From Head to Toe: Integrating Oral and Primary Health Care in the Dental Clinic

Welcome to Primary Care Considered, the blog of the Student Leadership Committee at the Center for Primary Care. Featured monthly in the Center’s newsletter, this section will highlight the projects, activities, and past successes of the SLC. Please join us at our events and share your thoughts!

In this post, SLC member and Harvard School of Dental Medicine (HSDM) student Lily Liu shares her experience as a fourth year student mentor to first year dental students participating in the new Foundational Continuity Clinic (FCC) at HSDM. In this clinic, first year and fourth years students work together to integrate the oral and primary health care of patients, with supervision by both Dental and Primary Care Medicine preceptors. The goal is to provide total, person-centered care for HSDM patients, and an innovative integrated learning opportunity for students at all stages of their training.

Wednesday mornings are unusually packed at 188 Longwood Ave.

Twice the normal number of student providers crowd the Harvard School of Dental Medicine (HSDM) Teaching Practice’s forty-three operatories. Half the students in blue disposable gowns zip from cabinet to cabinet, extracting supplies. We swipe disinfecting wipes across every surface, rustle instrument cassettes from autoclave bags, and click rapidly through the electronic medical record displayed on each operatory’s computer. We are the usual crew–fourth year students familiar with the clinic’s workings. But this year, my classmates and I are the first fourth year class to share our Wednesday mornings with some new guests.

It’s not hard to spot them. The second half of the students, attired identically in scrubs and blue gowns, begin the morning huddled in groups of two or three. They stand closely in these islands of friends, trying to take up less space as the clinic bustles around them.

These first year dental students spend almost all of their time in classrooms at Harvard Medical School across the courtyard, but every other Wednesday morning is a special chance to get acquainted with the clinic where they’ll spend their third and fourth years. They are the pilot class in a new initiative at the school: the Foundational Continuity Clinic (FCC).

FCC at HSDM is the sister of a similar initiative at HMS, which began as part of the Pathways curriculum in fall 2015. In FCC, medical students begin rotating at a primary care clinical site from year one and continue at the same site through their clinical years.

Many people don’t think of a dental clinic as a primary care site. However, dentists—general dentists especially—have a longitudinal and care coordinating role for their patients, managing their oral health from teething to dentures. According to the CDC’s most recent data on healthcare utilization, published in 2014, about 60% of Americans had a dental visit in the past year while only about 45% had at least one physician visit. This statistic, the increasing prevalence of chronic diseases in America, and our persistent primary care physician shortage has led to a number of calls for dentists to play a greater role in providing primary care services to patients. If primary care in the dental office is the practice landscape of the future, it makes sense for HSDM students to be prepared and trained in these competencies now.

HSDM Dean of Education, Dr. Sang Park, spearheaded the development of FCC. When we spoke on the subject, she shared that HMS and HSDM have strengthened their partnership in the past several years, with increased oral health education in the medical curriculum as well as increased primary care education in the dental school curriculum. She described FCC as a natural next step in this trend, a unique opportunity to combine oral health and primary care teaching and practice.

To make this innovative education effort possible, another set of new faces join HSDM clinical faculty on Wednesday mornings—primary care physicians. They and a number of the dental faculty act as preceptors, watching and providing feedback as the first years take histories and do basic physical exams on the patients. They also answer questions that patients may have about primary care needs.

For fourth year dental students, the Wednesday morning initiative goes by a different name, Leadership in Oral Health and Primary Care (LOHPC). For Dr. Park, peer mentorship and the opportunity for vertical relationships between classes were both important components of the new initiative. As the team leaders for each patient encounter, fourth years direct first years’ work while teaching them about both dentistry and primary care.

As a fourth year student myself, I was excited about this opportunity. I’ve always been passionate about the integration of oral and systemic health—it’s a major reason I came to HSDM for dental school. So I took this new responsibility as a chance to think critically about how to best integrate primary health care into my patient visits.

In the past, I have found this to be challenging, especially in the setting of certain appointments called “recall appointments.” In a typical recall appointment, I am meeting the patient for the very first time. My tasks include building rapport while skimming years of electronic medical record notes, updating the medical history, diagnosing new complaints, collecting pertinent consults, updating x-rays, performing intraoral and extraoral exams, and finally, completing a dental cleaning.

As compared to the many consecutive visits I get with the panel of patients I’m assigned longitudinally, the time constraint in recall appointments makes it difficult to get an in-depth picture of patients’ overall health. It is tempting to skimp on comprehensive history-taking in order to get everything else done. I imagine this tension mirrors that experienced by many practicing dentists who are routinely crunched for time.

But FCC brings history-taking front and center. After I introduce myself and my first year colleague, the first year student takes the lead on the patient interview, seeking to elicit the patient’s medical history comprehensively. Once in a while, I interject to clarify a particular part of the history I think warrants further exploration. With three more years of clinical knowledge under my belt, I feel a lot more comfortable going from broad questions to narrow, diagnosis-guiding ones. But for the most part, I try to listen quietly and give the first year student the opportunity to connect with our patient.

At the end of these appointments, I know much more about my recall patients than I used to before being joined by my first year colleagues. Dr. Hugh Silk of UMass Medical School, a leading advocate for oral health within primary care and one of the primary care physicians who acts as a preceptor for FCC, summed up what I was experiencing when I spoke with him: “Dentists, like any specialists, tend to get trained to become overly focused on one part of the body and can lose focus on the rest of the body. FCC helps students learn to take a much broader history.”

It’s an important habit for me to learn as a fourth year student. For the first year dental students, the importance of taking a thorough medical history is being instilled even earlier, with more time allotted in their training specifically for that purpose.

Going forward, Dr. Park intends to pursue increased medical-dental partnership. “Dentists have been strong advocates for oral health in medicine,” she says, “and it’s time to ask if the reverse is also happening.” Meanwhile, Dr. Silk asks the same question of physicians and physicians-in-training: “If you’re in primary care,” he notes, “there’s no part of your body that isn’t your domain, that you can just ignore. Every one of your patients is growing teeth, has teeth, or is in the process of losing teeth. You have to take that seriously.”

Wednesday mornings at HSDM prove that there are students, dentists, and physicians who are taking both primary care and oral health seriously, and their teamwork gives me confidence that even more opportunities for integration will arise in the years to come.
Lily Liu is a fourth year student at Harvard School of Dental Medicine. She is graduating this year and will be completing a general dentistry residency at FenwayHealth in Boston. She can be reached at