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OCR for page 65
CHAPTER SIX
ORAL HEALTH RESEARCH PERSONNEL
Oral health research (OHR) has paid great dividends
(Lathrop and Ranney, 19934. It has contributed to reduced
rates of dental caries as well as improvements in diagnosis,
prevention, and treatment of over oral diseases and abnor-
malities. OHR activities include research not only on tooth
structure and diseases of supporting tissues, but on cells,
tissues, and structures of the entire oral and craniofacial
region. Over important research areas include oral cancer,
salivary gland disorders, genetic diseases, and materials sci-
ence related to dental practice.
Estimates indicate that dental school research training
programs have less than half the faculty needed to provide a
strong research environment. Compared with all other fac-
ulty in dental schools, research faculty are aging and are not
being replaced at the rate they are retiring or otherwise leav-
ing the field or by faculty having the same level of training.
Unlike other medical fields that have access to a variety
of sources of research support, most OHR is supported by
the National Institute of Dental Research (NIDR). Because
of He anticipated demand for OHR, He number of training
awards in OHR and the resultant inability to replace an ag-
ing cadre of OHR scientists in faculties of dental schools,
the committee recommends a two-fold increase over the
1993 number of awards.
ADVANCES IN ORAL HEALTH RESEARCH
The history of OHR is closely related to the history of
NIDR, which celebrated its 45th anniversary in 1993. Origi-
nally, NIDR's mission was to "improve the oral health of
the American people." At Hat time, oral health focused on
caries Stood decay) because of its overwhelming preva-
lence. Initially, a group of intramural dental scientists took
on caries research largely through epidemiologic ap-
proaches. Taxis was the beginning of the remarkable tale of
6s
fluoride as an effective public heals measure. The initial
phase of epidemiology and prevention research has had a
tremendous impact on every aspect of dental education and
dental practice and saves the American people an estimated
$4 billion per year.
In recent years the scope of OHR has been greatly broad-
ened. In addition to the emphasis on dental caries, microbi-
ologists and biochemists now deal win basic issues related
to hard and soft oral tissues. The maturing of OHR has led
not only to the understanding of how took decay begins,
but to the improved understanding of He infectious base of
periodontal diseases. These complementary discoveries
have had major implications for the clinical management of
oral diseases.
In addition, researchers have made much progress in
areas such as neurobiology, developmental biology, cellu-
lar and molecular biology, oral microbiology and immunol-
ogy, and materials science and imaging technology. Dental
implants illustrate one practical application of the results of
recent oral heals research.
ASSESSMENT OF TO CURRENT MARKET FOR
ORAL HEALTH RESEARCH PERSONNEL
A database on dental educators compiled by He Ameri-
can Association of Dental Schools (AADS) provides the
best available current information on the OHR labor force.
Begun in 1981 this database includes all faculty appoint-
ments to dental education institutions in the United States
and is updated annually by a survey of AADS member in-
stitutions. It includes information on age, gender, race, Scat
demic rank, appointment status (full or part-time), academic
degrees held, and area of primary appointment. Analysis of
this database (Solomon, 1993) showed that He average age
of OHR scientists increased from 47.3 to 49.1 years from
OCR for page 66
MEETING THE NATION'S NEEDS FOR BIOMEDICAL ANI) BEHAVIORAL SCIENTISTS
1986 to 1992. AUso, compared with all full-6nne dental
school faculty, OHR scientists were somewhat older (48.6
to 49.1 years, 1992-19931. OHR scientists generally held
higher academic rank than full-time dental school faculty.
In 1992-1993,73 percent of OHR scientists held senior rank
(full or associate professors compared with 65 percent of all
full-time dental faculty. From 1986-1987 to 1992-1993, the
percentage of OHR scientists who identified Heir primary
appointments as clinical sciences decreased from 44 per-
cent to 36 percent (comparative figure for all full-time fac-
ulty is 58 percent). As a proportion of all OHR scientists,
those holding the Ph.D. only (without a clinical degree) de-
creased somewhat (51 percent to 45 percent). No change
was found for the dual-degree J).D.S./Ph.D.) OHR scien-
tists, whose proportion remained stable, but the category
"other" (predominantly clinical degree with or without Mas-
ters degree) increased from 4 to 10 percent of OHR scien-
tists (Figure 6-1~.
Over the time of analysis, OHR scientists turned over
(entered and left) by more than one-third (361 entered, 357
left). Most entries were in their 30s and early 40s; depar-
tures were evenly spread over He age range of the faculty.
Departing faculty OHR scientists were more likely to hold a
nonclinical doctorate than were entering OHR scientists.
These analyses indicate that OHR scientists are an aging
group, approaching retirement. Although total numbers of
OHR scientists are staying constant despite declines in total
faculty, reflecting increased emphasis on research in the
schools, those with Ph.D.s who leave seem to be replaced to
a greater extent by those without Ph.D.s. This reflects the
lack of growth in training programs for OHR since 1985. It
also suggests a concern for a decrease in competitive stature
for grants for OHR scientists among all research workers.
Other factors also contribute to the acute shortage of
OHR scientists. Because of He undersupply of research
workers for dental institutions, OHR scientists tend to 1)
not take postdoctoral training to the same extent as their
FIGURE 6-1 Percent academic degrees by
academic year. SOURCE: Solomon, 1993.
1986
1 989
1 992
competitors for research grants; 2) get drafted into, or oth-
erwise move too soon into, administrative positions; and 3)
have insufficient available mentoring capability existing in
the institutions where Hey are employed. In addition, insti-
tutional support is generally minimal, so that it is difficult
to find start-up funds or bridge support.
Additional factors that contribute to He shortage of OHR
scientists are similar to other areas of biomedical research.
These include low funding rates for grants, lower income
possibilities in academic endeavors Han in practice careers,
and the debt of graduating dental students. Dental students'
debt is the greatest of all health care professionals: it ex-
ceeds $55,000 on average and often exceeds $100,000.
OUTLOOK FOR ORAL EBEALTH
RESEARCH SCIENTISTS
Although much progress has been made, oral diseases
remain among He most prevalent diseases in He United
States. More than 84 percent of children, 96 percent of
adults, and 99.5 percent of those over 65 years of age in this
country have experienced dental caries. Many millions of
Americans have one or more periodontal diseases or other
oral disease. Over 17 million have lost all of their teeth. In
1989, 164 million hours were lost from work and 52 million
hours were missed from school because of dental condi-
tions. In 1992, $38.7 billion was spent for dental services.
By the year 2000 the annual cost for dental heals is ex-
pected to reach $62 billion.
Cancer of the oropharyngeal region is more common
Han leukemia, melanoma, Hodgkin's disease or cancers of
the brain, liver, bone, thyroid, stomach, ovary, or cervix. It
affects primarily older Americans and causes approximately
8,000 deaths per year. The 5-year survival rate for oral
cancer is 51 percent but only 31 percent for blacks.
Millions are at high risk for oral health problems be-
cause of other handicapping or medical conditions. These
· Other
'Ph.D.
rem
to; Doubts Doctorate
- .... ........
~=906
IN = 925
IN =910
0% 20% 40% 60% 80%
66
100%
OCR for page 67
ORAL HEALTH RESEARCH PERSONNEL
conditions affect quality of life, including pain, ability to
eat, speak, taste, and swallow. For example, cleft lip and
palate require extensive and expensive repair to avoid dis-
figurement. There are significant problems for individuals
with compromised immune systems, including those with
acquired immune deficiency syndrome (AIDS). These
problems include oral candidiasis, hairy leukoplakia of the
tongue, recurrent ulcers caused by Herpes simplex or other
viruses, oral Kaposi's sarcomas, and aggressive periodontal
disease, including necrosis of alveolar bone. Infectious oral
diseases increase risk for endocarditis, brain abscesses,
pneumonia, infection of prosthetic valves and joints, and
systemic infection of individuals who are undergoing organ
or marrow transplants. Thus, OHR now addresses oral and
dental health concerns across the life span, and high risk
and special populations are major targets of this research.
OHR needs more and better-trained scientists with spe-
cif~c interests in oral health. Training sites and mentors
must become magnets for the best and brightest of the
graduates. They must also provide role models for stu-
dents. Trainees must be kept in the system, and factors that
facilitate retention of oral health scientists already in the
work force need to be identified. It is extremely important
to ensure that there are an adequate number of clinical re-
search investigators and to enhance the clinical faculty in
dentistry. Finally, research results must be disseminated to
practitioners and to the public.
No funding source other than the NIDR significantly sup-
ports OHR or training specifically for OHR. Continued
support of training through NIDR is essential to continued
improvement of the quantity and quality of OHR personnel.
ENSURING DIVERSITY OF HUMAN RESOURCES
The percentage of women in the OHR scientist cohorts
increased from 12.7 percent in 1986-1987 to 16.3 percent in
1992-1993, but He percent of women among all full-time
dentalfaculty was stillhigher (18.7 percent, 1992-19934.
Asians and Hispanics increased in proportion slightly among
OHR scientists over the period studied, but the percentage of
black OHR scientists decreased (2.6 percent to 1.7 percent).
The OHR scientist group had a slightly higher representation
of whites and Asians than did full-t~me faculty in general.
Although the OHR scientist labor force is becoming more
diverse (more women and Hispanics), women and minorities
are still under-represented. This is especially true for blacks.
NATIONAL RESEARCH SERVICE AWARD
PROGRAM FOR ORAL HEALTH RESEARCH
Before the National Research Service Award program,
dental training centered around clinical specialty training.
Under the NRSA mechanism, the emphasis shifted to a pri
67
mary focus on research.2 There are now 288 people in NIDR-
supported training programs for a research career, including
approximately 160 in the NRSA program, excluding dental
students supported under the T35 mechanism for short-term
training. That number has been relatively stable throughout
the 1980s and 1990s, although there has been a slightreduc-
tion in the NRSA program. Of the 288 total, approximately
half are clinical researchers with a D.D.S. degree who are
studying for a Ph.D. (counted as postdoctoral trainees);
about 10 percent are predoctoral students studying for the
Ph.D.; and the remaining 40 percent are postdoctoral trainees
who hold the Ph.D. or D.D.S., including those in the NRSA
program as well as in other programs (Dentist-Scientists or
Physician Scientists for Dentists awards) (Table 6-1~.
The NRSA stipend varies with the number of years of
experience after the last professional degree and it ranges
from $18,600 to $32,000. However, the Dentist Scientist
Award (DSA) salary may go up to $50,000. The NRSA
mechanism has a modest institutional allowance, approxi-
mately $2,500 for a postdoc on a Gaining grant and $3,000
for a fellowship, whereas the DSA includes significant sup-
port for research of up to $75,000 over the 5-year project
period and mentors can receive salary support. Under the
NRSA no salary is available for mentors. Within the NRSA
awards there is a distinction between the fellowships and
training grants. Full tuition and fees are supplied in training
grants but not in fellowships.
Legislation Hat limits an NRSA trainee to only 3 years
of postdoctoral research experience is a significant problem
for support of OHR scientists. A dentist appointed to a
Gaining grant seeking a Ph.D. needs more than 3 years,
especially when concomitant clinical Gaining is involved.
Although the NIDR has been liberal in granting waivers
and extensions, it would ease recruitment if He legislated
limit were removed.
A good evaluation mechanism for the effects of different
types of training support is needed, so that differential im-
pacts of different programs can be known.
Programs in which dentists receive research Gaining in-
cluding the Ph.D. have been successful. Eighty-one percent
of the individual and 73 percent of the institutional DSA-
eligible awarders who have completed all requirements of
the DSA program have obtained a placement in a health
science setting (T. Valega, 1993~.
Of the NRSA graduates who began their training be-
tween 1975 and 1985, between 50 and 60 percent of those
who submitted project applications to NIH were subse-
quently funded. Clearly, both NIDR-supported NRSA and
DSA trainees are able to compete successfully for grants.
In Figures 6-2 and 6-3 the positive relationship between
months of Raining and success in obtaining grants is clear.
There is also a positive relationship between degree and
research grant history (Figure 6-4~.
OCR for page 68
MEETING THE NATION' S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS
TABLE 6-1 Aggregate Numbers of NRSA Supported Trainees and Fellows
In Oral Heateh Research for FY 1991 through FY 1993
Fiscal
Year Level of Training
1991 Number of awards
Predoctoral
Postdoctoral
Type of Support
TOTAL Trameeship Fellowship
218
78
140
186
78
108
32
o
32
1992 Number of awards 213 178 35
Predoctoral 77 77 0
Postdoctoral 136 101 35
1993 Number of awards 127 105 22
Postdoctoral 97 96 1
Predoctoral 127 105 22
NOTE: Based on estimates provided by the National Institutes of Health. See Summary Table 1
FIGURE 6-2 Individ- 120
ual NRSA (F32) train
ees: relation between
months of training and
research grant history,
1980-1990 (based on
individuals who began
training between 1975
and 1985~. SOURCE:
National Institute of
Dental Research, 1991.
100
80
60
40
20
o
FIGURE 6-3 Institu- 200
tional NRSA (T32) train
ees: relation between
months of training and
research grant history,
1980-1990 (based on
individuals who began
training between 1975
and 1985~. SOURCE:
National Institute of
Dental Research, 1991.
SO 150
._
0
O 100
at
50
O
~ All trainees
14
70
L
_~ 1 -I- ~ . . 1
85
0-12 12-24 25-36 36 +
Monthe of Training
0-12 12-24
68
139
Months of Training
~ At least 1 applicant
E:;1 At least 1 award
10
· Total trainees
lit] At least 1 applicant
I 1 At least 1 award
38
25-36 36 +
OCR for page 69
ORAL HEALTH RESEARCH PERSONNEL
250
200
·0 150
o
n
it
100
50
o
~ Total trainees
193
- 88
31
_~G]
~ At least 1 applicant
Al At least 1 award
136
F32-D. D. S. F32-Ph. D. T32-D. D.S. T32-Ph. D.
Award-Degree
· D.D.S./D.M.D. only
D.D.S. + Ph.D.
HI Ph.D./Dr.P.H.
· Other
1 00 °~ - ~
80%
60%
40%
20%
Clinical Biomedical Behavioral
Research Category
FIGURE 6-5 Percent of NIDR research grants (R01, R23, R29,
R37) by degree of principal investigator and research category:
FY 1990-1992. NOTE: "Other" category includes M.D., M.D. +
Ph.D., D.V.M. and non-postdoctoraldegrees. SOURCE: Nation-
al Institute of Dental Research, 1993.
Figure 6-5 considers He types of academic training asso-
ciated with the area in which research was performed. This
could be used to provide an indication of the background
needed for scientists to conduct clinical, basic biomedical,
and behavioral research. Investigators having a dental de-
gree, either alone or with a Ph.D., predominated for clinical
research. Among biomedical research projects the investi-
gators having only the Ph.D. predominated. No differences
were found between the investigators having dental degree
or only He Ph.D. for projects classified as primarily behav-
ioral. These findings support the need for appropriately
trained individuals having at least a dental degree to provide a
future adequate cadre of clinical oral heals researchers.
69
FIGURE 6-4 NRSA trainees: relation
between degree and research grant his-
tory, 1980-1990 (based on individuals
who began training between 1975 and
1985~. SOURCE: National Institute of
Dental Research, 1991.
RECOMMENDATIONS
Program Size
Because of rapid advances in biological and physical sci-
ences, He opportunity for advancing oral heals has never
been greater. However, there is an alarming shortage of
trained researchers in oral health to take advantage of those
opportunities.
Graduates of NRSA and DSA programs supply, on aver-
age, fewer than one clinical scholar or potential clinical
scholar per dental school per year. At least 200 graduates
per year are necessary to supply the institutions' needs
(Kennedy, 1990), roughly four times the number being pro-
duced. Thus there is a shortage from two points of view:
one, to address the research needs and two, to fill faculty
slots with capable researchers. At least half of a dental
school faculty should be clinical scholars. The over half,
though perhaps not researchers, should be scholarly clini-
cians, that is, critical about the literature, critical about what
they are teaching, and critical about their patients' needs.
Research training fulfUls both needs of a clinical faculty.
Looked at in another context, dental institutions are a
small but important consumer of Ph.D.s who do not hold
clinical degrees. However, nobody but the OHR commu-
nity and dental institutions has concern for He D.D.S./Ph.D.
supply Hat is critical to maintaining the quality and quan-
tity of research related to oral health. Dental schools today
are not able to find sufficient numbers of D.D.S./Ph.D.s to
fill available faculty positions.
There are clear indications that the clinical degree is im-
portant to site of employment after Raining has been com-
pleted. In 1985 Littleton and his colleagues reported Hat
62 percent of D.D.S./Ph.D.s trained win NIDR support
could be found on faculties of dental institutions, whereas
only 31 percent of all NIDR postdoctoral trainees were em-
ployed in dental institutions (Littleton, 1985~. It is thus
important to the future of OHR Hat people with clinical
OCR for page 70
MEETING THE NATION' S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS
degrees be encouraged, through adequate training support,
to enter the research work force.
There is an acute need for clinical dental researchers and
OHR workers in general. The National Research Council's
1985 report called for 320-400 new clinical dental research
trainees annually, but the NIDR has been unable to carry
out this recommendation because funds were not available.
A significant increment in training would substantially alle-
viate the shortage of OHR personnel.
We need to produce about 260 graduates per year. This
estimate includes needs for researchers in dental schools
and other settings. About 30 percent of NIDR's total re-
search support goes to non-dental school institutions. If the
current distribution between NRSA and other mechanisms
remains constant, roughly half should be supported by the
NRSA mechanism (130 per year). At 3 - 5 years per f~n-
ished trainee, this would be 390 - 650 in training through
the NRSA mechanism; the current total through the NRSA
is 213 and for all NIDR mechanisms is only about 300.
There is need and rationale, therefore, for a tripling to
quadrupling of training for OHR (Table 6-2~. Realistically,
however, the need is better met incrementally rather than
abruptly to ensure that existing high-quality training sites
are not overloaded and to stimulate identification and de-
velopment of additional high-quality sites.
RECOMMENDATION: The committee recommends
that the total number of training positions available for
preparation in oral health research double from approxi-
mately 210 positions in fiscal 1993 to 430 positions in
fiscal 1996 and remain steady thereafter.
Need for a Dental Scientist Training Program
The Medical Scientist Training Program (MS TP) offers
an integrated program of medical and graduate training lead-
ing to the combined M.D. and Ph.D. degrees. The success
of that program (see Chapter 5), coupled with the demon-
strated success of D.D.S./Ph.D. or D.M.D./Ph.D., suggests
that OHR would benefit from the development of a Dental
TABLE 6-2 Committee Recommendations for Relative Distribution of Predoctoral
and Postdoctoral Tra~neeship and Fellowship Awards for Oral Health Research
for FY 1994 through FY 1999
Fiscal
Y
1994
Recommended number of awards
Predoctoral
Postdoctoral
Type of Support
TOTAL Traineeship Fellowship
260 200 60
125
135
1995 Recommended number of awards
Predoctoral
Postdoctoral
1996 Recommended number of awards
Predoctoral
Postdoctoral
1997 Recommended number of awards
Predoctoral
Postdoctoral
1998 Recommended number of awards
Predoctoral
Postdoctoral
1999 Recommended number of awards
Predoctoral
Postdoctoral
345
210
135
430
290
140
430
290
140
430
290
140
430
290
140
100
100
230
130
100
265
160
105
265
160
105
265
160
105
265
160
105
25
35
115
80
35
165
130
35
165
130
35
165
130
35
165
130
35
70
OCR for page 71
ORAL HEALTH RESEARCH PERSONNEL
Science Training Program (DSTP) that is analogous to He
MSTP under He auspices of the NRSA legislation.
RECOMMENDATION: The committee recommends
that one-quarter to one-half of the new positions available
for training in OHR in fiscal 1994 and beyond be used by
NIDR to establish a Dental Scientist Training Program
(DSTP) under the NRSA act.
Other Considerations
Additional suggestions for improving the NRSA for
training OHR scientists have emerged in committee discus-
sions. Some of these suggestions are similar to those from
other fields and are included in the overall recommenda-
tions of this report. Other suggestions are unique to OHR,
and are mentioned in the paragraphs Hat follow.
Legislated policy requires Hat individual awards com-
prise at least 15 percent of the total NRSA allocation by the
funding institute, but there is no clear rationale for the
policy. NIDR sometimes has difficulty meeting the 15 per-
cent requirement for awards to individuals, and there is great
demand for institutional awards. It is possible that institu-
tions are competing for the best students through He insti-
tutional training mechanism, leaving relatively few students
for the pool of individual applicants. The committee be-
lieves that He 15 percent requirement for individual awards
for NIDR should be rescinded.
The long-term effectiveness of short-term exposure to
research experiences needs to be evaluated. At present, the
NIDR uses the T-35 mechanism to draw dental students
into research careers. However, this particular mechanism
is limited to 4 percent of the NRSA funds. The committee
suggests that this limitation be evaluated not only for the
long-term effect but also to explore whether the mechanism
should be extended for other purposes, such as retraining,
encouraging minorities and women to enter research tracks,
and stimulating clinical research.
Completion of a Ph.D. after a dental degree generally
requires more than 3 years. Also, other sources of support
for continuing such studies (e.g., Howard Hughes Institute,
clinical revenues) are not generally as available for dentists
as they may be for physicians. The committee suggests that
doctoral support be provided for 5 years and beyond for
dentists making satisfactory progress toward a Ph.D. under
an NRSA.
Finally, because of the disincentive for entering research
training that is inherent to the heavy debt load of dental
graduates (currently the highest of all health professional
graduates at greater Han $55,000, on average), loan for-
giveness would provide an incentive. The committee be-
lieves that a loan-forgiveness incentive should be provided
as a feature of NRSA programs.
In summary, what is particularly needed in OHR are ap
71
propriately Gained personnel to carry out a broadened scope
of research. There is an alarming personnel shortage of
research-aained full-time dental faculW. Many challenges
continue to arise as the twenty-first century approaches. These
challenges require enhanced resources and flexibility as well
as continued cooperation and collaboration among programs
and institutions if they are to carry out He mandate of Con-
gress to improve the oral heals of He American people.
NOTES
1. Much of the material in this chapter is based on the views of ex-
perts who convened a one-day workshop on July 9, 1993, in Washington,
DC (Lathrop and Ranney, 1993).
2. There are two major programs for training OHR scientists through
NIDR support, the NRSA and the Dentist/Physician Scientist Award
(DSA). NIDR's portfolio in the NRSA includes the following:
· F-32, individual postdoctoral fellowship;
· F-33, individual senior postdoctoral fellowship for senior faculty
members;
· F-35, intramural training grant;
· T-32, institutional training grant; and
· T-35, short-term summer training grant.
The DSA/PSA programs include the following awards:
· K-11, individual physician-scientist award for dentists;
· K-15, individual dentist-scientist award; and
· K-16, institutional dentist scientist award.
The F awards (fellowships) are all postdoctoral awards, either post Ph.D.
or post clinical doctorates. These postdocs receive the traditional
postdoctoral research Gaining and, in the case of clinical doctorates, that
may include earning a Ph.D. during postdoctoral training. The T awards
(training grants) can include predoctoral students. These people have
bachelor's or master's degrees and usually are in a program to obtain a
Ph.D. In rare cases, such as in biomaterials or epidemiology, they stop at a
master's level. The T-35 short-term grants are specifically for dental stu-
dents. The physician-scientist award for dentists and the dentist-scientist
awards appoint only dentists. All of these DSA appointees are in a pro-
gram to obtain a Ph.D.
REFERENCES
Kennedy, J.E.
1990 Faculty Status in a Climate of Change. Journal of Dental
Education 54(5).
Lathrop, L. and R.R. Ranney
1993 Proceedings of Meeting on National Needs for Oral Health
Research Personnel. National Academy of Sciences, Wash-
ington, D.C., July 9, 1993. Unpublished summary. Septem-
ber, 1993.
Littleton, P.A., L.J. Brown, and E.S. Solomon
1985 The Relationship Between National Institute of Dental Re-
search (NIDR) Supported Research Training and Careers in
Dental Research. Unpublished report. March, 1985.
Solomon, E.S.
1994 The Oral Health Research Work-Force. To be published in
Journal of Dental Education.
Valega, T.
1993
Report to Meeting on National Needs for Oral Health Re-
search Personnel, National Academy of Sciences, Washing-
ton, D.C., July 9, 1993. See Proceedings of Meeting (Lathrop
and Ranney, 1993).
OCR for page 72
Representative terms from entire chapter:
oral health
