In this article, we describe the impact of the Title VII, Section 747 Training in Primary Care Medicine and Dentistry (Title VII) grant program on the development, growth, and expansion of general dentistry and pediatric dentistry (PD) residency programs in the United States. We first briefly describe the legislative history of the Title VII program as it pertains to dental education, followed by a historical overview of dental education in the United States, including a description of the differences between dental and medical education and the routes to professional practice. We then present an extensive assessment of the role of the Title VII grant program in building general and pediatric dental training capacity, diversifying the dental workforce, providing outreach and service to underserved and vulnerable populations, stimulating innovations in dental education, and engaging collaborative and interdisciplinary training with medicine. Finally, we call for broadening the scope of the Title VII program to allow for predoctoral training (dental student education) and faculty development in general dentistry and PD.
Brief Legislative History of the Title VII Program
From 1963 to the present, the Title VII grant program has undergone many shifts in focus as a result of successive legislative acts.1 In the beginning, the 1963 Health Professions Education Assistance Act expanded the general supply of physicians and ensured the financial viability of health professions schools largely through school construction grants. The 1971 Comprehensive Health Manpower Training Act increased support for training primary care medical and dental providers, awarded start-up and conversion grants, and provided grants for postgraduate training of physicians and dentists.
Authorization of grant support for postdoctoral general dentistry (PGD) training began in 1976 with the Health Professions Education Assistance Act, which allowed for grants to dental schools and postgraduate dental training institutions to plan, develop, and operate general practice residency (GPR) programs. It also provided stipend support to residents enrolled in these programs.1
In the reauthorization of the Title VII grant program in 1985, the act was amended to include advanced education in general dentistry (AEGD).2 In 1992, the reauthorization amended the general dentistry section to include support of innovative and nontraditional methods of providing general dentistry education.2
The 1998 Health Professions Education Partnerships Act reauthorized and consolidated different federal health professions training programs previously authorized under Title VII of the Public Health Service. Title VII continued to focus on the production of primary care physicians, dentists, and physician assistants and on getting primary care health care providers into medically underserved communities. For the first time, pediatric dental residency training was included in the dental disciplines eligible for grant funding.1
Dental Education in the United States
In the United States, the education of dentists typically consists of four years of professional (predoctoral) training after three to four years of undergraduate (baccalaureate-level) university education. The predoctoral curriculum generally includes basic science and preclinical instruction in the first two years, and clinical science instruction in the latter two years. On graduation from dental school, graduates may apply for licensure and enter into general practice. Unlike medicine, dentistry does not have a universal residency requirement as a prerequisite for licensure, although some states are moving in this direction.3 Despite the lack of a requirement for dental residency training, a sizeable proportion of dental school graduates (38.6% in 2005) pursue advanced dental education immediately after graduation from dental school.4
In 2008, there are 58 dental schools in 34 states plus the District of Columbia and Puerto Rico that offer predoctoral dental education. From 1950 to 1980, the number of dental schools increased from 42 to 60. During that time, federal construction grants were available to meet a perceived need to expand the number of all health care professionals, including dentists.5 However, between 1985 and 1995, six private dental schools closed, and class sizes were reduced in many of the dental schools that remained open.3 As a result, the equivalent of 20 average-size schools closed between the 1980s and 1990s. In 1980, with 60 dental schools, the average class size was at its highest at 380. By 1993, with 54 dental schools, the average class size was 300.3 Consequently, the supply of U.S. dental school graduates decreased from a high of 5,756 in 1982 to 3,778 in 1998.3 Between 1995 and 2005, one additional dental school closed, and three new private schools opened, resulting in 56 dental schools and approximately 4,350 graduates annually.6 Two new dental schools have opened in 2008, and a few more are in the planning stages (personal communication, Gina G. Luke, director of legislative policy development, American Dental Education Association, June 23, 2008). During the time when these changes were occurring, the U.S. population has grown larger, aged, and become more diverse.3
Dental residency programs
Dental residency programs provide advanced education for dentists who wish to become dental specialists or who desire additional training in general dentistry. There are two types of advanced general dentistry training programs that are currently accredited by the American Dental Association Commission on Dental Accreditation (CODA): GPR and AEGD programs.7 There are 49 accreditation standards stipulated by CODA that regulate the format and content of PGD programs. Forty-four of these standards are identical for GPR and AEGD programs; meaningful differences exist in only five of the standards. Thus, the reasons for having two different accredited programs in PGD are now largely historical.8–10
In 2007, the most recent year for which information is available, there were 708 dental residency training programs in the United States, 341 at dental schools and 367 at sites other than dental schools, such as hospitals.11 These programs include 193 GPR programs, 83 AEGD programs, and 69 PD residency programs. The remaining 363 programs provide postgraduate training in the other dental specialties. The total number of first-year positions in these 708 programs was 2,881.11 This was roughly equivalent to two thirds of the number of dental school graduates (4,515) that same year,12 although some resident positions were occupied by non-U.S. dental graduates. Residency training is required to practice in any of the nine recognized specialties of dentistry: dental public health, endodontics, oral and maxillofacial surgery, oral and maxillofacial pathology, oral and maxillofacial radiology, orthodontics and dentofacial orthopedics, PD, periodontics, and prosthodontics. However, it is generally not required to practice general dentistry, which is the predominant mode of practice and potentially also the broadest in scope. A dental school graduate in the United States who has also passed one or more of the 14 regional or state licensing boards currently in operation, or completed a residency year in a few states (in lieu of the licensing examination), can enter directly into private dental practice.
General dentistry is responsible for the diagnosis, treatment, management, and overall coordination of services that address patients’ oral health needs.13 PD is an age-defined dental specialty that provides both primary and comprehensive preventive and therapeutic oral health care for children from infancy through adolescence, including those with special health care needs.13 In 2005, the latest year with available information, there were 176,634 practicing dentists in the United States.14 Of these total practicing dentists, approximately 80% were general dentists. Pediatric dentists made up of only 3% of the professional workforce.14
Dentists who complete residency training in general dentistry have received advanced training and experience in disease diagnosis and treatment planning, advanced technical procedures, management of medically compromised patients, multidisciplinary care, and cultural competency, beyond that which dental students experience within the typical dental school curriculum.15 Tejani et al, in a survey of dentists who completed a GPR program and of dentists who had not completed a hospital program, found practice characteristics suggesting enhanced clinical skills in oral surgery, periodontics, emergency dental care, and oral medicine/pathology in those completing a hospital program.16 Dixon et al found that dentists who completed a one-year U.S. Air Force AEGD program perceived themselves to be more competent in 9 out of 60 areas at the completion of their training than when they graduated from dental school.17 These areas were administering medications, managing patients with disabilities/special health care needs, and managing patients with periodontal disease.
PD residents receive advanced education and training in diagnostic and surgical procedures, child psychology and clinical management, oral pathology, pediatric pharmacology, radiology, child development, management of oral–facial trauma, caring for patients with special health care needs, conscious sedation, and treatment of children under general anesthesia. Residencies generally include rotations in pediatric medicine and experiences in other hospital settings, ambulatory medical care, and community clinic settings.15
Demand for postdoctoral dental education exceeds the number of postdoctoral residency positions. During the first 20-year history of Title VII funding for dental residencies, 72% of the net growth in programs and 77% of the net growth in positions occurred through the assistance of these federal funds. Yet, there remain an insufficient number of postgraduate training positions to meet the demand for residency training.15
Differences Between Dental and Medical Education and Routes to Professional Practice
Medicine has long required residency training as a prerequisite for practicing as a physician. This universal incorporation of residency training has allowed predoctoral medical education to focus primarily on knowledge acquisition and exposure to clinical experiences and career opportunities, thereby allowing the acquisition of advanced clinical skills and treatment of more difficult patients to occur in residency programs.3 An important factor in the adoption of required residency training in medicine was the significant economic advantage to hospitals provided by low-paid medical residents.10 A similar set of economic incentives for hospitals, providers, and other health care facilities to support required residency training does not currently exist in dentistry.
Although there have been numerous calls from national commissions and organizations for required dental residency training before granting a license to practice dentistry,10 most states still allow graduates of U.S. accredited dental schools to take state or regional board examinations and obtain a license to practice dentistry without first completing a residency. The lack of a universal residency requirement for dentistry has meant that the basic dental school curricula have been structured to prepare students for direct entry into practice on graduation. There have been concerns about the limitations of this traditional approach to educating dentists. These concerns include the growing difficulties in incorporating into dental school curricula an expanding basic and clinical knowledge base and the range of clinical experiences necessary to serve the needs of an aging and diverse population, the growing disparities between the extent of clinical competencies afforded by dental school curricula and the scope of procedures performed by practicing dentists, and the limited exposure of dental students to diverse patient populations in diverse clinical settings.3,18,19
Although dental education plays a crucial role in preparing dentists and other health practitioners to meet the oral health needs of the public, dental education has not received the benefit of broad public policy and support. Unlike medicine, where all but four states have at least one medical school and every state has numerous medical residency programs, as of 2005, 16 states had no direct means to educate dentists, and several states had no residency programs.3 Federal funding for dental education has been highly variable and has significantly declined in the past two decades, such that less than 1% of predoctoral dental education revenues in 2001 came from federal funds.20 State and local government support for dental education has also fallen drastically in recent years.20 Declines in public funding for dental education and dental schools’ inability to identify replacement funds, along with economic and political changes, are contributing factors in the closing and downsizing of U.S. dental schools during the past two decades.
In addition to reduced public funding for predoctoral dental education, there have also been significant reductions in the level of federal funding for postdoctoral training programs in dentistry when stricter regulations were imposed on the application of graduate medical education (GME) funds for hospitals. For a while, the opposite was true: in the Balanced Budget Act of 1997, Congress excluded dental and podiatric residents from a cap it imposed on allopathic and osteopathic residency slots. It also allowed hospitals to collect indirect GME payment for residents who receive their training in nonhospital settings, with the goal of expanding the number of dental and other residency slots in primarily nonhospital locations. This change allowed dental schools to partner with hospitals and resulted in a large increase in the number of dental residency programs that received support through this mechanism. However, in 2003, the federal Center for Medicare and Medicaid Services issued new regulations that disallowed many of these hospital/dental school collaborations.21 This and subsequent changes in regulations have resulted in the closure of many non-hospital-based dental residency programs and have discouraged the formation of new programs.
Current Challenges in Dental Education
The decline of public funding for dental education, along with associated weak economic conditions, has created an impending crisis in dental education. Preparing dentists to enter professional practice is expensive and labor intensive. The costs of providing clinical instruction are, on average, five times the costs of basic science instruction.3 The main reason for the high relative cost of clinical instruction in dental education is that a broad array of diagnostic, preventive, restorative, and surgical procedures are taught to individuals who have no prior clinical experience. This intensely “hands-on” learning process takes place in clinics operated by dental schools primarily for the purpose of student instruction. The dental clinics where students spend two or more years refining their patient-care skills are within the physical plant of the dental school. Therefore, each dental school operates a 100- to 200-chair outpatient surgical facility within its walls. This model is very different from the medicine model, where much of the clinical instruction and intense interaction with patients takes place after medical school in residencies operated by other entities that are primarily for delivering clinical services to the public, such as hospitals or ambulatory care facilities.3
As a result of the high cost of clinical instruction and the decline of public funding for dental education, dental school tuition has been escalating, and student debt has been on the rise. Rising tuition costs and student indebtedness affect career decisions, including practice locations and whether to specialize, participate in public programs such as Medicaid, and pursue academic careers.3
There is also a looming faculty shortage crisis,22 which in large part is related to the great disparity in income between dental school faculty and dentists in private practice. This compensation gap has occurred primarily because faculty salaries have not kept pace with income increases for private practice dentists.4,23–25 Vacant clinical science and basic science positions have increased significantly in recent years.3 As of 2002, few students in the pipeline were interested in academic careers,26 and there are no signs that this trend has changed. Only 0.8% of the 2005 dental school graduates intended to immediately enter into academic careers.4 This is a serious problem when one realizes that as long ago as 2002, 50% of all dental faculty were 50 years old or older and 20% were 60 or older.26
Dental education also recognizes that it has an urgent imperative to educate and train a more diverse workforce to meet the needs of an increasingly diverse population in the United States. Underrepresented minority (URM) enrollment in dental schools actually decreased in the decade of the 1990s.26 Major efforts are needed to strengthen the academic pipeline, including exposing minority and economically disadvantaged students and youths at a much earlier stage to information about careers in the health professions.
In the largest private funding program for dental education in history, the Robert Wood Johnson Foundation in 2000 and, subsequently, The California Endowment in 2001, established the National Dental Pipeline Program. The 15 dental schools that have participated in this program have significantly increased the number of URM and low-income students enrolled.27 Additionally, these schools have also increased the number of days students and residents spend in rotations to community sites treating diverse populations.27
Dental Workforce Trends
With the U.S. population increasing faster than the number of available dentists, there will be a steady decline in the supply of dental providers to meet the future demands for dental services.28 The aging of the population and the retention of teeth also contribute to the growing demand for dental care.29 The projected number of active dentists in 2020 is expected to decrease 23%, from a high in 1987.30 Presently, there is a geographic maldistribution of dentists, which contributes to the problem of difficult access to care for those in need.29 Additionally, there are striking disparities in oral disease prevalence and access to oral care by income, race, and ethnicity.31 The Health Resources and Services Administration (HRSA) reported that there were 3,706 dental health professions shortage areas in need of a total of 6,668 dentists in 2007 (personal communication, Steven Robeson, senior information specialist, HRSA Information Center, Merrifield, Va, July 22, 2008). This was an increase from 792 shortage areas in need of 1,400 dentists in 1993.3
In PD, there also is an anticipated shortage of pediatric dentists to meet the needs of the public.32 As a group, pediatric dentists have for some time provided a disproportionate amount of care to young, low-income, vulnerable children compared with general dentists.33,34 The projected shortage of pediatric dentists is of particular concern, because the Centers for Disease and Control and Prevention recently reported that the prevalence of dental caries in preschool children ages 2 to 5 years increased 15% during the past decade. Additionally, 74% of young children who have experienced caries were in need of dental repair.35
Barriers to Oral Health and Access to Oral Health Services
In 2000, the Surgeon General’s Report on Oral Health brought to public attention that despite substantial progress in improvements in the oral health of Americans, significant disparities persist and that, in fact, a “silent epidemic of oral diseases is affecting our most vulnerable citizens—poor children, the elderly, and many members of racial and ethnic minority groups.”31
Individuals with special health care needs have higher rates of oral and craniofacial diseases, but they must deal with significant barriers to accessing oral health care including transportation problems and physical, psychological, and economic factors. In fact, there are dramatic and increasing difficulties in obtaining dental services faced by people with physical, medical, and psychological disabilities.36 Factors that complicate access to oral health care, especially as individuals with disabilities move from childhood to adulthood, are the lack of availability of dental providers trained to serve special-needs populations and limited third-party support for the delivery of complex services. Special-needs patients and economically disadvantaged patients are more likely to receive their dental care from hospital-trained general dentists.37 That is often because hospital-trained general dentists are significantly more likely to be on hospital staffs and to treat medically compromised patients, thus improving access to dental care for underserved populations.38
In children with special health care needs (CSHCN), dental care has been reported to be the most common unmet health care need, with 8% of parents or caregivers reporting that their children needed dental care that they were unable to obtain.39 Major barriers to the delivery of oral health services for such children include cost, insurance coverage, and availability of appointments.40 In 2004, Casamassimo et al found that dentists with advanced general dentistry training, including hospital-based GPR experience, were no more likely to care for CSHCN than were dentists without this advanced training. They found that only 10% of the surveyed general dentists indicated that they treated CSHCN often or very often, whereas 70% reported that they rarely or never treated CSHCN.41 However, pediatric dentists have been more likely to provide care for CSHCN. In a 2002 survey of the members of the American Academy of Pediatric Dentistry, 95% of respondents indicated that they routinely treated CSHCN.42 We believe that this statistic has probably changed little.
A major barrier to oral health is the lack of dental insurance for a significant portion of the U.S. population. A federal survey found that 47% of dental care was paid out of pocket, 45% was by private insurance, and only 8% was by Medicaid.43 Even when there is dental coverage, the coverage is often limited and cost-prohibitive.44 More than 80% of uninsured persons under age 65 are members of working families. Their jobs do not provide insurance, and buying individual coverage is frequently too costly.45
The implications of poor access to oral health care extend well beyond the reaches of the Medicaid program. As of 2003, there were 108 million adults without dental insurance in the United States, more than two and a half times the number of people without medical insurance at that time44; matters have probably gotten worse since then. The Centers for Medicare and Medicaid Services estimated that only about one third of Medicaid-eligible children received a dental service in fiscal year 2005.46 Dental care has been reported to be the most common unmet need of poor children, who, in 2000, were three times more likely to have an unmet dental need than were nonpoor children.47 Children without continuous medical or dental coverage had the greatest unmet dental needs in 2000.48
For underserved populations, the demand for dental care will continue to be largely unmet regardless of the current or projected number of dentists, given the lack of dental providers who are available and willing to treat vulnerable populations. Ninety percent of dentists are in the private sector. Only 10% work in the safety net, dental education, and all other nonprivate practice settings combined.44
Title VII’s Impact on Dental Education and Training
Building general and pediatric dental training capacity
Title VII has played a vital role in the expansion and growth of both general dentistry and pediatric dental residency training in the United States. Duffy et al reported that, from 1977 to 1995, 72% and 77% of the net growth of PGD programs and positions, respectively, came from Title VII funds. During this period, Title VII funding was responsible for establishing 59 new residency training programs and 560 positions. A total of 115 institutions participated in the grant program during this period. There was a net gain of 72 residency programs, from 254 to 326, and a net gain of first-year positions of 477, from 753 to 1,230.2
In 2007, pediatric dental specialists constituted 3% of all dentists in the United States.14 General dentists made up approximately 80% of practicing dentists and provided the majority of dental services for children. However, as indicated by more recent reports, pediatric dentists are much more likely to see very young children, children with severe caries, children covered by Medicaid,49 and CSHCN41 and, thus, provide a significant proportion of dental services for these high-risk and more difficult-to-manage children.
In recognition of the nation’s need for pediatric dentists, Congress, in 1998, authorized postgraduate PD training to be eligible for Title VII funding for the first time. As administered, the program has provided limited three-year “start-up” funds to either increase PD positions at existing programs or to initiate new programs.15 From 1998 to 2006, 45 residency programs benefited from Title VII grant funding, with 7 of them being new programs. During this time, the number of first-year positions in PD increased from 180 to approximately 300 (personal communication, Scott Litch, JD, associate executive director, American Academy of Pediatric Dentistry, May 26, 2007). Thirty-nine programs are based in dental schools, and 26 are hospital based6 with an emphasis on primary care for well and ill children.
Diversifying the workforce
The racial and ethnic composition of the United States population has changed significantly in recent decades, and it is projected to become more diverse during the next 50 years. To improve the oral health and health care of the most vulnerable populations, greater diversity is needed in the dental workforce. It has been shown that graduates from low-income families, underprivileged backgrounds, or URM backgrounds are more likely to provide care to underserved communities.50 Compared with white dentists, practicing dentists who are minorities see high percentages of minorities in general and underserved minorities in particular.51 New graduates who were African American or Hispanic were more than twice as likely as white graduates to explain their choice of a dental career as motivated by a “high interest” in “providing service to vulnerable and low-income populations” and in “service to own race/ethnic group.”52
In 2000, African American and Hispanics constituted about 25% of the nation’s population but only about 10% of the student makeup of dental schools.53 In 2004, this percentage increased to 11.3%.54 The number of URM applicants to postgraduate dental educational programs has increased, as has the number of all applicants. As a consequence, the percentage of URMs within the overall applicant pool has remained level at 12% from 2002 to 2007.55
In 2003, Edelstein et al reported that Title VII-funded pediatric dental residency training programs had been successful in recruiting and training a higher percentage of URMs and individuals from disadvantaged backgrounds. In fact, 30% of residents in these programs were URMs,56 which is nearly three times the percentage of URM dental school graduates and applicants to all postgraduate dental education programs.
Although there have been no published reports on the racial and ethnic profiles of residents in general dentistry programs, our review of HRSA descriptions of Title VII-funded general dentistry and PD programs found programs whose mission was specifically to train ethnic and racial minorities. These descriptions, obtained from HRSA, are the abstracts/summaries sent by programs with their original applications to HRSA requesting funding (P. Preston Reynolds, MD, PhD, FACP, professor of medicine, University of Virginia, personal communication, March 2007). For example, some programs reserve training positions for individuals who are URMs or are from disadvantaged backgrounds. One program reported that of its last 190 general dentistry residents, 99 were African Americans, 37 were Asians, and 27 were Hispanics (P. Preston Reynolds, MD, PhD, FACP, professor of medicine, University of Virginia, personal communication, March 2007).
Atchison et al reported in 2002 that dentists who received postgraduate training in general dentistry, especially women, are more likely to choose career paths in government, hospital dentistry, or dental education rather than private practice, suggesting that HRSA-funded programs have been important in developing “safety-net” providers and academicians.57
Providing outreach and service to underserved and vulnerable populations
When general dentistry residency training was included in the Title VII legislation initially in 1976, a key congressional goal was to encourage the training of primary care training in dental education and medical education because of concerns about medical specialization and specialty maldistribution. Over the years, Congress, in its reauthorization of the Title VII grant program, became less concerned about specialization and more focused on training providers to care for a more diverse mix of patients, including the elderly, handicapped, and medically compromised, integrating oral health with general health and the delivery of primary care, and linking training with care delivery to underserved communities and populations.2
Atchison et al reported in 2002 that dentists who completed the GPR were more likely to treat medically compromised patients, including HIV/AIDS patients and geriatric patients, even after 10 years of practice. Furthermore, they were more likely to be on a hospital’s staff than were other general dentists, and they were less likely to seek specialty training.38 In addition to providing more complex services, dentists with postgraduate training in general dentistry referred less to specialists, indicating that general dentistry residency programs have the potential to train providers who are less dependent on specialists and more likely to practice in geographically underserved areas.57 However, as of 2004, general dentists who had completed residencies were no more likely to care for CSHCN than were dentists without advanced training.41
Pediatric dentists, on the other hand, who trained in programs that received Title VII grant funding seemed to be committed to caring for underserved children. In a survey conducted in 2003, virtually all graduates and current residents of these programs indicated that they planned to treat CSHCN. They were found also to be committed to both clinical and nonclinical efforts to improve access to care for underserved children.56
General dentistry residency programs overall were found to provide service to substantial populations of economically/socially disadvantaged populations. GPR programs, most of which are located within hospitals or medical centers, provide more care to underserved populations, including uninsured and Medicaid, children, and medically compromised patients than do AEGD programs, which are mostly sponsored by dental schools. However, both AEGD and GPR programs serve as safety net providers to underserved populations.58
A review of the Title VII-funded dental residency programs from 2003 to 2005 (P. Preston Reynolds, MD, PhD, FACP, professor of medicine, University of Virginia, personal communication, March 2007) found that they are meeting the special considerations in the legislation to train providers to care for underserved populations. In the abstracts of the proposals to HRSA, 15 out of the 22 general dentistry programs indicated specific objectives of improving the access to oral health care of individuals with special health care needs—including those who are medically compromised, have HIV/AIDS, are mentally, physically, or developmentally disabled, or are elderly—and enhancing the training of residents in the care of individuals with special health care needs. Virtually all of the programs focused on providing oral health care to underserved populations including disadvantaged, immigrant, or rural populations; homeless populations, using mobile dental vans; children in school systems; and the elderly in residential centers and nursing homes.
All 19 funded pediatric dental residency programs indicated that they were targeting underserved, underinsured, and uninsured children for the training of their residents as a means to increase access to oral health services for these children. Most of the pediatric dental residency programs focused on care to CSHCN. Additionally, the pediatric dental residency programs, particularly those in hospital locations, provide a major resource for young, vulnerable children in acute pain.43
Stimulating innovations in dental education
Traditionally, the primary focus of dental education has been to prepare students to enter private practice in a dental office setting. In consideration of future workforce requirements, the American Dental Education Association (ADEA) convened a group of national experts in 2002 to explore the roles and responsibilities of academic dental institutions in improving the oral health status of Americans. These experts concluded that academic dental institutions should include education about meeting the oral health needs of special populations such as the very young, the aged, the mentally and physically disabled, the medically compromised, and the underserved, and should teach skills in culturally competent care.59 Recommendations included exposing students to the delivery of care in community-based settings as early as possible in the educational process. Ideally, these community-based programs would be part of an integrated health system involving dental teams and nontraditional providers such as primary care physicians and nurses.59Additionally, this report recommended that the ADEA work with other organizations to advocate for a requirement that all dental graduates participate in a year of service and learning in an accredited PGY-1 program.59
Many dental schools have been using, for some time, service learning experiences in underserved communities to promote cultural competency, professionalism, and social responsibility, while at the same time providing unique clinical experiences for their students.60 Community-based experiences were given a boost in 2001 when the Robert Wood Johnson Foundation funded 15 U.S. dental schools to develop/enhance didactic and clinical curricula supporting community-based educational programs.27,60 In 2004, CODA adopted new accreditation standards for predoctoral dental and dental hygiene education programs, requiring that “graduates must be competent in assessing the treatment needs of patients with special needs.”61 This action of CODA was important because the only way to mandate inclusion of a topic in dental education is to incorporate it into the accreditation standards of the discipline in question.62 In 2003, New York state enacted legislation allowing dental school graduates to obtain a license to practice dentistry in that state on their successful completion of a PGY-1 residency program and in lieu of taking and passing a clinical licensure examination.63 However, there is presently no universal mandate for a PGY-1 residency.
Title VII-funded residency programs have developed innovative dental curricula, including educating residents about the oral health needs of patients with HIV/AIDS, medically compromising conditions, and mental and developmental disabilities, and they have also devoted curricula to the topics of the elderly and CSHCN. This federal funding also has been an important vehicle for structural changes in training programs, including increased focus on community-based educational models.64
Title VII grantees have been instrumental in promoting community-based training to increase access to oral health services to underserved and vulnerable populations in the medically and dentally underserved communities where they reside. A review of the Title VII general and pediatric dental training grants (personal communication, P. Preston Reynolds, MD, PhD, FACP, professor of medicine, University of Virginia, March 2007) found innovative, community-based training models. The University of Massachusetts Medical School initiated a combined program in general dentistry and PD in 2005 to focus on caring for high-risk and vulnerable underserved populations, where the training would take place at three federally qualified health centers. The University of Southern California Advanced Pediatric Dentistry Program in 2005 partnered with Children’s Hospital of Orange County and a nonprofit entity, Healthy Smiles for Kids of Orange County, to establish a satellite hospital site for its pediatric dental residency program that would include outreach services through Healthy Smiles at their children’s health dental center. The Title VII-supported Community Health and Advocacy Training in Pediatric Dentistry program at UCLA provides interdisciplinary training linking residents and faculty from pediatrics and PD and focuses on helping residents gain knowledge and skills for improving pediatric oral health within diverse communities and sociopolitical environments.
Distance learning tools—including video teleconferencing, developed and implemented with Title VII grant funds—represent innovative, advanced training models that have facilitated the initiation and expansion of community training in remote and rural locations for general dentistry and PD programs. These tools also have enabled the delivery of educational components of the training in the face of a faculty shortage while at the same time allowing for increased access to oral health services by underserved populations, and they have improved competence in the management of patients in underserved areas.
Engaging collaborative and interdisciplinary training with medicine
Primary care practice is the front line for underserved populations and potentially serves to provide dental screening, prevention, education, and referrals to dental professionals.64 Many oral diseases are preventable or more easily treated if identified early. Given the role that family physicians and other primary care providers have in promoting and protecting overall health and their historical role in serving minority and underserved families, these professionals are in a unique position to assure equity, access, and improvement in oral health for all.65
Because primary care physicians and nurses see children earlier and more frequently than dentists do, they are in the position to effectively screen children for the presence or risk of oral disease, promote oral health through parental counseling, and make early referrals for dental visits. In fact, pediatricians may see children up to 10 times for preventive visits by the age of two years.66 Although a national survey in 2000 showed that pediatricians were interested and willing to provide oral health to patients, they lacked formal training in oral health and lacked knowledge and skills.67 Nevertheless, primary care physicians and nurses represent excellent potential collaborators in improving oral health access.
Medical providers have begun to receive oral health education and training,68 with programs specifically focused on preventing early childhood caries integrated in medical practices on a limited basis.68,69 Pierce et al found that pediatric primary care providers achieved an adequate level of accuracy in identifying children with cavitated carious lesions after receiving only two hours of training in infant oral health.70 Glassman and Miller, in a recent demonstration project in California, established the ability of social workers and nurses to complete an oral health risk assessment for 0- to 3-year-old children at risk for developmental disabilities (Glassman P, Miller C. Integrating Oral Health Risk Assessment and Intervention into the Activities of Social Service and General Health Professionals [unpublished]). They also were able to manage a triage and referral system and provide oral health prevention counseling to families of these children.
Title VII has encouraged the development of collaborative and interdisciplinary training approaches in oral health between medicine and dentistry. Shortly after the release of Oral Health in America: A Report of the Surgeon General31 in 2000, HRSA, through Title VII, funded several programs to develop, implement, and evaluate oral health curricula for general pediatric or family medicine faculty and residents through cooperative agreements between medical and dental departments. Subsequently, these efforts may have spurred additional programs to institute collaborations and interdisciplinary training on oral health.
A review of Title VII grantees’ abstracts from 2003 to 2005 (personal communication, P. Preston Reynolds, MD, PhD, FACP, professor of medicine, University of Virginia, March 2007) has identified several programs that proposed interdisciplinary training between dentistry and medicine. One of the grantees indicated that such interdisciplinary training would result in an increased level of understanding between the disciplines, thereby reducing health care barriers and disparities for children from medically underserved communities.
The Title VII grantee at Children’s Hospital Boston has developed and implemented a unique, collaborative oral health educational and training program for pediatricians, pediatric residents, pediatric dental residents, and other health care providers by establishing integrated pediatric medicine–pediatric dental resident teams that emphasize the preparation of both medical and dental practitioners to care for underserved children and their oral health needs. Using this collaborative approach, this program has begun training 70 pediatric residents and 8 pediatric dental residents each year in oral health.66 In establishing true collaboration between pediatric medical and dental partners, the continuity clinic curriculum for the pediatric medical residents was structured to formally include oral health. The format of having pediatric resident–pediatric dental resident teams has allowed for direct referrals of young children for early preventive dental care. In fact, a notable outcome thus far has been a significant increase in the number of referrals of children for their first preventive dental visit, and at a much earlier age.71
Recommendations for the Future
The Title VII grant program remains the major vehicle for stimulating primary care education and training in the United States.15 This program has been important in the growth and expansion of postgraduate residency training in general dentistry and PD. In supporting general and pediatric dental residency training, it has been successful in facilitating a more diversified dental workforce and providing outreach and service to underserved and vulnerable populations. As the need for more pediatric dentists and general dentists with advanced training is expected to continue, Title VII’s role in expanding workforce capacity, and in supporting postgraduate general dentistry and PD curricula, will remain important in the foreseeable future.
However, because fewer than 40% of dental school graduates pursue advanced education immediately after dental school,4 Title VII’s impact on dental education clearly has been limited. Unlike family medicine, internal medicine, and general pediatrics programs and departments, general dentistry and PD programs are restricted from applying for grants from Title VII for predoctoral training, academic administrative units, and faculty development.13,15 Academic administrative units in primary care grants, as defined by HRSA, are to establish or expand an academic unit (department) in family medicine or develop a research infrastructure within an academic unit in family medicine. If predoctoral education in dentistry could be supported through Title VII funding, curricular innovations, such as caring for young children and special needs populations, community collaborations, and outreach, could be implemented earlier in the dental education process, thereby influencing the practice trends and preferences of students sooner. Earlier exposure to underserved and vulnerable populations could influence positively the career choices of future dental practitioners to provide dental care to these patients. Finally, Title VII could play an important role in addressing the dental faculty crisis if dental programs were eligible for faculty development grant funding and if Title VII funds could be eligible for faculty loan forgiveness.
In summary, Title VII federal funds have resulted in substantial growth in general dentistry and PD residency programs geared toward training dentists to care for underserved segments of the population. However, there exists a critical need to broaden the scope of Title VII to provide resources that will enable general dentistry and PD training programs to improve predoctoral dental students’ exposure to underserved areas and their ability to care for underserved populations, to recruit and develop additional faculty, to increase faculty diversity, and to stimulate ongoing innovations in predoctoral and residency education.
The authors wish to acknowledge William D. Hendricson, MS, MA, MMS, for his several insightful comments on a draft of this article.
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