For all its indispensability, the mouth simply does not register on the public's list of high-profile body parts. But don't tell that to UCSF oral medicine specialist Caroline Shiboski. To this Danish-born, Paris-reared and American-trained director of the School of Dentistry's Stomatology Clinical Center, the mouth functions as a wondrously balanced world of membranes, bone and fluid. Alter this balance and trouble brews -- and Shiboski is not just talking about dental caries or gum disease, important as they may be.

"The mouth is a window on a person's overall health," she explains. And although specialists in oral medicine are not well known generally, or is dentistry per se appreciated as a hotbed for diagnosticians, Shiboski and her four colleagues offer a very visible, very specialized service for the 100 or so patients who visit their referral clinic each week. Together they diagnose conditions ranging from the ulcers associated with some autoimmune diseases (such as lichen planus, pemphigoid or pemphigus), oral cancer and the dry mouth of Sjogren's syndrome to the side effects of certain drug regimens. Cyclosporin, for example, one of the primary immune suppressant drugs used by transplant recipients, causes gums to enlarge, and together with other immunosuppressive medications, increases the likelihood of various infections or even malignancies in the mouth. "Many patients are desperate for some relief and happy to find a clinic that can recognize and alleviate their problem."

At the same time, the ebullient Shiboski, who earned both a master's in public health and a PhD in epidemiology at UC Berkeley during the 1990s, retains a dental researcher's eye for overlooked connections. Indeed, it was this self-described "patient-driven" enthusiast, together with her UCSF colleagues, who first posed the question -- and then designed the ongoing study -- that asked if the poor oral health of some transplant patients was related to their number of rejection episodes. Her concern is rooted in simple arithmetic. "It doesn't seem right to be spending hundreds of thousands of dollars on individual transplants and a lifetime of antirejection drugs without also following the consequences of poor oral health." Shiboski's interest in graft versus host disease (GVHD) has also made the clinic an important outpost for children who have received bone marrow transplants. Mouth sores are sometimes the only sign of GVHD, making a visual inspection of the mouth a key component in the monitoring process.

A mother of two young boys who cannot remember a moment when her gender posed an obstacle to professional achievement, Shiboski has now gone international with her mouth-monitoring creed, thanks to funding from both the National Institute of Dental and Craniofacial Research and the UCSF School of Dentistry. Several weeks each year, she works at the University of Zimbabwe, where she teaches oral medicine and oral pathology to fourth- and fifth-year dentistry students. "The school, which opened a few years ago, has limited number of faculty and no one teaching oral medicine," she says. Shiboski, a co-investigator in the UCSF Oral AIDS Center, also designed a collaborative project with her Zimbabwean colleagues to explore the feasibility of training nurses in the diagnosis of HIV-related oral lesions and of using these lesions as surrogate markers for HIV disease progression. (The patients in the study are part of UCSF epidemiologist Nancy Padian's reproductive health cohort.) T-cell monitoring tests are prohibitively expensive in sub-Saharan Africa, making a visual system a key step in determining when antiretroviral therapy should begin -- assuming of course that such drugs will one day become both available and affordable in that part of the world.

Patient advocacy

Although Shiboski does not dwell on the injustice of drug distribution systems, she is quick to point out that the problems of access and availability are not confined to the developing world. "The lack of insurance for some of our patients is very frustrating. We end up doing a lot of social work trying to arrange specialty referrals for patients with limited or no insurance coverage." Worse, rumors that the dental benefit for MediCal, which serves California's low-income population, may be eliminated as part of the state's permanent budget restructuring frighten Shiboski. "Medically compromised patients with this type of coverage are in dire need of dental care."

Despite the frustrations inherent in a poorly designed health care system, Shiboski continues to find joy in both her clinical work and teaching activities. "It is incredibly rewarding to make the correct diagnosis and develop a treatment plan that will alleviate the pain a patient has been suffering for months." Teaching students to do the same and then watching as they develop their own diagnostic skills is even more gratifying. "In the end, it's all about caring for patients without letting the insurance companies alter the way we care -- and then transferring this intact spirit of caring to our students."