Considerations for the Evaluation of New and Established
Patients
The emerging data on COVID-19 pandemic clearly identifies that the
presence of comorbidities (i.e., diabetes, hypertension, cardiac
disease, and pulmonary disease) are responsible for a significantly
greater risk of mortality.9 Similarly, chronic
diseases have been identified to be more common in patients with OPMDs,
for instance, dyslipidemia and asthma have been identified as being more
prevalent in patients with oral leukoplakia in comparison to
case-controls.10 Furthermore, elderly patients (≥75
years of age) who develop oral leukoplakia have a higher 5-year
cumulative incidence (3.21%) for the development of oral
cancer.5 Tobacco use has also been identified in
increasing the risk for adverse events in patients with
COVID-19.11 Such data is additionally troubling with
regards to patients with OPMDs and oral cancer as tobacco use is the
main risk factor for the development of the majority of cases of OPMDs
and oral squamous cell carcinoma. Similarly, the CDC also considers
immunosuppressed patients at being high risk for serious illness from
COVID-19 including patients with “prolonged use of
corticosteroids and other immune weakening medications ” (Figure
1).2 This is also concerning for patients with severe
cases of oral lichen planus with long-standing systemic corticosteroid
use, or other immunosuppressing agents (e.g., tacrolimus, cyclosporine,
azathioprine, mycophenolate mofetil, cyclophosphamide, or methotrexate).
Therefore, one must consider the patient’s risk in developing severe
illness with COVID-19 in deciding the timing of their in-person
evaluation. Additionally, a major part of mitigation efforts surrounding
the COVID-19 pandemic have been focused on social distancing and
decreased patient visits to healthcare facilities unless medically
necessary. This is for the benefits of patients and health care
professionals, as healthcare workers represent anywhere from 3.8 – 20%
of infected individuals, with approximately 15% developing severe
illness or death.12 The specific impact on oral health
providers has yet to be identified, but based on the aerosolization
involved with assessing the oral cavity and performing invasive
procedures within the oral cavity, one must seriously consider the
higher risk of exposure for oral health providers as well as the
patients. .
In order to reduce density of patients within a healthcare facility we
have incorporated Telehealth into our daily office workflow for the
evaluation of new patients with oral mucosal lesions and re-evaluation
of known patients with OPMDs. While the convenience and social
distancing afforded by Telehealth are well aligned with ongoing
mitigation efforts, the limitations of Telehealth in the evaluation of
oral mucosal lesions become readily apparent, such as, the inability to
address the texture of a lesion, clearly delineate the borders of a
lesion, and evaluate for the presence of an endophytic component to a
lesion. Therefore, the use of Telehealth in the evaluation and
management of oral mucosal lesions is best suited for easily visible
lesions (i.e., lip, tip of tongue, anterior facial gingiva of the
maxilla or mandible) and is significantly limited in other locations of
the oral cavity (i.e., lingual gingiva of mandible, posterior floor of
mouth, maxillary vestibule, mandibular vestibule). From our experience
thus far, Telehealth plays an instrumental role in triaging patients and
minimizing the number of visits to the clinic for both new and
established patients (Figure 3). Below are individual considerations
that we are currently employing in the evaluation of new and established
patients that are summarized in Figure 3: