Presentation File

Interdisciplinary Children’s Oral Health Promotion (ICOHP)

University of WashingtonSupported by a cooperative agreement from the Bureau of Health Professions,

Health Resources and Services Administration

Additional Support

UW Comprehensive Center for Oral Health Research (NIDCR at NIH)

UW Center for Health Sciences Inter-professional Education and Research (UW and Macy Foundation)

UW Department of Pediatrics

UW Department of Pediatric Dentistry

UW Department of Dental Public Health Sciences

Partnership

Department of Pediatric Dentistry

Department of Family Medicine

UW Family Practice Residency Network

Department of Medical Education and Bioinformatics

Team Representation

Wendy Mouradian, MD, MS (PI) Pediatrics, Pediatric Dentistry, Health

Services (Public Health)

Penelope Leggott, DDS, MS Pediatric Dentistry

Sara Kim, PhD Family Medicine, Medical Education

ICOHP Team

Wendy Mouradian, MD, MS, Principal Investigator

Robert Crittenden, MD, MPH

Peter Domoto, DDS, MPH

Penelope Leggott, DDS, MS

Charlotte Lewis, MD, MPH

Heather Lynch, MD

Russell Maier, MD

Nancy Stevens, MD, MPH

ICOHP Team

Project Evaluation

Doug Schaad, PhD

Sara Kim, PhD

Additional Consultants

Diana Cantrell, RN

Noel Chrisman, PhD, MPH

Cristine Trahms, RD, MS

Project Staff

Cheryl Shaul

Linda Yedlin

Advisory Board

University/ community rep: Dec 2002

Positive response

Interest in expanding trainings to other target audience

Interest in models of sustainability at the community level

Interest in Web review project

ICOHP

Goal 1: Train family medicine residents and faculty in oral health

Objectives:

Develop curricula in children’s oral health

Pilot, implement, disseminate

Evaluate effect of training on knowledge, attitudes, behavior

ICOHP

Goals 2 and 3:

Explore sustainable mechanisms for training and delivery of oral health services

Develop leadership in primary care fields to advance oral health

University of Washington

Health Sciences Center for WWAMI:WashingtonWyomingAlaskaMontana IdahoAlmost 30% land mass of US

UW FP Residency Network: Sites

Alaska

WashingtonMontana

Idaho

Wyoming

Family Practice Residency

Affiliation Under Negotiation

Rural Training Track

Spokane*UW*

Yakima*

Boise

Olympia

Anchorage

Billings

UW FP Residency Network: Graduate

Distribution

Geographical barriers

Cultural factors

Racial & Ethnic Diversity

ICOHP Pilot Training Site

Alaska

WashingtonMontana

Idaho

Wyoming

Yakima

Yakima, WashingtonCentral Washington Family

Medicine

N = 18

Choice of Pilot site

High need area; typical of Network sites

Receptive dental community (ABCD)

Community health center (Yakima Valley Farmworker’s Clinic with UW pediatric dental residents on site (HRSA)

Family medicine faculty “champion”

FP Residency Network

Sites to some extent self-sustaining Closer to a typical community practice

Have didactic hours set aside Culture of learning is present

System across 15 sites that connects by intra-net, regular faculty development and communication, staff training

Assumptions

Biggest obstacle will be buy-in

Tailor curriculum to physician needs

Integration with dental sector in community is critical

Sustainability will require additional work and resources

Focus Groups: Faculty/ Residents, Staff

Barriers Oral health not on their radar screen; lack

knowledge/self-efficacy

Providers busy: oral health not a priority

Concerned about the evidence base

Confusion about physician role

Lots of baggage about dentists

Focus Groups: Faculty/ Residents, Staff

Opportunities Care about children in pain

Unable to answer parents’ questions

Prevention is a high priority

Already providing health education

Acutely aware of access issues, emergencies

Committed to underserved

Training Strategy

Address barriers and opportunities

Increase motivation Oral health important Impact on children

Increase practitioner knowledge Normal dental development Caries process

Training StrategyReview evidence base (USPSTF; CDC

Fluoride recommendations)

Frame in terms of primary care roles: Anticipatory guidance Nutrition/feeding Injury prevention; emergency management Special issues for CSHCN

Training StrategyApply principles of family-centered,

culturally competent care already part of residency culture / training

Involve dental practitioners partner with ABCD, community health

clinics, pediatric dental trainees Increase communication, lines of referral

Modules* Module 1: Public Health Overview; Oral

Health Promotion and Practice Module 2: Normal Dental Development/

Pathology Module 3: Dental Caries; Collaborating with

Dentists Module 4: Dental Trauma and Emergencies Module 5: Oral-systemic Health Interactions

*Approximately 1 hour each including Q&A

Additional Modules Requested

Atraumatic Restorative Technique

Maternal oral health (planned)

Module 1: Learning Objectives

After completion trainees will:

1. Understand public health context of children’s oral health

2. Understand evidence base in children’s oral health

3. Provide culturally competent, family-centered oral health care

4. Engage in “public health practice” in primary care

Key Public Health PointsProvide rationale for oral health training:1. Disparities in oral health:

Need to work with under-served communities

2. Science of caries prevention:Need to reach children early

3. Dental workforce shortages:Need to prevent disease in primary care

4. Education gaps:Need for primary care training programs

WA Smile Survey 2000: Children with Early Childhood Caries

10

19

8

0

2

4

6

8

10

12

14

16

18

20

Percent of Children

Washington1-year-olds

(10%)

Washington2-year-olds

(19%)

NHANES III2-year-olds

(8%)

10

19

8

WA Smile Survey 2000: Trends (Phipps et al)

19.2

40.7

Sealants

46.0

54.6

Caries Experience

16.921.6

Untreated Decay

1994

0

10

20

30

40

50

60

Per

cen

t o

f C

hild

ren

2000

Module 3: Caries and Collaborating with

DentistsAfter completion trainees will:1. Understand the caries process (ECC)

2. Understand PCP’s role in oral health care

3. Assess risk, take brief oral history

4. Recognize caries on an oral exam

5. Apply fluoride varnishes

6. Make appropriate dental referrals

7. Provide appropriate anticipatory guidance

Primary Care ProvidersRole in Preventive Oral Care:

1. Anticipatory guidance/ counseling

2. Oral screening exam

3. Risk assessment (includes oral history)

4. Applying fluoride varnish

5. Dental referral / collaboration

6. Monitor oral-systemic health interactions

7. Manage simple dental trauma

[8. Maternal oral health counseling]

Additional support in Yakima

Hands on training for varnishes

Pediatric dental resident on site weekly for first 6 months

Reference materials

Close contact with ICOHP team

ABCD providers to accept referrals

Year 2-3

Trainings in Olympia, Boise, Alaska, ? Montana

Evaluation in progress in all sites

Mesh with community or statewide oral health plans when possible (ie, Idaho, AK)

Disseminate through intra-net

Continued leadership in primary care

ICOHP Training Sites

Alaska

WashingtonMontana

Idaho

Wyoming

Seattle

Seattle (UW)

Feb 2003

N = 8 (R 1’s)

ICOHP Training Sites

Alaska

WashingtonMontana

Idaho

Wyoming

Spokane

Spokane, Washington

Feb 2003

N = 27

ICOHP Training Sites

Alaska

WashingtonMontana

Idaho

Wyoming

Olympia

Anchorage

Boise

Future trainings

APRIL, 2003

Olympia, WashingtonN = 17

Boise, IdahoN = 27

Anchorage: Train the trainer

Dec 2002

(N = 24)

What have we learned

We can teach it: knowledge, attitudes and self-efficacy shift

Taps into training need in underserved communities

Family practitioners v pediatricians

Long term evaluation needed

Fiscal issues loom large

CaveatsMedical and dental training models differVocabularies, conceptual frames differShifting priorities in medical settingDiagnosis and management, risk

assessment, medical vs dental conditionsHow to determines content of curriculum

and framing for medical audience? FM desire oral health knowledge for older

patients

Unexpected outcomes Leverage opportunities with other HRSA grants Family medicine /pediatric dental residents work

well together Family Medicine Network cultural change Expanded interest in oral health in the UW

(educational research; public/rural health area) Best Practices review expanded into Web review

project Political battles less apparent at local level Interest in curriculum outside of WWAMI region

Strategies for Success FACULTY CHAMPION Ensure buy in: frame for PCPs Address barriers: logistics, knowledge, attitudes Create / reinforce dental collaborations

Use pediatric dental residents for training

Identify other stakeholders Evaluate impact Plan for sustainability

Review of Web Resources:Purpose

To identify /review Web resources in pediatric oral health for primary care physicians

To develop strategies for designing Web-based training tools for primary care physicians.

Future Directions

Sustainability at community level: partner with local health depts

Move down educational level – medical school family practice clerkships

Regional center for training trainers Important educational research questionsCreation of WEB site

Future Directions

Longer term follow up needed: evaluation study

Train RNs, PAs, othersSustainability within AHC

Module 2: Normal Dental Development

After completion trainees will:

1. Examine the teeth of young children

2. Know the names/number of teeth, basic tooth anatomy

3. Differentiate normal from abnormal eruption

4. Identify causes of tooth discoloration

Module 4: Dental Trauma and Emergencies

After completion trainees will:1. Understand causes/ mgt dental pain2. Identify and manage simple dental infections3. Identify and manage simple tooth injuries 4. Know complications of dental injury/infection5. Understand when to refer injury/infection6. Counsel families to decrease injury risk

Module 5: Oral Systemic Health Interactions

After completion trainees will: 1. Understand why CSHCN are more vulnerable to oral disease/access problems2. Recognize systemic impact of oral disease3. Recognize the impact of systemic disease/

medical therapies on oral health, dental care 4. Recognize and manage common oral lesions5. Refer appropriately