J Dent Educ. 71(12): 1549-1553 2007
© 2007 American Dental Education Association
Milieu in Dental School and Practice |
Changes in Orthodontic Care Patterns in a Predoctoral Children’s Dentistry Clinic
Stanley A. Alexander, D.M.D.
Key words: orthodontic care patterns, predoctoral students, children’s clinic, decline in clinical experience
Submitted for publication 03/23/07;
accepted 09/04/07
 |
Abstract
|
|---|
The purpose of this study was to evaluate the changes in orthodontic care patterns over a sixteen-year period in a university clinical setting. The average numbers of students, clinical procedures, and orthodontic appliances were examined from the time period 1988–2003. Appliance number and type were evaluated as a function of increased predoctoral and postdoctoral class sizes, student to faculty ratios, and decreased operating budgets for faculty recruitment. For the period 1988–98, the insertion of orthodontic appliances by dental students remained constant. A permanent increase in the predoctoral class size occurred in 1996 without an increase in faculty support, contributing to a decline in appliance insertions by students from 1999 to 2003. This time period also saw major increases in the postdoctoral class size and a reorganization of the clinical facility that then began to require the pairing of dental students to provide comprehensive care, thus decreasing their clinical exposure to the care of children. The overall clinical experience at the predoctoral level in orthodontic procedures declined, which resulted in a change in clinical requirements and new methods to ensure clinical competency.
It is recognized that 33 to 50 percent of the orthodontic and pediatric dental services in the United States is provided by general practitioners, while the remainder of care is provided by specialists.1–3 A segment of the population still does not seek care nor acquire treatment when needed, thus remaining unserved. Additionally, economic, geographic, and transportation issues may contribute to this overall problem. As a result, pediatric patients are described as underserved in the U.S. surgeon general’s report on oral health care.4 While the majority of general dentists do treat child patients,5 they are selective in the age ranges they wish to treat. While educational preparedness may be responsible for this decision5 to treat or refer to a pediatric dentist or orthodontist, it remains a logical sequence of events to shift the emphasis from treating disease to maintaining children in a disease-free state when less restorative care is required6 in the university or the private practice setting. As a consequence, there is a natural evolution toward increased appliance therapy, as restorative care decreases in a pediatric dental school population.
Several factors have contributed to the undermining of dental students’ educational experiences in the care of children. These include decreased operating budgets for major health care centers at the university level,7 critical shortages of new and full-time faculty members to clinically supervise student patient care,8–11 and the "encouragement" by administrations to accept increased numbers of postdoctoral specialty students to provide care, bolster tuition revenue, and serve as junior faculty on the clinical floor.12 The results of these factors and implementations in dental schools should have a major impact on the way future general dentists diagnose, treat, or refer their pediatric patients for subsequent care. It has been suggested that the educational experiences concerning the treatment of pediatric dental patients will shape the attitudes and clinical behavior of future dental care providers,13 thus influencing the comprehensive care of children.
The Department of Children’s Dentistry at Stony Brook University was founded in 1973 as a combined specialty department of orthodontics and pediatric dentistry, responsible for teaching the scientific and clinical bases of these two disciplines to predoctoral dental students in a coordinated and logical manner. The purpose of this article is to discuss how the educational experience of predoctoral students in the area of children’s oral health care was modified over a sixteen-year period of time. A study conducted at the University of Manitoba found that students whose educational programs are substantially enhanced during their undergraduate training were more likely to perform complex procedures such as orthodontics with children after they entered practice, while the lack of a substantial predoctoral experience may detract from the willingness and confidence new graduates have in treating children.5
|
Methods
|
|---|
From 1988 to 2003, the predoctoral class size at the Stony Brook University School of Dental Medicine ranged from twenty-four to forty students, with a major increase occurring from 1996 to 2003 when the average was 38.25 students per year compared to 25.12 students from 1988 to 1995. Most of the students’ exposure to clinical procedures in pediatric dentistry and in orthodontics through the Department of Children’s Dentistry occurred in the third year of the predoctoral program. Students were required to treat patients six hours per week for approximately forty-four weeks, averaging 250 hours of clinical care in these combined disciplines. Patient assignment was random, and students carried a complete roster of patients to occupy the scheduled clinical rotation. The time committed to the discipline remained constant during the sixteen-year period. From 1996 to the present, the students have been paired to deliver patient treatment as a result of the new clinic design and the shortage of faculty to adequately and safely teach pediatric dentistry and orthodontics at the predoctoral level.
For both time periods (1988–98 and 1999–2003), students were required to treat their pediatric patients in a comprehensive manner. A complete diagnosis, preventive strategy, and treatment plan were generated for each patient. Restorative procedures ranged in difficulty from the placement of sealants to the fabrication of stainless steel crowns, with most of the care requiring the placement of amalgam or composite restorations. Orthodontic procedures ranged from the insertion of the more common simple unilateral and bilateral space maintainers, palatal expanders, and habit appliances to fully active edgewise appliances. Data for appliance insertion by predoctoral students were collected annually from 1988 to 2003 through computer tabulation and delivered to the chair of the department for review. The method of data collection was similar each year. In short, students were clinically exposed to a multitude of restorative procedures and to complex orthodontic care when needed for their patients. Two orthodontic appliances were required to be placed per student per year.
For this study, the t-test for independent data was used to evaluate the statistical significance between the time periods 1988–98 and 1999–2003 for the following criteria: the average number of procedures performed between the groups, the average number of appliances inserted, and the difficulty levels encountered in appliance design. Stepwise multiple regression analysis was used to assess relationships between student productivity (the number of appliances) as the dependent variable and the student to faculty ratio during the two time periods (1988–98 and 1999–2003) as the independent variables.
|
Results
|
|---|
From 1988 to 1998, the number of inserted orthodontic appliances by dental students remained constant and followed the levels of activity of previous classes from the inception of the predoctoral program in 1973 (Table 1
). When the two time periods of 1988–98 and 1999–2003 are compared, student class size increased by 52 percent, patient care per student decreased by 47 percent, the total number of clinical procedures decreased by 51 percent, and appliance therapy decreased by 41 percent. Differences between the time periods were statistically significant at the 95 percent level (p<.05) for all four variables. Appliance difficulty levels decreased by more than threefold between the two time periods. From 1999 to 2003, the average number of appliances defined as advanced for predoctoral students (e.g., rapid palatal expanders, quad-helices, and fully bonded edgewise appliances) decreased to an average of seven placed per year in comparison to the average of 22.9 placed per year from 1988 to 1998. This difference was statistically significant at the 99 percent level (p<.01). The ratio of the combined predoctoral and postdoctoral student body to the orthodontic faculty dramatically increased during 1988–2003 as a function of increased class sizes and decreased faculty numbers.
View this table:
[in this window]
[in a new window]
|
Table 1. Annual total student class size, total number of appliances inserted, and average number of appliances inserted from 1988 to 2003 at Stony Brook University School of Dental Medicine
|
|
The stepwise regression analysis displayed a strong correlation between the numbers of appliances placed during the two time periods and the increased student to faculty ratio (Table 2). The decrease in overall appliance placement from 1999 to 2003 when compared to 1988–98 indicated a statistically significant difference (p<.01) in appliance insertions. The student to faculty ratio in relation to appliance placement for the two time periods was also statistically significant at p<.05.
View this table:
[in this window]
[in a new window]
|
Table 2. Multiple regression analysis (stepwise) of time period I (1988–98) and time period II (1999–2003) of the average number of appliances inserted as a function of the student/faculty ratio
|
|
|
Discussion
|
|---|
The clinical significance of these results is highly relevant. From 1988 to 1998, the number of orthodontic appliances inserted by dental students remained relatively stable, while the total number of clinical procedures was constant. A rapid decline in appliance insertion occurred from 1999 to 2003, indicating a more than casual relationship between student productivity and faculty number. More importantly, the overall educational and clinical experience in pediatric and orthodontic procedures declined.
The events that led to the decreased clinical exposure of orthodontics in the Department of Children’s Dentistry for predoctoral dental students at one dental school are not likely to be unique to the institution described. The forces that influenced this change in clinical education in pediatric dentistry and orthodontics are most likely common to many dental schools. For these results to take place at Stony Brook University, 1) the predoctoral scenario included an increase in the dental class size without a corresponding increase in the size of the faculty; 2) the clinic geography and geometric design of the clinical facility were not conducive to large-scale teaching, so students were then paired to deliver treatment; as a result, the single student to patient approach that had been in place for twenty-three years had to be abandoned since it was not deemed safe to allow treatment by students without visual contact and under the supervision of fewer faculty; and 3) a net loss in faculty lines occurred, since no new faculty lines were created while student class size increased, resulting in a higher student to faculty ratio.
The impact of increasing the postdoctoral class size also had a direct influence on predoctoral educational and patient care patterns. From 1990 to 1994, the program consisted of four students in a twenty-four month program, which expanded both in size and duration to eleven students and thirty-six months. The reasons to increase the postdoctoral class size were threefold: 1) a greater number of students would result in higher total amounts of program fees to the parent institution; 2) since specialty students are more efficient than their predoctoral counterparts, clinical revenue would increase to offset decreased state allocations to the operating budget;7 and 3) postdoctoral students may serve as a less expensive source of labor when faculty positions remain unfilled.11 Another outcome of increasing the postdoctoral class size was that the more advanced orthodontic procedures once carried out by predoctoral students were channeled to the larger postdoctoral program. The graduate program required an abundance of patients in its clinical program, and these patients could also be charged increased fees since treatment is provided at a higher level of training.
The combined effect of all these variables converging during a brief period of time was a substantial decrease in dental students’ opportunities to provide patient care for children. As a corollary to Murphy’s Law, unfortunately, everything went wrong at the same brief time. The full impact in the net decreases in faculty lines and significant increases in the predoctoral and postdoctoral programs took approximately three to four years to manifest itself in the orthodontic care patterns of predoctoral students. On a simple arithmetic basis, the pairing of students should have decreased the clinical exposure to orthodontic procedures by 50 percent per student; this, however, was not the case since decreases in this subject category over the four-year period from 1999 to 2003 were as high as 60 percent on average, with a steady progression of less than one appliance placed per student and advanced care levels of experience all but becoming extinct.
Finally, it is feasible that other factors not under our control influenced the decreased exposure of orthodontics to the predoctoral students. A general decline in space maintenance or space-regaining procedures is possible as a result of preventive dentistry, improved caries control, and fewer extractions of primary teeth; however, the extraction patterns for the two time periods observed did not change. The need for space maintenance may have been lower due to the potential timing of primary tooth extraction to permanent tooth eruption of the patient population cohort seen during 1999–2003.
The orthodontic philosophy of the department remained unchanged for over a quarter of a century and provided a liberal education in orthodontic treatment for dental students, yet the exposure to these procedures decreased. Although there are some in dental education who question the role and scope of orthodontics in the undergraduate core curriculum, demand and need by the public exceed the capacity of the specialty to deliver the amount of care needed.3 It is imperative that the dental student and future general dentist be exposed to this clinical science since it is of extreme interest to both the student and generalist. Despite a lack of formal training, more than 75 percent of general practitioners do some orthodontics, while 20 percent may do comprehensive orthodontics.1
As a result of the decreased exposure to restorative care and orthodontic procedures, the clinical requirements of third-year dental students were changed and incorporated competency requirements on typodonts and manikins rather than actual patients. Care became simulated rather than direct, which may be one important method to implement when a decline in clinical procedures compromises competency requirements of dental students. Required lectures in pediatric dentistry and orthodontics decreased within the department as it shifted to a more case-based approach as well. In response to the decreased exposure to orthodontic care, resources should be reallocated in the curriculum to provide increased time in this discipline so that students have a longer clinical experience and gain the ability to perform competently in the care of children and contemporary general dentistry. Doing so may stimulate opposition and require modifications in other clinical disciplines, but to quote Daniel Patrick Moynihan, former U.S. senator from New York, "The future of a society may be forecast by how it cares for its young."14
At the same time, the emphasis on education, teaching, and research was replaced with the business of patient care when more clinical income produced by postdoctoral orthodontic students became necessary to offset decreased state allocations to a budget-poor environment. As Donoff states, the environment in which dental education operates has changed and is continuing to change.15 More importantly, if the lack of access to dental care of children exists, it becomes critical for the predoctoral dental curricula to ensure that future health care providers receive sufficient education and clinical experience.13 It is imperative to improve the quality and scope of care and increase the number of children who receive attention in dental school clinical facilities but with recognition that no two dental schools and curricula are alike and varied missions exist amongst dental institutions. However, as in the case at Stony Brook University, students’ overall exposure to pediatric and orthodontic procedures declined; as a result, once students graduate, they may more frequently refer such patients for specialty care. Due to our graduates’ insufficient clinical knowledge in common orthodontic procedures, patients’ need for treatment may now go undiagnosed and untreated in future years.
|
Conclusion
|
|---|
Changes that have occurred in the orthodontic care patterns of predoctoral dental students have resulted in a rapid decrease in the number of appliances inserted and an overall decline in the clinical experience. It is hypothesized that the changes described in care patterns in predoctoral education have resulted from the following circumstances: an increased student to faculty ratio resulting in less clinical contact; an increase in the postdoctoral orthodontic class size, which would draw patients from the predoctoral program; and a net loss of faculty lines, which required less-experienced postdoctoral students to teach their predoctoral counterparts.
The results of these factors have contributed to less than ideal clinical exposure to orthodontic procedures by predoctoral dental students. Schools of dentistry should review and reallocate resources and increase the clinical exposure for students in the predoctoral program in order to give the general practitioner an adequate foundation in pediatric dentistry and orthodontics for contemporary practice.
|
Footnotes
|
|---|
Dr. Alexander is Professor and Chair, Department of Pediatric Dentistry, School of Dental Medicine, Tufts University. Direct correspondence and requests for reprints to him at Department of Pediatric Dentistry, Tufts University School of Dental Medicine, One Kneeland Street, Boston, MA 02111; 617-636-3898 phone; 617-636-3473 fax; stanley.alexander{at}tufts.edu.
|
REFERENCES
|
|---|
- Wolsky SL, McNamara JA. Orthodontic services provided by general dentists. Am J Orthod Dentofacial Orthop 1996; 110(1):211–6.[Medline]
- Seale NS, Casamassimo PS. Access to dental care for children in the United States. J Am Dent Assoc 2003; 134(12):1630–40.[Abstract/Free Full Text]
- Bertolami CN. Rationalizing the dental curriculum in light of current disease prevalence and patient demand for treatment: form vs. content. J Dent Educ 2001; 65(8):725–35.[Abstract]
- Oral health in America: a report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000:7.
- Lekic PC, Sanche N, Odlum O, deVries J, Wiltshire WA. Increasing general dentists’ provision of care to child patients through changes in the undergraduate pediatric dentistry program. J Dent Educ 2005; 69(3):371–7.[Abstract/Free Full Text]
- Ripa LW. Change in care patterns in dental school children’s dentistry clinic. J Dent Educ 1986; 50:309–11.[Medline]
- Bailit HL, Beazoglou TJ, Formicola AJ, Tedesco L, Brown LJ, Weaver RG. U.S. state-supported dental schools: financial projections and implications. J Dent Educ 2006; 70(3):246–57.[Abstract/Free Full Text]
- Schenkein HA, Best AM. Factors considered by new faculty in their decision to choose careers in academic dentistry. J Dent Educ 2001; 65(9):832–40.[Abstract]
- Haden NK, Weaver RG, Valachovic RW. Meeting the demand for future dental school faculty: trends, challenges, and responses. J Dent Educ 2002; 66(9):1102–13.[Abstract]
- Livingston HM, Dellinger TM, Hyde JC, Holder R. The aging and diminishing dental faculty. J Dent Educ 2004; 68(3):345–54.[Abstract]
- Chmar JE, Weaver RG, Valachovic RW. Dental school vacant budgeted faculty positions: academic year 2004–05. J Dent Educ 2006; 70(2):188–98.[Abstract/Free Full Text]
- Field MJ. Dental education at the crossroads: challenges and change. A report of the Institute of Medicine. Washington, DC: National Academy of Sciences, 1995.
- Rich JP III, Straffon L, Inglehart MR. General dentists and pediatric dental patients: the role of dental education. J Dent Educ 2006; 70(12):1308–15.[Abstract/Free Full Text]
- Speech at the John F. Kennedy School of Government, Harvard University, March 16, 1998.
- Donoff RB. It is time for a new Gies Report. J Dent Educ 2006; 70(8):809–19.[Free Full Text]
Top
Abstract
Methods
