Promoting Oral Health Education in Physician Assistant ... · Nova Southeastern University Kerry L....
Transcript of Promoting Oral Health Education in Physician Assistant ... · Nova Southeastern University Kerry L....
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