J Dent Educ. 71(5): 572-578 2007
© 2007 American Dental Education Association
Caries Management: Transitioning from Education and Research to Improve Patient Care |
A New Curriculum Framework for Clinical Prevention and Population Health, with a Review of Clinical Caries Prevention Teaching in U.S. and Canadian Dental Schools
John P. Brown, B.D.S., M.S., Ph.D.
Key words: prevention, population health, curriculum, risk assessment, oral health, clinical teaching, clinical outcome, ethical values, dental care, health professions, dental caries
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Abstract
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To fulfill the Healthy People 2010 Objective 1.7, "Increase the proportion of . . . health professional training schools whose basic curriculum for health care providers includes the core competencies in health promotion and disease prevention," the Healthy People Curriculum Task Force has developed a curriculum framework for clinical prevention and population health for all the health professions. This framework has four components: 1) evidence base for practice; 2) clinical preventive services, including health promotion; 3) health systems and health policy; and 4) community aspects of practice. Within these four common components are nineteen domains, for which each health profession is identifying its own educational objectives. An inventory of knowledge and skills is being developed. A prerequisite to promoting change in the teaching of dental prevention and population oral health is to better understand the current status. Sixty-six of sixty-eight U.S. and Canadian dental schools provided input on the teaching of one important aspect of this wider topic—dental caries prevention—before a December 2002 Clinical Preventive Dentistry Leadership Conference in Cincinnati, OH. In clinical teaching, 68 percent of dental schools included caries risk assessment and also reevaluated preventive outcomes, but while 65 percent included remineralization procedures, only 38 percent specifically reevaluated this outcome. Faculty members have commonalities in attitudes about the advantages and problems in improving teaching in clinical prevention, yet dental schools act individually in curricular design and implementation. The conference introduced a method of conceptualizing change, so that dental schools might address organizational barriers in clinical curriculum development. Even with the new common curriculum framework, other barriers to improved dental prevention and population oral health exist: these include organizational change in dental schools, dental practices, and dental clinics; reimbursement issues and incentives; and lack of accepted and explicit standards in dental care.
The Healthy People 20101 national goals have encouraged a reexamination of clinical education by including an objective "to increase the proportion of schools of medicine, schools of nursing, and health professional training schools whose basic curriculum for health care providers includes the core competencies in health promotion and disease prevention." The Healthy People Curriculum Task Force, with representatives of all clinical health professional educational organizations, including the American Dental Education Association, accepted this challenge. The task force proposed a common curriculum framework for all health professions students and specified how this framework is to be named. It assumes the need for effective interprofessional communication and collaboration and increased opportunities for multiprofessional education and training. The resulting working document is the Clinical Prevention and Population Health Curriculum Framework for Health Professions.2
The knowledge base and skills for clinical prevention and population health are outlined therein, but underlying ethical values are not explicit in the framework and related documents.2 These values include the often accepted hierarchy of obligation in doing good,3 which has particular relevance to prevention:
- nonmaleficence, including the avoidance of iatrogenic harm (primum non nocere);
- beneficence in preventing pain, suffering, disability, and cost of disease and disorder;
- beneficence in the removal of potential and actual harm; and
- beneficence in doing and promoting that which is good.
Other ethical values inherent in prevention include veracity and its derivative fidelity, promoting autonomy of patients through self-care behaviors, and distributive justice.
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Clinical Prevention and Population Health Curriculum Framework
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This framework consists of four components with nineteen domains. The four common components are 1) the evidence base for practice; 2) clinical preventive services, including health promotion; 3) health systems and health policy; and 4) community aspects of practice. Under the nineteen domains, each health profession is to identify its content and education objectives. An inventory of knowledge and skills is being developed.4
Since this present series of articles concerns dental caries specifically, what follows focuses on that disease, particularly in Component 2. The other three components are more general. The proposed content and educational objectives will also have to be developed for prevention of periodontal disease, oral cancer, orofacial injury, oral infectious diseases, orofacial developmental disorders, etc.
Component 1: Evidence Base for Practice
The evidence base for practice has five domains:
- epidemiology of caries including biostatistics;
- methods to evaluate caries research literature, e.g., evidence-based and other reviews;
- outcome measurement: quality of life, quality of care, cost, mortality, and morbidity;
- health surveillance: vital statistics, surveillance reports, and risk factors; and
- determinants of health: disease burden, genetics, health behavior, socioeconomic status, environment, health care access, and quality.
Component 2: Clinical Preventive Services, Including Health Promotion
The focus is restricted to dental caries in this article. These four domains, which parallel the structure of the U.S. Preventive Services Task Force, include the set of skills dentists and dental hygienists most immediately associate with preventive services:
- screening—dental professionals too often think of this as simply case finding. However, it involves medical, dental, and preventive history, assessment of self-efficacy, oral health quality of life assessment, orofacial functional status, an appropriate range of caries detection tests, indicator oral bacterial and salivary tests, dietary assessment, and fluoride use. All elements of the above, at an appropriate level of intensity, lead to a summary caries risk assessment for the individual;
- counseling for health behavior change, utilizing contemporary health behavioral science;
- the task force proposed this domain be "immunization." For dentistry, it is suggested this be named "professionally applied preventive procedures"; and
- chemoprevention—in the case of dentistry, this is typically self-applied.
An outcome assessment should apply to all domains. For example, screening of individuals should lead verifiably to counseling, modified personal oral health behaviors, and professional preventive procedures and treatment, the outcomes of which are assessed, recorded, and if necessary modified.
Component 3: Health Systems and Health Policy
These four domains are the following:
- organization of clinical and public health systems;
- health services financing—public and private;
- the health workforce—regulation, discipline, minorities, relations to other disciplines, and legal and ethical dimensions; and
- the health policy process—how contemporary and best science is applied to help determine health policy at the three levels of government, policy process participation, impacts of policy on health and health care, and outcomes.
Component 4: Community Aspects of Practice
This component has six domains:
- communicating health information—community needs and strengths, health literacy, and cultural awareness in communication;
- environmental health—living conditions and discipline-specific aspects;
- occupational health—patients, the public, and health professionals;
- global health issues—varying responses to disease and disorder, outcomes under other systems for individuals and peoples, globalization, and international organizations;
- cultural dimensions of practice—influences on health care delivery and on recipients, including health beliefs; and
- community services—access, partners, community preventive services, and public health preparedness.
A more detailed elaboration of the nineteen domains is available.2 Recommendations for timing, coordination of the curriculum, integration of content, and competency assessment have also been published.5 Twenty-six responding U.S. dental schools were largely positive in an initial response to the Prevention and Population Health Curriculum Framework.6 They considered the components clear and concise, except for "health systems and health policy," which traditionally has not been taught. They thought the content was 1) highly relevant throughout, 2) valuable for planning a preventive curriculum, 3) somewhat valuable for assessment of students, and 4) valuable for fostering interdisciplinary collaboration (less so for clinical preventive services and health promotion, which is contradictory). Generally, they thought the content was too broad. Teaching the wider health care context and interprofessional collaboration is a major goal of the framework and one of its motivations. Perceived narrow professional boundaries are revealed as a barrier to this curriculum change.
These dental schools thought their environments were positive for the new framework with respect to incentives, responsiveness to advances, room for new topics, and promoting the schools’ image. However, they did recognize the difficulties of change and that there are already many curricular requirements. Apparently, some classroom attention is already given to the domains in many of these twenty-six dental schools. However, very few cover these in both a course and a practicum. Global health issues were recognized by the commentator schools as a current weakness. This domain is often missing from existing curricula, for which reason the task force seeks its enhancement. The challenge now is to harness the framework to systematize, improve, and better implement both clinical oral prevention and population oral health in dental schools for wider adoption in the private and public practice of dentistry as well as in community oral health programs.
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Current Status of Teaching Prevention of Dental Caries in U.S. and Canadian Dental Schools
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It is essential to better understand the teaching of dental prevention and population oral health as a prelude to desired change. Such a study was undertaken of the classroom and especially clinical teaching of dental caries prevention prior to a Clinical Preventive Dentistry Leadership Conference held in Cincinnati, OH, December 11–13, 2002. Although the survey concerned only the teaching of caries prevention, it was very revealing generally. Sixty-six of sixty-eight U.S. and Canadian dental schools responded. Attempts were made particularly to reach faculty with preventive teaching responsibilities, especially clinical instruction. Those who responded had formal responsibility for some or all of the teaching of biology of caries, diet and caries, individual patient oral health education theory and methods, and preventive agent formulations, actions, safety, efficacy, and modes of use, as well as clinical applications. They were dispersed across basic science and clinical disciplines and utilized combinations of lectures (100 percent), formal problem-based learning (26 percent), seminars (34 percent), and other methods (26 percent) in didactic teaching. One or more written competencies in preventive dentistry existed in 70 percent of U.S. and 66 percent of Canadian dental schools.
Forty percent of schools had so formalized clinical preventive dentistry that they had a course number for it. Eighty-six percent integrated this material into other clinical disciplines. Few had numerical requirements in clinical caries prevention (22 percent), and 25 percent did not grade student clinical performance in any way. These low frequencies cast doubt on the reported high levels of teaching some facets of clinical prevention, which are shown in Table 1
. In 31 percent of schools, no department or division was responsible for organizing caries prevention in the student clinics; in 23 percent, no such entity was responsible for actual clinical instructions. A small group of faculty, a departmental or divisional chairperson, or a curriculum committee was most influential in how clinical prevention was taught. It was rarely up to a single faculty member. Not surprisingly, a faculty prevention education advocate is most effective when not working alone.
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Table 1. Activities and procedures included in the teaching of clinical caries prevention in sixty-six U.S. and Canadian dental schools
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Table 1
presents the frequency of activities and clinical procedures included in the teaching of clinical caries prevention, when appropriate, by dental schools. It is evident that a great deficit is in reevaluation or outcome assessment. The roles of saliva and bacterial indicators in oral health and the contemporary science of remineralization of enamel caries are less frequently applied.
A summary was made of the advantages perceived versus the problems and attitudes encountered by these responding faculty as they worked to integrate caries prevention into clinical teaching. These opposing features are organized in Table 2 according to categories of science, dental care system, advantages for students and patients, or problems perceived by faculty. This reveals that the opportunity and expectations for enhanced clinical teaching in prevention are high in the view of these faculty. But, equally, they recognize several types of barriers in achieving change in teaching prevention and population health. Among these barriers are faculty lack of awareness of the existing evidence base and ill-preparedness in teaching and reinforcing science-based health behavioral change and counseling methods. Some faculty perceive the oral health care system and financing as negatively impacted by such teaching. This ignores the need to change this very system to refocus on oral health attainment and disease management, not just on clinical productivity, regardless of clinical outcome or cost to the public.
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Table 2. Advantages and problems in integrating caries prevention into clinical teaching as perceived by responding faculty in sixty-six U.S. and Canadian dental schools
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Dentistry has a strong tradition in clinical prevention for the individual patient; however, it is well recognized that fee-for-service-driven prevention and other treatment do not always change with information on disease etiology and outcomes. Some dentists and dental hygienists respond to this criticism as if there were an entitlement to insurance coverage, regardless of the evidence. Insurers are content to go along with this self-serving justification, and they also do not rely sufficiently on evidence of outcomes.
Overall, the survey showed that dental schools have commonalities in higher expectations of preventive teaching. They also largely agree on the barriers to its attainment. Yet they act very individually with respect to curricular design and implementation. Thus, when sixty-six dental schools have been consulted and ways to advance the teaching of prevention and population health are sought, sixty-six solutions are likely to be proposed. The Clinical Preventive Dentistry Leadership Conference sought to limit this excessive individuality of approach by asking faculty to apply a method for "systems change"7 within their own dental schools.8 As a result, by the following year, at least one-third of the dental schools developed plans for improved preventive teaching by applying the biological and behavioral sciences with an improved perception of how to achieve organizational change within their schools.
The common framework is itself likely to facilitate curricular collaborations among dental schools. In turn, this will increase the likelihood of testing new curricula under varying circumstances. Such a joint approach is much to be preferred, and a western U.S. coalition of dental school faculty is so engaged.9
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Moving Forward with the New Curriculum Framework
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Health professionals are not simply technicians implementing guidelines and protocols.10 Underlying knowledge of disease etiology and current evidence on interventions, supported by consistent ethical values with regard to the place of prevention in health and health care, is required of professionals. Intervening to improve the health of individuals and the population increasingly also requires knowledge of the structure of the health care system and how health policy is determined. The curriculum framework encourages flexibility of inclusion of its components throughout degree programs, as well as integration and synthesis of materials near their end, using case studies and external service-based learning.11 The framework offers an opportunity to bridge disciplines and specialties.
The American Dental Education Association has been asked to endorse and sponsor the framework,12 as have organizations of the other health professions. ADEA did so at its annual session in New Orleans in March 2007.
Organizational change by dental schools13 is not the only change required to improve dental prevention and population oral health. It is hoped that schools are the incubators; however, dental clinics, practice groups, and dentists also must change. Reimbursement issues and dental practitioner incentives must be harnessed.14 And establishing diagnostic criteria and standards of dental care is essential to make and measure progress.9 These barriers were the subjects of the other presentations at this symposium.
Finally, there are some precedents for progress from which lessons can be learned. Risk-based prevention has advanced the practice of medicine in many key areas. The sensitivity and specificity of the risk tests used are acceptable, though not perfect, but are numerically not so different from those available in dentistry. In medicine, such implementation has itself led to improved risk assessment and higher standards of care. Nevertheless, some dental faculty persist in calling for improved tests before implementing any changes.
There are also technical ways to move forward. We lack sufficient controlled clinical trials (CCTs) assessing risk, preventive behavioral interventions, preventive products, and procedures and always will to some degree. The lack of generalizability of the CCT can be its greatest weakness. Field or observational trials should typically follow CCTs. Observational studies, despite potentially unknown confounders and unequally distributed biases, can claim generalizability as a strength. They play an important role if well designed.15,16 Having both types of studies allows estimates of minimal and maximal effects—and both are needed.
Finally, with the actuality of detailed electronic dental record systems, and provided diagnostic and treatment standards are agreed upon, self-improving (smart) electronic systems for risk assessment, prevention, and outcome assessment are now feasible.
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Acknowledgments
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This work has been supported by Procter & Gamble Oral Care and Omni Oral Pharmaceuticals.
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Footnotes
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Dr. Brown is Professor and Chair, Department of Community Dentistry, University of Texas Health Science Center at San Antonio Dental School. Direct correspondence and requests for reprints to him at Dental School, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7917, San Antonio, TX 78229-3900; 210-567-3200 phone; 210-567-4587 fax; brown{at}uthscsa.edu.
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REFERENCES
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- U.S. Department of Health and Human Services. Healthy people 2010. McLean, VA: International Medical Publishing, 2000.
- Allan J, Barwick TA, Cashman S, Cawley JF, Day C, Douglass CW, et al. Clinical prevention and population health curriculum framework for health professions. Am J Prev Med 2004; 27:471–6.[Medline]
- Rule JT, Veatch RM. Ethical questions in dentistry. 2nd ed. Chicago: Quintessence, 2004:61–3.
- Lawrence RS, Runyan JW, Tilson HH, Wallace RB, Weise WH. An inventory of knowledge and skills relating to disease prevention and health promotion. At: www.atpm.org/publications/inventory/inventoryl.htm. Accessed: September 5, 2006.
- Association for Prevention Teaching and Research, formerly the Association of Teachers of Preventive Medicine. Curriculum guidelines, journal supplements. At: www.atpm.org/publications/listpublications.htm. Accessed: August 29, 2006.
- Douglas CW, Timothé P. Initial response by dental schools to clinical prevention and population health curriculum framework. American Dental Education Association meeting, Baltimore, March 2005. At: www.adea.org/Sec/Section-Community & Preventive Dentistry. "Clinical Prevention and Population Health." Accessed: September 7, 2006.
- Senge PM. The fifth discipline: the art and practice of the learning organization. New York: Doubleday, 1990.
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- Fontana M, Zero D. Bridging the gap in caries management between research and practice through education: the Indiana University experience. J Dent Educ 2007; 72(5): 579–91.
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