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Decide the purpose before taking or sharing an image

A photograph collected for clinical care and an image intended for a website or social media post serve different purposes. A practical clinic policy should identify those purposes rather than assume that one permission covers every future use.

The Revised Dentists Code of Ethics Regulations, 2014, addresses patient confidentiality. [1] Publication ethics guidance also requires attention to identifiable patient material and informed consent where anonymity cannot be assured. [2]

Explain the proposed use specifically

For planned public use, a prudent approach is separate, documented permission explaining the type of image, the purpose and the intended audience or platform. Explain that declining publicity should not compromise access to clinical care.

Do not treat agreement to treatment as automatic agreement to promotional use. If the proposed use changes substantially, reassess whether the permission obtained covers it.

De-identification requires more than cropping a name

ICMJE guidance notes that masking the eye region does not adequately guarantee anonymity. [2] Images, captions, unusual clinical details or accompanying reports may identify a person even when their name is absent.

Check the complete material before release: photographs, radiographs, reports, filenames and visible screen details. Remove unnecessary identifiers without altering findings in a way that changes scientific meaning.

Build a controlled workflow

My recommended practice is to keep clinical images in approved, access-controlled systems and identify who can export or publish them. Check the institution’s rules as well as applicable professional, privacy and advertising requirements. Permission from a patient does not establish that every promotional claim is permissible.

For educational cases, use a review process that checks the accuracy of the diagnosis, consent requirements and the suitability of the caption.

Be honest about online distribution

Avoid promising complete recall of an image once it is publicly shared. Copies may remain outside the clinic’s control. Explain this limitation before publication and keep a process for considering withdrawal requests.

The clinical value of an image should be preserved alongside the patient’s dignity, privacy and freedom to decide about public exposure.

References

[1] Dental Council of India. Revised Dentists Code of Ethics Regulations, 2014, section 4.2. Read source

[2] International Committee of Medical Journal Editors. Protection of Research Participants. Read source

Educational discussion. Check current regulatory and institutional requirements for the intended use.

Understand the reason for refusal

A refusal may reflect fear, cost, misunderstanding, a wish for another opinion or a concern about the procedure. Begin by asking what is making the decision difficult. A signature on a refusal form does not answer that question.

In Samira Kohli v. Dr. Prabha Manchanda, (2008) 2 SCC 1, the Supreme Court emphasised capacity, voluntariness and adequate information in consent. The information discussed includes the consequences of refusing treatment. [1] These principles support a meaningful conversation, with the individual’s circumstances considered.

Explain the clinical concern accurately

Describe the finding, the reason biopsy or referral is advised and the uncertainty it is intended to resolve. For suspicious oral lesions, professional guidance supports timely tissue investigation or specialist referral. [2]

Explain the possible consequences of delay without asserting an unconfirmed cancer diagnosis. Discuss reasonable options, including specialist assessment where appropriate. Check whether language or understanding is a barrier.

Record the actual decision

My recommended record includes the examination findings, proposed investigation, explanation of relevant risks and alternatives, questions asked, the patient’s stated reason and their decision. Record the date, the people involved and any written information or referral supplied.

If a patient declines to sign, document that fact and the discussion accurately. Do not create the appearance of consent or refusal by completing forms after the event as though they were contemporaneous.

Keep the next step explicit

Offer a clear review or referral pathway and explain which changes should prompt earlier assessment. Record how the patient can recontact the practice. Consider an appropriate reminder process with confidentiality in mind.

Where capacity, guardianship or urgent circumstances complicate the decision, obtain suitable clinical and legal guidance. A general blog cannot resolve these cases.

Refusal is not an automatic legal defence

The quality of assessment, explanation and follow-up still matters. A refusal form cannot substitute for those steps or guarantee immunity from a complaint. The aim is to respect the patient’s decision while making sure it is informed and that the clinical concern remains clearly communicated.

References

[1] Supreme Court of India. Samira Kohli v. Dr. Prabha Manchanda & Anr., (2008) 2 SCC 1, paragraph 32. Read source

[2] American Dental Association. Oral Cancer Guideline. Read source

Educational discussion of Indian principles and recommended practice. Case-specific legal assessment may be necessary.

Recognise the unresolved question

Clinicopathological discordance means the available clinical findings and the tissue interpretation do not fit together satisfactorily. It is a reason for structured review rather than immediate attribution of fault.

University oral pathology teaching cases show why clinical relationships and histology must be considered together: a plausible radiographic diagnosis may be unsupported by the other findings. [1]

Recheck the information chain

My suggested first step is to confirm the patient, anatomical site, specimen label and clinical history. Establish whether the tissue came from the lesion of concern and whether the pathologist had the relevant imaging and examination findings.

This is a practical review sequence, not a claim that misidentification is the usual explanation. The purpose is to examine the whole pathway before choosing the next investigation.

Ask a focused question of the pathologist

Instead of requesting “Please change the diagnosis,” explain the mismatch: for example, a persistent clinically concerning area that remains unexplained by the sampled tissue. Ask whether the material supports the reported conclusion and what further information would help.

The discussion may lead to review of the original slides, additional assessment of the available material, specialist consultation or a recommendation for further sampling. The appropriate choice depends on the case.

Preserve the evidence and record the decision

Keep earlier reports and document the reason for review. If a diagnosis is revised, the communication should make the change and its implications clear to the treating clinician.

CAP specimen guidance also emphasises direct surgeon–pathologist communication in orienting and examining complex head and neck specimens. [2] Communication should continue when interpretation remains uncertain.

Explain the situation to the patient

State what is known, what remains unresolved and what is proposed next. Avoid either declaring the case settled prematurely or suggesting that uncertainty itself proves an error.

A useful review ends with responsibility assigned for the next action and a date for reassessment. The goal is an explanation that fits the complete case closely enough to guide care.

References

[1] University of Washington School of Dentistry. Case of the Month, April 2013 diagnosis. Read source

[2] College of American Pathologists. Protocol for HPV Independent Oropharynx and Hypopharynx specimens, specimen orientation commentary. Read source

Start with a diagnostic question

Immunohistochemistry, or IHC, uses antibody-based staining to investigate selected proteins in tissue. In head and neck pathology, ancillary testing can help refine classification and, for certain markers and tumour types, provide information relevant to treatment. [1]

The useful question is what uncertainty a stain is expected to resolve. Ordering a long list without a defined differential diagnosis can make the result harder to interpret and consume limited material.

Morphology and context guide the panel

The following is a practical reasoning approach: describe the main morphological possibilities, select tests that distinguish them and interpret the staining pattern alongside the tissue architecture and clinical site. A positive stain should be understood within that framework rather than treated as an isolated diagnostic label.

For a small biopsy, discuss priorities before requesting further studies. Ask whether tissue must also be preserved for another clinically relevant investigation.

The anatomical site changes interpretation

p16 provides an important example. CAP guidance supports its use as a surrogate marker in appropriate oropharyngeal squamous cell carcinoma settings, with additional HPV-specific testing in defined circumstances. The same testing strategy should not be applied routinely to oral cavity squamous cell carcinomas for prognostic purposes. [2]

The oral tongue and base of tongue are different anatomical sites. Clear site information helps prevent an inappropriate assumption about what a result means.

Laboratory performance matters

CAP’s IHC validation guidance addresses the need to establish assay performance, including relevant specimen and scoring considerations. [3] Technical quality is part of interpretation, not an optional extra.

Communicate the conclusion

When a panel is requested, explain the question to the receiving laboratory. When reporting, connect the result to the diagnostic conclusion and state any remaining limitation.

For patients, a useful explanation is that extra staining may be needed to clarify the tissue findings. It does not automatically mean that the disease is more advanced.

IHC is most informative when the result answers a specific question and changes or strengthens the integrated interpretation.

References

[1] College of American Pathologists. Head and Neck Pathology. Read source

[2] College of American Pathologists. Human Papillomavirus Testing in Head and Neck Carcinomas, 2025 update. Read source[3] College of American Pathologists. Principles of Analytic Validation of Immunohistochemical Assays, 2024 update. Read source

What the term means

Oral epithelial dysplasia refers to abnormal changes in the lining epithelium assessed under the microscope. It is associated with increased cancer risk, but the finding does not mean that invasive cancer is already present or that progression is inevitable. [1]

This distinction matters when explaining the result. Reassurance should not erase the need for review, and discussion of risk should not be presented as certainty about a patient’s future.

What grading contributes

Reports may describe dysplasia as mild, moderate or severe, with other grading approaches also used in professional practice. The grade communicates the microscopic assessment and contributes to risk evaluation. Management requires consideration of the lesion and individual clinical circumstances, not a diagnosis line in isolation. [1,2]

Connect the report to the clinical finding

Record the site, extent and appearance of the lesion and identify exactly where the biopsy was taken. Ask whether the sample explains the area of greatest clinical concern.

For patients, useful questions include: What does this grade mean in my case? What are the management options? Who will monitor the area, and how will a change be assessed?

For clinicians, the discussion should make clear whether further examination, review or sampling is needed. Explain any uncertainty openly and document the plan.

Make surveillance understandable

AAOMS guidance addresses ongoing assessment and management of oral mucosal dysplasia. [2] The review schedule should be individualised; a short educational article cannot prescribe one interval suitable for every patient.

At each consultation, patients should understand what is being monitored and whom to contact if the area changes between visits. Keep reports and photographs organised so changes can be compared over time.

Explain without creating false precision

Avoid giving a single transformation percentage as though it were a personalised forecast. Ask what information supports the estimate and whether it applies to the patient’s lesion and circumstances.

A useful explanation combines the tissue diagnosis, the clinical assessment and a specific follow-up plan. That gives the patient something constructive to act on while acknowledging what cannot be predicted with certainty.

References

[1] Manchester University NHS Foundation Trust. Oral Epithelial Dysplasia patient information. Read source[2] American Association of Oral and Maxillofacial Surgeons. Oral Mucosal Dysplasia position paper. Read source