HNY Policy and Pathway Repository - York

Oral Medicine is the specialty of dentistry concerned with the care of adults and children with chronic, recurrent and medically related disorders of the oral and maxillofacial region, and with their diagnosis and non-surgical management.

The key difference from Oral Surgery and Oral & Maxillofacial Surgery is that in Oral Medicine the emphasis is on conditions that are primarily managed medically without the need for surgery.

The scope of Oral Medicine practice primarily includes disorders of:

• Oral soft tissues (including the lips)
• Salivary glands
• Pain & Neurological dysfunction including non-dental-related pain

Oral Medicine disorders may reflect:

• Local oral problems or
• Oral manifestations of systemic problems (e.g. gastrointestinal, rheumatological, dermatological, haematological, autoimmune, psychiatric or psychological disorders).
  • As part of the referral process this category can be marked as ’Oral presentation of a wider problem’.

Oral Medicine acts as a focus for specialist interdisciplinary care of patients and there is close collaboration with other dental, medical and surgical specialties as required.

Many conditions that fall within the scope of Oral Medicine practice are chronic and may have a significant psychological, as well as physical impact on the patient’s quality of life.

Further information about Oral Medicine can be found at: www.bsom.org.uk

Always consider if the presentation may represent mouth cancer.

The NICE 2015 guidelines are applicable to all clinicians and not just members of the Dental Team. The need to be inclusive of all clinicians is reflected in the 3 statements on ‘Head & Neck Cancers’:

• If you are a dentist, then read 1.8.4
• If you are another healthcare professional, then read 1.8.2 and 1.8.3.

1.8.2 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either: unexplained ulceration in the oral cavity lasting for more than 3 weeks or a persistent and unexplained lump in the neck. [new 2015]

 

1.8.3 Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either: a lump on the lip or in the oral cavity or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia. [new 2015]

 

1.8.4 Consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) for oral cancer in people when assessed by a dentist as having either: a lump on the lip or in the oral cavity consistent with oral cancer or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia [new 2015].

Further information about suspected cancer and referral is available in the Oral Medicine Full Referral Guide (FRG).

Where there may be an Oral Medicine (OM) condition and referral is being considered, there is a 5-step process to follow.

Abbreviations: OM (Oral Medicine – in Leeds and Sheffield); OMFS (Oral & Maxillofacial Surgery); 2WW (2 Week Wait).

Further supporting information is available in the Oral Medicine Full Referral Guide (FRG).

 

Initial Assessment of the Level of Care Required

When referring from primary care for an Oral Medicine condition:

• Assume that the complexity level is Level 2 unless there is a clear indication for Level 3 care, in which case this should be clear in the referral.

The complexity levels for conditions that fall within the scope of Oral Medicine practice are.

Level 1

Level 1 care involves:

• Recognition of normal features of the mouth and oropharynx that may be confused with pathology.
• Recognition of conditions and recording an initial (working) diagnosis.
• Initiation of management (e.g. identify & address concerns, appropriate information, interventions including oral hygiene and 1st line topical treatments) with appropriate follow-up.
• Recognition of situations where the presenting complaint indicates referral to either Level 2 or 3.
• Ongoing management as part of shared care or following discharge from Level 2 or 3 care.

Level 2

Level 2 care involves:

• Re-evaluation of the initial diagnosis and the aims of care.
• Re-evaluation and revision of management with follow-up.
• Recognition of situations where the presenting complaint indicates referral for Level 3 assessment.
• Ongoing management as part of shared care with Level 1 or 3 care.

Level 3

Level 3 care involves:

• Evaluation of presentations associated with prominent or unusual orofacial symptoms and/or signs (mucosal, salivary, pain or neurological).
• Evaluation of presentations that may represent an orofacial manifestation of a systemic or widespread problem with physical and / or psychological components.
• Re-evaluation where the diagnosis is unclear.
• Management is complicated by significant co-morbid illness (physical or mental health) or the management of this.
• Interventions at Level 2 have not achieved a satisfactory outcome.
• Management requires potent topical or systemic medications.
• Multi-disciplinary or multi-professional management is indicated.

Further supporting information is available in the Oral Medicine Full Referral Guide

Care Provider Preference

In the referral make a preference for the centre to provide the initial assessment.

Oral Medicine (OM)

• The regional NHS specialist Oral Medicine services are provided in:
  • Leeds Dental Institute.
  • Charles Clifford Dental Hospital, Sheffield.
• The main providers of Oral Medicine education and training in the region.
• Accept Level 2 referrals.
• The preferred centres for Level 3 care.

Local Oral & Maxillofacial Surgery (OMFS) Units

• Providers of NHS Oral Medicine care close to where patients are.

It is important to note that the preference made is for the initial assessment and ongoing care involve:

• A different provider
• Shared care between different providers.

 

Urgency of Referral

In the referral make a preference for urgency – ‘routine’ or ‘priority’.

When referring from primary care for an Oral Medicine condition:

• Assume that the urgency is ‘routine’ unless there is a clear indication for a ‘priority’ appointment, in which case make it clear in the referral that:
  • A ‘priority appointment’ is requested.
  • Why a ‘priority appointment’ is requested.
• A request for a ‘Priority’ appointment should be considered if:
  • The presentation is causing severe distress to the patient.
  • There is suspicion of a high stakes diagnosis such as a blistering condition, severe ulcerative mucosal disease significantly affecting eating and swallowing, or trigeminal neuralgia.

Further supporting information is available in the Oral Medicine Full Referral Guide.

Oral Medicine Full Referral Guide

 

Reference 

Oral Medicine Quick Referral Guide