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CHAPTER SIX ORAL HEALTH RESEARCH PERSONNEL Oral health research (OHR) has paid great dividends (Lathrop and Ranney, 19934. It has contributed to reduced rates of dental caries as well as improvements in diagnosis, prevention, and treatment of over oral diseases and abnor- malities. OHR activities include research not only on tooth structure and diseases of supporting tissues, but on cells, tissues, and structures of the entire oral and craniofacial region. Over important research areas include oral cancer, salivary gland disorders, genetic diseases, and materials sci- ence related to dental practice. Estimates indicate that dental school research training programs have less than half the faculty needed to provide a strong research environment. Compared with all other fac- ulty in dental schools, research faculty are aging and are not being replaced at the rate they are retiring or otherwise leav- ing the field or by faculty having the same level of training. Unlike other medical fields that have access to a variety of sources of research support, most OHR is supported by the National Institute of Dental Research (NIDR). Because of He anticipated demand for OHR, He number of training awards in OHR and the resultant inability to replace an ag- ing cadre of OHR scientists in faculties of dental schools, the committee recommends a two-fold increase over the 1993 number of awards. ADVANCES IN ORAL HEALTH RESEARCH The history of OHR is closely related to the history of NIDR, which celebrated its 45th anniversary in 1993. Origi- nally, NIDR's mission was to "improve the oral health of the American people." At Hat time, oral health focused on caries Stood decay) because of its overwhelming preva- lence. Initially, a group of intramural dental scientists took on caries research largely through epidemiologic ap- proaches. Taxis was the beginning of the remarkable tale of 6s fluoride as an effective public heals measure. The initial phase of epidemiology and prevention research has had a tremendous impact on every aspect of dental education and dental practice and saves the American people an estimated $4 billion per year. In recent years the scope of OHR has been greatly broad- ened. In addition to the emphasis on dental caries, microbi- ologists and biochemists now deal win basic issues related to hard and soft oral tissues. The maturing of OHR has led not only to the understanding of how took decay begins, but to the improved understanding of He infectious base of periodontal diseases. These complementary discoveries have had major implications for the clinical management of oral diseases. In addition, researchers have made much progress in areas such as neurobiology, developmental biology, cellu- lar and molecular biology, oral microbiology and immunol- ogy, and materials science and imaging technology. Dental implants illustrate one practical application of the results of recent oral heals research. ASSESSMENT OF TO CURRENT MARKET FOR ORAL HEALTH RESEARCH PERSONNEL A database on dental educators compiled by He Ameri- can Association of Dental Schools (AADS) provides the best available current information on the OHR labor force. Begun in 1981 this database includes all faculty appoint- ments to dental education institutions in the United States and is updated annually by a survey of AADS member in- stitutions. It includes information on age, gender, race, Scat demic rank, appointment status (full or part-time), academic degrees held, and area of primary appointment. Analysis of this database (Solomon, 1993) showed that He average age of OHR scientists increased from 47.3 to 49.1 years from

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MEETING THE NATION'S NEEDS FOR BIOMEDICAL ANI) BEHAVIORAL SCIENTISTS 1986 to 1992. AUso, compared with all full-6nne dental school faculty, OHR scientists were somewhat older (48.6 to 49.1 years, 1992-19931. OHR scientists generally held higher academic rank than full-time dental school faculty. In 1992-1993,73 percent of OHR scientists held senior rank (full or associate professors compared with 65 percent of all full-time dental faculty. From 1986-1987 to 1992-1993, the percentage of OHR scientists who identified Heir primary appointments as clinical sciences decreased from 44 per- cent to 36 percent (comparative figure for all full-time fac- ulty is 58 percent). As a proportion of all OHR scientists, those holding the Ph.D. only (without a clinical degree) de- creased somewhat (51 percent to 45 percent). No change was found for the dual-degree J).D.S./Ph.D.) OHR scien- tists, whose proportion remained stable, but the category "other" (predominantly clinical degree with or without Mas- ters degree) increased from 4 to 10 percent of OHR scien- tists (Figure 6-1~. Over the time of analysis, OHR scientists turned over (entered and left) by more than one-third (361 entered, 357 left). Most entries were in their 30s and early 40s; depar- tures were evenly spread over He age range of the faculty. Departing faculty OHR scientists were more likely to hold a nonclinical doctorate than were entering OHR scientists. These analyses indicate that OHR scientists are an aging group, approaching retirement. Although total numbers of OHR scientists are staying constant despite declines in total faculty, reflecting increased emphasis on research in the schools, those with Ph.D.s who leave seem to be replaced to a greater extent by those without Ph.D.s. This reflects the lack of growth in training programs for OHR since 1985. It also suggests a concern for a decrease in competitive stature for grants for OHR scientists among all research workers. Other factors also contribute to the acute shortage of OHR scientists. Because of He undersupply of research workers for dental institutions, OHR scientists tend to 1) not take postdoctoral training to the same extent as their FIGURE 6-1 Percent academic degrees by academic year. SOURCE: Solomon, 1993. 1986 1 989 1 992 competitors for research grants; 2) get drafted into, or oth- erwise move too soon into, administrative positions; and 3) have insufficient available mentoring capability existing in the institutions where Hey are employed. In addition, insti- tutional support is generally minimal, so that it is difficult to find start-up funds or bridge support. Additional factors that contribute to He shortage of OHR scientists are similar to other areas of biomedical research. These include low funding rates for grants, lower income possibilities in academic endeavors Han in practice careers, and the debt of graduating dental students. Dental students' debt is the greatest of all health care professionals: it ex- ceeds $55,000 on average and often exceeds $100,000. OUTLOOK FOR ORAL EBEALTH RESEARCH SCIENTISTS Although much progress has been made, oral diseases remain among He most prevalent diseases in He United States. More than 84 percent of children, 96 percent of adults, and 99.5 percent of those over 65 years of age in this country have experienced dental caries. Many millions of Americans have one or more periodontal diseases or other oral disease. Over 17 million have lost all of their teeth. In 1989, 164 million hours were lost from work and 52 million hours were missed from school because of dental condi- tions. In 1992, $38.7 billion was spent for dental services. By the year 2000 the annual cost for dental heals is ex- pected to reach $62 billion. Cancer of the oropharyngeal region is more common Han leukemia, melanoma, Hodgkin's disease or cancers of the brain, liver, bone, thyroid, stomach, ovary, or cervix. It affects primarily older Americans and causes approximately 8,000 deaths per year. The 5-year survival rate for oral cancer is 51 percent but only 31 percent for blacks. Millions are at high risk for oral health problems be- cause of other handicapping or medical conditions. These Other 'Ph.D. rem to; Doubts Doctorate - .... ........ ~=906 IN = 925 IN =910 0% 20% 40% 60% 80% 66 100%

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ORAL HEALTH RESEARCH PERSONNEL conditions affect quality of life, including pain, ability to eat, speak, taste, and swallow. For example, cleft lip and palate require extensive and expensive repair to avoid dis- figurement. There are significant problems for individuals with compromised immune systems, including those with acquired immune deficiency syndrome (AIDS). These problems include oral candidiasis, hairy leukoplakia of the tongue, recurrent ulcers caused by Herpes simplex or other viruses, oral Kaposi's sarcomas, and aggressive periodontal disease, including necrosis of alveolar bone. Infectious oral diseases increase risk for endocarditis, brain abscesses, pneumonia, infection of prosthetic valves and joints, and systemic infection of individuals who are undergoing organ or marrow transplants. Thus, OHR now addresses oral and dental health concerns across the life span, and high risk and special populations are major targets of this research. OHR needs more and better-trained scientists with spe- cif~c interests in oral health. Training sites and mentors must become magnets for the best and brightest of the graduates. They must also provide role models for stu- dents. Trainees must be kept in the system, and factors that facilitate retention of oral health scientists already in the work force need to be identified. It is extremely important to ensure that there are an adequate number of clinical re- search investigators and to enhance the clinical faculty in dentistry. Finally, research results must be disseminated to practitioners and to the public. No funding source other than the NIDR significantly sup- ports OHR or training specifically for OHR. Continued support of training through NIDR is essential to continued improvement of the quantity and quality of OHR personnel. ENSURING DIVERSITY OF HUMAN RESOURCES The percentage of women in the OHR scientist cohorts increased from 12.7 percent in 1986-1987 to 16.3 percent in 1992-1993, but He percent of women among all full-time dentalfaculty was stillhigher (18.7 percent, 1992-19934. Asians and Hispanics increased in proportion slightly among OHR scientists over the period studied, but the percentage of black OHR scientists decreased (2.6 percent to 1.7 percent). The OHR scientist group had a slightly higher representation of whites and Asians than did full-t~me faculty in general. Although the OHR scientist labor force is becoming more diverse (more women and Hispanics), women and minorities are still under-represented. This is especially true for blacks. NATIONAL RESEARCH SERVICE AWARD PROGRAM FOR ORAL HEALTH RESEARCH Before the National Research Service Award program, dental training centered around clinical specialty training. Under the NRSA mechanism, the emphasis shifted to a pri 67 mary focus on research.2 There are now 288 people in NIDR- supported training programs for a research career, including approximately 160 in the NRSA program, excluding dental students supported under the T35 mechanism for short-term training. That number has been relatively stable throughout the 1980s and 1990s, although there has been a slightreduc- tion in the NRSA program. Of the 288 total, approximately half are clinical researchers with a D.D.S. degree who are studying for a Ph.D. (counted as postdoctoral trainees); about 10 percent are predoctoral students studying for the Ph.D.; and the remaining 40 percent are postdoctoral trainees who hold the Ph.D. or D.D.S., including those in the NRSA program as well as in other programs (Dentist-Scientists or Physician Scientists for Dentists awards) (Table 6-1~. The NRSA stipend varies with the number of years of experience after the last professional degree and it ranges from $18,600 to $32,000. However, the Dentist Scientist Award (DSA) salary may go up to $50,000. The NRSA mechanism has a modest institutional allowance, approxi- mately $2,500 for a postdoc on a Gaining grant and $3,000 for a fellowship, whereas the DSA includes significant sup- port for research of up to $75,000 over the 5-year project period and mentors can receive salary support. Under the NRSA no salary is available for mentors. Within the NRSA awards there is a distinction between the fellowships and training grants. Full tuition and fees are supplied in training grants but not in fellowships. Legislation Hat limits an NRSA trainee to only 3 years of postdoctoral research experience is a significant problem for support of OHR scientists. A dentist appointed to a Gaining grant seeking a Ph.D. needs more than 3 years, especially when concomitant clinical Gaining is involved. Although the NIDR has been liberal in granting waivers and extensions, it would ease recruitment if He legislated limit were removed. A good evaluation mechanism for the effects of different types of training support is needed, so that differential im- pacts of different programs can be known. Programs in which dentists receive research Gaining in- cluding the Ph.D. have been successful. Eighty-one percent of the individual and 73 percent of the institutional DSA- eligible awarders who have completed all requirements of the DSA program have obtained a placement in a health science setting (T. Valega, 1993~. Of the NRSA graduates who began their training be- tween 1975 and 1985, between 50 and 60 percent of those who submitted project applications to NIH were subse- quently funded. Clearly, both NIDR-supported NRSA and DSA trainees are able to compete successfully for grants. In Figures 6-2 and 6-3 the positive relationship between months of Raining and success in obtaining grants is clear. There is also a positive relationship between degree and research grant history (Figure 6-4~.

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MEETING THE NATION' S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS TABLE 6-1 Aggregate Numbers of NRSA Supported Trainees and Fellows In Oral Heateh Research for FY 1991 through FY 1993 Fiscal Year Level of Training 1991 Number of awards Predoctoral Postdoctoral Type of Support TOTAL Trameeship Fellowship 218 78 140 186 78 108 32 o 32 1992 Number of awards 213 178 35 Predoctoral 77 77 0 Postdoctoral 136 101 35 1993 Number of awards 127 105 22 Postdoctoral 97 96 1 Predoctoral 127 105 22 NOTE: Based on estimates provided by the National Institutes of Health. See Summary Table 1 FIGURE 6-2 Individ- 120 ual NRSA (F32) train ees: relation between months of training and research grant history, 1980-1990 (based on individuals who began training between 1975 and 1985~. SOURCE: National Institute of Dental Research, 1991. 100 80 60 40 20 o FIGURE 6-3 Institu- 200 tional NRSA (T32) train ees: relation between months of training and research grant history, 1980-1990 (based on individuals who began training between 1975 and 1985~. SOURCE: National Institute of Dental Research, 1991. SO 150 ._ 0 O 100 at 50 O ~ All trainees 14 70 L _~ 1 -I- ~ . . 1 85 0-12 12-24 25-36 36 + Monthe of Training 0-12 12-24 68 139 Months of Training ~ At least 1 applicant E:;1 At least 1 award 10 Total trainees lit] At least 1 applicant I 1 At least 1 award 38 25-36 36 +

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ORAL HEALTH RESEARCH PERSONNEL 250 200 0 150 o n it 100 50 o ~ Total trainees 193 - 88 31 _~G] ~ At least 1 applicant Al At least 1 award 136 F32-D. D. S. F32-Ph. D. T32-D. D.S. T32-Ph. D. Award-Degree D.D.S./D.M.D. only D.D.S. + Ph.D. HI Ph.D./Dr.P.H. Other 1 00 ~ - ~ 80% 60% 40% 20% Clinical Biomedical Behavioral Research Category FIGURE 6-5 Percent of NIDR research grants (R01, R23, R29, R37) by degree of principal investigator and research category: FY 1990-1992. NOTE: "Other" category includes M.D., M.D. + Ph.D., D.V.M. and non-postdoctoraldegrees. SOURCE: Nation- al Institute of Dental Research, 1993. Figure 6-5 considers He types of academic training asso- ciated with the area in which research was performed. This could be used to provide an indication of the background needed for scientists to conduct clinical, basic biomedical, and behavioral research. Investigators having a dental de- gree, either alone or with a Ph.D., predominated for clinical research. Among biomedical research projects the investi- gators having only the Ph.D. predominated. No differences were found between the investigators having dental degree or only He Ph.D. for projects classified as primarily behav- ioral. These findings support the need for appropriately trained individuals having at least a dental degree to provide a future adequate cadre of clinical oral heals researchers. 69 FIGURE 6-4 NRSA trainees: relation between degree and research grant his- tory, 1980-1990 (based on individuals who began training between 1975 and 1985~. SOURCE: National Institute of Dental Research, 1991. RECOMMENDATIONS Program Size Because of rapid advances in biological and physical sci- ences, He opportunity for advancing oral heals has never been greater. However, there is an alarming shortage of trained researchers in oral health to take advantage of those opportunities. Graduates of NRSA and DSA programs supply, on aver- age, fewer than one clinical scholar or potential clinical scholar per dental school per year. At least 200 graduates per year are necessary to supply the institutions' needs (Kennedy, 1990), roughly four times the number being pro- duced. Thus there is a shortage from two points of view: one, to address the research needs and two, to fill faculty slots with capable researchers. At least half of a dental school faculty should be clinical scholars. The over half, though perhaps not researchers, should be scholarly clini- cians, that is, critical about the literature, critical about what they are teaching, and critical about their patients' needs. Research training fulfUls both needs of a clinical faculty. Looked at in another context, dental institutions are a small but important consumer of Ph.D.s who do not hold clinical degrees. However, nobody but the OHR commu- nity and dental institutions has concern for He D.D.S./Ph.D. supply Hat is critical to maintaining the quality and quan- tity of research related to oral health. Dental schools today are not able to find sufficient numbers of D.D.S./Ph.D.s to fill available faculty positions. There are clear indications that the clinical degree is im- portant to site of employment after Raining has been com- pleted. In 1985 Littleton and his colleagues reported Hat 62 percent of D.D.S./Ph.D.s trained win NIDR support could be found on faculties of dental institutions, whereas only 31 percent of all NIDR postdoctoral trainees were em- ployed in dental institutions (Littleton, 1985~. It is thus important to the future of OHR Hat people with clinical

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MEETING THE NATION' S NEEDS FOR BIOMEDICAL AND BEHAVIORAL SCIENTISTS degrees be encouraged, through adequate training support, to enter the research work force. There is an acute need for clinical dental researchers and OHR workers in general. The National Research Council's 1985 report called for 320-400 new clinical dental research trainees annually, but the NIDR has been unable to carry out this recommendation because funds were not available. A significant increment in training would substantially alle- viate the shortage of OHR personnel. We need to produce about 260 graduates per year. This estimate includes needs for researchers in dental schools and other settings. About 30 percent of NIDR's total re- search support goes to non-dental school institutions. If the current distribution between NRSA and other mechanisms remains constant, roughly half should be supported by the NRSA mechanism (130 per year). At 3 - 5 years per f~n- ished trainee, this would be 390 - 650 in training through the NRSA mechanism; the current total through the NRSA is 213 and for all NIDR mechanisms is only about 300. There is need and rationale, therefore, for a tripling to quadrupling of training for OHR (Table 6-2~. Realistically, however, the need is better met incrementally rather than abruptly to ensure that existing high-quality training sites are not overloaded and to stimulate identification and de- velopment of additional high-quality sites. RECOMMENDATION: The committee recommends that the total number of training positions available for preparation in oral health research double from approxi- mately 210 positions in fiscal 1993 to 430 positions in fiscal 1996 and remain steady thereafter. Need for a Dental Scientist Training Program The Medical Scientist Training Program (MS TP) offers an integrated program of medical and graduate training lead- ing to the combined M.D. and Ph.D. degrees. The success of that program (see Chapter 5), coupled with the demon- strated success of D.D.S./Ph.D. or D.M.D./Ph.D., suggests that OHR would benefit from the development of a Dental TABLE 6-2 Committee Recommendations for Relative Distribution of Predoctoral and Postdoctoral Tra~neeship and Fellowship Awards for Oral Health Research for FY 1994 through FY 1999 Fiscal Y 1994 Recommended number of awards Predoctoral Postdoctoral Type of Support TOTAL Traineeship Fellowship 260 200 60 125 135 1995 Recommended number of awards Predoctoral Postdoctoral 1996 Recommended number of awards Predoctoral Postdoctoral 1997 Recommended number of awards Predoctoral Postdoctoral 1998 Recommended number of awards Predoctoral Postdoctoral 1999 Recommended number of awards Predoctoral Postdoctoral 345 210 135 430 290 140 430 290 140 430 290 140 430 290 140 100 100 230 130 100 265 160 105 265 160 105 265 160 105 265 160 105 25 35 115 80 35 165 130 35 165 130 35 165 130 35 165 130 35 70

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ORAL HEALTH RESEARCH PERSONNEL Science Training Program (DSTP) that is analogous to He MSTP under He auspices of the NRSA legislation. RECOMMENDATION: The committee recommends that one-quarter to one-half of the new positions available for training in OHR in fiscal 1994 and beyond be used by NIDR to establish a Dental Scientist Training Program (DSTP) under the NRSA act. Other Considerations Additional suggestions for improving the NRSA for training OHR scientists have emerged in committee discus- sions. Some of these suggestions are similar to those from other fields and are included in the overall recommenda- tions of this report. Other suggestions are unique to OHR, and are mentioned in the paragraphs Hat follow. Legislated policy requires Hat individual awards com- prise at least 15 percent of the total NRSA allocation by the funding institute, but there is no clear rationale for the policy. NIDR sometimes has difficulty meeting the 15 per- cent requirement for awards to individuals, and there is great demand for institutional awards. It is possible that institu- tions are competing for the best students through He insti- tutional training mechanism, leaving relatively few students for the pool of individual applicants. The committee be- lieves that He 15 percent requirement for individual awards for NIDR should be rescinded. The long-term effectiveness of short-term exposure to research experiences needs to be evaluated. At present, the NIDR uses the T-35 mechanism to draw dental students into research careers. However, this particular mechanism is limited to 4 percent of the NRSA funds. The committee suggests that this limitation be evaluated not only for the long-term effect but also to explore whether the mechanism should be extended for other purposes, such as retraining, encouraging minorities and women to enter research tracks, and stimulating clinical research. Completion of a Ph.D. after a dental degree generally requires more than 3 years. Also, other sources of support for continuing such studies (e.g., Howard Hughes Institute, clinical revenues) are not generally as available for dentists as they may be for physicians. The committee suggests that doctoral support be provided for 5 years and beyond for dentists making satisfactory progress toward a Ph.D. under an NRSA. Finally, because of the disincentive for entering research training that is inherent to the heavy debt load of dental graduates (currently the highest of all health professional graduates at greater Han $55,000, on average), loan for- giveness would provide an incentive. The committee be- lieves that a loan-forgiveness incentive should be provided as a feature of NRSA programs. In summary, what is particularly needed in OHR are ap 71 propriately Gained personnel to carry out a broadened scope of research. There is an alarming personnel shortage of research-aained full-time dental faculW. Many challenges continue to arise as the twenty-first century approaches. These challenges require enhanced resources and flexibility as well as continued cooperation and collaboration among programs and institutions if they are to carry out He mandate of Con- gress to improve the oral heals of He American people. NOTES 1. Much of the material in this chapter is based on the views of ex- perts who convened a one-day workshop on July 9, 1993, in Washington, DC (Lathrop and Ranney, 1993). 2. There are two major programs for training OHR scientists through NIDR support, the NRSA and the Dentist/Physician Scientist Award (DSA). NIDR's portfolio in the NRSA includes the following: F-32, individual postdoctoral fellowship; F-33, individual senior postdoctoral fellowship for senior faculty members; F-35, intramural training grant; T-32, institutional training grant; and T-35, short-term summer training grant. The DSA/PSA programs include the following awards: K-11, individual physician-scientist award for dentists; K-15, individual dentist-scientist award; and K-16, institutional dentist scientist award. The F awards (fellowships) are all postdoctoral awards, either post Ph.D. or post clinical doctorates. These postdocs receive the traditional postdoctoral research Gaining and, in the case of clinical doctorates, that may include earning a Ph.D. during postdoctoral training. The T awards (training grants) can include predoctoral students. These people have bachelor's or master's degrees and usually are in a program to obtain a Ph.D. In rare cases, such as in biomaterials or epidemiology, they stop at a master's level. The T-35 short-term grants are specifically for dental stu- dents. The physician-scientist award for dentists and the dentist-scientist awards appoint only dentists. All of these DSA appointees are in a pro- gram to obtain a Ph.D. REFERENCES Kennedy, J.E. 1990 Faculty Status in a Climate of Change. Journal of Dental Education 54(5). Lathrop, L. and R.R. Ranney 1993 Proceedings of Meeting on National Needs for Oral Health Research Personnel. National Academy of Sciences, Wash- ington, D.C., July 9, 1993. Unpublished summary. Septem- ber, 1993. Littleton, P.A., L.J. Brown, and E.S. Solomon 1985 The Relationship Between National Institute of Dental Re- search (NIDR) Supported Research Training and Careers in Dental Research. Unpublished report. March, 1985. Solomon, E.S. 1994 The Oral Health Research Work-Force. To be published in Journal of Dental Education. Valega, T. 1993 Report to Meeting on National Needs for Oral Health Re- search Personnel, National Academy of Sciences, Washing- ton, D.C., July 9, 1993. See Proceedings of Meeting (Lathrop and Ranney, 1993).

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