Nova Southeastern University-- Jacksonville Campus

Physician Assistant Program

Promoting Oral Health Education in Physician Assistant Curriculum

Financial Disclosure

• Racheal McInnis has no financial relationships to disclose.

• Kerry Whitaker has no financial relationships to disclose.

• Suzie Wolf has no financial relationships to disclose.

Introduction Introduction Introduction Introduction

Racheal McInnis, PA-C, MPAS, MSN

Assistant Professor

Physician Assistant Program-Jacksonville

Nova Southeastern University

Kerry L. Whitaker, DHSc, PA-C, DFAAPA

Program Director/Assistant Professor

Physician Assistant Program-Jacksonville

Nova Southeastern University

Suzanne “Suzie” S. Wolf, MS PAS, PA-C

Assistant Professor

Physician Assistant Program-Jacksonville

Nova Southeastern University

1. Identify and review State of Florida oral health grade.

2. Discuss the importance of oral health and identify methods to

promote oral health in primary care.

3. Discuss the importance of interprofessional practice and

collaboration between the primary care provider and dental

profession.

Learning Objectives

“You are not healthy without good oral health…”

-David Satcher, MD

16th Surgeon General

Pre-Discussion Questions

• What is the most current oral health grade for the state of Florida?

• Name three predictors of poor oral health?

• What is the most common bacteria associated with tooth destruction?

Northeast Florida Oral Health Demographics

• In the 2010 census, the population of the city (Jacksonville) was cited as 821,784.

� 26.7% under the age of 18,

� 9.7% from 18 to 24,

� 32.3% from 25 to 44,

� 21.0% from 45 to 64, and

� 10.3% who were 65 years of age or older.

• The State of Florida received a grade of “F” for the State of Children’s Dental Health.

State of Florida Dental Health Grade

• Lack of oral health care access in Florida is a significant problem

� Reflected in the 115,000 emergency department visits for dental

conditions in 2010

�Costing over $88 million ($29.7 million was billed to Medicaid)

� Fewer than 8% of practicing dentists in Florida provide care to

patients on Medicaid.

Oral Public Health and Medical Providers

• Duval County statistics:� 108,209 Medicaid eligible children

� 18,362 received Medicaid dental services in 2010• Utilization rate of 17% compared with a statewide rate of 22.5%• Utilization rate for all ages is 12.1% countywide and 15% statewide

� Since 2008, the number of emergency department visits for dental complaints rose from 7,394 to 8,389

• Of these visits 980 were for children under 19 years of age

� In 2010, Medicaid was charged $2,431,617 for these visits

Oral Public Health and Medical Providers

Oral Health Through the Lifespan

• According to the World Health Organization [WHO] (2016), oral

health is being free from mouth and facial pain, oral and throat cancer,

oral infection and sores, periodontal (gum) disease, tooth decay, tooth

loss, and any other condition that limits biting, chewing, smiling,

speaking, and psychosocial well-being.

• Most common oral diseases

� Dental cavities, periodontal disease, oral cancer, oral infectious

diseases, trauma, and hereditary lesions

What is Oral Health?

• In the US, 47% of adults have severe gum disease

• Most common chronic disease of childhood

� Five times more common than asthma

• More than 70,000 oral cancers diagnosed every year

� Diagnosis usually late

� Leads to 14,000 deaths

Prevalence of Poor Oral Health

(Smiles for Life. 2013e)

• Gap between dental and medical professionals prevents mutual patients from achieving optimal health (Whitney, 2015).

• In the past, medical education curriculum had limited oral health content.

� More than 90% of physicians believe oral health should be addressed at well visits, however, more than 50% had minimal or no oral health training. (Smiles for Life, 2013e).

Oral Health: Bridging the Gap

Oral Health Care: Barriers

• Financial resources

• Lack of perceived need

• Fewer visits to dental providers

• Low socioeconomic status

• Lack of dental insurance coverage and access

• Dental provider shortage

• Fear of dental procedures

(Jacques et al., 2010; Office of Disease Prevention and Health Promotion, 2016)

• Tobacco use

• Excessive alcohol use

• Drug abusers

� Methamphetamine (“meth mouth”)

• Hygiene

• Poor nutrition

• Poor dentition

• Sugar

• Human papilloma virus (HPV)

� Associated with poor oral health; linked to 40-80% of oropharyngeal

cancers

Predictors of Poor Oral Health

(Pixabay, 2017)

(American Association for Cancer Research, 2013; Smiles for Life, 2013a)

• Tri-step process leading to tooth destruction

1. Bacteria (Streptococcus mutans) metabolizes

2. Sugars (dietary carbohydrates) which form acid

3. Teeth are demineralized leading to enamel breakdown and cavity formation

Dental Caries Etiology

(Smiles for Life, 2013b)

• An increasingly recognized role in the oral-systemic interaction is

inflammation

• Theory

� Dental plaque is made up of a polymicrobial biofilm

� Neutrophils attack bacteria

� Macrophages secrete inflammatory mediators

� Inflammatory cascade

Oral Health Systemic Health

(Smiles for Life. 2013e)

• Diabetes

� Vicious cycle: Poor glycemic control is associated with periodontal

disease and, in turn, periodontal disease leads to poor glycemic

control

� A 10-20% improvement in glycemic control occurs with treatment

of periodontal disease

Oral Health Systemic Health

(Smiles for Life. 2013e)

• Coronary heart disease and cerebrovascular disease

� Studies support an association between periodontitis and

atherosclerotic vascular disease

� Inflammatory cytokines involved in atherogenesis are also involved

in periodontitis

• Obesity

� Adipose tissue produces cytokines (tumor necrosis factor alpha

[TNF] and interleukin 6) that promotes bone breakdown and

inflammation which potentiates periodontal disease.

Oral Health Systemic Health

(Smiles for Life. 2013e)

• Menopause

� Decrease in hormones leads to atrophy of gums

� Associated with an increase in periodontitis; HRT shown to be

protective

• Helicobacter pylori

� Bacteria has been found in dental plaque

� Control of dental plaque shown to decrease prevalence of H. Pylori

Oral Health Systemic Health

(Smiles for Life. 2013e)

• Early Childhood Caries (ECC)

� Previously known as “nursing caries” or “baby bottle tooth decay”

� Destroys tooth structure

� Vertically transmitted from primary caregiver (usually the mother)

� Risk is decreased when caregivers receive regular dental care, limit

sugar in the diet, maintain good oral hygiene, and using toothpaste

with fluoride

Oral Health Across the Lifespan: Pediatric

(Smiles for Life, 2013b)

• Oral health assessment for pediatric population should begin around

four to six months of age or just before the first tooth erupts

• Fluoride use has significantly reduced dental caries rates

� Inhibits tooth demineralization

� Enhances remineralization

� Inhibits bacterial metabolism

Oral Health Across the Lifespan: Pediatric

(Smiles for Life, 2013b)

• Diet and Feeding Recommendations

� Breast feeding is encouraged

� Bottles should not be given at bedtime/naptime

� Best to hold infant during bottle-feeding

� Avoid juice for the first year of life

� No added sugar in snacks

� Cup is introduced by six months; bottle weaned at 12 months

Oral Health Across the Lifespan: Pediatric

(Smiles for Life, 2013b)

• The Dental Disconnect

� Women frequently do not see a dentist when pregnant

� Only 26-34% of all pregnant women visit the dentist

� Only 50% of pregnant women with a dental problem actually visit a dentist

� Even among women with dental insurance, dental care declines during pregnancy

Oral Health Across the Lifespan: Pregnancy

(Smiles for Life, 2013d)

• Adverse pregnancy outcomes

� Preterm birth (PTB) and low birth weight (LBW) risk associated with periodontitis

� Preeclampsia twice as likely if periodontitis present

• Inflammatory mediators proposed mechanism

Oral Health Across the Lifespan: Pregnancy

(Smiles for Life, 2013d)

• Pregnant women do not often seek dental care during pregnancy

because they are unsure about dental procedures and risks

• American College of Obstetricians and Gynecologists

recommendations:

� First prenatal visit should include an oral health assessment

� Provide reassurance to women that oral care is safe during

pregnancy and should not be postponed

� All pregnant and post-partum patients should be educated on oral

health

Oral Health Across the Lifespan: Pregnancy

(Smiles for Life, 2013d)

• More than 43 million elderly in US

• 80% have one or more chronic diseases

� Obesity

� Coronary artery disease

� Diabetes

� Prosthetic device infection

� Infective endocarditis

Oral Health Across the Lifespan: Seniors

(Smiles for Life, 2013c)

Oral Health Grant

• The National Interprofessional Initiative on Oral Health (NIIOH) is a

consortium of funders and health professionals with a vision to

eradicate dental disease.

• The mission of the NIIOH is to engage primary care clinicians to

identify patients’ oral health needs; provide preventative services to

patients of all ages; partner with dental specialists; and learn from,

with, and about each other.

National Interprofessional Initiative on Oral Health

(National Interprofessional Initiative on Oral Health, 2011)

National Interprofessional Initiative on Oral Health

(National Interprofessional Initiative on Oral Health, 2011)

• The NIIOHs core curriculum for integrating oral health and primary

care is Smiles for Life (http://www.smilesforlifeoralhealth.org)

� Originally developed in 2005 by the Society of Teachers of Family

Medicine Group on Oral Health

� Initial goal was to enhance physicians training in Family Medicine

residency programs

� Currently, 3rd edition broadened to include all primary care

clinicians.

Smiles for Life Curriculum

• Consists of eight modules

1. The Relationship of Oral to Systemic Health

2. Child Oral Health

3. Adult Oral Health

4. Acute Dental Problems

5. Oral Health & the Pregnant Patient

6. Caries Risk Assessments, Fluoride Varnish and Counseling

7. The Oral Examination

8. Geriatric Oral Health

Smiles for Life Curriculum

• The National Commission on Certification of Physician Assistants

(NCCPA) Health Foundation partnered with the NIIOH to provide PAs

with a leadership opportunity to design a research study that evaluates

the outcome of strategies to integrate oral health into educational

curriculum or practice (NCCPA Health Foundation, n.d.).

NIIOH Oral Health Grant

• Established in 2008

• First graduating class in 2011

• Goal of the program is to prepare PA graduates for primary health care to improve access, encourage life-long learning, and promote leadership roles in the PA profession.

Nova Southeastern University (NSU)—Jacksonville Physician Assistant Program

• Initially awarded in April 2013; extended in April 2015 to December 2016

• $3,000 NIIOH grant awarded to Nova Southeastern University—Jacksonville PA Program

• Three student cohorts participated in the NIIOH grant

� Class of 2015 (N = 52)

� Class of 2016 (N = 54)

� Class of 2017 (N = 60)

National Interprofessional Initiative on Oral Health (NIIOH)

• Null hypothesis: There is no difference in the means of the pretest and the posttest as well as the pretest and one-year posttest scores of the students regarding their oral health knowledge.

• Research hypothesis: The scores of the post-test, and one-year posttest will be higher than the pre-test scores.

Findings: NSU-Jacksonville PA Program

Class of 2015 Cohort

N = 52

Class of 2016 Cohort

N = 54

Class of 2017 Cohort

N = 60

Community Outreach: Winter 2014

Sacred Heart Elementary School

• Kindergarten & 1st grade

• 2nd – 5th grade

Community Outreach: Winter 2015

Sacred Heart Elementary School

• Kindergarten & 1st grade

Community Outreach: Winter 2016

Sacred Heart Elementary School

• Kindergarten & 1st grade

Smiles for Life Pre-Test: Summer 2014 Smiles for Life Pre-Test: Summer 2015 Smiles for Life Pre-Test: Summer 2016

Smiles for Life Post-Test: Summer 2014 Smiles for Life Post-Test: Summer 2015 Smiles for Life Post-Test: Summer 2016

Smiles for Life One-Year Post-Test: Summer

2015

Smiles for Life One-Year Post-Test: Summer

2016

Smiles for Life One-Year Post-Test: Pending

Summer 2014 Control Group:

• Created by including NSU-Ft. Lauderdale

PA Class of 2015

• Increased N of study from 52 to 123

Summer 2015 Control Group:

• Lost to follow-up due to one year post-

exam was not required

Summer 2016 Control Group:

• No control group utilized

• Change in student instructions caused

group to be ineligible

No additional oral health lectures Two oral health lectures

1. Pregnancy and pediatric oral health

given by local dentists

2. Geriatric oral health given by local

dentists

Two oral health lectures

1. Pregnancy and pediatric oral health

given by dental hygiene students from

Florida State College at Jacksonville

(FSCJ)

2. Geriatric oral health given by local

dentist

PA students from L to R: Lindsey Pereira, Kasey

Colborne, Stephanie Buck, Stephanie Lamm, Sergiu

Neiconi, and Holly Anderson

Sacred Heart Elementary School Kindergarten Class (Winter 2015)

PA students from L to R: Stephanie Buck,

Lindsey Pereira, Kasey Colborne, Stephanie

Lamm, Sergiu Neiconi, and Holly Anderson

Sacred Heart Elementary School First Grade Class (Winter 2015)

Sacred Heart Elementary School Kindergarten Class (Winter 2016)

PA students from L to R: Anna Pfaff, Kia Burch,

Jasmine Senatus, Kelsi Vilardo, Amanda Beyers,

Nicole Buzard, Kelsey Hoblick

�NSU-Jacksonville partnered with FSCJ to provide enhanced dental

learning experiences as well as provide collaborative opportunities for PA

students and led to a volunteer opportunity for our students

• Florida Mission of Mercy (FLA-MOM)

� Two day clinic held April 2016

� Provided free dental care to the underserved and uninsured in

Jacksonville, Florida with a goal of 2,000 patients

� 14 students from the Class of 2017 and two students from the class of

2016 volunteered for this event.

Leveraging Community Partnerships Through Volunteer Experiences

Research Findings

• Loss of research control cohort

• Lecture misalignment to Smiles for Life content

• Questioned if student testing attempts were earnest in nature

• Availability of student volunteers for community service opportunities

• Inability to participate in fluoride varnish application

• Challenge in recruiting free clinics for chairside opportunities

Research Limitations

Descriptive Statistics

Comparative Statistics

• Posttest scores were higher than pretest scores in all cohorts of students.

• Using a paired samples t-test evaluation, the null hypothesis was rejected

due to the obtained t-values being greater than, or more extreme than, the

critical t-value for the assigned degrees of freedom.

• Conclusion: Overall, the difference between the pretest and post scores

was due to the Smiles for Life curriculum and not due to chance. This

finding included comparisons from pretest scores to the one-year posttest

scores for the 2015 and 2016 cohorts.

Findings: NSU-Jacksonville PA Program

• NSU-Jacksonville PA program has permanently adopted curriculum

change to incorporate oral health content

� Oral health lectures in the CMS III courses will continue

� Smiles for Life curriculum will continue in the HPDP course

� Community outreach to Sacred Heart Elementary School will

continue

• As graduates enter clinical practice, learned knowledge of oral health

will be integrated into their clinical practice.

Impact of Integrating Oral Health in PA Education

Interprofessional Education (IPE)

• Without exposing our health professional

students to interprofessional education

(IPE) during their formative years, the

fruits of collaborative practice known as

the “triple aim”: better health outcomes,

improved patient experience, and lower

overall costs, are difficult to achieve

(American Dental Education Association,

2016).

• Interprofessional education (IPE)

� When students from two or more

professions learn about, from, and

with each other to enable effective

collaboration and improve health

outcomes (WHO, 2010).

• Dental Education Program Accreditation

Standards

• Healthcare Program Accreditation

Standards

IPE: Dental Programs and Health Programs

• Established relationship

• Encouraged communication

• Students used critical thinking skills during interactions

• Hope for this experience to transfer into the clinical setting

• NSU-Jacksonville PA Program

partnered with Florida State

College- Jacksonville (FSCJ)

dental hygiene students

• Partnership with FSCJ led to a

volunteer opportunity for our

students

NSU Jacksonville PA Program-IPE Opportunities in Oral Health Education

• “Enhancing the public’s access to oral health care and the connection of oral

health to general forms a nexus that links oral health care providers to

colleagues in other health professions” (Commission on Dental Accreditation,

2010, p. 12)

• Smiles for Life highlights of the importance of IPE and Interprofessional

communication for the overall improvement of patient outcomes. Specific

resources for Oral Health IPE are recommended.

• Communication & Collaboration

� Dentists identify systemic disease manifestations and refer to PCP

� PCP identify oral health manifestations promptly and refer to dentists

IPE Dentists and Primary Care Providers

• NSU PA Program- Jacksonville’s involvement with the NIIOH Grant

truly enhanced our students’ understanding of oral health and the

importance of the PCP & Dentist relationship.

• Breaking down these communication barriers will ultimately help

create stronger future generations of healthcare providers and healthier

patients.

Future Generation of Healthcare Providers

Post-Discussion Questions

• What is the most current oral health grade for the state of Florida?

� The Pew Center on the States in its 2010 report, the State of

Children’s Dental Health, gave a grade of “F” to the State of

Florida based on its ability to reach two or fewer of their eight

established key policy benchmarks.

Post-Discussion Questions

• Name three predictors of poor oral health?

� Tobacco use

� Excessive alcohol use

� Drug abusers

� Hygiene

� Poor nutrition

� Poor dentition

� Sugar

� Human papilloma virus (HPV)

Post-Discussion Questions

• What is the most common bacteria associated with tooth destruction?

� Bacteria (Streptococcus mutans)

Questions?

• American Association for Cancer Research. (2013). Poor oral health linked to

cancer-causing oral HPV infection. Retrieved from

https://www.sciencedaily.com/releases/2013/08/130821132341.htm

• American Dental education Association. (2016). Moving IPE forward: The role

for dental education. Retrieved from http://www.adea.org/movingIPEforward/

• Jacques, P.F., Snow, C., Dowdle, M., Riley, N., Mao, K., & Gonsalves, W.C.

(2010). Oral health curricula in Physician Assistant programs: A survey of

Physician Assistant program directors. Retrieved from

http://www2.paeaonline.org/index.php?ht=action/GetDocumentAction/i/110198

References

• National Interprofessional Initiative on Oral Health. (2011). Clinicians for oral health. Retrieved from https://www.niioh.org/

• Office of Disease Prevention and Health Promotion. (2016). Oral health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/oral-health

• Pixabay. (2017). Pixabay. Retrieved from https://pixabay.com/en/smoking-cigarette-smoke-unhealthy-1418483/

• Smiles for Life. (2013a). Adult oral health, Course 3. Retrieved from http://www.smilesforlifeoralhealth.org/buildcontent.aspx?tut=555&pagekey=62948&cbreceipt=0

References

• Smiles for Life. (2013b). Child oral health, Course 2. Retrieved from

http://www.smilesforlifeoralhealth.org/buildcontent.aspx?tut=555&pagekey=62948&c

breceipt=0

• Smiles for Life. (2013c). Geriatric oral health, Course 8. Retrieved from

http://www.smilesforlifeoralhealth.org/buildcontent.aspx?tut=555&pagekey=62948&c

breceipt=0

• Smiles for Life. (2013d). Oral health & the pregnant patient, Course 5. Retrieved from

http://www.smilesforlifeoralhealth.org/buildcontent.aspx?tut=555&pagekey=62948&c

breceipt=0

References

• Smiles for Life. (2013e). What is collaborative practice?, Course 1. Retrieved from http://www.smilesforlifeoralhealth.org/buildcontent.aspx?tut=583&pagekey=64476&cbreceipt=0

• World Health Organization. (2016). Oral health. Retrieved from http://www.who.int/mediacentre/factsheets/fs318/en/

References