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Report IX

Contemporary Issues in Medicine:Oral Health Education for Medicaland Dental Students

Medical School Objectives Project

Association ofAmerican Medical Colleges

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June 2008

Report IXContemporary Issues in Medicine:Oral Health Education for Medicaland Dental Students

Medical School Objectives Project

June 2008

To request additional copies of this publication, please contact:

Association of American Medical Colleges2450 N Street, NWWashington, DC 20037T 202-828-0439 F [email protected]

© 2008 by the Association of American Medical Colleges. All rights reserved.


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Introduction

A version of this report was publishedas “Curriculum and Clinical Trainingin Oral Health for Physicians andDentists: Report of Panel 2” as part ofthe New Models of Dental Educationinitiative funded by the Josiah Macy, Jr.Foundation. For the purpose of thisreport, the Association of AmericanMedical Colleges and the AmericanDental Education Associationconvened a joint expert panel toidentify common medical and dentalcurricula in oral-systemic health byarticulating learning objectives andeducational strategies needed toprepare dental and medical graduatesfor their next phase of practice orclinical training. Panel participantswere drawn from multiple medical anddental disciplines, representing eightmedical and dental academicinstitutions in the United States andCanada.

AcknowledgmentsThis report was developed in collabo-ration with the American DentalEducation Association, whose activitieswere funded in part by a grant fromthe Josiah Macy, Jr. Foundation to theColumbia University Center forCommunity Health Partnership.

Background

Across health professions, there is agrowing appreciation of the need toaddress patient care systemically andholistically. The development of twoseparate health professions—one medicaland one dental—has its origins in theearly nineteenth century,1 but advances

in biomedical science have blurred thisdistinction from both diagnostic andtherapeutic standpoints. The knowledgeand skills physicians need related toclinical dentistry and the knowledge andskills dentists need related to clinicalmedicine are progressively overlapping.The two professions hold commonbiomedical science foundations, whichinclude growing evidence of therelationship of oral to systemic health.This report’s primary goal is to identifylearning objectives in oral and systemichealth that will enhance each profession’scapacity to improve and maintain theoral and overall health of individuals andpopulations.

Another aim of this report is to drawattention to the cross-cuttingcompetencies for all health professionsstudents to promote the commonattitudes, knowledge, and skillsnecessary for effective practice andinterprofessional collaboration intoday’s health care environment. Whilemany different curricular innovationshave been proposed for the healthprofessions, broad agreement exists onthe need for reforms responsive to theemerging science, which includes oral-systemic linkages, as well as otherdemographic, sociocultural, andenvironmental factors.

Oral Health in America: A Report ofthe Surgeon General 2 remindededucators, practitioners, and the publicof the fundamental fact that oraldiseases and disorders present asystemic burden. The report broughtattention to the importance of oralhealth for overall health and to theevidence for profound oral healthdisparities—disparities that can be

aggravated by health professionals’ lackof oral health knowledge.Subsequently, The Face of a Child:Surgeon General’s Conference onChildren and Oral Health3 convenedmany health constituencies to considerways to address pediatric oral healthdisparities. In 2003, the National Callto Action to Promote Oral Healthspecifically called for revamping healthprofessions education to include oralhealth content as a key step towardseliminating oral health disparities.

In an earlier 1995 study, DentalEducation at the Crossroads:Challenges and Change,4 the Instituteof Medicine (IOM) had alreadyrecommended closer integration ofdentistry with medicine and the healthcare system as a whole. This IOMreport predicted that scientific andtechnological advances in molecularbiology, immunology, and genetics,along with an aging population withmore complex health needs, wouldincreasingly link dentistry andmedicine, leading to the need forchanges in dental education.

As physicians come to see oral healthas a legitimate domain of involvementfor their profession, and dentistsacquire better understanding of thesystemic implications of oral disease,asking the right questions will be asmuch a matter of perspective as ofknowledge and skills. Cultivating sucha perspective will require significantchange in the curricula of bothprofessions. This report is intended topromote curricular change by definingthe attitudes, knowledge, and skillsthat underlie such a perspective.

Association of American Medical Colleges, 2008

Oral-Systemic HealthBiomedical Knowledge andLearning Objectives

Existing standards in medicine5,6 anddentistry7-9 already support theinclusion of oral-systemic healthlearning objectives in the predoctoralcurriculum. Therefore, in many ways,organizational precedent is establishedfor the articulation of common andcollaborative educational practices.Learning objectives for knowledge,attitudes, and skills in the basic sciencearea, as well as in the applied clinicalsciences, overlap. At the same time,many areas will require differentdegrees of coverage in the curriculum,depending on whether these areasfocus primarily on preparation of adentist or a physician. This sectionserves to emphasize common systemicand oral conditions that both medicaland dental students should know.

KnowledgeTo address oral-systemic connectionsin collaborative patient care, learningobjectives should impart requisitefoundational knowledge and clinicalreference that enable an understandingof the oral manifestations of systemicdiseases and other oral-systemicinteractions. Educational strategiesshould be designed so that medicaland dental students acquire the type,breadth, and depth of informationrequired by their respective profession.

Prior to graduation, medical and dentalstudents should have demonstrated tothe faculty’s satisfaction biomedical andclinical understanding in the followingareas:

Basic and clinical science principles• anatomy/embryology

• histology

• biochemistry

• cell and system physiology

• principles of molecular biology

• pathology, including oral cancer

• pathophysiology of major diseases,including basics of caries andperiodontal diseases

• neurological sciences

• microbiology and immunology,including oral pathogens in cariesand periodontal diseases

• principles of medical therapeuticsand pharmacology, including oralimpact of common medications

• endocrinology, includingreproductive health

• genetics, including major syndromessuch as cleft lip and palate

• nutrition and impact on oral health

Clinical presentation of oral-systemicmanifestations and interactions relatedtomajor diseases and conditions• hypertension and cardiovascular

diseases

• diabetes, including interaction withperiodontal health

• obesity, including increased risk forcaries and periodontal disease

• eating disorders

• hematological disorders, includingbleeding diatheses, leukemia, andlymphomas—presentation in head,neck, and oral areas

• oral and pharyngeal cancers

• caries

• periodontal diseases

• sexually transmitted diseases,including oral manifestations

• medication and therapeutic impacton oral health (e.g., radiation,transplantation, immunesuppression, anticoagulation, etc.)

• HIV-AIDS and other immunedisorders, including oral manifes-tations and Sjögren’s syndrome

• infectious diseases and commonoral pathology (thrush, herpes,varicella, leukoplakia, lichen planus)

• depression and common mentalhealth conditions and oral impactof medication

• substance abuse (alcohol, tobacco,drugs, and related oral conditions,e.g., “meth-mouth”)

• violence and trauma, including oraland craniofacial manifestations ofchild abuse and neglect

• pain syndromes (tooth pain,temporomandibular jointdysfunction)

• human development across the lifespan—special issues for childrenand the elderly

• physical disabilities and cognitivespecial needs patients


2 Association of American Medical Colleges, 2008


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SkillsFor practicing physicians and dentists,a number of clinical skills have becomespecialized relative to their respectivearea of patient care. However, as a morecontemporary, collaborative approachevolves in health care delivery, commonskill competence will be required ofboth dentists and physicians as theymanaging broad patient health issues.These skills also relate to the use andinterpretation of laboratory data informulating treatment plans or makingappropriate professional referrals.

Prior to graduation, medical and dentalstudents should have demonstrated to thefaculty’s satisfaction the ability to:

• interview patients effectively acrossthe life cycle

• address cultural and linguisticaspects (i.e., effectively engageinterpreters)

• obtain a medical history, includingsexual history and genderorientation

• obtain an oral and dental healthhistory

• perform general physical exam andassess general habits

• perform head and neckexamination that includesrecognition of caries, periodontaldisease, dental erosion from eatingdisorders, cleft palate and otheranomalies, mucosal changes,indications of oral cancer

• assess basic mental health status ofpatients

• provide patient education andhealth counseling (i.e., motivationalinterviewing or other techniquesfor patient behavioral changerelated to nutrition, substance use,or oral hygiene habits)

• order appropriate laboratory,radiographic, and other diagnostictests, including biopsy of suspiciousoral lesions

• integrate information from physicalexam, history, and laboratory,radiographic, and other data toarrive at a differential diagnosis

• formulate treatment options for thepatient to include communicationof risks and benefits of theproposed treatment plans, as wellas health implications ofnontreatment

• obtain appropriate informedconsent (parental permission)

AttitudesFundamentally valuing the importanceof attending to oral-systemic health inpatient care, as well as recognizingenvironmental, sociocultural, andother factors that define an individual’slife experiences, will support andenhance health care providers’ abilityto deliver quality care in a coherent,systematic fashion. Instilling andfostering the value of recognizing thesefactors is essential to preparing medicaland dental graduates for practice.

Prior to graduation, medical and dentalstudents should have demonstrated tothe faculty’s satisfaction an appreciationfor the importance of:

• recognizing oral health informationas vital to a comprehensive medicalhistory

• including oral and mental healthstatus elements in the completephysical exam

• responding to behavioral andhabitual factors affecting patientand oral health

• collaborating in the care ofpatients’ oral and systemic health

• acknowledging a shared societalresponsibility between patients,families, and other health profes-sionals for the oral and systemichealth of patients and the public

• employing foundational basic andclinical science knowledge in oraland systemic health, and the needto remain current in both

• applying appropriate use oftechnology and recognizinglimitations of technological therapies

• exercising both medical andsurgical approaches to diseasemanagement (i.e., for treatment ofdental caries)


MedEdPORTALSubsequent to the oral health panel deliberations reported here, theAAMC and ADEA have formed a partnership to expand MedEdPORTAL(an online peer-reviewed repository for educational and teaching resources) toinclude oral health and dental education content. This partnership is designedto facilitate broad access to educational and instructional materials in order tofoster interdisciplinary education, thus improve the quality of patient care inthe medical and dental clinical settings.www.aamc.org/mededportal

Cross-Cutting Competenciesfor Health Professionals

Over the last decade, numerous groupsand individuals have emphasized theimportance of adopting educationalcompetencies that reach across thehealth professions. Overarchingcompetencies highlighted here aretaken principally from the 2003 IOM’sHealth Professions Education: ABridge to Quality.10 This landmarkreport concluded that all health profes-sionals should be educated to 1)provide patient-centered care, 2) workin interdisciplinary teams, 3) employevidence-based practice, 4) applyquality-improvement approaches, and5) utilize informatics. Thesecompetencies define an orientationinclusive of oral-systemic connections.In fact, cross-cutting competencies areessential for the future of a responsiveand responsible approach to healthissues.

While the external environmentalpressures for medicine and dentistry tocontinue educational change have beendescribed elsewhere in the literature,the issues are important enough torestate here. They represent concernsthat must orient and sustain the futurecurriculum of preparing bothphysicians and dentists, and for allthose who enter health careprofessions.

A Changing EnvironmentCross-cutting domains respond to thechanging environment in which allhealth professionals will practice. Thislandscape includes evolving scienceand technologies, an increasing use ofinformatics in health care and practice,and an emphasis on accountability andquality improvement across health

systems. Demographic shifts includepopulation growth and an increasinglydiverse society, with minorities nowconstituting one-third of the entirepopulation and almost half of childrenunder age six.11 There are risingnumbers of elderly people—many ofwhom have complex and chronichealth needs—and increased survivalof individuals with disabilities andother special health care needs. At theother end of the age span are the 40percent of children who live in poor orlow-income families12—poverty ratesfor children being twice that ofadults.13 Low socioeconomic status orbeing in a minority group placesindividuals of any age at greater riskfor oral health disparities and difficultyaccessing dental care. Finally, global-ization, with its implications for distri-bution of resources, commerce, andtravel, has the potential to dramaticallyaffect many aspects of health andhealth care.

Preparing for the FutureCross-cutting competencies recognizethat not only must medical and dentaleducators strive to graduate practi-tioners competent to meet presentclinical needs, they must also preparestudents to practice in a future healthcare environment that may be verydifferent from the current one. Bothphysicians and dentists will need tobecome more adept at integrating newknowledge, comfortable at theinterface of their disciplines andothers, and capable of applying thisknowledge collaboratively as caregiverson the patient’s health care team.Practitioners will also need a morerobust understanding of the overallwellness of patients, so that healthpromotion and disease preventionbecome goals for individuals as well as

communities. Health systems willincreasingly emphasize accountabilityand quality improvement and willleverage contractual arrangements toaccomplish these goals. All healthpractitioners must be prepared torespond as part of the health careworkforce in the face of widespreadpublic health threats. On a daily basis,practitioners will need the ability towork and communicate with ourincreasingly diverse patient population.To take on these challenges, educatorsmust train a culturally and linguis-tically competent and representativehealth workforce.

Integrating New Knowledge intoEvidence-Based PracticeTo integrate new knowledge and assessthe biomedical literature, graduatesmust be sophisticated users of scienceand technology. The goal is not tomake every dental or medical schoolgraduate a research scientist, but ratherto make every graduate a man orwoman of science—that is, a sophis-ticated consumer of research.14 Whilethe scientist is the producer ofresearch, the practitioner is theconsumer of that knowledge.Openness to new ideas, criticalthinking skills, and the ability tointerpret scientific results will beneeded to translate new evidence intopractice.

Curricular Choices, Professional EthicsTo ensure that both medical and dentalstudents have skills in evidence-basedpractice and lifelong learning, forcollaborative teamwork, cross-culturalcommunication, and other broadcompetencies, difficult curriculumdecisions will have to be made andpriorities reassessed. Inordinatedevotion to traditional curricula and




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technical skills will come at the price ofnot preparing students for success in aworld of increasing diversity andcomplexity, intensifying competition,and continual change. Such choices mayshortchange students in skills needed tocare for diverse populations or toengage in quality improvement.Similarly, without additional knowledgein oral-systemic health interactions,medical and dental students will be lessable to care for patients with complexhealth conditions, to promote oralhealth and address disparities in

vulnerable populations, and to workcollaboratively as members of the samehealth care team for patient care andpublic advocacy.

All curricular innovations support thehealth enterprise’s core ethicalmandate to improve individual andpublic health. Increased recognition ofthe importance of professionalism inboth medicine and dentistry hasaccompanied the changes altering theface of health care.15-18 Underlyingprinciples of ethics and profes-

sionalism must remain the bedrock ofprofessional training, even—orespecially—as the landscape of healthpractice changes. Content in this arenamust be reinforced and revitalized tokeep pace with the challenges ofcontemporary practice. Dental andmedical professionals are equallybound by these tenets.

Attitudes and values, knowledge, andskills, from a consideration of cross-cutting competencies, are listed inTable 1.


Attitudes and Values• Importance of patient and family-

centered health care in medicine anddentistry

• Respect for patients’ diversity and uniquevalue systems

• Commitment to ethical and professionaltenets for physicians and dentists

• Public health values, including diseaseprevention and universal access to healthand dental care

• Need for continual quality improvementand reflective practice

• Importance of lifelong learning• Importance of interprofessional collabo-

ration in patient care and publicadvocacy

• Value and limitations of technology

Knowledge• Patient- and family-centered health care1

• Cultural competency2,3

• Ethics and professionalism4,5 in patientcare, teaching, and research

• Principles of public health6,7

o multiple determinants of healthoutcomes, including oral health(biological, behavioral, environmental,sociocultural, and health system issues)

o risk factors for oral diseaseso existence of oral health disparities

among vulnerable groupso health promotion and disease

prevention measures, including the roleof fluorides

• Principles of continual quality assessmentand improvement

• Critical reading of the biomedicalliterature for evidence-based practice

• Interprofessional collaboration and team care8

• Differences in health profession cultures• Communication and effective referral

across professions• Appropriate community medical and

dental colleagues for referral andprofessional collaboration

• Information management and uses oftechnology9

Skills• Provide patient- and family-centered care• Provide culturally competent care• Exhibit professionalism in all settings• Utilize public health approaches• Promote disease prevention, wellness,

and healthy lifestyles, including oralhealth habits

• Assess patient risk for disease (e.g.,dental caries or oral cancer)

• Advocate for universal access to healthcare, including oral health care

• Apply principles of continual qualityassessment and improvement(from 2003 IOM report)10

• Critically evaluate biomedical literature toinform evidence-based practice

• Provide interprofessional team care• Identify appropriate community medical

and dental professionals for referral andcollaboration

• Effectively apply technology

1 Maternal and Child Health Bureau. Definitions of family-centered care and cultural/linguistic competence, July 17, 2005. At:www11.georgetown.edu/research/gucchd/nccc/documents/RolloutLetter.pdf. Accessed: October 14, 2007.

2 Association of American Medical Colleges, 2005. Cultural competence education. At: www.aamc.org/meded/tacct/culturalcomped.pdf. Accessed: October 14, 2007.3 National Center for Cultural Competence. At: www11.georgetown.edu/research/gucchd/nccc/. Accessed: October 14, 2007.4 Sax HC, ed. Medical professionalism in the new millennium: a physician charter, 2002. Ann Intern Med 2002;136(3):243–246. At: www.annals.org/cgi/reprint/136/3/243.pdf.

Accessed: October 14, 2007.5 Jonsen A, Siegler M, Winslade WJ. Clinical ethics: a practical approach to ethical decisions in clinical medicine. 5th ed. New York: McGraw-Hill, 2002.6 Healthy people 2010, chapter 23: public health infrastructure. At: www.healthypeople.gov/Document/HTML/Volume2/23PHI.htm. Accessed: October 14, 2007.7 Velarde LD, Kaufman A, Wiese W, Wallerstein NB. A public health certificate for all medical students: concepts and strategies. Educ Health 2007;20(1):1–5.

At: http://educationforhealth.net/publishedarticles/article_print_14.pdf. Accessed: October 14, 2007.8 Clark PG. What would a theory of interprofessional education look like? Some suggestions for developing a theoretical framework for teamwork training. J Interprofessional Care

2006;20(6):577–589.9 Association of American Medical Colleges. Contemporary issues in medicine: medical informatics and population health, 1998. At: www.aamc.org/meded/msop/msop2.pdf.

Accessed: October 14, 2007.10 Greiner AN, Knebel E, eds. Health professions education: a bridge to quality. Washington, DC: Institute of Medicine of the National Academies of Science, National Academies

Press, 2003. At: www.nap.edu/books/0309087236/html/. Accessed: October 14, 2007.

Table 1. Attitudes and values, knowledge, and skills from a consideration of cross-cutting competencies

Curriculum and EducationalStrategies

There are at least as many ways toincorporate oral-systemic learningobjectives into medical and dentalschool curricula as there are medicaland dental schools. In the case ofmedical students, specific oral-systemichealth learning objectives can becreated and matched with clinicallyrelevant experiences to enhance oralhealth knowledge and the collabo-ration with dental schools wherepossible. In the case of dental students,greater emphasis on systemic health inrelevant courses, increased interactionwith other health professions, andopportunities to participate as a teammember can help promote thesechanges.

In the area of cross-cuttingcompetencies, curriculumdevelopment can provide the contextfor more interprofessional collabo-ration and, potentially, cost efficienciesfor the involved schools. Someexamples of curricula and educationalstrategies in both oral-systemic contentand cross-cutting competencies areprovided.

Curriculum in Oral-Systemic HealthContentTo optimize learning of new oral-systemic health content for medicalstudents, a spiral curriculum issuggested (i.e., the information isoffered in basic science courses andthen reinforced at successively higherlevels of training and by clinicalexperiences), as has been implementedat the University of Washington Schoolof Medicine19 (Table 2).

Five major themes in oral health wereidentified (public health, caries,periodontal diseases, oral cancer, oral-systemic interactions), as wereassociated curricular elements acrossthe four years of medical school. (Table3 offers an elaboration of the carieslearning objective within the spiralcurriculum.) An oral health elective formedical students was also created,targeting first- and second-yearmedical students. This course addedseveral more themes to the curriculum(handling of dental emergencies andtrauma, oral health issues for patientswith special needs, specific skills inoral screening examination andapplication of fluoride varnishes).20

Another important contribution toidentifying appropriate learningmaterial has been the formulation oforal health content through a Societyof Teachers of Family Medicine projectthat developed oral health contentalong the line of competencies fromthe Accreditation Council on GraduateMedical Education.21

Case Western Reserve School of DentalMedicine is taking the oral-systemiccurriculum overlap to the next level andsimultaneously facilitating interprofes-sional collaboration by allowing studentsto complete foundational knowledge inboth medicine and dentistry. This newprogram will result in the granting ofD.M.D. and M.D. degrees in five years(see http://dental.case.edu/dmdmd/).

New strategies to better integrate oraland systemic learning objectives andpromote interprofessional collaborationinclude alignment of dental schools withother professional schools. Effectivestrategies already employed at someschools include training with physicaland occupational therapy (University ofSouthern California School ofDentistry), incorporating dental trainingwith nursing (New York UniversityCollege of Dentistry), and includingbasic science courses for dental andmedical students (many schools) andlargely common dental and medicalcurricula for the first two years (HarvardSchool of Dental Medicine).



Oral Cancer and Osteoradionecrosis of the Jaw“Nothing prepared me for the destruction that I witnessed on Mr. J’s jawcaused by osteoradionecrosis. His jaw bone melted away on the X-rays until hehad a fractured mandible, all because he had radiation treatment for oralcancer years ago. Mr. J developed root caries on one of his few remainingteeth. It had already advanced into the pulp, and when I saw him for dentalpain, the X-ray showed a large area of bone loss that quickly progressed inspite of our treatment. This experience has shown me that people who havehad radiation therapy for oral and pharyngeal cancer must be carefullyfollowed for preventive dentistry and emerging dental needs. Even years afterthe original cancer treatment, they may be at risk for radiation-associateddental caries and osteoradionecrosis. It is critical that the dentist and theoncology team communicate closely about the care of patients who have hadhead and neck radiation treatment for oral or pharyngeal cancer.”

—Ronald P. Strauss, D.M.D., Ph.D., reflections made while visiting University ofNorth Carolina at Chapel Hill School of Dentistry clinical rotation sites



Goals/Theme Areas Learning Objectives Competencies Targeted Courses for Each OH Theme Area

Public HealthThe medicalstudent graduateswith dental publichealth knowledgeand believes thatoral health (OH) isimportant andphysicians have arole in OH.

Knowledge• Dental public health overviewAttitudinal• OH is important• Physicians have a role in

preventing and recognizingoral disease

• Can describe which patients are atincreased risk for oral diseases(low socioeconomic status/minoritystatus, patients with specialneeds/disabilities, living in rural orunderserved areas)

• Can describe barriers toaccess/utilization of dental services(lack of insurance or providers,cultural/geographic issues, etc.)

• Can describe importance andsafety of public water fluoridation

• Can describe roles physicians canplay in identification/prevention oforal disease

Medicine, Health, and Society• Disparities in oral disease and access,

finance mechanisms, fluoridation and otherpolicy issues, costs of care, role ofphysicians

ICM*• Role of physicians in OHPediatrics/Medicine Clerkships• Populations/patients at risk, role of

physicians in OHChronic Care/Geriatrics• Access to dental care for elderly or special

needs patients

CariesThe medical studentgraduates withknowledge in cariesprevention and canscreen for caries andcollaborate withdentists.

Knowledge• The caries process• Impact of untreated caries

(pain, abscess, cellulitis, airway,other systemic impacts)

• How to prevent cariesAttitudinal• Caries is an important problem.• Physicians should help

prevent/identify caries• Physicians should collaborate

with dentists

• Can describe caries process andsequelae

• Can screen for caries on exam• Can assess risk factors for caries

(socioeconomic status, diet,hygiene, lack of fluoride, caries inmom or sibs of children at risk,meds with sugar or xerostomia,lack of access to dental care)

• Can counsel about caries processand prevention includingdiet/feeding fluoride and oralhygiene (especially brushing withfluoridated toothpaste)

• Can counsel mothers about trans-mission of cariogenic bacteria toinfants and need for maternal OH care

• Can recommend regular dental careand refer to dentists appropriately

Anatomy• Dental anatomyMicrobiology• Oral flora, cariogenic bacteriaICM*• Oral screening examNutrition• Role of diet, fluoride, calcium in cariesPharmacology• Xerostomia and caries riskPathology• Pathogenesis of cariesObstetrics and Gynecology• Maternal transmission of cariogenic bacteriaPediatrics/Medicine Clerkships• Oral exam; patient counseling on diet,

toothbrushing, fluorides; transmission ofcariogenic bacteria; infant nighttimefeedings; smoking; dental referrals

Periodontal DiseaseThe medical studentgraduates withknowledge inperiodontal diseaseprevention andrecognition, and cancollaborate withdentists.

Knowledge• Pathogenesis of periodontal

disease• Impact of periodontal disease

(tooth loss, systemic sequelae)• How to prevent periodontal

diseaseAttitudinal• Periodontal diseases are

important• Physicians should help

prevent/identify periodontaldisease

• Physicians should collaboratewith dentists

• Can describe periodontal disease,sequelae

• Can screen for periodontaldisease

• Can counsel about periodontaldisease prevention(smoking/tobacco; oral hygieneincluding brushing and flossing;role of medications in treating; orpromoting periodontal disease)

• Can recommend regular dentalcare and refer to dentistsappropriately

Anatomy• Oral structuresMicrobiology• Causative organisms in periodontal diseaseICM*• Oral screening examPathology• Pathogenesis of periodontal diseasePharmacology• Impact of medications on gums Obstetrics

and Gynecology• Periodontal disease and adverse pregnancy

outcomes MedicineClerkship• Oral exam; patient counseling: flossing,

dental care/referral, prevention/ cessation ofsmoking, tobacco use, impact of periodontaldisease on systemic health (diabetes,pregnancy outcomes, etc.)

Chronic Care/Geriatrics• Systemic impact of periodontal disease

Table 2. Examples of oral health learning objectives for medical studentsProposed Oral Health (OH) Goals and Learning Objectives for Medical Students, with Targeted Courses,University of Washington School of Medicine, 2005

Service-LearningThe use of service-learning experiencesin underserved communities is onestrategy that both dental and medicalschools have used to promote cross-cutting competencies such as culturalcompetency, professionalism, andsocial responsibility, while providingunique clinical experiences forstudents. Service-learning experiencesin dental schools were boosted by theRobert Wood Johnson Foundationprogram “Pipeline, Profession, andPractice: Community-based DentalEducation.” Augmented by grants fromthe California Endowment and W.K.Kellogg Foundation, the Pipelineprogram has supported service-learning, cultural competency

education, and recruitment/retentionof underrepresented minorities at 15U.S. dental schools.22,23 ColumbiaUniversity College of Dental Medicine,known for its extensive outreachprograms to underservedneighborhoods surrounding theschool, provided the prototype for theRobert Wood Johnson Pipelineprogram.

Other schools providing extendedcommunity-based clinical experiencesfor dental students include theUniversity of Colorado School ofDentistry and the University ofMedicine and Dentistry of New Jersey-New Jersey Dental School. TheUniversity of North Carolina School

of Dentistry includes a service-learning requirement and enhancesthe learning process from theseexperiences by the use of student self-reflection exercises.24 The University ofPittsburgh School of Dentistrymandates a community-servicerequirement for first-year dentalstudents in nondental settings.25 TheUniversity of Washington School ofDentistry’s new RIDE (RegionalInitiatives in Dental Education)program will combine extendedcommunity clinical rotations withinterprofessional education for dental,medical, and dental hygienestudents.26 The RIDE program buildson the successful WWAMI(Washington, Wyoming, Alaska,



Goals/Theme Areas Learning Objectives Competencies Targeted Courses for Each OH Theme Area

Oral CancerThe medical studentgraduates withknowledge of oralcancer risk factorsand can screen fororal cancer andcounsel patients.

Knowledge• Risk factors and early

identification of oralmalignancies

Attitudinal• Oral cancer screening is

important• Physicians should screen

for oral cancer

• Can screen for oral malignancy onexam

• Can assess risk factors formalignancy (smoking,tobacco/alcohol use)

• Can counsel patients aboutprevention strategies(prevention/cessation of smoking,tobacco, and alcohol use)

Medicine, Health, and Society• Disparities in oral cancer ICM• Oral cancer screening examMedicine Clerkship• Oral exam, risk factors, prevention/

cessation of smoking, tobacco, and alcoholuse Otolaryngology clerkship (elective)

• Oral exam, cancer screening ChronicCare/Geriatrics• Exam, risk factors, tobacco/alcohol

Oral-SystemicHealthInter-actionsThe medical studentgraduates withunderstanding ofimportantoral-systemicinteractions and canmonitor for these.

Knowledge• Understand impact of OH

on nutrition• Understand the oral impact of

conditions and medicaltreatments (certain drugs,cancer chemotherapy, AIDS,gastroesophageal reflux, etc.)

Attitudinal• Oral-systemic interactions are

important• Physician should help monitor

for such interactions

• Can monitor impact of OH onnutrition (especially ininfants/elderly and specialpopulations)

• Can monitor oral impact ofmedications, including erosion,caries, and periodontal disease

• Can assess/treat oral conditionsassociated with AIDS,chemotherapy

Nutrition• Interaction between OH and nutrition,

obesityPediatrics, Family Practice, and ChronicCare/Geriatrics• Impact of OH on nutrition; impact of

medical therapies on OH; interactionbetween periodontal disease and systemicconditions (stroke, cardiovascular disease,diabetes, adverse pregnancy outcomes,etc.); oral manifestations of systemicdisease

Continued Table 2. Examples of oral health learning objectives for medical studentsProposed Oral Health (OH) Goals and Learning Objectives for Medical Students, with Targeted Courses,University of Washington School of Medicine, 2005

*ICM=Introduction to Clinical Medicine; this course has a major emphasis on examining and interviewing patients.Source: Mouradian W, Reeves A, Kim S, Evans R, Schaad S, Marshall S, Slayton R. An oral health curriculum for medical students at the University of Washington.Acad Med 2005;80: 434-442.



Required/ Elective Year Main Oral Health Content Key Courses(quarter, year of training)

Projected Timeline(year)

Required Preclinical • Teeth, oral structures, innervations

• Caries pathogens, clinical sequelae

• Caries process, sequelae

• Exam and screening for caries

• Xerostomia, meds with sugar

• Role of diet, fluoride, calcium

• OH disparities (caries)

• Head/Neck Anatomy (Fall, 1)

• Microbiology (Spring, 1)

• Pathology (Spring, 2)

• ICM** I, II (Fall/Winter/Spring, 1, 2)

• Pharmacology (Fall, 2)

• Nutrition (Spring, 2)

• Medicine, Health, and Society(Winter, 2)

2004*

2004

2006

2004*

2005–06

2006

2004

Clinical • Cases with caries, oral screening exam,counseling, access issues, referral fordental care

• Transmission of cariogenic bacteria;emesis and dental erosion; establishinggood maternal and infant OH practices

• Caries as chronic diseasemanagement; oral problems of elderly

• Pediatrics (varies, 3) andFamily Medicine (varies, 3)

• Obstetrics and Gynecology(varies, 3)

• Chronic Care/Geriatrics(varies, 4)

2001*

TBD†

2005–06

TBD†

Electives‡ Preclinical • Disparities, fluoride varnishes

• Also dental emergencies, normaldental development, cleft lip andpalate, common oral pathology, riskassessment, mechanism of action offluorides, oral-systemic issues, specialpopulations

OH elective (Spring, 1,2) 2005

Clinical • Dental clinic exams,history, fluoride varnishes,assisting/dental residents and faculty

OH elective (varies, 2, 3) 2006–07

Table 3. Spiral curriculum example for medical student learning objectives for cariesTargeted Courses for the “Caries Sequence” Oral Health (OH) Content, Key Courses, and Projected Timeline for OH Curriculum,University of Washington School of Medicine, 2005

The Caries Sequence is one of the five theme areas (goals) of the curriculum. See Table 2 for a description of all five areas.*Some courses already included part or all of the OH content.**ICM=Introduction to Clinical Medicine; this course has a major emphasis on examining and interviewing patients.†TBD=To be determined.‡Other elective courses may also be targeted for inclusion of OH information such as electives addressing vulnerable popula¬tions, rural health issues, culturalcompetency, etc.Source: Mouradian W, Reeves A, Kim S, Evans R, Schaad S, Marshall S, Slayton R. An oral health curriculum for medical students at the University of Washington.Acad Med 2005;80:434-442.



Montana, Idaho) program for regionaland community-based medicaleducation at the University ofWashington School of Medicine.27

Many more examples exist of efforts bymedical and dental schools to supportcross-cutting competencies. It is hopedthat this report will promote furtherdevelopment and sharing of these sucheducational innovations.

Educational Methods

Educational methods are suggested bycontent area and level of the learner.For example, basic science learningobjectives in oral-systemic topics forfirst- and second-year students lendthemselves to didactic sessionssupported by online learning materialsand visual aids, with case presentationsand examples for relevance asappropriate. Clinical sciences add morecase examples and eventually patientcases to didactic materials.

Development of cross-cuttingcompetencies, including interprofes-sional collaboration, must emphasizeexperiential methods. Ideally, studentsfrom the different health professionswill participate in experiential activitiestogether, such as small-group and casediscussions, role-playing, and jointservice-learning experiences. Otheractivities include self-assessment andself-reflection, journaling, and usinginteractive online materials whereavailable. Case examples shouldinclude oral and systemic componentsto increase the relevance for dental andmedical students, respectively; otherhealth profession examples could alsobe included in cases, and thesestudents could be included in service-

learning experiences as well. Theseobjectives should also be reinforcedthrough a spiral curriculum, withrelevance reinforced by case examplesthat integrate specific medical anddental course content.

Similarly, assessment approaches mayalso be developed by content type andlevel of the learner. Multiple-choicetests may be appropriate in basicscience courses, while more probingquestions geared to case examples willbe more appropriate for clinicalmaterials. Skills in culturalcompetency and communication canbe demonstrated through directobservation in clinical encounters andobjective-structured clinicalexaminations (OSCEs). Educationalapproaches should be consistent withprinciples of adult learning that stressexperiential learning, learner self-assessment, and integration ofmaterial into the learner’s previousknowledge base.

InterprofessionalCollaboration

The attitudes associated with interpro-fessional collaboration—especiallymedical-dental collaboration—will beserved by bringing medical and dentalstudents together wherever possible.Institutions where dental and medicalschools are both located often sharebasic science courses, as mentionedearlier. However, these opportunitiesare just the beginning of possibleopportunities for shared learning, fewof which have been tried. Assuggested, some experiences mightinclude pairing medical and dentalstudents in service-learning sites.Others might include rotations indental clinics for medical students androtations in medical clinics and onhospital rounds for dental students.Since there are fewer than half asmany dental schools as medicalschools, strategies involving both

Oral Health Manifestations of Methamphetamine Addiction“When I visited our dental students on extramural rotation at the StateCorrectional Institution, I was shocked by the number of patients I saw in theprison dental clinic who have ‘meth mouth.’ This is a condition in whichaggressive dental caries occurs among persons who have a substance abuseproblem with methamphetamine. It was easy to imagine that it would be nearlyimpossible for these patients to return to the community and find employmentunless they got treatment for their addiction and also received dental rehabili-tation. In a rural state like this, it is amazing to realize how quickly metham-phetamine addiction has spread in nonurban settings; it is a true epidemic. Oneof the most startling aspects is how the characteristic oral deterioration canstigmatize the affected person even after the addiction has been managed. Thismade me think about how the social and psychological issues surroundingsubstance abuse may be compounded by oral health declines. For many ofthese individuals to return to productive community lives, they will require costlyoral care to take them out of pain and restore their appearance and dentalfunction; this is part of the process of rebuilding self-esteem.”

—Ronald P. Strauss, D.M.D., Ph.D., reflections made while visiting University ofNorth Carolina at Chapel Hill School of Dentistry clinical rotation sites



medical and dental students will belimited in some locales. However, itshould be possible to provide medicalstudents with rotations in communityhealth centers containing dentalclinics, in hospital-based dental clinics,or in private dental offices. Wheremedical and dental students are co-located, there are opportunities forinnovative, joint learning experiencesin cross-cutting competencies such ascultural competency andethics/professionalism, as well as inbasic medical and oral healthinterviewing and examination skills. Insome cases, joint electives may beoffered for additional curriculum intopical areas (e.g., public health,complementary and alternativemedicine). Dental students could alsomentor medical students in certainoral health skills, such as oral screeningand application of fluoride varnishes.20

Faculty Development

Faculty development presentssignificant challenges. Few medicalfaculty members have received anytraining in oral health. However, thoseworking in primary care fields ofpediatrics and family medicine—bothof which have included oral healthcompetencies in some portion ofrequired training—often appreciate theimportance of oral health issues andtheir predominance in underservedpopulations. Faculty in oncology orgenetics and those who participate inoral surgery involving the craniofacialcomplex (craniofacial plastic surgeons,otolaryngologists) or who see patientsin emergency rooms will also havesome overlapping areas of expertisethat can be tapped for medical studenttraining. Resources to support medicalfaculty may be found in some hospitals

and in regional or hospital-basedcraniofacial teams, even when there arenot co-located dental schools.

Dental school faculty who work indepartments of oral medicine, oral andmaxillofacial surgery, and periodon-tology typically will have moreexpertise in systemic health issues andcan provide leadership within thedental schools. An even larger numberof faculty members of co-locatedmedical and dental schools will be ableto provide resources for teaching theoral exam in the medical curriculum.

Faculty in pediatric dentistry, specialneeds, or geriatrics programs generallywill be familiar with many of thesystemic medical issues as well associocultural and ethical issues in thecare of vulnerable populations. Alldental schools are required to have some

Bisphosphonate Drug-Related Osteonecrosis of the Jaws“When Ms. L, a patient with advanced breast cancer, came to the dental clinic for an emergency visit, she complained of apainful tooth root ‘erupting’ in her lower jaw where an abscessed tooth had been pulled over a year ago. On examination,it was apparent that there was no tooth root in this area. Rather, she had necrotic exposed bone protruding towards hertongue. Her medical oncologist had been managing her metastatic bone disease with the intravenous bisphosphonatezoledronic acid for several years. Bisphosphonate-associated osteonecrosis of the jaws is a newly described, postmarketing, adverse effect of this class of osteoclast-inhibiting drugs that creates significant morbidity and has noestablished effective treatment. Concomitant poor oral hygiene and periodontal disease may play a role in itsdevelopment. New guidance from the dental, medical, and pharmaceutical communities suggests that prevention is of theutmost importance and involves coordination between the medical oncologist and dentist with optimizing oral health priorto implementing intravenous bisphosphonate use and continued oral health maintenance. Although thought to be a rareadverse event, numerous women are taking oral bisphosphonates such as alendronate and ibandronate for osteoporosisprevention, and cases are now being seen among this group.”

—Lauren L. Patton, D.D.S., Professor, Department of Dental Ecology, University of North Carolina at Chapel HillSchool of Dentistry



curriculum in the behavioral sciencesand the ethical and legal aspects ofdentistry; faculty in these courses mightbe tapped to strengthen teaching andassessment in this area. Collaborationbetween medical and dental faculty andjoint appointments will augment theresources available for teaching thesetopics. Critically, administrativeleadership is needed, or at least buy-in,before such initiatives can be launched.It is hoped that this report will serve asan impetus for such changes. It is oftenuseful to identify a faculty “champion”with interests in the respective areas whocan provide leadership and advocacy forsuch changes.

Towards a SharedResponsibility for OralHealth

The challenges in faculty developmentreflect the larger medical and dentalcultures that have separated oral healthfrom overall health for more than acentury. This schism has, for the mostpart, been widespread despite theobvious common scientificfoundations and missions of bothfields. It has played out in journals,scientific meetings, sites of practice,and health insurance systems. As aresult, physicians have not consideredoral health in their domain, anddentists have not considered overallhealth issues as their responsibility.New scientific data on oral-systemic

linkages and the drive to ameliorateoral health disparities are shifting thisperception, calling for more collabo-rative approaches. Although numerousefforts have been geared at educatingnondental health professionals in oralhealth issues, relatively few efforts havetargeted medical and dental studentsand the specific educationalcomponents that can help themunderstand each other’s professionsand collaborate better to improveindividual and public health. Thepanel hopes that the recommendationsarticulated in this report will serve tosupport increased collaborationbetween the dental and medicalprofessions as they work towardaccepting a shared responsibility forthe oral health of the public.



Oral Health Education Expert Panel

Wendy Mouradian, M.D., M.S. (co-chair)Director, Regional Initiatives in Dental Education (RIDE)University of Washington School of Dentistry

Charles N. Bertolami, D.D.S., D.Med.Sc. (co-chair)Dean, University of California, San Francisco School of Dentistry(currently Dean, New York University College of Dentistry)

Carol A. Aschenbrener, M.D.Executive Vice PresidentAssociation of American Medical Colleges

Sonia J. Crandall, Ph.D., M.S.Professor, Family and Community MedicineWake Forest University School of Medicine

Ronald M. Epstein, M.D.Professor and Associate Dean for Educational Evaluation and ResearchUniversity of Rochester School of Medicine and Dentistry

Marcio da Fonseca, D.D.S., M.S.Clinical Assistant Professor of Pediatric DentistryNationwide Children’s Hospital

N. Karl Haden, Ph.D.President, Academy for Academic Leadership

Alexis L. Ruffin, M.S.Director, Curriculum Innovation InitiativesAssociation of American Medical Colleges

James J. Sciubba, D.M.D., Ph.D.Professor, Otolaryngology and Head and Neck SurgeryJohns Hopkins School of Medicine

Susan Silverton, M.D., Ph.D., B.Sc.Academic Vice-President and ProfessorLaurentian University

Ronald P. Strauss, D.M.D., Ph.D., M.S.Distinguished ProfessorUniversity of North Carolina at Chapel Hill School of Dentistry

Lisa Tedesco, Ph.D.Vice-Provost for Academic Affairs–Graduate Studies and Dean of the Graduate SchoolEmory University



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