Mouradian, Wendy E. MD, MS; Reeves, Anne MPH; Kim, Sara PhD; Evans, Rachel; Schaad, Doug PhD; Marshall, Susan G. MD; Slayton, Rebecca DDS, PhD
Oral health disparities are a major public health problem, according to the U.S. Surgeon General. Physicians could help prevent oral disease, but lack the knowledge to do so. The purpose of the initiative described below was to create an oral health curriculum for medical students at the University of Washington School of Medicine. To this end, beginning in 2003, we (1) reviewed current evidence of medical education and physician training in oral health, (2) developed oral health learning objectives and competencies appropriate for medical students, and (3) identified current oral health content in the undergraduate curriculum at our institution along with opportunities for including additional material. Based on the results of these investigations, we propose a spiral curriculum in oral health targeting specific required courses, testing of oral health knowledge and competencies, and administrative leadership for accomplishing these changes. We also discuss the ethical values and attitudinal shifts supporting curricular innovation in oral health.
Oral disease and its impact.
Despite advances in dental treatment and care, there are serious disparities in oral health and access to care in the United States. According to the U.S. Surgeon General,1 the populations affected include low socioeconomic and minority groups, children, the elderly, those with disabilities and special health needs, and individuals living in rural and underserved areas.1,2 Significant consequences from neglected oral disease include poor growth and nutrition, spread of infection from decayed teeth, pain, time lost from school and work (still-relevant data from 1992 indicate almost 52 million hours per year for children and 164 million hours for adults3), unchecked oral cancer, and other systemic health impacts.4,5 Caries (tooth decay) is the most common chronic disease of children and adults. In 2000, the Surgeon General reported that one-fourth of U.S. adults suffered from severe periodontal disease, and 30,000 cases of oral cancer are diagnosed annually.1
Role of physicians in oral health.
Since the major oral diseases are largely preventable and/or amenable to early intervention,1 these disparities and health effects could be alleviated, in part, through increased physician training and participation in oral disease prevention. Through oral screening examinations, preventive interventions, patient counseling, and dental referral and collaboration, physicians could have a positive influence on oral health outcomes in vulnerable populations. However, because of the historic separation of medical and dental education and delivery of care, physicians have had little involvement in dental health.6–8 Yet physicians are often in a better position to prevent oral disease than are dentists. Studies show that primary care medical providers are more likely to see poor children early and to provide care for them on a continuing basis when compared with dentists.* Children are 2.6 times and adults three times more likely to have medical insurance than dental insurance.1,9 The American Academy of Pediatrics has recently called for physician involvement in oral health promotion.10 Many health maintenance guidelines already advise medical practitioners to provide anticipatory guidance related to oral health, such as nutrition counseling, use of fluoride supplements, tooth-brushing, and smoking cessation.11–13
Gaps in physician knowledge of oral health.
However, studies have shown that physicians lack the knowledge to promote oral health in their patients. In a national survey, pediatricians reported seeing dental problems regularly in their practices, yet only 9% could correctly answer all four basic knowledge questions about dental health.14 Physicians' fluoride-prescribing practices can be inconsistent or inappropriate, according to reviews prepared for the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention.15,16 Other studies have also found inadequate oral health knowledge and practices among physicians.17 In view of these gaps in oral health knowledge, in 2003 the U.S. Surgeon General called for efforts to “review and update professional educational curricula to include content on oral health.”18
In response to these studies and the federal call to action, we reviewed evidence for physicians' education and training in oral health, and the feasibility of integrating additional oral health content into medical student education at a large publicly funded university. We were interested in developing appropriate oral health learning objectives for medical students and a strategy for including this material in the curriculum.
Gathering Information to Develop Learning Objectives
Evidence for oral health training in medical education
A Medline search was performed to retrieve studies published between 1960 and 2004 related to medical education and physician training in oral health. We used the MESH terms medical education, dental health education, attitudes, and knowledge combined with the terms oral health, dentistry, and dental care. We identified and reviewed articles on oral health knowledge, attitudes, and education of medical students, as well as those related to oral health training and knowledge of residents and practicing physicians. In addition, we reviewed online national curricular databases and questionnaires, including the Association of American Medical Colleges' (AAMC's) Curriculum Management and Information Tool, CurrMIT and Graduation Questionnaire (GQ), Web sites of the Liaison Committee on Medical Education (LCME), and the United States Medical Licensing Examination (USMLE) Steps 1, 2, and 3.
Development of learning objectives
To develop medical student learning objectives for the oral health curriculum, we reviewed key oral health reports.1,10,12,16,18–21 We also reviewed numerous online oral health educational resources as reported in our previous study of pediatric oral health materials for physicians' training.22 In addition, oral health content areas and potential learning objectives were discussed with seven faculty from the School of Dentistry at the University of Washington. Finally, the past experience of our team in developing, piloting, and testing oral health curricula for family medicine residents and faculty informed this process.23
Identifying oral health content in our school's curriculum
To identify courses for current and potential inclusion of oral health information, we interviewed key medical school faculty and analyzed medical school course descriptions at the University of Washington School of Medicine. The associate dean for curriculum and course directors and instructors in Head and Neck Anatomy, Microbiology, and Introduction to Clinical Medicine (ICM) were interviewed to identify current oral health content in these key courses, and opportunities for greater emphasis on oral health in these and other courses in the curriculum. We also considered the head and neck examination “benchmarks” and oral health material that might be currently included in pediatrics and family medicine clinical clerkships. Finally, we reviewed these issues with the newly formed Oral and Systemic Health Curriculum Theme Committee, which included faculty from a wider range of disciplines and courses and a student representative.
What We Learned
Previous studies of physician training in oral health
Undergraduate medical education.
A limited number of articles addressing physicians' training in oral health were identified, with very few related to education in medical school. In 1985, Curtis et al. 24 surveyed U.S. and Canadian medical schools and reported that comprehensive instruction in dental topics did not take place in surveyed institutions. Another survey specifically addressed oral cancer curricula in U.S. medical schools, and found such training lacked “both adequacy and comprehensiveness.”25 One published study of undergraduate medical education discusses knowledge changes after incorporating pediatric oral health into the training of 56 osteopathic medical students.26
In our own institution, the University of Washington School of Medicine, an unpublished pilot survey of 229 medical students revealed generally positive attitudes towards the importance of oral health training, but low student knowledge of caries, oral–systemic interactions, and oral health disparities across all training years.27 We know of no other surveys of medical school students' oral health knowledge and attitudes.
We searched the CurrMIT database for oral health content across medical school curricula nationally.28 Several U.S. and Canadian schools include oral health information in courses, but the content, or whether these are elective or required courses, was not reported. The GQ, administered annually by the AAMC, does not include any questions that might enable us to speculate on the level of oral health training.29 The closest content area surveyed is nutrition, a critical area for oral health. Of interest, more than half of medical students reported inadequate training in nutrition (the highest gap in content for any area surveyed).
We searched the Web site of the LCME, the accrediting body that provides general guidance to medical schools on curriculum and other key issues. Guidelines state that “clinical instruction must cover all organ systems,” but a search of the LCME guidelines for oral or dental content did not produce any results.30 There is no specific oral health content listed for Step 1 of the USMLE—the portion that tests for knowledge of science and mechanisms underlying health, disease, and modes of therapy. On the other hand, Step 2 of the USMLE, which focuses on clinical knowledge, does specify disorders of the mouth, salivary glands, and oropharynx, including dental disorders, under “Nutritional and Digestive Disorders.”31 Step 3 of the USMLE, which addresses clinical skills, lists the following disorders: “teething syndrome, dental caries, stomatitis, disorders of teeth/jaw, and malignant neoplasms of lip, oral cavity, and pharynx.”32 These content areas are included in the list of clinical problems the generalist physician should be prepared to encounter. We do not know of specific oral or dental questions included on previous USMLEs, or of performance data in these areas. However, dental and oral health topics are clearly included in the list of clinical problems covered in these tests, despite the apparent lack of evidence that medical school curricula are addressing this subject.
Graduate medical education and beyond.
In contrast to undergraduate medical education, there are a number of published reports discussing inclusion of oral health in pediatric and family medicine residency training.17,23,33,34 There are also numerous online resources with oral health content,22,35 and community-based projects addressing oral health training for physicians.36–38 In a national study of pediatricians, half reported no previous dental health training in medical school or residency.14 In another study, pediatricians and family physicians reported receiving two hours or fewer of oral health education during their training.39 Krol17 reviewed the literature on pediatric oral health training for pediatricians at undergraduate, residency, and practitioner levels, and found insufficient content and no coherent approach for integrating oral health into pediatric training.
Oral health learning objectives
Five major theme areas emerged from our review of all resources and consultation with dental school faculty. These were dental public health issues/prevention (including disparities), caries (including fluoride), periodontal disease, oral cancer, and oral–systemic health interactions. We formulated learning objectives for each theme area, including knowledge-based and attitudinal items, and the respective competencies for medical student mastery (Table 1).
Oral health content in our school's curriculum
Preclinical courses (Years 1 and 2).
From course overviews and faculty interviews, we estimated that University of Washington medical students receive about two hours of oral health-related education across the four years of medical school. Relevant basic science courses may reference oral health topics, but do not necessarily identify this content as important for physicians or test students on the material. Among preclinical courses, only ICM includes a specific lecture on oral health. Faculty we interviewed suggested that at a minimum the following courses could be targeted for additional oral health information: Head and Neck Anatomy, Microbiology, Pharmacology, Clinical Nutrition, Pathology, ICM, and the interdisciplinary course Medicine, Health and Society.
Clinical clerkships (Years 3 and 4).
The pediatrics clerkship is the only required clinical rotation that specifically covers oral health topics. Rotations in family medicine, obstetrics–gynecology, and chronic care/geriatrics were identified as potential venues for additional oral health content. Head and neck examination benchmarks required students to perform an oral examination for normal structures and oral malignancy, but did not include screening for caries or periodontal disease.
Medical school faculty and administration also cited a number of barriers to integrating oral health information, including (1) limited time in the medical curriculum for new material, (2) lack of faculty knowledge in some oral health areas, and (3) lack of access to clinical material to be used in lectures.
To summarize, we identified five key oral health theme areas through our literature review and faculty interviews. With this information and the time limitations of medical undergraduate education in mind, we propose the following approach to the new oral health curriculum at the University of Washington School of Medicine, and hope that other schools will find our approach useful.
Creating an Oral Health Curriculum
Our overarching goal is for medical students to graduate with the knowledge, attitudes, and skills to engage in oral health preventive care, especially in the primary care setting. To create a curriculum to meet this goal we propose specific learning objectives and competencies and identify key targeted courses where this content could be incorporated (Table 1). Learning objectives include both knowledge and attitudes. Competencies are primarily the skills needed to screen for oral disease, counsel patients on oral disease prevention, and refer to dentists for care.
Knowledge objectives include a public health overview of oral disease and prevention (especially disparities), and the pathogenesis of the three most common oral diseases—caries, periodontal disease, and oral cancer. Behavioral aspects of oral health (e.g., links between tobacco and alcohol use and oral cancer risk, between diet and caries development, and between oral hygiene and periodontal diseases) are also covered. Knowledge objectives related to oral–systemic health interactions include the systemic impact of oral disease (e.g., association of low birth weight/prematurity and cardiovascular disease with periodontal disease), oral manifestations of systemic conditions (e.g., HIV/AIDS, diabetes), and the oral impact of medications and other medical therapies (e.g., cariogenic impact of medications causing xerostomia).
Key attitudinal objectives include the awareness that (1) oral health is important to overall health, (2) physicians have a role in preventing oral disease and identifying it early, and (3) physicians should collaborate with dentists in the care of patients. We are seeking to foster these attitudes by emphasizing the extent of oral health disparities in vulnerable populations, the preventable nature of oral disease, the impact of oral disease on systemic health, and the specific roles physicians can play in disease prevention and recognition. Central to these beliefs is an underlying professional value: where means of prevention and treatment exist, physicians have some ethical obligation to address important health concerns for patients, even if they fall out of the realm of “traditional” medical practice.
Since role models are important to the development of professional values, medical faculty with interest in health disparities and oral health will be needed to mentor students. We have identified a number of potential oral health “role models” who espouse these values and demonstrate commitment to addressing oral health in primary care.
We also defined competencies in the five theme areas, including demonstrating knowledge and the clinical skills that physicians will need to apply oral health knowledge to patient care, such as examining the mouth and teeth; screening for caries, periodontal diseases, and oral cancer; counseling about risk factors and referring patients for needed dental care. These competencies may represent a higher skill level than typically expected of third- and fourth-year medical students, so we consider them “emerging” competencies for students. Including these competencies also provides a signal to faculty that they will need to model them for students. Given the low level of oral health knowledge among medical practitioners, it is likely that faculty intending to model these clinical competencies will also need further instruction.
Implementation of learning objectives and competencies
To organize this new curriculum and to reinforce oral health knowledge, we recommend the spiral inclusion of oral health across four years. Table 2 outlines a specific sequence of learning based on one of the oral health themes, the Caries Sequence. Oral health basic science knowledge in the first two years should be reinforced with case examples and clinical skills (oral examinations and patient counseling) in the third and fourth years, with assessment of oral knowledge and clinical competencies required. We propose that oral health objectives be incorporated and emphasized in existing required courses (as indicated in Table 1), and augmented, if desired, with oral health elective(s).
Overcoming barriers to implementation
Given the extremely packed medical school curriculum, we approached implementation of the spiral curriculum into existing courses by targeting key courses in a stepwise fashion. Some courses touch on oral health but do not necessarily emphasize the importance for physicians, or test students on the material. For example, a microbiology lecture has covered oral flora, but without expanding on the role of oral pathogens in both caries and periodontal diseases. After discussing this with the microbiology course director, he added more detail on key oral pathogens and clinical correlates, and felt it actually increased students' interest in that particular lecture. Similarly, head and neck benchmarks (taught in ICM) include basic identification of teeth and oral structures, including the naming and numbering systems for teeth, as well as screening for oral malignancy. After reviewing these requirements, we recommended including signs of caries and periodontal disease and eliminating the naming/numbering system. (This change has been approved.) We are currently working with instructors in other targeted courses to augment, reframe, and update oral health material where it is most logically placed, and to suggest or provide additional material and/or contact with dental faculty as needed. In general we have found our medical school faculty very receptive to this approach, and it serves our goal of integrating oral health into foundational medical knowledge.
Several comments must be made about our development of learning objectives and their proposed inclusion in the medical curriculum. First, the focus of our learning objectives and curriculum plan reflect judgments we made about the relative importance of various oral health topics (although the importance of these objectives is substantiated by review of multiple sources). We did not address many other important oral topics (e.g., management of dental emergencies, or oral problems of children with special health care needs) that might be of interest and importance to medical students. We are addressing these shortcomings, in part, by developing a classroom-based oral health elective with clinical demonstrations, for first- and second-year students, which will be offered in the Spring Quarter of 2005. Also, we did not interview faculty of all required courses on inclusion of oral health material (although we reviewed course descriptions), so the finding of two hours of oral health in the medical curriculum may be an underestimate. However, this finding is consistent with previously published studies documenting low medical practitioner training and knowledge in this area, as well our institution's unpublished data on oral health knowledge of students. Whatever time is currently devoted to oral health is insufficient.
Medical school may be an opportune point for inclusion of oral health material. By the time physicians confront the challenges of busy medical practice they may be less open to acquiring new information or at least to adding more tasks to their already full plates.40 At that point, professional identity issues and attitudes of physicians towards oral health and/or dentists may also interfere with physicians' motivation to learn and practice important oral health promotion strategies.23 Our pilot survey suggests that at least a subset of medical students are very interested in receiving more oral health information, and view this area positively.
Despite the limitations of our investigation of the oral health content in our school's curriculum, this effort and the pilot medical student survey data were important for developing faculty and administrative support for including oral health information in the medical curriculum. With these efforts, the Oral and Systemic Health Theme Committee was formed in the medical school and charged with developing new curricula in oral health. The identification of key learning objectives and a proposed strategy for including oral health in preexisting courses (the spiral curriculum) now provides a clear pathway for the future. Finally, with committee members' input, the new oral health elective has been created and approved. We know of no U.S. medical schools that have taken steps to comprehensively integrate oral health information through the four years of undergraduate training. Many medical and dental students take some or all basic science courses together, but this strategy of sharing resources may not be intended to teach physicians about oral disease for use in clinical practice.
Faculty development in oral health is needed to fully implement this curriculum. This also presents an opportunity for interaction with dental faculty, and modeling of medical–dental collaboration for future practitioners. Since about half of our school's medical students plan on entering primary care, they could potentially play a significant role in decreasing oral health disparities in the patient populations they serve. Table 2 identifies which objectives have already been met in the caries sequence, and our projected timeline for incorporation of remaining curricular components. We anticipate that the remaining content areas related to public health, periodontal disease, oral cancer and oral–systemic health content will follow a similar schedule. Recently a Society of Teachers of Family Medicine project sponsored by the Health Resources and Services Administration developed resources and suggested topics for an oral health curriculum for medical students. Hopefully this effort, in addition to our own, will stimulate much needed work in this area.41
Given the historic separation of medicine and dentistry, a gradual approach to constituency building has been necessary to achieve our goal of developing an oral health curriculum for medical students at the University of Washington School of Medicine. Although most activities described here—development of learning objectives, medical student pilot survey, curriculum assessment, the creation of an oral health theme committee, and approval of the oral health elective—took place within a 15-month interval, work at the interface of medicine and dentistry has been ongoing within our institution for many years. However, this work dramatically accelerated with the Surgeon General's Conference on Children and Oral Health19 and the release of the Surgeon General's Report on Oral Health in 2000.1 Another clear call for action to include oral health in medical education was released by the Surgeon General in 2003.18 We believe the time is ripe for academic health centers to take definitive steps to incorporate oral health into the undergraduate medical curriculum. Without better integration of medical and dental knowledge, and collaboration of medical and dental practitioners, it will not be possible to address the profound oral health disparities in the United States. These disparities reflect, to some extent, the historic decision to separate the study of the mouth from the study of the body.7,8,42,43
For maximal efficacy, oral health content taught in medical school will need to be reinforced in residency training. The inclusion of oral health questions by the American Board of Pediatrics, development of an oral health interest group within the Society for Teachers of Family Medicine,44 and the incorporation of oral health in a number of residency training programs around the country, suggest a trend in this direction. Beyond this, development of continuing education for practitioners, practical strategies for including oral health care in medical settings, and appropriate billing policies for oral health preventive interventions by medical providers are also critical. Ultimately it is primary care physicians in underserved communities who will be in the best position to prevent oral disease, identify it early, and build the linkages with dental practitioners. But foundational knowledge in oral health will be needed to prepare medical students and residents to translate this knowledge into practice. We recognize the ambitious nature of this innovation, including the spiral curriculum we have proposed—although straightforward learning objectives and adequate time for implementation should make this feasible. More complex are the attitudinal issues and the inertia of more than a century of separation of medicine from dentistry. Yet underlying professional values and profound disparities in oral health require that medicine and dentistry begin this process—together.
Dr. Mouradian′s work is supported by funding from Health Resources and Services Administration, Bureau of Health Professions (cooperative agreement #8 U7 HP 00026–01) and Maternal and Child Health Bureau (training grant #1 T17 MC 00020–01), and by the Comprehensive Center for Oral Health Research through its grant from the National Institute of Dental and Craniofacial Research (NIH; #P60 DE13061). Ms. Reeves' and Dr. Kim's work is supported by funding from the Health Resources and Services Administration, Bureau of Health Professions (cooperative agreement #8 U7 HP 00026–01). Ms. Evan's work is supported by funding from the National Institute of Dental and Craniofacial Research (NIH; #T32DE07132). Dr. Schaad's work is supported by funding from the Health Resources and Services Administration, Bureau of Health Professions (cooperative agreement #8 U7 HP 00026–01) and Maternal and Child Health Bureau (training grant #1 T17 MC 00020–01).
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44RG, Meier, MD, residency program associate director, Central Washington Family Medicine, Yakima, Washington. Personal communication, May 18, 2004.
*For example, in 1998, 89% of poor children had a usual source of medical care (Centers for Disease Control and Prevention, Vital and Health Statistics, July 1997), and 74% of poor children 19–35 months old received all their immunizations (Centers for Disease Control and Prevention, National Immunization Program, 1998), while in 1996 fewer than 1% of Medicaid-eligible children had a dental visit in the first year of life, and fewer than 20% of all children 0–18 years had a preventive dental visit that year (U.S. Inspector General. Children's Dental Services Under Medicaid: Access and Utilization. San Francisco: U.S. Department of Health and Human Services, 1996. OEI 09-93-00240). The situation is still much the same today. Cited Here...