British Journal of Oral and Maxillofacial Surgery (2005) 43, 61—64

Training in oral disease, diagnosis and

treatment for medical students and
doctors in the United Kingdom
Patrick J. McCanna,∗, M. Petrina Sweeneyb, John Gibsonb, Jeremy Baggb

a Department of Oral and Maxillofacial Surgery, York District Hospital, Wigginton Road,
York YO31 8HE, UK
b University of Glasgow Dental School, 378 Sauchiehall Street, Glasgow G2 3JZ, UK

Accepted 26 August 2004

Available online 11 November 2004

KEYWORDS Summary To find out if the training of medical undergraduates and qualified doc-
Common oral disorders; tors was adequate to diagnose, investigate, manage, and refer common oral disor-
Diagnostic awareness; ders appropriately, we sent anonymous questionnaires to undergraduate and post-
Pathology graduate medical and dental deans, accident and emergency (A&E) doctors, and
dentists. We wanted to know if they were capable of diagnosing and treating 10
common oral disorders, and if their training was adequate to enable them to do so.
Ten clinical photographs with short clinical histories were sent to 48 A&E physicians
together with a structured questionnaire.
Twenty-one of the 29 medical schools in the UK responded to a questionnaire
about the teaching given in the current curriculum about oral anatomy and pathol-
ogy, and the prevention of oral disease. A questionnaire sent to the deans of the 16
British dental schools asked how many academic staff were involved in undergradu-
ate teaching, and how many in postgraduate courses. A third questionnaire was sent
to the 24 postgraduate medical deans to find out how many postgraduate courses
there were for qualified medical staff.
Of the 48 medical staff, 134 (28%) diagnosed cases correctly, compared with 194
(88.7%) of the 22 dentists, indicating serious deficiencies in diagnostic awareness.
Only 11 of the 21 medical schools who responded currently incorporate teaching of
oral pathology in their curricula. We conclude that doctors and medical students are
inadequately educated about oral diseases with obvious consequences.
© 2004 The British Association of Oral and Maxillofacial Surgeons. Published by
Elsevier Ltd. All rights reserved.

* Corresponding author. Present address: Pinderfields General Hospital, Aberford Road, Wakefield, WF1 4DG, England.
Tel.: +44 1924 212612; fax: +44 1924 212904.
E-mail address: PJMCCANN@doctors.org.uk (P.J. McCann).

0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2004.08.023
62
Introduction
Much has been written recently about the holis-
tic approach to patient care but awareness of oral
disease and the need for routine mouth care have
both been largely neglected by many doctors. This
can lead to unnecessary discomfort and functional
problems for patients, but also means that oral
complications of medical interventions (such as mu-
cositis induced by chemotherapy1 ), and oral signs
of systemic disease (for example HIV infection2 )
may be missed. Elderly people often have oral
problems,3 and also have an increased chance of
developing oral cancer.
The general public holds the view that dentists
fill cavities and provide dentures, but any other oral
problems are the province of the doctor. It is there-
fore clearly important that medical personnel have
a reasonable clinical knowledge about oral disease,
including its prevention, and are aware of which
cases should be referred for a further opinion. Two
of the authors, who are both medically and dentally
qualified, think that this is not the case.
Our aim was to assess the ability of physicians in
accident and emergency departments (A&E) to di-
agnose oral diseases from a photograph and short
history. We gave the same exercise to a control
group of hospital dentists. We also surveyed the
amount of teaching about oral disease that is cur-
rently part of the undergraduate medical curricu-
lum, and how many postgraduate opportunities
are available to qualified doctors to increase their
knowledge.
Methods
Knowledge about oral disease
Ten clinical photographs of oral conditions with
short clinical histories were given to 48 A&E physi-
cians working in Glasgow hospitals. Twenty-one
were senior house officers (SHO) (grades 1 and 2);
12 were SHO grade 3, registrars, or specialist regis-
trars; and 15 were not in training grades. They were
chosen because they provide a good cross-section
of specialties, grades, and training. A questionnaire
was given with clinical photographs that sought the
diagnosis, investigations required, details of man-
agement, whether a referral was necessary, and to
whom.
The control group comprised 22 hospital dental
staff, 3 of whom were junior house officers, 9 SHO,
3 specialist or senior registrar, and 7 non-training
grades, who were sent the same photographs, his-
P.J. McCann et al.
tories and questionnaires. All completed question-
naires were marked and analysed by the same au-
thor (J.G.).
Provision of training
An anonymous questionnaire was sent to the deans
of all 29 British medical schools asking about the
teaching currently provided about oral anatomy and
pathology, and the prevention of oral disease; the
stage at which this training was provided; and the
professional background of the teachers. There was
a specific question that sought any formal inter-
actions with a dental school or other dental per-
sonnel. Finally there was a space for general com-
ments.
Another questionnaire was sent to the deans of
the 16 British university dental schools to find out
how many academic dental staff were involved in
undergraduate medical education, and how many
dental staff were involved in postgraduate courses
for medical staff. We also sent a questionnaire to
the 24 postgraduate medical deans to find out if
there were any postgraduate courses in oral dis-
eases for qualified staff. These were all sent with
stamped addressed envelopes for replies, and re-
minders were sent four weeks later.
Results
The responses are summarised in Table 1. Dentally
qualified staff scored well on diagnosing both com-
mon and rarer conditions, though they were re-
luctant to make a clinical diagnosis of squamous
cell carcinoma (SCC) without histological evidence.
Nevertheless, the investigation, management, and
referral patterns for the patient with carcinoma
were appropriate.
Correct diagnoses by medical staff ranged from
3 (6%) for primary herpetic gingivostomatitis to 34
(71%) for SCC, which were surprisingly low.
The response rates to the questionnaires mailed
to the medical, dental and postgraduate deans
were 21/29 (72%), 16/16 (100%), and 20/24 (83%),
respectively. The amount of training given by the
medical schools is summarised in Table 2. Six of the
21 (29%) had some kind of formal interaction with a
university dental school or involved dental person-
nel in teaching about oral disease. General com-
ments were given by 12 schools, 3 of which said
that the questionnaire had stimulated them to re-
view their teaching practice.
The responses from the deans of dental schools
were similar to those from the medical deans. Den-
Training in oral disease, diagnosis and treatment 63

Table 1 Number (%) of responses of 48 medical staff and 22 dental staff to the clinical pictures.
Clinical condition Correct diagnosis Correct investigation Correct management Correct referral

Medical Dental Medical Dental Medical Dental Medical Dental

Geographic tongue 4 (8) 22 (100) 4 (8) 21 (96) 3 (6) 21 (96) 15 (31) 21 (96)
Primary herpetic 3 (6) 21 (96) 0 (0) 20 (91) 1 (2) 20 (91) 14 (30) 20 (91)
gingivostomatitis
Acute leukaemia 13 (27) 17 (77) 17 (35) 19 (86) 16 (34) 16 (73) 27 (56) 18 (82)
Reaction to atenolol 17 (35) 21 (95) 11 (23) 19 (86) 14 (29) 17 (77) 17 (36) 21 (96)
Angina bullosa 4 (8) 20 (91) 4 (8) 20 (92) 6 (11) 19 (86) 13 (27) 19 (86)
haemorrhagica
Squamous cell 34 (71) 15 (68) 28 (58) 20 (91) 32 (67) 20 (90) 42 (88) 21 (95)
carcinoma
Crohn’s disease 10 (21) 22 (100) 8 (17) 22 (100) 10 (21) 22 (100) 27 (56) 22 (100)
Kaposi’s sarcoma in 18 (38) 15 (68) 16 (33) 18 (82) 19 (40) 14 (64) 31 (65) 22 (100)
HIV
Stevens—Johnson 18 (38) 21 (95) 15 (31) 21 (95) 15 (31) 17 (77) 26 (54) 19 (86)
syndrome
Oral hairy 13 (27) 20 (92) 13 (27) 19 (86) 16 (34) 17 (77) 22 (46) 21 (95)
leukoplakia in HIV

Table 2 Summary of training on the mouth for undergraduate medical students in the 21 responding medical
schools.
Subject Provide Stage of course Having input from
instruction dental staff
Normal oral anatomy 15 (71) Preclinical (1st and 2nd year) 5 (24)
Oral pathology 11 (52) Clinical (3rd and 4th year) 4 (19)
Prevention of oral disease 6 (29) Preclinical (two schools) and 6 (29)
clinical (four schools)
Data are number (%).

tal staff from 9 (56%) of the UK dental schools
were involved in teaching medical undergradu-
ates and 6 (38%) dental schools were consulted
on the content of the local medical course. Den-
tal staff from 12/16 (75%) of the dental schools
were said to be involved in postgraduate educa-
tion for qualified medical staff, which conflicts with
the replies from the medical deans, only 3 (15%)
of whom claimed to organise postgraduate med-
ical courses on oral disease for doctors in their
areas.
Discussion
In a review4 of a textbook: The Mouth,5 Frankel (a
dermatologist) wrote:
‘. . .I suspect readers from other specialties will
agree that they too are only slightly less relieved
than their patients when the perfunctory ‘‘stick out
your tongue’’ part of the exam is over, as they move
to more familiar territories like the chest. . .’. He
went on to describe the book as ‘. . . a godsend for
other practitioners for whom the mouth is also a di-
agnostic wilderness’. The truth of these comments
is reflected in the poor performance of the hospital
doctors in this survey.
The most likely reason for the poor performance
is lack of training. Though three-quarters of med-
ical curricula include oral anatomy, this is taught
at an early stage in the course and will not im-
part a useful working knowledge of the topographic
anatomy of the mouth in a living person. Patients
are often referred to specialist oral and maxillo-
facial and oral medicine departments for opinions
on normal anatomical features such as lingual ton-
sil and circumvallate papillae, together with other
common and completely harmless variants of nor-
mal; only 4 (8%) of the medical staff in our sur-
vey correctly identified geographic tongue. A small
amount of training to familiarise them with the clin-
ical features of a healthy mouth and the more com-
64
mon and important oral diseases could transform
their diagnostic abilities.
Many studies have documented the benefit of
physicians being able to recognising oral diseases in
all sections of the population: children,6 elderly,7
and the general adult population.8 In particular,
it is important that a physician should be able to
recognise oral malignancy at an early (and there-
fore treatable) stage.9 This is particularly relevant
because of patients’ selective attendance for den-
tal care, particularly primary care.10 We noted that
physicians were more skilled at recognising cancer
than other conditions, but both doctors and dentists
should be more vigilant.
Mouth care for patients in hospital or being given
care in the community is the responsibility of med-
ical and nursing staff, but many studies have re-
ported deficiencies in mouth care for the system-
ically ill.3,11,12 If awareness of this problem is to
increase and practice improve, then doctors have
got to promote and support changes. Medical staff
working in palliative care have been particularly
active in raising the profile of oral care13 but this
will spread to other areas of medicine only if train-
ing opportunities for both undergraduates and post-
graduates are improved substantially. With the cur-
rent changes in many medical curricula (including
the shift towards problem-based learning) the in-
clusion of elements relating to the mouth would be
timely.
A resource pack which includes a CD-ROM for
training medical and nursing staff has recently been
produced by two of the authors,14 and could find
a useful place in undergraduate training. Interdis-
ciplinary postgraduate seminars funded by indus-
try and organised by the authors have already been
extremely successful, and the same could be used
locally by postgraduate deans.
With such training initiatives oral care can be im-
proved and so influence the overall quality of life
of many patients. Meanwhile oral and maxillofacial
surgeons can look forward to many perhaps inap-
propriate referrals.
P.J. McCann et al.
Acknowledgements
We thank the medical and dental staff who agreed
to take part in the clinical study, and the medical
and dental deans who completed the postal ques-
tionnaire.
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