The Residency Program of Oral Medicine

Speciality Training in Oral Medicine

General Overview of Residency Program
The Department of Oral Medicine focuses its activities on the diagnosis and treatment of the following sub-specialties:

  • oral mucosal lesions
  • orofacial pain (acute and chronic)
  • sensory neuropathies of the trigeminal nerve
  • salivary gland dysfunction
  • dental treatment of the medically compromised patient
  • dental treatment employing sedation and general anaesthesia

The aim of the residency program is to train postgraduate students and enable successful candidates to gain experience in clinical and theoretical aspects. The residency program is 4 years long, at the end of which candidates need to complete a 2-part examination from the Israel Ministry of Health in order to qualify for a diploma in Oral Medicine.

Upon successful completion of both the training period and examination, candidates are equipped with the necessary skills and knowledge to perform 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 in order to keep up-to-date in the field.

According to the requirements of the Israel Ministry of Health candidates are required to complete the following training periods:

2 1/2 years in the Oral Medicine Department
This includes a 3-month rotation in each of the following areas:

  • Pathology
  • Internal Medicine
  • Oral Radiology
  • One of other recognized departments in recognized institutes

Six-month rotation in basic science research

At the beginning of the resident program candidates are required to enroll in the Israel Dental Association. This association is responsible for overseeing all dental postgraduate training in Israel.

Candidates are exposed to the specialist clinics that run on a day-to-day basis in the department. 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.

Specialty Areas in Oral Medicine

Oral Mucosal Lesions
This clinic offers 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:

Related Literature:
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.
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.
Eisen D, Lynch DP (Eds): The Mouth, Diagnosis and Treatment, Mosby, St Louis 1998. Chapters: 5, 6, 7, 8, 9, 10,15.
Silverman S Jr. (Ed): Oral Cancer, Fourth Ed., BC Decker Inc., Hamilton 1998

Chronic Orofacial Pain and Sensory Neuropathies
This clinic provides 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 part of the entire process, which includes:

  • getting a patient's history (particularly related to the pain they are experiencing)
  • physical examination of craniofacial pain patients
  • temporomandibular joint
  • mastication muscles
  • examination of the cranial nerve
  • special tests for diagnosis and follow up
  • computerized tomography
  • serum drug levels
  • logical formation of a differential diagnosis based on the above
  • classification systems
  • learning how to choose the correct therapy

The resident is required to be proficient in the following areas:

  • basic anatomy and physiology of the nervous system
  • detailed anatomy of the cranial nerves in particular nerves V, VII, IX and XII.
  • the sensory, motor and autonomic innervation of craniofacial structures
  • the pharmacology of impulse transmission
  • the measurement of pain in humans
  • psychological aspects of chronic pain and its treatment
  • general principles of pain assessment and treatment goals
  • clinical pharmacology of commonly employed drugs
  • antidepressents (noradrenaline and serotonin reuptake inhibitors)
  • non-steroidal anti-inflammatory drugs and analgesics
  • antiepileptics and sodium channel blockers
  • opioids
  • myofascial pain syndromes and temporomandibular disorders
  • neuropathic pain syndromes
  • vascular pain syndromes
  • dental pain
  • secondary pain due to trauma or other pathological process
  • pain models in experimental animals, in particular those relating to the
  • trigeminal system

Related Literature
In addition to the above-mentioned classification systems the following texts and reviews are necessary reading material.

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.
Merskey, H. and N. Bogduk (1994). Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definition of Pain Terms. Seattle, IASP Press.
Okeson, J. P. (1996). Orofacial Pain: Guidelines for assessment, classification, and management. The American Academy of Orofacial Pain. Illinois, USA., Quintessence Publishing Co., Inc.
Olesen, J., P. Tfelt-Hansen, et al., Eds. (2000). The Headaches. Philadelphia, USA, Lippincott Williams & Wilkins.
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.
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)
Bradley RM., Essentials of Oral Physiology, Mosby, St. Louis 1995. (Chaps. 2-5, 8, 10)

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.

Residents must be proficient in the folowing areas:

  • Anatomy and neuroanatomy of the salivary glands
  • Histology and histopathology of salivary gland tissue
  • Salivary gland physiology: physiology of secretion
  • Flow rate; saliva composition; Hyposalivation & xerostomia

The training period is gives the resident the necessary knowledge and skills so that s/he may efficiently perform the following:

  • Perform all relevant clinical tests and examination
  • Choose the correct special tests to perform for each case
  • Correctly interpret common imaging techniques employed in salivary gland assessment
  • Be able to correctly diagnose cases on the basis of the above
  • Select appropriate treatment modalities for each case
  • Instruct patients on measures to prevent secondary oral health problems.

The resident helps treat patients suffering from salivary gland disorders as a result of various physiological, pathological, metabolic, autoimmune and drug induced mechanisms. The treatment methods include the following:

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.

Dysfunction and Disease of the Salivary Glands

  • Salivary function and aging
  • Developmental Anomalies Sialorrhea
  • Dysfunction of Salivary Gland Secretion
  • Environmental
  • Psychogenic
  • Iatrogenic
  • Systemic disease
  • Autoimmune conditions
  • E.g. Sjögren's syndrome
  • Granulomatous diseases
  • Neurological disorders
  • Parkinson's
  • Infectious
  • Acute, chronic
  • Viral, bacterial
  • Acute (suppurative) sialadenitis, chronic recurrent parotitis, epidemic (mumps) parotitis
  • Inflammatory
  • Chronic recurrent sialoadenitis
  • Sialodochitis fibrinosa (Kussmaul's disease)
  • Cystic processes
  • Congenital cysts
  • Acquired cysts
  • Tumors and tumor-like conditions
  • Epithelial tumors
  • Nonepithelial tumors
  • Miscellaneous
  • "Iodine mumps"
  • Recurrent juvenile parotitis
  • Sialolithiasis

Saliva and Oral Health:

  • Dental caries
  • periodontal disease
  • candidal infections

Treatment of salivary gland impairment

  • Sialogogues
  • Saliva substitutes
  • Salivary endoscopy

Saliva as a diagnostic tool

Salivary Gland References

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 treat patients with different medical problems employing currently accepted protocols. In general the problems with treating these patients include:

  • 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
  • Congestive heart failure
  • Pulmonary disease
  • Chronic renal failure and dialysis
  • Liver disease
  • Gastrointestinal disease
  • Sexually transmitted diseases
  • AIDS and transmitted diseases
  • Arthritis
  • Neurologic disorders
  • Diabetes
  • Adrenal insufficiency
  • Thyroid diseas
  • Pregnancy and breast-feeding
  • Allergy
  • Bleeding disorders
  • Blood dyscrasias
  • Oral cancer
  • Behavioral and psychiatric disorders
  • Organ transplantation
  • Prosthetic implants

Required Textbooks

Little J.W., Falace D.A., Miller C.S., Rhodus N.L.: Dental Management of the medically compromised patient, 6th Ed. Mosby St. Louis, 2003.

Recommended reading

Physiology

Ganong W.F.: Review Of Medical Physiology Appleton & Lange, Stanford 18th Ed. 1997 (Autonomic nervous system, Endocrinology and Metabolism, Circulation and cardiovascular homeostasis, Respiration, Renal function).

Clinical Pharmacology

Hardman J. G., Limbird L.E., Goodman & Gillman's: The pharmacological basis of therapeutics, 9th Ed., McGraw hill, New York 1996 Central nervous system, synaphic & neuroeffector junction, inflammation, cardiovascular, gastrointestinal, microbial diseases, blood forming organs.

Further Reading

Malamed S.: Emergencies in the medical office, 5th Ed. Mosby St. Louis, 2000.
Scully C., Cawson R.A.: Medical Problems in Dentistry, 4th Ed., Bristol Wright, 1998
Bricker S.L., Langlais R.P., Miller C.S. eds: Oral Diagnosis, Oral Medicine & Treatment Planning, Philadelphia, Lea & Febiger 1994
Sonis S.T., Fazio R.C., Fang L.: Principles and Practice of Oral Medicine, 2nd Ed. WB Saunders 1995

Current Editions of:

The Merck Manual of Diagnosis and Therapy
The Washington Manual of Medical Therapeutics
Harrison's Principles of Internal Medicine

Dental Treatment Under Sedation or General Anesthesia

This clinic treats patients with systemic illnesses, physical or mental handicaps, and dental phobia who require sedative or anesthetic techniques in order to be treated. The aims of this program are to teach the residents the following knowledge and skills:

Identification of patients needing sedation/general anesthesia.
Pharmacology of analgesic and anxiolytic drugs
Physical examination of the patient
Select the most appropriate technique for each individual case
Indications and contraindications and complications of each technique
Safe and efficient delivery of sedation techniques: IV, nitrous oxide.
Correct preparation of patients prior to general anesthesia
Correct monitoring of patients
Management of emergencies

Recommended Reading

American Dental Association, Council on Dental Education: Guidelines for teaching the comprehensive control of pain and anxiety in dentistry. J Dent Educ 36:62, 1972 updated Oct 2002.
American Dental Society of Anesthesiology: Guidelines for the teaching of pain and anxiety control and management of related complications in the continuing education program part III, Anesth Prog 26:51, 1979.
American Dental Association, Council on Dental Education: Guidelines for teaching the comprehensive control of pain and anxiety in dentistry. Chicago, 1993 the Association.
American Academy of Pediatric Dentistry: Guidelines for elective use of conscious sedation, deep sedation and general anesthesia in pediatric patients. In 1992 -1993 reference manual, Chicago 1993, The sacademy.
American Academy of periodontology, Research, Science, and Therapy committee: Guidelines for the use of conscious sedation in preiodontics. Chicago, 1992, the Academy
Malamed SF: Continuing education in intravenous sedation: Part 2, complications and non-use, Anesth Prog 28:158, 1981.
American Dental Association, ADA Position and statements. The use of conscious sedation and general anesthesia in dentistry: November 11, 1999.
Clayton E, Mackie IC. Conscious sedation - A referral guide for dental practitioners SAAD & Dental Sedation Teaching Group: British Dental Journal, 194, 561-5 2003.
General Anesthesia, Sedation and resuscitation in dentistry. Report of an Expert Working Party, prepared for the Dental Advisory Council. London, March 1990. Gale E: Fears of the dental situation. J Dent. Res51:964,1972.
Rosenberg M, Weaver J: General anesthesia, Anesth Prog 38(4-5)172, 1991.
Brady WF, Martinoff JT: Validity of health history data collected from dental patients and patient perception of health status, JADA 101:642, 1980.
Rosenberg MB, Campbell RL: Guidelines for intraoperative monitoring of dental patients undergoing conscious sedation, deep sedation, and general anesthesia, Oral Surg 71:2, 1991
Ries AL, Prewitt LM, Johnson JJ: Skin color and ear oxymetry, Chest 96:287, 1989.
Barberf J, Mayer D: Evaluation of the efficacy of and the neural mechanism of hypnotic analgesia procedure in experimental and clinical dental pain. Pain 3:41, 1977.
Lieblich SF, Horswell B: Attenuation of anxiety in ambulatory oral surgery patients with oral triazolam, J Oral Maxillofac Surg 49:792, 1991.
Tolksdorf W, Eick C: Rectal, oral and nasal premedication using midazolam in childrens aged 1-6 years: a comparative clinical study, Anaesthetist 40(12):661, 1991.
Jansen ST, Coke JM, Cohen L: Intramuscular injection technique, JADA 100: 700, 1980.
London MJ, Thhthill VJ: Effect of nitrous oxide on placental methionine synthase activity, Br J Anaesth 58(5):524, 1986.
Council on Dental Therapeutics, ADA: list of accepted products, JADA 105:940, 1982.
G, Zieglgänsberger w, Haselneder R, Schneck H.Nitrous oxide and xenon increase the efficacy of GABA at recombinant mammalian GABAA recetpros. Hapfelmeier Anesth Analg 200;91:1542-9
Jastak JT, Orendorff D: Recovery form nitrous oxide sedation, Anesth Prog 22:113, 1975.
Houck WR, Ripa LW: Vomiting frequency in children administration of nitrous oxide-oxygen in analgesic doses, J Dent Child 38:404, 1971.
Roowland AS, Baird DD, Weinberg CR et al: Reduced fertility among women employed as dental assistants exposed to high levels of nitrous oxide, N Engl of Med 327 (14) :993, 1992.
Agarwal RK, Kugel G, Karuri A, Gwosdow AR, Kuma MSA. Effect of low and high doses of N2O on preenkephalin mRNA and its peptide methionine enkephalin levels in the hypothalamus. Brain research 1996(730 47-51
Kugel G, Zive M,, Agarwal K R, Beumer RJ, Kumar MA.Effect of N2O on the concentration of opioid peptides, substance P, and LHRH in the brain and β-endorphin in the pituitary. Anesthesia Progress 38;206-211 1991.

Recommended Journals of Oral Medicine

Oral Oncology
Critical Reviews in Oral Biology and Oral Medicine
Oral Surgery, Oral Medicine, Oral Pathology, and Endodontics.
Pain (Elsevier)
Journal of Orofacial Pain
American Family Physician

Seminars

Residents help to organize and deliver a total of 30 hours of seminars in each of the topics detailed above.

Case Studies

Residents are required to collect and document a total of 35 cases in each of the clinics listed above. In addition residents are required to collect 2 sets of patients with similar disorders from each clinic.

For details please contact:
Ms. Dorit Haar
(9722) 6776140