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Student Oral Health Initiative

Allison M. DiMatteo, BA, MPS

Drexel University College of Medicine’s unique program offers comprehensive education and training in oral health.

It is well known that that D. Walter Cohen, DDS, chancellor emeritus of Drexel University College of Medicine, has long believed that physicians need to know more about oral health and oral disease, and that dentists need to know more about systemic problems. Many of Cohen’s own activities over the past nearly six decades have been devoted to the oral/systemic connection, whether he was teaching at Penn Dental School, or when he went to serve as president of MCP in 1986.

“The opportunity presented itself last year to do something even stronger than some of the things we have done in the past,” Cohen says. “We have been able to share our understanding of the oral/systemic link with cardiologists, OB/GYN specialists who are dealing with preterm, low birth-weight infants, and physicians treating patients with diabetes—all based on the implications of oral disease.”

The Dr. D. Walter Cohen Medical/Dental Integration Lecture Series has expanded its scope to become the Student Oral Health Initiative for medical students and launched at Drexel University College of Medicine, where Dr. Cohen is chancellor emeritus.

Cohen is referring to the Student Oral Health Initiative for medical students, which was launched at Drexel University College of Medicine. With the enthusiastic support of student Sam Zarbiv, who seized the opportunity to organize a group of medical students interested in grasping the value of understanding more about oral health, the program provides participants with greater skills than the average medical curriculum in the area or oral/systemic health. It simultaneously combines the study club activity with clinical experience.

“I have always said that when physicians put a tongue blade in the patient’s mouth, tell the patient to say ‘ah,’ and then look in the mouth, they really do not know the tissues they are looking at. They don’t understand their origins or how they behave in certain disease situations,” Cohen explains. “We wanted to try to overcome that deficiency. Therefore, together we established a series of lectures that could be of value, and the students have been very attentive.”

Those lectures represent the Dr. D. Walter Cohen Medical/Dental Integration Lecture Series (see Table), during which students learn from some of the most esteemed names in dentistry who volunteer their time and pay their own expenses. AmeriChoice/United Health Group provides sponsorship support of the program, providing meals for the students while attending the lectures. Students also work together with the community to help begin the task of building a more centralized “Health Home.” Through the Student Oral Health Initiative, the integration of oral health into total health is established within the minds of health professionals and the community.

Additionally, the elective, study-group program seeks to promote and facilitate oral health to children and the community through two key activities. One is “Drexel Smiles,” through which medical students teach oral health to children at local (ie, Philadelphia) Head Start programs. The second involves collaborations with medical/dental community healthcare clinics, including the clinic at Temple University School of Dentistry and Kids Smiles (http://www.kidssmiles.org), which is a comprehensive model in community healthcare.

Through such outreach efforts, a total of 25 “Oral Health Certificate” eligible medical students in groups of four are rotated through educational and clinical components of each of these facilities. As a result, every student is exposed to pediatric preventive public health dentistry and oral manifestations of chronic illness in adult populations.

According to Allen L. Finkelstein, DDS, the former chief dental officer at United Health Care and one of the program’s volunteer lecturers, the positive implications of such a program for physicians and dentists are clear.

“The primary care, family health, or pediatric physician usually is the first contact for youngsters age two and younger, who often only visit the dentist when they are in pain,” says Finkelstein, adding that dental caries in children is a socioeconomic disease that affects the poor and underserved more than anyone, with pediatric dental disease being the number-one chronic disease in children overall. “The average medical student doesn’t even receive 4 hours of total training in oral health, yet we are seeing more literature showing the oral systemic link. When these Drexel students get out into practice or in residency or internships, what they will be doing for the first time is a comprehensive examination, looking in the oral cavity and not just starting with the pharynx.”

Fittingly, one of the program goals is for students to learn the epidemiology and pathophysiology of oral diseases and how oral problems affect patients’ ability to live with other chronic illnesses. To this end, upon completion of the program, students will be able to describe the relationships between oral diseases and systemic diseases, including the associations with cardiovascular disease, preterm birth and low birth weight, and diabetes mellitus, osteoporosis, and osteopenia.

They also will be able to describe the incidence, prevalence, and public health implications of early childhood caries, adult caries, periodontal disease, common benign oral lesions (eg, tori, cystic lesions, ulcerations, white lesions), and oropharyngealneoplasms. Finally, they will be able to describe common oral microbial pathogens, including causative agents of dental caries, gingivitis, oral “thrush,” and periodontitis.

Creating a Health Home

The Student Oral Health Initiative also seeks to develop and nurture a mutually beneficial collaboration between medical students and their dental peers to promote medical/dental public health. Of paramount importance to achieving this objective are the students’ participation in Kids Smiles, and establishing Temple University School of Dentistry’s “Health Home” as an integrated medical/dental health center.

“We have to make our practitioners, dental and medical, more astute referrers who refer at the right time for the right outcomes. In medicine and dentistry, we really do not measure outcomes, nor do we reimburse a physician or a dentist for better outcomes. We just have a reimbursement policy based on the disease entity and how much disease they’re treating, rather than having a reimbursement policy by insurers such as AmeriChoice that is based on keeping people healthy,” explains Finkelstein. “Through this program at Drexel, we are trying to have the physician of the future be able to screen a child or an adult for two major diseases—periodontal disease and caries, and make the referral.”

According to Cohen, the Student Oral Health Initiative is even more relevant now than ever, particularly because some insurers are compensating physicians for using a fluoride varnish to help youngsters with early childhood caries. This is something new, he explains, adding that there are 29 states where physicians are permitted to use fluoride varnish. Further, some insurers, such as AmeriChoice, provide physicians with compensation if the patient is sent from the physician to a dental office after the fluoride varnish has been applied.

The Student Oral Health Initiative promotes the concept of a “Health Team,” one in which the medical students understand the role of the physician in dental emergencies and know how to properly follow up with dentists. Therefore, upon completion of the program, Drexel medical students will be able to describe the diagnosis and management of common dental emergencies, including dental pain, peri-apical and periodontal abscesses, dental trauma (eg, tooth luxation and avulsion), complications from dental extractions, and describe how the physician might follow up with the dentist after referral for a dental emergency.

“What makes this such a rewarding experience is that we are ensuring we become complete physicians,” admits Zarbiv. “It’s such an amazing experience, and a very humbling one. There are very important lessons to be learned here about communication and building a comprehensive healthcare team, and I hope this will be something that will be drafted within the medical curriculum.”

Core Competencies in Oral Health

Upon completion of the educational guidelines, student participants will receive a certificate of attendance in the oral health program that recognizes their scientific knowledge, participation in community oral healthcare programs to promote and facilitate a structured model of behavioral intervention, and their core clinical oral health competencies.

The medical and scientific knowledge that students are expected to understand includes normal anatomy and function of the oral cavity. Based on this knowledge, they also should be able to correctly identify normal anatomy; describe the function of the muscles, salivary glands, teeth, and temporomandibular joint; and describe the psycho-social implications of early childhood caries in developing children. Additionally, the program emphasizes the need to describe the implications of finding fulfilling employment in adults with poor oral health, as well as an appreciation of the role of poly-pharmacy in xerostomia and poor oral/total health in geriatric patients. They also learn to consider the possible roles of poor oral health as a risk factor for late-life depression.

Other competencies include being able to conduct an oral health interview (for medical practitioners) and appropriately examine patients, as well as be able to accurately identify the manifestations of oral disease and their risk factors. Therefore, throughout the program, students will have opportunities to demonstrate their abilities to:

• Perform appropriate oral health histories focused on identifying 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.
• Provide anticipatory guidance.
• Perform an appropriate oral examination that effectively visualizes all intraoral hard and soft tissue and identifies normal landmarks.
• Apply fluoride varnish to “high-risk” children.
• 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.

Community Oral Health

Community healthcare is a focal point of the program, based on the understanding that student participants must be introspective, creative, and critical. What’s more, they must be able to evaluate the successes and failures of previous generations with the guidance of the most experienced mentors.

At a time when healthcare reform will likely shift the focus of care toward “quality” and health promotion/disease prevention, students will analyze what has gone wrong in the past, and why. Therefore, the program provides a more robust preventive focus in order to prepare the medical students for tomorrow’s healthcare environment. However, an emphasis also is placed on the fact that small successes today will set the foundation for healthcare tomorrow.

“What I see here is an opportunity to build off of. There are many brilliant models in the field of dentistry that we have to learn from, and these really underscore the significance of students taking the initiative to broaden their own education and ensure that they have the best preventative skills to be excellent physicians in tomorrow’s healthcare environment,” explains Zarbiv. “I believe that this is a model that will inspire other students to realize that if they don’t like the way things are right now, they can change them.”

For example, Zarbiv says that one of his overarching goals is for dental students and medical students to work and communicate together, as well as collaborate on common projects that benefit the community. He emphasizes the need for reciprocity of knowledge between medical and dental students.

Through participation in the Student Oral Health Initiative, students will develop an understanding of the common points of intersection between medical and dental care and the physician’s role in those situations. By working in the community and directly with patients, they will gain experience in articulating and counseling patients about relevant links between oral and systemic disease and promoting health. They also will learn to address parents’ perceptions of early childhood caries as an infectious disease.

“We are trying to make people healthy at the earliest stages possible. That involves getting physicians to refer early to the dentist, and dentists understanding the systemic link and making those referrals to appropriate physicians, and there are myriad diseases they can refer for,” Finkelstein emphasizes. “It also involves patient education and controlling the environment and behavioral health patterns.”

Looking Ahead

The program is likely to continue into the future, with its sustainability being a direct function of student leadership development. Currently three tiers of student leadership—or a layered model of mentorship—are proposed for the program: Core Leadership, representing five second-year medical students and two first-year students who have demonstrated a commitment for community healthcare throughout the year (Brittany Behar, Christopher Chu, Eric Christenson, Georgia Davis, Alex Procaskey, Sam Zarbiv, and Laura Zung are the current Core Leaders); 25 to 30 first and second year medical students participating in the oral healthcare program next year; and Supporting Leaders, who are those students who wish to participate in the program but cannot commit to the full clinical process due to time constraints.

Core Leaders will receive direct mentorship from Dr. Cohen and the Advisory Board. Current Advisory Board members include Cohen, who is also the faculty advisor; Finkelstein; Claudia A. Hanson, MD, medical director for AmeriChoice/UHG; and Jack Dillenberg, DDS, MPH, dean of Arizona School of Dentistry and Oral Health. The 25 to 30 comprehensive participants will receive primary mentorship from the Core Leaders, with secondary mentorship possible from Cohen himself. Supporting Students will have opportunities for mentorship through study clubs and from their classmates and faculty.

Program descriptions and other information about the Student Oral Health Initiative can be found at http://www.DrexelMedOHI.org.

“I think the more physicians and dentists work closely together and understand each other’s areas of responsibility, the better it will be for both professions,” Cohen believes. “There are many diagnostic procedures being developed using saliva to detect systemic alterations. Everything that’s happening is important for the knowledge of the physician and the dentist, but most importantly for the health of the patient.”

Table

click here to view Table in pdf