Family Medicine Residency Directors Knowledge and Attitudes About Pediatric Oral Health Education for Residents

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1 Critical Issues in Dental Education Family Medicine Residency Directors Knowledge and Attitudes About Pediatric Oral Health Education for Residents Wanda C. Gonsalves, M.D.; Judith Skelton, Ph.D.; Lisa Heaton, M.S.; Timothy Smith, Ph.D.; Gerald Feretti, D.M.D., M.P.H.; James D. Hardison, D.M.D. Abstract: The Surgeon General s report on oral health called for improved education about oral health, a renewed understanding of relationships between oral and overall health, and an interdisciplinary approach to oral health involving primary care providers. This study examined the following: 1) family medicine residency directors knowledge of preventive dental care, 2) status of an oral heath curriculum in family medicine residencies, and 3) the likelihood of initiating an oral health curriculum. We conducted a fifty-item survey of family medicine program directors emphasizing pediatric oral health assessed demographics, knowledge of preventive procedures, existing oral health curriculum, composition, and time commitment for an oral health curriculum. Directors returned 208 (45 percent) surveys. Approximately 95 percent agreed that oral health knowledge should be a component of residency training. Most programs are teaching anticipatory guidance. The mean time program directors felt should be given to an oral health curriculum was four hours. Program directors lack knowledge of preventive dental procedures and oral health care recommendations. Oral health care knowledge is felt to be an important component of residency training. Program directors need faculty development for a successful delivery of an oral health curriculum. Dr. Gonsalves is Assistant Professor, Department of Family Medicine, Medical University of South Carolina; Dr. Skelton is Associate Professor, University of Kentucky College of Dentistry; Ms. Heaton is Research Fellow, Department of Behavioral Science, University of Kentucky College of Medicine; Dr. Smith is Professor, Department of Behavioral Science, University of Kentucky College of Medicine; Dr. Feretti is Associate Professor, University of Kentucky College of Dentistry; and Dr. Hardison is Associate Professor, University of Kentucky College of Dentistry. Direct correspondence and requests for reprints to Dr. Wanda C. Gonsalves, Department of Family Medicine, 295 Calhoun Street, P.O. Box , Charleston, SC 29425; phone; fax; gonsalvw@musc.edu. Key words: pediatric oral health, oral health curriculum, graduate medical education, family medicine residents Submitted for publication 12/13/04; accepted 2/4/05 Although the nation s oral heath is believed to be the best it has ever been, oral diseases remain common in the United States. In May 2000, Oral Health in America: A Report of the Surgeon General 1 called attention to a largely overlooked epidemic of oral diseases that is disproportionately shared by poor, young, and elderly Americans. The report called for improved education about oral health, a renewed understanding of the relationship between oral and overall health, and an interdisciplinary approach to oral health involving primary care providers. Family medicine is poised for such a task since graduating family physicians provide care to 12.9 percent of Medicaid, 25 percent rural, and 8 percent underinsured populations. 2 In order to achieve these recommendations, family physicians need to recognize oral health as an important component of overall health and introduce oral health education into residency curricula. The mouth is an integral part of the body, and there are oral manifestations of many systemic diseases that must be managed in both healthy and medically compromised children. Failure to diagnose oral conditions often results in significant additional health care cost to the patient or funding agency. Traditionally, physician training in oral health has been limited. 3 Patients suffering and the attendant costs could be reduced if primary care physicians could detect, diagnose, and refer these patients to the appropriate dental setting. Primary care providers who provide care to children before age two have the opportunity to provide oral health screening seven times more frequently than our dental colleagues as a result of well child visits. 446 Journal of Dental Education Volume 69, Number 4

2 It has been argued that family physicians and other primary care providers should play an important role in improving oral health in children and throughout life. 1,3-6 Since poor and minority populations have traditionally had limited access to dental care, integrating oral health disease prevention and health promotion strategies into these health care professionals practices would help improve access to oral health care. 7 Similar calls for involving the broader medical community in diagnosis of oral disease have been made, including the National Oral Cancer Awareness Program Very little published information is available about the willingness of family practitioners or other nondental health care workers to assess the oral health of their patients. The literature that does exist is focused on specific populations like children and the elderly or is targeted to specific diseases. This article will discuss the results of a national survey mailed to family medicine residency directors to determine the following: 1) their knowledge of preventive dental care, 2) the status of an oral health curriculum in family medicine residencies, and 3) the likelihood of initiating an oral health curriculum. Methods An interdisciplinary health care team, including physicians, dentists, and educational and assessment specialists, was formed to develop a survey strategy and instrument to determine knowledge of oral preventive procedures, current curriculum content, and likelihood for initiating an oral health curriculum for a family medicine residency program. A survey about preventive oral health knowledge and curricular status by Lewis et al. 4 was adapted for this study. The adaptation was submitted to and approved by the University of Kentucky Medical Institutional Review Board. The fifty-item survey included four items about program demographic characteristics: type of residency, location of the program, percentage of payer mix, and race/ethnicity. Program directors were also asked about the frequency of caries in their pediatric patients, knowledge of preventive oral or dental procedures, likelihood to teach oral health screening and counseling, difficulty in referral to dentists, and what they felt should be incorporated into an oral health curriculum. Program directors were also asked to rank whether they agreed or disagreed that certain items be included during a well child visit by residents. Lastly, they were asked if they agreed or disagreed that physicians would incorporate an oral health assessment in a well child visit even if they were not reimbursed. The four-page anonymous survey was mailed April 2003 to the directors of all 464 U.S. residency programs listed in the 2003 directory of residency programs. A cover letter described the survey and its purpose. Directors were invited to return their surveys in prepaid envelopes by mail. A reminder postcard was mailed four weeks after the initial mailing. Many of the items were in a five-point Likert scale format; a score of 1 indicated that they were very unlikely (or strongly disagree or not at all difficult), and a score of 5 indicated that they were very likely (or strongly agree or very difficult) to do so. The two extreme scores on either end of the scale were combined to produce a likely (agree or difficult) or not likely (disagree or not difficult) dichotomies. These values were entered into an SPSS data file, and means, medians, standard deviations, ranges, and frequency tables were determined for each item. Items that required responses such as percentages or number of hours or yes/no answers were similarly analyzed. Tables 1-6 and Figures 1 and 2 were based on these analyses. Results Of the 464 surveys mailed to Family Practice Program Directors, 208 (45 percent) were completed and returned. Over 70 percent (N=147) of the respondents described their residency programs as community-based, 24 percent (N=49) reported their programs as being university-based, and 5 percent indicated other for this item. Proportionately, the respondents are similar to those found nationally. 11 Forty-seven percent (N=98) indicated that they were located in an urban setting, 38 percent (N=78) were located in a suburban setting, and 14 percent (N=29) were located in a rural setting. Data regarding Medicaid, insurance, and immigrant status are presented in Table 1. The mean percentage of patients receiving Medicaid was 35.3 percent (s.d.=21.1), ranging from 0 to 100 percent, while the percentage of patients identified as uninsured or self-pay ranged from 0 to 80 percent, with a mean of 14.2 percent (s.d.=12.7). Estimated racial/ ethnic data are presented in Table 2. The percentage April 2005 Journal of Dental Education 447

3 Table 1. Insurance and immigration status of residency program patients (percentages) Item Minimum Maximum Mean Median Receive Medicaid Uninsured or self-pay Immigrants or born to parents who emigrated from another country Have parents who are non-english-speaking Table 2. Race/ethnicity of residency program patients (percentages) Item Minimum Maximum Mean Median White/Caucasian Black/African American Latino/Hispanic Asian/Pacific Islander Native American/Eskimo of Caucasian patients in residency programs ranged from 0 to 100 percent, with a mean of (s.d.=24.7). The mean percentage of Black/African American patients was 21.4 percent (s.d.=19.2), ranging from 0 to 95 percent. The percentage of Latino/ Hispanic patients ranged from 1 to 100 percent, averaging 20.6 percent (s.d.=22.3), and the percentage of patients of Asian/Pacific Islander descent ranged from 0 to 40 percent, averaging 5.8 percent (s.d.=6.5). The mean percentage of Native American/Eskimo patients in the residency programs surveyed was 1.5 percent (s.d.=5.4), ranging from 0 to 71 percent. Participants were asked how frequently they observed caries in their patients (Figure 1). Caries in school age or adolescent children were more common than early childhood caries (ECC). ECC was defined as the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child seven months of age or younger. Participants reported that ECC conditions were observed regularly in their residency programs. Eighty-eight percent (N=183) reported that they observed caries in their school age or adolescent patients at least once every six months, once per month or once per week, while 74 percent (N=154) observed early childhood caries during the same time period. 40 Early Childhood Caries 30 Caries in School-Age or Adolescent Children Once a week Once a month Once every six months Once a year Once every few years Frequency ( At least... ) Never Figure 1. Frequency of caries reported in family practice residency programs (%) 448 Journal of Dental Education Volume 69, Number 4

4 Participants were asked to report how likely you are to teach the residents in their programs to perform various oral health screening measures at well child visits for children less than five years of age. The two most extreme scores on either end of the scale were combined to produce a Likely or Not Likely dichotomy. Results of these items are shown in Table 3. Respondents were most likely to teach residents to inquire about whether a child was taking a bottle to bed (84.6 percent) and to counsel parents about the importance of regular dental visits (81.3 percent) and regular tooth brushing (77.4 percent). They were less likely to instruct residents in assessing a child s fluoride intake and determining the need for fluoride supplements (61.1 percent) and in examining a child s teeth for cavities (57.2 percent). Inquiring about a mother s dental health was least likely to be taught; 9.6 percent of respondents reported that they were likely to include this in their curriculum. Participants indicated the degree to which they agreed that certain oral health-related procedures should be part of routine well child care provided by their residents. The two most extreme scores on either end of the scale were combined to produce an Agree or Disagree dichotomy. Results of these items are shown in Table 4. Most participants agreed that residents should assess for early signs of dental problems (88.3 percent) and counsel parents on prevention of dental problems (87.4 percent), while fewer participants agreed that residents should refer child patients to a dentist by twelve months of age (37.6 percent) and should apply fluoride varnish to a child s teeth (33.0 percent). When asked if they felt physicians would be likely to incorporate oral health assessments in their well child visit even if they were not reimbursed, only 26 percent of participants agreed. However, on a related yes/no item, nearly 70 percent of respondents (N=143) indicated that oral health questions were included in their well child screening questionnaires. Participants indicated the degree to which they agreed that certain topics should be included in their residency curricula. The two most extreme scores on either end of the scale were combined to produce an Agree or Disagree dichotomy. Eighty to 84 percent felt that oral health screening should be included in the curriculum (Table 5). When asked if it was the responsibility of their training programs to train residents to identify and refer oral health problems, the majority of respondents (95.2 percent) said yes. Eighty-seven percent of participants indicated that they would implement an oral health module with their residents, were it available. When respondents were asked how much time in their curricula they would dedicate to teach- Table 3. Likelihood of teaching residents about oral health screening measures Please circle the response that indicates how likely you are to teach your residents to do the following at a well child care visit for a child less than five years of age. Likely (%) Not Likely (%) Inquire whether a child is taking the bottle to bed Counsel parents on the importance of going to the dentist on a regular basis Counsel parents on the importance of regular tooth brushing Assess a child s fluoride intake to determine the need for supplementation Examine a child s teeth for signs of cavities Inquire about mother s dental health Table 4. Agreement that oral health-related procedures should be part of routine well child care Do you agree or disagree that the following should be part of routine well child care provided by your residents? Agree (%) Disagree (%) Routine assessment for early signs of dental problems Counseling on the prevention of dental problems Referral to a dentist by twelve months of age Application of fluoride varnish to a child s teeth April 2005 Journal of Dental Education 449

5 Table 5. Program directors agreement that certain topics should be part of the residency curriculum Do you feel that the following should be included in your residency curriculum? Agree (%) Disagree (%) Clinical oral health screening Dental disease prevention and early intervention Early childhood caries Dietary practices Dental injuries and trauma Dental caries as an infectious disease Oral habits and early orthodontic problems Systematic and oral health relationships Professional and public awareness and roles in health policy Development of human dentition Facial growth and development ing oral health care, responses ranged from zero to forty hours, with an average of 4.3 hours (s.d.=4.39, median=3.5). Respondents were asked about their familiarity with techniques such as fluoride varnish and dental sealants for preventive dental care (Figure 2). While the majority of respondents reported not being familiar enough with these procedures to explain them to patients, many respondents were aware of these prevention techniques. Although residency directors were aware of these techniques, less than 30 percent (N=62) indicated that they were familiar enough with fluoride varnish, and only 44 percent reported being familiar enough with dental sealants to explain its purpose to patients. Additionally, a brief description of fluoride varnish was provided, including a description of the time ( about 5 minutes ) and cost ( less than 50 cents per patient ) involved in the application of fluoride varnish. Participants were then asked what dollar amount (from none to more than $50) per patient they would accept to provide fluoride varnish to patients. Responses ranged from zero to fifty dollars, with a mean of $18.99 (s.d.=12.11, median = $20.00). Difficulty in referring patients for dental care was assessed by asking: Please indicate how diffi- Yes No Fluoride Varnish Dental Sealants Are you familiar enough with that you could explain their purpose to a patient? Figure 2. Familiarity with preventive dental care (%) 450 Journal of Dental Education Volume 69, Number 4

6 cult you have found it to refer a patient to the dentist, given certain circumstances. The two most extreme scores of the scale were combined to produce a Difficult or Not Difficult dichotomy (Table 6). The majority of respondents reported that they had difficulty referring uninsured patients after hours for emergent dental care (83.4 percent), followed by uninsured patients requiring sliding scale fees (76 percent) and patients receiving Medicaid benefits (56.2 percent). Participants reported that it was less difficult to refer patients with significant developmental disabilities (52.9 percent), patients less than two years old (44.6 percent), and privately insured patients requiring after-hours emergent care (38.5 percent). Discussion Our data show that 95 percent of family medicine program directors feel that oral health care knowledge should be a component of residency training as evidenced by their positive response to the question Do you feel it is a responsibility of your training program to train residents to identify and refer oral health problems? Most respondents felt the components that would be important to include in the curriculum are routine assessment for early signs of dental problems and counseling on the prevention of dental problems (Table 4); however, fewer than 40 percent felt that referral to a dentist by twelve months and application of fluoride varnish should be part of a routine well child exam. The American Academy of Pediatrics and the American Academy of Pediatric Dentistry both advocate referral at twelve months. 10,12 Interestingly, most program directors reported the importance of oral assessments, yet only 26 percent felt that physicians would incorporate an oral health assessment if not reimbursed. This may indicate that physicians would look more favorably upon performing oral health assessments and services if they are reimbursed. Most programs teach residents to inquire about taking a bottle to bed (84 percent) and to counsel about the importance of going to the dentist (81 percent); however, 64 percent don t teach residents to inquire about a mother s dental health. Since transmission of Streptococcus mutans, a known cariogenic bacteria present in plaque, occurs from caregiver to infant, 13 family medicine residents have an opportunity to decrease the risk of ECC by assessing caries risk. 14 Our results mirror many of the results of a national survey by Lewis et al. 4 who examined the Role of the Pediatrician in the Oral Health of Children. Residency directors, who are also practicing physicians, and pediatricians felt they saw early childhood caries, although caries in older children were more frequent. Both groups were likely to counsel patients on tooth brushing and going to the dentist. Also similarly, few pediatricians (<15 percent) felt that a referral to the dentist at twelve months or application of fluoride should be part of routine well child care. Inquiring about mothers dental health was less likely to occur for both groups. And lastly, both groups had inadequate knowledge of preventive oral technologies and of dental caries as an infectious disease. In one study, family physicians were shown to be less informed of general dental knowledge and prevention than pediatricians. 14 Inferences from these data indicate that faculty development is necessary for a successful delivery of an oral health curriculum. Not surprisingly, given the growing competition of curricular components, most program directors felt that four hours should be the amount of time dedicated to an oral health curriculum. However, if family medicine educators see the importance of oral health as an integral component of one s overall Table 6. Program directors assessment of difficulty in referring patients to dentists Please indicate how difficult you have found it to refer a patient to the dentist if the patient... Difficult (%) Not Difficult (%) Is uninsured and has an emergent dental problem at night or on the weekend Is uninsured and needs a sliding scale Receives Medicaid dental benefits Has a significant developmental disability Is less than two years of age Has private dental insurance and has an emergent dental problem at night or on the weekend April 2005 Journal of Dental Education 451

7 health that requires an oral health assessment, counseling of dental problems, and identification of dental disease, then more knowledge and skill development in oral health care is needed for both faculty and residents. The primary limitation of our study is the somewhat low response rate by program directors. In addition, self-reporting may not reflect the actual practices by each program. Conclusions Oral diseases have been called an overlooked epidemic by the U.S. surgeon general in his May 2000 report. 1 One strategy for improving oral health status is to identify, educate, and employ preventive procedures early in the lives of children. Family practice physicians are one group of providers who have an opportunity to make a significant difference because of their access to families. Toward this end, this study provides data about family practice residency directors knowledge and attitudes toward oral health education for their residents. Results indicate that residency directors support the premise that oral health education, prevention knowledge, and recognition skills should be a component of residency training. More research is needed to assess what competencies in oral health education for primary care physicians should be taught and what educational strategies would be most effective and efficient in achieving learning and behavior change. In addition, an assessment of resident behaviors is needed following graduation from programs that have included an oral health curriculum. Acknowledgments This study was supported by grant D30HP40013 from the Health Resources and Services Administration (HRSA). We thank Lori Knutson and Amy Simmons from the University of Kentucky for clerical and survey administrative assistance. REFERENCES 1. Oral health in America: a report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, facts about family practice. Table 8. Practice profile of family physicians by family physician residency completion. At: Accessed: January 31, Sanchez O, Childers N, Fox L, Bradley E. Physicians views on pediatric preventive dental care. Pediatr Dent 1997;19(6): Lewis C, Grossman D, et al. The role of pediatricians in the oral health of children: a national survey. Pediatrics 2000;106(6): Mouradian W, Berg J, Somerman M. 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 2003;67(8): Mouradian W. The face of a child: children s oral health and dental education. J Dent Educ 2001;65(9): Drum MA, Chen DW, Duffy RE. Filling the gap: equity and access to oral health services for minorities and the underserved. Fam Med 1998;30: Edelstein B. Crisis in care: the facts behind children s lack of access to Medicaid dental care. Washington, DC: National Center for Education in Maternal and Child Health Policy Brief, May Bonner P. The national oral cancer awareness program. ORL-Head Neck Nurs 1998;16: American Academy of Pediatrics. Policy statement: oral health risk assessment timing and establishment of the dental home. Pediatrics 2003;3: facts about family practice. Table 118. At: Accessed: September 13, Oral health policies. Pediatr Dent 1999;21: Berkowiltz RH, Jones P. Mouth-to-mouth transmission of bacterium streptococcus mutans between mother and child. Arch Oral Biol 1985;30: Sanchez O, Childers N. Anticipatory guidance in infant oral health: rationale and recommendations. Am Fam Physician 2000;61:115-20, Gonsalves W, et al. Physicians oral health education in Kentucky. Fam Med 2004;36(8): Mouradian W, et al. Addressing disparities in children s oral health: a dental-medical partnership to train family practice residents. J Dent Educ 2003;67(8): Graham E, Negron R, Domoto P, Milgrom P. Children s oral health in the medical curriculum: a collaborative intervention at the university-affiliated hospital. J Dent Educ 2003;67(3): Journal of Dental Education Volume 69, Number 4