Vol. 119 No. 4 April 2015
Oral Medicine referrals at a hospital-based practice in the United States Alessandro Villa, DDS, PhD, MPH,a Shannon Stock, PhD,b Ali Aboalela, BDS, MMEd,a Mark A. Lerman, DMD,c Sook-Bin Woo, DMD, MMSc,a Stephen T. Sonis, DMD, DMSc,a and Nathaniel S. Treister, DMD, DMSca Objective. The objective of this study was to characterize the outpatient oral medicine (OM) clinic at Brigham and Women’s Hospital (BWH), with particular emphasis on patient demographic characteristics and referral patterns. Materials and Methods. A retrospective case record review of all initial consultations with OM experts at BWH from 2008 to 2010 was conducted. Data included demographic information, type of medical insurance, reason for referral, referring doctor’s specialty, and distance between the patient’s home and the referring doctor as well as BWH, number of prior doctors seen for the presenting problem (per patient report), tests ordered at the consultation visit, and clinical diagnoses. Results. There were 1043 new outpatient consultation visits. Patients lived a median distance of 9.5 miles from the referring doctor and 18.9 miles from BWH and saw a median of one doctor (range 0-9) before consultation. Two thirds of patients were referred by physicians. The most common diagnoses included immune-mediated mucosal conditions (27.2%), orofacial pain disorders (25.1%), benign tumors or neoplasms (10.3%), and dysplasia and cancerous conditions (7.6%). Biopsy was the most frequent test performed at consultation. Conclusions. Patients with oral conditions often see more than one doctor, before being referred to an OM expert and typically travel twice the distance to the expert compared with that between their home and the referring doctor. Equal efforts should be made to increase awareness of the importance of the specialty of OM among dentists, physicians, and the public. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:423-429)
The American Academy of Oral Medicine (AAOM) defines Oral Medicine (OM) as “the discipline of dentistry concerned with the oral health care of medically complex patientsdincluding the diagnosis and management of medical conditions that affect the oral and maxillofacial region.”1 Experts in OM care for patients with a wide range of conditions, including mucosal diseases, oral manifestations of systemic diseases, oral complications of cancer and other medical therapies, salivary gland disorders, orofacial pain, and temporomandibular conditions.2 They also serve play an advisory role in their interactions with other dental practitioners and help coordinate dental treatment for patients with complex medical conditions. OM is practiced all over the world, and most OM clinics are based in academic medical centers, dental schools, and other institutional settings.3 Despite the existence of OM postgraduate training programs in approximately 30 countries worldwide, the number of available clinicians remains limited, and a
Division of Oral Medicine and Dentistry, Brigham and Women’s Hospital, and Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, Massachusetts, USA. b Department of Mathematics and Computer Science, College of the Holy Cross, Worcester, Massachusetts, USA. c Department of Oral Pathology, Oral Medicine, and Craniofacial Pain, Tufts University School of Dental Medicine, Boston, Massachusetts, USA. Received for publication Nov 11, 2014; returned for revision Dec 3, 2014; accepted for publication Jan 1, 2015. Ó 2015 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2015.01.003
health care workers and the general public have a limited knowledge of OM and its practice.4,5 In the United States, OM is not recognized by the American Dental Association (ADA) as a dental specialty; however, the Commission on Dental Accreditation accredits OM residency programs, and OM residency program directors are required to be diplomates of the American Board of Oral Medicine.6,7 Possibly, at least partly as a result of a general lack of familiarity with the diagnosis and management of OM conditions among health care providers, patients with oral diseases are often seen by multiple clinicians before being evaluated by an OM expert and may be subjected to unnecessary and often inappropriate diagnostic tests, procedures, and therapies.8,9 Data describing the referral patterns of clinical OM in the United States are limited, and studies have mostly been conducted in other countries.10-13 The demand for OM clinical services within the general population and how this care can be most efficiently and effectively delivered throughout the health care system remain largely unknown. The objective of this study was to characterize comprehensively the outpatient OM practice in a hospital-based setting within a tertiary care
Statement of Clinical Relevance Greater publicity and recognition of the importance of oral medicine (OM) among health care professionals and the public are essential to improve the accuracy and timeliness of referrals. 423
ORAL MEDICINE 424 Villa et al.
academic medical center, with particular emphasis on patient demographic characteristics, clinical diagnoses, and referral patterns.
METHODS This study was a retrospective case record review of all new outpatients who were referred for OM consultation at the Division of Oral Medicine and Dentistry at Brigham and Women’s Hospital (BWH), Boston, Massachusetts, from January 1, 2008, through December 31, 2010. Patients were seen by a Boardcertified expert in Oral Medicine or Oral Maxillofacial pathology (the clinic had a total of four attending dentists). This study was approved by the Partners Health Care Human Research Committee. Study population The study population consisted of patients who had been referred for oral soft or hard tissue pathology, salivary gland disorders, orofacial pain and neurosensory conditions, or cancer- or cancer therapyerelated oral complications. Patients who were referred primarily for dental or oral surgery (exodontia) consultations (regardless of medical complexity), as well as all inpatient consultations (even if evaluated for one of the included conditions above), were excluded. Data collection Clinical data were abstracted from electronic medical records by using a standardized data collection form. Data were extracted by studying the records and from the codes for International Statistical Classification of Diseases and Related Health Problems (International Classification of Diseases, 9th edition [ICD-9] codes). Data included patient demographic information, type of medical insurance, reason for referral, referring doctor’s specialty, number of prior doctors seen for the presenting problem (per patient report), laboratory investigations and imaging tests ordered at the consultation visit, and clinical diagnosis. Google Maps (www.google.com) was used to calculate the distances between the patient’s home and the primary care physician (PCP), referring doctor, general dental practitioner (GDP), and BWH. In cases of patients who lived in distant states (e.g., Florida) during winter, providers from these states were not included in the distance calculations. Statistical analysis The distribution of participant characteristics, including patient and referring physician characteristics, were tabulated with the use of the Stata 13 statistical software package (StataCorp, College Station, TX). The clinical diagnoses were grouped into the following nine
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categories: (1) immune-mediated mucosal conditions, (2) orofacial pain disorders, (3) benign tumors or neoplasms, (4) reactive keratosis, (5) dysplasia and cancerous conditions, (6) salivary gland disorders, (7) infections, (8) osteonecrosis of the jaw, and (9) other mucosal or gingival conditions (i.e., diagnoses that did not fit one of the prior categories). Logistic regression models were used to explore the association between clinical diagnoses and measures of accessibility of care (number of doctors seen before referral and distance from patient’s home), with P values considered statistically significant at P < .05.
RESULTS Patient characteristics There were 1043 new patient consultations, with the median age being 56 years (range 15-96 years; Table I). There were more females (63.8%) than males, and the majority of patients were Caucasian (78.1%). Most patients (66.1%) had private medical insurance, with 16.3% having primary Medicare coverage and 5.7% having Medicaid; 11.2% of patients had a mix of public and private coverages, with the remaining 0.8% being uninsured (with or without free hospital care). Patients traveled a median distance of 18.9 miles (range 0.2-525) to BWH, with over 85% living within 60 miles of the hospital. Patients lived a median distance of 6.5 miles away (range 0.0-452) from their primary care physicians and 9.4 miles (range 0.1-525) from the referring doctor. Oral Medicine referrals Nearly three-quarters of patients were referred for definitive clinical diagnosis, in addition to medical management of their oral condition. Two thirds of patients were referred by physicians, with the greatest proportions coming from PCPs (22.8%), oncologists (16.7%), otolaryngologists (10.1%), and dermatologists (6.2%; Figure 1). Among the remaining one third referred by dentists, most were referred by GDPs (22.2%) and oral and maxillofacial surgeons (8.6%; Figure 2). Less than 5% of patients were referred directly without initial evaluation of their oral condition by another doctor; of those that visited one or more doctors (95.2%), 35.8% saw between two and four doctors, and 1% saw more than four doctors (see Table I). Approximately one quarter of patients presented with a provisional diagnosis (267 of 1043; 25.6%), and of these, 69% (184 of 267) were determined to be correct (k¼ 0.65; 95% confidence interval [CI]: 0.59%-0.71%]; data not shown). Diagnostic tests ordered Approximately one third of patients (344 of 1,043; 33%) had had at least one diagnostic test performed or ordered at
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Table I. Patient characteristics n (%) Median age (range) Gender Female Male Race/ethnicity Caucasian Hispanic African American Asian Other N/A Insurance Private Medicare Private, Medicare Medicaid Medicare, Medicaid Self-pay Private, Medicaid Free care In-state/Out-of-state In-state Out-of-state Median distance in miles (range) from patient BWH Referring doctor PCP GDP Doctors seen before OM consultation 1 2 3 4 5 6 7 8 9 N/A
55 (15-96) 665 (63.8) 378 (36.2) 815 55 38 30 12 93
(78.1) (5.3) (3.6) (2.9) (1.2) (8.9)
689 170 85 59 25 6 7 2
(66.1) (16.3) (8.1) (5.7) (2.4) (0.6) (0.7) (0.2)
890 (85.3) 153 (14.7)
18.9 9.4 6.5 5.3
(0.2-525) (0.1-525) (0.0-452) (0.0-411)
610 266 80 27 5 1 2 1 1 50
(58.5) (25.5) (7.7) (2.6) (0.5) (0.1) (0.2) (0.1) (0.1) (4.8)
BWH, Brigham and Women’s Hospital; GDP, general dental practitioner; OM, Oral Medicine; PCP, primary care physician.
the consultation visit, with the most frequent being biopsy (188 of 252; 74.6%; Table II). In the case of the 178 patients (17.1%) who had had an oral biopsy before the OM consultation visit, over one third of the previous biopsies (60 of 178; 33.5%; data not shown) were determined to be inadequate for a variety of reasons (e.g., the biopsy having been performed too long before the consultation, a nonspecific histopathologic diagnosis, or inadequate amount of tissue for diagnosis), necessitating a new biopsy in 15.7% (28 of 178) of these patients. With respect to incisional biopsies (72.3% of all biopsies) obtained at the initial visit, 6.6% were also submitted for direct immunofluorescence studies. Other diagnostic laboratory tests ordered at the consultation visit included microbiologic cultures
(43 of 1043; 4.2%) and blood work (21 of 1043; 2%; see Table II). Imaging studies ordered at first visit (92 of 1043; 8.8%) included intraoral radiography (45 of 92; 48.9%), panoramic radiography (35 of 92; 38%), computed tomography (5 of 92; 5.4%), and magnetic resonance imaging (1 of 92; 1.1%). Diagnosis and management The most frequent diagnoses rendered by the OM expert were immune-mediated mucosal conditions (27.2%), orofacial pain disorders (25.1%), benign tumors or neoplasms (10.3%), and dysplasia and cancerous disorders (7.6%; Table III). The odds of having been seen by multiple providers before referral was higher among those with orofacial pain disorders than those with all other conditions combined (odds ratio [OR]: 1.6; 95% CI: 1.2-2.1; P < .01; Table IV). Compared with all other diagnostic categories, patients with immune-mediated mucosal conditions and osteonecrosis of the jaw traveled longer distances to be seen by an OM expert (OR: 1.8; 95% CI: 1.4-2.4; and OR: 3.9; 95% CI: 1.1-14.2, respectively). Patients were prescribed a median of one medication (range 0-6) for their oral condition, with the most frequent being topical corticosteroids (218 of 375, 58.1%; data not shown). Following the OM consultation visit, 5.8% of patients were referred to other providers for further evaluation, management, or both. Within 6 months of the initial visit, approximately half the patients (444 of 1043; 43.6%) returned for follow-up. Discussion This single-center study provides a current and in-depth description of a hospital-based OM clinical service within an academic medical and cancer center in the United States. Patients were referred for evaluation and management of a wide spectrum of OM clinical conditions from a large geographic region and by a variety of health care providers. With regard to ethnic groups, our patient population was generally representative of Massachusetts. The majority of patients were Caucasian (78.1% in our patients; 81% in Massachusetts) or Hispanic (5.3%; 7.9%).14 Given the limited availability of OM experts and clinical practices nationally, we assume that the data from this study are likely reflective of other similar hospital-based OM practices in other parts of the United States. OM being a highly specialized hospital-based practice, it is not surprising that patients often were found to travel long distances to receive care for their oral conditions (see Table I). Patients with cancer (e.g., those evaluated for osteonecrosis of the jaw, chronic graft-versus-host disease [GVHD], and radiation-associated salivary gland hypofunction), for example, were, in many cases,
ORAL MEDICINE 426 Villa et al.
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Fig. 1. Referring physician by type and specialty. PCP, primary care physician.
Fig. 2. Referring dentist by specialty. OMFS, oral and maxillofacial surgery; GDP, general dental practitioner.
being seen by multiple other providers in addition to OM experts and traveled long distances, primarily for their cancer care. The distance that patients had to travel to receive OM care was approximately twice the median distance traveled to see the referring doctor, and nearly
three to four times the distance from their primary medical and dental providers. This suggests that the geographic location of the OM practice may be a barrier to accessing OM clinical care and may contribute to increased costs of care attributed to travel-associated
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Table II. Diagnostic tests and laboratory investigations ordered at the consultation visit Diagnostic tests Biopsy Incisional Punch Scalpel Excisional DIF ordered Blood test Viral culture Fungal culture Exfoliative cytology Bacterial culture Imaging studies Intraoral radiography Panoramic radiography Computed tomography Magnetic resonance imaging N/A
n (%) 188 136 132 4 52 9 21 18 16 8 1
(18.0) (72.3) (97.1) (2.9) (27.7) (6.6) (2.0) (1.7) (1.5) (0.8) (0.1)
45 35 5 1
(48.9) (38.0) (5.4) (1.1)
6 (6.5)
DIF, direct immunofluorescence.
costs and loss of productivity. Studies have demonstrated that as the distance from the home to the PCP or specialty care provider increases, so do disease burden and health care resource utilization.15-17 We did not collect data on disease severity (when applicable) at first visit or the total number of follow-up visits after the initial visit and therefore cannot comment on the association between distance from the hospital and overall burden of illness in this cohort. Furthermore, the conditions for which patients were being referred were heterogeneous (e.g., removal a fibroma vs. long-term management of mucous membrane pemphigoid), and as such, it is difficult to make generalizations about disease complexity. OM experts generally practice in institutional settings (e.g., dental schools, academic medical centers, and cancer centers) with patients referred from a wide variety of medical specialties, including oncology, transplantation, dermatology, gastroenterology, rheumatology, and allergy or immunology, as well as from dentists and dental specialists.3 The majority of patients in our cohort were referred by physicians, with most coming from PCPs and oncologists. Location and institutional characteristics likely play an important role in the referral patterns of any given OM practice. A study from the United States showed that 42.4% of patients were referred from general dentists and 37.1% from PCPs.13 Similarly, another study characterizing an OM practice at a dental hospital in London showed that nearly three quarters of the patients were referred by dentists.18 In a similarly designed study of hospitalbased and private practice OM clinics in Australia, it
Table III. Patient diagnoses Diagnosis
n (%)
Immune-mediated mucosal conditions Oral lichen planus cGVHD Aphthous ulcer Geographic tongue Orofacial granulomatosis* Mucous membrane pemphigoid Pemphigus vulgaris Orofacial pain disorders Oral dysesthesia/burning mouth syndrome Myofascial pain/headache Temporomandibular joint pain Trigeminal neuralgia Dysgeusia Trismus Benign tumors/neoplasms Fibroma Varix Papilloma Torus Benign salivary gland tumor Dysplasia and cancerous conditions Leukoplakia Oral squamous cell carcinoma Erythroplakia Metastatic cancer Reactive keratosis BARK, frictional keratosis Hairy tongue Salivary gland disorders Xerostomia/dry mouth Mucocele Sjögren syndrome Infections Candidiasis HSV Osteonecrosis of the jaw Other mucosal/gingival conditions Atrophic glossitis/papillitis Periodontal disease Amalgam tattoo Traumatic ulcer Othery
284 (27.2) 124 64 58 24 6 4
(11.9) (6.1) (5.6) (2.3) (0.6) (0.4)
4 (0.4) 262 (25.1) 155 (14.9) 47 (4.5) 27 (2.6) 14 11 8 107 47 22 19 17 2
(1.3) (1.1) (0.8) (10.3) (4.5) (2.1) (1.8) (1.6) (0.2)
79 (7.6) 59 (5.7) 13 (1.2) 5 2 76 50 26 49 25 17 7 27 23 4 14 97
(0.5) (0.2) (7.2) (4.8) (2.5) (4.7) (2.4) (1.6) (0.7) (2.6) (2.2) (0.4) (1.3) (9.3)
38 29 18 12 48
(3.6) (2.8) (1.7) (1.2) (4.6)
BARK, benign alveolar ridge keratosis; BMS, burning mouth syndrome; cGVHD, chronic graft-versus-host disease; HSV, herpes simplex virus; TMJ, temporomandibular joint. *Includes oral manifestations of Crohn disease. y Includes conditions that did not otherwise fit into one of the above categories, including dental pathology, anatomic variants of normal, traumatic ulcers, hairy or coated tongue, or no evident mucosal pathology.
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Table IV. Logistic regression analysis of access to care by diagnosis Number of doctors seen before referral 1 Diagnosis Immune-mediated mucosal conditions No Yes Orofacial pain disorders No Yes Benign soft tissue lesions* No Yes Dysplasia and cancerous conditions No Yes Salivary gland disorders No Yes Infections No Yes Osteonecrosis of the jaw No Yes
Distance from patient home to BWH (miles)
>1
0-20
>20
(N ¼ 784) (N ¼ 175) Odds ratio (95% CI) P value (N ¼ 523) (N ¼ 511) Odds ratio (95% CI) P value
429 (60.8) 167 (62.8)
277 (39.2) 99 (37.2)
0.9 (0.7-1.2)
.56
463 (64.0) 133 (53.4)
260 (37.0) 116 (46.6)
1.6 (1.2-2.1)
438 (59.5) 158 (66.9)
298 (40.5) 78 (33.1)
0.7 (0.5-0.9)
549 (61.2) 349 (38.8) 47 (563.5) 27 (36.5)
0.9 (0.6-1.5)
569 (61.5) 27 (57.4)
356 (38.5) 20 (42.6)
1.2 (0.7-2.1)
568 (60.9) 18 (66.7)
364 (39.1) 9 (33.3)
0.8 (0.3-1.8)
580 (61.4) 6 (42.9)
365 (38.6) 8 (57.1)
1.0 2.1 (0.7-6.2)
Oral Medicine referrals at a hospital-based practice in the United States Alessandro Villa, DDS, PhD, MPH,a Shannon Stock, PhD,b Ali Aboalela, BDS, MMEd,a Mark A. Lerman, DMD,c Sook-Bin Woo, DMD, MMSc,a Stephen T. Sonis, DMD, DMSc,a and Nathaniel S. Treister, DMD, DMSca Objective. The objective of this study was to characterize the outpatient oral medicine (OM) clinic at Brigham and Women’s Hospital (BWH), with particular emphasis on patient demographic characteristics and referral patterns. Materials and Methods. A retrospective case record review of all initial consultations with OM experts at BWH from 2008 to 2010 was conducted. Data included demographic information, type of medical insurance, reason for referral, referring doctor’s specialty, and distance between the patient’s home and the referring doctor as well as BWH, number of prior doctors seen for the presenting problem (per patient report), tests ordered at the consultation visit, and clinical diagnoses. Results. There were 1043 new outpatient consultation visits. Patients lived a median distance of 9.5 miles from the referring doctor and 18.9 miles from BWH and saw a median of one doctor (range 0-9) before consultation. Two thirds of patients were referred by physicians. The most common diagnoses included immune-mediated mucosal conditions (27.2%), orofacial pain disorders (25.1%), benign tumors or neoplasms (10.3%), and dysplasia and cancerous conditions (7.6%). Biopsy was the most frequent test performed at consultation. Conclusions. Patients with oral conditions often see more than one doctor, before being referred to an OM expert and typically travel twice the distance to the expert compared with that between their home and the referring doctor. Equal efforts should be made to increase awareness of the importance of the specialty of OM among dentists, physicians, and the public. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:423-429)
The American Academy of Oral Medicine (AAOM) defines Oral Medicine (OM) as “the discipline of dentistry concerned with the oral health care of medically complex patientsdincluding the diagnosis and management of medical conditions that affect the oral and maxillofacial region.”1 Experts in OM care for patients with a wide range of conditions, including mucosal diseases, oral manifestations of systemic diseases, oral complications of cancer and other medical therapies, salivary gland disorders, orofacial pain, and temporomandibular conditions.2 They also serve play an advisory role in their interactions with other dental practitioners and help coordinate dental treatment for patients with complex medical conditions. OM is practiced all over the world, and most OM clinics are based in academic medical centers, dental schools, and other institutional settings.3 Despite the existence of OM postgraduate training programs in approximately 30 countries worldwide, the number of available clinicians remains limited, and a
Division of Oral Medicine and Dentistry, Brigham and Women’s Hospital, and Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, Massachusetts, USA. b Department of Mathematics and Computer Science, College of the Holy Cross, Worcester, Massachusetts, USA. c Department of Oral Pathology, Oral Medicine, and Craniofacial Pain, Tufts University School of Dental Medicine, Boston, Massachusetts, USA. Received for publication Nov 11, 2014; returned for revision Dec 3, 2014; accepted for publication Jan 1, 2015. Ó 2015 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2015.01.003
health care workers and the general public have a limited knowledge of OM and its practice.4,5 In the United States, OM is not recognized by the American Dental Association (ADA) as a dental specialty; however, the Commission on Dental Accreditation accredits OM residency programs, and OM residency program directors are required to be diplomates of the American Board of Oral Medicine.6,7 Possibly, at least partly as a result of a general lack of familiarity with the diagnosis and management of OM conditions among health care providers, patients with oral diseases are often seen by multiple clinicians before being evaluated by an OM expert and may be subjected to unnecessary and often inappropriate diagnostic tests, procedures, and therapies.8,9 Data describing the referral patterns of clinical OM in the United States are limited, and studies have mostly been conducted in other countries.10-13 The demand for OM clinical services within the general population and how this care can be most efficiently and effectively delivered throughout the health care system remain largely unknown. The objective of this study was to characterize comprehensively the outpatient OM practice in a hospital-based setting within a tertiary care
Statement of Clinical Relevance Greater publicity and recognition of the importance of oral medicine (OM) among health care professionals and the public are essential to improve the accuracy and timeliness of referrals. 423
ORAL MEDICINE 424 Villa et al.
academic medical center, with particular emphasis on patient demographic characteristics, clinical diagnoses, and referral patterns.
METHODS This study was a retrospective case record review of all new outpatients who were referred for OM consultation at the Division of Oral Medicine and Dentistry at Brigham and Women’s Hospital (BWH), Boston, Massachusetts, from January 1, 2008, through December 31, 2010. Patients were seen by a Boardcertified expert in Oral Medicine or Oral Maxillofacial pathology (the clinic had a total of four attending dentists). This study was approved by the Partners Health Care Human Research Committee. Study population The study population consisted of patients who had been referred for oral soft or hard tissue pathology, salivary gland disorders, orofacial pain and neurosensory conditions, or cancer- or cancer therapyerelated oral complications. Patients who were referred primarily for dental or oral surgery (exodontia) consultations (regardless of medical complexity), as well as all inpatient consultations (even if evaluated for one of the included conditions above), were excluded. Data collection Clinical data were abstracted from electronic medical records by using a standardized data collection form. Data were extracted by studying the records and from the codes for International Statistical Classification of Diseases and Related Health Problems (International Classification of Diseases, 9th edition [ICD-9] codes). Data included patient demographic information, type of medical insurance, reason for referral, referring doctor’s specialty, number of prior doctors seen for the presenting problem (per patient report), laboratory investigations and imaging tests ordered at the consultation visit, and clinical diagnosis. Google Maps (www.google.com) was used to calculate the distances between the patient’s home and the primary care physician (PCP), referring doctor, general dental practitioner (GDP), and BWH. In cases of patients who lived in distant states (e.g., Florida) during winter, providers from these states were not included in the distance calculations. Statistical analysis The distribution of participant characteristics, including patient and referring physician characteristics, were tabulated with the use of the Stata 13 statistical software package (StataCorp, College Station, TX). The clinical diagnoses were grouped into the following nine
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categories: (1) immune-mediated mucosal conditions, (2) orofacial pain disorders, (3) benign tumors or neoplasms, (4) reactive keratosis, (5) dysplasia and cancerous conditions, (6) salivary gland disorders, (7) infections, (8) osteonecrosis of the jaw, and (9) other mucosal or gingival conditions (i.e., diagnoses that did not fit one of the prior categories). Logistic regression models were used to explore the association between clinical diagnoses and measures of accessibility of care (number of doctors seen before referral and distance from patient’s home), with P values considered statistically significant at P < .05.
RESULTS Patient characteristics There were 1043 new patient consultations, with the median age being 56 years (range 15-96 years; Table I). There were more females (63.8%) than males, and the majority of patients were Caucasian (78.1%). Most patients (66.1%) had private medical insurance, with 16.3% having primary Medicare coverage and 5.7% having Medicaid; 11.2% of patients had a mix of public and private coverages, with the remaining 0.8% being uninsured (with or without free hospital care). Patients traveled a median distance of 18.9 miles (range 0.2-525) to BWH, with over 85% living within 60 miles of the hospital. Patients lived a median distance of 6.5 miles away (range 0.0-452) from their primary care physicians and 9.4 miles (range 0.1-525) from the referring doctor. Oral Medicine referrals Nearly three-quarters of patients were referred for definitive clinical diagnosis, in addition to medical management of their oral condition. Two thirds of patients were referred by physicians, with the greatest proportions coming from PCPs (22.8%), oncologists (16.7%), otolaryngologists (10.1%), and dermatologists (6.2%; Figure 1). Among the remaining one third referred by dentists, most were referred by GDPs (22.2%) and oral and maxillofacial surgeons (8.6%; Figure 2). Less than 5% of patients were referred directly without initial evaluation of their oral condition by another doctor; of those that visited one or more doctors (95.2%), 35.8% saw between two and four doctors, and 1% saw more than four doctors (see Table I). Approximately one quarter of patients presented with a provisional diagnosis (267 of 1043; 25.6%), and of these, 69% (184 of 267) were determined to be correct (k¼ 0.65; 95% confidence interval [CI]: 0.59%-0.71%]; data not shown). Diagnostic tests ordered Approximately one third of patients (344 of 1,043; 33%) had had at least one diagnostic test performed or ordered at
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Table I. Patient characteristics n (%) Median age (range) Gender Female Male Race/ethnicity Caucasian Hispanic African American Asian Other N/A Insurance Private Medicare Private, Medicare Medicaid Medicare, Medicaid Self-pay Private, Medicaid Free care In-state/Out-of-state In-state Out-of-state Median distance in miles (range) from patient BWH Referring doctor PCP GDP Doctors seen before OM consultation 1 2 3 4 5 6 7 8 9 N/A
55 (15-96) 665 (63.8) 378 (36.2) 815 55 38 30 12 93
(78.1) (5.3) (3.6) (2.9) (1.2) (8.9)
689 170 85 59 25 6 7 2
(66.1) (16.3) (8.1) (5.7) (2.4) (0.6) (0.7) (0.2)
890 (85.3) 153 (14.7)
18.9 9.4 6.5 5.3
(0.2-525) (0.1-525) (0.0-452) (0.0-411)
610 266 80 27 5 1 2 1 1 50
(58.5) (25.5) (7.7) (2.6) (0.5) (0.1) (0.2) (0.1) (0.1) (4.8)
BWH, Brigham and Women’s Hospital; GDP, general dental practitioner; OM, Oral Medicine; PCP, primary care physician.
the consultation visit, with the most frequent being biopsy (188 of 252; 74.6%; Table II). In the case of the 178 patients (17.1%) who had had an oral biopsy before the OM consultation visit, over one third of the previous biopsies (60 of 178; 33.5%; data not shown) were determined to be inadequate for a variety of reasons (e.g., the biopsy having been performed too long before the consultation, a nonspecific histopathologic diagnosis, or inadequate amount of tissue for diagnosis), necessitating a new biopsy in 15.7% (28 of 178) of these patients. With respect to incisional biopsies (72.3% of all biopsies) obtained at the initial visit, 6.6% were also submitted for direct immunofluorescence studies. Other diagnostic laboratory tests ordered at the consultation visit included microbiologic cultures
(43 of 1043; 4.2%) and blood work (21 of 1043; 2%; see Table II). Imaging studies ordered at first visit (92 of 1043; 8.8%) included intraoral radiography (45 of 92; 48.9%), panoramic radiography (35 of 92; 38%), computed tomography (5 of 92; 5.4%), and magnetic resonance imaging (1 of 92; 1.1%). Diagnosis and management The most frequent diagnoses rendered by the OM expert were immune-mediated mucosal conditions (27.2%), orofacial pain disorders (25.1%), benign tumors or neoplasms (10.3%), and dysplasia and cancerous disorders (7.6%; Table III). The odds of having been seen by multiple providers before referral was higher among those with orofacial pain disorders than those with all other conditions combined (odds ratio [OR]: 1.6; 95% CI: 1.2-2.1; P < .01; Table IV). Compared with all other diagnostic categories, patients with immune-mediated mucosal conditions and osteonecrosis of the jaw traveled longer distances to be seen by an OM expert (OR: 1.8; 95% CI: 1.4-2.4; and OR: 3.9; 95% CI: 1.1-14.2, respectively). Patients were prescribed a median of one medication (range 0-6) for their oral condition, with the most frequent being topical corticosteroids (218 of 375, 58.1%; data not shown). Following the OM consultation visit, 5.8% of patients were referred to other providers for further evaluation, management, or both. Within 6 months of the initial visit, approximately half the patients (444 of 1043; 43.6%) returned for follow-up. Discussion This single-center study provides a current and in-depth description of a hospital-based OM clinical service within an academic medical and cancer center in the United States. Patients were referred for evaluation and management of a wide spectrum of OM clinical conditions from a large geographic region and by a variety of health care providers. With regard to ethnic groups, our patient population was generally representative of Massachusetts. The majority of patients were Caucasian (78.1% in our patients; 81% in Massachusetts) or Hispanic (5.3%; 7.9%).14 Given the limited availability of OM experts and clinical practices nationally, we assume that the data from this study are likely reflective of other similar hospital-based OM practices in other parts of the United States. OM being a highly specialized hospital-based practice, it is not surprising that patients often were found to travel long distances to receive care for their oral conditions (see Table I). Patients with cancer (e.g., those evaluated for osteonecrosis of the jaw, chronic graft-versus-host disease [GVHD], and radiation-associated salivary gland hypofunction), for example, were, in many cases,
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Fig. 1. Referring physician by type and specialty. PCP, primary care physician.
Fig. 2. Referring dentist by specialty. OMFS, oral and maxillofacial surgery; GDP, general dental practitioner.
being seen by multiple other providers in addition to OM experts and traveled long distances, primarily for their cancer care. The distance that patients had to travel to receive OM care was approximately twice the median distance traveled to see the referring doctor, and nearly
three to four times the distance from their primary medical and dental providers. This suggests that the geographic location of the OM practice may be a barrier to accessing OM clinical care and may contribute to increased costs of care attributed to travel-associated
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ORIGINAL ARTICLE Villa et al. 427
Table II. Diagnostic tests and laboratory investigations ordered at the consultation visit Diagnostic tests Biopsy Incisional Punch Scalpel Excisional DIF ordered Blood test Viral culture Fungal culture Exfoliative cytology Bacterial culture Imaging studies Intraoral radiography Panoramic radiography Computed tomography Magnetic resonance imaging N/A
n (%) 188 136 132 4 52 9 21 18 16 8 1
(18.0) (72.3) (97.1) (2.9) (27.7) (6.6) (2.0) (1.7) (1.5) (0.8) (0.1)
45 35 5 1
(48.9) (38.0) (5.4) (1.1)
6 (6.5)
DIF, direct immunofluorescence.
costs and loss of productivity. Studies have demonstrated that as the distance from the home to the PCP or specialty care provider increases, so do disease burden and health care resource utilization.15-17 We did not collect data on disease severity (when applicable) at first visit or the total number of follow-up visits after the initial visit and therefore cannot comment on the association between distance from the hospital and overall burden of illness in this cohort. Furthermore, the conditions for which patients were being referred were heterogeneous (e.g., removal a fibroma vs. long-term management of mucous membrane pemphigoid), and as such, it is difficult to make generalizations about disease complexity. OM experts generally practice in institutional settings (e.g., dental schools, academic medical centers, and cancer centers) with patients referred from a wide variety of medical specialties, including oncology, transplantation, dermatology, gastroenterology, rheumatology, and allergy or immunology, as well as from dentists and dental specialists.3 The majority of patients in our cohort were referred by physicians, with most coming from PCPs and oncologists. Location and institutional characteristics likely play an important role in the referral patterns of any given OM practice. A study from the United States showed that 42.4% of patients were referred from general dentists and 37.1% from PCPs.13 Similarly, another study characterizing an OM practice at a dental hospital in London showed that nearly three quarters of the patients were referred by dentists.18 In a similarly designed study of hospitalbased and private practice OM clinics in Australia, it
Table III. Patient diagnoses Diagnosis
n (%)
Immune-mediated mucosal conditions Oral lichen planus cGVHD Aphthous ulcer Geographic tongue Orofacial granulomatosis* Mucous membrane pemphigoid Pemphigus vulgaris Orofacial pain disorders Oral dysesthesia/burning mouth syndrome Myofascial pain/headache Temporomandibular joint pain Trigeminal neuralgia Dysgeusia Trismus Benign tumors/neoplasms Fibroma Varix Papilloma Torus Benign salivary gland tumor Dysplasia and cancerous conditions Leukoplakia Oral squamous cell carcinoma Erythroplakia Metastatic cancer Reactive keratosis BARK, frictional keratosis Hairy tongue Salivary gland disorders Xerostomia/dry mouth Mucocele Sjögren syndrome Infections Candidiasis HSV Osteonecrosis of the jaw Other mucosal/gingival conditions Atrophic glossitis/papillitis Periodontal disease Amalgam tattoo Traumatic ulcer Othery
284 (27.2) 124 64 58 24 6 4
(11.9) (6.1) (5.6) (2.3) (0.6) (0.4)
4 (0.4) 262 (25.1) 155 (14.9) 47 (4.5) 27 (2.6) 14 11 8 107 47 22 19 17 2
(1.3) (1.1) (0.8) (10.3) (4.5) (2.1) (1.8) (1.6) (0.2)
79 (7.6) 59 (5.7) 13 (1.2) 5 2 76 50 26 49 25 17 7 27 23 4 14 97
(0.5) (0.2) (7.2) (4.8) (2.5) (4.7) (2.4) (1.6) (0.7) (2.6) (2.2) (0.4) (1.3) (9.3)
38 29 18 12 48
(3.6) (2.8) (1.7) (1.2) (4.6)
BARK, benign alveolar ridge keratosis; BMS, burning mouth syndrome; cGVHD, chronic graft-versus-host disease; HSV, herpes simplex virus; TMJ, temporomandibular joint. *Includes oral manifestations of Crohn disease. y Includes conditions that did not otherwise fit into one of the above categories, including dental pathology, anatomic variants of normal, traumatic ulcers, hairy or coated tongue, or no evident mucosal pathology.
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Table IV. Logistic regression analysis of access to care by diagnosis Number of doctors seen before referral 1 Diagnosis Immune-mediated mucosal conditions No Yes Orofacial pain disorders No Yes Benign soft tissue lesions* No Yes Dysplasia and cancerous conditions No Yes Salivary gland disorders No Yes Infections No Yes Osteonecrosis of the jaw No Yes
Distance from patient home to BWH (miles)
>1
0-20
>20
(N ¼ 784) (N ¼ 175) Odds ratio (95% CI) P value (N ¼ 523) (N ¼ 511) Odds ratio (95% CI) P value
429 (60.8) 167 (62.8)
277 (39.2) 99 (37.2)
0.9 (0.7-1.2)
.56
463 (64.0) 133 (53.4)
260 (37.0) 116 (46.6)
1.6 (1.2-2.1)
438 (59.5) 158 (66.9)
298 (40.5) 78 (33.1)
0.7 (0.5-0.9)
549 (61.2) 349 (38.8) 47 (563.5) 27 (36.5)
0.9 (0.6-1.5)
569 (61.5) 27 (57.4)
356 (38.5) 20 (42.6)
1.2 (0.7-2.1)
568 (60.9) 18 (66.7)
364 (39.1) 9 (33.3)
0.8 (0.3-1.8)
580 (61.4) 6 (42.9)
365 (38.6) 8 (57.1)
1.0 2.1 (0.7-6.2)
