FPHI Oral Healthcare Survey Results
Executive Summary
The Oral Healthcare Survey was a fourteen-question survey conducted electronically and distributed to twenty-nine primary care residenciesin Florida specializing inPediatrics, Obstetrics and Gynecology,Family Medicine and Preventive Medicine. The respondents were residency program directors and chief medical residents.
The survey results found that primary care residency programs need to improve on oral health training delivered to their residents,since the extent of oral health educationcurrently providedis limitedor nonexistent in some residencies. Furthermore, the majority of residents are not assessed on their oral-health competence prior to graduation. The survey also revealed that most residency programs were particularly weak in using any of the dental educational materials available such as the Smiles for Life modules, training videos, patient education posters or pocket cards.
Despite the low level of oral health training in these programs, the majority of residencies believe that it is important for physicians to address their patients’ basic oral health care issues. Nevertheless, half of these Florida-based programs indicated that they are satisfied with the level of competency residents achieve in oral health by graduation. The main barriers that prevented programs from providing more oral health education to residents were, time in the curriculum, lack of faculty expertise in oral health and competing prioritieswhich were all deemed more essential than oral health training.
Recommendations would include encouraging programs to develop formal collaborative relationships with oral health experts so that supervised training can be offered to residents. A minimum number of oral health training hours should be made mandatory for these specialty primary care residencies in Florida. Additionally, more emphasis needs to be placed on oral health assessment prior to graduation. Finally,there needs to be an increased awareness and application of available dental educational resourcessuch as the Smiles for Life modules.
Methodology
The Florida Public Health Institute (FPHI) and the Oral Health Florida Coalition utilized an existing oral health assessment survey, originally reviewed and approved by University of Massachusetts Medical School, University of Louisville, and the American Academy of Pediatrics Institutional Review Boards [1]. These surveys were slightly modified and tailored to each of the four residency specialties. The survey was available electronically (via surveymonkey.com) from July 2012 to October 2012. All twenty-nine residency programs were notified of the survey via an email from the Director of the Florida Public Health Institute and all responses were completed electronically. Emails and phone calls were done with the residency programs to solicit additional responses. In October 2012, a follow-up letter was sent to the residencies that had not responded and had not opted out of the survey. The survey was redistributed to these residency directors and chief residents. Additional follow-up phone calls and emails were conducted for one week.
A total of sixteen out of twenty-nine residencies (55% response rate) responded to the survey and phone calls. Of the sixteen residencies that responded, 62.5% of the responses came from residency directors and 37.5% came from the chief residents. Six residencies stated they were not interested in participating in the survey. The remaining seven residencies did not respond, despite repeated attempts to encourage them to participate.
Several of the questions were yes/no answers and three of the questions were based on a five-point Likert scale. The Likert scale ranged from “strongly disagree” to “strongly agree” and was used to determine how important physicians felt it was to address basic oral health care needs and if residency programs were satisfied with their oral health competence and meeting ACGME program requirements.
Findings
44% of responses to the survey came from community-based, university-affiliated residencies, followed by 37% from university-based residencies, whereas military and community-based, non-affiliated residencies contributed to only 19% of responses. The results showed that the amount of time spent on oral health training is underwhelming and rarely done under the expert guidance of an oral health professional. More than 50% of the residency programs that responded spent two hours or less in lectures/workshops on oral health training (Chart 1). 75% of residencies do not have a formal collaborative relationship with an oral health expert and 94% of residencies spend no time with a dental professional over the course of training. Some residencies stated that dental issues were referred to dental residents at the institution, the oral maxilla-facial department on staff or dentists in the community.
Another interesting finding is that although 44% of the residencies learn how to apply fluoride varnish during training, only 25% routinely apply fluoride varnish when clinically indicated. Furthermore, only 50% of residents perform an oral health risk assessment to determine if a woman is at low or high risk of caries or other dental problems. 62.5% of programs do not assess residents on oral health topics and of the remaining 37.5%;only a quarter of these programs assessed oral health competence by direct observation in clinical settings (Chart 2). One pediatric residency stated their residents were not assessed on oral health competence since the board exams already had several oral health questions.
Furthermore, 94% of residencies do not use any of the Smiles for Life modules to teach their residents about oral health. Only one family medicine residency utilized the Child Oral Health module and Fluoride Varnish module. Moreover, 100% of residencies do not use any of the other Smiles for Life resources for example videos, test questions, patients educations posters/handouts and pocket cards but 25% utilize other oral health educational materials such as the John Hopkins Oral Health module and University of Minnesota Oral Health online module.
The most common topics where programshave oral health education weaved into the program are well-child care, nutrition and breastfeeding (Chart 3). All pediatric residencies that responded weaved oral health into their training underthe topic of well-child care. 67% of pediatric residencies also educated on oral health when teaching nutrition. Less than 20% of residencies taught oral health under diabetes, emergency medicine, sports medicine, injury/violence prevention, preterm labor and troop/sailor readiness. However, no oral health component was part of the curriculum when educating residents on child abuse, adolescent medicine and genetics.
Another important finding is that although 75% of residencies agree it is important for physicians to address their patients’ basic oral health care issues, only 56% agree that their program clearly meets ACGME requirements concerning oral health training and only50% agree that they are satisfied with the level of competence residents receive in oral health by graduation (Chart 4). They attribute the lack of attention given to oral health training to time constraints in the curriculum, competing program priorities,and a lack of faculty expertise in oral health. One pediatric program stated that there was a lack of interest from faculty in teaching more oral health to residents.
Chart 1: How many total hours of lecture/workshops on oral health education do your residents receive over the course of training?
Chart 2: How are you assessing resident oral health competence (knowledge, attitudes, skills)?
Chart 3: Please select any of the following topics where your residents currently have oral health education weaved into the teaching for that topic?
Chart 4: I am satisfied with the level of competency that my residents currently achieve in oral health by graduation
Conclusion
The survey results clearly indicate that primary care residency programs currently need improvement in oral health education provided to residents during training. Despite the fact that more than 50% of residency programs believe that their program’s oral health training requirements are satisfactory, the evidence indicates that this is not the case. Over 93% of residencies spend less than four hours on oral health lectures/workshops over the course of training and over 93% residencies do not engage their residents with a dental professional during their program. The survey results indicate that most residency programs believe that instead of physicians addressing dental issues, these issues should be referred out to dental professionals. Based on the survey responses, it is safe to assume that dental education is not made a high priority for primary care residency programs in Florida.
To bridge this gap, technical assistance and educationalprogramsshould be made available to residency programs that are interested in receiving them. Once these services have been utilized and fully implemented, a further assessment can be done to determine whether or not educational and other services have been effective in increasing the dental knowledge and skills of primary care residents.
Recommendations
The first recommendation is to increase awareness among primary care residencies about the importance of providing trainingon oral health for residents. A certain number of hours spent on oral health lectures/workshops with a dental professional should be made compulsory as part of the curriculum. This should involve dental topics relating to the specialty - for example pregnancy oral health issues and maternal/infant vertical transmission of carious bacteria should be taught to all obstetrics and gynecologyresidents. It is essential that all primary care residents be able to carry out a basic oral health screening on a patient and provide basic oral health needs for example fluoride application when clinically indicated.
The second recommendation is that each residency should establish a collaborative relationship with an oral health expert to supervise and coordinate oral health training in the program. It should be mandatory that any dental problem observed when the basic oral screening is done should not be overlooked but be referred out for further investigation. Although there may not be the need for full-time oral health advisors, there could be more frequent training and workshops for specialty-related oral health issues.
Another recommendation would be more thorough assessment of residents on their oral health training prior to graduations. There should be paper and pencil testing or computer/online testing as well as direct observation in clinical settings. It should be mandatory that these specialty residency programs meet ACGME program requirements concerning oral health training.
The fourth recommendation is to ensure residencies are aware of the dental educational tools available online,for examplethe Smiles for Life modules. The seven modules available can educate residents on the oral examination, oral and systemic health interaction, child, adult and urgent oral health, pregnancy and oral health and fluoride varnish. There are a number of other Smiles for Life resources that none of the programs use such as videos, test questions, patient education poster and handouts and pocket cards. These should be made available and used in conjunction with the modules to ensure residents are receiving proper training.
References
[1] Silk H, King R, Bennett I, Chessman A, Savageau J. Assessing Oral Health Curriculum in US Family Medicine Residency Programs: A CERA Study. Family Medicine 2012 Nov; 44(10):719-22.
1