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