Community-Based Dental Education Research Articles

Community‐Based Dental Education at The Ohio State University: The OHIO Project

In the late 1990s, Ohio's citizens expressed to the state leadership that access to dental care was their greatest unmet health need. State-sponsored surveys continued to report that certain populations-the poor, disabled, and minorities-experience higher-than-average rates of dental disease and cannot access care. The Ohio State University College of Dentistry sought to respond to this need by securing a $1.5 million grant from the Robert Wood Johnson Foundation in 2002 and began an experiment in engagement with community partners unprecedented in its history. As the state's flagship dental institution, the college committed to a fundamental change in its clinical education of students and began a process of making dental education relevant to our citizens, exposing students to populations they were being trained to help, and bolstering the fragile statewide network of safety-net clinics with providers. This case history offers an operational overview, including some challenges and successes, of one school's journey in community-based dental education.

Community‐Based Dental Education at Boston University

Community-based dental education has been integral to the Boston University Henry M. Goldman School of Dental Medicine's mission for the past thirty years. This report describes the programs, their history, and their outcomes. The three main educational experiences outside the school are the applied professional experience clerkship, the pediatric dentistry rotation, and the extramural training program. By all student and community outcomes measured, such as students' self-confidence, patient management skills, clinical technical skills, and increase in community members' access to care, these programs are a success.

Policy Implications of Assessing the Impact of Community‐Based Education on Dental School Finances

Dental schools are hard pressed to find the resources to adequately fund their mission of education, research, and service. Over the years, schools have tried to make up for the loss in public funds by increasing student tuition, increasing enrollment, and reducing the growth in faculty and staff salaries and program costs. Unfortunately, these strategies have not solved the financial problems. Declining resources are threatening the future of dental education. Data presented in this report attempt to answer the following question: will community-based dental education restore the fiscal health of dental schools and provide students an equal or better education? By reducing the number of chairs per student and developing revenue-sharing relationships with community clinics, community-based dental education offers a realistic option for putting dental schools on a solid financial footing.

Senior Dental Students’ Impact on Dental School Clinic Revenues: The Effect of Community‐Based Dental Education

Junior and senior dental students generate a significant portion of dental school clinical revenues. Some deans and faculty members are concerned that school clinic income declines when students spend substantial time in community clinics on extramural rotations. This study uses data from eight dental schools to examine the difference in senior clinic operating revenues and expenses between schools with extensive community-based dental education programs and those with limited community-based dental education programs. The analysis shows that schools with extensive programs have substantially lower per senior student clinic losses. This is due to having fewer chairs per student and having a larger class size, thus generating more tuition revenues. The economic advantages of community-based dental education programs for their schools are substantial.

Dental School and Community Clinic Financial Arrangements

In community-based dental education programs, student-provided services can be an important source of community clinic and practice revenues. The University of Michigan School of Dentistry has developed a revenue-sharing arrangement with multiple community clinics and practices. During their ten-week externship, senior students produce at least $800 a day in patient care revenues, and the school receives an average of $165 per student per day from community sites. These funds are used to cover program costs and enrich the curriculum. Revenue-sharing with community clinics and practices helps to ensure program longevity and is an increasingly significant source of school revenues.

Measuring Clinical Productivity in Community‐Based Dental Education Programs

Community-based dental education programs (CBDEPs) are an important part of the curriculum in many dental schools. This article describes the redesign of the CBDEP at the University of Kentucky College of Dentistry. As part of the formative evaluation of this CBDEP, information on clinical productivity was collected in order to educate intramural faculty members about the scope and extent of services provided in extramural sites; develop an understanding of the productivity expected; complement the intramural education by placing dental students in particular settings where they could enhance certain clinical disciplines; and serve as a decision making tool in the selection of sites that provide the richest clinical experiences. A total of 158 students participated in the CBDEP during the three years of our study (2006-08). Productivity per site was calculated based on total, mean, and median number of services provided, billing (utilizing Kentucky's Medicaid fees for 2006), and Relative Value Units (RVUs). A total of 26,202 services, $972,109 in billing, and 43,053 RVUs was generated by the students, with an average of 175 services, $6,481, and 287 RVUs per student. Four categories (restorative, oral surgery, preventive, and diagnostic) accounted for 88 percent of total RVUs for all sites and all years. Productivity measured with RVU was the highest at private practices. Students spent most of their time providing restorative and oral surgery services. Measuring clinical productivity can be an effective tool to establish benchmarks, improve the site selection process, and educate those skeptical about the benefits of extramural education. Such an evaluation will enable faculty and program administrators involved in CBDEP to make continuous improvements.

Evaluating the Impact of the ADEA Admissions Committee Workshops

Drawing on the interconnection of workforce diversity and oral health access, the American Dental Education Association (ADEA) is leading a novel approach to improve student body diversity in U.S. dental schools through an admissions committee development program. With funding provided by the Pipeline, Profession, and Practice: Community-Based Dental Education program and the Robert Wood Johnson Foundation, ten dental directors/deans of admissions from a cross-section of U.S. dental schools were selected through a competitive application process to participate in a Train-the-Trainers Admissions Committee Workshop. After completing intensive training that was built on legally sound admissions practices, these new trainers copresented ADEA Admissions Committee Workshops in two-member teams at six U.S. dental schools. This report summarizes the evaluation of both the train-the-trainers workshop and six workshops held in summer 2009. Also summarized are post-workshop outcomes relative to structural diversity at the participating schools.

Reforming dental workforce education and practice in the USA

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

Comparison of Extramural Clinical Rotation Days: Did the Pipeline Program Make a Difference?

Extramural clinical rotations are implemented by dental schools for a combination of clinical and didactic or behavioral goals. In the United States, the Pipeline, Profession, and Practice: Community-Based Dental Education program was launched to increase the number of underrepresented minority students who are recruited and retained in dental education, to expand the dental curriculum in cultural competence, and to incorporate community-based extramural rotations into the dental schools' clinical curriculum. The objective of this study was to conduct an impact analysis regarding the change in number of extramural clinical rotation weeks for Pipeline and non-Pipeline program students over the time period of 2003 to 2007. National data from the American Dental Education Association's senior survey and other secondary sources were used to determine what student, school, and community characteristics are associated with a difference in the student report of the number of required weeks they expect to spend during their last year in dental school providing care at extramural clinic settings. Students reported a mean of 7.2 weeks for Pipeline students and 6.4 weeks for non-Pipeline students in 2003, increasing to 8.2 weeks for Pipeline students and 6.6 weeks for non-Pipeline students (p<0.05) in 2007. The multivariable model showed the Pipeline program increased significantly the number of rotational weeks reported by students. Three other variables significantly increased rotation weeks: 1) a lower baseline number of reported weeks in community rotations; 2) a lower level of debt student reported upon graduation; and 3) student reports of a higher orientation toward service to others as a reason to enter dentistry.

The Impact of Community‐Based Dental Education on Students

Community-based dental education (CBDE) shifts a substantial portion of dental clinical education from dental school clinics to mainly public health settings. For dental students to learn effectively in community settings they need preparatory education in cultural awareness, communication skills, and the social and behavioral sciences. The effective integration of CBDE into a dental curriculum requires reflective components, evaluation, and highly organized community-based experiences. This chapter reviews organizational principles and specific strategies to ensure that CBDE is conducted in a fashion that enables student learning and community oral health service. CBDE has substantial potential for affecting the values and behaviors of dental students relative to health care access for underserved populations and for attracting diverse students to dental education. CBDE also provides dentistry with an opportunity to guide dental faculty and student values and orientation towards public service, engagement, ethics, and the health of the public.

Financial Impact of Community‐Based Dental Education

The financial impact of community-based dental education on dental school and community clinic budgets is a major issue. The evidence suggests that community experiences for dental students of fifty or more days, if effectively managed, can increase school net revenues due to the following factors: 1) the community rotations increase student productivity, approximating the loss of dental school clinical income; 2) the reallocation of unused clinical resources at the dental school reduces student clinic deficits; 3) schools and federally qualified health centers (FQHCs) that share surplus student patient revenues generate additional net income; and 4) enrollment of more students without additional new facilities and faculty increases total school tuition revenues. For FQHC dental clinics, student rotations increase the number of patients treated and may generate surplus revenues. Community-based dental education also provides schools and clinics important non-financial advantages.

Preface: About the Dental Pipeline Program

In 2001, the Robert Wood Johnson Foundation (RWJF) launched the nation’s largest dental education demonstration program, Pipeline, Profession, and Practice: Community-Based Dental Education. The primary goal of the program was to respond directly to the U.S. surgeon general’s report in 2000

Reflections on the Dental Pipeline Program's Efforts Regarding Community‐Based Dental Education

Although many changes are being made, many are still needed in educating future dental professionals about prevention programs, ethics, professionalism, communication, cultural competence, and access to care. It is not yet clear if producing more dentists will put these professionals into underserved areas where they are needed, with the skills they need. The achievements of the Pipeline, Profession, and Practice: Community-Based Dental Education program schools in increasing the amount of time students spend in community-based education and service-learning programs result from a widespread, national effort to meet this challenge. This article is a personal reflection and review of these programs, considering what has been learned and still needs to be learned about student educational impact and quality, faculty issues, program management, infrastructure and logistics, and financial impact, with suggestions for future study that can help dental schools design the most effective programs.

Organization and Management of Community‐Based Dental Education Programs: An Overview from the Dental Pipeline Program

Disparities in access to dental care are a major problem in the United States. Effectively run community-based dental education programs can make a significant contribution to reducing access disparities and at the same time enrich the educational experiences of dental students and residents. For complex historical reasons, dental schools did not base their clinical training programs in community hospitals and clinics like the other health professions. Now, because of trends in school finances, changes in societal values, and limitations in current educational experiences, schools are increasing the time students spend in community clinics. This is likely to continue. The chapters in the first section of the report on the Pipeline, Profession, and Practice: Community-Based Dental Education program--for which this chapter serves as an introduction-provide detailed information on the operation of community-based education programs.

The Experiences of Community Dental Clinic Directors with Dental Students and Dental School Collaborations

As part of the Pipeline, Profession, and Practice: Community-Based Dental Education program, Lake Research Partners, a national public opinion and political strategy research company, conducted nine telephone interviews in January and February 2010 with directors of community dental clinics. Table 1

Infrastructure for a Community‐Based Dental Education Program: Students and Clinics

The infrastructure of a community-based dental education program is important to its success. Thorough preparation of students for the community experience and careful selection of community clinical sites are indispensable. Student training in cultural competence, early community exposure, third-year clinical training, assignment of students to rotations, transportation, and housing all need careful attention. When selecting sites for the community rotation, it is important to have detailed site criteria or a wish list, a memorandum of understanding, and awareness of legal liability issues.

Effective Admissions Practices to Achieve Greater Student Diversity in Dental Schools

In this chapter we describe the institutional and policy-level strategies that dental schools in the Pipeline, Profession, and Practice: Community-Based Dental Education program used to modify their admissions practices to increase the diversity of their student bodies. Schools developed and used clear statements recognizing the value of diversity. They incorporated recent U.S. Supreme Court rulings regarding educational diversity into their revised admissions practices; these rulings cited diversity as both a "compelling interest" and its use in only "narrowly tailored" circumstances. We make a case for admissions decisions based on a comprehensive evaluation that balances the quantitative and qualitative qualities of a candidate. It refutes the practice of overreliance on standardized tests by detailing the whole-file review process to measure merit and professional promise. Also described is a range of noncognitive variables (e.g., leadership, ability to sustain academic achievement with competing priorities, volunteerism, communication, social background, and disadvantaged status) that schools can take into consideration in admissions decisions. Admissions committees can tie this comprehensive review of candidates into the case for promoting cross-cultural understanding and enhanced competence to provide care to patients from diverse backgrounds. In addition, the chapter reviews the challenges schools face in developing admissions policies and procedures that reflect the university's mission for diversity. It addresses the importance of a diverse composition of the admissions committee. It also describes how tailored workshops and technical assistance for admissions committees can help schools improve their student diversity and how admissions committees can engage in a process of periodic review of their diversity objectives in relationship to the school's mission.

Underrepresented Minority Dental Student Recruitment and Enrollment Programs: An Overview from the Dental Pipeline Program

By now, all dental schools should understand the need to increase the enrollment of underrepresented minority (URM) students. While there has been a major increase in the number of Hispanic/Latino, African American/Black, and Native American applicants to dental schools over the past decade, there has not been a major percent increase in the enrollment of URM students except in the schools participating in the Pipeline, Profession, and Practice: Community-Based Dental Education program, which have far exceeded the percent increase in enrollment of URM students in other U.S. dental schools during Phase I of the program (2002-07). Assuming that all dental schools wish to improve the diversity of their student bodies, chapters 9-12 of this report--for which this chapter serves as an introduction--provide strategies learned from the Pipeline schools to increase the applications and enrollment of URM students. Some of the changes that the Pipeline schools put into place were the result of two focus group studies of college and dental students of color. These studies provided guidance on some of the barriers and challenges students of color face when considering dentistry as a career. New accreditation standards make it clear that the field of dentistry expects dental schools to re-energize their commitment to diversity.

Components of Effective Outreach and Recruitment Programs for Underrepresented Minority and Low‐Income Dental Students

Dental schools in the Pipeline, Profession, and Practice: Community-Based Dental Education program that increased the number of underrepresented minority (URM) and low-income (LI) students in their predoctoral programs used focused approaches in their outreach, recruitment, and retention initiatives. Various combinations of approaches were used by the fifteen schools that received funding during Phase I of the program, which spanned 2003 to 2007. URM enrollment in the Pipeline schools increased from 184 students in 2003 to 246 in 2007. These enrollment numbers represent 16 and 20 percent of the first-year class in the Pipeline schools in 2003 and 2007, respectively. If the historically minority-serving institutions--Howard University College of Dentistry and Meharry Medical College School of Dentistry--are removed from these totals, the numbers changed from 100 in 2003 to 144 in 2007, representing 10 and 13 percent of the first-year classes. This chapter describes the approaches used by the fifteen Pipeline schools to increase the number of URM and LI students recruited to and enrolled in their predoctoral programs. It describes the internal infrastructural and organizational approaches these dental schools used to increase awareness about oral health careers among URM and LI students and to recruit applicants from these populations to their educational programs. The effective partnerships and collaborations these dental schools established with each other and external stakeholders to bolster their career outreach and recruitment efforts and some of the informal efforts that supported increased diversity are also examined.

Community‐Based Dental Education and the Importance of Faculty Development

Community-based dental education offers a variety of positive learning experiences for students while providing needed dental services for the underserved. More dental students are being instructed by a growing body of largely volunteer community-based faculty who practice in a wide range of community settings including community hospitals and clinics, nursing homes, and private practices. These geographically dispersed instructors may have little experience as educators. Their practice styles and their motivation to improve teaching effectiveness are likely to differ from the styles and motivation of school-based faculty members. Moreover, many dental schools have begun to emphasize practices that may be unfamiliar to community-based faculty such as evidence-based practice. Providing faculty development for them is challenging, yet crucial to the success of these programs and dental education in general. Fundamental elements that must be considered for effective community faculty development programming include fostering a culture of respect between school-based and community faculty members, basing programs on the actual needs of these educators, integrating principles of adult learning theory, and establishing ongoing institutional support. This article provides background on this movement, reviews the literature for faculty development programs geared specifically to community-based educators, makes recommendations for development programs for these dental educators, and includes suggestions for future research.