5
Oral Health Research

Although dentistry is often thought of in terms of professional practice, it is also a science that depends on researchers to develop new and better dental technologies and, through the training of dental practitioners, to bring those technologies to the general public. But the profession is now in jeopardy, since the need for dental school faculty to conduct research and to educate dental students is acute. Over the past decade, several hundred faculty positions in dental schools have gone unfilled each year. While not all of them would be filled by researchers, it is to the profession’s advantage—as it is in other sciences—to have as many research-trained Ph.D.s or D.D.S./Ph.D.s as possible in these positions. The shortage of research staff in universities carries over to the industrial and governmental sectors as well, where a significant amount of dental research is conducted.

The reasons for this shortage are many. To cite just one, a culture exists within dental schools that values technical training and private practice over research, resulting in deficiencies in the support mechanisms for whoever does do research. The following sections describe the nature and scope of the problem.

THE SHORTAGE OF DENTAL SCIENTISTS

In 2001 the American Dental Association issued a report, Future of Dentistry, which outlined many of the issues facing the dental profession including what is now called a crisis in dental education. This crisis may be more aptly termed a dental school faculty shortage that has become acute because few individuals choose academics and research as a career goal. In the late 1990s there were nearly 400 open faculty positions, but the estimate for 2002 was 373. This reduction in the number of unfilled positions has come mainly from the elimination of those positions (because of dental school budget cuts) rather than from faculty hires.

Figure 5-1 gives a 10-year history of vacant full-time faculty positions in U.S. dental schools. Given that the level has remained about constant over the past 5 or 6 years, the number is unlikely to decline in the near future. While the number of unfilled full-time positions is approximately 275, this should not be interpreted as the number of research faculty needed, as some of these positions are for clinical faculty. In Table 5-1, which shows the distribution of vacant positions by primary activity, 45 of them are in basic sciences and research. But in addition, some of the 194 clinical positions would be research oriented.

While the shortage is critical across all types of appointments, the job of filling research positions is particularly difficult because there is no pool of temporary or part-time employees—as is the case for the clinical positions, which can be filled by practicing dentists. Dental faculty are simply not trained to be researchers, and many of them may not have the interest or ability to explore new areas of knowledge. Clinicians who teach students to perform dental care are, without a doubt, critical to the mission of dental schools but are not discussed here.

This recruitment problem does not tell the whole story about the number of scientists needed in dental education for the next decade. A possibly more critical situation is the retention of current faculty. According to data from the American Dental Education Association’s 2001–2002 Survey of Dental Schools, 1,011 faculty members, or 9 percent, vacated their positions in 2001–2002.1 This level was about twice that of the previous academic year. In 2001–2002, 53 percent of faculty members left an academic position to go into private practice, an increase of 18 percent over the preceding year. Possible reasons for the shifts in 2001–2002 may be retirement, moving to other schools, and the downturn in the economy.

Institutional budgetary limitations are partly responsible for the recruitment and retention of dental faculty—in the past 10 years, faculty salaries have increased by about 25 to 30 percent, while income in private practice has gone up 78

1  

American Dental Association. 2001.



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Advancing the Nation’s Health Needs 5 Oral Health Research Although dentistry is often thought of in terms of professional practice, it is also a science that depends on researchers to develop new and better dental technologies and, through the training of dental practitioners, to bring those technologies to the general public. But the profession is now in jeopardy, since the need for dental school faculty to conduct research and to educate dental students is acute. Over the past decade, several hundred faculty positions in dental schools have gone unfilled each year. While not all of them would be filled by researchers, it is to the profession’s advantage—as it is in other sciences—to have as many research-trained Ph.D.s or D.D.S./Ph.D.s as possible in these positions. The shortage of research staff in universities carries over to the industrial and governmental sectors as well, where a significant amount of dental research is conducted. The reasons for this shortage are many. To cite just one, a culture exists within dental schools that values technical training and private practice over research, resulting in deficiencies in the support mechanisms for whoever does do research. The following sections describe the nature and scope of the problem. THE SHORTAGE OF DENTAL SCIENTISTS In 2001 the American Dental Association issued a report, Future of Dentistry, which outlined many of the issues facing the dental profession including what is now called a crisis in dental education. This crisis may be more aptly termed a dental school faculty shortage that has become acute because few individuals choose academics and research as a career goal. In the late 1990s there were nearly 400 open faculty positions, but the estimate for 2002 was 373. This reduction in the number of unfilled positions has come mainly from the elimination of those positions (because of dental school budget cuts) rather than from faculty hires. Figure 5-1 gives a 10-year history of vacant full-time faculty positions in U.S. dental schools. Given that the level has remained about constant over the past 5 or 6 years, the number is unlikely to decline in the near future. While the number of unfilled full-time positions is approximately 275, this should not be interpreted as the number of research faculty needed, as some of these positions are for clinical faculty. In Table 5-1, which shows the distribution of vacant positions by primary activity, 45 of them are in basic sciences and research. But in addition, some of the 194 clinical positions would be research oriented. While the shortage is critical across all types of appointments, the job of filling research positions is particularly difficult because there is no pool of temporary or part-time employees—as is the case for the clinical positions, which can be filled by practicing dentists. Dental faculty are simply not trained to be researchers, and many of them may not have the interest or ability to explore new areas of knowledge. Clinicians who teach students to perform dental care are, without a doubt, critical to the mission of dental schools but are not discussed here. This recruitment problem does not tell the whole story about the number of scientists needed in dental education for the next decade. A possibly more critical situation is the retention of current faculty. According to data from the American Dental Education Association’s 2001–2002 Survey of Dental Schools, 1,011 faculty members, or 9 percent, vacated their positions in 2001–2002.1 This level was about twice that of the previous academic year. In 2001–2002, 53 percent of faculty members left an academic position to go into private practice, an increase of 18 percent over the preceding year. Possible reasons for the shifts in 2001–2002 may be retirement, moving to other schools, and the downturn in the economy. Institutional budgetary limitations are partly responsible for the recruitment and retention of dental faculty—in the past 10 years, faculty salaries have increased by about 25 to 30 percent, while income in private practice has gone up 78 1   American Dental Association. 2001.

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Advancing the Nation’s Health Needs FIGURE 5-1 Unfilled full-time positions on dental school faculties, 1992–2002. SOURCE: American Dental Education Association. percent.2 An important related financial issue is the debt incurred by dental students during their studies. Among students who entered dental school in 1998, about 60 percent had no education debt. Those who reported debt had an average burden of $25,300. Hence, a rationale might be that a pool of applicants with little or no education debt would be more at liberty to select a career path aimed at pursuing interests, rather than immediately generating income for debt service. However, of those graduating from dental school in 2002, 29 percent reported debt levels of $100,000 to $149,999.3 Debt levels higher than $150,000 were reported by 29 percent of graduates. The average debt of all students upon graduation (from both public and private dental schools) was $107,500 (this average includes debt-free students). The average debt of those students who had at least some debt was $122,500. In general, their debt is higher than in any other profession, including medicine, because they are required to purchase instruments used in dental school. The impact of debt on career path is substantiated by the finding that nearly 24 percent of dental school seniors indicate debt as a factor influencing career plans. Further, as debt levels increase, a progressively higher percentage of seniors with the higher debt levels opt to immediately enter private practice. Perhaps the most significant factor driving the low interest in research among dentists is the prospect of a very lucrative career in private practice. General practitioners can expect an annual income of nearly $150,000, with specialists earning over $200,000, and there is no indication that these figures will decline in the future even with significant ad- TABLE 5-1 Vacant Faculty Positions in Dental Schools, 2001–2002 Primary Area of Appointment Vacant Positions Full-Time Part-Time Total Clinical sciences 194 63 257 Basic sciences 20 1 21 Administration 25 1 26 Allied dental 3 3 6 Research 25 2 27 Other 6 1 7 Total 273 71 344   SOURCE: American Dental Education Association. 2   Haden, N. K., R. G. Weaver, and R. W. Valachovic. 2002. 3   American Dental Education Association. 2001.

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Advancing the Nation’s Health Needs vances in oral health care. Thus many students who may be interested in research elect the higher-paid and, from their point of view, more secure careers in clinical practice. The aging of the dental school faculty will only make the shortages of the past decade more of a problem in the future. The average age of faculty members in 2001 was 49.6 years, and 20 percent of the faculty were over the age of 60. Because there is little difference in the average age of the basic science/research faculty and the clinical faculty, the projections of about 1,000 retirements in the over-60 age group in the next 10 years would mean a reduction in the basic science and research faculty of about 200. The fact that few associate professors are following closely behind these senior faculty members means that the pipeline has many gaps and that an even greater need for researchers will exist over the next 10 years. The shortage of senior faculty will also create a period during which junior faculty have few mentors to assist them in the activities necessary for tenure and promotion. In the context of the faculty shortage in dentistry, it is important to realize that not all research faculty in dental schools need be dentists. While clinicians trained as dentists are useful in answering clinical questions and are fundamental to clinical research, nondentist basic scientists trained to the highest standards are also an important part of the faculty mix. Although dental schools should have a mix of basic and clinical scientists to achieve the institutions’ and the nation’s research goals, few doctorates trained in the basic biomedical sciences have considered academic careers in a dental school. While some training may be necessary to make this adjustment in career goals, the benefit to the dental and biomedical professions would be significant. A complicating factor, however, is that some administrators in dental schools might not be willing to accept the qualifications of these basic scientists, even with the necessary training. POTENTIAL POOL OF DENTAL RESEARCHERS The size and quality of the national applicant pool for U.S. dental schools merit scrutiny. Because this pool represents a large and relatively robust population of people who have an interest in oral health and are willing to further their formal education through an extensive training experience, a large proportion of the next generation of oral health researchers will likely be drawn from this group. Additional scientists may come from abroad or from among those practitioners who gravitate to oral health research as a consequence of their interest in its scientific challenges. There are 56 dental schools in 34 states and Puerto Rico, enrolling 17,487 dental students and 5,266 dental residents in 2001. There were 4,448 first-year dental students, selected from a total applicant pool of 7,538.4 The current ratio of applicants to first-year enrollment for dental school is 1 to 68. Among applicants to dental school in 2001–2002, 83.9 percent possessed baccalaureate degrees, 2.5 percent had master’s degrees, and 0.1 percent had Ph.D. degrees, suggesting that preexisting research training or experience for this applicant pool is negligible. Clearly, if education in biomedical research is to be offered, it needs either to be a part of professional school study or provided as a postgraduate experience. The predental grade point average for the year 2000 entering class was 3.35 overall and 3.25 in the sciences.5 Dental Aptitude Test scores for the entering class of 2001–2002 were 18.65 (academic average) and 18.36 (science average), both on a 30-point standard scale.6 Thus, given the number of slots available each year in U.S. dental schools, the applicant pool’s academic quality, though above average, was not overwhelming. A key question is whether a subset of individuals at the high end of the academic distribution can be drawn from the national pool and attracted to careers in biomedical research. Given both the size of this group and its mean GPA of 3.25 in the sciences, the existence of a sizable subset of academic high performers seems plausible, yet the percentage of graduates interested in teaching, research, or administration is small and declining. Few students entering dental school are aware of a career path that includes oral health research, and even fewer consider this option as they complete their training. Interest in research dropped from about 1.3 percent in 1980 to 0.5 percent in 2002.7 This means that only about 20 of the nearly 4,000 dental school graduates each year consider a career in dental research. The reasons for this low interest, as noted earlier, include the prospects of a high income in dental practice; the accumulated student debt; and a culture in many dental schools, especially among the clinical staff, that values the technical aspects of dentistry and often marginalizes research. The National Institutes of Health (NIH) has two grant programs that support the infrastructure in dental schools: the R24 for planning research facilities and infrastructure and the R25 for planning curriculum structure. It is generally believed that a higher percentage of students, although small, are interested in dental research earlier as opposed to later in their education; it might be possible to influence dental students later in their education by integrating research into professional training through the NIH grant programs. However, most dental school applicants are interested in becoming dentists, not biomedical researchers. This intention is presumably based on applicants’ general understanding of what 4   Weaver, R. G., K. Haden, and R. W. Valachovic. 2002. 5   Center for Public Policy and Advocacy, American Dental Education Association (ADEA). 2003. Dental Education At-A-Glance 2003. Available at http://www.adea.org/CPPA_Materials/default.htm. Accessed on October 22, 2004. 6   American Dental Association. 2001–2002. 7   Ibid. 2:34.

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Advancing the Nation’s Health Needs dentists do. Inasmuch as 92.7 percent of professionally active dentists are engaged in private practice, with 92.1 percent of that number holding an equity share in a practice,8 it seems reasonable that most dental school applicants aspire to a career as a small-business person rather than as a biomedical scientist. Yet it is still from such a pool that the future biomedical research scientists in this field are likely to come. In other words, biomedical researchers in the oral health sciences start out wanting to be practicing dentists; but they apparently undergo a significant shift in career plans and professional identity sometime during either dental school or specialty training, usually under the influence of a mentor or because of some other significant academic experience. What dental schools can do to foster such a shift is an important question. Each year competition is great for the highest academic performers graduating from dental school. The most effective at siphoning off the best are the nine specialties in dentistry: oral and maxillofacial surgery, orthodontics, periodontics, endodontics, pediatric dentistry, prosthodontics, oral and maxillofacial pathology, oral and maxillofacial radiology, and public health dentistry. For 2001–2002, 1,264 students enrolled in these specialty programs. Although the number of applications for these positions is reported as 43,612, this figure is misleading because “applications” refers to the cumulative number of applicants to all programs and represents a duplicated count.9 Because of the inordinate length of some specialty training programs—anywhere from 2 to 7 years after dental school—some residents may exclude themselves from the additional training needed to become a biomedical scientist. On the other hand, departmentally based dental schools are, arguably, run by research-oriented dental specialists. Thus, while there are positions for general dentists in dental schools, leadership positions are often held by research-oriented specialists. The preferred model for training biomedical research scientists in the oral health sciences is to have dental specialists go on to research training, usually by studying for a Ph.D. Hence, the approximately 1,200 specialty students can be seen as the potential pool for the recruitment of future scientists—though a relatively small percentage of this number are actually attracted by the prospect of actually doing so. In recognition of this possibility, the National Institute of Dental and Craniofacial Research (NIDCR) has tried several programs leading to advanced research training (usually through the vehicle of a Ph.D.) in combination with either the dental school curriculum or clinical specialty training. One initiative that was instituted by NIDCR, in response to a recommendation from the National Research Council’s study of the National Research Service Award (NRSA) program, was a Dental Scientist Training Program (DSTP)—a dual-degree program leading to a D.D.S. and a Ph.D. In 2001–2002, 11 institutions had NIH-supported DSTPs, with a total of about 30 students. There were another 10 institutions with D.D.S./Ph.D. programs that did not have NIH support. The applicant pool for the DSTPs is very strong, and more students could be accepted into them if funding were available. The curriculum sequence for the DSTP at many institutions is similar to that of the Medical Scientist Training Program (MSTP)—the first 2 years are spent in dental training, the next 2 to 3 years are devoted to research training for the Ph.D., and then students return to dental school for 2 or more years to complete their dental degrees. One serious drawback to the DSTP is its funding mechanism. The MSTP students may receive support for up to 6 years under the NRSA requirements, and MSTP policy requires that every student be supported with stipends and total tuition for the entire period of dual degree. However, the DSTP student may only receive 5 years of support with the possibility of a sixth year under the T32 mechanism, and no full support requirement exists. This support usually applies during the Ph.D. portion of students’ training and part of their dental training, but other sources must be found to support their studies for the rest of the program. Some institutions have used the K award mechanism to secure the needed funding. Consequently, students can complete the DSTP and still have debt. This program is new—only a few students have completed it—but graduates appear to be dedicated to research careers and are now in postdoctoral training. Some insight comes from studying other training programs funded by NIDCR, given that this single institute funds the overwhelming majority of research training for oral health researchers. In fact, about 8.5 percent of the NIDCR budget in FY 2002 was spent on research training and career development10—approximately $20.4 million (total of both direct and indirect costs).11 In 2002 NIDCR supported at least a dozen separate categories of research training and career development awards, including 157 NRSA grants and research career development awards. Further, for FY 2003, 50.6 percent of training grant proposals reviewed by NIDCR were funded (averaged over the individual awards). Though useful, these data do not in themselves provide much information concerning the actual number of persons currently in training through these various vehicles since some represent awards to individuals while others represent awards to institutions—each of the institutional awards providing funding for multiple individuals (and differing numbers of indi- 10   American Dental Association. 2002. 11   Gordon, S. July 16, 2003. Presentation to the Committee to Monitor the Changing Needs for Biomedical and Behavioral Research Personnel Oral Health Panel. New York, NY. Note: Personal Communication. Director. National Institute of Dental and Craniofacial Research. Note: Success rate averages must be regarded with some caution inasmuch as applicants often apply more than once prior to award and often a single applicant may straddle fiscal years. Success rate also varies by type of mechanism. 8   Weaver, R. G., K. Haden, and R. W. Valachovic. 2002. op. cit. 9   American Dental Association. 1999.

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Advancing the Nation’s Health Needs viduals per training program). Further, they provide even less information about the number of applicants to each program. Were such data available—such as the number of applicants for each training slot—they would be useful as a gauge of interest in training programs, and they would inform projections concerning the potential shortfall of biomedical research personnel relative to the nation’s needs. Also they would help determine whether, from a national perspective, the number of applicants exceeds, matches, or falls short of the number of training slots available. A one-to-one match of applicants to available positions or, even more alarming, unfilled research training slots would not bode well either for the number of persons in the pipeline or, perhaps more significantly, for their quality. In any case, although the number of individual awards may give one indication of the demand for training through institutional awards, this effect has never been quantified—in part because NIH grants are attributed to the principal investigator, not the individual trainee. RESOURCES FOR RESEARCH TRAINING There is a need to systematically identify sources of collaborative funding for research training across government agencies and within the private sector. The goal of this effort is to facilitate communication and thereby expand the pool of funds that could be used for research training in fields related to oral health. Although it provides the largest single source of all dental research training funds, the research training budget of NIDCR is limited and under financial pressure in the current economic climate. For example, in 2002 there were 31 NRSA grants, 70 research career development awards, and 48 K12 and K16 awards, for a total of 149 research training awards across the nation. The level of support in NIDCR for NRSA T32 and T35 grants was about 2.9 percent of its total budget, and for NRSA F31 grants the support was at 0.4 percent. This was about average for these awards across the NIH institutes. When considering the relatively large amount of research training support within other agencies of the government and the private sector, it becomes apparent that the possibility of augmenting NIDCR research training funds with other governmental and private-sector funds could markedly increase the total research training capacity for dental research in the United States. Inspection of Tables 5-2 and 5-3 suggests that the research areas of concentration for FY 2002 could be linked to scientific research areas that are funded by other disciplines. For example, there are many research training programs across NIH and in other agencies of the government that fund the same or similar research disciplines being targeted by the NIDCR, such as microbiology, microbial pathogenesis, immunology, biotechnology, mammalian genetics, epithelial cell regulation, physiology, pharmacogenetics, molecular and cellular neurobiology, clinical trials and patient-oriented TABLE 5-2 Research Areas of Research Career Development Awardees, Fiscal Year 2002a Research Area Total Microbiology and microbial pathogenesis 6 Immunology and immunotherapy 4 AIDS 2 Biotechnology and biomaterials 4 Developmental biology and mammalian genetics 17 Epithelial cell regulation and transformation 7 Physiology, pharmacogenetics, and injury 6 Molecular and cellular neurobiology 2 Clinical trials and patient-oriented research 14 Behavioral research 3 Population sciences 4 Health disparities 1 Total 70 aResearch areas defined by primary NIDCR project code are self-reported; programs have more than one research area. SOURCE: NIH/NIDCR tabulation. research, behavioral research, and population sciences. Dental researchers being trained in any of these NIDCR-funded research training programs could be co-funded or co-supported by other research training funds that are similarly targeted toward these research disciplines. An NIH policy could facilitate and encourage co-funding of research trainees. Also, a barrier that needs lifting is the tendency to discourage dentist scholars from applying for research training funds within these disciplines. If applicants other than physicians are eligible, dentists should also be TABLE 5-3 Research Areas of Institutional National Research Service Award T32 Programs, Fiscal Year 2002a Research Area Total Microbiology and microbial pathogenesis 14 Immunology and immunotherapy 14 AIDS 0 Biotechnology and biomaterials 9 Developmental biology and mammalian genetics 7 Epithelial cell regulation and transformation 6 Physiology, pharmacogenetics, and injury 6 Molecular and cellular neurobiology 7 Clinical trials and patient-oriented research 6 Behavioral research 2 Population sciences 7 Health disparities 0 Total 78 aResearch areas defined by primary NIDCR project code are self-reported; programs have more than one research area. SOURCE: NIH/NIDCR tabulation.

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Advancing the Nation’s Health Needs eligible, while funds targeted specifically for physician research training would stay limited to physician applicants. With this broadening of the spectrum of research training sources to which dentist-researchers could apply, the opportunity for collaborative funding for research training in fields related to oral health would expand. Sources of research training funds could include various government agencies, foundations, universities, industrial organizations, and foreign governments. Aside from the funding method used for the DSTP program, there are serious problems with the way NIH programs are now being administered. For example, there is a need for more dental-oriented clinical researchers, especially those involved in translational research; clinical studies, such as Phase II or case-control studies; randomized controlled trials, including hypothesis-driven NIH Phase III type trials and Food and Drug Administration Phase II- and III-type trials; and Phase IV studies of side effects and interactions with co-therapies. Researchers with the ability to participate in all of these types of clinical investigations are needed. Clinical researchers who can participate in high-level development and applications research, such as the engineering of products, also are needed. The K30 institutional grants are designed to do just this. However, most of these applications appear to come from medical schools and nondental institutions, and the emphasis is not on training dental researchers. Finally, training in interdisciplinary and emerging fields is not now traditionally thought of as being within the dental research training profile. Dental research relies on or crosses other disciplinary areas (see the next section), but little support is given for training in these areas. This problem is partly one at NIH, where the tendency is not to support such training; but the educational institutions are also responsible, since they do not apply for T32 awards in interdisciplinary or emerging fields. NATIONAL RESEARCH SERVICE AWARD PROGRAM AND OTHER NATIONAL INSTITUTES OF HEALTH PROGRAMS In 2002, NIDCR funded 31 new, continuing, or noncompeting T32 training grants. These grants supported a total of 81 predoctoral students and 86 postdoctoral appointees. In addition, they provided support for 27 short-term projects under the T35 mechanism. Of the 31 funded T32 awards, 20 provided support for students in Ph.D. programs and the other 11 were for support of the DSTP. The 20 non-DSTPs supported about 50 students at the predoctoral level, and based on the statistics on vacant research positions in dental schools, these programs could eliminate any shortage in a few years. But many of the trainees do not view dental school and dental-oriented research as a career option. In terms of individual fellowship awards, there are 16 F30 awards for support of predoctoral students in dual D.D.S./ Ph.D. and D.M.D./Ph.D. programs, one F31 award for predoctoral support in a Ph.D. program, and nine postdoctoral fellowships. While the F30 award is designed to support training in an established dual-degree program for students who intend to be researchers, it is no guarantee that students will not pursue professional careers. Individuals in the dental community have made extensive use of the K award program, securing 70 awards in 2002. A little over half of these awards were for clinical training through the K02, K08, K23, and K24 mechanisms. There are 30 awards that could be considered transitional training, and 20 are the new K22 awards. This level of participation in the K22 is unusually high, since there were only 93 K22 awards across all NIH institutes. Of all the fields of study the K awards seem to work well for the dental profession, since the mission-oriented research of the profession fits with the rigid structure of these awards. One program at NIH that has not been widely used by dental professionals is loan repayment. In 2002 only six individuals with a D.D.S. participated in the clinical research loan repayment program, and no one with this degree applied to the program under the health disparity or disadvantaged-background features of the program. Considering the high level of debt that dentists have when they graduate from dental school, it seems this program would be attractive. Even though many committees and working groups have addressed the issue of clinical research training, there remains a critical shortage of clinical scientists in dentistry, particularly to perform Phase II- and III-type trials. There are a few oral health scientists trained in epidemiology who could carry out these clinical trials, but epidemiology or public health training often does not include the skills needed to conduct clinical trials. The recommendation in the clinical sciences chapter of this report that addresses the need for physician training in this area should apply equally to the training of dental clinicians. The issue of minority researcher training, and of the training of researchers in general to address the health of minorities, is as important in dentistry as it is in other fields. African Americans, Hispanic Americans, and Native Americans make up only about 10 percent of all students enrolled in dental schools, reflecting a steady 10-year downward trend that could have a major impact on the dental health of minority populations. After a slight increase in enrollment through the mid-1990s, only 810 African Americans, 913 Hispanic Americans, and 99 Native Americans were enrolled in dental schools during the 1999–2000 academic year. Minorities are also underrepresented in private practices, with African Americans making up 2.2 percent of dentists, Hispanic Americans accounting for 2.8 percent, and Native Americans representing 0.2 percent. The second aspect of minority research is the training of investigators who have competence and commitment to investigate health care disparities among populations. A broad array of investigators is needed—people with skills in molecular epidemiology, clinical trials, and field studies and who have knowledge and

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Advancing the Nation’s Health Needs interest in diseases that occur in populations that suffer from health care disparities. While many programs exist at NIH to address the shortage of minority researchers, the success of these programs is unclear. And in light of the general shortage of dental school faculty, it is unlikely that any changes will take place without strong programs that are specifically targeted in this area. CONCLUSION The need for augmented research in oral health clearly exists. However, equally clear is the shortage of faculty to carry out the training and act in the interest of dental trainees in research. For this situation to improve, dental schools must place a higher priority on research and ensure that exposure to research is part of the curriculum. Unfortunately, recommendations in this regard are beyond the scope of this committee. However, some positive steps can be taken in existing programs to provide incentives to prospective trainees. RECOMMENDATIONS Recommendation 5-1: This committee recommends that NIDCR fund all required years of the D.D.S./Ph.D. program. The current program is not sufficient to attract high-quality students. As with the highly successful MSTP, full support must be provided as an incentive for students to enter research. The partial support currently provided is not a good test as to whether a D.D.S./Ph.D. program is viable. The program should be closely monitored to assess the quality of applicants, the training of applicants, and the research success of applicants. Recommendation 5-2: This committee recommends that the NIDCR loan forgiveness program require documentation of time spent in research and scholarly success. Loan forgiveness should not be viewed as a means of providing general support for dental faculty but should instead be regarded as a means of promoting high-quality research in dentistry. Faculty members who receive loan forgiveness should provide evidence they have performed productive research, as judged by grant support and publications. Recommendation 5-3: This committee recommends that NIDCR should design and implement programs intended to increase the number and quality of dental school applicants who are committed to careers in oral health research. The creation of a cadre of high-quality oral health researchers has been severely hampered by the culture in dental schools, where the clinical faculty are often drawn from private practice and students enter with the intention of pursuing such careers. Dental schools associated with research universities can draw on colleagues in the basic sciences to supervise doctoral training for D.D.S./Ph.D. trainees, but D.D.S./Ph.D. programs in those schools will have trouble finding qualified applicants until a more suitable cadre of research-oriented students are attracted to dental schools. Innovative programs will likely involve the promotion of D.D.S./Ph.D. programs to undergraduates considering biomedical research careers. The dental school research culture will evolve slowly, but a necessary step toward the resolution of current problems may be the creation of well-trained D.D.S./Ph.D. graduates who can assume faculty positions and serve as role models in the future.