Oral medicine is “the discipline of dentistry concerned with the oral health care of medically complex patients, including the diagnosis and primarily nonsurgical treatment and/or management of medically related conditions affecting the oral and maxillofacial region.” In each of these areas, evidence-based medicine has shaped theoretic understanding and clinical practice. The available evidence allows for improved patient management. Further evidence, as it becomes available, should be reviewed on a regular basis to guide our clinical practice.
Key points
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The clinical practice of oral medicine requires guidelines formulated from evidence.
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Clinical Practice Guidelines in oral medicine define recommendations based in evidence.
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For areas with less clarity, emerging evidence base will provide the ability to shape future management recommendations.
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Some areas of oral medicine currently contain only limited evidence, based in expert consensus, and require further research.
Introduction
Evidence-Based Medicine
Evidence-based medicine has existed as a concept for many years, gaining recognition and respect especially in the past few decades. From its first appearance in the literature, the term “evidence-based medicine” quickly gained prominence, inspiring reviews and Clinical Practice Guidelines focused on using available, carefully gathered proof to define recommendations. These works have defined recommendations for and against medications, surgical interventions, management practices, and diagnostic testing modalities, and they have equally focused scientific awareness on areas in which convincing evidence does not yet exist. Of course, evidence-based medicine is fraught with challenges, including the burden of proof required to formulate Clinical Practice Guidelines, the necessarily narrow definitions of success and end points, and the inability for such combined statements to appropriately reflect individual patient presentations or outcomes.
Evidence-based guidelines, the studies that support them, and reviews of these studies are formulated by a variety of stakeholders, including patients, practicing clinicians, researchers, policy makers, and health care administrators. One major source of this knowledge, and of support for the synthesis of available data, is the Cochrane Collaboration. The Cochrane Collaboration employs dedicated staff to support subject-specific systematic reviews and meta-analyses, and distributes standards to guide the completion of such studies. Their efforts have helped to spread evidence-based medicine and highlighted its importance for all health care practitioners.
In dental medicine, the importance of evidence-based medicine has experienced a parallel evolution. Soon after evidence-based medicine became a recognized term, the concept of “evidence-based dentistry” likewise started to appear in literature. In the past 15 years, this term has also become widely used to refer to dental practice informed by scientific evidence. As they evolve, evidence-based dentistry recommendations have recently become increasingly specialty-specific and procedure-specific. As in medicine, evidence must be synthesized and disseminated in dental medicine to inform a Clinical Practice Guideline. The increase in available evidence-based guidelines has and will continue to refine and improve the worldwide practice of dentistry.
Oral Medicine
Oral medicine is a subset of dental medicine that has been defined by various sources. These include the American Academy of Oral Medicine, European Association of Oral Medicine, and multiple groups of practicing oral medicine physicians. In the United States, the definition of oral medicine has been proposed as “the discipline of dentistry concerned with the oral health care of medically complex patients, including the diagnosis and primarily nonsurgical treatment and/or management of medically related conditions affecting the oral and maxillofacial region.” The worldwide training of practitioners in this emerging field also has been recently defined, suggesting that residency programs focus on competency in the following:
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Diagnosis and primarily nonsurgical management of oral mucosal and salivary gland disorders
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Diagnosis and primarily nonsurgical management of temporomandibular, orofacial pain, and neurosensory disorders
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Management of the medically complex patient.
Oral medicine competency in the United States is in line with the training of oral medicine practitioners worldwide, although some variation exists between countries in scope of practice.
Clinical care in oral medicine is available across the United States in many practice settings, including hospitals, medical/dental schools, and private practice clinics. As defined by a recent study, patients are referred for oral medicine evaluation by a wide variety of practitioners, most commonly general dentists. Referrals also come from specialty physicians, including otorhinolaryngologists, hematologists, oncologists, radiation oncologists, rheumatologists, and dermatologists. As a dedicated link between dental and medical care, oral medicine physicians provide thorough medical and dental evaluations to reach an accurate diagnosis and recommend appropriate treatment. Broadly speaking, oral medicine providers are frequently consulted for evaluation, diagnosis, and treatment of oral lesions, salivary gland diseases, facial pain conditions, and care of medically complex patients. Some examples of these conditions are highlighted in Box 1 .
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Oral mucosal diseases/oral and perioral lesions
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Oral lesions, including erythroplakia, leukoplakia, oral submucosal fibrosis, pigmented lesions, ulcerations, or lesions associated with systemic conditions, including human immunodeficiency virus (HIV) disease
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Mucosal and perioral growths, such as fibroma, papilloma, hemangioma, seborrheic keratosis, actinic keratosis
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Ulcerative diseases, including recurrent aphthous stomatitis and Behçet disease
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Fungal infections, including angular cheilitis, candidiasis, or deep fungal infection (aspergillosis, histoplasmosis, mucormycosis, blastomycosis)
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Viral infections, including herpetic infections, Coxsackie infections
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Immune-mediated disorders, including erythema multiforme, oral lichen planus, mucous membrane pemphigoid, pemphigus vulgaris, or systemic lupus erythematosus
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Granulomatous disease, including orofacial granulomatosis and oral manifestations of systemic granulomatous disease
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Malignant conditions of the oral cavity
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Complications following medical treatments, including oral mucositis, oral graft-versus-host disease, osteonecrosis of the jaw
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Salivary gland disease and dysfunction
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Objective hyposalivation, caused by medications or previous exposure to radiation therapy
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Reduced salivary flow secondary to systemic diseases, including Sjögren syndrome and other autoimmune diseases
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Xerostomia, the subjective feeling of oral dryness
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Sialosis, enlargement of salivary glands
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Sialoadenitis, including infections of the salivary glands, such as parotitis
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Sialolithiasis, stones in the salivary glands
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Enlargement of salivary glands, as can occur in bulimia nervosa
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Diffuse infiltrative lymphocytosis syndrome in HIV disease
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Salivary gland malignancies
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Facial pain conditions
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Pain and dysfunction originating from the temporomandibular joint (TMJ) complex including myalgia, myofascial pain, TMJ capsulitis, TMJ arthralgia, and internal derangement of the TMJ
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Intraoral pain, including pain of odontogenic, periodontal, mucosal, or bone origin
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Neuropathic pains involving the oral cavity, including glossodynia or burning mouth syndrome
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Persistent idiopathic facial pain (atypical facial pain)
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Neuralgias of the orofacial region including trigeminal, auriculotemporal, and glossopharyngeal neuralgias
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Headache disorders, including tension-type headache, migraine, cluster headache, and rare autonomic cephalgias
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Pain of intracranial origin
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Referred pain from other sites or associated structures
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Pain arising as a complication of mental illness
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Medically complex patient dental care
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Assessment of patient fitness for dental treatment
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Provision or modification of appropriate dental treatment to patients with multiple or complex systemic diseases
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Treatment recommendations in oral medicine depend on the individual patient presentation, but in many cases consists of medications, behavioral modifications, and/or oral appliance fabrication. Patients may also be referred for medical evaluation when an oral cavity finding suggests a systemic disease. For patients with significant medical comorbidities, the role of the oral medicine practitioner also includes consulting with other members of the health care team and advising on the appropriate modifications to dental treatment or timing of treatment.
The importance of evidence-based practice in oral medicine stems directly from the theoretic and practical complexity of the field. The wide variety of conditions encountered in an oral medicine practice, as well as variations in the individual patient presentation and response to treatment, defines the need for careful evaluation and synthesis of practice recommendations to provide appropriate and effective treatment. The remainder of this article presents examples of how evidence related to each practice area of oral medicine has shaped clinical practice. Our examples show how the use of Clinical Practice Guidelines varies by topic and has evolved over time. They include a recently published Clinical Practice Guideline on the detection of potentially malignant oral disorders to show how evidence guides diagnostic practice, a review on treatment of salivary gland dysfunction that illustrates how existing data inform practice and refine additional study, a review of treatment for temporomandibular disorders that highlights the need for definitive diagnostic criteria, and a Clinical Practice Guideline on the use of prophylactic antibiotics in patients with prosthetic joint replacement to show how evidence-based dentistry benefits society. By highlighting existing examples, we also call attention to the need for further evidence-based guidelines to refine all areas of oral medicine practice.
Oral lesions
Oral lesions present a broad and primary focus of oral medicine practices. As exemplified in Box 1 , oral lesions can take on an almost infinite variety of clinical appearances based on their size, location, color, texture, and number. They may themselves be benign, premalignant, or malignant, and each lesion may provide information about underlying systemic conditions. Distinguishing based on these and other signs, as well as on symptoms and history can provide clues to the diagnosis of these lesions.
Oral lesions are common in the general population. In an early study, it was estimated that 10% of 23,616 patients studied had at least one oral lesion. These lesions ranged from solitary to widespread, from benign to malignant, and included all surfaces of the oral mucosa. Recognition and evaluation of these lesions is an important aspect of dental treatment. Accurate and thorough clinical evaluation and diagnostic testing are required to determine whether a given lesion may represent a potentially cancerous or a cancerous process.
The importance of early and accurate diagnosis of potentially malignant conditions cannot be overstated. Cancers of the oral cavity, 90% of which are squamous cell carcinoma, are estimated by the American Cancer Society to have accounted for 32,670 new cases and 6650 deaths in 2017. These are separated from cancers of the oropharynx, which accounted for approximately 17,000 new cases and 3050 deaths in 2017. The separation between the oral cavity and the oropharynx is defined as the soft palate, tonsillar pillars, and the base of the tongue, with the oral cavity comprising those areas anterior, including the mobile portion of the tongue, and the oropharynx including these borders and structures posterior. Squamous cell carcinoma of the oral cavity has an overall 5-year survival rate of 64.3% in the United States, with the rate dropping to 38.5% in patients who present with distant metastases. A wide body of literature covers the importance of careful screening of patients in general and specialty dental practice by trained providers to ensure early diagnosis and appropriate referral to treatment for all patients with oral lesions to improve these rates.
Given the importance of a timely and accurate diagnosis of malignancies, the assessment of potentially malignant oral lesions depends closely on robust evidence. Multiple studies have been completed and synthesized into a few systematic reviews on the use of diagnostic tests and adjuncts for diagnosis of oral lesions, which reinforce the impact of clear evidence-based recommendations. Still other studies have discussed the proper approach to lesions found to contain some level of epithelial dysplasia, although consensus on treatment of these lesions has not yet been established. Synthesizing previous recommendations, a recent report from the American Dental Association provided a Clinical Practice Guideline for evaluation of potentially malignant oral lesions.
This guideline reviews the level of evidence supporting various modalities available for evaluation of a potentially malignant oral disorder. The methods reviewed include the histopathological testing of lesions, salivary analysis, and use of adjunctive tests, such as cytologic sampling, oral mucosal staining, autofluorescence, or vital staining for adults with suspicious lesions in the oral cavity. Using available systematic reviews, as well as studies dealing with efficacy of adjunctive testing, the expert panel was able to reach recommendations for the use of these methods, which appear in Box 2 .
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The panel suggests that for adult patients with a clinically evident oral mucosal lesion considered to be suspicious of a PMD or malignant disorder, or other symptoms, clinicians should perform a biopsy of the lesion or provide immediate referral to a specialist. (Conditional recommendation, low-quality evidence.)
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The panel does not recommend cytologic adjuncts for the evaluation of PMDs among adult patients with clinically evident, seemingly innocuous, or suspicious lesions. Should a patient decline the clinician’s recommendation for performing a biopsy of the lesion or referral to a specialist, the clinician can use a cytologic adjunct to provide additional lesion assessment. (Conditional recommendation, low-quality evidence.)
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A positive or atypical cytologic test result reinforces the need for a biopsy or referral. A negative cytologic test result indicates the need for periodic follow-up of the patient. If the clinician detects persistence or progression of the lesion, immediately performing a biopsy of the lesion or referral to a specialist is indicated.
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The panel does not recommend autofluorescence, tissue reflectance, or vital staining adjuncts for the evaluation of PMDs among adult patients with clinically evident, seemingly innocuous, or suspicious lesions. (Conditional recommendation, low-quality evidence to very low quality evidence.)
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