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Training specialists in oral medicine

Bruce J. Baum, Crispian Scully

 

In the light of our decades of observations and experience in the field, we have chosen as the topic of this editorial to address the training of specialists in oral medicine and, as an unavoidable by-product, the education of dentists. As a given, dentistry is often defined as the branch of medicine that is involved in the study, diagnosis, prevention and treatment of diseases, disorders and conditions of the oral cavity, commonly those of the dentition but also the oral mucosa, and of adjacent and related structures and tissues, particularly in the maxillofacial area. Oral medicine is defined, for example by the UK General Dental Council, as being concerned with the oral health care of patients with chronic recurrent and medically related disorders of the mouth and with their diagnosis and non-surgical management. Yet beyond these accepted definitions, it is now important to recognize that the spectrum of oral diseases is in fact changing, in large part in relationship to infections brought about by HIV, iatrogenic immunosup- pression and the emergence of tropical diseases (e.g. Zarkowski et al, 2002; Scully and Samaranayake, in press), and such factors, as well as others, certainly indicate the need for much more medical experience and training for oral medicine specialists.

Oral medicine is generally recognized as a specialty of dentistry, with the formal necessity for medical qualifications having been abandoned even where formerly required. We are disappointed with this, which we regard as a retrogressive change. The scope of the current oral medicine practice, as the above definition indicates, is typically to provide non-surgical care to patients with a variety of conditions affecting the orofacial region, whether local disorders or related to systemic diseases (Stoopler et al, 2011). That oral medicine needs a dental training and education overtly makes sense, as most conditions occurring in the mouth are conventionally considered as dental in clinical purview. However, dentistry is considered by most people to be a surgical discipline within the spectrum of health professions, a fact that contributes to the concern we are addressing in this editorial.

In mainstream medicine, the care provided by ‘internal medicine’ and by ‘surgery’ represents two very different, yet complementary, approaches to addressing health-related problems. While at medical school, medical surgeons certainly receive a basic foundation in internal medicine, just as internists receive a basic foundation in surgical principles. However, there can be no denial that the pedagogical philosophy of surgical specialty training is clearly different from that of specialty internal medicine training. Throughout the world, practitioners of oral medicine are ‘professionally housed’ within dentistry and receive their predoctoral training in dental schools. Because of this circumstance, and as for all types of future dental surgeons, many oral medicine specialists are not provided foundational training in internal medicine. Indeed, it would be fair to say that dental students receive little to no practically applicable, general medical training (e.g. Donoff et al, 2014; Quock et al, 2014).

As co-editors of Oral Diseases, a journal focused on publishing research related to oral medicine; within our pages, we have never formally addressed pedagogical issues relevant to the specialty, much less to those related to the broader community of dentistry. It is reasonable therefore for our readers to ask, why bother to do this now? There is a short answer for this, and it is that we are honestly worried about our specialty, about dentistry and about patients with orofacial problems who require medi- cal management. Unfortunately, few of those medical clinicians who care for patients with oral medical disorders have received significant or even any training and education in dentistry – a further concern (e.g. McCann et al, 2005; Gill and Scully, 2006; Rabiei et al, 2012; Costa et al, 2014; Stoopler and Sollecito, 2014; Samaei et al, 2015), particularly in view of the number of patients seen in medical primary care services (Mason et al, 1994; Lockhart et al, 2000; Rabiei et al, 2012; Stoopler and Sol- lecito, 2014). Additionally, it is undeniable to anyone bothering to show interest that all aspects of biomedical science, that is the key interface of new knowledge where medicine interacts with the life sciences, are advancing at virtually exponential rates (Fontanarosa and Bauchner, 2015). We believe that an intimate familiarity with this interface between medicine and science is absolutely essential for specialists in oral medicine, indeed for all practitioners in the health professions, to provide their patients with the best possible care. Naturally, that should be of no surprise, because that is precisely the raison d’etre for publishing a journal like Oral Diseases.

While we recognize that dentistry has certainly made major scientific advances in the last few decades, we think that in terms of day-to-day practices within the broad spectrum of dentistry, most, but not all, of those advances involve the delivery of care that is more of a surgical nat- ure and, thus, are not necessarily relevant to oral medicine problems and practice. Concurrently, there has been no significant, generalized effort to provide all future dental surgeons with any substantive foundation in internal medi- cine. Indeed, several years ago, one of us called the inade- quate training of dentists in both medicine and science an impending crisis for dentistry (Baum, 2007), a theme sub- sequently echoed by many others in North America and

Europe (e.g. DePaola, 2008; Seoane et al, 2008; Dennis, 2010; Quock et al, 2014). We believe that such a crisis is on the doorstep and, in the absence of significant change, it will affect the professional status of dentists in societies worldwide, as well as the opportunities for dentistry to have a regular seat at the healthcare decision-making tables. What evidence is there for this? Perhaps most strik- ing to us are the many recent and varied calls for dental education to recognize that the nature of health care is changing, that it is increasingly global in scope and that there is a critical need for dentists to interact with other health professionals (e.g. Alfano, 2012; Brown and Nash, 2012; DePaola, 2012; Nash, 2012; Greenspan, 2013; Do- noff et al, 2014; Polverini, 2014). Indeed, within medi- cine, there is clear recognition of this changing landscape (Berwick, 2014). As dentistry is the mother profession of oral medicine, oral medicine now faces the prospect of diminished significance and impact.

A second reason that we are writing now is because we think it is the responsibility of oral medicine, as den- tistry’s closest link to general medicine (Sollecito et al, 2013), to assume a major leadership role in correcting this situation. Oral medicine can do this by being a vocal and articulate advocate, as well as an example, for the types of changes necessary in dental education to enable any newly graduated dental surgeon to have a meaningful foundation in general medicine and life science. Such changes will allow both general and specialist dentists to grow with biomedical science progress, to adapt better to changes in the evolving healthcare landscape, as well as to be integrated fully within the future healthcare work-force (Nash, 2012; Donoff et al, 2014; Quock et al, 2014).

Importantly for many readers of Oral Diseases, changes in predoctoral dental education will facilitate the correc- tion of an arguably schizophrenic situation in oral medicine training practices across the globe. Although all specialty-training programmes in oral medicine worldwide focus on a generally similar group of clinical conditions (Rogers et al, 2011), historically in Europe, many oral medicine practitioners had earned medical degrees in addition to their dental degrees, while in North America, most oral medicine practitioners do not have medical degrees. Indeed, the two of us, who identify with oral medicine as a clinical specialty, reflect this difference in training. It also seems to us that over the last decade or so, most oral medicine training programmes outside of North America have moved closer to the North American model, that is practitioners no longer are required to earn a medical, as well as a dental, degree (Seoane et al, 2008; Mighell et al, 2011; Stoopler et al, 2011). As Oral Diseases is identified with oral medicine, and affiliated with all of the major oral medicine organizations in the world, we also think it is reasonable for us to reflect on what kind of training would be optimal for a specialist to provide patients with non- surgical care in the orofacial region and, additionally, how that can translate to a leadership role for oral medicine within dentistry.

Without doubt, there is no ideal training method that fits all situations worldwide, so it is perhaps simpler to rephrase the question and pragmatically ask, ‘How much training in internal medicine is needed to be a skilled oral medicine practitioner?’ We suggest that in 2015, the answer to that question is at minimum one full year, that is the equivalent to the experience received in the first year of post-MD training by young physicians entering ophthalmology, still recognizing that nascent ophthalmologists currently have the benefit of receiving an internal medicine foundation from medical school. It seems that now residents in most oral medicine training programmes around the world undertake a series of clinical rotations in various medical specialties, not just internal medicine, that involve 1 year e.g., in the UK, or less and which we do not think is adequate. With 1 year of internal medicine training, plus additional time training in other relevant medical specialties, for example dermatology, anaesthesi- ology and otolaryngology, oral medicine trainees would doubtlessly obtain an increased practical facility in medi- cine, experience more inter-health professional cooperation because of common language and knowledge and, as a result, provide their patients with better care. It also was interesting for us to note that while oral medicine trainees in many programmes can obtain advanced degrees, those degrees are more likely research (MS, PhD) vs clinical (MD) in orientation (Rogers et al, 2011), that is perhaps indicating that only one part of the interface between medicine and science is being cultivated. It is fine to be well trained in generating new knowledge through research, and that leads, hopefully, to future advances in clinical care. However, patients need experienced clinical oral care in real time and care that is relevant to their overall health status.

From a societal perspective, since antiquity, the mouth clearly has been recognized as being important to all of medicine (e.g. see http://en.wikipedia.org/wiki/ Oral_medicine#Training_and_practise; accessed on April 22, 2015). Complementing this is a modern public health view, that is that you may not have good general health without good oral health (e.g. Oral Health in America, 2000). Within dentistry, there has been a long debate about training in medicine for the dental student and, indeed, whether dentistry should be a medical specialty akin to the past European model of stomatology (e.g. see Boston Medical and Surgical Journal editorial, 1925; Ship, 1968; Woodworth, 1970; Matthews, 1990; Hendricson and Cohen, 2001). We will not address that debate here, or that about titles, because we think that currently, such questions are irrelevant. However, it is worth noting the conclusion of the 1925 editorial in the Boston Medical and Surgical Journal, the forerunner of today’s New England Journal of Medicine, in which it was stated that, ‘We wish no injustice to the doctor of dental surgery, who has our heartiest respect and often our profound gratitude. Would he be more able to help either humanity or himself if the letters after his name were changed?’. Apart from the overtly sexist comments in the second sentence, we completely agree. We think it is totally irrelevant which degrees practitioners of oral medicine have earned. What is critically important, how-ever, is that they have a sound general understanding of medicine and biomedical science, something that we think can be acquired in different ways and something


Editorial
Oral Diseases

Editorial that will lead to better, integrated health care for their patients.

As well stated recently by Quock et al (2014), ‘...dentists as doctors and leaders in oral health should demonstrate the highest scholarship; absence of scholarship risks the perception of dentistry as a trade. All dentists can consistently manifest scholarship by integrating basic science, as well as incorporating dental evidence-base, into daily practice’. They later add bluntly, ‘We are not advocating that dentistry be engulfed by medicine. However, we. . . feel there need to be more links between medical and dental education’ (Quock et al, 2014). As indicated earlier, they are not alone in their call for inclusion of more medi- cine and science in the clinical training of dentists (e.g. Baum, 1997, 2007; DePaola, 2008; Seoane et al, 2008; Dennis 2010; Nash, 2012; Miller et al, 2014). To be a clinical scholar in oral medicine means being able to place your patients’ problems in the context of their general health and well-being, something that requires a sound foundation in internal medicine and life sciences.

There is an increasingly publicized perspective, particularly related to periodontal diseases, that caring for oral health may give rise to better outcomes in general health (e.g. Jeffcoat et al, 2014; Wilder et al, 2014). While some debates still surround this viewpoint (e.g. Sheiham, 2015), from our perspective, it nonetheless leads to a very strong and quite reasonable conclusion that there should be an end to the ‘artificial and harmful separation between the mouth and the rest of the body’ (Donoff et al, 2014). To us, as to the editors of the Boston Medical and Surgical Journal in 1925, it is not important whether dentists, or oral medicine clinicians, receive a MD degree. Rather, what is important is that those who have responsibility for oral health care have training in human medicine such that they can inte- grate, and work cooperatively, with physicians, nurses and others, speaking a common language about the patients for whom they all provide care (Nash, 2012; Berwick, 2014; Quock et al, 2014; Wilder et al, 2014).

Despite our call for a minimum of 1 year of training in internal medicine for oral medicine trainees, we recognize that there is likely no one ‘best’ pedagogical approach to train oral medicine specialists or for that matter dentists. What is important is that the goal for oral medicine practitioners, and through their example to all of dentistry, should be to have the ability to place the oral problems of their patients into the broadest context of the latter’s well- being. As Donoff et al (2014) clearly state, ‘The separation between oral health and systemic health does not serve the needs of patients, who would benefit from efficient communication between their oral health care providers and primary care providers’. It is simply wrong to divorce oral health from general health and, therefore, any practitioner who cares for the oral problems of individuals must be cognizant of their patients’ general well-being, in addition to having the technical tools available to ensure oral health. To do anything less is not professional and unworthy of a clinician who benefits from the public trust. Oral medicine clinicians, who are at the interface of the connection between dentistry and medicine, must, in our view, provide the leadership and the example for the rest of dentistry to follow.



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