Oral medicine is the specialty of dentistry that deals with the oral health care of patients with chronic, recurrent and medically related disorders of the oral and maxillofacial region and with their diagnosis and non-surgical management.
As such, oral medicine lies at the interface between dentistry and medicine. Effective collaboration between the dentist and general practitioner (GMP) will allow many patients with oral medicine problems to be successfully treated in primary care without the need to refer them to secondary care.
This multi-professional work directly benefits the patient and reduces pressure on specialist services, which can then deal with more complex cases.
The aim of this short article is to present some ’clinical tips’
- Assessment of orofacial tissues . An abnormality in the orofacial tissues is likely to be detected visually initially. However, manual palpation can also reveal a change. As a basic principle, a sinister condition, such as a carcinoma, is firm to palpation (indurated), while a non-sinister abnormality, for example, a cyst, is soft to palpation. All visual and palpable findings should be recorded in the clinical notes. The use of the term ’injury’ , which is derived from the Latin noun ’laesio’ meaning injury, should be avoided as in a descriptive sense it is effectively meaningless. It is preferable to refer to a change within the orofacial tissue as an ’abnormality’ and use descriptive terms such as ulcer, red spot or swelling. 1This is particularly relevant in the written text of a patient referral, as it may influence the degree of urgency during investigation by secondary care. Furthermore, the usefulness of clinical photography cannot be overstated both for monitoring an abnormality in practice and for including an image in a referral.
- Special investigations . The range of special investigations available to assist in the diagnosis and monitoring of patients with orofacial disease is broad. Liaison with doctor to get basic test results is really helpful. For oral mucosal disease, the most useful hematologic investigations are complete blood count (FBC), folate, vitamin B 12, and ferritin. HbA1c is the most reliable indicator of diabetic status in relation to a patient with dry mouth or oral candidiasis.
- Prescribing The British National Formulary (BNF), which includes the Dental Practitioner Formulary (DPF), provides the most comprehensive source of advice on all aspects of prescribing, including drug interactions and adverse reactions. However, the Scottish Dental Clinical Effectiveness Program (SDCEP) guidelines for dental prescribing provide concise information on surgery. The use of abbreviations, such as tds or tid , for dosing frequency should be avoided in both prescribing and case records. It is preferable to write ’every 8 hours’ or ’three times a day’ to avoid possible errors of interpretation.
- Pain management . Orofacial pain of non-dental origin is not usually associated with visible clinical signs and, therefore, the diagnosis should be based on a detailed evaluation of the symptoms. The severity of the pain should be recorded on a scale of zero to ten, where 0 corresponds to ’no pain’ and 10 indicates ’the worst pain ever experienced’ . The patient should be asked to describe the nature of the pain. Don’t suggest particular words, but ask the question, ’How would you describe the nature of the pain?’ The response often involves ’shoot’, ’burn’ or ’grab’. As a generalization, a ’10 out of 10’ stabbing pain that lasts seconds is trigeminal neuralgia (any score less than 10 would suggest it is not trigeminal neuralgia), while an ’8 out of 10’ burning sensation that lasts the entire day it is likely to be burning mouth syndrome (BMS). A constant ’7 out of 10’ pain that is probably persistent idiopathic facial pain (PPIF).
to. Trigeminal neuralgia : This is the worst pain the patient has ever suffered (women often report that it is worse than childbirth) so it is essential to relieve it as soon as possible. Carbamazepine (in DPF) should be prescribed as 100 mg tablets twice a day for ten days. The general practitioner should be informed along with a request for liver function tests. If trigeminal neuralgia is present, administration of carbamazepine will result in some improvement of symptoms within 48 hours, a finding that helps confirm the diagnosis.
b. Burning mouth syndrome : The oral mucosa will appear normal in burning mouth syndrome (BMS). Patients with SBA are typically anxious about the presence of an ominous disease in the mouth, particularly cancer (known as cancerophobia). The patient will never ask ’Do you think I have cancer?’ However, it is essential to raise this issue and provide strong assurance that there is no evidence of sinister illness. The patient should also be reassured that BMS is a common condition within the population. Interestingly, patients have never heard of the condition or met anyone else who may have it. There will be a need to liaise with the general practitioner to exclude other systemic etiological factors and discuss the likely use of antidepressant medication (usually low dose amitriptyline at night) for 3 to 6 months.
c. Persistent idiopathic facial pain: If a dental cause for orofacial pain has been excluded and persistent orofacial pain is suspected, then it is appropriate to contact the general practitioner to consider administering a low dose of an antidepressant drug, such as amitriptyline, in the evening.
- Dry mouth (xerostomia): In addition to an obvious lack of saliva accumulation on the floor of the mouth at rest, a simple test to determine if a patient has dry mouth is to place an examination mirror against the oral mucosa. If the mirror face sticks, there is likely reduced or impaired saliva production. The most common cause of dry mouth is an adverse event associated with drug therapy, so the potential for alternative medications should be considered with your general practitioner. It is also essential to exclude diabetes by requesting a glycosylated hemoglobin (HbA1c) test.
- Mucosal disorders.
to. Recurrent aphthous stomatitis (RAS): For frequent patients, it is useful to request the results of basic hematological tests. If present, the underlying cause of any blood deficiency (most commonly iron) should be identified and corrected by the general practitioner. All patients with RAS should receive dietary advice on the avoidance of tomatoes and benzoate-based preservatives, particularly carbonated soft drinks, as hypersensitivity to these foods may occur.
b. Lichen planus – The characteristic presentation of lichen planus involves a bilateral, symmetrical distribution of lacy white lines. An asymmetrical distribution or physical contact with an amalgam restoration is likely a lichenoid reaction. If the lateral margin of the tongue is affected, it is essential to refer for a biopsy to rule out epithelial dysplasia or carcinoma.
c. Geographic tongue : Patients with geographic tongue are often anxious that mucosal changes represent an infection or malignancy. Assurance that it is neither of these conditions is essential. Symptomatic geographic tongue will often respond to a zinc sulfate mouthwash. Liaise with the general practitioner to prescribe 125 mg of effervescent zinc sulfate dissolved in 10 ml and used as a mouthwash for two minutes three times a day. This preparation is also useful in patients with complaints of altered or metallic taste.
d. Candidiasis : The basic principle for the management of any form of oral candidiasis, historically known as the ’disease of the sick’ , is the identification of the underlying predisposing factor that promotes opportunistic infection. A wide range of local and medical factors should be investigated, some of which require the results of routine hematological testing. The agent of choice for the treatment of most cases of oral candidiasis is fluconazole (50 mg capsule once a day for seven days). Topical antifungals have limited benefit.
and. Red and white spots : The vast majority of leukoplakia cases will never undergo malignant transformation. However, a red spot (erythroplakia) or a red/white spot (erythroleukoplakia) is associated with a high risk of cancer and as such should be submitted, including a photograph, as urgent suspicion of cancer (USC) according to the guidelines. NICE guidelines.
