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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 32  |  Issue : 1  |  Page : 37-40

Practicing oral medicine and radiology in private setup: A comprehensive review


1 Department of Oral Medicine and Radiology, Surendera Dental College and Research Institute, H. H Gardens, Power House Road, Srigangangar, Rajasthan, India
2 Department of Oral Medicine and Radiology, H. P Government Dental College and Hospital, Shimla, Himachal Pradesh, India

Date of Submission23-Dec-2019
Date of Decision11-Mar-2020
Date of Acceptance12-Mar-2020
Date of Web Publication17-Apr-2020

Correspondence Address:
Dr. Pradhuman Verma
Department of Oral Medicine and Radiology, Surendera Dental College and Research Institute, H. H Gardens, Power House Road, Srigangangar - 335 001, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_207_19

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   Abstract 


Oral Medicine and Radiology (OMR) branch is an important bridge between Dentistry and Medicine and it must not be regarded largely as an institutional specialty. The vitality of the specialty can be advanced through establishment of an independent Private practice (PP) option as is found in all other clinical dental specialities. The option of PP might create broader appeal for entry into specialty and moreover, the patients also can avail the expertise of Oral physician more easily. Therefore, together we need to develop a global strategy to promote the clinical practice of Oral Medicine among patients and all other healthcare professionals to increase awareness of the speciality.

Keywords: Oral physician, private practice, treatment


How to cite this article:
Verma P, Prasad R G, Kumar N, Jaral S. Practicing oral medicine and radiology in private setup: A comprehensive review. J Indian Acad Oral Med Radiol 2020;32:37-40

How to cite this URL:
Verma P, Prasad R G, Kumar N, Jaral S. Practicing oral medicine and radiology in private setup: A comprehensive review. J Indian Acad Oral Med Radiol [serial online] 2020 [cited 2020 Jun 4];32:37-40. Available from: http://www.jiaomr.in/text.asp?2020/32/1/37/282619




   Introduction Top


“A career in Oral Medicine means you can treat medically compromised patients, use your knowledge of pharmacology and biology to help manage patients with chronic painful disorders, or help establish new clinical guidelines for patient care.” - Dr. Craig Miller

The Dental council of New Zealand defines “Private practice (PP) of dentistry as the maintenance of health through the assessment, diagnosis, management, treatment, and prevention of any disease, disorder, or condition of the orofacial complex and associated structures within the scope of the practitioner's approved education, training, and competence in his/her personnel dental office.[1]” Oral Medicine and Radiology (OMR) branch is an important bridge between Dentistry and Medicine and it must not be regarded largely as an institutional speciality. The vitality of the speciality can be advanced through the establishment of an independent PP option as is found in all other clinical dental specialities. The option of PP might create broader appeal for entry into specialty and moreover, the patients also can avail the expertise of Oral physician more easily. The OMR clinical practice has been greatly advanced through the development and availability of new technologies in clinical diagnosis of oral lesions/pathologies, emergence of new imaging methods of maxillofacial region, and availability of many pharmacological agents.[2] The OMR specialist in PP should also get empowered to develop communications with other medical colleagues in dermatology, oncology, otolaryngology, etc. for appropriate referral of cases from them. All these networking will enhance proper functioning of patient's health care system cum separate identification to this dental speciality in Private Practice.[3] Recently, on 2nd March, 2020, American Dental Association (ADA) recognized Oral Medicine as the 11th ADA dental speciality who will be responsible for the oral healthcare of medically compromised patients and for the diagnosis and management of medically related disorders or conditions affecting the oral and maxillofacial region.[4]

There are few broad areas which are providing a good scope of Private practice for an Oral Medicine and Radiology specialist in the Indian context.

Maxillofacial diagnostic and imaging centers

According to an old saying “with great power comes a great responsibility,” hence with so many new advanced imaging modalities for maxillofacial region available in our investigative quest, there is an immediate need to exploit our radiology knowledge in PP to establish ourselves. There are no maxillofacial imaging specific standards for assuring the quality of these machines. The standard applicable to general radiology machines may either be too strict or too lenient on different aspects in the contest of maxillofacial imaging. A beginning has been made in this direction by the AERB in India as per the letter AERB/RSD/MRAS/DR/DCI/2019/1476 dated 06 September, 2019 that for diagnostic imaging of maxillofacial region, a dentist with MDS (Oral Medicine and Radiology) qualification can only act as Radiation Safety Officer (RSO) for Dental Intraoral X-ray/OPG/CBCT facilities. Moreover, with increasing demand to 3D digital imaging for various indications in different dental and ENT specialities with the advent of cone beam computerized tomography (CBCT), the PP scope of OMR specialist is definitely increased.[5] The treatment planning in orthodontics as well as dental implantology would benefit immensely with the expert reporting of maxillofacial region by OMR specialist. The development of indigenous software has helped OMR specialist to extend his/her imaging up to 3D printing and planning needs.[6]

Orofacial pain clinics

Oral physicians in PP settings provide specialized care for the orofacial conditions such as (growths, ulcers, infection, allergies, immune-mediated and autoimmune disorders, cancers), salivary gland disorders, temporomandibular disorders (e.g. problems with the TMJ), facial pain (due to musculoskeletal or neurologic conditions), and taste and smell disorders; and recognition of the oral manifestations of systemic and infectious diseases. These may be done in a group or solo practice setting, providing a mix of the practice of dentistry and medicine. The specialized clinical procedures which an OMR specialist can perform in his/her own Orofacial pain clinic include specialized injections in the mouth or face for diagnostic purposes or for administration of medication for pain relief, anesthesia, or inflammation; prescribing and interpretation of tests such as imaging studies (X-rays, CT scans, MRIs), salivary and blood tests, and microbiological investigations; surgical removal of tissue or bone specimen (Biopsies) for analysis to obtain a diagnosis; and medical managements with topical and systemic medications to treat a wide range of orofacial lesions/conditions. In America, the National Commission on Recognition of Dental Specialties and Certifying Boards has reviewed and accepted the application from the American Academy of Orofacial Pain (AAOP) to make Orofacial Pain the new speciality of Dentistry in both academics and PP which will be dealt by an oral physician specialized in Orofacial pain training.[7] The Orofacial pain clinics in PP can let the OMR specialist earn a lot of money and fame. The unique structure of the clinic allows for effective assessment and management of: a. Pain diagnosis and treatment; b. Orofacial pain in children and adolescents; c. Sleep treatment; and d. screening and clearance for patients before starting radiation therapy or chemotherapy, receiving implant or starting the use of Bisphosphonates/Denosumab. One of the comments of the patient who visited an Orofacial pain clinic as PP in Bombay (India) on 20th January 2019. “I feel extremely lucky and blessed to have found this private clinic which was run by an Oral medicine speciality dentist. I had lived with pain for more than nine months and the treatment here is what gave me my life back.”[8]

Oral cancer screening clinics/palliative care centers

Private dental practitioners constitute approximately 43.7% of all registered dentists in India with OMR specialist constituting only 1.21% in PP.[9] Oral cancer screening is an examination performed by an Oral Physician to look for signs of cancer or precancerous conditions in your mouth. A panel convened by the American Dental Association's Council on Scientific Affairs published a systematic review in 2010 with evidence-based recommendations regarding screening for oral cancer. The panel suggestedthat “clinicians remain alert for signs of potentially malignant lesions or early-stage cancers while performing routine visual and tactile examinations in all patients, but particularly in those who use tobacco or who consume alcohol heavily.” The AAOM (American Academy of Oral Medicine) recognizes that more than 35% of oral and pharyngeal cancers are diagnosed at early stages in America by Oral cancer clinics looked after by OMR specialist,[10] but in India, there is a paucity of evidence to support or refute the PP of oral cancer screening. A wide variety of screening tools is nowadays available in the scientific arena to be used in oral screening private centers ranging from self-oral examination, examination by a trained oral physician, vital tissue staining, and use of specific tools to telemedicine intervention.

In addition, there is a large scope of OMR specialist in Oncology management teams of private Onco-hospitals for planning chemotherapy, radiotherapy, hematopoietic stem cell transplantation, antiresorptive (bone-strengthening) therapies, and complications arising from such interventions including dry mouth, mucositis (mouth sores), infections, jaw osteonecrosis, graft-versus-host disease, and other conditions.

Oral medicine specialty clinics

Oral medicine private clinics definitely will provide money cum identity to the Oral physicians. Either these clinics will be opened up as solo or joined clinics with oral surgeon, oral pathologist, and dermatologist. Most of the systemic diseases are diagnosed early in such clinics after investigations as a result of oral lesions, e.g. maturity onset Diabetes Mellitus is frequently diagnosed when patients are investigated for persistent oral candidiasis. According to the data of one of the Oral Medicine private clinic in America in 2008,[11] out of 320 patients visited with oral lesions in 6 months, in 100 patients possible systemic etiology was diagnosed as the cause of oral lesions after investigations. Dermatologist and immunologist can investigate those aspects of oral diseases which are related to immunology. Even tobacco smoking cessation practice can be incorporated in the speciality clinics including psychological and pharmacological management. Matthews et al.[12]reviewed the diagnosis on 1000 patients reporting to an emergency department of a private hospital outpatient clinic in Britain. They concluded that over 10% of the patients did not have problems related directly to teeth, gingiva, or denture but were of an oral medicine nature. Over the past few decades, the use of lasers among OMR specialist in oral and maxillofacial lesions has grown dramatically. Lasers offer many useful clinical applications for dentists in the diagnosis and treatment of patients with different type of oral mucosal lesions and maxillofacial disorders in PP. Laser may seem to have a much greater role in the specialist Oral Medicine clinics anywhere else.

Temporomandibular disorders (TMD) specialist clinics

A temporomandibular disorder (TMD) is a very common problem affecting up to 33% of individuals within their lifetime.[13] TMD pain is due to diverse factors. The TMD/Orofacial TMJ pain clinics provide care to patients with TMJ pain (TMJ head or neck) with/without clicking, locking, difficulty in jaw movements. The team of Oral physician, Psychologist, Prosthodontics, and Oral and Maxillofacial surgeon could follow a unique approach for management of these challenging types of orofacial pains. The equipment like electrodiagnostic system, 3D jaw tracker, electromyography, T-SCANS for digital occlusal analysis, joint vibration analysis, and TENS therapy can be installed in such clinics. There are a total of twelve successfully established TMD clinics already established in India till 2019.

Dental management clinics for medically compromised patients

The term medically compromised refers to dental patients with impaired health status like pregnancy, or patients with systemic diseases like ischemic heart disease, congenital heart disease, liver disease, renal disease, asthma, patients with immunodeficiency, and patients with altered immune status. The absence or inadequacy of precautions needeto be taken while carrying out routine dental treatment in these patients which may otherwise result in worsening their medical status or even result in a fatality. Care needs to be taken while prescribing medications for these patients in the form of altered dosage or altering the medications themselves. Medico-legal litigations are reportedly on the rise in all the countries across the globe due to increased patient activism and awareness of their rights and sensationalization of such cases by the media. Worsening of the patient's medical status or fatality occurring as a result of the inadequacy of precautions can prove to be nightmare to the dentist's practice, life, and reputation. Many of these medical conditions can be identified by detailed case history recording and thorough clinical examination. There may be alterations in the oral cavity as a result of some of these systemic diseases or due to medications/treatment received for these diseases which may present as taste alterations, salivary alterations, oral ulcerations, petechiae, ecchymosis, pigmentations, candidiasis, necrosis, and gingival overgrowth.[14] These presentations will be highlighting the role of these specialist clinics where Oral physicians are diagnosing the presence of the underlying systemic conditions and precautions needto be taken during the dental treatment of these patients.

OMR specialist as general dental practitioner in PP

The OMR specialist is normally called as “physicians of mouth.” According to a study conducted by Sardella et al.[15] in 2007 in Italy regarding the accuracy of oral diagnosis and treatment of dental hard tissues by Oral Medicine specialist versus General dentist in PP, it was found that only 40% of the provisional diagnosis (122/305) coincided with the diagnosis made at the OMR specialist in PP. In addition, the Italian general dentists have limited knowledge in diagnosing the dental problems which had affected the treatment outcome. The OMR specialist in PP can perform most of the general dental treatment far better than GDP because of his/her strength in approaching the diagnosis either by clinical examination or by way of better utilizing the dental imaging for the same. Moreover, OMR specialist as a private practitioner have a better knowledge of logistic use of drug preparations like medium/high potency topical steroidal orapaste, chemotherapeutic orapaste and mouthwashes, antihistaminic orapaste, miracle mouthwashes, immunomodulators, mucin stimulators, antibiotics, saliva substitutes, nonfoaming nonflavored tooth paste preparations, Benzydiamine mouth washes, probiotics, etc., that may prove valuable to maintain a long symptom-free period in patients.[16]


   Challenges Faced by Omr Specialist in Setting of Private Practice Top


  1. Priority one: “Lack of referrals from medical/general dental practitioners.”
  2. Priority two: “Lack of awareness among patients regarding Oral physicians as specialist in treating oral mucosal lesions.”
  3. Priority three: “Including OMR specialist in Oncology teams.”
  4. Priority four: “Head and Neck cancer patients lacking awareness about oral medicine and radiology dental speciality.”
  5. Priority five: “Overlapped OPD with dermatology, ENT, and oncology.”
  6. Priority six: “Lack of awareness for dental radiologist as diagnostic and interventional imageologist.”
  7. Priority seven: “Medically compromised patients with Oral lesions, TMD patients lack referred to Oral Physicians.”
  8. Priority eight: “Patients with atypical orofacial pain and idiopathic pains unaware of OMR speciality.”
  9. Priority nine: “Nonuniformly established Maxillofacial Diagnostic and Imaging Centers in India.”
  10. Priority ten: “Lack of OMR specialist setups in rural areas.”



   Conclusion Top


Change is the only constant thing in life.” As this famous saying goes, there is a constant need to assess, review, and upgrade ourselves to the changing and adapting to the suit of the future times for an OMR PP in Indian scenario. Inspite of the speedy progress being made in the field of dental imaging, the lack of support and understanding of the an OMR expert opinion among medical fraternity and general dental practitioners, the brighter side of the speciality has been neglected and gone unnoticed. Overall, India was noted to have the largest increase in the number of OMR services as defined by intensifying numbers of PP clinicians within the speciality as compared to other countries.[17] This could be due to the role of the OMR practitioner serving as an initial point of health screening for patients attending in many dental hospitals attached to dental colleges, but still not able to establish the specialty in PP. Oral Medicine is principally considered as medical speciality but ended up in dentistry, and now suffers an “Identity crisis,” bestriding both dentistry and medicine.[18]

In conclusion, together we need to develop a global strategy to promote the clinical practice of Oral Medicine among patients and all other healthcare professionals to increase awareness of the speciality, thus encouraging the budding OMR dentist to establish themselves independently in PP too.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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