J Dent Educ. 70(3): 231-245 2006
© 2006 American Dental Education Association
Critical Issues in Dental Education |
Scope of Practice Comparison: A Tool for Curriculum Decision Making
Eric Solomon, D.D.S.;
John Murray, M.Ed.;
William W. Dodge, D.D.S.;
Spencer W. Redding, D.D.S.;
John A. Valenza, D.D.S.;
Catherine M. Flaitz, D.D.S.;
James S. Cole, D.D.S.;
Kenneth L. Kalkwarf, D.D.S.
Key words: dental education, curriculum, clinical competence, clinical skills, denture-complete removable, endodontic therapy, periodontal surgery, dental restoration-permanent
Submitted for publication 09/07/05;
accepted 11/14/05
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Abstract
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The proportion of claims filed for specific dental procedures (ADA codes # 05110, 05120, 03320, 03330, 04260, 02150) between January 1, 2000 and June 30, 2004 by Texas general practitioners participating in a preferred provider network was compared to the proportion of these procedures performed by students graduating from the three Texas dental schools during the same period. Analysis of the data revealed that Texas dental students provide class two amalgam restorations in permanent teeth (02150) at approximately the same frequency as Texas general practitioners. Both groups provide periodontal osseous surgery (04260) at an extremely low frequency (<0.02% of total procedures). Bicuspid endodontic procedures (03320) were performed at a slightly higher frequency by students (0.43% of all procedures) than by general practitioners (0.36% of all procedures), and molar endodontic procedures (03330) were performed at a slightly higher frequency by general practitioners (0.65%) than by students (0.36%). Significant discrepancies between the groups were noted for the two complete denture procedures (05110, 05120). Students provided these procedures at frequencies fifteen times (05110) and twenty-five times (05120) greater than general practitioners. Dental schools should use data provided by scope of practice analyses to help determine an appropriate breadth and depth for their educational programs.
While some faculty members within dental education adhere to the philosophy of "If it ain’t broke, don’t fix it!,"1 other dental educators2,3 have provided elegant discussions of significant shortcomings that exist within the current U.S. dental education system. Many dental educators point to a curriculum crowded with redundant or marginally useful materials4 as the primary deterrent to progressive curriculum reform capable of addressing present and future oral health care needs. Others report that efforts to dislodge outdated information or clinical approaches often fail due to "entrenched turfdom."5 Bertolami3 questioned the wisdom of continuing to expect all dental students to learn and become competent in delivering treatment procedures for which there is diminishing demand. He makes his case by pointing out that the time involved in producing a general dentist competent to provide a specific procedure is no different whether the individual is expected to deliver the procedure one time during his or her practice career or hundreds of times.
Methods to ascertain a diminishing demand for specific dental procedures include alumni and/or practitioner surveys to determine the percentage of general dentists that currently provide specific oral health care procedures. However, survey approaches are typically fraught with suspicions related to the accuracy of the "self-reporting." Leggott et al. conducted one of the first objective investigations of the relationship between procedures performed in practice and by dental students.6 They analyzed the frequency at which oral health care procedures were performed in the Washington Dental Service (WDS) practices and compared these data to the frequency at which dental students at the University of Washington performed the same procedures. They concluded that the "relative mix of all services" was similar between the WDS providers and the dental students. However, their data showed that relative proportions of endodontic procedures were 2.6 times greater in WDS practices and the relative proportion of complete dentures provided was ten times greater for the dental student group. These data are intriguing, but do not allow one to answer the ultimate question: "Must all general dentists be competent in a specific procedure to take care of patient demand for that therapy?"
In an attempt to address that question for a subset of specific dental procedures, the three institutions that sponsor a predoctoral dental education program in Texas—Baylor College of Dentistry, Texas A&M Health Science Center (BCD); the University of Texas Health Science Center at Houston Dental Branch (UTDB-H); and the University of Texas Health Science Center at San Antonio Dental School (UTHSCSA)—partnered with the Metropolitan Life Insurance Company (MetLife) to compare data describing the frequency at which individual general dentists and dental students provide such care. Two of the schools (BCD and UTDB-H) have been in existence for over 100 years, while the third (UTHSCSA) opened thirty-five years ago. Each of the schools has a general practice-based, comprehensive care model for their clinical education. The majority of graduates from each of the three schools eventually practice general dentistry in the state of Texas. MetLife is a large national sponsor of preferred provider networks primarily designed to provide care for employee-sponsored dental plans. In July 2005, more than 5,700 of the 11,941 licensed dentists (including generalists and specialists) in Texas were affiliated with MetLife.
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Methods
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This study was reviewed and approved, or determined to be exempt, by the institutional review boards at Baylor College of Dentistry, Texas A&M Health Science Center; the University of Texas Health Science Center at Houston; and the University of Texas Health Science Center at San Antonio.
Data from claims submitted between January 1, 2000 and June 30, 2004 by all Texas general practitioners continuously participating in the MetLife network during that time period were obtained from the MetLife "DataMart," the central database containing the company’s claim information. Each Texas dentist participating in the MetLife Preferred Provider Organization (PPO) is listed as a preferred provider for all plans provided by MetLife in the state of Texas. Participation in a PPO requires a practitioner to accept a discounted fee for services provided to plan participants. Employees covered by a PPO, and receiving care from a preferred provider, are assured of receiving care at the discounted fee after paying a designated deductible and copayment. All procedures evaluated in this assessment are covered by all Texas MetLife PPO plans and subject to each plan’s deductibles and copayments.
The following information was extracted from the database for each Texas general practitioner (each practitioner was identified only by a unique identity number unknown to the investigators):
- dental school from which they graduated reported by an identifying number;
- the year of graduation from dental school;
- the "Geoaxis" designation of their practice location (urban, suburban, rural);
- the total number of claims submitted to MetLife during the period of January 1, 2000 through June 30, 2004;
- the number of claims for 05110-Complete Dentures, Maxillary treatment codes submitted to MetLife during the period of January 1, 2000 through June 30, 2004;
- the number of claims for 05120-Complete Dentures, Mandibular treatment codes submitted to MetLife during the period of January 1, 2000 through June 30, 2004;
- the number of claims for 03320-Root Canal Therapy, Bicuspid treatment codes submitted to MetLife during the period of January 1, 2000 through June 30, 2004;
- the number of claims for 03330-Root Canal Therapy, Molar treatment codes submitted to MetLife during the period of January 1, 2000 through June 30, 2004;
- the number of claims for 04260-Periodontal Osseous Surgery treatment codes submitted to MetLife during the period of January 1, 2000 through June 30, 2004; and
- the number of claims for 02150-Amalgam, Two Surfaces, Permanent treatment codes submitted to
MetLife during the period of January 1, 2000 through June 30, 2004.
Four of the targeted procedures (02150, 03320, 03330, and 04260) are traditionally benefited to the patient at 80 percent of the established fee, and two procedures (05110 and 05120) are traditionally benefited at 50 percent.
Data documenting care provided by all dental students graduating from one of the three Texas dental schools between January 1, 2000 and June 30, 2004 were obtained from the clinical information systems at each of the schools. Students were not identified to the investigators other than by a unique identifying number. The total number of procedures completed, as well as the number of target procedures (05110, 05120, 03320, 03330, 04260, 02150) completed during their dental school educational program, was obtained for each student.
An administrator at each school was asked to estimate, using curriculum schedules and/or course syllabi or discussions with course directors, the number of clock hours in their total curriculum devoted to the development of clinical competency for the targeted procedure codes (05110, 05120, 03320, 03330, 04260) for each of their predoctoral dental students. They were also asked to break the estimated hours into three categories: 1) didactic, 2) preclinical laboratory/simulation, and 3) clinical.
A "proportion of total procedures" for practitioners was calculated for each of the six treatment procedures by dividing the number of claims practitioners filed for each procedure by the total number of claims submitted by the practitioners. Proportions of total procedures for students were calculated by dividing the number of times each procedure was completed by the total number of procedures completed. For example, if students completed 1,000 total procedures and 30 were two surface amalgam restorations, then the proportion of two surface amalgam restorations would be 3 percent (30/1000).
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Results
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Six hundred forty-one Texas general dentists continuously participated in the MetLife Preferred Provider Network throughout the time period of January 1, 2000 through June 30, 2004. Data from each of these practitioners were analyzed. They submitted claims for 1,415,796 dental procedures during that period. Data were also obtained for each of the 1,125 dental students who completed their education at one of the Texas dental schools during that same period. These students performed 648,416 total dental procedures. "GeoAxis" identification of practice location of the general dentists determined that 222 practitioners had offices in a "Suburban" location, 308 were located in an "Urban" location, and 111 practiced in a "Rural" location. Data revealed that 198 of the general dentists graduated from UTDB-H, 186 graduated from BCD, 132 graduated from UTHSCSA, and 125 graduated from a dental school outside the state of Texas. For analysis purposes, the general dentists were clustered into four approximately equal-sized groups according to their graduation year: after 1997 (177 practitioners); from 1992 to 1997 (156 practitioners); from 1981 to 1991 (163 practitioners); and before 1981 (145 practitioners).
The initial analyses focused on whether the general dentists in the study performed the target procedures at a frequency that could be considered a routine part of their practice. For the purpose of this assessment, routine was defined as providing the procedure at a frequency that averaged more than once per year over the period of analysis.
Figure 1
shows the frequency distribution of claims submitted for maxillary complete dentures (05110) among the general dentists in the study. Over half (52.6 percent) of the general dentists in the study did not submit a claim for a single maxillary complete denture during the four and one-half year period evaluated, and 93.3 percent submitted claims for less than five maxillary complete dentures. Claims for mandibular complete dentures (05120) were submitted less frequently (Figure 2). Of the participating dentists, 68.8 percent did not submit a claim for a single mandibular complete denture; 97.8 percent submitted claims for less than five of these dentures during the study period. In contrast, practitioners submitted claims for endodontic procedures much more frequently. In this assessment, 92.7 percent of the general dentists submitted a claim for at least one bicuspid endodontic procedure (03320) (Figure 3), and 90.6 percent submitted a claim for a molar endodontic procedure (03330) (Figure 4). The participating dentists submitted claims for a mean of 11.2 bicuspid and 20.6 molar endodontic procedures over the four and one-half years. Claims for periodontal osseous surgery procedures (04260) were submitted with the least frequency (Figure 5). Of the general dentists, 93.4 percent did not submit a single claim for periodontal osseous surgery during the four and one-half years. As expected, 98.8 percent of the study participants completed a two-surface amalgam restoration (02150) (Figure 6). The mean number of claims for two-surface amalgam restorations submitted by the practitioners during the assessment period was 91.7.
The next set of analyses looked at each general dentist’s year of graduation, school of graduation, and practice location to determine if these factors influence the frequency of providing the target procedures. The general dentists in the study were divided into four approximately equal groups based upon the length of time since their dental school graduation. A one-way analysis of variance was conducted for each of the dental procedures with year of graduation serving as the classifying variable. Significant differences were found for only the complete denture procedures (05110, 05120) (Table 1). A multiple range test was performed for these two procedures, and a statistically significant, positive linear relationship between length of time out of school and the number of claims submitted for complete dentures was found (Table 2). On average, the group of dentists who had graduated before 1981 submitted claims for the most dentures (average of 1.93 maxillary and 0.96 mandibular over four and one-half years), and the group who graduated most recently (after 1997) submitted the least number of claims (average 0.72 maxillary and 0.33 mandibular over four and one-half years).
The influence of school of graduation was assessed next. The two-surface amalgam restoration (02150) was the only procedure that had a statistically significant difference related to the school from which the practitioner graduated (Table 3). The subsequent multiple range test showed a statistically higher number of claims submitted for two-surface amalgams by BCD graduates versus UTDB-H graduates (Table 4).
The next analysis looked at practice location to determine its relationship to the number of claims submitted. Significant differences were found for the two complete denture procedures (05110, 05120) (Table 5). Multiple range tests (Table 6) demonstrated that, on average, claims for complete dentures were most frequently submitted in rural areas (average of 2.04 maxillary and 0.97 mandibular over a four and one-half year period) and least frequently in suburban areas (average of 0.95 maxillary and 0.40 mandibular over a four and one-half year period).
In the last analysis, the proportion of claims submitted for the targeted procedures by the Texas general practitioners was compared with the proportion of those procedures performed by the dental students during their educational program. For Texas general dentists, the total number of claims for each procedure code was divided by the total number of claims submitted to derive a percentage for each procedure code. Similarly for students, a percentage was calculated for each procedure code by dividing the number of procedures completed in each of the targeted codes by the total number of procedures completed by the students. The resulting percentages for the dentist group were compared with the percentages for the student group using a Student’s t-test. Statistically significant differences were found between the dentists and the students for all the procedures except periodontal osseous surgery (04260) (Table 7). Some of the differences were quite dramatic. When compared to the general dentists, the percentage of all procedures devoted to maxillary complete dentures was fifteen times higher for students; and for mandibular complete dentures, the percentage of procedures was twenty-five times higher for students. Although statistically significant, the difference between the percentages of endodontic procedures provided by the two groups was not numerically large. Bicuspid endodontic procedures represented 0.43 percent of all clinical procedures for students and 0.36 percent of all claims for Texas general dentists. Molar endodontic procedures represented 0.65 percent of all claims filed by Texas general dentists and 0.36 percent of all procedures completed by the students. Both groups completed a greater number of two-surface amalgam restorations. Two-surface amalgam represented 2.82 percent of all general dentist claims and accounted for 2.31 percent of all the clinical procedures students completed. These differences, while statistically significant, were numerically small.
The Texas dental schools estimated the time they spend in a dental student’s educational program (didactic instruction, preclinical instruction, and clinical instruction) for each of the specific procedures evaluated in this study. The results are presented in Table 8. Didactic hours and preclinical hours are in lecture and/or small group education sessions. Clinical hours are calculated as individual instruction.
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Discussion
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The primary purpose of this assessment was to evaluate if specific dental procedures were delivered on a routine basis in Texas general practices. Six target procedures were chosen for evaluation. Three of the procedures (periodontal osseous surgery, maxillary complete denture, and mandibular complete denture) were selected because anecdotal comments from alumni suggested that many graduates were not delivering the procedures. The other three procedures were chosen because discussions indicated that some graduates were doing these procedures on a routine basis. Each of the selected target procedures was covered in all MetLife plans in Texas. The curricula at the three Texas dental schools were designed at the time of the assessment to develop clinical competence in all students for five of the procedures (05110, 05120, 03320, 03330, 02150). The schools did not attempt to develop clinical competence for all graduates in providing periodontal osseous surgery (04260).
Is it reasonable to expect that practitioners doing a limited number of procedures will remain competent in those procedures? Data from medical studies suggest that a minimal number of clinical experiences are needed to maintain optimum clinical outcomes.7 While it is not possible to determine exactly how often an individual dentist must complete a procedure to remain competent, we assumed that a practitioner not completing at least one procedure a year would have difficulty maintaining competence. That procedure could not be considered a routine part of their practice. The results of this analysis indicate that dentists participating in this study do not submit claims for certain dental procedures on a routine basis. This was most evident for complete dentures and periodontal surgery. Over the four and one-half year period of analysis, less than 7 percent of the participants submitted claims for five or more maxillary complete dentures, and less than 3 percent of the participants submitted claims for five or more mandibular complete dentures. Over 98 percent of participants submitted less than five claims for a periodontal osseous surgery procedure during the assessment period. In contrast, more than 63 percent of the participants submitted claims for five or more bicuspid endodontic procedures, and more than 74 percent submitted claims for five or more molar endodontic procedures during the four and one-half years. Of the general dentists, 97.5 percent submitted claims for five or more two-surface amalgam restorations during the assessment period.
Many factors may influence the frequency of claims submitted in a general dentistry practice. Year of graduation had a significant relationship to the number of claims submitted for complete dentures. There was a positive linear relationship between the number of years out of school and the total number of claims submitted for complete dentures. The group out of school the longest submitted claims for more than twice as many complete dentures as the most recently graduated participants. However, all the numbers are extremely small. The group out of school the longest submitted claims for less than one mandibular and less than two maxillary complete dentures over the four and one-half year period of analysis.
Statistically significant differences were found between the dental school attended and the number of claims submitted for class-two amalgam restorations. However, the average number of claims submitted was relatively high for all groups, and the differences are not of numerical relevance. Practice location did have a statistically significant impact on the number of claims submitted for complete dentures. Participants in rural areas submitted claims for a statistically significantly higher number of complete dentures than participants in urban areas and especially suburban areas. Once again, however, the numbers were very low. Rural practitioners submitted claims for an average of two maxillary complete dentures and one mandibular complete denture over the four and one-half year evaluation period.
An important aspect of this assessment involves a comparison of the proportion of target dental procedures completed by general practitioners versus the proportion completed by dental students. When these proportions were compared, all procedures except periodontal osseous surgery had statistically significant differences. It appears that the decision by the Texas dental schools to not educate all graduates to competency in providing periodontal osseous surgery is in sync with the need for this therapy in Texas general practices. The differences in the proportion of endodontic procedures between practitioners and students were numerically small and probably inconsequential. However, for the complete denture procedures, the differences were numerically, as well as statistically, relevant. The proportion of complete dentures completed by students was fifteen to twenty-five times higher than for participating general dentists.
Claims data from PPO databases are sometimes criticized as not being representative of the services provided to the entire population seeking dental care. Previous studies have demonstrated that insured patients 1) have higher incomes and are more likely to visit a dentist; 2) receive preventive and restorative treatments, as opposed to extractions; 3) are dentate versus edentulous; and 4) receive more periodontal and fewer denture services than the uninsured.8–11 Conversely, it has been shown that edentulous and poorer adults, particularly those living in rural areas, are less likely to have dental coverage and less likely to seek dental treatment.12,13 Differences in utilization rates between public (Medicaid) and private dental insurance have also been compared and indicate that Medicaid enrollees, presumably in poorer economic condition, visit the dentist less frequently and are four times as likely to have a tooth extracted as patients with private insurance.14 From these studies it can be concluded that there are differences between insured and uninsured patient cohorts, especially between those individuals with private dental insurance versus the poor and uninsured. Patients with private dental insurance do retain their teeth at higher rates than the uninsured and are less likely to utilize complete denture services than noninsured patients.
However, does acknowledging that there are uninsured and poorer people with need for complete dentures invalidate the usefulness of analyzing insurance data to assist curricular decisions? The answer may be no, for the question posed isn’t how to address known oral health disparities and unmet need, but rather, how to use this information to make rational decisions regarding predoctoral curriculum content. If a dental school’s role is to prepare most graduates for the private practice of general dentistry, shouldn’t the curriculum prepare them to competency in the services general dentists actually provide, or are likely to provide, in the future?
Legitimate data regarding the service mix in general dental practices are difficult to obtain. Self-reported surveys of graduates can be used, but data from these sources are highly questionable. Dental insurance databases are data-rich, but they have been criticized for not being comparable to the needs of the general population who seek dental care. Before dismissing claims data as being biased, it is reasonable to evaluate other dental practice information that supports the premise that the patient cohort in this study is representative of patients in most dental practices. The 2001 American Dental Association (ADA) Survey of Dental Practice reported that 47.7 percent of the payments for dental services made in the year 2000 were from private insurance.15 The same survey reported the average cost per visit was $203.80. This seems to indicate that many patients who seek care either have third-party coverage, the means to afford significant out-of-pocket expense, or a combination of the two. And, though there is evidence indicating that since 1989 the number of insured patients has decreased, the same study points out that the percentage of patients with at least one dental visit during the past year has grown.16 A trend, if it continues, suggests the burden for payment will increasingly become the patient’s and in turn diminish accessibility to dental care for lower socioeconomic groups, such as those needing dentures. Finally, additional data in this and at least one other study13 suggest a positive correlation between a rural practice location and demand of patients for complete dentures. If significant numbers of dental school graduates are seeking to practice in areas with high demand for complete denture therapy (rural), it would need to be taken into account. However, this isn’t the case. Information available about future practice and location plans indicates graduating senior dental students continue to choose metropolitan and urban/suburban areas (95 percent) over rural ones (5 percent).17 Taken in total, this suggests that dentists choose to practice in nonrural settings and provide services to patients who have the means to afford them. Their patients, more than likely, are of higher socioeconomic status, are employed, have their teeth, and intend to keep them. Thus, the differences regarding the scope of care required by patients with private third-party dental insurance and that required by patients making up the backbone of most dental practices may be minimal.
Target procedures were selected that were covered by all MetLife PPO plans in Texas to ensure optimal data were available. Maxillary and mandibular complete immediate dentures (05130, 05140) were not included in the targeted group because these procedures were not covered in all plans. Two-surface posterior composite restorations were not included for the same reason. It is acknowledged that immediate complete dentures and posterior composite restorations are completed in Texas general dentistry practices. This assessment does not allow determination of the number of practitioners that routinely deliver that care.
The data describing curricular hours submitted by the Texas dental schools (Table 8
) indicate that the time committed to periodontal osseous surgery, endodontic therapy, and amalgam restorations appears to be in line with the schools’ educational expectations (exposure to periodontal osseous surgery, clinical competency in endodontic therapy, and amalgam restorations). It also appears that the relative number of clinical experiences in these procedures offered to the students is compatible with the skills necessary to meet the treatment needs in a Texas general practice.
The data calculated by the Texas dental schools as an estimate of the time they devote in their curricula to complete dentures are in line with the data collected in a 2001 survey of all U.S. dental schools.18 That survey reported the mean preclinical laboratory time devoted to complete dentures (maxillary and mandibular) as seventy-four hours with a range of 31.5 hours to 160 hours. This compares with a mean of 89.9 hours of preclinical laboratory instruction in complete dentures at the Texas dental schools. The survey reported that the mean "lecture" time devoted to complete dentures was twenty-eight hours, with a range of twelve hours to eighty hours. The Texas dental schools report a mean of twenty-six hours devoted to didactic instruction in complete dentures. When one considers the didactic hours, the preclinical hours (for which U.S. dental schools report student/faculty ratios averaging 12:1),18 and the amount of faculty time devoted to supervising predoctoral students delivering complete denture care (again under relatively low student to faculty ratios), it must be concluded that each Texas dental school commits a significant portion of its educational resources to prepare each graduate to attain clinical competency in delivering complete dentures.
The literature contains little information regarding the frequency with which general dentists deliver complete denture care.19,20 However, the available data confirm the findings of this assessment that, overall, the fabrication and delivery of complete dentures consume an extremely small portion of a general dental practice. Population studies21,22 show a rapidly decreasing rate of edentulism in the United States. While some authors23 predict that less than 15 percent of the population will be edentulous by 2020, others,24 using algorithms that involve significant speculation and extrapolation, predict that the need for complete denture care will increase by 2020. In spite of this uncertainty, many authors23,25,26 predict that patients needing complete dentures in the future will be older, medically and physically frail, clinically complex to manage, and require more specialized care. Faced with this information, dental schools must carefully consider how these services will be provided in the future and whether all graduates should be expected to provide complete denture therapy in their practices.
Since the graduates of many U.S. dental schools end up in a variety of geographic locations, schools tend to use national oral disease data when analyzing the scope and depth of their curricula. All of the three Texas dental schools are financially state-assisted and are dictated by state law to matriculate a high percentage of Texas residents. When this fact is combined with historical outcomes data describing ultimate location of practice for the schools’ alumni, the Texas dental schools can safely predict that the vast majority of their future graduates will practice within Texas.
The general dentists assessed in this study practiced within the state of Texas and are presumed to primarily treat Texas residents. Texas has a significantly lower rate of edentulism (17 percent) in its population compared to the U.S. population (24.4 percent edentulous).27 This may, at least partially, explain the low frequency of claims submitted for complete dentures by Texas general dentists in this assessment and the extremely low number of practitioners who provide complete dentures as a routine part of their practice. If Texas dental schools carefully assess the preceding data, it appears that questions must be asked regarding the amount of time and effort within their educational program that is devoted to ensuring that all graduates are competent in providing complete denture care. However, one must be careful in extrapolating this rationale to other dental schools or geographic regions. The U.S. surgeon general’s report22 lists states with state-assisted dental schools that have much higher rates of edentulism (West Virginia, 44.9 percent; Kentucky, 44.0 percent; Louisiana, 43.0 percent), indicating that a greater percentage of general practitioners delivering complete denture care may be necessary to meet the societal demand in those regions. Schools must use data describing the practice location of their graduates and scope of practice assessments from those locations to determine the appropriate scope and depth of their curricula.
Obviously, dental schools must consider many factors when they analyze the significance of specific areas within their curricula. Perhaps some of the procedures in this assessment (or others provided infrequently in private practice) are important to teach students principles that cannot be addressed through other means. For example, are periodontal surgery experiences necessary for students to observe the clinical phases of wound healing?
Patient selection in dental schools is also directly affected by the school’s curriculum. Patients are typically selected based on how well their treatment needs coincide with the educational needs of the institution. Many schools routinely turn away patients who represent the "norm" that would enter a private practice because they may not have the specific needs to ensure that students get an adequate breadth of experiences. Would accepting more patients who fit the private practice "norm" contribute to a more competent and well-rounded practitioner? In many schools this is more of a philosophical question than a practical one because of the numerous variables that influence the type of patients presenting for treatment, including clinic location, clinic hours, fees, and length of appointments.
Determining the areas of oral health care in which dental schools should educate all predoctoral students to a level of competence is not an easy task. One must first consider that many current students will graduate within the next few years and enter a general dental practice. Many of them will choose to step immediately into an associateship or group practice and must be capable of efficiently and effectively delivering the scope of care expected by the other members of the practice. Others may choose to initiate their own solo general practice and must deliver care that patients currently expect and want. Irrespective of practice mode, graduates must be capable of providing care within the present scope of practice and meeting the existing standards of care. Graduates must also be prepared to address expanding or developing areas of oral health care that will ultimately evolve into general dentistry’s scope of practice. Determining the appropriate balance between educating the general dentist for today’s practice and preparing him or her for the challenges of tomorrow have stimulated lively debates within dental school curriculum committees.
Faculty members typically stay abreast of the latest literature on therapy approaches likely to impact the future scope of general dentistry. A variety of emerging therapies and techniques are likely to exert a major impact upon the practice lives of our current students including more effective and esthetic restorative materials, biocompatible restorative and implant materials, computer-assisted design and fabrication of restorations, biologically engineered substitutes for diseased or missing oral and paraoral tissues, genetic-based diagnostics, and computer-assisted diagnosis/treatment planning/therapy. Faculty members in all dental schools face the challenge of how to incorporate these emerging technologies and therapeutic advances into the curriculum. A much more difficult challenge is identifying the material that is less relevant for the future and thus should be removed from the already overcrowded dental school curriculum.
Some faculty members continue to argue that if a therapy approach is still needed by some patients, then it must be taught to a level of competence for all dental students because any one of them, as a general dentist, may be called upon to deliver that therapy. Perhaps there is another way to look at this issue. Not all general dentists provide all aspects of oral health care in their practices. Many narrow the breadth of their practice based upon the number of times they are called upon to deliver certain types of care, the availability of specialty care, or their comfort level with providing specific procedures. If the demand for a specific type of care has diminished to a level that doesn’t require all general dentists to be competent in delivering it, why should dental schools continue to invest the time and effort to ensure that all graduates can competently provide that type of care? Wouldn’t it be better to provide education for that specific area, via electives or selectives, to a subset of graduates with a specific interest in delivering that type of care in their practice? Another solution would be to target advanced general dentistry programs (GPR, AEGD) or formalized postdoctoral, continuing education, or preceptor programs to prepare selected general practitioners to competently perform these procedures.
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Conclusions
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The data obtained in this assessment demonstrate a reasonable match between curricular time, as well as the proportion of patient care experiences, for students in Texas dental schools and the skills needed in a Texas general dentistry practice for the following procedures: periodontal osseous surgery, endodontic therapy, and amalgam restorations. There is a significant disparity between the didactic and clinical curricular time devoted to complete denture education at Texas dental schools compared to the extremely low frequency with which the Texas general dentists in this study submitted claims for such care. When faced with overcrowded curricula, dental schools should use data such as reported in this study to determine the appropriate scope and breadth of students’ educational activities. The creation of expanded and robust databases that include information from fee-for-service general dentistry practice would assist schools in making improved curriculum decisions.
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Acknowledgments
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The authors sincerely thank Ms. Susan Baker-Keene for her coordination of the activities between the dental schools and MetLife during this assessment and Dr. Jim Kennedy for his review of this manuscript and editorial comments.
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Footnotes
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Dr. Solomon is Professor of Public Health Sciences and Executive Director, Institutional Research, Texas A&M Health Science Center; Mr. Murray is Manager, Finance at MetLife Dental; Dr. Dodge is Professor of General Dentistry and Vice Dean, University of Texas Health Science Center at San Antonio Dental School; Dr. Redding is Professor of General Dentistry and Interim Chair of Dental Diagnostic Science, University of Texas Health Science Center at San Antonio Dental School; Dr. Valenza is Associate Professor of Diagnostic Sciences and Executive Associate Dean, University of Texas Health Science Center at Houston Dental Branch; Dr. Flaitz is Professor of Diagnostic Sciences and Dean, University of Texas Health Science Center at Houston Dental Branch; Dr. Cole is Professor of Restorative Sciences and Dean, Baylor College of Dentistry, Texas A&M Health Science Center; and Dr. Kalkwarf is Professor of Periodontics and Dean, University of Texas Health Science Center at San Antonio Dental School. Direct correspondence and requests for reprints to Dr. Kenneth L. Kalkwarf, UTHSCSA-Dentistry, 7703 Floyd Curl Drive, San Antonio, TX 78248; 210-567-3160 phone; 210-567-6721 fax; kalkwarf{at}uthscsa.edu.
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