Innovation in Undergraduate Dental Education: Forging a Pathway to Dentistry's Future
Jack Dillenberg, DDS, MPH; and Leonard B. Goldstein, DDS, PhD
The dental profession, in conjunction with the development and implementation of "whole person healthcare" and dental/systemic disease prevention, must continue to push forward, and the A.T. Still University Center for the Future of the Health Professions intends to help it do just that.
Guided by the ATSU mission of, "commitment to continue its osteopathic heritage and focus on whole person healthcare, scholarship, community health, interprofessional education, diversity, and underserved populations," the Center's overarching goals are aligned with those of the Health and Human Services (HHS) "Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030." These goals include attaining health literacy and health equity, eliminating disparities, and improving the health and well-being of all populations. Additionally, the Center recognizes the number one barrier to dental care that must be addressed, especially for the underserved: cost.1
This challenging task for dentistry must begin with some changes in dental education. For clarity, one can look to the past, where in the early 20th century a group that called themselves “stomatologists” wanted all dentists to be recognized medical specialists, while most medical professionals preferred dentistry to continue as it began in the mid-1800s as a trade rather than a medical profession. The establishment of dental education as a separate pathway was initiated due to a lack of interest in dental problems by medical educators.2,3 In the 1920s Dean Alfred Owre of Columbia University College of Dental Medicine first noted there were some students who as “dental mechanics should be taught to do the more manual work, while the dentist would be the diagnostician and treat the complex cases.”4 “Oral Health in America: A Report of the Surgeon General” (2000) states, “Oral health is integral to general health; this report provides important reminders that oral health means more than healthy teeth, and that you cannot be healthy without oral health.”5 Therefore, obtaining and maintaining oral health cannot be separated from overall health, and dentistry cannot be separated from medicine.
Stamping Out Inequities
Healthcare today is marked by structural inefficiencies, unprecedented costs, and fragmented care delivery, and despite America's investment in healthcare and the availability of state-of-the-art technology, inequities in oral health/healthcare persist across populations.6 Breakthroughs in biomedical science have generated new treatments for dental and systemic disease problems that were previously untreatable or only symptomatically managed. Diagnostic technologies also have become more precise and can potentially transform dentistry by tailoring diagnostics, therapeutics, and prevention measures to individual patients.7
Uncertainties continue to abound about whether, how, and how quickly emerging care delivery models might affect dentist supply and demand. Growth in demand for healthcare services is projected to exceed the growth of dentist supply. This may exacerbate geographic balances in supply, thus aggravating extant disparities in geographic distribution.
As George E. Thibault, MD, president of the Josiah Macy Jr. Foundation, stated in that organization's 2015 Annual Report: “In our vision for the future of health professions education, intelligent use of educational and information technologies supports the linkage between education and delivery systems to create a continuously learning health system. In this system, teachers, learners, and clinical data inform continuous improvement processes, enable lifetime learning, and promote innovation to improve the health of the public.”8
Dental education must be aligned with the changing healthcare delivery system and changing societal needs. A transformation must take shape in dental education that leads to clinical practices, whether individual or group, aligning with the healthcare needs of society. Despite the rapid and dramatic changes in healthcare, with an aging population growing more diverse and experiencing higher rates of chronic conditions, some dental education must emphasize quality improvement, community-based training opportunities, and/or interprofessional education and teamwork.
While a mismatch exists between the supply and demand for dentists in certain regions, this mismatch is seemingly more a maldistribution of dentists rather than an absolute shortage. Affluent communities appear to be adequately served, while rural and lower-income areas are underserved. Our challenge includes finding ways to create more community-based clinical training programs in these underserved regions.
Dental education can and must innovate to address the needs of local communities while creating opportunities for dental students to acquire skills in community health, population health, and social determinants of health by gaining meaningful experience in caring for underserved patients in clinics serving the homeless, free clinics, and federally qualified health centers (FQHCs). Clinical rotations should be established at nontraditional settings, including FQHCs, community hospitals, rural health clinics, Indian health service and tribal clinics, and homeless shelters.
Exposure to rural communities appears to positively influence student attitudes about treating underserved populations. Additionally, dental students from rural areas are more likely to return to rural areas to practice.9,10 Dental school graduates from rural areas are three times more likely to return to rural areas compared to dental school graduates from urban areas—18% compared to 6%.11
Lack of access to basic dental services contributes to profound and enduring oral health disparities in the United States. Millions of children and adults do not receive needed clinical and preventive services. In 2011, 6.1% of children and 16.4% of adults did not receive necessary dental care because their families could not afford it.12 Children are only one of many vulnerable and underserved populations that face persistent, systemic barriers to accessing oral healthcare.13 Population health encompasses clinical and nonclinical approaches for improving health, preventing disease, and reducing health disparities. Fostering effective and sustainable partnerships is integral to building a culture of health and expanding opportunities for community health improvement, regardless of ethnic, geographic, racial, socioeconomic, or physical circumstances.
Innovation in Dental Education: The ASDOH Experience
Donald B. Giddon, DMD, PhD, in his Annual Lecture in Behavioral Medicine and Dentistry at Harvard University titled, “Revolution Redux: 150 Years After Beginning the First University Dental School,” commented on the relatively new dental school at A.T. Still, which, “not modeled after Harvard School of Dental Medicine…recognized that dental practice as we know it today does not necessarily lead to oral health. To ensure that both therapeutic and preventive measures are included, Jack [Dillenberg] named his new school the Arizona School of Dentistry And Oral Health (ASDOH). This was done to secure that a core value of ASDOH was and is the integration of oral health into whole person health, which leads to the inclusion of oral health in primary care.”
ASDOH was the first dental school to require all students to obtain a Certificate in Public Health (CPH) through online courses to ensure graduates had basic knowledge of population health and the important role of dentists in leading their communities to higher levels of health and wellness. Many ASDOH students graduate with both Doctor of Dental Medicine (DMD) and Master of Public Health (MPH) degrees. ASDOH has established an extensive collaboration with FQHCs and community health centers (CHCs) for dental student rotations. ASDOH requires that students spend half of their fourth year in external sites, from Hawaii to Maine, for up to 5 weeks, supervised and educated by ASDOH adjunct faculty employed by the site. These sites, which are able to keep the significant revenue generated by the ASDOH students, are encouraged to provide housing for the students, who pay for their travel through funds secured in their student loan package.
ASDOH has further continued the concept of innovation by creating a “faculty advance” (not retreat!) to bring together all of the onsite adjuncts to the school in Arizona for training, calibration, team building, and personal growth. Students write reflections of their experiences, which demonstrate to ASDOH leadership the profound positive effect these experiences have on preparing the students for the potential of practicing in rural and underserved communities.
Additionally, ASDOH is committed to recruiting and retaining American Indian (A-I) students to meet the compelling shortage of A-I dentists in America. When ASDOH began, there were only 98 A-I dentists out of more than 150,000 dentists in the United States. ASDOH hired Dr. George Bluespruce, the first A-I to graduate from an American dental school, as Assistant Dean for American Indian affairs. He had founded the Society of American Indian Dentists (SAID) and served as its president for more than a decade, and continues to recruit and mentor ASDOH A-I students. ASDOH has graduated A-I dentists from over 40 tribes, and all but one are practicing in A-I communities.
ASDOH developed a modular format for the delivery of its basic science curriculum. This accelerated though rigorous format enables students to take part one of the national boards after their first year. This frees up significant time in year two for the students to develop their leadership skills, working on “dentistry in the community” activities, receiving extensive simulation experience, and entering the clinic early in their education, while working on their CPH.
Finally, ASDOH requires that all students care for and manage patients with intellectual developmental disabilities and medically complex conditions. The school's annual Day for Special Smiles, a national program that provides free care for children with these conditions, was started by an ASDOH student. Also, ASDOH was the 2014 recipient of the William Gies award for Innovation.
Other dental schools are beginning to recognize the importance of many of the innovations at ASDOH and are moving toward positive changes in their curriculum and clinical training. Now, it is the responsibility of the dental profession to embrace these innovations in practice, including interprofessional, team-based diagnosis, treatment, and case management.
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