Oral Health and Interprofessional Education Experiences in Family Medicine and Pediatric Residency

INTRODUCTION Prevention of dental diseases in children requires interprofessional education (IPE) and care coordination between oral health professionals and primary care providers; however, the extent of preparation of medical residents and its impact on their provision of preventive oral health services in clinical practice requires further investigation. METHODS A two-stage cluster sample of 470 US family medicine and 205 pediatric residency programs was used. A random sample of 30% (N=140) of family medicine and 29% (N=60) of pediatric residency programs were randomly selected. Of these, 42 programs (21%) invited residents to participate. Residents (N=95, 28%) completed an online questionnaire regarding oral health training in residency. Statistical analysis included frequencies and Spearman’s rank correlations. RESULTS Eighty-three percent of family medicine and pediatric residents combined reported receiving oral health education. Clinical experiences involving oral healthcare were frequently reported (77%, n=75); however, IPE with an oral health professional was limited. Both groups indicated they provided anticipatory guidance regarding regular dental visits and toothbrushing “very often” and avoiding bottles at bedtime “often.” Residents reported performing dental caries assessments “often” and applying fluoride varnish “occasionally.” For family medicine residents, moderate correlations (p ≤ 0.01) were found between hours of oral health education and providing anticipatory guidance. For pediatric residents, a moderate correlation (p < 0.01) was found between hours of oral health education and assessing teeth for demineralization. CONCLUSION Increased effort is needed to meet national recommendations for educating family medicine and pediatric residents regarding oral healthcare for children, including increased IPE involving oral health professionals. Received: 05/25/2015 Accepted: 08/28/2015 Published: 10/22/2015 © 2015 Bailey et al. This open access article is distributed under a Creative Commons Attribution License, which allows unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. H IP & Oral Health and Interprofessional Education ORIGINAL RESEARCH 2(3):eP1081 | 2 Introduction Oral health is a vital component of overall health and, therefore, the responsibility of pediatricians. Accordingly, the American Academy of Pediatrics (AAP) recommends pediatricians play an integral role in children’s oral health by providing preventive oral health services including anticipatory guidance, oral health screenings and assessments, and fluoride varnish applications during well-child visits (AAP, 2014). This recommendation applies not only to pediatricians but to other primary care providers (PCP), such as family physicians, nurse practitioners, and physician assistants (PA) (National Interprofessional Initiative on Oral health [NIIOH], 2011). In 2014, the U.S. Preventive Services Task Force (USPSTF) recommended PCP prescribe fluoride supplementation to children beginning at 6 months of age if they reside in areas with suboptimal fluoride concentration in the drinking water and provide fluoride varnish applications to all children beginning at eruption of the first tooth (USPSTF, 2014). In support of these recommendations, medical insurers are requir-ed to reimburse providers under the Affordable Care Act (ACA) for services assigned a grade A or B by the USPSTF. This reimbursement includes fluoride varnish applications for children ages 0-5 years (Kaiser Family Foundation [KFF], 2014). These national children’s oral health initiatives coincide with the recent emphasis on integrating interprofessional education (IPE) opportunities across the healthcare professions to improve the health of the nation and overall quality of care (Institute of Medicine [IOM], 2011). IPE opportunities involving oral health experts such as dental hygienists, dentists, and/or dental professional students are integral to effectively train PCP to de-liver preventive oral health services to children. Little is known about IPE opportunities involving dental professionals in family medicine and pediatric residencies. Patients of all ages experience needless dental diseaserelated pain and expense, in part, because their PCP has not been trained to provide preventive oral health services (NIIOH, 2009). The general health status of children and adolescents can be improved by prevention and early intervention of oral diseases, including dental caries, before they develop into more complicated Implications for Interprofessional Practice


Introduction
Oral health is a vital component of overall health and, therefore, the responsibility of pediatricians.Accordingly, the American Academy of Pediatrics (AAP) recommends pediatricians play an integral role in children's oral health by providing preventive oral health services including anticipatory guidance, oral health screenings and assessments, and fluoride varnish applications during well-child visits (AAP, 2014).This recommendation applies not only to pediatricians but to other primary care providers (PCP), such as family physicians, nurse practitioners, and physician assistants (PA) (National Interprofessional Initiative on Oral health [NIIOH], 2011).In 2014, the U.S. Preventive Services Task Force (USPSTF) recommended PCP prescribe fluoride supplementation to children beginning at 6 months of age if they reside in areas with suboptimal fluoride concentration in the drinking water and provide fluoride varnish applications to all children beginning at eruption of the first tooth (USPSTF, 2014).In support of these recommendations, medical insurers are requir-ed to reimburse providers under the Affordable Care Act (ACA) for services assigned a grade A or B by the USPSTF.This reimbursement includes fluoride varnish applications for children ages 0-5 years (Kaiser Family Foundation [KFF], 2014).
These national children's oral health initiatives coincide with the recent emphasis on integrating interprofessional education (IPE) opportunities across the healthcare professions to improve the health of the nation and overall quality of care (Institute of Medicine [IOM], 2011).IPE opportunities involving oral health experts such as dental hygienists, dentists, and/or dental professional students are integral to effectively train PCP to de-liver preventive oral health services to children.Little is known about IPE opportunities involving dental professionals in family medicine and pediatric residencies.
Patients of all ages experience needless dental diseaserelated pain and expense, in part, because their PCP has not been trained to provide preventive oral health services (NIIOH, 2009).The general health status of children and adolescents can be improved by prevention and early intervention of oral diseases, including dental caries, before they develop into more complicated

Implications for Interprofessional Practice
This study: • Serves as a current assessment of the level of interprofessional education within the oral health training of family physicians and pediatricians.
• Emphasizes the importance of primary care providers and oral health professionals working together in an interprofessional approach for the overall health of the nation's children.
• Emphasizes the need for family medicine and pediatric residency programs to continue to increase implementation of national recommendations and interprofessional education into clinical practice.
• Suggests a need for increased collaboration among dental hygienists, dentists, and dental professional students within the interprofessional education and oral health training of primary care providers and provides an educational model designed to foster that goal.Charitable Trust, 2014).IPE for these providers on the front line of children's healthcare provides an opportunity to expand access to preventive care.Limited evidence suggests that IPE experiences can impact the delivery of preventive oral health services in the daily practices of family medicine and pediatric residents.A pilot study by Gonsalves, Skelton, Smith, Hardison, and Ferretti (2004)  health training including IPE experiences with an oral health professional and the provision of preventive oral health services to children needs further examination.The purpose of this study was to determine family medicine and pediatric residents' self-reported experiences regarding: 1) oral health education in residency, 2) type of instruction including IPE, and 3) whether a relationship exists between the delivery of preventive oral health services during well-child visits and the total number of hours of oral health education.

Methods
An online survey was adapted from the 2006 AAP Annual Survey of Graduating Residents (Caspary et al., 2008) and the survey developed by Lewis et al. (2009).
The content was validated by five experts in IPE and/ or the development of oral health education for PCP.
Recommendations from the experts were incorporated in the final survey instrument.In addition, test-retest reliability was established by family medicine residents (n=4) from the university affiliated with the study.
Results indicated reliability (r=0.93) between the two surveys completed one week apart.This adapted, validated instrument was used to assess the family medicine and pediatric residents' self-reported total number of oral health education hours received during residency, type of instruction received, and frequency of delivering preventive oral health services during well-child visits.
A simple two-stage cluster sample of 470 family medicine and 205 pediatric residency programs was used.In the first stage, 30% of U.S. family medicine programs (N=140) and 29% of U.S. pediatric residency programs (N=60) were randomly selected for inclusion using an online research randomizer.
After receiving a Certificate of Exemption from the sponsoring university's Human Subjects Committee, all third-year residents enrolled in the randomly selected programs were invited to participate in the study, pending assistance by the program director or residency coordinator.Program contact information was obtained from the Accreditation Data System list managed by the ACGME (2013); each program was assigned a code for confidentiality.
Individual e-mails were sent to all program contacts to garner support for the study and personalize the invitation to facilitate data collection (Dillman, Smyth, & Christian, 2009).The e-mail communication provided a description and study purpose, encouraging the program's contact person to forward the study consent form and online survey link to thirdyear family medicine or pediatric residents.A reply regarding willingness to forward the study materials to residents and the number of third-year residents enrolled was requested.The total number of enrolled third-year residents was used to determine an accurate response rate for the second stage cluster sample of residents.Several attempts were made to follow up with non-respondents via email, telephone, and messages.
The online survey link was e-mailed to program contacts willing to invite third-year residents' participation.
An online survey platform, Qualtrics, was used to collect data from third-year family medicine and pediatric residents.Residents accessed the online survey instrument, instructions, and informed consent through a forwarded e-mail from their program contact.A drawing for a $300.00Amazon gift card was offered to the program contacts and the third-year residents as an incentive to participate in the study.
After the residents elected to participate, and completed the online informed consent form and online survey, each was asked to voluntarily provide the name of the residency program where they were enrolled.They were assured this information would be coded and kept confidential.The final participant response rate was determined utilizing the number of enrolled thirdyear residents provided by each program contact and the number of online survey responses received.
Statistical analysis included descriptive statistics for participant demographics.Percentages and frequencies were used to summarize residents' responses in relation to the amount and type of learning activities received in their oral health education.Spearman's rank correlation coefficient was computed to identify relationships between frequency of the delivery of oral health services and the total number of hours spent in oral health education.

Results
Response rates for the residency programs that facilitated delivery of the online survey to their thirdyear residents were 21% (N=42 of 201) for all programs combined, 14% (n=20 of 141) for family medicine residency and 37% (n=22 of 60) for pediatric programs.
Response rates for the third-year resident participants were 28% (N=95 of 336) for all residency programs combined, 36% (n=38 of 105) for family medicine, and 25% (n=57 of 231) for pediatric.Two responses were not included because the participants completed only the demographics portion of the survey.
Table 1 presents demographic data for the sample of third-year residents.The average age of respondents was 30.5 years, ranging from 28 to 40 years.The majority of the participants reported their race as White, non-Hispanic (75.8%, n=72).Survey question options and responses regarding race are listed in Table 1.Gender was not included in the demographic data due to a malfunction in the online survey program for that item.
Eighty-three percent of all third-year family medicine (n=38) and pediatric (n=57) residents reported receiving some type of oral health education in the residency program.Percentage of participants reporting no oral health education during residency were 17% (n=16) for all respondents, 32% (n=12) for family medicine residents, and 7% (n=4) for pediatric residents.Although 45% (n=17) of the family medicine residents (n=38) and 42% (n=24) of pediatric residents (n=57) reported receiving 1 to 3 hours of oral health instruction, the median number of hours reported was 1 to 3 hours for family medicine, 4 to 6 hours for pediatrics, and 1 to 3 hours for all third-year residents combined (Table 2 (following page).
Tables 3 and 4 (following page) report frequency of the type of oral health instruction received during residency including classroom, community, and clinically based activities.The most frequent response was 1 to 3 hours of classroom instruction for family medicine (n=15 of 24, 63%) and pediatric (n=35 of 48, 73%) respondents.Clinical activities also were reported frequently.One to    three hours were reported by 46% of family medicine (n=11) and 58% of pediatric (n=29) residents.Both groups included additional respondents reporting more than three hours, indicating a majority of residents in both groups underwent some clinical experience during residency.
Tables 5 and 6 display data summarizing responses of those residents who responded to the items concerning IPE experiences involving an oral health professional or student: 66% of family medicine residents (n=25) and 84% of pediatric residents (n=48).A majority of both family medicine and pediatric residents, respectively, reported having had no exposure to IPE in the classroom (60%, n=15 and 54%, n=26), community, (88%, n=22 and 85%, n=41), or clinical setting (76%, n=19 and 67%, n=32) during their oral health education.Respondents who reported having any type of IPE during their oral health education with an oral health professional most commonly indicated that a dentist was the oral health professional involved.
The median number of family medicine (n=36) and pediatric residents' (n=54) responses regarding the frequency of preventive oral health services during well-child visits is presented in   giving a child juice, sweetened, or carbonated beverages.
Both family medicine and pediatric residents reported "rarely" assessing parents'/caregivers' oral health history.Applying fluoride varnish to children's teeth was reported as "rarely" provided by family medicine residents and "occasionally" provided by pediatric residents.
Spearman's Rank Correlation was used to determine the magnitude and direction of the relationship between reported preventive oral health services provided by participants during well-child visits and the total hours of oral health education reported.Correlation data and p values are presented in Table 8 (following page).
Although several correlations had statistical significance (p < 0.05), the strength of some of the associations were weak.For family medicine residents, total hours of oral health education were moderately associated with providing education to patients and parents/caregivers on the oral health effects of a child sleeping with a bottle with something other than water (r=.566,p < 0.001), importance of regular visits to the dentist (r=.539, p < 0.01) and regular toothbrushing (r=.568, p < 0.001).For pediatric residents, assessing children's teeth for enamel demineralization (r=.435, p < 0.01) during well-child visits was moderately correlated with the total number of hours of oral health education.

Discussion
Family physicians and pediatricians play an important role in children's oral health, especially for those at high risk for dental disease.Notwithstanding an accreditation standard requiring family medicine residency programs provide oral health education and numerous available online CME-approved courses, 32% of family medicine respondents reported receiving no oral health education during residency.The median response regarding total number of hours by family medicine residents was one to three hours, possibly slightly more than findings by Douglass et al. (2009) citing one to two hours and supporting findings of Silk et al. ( 2012) who concluded oral health instruction had increased in family medicine residencies.Silk indicated, however, that 45% of family practice residency program directors reported three or more hours, a total higher than reported by these residents.
No similar accreditation standard for pediatric residecy programs exists; however, the AAP has emphasized the pediatrician's role in children's oral health and recommended pediatricians provide oral health services to children and offered related online CME courses.These and other national initiatives have apparently positively impacted oral health curriculum content in pediatric residencies, as only 7% of pediatric residents indicated receiving no education, in contrast to Caspary's et al. (2008) findings of 21%.Pediatric residents responding to this study reported receiving a total of four to six hours of oral health instruction, whereas family medicine residents reported one to three hours.Although pediatric residents reported receiving more hours than family medicine residents, all of these residents continue receiving limited hours of oral health education.
Another factor that could affect family physicians' or pediatricians' provision of preventive oral health services to children is the type of educational experiences included in the curriculum.Clinical activities incorporating the delivery of preventive oral health services were reported by over three out of four of these family medicine and pediatric residents, with the most frequent estimate of total clinical experiences being one to three hours.Apparently, most family medicine and pediatric residents are benefiting from combined oral health-related didactic and clinical activities.
Nonetheless, respondents to this survey reported receiving most of their oral health education through classroom instruction.This type of instruction may have included oral health education delivered through online programs, although this study did not differentiate online instruction from classroom instruction when assessing the method of delivery.Some residents could have interpreted online programs to be a subcategory of classroom instruction.Others may not have considered online instruction.
Some methods of education are more effective than others in increasing oral health knowledge of healthcare providers and increasing the preventive oral health services provided by health professional students.One approach that has been reported as positive is an IPE component involving and oral health professional in the training (Anderson, Smith, & Brown, 2013;Gonsalves et al., 2004;Skelton et al., 2002;Talib et al., 2012;Wawrzyniak et al., 2006) , 2015).These oral health promotion efforts might be the impetus for increasing access to preventive oral healthcare for children in the U.S.
Relationships were evident in this study between certain preventive oral health services provided at wellchild visits by family medicine and pediatric residents and the total hours of oral health education received.Assessing children's teeth for enamel demineralization was moderately correlated with pediatric residents providing number of hours of oral health education received.However, the moderate correlations between preventive oral health services provided and total hours of related instruction were limited to providing anticipatory guidance for family medicine residents.This difference could be due to the amount of attention the AAP has dedicated to pediatricians delivering these services, and the resources they have provided (AAP, 2014), rather than the number of hours of oral health education included in the curriculum.Herndon et al. (2010) found no correlation between total hours of instruction and delivery of preventive oral health services, and this study found few.Perhaps the more important factor is the type of education and experiences related to oral health being included in the residency curriculum.This issue requires further investigation.The low number of responses to the IPE items in this survey precluded statistical analysis of these associations.
One of the limitations of this study was a low response rate of residency programs and third-year residents participating in the study, which is common among studies involving healthcare providers as participants (VanGeest, Johnson, & Welch, 2007).Although response rates were low, this study utilized a random sample, was conducted on a national level, and had a small, but representative sample of third-year residents.According to Cook, Health and Thompson (2000), the representativeness of survey responses is more important than response rate.The monetary incentives, short survey and involvement of a medical peer used in this study have all been shown to increase physician response rates (VanGeest, Johnson, & Welch, 2007).
Other factors that limited the number of responses were the high number of surveys conducted with medical residency programs and the fact the timing of the study being near the time of graduation for third-year family medicine and pediatric residents.Several family medicine residency programs refused to invite their third-year residents due to frequent survey requests, and several program administrators failed to return voicemails.When comparing the response rates of online and mail surveys, online surveys traditionally have a lower response rate (Manfreda, Bosnjak, Berzelak, Haas & Vehovar, 2008).Lastly, the participants' lack of interest in oral health education, otherwise known as topic saliency, might have influenced response rates.Topic saliency has shown to play a role in studies with low response rates (Adua & Sharp, 2010).

Conclusion
Findings from this study provide valuable insight into oral health curricular content in US family medicine and pediatric residency programs.There is a clear need for more effort in this area to meet national recommendations regarding the need for provision oral health assessments and preventive services by PCP.
This study provides insight into the role oral health professionals may be playing in IPE.Results indicate oral health education, in addition to IPE, may have slightly increased in pediatric residency programs across the nation over the past five to ten years, possibly influenced by the addition of clinical experiences, based on a comparison of findings with previous reports in the literature.Further research is needed on the role IPE plays in these providers delivering preventive oral health services to children during well-child visits and on the effects the USPSTF recommendation and increased insurance reimbursement have on the provision of these services.Innovative methods for delivery of education in this area are needed with emphasis on the alignment of learning objectives with national recommendations.

A Proposed Model for Oral Health-Related IPE for Primary Care Providers
To address the documented need to enhance preparation of medical residents in oral disease prevention and the potential impact of enhanced preparation on the care of children, an educational model to attain these goals is demonstrated in Figure 1 Practice | commons.pacificu.edu/hip2(3):eP1081 | 5

Table 1 .
Respondents' Age and Race Characteristics a Standard deviation in parentheses H IP & Oral Health and Interprofessional Education ORIGINAL RESEARCH 2(3):eP1081 | 6

Table 2 .
Respondents Reporting Total Hours of Oral Health Training and Education during Residency* Note: Totals equal ˃ 100 percent as respondents selected all responses that applied.

Table 3 .
Respondents Reporting Total Classroom, Community, and Oral Health Clinical Activities Hours of Instruction for Family Medicine Programs Note: Totals equal ˃ 100 percent as respondents selected all responses that applied

Table 5 .
Respondents Reporting Type of IPE Training Provided by an Oral Health Professional in Family Medicine Residency (N=38)* *Respondents selected all that applied; percentages are based on 48 respondents for each item.A total of 9 pediatric resident respondents did not answer the questions.

Table 6 .
Respondents Reporting Type of IPE Training Provided by an Oral Health Professional in Pediatric ORIGINAL RESEARCH2(3):eP1081 | 8

Table 8 .
Spearman's Rank Order Correlations for Relationship between Frequency of Oral Health Services at Well-Child Care Visits by Total Hours of Oral Health Education/Training *p < 0.05**; p <0.01***; p < 0.001*** (following page).Educational programs providing training for PCP can incorporate oral health education into their existing curricula by utilizing Smiles for Life: A National Oral Health Curriculum (SFL) as an online educational unit assigned as independent study to save classroom hours in already overcrowded curriculums.After completing SFL, residents can learn how to provide oral health screenings and fluoride varnish applications through IPE demonstrations and experiences involving oral health professionals within existing or new clinical and community settings.Implementing this curricular model would allow medical residency programs to support evidencebased best practices, national recommendations, and help prevent dental disease in children.