General Overview of Residency
The department of Oral Medicine focuses its activities on the diagnosis and treatment of the following major entities:
v Oral mucosal lesions
v Orofacial pain (acute and chronic)
v Sensory neuropathies of the trigeminal nerve
v Salivary gland dysfunction
v Dental treatment of the medically compromised patient
v Dental treatment employing sedation and general anaesthesia
The aim of the resident program is to train postgraduate students and to enable successful candidates to attain clinical and theoretical expertise in these areas. The residents are trained for a total of 4 years at the end of which candidates need to complete a 2-part examination from the Israel Ministry of Health in order to attain the Oral Medicine Specialist diploma. On completion of the training period and examination candidates should have all the necessary skills and knowledge to independently fulfill duties as an Oral Medicine specialist in both public and private sectors. The training program places particular emphasis on the acquisition of a routine of continuous self-education to consistently maintain a high level of knowledge.
According to the requirements of the Israel Ministry of Health candidates are required to complete the following training periods:
Two and a half years within an Oral Medicine Department
v A 3 month rotation in each of the following
§ Pathology
§ Internal Medicine
§ Oral Radiology
§ One of other recognized departments in recognized institutes
v A six month rotation in basic science research
At the beginning of the resident program candidates are required to enroll in the Israel Dental Association that oversees all postgraduate training in Israel.
In order to achieve these goals the candidates are exposed to the specialist clinics that run on a day-to-day basis in the department. The activities of these clinics are detailed below. As the training advances candidates take a more active role in the diagnostic and therapeutic processes. Additionally the candidates are expected to participate in clinical studies, departmental seminars, teaching of undergraduate students, and in national and international conferences.
Oral Mucosal Lesions
This clinic deals with the diagnosis and treatment of soft tissue lesions as a result of various pathological processes. Training in this clinic is aimed at enabling the candidate to successfully diagnose, treat and follow-up the spectrum of lesions of the oral mucosa and include:
Diagnostic process: Physical assessment of the patient including examination of the head and neck and the oral mucosa. The candidates will be exposed to the correct use of additional diagnostic aids such as tissue staining (toluidine blue), culture swabs, deep cytology, biopsy and various staining techniques including immunohistochemistry, imaging, blood serology haematology and biochemistry, and tissue antigen typing.
Treatment: Candidates are exposed to a wide variety of topical and systemic therapies prescribed as a result of the diagnostic process. Candidates will be expected to achieve a high level of knowledge in regards to the clinical pharmacology of the commonly employed drugs. Areas of therapeutic expertise include:
v Infectious diseases of the oral mucosa: Viral diseases, fungal diseases, chronic infections, viral latency, infections and cancer, autoimmunity: immune system activity.
v Immuno-dermatoses: Pemphigus vulgaris, Pemphigoid, Dermatitis herpetiformis, Linear IgA disease, Oral Lichen Planus.
v Recurrent aphthous ulceration: Aphtous stomatitis, Aphthae as manifestations in systemic diaease: Crohn’s, Ulcerative colitis, Coeliac disease and Behcet’s disease.
v Oro-Facial Granulomatosis: Sarcoidosis, Tuberculosis, Syphilis, Wegener’s, Melkerson-Rosenthal, Miescher’s, Cat-Scratch disease, Toxoplasmosis, Histoplasmosis
v Allergic stomatitis: Oral therapy
v Burning Mouth Symptoms
v Disorders of Pigmentation: hereditary, drug induced, endocrine, syndromes, manifestation of occult cancer, melanoma. Normal pigmentation, intrinsic and extrinsic factors altering pigment concentration: naevi in the oral cavity, Peutz Jegher’s Syndrome, Addison disease, Laugier Hunziker Syndrome, Acanthosis nigricans.
v Cancer and Precancerous conditions of the Oral mucosa: Risk factors; Epidemiology: the phenomenon of malignant transformation, serological markers, prevention.
Literature
1. Neville BW, Damm DD, Allen CM, Bouquot JE (Eds): Oral & Maxillofacial Pathology, W B Saunders Co. Philadelphia, PA., 1995. Chapters: 1, 4, 5, 6, 7, 8, 9, 10, 12, 16, 17.
2. Langlais RP, Miller CS (Eds): Color Atlas of Common Oral Diseases, Second Ed. Lippincott Williams & Wilkins, Philadelphia, PA., 1998. Sections IV (p. 44-78), V, VI.
3. Eisen D, Lynch DP (Eds): The Mouth, Diagnosis and Treatment, Mosby, St Louis 1998. Chapters: 5, 6, 7, 8, 9, 10,15.
4. Silverman S Jr. (Ed): Oral Cancer, Fourth Ed., BC Decker Inc., Hamilton 1998
Additionally the resident is required to be familiar with recent articles that will be reviewed together with a senior member of the departmental staff within a framework of seminars (30 hours).
Chronic Orofacial Pain and Sensory Neuropathies
This clinic deals with the diagnosis and treatment of chronic orofacial pain including temporomandibular disorders. Sensory trigeminal neuropathies are diagnosed, assessed, and followed up with qualitative sensory testing that includes thermal, mechanical, and electrical modalities. The diagnostic criteria employed in the clinic are based on accepted classification systems as published by:
The International Headache Society
Headache Classification Committee of the International Headache Society. Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias and Facial Pain. Cephalalgia. 1988. 8(suppl 7).
The International Association for the Study of Pain
Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definition of Pain Terms. Merskey H, Bogduk N. (eds), 2nd edn. Seattle, IASP Press. 1994:68-71.
The American Academy of Orofacial Pain
Okeson J.P. Orofacial Pain: Guidelines for Assessment, Diagnosis and Management. Quintessence Pub. Co. Inc. Chicago 1996
In addition the diagnostic process involves the use of a variety of special tests including imaging.
The resident is given experience in the following processes:
v Collection of a pain history
v Physical examination of craniofacial pain patients
o Temporomandibular joint
o Muscles of mastication
o Cranial nerve examination
v Use of special tests for diagnosis and follow up
o Computerized tomography
o Serum drug levels
v Logical formation of a differential diagnosis based on the above classification systems
v The correct choice of therapy and dosing as relevant for each diagnosis
The standard modes of treatment for primary facial pain or headache include pharmacological treatment, physical therapy and other accepted therapeutic modes. In cases where a diagnosis of pain secondary to a pathological process is made treatment is offered in conjunction with other relevant departments.
The resident is required to attain proficiency and knowledge in the following areas:
v Basic anatomy and physiology of the nervous system
v Detailed anatomy of the cranial nerves in particular nerves V, VII, IX and XII.
v The sensory, motor and autonomic innervation of craniofacial structures
v The pharmacology of impulse transmission
v The measurement of pain in humans
v Psychological aspects of chronic pain and its treatment
v General principles of pain assessment and treatment goals
v Clinical pharmacology of commonly employed drugs
o Antidepressives (noradrenaline and serotonin reuptake inhibitors)
o Non steroidal anti-inflammatory drugs and analgesics
o Antiepileptics and sodium channel blockers
o Opioids
v Myofascial pain syndromes and temporomandibular disorders
v Neuropathic pain syndromes
v Vascular pain syndromes
v Dental Pain
v Pain secondary to trauma or other pathological process
v Pain models in experimental animals, in particular those relating to the trigeminal system
Basic Texts
In addition to the above-mentioned classification systems the following texts and reviews are necessary reading material.
1. Headache Classification Committee of the International Headache Society (1988). "Classification and diagnostic criteria for headache disorders, cranial neuralgia, and facial pain." Cephalalgia 8(Suppl 7): 1-96.
2. Merskey, H. and N. Bogduk (1994). Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definition of Pain Terms. Seattle, IASP Press.
3. Okeson, J. P. (1996). Orofacial Pain: Guidelines for assessment, classification, and management. The American Academy of Orofacial Pain. Illinois, USA., Quintessence Publishing Co., Inc.
4. Olesen, J., P. Tfelt-Hansen, et al., Eds. (2000). The Headaches. Philadelphia, USA, Lippincott Williams & Wilkins.
5. Sharav, Y. and R. Benoliel (1993). Temporomandibular pain. Progress in Fibromyalgia and Myofascial Pain. H. Vaeroy and H. Merskey. Amsterdam, Elsevier Science Publishers BV. 6: 237-252.
6. Wall, P. D. and R. Melzack, Eds. (1999). Pain. London, UK., Churchill Livingstone.Textbook of Pain 4th Ed., Churchill Livingstone, Edinburgh 1999 (Chaps. 1-11, 14,16,31-36,49-53)
7. Bradley RM., Essentials of Oral Physiology, Mosby, St. Louis 1995. (Chaps. 2-5, 8, 10)
Review and Recommended Articles
Reading material will be covered within seminars (30 hours) over the residency period.
Salivary Dysfunction Clinic
This clinic deals with the diagnosis and treatment of dysfunction of the major salivary glands and the management of xerostomia and ensuing oral health problems.
Required knowledge
Knowledge in the following basic areas is required:
v Anatomy and neuroanatomy of the salivary glands
v Histology and histopathology of salivary gland tissue
v Salivary gland physiology: physiology of secretion
o Flow rate; saliva composition; Hyposalivation & xerostomia
The training period is aimed at giving the resident all the necessary knowledge and skills so that he/she may efficiently perform the following tasks:
v Perform all relevant clinical tests and examination
v Choose the correct special tests to perform for each case
v Correctly interpret common imaging techniques employed in salivary gland assessment
v Be able to correctly diagnose cases on the basis of the above
v Select appropriate treatment modalities for each case
v Instruct patients on measures to prevent secondary oral health problems.
The resident is exposed to patients with salivary gland disorders as a result of various physiological, pathological, metabolic, autoimmune and drug induced mechanisms and include the following areas:
Areas of activity
1. Imaging techniques
§ Plain radiography
§ Sialography
§ Computed sectional imaging: CT, CT sialography, MRI, MR sialography, spectroscopy
§ Noncomputed tomographic sialography:
§ Ultrasound, scintigraphy, angiography, catheter dilatation and endoscopy, fine needle aspiration, positron emission tomography scanning.
2. Dysfunction and Disease of the Salivary Glands
· Salivary function and aging
· Developmental Anomalies Sialorrhea
· Dysfunction of Salivary Gland Secretion
- Environmental
o Psychogenic
o Iatrogenic
· Systemic disease
· Autoimmune conditions
o E.g. Sjögren’s syndrome
· Granulomatous diseases
· Neurological disorders
o Parkinson’s
· Infectious
o Acute, chronic
o Viral, bacterial
o Acute (suppurative) sialadenitis, chronic recurrent parotitis, epidemic (mumps) parotitis
· Inflammatory
· Chronic recurrent sialoadenitis
· Sialodochitis fibrinosa (Kussmaul’s disease)
· Cystic processes
o Congenital cysts
o Acquired cysts
· Tumors and tumor-like conditions
o Epithelial tumors
o Nonepithelial tumors
§ Miscellaneous
· “Iodine mumps”
· Recurrent juvenile parotitis
· Sialolithiasis
3. Saliva and oral health:
Dental caries, periodontal disease, candidal infections
4. Treatment of salivary gland impairment
· Sialogogues
· Saliva substitutes
· Salivary endoscopy
5. Saliva as a diagnostic tool
1. Mandel L, Surattanont F. Bilateral parotid swelling: a review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002 Mar;93(3):221-37.
2. Bell M, Askari A, Bookman A, Frydrych S, Lamont J, McComb J, Muscoplat C, Slomovic A. Sjogren's syndrome: a critical review of clinical management. J Rheumatol. 1999 Sep;26(9):2051-61.
3. Haneji N, Nakamura T, Takio K, Yanagi K, Higashiyama H, Saito I, Noji S, Sugino H, Hayashi Y. Identification of alpha-fodrin as a candidate autoantigen in primary Sjogren's syndrome. Science. 1997 Apr 25;276(5312):604-7.
4. Fox RI. Sjogren's syndrome: evolving therapies. Expert Opin Investig Drugs. 2003 Feb;12(2):247-54.
5. Garcia-Carrasco M, Ramos-Casals M, Rosas J, Pallares L, Calvo-Alen J, Cervera R, Font J, Ingelmo M. Primary Sjogren syndrome: clinical and immunologic disease patterns in a cohort of 400 patients. Medicine (Baltimore). 2002 Jul;81(4):270-80.
6. Vitali C, Bombardieri S, Jonsson R, Moutsopoulos HM, Alexander EL, Carsons SE, Daniels TE, Fox PC, Fox RI, Kassan SS, Pillemer SR, Talal N, Weisman MH; European Study Group on Classification Criteria for Sjogren's Syndrome. Classification criteria for Sjogren's syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis. 2002 Jun;61(6):554-8.
7. van Doornum GJ, Lodder A, Buimer M, van Ameijden EJ, Bruisten S. Evaluation of hepatitis C antibody testing in saliva specimens collected by two different systems in comparison with HCV antibody and HCV RNA in serum. J Med Virol. 2001 May;64(1):13-20.
8. Turner RJ, Sugiya H. Understanding salivary fluid and protein secretion. Oral Dis. 2002 Jan;8(1):3-11.
9. Pedersen AM, Bardow A, Jensen SB, Nauntofte B. Saliva and gastrointestinal functions of taste, mastication, swallowing and digestion. Oral Dis. 2002 May;8(3):117-29.
10. Streckfus CF, Bigler LR. Saliva as a diagnostic fluid. Oral Dis. 2002 Mar;8(2):69-76.
11. Ship JA. Diagnosing, managing, and preventing salivary gland disorders. Oral Dis. 2002 Mar;8(2):77-89.
12. Salivary gland pathology, chapter 11 In: Oral & Maxillofacial Pathology 2nd Edition. Neville, Damm, Allen, Bouquot. W.B. Saunders company. 2002.
13. Salivary Glands: Anatomy and Pathology chapter 39 In: Head and Neck Imaging 4th edition. Som PM, Curtin HD. Mosby 2003.
Dental Treatment for the Medically Compromised Patient
This clinic treats patients with systemic illnesses that need treatment planning modifications and attention to the delivery of dental treatment.
Residents receive and personally treat a selection of patients with different medical problems employing currently accepted protocols. In general the problems with treating these patients lie in the following areas:
· The spread of infection
· Bleeding and coagulation
· Impaired healing
· Immune deficient
· Replacement therapies
Particular areas of expertise are acquired in the following topics:
· Infective endocarditis
· Rheumatic fever, reheumatic heart disease and murmurs
· Congenital heart disease
· Surgically corrected cardiac and vascular disease
· Hypertension
· Ischemic heart disease
· Cardiac arrhythmias
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