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Oral Health

Jeffrey Stearns, MD (Preclerkship Collaborative Workgroup) and David Schneider, MD (Family Medicine Clerkship/Post Clerkship Workgroup) and Ardis Davis, MSW, FMCR Project Manager.

Consultant Authors: Alan Douglass, MD, and Joanna Douglass, BDS, DDS, Family Practice Residency Program; Middlesex Hospital and the University of Connecticut Schools of Medicine and Dental Medicine; and Paul E. Gates, DDS, Bronx-Lebanon Hospital Center

Contributing input from: Wendy Mouradian, MD, and Sara Kim, PhD, University of Washington HRSA funded Interdisciplinary Children's Oral Health Promotion Project

OVERVIEW

In the Surgeon General's Report on Oral Health in America, oral health is defined as "encompassing all the immunologic, sensory, neuromuscular, and structural function of the mouth and craniofacial complex. Oral health influences and is related to nutrition, communication, self-image and societal functioning."

Oral health is a critical component of overall health and must be included in the provision of health care and the design of community programs. Disparities exist across population groups at all ages, and access to appropriate dental care is frequently lacking. More than one-third of the U.S. population (100 million people) has no access to community water fluoridation. Over 108 million children and adults lack dental insurance, which is more than twice the number that lack medical insurance. Physicians can have a significant impact in improving access to care through patient advocacy within their communities.

The role of primary care physicians in the area of oral health is being increasingly recognized as vital to the effective delivery of health care in the United States.   Most patients have a medical home, but many fewer have a dental home. Dental caries and periodontal disease are highly prevalent, oral lesions are common, and and many systemic diseases have oral manifestations of systemic diseases and therapies occur frequently. Family physicians are often the first health care professionals to see patients with oral pain or trauma, and they provide well care and preventive services for a large proportion of the nation's children and adults . In short, family physicians can significantly reduce the burden of oral disease through screening, prevention, and facilitating appropriate dental referral. The importance in partnering with the dental profession around oral health education, in particular with regard to teaching about oral health in pediatric populations, is clear.

An understanding of the interrelationships between oral and systemic disease is vital for physicians. Associations between periodontal disease and diabetes are well documented. New research points to associations between chronic oral infections and cardiovascular disease and low-birth-weight, premature births.   In caring for these patients there is a critical need for clear and effective communication between medical and dental professionals.

TOPIC LEARNING GOALS AND OBJECTIVES
(Organized by ACGME Competencies)

Patient Care

GOAL: Students will appropriately interview and examine patients and accurately identify the manifestations of oral disease and its risk factors.

OBJECTIVES: Students will:

  • Perform an appropriate oral health history focusing on identification of risk factors for oral diseases.
  • Perform an appropriate dietary history focusing on factors that increase the risk of oral diseases such as tobacco and alcohol use and the frequency of sugar intake.
  • Perform an appropriate oral examination that effectively visualizes all intra-oral hard and soft tissue, and identifies normal landmarks.
  • Correctly identify common oral abnormalities including dental caries, periodontal disease, oral infections, and common benign and malignant oral lesions.
  • Generate an appropriate differential diagnosis for common abnormal oral findings.
  • Appropriately document oral findings and diagnoses.

GOAL: Students will understand the importance of preventive care in the maintenance of oral health.

OBJECTIVES: Students will be able to counsel patients and families appropriately regarding:

  • Appropriate diet for all age groups, with a focus on factors that increase the risk of dental caries such as frequency of sugar consumption.
  • Avoidance of unhealthy habits that increase oral cancer risk such as alcohol and tobacco use.
  • Brushing and flossing.
  • Appropriate intervals for dental care and selection of an appropriate dental professional.
  • Systemic fluoride supplementation in children.
  • Appropriate use of fluoride varnish under special circumstances.
  • Prevention of oral trauma and the use of facemasks and mouth guards.
  • Links between oral and systemic disease.

Medical Knowledge

GOAL: Students should understand normal anatomy and function of the oral cavity.

OBJECTIVES: Students will:

  • Correctly identify normal anatomy.
  • Describe the function of the muscles, salivary glands, teeth, and temporomandibular joint.
  • Describe common developmental abnormalities of the oral cavity and their impact on function.
  • Describe the neural functioning of the head and neck.

GOAL: Students will learn the epidemiology and pathophysiology of oral health diseases, and how oral health problems affect patients' ability to live with other chronic illnesses.

OBJECTIVES: Students will:

  • Describe the relationships between oral diseases and systemic diseases, including the oral manifestations of tobacco use (either smoked or chewed), systemic medications, alcohol use, autoimmune disease, and immune deficiency, and associations with cardiovascular disease, pregnancy, and diabetes mellitus.
  • Describe the incidence and prevalence, risk factors, and pathophysiology of:
    • Early childhood caries
    • Adult caries
    • Periodontal disease
    • Common benign oral lesions including tori, cystic lesions, ulcerations, and white lesions
    • Oropharyngeal neoplasms
    • Chronic facial pain
    • Temporomandibular joint disorders
    • Craniofacial birth defects
    • Facial trauma
    • Oral infections caused by viruses, fungi, and bacteria
    • Common neural disorders of the head and neck, including trigeminal neuralgia and facial nerve palsies
    • The oral manifestations of autoimmune disorders
  • Describe the diagnosis and management of common dental emergencies including:
    • Dental pain
    • Peri-apical and periodontal abscesses
    • Cellulitis and infection of the deep spaces of the head and neck
    • Dental trauma, including tooth luxation and avulsion
    • Pericoronitis
    • Complications of dental extractions

GOAL: Students will understand common points of intersection between medical and dental care, and the physician's role in those situations.

OBJECTIVES: Students will:

  • Understand the risks and indications for temporary cessation of anticoagulation therapy in preparation for dental surgery.
  • List the indications and appropriate dosing for the administration of antibiotic prophylaxis prior to dental procedures to reduce the risk of infection of cardiac structures and implanted medical devices per American Heart Association guidelines.

Practice-Based Learning and Improvement

GOAL: Students will understand how screening for oral health in primary care can identify patients in need of oral health treatment and how this can yield to improved patient care outcomes.

OBJECTIVES: Students will:

  • Identify screening methods that can be used by a primary care physician to detect oral health problems in a primary care physician's practice.
  • Describe how screening can yield improved patient care outcomes.

GOAL: Students will demonstrate appropriate self-directed learning and application of evidence to knowledge acquisition.

OBJECTIVES: Students will:

  • Choose appropriate print and electronic resources.
  • Appropriately utilize those resources in a self-directed manner.
  • Recognize the importance of basing knowledge acquisition and clinical decision making on evidence-based resources.

Interpersonal Communication Skills

GOAL: Students should communicate effectively with patients around oral health issues.

OBJECTIVES: Students will:

  • Create and sustain effective therapeutic relationships.
  • Effectively communicate the importance of oral health in the context of total health.
  • Demonstrate sensitivity to race, religion, gender, age, and cultural issues.

Professionalism

GOAL: Students will demonstrate professionalism in the care of patients with oral health needs.

OBJECTIVES: Students will:

  • Maintain confidentiality.
  • Act professionally at all times.

Systems-Based Practice

GOAL: Students will recognize the role of the primary care physician in maintaining oral health, and how it is influenced by barriers to care and social and cultural determinants of health.

OBJECTIVES: Students will be able to:

  • Articulate the public health argument for the need for fluoridation of the public water supply.
  • Recognize current barriers to access to dental care, and advocate for patients in circumventing them.
  • Work within their communities to improve access to dental care.
  • Appropriately partner with case managers and coordinate care with other health care professionals.
  • Facilitate effective communication between medical and dental professionals.
  • Discuss factors that impact oral health in multicultural populations.

EDUCATIONAL METHODS AND RESOURCES

Teaching Strategies

  • Case-based learning using visual/auditory adjuncts
  • Standardized patient interviews to develop communication skills
  • Case-based lectures
  • Clinical experiences (see below)

Integration Strategies

  • During interview training, utilize patient instructors with oral disease histories.
  • Link oral health material with the goals and objectives of Healthy People 2010 and teaching on public health strategies for population health.
  • Emphasize treatment of oral disease on specific clerkships.
  • Include oral health topics in physiology/pathology course.
  • Emphasize the comprehensive oral examination and recognition of dental caries, enamel defects, periodontal disease, and common oral lesions during physical examination course, with reinforcement on specific clerkships.
  • Include oral health topics in discussions of the effects of socioeconomic status on illness.
  • Include oral health topics during training in patient education.

Clinical Experience

  • Oral examination of children and counseling of their parents at routine well child visits.
  • Oral examination and counseling of adults at routine office visits in the primary care setting.
  • ENT, oral surgery, or dental clinic experiences.
  • Observations of interviews that involve cross-cultural issues and subsequent group discussion or journaling.
  • Observations of care in community health settings such as screening programs, daycare centers, Head Start, etc.
  • Participation in patient education activities in community health settings.

Lectures

  • PowerPoint lecture on infant oral health is available through the University of Connecticut's oral health Web site at
    http://oralhealth.uchc.edu
  • The American Academy of Pediatrics is developing a PowerPoint lecture on infant oral health that will be available through their Web site. It goes live November 1, 2004. Contact Wendy Nelson in the AAP Division of Community Pediatrics at 1-800-433-9016 x7789.
  • Lectures will be available on Web sites through the University of Washington, University of Kentucky, and University of Texas at San Antonio's Interdisciplinary Children's Oral Health Promotion Projects that will go live in the first quarter of 2005.

Independent Learning

  • Journaling in conjunction with observations of interviews
  • CD-ROMs self-instructional tools
  • Web-based instructional modules
  • Core textbook
  • Compilation of relevant articles (either in print or computer-based)

Curricular Resources

  • University of Connecticut Oral Health Web-based Curriculum
    http://oralhealth.uchc.edu/
    Provides extensive resources on infant oral health including a downloadable and viewable PowerPoint lecture, case-based exercised, fluoridation information, and handheld downloads.

    Interdisciplinary Children's Oral Health Promotion Projects
    Modules developed through HRSA Cooperative Agreements to educate family practice residents on oral health in child populations at the University of Washington, University of Kentucky, and the University of Texas at San Antonio). They are anticipated to go live in the first quarter of 2005.
  • National Maternal and Child Oral Health Resource Center
    http://www.mchoralhealth.org/default.html
    This provides links to 2 well-designed on-line learning modules on child oral health: Open Wide ( http://www.mchoralhealth.org/OpenWide/index.htm ) and A Health Professional's Guide to Pediatric Oral Health Management ( http://www.mchoralhealth.org/PediatricOH/index.htm) . These modules include information on performing oral screening, identifying infants and children at risk for oral health problems, coordinating referrals to oral health professionals, and providing parents with anticipatory guidance.

Published Material for Learners

  • USDHHS. Oral Health in America: A Report of the Surgeon General.
    http://www.surgeongeneral.gov/library/oralhealth/
  • Weinberg MA and Estefan DJ.   Assessing oral malignancies
    Am Fam Physician. 2002;65:1379-84,1385-6.
    http://www.aafp.org/afp/20020401/1379.html
  • American Academy of Pediatric Dentistry. Guideline on fluoride therapy. Pediatric Dentistry. 2002; 24(7): 66-67. UPDATE
  • Douglass AB and Douglass JM. Common Dental Emergencies. Am Fam Physician. 2003; 67(3): 511-516
  • Douglass JM, Douglass AB, Silk H. A Practical Guide to Infant Oral Health. Am Fam Physician. December 1, 2004. (in press).
  • Douglass AB et al. Oral Health for the Family Physician. FP Essentials, Edition No. 304, AAFP Home Study. Leawood, Kansas: American Academy of Family Physicians, September 2004.

Published Material for Teachers

  • Graham E, Negron R, Domoto P, Milgrom P. 2003. Children's oral health in the medical curriculum: A collaborative intervention at a university-affiliated hospital. J Dent Educ. 67(3): 338-347
  • Mouradian WE, Schaad DC, Kim S, Leggott PJ, Domoto PS, Maier R, Stevens NG, Koday M. 2003. Addressing disparities in children's oral health: A dental-medical partnership to train family practice residents. J Dent Educ. 67(8): 886-895.
  • Mouradian WE, Berg JH, Somerman MJ. 2003. Addressing disparities through dental-medical collaborations, part 1. The role of cultural competency in health disparities: Training of primary care medical practitioners in children's oral health. J Dent Educ. 67(8): 860-868.

Published Material (Miscellaneous)

  • Mouradian WE. The face of the child: children's oral health and dental education. J Dent Educ. 2001; 65:821-31.
  • Mouradian W, Wehr L and Crall JJ: Disparities in Children's Oral Health and Access to Care. JAMA. Nov 22/29, 2000; 284(20): 2625-2631.
  • Lewis CW, Grossman DC, Domoto PK, Deyo RA. The role of the pediatrician in the oral health of children: a national survey. Pediatrics. 2000; 106:1-7.
  • Hendricson WD, Cohen PA. Oral health care in the 21st century: implications for dental and medical education. Acad Med. 2001; 76:1181-1204.
  • Hale KJ, American Academy of Pediatrics Section on Pediatric D. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003; 111(5): 1113-6.
  • Anonymous. Recommendations for using fluoride to prevent and control dental caries in the United States. Centers for Disease Control and Prevention. Morbidity & Mortality Weekly Report. Recommendations & Reports. 2001 Aug 17; 50(RR-14): 1-42.
  • Romito LM. 2003. Introduction to nutrition and oral health. Dental Clinics of North America 47(2): 187-207.
  • Rozier RG, Sutton BK, Bawden JW, Haupt K, Slade GD, King RS. 2003. Prevention of early childhood caries in North Carolina medical practices: Implications for research and practice. J Dent Educ. 67(8): 876-885.

Web Sites

  • Healthy People 2010: Section 21, Oral Health
    http://www.healthypeople.gov/Document/HTML/Volume2/21Oral.htm
    This site provides background information on oral health as well as the actual Oral Health 2010 objectives.
  • NIDCR National Oral Health Information Clearing House
    http://www.nidcr.nih.gov
    Clicking on the "Health Information" icon at the top brings up an indexed list of oral health topics.
  • CDC Oral Health Resources
    http://www.cdc.gov/oralhealth/
    This site is set up to permit searches and to browse by topic.
  • Oral Health America
    http://www.oralhealthamerica.org
    Oral Health America is a fully independent non-profit for public benefit that follows a path of broad-based public advocacy through targeted programs and communications efforts to improve oral health for all Americans. Of particular use at this site are the "Report Cards" that include topics such as the oral health of older Americans.
  • Maternal and Child Health Library: Knowledge Path - Oral Health and Children and Adolescents
    http://www.mchlibrary.info/KnowledgePaths/kp_oralhealth.html
    This knowledge path offers a comprehensive collection of links and resources, although it may not be easy to identify the most useful resources.
  • Children's Dental Health Project
    http://www.cdhp.org
    This site contains a wealth of resources about children's oral health, particularly issues involving access to care, financing programs, and health disparities.   Of particular note is the Interfaces project that explores the relationship between medicine and dentistry in meeting the oral health needs of young children.
  • American Academy of Pediatric Dentistry
    http://www.aapd.org
  • American Dental Association
    http://www.ada.org
  • American Academy of Pediatrics has developed a comprehensive Web site on infant and child oral health. It is scheduled to go live November 1, 2004. Contact Wendy Nelson in the AAP Division of Community Pediatrics at 1-800-433-9016 x7789.

ASSESSMENT STRATEGIES

  • Demonstration of awareness and utilization of Web sites to solve problems and access information
  • OSCE
  • Clinical observation
  • Physical exam course testing and demonstration of oral examination skills during specific clerkships
  • Interviews of standardized patients
  • Diaries identifying barriers to care and how they were approached and surmounted
  • Creation of short reports after observations and self-directed learning
  • Exit interviews with patients/families regarding the effectiveness of student patient education
 

For questions or comments, please contact Webmaster or Ardis Davis

This page last updated November 6, 2004