Journal of the American College of Dentists

Schools’ Role in Access

Winter 2008 Volume 75 Number 4 Journal of the American College of Dentists

A publication advancing excellence, ethics, professionalism, Mission and leadership in dentistry he Journal of the American College of Dentists shall identify and place The Journal of the American College of before the Fellows, the profession, and other parties of interest those issues Dentists (ISSN 0002-7979) is published that affect dentistry and oral health. All readers should be challenged by the quarterly by the American College of T Dentists, Inc., 839J Quince Orchard Journal to remain informed, inquire actively, and participate in the formulation Boulevard, Gaithersburg, MD 20878-1614. of public policy and personal leadership to advance the purposes and objectives of Periodicals postage paid at Gaithersburg, the College. The Journal is not a political vehicle and does not intentionally promote MD. Copyright 2008 by the American College of Dentists. specific views at the expense of others. The views and opinions expressed herein do not necessarily represent those of the American College of Dentists or its Fellows. Postmaster–Send address changes to: Managing Editor Journal of the American College of Dentists 839J Quince Orchard Boulevard Objectives of the American College of Dentists Gaithersburg, MD 20878-1614 HE AMERICAN COLLEGEOF DENTISTS, in order to promote the highest ideals in The 2008 subscription rate for members of the American College of Dentists is $30, health care, advance the standards and efficiency of dentistry, develop good and is included in the annual membership Thuman relations and understanding, and extend the benefits of dental health dues. The 2008 subscription rate for non- to the greatest number, declares and adopts the following principles and ideals as members in the United States, Canada, and Mexico is $40. All other countries are $60. ways and means for the attainment of these goals. Foreign optional airmail service is an additional $10. Single-copy orders are $10. A. To urge the extension and improvement of measures for the control and prevention of oral disorders; All claims for undelivered/not received issues must be made within 90 days. If B. To encourage qualified persons to consider a career in dentistry so that dental claim is made after this time period, it will health services will be available to all, and to urge broad preparation for such not be honored. a career at all educational levels;

While every effort is made by the publishers C. To encourage graduate studies and continuing educational efforts by dentists and the Editorial Board to see that no and auxiliaries; inaccurate or misleading opinions or statements appear in the Journal, they wish to D. To encourage, stimulate, and promote research; make it clear that the opinions expressed E. To improve the public understanding and appreciation of oral health service in the articles, correspondence, etc. herein are the responsibility of the contributor. and its importance to the optimum health of the patient; Accordingly, the publishers and the Editorial F. To encourage the free exchange of ideas and experiences in the interest of better Board and their respective employees and service to the patient; officers accept no liability whatsoever for the consequences of any such inaccurate G. To cooperate with other groups for the advancement of interprofessional or misleading opinions or statements. relationships in the interest of the public; For bibliographic references, the Journal H. To make visible to professional persons the extent of their responsibilities to is abbreviated J Am Col Dent and should the community as well as to the field of health service and to urge the acceptance be followed by the year, volume, number and page. The reference for this issue is: of them; J Am Col Dent 2008; 75(4): 1-68 I. To encourage individuals to further these objectives, and to recognize meritorious achievements and the potential for contributions to dental science, art, education, Publication Member of literature, human relations, or other areas which contribute to human welfare— aa the American Association by conferring Fellowship in the College on those persons properly selected for of Dental Editors de such honor. Editor David W. Chambers, EdM, MBA, PhD 2008 ACD Annual Meeting

Managing Editor 4 An Ethics War Stephen A. Ralls, DDS, EdD, MSD ACD President-elect’s Address Max M. Martin, Jr., DDS, FACD Editorial Board Bruce J. Baum, DDS, PhD 8 Responding to a Culture-Based Health Need Norman Becker, DMD Convocation Address Fred Bremner, DMD Francisco G. Cigarroa, MD D. Gregory Chadwick, DDS Eric K. Curtis, DDS 11 2008 ACD Awards Kent W. Fletcher 15 2008 Fellowship Class Steven A. Gold, DDS Theresa S. Gonzales, DMD, MS, MSS Bruce S. Graham, DDS Donna Hurowitz, DDS Schools’ Role in Access Frank J. Miranda, DDS, MEd, MBA Laura Neumann, DDS 20 Dental Schools and Access Disparities: What Roles Can Schools Play? Ian Paisley, DDS Howard Bailit, DMD, PhD, FACD Don Patthoff, DDS Marcia Pyle, DDS 24 Dental Pipeline Program: A National Program Linking Dental Schools Cherlyn Sheets, DDS with the Issue of Access to Care Allan J. Formicola, DDS, MS, FACD Design & Production Annette Krammer, Forty-two Pacific, Inc. 29 California Pipeline Program: Phase II Paul Glassman, DDS, MA, MBA, FACD Correspondence relating to the Journal should be addressed to: 35 East Carolina University School of Dentistry: Impact on Access Disparities Managing Editor D. Gregory Chadwick, DDS, MS, FACD and James R. Hupp, DMD, DDS, Journal of the American College of Dentists JD, MBA, FACD 839J Quince Orchard Boulevard Gaithersburg, MD 20878-1614 42 The Role of Dental Schools in the Issues of Access to Care Caswell A. Evans, DDS, MPH, FACD Business office of the Journal of the American College of Dentists: Tel. (301) 977-3223 Fax. (301) 977-3330 Issues in Dental Ethics

Officers 47 The Intersection of Dental Ethics and Law Max M. Martin, Jr., President David J. Owsiany, JD Thomas Wickliffe, President-elect Thomas F. Winkler III, Vice President W. Scott Waugh, Treasurer John M. Scarola, Past President Departments

Regents 2 From the Editor Herb H. Borsuk, Regency 1 Loose Talk Robert A. Shekitka, Regency 2 T. Carroll Player, Regency 3 55 Leadership Dennis A. Burns, Regency 4 Practice Bert W. Oettmeier, Regency 5 Patricia L. Blanton, Regency 6 64 2008 Manuscript Review Process Paul M. Johnson, Regency 7 65 2008 Article Index R. Terry Grubb, Regency 8 Kenneth L. Kalkwarf, At Large Jerome B. Miller, At Large This issue is supported by the American College of Dentists Foundation. Linda C. Niessen, At Large Cover Photograph: As practitioners, it is important that we help patients approach their oral Eugene Sekiguchi, At Large health one step at a time. Addressing their neglected oral health can seem intimidating. Lawrence P. Garetto, ASDE Liaison ©2009 Nikada Photography/iStockphoto.com Editorial

From the Editor

Loose Talk

oose talk creates distance between Pellegrino observed that it is unethical to people. When we hear something say something just because you want it Advertisements are Lthat does not seem to square with to be true without actually believing it to our views, it is human nature to build in be so. This is not a First Amendment examples of loose talk; a bit of safety space. We want to know issue. Just because one has a right to say they are “drive-by” why a dentist is critical of a colleague’s something does not mean that it is right work, why that blog is still getting hits, to say it. This thought came to mind last claims that refuse to and the foundation for the rumors that year when Columbia University invited engage in conversation. are circulating about a candidate for Mahmoud Ahmadinejad to address office in the state association. We reserve the school community. President Lee that space for an explanation, and Bollinger publicly insulted his guest; the when explanations are not forthcoming president of Iraq returned the favor, and this distance creates looseness in the the whole business was passed off as an professional community. exercise in free speech. I think of loose talk as statements What is necessary to participate in that do not come with reasons. They the rational community (to avoid loose are attempts to tell me what to believe talk) is a willingness to discuss reasons without giving me the little kit that for the claims one puts forward. explains how this new claim is supposed Informed consent is a code of honoring to be hooked up to my current under- requests for reasons. standing. Advertisements are examples It would be tedious to accompany of loose talk; they are “drive-by” claims every statement with a reason, and we that refuse to engage in conversation. only have to be prepared to bring forth So is the snide, third-person insinuation our reasons when asked. If the dentist at the committee meeting that “there says, “Agent X is the only acceptable are many questions this proposal leaves deep pocket irrigant,” that is a pretty unanswered”—leaving unanswered loose way of talking. The challenge what those questions might be or who might come, “I have been wondering is raising them. Manuscripts have been about that. Why do you say Agent X is turned down for publication based on the only alternative?” “It is approved by suspicions that “they might be biased” with the FDA” and “I only use it on patients no hint about what that bias could be. where it is indicated” fill in the picture in In a rational community, members different ways: the first response is wimpy; are expected to take responsibility for the second is highly idiosyncratic. what they say. The bioethicist Edmund As an editor, I occasionally get comments that something in the journal should not have been said. I respond (per the ACD/AADE Code for Editors) that space is provided for reasonable alternative positions in the format of 2 letters to the editor. Often this leads to

2008 Volume 75, Number 4 Editorial

useful exchanges; sometimes the topic Me too: “I agree with the last speaker is dropped, leaving me to wonder what and offer this example; I can top that; As the real reasons are. long as we’re talking about some of the Private opinions can live long What I find unacceptable is refusal problems with dental education…” Here and happy lives disconnected to provide reasons when they are the loose talk serves the purpose of requested, or assuming a stance that marking the speaker as a member of from reasons. But when implies that reasons should not be the group. The group has no interest in they go out in public, they expected. Here are a few of the common asking for reasons, it is recruiting. unreasonable postures. Opportunism: “I know of no better have to get dressed up in an The put down: “You would not product; This will meet all your needs; acceptable fashion. understand; This is beyond the scope of Obvious superiority…” We wink at our discussion; This is technical.” The self-serving claims. They are understood message here is, “I do not want to be to be puffery and thus exaggerated, and challenged: you should accept what I have so we accept claims that are intended to say based on my status as an authority: to be clear whoppers while at the same you are not a member of my group.” time we demand proof for claims that Insider status move: “I am not are meant to be accurate. One year I allowed to tell you where I heard this; assigned students in my Critical Thinking I have it on good authority; Didn’t you course to phone or e-mail companies that know (everyone else seems to)?” This is mentioned in their dental ads that “data a grab for recognition as having access are on file.” I stopped the project because to important people, of being “in the no company had any data on file. know”.It is trafficking in information as Private opinions can live long and power, and it is what fuels rumor mills. happy lives disconnected from reasons. When no reasons are requested or when But when they go out in public, they the speaker gets away with the “it’s have to get dressed up in an acceptable confidential” move, some pretty loose fashion. Making a claim in a professional talk is generated. community is more than expressing an Passionate idealism: “It would be just opinion. It involves engaging others, like them to…; Let me give you a bunch and so there must be some common of reasons consistent with my view; ground for that engagement. In rational Their motive must have been…” It is communities that means being prepared human nature to fill in the gaps with to provide reasons. details that make our picture of reality consistent. Hiding the reasons for loose talk can become a strategy used to protect a picture of the world from critical analysis. Some people have pretty unconventional pictures.

3 Journal of the American College of Dentists 2008 ACD Annual Meeting

An Ethics War

Max M. Martin, Jr., DDS, FACD ood morning and welcome. American rose. Paul Dobson is our I especially want to welcome Comptroller and Director of Meetings. ACD President-elect’s Address Gand congratulate all of the He keeps our finances in order and is October 16, 2008 candidates in the room. I have not had responsible for all the logistics at our San Antonio, Texas the privilege of meeting each of you annual meeting. While we get to “sit individually, but I do know that you back and enjoy” such a wonderful have contributed much to our profession, meeting as this, Paul gets to worry about and for that I want to personally thank all the details. And then there is the rest you from the bottom of my heart. My of the staff, Sarah, Erica, Monique, and name is Max Martin, Jr., and I am the Claudia, who do so much (behind the President-elect of the American College scenes) to make us look good! of Dentists. I am both honored and humbled at the challenge of leading this Who Am I? wonderful organization. I think it is important for the coming year that you know a little about the Who Are We? person standing in front of you today. As many of you know, and as you “soon- It is important because I want you to to-be” Fellows will discover, our College know that, as your President, I will do would not run as efficiently as it does everything in my power to make this without our excellent staff. I want to outstanding organization an even better formally thank Dr. Steve Ralls, our organization and I will do everything Executive Director, for his outstanding to help your Section in any way that I leadership. Our movement into action am able. on many national fronts such as our I am a general dentist practicing in online ethical dilemmas and online Lincoln, Nebraska. I grew up in a small leadership courses and dental history town in southeast Nebraska and gradu- CD, our four Ethics Summits, and our ated from the University of Nebraska. I Professional Ethics Initiative are direct married a native Nebraskan, Mary, my results of Dr. Ralls’s ideas, dedication, wife of 39 years. She has been my best and hard work. Karen Matthiesen, our friend and supporter throughout my Office Manager and Assistant to the dental career. We have been blessed with Executive Director, is the glue that holds two wonderful children. Our daughter, everything together in the central office. Her job description is too long to cover, but if you see her, give her a big “thank Dr. Martin maintains a general dental practice in you” for all she does for the College. Lincoln, NE; mmmartinjr@ Believe me, she bleeds lilac and hotmail.com

2008 Volume 75, Number 4 2008 ACD Annual Meeting

Kara, graduated from the University of you can see, I owe a lot to these friends. Minnesota and now resides in Rochester, Finally, I would be remiss if I failed to Minnesota, with her husband and two mention my parents, Max and Elizabeth The question arises: of our three grandchildren. Our son, Martin, and the influence they had on can we afford to be moral, Judson, graduated from Texas Christian me in my formative years. Even though University and lives down the road in they have both passed on, the core values even if the cost of Houston, Texas, with his wife and our that I have today are a direct result of compliance is high? The grandson. Nebraska to Minnesota to the Christian upbringing that they Texas was no big deal until the grandkids instilled in me and my two younger answer is a resounding arrived. Now we wish that we all lived brothers. My mother was perhaps the in closer proximity. most positive person I have ever known. yes. After all, the cost of I would not be here today if it were One of her favorite sayings was, “You failure is catastrophic! not for several dentists who took the know, Max, you can be whatever you time to mentor me. Dr. Charles Anderson want to be and do whatever you want to has been a colleague and partner of do in this world.” And then there was my mine since 1971. He took a very green, dad. He taught me the values of honesty, young dentist and taught me the dependability, and good, hard work. “right way” to treat patients ethically The Bible passage by which he lived his and professionally. He encouraged my life is Micah 6:8: “What does the Lord involvement in organized dentistry and require of you but to do justice, to love was always there as a sounding board kindness, and to walk humbly with your whenever I needed assistance. Dr. Ray God.” I have indeed been blessed with a Steinacher was my predental advisor great foundation. and professor. He has encouraged me in That being said, I know that we all many areas of my professional career are here because someone, somewhere, and nominated me for Fellowship in sometime had faith in us and helped 1987. I am forever in his debt. Dr. us along. Our nominating process is Richard Bradley, Past President of the representative of that alone. You “soon- College, was dean of the University of to-be” Fellows have achieved a great Nebraska College of Dentistry when I deal. Congratulations! The College’s was a student. He and his wife, Doris, expectations for you are high and I am have been very supportive of both Mary sure each of you is capable of exceeding and me as I have become involved in the these expectations. College. Dick has been a very positive influence on me throughout my career. Lastly, I want to thank Dr. John Haynes, former Regent and President of the College. It is with his encouragement that I ran for and was elected Regent and, as they say, “the rest is history.” So, as 5 Journal of the American College of Dentists 2008 ACD Annual Meeting

What Do We Stand for? And so, the question arises: can we I have entitled my “formal” remarks this afford to be moral, even if the cost of morning “An Ethics War.” It sounded like compliance is high? The answer is a a catchy title and, as I look around at resounding yes. After all, the cost of this world we live in, it is obvious that failure is catastrophic! As I asked earlier, we need to advance ethical behavior and What is the ethic by which we live? actions more than ever. When I graduated So what are we, as a profession, from the University of Nebraska College facing today? I already alluded to our of Dentistry in 1970, the dental profession free fall from number two to seven, eight, was rated number two on the list of most or nine. There have been numerous trusted professions. Today, we are ranked instances of cheating in our dental Now, after seven years around seventh to ninth, depending on schools that have been publicized. It is easy to point fingers at our educators and on the Board of Regents, which survey you believe. For that I apologize because it was my generation say, “See, it’s your fault that the public I say, “The really important of dentists that contributed to the decline. looks on us with disfavor.” But wait; let us look at the private practitioner. What work gets done at the We need to reverse this trend and we need to do it now. have we done to enhance the image of Section level.” The College’s cornerstone has our great profession? We have yellow always been the advancement of ethics. pages filled with advertisements that What is meant by that statement? Some make all sorts of questionable claims. We might say it is the ethics we, the College, list “quasi degrees” and numerous letters espouse or are asking you to pass on. after our names to make us look better I would suggest, however, that the more than our competitor down the street. important question is: “What is the ethic Note that I said competitor, not colleague. by which we live?” That has been a dramatic change in the Several months ago, I was watching last 38 years. When I started attending a TV program and one of the guests our local society meetings, there was a made the comment, “I’m not sure I feeling of congeniality and helpfulness, (meaning his company) can afford to be a real desire to assist the “new kid on moral.” I was astounded. He went on to the block” and help him or her succeed. argue that all of the extra costs to comply Now, our membership numbers are up with government rules and regulations and our attendance numbers are down would negatively impact the bottom line. because nobody seems to want to take I expect that we too could quantify the the time unless it benefits the big “me.” cost of compliance externally imposed on What a different perspective! No wonder us by our own personal standards, but our profession is facing so many chal- do we really want to put a number on lenges. So, do we throw our arms up in the “price” of ethical action? Following the air and play the blame game, or do the Enron scandal, we witnessed one of we try to make our profession and our the most spectacular business collapses community a better place? of all time because of a huge moral failure, an ethical debacle, if you will. How Can We Accomplish It? I have always liked the following quote from Vince Lombardi: “The quality of a person’s life is in direct proportion to their commitment to excellence, regardless of their chosen field of endeavor.” This speaks to me and I hope to you too. If we would devote our efforts to 6

2008 Volume 75, Number 4 2008 ACD Annual Meeting excellence and helping our colleagues level when we get involved! I would urge along, we can make a difference. The each of you new Fellows to go home, College has always stood on sound prin- attend your Section meetings, and ciples, principles that, over time, have encourage the members to take on a never varied, as illustrated in the follow- new project that will help expand the ing excerpt from College documents that College’s emphasis on excellence, ethics, describes the early standards set forth by professionalism, and leadership in our founders. And I quote, “Some of the dentistry. And to you “more mature” aims of the College are to cultivate and Fellows, I first want to thank you for encourage the development of a higher taking the time and making the effort to type of professional spirit and a keener nominate these fine individuals. But I sense of social responsibility throughout want to encourage you to make certain I challenge you to make a the profession; by precept and example these newest Fellows attend your next personal commitment to go to inculcate higher ideals among the Section meeting. Visit with them about younger element of the profession, and what new project your Section could back to your community hold forth its Fellowship as a reward to undertake and then make it happen. If after this meeting and to those who faithfully follow such ideals.” we all make these commitments as we We can all be proud of that aspiration, return to our respective Sections, what contact a new dentist in but we cannot rest on our laurels. We a positive difference we will make! For your community or area. must put in the time and the effort to my part, I am looking forward to being improve ourselves and to encourage our invited, and will try to be available, to fellow dentists, especially our younger, attend your Section meetings and assist newer dentists. We need to look upon you in any way that I can. I would them as colleagues and not competitors. appreciate as much advance notice as I was mentored. I am currently mentoring. possible so my schedule can be arranged. I believe strongly in mentoring because In closing, I would like to quote a it does work! The young men and famous Nebraskan, William Jennings women that are entering our profession Bryan, when he said: “Destiny is not need our help and guidance. I challenge written by chance. It’s a matter of you to make a personal commitment to choice.” Let’s make the right choices go back to your community after this for the right reasons and elevate our meeting and to contact a new dentist in profession to the level it deserves. With your community or area. Extend an everyone doing his or her part, we will invitation to lunch or to the next local be successful! meeting. Show an interest in him or her I look forward to leading this excep- and offer to be a helping hand, if one is tional organization during the next year. needed. Each of you will have your own Thank you for giving me this opportunity. unique way to meet this challenge. I plan to do the best I can, with what I As Teddy Roosevelt said, “Do what have, where I am. I wish each of you a you can, with what you have, where you successful and meaningful meeting. are.” It is that simple. Go for it. Enjoy the moment. Many thanks. I I used to say that the really important work gets done at the Section level. Now, after seven years on the Board of Regents, I say, “The really important work gets done at the Section level.” However, we can only influence change at the Section

7 Journal of the American College of Dentists 2008 ACD Annual Meeting

Responding to a Culture-Based Health Need

Francisco G. Cigarroa, MD would also like to extend my congrat- in other words, graduate from college ulations to the Fellows who will be within six years. This problem only Convocation Address Iinducted into this prestigious organi- worsens for students who are raised, October 16, 2008 zation. The American College of Dentists through no fault of their own, in low San Antonio, Texas is a highly regarded and well-respected socioeconomic environments, many of professional society, and I am both whom are underrepresented minorities honored and humbled to stand here such as Hispanic and African American among the finest dentists in the world. students. And this is the population Thank you for allowing me the which is to grow exponentially over the privilege of sharing with you the current coming decades. According to the U.S. conditions and outlook for underrepre- Census Bureau, minority students will sented minorities in the academic compose the majority of students, medicine and health care fields and what increasing to 54% by 2050. we are doing to improve these conditions. Given my background, having been I recognize that I am speaking with a educated through public schools in one distinguished and most knowledgeable of the poorest cities in the United States, group of health care experts and leaders. with my training as a pediatric and I hope my insights will add value to transplantation surgeon at Massachusetts your perspectives. General Hospital and at John Hopkins Let me begin by stating that a strong Hospital, and now, as the first Hispanic education for all citizens is fundamental president of a major academic health to a vibrant nation and a high perform- science center in the United States, every ance healthcare system. The disciplines step of my collective educational and life —art, science, philosophy, literature, experiences has provided me with the mathematics—required for an integration attributes helpful in leading an academic of true learning and innovation in all health center and acquiring the trust of fields, including health care, are no faculty, students, and staff alike. My longer the fabric of many American upbringing as a Hispanic, educated in a students’ academic backgrounds. Our poor public school system in Laredo, educational system is not where it needs Texas, and my subsequent education to be and, in fact, is more strained than and training has provided me with a ever before. unique insight so that I can carry out the Listen to these disturbing statistics: mission of the University of Texas Health in the United States, only 71% of entering Science Center at San Antonio and ninth graders graduate from high school, oversee a medical, dental, nursing, only 39% enter college, only 27% enroll for a second year in college, and only Dr. Cigarroa is president 18% graduate within a six-year time and professor of pediatric and transplantation surgery, frame. Only 18 out of 100 ninth graders, the University of Texas Health Science Center, San Antonio, TX. 8

2008 Volume 75, Number 4 2008 ACD Annual Meeting

health professions, and graduate school much less than half of that, with only of biomedical sciences with more than 113 physicians per 100,000 people. 3,000 students and 5,000 faculty and Nationally there are 61 dentists per Our educational system staff members. 100,000 people, and along the Texas- As president of the Health Science Mexico border region there are 19 is not where it needs to Center, I have made it a priority to dentists per 100,000 people. be and, in fact, is more implement programs that nurture and Compounding the issue of a shortage encourage minorities in the health of providers are other severe problems. strained than ever before. professions. Health services research has Large numbers of persons in South shown that minority health professionals Texas lack health insurance. Thirty-one are more likely to serve minority and percent of the population falls below medically underserved populations; the federal poverty level. Moreover, the yet there is a severe underrepresentation challenges regarding health care resources of minorities in the health professions. led the Health Resources and Services Presently African Americans, Hispanic Administration of the federal Department Americans, and American Indians of Health and Human Services to account for less than 9% of nurses, only designate this area of our nation as a 6% of physicians and 5% of dentists, medically underserved region. according to a report of the Sullivan To address this problem, the Commission entitled Missing persons: University of Texas Health Science Minorities in the health professions. Center established a Regional Academic The numbers are far worse in academic Health Center along the Texas–Mexico medicine, as underrepresented minorities border in the communities of Harlingen account for only 4.2% of medical school and Edinburg with both a health profes- faculties in the United States, less than sional education and medical research 10% of the baccalaureate and graduate division. Working with the Texas nursing school faculties, and 8.6% of Legislature, we have acquired $100 dental faculties. million in capital funding, and we are The gap between healthcare partnering with major hospital systems providers and the diverse populations as well as recruiting the Veterans Health they serve will only increase if changes Care Administration in order to provide are not quickly instituted. The University additional clinical venues for the educa- of Texas Health Science Center, for tion of our students. We have acquired example, serves South Texas, whose $10 million in annual recurrent funding demography includes a population to recruit clinical faculty for medical which is 80% Hispanic. It is a severely education for both undergraduate medically underserved region. Let me students, residents, and the recruitment paint for you the landscape. Nationally, there exists an average of 266 physicians per 100,000 people. In South Texas, it is 9 Journal of the American College of Dentists 2008 ACD Annual Meeting

of scientists to begin biomedical research Department to provide clinical training on diseases that particularly affect the sites for students, residents, and faculty. population along the Texas–Mexico We estimate that between 4,000 and border region, such as: diabetes, mental 5,000 children will be treated by the health disease, multi-drug resistant pediatric residency training program tuberculosis, hepatitis C, and cancer. and approximately 3,500 to 4,500 adults Fifteen percent of our medical students will be treated by the general dentistry are completing their third- and fourth- residency training program annually at year clinical rotations in these regional the newly expanded and renovated campuses. Thus far, we have educated Laredo Health Department Dental Clinic. more than 600 medical students who Our goal is to establish this dental Let us ensure that have done their third and fourth years of regional education program and create, incredible choices and medical school at the Regional Academic for Laredo, one that will become a Health Center. Sixty percent of physicians national model. junctures are open for completing their residencies in our border I strongly believe that this paradigm future generations of campuses are staying there to practice, in establishing regional academic health and many also are responding to the needs centers will be an important means of health care providers of the uninsured by choosing to practice addressing access to health care, serving through the choices in federally qualified health clinics. as a catalyst to increase opportunities for Our campus in Laredo is also creat- students of all backgrounds to pursue we are making. ing a new model of dental health care. health professional education, especially The U.S. Department of Health and those who might have otherwise felt Human Services notes that the dentist- that their dream to become a healthcare to-population ratio for the Laredo area professional was impossible. is 75% below the state and national Let us ensure that incredible choices averages. We conducted a survey along and junctures are open for future gener- the Texas–Mexico border region last ations of healthcare providers through year and found that two-thirds of those the choices we are making. We must screened had not visited a dentist in the ensure that the student pipeline to previous year. From those screened, health professional education remains more than half of the adults and more wonderfully competitive, diverse, open, than a third of children had untreated and bountiful; that our students from dental decay, which left untreated can kindergarten through college pursue lead to other, more serious, health issues. knowledge through a deep love of Laredo is one of the fastest growing learning which can cross disciplines in communities in the United States and creativity and flashes of brilliance; and the shortage of dental professionals is ensure that our academic health centers expected to worsen significantly unless become conduits for serving the under- considerable measures are taken, not privileged and the vulnerable in our only here but throughout the nation. changing America. To help address this concern, the This moment in history demands University of Texas Health Science such a collective effort. Let us choose to Center is working to develop a Border seize the moment and follow inspired Regional Academic Health Center decisions to their realization. This will focused on dentistry. We aim to establish make a world of difference for the next additional dental student training generation of healthcare providers. I programs through this initiative. We have created a partnership with the City of Laredo and the Laredo Health 10

2008 Volume 75, Number 4 2008 ACD Annual Meeting

2008 ACD Awards

the national dialogue in dental ethics • Development, administration, and Ethics and through publication, research, and analysis of a national survey, Professionalism presentation of seminars, workshops, “Teaching and Learning Professional Award forums and other educational programs Ethics in U.S. Dental Schools” The Ethics and Professionalism Award locally, nationally, and internationally. • Publication of papers related to ethics recognizes exceptional contributions by Activities and accomplishments of ASDE and professionalism in numerous individuals or organizations for effectively in the area of ethics and professionalism peer-reviewed journals including the promoting ethics and professionalism in are summarized below: Journal of the American College of dentistry through leadership, education, • Presentation of faculty development Dentists, and the Journal of Dental training, journalism, or research. It is workshops, section programs, special Education, as well as in the journals the highest honor given by the College interest group programs, symposia, of many state dental societies in this area. The American College of and lunch and learn sessions at the This award is made possible through Dentists recognizes the American Society annual meeting of, as well as other the generosity of the Jerome B. Miller for Dental Ethics as the recipient of the meetings sponsored by the American Family Foundation. 2008 Ethics and Professionalism Award. Dental Education Association Accepting the award on behalf the • Presentation of intensive workshops William John Gies Award Society is Dr. Larry Garetto, Past President. for dental educators at meetings of The highest honor the College can The American Society for Dental the International Dental Ethics and bestow upon a Fellow is the William Ethics (ASDE) was founded in 1987 as Law Society John Gies Award. This award recognizes the Professional Ethics in Dentistry • Presentation of programs at local Fellows who have made broad, excep- Network (PEDNET). It is an international, and state dental society meetings tional, and distinguished contributions nonprofit organization of dental and at national meetings of the to the profession and society while educators, practicing dentists, dental American Dental Association upholding a level of leadership and pro- organization officers, dental hygiene • Presentation of programs as fessionalism that exemplifies Fellowship. faculty, organization officers, ethicists, co-sponsors at meetings of the The impact and magnitude of such and others involved in oral health care. American College of Dentists contributions must be extraordinary. The society exists to support ethics as an • Presentations on ethics and professionalism for the dental affinity integral value for the oral healthcare Dr. Harry Rosen professions. ASDE is dedicated to con- group of the American Society for Dr. Rosen is recognized tributing to and enhancing the growing Bioethics and Humanities for his contributions to dialogue about ethical issues in oral • Presentations on ethics and profes- organized dentistry, den- health care and fostering more effective sionalism in association with the tal education, research, ethics education in the dental and dental Academy of General Dentistry and prosthodontics, the American College of allied health professions. Members of the American Association of Dental Dentists, and his community. He has ASDE have for many years contributed to Examiners • Participation in national committees been an extremely valued resource to and task forces related to ethics and dentistry and his country (Canada), and ethics education sponsored by ACD, ADA, and ADEA

11 Journal of the American College of Dentists 2008 ACD Annual Meeting

his record of accomplishment is broad- • Distinguished Service Award, • Assistant Executive Director, based and meaningful. Dr. Rosen is held Canadian Dental Association Massachusetts Dental Society in highest regard, not only by his col- • W. W. Wood Award of the Association • Interim Executive Director, leagues, but also by his friends and of Canadian Faculties of Dentistry Massachusetts Dental Society associates. Dr. Rosen’s record can be • Fellowship, L’Academie Dentaire • President, Meeting Planners summarized as follows: du Québec International, New England Chapter • BSc, McGill University • President-elect, L’Academie Dentaire • Board of Directors, Meeting Planners • Gold Medalist, DDS, McGill University, du Québec International, New England Faculty of Dentistry • Award of Excellence, American • Board of Directors, American • Certificate in Prosthodontics, Academy of Operative Dentistry Society of Association Executives, Royal College of Dental Surgeons • Dental volunteer for tubercular Inuit New England of Ontario children • American Dental Association, • Certificate in Prosthodontics, • Accomplished artist, featured in Consultant, Council on Annual National Dental Examining Board, documentaries including Canadian Sessions Royal College of Dentists Broadcasting Corporation • Vice President and Board of • Member, Royal College of Dentists Managers, Junior League of Boston in Prosthodontics Honorary Fellowship • Trainer in facilitation, and manage- • Professor Emeritus, McGill University, ment skills, American Management Honorary Fellowship is a means to Faculty of Dentistry Association bestow Fellowship on deserving non- • Inaugurated the first Canadian • Outstanding Service Award, dentists. This status is awarded to graduate program in prosthodontics American College of Dentists, individuals who would otherwise be in 1970, enabling graduate students New England Section candidates for Fellowship by virtue of to qualify in both operative dentistry • Distinguished Service Award, demonstrated leadership and achieve- and crown and bridge prosthodontics International College of Dentists, ments in dentistry or the community, • Provided major input into the District One except that they are not dentists. implant dentistry program at • Outstanding Contribution to Honorary Fellows have all the rights McGill University Dentistry Award, Pierre Fauchard and privileges of Fellowship except • Member, Ordre des Dentistes Academy they cannot vote or hold elected office. du Québec • New England Meeting Planner of This year there are four recipients of • Co-founder, Halder Study Club for the Year Honorary Fellowship. Restorative Excellence • Spirit of Achievement Award, • Charter member and first President, Ms. Michelle V. Curtin Greater Boston Convention and Canadian Academy of Restorative Visitors Bureau Ms. Curtin has been the Dentistry convention planner for • Montreal Dental Club Gold Medal Mr. Stephen A. the Yankee Dental • President, Mount Royal Dental Hardymon Congress for 30 years and Society Mr. Hardymon has served Assistant Executive Director of the • Maimonides Award, first honoree of organized dentistry with Massachusetts Dental Society for 24 years. Mount Royal Dental Society and the Ohio Dental Associa- Her dedication, resourcefulness, and Alpha Omega Fraternity tion, American Dental Association, zeal are noteworthy and have strongly • Honorary Member, Canadian Illinois State Dental Society, and Florida contributed to the positive experience Academy of Restorative Dentistry Dental Association. He currently serves of the many dentists interacting with and Prosthodontics as the Executive Director of the her Society. Key accomplishments and • Honorary Member, Montreal Washington State Dental Association, credentials of Ms. Curtin include: Dental Society demonstrating innovation and foresight • BA, Connecticut College, Phi Beta in his service to the profession. His Kappa and Cum Laude record is summarized below: • Yankee Dental Congress convention planner

2008 Volume 75, Number 4 2008 ACD Annual Meeting

• Executive Director, Washington State Mr. David S. Horvat Ms. Martha S. Phillips Dental Association (WSDA) Mr. Horvat is Executive Ms. Phillips is the Executive • Worked diligently to establish firm Director of the Tennessee Director of the Georgia financial grounding for the associa- Dental Association, and Dental Association (GDA) tion through the WSDA’s for-profit he has an exemplary and Chief Operating subsidiary, Washington Dentists’ record of leadership and achievement in Officer for two for-profit subsidiaries: Insurance Agency organized dentistry. His efforts have Georgia Dental Insurance Services, Inc. • Integral in the March 2007 partner- resulted in numerous positive changes and Professional Debt Recovery Services, ship between the WSDA and the ODS to the association and have greatly Inc. She has been with the GDA for 31 Companies of Oregon to purchase contributed to the advancement of years, as its Executive Director for 22 Northwest Dentists Insurance dentistry and oral healthcare delivery. years. Ms. Phillips is known in Georgia Company, Washington’s leading Key events and accomplishments in the as dentistry’s consummate advocate for professional and general liability career of Mr. Horvat include: oral health. Key accomplishments in her insurance company for dentists • MS, Communications, Ohio career are summarized below: • Focused on raising the profile and University • Executive Director, Georgia Dental improving the public image of • Executive Director, Tennessee Dental Association dentistry, working to develop a Association • Chief Operating Officer, Georgia comprehensive public affairs strategy • Managing Editor, Tennessee Dental Dental Insurance Services, Inc. with the ADA and promoting the Association Newsletter • Chief Operating Officer, Professional good deeds of dentists through the • Member, TennCare Dental Program Debt Recovery Services, Inc. Washington Oral Health Foundation, Advisory Committee • Award of Merit, American College the charitable arm of the WSDA • Member, State of Tennessee Adult of Dentists • Helped secure a $21 million per Emergency Oral Health Care Strategic • Honorary Fellowship, International annum increase in the Medicaid Planning Committee College of Dentists budget for children’s dental care • Past Assistant Executive Director, • Honorary Member, Omicron • Played an integral role in moving Ohio Dental Association Kappa Upsilon the WSDA’s relationship with the • Past Executive Director, Dr. John • Honorary Member, American University of Washington School Harris Dental Museum Foundation Dental Association of Dentistry from one of minimal • Past President, American Society of • Honorary Member, Georgia Dental existence to one of high regard, Constituent Dental Executives Association support, and respect • Past Treasurer and Past Editor, • Presidential Commendation, • Brought two student delegates into Tennessee Society of Association Georgia Dental Association the WSDA’s House of Delegates Executives • Member, ADA Sesquicentennial • Established a mentorship program • Oversaw completion of new $4 Planning Committee that pairs incoming dental students million Tennessee Dental Association • Board of Directors, Georgia Chamber with a member of the WSDA Headquarters Building of Commerce • Helped develop a truly unique • Member, Kappa Tau Alpha, national • Governmental Affairs Committee, mentor program, called the Rural journalism honorary society Georgia Chamber of Commerce Internship in Private Practice • Honorary Fellow, International • Member, Governor’s Coalition on program, which provides students College of Dentists Healthcare Policy with the experience of living and • Honorary Member, Academy of • President, American Society of working in a rural community by General Dentistry Constituent Dental Executives partnering them with rural dentists • Honorary Member, American Dental • American Dental Association for a two-week summer internship Association Executive Director’s Advisory • Honorary Member, American Dental Committee Association • Honorary Fellow, International College of Dentists • Honorary Fellow, Pierre Fauchard Academy 13 Journal of the American College of Dentists 2008 ACD Annual Meeting

• Award of Appreciation, Medical teaching model that includes case-based Section Newsletter Award College of Georgia School of discussions. The students have been very Effective communication is a prerequisite Dentistry receptive to learning from practicing for a healthy Section. The Section • Volunteer of the Year, Georgia dentists and discussing ethical dilemmas Newsletter Award is presented to an ACD Secretary of State that they are likely to encounter when Section in recognition of outstanding • Editor, Georgia Society of Association entering practice. Dr. Logan also organ- achievement in the publication of a Executives izes a learning experience for senior Section newsletter. The award is based students in which the student writes and on overall quality, design, content, Award of Merit reflects upon an ethical dilemma that and technical excellence of the they have faced while in school. ACD The Award of Merit is awarded to newsletter. This year’s recipient is the Fellows read these reflections, discuss non-dentists for specific, outstanding Ontario Section. them with the students, and use these achievements that significantly con- essays to select the recipient of the ACD- tribute to the betterment of dentistry, sponsored senior student award. Dr. 2008 Lifetime the dental profession, or dental Logan is recognized for helping create Achievement Awardees public health. the Ethics Workshops at the University William E. Brown of Florida College of Dentistry and for Dr. Henrietta L. Joseph B. Chetwin Logan her exceptional efforts in helping make the program an overwhelming success. Russell D. Coleman Dr. Logan has served as a Her passion for the program continues Richard D. Korns Professor of Community to motivate and inspire students. Dentistry and Behavioral Bruno W. Kwapis Science at the University of Florida, Franklin H. Locke, Jr. College of Dentistry, since 1999. She Section Achievement Award Benjamin L. Lynch (deceased) has an extraordinary record of accom- The Section Achievement Award plishment as a faculty member at both recognizes ACD Sections for effective H. Cameron Metz, Jr. the University of Iowa and the University projects and activities in areas such as Melvin A. Noonan professional education, public education, of Florida. Her career has been devoted C. E. Rudolph, Jr. (deceased) to dental education, service, and or community service. This year there Walter C. Sandusky, Jr. research. She is passionate about incor- are two recipients of the Section porating the topics of ethics and Achievement Award. Harold R. Schreiber professionalism in the curriculum, and The Mississippi Section is the first Ray H. Steinacher recipient of the 2008 Section Achieve- she was a key leader behind the joint Henry M. Tanner (deceased) initiative to expand the curriculum ment Award. The Mississippi Section is content in ethics and professionalism in honored for its comprehensive ethics collaboration with the Florida Section program for all dental students, encom- of the American College of Dentists. passing an ethics ceremony (freshmen), Each year, members of the Florida a White Coat Ceremony (sophomores), Section spend a day with the clinical a professionalism and ethics program dental students using an innovative (juniors), and an ethics seminar (seniors). All New York Sections—Hudson- Mohawk Section, New York Section, and Western New York Section—collectively serve as the second recipient for working to pass legislature requiring a three-hour course in ethics as part of New York continuing education requirements.

2008 Volume 75, Number 4 2008 ACD Annual Meeting

2008 Fellowship Class

The Fellows of the American Stephen N. Abel David A. Banach Edward P. Burvant College of Dentists represent Fort Lauderdale, FL Jamestown, NY Covington, LA the creative force of today Marc B. Ackerman Donna J. Barefield Donald G. Butler and the promise of tomorrow. They are leaders in both Jacksonville, FL Duncanville, TX St. John’s, NF their profession and their James W. Adams Bruce J. Barrette Michael Cadra communities. Welcome to Gettysburg, PA Marinette, WI Modesto, CA the 2008 Class of Fellows. Paul S. Albicocco Rebecca A. Barton Mario J. Canal Staten Island, NY Eads, TN Cherry Hill, NJ Eugene T. Altiere Cynthia S. Beeman Michael J. Carl Duluth, MN Lexington, KY Cincinnati, OH Gary I. Altschuler Gary P. Benson Bruce E. Carter Gainesville, FL Denver, CO Lawrenceville, GA Steve F. Anderson Robert F. Berger Scott R. Cayouette Grand Island, NE Columbia, SC Charleston, SC Steven B. Aragon John F. Bickford John A. Cerrato Englewood, CO Dallas, GA Garden City, NY Jeffery A. Arigo Nathan S. Birnbaum Lawrence R. Chewning, Jr. Fairport, NY Wellesley, MA Florence, SC Carl O. Atkins, Jr. Marielle Blake Christopher D. Childs Richmond, VA Dublin, Ireland Gainesville, GA Ralph C. Attanasi Steven Bloom Miranda M. Childs Bebee Delray Beach, FL St. Petersburg, FL Arkadelphia, AR Mary A. Aubertin Philip W. Bonds Tom J. Clark Memphis, TN Florence, SC Crestwood, KY James E. Austin George I. Bridges Russell D. Clemmons Bloomfield Hills, MI Lawton, OK Savannah, GA Estela V. Avendano Bloyce H. Britton III Joseph R. Cohen Covina, CA San Antonio, TX Phoenix, AZ L’ Tanya J. Bailey John G. Buchanan Jeff T. Cohlmia High Point, NC Lexington, NC Oklahoma City, OK C. Bruce Baird Michael F. Buckley Jeffrey M. Cole Sewanee, TN Sandwich, MA Wilmington, DE J. Newsom Baker Usa Bunnag James A. Coll Maryville, TN Kensington, MD York, PA

15 Journal of the American College of Dentists 2008 ACD Annual Meeting

H. Byron Colley, III Jonathan S. Dubin Chester J. Gary Savannah, GA Atlanta, GA Depew, NY Christopher M. Connell Dwight D. Duckworth Lynne Gerlach Lyndhurst, OH Springdale, AR Plano, TX Kevin J. Corry Joseph V. Dufresne Francis T. Giacona Union, NJ Mineral Bluff, GA Metairie, LA Colleen Cournot Michael G. Durbin Gregg H. Gilbert New York, NY Des Plaines, IL Birmingham, AL Kirk A. Coury Timothy B. Durtsche Henry G. Goble Amarillo, TX La Crosse, WI Gainesville, GA David R. Cox Mark W. Dusek Ashton G. Gouldin Weatherford, TX Savannah, GA Falls Church, VA Karen A. Cox Haymaker Jillian A. Easton Edward G. Grace Hennessey, OK Baltimore, MD Timonium, MD Michael J. Cristy Ellyn M. English N. Robert Greenbaum Chesapeake, VA Winona, MN Toronto, ON Robert M. Crooks, Jr. Thomas N. Ewing Edward N. Griggs III Columbia, SC Houston, TX Midlothian, VA James W. Curtiss, Jr. David K. Fagundes Marion L. Grubbs Maryville, TN La Grange, GA Jackson, MS Charles S. Czerepak Charles B. Felts III Robert S. Hall, Jr. Evanston, IL Chattanooga, TN Farmington, CT John S. Davis Harold S. Fergus Leslie B. Hardy, Jr. Olympia, WA Memphis, TN Oklahoma City, OK Joseph R. Deatherage Anderson D. Ferguson Barrie E. Harnett Birmingham, AL West Point, GA Ancaster, ON William R. Dennis Christopher G. Fielding John F. Harrington, Jr. Shrewsbury, MA Frederick, MD Milledgeville, GA Amber A. Determan Thomas H. Finken Jennifer A. Hathaway Mitchell, SD Averill Park, NY Bryan, TX Fred J. Diedrichsen Patrick J. Foy Todd Haworth Holdredge, NE Minneapolis, MN Port Angeles, WA Harold A. Doerr Charles D. Frank Joseph F. Heidelman Rapid City, SD Tecumseh, ON Indianapolis, IN Bernard Dolansky Donald J. Fuchs Kevin A. Henner Ottawa, ON Cuba, MO Deer Park, NY Michael J. Donato, Jr. Tonya K. Fuqua Bernard J. Hennessy Staten Island, NY Southlake, TX Nolanville, TX Steven I. Ganzberg John L. Henson Columbus, OH Jackson, MS Mitchell J. Gardiner Fair Haven, NJ

2008 Volume 75, Number 4 2008 ACD Annual Meeting

Robbie W. Henwood Jon J. Johnston Tristram C. Kruger Patrick J. Louis San Antonia, TX Punxsutawney, PA Potomac, MD Birmingham, AL Aidee N. Herman Robert L. Jolly Terry L. Kunkle II Wilson E.B. Loveys Canton, MA North Little Rock, AR Moncks Corner, SC Corner Brook, NF William K. Hettenhausen Jeffrey R. Jones Andrew J. Kwasny Donald M. Lunn Thunder Bay, ON Eau Claire, WI Erie, PA Nashville, TN Joseph M. Hildebrand Judith A. Jones Tommie Harold Lancaster Christopher L. Maestrello Birmingham, MI Billerica, MA Kinston, NC Richmond, VA W. Dulany Hill David M. Jordan Frederick S. Landy Ashraf M. Maher Ellicott City, MD Columbia, SC Glastonbury, CT Kalamazoo, MI Myron S. Hilton Anil Joshi Jonathan H. Lang Carolyn J. Malon Oklahoma City, OK Moncton, NB Montreal, QC Farmington, CT Charles W. Hipp Milan J. Jugan Ray A. Langston Paul Markowitz Charleston, SC San Diego, CA Manning, SC Bohemia, NY Harry F. Hoediono David M. Kalish Lilia Larin Stephen J. Maroda Kitchener, ON Macon, GA National City, CA Germantown, TN Hanna Hoesli William H. Karp Maureen E. Lawton Bryan T. Marshall Hollywood, CA Fayetteville, NY St. John’s, NF Weeki Wachee, FL Charles E. Holt, Jr. Kelly W. Keith Paul R. Leary Rosa Martinez-Rosenberg Chattanooga, TN Austin, TX Smithtown, NY Valhalla, NY Kenny A. Hooper Carole J. Kelley Ronald Lee David G. Martyn Baltimore, MD Hilliard, OH Colleyville, TX Mequon, WI Bradford B. Hoopes Thomas S. Kelly William G. Leffler Michael Mashni Muskogee, OK Beachwood, OH Massillon, OH Fullerton, CA Howard W. Horsman John K. Kelp Peter G. Lemieux Rollin M. Matsui Riverview, NB Austin, TX Winter Park, FL Richmond Hill, ON J. Barry Howell Lonnie W. Kennel Ralph H. Leonard, Jr. James A. Maxwell, Jr. Urbana, IL Geneva, NE Chapel Hill, NC Springfield, OH Jed J. Jacobson Allen W. Kessler Neal R. Levitt Jandra M. Mayer-Ward Okemos, MI Fairfield, AL Webster, NY Vinta, OK Fred J. Jaeger Sharukh S. Khajotia Richard J. Lewenson Michael A. McBride Madison, WI Oklahoma City, OK New York, NY Memphis, TN John H. Jameson Martha V. Kirkland William L. Lewis Thomas J. McCarter Davis, OK Alpharetta, GA Greenville, NC St. Paul, MN Benjamin K. Jamison Ronald W. Kosinski John J. Liang Michael S. McCracken Murfreesboro, TN New Hyde Park, NY Utica, NY Birmingham, AL Gerald A. Jelacic Maharukh Kravich Lee M. Lichtenstein Milwaukee, WI Chicago, IL Holmdel, NJ Ben Jernigan, Jr. Cary J. Limberakis Decatur, GA Jenkintown, PA Glenn J. Jividen, Jr. Kimberly A. Lindquist Dayton, OH Duluth, MN

17 Journal of the American College of Dentists 2008 ACD Annual Meeting

C. Christopher McFarland Carol Anne Murdoch-Kinch Norman A. Petti Paula L. Russo Duluth, GA Ann Arbor, MI White Plains, NY Washington, DC Gregory D. McGann Rhett L. Murray Jacqueline M. Plemons Charles D. Samaras Mount Laurel, NJ Aurora, CO Dallas, TX Pinehurst, NC Andrew S. Melinger David A. Narramore Thomas D. Pollard Mark A. Saxen New York, NY Whitesburg, KY Portland, OR Indianapolis, IN Andrew J. Mesaros, Jr. Richard A. Newman Scott A. Preisler Arthur Roddy Scarbrough Beavercreek, OH West Orange, NJ Fargo, ND Richton, MS Raymond G. Miller Peter Ngan Jill M. Price Werner W. Schneider Buffalo, NY Morgantown, WV Portland, OR Little Rock, AR Jacqueline M. Miller Tina Nichols Henry F. Pruett, Jr. Martin L. Schroeder Washington, MO Little Rock, AR Pensacola, FL Biglerville, PA Louis C. Miller Ned L. Nix Jose E. Rabell Mark J. Schulte Colleyville, TX San Jose, CA San Sebastian, PR Louisville, KY Bhagwati J. Mistry Kevin H. O’Boyle Louvenia A. Rainge Stuart L. Segelnick Tarrytown, NY Dublin, Ireland Augusta, GA Brooklyn, NY Julian R.D. Moiseiwitsch Robert J. O’Donnell, Vincent U. Rapini Jeffrey Seiver Washington, DC Alpharetta, GA Webster Groves, MO East Islip, NY Steven J. Mondre Terry O’Shea Harold H. Reed Jeffrey S. Senzer New York, NY Acworth, GA Morgantown, WV New York, NY Philip C. Mooberry Gregory K. Oelfke Richard F. Roadcap James J. Severs Tucson, AZ Houston, TX Colonial Heights, VA Vancouver, BC T. Delton Moore Gregory Y. Ogata Scott A. Roberson Samuel M. Shames Woodville, MS Sammamish, WA Independence, MO Wayland, MA Steven R. Moore Gregory M. Pafford David L. Roberts Jonathan D. Shenkin West Chester, OH Phoenix, AZ Dallas, TX Bangor, ME Gene P. Moore Ethan A. Pansick James D. Robinson Charles Shuler San Diego, CA Delray Beach, FL Buffalo Grove, IL Vancouver, BC Jack T. Morrison Kim G. Parlett John T. Robinson Richard J. Simonsen Elk City, OK Bracebridge, ON Eugene, OR Scottsdale, AZ Robert B. Moss, Jr. Mary Norma Partida Jeffrey W. Rodden Donald C. Simpson Albany, GA San Antonio, TX Keene, NH Sierra Vista, AZ Richard C. Mullens Sanjay Patel James A. Roos Paramjit Singh Jacksonville, FL Pittsburg, CA Smyrna, GA New Delhi, India Robert W. Payne William F. Rose, Jr. Jonathan I. Skuba Mariana, FL Schertz, TX Edmonton, AB David W. Perry Kenton A. Ross Steven D. Slott Augusta, GA Fayetteville, AR Burlington, NC Thomas A. Routledge Coquitlam, BC Salvatore L. Ruggiero Lake Success, NY

2008 Volume 75, Number 4 2008 ACD Annual Meeting

Ronald C. Smiley James W. Tom Edward E. White Savannah, GA Los Angeles, CA Elizabethtown, PA J. Douglas Snowden Douglas Torbush Edward M. Wilby Florence, SC Conyers, GA Richmond, BC Steven I. Snyder Wade H. Townsend III James M. Williams Holbrook, NY Gainesville, FL Blytheville, AR Jay A. Solnit Scott A. Trapp Edward J. Williams Beverly Hills, CA Detroit Lake, MN St. John’s, NF Eric S. Solomon Ronald Trotman Galen R. Williams Dallas, TX Portland, OR Angola, IN Robert A. Sorrentino Ronda Trotman James G. Wilson Staten Island, NY Tualatin, OR Tampa, FL Gregory K. Spackman Alex Tsui Heidi E. Winquist San Antonio, TX New York, NY Boulder, CO Thomas M. Spivey Gary T. Umeda William J. Winspear Paris, AR Honolulu, HI Sydney, Australia Mitchell A. Stark Byron M. Wade Theresa T.L. Wong Rockville, MD Niceville, FL Burnaby, BC John W. Starr, Jr. Mark V. Walker Charles S. Wood, Jr. Columbus, MS Kent, WA West Memphis, AR James M. Startzell Bryan E. Walls Marjorie A. Woods Boerne, TX Essex, ON Memphis, TN Robert D. Stevenson Thomas H. Ward Mary E. Wynn Highland, CA Miami, FL Cincinnati, OH Robert Stuchell Walter S. Warpeha, Jr. K. Robert Zaiman Morgantown, WV Minneapolis, MN Omaha, NE Kris K. Swanson Michael H. Wasserman David A. Zelby Bellevue, WA Pittsfield, MA Atlanta, GA Peter E. Swartberg Ian D. Watson Cannes, France Mississauga, ON Larry P. Tadlock Eric L. Weinstock Keller, TX Canton, MA Wayne K. Tanaka Eric C. Weiss Loma Linda, CA Livingston, NJ John H. Taylor Curtis M. Werking Marietta, GA Rockville, MD Christine S. Tempas Scott P. Werner Sheboygan Falls, WI Memphis, TN Timothy Temple Orlando, FL Robert B. Tilkin Kensington, MD

19 Journal of the American College of Dentists Schools’ Role in Access

Dental Schools and Access Disparities What Roles Can Schools Play?

Howard Bailit, DMD, PhD, FACD isparities in access to health care the capacity to treat about eight million have received a great deal of people per year. Thus, the dental safety Abstract Dnational attention and are clearly net can care for about 10% percent of Dental schools can address access a major political issue. With respect to the approximately 85 million Americans disparities in several ways: the direct dentistry, family income, education, who have low incomes and dental delivery of dental care to underserved race, and geographic location are all utilization rates. population; the recruitment of students major determinants of dental care Dental schools are a component of more likely to provide care to underserved population; clinical experiences utilization and oral health status. As is the dental safety net, and the purpose that will influence student and resident well-known, the poor receive less care of this paper is to provide a general career decisions, and basic and clinical and have more untreated disease. Of framework for considering the role of research. Currently, schools are having special concern, disparities in access to dental schools in caring for underserved a modest impact on the access problem, dental care are larger than for other patients. The paper is divided into two and there are several promising new medical services. For example, 22.9% sections: (a) the current role of dental efforts underway. These include establishment of dental school clinics in of low-income versus 56.5% of upper- schools and (b) new initiatives to reduce underserved areas that are run as real income Americans visit dentists access disparities. delivery systems rather than as teaching annually. In comparison, 78.9% versus laboratories; the recruitment of more 87.8% of low- and upper-income people, Current Role of Dental Schools underrepresented minority and low- respectively, visit physicians each year. As background information, there are income students; the assignment The reasons for these disparities 56 dental schools in the United States, of senior students and residents to community clinics; and basic and are also well-known. The two national graduating about 4,700 students per clinical research. strategies for providing low-income year. These schools also train some populations access to care—Medicaid 3,306 residents and graduate students dental insurance and the dental safety (the term resident is used to describe net system—have significant limitations. all students enrolled in postgraduate Medicaid dental programs do not cover clinical training programs) and are adults in most states, have low fees, and staffed by 4,636 full-time equivalent often have cumbersome administrative clinical faculty members. Junior and processes. As a result, relatively few senior dental students, residents, and dentists nationally (26%) treat faculty all provide dental care to patients Medicaid patients. —a total workforce of approximately The second basic strategy to address 17,342 people. In the next several years, access disparities includes dental clinics another seven to ten new dental schools operated by the public and voluntary sectors as safety nets. The size of the Dr. Bailit is Professor dental safety net is not precisely known, Emeritus, School of Medicine, but a recent paper suggests that it has University of Connecticut; [email protected]

2008 Volume 75, Number 4 Schools’ Role in Access

are expected to open, producing another and from rural areas are more likely to 500 to 1,000 graduates per year. practice in underserved areas and care In terms of the safety net, dental for low-income patients. Currently, The two national strategies schools have three important roles: 12.5% of dental students are under- (a) direct delivery of care; (b) education represented minorities (Hispanic, for providing low-income of students and residents; and (c) African American, and Native American) populations access to dental research. and 25% are from families earning $50,000 or less per year. The percentage care—Medicaid dental Delivery of Care of students from rural communities insurance and the dental As an upper boundary estimate, the is unknown. average dental school with 85 students The percentage of underrepresented safety net—have significant per class and 59 residents cares for about minority students enrolled in dental limitations. 30,000 patients per year or a total of school has declined from a high point 1.7 million patients across all 56 dental in 1989. One reason for the decline is schools. Patients treated by faculty rapidly rising tuition and fees, making it members are not counted, because most difficult for students from lower-income are middle class or higher and pay full families to afford a dental education. fees. Although only 10% of dental Another reason is the elimination of school patients treated by students and federal support for programs to recruit residents are enrolled in the Medicaid underrepresented minority students. program, the majority of patients have On the positive side, several private relatively low family incomes and can foundations have provided funds for be considered underserved. Thus, minority dental student recruitment dental schools care for about 2% of the programs and scholarships. This is one low-income population. factor that explains the modest increase in underrepresented minority student Education of Students and enrollment in the last few years. Residents There is also evidence that senior Dental schools also impact access students who spend time in community disparities by their influence on the clinics caring for diverse, low-income, career decisions of students and residents. and medically disabled patients are more This includes graduates working in likely to seek employment in community community health centers and caring clinics and to report that they intend to for low-income patients in their private treat low-income and disabled patients practices. The schools’ major levers to in their practices. Several dental schools influence career decisions are student report that a small, but significant, selection and clinical training experiences. Students who are underrepresented minorities, from low-income families,

21 Journal of the American College of Dentists Schools’ Role in Access

number of senior students who partici- Delivery of Care pated in externships seek employment In the big picture, dental schools provide in community clinics after graduation. relatively little care to patients. This is Likewise, community clinic dental because their clinics are primarily directors report that student externship organized as teaching laboratories for programs provide them a source of students and residents rather than new dentists. patient-centered practices that are designed to provide care to large numbers Dental Research of patients. Under the traditional dental The majority of dental schools are based education model, students seldom see in research-intensive universities, where It turns out that many more than two patients per day, clinics tenure-track, full-time faculty members are closed many days for student and students are more are expected to generate new knowledge faculty vacations, and few hygienists and through research. Both basic science productive when they assistants are employed. Also, unlike and clinical research studies have the other health professions (e.g., medicine, return from their potential to reduce disparities in oral pharmacy, or nursing) faculty do not health. For example, over the past 30 community assignments. practice as they teach. Because of this years there has been a dramatic decline clinical education system, dental school Evidently, their skill levels in tooth decay and missing teeth in clinics run large deficits and require low-income children, reducing oral and self-confidence substantial subsidies. health disparities. The primary reason In the past 20 years, state and federal improve significantly for the reduction is community-level support for dental education has prevention programs, such as water during their time in declined, and most schools face serious fluoridation, the use of topical fluorides financial problems. One strategy for community clinics. and sealants, and oral health education dealing with these financial problems is programs. These preventive technologies to change the basic model of clinical all come from years of dental school dental education. Indeed, a few schools research, and impact the entire popula- are building group practices in low- tion, especially the poor. income neighborhoods and rural communities and are running these New Initiatives practices as real delivery systems rather Although dental schools cannot solve the than as teaching laboratories. In this access problem, they have a critical role new model, faculty members practice as to play, and they are moving in the right they supervise a small group of residents direction. Among the promising new and senior students, and all clinicians programs for addressing issues of access make full use of trained support staff. to oral health through schools are (a) These practices have the capacity to treat new delivery systems, (b) education and many more patients than traditional recruitment, and (c) further research. dental school clinics and are expected to significantly reduce access disparities. An example of this new clinical educational model is the new dental school at East Carolina University.

Education of Students and Residents The recruitment of more underrepresented minority and low-income students is a mixed picture. The majority

2008 Volume 75, Number 4 Schools’ Role in Access of dental schools are making little clinics located in their home towns. The Dental Research progress for the reasons previously noted, school also has special arrangements In the long run research has the greatest but there are a few bright spots. One with Federally Qualified Health Centers potential for reducing oral health dispar- interesting development is the formation to place graduates in these facilities. ities. In time, new and more effective of recruitment collaboratives, where The long-term impact of this strategy on preventive methods at the community several schools in the same state or reducing access disparities is unknown, and patient levels will become available region work cooperatively to recruit but it has promise. to reduce the incidence of the major oral more underrepresented minority Both for financial and educational diseases. Research may have less impact students. There are many advantages reasons, many dental schools are on reducing access disparities, but the of cooperation such as significant increasing the time that senior students National Institute for Craniofacial and economies of scale in running one large and residents spend in community Dental Research has funded several summer enrichment or post-baccalaureate clinics providing care to underserved dental schools to undertake community- program for a region rather than patients. Financially, this allows schools based demonstration programs to many small programs. All California to increase their class sizes and generate reduce access and oral health disparities dental schools formed a recruitment more tuition dollars without building in low-income communities. The goal collaborative and doubled (5% to 11%) more facilities. For some schools, the of this multimillion-dollar program the percentage of underrepresented space previously occupied by dental “is to broadly encourage developmental, minority students in their freshman students is used for other purposes (e.g., exploratory, or pilot clinical research to: classes in just four years (2003-2007). research, administration) that do not (a) document oral conditions and risk Another encouraging development require subsidies, and it even generates factors for oral and craniofacial diseases is the participation of dental schools in additional revenues. and disorders; (b) investigate new established medical school summer At the same time students and methods of diagnosing oral disease; enrichment programs for minority college residents assigned to community clinics (c) address behavioral and health students. The Robert Wood Johnson for several weeks have the opportunity promotion topics relevant to oral health, Foundation (RWJF) has sponsored a very to work with dental assistants and dental care, or oral health promotion; successful summer enrichment program experienced administrative staff that are and (d) identify promising culturally for medical students for over 20 years. not available in dental schools. In this appropriate approaches to prevent and Now nine dental schools participate in a setting, students often see five to eight reduce oral health disparities.” It is still joint RWJF supported summer program patients per day and gain a great deal of too early to assess the impact of this with medical schools, and about 180 clinical experience and self-confidence. effort, but it is hoped that new and more college students interested in dentistry Importantly, this results in a large effective approaches to providing care to are enrolled in this eight-week summer increase in the number of underserved low-income populations will reduce program. The expectation is that 50% patients receiving care. Interestingly, access and oral health disparities. I or more of participating students will most schools are not experiencing a loss eventually enroll in dental school. of student-generated patient revenues, A third significant development is because of the time spent in community the establishment of several new dental clinics. It turns out that many students schools associated with Osteopathic are more productive when they return Medicine. One such school (A. T. Stills in from their community assignments. Arizona) makes a special effort to recruit Evidently, their skill levels and self- students from rural areas who are inter- confidence improve significantly during ested in community service. As part of their time in community clinics. the formal curriculum, students spend Private foundations have encouraged much of their senior year providing care this new direction for dental education to low-income patients in community and have provided funds to several dental schools to build and expand their community-based education programs.

23 Journal of the American College of Dentists Schools’ Role in Access

Dental Pipeline Program A National Program Linking Dental Schools with the Issue of Access to Care

Allan J. Formicola, DDS, MS, FACD he dental profession is currently dramatically improving access to care in realigning itself with the needs of this country will require government Abstract Tsociety. As documented in the 2000 working in harmony with the profession. The Dental Pipeline Program grew out of publication of the Surgeon General’s As a key component of the profession, work at the Columbia University College Report on the oral health of the nation, dental schools have a prime role to play of Dental Medicine in the 1990s designed the disparity in oral health between in the issue of access to care through to address access to oral healthcare needs low-income and high-income individuals their education mission. This must be in New York City. Since then the Robert Wood Johnson Foundation, the W. K. and between racial/ethnic minorities adjusted in order for the schools to edu- Kellogg Foundation, and The California and the majority population has cate a new generation of practitioners Endowment have combined to fund the reached epic proportions. The Surgeon fully capable of understanding issues of largest dental education program in General called this a “silent” epidemic access to care, the biggest issues facing history. The Dental Pipeline Program has of oral disease! the profession, and for schools to use involved 23 dental schools in two phases. Recently, two stories that reached their vaulted position in higher educa- The goal of the program is to address issues of access (a) by providing dental the national media underscore the tion in service to the people. care with volunteers in communities in access to dental care problem in the To be sure, the manner in which we, need, (b) by seeking either full- or United States. The death of a 12-year-old the profession, respond to the issue of part-time positions in community health boy in Prince Georges County, Maryland, access to care has the capacity to either facilities, and (c) by preparing dentists from untreated abscessed maxillary strengthen or weaken the public trust to be advocates for the needs of the incisors was widely reported in the news in dentistry. Through the Pipeline, underserved. This is a preliminary report of the types of curricular changes that as an inability of low-income individuals Profession & Practice: Community-Based have been introduced and some promising to obtain dental care. This tragic death Dental Education (Dental Pipeline) results in terms of oral health care prompted both a media response and the program (Bailit et al, 2005), the largest provided, minority enrollments in dental attention of federal and state legislators. foundations in this country placed great schools, and expressed intentions to In the second story, a front-page article confidence in dental schools to become practice in underserved areas. in the New York Times reported that active participants in solving access the Alaskan Native Health Council has problems. This article will describe the employed dental health aide therapists Robert Wood Johnson Foundation’s to provide dental treatment (under initiative to work with dental schools on the supervision of dentists) for their the problem of access to care. remote population groups who suffer some of the worst oral health conditions Dr. Formicola is Professor of of all Americans. Dentistry at the College of Dental Medicine, Columbia These two stories bring to the University and co-director of forefront the facts that there is (a) a the Pipeline, Profession & Practice: Community-Based major access problem that has come to Dental Education program; the attention of the public and (b) the www.dentalpipeline.org. underserved will find a way to solve Acknowledgments: The their access problem if other solutions author expresses appreciation to Stephen Marshall, Dennis are not forthcoming. It is clear that Mitchell, and David Albert who first implemented the model at CDM. 24

2008 Volume 75, Number 4 Schools’ Role in Access

Pipeline, Profession & Practice: Children, and five dental clinics in Community-Based Dental Education community health facilities in the various neighborhoods to serve 400,000 people. The Robert Wood Johnson Foundation It is clear that dramatically (RWJF), stimulated in part by the 2000 Community DentCare provides 43,000 Surgeon General’s Report on the oral patient visits per year, in addition to the improving access to care care provided in CDM’s main clinics and health of the nation, decided to inter- in this country will require vene in the dental access problem. After the care provided by the Harlem Hospital searching for ways to do so, the senior Dental Service. Community DentCare government working in project officer at RWJF focused in on sites were designed to get directly into working with dental schools. The the neighborhoods to make care more harmony with the profession. Community DentCare project (Formicola easily accessible by those in need. et al, 1999) at the Columbia University The RWJF saw the wisdom of College of Dental Medicine (CDM) replicating this model in some fashion came to the attention of the RWJF and in dental schools throughout the nation. they wished to model their effort on Further, they were impressed by a Macy that initiative. Foundation study (Formicola et al, 1999) Community DentCare was conceived that demonstrated the educational in the early 1990s and was a response benefit of student rotations to clinics in to the fact that in spite of the safety net underserved communities. Another clinics operated by the CDM and the motivation underlying the Macy Harlem Hospital Dental Service, there Foundation effort was to increase the were thousands of individuals in the enrollment of underrepresented minorities Harlem and Washington Heights neigh- in the dental schools, because the borhoods, two low-income minority Surgeon General’s report linked their communities, that could not get access lack of representation in the profession to care. The dental college recognized with the worsened oral health of people this need by expanding its patient care of color. With these thoughts in mind, mission to include active service programs the Pipeline, Profession & Practice: in the community and by strengthening Community-Based Dental Education its collaboration with the Harlem Hospital program was launched in 2002. Center to improve the recruitment of The RWJF initiative caught the underrepresented minority students. attention of two other foundations, With the assistance of the W. K. The California Endowment and the Kellogg Foundation, by the year 2000, W. K. Kellogg Foundation. The three the Community DentCare network was foundations collaborated on the already well established in upper Manhattan. The network consists of dental programs in seven public schools, a mobile van to reach Head Start

25 Journal of the American College of Dentists Schools’ Role in Access

program, with the RWJF providing $19 deal with access issues as practitioners, million, The California Endowment (b) sending senior students and some $6.3 million, and the Kellogg Foundation residents (in California) to work in clin- $1.1 million. This is the largest foundation ics located in underserved communities, effort ever undertaken in the nation in and (c) recruiting and enrolling more the field of dentistry. underrepresented minority students. These goals provide both long- and The Dental Pipeline Program short-term solutions to the access issue. in Action In the long term, they aim to educate Twenty-three of the nation’s 56 dental future practitioners with more knowledge, schools are participating or have partici- skills, and greater sensitivity about access The Pipeline Program pated in the Dental Pipeline Program. problems. In the short term, they aim to has shown that dental This is almost half of the U.S. dental get additional treatment to underserved schools! The program began in 2002 populations. It has been shown that schools can educate and the first phase concluded in 2007. students put into practice what they students to have a keener Currently, there is a second phase under learn in dental school (Ko et al, 2005; way. In the first phase, 15 dental schools Smith et al, 2006). understanding, improved were selected from an initial group of An enriched education in public skills, and better attitude 42 dental school applicants to implement health and cultural issues will provide the Dental Pipeline Program. In phase dental graduates with more confidence toward the problems of two, eight dental schools selected from to deal with access issues (a) by providing the underserved. 21 applicants are participating in an care as volunteers in communities in RWJF funded project. The five California need, (b) by seeking either full- or dental schools have been involved in part-time positions in community health both phases. facilities, and (c) by preparing them to In Phase 1 (2002-2007), the RWJF be advocates for the needs of the under- supported the schools at the following served. Students participate in rotations universities with five-year grants averag- to community sites and learn more ing $1.3 million: Boston, Connecticut, about the oral health and general needs Temple, Howard, West Virginia, North of the underserved while they hone Carolina, Meharry, Illinois (Chicago), clinical skills. Ohio, Washington, and UCSF. The The schools have students undertake California Endowment supported public health projects and write essays Pacific, UCLA, Loma Linda, and USC. on critical incidents that deepen their In Phase 2 (2007-2010), RWJF supports knowledge of the problems of the under- schools at the following universities served. While on rotation, the students with 27-month grants of $200,000: provide more care to patients in often Arizona, Baylor, Creighton, Virginia understaffed clinics, getting an immedi- Commonwealth, Florida, New Jersey, ate benefit of more care to patients in Georgia, and Maryland. The California need. Finally, increasing the number of Endowment is supporting all five underrepresented minorities in the field California schools. (African Americans, Hispanics, and There are three overlapping goals Native Americans) means that there will that participating schools are working be more practitioners who will devote to achieve. These are: (a) providing their attention to improving the oral students with an enriched didactic health of racial and ethnic minorities, education to better understand and where there is a disparity in oral health. How does the program work? Each of the participating schools has made 26 affiliation contracts with dental facilities

2008 Volume 75, Number 4 Schools’ Role in Access in mainly underserved communities. rotation seminars with the students sending out students who lack an under- Frequently they are affiliating with to discuss what they have learned. In standing of principles of service learning Federally Qualified Healthcare Centers some schools, students present a case will not change students’ attitudes or FQHCs that are located in federally report or prepare an essay on what toward the underserved. When done designated practitioner shortage areas. they have learned. properly, students respond accordingly. On average, schools are affiliating with For example, students at the University about 23 such facilities in urban and rural The Dental Pipeline Program Is a of North Carolina have taken a pledge areas, some of which are nearby and Means to an End to devote four hours a month to treating others that are thousands of miles away. The outcomes of the Dental Pipeline the underserved throughout their Students are spending up to 12 Program clearly demonstrate that dental professional careers. If one considers weeks in the senior year working in schools can realign their curricula to the number of graduates from North these facilities. In California, both senior include more content in the problems of Carolina (approximately 80), that is students and residents (general practice oral healthcare access. Some of the 15 the equivalent of almost two full-time and pediatric dentistry residents) are schools participating in the first phase of practitioners devoting their energies to rotated to the facilities. Prior to these the program had no off-site education at the problems of the underserved! rotations, students are prepared with the beginning of the project, and several The 2006 American Dental enriched curriculum content in such of the schools had no underrepresented Education Association Senior Survey areas as epidemiology and cultural minority students enrolled. According showed there is still a great need to competency. The latter subject matter to the data collected by the national sensitize students about the problems of provides students with appropriate program office for the project, by the the underserved (Chmar et al, 2007). background information on the relation- end of the first five years (Bean et al, That survey showed that almost 20% ship between provider biases and the 2007), substantial change had occurred. of graduates did not agree that there is patient’s culture, race, and ethnicity in The majority of participating schools’ an access problem in the United States the practice setting. first-year enrollment of underrepresented and approximately 15% did not agree The clinicians at these sites are minority students grew from 5% of the that all elements of society have a right enjoying having students there and entering class to 10%, and the average to basic dental care. Prior to the Dental report patients readily accept them. time spent in community-based settings in Pipeline Program (2001-2002), the The students are very productive in this the senior year grew from approximately national data on the time devoted to environment because normally only one two weeks to ten weeks. All of the community dentistry and public health or two students rotate at any one time schools upgraded their curricula with issues and principles of behavioral to a facility and therefore there is an cultural content. Comprehensive reports sciences in dental schools was minor at excellent mentor relationship with the on the evaluation and outcomes of the best —157 and 43 hours of instruction dentists. They are also usually assigned project are to be published elsewhere. respectively out of almost 4,900 total dental assistants, which allow them to The Dental Pipeline Program has hours of instruction. Also, most schools be more efficient providers (Bean et al, shown that dental schools can teach did not provide a significant extramural 2007). It has been reported that after an students to have a keener understanding program as only a mean of 251 hours initial orientation period, the students of and improved skills and better attitude (5.7%) of extramural patient care out can see up to seven patients a day, giving toward treating the problems of the of the over 2,000 hours of patient care the facility more manpower to help underserved. Getting students away from provided (American Dental Association, whittle down long waiting lists. Students the dental school building and into the 2002). are enthusiastic about the programs and practical world provides them with an Dental education is fortunate to come back to the dental school with enriched education and a better appreci- attract bright and talented students, and renewed confidence. Most receive credit ation for the problems of the underserved. they need to be exposed to the problems towards graduation requirements for The educational program has to facing all Americans if dentistry expects work performed at extramural sites. be organized as a service learning All of the schools have pre- and post- program, including appropriate didactic preparation, pre- and post-rotation seminars, and service learning reflective assignments (Strauss et al, 2003). Just 27 Journal of the American College of Dentists Schools’ Role in Access

to maintain its contract with society. References Further, the schools are the only place American Dental Association (2002). that can rectify the imbalance of practi- 2001/02 Survey of Predoctoral Dental tioners of color. The U.S. population is Education. Curriculum: Volume 4. Chicago, IL: The Association. dramatically shifting towards a greater percentage of minorities, but the Bailit, H. L., Formicola, A. J., Herbert, K. D., Stavisky, J. S., & Zomora, G. (2005). The profession still has a long way to go in origins and design of the Dental Pipeline catching up with that change. The Program. Journal of Dental Education, 69 schools in the Pipeline Program have (2), 232-238. shown that the dental curriculum can Bean, C., Rowland, M., Soller, H., support a substantial service-based Casamassimo, P., Sickle, R., Levings, K., & Agunga, R. (2007). Comparing fourth A just society makes learning component and that schools year dental student productivity and can recruit and enroll more underrepre- experiences in a dental school with sure that it takes care of sented minority students. Community- community-based clinical education. Journal of Dental Education, 71 (8), those in need as well as based dental education is as important 1020-1026. an educational movement as was the those who have the means Chmar, J., Harlow, A., Weaver, R., & comprehensive care movement that Valachovic, R. (2007). Annual ADEA survey to obtain treatment. began in the 1970s or competency-based of dental school seniors. Journal of Dental education in the 1990s. Education, 71 (9), 1228-1253. Finally, by enriching the learning Formicola, A., McIntosh, J., Marshall, S., environment, the Dental Pipeline Program Albert, D., Mitchell-Lewis, D., Zabos, G., & Garfield, R. (1999). Population-based will create a core of practitioners who primary care and dental education: A new will be more inclined to be advocates role for dental schools. Journal of Dental for the needs of those in society who Education, 63 (4), 331-338. are the most at risk. These include the Ko, M., Edelstein, R. A., Heslin, K. C., uninsured, low-income individuals, Rajagopalan, S., Wilkerson, L., Colburn, L., & Grumbach, K. (2005). Impact of the the elderly, and the handicapped. The University of California, Los Angeles/ profession must be on the front line of Charles R. Drew University Medical advocating locally, statewide, and Education program on medical students’ federally if we are to maintain public intentions to practice in underserved areas. Academic Medicine, 80 (9), 803-808. trust. Graduates with community-based Smith, C., Ester T. V., & Inglehart, M. R. education are better equipped to (2006). Dental education and care for advocate for those in need. A just society underserved patients: An analysis of makes sure that it takes care of those in students’ intentions and alumni behavior. need as well as those who have the Journal of Dental Education, 70 (4), 398-408. means to obtain treatment. I Strauss, R., Mofidi, M., Snadler, E., Williamson, R., McMurtry, B., Carl, L., & Neal, E. (2003). Reflective learning in community-based dental education. Journal of Dental Education, 67 (11), 1234-1242. U. S. Department of Health and Human Services (2000). Oral health in America: Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health.

2008 Volume 75, Number 4 Schools’ Role in Access

California Pipeline Program: Phase II

Paul Glassman, DDS, MA, MBA, FACD ental education has a long In 2001, The Robert Wood Johnson history of being practiced in Foundation (RWJF) approved a grant for Abstract Dthe community. In fact, dental the Pipeline, Profession, and Practice: The California schools’ accomplishments education started as a profession that Community-Based Dental Education in the national Dental Pipeline Program led one would enter through an apprentice- program to address disparities in access to funding by The California Endowment ship. The first dental school was founded to dental care. The W. K. Kellogg of a California Pipeline Phase II program. in the United States in 1840. However, Foundation contributed financial aid to There are a number of unique aspects of this program that provide great promise dentists continued for years to be trained students recruited under the Dental for the future of dental education and oral in community-based apprenticeships, Pipeline Program (Bailit et al, 2005). health for underserved populations. First, and now there is renewed interest in A year later, The California Endowment they include the collaboration of the five his aspect of training. As schools came (TCE) joined this effort and provided and soon to be six California dental to be based in universities, as curricula funds to support the four additional schools in multiple areas. The schools have became more scientifically rigorous, California dental schools not originally been able to demonstrate their ability to accomplish things together that could not and as research and clinical practice included in the RWJF funding. This have been done individually. Second, developed, predoctoral dental education created a unique situation in California, collaboration has been established among became primarily located in the school as a state with five dental schools at the the California dental schools and other opposed to the community (Field, 1995). time, where all the state’s dental schools Dental Pipeline Program partners, including Since the 1960s when many schools had were participating in this program. the California Dental Association, the Departments of Community Dentistry, Because of this situation, the California California Primary Care Association, the Hispanic Dental Association, the National these departments have been renamed schools were able to form statewide Dental Association, and other community and the focus of many schools has turned partnerships and collaborations in ways partners. This has created a major force away from community experiences. that were not available to other states. in California that has the ability to The historic report of the Surgeon influence strategy, policy, funding, care, General on oral health in America in and education in a way that has not been Dr. Glassman is Professor 2000 raised the nation’s awareness that and Director of Community previously possible. Lessons learned from profound oral health disparities still exist Oral Health, University of this program will have broad implications the Pacific Arthur A. Dugoni for health and educational strategy. and are linked to race, socioeconomic School of Dentistry in status, and disabilities. It has also become San Francisco; [email protected]. apparent that the oral health safety net Acknowledgements: The for many underserved populations is California Pipeline Project, experiencing considerable stress. One of Phases I and II, were funded the numerous reasons is the difficulty with help from Ignatius Bau and George Zamora of The faced by many community health centers California Endowment. Help in recruiting and hiring dentists (Monts, has also been provided by the National Program Office of 2001). These circumstances provide an the RWJF National Dental important opportunity for dental schools Pipeline Program, Dr. Howard to refocus efforts in the community and Bailit, co-director. to partner with and educate students in community health centers (CHCs) (Bailit, 2008). 29 Journal of the American College of Dentists Schools’ Role in Access

The RWJF funding for Phase I of the regional recruitment program for under- all spend the time they would like in Dental Pipeline Program ended in 2007. represented and low-income students all of the potential feeder schools for The California Endowment, however, and a coordinated and comprehensive URM students. They chose to cooperate continued funding for the California state and federal health policy agenda. on visits to feeder schools. When repre- schools for a Phase II Pipeline program The purpose of the policy effort was to sentatives from any of the dental schools which began in 2007 and continues sustain recruitment of community-based make a presentation at a feeder school, today. This paper will outline the unique education and disadvantaged students they talk about dentistry as a career and aspects of the California Pipeline in after the Pipeline Program ends and, about all the schools being great places Phase I and the objectives of the Phase II more broadly, to reduce disparities in to become a dentist. Other areas of the of the program. oral health. country have now adopted this method- While the national Dental Pipeline ology and formed regional recruitment The Phase I California Pipeline Program was very successful in general, programs (Price et al, 2007). In addition Program there were a number of accomplish- to collaborating on recruitment of URM The general goals of the California ments that were unique to California. students, the California schools also Pipeline Phase I program were the same The average percent of underrepresented cooperated on regional post-baccalaureate as those of the other schools funded by minority (URM) students enrolled in programs that formally strengthen RWJF. These were: Pipeline dental schools increased during potential applicants’ qualifications to • Have senior students spend an the program period but remained fairly apply for admission to dental school. average of 60 days in community static among non-Pipeline schools There is now one program in the north clinics and practices treating under- (Andersen et al, 2007). The percent of of the state and one in the south. served patients URM students enrolled in the California Phase I was also successful in increas- • Provide students with didactic courses dental schools nearly doubled between ing the number of days that students and clinical experiences to prepare 2000 and 2005 (Price et al, 2007). This spent in rotations to community clinics. them for treating disadvantaged was a remarkable achievement given In 2006, U.S. dental schools overall had patients in community sites that the state schools in California are senior students averaging two days in • Increase the number of under- hampered by state Proposition 209. community rotations while the Pipeline represented minority and low-income This 1996 ballot initiative amended the schools averaged about 40 days and students enrolled in Pipeline dental state constitution to prohibit public the California schools over 50 days. schools institutions from considering race, sex, (As indicated earlier, the California There were also a number of aspects or ethnicity in admissions decisions schools used a mixture of students and of the California Pipeline Program Phase I (as explained in a Hastings Law Library residents in these community experi- that were unique to California. In posting: http://library.uchastings.edu/ ences, so the systems are not completely addition to senior students, TCE accepted cgi-bin/starfinder/9466/calprop.txt). comparable between California and experiences of general and pediatric The California schools decided early other Pipeline schools.) dentistry residents to meet the average in the Pipeline Program that they would The other major area of activity in of 60 days in community-based facilities not use their efforts to try to capture Phase I was cultural competency educa- treating underserved patients. Also, individually a greater share of the avail- tion. The California schools engaged in TCE required the California schools to able URM applicants. Rather they would similar strategies to the other Pipeline cooperate in the development of a use their collective resources to increase schools by reforming the curriculum to the size of that pool. To that end, they better prepare students to work with developed collaborative marketing diverse populations. These curriculum programs. They created brochures about reforms included adding new educational dentistry as a career that listed all the materials, rearranging courses, and schools as resources for further informa- devoting more time to some existing tion. They realized that they could not courses. In some schools, reflective seminars were added to help students integrate their experiences in the community with other educational experiences. It is notable that a study of 30

2008 Volume 75, Number 4 Schools’ Role in Access graduating dental students’ practice National Dental Association, and other plans published in 2007 revealed that community representatives. graduating from a California dental The overall goal remains the same school was one of three variables that as in Phase I and centers on developing was predictive of students’ plans to care and testing strategies to reduce disparities for underserved minority patients upon in access to dental care. As in Phase I, graduation. Attendance at other dental this goal is based on the fact that large schools did not have this predictive numbers of California children and value (Davidson et al, 2007). adults have limited access to dental care Finally, an important step in develop- and suffer greatly from preventable and ing health policy reform in California treatable dental diseases. Most California was achieved with a major study of the residents are not enrolled in private A survey revealed a dental safety net in California. A survey dental insurance plans and the state’s system stretched beyond conducted by the University of the public dental insurance plan, Denti-Cal, Pacific School of Dentistry of all has many restrictions that make it capacity and struggling California community health centers difficult for eligible people to find to meet the mission of with dental facilities revealed a system dentists to treat them. Further, the stretched beyond capacity and struggling California dental safety net system has providing basic care to to meet the mission of providing basic relatively limited capacity to treat care to underserved populations in underserved populations. In California underserved populations California. The results of this survey as in other states, only half as many in California. are available on the school’s Web site lower-income adults and children visit (http://dental.pacific.edu/Community_ dentists annually as do middle- and Involvement/Dental_Pipeline_ upper-income families. At the same time, Program.html) as an interactive most untreated oral diseases are seen in database of CHCs. lower socioeconomic groups. The California Phase II Pipeline The Phase II California Pipeline Program focuses on three strategies to Program reduce dental access disparities: (a) part- Because of the accomplishments of nerships between each California dental the California schools in Phase I, TCE school and Community Health Center provided funding for a Phase II of this (CHC) dental programs to increase program. The second phase is being the amount and quality of dental care administered through a California provided to underserved patients; (b) Pipeline Program Office at the University cultural competency programs in dental of the Pacific School of Dentistry. Partners school and community clinics, and (c) in the Phase II program include the five continued efforts to increase the number existing California dental schools, the of underrepresented minority and low- new California dental school being income (URM/LI) students recruited into developed through Western University in California dental schools. Southern California, the California Dental Collaborative committees have been Association, the California Primary Care established in the areas described above. Association, the California chapters of Each group includes membership from the Hispanic Dental Association, and the all the schools as well as community partners. These program components are described in the following sections.

31 Journal of the American College of Dentists Schools’ Role in Access

Community-Based Education involve the use of tele-dentistry treatment of diverse populations. The The primary goal of the community services. In addition, schools will California Phase II program is emphasiz- education activities in the Phase II recruit alumni members who ing the cultural competence of the Pipeline Program is to increase collabo- practice near CHCs to spend some schools themselves and their partner ration between dental schools and CHCs time “teaching” at the CHC. While clinics as institutions and healthcare in an effort to educate oral health these community specialists are not delivery systems. These are areas that providers and provide dental services to likely to want to “practice” in the can be approached collaboratively and underserved populations. Each dental CHC, experience has demonstrated are likely to achieve greater gains in school is establishing relationships the ability to recruit specialists to service and education than concentrating with two to three CHCs for this aspect of teach there. This teaching role on dental student education alone. the program. provides specialty consultation for Several activities are already under way: Previous school-CHC partnerships the CHC and its patients. • A basic, one-hour introduction to involved an exchange between the • Schools provide operations manage- using language interpreters has been school and the CHC. The CHCs received a ment consultation and training for developed and disseminated to all the workforce to help meet their mission in CHCs. The California schools are schools. Participants will be able to an era when it is hard for many of them engaging practice management recognize a proper interpretation to hire dentists. The schools got a place expertise and developing a collabora- session and take corrective action to educate students in the community. tive system for making this expertise when an interpretation session is not The Phase II partnerships continue this available to partner clinics. being properly conducted. All the exchange, but they add several additional The California Primary Care California dental schools have components: Association (CPCA) is an important committed to having every student, • CHCs participate financially in the partner in the Phase II program. CPCA staff member, and faculty member student and resident rotations by is assisting in several areas related to go through at least a one-hour sharing new revenue produced by community-based education: interpreter training introduction students and residents minus • The CPCA is responsible for facilitat- using this curriculum. marginal expenses for supporting ing communications between the • A survey of the California dental those student and resident providers. schools and CHCs in the state. To schools was developed to assess This may be in the form of direct this end, the CPCA is hosting special multiple areas of institutional payments to the schools, support of oral health forums at its annual cultural competence. These areas student housing or transportation, meetings, convening dental director include administration, the educa- or other financial arrangements. worshops, and providing access to its tional program, clinical services, and • Schools provide targeted educational online technology and collaboration community rotations. The results of experiences for CHC dentists and network and tools. this survey now constitute a baseline staff. The schools are currently • The CPCA is facilitating the develop- for comparison as the competence collaborating on the development ment of operations consultations of schools develops in this area. of distance education and regional systems. An important part of this • A survey of the impact of language in-person programs specifically aspect of the program will be the barriers on dental school clinic targeted to CHCs. dissemination of data about the operations was developed and distrib- • Schools assist with specialty effectiveness of these activities and uted. Preliminary results point out a consultation services for CHCs. development of strategies to extend number of areas for further work Models are being developed that these operations across the state. and confirm the expectation that language issues do impact the Cultural Competency delivery of care, slow down clinic operations, and can lead to misun- Phase I of the National Dental Pipeline derstandings and complaints. Program emphasized educating students • The dental schools are collaborating about issues related to diversity and on the development of resources to create signage in multiple languages in school clinics. The schools 32

2008 Volume 75, Number 4 Schools’ Role in Access

will agree on common signs and Associations have agreed to support this contract centrally with translation program. Pilot sites may be established services and production facilities. in conjunction with a similar program The goal is that each school will be being developed by the national Pipeline able to order signs they need without office and funded by RWJF. having the burden of all of the developmental work. Health Policy • Strategies are being developed to The California Pipeline Phase II health assess the cultural competence of policy effort is focused on the long-term dental students. A number of useful goal of establishing a state subsidy for tools have been collected and made community-based dental education. The available. The California schools will California Dental Association is the lead Strategies are being work with these instruments in an partner in this effort. The CDA arranged effort to develop common tools. the first of three Health Policy Summit developed to assess the meetings in the spring of 2008. That cultural competence of Recruitment initial summit brought together state The successful collaborative efforts in officials and Pipeline partners to begin dental students. A number the Phase I program to increase the this process. Future work will build on of useful tools have number of URM enrollees and dental this summit in the following areas: students from disadvantaged back- • Develop the case for state support of been collected and grounds will continue. Several additional community-based dental education. made available. strategies are being developed and The basic argument is that the tested as well. problem of access to dental care is The regional post-baccalaureate getting worse and more visible, and programs to prepare applicants for that the collaboration between dental dental school have been strengthened education institutions and community in northern and southern California. partners is one of the few viable In northern California, the University strategies for addressing this problem of California at San Francisco and the in a meaningful way. In addition, University of the Pacific dental schools it is likely to be a less costly strategy jointly support a post-baccalaureate than other alternatives. program run by San Francisco State • Develop the coalition of organizations University. The schools contribute finan- and individuals to advocate for this cially to the program, assign mentors to strategy. the students, host simulation sessions, • Develop a long-term plan for and participate in presentation sessions implementation of this strategy. by the students. In southern California While it is recognized that California, the post-baccalaureate students from the like a number of other states, is not in University of California in Los Angeles, the position now to invest in a new oral the University of Southern California, heath strategy, it will be at some time in and Loma Linda University all attend a the future. It is critical that the ground- unified, six-week summer program work be laid now to take advantage and come together again during the year of a different fiscal and political climate for joint educational programming. when it arises. A mentoring program has been designed to involve community dentists as mentors for potential URM applicants. The Hispanic and National Dental

33 Journal of the American College of Dentists Schools’ Role in Access

Conclusions References The success of the California Pipeline Andersen, R. M., Carreon, D. C., Friedman, Phase I Program has led to funding by J. A., Baumeister, S. E., Afifi, A. A., Nakazono, T. T. & Davidson, P. L. (2007). TCE of Phase II. The components, goals, What enhances underrepresented minority and activities of Phase II have been recruitment to dental schools? Journal of described. There are a number of unique Dental Education, 71 (8), 994-1008. aspects of this program that Bailit, H. L. (2008). Models for funding provide great promise for the future of clinical dental education: What’s likely and what’s not. Journal of Dental Education, 72 dental education and oral health for (2), 21-24. underserved populations. They are: Bailit, H. L., Formicola, A. J., Herbert, K. D., The collaboration of the • The collaboration of the five and Stavisky, J. S., & Zomora, G. (2005). The soon to be six California dental origins and design of the Dental Pipeline five California dental schools has been a key component of Program. Journal of Dental Education, 69 (2), 232-238. the past and current program. In schools has been a key Davidson, P. L., Carreon, D. C., Baumeister, multiple areas, the schools have been S. E., Nakazono, T. T., Gutierrez, J. J., Afifi, component of the past able to demonstrate their ability to A. A., & Andersen, R. M. (2007). Influence of contextual environment and community- and current program. accomplish things together that could not have been done individually. based dental education on practice plans of graduating seniors. Journal of Dental In multiple areas, the • The collaboration between the Education, 71 (3), 403-418. California dental schools and other schools have been able Field, M. J. (Ed.) (1995). Dental education Pipeline partners has taken the at the crossroads: Challenges and change. to demonstrate their schools’ collaborative efforts to Washington, DC: Committee on the Future another level. Adding professional of Dental Education, Division of Health ability to accomplish Care Services, Institute of Medicine. associations and other community Monts, R. (2001). Dental care: Clinics facing things together that partners has created a major force in crisis. Community Health Forum, 14-18. California that has the ability to could not have been Price, S. S., Brunson, W. D., Mitchell, D. A., influence strategy, policy, funding, Alexander, C. J., & Jackson, D. L. (2007). done individually. care, and education in a way that has Increasing the enrollment of underrepre- not been previously possible. sented minority dental students: Experiences from the Dental Pipeline The California Pipeline Phase II Program. Journal of Dental Education, 71 program represents a unique opportunity (3), 339-347. for dental education to become a full U.S. Department of Health and Human and important partner in the effort to Services (2000). Oral health in America: A report of the Surgeon General. Rockville, improve the oral health of underserved MD: National Institute of Dental and populations in our country. Lessons Craniofacial Research, National Institutes learned from this program will have of Health. broad implications for health and educational strategy. I

2008 Volume 75, Number 4 Schools’ Role in Access

East Carolina University School of Dentistry Impact on Access Disparities

D. Gregory Chadwick, DDS, MS, FACD orth Carolina, like many states, state. The intent of this paper is to and James R. Hupp, DMD, DDS, JD, is facing growing challenges highlight some of the features planned MBA, FACD Nto access to oral health care. for the school that will address the Historically, in times of need the state state’s growing access disparities. Abstract has looked to its excellent statewide Under the “Plan for Dentistry in North educational resources for solutions. Chief The North Carolina Environment Carolina,” the existing dental school will among those resources is the University The majority of North Carolinians enjoy increase its class size and enhance its of North Carolina, a sixteen-campus excellent oral health and benefit from an research efforts and a new dental school public university. As the state faces both outstanding dental workforce that has will be opened on the campus of East Carolina University. These initiatives are a shortage and a maldistribution of its been dedicated over the years to providing designed to address a growing gap dental workforce, the university and the excellent care and has been successful between oral health needs and capacity General Assembly (the state legislature) in improving oral health. However, a to meet that need in the state, especially are working together to address the significant proportion of the population in rural areas. The new school will focus problem. Recently the General Assembly has historically experienced difficulty on educating well-qualified primary approved capital funding to develop a in accessing adequate care. A growing care dentists who desire to address the challenges of providing care in the rural School of Dentistry at East Carolina number of factors present challenges to and underserved areas of the state. University (ECU), located in Greenville, providing adequate care in the future This paper describes the objectives, North Carolina. ECU will use this oppor- to all populations, but especially to the quality, research, patient care model, tunity to expand dental education’s rural and low-income populations. economic model, recruitment and financial role as a safety net provider by moving North Carolina ranks forty-seventh considerations for students, and community many senior-year dental education out of 50 states in the ratio of dentists to benefits of the program. A key feature of the ECU program will be the fourth-year experiences into efficient community- the population. In October 2005, North experience in Service Learning Centers based practices in areas of the state Carolina had 3,772 dentists actively prac- located in rural communities. experiencing significant access disparities. ticing in 96 of the state’s 100 counties. This strategy will be unique in American The state’s ratio of 44 dentists per dental education. 100,000 population falls well below the The new school will focus on educat- national average of 60 dentists per ing well-qualified primary care dentists 100,000 population (Cecil G. Sheps Center who desire to address the challenges for Health Services Research, 2007). of providing care in the rural and underserved areas of the state. In addition Dr. Chadwick is Associate to graduating more dentists to serve Dean for Planning and these areas, during the course of the Extramural Affairs and Dr. Hupp is Dean, East educational process students, residents, Carolina University, and faculty will provide significant care School of Dentistry; [email protected]. and enhance their clinical skills in dental school practices located in chronically underserved areas of the

35 Journal of the American College of Dentists Schools’ Role in Access

The distribution of dentists in North Private practitioners deliver the vast 100 students per year. ECU will start a Carolina is an increasing concern as majority of dental services provided in new school of dentistry with a class size one looks to the future. While the supply North Carolina each year. Of the care of up to 50 predoctoral students per year of dentists in the metropolitan areas has provided in 2005, private practitioners starting recently increased to 49 dentists per provided over 80% of the care for children in 2011. ECU will focus on addressing 100,000 population, the nonmetropolitan under 21 years of age, approximately the oral health needs of the rural and counties have remained relatively 94% of the care for the non-elderly adult undeserved areas of the state while constant at around 31 dentists per population, and 98% for the elderly offering innovative options to some of 100,000 population for the past 25 years. population (North Carolina Institute of the challenges facing dental education. Twenty-six percent of the counties Medicine, 2005). The remaining dental Although the two North Carolina have 20 or fewer dentists per 100,000 services were provided by safety net schools will have different but comple- populations (Sheps Center, 2007). dental providers which consist primarily mentary missions, there will be many North Carolina’s population growth of local and county health departments, opportunities for collaboration. Some is projected to be the fifth largest in community health centers, dental possibilities include using distance the country, according to U.S. Census education facilities, and free clinics. Some education technology for selected Bureau data, resulting in a 52% growth of these have permanent staff, fixed instruction, collaborating on specialty rate over the first 30 years of this century. locations, and regular hours of operation rotations or patient-care experiences in As a result, the state will be the seventh while others are operated on a voluntary community-based sites, exploring ways largest by 2030. The supply of dentists basis, and still others are mobile or to share faculty resources or leverage has not kept pace with this growth as portable dental programs. A recent faculty resources through joint appoint- illustrated by the decline in the dentist estimate is that there are approximately ments, and developing research per population ratio in 33 counties 105 safety net providers in 76 of the partnerships capitalizing on the respec- over the period 1996 through 2005. state’s 100 counties (http://www. tive strengths of each institution. Nonmetropolitan counties accounted communityhealth.dhhs.state.nc.us/ Traditionally, dental schools influence for 26 of the counties experiencing a dental/safety_net_clinics.htm). There is access to dental services primarily by decline (Sheps Center, 2007). a need for increased access to dental increasing the number of dentists who The aging of the dentist workforce, services in the population that does not provide care. Unless special efforts especially in the nonmetropolitan areas have access to a dentist on a regular are made to recruit applicants from of the state, is also a growing concern as basis. This provides an opportunity for underrepresented and underserved dentists retire. Dentists in nonmetropolitan dental education to play an increased populations and mentor students and counties are, on average, three years role in delivering care to this population provide them community-based extra- older than their metropolitan counter- while educating dentists in these areas. mural experiences, most dental school parts. In 38 counties, the average age of graduates practice in middle- and upper- the dentists is 50 years of age or older The Plan for Dentistry in income urban or suburban areas. Simply and 31 of these are nonmetropolitan coun- North Carolina graduating more dentists has limited ties. The challenges of an aging dental Working together under the leadership impact on increasing access to dental workforce in nonmetropolitan counties of the sixteen-campus University of care in low-income and rural areas. will accentuate the shortages of providers North Carolina System, the University of Generally, dental schools provide in these areas (Sheps Center, 2007). North Carolina at Chapel Hill (UNC-CH) relatively modest amounts of care in With an aging dental workforce, an and East Carolina University (ECU) crafted their student clinics. In the 2003-2004 unfavorable dentist-to-population ratio an approach to leverage the strengths academic year, the median revenue in rural areas, and an unfavorable distri- of both institutions in addressing dental generated by senior dental students in bution of dentists in a rapidly growing education’s impact on the future oral American schools was $13,602 or $15.59 state, it is clear that if the challenges are health workforce of the state. This per hour. General Practice Residency not addressed the workforce shortage collaboration became known as the (GPR) and Advanced Education in and maldistribution will only get worse. “Plan for Dentistry in North Carolina.” General Dentistry Residency (AEGD) Under the plan, the UNC-CH School of residency programs reported $66,474 Dentistry will modernize and expand its research and teaching facilities and 36 increase its predoctoral class size up to

2008 Volume 75, Number 4 Schools’ Role in Access and $63,860 per resident, respectively. emphasizing primary care and a success- It is difficult to make assumptions about ful record of improving the health of the the role dental school clinics play as people of the state, especially in rural safety-net providers. Nevertheless, the areas. The dental school will have 50 percentage of revenue schools derive students per class. In addition, the school from Medicaid and the percentage of will have three residency programs; a uncompensated care can give us a clue General Practice Residency, an Advanced as to the amount of care provided to low- Education in General Dentistry Residency income patients. Dental schools reported and a Pediatric Dentistry Residency. that Medicaid accounted for about 12.8% The dental school’s emphasis on general of dental school clinical revenues and dentistry and pediatric dentistry comple- Unless special efforts are uncompensated care for the junior and ments ECU’s primary-care mission. senior years averaged about 15% Consistent with its focus on primary made to recruit applicants (Weaver, 2006). care and general dentistry, general dentists will outnumber specialists on from underrepresented and ECU School of Dentistry the dental faculty. Most specialty areas underserved populations What will the ECU dental program look will be represented by two specialists. like and how will it differ from traditional Since pediatric dentistry will be the only and mentor students and dental education models? specialty residency program, it will have a provide them community- larger faculty. The use of clinical practice Objectives groups or teams headed by general based extramural The primary objectives of the ECU School dentists during years two and three will experiences, most dental of Dentistry will be providing a quality serve to improve efficiencies and clinical education and graduating skilled reinforce the primary care approach and school graduates practice in primary care dentists who will positively use general dentists as role models. affect the availability of care in rural middle- and upper-income and underserved areas of North Carolina. Curriculum urban or suburban areas. During the educational process, students, Graduates of the school will require residents, and faculty will provide signifi- strong diagnostic, clinical, critical cant patient care in the school’s eight to thinking, and practice management ten community-based Service Learning skills in order to be successful. ECU has Centers (SLCs) located in chronically the unique opportunity to create a underserved areas of the state. A focus curriculum that will enhance and support will be made on recruiting students who the mission of the school, preparing are truly interested in the mission of students for their senior-year, community- the school and show evidence of serving based experience. The school will depend the underserved. The SLCs will have a on the extensive use of technology as significant positive effect on the an educational bridge supporting an economies of their local communities educational environment with students, and play a role in building the local residents, and faculty in multiple locations healthcare infrastructure. across the state. Electronic technology will be as important as a dental chair Quality Dental Education in meeting the education and delivery East Carolina University’s School of of care mission of the school in Dentistry is located on the Academic this environment. Health Sciences Campus in Greenville, North Carolina, alongside the ECU School of Medicine, College of Nursing, and College of Allied Health. The academic health center at ECU has a history of 37 Journal of the American College of Dentists Schools’ Role in Access

The curriculum is being designed state. Most of this care will be delivered that the faculty will provide care in the to integrate the basic and dental sciences in up to ten SLCs located in areas of range of 70% of their colleagues in throughout all four years and to ensure significant need where opportunities private practice, having access to up to that the fourth year is a rich and exist to collaborate with the practicing four operatories, two dental assistants, well-structured experience, involving community and enhance safety net and a dental hygienist. The effective use both basic science and clinical faculty dental services. Many or perhaps all of of auxiliary personnel and state-of-the- and highlighting the most important these SLCs will be operated and managed art technology will allow students and concepts and knowledge through by ECU. They will be conducted as residents to see many more patients focused seminars. These seminars, efficient group practices, based on sound than in a traditional dental school designed to connect didactic instruction, business principles, using a professional program and gain increased clinical case correlation, critical thinking, and practice management team. Educationally, experience and confidence in situations current literature with actual patient they will be operated as an integral that approach what they might expect to experiences, will be developed over all part of the dental school and provide see in private practice. It is anticipated four years but will culminate in the significant amounts of care in areas of that the residents will provide care in SLC experiences. the state where it is most needed. the range of 50% to 60% of what their The SLCs will focus on primary private practice colleagues are providing Research care using a clinical medical education while having access to two operatories, Research and the creation of new model with faculty, residents, and a dental assistant, and a shared dental knowledge are important aspects of a students all providing high quality care. hygienist. The dental students will have dental school which are being developed A key feature of the ECU model is that access to one operatory and a dental within a university that values research the general dental faculty will practice assistant, and, assuming they see at least and has a vision of doubling its research while supervising small groups of six to seven patients a day, they will productivity in the next five years. The residents and senior students, thus more than double the level of services dental school has several opportunities significantly increasing the care delivered that they would provide in a dental to contribute to this momentum during and contributing to the bottom line school building clinical environment. its formative years. The first area of of the practices. Residents also will The SLC experience, in addition to research interest will be in the area of participate in the supervision of senior developing clinical, diagnostic, and epidemiological and health services dental students under the leadership critical thinking skills, will give students research using the SLCs as a practice of a general dentist. This is a model an opportunity to establish a close research network to study oral health routinely used in medical education and mentoring relationship with faculty. disparities in rural and underserved commonly used in dental specialty They will also experience the rewards areas. Practice-based clinical research in programs such as pediatric dentistry of providing care in geographic areas the SLCs, collaborating with researchers and oral-maxillofacial surgery. where it is most needed. Students will in Greenville or at other institutions, will Senior students will have the have the opportunity to provide patient- occur as the school develops its network opportunity to spend approximately 24 centered care and gain significantly of centers. weeks (three, eight-week rotations) in more experience and a broader range the school’s SLCs, gaining valuable of experiences than under traditional Patient Care experience practicing in a real delivery models. It is anticipated that students In addition to its educational mission, a system that functions like an efficient will gain from this experience and be significant feature of the school will be private practice. For the remainder of influenced to choose to incorporate providing high quality, patient-centered the time, the fourth-year students will service to similar populations, in whole care in rural and underserved areas of the take part in specialty rotations and more or in part, in their practice careers. traditional extramural rotations. The SLCs will be an integral part The faculty members leading the of the dental school. They will retain teams in the SLCs will provide care, in the features of more traditional models addition to teaching and mentoring. where students receive most of their Compared to a full-time practitioner, the faculty will likely provide a somewhat reduced amount of care due to educa- 38 tional responsibilities. It is anticipated

2008 Volume 75, Number 4 Schools’ Role in Access education within the dental school main school fee structure” as sources of facility and have access to all faculty, revenue for the extramural practices. records, and management systems. ECU’s The staffing and operating expenses of goal is to combine the advantages of the practices will be carefully monitored being in a dental school main facility and sized, similar to efficient and profes- environment with additional advantages sionally managed private group practices. of the enhanced educational experiences Medicaid patients will be the primary and delivery of care at extramural sites. insured population. The characteristics The use of electronic technology, a of the Medicaid program in North common records management system, a Carolina, in combination with the ability comprehensive curriculum focused on to place educational group practices in care delivery in rural settings, and a areas where there are few dentists and Simply graduating committed faculty are all necessary high demand for dental services create elements to assure that the SLCs are opportunities for the SLCs. The North more dentists has little an integral part of the dental school’s Carolina Dental Medicaid Program covers impact on increasing program. many diagnostic and preventive services, The faculty at the SLCs will be as well as a number of restorative and access to dental care full-fledged faculty, accomplished in all surgical procedures for both children in low-income and aspects of general dentistry. They will be and adults. In addition, North Carolina well-versed in the curriculum provided allows dental schools, as public institu- rural areas. students during the first three years and tions, a cost settlement option to recover what the students will be expected to some expenses attributed to providing experience and learn during their senior Medicaid services where reimbursement year. Because the SLCs are part of the rates are below the state match. dental school, equipment, instrumenta- The North Carolina Dental Medicaid tion, and routines will be standardized, budget for the current fiscal year is in thus making the transition easier from excess of $260 million, and the program the main dental school facility to the has modestly raised reimbursement extramural delivery system environment. rates recently for approximately 75 In addition, student and financial covered services. Although policy restric- management systems will be the same tions exclude a number of procedures, at all facilities. many others are covered, although at relatively low reimbursement rates. Economic Model Reduced fees will be charged for services The SLCs will be operated by a for many patients that are not covered professional management team and be by Medicaid and are unable to afford expected to be financially sustainable. usual and customary fees. This will Even if they are operated close to their allow for the care of a broader range of break-even point, they will reduce the patients, and for the ability to provide overall cost of the fourth year of dental services and procedures that give school while providing a cost-efficient students the depth and breadth of approach to educating senior dental experience and confidence they need students and residents. ECU will leverage to become successful practitioners. the use of public funds, including Medicaid, Graduate Medical Education (GME) funding, and state supported faculty base salaries, along with non-public funding sources such as a sliding-fee schedules and a “dental 39 Journal of the American College of Dentists Schools’ Role in Access

Understanding Business Principles attracting candidates from underrepre- As mentioned earlier, the SLCs will be sented groups. The importance of operated on sound business principles. recruiting individuals that best fit the It will be necessary for graduates, in dental school’s mission and providing addition to their clinical skills, to have a the student with educational experiences good understanding of the business and in rural and underserved areas cannot operations side of managing a dental be overstated. practice if they are to be successful in rural and underserved areas of the state. Student Finances Since the SLCs will be operationally The current pattern of increasing tuition Access to oral health similar to private practices, the students and rising levels of student debt across and residents will be expected to become the country will have an impact on the care is a multifaceted familiar with the business side of the applicant pool for dental schools and the challenge and dental SLCs and to acquire an understanding of career choices of those graduating from the financial, personnel, and regulatory dental school. As the costs of dental education’s leadership aspects of the practice of dentistry. education rise, it is safe to assume that role is only one strategy. Although each SLC will be unique, increased financial burdens will make it depending on location and collaborative difficult for students from rural and Additional necessary opportunities in each community, the underrepresented populations to choose strategies include business operating principles will be the to go to dental school, and even more same, and the opportunity to learn in real- difficult to locate in practice situations financial incentives, loan life practice settings will give the students that provide care for those populations. repayment programs, and residents an excellent foundation. As a state-supported school, ECU will need to hold down the portion of the scholarships, increased Recruiting Students educational costs borne by students in Medicaid coverage, and As part of its mission, the ECU School of the form of tuition and fees, thus Dentistry will seek to identify and recruit allowing students to graduate with less community involvement. individuals from rural and underrepre- debt. In addition to lower student debt, sented populations to encourage them to help will be needed in the form of schol- pursue dental careers and practice in arships, loan repayment programs, and underserved areas. The recruiting community assistance programs to further process must begin early to attract enable graduates to enjoy careers candidates interested in eventually providing care where it is most needed. serving underserved populations. Simply accepting applications will not be Community Benefits enough. It will take a concerted effort to There will be significant economic identify potential students early in the benefits to the chronically underserved educational pipeline by collaborating areas in which SLCs will be located. with community organizations and This will be in addition to improving the college guidance counselors to assure local healthcare infrastructure and the that these individuals will have the back- oral health in communities where SLCs ground and knowledge to be successful are established. There will be a direct in dental school. This will also necessitate economic impact via the jobs in the SLCs, ensuring that recruiting efforts include and the goods and services consumed by SLC employees. This lasting economic impact will extend into the communities surrounding the centers.

2008 Volume 75, Number 4 Schools’ Role in Access

Another important aspect of locating quality of its graduates, the number of the SLCs in the rural areas will be in dentists seeking to improve access to care supplementing community resources to in chronically underserved areas of the educate the public about the importance state, and the economic success of the of good oral health and prevention. SLCs, as well as the care they provide and The faculty, staff, and students will have the impact of school’s research focus. the opportunity to work within the Access to oral health care is a multi- community and surrounding areas to faceted challenge and dental education’s develop and deliver a message about the leadership role is only one strategy. importance of good oral health as part Additional necessary strategies including of good overall health. financial incentives, loan repayment programs, scholarships, increased Current Status of the School Medicaid coverage, and community The dental profession The ECU School of Dentistry is currently involvement. The dental profession and and the dental education under development. The capital funding the dental education community need has been obligated and is being provided to be at the table and need to provide community need to be by the state. The majority of the initial solutions, but it will take the commitment at the table and need operating funds are projected to be of the public and our policymakers to provided by the General Assembly and reach comprehensive long-term solutions. to provide solutions, but will eventually be supplemented with I tuition, clinical revenue, research, and it will take the commitment philanthropic funds. After the architec- References of the public and our tural design phase is completed, Cecil G. Sheps Center for Health Services construction will begin by 2009 on the Research (2007). Trends in the supply of policy makers to reach dentists in North Carolina. 1996-2005. 112,500-square foot main school facility Chapel Hill, NC: The Center. comprehensive long-term and the first SLCs. The initial faculty, North Carolina Institute of Medicine (2005). administrators, and staff are being 2005 North Carolina oral health summit on solutions. recruited and hired. When the school is access to dental care: Summit proceedings fully operational, it will have approxi- and action plan. Durham, NC: The Institute. mately 68 faculty members and Weaver, R. G. (2006). ADEA survey of clinic fees and revenue: 2003-04 academic administrators (including ten general year. Journal of Dental Education, 70 (4), dentists in the SLCs), plus staff. The 448-462. school is expected to accept its first predoctoral class in 2011, and initiate AEGD and Pediatric Dentistry residency programs that same year, perhaps sooner.

Conclusions The ECU School of Dentistry is committed to educating well-qualified primary care dentists, improving oral health and playing a leadership role in reducing access disparities in the rural and other underserved areas of North Carolina. By moving senior-year dental education experiences into the school’s SLCs, faculty, students, and residents will provide significant care in areas across the state where it is most needed. ECU’s effectiveness will be measured by the 41 Journal of the American College of Dentists Schools’ Role in Access

The Role of Dental Schools in the Issues of Access to Care

Caswell A. Evans, DDS, MPH, FACD here is variation in the range of Dental education can also be academic attention to the issues approached from the perspective of oral Abstract Tof access to care among dental health, inextricably linked to general Some individuals emphasize dentistry schools. The role of dental schools health and well-being. In this view, dental as the provision of services; others regarding access to care may depend care may be provided in the context of concentrate on achieving specified levels upon often unstated, but operationally its contribution to achieving improved of oral health. One’s vision of dentistry evident, educational philosophies. Some oral and general health. Students and affects how the issue of access is viewed. The University of Illinois at Chicago school curricula focus more on the graduates of these schools may refer to College of Dentistry has been the technical skills essential to the provision their role as “providing healthcare recipient of a Profession and Practice: of clinical care, to the near exclusion of services to improve oral health.” Because Community-Based Dental Education surrounding issues such as access to the issues of access to care affect the oral project (the Pipeline) grant to promote care, health disparities, organization health status of people and populations, oral health in underserved communities and financing of dental care, and under- this academic subject is probably more and to train students to function effectively in such settings. The School’s Extramural standing the health services sector. likely to be incorporated in the curricula Clinical Experience is described. This Some schools make a dedicated effort of schools whose educational philosophies involves 60 days of providing care in to weave these subject themes into their place them at this end of the spectrum. In seventeen sites for students in their fourth curricula in a manner intended to at general, dental schools offer discounted year of training. Students must qualify least inform students that such issues fees for patients to compensate for for these rotations based on clinical exist and will confront them during students providing care. These discounted competency and they must document their experiences. The positive effects observed their careers. fees allow a wide variety of patients to so far in this program are described. access oral health care services that may Vision of Dentistry not be financially able to seek care from This range of difference may be caused, private practitioners in the area. in part, by differing academic perceptions Issues of access to care seem to be of what dentistry is and what dentists do. important for dental school curricula for On one side of the spectrum, dentistry several reasons. Access to care is currently can be viewed as the provision of dental a significant issue in Congress. Access to services for individual patients, with the care issues also underpin the disparities emphasis placed on repair and protection in oral health status witnessed in the of teeth and related tissues. Students and population, they drive concerns for graduates of such schools may refer to equity and social justice, and place their role as “working on patients to improve the form and function of teeth.” Dr. Evans is Associate Dean In this view, issues of access to care may for Prevention and Public only be related to a patient’s willingness Health Sciences, University of Illinois at Chicago College of to accept treatment plans with extensive Dentistry; [email protected]. procedures and the restoration of the complete dentition.

2008 Volume 75, Number 4 Schools’ Role in Access

before us basic questions regarding care. Once a shortage area designation is the purpose and value of the dental made, federal funds can be obtained to profession to society. attract health providers, including den- Dental education can While access to care may have tists, to the area. Even so, a large number also be approached from inherent societal value and be considered of the slots in shortage areas go unfilled. to be “good to have,” the issue is also Racial and ethnic imbalances are the perspective of oral driven by health disparities and the evident when the demographics of the health, inextricably apparent need for care demonstrated overall population are compared to the among those population groups that dentist workforce. These imbalances linked to general health have insufficient access. In turn, concern also appear to contribute to problems for the resolution of health disparities is of access to care. While the general and well-being. driven by concepts of social justice and population is approximately 13% black equity of opportunity. Dentists who are and 15% Hispanic, black and Hispanic more sensitive to such values would be dentists each constitute only 3% of the more inclined to contribute as best they dentist workforce. Nationally, black can to correct health status imbalances students currently represent about 5% among population groups. Others not of entering dental classes, and Hispanic so affected by these concerns would students represent approximately 6%. probably pay less attention to these Studies have shown that race and ethnic types of problem. concordance of patient and provider is a Data from numerous sources demon- determinant of healthcare utilization strate substantial oral health disparities and consequently affects access to care. among age cohorts and populations that From a didactic perspective, the are influenced by issues of access to care. Surgeon General’s Report (Oral health The elderly demonstrate a variety of oral in America: A report of the Surgeon health disparities and these disparities General, 2000) focused these concerns are more pronounced for institutionalized in a manner that drew wide-spread and debilitated elderly. It is important to attention, well beyond the typical dental note that Medicare does not cover dental or oral health spheres of interest. care. At the same time, those who are Information and data from this report 65 years and older represent the fastest was incorporated in dental school growing age cohort in the United States. curricula. In addition, some dental People residing in rural and remote schools have had a long history of areas, and many inner-city areas as well, placing students in community-based, face challenges of distance and provider service-learning settings as part of their supply and availability, resulting in formal programs; other dental schools difficulty gaining access to care. The number of designated Health Profes- sional Shortage Areas has increased in recent years due to issues of access to 43 Journal of the American College of Dentists Schools’ Role in Access

have included such experiences on a The curriculum was enhanced in its volunteer basis, or with experiences content related to cultural awareness scheduled over holiday or vacation and diversity, health and oral health periods. This type of learning is funda- disparities, and issues of access to care. mental to the concept and operation of A major achievement was the develop- the recently opened Arizona School of ment of a new required for-credit course Dentistry and Oral Health. Other new for fourth-year dental students (D4s) dental schools are currently being known as the Extramural Clinical developed using variations of this educa- Experience (ECE). This course contains tional concept. several didactic elements presented in The Pipeline, Profession and Practice: classroom format, as well as a clinical Concern for the resolution Community-Based Dental Education component of 60 days of community- Program, funded by the Robert Wood based service-learning for each D4 of health disparities is Johnson Foundation, The California student. The 60 days are arranged in driven by concepts of Endowment, and the W. K. Kellogg clinic assignment rotations of three to Foundation, enabled 15 dental schools four weeks each. There are six such social justice and equity to develop and expand their academic rotation periods fixed in the college’s of opportunity. programs addressing issues of access to academic calendar. The overall curricu- care and health disparities, including an lum is competency-based and the clinical objective to have senior dental students faculty determines the point at which placed in community-based clinical students are prepared to enter into the locations for 60 days. The intent is to ECE course. However, the clinical faculty afford these students an opportunity to is also challenged with the specific experience these issues directly and objective to fully prepare students for learn from their exposure. The Pipeline the course and its community-based Program also includes an objective to service learning element. This objective recruit and retain underrepresented also drives the third-year (D3) clinical students and faculty in the participating curriculum as the essential precursor of dental schools. A second but smaller education, training, and skill development round of funding under this initiative that provides a basic foundation for the has enabled additional dental schools to D4 year and the ECE course. pursue these directions as well. The full At the community level, 17 sites evaluation of the first round of projects have been identified to serve as clinic will be released soon. In the meantime, locations for the ECE rotations. At the anecdotal information has proved most formal level of collaboration, the interesting and compelling. executive administration of each site enters into an affiliation agreement with Extramural Clinical Experience the University of Illinois. One or more at UIC dentists at each site must be successfully The University of Illinois at Chicago credentialed as adjunct faculty of the College of Dentistry was awarded college. The processes for completing Pipeline Program funding and proceeded the affiliation agreement take eight or to change its curriculum significantly. nine months to complete; and the credentialing process for adjunct faculty may require several months. Community sites are selected based on a list of criteria, including: willingness and interest in collaborating in this way with the college and university, sufficient dental 44

2008 Volume 75, Number 4 Schools’ Role in Access operatories so that the presence of service system, and population served Children’s Healthcare Foundation, initi- students does not preclude the site staff are among the strengths of these ated a pilot project involving 12 carefully and adjunct faculty from providing care, rotation experiences. selected D4 students who are gaining physical quality of the site, dental Students can also request placement approximately half of their clinical assistants for the students, and protocols at other sites they may have identified experience in community-based for quality assurance and safety, to name for their rotation experiences. If the site service-learning sites. The 12 students only a few. An objective has been to proves to satisfy course requirements, are organized into six teams of two have access to sites that offered a wide a substitution can be accommodated. students each. Two teams are assigned range of distinctive health systems and For example, students have completed to each of three community sites chosen oral health service delivery models. In rotations in the country of Tanzania, the by the college for the pilot. Teams alter- this way, students could anticipate state of Minnesota at the White Earth nate, spending two weeks in the dental experiences that offer exposure to India Reservation, and in Los Angeles at college and two weeks at the site. In different practice models and approaches the Union Rescue Mission. that regard, each site has the benefit of to increasing access to care for under- As part of the didactic element of the continuity of student providers during served populations. course students complete a “photo voice” the academic year. The student teams Sixteen of the rotation sites are located project in which they take pictures of change sites every four months so that in Illinois and are distributed among any scenes, excluding patients and each student has the opportunity for rural, suburban, and urban settings. The patient care, and provide a brief personal in-depth experience with three distinct other is located in rural Guatemala. interpretation of the scenes as they dental care delivery systems and modes The Guatemala rotation is quite special relate to their rotation experience. One of practice. and highly sought after by students. The student pictured the long flight of stairs One site is a closed-panel, union- in-state sites include the following types ascending to the Chicago loop elevated sponsored medical and dental clinic for of clinics and corresponding service train. This view was interpreted to members of a Chicago food workers models: free-standing Federally Qualified represent the problems of access to union. Another site is an FQHC. The Health Centers (FQHCs) and an FQHC needed services and care, particularly for third site is philanthropically funded and situated within a local health department those with disabilities. The photo voice has a long and distinguished history of structure, faith-based clinic and health pictures and statement are posted on the health and social services. Part of the system, philanthropically supported walls of the student lounge area for all didactic requirement for this project is clinics, Veterans Administration hospital students and faculty to see. Students also to write a report reviewing the history, and two other hospital clinic settings complete a reflective essay regarding administration, fiscal structure, policy located in underserved communities, a their experiences. In the essay they are issues, and clinical service model of clinic for developmentally disabled asked to respond to any, or all, of the these sites. In that way the students patients, mobile clinic services, and a following questions: will have an opportunity to better under- dental service within a closed-panel • How did you change as a result of stand various health service systems. union-operated health center. these experiences? From a training and education Quality assurance measures are • What did you learn about: other perspective, there are many other benefits verified as a component of a site assess- people, cultures, value systems, com- that have been noted as a result of the ment process. The intent is to ensure munities, social customs, or beliefs ECE course and the experiences derived that quality standards are acceptable at relating to health (in effect, the from the community-based service- all rotation sites, but there is no attempt sociocultural dimension of health)? learning rotations. As examples, students to standardize sites to the exact specifica- • What did you learn about the tion of dental school procedures and health sector? methods. In fact, the range of difference • What did you learn about oral that the sites afford in terms of practice health’s intersection with general settings, procedures, organization of the health and well-being? This current academic year the UIC College of Dentistry, with assistance of grant funding from the Illinois

45 Journal of the American College of Dentists Schools’ Role in Access

are eager and excited about the rotations. the community. In such settings, not all Dental students upon graduation have patients can be accommodated, despite been recruited or otherwise found entry dedicated efforts to do so. All dental level service positions within the health schools face the challenge of people systems through which they have seeking care whose oral health conditions rotated during the ECE course. Students do not fit well with the teaching objectives gain heightened confidence as a result for students. In such instances, dental of being student doctors in these schools may need to point out their own community settings and providing care frailties regarding access to care to avoid outside the college. Upon returning to representing an unintended paradox. the school from rotations, D4 students Dental schools are teaching and are more productive in terms of levels of offering experiences that address access services provided. The ECE course also to care issues. In part this is in response provides unique motivation for student to the growing problem and the need for The number of designated development. Clinical faculty members dentists to be more aware of these issues Health Professional determine students’ preparedness for the and their options to contribute to their ECE course as the knowledge and skills amelioration. There is no expectation Shortage Areas has of the students develops and matures. As that any single dentist would be in a increased in recent years a result, the initial students reaching this position to resolve these issues; but it is level of competency are the first to enter not unreasonable to think that sufficient due to issues of access the course and to participate in the rota- numbers of dentists, each addressing to care. tions. The next group follows and so on. some piece of the problem, could The accomplishment and status of being profoundly improve opportunities for determined ready for the course is a access to oral health care and services. distinction among students and there is I clear drive among them, now perceptible as early as the D2 year, to be in the first group or at least early the rotations. Despite the best efforts of dental schools there is a disturbing and perhaps unavoidable problem that many schools encounter that compromises their ability to model ideal practices relating to access to care in their daily operations. These schools may be located in urban or other settings where they serve as major safety net providers due to the lack of availability of care elsewhere in

2008 Volume 75, Number 4 Issues in Dental Ethics

Issues The Intersection of Dental Ethics and Law in Dental Ethics

American Society for Dental Ethics David J. Owsiany, JD he Ohio Dental Association (ODA) has a hot line its member dentists call to discuss dental practice issues Abstract T with ODA staff members who have Associate Editors Dentists are regularly confronted with expertise in, among other areas, law situations that involve interrelated James T. Rule, DDS, MS and dental ethics. Currently, the ODA’s David T. Ozar, PhD ethical, risk management, and legal and regulatory compliance issues. This staff includes two full-time attorneys and Editorial Board article discusses six of the most common a full-time dental services director. Muriel J. Bebeau, PhD such situations where dentists must Together, they have nearly 40 years of Phyllis L. Beemsterboer, RDH, EdD sort out various ethical and legal issues. experience in dealing with dental prac- Larry Jenson, DDS Sometimes taking steps to minimize tice issues. In addition, the staff works exposure to liability or comply with Anne Koerber, DDS, PhD closely with ODA council and committee legal and regulatory mandates is also Donald E. Patthoff, Jr., DDS members who provide regular guidance Bruce N. Peltier, PhD, MBA consistent with applicable ethical Jos V. M. Welie, MMedS, JD, PhD standards. At other times, however, in specific cases. When necessary, the Gary H. Westerman, DDS, MS in order to meet the highest ethical ODA staff also consults faculty members Gerald R. Winslow, PhD standards, dentists must go beyond mere at The Ohio State University College Pamela Zarkowski, RDH, JD legal compliance and risk management. of Dentistry and the Case School of By acting in accordance with the highest Dental Medicine. The ODA’s most recent ethical standards, dentists ensure they Correspondence relating to the membership survey shows that members Issues in Dental Ethics section of the are protecting not just their own interests Journal of the American College of but their patients’ interests as well. rate the provision of dental practice Dentists should be addressed to: information as one of the ODA’s most James Rule valuable services. 8842 High Banks Drive Member dentists’ questions often Easton, MD 21601 Mr. Owsiany has been the Executive Director of involve ethical considerations, risk [email protected] the Ohio Dental Association management, and regulatory and legal since 2002 and served as compliance. Many times, the issues the ODA’s director of legal and legislative services dentists wrestle with include interrelated from 1994 to 1999; ethical and legal considerations. The [email protected]. “right” answer from an ethical perspec- This article is intended to be informational only and tive is often also the prudent approach should not be construed as to minimize exposure to liability or to legal advice. Dentists should ensure compliance with applicable state always seek the advice of their own attorneys regarding and federal laws. At other times, however, specific circumstances. a dentist’s ethical duty requires more than just minimizing legal risk or merely complying with the law.

47 Journal of the American College of Dentists Issues in Dental Ethics

Following the law or minimizing Ethical considerations must be aware of the laws and ethical legal risks may help protect the dentist Dentists must avoid acting in a discrimi- guidelines that govern discrimination from civil liability or administrative natory manner when selecting patients and must avoid acting in violation of discipline by a state dental licensing for their practices. Dentists should avoid those laws and guidelines. board. By going further and following “abandoning” patients when terminating Once a dentist-patient relationship the highest ethical standards, the dentist the dentist-patient relationship by pro- is established, however, the dentist’s will do more than just protect his or her viding the patient adequate notice and obligations change, and a duty may own interests. In most cases, the den- an opportunity to secure the services of exist beyond the traditionally protected tist’s commitment to following ethical another dentist. classifications based on race, creed, standards will also ensure the patient’s color, sex, and national origin. In interests are protected and, in the Discussion terminating an existing relationship process, may enhance the dental There is a difference between refusing to with a patient, the dentist must avoid profession’s reputation and image. treat new patients and terminating an “abandoning” the patient. In defining This paper is based upon representa- existing patient relationship. Generally, “patient abandonment,” the ADA Code tive issues raised by callers on the ODA dentists are free to accept new patients states, “Once a dentist has undertaken a hot line and the experiences of the into their practices as they see fit. course of treatment, the dentist should ODA staff in responding to them. Where However, there are exceptions to this not discontinue that treatment without possible, examples from our callers are general rule. The “Obligation to Treat giving the patient adequate notice and used, as are “real life” answers from Patients” section of the American College the opportunity to obtain the services of ODA staff. Below is a discussion of six of of Dentists ACD Ethics Handbook another dentist” (ADA Code, Sec. 2.F.). the issues about which ODA members for Dentists states that dentists should The concept of “abandonment” may also regularly inquire. “avoid actions that could be interpreted be the basis of a civil lawsuit if the dentist as discriminatory” and advises that does not exercise care in terminating the Obligation to Treat Patients dentists “must be aware of laws and dentist-patient relationship. Liability for The Issue regulations that govern discrimination” patient abandonment can arise when Oftentimes, dentists call to inquire about (ACD Ethics Handbook). Similarly, the the dentist does not give adequate notice accepting new patients and especially American Dental Association Principles of termination and the refusal to treat about their obligations to continue to of Ethics and Code of Professional causes injury to the patient. treat patients who are already in their Conduct mandates that dentists avoid The best way to avoid a claim of practices. Dentists describe scenarios refusing to treat a patient based solely abandonment is to avoid terminating where the patient is in the middle of a on his or her race, creed, color, sex, or the dentist-patient relationship during somewhat complex multi-appointment national origin (ADA Code, Sec. 4.A.). the course of treatment. If the relation- treatment plan, but difficulties have Of course, state and federal laws provide ship must be terminated prior to the arisen because of the patient’s behavior. heightened protection for people in completion of treatment, the dentist In some cases, the patient is behind in these protected classes as well. (See should discuss the problem with payment, regularly misses appointments, Ohio Revised Code, Sec. 4112.02.) the patient, offer to assist in finding the or refuses to follow the dentist’s recom- Similarly, pursuant to the Americans patient a new dentist, and obtain the mended oral care instructions between with Disabilities Act, a dentist should not patient’s consent to end the relationship, appointments. Dentists want to know refuse to treat a patient because he or if possible. Even if the patient is behind what their legal and ethical obligations she has a disability (42 United States in payment or otherwise uncooperative, are to these patients. Code, Sec. 12101). For example, a dentist the dentist must make every attempt to should not refuse to treat a patient solely ensure the patient’s oral health is in a because the patient is HIV positive or has stable condition before terminating the been diagnosed with AIDS (Bragdon v. dentist-patient relationship. It may be Abbott, 524 U.S. 624, 1998). In general, necessary to see the treatment plan when accepting new patients, dentists through to its completion in order to fully satisfy the dentist’s ethical obligations to the patient before terminating the dentist-patient relationship. 48

2008 Volume 75, Number 4 Issues in Dental Ethics

If the dentist does act to end the Ethics Handbook recognize the impor- relationship, he or she should document tance of safeguarding the confidentiality each step in writing. The best practice of patient records (ADA Code, Sec. 1.B.; may be to send the termination letter via ACD Ethics Handbook). In addition, certified mail so that the dentist can doc- most states have laws providing that ument termination and the date notice communications between a dentist was provided. Because both dental ethics and a patient are privileged (i.e., confi- and the law generally favor the patient dential). (See Ohio Revised Code, Sec. having adequate notice and opportunity 2317.02.) Privileged communications to secure a new dentist, a dentist’s duty may include, among other things, dental to the patient does not necessarily end records, charts, diagnosis, and lab with the sending of the termination results. Dentists should take steps to While dentists enjoy letter. If a dental emergency arises before limit accessibility to the health informa- the same legal rights of the patient has a reasonable time to tion included in patient records. For establish a relationship with a new example, dentists should have specific free speech as others, dentist, the terminating dentist may have policies prohibiting staff discussion of a an obligation to provide emergency care. patient’s oral health issues in front of they also have the ethical other patients. And dentists should obligation to maintain Patient Records avoid placing patients’ health status The Issue information on the outside of the professionalism in Dentists are often confused about how physical patient record where other their communications to handle issues related to patient patients might see it. records. Dentists seem to understand Dentists, who use electronic with patients. that patient records are confidential but transactions, including electronic claims do not always take the steps necessary submissions to third-party payers, may to ensure such confidentiality. Many also have a duty to protect patients’ dentists believe that the records belong health information under the Health to them and do not fully appreciate their Insurance Portability and Accountability obligation to make relevant records Act (HIPAA) Privacy and Security available to patients or patient represen- Regulations (45 Code of Federal tatives. On occasion, dentists will inquire Regulations, Parts 160, 162, & 164). if they can make the provision of records The confidentiality of the patient’s conditional upon the patient paying record is a privilege that belongs to the an unpaid bill. patient and may only be waived by express consent of the patient. Generally, Ethical considerations a dentist should not provide patient Dentists should protect the confidentiality records to a third party absent a signed of patient records. Upon request of the written release from the patient, the patient, a dentist should provide copies patient’s legal representative, a court of dental records to the patient or another order, or other mandate under law. dentist designated by the patient, in Patient releases or court orders to testify accordance with applicable laws. or release documents should be included in the patient’s file in order to protect Discussion the dentist from future claims of breach Both the “Patient Records” section of of confidentiality. the ADA Code of Ethics and the “Confidentiality” section of the ACD

49 Journal of the American College of Dentists Issues in Dental Ethics

Generally, a patient waives the Duty to Report Child Abuse dentist-patient privilege when he or she The Issue directs a claim to be submitted to Occasionally, dentists report stories Medicaid, an insurance company, or about minor patients who have suspi- other third-party payer. Accordingly, the cious bruises or other injuries around dentist may provide copies of patient the face, head, or neck. Parents or records to third-party payers regarding guardians sometimes offer reasons for services submitted for coverage. the injuries that raise suspicions of In many states, while a dentist may abuse. While they are genuinely con- technically “own” the original patient cerned about the safety of their minor records, the patient still has an absolute patients, some dentists may be reluctant right to a copy of his or her records. In many jurisdictions, to “get involved” because they feel When possible, depending on applicable their suspicions of abuse might prove court rules or codes of state laws, dentists should provide copies to be unfounded. professional conduct of the record and retain the originals because original records are generally Ethical considerations for lawyers prohibit the best defense in the event of a mal- Dentists should understand how to practice lawsuit or state dental board contingency fee detect child abuse. Dentists should report disciplinary action. In most states, the good faith suspicions or actual knowl- arrangements for expert dentist may charge a reasonable, edge of abuse of a minor patient to the cost-based fee for copying records. Some testimony…such appropriate authorities. states specifically define in statute or arrangements create rule how much health care providers Discussion may charge for copies (See Ohio undue financial incentives A significant percentage of child abuse Revised Code, Sec. 3701.741). injuries involve the head, neck, and for biased testimony in In general, both the courts and mouth areas. Accordingly, dentists are dental ethics favor patients having favor of the hiring party. sometimes confronted with the situation access to the information included in where they suspect that one of their their health care records. Even if the minor patients is being abused. The dentist-patient relationship has broken “Abuse and Neglect” section of the ADA down, the dentist must still make the Code of Ethics and the “Child Abuse” records available so the patient can get section of the ACD Ethics Handbook subsequent dental treatment. An recognize that dentists are in a position advisory opinion related to the “Patient to detect abuse and have an ethical Records” section of the ADA Code of obligation to be familiar with the signs Ethics provides that the fact that a of abuse and report suspicions of abuse patient has not paid for services per- to appropriate authorities (ADA Code, formed by the dentist is not sufficient Sec. 3.E.; ACD Ethics Handbook). reason for withholding a copy of the Furthermore, many states have laws records. (ADA Code, Sec. 1.B.1.) that place an obligation on dentists and Accordingly, a dentist must not hold other health care providers, who are patient records hostage as a means of working in their professional capacity attempting to secure payment for an and come to know or suspect a child has unpaid bill. been abused, to immediately file a report with the appropriate government agency. (See Ohio Revised Code, Sec. 2151.421.) In most cases, confirmed knowledge of abuse is not required before filing a 50

2008 Volume 75, Number 4 Issues in Dental Ethics report. A dentist’s duty to report arises Ethical considerations commenced. By making a call to the when he or she has a reasonable suspi- Dentists should inform new patients of previous dentist in addition to reviewing cion that abuse has occurred. The intent their current oral health status without the patient’s records, the dentist was of these laws is to encourage health care unjustified disparaging comments about able gain a complete understanding of professionals, including dentists, to prior services. When providing expert the patient’s situation, including the fact report suspicious signs of child abuse. In testimony, dentists should provide their that he chose a plan different from the many states, a dentist who makes a good honest, objective opinions, free from one recommended for him. faith report of suspected child abuse is any financial influences that could lead In the situation where the patient immune from civil or criminal liability to bias. and the dentist have significant concerns which might otherwise arise as a result about prior dental treatment, the dentist of filing the report. (See Ohio Revised Discussion may suggest that the patient contact the Code, Sec. 2151.421.) Accordingly, dentists While dentists enjoy the same legal state or local dental society’s peer review should not be reluctant to make a report rights of free speech as others, they also process, which is designed to resolve for fear of liability should their suspicions have the ethical obligation to maintain dentist-patient treatment issues outside eventually fail to be confirmed. Ultimately, professionalism in their communications of the traditional court system. The ADA state laws and dental ethics recognize with patients. Accordingly, dentists advisory opinion makes clear, however, dentists are in position to detect abuse ought to exercise care when discussing that a “difference of opinion as to and place a corresponding obligation on prior treatment with their patients. preferred treatment should not be dentists to act on any suspicion of abuse The ADA Code of Ethics provides that communicated to the patient in a they gain through their treatment of “Patients should be informed of their manner which would unjustly imply minor patients. present oral health status without mistreatment” (ADA Code, Sec. 4.C.1.) Dentists have a respected and valued disparaging comment about prior In the end, the dentist’s main goal position in society because of their services” (ADA Code, Sec. 4.C). should be to explain to the patient his compassion and commitment to their The advisory opinion related to the or her current oral health status and patients. By educating themselves on “Justifiable Criticism” section of the ADA develop a treatment plan to get the how to recognize signs of abuse and Code of Ethics states that “Patients are patient on a path to improved oral understand what to do when such signs dependent on the expertise of dentists to health. Unjustified criticism of prior are present, dentists are not only fulfilling know their oral health status” (ADA treatment does nothing to advance the their legal and ethical obligations, they Code, Sec. 4.C.1). Because dentists are patient’s oral health. are also protecting those in our society in this position of trust, they should Occasionally, a patient’s dissatisfac- who can least protect themselves. exercise care to ensure their comments tion with treatment may lead to are “truthful, informed, and justifiable” litigation or the filing of a complaint Unjust Criticism and Expert (ADA Code, Sec. 4.C.1). In some instances, with the state dental licensing board. Testimony it may be appropriate for a dentist to Dentists often have the opportunity to The Issue consult with the prior dentist to determine testify as expert witnesses in such civil Dentists often inquire as to what they the circumstances and conditions sur- lawsuits or dental board disciplinary should do when patients come to their rounding the previous treatment. proceedings. In fact, the ADA Code of practices with concerns about prior For example, a dentist in Ohio had Ethics contemplates dentists testifying dental treatment. Specifically, they want concerns about whether a new patient’s “when that testimony is essential to to know what they can say to patients prior treatment plan was appropriate a just and fair disposition of a judicial about the treatment provided by previous and decided to call the patient’s former or administrative action” (ADA Code, dentists. Additionally, a growing number dentist. During their conversation, he Sec. 4.D). of dentists report being asked to testify learned that the previous dentist had However, it is considered unethical as expert witnesses in civil or adminis- recommended a treatment plan that the for a dentist to provide expert testimony trative actions. Many want to testify but patient rejected. Ultimately, the patient where his or her fee is contingent upon are unsure what their obligations are chose to pursue a different, less optimal, the favorable outcome of the litigation with respect to providing such testimony. treatment plan. The previous dentist explained the pros and cons of each approach and secured a signed informed consent document before treatment 51 Journal of the American College of Dentists Issues in Dental Ethics

or administrative proceeding (ADA Code, Discussion be entirely appropriate for a general den- Sec. 4.D.1). In fact, in many jurisdictions, In today’s competitive marketplace, tist to advertise that he or she provides court rules or codes of professional there has been a marked increase in the “cosmetic dental services.” Advertising conduct for lawyers prohibit contingency number of dentists who advertise via oneself as a “certified cosmetic dentist,” fee arrangements for expert testimony. print, broadcast, and electronic means. however, may be problematic if patients (See Ohio Supreme Court Rules of Ensuring such advertisements are might reasonably interpret such a claim Professional Conduct, Rule 3.4). The consistent with legal mandates and to indicate specialization. main objection is that such contingency professional ethics can present signifi- Because of the wide variety of arrangements create undue financial cant challenges. regulations related to the advertising of incentives for biased testimony in favor The regulation of advertising related credentials and specialty status, it is of the hiring party. to the announcement of available services important that dentists are fully aware When giving expert testimony, and professional dental credentials of their own state’s specific advertising dentists should provide their opinions varies greatly from state to state. For regulations as well as the guidelines in an honest, objective manner, based example, many states expressly allow contained in the ADA Code of Ethics. on the information before them. They announcement of credentials in specialty Underlying the specialty advertising should also be willing to acknowledge areas recognized by the ADA. (See Ohio rules is the principle that professional any limitations on their ability to Administrative Code, Sec. 4715-5-04 & advertising should be truthful and speak definitively regarding the issues Sec. 4715-13-05.) Some states require a should help members of the public make under scrutiny. state-issued specialty license in order to informed decisions related to the care The role of the expert is to assist the advertise as a specialist. (See South they seek. Accordingly, the ADA Code fact-finding body—whether a jury, judge, Carolina Code of Laws, Sec. 40-15-220). of Ethics, ACD Ethics Handbook, and or administrative agency—by providing When announcing available services, many states forbid any dental advertising objective, scientific testimony. Doing some states require general dentists to that is false or misleading. Establishing anything other than that when providing disclose that they are general dentists in what is false and misleading, however, expert testimony is not only unfair to their advertisements. (See Texas can be tricky. Both the ADA Code of the parties but is detrimental to the Administrative Code, Title 22, Part 5, Ethics and the “Advertising” section of administration of justice. Section 108.54.) Additionally, when the ACD Ethics Handbook provide announcing credentials in an area not specific examples of things to avoid in Advertising recognized as a specialty by the ADA, order to protect against false and mis- The Issue some states require dentists to specifically leading advertisements. For example, The amount of advertising by dentists disclose that the practice area announced dentists should avoid advertisements has grown dramatically in recent years. is not a specialty recognized by the ADA. that: (a) contain material misrepresenta- Many dentists are unsure what they (See Texas Administrative Code, Title tions of facts, (b) create deception by can or cannot say when advertising 22, Part 5, Sec. 108.55.) The ADA Code of only partially disclosing relevant facts, their services and credentials. Others Ethics states that “Dentists who choose (c) create unjustified expectations of feel their colleagues go too far in to announce specialization should use favorable results, (d) represent or imply their advertisements. ‘specialist in’ or ‘practice limited to’ and that the services of a practitioner are shall limit their practice exclusively to superior to those of other dentists Ethical considerations the announced special area(s) of dental unless such representations can be Dentists who choose to advertise should practice, provided at the time of the reasonably verified by the public, or develop a full understanding of the announcement such dentists have met (e) misrepresent fees for dental services advertising regulations in their state. in each approved specialty for which (ADA Code, Sec. 5.F.2. and Sec. 5.B.; Dentists must avoid placing advertise- they announce the existing education ACD Ethics Handbook). ments that are false and misleading. requirements and standards” set forth Dentists, like all professionals, have by the ADA (ADA Code, Sec. 5.H). protected commercial speech rights Dentists are generally entitled to when it comes to advertising. Courts, announce the services they provide and, however, also recognize that states and in fact, such information may be useful professional associations have the ability, for patients in finding a dentist right for 52 them. Accordingly, for example, it may

2008 Volume 75, Number 4 Issues in Dental Ethics and some would argue the responsibility, Delegable Duties and Supervision to protect the public from false and of Staff misleading advertising, especially The Issue considering the disparity of information State laws and regulations are changing and knowledge related to dentistry with rapidity regarding permissible between dentists and the public. delegable duties and supervision of staff. Some commentators believe that the Many of these changes create flexibility prevalence of dental advertising may in the office by permitting additional have a negative impact on the public’s delegation that results in greater office perception of dentists. They suggest that efficiency or may even permit, under ads implying that some dentists are certain circumstances, a dental hygienist superior necessarily imply that other Ads that focus on cosmetic to work on a patient when the dentist dentists are inferior. Ads that focus on is not physically present in the office. and elective services cosmetic and elective services may lead Dentists often have questions regarding the public to view dentists as “oral cos- may lead the public to staffing when they learn of changes in metologists,” thereby undermining their the law or regulations in this area. They long-standing reputation as dedicated view dentists as “oral may be considering adding a dental healthcare professionals committed to assistant to take advantage of additional cosmetologists,” thereby promoting patients’ oral health care. delegation of duties or a dental hygienist And the burgeoning number of ads may undermining their in order to keep the office open longer give the overall impression that dentists for hygiene services even when the long-standing reputation are more concerned with the commer- dentist is away. cial aspects of dentistry than delivering as professionals committed quality oral health care services. Ethical considerations to promoting patients’ Invariably, the regulation of profes- Dentists should know, and comply with, sional advertising involves subjective oral health care. the laws in their own states regarding determinations as to what rises to the delegation of duties to, and supervision level of false and misleading. Because of, dental assistants, hygienists, and such subjective decisions can be difficult other staff members. A dentist should and tend to raise significant legal consider the impact on the quality of questions, enforcement of advertising patient care when determining whether laws, rules, and professional guidelines to delegate a task to, or permit relaxed vary from state to state. Regardless of the supervision of, a dental staff member, level of enforcement activity, however, regardless of what the law permits. the dental profession’s long-term reputation depends on each dentist’s Discussion willingness to act ethically and profes- While dental staff members play an sionally when developing and placing important role in assisting in providing advertisements. The “Advertising” care to patients, the delegation of duties section of the ACD Ethics Handbook in the dental office is another area that reminds dentists that the “best presents interrelated issues of law and advertising is always word-of-mouth ethics. Both the “Use of Auxiliary recommendations by satisfied patients” Personnel” section of the ADA Code of (ACD Ethics Handbook). Ethics and “Delegation of Duties” section of the ACD Ethics Handbook provide that dentists may only delegate duties to dental hygienists, dental assistants, and

53 Journal of the American College of Dentists Issues in Dental Ethics

others that are consistent with applicable actions are also consistent with legal laws and regulations, which vary from mandates and may help to limit dentists’ state to state (ADA Code, Sec. 2.C.; ACD exposure to civil liability. Ethics Handbook). The ADA Code of In other cases, however, merely Ethics also mandates that “Dentists complying with the law or acting to shall be further obliged to prescribe and limit potential liability is not enough. supervise the patient care provided by Being an ethical professional sometimes all auxiliary personnel working under requires a dentist to accept additional their direction” (ADA Code, Sec. 2.C). obligations beyond what is required by Accordingly, it is important for a dentist the law. As discussed above, despite a to know his or her own state’s laws and dentist’s right to engage in free speech Talking to an attorney, regulations on the delegation of specific like anyone else in society, professional however, may not be duties (coronal polishing, administration ethics requires dentists to respect their of nitrous oxide and local anesthesia, patients, colleagues, and the dental enough. Dentists should scaling, etc.) and the corresponding profession generally, by avoiding making also take steps to required level of dentist supervision for unjust criticism of prior treatment. specific dental staff members. Similarly, regardless of the likelihood of understand their ethical Dentists should also remember that legal jeopardy, dentists should avoid obligations in such in the context of delegable duties and placing advertisements that may mislead supervision, there is an ethical responsi- the public or potentially depict the den- situations. bility to maintain the quality of patient tal profession in a negative light. Finally, care. The ACD Ethics Handbook notes dentists should not delegate duties to that in addition to determining the staff members merely because the law legality of delegating a specific task to a permits them to do so. Dentists also particular staff member, the dentist have the ethical obligation to ensure should ask him or herself whether the that the delegation of a specific duty to quality of care for the patient will be a particular staff person can be done in maintained (ACD Ethics Handbook). a manner that does not jeopardize the Just because the law permits delegation quality of patient care. of a duty or relaxation of supervision The issues discussed above are just does not relieve the dentist of his or her a few examples of the many situations ethical duty to ensure the provision of where dentists must confront their quality dental care. ethical and legal obligations together. In such cases, it is important for dentists Conclusion to consult legal counsel to get advice The issues discussed in this essay related to their specific situations and demonstrate the interconnectivity of gain a full understanding of the underly- dental ethics and legal issues. In many ing legal issues. Talking to an attorney, cases, complying with the law and tak- however, may not be enough. Dentists ing steps to limit exposure to liability should also take steps to understand will also be consistent with the dental their ethical obligations in such situations. profession’s principles of ethics. For Following the law and limiting exposure example, acting to protect the confiden- to liability are important considerations. tiality of patient records, taking steps to The ethical practice of dentistry, however, avoid patient abandonment, and report- sometimes requires more. I ing child abuse are all actions that are consistent with the ethical tenants of the dental profession. As shown above, such

2008 Volume 75, Number 4 Leadership

Practice

David W. Chambers, EdM, MBA, ractice has the unfortunate Individuals in a practice may come and PhD, FACD connotation of boring drill required go, and that usually does affect the tone Pbecause one is not good enough of the practice because the practice Abstract yet. There are some lame jokes about supersedes its specific members. The Practice refers to a characteristic way dentists practicing all their lives because U.S. Supreme Court is an example of a professionals use common standards to they have not quite mastered their skills practice with continuity despite changing customize solutions to a range of and offices that are called practices membership. The ADA and dental schools problems. Practice includes (a) standards because they run repetitive routines. are too big to be practices, although they for outcomes and processes that are shared with one’s colleagues, (b) a rich This essay presents an alternative view, contain many work groups that are. repertoire of skills grounded in diagnostic arguing that practice is a distinguishing Customized Problem Solving Practice acumen, (c) an ability to see the actual characteristic of dentistry when done at involves a balance between the routine and the ideal and work back and forth its very best. Saying that a dentist is a and the unique. Assembly-line workers between them, (d) functional artistry, and practitioner is saying something defining (e) learning by doing that transcends are not usually regarded as practicing and special. scientific rationality. Communities of because they do the same thing over practice, such as dental offices, are small The term practice can be used to and over again. Artists and pure research groups that work together in interlocking describe either a group working together scientists are also not good examples of roles to achieve these ends. in a certain way or to the work itself. So practitioners because their work is so hygienists and assistants practice as part individualized and creative. Dentistry of a dental practice. A practice in either exemplifies the required balance of sense is a specific pattern of work, usually customizing standard procedures to the centered on professional expertise and needs of individual patients. Although often performed by a small group work- there are common features in some ing in close collaboration. It is not the crowns, each seems to present unique only way to get things done, but it is one challenges. There are office rules about of the most common and effective, and patient flow; but there are also some there is a good deal known about what patients who require special handling. makes practices good. Practices are characterized by mastery Practice has these three characteristics: of a repertoire of skills, applied through Small, Interdependent Groups Practices judgment to solve general types of involve a few people performing coordi- customized problems. nated roles on a sustained basis. Almost Personal and Professional Practices are all dental offices are practices; so are intensely personal and at the same time law offices, police departments in small they conform to industry or professional towns, and rock bands. Members of a standards. Practices make up many of practice know each other personally, and their own rules; that is what gives them they make adjustments for individual their individual character. NASCAR pit styles. The group as a whole has a collective wisdom, a core of tacit knowledge that exceeds what can be told or what is known by the members individually. 55 Journal of the American College of Dentists Leadership

crews have their own language, dress, are not universal or uniform, but they with rules for every patient phone work habits, unforgivable sins, and do exist and they are significant conversation (just turn to the correct favorite foods. This is part of the custom- enough to be part of the definition of page), instrument management, billing, izing to both the individuality of the professional practice. recall, and personnel policy. There are members and the circumstances in which It is obvious that there are knowledge plenty of flow charts, some of them they work. The members and the work and skill standards, as well as procedural terminating in a master node labeled patterns in a cosmetically-oriented routines that are exchanged across “Ask Doctor.” Because of Dr. Kingsmiller’s Beverley Hills dental practice, a small-town practices. But when I listen to dentists bragging on it, Francis’s office manual family practice in Oxford, Mississippi, and staff members, I also hear language has been shared with many colleagues; and a community clinic in Miami could that could only be described as artistic. and although much admired, it has not be effectively interchanged. Dentists admire the beauty of each others’ never been incorporated, even in part, But despite these differences, there work; and front desk staff are likely to in any other office. is a core way of doing things that can be describe an effective scheduling or recall The hygienists, Anne and Pamela, recognized in all practices. In dentistry system as “elegant.” Perhaps, we should are a study in contrasts. Both are techni- there are internalized ideals for quality understand EBD to mean ethics-based cally proficient, efficient, long-term restorative results, infection control, ethical dentistry or esthetics-based dentistry. employees. The office has a slight treatment of patients, insurance billing preference for Pamela, appreciating her practices, and so forth that transcend Practitioners business-like demeanor, incredible local circumstances. For the most part, Here is a description of an imaginary exactness on appointment times, and these ideals are informal and voluntary. dental office. See if you can pick out the perfect chart notes. Anne is the favorite OSHA and reimbursement guidelines characteristics that constitute practice of the patients. She treats everyone as exist, but their interpretation is some- and those that do not. an individual. Her motto is “01110 is an what flexible. Whole practices attend Dr. Kingsmiller’s office is in suburban insurance billing code, not the name local, state, and district meetings to com- Maryland and has been providing family of a health service.” Some of Anne’s pare notes on inter-practice standards. care since the dentist graduated from appointments are long on engaging There are two species of standards dental school two decades ago. The the patient in self-diagnosis, some are that appear to play a unique role in practice is stable, with many loyal rigorous calculus search-and-destroy harmonizing practices—especially in the patients. There are two hygienists, an missions, sometimes there is a lot of case of dentistry. There are important office manager, a chairside assistant, joking, some run over time. standards having to do with ethics and a part-time general assistant. The Dr. Kingsmiller prides himself on his and with beauty. Practice acts and reim- profile of procedures is traditional, and professional standards. He is careful to bursement contracts define minimal the office is well supported by nearby avoid questionable techniques. “I want performance requirements across specialty practices. The office is open to be in complete control of the dentistry practices. But they are inadequate to four days per week. I offer my patients.” Many of these explain the degree of uniformity in the Francis, the office manager has been patients have been in the practice for way dentistry is performed from practice with Dr. Kingsmiller for fifteen years. years and the dentist knows which are to practice. Across a wide range of She is tireless, dedicated, thorough, and interested in function and which orient situations, dentists and members of their “the most organized individual in the toward esthetic considerations. The use teams make very similar individual world.” Dr. Kingsmiller jokes that of composite is largely influenced by choices about what is best for their “Francis showed up at the perfect time in patient preferences. His treatment plans patients. This ethic of care can only be my career. When first out of school, I are comprehensive and thoughtfully explained by assuming that part of what was preoccupied with getting my speed presented. He has served several tours it means to practice is to internalize a up and making my loan payments. on the competent society peer review common professionalism. Such standards Francis took charge of the office and I panel and has seen enough questionable haven’t had to give it a second thought dentistry to make him concerned over since.” Within six months Francis had the future of the profession. developed an office manual, detailing Dr. Kingsmiller is also a technical every aspect of the office routine. wizard. He is happy about the speed he Through constant revision, the manual 56 is now more than 300 pages in length,

2008 Volume 75, Number 4 Leadership developed in the formative years of his There are dangers in idiosyncratic practice. He has mastered his craft so standards, seeing every case as either well that he usually skips intermediate routine or unique, restricting one’s skill steps such as study models. “I do essential set unnecessarily, or undervaluing the dental procedures better than most artistic ideal and learning by doing. dentists and I avoid the experimental ones. The basics have not changes in Professional Standards dentistry, and every dentist owes it to his The outstanding example of practice in patients to have these perfectly under this case is Dr. Kingsmiller’s reliance on control. I know exactly how things are professional standards. He has a value- going to turn out before I begin, or I driven practice, and his colleagues don’t pick up the handpiece.” would embrace most of his ideals. Many Arguably, the single Dr. Kingsmiller also prides himself of the problems he faces each day may on knowing the scientific foundation of be unique, but the overarching goal is greatest determinant of dentistry. He usually has twice the not in question. Contrast that with the quality of dental care number of CE hours required for dentist who lets the conflicting interests relicensure and is a regular reader of of making money or making a name is ethical standards. the literature. Recently he took a course creep into practice decisions; the time- on evidence-based dentistry, and he is serving associate or salaried dentist suspicious of dentists who place credence in a “mill”; or even the unavoidably in their own experience. For the most conflicted motives of dental students. part, he has stayed away from expensive Arguably, the single greatest equipment that would require a change determinant of quality dental care is in office routine, such as digital radiog- ethical standards. Technical skill and raphy or implants. But he can be a bit knowledge are necessary, and they are annoying to his colleagues when he usually ensured through education. quotes the shear strength in MagaPascals Consider two dentists: one has high of the various bonding materials he uses standards and low skill and knowledge and does not use. His friends kid him, levels; the other has high skill and saying that he knows as much about the knowledge levels but low ethical standards. technical properties of dental materials Both are a danger to patients and an as the industry reps, or even as much embarrassment to the profession. But as faculty members in dental schools. the dentist who knows he or she could Dr. Kingsmiller is fond of chiding his do better will eventually correct the colleagues in return that dentistry is shortcomings. There are ample CE unambiguous, precise, and lawful. courses, conscientious self-improvement Being realistic, this is a mixed case. opportunities, and helpful colleagues to There are examples in Dr. Kingsmiller’s make this happen. The dentist with low office of exemplary practice and there standards will never exceed them, will are instances that run counter to make excuses for poor work, and may practice. Some parts of the case can be even use his or her natural talents to profitably debated to bring out a clearer more effectively and profitably cut idea of the concept of practice. None of corners. There are some critical things this should be taken as detracting from the effectiveness of the dentist or the office. Everything that dentists do well is not necessarily an example of practice, but dentistry loses something when it is not deeply grounded in practice. 57 Journal of the American College of Dentists Leadership

Principal Characteristics of Communities of Practice, in dentistry that are learnable through billable procedures instead of patient Such as Dental Offices practice but not teachable—at least not in needs for long-term care. Much of dental journals and CE courses. advertising can be seen as lobbying the As a rule, practitioners are uncom- profession for legitimacy of procedure- Sustained mutual relationships fortable regarding advertising. In the based practice. Shared ways of engaging in doing first place, the office of the Secretary things together of the United Nations; the Mormon Skill Repertoire Rapid flow of information and Tabernacle Choir; and the best of It is admirable that Dr. Kingsmiller is propagation of innovation architects, physicians, lawyers, and a technical wiz, but his patients are dentists—all examples of practices—do probably unfazed by the fact that he can Absence of introductory preambles (as if conversations were merely not do it. Large commercial interests and cut a crown prep ten minutes faster than continuation of ongoing process) policy causes—which are not practices— his colleagues or cure a composite ten do it. Those dentists who do advertise seconds faster. The essence of practice is Very quick setup of problems for discussion are likely to outsource the details of this having a larger and more appropriate function. Dentists who are the customers repertoire of skills to draw on as needed Substantial overlap in participants’ of advertising firms purchase ads rather rather than being good and fast at a descriptions of who belongs than create them. small range of procedures. Standardizing Knowing what others know, what There are two corrosive effects of on procedures rather than on patient they can do, and how they contribute advertising in dentistry. One is the outcomes is what makes mass-produced Mutually defining identities competitive tension it creates within assembly line productivity in off-shore Ability to assess appropriateness of the profession. Friedman and others countries so wonderful. By contrast, actions and outcomes showed in a Journal of Dental Practice practice raises diagnosis to a higher level Specific tools, representations, and Administration article in 1988 that than procedures, and the mark of a other artifacts dental advertising seldom increases the better practitioner is one who can number of individuals seeking oral diagnose more problems and has the Local lore, shared stories, inside jokes, knowing laughter health care: mostly it transfers patients range of repertoire to solve them. from one practitioner to another and Dentists deal with ambiguity, insta- Jargon and shortcuts to in the process undermines the ideal of bility, and divergent aspirations—not communication continuous, comprehensive care. the “unambiguous, precise, and lawful” Certain style for recognizing and But there is another, and perhaps patterns Dr. Kingsmiller seems to find at displaying membership potentially more powerful, effect of dental work. Patients bring this sort of thing to Shared reflective discourse advertising. Consider the possibility that the office every day; so do the staff. The much of the advertising message might last truly ideal preparation done under actually be aimed at other dentists absolutely standardized circumstances instead of at patients. A quick look will most dentists have seen was in the be sufficient to confirm that much of the preclinical restorative dentistry lab in advertising is cosponsored by industry dental school. Now they see malposed or by institutes, academies, and others teeth, compromising adjacent teeth, advancing a particular flavor of dentistry. polyphamacy, reluctant or confused These advertisements can be seen as patients, a schedule that has not yet arguments for the credibility of certain seated the 11:00 a.m. patient by 11:45 kinds of practice, usually ones that a.m., and a staff member who has involves financial investment in unwittingly encouraged the patient’s equipment or specialized procedures. unrealistic expectations. Dentists long for Such ads place value on high-margin and strive for control and predictability. But this is not because that is the ultimate nature of practice; it is a sign that unconscious progress is being made in addressing the customized diversity 58 inherent in practice. In the same way,

2008 Volume 75, Number 4 Leadership feeling hungry is a good sign when one policy of getting better and better at preclinical restorative dentistry course at is on a weight-loss program. fewer and fewer procedures is an the school grade them. All preparations There are two ways in which practi- understandable response to the growing were clinically acceptable and there tioners might function to help people diversity of oral healthcare needs and were no differences in quality across the with intrinsically complex problems. potential responses to them. It would three groups. One is to grow the range of diagnostic certainly be irresponsible for an One of the faculty members who and technical repertoire appropriate to individual dentist or the profession as participated in this study is my personal the challenges that arise in practice; a whole to place its reputation on the dentist. I do not go to him because he the other is to limit the practice to a line through dabbling in unproven cuts crowns faster or better than another comfortable range of services. The procedures or ones the dentist has not of the many other fine dentists in debate between these approaches has mastered. And dentists, generally, San Francisco. I go to him because he become central to the identity of the have responded by extensively and understands everything going on in my dental profession today. continuously retraining themselves. mouth, takes the long view regarding The very much increased complexity The question is, can dentistry continue my oral health, and comes up with of dentistry today is a function of as a practice or is it in danger of multiple approaches for the 65-year tremendous advances in product fragmentation along technique lines? history of strange things that have engineering, increased consumerism, Consistency of outcomes (despite happened to me, and he talks with me and the intrusion of multiple decision diversity of circumstances) is a good about them. Size matters: and I will makers (payers). (When the biological criterion for expertise. Speed is not. Some always go with the practitioner who has revolution hits offices the way the years ago, a colleague and I videotaped the biggest skill repertoire over the one engineering revolution of the past half individuals performing a Class II prepa- with a small repertoire who is looking century has, a whole new level of ration on Ivorine teeth in a mannequin. for patients to fit it. complexity will emerge.) There simply Some of the operators were students at are more choices now than there were the end of their preclinical training, Conversations with the Ideal in the dental office of 50 years ago. some were students just approaching There are two interpretations of “the Some of the responses the profession graduation, and some were faculty ideal,” and that can cause confusion. has made are encouraging. Continuing members. Students performed a three- In Olympic diving, circumstances are education is up, group practices and step procedure: outline form, parallel standardized and judges only need to referrals are increasing, and dental walls and flat cavosurface, and then determine which diver best performs the education has responded with a heavier refinement. Practitioners (faculty routine. In soccer, circumstances such emphasis on diagnosis and clinical members) performed a two-step produce as the opposing team’s personnel and problem solving. There are, however, to accomplish the same end: cut and strategy or even the weather vary responses that are more questionable. refine. My wife reviewed the tapes and considerably—but within a predictable Some consulting gurus have advocated almost perfectly identified each of the range. Excellence is determined by that dentists cherry-pick high-end operators by their skill level, despite the correctly identifying the relevant factors procedures and high-income patients. fact that she could not even see which and choosing and executing from The reason access has become an issue tooth was being prepared. Patients are among one’s repertoire of procedures may be as a consequence of successful pretty good at this sort of thing. those that are most appropriate, including market segmentation in the profession. Now for the surprises. By stopwatch, making adjustments as one goes. Dental When a fixed supply of service is increas- there was almost no difference among students are taught procedures that are ingly concentrated on one portion the three groups of operators in the ideal in school; practitioners learn of the patient pool, the other segments amount of time the bur was on the patient care that is ideal in practice. will suffer. tooth. Novices took much longer overall, At the level of the individual practice, but only in general management of the it matters how comprehensive the prac- case and not in the performance of the titioner chooses to be. Dr. Kingsmiller’s procedure. Practitioners get more efficient but not faster. Then, unbeknownst to me, my colleague collected and coded the teeth and had the staff in the 59 Journal of the American College of Dentists Leadership

Consider Francis—the gem of an would be concerned with making sure and responsive to needed adjustments. office manager. Dr. Kingsmiller is that patients make knowledgeable They approach the ideal outcome rather probably justified in his praise of her, decisions they will not regret in the than take their best shot at what might and in a curious way, she may make it future. (This is actually the dentist’s work generally. Recall the experiment easier for other members of the office responsibility.) Francis probably gets a with students and faculty members (especially the dentist) to practice; but sense of satisfaction out of a short and preparing Class II preps mentioned she is not a good example of a practitioner businesslike phone conversation with above. Another difference between the herself. She is a rule-monger. Her goal in new patients, where she checks off her beginners and the experts concerned professional life is to drive all variability list of vital facts. By contrast, a practitioner the role of evaluation. Experienced and judgment out of dentistry. If a would try to discover whether there is practitioners spend a larger proportion situation arises that is not covered in anything special about each patient. of their time evaluating their work— the office manual, she will invent a new There is also something troubling in they began evaluating earlier, and rule. That shows that she is not in charge: Dr. Kingsmiller’s boast that he does not they smoothly incorporated evaluation she is reacting in hopes of getting use study models and has chopped out with cutting. control and becoming in charge. We can intermediate steps in some procedures. guess that her trump rule, “Ask Doctor,” We can take him at his word without Functional Artistry is seldom invoked, unless she has a being impressed. This probably means Who is the artist and who is the manu- codependent boss. that as a dentist he has constricted the facturer: Anne or Pamela? It is not quite If you have ever played basketball, range of procedures offered to a small accurate to say that artists are folks who you know that a shooter never looks at number of routine and standardized come up with things no one could have the ball: he or she looks directly at the cases. If he knows exactly how things imagined before. Artists create within basket and is simultaneously aware of will turn out before beginning a piece norms. Even more, they draw out the anything unusual on the court generally. of work, he is only doing simple cases potential in their media rather than It matters what one pays attention to. and has cut himself off from learning. randomly generating novelty. They can Practitioners engage in a conversa- Practitioners use a rich collection of see the ideal in the actual, and they tion with reality, including recognizing professional vocabulary (that pictures work back and forth to get as close to both the particular and the general, both various steps and outcomes), models, the idea as possible. the given and the ideal. Patients do not chart notes, and other aids as both I have a feeling that we would get like to be treated as examples of rules. images of the ideal and aids to check different answers from Anne and No one ever built loyalty to the practice and guide intermediate progress. Pamela if we asked them to describe the by saying, “Because it’s policy.” Of Practitioners adapt. same patients. Pamela’s descriptions course, it would be chaos if everything Practitioners are also open to some would tend to be brief and uniform, with was considered without precedent and give and take with reality. They tend to some variation related to the difficulty as totally unique (as might have been value effectiveness over efficiency. On certain patients presented for getting the case when Dr. Kingsmiller first hired pressure days and when fatigued, they the procedure accomplished—“lots of Francis). But the distinction to be drawn may be willing to accept their first, calculus” or “tends to come late.” By is between pushing individual cases into best effort and then argue about poor contrast, Anne’s descriptions would rule boxes or pulling them toward ideal outcomes later. But at the top of their likely be fuller and more customized— types. Francis might consider informed games, practitioners engage in back- “really concerned about anterior consent to be a matter of getting signa- and-forth approximations to the ideal. aesthetics,” “never pays attention to tures on the right forms; a practitioner Crowns need try-ins, treatment plans anything I say,” or “she is the sweetest include alternatives, resistant Perio lady.” As a practitioner, Anne will also pockets are exposed to several treatments. more likely see the potential in each of And Francis would probably be well- her patients. She will set different goals served to offer patients several choices for each and take different approaches. for the next appointment rather than a She is capable of seeing the potential in single date and time. the actual, and resolving each discrepancy Practitioners are also skilled at verifying the outcomes of their efforts 60

2008 Volume 75, Number 4 Leadership is what will drive her work. She need rules apply in particular cases and how not start from scratch with each patient, these must be modified to best match and she will use her experience as a unique patient needs. They practice by practitioner to group patients into typical being consistent with the rules of groups. She will also attempt to engage science but not by the rules of science. her patients in visualizing potential Practitioners read more patients than ideal outcomes. journal articles. Often their recourse to the literature is motivated by a curiosity Learning by Doing about whether the procedures or The ADA is putting dues money to work materials are acceptable when they on evidence-based dentistry; so is the have already been chosen because of insurance industry. Critical thinking convenience, cost, patient characteristics, Practitioners read courses are the new PBL in dental or other reasons. education. Industry is disguising its ads Dentists learn by doing. This applies more patients than to look like journal articles. Dr. two ways. First, dentists learn from journal articles. Kingsmiller is proud of his efforts to experiences what they should add to place scientific foundations under his the repertoires of skills and where these practice. All of this is to the good, but it are effective. They come to understand is not part of practice. which patterns of practice match the I personally know the scientific cases they confront. Second, learning by literature of dentistry pretty well and I doing describes the way practitioners have taught critical thinking for a decade: execute procedures. It also applies to but that does not make me a very good the execution of procedures in process. dentist. The leading researcher on Dentists monitor their performance professional learning, Donald Schön, and modify work-in-progress to best puts it this way: “Universities have approximate the ideal. They reflect both assumed that academic research yields on practice and in practice, and to the useful professional knowledge and that extent that they are true practitioners, the professional knowledge taught in they make adjustments to approach the the schools prepares students for the ideal rather than persist with approaches demands of real-world practice. Both others say might work. assumptions are coming increasingly Donald Schön defines learning in into question.” The problem is that a practice, as distinct from learning in technical-rational approach to dentistry research, in these terms: “It is this is about the theory of dentistry and ensemble of problem framing, on-the- not about its practice. spot experimentation, detection of The best practitioners know the consequences and implications, ‘back scientific generalizations (averages under talk’ [feedback] and response to controlled conditions) and principles back talk, that constitutes a reflective (general properties of materials, tissue conversation with the materials of a response, and economics), but they also situation—the design-like artistry of make careful judgments as to which professional practice.” Four times in the past 25 years, the University of the Pacific has surveyed its recent graduates, those who are becoming practitioners. Over 150 dental procedures and professional activities

61 Journal of the American College of Dentists Leadership

such as engagement in organized it or such-and-such scientific principle belonging. Finally, communities of dentistry and volunteer service have was responsible. When practitioners practice establish unique identities by been rated for how often they are evaluate their work, at intermediate practicing together. Even without the performed and where the skills were steps or overall, they are checking to T-shirts and the talk about “our team,” learned (as well as why some are determine the validity of the moves a solid office can be recognized by avoided and delegated). Especially for they have made, not the validity of the patients and even by alert individuals fundamental procedures such as root underlying science. outside the dental office. canal therapy and radiographic diagnosis, Etienne Wenger’s book in the the number one source of learning is Practice as Professional Identity Recommended Readings list should be dental school. Tied for last place are Practice is more than what one does; of particular interest to dentists. He expert sources such as consultants, it is also bound up with who one is. presents a 40-page account of an former faculty members, and the ADA. Insurance consultants, dental educators, insurance claims operation as a case These sources of learning are just a bit association executives, and others who study in a community of practice. What less popular than are the literature and never don gloves can still call themselves may come as a surprise is the extent to CE programs. The second-leading source dentists and usually do so. A great which claims processors use judgment of changing practice patterns, especially incentive for successful recovery from and negotiation between policy writers for newly emerging skills, is trial-and- substance abuse is the fear of losing one’s and service providers. An especially error. This learning by doing is involved license. Identity matters to practitioners. interesting part of the case involves the in some way in choosing and improving Part of that identity comes from the collective efforts of the processors to performance in over half of the activities act of practice itself, and this has been bring consistency to their practice dentists use. explored in the preceding pages. Part of where policies are ambiguous. Understanding through performance it comes from belonging to a community Sometimes we learn to appreciate incorporates a blended set of skills that of practice: a small group that regularly strong communities of practice by are normally separated for scientific works in interlocking patterns, such as comparing them with groups that are study. The practitioner combines dental offices. Practice communities poor examples of practice. I have been diagnosis (including collateral factors), provide the work environments that on several committees and more than the materials and moves of the procedure, allow for specialized practice, emotional one project team that I would not be and the fine-tuning of these in a smooth and professional recognition and support, proud to mention. Their dysfunctional and often nearly unique whole. The and a sense of meaning that surrounds nature existed despite most of the trick is that virtuoso practitioners have a the work. Many dentists have experienced members being likeable and talented rich repertoire of approaches, the ability the difference it makes in their own people. We simply never had the to see the ideal in the present reality, practice satisfaction when improvements opportunity to blend our individual and professional standards used to judge are made in other parts of the office. strengths and experience the collective which outcomes are most desirable. All Practitioners learn and grow: so do success needed to become a community. of this is under the control of monitored communities of practice. Reflect for a On many occasions, we spent too much outcomes rather than general evidence. moment on your practice now compared time on the task and not enough on Dentists understand good dentistry by to ten years ago. Very likely you will be understanding what it meant. producing it. able to identify a handful of high-impact Practitioners become who they are If you ask a dentist what caused the experiences that constitute a shared because of what they do. Specifically, patient’s gingiva to heal or a veneer to history that give meaning to your they learn by doing, continually expand match so perfectly, their response may community of practice. One would hope their repertoires of skills as functional very well be “I did it.” It would be more there has also been a growth in the artists in conversations with the ideal, surprising for them to say the curette did capacity of the whole office to manage while embracing standards shared with new and challenging situations. The their colleagues. I office learns by doing just as the individual practitioner does. Healthy offices develop deeper bonds of community as new members are recognized as

2008 Volume 75, Number 4 Leadership Recommended Reading

Chambers, D. W., & Geissberger, M. Schön, Donald A. (1983). (1997). The reflective practitioner: How Toward a competency analysis professionals think in action. * of operative dentistry technique New York, NY: Basic Books. skills. ISBN 0-465-06878-2; 375 pages; Journal of Dental Education, 61, cost unknown. 795-803. Practice is defined as “the artful inquiry This is a detailed study of differences in by which [professionals] sometimes performance between beginning and deal with situations of uncertainty, competent students and faculty-member instability, and uniqueness. This is the experts in performing a Class II cavity pattern of reflection-in-action, which is preparation. Experienced practitioners called ‘reflective conversation with the were more efficient (but not faster), situation.’” “I have become convinced performed several steps simultaneously, that universities are not devoted to the Summaries are available for the three and evaluated their work earlier and production and distribution of funda- recommended readings with asterisks. more continuously than did beginners. mental knowledge in general. They are Each is about ten pages long and There were, however, no differences in institutions committed, for the most conveys both the tone and content of the amount of time the bur was in part, to a particular epistemology, a the original source through extensive contact with the tooth or in the quality of view of knowledge that fosters selective quotations. These summaries are the preparations across the experience inattention to practical competence and designed for busy readers who want level of the operators. professional artistry.” “When people use the essence of these references in terms such as ‘art’ and ‘intuition,’ they 20 minutes rather than five hours. Schön, Donald A. (1987). usually intend to terminate discussion Summaries are available from the Educating the reflective rather than to open up inquiry.” “We are ACD Executive Offices in Gaithersburg. practitioner: Toward a new in need of inquiry into the epistemology A donation to the ACD Foundation design for teaching and learning of practice.” of $15 is suggested for the set of in the professions.* summaries on practice; a donation San Francisco, CA: Jossey-Bass. Wenger, Etienne (1998). of $50 will bring you summaries for ISBN 1-55542-220-9; 355 pages; Communities of practice: all the 2008 leadership topics. cost unknown. Learning, meaning, and identity.* Cambridge, UK: Cambridge University The reflective practitioner, one who Press. ISBN 9-780521-663632; combines knowledge and art in practice, 318 pages; about $20. Chambers, D. W. (2001). must be taught in ways beyond tradi- Outcomes-Based Practice. tional, didactic, or rational theory and Social practice is the fundamental Dental Economics. facts separated from context. The alter- process by which we learn who we A series of 12 short articles, one each native proposed is the practicum, a are and the primary unit of analysis is month for the year, explaining simple learning by doing in a controlled envi- neither the individual nor the institution. techniques practitioners can use in their ronment under the care of a coach. The Communities of practice are small offices to focus on quality outcomes and need for this approach, what learners groups that participate in mutual thus guide learning by doing. These are get from it, and the dynamics of the engagement using shared repertoires techniques practitioners can use to coaching relationship are presented. to accomplish a joint enterprise. They verify that their practices work, whether There are several examples—architecture, share common identity negotiated developed through trial-and-error or music, psychology, consulting—worked through learning and meaning. borrowed from the literature. out in great detail, with original case material.

63 Journal of the American College of Dentists 2008 Manuscript Review Process

2008 Manuscript Review Process

our unsolicited manuscripts were format presented in an AADE journal Bruce Graham, DDS, FACD received for possible publication that promotes excellence, ethics, profes- Chicago, IL in the Journal of the American sionalism, and leadership in dentistry. F Donna B. Hurowitz, DDS, FACD College of Dentistry during 2008. Two Thirteen manuscripts were nominated San Francisco, CA were transferred for separate review in for consideration. The winner was a the Issues in Dental Ethics Section of discussion of academic integrity in Paul M. Johnson, MBA, DDS, FACD the publication following peer review of dental schools and the profession, Newport Beach, CA the other two; one manuscript was not “Preserving the privilege,” written by Michael Maihofer, DDS accepted; and the other was accepted Dr. Fred Bremner and appearing in the Roseville, MI contingent upon substantial revisions. August 2007 issue of Membership Nine reviews were received for these Matters, the publication of the Oregon Max M. Martin, Jr, DDS, FACD manuscripts, yielding an average rating Dental Association. Fifteen judges Lincoln, NE of 4.5 per manuscript. Consistency of participated in the review process. Their Frank J. Miranda, DDS, MEd, MBA reviews was determined using Cramer’s names are listed among the Journal Oklahoma City, OK V statistic, a measure of association reviewers below. The Cronbach alpha for Detlef B. Moore between review recommendations and consistency among the judges was .943. Milwaukee, WI the ultimate publication decision. The The College thanks the following Cramer value was .863, where 0.00 professionals for their contributions, Michael Meru, BS represents chance agreement and 1.00 sometimes multiple efforts, to the dental Los Angeles, CA represents perfect agreement. The College literature as reviewers for the Journal Nader Nadershahi, DDS, EdM, MBA, FACD feels that authors are entitled to know of the American College of Dentists San Francisco, CA the consistency of the review process. during 2008. The Editor also follows the practice of Laura Neumann, DDS sharing all reviews among the reviewers Chris Anderson, DDS, FACD Chicago, IL as a means of improving calibration. Lubbock, TX John O, Keefe, DDS, FACD The Editor is aware of two requests Anika Ball, RDH, MA Ottawa, ON to reprint articles appearing in the journal Loma Linda, CA and three requests to copy articles for Don Patthoff, DDS educational use received and granted Norman Becker, DMD Martinsburg, WV during the year. There were two requests Shirley, MA Bruce Peltier, PhD for summaries of recommended reading Fred Bremner, DMD San Francisco, CA associated with Leadership Essays. Milwaukie, OR In collaboration with the American Steve Ralls, DDS, FACD Association of Dental Editors, the College D. Gregory Chadwick, DDS, FACD Gaithersburg, MD sponsors a prize for a publication in any Charlotte, NC Patty Reyes, BA Steven A. Gold, DDS Sacramento, CA Santa Monica, CA Cherilyn Sheets, DDS, FACD Theresa S. Gonzales, DMD, MS, MSS, FACD Newport Beach, CA Fort Hood, TX

2008 Volume 75, Number 4 2008 Article Index

2008 Article Index Journal of the American College of Dentists, 2008, Volume 75

Editorials Ethics as Permissible Behavior...... Number 3, page 2 David W. Chambers

Loose Talk...... Number 4, page 2 David W. Chambers

Positive Ethics...... Number 2, page 2 David W. Chambers

Thin Soup...... Number 1, page 2 David W. Chambers

Letters to the Editor Luther L. Paine...... Number 3, page 4

College Matters An Ethics War [President-elect’s address]...... Number 4, page 4 Max M. Martin, Jr.

Responding to a Culture-Based Health Need [Convocation address] ...... Number 4, page 8 Francisco G. Cigarroa

2008 ACD Awards...... Number 4, page 11

2008 Fellowship Class...... Number 4, page 15

2008 Manuscript Review Process ...... Number 4, page 64

Theme Papers Balancing Act: The Salvation Army in the United States...... Number 1, page 12 Melissa Temme

California Pipeline Program: Phase II ...... Number 4, page 29 Paul Glassman

65 Journal of the American College of Dentists 2008 Article Index

Canadian Red Cross ...... Number 1, page 8 Colleen Lavender

Dental Pipeline Program: A National Program Linking Dental Schools with the Access to Care Issue ...... Number 4, page 24 Allan J. Formicola

Dental Schools and Access Disparities: What Roles Can Schools Play?...... Number 4, page 20 Howard Bailit

Dental Students Persuade the Michigan Dental Association to Strengthen Its Codes of Ethics...... Number 2, page 22 Marilyn S. Lantz

Dr. Ben Pavone: Getting the Fit Right...... Number 3, page 14 David W. Chambers

Dr. Daniel Laskin: Calling Attention to What Matters in the Profession...... Number 3, page 9 David W. Chambers

Dr. Howard I. Mark on What It Means to Be a Professional...... Number 3, page 19 David W. Chambers

Dr. William E. Brown: A 50-Year ACD Member ...... Number 3, page 17 Krista M. Jones

East Carolina University School of Dentistry: Impact on Access Disparities...... Number 4, page 35 D. Gregory Chadwick and James R. Hupp

Ethics in a Postgraduate Program ...... Number 2, page 14 Hans S. Malmstrom

Fifty Years of Change in Dentistry with Dr. Gordon Rovelstad...... Number 3, page 5 Gordon H. Rovelstad and Stephen A. Ralls

The Honor Society of Phi Kappa Phi...... Number 1, page 4 Perry A. Snyder

Hugo A. Owens: Dentist, Civil Rights Leader, Politician ...... Number 2, page 6 James T. Rule and Muriel J Bebeau

Pointing the Profession in the Right Direction...... Number 2, page 18 Brooke Loftis

Positive Ethics and Dental Students ...... Number 2, page 27 Sigmund H. Abelson

The Role of Dental Schools in the Issues of Access to Care...... Number 4, page 42 Caswell A. Evans

2008 Volume 75, Number 4 2008 Article Index

Rotary International...... Number 1, page 17 Janis Young

A Student-Initiated Movement toward a More Positive Ethics ...... Number 2, page 11 Alvin Rosenblum

These Are Wonderful People...... Number 2, page 4 Phyllis Beemsterboer

Transforming an Icon: Girl Scouts of America ...... Number 1, page 21 Michelle Tompkins and Victor Inzunza

Walter C. Sandusky, Jr...... Number 3, page 12 Carl L. Sebelius, Jr.

Manuscripts Blurring the Lines Between General Dentistry and Dental Specialties [ACD/AADE Prize]...... Number 3, page 28 Eric K. Curtis

Issues in Dental Ethics The Intersection of Dental Ethics and Law ...... Number 4, page 47 David J. Owsiany

The Future of Dental Ethics: Promises Needed...... Number 3, page 21 Donald E. Patthoff

Ethical and Legal Considerations in a Case of Research Fraud Practical and Ethical Challenges...... Number 2, page 29 Sigrid I. Kvaal

What to Hope for and the Challenge of Getting There ...... Number 1, page 25 David T. Ozar

Leadership Essay Practice...... Number 4, page 55 David W. Chambers

Gentlemen...... Number 1, page 30 David W. Chambers

Large Ethics ...... Number 2, page 36 David W. Chambers

Stress ...... Number 3, page 33 David W. Chambers 67 Journal of the American College of Dentists Journal of the American College of Dentists

2008 Statement of Ownership and Circulation The Journal of the American College of Dentists is published quarterly by the American College of Dentists, 839J Quince Orchard Boulevard, Gaithersburg, Maryland 20878-1614. Editor: David W. Chambers, EdM, MBA, PhD.

The American College of Dentists is a nonprofit organization with no capital stock and no known bondholders, mortgages, or other security holders. The average number of readers of each issue produced during the past twelve months was 5,363, none sold through dealers or carriers, street venders, or counter sales; 5,514 copies distributed through mail subscriptions; 5,352 total paid circulation; 162 distributed as complimentary copies. Statements filed with the U.S. Postal Service, September 25, 2008.

American College of Dentists Periodicals Postage 839J Quince Orchard Boulevard PAID Gaithersburg, MD 20878-1614 at Gaithersburg, MD