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: