Policy Implications for Dental Education

Vol. 41, No. 1-Winter, 1981 41 PANEL DISCUSSION zy Policy Implications for Dental Education H. Garland Hershey, DDS, MS* Dentistry has made great progress, particularly in the last few decades, through advances in the clinical, basic, and behavioral sciences, and the profession stands today as a mature and respected member of the health care system. Clearly the dental profession has done well, and much of the credit must go to the dental schools themselves. However, if schools are to provide continuing leadership, they must pay additional attention t o the needs of society as well as to the scientific and technical needs of the several dental disciplines. Dental curricula in the United States have not been designed with the healthcare needs of the public as the primary focus. Clinical competence in all areas of general practice has been the curriculum goal of most dental schools. The curriculum is expressed as a mosaic of the wants and needs of six to 10 clinical disciplines, each seeking to provide excellent training in its own area. Unfortunately, this broad scope of clinical competency may not meet the overall needs of the student, the profession or society. What does this mean in the context of this discussion? It means that a dental school must not only ensure that its graduates can produce an acceptable root canal filling or negotiate the intricacies of a fixed bridge, but also ensure that its graduates are capable of understanding and meeting the health care needs of the population they may be called on to serve. How? This is where the Manpower Study can have an important place in directing future curricular design. The first step is to determine the health care needs of the target population. Through the combined efforts of the North Carolina Dental Society, the Health Services Research Center, and the School of Dentistry, a description of the oral health care needs of the target population is available for the citizens of North Carolina. Step one has been accomplished. The second step is to assure the dental educator that the data are of sufficient quality and quantity to justify basing a review of the dental curriculum on the results. Although there are several areas which require and are receiving more attention, the UNC faculty think that the study has much valuable information that can and should be used in the educational process, and are convinced that the findings have important implications for the School of Dentistry as a component of curricular review and revision. In addition to its value in curricular planning, the Manpower Study is important enough for our students to understand the study as an end in itself. Both the methods and findings should be made available as part of the DDS instructional program. The complexity of the Manpower Study and the problems of linkages between and among the several components of the project provide excellent real life illustrations of some of the most significant challenges facing dentistry today. Add to this the data describing North Carolina manpower supply and distribution, the need and demand for dental care in the State, individual office productivity data, and the implications of third- zyx *Assistant Dean, School of Dentistry, University of North Carolina, Chapel Hill, NC 27514 42 zyxwvutsr Journal of Public Health Dentistry party dental coverage, and there is a wealth of information available to students at the beginning of their careers in dentistry. In order to communicate and use the results effectively, dental faculty must understand the background, rationale, methods, and findings of the study. Because of the potential influence of the study on the educational process, wide discussion and involvement by the faculty will be important. Discussion of the study at a faculty retreat and in seminar groups could ensure wide exposure and added input. When integrating the findings of the manpower study into the educational process it is vital to keep the perspective a s broad as possible and not become mired in detailed discussions of specific facts or findings. Any discussion of the study should begin from a broad philosophical perspective rather than debate the specifics of a reported number of percentage. For example, when North Carolina dentists, dental faculty, and dental students discuss the study, the one subject that is always at the top of the list is the high prevalence of periodontal disease in the state. A comment that usually follows is to suggest increasing the curriculum time for periodontics in order to solve the problem. Looking at this situation with a broader perspective, however, makes it clear that this is not a solution at all. The disease process that is so widespread is recognized as mild to moderate periodontitis, an entity well within the treatment capabilities of current DDS graduates, and, in fact, treatable by the current graduates of the dental hygiene program as well. Clearly more curriculum time for routine scaling or curetteage procedures would be an ineffectual means of dealing with the problem, as would time devoted to more involved surgical periodontics. The disease that is rampant is well within the management capacity of current graduates. Is it possible that practitioners d o not recognize the disease process? Sophisticated and recently improved evaluation measuring students’ ability to diagnose periodontal disease indicates this is not the problem. Dentists know what periodontal disease is and what it looks like. The dental graduate has both the technical or psychomotor skills and the diagnostic or cognitive knowledge to recognize and treat periodontal disease. Yet periodontics is not well controlled in North Carolina, even though the dentists and their auxiliaries can recognize the disease process and have the technical skills to treat it. Solving the problem is a challenge and there is no simple solution, but at least in regard to the issue of periodontal disease there are indications that progress will be made by exploring three fronts: first, behavioral science research into why dentists are not treating periodontal disease effectively even though they are well trained to d o so; second, why patients have so little understanding of the disease and have so little commitment to self-care; and third, basic research into the periodontal disease process itself is needed. Clearly the solution is not a different shaped curette or a new scaling technic. Review of the periodontal disease situation illustrates how traditional dental approaches with a technic or procedure orientation may not adequately deal with the dental problems of the future. More emphasis and activity in the affective domain of learning may be required if the profession is to continue to progress; and unless the basic approach to treatment of periodontal disease changes substantially, the disease will not be effectively controlled. Although it is difficult for those who are procedureoriented to admit this, the findings of the manpower study strongly suggest that we investigate the possibility. A planned future study comparing practice styles of recent graduates to long time practitioners will provide valuable information in this area. A final point to emphasize is the desirability of using the health needs of a target zyx zyxwvuts zyxwvu Vol. 41, No. 1-Winter, 43 1981 population as a basis for curricular design. In the past, dental curricula were designed to train dental students to d o what practicing dentists did (past orientation). Recently we have advanced to where our dental curriculum is based on behavioral objectives and on what dental faculty think the students should d o (present orientation). Data like those from the Manpower Study will make it possible to base the curriculum on what the population served will actually need (future orientation). This is an attractive concept, and one that is currently being investigated. Like any landmark work, the North Carolina Dental Manpower Study will raise more questions than answers. Clearly we need better data on what dentists d o and more especially why they do what they do. There are pressing needs to investigate the benefits of preventive procedures and determine the effects of involving patients more actively in maintaining their own oral health. Answers to these and other questions will lead ultimately to difficult decisions regarding changes in dental school enrollment, different teaching styles, changes in curricular emphasis for the various dental disciplines, altering the length of the educational experience, the role of dental specialties, and the position of continuing education in dental education. Use of the data provided by the Manpower Study when considering these challenging areas should assist in maximizing the potential contribution of dental education to the continued growth of the profession. zyxwv Policy Implications for Dental Research Raymond P. White, DDS, PhD* A good research study poses new questions as well as answering those formulated a t the beginning of the study. The North Carolina Research program is no exception. These remarks are intended to serve as a springboard for future research activity. Much has been learned in the past five years and all of us in North Carolina are hopeful that our studies will continue and that we can count on the help of the UNC Health Services Research Center in that effort. Dental indices utilized in epidemiology studies need a new look. The indices available for determining the prevalence of dental caries, periodontal disease, oral hygiene, and facial deformity do underestimate the need in our population. That fact must be reiterated to all those interested in dental health care. The established indices need some relation to patterns of providing dental health care. What is necessary to take a population with a given set of needs to an appropriate level of treatment? Data in the North Carolina study focused on an area as small as one of our six health systems agency (HSA) regions. Can projections be made to county levels from these data? Can the NHANES I data be utilized in other states and regions or must an indepth study similar to the one in North Carolina be done in each state? Hopefully, the North Carolina study can be used to determine an answer to such a question. *Professor of Oral and Maxillofacial Surgery and Dean, School of Dentistry, University of North Carolina, Chapel Hill, NC 27514. 44 zyxwvutsrq Journal of Public Health Dentistry A challenge for dental education will be the best utilization of the North Carolina data in the years ahead. How does the curriculum in the Dental School relate to what is happening in practice? How does the need and the pattern of demand affect both practice and the dental curriculum? Does the opinion of an “expert panel” regarding appropriate dental care in general practice bear any relation to the need and demand of the population and the dental school curriculum? What role can a concerted effort by the dental profession in health promotion and disease prevention have in reducing dental disease? Can a public health approach outside of the public school system be effective? Continued support for health services research remains a major problem particularly as it relates to manpower and patterns of care. The Kellogg Foundationdeserves much credit for their funding of the demonstration project in North Carolina. Many foundations struggle with the dilemma over funding demonstration projects vs. research. If we are to solve our health care problems somehow the focus must shift from basic research to results that can be translated into action with the shortest lead time possible. The National Institutes of Health and the Public Health Service must focus more on the problems of provision of health care in dentistry. Perhaps the dental profession has not made its needs known appropriately, but it is time to do so with a dedicated effort. The Health Services Research effort needs involvement from individuals currently in training in our education institutions. Involvement must come also from clinicians and others who have not seen this area of research as one needing their interests in the past. Only an effective new thrust will solve our problems in the future. I am confident that this effort will occur in the decade of 1980 and that the North Carolina Research studies are only beginning. The Implications of the N. C. Dental Manpower Survey and Epidemiological Survey for the Private Practitioner Mitchell Wallace, DDS* As an officer in the North Carolina Dental Society, I express the thanks of the dental profession in North Carolina to Dr. Gordon DeFriese and his staff at the Health Services Research Center in Chapel Hill for the untiring work that they have done and the unusual interest that they have shown in the Dental Manpower Survey and the Epidemiological Study. Further, may I express appreciation to Dr. Gary Rozier and Dr. John Hughes for their specialized work on this study. How is the dental profession in North Carolina implicated by this study? First I would like to talk about the positive implications. When we compare the dental health status of North Carolinians in 1976-77 with data 15 years ago we find that the dental profession has made significant contributions as follows: *President, Dental Society of North Carolina, Raleigh, NC zy zyxwvuts Vol. 41, No. 1-Winter, 1981 45 1. We find that our statewide fluoridation programs are working. Over the past 15 years there has been approximately a 15 percent overall reduction of caries in the total population under 35 years of age. Part of this reduction can be attributed to the fluoridation of public and rural water systems and school prevention programs, but we must also recognize that the dental profession in N.C. is prevention-oriented and has also contributed to this decrease. Because we are so prevention-oriented, you may understand why I was shocked by the increase in periodontal disease found in our state. 2. We are restoring more teeth in every age group-in both the black and white populations-than we were 15 years ago. 3 . While the number of missing teeth has increased among blacks, there are fewer missing teeth among whites. I feel that this is due to the increased availability or access to care for the disadvantaged. North Carolina has a comprehensive Medicaid program that includes dentistry. If a person has a toothache and meets Medicaid’s qualifications, he can have that tooth extracted. As we know, a toothache will motivate an individual to seek dental care; but the problem for all is to motivate him to seek care before his dental condition is hopeless and it becomes necessary to extract teeth. The white population seems to be more prevention-oriented and seems more motivated to have teeth restored than the black population; hence, whites are losing fewer teeth. 4. Edentulism is no longer a problem in N.C. since 95 percent of the edentulous people in our state have dentures-whether they wear them or not. There are networks of lowcost denture clinics across the state, and the N.C. Dental Society provides a denture referral service that allows anyone who can’t afford a denture at regular fees to purchase one for a negotiated fee that he can afford; therefore, anyone in our state who needs a denture should be able to get one. 5 . The study shows that we have an optimal number of dentists in N.C. to meet the current demand for dental services. There is a maldistribution of dentists in the state, and we are making efforts to place practitioners in remote or underserved areas of the state. Perhaps the problem isn’t a maldistribution of dentists, but a maldistribution of the population. Many feel that we have too many dentists in N.C. as well as across the country, and private practitioners have expressed a desire to decrease class sizes in dental schools. If the demand for dental services on a regular basis were increased by just 10 percent in N.C. and across the country, I wonder if there would really be an excess of dentists. zyxwvutsr zyxwvu zy zy To recount, the profession is implicated positively by the findings of the manpower survey and the epidemiological study in the following ways: 1. 2. 3. 4. 5. Our fluoridation programs are working We are restoring more teeth. We are extracting fewer teeth. We are meeting the demand for dentures. We have an adequate number of dentists for current demand. We can be proud of these accomplishments, but what about the negative implications of this study for the profession? As stated earlier, I was shocked to find that there is an epidemic of periodontal disease in North Carolina. My first reaction, to such an incredulous statement was that the data were wrong, the indices for determining prevalence were wrong, and the sample was biased; but as I looked at the study in detail, I found nothing to disprove the findings. Since the dental profession is clearly implicated by the findings on periodontal disease, I began to ponder the reasons for this epidemic. I would like to share some of my thoughts with you. The life-style of our non-white population has changed. Nonwhites are eating more of the wrong kinds of food. They are also becoming subjected 46 zyxwvutsr Journal of Public Health Dentistry to more stressful situations than 15 years ago. However, I feel that the chief cause is attitudinal on the part of the practitioner, the patient, and the educators. We have just gone through a period of great economic growth in our country, and the population can afford good restorative dentistry; therefore, the emphasis has been on restoration. Also, the dentist, because of high-speed technology and new impression technics, can provide crown and bridges easier than he could two decades ago. This is possibly another reason emphasis has apparently been placed on restoration. Thus, I feel that we are not as periodontally oriented as we should be. Continuing education courses are restorative oriented. We need more courses in the recognition, prevention, and treatment of periodontal disease. Curriculums in dental schools need to be assessed to see if enough time is being allocated to periodontics. Patients need to be taught that no amount of restorative care will save their teeth; and that unless they control plaque, eat the right foods, and practice good prevention technics, dentists are saving teeth now so that patients can loose them later. I feel that the problem of periodontal disease in our state is no better or worse than it is in other parts of the country. We have just identified it. Now we must d o something about it. When this study is replicated 10 years from now, I feel that the findings will show that we are making good progress toward the control of periodontal disease in our state. This study will be of value only to the extent that this is accomplished. Policy Implications for Dental Public Health E. A. Pearson, Jr., DDS, MPH* First, let me speak to policy implications for career dental health administrators. When I entered dental public health in the midJOs, the vast majority of dental health program administrators were dentists who had some private practice experience immediately following graduation from dental school (D.D.S. degree); then changing their careers from private practitioners to dental public health practitioners-with little or no experience or preparation in public health administration and research. John Hughes and I joined the staff of the North Carolina State Health Department about the same time. We were “fresh out” of private practice with a zeal to improve the dental health of the people of North Carolina. We soon recognized the need for special training in public health practice and philosophy. We went to the University of North Carolina School of Public Health and received our Masters in Public Health Administration. Being fortunate in having one of the most outstanding teachers, Edward McGavran, who taught us some of the “tools of the trade” used in public health administration, we gained insight into the philosophy of public health practice and the scientific process; i.e., how to make a diagnosis of a community. I a m pleased to quote Dr. McGavran’s philosophy: zyxwvuts *Retired Chief, Dental Health Section, Dept. of Human Resources, Raleigh, NC 27602. Vol. 41, No. 1-Winter, 1981 It becomes imperative that the purposes, objectives, functions, and missions of public health be clearly defined and understood; first, by the public health people themselves, and second, by other professions and the public at large. 47 zy I like Dr. McGavran’s philosophy! Policy-makers must have valid, defendable data upon which to make policy decisions-be they pertaining to programs, budgets, or staff. The policy-maker must know what is going on in the field of research within the state relative to the field of dentistry. There is an old adage: “Time waits for no one.” By the same line of reasoning, with the passage of time comes change. Change usually dictates that things could be done differently and more effectively. Thus, the scientific process must be applied in the collection, analysis, and reporting of the facts discovered. If these facts dictate change, one should be willing to make changes accordingly. The 1963 survey of the “Natural History of Dental Diseases” was obtained through the scientific method and was used in assessing cost-effectiveness, methods, and cause and effect relating to dental disease. This was the first time that the “tools of the trade” were used in developing our state dental health program plan. North Carolina data seemed to have greater impact on policy-makers and appropriating bodies than data collected elsewhere and then comparisons made to North Carolina. The North Carolina Legislature was much impressed with our methods of getting factual data and using them in developing our state dental health program plan. The preparation and defense of our budget before the Legislature for dental program expansion, and staffing patterns. These data and similar program-plan development were used by city and county appropriating bodies most effectively. With the information obtained through dental research and its application, the practice of dental public health changed in North Carolina-for the better, I’m happy to state. One objective of the transition from the first study (1963) to the second study (1976) was to measure what had happened over this 13-year period. The second objective was to establish a baseline to measure the effectiveness of the preventive dental program. 48 zyxwvutsrqp zy Journal of Public Health Dentistry zyxw AMERICAN ASSOCIATION OF PUBLIC HEALTH DENTISTS THE ASSOCIATION IN ACTION zyxw FORTY-THIRD ANNUAL MEETING The Forty- Third Annual Meeting of the Association was held at the Monteleone Hotel, New Orleans, LA, October 10, II,12,1980. f i e following reports of the minutes of the four sessions include: The First Session of the Executive Council on October 10; the Scientific Session on the I I th; and the Business Session and the Second Session of the Executive Council both on the 12th.