LETTERS EQUIPPING THE PHYSICIAN ASSISTANT WORKFORCE TO END ORAL HEALTH DISPARITIES The recent article by Haber et al.1 rightfully emphasizes the public health crisis reinforced when providers overlook the oral---systemic connection; and the innovative HEENOT approach to physical examination is a potential boon for putting the mouth back in the body while fostering the development of interprofessional competencies among providers who will have a shared way of conducting a physical examination that appropriately includes the mouth. Like our nursing colleagues, the physician assistant (PA) profession has embraced oral health as the low hanging fruit of prevention, aiming to ensure that PAs are equipped with appropriate oral health competencies. In 2008, seminal work by Jacques et al. found that only 32.8% of responding PA programs (n = 83) provided oral health instruction.2 Shortly thereafter in 2010, the four major national PA organizations, representing the profession’s regulatory, educational, and membership entities, came together to leverage a collective impact strategy.3,4 They would use this strategy to achieve the shared goal of equipping the PA workforce of more than

Letters to the editor referring to a recent Journal article are encouraged up to 3 months after the article's appearance. By submitting a letter to the editor, the author gives permission for its publication in the Journal. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 10 references. Submit online at www. editorialmanager.com/ajph for immediate Web posting, or at ajph.edmgr.com for later print publication. Online responses are automatically considered for print publication. Queries should be addressed to the Editor-in-Chief, Mary E. Northridge, PhD, MPH, at [email protected].

100 000 certified PAs5 to make the oral--systemic connection and contribute to the improvement of oral health in our country. With support from the National Interprofessional Initiative on Oral Health (NIIOH) and funding from the DentaQuest Foundation, Washington Dental Service Foundation, and the Connecticut Health Foundation, the PA Leadership Initiative in Oral Health fosters the organizations’ ability to work together in mutually supportive ways on activities that each organization is uniquely equipped to conduct in support of shared goals. Annual summits allow for environmental scanning, sharing of outcomes, evaluation of lessons learned, and the opportunity to vision together about future activities to advance the profession’s capacity to be part of the solution for reducing oral health disparities. Four short years later, the PA profession has expanded its reach, partnering with stakeholders across medicine, dentistry, nursing, pharmacy, HRSA, the workforce community, and others as a way for PAs to advance this important public health issue. A 2014 national survey of PA program directors measured oral health penetration in their curriculum, and the results indicated a significant uptake of oral health topics; 78.4% of responding programs (n = 125) had integrated oral health content,6 a notable increase over the 2008 study. These efforts reflect our belief that public health is best served through the collective impact of health professions that innovatively equip practitioners with the appropriate competencies and skills to achieve shared goals of improving health. j Cynthia Booth Lord, MHS, PA-C

About the Author Cynthia Booth Lord is with the nccPA Health Foundation, a supporting organization of the National Commission on Certification of Physician Assistants (NCCPA), and the Physician Assistant Program at Case Western Reserve University, Cleveland, OH. Correspondence should be sent to Cynthia Booth Lord, Chair, nccPA Health Foundation, 12000 Findley Road, Suite

May 2015, Vol 105, No. 5 | American Journal of Public Health

100, Johns Creek, GA 30097 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted February 9, 2015. doi:10.2105/AJPH.2015.302632

References 1. Haber J, Hartnett E, Allen K, et al. Putting the mouth back in the head: HEENT to HEENOT. Am J Public Health. 2015;105(3):437---441. 2. Jacques PF, Snow C, Dowdle M, Riley N, Mao K, Gonsalves WC. Oral health curricula in physician assistant programs: a survey of physician assistant program directors. J Physician Assist Educ. 2010;21(2):22---30. 3. Kania J, Kramer M. Collective impact. Stanford Soc Innov Rev. 2011;(82): 36---41. 4. Hanleybrown F, Kania J, Kramer M. Channeling change: making collective impact work. Stanford Soc Innov Rev. 2012;(20):1---8. 5. NCCPA. Fact Sheet 2015. Available at: http://www. nccpa.net/Upload/PDFs/NCCPA%20Fact%20Sheet. pdf. Accessed February 2, 2015. 6. Langelier MH, Glicken AD, Surdu S. Adoption of oral health curriculum by physician assistant programs. J Physician Assist Educ. In press.

HABER ET AL. RESPOND We thank Lord for her thoughtful letter in response to our recent article. We salute the physician assistant (PA) profession for their commitment to increasing the integration of oral health and its relation to overall health in the curriculum of PA programs. The comparison between her 2008 and 2014 data for responding PA programs (n = 125) is noteworthy; to achieve a greater than 75% uptake in the PA program integration of oral health topics in six years is impressive. Oral health and its links to overall health is an all-too-often forgotten aspect of primary care. The potential contribution of the primary care workforce in increasing oral health access, decreasing oral health disparities, and improving oral health and overall health outcomes is significant. In a recent article in the New England Journal of Medicine, Donoff et al.1 support the idea that a national effort is needed to integrate oral health care and medical care, particularly in primary care and the primary care medical home. Central to achieving this

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objective is a national policy change requiring integration of oral health and its relationship to overall health as a standard component of the curriculum of all health professionals. The report, Integrating Oral Health and Primary Care Practice,2 disseminates interprofessional oral health core competencies that can be used for guiding oral health curriculum integration in medical, nurse practitioner, midwifery, physician assistant, dental, and pharmacy programs. Transitioning the head, eyes, ears, nose, and throat (HEENT) component of the health history and physical examination to the teeth, gums, mucosa, tongue, and palate examination (HEENOT) approach is a first step in making sure that the oral cavity is not a forgotten part of health care! Equally important is widening the general health lens that our dental colleagues use in their practice. Recent revision of accreditation standards across the professions requiring evidence of interprofessional education and practice experiences make oral-systemic health the perfect exemplar to use for meeting interprofessional accreditation standards and criteria. Opportunities for collaboration and referral abound; the ultimate population health beneficiaries of “putting the mouth back in the head” are our patients, who, across the life span, will have more effective “whole person” health care. j

This letter was accepted February 20, 2015. doi:10.2105/AJPH.2015.302648

Contributors All authors contributed equally to this letter.

References 1. Donoff B, McDonough JE, Riedy CA. Integrating oral and general health care. N Engl J Med. 2014;371 (24):2247---2249. 2. Integration of Oral Health and Primary Care Practice. Rockville, MD: US Department of Health and Human Services, Health Resources and Services Administration; 2014.

Judith Haber, PhD, APRN, BC Erin Hartnett, DNP, CPNP, BC Kenneth Allen, DDS, MBA Donna Hallas, PhD, CPNP, BC Caroline Dorsen, PhD, FNP, BC Julia Lange-Kessler, DNP, CM, RN Madeleine Lloyd, MS, FNP, BC, PMHNP, BC Edwidge Thomas, DNP, ANP, BC Dorothy Wholihan, DNP, ANP, BC, PCNP, BC

About the Authors Judith Haber, Erin Hartnett, Donna Hallas, Caroline Dorsen, Madeleine Lloyd, Edwidge Thomas, and Dorothy Wholihan are with the College of Nursing, New York University, New York, NY. Kenneth Allen is with the College of Dentistry, New York University. Julia Lange-Kessler is with the School of Nursing and Health Studies, Georgetown University, Washington, DC. Correspondence should be sent to Judith Haber, Associate Dean of Graduate Programs, New York University, College of Nursing, 433 First Avenue, 5th Floor, New York, NY 10010 USA (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

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American Journal of Public Health | May 2015, Vol 105, No. 5

Haber et al. respond.

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