Oral Medicine—the new dental specialty

In the court case American Academy of Implant Dentistry et al. vs Texas State Board of Dental Examiners et al., I was asked, under oath, by the Attorney General of the State of Texas, “What is a specialist?” I replied, “Well, that is a good question. To an extent, it depends on who is making that determination. Do you mean in dentistry? Because there are air conditioning specialists and foreign car mechanic specialists, etc.” The attorney quickly specified, “In regards to dentistry.”

There is still no easy answer to his question because in dentistry the definition is geographically influenced. For example, in Canada, Israel, and many countries in Europe and around the globe, Oral Medicine is a dental specialty. However, in the United States, there are two different opinions on this topic: According to the American Dental Association (ADA), Oral Medicine is not a dental specialty. In contrast, according to the American Board of Dental Specialties (ABDS), Oral Medicine is a recognized dental specialty, based on approval of the application submitted by the American Board of Oral Medicine in 2015.

Of note, in our profession within the United States, the definition of a “dental specialty” has been historically managed by the ADA. Here, for many years, the ADA has defined a “specialty” as an entity that meets all six requirements (as presented at the ADA's website), as determined following review of an application by the Council on Dental Education and Licensure and by vote of the House of Delegates on each individual requirement. Most state dental boards of dentistry agree with this definition and process; to date, nine dental specialties have been recognized by the ADA.

In the past four decades, five emerging specialties (Dental Anesthesiology, Implant Dentistry, Oral Medicine, Oral and Maxillofacial Radiology, and Orofacial Pain) have attempted to gain ADA specialty recognition status. However, only one of the organizations for these specialties, the American Academy of Oral and Maxillofacial Radiology, managed to obtain this status. Oral and Maxillofacial Radiology's recognition was achieved after its application was first rejected, when Peter Sfikas, legal counsel to the ADA, stepped in and convinced the ADA House of Delegates to conduct a revote. The revote most likely took place as a result of pressure from the Federal Trade Commission following its year-long investigation of the ADA's potential restriction of trade; the investigation resulted from the fact that more than 35 years had elapsed between the approval of Endodontics as a specialty and the ADA's vote on Oral and Maxillofacial Radiology.

It is now 2016, and the ADA has recognized only one new dental specialty since 1963. This is, in large part, due to a process that involves the ADA's House of Delegates. Disregarding the political aspects of this process, this situation raises a question: Has the dental profession not advanced in any significant way that would warrant recognition of any new dental specialties? For example, did we know about the existence of such significant pathogens as human immunodeficiency virus, hepatitis C virus, Ebola virus, and Zika virus in 1963? Were antivirals available then? What about antibiotic resistance? Fifty years ago, were patients living as long with medical comorbidities that potentially affect the provision of dental care? Have we not experienced an explosion of technological and scientific advances that include the use of dental implants, genomics and proteomics, recombinant vaccines, many new drugs, biologic agents, and effective immunotherapies for the treatment of autoimmune diseases and cancer since the 1960s? What about regenerative therapies that are likely to result in tooth buds being placed in the near future? Clearly, the escalating pace of knowledge in medicine and dentistry requires that the dental profession keep pace so that our patients continue to benefit.

In the meanwhile, it is not surprising that a new entity has come into existence to fill the gap created by the ADA's inability to keep pace and to recognize emerging dental specialties. This new entity is the American Board of Dental Specialties (ABDS), an organization founded by organizations of aspiring specialties whose stated mission is to encourage further development of the profession of Dentistry through independent recognition of specialty-certifying boards, to improve the quality of care, and ultimately to protect the public. The ABDS requires that applicants demonstrate advanced knowledge and clinical as well as decision-making skills in a field, as demonstrated by passing written and oral examinations, in which candidates are evaluated by using valid, reliable, and calibrated testing methods. Successful achievement of these standards is designated through Board Certification by the respective specialty boards. Accordingly, the ABDS has recognized four new dental specialties since 2012: Dental Anesthesiology, Implant Dentistry, Orofacial Pain, and Oral Medicine. The ABDS invites emerging specialties to apply because the organization believes that dentistry should grow through advanced education programs. Moreover, these new dental specialties now have some weight because the plaintiffs won the court case I mentioned at the beginning of this editorial. Thus, this court ruling allows these newly recognized specialists to advertise that they are dental specialists, at least in the state of Texas, which is a major achievement for the dental profession and the members of the aforementioned Boards and Academies. It is important to acknowledge that this decision is in appeal and that the appeal decision will occur in the U.S. Fifth Circuit Court, which includes Texas, Louisiana, and Mississippi. Although some may think that the Texas ruling has little bearing on other states, the decision opens the door for similar lawsuits to occur in other states, with potential impact from the associated Federal court decision.

So, back to the original question: “What is a dental specialist?” Webster defines a “specialist” as “a person who has special knowledge and skill relating to a particular job, area of study, etc.” I believe this definition is reasonable and covers most of the bases; however, in dentistry a more distinct definition is required. At a minimum, and in my opinion, a dental specialist is a dentist who has graduated and has also received education beyond that of dental school for a defined period in an accredited program or at an accredited institution; who, as a result of his or her education, has acquired advanced knowledge and skills in a particular field; and who has demonstrated this knowledge and skill by passing a certified board examination that employs valid, reliable, and calibrated testing methods. More specifically, the ABDS states that the following criteria are needed for recognition of a dental specialty board:

• 1.
  Reflecting a distinct and well-defined area of expertise in dental practice, above and beyond that provided at the level of predoctoral dental education, that is founded in evidence-based science, contributes to professional growth and education, and directly benefits clinical patient care.
• 2.
  Fostering a clear public and professional understanding that there is single standard of preparation and evaluation in the dental specialty area, only one certifying board can represent the general specialty area.
• 3.
  Requiring a minimum of two full-time, formal, advanced educational programs in recognized educational institutions that are a minimum of 2 years in duration. Current accreditation by the Commission on Dental Accreditation or another recognized accreditation body, or a plan for interim accreditation, must be presented.
• 4.
  Providing evidence of psychometric evaluation of written examinations and processes to ensure consistency in oral examinations for a minimum of five years.
• 5.
  Providing an effective mechanism to maintain certification.
• 6.
  Existing as an independent entity, not under any governance control by a related specialty society or other professional or trade organization, whose main purpose is to evaluate candidates for board certification.

These minimum standards have some similarities to as well as differences from the ADA criteria, and they are an attempt to advance the profession in a manner that reduces the political influences that have arisen in the ADA House of Delegates.

In the context of our modern world, a dental specialist serves as a unique resource for patients, general dentists, and the dental profession. Specialists have advanced knowledge and skill that can be utilized to solve specific patient and public health issues in an efficient manner. As a result, the specialist provides great benefit to the public and to society.

In closing, I wish to make one final point: The state dental boards should take notice of this potential paradigm shift and consider discarding language that limits specialties to only those approved by the ADA. If the state dental boards choose to take this approach, they will need to work with the profession and with legislators to revise the State Dental Practice Acts to expand the scope of dental specialties to include the rubric of the ABDS. The accomplishment of this will lead to advancement of our profession. Alternatively, the state dental boards may resist change, wait to see if a lawsuit will be filed in their states, defend the case if necessary, and potentially spend enormous amounts of money in associated legal fees.