A Symposium on the Future of Dentistry Report: Implications for the Public Sector: Does Dentistry as We Know It Have a Future?

The American Dental Association's Strategic Plan for the Future of Dentistry is primarily a self-serving document in that it attempts to protect the dentist regardless of the changing oral health needs of the population. Marketing, even if initially successful, will not increase the absolute demand for dental services, because persons on maintenance care require less care per year than sporadic users. Higher use will be balanced by less need. Excess supply creates incentive to overtreat. Today's dentist, as the dominant provider, does not have major motivation toward prevention, either by training or economic self-interest. The paper proposes that a modified hygienist, with more diagnostic training, should become the primary dental provider, with a better trained dentist as a secondary provider, combining problem solving and "surgical" skills. These changes would function best under a system combining group practice with a national health service.     

Dental health changes in an Australian Defence Force population

The dental histories of 100 long-term members of the Royal Australian Air Force were obtained from their dental records. Data relating to dental health status, as measured by the DMF indices and the T-Health scores, were tested to determine if there were any correlations present between changes in dental health and certain risk factors which had been identified by previous studies in the General Dental Service in Scotland. These studies had demonstrated positive relationships between the frequency of dental examination and the frequency with which patients changed their dentist, with the amount of dental treatment the patients received. However, within the potential limitations imposed by the sample size, the present long-term study did not detect any significant associations between the frequencies of dental examination or change of dentist, with changes in dental health.     

External forces impacting U.S. health care: implications for future of dental practice

Prognostication requires extrapolation of existing conditions and trends into the future. Alternative perspectives and starting points will suggest alternative futures. Since dentistry does not exist independently of the larger health care environment, it is useful to start by considering external forces that impact the overall health care system in order to anticipate both short-term and long-term changes in the dental profession. This contribution to the Future of the Dental Profession symposium considers dentistry's role within the larger health care environment, examines a variety of forces influencing health care--specifically demography, equity, population health, and social determinants of health, identifies likely demands on the profession, and iterates nine likely changes in the profession.     

Communicating with each other

Most dentists commit their professional lives to improving oral health by providing preventive and treatment services to their patients. In addition, dentists often participate in community, professional or legal activities that promote oral health. This paper describes five ways that dentists have worked with each other and with others to enhance oral health: (1) Dentists working with each other to promote oral health without the use of organized dentistry. Described as an example is the experience of all the periodontists in one city in the USA in providing community education. (2) Dental associations organizing or facilitating groups of dentists and other dental health professionals to develop and implement programmes that promote oral health. Two community-based educational efforts stimulated by the American Dental Association are described. (3) Dental specialty associations encouraging and facilitating specialists to work with other dentists to enhance their knowledge and skills in prevention, treatment and appropriate referral. The American Academy of Periodontology's efforts to teach communication skills to periodontists and diagnosis and treatment skills to general practitioners is cited as an example. (4) Dentists working with physicians and other non-dental health professionals to promote oral health. Integrating dental education into childbirth preparation classes for expectant parents is one instance of an interdisciplinary approach. (5) An individual dentist taking a leadership role to positively influence legislation to regulate a harmful substance. The efforts of one dentist to restrict the sale and promotion of smokeless tobacco are described. Working with other dentists, health care providers and legislators represent alternative ways that dentists have affected the oral health of individuals.     

The Dental Curriculum: What Should Be New in the 21st Century?

Dental education is at a critical juncture. The success of water fluoridation has reduced the caries burden of Americans and, consequently, has raised questions about the disproportionate technical emphasis on treating the sequelae of caries in US dental schools. Additionally, several powerful external factors—such as changing demographics, advances in biological science, fundamental changes in our health care delivery system, and a modest US economy—are forcing dental educators to question the appropriateness of retaining the current dental curriculum into the 21st century. The author considers these factors, suggests what type of dentist will be needed by society in approximately 20 years, and concludes that today's dental educational system is inadequate to produce such a dentist Several elements, in addition to technical excellence, are required for the dental curriculum, including major changes in pedagogy, relevant science training, practical fluency in medicine, an increased mix of stomatologic skills, and broader contact with other health care providers.     

The future of dentistry: an overview of a new report.

BACKGROUND AND OVERVIEW: The 2001 Future of Dentistry, or FOD, report was commissioned by the American Dental Association in 1999, developed by an oversight committee, and presented to the ADA House of Delegates in October 2001. The FOD report was intended to describe the current status of the U.S. dental profession, observe the recent trends that have guided the profession, envision challenges that the profession will face in the next five to 15 years and, finally, make recommendations about how to meet those challenges. This article presents a digest of some of the issues that are perceived to be of greatest interest and concern to the country's practicing dentists. CONCLUSIONS: The analyses in the FOD report lead to the conclusion that the profession is strong and healthy and that revolutionary changes are not necessary. Rather, a concerted effort to address the areas of concern is important to assure the American people of access to the finest dental health care possible. This will require the cooperation of all those involved in the delivery of dental care--not only the profession itself, but also industry, policy-makers and the public. CLINICAL IMPLICATIONS: The FOD report is a road map that will give every practitioner in his or her office more tools to provide the best care to the public. All of the recommendations--whether they involve education, research, finance or clinical practice--are meant to stimulate thoughts and actions that will help dentists and their patients in the pursuit of optimal oral health.     

The Influence of Dental Insurance on Institutionalized Older Adults in Ranking Their Oral Health Status

To assess whether dental insurance influences how institutionalized older adults ages 65 and older rank their oral health status, a census survey was designed for residents of Durham's (Canada) Municipal Homes for the Aged. The odds ratio (OR) and the Cochran & Mantel‐Haenszel's OR were used to estimate the crude and adjusted effect of dental insurance on oral health status, respectively. Overall, 64 percent participated in the interview. Oral health status was ranked as “good,”“very good” or “excellent” by 57 percent of the participants. This ranking was clearly unrelated to the residents having dental insurance, as only 28 percent had dental coverage. Significant effect modifiers included age, dental status and whether the participant had visited the dentist within the last year. Dental insurance positively influenced how dentate participants ranked their oral health status (OR = 2.26; 95 percent CI 1.19; 4.28). In edentulous participants, age and visiting the dentist within the last year modified the effect of dental insurance on oral health status. Having dental insurance reduced the odds of reporting “good,”“very good” or “excellent” oral health (OR = 0.20; 95 percent CI = 0.08; 0.49) among the participants ages 85 and older who did not visit the dentist within the last year; however, the opposite was true for their younger counterparts who visited the dentist within the last year (OR = 7.20; 95 percent CI = 1.08; 47.96). In this population, therefore, dental insurance was associated with higher oral health status rank among the dentate, but its effect on the edentulous population depended on age and the pattern of visiting the dentist.     

The independent practice of dental hygiene

Dental hygienists are health care professionals specially trained and licensed to provide preventive oral health care and information to patients. In 49 of the 50 states, dental hygienists practice their profession under some type of supervision by a dentist. They are prohibited by state law from practicing independently in their own dental hygiene offices. The independent practice of dental hygiene and the controversial issues concerning dentists and dental hygienists are the issues examined in this article.     

Halitosis prevention campaign: a report of oral health promotion activities in Japan

A local dental association, Hakodate Dental Association, has been conducting an oral health promotion campaign, 'Good-bye Bad Breath', in a local community since April 1998. The purpose of this campaign was not only to prevent oral malodour but also to raise people's awareness about oral health. Oral health education has been provided at schools and through television commercials, radio programmes and newspaper articles. Campaign posters and leaflets on bad breath have also been distributed to drug stores, medical clinics and schools, as well as dental clinics. It has been emphasised that oral malodour is a preventable condition and that the dentist can provide adequate advice and suitable treatment. Medical and pharmaceutical associations have cooperated with the Dental Association in running the campaign. Dental care was provided free of charge to the local residents. The free services provided included the assessment of oral malodour using a portable sulphide detector, instructional programmes, and consultations with dentists. This campaign offered a good opportunity to encourage people to visit the dentist for regular check-ups. The number of regular check-ups and halitosis patients has increased in 70% of the clinics belonging to the Dental Association.     

Oral health beliefs in adolescence and oral health in young adulthood

According to theory, health beliefs are related to health behaviors. We investigated whether individuals who hold favorable oral-health-related beliefs over time have better adult oral health than those who do not. Beliefs about the efficacy of water fluoridation, keeping the mouth clean, avoiding sweet foods, visiting the dentist, using dental floss, and using fluoridated toothpaste were assessed in a birth cohort at ages 15, 18, and 26 years. At each age, the majority of participants endorsed the importance of each practice. However, there was also evidence of instability across time. Individuals who held stable favorable dental beliefs from adolescence through adulthood had fewer teeth missing due to caries, less periodontal disease, better oral hygiene, better self-rated oral health, and more restorations. Dental beliefs can change between adolescence and young adulthood, and these changes are related to oral health. In particular, unfavorable dental health beliefs are related to poorer oral health.     

The role of dental hygienists in oral health prevention

Most dental diseases are preventable. This indicates that the main concept of dentistry could be changed to a situation in which the dental hygienist becomes the principal oral care professional. The competencies of dental hygienists focus on disease prevention and oral health promotion; thus referral to a dentist would only become necessary in the event of a failure in the preventive program where disease cannot be controlled. Future oral health care personnel need to be better educated to encourage people to implement healthy lifestyles rather than to treat teeth. In addition, the connection between oral health, general health and health-related quality of life will necessitate a multidisciplinary approach to prevention and oral health promotion. To focus strictly on oral health would too narrowly define the role of the dental hygienist in comprehensive prevention and health promotion. There is no precise boundary between the oral cavity and the rest of the body. Dietary advice to prevent dental caries and smoking cessation counseling to prevent periodontal disease and oral cancer also promote general health. Consequently the focus on prevention and health promotion makes the dental hygienist a very important person in the dental team of the future.     

The dentist as biobehavioral clinician.

At the core of all clinical dental practice is the interpersonal interaction between dentist and patient. An expansion of the dentist's responsibility in the unique dentist-patient relationship is suggested. Such an expanded role encourages dentists to engage the emotional and behavioral health of dental patients who are appearing in dental offices for treatment of orofacial diseases and other conditions. The term "biobehavioral clinician" is used to refer to this broadened role for the dentist. It is suggested that such a biobehaviorally oriented dentist will be a powerful ally on behalf of the health of patients, attending to more dimensions of the patient's presentation and management than the diagnosis and treatment of oral pathobiology. It seems entirely appropriate that dentists have such a role in its future, engaging as they do millions and millions of Americans on a regular basis and a productive and collaborative dentist-patient relationship is already an accomplished fact for most dentists with most of their patients across all stages of the life span. The benefit to patients' overall health and well-being could be tremendous and would add an enriching and personally rewarding dimension to being a dentist.     

Written Testimony from the American Board of Dental Public Health

The American Board of Dental Public Health strives to improve the health of our nation by establishing and promoting standards for dental public health practice and recognizing dentists for their special knowledge and ability in dental public health and preventive dentistry. As one of the eight specialties recognized by the American Dental Association, this specialty focuses upon the oral health of communities and population groups with an emphasis on oral health promotion, disease prevention, and access using organized community efforts. The board offers the following 12 recommendations:

• 1 Dental education must actively support diversity in education and practice to meet the public's needs in a culturally sensitive and cost-effective manner. Also, dental education must define its educational base in light of current as well as emerging and evolving needs of society.
• 2 Dental education must incorporate the interdisciplinary and multidisciplinary aspects of health services delivery.
• 3 3. Disease prevention and health promotion must be given a much higher priority in dental education.
• 4 Basic knowledge and experience in dental public health must be an integral component of predoctoral education.
• 5 The number of specialists in dental public health needs to be increased, and graduate training in both traditional and expanded areas of dental public health needs to be enhanced and increased.
• 6 Dental education must develop methods for incorporating new scientific knowledge and technologies into the curriculum and practice.
• 7 A systematic, objective approach needs to be developed to improve and enhance the role of oral health professionals to respond to a constantly evolving social and political environment and science base.
• 8 The role of dental education institutions in continuing education must be restructured and improved to address practitioner competency and relevancy to the needs of society.
• 9 Dental practice guidelines need to be established and monitored.
• 10 Accreditation, licensure, and certification need to be restructured to meet the health needs of the public.
• 11 Education and behavioral research to improve the dental education process needs to be reestablished, improved, and expanded.
• 12 Pilot programs need to be developed, implemented, and supported to stimulate the necessary changes in dental education to be more responsive to the needs of society.

The American Board of Dental Public Health (ABDPH) appreciates this opportunity to provide written testimony to the Institute of Medicine's (IOM) Committee on the Future of Dental Education. The recommendations of this committee will provide the nation with critical guidance toward meeting the oral health needs well into the next century.     

A study of oral status of adults who received regular checkups and professional care

The purpose of this study was to investigate the effect of regular professional care on oral health status. We examined the oral health status of 255 adults (76 males, 179 females; 61.8 +/- 7.8 yrs) who received professional dental care at the Dental Hospital of Tokyo Medical and Dental University at least once a year. The oral health care included checkups and prevention (oral health education, scaling, polishing, topical application of fluoride). We compared the oral health status of adults who received regular professional care with the status of subjects of similar age reported in national and Tokyo surveys of dental diseases in 1999. The following results were obtained. 1. The number of teeth present among adults who received regular oral health care was greater than that reported in the national and Tokyo surveys of dental diseases in 1999. 2. The number of untreated decayed teeth among adults who received regular oral health care was smaller than that reported in the national and Tokyo surveys of dental diseases in 1999. The results show that the oral health status of adults who received regular oral health care was better than the oral health condition of those reported in the national and Tokyo surveys of dental diseases in 1999. Therefore, it is suggested that regular professional care by a dentist or dental hygienist will assist in achieving the objective of the 8020 movement (20 healthy teeth at age 80).     

Understanding dental students' knowledge and perceptions of older people: toward a new model of geriatric dental education

Increasing numbers of older people and the decreasing rates of edentulism highlight the importance of dental education that focuses on oral health and aging. This evaluation study assessed dental students' knowledge and beliefs about older people as well as their awareness of the biopsychosocial concerns that are potential barriers to oral health care. Dental students' (N=202) knowledge and perceptions of older people were evaluated before and after the first year of a new educational program. Students completed the Palmore Facts on Aging Quiz II (FAQ II) and answered questions about health problems and social concerns that may influence patient care. The intervention was twofold: 1) the CARES (Counseling, Advocacy, Referral, Education, and Service) Program, a clinical collaboration between the schools of Dental Medicine and Social Work, was initiated; and 2) all students were exposed to geriatric educational interventions. FAQ II scores did not significantly change, but dental students' awareness of mental health, independence, and social concerns increased between Times 1 and 2. The results of the study suggest that positive interactions with older adults by health care providers may depend more on positive perceptions toward older people than increased knowledge about aging. Future research will focus on positive experiences with older adults and attitudes of dental students toward the elderly.     

State Medicaid Early and Periodic Screening,Diagnosis, and Treatment guidelines: Adherence to professionally recommended best oral health practices

BackgroundThe authors evaluated the adherence of state Medicaid Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) guidelines to recommended best oral health practices for infants and toddlers.MethodsThe authors obtained state EPSDT guidelines via the Internet or from the Medicaid-CHIP State Dental Association, Washington. They identified best oral health practices through the American Academy of Pediatric Dentistry (AAPD), Chicago. They evaluated each EPSDT dental periodicity schedule with regard to the timing and content of seven key oral health domains.ResultsThirty-two states and the District of Columbia (D.C.) had EPSDT dental periodicity schedules. With the exception of the dentist referral domain, 29 states (88 percent) adhered to the content and timing of best oral health practices, as established by the AAPD guideline. For the dentist referral domain, 31 of the 32 states and D.C. (94 percent) required referral of children to a dentist, but only 11 states (33 percent) adhered to best oral health practices by requiring referral by age 1 year.ConclusionsWith the exception of the timing of the first dentist referral, there was high adherence to best oral health practices for infants and toddlers among states with separate EPSDT dental periodicity schedules.Practical ImplicationsStates with low adherence to best oral health practices, especially regarding the dental visit by age 1 year, can strengthen the oral health content of their EPSDT schedules by complying with the AAPD recommendations.     

Barriers to and enablers of older adults' use of dental services

The theme of the Elders' Oral Health Summit is older adults' access to dental care and how this situation can be improved for future cohorts. A major question is whether older adults today, as well as baby boomers who will be entering their seventies within the next decade, will demand dental care as part of their overall well-being. The current cohort of elders varies widely in its use of dental services, from regular preventive users to non-users who report that they have not been to a dentist in more than twenty years. In 1999, 53.5 percent of older adults reported that they had visited a dentist, the lowest rate of any age group beyond eighteen. This article examines some determinants of older persons' dental service utilization, both barriers and enablers, as a means of understanding why some people continue seeking preventive dental care throughout their lives while others are lifelong irregular users and still others discontinue regular use after retirement or relocation to a new community or long-term care facility. Based on the epidemiological and psychosocial literature available on this topic, barriers and enablers include cohort and age, race and ethnicity, income and education, availability of dental and medical insurance, urban vs. rural residence, physical access to a dental office, and systemic and functional health. Attitudes toward oral health and dental care and other psychosocial variables may override some of these demographic and structural variables. Research in medical and dental service utilization offers insights into the relative predictive ability of these variables. Dental providers can also be potent enablers or barriers to older adults' access to dental care. Each of these factors plays a role in older adults' use of dental services. Under different situations some serve as both barriers and enablers.     

Consumers' choice of dentists: how and why people choose dental school faculty members as their oral health care providers

This study aimed to better understand how and why people choose dental school faculty members as their oral health care providers. Increasing financial constraints in U.S. dental schools have led their administrators to seek alternative funding sources, one of which can be revenues from dental school faculty practice. To effectively promote faculty practice, it is necessary to understand how and why one chooses a dental school faculty member as his or her oral health care provider. A survey of 1,150 dental school faculty practice patients who recently chose their dentist was conducted, and 221 responded. The information sources these respondents said they used and rated highly were other dentists, friends, family members, clinic website, the Internet, and the insurance directory. Dentist-related attributes that were perceived to be important were quality of care, professional competence of dentist, and explanation of treatment/patient participation in the treatment decision. Dental practice-related attributes perceived to be important were the ability to get appointments at convenient times, reasonable waiting time to get appointments, and attitude/helpfulness of staff. This study found that traditionally popular (family, friends) and newly emerging information sources (the Internet, clinic website, and insurance directory) were both used and perceived to be important by patients of the dental school faculty practice. Dental schools and dentists can use this study's findings to select appropriate communication channels to promote their practices and to focus on attributes that dental consumers value the most.     

The future of dental care for the elderly population

The U.S. population is aging, and the elderly are maintaining many of their natural teeth. Studies have shown that if older people have teeth, they tend to utilize dental services to a similar extent as younger cohorts. Geriatric dental care is the diagnosis, treatment, and prevention of dental and oral diseases for all older adults. A functional categorization of the aging population is more useful in dentistry than a chronological one, and 70 percent of this population, or 23.2 million people, is able to visit a dentist in his or her office. The oral health care of older adults has become more challenging because they will no longer accept extraction and dentures as a solution to complex restorative needs. This paper discusses these issues and looks at the future of geriatric dental care.