Oral Health Education for Medical Students: Malaysian and Australian Students’ Perceptions of Educational Experience and Needs

Discussion

This study investigated Malaysian and Australian medical students’ learning experiences in areas relating to oral health care as well as their perceptions of oral health education and practice. Malaysia is a developing country with an increased awareness of health care promotion and provision of services.¹⁵ Australia was studied as a comparison because it is considered a benchmark in medical education and practice for countries in the Asia Pacific region.^15,16

This study found that high percentages of medical students in both countries reported encountering patients with oral health conditions. Presentation of oral diseases in medical settings is not uncommon, especially in these two countries where high prevalence of oral diseases has been reported in national oral health surveys.^17–20 Moreover, a shortage of dentists, especially in rural regions where oral diseases have been found to be higher, requires an increasing role for physicians in managing oral complications in patients.^21–26

The experience of encountering patients with oral conditions found in our study, especially among students at institutions without a co-existing dental school, indicates an expansion of the oral disease burden to medical practitioners for provision of oral health care. These patients may have limited access to dental practitioners, including those in university dental services. In these instances, one of the roles physicians play is identification of oral diseases that require prompt referral, such as oral cancer, since early management leads to better prognosis and increased rate of survival.^27,28 The presence of acute cases and dental trauma in medical settings found in our study also highlights medical practitioners’ role in providing comfort and relief, as well as prevention of life-threatening complications.²⁹ In addition, physicians’ competence in performing oral examinations may help identify systemic conditions that manifest in the oral cavity, such as diabetes, HIV infection, Crohn’s disease, gastroesophageal reflux disorder, and leukemia.^30–34

The high prevalence of oral health conditions encountered by medical students in both countries in our study also highlights the role of physicians in other areas of preventive care such as smoking cessation, promotion of a healthy and non-cariogenic diet, guidance in oral hygiene practice, and advice for regular dental check-ups. Such preventive care is especially important in patients with special health care needs who are at higher risk of developing oral diseases.³⁵ The high utilization of medical services among the increasing number of people with special health care needs in Malaysia and Australia supports the need for physicians to be involved with promotion of daily oral hygiene care.^36–39 Maintenance of oral hygiene has been found to be an effective preventive measure against systemic conditions such as aspiration pneumonia, infective endocarditis-related bacteremia, Ludwig’s angina, mediastinitis, cavernous sinus thrombosis, and cerebrovascular accident.^40–45

In terms of comfort in undertaking oral health-related activities, a significantly higher percentage of the Malaysian medical students than the Australian students in our study reported being comfortable performing oral examinations, delivering oral hygiene instruction, and arranging for dental referrals. The Malaysian students were also more positive about their roles in preventive oral health care. This comfort and beliefs reported by these students may be associated with their educational experience since almost half of Malaysian medical schools provide dedicated teaching hours in oral health.⁴⁶ In spite of this widespread training, only a low percentage of the Malaysian medical students in our study perceived that they had received good training in the various aspects of oral health care. Similarly, a low percentage of the Australian students in our study perceived they had received good training in oral health, although an earlier study found that most Australian medical students received some form of IPE in oral health, but not within dedicated teaching hours.⁴⁶ Perhaps curriculum revision is needed in both countries, along with structured assessment to measure the effectiveness of educational programs in oral health for medical students.

When we compared students’ responses according to the presence or absence of a dental school at the same university, we were surprised that those students at institutions without a co-existing dental school were more supportive of oral health education than those at institutions with a dental school. In addition, students on campuses without a dental school were no less comfortable in performing various oral health-related activities than their counterparts on campuses with a dental school. Contrary to our assumptions about IPE, having a co-existing dental school had no significant impact on the medical students’ performance in or attitudes about oral health education and practice. These students’ perceptions of having received good training in various oral health-related areas were also not significantly higher for those at institutions with a co-existing dental school.

Our survey did not ask how the medical students received their oral health education—specifically, whether it was taught by dental school faculty members—so we cannot determine what level of collaboration, if any, existed between medical and dental schools from the same or different campuses in providing this part of the medical curricula. Indeed, medical educators in another study reported a lack of involvement of their dental colleagues in oral health educational activities.⁴⁶ Nevertheless, we would argue that collaboration between medical and dental faculty members has the potential to enhance oral health education programs for medical students. Dental school faculty members can be valuable colleagues and resources for medical faculty members in educating medical students about oral health care as described in a previous study.⁴⁷

Whilst interfaculty collaboration should be encouraged at universities with medical and dental schools on the same campus, support in teaching and learning should also be provided to medical schools that lack inter-institutional access to dental faculty members. The large number of encounters with patients with oral health conditions by students at medical schools without a co-existing dental school found in our study supports the need for at least limited clinical training for medical students in oral health care. To ensure quality training for students without dental faculty members and students on the same campus, teaching and learning collaboration in this area should also be established at the inter-university level. IPE that places medical and dental students together in learning situations can be particularly effective in helping students in both professions learn from each other and prepare them for interprofessional care.⁴⁸

While medical schools endeavor to provide effective training programs for future physicians in collaborative oral health care, guidelines in medical practice and educational requirements also need to be modified to highlight the roles of medical practitioners in oral health maintenance. At present, there is no clear description in the scope of practice defining the role of medical professionals in oral health care for Malaysia and Australia. Accreditation standards of medical curricula, requirements for completion of internship programs, and guidelines on professional duty of care produced by the Malaysian Medical Council, Medical Board of Australia, and other governing bodies in both countries provide only general descriptions of the role of medical professionals in interprofessional practice, with no specific reference to oral health.^49–56 It may be advisable for Malaysia and Australia to emulate the practice in the United States, where the important role of physicians in collaborative oral health care is shown in the compulsory oral health components of the United States Medical Licensing Examination (USMLE), which is required for licensing of practicing medical professionals in that country.⁵⁷

Collaborative efforts in oral health maintenance involving medical practitioners should also include working with specialists in special needs dentistry. These specialists provide oral health management of patients who are medically compromised and/or experiencing some health care conditions that may limit the person’s capacity to attain satisfactory oral health.⁵⁸ As physicians manage patients with medical conditions, referral of patients to dentists is sometimes necessary to prevent complications that may result from medical therapy or deterioration of systemic disorders.⁵⁹ Therefore, involvement of special needs dentistry specialists in interprofessional care is important to ensure successful treatment outcome and attainment of overall well-being of patients. It was alarming, however, to see the significantly poor responses among the Australian respondents in our study regarding their awareness of special needs dentistry as a specialty, although this field of dentistry has been recognized in Australia for more than a decade.⁶⁰ Awareness of the roles of such specialists is imperative to ensure appropriate referral and management of these patients when they require dental treatment or consultation. Understanding each other’s roles, which is crucial in ensuring effective collaborative care, may be developed through introduction of IPE activities involving these two professions.

In spite of some negative findings, the support for training in oral health expressed by the medical students in this study has positive implications for the future development of education and practice in this area. These students’ perceptions of important oral health-related areas can provide administrators or relevant bodies with guidance on topics to be emphasized in designing educational programs in oral health to be incorporated into medical curricula.

Possible limitations of this study include the absence of a sound validation process for the instrument used and the potential for respondent bias previously reported in self-administered surveys.⁶¹ Furthermore, the use of basic statistical analyses in this study offered limited information, limiting our ability to draw substantive conclusions. However, the information generated by this study does provide useful early findings on the topic, which can support curricular development and guide further in-depth investigation of this subject matter. Future studies should use a survey instrument that has undergone a strong validation process and perform more advanced statistical measurement to provide further useful information.