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--> Dental Education at the Crossroads Challenges and Change Committee on the Future of Dental Education Marilyn J. Field, Ph.D., Editor Division of Health Care Services Institute of Medicine National Academy Press Washington, D.C. 1995
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--> National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Support for this project was provided by the Robert Wood Johnson Foundation under Grant No. 19634, the American Fund for Dental Health, the National Institute of Dental Research under Contract No. NO1-DE-22594, the Health Resources Services Administration under Contract No. 240-91-0051, the Department of Veterans Affairs, the Department of Defense, the American Association of Retired Persons, and CIGNA Dental Health, Inc. The views presented are those of the Institute of Medicine Committee on the Future of Dental Education and are not necessarily those of the funding organizations. Library of Congress Cataloging-in-Publication Data Dental education at the crossroads : challenges and change / Committee on the Future of Dental Education, Division of Health Care Services, Institute of Medicine ; Marilyn J. Field, editor. p. cm. Includes bibliographical references and index. ISBN 0-309-05195-9 1. Dentistry—Study and teaching—United States. 2. Dental policy—United States. I. Field, Marilyn J. (Marilyn Jane). II. Institute of Medicine (U.S.). Committee on the Future of Dental Education. RK91.D39 1995 94-41301 617.6′0071′173—dc20 CIP The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin. Copyright 1995 by the National Academy of Sciences. All rights reserved. Printed in the United States of America
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--> Committee On The Future Of Dental Education JOHN P. HOWE III (Chair), President, The University of Texas Health Science. Center at San Antonio, San Antonio, Texas MYRON ALLUKIAN, Jr.,* Assistant Deputy Commissioner and Director, Personal Health Services and Community Dental Programs, Department of Health and Hospitals, City of Boston, Boston, Massachusetts HOWARD L. BAILIT,* Senior Vice President, Health Services Research, Aetna Life and Casualty, Hartford, Connecticut EVA C. DAHL, Practice of Endodontics and Oral Pathology, Department of Dental Specialists, Gundersen Clinic, Ltd., La Crosse, Wisconsin CHESTER DOUGLASS, Professor and Chairman, Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, and Professor of Epidemiology, Harvard School of Public Health, Boston, Massachusetts RASHI FEIN,* Professor of the Economics of Medicine, Department of Social Medicine, Harvard Medical School, Boston, Massachusetts JOEL F. GLOVER, Private Practice, Reno, Nevada JOSEPH L. HENRY,* Associate Dean, Professor, and Chair, Department of Oral Diagnosis and Oral Radiology, Harvard School of Dental Medicine, Boston, Massachusetts CARLOS MANUEL INTERIAN, JR., Private Practice, Miami, Florida JAMES D. ISBISTER, President, Pharmavene, Inc., Gaithersburg, Maryland MARJORIE K. JEFFCOAT, Rosen Professor and Chairman, Department of Periodontics, School of Dentistry, University of Alabama, Birmingham, Alabama TERRELL E. JONES, Oral Surgery Resident, The University of Tennessee, College of Dentistry, Memphis, Tennessee LINDA G. KRAEMER, Senior Associate Dean, College of Allied Health Services, Thomas Jefferson University, Philadelphia, Pennsylvania J. BERNARD MACHEN, Dean, School of Dentistry, University of Michigan, Ann Arbor, Michigan ELIZABETH F. NEUFELD,* Professor and Chairman, Department of Biological Chemistry, School of Medicine, University of California, Los Angeles, California
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--> J. DENNIS O'CONNOR, Chancellor, University of Pittsburgh, Pittsburgh, Pennsylvania NEAL A. VANSELOW,* Chancellor, Tulane University Medical Center, New Orleans, Louisiana THERESA VARNER, Director, Public Policy Institute, American Association of Retired Persons, Washington, D.C. Study Staff LISA M. CHIMENTO, Program Officer (through June 1994) MARILYN J. FIELD, Study Director KATHLEEN N. LOHR, Director, Division of Health Care Services (from September 1993) NINA SPRUILL, Financial Officer DONNA D. THOMPSON, Administrative Assistant KARL D. YORDY, Director, Division of Health Care Services (through September 1993) * Institute of Medicine member
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--> Preface Early in 1990, a group of leaders in dental education asked whether the Institute of Medicine (IOM) would undertake an independent assessment of dental education. After the governing bodies of the IOM approved a preliminary proposal for such a project, the IOM convened a planning meeting in June 1990 that recommended a study to identify measures to strengthen dental education in the United States and stabilize its position within the university. The next step involved discussions with other leaders in dentistry to determine their interest in and receptivity to an IOM study. The study was not conceived as a follow-on project to any previous study but as an independent examination of dental education. It was overseen by an 18-member committee of experts in dental practice and education, oral health and health services research, other areas of health professions and higher education, health care delivery and financing, and public policy. During its work, the committee faced a number of questions about the nature of the IOM. The IOM is part of the National Academy of Sciences, a private nonprofit organization Chartered by Congress in 1863 to provide advice on scientific matters. IOM members include physicians, dentists, nurses, biomedical and health services researchers, and others. Despite its name, one-quarter of the Institute's members must by charter come from outside the health field. Funding for studies comes from both public and private organizations.
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--> The work of the IOM has covered a broad range Of health issues since its founding nearly 25 years ago. In recent years, it has issued reports on such disparate issues as the future of public health, measuring access to health care (including oral health services), the effects of mustard gas, preventing mental illness, career paths for clinical research (including dentistry), food and nutrition, employment and health benefits, health care data systems, and health care reform. Past or planned reports on health professions education and supply include studies of the allied health services (including dental hygiene), education for primary care, nursing education, health professions education and minorities, geriatric care in physician training, physician staffing for veterans' hospitals, and nurse staffing in community hospitals. In 1980, the IOM issued a report on financing dental care, and a 1994 report on career paths for clinical researchers includes oral health research. Elsewhere in the National Academy of Sciences, the Office of Scientific and Engineering Personnel issues periodic reports on national needs for such personnel. Its 1985 and 1994 reports cover oral health research workers. By way of historical note, within the National Academy of Sciences, the first committee to consider issues in dental science was formed in 1919 by the Division of Medical Sciences. This group later considered priorities for research grants awarded by the American Dental Association. Charge To The Committee The charge to the Committee on the Future of Dental Education, as revised by the committee, is as follows. The IOM committee will assess dental education in the United States and make recommendations regarding its future. It will examine the current status of dental education and oral health in the United States and consider future scientific, demographic, economic, organizational, and other developments that may affect oral health status and the system for educating dentists and other dental personnel; develop a statement of how, over the next 25 years, oral health and oral health services should be improved in the United States, and identify the short-term and long-term implications of this statement for dental education and public policy; describe strategies that will help dental education, research, and practice improve oral health by responding effectively to current problems and future developments in both science and society; and
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--> consider ways in which each dental school can better relate to the mission of its university and to the community at large. Committee Approach The committee engaged in a very broad-ranging effort to collect information and perspectives on dental education in the context of the broader systems of health professions education and health care delivery. Members made site visits to 11 of the 54 U.S. dental schools and in the process visited with approximately 600 faculty, students, administrators, alumni, and dental society leaders. (The committee chair and the study director participated in every site visit.) The committee also undertook a mail survey of all deans of dental schools (in cooperation with the American Association of Dental Schools) and a telephone survey of two dozen university presidents, chancellors, and other senior officials. A public hearing in September 1993 generated oral testimony from 25 groups and written testimony from nearly 30 more (out of more than 80 groups invited). In addition, the committee established and met with three liaison panels representing regional dental society leadership, specialty societies, and dental school faculty. Members of the committee met with leaders of major dental organizations including the American Association for Dental Research, the American Association of Dental Schools, the American College of Dentists, the American Dental Association, the American Dental Assistants' Association, and the American Dental Hygienists' Association. Committee members and staff also discussed the project at annual meetings and other sessions organized by a number of dental groups. To inform its analyses and provide additional background for this report, the committee commissioned, seven papers that are being published separately by the Journal of Dental Education. In addition, committee and staff reviewed a wide variety. of published and unpublished literature on topics related to the committee's charge. The committee also consulted the literature on medical education and sometimes cites it as a reference point but not necessarily a standard or ideal. The committee report was reviewed under the procedures of the National Research Council. This document constitutes the committee's final statement.
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--> Acknowledgments Many individuals and groups assisted the study committee and staff in the development of this report. Initial direction for this project was provided by a planning committee that met in June 1990. That meeting was chaired by John C. Greene, and the participants were Howard Bailit; Ben Barker; James Beck; Jack Brown; Teresa Dolan; Chester Douglass; Robert Ferris; Allan Formicola; James Gaines; Robert Genco; Robert Gerlach; Jay Gershen; Joel Glover; Albert Guay; Robert Heaney; Garland Hershey, Jr.; George Keller; Linda Kraemer; Warren Lesmeister; James Lipton; Preston Littleton; Kent Nash; Howard Oaks; Richard Ranney; Paul Schwab; Jeanne Sinkford; Paul Van Ostenberg; Neal Vanselow; and Richard Weaver. Many of those involved in this meeting continued to play a role in the study either as committee members or as sources of advice and information. Michael Millman, who was senior staff officer for the study before leaving for the Department of Health and Human Services, developed the project proposal and fund-raising strategy over a 2-year period. He left a valuable legacy to the committee and staff who came later. Karl Yordy, who was director of the Division of Health Care Services from the point at which this study was first discussed through September 1993, continued to take an active role in the study even after his departure from Washington, D.C. Samuel Thier, former president of the Institute, took a particular interest in launching this project.
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--> The members of three liaison panels that met with committee members are listed in Appendix A. Members of these panels also assisted by reviewing background materials developed by the committee and by answering a variety of questions. Appendix B lists the organizations that prepared written testimony for the committee's public meeting in the fall of 1993. The committee commissioned seven papers that provided useful background and insights for this report, as did two other papers drafted by committee members. These papers, which are being published in the January 1995 issue of the Journal of Dental Education, are listed with their authors in Appendix C. In addition to preparing background papers, James Bader, Eli Capilouto, William Clark, Lisa Tedesco, and Alex White contributed more generally to the study through their ideas and comments. During one of the committee meetings, Eli and Mary Lynne Capilouto also participated in a panel discussion of dental work force issues that also included James Bader, Gloria Bronstein, Norman Clark, Steven Eklund, Kent Nash, and Eric Solomon. Joseph Consani and Lindsay Hunt helped in sorting out the complexities of dental school financing by meeting with the committee and reviewing background materials. The American Association of Dental Schools (AADS) and the American Dental Association (ADA) have been unfailingly helpful in providing information, answering our many questions, and giving us the opportunity to discuss the report during their annual meetings and board meetings and at other sessions. At the AADS, we particularly appreciate the assistance of Thomas Freeland, Carolyn Gray, Martha Liggett, and Preston Littleton. Without their help, the survey of dental school deans would not have been feasible. Of course, without the constructive responses received from all 54 deans, the survey also would not have been useful. Linda DeVore and Arthur Dugoni, while each was president of the AADS, also supported the committee's work in a variety of ways. The ADA provided extensive assistance including a wealth of statistical information on dental education, licensure, accreditation, and practice as well as help in sorting out the limits of the information's use. The committee particularly appreciates the perspectives and information provided by Thomas Berger, Tommi Cole, Clifford Miller, and John Zapp and by ADA Presidents James Gaines and Jack Harris. The AADS also contributed to the American Fund for Dental Health, which helped fund this study; other major contributors to the Fund were Colgate-Palmolive and Warner-Lambert.
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--> The committee and staff also met with representatives of the American Association for Dental Research (John Clarkson and Harold Slavkin), the American College of Dentists (Juliann Bluitt and Sherry Keramidas), the American Dental Assistants' Association (Judith Andrews and Kathy Zweig), the American Dental Hygienists' Association (Kathleen Alvarez, Gail Bemis, Elizabeth Brutvan, and Sarah Turner) to discuss issues of concern to the organizations and their members. John Clarkson, Jane Kendall, Karen Sealander, and Kathy Zweig also answered questions and provided information to the committee on a number of issues. In addition, staff and members of the American Board of Dental Examiners, American College of Dentists, American Academy of Oral Pathology, American Academy of Pediatric Dentistry, American Academy of Periodontology, American Association of Endodontists, American Association of Oral and Maxillofacial Surgeons, American Association of Orthodontists, American Board of Dental Public Health, American College of Prosthodontists, and the Academy of General Dentistry patiently answered our questions. Many staff of the National Institute of Dental Research helped the committee in a variety of ways. James Corrigan, the project officer for this study, was an invaluable resource. Harold Löe and Dushanka Kleinman met with the committee to discuss research issues and directions and were supportive throughout the project. At the Department of Defense, Robert Augsburger, the project officer, helped answer a number of questions about dental issues for the military. Although we agreed not to identify them individually, the chancellors and other senior officials of over 22 universities and academic health centers took time from their busy schedules to participate in telephone interviews or personal interviews with committee members and staff. Others provided time during the committee's site visits to 11 dental schools. The deans, faculty, and administrative staff at each of these schools made every effort to broaden and deepen our understanding of dental education and its environment, as evidenced by the meetings they arranged with some 800 people including students, faculty from inside and outside the dental schools, community practitioners, dental society leaders, and alumni. The committee particularly acknowledges the substantial effort required to arrange the site visits and thanks: Allen Formicola and Zoila Noguerole at Columbia University; Robert Knight and Ethel Newman at Howard University; Edward Kaufman and Joan Pano at New York University; Michael Heurer at Northwestern University; Arthur Dugoni and Edward Hayashida at the
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--> University of the Pacific; Henry Cherrick, Jay Gershen, and Christy Kemp at the University of California, Los Angeles; Allen Anderson and Michael Valadez at the University of Illinois at Chicago; John Stature at the University of North Carolina; John Greene and Anne Buchanan at the University of California at San Francisco; Howard Landesman and Janice Balin at the University of Southern California; and Kenneth Kalkwarf and Karen Fuller at the University of Texas at San Antonio. (In addition, the study director, whose dental emergency provided an unplanned opportunity to learn about an advanced general dentistry clinic, thanks John Greene, Terry Chin, and Ed Hayashida for their advice and assistance). Among the many others who contributed substantively to the committee's understanding of dental education and its environment were Brownell Anderson, Roger Bulger, Charles Cartwright, Kenneth Chance, Skip Collins, Stephen Corbin, Dominick De Paola, David Denton, Linda DeVore, Arthur Dugoni, Patrick Ferillo, Jay Gershen, James Kennedy, Sherry Keramidas, Rowland Hutchinson, Peter Lockhardt, Lawrence Meskin, Linda Niessen, David Nash, Spencer Redding, Henry Sazima, Aidan Stephens, and Barry Wogelman. At the University of Texas Health Science Center at San Antonio, Sylvia Cantu helped coordinate work with the committee chairman. Frances Poillon was our most helpful copy editor, and Sally Stanfield at the National Academy Press was supportive, as always. Nina Spruill helped us keep our somewhat complicated financial accounts straight, and Claudia Carl managed the logistics of an extensive report review process. Although she participated in all aspects of the study, Lisa Chimento made particular contributions in literature review, data collection and analysis, and planning and analysis of the public meeting and site visits. During the final stages of report preparation, Helen Rogers provided assistance with references and fact checking, especially in the regulatory area. With her superb computer and logistical skills and unflappable good humor, Donna Thompson handled smoothly the preparation of the committee report, the revising of the commissioned papers, and the arrangements for an extensive array of meetings and other activities. The committee also benefited from the work of other committees and staff of the Institute of Medicine or the National Research Council that produced the reports noted in the reference list, in particular, the reports on national needs for biomedical and behavioral science researchers, careers in clinical research, and racial and ethnic diversity in the health professions.
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--> Contents Summary 1 1 Background and Introduction 21 Dental Education in Context 23 Envisioning the Future 28 Missions of Dental Education and Organization of Report 31 Appendix 1.A 33 2 Evolution of Dental Education 35 Origins of Dental Instruction 38 Formal Education: Early Developments 39 Education Reform 43 The Struggles Over Educational Standard Setting 48 Building a Research Base in the University 51 Health Status and Epidemiological Research 53 Other Controversies 55 Summary 58 3 Oral Health Objectives and Dental Education 59 Data Sources 59 Oral Health Status 61 Prospects for the Future 68
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--> Recommendations of Other Groups 75 Committee Findings and Recommendations 78 Summary 81 Appendix 3.A 82 Appendix 3.B 85 Appendix 3.C 85 Appendix 3.D 86 4 The Mission of Education 88 Curriculum in Context 89 Background Data 91 Issues and Controversies 94 Advanced Education 111 Continuing Education 118 Faculty 122 Students 131 Findings and Recommendations 140 Summary 143 5 The Mission of Research 144 Broad Goals for Research in the Dental School 145 Research Revenues, Expenditures, and Publications 149 Focus of Research and Research Training 151 The Research Work Force 156 Expanding Research Capacity and Accomplishments 157 Research and the Mission of Education 170 Findings and Recommendations 171 Summary 173 6 The Mission of Patient Care 174 Context 174 Issues and Challenges 181 Rethinking the Mission of Patient Care 191 Findings and Recommendations 196 Summary 198 7 Dental Schools and the University 199 The University in a Changing World 200 Schools at Risk 202 Financing Dental Education 203 Strengthening the Dental School Within the University 220 Findings and Recommendations 225 Summary 227
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--> 8 Dental Schools, the Profession, and the Public 228 Accreditation 229 Licensure 237 Findings and Recommendations 250 Summary 253 9 A Dental Work Force for the Future 254 Work Force Trends and Projections 255 Forecasting Models and Their Limitations 263 Planning for Uncertainty 269 Work Force Distribution and Composition 275 Findings and Recommendations 278 Summary 280 10 Summary and Conclusions 281 Trends and Developments 282 Strengths and Weaknesses 285 Directions for the Future 286 From Recommendations to Action 294 References 296 Appendixes A Committee on the Future of Dental Education Liaison Panels 319 B Organizations Submitting Testimony at the Public Hearing 322 C Commissioned Papers and Authors 324 D Committee Biographies 325 Index 333 Tables And Figures Tables 1.1 Number of U.S. Dental Schools, 1970-1993 22 2.1 Time Line of Selected Dates in Dentistry and Dental Education, 36 2.2 Conclusions of the Gies Report on Dental Education, 1926 44
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--> 3.1 Mean Number and Percentage Component of Decayed, Missing, and Filled Permanent Teeth (DMFT) Among Children by Age Group and Race, United States 1963-1987 65 4.1 Variability in Curriculum Requirements—Basic Sciences, Clinical Sciences, and Behavioral Sciences 93 4.2 First-Year Enrollment in Advanced General and Specialty Education Programs 113 4.3 Survey of Deans' Priorities for Dental School Faculty Development over the Next 15 Years 126 5.1 Research Standards for Accreditation 146 5.2 Dental School Expenditures (dollars) for Research, 1993 151 5.3 Dental School Revenues (dollars) from Research, 1993 151 5.4 NIDR Research Centers Support: Number of Projects and Number of Subprojects by Type of Center and Institution, FY 1993 154 5.5 Total NIDR Appropriations FY 1970-1993 in Current and Constant Dollars 160 5.6 Research Grant Activity (FY 1985-1992) of Physician (K11) and Dentist (K15, K16) Scientists 164 6.1 Standard 6—Patient Care and Clinic Management 187 7.1 Sources of Dental School Revenue as Percentage of Total Revenue 205 7.2 Dental School Expenditures and Revenues per Student, 1977-1991 (in dollars) 206 7.3 Sources of Income and Revenue for Dental Schools and Medical Schools, 1990-1991 (in $millions) 208 7.4 Number of Dental Schools Subjected to Intensive Review over the Last Five Years 223 7.5 Deans' Perceived Sources of Support for Changes in Educational Programs 224 8.1 Number of Programs Accredited by Commission on Dental Accreditation 230 8.2 States Participating in Regional Dental Testing Agencies, January 1994 239 9.1 Deans' Responses to Supply Questions in Institute of Medicine and American Association of Dental Schools Survey 256 9.2 Projection of Active U.S. Dentists by Year of Published Prediction 266 10.1 Recapitulation of Guiding Principles 282
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--> Figures 1.1 Trends in age distribution of U.S. population aged 65 and over, 1990-2030 25 1.2 Trends in the supply of dentists 27 3.1 Age-adjusted mortality rates for oral and pharyngeal cancers by race, gender, and year of death, 1973-1987 66 4.1 Alternative configurations of basic and clinical science education 96 4.2 Survey of dental school seniors: Ratings of curriculum emphasis 101 4.3 Trends in number of full-time and part-time clinical faculty 124 4.4 Dental schools, by size of enrollment 133 4.5 Average resident tuition and fees in constant dollars by school type 136 4.6 Student debt in constant dollars 137 5.1 Percentage distribution of National Institute of Dental Research (NIDR) extramural obligations, FY 1993 152 5.2 Distribution of total FY 1993 National Institute of Dental Research (NIDR) extramural funds by research areas ($thousands) 153 6.1 Trends in dental school enrollments and total patient visits, 1984-1992 179 8.1 Overall failure rate on Northeast Regional Examination Boards by school 243 9.1 Trends in supply of dentists, 1990-2020 258-259 9.2 Enrollment trends in allied dental programs 264-265