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Strive-Special Feature
Oral Cancer Screening for Women Recovering from Addictions:
By Mara Beth Womack, RDH, MS, CDA, and Emily Holt, RDH, MHA, CDA Introduction Senior dental hygiene students at the University of Southern Indiana (USI) participate in a service learning project providing oral cancer screenings and oral health education to residents of the Women’s Addiction Recovery Manor (WARM) in Henderson, Ky. Students and faculty work together to educate WARM residents about oral cancer risks, signs and symptoms and to provide oral health care education and instruction. The students screen and assess each resident while faculty members supervise. A USI faculty dentist evaluates any suspicious oral lesions or pathology detected by the students and refers residents as necessary. The USI dental hygiene students are prepared to participate in the program through training in classroom and clinical settings. Course coordinator Emily Holt, RDH, MHA, CDA, prepares and delivers the didactic training, including a step-by-step process for the care to be provided and explanation of the associated documentation. Faculty member Mara Beth Womack, RDH, MS, CDA, educates the students about addictions and what to expect with this population. Because Womack collaborates with the USI occupational therapy and occupational therapy assistant students to provide bi-weekly daily life skills instruction to WARM residents, they work with her regularly and feel comfortable with her. Whether as a direct result of the court system or by personal choice, residents at the WARM facility are in rehabilitation as they seek to overcome chemical dependency and addiction. The Kentucky Alliance program, which installed rehabilitation centers throughout the state, is based on a social rather than a medical rehabilitation model, using a peer-to-peer self-help recovery system rather than medical detoxification. The non-profit organization offers a year-long recovery program based on personal accountability, peer support and job responsibilities. As a residence for homeless women suffering from alcohol or drug addiction, WARM is an apt acronym, offering a home-like atmosphere. A lobby adjoins a living room with a fireplace used during the winter months, and warm colors were selected for the decor. Family are welcome during visiting hours; many residents have children, most of whom have been surrendered to the state or to family members willing to assist them during the recovery process. “My crime is considered a victimless one, but I say, there are no victimless crimes. My family, my children and I are the victims of my crime. My crime is a disease: the disease of addiction is cunning, baffling and powerful.”[1] Four separate housing units represent the four progressive phases of the program: two “Safe Off the Street” (SOS) units and one each for Phase I and Phase II. All four units flow into a central hall connecting the kitchen, lobby and living room. As a resident earns trust through program compliance, she advances to a different section of the facility. Each step affords the resident increased living space and privileges. Residents are accountable for their personal space and its cleanliness, including their own laundry. Resident responsibilities include gardening, cooking and preparing meals, housekeeping, plumbing, lawn care and other duties. Fulfilling these responsibilities counts as program compliance, so the WARM facility is impeccably kept.
Project Objectives Increased Oral Awareness and Education for the WARM Resident A 2008 study by Barbadoro and coauthors found that “education of alcohol-dependent individuals in a rehabilitation setting may contribute to their attention to oral health and willingness to change habits.”[2] USI dental hygiene students find the residents in desperate need of oral health instruction. Students provide basic oral care information, such as tooth brushing and flossing instruction, a description of periodontal disease and its risk factors, and nutritional information. Addicts tend toward a poor diet that can be high in carbohydrates—especially sugars and acidic beverages, which contribute to dental problems. After completing the oral cancer screening, residents often express interest in how their personal risk factors, especially sexual activity, contribute to increased risk for oral cancer. Students are able to provide personalized explanations based on individuals’ risk assessments. Early Intervention and Decreased Cost to the Resident and Community Individuals fighting addictions are at a higher risk of developing oral cancer due to lifestyle factors such as drug and alcohol abuse and unsafe sexual activity. This population has limited access to dental services due to lower incomes and mental health concerns related to their addictions. The service learning project addresses the needs of both students and residents since it allows the students to experience serving a diverse population of individuals who normally do not seek preventive dental services but do seek acute care for dental emergencies. This high-risk population frequently seeks care through the hospital emergency room instead of routine dental office visits: a poor use of hospital resources that can lead to a serious financial burden for the individual and the community. Through the service learning project, students address residents’ concerns about oral conditions such as decayed and abscessed teeth, damage from methamphetamine use, aphthous ulcers and dry mouth. Students advise residents of their oral health status and refer them as necessary, an early intervention that helps prevent the need for emergency treatment. Residents’ oral problems, such as caries and periodontal disease, can also be diminished through the oral health education the students provide. Students evaluate toothbrushing and flossing skills and give residents the tools to perform these procedures correctly. Students also address tobacco cessation and distribute quit line cards to residents interested in learning about local tobacco cessation resources. This can reduce the risk for both periodontal disease and oral cancer. A report by UCLA’s Semel Institute for Neuroscience and Human Behavior suggests that the public has a clear financial incentive to allow offenders to enroll in a drug treatment facility versus imprisonment. Undertaken to review the first 30 months following implementation of California law allowing treatment as an alternative to prison, the study found that taxpayers saved nearly $2.50 for every dollar (a total of more than $173,000,000) invested in drug treatment, a finding corroborated by many other studies. Savings to the taxpayers increased to nearly $4.00 for each dollar spent if the offender successfully completed the rehabilitation program. Researchers factored in savings due to the decrease in probation fees, inmate housing fees, parole and re-arrests, as well as future court fees.[3]
Challenges Faced Establishment of Community Partnership Due to her personal interest in voluntary service to individuals struggling with addictions, Womack established a working relationship with the board members and executive director of WARM in 2007, before the facility opened to the public. This relationship, along with the life skills program involving the occupational therapy and dental hygiene students that began once residents began the recovery program, opened the door for the oral cancer screening program provided by dental hygiene students and faculty.
Development of the Project The oral cancer screening project evolved out of the personal interests of Womack and Holt to serve a diverse population of individuals working to recover from addictions. The addictive individual’s risk for oral cancer is high due to previous or present lifestyle choices coupled with limited access to care. Some local dental offices choose not to serve them due to their history of chemical dependency. Unemployment, homelessness and lack of transportation and financial resources are some of the obstacles this population faces daily. Additionally, the intensive nature of the Kentucky Alliance WARM rehabilitation program renders residents unemployable for 9-12 months. Neither Womack nor Holt had ever participated in an oral cancer screening program for a similar population, so it needed to be created from the ground up. They created all the documents based on others from current screening and risk assessment programs. These included a risk assessment tool filled out by the resident with space for the student to note the types of screenings performed and any suspicious lesions noted, as well as a diagram for the students to give each resident illustrating their oral cancer risk level. The tool was built to facilitate data collection for future research.
Limited Resources and Grant Writing Since this project was a novel idea in the dental hygiene program, no financial resources were in place to completely support its cost. With limited funding as an obstacle, Holt secured a small one-year grant from the Southwestern Indiana Oral Health Foundation, which made initiation of the project possible. The following year, an Indiana Campus Compact Scholarship of Engagement Faculty Grant provided funds for the project to continue. These funds were used for clinical supplies, screening kits, oral health education tools and printing the forms used to document data from students and residents. ViziLite™, a system comprising a chemiluminescent light source to improve visualization of lesions that might otherwise be invisible, was used as an adjunct to the conventional head and neck examination. ViziLite™ is designed to be used in a patient population with an increased risk for oral cancer.
Travel Students provided their own transportation to the WARM facility, carpooling with other classmates to Henderson, Ky., from Evansville, Ind., a journey of approximately 35 minutes one way. Students voiced no concerns related to travel, and they enjoyed the camaraderie, with several of them meeting for lunch prior to the project.
Lighting The first year, student clinicians used individual pen lights to carefully view the residents’ oral tissues. Since the natural lighting in the large activity room cannot be adequately reduced, it was a challenge to use the ViziLite™ screening kits correctly. In 2009, resources from the Indiana Campus Compact Scholarship of Engagement Faculty Grant and funding from a research grant allowed for investment in 25 pairs of ViziLite™ goggles. The goggles served to decrease the lighting in the room and provide a better contrast when assessing the oral cavity, enhancing identification of pathology.
Oral Cancer Screening Project Procedures Faculty asked the students to arrive 30 minutes early to set up infection control and screening materials. The first year, the project served approximately 75–100 WARM residents and lasted about two hours. This ongoing project aims to serve 100 residents each year. The project proceeded as follows: 1. Introduction of faculty and student clinicians to the WARM residents
Rewards and Reflections Rewards for the WARM Residents During the spring semester in 2009, as WARM residents neared graduation from the rehabilitation program, they were rewarded for program compliance. Dental hygiene appointments were scheduled with one of the senior dental hygiene students who had participated in the fall oral cancer screening project. Many of the residents had not received dental hygiene treatment or radiographs for many years. Upon completion of their dental hygiene treatment, residents were prepared to advance to job interviews and re-enter the workforce with a healthier smile and improved self-esteem. This activity was a huge confidence-builder for the WARM residents. While the 2008 screening did not require additional follow up care/referrals, the 2009 oral screening did identify two residents in needed of referral for follow up care. They were assessed and examined by an oral surgeon donating services, and their abnormal-appearing lesions were determined to be benign.
Students’ Comments At the end of the oral screening project, the dental hygiene students and faculty members were invited to join WARM residents for a prayer—a tradition of Alcoholics Anonymous that was unfamiliar to many students. The social intimacy the students experienced helped them bond emotionally with the WARM residents. The students wrote a reflective paper about their experience. They shared comments such as, “My mom is an alcoholic,” and ”The WARM residents are people just like us, who made bad decisions,” and “That could have been my sister who has a drug problem.” Students observe firsthand the actions and reactions of residents in an environment conducive to improving mental health and how it impacts their physical well-being. The WARM project allows students an opportunity to utilize oral cancer screening techniques they studied and tried on each other in the classroom. Student reflection papers indicated that the experience increased their awareness about the potential for chemical dependency and drug use to affect their other patients.
Increased Desire to Continue Community Service Students’ experiences expanded their learning and helped them recognize that a community facility such as WARM falls well within their scope of practice and professional service learning. Several students indicated a desire to incorporate service into their careers and to build the interpersonal skills needed to work with patients with mental health issues manifesting as addictions. During the final semester of the year the project started, a professional issues course assigned a political action paper. Over 75 percent of the students chose to address the use of tax dollars for addiction rehabilitation versus incarceration. As one student wrote, “Harm reduction seeks to restore basic human dignity to dealing with the disease of addiction.”[4] This is exactly what programs such as WARM provide: a reduction protocol to restore dignity to those who are willing to have it restored. Review of the students’ political action papers convinced the instructor that their attitude was a direct result of the WARM oral cancer screening experience. Educators’ Reflections The WARM oral cancer screening is a wonderful, worthwhile teaching experience for USI dental hygiene students and faculty members. The screening session allows students to interact directly with people who appear very different from their typical patients in a dental setting. The students’ insightful comments captured in the reflection papers differ from the thoughts they expressed prior to visiting the WARM facility. Initially, they had anxiety about what they would encounter when they arrived and uneasiness about their interaction with the drug-addicted women. Their ideas about this population changed, and their preconceived notions were discarded following the project. It is refreshing as an educator to see the mental transformation and attitudinal change occur in the students. The students achieved a heightened awareness and an increased level of comfort when conversing with their clients about chemical addictions. At the university level, a student’s didactic performance is emphasized, but this clinical experience gives and requires something more. Books, lectures and teacher comments mean very little until an individual experiences something for themselves. Personal views can remain biased or distorted due to the lack of interaction or personal knowledge. The WARM experience for the USI dental hygiene students was a turning point to a better understanding of a diverse population that many had not previously understood.
References 1. Alcoholics Anonymous World Services, Inc. The AA big book, how it works, 4th ed. New York: Alcoholics Anonymous World Services, Inc., 2001. Mara Beth D. Womack RDH, MS, CDA, practiced clinically as a dental assistant and dental hygienist for over 27 years before joining the faculty of the University of Southern Indiana, at which time she was responsible for numerous didactic and clinical teaching responsibilities in both the dental assisting and dental hygiene programs. She is an active member of the Kentucky Dental Hygienists’ Association, holding a variety of leadership positions at the component and state level since 1978. Presently, she is a member of the KDHA Board of Trustees and a member of the Kentucky Board of Dietitians and Nutritionists. Emily Holt, RDH, MHA, CDA, is an assistant professor of Dental Hygiene and Dental Assisting at the University of Southern Indiana in Evansville, Indiana. Mrs. Holt incorporates service learning into her General and Oral Pathology course for senior dental hygiene students. She can be reached at erholt@usi.edu.
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