COMMENTARY

Putting the Mouth Back in the Head: HEENT to HEENOT

Improving oral health is Judith Haber, PhD, APRN, BC, Erin Hartnett, DNP, CPNP, BC, Kenneth Allen, DDS, MBA, Donna Hallas, PhD, a leading population health CPNP, BC, Caroline Dorsen, MSN, FNP, BC, Julia Lange-Kessler, DNP, CM, RN, Madeleine Lloyd, MS, FNP, BC, goal; however, curricula pre- PMHNP, BC, Edwidge Thomas, DNP, ANP, BC, and Dorothy Wholihan, DNP, ANP, BC, PCNP, BC paring health professionals have a dearth of oral health DURING THE DECADE FOLLOW- have untreated dental caries. The base nor a set of oral health content and clinical experi- ing publication of the Surgeon survey data further reveal that clinical competencies.12---16 The ences. ’ We detail an educational General s Report, Oral Health in 19% of non-Hispanic Black chil- PA programs have generally fol- and clinical innovation transi- America, health professionals, dren aged 3 to 5 years and 26% lowed medical school curricula and tioning the traditional head, physicians (MDs), nurse practi- of Hispanic children aged 6 to 9 have not required curricular oral ears, eyes, nose, and throat tioners (NPs), nurse---midwives years had untreated dental caries health content or competencies.17 (HEENT) examination to the (NMs), and physician assistants compared with non-Hispanic The recent publication of sev- addition of the teeth, gums, (PAs) began to align with the White children aged 3 to 5 years eral important national reports, mucosa, tongue, and palate dental profession to heed Satcher’s (11%) and 6 to 9 years (14%).6 two oral health reports by the examination (HEENOT) for call to “view the mouth as a win- Although national statistics show Institute of Medicine,10,18 the list- assessment, diagnosis, and dow to the body.”1 The most signif- an improvement in access to oral ing of oral health as one of the treatment of oral–systemic icant interprofessional movement health care for children aged 5 Healthy People 2020 Leading health. Many New York Uni- 19 versity nursing, dental, and that followed this report occurred years and older, the data reveal Health Indicators, the release of fi medical faculty and students with family practice and pediatric signi cant disparities in access to the Health Resources and Services have been exposed to in- physicians coming together to care for children aged 2 to 4 Administration document “Inte- terprofessional oral health work on preventive oral health years.7 gration of Oral Health and Pri- HEENOT classroom, simula- initiatives for children in which In the adult population, oral mary Care Practice,”20 and the tion, and clinical experiences. those professionals would provide cancer morbidity and mortality dissemination of “Oral Health This was associated with in- screenings, fluoride varnish, and rates have not declined over the Care During Pregnancy: A Na- creased dental–primary care 21 referrals for children to find dental past 10 years, at least in part tional Consensus Statement” referrals. homes. related to absent or inadequate all reaffirm oral health as a popu- This innovation has po- Mobilization of the overall oral examinations,8 and human lation health issue of importance tential to build interprofes- sional oral health workforce health community to work collab- papillomavirus is associated with for primary care providers with capacity that addresses a oratively has been slower. Devel- the recent rise in the incidence of all data emphasizing the links significant public health is- opment of “Smiles for Life: A oropharyngeal cancer.9 Among between oral health and overall sue, increases oral health National Oral Health Curriculum”2 adults aged 65 years and older, health and the magnitude of the care access, and improves represented an important interpro- only 30% have a dental benefit.10 national oral health access di- oral–systemic health across fessional “tipping point” for engag- Primary care providers have been lemma. The interprofessional ed- Am J Public the lifespan. ( ing health professionals focused challenged by the Institute of ucation competencies22 provided Health. Publishedonlineahead on treating populations across the Medicine to play a significant role significant momentum for inter- of print January 20, 2015: e1–e5. lifespan in considering oral health in improving these oral health professional oral health leaders to doi:10.2105/AJPH.2014.302495) and its relationship to overall disparities by building interpro- capitalize on the “perfect storm” health as an integral component fessional oral health workforce created by the confluence of of their practice. capacity.10 seminal reports to propose that Yet, evidence from national da- One important component of oral---systemic health is a perfect tabases monitoring oral health the problem is that the majority population health exemplar to data continue to reveal a high in- of curricula for preparing health illustrate the interprofessional cidence and prevalence of dental professionals have a dearth of oral competency domains across caries, especially in lower socio- health content and clinical experi- health professions curricula.23,24 economic and minority group ences. Approximately 70% of However, the science of per- populations.3,4 Data from the medical schools include 4 hours or forming a physical examination, 2009---2012 National Health and less on oral health in their curric- initially established by Hippo- Nutrition Examination Survey5 ulum; 10% have no oral health crates more than 3000 years ago reveal that approximately one in content at all.11 Similarly, NPs and and refinedinthe13thcenturywith four children (14%) aged 3 to 5 NMs have also not had a defined the resumption of the dissection of years living at the poverty level oral health curricular knowledge human bodies for education, does

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not focus on the oral examination.25 health workforce capacity by Health care providers have per- “putting the mouth back in the Interprofessional Oral Health Core Competencies formed physical assessment of the head.” Building on the Health as Identified by New York University College of Nursing head, ears, eyes, nose, and throat Resources and Services Adminis- (HEENT)inthesamefashionsince tration report, “Integrating Oral Demonstrate inclusion of oral health in the HEENT components of the comprehensive its inception centuries ago. For the Health and Primary Care Prac- history and physical examination (HEENOT). majority of primary care providers, tice,”20 we have identified inter- Develop a risk profile that includes oral and oral–systemic health problems. the traditional HEENT examination professional oral health core Develop a patient-centered management plan that includes oral health interventions excludes examination of the oral competencies for our NP and NM related to overall health. cavity, as well as omitting oral health primary care students, introducing Smoking cessation and its linkages to overall health in an oral health knowledge base Tooth brushing and flossing the health history.1,10---12 and clinical competencies (see the Fluoride varnish application A simple solution to this prob- box on this page) early in the Oral cancer screening lem is to introduce a paradigm shift curriculum that are consistently Engaging patients in behavioral change by using motivational interviewing to teaching the HEENT examina- built on and reinforced in diagnosis Parental anticipatory guidance tion by using the “HEENOT” ap- and management courses and clin- Lifestyle counseling proach. Incorporating “O,” for oral ical rotations. Our innovation is the d Eating disorders cavity assessment, adds a compre- transformation from HEENT to d Diabetes hensive focus on the oral---systemic HEENOT, so that oral health and d Hypertension history and examination of the its relation to overall health is in- d Sexually transmitted diseases teeth, gums, mucosa, tongue, and tegrated in the history, physical d Dentures palate. The HEENOT approach examination, risk assessment, and Symptom management means that educators and clinicians management plan completed by d Xerostomia can “NOT” omit oral health and primary care NP and NM students. d Mucositis intraoral assessment from the his- This innovation is applicable in d Oral lesions tory and physical examination per- MD, PA, and pharmacy programs. Collaboration and referral formed by NPs, NMs, MDs, PAs, Notes. HEENOT = head, ears, eyes, nose, oral, throat examination; HEENT = head, ears, and other health professionals. This Oral Health and Advanced eyes, nose, and throat examination. The oral examination includes examination of the strategy will increase oral health Health Assessment Courses teeth, gums, mucosa, tongue, and palate. screenings, detection of oral health The advanced health assess- comorbidities, and preventive in- ment courses taken by NP and NM terventions, including referrals to students are designed to develop dental colleagues by primary care interprofessional oral health core the clinical simulation learning involving intraoral inspection, as providers in community-based set- competencies that are integrated center as they practice their oral well as placing hands inside the tings for acute or chronic health into the comprehensive health examination skills as a component oral cavity, are frequently un- problems commonly seen in pri- history and physical examination of the HEENOT assessment and, familiar occurrences for patients; mary care practice. This report (see the box on this page). ultimately, in the overall physical therefore, students integrate re- outlines an innovative process for Faculty and preceptor develop- examination teach-back and com- assurance and patient education introducing the HEENOT exami- ment to build clinical competencies petency evaluation. about the importance of the oral nation in physical assessment and an oral health knowledge base Classroom presentations inte- examination and its link to courses and reinforcing the com- has been essential. Innovative cur- grate oral health with traditional overall health that is appropriate petency throughout graduate ricular strategies have been devel- head and neck content. In the to the patient’s health literacy health professions curricula. oped to introduce the HEENOT clinical simulation center, students and cultural background. Sum- content and clinical competency. participate in simulation experi- mative evaluation includes METHODS Depending on the NP or NM pro- ences that include HEENOT a performance examination and gram’s population focus, students complaints such as mouth pain, checklist; each student must New York University (NYU) are required to complete appro- bleeding gums, mucosal ulcera- conduct a comprehensive his- College of Nursing, with its unique priate modules from Smiles for Life tions, and sore throat; they sub- tory and physical examination organizational partnership with (SFL), the Web-based interprofes- sequently complete a variety of on a standardized patient, in- the NYU College of Dentistry, is sional oral health curriculum,2 in case-based clinical history and cluding demonstration of the capitalizing on the growing mo- preparation for didactic and clinical physical examination simulation HEENOT competency. mentum of the national movement experiences. The SFL modules of- and standardized patient experi- The oral health curriculum to build interprofessional oral fer visual references to students in ences. Thorough oral examinations thread is reinforced and increases

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in complexity in diagnosis and competency as a component of past year is referred to general subsequent diagnosis and manage- management courses. Specific SFL client encounters. At NYU College practice dental clinics. Dental stu- ment courses. Students have modules assigned as review mate- of Nursing’s Nursing Faculty dents and faculty refer dental pa- a three-week rotation with second- rial or new modules are added as Practice (NFP), an NP-managed tients to the NFP if they have not year DDS students at a Head Start assigned course preparation. In adult primary care practice lo- had physicals in the past year, do Center in which up to 50 high-risk the Health Promotion course, stu- cated at NYU College of Dentistry, not have primary care providers, or children are screened and evalu- dents complete the Geriatric Oral the standard of care has been re- have untreated general health ated at each session. The NP and Health module because they par- vised to include interprofessional problems such as hypertension. DDS students collaborate; dental ticipate in interprofessional oral oral health core competencies (see Primary care providers also students teach PNP students how to cancer and diabetes screenings the box on page e2), and NP manage the oral health compo- complete an oral assessment by and health promotion presenta- and NM students are expected to nent of systemic health problems using the knee-to-knee approach tions at senior centers focusing on demonstrate these competencies. (see the box on this page). For and to apply fluoride varnish. Nurse oral health and overall health. In Changes made to the electronic example, an older adult patient practitioner students teach the den- the Geriatric Syndromes course health record templates prompt presented with a chief complaint tal students how to use motivational they integrate geriatric oral health student and faculty NPs to include of dry mouth (xerostomia). Overall interviewing as a tool to provide with overall health needs of frail oral health questions in the health assessment data, including HEE- parents with oral health anticipatory older clients with multiple chronic history (e.g., orofacial pain, loose NOT, revealed that the patient was guidance and how to behaviorally health problems. Diagnosis and teeth, mouth burning, and so on). taking multiple medications for hy- manage young children in a dental management courses integrate Prompts have been added to the pertension, chronic obstructive pul- setting.27 oral health assessment into overall physical examination section of the monary disease, and depression, all assessment and completion of an electronic health record for docu- of which have an anticholinergic oral---systemic risk assessment mentation of oral clinical findings effect contributing to the xerosto- RESULTS profile, the development of the based on assessment of the lips, mia. The NP student educated the differential diagnosis, and a man- tongue, gums, mucosa, teeth, and patient to consider use of sugarless The HEENOT curriculum in- agement plan within the scope of hard and soft palate. candy, toothpaste designed for dry novation at NYU, designed to practice. Data from the comprehensive mouths, and mouthwash to pro- build interprofessional oral health Recognizing that adequate ac- or focused history and physical mote symptom improvement, and primary care workforce capacity, cess to oral health care is a major examination, including HEENOT evaluated the patient’s medications demonstrates significant scalabil- public health concern, students findings, are considered when for a potential change in dosage or ity potential. Between 2011 and communicate with, collaborate students and faculty NPs synthe- product to decrease the severity of 2014, more than 150 NP, NM, with, and refer to dental col- size information obtained from the the xerostomia. DDS, and MD faculty at NYU leagues, and expect reciprocal history and physical to formulate In the pediatric nurse practitioner have participated in oral health collaboration and referral pat- risk assessments and develop (PNP) program, the HEENOT ex- and interprofessional education terns from dental practices to treatment plans that include pri- amination is first introduced in the professional development pro- their primary care counterparts. mary, secondary, and tertiary health promotion course with grams; approximately 350 adult, Innovative interprofessional prevention oral health interven- SFL modules and reinforced in family, pediatric, and psychiatric NP clinical simulations using stan- tions within scope of practice, dardized patients and case study including collaboration and re- sessions, using oral---systemic ferral. The oral---systemic con- Systemic Health Issues With Oral Health Comorbidities, health and HEENOT as an ex- nection becomes a clinical reality New York University College of Nursing emplar, are held with NP, NM, when patients with diabetes are dental (DDS), and MD students assessed and diagnosed: the risk Diabetes: periodontal disease to develop HEENOT as well as for periodontal disease is docu- Cancer: mucositis, xerostomia, bleeding gums, osteonecrosis collaborative competencies, as out- mented, especially if bleeding or Hypertension: periodontal disease lined in the interprofessional edu- red gums and loose teeth are Autoimmune diseases (e.g., pemphigus, lupus, Sjo¨gren’s): xerostomia 22,26 cation competencies. observed and the hemoglobin Eating disorders: enamel erosion A1c is elevated. Management HIV: oral lesions Implementing of diabetes is provided by NP Human papillomavirus: oropharyngeal cancer lesions Interprofessional Oral Health faculty and students, and refer- Sinus infection versus tooth abscess Competencies rals are made to NYU College Older adults: xerostomia resulting in caries, root caries, diabetes, oral pain, and Primary care student clinical of Dentistry periodontal clinics. Any poor nutrition from ill-fitting dentures or bridges, and so on. experiences provide opportunities patient who does not have a dentist Palliative care: symptom management to integrate the HEENOT or has not had a dental visit in the

Published online ahead of print January 20, 2015 | American Journal of Public Health Haber et al. | Peer Reviewed | Commentary | e3 COMMENTARY

and NM students have demon- among nondental providers. Contributors 10. Institute of Medicine. Improving strated interprofessional oral health A paradigm shift from the tradi- All authors worked to develop the access to oral health care for vulnerable HEENOT innovation, integrated it into and underserved populations. 2011. competencies by including HEE- tional HEENT to the HEENOT their practices, and contributed to the text. Available at: http://www.iom.edu/ NOT in the history and physical approach will prepare the primary Reports/2011/Improving-Access-to- examination as well as integrating care workforce to meet this chal- Oral-Health-Care-for-Vulnerable-and- Acknowledgments Underserved-Populations.aspx. Accessed oral---systemic health data into their lenge by thinking about oral--- We acknowledge funding by Dentaquest, July 30, 2014. ’ the Washington Dental Service Founda- patients risk assessment and man- systemic health as an important 11. Ferullo A, Silk H, Savageau J. tion, the Connecticut Health Foundation, agement plan. One hundred percent population health issue and by Teaching oral health in U.S. medical and the Health Resources and Services schools: results of a national survey. Acad of our NP and NM student cohort considering interprofessional oral Administration. Med. 2011;86(2):226---230. completedrequiredSFLmodules; health core competencies as inte- 12. Dolce MC, Haber J, Shelley D. Oral 98% demonstrated oral health gral with the traditional compre- References Health Nursing Education and Practice competencies in physical assessment hensive approach to assessment, 1. US Department of Health and Hu- Program. Nurs Res Pract. 2012;2012: man Services. Oral Health in America: A performance examinations. diagnosis, and treatment.18 Em- 149673. Report of the Surgeon General. 2000. A random retrospective elec- bedding interprofessional educa- Available at: http://profiles.nlm.nih.gov/ 13. Jablonski R. Nursing education and research (geriatrics). Talk presented at: tronic health record adult patient tion competencies about commu- ps/retrieve/ResourceMetadata/NNBBJT. Accessed July 30, 2014. Committee on an Oral Health Initiative; chart review at the NFP docu- nication and team building will June 28, 2010; Washington, DC. 2. Clark MB, Douglass AB, Maier R, mented inclusion of HEENOT facilitate preparation of a collabo- et al. Smiles for Life: A National Oral Health 14. National Organization of Nurse Practi- data by 58% of NP students and rative practice-ready primary care Curriculum. 3rd ed. Society of Teachers of tioner Faculties. Nurse practitioner core com- petencies. 2011. Available at: http://www. NP providers. The PNP students workforce that functions as high- Family Medicine; 2010. Available at: http://www.smilesforlifeoralhealth.com. nonpf.org/resource/resmgr/competencies/ revealed 100% integration of oral performance interprofessional fi Accessed July 30, 2014. npcorecompetencies nal2012.pdf. Accessed health data documented in patient teams in accountable care organi- July 30, 2014. 3. Centers for Disease Control and charts. Since 2007, 115 PNP, 20 zations and primary care medical Prevention, National Center for Health 15. National Organization of Nurse family nurse practitioner, 20 MD, homes. Statistics. National Oral Health Surveil- Practitioner Faculties. Population-focused nurse practitioner competencies. 2013. and 860 DDS students, as well The results of the HEENOT lance System. 2010. Available at: http:// www.cdc.gov/nohss. Accessed July 29, Available at: http://www.nonpf.org/ as 130 pediatric dental residents initiative at NYU College of Nurs- 2014. resource/resmgr/competencies/ populationfocusnpcomps2013.pdf. have been exposed to interprofes- ing and College of Dentistry pro- 4. Dye BA, Thornton-Evans G. Trends Accessed July 30, 2014. sional oral health experiences. vide evidence that NP and NM in oral health by poverty status as mea- 16. American College of Nurse-Mid- Data from interprofessional adult students are ideal to involve with sured by Healthy People 2020 objectives. Public Health Rep. 2010;125(6):817--- wives. ACNM Core Competencies for oral---systemic health clinical sim- dental students, as well as medical 830. Basic Midwifery Practice. 2012. Available at: http://www.midwife.org/ ulations and case study experi- students, for interprofessional 5. Centers for Disease Control and ACNM/files/ACNMLibraryData/ Prevention, National Center for Health ences reveal that 330 MD, NP, oral---systemic health experiences UPLOADFILENAME/000000000050/ Statistics. National Health and Nutrition NM, and DDS students demon- that lead to the acquisition of in- Core%20Comptencies%20Dec% Examination Survey. 2014. Available at: 202012.pdf. Accessed July 29, 2014. strated evidence of competency for terprofessional oral health com- http://www.cdc.gov/nchs/nhanes.htm. interprofessional oral---systemic petencies and become an integral Accessed July 30, 2014. 17. Hooker RS, Berlin LE. Trends in the supply of physician assistants and nurse 6. Dye BA, Xianfen L, Thornton-Evans health assessment and treatment component of primary care prac- practitioners in the United States. Health G. Oral health disparities as determined planning. Improvement in collabo- tice, thus contributing to the Aff (Millwood). 2002;21(5):174---181. by selected Healthy People 2020 oral ration and referral is evidenced by Healthy People 2020 goals for health objectives for the United States, 18. Institute of Medicine. Advancing oral more than 1000 referrals between improving oral health. j 2009---2010: NCHS data brief, No. health in America. 2011. Available at: http://iom.edu/Reports/2011/ 2008 and 2014 to the NFP from 104, August 2012. Available at: http://www.cdc.gov/nchs/data/ Advancing-Oral-Health-in-America. the NYU dental clinics that resulted About the Authors databriefs/db104.htm. Accessed July aspx. Accessed July 30, 2014. in actual primary care appointments, Judith Haber, Erin Hartnett, Donna Hallas, 30, 2014. 19. US Department of Health and and more than 500 referrals to the Caroline Dorsen, Madeleine Lloyd, Edwidge 7. Federal Interagency Forum on Child Human Services. Healthy People 2020: Thomas, and Dorothy Wholihan are with ’ NYU dental clinics from the NFP.26 and Family Statistics. America s Children: Leading Health Indicators. 2014. Avail- New York University College of Nursing, New Key National Indicators of Well-Being, able at: http://healthypeople.gov/2020/ York, NY. Julia Lange-Kessler is with 2013: Oral Health. 2013. Available at: LHI/default.aspx. Accessed July 30, DISCUSSION Georgetown University School of Nursing http://www.childstats.gov/pdf/ac2013/ 2014. and Health Studies, Washington, DC. ac_13.pdf. Accessed July 29, 2014. 20. US Department of Health and Kenneth Allen is with New York University Human Services, Health Resources and The national public health College of Dentistry, New York, NY. 8. National Cancer Institute. SEER Can- Services Administration. Integration of Correspondence should be sent to Judith cer Statistics Review, 1975---2007. 2009. challenge to improve access to oral oral health and primary care practice. Haber, New York University College of Nursing, Available at: http://seer.cancer.gov/csr/ health, thereby decreasing health 726 Broadway 10th Floor, New York, NY 1975_2007. Accessed July 30, 2014. 2014. Available at: http://www.hrsa. disparities and improving both 10003 (e-mail: [email protected]). 9. Cohan DM, Popat S, Kaplan SE, gov/publichealth/clinical/oralhealth/ primarycare/integrationoforalhealth. oral health and overall health Reprints can be ordered at http://www.ajph.org Rigual N, Loree T, Hicks WL Jr. Oropha- by clicking the “Reprints” link. ryngeal cancer: current understanding pdf. Accessed July 30, 2014. outcomes, requires building inter- This article was accepted on November and management. Curr Opin Otolaryngol 21. Oral Health Care During Pregnancy professional workforce capacity 24, 2014. Head Neck Surg. 2009;17(2):88---94. Expert Workgroup. Oral health care

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during pregnancy: a national consensus statement. 2012. Available at: http://www.cdph.ca.gov/programs/ MCAHOralHealth/Documents/MCAH- OHP-OralHealthPregnancyConsensus2011. pdf. Accessed July 30, 2014. 22. Interprofessional Education Collab- orative Expert Panel. Core competencies for interprofessional collaborative prac- tice: report of an expert panel. 2011. Available at: http://www.aacn.nche.edu/ education-resources/ipecreport.pdf. Accessed July 30, 2014. 23. Haber J. Building a culture of col- laboration: interprofessional education and practice. J Acad Disting Educ. 2014; 2(1):12---14. 24. Klink K, Joskow R. Interprofessional education and practice: an opportunity to reunite the mouth with the body and make the patient whole. J Acad Disting Educ. 2014;2(1):6---11. 25. Walker HK. The origins of the history and physical examination. In: Walker HK, Hall WD, Hurst JW, eds. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Boston, MA: Butterworths; 1990. 26. Haber J, Spielman A, Wolff M, Shelley D. Interprofessional education between dentistry and nursing: the NYU experience. J Calif Dent Assoc. 2014; 42(1):44---51. 27. Hallas D, Fernandez JB, Herman NG, Moursi A. Identification of pediatric oral health core competencies through inter- professional education and practice. Nurs Res Pract. In press.

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