Reconnecting the Mouth to Medical Education

Virginia Tech Carilion School of Medicine “a medical school with a mouth”

Collaborating Across Borders VI Banff, Alberta Canada

October 1-4, 2017 Richard C. Vari, PhD Cynda A. Johnson, MD, MBA Bruce E. Johnson, MD Lynne Pearo, RN

Bud Conklin, MD

Welcome and Introductions

I. Audience Expectations II. Outline a. Overview of the status and importance of Oral Health Education b. Identify the challenges of Implementation c. Identify opportunities to overcome the challenges

Oral health and medical education…Where are we? a. Historical perspective b. Virginia Tech Carilion School of Medicine impetus for change

Dissection of the mouth from rest of the body Two major or “watershed” events: (1) Baltimore College of Dental Surgery, founded in 1840 becomes the first US dental college, establishing a formal education leading to DDS degree. Thus, a separate tower of learning is established, which exists today with few “crosswalks” to integrate the disciplines of medical and dental education. (2) 1966 Medicare excludes coverage for oral health services. Thus, deemphasizing the importance of oral health to overall general health.

Result and Present Situation: Few osteopathic or allopathic MD granting schools have integrated oral health topics into the medical education curriculum

Teaching Oral Health in U.S. Medical Schools: Results of a National Survey Academic Medicine, Vol. 86, No.2/ February 2011 154 US Medical Schools surveyed - 88 respondents Educational hours offered: • 61 offered less than 5 hours • 25 offered 1 to 2 hours • 9 had no curriculum • 26 reported evaluating students on oral health topics • Only 10 reported evaluations by clinical observations Conclusion: The majority of the responding U.S. Medical Schools offered very little oral health education.

Virginia Tech Carilion School of Medicine Impetus for Change Personal Reflections and Commitment (Dean Cynda Johnson) Seizing an opportunity for interprofessional collaboration

Audience Discussion: History

Reflection Impetus

Recognizing the importance of medical education reconnecting the mouth to rest of the body

Define the relationship of periodontal pathogens inflammatory role in diabetes, coronary artery disease, stroke and most recently their association in oncologic tumors.

Conditions in which knowledge of dental disease (e.g. gingivitis, extensive cavities, abscesses) influence medical decision-making • diabetes - type 1 and probably type 2 • heart valves - artificial and porcine • artificial (metal) joint prostheses • cardiovascular (coronary) atherosclerosis • role/treatment of inflammatory stimulus • others

Based on patient healthcare visits, it is more likely a patient will have a physician visit in a given year than a dental visit.

Patient and Provider Outcomes

1. Improved patient care outcomes through early diagnosis of oral cancer and oral manifestations of systemic disease. 2. Identification and elimination of oral disease which has the potential to adversely impact systemic disease. 3. Improved and enhanced interprofessional collaboration

Key challenges for integrating oral health into the VTC learning environment

• Lack of impetus/institutional leadership • No available time in the curriculum • Lack of resources for development and implementation • Lack of institutional collaborators • Faculty development issues (teaching and assessment) • Development of assessment strategies • Minimal accreditation expectations (LCME)

Identify key challenges for integrating oral health into a learning environment

List the challenges at your school

VTC “ Our Story ”

“ a groundbreaking program” ADA News August 20, 2012

VTC- One Pathway to Success • Leadership and Interprofessional Collaborators- Shared vision

• Flexible curriculum (PBL-Hybrid model, clinical science and skills early,

Interprofessionalism, Research) – Time in curriculum (PBL cases, clinical skills, clerkships)

• Funding resource identified: Delta Dental (Speaker Series and Curriculum)

• Curriculum driven by objectives and assessment

• Conduct research and establish effectiveness

General Learning Objectives VTC Oral Medicine / Oral Health Curriculum

1. Understand the importance of oral health as it relates to general health. 2. Understand the physicians role in early diagnosis of oral mucosal lesions and the impact they have in improving quality of care and patient care outcomes. 3. Develop clinical recognition skill sets that support identification of oral pathology which leads to differential or definitive diagnoses. 4. Recognize the relationships between oral and systemic disease. For example the relationship between coronary artery and periodontal disease. 5. Identify the most common oral mucosal lesions and their clinical management. 6. Acquire a fundamental knowledge of patient care management at the medical / dental interface that supports a collaborative inter professional patient care model.

Oral Medicine / Oral Health Curriculum Va Tech Carilion School of Medicine

Thirty-Six Hours: M1,M2, M3 Block IV ( M 1) •Introduction to Oral Health /Oral Medicine •Oral Anatomy •The Oral Assessment Workshop ( developing clinical skills )

Block VIII (M 2) – Oral Health Week •Dental Caries, Periodontal Disease & Fluoridation •Oral Manifestations of Systemic Disease •Oral Cancer •Common Oral Pathologies •Describing Oral Lesions (Workshop) • Integrating Medicine and Dentistry into Patient Care (Workshop) • Developing Clinical Recognition Skills: Patient Focused Learning Lab •Integrated Oral Health / Oral Medicine Case Based Learning •Integrating the Oral Exam into HEENT Exam & SOAP Note with SP’s •Delta Dental Lecture Series

M 3 •Dental Clinic Rotation ( 1/ 2 day…Mandatory) Emphasis placed on the inclusion of the oral exam into the HEENT exam M 4 • Fourth Year Elective ( 2 week) Emphasis placed on student participation in patient care

VTC Assessment and Outcome Measures Years 1 and 2

• HEENOT Exam / Standardized Patient M1

O= Oral= 1. Generalized description of the dentition 2. Generalized description of the periodontal tissues 3. Oral soft tissue exam or oral cancer screening exam 4. Oral findings correlated with patient care

VTC Assessment and Outcome Measures Years 1 and 2

• Written Integrated Case Exam (M2, Block VIII) – Patient case – dental issues

VTC Integrated Case Exam Example Ms. Johnson is a 54 year old female who presents to your office for her annual physical exam. She has been fasting since midnight. She reports no current complaints or changes in her health or habits during the past twelve months. Past Medical History: aortic prosthetic heart valve replacement two years ago mild coronary artery disease first diagnosed five years ago insulin dependent diabetes mellitus diagnosed when she was 36 years old Medications: Aspirin/extended release dipyridamole, a platelet inhibitor, one tablet by mouth twice daily Regular Insulin 6 units AM and 6 units PM Allergies: None

The oral portion of the HEENOT exam reveals the following clinical findings: • Lips Retracted

• Mandibular left quad (bony like mass, mandibular inner table) • Right Buccal Mucosa

Questions 33. From the oral exam on Ms. Johnson, describe at least two clinical findings

in each major area (dentition, periodontal tissues, soft tissue/oral cancer) of the oral exam.

Case unfolds: You have identified a white lesion and a pigmented lesion in Ms. Johnson’s right buccal mucosa. The two lesions are asymptomatic and the patient was not aware of these lesions until you brought them to her attention.

34. Provide at least two (2) differential diagnoses for each lesion (white and pigmented) and for each differential diagnosis describe how you would make a definitive diagnosis based on clinical or laboratory exam.

You are concerned that Ms. Johnson’s oral health may impact her general health and existing medical conditions. 35. Describe (3) medical problems that may develop from her poor oral health. M2 students doing very well: 89% overall average; passing is 75%

Assessment and Outcome Measures

• HEENOT Exam M3

M3 Required Oral Exam/ HEENOT

HEENOT write-up for my patient with Strep throat.

Head: normocephalic, no rashes or lesions on face, scalp well hydrated Eyes: PERRLA; no scleral icterus, no conjunctivitis. Ehe-lids and pupils symmetric bilaterally. Optic disc margins sharp. No vascular lesions appreciated. Ears: TM’s clear and intact bilaterally. No inflammation of the auditory canal. Nose: no pain on palpation, no inflammation of the nasal turbinates. No discharge. Mouth: MMM, good dentition, No evidence of gingivitis or periodontitis. No masses or lesions on lateral aspect of tongue, floor of mouth, buccal mucosa, hard and soft palate, Oropharynx inflamed with bilateral white tonsilar exudates. Neck/Throat: Supple. Trachea midline. Pronounced anterior cervical LAD present bilaterally. Moderate posterior cervical LAD bilaterally, Thyroid of normal size and consistency.

Ongoing Research

• A Retrospective Chart Review: Incorporating the oral exam into the HEENT exam.

• A comparison between physician and VTC student documentation (outside of required report).

Realistic expectations

Develop the curriculum based on available resources and grow it through meaningful and applicable learning that results in positive outcomes that build support. In other words, do it well, do not try to do too much with too little.

Partnerships “Making a Difference in Medical Education”

Our Success!