Oral medicine: Two disciplines, one purpose
By Kristen Zapata
When she arrived at the UT Health San Antonio Oral Medicine Clinic at UT Dentistry, Richardine Taylor’s pain had become so debilitating she could no longer tolerate eating. Her mouth had developed ulcers and her sore gums had started to bleed. She needed relief. Not sure what to expect, Taylor waited in the dental chair assigned to David Ojeda Diaz, DDS, assistant professor of oral medicine and board-certified oral medicine diplomate.
“My gums were so inflamed that I went to the emergency dental clinic,” Taylor said. “They examined me, and a dental student quickly walked me into oral medicine. I immediately thought this was serious.”
Taylor had been seen by other providers before visiting the emergency clinic, but left those appointments without a definitive diagnosis or treatment. Little did Taylor know that Ojeda and his students would welcome and guide her on a bridge that had been built between medicine and dentistry — a place where she would find both answers and relief.
“Oral physicians,” “physicians of the mouth” or “oral medicinists” are terms that have been used to describe oral medicine specialists. Their discipline integrates medicine and dentistry to promote the optimal health of a patient. It is primarily a nonsurgical practice that includes the diagnosis and management of oral mucosal, salivary gland and oral complications of systemic diseases. Temporomandibular disorders and orofacial pain as well as the dental management of medically complex patients are also within their scope of work.
In spring 2020, the American Dental Association officially recognized oral medicine as the 11th dental specialty. Although the designation is new, the formal practice of oral medicine in the U.S. began in 1945 when a New York University professor of periodontology, Samuel Charles Miller, DDS, revised his curriculum to integrate dental and medical issues. Along with his colleagues, Miller founded the American Academy of Oral Medicine.
More than 75 years later, the field continues to prove itself to be a diagnostic science that links medicine and dentistry.
“The mouth is much more than just the teeth,” Ojeda said. “In the mouth we have many tissues like the lips, gums, cheeks, palate and tongue from which pathology can arise. Often some of the first signs of a systemic condition can manifest in the mouth. For example, gastrointestinal, autoimmune and hematologic conditions can affect the mouth even before affecting other organs and can be the patient’s initial complaint.”
Over 300 diseases can occur within and around the mouth. Many are unique to the oral region, while others can spread there from other parts of the body.
“Not only systemic conditions can affect the mouth,” explained Ojeda. “We know oral conditions can also affect systemic health. For example, advanced periodontal disease can influence optimal glycemic control in diabetic patients and cause preterm or low weight at birth. This is proof of the bidirectional relationship of oral and systemic health.”
Armed with this evidence and a strengthening alliance with local physicians and dentists, oral medicinists are equipped to bridge the historical gap between the two practices for patients like Taylor.
The art of listening
Some conditions affecting the mouth can be difficult to diagnose.
“This is because they often share symptoms and mimic other conditions, but if you develop the skill of listening, 70% of the time, you can reach an accurate preliminary diagnosis even before physically evaluating a patient,” Ojeda said.
Michaell A. Huber, DDS, retired professor of oral medicine and class of 1980 alum, agrees that listening to a patient is the bedrock upon which oral medicinists construct their findings.
“In routine practice, dentists ask a battery of questions like, ‘Do you have high blood pressure or diabetes?’” Huber said. “However, when assessing why the patient has come to us for an evaluation, we often have to dig much deeper into their medical history, and we encourage them to tell us everything they can regarding their complaint. It’s not uncommon for us to spend up to an hour listening to the patient before we ever examine them. But that diligent listening often uncovers critical clues to help us determine the diagnosis.”
Mastering the skills of communication and critical thinking are precisely what Ojeda and Tiffany Tavares, DDS, DMSc, clinical assistant professor of oral medicine, strive to teach their students.
“From the school’s inception, our university has given consideration to oral medicine,” Ojeda said. “We have been given space and opportunity alongside the other dental disciplines. Unfortunately, not every dental school has the ability to give their students real experience in an oral medicine practice. Other schools expose their students to the concepts in lectures, but our students have the advantage of meeting the patients and seeing the conditions firsthand. That is a different level of learning.”
During students’ first two years in the School of Dentistry, they are enrolled in nine courses covering medical science, where they also learn about conditions affecting the mouth. In their third year, students take a course exclusively dedicated to oral medicine.
“It was extensive,” said senior dental student Rodrigo Guerrero. “I think the fact that the curriculum integrated multiple topics together allowed for effective learning and understanding of various pathologic conditions.”
During the course, students attend a weeklong rotation in the oral medicine clinic. Senior dental student Rachel Boice appreciated the exposure to the clinic’s patients because it allowed her to apply the lecture information in a real-world, clinical setting.
“I knew we would go through the health history process, and I wanted to tie all we had learned together,” Boice said. “By the end of the week, I did. The patient would come in, and we would work through our process together. It was like a puzzle. I liked the ability to give them peace of mind, to tell them that we can work through their condition.”
After clinic, students would meet to discuss cases as a group with Ojeda and Tavares, who would reinforce the findings with a short lecture.
“To my surprise, I encountered some very important conditions,” Guerrero said. “I found it extremely helpful and engaging.”
Guerrero and Boice agree that the clinical component of oral medicine greatly added to their overall educational experience, something Ojeda said makes teaching in the clinical setting especially rewarding.
“In the classroom, the students learn all sorts of facts about conditions, but they never have that ’aha!’ moment until they see it in real life,” Ojeda said. “One of the most gratifying feelings as a faculty member is seeing a student working on a patient and watching their eyes search around as they begin to put the pieces together. You can see the moment when it becomes so clear to them the significance of what we do — that’s the beauty of teaching in the clinic.”
Exposing students to oral medicine patients also gives them an edge as providers who pursue differential diagnoses and recognize when a patient referral is necessary.
“Just the clinical experience in itself makes a better provider,” Ojeda said. “I feel confident that our graduates leave with a strong background in medicine, so they will know what to do when facing complex situations.”
The road to recovery
Once Taylor was escorted to the oral medicine clinic, Ojeda collected her medical history, listened to her chief complaints of intense pain, ulcers and soreness of her gums. He then examined her and discovered lesions beginning to develop on her face. Ojeda followed the diagnostic process and conducted a biopsy of Taylor’s mouth.
“I didn’t feel a thing,” Taylor said. “The whole appointment was smooth, and Dr. Ojeda is a very clear communicator. He shared the possibilities with me, so when the results came back, I knew more or less what to expect.”
Taylor was soon diagnosed with mucous membrane pemphigoid. This rare and chronic autoimmune disorder is characterized by lesions that affect the body’s mucous membranes such as those in the mouth, eyes and nose. The severity of symptoms varies by individual; however, lesions caused by the disorder can potentially lead to scarring, causing severe complications affecting the mouth and eyes.
In Taylor’s case, shortly after her diagnosis, she developed blistering skin lesions all over her body, including her scalp. As the lesions healed, the scarring on her scalp obstructed new hair growth, leading to alopecia. Another skin biopsy revealed that Taylor had developed a rare cross-over syndrome called lichen planus pemphigoides, characterized by a rash and skin lesions of various sizes.
For the past five years, Ojeda has coordinated Taylor’s long-term care alongside her dermatologist, ophthalmologist and primary care provider.
“She is a very compliant patient,” Ojeda said. “She is doing great and living a normal life. That makes me happy.”
Taylor is pleased with her experience in the oral medicine clinic and feels that in navigating her autoimmune conditions, she couldn’t have found a better treatment team.
“I personally feel you get the best care in a teaching practice,” Taylor said. “The interactions I’ve had with Dr. Ojeda and the dental students have been great. The coordination and communication with my doctors have been so smooth. I don’t know what I would have done, because I can’t imagine getting this kind of care elsewhere. I have to say, they really saved me.”
Crusading for awareness
In April, the School of Dentistry hosted the nation’s largest 2022 Oral Cancer Walk. Led by David Ojeda Diaz, DDS, assistant professor of oral medicine, the event was held in observation of Oral Cancer Awareness Month to raise funding toward advances in research, patient support and awareness of the disease. More than 250 survivors and their families attended the event. Student and faculty volunteers from the School of Dentistry and the School of Nursing provided free oral cancer screenings and human papillomavirus vaccinations to attendees.
Tiffany Tavares, DDS, DMSc, clinical assistant professor of oral medicine, said events such as the walk provide a national platform that reaches patients and providers with information on disease prevention and the practice of oral medicine.
“We have patients who come from Austin, South Texas and even some patients from Dallas,” she said. “In general, about half of our referrals come from community providers and half of those are referred from medical providers. I think the medical community is very willing to partner with oral medicine.”
Although they have a robust referral base, they know that there are many medical and dental providers who are unaware of their services, she said.
“The need for oral medicine is great, so there is always work to be done on the exposure and awareness front,” Tavares said.