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  1. 1. 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. Abstract: 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 experi- ences 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. Dr. Thikkurissy is Assistant Professor, Section of Pediatric Dentistry, The Ohio State University College of Dentistry; Dr. Row- land is Assistant Professor, Section of Primary Care, The Ohio State University College of Dentistry; Dr. Bean is Associate Clini- cal 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; Key words: pediatric dentistry, dental education, community-based education Submitted for publication 12/10/07; accepted 3/21/08 E arly childhood caries (ECC) is defined by the by nonspecialists. It is estimated that 33 percent of American Academy of Pediatric Dentistry all U.S. pediatric dentistry education is taught by (AAPD) as “one or more decayed (noncavi- general dentists.5 tated or cavitated lesions), missing (due to caries), or Several authors have suggested that chang- filled tooth surfaces in any primary tooth in a child ing patterns of disease have also contributed to this 71 months of age or younger.”1 Recent estimates are lack of preparation. Permanent tooth dental caries that 60 percent of all children in the United States continues to decline; correspondingly, the popula- meet this definition by the age of five.2 In spite of tion of “teaching patients” old enough to cooperate this, in 2002–03, only about 11 percent of general in restorative care performed by dental students in dentists reported seeing patients younger than four a university setting has been reduced as well. This years of age.3 While the factors leading to the in- overall change in the epidemiology of ECC has been creased prevalence of ECC are varied, one strategy mentioned by several authors, including Seale and for management is preparing dental students to treat Casamassimo, as another factor because it shifts these children through direct experience. need to a younger, less manageable group that is not Seale and Casamassimo have suggested that well suited for dental students. In 2007 the Centers lack of preparation of dental students is one element for Disease Control and Prevention (CDC) reported of an overall access disparity that exists for certain the first-ever increase (a net increase of 4 percent) populations.4 A number of factors contribute to this in caries experience in children two to five years lack of preparation. One is an overall declining work- old.6 ECC is more prevalent in low-income, minority force in pediatric dental education as noted by Casa- children as compared to those from higher socioeco- massimo et al.,5 compounded by a mean 10 percent nomic groups. The implication for dental education increase in the number of dental students. Another is is that very young children who are more difficult to the growing trend to have pediatric dentistry taught manage have more decay, and many of these children 662 Journal of Dental Education ■ Volume 72, Number 6
  2. 2. are from low-income families and unable to pay for dition, CBE may offer financial relief for a dental care, which is a budgetary concern for many dental education system under financial stress. In a cost schools. In addition, participation rates of Medicaid analysis examining a scenario in which senior dental children have traditionally been low, which is another students spent seventy days in community-based barrier to the provision of care by students within clinics, the net savings was $2.7 million per school, dental school clinics for children with high disease which represented a projected net gain in revenue incidence and acuity.7 of 8.1 percent.13 Seale and Casamassimo have proposed that the Given this background, the aims of this ob- disproportionate lack of dental education regarding servational study were to 1) examine the pediatric specific demographic populations such as infants and procedures performed in both a dental school and patients with special needs is a factor in the decreased community-based extramural setting and 2) assess care of young children by general dentists. Lewis et the contribution of CBE experiences to students’ al. noted that the majority of children younger than overall experience treating diverse populations. 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 treat- ing federally empanelled (i.e., Medicaid) populations Methods were significantly less likely to include these children This retrospective study evaluated procedural in their practices, irrespective of procedure. data of the ninety-two-member dental class of 2007 Does community-based education (CBE) of- at The Ohio State University College of Dentistry fer any opportunities for pediatric dental education? (OSUCOD) provided during the academic year Baumeister et al. noted that dental student interest 2006–07. The OSUCOD clinical pediatric dentistry in serving special care populations (including very experience is a composite of campus-based patient young children and federally empanelled patients) care, in which students learn basic procedures in their was directly correlated to the number of weeks spent third year, and community-based education taught in extramural clinical rotations.9 These CBE rota- by faculty pediatric dentists and community-based tions have been seen as a way to educate students in general dentist adjunct faculty in their fourth year. providing effective patient-provider relationships and With a five-year, $1.5 million grant from the building case management skills.2 CBE often targets Robert Wood Johnson Foundation, the OSUCOD specific populations, such as pediatric patients, geri- developed a community-based outreach program atric patients, or patients with special needs. Thind et entitled the Oral Health Improvement through Out- al.10 demonstrated that increased time in extramural reach (OHIO) Project. As part of their general clini- rotations positively influenced a dental student’s cal curriculum, dental students spend approximately ability to provide care to diverse patient populations. sixty days of their fourth year in community-based This positive perception was created by affecting outreach clinics throughout Ohio treating both adults the service orientation scale as well as reinforcing a and children; they spend the remaining time treating socially conscious attitude. Novak et al.11 analyzed patients at the College of Dentistry’s campus-based dental school alumni behavior and observed that the clinic. Fifty of these outreach community-based days “perceived importance to include diversity-specific are pre-assigned, and ten are scheduled by students content in the dental curriculum had moderately as electives with the community partner clinics or positive correlations with students’ perceptions of private practices. Bean et al.14 described the compo- their competency or ability to serve and work with nents of the OHIO Project in an article that appeared diverse populations.” in the August 2007 issue of the Journal of Dental A significant body of literature addressing the Education. In addition, in their third year, dental placement of extramural rotations within the cur- students spend a week treating children on campus riculum exists, but evidence examining the clinical in the dental school. exposure of dental students to pediatric-specific For every patient encounter in the community, procedures is rare. Some authors suggest that CBE students are required to complete a form detailing may provide a significant increase in perceived procedures completed during that encounter, the procedure-specific confidence with respect to such site location, and patient demographics including procedures as stainless steel crowns, primary molar ethnicity, age, and financial status. These forms pulpotomies, and primary tooth extractions.12 In ad- provided the basis for collecting demographic and June 2008 ■ Journal of Dental Education 663
  3. 3. procedure information for this analysis. Data forms encounters and procedures, which are tallied using are submitted by community partner sites, and data American Dental Association (ADA) procedural are entered by OHIO Project staff on a regular ba- codes. For this analysis, procedures per encounter sis. Further information on the OHIO Project can and encounters per student were also determined. The be found in a previous report.14 At the OSUCOD 2000 Ohio census report15 was used to compare the campus-based clinic, procedures are entered into the ethnic backgrounds of patients served by the com- school’s data management system (Windent) at each munity-based clinics with the population of Ohio. appointment and are retrievable for analysis from the Using the dental literature, we also developed a list of system database. dental procedures considered core experiences in the For the analysis, sites were divided into two pediatric dental clinical curriculum. Only procedures CBE categories: pediatric-dedicated community- and encounters in children up to eighteen years of based clinics (PCBs) treating primarily children, and age were included in this analysis. 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 Results days in their third year treating children. Table 1 presents demographic data for both Demographic data included ethnicity, race, and pediatric and general claims from all the community- age, while procedural data included the number of based sites and provides the population percentages Table 1. Diversity of patients in pediatric-dedicated (PCB) and general dental (GDC) community-based clinics com- pared with Ohio population census statistics African Native Site Site Total White American Hispanic American Asian Other Dedicated Pediatric Sites (PCBs) Cochocton Dental Clinic 417 394 13 2 – 1 7 Mobile Dental H.O.M.E. Coach 1,913 572 1,204 65 1 12 59 Nationwide Children’s Hospital 880 341 415 65 – 13 46 Johnstown Road Clinic 587 98 123 325 2 17 22 Nisonger Center 45 35 10 – – – – PCB Subtotal 3,842 1,440 1,765 457 3 43 134 General Dental Sites (GDCs) Third Street Clinic, Mansfield 309 209 90 5 – – 5 McMickin, Cincinnati 35 3 31 – – 1 – North Side, Cincinnati 126 18 102 4 – 1 1 Lincoln Heights, Cincinnati 64 7 23 33 – – 1 Miami Valley, Dayton 54 30 21 2 – – 1 East Central, Columbus 44 7 29 6 – – 2 Health Department, Columbus 58 8 11 32 – 2 5 St. Elizabeth’s, Youngstown 55 19 31 2 2 – 1 Forum Health, Youngstown 36 15 20 1 – – – Ross County, Chilicothe 63 59 3 – – – 1 Stark County Health, Canton 106 76 19 5 – 1 5 Northwest Dental, Toledo 98 34 58 6 – – – Dental Center, Lima 76 75 1 – – – – Metrohealth Medical, Cleveland 25 9 9 6 – – 1 GDC Subtotal 1,149 569 448 102 2 5 23 PCB + GDC Total 4,991 40.3% 44.4% 11.2% 0.1% 0.9% 3.1% Ohio Population Percentages as of 2000 11,353,140 85.0% 11.5% 1.3% 0.2% 1.2% 0.8% 664 Journal of Dental Education ■ Volume 72, Number 6
  4. 4. for majority and minority groups in Ohio. Nearly 60 ing school-aged children in the Columbus public percent of all patients served in community sites are school system, provided the greatest number of total minorities, including African Americans, Hispanics, pediatric procedures (6,411), the highest number of Native Americans, and others. These same population encounters per student (21.1), and the highest number groups represent 15 percent of the state population. of procedures per student (69.7). Students achieved Comparative data for the OSU clinic experience are almost 50 percent of their OSU-based pediatric ex- not available due to inconsistent data collection. perience while practicing at CBE sites that were not Table 2 lists total pediatric encounters and pediatric dedicated. procedures for the three specific clinic types. We Table 3 shows a comparison of the three treat- considered the aggregate pediatric procedures as ment settings for twelve diagnostic, preventive, and the denominator in this analysis. PCBs provided treatment procedures (based on ADA procedure 57.3 percent of the net pediatric procedures and 54 codes) considered core experiences for students in percent of the net pediatric encounters. With respect pediatric dentistry. These include comprehensive to procedures accomplished per encounter, the OSU oral exam, periodic oral exam, bitewing radiographs, clinic averaged 2.71 procedures per encounter, the prophylaxis, topical fluoride treatment, pit and fissure PCBs 2.56, and the GDCs 1.94. Patient encounters sealants, one and two surface resin restorations, one per student were 15.12 for OSU, 50.6 for the PCBs, and two surface amalgam restorations, prefabricated and 25.8 for the GDCs. Among the PCBs, the OSU stainless steel crowns, and therapeutic pulpotomies. Dental H.O.M.E. Coach, a mobile dental clinic serv- There was nearly a tenfold difference in stainless steel Table 2. Comparison of pediatric dedicated (PCB), general dental (GDC), and OSU school clinics for pediatric dental procedures Site Name Total Pediatric Total Pediatric Procedures Encounters Procedures Encounters Procedures per Encounter per Student per Student Dedicated Pediatric Sites (PCBs) Coshocton Dental Clinic 417 826 1.98 4.53 8.98 Mobile Dental H.O.M.E. Coach 1,943 6,411 3.30 21.10 69.70 Nationwide Children’s Hospital 1,085 1,934 1.78 11.80 21.00 Johnstown Road Clinic 591 1,658 2.81 6.40 18.00 Nisonger Center 616 1,092 1.77 6.70 11.90 PCB Subtotal 4,652 11,921 2.56 50.60 129.60 General Dental Sites (GDCs) Third Street Clinic, Mansfield 309 457 1.48 3.36 4.97 McMickin, Cincinnati 35 119 3.40 0.38 1.29 Northside, Cincinnati 126 270 2.14 1.37 2.93 Lincoln Heights, Cincinnati 64 86 1.34 0.70 0.93 Miami Valley, Dayton 54 134 2.48 0.59 1.46 East Central, Columbus 399 621 1.56 4.34 6.75 Health Department, Columbus 923 2073 2.25 10.00 22.50 St. Elizabeth’s, Youngstown 55 115 2.09 0.60 1.25 Forum Health, Youngstown 36 62 1.72 0.39 0.67 Ross County, Chilicote 63 119 1.89 0.68 1.29 Stark County Health, Canton 106 166 1.57 1.15 1.80 Northwest Dental, Toledo 105 175 1.67 1.14 1.90 Dental Center, Lima 76 142 1.87 0.83 1.54 MetroHealth, Cleveland 25 63 2.52 0.27 0.68 GDC Subtotal 2,376 4,602 1.94 25.80 50.00 Total Community (PCB + GDC) 7,028 16,523 2.35 76.40 179.60 College of Dentistry (OSU) 1,572 4,268 2.71 15.12 41.04 Total CBEs + OSU 8,600 20,791 2.42 93.52 226 June 2008 ■ Journal of Dental Education 665
  5. 5. 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) Procedure Description ADA Code CBEs OSU Total All Sites Procedures Per Student Comprehensive Oral Examination 0150 1,824 619 2,443 26.6 Periodic Oral Examination 0120 1,102 424 1,526 16.6 Bitewings (2) 0272 801 432 1,233 13.4 Prophylaxis, Child 1120 1,150 627 1,777 19.3 Topical Fluoride Treatment 1203 1,509 783 2,292 24.9 Pit and Fissure Sealants 1351 3,111 407 3,518 38.2 Resin, One Surface, Anterior 2330 803 26 829 9.0 Resin, One Surface, Posterior 2391 2,125 180 2,305 25.1 Amalgam, One Surface 2140 729 7 736 8.0 Amalgam, Two Surface 2150 790 19 809 8.8 Prefab Stainless Steel Crown 2030 445 49 494 5.4 Therapeutic Pulpotomy 3220 159 8 167 1.8 Total 14,548 3,581 18,129 197.1 crowns placed at the College of Dentistry (49) versus student, these were heavily skewed to diagnostic the CBE sites (445).There was almost an eightfold and preventive procedures. The school-based clinic difference in the number of pit and fissure sealants could not supply students with even one procedure placed (OSU: 407, CBE: 3,111). In every category per student in five of six restorative categories. The evaluated, students obtained more clinical experi- CBE sites, on the other hand, provided multiple ence at the CBE sites than at the university-based treatment experiences, with the majority of these pediatric clinic. performed under the supervision of pediatric dentist faculty in the pediatric dentistry dedicated clinical experiences (PCBs). Discussion The delivery system of pediatric dentistry clini- cal education at The Ohio State University College of The purpose of this retrospective observational Dentistry incorporates the strengths of campus-based study was to look at the relative contribution of com- education, which are control and simplicity, with munity-based and campus-based clinical experiences those of the CBE sites, which are patient availabil- to the dental students’ exposure to pediatric dentistry, ity and the efficiency of a treatment-based system. both procedurally and in relation to populations that OSU dental students learn basic clinical procedures have been traditionally underserved by the health and principles of pediatric care in the third year in a care system. In the study, 57.3 percent of the patients one-week campus-based rotation under the supervi- served were classified as minorities, who represent sion of pediatric dentists. This core experience is approximately 15 percent of the state population. augmented by required experiences in five additional While no financial data were obtained, many of the pediatric-dedicated CBE clinics, also under pediatric CBE sites are based in economically depressed com- dentist supervision, combined with general dentist- munities. Our results suggest that CBE can provide supervised pediatric experiences in more than a dozen a significant contribution to overall pediatric dental general dental sites around the state, offering diverse education from both dedicated pediatric experiences patient populations. These diverse groups include and those that occur in general dental settings serv- inner-city minority, urban Latino, rural Appalachian, ing all ages. homeless, and special needs populations. The data not only demonstrate that students The classic dental education curriculum has performed more clinical procedures during the CBE focused on procedure-oriented competency, in rotations, but they also performed procedures that which students perform enough procedures at a are deemed central to pediatric dentistry treatment. satisfactory level to be deemed competent. Only While the university-based system did provide more recently has health care in general and dental care encounters per student and more procedures per in particular recognized the contribution of com- 666 Journal of Dental Education ■ Volume 72, Number 6
  6. 6. munity influences on oral health and care delivery. from a survey of over 2,000 dental students the pri- A frequent concern by dental educators about com- mary perceived weakness within dental school was munity-based education is that care rendered may not an unproductive clinical environment.17 Many dental be of the same quality as required by dental faculty schools have used CBE to encourage development in in the controlled dental school environment. Such students of what Beemsterboer has called the “ethic concerns have not been borne out by the evidence, of access to care,”18 but also to offset deficiencies in and it should be noted that medical education relies the recruitment and retention of dental faculty mem- heavily on community-based care to educate phy- bers, as discussed by Seale and Casamassimo.4 sicians. One goal of this report is to suggest that In conclusion, dental students rotating through the opportunities presented by community-based community-based experiences as part of their cur- learning, as evidenced by the substantial number of riculum obtained more net pediatric encounters and experiences, is to develop these educational links performed more net pediatric-focused procedures between the dental school and the community-based than in the dental school clinic. In this model, com- clinics. Readers should be assured that agencies, munity-based education demonstrated itself to be hospitals, and clinics often have well-designed and a valuable source of predoctoral pediatric dental sophisticated quality assurance mechanisms for education. patient care that are often not as well developed in dental schools. The medical education system Acknowledgments has recognized that a procedure-based system of This study was supported by the Robert Wood teaching removes procedures from the context of Johnson Foundation Pipeline Project. care delivery. Intervention from the Accreditation Council for Graduate Medical Education now de- REFERENCES fines six general competencies: patient care, medical 1. American Academy of Pediatric Dentistry. 2007–2008 knowledge, practice-based learning, interpersonal definitions, oral health policies, and clinical guidelines: skills, professionalism, and systems-based practice.16 reference manual. Pediatr Dent 2006;28(7):34–7. The findings of our study indicate that students had 2. Brown A, Lowe E, Zimmerman B, Crall J, Foley M, Neh- an opportunity to care for a diverse population not ring M. Preventing early childhood caries: lessons from available to them in the dental school environment the field. Pediatr Dent 2006;28:553–60. 3. Seale NS, Casamassimo PS. 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