J Dent Educ. 72(3): 344-351 2008
© 2008 American Dental Education Association
Milieu in Dental School and Practice |
Advanced General Dentistry Program Directors’ Attitudes and Behaviors Regarding Pediatric Dental Training for Residents
Christi Sporl Massey, M.A.;
Ted P. Raybould, D.M.D.;
Judith Skelton, Ph.D.;
A. Stevens Wrightson, M.D.;
Tim A. Smith, Ph.D.
Key words: GPR, AEGD, pediatric, health disparities
Submitted for publication 05/30/07;
accepted 11/14/07
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Abstract
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The oral health of children became a more prominent concern with the U.S. surgeon general’s report on oral health in America in 2000. The purpose of our study was 1) to assess General Practice Residency (GPR) and Advanced Education in General Dentistry (AEGD) (here jointly referred to as advanced general dentistry [AGD] programs) directors’ current behaviors with regard to pediatric training of residents and 2) to assess their attitudes about which components of pediatric oral health training should be included in AGD programs. A twenty-one item survey was mailed to all GPR and AEGD programs accessed through the American Dental Association website. Seventy percent of directors (N=187) completed and returned the survey. Responses indicated that AGD residents receive adequate clinical exposure to pediatric patients and provide much-needed services to uninsured, underinsured, and underserved people. Although clinical training in pediatric treatment was high, didactic hours focused on pediatric treatment did not seem commensurate with clinical activity. Program directors indicated strong attitudinal support for teaching residents many components of pediatric oral health care, although most directors have concerns over increasing didactic hours spent on pediatric oral health due to already crowded curricula. Approximately 88 percent of directors said that they would implement a pediatric oral health module in their curricula if they had access to one.
The oral health of children is a growing concern. In May 2000, the surgeon general’s report on oral health in America stated that caries in the primary dentition have not decreased in the past ten years.1,2 The American Academy of Pediatric Dentistry (AAPD) published recommendations in 2000 stating that infants should have an initial oral evaluation within six months of the eruption of the first primary tooth and no later than one year of age.3 Possibly due to the recent increased interest spurred by the surgeon general’s report, leading professional health organizations have reached a consensus on pediatric oral health: the earlier a child receives preventive oral health services, the less his or her risk of developing dental disease.3
As with many health problems, health disparities exist in regard to the oral health of children. Children living in poverty, children from some racial/ethnic minority groups, disabled children, and children living with HIV infection suffer from the most advanced oral health diseases.1 Poor children have twice as many dental caries as their peers and are more likely to go untreated.1 Unfortunately, their greater need for care does not always result in access to care. Many studies show that low Medicaid reimbursement rates significantly lower the likelihood that dentists will treat indigent patients.4 Even when the supply of general dentists and specialists who treat pediatric patients (ages from birth to eighteen) and low-income patients is adequate, the discrepancy between need and demand is problematic. Many parents and guardians are not bringing their children in for a first dental visit until age three or later.5
In October 2000, following the surgeon general’s report, the House of Delegates of the American Dental Association (ADA) adopted resolution 59H-2000 to review predoctoral education standard 2.25 in regard to pediatric dentistry to ensure "adequate and sufficient clinical skills of graduates."2,6 This resolution was one way to address the low level of confidence among many practitioners who report not feeling adequately trained to treat young patients.2 According to the American Dental Education Association annual survey of graduating dental students, the level of satisfaction with their education on pediatric dentistry has fallen since 1993.2,6 Fewer dental students surveyed from 1996 to 1998 felt satisfied with the amount of time devoted to pediatric dentistry education than dental students surveyed just three years earlier.
Accompanying this lowered confidence in skill with pediatric patients among graduating dental students are current trends among practicing general dentists. General dentists are less likely to treat young children if they have an available referral source.5 General dentists with a larger Medicaid patient population are more likely to refer three- to five-year-olds to a pediatric dentist.4,5 A recent study shows that pediatric dentists are almost three times more likely to treat Medicaid patients than general dentists and see more than twice as many Medicaid patients per dentist per quarter.4 Pediatric patient characteristics that lead to higher referrals are patient demeanor (those labeled "uncooperative"), severe caries/extensive treatment needs, special health care needs, and having public insurance.5 General dentists who felt they had adequate predoctoral exposure to children were less likely to refer pediatric patients to specialists.5
Referrals are not always an option, however, due to an insufficient number of pediatric dentists. According to the AAPD, there is a shortage of pediatric dentists, so much so that it is reaching "crisis proportions."7,8 According to a 2000–01 study, there were 4.03 pediatric dental practitioners for every 100,000 U.S. children.7 Another major finding of this study was that there was wide variation in the provider-patient ratio by state. Maine had the fewest pediatric dentists, with 1.00 dentist per 100,000 children, while Massachusetts had the highest number, with 7.73 dentists per 100,000 children.7 Since access to dental care and high rates of dental disease are major issues for indigent and Medicaid patients, a lack of confidence in treating pediatric patients by general practitioners and a lack of pediatric dentists add additional barriers to care for low-income children.
Advanced general dentistry (AGD) programs (which include General Practice Residency [GPR] and Advanced Education in General Dentistry [AEGD] programs) can benefit special population groups because many program directors recognize that their programs serve as a safety net for disadvantaged populations.9 However, AGD programs are not standardized in regard to program content and learning activities for residents, including pediatric oral health. A 2002 longitudinal study by Lefever et al.10 demonstrated that some AGD programs are increasing their residents’ curricular training in pediatric oral health care, but many programs have decreased emphasis on pediatric oral health. Lefever et al.’s analysis of AGD program changes over a five-year period showed an increase in curricular emphasis on pediatric dentistry among 21 percent of all civilian and military AGD programs and an increase in emphasis on pediatric care with regard to behavior management among 16 percent of all programs. Among civilian AGD programs, decreases in emphasis occurred in only four of thirty curriculum areas, but two of these areas were related to pediatric care (pediatric dentistry and behavior management). There was a decrease in curricular emphasis in pediatric dentistry among 16 percent of programs and a decreased emphasis in pediatric care/behavior management among 13 percent.
The purposes of our survey were 1) to assess AGD program directors’ current behaviors with regard to pediatric treatment and training of residents in pediatric oral health care and 2) to assess their attitudes about which components of pediatric oral health training should be included in AGD programs.
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Methods
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A survey created to assess pediatricians’ knowledge, attitudes, and experience regarding children’s oral health11 (supported by the Robert Wood Johnson Clinical Scholars Program) was adapted to gather data from directors of AGD programs in order to assess their knowledge, attitudes, and behaviors regarding pediatric oral health. Minimal changes in the survey were made to maintain the integrity of the instrument in order to allow for comparisons between this survey and the original; therefore, no pilot testing was deemed necessary. The adapted survey was submitted to and approved by the University of Kentucky Medical Institutional Review Board. The twenty-one item survey was mailed to all General Practice Residency and Advanced Education in General Dentistry programs accessed through the ADA website. A cover letter was sent describing the survey, and prepaid envelopes were included to expedite the return of the survey, with a requested return date in October 2005. A reminder letter along with another survey and prepaid envelope was mailed in November 2005 to encourage maximum response. Seventy percent of directors (N=187/267) completed and returned the survey.
The first eight items of the survey addressed the demographics of the residency programs, such as number and type of residents, and the sociodemographics of patients treated by the residency programs, such as insurance status and race. Nine items on the survey addressed pediatric components of the residency program curriculum. Directors were asked how frequently they see early childhood caries and caries in school-age children. Directors were asked if they feel that AGD programs should address early (aged birth to five) pediatric oral health issues and the age they recommend first dental visits for pediatric patients. They were asked to report the likelihood of teaching pediatric oral health topics to their own residents, as well as their attitudes about the inclusion of particular components of pediatric dental education in AGD curricula. Directors were then asked to indicate the number of clinical and classroom hours spent on pediatric dentistry and if they would use a pediatric oral health module if one were made available to them. Finally, directors were asked to identify barriers to increasing curriculum hours dedicated to pediatric patient care.
The survey items concerning their likelihood of teaching certain pediatric oral health topics and the attitudinal survey questions addressing the inclusion of pediatric dental components in AGD training were measured using a five-point Likert scale ranging from "strongly agree" to "strongly disagree." For the descriptive analysis of the scaled responses, the "strongly agree" and "agree" categories were collapsed into a single "agree" category (as were the two "disagree" categories), and the middle "neutral" category was excluded from analysis. Items were left as a five-point scale for analysis of associated variables. All data were entered into an SPSS data file. Spearman’s rho was used to determine correlation among variables that had a non-normal distribution. Pearson’s correlation was used to determine relationships among interval-ratio data with normal distributions.
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Results
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Seventy percent of the respondents described their residency program as a GPR program. The program directors reported a range of one to thirty-six residents, with an average of 5.8 residents per program. The majority of programs were located in urban (64.1 percent) or suburban communities (24.5 percent), with less than 10 percent of programs located in rural communities (7.4 percent).
The racial and ethnic makeup of patients is displayed in Table 1
. The reported average size of the non-Hispanic white patient population was 40.5 percent. The reported African American patient population averaged 28.3 percent among the responding programs, and the Latino/Hispanic patient population averaged 21.9 percent. The average patient population of Asian/Pacific Islanders and Native Americans was 6.8 percent and 2.8 percent, respectively.
The majority of directors (88.7 percent) reported spending at least some time each week providing care for underserved patients. Overall, program directors and their residents spent an average of 60 percent of their time treating underserved patients, with 18.1 percent of directors spending all of their time treating underserved populations. Most directors (76.6 percent) reported having patients on Medicaid. The estimated average of Medicaid patients for these AGD programs was much higher at 41.2 percent than the national average of Medicaid recipients, which is 14 percent (Table 2).9 Respondents also estimated that an average of 25 percent of patients were uninsured or self-pay patients. Some program directors (13.5 percent) reported having no patients who were immigrants or were the children of immigrants, but the majority of directors reported having at least some immigrants or children of immigrants as patients, constituting an average of 22 percent of the total patient population. Directors reported a slightly smaller average percentage of patients with non-English speaking parents (16.4 percent) than immigrant patients.
Most of the general dentistry programs surveyed had pediatric patients (Table 3). Nine percent of responding directors reported no patients aged six to eighteen, and 18.8 percent reported no patients aged five and younger. Only thirteen directors (7 percent) reported having no pediatric patients (age birth to eighteen) at all. A majority of directors (65.8 percent) reported having up to one-quarter of their patients between the ages of six and eighteen, and even more directors (73.4 percent) reported having up to one-quarter of their patients aged five and younger. Although the majority of directors had pediatric patients, they varied greatly on the age that they recommended parents take their children for their first dental visit. Slightly more than one-third of directors (36.3 percent) reported that they recommend that parents take their children for their first dental visit by one year of age. Approximately one-third of directors (36.3 percent) recommended a first dental visit between one and a half and two years of age, while 24.7 percent recommended a first dental visit at three years of age or later.
Caries was frequently seen among the pediatric population of these AGD programs (Figure 1). Many directors (39.1 percent) reported that they saw early childhood caries at least once a week, and most of the directors (69.4 percent) observed caries in school age or adolescent children at least once a week. Despite the high frequency of seeing pediatric caries, the majority of these directors (65.1 percent) reported ten hours or less of pediatric dentistry education in their residency programs. Slightly less than 10 percent (9.8 percent) of residency directors reported twenty hours or more of coursework focused on pediatric dentistry. Directors included more clinical hours focused on pediatric dentistry than classroom hours in their programs, with an average of ten to fifteen hours per program that were focused on pediatric patients. Almost 50 percent of directors reported more than twenty hours of clinical training in pediatric dentistry. A majority of directors (88.3 percent) said they would implement a preplanned pediatric oral health curriculum module if they had access to one.
Pediatric caries was correlated with both Medicaid status and immigrant status. Directors who had a high number of Medicaid patients were much more likely to report higher percentages of early childhood caries and adolescent or school-age caries (Table 4). Likewise, directors who reported a higher percentage of immigrant patients also saw a higher percentage of early childhood caries and adolescent or school-age caries. The percentage of uninsured/self-pay patients was not correlated with caries frequency. Residency directors were asked how likely they are to teach their residents about oral health screening procedures for children under five years of age (Table 5). Most directors reported being likely or very likely to teach residents to counsel parents on the importance of going to the dentist on a regular basis (96.3 percent), to counsel parents on the importance of regular tooth brushing (94.4 percent), and to inquire about whether a child is taking a bottle to bed (93.8 percent). Fewer directors reported being likely to teach residents to inquire about the mother’s dental health (74.6 percent) and to assess a child’s fluoride intake to determine the need for supplementation (69.4 percent).
Residency directors were then asked if certain topics concerning pediatric dentistry should be a part of their residency curriculum (Table 6). Over 75 percent of directors agreed on the inclusion of most of the pediatric dental topics listed in Table 6. The lowest rated curriculum topics were the development of the human dentition (62.1 percent), professional/public awareness and roles in health policy (59.7 percent), and pediatric facial growth and development (54.9 percent). When asked to rank order barriers to increasing curriculum hours dedicated to pediatric patients, the most frequently reported barrier was having an already crowded curriculum (N=114), and this item was reported as the primary barrier by many respondents (N=88). Some directors reported having limited access to pediatric patients (N=62), while others reported that curriculum hours on pediatric oral health are not required by accreditation standards (N=51).
Residency directors who frequently saw early childhood caries and adolescent/school-age caries were much more likely than other directors to provide instruction for their residents in a wide variety of pediatric dentistry topics and issues with the exception of inquiring about the mother’s dental health (Table 7). Directors who reported a high percentage of Medicaid patients were also more likely to provide their residents with instruction in many pediatric dentistry topics, with the exception of inquiring about the mother’s dental health and assessing a child’s fluoride intake. Due to the high correlation among frequency of caries and Medicaid status, however, controlling for caries frequency eliminated all the correlations between Medicaid status and the likelihood of teaching pediatric dental components. Uninsured or self-pay status was negatively associated with the likelihood of teaching many pediatric dentistry components. Immigrant status of patients was not related to an increased frequency in teaching pediatric dental components.
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Table 7. Relationship between type of patients and residency directors’ likelihood of teaching components of pediatric dentistry
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Discussion
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The AGD programs participating in this study reported that they provide a significant amount of care to special patient populations. A large percentage of their patient populations are underserved groups, including immigrants or immediate descendants of immigrants, racial/ethnic minorities, and Medicaid recipients. AGD programs are also treating a sizable percentage of pediatric patients with treatment needs. More than half of the directors reported seeing caries in school-age children at least once a week, and almost half of the directors reported seeing caries in children five years of age and younger at least once a week. There was a strong correlation among the percentage of Medicaid patients and childhood caries frequency, supporting the idea that Medicaid patients probably have more treatment needs than their privately insured counterparts. Immigrants or children of immigrants also had higher rates of caries frequency than average, underscoring their need for treatment and prevention.
Our results show that there is great variation in curricular emphasis on pediatric issues among AGD programs. The number of classroom hours spent on pediatric dentistry ranged from the lowest category of "0–5 hours" to the highest category of "20 hours or more." Similarly, clinical hours ranged from "0–5 hours" to "20 hours or more." While the average number of clinical hours working with pediatric patients may be adequate with almost 50 percent of programs (47.8 percent) spending twenty hours or more on clinical training, the overall average of classroom hours focused on pediatric patients does not seem commensurate with the number of clinical hours; the majority (65.1 percent) of program directors reported ten classroom hours or less focused on pediatric oral health issues. Likewise, the number of classroom hours does not seem commensurate with the strong attitudes about the inclusion of many of the presented components of pediatric oral health care in AGD training or the likelihood of the directors teaching their residents to ask important dental questions and inform parents about dental care and prevention.
These results indicate that program directors’ attitudes and behaviors in regard to pediatric oral health training are inconsistent. This disconnect could be due to the most frequently perceived barrier to increasing curricular emphasis on pediatric oral health: an already crowded curriculum. The large majority of residency directors (88.3 percent) reported that they would use a preplanned curriculum module on pediatric oral health if one was available to them, but if classroom hours are already strained, ways to implement this module will need to be addressed. Over one-fourth of directors reported that they do not include these pediatric components because it is not required by AGD accreditation standards. Without requirements through the standards, pediatric dentistry training may be more dispensable when curriculum cuts need to be made. Due to the low number of pediatric dentists in many regions of the United States, there may be a need for addressing AGD accreditation standards in regard to pediatric dental education.
It is possible that a program’s patient demographics is a driving force in curricular content (as it definitely affects clinical training), but further research needs to be conducted to see if this is the case. Unfortunately, the lack of focus on pediatric oral health care in AGD standards allows programs to have considerable variability in pediatric training. This could contribute to the lack of confidence some graduates show in treating this population and in frequent specialist referrals, both of which lead to access to care issues for needy patients. Further research is needed to see if AGD graduates are less likely than dentists who do not seek advanced general dentistry training to limit their pediatric patient base and/or to refer children to a specialist.
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Conclusion
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Based on the results of our survey-based study, we conclude that AGD programs are a viable source of care for underserved pediatric populations. We also conclude that, if certain issues are addressed in regard to AGD training, these programs can be even more beneficial for pediatric patients.
We found that great variation exists in AGD pediatric dental training, ranging from no training to significant amounts of didactic and clinical education. While clinical hours seem sufficient, classroom hours vary considerably. We propose accreditation standards be developed for pediatric training in AGD programs.
Our study also illustrates AGD program directors’ support for the inclusion of many pediatric oral health components in their programs as well as strong support for implementation of a pediatric oral health module. Certain barriers exist, however, that impede the inclusion of more curricular content focused on pediatric oral health. Inclusion and implementation problems, particularly already overcrowded curricula, should be addressed through continued research and program modifications.
Finally, we propose that research be conducted to identify the most useful content to provide AGD residents with confidence in treating pediatric patients. Since lack of confidence in treating pediatric patients has been illustrated through other recent studies, and our study illustrates AGD program directors’ support for pediatric oral health training, it may be a good time to reassess curricular content to maximize confidence and skills with treating pediatric patients among AGD graduates. The results may not only strengthen the safety net that AGD programs provide for underserved children, but they may also carry over into AGD graduates’ practices and, simultaneously, decrease specialist referrals.
On a positive note, the findings from our study suggest that most advanced general dentistry program residents receive adequate clinical exposure to special population patients, including pediatric patients, and provide much needed services to uninsured, underinsured, and underserved children who cannot obtain treatment in the private sector. Proper pediatric oral health training could benefit many disadvantaged children and give residents the background and exposure they need to feel confident treating pediatric patients in the future.
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Author Information
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Ms. Massey is Research Assistant, Department of Behavioral Science, College of Medicine; Dr. Raybould is Professor, Department of Oral Health Science, College of Dentistry; Dr. Skelton is Associate Professor, Department of Oral Health Science, College of Dentistry; Dr. Wrightson is Assistant Professor, Department of Family and Community Medicine, College of Medicine; and Dr. Smith is Professor, Department of Behavioral Science, College of Medicine—all at the University of Kentucky. Direct correspondence and requests for reprints to Dr. Ted P. Raybould, Dentistry Kentucky Clinic, A219 Kentucky Clinic 0284, Lexington, KY 40506; 859-257-3462 phone; 859-323-2036; tprayb1{at}uky.edu.
This study was supported by HRSA Grant 1 D59HP04084-03-00.
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REFERENCES
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- 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.
- Seale NS, Casamassimo PS. Access to dental care for children in the United States: a survey of general practitioners. J Am Dent Assoc 2003; 134:1630–40.[Abstract/Free Full Text]
- Wessel L, Rhee K, Wolpin S. Fighting the silent epidemic of poor oral health. Am Fam Physician 2007; 75(4): 475–6.[Medline]
- Mayer ML, Stearns SC, Norton EC, Rozier RG. The effects of Medicaid expansions and reimbursement increases on dentists’ participation. Inquiry 2000; 37:33–44.[Medline]
- McQuistan MR, Kuthy RA, Daminano PC, Ward MM. General dentists’ referrals of 3- to 5-year-old children to pediatric dentists. J Am Dent Assoc 2006; 137:653–60.[Abstract/Free Full Text]
- American Dental Education Association. ADEA survey of dental school seniors: 1986–1999 graduating classes. Washington, DC: American Dental Education Association, 1999.
- Nainar SMH, Feigal RJ. Geographic distribution of pediatric dentists in private practice in the United States. Pediatr Dent 2004; 26(6):526–9.[Medline]
- Davis MJ. Pediatric dentistry workforce issues: a task force white paper. Pediatr Dent 2000; 22(4):331–5.[Medline]
- Atchison KA, Cheffetz SE. Critical issues for dentistry: PGD program directors respond. J Dent Educ 2002; 66(6):730–8.[Abstract]
- Lefever KH, Atchison KA, Mito RS, Lin S. Curriculum emphasis and resident preparation in postgraduate general dentistry programs. J Dent Educ 2002; 66(6):747–56.[Abstract]
- Lewis CW, Grossman DC, Domoto PK, Deyo DA. The role of the pediatrician in the oral health of children: a national survey. Pediatrics 2000; 106(6):e84.[Abstract/Free Full Text]
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Abstract
Methods
