Vol. 91 No.
3 March 2001
ORAL SURGERY
ORAL MEDICINE
ORAL PATHOLOGY
EDITORIAL
Fragmentation hinders development of diagnostic disciplines
I appreciate the opportunity to serve as the editor of the
Oral Medicine section of this respected Journal, and I
thank my colleagues for the honor. This is a particularly
interesting time to be the editor of the Oral Medicine
section because the advances in clinical medicine,
combined with the turmoil in the health care delivery
system, will have a profound impact on the practice of
oral medicine. These developments bring new challenges
but also new opportunities for academics and clinicians
working in the diagnostic dental disciplines. I encourage
the submission of manuscripts that will inform clinicians
and academics of these important changes so we can
incorporate the relevant advances into our field for the
benefit of our students and patients. The editorial page
will be used to open a serious dialogue with readers of
this Journal about the ways we should be responding to
the social and the economic changes affecting the disci-
plines included in the broad area of oral medicine.
A number of important positive developments have
occurred in the oral medicine–related diagnostic dental
disciplines during the past decade. One encouraging
example is the evolution taking place in the field of
facial pain and temporomandibular disorders. This
field, once largely dominated by the observations and
philosophies of charismatic personalities, is being
nudged into a more rational scientific approach by
academically based clinicians and researchers. Oral and
dental care for patients with serious complex medical
disorders has been advanced by dentists who have made
significant contributions—particularly in the fields of
oral disorders associated with infectious diseases and
oral complications resulting from new cancer therapies.
The work of these investigators and clinicians has
significantly improved the lives of patients with
HIV/AIDS, as well as of cancer patients receiving toxic
cancer chemotherapy regimens, radiation therapy, and
bone marrow transplantation.
New drugs show promise in the management of
severe oral mucosal diseases, salivary gland dysfunc-
tion, and facial pain disorders, and the dentists trained
to use them are skillfully treating patients who previ-
ously received inadequate care. This group of dentists
trained in oral medicine and other diagnostic, nonsur-
gical dental disciplines provides consultation services
to medical and dental colleagues both in large academic
medical centers and in small referral practices. They
have elevated the medical services available to patients
with oral mucosal diseases, salivary gland disorders,
facial pain, and temporomandibular disorders. Patients
with serious medical diseases who require oral and
dental care also have more opportunities to receive
excellent treatment from highly trained dentists.
Even with all these encouraging developments, we are
not advancing nearly rapidly enough to take the steps
required to remain relevant in this fast-moving, highly
competitive health care environment. Small groups of
specialists working in relative isolation will not be able to
compete for research funding, for funding for clinical
programs, or for the best students graduating from dental
schools. One major obstacle impeding the development
of this field is fragmentation. The number of full-time
clinicians and academics devoting their careers to the
diagnostic, nonsurgical fields of dentistry is small, yet
historically we have subdivided ourselves into even
smaller groups, which not only dilutes our academic and
research potential, but seriously undermines our negoti-
ating position with professional organizations, insurance
companies, health maintenance organizations, and health
care facilities. It also confuses potential referring dentists
and physicians, as well as the public, who are perplexed
by our lack of a unified image.
In addition to a major division between oral pathology
and oral medicine, there are completely separate organi-
zations and administrative structures for clinicians with
interest in orofacial pain, oral oncology, oral diagnosis,
and hospital dentistry. It is apparent that these organiza-
tions must find a way to work together closely if the diag-
nostic dental fields are going to have a significant role in
health care in the future. Small groups of interested clin-
icians may have been necessary for the initial develop-
ment of these fields, but separate small organizations
competing for recognition and funding are likely to
receive little attention from professional groups, acad-
emic centers, funding organizations, or the public. We
will have a much greater impact if we combine our
efforts. There are highly talented, skilled individuals in
261
262 Greenberg
each of these organizations. Many of us already belong to
more than one. Imagine the creativity that would be
released if our efforts were combined. Solving the
problem of fragmentation would have a major effect on
several important problems. For example:
1. Presently, a student considering a career in a diag-
nostic, nonsurgical dental specialty must choose
among programs in oral pathology, oral medicine,
hospital dentistry, orofacial pain, and so on. This
choice places limits on students before it is necessary
and discourages some of the best students from
applying to any of the programs. The unification of
these programs would be a major step forward,
allowing for an initial period of combined training
followed by a period of subspecialization in one or
several of the disciplines. This will result in better use
of limited resources and improve training for post-
doctoral students and residents entering the field.
2. Sophisticated, well-financed clinical research in this
field is limited and inadequate. Listing the number of
promising new forms of therapy that remain untested
or inadequately tested would require another long
editorial. If we were to combine disciplines, this
would encourage cooperation among a larger num-
ber of researchers, expanding the opportunity for
increased numbers of well-funded, sophisticated,
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
March 2001
multicentered clinical trials of promising new forms
of therapy. The results of these projects will not only
improve our own discipline, but also substantially
increase our contribution to dental and medical
care in general. A larger number of well-designed
research projects should also improve the quality of
life of new journal editors in this field.
Combining disciplines means more than simply
attending more than one annual meeting or occasionally
negotiating for joint meetings. It requires us to relinquish
our cherished, comfortable academic and social tradi-
tions. It will require hard work and difficult negotiations
to forge a stronger, more powerful discipline from the old
separate organizations. This will be difficult for those of
us who are comfortable with the present structure, but I
believe if we remain fragmented, we will be relegated to
a peripheral position in dentistry and in medicine. If we
unite, we can elevate our importance in dental education,
clinical practice, and research. This will not only improve
our training programs, but also improve the care we are
able to give our patients—and that is the primary reason
we initially chose to enter this challenging field.
Martin S. Greenberg, DDS
Editor, Oral Medicine Section
doi:10.1067/moe.2001.114616