Introduction and Oral Medicine in Clinical Practice
The aim of this chapter is to outline the development of oral medicine and to describe the oral medicine consultation.
After reading this chapter you should understand the importance and structure of an oral medicine consultation.
Oral medicine has been defined as ‘the speciality of dentistry concerned with the health care of patients with acute or chronic, recurrent and medically related disorders of the oral and maxillofacial region, and with their diagnosis and medical management. It is also concerned with the investigation, aetiology and pathogenesis of these disorders leading to understanding that may be translated into clinical practice. Oral medicine is a clinical and academic speciality that is dedicated to the investigation, diagnosis, management and research into medically related oral diseases, and the oral and facial manifestations of systemic diseases. These include diseases of the gastrointestinal, dermatological, rheumatological and haematological systems, autoimmune and immunodeficiency disorders, and the oral manifestations of neurological and psychiatric diseases.’
The practice of oral medicine requires a sound knowledge of medical science in order to provide a rational approach to diagnosis and clinical management. It is also essential for the competent provision of dental care to those with special needs – patients with physical, mental or medical disability.
Oral medicine permeates virtually all branches of dentistry and many areas of medicine. It can be regarded as the interface between medicine and dentistry. This book covers in a practical manner the scope of oral medicine most likely to be encountered in a dental setting. It does not pretend to be all-inclusive, and readers are advised to make reference to more specialist publications where appropriate. Some of these are suggested at the end of each chapter. In addition, some conditions more usually managed by maxillofacial, ear, nose and throat (ENT) or plastic surgery have been deliberately excluded.
The initial appointment is often the most important time in patient’s management. This meeting sets the tone for all remaining visits. The patient forms opinions about the expertise and competence of the practitioner. The clinician forms views about the patient and his or her problem. As communication, empathy and trust form a large part of treatment, it is important that the process gets off to a good start on both sides.
An effective practitioner will manage to put patients at their ease. This can establish trust, allowing full disclosure of information relevant to the problem to be obtained. Many factors are important in this. The following can all play a part:
seating position and arrangement
One of the most important lessons for the inexperienced clinician to learn is when not to talk and to encourage the patient to keep providing information. It is important to retain control of the consultation, however, and not be afraid to redirect patients when they digress from pertinent information.
The stages of the consultation are as follows:
review and discussion
conclusion and future planning.
Each stage is important and will take place at every consultation, but the emphasis on each will vary between initial and review consultations.
This is the first contact between the patient and the clinician. It may occur when collecting the patient from the waiting area or as the patient enters the surgery. The clinician should greet the patient in an open and welcoming manner, introducing himself and all other people present at the consultation by giving their name, position and their role. The patient should be seated comfortably, facing the clinician in preparation for the next stage of the consultation. If the patient has brought a supporter, ideally he or she should be seated able to face and communicate with the patient and the clinician. Where possible all individuals in the consultation room should be easily visible to the patient, as this helps relaxation.
The clinician should outline the purpose of the appointment – for example, a referral from another practitioner, a review of investigation results or treatment progress. An outline of the process of the consultation is appropriate at the initial visit, informing the patient of the different stages to expect – history, review and the possible need for discussion with other health care workers, special investigations and arrangements for management. Many complaints from patients relate to communication failures rather than to treatment problems. It is important that the patient and the clinician are equally clear about the purpose and scope of the consultation at this visit.
The history should follow a standard format to enable reproducibility. A sample history-taking plan is given in Table 1-1. Some aspects of the history process will be identical for all patients and some – in particular, the history of the presenting complaint – will vary according to the problem. Some of the key issues in a patient with recurrent oral ulceration will be of little relevance in someone with chronic facial pain, but a thorough medical and social history will be important for both. In this book, where there is information required for a particular oral complaint, the specific history points to cover will be reviewed in the appropriate chapter. All sources of information including, if appropriate, the opinions of the supporter, can be important and should be canvassed. At the end of the history, it is helpful to read back to the patient the clinician’s understanding of the presenting problem, its course and management to this point. Any misunderstandings or misinterpretations on the part of the clinician can then be set aside at an early stage.