J Dent Educ. 72(6): 662-668 2008
© 2008 American Dental Education Association
Critical Issues in Dental Education |
Rethinking the Role of Community-Based Clinical Education in Pediatric Dentistry
S. Thikkurissy, D.D.S., M.S.;
Michael L. Rowland, Ph.D.;
Canise Y. Bean, D.M.D., M.P.H.;
Ashok Kumar, B.D.S., M.S.;
Kevin Levings, B.A.;
Paul S. Casamassimo, D.D.S., M.S.
Key words: pediatric dentistry, dental education, community-based education
Submitted for publication 12/10/07;
accepted 03/21/08
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Abstract
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The early childhood caries epidemic has prompted a look at predoctoral clinical dental education in pediatric dentistry. The purpose of this study was to examine the contribution of community-based clinical education (CBE) to procedural and patient diversity in predoctoral pediatric dental education. Using procedural and demographic data from pediatric clinical experiences of the dental class of 2007 at The Ohio State University College of Dentistry, profiles of patient diversity, clinical pediatric dental procedures, and student efficiency were developed for both CBE sites and the campus-based clinic. Ninety-two students performed 16,523 procedures on children in the fourth year in CBE sites in the community compared to 4,268 on campus in their third year. Pediatric-dedicated CBE sites accounted for almost 12,000 pediatric dental procedures. Approximately 56 percent of children treated at CBE sites were minorities. CBE sites accounted for most of the dental student restorative experience for pediatric patients for the Class of 2007, giving each student on average multiple restorative procedures. The campus-based clinic provided largely diagnostic and preventive procedures but few restorative opportunities. We conclude that community-based dental clinical education presents an opportunity to enhance pediatric predoctoral student clinical experiences in both quantity and diversity.
Early childhood caries (ECC) is defined by the American Academy of Pediatric Dentistry (AAPD) as "one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger."1 Recent estimates are that 60 percent of all children in the United States meet this definition by the age of five.2 In spite of this, in 2002–03, only about 11 percent of general dentists reported seeing patients younger than four years of age.3 While the factors leading to the increased prevalence of ECC are varied, one strategy for management is preparing dental students to treat these children through direct experience.
Seale and Casamassimo have suggested that lack of preparation of dental students is one element of an overall access disparity that exists for certain populations.4 A number of factors contribute to this lack of preparation. One is an overall declining work-force in pediatric dental education as noted by Casamassimo et al.,5 compounded by a mean 10 percent increase in the number of dental students. Another is the growing trend to have pediatric dentistry taught by nonspecialists. It is estimated that 33 percent of all U.S. pediatric dentistry education is taught by general dentists.5
Several authors have suggested that changing patterns of disease have also contributed to this lack of preparation. Permanent tooth dental caries continues to decline; correspondingly, the population of "teaching patients" old enough to cooperate in restorative care performed by dental students in a university setting has been reduced as well. This overall change in the epidemiology of ECC has been mentioned by several authors, including Seale and Casamassimo, as another factor because it shifts need to a younger, less manageable group that is not well suited for dental students. In 2007 the Centers for Disease Control and Prevention (CDC) reported the first-ever increase (a net increase of 4 percent) in caries experience in children two to five years old.6 ECC is more prevalent in low-income, minority children as compared to those from higher socioeconomic groups. The implication for dental education is that very young children who are more difficult to manage have more decay, and many of these children are from low-income families and unable to pay for care, which is a budgetary concern for many dental schools. In addition, participation rates of Medicaid children have traditionally been low, which is another barrier to the provision of care by students within dental school clinics for children with high disease incidence and acuity.7
Seale and Casamassimo have proposed that the disproportionate lack of dental education regarding specific demographic populations such as infants and patients with special needs is a factor in the decreased care of young children by general dentists. Lewis et al. noted that the majority of children younger than three years of age had some form of dental insurance, but very few received preventive dental care.8 Lewis et al. also noted that dentists with no training in treating federally empanelled (i.e., Medicaid) populations were significantly less likely to include these children in their practices, irrespective of procedure.
Does community-based education (CBE) offer any opportunities for pediatric dental education? Baumeister et al. noted that dental student interest in serving special care populations (including very young children and federally empanelled patients) was directly correlated to the number of weeks spent in extramural clinical rotations.9 These CBE rotations have been seen as a way to educate students in providing effective patient-provider relationships and building case management skills.2 CBE often targets specific populations, such as pediatric patients, geriatric patients, or patients with special needs. Thind et al.10 demonstrated that increased time in extramural rotations positively influenced a dental student’s ability to provide care to diverse patient populations. This positive perception was created by affecting the service orientation scale as well as reinforcing a socially conscious attitude. Novak et al.11 analyzed dental school alumni behavior and observed that the "perceived importance to include diversity-specific content in the dental curriculum had moderately positive correlations with students’ perceptions of their competency or ability to serve and work with diverse populations."
A significant body of literature addressing the placement of extramural rotations within the curriculum exists, but evidence examining the clinical exposure of dental students to pediatric-specific procedures is rare. Some authors suggest that CBE may provide a significant increase in perceived procedure-specific confidence with respect to such procedures as stainless steel crowns, primary molar pulpotomies, and primary tooth extractions.12 In addition, CBE may offer financial relief for a dental education system under financial stress. In a cost analysis examining a scenario in which senior dental students spent seventy days in community-based clinics, the net savings was $2.7 million per school, which represented a projected net gain in revenue of 8.1 percent.13
Given this background, the aims of this observational study were to 1) examine the pediatric procedures performed in both a dental school and community-based extramural setting and 2) assess the contribution of CBE experiences to students’ overall experience treating diverse populations.
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Methods
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This retrospective study evaluated procedural data of the ninety-two-member dental class of 2007 at The Ohio State University College of Dentistry (OSUCOD) provided during the academic year 2006–07. The OSUCOD clinical pediatric dentistry experience is a composite of campus-based patient care, in which students learn basic procedures in their third year, and community-based education taught by faculty pediatric dentists and community-based general dentist adjunct faculty in their fourth year.
With a five-year, $1.5 million grant from the Robert Wood Johnson Foundation, the OSUCOD developed a community-based outreach program entitled the Oral Health Improvement through Outreach (OHIO) Project. As part of their general clinical curriculum, dental students spend approximately sixty days of their fourth year in community-based outreach clinics throughout Ohio treating both adults and children; they spend the remaining time treating patients at the College of Dentistry’s campus-based clinic. Fifty of these outreach community-based days are pre-assigned, and ten are scheduled by students as electives with the community partner clinics or private practices. Bean et al.14 described the components of the OHIO Project in an article that appeared in the August 2007 issue of the Journal of Dental Education. In addition, in their third year, dental students spend a week treating children on campus in the dental school.
For every patient encounter in the community, students are required to complete a form detailing procedures completed during that encounter, the site location, and patient demographics including ethnicity, age, and financial status. These forms provided the basis for collecting demographic and procedure information for this analysis. Data forms are submitted by community partner sites, and data are entered by OHIO Project staff on a regular basis. Further information on the OHIO Project can be found in a previous report.14 At the OSUCOD campus-based clinic, procedures are entered into the school’s data management system (Windent) at each appointment and are retrievable for analysis from the system database.
For the analysis, sites were divided into two CBE categories: pediatric-dedicated community-based clinics (PCBs) treating primarily children, and general dental community-based clinics (GDCs), which serve a mix of all ages. A third site used in this comparison was the dental clinic on the College of Dentistry campus (OSU) where students spend five days in their third year treating children.
Demographic data included ethnicity, race, and age, while procedural data included the number of encounters and procedures, which are tallied using American Dental Association (ADA) procedural codes. For this analysis, procedures per encounter and encounters per student were also determined. The 2000 Ohio census report15 was used to compare the ethnic backgrounds of patients served by the community-based clinics with the population of Ohio. Using the dental literature, we also developed a list of dental procedures considered core experiences in the pediatric dental clinical curriculum. Only procedures and encounters in children up to eighteen years of age were included in this analysis.
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Results
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Table 1
presents demographic data for both pediatric and general claims from all the community-based sites and provides the population percentages for majority and minority groups in Ohio. Nearly 60 percent of all patients served in community sites are minorities, including African Americans, Hispanics, Native Americans, and others. These same population groups represent 15 percent of the state population. Comparative data for the OSU clinic experience are not available due to inconsistent data collection.
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Table 1. Diversity of patients in pediatric-dedicated (PCB) and general dental (GDC) community-based clinics compared with Ohio population census statistics
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Table 2 lists total pediatric encounters and procedures for the three specific clinic types. We considered the aggregate pediatric procedures as the denominator in this analysis. PCBs provided 57.3 percent of the net pediatric procedures and 54 percent of the net pediatric encounters. With respect to procedures accomplished per encounter, the OSU clinic averaged 2.71 procedures per encounter, the PCBs 2.56, and the GDCs 1.94. Patient encounters per student were 15.12 for OSU, 50.6 for the PCBs, and 25.8 for the GDCs. Among the PCBs, the OSU Dental H.O.M.E. Coach, a mobile dental clinic serving school-aged children in the Columbus public school system, provided the greatest number of total pediatric procedures (6,411), the highest number of encounters per student (21.1), and the highest number of procedures per student (69.7). Students achieved almost 50 percent of their OSU-based pediatric experience while practicing at CBE sites that were not pediatric dedicated.
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Table 2. Comparison of pediatric dedicated (PCB), general dental (GDC), and OSU school clinics for pediatric dental procedures
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Table 3 shows a comparison of the three treatment settings for twelve diagnostic, preventive, and treatment procedures (based on ADA procedure codes) considered core experiences for students in pediatric dentistry. These include comprehensive oral exam, periodic oral exam, bitewing radiographs, prophylaxis, topical fluoride treatment, pit and fissure sealants, one and two surface resin restorations, one and two surface amalgam restorations, prefabricated stainless steel crowns, and therapeutic pulpotomies. There was nearly a tenfold difference in stainless steel crowns placed at the College of Dentistry (49) versus the CBE sites (445).There was almost an eightfold difference in the number of pit and fissure sealants placed (OSU: 407, CBE: 3,111). In every category evaluated, students obtained more clinical experience at the CBE sites than at the university-based pediatric clinic.
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Table 3. Comparison of combined community-based education sites (PCBs and GDCs) with OSU campus-based clinic for core pediatric dental procedures (Class of 2007, 92 students)
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Discussion
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The purpose of this retrospective observational study was to look at the relative contribution of community-based and campus-based clinical experiences to the dental students’ exposure to pediatric dentistry, both procedurally and in relation to populations that have been traditionally underserved by the health care system. In the study, 57.3 percent of the patients served were classified as minorities, who represent approximately 15 percent of the state population. While no financial data were obtained, many of the CBE sites are based in economically depressed communities. Our results suggest that CBE can provide a significant contribution to overall pediatric dental education from both dedicated pediatric experiences and those that occur in general dental settings serving all ages.
The data not only demonstrate that students performed more clinical procedures during the CBE rotations, but they also performed procedures that are deemed central to pediatric dentistry treatment. While the university-based system did provide more encounters per student and more procedures per student, these were heavily skewed to diagnostic and preventive procedures. The school-based clinic could not supply students with even one procedure per student in five of six restorative categories. The CBE sites, on the other hand, provided multiple treatment experiences, with the majority of these performed under the supervision of pediatric dentist faculty in the pediatric dentistry dedicated clinical experiences (PCBs).
The delivery system of pediatric dentistry clinical education at The Ohio State University College of Dentistry incorporates the strengths of campus-based education, which are control and simplicity, with those of the CBE sites, which are patient availability and the efficiency of a treatment-based system. OSU dental students learn basic clinical procedures and principles of pediatric care in the third year in a one-week campus-based rotation under the supervision of pediatric dentists. This core experience is augmented by required experiences in five additional pediatric-dedicated CBE clinics, also under pediatric dentist supervision, combined with general dentist-supervised pediatric experiences in more than a dozen general dental sites around the state, offering diverse patient populations. These diverse groups include inner-city minority, urban Latino, rural Appalachian, homeless, and special needs populations.
The classic dental education curriculum has focused on procedure-oriented competency, in which students perform enough procedures at a satisfactory level to be deemed competent. Only recently has health care in general and dental care in particular recognized the contribution of community influences on oral health and care delivery. A frequent concern by dental educators about community-based education is that care rendered may not be of the same quality as required by dental faculty in the controlled dental school environment. Such concerns have not been borne out by the evidence, and it should be noted that medical education relies heavily on community-based care to educate physicians. One goal of this report is to suggest that the opportunities presented by community-based learning, as evidenced by the substantial number of experiences, is to develop these educational links between the dental school and the community-based clinics. Readers should be assured that agencies, hospitals, and clinics often have well-designed and sophisticated quality assurance mechanisms for patient care that are often not as well developed in dental schools. The medical education system has recognized that a procedure-based system of teaching removes procedures from the context of care delivery. Intervention from the Accreditation Council for Graduate Medical Education now defines six general competencies: patient care, medical knowledge, practice-based learning, interpersonal skills, professionalism, and systems-based practice.16 The findings of our study indicate that students had an opportunity to care for a diverse population not available to them in the dental school environment because of financial and other issues.
Recent literature suggests that this type of experience has a positive influence on students’ later practices and may contribute to improvement in health disparities and access to care.9,10 At The Ohio State University College of Dentistry, fourth-year students complete behavior, restorative, and preventive clinical competencies in one of two high-procedure pediatric dentistry-dedicated sites (Dental H.O.M.E. Coach and Nationwide Children’s Hospital) under the scrutiny of pediatric dentists. These competencies are performed within the real health care environment where children of the underserved actually seek and receive dental care. This adds a dimension of reality not common to staged competency testing in much of dental education, in which patients are selected for convenience by procedure.
In this study, we found that the combination of pediatric-dedicated and general dental community-based experiences far exceeded what was possible at the school-based clinic. In fact, the general dental community experiences alone exceeded total pediatric procedures done on campus. Dental school clinics are known for their inefficiencies. Henzi et al. noted from a survey of over 2,000 dental students the primary perceived weakness within dental school was an unproductive clinical environment.17 Many dental schools have used CBE to encourage development in students of what Beemsterboer has called the "ethic of access to care,"18 but also to offset deficiencies in the recruitment and retention of dental faculty members, as discussed by Seale and Casamassimo.4
In conclusion, dental students rotating through community-based experiences as part of their curriculum obtained more net pediatric encounters and performed more net pediatric-focused procedures than in the dental school clinic. In this model, community-based education demonstrated itself to be a valuable source of predoctoral pediatric dental education.
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Acknowledgments
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This study was supported by the Robert Wood Johnson Foundation Pipeline Project.
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Author Information
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Dr. Thikkurissy is Assistant Professor, Section of Pediatric Dentistry, The Ohio State University College of Dentistry; Dr. Rowland is Assistant Professor, Section of Primary Care, The Ohio State University College of Dentistry; Dr. Bean is Associate Clinical Professor, Section of Restorative Dentistry, The Ohio State University College of Dentistry; Dr. Kumar is Assistant Professor of Clinical Dentistry, Section of Pediatric Dentistry, The Ohio State University College of Dentistry; Mr. Levings is Program Assistant, The OHIO Project, The Ohio State University College of Dentistry; and Dr. Casamassimo is Professor and Head, Section of Pediatric Dentistry, The Ohio State University College of Dentistry. Direct correspondence and requests for reprints to Dr. S. Thikkurissy, Section of Pediatric Dentistry, The Ohio State University College of Dentistry, 305 West 12th Avenue, Room 4126, Columbus, OH 43218; 614-292-1788 phone; 614-292-1125 fax; thikkurissy.1{at}osu.edu.
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REFERENCES
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