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Prevalence and Nature of Orofacial and Dental Problems in Family Medicine
Peter B. Lockhart, DDS;
David K. Mason, BDS, MD;
Joseph C. Konen, MD, MSPH;
M. Louise Kent, RN;
John Gibson, PhD, MBChB, BDS
Arch Fam Med. 2000;9:1009-1012.
ABSTRACT
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Objective To determine the prevalence and nature of orofacial and dental problems in 2 family medicine practices.
Design Prospective, cross-sectional analysis of consecutive patient visits.
Setting Urban and rural family medicine practices.
Patients and Participants Four hundred seventy-two patients between age 10 and 86 years.
Interventions None.
Main Outcome Measures Prevalence and nature of patient visits to family medicine practices that were either initiated by problems in the region of the oral cavity or that involved questions raised by the patient concerning oral or perioral sites.
Results Twenty-one patients (4.5%) of 472 met the inclusion criteria, 16 (76%) of whom had an oral problem as the primary or secondary reason for their visit. Perioral pain and mucosal ulcerations were the most common problems, and gingival tissue was the most common location. Almost two thirds of these patients had bacterial, fungal, or viral infections. Regarding treatment, 13 (62%) of these patients received advice, 10 (48%) received prescriptions, and 3 (15%) were referred to a dentist or another medical specialist.
Conclusions Oral and perioral problems are common in the practice of family medicine, which suggests the desirability for specific oral medicine topics in the training and continuing education of primary care physicians.
INTRODUCTION
DENTISTRY EVOLVED as a distinct profession in the United States in the mid 19th century with a major focus on problems of the teeth and their supporting structures. Since that time, clinical problems with the mouth and perioral region have been treated by an increasing array of specialists in both professions.
In recent decades dentists have received broader didactic and clinical training concerning the wide spectrum of problems that occur in the maxillofacial region,1 and recognized subspecialties have evolved within dentistry (eg, oral surgery and endodontics) that deal with essentially surgical problems. The medical profession also has several specialties (eg, otolaryngology and dermatology) with an interest in this complex anatomical region. Therefore, patients and primary care practitioners in both professions may be unsure as to whom should care for a given problem. Other forces determine who sees these patients, such as referral patterns, a variety of access to care issues, and a changing healthcare system that encourages or requires patients to be seen first by their primary care physician. Of great concern is the number of people without dental insurance who cannot afford dental care,2 but the extent to which these patients seek care from their primary care physician for an oral problem is unknown. Although we could find no articles concerning this issue in the North American literature, there have been several reports from the United Kingdom that suggest a prevalence of 0.3% to 6.5%.3-4
The primary goal of this prospective, cross-sectional study was to determine the prevalence and nature of patient visits to 2 different family medicine practice locations that were initiated by problems in the region of the oral cavity or that involved questions raised by the patient about oral or perioral sites. Secondary goals included an analysis of demographic data, clinical management, and payment methods, as well as the identification of topics for continuing education courses for medical personnel (eg, physicians and nurses) that focus on common oral and perioral problems in family medicine.
METHODS
Two family practice sites were selected for a prospective, on-site analysis of consecutive patients. The first site, to be referred to as rural, is a 6-practitioner group practice with 4 full-time equivalent family practice residents located in a semirural area of North Carolina. The second site, referred to as urban, serves as the principal training site for the Department of Family Medicine at Carolinas Medical Center, Charlotte, NC, residency training program, which includes 10 full-time faculty and 24 residents.
The rationale and methods for the study were explained during a group meeting to the clinicians and nursing staff at each site. They were instructed not to alter their usual routine for seeing patients and, in particular, not to address the issue of dental problems or care unless first raised by the patient. Data were collected on practice site, patient age, sex, payment source, patient's dentist, nature of the primary and secondary oral complaint or inquiry, anatomical region involved, provisional diagnosis, questions asked by the patient concerning existing dental disease or oral disease prevention, treatment of the problem, and any referrals made to other practitioners for these problems. The anatomical areas of interest were defined as (1) extraoral, the area between the temporomandibular joints anteriorly to the upper lip and inferiorly to include the chin, and (2) intraoral, the oral mucosa and adjacent structures (eg, teeth and salivary glands) anterior to the tonsils to include the soft palate. To be considered as having orofacial or dental problems for this study, patients must have given 1 or more dental problem as their chief or secondary complaint or spontaneously raised a question or a problem involving the anatomical areas described above. Patients seen for routine follow-up appointments or school physical examinations were excluded from the study. Our institutional review board determined that signed informed consent was unnecessary since the data forms would make no reference to patient identities.
Given the reports in the world literature on this issue and our estimate of the prevalence of such patient visits, we determined the need to review more than 200 eligible patient records at each site to provide reliable data. At least 1 oral medicine research nurse was at the practice site throughout the data-gathering phase of the study to explain and reinforce the study protocol to office personnel and to ensure that the study methods were maintained throughout. A colored tag with "Yes" and "No" printed on it was attached to the front of all medical charts to remind clinicians of the study protocol as they prepared to see each patient. If a patient spontaneously raised an issue concerning the anatomical region of interest, the clinician was to circle "Yes" on the colored tag and, at the end of the visit, to answer specific questions on the data form relating to such things as chief complaint, anatomical region involved, and diagnosis. Patient medical records were then returned to the reception desk. The research nurse (M.L.K.) gathered the remaining data (eg, demographics) for tagged charts indicating "Yes," and she also performed an audit of all charts to confirm inclusion or exclusion compliance. Incomplete or unclear data forms were returned to the appropriate clinician for completion.
RESULTS
Three hundred thirty-nine consecutive patients were screened at the rural site over a 3-day period. Of these visits, 103 were for routine follow-up and school physical examinations, leaving 236 subjects (70%) eligible for entry into the study. Approximately 1 month later, consecutive patients were seen at the urban site until 236 eligible patients were entered into the study, thereby ensuring the same number of patients for analysis at each site. Of these 472 study subjects, 11 (4.7%) at the rural and 10 (4.2%) at the urban site raised issues concerning the oral and perioral regions, for an overall prevalence of 4.5%. A maxillofacial problem was the primary reason for the visit for 8 patients (38%) and the secondary reason for 8 others (38%). The remaining 5 patients (24%) inquired about a dental issue (3 concerning existing dental disease and 2 concerning oral disease prevention). Thirteen (62%) of 21 were women and 8 (38%) were men, with a median age of 40 years (age range, 10-86 years). Perioral pain was the most common complaint (7 [33%]), followed by mucosal ulceration (4 [19%]) (Table 1). Although the gingiva was the most common anatomical region of complaint (5 [24%]), the hard and soft palate, lips, teeth, and tongue were also areas of involvement (Table 2). The provisional diagnoses on the part of the family physicians included bacterial, viral, and fungal infections (13 [62%]) and a variety of other problems (Table 3). Regarding clinical treatment, 13 patients (62%) were given advice, 10 (48%) were prescribed a medication, 4 (20%) had treatment administered in the office, 2 (10%) were referred to a dentist, and 1 was referred to a medical specialist. Ten patients (48%) had a family dentist, 10 (48%) had no dentist of record, and 1 (5%) went to the Union County Public Health Department for dental care. A managed-care organization provided medical coverage for 12 subjects (57%). Other subjects had either Medicare (6 [33%]) or other insurance coverage (3 [10%]). None of these individuals had dental insurance.
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Table 1. Oral Complaint or Inquiry Raised During the Office Visit
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Table 2. Oral and Perioral Regions Involved
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Table 3. Provisional Diagnoses
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COMMENT
A reasonable number of potential subjects were screened for this study, and 4.5% may be a good estimate of the prevalence of oral and perioral problems in a family medicine practice. Given that these are the only data on this issue in the North American literature, a larger, multicenter study is desirable. We attempted to eliminate differences that might exist between practice settings by conducting this survey in both an urban and rural practice. Nevertheless, these data were collected during several days at a specific time of year (autumn), and the results cannot necessarily be extrapolated to family medicine practices in general. Our study population is skewed by our exclusion of patients from the study who were having school physical examinations, as this is a seasonal influx of essentially healthy patients into the practice, and by our exclusion of patients having follow-up visits, as they were more likely to represent brief, focused visits for already existing problems that were unlikely to include orofacial and dental problems. As much as possible, we attempted to control the bias of physician solicitation of oral problems, and we only included patients who spontaneously raised this issue. Nevertheless, given the potential for bias with the use of flagged charts and the presence of study personnel in the office, our results should be confirmed by additional work in this area.
A comparison of the results of this study with data from the United Kingdom may provide insight on the impact of different health care systems, payment mechanisms, referral patterns, and practice standards, as well as access to care issues. For example, lack of access to dental care may be due to financial, medical, or physical limitations. Regarding payment mechanisms in the United States, Medicare and managed care companies generally do not cover any outpatient dental services. Medicaid provides limited coverage for certain populations (eg, children) and certain dental procedures in some states, but usually at a rate far below usual and customary fee schedules.
Regarding clinical problems, Robertson5 found a similar prevalence (6.5% of 527 patients) in a practice of 10 general medical practitioners in Glasgow and Edinburgh, Scotland. Their list of oral and perioral problems and anatomic sites of involvement was similar to ours as well, with a virtually identical female/male distribution (65/35). However, a retrospective study by Anderson et al3 found that 0.30% (range 0.02%-0.67%) of more than 1.5 million patient visits to 30 family practices in Wales were for oral or dental problems. Forty-four percent of these were problems with teeth, and 42% were for diseases of the soft tissues, salivary glands, or the tongue. Of interest was their finding that patients with dental problems had twice the number of medical office visits as other patients, and they were 3 times as likely to seek treatment on weekends. The extent of this perceived problem in the United Kingdom is such that the British Medical Association has published guidelines on the treatment of patients presenting with dental problems.6
Maxillofacial and perioral problems seen by family physicians are varied. Our finding of tooth-related problems occurring in 38% of patients (Table 2) is identical to that of the Wales study (44%) if we correct for their larger pediatric population with its 6% prevalence of tooth development and/or eruption disorders (eg, teething pain).3 However, they found a much lower overall prevalence (0.3%) of such visits (except on weekends), 74% of which were for dental problems alone, as opposed to our finding of 38%. There is a problem with a comparison of our data with that of the Wales study in that theirs was a retrospective analysis of a large database with all the inherent problems of coding accuracy vs our approach of an on-site, prospective data gathering with a medical chart review to ensure accuracy.
An overriding difficulty with the coordination and delivery of care for nondental problems of the oral and perioral region in both the United States and United Kingdom is that physicians and dentists are generally trained in different locations, and this separation continues into the clinical practice arena as well.7 In addition, dentistry is practiced in relative isolation from the rest of the healthcare system, and communication between dental and medical practitioners is therefore limited, which can affect the quality of patient care. For example, Haughney et al,4 in a comparison of a medical and a dental practice caring for the same patients, found that 40% of the medical and dental records had discrepancies (ie, medical history, disease, medications, allergies), and some of those discrepancies were potentially life-threatening. After creating a combined medical/dental practice with an integrated record system, the discrepancies largely disappeared. They noted additional benefits as well, such as the initiation of screening programs (eg, oral cancer), an increase in joint consultations, and a reduction of unnecessary specialty consultations. They also noted improved work practices, staff communication, education, and morale.8
There is an overlap with regard to clinicians in medicine and dentistry who are called on to treat patients seeking care for nondental problems of the oral soft tissues and maxillofacial region, which may represent the lack of a well-defined specialist. The United States is unusual in that oral medicine is not a recognized specialty within the dental profession, and therefore problems of the lower face and oral cavity are seen and cared for by a wide variety of clinicians in both professions. In the United Kingdom, where this issue has been examined, a survey of physicians and dentists revealed that 50% of medical trainees and 31% of practicing physicians did not feel competent to carry out an adequate examination of the oral cavity.9 Such data does not exist in the US literature, but oral medicine is a long-standing, recognized specialty in the United Kingdom, which requires lengthy residency training beyond full qualifications in both dentistry and medicine. Therefore, a well-established referral system exists in the United Kingdom for patients with oral and perioral problems that often fall between the mainstream practices of physicians and dentists in the United States. Nevertheless, Robertson5 found that such patients often seek care from their physicians in spite of oral medicine clinics that are in close geographic proximity, which likely reflects long waiting lists for such specialist visits. Lack of access to dental care in the United States likely leads to patients seeking care from their physicians. Therefore, the frequency of such visits and the similarities in reported problems in both the United Kingdom and United States suggests topics for both didactic and clinical training for primary care physicians.
AUTHOR INFORMATION
Accepted for publication September 14, 2000.
This work was initiated during Dr Lockhart's T.C. White Visiting Professorship at the Royal College of Physicians and Surgeons in Glasgow.
The authors wish to recognize the following individuals for their help in this study: John Trotter, MD, John Moore, DO, John Vick, MD, Eugene Cook, MD, Dianne Moser, LPN, and other practitioners at Union Family Practice in Monroe, NC; Mary Hall, MD, Tom Barringer, MD, Joan Schwanz, MD, and J. Lewis Sigmon, MD, at Carolinas Medical Center, Charlotte, NC; and Michelle Bruchon, RN, for her help with data collection and word processing.
Corresponding author and reprints: Peter B. Lockhart, DDS, Department of Oral Medicine, Carolinas Medical Center, PO Box 32861, Charlotte, NC 28232-2861.
From the Departments of Oral Medicine (Dr Lockhart and Ms Kent) and Family Medicine (Dr Konen), Carolinas Medical Center, Charlotte, NC; and the Department of Oral Medicine and Oral Surgery (Drs Mason and Gibson), Glasgow Dental Hospital and School, Glasgow, Scotland.
REFERENCES
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1. McCallum CA. Encourage an environment of interaction between medicine and dentistry: the interrelation of medicine and dentistry in total health care. J Am Coll Dent. 1986;53:15-19.
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2. US Dept of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. NIH publication 00-4713.
3. Anderson R, Richmond S, Thomas DW. Patient presentation at medical practices with dental problems: an analysis of the 1996 General Practice Morbidity Database for Wales. Br Dent J. 1999;186:297-300.
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4. Haughney MGJ, Devennie JC, Macpherson LMD, Mason DK. Integration of primary care dental and medical services: a three-year study. Br Dent J. 1998;184:343-347.
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5. Robertson J. Oral Problems in Medical Practice [dissertation]. Glasgow, Scotland: Glasgow Dental Hospital; 1989.
6. General Medical Services Committee, British Medical Association. Patients Presenting With Dental Problems. London, England: British Medical Association; 1994.
7. Nash DA. And the band played on .... J Dent Educ. 1998;62:964-974.
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8. Mason DK, Gibson J, Devennie JC, Haughney MGJ, Macpherson LMD. Integration of primary care dental and medical services: a pilot investigation. Br Dent J. 1994;177:283-286.
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9. Tapper-Jones L. A comparison of general medical and dental practitioners' attitudes to diagnosis and management of common oral and medical problems. Postgrad Educ Gen Pract. 1993;4:192-197.
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