Oral medicine, as defined by the American Academy of Oral Medicine, is “the specialty of dentistry responsible for the oral health care of medically complex patients and for the diagnosis and management of medically related disorders or conditions affecting the oral and maxillofacial region.” Definitions vary in different parts of the world, but most include the diagnosis and nonsurgical management of oral mucosal and salivary gland disease, orofacial pain, and dental treatment of patients with medical disorders.
The overall goal for all oral healthcare professionals is to deliver and maintain optimal health for their patients. A recent definition was approved by the World Dental Parliament in 2016, which expanded the definition to include three different domains: disease and condition status, psychosocial status, and physiologic function.1 The inclusion of a psychosocial status and physiologic function deviates from traditional definitions that mainly focused on the presence or absence of disease, and, further, it promotes the inclusion of patient values and preferences, as well as elevates the importance of subjective findings. This approach is more aligned with a person‐centered care approach that emphasizes a patient’s problem in the context of behavioral, socioeconomic, and environmental aspects, and their impact on the patient and on the care that needs to be delivered.2–4 This definition has also been the underlying framework to establish outcomes that can be used to measure the oral status of an individual.5
Given the nature, complexity, and potential systemic implications for some oral conditions, coupled with an aging population with multimorbidities (multimorbidities do not identify an index disease, while comorbidities focus on an index disease and other diseases) and individuals taking numerous medications, all oral healthcare clinicians are required to enhance their knowledge of many aspects of medicine. Therefore, what previously was considered the purview of oral healthcare professionals with hospital‐based training has become increasingly more important in general and specialty dental practice.
Advances in clinical practice are influencing many aspects of patient care, from our initial contact with a patient, through medical history‐taking, diagnosis, and treatment options. For example, electronic health records (EHRs) allow for sharing health information among multiple clinicians caring for the same patient and can provide point‐of‐care algorithms for eliciting and using health information. Modern imaging techniques, such as computerized tomography scans (CTs) and magnetic resonance imaging (MRI), provide more detailed information and are a means to acquire more sophisticated data, but require enhanced training for accurate interpretation. Nevertheless, one of the most important skills for accurate diagnosis and management remains an experienced clinician with highly developed skills of listening and examination.
The initial encounter with a patient may influence all subsequent care. The skilled, experienced practitioner has learned to elicit the subjective (i.e., history‐taking) and objective (e.g., clinical, laboratory) findings and other necessary information required for an accurate diagnosis. This process is an art, as well as a skill. Although mastering a patient evaluation can be assisted by specific clinical protocols, the experienced practitioner will add their own skills and experience to the diagnostic methodology.
A variety of accessible sources of healthcare information are now readily available to patients, and many will use this information to self‐diagnose, as well as demand specific treatments. As a person‐centered approach is encouraged, where a patient’s preferences and values will influence care, the practitioner must listen to the patient to understand their needs, fears, and wishes and address them to arrive at an appropriate treatment plan that results in informed, scientific, and evidence‐based choices. Furthermore, part of a shared decision‐making approach includes the responsibility of the oral healthcare professional to educate their patient about the implications and consequences of a diagnosis and subsequent treatment. Creating an environment for effective communication between provider and patient has been shown to improve health outcomes.6
The process of obtaining, evaluating, and assessing a patient’s oral and overall health status can arbitrarily be divided into seven major, sometimes overlapping, parts:
- History and examination.
- Establishing a differential diagnosis.
- Obtaining necessary consultations, as well as appropriate laboratory tests, such as specific blood investigations, a biopsy, and imaging studies, all based upon the initial differential diagnosis.
- Final diagnosis.
- Formulating a plan of action.
- Initiating treatment.
- Follow‐up assessment of response to treatment.
An appropriate interpretation of the information collected through a medical history and patient examination achieves several important objectives. It affords an opportunity for:
- Gathering the information necessary for establishing a diagnosis for the patient’s chief complaint.
- Assessing the influence of the patient’s systemic health on their oral health.
- Detecting other systemic health conditions of which the patient may not be aware.
- Providing a basis for determining whether dental treatment might impact the patient’s systemic health.
- Giving a basis for determining necessary modifications to routine dental care.
- Monitoring medical conditions of relevance to the maxillofacial condition.
Obtaining an appropriate and accurate medical history is a critical first step for all patient care. It begins with a systematic review of the patient’s chief or primary complaint, a detailed history related to this complaint, information about past and present medical conditions, pertinent social and family histories, and a review of symptoms by organ system. A medical history also includes biographic and demographic data used to identify the patient.
There is no universally agreed method for obtaining a medical history, but a systematic approach will help the practitioner to gather all necessary information without overlooking important facts. The nature of the patient’s oral health visit (i.e., initial dental visit, complex diagnostic problem, emergency, elective continuous care, or recall) often dictates how the history is obtained. The two most common means of obtaining initial patient information are a patient self‐administered preprinted health questionnaire, or recording information during a systematic health interview without the benefit of having the patient fill out a questionnaire. The use of self‐administered screening questionnaires is the most common method in dental settings. This technique can be useful in gathering background medical information, but the accurate diagnosis of a specific oral complaint requires a history of the present illness and other verbal information. While the basic information for a past medical history may be obtained by a questionnaire, a vital part of the evaluation of a patient with a complex diagnostic problem is the history of the present illness, which is a combination of science and art and should be taken directly by the clinician.
The challenge in any healthcare setting is to use a questionnaire that has enough items to obtain the essential medical information, but is not too long to deter a patient’s willingness and ability to fill it out. These questionnaires should be constructed in a manner that allows the clinician to query the patient about the most essential and relevant required information, yet provides a starting point for a dialogue with the patient about other pertinent information not included on the health form. Preprinted self‐administered or online health questionnaires are readily available, standardized, and easy to administer and do not require significant “chair time.” They give the clinician a starting point for a dialogue to conduct more in‐depth medical queries, but are restricted to the questions chosen on the form and are therefore limited in scope. The questions on the form can be misunderstood by the patient, resulting in inaccurate information, and they require a specific level of reading comprehension. Preprinted forms cover broad areas without necessarily focusing on particular problems pertinent to an individual patient’s specific medical condition. Therefore, the use of these forms requires that the provider has sufficient background knowledge to understand the reasons for the questions on the forms. Furthermore, the provider needs to realize that a given standard history form necessitates timely and appropriate follow‐up questions, especially when positive responses have been elicited. An established routine for performing and recording the history and examination should be followed conscientiously.
The oral healthcare professional has a responsibility to obtain relevant medical and dental health information, yet the patient cannot always be relied upon to know this information or to provide an accurate and comprehensive assessment of their medical or dental status.
All medical information obtained and recorded in an oral healthcare setting is considered confidential and may in many jurisdictions constitute a legal document. Although it is appropriate for the patient to fill out a history form in the waiting room, any discussion of the patient’s responses must take place in a private setting. Furthermore, access to the written or electronic (if applicable) record must be limited to personnel who are directly responsible for the patient’s care. Any other release of private information should be approved, in writing, by the patient and that approval retained by the dentist as part of the patient’s medical record.
Given that medical status and medication regimens often change, a patient’s health status or medication regimen should be reviewed at each office visit prior to initiating dental care. The monitoring of patients’ compliance with suggested medical treatment guidelines and prescribed medications is part of the oral healthcare professional’s responsibilities. The following strategies are common to nearly all methods of history‐taking:
- Review available patient information prior to meeting the patient.
- Greet the patient; use the patient’s name; ensure privacy; sit rather than stand, preferably at eye level; maintain eye contact as often as possible; listen carefully to the patient’s concerns; do not rush the interview process.
- Do not concentrate chiefly on entering the information into an electronic health record, as this may distract you from listening to pertinent information.
- Use the patient’s own words (in quotation marks) to describe the primary reason(s) to seek care/consultation; i.e., be absolutely clear about the patient’s chief complaint(s).
- Use open‐ended questions to encourage open dialogue with the patient. Although all information should be collected in a systematic fashion, the order is not as important as is initiating a dialogue with the patient about their health.
- Create a timeline of the reported patient‐related events. An accurate chronology is an extremely important element to establish or deny a causative relationship.
The medical history traditionally consists of the following subcategories:
- Identification—name, date and time of the visit, date of birth, gender, ethnicity, occupation, contact information of a primary care provider (physician and, if applicable, dentist), referral source.
- Chief complaint (CC)—the main reason for the patient seeking care or consultation and the length of time these symptoms have been present, recorded in the patient’s own words.
- History of present illness (HPI)—taking an effective HPI takes experience and is often the key to making an accurate differential diagnosis. It includes a chronologic account of events; state of health before the presentation of the present problem; description of the first signs and symptoms and how they may have changed; description of occurrences of amelioration or exacerbation; previous clinicians consulted, prior treatment, and degree of the response to previous treatment. For those who favor mnemonics, the nine dimensions of a medical problem can be easily recalled using OLD CHARTS (Onset, Location/radiation, Duration, Character, Habits, Aggravating factors, Reliving factors, Timing, and Severity).7
- Review of systems (ROS)—identifies symptoms in different body systems (Table 1‐1). The ROS is a comprehensive and systematic review of subjective symptoms affecting different bodily systems. It is an essential component for identifying patients with a disease that may affect dental treatment or associated symptoms that will help determine the primary diagnosis. For example, a patient with skin, genital, or conjunctival lesions who also has oral mucosal disease, or a patient with anesthesia, paresthesia, or weakness who also presents with orofacial pain. The clinician records both negative and positive responses. Direct questioning of the patient should be aimed at collecting additional data to assess the severity of a patient’s medical conditions, monitor changes in medical conditions, and assist in confirming or ruling out those disease processes that may be associated with patient’s symptoms.
Table 1‐1 Review of Systems (ROS): A systematic approach to ascertain mostly subjective symptoms associated with the different body systems.
General: Weight changes, malaise fatigue, night sweats Head: Headaches, tenderness, sinus problems Eyes: Changes in vision, photophobia, blurring, diplopia, spots, discharge Ears: Hearing changes, tinnitus, pain, discharge, vertigo Nose: Epistaxis, obstructions Throat: Hoarseness, soreness Respiratory: Chest pain, wheezing, dyspnea, cough, hemoptysis Cardiovascular: Chest pain, dyspnea, orthopnea (number of pillows needed to sleep comfortably), edema, claudication Dermatologic: Rashes, pruritus, lesions, skin cancer (epidermoid carcinoma, melanoma) Gastrointestinal: Changes in appetite, dysphagia, nausea, vomiting, hematemesis, indigestion, pain, diarrhea, constipation, melena, hematochezia, bloating, hemorrhoids, jaundice Genitourinary: Changes in urinary frequency or urgency, dysuria, hematuria, nocturia, incontinence, discharge, impotence Gynecologic: Menstrual changes (frequency, duration, flow, last menstrual period), dysmenorrhea, menopause Endocrine: Polyuria, polydipsia, polyphagia, temperature intolerance, pigmentations Musculoskeletal: Muscle and joint pain, deformities, joint swellings, spasms, changes in range of motion Hematologic: Easy bruising, epistaxis, spontaneous gingival bleeding, increased bleeding after trauma Lymphatic: Swollen or enlarged lymph nodes Neuropsychiatric: Syncope, seizures, weakness (unilateral and bilateral), changes in coordination, sensations, memory, mood, or sleep pattern, emotional disturbances, history of psychiatric therapy
- Past medical history (PMH) (may not have been revealed in systems review)—general health; immunizations; major adult illnesses; any surgical operations (date, reason, and outcome); medications (prescribed medications, over‐the‐counter medications, supplements) and home remedies; allergies.
- Personal and social history (SH)—birthplace; marital status; children; habits (tobacco use, alcohol use, recreational drug use); occupation; religion (if it may have an impact on therapy); sexual history if relevant to complaint.
- Family history (FH)—health or cause of death of parents, siblings, and children. The FH should also include diseases important to the patient’s chief compliant, including genetic disorders; and common diseases, such as cardiovascular diseases or diabetes mellitus.
The examination of the patient represents the second stage of the evaluation and assessment process. An established routine for examination decreases the possibility of missing important findings (signs).
A routine head and neck examination should be carried out at least annually or at each recall visit. This includes a thorough inspection (and when appropriate palpation, auscultation, or percussion) of the exposed surface structures of the head, neck, and face and a detailed examination of the oral cavity, dentition, oropharynx, and adnexal structures. Laboratory studies and additional special examination of other organ systems may be required for the evaluation of patients with orofacial pain, oral mucosal disease, or signs and symptoms suggestive of otorhinologic or salivary gland disorders, or signs or symptoms suggestive of a systemic etiology. A less comprehensive but equally thorough inspection of the face and oral and oropharyngeal mucosa< ?span Start cssStyle="text-decoration:line-through"?>e should be carried out at each visit and the tendency to focus on only the tooth or jaw quadrant in question should be strongly resisted.
Each visit should be initiated by a deliberate inspection of the entire face and oral cavity prior to intraoral examination. The importance of this approach in the early detection of head and neck cancer cannot be overstated (see Chapter 7, Oral and Oropharyngeal Cancer).
Examination carried out in the dental office (surgery) is traditionally restricted to that of the superficial tissues of the oral cavity, head, and neck and the exposed parts of the extremities. On occasion, evaluation of an oral lesion logically leads to an inquiry about similar lesions on other skin or mucosal surfaces or about the enlargement of other regional groups of lymph nodes. Although these inquiries can usually be satisfied directly by questioning the patient, the oral health professional may also quite appropriately request permission from the patient to examine axillary nodes or other skin surfaces, provided that the examination is carried out competently and there is adequate privacy for the patient. A male oral health professional should have a female assistant present in the case of a female patient; a female oral health professional should have a male assistant present in the case of a male patient. Similar precautions should be followed when it is necessary for a patient to remove tight clothing for accurate measurement of blood pressure. A complete physical examination should not be attempted when facilities are lacking or when religious or other customs prohibit it, or when no chaperone is present.
The degree of responsibility accorded to the oral health professional in carrying out a complete physical examination varies among institutions, hospitals, states, and countries.
The examination procedure in a dental office setting may include any or all of the following six areas:
- Registration of vital signs (respiratory rate, temperature, pain level, pulse, and blood pressure).
- Examination of the head, neck, and oral cavity, including salivary glands, temporomandibular joints, and head and neck lymph nodes.
- Lesions of the oral mucosa should have a detailed description including location, size, color, ulceration and induration, and an assessment of the severity made. Detailed descriptions of specific diseases presenting as ulcers, blisters, or white or red lesions can be found in Chapters 3–7.
- Assessment of cranial nerves, particularly when the patient presents with nondental orofacial pain, weakness, anesthesia, or paresthesia.
- Examination of other organ systems, when appropriate.
- Ordering indicated laboratory studies.
Requesting Consultations from Other Clinicians
The overall purpose of a consultation is to clarify issues or help with diagnosis or management. Oral medicine clinicians are involved with two major types of consultations: those that they initiate for their own patients as a request from another healthcare professional; and those in response to a request for help with a patient of another healthcare professional.
Consent from the patient is needed before a consultation is initiated. All verbal and written consultation should be documented in the patient’s record. A consultation letter should identify the patient and contain a brief overview of the patient’s pertinent medical history and a request for relevant and specific information. The written request should be brief and should specify the particular concern and items of information needed from the consultant (Box 1‐1).
Patients who may need medical consultation include:
- Those with known medical problems who are scheduled for either inpatient or outpatient dental treatment and cannot adequately describe all of their medical problems.
- Those with abnormalities detected during history‐taking, on physical examination, or through laboratory studies.
- Those who have a higher risk for the development of a particular medical problem (e.g., diabetes with increased risk of atherosclerotic cardiovascular disease).
- Those for whom additional medical information is required that may impact the provision of dental care or assist in the diagnosis of an orofacial problem.
- Those with an orofacial disorder, which may also affect other parts of the body. For example, oral lesions may also involve the skin and conjunctiva.
- Those who are being considered for a medication that may have an adverse effect on another medical problem, such as diabetes or hypertension, or drug interactions.
Requests for consultation should include the problem and the specific questions to be answered and should be transmitted to the consultant in writing. Adequate details of the planned oral or dental procedure, include, as appropriate:
- Estimated risk of clinically significant bleeding.
- Assessment of time and stress to the patient.
- Expected period of post‐treatment disability.
- Details of the particular symptom, sign, or laboratory abnormality that gave rise to the consultation.
Medically complex patients may have a medical condition that suggests the need for an opinion from the patient’s physician as to risks involved in an invasive or stressful dental procedure, too often referred to as “clearing the patient for dental care.”8 In many cases, the physician is provided with too little information about the nature of the proposed dental treatment (type of treatment, amount of local anesthetics, anticipated bleeding, etc.) to help in this regard. Physicians cannot be expected to understand the nature of dental procedures and they should not be asked to “clear” patients for dental treatment. They should be contacted for pertinent medical information that will help the oral healthcare provider make the decision as to the appropriateness of the dental treatment plan. The response of a given patient to specific dental interventions may be unpredictable, particularly patients with comorbidities and those taking one or more medications. A physician’s advice and recommendation may be helpful in managing a patient, but the responsibility to provide safe and appropriate care lies ultimately with the clinician performing the procedure.9 Another health professional cannot from a legal standpoint “clear” a patient for any dental procedure and thus a request for “medical clearance” should be avoided.8
Responding to Consult Requests from Other Clinicians
There are three major categories of oral medicine consultations:
- Diagnosis and nonsurgical treatment of orofacial disorders, including oral mucosal disease, temporomandibular and myofascial dysfunction, chronic lesions involving the maxilla and the mandible, orofacial pain, dental anomalies, maxillary and mandibular bone lesions, salivary gland disorders, and disorders of oral sensation, such as dysgeusia, dysesthesia, and glossodynia.
- Dental treatment of patients with medical problems that affect the oral cavity or for whom modification of standard dental treatment is required to avoid adverse events.
- Opinion on the management of dental disease that does not respond to standard treatment, such as rampant dental caries or periodontal disease in which there is a likelihood of a systemic etiologic cofactor.
In response to a consultation request, the diagnostic procedures outlined in this chapter may be followed, with the referral problem listed as the chief complaint and with supplementary questioning (i.e., history of the present illness) directed to the exact nature, mode of development, prior diagnostic evaluation/treatment, and associated symptomatology of the primary complaint. An examination of the head, neck, and oral cavity is important and should be fully documented, and the ROS should include an exploration of any associated symptoms and including pertinent negatives. When pertinent, existing laboratory, radiographic, and medical records should be reviewed and documented in the consultation record, and any additional testing or specialized examinations should be ordered.
A comprehensive consultation always includes a written report of the consultant’s examination, usually preceded by a history of the problem under investigation and any items from the medical or dental history that may be relevant to the problem. A formal diagnostic summary follows, together with the consultant’s opinion on appropriate treatment and management of the issue. Other previously unrecognized abnormalities or significant health disorders should also be communicated to the referring clinician. When a biopsy or initial treatment is required before a definitive diagnosis is possible, and when the terms of the consultation request are not clear, a discussion of the initial findings with the referring clinician is appropriate before proceeding. Likewise, the consultant usually discusses the details of their report with the patient, unless the referring dentist specifies otherwise. In community practice, patients are sometimes referred for consultation by telephone or are simply directed to arrange an appointment with a consultant and acquaint them with the details of the problem at that time; a written report is still necessary to clearly identify the consultant’s recommendations, which otherwise may not be transmitted accurately by the patient. The details of an oral consultation must be documented on the patient’s chart.
An important responsibility for hospital‐based dentists is responding to consults from medical and surgical services. It is not at all uncommon for hospitalized patients to have routine maxillofacial problems (e.g., toothache) that have nothing to do with their reason for hospitalization. More commonly, patients may have a wide variety of problems that are directly related to their medical condition or its treatment (e.g., mucositis secondary to cancer chemotherapy) or require a dental exam to eliminate a possible source of infection during cancer chemotherapy.9
In hospital practice, the dental consultant is always advisory to the patient’s attending physician; the recommendations listed at the end of the consultation report are suggestions and not orders, and are not implemented unless authorized by the attending physician. For some oral lesions and mucosal abnormalities, a brief history and examination of the lesion will readily identify the problem, and only a short report is required; this accelerated procedure is referred to as a limited consultation (Box 1‐2).
Both custom and health insurance reimbursement systems recognize the need of individual practitioners to request the assistance of a colleague who may have more experience with the treatment of a particular clinical problem or who has received advanced training in a medical or dental specialty pertinent to the patient’s problem. However, this practice of specialist consultation is usually limited to defined problems, with the expectation that the patient will return to the referring primary care clinician once the nature of the problem has been identified (diagnostic consultation) and appropriate treatment has been prescribed or performed (consultation for diagnosis and treatment).
ESTABLISHING A DIFFERENTIAL AND FINAL DIAGNOSIS
Before establishing a final diagnosis, the clinician often needs to formulate a differential diagnosis based on the history and physical examination findings. The disorders included in the differential diagnosis will determine which laboratory tests, such as biopsies, blood tests, or imaging studies, are required to reach a final diagnosis.