Is Oral Health Important For Hospital Physicians?

I was honored to be selected for a longitudinal grant from the Student Hospitalist Scholar Program, and it has been wonderful to spend my last year of medical school on a project I cared so much about. 

1. Project Title, Your Name, Your Mentor’s Name

A Survey of Physician Oral Health Knowledge in the Care of Hospitalized Patients
Lisa Simon (Mentor: Dr. Anita Vanka MD)

2. Specific Aims of the Project

The purpose of this study was to validate and disseminate a survey evaluating hospital physicians’ oral health knowledge and the perceived importance of oral health on patients’ outcomes while in the hospital.

3. Studies and Preliminary (or Final) Results

This was a cross-sectional survey-based study. A 30-item survey was developed. Survey items were selected based on feedback from content experts in dentistry, family medicine, and hospital medicine. The survey was disseminated via an online survey platform (Qualtrics, Inc.) that was both desktop and mobile compatible and took approximately three minutes to complete. The survey was evaluated for face validity by two internal medicine physicians and one family medicine physician. Test-retest reliability was evaluated by having three internal medicine physicians at a difference institution complete the survey twice, two weeks apart, with a mean intra-class correlation of 0.63 (range 0.0-0.93) across all responses. Survey dissemination was approved by the Harvard Medical School and Beth Israel Deaconess human subjects review boards (IRB numbers IRB19-1534 and 2019P000782). Attending physicians on the hospitalist service, internal medicine and preliminary medicine interns, and internal medicine junior and senior residents were invited to participate. Data analysis was performed using Stata statistical analysis package version 15 (StataCorp, College Station, Texas, USA).
            A total of 33 attending physicians and 49 residents responded to the survey, for a response rate of 33% and 29%, respectively. Resident respondents were evenly distributed among post-graduate years (18 intern, 16 PGY-2, and 15 PGY-3 respondents). There were 40 male, 39 female or transgender female respondents, one gender nonbinary respondent, and one respondent who declined to state their gender. Attending physicians had been in practice for an average of 7.8±5.4 years.
            Overall, the internal consistency of the survey was acceptable, with a Cronbach’s alpha of 0.77 (0.76 for resident respondents and 0.78 for attending respondents).
            Respondents were asked how frequently they examined a patient’s mouth for several admission diagnoses. Results are displayed in table 1. Residents were significantly more likely to examine the mouth of a patient receiving chemotherapy (90.4±12.8% of the time versus 73.9±29.3%, p=0.004), and attendings were significantly more likely to examine the mouth of patients with a fever of unknown etiology (78.8±23.1% of the time versus 60.2±29.6%, p=0.01).
            Respondents were asked how frequently they looked for different findings when examining a patient’s mouth (table 1). The most common examination was to look for abnormal lesions (67±32% of the time), followed by examining under the tongue (50±33%). The least common exam procedure was to evaluate for loose teeth (15±24%). An estimated 28±17% of hospitalized patients were completely edentulous. There were no significant differences in response between residents and attendings.
            Most residents and attendings somewhat disagreed or strongly disagreed that they received enough oral health training in medical school or residency (mean disagreement 4.3±1.1 and 4.4±0.9 on a 5-point Likert scale, with 1 being “strongly agree” and 5 “strongly disagree”). Respondents also strongly disagreed that they knew how to help a patient find a dentist if a patient needed to be evaluated after being in the hospital (mean disagreement 4.0±1.1).
            The plurality of respondents indicated that learning how to conduct an oral cancer screening would be extremely or very useful in the hospital medicine setting (29 of 67 respondents to the item, 43%), but believed that dental anesthesia and tooth extraction would be not at all useful (38 respondents for both items, 57%).

4. Significance of Results

Poor oral health is a common co-morbidity for hospitalized patients, most especially vulnerable patients such as those with low socioeconomic status, multiple medical comorbidities, substance use disorders, and limited English proficiency. Patients’ oral health status actually declines over the course of hospitalization, and hospitals are a common site of denture loss for older adults.
The results of this survey indicate that residents and hospitalists caring for patients in the hospital do not feel well-equipped to help meet patients oral health needs during a hospital stay. Even though respondents examined patients’ mouths during a physical exam more than half the time for select admission diagnoses, they were not confident in their ability to diagnose oral problems and did not believe they received sufficient training in oral health during medical school or residency.

5. Plans for Future Work

This study prompted multiple avenues for future work. We are working on producing a comparable survey for hospital nursing staff, with questions tailored to bedside nursing. We also plan on disseminating the validated survey to housestaff and hospitalists at several other tertiary care centers in the Boston area and nationally.
            Originally, we scheduled one-hour teaching sessions to be delivered to both housestaff and as continuing medical education to the hospitalist faculty. Due to the COVID-19 pandemic, both sessions were deferred and will now be delivered in May 2020 via videoconferencing software. We will distribute post-session surveys to evaluate changes in knowledge and attitude based on our teaching materials.