Dr. Silvina Friedlander-Barenboim
Director, Oral Medicine Specialty Program, Sheba Medical Center
Head of DentoMaxillofacial Radiology Service, Sheba Medical Center
DMD (Dental Medical Doctor), Tel-Aviv University
Oral Medicine specialist
What drove you to specialize in oral medicine?
I come from a family of dentists, including my grandmother, mom, dad and brother. So, I was surrounded by dentists and dental knowledge, all around me, from childhood. But when I started studying at university, I chose to study medicine instead. I thought medicine would be more interesting and fulfilling and did not want to follow my family trait. So, I studied medicine for 3 years. However, in the 3rd year I was exposed to life in the hospital and decided it was not for me. I wanted to work in something that enables a better work-life balance. Something that would allow me to be dedicated to my career as well as to raising a family.
As a result, I made a “U-turn”, and specialized in Oral Medicine. It turned out that my 3 years of general medicine studies helped me and were pretty useful for completing the Oral Medicine specialty. There is a lot of overlap between medicine and oral medicine, and general medicine studies also provided me with a broader perspective and a whole-body-system approach to treating patients.
During my specialty studies, I found I was interested in oral and maxillofacial radiology and in Digital Imaging. That was, at that time (1999), a new field of expertise, which fascinated me, and felt like something I could excel at. But in Israel, at that time, there was no specialty program for Dental Radiology, so I ended up specializing in Oral Medicine, which included Dental Radiology as a sub-discipline in it.
What drives you in your profession?
My passion is to innovate, to introduce new technologies that enable dentists to provide better care and improved treatment. Routine makes me bored easily, and I look for things to develop, as I like and welcome challenges.
For 11 years I managed the DentoMaxilloFacial unit at The Hadassah University Hospital – Ein-Kerem, in Jerusalem. During that period, I launched two innovative solutions CR (Computed Radiography) in 2005 and DR (Digital Radiography) in 2010. Getting veteran colleagues to adopt new technologies was challenging, while the younger generation of dentists were keen to adopt. In 2005 I introduced the first Cone Beam scanner implemented into a dental school in Israel, a NewTom machine, which was still used in supine (laying back) position.
Innovation still drives and motivates me every day, and I am always looking for new technologies and methods that can help provide better dentistry treatment.
Can you share with us a clinical case that you consider fascinating or unusual?
There are so many… One particularly interesting case was of a young female patient with floor mouth elevation, suspected of suffering from a salivary gland pathology. Her swelling was reduced with Antibiotics, and reappeared when antibiotic treatment ended. Examination of the submandibular salivary gland using a dedicated imaging scan with contrast agent was within normal limits. An Endodontist ruled out the tooth origin of the complaint, all teeth on the right lower jaw were intact. A Periodontist did not find any periodontal disease nor fissures or fractures in any of the teeth. So, the patient was sent for a CBCT scan, and the resulting CBCT scan was sent to me for consultation, which resulted in an enamel pearl in the furcation of tooth #46 being the cause for the recurrent infection that had spread through the mandible and perforated the lingual plate inferiorly to the mylohyoid muscle into the floor of the mouth, thus mimicking a salivary gland pathology.
Usually, I prefer to meet the patients in person, in order to also inspect them physically. But in this case, I never actually met her. I agreed to inspect only the DICOM file, in the hope of providing some useful observations, diagnosis and recommendations. I used special reconstructions generated from the DICOM file, which allowed me to find an enamel pearl that couldn’t have been detected otherwise. This enamel pearl prevented the periodontist from finding the periodontal defect with a regular probe. The infection resulting from the Enamel pearl made its way to the lingual area, and eventually the tooth was extracted. The patient no longer suffered, and the problem was solved.
Can you recommend a scientific article that dental professionals should read?
Maxillofacial cone beam computed tomography: essence, elements and steps to interpretation; Australian Dental Journal, Mar 2012; WC Scarfe, Z Li, W Aboelmaaty, SA Scott, AG Farman
Link to the article: onlinelibrary.wiley.com/doi/10.1111/j.1834-7819.2011.01657.x
I recommend this article as it provides important and useful guidance to dentists on how to approach CBCT interpretation, in order to better understand the importance of a professional and thorough report of 3D scans and hence provide better treatment to patients.
What advice would you give to dentists?
My main advice to dentists is to learn to work in a multi-disciplinary team. Dentistry involves many fields of expertise, and as a dentist it is essential to collaborate and consult with experts if you wish to provide better care to your patients, as well as to enable yourself to constantly learn, develop and evolve professionally. Naturally, this is even more relevant and essential when facing complicated or unusual dental cases.
How do you keep yourself professionally updated?
As the Director of Oral Medicine specialty program at Sheba Medical Center, I constantly expand my horizons. We create new materials for seminars every semester, and since I work in a hospital, I encounter many unusual and interesting clinical cases every month.
I also attend many professional conferences (many of which are international) and am on the board of several medical committees. Needless to say, I’m subscribed to, and dedicate time for reading, professional journals.
All in all – I learn and educate myself constantly. If something is new in Oral Medicine – I will take interest in it. I believe this will always be the case. The horizons are endless and will never cease to amaze me.
How do you see the future of your field of expertise?
Oral Medicine is concerned with the oral health care of patients with chronic, recurrent, and medically related disorders of the oral and maxillofacial region. As such, Oral Medicine includes many sub-specialties, such as: Oral mucous membranes diseases (including cancer cases), Orofacial pain of the face and the jaws (including TMJ cases), Dryness of the mouth (usually related to the salivary gland), treatment of patients with systemic underlying conditions (that cannot be treated within common dental clinic setup), dental treatment under general anesthesia (for patients suffering from acute anxiety to dental treatment, for non-compliant patients, and more). With so many sub-disciplines, the future is endless – ever evolving and changing, and so is the Oral Medicine profession.
Some trends in Oral Medicine are already predictable. Oral Medicine is growing bigger in hospitals, and dentists need to know when to refer to a hospital. Artificial Intelligence (AI) tools, and Intraoral scans superimposed with DICOM files are all used more frequently, as dental treatment is improving.
Oral pathology is going through an innovation era as well, to become more time consuming in reporting histopathology through the utility of sophisticated scanners. Via automation of the processing, the biopsy sample is placed in sensitive scanners and undergoes powerful computer assessment. The computer produces all the sections digitally and automatically, and AI will provide high-quality interpretations, diminishing the need for physical sections inspected under a microscope.
Which technologies or developments, in your opinion, will shape the future of dental imaging?
Ultrasound will become a more common tool for maxillofacial Imaging. It is a non-invasive imaging technology (involving non-ionizing radiation and thus safer), and it enables the inspection of soft tissues – including blood flow in areas of infection, suspected lesions and salivary glands. Ultrasound is highly dependent on the skills of the operator, and therefore it will take some time until it will be assimilated in Oral Medicine.
Ultrasound imaging can help us detect things that are hard to observe during regular clinical observation. As mentioned above, it enables us to inspect soft tissues and identify the source of infections, and therefore it is a complementary technology to hard tissue inspection by x-ray imaging. I strongly believe it will become an integrated and valuable part of oral maxillofacial Imaging, with time.
What are your thoughts about the future of dental radiology?
I predict more and more digitization and AI usage, while using less ionizing radiation, and photon counting techniques, via dedicated and advanced sensors. Improved algorithms that will enable a clearer presentation of pathologies to the dentist, while reducing imaging radiation.
It is important to reduce the level of radiation, especially since not all referrals to imaging tests are necessary. In the past, orthodontics used to send patients to CBCT scan before, during and after the orthodontic treatment. And since most orthodontic patients are young, and since x-ray radiation damages young people 2-3 times more when compared to the potential damage to older populations, there was a big dispute about the use of CBCT imaging this way. There are specific guidelines to follow when using CBCT for orthodontic diagnosis and treatment plan.
In addition, the biggest disadvantage of CBCT is that it cannot differentiate between various soft tissues. So, as mentioned above, we need other technologies, such as Ultrasound, to detect and analyze soft tissues or find new technologies that will be able to present soft tissues in CBCT.
You said you decided to specialize in Oral Medicine in order to keep a good Work-Life balance. Well, how did that work for you so far?
I try to balance work-life, though it is not easy. Me and my husband (who is also a doctor, and serves as a hospital manager) are both workaholics… So, our starting point for work-life balance is not ideal…
I did manage to dedicate significant time to raising 4 daughters (all grown-up and with independent careers by now). We always have Friday night dinner with the family, we dedicate weekends to spend time together. Personally – I play Squash twice a week, and also practice Pilates. All these help me balance the workload and regenerate strength.
As for the professional part – in addition to my hospital work I have a private clinic and frequently attend conferences. However, I finish work early (at 4 PM) twice a week. In this respect, I am quite happy I chose to specialize in Oral Medicine, as I believe it indeed provided me with more self- fulfillment and opened my mind to various areas in dentistry and medicine.