Telemedicine contributing to an incidental finding of a premalignant lesion

Background

Taking self-portraits with mobile phones or tablets has become a way of life, and has increased considerably with the COVID-19 pandemic. As part of telemedicine, patients can now send photographs to health professionals for medical advice, triage, follow-up, etc. Because of the visual aspect of many oral manifestations, the practice of telemedicine coupled with photography of the oral cavity is becoming particularly interesting for oral medicine [1]. Teledentistry can be defined as the application of various information and communication technologies to facilitate oral health care for patients and/or practitioners remotely [2]. Teledentistry includes various sub-systems: teletriage, teleconsultation, tele-expertise, and telemonitoring [3]. Telemedicine involves securing the sending of photographs and accompanying information as they are medical documents and form part of the patient’s record [4], [5], [6]. They must be transmitted and stored in a secure manner in order to preserve patient confidentiality. Accelerated by the covid-19 pandemic, the sending of photographs to the dentist for advice/follow-up is becoming more and more frequent – and a photo may highlight anatomical areas unconnected to the initial reason for sending the photo.

Case report

An 87-year-old gentleman patient with no previous medical history telephoned his attending dentist with a question about his prosthetic restorations. The patient felt that the ceramic part of his metal-ceramic restorations had fractured in the right mandibular area. Given the health context of the COVID-19 pandemic and in the absence of pain and signs of infection described by the patient, the practitioner suggested that the patient send him some photos before scheduling a possible appointment. Among the photos sent, one in particular caught the practitioner's attention. This photo showed some red and white lesions on the patient's lower lip, which had not been mentioned by the patient during the telephone interview (see Fig 1 ). The practitioner had no note of any particular history of these lesions in the patient’s file. The practitioner contacted the patient again to clarify the occurrence of these lesions. The patient reported the presence of “chapped skin” for several weeks without pain, which had been evolving for many weeks and was slow to heal. The patient tore off the crusts, which, in his opinion, explained the delay in healing and did not worry him too much. In the photo, these lesions showed an ulcerative crusted appearance with scaling.

Fig. 1.

Incidental finding of actinic cheilitis localized on the lower lip.

The persistent aspect of these lesions associated with a delay in healing on a lower lip alerted the practitioner, who asked for an evaluation by one of his colleagues specialising in oral mucosal diseases, within the framework of a tele-expertise. From the photo, the specialist observed a pearly and erythematous background associated with oedema and the presence of pearly patches with a little oedema. The specialist decided to summon the patient for examination and then to perform a biopsy of the lip lesion. Histological finding was consistent with actinic cheilitis. The vermilionectomy technique was used to treat this patient.

Discussion

Labial lesions are often at the crossroads of several medical specialties and it is important not to underestimate the significance of a labial lesion. Actinic cheilitis is a chronic degenerative painless disorder considered as a premalignant condition located electively on the lower lip and related to prolonged sun exposure [7]. It is more frequently observed in subjects over 50 years of age with outdoor activities, particularly at altitude or on the sea. In this case report, the patient is an amateur skipper and was therefore exposed to a lot of sunlight with reverberation effect on the water. With this clinical case, we would like to draw attention to such potential incidental findings.

Incidental findings are previously undiagnosed medical conditions that are discovered unintentionally and when assessing a different medical condition. Such discoveries can occur in a variety of contexts, and telemedicine can be one of them. The legal and ethical issues raised by telemedicine are still relevant [4], [5], [6]. They also include the particular question of the practitioner's responsibility in the event of the photograph sent by the patient leading to an incidental finding.

This case study illustrates two important points of teledentistry. On the one hand, the photographs can easily show the patient's mouth in sufficient quality. It is important, as in imaging, to have a good view of all the anatomical parts that are within the competence of a dental surgeon. And, even though a diagnosis is never established from a photograph, it generally proves to be a sufficient support to plan an appointment or to refer to a specialist in case of doubt. In addition, because of the rapidity with which photos can be transferred between health professionals, tele-expertise offers the possibility of referral to a specialist to adapt treatment more quickly [8]. A face-to-face appointment is then essential for a real oral examination and to adapt the management.

It is important to remember that any premalignant lesion of the oral mucosa should be monitored. Actinic chelitis may present with some degree of epithelial dysplasia and some may transform to oral squamous cell carcinoma [9]. The incidental finding of an oral premalignant lesion in this elderly gentleman could be described as a life-saver.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.