Dental safety net: current capacity and potential for expansion

OBJECTIVES: The authors' objectives were to determine the size and characteristics of the dentally underserved U.S. population, describe the capacity of the safety net system to treat the underserved, explore policy options for expanding the system and discuss the policy implications of these findings. METHODS: The data came from published reports from health care organizations and researchers, as well as from public officials, dental educators and clinic directors. The values presented are estimates from available data. RESULTS: The underserved population consists of 82 million people from low-income families. Only 27.8 percent of this population visits a dentist each year. The primary components of the safety net are dental clinics in community health centers, hospitals, public schools and dental schools. This system has the capacity to care for about 7 to 8 million people annually. The politically feasible options for expanding the system include increasing the number of community clinics and their efficiency, requiring dental school graduates to receive one year of residency training, and requiring senior dental students and residents to work 60 days in community clinics and practices. This could increase the capacity of the system to treat about 10 million people annually. CONCLUSIONS AND CLINICAL IMPLICATIONS: The safety net system has limited capacity but could be improved to care for another 2.5 million people. Even if it is expanded, however, the majority of low-income patients would need to obtain care in private practices to reduce access disparities. The biggest challenge is convincing the American people to provide the funds needed to care for the poor in safety net clinics and private practices.     

Dental education and special-needs patients: challenges and opportunities

Pediatric dentists have, by tradition and default, provided care for persons with special health care needs (PSHCN), regardless of age. Deinstitutionalization of PSHCN in the 1960s, however, overwhelmed the dental care system, and oral health care became one of the greatest unmet needs of this population. This presentation follows the history of training for dentists in this aspect of care, from the first demonstration programs in the 1970s to the current educational programs in U.S. dental schools. Today's dental students must be competent in assessing the treatment needs of PSHCN, but accreditation standards do not require competency in the treatment of this group of patients. Recommendations to rectify this include revising dental school curricula to be more patient-centered, improving technology in schools, earlier clinical experiences for dental students, and the use of community-based clinics.     

Australian dental schools: moving towards the 21st century

In Australia nearly all tertiary education is funded through the Federal Government. With reductions in government spending tertiary education has had to accommodate its share of the cuts. Under such a climate dental schools in Australia face serious financial difficulties, in addition to many other diverse threats, as they head towards the 21st century. Most seriously, and almost uniformly felt, is the diminution of Federal Government funding to a point where the operation of some dental schools remains viable only by way of supplementary funding (direct or in-kind) from State Governments. In this report the authors have developed one possible model of academic, clinical and financial structures of a dental school, based on sound educational and economic grounds, that can overcome some of the short-comings of the paradigm that exists in some schools in Australia. The two key factors underlying the principles of this model for a new style of dental school are flexibility and professional responsibility. Based on the existing academic and economic realities it would be much more appropriate to outsource a significant proportion of the educational and clinical component of a dental school. Highly trained individuals from the dental profession would be invited to provide training in their area of expertise. The role of the dental school would evolve to be like a facilitation centre, organizing the various courses. It would mean that the 'core' curriculum would be the responsibility of the school's academic staff and the outsourced professional members would contribute within the bounds of the basic framework. On the basis of this model a dental school of approximately 225 full-time undergraduate students (50 per year, less some student loss) in a five year programme is planned, and annual staffing costs are estimated at $1.4 million.     

Identifying and responding to competing needs: a case study of a dental school-operated community dental clinic

Dental schools face challenges and competing needs when they seek to initiate or expand their community dental programs. This article uses a dental school community clinic as a case study to frame the tensions between competing needs of educational requirements, access to dental care, financial viability, and service to the community that clinics must learn to manage if they are to be successful. The identification of competing needs provides community-oriented dental school clinics the ability to examine factors that come into play as communities and their environments change. The outcome of this assessment process is strategies that can facilitate the provision of a higher level of services more efficiently, while at the same time taking into account future limitations in availability of resources. The concluding section of this article presents a model for a community-based dental clinic that is directed more toward patient care, involves dentists/specialists as primary providers, allows postdoctoral residents to take on more responsibility, and allows dental students to provide patient care on a more regular and longitudinal basis.     

The origins and design of the Dental Pipeline program

Funded by The Robert Wood Johnson Foundation and the California Endowment and with student financial aid from the W.K. Kellogg Foundation, the primary goal of the Pipeline, Profession, and Practice: Community-Based Dental Education program is to reduce disparities in access to dental care. In a national competition, fifteen dental schools were selected to participate. By the final year (2007) of the five-year project, the schools are expected to achieve three objectives: 1) increase the time (sixty days/year) that senior students and residents spend in patient-centered community clinics and practices treating underserved populations; 2) provide didactic and clinical courses for students and residents that prepare them for their community experiences; and 3) recruit more underrepresented minority and low-income students. The national program office that directs the project is located at Columbia University, and a national advisory committee oversees the program for the sponsoring organizations. The challenge is to demonstrate that the Pipeline objectives are achievable and that the program is sustainable without external support.     

The dental health status of children not included by parents in the South Australian School Dental Programme. A pilot study

ABSTRACT About 90 per cent of children have received school dental care at South Australian schools where this care has been available. However, following recent extension of the dental programme to metropolitan schools without clinics located in their grounds, lower participation rates of about 74 per cent have emerged.
A pilot study of 161 children not included in the school dental programme at 13 of these metropolitan schools without clinics was conducted to evaluate their dental health status and determine why they were not enrolled for school dental care.     

Impact of Dental Therapists on Productivity and Finances: III. FQHC-Run, School-Based Dental Care Programs in Connecticut

In many developed countries, the primary role of dental therapists is to care for children in school clinics. This article describes Federally Qualified Health Center (FQHC)-run, school-based dental programs in Connecticut and explores the theoretical financial impact of substituting dental therapists for dentists in these programs. In schools, dental hygienists screen children and provide preventive services, using portable equipment and temporary space. Children needing dentist services are referred to FQHC clinics or to FQHC-employed dentists who provide care in schools. The primary findings of this study are that schoolbased programs have considerable potential to reduce access disparities and the estimated reduction in per patient costs approaches 50 percent versus providing care in FQHC dental clinics. In terms of substituting dental therapists for dentists, the estimated additional financial savings was found to be about 5 percent. Nationally, FQHC-operated, school-based dental programs have the potential to increase Medicaid/CHIP utilization from the current 40 percent to 60 percent for a relatively modest increase in total expenditures.     

Exposures to blood and body fluids among dental school-based dental health care workers.

A survey of United States dental schools was conducted to determine the annual incidence of reported percutaneous and mucosal exposures to blood and other body fluids among dental school-based dental health care workers (DHCW). A response rate of 51.9 percent provided information on 10,433 DHCW and 1.6 million student clinic and 169,836 school-based faculty practice patient visits. This response represents approximately half of all DHCW and student clinic visits in U.S. dental schools in AY 1996/1997. A total of 652 exposures were reported, of which 629 occurred in student clinics. Dental schools averaged twenty-three reported exposures per year, and the overall annual reported exposure rate in student clinics was 4.0/10,000 patient visits and 1.3/10,000 in faculty practice. Dental students accounted for 62.5 percent of all reported exposures, a rate of 106.3/1000 students per year. The exposure rate for dental students was significantly greater that any other category of DHCW. Expressed in terms of person years, an exposure rate of 0.17 was comparable to that reported for dental schools but considerably less than found in other dental care settings. A second survey directed to individual DHCW drew responses from only 8.3 percent of the 10,433 DHCW. Among these respondents, 31 percent of those acknowledging an exposure reported it. A judgment that the injury was not serious, the time necessary to report an exposure, and a belief that the patient was healthy were the primary reasons for not reporting. The results of this study provide dental schools with benchmarks for comparing their reported exposure experience and assessing programs intended to prevent and manage exposures.     

The Dental Pipeline Program's Impact on Access Disparities and Student Diversity

BackgroundThe Robert Wood Johnson Foundation, Princeton, N.J., the W.K. Kellogg Foundation, Battle Creek, Mich., and The California Endowment, Los Angeles, collaborated in funding a five-year (2002–2007) national demonstration program (Pipeline, Profession & Practice: Community-Based Dental Education [Dental Pipeline]) to reduce dental care access disparities. Fifteen dental schools were selected to participate in the Dental Pipeline program. The goals were to have senior students spend more time in community sites providing care to underserved patients; to prepare students to treat diverse, low-income patients; and to increase enrollment of underrepresented minority (URM) students.MethodsA national program office at Columbia University in New York City administered the Dental Pipeline program. The participating dental schools developed networks of community clinics and practices for student rotations, established courses in cultural competency and public health and implemented new programs to recruit URM students.ResultsThe average time senior students spent in community clinics and practices increased from 10 to 50 days; all schools developed courses in cultural competency and public health; and enrollment of UMR students increased 54.4 percent (excluding two of the schools) versus 16 percent in non–Dental Pipeline schools.ConclusionsOn average, the participating dental schools were successful in meeting program goals.     

Educating dental students about oral health care access disparities

Dental educators provide learning experiences for dental students that help them develop the belief that universal access to oral health care is a social justice imperative that will compel them to provide care to underserved patients after they graduate. To accomplish these learning outcomes, dental schools first recruit underrepresented minority students and students with previous volunteerism experiences. Dental educators then expose dental students to learning experiences in the classroom and in the community, dental school-based clinics, and community health clinics, to help them to develop the requisite knowledge, values, and competencies for serving underserved populations. The long-term, educational outcomes of these learning experiences have not been assessed to date. Systematic surveys should be conducted of dentists who have had these educational experiences to measure the number who actually care for the underserved in private dental offices, community health "safety net" clinics, and the Indian and Public Health Services.     

The dental safety net in Connecticut

BACKGROUND: Many poor, medically disabled and geographically isolated populations have difficulty accessing private-sector dental care and are considered underserved. To address this problem, public- and voluntary-sector organizations have established clinics and provide care to the underserved. Collectively, these clinics are known as "the dental safety net." The authors describe the dental safety net in Connecticut and examine the capacity and efficiency of this system to provide care to the noninstitutionalized underserved population of the state. METHODS: The authors describe Connecticut's dental safety net in terms of dentists, allied health staff members, operatories, patient visits and patients treated per dentist per year. The authors compare the productivity of safety-net dentists with that of private practitioners. They also estimate the capacity of the safety net to treat people enrolled in Medicaid and the State Children's Health Insurance Program. RESULTS: The safety net is made up of dental clinics in community health centers, hospitals, the dental school and public schools. One hundred eleven dentists, 38 hygienists and 95 dental assistants staff the clinics. Safety-net dentists have fewer patient visits and patients than do private practitioners. The Connecticut safety-net system has the capacity to treat about 28.2 percent of publicly insured patients. CONCLUSIONS: The dental safety net is an important community resource, and greater use of allied dental personnel could substantially improve the capacity of the system to care for the poor and other underserved populations.     

Evolution of dental school clinics as patient care delivery centers

Dental school clinics, originally envisioned as closely similar to private practice, evolved instead as teaching clinics. In the former, graduate and licensed dentists perform the treatment while undergraduate dental students are assigned treatment within their capabilities. In the latter, dental students provide the treatment under faculty supervision. It is generally recognized that the care provided by the teaching clinics is inefficient. However, in the last quarter of the twentieth century, dental school clinics began to pay much more attention to how treatment is rendered. The comprehensive care movement and quality assurance systems are leading towards more efficient patient-centered care. Case studies at the University of Maryland, Columbia University, and University of Louisville describe activities to make their clinic programs more efficient and patient-friendly. This article explores whether the potential exists for faculty to take a direct patient care delivery role in dental clinics in order for those clinics to become efficient patient care delivery systems as originally envisioned in the early part of the twentieth century.     

Reforming dental workforce education and practice in the USA

The USA dental education programmes are facing challenges similar to those confronting countries around the globe, particularly amongst the industrialised nations. The purpose of this study was to evaluate the educational programmes of 15 USA dental schools to determine their impact on improving workforce diversity and oral health care access. The study investigates the predictors of public service plans of dental school seniors in Pipeline and non‐Pipeline Program dental schools. We analysed baseline and post‐intervention data collected in the American Dental Education Association (ADEA) Annual Survey of Dental School Seniors and a set of contextual variables. Public service plans (dependent variable) was predicted by four types of independent variables: intervention, contextual, community‐based dental education (CBDE), and student characteristics. Findings from the study show that access to a state or federally sponsored loan repayment program was the most significant predictor of public service plans and that increasing educational debt was the most significant barrier. In the short‐term we may be able to sustain the USA loan repayment programs to motivate senior dental students to provide public service to address the oral health care access crisis. However, in the long‐term, a new workforce development initiative will be required to transform dental education and practice, modelled after the well‐respected licensure programmes for Physician Assistants and/or Advanced Practice Registered Nurses, to expand oral health care access, particularly amongst vulnerable population subgroups, such as low‐income children and families.     

Preparing dental graduates to provide care to individuals with special needs

In 2004, the Commission on Dental Accreditation (CODA) adopted a new standard that directs dental and dental hygiene programs to prepare dental professionals for the care of persons with special health care needs. This article reviews the demographics of individuals with special needs, documents that most dental schools provide their students with very limited educational opportunities related to the care of this population, describes the path that was followed to bring about change in the accrediting standard, and discusses the difficulties involved in developing the needed educational programs. Educational programs at two dental schools are presented as examples of how schools can provide students with learning experiences pertinent to the new CODA standard that states: "Graduates must be competent in assessing the treatment needs of patients with special needs."     

The provision of dental services in the Third World

The primary health care approach has been selected as the basic health care planning philosophy in the developing countries and as oral health is an integral part of general health, this approach could be applied for oral health promotion too. Sri Lanka shares most of the oral health problems common to other developing countries. Dental care is delivered free through hospital dental clinics to adults and school clinics to children. Field medical staff, village health volunteers, religious leaders, school-teachers, traditional medical practitioners and senior students in schools are deeply involved in oral health promotional activities. The traditional concept of health care delivery filtering through a number of layers has been replaced by an upward movement initiated by the people. Every effort is being made to strengthen the base of this structure where non-dental personnel are involved, the dental auxiliary personnel providing the services at the first referral level and the scarce professionals being concerned only with high quality oral care at the final referral level. In addition to preventive and educational services a certain amount of treatment has to be provided. These are supplied in static hospital clinics, in mobile clinics or portable equipment is used to set up temporary dental centres in remote areas. Highly sophisticated equipment imported from industrialized countries is used in the hospital service but this service is disrupted due to frequent breakdowns and lack of spares. Local production of dental equipment should be encouraged and research should be conducted to assess the most suitable equipment for third world countries.     

Developing dental education in primary care: the student perspective

A pilot outreach course in restorative dentistry based in community clinics began in 2001. As part of the evaluation, 48 fourth year students completed a questionnaire about their opinions of the new course, and about restorative dentistry clinics in the dental hospital. Time management was the most frequently mentioned gain from outreach. In relation to the dental school, students most often saw the specialised teaching staff as a gain. Outreach was equally or more important for students' confidence in clinical diagnosis of dental caries, treatment planning, direct restorations, communicating with patients, and managing patients, time, and resources. The dental hospital was equally or more important for their confidence in the diagnosis of periodontal disease, root planing, crowns, bridges, dentures, and communicating effectively with laboratory staff. Patients in outreach were seen as different from those at the dental hospital because they were unselected, and had different treatment needs. Meeting course requirements was the most frequent concern about outreach. In relation to the dental hospital, students were most often concerned about the quality of teaching and support available. Outreach and the dental hospital provided complementary experiences and the new course met its educational objectives.     

North American dental students' perspectives about their clinical education

Many North American dental schools face the challenge of replacing the majority of their "boomer generation" clinical instructors over the next ten years as this cohort of faculty reaches retirement age. Developing a new cadre of clinical instructors poses a substantial faculty development challenge: what instructional techniques should be integrated into routine educational practice by the dental faculty of the future, and what aspects of the clinical learning environment should be addressed to improve the overall quality of the experience for patients, students, and the new cohort of instructors? To gain insight that might guide faculty development for new clinical instructors and enhance understanding of the learning environment in dental school clinics, this study addressed the following question: what are dental students' perceptions of their learning experiences in the clinical setting? The purpose of the study was to evaluate the effectiveness of the clinical instruction from the perspectives of the actual "consumer" of dental education: the student. This consumers' perspective was provided by 655 junior, senior, and graduate dental students at twenty-one North American dental schools who completed the Clinical Education Instructional Quality Questionnaire (ClinEd IQ) in 2003-04. The ClinED IQ examines four components of students' clinical experiences: 1) clinical learning opportunities, 2) involvement in specific learning activities, 3) interaction with clinical instructors, and 4) personal perceptions about clinical education. With the exception of inconsistent feedback and instruction and lack of continuous contact with the same instructors, juniors, seniors, and graduate students rated their interaction with clinical instructors favorably (mean=4.76 on a 6.00 scale), but provided lower ratings for clinical learning opportunities (mean=4.26 on a 6.00 scale) due to concerns about the efficiency of the dental clinic environment and lack of opportunity to treat patients in a variety of clinical settings. Analysis of more than 1,000 written comments provided by these students indicated four areas of concern: 1) inconsistent and sometimes insensitive (patronizing, rude) feedback from faculty; 2) excessive amounts of noneducational "legwork" such as billing, patient scheduling, phone calling, completing paperwork, and performing other clinic operations tasks; 3) limited access to faculty because of insufficient numbers of instructors on the clinic floor or difficulty locating faculty when they were needed for coaching, work evaluation, and chart signatures; and 4) concerns about the strategies employed to meet procedural requirements that some students saw as ethically questionable. Junior, senior, and graduate dental students at twenty-one North American dental schools perceived that the strongest aspect of their clinical education was their relationship with the faculty, but also reported that the dental school clinic was often an inefficient learning environment that hindered their opportunity to develop clinical competency. Students also sensed that faculty shortages, a growing crisis for dental education, hindered their progress in the clinic and made learning less efficient.     

A preliminary survey of interprofessional education

The purpose of this article is to review the literature on interprofessional education (IPE) and report on a preliminary survey of the current status of interprofessional education in seven academic health centers (AHCs) that have schools of dentistry associated with them. There is wide variability in interpretation of the term "interprofessional," and many barriers to interprofessional education exist including already overcrowded curricula in health professions schools, lack of support from faculty and administration, and financial constraints. Based on interviews completed at the authors' home institutions, it was recommended that topics such as ethics, communication skills, evidence-based practice, and informatics could be effectively taught in an interprofessional manner. Currently, some academic health centers are attempting to develop interprofessional education programs, but most of these efforts do not include dental students. Of the seven AHCs investigated in this study, only two had formal interprofessional educational activities that involved students from two or more health professions education programs. Dental school participants in this study professed a strong interest in interprofessional programs, but many interviewees from other professional schools and AHC administrators perceived that the dental school was isolated from other schools and disinterested in IPE. Many health care setting models in the future will include dentists as part of an interdisciplinary health care team; consequently, it is important for dental schools to become an active participant in future interprofessional educational initiatives.     

Dental education about patients with special needs: a survey of U.S. and Canadian dental schools

The objectives of this study were to explore how U.S. and Canadian dental schools educate students about special needs patients and which challenges and intentions for curricular changes they perceive. Data were collected from twenty-two dental schools in the United States and Canada with a web-based survey. While 91 percent of the programs covered this topic in their clinical education, only 64 percent offered a separate course about special needs patients. The clinical education varied widely. Thirty-seven percent of the responding schools had a special clinical area in their school for treating these patients. These areas had between three and twenty-two chairs and were funded and staffed quite differently. Most programs covered the treatment of patients with more prevalent impairments such as Down syndrome (91 percent), autism spectrum disorders (91 percent), and motion impairments (86 percent). Written exams were the most common outcome assessments (91 percent), while objective structured clinical examinations (18 percent) and standardized patient experiences (9 percent) were used less frequently. The most commonly reported challenge was curriculum overload (55 percent). The majority (77 percent) planned educational changes over the next three years, with 36 percent of schools planning to increase clinical and 27 percent extramural experiences. The findings showed that the responding U.S. and Canadian dental schools had a wide range of approaches to educating predoctoral students about treating special needs patients. In order to eliminate oral health disparities and access to care issues for these patients, future research should focus on developing best practices for educational efforts in this context.     

ADEA annual survey of clinic fees and revenue: 1998-1999 academic year

The American Dental Education Association's 1998-1999 Survey of Clinic Fees and Revenue obtained data by which to report, by school, clinic revenue information per undergraduate student. Fifty of the fifty-five U.S. dental schools responded to the survey. The median revenue per third-year student was $6,313. It was $11,680 for fourth-year students. Clinic revenue data was also obtained by type of postdoctoral program. The postdoctoral general dentistry programs had the highest per student clinic revenues, at over $59,000 per AEGD student and almost $35,000 per student of GPR programs. Other areas of the survey provided information regarding clinic fees by type of program, levels of uncompensated care by type of program, clinic revenue by source of payment, and dental school fees as a percent of usual and customary private practice fees.