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J Dent Educ. 73(1): 38-52 2009
© 2009 American Dental Education Association
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Transfer of Advances in Sciences into Dental Education

Periodontal-Systemic Disease Education in U.S. and Canadian Dental Schools

Rebecca S. Wilder, B.S.D.H., M.S.; Anthony M. Iacopino, D.M.D., Ph.D.; Cecile A. Feldman, D.M.D., M.B.A.; Janet Guthmiller, D.D.S., Ph.D.; Jeffrey Linfante, D.M.D.; Salme Lavigne, R.D.H., B.A., M.S.D.H.; David Paquette, D.M.D., D.M.Sc.

Key words: dental education, periodontitis, oral-systemic, dental curricula, interdisciplinary education, curriculum, inflammation

Submitted for publication 06/11/08; accepted 10/27/08


   Abstract
Top
 Author information
 Abstract
Methods
 Results
 Discussion
 Conclusions
 References
 
Research has proliferated in recent years regarding the relationship of oral disease to systemic conditions. Specifically, periodontal disease has been studied as a potential risk factor for multiple conditions such as cardiovascular disease (CVD) and adverse pregnancy outcomes, while other research focuses on exposures or behaviors associated with oral disease. However, few articles have been published reporting how this information is integrated into schools of dentistry, both in the classroom and clinical curriculum. For our study, a thirty-three-item survey and cover letter were electronically mailed to academic deans at sixty-five accredited dental schools in the United States and Canada in the fall of 2007. The response rate was 77 percent. According to the responses to this survey, the primary topics covered in the didactic curriculum regarding periodontal oral-systemic disease are aging, CVD, diabetes, and tobacco use. Eighty-eight percent of the respondents reported that their students are knowledgeable about the role of inflammation and its impact on oral-systemic conditions. Forty-eight percent of the respondents said they provide formal training for their students in how to discuss or communicate aspects of periodontal oral-systemic disease with patients. Only seven schools reported teaching didactic content to dental students intermixed with other health professions students, and only two schools reported conducting joint projects. Only 9 percent of the respondents said they think nurses and physicians are knowledgeable about oral-systemic disease. The findings indicate that dental schools are confident about the knowledge of their students regarding oral-systemic content. However, much work is needed to educate dental students to work in a collaborative fashion with other health care providers to co-manage patients at risk for oral-systemic conditions.

Since 1911, when Hunter introduced the concept of the focal infection, interest has varied regarding the impact of an oral infection on distant sites in the body.1 In 1989, a cross-sectional study from Finland provided observational evidence for an association of poor oral health and cardiovascular disease.2 Since that time, numerous studies have been conducted to investigate the link between oral and systemic disease, and hundreds of publications have sought to explain the potential relationship.

The infectious and inflammatory burden of periodontal disease has been consistently associated in various populations with diabetes,3–5 respiratory diseases,6 adverse pregnancy outcomes,7,8 cardiovascular disease,9–11 stroke,12,13 kidney disease,14 obesity,15 osteoporosis,16 and other chronic conditions.17 In addition, the impact of behaviors such as tobacco use on periodontal disease has been extensively studied.18,19 Although the science is not conclusive about all relationships between periodontal disease and systemic health,20 it is imperative that oral health care providers stay abreast of the latest evidence about periodontal oral-systemic disease connections and potential risk factors as they relate to patient assessment, diagnosis, treatment planning, and referral to dental specialists and medical providers.

It has been predicted that dentists will need to work more closely with other health care providers in the future to manage a vast array of conditions that impact oral and overall health.21 Already dentistry is seeing a change in the health care industry with the coverage of dental services for patients who have periodontal disease, are pregnant, or have cardiovascular disease or diabetes.22 Not only will dentists be expected to have exceptional technical skills, but they will also be required to possess exceptional diagnostic skills to be "capable of assessing and managing a multitude of oral pathologies and knowledgeable about sophisticated biomedical science concepts," as Hendricson and Cohen have said.23

Diabetes mellitus and tobacco use are known risk factors for periodontal disease.19,24,25 The rate of diabetes is increasing in the U.S. population. Approximately 5 percent of all patients seen in dental offices are estimated to have diabetes, and the prevalence increases to 20–25 percent in patients sixty to seventy-four years of age.26,27 In one meta-analysis of eighteen comparative cross-sectional studies, subjects with diabetes had substantially more severe periodontal disease when compared to healthy subjects.25 In another meta-analysis of ten intervention studies, periodontal treatment resulted in a 0.66 percent reduction in absolute HbA1c levels among patients with type 2 diabetes.28

In 2001, Kornman suggested that diabetes greatly increases demands on the health care system.29 He recommended that dental students be trained to manage the risk for periodontal disease among diabetic patients since this method can provide an effective and focused mechanism for learning about clinical management of diabetes. However, no reports could be identified in the literature regarding what dental students are taught about diabetes diagnosis and management.

Kunzel et al. investigated the role of the general dental practitioner in both smoking cessation activities and diabetes management.30 Their survey of 132 active general dentists found that a majority of the respondents do not incorporate smoking-cessation activities into their practices on a routine basis. In addition, while these general dentists inquire about a new patient’s diabetic status, most do not behave proactively (monitoring blood glucose levels, communicating with the patient’s physician, and adjusting the frequency of dental visits). The majority of the respondents reported having a lack of knowledge or viewing these activities as peripheral to their role. This 2005 report was the first to document the extent of dentists’ practice activities regarding management of patients with diabetes.

The American Dental Education Association (ADEA) has established basic core competencies for dental education relevant to the issue of periodontal-systemic disease education. The ADEA Policy Statement on research states that "dental educators should be expected to include new information and research findings in their courses of instruction and to encourage students to engage in critical thinking and research."31 The Competencies for the New General Dentist approved by the ADEA House of Delegates in 200832 also emphasizes the need for the general dentist to go beyond the traditional practice of focusing only on oral health and being able to practice evidence-based comprehensive dentistry both independently and collaboratively to improve the health of society. These goals will be accomplished by expanding the broad biomedical and clinical education of dentists. (See Figure 1Go.)


Figure 1
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  		Figure 1. Examples from ADEA Policy Statements and Competencies for the New General Dentist that emphasize content/experiences in periodontal-systemic disease connections

 
What is not known from the dental literature is what is actually being taught to dental students regarding periodontal disease and systemic conditions and how students are being prepared to manage patients with potential risk factors. We do not know if they are evaluated on their ability to identify potential risk factors or on their communication skills with patients and other health care providers about the patient’s condition. We also do not know the topics or extent of information dental students receive regarding periodontal oral-systemic disease. To address this knowledge gap, our study was conducted to 1) determine what topics that address periodontal and systemic disease are included in the didactic and clinical curricula of dental schools; 2) evaluate the extent to which periodontal oral-systemic disease content is taught in an interdisciplinary format involving dental students and other health professions students; 3) ascertain the opinions of academic deans/dental administrators about the level of education their students receive pertaining to the relationship between periodontal and systemic disease; 4) elicit academic deans/dental administrators’ opinions about the knowledge level of other health professions faculty in their institution and in the community concerning the relationship of oral health to systemic disease; and 5) identify resources needed to teach this content. For purposes of this article, the term "periodontal-systemic disease connection" will be used as it relates to the influence of periodontal conditions on systemic disease as well as the reverse scenario whereby systemic disease may influence the periodontal condition.


   Methods
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 Author information
 Abstract
 Methods
Results
 Discussion
 Conclusions
 References
 
A thirty-four question survey was designed and organized into five sections: institutional demographics, topics included in the didactic curriculum, topics included in the clinical curriculum, opinions, and resource materials. The survey contained Likert-scale questions along with open-ended and closed-ended questions. The survey was developed with the assistance of experts in survey design as well as content experts on periodontal oral-systemic disease connections. Once designed, the survey instrument was approved by the University of North Carolina Institutional Review Board (IRB) and pilot-tested with the assistance of five dental school academic deans from different institutional settings. Minor corrections were made, and the survey was resubmitted to the IRB for final approval. The final survey was posted on Survey Monkey, an online survey website engine, which provided a URL for the survey.

School websites along with telephone calls were utilized to locate email addresses for the academic deans. The survey instrument URL and cover letter explaining the purpose of the survey were emailed to the academic deans of sixty-five accredited U.S. and Canadian dental schools in fall 2007. The letter requested that the survey be completed by the most appropriate person in the recipient’s school. A second email with the URL to the survey was sent three weeks after the first mailing. Finally, a paper copy of the survey was mailed to all nonrespondents in an attempt to increase the response rate. The academic deans were informed that their participation was voluntary, with no incentives other than contributing to the dental literature.

The data were analyzed using descriptive statistical methods. The open-ended questions were separated into categories based on how the participants responded.


   Results
Top
 Author information
 Abstract
 Methods
 Results
Discussion
 Conclusions
 References
 
A total of fifty schools responded to the online and paper surveys, achieving a response rate of 77 percent. Six of the respondents were from Canadian institutions. No differences were noted between the U.S. and Canadian responses. Forty-nine percent of the respondents were located in health science centers, and 47 percent were in universities with a medical school. All schools said they offer a D.D.S. or D.M.D. degree, 75 percent an M.S. or M.Sc., and 47 percent a Ph.D. Thirty-one percent of the schools reported employing between forty-one and sixty full-time faculty members, and 23 percent employ 100 or more. Seventy-one percent of the respondents identified themselves as being in the position of associate dean or dean, and 18 percent a program director or chair. Primary response patterns are discussed below. Not all questions were answered by every respondent.

Topics Included in the Didactic Curriculum
Respondents were asked to estimate the number of hours used to teach various topics typically included when considering the interaction between periodontal and systemic diseases. Topics listed were adverse pregnancy outcomes, aging, cardiovascular disease (CVD), diabetes, genetics of periodontal diseases in chronic periodontitis and aggressive periodontitis, genetics (periodontal diseases with genetic syndromes), HIV, obesity, osteoporosis, respiratory disease, stress, stroke, and tobacco use (Table 1Go). The topics said to be taught the most (≥6 hours) are aging (56 percent), CVD (53 percent), diabetes (53 percent), tobacco use (52 percent), and HIV (48 percent). In the three-to-five-hour category, the topics receiving the most didactic time were said to be HIV (36 percent), genetics in chronic and aggressive periodontitis (34 percent), stress (33 percent), tobacco use (33 percent), and stroke (32 percent). Only 26 percent (N=11) of the respondents reported that their students receive three or more hours of instruction about adverse pregnancy outcomes as it relates to periodontal-systemic disease connections.


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  		Table 1. Topics and hours included in the didactic curriculum regarding periodontal-systemic disease associations, by number and percentage of total respondents
 
A list of nineteen courses was provided for respondents to select where in the curriculum content is taught regarding periodontal-systemic disease interactions/connections. The majority responded that they teach this content in periodontology (93 percent), followed by oral medicine (85 percent), general and oral pathology (80 percent), clinical periodontics (76 percent, first- or second-year didactic course), and clinical periodontics (74 percent, third- or fourth-year didactic course). One hundred percent reported they use lectures to teach the content. Case-based instruction is used by 70 percent, followed by seminars (47 percent) and problem-based learning (23 percent). All respondents said they use multiple-choice testing to evaluate knowledge of content, followed by case-based questions (68 percent).

Reference materials used to teach about periodontal-systemic disease connections are listed in Table 2Go. Ninety-three percent said they use journal articles, followed by dental textbooks (89 percent). Table 3Go lists journals and other publications used to teach about this content. The top three journals that the respondents say they use are the Journal of Periodontology (87 percent), Journal of the American Dental Association (75 percent), and Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology (55 percent). No respondents reported that their school uses corporate publications, and only 2 percent reported use of national health care agency publications. Other publications used by respondents that were named in the "other" category are the New England Journal of Medicine and Journal of the American Medical Association. When asked which websites they use (if any) to communicate this content, respondents listed the American Academy of Periodontology (70 percent), Cochrane Library (44 percent), American Dental Association (37 percent), and National Institutes of Health (37 percent). No respondent indicated using corporate websites (Table 4Go).


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  		Table 2. Resource materials used to teach about periodontal-systemic disease connections
 

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  		Table 3. Journals used to teach about periodontal-systemic disease connections
 

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  		Table 4. Websites used to teach about periodontal-systemic disease connections
 
Only 16 percent of the respondents (N=7) reported that they teach periodontal-systemic content to interdisciplinary student groups such as dental hygiene, nursing, medical, or other allied health students. The courses taught with dental students and other groups were reported as Periodontics I and II, Anesthesia, Introduction to Patient Care, Microbiology, Radiology, Infection and Immunity, Interprofessional Learning, Oral Medicine, Pharmacology, and General Pathology. The faculty who teach the joint courses were identified by respondents as dental clinicians, basic scientists, and medical clinicians. One school reported that a dental hygiene faculty member teaches a course to interdisciplinary student groups. Only two respondents indicated they conduct joint projects or patient education in the area of periodontal-systemic connections in conjunction with other health professions students. One respondent noted that students complete the projects in a course called Population Health. Another indicated that rural rotations are multidisciplinary, and another wrote that the school is not yet doing joint projects but is working towards that goal.

Forty-eight percent of the respondents indicated that they provide formal training for their students in how to discuss or communicate aspects of periodontal-systemic disease connections with patients. Methods reported by respondents include observing the treatment planning process, discussing risk assessment with patients, patient care simulations, and role-playing; another provides the content as a component of a PBL curriculum. One respondent indicated the students at that dental school are evaluated on patient communication in all of the clinical competencies. One respondent indicated it is taught somewhat but not to achieve competence.

Topics Included in the Clinical Curriculum
Respondents also provided information on how dental students are evaluated in the clinic on their ability to assess for periodontal-systemic disease connections, discuss those risks with the patient, and refer the patient to a specialist based on risk factors (Table 5Go). Forty-four schools responded to this question and indicated that their students are evaluated for their ability to assess or perform a dental diagnosis or to discover a potential risk for systemic complications of periodontitis on the majority of their patients in relation to several health behaviors and medical conditions. Of the respondents, 67 percent reported that their students are evaluated on assessing risk for potential systemic disease with tobacco use, HIV (63 percent), CVD (62 percent), and diabetes (59 percent). Adverse pregnancy outcomes (51 percent) and genetics (43 percent) were said to be less frequently assessed. Likewise, the students’ ability to discuss risks with patients was said to be evaluated mostly with tobacco use (86 percent), diabetes (77 percent), CVD (71 percent), and HIV (70 percent). Participants were asked if their students are evaluated on their ability to refer the patient to a specialist based on the patient’s risk factor(s) for periodontal oral-systemic disease connections. According to the respondents, fewer programs evaluate students on referral ability, but when they are evaluated, the most frequently reported conditions for referral are CVD (64 percent), diabetes (61 percent), HIV (53 percent), and tobacco use (50 percent). Ten schools reported that they did not know if and how risk assessment and medical referrals for adverse pregnancy outcomes are evaluated in their curricula.


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  		Table 5. Evaluation of D.D.S. students on ability to assess, discuss risks, and refer patients who present with oral disease and systemic complications or risk factors for disease, by number and percentage of total respondents
 
Opinions
One section of the survey focused on opinions of the respondents regarding periodontal-systemic education, resource materials, and levels of expertise in their programs and community (Table 6Go). The respondents said they feel confident in their clinical faculty members’ knowledge level regarding oral-systemic content (70 percent strongly agreed [SA] or agreed [A]) and also in their ability to evaluate critically the literature and determine levels of evidence (97 percent SA or A). However, 58 percent strongly agreed or agreed that they need more experts at their dental school to teach such content. Most respondents (89 percent SA or A) judged their dental students as knowledgeable about the role of inflammation and its impact on periodontal-systemic conditions. Regarding the role of future dentists in assessing patients’ risk for systemic complications due to oral health status, 93 percent rated the dentists’ role as important. Eighty-two percent reported that their school is doing an excellent job of didactically teaching dental students regarding periodontal oral-systemic disease connections; however, only 51 percent perceive that their school is doing an excellent job with evaluation of the content in the clinical setting. Regarding the knowledge level of medical colleagues (physicians and nurses) about periodontal-systemic disease connections, most respondents disagreed or strongly disagreed that the professionals in their geographic location, health science center, or in general are knowledgeable about this area of care (76 percent, 63 percent, and 79 percent, respectively). Finally, the majority of the respondents (86 percent) reported they could use more evidence-based educational materials to teach dental students about periodontal-systemic disease connections.


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  		Table 6. Opinions of academic deans/administrators/faculty members on the individual parameters regarding oral-systemic disease at their institution, by number and percentage of total respondents
 
Resources
The respondents were asked if their program supplies resource materials on periodontal-systemic disease associations such as patient literature or medical referral letters and templates. Fifty-one percent said their program supplies resource materials, and 67 percent said they provide referral letters to patients. The final question asked if there was anything the respondents would like to have that would assist them in teaching this content to dental students. Resources identified include patient pamphlets in both English and Spanish; instructional modules; access to a speaker’s bureau with individuals who can teach this content and be "trusted"; and an outside consultant to work with the clinical faculty, curriculum committee, or academic dean to develop and implement a plan for revision of this part of the curriculum.

The final question asked participants for comments about the survey or if their school had future plans for curriculum content related to periodontal-systemic disease research. The answers varied regarding the level of emphasis on this area in the dental curriculum from a full curriculum revision to very little change and integration (Figure 2Go).


Figure 2
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  		Figure 2. Selected comments from respondents regarding the survey and their future plans for periodontal-systemic content at their institution

 

   Discussion
Top
 Author information
 Abstract
 Methods
 Results
 Discussion
Conclusions
 References
 
Since 1995, several national reports have focused on the importance of oral health to systemic conditions and the need for more integration of dentistry with medicine and the health care system as a whole.33–36 The Institute of Medicine report (IOM) published in 1995 recommended that dentists be prepared for more medically based modes of oral health care and be prepared to work with more medically compromised patients along with their colleagues in medical schools and academic health centers.35 The surgeon general’s report on oral health focused national attention on the importance of oral health.33 It discussed the emerging associations between oral health and systemic conditions and emphasized the impact of systemic health problems on poor oral health. Specifically, the report discussed emerging associations of chronic oral infections such as periodontal disease to diabetes, heart and lung diseases, stroke, adverse pregnancy outcomes, and other conditions. However, although much attention has been paid to this important area in the literature, our study reported in this article is the first documenting the periodontal-systemic disease content taught to U.S. and Canadian dental students.

Overall, we found that academic deans and administrators are confident in their faculties’ ability to teach dental students about periodontal-systemic disease connections. Ninety-eight percent reported that the faculty members who teach these concepts effectively and critically evaluate evidence on these associations. While the literature is not conclusive regarding any etiologic role for oral/periodontal disease on systemic conditions, it is important for faculty members to teach students how to read the literature and stay abreast of current findings in this area. Considering predictions that dentists and other oral health care providers will play an important role in overall health care,33–36 it is vital that dental students begin that preparation while in the academic setting.

All of the respondents to our survey reported that lecture methods are used to teach this content, followed by case-based instruction (used by 70 percent). Seminars and problem-based learning were said to be used by less than half of the schools to teach about periodontal oral-systemic conditions. This is not surprising given the overcrowded curriculum in the majority of dental schools. Yet, reports indicate that the process of teaching students to practice according to evidence does not happen with lecture methods alone. Hendricson et al.,37 drawing on work by Werb and Matear,38 Bertolami,39 and Haden et al.,40 described evidence-based practice (EBP) as "educating dental students to provide patient care that is supported by research evidence versus the historical ‘in my experience’ approach and to instill an educational culture that values and promotes intellectual curiosity, based on the intertwined mental capacities of critical appraisal, self-directed learning, self-assessment, and reflection upon actions, decisions, and behaviors." Coormarasamy and Khan conducted a systematic review of published research regarding educational strategies to help medical students and residents acquire skills associated with EBP.41 Specifically, they looked at the effect of "stand-alone" teaching strategies such as classroom-based teaching versus clinically integrated teaching such as literature searching assignments, case simulations, and case conferences. The authors concluded that the clinically integrated methods all reported substantial enhancements in critical appraisal skills and improvement in student attitudes and confidence in applying EBP methods to patient care. The classroom-restricted methods, on the other hand, produced only weak and inconsistent evidence for these changes in the students.

Since dental students will not have ready access to faculty members or senior mentors after they graduate, it is imperative that they learn critical appraisal and critical thinking skills while in the academic institution so they can implement EBP throughout their careers. Haden et al. reported that traditional pedagogy in dental education focuses on how well the student can memorize facts.40 But is it possible for students to learn or comprehend all of the information they need to become competent dentists? According to Haden et al., "Students must learn how to learn, and faculty must serve as role models who understand and value scientific discovery."40 In addition, as dental schools look to the curriculum they will need in the future, perhaps the sorts of redesign of biomedical science instruction proposed by Geissberger et al. should be considered.42 Freeing time in the dental curriculum for development of critical thinking, problem-solving, and lifelong learning skills may contribute to producing the well-prepared dentist of the future.

The abilities to problem-solve and think critically coincide with the ability to access evidence-based information. Respondents in our study reported that their institutions use journal articles and dental textbooks as the primary resource materials to teach content on periodontal-systemic disease connections. Of the journals used, the most frequently named were peer-reviewed publications such as the Journal of Periodontology (87.5 percent) and Journal of the American Dental Association (75 percent). Also mentioned was the use of websites such as those of the American Academy of Periodontology (77 percent) and the Cochrane Library (44 percent). These findings are consistent with a recent study of periodontal-systemic disease education in U.S. dental hygiene programs that found them utilizing journal articles and dental hygiene textbooks (90 percent and 87 percent, respectively) and peer-reviewed journals such as the Journal of Periodontology (84 percent) to teach this content.43 Academic institutions should incorporate evidence-based readings and websites into their dental curricula to ensure that students will be prepared to continue these practices after graduation.

Even though the respondents to our survey reported that the clinical faculty members at their institutions are knowledgeable about periodontal-systemic research, over one-third said they do not think their institution is doing an excellent job of evaluating dental students’ knowledge of this content in the clinical setting. Many dental school faculty members do not have education or training in pedagogy or effective teaching strategies. Faculty development programs can be used to enhance their skills and encourage them to develop clinically integrated learning activities as well as critical thinking and problem-solving skills in students. As reported by Hendricson et al., the following characteristics produce the highest level of satisfaction in faculty development programs: incorporation of experiential learning such as hands-on practice of teaching skills; provision of feedback to participants about their performance; opportunities for participants to apply skills within the program or soon after; use of peers to model exemplary teaching behaviors and share perspectives on teaching; programs designed to facilitate peer interaction and the building of colleague relationships; use of a variety of learning experiences; and opportunities for post-program assessment of skills.37

According to the results of our survey, the topics that receive the most didactic hours on periodontal oral-systemic disease content in dental curricula are aging, CVD, diabetes, and tobacco use. A recent study of dental hygiene programs found that the most didactic hours are also allotted to diabetes, tobacco use, and CVD.43 The incidence of diabetes is expected to increase in the future and already impacts the majority of dental practices.44 Tobacco use is a high-risk factor for periodontal disease and oral cancer and should be emphasized in dental curricula as a periodontal systemic risk.19,45

Academic deans/administrators responding to our survey reported varying levels of clinical evaluation regarding dental students’ ability to access periodontal systemic risks/complications and communicate with patients concerning these issues. When one looks at how the risk factors that receive the most didactic hours in dental curricula (Table 1Go) are translated into the clinical setting, there is much variation. For example, 67 percent of respondents said their schools evaluate students’ ability to assess tobacco use, and 86 percent evaluate students’ ability to discuss risks, yet only half evaluate students’ decision making process in referring patients to a specialist for treatment. The survey did not ask about tobacco cessation activities provided by the dental schools, but the literature has reported a lack of tobacco cessation efforts by dentists and other health professionals.46,47

Likewise, according to our survey, diabetes assessment is evaluated by 59 percent of programs, yet respondents said that students are evaluated on their ability to discuss the condition with the patient in 77 percent of the programs. The ability to refer to a specialist was said to be evaluated the most for CVD and diabetes. This finding is consistent with findings for U.S. dental hygiene programs.43 It is encouraging that the majority of dental and dental hygiene programs evaluate students’ ability to perform these skills.

Surprisingly, dental students’ ability to assess for genetic factors was said to be evaluated the least of all listed factors. Their ability to discuss risks with their patients was also near the bottom in responses to our survey, when compared to other risk factors. The recent Macy Study report on genetics and dentistry emphasizes the need for dentists to be able to discuss genetic factors and genetic tests with patients.48 In addition, that report stresses the need for oral health professionals to be prepared to answer patients’ questions and know where to refer them for additional information or counseling.

A significant finding of our study is the very limited amount of interprofessional education and collaboration in U.S. and Canadian dental schools. Our study found that only seven schools (16 percent) present periodontal oral-systemic content to interdisciplinary student groups including groups such as nursing, dental hygiene, or medical students. In addition, only two schools reported conducting joint projects or patient education with interprofessional students in the area of periodontal-systemic connections. Only 8 percent of schools said they were not affiliated with an academic health science center or other university structure that did not include a medical school; hence, the opportunity for some level of collaboration exists at most institutions. It was interesting that over half of the academic deans/ administrators reported that their dental students are knowledgeable about how to work in interdisciplinary teams to promote oral-systemic health, yet this survey found that most receive no formal experience in interdisciplinary learning. Hendricson and Cohen wrote that, in the twenty-first century, "The dental profession will have to decide whether it wants to become a more integrated competent of the overall health care system versus continuing the ‘splendid isolation’ tradition of dental practitioners functioning in relative isolation from physicians and other health care providers."23 The recent Macy Study report on clinical training in oral health emphasizes the overlap between the clinical dentistry knowledge needed by physicians and the clinical medicine knowledge needed by dentists to provide better health care to patients.49 Dentistry is at a crossroads, with dentists having an opportunity to provide collaborative care.

Other health professionals are beginning to realize the importance of oral health to overall health. A recent issue of the American Journal of Child and Maternal Nursing is entirely devoted to oral health, with one article entitled "Improving Oral Health in Women: Nurses’ Call to Action."50 The article provides a nurses’ plan of action to emphasize the management of oral health conditions that are said to be "largely preventable." Finally, the article notes that nurses are in an ideal position to provide health promotion education and screening regarding oral health and risk factors for oral disease across the multitude of settings in which they work. Yet, nurses do not report a high level of knowledge regarding oral health and periodontal disease risks. A University of North Carolina study found that, of 240 North Carolina nurse practitioners, physician assistants, and certified nurse midwives, 62 percent reported having received no information in their educational curricula about oral health and periodontal disease. More than half were interested in attending continuing education courses to learn more about oral health.51 At the University of Washington, Mouradian et al. have recently reported on an oral health curriculum in the university’s medical school.52 The findings of this survey indicate that, for the most part, dentistry continues to educate students in isolation from other health care professionals. Most predictions indicate that this philosophy will not be conducive to meeting the public’s oral health care needs and expectations of the future.49–53

In our survey, only 9 percent of academic deans/administrators agreed or strongly agreed that nurses and physicians in their geographic location are well educated about periodontal-systemic disease connections. However, the percentage increased to 23 percent when respondents were asked about their particular health science center or academic campus. Thomas et al. found that nurse practitioners and certified nurse midwives were more likely to provide oral health exams if they had graduated from a school in close proximity to a dental school.51 Perhaps being near a dental school increases the knowledge or conscientiousness level about oral health. In our study, 14 percent of the respondents answered that they did not know about the knowledge of nurses and physicians in their geographic location or academic institutions. A 2007 study reported the results of an investigation of knowledge level and behaviors of obstetricians and gynecologists regarding periodontal disease and adverse pregnancy outcomes.54 A high number of obstetricians correctly associated periodontal disease with bacteria, but believed periodontal disease to be associated with tooth decay, aging, and excess sugar. The study also found limited incorporation of oral health knowledge into clinical practice.

The exact nature of the effect of periodontal disease on adverse pregnancy outcomes has not yet been confirmed.7,20 However, it is clear that, at the very least, good periodontal health is important to the well-being and comfort of the pregnant patient. Some critics contend that the level of evidence of a periodontal-systemic disease connection varies with the condition and ask, since a cause-effect relationship has not been established, why would it be important to incorporate this information into the academic setting or devote precious curriculum time to a discussion of possible effects? While the level of evidence varies according to the condition, the promotion of good oral health in itself is important to the reduction of disease, infection, and unnecessary suffering. A reduction in the detrimental effects of periodontal and oral disease is best accomplished through collaboration between dental and other health care professionals and is best reinforced while students are in the academic setting.

Dental schools can develop alliances with other members of the health care team to promote better periodontal health and teach other professionals about risks for periodontal oral-systemic disease. The Macy Study panel 2 report provides suggestions for promoting interprofessional collaboration in medicine and dentistry.49 Sharing basic science courses is not enough, the authors of the report argue. Suggestions start with pairing medical and dental students at service-learning sites. Medical students could rotate through dental schools or community health centers and engage in joint learning experiences in cross-cutting competencies such as oral heath interviewing and examination skills. Dental students could also serve as mentors to medical students regarding oral health skills and vice versa for selected medical/diagnostic skills. As noted in the report of panel 1 of the Macy Study,55 multidisciplinary education must become the norm in addressing the meaning and purposes of primary care as it applies to dentistry. The authors of that report recommend educational sequences including rotation strategies across discipline specialties in medicine and dentistry, clerkships and hospital rotations, and experience in faculty and residency clinics. As an example, they recommend a dental presence in medical rotations to specialty clinics in endocrinology or dermatology or in special facilities for geriatric patients.

New York University (NYU) began an innovative collaboration when the NYU College of Nursing merged with the College of Dentistry.56 The College of Nursing faculty practice, located at the College of Dentistry, has the opportunity to see more than 300,000 patients per year, many of whom would not get needed medical care otherwise. In addition, the nurse practitioners work collaboratively with the dental students to provide ongoing primary care and other health promotion/disease prevention services and to refer patients as needed. This is just one example of how interprofessional collaborations can help ease the access to care crisis, while promoting better periodontal health and potentially lowering the risk for systemic conditions.

With curriculum change and innovation, dentistry can be at the forefront of meeting the oral health care needs of the future. Collaborative practice models must be developed and implemented in order to meet the oral health needs of the public and reduce the incidence of systemic manifestations of oral disease. Future research should focus on methods of integrating periodontal oral-systemic research into the classroom and clinical settings to promote critical thinking skills and EBP. In addition, strategies should be implemented to increase the level of interprofessional education in oral-systemic risk factors, prevention, and patient management across disciplines.


   Conclusions
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The findings from this survey suggest that academic deans of North American dental schools are confident about the knowledge level of their students regarding periodontal-systemic disease connections. However, more than half of the respondents indicated they need to provide more educational experiences in this area. Only a few dental schools implement courses on this topic in which dental students participate in interprofessional learning experiences with other health care students. In addition, most academic deans/administrators do not think that nurses and physicians are knowledgeable about oral health and its relationship to systemic disease. More research needs to be conducted to identify strategies that will assist the efforts of faculty to translate this area of science into dental curricula. In addition, curricular revisions need to occur to plan for increased inter-professional collaboration.


   Acknowledgments
 
This study was supported by an unrestricted grant from Colgate Oral Pharmaceuticals. Colgate provided input into the initial review of the questionnaire only.


   Author Information
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Prof. Wilder is Associate Professor, Director of Faculty Development, and Director of Graduate Dental Hygiene Education, University of North Carolina at Chapel Hill School of Dentistry; Dr. Iacopino is Dean, University of Manitoba Faculty of Dentistry; Dr. Feldman is Dean, University of Medicine and Dentistry of New Jersey/New Jersey Dental School; Dr. Guthmiller is Associate Dean of Academic Affairs, University of North Carolina at Chapel Hill School of Dentistry; Dr. Linfante is Director of Admissions and Student Recruitment, University of Medicine and Dentistry of New Jersey/New Jersey Dental School; Prof. Lavigne is Professor and Director, School of Dental Hygiene, University of Manitoba Faculty of Dentistry; and Dr. Paquette is Assistant Dean for Graduate Studies and Director of Graduate Periodontology, University of North Carolina at Chapel Hill School of Dentistry. Direct correspondence and requests for reprints to Prof. Rebecca S. Wilder, Graduate Dental Hygiene Education, School of Dentistry, University of North Carolina at Chapel Hill, CB #7450, Room 3280 Old Dental Building, Chapel Hill, NC 27599-7450; 919-966-8221 phone; 919-966-6761 fax; Rebecca_wilder{at}dentistry.unc.edu.


   REFERENCES
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