Oral-Dental Health Training for Senior Medical Students: A Medical and Dental School Collaborative Curriculum David L. Gaspar MD Associate Professor, Department of Family Medicine University of Colorado Denver-School of Medicine Mark Deutchman MD Professor, Department Family Medicine University of Colorado Denver-School of Medicine Professor, School of Dental Medicine

Objectives Understand how this element of curriculum fits into the overall medical school curriculum. List the elements of the educational program and faculty needed to conduct the instruction. Understand the logistics of using Dental School facilities for Medical School teaching. Describe an evaluation strategy for this collaborative Dental-Medical education and results from one institution.

Background for the Project Improving oral health is a national priority in Healthy People Physicians have many opportunities to identify oral health and dental problems but many feel their education on this topic is lacking. Providing basic knowledge and skills in oral health assessment can help physicians improve the overall health of their patients by making earlier interventions and by directing their patients to establish a dental home.

Importance to healthcare access In Colorado: –9 counties with no dentist –24 counties with no dentist accepting Medicaid –Less than 12% of CO licensed dentists are Medicaid providers –2.3 million Colorado adults do not have dental insurance –Only 30 percent of Colorado children eligible for Medicaid received any dental services

Design of the Project In 2007, twenty-four 4th year students took part in a non-required “selective” on Oral-Dental Health In 2008 became a required element for all 4th year medical students. This training was one more element of oral- dental curriculum institutionalized in the SOM Collaboration: Delta Dental Frontier Center, STFM Smiles for Life, School of Medicine, School of Dental Medicine

What else is happening in the SOM? Phase I – Problem-Based Learning casePhase I – Problem-Based Learning case Phase II – Oral-systemic connectionPhase II – Oral-systemic connection Phase III – Oral exam intro and intraoral lesion instruction in Rural & Community Care clerkshipPhase III – Oral exam intro and intraoral lesion instruction in Rural & Community Care clerkship Phase IVPhase IV –Required Oral exam workshop –Elective in acute oral care –Elective in child oral health 6

Educational Concept and Curricular Design Planning was carried out collaboratively between SOM and SODM Held during Integrated Clinicians Course (week before 4 th year starts) Format: Hour One –Interactive didactic held in the Dental School provided by two Department of Family Medicine and one School of Dental Medicine faculty member –Material for the didactic was taken primarily from the STFM Smiles for Life materials.

Educational Concept and Curricular Design Format: Hour Two –One hour of hands-on practice and demonstration of a complete oral-dental physical exam. –32 third year dental students assigned to proctor 2-3 medical students each for two or more of 8 sessions –Dental school administration scheduled 10 chairs in the dental clinic operatories for each of 8 exam sessions. –We provided each medical student a toothbrush, toothpaste, dental floss and a stainless steel dental mirror which was theirs to keep. –At least one dental faculty and one medical faculty supervised the clinic sessions and answered questions posed by both the dental and medical students.

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Pre - Evaluation 1. Previous experience with interdisciplinary dental-medical education 2. Basic oral-dental knowledge 3. Confidence in identifying common oral lesions 4. Confidence in performing a basic oral, head, neck, physical exam.

Post - Evaluation 1.Confidence in physical exam 2.Confidence in oral lesion recognition skills 3.Basic oral-dental knowledge 4.Five additional questions to assess the utility of the curriculum

Phase IV Oral Health Workshop School of Medicine I am confident in oral exam skills: 56/118 –Pre-56/118 agreed or strongly agreed 113/114 –Post- 113/114 I am confident in my ability to identify intraoral lesions: 20/118 –Pre-20/118 agreed or strongly agreed 109/114 –Post- 109/114

Phase IV Oral Health Workshop School of Medicine 45.5 %Students correctly answered 45.5 % of questions on a 6 item pre-test of basic oral- dental knowledge. Percent of Students Answering Correctly: –Age range when primary teeth erupt-78.0% –Number of primary teeth-36.4 % –bacterium that primarily causes dental caries 38.1 % –finding in a child that is a precursor to dental caries 28.8 % – most common area to find oral cancers-33.9 % 96.0%Students answered 96.0% of the same 6 questions correctly on a post-test that followed the curriculum.

Phase IV Oral Health Workshop School of Medicine 6.8Few students indicated that they had ever been taught by dental professionals. (8/118=6.8%) Following the curriculum: –98% –98% of students felt they had an enhanced knowledge of the connection between oral and systemic health, –99% –99% stated that the material was new information not covered in their medical education to date,

Phase IV Oral Health Workshop School of Medicine Following the curriculum: –100% –100% felt the didactic instructor presented their material in an interesting and understandable manner, –100% –100% liked the fact that the 2 professional schools were collaborating to teach the course and –99% –99% agreed or strongly agreed that it was worthwhile for medical students to be taught by dental students and dentists.

Conclusions Even at the end of the year 3 clinical clerkships, student self-reported confidence in performing an oral/head/neck exam and basic oral-dental knowledge appears low Providing a 2-hour curriculum on oral-dental health provides knowledge that fills a gap identified by medical students in their education. Large improvements in confidence in physical exam, oral lesion recognition and knowledge appeared to be seen after this 2-hour educational session. Most medical students have not had the opportunity to teach or learn from dental professionals or trainees. Students were receptive to having other professional students teach them clinical skills.

Dental student evaluation data

Dental Student Evaluation Data Only 4 of 32 (11%) of the dental students had prior experience acting as a teacher to a medical student of a physician. Thirty one of the 32 students (97%) liked the fact that medical and dental school faculty were collaborating to teach this course.

Dental Student Evaluation Data Perceptions of the medical students’ receptivity to dental students acting as teachers were uniformly positive. Of the 32 dental students surveyed, 18 strongly agreed and 14 agreed that medical students were receptive to being taught by dental students. All students (19 strongly agreed and 13 agreed) that it was worthwhile for dental students to teach medical students 30 of the 32 sought opportunities for dental students to learn from their medical student counterparts.

Additional curriculum details

25 Phase I - PBL Case Case outline: –Patient presents to physician with vague oral symptoms. –Diagnosis initially missed, then caught on follow-up –Biopsy and excision show CIS Learning issues: –Oral precancer and cancer –Oral lesions and infections –Importance of the oral/head/neck exam –Risk factors and health behavior change

26 Phase II – oral/systemic Describe normal child and adult oral anatomy. Understand how oral and systemic health are inter-related – Caries – Periodontal disease – Cancer –Obesity –Diabetes –Coronary Heart Disease –Adverse Pregnancy Outcome Encourage medical-dental collaboration

New Phase IV Elective in Acute Adult Dental Care Two weeksTwo weeks 3 days/week in dental emergency clinic3 days/week in dental emergency clinic 1 day/week in oral surgery clinic1 day/week in oral surgery clinic 7 days and nights on call paired with a dental resident7 days and nights on call paired with a dental resident Skill objectives:Skill objectives: –Intraoral blocks –Abscess drainage –Dental radiography –Patient evaluation, triage and referral

New Phase IV Elective in Child Oral Health 2 weeks2 weeks Child oral urgent care clinicChild oral urgent care clinic Dental screening/treatment vanDental screening/treatment van Skill objectives:Skill objectives: –Oral examination of children –Fluoride varnish application –Patient evaluation/triage/referral

Conclusions Curriculum Considerations and Portability of this Instruction Timing may be an issue in both terms of student readiness for this instruction. While it would make sense to provide this instruction before the year 3 clerkships begin so that students could practice using oral-dental skills throughout the year, students may not feel this topic of instruction was important at an earlier stage of their clinical curriculum. On the other hand if there is no time during year 4 when all students are required to return to the home campus or no curricular time for new instruction, this type of training cannot be accomplished since it requires a concentration of faculty effort and infrastructure over a relatively short period of time. It is unclear how the use of the dental school clinics and dental students affected evaluations. One may speculate that medical student evaluation of this effort may have been different if either dental students were not involved in the clinical instruction or if the workshops were conducted on medical exam tables rather than in the dental clinics. Therefore, this educational intervention is highly dependent on cooperation of the School of Dental Medicine, dental faculty and dental students. Finding ways to “repay” the dental school with medical faculty teaching, optimizing dental clinic use and the using the dental students’ time most efficiently will determine future success with this program.