Summary and Conclusions
As the end of twentieth century approaches and the challenges of the twenty-first century approach, it is instructive to recall how the century opened for dental education—with an abundance of proprietary schools, a trade not fully transformed into a profession, a minuscule research and science base, a population beset by serious dental disease and resigned to tooth loss, and a limited set of treatments. During the twentieth century, dental health, practice, and education have been transformed. Oral health research has led to preventive, diagnostic, and management strategies that have greatly diminished the incidence and severity of dental disease. Independent proprietary schools have vanished amidst a series of educational reforms in student recruitment and qualifications, faculty responsibilities, and instruction in the basic, clinical, and behavioral sciences.
These changes flow in part from broader scientific and social developments including public policies to promote individual and community health. Beyond these influences, however, lies the dedication of several generations of dental practitioners, educators, researchers, and public officials to improving oral health through educational, professional, and scientific achievements. Because it is in the nature of reports such as this one to be critical, the committee wants to stress that it recognizes these contributions.
Some of the principles upon which these contributions have been founded remain solid, for example, dentistry's commitment
TABLE 10.1 Recapitulation of Guiding Principles
to prevention. Others need to be reinvigorated, reformulated, or even replaced to prepare the profession for the future. Table 10.1 summarizes the key principles that guided this committee's work.
In considering the future of dental education, the committee had three basic tasks. One task was understanding and describing the current system and its evolution. A second task was trying to assess the forces that would shape dental practice and education in the future. The third was to draw conclusions about the reasonable and desirable steps that dental educators and others should take to capitalize on the positive opportunities before the profession and minimize the negative consequences of change.
Each of the preceding chapters has presented the results of the committee's work. This final chapter reviews the committee's findings about the key trends that will shape dental education and dental practice in the future, considers how the field is positioned to manage that future, and summarizes the committee's recommendations. A list of the formal recommendations is included in the summary at the beginning of this report.
Trends and Developments
The broad scientific, economic, social, and other forces that will shape dental practice are, for the most part, clear. Much less predictable are the magnitude, timing, scope, and details of devel-
opments in each area and the complex ways such developments may interact.
The scientific and demographic context of dental practice will undoubtedly continue to change. These changes will result from
- new scientific and technological advances (e.g., better understanding of the oral effects of various diseases and their treatment, increasing availability of pharmacological methods of preventing or treating oral diseases, and telecommunication tools to support diagnostic and other consultations);
- the continued impact of past scientific developments (e.g., water fluoridation and other uses of fluorides that have reduced the incidence of caries in children and changed the mix of oral health problems they present as adults);
- increased research on the outcomes of alternative preventive, diagnostic, and treatment strategies, as well as more evidence-based guidelines for appropriate dental practice; and
- an increase in the number and proportion of older patients who not only will have chronic problems and complicating medical conditions but also will be more highly educated, and possibly have higher expectations and demands for dental care; than their predecessors.
In addition, the management and conduct of dental practice will be altered by other social, economic, political, and technological developments that may or may not include legislative reform of the health care system. With or without federal action, the health care system is restructuring itself in ways that will affect dental practice and dental education. It appears that the pace of change for dentistry may be slower in some respects, but the directions are reasonably clear. The future will bring
- continued creation and diffusion of sophisticated information management technologies that will allow individual patient care, practice costs, and other variables to be tracked and assessed more readily;
- ongoing evolution of expectations and methods for assessing and improving the quality and efficiency of care provided in ambulatory settings;
- intensified pressure for control of health care costs;
- further growth of managed care and integrated care systems as a prevalent if not dominant method of organizing and administering medical and other health services; and
- greater emphasis on the contributions of health care to community as well as individual well-being.
Dental education will also be affected by changes in the university environment. Financial pressures on educational institutions undoubtedly will persist, although their severity may vary over time and across schools. Universities—and government policymakers—will continue to reevaluate their programs—adding, deleting, and restructuring them. Procedural changes in areas such as financial management, information systems, tenure, evaluation of educational outcomes, and accreditation may make life more difficult for educators in some ways and easier in others. Academic health centers will be under stress from the same changes in health care organization and financing that will affect dental schools, and in some respects, the impact of these changes may be more traumatic for medical schools and university hospitals than for dental schools. Overall, the world of higher education is likely to become less stable and thus more unpredictable and stressful for its constituent parts.
The implications of these trends and prospects for dental practice and dental education are clearer in some areas than in others. Dental schools and the dental community generally will see continued demands for greater professional accountability and evidence of effectiveness from public and university officials, institutional purchasers of dental services, managed care organizations, organized consumer or patient groups, and students. Relatedly, traditional practice and education will be challenged by a renewed focus on the dental practice team, multidisciplinary health care, and practice beyond the office setting. Dental practitioners will be relying more on medical management of a broad range of oral health problems, treating more patients who have chronic or complex medical problems, and undertaking a greater proportion of complex surgical and restorative services. For the majority of the population, however, the emphasis will continue to be on individual and community-based preventive and primary care services.
Much less clear is how changes in technology, demography, public policy, and health care organization will interact to affect the supply, demand, and need for oral health services. Although educators have no choice but to plan for the future and make choices that may affect the supply of dental services, this planning must account for uncertainty and consider alternative futures.
Further, although oral health status will continue to improve, it is not clear whether the society will commit the resources needed to reduce disparities in oral health status. Even if relatively inexpensive new preventive strategies were to emerge in the next few years, the problems—untreated caries, periodontal disease, and tooth loss—that now characterize disadvantaged groups
will create continued needs for care for many years to come. These groups have been a traditional source of patients for dental school clinics, but dental school efforts to extend their services into the community are vulnerable to public budget-cutting. Resource constraints also dictate less than optimal treatment in many cases. In theory, health care reform that extends coverage to dental services could give poor patients more choices, but the immediate prospects for such reform seem dim.
The difficult debate over health care reform in 1993 and 1994 illustrates both the short- and the long-term uncertainties facing those responsible for dental education and work force policies. Although important policy changes may be slow in coming, they could occur relatively quickly. The dental community should be cognizant of this possibility. Accordingly, it should be ready to explain the role of oral health in total individual and community health to those who develop health care policy, be organized to evaluate the implications of possible policy changes, and be prepared to take action to preserve the integrity of the oral health of the nation and the educational, research, and patient care missions of the dental school.
Strengths and Weaknesses
How are dental schools and dental professionals situated when it comes to responding constructively to the scientific, organizational, financial, and other challenges outlined above? Answering this question requires a look at the current strengths and weaknesses of the field.
The strengths of dental education and the dental profession are, in the committee's view, both significant and in need of constant protection. These strengths include
- a tradition of, and continuing commitment to, prevention and general practice that have helped achieve significant improvements in oral health;
- a valuing of oral health and a reservoir of trust in the population, despite a ''fear of the dentist's chair" that is both cliché and reality;
- a core of educators, researchers, and practitioners dedicated to educational progress and advances in oral health;
- a surrounding community of educators, health professionals, and public officials that supports the search for more effective and efficient educational strategies, on the one hand, and more effective and efficient health care, on the other; and
- a research and development establishment that produces a steady stream of technological and scientific advances.
Still, dental education, like any other enterprise, suffers from a myriad of problems ranging from minor irritants to potentially disabling conditions. The major weaknesses of concern to the committee fall in several areas. The mission of education is undermined by curricula and faculty that have become out of touch with the needs of students and prospective practitioners, patients, or communities. The mission of research is frustrated by the small numbers of qualified researchers and the limited acceptance by clinical faculty of the importance of research and scholarship. The mission of patient care has been subservient to that of education, leaving most dental schools ill-prepared to attract patients in a world marked by increasing competition, organizational integration, and managed care.
Further, each mission is weakened by dental schools' isolation from the intellectual and organizational life of the university, from the broader research community, and from the larger health care system. This isolation puts dental schools at risk within the university. Other risk factors include relatively high costs for education and patient care, low research productivity, uneven student quality, and resistance to change. Uncompetitive patient care programs are becoming a financial threat to schools.
Dentistry has been relatively slow to support outcomes research, to investigate the rationale for practice variations, and to demand proof of cost-effectiveness for new technologies. In a broader health care environment increasingly concerned about the effectiveness of health services, this stance is a liability.
In addition, tensions between the academic and practice communities too often impede efforts to revise educational standards, rationalize professional licensure, and improve community health. Politically, much of organized dentistry views distance from health care reform as a way of insulating the profession from demands for change and accountability. To a worrisome degree, dental education lacks strong allies to sustain it in the face of high costs and constrained resources.
Directions for the Future
Stated in very broad terms, the committee envisions a future for dental education based on four propositions. First, dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient
care. Second, to prepare both their students and their schools for change, dental educators will need to teach and display desirable models of clinical practice. Third, securing the resources essential for educational improvement and, indeed, survival will require that dental schools demonstrate their contributions to their parent universities, academic health centers, and communities through achievements not only in education but also in research, technology transfer, and community and patient service. Fourth, to prepare for the future, the dental community—educators, practitioners, regulators, and policymakers—will benefit from continued testing of alternative models of education, practice, and performance assessment for both dentists and allied dental professionals.
In developing specific recommendations, the committee attempted to be both principled and pragmatic. That is, it tried to be neither so idealistic that its recommendations would be of little use to real-world decisionmakers nor so fixated on the practical difficulties of change that it would provide no direction, motivation, or benchmarks to help decisionmakers move through difficulties toward desired goals. Still, the following recommendations individually or collectively may strike some as weighted toward the idealistic and others as weighted toward the status quo. If, however, a 10- to 20-year horizon is accepted as necessary and reasonable for the more demanding recommendations, then the possible and the ideal draw closer together.
Similarly, as the committee concluded in several instances, the case for some recommendations may not be robust when grounded in a single objective but may be convincing when supported by benefits on multiple fronts. In particular, a number of the education financing recommendations promise only modest economic benefits but would, if implemented, strengthen clinical education and research.
The recommendations reflect the principles that guided the committee, its findings about the current status and future prospects of dental schools and its broad judgments about directions for dental education. These judgments attempt to balance idealism, realism, and prudence. They are not, however, a blueprint for the future. Such a blueprint would have required confident predictions about the pace and direction of key scientific, economic, and social changes, and the committee either found current knowledge insufficient to warrant such confidence or disagreed about what the predictions should be. In addition, the committee did not reach consensus on some policy matters. Finally, the committee believes that no single blueprint is appropriate for all dental schools or all policymaking organizations.
Oral Health Status and Services
The committee emphasized four broad objectives for the effective use of health resources to advance the nation's oral health. These objectives are to
- improve our knowledge of what works and what does not work to prevent or treat oral health problems;
- reduce disparities in oral health status and services experienced by disadvantaged economic, racial, and other groups;
- encourage prevention at both the individual level (e.g., feeding practices that prevent baby-bottle tooth decay, reduced use of tobacco) and the community level (e.g., fluoridation of community water supplies and school-based prevention programs); and
- promote attention to oral health (including the oral manifestations of other health problems) not just among dental practitioners but also among primary care providers, geriatricians, educators, and public officials.
Dental education can play a central role in each of these areas. In particular, dental educators should be involved in basic science, clinical, and health services research to distinguish effective and ineffective oral health services, to clarify oral disease patterns and trends and the factors affecting them, and to develop cost-effective strategies likely to help those with the poorest health status and those with limited access to oral health services. Such strategies should include both technologies and new ways of organizing and delivering services to reach underserved populations. In their outreach activities, dental educators and practitioners should continue to encourage physicians, nursing home personnel, public officials, and others to be alert to oral health problems among those whom they serve and to provide information about good oral health habits.
Public support is critical if disparities in health status and access to oral health services are to be reduced. This committee therefore recommends that all parts of the dental community work together to secure more adequate public and private funding for personal dental services, public health and prevention programs, and community outreach activities, including those undertaken by dental school students and faculty.
In their efforts to improve oral health status, both educators and policymakers are hampered by inconsistent and insufficient information on oral health status and services. Thus, this committee recommends a stronger public commitment to the regular collection and analysis of data on oral health status and services;
the formulation and implementation of outcomes research agenda; and the translation of knowledge into clinical advice for practitioners and patients.
The Mission of Education
In terms of education, the problem is not so much consensus on directions for change but difficulty in overcoming obstacles to change. Agreement on educational problems is widespread. The curriculum is crowded with redundant or marginally useful material and gives students too little time to consolidate concepts or to develop critical thinking skills. Comprehensive care is more an ideal than a reality in clinical education, and instruction still focuses too heavily on procedures rather than on patient care. Linkages between dentistry and medicine are insufficient to prepare students for a future of patients with more medically complex problems and more medically oriented strategies for prevention, diagnosis, and treatment. The basic and clinical sciences do not adequately relate the scientific basis of oral health to clinical practice. Lack of flexible tenure and promotion policies or of resources for faculty development limits efforts to match the faculty to educational needs. Despite progress, an insensitivity to students' needs is still a concern. All of these weaknesses undermine efforts to prepare students for lifelong learning.
Agreement on the obstacles to educational change is also strong. Obstacles include a lack of specific information on course content, limited evaluation of educational outcomes, financial constraints, university policy restrictions, and faculty conservatism.
In the hope of stimulating movement toward generally held goals, the committee proposes that each dental school develop a plan and timetable for Curriculum reform. It urges closer integration of dental and medical education and more experimentation with new formats for such integration. Using excellent practice in the community as a model, dental school clinics should seek to be more patient-centered and efficient and to provide students with a greater volume and breadth of clinical experience. All dental graduates should have the opportunity for a year of postgraduate education with an emphasis on advanced education in general dentistry.
The Mission of Research
Research is a fundamental mission of dental education, but too many dental schools and dental faculty are minimally involved in
research and scholarship. A commitment to research in dental schools is important because research builds a knowledge base for improving the effectiveness and efficiency of oral health services; enriches the educational experience for students; reinforces the school's role as a disseminator of validated practice advice to dental practitioners; and strengthens the stature of dentistry within the university and in the broader community.
The committee recognizes the problems facing schools that are trying to build or maintain a strong research program, most notably, limited funding and a dearth of r capable researchers. The expansion of the oral health research work force is an important priority.
Dental schools will differ in how they define the specifics of their research priorities, but all schools need to formulate a program of faculty research and scholarly activity that meets or exceeds the expectations of their universities. To build research capacity and resources, as well as foster relationships with other researchers, it is important for dental schools to pursue collaborative research opportunities that start with the academic health center or the university and extend to industry, government, dental societies, and other institutions able to support or assist basic science, clinical, and health services research. Throughout this report, the committee has tried to point out opportunities for dental school faculty to participate in clinical, behavioral, and health services research that will support the missions of education and patient care and will help improve voluntary and governmental oversight of the profession.
The Mission of Patient Care
The typical dental clinic, put simply, is not patient-centered, Current trends in health care delivery and financing are requiring academic health centers to compete for patients and inclusion in managed care plans of various sorts. Whether the patient care activities of the dental school add or subtract from the overall institution's market position is likely to be an issue in its future. At a minimum, financial viability is likely to require that schools put more emphasis on efficiency, quality, and accountability for care from the patient's perspective.
Over the long-term, the committee believes that dental schools have no ethical or practical alternative but to make their programs more patient-centered as well as more economically viable and to develop the programs and the data needed to assess and
document the quality and efficiency of care. They will have to ensure that their activities and objectives are compatible with those of their parent institutions.
The Dental School in the University
To fulfill and improve their basic missions of education, research, patient care, and service, dental schools need the intellectual vitality, organizational support, and discipline of universities and academic health centers. In return, dental educators must contribute to university life, especially through research, scholarship, and efficient management of educational and patient care programs. More generally, leaders in dental education and practice should work together to diminish the divisions that may undermine public and private support for dental schools and oral health.
The closure of several dental schools has, however, made the vulnerability of their relationship to the university clear. Reduction in the factors that put dental schools at risk in the university is not an overnight task, and some factors are less subject to a school's influence than others. This makes it all the more important that each school assess its own position and develop a specific plan for analyzing and reinforcing its position within the university.
Although education at all levels faces financial constraints ranging in severity from routine to critical, dental education faces particular challenges given its relatively high costs and specialized needs. For most schools, financial health will not be achieved through a single grand solution. Rather, some combination of more modest and difficult steps will be necessary. Schools will need to develop better cost and revenue data if they are to design steps that match their particular problems and characteristics and minimize harm to their educational, research, and patient care missions.
Accreditation and Licensure
Accreditation and licensure are components of a broad social strategy to ensure the quality of dental care by protecting the public from poorly trained, incompetent, or unethical dental practitioners. They also account for many of the tensions between dental schools and the profession. The dental community has taken important actions to improve licensure and accreditation processes, but further work is needed.
The accreditation process remains too focused on process and too inhospitable to educational innovation. The committee believes that the process tolerates some inferior educational programs, although data to document this are not publicly accessible. Accreditation reform should focus on standards and methods that will identify and improve those schools that are not educating their students effectively or ethically, and that will not allow persistently poor performance. At the same time, excessively detailed assessments of structures and processes should be trimmed. In addition, dental accreditors and educators should be prepared to respond constructively to reasonable demands for increased public accountability and information.
In the view of this committee, the most important deficiencies of dental licensure are concentrated in a few areas: the use of live patients in clinical licensure examinations; variations in the content and relevance of clinical examinations; unreasonable barriers to movement of dentists and dental hygienists across state lines; practice acts that unreasonably restrict the use of appropriately trained allied dental personnel; and inadequate means of assessing competency after initial licensure.
The committee understood and sympathized with concerns expressed about self-regulation of dental education and parochial state regulation of the profession. It concluded, however that it is neither practical nor necessary to construct new national systems for licensure and accreditation. Rather, the committee urges dental leaders to cooperate to achieve greater uniformity in licensing, minimize barriers to professional mobility, and revise laws that limit dentists from working more productively with allied dental personnel. A uniform national clinical examination (one that does not include real patients) should be developed for acceptance by each state. Voluntary accreditation should focus on dental schools with significant deficiencies and reduce administrative burdens on other schools.
Improvements in methods of assessing educational outcomes are as central to accreditation reforms as they are to improvements in predoctoral education, entry-level licensure, and assessment of continued competency. Thus, cooperation and coordination among responsible organizations in each of these arenas should be established to avoid conflicting strategies and costly duplication of effort. Improvements in the processes for collecting information—particularly those based on electronic transfer of data—likewise will produce multiple benefits and should be coordinated.
Dental Work Force
The dental community is characterized by much anxiety and disagreement about whether the nation faces a future shortage or a future oversupply of dental services. The committee found no compelling evidence that would allow it to predict either outcome with sufficient confidence to warrant recommendations that dental school enrollments be increased or decreased. On the one hand, the ratio of dentists to the general population is declining, and the coverage of dental services under expanded public or private health insurance could substantially increase the demand for such services, especially if additional efforts are made to reach those with significant unmet needs. On the other hand, the current dental work force appears to have reserve capacity that could be mobilized through better use of allied dental personnel, improved identification and elimination of care with little or no demonstrated health benefit, and more efficient delivery systems. Scientific and technological developments could increase or reduce overall need and demand depending on whether they promoted prevention or expensive treatment.
In the face of uncertainty, the committee believes it is prudent to continue monitoring trends in the supply of dental personnel and developing better understanding of their productivity, of the appropriateness of dental services, and of the factors that impede access to dental care. This course will require a more sustained investment in a comprehensive oral health data infrastructure than has been evident over the last decade.
To respond to any future shortage of dental services and to improve the effectiveness, efficiency, and availability of dental care generally, educators and policymakers should continue efforts to increase the productivity of the dental work force, including appropriately credentialed and trained allied dental personnel, and to support research to identify and eliminate unnecessary or inappropriate dental services.
Two persistent work force problems involve dental shortage areas and minority representation in the future. The National Health Service Corps (NHSC) and other federal or state programs link financial assistance to practice in underserved areas and also help relieve the serious problem of high student debt. The shrinkage in dental positions in the NHSC should be reversed. Building a dental work force that reflects the nation's diversity will require broad-based efforts to reduce attrition among predoctoral students and to enlarge the pool of candidates for dental school admission
through information, counseling, financial aid, improved precollegiate education in science and mathematics, and other supportive programs for precollegiate and collegiate students.
From Recommendations to Action
From the beginning, this committee was quite aware that reports like this one are far from self-implementing. Indeed, one goal of this report has been to stimulate renewed efforts to implement reforms that have long been recommended and are even more urgently needed today. Members of this committee look forward to discussing the report's analyses and recommendations with many groups, and they hope to see the creation of task forces and similar groups to turn those recommendations that require collective responses into specific, workable action plans. Such groups may be organized both within and across leadership organizations such as the American Association of Dental Schools, the American Association of Dental Examiners, the American Dental Association, the American Dental Assistants' Association, and the American Dental Hygienists' Association. Given its discussions with leaders of these groups, the committee trusts that activities like these will be organized in the months following publication of this report.
Many of this report's recommendations explicitly recognize that dental educators, regulators, researchers, and practitioners will have to work together with an understanding that they are investing in the well-being of their profession and their communities. Further, the dental community collectively will have to enlist support from university and public officials and from other health professionals, a task that current tensions sometimes make difficult.
Individually, each dental school will find itself in a different position with respect to the problems, opportunities, and directions identified here. Each school will need to tailor a strategy that reflects its objectives and resources—but does not simply capitulate to obvious difficulties. Notwithstanding differences in their individual circumstances, dental schools will gain by sharing ideas and strategies for solving common problems.
Finally, the committee recommends that the Institute of Medicine convene a conference or workshop to bring interested parties together, within a year after this report's publication to assess the initial impact of this report. The agenda would include the responses of different organizations, discussion of initial individual
or collective steps to implement recommendations, and suggestions about follow-up strategies. If the spirit of cooperation among dental leaders that led to this study persists, that gathering should find that this effort has begun to make a constructive contribution to the health of the profession and the public.