Who should patients with recurrent oral lesions be referred to?

Referral for Recurrent Oral Lesions

Patients with recurrent oral lesions should be referred to an oral medicine specialist, oral and maxillofacial surgeon, or dentist/periodontist for initial evaluation, with subsequent referral to appropriate specialists based on findings. 1, 2

Primary Referral Pathway

Initial Specialist Consultation

• Refer to an oral medicine specialist or oral and maxillofacial surgeon for any oral ulcer or lesion lasting more than 2 weeks or not responding to 1-2 weeks of initial treatment 2
• Refer to a dentist or periodontist for thorough evaluation of oral mucosal changes, particularly when dental or periodontal causes are suspected 1
• Most US general dental practitioners (87.2%) refer suspicious oral lesions to oral and maxillofacial surgeons for consultation and biopsy 3

Timing of Referral

• Immediate referral is warranted for lesions suspicious for malignancy or premalignancy, including non-healing ulcers, white or red patches, or masses 1
• Urgent referral for signs and symptoms of head and neck cancer recurrence, including: swelling that does not heal, persistent red or white patches, lumps or masses, persistent sore throat, foul oral odor independent of hygiene, loose teeth, or unexplained weight loss 1

Condition-Specific Referral Pathways

For Suspected Malignancy or Premalignancy

• Refer to head and neck cancer specialist if signs of local recurrence are present in cancer survivors 1
• Refer to oral and maxillofacial surgeon for biopsy of lesions suspicious for malignancy/premalignancy (65.4% of practitioners follow this approach) 3
• Biopsy is indicated for ulcers lasting over 2 weeks or not responding to treatment 2

For Orofacial Granulomatosis or Oral Crohn's Disease

• Refer to oral medicine clinic for assessment of orofacial granulomatosis, as gastroenterologists miss approximately 50% of oral lesions compatible with oral Crohn's disease compared to dentist examination 1
• Consider gastroenterology referral for luminal assessment, particularly in younger patients where positive findings are more likely 1

For Complex or Refractory Cases

• Refer to superior pathologists for consultation when initial biopsy results are non-specific (e.g., "inflammatory ulcer, infiltration of lymphocyte") 1
• Multi-disciplinary team consultation may be necessary for diagnostic uncertainty after initial workup 1
• Consider referral to rheumatology or immunology for suspected autoimmune conditions (e.g., Behçet's syndrome, pemphigus) 2

Pre-Referral Actions

Essential Diagnostic Steps Before Referral

• Perform blood tests including full blood count, coagulation studies, fasting blood glucose, HIV antibody, and syphilis serology before biopsy to exclude contraindications and provide diagnostic clues 2
• Document lesion characteristics including location, size, duration, associated symptoms, and photographic documentation when possible 3
• Obtain detailed history including medical conditions, medications, tobacco/alcohol use, and history of similar lesions 1

Information to Include in Referral

• Lesion location, signs/symptoms, and history (reported by 83.9-87.0% of practitioners) 3
• Medical and dental history (48.8-50.6% of practitioners) 3
• Radiographs (59.3%) and photographs (42.4%) when available 3

Common Pitfalls to Avoid

• Do not delay referral for lesions persisting beyond 2 weeks, even if initially appearing benign 2
• Do not assume benign etiology in cancer survivors, as recurrence can mimic benign inflammatory conditions 1
• Do not rely solely on primary care examination for oral cavity assessment in patients with history of head and neck cancer, as specialist nasopharyngolaryngoscopy is essential 1
• Do not overlook systemic disease associations with recurrent oral ulceration, including inflammatory bowel disease, Behçet's syndrome, and immunodeficiency 1