1

Introduction to Oral Medicine and Oral Diagnosis: Patient Evaluation

Michael Glick, DMD, FDS RCSEd
Martin S. Greenberg, DDS, FDS RCSEd
Peter B. Lockhart, DDS, FDS RCSEd, FDS RCPS
Stephen J. Challacombe, PhD, FDS RCSEd FRCPath, FDSRCS

❒❒ INFORMATION GATHERING ❒❒ CLINICAL OUTCOMES AND ORAL DISEASE

Medical History SEVERITY SCORING
Patient Examination Oral Disease Severity Scoring
Consultations Patient-Reported Outcome Measures and Oral
❒❒ ESTABLISHING A DIFFERENTIAL AND FINAL Mucosal Disease
DIAGNOSIS ❒❒ THE DENTAL AND MEDICAL RECORD
Problem-Oriented Record
❒❒ FORMULATING A PLAN OF ACTION
SOAP Note
Medical Risk Assessment
Confidentiality
Modification of Dental Care for Medically
Informed Consent
Complex Patients
Monitoring and Evaluating Underlying Medical ❒❒ TELEHEALTH/TELEDENTISTRY
Conditions

Oral medicine, as defined by the American Academy of Oral patient values and preferences, as well as elevates the impor-
Medicine, is “the specialty of dentistry responsible for the tance of subjective findings. This approach is more aligned
oral health care of medically complex patients and for the with a person‐centered care approach that emphasizes a
diagnosis and management of medically related disorders or patient’s problem in the context of behavioral, socioeco-
conditions affecting the oral and maxillofacial region.” nomic, and environmental aspects, and their impact on the
Definitions vary in different parts of the world, but most patient and on the care that needs to be delivered.2–4 This
include the diagnosis and nonsurgical management of oral definition has also been the underlying framework to estab-
mucosal and salivary gland disease, orofacial pain, and den- lish outcomes that can be used to measure the oral status of
tal treatment of patients with medical disorders. an individual.5
The overall goal for all oral healthcare professionals is to Given the nature, complexity, and potential systemic
deliver and maintain optimal health for their patients. implications for some oral conditions, coupled with an aging
A recent definition was approved by the World Dental population with multimorbidities (multimorbidities do not
Parliament in 2016, which expanded the definition to include identify an index disease, while comorbidities focus on an
three different domains: disease and condition status, psy- index disease and other diseases) and individuals taking
chosocial status, and physiologic function.1 The inclusion of numerous medications, all oral healthcare clinicians are
a psychosocial status and physiologic function deviates from required to enhance their knowledge of many aspects of
traditional definitions that mainly focused on the presence or medicine. Therefore, what previously was considered the
absence of disease, and, further, it promotes the inclusion of purview of oral healthcare professionals with hospital‐based

Burket’s Oral Medicine, Thirteenth Edition. Edited by Michael Glick, Martin S. Greenberg, Peter B. Lockhart, and Stephen J. Challacombe.
© 2021 John Wiley & Sons, Inc. Published 2021 by John Wiley & Sons, Inc.
2 Burket’s Oral Medicine

training has become increasingly more important in general 4) Final diagnosis.

and specialty dental practice. 5) Formulating a plan of action.
Advances in clinical practice are influencing many 6) Initiating treatment.
aspects of patient care, from our initial contact with a 7) Follow‐up assessment of response to treatment.
patient, through medical history‐taking, diagnosis, and
treatment options. For example, electronic health records
(EHRs) allow for sharing health information among mul- ­I NFORMATION GATHERING
tiple clinicians caring for the same patient and can pro-
vide point‐of‐care algorithms for eliciting and using An appropriate interpretation of the information collected
health information. Modern imaging techniques, such as through a medical history and patient examination achieves
computerized tomography scans (CTs) and magnetic reso- several important objectives. It affords an opportunity for:
nance imaging (MRI), provide more detailed information
and are a means to acquire more sophisticated data, but ●● Gathering the information necessary for establishing a
require enhanced training for accurate interpretation. diagnosis for the patient’s chief complaint.
Nevertheless, one of the most important skills for accu- ●● Assessing the influence of the patient’s systemic health on
rate diagnosis and management remains an experienced their oral health.
clinician with highly developed skills of listening and ●● Detecting other systemic health conditions of which the
examination. patient may not be aware.
The initial encounter with a patient may influence all ●● Providing a basis for determining whether dental treat-
subsequent care. The skilled, experienced practitioner ment might impact the patient’s systemic health.
has learned to elicit the subjective (i.e., history‐taking) ●● Giving a basis for determining necessary modifications to
and objective (e.g., clinical, laboratory) findings and routine dental care.
other necessary information required for an accurate ●● Monitoring medical conditions of relevance to the maxil-
diagnosis. This process is an art, as well as a skill. lofacial condition.
Although mastering a patient evaluation can be assisted
by specific clinical protocols, the experienced practitioner Medical History
will add their own skills and experience to the diagnostic
methodology. Obtaining an appropriate and accurate medical history is a
A variety of accessible sources of healthcare information critical first step for all patient care. It begins with a system-
are now readily available to patients, and many will use this atic review of the patient’s chief or primary complaint, a
information to self‐diagnose, as well as demand specific detailed history related to this complaint, information about
treatments. As a person‐centered approach is encouraged, past and present medical conditions, pertinent social and
where a patient’s preferences and values will influence care, family histories, and a review of symptoms by organ system.
the practitioner must listen to the patient to understand A medical history also includes biographic and demographic
their needs, fears, and wishes and address them to arrive at data used to identify the patient.
an appropriate treatment plan that results in informed, sci- There is no universally agreed method for obtaining a
entific, and evidence‐based choices. Furthermore, part of a medical history, but a systematic approach will help the
shared decision‐making approach includes the responsibil- practitioner to gather all necessary information without
ity of the oral healthcare professional to educate their patient overlooking important facts. The nature of the patient’s oral
about the implications and consequences of a diagnosis and health visit (i.e., initial dental visit, complex diagnostic prob-
subsequent treatment. Creating an environment for effective lem, emergency, elective continuous care, or recall) often
communication between provider and patient has been dictates how the history is obtained. The two most common
shown to improve health outcomes.6 means of obtaining initial patient information are a patient
The process of obtaining, evaluating, and assessing a self‐administered preprinted health questionnaire, or
patient’s oral and overall health status can arbitrarily be recording information during a systematic health interview
divided into seven major, sometimes overlapping, parts: without the benefit of having the patient fill out a question-
naire. The use of self‐administered screening questionnaires
1) History and examination. is the most common method in dental settings. This tech-
2) Establishing a differential diagnosis. nique can be useful in gathering background medical infor-
3) Obtaining necessary consultations, as well as appropriate mation, but the accurate diagnosis of a specific oral
laboratory tests, such as specific blood investigations, a complaint requires a history of the present illness and other
biopsy, and imaging studies, all based upon the initial dif- verbal information. While the basic information for a past
ferential diagnosis. medical history may be obtained by a questionnaire, a vital
 Chapter 1 Introduction to Oral Medicine and Oral Diagnosis 3

part of the evaluation of a patient with a complex diagnostic gested medical treatment guidelines and prescribed
problem is the history of the present illness, which is a com- medications is part of the oral healthcare professional’s
bination of science and art and should be taken directly by responsibilities. The following strategies are common to
the clinician. nearly all methods of history‐taking:
The challenge in any healthcare setting is to use a ques-
tionnaire that has enough items to obtain the essential medi- ●● Review available patient information prior to meeting the
cal information, but is not too long to deter a patient’s patient.
willingness and ability to fill it out. These questionnaires ●● Greet the patient; use the patient’s name; ensure privacy;
should be constructed in a manner that allows the clinician sit rather than stand, preferably at eye level; maintain eye
to query the patient about the most essential and relevant contact as often as possible; listen carefully to the patient’s
required information, yet provides a starting point for a dia- concerns; do not rush the interview process.
logue with the patient about other pertinent information not ●● Do not concentrate chiefly on entering the information
included on the health form. Preprinted self‐administered or into an electronic health record, as this may distract you
online health questionnaires are readily available, standard- from listening to pertinent information.
ized, and easy to administer and do not require significant ●● Use the patient’s own words (in quotation marks) to
“chair time.” They give the clinician a starting point for a describe the primary reason(s) to seek care/consultation;
dialogue to conduct more in‐depth medical queries, but are i.e., be absolutely clear about the patient’s chief complaint(s).
restricted to the questions chosen on the form and are there- ●● Use open‐ended questions to encourage open dialogue
fore limited in scope. The questions on the form can be mis- with the patient. Although all information should be col-
understood by the patient, resulting in inaccurate lected in a systematic fashion, the order is not as impor-
information, and they require a specific level of reading tant as is initiating a dialogue with the patient about their
comprehension. Preprinted forms cover broad areas without health.
necessarily focusing on particular problems pertinent to an ●● Create a timeline of the reported patient‐related events.
individual patient’s specific medical condition. Therefore, An accurate chronology is an extremely important ­element
the use of these forms requires that the provider has suffi- to establish or deny a causative relationship.
cient background knowledge to understand the reasons for The medical history traditionally consists of the following
the questions on the forms. Furthermore, the provider needs subcategories:
to realize that a given standard history form necessitates
timely and appropriate follow‐up questions, especially when ●● Identification—name, date and time of the visit, date of
positive responses have been elicited. An established routine birth, gender, ethnicity, occupation, contact information
for performing and recording the history and examination of a primary care provider (physician and, if applicable,
should be followed conscientiously. dentist), referral source.
The oral healthcare professional has a responsibility to ●● Chief complaint (CC)—the main reason for the patient
obtain relevant medical and dental health information, yet seeking care or consultation and the length of time these
the patient cannot always be relied upon to know this infor- symptoms have been present, recorded in the patient’s
mation or to provide an accurate and comprehensive assess- own words.
ment of their medical or dental status. ●● History of present illness (HPI)—taking an effective HPI
All medical information obtained and recorded in an oral takes experience and is often the key to making an accurate
healthcare setting is considered confidential and may in differential diagnosis. It includes a chronologic account of
many jurisdictions constitute a legal document. Although events; state of health before the presentation of the pre-
it is appropriate for the patient to fill out a history form in sent problem; description of the first signs and symptoms
the waiting room, any discussion of the patient’s responses and how they may have changed; description of occur-
must take place in a private setting. Furthermore, access to rences of amelioration or exacerbation; previous clinicians
the written or electronic (if applicable) record must be lim- consulted, prior treatment, and degree of the response to
ited to personnel who are directly responsible for the previous treatment. For those who favor mnemonics, the
patient’s care. Any other release of private information nine dimensions of a medical problem can be easily
should be approved, in writing, by the patient and that recalled using OLD CHARTS (Onset, Location/radia-
approval retained by the dentist as part of the patient’s tion, Duration, Character, Habits, Aggravating
medical record. ­factors, Reliving factors, Timing, and Severity).7
Given that medical status and medication regimens often ●● Review of systems (ROS)—identifies symptoms in differ-
change, a patient’s health status or medication regimen ent body systems (Table 1‐1). The ROS is a comprehensive
should be reviewed at each office visit prior to initiating den- and systematic review of subjective symptoms affecting
tal care. The monitoring of patients’ compliance with sug- different bodily systems. It is an essential ­component for
4 Burket’s Oral Medicine

Table 1-1  eview of Systems (ROS): A systematic approach

R outcome); medications (prescribed medications, over‐the‐
to ascertain mostly subjective symptoms associated counter medications, supplements) and home remedies;
with the different body systems.
allergies.
General: Weight changes, malaise fatigue, night sweats ●● Personal and social history (SH)—birthplace; marital
Head: Headaches, tenderness, sinus problems ­status; children; habits (tobacco use, alcohol use, recrea-
Eyes: Changes in vision, photophobia, blurring, diplopia, spots, tional drug use); occupation; religion (if it may have an
discharge impact on therapy); sexual history if relevant to
Ears: Hearing changes, tinnitus, pain, discharge, vertigo complaint.
Nose: Epistaxis, obstructions ●● Family history (FH)—health or cause of death of parents,
Throat: Hoarseness, soreness siblings, and children. The FH should also include ­diseases
Respiratory: Chest pain, wheezing, dyspnea, cough, important to the patient’s chief compliant, including
hemoptysis genetic disorders; and common diseases, such as cardio-
Cardiovascular: Chest pain, dyspnea, orthopnea (number of vascular diseases or diabetes mellitus.
pillows needed to sleep comfortably), edema, claudication
Dermatologic: Rashes, pruritus, lesions, skin cancer
(epidermoid carcinoma, melanoma)
Patient Examination
Gastrointestinal: Changes in appetite, dysphagia, nausea, The examination of the patient represents the second stage
vomiting, hematemesis, indigestion, pain, diarrhea, of the evaluation and assessment process. An established
constipation, melena, hematochezia, bloating, hemorrhoids,
jaundice
routine for examination decreases the possibility of missing
important findings (signs).
Genitourinary: Changes in urinary frequency or urgency,
dysuria, hematuria, nocturia, incontinence, discharge, A routine head and neck examination should be carried
impotence out at least annually or at each recall visit. This includes a
Gynecologic: Menstrual changes (frequency, duration, flow, thorough inspection (and when appropriate palpation, aus-
last menstrual period), dysmenorrhea, menopause cultation, or percussion) of the exposed surface structures
Endocrine: Polyuria, polydipsia, polyphagia, temperature of the head, neck, and face and a detailed examination of
intolerance, pigmentations the oral cavity, dentition, oropharynx, and adnexal struc-
Musculoskeletal: Muscle and joint pain, deformities, joint tures. Laboratory studies and additional special examina-
swellings, spasms, changes in range of motion tion of other organ systems may be required for the
Hematologic: Easy bruising, epistaxis, spontaneous gingival evaluation of patients with orofacial pain, oral mucosal dis-
bleeding, increased bleeding after trauma ease, or signs and symptoms suggestive of otorhinologic or
Lymphatic: Swollen or enlarged lymph nodes salivary gland disorders, or signs or symptoms suggestive
Neuropsychiatric: Syncope, seizures, weakness (unilateral of a systemic etiology. A less comprehensive but equally
and bilateral), changes in coordination, sensations, memory, thorough inspection of the face and oral and oropharyn-
mood, or sleep pattern, emotional disturbances, history of
geal mucosae should be carried out at each visit and the
psychiatric therapy
tendency to focus on only the tooth or jaw quadrant in
question should be strongly resisted.
identifying patients with a disease that may affect dental Each visit should be initiated by a deliberate inspection of
treatment or associated symptoms that will help deter- the entire face and oral cavity prior to intraoral examination.
mine the primary diagnosis. For example, a patient with The importance of this approach in the early detection of
skin, genital, or conjunctival lesions who also has oral head and neck cancer cannot be overstated (see Chapter 7,
mucosal disease, or a patient with anesthesia, paresthe- Oral and Oropharyngeal Cancer).
sia, or weakness who also presents with orofacial pain. Examination carried out in the dental office (surgery) is
The clinician records both negative and positive responses. traditionally restricted to that of the superficial tissues of
Direct questioning of the patient should be aimed at col- the oral cavity, head, and neck and the exposed parts of the
lecting additional data to assess the severity of a patient’s extremities. On occasion, evaluation of an oral lesion logi-
medical conditions, monitor changes in medical condi- cally leads to an inquiry about similar lesions on other
tions, and assist in confirming or ruling out those disease skin or mucosal surfaces or about the enlargement of
processes that may be associated with patient’s other regional groups of lymph nodes. Although these
symptoms. inquiries can usually be satisfied directly by questioning
●● Past medical history (PMH) (may not have been revealed in the patient, the oral health professional may also quite
systems review)—general health; immunizations; major appropriately request permission from the patient to
adult illnesses; any surgical operations (date, ­reason, and examine axillary nodes or other skin surfaces, provided
 Chapter 1 Introduction to Oral Medicine and Oral Diagnosis 5

that the examination is carried out competently and there Patients who may need medical consultation include:
is adequate privacy for the patient. A male oral health pro-
●● Those with known medical problems who are scheduled
fessional should have a female assistant present in the case
for either inpatient or outpatient dental treatment and can-
of a female patient; a female oral health professional
not adequately describe all of their medical problems.
should have a male assistant present in the case of a male
●● Those with abnormalities detected during history‐­taking,
patient. Similar precautions should be followed when it is
on physical examination, or through laboratory studies.
necessary for a patient to remove tight clothing for accu-
●● Those who have a higher risk for the development of a
rate measurement of blood pressure. A complete physical
particular medical problem (e.g., diabetes with increased
examination should not be attempted when facilities are
risk of atherosclerotic cardiovascular disease).
lacking or when religious or other customs prohibit it, or
●● Those for whom additional medical information is
when no chaperone is present.
required that may impact the provision of dental care or
The degree of responsibility accorded to the oral health
assist in the diagnosis of an orofacial problem.
professional in carrying out a complete physical examina-
●● Those with an orofacial disorder, which may also affect
tion varies among institutions, hospitals, states, and
other parts of the body. For example, oral lesions may also
countries.
involve the skin and conjunctiva.
The examination procedure in a dental office setting may
●● Those who are being considered for a medication that may
include any or all of the following six areas:
have an adverse effect on another medical problem, such
●● Registration of vital signs (respiratory rate, temperature, as diabetes or hypertension, or drug interactions.
pain level, pulse, and blood pressure).
Requests for consultation should include the problem and
●● Examination of the head, neck, and oral cavity, including
the specific questions to be answered and should be trans-
salivary glands, temporomandibular joints, and head and
mitted to the consultant in writing. Adequate details of the
neck lymph nodes.
planned oral or dental procedure, include, as appropriate:
●● Lesions of the oral mucosa should have a detailed description
including location, size, color, ulceration and induration, and ●● Estimated risk of clinically significant bleeding.
an assessment of the severity made. Detailed descriptions of ●● Assessment of time and stress to the patient.
specific diseases presenting as ulcers, blisters, or white or red ●● Expected period of post‐treatment disability.
lesions can be found in Chapters 3–7. ●● Details of the particular symptom, sign, or laboratory
●● Assessment of cranial nerves, particularly when the abnormality that gave rise to the consultation.
patient presents with nondental orofacial pain, weakness,
Medically complex patients may have a medical condition
anesthesia, or paresthesia.
that suggests the need for an opinion from the patient’s phy-
●● Examination of other organ systems, when appropriate.
sician as to risks involved in an invasive or stressful dental
●● Ordering indicated laboratory studies.
procedure, too often referred to as “clearing the patient for
dental care.”8 In many cases, the physician is provided with
Consultations
too little information about the nature of the proposed den-
Requesting Consultations from Other Clinicians tal treatment (type of treatment, amount of local anesthet-
The overall purpose of a consultation is to clarify issues or ics, anticipated bleeding, etc.) to help in this regard.
help with diagnosis or management. Oral medicine clini- Physicians cannot be expected to understand the nature of
cians are involved with two major types of consultations: dental procedures and they should not be asked to “clear”
those that they initiate for their own patients as a request patients for dental treatment. They should be contacted for
from another healthcare professional; and those in response pertinent medical information that will help the oral health-
to a request for help with a patient of another healthcare care provider make the decision as to the appropriateness of
professional. the dental treatment plan. The response of a given patient to
Consent from the patient is needed before a consulta- specific dental interventions may be unpredictable, particu-
tion is initiated. All verbal and written consultation larly patients with comorbidities and those taking one or
should be documented in the patient’s record. A consulta- more medications. A physician’s advice and recommenda-
tion letter should identify the patient and contain a brief tion may be helpful in managing a patient, but the responsi-
overview of the patient’s pertinent medical history and a bility to provide safe and appropriate care lies ultimately
request for relevant and specific information. The written with the clinician performing the procedure.9 Another
request should be brief and should specify the particular health professional cannot from a legal standpoint “clear” a
concern and items of information needed from the con- patient for any dental procedure and thus a request for
sultant (Box 1‐1). “medical clearance” should be avoided.8
6 Burket’s Oral Medicine

Box 1-1 Oral Medicine Inpatient Consultation

Patient: BRADLEY, BOB MRN: 0002222222
Age: 36 years Sex: Male DOB: 5/4/1983
Oral Medicine Resident: Dr. Alexandra Howell
Requesting Service: Hematology Attending Physician: INPATIENT HEMATOLOGY
Reason for Admission: LEUKOCYTOSIS; THROMBOCYTOPENIA
Date of Admission: 01/24/2020 Hospital Day: 2
Reason for Consult: Hospital dentistry consult requested by Dr. Green for oral evaluation and to rule out oral infection
prior to immunosuppressive chemotherapy.
Source of History: Patient and medical record.
Chief Complaint: Patient not aware of any problems with his mouth in the past 6 months. He denies active dental pain
but says that his "enamel keeps chipping off."
History of Present Illness:
Patient is a 36 y/o male with past medical history of chronic acid reflux who presented to our Emergency Room on January
24 with right-sided abdominal & flank pain and decreased urine output. He was found to have an acute kidney injury with
hyperkalemia. CT of his abdomen/pelvis showed hydronephrosis/hydroureter and splenomegaly. CBC revealed white
blood cell count of 53.9, hemoglobin of 10, and platelets 29,000. He was transferred to the inpatient hematology service
for further evaluation and management of acute T-cell ALL and tumor lysis.
Health Status
Allergies: None known
Current Medications:
allopurinol 300mg per 1 tablet ORAL daily
hydroxyurea (Hydrea) 1,000 mg per 2 capsules ORAL q8h
sevelamer (sevelamer carbonate 800 mg oral tablet) 800 mg per 1 tablet ORAL TIDWM (3 times a day with meals)
Labs from 01/25/2020: ANC = 3150; INR=1.2; aPTT = 32.8; ALT/AST = 26/28.
Past Medical History: No active or resolved past medical history items have been selected or recorded. Patient states he
has not seen a dentist in 10+ years.
Family History: Cancer—mother. Diabetes mellitus—father.
Extraoral examination: No trismus or swelling noted. Significant lymphadenopathy in postauricular area bilaterally.
Intraoral examination: Very poor oral hygiene with heavy plaque and calculus. Rampant dental caries with several retained
root tips and fractured teeth. Noted a draining sinus tract/fistula on the buccal gingiva of lower left first molar (root tip)
with moderate swelling and erythema. Also noted possible sinus tract above tooth #8.
Review/Management: Reviewed soft tissue neck CT. Relevant dental findings include numerous dental caries and exten-
sive periodontal disease with periapical lucencies involving the mandibular left second molar, mandibular left first molar,
mandibular right first molar, and multiple maxillary and mandibular incisors. Multiple root tips, and grossly enlarged and
erythematous gingiva.
Impression: Diagnosis: dental caries, root tips, and advanced periodontal disease. Multiple draining sinus tracts/fistulas of
the buccal gingiva. Posterior auricular bilateral lymphadenopathy R>L, moderate sized.
Recommendations: Patient does have clear signs of active dental infection. Recommend patient be transported to the
dental clinic by wheelchair for a comprehensive clinical examination, full mouth series of radiographs and a Panorex for
full treatment planning. We have tentatively scheduled him for the dental clinic on Monday morning, 1/27/20 at 10:00 am,
pending medical stability. Treatment recommendations will be available following our department case conference on
Tues 1/28/20.
 Chapter 1 Introduction to Oral Medicine and Oral Diagnosis 7

Responding to Consult Requests from Other Clinicians directed to arrange an appointment with a consultant and
There are three major categories of oral medicine acquaint them with the details of the problem at that time;
consultations: a written report is still necessary to clearly identify the
consultant’s recommendations, which otherwise may not
●● Diagnosis and nonsurgical treatment of orofacial disor-
be transmitted accurately by the patient. The details of an
ders, including oral mucosal disease, temporomandibular
oral consultation must be documented on the patient’s
and myofascial dysfunction, chronic lesions involving the
chart.
maxilla and the mandible, orofacial pain, dental anoma-
An important responsibility for hospital‐based dentists
lies, maxillary and mandibular bone lesions, salivary
is responding to consults from medical and surgical ser-
gland disorders, and disorders of oral sensation, such as
vices. It is not at all uncommon for hospitalized patients to
dysgeusia, dysesthesia, and glossodynia.
have routine maxillofacial problems (e.g., toothache) that
●● Dental treatment of patients with medical problems that
have nothing to do with their reason for hospitalization.
affect the oral cavity or for whom modification of standard
More commonly, patients may have a wide variety of prob-
dental treatment is required to avoid adverse events.
lems that are directly related to their medical ­condition or
●● Opinion on the management of dental disease that does
its treatment (e.g., mucositis secondary to cancer chemo-
not respond to standard treatment, such as rampant ­dental
therapy) or require a dental exam to eliminate a possible
caries or periodontal disease in which there is a likelihood
source of infection during cancer chemotherapy.9
of a systemic etiologic cofactor.
In hospital practice, the dental consultant is always advi-
In response to a consultation request, the diagnostic pro- sory to the patient’s attending physician; the recommenda-
cedures outlined in this chapter may be followed, with the tions listed at the end of the consultation report are
referral problem listed as the chief complaint and with sup- suggestions and not orders, and are not implemented unless
plementary questioning (i.e., history of the present illness) authorized by the attending physician. For some oral lesions
directed to the exact nature, mode of development, prior and mucosal abnormalities, a brief history and examination
diagnostic evaluation/treatment, and associated symptoma- of the lesion will readily identify the problem, and only a
tology of the primary complaint. An examination of the short report is required; this accelerated procedure is referred
head, neck, and oral cavity is important and should be fully to as a limited consultation (Box 1‐2).
documented, and the ROS should include an exploration of Both custom and health insurance reimbursement sys-
any associated symptoms and including pertinent negatives. tems recognize the need of individual practitioners to
When pertinent, existing laboratory, radiographic, and med- request the assistance of a colleague who may have more
ical records should be reviewed and documented in the con- experience with the treatment of a particular clinical prob-
sultation record, and any ­additional testing or specialized lem or who has received advanced training in a medical or
examinations should be ordered. dental specialty pertinent to the patient’s problem.
A comprehensive consultation always includes a writ- However, this practice of specialist consultation is usually
ten report of the consultant’s examination, usually pre- limited to defined problems, with the expectation that the
ceded by a history of the problem under investigation and patient will return to the referring primary care clinician
any items from the medical or dental history that may be once the nature of the problem has been identified (diag-
relevant to the problem. A formal diagnostic summary fol- nostic consultation) and appropriate treatment has been
lows, together with the consultant’s opinion on appropri- prescribed or performed (consultation for diagnosis and
ate treatment and management of the issue. Other treatment).
previously unrecognized abnormalities or significant
health disorders should also be communicated to the
referring clinician. When a biopsy or initial treatment is ­ STABLISHING A DIFFERENTIAL
E
required before a definitive diagnosis is possible, and AND FINAL DIAGNOSIS
when the terms of the consultation request are not clear, a
discussion of the initial findings with the referring clini- Before establishing a final diagnosis, the clinician often
cian is appropriate before proceeding. Likewise, the con- needs to formulate a differential diagnosis based on the his-
sultant usually discusses the details of their report with tory and physical examination findings. The disorders
the patient, unless the referring dentist specifies other- included in the differential diagnosis will determine which
wise. In community practice, patients are sometimes laboratory tests, such as biopsies, blood tests, or imaging
referred for consultation by telephone or are simply studies, are required to reach a final diagnosis.
8 Burket’s Oral Medicine

Box 1-2 Outpatient Oral Medicine Consultation

Date: _____________
To: John Doe MD
From: Robert Dent DMD
Patient Name and Date of Birth
The patient is a 19-year-old female sent for a consultation for evaluation of recurring oral ulcerations, which have been
increasing in severity for the past 5 months.
The patient has a history of occasional oral ulcers since age 10 with 2 to 3 ulcers occurring 3 to 4 times yearly and lasting
8 to 10 days. Five months ago, she began to experience 5 to 10 ulcers each month lasting 2 to 3 weeks. Each episode has
been treated with prednisone 30 mg once daily for 5 to 7 days. The lesions heal with this regimen, but recur in 3 to 4
weeks.
The patient denies conjunctival lesions, although on 2 occasions during the past 3 months she had a vaginal ulcer.
She has acne-type facial lesions since taking prednisone monthly.
Her past medical history is remarkable for depression. She denies hospitalizations or surgery and has no known drug allergies.
She takes Lexapro for depression, but no medications other than prednisone for oral ulcers.
Her review of systems is remarkable for weekly episodes of intestinal cramping and diarrhea. She denies GI bleeding or
black tarry stools. The remainder of the review of systems is noncontributory except for the skin and vaginal lesions noted
above.
The family history is significant for her mother and maternal grandmother having a history of recurring oral ulcers during
adolescence. Her father is of Japanese descent and her mother is Caucasian.
She is currently a college student and denies smoking or use of recreational drugs.
The examination showed multiple acne-like lesions of the skin of the face.
There was no cervical lymphadenopathy or salivary gland enlargement.
Cranial nerves II–XII were grossly intact.
The oral mucosa had 5 shallow ulcers 5 mm to 8 mm in diameter surrounded by inflammation: two involving the left lateral
tongue, one on the dorsal tongue, and one involving the left buccal mucosa. No vesicles or white lesions were present.
Impressions
1) Recurrent aphthous ulcers; increasing in severity during the past 5 months
2) R/O Behçet’s disease
3) R/O Lupus
4) R/O celiac disease
5) R/O blood dyscrasia
Plan:
1) Order the following laboratory studies: CBC, CMP, ANA, ESR, tTG-IgA
2) Dermatology consult for evaluation of skin and vaginal lesions, and pathergy test
3) Ophthalmology consult to rule out uveitis or retinal vasculitis suggestive of Behçet’s disease
4) GI consultation
5) Biopsies of oral ulcer for routine histology and lupus band test
6) Begin treatment with Clobetasol propionate gel, 0.05% directly to lesions tid
7) If the above laboratory tests and consultations are normal and there is inadequate benefit from topical steroids, con-
sider a trial of pentoxifylline or colchicine
 Chapter 1 Introduction to Oral Medicine and Oral Diagnosis 9

The rapidity and accuracy with which a diagnosis or set of “symptomatic.” If a note is written prior to a definitive diag-
diagnoses can be achieved depend on the history and exami- nosis, a clinician may list a descriptive term such as chronic
nation data that have been collected and on the clinician’s oral ulcer with the diseases that must be “ruled out” (R/O)
knowledge and ability to match these clinical data with sus- listed, from most to least likely. For example:
pected disease processes. Experienced clinicians with a more
oral ulcer from chronic trauma
extensive knowledge of physiology and maxillofacial dis-
R/O squamous cell carcinoma
ease, and a broader knowledge of the relevant literature, can
R/O granulomatous disease
more rapidly establish a differential and diagnosis. Such
“mental models” of disease syndromes also increase the effi- The clinician must decide which terminology to use in
ciency with which experienced clinicians gather and evalu- conversing with the patient and whether to clearly identify
ate clinical data and focus supplemental questioning and this diagnosis as “undetermined.” It is important to recog-
testing at all stages of the diagnostic process. nize the undiagnosed nature of the patient’s problem and to
For effective treatment, as well as for health insurance and schedule additional evaluation, by referral to another con-
medicolegal reasons, it is important that a diagnosis (or diag- sultant, additional testing, or placement of the patient on
nostic summary) is entered into the patient’s record, follow- recall for follow‐up studies.
ing the detailed history and physical, radiographic, and Unfortunately, there is no generally accepted system for
laboratory examination findings. This may be a provisional identifying and classifying diseases, and diagnoses are often
diagnosis dependent on the results of investigation. When written with concerns related to third‐party reimbursement
more than one health problem is identified, the diagnosis for and to medicolegal and local peer review, as well as for the
the primary complaint is usually listed first. Previously diag- purpose of accurately describing and communicating the
nosed conditions that remain as actual or potential problems patient’s disease status. Within different specialties, attempts
are also included, with the qualification “by history,” “previ- have been made to achieve conformity of professional
ously diagnosed,” or “treated” to indicate their status. expressions and language.
Problems that were identified but not clearly diagnosed dur- Some standardization of diagnoses has been achieved in
ing the current evaluation can also be listed with the com- the United States as a result of the introduction in 1983 of
ment “to be ruled out.” Since oral medicine is concerned the diagnosis‐related group (DRG) system as an obligatory
with problems that may be modified or linked to concurrent cost‐containment measure for the reimbursement of hospi-
systemic diseases, it is common for the list of diagnoses to tals for inpatient care. However, groupings are mostly based
include both the oral problem such as a lesion or pain and on medical diagnoses, such as the International Classification
systemic problems of actual or potential significance in the of Diseases, Tenth Revision (ICD‐11).10 The DRG system is
etiology or management of the oral problem. Items in the designed for fiscal use rather than as a system for the accu-
medical history that do not relate to the current problem and rate classification of disease. It also emphasizes procedures
are not of major health significance usually are not included rather than diseases and has a number of serious flaws in its
in the diagnostic summary. For example, for a presenting classification and coding system. The ICD system, by con-
complaint of pain and swelling in the left side of the face in trast, was developed from attempts at establishing an inter-
a 62‐year‐old female, a diagnosis list might read as follows: nationally accepted list of causes of death and has undergone
numerous revisions in the past 160 years since it was first
Current: 1) Alveolar abscess, mandibular left first molar suggested by Florence Nightingale; it is maintained by the
Rampant generalized dental caries secondary to World Health Organization. It relates to the various empha-
2)
radiation‐induced salivary hypofunction ses placed on clinical, anatomic, biochemical, and perceived
3) Hyperglycemia; R/O diabetes etiologic classification of disease at different times and dif-
ferent locations. However, the categories for symptoms,
Previous 4) Carcinoma of the tonsillar fossa, by history,
excised and treated with 65 Gy 2 years ago lesions, and procedures applicable to oral cavity conditions
are ­limited and often outdated.
5) Cirrhosis and prolonged prothrombin time, by
history The patient (or, when appropriate, a responsible family
member or guardian) should also be informed of the
A definite diagnosis cannot always be made, despite a care- ­diagnosis, as well as the results of the examinations and tests
ful review of all history, clinical, and laboratory data. In such carried out. Because patients’ anxieties frequently empha-
cases, a descriptive term (rather than a formal diagnosis) may size the possibility of a potentially serious diagnosis, it is
be used for the patient’s symptoms or lesion, with the added important to point out (when the facts allow) that the biopsy
word “idiopathic,” “unexplained,” or (in the case of symp- specimen revealed no evidence of a malignant growth, the
toms without apparent physical abnormality) “functional” or blood test revealed no abnormality, and no ­evidence of
10 Burket’s Oral Medicine

­ iseases, such as diabetes, anemia, leukemia, or other can-

d preceded by conscious consideration of the potential risk of
cer, was found. Equally important is the ­necessity to explain the planned procedure. Establishing a formal medical risk
to the patient the nature, significance, and treatment of any assessment ensures a continuous evaluation process. A sum-
lesion or disease that has been diagnosed. mary of the medical risk assessment, delineating potential
risks from the ­proposed plan of action, should be entered in
the patient record.
The Medical Complexity Status (MCS) was specifically
­F ORMULATING A PLAN OF ACTION
developed for dental patients and has been used successfully
for patients with medical problems ranging from
Medical Risk Assessment
­nonsignificant to very complex diseases and conditions.11
Medical risk assessment of patients before oral or dental The MCS protocol is based on the premise that complica-
treatment offers the opportunity for greatly improving den- tions will rarely arise during provision of routine dental care
tal services for patients with complex health conditions. It in an outpatient setting to patients with stable or controlled
requires considerable clinical training and understanding of medical conditions. However, modification of dental care
the natural history and clinical features of systemic ­disease. may still be necessary in some circumstances and should be
It is hoped that revisions in dental pre‐doctoral training will based on the level of the anticipated complication. The MCS
recognize this need and provide greater emphasis on both classification and protocol, with examples, are described in
the pathophysiology of systemic disease and the practical more detail in Table 1-2.
clinical evaluation and management of medically complex
patients.
Modification of Dental Care for Medically
The information gathering described above is also
Complex Patients
designed to help the oral health professional:
Although there are many different medical conditions that
●● Recognize a general health status that may affect dental
may require modification of dental care, and protocols for a
treatment.
wide variety of situations, the assessment of risk to medi-
●● Make informed judgments on the risk of dental
cally complex patients follows similar guidelines. It is help-
procedures.
ful to focus on the following three questions, which will
●● Identify the need for medical consultation to provide assis-
change according to the severity of the underlying disease or
tance in ascertaining the presence of a systemic disease
condition:
that may be associated with an oral pathology or that may
adversely impact on the proposed dental treatment. ●● What is the likelihood that the patient will experience an
adverse event due to dental treatment?
Reaching the end point of the diagnostic process and
What are the nature and severity of the potential adverse
the formulation of a plan of action are usually not a sim-
●●

event?
ple process. In order to minimize any adverse events, an
What is the most appropriate setting in which to treat the
assessment of any special risks associated with a patient’s
●●

patient?
compromised medical status that could be triggered by
the planned anesthetic, diagnostic, or medical or surgical Each of these questions can be subdivided into smaller
treatment procedure must be entered in the patient entities, which will facilitate the assessment of the
record, usually as an addendum to the plan of treatment. patient.
This process of medical risk assessment is the responsibil- The four major concerns that must be addressed when
ity of all clinicians prior to initiating any treatment or assessing the likelihood of the patient experiencing an
intervention and applies to outpatient as well as inpatient adverse event are:
situations.
Potential for impaired hemostasis from medications or
A routine of initial history‐taking and physical examina-
●●

disease.
tion is essential for all dental patients, as even the apparently
Potential susceptibility to infection, both maxillofacial and
healthy individual may, on evaluation, be found to have a
●●

distant to the oral cavity (e.g., infective endocarditis).

history or examination findings of sufficient significance to
Drug actions and interactions.
require a modification to the plan of treatment, a change to
●●

Patient’s ability to tolerate the stress and trauma of the

a medication, or deferring dental treatment until additional
●●

dental procedure.
diagnostic data are available. To respect the familiar medical
axiom primum non nocere (first, do no harm), all procedures Patients are designated to an MCS category at their initial
carried out and all prescriptions given to a patient should be dental visit, which may be modified during subsequent visits
 Chapter 1 Introduction to Oral Medicine and Oral Diagnosis 11

Table 1-2 Medical complexity status classification and protocol.

Major categories
MCS 0 Patients with no medical problems
MCS 1 Patients with controlled or stable medical conditions
MCS 2 Patients with uncontrolled or unstable medical conditions
MCS 3 Patients with medical conditions associated with acute exacerbation, resulting in high risk of mortality
Subcategories
A No anticipated complications
B Minor complications are anticipated. “Minor complications” are defined as complications that can be successfully addressed in the
dental chair
C Major complications are anticipated. “Major complications” are defined as complications that should be addressed by a medical
provider and may sometimes require a hospital setting
Examples of different MCS categories
MCS–0
A healthy patient
MCS–1A
A patient with controlled hypertension
(No modifications to routine dental care are necessary)
MCS–1B
A patient with epilepsy (petit mal) that is controlled with medications
(The patient’s epilepsy status is controlled, but if the patient has a seizure, it will pass without any interventions from the oral
healthcare practitioner. It would be pertinent to avoid any dental treatment that may bring about a seizure)
MCS–1C
A patient with a penicillin allergy
(The allergy will not change a stable condition, but if penicillin is given, a major complication may ensue)
MCS–2A
A patient with hypertension and a blood pressure of 150/95 mm Hg but without any target organ disease (see Chapter 14, “Diseases
of the Cardiovascular System”)
(The patient’s hypertension is by definition not controlled, i.e., it is above 140/90 mm Hg. Yet this level of blood pressure, in an
otherwise healthy patient, does not justify instituting any dental treatment modifications)
MCS–2B (see Chapter 22, “Disorders of the Endocrine System and of Metabolism”)
A patient with diabetes mellitus and a glycosylated hemoglobin of 11%
(Because of the patient’s poor long‐term glycemic control, the patient may be more susceptible to infections and poor wound
healing. Dental modifications, such as possible antibiotics before a surgical procedure, may be indicated)
MCS–2C
A patient with uncompensated congestive heart failure
(Because of the patient’s compromised medical condition, it is important to avoid placing the patient in a supine position in the
dental chair as this may induce severe respiratory problems)
MCS–3
A patient with unstable angina

according to the patient’s changing medical status. Based on ●● An inpatient operating room setting. Most medically com-
several critical items—MCS category, experience of the oral plex patients can be safely treated when the factors men-
healthcare professional, the patient’s ability to tolerate den- tioned earlier have been addressed.
tal care, adequacy of the dental facility—a determination of
A plan of treatment of this type, which is directed at the
where the patient is best treated should be made:
causes of the patient’s symptoms rather than at the symp-
●● A non‐hospital‐based outpatient setting. toms themselves, is often referred to as rational, scientific, or
●● A hospital‐based outpatient setting. definitive (in contrast to symptomatic, which denotes a treat-
●● An inpatient short‐procedure unit setting. ment plan directed at the relief of symptoms, irrespective of
12 Burket’s Oral Medicine

their causes). The plan of treatment (similar to the diagnostic Table 1-3  merican Society of Anesthesiologists (ASA) physical
A
summary) should be entered in the patient’s record and status classification system.
explained to the patient in detail. This encompasses the pro- ASA I A normal healthy person
cedure, chances for improvement or cure (prognosis), poten- ASA II A patient with a mild disease
tial complications and side effects, and number of ASA III A patient with a severe systemic disease
appointments and expense. As initially formulated, the plan ASA IV A patient with a severe systemic disease that is a
of treatment usually lists recommended procedures for the constant threat to life
control of current disease as well as preventive measures ASA VI A declared brain‐dead patient whose organs are
designed to limit the recurrence or progression of the disease being removed for donor purposes
process over time. For medicolegal reasons, the treatment In the event of an emergency, precede the number with an “E.”
that is most likely to eradicate the disease and preserve as Adapted from American Society of Anesthesiologists. ASA Physical
much function as possible (i.e., the ideal treatment) is usually Status Classification System. https://www.asahq.org/standards‐and‐
entered in the chart, even if it is clear that compromises may guidelines/asa‐physical‐status‐classification‐system. Accessed
September 22, 2020.
be necessary to obtain the patient’s consent to treatment.
It is also unreasonable for the clinician to prejudge a
patient’s decision as to how much time, energy, and expense applicability to both inpatient and outpatient dental proce-
should be expended on treating the patient’s disease or how dures is limited. Importantly, the ASA score was developed
much discomfort and pain the patient is willing to tolerate. for and is used to assess a patient’s ability to tolerate general
Patient involvement in decisions regarding the treatment anesthesia and should therefore not be used to predict com-
plan—shared decision‐making—is necessary to help achieve plications associated with dental surgery in the outpatient
a satisfactory outcome. Such an approach has been promul- setting.
gated by the Institute of Medicine as “patient‐centered care”
and is defined as “Providing care that is respectful of and Monitoring and Evaluating Underlying Medical
responsive to individual patient preferences, needs, and val- Conditions
ues, and ensuring that patient values guide all clinical
decisions.”12 Several major medical conditions can be monitored by oral
The plan of treatment may be itemized according to the healthcare personnel.14 Signs and symptoms of systemic
components of the diagnostic summary and is usually writ- conditions, the types of medications taken, and the patient’s
ten prominently in the patient record to serve as a guide for compliance with medications can reveal how well a patient’s
the scheduling of further treatment visits. If the plan is com- underlying medical condition is being controlled. Signs of
plex or if there are reasonable treatment alternatives, a copy medical conditions are elicited by physical examination,
should also be given to the patient to allow consideration of which includes measurements of blood pressure and pulse,
the various implications of the plan of treatment that they or laboratory or other diagnostic evaluations. Symptoms are
have been asked to agree. Modifications of the ideal plan of elicited through an ROS, whereby subjective symptoms that
treatment, agreed on by patient and clinician, should also be may indicate changes in a patient’s medical status are ascer-
entered in the chart, together with a signed disclaimer from tained. A list of the patient’s present medications, changes in
the patient if the modified plan of treatment is likely to be medications and daily doses, and a record of the patient’s
significantly less effective or unlikely to eradicate a major compliance with medications usually provide a good indica-
health problem. tor of how a medical condition is being managed. The com-
Numerous protocols have been proposed to facilitate effi- bined information on signs, symptoms, and medications is
cient and accurate preoperative assessment of medical risk. ultimately used to determine the level of control and status
Many of the earlier guides were developed for the assess- of the patient’s medical condition.
ment of risks associated with general anesthesia or major
surgery and focus on mortality as the dependent variable.
All too often, these were adopted for risk assessment associ- ­ LINICAL OUTCOMES AND ORAL
C
ated with invasive dental procedures performed under local DISEASE SEVERITY SCORING
or regional anesthesia. Of these, the most commonly used is
the American Society of Anesthesiologists (ASA) Physical All fields in medicine work toward evidence‐based therapy. It
Scoring System (Table 1-3).13 Although scores such as the is regarded as essential for the advancement of any field,
ASA classification are commonly included in the preopera- including oral medicine, that there is continuous assessment
tive evaluation of patients admitted to hospitals for dental of the results of treatment, so leading to progress in manage-
surgery, they use relatively broad risk categories, and their ment. However, it is true that many treatments for oral
 Chapter 1 Introduction to Oral Medicine and Oral Diagnosis 13

­ iseases are not evidence based, even those regarded as

d treatment, patient‐reported outcomes record outcomes from
standard therapies. Until the last few years, there had been a a patient’s perspective and are equally important in overall
lack of any method to routinely assess disease severity and outcome success. On occasion, the PROMs score will dem-
thus to quantify responses to therapies. This led to the obvi- onstrate satisfaction at the outcome, even though the ODSS
ous need to devise and validate oral disease severity scores for may be unchanged or vice versa. There are now simple, vali-
a variety of conditions seen in routine clinical practice, which dated systems for PROMs15 and it is appropriate for both to
could also be used for assessing treatment responses. The be recorded.
accepted principle in medicine and surgery is that the
response to therapy should be assessed in every single patient
seen. This can be performed both from the perspective of the ­ HE DENTAL AND
T
clinician (disease severity scores) and from the patient MEDICAL RECORD
(patient‐reported outcome measures or PROMs).
Disease severity scoring systems are tools that can help clini- The patient’s record is customarily organized according to
cians assess both the severity of the objective clinical findings the components of the history, physical examination, diag-
as well as the subjective features of the disease, including its nostic summary, plan of treatment, and medical risk assess-
impact on patients’ lives. There are three essential aspects that ment described previously in this chapter. Test results
are important in defining the “intensity of the disease”: clinical (diagnostic laboratory tests, radiographic examinations, and
score measuring the level of inflammation, area, and specific consultation and biopsy reports) are filed after this, followed
clinical features (e.g., ulceration); subjective reporting of pain by dated progress notes recorded in sequence. Separate
that the disease is inflicting; and a questionnaire relating to sheets are incorporated into the record for the following: (1)
how the condition affects patients’ functioning and their lives, a summary of medications prescribed for or dispensed to the
known as oral health‐related quality of life (OHRQoL).15 There patient; (2) a description of surgical procedures; (3) the anes-
are now several validated and universally used tools for oral thetic record; (4) a list of types of radiographic exposures;
diseases that should be used at every patient visit. and (5) a list of the patient’s problems and the proposed and
actual treatment. This pattern of organization of the patient’s
record may be modified according to local custom and to
Oral Disease Severity Scoring
varying approaches to patient evaluation and diagnostic
The benefits of a scoring system for mucosal disease severity methodology taught in different institutions.
are that (1) they can indicate the severity of disease; (2) they In recent years, educators have explored a number of
are needed to indicate the efficacy of any treatments; (3) they methods for organizing and categorizing clinical data, with
may distinguish between or reveal subgroups of activity; (4) the aim of maximizing the matching of the clinical data with
they may assist in deciding to implement or withhold treat- the “mental models” of disease syndromes referred to earlier
ment; and (5) they are a routine clinical audit tool that can in this chapter. The problem‐oriented record (POR) and the
also be used for research. condition diagram are two such approaches; both use unique
Any such oral disease scoring systems (ODSS) much be methods for establishing a diagnosis and also involve a reor-
objective, must be reproducible, should be easy to use, and ganization of the clinical record.
should be widely applicable. Fortunately, such ODSSs have
been created, validated, and are in use for recurrent aph-
Problem-Oriented Record
thous ulceration, oral lichen planus pemphigus, mucous
membrane pemphigoid, orofacial granulomatosis, and dry The POR focuses on problems requiring treatment rather
mouth assessment.15–20 Although additional work is required than on traditional diagnoses. It stresses the importance of
before these scoring systems are universally accepted and complete and accurate collecting of clinical data, with the
utilized, the principle of assessing disease severity at each emphasis on recording abnormal findings rather than on
clinical consultation is regarded as good clinical practice. compiling the extensive lists of normal and abnormal data
See Chapter 4 for more on oral disease severity scoring. that are characteristic of more traditional methods (consist-
ing of narration, checklists, questionnaires, and analysis
summaries). Problems can be subjective (symptoms), objec-
Patient-Reported Outcome Measures and Oral
tive (abnormal clinical signs), or otherwise clinically signifi-
Mucosal Disease
cant (e.g., psychosocial) and need not be described in
Alongside oral disease severity scoring, it is important to prescribed diagnostic categories. Once the patient’s prob-
record PROMs. Whereas ODSSs are physician records of dis- lems have been identified, priorities are established for fur-
ease severity that allow clinical assessment of response to ther diagnostic evaluation or treatment of each problem.
14 Burket’s Oral Medicine

These decisions (or assessments) are based on likely causes record in institutions accredited by the Joint Commission on
for each problem, risk analysis of the problem’s severity, cost Accreditation of Healthcare Organizations. Furthermore,
and benefit to the patient as a result of correcting the prob- the use of a problem‐oriented approach may enhance the
lem, and the patient’s stated desires. The plan of treatment is utilization of and satisfaction with EHRs.25
formulated as a list of possible solutions for each problem.
As more information is obtained, the problem list can be
SOAP Note
updated, and problems can be combined and even reformu-
lated into recognized disease categories. The SOAP note concept, as well as POR, was initially pro-
The POR is helpful in organizing a set of complex clinical posed by Dr. Lawrence (“Larry”) Weed in the 1960s and has
data about an individual patient, maintaining an up‐to‐date ever since been a mainstay in teaching and clinical care.26,27
record of both acute and chronic problems, ensuring that all The purpose of this type of documentation was to provide a
of the patient’s problems are addressed, and ensuring that clinician with a systematic and structured method—a check-
preventive as well as active therapy is provided. Furthermore, list—to record patient findings. The SOAP note is also used
the POR facilitates interprofessional communication and is for communication between healthcare professionals and as
a foundation for collaborative practice and teaching.21,22 It is a teaching aid.
also adaptable to computerized patient‐tracking programs. The four components of a problem—Subjective, Objective,
However, without any scientifically based or accepted Assessment, and Plan—constitute the SOAP mnemonic for
nomenclature and operational criteria for the formulation of organizing progress notes or summarizing an outpatient
the problem list, data cannot be compared across patients or encounter (see Box 1‐3). The components of the mnemonic
clinicians. An additional ­concern that has been put forward are as follows:
is the reliance on a POR to “automatically” generate a diag-
S or Subjective—the patient’s experience, complaint,
nosis.23 Although the POR will allow for a systematic
●●

symptoms, and medical history (a brief review of the chief

approach to delineate ­specific problems, clinicians need to
complaint, HPI, PMH, ROS, current medications, and
be able to synthesize findings into an appropriate
allergies).
diagnosis.24
●● O or Objective—the general clinical examination (physical
Despite these shortcomings, two features of the POR have
examination, vital signs); review of laboratory data, imag-
received wide acceptance and are often incorporated into
ing results, other diagnostic data; review of documenta-
more traditionally organized records: the collection of data
tion from other healthcare providers; and a focused
and the generation of a problem list. The value of a problem
evaluation of the chief complaint or the area of the proce-
list for individual patient care is generally acknowledged
dure to be undertaken.
and is considered a necessary component of the hospital

Box 1-3 SOAP Note: Example: A progress note placed in a patient’s chart after an oral medicine evaluation
Date ____________
S—The patient is a 32-year-old women with a history of multiple sclerosis and recent increasing loss of visual acuity and
muscle weakness, with sudden onset of severe but brief episodes of pain involving the left mandibular region. She was
admitted by Neurology for evaluation and treatment with intravenous methylprednisone and interferon.
O—Touching lower left lip or gingiva in the region of the mental foramen triggers brief electric shock-like pain.
Extraoral exam reveals no lymphadenopathy, major salivary gland tenderness, or enlargement.
Intraoral exam shows no mucosal lesions or masses in the area of the left mandible. Teeth are not tender to ­percussion
and no dental caries, fractured teeth, or removable prosthesis noted.
Panoramic radiography of the left mandible showed no dental or bony pathology.
A recent MRI of the brain, reviewed with radiology, demonstrated a demyelinating plaque involving the left ­trigeminal
nerve root.
A—Trigeminal neuralgia secondary to multiple sclerosis, no evidence of an oral source for her pain.
P—Current plan includes a trial of carbamazepine or oxcarbazepine.
Signature_______________________
 Chapter 1 Introduction to Oral Medicine and Oral Diagnosis 15

●● A or Assessment—a synthesis of the subjective and objective extent that the information may be pertinent to the diagnosis
findings to arrive at a diagnosis (problem list and ­differential of oral disease and its effective treatment.
diagnosis) for the specific problem being addressed. Conversations about patients, discussion with a colleague
●● P or Plan—the need for additional information (e.g., labo- about a patient’s personal problems, and correspondence about
ratory tests, consultations); referrals; treatment recom- a patient should be limited to those occasions when informa-
mendation; patient education for the purpose of shared tion essential to the patient’s treatment has to be transmitted.
decision‐making. Lecturers and writers who use clinical cases to illustrate a topic
should avoid mention of any item by which a patient might be
The SOAP note is a useful tool for organizing progress
identified and should omit confidential information.
notes in the patient record for routine office procedures and
Conversations about patients, however casual, should never be
follow‐up appointments. It is also quite useful in a hospital
held where they could possibly be overheard by unauthorized
record when a limited oral medicine consultation must be
individuals, and discussion of patients with nonclinical col-
documented. However, in order for other healthcare profes-
leagues, friends, family, and others should always be avoided
sionals to more easily retrieve the most relevant information,
and should never include confidential patient information.
it might be better to reorganize and document the SOAP note
as an ASOP note (Assessment, Plan, Subjective, Objective).
One significant drawback with the SOAP framework is the Informed Consent
lack of a temporal or time component. This can be remedied
Prior consent of the patient is needed for all diagnostic and
by including a time component before consecutive SOAP
treatment procedures, with the exception of those consid-
notes. For example, “The present SOAP note is recorded 14
ered necessary for treatment of a life‐threatening emergency
days following the last SOAP note. During this time the fol-
in a comatose patient.28 In dentistry, such consent is more
lowing changes have occurred: ….”
often implied than formally obtained, although written con-
sent is generally considered necessary for surgical proce-
dures (however minor), for the administration of general
Confidentiality
anesthetics, and for clinical research.
Patients provide dentists and physicians with confidential den- Consent of the patient is often required before clinical
tal, medical, and psychosocial information, on the understand- records are transmitted to another dental office or institu-
ing that the information (1) may be necessary for effective tion. In the United States, security control over electronic
diagnosis and treatment; (2) will remain confidential; and (3) transmission of patient records has since 1996 been ­governed
will not be released to other individuals without the patient’s by the Health Insurance Portability and Accountability Act
specific permission. This information may also be entered in (HIPAA). The creation and transmission of electronic
the patient’s record and shared with other clinical personnel records are an evolving process that is mainly dependent on
involved in the patient’s treatment, unless the patient specifi- technological advances and fast movement of the integra-
cally requests otherwise. Patients are willing to share such tion of electronic patient information.29
information with their dentists and physicians only to the There may also be specific laws that discourage discrimi-
extent that they believe that this contract is being honored. nation against individuals infected with infectious diseases,
There are also specific circumstances in which the confi- such as HIV, by requiring specific written consent from the
dentiality of clinical information is protected by law and patient before any HIV‐related testing can be carried out and
may be released to authorized individuals only after compli- before any HIV‐related information can be released to insur-
ance with legally defined requirements for informed consent ance companies, other practitioners, family members, and
(e.g., psychiatric records and confidential HIV‐related infor- fellow workers.30 Oral healthcare professionals treating
mation). Conversely, some medical information that is con- patients whom they believe may be infected with HIV must
sidered to be of public health significance is a matter of therefore be cognizant of local law and custom when they
public record when reported to the local health authorities request HIV‐related information from a patient’s physician,
(e.g., clinical or laboratory confirmation of reportable infec- and they must establish procedures in their own offices to
tious diseases such as syphilis, hepatitis, or AIDS). Courts protect this information from unauthorized release. In
may also have the power to subpoena medical and dental response to requests for the release of psychiatric records or
records under defined circumstances, and records of patients HIV‐related information, hospital medical record depart-
participating in clinical research trials may be subject to ments commonly supply the practitioner with the necessary
inspection by a pharmaceutical sponsor or an appropriate additional forms for the patient to sign before the records are
drug regulatory authority. Dentists are generally authorized released. Psychiatric information that is released is usually
to obtain and record information about a patient to the restricted to the patient’s diagnoses and medications.
16 Burket’s Oral Medicine

­T ELEHEALTH/TELEDENTISTRY there exist electronic stethoscopes, dermatoscopes, and

scales, as well as tele‐ophthalmoscopes, video‐otoscopes, and
Telehealth has been defined as “communication and infor- digital endoscopes.33 However, studies have been performed
mation technologies [used] to provide or support long‐­ where individuals can take pictures with their smartphones
distance clinical health care, patient and professional and share these images with a specialist who can make dif-
health‐related education, public health, and health admin- ferential diagnoses and determine the need for additional
istration.”31 Although sometimes used interchangeably, sev- studies, such as biopsies. This technology has enabled early
eral designations, such as telemedicine, mHealth, and detection of oral cancer, as well as HIV‐associated lesions,
eHealth, have been used to described how to interact and among individuals in areas without immediate access to spe-
provide care when there is no direct physical contact— cialists.34,35 Another study using a mobile telemedicine sys-
remotely—between providers and patients. According to tem to diagnose oral mucosal lesions remotely showed a high
some definitions, telehealth refers to a broad scope of degree of accuracy, demonstrating the potential for future use
remote healthcare services that may include nonclinical of this technology in oral medicine.36
services, while telemedicine specifically refers to remote The need to develop better, more reliable, and validated
clinical services.32 mHealth is usually employed to describe technology for oral medicine purposes will enhance our
technology used by patients to capture their own health ability to provide care to individuals not only in remote
data with the help of apps on devices such as smartphones areas, but also during circumstances where person‐to‐
and tablets, while eHealth mostly refers to utilizing the person interactions are being discouraged due to, for
internet and similar technology. example, a pandemic. The Covid‐19 pandemic has sub-
One of the major drawbacks for the utilization of teleden- stantially increased the routine use of telemedicine by
tistry in oral medicine is the inability to perform a clinical many clinicians, including oral medicine specialists. It is
examination that includes components such as touch and expected that as these clinicians become experienced
palpation. In telemedicine there are already armamentaria using telemedicine, its use will continue to expand in
that aim to overcome these types of limitations. For example, clinical practice.

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