spots (ectopic sebaceous glands). During the year, 16 patients were tested for allergy to local anaesthesia. (xylocaine and citanest) but only one was found to be.
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Journal of the Royal Society of Medicine Volume 87 July 1994
The oral medicine clinic - what is its role?
J M Zakrzewska MD' C Downer FDS RCS2 V Lopes FDS RCS2 lDepartment of Oral and Maxillofacial Surgery, University College London, Mortimer Market, London WC1E 6AU and 2Joint Department of Maxillofacial Surgery and Oral Medicine, Institute of Dental Surgery, 256 Gray's Inn Road, London W1CX 8LD, UK Keywords: oral medicine; orofacial pain; stomatitis; cell carcinoma
squamous
Summary The total number of new patients seen over a period of 12 months in an oral medicine department was 963. Of these 587 were seen by an oral physician, 168 by a liaison psychiatrist, 137 by an oral immunologist and 71 by a dermatologist with a special interest in diseases of the mouth. The broad categories of disease seen were: 364 with orofacial pain of non-dental origin; 263 with benign diseases of the oral mucosa; 149 with potentially malignant lesions, six with frank carcinomas; 100 with oral manifestations of a systemic disease; and 81 patients with conditions considered to be normal. Introduction Oral medicine includes the diagnosis and medical management of diseases specific to the orofacial tissues and of oral manifestations of systemic diseases and behavioural disorders, and the oral treatment of medically compromised patients. In the last 20 years the specialty of oral medicine in the UK has become increasingly important and now has its own distinct training pathway as one of the additional dental medicine specialties. In dental schools and hospitals it is often linked with departments oforal pathology, oral and maxillofacial surgery and in some with periodontology. In district general hospitals the maxillofacial surgeons usually see patients with oral medicine problems as the specialty is not usually represented in non-teaching hospitals. Apart from one post in London and two in Scotland all posts are University funded. Oral physicians are generally medically and dentally qualified and also have a research degree. There is considerable overlap with other specialties and joint clinics are often organized with maxillofacial surgeons, dermatologists, psychiatrists, rheumatologists, pain specialists, oncologists and venereologists. Oral physicians refer, among others, to gastroenterologists, haematologists, neurologists, neurosurgeons and endocrinologists. The purpose of this study was to exmne the pattern of referral and diagnosis in a London oral medicine department staffed by both dentally and medically qualified specialists, and to provide referral guidance for practitioners in primary and secondary medical care. Method Over a period of 1 year (1991) all new patients attending an oral medicine clinic were entered into Correspondence to: Dr J Zakrzewska
the study. On the basis of the referral letter patients were allocated to the appropriate clinician, either an oral physician, a liaison psychiatrist specializing in facial pain, an oral immunologist or a dermatologist with a special interest in mucocutaneous lesions. The lesions were assigned to the following diagnostic groups: orofacial pain excluding dental pain; benign diseases of the oral cavity; potentially malignant lesions; carcinomas; oral manifestations of systemic diseases including HIV infection and positive allergy testing; and normal or variations of normal structures including negative responses to local anaesthetic allergy testing. A random sample of 500 referral letters was selected and the source of the referral of each was noted. The letters of referral were then classified according to source: general medical practitioner, general dental practitioner, another hospital, or another department within the same hospital. Results Of the 500 referral letters selected: 216 (43.2%) were from general dental practitioners; 127 (25.4%) from general medical practitioners; 95 (19%) were tertiary referrals from other departments within the hospital; and 62 (12.4%) were tertiary referrals from other hospitals. A total of 963 patients were seen in the 12 month period: 587 by the oral physician; 168 by the psychiatrist; 137 by the oral immunologist; and 71 by the dermatologist. Atypical facial pain, facial arthromyalgia (TMJ dysfunction syndrome) and oral dysaesthesia are all considered to be stress related pains. Of the 168 new patients seen by the liaison psychiatrist in the 12 month period all but six had pain of a psychological, psychiatric or neurological origin, the six patients had pain of dental origin. One hundred and twenty patients with these stress related illnesses were seen by the other clinicians and, in general, these patients were less likely to have a psychiatric illness than those seen by the psychiatrist. Table 1. Categories of disease
Category
Code
Number %
Orofacial pain Benign diseases of oral mucosa Potentially malignant lesions Carcinomas Oral manifestations of systemic diseases Variation of normal Total
OFP BDM PML Ca
364 263 149 6 100
37.8 27.3 15.5 0.6 10.4
81 963
8.4 100
OMS N
-
Journal of the Royal Society of Medicine Volume 87 July 1994 Table 2. Conditions diagnosed most frequently (five or nmre cases) in the oral medicine department over a period of 1 year
Category Condition OFP PML BDM N OFP BDM BDM BDM N BDM BDM OMS PML BDM BDM Ca BDM
OMS OMS -
No. of patients %
310 Stress related pain 115 Lichen planus 56 Recurrent oral ulceration 43 Hyperkeratosis 42 Trigeminal neuralgia 41 Acute candidiasis 22 Geographic tongue 18 Papillomas 15 Negative LA testing 15 Mucocoeles 15 Polyps 14 Sjogren's syndrome 12 Epithelial dysplasia 11 Periodontal disease 10 Haemangioma 6 Squamous cell carcinoma 6 Angina bullosa haemorrhagica 5 Mucous membrane pemphigoid 5 Crohn's disease 761 Total
31.7 11.7 5.7 4.5 4.3 4.2 2.2 1.8 1.5 1.5 1.5 1.4 1.2 1.1 1.0 0.6 0.6 0.5 0.5 79.0
LA=Local anaesthetic allergy
The remaining 675 patients were referred for oral lesions and were seen by the oral physician, the immunologist and the dermatologist. The breakdown of numbers of patients in each disease category is summarized in Table 1. Those conditions which occurred most commonly, i.e. which were represented by at least five cases, are summarized in Table 2. Two hundred and sixty-nine patients had lesions which were localized to the mouth, 61 of which were managed by an excision biopsy or cryosurgery (these included polyps, papillomas, haemangiomas and mucocoeles). Fifty-six patients were referred for recurrent oral ulceration, which can be associated with underlying systemic disease. Forty-one patients had acute candidiasis which in most patients was related to denture wearing, but in some patients systemic factors such as diabetes or HIV needed to be eliminated. Included in the category of potentially malignant conditions was lichen planus, candidal leukoplakia, verrucous leukoplakia, epithelial dysplasia, submucous fibrosis, actinic keratosis, sublingual keratosis and stomatitis nicotinia. All patients with a histological diagnosis of epithelial dysplasia presented with white or red patches and 11 were associated with a history of smoking. All of the six carcinomas were associated with smoking. Three presented with white patches and three presented with, ulceration. The patients with necrotic ulceration had the shorter history prior to presentation and diagnosis. This ranged from 1-5 months. Of the other three patients presenting with carcinoma, the white patches had been present for 1 year and 3 years, while the third was symptomless and therefore of unknown duration. There were 320 (43.4%) patients investigated for a possible systemic aetiology, which was present in 100 patients. Systemic diseases diagnosed after investigation included pemphigus vulgaris, benign mucous membrane pemphigoid, erythema multiforne, orofacial granulomatosis suggestive of Crohn's disease, Sj6gren's syndrome and various viral diseases. HIV/AIDS
patients were referred from a Genito-urinary Medicine unit. Patients were diagnosed as having oral hairy leukoplakia, acute candidiasis, Kaposi's sarcoma, intra-oral viral warts and one case of bacillary epithelioid angiomatosis, in only the latter case was the diagnosis made from the oral lesions. Within the category of normal variation of the oral mucosa there were 81 patients of which the major findings were 44 with hyperkeratosis mostly of the buccal mucosa secondary to a cheek biting habit; others included racial pigmentation and Fordyce's spots (ectopic sebaceous glands). During the year, 16 patients were tested for allergy to local anaesthesia (xylocaine and citanest) but only one was found to be positive. One patient was found to be allergic to penicillin and one to carbamazepine. Six patients with suspected contact allergy were patch tested to cobalt, nickel, mercury, amalgam, rubber or colophony (Elastoplast) and all were found to be positive. Discussion Oral medicine attracts referrals from a wide range of practitioners and specialists with 68% of referrals being primary and the remainder tertiary. The frequency of cases presenting in a hospital department does not necessarily reflect the prevalence of the various conditions in the population. Marked variations in case content in reported studies are clearly dependent on other factors. Matthews et al. reviewed the diagnosis on 1000 patients presenting to an emergency outpatient clinic in a British dental teaching hospital. They concluded that over 10% of the patients did not have problems related directly to teeth, gingivae or denture but were of an oral medicine nature1. A series reviewing 981 consecutive patients attending an oral medicine clinic in North America over an 8 year period arranged their patients into four broad categories: mucosal conditions (55.2%); pain and dysfunction (23.3%); periodontal and tooth (17.1%); and variations of normal and second opinions (4.4%)2. In contrast to this we had a significantly higher referral rate for pain 36.6% compared to 23.3%. This is a reflection of our particular interest in facial pain including trigeminal neuralgia and the availability on site of a liaison psychiatrist. Trigeminal neuralgia was diagnosed in three patients in the North American series compared to 42 patients in this study. Many of the patients who have stress related facial pain may also suffer from back, neck and abdominal pain, headaches, tinnitus and pruritus. It is therefore important to recognize these symptoms as part of the same condition and to develop one treatment protocol. The most effective treatment for stress related facial pain is considered to be with antidepressant
therapy3. Lichen planus was the most frequently referred soft tissue lesion (n=115), this was also the case in the series of patients seen by Bottomley et al. (n= 193)2. Lichen planus is considered to be a potentially malignant lesion. This point remains controversial, however, as many people now believe that the classical reticular lichen planus is not potentially malignant4. Other forms of the condition are more likely to become dysplastic and therefore may progress to neoplasia. It would seem prudent to review all but the reticular type of lichen planus regularly. Lichenoid lesions clinically identical to lichen planus and histologically similar can be associated with
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systemic medication, for example methyl dopa, or local hypersensitivity reactions5. Oral manifestations of systemic disease are common. The systemic disease is sometimes already known at the time of consultation, however in some cases the diagnosis is made after investigation as a result of the oral lesions. The development of oral lesions in systemic diseases may also reflect the progression of the disease, for example the development of oral candidiasis in HIV infection, oral ulceration and lip swelling in Crohn's disease, or development of lymphomas in the parotid gland in patients with Sj6gren's syndrome. Maturity onset diabetes is frequently diagnosed in oral medicine clinics when patients are investigated for persistent candidiasis. Haematological abnormalities are often discovered. Dermatologists play a crucial role in oral medicine clinics as they manage patients with oral and skin lesions. The oral immunologist investigates those aspects of oral diseases which relate to immunology. Oral medicine clinics play an important role detecting and monitoring potentially malignant lesions and small carcinomas as these afford a better prognosis. Bottomley et al. 2 had five patients with carcinoma, Matthews et al. 1 had two patients and we had six patients. We see patients with epithelial dysplasia and early carcinomas on joint clinics with oral physicians, maxillofacial surgeons and oral pathologists. Health promotion plays an important role and all patients are encouraged to stop smoking. Lesions will often regress after patients have stopped smoking. The patients at greatest risk of developing
(Accepted 27 September 1993)
Some recent books
The Man Who Tasted Shapes. Richard E Cytowic (pp 249) ISBN 0349105480, London: Abacus, 1993.
Abnormalities of Personality: Within and Beyond the Realm of Treatment. Michael H Stone (pp 546) ISBN 0393701271, London; New York: W W Norton & C., 1993. Cataract: Detection, Measurement and Management in Optometric Practice. William A Douthwaite, Mark A Hurst (pp 140) ISBN 0750603690, Oxford: Butterworth-Heinemann Ltd, 1993. Clinical ENT Radiology. P D Phelps, J M Stansbie (pp 188), ISBN 0750615966, Oxford: Butterworth-Heinemann Ltd, 1993. Diagnostic Tests in Endocrinology and Diabetes, 1st edn. P-MG Bouloux, L H Rees (pp 313) ISBN 0412352001, London: Chapman & Green, 1994. District Action Research and Education. Liz Barnett, Fred Abbatt (pp 136) ISBN 0333587588, Basingstoke: Macmillan Distribution Ltd, 1994. Empowered Psychotherapy: Teaching SelfProcessing. A New Approach to the Human Psyche and its Reintegration. Robert Langs (pp 252) ISBN 1855750570, London: H. Karnac (Books) Ltd, 1993. Epilepsies of Childhood, 3rd edn. Niall V O'Donohoe (pp 340) ISBN 0750615982, Oxford: Butterworth-Heinemann Ltd, 1994. Human in vitro Fertilization. A Case Study in the Regulation of Medical Innovation. Jennifer Gunning, Veronica English (pp 219) ISBN 1855213478, Hampshire: Dartmouth Publishing Company Ltd, 1993.
oral carcinoma are those over 40 years of age, smokers and infrequent users of dental services6.
Conclusion Oral medicine provides a link between medicine and dentistry and is a specialty that should be recognized more widely as it provides a very useful diagnostic and treatment service for medical practitioners in primary and secondary medical care. Acknowledgments: We would like to thank Dr J G Gilkes, Dr L I Ivanyi, Dr C Feinmann and Professor M Harris for their help with data collection and advice preparing the manuscript.
References 1 Matthews R, Scully C, Porter K, Grifflths M. An analysis of conditions presenting to a dental hospital emergency clinic. Hlth Trends 1992;24:126-8 2 Bottomley WK, Brown RS, Lavigne GJ. A retrospective survey of the oral conditions of 981 patients referred to an oral medicine private practice. J Am Dent Assoc 1990;120:529-33 3 Feinmann C, Harris M, Cawley R. Psychogenic pain: presentation and treatment. BMJ 1984;228:436-8 4 Eisenberg E, Krutchkoff DJ. Lichenoid lesions of oral mucosa. Oral Surg Oral Med Oral Pathol 1992;73:699-704 5 Holmstrup P. Reactions of the oral mucosa related to silver amalgam. J Oral Pathol Med 1991;20:1-7 6 Johnson NW. Oral cancer. Detection of patients and lesions at risk. In: Risk Markers for Oral Diseases, Vol 2. Cambridge University Press, 1991
The Management and Prevention of Diarrhoea: Practical Guidelines, 3rd edn. World Health Organization (pp 50) ISBN 9241544546 Geneva: World Health Organization, 1993. The Management of Common Metabolic Bone Disorders. Gordon Campbell, Juliet Compson, Adrian Crisp (pp 170) ISBN 0521430372, Cambridge: Cambridge University Press, 1993.
Marital Tensions: Clinical Studies Towards a Psychological Theory of Interaction. Henry V Dicks (pp 354) ISBN 1855750643, London: H Karnac (Books) Ltd, 1993. Medical Contact Lens Practice: A Systematic Approach. Ian A Mackie (pp 227) ISBN 0750609397, Oxford: ButterworthHeinemann Ltd, 1993. Molecular Imaging in Neuroscience: A Practical Approach. N A Sharif (pp 245) ISBN 0199633819, Oxford: Oxford University Press, 1993.
Pediatric Occupational Therapy and Early Intervention. Jane Case-Smith (pp 389) ISBN 1563720264, Oxford: Andover Medical Publishers, 1993. Practicing Therapy: Exercises for Growing Therapists. A H Rambo, Anthony Heath, Ronald J Chenail (pp 276) ISBN 039370159X, London: W W Norton & Co., 1993.
Prejudice and Dignity: An Introduction to Community-Based Rehabilitation. Einar Helander (pp 241), ISBN 9211260329, Geneva: United Nations Development Programme, 1993.
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