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World Workshop on Oral Medicine VI: an international validation study of clinical competencies for advanced training in oral medicine John C. Steele, MB ChB, BDS, MFDS RCSEd, FDS (OM) RCSEd, Dip Oral Med, PGCTLCP, FHEA,a Hadleigh J. Clark, BSc, BDS, MB ChB,b Catherine H.L. Hong, BDS, MS,c Sabine Jurge, DDS, MBBS, MSc, MFDS RCS, FHEA,d Arvind Muthukrishnan, BDS, MDS, Dip Oral Med, MFDS RCPS (Glasg),e A. Ross Kerr, DDS, MSD,f David Wray, MD (Hons), BDS, MB ChB, FDS RCPS (Glasg), FDS RCSEd, F Med Sci.,g Linda Prescott-Clements, PhD, PhD, MHPE (Hons), BSc (Hons), PFHEA,h David H. Felix, BDS, MB ChB, FDS RCS (Eng), FDS RCPS (Glasg), FDS RCSEd, FRCP (Edin),i and Thomas P. Sollecito, DMD, FDS RCSEdj Objective. To explore international consensus for the validation of clinical competencies for advanced training in Oral Medicine. Study Design. An electronic survey of clinical competencies was designed. The survey was sent to and completed by identified international stakeholders during a 10-week period. To be validated, an individual competency had to achieve 90% or greater consensus to keep it in its current format. Results. Stakeholders from 31 countries responded. High consensus agreement was achieved with 93 of 101 (92%) competencies exceeding the benchmark for agreement. Only 8 warranted further attention and were reviewed by a focus group. No additional competencies were suggested. Conclusion. This is the first international validated study of clinical competencies for advanced training in Oral Medicine. These validated clinical competencies could provide a model for countries developing an advanced training curriculum for Oral Medicine and also inform review of existing curricula. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;-:1-9)

The scope of Oral Medicine practice frequently varies from one country to another as a result of differing definitions among countries. As examples, the American Academy of Oral Medicine (AAOM) defines Oral a Consultant, Honorary Senior Lecturer & Specialist in Oral Medicine, Department of Oral Medicine, Leeds Dental Institute, Clarendon Way, Leeds, UK. b Oral Medicine Registrar, Westmead Centre for Oral Health, Westmead, New South Wales, Australia. c Assistant Professor, Discipline of Orthodontics and Paediatric Dentistry, Faculty of Dentistry, National University of Singapore, Singapore, Republic of Singapore. d Academic Clinical Fellow in Oral Medicine, Oral Medicine Unit, Eastman Dental Hospital UCLHT/Eastman Dental Institute University College London, London, UK. e Professor and Academic Head e Oral Medicine and Radiology, Saveetha Dental College and Hospital, Saveetha University, Chennai, India. f Clinical Professor, Department of Oral & Maxillofacial Pathology, Radiology & Medicine, New York University College of Dentistry, New York City, NY, USA. g Dean and Professor of Oral Medicine, Dubai School of Dental Medicine, Dubai Healthcare City, Dubai, UAE. h Professor of Professional Education, Northumbria University, Coach Lane Campus, Benton, Newcastle upon Tyne, UK. i Postgraduate Dental Dean, NHS Education for Scotland, Edinburgh, UK. j Professor and Chair of Oral Medicine, University of Pennsylvania, School of Dental Medicine, Department of Oral Medicine, Philadelphia, PA, USA. Received for publication Sep 23, 2014; returned for revision Nov 10, 2014; accepted for publication Dec 16, 2014. Ó 2015 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2014.12.026

Medicine as the “discipline of dentistry concerned with the oral health care of medically complex patientsdincluding the diagnosis and management of medical conditions that affect the oral and maxillofacial region”;1 the Oral Medicine Academy of Australasia (OMAA) definition is similar in intent and scope.2 However, the definition by the British Society for Oral Medicine (BSOM)d“Oral Medicine is the specialty of dentistry concerned with the oral healthcare of patients with chronic, recurrent and medically related disorders of the oral and maxillofacial region, and with their diagnosis and non-surgical management.”ddiffers in that the dental management of medically complex patients is not part of the practice of Oral Medicine.3 It would, therefore, be expected, due to definition variation between regional Oral Medicine professional groups, that different regions’ postgraduate Oral Medicine training curricula would also vary.

Statement of Clinical Relevance This study reports validated clinical competencies that could form part of a global international curriculum and offers a model for countries developing an advanced training curriculum for Oral Medicine. This can only improve the quality of training, education, and clinical care. 1

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Oral Medicine is a recognized specialty in some countries and not in others; therefore, for the purposes of this paper, the term “advanced training” will be used instead of “specialty training.” To better define the study and practice of Oral Medicine globally, the World Workshop on Oral Medicine V (WWOM V) carried out two surveys in 2010 to determine the scope of clinical practice of Oral Medicine and postgraduate training standards from various countries. The latter revealed considerable similarities in syllabi content between Oral Medicine training programs globally, particularly with respect to attaining proficiency in the diagnosis and management of oral mucosal diseases and orofacial pain.4 Not surprisingly, this directly reflected aspects of the scope of practice study5 whereby Oral Medicine practitioners considered management of oral mucosal diseases and orofacial pain an integral part of their practice. These findings have helped homogenize the definition of Oral Medicine as a distinct specialty on a global level. However, the 2010 WWOM survey on postgraduate training programs also highlighted significant global variation with regard to recognition of Oral Medicine as a distinct field of study, entry requirements for postgraduate training, as well as the length of training between countries.4 One perceived corollary of this is that a lack of uniformity in the training and credentialing of Oral Medicine specialists may have hindered specialty recognition in some countries. As such, an important preliminary step for Oral Medicine would be to establish a competency framework for postgraduate training programs. There is an increasing emphasis on a competency-based rather than a time-based education model in medical and dental undergraduate and postgraduate curricula.6-9 Development of a clinical competency framework would demonstrate a commitment on the part of Oral Medicine educators to ensure that all specialists and graduates of advanced training programs are proficient in a uniform set of training requirements and have attained the skills and knowledge needed to deliver the best clinical care to their patients. Due to the varied and detailed educational pathways in postgraduate Oral Medicine training programs, it was difficult for the previous WWOM V survey to capture all the similarities and differences among programs. However, it is apparent that there are congruencies in clinical practice and teaching among programs, and, as such, an international core clinical Oral Medicine curriculum should be feasible. Therefore, the goal of the WWOM VI study was to formulate an Oral Medicine clinical competency framework that would be validated by international consensus agreement. It is important to consider the definition of a health careebased competency, such as that described by Frank et al. (2010): “An observable ability of a health

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professional, integrating multiple components such as knowledge, skills, values and attitudes.” They are observable and assessable and can be “assembled like building blocks to facilitate progressive development,” and this outcomes-based approach is the mainstay of competency-based medical education.10

MATERIALS AND METHODS This study was undertaken by members of the WWOM VI Study Group 5, which comprised the authors as well as consultants listed in the Acknowledgments section. Ethical approval was not required following a query to the Institutional Review Board of the University of Pennsylvania, since the study did not meet the definition of research with human patients. Consideration was given to existing curricula and competency frameworks to draft a new international framework for clinical competencies in Oral Medicine. These competencies were initially based on the Oral Medicine Curriculum of the General Dental Council (GDC) of the UK,11 where Oral Medicine is a recognized clinical specialty with an approved curriculum and on those used in the USA through the Commission on Dental Accreditation (CODA).12 Consultation and agreement between the research group members resulted in the further refinement of existing competencies and the inclusion of additional competencies, which enabled the formulation of a final draft. The format included seven Clinical Domains (Examination and Diagnosis; Patient Treatment and Management; Oral Soft Tissues; Salivary Glands; Orofacial pain, including Temporomandibular Disorder; Interface of Oral and Systemic Disease; and Behavioral and Mental Health), each of which had a number of individual competencies, numbering 101 in total (see online Supplementary Material Table I: Clinical domains and their number of supporting competencies). An online electronic survey (Fluidsurveys, Ottawa, Canada; http://www.fluidsurveys.com), to be completed in English, was developed to gather opinion and consensus agreement relating to these specific competencies that could be used to formulate a postgraduate international Oral Medicine curriculum. This was initially piloted among the group members to assess its functionality and ease of use. Within the survey, a response was required from the participants regarding each individual competency statement for the following options: (1) Keep the competency in its current format, (2) change the competency or rephrase it, or (3) delete the competency. A box for free text was provided to suggest how a competency might be rephrased. At the end of the survey, a free text box was provided for suggesting the addition of further competencies. Demographic data were also captured. This utilized a published validated approach.13

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Table I. Results per clinical domain Clinical domain

Number of competency statements

Examination and Diagnosis Patient Treatment and Management Oral Soft Tissues Salivary Glands Orofacial Pain, including Temporomandibular Disorder Interface of Oral and Systemic Disease Behavioral and Mental Health

20 34 15 8 12 7 5

A standardized email message was sent by group members to identify relevant individual international stakeholders through recognized national or international Oral Medicine societies. In recognition of the fact that in some areas of the world, there are no formal Oral Medicine societies, the standardized email message was also circulated through identified clinical professional networks. Individual invitations, with a link to the e-survey, were then distributed via email by a single designated group member over a 10-week period from 22 November, 2013, to 31 January, 2014. The survey was “live” during this period, with recruitment of participants continuing throughout this duration. Participants were received a maximum of three email reminders depending on when they were recruited. The quantitative and qualitative data were analyzed by Fluidsurveys (Ottawa, Canada) and by using Microsoft Excel (Windows 8) for each individual competency statement. A cut-off was established at 90% or greater agreement to keep the statement in its current format. This high benchmark was set to ensure that any issues regarding the competency statements were considered.13 Those competency statements that did not achieve this level of agreement were submitted, along with all associated comments or feedback, to a focus group consisting of individuals from the research group. The focus group then decided on acceptance, redrafting, or deletion of individual competency statements. The focus group’s decisions were then approved by the entire WWOM VI Study Group 5 (see online Supplementary Material: Supplementary Flowchart SII: Materials and methods flowchart).

RESULTS Participation and demographic characteristics Direct invitations to complete the online survey were sent via email to individual stakeholders who had volunteered to contribute from a total of 31 countries. Responses were received from all geographic regions: Africa (4 countries), Asia (6), Australasia (2), Europe (12), Middle East (2), North America (2), and South America (3) (see online Supplementary Material Table III: List of countries of respondents).

Number (%) of statements with Oral Medicine 90% agreement 16 33 15 7 11 7 4

(80%) (97%) (100%) (87.5%) (92%) (100%) (80%)

Number (%) requiring review by focus group 4 (20%) 1 (3%) 0 1 (12.5%) 1 (8%) 0 1 (20%)

Out of a total of 446 responses, 261 (58.5%) contained sufficient data for analysis. Of the respondents, 201 fully completed the survey, and 60 partially completed it but provided enough data for inclusion and analysis. The remaining 185 (41.5%) responses were not included in the analysis, as no responses on the competency statements were provided. The number of responses (the number of people who accessed the e-survey and provided sufficient data for analysis) was high given both the length of time taken to complete the survey (>1 hour) and that many respondents were from countries where English is not the first language. Competency evaluation From a total of 101 clinical competencies, 93 (92.0%) exceeded the benchmark of agreement value of 90% or greater. Only 8 (8%) competency statements were below the 90% agreement value ranging from 69.2% to 89.9% and so warranted further attention. The lower figure of 69.2% suggested a greater need to change, rephrase, or even possibly delete the statement. No additional competencies were suggested by the respondents (see online Supplementary Material Table IV: Individual competency validation responses). Table I shows the results for each of the seven clinical domains and the number of competencies within each that required further review by the Focus Group. The outcome from the focus group’s analysis of the eight nonvalidated competency statements led to 6 (75%) competencies being rephrased, 1 (12.5%) competency being retained unchanged, and 1 (12.5%) competency being deleted (see online Supplementary Material Table V: Focus group outcomes). The final validated competencies can be seen in Table II.

DISCUSSION A paradigm shift in health care education and its research has occurred in the past two decades with a transition from time- and process-based educational frameworks to a competency-based framework. The overall goal of this dynamic has been to improve education and training.7,13-16

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Table II. Validated clinical competencies for advanced training in oral medicine EXAMINATION AND DIAGNOSIS 1. The practitioner will be able to elicit, record, and interpret an accurate medical or dental history from patients of any age within the scope of Oral Medicine practice, through: a. Identifying and recording of risk factors for conditions relevant to the presentation b. Understanding and interpreting the spectrum of illness or disease patterns in Oral Medicine practice c. Consideration of possible local or systemic triggers (including iatrogenic causes), and/or the likelihood of a significant underlying condition d. Consideration of the use of supporting methods such as structured questionnaires when necessary 2. The practitioner will be able to perform a comprehensive and appropriate clinical examination and medical risk assessment on patients within the scope of Oral Medicine practice (including complex conditions), through: a. Considering the patient’s presentation and risk factors, to determine a valid, targeted and time efficient approach that includes orofacial tissues and other body systems, when relevant b. Interpreting the pathophysiologic and anatomic basis for clinical signs, and considering the likelihood of a significant underlying diagnosis c. Applying validated disease severity indices, when appropriate d. Considering mood and cognitive function, when appropriate, during interpretation of findings 3. The practitioner will be able to select, request, and, in some cases, undertake appropriate and relevant investigations (including radiography) within the scope of Oral Medicine Practice, through: a. Understanding the different investigations used (including bodily fluid studies, cytology, culture, biopsy, and cytogenetics) and their relationship to relevant basic sciences b. Consideration of the relevance of investigation results to health and disease c. Understanding of the best procedures to maximize information yield and minimize artefacts and false or spurious results d. Understanding the specificity, sensitivity and predictive value of investigations e. Consideration of differential (possible) diagnoses (in discussion with relevant colleagues) to inform choice of investigation f. Knowledge of benefits and risks of investigations and awareness of the financial implications 4. The practitioner will be able to interpret and seek clarification on the meaning of a range of laboratory and imaging investigation results to inform appropriate subsequent patient care, through: a. The ability to identify abnormalities in the results of laboratory and imaging investigations b. Considering the patient’s presentation and risk factors, to determine a valid, targeted and time efficient approach that includes orofacial tissues and other body systems, when relevant c. Interpreting the pathophysiologic and anatomic basis for clinical signs, and consideration of the likelihood of a significant underlying diagnosis d. Applying disease severity indices, where appropriate e. Considering mood and cognitive function when appropriate during interpretation of findings

PATIENT TREATMENT AND MANAGEMENT 5. The practitioner will be able to undertake expert or specialist assessment and management of a patient of any age within the scope of Oral Medicine Practice, in both an outpatient and inpatient hospital setting, through: a. Understanding safe, effective, quality-assured, and evidence-based patient care, and the practice thereof b. Considering causes of reduced patient compliance, and ways in which this can be changed c. Considering the barriers (including cultural or religious) to changing patients’ beliefs and attitudes and the resulting impact on improving patient management and outcomes d. Understanding the differences between patient and doctor centered care e. Appropriate assessment and prioritization of patient care needs from written or verbal referrals f. Formulating accurate and complete differential diagnoses with appropriate prioritization following consideration of both common and rare conditions g. Prompt and effective action following investigation results h. Effective recognition of patients with oral presentations requiring urgent or immediate assessment and management and differentiation from nonurgent cases i. Effective recognition of patients with oral presentations potentially associated with high morbidity (including malignancy) or where associated with a significant underlying disease at other sites j. Timely and accurate communication of information regarding treatment interventions with other relevant health care providers (including between primary and secondary care) k. Recognizing the importance of assessing new therapies l. Recognizing their own limitations and the need to obtain advice or input from other colleagues, where appropriate m. Involving the patient in decision making and agreement of treatment plans in partnership with the patient and/or parent or guardian n. Communicating the aims and likely success of treatment and the prognosis of the condition to the patient and/or parent or guardian o. The ability to break bad news in an empathic and supportive manner 6. The practitioner will be able to undertake the safe and effective prescription of medication, through: a. Detailed understanding of the issues requiring consideration when making an informed choice of medication, such as aims of care, indications and contraindications, adverse effects, drug interactions (including with complementary medicines), safe monitoring, and duration of therapy b. Considering the evidence base for use of topical, intralesional, and systemic drugs c. Considering procedures for pre-prescription baseline assessment and subsequent drug monitoring (including the interpretation of results) (continued on next page)

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Table II. Continued d. Appropriate management of local and systemic adverse reactions to prescribed drugs e. Considering issues involved in prescribing medications “off licence” (“off label”) f. Considering patient safety in prescribing, taking into account contraindications, side effects, and drug interactions, and tools or materials available to support this g. Effective communication with patients, when required, including the risks and benefits of pharmacologic therapeutic options that are “off licence” (“off label”) and in the promotion of patient concordance h. Critically appraising new therapies and interventions and keeping up to date with therapeutic alerts i. Considering the issues involved in using opioids and other habit-forming drugs and recognizing patients who may be addicted to such drugs j. Regularly reviewing the effects of long-term medication use k. Managing risk to patients with regard to drug prescription following therapeutic drug monitoring or physiologic change (e.g., dose adjustments) 7. The practitioner will be able to safely and effectively undertake operative techniques as (i) definitive management of localized benign disease, or (ii) to establish a tissue diagnosis (including where oral soft tissue malignancy or potentially malignant disorder is suspected), through: a. Knowledge and understanding of basic sciences relevant to operative techniques b. Considering the different operative techniques (including scalpel surgery, laser surgery, and cryotherapy) and their evaluation for use with different oral tissue lesions c. Evidence-based consideration of options for operative intervention informed by aims of care, indications, contraindications, and complications d. Considering key features of safe and effective local anesthesia (including regional anesthesia). e. Understanding of the role of operative management in orofacial disorders f. Safe, competent, and effective execution of soft tissue excisional and incisional biopsy g. Assessing outcomes and appropriate follow-up h. Recognizing their own limitations and willingness to consult colleagues when necessary

ORAL SOFT TISSUES 8. The practitioner has knowledge and understanding of the structure and function in health of lips and oral soft tissues, and correlates this with that of diseased states to inform patient care. 9. The practitioner has detailed knowledge of the basic sciences with regard to health of oral soft tissues and understands alterations of these in diseased states (including anatomy, physiology, immunology, microbiology, biochemistry, molecular biology, neuroscience, pathology, and nutrition). 10. The practitioner can apply basic sciences knowledge when assessing patients, during the formulation of differential diagnoses and treatment plans and in the selection of appropriate interventions. 11. The practitioner will be able to undertake expert or specialist assessment and management of oral soft tissue disease, through: a. Understanding the repertoire of responses of oral soft tissues to trauma or pathology b. Understanding the clinical features and underlying pathophysiology of localized oral soft tissue disorders, and diseases with extraoral manifestations that present with oral soft tissue disorders c. Considering the different medication or drug or operative intervention options (including potential advantages and disadvantages) 12. The practitioner will be able to investigate, diagnose, and manage patients with oral soft tissue disease with hypersensitivity bias, immune basis, or developmental and genetic bias and those without apparent cause, through: a. Considering mechanisms involved in soft tissue disorders with an etiology related to underlying hypersensitivity b. Considering the indications, contraindications, and limitations of contact urticarial testing, patch testing, immunofluorescence, enzymelinked immunosorbent assay, and related investigations. c. Evaluating different options for eliminating or reducing patient exposure to triggers of hypersensitivity reactions 13. The practitioner will be able to diagnose and manage viral, bacterial, fungal, and other infections of the oral soft tissues, through: a. Detailed knowledge and understanding of normal oral flora and the pathogenesis and epidemiology of orofacial diseases b. Considering the clinical features, investigation, and management of infections that are primary or reactivated infections of oral soft tissue or that also involve other parts of the body c. Understanding the clinical features of infections in immunocompromised patients d. Identifying appropriate measures to reduce risk of infection spread. e. Considering risk factors during history taking (e.g., sexual history, risks associated with bloodborne viruses) f. Selecting appropriate investigations and, where necessary, microbiologic samples for culture, microscopy, polymerase chain reaction, and serology

SALIVARY GLANDS 14. The practitioner has detailed understanding of the structure and function of the salivary glands and saliva in health and in diseased states. 15. The practitioner has detailed knowledge of the basic sciences with regard to health of the salivary glands and saliva and understands alterations of these in diseased states (including anatomy, physiology, immunology, microbiology, biochemistry, molecular biology, neuroscience, and pathology). 16. The practitioner applies knowledge of basic sciences when assessing patients, during the formulation of differential diagnoses and treatment plans and in the selection of appropriate interventions. (continued on next page)

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Table II. Continued 17. The practitioner will be able to diagnose and appropriately manage patients presenting with disorders of major and minor salivary glands, through: a. Knowledge of the clinical features and pathophysiology of localized and iatrogenic salivary gland disorders and diseases with extraoral manifestations that present with salivary gland disorders b. Appropriate clinical examination, including chairside saliva volume measurements, and referral for or performance of Schirmer I tests, where indicated c. Considering relevant diagnostic criteria for patients with dry mouth d. Understanding the application and interpretation of imaging modalities and/or laboratory investigations for different salivary gland diseases, including consideration of the advantages and disadvantages e. Considering the different medication or drug or operative intervention options (including potential advantages and disadvantages)

OROFACIAL PAIN, INCLUDING TEMPOROMANDIBULAR DISORDER 18. The practitioner has knowledge and understanding of the structure and function in health of the nervous system and is able to correlate this with that of diseased states to inform patient care. 19. The practitioner has detailed knowledge of the basic sciences with regard to health of the musculoskeletal and nervous systems and understands alterations of these in diseased states (including anatomy, physiology, immunology, microbiology, biochemistry, molecular biology, neuroscience, and pathology). 20. The practitioner is able to apply knowledge of basic sciences when assessing patients, during the formulation of differential diagnoses, treatment plans, and in the selection of appropriate interventions. 21. The practitioner will be able to diagnose and appropriately manage patients presenting with orofacial pain of odontogenic and non-odontogenic origin, through: a. Considering different manifestations of orofacial pain and how the nature of the presentation varies between them b. Understanding the pathophysiology of orofacial pain c. Considering indications for imaging studies and other investigations in the context of orofacial pain d. Considering the different evidence-based therapeutic options, including drugs, psychological therapies, selected complementary and alternative medicines, and operative interventions, including the advantages and disadvantages of each 22. The practitioner is able to perform an appropriate neurological examination. 23. The practitioner will be able to diagnose and appropriately manage patients presenting with altered cranial nerve function, related or unrelated to other neurologic abnormalities, through: a. Understanding the clinical features and underlying pathophysiology of localized and iatrogenic cranial nerve disorders and diseases with extraoral manifestations that present with cranial nerve disorders b. Considering the indications for and choice of imaging studies or other diagnostic investigations 24. The practitioner is able to interpret the results of investigations and diagnose conditions presenting with orofacial pain, including the recognition of orofacial pain with potentially high morbidity (including suicide risk or malignancy) or where associated with underlying systemic illness. 25. The practitioner understands the definitions, terms, classifications, pathophysiology, and theories of orofacial pain.

INTERFACE OF ORAL AND SYSTEMIC DISEASE 26. The practitioner is able to relate health and disease of orofacial tissues to other relevant body systems (including different organs). 27. The practitioner is able to take an appropriate history of patients presenting with chronic conditions and perform a detailed physical examination relevant to orofacial health and other body systems, where appropriate. 28. The practitioner is able to select appropriate investigations; formulate an accurate, complete, and differential diagnosis for patients presenting with conditions across the interface of oral and systemic disease; and select an appropriate treatment plan. 29. The practitioner is able to develop a management plan for chronic disease, including self-care and the use of a supportive multidisciplinary team approach, through: a. Understanding the natural history of diseases that run chronic courses b. Recognizing medical disease, presentations and management, including complications of management 30. The practitioner has a detailed understanding of current best practice in safe prescribing, including: a. Knowledge of the range of adverse drug reactions to commonly used drugs and the drugs requiring therapeutic drug monitoring b. The effects of patient factors and concomitant disease on prescribing

BEHAVIOURAL AND MENTAL HEALTH 31.The practitioner will be able to identify serious or incidental psychiatric morbidity in patients presenting with oral disease, through: a. Considering psychiatric symptoms and differential diagnosis relevant to orofacial disease b. Understanding the features of depression and risk factors for suicide c. Identifying a patient’s psychiatric history d. Performing a preliminary risk assessment of suicide or self-harm in a patient, where indicated, and refer appropriately e. Understanding the basic use of antidepressants in the management of orofacial pain disease

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Examples of competency-based curricula and their validation processes can be seen across a broad range of established and emerging medical17-20 and dental15,21-24 disciplines and specialties, as well as other health professions.25-28 This study is the first internationally validated study of clinical competencies specific to advanced training in Oral Medicine. Some of these competencies are not exclusive to Oral Medicine but, in aggregate, define the main competencies within the clinical domains necessary for advanced trainees in Oral Medicine. Importantly, the majority (92%) of the competencies exceeded our high benchmark of 90% or greater agreement among international stakeholders. From a curriculum development standpoint, competency frameworks do not prescribe how the teacher should teach or the learner should learn but, rather, inform the process of how a curriculum may be developed, assessed, and evaluated to produce a graduate of the desired qualities for that profession.7 Frank et al. suggested that competency development is only step two of a six-step competency-based curriculum development, preceded by (1) identifying the abilities needed by graduates; followed by (2) development of milestones in the development path; (3) educational activities, experiences, and instructional methods; (5) assessment tools to measure those milestones; and (6) outcome evaluation of the overall program.10 For clarification on the terminology used within the competency-based education literature, the reader is encouraged to see reviews by Fisher et al. (2010)10,16 and Iobst et al. (2010).7 Competency-based curricula also allow for debate on what is relevant and allow curricula to keep pace with changes not only in course content but also in delivery methods.15 We believe that this study provides a competency list that, although not intended to be prescriptive or reductionist, could provide a model for countries developing an advanced training curriculum for Oral Medicine. More competencies could be added, depending on the local health care needs and regulations. There are also other benefits to providing a framework of clinical competencies for a professional group, particularly on an international level. In a recent study of international oral and maxillofacial pathology specialty training, Hunter et al. (2014) noted that a need to establish training equivalence and standardization of expertise was a driving force for global curriculum development, especially in the context of a globalized employment market.29 Furthermore, other authors have touched on the fact that there is reciprocity between competency and practice standard development and specialty recognition.18,30 Failure of a profession to formalize such educational aspects may send a message to both the profession and public that it can be taught in an ad hoc fashion and does not deserve the same priority accorded to other disciplines.20

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“Blueprinting” or defining curriculum content from a specified domain can be done by subject matter experts (SMEs), published curricula, or examination questions, based on observational studies that analyze what the learner needs to master or a combination of these approaches.31 In the present study, a combination approach was used, with global observational data from previously described WWOM V practice and postgraduate training surveys also informing the process.4,5 A total of three SMEs (authors LP-C, DHF, and TPS) with a mixture of pedagogic, clinical, and statistical expertise also consulted a number of published curricula11,12 as well as other published manuscripts32,33 in producing the initial competency content. An electronic survey design provides a quick, costeffective method for rapid distribution of a large-scale survey and allows for systematic control of the order in which respondents see specific questions.34-36 It also allows for rapid transfer and analysis of respondent data through transfer to analysis software. However, variable response rates have been reported with electronic survey methods.34,37 Despite using techniques to improve the survey response rates (e.g., advanced warnings of survey and follow-up emailsdboth used in this study), it is noted that mean health care professional response rates to surveys are less than 55% and have continued to decline over the last half century.37,38 It is difficult to determine our exact response rate due to the methodology employed, but the overall number of analyzable responses for both individual and country representations, is similar to those of previous WWOM V surveys.4,5 Importantly, we believe that adequate global penetrance and external validity have been achieved, as evidenced by the high level of agreement both within and among countries in competency acceptance. We note, however, that the approximate time to complete the survey due to its length (>1 hour) and provision in the English language may have created barriers to survey participation. We acknowledge that this may be a source of foreign language exclusion bias and that translation of competency statements may have increased survey participation, but this was not possible within the constraints of our study. Penetrance may have also been minimized because of our inability to identify formal professional Oral Medicine groups within countries or, in some cases, because no formal networks exist. However, despite these potential limitations, we achieved a response rate that far exceeded those of surveys of this type, highlighting the commitment and motivation of the profession to contribute to this important initiative. The overall process (content design, expert panel revision, pilot testing, consensus by stakeholders, and the subsequent focus group discussions for adjustment of competencies) was based on a previously validated approach.13 Of the 8 competencies warranting further

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attention from our focus group, it is important to note that 6 achieved 82% or greater general agreement (3 of which were 89% general agreement) and only required minor rephrasing. The deleted competency approached 20% (17.2%) consensus to deletion. Yet the most interesting competency for reassessment was the rephrased competency in the Behavior and Mental Health clinical domain pertaining to assessment of suicide risk. This was interesting because it was, in fact, the penultimate competency (of 101 competencies) that stakeholders could comment on. The fact that it created the most conjecture (or least consensus) of all competencies and yet fell toward the end of an hour-long survey suggests that fatigue was not an issue for our respondents and therefore consensus was not artificial. This study represents the first step in exploring clinical competency development for a global advanced training curriculum for Oral Medicine. It provides an important benchmark from which to work, but other training domains, such as health care management or research relevant to Oral Medicine training and practice, require exploration of their own domain competencies. It also did not explore the assessment processes of these clinical competencies. Further work is needed to identify the most valid, reliable, explicit, equitable, transparent, and feasible assessments in advanced training in Oral Medicine. Future WWOM groups could explore the assessment tools currently available for use by Oral Medicine trainees and develop an assessment framework for clinical competencies taking into account the competency frameworks established. Ideally, an assessment framework would comprise both formative and summative assessments and aim to assess the highest levels of Miller’s Pyramid of Assessment (framework for assessing clinical competence in medical education) through use of workplace-based assessments, as is the established and current standard for a number of existing health curricula.39,40

CONCLUSIONS We would hope that these internationally validated clinical competencies for advanced training in Oral Medicine will not only improve the quality of advanced training and education but also the quality of clinical care. The study was supported by the World Workshop on Oral Medicine VI. The authors were all members of Study Group 5. The group was represented by 14 countries covering 6 continents. The authors would like to thank and acknowledge the input of the following for supporting the group’s work: Gbemisola Agbelusi (Nigeria), Imad Elimairi (Sudan), Hong Hua (China), Meltem Koray (Turkey), Marinka Mravak-Stipetic (Croatia), KS Nagesh (India), Pablo Vargas

OOOO Month 2015 (Brazil), Michele Williams (Canada), and Li-Wu Zheng (China). The authors would also like to thank the following societies for assistance in raising awareness of the questionnaire among their members: American Academy of Oral Medicine (AAOM), British Society for Oral Medicine (BSOM), Canadian Academy of Oral and Maxillofacial Pathology and Oral Medicine, Chinese Academy of Oral Medicine, Croatian Dental Society, Croatian Society for Oral Medicine, European Association of Oral Medicine (EAOM), Indian Academy of Oral Medicine and Radiology, Oral Medicine Academy of Australasia (OMAA), and the Turkish Society of Oral Medicine. The authors would like to gratefully acknowledge the following organizations, individuals, and companies for providing unrestricted financial support of World Workshop on Oral Medicine VI (WWOM VI): American Academy of Oral Medicine, European Association of Oral Medicine, Anonymous gifts from patients of Dr. David Sirois, New York University College of Dentistry, Biocosmetics, Elsevier, Johnson and Johnson, The Oral Cancer Foundation, and Unilever. In addition, the authors, including selected members of the WWOM VI Steering Committee, express their sincere appreciation for the opportunity to collaborate with the full WWOM VI Steering Committee over these past 2 years. This Committee provided the conceptual framework and logistical support to produce the WWOM VI Conference in April 2014 in Orlando, Florida, USA. In addition, the Steering Committee provided scientific and editorial critiques of this manuscript. The entire Steering Committee is listed below, in alphabetical order: Martin S. Greenberg (USA) Timothy A. Hodgson (United Kingdom) Siri Beier Jensen (Denmark) A. Ross Kerr (USA) Peter B. Lockhart (USA) Giovanni Lodi (Italy) Douglas E. Peterson (USA) David Wray (United Kingdom and Dubai)

REFERENCES 1. The American Academy of Oral Medicine (AAOM). Available at: http://www.aaom.com/. Accessed April 27, 2014. 2. Oral Medicine Academy of Australasia. Available at: http://www. omaa.com.au/. Accessed April 27, 2014. 3. The British Society for Oral Medicine. Available at: http://www. bsom.org.uk/home/what-is-oral-medicine/. Accessed April 27, 2014.

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4. Rogers H, Sollecito TP, Felix DH, et al. An international survey in postgraduate training in Oral Medicine. Oral Dis. 2011;17:95-98. 5. Stoopler ET, Shirlaw P, Arvind M, et al. An international survey of oral medicine practice: Proceedings of the 5th World Workshop in Oral Medicine. Oral Dis. 2011;17:99-104. 6. Boyd MA, Gerrow JD, Chambers DW, Henderson BJ. Competencies for dental licensure in Canada. J Dent Educ. 1996;60: 842-846. 7. Iobst WF, Sherbino J, Cate OT, et al. Competency-based medical education in postgraduate medical education. Med Teach. 2010;32:651-656. 8. Licari FW, Chambers DW. Some paradoxes in competency-based dental education. J Dent Educ. 2008;72:8-18. 9. Plasschaert AJ, Holbrook WP, Delap E, Martinez C, Walmsley AD. Profile and competences for the European dentist. Eur J Dent Educ. 2005;9:98-107. 10. Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32:638-645. 11. General Dental Council. Available at: Www.gdc-uk.org. Accessed April 27, 2014. 12. Commission on Dental Accreditation. Available at: Http://www. ada.org/117.aspx. Accessed April 27, 2014. 13. Prescott L, Hurst Y, Rennie JS. Comprehensive validation of competencies for dental vocational training and general professional training. Eur J Dent Educ. 2003;7:154-159. 14. Albanese MA, Mejicano G, Mullan P, Kokotailo P, Gruppen L. Defining characteristics of educational competencies. Med Educ. 2008;42:248-255. 15. Chadwick SM. Current products and practices: curriculum development in orthodontic specialist registrar training: Can orthodontics achieve constructive alignment? J Orthod. 2004;31:267-274. 16. Frank JR, Mungroo R, Ahmad Y, Wang M, De Rossi S, Horsley T. Toward a definition of competency-based education in medicine: a systematic review of published definitions. Med Teach. 2010;32:631-637. 17. Angelino A, Lyketsos CG. Training in psychosomatic medicine: a psychiatric subspecialty recognized in the United States by the American board of medical specialties. J Psychosom Res. 2011;71:431-432. 18. Brice JH, Perina DG, Liu JM, Braude DA, Rinnert KJ, MacDonald RD. Development of an EMS curriculum. Prehosp Emerg Care. 2014;18:98-105. 19. Lieff SJ, Kirwin P, Colenda CC. Proposed geriatric psychiatry core competencies for subspecialty training. Am J Geriatr Psychiatry. 2005;13:815-821. 20. Seely JF, Scott JF, Mount BM. The need for specialized training programs in palliative medicine. Can Med Assoc J. 1997;157: 1395-1397. 21. Donos N, Mardas N, Buser D. An outline of competencies and the appropriate postgraduate educational pathways in implant dentistry. Eur J Dent Educ. 2009;13:45-54. 22. Iacopino AM, Taft TB. Core curricula for postdoctoral dental students: recent problems, potential solutions, and a model for the future. J Dent Educ. 2007;71:1428-1434. 23. Van der Velden U, Sanz M. Postgraduate periodontal education. Scope, competences, proficiencies and learning outcomes: consensus report of the 1st European Workshop on Periodontal Educationdposition paper 3 and consensus view 3. Eur J Dent Educ. 2010;14:34-40. 24. Weintraub JA. The development of competencies for specialists in dental public health. J Public Health Dent. 1998;58:114-118.

25. Bok HG, Jaarsma DA, Teunissen PW, van der Vleuten CP, van Beukelen P. Development and validation of a competency framework for veterinarians. J Vet Med Educ. 2011;38:262-269. 26. Leight SB, Leslie NS. Development of a competency-based curriculum for training women in breast self-examination skills. J Am Acad Nurse Pract. 1998;10:297-302. 27. Myint J, Edgar DF, Kotecha A, Crabb DP, Lawrenson JG. Development of a competency framework for optometrists with a specialist interest in glaucoma. Eye (Lond.). 2010;24:1509-1514. 28. O’Connell J, Gardner G. Development of clinical competencies for emergency nurse practitioners: a pilot study. Australas Emerg Nurs J. 2012;15:195-201. 29. Hunter K, Speight P, Wright J, van Heerden W, Rich A, Franklin C. An international survey of speciality training in oral and maxillofacial pathology. J Oral Pathol Med. 2014;43:232-236. 30. von Gunten CF, Lupu D. Development of a medical subspecialty in palliative medicine: progress report. J Palliat Med. 2004;7:209-219. 31. Cumyn A, Harris IB. A comprehensive process of content validation of curriculum consensus guidelines for a medical specialty. Med Teach. 2012;34:e566-e572. 32. Sollecito TP, Rogers H, Prescott-Clements L, et al. Oral medicine: defining an emerging specialty in the United States. J Dent Educ. 2013;77:392-394. 33. Kragelund C, Reibel J, Hietanen J, et al. Scandinavian Fellowship for Oral Pathology and Oral Medicine: guidelines for oral pathology and oral medicine in the dental curriculum. Eur J Dent Educ. 2012;16:246-253. 34. Braithwaite D, Emery J, De Lusignan S, Sutton S. Using the Internet to conduct surveys of health professionals: a valid alternative? Fam Pract. 2003;20:545-551. 35. Schleyer TK, Forrest JL. Methods for the design and administration of web-based surveys. J Am Med Infrom Assoc. 2000;7: 416-425. 36. Wyatt JC. When to use web-based surveys. J Am Med Infrom Assoc. 2000;7:426-429. 37. Cho YI, Johnson TP, Vangeest JB. Enhancing surveys of health care professionals: a meta-analysis of techniques to improve response. Eval Health Prof. 2013;36:382-407. 38. Burns KE, Duffett M, Kho ME, et al. A guide for the design and conduct of self-administered surveys of clinicians. Can Med Assoc J. 2008;179:245-252. 39. Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990;65:S63-S67. 40. Norcini JJ. Work based assessment. BMJ. 2003;326:753-755. Reprint requests: John C. Steele Consultant Honorary Senior Lecturer and Specialist in Oral Medicine Department of Oral Medicine Leeds Dental Institute Clarendon Way Leeds LS2 9 LU UK [email protected]

SUPPLEMENTARY DATA Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.oooo.2014.12.026.

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Supplementary Table I. Clinical domains and their number of supporting competencies Clinical domains Examination and Diagnosis Patient Treatment and Management Oral Soft Tissues Salivary Glands Orofacial Pain, including Temporomandibular Disorder Interface of Oral and Systemic Disease Behavioral and Mental Health

Number of supporting competencies 20 34 15 8 12 7 5

Supplementary Table III. List of countries of respondents Australia Brazil Canada Chile China Croatia Denmark Ghana Greece Hong Kong Iceland India Ireland Israel Italy Japan

Supplementary Flowchart II. Materials and methods flowchart

Latvia The Netherlands New Zealand Nigeria Peru Portugal Saudi Arabia Singapore South Africa Sudan Sweden Thailand Turkey United Kingdom United States of America

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Supplementary Table IV. Individual competency validation responses Validation responses Competency EXAMINATION AND DIAGNOSIS 1. The practitioner will be able to elicit, record, and interpret an accurate medical or dental history from patients of any age within the scope of Oral Medicine practice, through: a. Identifying and recording of risk factors for conditions relevant to the presentation b. Understanding and interpreting the spectrum of illness or disease patterns in Oral Medicine practice c. Consideration of possible local or systemic triggers (including iatrogenic causes), and/or the likelihood of a significant underlying condition d. Consideration of the use of supporting methods such as structured questionnaires when necessary 2. The practitioner will be able to perform a comprehensive and appropriate clinical examination and medical risk assessment on patients within the scope of Oral Medicine practice (including complex conditions), through: a. Considering the patient’s presentation and risk factors, to determine a valid, targeted and time efficient approach that includes orofacial tissues and other body systems, when relevant b. Interpreting the pathophysiologic and anatomic basis for clinical signs, and considering the likelihood of a significant underlying diagnosis c. Applying disease severity indices, when appropriate d. Considering mood and cognitive function, when appropriate, during interpretation of findings 3. The practitioner will be able to select, request, and, in some cases, undertake appropriate and relevant investigations (including radiography) within the scope of Oral Medicine Practice, through: a. Understanding the different investigations used (including bodily fluid studies, cytology, culture, biopsy, and cytogenetics) and their relationship to relevant basic sciences b. Consideration of the relevance of investigation results to health and disease c. Understanding of the best procedures to maximize information yield and minimize artefacts and false or spurious results d. Understanding the specificity, sensitivity and predictive value of investigations e. Consideration of differential (possible) diagnoses (in discussion with relevant colleagues) to inform choice of investigation f. Knowledge of the financial and biological cost of these investigations 4. The practitioner will be able to interpret and seek clarification on the meaning of a range of laboratory and imaging investigation results to inform appropriate subsequent patient care, through: a. The ability to identify abnormalities in the results of laboratory and imaging investigations b. Considering the patient’s presentation and risk factors, to determine a valid, targeted and time efficient approach that includes orofacial tissues and other body systems, when relevant c. Interpreting the pathophysiologic and anatomic basis for clinical signs, and consideration of the likelihood of a significant underlying diagnosis d. Applying disease severity indices, where appropriate e. Considering mood and cognitive function when appropriate during interpretation of findings f. Understanding pediatric and women’s oral health and identification of diseases relevant to oral medicine practice. PATIENT TREATMENT AND MANAGEMENT 5. The practitioner will be able to undertake expert or specialist assessment and management of a patient of any age within the scope of Oral Medicine Practice, in both an outpatient and inpatient hospital setting, through: a. Understanding safe, effective, quality-assured, and evidence-based patient care, and the practice thereof

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266 (98.9%) 247 (92.2%)

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253 (95.1%)

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2 (1%)

Validated

237 (89.1%)

16 (6%)

13 (5%)

231 (93.5%)

14 (5.7%)

2 (0.8%)

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6 (2.4%)

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222 (89.9%) 228 (92.3%)

14 (5.7%) 7 (2.8%)

11 (4.5%) 12 (4.9%)

214 (91.8%)

19 (8.2%)

0 (0%)

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220 (94.4%) 218 (93.6%)

7 (3%) 10 (4.3%)

6 (2.6%) 5 (2.1%)

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218 (93.6%) 219 (94%)

9 (3.9%) 12 (5.2%)

6 (2.6%) 2 (0.9%)

Validated Validated

198 (85%)

23 (9.9%)

12 (5.2%)

213 (95.5%)

9 (4%)

1 (0.4%)

Validated

209 (93.7%)

8 (3.6%)

6 (2.7%)

Validated

212 (95.5%)

4 (1.8%)

6 (2.7%)

Validated

200 (90.1%) 201 (90.5%)

12 (5.4%) 10 (4.5%)

10 (4.5%) 11 (5%)

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174 (78.4%)

32 (14.4%)

16 (17.2%) Focus Group

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Supplementary Table IV. Continued Validation responses Competency b. Considering causes of reduced patient compliance, and ways in which this can be changed c. Considering the barriers (including cultural or religious) to changing patients’ beliefs and attitudes and the resulting impact on improving patient management and outcomes d. Understanding the differences between patient and doctor centered care e. Appropriate assessment and prioritization of patient care needs from written or verbal referrals f. Formulating accurate and complete differential diagnoses with appropriate prioritization following consideration of both common and rare conditions g. Prompt and effective action following investigation results h. Effective recognition of patients with oral presentations requiring urgent or immediate assessment and management and differentiation from nonurgent cases i. Effective recognition of patients with oral presentations potentially associated with high morbidity (including malignancy) or where associated with a significant underlying disease at other sites j. Timely and accurate communication of information regarding treatment interventions with other relevant health care providers (including between primary and secondary care) k. Recognizing the importance of assessing new therapies l. Recognizing their own limitations and the need to obtain advice or input from other colleagues, where appropriate m. Involving the patient in decision making and agreement of treatment plans in partnership with the patient and/or parent or guardian n. Communicating the aims and likely success of treatment and the prognosis of the condition to the patient and/or parent or guardian o. The ability to break bad news in an empathic and supportive manner 6. The practitioner will be able to undertake the safe and effective prescription of medication, through: a. Detailed understanding of the issues requiring consideration when making an informed choice of medication, such as aims of care, indications and contraindications, adverse effects, drug interactions (including with complementary medicines), safe monitoring, and duration of therapy b. Considering the evidence base for use of topical, intralesional, and systemic drugs c. Considering procedures for pre-prescription baseline assessment and subsequent drug monitoring (including the interpretation of results) d. Appropriate management of local and systemic adverse reactions to prescribed drugs e. Considering compliance and issues involved in prescribing “off licence” (“off label”) f. Considering patient safety in prescribing, taking into account contraindications, side effects, and drug interactions, and tools or materials available to support this g. Effective communication with patients, when required, including the risks and benefits of pharmacologic therapeutic options that are “off licence” (“off label”) and in the promotion of patient concordance h. Critically appraising new therapies and interventions and keeping up to date with therapeutic alerts i. Considering the issues involved in using opioids and other habit-forming drugs and recognizing patients who may be addicted to such drugs j. Regularly reviewing the effects of long-term medication use k. Managing risk to patients with regard to drug prescription following therapeutic drug monitoring or physiologic change (e.g., dose adjustments) 7. The practitioner will be able to safely and effectively undertake operative techniques as (i) definitive management of localized benign disease, or (ii) to establish a tissue diagnosis (including where oral soft tissue malignancy or potentially malignant disorder is suspected), through: a. Knowledge and understanding of basic sciences relevant to operative techniques

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203 (93.1%)

11 (5%)

4 (1.8%)

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201 (92.6%)

17 (7.8%)

9 (4.1%)

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197 (90.8%) 204 (93.6%)

13 (6%) 6 (2.8%)

7 (3.2%) 8 (3.7%)

Validated Validated

211 (96.8%)

3 (1.4%)

4 (1.8%)

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206 (94.5%) 204 (93.6%)

7 (3.2%) 8 (3.7%)

5 (2.3%) 6 (2.8%)

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208 (95.4%)

7 (3.2%)

3 (1.4%)

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211 (98.6%)

4 (1.8%)

3 (1.4%)

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200 (91.7%) 207 (95%)

16 (7.3%) 8 (3.7%)

2 (0.9%) 3 (1.4%)

Validated Validated

209 (95.9%)

7 (3.2%)

2 (0.9%)

Validated

210 (96.3%)

5 (2.3%)

3 (1.4%)

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196 (90.7%)

13 (6%)

7 (3.2%)

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205 (97.1%)

5 (2.4%)

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202 (95.7%) 205 (97.1%)

5 (2.4%) 5 (2.4%)

4 (1.9%) 1 (0.5%)

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204 (96.7%)

7 (3.3%)

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188 (89.1%)

17 (8.1%)

6 (2.8%)

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200 (94.8%)

6 (2.8%)

5 (2.4%)

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199 (94.3%)

8 (3.8%)

4 (1.9%)

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203 (96.2%)

5 (2.4%)

3 (1.4%)

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197 (93.4%)

7 (3.3%)

7 (3.3%)

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203 (96.2%) 202 (95.7%)

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4 (1.9%) 2 (1%)

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4 (1.9%)

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Supplementary Table IV. Continued Validation responses Competency b. Considering the different operative techniques (including scalpel surgery, laser surgery, and cryotherapy) and their evaluation for use with different oral tissue lesions c. Evidence-based consideration of options for operative intervention informed by aims of care, indications, contraindications, and complications d. Considering key features of safe and effective local anesthesia (including regional anesthesia). e. Understanding of the role of operative management in orofacial disorders f. Safe, competent, and effective execution of soft tissue excisional and incisional biopsy g. Assessing outcomes and appropriate follow-up h. Recognizing their own limitations and willingness to consult colleagues when necessary ORAL SOFT TISSUES 8. The practitioner has knowledge and understanding of the structure and function in health of lips and oral soft tissues, and correlates this with that of diseased states to inform patient care. 9. The practitioner has detailed knowledge of the basic sciences with regard to health of oral soft tissues and understands alterations of these in diseased states (including anatomy, physiology, immunology, microbiology, biochemistry, molecular biology, neuroscience, pathology, and nutrition). 10. The practitioner can apply basic sciences knowledge when assessing patients, during the formulation of differential diagnoses and treatment plans and in the selection of appropriate interventions. 11. The practitioner will be able to undertake expert or specialist assessment and management of oral soft tissue disease, through: a. Understanding the repertoire of responses of oral soft tissues to trauma or pathology b. Understanding the clinical features and underlying pathophysiology of localized oral soft tissue disorders, and diseases with extraoral manifestations that present with oral soft tissue disorders c. Considering the different medication or drug or operative intervention options (including potential advantages and disadvantages) 12. The practitioner will be able to investigate, diagnose, and manage patients with oral soft tissue disease with hypersensitivity bias, immune basis, or developmental and genetic bias and those without apparent cause, through: a. Considering mechanisms involved in soft tissue disorders with an etiology related to underlying hypersensitivity b. Considering the indications, contraindications, and limitations of contact urticarial testing, patch testing, immunofluorescence, enzyme-linked immunosorbent assay, and related investigations. c. Evaluating different options for eliminating or reducing patient exposure to triggers of hypersensitivity reactions 13. The practitioner will be able to diagnose and manage viral, bacterial, fungal, and other infections of the oral soft tissues, through: a. Detailed knowledge and understanding of normal oral flora and the pathogenesis and epidemiology of orofacial diseases b. Considering the clinical features, investigation, and management of infections that are primary or reactivated infections of oral soft tissue or that also involve other parts of the body c. Understanding the clinical features of infections in immunocompromised patients d. Identifying appropriate measures to reduce risk of infection spread. e. Considering risk factors during history taking (e.g., sexual history, risks associated with bloodborne viruses) f. Selecting appropriate investigations and, where necessary, microbiologic samples for culture, microscopy, polymerase chain reaction, and serology

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5 (2.4%)

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202 (96.2%) 200 (95.2%)

6 (2.9%) 10 (4.8%)

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206 (98.1%) 198 (94.3%)

3 (1.4%) 9 (4.3%)

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10 (4.8%)

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195 (93.3%)

7 (3.3%)

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196 (96.6%) 201 (99%)

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Supplementary Table IV. Continued Validation responses Competency SALIVARY GLANDS 14. The practitioner has detailed understanding of the structure and function of the salivary glands and saliva in health and in diseased states. 15. The practitioner has detailed knowledge of the basic sciences with regard to health of the salivary glands and saliva and understands alterations of these in diseased states (including anatomy, physiology, immunology, microbiology, biochemistry, molecular biology, neuroscience, and pathology). 16. The practitioner applies knowledge of basic sciences when assessing patients, during the formulation of differential diagnoses and treatment plans and in the selection of appropriate interventions. 17. The practitioner will be able to diagnose and appropriately manage patients presenting with disorders of major and minor salivary glands, through: a. Knowledge of the clinical features and pathophysiology of localized and iatrogenic salivary gland disorders and diseases with extraoral manifestations that present with salivary gland disorders b. Appropriate clinical examination, including chairside saliva volume measurements and Schirmer I tests, where indicated c. Considering relevant diagnostic criteria for patients with dry mouth d. Understanding the application and interpretation of imaging modalities and/ or laboratory investigations for different salivary gland diseases, including consideration of the advantages and disadvantages e. Considering the different medication or drug or operative intervention options (including potential advantages and disadvantages) OROFACIAL PAIN, INCLUDING TEMPOROMANDIBULAR DISORDER 18. The practitioner has knowledge and understanding of the structure and function in health of the nervous system and is able to correlate this with that of diseased states to inform patient care. 19. The practitioner has detailed knowledge of the basic sciences with regard to health of the musculoskeletal and nervous systems and understands alterations of these in diseased states (including anatomy, physiology, immunology, microbiology, biochemistry, molecular biology, neuroscience, and pathology). 20. The practitioner is able to apply knowledge of basic sciences when assessing patients, during the formulation of differential diagnoses, treatment plans, and in the selection of appropriate interventions. 21. The practitioner will be able to diagnose and appropriately manage patients presenting with orofacial pain of odontogenic and non-odontogenic origin, through: a. Considering different manifestations of orofacial pain and how the nature of the presentation varies between them b. Understanding the pathophysiology of orofacial pain c. Considering indications for imaging studies and other investigations in the context of orofacial pain d. Considering the different evidence-based therapeutic options, including drugs, psychological therapies, selected complementary and alternative medicines, and operative interventions, including the advantages and disadvantages of each 22. The practitioner is able to perform an appropriate neurological examination. 23. The practitioner will be able to diagnose and appropriately manage patients presenting with altered cranial nerve function, related or unrelated to other neurologic abnormalities, through: a. Understanding the clinical features and underlying pathophysiology of localized and iatrogenic cranial nerve disorders and diseases with extraoral manifestations that present with cranial nerve disorders b. Considering the indications for and choice of imaging studies or other diagnostic investigations 24. The practitioner is able to interpret the results of investigations and diagnose conditions presenting with orofacial pain, including the recognition of

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7 (3.4%)

5 (2.5%)

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10 (4.9%)

6 (3%)

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9 (4.4%)

4 (2%)

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198 (98%)

1 (0.5%)

3 (1.5%)

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176 (87.1%)

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2 (1%) 3 (1.5%)

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189 (93.6%)

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6 (3%)

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12 (5.9%)

3 (1.5%)

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11 (5.4%)

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199 (98.5%) 193 (95.5%)

1 (0.5%) 3 (1.5%)

2 (1%) 6 (3%)

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192 (95%)

6 (3%)

4 (2%)

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167 (82.7%)

20 (9.9%)

15 (7.4%)

192 (95%)

5 (2.5%)

5 (2.5%)

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5 (2.5%)

6 (3%)

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13 (6.4%)

3 (1.5%)

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Supplementary Table IV. Continued Validation responses Competency orofacial pain with potentially high morbidity (including suicide risk or malignancy) or where associated with underlying systemic illness. 25. The practitioner understands the definitions, terms, classifications, pathophysiology, and theories of orofacial pain. INTERFACE OF ORAL AND SYSTEMIC DISEASE 26. The practitioner is able to relate health and disease of orofacial tissues to other relevant body systems (including different organs). 27. The practitioner is able to take an appropriate history of patients presenting with chronic conditions and perform a detailed physical examination relevant to orofacial health and other body systems, where appropriate. 28. The practitioner is able to select appropriate investigations; formulate an accurate, complete, and differential diagnosis for patients presenting with conditions across the interface of oral and systemic disease; and select an appropriate treatment plan. 29. The practitioner is able to develop a management plan for chronic disease, including self-care and the use of a supportive multidisciplinary team approach, through: a. Understanding the natural history of diseases that run chronic courses b. Recognizing medical disease, presentations and management, including complications of management 30. The practitioner has a detailed understanding of current best practice in safe prescribing, including: a. Knowledge of the range of adverse drug reactions to commonly used drugs and the drugs requiring therapeutic drug monitoring b. The effects of patient factors and concomitant disease on prescribing BEHAVIOURAL AND MENTAL HEALTH 31. The practitioner will be able to identify serious or incidental psychiatric morbidity in patients presenting with oral disease, through: a. Considering psychiatric symptoms and differential diagnosis relevant to orofacial disease b. Understanding the features of depression and risk factors for suicide c. Identifying a patient’s psychiatric history d. Evaluating the risk of suicide in a patient e. Understanding the basic use of antidepressants in the management of orofacial pain disease

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196 (97%)

4 (2%)

2 (1%)

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198 (98%)

2 (1%)

2 (1%)

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6 (3%)

3 (1.5%)

Validated

192 (95%)

9 (4.5%)

1 (0.5%)

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193 (96%) 189 (94%)

6 (3%) 10 (5%)

2 (1%) 2 (1%)

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194 (96.5%)

6 (3%)

1 (0.5%)

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197 (98%)

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189 (94%)

7 (3.5%)

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181 183 139 182

9 (4.5%) 10 (5%) 28 (13.9%) 10 (5%)

(90%) (91%) (69.2%) (90.5%)

11 (5.5%) 8 (4%) 34 (16.8%) 9 (4.5%)

Validated Validated Focus Group Validated

ORAL MEDICINE 9.e7 Steele et al.

OOOO Month 2015

Supplementary Table V. Focus group outcomes Clinical domain Examination and Diagnosis

Competency statement requiring attention Consideration of the use of supporting methods, such as structured questionnaires, when necessary Applying disease severity indices, when appropriate Knowledge of the financial and biologic cost of these investigations

Patient Treatment and Management Salivary Glands

Orofacial Pain, including Temporomandibular Disorder Behavioral and Mental Health

Understanding pediatric and women’s oral health and identification of diseases relevant to oral medicine practice Considering compliance and issues involved in prescribing “off license” Appropriate clinical examination, including chairside saliva volume measurements, and referral for or performance of Schirmer I tests, where indicated The practitioner is able to perform an appropriate neurological examination Evaluating the risk of suicide in a patient

Focus group decision UNCHANGED REPHRASED as “Applying validated disease severity indices, when appropriate” REPHRASED as “Knowledge of benefits and risks of investigations and awareness of the financial implications” DELETED

REPHRASED as “Considering issues involved in prescribing medications “off license” (“off label”) REPHRASED as “Appropriate clinical examination, including chairside saliva volume measurements and refer for, or perform, Schirmer I tests, where indicated.” REPHRASED as “The practitioner is able to perform an appropriate cranial nerve examination” REPHRASED as “Performing a preliminary risk assessment of suicide or self-harm in a patient, where indicated, and referring appropriately.”

World Workshop on Oral Medicine VI: an international validation study of clinical competencies for advanced training in oral medicine.

To explore international consensus for the validation of clinical competencies for advanced training in Oral Medicine...
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