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--> 5 The Mission of Research Oral health researchers in U.S. dental schools and universities, together with researchers in government, postgraduate institutes, and industry, have built a base of scientific and clinical knowledge that has been widely communicated and used to improve oral health. Their ongoing research initiatives combined with broad advances in the biomedical sciences will add to these achievements in the future. Discoveries in genetics, molecular and cell biology, immunology, and pharmacology, as well as in materials and computer sciences, will reshape the character and focus of dental practice and dental education itself. Vaccines against caries and periodontal disease, new anti-infectious agents, sophisticated simulation models, even genetic therapies are all likely to materialize in the future. The main questions are not whether but when they will arrive and in what specific form. Many of the basic science discoveries that will be most influential in shaping future oral health and oral health practice will occur outside dental schools—in university science departments, in medical schools, and in government, industrial, and other research laboratories. This means that dental school research programs must be linked to basic research programs outside the school. Involvement with medical school and other university research activities will be increasingly important. Some dental schools are vital centers for the creation of new knowledge about oral diseases and their prevention or treatment.
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--> Nonetheless, many dental schools and dental faculty still have little or no involvement with research or, more broadly, scholarship. Twenty percent of the dental schools received two-thirds of the research and training funds distributed by the National Institute of Dental Research (NIDR) in 1991. As described in Chapter 2, NIDR was created in 1948 to bolster the very limited research and research training capacity of dental schools as well as to conduct its own research program. It remains the major source of support for oral health research and for training of oral health researchers. This chapter begins with a discussion of broad goals for dental schools. It then reviews basic data on funding sources, amounts, and targets of oral health research. Later sections discuss major issues and concerns, in particular, funding constraints and shortages of well-trained oral health researchers. The background papers by Greenspan and by Jeffcoat and Clark provide a selective overview of the current state of, and future prospects for, oral health science and technology and of the role of dental schools in technology transfer. The paper by Bader and Shugars focuses on outcomes and health services research. Broad Goals For Research In The Dental School As stated in Chapter 1, the committee strongly believes that dental education should be scientifically based and undertaken in an environment in which the creation and acquisition of new scientific and clinical knowledge are valued and vigorously pursued. The research standards for dental schools published by the Commission on Dental Accreditation support this goal (Table 5.1). In addition to creating new knowledge, the research mission includes disseminating such knowledge, educating clinicians to critically assess scientific and technological innovations, and educating future researchers. Conceptualized somewhat differently, these dimensions include a mix of scholarly activities: discovery, integration, application, and teaching (Boyer, 1990; Bepko, 1991). However categorized, these elements of research and scholarship are linked by the broad common goal of improved oral health and should influence all elements of the dental school curriculum. Their scope is sufficiently broad that they offer opportunities for faculty contributions beyond the laboratory or clinical trial—important as those traditional venues of research are. The creation or discovery of new knowledge is the heart of the university's research mission. Within the diverse components of
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--> TABLE 5.1 Research Standards for Accreditation 1. Research, the process of scientific inquiry involved in the development and dissemination of new or improved knowledge, must be an integral component of the mission of each dental educational institution. As the advancement of the profession, and ultimately the health of the public, depends upon the development and dissemination of new or improved knowledge, dental education institutions must accept the obligation to do research. Research, whether basic, clinical, behavioral or that leading to improved oral health care delivery, must be in evidence. Although it is recognized that institutional priorities will vary in relation to research, education and service, research efforts must be of such quantity and quality as to support the stated mission of the institution. In addition, there should be an appropriate balance among these three activities to ensure that institutional objectives are being fully realized. 2. A formal research development plan must be evident to ensure the continual support of the research mission of the institution. The administrative responsibilities for the development, monitoring and continuance of research activities should be clearly outlined. 3. The amount of time and resources available for faculty research should be sufficient to support the objectives of the institution. There should be clearly evident a mechanism whereby interested faculty and students at all levels might become meaningfully involved in research endeavors. Institutional resources should be available to provide interim support for faculty in the event that funds for sponsored research lapse. SOURCE: CDA, 1993a. the modem university, discovery can take varied forms. Past Institute of Medicine (IOM) studies of health research have identified a ''continuum" of relevant research fields, including: "the biomedical sciences, which inquire into the basic nature of life through deeper understanding of life process; the clinical sciences, which translate fundamental research into medical practice; population-based sciences, such as epidemiology and biostatistics; the behavioral and social sciences; biophysics, bioengineering, and clinically oriented medical engineering and physics; the hybrid sciences, such as nutritional and environmental sciences; health services research, which studies the health care system; and technology transfer" (IOM, 1979, 1990d, p. 30, emphasis added). The creation of new knowledge often involves studies that cross disciplines. For dental faculty, interdisciplinary research—particularly when it involves clinical faculty—has the additional benefit of reducing the isolation for which dental schools have sometimes been criticized (Hogness, 1982; McCallum, 1983; Ranney,
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--> 1989; Littleton, 1992). The focus of such integrating research is highly varied and includes basic biological processes at the cellular and molecular levels, pharmacological methods for preventing or treating oral disease, biomaterials development, ''hard tissue engineering" (involving bone and tooth structures), and oral health epidemiology and behavior. The background paper by Greenspan, for example, discusses how approaches combining molecular biology, molecular immunology, and epidemiology are advancing basic scientific knowledge of periodontal diseases. In addition to basic and clinical research, both behavioral research and health services research are essential for the improvement of oral health in individuals and populations. Basic scientific discoveries and clinical advances do not automatically benefit individuals or communities. Access to these advances may be limited by organizational, behavioral, financial, or other barriers, and clinical advances may not directly address the problems of particular population subgroups. A major goal of behavioral, epi-demiological, and health services research is to identify the factors that encourage or thwart the various steps required to move from scientific knowledge to improved health. Basic, clinical, and health services research, taken together, can reinforce and support the emphasis on health outcomes that is demanded in today's health care system. In addition to creating knowledge, dental schools are also important vehicles for disseminating and integrating knowledge through their predoctoral, graduate, and continuing education programs. They play a role in the process of technology transfer, which involves the movement of new applications of knowledge from academic, governmental, and commercial research centers to the practice setting. At their best, dental school faculty and curricula act as critical filters that help students and practitioners to separate well-founded from ill-founded claims for the effectiveness of specific new—and old—interventions. At their worst, as this committee heard on occasion, faculty are neither immersed in advances in science and technology nor prepared to scrutinize rigorously claims for the effectiveness of new (to say nothing of established) clinical practices.1 The committee's site visits produced repeated references 1 The somewhat tenuous standing of oral research in the broader research community is suggested by the periodic reports on needs and training for biomedical and behavioral sciences developed by the Office of Scientific and Engineering
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--> to the archetype of the nonscholarly faculty member—the "checker" who inspects student work but makes no contribution through critical thinking or research.2 In disseminating knowledge and participating in technology transfer, the objectives for dental education are not merely to promote the appropriate adoption of new techniques, drugs, or materials but more generally to promote informed and intelligent practice. This requires the curricular framework described in Chapter 4, one that provides a practice-relevant foundation in the basic sciences and that incorporates research findings and evaluation in classroom and chairside clinical instruction. Coursework in research methods and participation in research projects are other components of a curriculum designed to promote professional inquisitiveness, intellectual confidence, and critical appraisal skills that students will take with them into practice. Further, faculty who are actively involved in the conduct and evaluation of research can exemplify the critical cast of mind that all health professionals should possess. Continuing education programs offer a potentially important opportunity for dental schools to help clinicians learn about scientific and clinical advances and to evaluate their effectiveness critically. In the committee's site visits, faculty and practitioners argued that dental schools can go beyond the narrow technique and product focus of many commercial programs to present practitioners with an evidence- and outcomes-oriented assessment of new technologies. Such assessments are particularly important for practitioners whose formal education did not provide the evaluative skills and perspectives advocated in this report and who, thus, may be more vulnerable to enthusiastically promoted but inadequately tested new technologies. Finally, with the active support of NIDR, dental schools have a major responsibility for educating future dental researchers. Small Personnel (OSEP) of the National Academy of Sciences. In 1985, training for oral health research was covered solely under the topic of clinical sciences; the 1989 report did not even consider it (NAS, 1985, 1989). Putting oral health research on the agenda for the 1994 OSEP report required a special effort from the dental research community. The results of that effort are reflected in the proceedings of a workshop held in July 1993 and in the sections of the 1994 report discussed later in this chapter. 2 Apropos of this is Meskin's tongue-in-check dictionary definition of research: "1. a state to be avoided at all costs 2. less common, an unnatural act required of dental faculty in order to achieve the state of tenure 3. much less common, an arduous task fraught with pain but achievable 4. much, much less common . . . an enjoyable pursuit to achieve academic excellence" (Meskin, 1983).
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--> but important support for research training also comes from private foundations (e.g., the Robert Wood Johnson clinical scholars program) and industry. Oral health research does and should draw on researchers trained in medical schools and graduate schools, but a stronger dental school role in research education is an important means to strengthen the link between the basic and clinical sciences in dental schools, solidify the position of dental schools in research-intensive universities and academic health centers, and direct research to oral health problems. Expanding and strengthening the pool of capable basic science and, especially, clinical researchers are, at the same time, preconditions for expanding and strengthening the research productivity of dental schools. Research Revenues, Expenditures, And Publications Measuring the output of research activities in dental schools is difficult. Therefore, this summary focuses on inputs, in particular, research funding. It also includes some information on research productivity as measured by publications. Data on research revenues and expenditures for dental schools come from two primary sources, the American Dental Association (ADA) and the National Institute of Dental Research. ADA data do not include institutions that offer only postgraduate dental education programs such as the Eastman Dental Center and the Mayo Graduate School of Medicine. To the extent that dental faculty are involved in multidisciplinary research projects that are administered by other units (e.g., medical schools), dental school involvement in research may be understated. In addition, the research activity of dental school faculty may not be reflected in the financial figures for other reasons, for example, if foundations refuse to pay full overhead costs for research contracts, schools may categorize the funds they do provide as gift income not research revenues. The ADA reports dental school expenditures for research in four categories: basic science, clinical science, behavioral science, and training grants (Table 5.2). As measured by expenditures, the major focus of research is clinical, followed by basic science, training, and—a very distant fourth—behavioral science research. ADA data for 1993 show that 46 of 55 schools reported expenditures for clinical research, 38 for basic science, 34 for training, and 11 for behavioral research. For the reporting year ending June 30, 1993, revenues from sponsored education, research, and research training accounted for more than
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--> $125 million out of total dental school revenues of more than $1 billion.3 The contribution of sponsored education, research, and training to total revenues varies enormously across schools. It ranges from less than 2 percent at nine schools to 56 percent at one school. For the next highest school, the figure drops to just under 28 percent (ADA, 1994a). The mean for all schools is about 10 percent. By way of comparison, federal research grants and contracts alone account for 12 percent of medical school revenues, and all sources of research and training grants and contracts contribute about 20 percent of their revenues (Krakower et al., 1993). In 1993, more than 70 percent of dental school research revenues came from the federal government, while 22 percent came from nongovernmental sources and 7 percent from state and local governments (Table 5.3). The great majority of federal support comes from NIDR, with other agencies—including other divisions of the National Institutes of Health—contributing the remainder. The committee found no comprehensive data on these other sources.4 NIDR spending for its external or extramural research program falls into several categories as depicted in Figure 5.1. The entire extramural program receives not quite 75 percent of the total NIDR budget, about 90 percent of which goes for specific research projects, support for research centers, and other research. About one-third of NIDR extramural research funds are provided to institutions other than dental schools (e.g., advanced education institutions and medical schools). A commonly used measure of research productivity relies on individual or institutional publications (Harrington, 1987; McGuire et al., 1988). The rationale is that the number of scientific publications and the type of these publications are useful indicators of "an institution's contribution to knowledge" (Lipton, 1990). One analysis found 50 dental institutions worldwide (including advanced education institutions) with 40 or more articles published in 1987 and 1988 in journals included in the Science Citation Index. Thirteen of these 50 institutions had 90 or more articles. (Of the 4,300 3 About 10 percent of these revenues involve sponsored educational programs. 4 Examples can, however, illustrate the range of organizations that might reasonably fund research in dental schools: the National Cancer Institute for work on oral cancer; the National Institute for Arthritis and Musculoskeletal and Skin Diseases for research on connective tissue biochemistry and bone mineralization; the National Institute on Aging for studies of oral health problems in geriatric populations; and the National Institute of Allergy and Infectious Diseases for AIDS research.
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--> TABLE 5.2 Dental School Expenditures (dollars) for Research, 1993 Sponsored Research and Training Public Private All Basic science 42,321,201 (46%) 11,440,330 (54%) 53,761,532 (47%) Clinical science 43,639,741 (47%) 6,499,781 (31%) 50,139,523 (44%) Behavioral science 955,682 (1%) 145,949 (1%) 1,141,631 (1%) Training grants 5,677,073 (6%) 3,044,359 (14%) 8,721,432 (8%) Total 92,633,697 (100%) 21,130,419 (100%) 113,764,118 (100%) SOURCE: Data compiled from American Dental Association, 1994a. TABLE 5.3 Dental School Revenues (dollars) from Research, 1993 Sponsored Research and Training Public Private All Nongovernment 22,017,372 (23%) 5,492,424 (20%) 27,509,796 (22%) State or local government 5,864,445 (6%) 2,849,836 (10%) 8,714,281 (7%) Federal government 69,243,174 (71%) 19,554,257 (70%) 88,797,431 (71%) Total 97,144,991 (100%) 27,896,517 (100%) 125,021,508 (100%) SOURCE: Data compiled from American Dental Association, 1994a. journals indexed, 29 focused on dentistry.) Twenty-two of the first group of 50 institutions and seven of the second group of 13 most productive schools were located in the United States; three of the six foreign institutions were in Scandinavian countries (Lipton, 1990). Focus Of Research And Research Training As indicated by the ADA expenditure data reported above, clinical research accounts for the major part of dental school research, with basic research a relatively close second. Although ADA reports do not further identify the substantive focus of research, NIDR data are helpful here.
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--> Figure 5.1 Percentage distribution of National Institute of Dental Research (NIDR) extramural obligations, FY 1993 (total extramural program - $118,363,000; research projects - $77,805,000). A: All programs; B: Research project grants (RPGs). NOTE: R01 - traditional project grants; R29 - first independent research support and transition (FIRST) award; and P01 - research program projects. Center grants: P20, P30, and P50. SOURCE: NIDR, 1993a. The focus of NIDR funding has shifted considerably over the institute's history. As reported by Harris (1989), 37 percent of research grants in the NIDR's first three award years were devoted to caries, fluoride, and restorative materials; 10 percent to periodontal disease; 10 percent to nutrition; and 8 percent to craniofacial abnormalities. By 1985, caries and restorative materials accounted for 28 percent of funding; periodontal and soft tissue disease for 34 percent; and craniofacial development, pain, and behavioral science research for 27 percent. Figure 5.2 shows the distribution of NIDR extramural funds across 19 research areas in 1993. NIDR data do not distinguish between basic and clinical research projects. Data reported by Harris (1989) indicate that the majority of articles published by extramural researchers supported by NIDR concerned "bioscientific" topics not confined to oral conditions. In addition to individual research projects, NIDR supports 29 research centers, most of them affiliated with dental schools. The varied foci of these centers are revealed in Table 5.4. In FY 1993,
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--> Figure 5.2 Distribution of total FY 1993 National Institute of Dental Research (NIDR) extramural funds by research areas ($thousands). Source: NIDR, 1993a.
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--> TABLE 5.4 NIDR Research Centers Support: Number of Projects and Number of Subprojects by Type of Center and Institution, FY 1993 Type of Center and Institution Department No. of Projects No. of Subprojects Awarded Amounts Research Centers in Oral Biology 5 27 $ 4,720,173 State University of New York at Buffalo Oral Biology University of Alabama at Birmingham Oral Biology University of California at San Francisco Stomatology University of Pennsylvania Research Center in Oral Biology University of Washington Oral Biology Research Centers on Oral Health in Aging 2 8 1,252,581 University of Iowa Dows Institute for Dental Research University of Texas Health Science Center at San Antonio Dental Diagnostic Science Caries Research Centers 2 11 1,570,588 Forsyth Dental Center Clinical Trials/Experimentation University of Rochester Dental Research Craniofacial Anomalies Research Centers 3 12 2,074,512 University of Iowa Biology University of Pennsylvania Human Genetics University of Southern California Basic Sciences Materials Science Research Centers 3 12 2,070,843 American Dental Association Health Foundation Paffenbarger Research Center University of Florida Dental Biomaterials University of Michigan at Ann Arbor Biologic and Materials Sciences
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--> limiting their debt load, a burden that can deter dental graduates from research training. It requires, however, a commitment of dental schools and universities to provide the appropriate educational opportunities. In an attempt to assess the productivity of its research training programs, NIDR has tracked the number of trainees in different programs who have later submitted applications for its funds and received awards. This short-term analysis is presented in Table 5.6. The data indicate a fairly low yield in applications and awards for some programs, and NIDR is proposing to restructure some of them. The committee noted, however, that short-term training programs to improve student and faculty awareness and appreciation of research and research methods should not be expected to produce research grants and, thus, cannot be appropriately evaluated with conventional measures. This activity accounts for a small proportion of training funds and, in the committee's view, warrants continuation as a small but visible sign that an appreciation and understanding of research is important for nonresearchers. A number of problems with the dental scientist program were noted in the committee's site visits, liaison panel meetings, and other information collection activities. One is the competitiveness gap and, relatedly, the tenure issue mentioned earlier. A second problem, reported by dental school deans, involves salary disparities. The stipend for those in some NIDR training programs may be higher than starting salaries at dental schools. NIDR is planning to adjust stipends to avoid such disparities. A recent task force created for an Institute of Medicine study of career paths in clinical research set forth priorities for expanding the research capacity (Appendix B in IOM, 1994b, reprinted in the June 1994 issue of the Journal of Dental Education). The group distinguished three categories of research talent: (l) the senior dental clinical scientist who has specialty training,7 a Ph.D., and postdoctoral training in research methods, who can plan and manage major clinical research projects; (2) the dentist scientist who has specialty training, preferably a basic science Ph.D., and research experience, who can become involved in clinical research in collaboration with research methodologists and other clinical investigators; and (3) dental clinical research associates, who have 7 This category may include those with education in advanced general dentistry beyond the first postgraduate year.
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--> TABLE 5.6 Research Grant Activity (FY 1985-1992) of Physician (K11) and Dentist (K15, K16) Scientists Mechanism No. of Appointees No. of Graduates No. of Grant Applicants (% of graduates) No. of Applications No. of Grantees (% of graduates) No. of Grants Grants as Percentage of Applicants K11 40 23 13 (57%) 38 8 (35%) 13 34 K15 41 24 7 (29%) 23 2 (8%) 4 17 K16 145 59 13 (22%) 23 8 (14%) 8 35 Total 226 106 33 (31%) 84 18 (17%) 25 30 SOURCE: National Institute of Dental Research, 1993a.
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--> little formal research training but are excellent clinicians able to be active participants in research. This committee supports these distinctions and directions but would add that advanced general dentistry be considered as a form of specialty training in this context. In addition, the committee notes that training need not result in a Ph.D. to increase clinical research capacity. For example, although Chapter 4 argues that a master's degree in a dental specialty is not sufficient training for a research career, it can help prepare clinical faculty to participate as partners in clinical research under the direction of fully trained researchers. In addition, those in specialty fellowship programs could be placed in clinical research centers or laboratories of established investigators inside or outside the dental school to learn the scientific method by participation. Faculty Development Programs A major objective of many faculty development programs is to improve research skills. In the responses of the deans surveyed, however, this objective was outranked as a priority for faculty development by four other areas.8 One of these areas, patient outcomes assessment, however, covers some similar methodological and conceptual ground. Limits of (existing) faculty development strategies should be noted. To free faculty time for research training requires financial resources. It may also require schools to bring in clinicians from the community to fill in for absent clinical faculty, and finding the appropriate person may be difficult, particularly in smaller communities (Dirksen, 1992). Nonetheless the committee believes all schools should attempt to build faculty capacity even when circumstances are difficult. Other Issues Other problems also complicate dental school efforts to build and maintain a research faculty. These problems involve personnel policies, organizational arrangements, and physical location. 8 The higher-ranking priorities were increasing sensitivity to student needs and concerns, increasing emphasis on patient outcomes assessment, improving instructional skills, and developing competency-based evaluations of student clinical skills.
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--> As noted in Chapter 4, many dental and medical schools have revised unduly restrictive personnel policies by creating nontenure career tracks for clinical faculty and sometimes research faculty (Kennedy, 1984; Kalkwarf, 1986). This special track strategy acknowledges that many valuable faculty may not be ''triple threats" in research, teaching, and service. It aims less at the problem of adding research capacity than at obstacles to the sensible use and rewarding of trained researchers. The organizational structure of universities and academic health centers may also create difficulties for dental schools. On the one hand, when basic science faculty are part of the medical school, they may have little attachment to the research and educational missions of the dental school. On the other hand, when these faculty are located in the dental school, they may lack the critical mass to generate fundable research. Some of these problems might be resolved by a separate basic sciences unit designed and managed to serve the research and teaching missions of all the health professions schools (and, to some degree, other parts of the university). Depending on particular institutional circumstances, a freestanding department could create additional overhead and coordination costs; or it could permit some economies of scale in both stimulating and conducting multidisciplinary research. Some dental schools are physically and organizationally isolated from their parent university or academic health center. This isolation impairs communication (even with the advent of electronic mail); imposes bureaucratic costs; and limits the sharing of expensive facilities, equipment, and support staff. These are not insignificant problems, although the existence of multiuniversity and even multinational research projects demonstrates that collaborative work among physically separate researchers is possible. Dental schools may structure their research activities in several different ways. Some are organized along traditional departmental structures. As indicated above, some schools have created research centers with support from NIDR, and others have created centers with different sources of support (e.g., the periodontal research center at the University of Alabama at Birmingham, which receives support from other public and private sources). Extending Research Opportunities In addition to building oral health research capacity by training more and better researchers and seeking additional research funds, researchers and policymakers should also explore creative strategies to extend traditional avenues for acquiring clinical knowl-
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--> edge and to make use of untapped faculty resources. Such strategies will also help schools to respond to patient and purchaser pressure for more and quicker information about the effectiveness of different clinical strategies. Used carefully and critically, quasi-experimental and nonexperimental (e.g., survey and epidemiological) research can help build understanding of what works and what does not work in health care. The focus of such strategies tends to be on clinical and behavioral rather than basic science research. The idea is not to replace or undermine the most demanding of traditional research strategies but to supplement them. The exacting requirements and high expense land sometimes ethical or practical infeasibility) of randomized controlled clinical trials (RCTs) restrict their use and probably contribute to faults in their practical implementation (Moher et al., 1994; Schulz et al., 1994). A poorly designed or executed RCT may provide less valid and reliable information than another, theoretically less rigorous strategy. In addition, because RCTs aim to ascertain efficacy (effects under controlled conditions) rather than effectiveness (results under actual conditions of practice), their value to clinicians may be limited. Alternatives to the classical RCT include ''large simple trials" (Zelen, 1993),9 analyses of large data bases collected for other purposes (e.g., insurance claims) (Tilson, 1993; IOM, 1994d),10 and 9 Such trials are "simple" only by comparison to RCTs. Zelen proposes, for example, an open protocol system that would allow patients and clinicians anywhere in the United States to participate in a trial under defined conditions of eligibility according to specific treatment protocols. Among the key elements are sophisticated statistical controls, broad eligibility requirements, and streamlined data collection. Implementation would require regional training programs, a national support hotline and electronic mail network, and a roster of participating clinicians who would be paid for data collection and have their records audited periodically. Zelen insists that trials must always be randomized and always include a treatment (i.e., never include "watchful waiting" or a placebo). Such trials would not be inexpensive or easy to organize. 10 In general, better data exist for inpatient care than for ambulatory care, even though many such data, whether in the form of hospital discharge summaries or insurance claims, suffer from numerous inadequacies. However, in both health care generally and dentistry specifically, improvements in computer-based patient records, electronic transmission of images and other patient data, and refinements in claims forms (similar to those designed for Medicare and private health insurance) are being encouraged and pursued to build a future research data base for ambulatory services. As in any research, the limitations of specific data need to be carefully evaluated (OTA, 1994).
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--> nonrandomized clinical practice studies (Horn and Hopkins, 1994). Clinical practice studies generally focus on areas in which important patient outcomes (e.g., postsurgicial infections) occur and can be measured within a short period rather than over many months or years.11 They are often relatively easily replicated and thus amenable to confirming tests in additional sites. In discussions of the merits of simpler research strategies, randomization and physical rather than statistical control of patient variability are among the most controversial issues. At their best, simpler clinical studies would generate outcomes information that is superior to the impressionistic and anecdotal "knowledge" base that must often be relied upon today. They would require (1) careful selection of target clinical processes, patients, and outcomes of interest; (2) definition, application, and monitoring of replicable study protocols; (3) valid and reliable measures of key variables; (4) statistical procedures to control for other factors that might influence outcomes (e.g., age of patient; comorbid conditions); and (5) adequate systems for recording, retrieving, and analyzing information. In principle, research sites could include general and specialty student clinics, faculty practice plans, extramural clinics, and even private practices. In any research that extends across multiple research sites, the strict adherence of investigators to research protocols is an important concern as demonstrated by the controversy over the violations discovered in the National Surgical Adjuvant Breast and Bowel Project (Angell and Kassirer, 1994). Dental schools, dental societies, and other organizations interested in oral health research (e.g., NIDR, AADS, American Association for Dental Research, ADA, American Dental Hygienists' Association) should evaluate the opportunities for expanded use of simple clinical studies in dentistry and consider collaborating on protocols and priorities for such studies. They might, for example, (l) identify important clinical questions to which relatively inexpensive research strategies could make a contribution; (2) develop standardized designs, measures, software and communications networks, and reporting formats that could be used or modified by clinical faculty; (3) test and replicate the approach in selected schools; (4) develop supportive training programs and an ongoing clearinghouse function; and (5) seek funding for these 11 Recent examples of inexpensive, nonrandomized, nonblinded controlled clinical trials are described in East et al., 1992; Horn and Hopkins, 1994; McDonald and Overhage, 1994; and Stiell et al., 1994.
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--> activities from government, industry, foundations, health agencies (e.g., American Cancer Society), and intramural university sources. Dental schools provide a practical place to conduct clinical studies because they have available large numbers of eligible patients who, in the normal course of events, will receive treatments of interest to researchers. The simplest studies would impose protocols to structure clinical observations and assessments, while more ambitious studies could attempt quasi-experimental designs.12 As with any such studies, threats to internal and external validity of findings would have to be carefully considered to assess, for example, the possible impact of special characteristics of the patient population or the extent to which patients were lost to follow-up. In their background paper, Bader and Shugars suggest that "practitioner networks" based on study clubs, continuing education courses, and general practice residencies could be employed to extend the range of research. Dental schools and dental societies could play a role in structuring and facilitating the activities of these groups, for example, by helping establish computer links for the easy exchange of protocols, data, and questions. Such involvement would have the added advantage of increasing communication between the schools and the practice community and guiding inquiry to issues of direct concern to practitioners. To repeat, the call here is not for casual or uncritical research but for the careful planning and discriminating application of research strategies to extend knowledge and encourage broader faculty participation in research.13 Given, however, the history of 12 To cite an example of a possible descriptive study topic, when replacement of an amalgam restoration is planned because margins have deteriorated but no caries are evident, clinicians could record what they found when the restoration was removed. A observation protocol would provide for standardized clinical criteria to be used to characterize (1) the extent of margin deterioration; (2) the patient's level of risk for caries; and (3) the presence or absence of caries after the restoration is removed. One pilot study has suggested a minimal association between caries risk and margin deterioration, but no larger study of this common dental practice has been undertaken (Maryniuk and Brunson, 1989). To illustrate a more ambitious project, a study could randomly assign established clinic patients (with their consent) to 6-, 12-, and 24-month recall intervals and then compare their health status and disease experience using appropriate annualized measures of caries incidence, surface replacements, and attachment loss. 13 Nonetheless, weak studies can have some value as part of a learning process if at least one capable researcher is periodically available for a "post mortem" review of research deficits. For example, a school could phase in procedures for
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--> disputes over the allocation of resources between basic and applied research in many fields of science, decisionmakers should be prepared to manage similar conflicts and protect research integrity if the directions discussed here are pursued. In addition, innovative research strategies need to be scrutinized for potential harms to patients including failure to secure informed consent when appropriate. Research And The Mission Of Education The ardent pursuit of research funding and reputation can strengthen or weaken the educational mission of the dental school. A re-search-oriented school also needs to recognize and reward excellence in teaching, incorporate a scientific perspective into all elements of dental education, and invigorate the curriculum with the spirit of faculty research. In addition, interested students should have a direct opportunity to learn research methods, to undertake research projects as part of regular classes, and to participate in faculty and independent research projects. Providing the latter opportunity requires the following: faculty to teach and to guide or mentor students; facilities accessible to students; some funds for materials and supplies; time aside from the crush of required coursework and clinical experience; and a showcase for students to present their research (Clarkson and Kremenak, 1983; Gibson, 1993; Keller et al., 1993; Winston, 1993). These requirements, in turn, dictate that schools designate a faculty member or administrator responsible for seeing that these conditions are met. The results of student research (in process or final) can be presented through "table clinics" and poster sessions at individual schools, professional conferences, and similar settings. In particular, presentations at the annual meeting of the American Association for Dental Research offer exposure to the broader dental research community. enrolling all patients in a clinical protocol for some problem and then tracking them over time. Participants could learn about the "controllable" ways that information is lost or compromised, for example, through poor adherence to protocols and incomplete or imprecise record keeping. By assessing the impact of these and other less controllable problems such as the loss of patients to follow-up, clinicians could ask the critical question: Is some information (what has been collected) better than none, or is the information so flawed as to be seriously misleading? Even if the answer in the initial stages is the latter, a base has been laid for better future performance.
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--> Beyond broadly encouraging scientific habits of mind in students, dental schools should continue to seek, identify, and inspire predoctoral students with the requisite interest and talents to pursue research careers. Creating research opportunities for students and providing faculty mentors are important strategies for doing so (Hein, 1983). Since 1979 the NIDR has provided short-term training grants to support and stimulate student research programs. With its lower research profile, dentistry may be less attractive than medicine to students with the interests, background, and mind-set that would make them candidates for a research career, but it is still important to search for and encourage such students. Findings And Recommendations Too many dental schools and dental faculty are minimally involved in research and scholarship. The low priority placed on research has important negative consequences. First, faculty in such schools contribute little to the knowledge base for improving oral health or increasing the effectiveness and efficiency of oral health services. Second, students in these schools miss the stimulation and critical edge provided by a research-engaged faculty. Third, schools with low research productivity put themselves in jeopardy in most universities and academic health centers, and they may detract from the reputation of dental research and education more generally. Fourth, lack of research and scholarship within a dental school tends to diminish the school's role as a disseminator of critically evaluated practice advice to dental practitioners. The committee concurs generally in the finding of the National Academy of Sciences' Office of Scientific and Engineering Personnel that a substantial increase in oral health research graduates is needed (NAS, 1994). It also recognizes the problems facing schools that are trying to build or maintain a strong research program. These include, most notably, limited funding and a dearth of capable researchers. The organizational structure of the basic science faculty may contribute as well. Other problems include the time demands on many clinical faculty and their frequent isolation from possible collaborators elsewhere in the university or academic health center. Institutions without a strong track record in research may lack the administrative and departmental leadership necessary to plan and achieve change. For institutions committed to research, achiev-
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--> ing a reasonable balance between research and educational missions may be a challenge. The committee urges dental schools to work together and to involve national and local professional societies in devising new avenues for clinical knowledge development. In doing so, they can take advantage of the statistical, data base, communications, measurement, and other research techniques and protocols that are emerging from the growing field of outcomes research. The committee understands that dental schools will differ in how they define the specifics of their research mission. Schools will need to be selective and set priorities for establishing and maintaining research capacity based on a critical mass of faculty talent, physical facilities, funding, and other resources. Some schools can reasonably aspire to be real centers of research excellence; all dental schools should value scholarship and the creation of new knowledge. To expand oral health knowledge and to affirm the importance of research and scholarship, each dental school should support a research program that includes clinical research, evaluation and dissemination of new scientific and clinical findings, and research on outcomes, health services, and behavior related to oral health; extend its research program, when feasible, to the basic sciences and to the transformation of new scientific knowledge into clinically useful applications; meet or exceed the standard for research and scholarship expected by its parent university or academic health center; expect all faculty to be critically knowledgeable about scientific advances in their fields and to stay current in their teaching and practice; and encourage all faculty to participate in research and scholarship. To build research capacity and resources, as well as foster relationships with other researchers, all dental schools should develop and pursue collaborative research strategies that start with the academic health center or the university and extend to industry, government, dental societies, and other institutions able to support or assist basic science, clinical, or health services research. To strengthen the research capacity of dental schools and
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--> faculty, the committee recommends that the National Institute of Dental Research continue to evaluate and improve its extramural training and development programs; focus more resources on those extramural programs with greater demonstrated productivity in strengthening the oral health research capacity of dental schools and faculties; and preserve some funding for short-term training programs intended primarily to increase research understanding and appreciation among clinical teaching faculty and future practitioners. Summary Research is a fundamental mission of dental education, but one not uniformly honored among schools. Certainly, the situation is vastly improved from the 1940s and 1950s, thanks largely. to training programs supported by the National Institute of Dental Research. Nonetheless, the field still suffers from a shortage of well-trained researchers, particularly clinical researchers. Improving research productivity in dentistry will require leadership from inside and outside—that is, from the university and the academic health center, from the public and private sectors, and from the practice community. The key objectives are to establish research as a priority; to secure new funding and redistribute existing resources; to develop creative strategies to extend the scope of oral health research; to attract qualified new people and develop existing faculty; and to sustain this capacity over time.
Representative terms from entire chapter: