perio across the curriculum - online event69.59.162.218/adea2013/washington state...

Perio Across the Curriculum

Plant it early & Watch what happens!

Andrew R. Dentino DDS,

PhD

Professor

Director, Pre-Doctoral Program in Periodontics

LynnAnn B. Bryan

BSDH, RDH, MEd

Associate Professor

Coordinator

Non-Surgical Periodontics

Marquette University School of Dentistry

Marquette University School of Dentistry pre 1970

Marquette University School of Dentistry 2002

ABSTRACT:

Thoughtful periodontal curriculum timing, as well as

early integration of periodontal psychomotor and

didactic elements can allow for the safe, early (D1)

entry into clinical patient care in the sophomore recall

program. Continuous cultivation of D2, D3 and D4

comprehensive periodontal patient management allows

oversight of the growth and development of critical

thinking and decision making in periodontal diagnosis

and treatment planning, as well as in the

implementation and self-assessment of periodontal

care, follow up and referral. This session outlines the

four year Sim Lab and clinical progression of this

unique periodontal curriculum and demonstrates

alternative sim lab, basic skill assessment and clinical

competency assessment methodologies.

Learning OBJECTIVE 1: “Upon completion of this session, participants will be able to : Identify timing and didactic elements that would allow and challenges that would prevent cultivation of periodontics across your curriculum.

Learning OBJECTIVE 2: “Upon completion of this session, participants will be able to : Evaluate unique didactic, sim lab/preclinical and clinical assessment methods and weigh the feasibility of integration with your current assessment model.

Learning OBJECTIVE 3: “Upon completion of this session, participants will be able to : Describe factors to enhance the understanding of interprofessional and collaborative therapy in periodontics in our dental school clinics as well as in the private practice setting

The Foundational Curriculum: Historical Perspective

• MUSoD Nearly Closes

• 1991

• New Dean, Building & Curriculum

• 1992-96 –

K. Zachariassen

• 1997- p. -

William Lobb

• Dean’s Foundational Curriculum

– Subversive Faculty

• The Double Helix of Rochester

• Vertical Integration of Clinics

• Nov 1999

– Curriculum Innovation

• R-25 Grant

• 2001

– New School Opens

• 2002

• 2013 working on expansion

– Clinic Revenues Increased

• Vertical integration

• More efficient clinic scheduling

2012 AAP PreDoc Director’s Workshop

“Vertical Integration of Periodontics throughout the Four Year DDS/DMD Curriculum”

Presentations are available for members on the AAP website

• Integrating Periodontal Education in the Pre-Doctoral Dental Curriculum- D. Rolf

• From Passive Lectures to Interactive EB Approach- E.Chaves

• Periodontal Education in the Age of Google, Vertical Integration of Periodontal Predoctoral Curricula- M. Geisinger

• The Periodontal Faculty Role- G. Branch-Mays

General Dental

Sciences

Surgical Sciences

Clinical Services

Developmental Sciences

MUSoD

Endodontics Periodontics Oral &

Maxillofacial Pathology

Oral & Maxillofacial

Surgery

Department of Surgical Sciences

Clinical Practice A

Clinical Practice B

Clinical Practice D

Clinical Practice C

Department of Clinical Services

Group 1 Group 2

Group 3 Group 4

Group 5 Group 6

Group 7 Group 8

D1-10 D2-10 D3-10 D4-10

D1-10 D2-10 D3-10 D4-10

D1-10 D2-10 D3-10 D4-10

D1-10 D2-10 D3-10 D4-10

D1-10 D2-10 D3-10 D4-10

D1-10 D2-10 D3-10 D4-10

D1-10 D2-10 D3-10 D4-10

D1-10 D2-10 D3-10 D4-10

#1 This presentation includes:

* Identification of the periodontal curriculum timing features that creates clinical readiness and allows early D1.5 introduction to the patient care setting

D1 fall curriculum

– General Histology

– Biomedical Systems 1

– Preservation and Restoration of Tooth Structure 1

(Pres Res 1)

– Dental Anatomy & Occlusion 1

– Foundations of Oral Health 1

– Dental Rounds 1

– Introduction to Clinical Practice ICP 1

– ICP 1- Rotations • OSHA

• CS

• Radiology

• 4 handed dentistry & Assist

– ICP 1- Perio Modules- AM ‘traditional perio’ • 14 weeks x 3 hours

• Written Test Evaluations

– ICP 1- Perio Modules- PM

NSPT Instrumentation • 14 weeks x 3 hours

• 6 Self Assessment(s)

• 14 Self Directed Learning

• 6 Basic Skills Assessment(s) • BSA or Competencies

ICP 1 AM= traditional topics

• The Periodontium in Health

• The Periodontal Examination

• Instrument Design & Use

• Probes & Probing

• Root Morphology

• Explorers & Exploring

• Dental Deposits

– Biofilm & Plaque

– Calculus

• Dental Contributing Factors

• Attached Gingiva

• PI- Disclosing-OHI

• Toothbrushing

• Proximal Cleaning

• Instrument Sharpening

• Concepts of Deposit Removal

• Anterior Deposit Removal

• Posterior Deposit Removal

Fantastic Fridays High -Five Friday

Far-Out Friday Perfectly Perio

Perio _______

“Perio Friday” AM=traditional topics

• Prophy vs Perio Mntc

vs S/RP

• Post Therapy ReEvaluation

• Powered Instrumentation

• Dental Stains

• Extrinsic Stain Removal

• Chemotherapeutics- Topical

• Local Drug Delivery

• End Points of NSPT

• Periodontal Referral

• The Periodontium in Disease

• Periodontal Parthenogenesis

• Periodontal Disease Classification

• Non-Surgical Periodontal Therapy – Concepts

– Treatment Plans

– Delivery

“Perio Friday” PM= Sim Lab…..ALL Hands-On

• Ergonomics *

• Patient Operator Positioning*

• Glove Fit

• Pen Grasp/fulcrum

• Probe(s) & probing *

• Gingival Descriptions

• Periodontal Terminology

• Perio Charting

• Explorer(s) & exploring *

• Calculus ID / charting

• Disclose/PI/OHI

• TB & Prox Cleaning

• Sickle scalers & scaling *

• Universal curets & scaling *

• Area specific curets & scaling *

• CAL charting & ‘math’

• Cases-

– ID Classification

– ID Treatment Plan

• Ultrasonic

• Air Polisher

• Engine Polisher

• Chemo & LDD

* BSA-Basic Skills Assessment*

• D1 spring – Microbiology

– Biomedical Systems 1, 2

– Pres Res 2

– Dental Anatomy & Occlusion 2

– Foundations of Oral Health 2

– Oral Biology

– Dental Rounds 2

– ICP 2-

• 4 week Appointment Process

• 14 week Prophy Rotation

….. first human – prophy !

• Radiology

• Dental Clinic- Assist

• D1.5 summer – Pres Res 3

– Preclinical Prosth 1

• First Denture Patient

– Oral Medicine & Diagnosis 1

– Dental Rounds 3

– ICP 3

• First Assigned

Recall Patients

D1 Integrated Curriculum Perio Participation Foundations 2 DEIN 7120

Perio Modules ICP 2 DEIN 7124 Soph Recall ICP 3 DEIN 7134

Oral Biology DEIN 7121

• Smoking & The Periodontium

• Smoking Cessation

• Leukoplakia

• Risk Assessment

• Dentinal Hypersensitivity

• Prognosis in Periodontics

• Perio-Systemic Considerations

• Dx & Surgical Tx of Chronic Periodontitis

• Prognosis, Tooth Mortality

• Clinical- Prophy Rotation

• Scaling/Root Planing

• Histology of the Oral Tissues

• Microbiology

• Immunology of the Oral Cavity

• Periodontal Epidemiology & Measurement

#2 This presentation includes :

• Discussion of the sim lab assessment methods utilized by the D1 students, peer and faculty

D1 Sim Lab Assessment Features

• Sim Lab

– Self Evaluation

• Pre BSA

– BSA= Basic Skills Assessments

– Comprehensive BSA

• Prophy Rotation

– Clinical BSA

• D1.5 summer session

– DPA- formative

• Student

– Process Oriented

– Self Assessment

– Peer Assessment (?)

• Faculty

– Process Oriented

– Formative

– Instruction and assessment is very faculty driven

#3 This presentation includes:

• Explanation of escalating D2, D3 and D4 clinical expectations, case completion requirements and evolving clinical assessment methods, including basic skills and competency evaluation, mock board examination and written periodontal capstone examination

D2 Integrated Curriculum Perio Participation Dental Rounds

Clinical Perio Therapy DESS 7210 Biomedical Systems BISC 7517 & 7518

• Treatment Algorithms

• Therapeutic Outcomes Periodontal Surgical Therapy

• Principles, Osseous Resection, Regeneration

• Mucogingival surgery

• Periodontal - Endodontic Lesions & Therapy

• Perio Systemic Connection

• Host Modulation

• Perio & Genetics

• Chemotherapeutics

• Local Drug Delivery

• Occlusion & Periodontal Therapy

• Esthetic, Functional Crown Lengthening

D2 Continued

• Clinical correlates: Inflammation

• Wound Healing

• Diabetes

• Dx & Tx of Periodontitis, Osseous Defects

• Regeneration

• Bone Grafting

• Root Resection

• Dx & Tx Aggressive Periodontitis, Ortho-Perio

• Implant Considerations

• Periodontal Dx & Tx Planning

• Implants

• Osteo-integration

• Surgical Stent

• Site Preparation

• Treatment Planning

D3 & D4 Clinical Participation

• Critical Thinking

• Professionalism

• Communication and Interpersonal Skills

• Health Promotion

• Practice Management

• axiUm & Informatics

• Patient Care

– Assessment, Diagnosis, and Treatment Planning

– Establishment and Maintenance of Oral Health

– Delivery of Care

– ReEvaluation

– Referral

ADEA Competencies for the New General Dentist

(As approved by the 2008 ADEA House of Delegates)

J Dent Educ. 73(7): 866-869 2009

© 2009 American Dental Education Association

D2 Fall

• Sophomore Recall

• ‘easy’ healthy prophy & stable periodontal maintenance patients

• Periodontal exam

D2 Spring

• Moderate recalls possible first s/rp; (possible) first anesthetic

• Periodontal exam

• Perio Capstone Case Based Written Exam

D2.5 Summer

• (First) comp exams

• Any patient- any perio type

• First scaling & root planing

• Periodontics Credentialing Card Introduced

D2 Clinical Milestones

D3

• ‘All Clinic – All the time!’

• Prophy Competency

• Sharpening Competency

• Perio Credentialing Card

• Minimum 4 quads

• CRDTS quality

• ‘guided’ instruction

• S/RP Competency

• 2 of 5 Case Completions

• ‘active’ therapy ie s/rp

• Reeval & follow through

• recall

D4

• All Clinic – All the time!’

• Sharpening Competency

• MOCK Board –Perio

• Mock Remediation prn

• 5 of 5 Case Completions

• Senior Surgery (optional)

• Dental Hygiene Externship Program: ‘Private Practice’ Clinical Experience (optional)

Clinical Perio Advancement Requirements

D2

• Inquiry & Instruction

• Faculty driven

• Decision making & Tx Planning-

• Healthy Case Based

• Faculty driven

• Evaluation of Process

• Faculty driven

• Formative

D3

• Inquiry & Instruction

• Faculty AND student driven

• Decision making & Tx Planning

• Diseases Case based

• Faculty AND student driven

• Evaluation of Process & Product

• Faculty AND student

• Summative & Formative

D4

• Inquiry

• Student driven

• Decision Making & Tx planning

• Any Case based

• student driven

• Evaluation of Product

• Student summative

• Faculty summative

Promotion of Critical Thinking

in Support of Clinical Decision Making

Site and Patient-level criteria to consider in assessing the stability of periodontal maintenance patients

Inflammation measured by (BOP) bleeding on probing

Likely Stable -Sites that consistently show no BOP Unstable if - Full mouth BOP > 15%

- Consistent BOP over time

Probing depth measurements(PD) Unstable if- - PD increase of > 2 mm from baseline/ previous visit - # of significant PD increase - 10 or more sites > 4mm PD - 6 mm or greater PD at any site - > gingival recession from baseline / previous

Radiographic considerations on vertical bite wings

Likely Stable if- Consistent crestal lamina dura Unstable if- Loss of crestal bone height based

Patient-level considerations Unstable if- - Poor hygiene in the presence of attachment loss - PI: > 30% - Smoking: > ½ Pack /day - Diabetes: HBA1c > 9 - Obesity: BMI > 30 - High stress life events: divorce, loss of loved one, unemployment, etc

End Points of Therapy- Criteria for Assessing Stability

Dentino et al., Perio 2000; 2013

DPA Daily

Performance

Assessment

D3 Periodontics Credentialing Card

- 4 quads (min) - ’CRDTS’ quality - 4+ mm PD - ‘guided’

instruction

- Completed PRIOR to challenging S/RP Comp

• Description of the role of periodontics and the integration of D1, D2, D3 and D4 student teams in the Dental Research and Clinical Rounds

#4 This presentation includes:

Why General Dental Rounds?

• Reinforcement of didactic material

• Integration of clinical and basic science material

• Encourage students to understand their treatment plans and decision making

• Practical exercise in evidence-based decision making

Goals of Dental Rounds

• Engaging Students & Faculty in EBD

• Incorporate the Socratic Method

• Encourage Critical Thinking

• More Efficient Use of Resources

• Design Rooms Based on Curricular Needs

Periodontal Integration: Rounds

• Student teams

– D-4 Leader chooses case & presents & defends

– D-3 Selects PICO Question with faculty guidance

– D-2 Reviews relevant pathology

– D-1 Presents a basic science aspect of the case

• Summer Rounds: Treatment Planning

– D-3.5, D-2.5, D-1.5

PBL room in medical education

MUSoD General Dental Rounds Rooms

Dental Rounds Formats

• Case presentations

• Clinical pathological conferences

• Morbidity Reports

• Literature Reviews

• Treatment Planning Seminars (Summer)

D-1 Presents Histology of Periodontium D-2 Reviews Types of Altered Passive Eruption D-3 Prevalence of Gummy Smile Post Ortho D-4 Differential Dx and Tx

Teaching Tactics & Group Size

Full class (80)

Lecture

Sim lab

Medium Groups (20)

CPMG Rounds

Pod Groups Sim Lab

1 on 1

Clinic

Sim Lab

CDC Clinics

1 or 2 to 1

Surgical Suite

Small Groups (10)

Clinic groups

CDC Clinics

Prophy Rotation

Remediation

Advanced Standing

Informal

D1 Faculty Role

• Multidisciplinary Courses

• Periodontology Modules-Lecture

• Small Discussion Groups

• Sim Lab Instruction

• Small lab groups

• Rounds Mentors

D2 Faculty Role

• Periodontology Module-lecture

• Small Discussion Groups

• Surgical Labs

• Sim Lab Instruction

• Small lab groups

• Rounds Mentors

• Clinic

D3 Faculty Role

• Clinic

• Small lab groups

• Rounds Mentors

• Honors

– Journal club

– Case presentations

– Case calibrations

D4 Faculty Role

• Clinic

– MOCK Board Calibration

• Honors

– Journal club

– Case presentations

– Case calibrations

Periodontists

• 4 FT

• 8 PT periodontists

• 8 surgical practitioners

• 4 board certified

• + 350 years of clinical

• + 200 years teaching

‘Periodontal Consultants’ -RDH

• 13 RDHs 1FT

• 10 Private practice

• 12 BSDH – 4 Masters (MEd, MS)

– 2 almost MEd, MS

– 1 PhD

• + 360 years of clinical

• + 230 years of teaching

“Our” Faculty

In The Clinic

Periodontist

• During Comprehensive Exam- Periodontal Exam

– Periodontal Diagnosis

– Perio treatment planning

• Non-surgical

• Surgical

• Implants

• During Perio Consultation

• During Perio ReEval

• During Surgery & Post Op

Guide, mentor, monitor

and encourage

critical thinking &

decision making

related to periodontal

diagnosis,

comprehensive (perio)

treatment planning,

treatment

implementation and

timely referral

In The Clinic

• During Perio Mntc Appt

• During S/RP Appts

• During Perio Reeval Appts

• Validate info gathering, question self evaluation and final product of work; encourage thoughtful decision making leading toward private practice

RDH

Guide, mentor, monitor &

encourage:

-Critical thinking &

decision making related to

periodontal therapy,

reevaluation, end points of

therapy and periodontal

referral

In The Clinic

• Lecture

• Sim Lab

• Prophy Rotation

• Clinic

• Association Membership

• CE & Prof Devel

• Volunteer Work

RDH

Guide, mentor, monitor &

encourage:

-Self reflection and the

development of their own

personal philosophy

related to DDS / RDH

collaboration- both

professionally and in their

own private practice

Faculty Calibration

Sim Lab

• Weekly prep email

• D2L ‘homework’

• Weekly huddle

• Weekly post-mortem

• ‘after hours’

Clinic

• ‘Work’ Sim Lab- required?

• RDH Roundtable

• ‘Let’s Do Lunch”

Reflections

National Board Scores

• ‘92-’97

– Double digit failure rates

• ‘98- ‘04

– @ national average

• ‘06-’11

– Significant improvement

– @ Half the national average for failure rate

• ‘12-

Regional Board Scores

• CRDTS

• Failures – 2010- 2- pt selection

– 2011- 1- pt selection

– 2012- 0

– 2013- 2 selection/ 2 points

• Pass Rates & Scores

Perio Graduate Program Interest & Acceptance

• Graduate Student Enrollment into Perio Grad Programs

– ‘99-’10 1 /year

– ‘11-p 3 /year

• Grad Student Feedback

Interprofessional Collaboration

• DDS / RDH

• Understanding of the ‘work’

• End Points of Therapy

• Team Perio Success in private practice

• Team Perio Success in Specialty Referral

• Perio Health of Patients

Reflections on the ‘bottom line’

D1

• D1.5 summer 3.8 pro

• X 80 students

• 304 appointments filled

• X prophy fee

D2

• D2 fall 2.6 prophy

• D2 spring 4.5 prophy

• D2.5 summer ‘own’ pts

• Comp Exams 6

• ‘12 10.8 s/rp quad

= clinic utilization up

= clinic income up

D3

• Exams

– Comp Ex 25

– POE 35

• Prophy 28

• Perio Mntc 14

• S/RP quads 16

• Surgical 3

• (average ‘11 & ‘12)

D4

• Exams

– Comp 47

– POE 96

• Prophy 66

• Perio Mntc 29

• S/RP quads 27

• Surgical 7

• (average)

How Are We

Doing?

+ 10 perio visits/session

x 2 sessions/day

20 perio visits/ day

x 4 clinics /building

+ 80 perio visits/day

x 5 days/week

+ 400 perio visits/wk

x 4 wks/ month

+ 1600 perio visits/month

x 10.5 months/year

+ 16800 perio visits/ year

+ 7 perio visits/session

x 2 sessions/day

14 perio visits/ day

x 4 clinics /building

+ 56 perio visits/day

x 5 days/week

+ 280 perio visits/wk

x 4 wks/ month

+ 1120 perio visits/month

x 10.5 months/year

+ 11760 perio visits/ year

How Are We Doing?

FY 2001-2002

• D1110 1114

• D4341 373

• D4342 0

• D4910 50

• Total 1519

• $49,531

FY 2011-2012

• D1110 1820

• D4341 273

• D4342 509

• D4910 1045

• Total 3650

• $190,456

Marquette University School of Dentistry 2013-and beyond!!!

Thank You!

lynn.bryan@marquette.edu

andrew.dentino@marquette.edu