Incorporating Oral Health into Family Medicine Training - Family and ...

Incorporating Oral Health into
Family Medicine Training
UCSF Department of Family & Community
Medicine Colloquium
May 10, 2007
Irene Hilton DDS, MPH
SF DPH, Dental Bureau
UCSF School of Dentistry/ DFCM
Rosalía a Mendoza MD, MPH
UCSF Post Doctorate Research Fellow

Session Objectives
Understand the rationale for incorporating oral
health (OH) into Family Medicine Education
Describe the various educational components of the
UCSF Family Medicine (FM) OH program
Understand the educational role of the Childhood
OH Clinic
Describe Clinical Results
Review Impact Evaluation

Rational for Medical Training in
Oral Health
Surgeon General Report 2000
Disparities exist in OH status that can be
reduced through early identification and mgt in
medical setting
Emerging research continues to explore the
associations between OH conditions and
systemic health, while defining biological
mechanisms
Collaboration between dental and medical fields
continues to expand

The Caries Etiology Triad
Oral bacteria (Strep mutans) break down
dietary sugars into acids which eat away
the tooth
Bacteria
Teeth
Caries
Sugars

Early Childhood Caries Disparities
% 2-4 y/o Untreated Decay
Percent
35
30
25
20
15
10
19.3
24.6
31.5
5
0
2-4 Years
NHANES 1999-2000
Non-Hispanic White Non-Hispanic Black Mexican American
Data Source: NHANES IV, 1999-2000, NCHS/CDC.

UCSF Oral Health Program
Goals
Increase OH awareness for medical
students and FM residents
Provide a practical, hands-on clinical
educational experience
Screen children ages 0-50
5 for early
childhood caries (ECC)
Improve pediatric dental access
Evaluate pilot program

The OH Curriculum Components
Didactic Lectures
Preview CD for Learners
OH Screening Clinic Rotation
Evaluation

Family Health Center
Screening Clinic Logistics
Screening:
– Referral only
– All children 0-50
5 referred by PCPs (MD, NP)
– Regardless of established dental home
Two ½ day clinics/ month, 30 minute visits
Families seen by OH teamlet

Oral Health Learners
2 nd year UCSF Family
Medicine Residents
3 rd year UCSF
FCM 110 Medical
Students (in San
Francisco)
OH Teamlet
Teachers
FCM Clinical
Instructor
DPH Dentist
(Trainer to Trainer
Model)

Conduct Early Childhood Caries Risk Screening
Supervising Attending: _____________________________CHN # ____________ Date of Service: __________
COMMUNITY HEALTH NETWORK
SAN FRANCISCO GENERAL
HOSPITAL MEDICAL CENTER
FAMILY HEALTH CENTER
PEDIATRIC ORAL HEALTH SCREENING
PROGRESS NOTE
NAME
DOB
MRN
PCP
Patient ID / Addressograph
Chief complaint or reason for referral-
Caries risk indicators Š based on parent interview Y N Notes
(a) Mother/ primary caregiver has had active dental decay in past
12 months
(b) Older siblings with history of dental decay
(c) Continual use of bottle containing beverages other than
water/milk. Bottle use > 24months old.
(d) Child sleeps with a bottle or nurses on demand
(e) Frequent (greater 3x/day total) candy, carbohydrate snacks
(junk food), soda, sugared beverages (including processed juice)
(f) Medical Issues:
1. Saliva-reducing meds (asthma, seizure, hyperactivity etc.)
2. Developmental problems etc.
3. H/O anemia or Fe+ Rx
Protective factors Š based on parent interview Y N Notes
(a) Child lives in fluoridated community AND drinks tap water daily
(b) Teeth cleaned with fluoridated toothpaste (pea size) daily
(c) Child has a dental home and regular dental care
Oral examination Y N
a) Obvious white spots (decalcifications), or obvious decay
present on the childÕs teeth: NOTE ON DIAGRAM →
(b) Plaque is obvious on the teeth and/or gums bleed easily
ECC (Early Childhood Caries) Diagnosis:
No visible ECC
Non-cavitated ECC
Cavitated ECC
Initial
Follow-up
R
Assessment: ChildÕs caries risk status (any checked item in shaded areas confers high risk):
L
LOW HIGH
Plan: Health education handouts
Self Management Goals 1._______________________________________________________
2._______________________________________________________
Dispense toothpaste and toothbrush
Prophy/ fluoride varnish
FHC Oral Health Clinic follow-up appointment (high risk) _______ months
Urgent outside dental referral (high risk, needs tracking)
Routine dental referral for dental home (all others)
Signature of Rendering Provider: ________________
_____ Name: __________________CHN # ___________

Knee-to
to-Knee Exam
• Conduct oral exam
• Demonstrate tooth brushing
• Fluoride Varnish application
1. Child is facing caregiver in a straddle position
2. Child leans back onto examiner while caregiver
holds child’s hands.
3. Provider performs exam while caregiver holds
child’s hands & arms.

Oral Health Screening Clinic Visit
Anticipatory Guidance
– Educational handouts
– Language appropriate, individually
tailored action plan by individual risk
assessment
Disposition (3 options)
– Routine outside referral
– In-house F/U
– Urgent referral

First 11 months
Children Seen
117 patients
Payer Source
Average 5 visits/ clinic
Goal: 6 visits clinic
MCAL
HK
HF
Gateway

Ethnicity of Children Screened
8%
13%
2% Latino
Asian Other (Chinese,
VN)
Filipino
5%
5%
67%
Middle Eastern
African American
Caucasian

Most Children Lacked a Dental
Home
# Seen
90
80
70
60
50
40
30
20
10
0
89
28
18
No Yes Return Visit
Dental Home

Categories of Tooth Decay
No ECC
Non-Cavitated ECC
Cavitated ECC

Caries Severity Distributed by Age
4+
Age
3
2
1
Cavitated ECC
Non-Cavitated ECC
No ECC
< 1
0 5 10 15 20
# Seen

Bottled Water Usage at Family
Health Center
13
Bottled Water
43
61
SF Tap Water (Filtered
15)
Mixed (Filtered 1)

Clinical Summary Points
Majority of screened children are at high risk to
develop caries
More than half already have evidence dental
decay on initial screening
Most children do not have a dental home &
receive delayed care
Many children had been lost to dental F/U
Most families not drinking SF fluoridated tap
water

Resident Evaluation
Prior to training:
– Most knew of OH skills from Peds rotation
– Reported low “level of comfort” performing OH
screening and exam skills
– Reported conducting OH skills infrequently
– Inappropriately delaying referrals
– Unaware of the dental referral system

After training:
Resident Learners
– Reported increased frequency of screening,
conducting exams, appropriate dental
referrals
– Reported increased “level of comfort” while
performing OH skills
– Many reported “very likely” to perform OH
techniques after residency
– Fewer reported “likely” to perform fluoride
varnish applications after residency

Medical Student Learners
Lack knowledge of age appropriate
referral
Reported seeing fewer children at baseline
Reported similar “comfort level” as
residents after training
Reported lower “comfort level” to perform
OH skills in “didactic only” group vs.
“lecture plus clinic experience” group

Qualitative Comments
Excellent hands-on repetition of skills
No exposure in prior training – much
needed exposure
Great supplementary material
I enjoyed the people who educated me
and interacting with patients
Will refer patients more
All said they would recommend this
training to other MS and residents

Educational Summary Points
Medical students and FM residents are
interested in acquiring basic clinical skills
in oral health.
The clinical experience component is
critical to gaining competency and learner
satisfaction.
Medical-Dental Collaboration works!

UCSF Oral Health Pilot Program
Collaborators
Dr. Francisco Ramos-Gomez, UCSF School of
Dentistry
Dr. Irene Hilton, SF DPH, Dental Bureau
First Five California/ Molina Healthcare, Inc.
UCSF Center to Address Disparities in
Children’s Oral Health (CANDO)

Funders