Vol. 126 No.

5 November 2018

EDITORIAL

Oral medicine: Today’s future can become tomorrow’s reality

There have been strategic clinical, educational, and research advances in the field of Oral Medicine over the past several decades. In
many cases, Oral Medicine experts are contributing the lead role in these advances nationally and internationally. In addition, Ameri-
can Board of Dental Specialty recognition of Oral Medicine as a specialty in 2015 has positioned Oral Medicine professionals to sub-
stantively enhance the delivery of oral health care to medically complex patients as well. It is now important and timely to capitalize
on this contemporary foundation, to advance the field of Oral Medicine in the United States for the next generation of Oral Medicine
specialists and practitioners. This article provides the results of analyses of the present dynamics and economic opportunities, as well
as solutions to existing perceived barriers. (Oral Surg Oral Med Oral Pathol Oral Radiol 2018;126:409
414)

At the April 2017 American Academy of Oral Medi- Oral Medicine is poised to strategically escalate its
cine (AAOM) annual meeting, we had the opportunity prominence both within dental medicine and across
to reflect on Dr. Jonathan Ship’s legacy after his the health care enterprise. However, its future is
untimely passing in 2008. His life continues to inspire wrought with many uncertainties, as well as strategic
us and our Academy on many levels, especially in opportunities for Oral Medicine clinicians, research-
striving to strengthen the understanding and relation- ers, and educators to contribute to a multidimen-
ships between medicine and dental medicine. This sional framework in science, education, and health
modeling is important for a number of scientific, clini- care delivery. The present dynamic, thus, calls upon
cal, and health professional reasons, all of which have its members and leaders to explore what this transi-
collectively led to Oral Medicine recently emerging as tion means and to guide the decision-making process
a recognized dental specialty in the United States.1 by using relevant information. Therefore, now is an
Specialty recognition has been a long and important opportune time to critically examine the value, bene-
step in the 81-year history of the AAOM. This history is fits, and opportunities associated with specialty rec-
significant for the AAOM’s achievements as well as the ognition and to delineate an optimal evidence base
complexities and political relationships between the to help guide our future.
American Dental Association (ADA) and the American In this commentary, we discuss several of these
Board of Dental Specialties. This interaction intersected issues by providing context and logical framing. In sev-
again with the presentation of Resolution 65 at the Octo- eral instances, we merely pose questions, in as much as
ber 2016 annual ADA meeting (https://maaom.member we are uncertain of the answers and the future. This
clicks.net/resolution-65—fall-2016). As a result, Oral collective dialogue will hopefully provide a beneficial
Medicinists* join the 39,000 dental specialists across the construct for our current and future leaders in Oral
country whose advanced knowledge and skills can be Medicine moving forward.
advertised and implemented, as permitted by state regu-
lations,** to benefit the health of the public.
Yes, this is clearly a new era for Oral Medicine. The
specialty is now in a youthful maturation phase, and Statement of Clinical Relevance
This essay delineates present dynamics, challenges,
Presented in part as the Jonathan Ship Lecture, American Academy
of Oral Medicine Annual Meeting, Orlando, FL, USA, April 6, 2017.
and clinical practice opportunities in the field of
*A dentist with advanced training specializing in the recognition and Oral Medicine. Successful management of these
treatment of oral conditions resulting from the interrelationship between opportunities by current and next generation Oral
oral disease and systemic health. The Oral Medicinist manages clinical Medicine practitioners should enhance the role of
and nonsurgical treatment of nondental pathologies/conditions affecting Oral Medicine in the profession.
the oral and maxillofacial region, such as cancer, organ transplantations,
and acute and chronic pain. Activities include provision of interdisci-
plinary patient care in collaboration with medical specialists and other
dentists in hospitals and outpatient medical clinics in the management
of patients with complex medical conditions requiring multidisciplinary
CORE VALUES
health care intervention. (National Provider Identifier Database: https://
npidb.org/taxonomy/125Q00000X/). Let us begin with the core values of Oral Medicine
**Advertising regulations vary on a state-by-state basis. from our perspective.

409
EDITORIAL OOOO
410 Miller November 2018

Core value #1—provision of increased access to QUESTIONS AND OPPORTUNITIES

and delivery of care to patients The clinical environment
At the most strategic level, we believe that value Our profession leads in providing interdisciplinary and
includes the provision of increased access to and deliv- coordinated care to benefit public health. We view
ery of care to patients, which should help address the development of answers to the following questions as
national unmet medical need for Oral Medicine care. essential to further escalating this leadership role:
Increased marketing and advertisement and improved
access to care should also address the longstanding  How many clinicians do we need to meet the Oral
delays in receiving care from an Oral Medicinist.2,3 Medicine needs of the U.S. population?
 Based on this number, is there a shortage of Oral
Core value #2—deriving value from fostering the Medicine providers?
growth of clinical practices in Oral Medicine
nationally If so:
As a direct result of the first principle, value is derived
from fostering the growth of clinical practices in Oral  Do we need to produce more practitioners or
Medicine nationally. The modeling could lead to specialists?
increased access to interprofessional health care by  What is the number of providers needed to provide
patients via integration of Oral Medicine clinical care specialty Oral Medicine care?
into current and emerging models of health care deliv-  How many Oral Medicine specialists are needed to
ery. This growth is wholly complementary to the cur- achieve optimal public benefit?
rent academically based Oral Medicine programs. This  How does the addition of specialists affect the cur-
synergistic relationship should inherently lead to an rent and future economic models of health care
expansion in the number of Oral Medicine programs delivery in America?
nationally, with an increased residency applicant pool.
The published literature indicates that Oral Medici-
Core value #3—provision of new solutions for the nists manage many conditions. Oral mucosal disease and
prevention, diagnosis, and treatment of clinical orofacial pain are included in this scope of practice.4
disorders relevant to Oral Medicine based on These data lead one to ask whether Oral Medicinists can
laboratory and clinical research make a living financially in the current and future mod-
Value will be gained from the provision of new solu- els of health care delivery diagnosing and managing
tions for the prevention, diagnosis and treatment of patients limited to these conditions. And, if so, how
clinical disorders relevant to Oral Medicine. many practitioners can make a living by practicing in
Although specialty recognition may not be needed to this manner? Table I illustrates the key aspects of patient
perform basic and clinical translational research, hav- billing relative to this question. In a minimalist scenario,
ing specialty recognition should lead to increased a provider who sees 8 patients a day and bills and col-
membership, financial growth, and visibility. This lects, on average, $200 per patient would have 1536
expansion could facilitate an increase in research fund- unique patient visits (based on a work schedule of
ing and opportunities for investigators who are target- 4 days a week, 48 weeks a year and 60% overhead),
ing Oral Medicine
based questions. yielding $122,800 in income. Table I further illustrates
These core values, thus, foster multiple benefits the financial parameters associated with alternative
directed toward enhanced patient care nationally. They workloads and payment collection efficiencies. These
also strategically expand the Oral Medicine care pro- data suggest that an Oral Medicinist can enjoy a finan-
vider pipeline via expanded number of residency pro- cially rewarding and durable career and lifestyle.
grams, fellowship programs, and potential funding Within this context, it is important to ask how many
opportunities for investigators who are pursuing Oral Oral Medicinists are needed in the United States if each
Medicine
based research. provider limits his or her practice to the conditions

Table I. Estimated annual income based on number of patients seen and average payment collected per patient
No. of patients/day $100/visit $150/visit $200/visit $250/visit $300/visit
8 $61,440 $92,160 $122,880 $153,600 $184,320
12 $92,160 $138,240 $184,320 $230,400 $276,480
16 $122,880 $184,320 $245,760 $307,200 $368,640
24 $184,320 $276,480 $368,640 $460,800 $552,960
Based on a schedule of 4 days per work week, 48 work weeks per year (192 working days) and 40% net on amount collected.
OOOO EDITORIAL
Volume 126, Number 5 Miller 411

where oral mucosal disease predominates, as presented There are additional considerations for a maturing
in the 2015 survey. Here, we make 3 key assumptions. specialty, such as Oral Medicine, directed to surveil-
First, the majority of patients seeking Oral Medicine lance and quality of care. These include the following:
care are typically older than 45 years; this cohort repre-
sents an estimated 62 million eligible patients. Com-  What percentage of patients receives the standard of
plementary to this assumption is that Oral Medicinists care?
also manage patients age less than 45 years, including  What percentage of our patients improves with resul-
children. tant cure, disease stabilization, or remission of the
Second, there may be selected competition for Oral condition being managed?
Medicine management among general dentists, oral  How is “patient improvement” determined and docu-
and maxillofacial surgeons, oral and maxillofacial mented? What are the best outcome measures?
pathologists, periodontists, otolaryngologists, and  How can we apply effective strategies to clinical
dermatologists. practice?
This competition could result in only 1 in 5 patients  How can knowledge relative to successful prevention
who have said conditions presenting to an Oral Medici- and treatment be disseminated to other practitioners?
nist. Additional considerations to the modeling include  What are the significant gaps in care?
the following:  What is the recall rate of patients, and is a recall pro-
gram needed for clinical success? In this regard,
what percentage of patients returns for visits on a
 Only 62% of the adult population seeks care from a regular basis? What is the percentage of patients
dentist annually.5 This figure, although used in our whose conditions have been cured or are in remission
modeling framework, likely underestimates the num- at 1 year, 5 years, and 10 years, and what is the
ber of individuals who would seek care from an Oral proper recall interval for specific conditions?
Medicine provider. For example, this underestimation  What percentage of patients experience subsequent
likely occurs in the context of pain motivating patients oral and/or systemic complications, as related to the
to seek care, with billing under medical insurance initial oral lesion and its management by the Oral
plans presumably subsidizing the cost of the visit. Medicine practitioner?
 Only an estimated 5% of the population suffers from  What percentage of patients seeks care from other
oral mucosal disease,6
9 and potentially only 50% of health care providers?
these individuals are symptomatic. This likely underesti-
mating paradigm results in a referral base yielding (62 Clearly, answers to these questions are important to
million £ 1/5 £ 0.62 £ 0.05 preva- the evolution of our specialty and represent opportuni-
lence £ 0.5) = 192,200 patients. ties for research investigation as well.

The Residency environment (advanced education

Third, and on the basis of the first two assumptions, programs)
an Oral Medicinist in full-time private practice would We now turn our attention to the Oral Medicine Resi-
manage at least 1536 patient visits/year, translating to dency programs in relation to the next generation of
a need of approximately 125 practitioners with their Oral Medicine practitioners. Here, the history is rich
practice limited primarily to the management of muco- with advanced education programs that have trained
sal lesion disease. However, if one expands the practice many Oral Medicinists. Programs that were initiated in
of Oral Medicine to include orofacial pain and tempo- the late 1960s and early 1970s originated at Indiana Uni-
romandibular disorders, evidence then suggests that versity, the University of Washington, the University of
there are approximately 30 million people who suffer Pennsylvania, and the University of California at San
from these conditions.10,11 If one then adds in preven- Francisco. During the 1980s, programs emerged at the
tive, wellness, and dental care of medically complex/ National Institutes of Health, the U.S. Navy, and the
compromised patients, an additional 25 million University of Texas Health Science Center at San Anto-
patients are estimated to require oral health care.3 nio. During the last 20 years, there have been programs
Thus, depending on the type of private practice an Oral at the University of Medicine and Dentistry of New Jer-
Medicinist seeks to implement, one could interpret that sey, Harvard University, the Carolinas Medical Center,
we have sufficient numbers currently. Furthermore, based the University of Southern California, and Tufts Univer-
on inclusion of orofacial pain, temporomandibular disor- sity, and in the University of Alberta and the University
ders, medically complex dental care and wellness oppor- of British Columbia in Canada. Critical to these training
tunities,12 there is a need to increase the number of Oral programs are questions that encompass the number of
Medicinists. graduates needed, the career path of these graduates, and
EDITORIAL OOOO
412 Miller November 2018

Industry/Unknown
the skillset required for these graduates to serve the pub-

6 (19.4%)
2 (12.5%)

10 (11.9%)
1 (1.7%)

2 (7.4%)

21 (7.2%)
lic during a 35-year career that will span 2020 to 2055.

0 (0%)

0 (0%)

0 (0%)
0 (0%)
In an effort to address these issues, we surveyed the
Program Directors of the 11 active advanced education
programs in Oral Medicine in North America. Informa-
tion regarding their graduates, year of graduation, Diplo-
mate status, and employment status were requested. In
addition, 179 American Board of Oral Medicine
(ABOM) Diplomates who were in “active status” were
6 (42.9%)
40 (47.6%)

6 (22.2%)

89 (30.5%)
9 (29%)
4 (25%)

2 (40%)

2 (10%) e-mailed a request for information regarding their year

Private

20 (33.9)

0 (0%)

of graduation and name of the Oral Medicine Residency

program they attended. Responses were received from 9
Program Directors and 154 of 179 (86%) of the active
Diplomates. Table II presents a compilation of these
data and demonstrates that a majority of graduates suc-
cessfully pass the ABOM Board examination and enter
Academia/Government

academia or a government position. Approximately a

15 (48.4%)
10 (62.5%)
38 (64.4%)
8 (57.1%)
34 (40.5%)

22 (81.5%)

184 (63.0%)

third is in private practice, and a minority is in industry

36 (100%)
3 (60%)

18 (90%)

or has an unknown status. Figure 1 illustrates the growth

trend in the number of ABOM Diplomates by decade
since 1956. Growth in the number of Diplomates has
plateaued over the past 3 decades, with an average of
3.9 graduates obtaining ABOM Diplomates status annu-
ally in the past 2 decades. This number is nearly equiva-
lent to the 3.8 Diplomates predicted to retire per year
over the next decade based on a 35-year career.
ABOM Diplomate

These data indicate that the current number of Diplo-

29 (49.2%)
5 (35.7%)
11 (13.1%)

34 (94.4%)

12 (44.4%)

125 (42.8%)
22 (71%)
8 (50%)

4 (20%)

mates is stable but not growing. We therefore ask, “Is

0 (0%)

that concerning?” Should the Academy and directors

of advanced education programs in Oral Medicine be
strategically planning for tackling this issue and begin
wrestling with this early maturation of the specialty?
Targets for discussion include addressing the need for
Note: Graduates may have held positions in more than one employment category.

trained providers and specialists who seek a career in

Table II. Active and past Oral Medicine Residency programs

private practice, the presence of a perceived shortage,

not reported

not reported
Graduates

the current and predicted wait times for appointments,

and the number of practitioners needed to treat the con-
292
31
16
59
14
84

36
20
27

ditions we train our graduates to manage. As our insti-

5

tutions continue to grapple with these issues, there is

an additional layer of complexity involving how Oral
Medicine accommodates training to emphasize preci-
sion medicine, augmented cognition, big data, molecu-
University of California at San Francisco* (1975)

lar biology, and creative disruption.

Fortunately, there is considerable potential for
University of Texas San Antonioy (1980)

impact and health care changes resulting from specialty

National Institutes of Healthy (1985)

recognition and our Academy, Diplomate, Fellow, and

University of Pennsylvania* (1968)

University of Southern California*

University of Washington* (1970)
Carolinas Medical Center* (2002)

graduate programs working in unison toward a com-

University of Toronto* (2013)

mon goal. For example:

Harvard University* (1999)

Indiana Universityy (1960s)

United States Navyy (1971)

 Patients can benefit from implementing the objec-

*Active program.

tives of the “Choosing Wisely” program advocated

Past program.

by the American Board of Internal Medicine Founda-

tion.13 The aims of this modeling are to promote con-
TOTALS
Program

versations between clinicians and patients by helping

patients choose care that is (1) supported by evidence,
y
OOOO EDITORIAL
Volume 126, Number 5 Miller 413

Fig. 1. Growth trend data regarding number of American Board of Oral Medicine Diplomates over the past 3 decades demon-
strate a stable but plateaued trajectory.

(2) not duplicative of other tests or procedures already stimulate growth and prominence of Oral Medicine
received, (3) free from harm, and (4) truly necessary. both in clinical practice and at academic centers.
 In this context, access to care can be improved by for-
mally targeting insurance and legislative decision-
makers, whereupon payers of health care are educated CONCLUSIONS
of the importance of Oral Medicine
related health Oral Medicine continues to mature as a specialty,
care issues and the difference we can make in provid- grounded in education, science, and its clinical
ing improved quality of life for millions of patients. translation, as well as addressing the unmet health
 Oral Medicine Residency Program Directors should care needs of Americans. In addition to research as
be actively engaged in enhancing the curricula and well as predoctoral dental, fellowship training, and
training experiences that allow for growth in the residency education, Oral Medicine contributes to
numbers of applicants, in the training of residents, interdisciplinary and coordinated care and to the
and in the creation of opportunities for externs and design and implementation of interprofessional
fellows to expand their knowledge base and types of education curricula to strategically enhance health
issues they could be addressing, with consideration care delivery across the country. Specialty recogni-
of the needs of the future. tion is but one step in positioning our American
 Continued involvement in the World Workshop of Oral Academy of Oral Medicine (AAOM) for promi-
Medicine (WWOM) remains critical to the collabora- nence within dental medicine, across the health
tive growth of our profession. WWOM VI was con- care enterprise, and in taking a leadership role in
ducted in April 2014 in collaboration with the AAOM interprofessional education that translates effec-
in Orlando, FL, USA. Twenty-five countries were rep- tively into interprofessional practice. This new
resented in this conference. WWOM VII is scheduled phase represents a strategic time to reflect on how
for September 24
26, 2018, in Gothenburg, Sweden, our patients and the public benefit from the cultiva-
in conjunction with the 14th Biennial European Associ- tion of a new generation of academicians, trained
ation of Oral Medicine Congress, September 27
29, knowledge experts, and clinicians who can and
2018. As with prior World Workshops, the roster of will be responsible for strategically advancing the
WWOM VII attendees represents a comprehensive mission of Oral Medicine.
registry of participants from around the globe.
 Interprofessional education can grow and benefit
from our involvement.14 D1X XCraig S. Miller, D2X XDMD, MS
Professor and Chief, Division of Oral Diagnosis, Oral
These activities will require financial, personal, Medicine, Oral Radiology, University of Kentucky Col-
organizational, and political investments that will lege of Dentistry, Lexington, KY, USA
EDITORIAL OOOO
414 Miller November 2018

3XD XDouglas E. Peterson, D4X XDMD, PhD, FDS RCSEd 7. Demko CA, Sawyer D, Slivka M, Smith D, Wotman S. Preva-
lence of oral lesions in the dental office. Gen Dent. 2009;57:504-
Professor and Head, Oral Medicine, Department of
509.
Oral Health and Diagnostic Sciences, School of Dental 8. Carrard V, Haas A, Rados P, et al. Prevalence and risk indicators
Medicine; Co-chair, Head & Neck Cancer/Oral of oral mucosal lesions in an urban population from South Brazil.
Oncology Program, Neag Comprehensive Cancer Cen- Oral Dis. 2011;17:171-179.
ter, UConn Health Farmington, CT, USA 9. Bouquot JE, Gorlin RJ. Leukoplakia, lichen planus, and other
oral keratoses in 23,616 white Americans over the age of 35
years. Oral Surg Oral Med Oral Pathol. 1986;61:373-381.
https://doi.org/10.1016/j.oooo.2018.07.001 10. Schiffman EL, Fricton JR, Haley DP, Shapiro BL. The preva-
lence and treatment needs of patients with temporomandibular
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