Career: Where dentistry meets medicine

IT’S surprising to consider just how much overall health is reflected in oral health. It has been estimated that 90 per cent of systemic diseases have oral manifestations – be it mouth ulcers in Crohn’s disease, angular cheilitis in iron deficiency or xerostomia in diabetes. Conversely, significant orofacial pain or disease has a profound effect on the wellbeing of any patient.

Oral medicine sits at the interface between dentistry and medicine and can be defined as a dental specialty “concerned with the oral healthcare of patients with chronic, recurrent and medically-related disorders of the oral and maxillofacial region, and with their diagnosis and non-surgical management.”

Specialists practising oral medicine in the UK must qualify for inclusion on the Oral Medicine Specialist List maintained by the General Dental Council. To achieve a CCST (Certificate of Completion of Specialist Training) in Oral Medicine from the GDC requires a training programme normally of five years duration. This may be reduced for those who apply to the programme with additional qualifications such as a medical degree.

The job

Oral medicine is an out-patient specialty for the most part, with clinics involving referrals from primary dental and medical care. However, increasingly specialists are receiving referrals from other medical specialties in secondary care, including rheumatology, gastroenterology, dermatology, GU medicine, neurology and even psychiatry. An oral medicine specialist is therefore expected to be conversant with colleagues across these specialties in the management and onward referral of patients.

Oral medicine specialists are often involved in teaching, as the subject is a core component of the undergraduate dental student curriculum in the UK. They also have an important role in delivering postgraduate education for professional examinations and CPD for practising dentists. Specialists in oral medicine are often in demand from postgraduate deaneries to deliver courses on facial pain, soft tissue disease and the management of medically compromised patients in general dental practice.

Oral medicine is one of the smallest dental specialties with 16 units across the UK, mainly based within dental teaching hospitals, and around 40 practising consultants. The consensus from the British Society for Oral Medicine is there should be one consultant in place for every one million of the population and the Society is actively working towards securing new posts and increasing trainee numbers.

Entry and training

Posts in oral medicine specialty training programmes in the UK can be few and far between and competition is keen. The basic entry requirement is two years of postgraduate foundation training in dentistry, including experience in primary and secondary care settings. A diploma of membership (MFDS) in a dental faculty of a Royal College is not essential but strongly recommended. Previously a second degree in medicine was required and trainees may still choose to pursue this route before entering specialty training.

Training involves significant time spent in oral medicine outpatient clinics, seeing new and review patients under the supervision of a consultant. Trainees are encouraged to see hospital in-patient referrals on the wards and there is a notable overlap with the work of colleagues in special care dentistry in managing the most medically-complex patients. Experience of a hospital environment through oral and maxillofacial house jobs, while not essential, gives invaluable insight into the workings of a hospital and can be very useful to dentists aspiring to a training place in oral medicine.

Trainees are required to attend additional specialised out-patient clinics, such as dermatology, gastroenterology and rheumatology, and are encouraged to visit other oral medicine units. Another mandatory component of the curriculum is proficiency in soft tissue biopsies through a dedicated biopsy list.

A new development in specialty training for oral medicine has been the national Specialty Training Forum organised by the BSOM. The forum brings together trainers and trainees to gain experience with Work-Based Assessment tools in a safe supportive environment and aids preparation for both ARCP and ISFE (see later).

As with other specialties there are many opportunities to attend training events and meetings across a number of medical and dental specialties. Trainees should be active in presenting at interdepartmental and regional clinico-pathological case conferences to develop their skills in interpretation and conversing with colleagues in oral pathology.

Trainee specialists will be expected to publish at least one paper during their training and this may take the form of basic science, translational research, clinical audit or case reports. Presentations at national and international meetings are encouraged and the BSOM offers prizes at undergraduate and junior trainee level.

A CCST in oral medicine is awarded by the GDC on the recommendation of the local postgraduate dental dean following evidence of satisfactory completion of the oral medicine curriculum and the Intercollegiate Specialty Fellowship Examination (ISFE) in Oral Medicine. Candidates must also achieve a successful outcome in the Annual Review of Competence Progression (ARCP) process as outlined in A Guide to Postgraduate Dental Specialty Training in the UK (Dental Gold Guide).

Most oral medicine specialists will work either in the NHS as a consultant or in an academic university post with an honorary consultant appointment. For more information on a career in oral medicine visit the website of the British Society for Oral Medicine (see below).

Dr Clare Marney, honorary specialty trainee in oral medicine, Glasgow Dental School, with Jim Killgore, publications editor, MDDUS

Sources

Atkin P, et al. Oral medicine. BMJ Careers 2006 332:33.

The British Society for Oral Medicine website: http://www.bsom.org.uk/

GDC. Specialty training curriculum for oral medicine. SAC in the Additional Dental Specialties. Access on the GDC website at http://www.gdc-uk.org/

Pros and cons of oral medicine

Pros

+ Interesting, varied and intellectually stimulating

+ Uses breadth of medical and dental training

+ Generally no on-call requirements

+ 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 ST posts

- Geographic restrictions in UK and abroad

From Atkin, et al

Q&A

Dr John Steele, specialty registrar/ honorary clinical lecturer in oral medicine

What attracted you to a career in oral medicine?

During my dental undergraduate years in Glasgow I was most interested in oral medicine and pathology and the excellent department there fuelled my curiosity. Following VT, I took up an SHO post at Dundee Dental Hospital in oral medicine and pathology and this made me determined to pursue oral medicine as a career. With this in mind, I accepted a three-year post as lecturer in oral medicine in Liverpool. This gave me vast experience of the spectrum of oral medicine and also research opportunities. I then went to medical school in Birmingham and following this worked as a doctor for a few years back in Merseyside. I then started in my current post as a specialty registrar/honorary clinical lecturer in oral medicine in Liverpool.

What do you enjoy most about the specialty?

I enjoy the medical management of the numerous conditions that affect the oral and maxillofacial region. Oral medicine lies at the interface of dentistry and medicine and has crossover with a number of medical specialties including dermatology, gastroenterology, rheumatology, ophthalmology, infectious disease, haematology and psychiatry. Many cases can provide both a diagnostic and management challenge due to patients’ co-morbidities and their polypharmacy. Also, after doing weeks of nights and weekends on call as a medical/surgical doctor and unsociable hours working in the emergency department, the nine-to-five regular hours of outpatient clinics are highly desirable!

Are there any downsides?

Oral medicine, as a distinct specialty, is practised currently by only 36 consultants based in dental hospitals. This means that there are only 16 oral medicine departments in total in the whole of the UK and Ireland. This limits where a potential trainee could work.

What have you found most challenging in your training?

The financial ramifications of returning to medical school and therefore losing a regular income and associated pension contributions were challenging. However, the actual learning experience was invaluable.

Have you been surprised by any aspect of your training?

Not really. I knew what to expect having worked in my current unit before and also having read the oral medicine curriculum in advance.

What advice would you give to a dentist considering oral medicine?

Now that studying medicine and being registered with the GMC is no longer a requirement to enter specialist training, I would advise dentists to seek SHO/ clinical teaching posts in the specialty to gain valuable experience/publications prior to applying for a specialty registrar position. I would also recommend joining the British Society for Oral Medicine (BSOM, www.bsom.org.uk) to keep abreast of clinical updates, specialty meetings and job opportunities.

What is your most memorable experience so far in the specialty?

The most memorable experiences are the challenging, interesting and rare cases that present. It is also very rewarding to reassure a highly anxious patient that they do not have the life-threatening condition they were anticipating. Also, having recently passed my exit exam (ISFE) in oral medicine I do not have to sit another exam ever again!