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

409
EDITORIAL
410 Miller
Core value #1—provision of increased access to
and delivery of care to patients
At the most strategic level, we believe that value
includes the provision of increased access to and deliv-
ery of care to patients, which should help address the
national unmet medical need for Oral Medicine care.
Increased marketing and advertisement and improved
access to care should also address the longstanding
delays in receiving care from an Oral Medicinist.2,3
Core value #2—deriving value from fostering the
growth of clinical practices in Oral Medicine
nationally
As a direct result of the first principle, value is derived
from fostering the growth of clinical practices in Oral
Medicine nationally. The modeling could lead to
increased access to interprofessional health care by
patients via integration of Oral Medicine clinical care
into current and emerging models of health care deliv-
ery. This growth is wholly complementary to the cur-
rent academically based Oral Medicine programs. This
synergistic relationship should inherently lead to an
expansion in the number of Oral Medicine programs
nationally, with an increased residency applicant pool.
Core value #3—provision of new solutions for the
prevention, diagnosis, and treatment of clinical
disorders relevant to Oral Medicine based on
laboratory and clinical research
Value will be gained from the provision of new solu-
tions for the prevention, diagnosis and treatment of
clinical disorders relevant to Oral Medicine.
Although specialty recognition may not be needed to
perform basic and clinical translational research, hav-
ing specialty recognition should lead to increased
membership, financial growth, and visibility. This
expansion could facilitate an increase in research fund-
ing and opportunities for investigators who are target-
ing Oral Medicine
based questions.
These core values, thus, foster multiple benefits
directed toward enhanced patient care nationally. They
also strategically expand the Oral Medicine care pro-
vider pipeline via expanded number of residency pro-
grams, fellowship programs, and potential funding
opportunities for investigators who are pursuing Oral
Medicine
based research.
Table I. Estimated annual income based on number of patients seen and average payment collected per patient
No. of patients/day $100/visit
8 $61,440
12 $92,160
16 $122,880
24 $184,320
Based on a schedule of 4 days per work week, 48 work weeks per year (192 working days) and 40% net on amount collected.
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November 2018
QUESTIONS AND OPPORTUNITIES
The clinical environment
Our profession leads in providing interdisciplinary and
coordinated care to benefit public health. We view
development of answers to the following questions as
essential to further escalating this leadership role:
 How many clinicians do we need to meet the Oral
Medicine needs of the U.S. population?
 Based on this number, is there a shortage of Oral
Medicine providers?
If so:
 Do we need to produce more practitioners or
specialists?
 What is the number of providers needed to provide
specialty Oral Medicine care?
 How many Oral Medicine specialists are needed to
achieve optimal public benefit?
 How does the addition of specialists affect the cur-
rent and future economic models of health care
delivery in America?
The published literature indicates that Oral Medici-
nists manage many conditions. Oral mucosal disease and
orofacial pain are included in this scope of practice.4
These data lead one to ask whether Oral Medicinists can
make a living financially in the current and future mod-
els of health care delivery diagnosing and managing
patients limited to these conditions. And, if so, how
many practitioners can make a living by practicing in
this manner? Table I illustrates the key aspects of patient
billing relative to this question. In a minimalist scenario,
a provider who sees 8 patients a day and bills and col-
lects, on average, $200 per patient would have 1536
unique patient visits (based on a work schedule of
4 days a week, 48 weeks a year and 60% overhead),
yielding $122,800 in income. Table I further illustrates
the financial parameters associated with alternative
workloads and payment collection efficiencies. These
data suggest that an Oral Medicinist can enjoy a finan-
cially rewarding and durable career and lifestyle.
Within this context, it is important to ask how many
Oral Medicinists are needed in the United States if each
provider limits his or her practice to the conditions
$150/visit $200/visit $250/visit $300/visit
$92,160 $122,880 $153,600 $184,320
$138,240 $184,320 $230,400 $276,480
$184,320 $245,760 $307,200 $368,640
$276,480 $368,640 $460,800 $552,960
OOOO
Volume 126, Number 5
where oral mucosal disease predominates, as presented
in the 2015 survey. Here, we make 3 key assumptions.
First, the majority of patients seeking Oral Medicine
care are typically older than 45 years; this cohort repre-
sents an estimated 62 million eligible patients. Com-
plementary to this assumption is that Oral Medicinists
also manage patients age less than 45 years, including
children.
Second, there may be selected competition for Oral
Medicine management among general dentists, oral
and maxillofacial surgeons, oral and maxillofacial
pathologists, periodontists, otolaryngologists, and
dermatologists.
This competition could result in only 1 in 5 patients
who have said conditions presenting to an Oral Medici-
nist. Additional considerations to the modeling include
the following:
 Only 62% of the adult population seeks care from a
dentist annually.5 This figure, although used in our
modeling framework, likely underestimates the num-
ber of individuals who would seek care from an Oral
Medicine provider. For example, this underestimation
likely occurs in the context of pain motivating patients
to seek care, with billing under medical insurance
plans presumably subsidizing the cost of the visit.
 Only an estimated 5% of the population suffers from
oral mucosal disease,6
9 and potentially only 50% of
these individuals are symptomatic. This likely underesti-
mating paradigm results in a referral base yielding (62
million £ 1/5 £ 0.62 £ 0.05 preva-
lence £ 0.5) = 192,200 patients.
Third, and on the basis of the first two assumptions,
an Oral Medicinist in full-time private practice would
manage at least 1536 patient visits/year, translating to
a need of approximately 125 practitioners with their
practice limited primarily to the management of muco-
sal lesion disease. However, if one expands the practice
of Oral Medicine to include orofacial pain and tempo-
romandibular disorders, evidence then suggests that
there are approximately 30 million people who suffer
from these conditions.10,11 If one then adds in preven-
tive, wellness, and dental care of medically complex/
compromised patients, an additional 25 million
patients are estimated to require oral health care.3
Thus, depending on the type of private practice an Oral
Medicinist seeks to implement, one could interpret that
we have sufficient numbers currently. Furthermore, based
on inclusion of orofacial pain, temporomandibular disor-
ders, medically complex dental care and wellness oppor-
tunities,12 there is a need to increase the number of Oral
Medicinists.
EDITORIAL
Miller 411
There are additional considerations for a maturing
specialty, such as Oral Medicine, directed to surveil-
lance and quality of care. These include the following:
 What percentage of patients receives the standard of
care?
 What percentage of our patients improves with resul-
tant cure, disease stabilization, or remission of the
condition being managed?
 How is “patient improvement” determined and docu-
mented? What are the best outcome measures?
 How can we apply effective strategies to clinical
practice?
 How can knowledge relative to successful prevention
and treatment be disseminated to other practitioners?
 What are the significant gaps in care?
 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
regular basis? What is the percentage of patients
whose conditions have been cured or are in remission
at 1 year, 5 years, and 10 years, and what is the
proper recall interval for specific conditions?
 What percentage of patients experience subsequent
oral and/or systemic complications, as related to the
initial oral lesion and its management by the Oral
Medicine practitioner?
 What percentage of patients seeks care from other
health care providers?
Clearly, answers to these questions are important to
the evolution of our specialty and represent opportuni-
ties for research investigation as well.
The Residency environment (advanced education
programs)
We now turn our attention to the Oral Medicine Resi-
dency programs in relation to the next generation of
Oral Medicine practitioners. Here, the history is rich
with advanced education programs that have trained
many Oral Medicinists. Programs that were initiated in
the late 1960s and early 1970s originated at Indiana Uni-
versity, the University of Washington, the University of
Pennsylvania, and the University of California at San
Francisco. During the 1980s, programs emerged at the
National Institutes of Health, the U.S. Navy, and the
University of Texas Health Science Center at San Anto-
nio. During the last 20 years, there have been programs
at the University of Medicine and Dentistry of New Jer-
sey, Harvard University, the Carolinas Medical Center,
the University of Southern California, and Tufts Univer-
sity, and in the University of Alberta and the University
of British Columbia in Canada. Critical to these training
programs are questions that encompass the number of
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
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Volume 126, Number 5
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
received, (3) free from harm, and (4) truly necessary.
 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
of the importance of Oral Medicine
related health
care issues and the difference we can make in provid-
ing improved quality of life for millions of patients.
 Oral Medicine Residency Program Directors should
be actively engaged in enhancing the curricula and
training experiences that allow for growth in the
numbers of applicants, in the training of residents,
and in the creation of opportunities for externs and
fellows to expand their knowledge base and types of
issues they could be addressing, with consideration
of the needs of the future.
 Continued involvement in the World Workshop of Oral
Medicine (WWOM) remains critical to the collabora-
tive growth of our profession. WWOM VI was con-
ducted in April 2014 in collaboration with the AAOM
in Orlando, FL, USA. Twenty-five countries were rep-
resented in this conference. WWOM VII is scheduled
for September 24
26, 2018, in Gothenburg, Sweden,
in conjunction with the 14th Biennial European Associ-
ation of Oral Medicine Congress, September 27
29,
2018. As with prior World Workshops, the roster of
WWOM VII attendees represents a comprehensive
registry of participants from around the globe.
 Interprofessional education can grow and benefit
from our involvement.14
These activities will require financial, personal,
organizational, and political investments that will
EDITORIAL
Miller 413
stimulate growth and prominence of Oral Medicine
both in clinical practice and at academic centers.
CONCLUSIONS
Oral Medicine continues to mature as a specialty,
grounded in education, science, and its clinical
translation, as well as addressing the unmet health
care needs of Americans. In addition to research as
well as predoctoral dental, fellowship training, and
residency education, Oral Medicine contributes to
interdisciplinary and coordinated care and to the
design and implementation of interprofessional
education curricula to strategically enhance health
care delivery across the country. Specialty recogni-
tion is but one step in positioning our American
Academy of Oral Medicine (AAOM) for promi-
nence within dental medicine, across the health
care enterprise, and in taking a leadership role in
interprofessional education that translates effec-
tively into interprofessional practice. This new
phase represents a strategic time to reflect on how
our patients and the public benefit from the cultiva-
tion of a new generation of academicians, trained
knowledge experts, and clinicians who can and
will be responsible for strategically advancing the
mission of Oral Medicine.
D1X XCraig S. Miller, D2X XDMD, MS
Professor and Chief, Division of Oral Diagnosis, Oral
Medicine, Oral Radiology, University of Kentucky Col-
lege of Dentistry, Lexington, KY, USA
EDITORIAL
414 Miller
3XD XDouglas E. Peterson, D4X XDMD, PhD, FDS RCSEd
Professor and Head, Oral Medicine, Department of
Oral Health and Diagnostic Sciences, School of Dental
Medicine; Co-chair, Head & Neck Cancer/Oral
Oncology Program, Neag Comprehensive Cancer Cen-
ter, UConn Health Farmington, CT, USA
https://doi.org/10.1016/j.oooo.2018.07.001
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Reprint requests:
Craig S. Miller, Professor and Chief
Division of Oral Diagnosis, Oral Medicine, Oral Radiology
University of Kentucky College of Dentistry, 800 Rose Street,
Lexington, KY 40536-0297
USA
cmiller@uky.edu