Proceedings of the Closed Round Table and Italian Consensus on Clinical Appropriateness in Oral Medicine and Oral Surgery – Part I
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1
University of Palermo, Italy
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2
University of Messina, Italy
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3
Study group for SIPMO (http://www.sipmo.it/) (L. Lo Muzio, G. Campisi, S. Abati, V. Panzarella, M. Pentenero, U. Romeo), Italy
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4
Italian Society of Odontostomatological Surgery (SIdCO), Italy
The aim of the present publication is to briefly present what was discussed and approved in Consensus in Messina (8-9 September 2017) on the subject of clinical appropriateness in dentistry procedures with the aim of drawing up the good practices for the prevention of the diagnosis and treatment of some oral diseases and for the promotion of oral health in Italy. The following indications about good practices derives from the results of a survey conducted among a sample of Italian dental practitioners to verify the degree of appropriateness and awareness on the most frequent procedures of oral surgery and oral medicine. It emerged as the drafting of a coherent list of recommendations regarding prescriptions of drugs/examinations and preventive/diagnostic measures in oral medicine and oral surgery was of absolute importance. Based on the results of the survey, the topics on which to raise awareness were addressed during a closed meeting and evaluated to establish what is the most appropriate behavior for the specific clinical situation.
The panel of experts consists of two groups, with different skills and clinical experience of two Italian scientific societies, the Italian Society of Oral Pathology and Medicine (SIPMO) and the Italian Society of Odontostomatological Surgery (SIdCO). The methodology adopted, for these closed and open round tables, was derived and modified from Choosing Wisely and was inspired by the principles of Slow Medicine. During the closed meeting, the statements that the authors submitted for each issue were evaluated. Opinions were discussed in Consensus and synthesized by the following Italian experts. After reaching a Consensus on the discussed topics an Open Meeting was held in Rome (13 April 2018) with the purpose to promote these clinical good practices and to reduce medical/dental care at high risk of inadequacy. Clinical indications were conceived as a possible and effective contribution to the general care and welfare of the community. Good practices are mainly addressed to dentists, surgeons and oral doctors, general practitioners, but also to the community of patients.
Practices at risk of inappropriateness in Oral Medicine (edited by SIPMO) for the following issues:
1. Ulcerative lesions of the oral mucosa
2. Prevention of oral carcinoma
3. Prescription of antifungal drugs
4. Prescription of corticosteroids
5. Treatment of non-plaque related periodontal diseases)
1. Ulcerative lesions of the oral mucosa
An ulcer is a discontinuity of the oral mucosa, frequently painful, notably with hot, acid, spicy or salty foods. It is mainly caused by trauma against sharp or fractured teeth or by accidental self-biting; but it can also be associated with inflammatory diseases such as recurrent aphthous stomatitis and benign or malignant tumours. If it does not heal within two weeks, it is necessary to investigate the causes carefully.
Practice at risk of inappropriateness
PRESCRIBING rinses or other medical devices that relieve the pain and delay the execution of diagnostic procedures (e.g. biopsy).
Good practice
ELIMINATE any local irritants and RE-EVALUATE the patient within 15 days.
2. Prevention of oral carcinoma
The mouth may be affected by various malignant tumoral diseases that must be correctly recognized. Among these, oral carcinoma is the most frequent and is characterized by poor survival rate, but if diagnosed and treated in the earlier stages, has excellent chances of healing without serious consequences. Anyone can get oral carcinoma, not just people exposed to recognized risk factors, such as tobacco, alcohol and spirits; it is advisable to pay attention also to the poor condition of the oral cavity, to chronic traumas to the oral mucosa and, for the oropharyngeal sites adjacent to the oral cavity (base of tongue, tonsils), to the HPV infection.
Practice at risk of inappropriateness
UNDERVALUING oral signs. In any oral subsite, any alteration of shape or color or consistency of oral tissues may be a premalignant or malignant disease.
Good practice
INFORM all patients, irrespective of gender or age about the main risk factors of oral cancer.
3. Prescription of antifungal drugs
Oral candidiasis is caused by pathogenic microbes, usually microscopic yeasts of the genus Candida. It can manifest in various forms, with removable white-yellowish plaques or membranes (i.e. the so-called “thrush” or pseudomembranous candidosis), more frequently with red areas (erythematous candidosis) of the oral mucosa, sometimes with fissures at the corners of the mouth or persistent white plaques. Oral candidiasis often presents in immunosuppressed patients, or diabetics, or in patients treated for malignant tumors, or affected with dry mouths. It can usually be treated effectively with local antifungal drugs.
Practice at risk of inappropriateness
PRESCRIBING antifungal drugs, WITHOUT a clinical and/or microbiological diagnosis of oral fungal infection.
Good practice
Local or systemic antifungal drugs ARE INDICATED EXCLUSIVELY for the treatment, with appropriate clinical control, of oral fungal infections (e.g. oral candidiasis). PRESCRIBE antifungal drugs, ONLY in presence of a confirmed clinically and/or microbiologically DIAGNOSIS of oral fungal infection.
4. Prescription of steroids for oral mucosal diseases
The oral mucosa can be affected by immune-mediated inflammatory diseases associated to very painful and persistent clinical signs and symptoms; their treatment involves the use of local or systemic cortisone drugs. These drugs should be prescribed only after an accurate and precise diagnosis, usually based on oral biopsy and serological exams. When prescribing these types of drugs, attention must be paid about their efficacy on the specific disease and about the presence of side effects or drug interactions. In these patients, collaboration with the general practitioner or other specialists must be considered.
Practice at risk of inappropriateness
PRESCRIBING steroids for common oral lesions without a certain diagnosis.
Good practice
NOT prescribe steroids for common oral lesions without a certain diagnosis.
5. Management of non-plaque related periodontal diseases
The most common cause of gum inflammation and bleeding is the presence of bacterial dental plaque, responsible for gingivitis and periodontitis. Professional plaque and dental calculus removal provide a clinically clear improvement of this type of pathologies, especially if they are followed by an accurate domiciliary oral hygiene. If widespread redness, bleeding and pain persist despite these measures, it should be considered the possibility that gingival inflammation may be caused by to immune-mediated disease, such as oral lichen planus, pemphigus or pemphigoid.
Practice at risk of inappropriateness
CONSIDERING gingival inflammation, diffuse and persistent, exclusively caused by bacterial plaque or local irritants.
Good practice
CONSIDER non-plaque gingival inflammation as a possible manifestation of immune-mediated diseases (e.g. lichen planus, pemphigoid, pemphigus) requiring specialized procedures and competence for correct diagnosis (e.g. immunofluorescence biopsy) and adequate therapy.
References
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3. Brocklehurst et al. Systemic intervention for recurrent aphthous stomatitis (mouth ulcers). Cochrane Database Syst Rev. 2012:CD005411.
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5. Ministero della Salute Raccomandazioni cliniche in odontostomatologia, 2017 http://www.salute.gov.it/imgs/C_17_pubblicazioni_2637_allegato.pdf
6. Brocklehurst P. et al. Screening programmes for the early detection and prevention of oral cancer. Cochrane Database Syst Rev. 2013:CD004150.
7. Lingen M. Critical Evaluation of Diagnostic Aids for the Detection of Oral Cancer. Oral Oncol. 2008;44:10-22.
8. Pentenero M, et al. Clinical features of microinvasive stage I oral carcinoma. Oral Dis. 2011;17:298-303.
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11. Fariba S. Younai Oral Candidiasis. BMJ Best Practice, 2017.
12. Pankhurst C. Candidiasis (oropharyngeal). BMJ Clin Evid. 2013:1304.
13. Worthington HV et al. Interventions for treating oral candidiasis for patients with cancer receiving treatment. Cochrane Database Syst Rev. 2010:CD001972.
14. Carbone M et al. Topical clobetasol in the treatment of atrophic-erosive oral lichen planus: a randomized controlled trial to compare two preparations with different concentrations. J Oral Pathol Med. 2009;38:227-33.
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18. Campisi G et al. A new delivery system of clobetasol-17-propionate (lipid-loaded microspheres 0.025%) compared with a conventional formulation (lipophilic ointment in a hydrophilic phase 0.025%) in topical treatment of atrophic/erosive oral lichen planus. A Phase IV, randomized, observer-blinded, parallel group clinical trial. Br J Dermatol. 2004;150:984-90.
19. Al-Abeedi F et al. The differential diagnosis of Desquamative Gingivitis review of the literature and Clinical Guide for dental undergraduates. J Int Oral Health. 2015;7:88-92.
20. Arduino PG et al. A practical clinical recording system for cases of desquamative gingivitis. Br J Dermatol. 2017;177:299-301.
21. Lo Russo L et al. Diagnostic pathways and clinical significance of desquamative gingivitis. J Periodontol. 2008;79:4-24.
22. Lo Russo, L et al. Periodontal clinical and microbiological data in desquamative gingivitis patients. Clinical oral investigations. 2014;18:917-25.
23. Stone SJ et al. Cost-effectiveness of personalized plaque control for managing the gingival manifestations of oral lichen planus: a randomized controlled study. J Clin Periodontol. 2013;40:859-67.
Keywords:
Oral Ulcer,
OSCC (oral squamous cell carcinoma),
Antifungal drug,
Corticosteorids,
Periodontal disease,
SIPMO,
SIdCO
Conference:
5th National and 1st International Symposium of Italian Society of Oral Pathology and Medicine., Ancona, Italy, 19 Oct - 20 Oct, 2018.
Presentation Type:
oral presentation
Topic:
Oral Diseases
Citation:
Campisi
G,
Oteri
G,
Study Group
S and
Study Group
S
(2019). Proceedings of the Closed Round Table and Italian Consensus on Clinical Appropriateness in Oral Medicine and Oral Surgery – Part I.
Front. Physiol.
Conference Abstract:
5th National and 1st International Symposium of Italian Society of Oral Pathology and Medicine..
doi: 10.3389/conf.fphys.2019.27.00052
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Received:
12 Dec 2018;
Published Online:
09 Dec 2019.
*
Correspondence:
Prof. Giuseppina Campisi, University of Palermo, Palermo, Sicily, 90127, Italy, campisi@odonto.unipa.it