Specialty Recognition of Oral Medicine

I have attended numerous ADA and dental society meetings, and I have been surprised by the lack of awareness and knowledge regarding the current status of oral medicine as a possible dental specialty. First of all, many dentists do not know the definition or the history of oral medicine, and secondly, many think that oral medicine is already a dental specialty recognized by the ADA.

The definition of oral medicine is as follows: oral medicine is the discipline of dentistry concerned with the oral healthcare of medically complex patients and with the diagnosis and nonsurgical management of medically related disorders or conditions affecting the oral and maxillofacial region. As a practicing oral medicine clinician and a Diplomate of the American Board of Oral Medicine (ABOM), I am involved in the diagnosis and therapy of such conditions as oral lichen planus, oral pemphigoid and pemphigus, glossodynia, deep somatic orofacial pain, deep visceral orofacial pain, atypical odontalgia, xerostomia, Sjögren's syndrome, oral cancer, oral candidiasis, oral viral infections, aphthous stomatitis, and treatment of medically complex dental patients. These patients are referred primarily by dental general practitioners, dental specialists, primary care physicians, and physician specialists. Referral of similar patients to my oral medicine colleagues occurs daily. The reason these clinicians refer to oral medicine clinicians is that they understand that oral medicine clinicians are highly skilled in treating these patients.

THE AMERICAN ACADEMY OF ORAL MEDICINE: HISTORY
The American Academy of Oral Medicine (AAOM) was founded in 1945 as the American Academy of Dental Medicine. It took its current name in 1966. The members of the AAOM include an internationally recognized group of healthcare professionals concerned with the diagnosis and treatment of non-odontogenic oral conditions and the oral healthcare of medically complex patients. The AAOM first sponsored the ABOM in 1956. The AAOM is a sponsor of the ABOM, the body responsible for examining and certifying candidates who have received approved postdoctoral training within the field of oral medicine. There are, at present, 6 graduate oral medicine residency programs. These oral medicine residency programs range from 2 to 3 years, with additional time (in some instances) added to complete research-related degrees.

Oral medicine is presently not a dental specialty recognized by the ADA. There are currently 9 ADA-recognized dental specialties. These specialties are orthodontics and dentofacial orthopedics, oral and maxillofacial surgery, periodontics, endodontics, pediatric dentistry, prosthodontics, oral and maxillofacial pathology, public health dentistry, and oral and maxillofacial radiology. Oral and maxillofacial radiology is the most recent dental specialty; it was recognized in 2000. Endodontics is the second most recent dental specialty; it was recognized as a dental specialty in 1963. The ADA's Commission on Dental Accreditation (CODA) is responsible to the federal government for accrediting dental educational graduate programs. Oral medicine graduate residency programs were approved by CODA in 2007 and implemented in 2008. Graduate education approval is separate from the specialty recognition process. The latter requires approval by the ADA at multiple levels, beginning with Committee G, then the Council on Dental Education and Licensure (CDEL), and finally the House of Delegates.

To gain specialty recognition, a sponsoring organization such as the AAOM has to comply with a strictly defined application process and meet all 6 of the following requirements as outlined by ADA CDEL.1

THE SIX REQUIREMENTS FOR ADA SPECIALTY RECOGNITION

1. To be recognized as a specialty, the discipline must be represented by a sponsoring organization (a) whose membership is reflective of the special area of dental practice and (b) that demonstrates the ability to establish a certifying board.

2. A specialty must be a distinct and well-defined field that requires unique knowledge and skills beyond those commonly possessed by dental school graduates as defined by the predoctoral accreditation standards.

3. The scope of the specialty requires advanced knowledge and skills that (a) are separate and distinct from any recognized dental specialty or combination of recognized dental specialties and (b) cannot be accommodated through minimal modification of a recognized dental specialty or combination of recognized dental specialties.

4. The specialty must document scientifically, by valid and reliable statistical evidence/studies, that it (a) actively contributes to new knowledge in the field, (b) actively contributes to professional education, (c) actively contributes to research needs of the profession, and (d) provides oral health services for the public, all of which are currently not being met by general practitioners or dental specialists.

5. A specialty must directly benefit some aspect of clinical patient care.

6. Formal advanced education programs of at least 2 years beyond the predoctoral dental curriculum as defined by CODA's Standards for Advanced Specialty Education Programs must exist to provide the special knowledge and skills required for practice of specialty.2

After CDEL convenes and reviews the application, their recommendations are forwarded and reviewed by the ADA trustees, and recommendations from both bodies are forwarded to the ADA House of Delegates for action. Ultimately, it is the members of our profession, our ADA delegates, whose votes decide on whether or not a specialty should exist within our profession.

Oral medicine did not apply for dental specialty recognition during the main wave that occurred in the 1950s and 60s. Instead, oral medicine grew more slowly and only recently applied for dental specialty recognition in 1996 and 2000. In both instances, the ADA House of Delegates found that the application fulfilled most, but not all, of the requirements. Since then, the AAOM has worked diligently to address the identified shortcomings. Specifically, the AAOM continues to contribute new knowledge to the field, provide direct benefit to patient care, and now has approval from CODA for accreditation of the graduate programs in oral medicine. Currently, all 6 residency programs in oral medicine are CODA accredited.

Dr. Mike Siegel,1 an oral medicine clinician and educator, noted that in 1933, only 4 specialties were recognized in the field of medicine (ophthalmology, otolaryngology, obstetrics and gynecology, and dermatology). At that time, the American Medical Association (AMA) was in control of the specialty recognition process and had limited new and emerging medical specialties, such as cardiology and pediatrics, from receiving medical specialty recognition. As opposition mounted within these emerging medical specialties, the American Board of Medical Specialties (ABMS) was formed. This board was established as an independent entity from AMA oversight. Accordingly, the ABMS has independently recognized 24 medical specialties to date. Arguably, there has been concern that there is too much specialization within medicine as a result of the AMA losing control of the process. However, when a process is inoperative, the natural state of affairs is that alternative processes will eventually emerge. In comparison, during the last 40 years, dentistry has only brought in one new dental specialty; this despite the fact that knowledge and patient-oriented therapeutics are advancing at speeds that suggest new specialties should be considered. I share Dr. Siegel's concern that history could repeat itself, and the profession could lose control of the process.1

So where does oral medicine fit into the profession of dentistry? I believe that oral medicine is an integral and unique component of the dental profession. Our clinicians are integral components of organized dentistry and have been paramount in education, research, and publications. Oral medicine educators are represented in a notable majority of dental educational institutions. Oral medicine researchers have been active particularly with regards to such areas of dental research as immunology, pharmacology, and therapeutics. Oral medicine has represented dentistry in the important area of antibiotic prophylaxis and aided in the publication of many current guidelines and position papers.3-6

As an oral medicine clinician, I provide service to an underserved population, and by doing so, I provide direct clinical benefit to many patients annually. My referring dentists are comfortable in communicating with me as another dentist, and referring physicians are happy to direct patients with oral symptoms and lesions to me because of my diagnostic and therapeutic background. As an oral medicine clinician, I provide expertise outside the experience of other dental and medical clinicians. However, because oral medicine is not currently a recognized dental specialty, it is often the case that these patients see any number of dental and medical clinicians be-fore being referred to my practice. This situation is inefficient, and it also adds to the cost of healthcare.

The diagnosis and management of oral soft-tissue inflammatory and neuropathic conditions may be regarded as unusual for most dentists and physicians, but such cases are the bread and butter of an oral medicine clinical practice. A number of these oral conditions are best managed nonsurgically. The alternative for dentists in many cases would be referral of these patients to physicians. It is my opinion that these oral conditions are not high on the list within medical education; however, oral medicine clinicians routinely provide care that alleviates discomfort and leads to healing for this underserved patient population.

ORAL MEDICINE, A DIAGNOSTIC AND THERAPEUTIC SPECIALTY
Diagnostic skills are required of all specialties; however, the types of diagnostic procedures varies by the presenting signs and symptoms. Many ADA-recognized dental specialists do not have practices that dedicate significant time for the diagnostic procedures necessary to provide insight into the diagnostic differences between oral soft-tissue inflammatory (including infectious and immune-related) conditions, metabolic and systemic health conditions with oral manifestations and/or oral/dental treatment concerns, and neuropathic orofacial pain conditions. Providing ADA specialty recognition should improve the ability of these patients to find experts who can provide them with successful diagnosis and therapies, leading to relief.7,8

CLOSING COMMENTS
In summary, the AAOM and the ABOM were founded more than 55 years ago. Clearly, the AAOM is a proud part of the heritage to dentistry, and our clinicians have served the public admirably for dec-ades with regard to clinical patient care, academics, and research. In my opinion, it is time for dentistry to recognize oral medicine at the highest level that will yield the greatest public benefit. As an oral medicine clinician, I encourage you to support ADA specialty recognition for oral medicine.


References

  1. Siegel MA. Member clarifies specialty recognition, CODA approval. Todays FDA. 2005;17:13-14.
  2. American Dental Association. Requirements for recognition of dental specialties and national certifying boards for dental specialists. ada.org/sections/educationandcareers/pdfs/requirements.pdf. Accessed February 10, 2012.
  3. Little JW, Jacobson JJ, Lockhart PB; American Academy of Oral Medicine. The dental treatment of patients with joint replacements: a position paper from the American Academy of Oral Medicine. J Am Dent Assoc. 2010;141:667-671.
  4. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc. 2007;138:739-760.
  5. American Dental Association; American Academy of Orthopedic Surgeons. Antibiotic prophylaxis for dental patients with total joint replacements. J Am Dent Assoc. 2003;134:895-899.
  6. Herman WW, Konzelman JL Jr, Prisant LM; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. New national guidelines on hypertension: a summary for dentistry. J Am Dent Assoc. 2004;135:576-584.
  7. Brown RS, Silverman S Jr, Hall EH. The oral physician: how do we get from here to there? Dent Today. 2001;20:8-11, 128.
  8. Miller CS, Hall EH, Falace DA, et al. Need and Demand for Oral Medicine Services in 1996. A report prepared by the Subcommittee on Need and Demand for Oral Medicine Services, a subcommittee of the Specialty Recognition Committee, American Academy of Oral Medicine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;84:630-634.

Dr. Brown is professor in the Departments of Oral and Maxillofacial Pathology and Oral Diagnosis and Radiology at Howard University College of Dentistry and a clinical associate professor in the Department of Otolaryngology at Georgetown University Medical Center. He is past president of the American Academy of Oral Medicine. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosure: Dr. Brown is Diplomate and secretary of the American Board of Oral Medicine.