Prognosis

This last month I finished the last of six of “morning huddles” with the six group practices in our DMD clinics. I started each huddle with a customary introductory talk about how proud I am to be the 17^th Dean of our 150-year institute (a tremendous legacy) and I talked about our four “Ps-Purpose, Passion, People, Place.” 

I then shared with the groups of students, faculty and staff what I considered to be some of the most important parts of a patient exam and planning process: conducting a thorough oral cancer screening process and thinking about “prognosis” (both from a tooth-by-tooth perspective and also from an overall patient perspective).

Recently the American Dental Association expanded its oral cancer screening policy to include oropharyngeal cancers (stating that dentists should conduct both visual and tactile exams). In this ADA News release (https://www.ada.org/en/publications/ada-news/2019-archive/september/ada-expands-policy-on-oral-cancer-detection-to-include-oropharyngeal-cancer), there was also a statistic that the CDC reported that 70% of oropharyngeal cancers are associated with the human papillomavirus (HPV). The ADA also supports the use of the HPV vaccine for preventive purposes. Dr. Mark Lerman (D02), Division Director of Oral Pathology and Interim Chair of Diagnostic Sciences, reports that the oral pathology curriculum has recently been revised to include more content devoted to oropharyngeal cancers, which have now surpassed even cervical cancers as the most common HPV-associated malignancy. Emphasis is also given to the important role dentists have an opportunity to play in screening for both oral cancer and oropharyngeal cancer.

Despite all our training there can be a tendency to look past the extraoral and intraoral exams and go right to the “chief complaint” area or the hard/soft tissue charting.

In fact, the same ADA news article also referenced a study that found that only “…about one-third of U.S. adults 30 and older who had visited a dental practice within the last two years reported receiving an oral cancer screening exam”. I was reminded of an article I read in The New Yorker that told the story of a chef who needed part of his tongue resected due to a missed diagnosis of an oral cancer (https://www.newyorker.com/magazine/2008/05/12/a-man-of-taste).

My message to each huddle group was to get into the habit of conducting an extraoral and intraoral examination for every patient to screen for oral cancer.

The second topic that I reminded our “gatherees” about was prognosis. An overall prognosis takes many factors into account, including a patient’s health status, past history, risk factors, social determinants etc. An overall prognosis allows a practitioner and patient to place treatment plans into a broader framework and context that hopefully leads to long-term success. At the “huddles” I also talked about using a tooth-by-tooth prognosis (Prognosis Versus Actual Outcome: A Long-Term Survey of 100 Treated Periodontal Patients Under Maintenance Care MK McGuire. February 1991. Journal of Periodontology. 62(1): 51-8.) for similar treatment planning/treatment decisions. It just happened that my literature review session with the Periodontology residents this past month also included the topic of prognosis. The classification systems for tooth-by-tooth prognosis usually range from “hopeless” to “excellent.” A discussion about tooth-by-tooth prognosis gives the clinician and patient a basis to discuss treatment plans in the context of short- and long-term success. It won’t be long before technology will automate this process for patients and clinicians.

I am oftentimes forced to reflect on the “prognosis” of our school. Is it “excellent, good, fair, questionable, or hopeless?” Of course this is a hard question to answer since there are so many variables to consider.

How does one measure the outcomes of our three “passions:” education committed to clinical excellence, knowledge to improve oral and general health, and care and community? One way of measuring the outcomes of our programs is through the efforts of our Outcomes Assessment Committee. I have been meeting with Dr. Lerman, Mrs. Mary-Ellen Marks and Executive Associate Dean Mark Gonthier to outline the schematic to measure our institutional outcomes. At a quick glance I would have to say many of the objective outcomes of our programs are good/excellent. I look forward to the codification of all outcomes and the work ahead to move some of the “poor” areas into better categories. Thank you to faculty, staff and students that are involved in this important work.

Another way of measuring the prognosis of our school is to look towards our alumni and to learn how they perceive TUSDM. This month I had the pleasure of traveling to California and Florida with our Development/Advancement team (Ms. Betty-Ann Kearney, Marianne Blaney and Bridget Kent) on trips to meet with alumni. In San Francisco Dr. Steven Dugoni (D79, Ao8P, A12P) and his wife Lisa hosted some of our California alums/parents. In Florida we had individual meetings with Drs Martin Sachs (A54, D56), Robert Hunter (D63), Louis Fiore (D62), James Kane (D74, DG 76, AG 78, DG79, D04P, DG06_), Samuel Meline (A54, D58, DG62, A82P, J84P, M87P) , John Marchetto (D85, DG87), and we hosted a reception for other alumni.  Dr. Peter Delli Colli (A69, D73) spoke at the reception about how alumni can get involves through the Tufts Dental Alumni Association (TUDAA).

At each of these gatherings, there were many stories shared about days at TUSDM, both prior to One Kneeland and at One Kneeland. Three themes emerged. A strong clinical foundation, committed faculty and the sense of pride about TUSDM. Stories about patients and procedures and classmates were remembered with much pride and laughter. Alumni talked about faculty that were “hard” and “challenging,” e.g. oral pathologist H Spencer Glidden (A27, M31, G62P). The sentiment was that these faculty strove for excellence—and the appreciation for the rigor has benefited many alumni when they have been in practice. Alumni remain engaged in several ways; many are annual donors to the Tufts Dental Fund, volunteers for their reunion and major gift donors and our building (e.g. Rachel’s Amphitheater named in remembrance of Dr. Fiore’s mother, Rachel Valvo Fiore) and students (financial aid and scholarships) are the beneficiaries of this generosity. Our alumni are active in ensuring our school has a great prognosis!

In other events this month we recognized our staff from central sterilization facilities (CSF) at the Dean’s Faculty/Staff breakfast. CSF Staff start their days at 7:00 AM, with “pick-ups” from the floors starting at 10:30 AM and ending at 7:30 PM. Sarah Irias who heads up our CSF staff reports to me that they run the autoclaves 22 times per day (100-150 items per cycle). Every single cassette, hand piece, bur block, implant kit, etc. is inspected by a technician for quality control before sterilization. Staff conduct 36 “pick-ups” of instruments from floors 2, 3, 4, 5, 8, 11, 12 per day, and they “drop-off” about 1,700 kits per day.

It has been another busy month! I am thankful that our faculty, staff, students and alumni are all ensuring that the prognosis of our patients and school is good/excellent!

Dean Nadeem Karimbux