6
Oral Health

INTRODUCTION

With the publication in 2000 of Oral Health in America: A Report of the Surgeon General,1 the significant impact that oral health can have on overall health and well-being came to widespread public attention. Central to that report’s methodology was its effort to identify: (1) the determinants of health and disease, with a primary focus on factors such as prevention and producing health rather than restoring health; (2) the burden of oral diseases and disorders in the nation as a whole; and (3) the evidence for actions to improve oral health to be taken throughout life. With a strong orientation toward the future, the report emphasized leading-edge technologies and research that could be brought to bear in improving the oral health of individuals and communities. Implicit in its conclusions was a need to support and maintain a biomedical research infrastructure that includes research personnel of sufficient quantity, skill, and inclination to succeed in the task of diminishing oral disease and bringing about the attendant benefits that improved oral health promises for the general health of the U.S. population.

Accordingly, the Surgeon General’s report envisions a biomedical research workforce that could competently address oral diseases and disorders such as dental caries and periodontal diseases; oral mucosal infections and conditions such as oral candidiasis, herpes simplex virus infections, oral human papillomavirus infections, recurrent aphthous ulcers, and oral and pharyngeal cancers and precancerous lesions; and developmental disorders such as craniofacial anomalies caused by altered branchial cleft arch morphogenesis, cranial bone and dental anomalies, craniofacial defects secondary to other developmental disorders, and craniofacial manifestations of single-gene defects. The report also recognized the need for research personnel who could devise new treatments, cures, and diagnostic methods for chronic and disabling conditions such as Sjögren’s syndrome, acute and chronic orofacial pain, and temporomandibular disorders.

Research in areas of human health that have such broad scope and significance cannot rely exclusively on dental researchers as conventionally understood, but rather requires a broader biomedical research workforce that is part of, and fully integrated into, the biomedical sciences generally. Thus, there is no qualitative difference between oral health scientists and other biomedical scientists—only a quantitative need for a sufficient number of researchers who are interested in oral health problems and are willing to direct their attention to this particular field of endeavor. Lacking any intrinsic difference in training between oral health scientists and other biomedical scientists, facile movement of scientists into and out of this particular area of biomedical research should be possible as the nation’s needs warrant.

The 2009 NIDCR Strategic Plan

The principles described in the 2000 Surgeon General’s Report are evident in the recent strategic plan promulgated in May 2009 by the National Institute of Dental and Craniofacial Research (NIDCR).2 That plan embraces the central goal of bringing the best science to bear on problems in oral, dental, and craniofacial health. The plan observes that dental disease itself remains quite common, with dental caries (decay) comprising the most common infectious disease of childhood (Figure 6-1). A constellation of common yet debilitating disorders requires research directed at improved approaches to treatment and prevention. Equally important, however, are technological innovations that promise breakthroughs, such as “labs on a chip,” in which saliva is used as a diagnostic fluid not only for oral conditions, but also for systemic disorders as well. The prospect of bioengineered

1

U.S. Public Health Service. 2000. Oral Health in America: A Report of the Surgeon General. Washington, DC: Department of Health and Human Services.

2

NIDCR. 2009. Strategic Plan 2009-2013. NIH Publication No. 09-7362. Washington, DC: NIH. Available at http://www.nidcr.nih.gov/NR/rdonlyres/79812F51-8893-46BD-AE9D-2A125550533B/0/NIDCR_StrategicPlan_20092013.pdf.



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6 oral health iNtroduCtioN disabling conditions such as Sjögren’s syndrome, acute and chronic orofacial pain, and temporomandibular disorders. With the publication in 2000 of Oral Health in America: Research in areas of human health that have such broad A Report of the Surgeon General,1 the significant impact scope and significance cannot rely exclusively on dental that oral health can have on overall health and well-being researchers as conventionally understood, but rather requires came to widespread public attention. Central to that report’s a broader biomedical research workforce that is part of, and methodology was its effort to identify: (1) the determinants fully integrated into, the biomedical sciences generally. Thus, of health and disease, with a primary focus on factors such as there is no qualitative difference between oral health scien- prevention and producing health rather than restoring health; tists and other biomedical scientists—only a quantitative (2) the burden of oral diseases and disorders in the nation as a need for a sufficient number of researchers who are interested whole; and (3) the evidence for actions to improve oral health in oral health problems and are willing to direct their atten- to be taken throughout life. With a strong orientation toward tion to this particular field of endeavor. Lacking any intrinsic the future, the report emphasized leading-edge technologies difference in training between oral health scientists and other and research that could be brought to bear in improving the biomedical scientists, facile movement of scientists into and oral health of individuals and communities. Implicit in its out of this particular area of biomedical research should be conclusions was a need to support and maintain a biomedical possible as the nation’s needs warrant. research infrastructure that includes research personnel of sufficient quantity, skill, and inclination to succeed in the task the 2009 NidCr Strategic Plan of diminishing oral disease and bringing about the attendant benefits that improved oral health promises for the general The principles described in the 2000 Surgeon General’s health of the U.S. population. Report are evident in the recent strategic plan promulgated Accordingly, the Surgeon General’s report envisions in May 2009 by the National Institute of Dental and Cranio- a biomedical research workforce that could competently facial Research (NIDCR).2 That plan embraces the central address oral diseases and disorders such as dental caries and goal of bringing the best science to bear on problems in oral, periodontal diseases; oral mucosal infections and conditions dental, and craniofacial health. The plan observes that dental such as oral candidiasis, herpes simplex virus infections, oral disease itself remains quite common, with dental caries human papillomavirus infections, recurrent aphthous ulcers, (decay) comprising the most common infectious disease and oral and pharyngeal cancers and precancerous lesions; of childhood (Figure 6-1). A constellation of common yet and developmental disorders such as craniofacial anomalies debilitating disorders requires research directed at improved caused by altered branchial cleft arch morphogenesis, cranial approaches to treatment and prevention. Equally important, bone and dental anomalies, craniofacial defects secondary however, are technological innovations that promise break- to other developmental disorders, and craniofacial manifes- throughs, such as “labs on a chip,” in which saliva is used as tations of single-gene defects. The report also recognized a diagnostic fluid not only for oral conditions, but also for the need for research personnel who could devise new systemic disorders as well. The prospect of bioengineered treatments, cures, and diagnostic methods for chronic and NIDCR. 2009. Strategic Plan 00­0. NIH Publication No. 09-7362. 2 U.S. Public Health Service. 2000. Oral Health in America: A Report of Washington, DC: NIH. Available at http://www.nidcr.nih.gov/NR/rdonlyres/ 1 the Surgeon General. Washington, DC: Department of Health and Human 79812F51-8893-46BD-AE9D-2A125550533B/0/NIDCR_StrategicPlan_ Services. 20092013.pdf. 8

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8 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES since 2000, with another eight under consideration for estab- lishment. Of the 12 new and potential dental schools since 2000, 7 are associated with osteopathic medical schools.5 Although these data are viewed in aggregate, it appears that a redirection of dental education away from its historic mission of research, teaching, and service toward a more limited and exclusive focus on teaching may be taking place. This interpretation is corroborated by the decline in the total number of dental faculty members in the biomedical sciences from 933 in 1998 to 663 in 2008 (Figure 6-3).6 This decline FIGURE 6-1 Dental caries among 5- to 17-year-olds. of nearly 30 percent in biomedical sciences faculty in dental SOURCE: National Center for Health Statistics, 1996. schools contrasts with the nearly constant number of faculty 6-1.eps in the dental and clinical sciences. The implications of this drop are discussed in detail below in the section on faculty bitmap shortages. tissue replacements and molecular imaging tools that utilize One factor that may be propelling this trend is a sub- the oral cavity as an exceptionally accessible window into stantial increase in the compensation of practicing dentists, complex biological systems beyond the mouth is no longer leading to a greater demand for dental education from an a starry ideal, but an increasingly practical reality. expanded pool of academically outstanding dental applicants The findings of the 2009 NIDCR strategic plan mirror the for whom high compensation is a key driver in the selec- thinking of the present committee in terms of its assessment tion of an occupation. Between 2003 and 2008 the overall of the national needs for biomedical, behavioral, and clini- college grade point average (GPA) of applicants to dental cal research personnel. The direction set by the new NIDCR schools increased from 3.43 to 3.55 (see Figure 6-4), and strategic plan is consistent with the committee’s view of the the science GPA increased from 3.34 to 3.47. Existing dental problems related to the need for researchers in the oral health schools have adapted to this market demand by admitting sciences and reflects both previous (2005) and current com- these highly competitive applicants. Moreover, as a further mittee recommendations in this area.3 response, a new style of non-research-intensive dental school Although a tighter integration of research, clinical prac- has emerged.7 Such schools have been founded with a simple, tice, and health educational communities is essential, it will tuition-based, financial plan, often in non-research-intensive be equally important to establish and maintain a critical mass universities. Some of these schools do not support a large of investigators possessing a unique and intimate knowledge resident faculty, tenure, or basic scientists. They may have of orofacial structures and disorders. Only in that way can little or no preclinical educational infrastructure and tend schools of dentistry become more competent collaborators not to run large (often money-losing) student clinics or in the biomedical research enterprise in the quest to create operate research laboratories. As dental schools apparently vibrant research pathways for students and faculty and, ulti- disengage, research in the oral health sciences has been mately, to improve the health of the public. Recent evidence, undertaken by medical schools, engineering schools, hospi- however, suggests the reverse trend; that is, a gradual de- tals, and other academic institutions. emphasis of research in the nation’s dental schools. Figure 6-2 Obviously research scientists cannot be trained in an shows the proportion of NIDCR extramural grant support by environment in which research is not being conducted, and, type of academic institution. Although NIDCR extramural as a response, the proportion of NIDCR extramural training grant support increased by more than 2.6-fold between 1993 and career development support going to dental schools and 2008, the percentage of funding going to dental schools decreased from 89.4 percent in 1993 to 73.1 percent in 2008 decreased from 68.7 percent to 46.7 percent. This suggests (Figure 6-5)—again, despite a near doubling of NIDCR sup- that the nation’s dental schools are not competing as effec- port for this purpose. tively for available research dollars in the oral health sciences If this trend is a manifestation of a change in the mission of as are other kinds of academic institutions that have gravitated existing dental schools or a reflection of new dental schools to dentally related research. Over the past 50 years the number of dental schools fluctu- ated between a low of 47 in 1961 and a high of 60 in 1980.4 IOM. 2009. The U.S. Oral Health Workforce in the Coming Decade: 5 Between 1982 and 2000, seven dental schools closed—none A Workshop. Washington, DC: The National Academies Press. See in par- ticular Chapter 4, ”Current Demographics and Future Trends of the Dentist having a significant research portfolio—and four have opened Workforce.” American Dental Education Association, Center for Educational Policy 6 NRC. 2005. Adancing the Nation’s Health Needs: NIH Research Train­ and Resources, 2009. 3 ing Programs. Washington, DC: The National Academies Press. American Dental Association. 2009. Surey of Dental Education, 7 IOM. 1985. Personnel Needs and Training for Biomedical and Beha­ Volume : Faculty and Support Staff. Available at https://www.ada.org/ 4 ioral Research. Washington, DC: National Academy Press. sections/professionalResources/pdfs/survey_ed_vol3.pdf.

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8 ORAL HEALTH FIGURE 6-2 Extramural grant support by type of academic institution. 6-2.eps SOURCE: NIDCR Strategic Plan, 2009-2013. bitmap Biomedical Sciences Dental/ Clinical Sciences 5,000 4,638 4,519 4,46 8 4,44 5 4,50 0 4,348 4, 28 4 4, 258 4, 215 4, 20 5 4,0 00 3,50 0 Number of Faculty 3,00 0 2,50 0 2,000 1,50 0 933 1,000 851 767 76 6 757 679 663 601 59 8 500 N /A - — 1998 - 1999 - 2000 - 2001- 2002- 2003 - 2004- 2005 - 2006 - 2007- 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Academic Year FIGURE 6-3 Biomedical science and dental/clinical science full-time equivalent faculty, 1998-1999 to 2007-2008. 6-3.eps SOURCE: American Dental Education Association, Center for Educational Policy and Resources, 2009.

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8 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES 3.60 Science Overall 3.55 3.55 3.52 3.49 3.50 3.47 3.47 3.45 Grade Point Average 3.45 3.43 3.42 3.40 3.40 3.34 3.35 3.30 3.25 3.20 2003 -2004 2004-2005 2005 -200 6 2006 -2007 2007-2008 Academic Year FIGURE 6-4 Average pre-dental GPA of first-year students, 2003-2004 to 2007-2008. SOURCE: American Dental Association. 2009 (April). 00­008 Surey of Dental Education. Volume : Tuition, Admission, and Attrition. 6-4.eps Chicago, IL: ADA. FIGURE 6-5 Proportion of NIDCR extramural training and career development support by type of academic institution. SOURCE: NIDCR Strategic Plan, 2009-2013. 6-5.eps bitmap

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8 ORAL HEALTH whose long-term institutional commitment coalesces around able dollars in this arena, and the oral health sciences will teaching the technical aspects of dentistry while minimizing continue to advance. research as the foundation of professional practice, then As mentioned earlier, while supporting the best science, the decrease in focus on research could well continue over it does seem prudent also to encourage development of a an extended period, undercutting the pipeline of potential core of researchers whose interest is, uniquely, in the area research scientists coming from the nation’s dental schools. of oral health and whose commitment to this field is both This will decrease further the amount of research conducted continuous and unambiguous. This view is embodied in within dental schools, thus strategically weakening the the NIDCR strategic plan’s goal of strengthening a diverse nation’s oral health research infrastructure. Interestingly, pipeline of researchers in the field who will constitute a should the demand for clinical dental education decline, the predictable and consistent source of fully committed inves- market forces that led to the emergence of a new model for tigators over the long term. Such individuals are likely to be dental schools may disappear; however, this does not sug- the most intimately familiar with the nature of oral disease gest a return to a more research-oriented educational model. and the opportunities for oral health research. Even if the Rather, non-research-intensive dental schools may well nation’s dental schools seem less able or interested in com- be the survivors of a downsizing of the dental educational peting for dental research dollars, it does not alter the fact establishment. Based on high tuition and a robust business that the investigators most committed to this subject area plan that excludes the costs associated with basic scientists, will still come from among the ranks of research faculty in research laboratories, preclinical educational infrastructure, the nation’s dental schools. Assuming that this is the case, large student clinics, or tenured faculty, the newer schools finding sufficient numbers of qualified oral health research will have far lower fixed expenses. Should demand for dental personnel will be difficult, not only because of a re-purposing education decline in the future, it may be research-oriented of dental education to a more narrow teaching function, but dental schools that are most likely to close. also because of a significant and longstanding shortage of The NIDCR Strategic Plan for 00­0 recognizes dental school faculty in general. these trends, yet is bold in setting for itself the goals of Although the shortage of biomedical researchers in the broadening its scope of inquiry, strengthening the research oral health sciences and the shortage of dental school fac- pipeline, fostering novel clinical research avenues, and ulty may not be completely interdependent, they are almost eliminating oral health disparities. The NIDCR strategic plan certainly linked. For a variety of reasons, for the majority of takes a step forward in recognizing the importance of closer dental students an academic research career is a less attractive integration among research, practice, and education com- career path than private practice. The NIDCR strategic plan munities with the goal of understanding and ameliorating addresses the pipeline of researchers dedicated to solving disorders affecting the oral and craniofacial complex. The problems in oral, dental, and craniofacial health by envision- NIDCR strategic plan consciously recognizes unique chal- ing greater collaboration with schools of dentistry, animating lenges at a time when greater cross-talk, not less, is needed interest, and providing clearer pathways for students and among clinicians, scientists, and educators in order to sustain faculty interested in research. The plan emphasizes training progress. The question is whether the language and syntax and career development of individuals and welcomes new of science required for such cross-talk will be intelligible to disciplines poised to expand oral, dental, and craniofacial the dental clinician of the future. research. Accomplishing this task by encouraging vocations Whether research in the oral health sciences emanates in dental education is discussed in detail in the Faculty Short- from the traditional dental community or from other kinds age section below. of institutions and organizations is unimportant as long as Another goal of the NIDCR strategic plan—and one the best science is brought to bear on the critical questions that is related to the issue of the pipeline of oral health of oral health. The NIDCR commitment to widening the researchers—is innovation in clinical research. One objec- scope of inquiry and doing so because “diseases have no tive within this category is to ensure breadth and depth of the disciplinary boundaries” is strongly endorsed by the present clinical research pipeline, fostering collaboration between committee. Such an approach can indeed bring the best sci- oral health care practitioners, clinical scientists, and basic ence to oral, dental, and craniofacial health through multi- researchers. This area includes opportunities for combined and interdisciplinary collaboration, including the behavioral D.D.S./Ph.D. training. According to the NIDCR, dentist- and social sciences. Where the researchers will come from, if scientists need enhanced opportunities to obtain high-quality they do not come from the nation’s dental schools, remains postdoctoral training with protected research time to help an open question; however, astute investigators in many dif- them become more competitive for independent research ferent fields inevitably gravitate to areas that are prioritized awards. Such postdoctoral programs are still relatively to receive funding. Thus, if NIDCR is able to provide sup- uncommon for dentists who have completed Ph.D. train- port to maintain robust intramural and extramural research ing, and, as a result, these research-oriented dentists have programs, researchers from different disciplines, including had less success in securing research funding. This was non-dental researchers, will undoubtedly compete for avail- recognized and noted 25 years ago in our 1985 predecessor

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8 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES highly motivated students “are able, unexpectedly, to com - report, Personnel Needs and Training for Biomedical and plete the D.D.S./D.M.D. component of the curriculum in Behaioral Research, which stated: just four years and that the opportunity to earn practice Dentists are faced with a serious disincentive to pursue income provides an exhilarating strategy to cope with the training as clinical investigators. Whereas the young physi- financial struggles dental students pursuing biomedical cian receives a salary and benefits as a hospital resident and research training typically encounter. Placing such students subspecialty fellow, similar payment for the newly graduated into community outreach programs as salaried personnel is dentist is limited largely to hospital-based training in oral also an option.” surgery and oral pathology. Training in the other specialties Of particular importance is an analysis of training data rarely provides compensation and may indeed require tuition undertaken by NIDCR to assure that the institute’s research payment by the trainees.8 training investment is targeted to best achieve its goals. Surprisingly, it found that trainees supported by individual Although efforts have been made since the publication fellowships are more likely to obtain independent NIH of that report to place dental specialization trainees on the research funding, particularly with respect to R01 grants, same footing as medical trainees through the vehicle of the than those supported by institutional training grants. An Graduate Medical Education (GME) allocation to hospitals NIDCR study reveals that a significantly higher proportion from the Medicare trust, the outcome has been decidedly of faculty with prior NIH career development (K) awards are mixed. More pertinent to the financing of the education of in full-time employment than are those who had prior NIH dentists pursuing training in the biomedical sciences is the training grant or other NIH fellowship award support (T and insight of Grayson Marshall: F awards, respectively). Furthermore, “a recently conducted NIDCR research training program analysis highlighted NIH financing of D.D.S./D.M.D./Ph.D. programs needs to be the troubling pipeline trend that few NIDCR dental school encouraged as a high educational priority. To the extent that trainees go on to independent research careers: The evidence it is fiscally feasible, dental schools need to enhance stipends suggests that dentists are not as successful as those without for graduate students without, if possible, causing students to lose eligibility for low-interest student loans. In conjoint dental degrees in obtaining independent research funding.” D.D.S./D.M.D./Ph.D. programs when the clinical degree is This revelation is as astonishing as it is disturbing. It almost awarded before the Ph.D., the NIH needs to be encouraged suggests that the dental degree itself (or some antecedent to permit postdoctoral stipend levels to apply during the post- factor that causes an individual to go to dental school) is D.D.S. phase (as opposed to the lower, predoctoral stipend a direct impediment to success as a researcher in the oral levels). To the extent possible, tuition waivers (or tuition health sciences. Details at this level of specificity (offering supplements) need to be found to allow most or the entire individual versus institutional fellowships for instance) and burden of D.D.S./D.M.D. tuition to be covered.9 related issues of format and logistics of particular fellow- ship opportunities provided by NIDCR to dentists seeking In general, the greater assets available to the biomedical research careers may play an unexpected but key role in community as a whole have made tuition waivers and sti - differentiating what works from what does not. pend supplements possible beyond the amounts provided by NIH. This has not been the case under the more constrained financial circumstances of dental schools. Marshall also the faCulty Shortage suggests that supplementary clinical practice might also be There are 58 dental schools operating in the United a convenient way of helping to partially finance research S tates with roughly 4,800 full-time faculty members training. Specifically, he wrote, “It is both natural and (Figure 6-6). This compares with 2,810 full-time faculty exciting for D.D.S./D.M.D./Ph.D. students to look forward members distributed among 52 dental schools in 1969 and a to completing the D.D.S./D.M.D. phase of the program peak of 5,706 full-time faculty members distributed among and then be allowed to engage in an intramural practice, 60 dental schools in 1982. All schools award the Doctor deriving direct salary supplements from this source. This of Dental Surgery (D.D.S.) degree or the Doctor of Dental opportunity offers great motivation to complete the D.D.S./ Medicine (D.M.D.) degree, the two degrees being func- D.M.D. component of the program in as short a time as tionally equivalent. The number of part-time and volunteer possible.” He offers an example of a pilot where this was faculty has steadily increased in recent years, from 6,167 in successfully tried, and he further shows that, despite the 2001 to 7,320 in 2006. A decision to allocate an increasing combined clinical and research elements of the program, number of faculty slots to part-time faculty at the expense of full-time faculty is consistent with an increased emphasis IOM. 1985. Personnel Needs and Training for Biomedical and Beha­ 8 on teaching and a decreased emphasis on research. This ioral Research. Washington, DC: National Academy Press. G. Marshall, as cited in Bertolami, C.N. 2009. Creating the dental conclusion is founded on the reasonable presumption that 9 school faculty of the future: A guide for the perplexed. In ADEA, Beyond most NIH-funded research conducted in dental schools is the Crossroads. ADEA Commission on Change and Innoation (pp. 90-91). probably performed by full-time faculty. Amplifying the Washington, DC: American Dental Education Association.

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8 ORAL HEALTH FIGURE 6-6 Full-time and part-time and volunteer faculty at dental schools, 1997-2007. 6-6.eps SOURCE: Data for 1997-2003 from ADEA Web site: “Trends in Dental Education” dated 2007. Data for 2004-2006 taken from JDE articles in 2006, 2008. Data for 2007 are estimates provided by ADEA. bitmap effect of this decrease is the nearly 30 percent drop in the departments in dental schools in 1982. If this is chosen as absolute number of biomedical science faculty discussed the basis for comparison, it results in a dramatic 65 percent earlier. drop in biomedical science or basic science faculty in The key evidence for a shortage of dentist-scientists little more than 25 years. Admittedly, this last comparison is found in the annual number of vacant budgeted faculty needs to be made cautiously inasmuch as methodologies positions (Figure 6-7), which totaled 316 such positions in may have differed between the two surveying organiza- 2007-2008 (see Table 6-1).10 By way of comparison, the tions (the American Dental Education Association and the corresponding figure was 293 in 1969.11 Although much American Dental Association—one looking at biomedical has been made of the number of vacant budgeted faculty science faculty and the other looking at faculty in basic positions as a metric for a faculty shortage, a difference science departments). Nevertheless, whether viewed from of just 23 when comparing 1969 to 2008 does not seem the perspective of vacant slots in the biomedical sciences, that impressive over a nearly 40-year time span. What is the total number of basic science faculty, the proportion impressive, however, is that in 1969, of the 293 full-time of full-time to part-time faculty, or the share of NIDCR vacant budgeted positions, 110 were in the basic sciences. funding going to dental schools, it does appear that dental By 1984, this number had decreased to 50, and by 2008 education is moving away from the biomedical sciences in it had decreased further to just 18.12 Such a decline could its educational programs. occur either by a rapidity in filling slots or by defunding Two presumed drivers of the difficulty of recruiting and them. Perhaps both approaches were in play, given some of retaining dental school faculty are compensation and student the striking trends that are apparent over extended periods debt. of time. As mentioned, between 1998 and 2008 the number of biomedical science faculty declined from 933 to 663—a Compensation decrease of nearly 30 percent over a 10-year period. Inter- estingly, there were 1,917 faculty members in basic sciences The most recent survey of the net income of dental practitioners published by the American Dental Association in 2009 shows that 91.8 percent of all professionally active Chmar, J.E., R.G. Weaver, and R.W. Valachovic. 2008. Dental school 10 dentists are active private practitioners. The net income of vacant budgeted faculty positions, academic years 2005-2006 and 2006- dentists in 2006 (the most recent year for which data are 2007. Journal of Dental Education 72(3):377. available) amounted to $224,190, averaging both general IOM. 1985. Personnel Needs and Training for Biomedical and Beha­ 11 ioral Research. Washington, DC: National Academy Press. dentists and specialists (Figure 6-8). During the 1990s, the If basic science faculty are combined with a group of faculty identified 12 average net income of solo private practitioners increased 78 as “research,” the combined total for 2006-2007 would be 54 vacant posi- percent, while the salaries of full-time dental clinical faculty tions, and the total for 2007-2008 would be 59.

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88 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES 40 0 374 365 Full-Time Part-Time F TE 350 33 4 30 0 287 282 28 0 273 272 271 256 250 Number of Vacancies 241 250 23 4 231 200 181 150 10 0 86 74 71 67 58 58 58 55 50 45 43 41 50 27 26 24 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year FIGURE 6-7 Number of vacant budgeted faculty positions in U.S. dental schools, 1997-2007. SOURCE: Data from 1993-2006 from Okwuji, A. S., E. Anderson, R. Valachovic. “Dental School Vacant Budgeted Faculty Positions 2007-08” Journal of Dental Education, 2009 73:1415-1422. 6-7.eps TABLE 6-1 Vacant Positions by Primary Area of Appointment 2006-2007 Vacant Positions 2007-2008 Vacant Positions Primary Area of Appointment Full-time Part-Time Total Full-time Part-Time Total Clinical Sciences 254 38 292 233 41 274 Basic Sciences 24 0 24 18 0 18 Administration 24 0 24 15 1 16 Allied Dental 4 0 4 4 0 4 Research 30 0 30 41 0 41 Behavioral Science 4 0 4 5 1 6 Total Reported 340 38 378 316 43 359 SOURCE: 2006-2007 data from Okwuji, A. S., E. Anderson, R. Valachovic. “Dental School Vacant Budgeted Faculty Positions 2007-08” Journal of Dental Education, 2009 73: 1415-1422; Chmar, J., R.G. Weaver, and R. Valachovic. “Dental School Vacant Budgeted Faculty Positions, Academic Years 2005–06 and 2006–07” Journal of Dental Education 2008 72:370-385. at the professorial level (assistant, associate, or full) rose by than general dentists. This is potentially important because only 25 to 30 percent (see Figure 6-9).13,14 most dentists pursuing research training beyond dental Several factors influence the income of dentists. Dentists school, particularly in the form of the Ph.D. degree, have also in group practices generally have considerably higher income secured training as specialists in one of the 10 dental special- than sole practitioners, and specialists earn considerably more ties. Difference in income as a function of age may also be significant inasmuch as entering either a research career or pursuing research training during the early years after dental Haden, N.K., R.G. Weaver, amd R.W. Valachovic. 2002. Meeting the 13 school calls into the play the contrast between the income of demand for future dental school faculty: Trends, challenges, and responses. Journal of Dental Education 66(9):1102-1113. dental research faculty and the income of early career practi- ADA. 2009. 2007 Surey of Dental Practice: Income from the Priate 14 tioners, both in terms of the differential in income per se and Practice of Dentistry. Chicago, IL: ADA Survey Center, American Dental also as it relates to the long-term impact of compensation Association.

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8 ORAL HEALTH $ 350,000 $ 329,980 $ 315,160 $ 3 04,020 $ 3 00,200 $291,250 $ 30 0,000 $ 250,000 $ 224,190 $ 216,550 $ 206,9 90 $ 200,0 00 $193,980 $ 20 0,000 Net Income $ 202,930 $198,350 $185,940 $177,3 40 $174,350 $150,0 00 $10 0,000 Specialists All Independent (Weighted) General Practitioners $50,0 00 $— 2002 2003 2004 2005 2006 Year FIGURE 6-8 Net income from private practice of independent dentists, 2002-2006. SOURCE: Tabulation from the American Dental Association. 2008. Surey of Dental Practice. Volume : Income from Priate Practice of Dentistry 008. Chicago, IL: ADA. 6-8.eps FIGURE 6-9 Net income from private practice dentists and dental faculty, actual and projected, 1990-2015. SOURCE: Bailit, H.L, T.J. Beazoglou, A.J. Formicola, L.A. Tedesco, L.J. Brown, and R.J. Weaver. U.S. state-supported dental schools: financial projections and implications. 2008. Journal of Dental Education. 72(2 Suppl.):98-109 in: New Models of Dental Education, The Macy Foundation Study, Reconsidering Dental Education: Planning for the Future, p. 103. 6-9.eps bitmap and benefits that have been foregone (Figure 6-10). Thus, 49.6 years, and the average age for full-time faculty was very early career dentists earn about $200,000 per year and 50.6 years.15 Furthermore, “Fifty percent of all faculty are are approaching their peak earning capacity in their early forties—about the same age at which biomedical research Haden, N.K., R.G. Weaver, and R.W. Valachovic. 2002. Meeting the 15 scientists secure their own first R01 grant. demand for future dental school faculty: Trends, challenges, and responses. In 2001, the average age for all dental faculty was Journal of Dental Education 66(9):1102-1113.

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0 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES FIGURE 6-10 Net income from the primary private practice of independent dentists by age, 2006. SOURCE: ADA. 2007. 00 Surey of Dental Practices. Chicago, IL: ADA Survey Center, American Dental Association. 6-10.eps bitmap 50 years old or older, and 20 percent (2,266 individuals) are viewed in the light of important countertrends. For instance, 60 or older.” In a report published in 2008, respondents to beyond the obvious rationale of gauging the likely number a survey indicated that 28 percent were 60 years of age or of dentists entering the workforce to meet the nation’s dental older, 37 percent were 50 to 59, 20 percent were 40 to 49, treatment needs, the population of matriculated students in and only 15 percent were younger than age 40.16 the nation’s dental schools represents the single most likely reservoir of future researchers in the oral health sciences. It is therefore fortunate that the size and quality of the national debt applicant pool for U.S. dental schools is strong, as evidenced Total resident and non-resident costs for all four years of by a nearly 3-to-1 ratio of applicants to available seats. This dental school from 1998 to 2008 are shown in Figure 6-11. upward trend in applicants to positions has continued since The cumulative debt of dental graduates and its growth is 2001-2002. Dental education has responded to this demand shown in Figure 6-12. Clearly, the debt burden of dental by increasing the seats in existing dental schools and by graduates is substantial and offers a strong incentive to seek opening several new dental schools, which, in aggregate, the higher paying clinical practice option rather than a career added up to an overall increase in dental enrollment of more in biomedical research. than 500 students for the 10 years between 1998 and 2008. Apart from the implications of this increase for dental care services to the public, this trend enlarges the potential pool a Plausible approach for the future: from which future researchers might be drawn while simulta- Compensation, debt, and integrating the NidCr Plan neously adding pressure to an already fragile ratio of students Without underestimating the difficulties of building a to available professors. robust oral health research infrastructure when trends within Consistent with the increase in dental school enroll - the dental profession and dental education are moving in the ment are ADA figures showing that “the overall number of opposite direction, the NIDCR goals of broadening the scope dental school graduates increased by 16.7 percent between of inquiry, strengthening the research pipeline, fostering 1998 and 2007 (from 4,041 to 4,714),” as can be seen in novel clinical research avenues, and eliminating oral health Figure 6-13.17 disparities are not unrealistic. This is especially true when Of special note is the growing percentage of dental gradu- ates who seek positions as employees. The prospect of an Haden, N.K., W. Hendricson, R.R. Ranney, A. Vargas, L. Cardenas, 16 W. Rose, R. Ross, and E. Funk. 2008. The quality of dental faculty work- life: Report on the 2007 Dental School Faculty Work Environment Survey. ADA. 2009. 00­008 Surey of Dental Education. Volume . Aca­ 17 Journal of Dental Education 72(5):514-529. demic Programs, Enrollment, and Graduates. Chicago, IL: ADA, p. 46.

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 ORAL HEALTH 250,000 Non esident Resident -R $206,423 $194,481 200,000 $179,344 $173,035 $159,025 $150,083 $147,409 150,000 $138,781 $137,715 $130,236 $128,453 Dollars $122,683 $121,434 $113,985 $111,807 $110,079 $103,645 $95,311 100,000 $88,534 $84,819 $78,835 $74,321 50,000 0 1998- 1999- 2000- 2001- 2002- 2003- 2004- 2005- 2006- 2007- 2008- 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Academic Years FIGURE 6-11 Average total resident and non-resident cost for all four years, 1998-1999 to 2008-2009. SOURCE: American Dental Association. 2009 (April). 00­008 Surey of Dental Education. Volume : Tuition, Admission, and Attrition. Chicago, IL: ADA. 250,0 00 Average of All Schools Public Schools 200,0 00 Private/ Private State-Related Schools Average Debt in U.S. Dollars 150,0 00 10 0,0 00 50,0 00 0 1990 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year FIGURE 6-12 Average cumulative debt of all dental school graduates, 1990 to 2009. SOURCE: Data adapted from the American Dental Education Association. ps Journal of Dental Education. 74(9):1011-1016. 6-12.e 2010.

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 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES 6,00 0 5,000 Males Females Number of Graduates 4,0 00 2135 20 99 1755 1637 16 89 2026 19 62 1814 14 46 16 47 3,00 0 2,000 273 0 26 88 26 61 26 60 26 49 2615 2536 2524 2516 2489 1,000 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year FIGURE 6-13 Dental school graduates, 1998-2007. NOTE: ADA surveys of the immediate career plans of graduates are particularly significant (see Table 6-2). SOURCE: Data adapted from ADA. 2009. 00­008 Surey of Dental .eps 6-13Education. Volume : Academic Programs, Enrollment, and Graduates. Chicago, IL: ADA. TABLE 6-2 Immediate Plans upon Graduation, by Percentage of Respondents Immediate Plans 1985 1990 1995 2000 2001 2002 2003 2004 2005 2006 Private Practice Solo 9.4 5.8 5.8 5.5 4 4.7 4.4 4.1 3.7 3.8 Partner/group 14.3 12 11.1 9.5 7.7 8.7 7.4 6 6.1 6.6 Associate/employed 34.4 31.3 32.9 36.5 41.1 38.9 38.5 40.3 41.8 42.1 Total Private Practice 58.1 49.1 49.8 51.5 52.8 52.2 50.3 50.4 51.6 52.5 Advanced Education 23.6 33.4 36 34.1 34.4 35.7 37.1 38.6 38.6 37.8 Teaching/research/admin. 0.9 1 1.1 0.5 0.6 0.5 1.9 0.5 0.8 0.5 Government Service 10.3 11.6 8.9 11 10 9.3 7.6 7.5 6.1 5.9 Undecided 7.2 4.9 4.2 2.9 2.3 2.2 3 2.9 3 3.2 SOURCE: Chmar, J.E., A.H. Harlow, R.G. Weaver, and R.W. Valachovic. 2007. Annual ADEA survey of dental school seniors, 2006 graduating class. Journal of Dental Education 71(9):1241. immediate (but more modest) income in a salaried position research careers offers a potentially more effective strategy as an associate in an established dental practice clearly has that has not been tried when eliciting interest in research appeal as a debt-payment strategy in comparison with the careers among dental students: Ordinarily, comparisons are need to forgo immediate income while seeking additional made between only two career choices: dentist (or special- financing to build an independent dental practice. This trend ist) versus academic (professor or researcher). As Charles may actually represent a potential opportunity for directing Bertolami suggests, an interested subset of dental graduates into comparably One way to address the problems stemming from income paying research positions. Specifically, a more granular differential between dental educators and practicing dentists approach to understanding the impact of differential com- is to argue that these categories actually encompass three, pensation and student debt as disincentives to biomedical

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 ORAL HEALTH 6-15 show that a “good part of the differential between fac- rather than two, discrete occupations: dentist (or specialist); professor; and businessperson (understood as owner or pro- ulty compensation and owner/private practitioners can be prietor of a practice). Different levels of work, responsibility, explained as the premium that the latter receive for accepting and risk distinguish these three jobs.18 the business risk of owning a practice. These risks include capital investment and management risk.” However (and Assuming that the blend of work, responsibility, and most significant in this discussion), among those dentists risk determines compensation, it is important for dental choosing to be employees, the lifetime differential in income graduates to understand that it is the assumption of higher between faculty members and practitioners is small. It is only risk—especially financial risk—that correlates with a greater when comparisons are made with owners and proprietors financial return. Therefore, it is the category of owner or of dental businesses that the large differentials in income proprietor of a dental practice—in effect, a business person— emerge. “Owning and equipping a dental office is expensive whose compensation is relatively high that skews the average and not risk free. . . . Illness or accident can end a career income of practicing dentists to the higher income brackets before accrued debt is paid off . . . [and] both the capital risks when viewed in aggregate. These high aggregated income and management risks must be compensated. . . . In addition, figures are what graduating dentists have in mind when such owner/proprietors very likely initiate their businesses by entering clinical practice. However, as mentioned earlier, first going out to secure a business loan. In contrast, neither the percentage of dental graduates whose immediate plans employed dentists nor dental school faculty members are upon graduation are to become employed dentists is both asked to make equity investments that require them to begin substantial and increasing, up from 34.4 percent in 1985 to their careers by assuming yet more debt.” Distinguishing 42.1 percent in 2006 (Table 6-2). That an increasing percent- between employee/dentists and owner/proprietor dentists, as age of dentists is accepting of the idea of being an employee suggested by Nash and Brown, may be very useful in com- (at a lower income than that of an owner or proprietor, while municating research career opportunities to dental students. still meeting student debt obligations) may mean that a sig- Although dental faculty positions can never be expected to nificant subpopulation of students exists in dental schools offer salaries competitive with dentists who are proprietors for whom the option of employment not in a private practice of a business, the difference is not great between research but as a dental academic or researcher could be attractive, and faculty dentists and the growing segment of employed assuming the compensation is about the same. dentists. Even in 2006, before the impact of a major eco- Critically, then, the question is not how compensation nomic downturn on the economics of dental practice had differs between dental professors and researchers versus materialized, employed dentists earned almost 40 percent practicing dentists, but rather how compensation compares less than owner/proprietors. In light of this finding, and to between professors and researchers and the category of the extent that financial comparisons are made between fac- employed (non-owner) dentists. Furthermore, how the ben- ulty positions and practice positions, they should be made efits of being an employee (including retirement and health only among the category of employed dentists: “This is the benefits, paid vacation time, portability, and relative freedom premium such individuals pay for the kinds of freedoms from financial risk)—and not just starting salary—translate employees typically enjoy—including paid vacation time, into prized values over an entire career becomes a central possibly sick time, a lack of assets at risk, and relative ease issue. Dental graduates willing to put personal financial of moving from job to job or place to place.” assets at significant risk in the building up and running of The practical significance of the Nash and Brown analysis a business-based dental practice in return for significant is that it might be advantageous not to view the dental student economic reward associated with these risks will find an population as homogeneous and undifferentiated. Rather, academic research career relatively unattractive. This may research careers in the oral health sciences can be credibly not be the case, however, for the employed dentist who is marketed to a significant and identifiable subpopulation of unable or unwilling to place personal assets at risk. For the dental students: specifically, those with an inclination to person contemplating a career in dental academics, Nash accept a long-term position as an employee rather than as an and Brown pose the crucial question: “Are the monetary owner/proprietor. Bringing this choice to the awareness of benefits from dental training large enough to repay all costs dental students early in their education could have an impact of training and yield a positive net return to the dental school on the appeal of research careers for some students. faculty member?”19 The comparisons in Figures 6-14 and Our predecessor report made several observations that are as true today as they were when the report was issued in 2005, including: Bertolami, C.N. 2007. Creating the dental school faculty of the future: 18 A guide for the perplexed. Journal of Dental Education, 71(10):1267-1280. • If education in biomedical research is to be offered to American Dental Education Association. Nash, K.D., and L.J. Brown. 2004. Rate of return from a career as dentists, it needs either to be a part of professional school 19 dental school faculty. In L.J. Brown and L.H. Meskin, eds. The Economics study or provided as a postgraduate experience. of Dental Education. Chicago: American Dental Association, Health Policy Resources Center, pp. 41-79.

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 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES +$$ Dental Net Monetary Benefits (Premium) 4 Years College Foregone Earnings 0 Direct Expenses -$$ 22 26 Age FIGURE 6-14 Model of estimating the rate of return to an investment in a dental education. SOURCE: Nash, K.D., and L.J. Brown. 2004. Rate of return from a career as dental school faculty. In L.J. Brown and L.H. Meskin, eds. The Economics of Dental Education. Chicago, IL: ADA, Health Policy Resources Center. $350,000 $300,000 $250,000 $200,000 $150,000 $100,000 $50,000 $0 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72 74 -$50,000 Age -$100,000 4-Year College Specialist Faculty (ROR=13.7%) Owner Specialists (ROR=28.0%) Non-Owner Specialists (ROR=15.4% ) FIGURE 6-15 Average earnings of dental specialists in various careers and average earnings of four-year college graduates, by age, 2000. SOURCE: Nash, K.D., and L.J. Brown. 2004. Rate of return from a career as dental school faculty. In L.J. Brown and L.H. Meskin, eds. The Economics of Dental Education. Chicago, IL: ADA, Health Policy Resources Center.

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 ORAL HEALTH • Individuals at the high end of the academic distribution high gradient against which dental educators have to prevail are not being attracted to careers in biomedical research. if such students are to be attracted to an academic career in • The percentage of dental graduates interested in teach- spite of an explicit and antecedent decision against it.” ing, research, or administration is small and declining. Few students entering dental school are aware of a career path reCommeNdatioNS that includes oral health research, and even fewer consider this option as they complete their training. Clearly, the best science needs to continue to be brought • The reasons for this low interest include the prospects to bear on problems in oral, dental, and craniofacial health. of a high income in dental practice; accumulated high stu- At the same time, however, a critical mass of investigators dent debt; and a culture in many dental schools, especially who possess a special and long-term commitment to research among the clinical faculty, that values the technical aspects in the oral health sciences must be maintained. With these of dentistry and often marginalizes research. goals in mind, the committee believes that the following recommendations are consistent with the 2009 NIDCR The 2005 report lamented the fact that competition is great strategic plan and that they offer a path forward for achiev- for the highest academic performers graduating from dental ing that plan’s goals, namely, to increase the biomedical school and that the occupational activities most effective at research workforce in the oral health sciences in order to siphoning off the best graduates academically are the vari- bring the best science to bear on problems in oral, dental, ous clinical specialties in dentistry. These training programs and craniofacial health. require anywhere from 2 to 7 years of additional study after Recommendation 6–1: Working through appropriate dental school. Accordingly, the appeal of studying several organizations such as the American Association for Den- more years for a Ph.D. degree to enter a field guaranteed to tal Research, the American Dental Education Associa- offer a lower level of compensation does not enter the con- tion, and research-intensive dental schools, the National sciousness of most graduates of dental programs. Although Institute of Dental and Craniofacial Research must the current situation relative to the research personnel needs increase efforts to achieve closer integration between in the oral health sciences is about the same as described schools of dentistry and the broader research, practice, in the 2005 report, and though a new and disturbing trend and education communities with the goal of generating has emerged that seems to de-emphasize research in dental new and vibrant research pathways and partnerships for schools, the goals of the new NIDCR strategic plan are well students and faculty. suited to addressing the key problems. Assuming the current university-based model of both R ecommendation 6–2: Because individual research educating and employing research scientists in dentistry fellowships have proven more effective in terms of gen- remains the operative paradigm, a key question is: What will erating long-term research career commitments than it take to make both teaching and the research integral to a institutionally based programs, greater opportunities university-based teaching model appealing to the kinds of for independent NIH research fellowship support is individuals required by the biomedical research enterprise in encouraged, including K awards, programs to support the oral health sciences? Implicit in the previous discussion postdoctoral research for dentists, Ph.D. programs for have been the significant impediments to careers in educa- non-dentists in subject areas relevant to oral health, and tion and research that materialize as a consequence of dental programs for internationally trained non-U.S.-citizen graduate debt and the need to balance salary and working dentists seeking Ph.D. and postdoctoral fellowships. environment. Partnerships with other components of the academic What dental educators are really doing when they ask health system need to be developed and maintained based dental students to consider a research career is inducing on recognition of the value added by the oral health sci- them to make a dramatic break with their settled career ences through systems-oriented approaches as already aspiration of becoming a dentist. The available population embodied in programs such as the Clinical and Trans- of potential candidates is not only relatively small—fewer lational Science Award programs and practice-based than 5,000 nationally—but also prejudicially filtered: All research networks. All such NIH-sponsored initiatives dental students have gone to college where they encountered should explicitly identify a collaborative role for oral research scientists. “They know what academic life is all health research. about and understand what it means to be a professor,” Nash and Brown explain. “In deciding to go to dental school, they Recommendation 6–3: Ideally, programs need to be have consciously rejected the notion of an academic career. developed that offer tuition waivers or supplements, or The fixity of this idea in a student’s mind—that they are loan forgiveness, or both, for the dental school component going to be a dentist not a professor—generates a relatively

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 RESEARCH TRAINING IN THE BIOMEDICAL, BEHAVIORAL, AND CLINICAL RESEARCH SCIENCES of combined D.D.S./D.M.D./Ph.D. programs. This would the Ph.D., the NIH needs to be encouraged to permit post- allow most or all of the burden of the D.D.S./D.M.D. doctoral stipend levels to apply during the post-D.D.S. tuition to be covered for students who commit to long- phase (as opposed to the lower, predoctoral stipend term careers in dental research. Enhanced stipends for levels). The feasibility of adaptations of the existing graduate students should be provided if fiscally feasible Medical Science Training Program (M.D./Ph.D.) model without causing students to lose eligibility for low-inter- to dental education—including full funding for eight or est student loans. In conjoined D.D.S./D.M.D.-Ph.D. so years—should be explored. programs, when the clinical degree is awarded prior to