Career: The science of dentistry

IT may be the smallest dental specialty in terms of the number of practitioners on the General Dental Council specialist list, but its impact on everyday clinical practice has been huge.

The field of oral microbiology offers a fascinating and varied career that goes well beyond the expectations of many dental graduates, combining both the clinical and academic spheres. The results of the work carried out by specialists can be seen in practices across the country – a prime example being the major overhaul of dental decontamination procedures in 2009.

The Royal College of Surgeons of England describes oral microbiology as a clinical dental specialty, undertaken by laboratory-based personnel, which is concerned with the diagnosis and assessment of diseases of the oral and maxillofacial region. It is a branch of medical microbiology and, in common with medical microbiologists, oral microbiologists provide reports, advice and clinical liaison based on interpretation of microbiological samples.

Most specialists are senior academics with honorary consultant status based in dental schools and these are the posts most trainees will be competing for. As such, trainees will be required, for their academic advancement, to obtain higher academic degrees related to proficiency in research (PhD), as well as specialist training in oral microbiology.

Entry and training

Dental graduates looking to develop their career in this specialty must have at least two years general professional training in dentistry – including a period of training in secondary care – and have obtained the FDS, MFDS or equivalent. Clinical training lasts for five years and competition for places can be fierce.

Specialty trainees must pass the fellowship examination of the Royal College of Pathologists (RCPath) in medical microbiology – part one of the FRCPath can be taken after a minimum of 18 months training. On completion of part one, further training is required in medical microbiology before being eligible to sit part two – usually after approximately four years. As there is no specific RCPath examination in oral microbiology, specialty trainees will need to obtain adequate experience in a specialist oral microbiology facility.

A certificate of completion of specialist training (CCST) in oral microbiology is awarded by the GDC on the recommendation of the local postgraduate dental dean following evidence of satisfactory completion of the FRCPath examination and the oral microbiology curriculum. In accordance with other specialties, trainees 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).

In recent years, training programmes have been based in Glasgow and London: these must have the approval of the RCPath and the Specialty Advisory Committee (SAC) for the Additional Dental Specialties.

The skills trainees are expected to develop over the five years include:

• Specialised factual knowledge of the natural history of the infections underpinning medical and oral microbiology
• Interpretative skills so that a clinically useful opinion can be derived from laboratory data
• Antimicrobial stewardship and advice
• Research and development experience
• Technical knowledge gained from close acquaintance with laboratory personnel, so that methodology appropriate to a clinical problem can be chosen, and so that quality control and quality assurance procedures can be implemented.

It should be noted that specialty trainees without a higher research degree will be expected to apply to the deanery to undertake three years out-of-programme research experience and enrol for a PhD.

The GDC maintains a specialist list for oral microbiology and anyone wishing to practise as a specialist in this field must be registered on this list. Those with academic aspirations will also be required to provide leadership for the training of undergraduates and postgraduates in the key disciplines of Infection prevention and antimicrobial stewardship.

The job

Excellent communication skills and the ability to liaise with a range of healthcare professionals are key to the job of a microbiologist. The move from clinical dentistry to oral microbiology has been described as something of a culture shock. It is often said to suit those of a more intellectual nature who have a clear interest in infection and enjoy investigative work.

Training is broadly similar across the country although regional variations can occur – some trainees may form close ties with oral medicine while others come to work closely with medical microbiologists (sometimes even finding themselves on the hospital’s on-call rota).

Typical days can be hard to define – especially in the event of an impending outbreak (such as the 2010 anthrax outbreak in Glasgow) or perhaps some kind of exciting experimental breakthrough.

For a clinical microbiologist, the day might start with a handover meeting summarising the overnight developments with the on-call microbiologist. Later, authorisation of laboratory reports including the request of any relevant additional tests by considering the clinical picture of patients and liaising with laboratory staff . urgent results and updates will be telephoned, e.g. positive blood cultures from patients with suspected septicaemia.

You may also be responsible for taking incoming calls from clinicians and/or preparing for a ward round by ensuring all laboratory results are updated. In the afternoon, there will be consultant-led ward rounds where individual patients are discussed; the microbiological results and management communicated with the relevant teams, e.g. intensive care, maxillofacial or orthopaedics. Alternatively, there may be journal clubs or teaching duties. Those working as the on-call microbiologist would not want to venture too far from the telephone. With new and emerging infections popping up every year (SARS and Ebola as examples), it’s the hottest specialty on the GDC specialist list. We hope to one day see a consultant oral microbiologist in every dental school.

Useful links:

• The Royal College of Pathologists
• The curriculum for specialty training in oral microbiology

Professor Andrew Smith is a consultant microbiologist based at the University of Glasgow. Dr Deborah Lockhart is a specialist registrar in microbiology and MRC clinical research fellow based at the University of Dundee

Q&A - Dr Deborah Lockhart, specialist registrar in microbiology and MRC clinical research fellow

What attracted you to a career in oral microbiology?

I was taught by some inspiring clinical oral microbiologists at the University of Glasgow and thought their job sounded incredibly exciting. Stories of flesh-eating superbugs completely captivated me although I was a little bewildered that a degree in dentistry could lead to involvement with such cases. Looking back I was incredibly naïve, but I loved my intercalated BSc in microbiology and thereafter sought every opportunity to get involved in small projects and to fi nd out more about the specialty. It was the combination of research and behind the scenes patient management that I found enticing.

What do you enjoy most about the specialty?

Microbiology infiltrates all specialties and disciplines so no two days are the same. For example, I can be discussing a MRSA wound infection with a GP, visiting the intensive care unit and teaching dental students, all in the space of a few hours. Another exciting aspect is identifying clinical problems and taking these to the laboratory to find solutions. This led me to join a group of talented scientists to evaluate new targets for antifungal drugs during my PhD. I am also very pleased to have recently been awarded a Wellcome Trust clinical postdoctoral research fellowship.

What do you find most challenging?

One of the biggest challenges is that many people are unaware the specialty even exists. This could refl ect the fact that there are only eight registrants on the oral microbiology GDC specialist list. Consequently there are no clearly defined career pathways following completion of specialty training. NHS consultant posts in oral microbiology are non-existent at present (discussions are ongoing with the NHS commissioning groups). This, however, can be turned into an advantage as it affords the flexibility to create your own niche area provided you can convince someone to fund your ideas.

Have you been surprised by any aspect of the job?

When I was initially appointed as a specialty trainee I had not fully comprehended that the oral microbiology curriculum covered the entire spectrum of medical microbiology. I never thought I would be providing antimicrobial advice for patients with endocarditis or attending outbreak meetings.

What personal attributes do you feel are important in oral microbiology?

This is a very challenging training pathway but hard work and perseverance will provide an intellectually stimulating and rewarding career. I think it is important for prospective trainees to demonstrate strong resilience, an ability to adapt to new working environments, multitask and liaise with a range of healthcare professionals.

What advice would you give to a student or trainee considering the specialty?

Dental graduates with an interest in infection might consider pursuing a PhD as a pre-requisite given the current scarcity of specialty training posts. In the last 10 years only three oral microbiology posts were available in the UK (two in London and the one I was appointed to in Glasgow). In addition, changes to the medical microbiology curriculum may impact future training of dentally qualified candidates. I would strongly advise prospective oral microbiologists to contact someone on the specialist list for specific advice. We are a friendly group and would be delighted to hear from you.