Oral disease

[deltamed]

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Out of curiosity, do dentists get much training in medical disorders with oral manifestations? I'm in dermatology and it seems that dentists don't know much about things like lichen planus, pemphigus, burning tongue, em major etc and even refer easy procedures like tongue/lip biopsies / simple mucocele excisions etc to an oral surgeon or to me.

Not trying to be rude- just curious. Wouldn't these sorts of things be easy turf that dentistry should be covering in training?

 

[uhds]

Yes, of course this is covered. Even dental assisting schools and hygiene schools cover this as well. Doing a biopsy is to know for sure since you can't just diagnose it and assume you're right. Doing a biopsy is an oral surgeon's specialty not really something a general dentist or another kind of specialist would do like an orthodontist.

 

[AlbinoPolarBear]

Every dental school has an oral pathology course that teaches us all of the things you've mentioned.
It's about being efficient with your time and decreasing liabilities. Most general dentists would like to keep their liabilities to a minimum and stick to lesser invasive procedures. If they don't do many biopsies, it would very inefficient for them to do it even if they know how.
They could have done 4 fillings or crown preps during that time and it would make them way more money than doing the biopsy.
Most general dentists even refer out things they are supposed to be able to do competently just because it's inefficient for them to do it. Specifically, wisdom teeth extraction and molar endo are huge money makers that get referred out regularly.

 

[deltamed]

Every dental school has an oral pathology course that teaches us all of the things you've mentioned.
It's about being efficient with your time and decreasing liabilities. Most general dentists would like to keep their liabilities to a minimum and stick to lesser invasive procedures. If they don't do many biopsies, it would very inefficient for them to do it even if they know how.
They could have done 4 fillings or crown preps during that time and it would make them way more money than doing the biopsy.
Most general dentists even refer out things they are supposed to be able to do competently just because it's inefficient for them to do it. Specifically, wisdom teeth extraction and molar endo are huge money makers that get referred out regularly.

Sure -as a specialist I understand efficiency and referring out things that I don't want to do. But realistically, an oral biopsy takes me 1-3 minutes. I don't understand why the experts in that body area don't routinely do it (especially for oral cancers which you screen for).

Regarding the oral diseases I understand you learn about them, but how much do you get to see in school? I unfortunately had a pemphigus vulgaris patient recently that was getting worse and worse after months of repeated pocket depth reductions for "severe gum recession." I would think his general dentist would suspect something is up?

 

[oralcare123]

Sure -as a specialist I understand efficiency and referring out things that I don't want to do. But realistically, an oral biopsy takes me 1-3 minutes. I don't understand why the experts in that body area don't routinely do it (especially for oral cancers which you screen for).

Regarding the oral diseases I understand you learn about them, but how much do you get to see in school? I unfortunately had a pemphigus vulgaris patient recently that was getting worse and worse after months of repeated pocket depth reductions for "severe gum recession." I would think his general dentist would suspect something is up?

General dentist refers for biopsy maybe ones a year, sees an oral manifestation a couple of times a year. Isn't it true, that most of the skin diseases are not curable anyway?

 

[AlbinoPolarBear]

I don't know about the general dentist treating your pemphigus vulgaris patient. Probably best to call the dentist and ask why.

 

[deltamed]

I don't know about the general dentist treating your pemphigus vulgaris patient. Probably best to call the dentist and ask why.

I wouldn't expect treating. I'd hope for recognizing it, referring and not making it worse with repeated procedures (or at least knowing what it was).

 

[deltamed]

General dentist refers for biopsy maybe ones a year, sees an oral manifestation a couple of times a year. Isn't it true, that most of the skin diseases are not curable anyway?

Seems odd that low rate given they do oral exams all day. I see about 1 oral cancer a week but none referred from dentists (mostly melanotic macules, bite fibromas and venous lakes).

True that most skin diseases are not curable. But that doesnt mean patients have to suffer for years without a diagnosis/ treatment. Pv untreated has a 50 percent mortality rate by the way.

 

[yappy]

Seems odd that low rate given they do oral exams all day. I see about 1 oral cancer a week but none referred from dentists (mostly melanotic macules, bite fibromas and venous lakes).

True that most skin diseases are not curable. But that doesnt mean patients have to suffer for years without a diagnosis/ treatment. Pv untreated has a 50 percent mortality rate by the way.

50% of the population doesn't go to the dentist regularly and the patient population tend to be healthier/younger. I agree that receiving dx/tx is important.

 

[oralcare123]

Seems odd that low rate given they do oral exams all day. I see about 1 oral cancer a week but none referred from dentists (mostly melanotic macules, bite fibromas and venous lakes).

True that most skin diseases are not curable. But that doesnt mean patients have to suffer for years without a diagnosis/ treatment. Pv untreated has a 50 percent mortality rate by the way.

People go to a dentist to fix cavities and broken teeth, they go to you with suspicious lesions, that is why the frequency is different and not because you are such a good doctor and dentists are not. Oral Surgeons see those patients more often

 

[cacazor]

deltamed, you will prob get a better answer on dentaltown. Hardly any of us here are practicing dentist. We might get training on oral pathology, but how it translate into private practice is a different story. For example, it's a big thing in my school to instill the habit of always doing an oral cancer screening for every patient; they argue that it barely takes any time and it could save lives. But the same profs also lament that some/not all/ many (?) practicing dentists would take the time during their practice to do it. I imagine older dentist have different habits they carry into their own practice too because they were taught differently.

If you ever post the same question on dentaltown, let me know. I am curious as to how the dentists answer.

 

[deltamed]

People go to a dentist to fix cavities and broken teeth, they go to you with suspicious lesions, that is why the frequency is different and not because you are such a good doctor and dentists are not. Oral Surgeons see those patients more often

Not trying to insinuate anyone is a good doctor or not. Just trying to get an idea of where dentists are coming from (training and practice wise) when I get these referrals. I assumed dentists are well-versed in the entire scope of oral disease and see cancer and inflammatory disorders all the time (maybe I was getting skewed by a few random experiences) but clearly am making bad assumptions.

 

[oralcare123]

Not trying to insinuate anyone is a good doctor or not. Just trying to get an idea of where dentists are coming from (training and practice wise) when I get these referrals. I assumed dentists are well-versed in the entire scope of oral disease and see cancer and inflammatory disorders all the time (maybe I was getting skewed by a few random experiences) but clearly am making bad assumptions.

You did imply that since one person did not diagnose pemphigus in time, that none of us can recognize an oral pathology.
Dentists get appropriate training in oral pathology, some things just difficult to diagnose. Should we really say, that the MD did not get a proper training if he could not diagnose hypothyroidism easily?

 

[deltamed]

You did imply that since one person did not diagnose pemphigus in time, that none of us can recognize an oral pathology.
Dentists get appropriate training in oral pathology, some things just difficult to diagnose. Should we really say, that the MD did not get a proper training if he could not diagnose hypothyroidism easily?

Ok- no offense meant. But what I'm really getting at is do dentists see much cancer or oral inflammatory disease in school or in practice? Sure, you can read/learn about stuff - but I would be the first to admit I could read a thousand dental textbooks and still not know the first thing about treating teeth because I never do it.

So I guess with a less rare condition would it be common or reasonable for a dentist to diagnose something like oral lichen planus and initiate some easy first-line treatment like dexamethasone swish/spit? Or excising a simple inflamed mucocele? Or diagnosing an oral contact dermatitis?

Honestly just want to know if there is any overlap between clinical practice. Or if dentists really practice 99.9% teeth and rest of oral diagnosis/treatment falls to derm and ent.

 

[oralcare123]

Ok- no offense meant. But what I'm really getting at is do dentists see much cancer or oral inflammatory disease in school or in practice? Sure, you can read/learn about stuff - but I would be the first to admit I could read a thousand dental textbooks and still not know the first thing about treating teeth because I never do it.

So I guess with a less rare condition would it be common or reasonable for a dentist to diagnose something like oral lichen planus and initiate some easy first-line treatment like dexamethasone swish/spit? Or excising a simple inflamed mucocele? Or diagnosing an oral contact dermatitis?

Honestly just want to know if there is any overlap between clinical practice. Or if dentists really practice 99.9% teeth and rest of oral diagnosis/treatment falls to derm and ent.

All mentioned above suppose to be easily diagnosed by a dentist, there are plenty of training. Maybe not too many cases one can see in school, but enough in my opinion. Obviously, all of us can have problems with something unusual.
I think a problem is , that some people just do not want to be bothered or just so used to see the same thing over and over again

 

[cacazor]

@deltamed

Sorry that your post is being misunderstood by someone who is (a) probably ESL and (b) is not a dentist nor even in dental school. Please ignore that person's conjecture.

You're absolutely right that dentists should be doing a better job at recognizing and biopsying the obvious, slam dunk oral manifestations that you mention. This is an issue of where dental education and training falls short of medical education and training.

I agree that oralcare123 last few comments were quite egregious and rather rude. However, don't you think it is jumping the gun to say that dental education falls short of medical education. There could be many reasons why 1. this dentist failed to properly diagnosis the pemphigus vulgaris patient 2. this derm sees no referral from dentists. Saying that medical education is better than dental education is simply polarizing to start with, but to point to this particular case and say that this is evidence of medical education being better than med is simply quite an inaccurate portrayal of the situation at hand.

 

[oralcare123]

@deltamed

Sorry that your post is being misunderstood by someone who is (a) probably ESL and (b) is not a dentist nor even in dental school. Please ignore that person's conjecture.

You're absolutely right that dentists should be doing a better job at recognizing and biopsying the obvious, slam dunk oral manifestations that you mention. This is an issue of where dental education and training falls short of medical education and training.

1.People, who know two and more languages generally have more developed brain compared to people, who only speak one language.
2. Some people prefer to withhold their private information on line
We all should do a better job, but world is not ideal, so we should just try not to behave like an AH

 

[deltamed]

I agree that oralcare123 last few comments were quite egregious and rather rude. However, don't you think it is jumping the gun to say that dental education falls short of medical education. There could be many reasons why 1. this dentist failed to properly diagnosis the pemphigus vulgaris patient 2. this derm sees no referral from dentists. Saying that medical education is better than dental education is simply polarizing to start with, but to point to this particular case and say that this is evidence of medical education being better than med is simply quite an inaccurate portrayal of the situation at hand.

I'm not trying to say dental education falls short of medical. It's just more clear to me now they are quite separate and much oral pathology (excluding teeth and gumline) falls largely under medical. That's fine. Again, I would have no idea how to diagnose or treat anything to do with teeth.

 

[cacazor]

I'm not trying to say dental education falls short of medical. It's just more clear to me now they are quite separate and much oral pathology (excluding teeth and gumline) falls largely under medical. That's fine. Again, I would have no idea how to diagnose or treat anything to do with teeth.

Hey deltamed. I want to clarify that I didn't say you made the statement; it was Outrun that did.

To be honest, I think dentists are suppose to be responsible for knowing how to identify oral pathology and anything that goes in the oral cavity (and even head and neck in general). At least that's a point my school tries to emphasis in my pre-clinical training. I also wouldn't say that oral pathology that a general dentist can't deal with would fall under medical either because oral pathology is an existing specialty with in dentistry.

However, personally speaking, I would see my primary physician regarding abnormal oral pathology not directly related to my teeth because I didn't have dental insurance and my PP is an easy line of contact for me.

 

[deltamed]

Hey deltamed. I want to clarify that I didn't say you made the statement; it was Outrun that did.

To be honest, I think dentists are suppose to be responsible for knowing how to identify oral pathology and anything that goes in the oral cavity (and even head and neck in general). At least that's a point my school tries to emphasis in my pre-clinical training. I also wouldn't say that oral pathology that a general dentist can't deal with would fall under medical either because oral pathology is an existing specialty with in dentistry.

However, personally speaking, I would see my primary physician regarding abnormal oral pathology not directly related to my teeth because I didn't have dental insurance and my PP is an easy line of contact for me.

That makes sense. I was not aware that oral pathology is a sub specialty of dentistry.

I think the main reason dentists dont see/treat much inflammatory oral disorders is they dont train to use systemic immunosuppression - ie cellcept, imuran, methotrexate, rituxan, long-term prednisone is really out of dentisty scope and these are often needed.

I still dont understand why general dentists dont do their own biopsies to rule out cancer though. You guys do way more invasive and complex procedures otherwise.

 

[oralcare123]

Could someone tell me what is the dentist fee for the biopsy?

 

[cacazor]

I still dont understand why general dentists dont do their own biopsies to rule out cancer though. You guys do way more invasive and complex procedures otherwise.

I don't know if this answers your question regarding the biopsy, but here's an excerpt from the ADA.
http://www.ada.org/~/media/ADA/Publications/Files/JADA_Landmark_June.ashx

"It is important that clinicians be able to screen and treat premalignant lesions accurately before they become cancerous. While a variety of tests and instruments have been developed for screening premalignant oral lesions, these screening methods have yet to be scientifically validated as being effective in reducing oral cancer incidence or death from oral carcinoma. A systematic review of screening for oral squamous cell carcinoma was recently published in JADA.22 It reviewed screening methods that used tissue reflectance, autofluorescence, transepithelial cytology, a combination of tissue reflectance and autofluorescence, and clinically based screening programs. It was concluded “that screening by means of visual and tactile examination to detect potentially malignant and malignant lesions may result in detection of oral cancers at early stages of development, but that there is insufficient evidence to determine if screening alters disease-specific mortality in asymptomatic people seeking dental care.” The authors of this review also suggested that “clinicians remain alert for signs of potentially malignant lesions or early-stage cancers while performing routine visual and tactile examinations in all patients, but particularly in those who use tobacco or who consume alcohol heavily.” The article emphasized the need for additional research in the area of oral cancer screening."

Although I have not formally taken oral pathology yet, our professor had a minor discussion with us that many types of screenings and biospy (i.e: brush) is not effective. The only one that is really conclusive with good support is excisional biopsy. With that said, I have no idea how easy it is for a dentist to perform an excisional biopsy.

I think the main reason dentists dont see/treat much inflammatory oral disorders is they dont train to use systemic immunosuppression - ie cellcept, imuran, methotrexate, rituxan, long-term prednisone is really out of dentisty scope and these are often needed.

I have not learned about systemic immunosuppression drugs (and their relevance...yet), but gingivitis and periodontitis are both inflammatory oral disease that dentists see far too often. Not sure about other types. I guess it is easy to misdiagnose if you become too complacent (which is terrible ofc).

 

[b-rad12]

Out of curiosity, do dentists get much training in medical disorders with oral manifestations? I'm in dermatology and it seems that dentists don't know much about things like lichen planus, pemphigus, burning tongue, em major etc and even refer easy procedures like tongue/lip biopsies / simple mucocele excisions etc to an oral surgeon or to me.

Not trying to be rude- just curious. Wouldn't these sorts of things be easy turf that dentistry should be covering in training?

Oral surgery is dentistry..

 

[Sublimazing]

I still dont understand why general dentists dont do their own biopsies to rule out cancer though. You guys do way more invasive and complex procedures otherwise.

There's no point. An OMFS is going to be faster and much more experienced at this. Not to mention if you come back with something that requires surgical intervention they'll have to make the referral at that point anyway. It's always better if the person who does the biopsy is the one that's going to remove the disease.

If a general dentist takes an excisional biopsy of something that comes back scc...makes it harder to plan excision/margins for the surgeon when he sees a lesion which has been altered and "healed". Not to mention the general dentist would have to bring the patient back for the biopsy results and tell them they have squamous cell when he probably doesn't know what the next steps will be.

 

[deltamed]

There's no point. An OMFS is going to be faster and much more experienced at this. Not to mention if you come back with something that requires surgical intervention they'll have to make the referral at that point anyway. It's always better if the person who does the biopsy is the one that's going to remove the disease.

If a general dentist takes an excisional biopsy of something that comes back scc...makes it harder to plan excision/margins for the surgeon when he sees a lesion which has been altered and "healed". Not to mention the general dentist would have to bring the patient back for the biopsy results and tell them they have squamous cell when he probably doesn't know what the next steps will be.

Not really. Although I treat 90% of cancers I biopsy myself, its no problem referring the ones I cant after the biopsy. I take a photograph so there is no question of location. A small punch is easily adequate to diagnose SCC- you don't need an excision. And its not a hard procedure except perhaps the posterior 1/3 of the tongue or the soft palette.

And there are multiple reasons why its not "always better" for the treating surgeon to also do the biopsy. 1. Surgeons are good at surgery but not good at finding cancer. If its an obvious lesion fine but a subtle lesion they may not see it. 2. If you dont do a biopsy on the spot there is a good chance the patient will not follow up with whoever you recommended. 3. There are many in-situ lesions that do not require surgical intervention. Surgeons are not well-versed in non-surgical options.

In any case this thread has gotten way off topic so I will sign off and go back to lurking my usual areas.

 

[oralcare123]

May be you will understand,if you knew, that dentists have different guidelines on what to do in those situations, compared to you?
1. Oral surgeons are good at diagnosing cancer
2. If patient does not understand the seriousness of the situation, biopsy on a spot is not going to save a world
3. In situ lesions are not referred to an Oral Surgeon, they are either treated by a GP or by specialist in Oral Medicine

 

[doctalaughs]

.

 

[Sublimazing]

Not really. Although I treat 90% of cancers I biopsy myself, its no problem referring the ones I cant after the biopsy. I take a photograph so there is no question of location. A small punch is easily adequate to diagnose SCC- you don't need an excision. And its not a hard procedure except perhaps the posterior 1/3 of the tongue or the soft palette.

And there are multiple reasons why its not "always better" for the treating surgeon to also do the biopsy. 1. Surgeons are good at surgery but not good at finding cancer. If its an obvious lesion fine but a subtle lesion they may not see it. 2. If you dont do a biopsy on the spot there is a good chance the patient will not follow up with whoever you recommended. 3. There are many in-situ lesions that do not require surgical intervention. Surgeons are not well-versed in non-surgical options.

In any case this thread has gotten way off topic so I will sign off and go back to lurking my usual areas.

Surgeons are not good at finding cancer? Where's the evidence on that? You do know that surgeons are the ones that create the margins in the OR? You think they're just blindly cutting?

Surgeons are well versed in non-surgical options...again where is this coming from?

And "there is a good chance that the patient will not follow up"...then why bother with any of it?

Look, you're being inflammatory and came on this forum to start trouble. When pressed on the issue you made a lot of sweeping unfounded statements. Please ago away and never come back.

 

[deltamed]

Okay, I'll stop commenting on this forum after this.

I honestly don't care if you guys do oral biopsies or not. Refer every last suspicious lesion to an oral surgeon or to your local ENT or dermatologist. I just thought dentists were (mostly) enterprising business-oriented people so I couldn't understand why they don't include a (very) simple procedure in their scope of practice when they are on the front lines doing the oral screening exams and seeing a large percentage of the population twice yearly.

When I said surgeons are not good at finding cancers of course I didn't mean they aren't good at "creating the margins" and cutting every last cancer cell out. What I meant is they typically don't want to spend the majority of their time in clinic doing screening, and biopsying 5 benign lesions for every 1 cancerous one (when they could better use their skills in the OR). Patients certainly don't want a 2nd appointment when many times it's actually not cancer so they have no need of a surgeon. I don't think that's either efficient or patient-centric.

All I know is I've done over 1000 oral biopsies so I'm pretty sure it's not a bad idea for the person doing the screening to make the initial and definitive diagnosis.

 

[oralcare123]

That would be the best, because you do not like our answers and still think, that you are a much better specialist. You should be more careful comparing things you have no knowledge about

 

[diasIItema]

Out of curiosity, do dentists get much training in medical disorders with oral manifestations? I'm in dermatology and it seems that dentists don't know much about things like lichen planus, pemphigus, burning tongue, em major etc and even refer easy procedures like tongue/lip biopsies / simple mucocele excisions etc to an oral surgeon or to me.

Not trying to be rude- just curious. Wouldn't these sorts of things be easy turf that dentistry should be covering in training?

Dental students are taught extensive oral pathology regarding pemphigus/pemphigoid, lichen planus, erythema multiforme, etc. We also take a differential diagnosis course after two semesters of oral path in which we are expected to know the single most likely diagnosis, top 3, histology, what type of biopsy to perform, etc. They are also tested on NBDE II national boards. So to answer your question, yes, they are covered in training and a competency for practice.

As for dermatology, I went to a dermatologist who told me I had ringworm. Three antifungals and no change later, I went to the school general physician who simply looked at me and told me I had pityriasis rosea. Went back to the derm, he didn't believe me, took a biopsy, confirmed the GP's diagnosis. Now I have a lovely biopsy scar and three expensive tubes of antifungals that I've never needed.

So looks the kid at the top of his med school class doesn't know his "easy turf" and how to take a simple KOH test. Not trying to be rude...

 

[Dr.p53]

Out of curiosity, do dentists get much training in medical disorders with oral manifestations? I'm in dermatology and it seems that dentists don't know much about things like lichen planus, pemphigus, burning tongue, em major etc and even refer easy procedures like tongue/lip biopsies / simple mucocele excisions etc to an oral surgeon or to me.

Not trying to be rude- just curious. Wouldn't these sorts of things be easy turf that dentistry should be covering in training?

I'm a Nurse and a first year dental-proper student. I'm also curious on how much Oral Dx and Tx does Dentist perform (with exception to OMFS and OMFP) I have not yet taken any Oral pathology class but as a Nurse I have enough knowledge about oral diseases because of my exposure to ENT's and Dermatologists in the hospital. But I always wonder why many Dentist refer Patients with Oral diseases and even localized oral diseases to other specialists since they also have oral pathology, hospital dentistry and pharmacology in Dental School and Oral diseases in clearly a part of Dental scope. But surely I'll find the answer after I finish Dental School and I promise to share it with you .

 

[oralcare123]

I'm a Nurse and a first year dental-proper student. I'm also curious on how much Oral Dx and Tx does Dentist perform (with exception to OMFS and OMFP) I have not yet taken any Oral pathology class but as a Nurse I have enough knowledge about oral diseases because of my exposure to ENT's and Dermatologists in the hospital. But I always wonder why many Dentist refer Patients with Oral diseases and even localized oral diseases to other specialists since they also have oral pathology, hospital dentistry and pharmacology in Dental School and Oral diseases in clearly a part of Dental scope. But surely I'll find the answer after I finish Dental School and I promise to share it with you .

Did you read the thread?