Both custom and health insurance reimbursement systems recognize the need of individual practitioners to request the assistance of a colleague who may have more experience with the treatment of a particular clinical problem or who has received advanced training in a medical or dental specialty pertinent to the patient’s problem. However, this practice of specialist consultation is usually limited to defined problems, with the expectation that the patient will return to the referring primary care clinician once the nature of the problem has been identified (diagnostic consultation) and appropriate treatment has been prescribed or performed (consultation for diagnosis and treatment). In general, referrals for oral medicine consultation cover the following:
1. Diagnosis and nonsurgical treatment of a variety of orofacial problems, including oral mucosal disease, temporomandibular and myofascial dysfunction, chronic jaw and facial pain, dental anomalies and jaw bone lesions, salivary hypofunction and other salivary gland disorders, and disorders of oral sensation, such as dysgeusia, dysesthesia, and glossodynia
2. Dental treatment of patients with medical problems that affect the oral cavity or for whom modification of standard dental treatment is required, to avoid adverse effects
3. Opinion on the management of dental disease that does not respond to standard treatment, such as rampant dental caries and such as periodontal disease in which there is a likelihood that systemic disease is an etiologic cofactor
In response to a consultation request, the diagnostic procedures outlined in this chapter are followed, with the referral problem listed as the chief complaint and with supplementary questioning (ie, HPI) directed to the exact nature, mode of development, prior diagnostic evaluation/treatment, and associated symptomatology of the primary complaint. A thorough examination of the head, neck, and oral cavity is essential and should be fully documented, and the systems review should include a thorough exploration of any associated symptoms. When pertinent, existing laboratory, radiographic, and medical records should be reviewed and documented in the consultation record, and any additional testing or specialized examinations should be ordered.
A comprehensive consultation always includes a written report of the consultant’s examination, usually preceded by a history of the problem under investigation and any items from the medical or dental history that may be pertinent to the problem. A formal diagnostic summary follows, together with the consultant’s opinion on appropriate treatment and management of the problem. Any other previously unrecognized abnormalities or significant health problem should also be drawn to the attention of the referring clinician. When a biopsy or some initial treatment is required before a definitive diagnosis is possible and when the terms of the consultation request are not clear, a discussion of the initial findings with the referring clinician is often appropriate before proceeding. Likewise, the consultant usually discusses the details of his report with the patient unless the referring dentist specifies otherwise. In community practice, patients are sometimes referred for consultation by telephone or are simply directed to arrange an appointment with a consultant and acquaint him or her with the details of the problem at that time; a written report is still necessary to clearly identify the consultant’s recommendations, which otherwise may not be transmitted accurately by the patient.
In hospital practice, the consultant is always advisory to the patient’s attending dentist or physician, and the recommendations listed at the end of the consultation report are not implemented unless specifically authorized by the attending physician, even though the consultation report becomes a part of the patient’s official hospital record. For some oral lesions and mucosal abnormalities, a brief history and examination of the lesion will readily identify the problem, and only a short written report is required; this accelerated procedure is referred to as a limited consultation.