Abstract
Purpose The integration of oral health and primary care offers promising solutions to overcome barriers hindering patient access to oral health care. However, primary care providers require training in basic preventive oral health care and information regarding interprofessional practice opportunities. The purpose of this feasibility study was to examine the perspective of families, learners, faculty, and administrators who engaged in an interprofessional training experience for family medicine residents and dental hygiene students.
Methods Family medicine residents and dental hygiene students participated in an interprofessional oral health integration training experience, which included didactic, preclinical, and clinical components. The clinical experience was conducted during a Medicaid Managed Care clinic session, which included the participation of children who had not undergone a well-child visit within the past year. The care teams were comprised of a family medicine resident and dental hygiene student, who collaborated on the provision of preventive oral health care services, including oral examinations, preventive interventions, patient education, and care coordination. Qualitative data gathered using field notes, focus groups, and key informant interviews were analyzed to identify themes from care team, patient/family, and administrative perspectives.
Results The care teams provided preventive health oral health care services to 10 pediatric patients during their well child visit. Patients and family members reported appreciating the convenience and value of the care provided. The experience was well received by family medicine residents, dental hygiene students, and clinical faculty members, who highlighted the value of the experience in expanding access to care. The family medicine residents reported the training and interprofessional practice opportunity to be highly valuable, reporting better preparation for the identification, evaluation, and treatment of oral conditions that they may have otherwise overlooked or misdiagnosed.
Conclusions This interprofessional educational experience demonstrates the potential value of integrating preventive oral health in primary care visits for children. This care integration may be especially helpful for populations that experience barriers to oral health care. Results of this study suggest that expanding interprofessional education between dental hygiene programs and family medicine residencies may be beneficial for preparing the future workforce for integrated care. Additional research is needed to formalize training models that support integration and promote interprofessional collaboration and practice.
- interprofessional collaboration
- access to oral health care
- integrated care
- dental hygiene students
- family medicine residents
INTRODUCTION
More than twenty years have passed since the United States Surgeon General issued the first report on Oral Health in America.1 While enormous strides have been made since that landmark report, much work remains to be done to improve the oral health of the American population. The need for support from the broader health care workforce, especially medical professionals, was among the several strategies raised by the Surgeon General’s report. Following this call to action, numerous initiatives have been led by health care professionals, focused on increasing awareness of oral health and its incorporation into patient care across health-care delivery systems.2-5
Integrating oral health and primary care is one of the chief health system strategies aimed at improving oral health, especially for children.6,7 Limited access to preventive oral health care services among children can lead to dental morbidity, emergency department visits, and increased costs of health care services.1,8 Moreover, low-income children covered by Medicaid, especially African American and Hispanic or Latino children, are found to have the greatest dental disease burden, since they face the greatest barriers that hinder access to preventive oral health care.8 Oral health interventions delivered in the context of primary care visits, such as the placement of fluoride varnish at well-child visits, are associated with improvement in oral health.1,9 These interventions can be delivered by primary care clinicians with the appropriate training, or by dental professionals who are co-located with or integrated into the primary care team.
Dental hygienists are well-positioned to be a part of oral health and primary care integration. Several studies have examined the role of dental hygienists in this integration and explored interprofessional models involving dental hygienists.10-14 The results of these studies are promising, but the models have only been tested in certain states and settings or in limited capacity; broad adoptions have not been implemented.
The support of primary care clinicians has been identified as critical to initiating and integrating oral health and primary care.15,16 Unfortunately, medical school programs do not cover oral health in a consistent or comprehensive manner, despite the increasing awareness of the importance of oral health.17 Medical school is largely focused on expanding the medical knowledge of students, and only includes limited patient care training. Medical residency, generally completed following graduation from medical school, is a key period of physician training, where physicians receive applied patient care training in a specific specialty. As such, primary care residencies are well suited for an interprofessional education experiences integrating oral health into patient care.
Integration of oral health with primary care through interprofessional practice involving dental hygienists has been studied previously, but not in the context of primary care residencies. Most studies that have examined strategies for integrating dental hygienists into interprofessional teams in the primary care setting involved experienced professionals, as opposed to students or learners.12-14,18 The feasibility of incorporating these models into the residency experience and the potential impact on physicians’ interest in integrating oral health into their practice has not been studied previously.
The purpose of this study was to examine the perceptions of patient families, learners, and faculty engaged in a pilot interprofessional clinical education experience which integrated oral health into well child visits.
METHODS
This on-site feasibility study was conducted at a downtown Indianapolis family medicine center (FMC) affiliated with the Indiana University School of Medicine. The FMC collaborates with Medicaid-managed care entity to offer well-child appointments to pediatric Medicaid enrollees who have not had this type of visit within the last year. The feasibility study took place in conjunction with well-child check-ups at the FMC. The study was approved by the Indiana University Institutional Review Board (IRB #1705593195).
Training and Preparation
The outline of the oral health integration training experience is summarized in Table I. The training program consisted of didactic and preclinical sessions on oral health and interprofessional practice, followed by an interprofessional clinical experience. The program incorporated the five interprofessional oral health core clinical competencies established in the Health Resources and Services Administration’s Integration of Oral Health and Primary Care Practice (IOHPCP) framework: risk assessment, oral health evaluation, preventive intervention, communication and education, and interprofessional collaborative practice.19
Process for Oral Health Integration Training Experience
Four care teams were established, each comprising of one family medicine resident, one dental hygiene student, and one faculty preceptor from family medicine, dental hygiene, and dentistry. For the didactic portion of the training, family medicine residents and faculty participants completed five web-based courses and post-assessments from Smiles for Life (SFL): A National Oral Health Curriculum. The courses included: 1) The Relationship of Oral and Systemic Health; 2) Child Oral Health; 3) Acute Dental Problems; 4) Caries Risk Assessment, Fluoride Varnish, and Counseling; and 5) The Oral Examination. Smiles for Life is a comprehensive oral health curriculum for primary care trainees and clinicians developed by the Society of Teachers in Family Medicine.20 Following completion of the SFL courses, all care team members completed a supplemental 90-minute instructor led course developed by experts in oral health integration and interprofessional education. The instructor led course included a preclinical session with a dental manikin for family medicine residents to practice certain dental procedures such as oral health examination using a dental mirror and explorer. The supplemental content was designed to complement the SFL curriculum and ensure that care team members completed training consistent with all five domains outlined within the IOHPCP framework. No post-assessment was administered for the supplemental training.
The clinical experience was conducted in FMC procedure rooms already outfitted with reclining chairs and ceiling lamps. A portable compressor was procured for the dental prophylaxis and fluoride varnish application procedures. Oral healthcare kits were obtained from the Indiana University School of Dentistry.
Patient Recruitment
Medicaid-enrolled pediatric patients between the ages of 2 and 18 years who resided in Indianapolis and had not undergone a well-child visit within the last 12 months received a telephone invitation from case managers to attend the FMC well-child clinic. As part of the invitation, parents were also asked whether their child had undergone a dental visit in the previous year. If their response was negative, they were assumed to not have a dental home and were offered the opportunity to have their child receive preventive oral health services as part of the well-child visit. Fifty children were scheduled for well-child visits. Among these, the parents of 10 patients provided verbal consent at check in to participate in the study. Preventive oral health care, which was offered at no additional cost, included the following: 1) oral health risk assessment; 2) oral health evaluation; 3) preventive interventions (i.e., prophylaxis, fluoride varnish, and pit and fissure sealants); 4) education (including anticipatory guidance); and 5) dental care coordination (including dental referral).
Integrated Healthcare and Treatment
The pediatric patients checked in with the FMC receptionist upon arrival for the well-child visit and were admitted to the clinic. A medical assistant, observed by a dental hygiene student, recorded the patient’s medical history, examined vital signs, and prepared the patient for the well-child visit. The family medicine resident performed the well-child examination.
Subsequently, the family medicine resident and dental hygiene student collaboratively performed an oral health risk assessment and evaluation. They formulated an oral health treatment plan, which was discussed and confirmed with the faculty preceptors prior to the administration of preventive oral healthcare or coordinating dental referrals.
The dental hygiene student acted as a care coordinator and managed direct referral to a community dentist if the patient required additional dental services to address active dental disease. If the patient did not require additional dental services, the dental hygiene student and/or family medicine resident delivered preventive oral health services consistent with the treatment plan. Finally, the FMC receptionist scheduled a follow up well-child visit in addition to their next dental visit (i.e., after 6 months).
Data Collection
Two researchers who supervised the implementation of the integrated oral health training experience took field notes throughout the duration of the study. Families who participated in the feasibility study were interviewed to obtain their feedback on the preventive oral healthcare provided immediately following the well-child appointment. At the conclusion of the day-long study period, each care team (family medicine resident, dental hygiene student, and faculty preceptors) participated in a focus group. The focus groups were led by an experienced researcher and licensed clinician with expertise in oral health integration. The focus groups were designed to gather qualitative information on the perceptions of the care team members on this interprofessional experience. The focus groups were 60 min long and were transcribed synchronously. Two researchers independently reviewed the focus group transcripts to categorize the responses. After reviewing the results and reaching concordance, the researchers further grouped the categories based on the emerging themes. An administrator was also interviewed to understand the logistical barriers and overall feasibility of implementing this oral health integration model.
RESULTS
The parents/legal guardians of 10 pediatric patients verbally consented to their children participating in the interprofessional clinical experience integrating the oral health examination into the well-child visit. The 10 participants were Medicaid recipients aged 2 to15 years that had not received any oral healthcare within the previous 12 months. Eight participants presented with active dental caries; two participants had dental abscesses requiring immediate attention and referral to an emergency dental clinic. In one case, a family medicine resident was able to identify an acute dental condition in a participant who presented with a slight fever that they would have initially attributed to a common viral infection. Because of the additional training and collaboration with oral health providers, this resident was able to conduct a comprehensive oral examination, revealing a draining fistula requiring immediate referral to a dentist.
The Care Team’s Perspective
The qualitative feedback obtained from the care team members is summarized in Table II. The perceived value of the integration model was clearly and consistently articulated by care team members, as was the recognition of the value and importance of collaborating with dental hygiene professionals. All care team members agreed that oral health care must become part of primary care to ensure the provision of high-quality comprehensive primary care to patients. One dental hygiene student highlighted the value of this model as follows: “The model increases access to care and breaks down barriers.”
Qualitative feedback from care team members
The family medicine residents reported that they enjoyed working with the dental hygiene students, noting their contribution to the successful integration of preventive oral healthcare into the well-child visit. The residents also agreed that it was generally feasible to deliver preventive oral healthcare with the assistance of a dental hygienist on the primary care team when considering the time constraints of primary care delivery. This was reflected in one resident’s response: “Yes, oral exams didn’t take a lot of time. Having a dental hygienist on site would be really great.”
With respect to the effectiveness of training strategies, there was a general consensus that the oral health curriculum was lacking in both medical school and residency training, and that this training experience enhanced the family medicine residents’ comfort level and ability to integrate oral health care into their practice. Residents particularly appreciated the SFL modules and hands-on training with the dental manikin, as well as the ability to apply their new knowledge and skills during the clinical experience. One resident expressed this appreciation for the complementary training as follows: “During med school I had a couple of lectures on oral health but nothing since then. Today I learned how to find [dental] risk and take a proactive approach!”
While there was positive feedback from this experience, the care team also experienced challenges. The primary challenge identified by care team members was referral coordination. Eight patients required referral to a community dental office for additional treatment. The two children with dental abscesses were referred to a hospital-based pediatric dental clinic for a same-day emergency appointment. A list of Medicaid enrolled dentists and dental practices in the community was available and used for referral coordination for the remaining children with dental caries. However, several dental offices that were contacted by telephone stated that they did not accept new Medicaid patients. Finding a dental office that accepted referrals was time consuming, and care team members indicated the need for better referral procedures and more Medicaid-participating dentists.
While the FMC had very little difficulty in integrating preventive oral health care into the facility and well-child visits, the financial sustainability of the model was questioned by the FMC administration. These concerns were driven by the additional clinic time required for integrating oral healthcare services. However, the possibility of reimbursement for certain services, such as fluoride varnish application and care coordination, were identified as potential opportunities for funding.
Patient Family Perspective
The qualitative feedback obtained from the families that participated in the study is presented in Table III. Parents/guardians were grateful that the integrated appointment reduced logistical barriers that had previously prevented them from gaining access to preventive oral healthcare for their children. This was reflected in the following response provided by one parent:
Qualitative feedback from participating families
“I don’t have transportation. He could get his teeth looked at and cleaned here, it was great!” They also described the convenience of receiving all of their children’s health care at one appointment. The participating families emphasized the value of receiving patient education on oral health care, in addition to the positive response regarding the convenience of integrated oral health and primary care, as explained by another parent: “…I really appreciated the opportunity to be in the room. I learned a lot.”
DISCUSSION
Previous research has demonstrated that oral health champions at various levels (leadership, providers, support staff) are key to the success oral health integration in the primary care setting. The findings of this study confirm this research, demonstrating the potential for this oral health training experience for family medicine residents where interprofessional collaboration with dental hygiene students facilitated successful integration of oral health services into their practice setting. Given the scarcity of oral health content within the traditional medical school curriculum, this form of hands-on training is essential to equip family physicians with the necessary skills to fully integrate preventive oral health care services and participate in interprofessional collaborative primary care teams.
Discussions on the integration of oral health and primary care have largely resulted from research demonstrating that the integration of oral health services has the potential to improve overall health by removing barriers that restrict access to oral health care.9,11,12,21 However, true integration requires more than just co-location.15 Some preliminary studies have demonstrated that successful integration programs rely on physician champions that value oral health care as a part of their primary care delivery.16,22,23 Training programs similar to the curriculum used in this study empower physicians to provide higher quality and comprehensive primary care by including preventive oral health care in the treatment.24 However, the limited availability of research on the effectiveness of education models necessitates the performance of larger studies that can support the need for oral health training for medical residents.15 Before major investments are made to facilitate robust testing, feasibility studies, such as the current study, offer researchers and health care professionals the opportunity to determine whether a new model would be more appropriate for further testing.25
Many Americans face numerous barriers to accessing oral health care services, including a lack of Medicaid dental providers, transportation, or general awareness.26 Although patients may not routinely visit the dental office due to these barriers, they are more likely to see their primary care physician.26 Thus, integration creates an opportunity for overcoming these barriers. The majority of children examined had active dental disease that likely would have gone unidentified or undiagnosed for an indeterminate period of time had they not participated in this clinical training experience. Removing transportation and time barriers reported by parents allowed these children to receive timely oral health care. Overall, the oral health integration training experience is well-aligned with the national movement toward population health management.27
LIMITATIONS
The findings from this feasability study must be considered within the context of limitations that are commonly associated with preliminary research. There is the possibility of selection bias since the family medicine residents, dental hygiene students, faculty and patients volunteered to participate in this study. These individuals may be more inclined to engage in an oral health integration delivery model compared to their peers. Moreover, pre-testing knowledge, attitudes, or experience with oral health integration were not assessed, which may have affected participants’ opinions on the feasibility and acceptability of the interprofessional clinical training experience. Finally, the sample size was small with only 10 patients. Additional research is needed to fully understand the impact this learning experience on future practice patterns. Even so, training primary care providers in preventive oral health care and integrating dental hygienists into the primary care team may be a promising approach, which warrants further testing.
CONCLUSION
Primary care physicians tend to share strong and lasting relationships with their patients and are responsible for providing patient-centered medical care and ensuring their overall health, including oral health. Embedding dental hygienists into primary care is a promising approach toward achieving overall health. Interprofessional education experiences involving dental hygiene students and family medicine residents may help to prepare the future workforce for interprofessional practice models that support oral health integration into primary care.
DISCLOSURES
The authors have no conflicts of interest to disclose.
Footnotes
NDHRA priority area, Professional development: Education (educational models).
- Received February 19, 2024.
- Accepted May 3, 2024.
- Copyright © 2024 The American Dental Hygienists’ Association
