Oral medicine: Linking medicine and pathology

I have written the oral pathology column for RDH since 2007, and now I’m broadening my focus somewhat to cover oral medicine and oral pathology content. In the past, I focused on oral pathology from the perspective of oral medicine, but I hope to make this concept even more evident in future articles. Our textbook, General and Oral Pathology for the Dental Hygienist, is now in its third edition and is written from this perspective.¹

You may be wondering, what exactly is oral medicine? The American Academy of Oral Medicine (AAOM) released the following statement related to the designated dental specialty: “The AAOM defines oral medicine as: the specialty of dentistry responsible for the oral health care of medically complex patients and for the diagnosis and management of medically related disorders or conditions affecting the oral and maxillofacial region.”²

On March 2, 2020, the National Commission on Recognition of Dental Specialties and Certifying Boards voted in favor of the specialty recognition of oral medicine. This makes oral medicine the 11th dental specialty recognized by the American Dental Association (ADA).³ The ADA states, “Dental specialties are recognized by the National Commission on Recognition of Dental Specialties and Certifying Boards to protect the public, nurture the art and science of dentistry, and improve the quality of care. It is the National Commission’s belief that the needs of the public are best served if the profession is oriented primarily to general practice. Specialties are recognized in those areas where advanced knowledge and skills are essential to maintain or restore oral health (Association policies are contained in the ADA Principles of Ethics and Code of Professional Conduct).”³ 

The AAOM was founded in 1945 by Dr. Samuel Charles Miller, who was a professor at New York University. The AAOM is the membership organization representing the discipline of oral medicine.⁴ Dr. Miller introduced the concept of graduate courses in which both dental and medical courses were synthesized, resulting in a “total patient care” approach. 

The AAOM’s well-known journal, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, is headed by current editor-in-chief Dr. Mark W. Lingen.⁵ Many of AAOM’s members serve as authors of the publication. 

The American Board of Oral Medicine, sponsored by the AAOM, is responsible for examining and certifying candidates who have received approved postdoctoral training. Both regular and affiliate memberships are available to licensed dental professionals. As a result of early efforts by key individuals, training programs in oral medicine became available throughout the United States at universities and military training institutions.

The AAOM’s annual meeting provides valuable information on the treatment of various diseases/conditions and is worth attending to gain information about new treatment modalities. Members who present are generally actively involved in research and publications.

You can learn more about the AAOM on their website.⁶ I have been an affiliate member of the AAOM since 1997 and an academic affiliate fellow since 2016. 

Oral medicine encompasses many disciplines in addition to dentistry, including medicine and the subgroups of each of these disciplines. With so many specialty areas in the fields of dentistry and medicine, the scope of expertise is boundless. However, practitioners often feel uncomfortable integrating other specialty areas. Oral medicine has always been directed toward the medically complex patient and those with systemic disease that affects the oral tissues. Systemic disease often has a profound effect on the patient’s total body health. Integrating specialists in medicine is often necessary for the treatment and maintenance of optimal health.

Accredited oral medicine residency programs

Information about oral medicine- accredit­ed university programs⁷ is available on the AAOM website. Clinics and other oral medicine programs, staffed by dentists who are trained and certified in oral medicine, operate throughout the United States. Often, practitioners who are long-time members of the AAOM practice in private clinics as well, and some may even be located in remote areas of the United States. 

Protocol in an oral medicine clinic

The Stomatology Center at Texas A&M University, College of Dentistry, Department of Periodontics, in Dallas, Texas, directed by Dr. Jacqueline Plemons, is an oral medicine clinic that provides diagnosis and treatment to a large number of patients each year.⁸ Dr. Plemons and Dr. Celeste Abraham, a clinical associate professor, offer care and instruction to patients and students. Patients seeking care often present with a wide range of oral lesions, skin lesions, perioral lesions, and systemic diseases with accompanying complexities.

Some systemic diseases may be obvious, while others are very difficult to diagnose during initial examination and treatment. Expertise is often needed to arrive at a diagnosis and give patients the long-term care they need. This chronicity of disease highlights an element of palliative care for patients who have long-term health issues with recurring oral lesions.

Palliative care,⁹ usually associated with medicine, involves assisting patients in securing diagnosis and treatment for issues related to their particular systemic disease. In medicine, palliative care providers can assist patients in organizing their health care. The benefits of having other health-care providers in close proximity within the various departments of a dental school and adjoining hospital are many. One is that patients have access to a wide range of health-care providers who are experts in their field of study. 

For more than 23 years, Dr. Terry Rees and I have had the privilege of producing and facilitating the International Oral Lichen Planus Support Group (IOLPSG),¹⁰ which is supported by the Department of Periodontics and the Stomatology Center at Texas A&M University College of Dentistry, Health Science Center. The online support group provides a form of palliative care to many patients.

Lichen planus is a chronic dermatologic disorder that can manifest within the oral cavity and has a potential for malignancy. We have heard from many patients over the years following their initial diagnosis, and some have even been part of the IOLPSG since its initiation in 1997. Patients all over the world use the support group to inquire about referrals, convey concerns about their existing problems, and discuss treatment information and current research. We also provide webcasts with internationally noted specialists. The webcasts are then posted on the website to be reviewed by patients at their leisure. IOLPSG provides patient education materials that meet the specific needs of the patient. 

Appointment sequencing in an oral medicine-based clinic

Assessment. Preliminary assessment of what the appointment will involve includes who will be evaluating the patient, what tests (if any) will be performed, and any past reports that need to be reviewed prior to the appointment. There is usually a team of specialists, residents, and other students who provide their own assessments and opinions. The initial assessment would also include social determinants of health care for current and future treatment.¹¹

Preparatory items. This includes a complete medical and dental history. Preliminary issues also include obtaining vital signs and eliciting the patient’s chief complaint. At this stage, a determination of the need for specialists is made. 

Oral examination. A complete and thorough intraoral and extraoral examination is always performed. Oral images (clinical photographs) are taken at the initial appointment and then repeated periodically as treatment progresses. Oral images allow the clinician to compare tissue changes and response to therapy. Lesions are documented in both written form and as verbal descriptions in the clinical presentation. With most skin diseases that manifest intraorally, cutaneous areas are evaluated as well. Many clinical sessions in oral medicine clinics also provide access to dermatologists who can perform these evaluations and add another focus/expertise for treatment. 

Biopsy and pathology findings. Most skin diseases affecting the oral cavity are diagnosed clinically, but some conditions affecting the oral tissues appear very similar. A biopsy is often performed to differentiate between diseases with similar clinical findings. In a later column, I will address the biopsy and histological findings that can assist in a diagnosis, including routine histology and immunofluorescence used to arrive at a definitive diagnosis.

Cytology and lab test. The use of corticosteroids in the treatment of oral lesions often results in the development of candidiasis, so tests for Candida albicans may be needed. Tests are often performed to determine the presence of pathogenic yeast so that treatment to combat fungal development can occur right away. Additional lab tests—such as smears, pH measurement, and blood studies—may be needed depending upon the clinical findings.

Medication and dental product education. Topical and systemic immunosuppressive agents are the usual choice for the treatment of lichen planus. Specific patient education is crucial to both the continuation and initial application of products. Patients may be more prone to recurrence of lesions when exposed to certain environmental agents, home-care products, foods, and flavoring agents. 

Palliative care. Palliative care includes assisting patients in securing necessary treatment, providing emotional support, and assisting with stress reduction. Patients may experience psychological challenges related to lichen planus and the potential changes in physical appearance that it can cause. Lesions may appear on the outer skin surfaces as well as the perioral surfaces, such as the lips and tongue.^12,13 For many patients, lesions that appear on the lips tend to be not only painful but also unsightly. Patients who have ongoing issues with this external manifestation of lichen planus report that sometimes they do not even leave their homes during disease flare-ups. Stress reduction is important, so it is beneficial to listen to patients’ concerns and provide information with further recommendations.

Follow-up appointments and referrals. With many chronic oral dermatologic diseases, lesions may go into remission only to resurface at a later time. Manifestations are often unpredictable and unique to each patient.^14,15 Once the lesions are under control, patients are periodically evaluated— particularly when lesions recur or clinical features change significantly. 

Conclusion

This column was written to introduce you to the concept of oral medicine. In future articles, I will focus on each of the protocols for patient management and expand on them to include evaluation of patient case studies. As always, listen to your patients and continue to ask good questions.  

References

1. Delong L, Burkhart NW. General and Oral Pathology for the Dental Hygienist. Enhanced 3rd ed. Jones & Bartlett Learning; 2019.
2. Oral medicine is now an ADA-recognized dental specialty. News release. The American Academy of Oral Medicine. April 10, 2020. https://www.aaom.com/index.php?option=com_content&view=article&id=588:press-release—oral-medicine-is-now-an-ada-recognized-dental-specialty 
3. Dental specialties. National Commission on Recognition of Dental Specialties and Certifying Boards. https://www.ada.org/en/ncrdscb/dental-specialties 
4. History. The American Academy of Oral Medicine. https://www.aaom.com/history
5. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology home page. www.oooojournal.net
6. The American Academy of Oral Medicine home page. https://www.aaom.com/ 
7. Residency programs. The American Academy of Oral Medicine. https://www.aaom.com/residency-programs 
8. Stomatology Center. Department of Periodontics. Texas A&M College of Dentistry. https://dentistry.tamu.edu/outreach/stomatology.html 
9. Burkhart NW. Have we forgotten palliative care? RDH magazine. January 21, 2015. https://www.rdhmag.com/pathology/oral-pathology/article/16405217/have-we-forgotten-palliative-care 
10. Burkhart NW. The International Oral Lichen Planus Support Group. Accessed August 31, 2020. https://dentistry.tamhsc.edu/olp/
11. Burkhart NW. Where is the dental community heading in 2020? RDH magazine. August 1, 2019. https://www.rdhmag.com/career-profession/continuing-education/article/14068566/where-is-the-dental-community-heading-in-2020 
12. Hasan S. Lichen planus of lip - Report of a rare case with review of literature. J Family Med Prim Care. 2019;8(3):1269-1275. doi:10.4103/jfmpc.jfmpc_24_19
13. Burkhart NW. Lichen planus of the lip. RDH magazine. May 1, 2009. https://www.rdhmag.com/patient-care/in-office-preventive/article/16405065/lichen-planus-of-the-lip
14. Laudenbach JM, Kumar SS. Common dental and periodontal diseases. Dermatol Clin. 2020;38(4):413-420. doi:10.1016/j.det.2020.05.002
15. Napeñas JJ, Brennan MT, Elad S. Oral manifestations of systemic diseases. Dermatol Clin. 2020;38(4):495-505. doi:10.1016/j.det.2020.05.010

Nancy W. Burkhart, EdD, MEd, BSDH, AAFAAOM, is an adjunct professor in the department of periodontics-stomatology at Texas A&M University College of Dentistry. Dr. Burkhart is founder and cohost of the International Oral Lichen Planus Support Group (dentistry.tamhsc.edu/olp) and coauthor of General and Oral Pathology for the Dental Hygienist, in its third edition. She was awarded an academic affiliate fellow status in the American Academy of Oral Medicine in 2016. She received the Dental Professional of the Year award in 2017 through the International Pemphigus and Pemphigoid Foundation and is a 2017 Sunstar/RDH Award of Distinction recipient. She can be contacted at [email protected].