Modern Management Principles Come to the Dental School.

The University of Washington School of Dentistry may be the first dental school in the nation to apply lean process management principles as a primary tool to re-engineer its operations and curriculum to produce the dentist of the future. The efficiencies realized through re-engineering will better enable the school to remain competitive and viable as a national leader of dental education. Several task forces conducted rigorous value stream analyses in a highly collaborative environment led by the dean of the school. The four areas undergoing evaluation and re-engineering were organizational infrastructure, organizational processes, curriculum, and clinic operations. The new educational model was derived by thoroughly analyzing the current state of dental education in order to design and achieve the closest possible ideal state. As well, the school's goal was to create a lean, sustainable operational model. This model aims to ensure continued excellence in restorative dental instruction and to serve as a blueprint for other public dental schools seeking financial stability in this era of shrinking state support and rising costs.

Chapter Oral Health Advocates: A Nationwide Model for Pediatrician Peer Education and Advocacy about Oral Health.

Objective. (1) To describe an innovative program training US pediatricians to be Chapter Oral Health Advocates (COHAs). (2) To provide insight into COHAs' experiences disseminating oral health knowledge to fellow pediatricians. Patients and Methods. Interviews with 40 COHAs who responded to an email request, from a total of 64 (62% response). Transcripts were analyzed for common themes about COHA activities, facilitators, and barriers. Results. COHAs reported positive experiences at the AAP oral health training program. A subset of academic COHAs focused on legislative activity and another on resident education about oral health. Residents had an easier time adopting oral health activities while practicing pediatricians cited time constraints. COHAs provided insights into policy, barriers, and facilitators for incorporating oral health into practice. Conclusions. This report identifies factors influencing pediatricians' adoption of oral health care into practice. COHAs reported successes in training peers on integrating oral health into pediatric practice, identified opportunities and challenges to oral health implementation in primary care, and reported issues about the state of children's oral health in their communities. With ongoing support, the COHA program has a potential to improve access to preventive oral health services in the Medical Home and to increase referrals to a Dental Home.

Beyond word recognition: understanding pediatric oral health literacy.

PURPOSE: Parental oral health literacy is proposed to be an indicator of children's oral health. The purpose of this study was to test if word recognition, commonly used to assess health literacy, is an adequate measure of pediatric oral health literacy. This study evaluated 3 aspects of oral health literacy and parent-reported child oral health. METHODS: A 3-part pediatric oral health literacy inventory was created to assess parents' word recognition, vocabulary knowledge, and comprehension of 35 terms used in pediatric dentistry. The inventory was administered to 45 English-speaking parents of children enrolled in Head Start. RESULTS: Parents' ability to read dental terms was not associated with vocabulary knowledge (r=0.29, P<.06) or comprehension (r=0.28, P>.06) of the terms. Vocabulary knowledge was strongly associated with comprehension (r=0.80, P<.001). Parent-reported child oral health status was not associated with word recognition, vocabulary knowledge, or comprehension; however parents reporting either excellent or fair/poor ratings had higher scores on all components of the inventory. CONCLUSIONS: Word recognition is an inadequate indicator of comprehension of pediatric oral health concepts; pediatric oral health literacy is a multifaceted construct. Parents with adequate reading ability may have difficulty understanding oral health information.

Parents' perspectives on a dental home for children with special health care needs.

The authors surveyed parent-leaders about aspects of a dental home for children with special health care needs (CSHCN). State leaders in two advocacy groups completed the survey; the response rate was 70.6% of all states. Two of the most highly rated aspects of a dental home, endorsed as "essential" by 89% of respondents, pertained to dentist-parent interactions: the dentist listens carefully to the family, and the dentist helps the family feel like a partner in treatment decisions. Likewise, 89% said it was essential that insurance coverage allows the child to see needed providers. Dentists' lack of knowledge or willingness to treat CSHCN and refusal of Medicaid insurance coverage were identified as major barriers to care. More than 84% of respondents reported that parents were unaware of the recommendation to establish dental care by 1 year of age. Establishing policy and educational strategies should help parents meet this dental health goal.

The challenge to delivering oral health services in rural America.

OBJECTIVES: This review identifies the challenges to oral health in rural America and describes areas of innovation in prevention, delivery of dental services, and workforce development that may improve oral health for rural populations. METHODS: This descriptive article is based on literature reviews and personal communications. RESULTS: Rural populations have lower dental care utilization, higher rates of dental caries, lower rates of insurance, higher rates of poverty, less water fluoridation, fewer dentists per population, and greater distances to travel to access care than urban populations. Improving the oral health of rural populations requires practical and flexible approaches to expand and better distribute the rural oral health workforce, including approaches tailored to remote areas. Solutions that involve mass prevention/public health interventions include increasing water fluoridation, providing timely oral health education, caries risk assessment and referral, preventive services, and offering behavioral interventions such as smoking and tobacco cessation programs. Solutions that train more providers prepared to work in rural areas include recruiting students from rural areas, training students in rural locations, and providing loan repayment and scholarships. Increasing the flexibility and capacity of the oral health workforce for rural areas could be achieved by creating new roles for and new types of providers. Solutions that overcome distance barriers include mobile clinics and telehealth technology. CONCLUSIONS: Rural areas need flexibility and resources to develop innovative solutions that meet their specific needs. Prevention needs to be at the front line of rural oral health care, with systematic approaches that cross health professions and health sectors.

Oral health and pediatricians: results of a national survey.

OBJECTIVE: Pediatricians have regular opportunities to perform screening dental examinations on young children and to educate families on preventive oral health. We sought to assess pediatricians' current attitudes and practices related to oral health of children 0-3 years old. METHODS: A Periodic Survey of Fellows, focused on oral health in pediatricians' office settings, was sent to 1618 postresidency fellows of the American Academy of Pediatrics. RESULTS: The response rate was 68%. More than 90% of pediatricians said that they should examine their patients' teeth for caries and educate families about preventive oral health. However, in practice, only 54% of pediatricians reported examining the teeth of more than half of their 0-3-year-old patients. Four percent of pediatricians regularly apply fluoride varnish. The most common barrier to participation in oral health-related activities in their practices was lack of training, which was cited by 41%. Less than 25% of pediatricians had received oral health education in medical school, residency, or continuing education. Most pediatricians (74%) reported that availability of dentists who accept Medicaid posed a moderate to severe barrier for 0-3-year-old Medicaid-insured patients to obtain dental care. CONCLUSIONS: Pediatricians see it within their purview to educate families about preventive oral health and to assess for dental caries. However, many pediatricians reported barriers to fully implementing preventive oral health activities into their practices. Pediatricians and dentists need to work together to improve the quality of preventive oral health care available to all young children.

Dental education's role in improving children's oral health and access to care.

In 2000, Oral Health in America: A Report of the Surgeon General identified disparities in oral health and access to care for vulnerable populations, including children. The report identified a declining dental school applicant pool, shortages of dental school faculties, and an overcrowded curriculum as dental education factors affecting disparities. Dental school applications are up, but the dentist/population ratio is projected to decline, and the shortage of dental faculty has worsened-limiting dental students' experiences with children. Current Commission on Dental Accreditation (CODA) standards do not include essential curriculum required to care for children. We recommend that CODA revisions to predoctoral and postdoctoral programs include care of infants, characteristics of children that distinguish them from adults, mandatory service learning experiences, emphasis upon social responsibility for all dentists, and use of objective standardized clinical examinations (OSCEs). Additionally, we recommend prioritization of limited pediatric dental resources to young children with disease and older children with complex dental requirements or special health care needs. Critical dental education goals for children should be developed through a special American Dental Education Association task force. Only the dental education community can assure that the dental workforce is better trained to care for children.

Addressing children's oral health in the new millennium: trends in the dental workforce.

Oral Health in America: A Report of the Surgeon General (SGROH) and National Call to Action to Promote Oral Health outlined the need to increase the diversity, capacity, and flexibility of the dental workforce to reduce oral health disparities. This paper provides an update on dental workforce trends since the SGROH in the context of children's oral health needs. Major challenges remain to ensure a workforce that is adequate to address the needs of all children. The dentist-to-population ratio is declining while shortages of dentists continue in rural and underserved communities. The diversity of the dental workforce has only improved slightly, and the the diversity of the pediatric population has increased substantially. More pediatric dentists have been trained, and dental educational programs are preparing students for practice in underserved areas, but the impact of these efforts on underserved children is uncertain. Other workforce developments with the potential to improve children's oral health include enhanced training in children's oral health for general dentists, expanded scope of practice for allied dental health professionals, new dental practitioners including the dental health aid therapist, and increased engagement of pediatricians and other medical practitioners in children's oral health. The evidence for increasing caries experience in young children points to the need for continued efforts to bolster the oral health workforce. However, workforce strategies alone will not be sufficient to change this situation. Requisite policy changes, educational efforts, and strong partnerships with communities will be needed to effect substantive changes in children's oral health.

Ethics and leadership in children's oral health.

PURPOSE: This paper reviews key ethical precepts in health care for children, and explores how interpretations of justice predict different and sometimes conflicting approaches to children's dental needs. Ethics is a core competency for health professionals because of their special responsibilities toward patients and the public. Ethical principles guiding health professionals include: (1) beneficence; (2) nonmaleficence; (3) respect for autonomy; and (4) justice. Different theories of justice lead to different responses toward public needs, such as access to dental care. The most frequently encountered response in the dental community is volunteerism, consistent with the libertarian perspective on justice. Though desirable, volunteerism alone will never solve dental access issues because such efforts do not address the problems systematically. A policy statement of the American Academy of Pediatric Dentistry (AAPD) explicitly recognizes that children have a right to oral health care. Children's unique characteristics--their vulnerability, dependence, and developmental processes-call for special arrangements to address their health needs. Given the importance of children to society, it is critical that all health sectors work together to address children's health and well-being. However, those with the greatest knowledge of children's oral health needs-pediatric dentists-must take a leadership role in creating and supporting solutions to these needs. The AAPD has an opportunity to support systemic solutions at the state and national level to ensure that all children have access to oral health care. One example of a systemic solution is the Access to Baby and Child Dentistry (ABCD) program in Washington State.

Beyond access: the role of family and community in children's oral health.

Children's health outcomes result from the complex interaction of biological determinants with sociocultural, family, and community variables. Dental professionals' efforts to reduce oral health disparities often focus on improving access to dental care. However, this strategy alone cannot eliminate health disparities. Rising rates of early childhood caries create an urgent need to study family and community factors in oral health. Using Los Angeles as a multicultural laboratory for understanding health disparities, the Santa Fe Group convened an experiential conference to consider models of ensuring child and family health within communities. This article summarizes key conference themes and insights regarding 1) children's needs and societal priorities; 2) the science of child health determinants; 3) the rapidly changing demographics of the United States; and 4) the importance of communities that support children and families. Conference participants concluded that to eliminate children's oral health disparities we must change paradigms to promote health, integrate oral health into other health and social programs, and empower communities. Oral health advocates have a key role in ensuring oral health is integrated into policy for children. Dental schools have a leadership role to play in expanding community partnerships and providing education in health determinants. Participants recommended replicating this experiential conference in other venues.

Future directions in leadership training of MCH professionals: cross-cutting MCH leadership competencies.

Leadership in Maternal and Child Health (MCH) requires a repertoire of skills that transcend clinical or academic disciplines. This is especially true today as leaders in academic, government and private settings alike must respond to a rapidly changing health environment. To better prepare future MCH leaders we offer a framework of MCH leadership competencies based on the results of a conference held in Seattle in 2004, MCH Working Conference: The Future of Maternal and Child Health Leadership Training. The purpose of the conference was to articulate cross-cutting leadership skills, identify training experiences that foster leadership, and suggest methods to assess leadership training. Following on the work of the Seattle Conference, we sub-divide the 12 cross-cutting leadership competencies into 4 "core" and 8 "applied" competencies, and discuss this distinction. In addition we propose a competency in the knowledge of the history and context of MCH programs in the U.S. We also summarize the conference planning process, agenda, and work group assignments leading to these results. Based on this leadership competency framework we offer a definition of an MCH leader, and recommendations for leadership training, assessment, and faculty development. Taken as a set, these MCH leadership competencies point towards the newly-emerging construct of capability, the ability to adapt to new circumstances and generate new knowledge. "Capstone" projects can provide for both practice and assessment of leadership competencies. The competency-based approach to leadership that has emerged from this process has broad relevance for health, education, and social service sectors beyond the MCH context.

A new oral health elective for medical students at the University of Washington.

BACKGROUND: Oral health is an important but inadequately addressed area in medical school curricula. Primary care practitioners are in an ideal position to help prevent oral disease but lack the knowledge to do so. PURPOSES: We developed an oral health elective that targeted 1st- and 2nd-year medical students as part of a previously described oral health initiative and oral health curriculum. METHODS: To promote interprofessional collaboration, we utilized medical-dental faculty teams for lectures and hands-on peer instruction by dental students for clinical skills. RESULTS: Evaluations revealed positive shifts in attitudes toward oral health and significant gains in oral health knowledge and self-confidence. Students rated the course highly and advocated for further integration of oral health into required medical curricula. CONCLUSIONS: We describe the elective including curriculum development, course evaluation results, and steps for implementing a successful oral health elective into medical education. We highlight interprofessional collaboration and constituency building among medical and dental faculty and administrators.

Band-aid solutions to the dental access crisis: Conceptually flawed--a response to Dr. David H. Smith.

Though laudable, "band-aid solutions" are inadequate to solve dental access problems. By nature, such efforts are provider-driven and not designed to match the needs of underserved populations. They do not empower patients, families, or communities or provide for ongoing care. Band-aid solutions do not ensure a workforce with the capacity or geographic distribution to meet the needs of the underserved. Neither do such solutions address systemic issues such as lack of dental insurance or the need to prioritize prevention. Such solutions do not engage other health professionals in promoting oral health. Furthermore, such solutions maintain the prevailing viewpoint that dental volunteer efforts are all that is required of the dental profession; they fail to acknowledge that a response is mandated by the social contract between dentistry and society. Finally, such an approach fails to recognize the complexity of health disparities and the broad solutions that must be advanced. In the case of children, it is possible to outline an approach to defining a basic standard of oral health care and to argue that all children should receive such care. Band-aid solutions could never ensure a population-wide distribution of care and hence are not morally defensible.

An oral health curriculum for medical students at the University of Washington.

Oral health disparities are a major public health problem, according to the U.S. Surgeon General. Physicians could help prevent oral disease, but lack the knowledge to do so. To create an oral health curriculum for medical students at the University of Washington School of Medicine, the authors (beginning in 2003) (1) reviewed current evidence of medical education and physician training in oral health, (2) developed oral health learning objectives and competencies appropriate for medical students, and (3) identified current oral health content in the undergraduate curriculum and opportunities for including additional material. The authors identified very few Medline articles on medical student education and training in oral health. The United States Medical Licensing Examination Steps 2 and 3 require specific clinical knowledge and skills in oral and dental disorders, but other national curriculum databases and the Web site of the Liaison Committee on Medical Education devote no significant attention to oral health. To develop learning objectives, the authors reviewed major oral health reports, online oral health educational resources, and consulted with dental faculty. The curriculum was assessed by interviewing key medical school faculty and analyzing course descriptions, and was found to be deficient in oral health content. The authors developed five learning themes: dental public health, caries, periodontal disease, oral cancer, and oral-systemic interactions, and recommend the inclusion of corresponding competencies in targeted courses through a spiral curriculum. Current progress, the timeline for curriculum changes at the University of Washington, and the ethical values and attitudinal shifts needed to support this effort are discussed.

Approaches to craniofacial-specific quality of life assessment in adolescents.

OBJECTIVE: To ascertain the domains that adolescents aged 11 to 18 years with congenital and acquired craniofacial differences (CFDs) consider important to their quality of life (QoL) to create a craniofacial-specific module. DESIGN: Interviews and inductive qualitative methods were used to guide the development of a conceptual and measurement model of QoL among adolescents with CFDs. SETTING: The Craniofacial Center at Children's Hospital and Regional Medical Center in Seattle, Washington. PATIENTS, PARTICIPANTS: Thirty-three in-depth interviews with adolescents (aged 11 to 18 years), one young adult interview (age 19 years), 14 in-depth interviews with parents, one young adult focus group, one parent focus group, and one panel of researchers and clinical professionals working in the field. RESULTS: Using the qualitative methodology, grounded theory, seven domains that adolescents with CFDs perceive are important to having a good QoL were found. Six of the domains (coping, stigma and isolation, intimacy and trust, positive consequences, self-image, and negative emotions) comprised the Youth Quality of Life Instrument-Facial Differences module. One other domain, surgery, was a salient issue for many of the youth, but not all, so it was made into a separate module, the Youth Quality of Life Instrument- Craniofacial Surgery module. This module relates to the experience of surgery, outcomes of surgery, and preferences for future surgery. CONCLUSIONS: Using an established qualitative methodology, two QoL modules specific to adolescents with CFDs were developed and are ready for psychometric validation. Potential uses of the instruments are discussed.

Implications for designing online oral health resources: a review of fifty-six websites.

We conducted a review of websites in oral health to identify content areas of our target interest and design features that support content and interface design. An interprofessional team evaluated fifty-six oral health websites originating from non-governmental organizations (NGOs) and associations (28.6 percent), regional/state agencies (21.4 percent), federal government (19.6 percent), academia (19.6 percent), and commercial (10.7 percent) sources. A fifty-two item evaluation instrument covered content and web design features, including interface design, site context, use of visual resources, procedural skills, and assessment. Commercial sites incorporated the highest number of content areas (58.3 percent) and web design features (47.1 percent). While the majority of the reviewed sites covered content areas in anticipatory guidance, caries, and fluorides, materials in risk assessment, oral screening, cultural issues, and dental/medical interface were lacking. Many sites incorporated features to help users navigate the content and understand the context of the sites. Our review highlights a major gap in the use of visual resources for posting didactic information, demonstrating procedural skills, and assessing user knowledge. Finally, we recommend web design principles to improve online interactions with visual resources.