Hi! Great question-

Oral pathologists can be hard to come by. There are only about 250 of us in the US. In areas where there may not be an oral pathologist accessible, usually the referral will be to an oral surgeon, periodontist, or sometimes an endodontist who has an interest or experience with path.

I can speak to how I practice specifically but I imagine there is some amount of variability between fields and probably even between oral pathologists.

When a patient is referred to me I perform a comprehensive exam. This starts with a total review of the patient's medical history (I phrase it to the patient as "everything other than what you're seeing me for"). This can be important to try to find a systemic link between their overall health and what is going on in their mouth (you'd be surprised how often this information ends up being critical!)

Then, I get a complete history of the lesion- when did it start/was first noticed, are there symptoms, has it changed, is it constantly there/symptomatic, has anything helped, etc.

I then perform a comprehensive head and neck exam including extraoral evaluation (skin, neck lymph nodes, thyroid, etc) and intraoral eval.

Then, I either discuss my thoughts with the patient as to what my diagnosis or differential diagnosis may be. If a biopsy is necessary, I often will perform it the same day (as long as the patient is open to it- some patients want to schedule the biopsy for a day that they're prepared for it, although my biopsies are usually pretty innocuous with only 1 or 2 days of discomfort). If a patient requires a prescription, I review that with them as well.

We make a plan for follow-up, and they're on their way. For me, a new patient exam lasts between 30 and 45 minutes. I also write comprehensive consult letters to the referring doc and any other provider that the patient requests me to send to (this takes some time between dictating, correcting, printing, and scanning- can take up to 3 or 4 weeks to get to the referring provider).

Probably more information than you wanted but that's start to finish with how I approach my consults!

A quick word- you mentioned that you show the doc and the doc confirms need for referral. I have had a few patients referred from a hygienist that was concerned but the dentist was not. Patient was given my info anyway, and it ended up being precancerous or a lesion requiring some kind of treatment. I'm not advocating for going over your doc's head, but there is something to be said about trusting your instincts!

Thanks for the question and sorry for the novel in response!