Welcome back to the journal review. This month we're covering the May twenty twenty-six issue of the Journal of the American Academy of Dermatology, and we've got three pieces to walk through — a medico-legal outcomes study out of Canada, and then a two-part continuing medical education series on the dermatologic oral examination that's genuinely relevant to anyone doing lip and oral mucosal surgery. Let's get into it.

First up is a retrospective review titled "A Forty-Year Review of Canadian Medico-Legal Cases Involving Skin Cancer," out of McGill and University of Toronto dermatology groups. This is an original study, though a fairly specific kind — a legal-database chart review rather than a clinical cohort.

The background here is straightforward and worth sitting with. Skin cancer is the most commonly diagnosed malignancy in Canada, incidence is rising across melanoma and non-melanoma subtypes, and data from the Canadian Medical Protective Association — their national physician liability body — shows dermatologists make up a tiny slice of closed medico-legal cases, only about one percent, but skin cancer is disproportionately the most common complaint category when dermatologists are named. The gap the authors are addressing is that nobody had systematically characterized what actually goes wrong in these cases — is it diagnostic error, communication, documentation, and does what patients complain about actually match what regulators and courts rule on.

Methodologically, they did a retrospective search of three legal databases — LexisNexis, Westlaw, and CanLII — covering four decades, November nineteen eighty-three through March twenty twenty-five. They included any physician-involved allegation tied to skin cancer diagnosis, management, or follow-up, and excluded cases involving non-physician providers. This is really the only design available for this question — you can't prospectively study litigation, and there's no registry of medico-legal skin cancer complaints, so mining public legal databases is the only way to get systematic data on this. The authors don't spell out why they chose these particular three databases, but it's a reasonable inference that together LexisNexis, Westlaw, and CanLII give the most comprehensive coverage of Canadian regulatory and court decisions, spanning both civil litigation and provincial college disciplinary rulings.

Now the results. Of five hundred thirty-three initial hits, one hundred eight met inclusion criteria — fifty-two closed medico-legal cases plus fifty-six related decisions like appeals or procedural rulings. The closed cases are really the meat of the analysis. About eight in ten of these were adjudicated by provincial regulatory colleges rather than courts, and the great majority came out of Ontario, with British Columbia a distant second.

Melanoma was the dominant cancer type, accounting for just over half of all cases, with basal cell and squamous cell carcinoma each contributing smaller shares, roughly one in six and one in seven respectively. About one in three cases involved metastatic disease at the time of the complaint, and melanoma made up the overwhelming majority of those metastatic cases — something like seven out of every eight. Patient death was documented in about fifteen percent of cases. Most of these arose in the public healthcare setting rather than private practice. Sixty physicians and four trainees were named across the cohort, and by specialty, family physicians were the most frequently implicated group at about a third, followed by dermatologists at a quarter, then plastic surgeons and oncologists trailing behind.

In terms of what patients actually alleged versus what got physicians in trouble, failure to diagnose was the leading allegation, cited in about two-thirds of cases, followed by inadequate communication in nearly half, and documentation deficiencies in over four in ten. Adverse findings against physicians occurred in about four in ten cases overall, and when there was an adverse finding, the drivers were consistently poor documentation, failure to biopsy a suspicious lesion, and inadequate follow-up.

The discussion point that I think is the clinically important takeaway is the divergence between what patients complain about and what regulators actually rule on. Patients' complaints skewed toward interpersonal dissatisfaction — not being told a lesion looked suspicious, not being properly introduced to, feeling like information wasn't shared. But when regulatory bodies and courts actually adjudicated, they focused almost entirely on the thoroughness of the medical record and the clinical workup — did you document lesion size, shape, and color, did you record the physical exam and the conversation you had, did you biopsy what needed biopsying, did you follow up on results. Interestingly, none of the case documents mentioned whether the missed diagnosis or error was ever disclosed to the patient, which limited the authors' ability to look at disclosure as its own variable.

Limitations are honestly stated by the authors — this relies entirely on publicly available case reports, which by definition excludes settled or confidential cases, and the sample size is modest, fifty-two closed cases over four decades. They also flag that non-physician provider liability, say nurse practitioners or physician assistants doing skin checks, wasn't captured and is a gap for future work.

For practice, I'd call this genuinely practice-relevant, if not surprising. The paper comes with a table of concrete suggestions that map onto exactly what a Mohs and derm-onc practice already should be doing — biopsy suspicious lesions promptly, and if you defer, document why and set a short-interval follow-up, ideally within three months; maintain some systematic way of tracking pathology results, either a biopsy log or an automatic follow-up booking so nothing falls through the cracks; document lesion morphology and your clinical reasoning explicitly, including phrases like "concerning for skin cancer, biopsy recommended," rather than vague reassurance language; and follow a named guideline, like NCCN, for surveillance intervals and document that you're doing so. None of this is new clinical knowledge, but the data here is a useful reminder that regulators don't care as much about diagnostic accuracy in isolation as they care about whether your workup and documentation trail can withstand scrutiny after the fact.

Now let's shift to the second and third articles, which are a linked two-part CME series from Mayo Clinic Florida and Arizona in collaboration with Charles University's Institute of Dental Medicine, on the dermatologic oral examination. These aren't original studies — they're educational review and practice-guide pieces — so I'll walk through them as the teaching content they are rather than forcing a results-and-limitations structure onto them.

Part One is titled "The Dermatologic Oral Examination and Biopsy: A Guide for Incorporation into Everyday Practice." The framing problem is a training gap — the World Health Organization estimates about half the global population has some form of oral disease, yet the authors cite a twenty twenty-three survey of dermatology residency program directors in which barely a third felt confident their residents could diagnose oral mucosal disease, only about four in ten felt confident about residents performing oral procedures, and only about six in ten felt residents reliably included the oral mucosa in a complete skin exam at all. The authors also note, reasonably, that masking during the COVID pandemic likely further reduced the frequency of oral exams and that habit may have persisted. Their point, which I think is well taken for our specialty specifically, is that oral mucosa falls squarely under dermatology's purview, and it's on us to close this gap.

The bulk of Part One is a structured review of oral cavity anatomy — the lips and their subcomponents like the vermilion, the commissures, the philtrum and Cupid's bow; the vestibule versus the oral cavity proper; the three functional mucosal types, meaning masticatory mucosa, which is heavily keratinized and covers the hard palate, alveolar ridges, and attached gingiva; soft or loose mucosa, which is non-keratinized and covers the buccal, labial, floor-of-mouth, and soft palate surfaces to allow flexibility; and specialized mucosa, which covers the dorsal tongue and the vermilion lip itself, with its characteristic thin stratum corneum and rich vascularity that gives the lips their color. They then move into a step-by-step examination protocol — take a focused history first, including occupation, habits, oral hygiene, and any dermal filler or dental procedures, obtain consent given how richly innervated and potentially painful oral structures are to manipulate, position the patient upright to allow full range of exam motion, and use basic supplies — gloves, a tongue blade, gauze, and a light source, nothing specialized. The extraoral portion starts with frontal inspection and palpation of the lip structures, checking specifically for induration, nodules, or ulceration — which, notably, is exactly the kind of finding a Mohs surgeon or derm-oncologist would want flagged early for a lip primary. The manuscript's stated scope also includes guidance on performing oral biopsies, positioning this as a complete toolkit for bringing the oral exam into routine dermatologic practice, on par with the skin, hair, and nail exam we already do reflexively.

Part Two, "The Dermatologic Oral Examination: Navigating the Oral Dermatoses Map," picks up where Part One leaves off and is essentially a differential-diagnosis atlas organized by anatomic site — genuinely useful as a quick-reference tool. The authors cite a UK and Ireland survey showing ninety percent of dermatologists don't routinely examine the oral cavity, barely half were confident recognizing normal variants, just over half confident recognizing oral malignancy, and under half confident distinguishing forms of oral ulceration — reinforcing the same practice gap from Part One. Their organizing device is what they call the Oral Dermatoses Map, pairing common conditions to the anatomic zones where they characteristically present.

On the lips, they walk through herpes simplex labialis, presenting as painful grouped papulovesicles after a burning prodrome; granulomatous cheilitis, indurated swelling of the lip that when paired with facial nerve palsy and a fissured tongue constitutes Melkersson-Rosenthal syndrome, and which requires ruling out angioedema first given the airway risk, plus excluding Crohn's disease, sarcoidosis, contact dermatitis, and filler-related foreign body reactions; venous lake, a benign blanching violaceous papule on the vermilion that's diagnosed clinically and treated with observation, electrosurgery, laser, or excision if desired; labial melanotic macule, the most common pigmented lesion of the vermilion lip, typically a well-defined brown-to-black macule where observation is reasonable but atypical pigmentation should prompt biopsy — worth flagging for us specifically, since the differential there explicitly includes junctional nevus and melanoma; angular cheilitis at the commissures, usually multifactorial from aging-related saliva pooling plus yeast or staph colonization; and secondary syphilis, which can produce the nearly pathognomonic split papule at the labial commissure along with condyloma lata and denuded mucosal patches.

Moving further in, the labial and buccal mucosa host condyloma acuminata, mucocele, erythema multiforme, morsicatio buccarum from habitual cheek-biting, and recurrent aphthous stomatitis. The gingiva is where oral lichen planus and desquamative gingivitis live, the latter presenting as erosive, blistering, diffusely erythematous masticatory gingiva. The tongue carries the longest differential — geographic tongue, atrophic glossitis, lingual varicose veins, traumatic ulcers, leukoplakia as an oral potentially malignant disorder, and oral cavity squamous cell carcinoma itself, which the authors note classically favors the ventral or posterior lateral tongue, the floor of the mouth, or the vermilion lip — all sites that should trigger a low threshold for biopsy in anyone with a dermatologic-oncology practice. Finally, the hard and soft palate and the fauces round out the map with hand-foot-and-mouth disease, recurrent intraoral herpes simplex confined to keratinized masticatory mucosa, and acute herpetic gingivostomatitis affecting both keratinized and non-keratinized surfaces more diffusely.

Because these two pieces are educational reviews rather than studies, there's no results or limitations section to weigh — the value here is entirely in the reference framework itself. For practical takeaway, I'd frame this pair as genuinely useful rather than practice-changing in the traditional sense: it won't alter your surgical technique, but it's a legitimate nudge to formalize oral mucosal inspection as a routine part of your total body and lip exams, particularly given how many of the entities on this map — leukoplakia, oral cavity squamous cell carcinoma, atypical labial melanotic macules — sit directly in our diagnostic lane and can otherwise be missed simply because the mouth doesn't get opened.

That wraps our three articles for this issue. To summarize the actionable threads — tighten your documentation and follow-up systems, since that's what actually drives medico-legal exposure in skin cancer cases, and consider formally incorporating an oral mucosal exam into your routine skin checks, using site-based differentials to keep your threshold for biopsy appropriately low on the lip and tongue. Thanks for listening, and we'll see you next month.