lesion(s), then it is possible to effect early detection of changes. In addition,
it would also be possible to intervene and advise those with risk habits to
modify, or at best, to stop these habits. On these grounds, a decision was
made that a national programme for primary prevention and early detection
of oral precancer and cancer lesions would offer a cost-effective option
towards a reduction in the overall morbidity and mortality due to oral cancers
in Malaysia.
A combination of this high-risk strategy together with
opportunistic screening at dental attendance would offer the best approach.

2.

LITERATURE REVIEW
In 1998, oral cancers were found to account for 7.1% of cancer deaths in
Ministry of Health facilities9. In the same year, a report on retrospective
records of a large Penang public hospital showed that lip and oral cavity
cancers accounted for about 3% of cancer admissions10. Each year, about
150 200 cases are diagnosed at the Stomatology Unit of the Institute for
Medical Research within the Ministry of Health4 although it has been
suggested that the numbers are probably 1.5 2 times higher as there are
other hospitals and laboratories managing such cancers. Records from
Penang found that more than 80% presented at Stage 3 and 4. With oral
cancers cited at a prevalence of 0.04%5, the percentage of cancers
admissions and deaths attributed to oral cancers would indicate high
morbidity and mortality rates.
Oral cancer is the sixth most common cancer in the world11. In Bangladesh,
India, and Pakistan, oral cancer is the most common cancer12. Oral cancer is
the fifth most common cancer in Malaysia13. In the United Kingdom, oral
cancers account for about 1% of cancers, yet only 30 40% of patients
survive five years. This high mortality rate is associated mainly with late
detection14.
Tobacco and alcohol are well known risk factors in Western countries15. In
South Asian countries, chewing of betel quid with tobacco is largely
responsible for the high incidence of oral cancer16. This habit of betel quid
chewing is also the common cause of oral cancer in this country17.
In the survey of oral mucosal lesions of adults in Malaysia in 1993/1994, it
was found that oral mucosal lesions were found more in the other
Bumiputera subjects (17.0%) and Indian subjects (14.5%)5. This is further
proven by surveys or screening program carried out in the states of
Pahang18, Malacca19 and Sabah20 in 1995. In Pahang where Indians form
57% of the sample examined, 4.5% were found to have leukoplakia, 0.8%
erythroplakia and 0.4% speckled leukoplakia. In Malacca where 76.5 % of
the sample was Indians, 6.6 % of them were found to have precancerous or
suspicious lesions. The study in Sabah was done among the other
Bumiputera groups - the Bajaus, Kadazans and Illanuns. In this study, out of
150 Bajaus examined, 17 (11%) had precancerous lesions; out of 35
Kadazans examined, 3 (8.5%) had these lesions and out of 16 Illanuns
examined, 5 (31%) had these lesions.
The study by Tan BS8 in 1996 found that captive groups of Indians in estate
communities have a 6 to 7-fold propensity for betel quid chewing and a 4fold propensity for alcohol compared to the general population. The study
found that primary prevention and screening has a positive influence on the
16.9% of the population examined.

3.

OBJECTIVES

3.1

General Objectives
To reduce prevalence and incidence of oral precancers and cancers in
identified high-risk communities.

3.2

Specific Objectives
i)
ii)
iii)

4.

To screen adults aged 20 years and above in identified high-risk

communities.
To detect cases of oral precancers and cancers and to make the
necessary referrals.
To educate high-risk communities on the risk factors for oral cancers.

PROGRAMME TEAM
A National Steering Committee shall be formed for the programme to look
into protocol building, training for implementation and monitoring and
evaluation on a national level. The national committee shall also be
responsible to source out new materials for oral health promotion for oral
cancers. Members of the National Steering Committee and the Protocol
Working Group are shown in Appendix 1.
State committees shall be formed for the purpose of:
i)
ii)
iii)

iv)
v)

Planning outreach programmes at state and district levels.

Identification of, and liaison with, estates/kampung/clinics as well as
other communities exhibiting high-risk habits.
Monitoring and evaluation of the programme through the following:
managing data collection through clinical examination formats;
ensuring efficient data flow for compliance of referral cases
between primary and secondary oral healthcare at state level;
monitoring management of patients found with oral lesions at
primary and secondary healthcare at state level;
producing an annual evaluation report on the programme for the
national steering committee.
Planning for training and standardisation of dental officers for oral
lesion identification with state oral surgeons.
Planning for training in all other aspects deemed necessary for the
implementation of the national programme.

At state level the Deputy Director of Health (Dental) will act on behalf of the
Programme Director and shall form his own committee comprising the Oral
Surgeon, Senior Dental Officers and other committee members.
Examiners:

All / selected dental officers

Recorders:

Dental Surgery Assistants shall assist in the

screening as well as registration of subjects and
recording of findings.

Support Staff:

Include drivers, attendants and dental staff nurses,

the latter being primarily involved in oral health
promotive / preventive efforts on oral cancer and
precancer lesions, such as talks and exhibitions to be
held in conjunction with the programme.

This programme will require close co-operation between the various

departments of the Ministry of Health, and strong collaboration with other
related agencies; in particular, the plantation sector and other identified
high-risk communities.
5.

METHODOLOGY
A high-risk strategy involving screening/case detection within high-risk
groups shall be employed.

5.1

The Target Population

5.1.1

Primary Prevention

Oral health education shall be undertaken for all high-risk individuals, their
family members and other members of the estate communities with the
objective of increasing awareness 1) on the associated risks of high-risk
habits as well as 2) on the signs and symptoms of oral precancer and cancer
lesions.
5.1.2

Oral Examination

This will include individuals aged 20 years and above known to have high-risk
habits or living in a community which is more prone to take up that habit.
i).
Indian community in rubber and palm oil estates in Peninsular
Malaysia
ii).
Other Bumiputeras in Sabah and Sarawak are among those identified
for the programme.
iii).
Other identified high-risk communities.
5.2

Sampling
5.2.1

Sampling frame

Identified estates and kampungs will form the sampling frame. This
sampling frame shall be obtained from individual states.
This shall include the list of large estate holdings from the United Planters
Association of Malaysia (UPAM), and a list of smallholders from the Human
Resource Department of Local Authorities as well as other relevant
information from census data from the Statistics Department.
Dental officers, especially in Sabah, Sarawak, Wilayah Persekutuan Kuala
Lumpur and Putrajaya, Kelantan and Perlis shall also obtain information on
communities where there is widespread prevalence of high-risk habits or
identified cancer cases.

5.2.2

Sampling Units

Inclusion criteria
All adults aged 20 years and above, with, or without the high-risk habits,
shall form the sampling units.

Younger individuals known to have high-risk habits shall also be included in

the programme.
Exclusion criteria
Non - Malaysians shall be excluded.
Appendix 2 shows the Flow Chart for the Implementation of the National
Programme for Primary Prevention and Early Detection of Oral Precancer and
Cancer Lesion.
5.3

Target Population for Opportunistic Screening

Adults with high-risk habits attending dental clinics shall be rendered an oral
examination for oral lesions.

5.4

Standardisation of Examiners
A two-tiered standardisation process is proposed.

At national level, a standardisation exercise, involving all oral

surgeons, shall be conducted using colour slides and on patients.

At state level, oral surgeons shall conduct echo sessions for all
potential examiners.

The Stomatology Unit, Institute for Medical Research (IMR) as well as the
Oral Health Division of the Ministry of Health (MOH), shall provide slides for
the purposes of training of examiners. The Oral Health Division shall be
responsible for the national level training session.
5.5

Screening Period
This programme shall be part of the oral health community programmes and
all effort shall be made to ensure its sustainability.

Every estate/kampung/location in the programme shall be revisited at least

once in 5 years.
5.6

Management of Programme
Permission shall be sought from the management of identified
estates/kampungs/locations. A presurvey visit/liaison is recommended to
establish:

5.7

details of the estate - location, access road, racial composition, and

availability of amenities (water, electricity, etc.);
contact / resource personnel - this is normally the estate medical
assistant or supervisor who can help with organisation, publicity
work and referrals;
rapport with any visiting medical officer for purposes of referral and
compliance of subjects;
manpower and logistics details for the study team;
location for screening exercise and oral health promotion - house-tohouse visits are recommended to ensure maximum recruitment. If
this is not feasible, an activity centre shall be identified and efforts
made to increase uptake.

Oral Health Education

This shall be done through exhibitions, oral/poster/video presentations, etc.
Material shall cover smoking, alcohol consumption, and betel quid chewing as
risk habits for oral precancers and cancers. Visual presentation of common
precancer and cancer lesions shall be shown. Information to subjects must
emphasise that oral precancer lesions can be prevented from progressing or
may even regress with cessation, reduction, and modification of habits.
The Oral Health Promotion Unit, MOH in collaboration with the Stomatology
Unit, IMR shall prepare slide packages for training/calibration purposes and
for oral health education activities. However, the states are encouraged to
source out their own resource materials for educational purposes.

5.8

Forms and Recording Instructions

5.8.1

Clinical Format for Screening (Appendix 3).

This form is designed to capture salient points on demographic particulars;

type, size and site of lesions; risk habits and the commitment of subjects to
quit habits; as well as family history on oral cancer.
Recording instructions for this format is shown in Appendix 3_1.
An EPI INFO 6 rec.file shall be built specifically for the purpose of data entry
from Appendix 3. Data entry shall be undertaken in duplicate diskettes, one
to be sent annually, by 31 January the following year, to the Oral Health
Division.
All patients found with suspicious oral lesions shall be referred to the oral
surgeon using the referral form shown in Appendix 4.
5.8.2

Register of Referral Cases (Appendix 5)

Appendix 5 is designed to capture information on cases with oral lesions

referred from primary level to the oral surgeon. Information capture pertains
to demographic particulars; provisional diagnoses made by dental officers

and oral surgeons; as well as management of patients with reference to

biopsies and histological findings.
Instructions for filling in Appendix 5 are shown in Appendix 5_1.
Note:

Appendix 5 shall be managed as a manual form between primary and

secondary level. However, an MSExcel file for Appendix 5 shall be provided
for keeping a computerised register of referred cases at state level.
The flow of data as described below between primary, secondary oral health
care and between state and national levels is shown graphically in Appendix
6.

5.8.3

At the end of each outreach-screening visit the dental officer shall

enter, in duplicate, data on referred cases in Appendix 5 (Columns 1
11). One form shall be sent to the State Committee.
State Committees shall compile all information from clinics/districts
every 3 months (March, June, September and December) to be
printed in 3 copies, two of which are to be sent to the Oral Surgeon.
The Oral Surgeon completes information on patients who attend
their clinics (Columns 12 18) for both copies of Appendix 5
received. One copy shall be sent back to the State Committee (by 2
January of the following year).
All information on the completed Appendix 5 shall be entered into an
MSExcel file designated Appendix 7 (Data for Analysis on
Referral Cases).
Data for Analysis on Referral Cases (Appendix 7)

Appendix 7 is designed to capture essential data on referred cases that

attend oral surgery clinics (compliance). It gives a profile on demographics;
compliance rates within designated time frames; provisional diagnoses on
lesions detected; as well as information on biopsies and histological findings.
An MSExcel file shall be used to input data for Appendix 7. Data entry shall
be undertaken in duplicate diskettes. One diskette shall be sent to the Oral
Health Division, to reach by 31 January the following year.
Instructions for filling in Appendix 7 are shown in Appendix 7_1.
5.8.4

Daily Record of Patients Examined (Appendix 8)

Appendix 8 shall be used as a daily register for each outreach-screening

visit. It is designed to capture particulars of cases screened, as well as their
habit(s) and lesion(s) status.
Instructions for filling in Appendix 8 are shown in Appendix 8_1.

Note:

Appendix 8 shall be kept separately for each estate/ kampung/ location.

When an estate/kampung/location is revisited, information on the current
Appendix 8 shall be compared to the previous Appendix 8 list to trace
repeat cases.
5.8.5

Reporting Format (Appendices 9,10,11 and 12)

Appendices 9,10, and11 are reporting forms that are to be filled by the State
Committee.
Appendix 9 on General Data captures data on locations visited, the
number of adults aged 20 years and above traced and screened at each
location, and the details on oral health education sessions held at each
location.
Appendices 10 and 11 are dummy tables designed to capture data from
the EPI INFO 6 rec.file for each state. These forms should be utilised by
State Committees for their annual evaluation report.
National Level Reports
6-monthly Status Report
Appendix 9 shall be filled by the State Committee and sent to the Oral Health
Division by 31 July each year. Management of this report at state and district
levels shall be at the discretion of the State Committee.
Annual Report
Appendices 9, 10 and 11 shall be filled by the State Committee and sent to
the Oral Health Division annually to reach by 31 January the following year.
6.

EQUIPMENT (Appendix 12)

The essential equipments for examination of all subjects are
disposable gloves
wooden spatulas
cotton
gauze
torchlight
plastic bags to hold waste.
In addition, cases with lesions may require an examination set of
2 mouth mirrors
probes
tweezers
stainless steel rulers for detailed documentation.
A suggested list of equipment and materials for each outreach-screening visit
is in Appendix 12.

7.

EXAMINATION PROCEDURES
The registration and examination of the subjects shall be carried out as a
single exercise.
i)
ii)
iii)
iv)
v)

8.

A daily record of subjects screened shall be kept (Appendix 8) for

each estate/kampung/location.
An enquiry of the subjects medical / dental history and extra-oral
examination shall precede the intraoral examination.
Dentures shall be removed prior to clinical oral mucosal examination.
Subjects shall be seated upright on ordinary / dental / mobile chairs
and examined using adequate artificial light.
Two mouth mirrors may be used for examination if necessary.

AID FOR EXAMINERS

The TNM Classification for Lip and Oral Cavity Cancer is shown in Appendix
13.
The steps for Clinical Examination for Oral Mucosal Lesion are shown in
Appendix 14.
For Diagnostic Criteria for Oral Mucosal Lesions as well as graphical
presentation of steps for clinical examination for oral lesions, please refer to
the following illustrated handbook :

Rosnah Z, Ikeda N, Reichart PA, Axell TE. Clinical Criteria for

Diagnosis of Oral Mucosal Lesions. An Aid for Dental and Medical
Practitioners in the Asia-Pacific Region.
Information for District Codes according to the Health Management
Information System of the Ministry of Health is given in Appendix 15.
9.

DATA COLLECTION, COLLATION, PROCESSING AND ANALYSIS

Annually 2 diskettes shall be sent to national level.

9.1

Data entry diskette (Appendix 3)

At state level, all information from Appendix 3 (Format for Screening and
Early Detection of Oral Precancer and Cancer Lesions) shall be entered into
the EPI INFO 6 rec.file designed for the purpose of this programme.
Data entry shall be undertaken in duplicate diskettes. One diskette shall be
sent annually to the Oral Health Division, to reach by 31 January the
following year.

9.2

Data entry diskette (Appendix 7)

Information from Appendix 5 (Register of Referral Cases) shall be
transferred into the MSExcel file for Appendix 7 (Data for Analysis on
Referral Cases) specifically designed to capture data pertaining to referral
cases.
Data entry shall be undertaken in duplicate diskettes. One diskette shall be
sent annually to the Oral Health Division, to reach by 31 January of the
subsequent year.

9.3

Minimising data entry error

For verification purposes and to minimise data entry error, data shall be
entered twice on the same file either by

the same dental personnel after a break of time; or

by different dental personnel.

9.4

Data analysis
Descriptive analysis of data shall be undertaken using both the Epi Info 6
Programme and the SPSS Version 10.
Each state committee shall send the following forms and two diskettes to the
Oral Health Division.

10

9.5

Data Flow from State to National Level

At 6 months (to reach by 31 July of each year)
Oral Health
Division,
MOH

Appendix 9

Annually (to reach by 31 January the following year)

Appendix 9
Appendix 10
Appendix 11

1 copy of each form to be sent

by 31 January the following
year

Back-up to be kept at state

level
2
EPI INFO 6
rec.file for
Appendix 3

Oral Health
Division,
MOH

1
1 copy of each diskette to be
sent by 31 January the
following year

Back-up to be kept at state

level
2
MSExcel file for
Appendix 7

11

9.6

Data Collection and Flow at District Level

Every Screening Visit
Fill Appendix 3 (Clinical Format for
Screening) for each person
examined.

All
patients

Enter data into Appendix 8 (Daily

Record of Patients Examined) for each
location.

File Appendix 8 for the next screening

visit to the same location.

Enter data into EPI INFO6 rec.file in

duplicate after each screening visit.
An initial diskette with rec.file shall
be provided.

With lesions
Patient takes
referral letter

For those with lesions, fill out

Appendix 4 (referral letter to Oral
Surgeon).

Oral
Surgeon
Send 1 diskette by midJanuary of following
year

Manually enter data into Appendix 5

in duplicate (Register of Referral
Cases) after completion of each
screening visit.

Send 1 copy after

each screening visit.

Information capture (Columns 1-11)

from Appendix 3 + 4.

Send 1 copy every 6

months

Every 6 months

Fill in Appendix 9 in duplicate

(General Data) every 6 months.

To reach State Committee by mid-July

of each year and mid-January the
following year.

12

State Committee

9.7

Data Collection and Flow at State Level

Every 3 months (end of March, June, September, December)
Compile all Appendix 5 (Register of
Referral Cases) information from
districts every 3 months. Print 3 copies.

Send 2 copies
every 3 months

An MsExcel file shall be provided for

Appendix 5.

Oral
Surgeo
n

Returns 1 copy to State

Committee after filling in
Columns 12-18 by 2 January
of following year.

Register shall be updated for the year.

At 6 months
Compile Appendix 9 (General Data)
information from districts by 31 July
each year.

Send 1 copy
(6 months data)

Print and send 1 copy to National Level

by 15 July each year.

Oral
Health
Division,
MOH

Annually (to reach National Level by 31 January the following year)

Merge data (Appendix 3) of EPI
INFO6 rec.file from all districts in
duplicate diskettes.
Send 1 diskette to National Level

Send 1 copy of
diskette

Compile cumulative data from

Appendix 9 (General Data) from all
districts in duplicate.
Analyse data from merged EPI INFO6
rec.file to fill in Appendix 10 and 11.
Appendices to be filled in duplicate.

Send 1 copy of
each Appendix

Send 1 copy of Appendix 9,10 and 11

to National Level.

MSExcel files shall be provided for

Appendices 9,10,11.
Send 1 copy
of diskette

Enter relevant data from annual

Appendix 5 (Register of Referral
Cases) into Appendix 7 (Data for
Analysis of Referral Cases) in duplicate
diskettes.
Send 1 diskette to National Level.

An MSExcel file shall also be provided

for Appendix 7.

13

Oral
Health
Division,
MOH

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Boyle P, Macfarlane GI, Scully C. Oral Cancer: Necessity for Prevention

Strategies. Lancet 1993;342:1129.
Gupta PC. Betel Quid and Oral Cancer: Prospects for Prevention. IARC
Scientific Publication 1991;105:466 - 70.

17.

Ramanathan K, Lakshimi S. Oral Carcinoma in Peninsular Malaysia : Racial

Variations in the Indians, Malays, Chinese and Caucasians. Gann Monograph
on Cancer Research 1976;18:27-36.

18.

Pahang Dental Department. Oral Precancer and Cancer Survey 1995. A

report by Bahagian Perkhidmatan Pergigian , Negeri Pahang.

19.

Melaka Dental Department. Oral Cancer Screening and Detection Programme

In Estates In Malacca 1995. A report by Bahagian Perkhidmatan Pergigian

Negeri Melaka.
20.

Norma AJ, Ferdinand JK, Zaiton T. Oral Precancer, Cancer Screening Project
in Kota Belud, Sabah 1995.

Protocol_OCA2002

15

Appendix 1

NATIONAL STEERING COMMITTEE

2002
Chairman

Datin Dr. Rohani binti Ramli,

Oral Health Director,
Ministry of Health Malaysia.

Co-Chairman

Dr. Norain binti Abu Talib

Deputy Oral Health Director,
Oral Health Division,
Ministry of Health Malaysia.

Secretary

Dr. Khairiyah Abd. Muttalib

Principal Assistant Director,
Oral Health Division,
Ministry of Health Malaysia.

Members

Dato Dr. Wan Mohamad Nasir bin Wan Othman

Deputy Oral Health Director,
Oral Health Division,
Ministry of Health Malaysia.
Dr. Ng Kok Han,
Dental Specialist (Oral Medicine/Oral Pathology),
Stomatology Unit,
Institute for Medical Research,
Ministry of Health Malaysia.
Dr. Wan Mahadzir bin Wan Mustafa,
Consultant Oral Surgeon,
Dental Department,
Hospital Kuala Lumpur.
Dr. Lau Shin Hin,
Dental Specialist (Oral Medicine/Oral Pathology),
Stomatology Unit,
Institute for Medical Research,
Ministry of Health Malaysia.
Dr. Chew Yoke Yuen
Assistant Director,
Oral Health Division,
Ministry of Health Malaysia.

16

MEMBERS OF THE PROTOCOL WORK GROUP

Chairman

Dr. Norain binti Abu Talib

Deputy Oral Health Director,
Oral Health Division,
Ministry of Health Malaysia.

Secretary

Dr. Khairiyah Abd. Muttalib

Principal Assistant Director,
Oral Health Division,
Ministry of Health Malaysia.

Programmer

Dr. R. V. Varatha Raju,

Senior Dental Officer,
Sungai Petani Dental Clinic,
Kedah.

Members

Datin Dr. Nooral Zeila Junid

Principal Assistant Director,
Oral Health Division,
Ministry of Health Malaysia.
Dr. Peace Indrani Chelvanayagam,
Oral Surgeon,
Hospital Tengku Ampuan Rahimah,
Klang, Selangor.
Dr. Lau Shin Hin,
Dental Specialist (Oral Medicine/Oral Pathology),
Stomatology Unit,
Institute for Medical Research,
Ministry of Health Malaysia.
Dr. Habesah Sulaiman,
Principal Assistant Director,
Kelantan Dental Department,
Kota Bharu, Kelantan.
Dr. Yaw Siew Lian,
Principal Assistant Director,
Sarawak Dental Department,
Kuching, Sarawak.
Dr. Wardati Abdul Malek,
Principal Assistant Director,
Perak Dental Department,
Ipoh, Perak.
Dr. Lee Keng Chin,
Dental Public Health Officer,
Melaka Tengah Dental Clinic,
Jalan Tun Sri Lanang,
Melaka.

17

Dr. Selvaruby Selvadurai,

Dental Public Health Officer,
Seremban Dental Clinic,
Negeri Sembilan.
Dr. Amdah Mat,
Dental Public Health Officer,
Banting Dental Clinic,
Kuala Langat, Selangor.
Dr. Chew Yoke Yuen
Assistant Director,
Oral Health Division,
Ministry of Health Malaysia.
Dr. Muzini Mohamad,
Assistant Director,
Oral Health Division,
Ministry of Health Malaysia.

18

Appendix 2

Flow Chart:
PRIMARY PREVENTION AND EARLY DETECTION OF ORAL PRECANCER AND CANCER
Training & standardisation of dental officers

PRIMARY CARE LEVEL

Identification and liaison with estates/kampung/locations

Fix date and venue for screening programme

Oral Health Education

Registration Daily Record of Patients

Examined (Appendix 8)
Follow-up on subjects
commitment to quit.
Examination (Appendix 3)

Yes

No

Lesion
detected

SECONDARY CARE LEVEL

High-risk
habits?

Yes

Refer to Oral Surgeon

(Fill out Appendix 4 and 5)

No

Suspicious of
cancer?

Yes

No

Take
biopsy?

Yes
Send to IMR/local pathologist
(at discretion of OS)

No

Confirm
diagnosis malignant?

Yes
Patient Management by OS
(complete Appendix 5)

No
Follow-up by Dental
Officer in clinic?

Yes
Record

Data entry/ Record of compliance

(update Appendix 5 and enter data into Appendix 7)

19

No

Appendix 3_1

GENERAL INSTRUCTIONS FOR APPENDIX 3

Data Management
1. EPI INFO 6 is a freeware programme that is available at no cost to the state
committee. An EPI INFO 6 rec.file has been built specifically for data entry for this
programme. All data from Appendix 3 are to be entered into this EPI INFO 6
rec.file.
2. Diskettes provided by national level:
- 3 diskettes for installation of EPI INFO 6 shall be provided to each state
committee.
A diskette with the relevant EPI INFO 6 rec.file shall be provided to all state
committees.
3. State committee members shall be responsible for making 2 back-up diskettes of
this master rec.file. One diskette shall be stored as back-up for rec.file at state
level.
Data Entry
1. At any one time, 2 diskettes shall be used for data entry.
2. Data entered shall be backed-up in the second diskette at the end of each day.
Data Verification
1. For verification purposes, data entry is to be conducted twice
either by the same personnel after a break of time,
or by different personnel on different occasions.

RECORDING INSTRUCTIONS FOR APPENDIX 3

GENERAL RECORDING INSTRUCTIONS

1.

To maintain examiners objectivity during examination, ORAL MUCOSA

EXAMINATION (Section D) will precede the enquiry of HABITS and
SUBJECTS COMMITMENT TO QUIT their habits (Section E) and FAMILY
HISTORY (Section F).

2.

ENTER ALL DATA IN CAPITAL LETTERS.

23

SPECIFIC INSTRUCTIONS
Item Name

Specific Instructions

Personal ID

Enter an 8-digit number

- the first 2 numbers are to be the state code
- the second 2 numbers are to be the district
code
- the last 4 numbers to be in the order of
examination of patient.

**please see instructions

under Attendance
**Refer to Appendix 15

for District Codes

For example, the first patient examined in Melaka (08) in

the district of Melaka Tengah (05) will be
0

Registration Number

Enter the last 4-digits of the patients identity card (IC)

number.

Case

Enter
1 = screening
(for cases seen during screening exercise held in
the estates/kg/location)
2 = walk-in cases
(cases seen as outpatients in dental clinics)

Attendance

Enter
1 = new
*Ask patient whether
2 = repeat (if patient has been examined before,
they have been examined
regardless of year of examination).

before.

If patient is a repeat case, the original Personal ID given

at the first screening session must be used (trace from
previous Appendix 8 of visits to the estate/kg/location
Daily Record of Patients Examined).

Year

Enter the year of screening.

Date of Screening

Enter the actual date of screening.

For example:
2 5 1 1 2 0 0
day month
year

A. SOCIO-DEMOGRAPHIC PARTICULARS
State

Enter the state code

01 = WP Kuala Lumpur & Putrajaya
02 = Perlis
03 = Kedah
04 = Pulau Pinang
05 = Perak
06 = Selangor
07 = Negri Sembilan
08 = Melaka

24

09
10
12
13
14
15
16

=
=
=
=
=
=
=

Johor
Pahang
Terengganu
Kelantan
Sabah
Sarawak
WP Labuan

District

Enter the district code. (*refer to Appendix 15)

Estate/Kampung/Location

Enter the name of the estate/kampung/location.

Name

Enter the name of the subject as it appears in the

Identity Card.

Address

Enter the full address of the subject for purposes of

follow-up.

IC No.

Enter the patients old/new identity card number (boxes

are provided to accommodate new IC numbers).

Gender

Enter
1 = male
2 = female

Date of Birth

The patients actual date of birth is to be documented for

verification purposes, for example, a person born on
1.1.1950 is to be recorded as
0 1 0 1 1 9 5
day month
year

Age

The age in years will be automatically computed on data

entry.

Ethnic Group

Use the following codes and enter accordingly

01 = Malays
02 = Chinese
03 = Indian/Pakistani
04 = Kadazan
05 = Murut
06 = Bajau
07 = Iban
08 = Bidayuh
09 = Melanau
10 = Other Bumiputera
11 = Others

B.

MEDICAL HISTORY

Medical History

Enter
0 = No
1 = Yes
If yes, please specify the medical condition(s).

25

C.

LYMPH NODES

Lymph Nodes

D.

Enter
0 = No
1 = Yes
If yes, please specify site(s) of node(s) involved.

ORAL MUCOSA EXAMINATION

If 1=Yes has been entered for Any Lesion please ensure that all boxes are filled by entering a 0 = not
applicable where relevant.

Any Lesion

Enter
0 = No (If No, go straight to Section E).
1 = Yes (If yes, specify TYPE, SIZE and SITE of lesion).

Type, Size and Site of

Lesion

The patient may have more than 1 type of lesion. Boxes

have been provided to accommodate for 1st, 2nd and
3rd Lesion and Other Pathology.
For each type of lesion detected, enter:
0 = not applicable
1 = leukoplakia
2 = erythroplakia
3 = lichen planus
4 = submucous fibrosis
5 = suspicious of oral cancer

Criteria for identification of lesion must be strictly

adhered to. For example, an ulcer that is established
because of a traumatic episode, and is not clinically
suspicious, is recorded as Other Pathology and specified
as traumatic ulcer.
For each of the lesion detected, specify the overall size
of lesion by entering the following codes:
0 = not applicable
1 = 0 - 2 cm
2 = > 2 - 4 cm
3 = > 4 - 6 cm
4 = > 6 cm.
For each of the lesion detected, enter the code(s) for
site(s) of lesion according to the graphical presentation
given. Boxes for four sites have been provided.
If more than 4 sites are involved, record the lesion as
code = 44 (widespread) in boxes for Site 1. Enter Code
00 for all other sites for that lesion.
Enter Code 00 if not applicable

26

E.

HABITS

If 1=Yes has been entered for Any present or past habits please ensure that all boxes are filled by
entering a 0=no such habit/not applicable where relevant.

Any present or past

habit(s).

Enter
0 = No (If No, go straight to Section G).
1 = Yes (If yes, specify).

Habit(s) not categorised under 1 10 are to be

recorded as 11 = Other habits and specified.
Habit

For each of the habit specified enter:

0 = no such habit
1 = habit currently practised
2 = past habit now has stopped

Duration (in years)

Enter the duration of present or past habit(s)

0 = not applicable
1 = 5 years and below
2 = > 5 years to 10 years
3 = > 10 years

Subjects Commitment To
Quit

This section records the patients own perception of how

committed he/she is to quit the habit after having been
informed of the dangers of smoking, alcohol drinking,
and betel quid chewing. The subject may have different
degree of commitment to quit for different habit(s). For
example, he/she may feel that betel quid chewing may
be given up easily and will succeed but may admit to
not being able to give up smoking. As this section is
very subjective, caution must be exercised so that the
appropriate answer could be obtained. Use language
that can be understood by the subject.
Ask the following question.

Now that you have been informed about the

danger of your habit(s)
[smoking, alcohol
drinking and betel, quid chewing], what do you
think you will do?
or in Bahasa Melayu
(Setelah anda diberitahu tentang bahaya tabiat
yang anda amalkan (merokok, minum arak dan
makan sireh atau songel tembakau), apakah
langkah selanjutnya yang akan anda ambil ?)

Read to the subject the options (1 4 below) and ask

him/her to choose one answer that best describes what
his/her next action will be.

27

All boxes must be filled.

0 = not applicable (no such habits)

(tidak berkenaan)

1= quit with great determination, thinks will succeed

(penuh keyakinan akan berhenti dan berjaya).

2 = attempt to quit, does not think will succeed

(berusaha untuk berhenti, tetapi tidak yakin akan

berjaya).

3 = reduce or modify habit

(akan mengurangkan atau menukar tabiat).

4 = continue and accept consequences

(akan meneruskan tabiat dan bersedia menerima

akibatnya).

F.

FAMILY HISTORY

Any family history of

cancer is to be indicated

0 = No,
1 = Yes.. (If Yes, specify type of cancer).
Specify the relationship of the affected person to the
patient.
1 = parent
2 = sister/brother
3 = grandparent
4 = aunt/uncle
5 = cousin
6 = other relation, specify.

G.
H.

EXAMINER (Enter the name of the Dental Officer).

REFERRAL TO DENTAL SPECIALIST

Referral to dental
specialist

0 = No
1 = Yes
Enter Date Referred

28

Appendix 3
CLINICAL FORMAT FOR SCREENING
PRIMARY PREVENTION AND EARLY DETECTION OF
ORAL PRECANCER AND CANCER PROGRAMME
ORAL HEALTH DIVISION, MINISTRY OF HEALTH MALAYSIA

Personal ID:
Registration Number:
Case:

(1=Screening, 2=Walk-in Case)

Attendance:

(1=New, 2=Repeat)

Year:
Date of Screening:
Day

A.

Month

Year

SOCIO-DEMOGRAPHIC PARTICULARS:
District:

State:

Estate/kampung/location: _______________________________________
Name:

___________________________________________________

Address:

___________________________________________________
___________________________________________________

IC No:
Gender:

(1=Male, 2=Female)

Age:

Date of Birth:
Ethnic Group:

B.

MEDICAL HISTORY:

(01=Malay, 02=Chinese, 03=Indian/Pakistani, 04=Kadazan,

05=Murut, 06=Bajau, 07=Iban, 08=Bidayuh, 09=Melanau,
10=Other Bumiputra, 11=Others)

(0=No, 1=Yes)

If Yes, specify: ____________________________________________________

C.

LYMPH NODES:

(0=No, 1=Yes)

If Yes, specify: ____________________________________________________

20

D.

ORAL MUCOSA EXAMINATION:

Any lesion:

(0=No, 1=Yes)

(If NO, go straight to Section E)

If Yes, specify TYPE, SIZE and SITE of lesion:

LESION TYPE
0 = not applicable
1 = Leukoplakia
2 = Erythroplakia
3 = Lichen Planus
4 = Submucous fibrosis
5 = Suspicious of oral cancer

SIZE
0 = not applicable
1 = 0 - 2 cm
2 = > 2 - 4 cm
3 = > 4 6 cm
4 = > 6 cm

TYPE

SITE OF LESION
Use codes given below. If more than 4
sites are involved, enter 44 =
WIDESPREAD in boxes marked for
Site 1.
Code 00 if not applicable

SIZE

SITE 1

SITE 2

SITE 3

SITE 4

st

1. 1 lesion
2. 2nd lesion
3. 3rd lesion
4. Other pathology,
Please specify:

_______________

SITE OF LESION: Please draw / indicate on diagram to facilitate identification of numbers.

00 = not applicable
01 = Right Lip commissure
02 = Right buccal mucosa
03 = Left lip commissure
04 = Left buccal mucosa
05 = Upper labial mucosa
06 = Lower labial mucosa
07 = Right upper buccal sulcus
08 = Upper labial sulcus
09 = Left upper buccal sulcus
10 = Right lower buccal sulcus
11 = Lower labial sulcus
12 = Left lower buccal sulcus
13 = Right upper buccal alveolar mucosa
14 = Labial alveolar mucosa
15 = Left upper buccal alveolar mucosa
16 = Right lower alveolar mucosa
17 = Lower labial alveolar mucosa
18 = Left lower alveolar mucosa
19 = Right upper palatal alveolar mucosa
20 = Upper palatal alveolar mucosa
21 = Left upper palatal alveolar mucosa
22 = Right lower lingual alveolar mucosa
23 = Lower lingual alveolar mucosa
24 = Left lingual alveolar mucosa
25 = Right floor of mouth
26 = Anterior floor of mouth
27 = Left floor of mouth
28 = Right ventral surface of tongue
29 = Left ventral surface of tongue
30 = Right lateral border of tongue
31 = Left lateral border of tongue
32 = Tip of tongue
33 = Right dorsal surface of tongue
34 = Left dorsal surface of tongue
35 = Posterior tongue
36 = Right palatal mucosa
37 = Left palatal mucosa
38 = Right soft palate
39 = Left soft palate
40 = Right retromolar
41 = Left retromolar
42 = External upper lip
43 = External lower lip
44 = WIDESPREAD

21

E.

HABITS:
Any present or past habits:

If YES, specify:

(0=No, 1=Yes)

HABITS
0 = no such habit
1 = habit currently
practiced
2 = past habit now has
stopped

(If NO, go straight to Section G)

DURATION (IN YEARS)

SUBJECTS COMMITMENT TO QUIT

0 = not applicable
1 = 5 years and below
2 = > 5 years to 10
years
3 = > 10 years

0 = not applicable
1 = quit with great determination,
thinks will succeed
2 = attempt to quit, does not think will
succeed
3 = reduce or modify habit
4 = continue and accept consequence

1. Betel quid (areca nut + tobacco)

2. Betel quid (tobacco only)
3. Betel quid (areca nut only)
4. Tobacco quid (no betel leaf)
5. Areca quid (no betel leaf)
6. Smoking cigarette
7. Smoking cigar/cheroot
8. Smoking bidi
9. Smoking pipe
10. Alcohol
11. Other habits:
please specify: ______________________________________

F.

FAMILY HISTORY:
Has any member of family had cancer?

(0=No, 1=Yes)

If yes please specify: ________________________________________

Relationship to patient
1=Parent
2=Sister/brother
3=Grandparent
4=Aunt/uncle
5=Cousin
6=Other relation, please specify: ________________________________

G.

EXAMINER:

_______________________________________

H.

REFERRAL TO DENTAL SPECIALIST:

(Date referred:_________________________ )

22

(0=No, 1=Yes)

Appendix 4

Kepada,
Pakar / Pegawai Pergigian
Klinik Pergigian
_________________________________________
_________________________________________
Tuan / Puan Doktor,
PROGRAM PRIMARY PREVENTION AND EARLY DETECTION OF ORAL
PRECANCER AND CANCER LESIONS.
Nama Pesakit:
No. Kad Pengenalan:
Estet/kampung/klinik:
Personal ID
-------------------------------------------------------------------------------------------------------Pesakit ini telah diperiksa di klinik saringan yang dijalankan di
...
pada tarikh.. dan dalam pemeriksaan tersebut didapati

diagnosa

awalan adalah.

. yang mungkin
memerlukan biopsi / rawatan lanjut. Diharap beliau dapat diberi rawatan yang
diperlukan.
Sekian. Terima kasih.
BERKHIDMAT UNTUK NEGARA
Saya yang menurut perintah,

....................................................

29

Appendix 5
REGISTER OF REFERRAL CASES
Primary Prevention and Early Detection of Oral Precancer and Cancer Lesions Programme
This form is for use at clinic/district as well as at state level (fill in where applicable)

State
Estate/Kampung/Location

District..

To be filled in at Primary Oral Healthcare Level

Clinical
TNM
Prov.
Date seen by
OS
Diagnosis OS Code
Diagnosis DO
Age

Estate/Kg/
Location

Ethnicity

IC

Gender

Name

State

Ser Date referred Personal ID

10

11

12

13

14

To be filled in by Oral Surgeon

Biopsy
HistoLesion
done
Diagnosis
Status
15

16

17

Comments

18

Appendix 5_1
Instructions for Filling In Appendix 5
REGISTER OF REFERRAL CASES
1.

Appendix 5 shall be managed as a manual form between primary and secondary oral
healthcare level. However, an MSExcel file of Appendix 5 shall be provided for
keeping a computerised register of referred cases at state level.

2.

This diskette is not required at national level.

3.

Appendix 5 is for use at clinic/district/state level. At state level, all information from
clinic/district (Columns 1 11) are compiled every quarter (Mar, Jun, Sept, Dec) and
sent on to the Oral Surgeon.

4.

The Oral Surgeon completes information (Columns 12 18) and returns 1 copy of
Appendix 5 to the State Committee by 2 January the following year.

5.

If the Oral Surgeons receives a referral case from another state, columns 1 18
should be filled in (as many as possible) by the Oral Surgeon. These cases are to be
noted at the bottom most portion of Appendix 5 at the end of the year. Inter-state
liaison should be undertaken by the State Committee to alert the other state(s)
concerned (check State Code).

Column No.

Column Name

Definition

Columns 1 11 to be filled in at Primary Oral Healthcare Level

Column 1

Ser

Begin with number 1 and so on.

Column 2

Date referred

Enter date of referral by dental officer to Oral

Surgeon

Column 3

Personal ID

Enter the Personal ID number as recorded on the

examination form (Appendix 3).

Column 4

Name

Enter the name of referred patient.

Column 5

IC

Enter patients identification card no.

Column 6

State

Enter the state code

01 = WP Kuala Lumpur & Putrajaya
02 = Perlis
03 = Kedah
04 = Pulau Pinang
05 = Perak
06 = Selangor
07 = Negri Sembilan
08 = Melaka
09 = Johor
10 = Pahang
12 = Terengganu
13 = Kelantan
14 = Sabah
15 = Sarawak
16 = WP Labuan

31

Column 7

Estate/Kg/Location

Enter the name of estate/kampung/location

Column 8

Gender

Enter
1 = male
2 = female

Column 9

Ethnicity

Enter coding for ethnic group

01 = Malay
02 = Chinese
03 = Indian/Pakistani
04 = Kadazan
05 = Murut
06 = Bajau
07 = Iban
08 = Bidayuh
09 = Melanau
10 = Other Bumiputera
11 = Others

Column 10

Age

Enter the age of patient (cross check with age

automatically computed in EPI INFO file).

Column 11

Prov. Diagnosis DO

Enter code for the provisional diagnosis of dental

officer

(if there is more than

one provisional
diagnosis , please
enter all relevant
codes
e.g. 1,3,4)

1
2
3
4
5
9

=
=
=
=
=
=

Leukoplakia
Erythroplakia
Lichen Planus
Submucous fibrosis
Suspicious of oral cancer (potentially malignant)
Other pathology

Columns 12 18 to be filled in by Oral Surgeon

Column 12

Date seen by OS

Enter date first seen by Oral Surgeon.

Column 13

Clinical Diagnosis OS

Enter code for the clinical diagnosis of Oral Surgeon

(if there is more than

one clinical diagnosis,
please enter all
relevant codes
e.g. 1,3,4)

1
2
3
4
5
9

TNM Code

Enter the TNM clinically assessed by Oral Surgeon

Column 14

1
2
3
4
Column 15

Biopsy

=
=
=
=
=
=

=
=
=
=

Leukoplakia
Erythroplakia
Lichen Planus
Submucous fibrosis
Suspicious of oral cancer (potentially malignant)
Other pathology

Stage
Stage
Stage
Stage

1
2
3
4

If biopsy done enter 1 = yes, otherwise insert a dash

( - ).

32

Column 16

Column 17

Histological Diagnosis

Enter diagnosis based on histological findings

(if there is more than

one histological
finding , please enter
all relevant codes
e.g. 1,4,7)

1
2
3
4
5
6
7

Lesion Status

Enter code
0 = benign,
1 = pre-malignant
2 = malignant

*If there is more

than 1 lesion, record
the status of the
most severe lesion.

Column 18

Comments

=
=
=
=
=
=
=

Hyperkeratosis
Epithelial dysplasia
Carcinoma-in-situ
Invasive squamous cell carcinoma
Oral lichen planus
Oral submucous fibrosis
Other malignancies (please specify in Column
18)
8 = Benign pathologies (please specify in Column 18)

Lesion status is based on histological diagnosis. If

there is no histological diagnosis, then lesion status
shall be based on clinical diagnosis.
Enter any comment(s) e.g. description of other
pathology, refusal for management etc.
If Column 16 for Histological Diagnosis is coded
either 7 or 8, please specify lesion here.

33

Appendix 6
FLOW CHART FOR REFERRAL CASES DATA
PRIMARY PREVENTION AND EARLY DETECTION OF ORAL PRECANCER AND CANCER

Fill in 2 copies of Appendix 5 for cases

referred to Oral Surgeon (Columns 1 11)
- 1 to be sent to State Committee
- 1 to be kept at clinic

Clinic/District

Send 1 copy of Appendix 5 to State Committee on

completion of screening

Compilation of Appendix 5 every quarter (Mar, Jun,

Sept, Dec).
Information to be typed into MSExcel file and printed
in 3 copies
- 2 to be sent to Oral Surgeon
- 1 to be kept by State Committee

State Committee

Send 2 copies of Appendix 5 to Oral Surgeon

Oral Surgeon to fill in additional information on Appendix 5

received (Columns 12 18) in duplicate
- 1 to be sent back to State Committee
- 1 to be kept at Oral Surgery Clinic

Oral Surgeon

Oral Surgeon to send back 1 copy of Appendix 5

annually (by 2 Jan of the following year)

Update Appendix 5 MSExcel file annually.

Information from Appendix 5 to be transferred into Appendix
7 MSExcel file (computerised register for referral cases).
Appendix 7 diskettes to be in duplicate
- 1 to be sent to national level
- 1 to be kept at state level

State Committee

Send 1 copy of diskette to national committee

annually (by 31 Jan of the following year)

National Committee

SPSS Analysis of information from

Appendix 7 diskette annually

34

Appendix 7
DATA FOR ANALYSIS ON REFERRAL CASES
Primary Prevention and Early Detection of Oral Precancer and Cancer Lesions Programme
This form is to be submitted as an MSExcel file only
State

District

PersonalID

Compliance

Gender

Ethnicity

PDDO 1

PDDO 2

PDDO 3

PDOS 1

PDOS 2

PDOS 3

TNM

Biopsy

HD1

HD2

HD2

Lesion Status

Appendix 7_1

Instructions for Filling In Appendix 7

DATA FOR ANALYSIS ON REFERRAL CASES
1.

Information from Appendix 5 is to be transferred into an MSExcel file (Appendix

7) in duplicate diskettes. 1 diskette is to be sent to the Oral Health Division
annually, to reach by 31 January the following year.

2.

PDDO = Provisional Diagnosis by Dental Officer

3.

PDOS = Provisional/Clinical Diagnosis by Oral Surgeon.

Columns

Information to be taken from Appendix 5

State

Enter the recorded state code

District

Enter the recorded district code

PersonalID

Enter the recorded 8-digit personal ID

Compliance

Estimate period of compliance

*Date seen by OS

1
2
3
4
5
9

Gender

Enter the recorded code for gender.

Ethnicity

Enter the recorded code for ethnic group.

PDDO 1

Enter the recorded code for the first provisional diagnosis of

dental officer.

PDDO 2

Should there be more than one provisional diagnosis, enter

the second recorded code in Column PDDO 2.

PDDO 3

Enter the third recorded code in Column PDDO 3.

PDOS 1

Enter the recorded code for the first provisional/clinical

diagnosis of Oral Surgeon.

PDOS 2

Should there be more than one clinical diagnosis, enter the

second recorded code in Column PDOS 2.

PDOS 3

Enter the third recorded code in Column PDOS 3 (if any).

TNM

Enter the recorded TNM code.

Date referred.

=
=
=
=
=
=

within 6 months
> 6 months to 1 year
> 1 to 2 years
> 2 to 3 years
> 3 to 5 years
> 5 years

36

Biopsy

Enter the number 1 where recorded.

Columns left blank are to be recorded as zero 0.

HD 1

Histological Diagnosis 1. Enter the first recorded code.

HD 2

Histological Diagnosis 2. Should there be more than one

histological finding; enter the second recorded code in
Column HD 2.

HD 3

Histological Diagnosis 3. Enter the third code recorded (if

any).

Lesion Status

Enter code 0, 1 or 2 as recorded.

37

Appendix 8

areca + tobacco

areca

tobacco areca

only

nut only

quid

quid

10

11

12

13

Cigar-

16

17

18

ette (cheroot)

14

Examiner...........................
Clinic.......................................

Lesions (1 = Yes)
Cigar
Alcohol

tobacco

No betel leaf

Pipe

Habits ( 1 = Yes)
With betel leaf

Bidi

IC No.

Ethnic Gp.

Name

Gender

RN

Age (in years)

No.

PersonalID

DAILY RECORD OF PATIENTS EXAMINED

Total estimated pop.
State.......................................District.................................................
Name of Estate/Kampung/Location.....................................................................
20 or more years (M'sian)
Date ....................................
.

15

Leuko- Erythro-

Lichen

plakia

Planus

19

plakia

20

21

Remarks

Sub- Suspicious

Other

mucous

of oral

pathology

fibrosis

cancer

(specify)

22

23

24

(inc. other habits)

25

Appendix 8_1

Instructions for Filling In Appendix 8

DAILY RECORD OF PATIENTS EXAMINED
Note:
1.
This form is to be filled in after each screening session is completed.
2.

This list is to be kept and referred to on subsequent follow-up visits to the

estate/kampung/location in order to trace repeat cases.

Column No.
Column 1

Column
Name
No.

Definition

Column 2

Personal ID

Enter the personal ID recorded on Appendix 3

(Clinical Format for Screening).

Column 3

RN

Enter the last 4 digits of IC Number (old or new)

Column 4

Name

Enter patients name.

Column 5

IC No.

Enter the full identification card number of patient.

Column 6

Age (in
years)

Estimate the patients age in years by calculating

Date of Screening Date of Birth

Column 7

Gender

Enter code
1 = male
2 = female

Column 8

Ethnic Gp.

Enter coding for ethnic group

01 = Malay
02 = Chinese
03 = Indian/Pakistani
04 = Kadazan
05 = Murut
06 = Bajau
07 = Iban
08 = Bidayuh
09 = Melanau
10 = Other Bumiputera
11 = Others

Columns 9 - 18

Habits

If habit(s) is present enter 1 for Yes where

applicable, otherwise leave blank.

Columns 19 - 24

Lesions

If lesion(s) is present enter 1 for Yes where

applicable, otherwise leave blank.

Column 25

Remarks

Enter any remarks as necessary, e.g. other habits

etc

Begin with number 1 and so on.

39

Appendix 9
GENERAL DATA
PRIMARY PREVENTION AND EARLY DETECTION OF ORAL PRECANCER AND CANCER LESIONS PROGRAMME
STATE

DISTRICT

YEAR

No. of high-risk Estates/Kampungs/Locations identified in state/district.

No.

Name of estate/kg/location visited

TOTAL

Total estimated
pop. aged > 20
years (from
Appendix 8)

Adults = 20 years or more

Oral health promotion sessions for oral

precancer and cancer (from PKP 201)
TOTAL

20-29

30-39

40-49

50-59

60-69

> 69

n exam.

n exam.

n exam.

n exam.

n exam.

n exam.

n exam.

%
examined

10
(Sum 4 to 9)

11
(10/3 x
100)

No. of
No. of DHE
exhibitions etc sessions
12

13

No. of
participants (if
available)
14

Appendix 10
DISTRIBUTION OF TYPE OF ORAL MUCOSAL LESIONS
STATE ..............................................
NAME OF ESTATE / KAMPUNG / LOCATION ..................................................................
ETHNIC GROUP .................................................
Age Group

Gender

20-29

M
F
Total

30-39

M
F
Total

40-49

M
F
Total

50-59

M
F
Total

60-69

M
F
Total

70 or more

M
F
Total

GRAND
TOTAL

M
F

No.
exam
N

No. found with

lesions (% of N)

4/3 x 100

No. of
lesions
detected

Data can be obtained from merged data of Appendix 3 in EPI INFO rec.file

Type of Lesion (% calculated based on no. of lesions detected)

Leukoplakia

Erythroplakia

Lichen Planus

Submucous
Fibrosis

Suspicious of oral
cancer

Other Pathology

6/5 x 100

7/5 x 100

8/5 x 100

9/5 x 100

10

10/5 x 100

11

11/5 x 100

Total

Appendix 11
DISTRIBUTION OF TYPE OF RISK HABITS
STATE.................................................
NAME OF ESTATE/KAMPUNG/LOCATION............................................
ETHNIC GROUP ................................................
Data can be obtained from merged data of Appendix 3 in EPI INFO rec.file
Age
Group

Gender

20-29

M
F
Total

30-39

M
F
Total

40-49

M
F
Total

50-59

M
F
Total

60-69

M
F
Total

>69

M
F
Total

GRAND M
TOTAL
F

N
(No.
exam.)

No. found with

habits (% of N)

4/3 x
100

No. of
Quid (with betel leaf)
habits
detected areca + tobacco tobacco only
areca nut only

tobacco quid

Alcohol

Smoking

Quid (no betel leaf)

areca quid

cigarettes

cigar (cheroot)

bidi

No Habits

pipe

6/5 x
100

7/5 x
100

8/5 x
100

9/5 x
100

10

10/5 x
100

11

11/5 x
100

12

12/5 x
100

13

13/5 x
100

14

14/5 x
100

15

15/5 x
100

16

16/5 x
100

Total

Appendix 12

EQUIPMENT AND MATERIALS

1.

mouth mirrors

2.

probes

3.

tweezers

4.

stainless steel rulers

5.

disposable gloves

6.

disposable masks

7.

wooden spatulas

8.

pre-sterilised cotton

9.

pre-sterilised gauze

10.

cold sterilising solution

11.

torchlight / Waldmann light

12.

mobile dental / household chair

13.

clinical waste container/bag

14.

Appendix 3 (Format for Screening and Early Detection of Oral Precancer and
Cancer Lesions)

15.

Appendix 8 (Daily Record of Patients Examined)

16.

Appendix 8 of previous visit(s) if available

17.

Oral Health Promotion Materials

43

Appendix 13
TNM CLASSIFICATION FOR LIP AND ORAL CAVITY
T = Extent of the Primary tumour

Includes both the clinical (T) and pathologic (pT) categories

T designation varies according to the anatomic site involved
primary tumour cannot be assessed
Tx no evidence of primary tumour
T0 carcinoma in-situ
Tistumour 2 cm or less in greatest dimension
T1 tumour more than 2 cm but not more than 4 cm in greatest dimension
T2 tumour more than 4 cm in greatest dimension
T3 tumour invades adjacent structures (tongue, skin of neck, and through
T4 cortical bone)
N = Absence/ presence and extent of regional lymph node metastasis

Includes both the clinical (N) and pathologic (pN) categories

Nx N0 N1 N2 -

N3-

regional lymph nodes cannot be assessed

no regional lymph node metastasis
metastasis in a single ipsilateral lymph node, 3 cm or less in greatest
dimension
metastasis in a single ipsilateral lymph node, more than 3 cm but not
more than 6 cm in greatest dimension or metastasis in multiple ipsilateral
lymph nodes none more than 6 cm in greatest dimension or metastasis in
bilateral or contralateral lymph nodes none more than 6 cm in greatest
dimension
Metastasis in a lymph node more than 6 cm in greatest dimension.

M = absence or presence of distant metastasis; includes both the

clinical (M) and pathologic (pM) categories
Mx M0 M1 -

not assessed
no distant metastasis
distant metastasis present

CLINICAL STAGE
STAGE I

T1N0M0

STAGE II

T2N0M0

STAGE III

T3N0M0 or T1N1M0 or T2N1M0

STAGE IV

T4N0M0 or T4N1M0;
Any T, N2 or N3, M0; Any T, any N, M1

44

Appendix 14

CLINICAL EXAMINATION FOR ORAL MUCOSAL LESIONS

See HANDBOOK

1.

STEPS FOR INTRA-ORAL

EXAMINATION
Anterior/Lower labial mucosa

2.

Right lower labial sulcus

Right lower sulcus and alveolus

3.

Right buccal mucosa

Right commissure, and right buccal

mucosa

4.

Right upper labial sulcus

Right upper sulcus and alveolus

5.

Anterior/Upper labial mucosa

Anterior upper labial mucosa, sulcus and

alveolus

6.

Left upper labial sulcus

Left upper sulcus and alveolus

7.

Left buccal mucosa

Left commissure, and left buccal mucosa

8.

Left lower labial sulcus

Left lower sulcus and alveolus

9.

Tongue
- hold in protruded position with
a piece of gauze around the tip;
- move it right and left
- raised to touch palate

Posterior third, tonsillar region, dorsum

and right and left lateral borders of the
tongue

10.

Head tilted backwards, mouth

opened

SITE
Anterior lower labial mucosa, sulcus and
alveolus

Ventral surface of tongue and floor of

mouth and lingual alveolar mucosa.
Palate - hard and soft

45

Appendix 15
DISTRICT CODES BY STATE
STATE
WILAYAH
PERSEKUTUAN KL &
PUTRAJAYA

STATE CODE
01

DISTRICT
Cahaya Suria
Bangsar
Jinjang
Dato Keramat
Putrajaya

DISTRICT CODE
01
02
03
04
05

PERLIS

02

No division by district

02

KEDAH

03

PULAU PINANG

04

PERAK

05

SELANGOR

06

NEGRI SEMBILAN

07

MELAKA

08

Alor Setar / Pendang

Kuala Muda
Kubang Pasu
Padang Terap
Sik
Yan
Kulim / Bandar Baru
Baling
Langkawi
Seberang Perai Utara
Seberang Perai Tengah
Seberang Perai Selatan
Timur Laut
Barat Daya
Hilir Perak
Hulu Perak
Manjung
Kerian
Kuala Kangsar
Batang Padang
Larut, Matang, Selama
Kinta
Perak Tengah
Gombak
Petaling
Kuala Selangor
Hulu Langat
Sepang
Sabak Bernam
Hulu Selangor
Klang
Kuala Langat
Seremban
Kuala Pilah
Tampin
Port Dickson
Jelebu
Melaka Tengah
Alor Gajah
Jasin

01
02
03
04
05
06
07
08
09
08
09
10
11
12
15
16
17
18
19
20
21
22
23
08
09
10
11
12
13
14
15
16
08
09
10
11
12
05
06
07

46

STATE

STATE CODE

JOHOR

09

PAHANG

10

TERENGGANU

12

KELANTAN

13

SABAH

14

SARAWAK

15

WP LABUAN

16

DISTRICT
Johor Bharu
Muar
Batu Pahat
Kluang
Segamat
Pontian
Kota Tinggi
Mersing
Kuantan
Pekan
Lipis
Temerloh
Jerantut
Raub
Bentong
Cameron Highlands
Rompin
Maran
Kuala Terengganu
Hulu Terengganu
Besut
Dungun
Kemaman
Marang
Setiu
Kota Bharu
Pasir Mas
Pasir Puteh
Machang
Bachok
Tanah Merah
Kuala Krai
Tumpat
Gua Musang
Jeli
Kota Kinabalu
Kudat
Keningau
Beaufort
Tawau
Lahad Datu
Sandakan
Kuching
Sri Aman
Sibu
Miri
Limbang
Sarikei
Kapit
Kota Samarahan
Bintulu
Labuan

47

DISTRICT
CODE
01
02
03
04
05
06
07
08
11
12
13
14
15
16
17
18
19
20
07
08
09
10
11
12
13
10
11
12
13
14
15
16
17
18
19
01
02
03
04
05
06
07
01
02
03
04
05
06
07
08
09
08