Nurse practitioners (NPs) are a significant segment of the US primary care workforce and have a pivotal role in improving access to oral health (OH) care. The purpose of this research was to assess OH curricular integration in primary care NP programs and to examine factors that influence integration and satisfaction with graduates' level of OH competence.
A cross-sectional, national survey of NP programs (N = 466) was conducted using an electronically distributed 19-item, self-administered questionnaire. Data analysis included univariate, bivariate, multivariate statistics, and logistic regression modeling.
The large majority of pediatric, family, and adult-gerontology primary care programs are educating NP graduates about OH. Significant factors promoting integration and satisfaction with graduates' level of competence included the presence of a faculty champion and routine teaching by a dental professional or nondental OH expert.
IMPLICATIONS FOR PRACTICE:
With adequate OH education, NPs are ideally positioned to integrate OH and primary care services in practice, thereby, improving access to OH care.
BACKGROUND AND OBJECTIVES: National initiatives have encouraged oral health training for family physicians and other nondental providers for almost 2 decades. Our national survey assesses progress of family medicine residency programs on this important health topic since our last survey in 2011.
METHODS: Family medicine residency program directors (PDs) completed an online survey covering various themes including number of hours of oral health (OH) teaching, topics covered, barriers, evaluation, positive influences, and program demographics.
RESULTS: Compared to 2011, more PDs feel OH should be addressed by physicians (86% in 2017 vs 79% in 2011), yet fewer programs are teaching OH (81% vs 96%) with fewer hours overall (31% vs 45% with 4 or more hours). Satisfaction with the competence of graduating residents in OH significantly decreased (17% in 2017 vs 32% in 2011). Program directors who report graduates being well prepared to answer board questions on oral health topics are more likely to have an oral health champion (P<0.001) and report satisfaction with the graduates’ level of oral health competency (P<0.001). Programs with an oral health champion, or having a relationship with a state or national oral health coalition, or having routine teaching from a dental professional are significantly more likely to have more hours of oral health curriculum (P<0.001).
CONCLUSIONS: Family medicine PDs are more aware of the importance of oral health, yet less oral health is being taught in residency programs. Developing more faculty oral health champions and connecting programs to dental faculty and coalitions may help reduce this educational void.
Oral health (OH) has received increased recognition for almost 2 decades as an important health topic. Dental caries cause local pain and infections, have important social implications such as missed school and failure to gain employment, and can even lead to death.1 In addition, periodontitis influences systemic illness such as heart disease, pregnancy outcomes, and autoimmune disorders.2 In fact, one study shows that dental treatment of periodontitis alone can reduce hospitalizations for diabetic patients by 39%.3
In 2000, the Surgeon General Report stimulated interest in oral health.4 David Satcher concluded with a clear statement, “You are not healthy without good oral health.” In 2003, another report, A National Call to Action to Promote Oral Health, encouraged physicians to address oral health in their patients.5 By 2005, family medicine program directors (PDs) were acknowledging the importance of OH. In a nationwide study, 95% felt it was their responsibility to train residents to identify oral health problems; 87% indicated they would implement modules if they existed, and a 4-hour curriculum was the average amount of time PDs felt their residents should devote to OH training.6 Also in 2005, family doctors formed a Group on Oral Health at the Society of Teachers of Family Medicine (STFM), and created a curriculum called Smiles for Life: A National Oral Health Curriculum funded by DentaQuest Foundation and others.7 In 2011, family medicine residency PDs were resurveyed. While only 72% of PDs now felt it was important to address OH issues, 96% of programs had some OH curriculum. And while only 45% had 3 or more hours of OH training, 74% were aware of Smiles for Life (SFL) and 22% were using it for teaching.8
Meanwhile, national oral health efforts continued to evolve. In 2011, the Institute of Medicine (IOM) issued two reports on this subject amplifying that nondental health professional training programs should have well-defined OH competencies and curricula.9,10 The Accreditation Council for Graduate Medical Education (ACGME) added oral health care requirements for family medicine in 2006 with the aim of promoting increased resident training in oral health11 (but by 2015, they removed them when streamlining requirements).12 Meanwhile, other specific movements have positively affected family medicine. Qualis Health made it a priority for OH to have a key role in medical homes and piloted systems approaches in Federally Qualified Health Centers (FQHCs).13,14,15 STFM added oral health topics in the Family Medicine Residency Curriculum Resource and the American Academy of Family Physicians created an Oral Health Member Interest Group.16,17 Finally, in 2014 the US Preventive Services Task Force (USPSTF) designated the application of fluoride varnish by medical providers a level B recommendation for children under the age of 6 years,18 which led to all 50 states reimbursing pediatric primary care providers to perform fluoride varnish.19
Our study assesses the impact over the last 5 years of the above-noted efforts and the influence on oral health care training in family medicine residency programs nationwide. We are unaware of any other studies of this impact over this time period. We aimed to learn what OH topics family medicine residency programs are currently teaching, how much they are teaching, how they evaluate this teaching, influences on the quality and quantity of curriculum, and resource materials being used. Our research is a project of the recently formed Center for Integration of Primary Care and Oral Health (CIPCOH), a joint endeavor of the Harvard Schools of Medicine and Dental Medicine and the University of Massachusetts Medical School’s Department of Family Medicine and Community Health.