Remote telephone clinics in oral medicine: reflections on the place of virtual clinics in a specialty that relies so heavily on visual assessment. A note of caution.

During the COVID-19 pandemic, NHS services had to convert face-to-face consultations to remote consultations to facilitate the ongoing provision of healthcare. Many specialties including Oral and Maxillofacial Surgery and Rheumatology have found such virtual clinics effective and appreciated by both patients and clinicians. In Oral Medicine, whilst responses to virtual clinics have been positive, we have recognised that they are not sufficient. In this reflective piece, we describe our experiences and our approach to their use in the management of Oral Medicine and Behçet's disease patients, which has developed iteratively during the lockdown period. We also consider the role of virtual clinics in Oral Medicine in the post-COVID-19 era.

Screening for oral cancer utilising risk-factor analysis is ineffective in high-risk populations.

Screening for oral cancer by direct visual examination is believed to be ineffective because of the difficulty in differentiating a small number of malignancies from the much more prevalent benign oral mucosal lesions (OML) that are found in high-risk individuals. Standardised clinical diagnoses were recorded for all the OMLs identified during oral visual examination of 1111 individuals with risk factors for oral cancer, including tobacco and areca nut (paan) consumption. Suspicious lesions were referred for biopsy and definitive diagnosis. A total of 1438 OMLs with 32 different clinical diagnoses were identified in 604 participants. Analysis of referrals revealed two distinct groups: visually benign lesions (VBLs) none of which was referred, and visually complex lesions (VCLs) comprising 661 OMLs with nine different clinical diagnoses. After biopsy the VCLs included known potentially malignant disorders (PMDs) as well as benign lesions such as paan mucositis. VCLs (but not VBLs) share risk factors with oral cancer (p<0.05 for paan 5.82 (CI: 1.98 to 8.43), and smoking 3.59 (CI: 1.12 to 4.47)). They are clinically indistinguishable from, but much more prevalent than, oral cancer, and most will never undergo malignant change. They therefore can prevent dentists from accurately detecting malignancy during the clinical examination of high-risk patients. However, they can easily be differentiated from other benign lesions by visual examination alone. Further research into diagnostic technology is needed to help differentiate them from oral cancers.

Oral Medicine for undergraduate dental students in the United Kingdom and Ireland-A curriculum.

INTRODUCTION: Oral Medicine focuses on care for patients with chronic, recurrent and medically related disorders of the orofacial region that are distinct from diseases of the periodontal and tooth tissues, with an emphasis on non-surgical management. At present, there are no shared outcomes for Oral Medicine to define the standards to be achieved before new graduates become registered dentists engaged with ongoing professional development. CURRICULUM: We present a consensus undergraduate curriculum in Oral Medicine agreed by representatives from 18 Dental Schools in the United Kingdom and Republic of Ireland. The scope of Oral Medicine practice includes conditions involving the oral mucosa, salivary glands, neurological system or musculoskeletal tissues that are not directly attributable to dental (tooth and periodontium) pathology. Account is taken of the priorities for practice and learning opportunities needed to support development of relevance to independent clinical practice. The outcomes triangulate with the requirements set out by the respective regulatory bodies in the UK and Republic of Ireland prior to first registration and are consistent with the framework for European undergraduate dental education and greater harmonisation of dental education. CONCLUSIONS: This curriculum will act as a foundation for an increasingly shared approach between centres with respect to the outcomes to be achieved in Oral Medicine. The curriculum may also be of interest to others, such as those responsible for the training of dental hygienists and dental therapists. It provides a platform for future collective developments with the overarching goal of raising the quality of patient care.

Clinical medical sciences for undergraduate dental students in the United Kingdom and Ireland - a curriculum.

The technical aspects of dentistry need to be practised with insight into the spectrum of human diseases and illnesses and how these impact upon individuals and society. Application of this insight is critical to decision-making related to the planning and delivery of safe and appropriate patient-centred healthcare tailored to the needs of the individual. Provision for the necessary training is included in undergraduate programmes, but in the United Kingdom and Ireland there is considerable variation between centres without common outcomes. In 2009 representatives from 17 undergraduate dental schools in the United Kingdom and Ireland agreed to move towards a common, shared approach to meet their own immediate needs and that might also be of value to others in keeping with the Bologna Process. To provide a clear identity the term 'Clinical Medical Sciences in Dentistry' was agreed in preference to other names such as 'Human Disease' or 'Medicine and Surgery'. The group was challenged to define consensus outcomes. Contemporary dental education documents informed, but did not drive the process. The consensus curriculum for undergraduate Clinical Medical Sciences in Dentistry teaching agreed by the participating centres is reported. Many of the issues are generic and it includes elements that are likely to be applicable to others. This document will act as a focus for a more unified approach to the outcomes required by graduates of the participating centres and act as a catalyst for future developments that ultimately aim to enhance the quality of patient care.

The period prevalence of oral lichen planus in a cohort of patients with vulvar lichen sclerosus.

BACKGROUND: Lichen sclerosus and lichen planus are chronic inflammatory mucocutaneous disorders that may coexist. OBJECTIVE: The aim of this study was to estimate the period prevalence of oral lichen planus in a cohort of patients with vulvar lichen sclerosus and to document their clinical characteristics. METHODS: We report a series of cases of vulvar lichen sclerosus presenting to two dermatologist-led vulvar clinics in Oxfordshire, England between 1997 and 2007 with coexistent clinical signs of oral lichen planus. RESULTS: Thirteen cases with coexistent vulvar lichen sclerosus and oral lichen planus were identified, of which five had oral biopsies. Four oral biopsies showed histological features consistent with lichen planus. One oral biopsy was not diagnostic but compatible with oral lichen planus. No cases of oral lichen sclerosus were identified. The period prevalence of oral lichen planus was 6 per 1000 cases of vulvar lichen sclerosus. CONCLUSION: The period prevalence of oral lichen planus in women with vulvar lichen sclerosus (0.6%) is similar to that reported for oral lichen planus in the general population (1-2%).

An audit of the UK national cancer referral guidelines for suspected oral mucosal malignancy.

BACKGROUND AND OBJECTIVE: This study aimed to assess the effectiveness of the UK National Guidelines for identifying patients with potentially malignant oral disease which were introduced in 2000. DESIGN: Retrospective audit. SETTING: The oral medicine unit in a university teaching hospital in London. METHODS: All new referrals over a one year period were retrospectively reviewed in a departmental audit to evaluate guideline effectiveness. Reasons for referral and final diagnosis were compared in a randomly selected sub-population. RESULTS: Four hundred and eighty-seven of 901 new patients referred were classified as having potentially malignant disease from the referral letter. In a randomly selected subgroup of 241 patients, 18 actually had malignant (8) or dysplastic lesions (10). Of 75 patients referred with a persistent oral ulcer, only nine were actually malignant or dysplastic. Eight of 116 patients referred with a white patch and none with red patches were found to have dysplastic or malignant lesions. The criteria failed to identify three carcinomas and two severely dysplastic lesions (15% of the malignant or dysplastic lesions). All of the latter had been referred by primary care physicians with orofacial pain of unknown cause. CONCLUSIONS: UK National Guidelines discriminate poorly between potentially malignant and other oral mucosal disease.

Necrotizing stomatitis in the developed world.

We present a case of a malnourished 68-year old man with occult hypothyroidism who presented with malaise, pyrexia, tongue swelling, oral ulceration and dysphagia after a 6-month period of increasing lethargy and failing self-care. Severe necrotic oral ulcerative lesions were accompanied by cutaneous purpura, blood-filled blisters and bedsores. It was concluded that the patient's clinical condition reflected necrotizing stomatitis on a background of malnutrition with scorbutic skin lesions and hypothyroidism. The patient made a good recovery with scrupulous oral hygiene, debridement, intravenous metronidazole and nutritional support. Healing occurred with marked fibrosis and trismus, which has slowly improved with mouth-opening exercises. Necrotizing stomatitis is more commonly encountered in malnourished children in developing countries, and may subsequently result in devastating facial defects and death. Patients in the developed world with poor oral hygiene, malnourishment and immunosuppression are also at risk, but early diagnosis and treatment is life-saving and reduces subsequent disability.

An audit of the efficacy of the oral brush biopsy technique in a specialist Oral Medicine unit.

The diagnosis of oral epithelial dysplasia has traditionally been based upon histopathological evaluation of a full thickness biopsy specimen from lesional tissue. It has recently been proposed that cytological examination of "brush biopsy" samples is a non-invasive method of determining the presence of cellular atypia, and hence the likelihood of oral epithelial dysplasia. The present audit determined, retrospectively the sensitivity, specificity and positive and negative predictive values of the oral brush biopsy technique in the diagnosis of potentially malignant disease in a group of 112 patients attending a specialist Oral Medicine unit. The sensitivity of detection of oral epithelial dysplasia or squamous cell carcinoma of the oral brush biopsy system was 71.4% while the specificity was 32%. The positive predictive value of an abnormal brush biopsy result (positive or atypical) was 44.1%, while the negative predictive value was 60%. It is concluded that not all potentially malignant disease is detected with this non-invasive investigative procedure.