British Journal of Oral and Maxillofacial Surgery (2005) 43, 61—64
Training in oral disease, diagnosis and treatment for medical students and doctors in the United Kingdom Patrick J. McCanna,∗, M. Petrina Sweeneyb, John Gibsonb, Jeremy Baggb a
Department of Oral and Maxillofacial Surgery, York District Hospital, Wigginton Road, York YO31 8HE, UK b University of Glasgow Dental School, 378 Sauchiehall Street, Glasgow G2 3JZ, UK Accepted 26 August 2004 Available online 11 November 2004 KEYWORDS Common oral disorders; Diagnostic awareness; Pathology
Summary To find out if the training of medical undergraduates and qualified doctors was adequate to diagnose, investigate, manage, and refer common oral disorders appropriately, we sent anonymous questionnaires to undergraduate and postgraduate medical and dental deans, accident and emergency (A&E) doctors, and dentists. We wanted to know if they were capable of diagnosing and treating 10 common oral disorders, and if their training was adequate to enable them to do so. Ten clinical photographs with short clinical histories were sent to 48 A&E physicians together with a structured questionnaire. Twenty-one of the 29 medical schools in the UK responded to a questionnaire about the teaching given in the current curriculum about oral anatomy and pathology, and the prevention of oral disease. A questionnaire sent to the deans of the 16 British dental schools asked how many academic staff were involved in undergraduate teaching, and how many in postgraduate courses. A third questionnaire was sent to the 24 postgraduate medical deans to find out how many postgraduate courses there were for qualified medical staff. Of the 48 medical staff, 134 (28%) diagnosed cases correctly, compared with 194 (88.7%) of the 22 dentists, indicating serious deficiencies in diagnostic awareness. Only 11 of the 21 medical schools who responded currently incorporate teaching of oral pathology in their curricula. We conclude that doctors and medical students are inadequately educated about oral diseases with obvious consequences. © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Present address: Pinderfields General Hospital, Aberford Road, Wakefield, WF1 4DG, England. Tel.: +44 1924 212612; fax: +44 1924 212904. E-mail address:
[email protected] (P.J. McCann).
0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjoms.2004.08.023
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Introduction Much has been written recently about the holistic approach to patient care but awareness of oral disease and the need for routine mouth care have both been largely neglected by many doctors. This can lead to unnecessary discomfort and functional problems for patients, but also means that oral complications of medical interventions (such as mucositis induced by chemotherapy1 ), and oral signs of systemic disease (for example HIV infection2 ) may be missed. Elderly people often have oral problems,3 and also have an increased chance of developing oral cancer. The general public holds the view that dentists fill cavities and provide dentures, but any other oral problems are the province of the doctor. It is therefore clearly important that medical personnel have a reasonable clinical knowledge about oral disease, including its prevention, and are aware of which cases should be referred for a further opinion. Two of the authors, who are both medically and dentally qualified, think that this is not the case. Our aim was to assess the ability of physicians in accident and emergency departments (A&E) to diagnose oral diseases from a photograph and short history. We gave the same exercise to a control group of hospital dentists. We also surveyed the amount of teaching about oral disease that is currently part of the undergraduate medical curriculum, and how many postgraduate opportunities are available to qualified doctors to increase their knowledge.
Methods Knowledge about oral disease Ten clinical photographs of oral conditions with short clinical histories were given to 48 A&E physicians working in Glasgow hospitals. Twenty-one were senior house officers (SHO) (grades 1 and 2); 12 were SHO grade 3, registrars, or specialist registrars; and 15 were not in training grades. They were chosen because they provide a good cross-section of specialties, grades, and training. A questionnaire was given with clinical photographs that sought the diagnosis, investigations required, details of management, whether a referral was necessary, and to whom. The control group comprised 22 hospital dental staff, 3 of whom were junior house officers, 9 SHO, 3 specialist or senior registrar, and 7 non-training grades, who were sent the same photographs, his-
P.J. McCann et al. tories and questionnaires. All completed questionnaires were marked and analysed by the same author (J.G.).
Provision of training An anonymous questionnaire was sent to the deans of all 29 British medical schools asking about the teaching currently provided about oral anatomy and pathology, and the prevention of oral disease; the stage at which this training was provided; and the professional background of the teachers. There was a specific question that sought any formal interactions with a dental school or other dental personnel. Finally there was a space for general comments. Another questionnaire was sent to the deans of the 16 British university dental schools to find out how many academic dental staff were involved in undergraduate medical education, and how many dental staff were involved in postgraduate courses for medical staff. We also sent a questionnaire to the 24 postgraduate medical deans to find out if there were any postgraduate courses in oral diseases for qualified staff. These were all sent with stamped addressed envelopes for replies, and reminders were sent four weeks later.
Results The responses are summarised in Table 1. Dentally qualified staff scored well on diagnosing both common and rarer conditions, though they were reluctant to make a clinical diagnosis of squamous cell carcinoma (SCC) without histological evidence. Nevertheless, the investigation, management, and referral patterns for the patient with carcinoma were appropriate. Correct diagnoses by medical staff ranged from 3 (6%) for primary herpetic gingivostomatitis to 34 (71%) for SCC, which were surprisingly low. The response rates to the questionnaires mailed to the medical, dental and postgraduate deans were 21/29 (72%), 16/16 (100%), and 20/24 (83%), respectively. The amount of training given by the medical schools is summarised in Table 2. Six of the 21 (29%) had some kind of formal interaction with a university dental school or involved dental personnel in teaching about oral disease. General comments were given by 12 schools, 3 of which said that the questionnaire had stimulated them to review their teaching practice. The responses from the deans of dental schools were similar to those from the medical deans. Den-
Training in oral disease, diagnosis and treatment
Table 1
Number (%) of responses of 48 medical staff and 22 dental staff to the clinical pictures.
Clinical condition Geographic tongue Primary herpetic gingivostomatitis Acute leukaemia Reaction to atenolol Angina bullosa haemorrhagica Squamous cell carcinoma Crohn’s disease Kaposi’s sarcoma in HIV Stevens—Johnson syndrome Oral hairy leukoplakia in HIV
Table 2 schools.
63
Correct diagnosis
Correct investigation
Correct management
Correct referral
Medical
Medical
Dental
Medical
Dental
Medical
Dental
4 (8) 3 (6)
22 (100) 21 (96)
Dental
4 (8) 0 (0)
21 (96) 20 (91)
3 (6) 1 (2)
21 (96) 20 (91)
15 (31) 14 (30)
21 (96) 20 (91)
13 (27) 17 (35) 4 (8)
17 (77) 21 (95) 20 (91)
17 (35) 11 (23) 4 (8)
19 (86) 19 (86) 20 (92)
16 (34) 14 (29) 6 (11)
16 (73) 17 (77) 19 (86)
27 (56) 17 (36) 13 (27)
18 (82) 21 (96) 19 (86)
34 (71)
15 (68)
28 (58)
20 (91)
32 (67)
20 (90)
42 (88)
21 (95)
10 (21) 18 (38)
22 (100) 15 (68)
8 (17) 16 (33)
22 (100) 18 (82)
10 (21) 19 (40)
22 (100) 14 (64)
27 (56) 31 (65)
22 (100) 22 (100)
18 (38)
21 (95)
15 (31)
21 (95)
15 (31)
17 (77)
26 (54)
19 (86)
13 (27)
20 (92)
13 (27)
19 (86)
16 (34)
17 (77)
22 (46)
21 (95)
Summary of training on the mouth for undergraduate medical students in the 21 responding medical
Subject
Provide instruction
Stage of course
Having input from dental staff
Normal oral anatomy Oral pathology Prevention of oral disease
15 (71) 11 (52) 6 (29)
Preclinical (1st and 2nd year) Clinical (3rd and 4th year) Preclinical (two schools) and clinical (four schools)
5 (24) 4 (19) 6 (29)
Data are number (%).
tal staff from 9 (56%) of the UK dental schools were involved in teaching medical undergraduates and 6 (38%) dental schools were consulted on the content of the local medical course. Dental staff from 12/16 (75%) of the dental schools were said to be involved in postgraduate education for qualified medical staff, which conflicts with the replies from the medical deans, only 3 (15%) of whom claimed to organise postgraduate medical courses on oral disease for doctors in their areas.
Discussion In a review4 of a textbook: The Mouth,5 Frankel (a dermatologist) wrote: ‘. . .I suspect readers from other specialties will agree that they too are only slightly less relieved than their patients when the perfunctory ‘‘stick out your tongue’’ part of the exam is over, as they move
to more familiar territories like the chest. . .’. He went on to describe the book as ‘. . . a godsend for other practitioners for whom the mouth is also a diagnostic wilderness’. The truth of these comments is reflected in the poor performance of the hospital doctors in this survey. The most likely reason for the poor performance is lack of training. Though three-quarters of medical curricula include oral anatomy, this is taught at an early stage in the course and will not impart a useful working knowledge of the topographic anatomy of the mouth in a living person. Patients are often referred to specialist oral and maxillofacial and oral medicine departments for opinions on normal anatomical features such as lingual tonsil and circumvallate papillae, together with other common and completely harmless variants of normal; only 4 (8%) of the medical staff in our survey correctly identified geographic tongue. A small amount of training to familiarise them with the clinical features of a healthy mouth and the more com-
64 mon and important oral diseases could transform their diagnostic abilities. Many studies have documented the benefit of physicians being able to recognising oral diseases in all sections of the population: children,6 elderly,7 and the general adult population.8 In particular, it is important that a physician should be able to recognise oral malignancy at an early (and therefore treatable) stage.9 This is particularly relevant because of patients’ selective attendance for dental care, particularly primary care.10 We noted that physicians were more skilled at recognising cancer than other conditions, but both doctors and dentists should be more vigilant. Mouth care for patients in hospital or being given care in the community is the responsibility of medical and nursing staff, but many studies have reported deficiencies in mouth care for the systemically ill.3,11,12 If awareness of this problem is to increase and practice improve, then doctors have got to promote and support changes. Medical staff working in palliative care have been particularly active in raising the profile of oral care13 but this will spread to other areas of medicine only if training opportunities for both undergraduates and postgraduates are improved substantially. With the current changes in many medical curricula (including the shift towards problem-based learning) the inclusion of elements relating to the mouth would be timely. A resource pack which includes a CD-ROM for training medical and nursing staff has recently been produced by two of the authors,14 and could find a useful place in undergraduate training. Interdisciplinary postgraduate seminars funded by industry and organised by the authors have already been extremely successful, and the same could be used locally by postgraduate deans. With such training initiatives oral care can be improved and so influence the overall quality of life of many patients. Meanwhile oral and maxillofacial surgeons can look forward to many perhaps inappropriate referrals.
P.J. McCann et al.
Acknowledgements We thank the medical and dental staff who agreed to take part in the clinical study, and the medical and dental deans who completed the postal questionnaire.
References 1. Symonds RP. Treatment-induced mucositis: an old problem with new remedies. Br J Cancer 1998;77:1689—95. 2. Classification and diagnostic criteria for oral lesions in HIV infection. EC-clearing house on oral problems related to HIV infection and WHO collaborating centre on oral manifestations of the immunodeficiency virus. J Oral Pathol Med 1993;22:289—91. 3. Sweeney MP, Shaw A, Yip B, Bagg J. Oral health of elderly institutionalised patients. Br J Nurs 1995;4:1204—8. 4. Frankel DH. Mouth matters. Lancet 1997;350:1333. 5. Eisen D, Lynth DP. The mouth. Diagnosis and treatment. St. Louis: Mosby; 1997. 6. Cooley RO, Sanders BJ. The pediatrician’s involvement in prevention and treatment of oral disease in medically compromised children. Pediatr Clin North Am 1991;38:1265—88. 7. Pyle MA, Terezhalmy GT. Oral disease in the geriatric patient: the physician’s role. Cleve Clin J Med 1995;62:218—26. 8. Westman EC, Duffy MB, Simel DL. Should physicians screen for oral disease? A physical examination study of the oral cavity. J Gen Intern Med 1994;9:558—62. 9. Alvi A. Oral cancer: how to recognise the danger signs. Postgrad Med 1996;99:149—52. 10. Yellowitz JA, Goodman HS. Assessing physicians’ and dentists’ oral cancer knowledge, opinions and practises. J Am Dent Assoc 1995;126:53—60. 11. Eadie DR, Schou L. An exploratory study of barriers to promoting oral hygiene through carers of elderly people. Community Dent Health 1992;9:343—8. 12. Sweeney MP, Bagg J, Doig P, McGill M, Milligan S, Malarkey C. Provision of mouth care by nursing staff for cancer patients in Scotland: current status and the role of training. Nurs Times Res 1996;1:389—95. 13. Kirkham S, editor. Management of sore mouth. Eur J Palliative Care 1995;2(Suppl 1):1—15. 14. Sweeney MP, Bagg J. Evaluation of a mouth care resource pack for medical and nursing staff. J Dent Res 1999;78(special issue):406.
