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Meeting Dental Health Needs through Dental Education
Meeting dental health needs through dental education
Alvin L. Morris, Lexington, Ky
It has been established beyond any doubt that the dental health needs of our nation are serious in nature and staggering in magnitude. In oversimpli fied terms, the dental health needs can only be met through dental health manpower and the key to dental health manpower is dental education. In less simple terms, the dental need of the nation is for more dental health care, more evenly distrib uted geographically, and provided at lower cost to the public. In my opinion, this need cannot and will not be met through the education of more dentists.
tists in the future” in that the output of new schools for which there were plans, but no commitment, were included. Also, the projections of dentists needed, from which deficits were calculated, were also described as “very conservative estimates.” In my opinion, they are so conservative as to place their usefulness for future planning in serious ques tion. This view is based on the fact that the cur rent dentist-to-population ratio was regarded as adequate to meet the present-day needs and was used as a base line from which to project. In addi tion, the figures admittedly fail to take into ac count the changes in needs that will surely ac company pressures created by a national health program.
Toward a broad educational approach The manpower problem Although I believe that the manpower problem cannot be solved solely through the education of dentists, I do not mean to imply that the produc tion of dentists in greater numbers is not a require ment of the future. The Carnegie Commission’s report on Higher Education and the Nation’s Health included the recommendation that in the next decade, the capacity for training dentists must be increased by 20%. The American Asso ciation of Dental Schools has gone on record as disagreeing with this estimate, indicating that it should be significantly higher. The recently published report of the Task Force on National Health Programs of the American Dental Association projected a deficit of over 7,000 dentists in 1980, and a 16,553 deficit by 1990. These figures were described as based on “some what optimistic estimates of the production of den1076 ■ JADA, Vol. 84, May 1972
Thus, in spite of the most optimistic estimates of the production potential of the nation’s dental schools, it will clearly not be possible to meet the dental health needs solely through the education of dentists. Therefore, if the needs are to be met through education, we must consider educating individuals who will share the dentist’s work load. Of course, I am referring to auxiliaries or allied dental health personnel. But let me emphasize that I am not talking about personnel who will merely help the dentist, but individuals who must be edu cated to perform many of the intraoral procedures now regarded as the sole responsibility of the den tist. Specifically, I am assuming that the existing auxiliaries must be taught to assume different and expanded roles. It is also assumed that one or more new types of health worker must be added to the dental health team. Indeed, there is every rea son to expect that the role of the dentist himself will be altered.
Challenges of the future
Believing sincerely that these changes must be part of our future, I wish to focus attention on the challenges that lie ahead and that must be faced. In this process, reference will be made to experi ences in other health fields. Many of the prob lems that will be discussed are generic in nature, and dentistry can derive much benefit from an ob servation of those commendable and unfortunate events that are taking place in medicine and nursing. ■ Professional confusion: The key educational question is: What should be taught to whom? Very real confusion that exists within the profession must be resolved before educational goals can be defined. Is it the dental hygienist to whom the major expanded intraoral functions should be dele gated, or should a new dentist’s associate or assis tant dentist be trained? If it is the hygienist who is to play this role, who will replace her in the performance of prophylaxes and preventive mea sures? Should the dental assistant continue merely as an extra pair of hands for the dentist or should her intraoral role be expanded? Is there a legiti mate function for the technician in the dental operatory? How much time will be required to prepare each auxiliary for the duties that will be assigned? Much time will be lost and much confusion will be perpetuated if dentistry fails to take an orga nized, coordinated approach to answering these questions. The evolution of the physician’s assis tant is in its seventh year. It is most difficult to assess the progress in this movement, in that in dividuals bearing that title are now being trained in one, two, and four years to perform a wide range of tasks. In addition, independent training pro grams exist for surgeons’ assistants, urology as sistants, orthopedic assistants, and medical spe cialty assistants. There is no consistency in the edu cational prerequisites for those entering training. In the field of pediatrics alone, pediatric nurse practitioners are being trained in four months; pediatric assistants are being trained in two years; and child health associates are being produced in a three-year program. Besides establishing the concept that individuals with less than the MD degree can be trained to share, in a meaningful way, the direct patient-
related work load of the physician, the experience of these seven years has taught us some lessons. Dentistry must not repeat this pattern. ■ Professional acceptance: As dentistry builds a new dental health team, it is inevitable that many complications will develop at the interface between this team and higher education, national agencies, existing legislation, and the public. Is it inevitable that the major complications will be those that arise within dentistry itself? Will the greatest impedi ment to progress be lack of intraprofessional ac ceptance of change? Will the dentist and the Ameri can Dental Association provide strong and wise guidance for the development of the new team without imposing leadership that is primarily selfserving? Will the hygienist and the American Den tal Hygienists’ Association accept the role they will be invited to play, or will they stand behind their separate licensing and accrediting procedures, pretending that separate means equal, and de manding the right to control their own destiny— thereby losing the opportunity to exercise their legitimate influence as the key decisions are made? In my opinion, it is from dental hygiene that the new assistant dentist should emerge. Similarly, it is my opinion that the baccalaureate nurse is the most logical resource from which to develop the physician’s assistant. But the gap that has devel oped between nursing and medicine is now so diffi cult to bridge that the validity of my opinion is un likely to be tested. This gap represents one of the very real tragedies of the contemporary health care delivery scene. Sadly, medicine and nursing and the patients they mutually serve have all suffered. It is my recommendation that the nurturing of the re lationship between dentistry and dental hygiene at the national, state, and local level be made a matter of high priority now as a vital investment for the future. ■ Accreditation and legal recognition: In its broad est sense, the bureaucracy to which our society seems so committed appears to exist primarily for the purpose of preserving and protecting the status quo. But our discussion here is focused on a de liberate and intentional effort to modify the status quo in the allied dental health fields. A field is recognized to have status when educational stan dards are defined and accreditation is awarded to training programs that meet those standards. In some fields, there is statutory definition of practice Morris: MEETING DENTAL HEALTH NEEDS • 1077
behavior and state government provides a license for those who are prepared to exhibit such behavior and continue to do so. How then does a profession manage the inevitable crunch between educational institutions and accrediting agencies and state laws during a time when educational standards are be ing intentionally modified and practice behavior is being redefined? Also, what is the most orderly and expeditious approach that can be taken to gain recognition of a totally new allied health field? And in the background, as these questions are asked, lurks the moral discomfiture of educators who encourage young people to be their educa tional guinea pigs, recognizing the possibility that they may ultimately be denied employment op portunities. Answers to these questions are not available and will not come easily. But to ignore their existence and their seriousness is to deny the opportunity for orderly progress. In my opinion, deliberations on these problems should begin now at the state and national level. ■ Role of higher education: The health profes sions and the public which they serve are ulti mately dependent on higher education for the so lutions to the health manpower problems. But viewed from another vantage point, it is in the fields of health that higher education has an opportunity of unusual proportions to respond to the society we are committed to serve. Our country is entering an era during which a sharp increase will occur in the health expectations of the public. If we in higher education fail to respond to these ex pectations, we do so at our own peril. The members of Congress are now aware that other countries lead the United States in national health standards and they do so at a cost for health care that is proportionately and absolutely much less. With the interest of such groups as or ganized labor now focused on health, it is no longer a hidden fact that our nation is investing over 6.5% of the gross national product on health. But there is wide recognition that, in spite of this in vestment, the health care delivery system of this nation is inadequate. Even the marginally sophis ticated taxpayer recognizes that the inadequacy is directly related to quality and quantity of man power. From the standpoint of funding at both the state and national level, the public will not con tinue to sustain a system of higher education that fails to provide the manpower necessary to meet 1078 ■ JADA, Vol. 84, May 1972
at least its basic health needs. My remarks suggest that the potential solution to the health manpower problem rests with higher education. A careful observer, however, might well charge that higher education is the problem. Such a charge reflects a realization of the fact that, at a time when innovation and change in health edu cation are badly needed, the traditions and internal bureaucracy of higher education seriously com promise the process of change and render it cum bersome and often ineffective. Permit me to illusstrate such compromise by citing some examples from the University of Kentucky that, I feel cer tain, are not unique to our institution. ■ Need for change in higher education: It has been established that a certain body of knowledge must be acquired by a student to qualify him for a de gree in a given field, and therefore, a minimum standard of competence has been established. What we are unable to accommodate intelligently is the student who brings some of this knowledge and competence with him. If knowledge is what is im portant, why must it be acquired in a certain class room to be a valid part of the educational process? There are those on the faculty who believe that such knowledge should be accepted as valid if it can be demonstrated’ through successful perform ance on an equivalency or bypass examination. But this group of faculty is divided as to whether the student should be granted credit toward his education goal without the substitution of an alternative educational experience. Another example can be taken from the field of engineering where the need has evolved for a con tinuum of education providing vocationally trained draftsmen, engineering technicians with an Asso ciate in Arts degree, plus baccalaureate- and gradu ate-trained engineers. By far, the most effective and inexpensive approach to this educational con tinuum would be to provide all levels of training on our campus. However, by statutory regulation, we cannot engage in vocational or sub-baccalau reate training. Therefore, complicated relation ships are required with a technical institute and community colleges. These examples were deliberately chosen from our Division of Colleges. They have direct applica bility, however, to the health fields. Without sug gesting that we have all the solutions identified, our College of Allied Health Professions has given much thought to admittedly ideal but possibly ef
fective education programs in medicine and den tistry. Unfortunately, our system of higher educa tion is not sufficiently flexible to permit the model to be tested. ■ A model for dental education: Permit me to briefly describe a model as an example of an approach that deserves consideration. In simpli fied terms, all dental health science students would share the experiences of a core curriculum as they began a common path to varying educational goals. There would be multiple exit points with some differentiated experiences depending on the goal initially chosen. For example, after the first year, the “prophnician,” the dental secretary, and the dental assistant would exit. The second year, the dental hygienist and laboratory technician would depart the system. After the fourth year, the as sistant dentist would receive a baccalaureate de gree. In two additional years, the dentist would receive the DMD degree, and after the eighth year, the specialist would have completed his education. An important feature of this model is that each exit point is also a reentry point. Accordingly, at all times the potential for upward mobility exists and an individual could come back into the sys tem, undergo a refresher experience, and continue up the ladder. Admittedly, this description is oversimplified and fails to acknowledge many problems. The points of exit and the titles assigned are unimpor tant. Certainly, one can suggest multiple areas in nursing and medicine where some version of the model has potential application. I believe, how ever, that some major modification of our approach to health education must be realized and our sys tem of higher education must not impose limita tions which make this impossible.
Dentistry’s strategy for change: a plan
The effectiveness and speed with which education ultimately solves the manpower problems will re flect in large measure the extent to which the chal lenges I have cited are accurately identified and squarely faced. I believe that at this time in history, the dental profession’s highest priority of need is for coordi nated leadership at the top, leading to the develop ment of dentistry’s strategy for change. I ask that your coordinated attention be directed to the ap
pointment of a panel that would be charged with defining the dental health team of 1980. The panel, comprised of the top 20 leaders from all areas of the dental and allied professions, would formulate recommendations on the following questions. ■ What should be the composition of the den tal health team of 1980? ■ What titles should be assigned to the various members of the team? ■ What general role should be assigned to each member of the team? ■ How many years should be devoted to the education of each member of the team? When the panel has completed its work, its recommendations would provide the subject for a national conference. I would recommend that the conferees number 200, selected to provide breadth and depth representation from the total dental com munity. The purpose of the conference would be to discuss, modify, and ultimately agree on final answers to the above questions, thus identifying the profession’s goals for the future. It is not anticipated that the dental health team as defined would become a common and function ing reality much before 1980. It would take some years for the House of Delegates of the American Dental Association to express its will and take ap propriate actions. It would take time for accredit ing agencies to adjust, and state laws to be modi fied. It would take time for higher education to experiment with various approaches to achieving the identified educational goals. Time would be provided for constructive changes to be made, and mistakes to be corrected. But throughout the en tire period, all of dentistry would have guidelines for change, and coordination of efforts would be possible. I solicit your thoughtful consideration of my suggestion or a modification thereof. I sincerely believe that a strategy for change must evolve if the dental needs of the nation are to be met through dental education.
This paper was presented at the School of Dentistry of the Medical College of Georgia, Nov 8, 1971. Dr. Morris is vice president for adm inistration at the University of Kentucky, Lexington, 40506. Morris: MEETING DENTAL HEALTH NEEDS ■ 1079
Alvin L. Morris, Lexington, Ky
It has been established beyond any doubt that the dental health needs of our nation are serious in nature and staggering in magnitude. In oversimpli fied terms, the dental health needs can only be met through dental health manpower and the key to dental health manpower is dental education. In less simple terms, the dental need of the nation is for more dental health care, more evenly distrib uted geographically, and provided at lower cost to the public. In my opinion, this need cannot and will not be met through the education of more dentists.
tists in the future” in that the output of new schools for which there were plans, but no commitment, were included. Also, the projections of dentists needed, from which deficits were calculated, were also described as “very conservative estimates.” In my opinion, they are so conservative as to place their usefulness for future planning in serious ques tion. This view is based on the fact that the cur rent dentist-to-population ratio was regarded as adequate to meet the present-day needs and was used as a base line from which to project. In addi tion, the figures admittedly fail to take into ac count the changes in needs that will surely ac company pressures created by a national health program.
Toward a broad educational approach The manpower problem Although I believe that the manpower problem cannot be solved solely through the education of dentists, I do not mean to imply that the produc tion of dentists in greater numbers is not a require ment of the future. The Carnegie Commission’s report on Higher Education and the Nation’s Health included the recommendation that in the next decade, the capacity for training dentists must be increased by 20%. The American Asso ciation of Dental Schools has gone on record as disagreeing with this estimate, indicating that it should be significantly higher. The recently published report of the Task Force on National Health Programs of the American Dental Association projected a deficit of over 7,000 dentists in 1980, and a 16,553 deficit by 1990. These figures were described as based on “some what optimistic estimates of the production of den1076 ■ JADA, Vol. 84, May 1972
Thus, in spite of the most optimistic estimates of the production potential of the nation’s dental schools, it will clearly not be possible to meet the dental health needs solely through the education of dentists. Therefore, if the needs are to be met through education, we must consider educating individuals who will share the dentist’s work load. Of course, I am referring to auxiliaries or allied dental health personnel. But let me emphasize that I am not talking about personnel who will merely help the dentist, but individuals who must be edu cated to perform many of the intraoral procedures now regarded as the sole responsibility of the den tist. Specifically, I am assuming that the existing auxiliaries must be taught to assume different and expanded roles. It is also assumed that one or more new types of health worker must be added to the dental health team. Indeed, there is every rea son to expect that the role of the dentist himself will be altered.
Challenges of the future
Believing sincerely that these changes must be part of our future, I wish to focus attention on the challenges that lie ahead and that must be faced. In this process, reference will be made to experi ences in other health fields. Many of the prob lems that will be discussed are generic in nature, and dentistry can derive much benefit from an ob servation of those commendable and unfortunate events that are taking place in medicine and nursing. ■ Professional confusion: The key educational question is: What should be taught to whom? Very real confusion that exists within the profession must be resolved before educational goals can be defined. Is it the dental hygienist to whom the major expanded intraoral functions should be dele gated, or should a new dentist’s associate or assis tant dentist be trained? If it is the hygienist who is to play this role, who will replace her in the performance of prophylaxes and preventive mea sures? Should the dental assistant continue merely as an extra pair of hands for the dentist or should her intraoral role be expanded? Is there a legiti mate function for the technician in the dental operatory? How much time will be required to prepare each auxiliary for the duties that will be assigned? Much time will be lost and much confusion will be perpetuated if dentistry fails to take an orga nized, coordinated approach to answering these questions. The evolution of the physician’s assis tant is in its seventh year. It is most difficult to assess the progress in this movement, in that in dividuals bearing that title are now being trained in one, two, and four years to perform a wide range of tasks. In addition, independent training pro grams exist for surgeons’ assistants, urology as sistants, orthopedic assistants, and medical spe cialty assistants. There is no consistency in the edu cational prerequisites for those entering training. In the field of pediatrics alone, pediatric nurse practitioners are being trained in four months; pediatric assistants are being trained in two years; and child health associates are being produced in a three-year program. Besides establishing the concept that individuals with less than the MD degree can be trained to share, in a meaningful way, the direct patient-
related work load of the physician, the experience of these seven years has taught us some lessons. Dentistry must not repeat this pattern. ■ Professional acceptance: As dentistry builds a new dental health team, it is inevitable that many complications will develop at the interface between this team and higher education, national agencies, existing legislation, and the public. Is it inevitable that the major complications will be those that arise within dentistry itself? Will the greatest impedi ment to progress be lack of intraprofessional ac ceptance of change? Will the dentist and the Ameri can Dental Association provide strong and wise guidance for the development of the new team without imposing leadership that is primarily selfserving? Will the hygienist and the American Den tal Hygienists’ Association accept the role they will be invited to play, or will they stand behind their separate licensing and accrediting procedures, pretending that separate means equal, and de manding the right to control their own destiny— thereby losing the opportunity to exercise their legitimate influence as the key decisions are made? In my opinion, it is from dental hygiene that the new assistant dentist should emerge. Similarly, it is my opinion that the baccalaureate nurse is the most logical resource from which to develop the physician’s assistant. But the gap that has devel oped between nursing and medicine is now so diffi cult to bridge that the validity of my opinion is un likely to be tested. This gap represents one of the very real tragedies of the contemporary health care delivery scene. Sadly, medicine and nursing and the patients they mutually serve have all suffered. It is my recommendation that the nurturing of the re lationship between dentistry and dental hygiene at the national, state, and local level be made a matter of high priority now as a vital investment for the future. ■ Accreditation and legal recognition: In its broad est sense, the bureaucracy to which our society seems so committed appears to exist primarily for the purpose of preserving and protecting the status quo. But our discussion here is focused on a de liberate and intentional effort to modify the status quo in the allied dental health fields. A field is recognized to have status when educational stan dards are defined and accreditation is awarded to training programs that meet those standards. In some fields, there is statutory definition of practice Morris: MEETING DENTAL HEALTH NEEDS • 1077
behavior and state government provides a license for those who are prepared to exhibit such behavior and continue to do so. How then does a profession manage the inevitable crunch between educational institutions and accrediting agencies and state laws during a time when educational standards are be ing intentionally modified and practice behavior is being redefined? Also, what is the most orderly and expeditious approach that can be taken to gain recognition of a totally new allied health field? And in the background, as these questions are asked, lurks the moral discomfiture of educators who encourage young people to be their educa tional guinea pigs, recognizing the possibility that they may ultimately be denied employment op portunities. Answers to these questions are not available and will not come easily. But to ignore their existence and their seriousness is to deny the opportunity for orderly progress. In my opinion, deliberations on these problems should begin now at the state and national level. ■ Role of higher education: The health profes sions and the public which they serve are ulti mately dependent on higher education for the so lutions to the health manpower problems. But viewed from another vantage point, it is in the fields of health that higher education has an opportunity of unusual proportions to respond to the society we are committed to serve. Our country is entering an era during which a sharp increase will occur in the health expectations of the public. If we in higher education fail to respond to these ex pectations, we do so at our own peril. The members of Congress are now aware that other countries lead the United States in national health standards and they do so at a cost for health care that is proportionately and absolutely much less. With the interest of such groups as or ganized labor now focused on health, it is no longer a hidden fact that our nation is investing over 6.5% of the gross national product on health. But there is wide recognition that, in spite of this in vestment, the health care delivery system of this nation is inadequate. Even the marginally sophis ticated taxpayer recognizes that the inadequacy is directly related to quality and quantity of man power. From the standpoint of funding at both the state and national level, the public will not con tinue to sustain a system of higher education that fails to provide the manpower necessary to meet 1078 ■ JADA, Vol. 84, May 1972
at least its basic health needs. My remarks suggest that the potential solution to the health manpower problem rests with higher education. A careful observer, however, might well charge that higher education is the problem. Such a charge reflects a realization of the fact that, at a time when innovation and change in health edu cation are badly needed, the traditions and internal bureaucracy of higher education seriously com promise the process of change and render it cum bersome and often ineffective. Permit me to illusstrate such compromise by citing some examples from the University of Kentucky that, I feel cer tain, are not unique to our institution. ■ Need for change in higher education: It has been established that a certain body of knowledge must be acquired by a student to qualify him for a de gree in a given field, and therefore, a minimum standard of competence has been established. What we are unable to accommodate intelligently is the student who brings some of this knowledge and competence with him. If knowledge is what is im portant, why must it be acquired in a certain class room to be a valid part of the educational process? There are those on the faculty who believe that such knowledge should be accepted as valid if it can be demonstrated’ through successful perform ance on an equivalency or bypass examination. But this group of faculty is divided as to whether the student should be granted credit toward his education goal without the substitution of an alternative educational experience. Another example can be taken from the field of engineering where the need has evolved for a con tinuum of education providing vocationally trained draftsmen, engineering technicians with an Asso ciate in Arts degree, plus baccalaureate- and gradu ate-trained engineers. By far, the most effective and inexpensive approach to this educational con tinuum would be to provide all levels of training on our campus. However, by statutory regulation, we cannot engage in vocational or sub-baccalau reate training. Therefore, complicated relation ships are required with a technical institute and community colleges. These examples were deliberately chosen from our Division of Colleges. They have direct applica bility, however, to the health fields. Without sug gesting that we have all the solutions identified, our College of Allied Health Professions has given much thought to admittedly ideal but possibly ef
fective education programs in medicine and den tistry. Unfortunately, our system of higher educa tion is not sufficiently flexible to permit the model to be tested. ■ A model for dental education: Permit me to briefly describe a model as an example of an approach that deserves consideration. In simpli fied terms, all dental health science students would share the experiences of a core curriculum as they began a common path to varying educational goals. There would be multiple exit points with some differentiated experiences depending on the goal initially chosen. For example, after the first year, the “prophnician,” the dental secretary, and the dental assistant would exit. The second year, the dental hygienist and laboratory technician would depart the system. After the fourth year, the as sistant dentist would receive a baccalaureate de gree. In two additional years, the dentist would receive the DMD degree, and after the eighth year, the specialist would have completed his education. An important feature of this model is that each exit point is also a reentry point. Accordingly, at all times the potential for upward mobility exists and an individual could come back into the sys tem, undergo a refresher experience, and continue up the ladder. Admittedly, this description is oversimplified and fails to acknowledge many problems. The points of exit and the titles assigned are unimpor tant. Certainly, one can suggest multiple areas in nursing and medicine where some version of the model has potential application. I believe, how ever, that some major modification of our approach to health education must be realized and our sys tem of higher education must not impose limita tions which make this impossible.
Dentistry’s strategy for change: a plan
The effectiveness and speed with which education ultimately solves the manpower problems will re flect in large measure the extent to which the chal lenges I have cited are accurately identified and squarely faced. I believe that at this time in history, the dental profession’s highest priority of need is for coordi nated leadership at the top, leading to the develop ment of dentistry’s strategy for change. I ask that your coordinated attention be directed to the ap
pointment of a panel that would be charged with defining the dental health team of 1980. The panel, comprised of the top 20 leaders from all areas of the dental and allied professions, would formulate recommendations on the following questions. ■ What should be the composition of the den tal health team of 1980? ■ What titles should be assigned to the various members of the team? ■ What general role should be assigned to each member of the team? ■ How many years should be devoted to the education of each member of the team? When the panel has completed its work, its recommendations would provide the subject for a national conference. I would recommend that the conferees number 200, selected to provide breadth and depth representation from the total dental com munity. The purpose of the conference would be to discuss, modify, and ultimately agree on final answers to the above questions, thus identifying the profession’s goals for the future. It is not anticipated that the dental health team as defined would become a common and function ing reality much before 1980. It would take some years for the House of Delegates of the American Dental Association to express its will and take ap propriate actions. It would take time for accredit ing agencies to adjust, and state laws to be modi fied. It would take time for higher education to experiment with various approaches to achieving the identified educational goals. Time would be provided for constructive changes to be made, and mistakes to be corrected. But throughout the en tire period, all of dentistry would have guidelines for change, and coordination of efforts would be possible. I solicit your thoughtful consideration of my suggestion or a modification thereof. I sincerely believe that a strategy for change must evolve if the dental needs of the nation are to be met through dental education.
This paper was presented at the School of Dentistry of the Medical College of Georgia, Nov 8, 1971. Dr. Morris is vice president for adm inistration at the University of Kentucky, Lexington, 40506. Morris: MEETING DENTAL HEALTH NEEDS ■ 1079