Redefining Diagnostic Pathways in Oral Squamous Cell Carcinoma: Insights from a Two-Year Cohort Managed Without Biopsy

Background: Oral squamous cell carcinoma (OSCC) accounts for the majority of oral malignancies in South Asia. Biopsy, the diagnostic gold standard, is often delayed due to systemic, financial, and sociocultural barriers. This study evaluates the role of structured clinical frameworks, imaging, and supportive care in the management of OSCC referrals without biopsy and histopathological examination. Methods: A retrospective cohort study was conducted on 242 patients referred to a tertiary dental outpatient department between January 2023 and December 2024 with suspected OSCC, no prior biopsy, and available contrast-enhanced computed tomography (CECT). Assessments included the Seven S lesion framework, Simplified Oral Hygiene Index (OHI-S), trismus grading, lymph node examination, provisional TNM staging (AJCC 8th edition), and CECT findings. All patients received standardized symptomatic management (analgesics, antimicrobials, antiseptic mouthwash, gastroprotectants, nutritional supplements) and counselling for habit cessation. Descriptive statistics were applied. Results: Of 242 patients (198 males [81.8%], 44 females [18.2%]; median age 39 years), the majority reported gutka (51% males, 70% females) or smokeless tobacco use. Lesions primarily involved the retromolar trigone (46%) and gingivobuccal sulcus (37%). OHI-S was poor in 68% of cases. Trismus occurred in 47%. CECT revealed cortical erosion (27%), muscle infiltration (39%), and level IIb nodal involvement (14%). Provisional TNM staging included cT2N0 (36%), cT3N1 (24%), and cT4N2 (19%). Reported barriers to biopsy were financial constraints (33%), fear (24%), lack of facilities (20%), sociocultural reasons (11%), and anatomical difficulty (12%). Conclusion: In the absence of biopsy, structured clinical assessment, imaging, and supportive care enable effective provisional diagnosis and timely referral. This approach provides a practical diagnostic pathway with implications for policy, education, and early OSCC management.