Intended for healthcare professionals

Career Focus

Oral medicine

BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7535.s33-a (Published 28 January 2006) Cite this as: BMJ 2006;332:s33
  1. Alan Mighell, senior lecturer and honorary consultant in oral medicine
  1. Leeds Dental Institute

Abstract

As Philip Atkin, Rigel Allan, and Alan Mighell explain, oral medicine has come a long way from the skills practised by barber surgeons

History

Pyostomatitis vegetans gingiva

As medicine evolves, specialties and subspecialties develop, and dentistry is no different. Dentistry was practised at the time of the pharaohs, and barber surgeons travelled around country fairs well into the 18th century. The Dentists Act in 1878 provided for the registration of qualified dentists. A subset of hospital based consultant dental surgeons evolved into two distinct specialties that require degrees (or primary registerable qualifications) in both medicine and dentistry—oral medicine and oral and maxillofacial surgery. Both are a long way from barber surgeons yet still draw on their dental skills while practising in the context of modern medicine. During this evolution oral medicine has become a dental specialty of the General Dental Council (GDC) whereas oral and maxillofacial surgery, is overseen by the General Medical Council (GMC).

What is oral medicine?

The specialty of oral medicine has been defined by the British Society for Oral Medicine as, “the specialty of dentistry concerned with the oral health care of patients with chronic recurrent and medically related disorders of the oral and maxillofacial region, and with their diagnosis and non-surgical management.”

Oral medicine is one of the smallest specialties, and there are currently 29 consultants/honorary consultants in the United Kingdom. There is scope for specialty expansion at all levels. The number of specialist registrar (SpR) posts is variable, but currently there are around five SpRs in training at any one time. The specialty is outpatient based with no on calls, although ward visits are not unusual. The British Society for Oral Medicine forms an active focus via its website and meetings for oral medicine activities.

Initial training

Typically, dentistry is taken as a first clinical degree, although a number of consultants began with a medical degree. On completion of the dental degree a dentist will usually work in a general dental practice as part of a vocational training scheme, followed by a further year as a hospital based senior house officer (SHO). Commonly this will be an oral and maxillofacial surgery post with on-call duties, but alternatively may be in oral medicine or oral pathology. During this time the various parts of the examination of the Membership of Faculty of Dental Surgeons (MFDS) of one of the surgical royal colleges are taken. For those who have started with a medical degree, there are opportunities to work in a wider range of junior posts.

The chance to be a student again

There follows a second undergraduate degree programme, in either medicine or dentistry. For dental or medical graduates, courses shortened from the more typical five years for the second clinical degree are often available. However, these short courses are offered at the discretion of the university concerned and the length and availability varies, almost from year to year. The constant change is often related to alterations in the undergraduate medical programme as educational approaches change. Into the mix have been added dedicated graduate entry medical degree programmes and new medical schools. The undergraduate degree opportunities for aspiring oral physicians are certainly increasing with time.

Squamous carcinoma of the side of the tongue

Box 1: Pros and cons of oral medicine

Pros

  • Interesting, varied, and intellectually stimulating

  • Uses breadth of medical and dental training

  • No on call

  • Clinical, learning and teaching, research, and administrative opportunities in either NHS or academia

  • Scope for specialty expansion

  • Starting consultant salary takes account of second clinical degree

Cons

  • Long training

  • High cost of training (but ability to locum)

  • Exam fatigue

  • Availability of SpR posts

  • Geographic restrictions in UK and abroad

Box 2: Some conditions managed in oral medicine

  • Mucosal cancers and pre-cancers*

  • Recurrent aphthous stomatitis

  • Mucocutaneous disease

  • Lichen planus

  • Lichenoid reaction

  • Pemphigus

  • Pemphigoid

  • Lupus

  • Erythema multiforme

  • GVHD

  • Salivary gland disease

  • Dry mouth including Sjögren's syndrome

  • Systemic illness with salivary gland involvement

  • Acute and chronic sialadenitis

  • Sialosis

  • Gastrointestinal disease**

  • Crohn's disease

  • Coeliac disease

  • Ulcerative colitis

  • Infectious diseases

  • Candida

  • Herpes simplex viruses

  • HIV

  • HPV

  • Tuberculosis

  • Syphilis

  • Chronic orofacial pain and dysaesthesias

  • Trigeminal neuralgia

  • Burning mouth syndrome

  • Atypical facial pain

  • Atypical odontalgia

  • Jaw joint and muscle pain

  • Other conditions

  • Orofacial granulomatosis

  • Angioedema

  • Behçet's disease

*A significant proportion of clinical time is spent in examining potentially malignant lesions of the oral mucosa. These may present as ulcers, white patches, red patches, or speckled lesions or growths requiring further investigation.

**Deficiency states (for example, vitamin B12, folate or ferritin) have many oral manifestations.

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As well as competitive entry to a second degree programme a further consideration has been the associated costs. Universities now have more discretion in setting fees, and unfortunately the costs to students have increased. However, qualified doctors or dentists beginning a second degree have numerous possibilities for income generation.

Student days are over

Dentists graduating in medicine and who are potential oral medicine trainees should complete F1 posts and register with the GMC. There is scope to undertake further general professional training (GPT) and some people choose to achieve further professional qualifications (for example, MRCP) before entering specialist training. Although an extended period of GPT is not a requirement of oral medicine training, it allows individuals to bring a diverse range of skills to the specialty. Doctors graduating as bachelors of dental surgery should spend time in general professional training in dentistry. The nature of this will depend upon their previous professional experiences.

Specialist training

Specialist training posts in oral medicine are based in dental hospitals and schools. There are 15 schools in the United Kingdom although not all of them have training posts at any one time. The specialist training posts are usually either university lecturer posts with an honorary SpR contract, or NHS SpR posts, often with an honorary university contract. The minimum specialist training period is three years, but training posts linked to university lecturer posts may well be longer to accommodate a higher research degree or learning and teaching qualifications. Training posts are approved by the specialist advisory committee (SAC) for the additional dental specialties, and administered by the Joint Committee for Specialist Training in Dentistry (JCSTD). The need for flexibility in training programmes is recognised. The training post must have sufficient breadth to allow a comprehensive clinical training experience and also demonstrate an appropriate educational environment. SpR programmes typically have either formal, or less formal arrangements with other oral medicine units to allow trainees to broaden their clinical experience outside the primary training unit.

Oral medicine training pathway

In specialist training the usual rules of RITA (record of in-training assessment) apply and annual assessments occur via the postgraduate deanery.1 In the final year of training candidates will enter themselves for the intercollegiate exit fellowship examination (FDS Oral Medicine) of the royal colleges. On successful completion, application for a certificate of completion of specialist training (CCST) from the GDC, and entry to the specialist list in oral medicine are made. By this stage, an aspiring consultant in oral medicine will be in possession of at least primary qualifications in dentistry and medicine, MFDS and FDS (Oral Medicine), a CCST, and entry in the GDC specialist list in oral medicine.

A typical week in the life of an oral medicine SpR

During a 10 session week, at least five sessions must be clinically based and consultant led. Outpatient clinics in oral medicine are very like general medical outpatient clinics. General dental and medical practitioners refer patients from primary care. Referrals will also come from other medical and surgical specialties in secondary care, such as dermatology, GU medicine, gastroenterology, immunology, ophthalmology, psychiatry, neurology, neurosurgery, and chronic pain clinics. There is a steady exchange of patients between oral medicine and oral and maxillofacial surgery. Interdisciplinary joint clinics with other specialties are established in many units. Of the five remaining sessions, time is allowed for patient related administration, professional development, and opportunities for teaching and research.

Pyostomatitis vegetans palate (a condition associated with inflammatory bowel disease)

The broad based dental and medical background of oral medicine allows for comprehensive assessment, diagnosis, and further management of patients. The orofacial aspects of conditions managed will include, but are not limited to, those given in box 2.

Research, learning, and teaching

Research is an important part of training, and presentations at national and international meetings (see further information box) are encouraged. In the lecturer and honorary SpR programmes research will be a formal component of training, but NHS SpRs have opportunities to contribute to research projects. All SpRs will be involved in learning and teaching in different settings including undergraduate and postgraduate programmes, as well as continuing professional development for dental and medical practitioners. Since oral medicine is based in dental teaching hospitals undergraduate and/or postgraduate students will attend most clinics. A significant component of the dental undergraduate programme is dedicated to understanding human disease. This includes medicine, surgery, pathology, pharmacology, therapeutics, and medical emergencies. The nature of oral medicine training means that staff in oral medicine units often lead human disease courses. Many SpRs incorporate a teaching qualification into their own SpR training and are then eligible for membership of the Higher Education Academy (HEA, formerly the Institute for Learning and Teaching, ILT). Possession of a teaching qualification is an advantage as a consultant.

Keratosis on underside of the tongue (a typical presentation of the sorts of pre-malignant lesions referred to oral medicine clinics)

Consultant appointment

After completing specialist training, appointments will be to either an NHS consultant post or an academic university post with an honorary consultant appointment. The training undertaken by consultants in oral medicine provides the skills to bridge the gap between dentistry and medicine. It also provides great scope and opportunities for subsequent rapid career development to a portfolio of varied and challenging responsibilities.

In summary

Oral medicine acts as a focus for specialist interdisciplinary care of patients with either orofacial manifestations of systemic conditions or localised orofacial problems unrelated to the teeth. The broad based dental and medical background allows for comprehensive assessment, diagnosis, and non-surgical management of varied and challenging cases while also providing opportunities as an educator or researcher in local, national, and international arenas. ■

Further information

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References

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