摘要：Improving oral health is a leading population health goal; however, curricula preparing health professionals have a dearth of oral health content and clinical experiences. We detail an educational and clinical innovation transitioning the traditional head, ears, eyes, nose, and throat (HEENT) examination to the addition of the teeth, gums, mucosa, tongue, and palate examination (HEENOT) for assessment, diagnosis, and treatment of oral–systemic health. Many New York University nursing, dental, and medical faculty and students have been exposed to interprofessional oral health HEENOT classroom, simulation, and clinical experiences. This was associated with increased dental–primary care referrals. This innovation has potential to build interprofessional oral health workforce capacity that addresses a significant public health issue, increases oral health care access, and improves oral–systemic health across the lifespan. During the decade following publication of the Surgeon General’s Report, Oral Health in America, health professionals, physicians (MDs), nurse practitioners (NPs), nurse–midwives (NMs), and physician assistants (PAs) began to align with the dental profession to heed Satcher’s call to “view the mouth as a window to the body.” 1 The most significant interprofessional movement that followed this report occurred with family practice and pediatric physicians coming together to work on preventive oral health initiatives for children in which those professionals would provide screenings, fluoride varnish, and referrals for children to find dental homes. Mobilization of the overall health community to work collaboratively has been slower. Development of “Smiles for Life: A National Oral Health Curriculum” 2 represented an important interprofessional “tipping point” for engaging health professionals focused on treating populations across the lifespan in considering oral health and its relationship to overall health as an integral component of their practice. Yet, evidence from national databases monitoring oral health data continue to reveal a high incidence and prevalence of dental caries, especially in lower socioeconomic and minority group populations. 3,4 Data from the 2009–2012 National Health and Nutrition Examination Survey 5 reveal that approximately one in four children (14%) aged 3 to 5 years living at the poverty level have untreated dental caries. The survey data further reveal that 19% of non-Hispanic Black children aged 3 to 5 years and 26% of Hispanic children aged 6 to 9 years had untreated dental caries compared with non-Hispanic White children aged 3 to 5 years (11%) and 6 to 9 years (14%). 6 Although national statistics show an improvement in access to oral health care for children aged 5 years and older, the data reveal significant disparities in access to care for children aged 2 to 4 years. 7 In the adult population, oral cancer morbidity and mortality rates have not declined over the past 10 years, at least in part related to absent or inadequate oral examinations, 8 and human papillomavirus is associated with the recent rise in the incidence of oropharyngeal cancer. 9 Among adults aged 65 years and older, only 30% have a dental benefit. 10 Primary care providers have been challenged by the Institute of Medicine to play a significant role in improving these oral health disparities by building interprofessional oral health workforce capacity. 10 One important component of the problem is that the majority of curricula for preparing health professionals have a dearth of oral health content and clinical experiences. Approximately 70% of medical schools include 4 hours or less on oral health in their curriculum; 10% have no oral health content at all. 11 Similarly, NPs and NMs have also not had a defined oral health curricular knowledge base nor a set of oral health clinical competencies. 12–16 The PA programs have generally followed medical school curricula and have not required curricular oral health content or competencies. 17 The recent publication of several important national reports, two oral health reports by the Institute of Medicine, 10,18 the listing of oral health as one of the Healthy People 2020 Leading Health Indicators, 19 the release of the Health Resources and Services Administration document “Integration of Oral Health and Primary Care Practice,” 20 and the dissemination of “Oral Health Care During Pregnancy: A National Consensus Statement” 21 all reaffirm oral health as a population health issue of importance for primary care providers with all data emphasizing the links between oral health and overall health and the magnitude of the national oral health access dilemma. The interprofessional education competencies 22 provided significant momentum for interprofessional oral health leaders to capitalize on the “perfect storm” created by the confluence of seminal reports to propose that oral–systemic health is a perfect population health exemplar to illustrate the interprofessional competency domains across health professions curricula. 23,24 However, the science of performing a physical examination, initially established by Hippocrates more than 3000 years ago and refined in the 13th century with the resumption of the dissection of human bodies for education, does not focus on the oral examination. 25 Health care providers have performed physical assessment of the head, ears, eyes, nose, and throat (HEENT) in the same fashion since its inception centuries ago. For the majority of primary care providers, the traditional HEENT examination excludes examination of the oral cavity, as well as omitting oral health and its linkages to overall health in the health history. 1,10–12 A simple solution to this problem is to introduce a paradigm shift to teaching the HEENT examination by using the “HEENOT” approach. Incorporating “O,” for oral cavity assessment, adds a comprehensive focus on the oral–systemic history and examination of the teeth, gums, mucosa, tongue, and palate. The HEENOT approach means that educators and clinicians can “NOT” omit oral health and intraoral assessment from the history and physical examination performed by NPs, NMs, MDs, PAs, and other health professionals. This strategy will increase oral health screenings, detection of oral health comorbidities, and preventive interventions, including referrals to dental colleagues by primary care providers in community-based settings for acute or chronic health problems commonly seen in primary care practice. This report outlines an innovative process for introducing the HEENOT examination in physical assessment courses and reinforcing the competency throughout graduate health professions curricula.
