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--> 2 Evolution of Dental Education The history of dental education is marked by both change and continuity. As dental science and technology have advanced, instruction in dental practice has become more sophisticated both in substance and in method. During the last century and a half, training through apprenticeship—and purely self-taught and self-proclaimed competency—have been replaced by a lengthy period of formal instruction. Free-standing, profit-making schools have given way to university-based schools of dentistry, and postgraduate education in general and specialized fields of practice has become widespread. Despite convergence in many areas, differences in opinion about dental practice and education persist. One fundamental disagreement involves the relationship between medicine and dentistry. Another involves the relative importance of instruction in technique versus education in scientific and critical thinking. The question of who should assess dental practice and education—and in what fashion—has provoked controversy for more than a century. The following brief account of the evolution of dental education provides context for the rest of this report. Table 2.1 summarizes key dates in dentistry and dental education with an emphasis on developments before 1970. Additional historical information is also found in later chapters of this report and in the background papers.
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--> TABLE 2.1 Time Line of Selected Dates in Dentistry and Dental Education 1530 First textbook on dentistry published in Leipzig 1683 Van Leeuwenhoek identified microorganisms in material scraped from teeth 1728 Fauchard's comprehensive dental textbook published in France, noted need for school of surgery to include dentistry 1765 First U.S. medical school founded in Philadelphia (later became the University of Pennsylvania) 1801 First American book on dentistry published 1839 Journal of Dental Science initiated, first national dental journal (discontinued in 1860) 1840 First American dental school founded in Baltimore by four physicians 1840 First national dental organization founded (disbanded in 1850s following split over safety of mercury in amalgams, the so-called amalgam wars) 1844 Effectiveness of nitrous oxide as dental anesthetic demonstrated 1859 American Dental Association (ADA) created 1860 Four U.S. dental schools in existence 1867 Harvard started first university-based dental department in close association with medical department 1868 Kentucky, New York, and Ohio passed first effective dental licensing laws and created first dental examiner boards with power to license graduates of reputable schools 1870 Fifteen percent of dentists held dental school diplomas 1872 Practical dental drilling engine invented 1882 ADA offered prize for paper on etiology of caries 1884 National Association of Dental Faculties established to encourage standardization of curricula 1884 Dental school established at Howard University 1891 Data published indicating infectious basis of tooth decay 1891 Two-year dental school curriculum required by dental faculties association 1894 University of Michigan offered first graduate courses in dentistry 1896 Use of X rays (discovered in 1895) first promoted in dentistry 1899 Dental licensure requirements adopted by all states 1902 U.S. Public Health Service (PHS) published its first article on dentistry (observations linking mottled teeth to drinking water) 1905 National Board of Dental Examiners published percentage of graduates of schools who failed licensing examinations 1906 First dental hygienist trained 1906 First public school-based dental assessment funded in Rochester, New York 1909 Dental Educational Council Of America established by national organizations of dental examiners, dental faculties, and dental practitioners 1910 Novocaine introduced in the United States 1910 Publication of Abraham Flexner's report on medical education 1910 Graduation from high school established as prerequisite for dental school admission 1911 Army Dental Corps established
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--> 1913 Tri-State Dental Association of Negro dentists founded (predecessor of present-day National Dental Association) 1913 First school of dental hygiene founded in Connecticut 1913 Scientific Foundation and Research Commission created by ADA 1916 First university-based dental hygiene program established at Columbia University 1916 Virginia became first state to include dentist on Board of Health 1917 Requirement for three-year dental curriculum adopted 1918 First rating of dental schools published by Dental Educational Council (at the request of the Army Surgeon-General) 1919 Committee on dental investigation appointed by National Research Council (NRC) of National Academy of Sciences (disbanded 1924, reappointed 1928) 1919 National Bureau of Standards created dental research unit (prompted by Army interest in dental filling materials) 1919 PHS commissioned first dental officer 1920 International Association for Dental Research established 1923 American Association of Dental Schools established (by merger of several organizations) 1923 American Dental Hygiene Association established 1924 University of California Dental School funded by Carnegie Foundation and NRC for study of pyorrhea 1925 NRC appointed committee to investigate mottled teeth 1926 Publication of William Gies' report on dental education 1931 Link between fluoride and mottled teeth established, potential for caries protection reinforced 1931 NRC dental advisory committee recommended creation of dental research bureau 1933 First national written board examinations administered 1941 Dental school accreditation standards published by ADA council 1944 Dental problems identified as major reason for rejecting recruits during World War II 1945 First controlled water fluoridation projects initiated by PHS in Grand Rapids, Michigan to test effect on decay 1948 National Institute of Dental Research (NIDR) established 1951 U.S. Surgeon General and NRC encouraged fluoridation 1956 NIDR initiated funding of extramural training centers at several universities 1959 First National Health and Nutrition Examination Survey conducted 1961 Hollinshead survey of dental education published 1963 Health Professions Educational Assistance Act passed 1970 National Health Service Corps established for medically and dentally underserved areas 1971 Comprehensive Health Manpower Act passed to increase health work force 1980 Kellogg report on advanced dental education published 1984 Pew Foundation National Dental Education Program initiated SOURCES: Guerini, 1909; Gies, 1926; Prinz, 1945; McCluggage, 1959; Sissman, 1971; Ward, 1972; Kidd, 1979; Hoffman-Axhelm, 1981; Starr, 1982; Harris, 1989; Burr and Eklund, 1992.
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--> Origins Of Dental Instruction In a very broad sense, the origins of dental education lie in the works of the ancient Middle Eastern and Asian writers who recorded explanations, descriptions, and advice—that is, instruction— about an array of health problems including oral health problems.1 These writers often mixed myths with potentially helpful prescriptions for herbal and other compounds to treat pain, clean teeth, and combat foul breath. A 5,000-year-old Sumerian clay tablet, for example, refers to the legend of the ''tooth worm'' as the source of tooth decay ("let me [the tooth worm] drink among the teeth, and set me on the gums") (Prinz, 1945, p. 15). The tablet recommends treatment with pulverized henbane, gum mastic, and a thrice-repeated incantation. (The attribution of tooth decay to worms was not put finally to rest until the eighteenth century.) The most famous early discussion of dental problems is found in the Ebers papyrus, which has been dated to 1550 B.C. and may include segments from much older sources. It prescribes several herbal and other compounds to treat pain and swelling but makes no reference to dental restorations, extractions, or appliances. Later Greek and Roman medical texts by authorities such as Hippocrates (ca. 460-377 B.C.) and Galen (A.D. 129-201) routinely discussed oral health problems and advised pharmacological and mechanical strategies for managing and sometimes preventing pain, tooth decay, tooth loosening, bad breath, gum swelling, and abscesses. After the fall of Rome in the fifth century A.D., medical and scientific progress suffered throughout Western Europe for a millennium. In the Arabic-Persian world, however, advances continued despite religious limits on anatomical research and surgery. Once medical science begin to revive in the West during the Renaissance, few medical experts considered oral health interesting or challenging. Many kinds of surgery were likewise viewed as uninteresting and mechanical, but dental problems and services became, in particular, more isolated from medicine. Elite physicians and surgeons might minister to the teeth of princes and bishops, but dental services in Europe became largely the preserve of barber-surgeons and other nonphysicians. Other factors may 1 Sources for this discussion include Guerini, 1909; Gies, 1926; Prinz, 1945; Hoffman. Axhelm, 1981; and Harris, 1989. These texts occasionally disagree about facts and interpretations of early texts; the most generally plausible account was used. No significant independent effort to resolve disputes was attempted.
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--> also have contributed to occupational segregation. One early twentieth century history of dentistry suggests that from Hippocrates onward, physicians tended to favor a very slow—and painful—process of tooth extraction (Guerini, 1909). In contrast, "lay" practitioners such as barbers got the job done quickly. Such dispatch presumably would have encouraged people with this common problem to seek attention from nonphysicians and would, thus, have contributed to the separation of dental from medical care. During the 1500s, advances in anatomy, microbiology, and other areas laid the foundations for specialized treatises on dentistry and for a theoretical—not just mechanical and empirical—approach to oral health. These advances included detailed anatomical descriptions of teeth and related structures, as well as van Leeuwenhoek's identification of microscopic organisms in tooth scrapings. In 1728, Fauchard (1678-1761), who is widely described as the father of modern dentistry, published a two-volume text on the practice of dentistry, the first comprehensive treatment of the subject. This text has been called "a milestone" in the "separation of dentistry from the discipline of surgery, not medicine" (Bánóczy, 1993, p. 634). Fauchard saw the need for schools of surgery that would include instruction in dentistry, but he conceded that there was a dearth of written materials available to guide such instruction. Although a few medical schools included lectures on dentistry, the practice of dentistry was the province of either those who learned their "trade'' through some kind of apprenticeship (or, later and more formally, a preceptorship) or those who simply offered their services without even this kind of training. Formal Education: Early Developments A Slow Start Formal or institutional dental education began in the United States in 1840 when the state of Maryland chartered the Baltimore College of Dental Surgery, possibly after the medical department of the University of Maryland refused a request that it include dental education in its curriculum.2,3 Regardless of its origins, 2 Interestingly, in his 1910 report on medical education, Abraham Flexner refers to this institution as the "so-called medical department of the so-called University of Maryland," one that established early in the nineteenth century the "harmful precedent" of proprietary institutions that "were not a branch
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--> the college was eventually incorporated into the University of Maryland in 1923. The nineteenth century saw a continuing debate about whether dental education was best organized within a medical school or in independent schools. Some groups viewed the establishment of independent schools as more practical on grounds that medical schools would be unwilling to supply the requisite physical space and expensive equipment, to support the greater technical or mechanical training needed by dentists, or to maintain truly collegial relationships with dental faculty (Sissman, 1971). Nonetheless, when the medical community sought out dentists, the latter could be skeptical and even hostile. For instance, "dentistry [is] altogether too large to be made the tail end of the kite of medical practice" and "the majority of the medical schools ... are not so enviable in their reputation as to offer inducements for entering into relations with them" (quoted in McCluggage, 1959, p. 171). An alternative view was that "if we are not medical specialists we are a set of carpenters" (quoted in McCluggage, p. 169). Whether or not the independent strategy was relatively easier than incorporation within a medical school, only four dental schools were in place by 1865. All were freestanding. The slow growth of dental schools reflected resistance on the part of both students and practitioners. Prospective dentists often found it less disruptive and expensive to serve an apprenticeship with an established local dentist rather than enroll in a formal program in a distant city.4 For their part, established dentists profited financially by acting as preceptors. Arguing that the preceptor concept was inadequate mounted to arguing that the majority of existing practitioners were ill-trained. This was a politically unappealing position given that perhaps 15 percent of the nation's nearly 8,000 dentists were dental school graduates by 1870; the remainder had been trained under preceptor arrangements or were simply self-proclaimed as dentists. growing out of the living university trunk" and that had, at best, "makeshift" connections with a university's core, its school of arts and sciences (p. 5). Flexner contrasted the Maryland example with the university-based medical departments or schools founded in the 1700s in Philadelphia (now the University of Pennsylvania), New York (now Columbia University), Cambridge (Harvard University), and Dartmouth. 3 This discussion relies primarily on McCluggage, 1959, and also on Gies, 1926; Sissman, 1971; and Hoffman-Axhelm, 1981. 4 "We live in a busy age; it takes but a little while to become a grandfather in dentistry, that is, to send out a student who in a short time will have sent out his student" (quoted in McCluggage, 1959, p. 163).
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--> In gradually formalizing dental education, dentistry followed a path trod by other professions in response to dual concerns about the prevalence of outright quackery on the one hand and the large number of reputable but poorly trained practitioners on the other hand. Other responses included the establishment of professional societies, the creation of journals and other vehicles for professional communication of new information and ideas, the adoption of organizational certificates of competency and other forms of self-regulation, and the quest for statutory protection (e.g., licensure). Initial steps in each of these directions occurred in the late 1830s and early 1840s. In 1860, the newly organized American Dental Association (ADA)5 charged one of its committees with preparing an annual report on the state of dental education (McCluggage, 1959). This activity provided a forum for collective discussion and debate about dental education when the initial efforts of dental schools to organize an association dissolved amidst disputes about criteria for granting degrees, in particular, unearned degrees. Between 1865 and 1870, five new dental schools were founded. This group included the first university-based dental program, which was established at Harvard in 1867—in "affiliation" with the medical school—following appeals by the president of the Massachusetts Dental Society (Gies, 1926). The other four schools were freestanding. By 1884, twelve additional schools had been founded— nine university-based programs and three freestanding schools. In Europe, the origins of formal dental education were more diverse (Bánóczy, 1993). Several dental schools, primarily in northern Europe, were founded on the U.S. model of independent or at least separate schools. In southern Europe, dental education was more likely to develop as a discipline (labeled stomatology from the Greek word, stoma, for mouth) within a medical school, and graduates received a medical degree. As a result of changes in the 1980s spurred in part by directives of the European Economic Community, only Austria still links dental licensure to a medical degree. (For additional discussion, see the background paper by Guarino.) 5 The ADA was renamed the National Dental Association in 1897 following a merger with the Southern Dental Association, which had been created after the Civil War. The ADA then resumed its original name in 1922 and later relinquished its right to the other name. In 1932, what had been first the Tri-State and then the Interstate Dental Association became the National Dental Association (Kidd, 1979). As early as the 1890s, however, African-American dentists had met as a dental section of the National Medical Association (Dummett, 1952).
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--> Proprietary Schools: Advance and Retreat During the 1880s and 1890s, dozens of freestanding proprietary (for-profit) schools were founded in the United States. In Illinois alone, 28 dental schools were chartered between 1883 and 1902 (Gies, 1926). Illinois was also known as "the prolific mother of thirty-nine medical colleges" (Flexner, 1910, p. 6). By 1900, the nation had 57 dental schools. The major impetus for the rapid growth in proprietary dental schools was the adoption of state laws regulating dental practice. These laws often granted graduates of dental schools license to practice, without requiring that they take any qualifying examination. By 1900, about 60 percent of dentists were dental school graduates. By the mid-1920s, it was estimated that less than 3 percent of active dentists had trained under preceptor arrangements (Gies, 1926). The regulatory stimulus for the creation of dental schools was not initially matched by corresponding standards of quality for those schools. The result was the creation of a number of dubious educational enterprises. More colorfully put, "Some of the dental schools of this period were busy diploma mills, which [were] created under the. sanction of indifferent state laws, conducted with the collusion of unworthy dentists, and protected by unfaithful practitioners in posts of public responsibility, freely sold the degree of doctor of dental surgery at home and abroad, [and led] to the disgrace of the profession and to the dishonor of dental education. Many of the dental schools that were chartered since 1884 have been ... completely worthless" (Gies, 1926, p. 28). Eventually, the proliferation of proprietary schools prompted a reaction. State practice acts began to require that graduates of dental schools take licensure examinations and that only graduates of "reputable" schools be permitted to take such examinations. (The term "reputable" was not defined but was essentially a code word for nonproprietary schools.) Not only did the founding of new schools drop off, but the charters of many schools were withdrawn. For example, between 1902 and 1905, 22 of the Illinois schools lost their charters. Also, as a result of "increasing requirements in equipment, supplies, teaching, and research," dental education ceased being a ''profitable business" (Gies, 1926, p. 49). Dental Hygiene Education The first short-lived dental hygiene school was established in 1910 and graduated one class before local dentists succeeded in
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--> closing it (Motley, 1986). In 1913, a second program, the Fones School of Dental Hygiene, was created in Bridgeport, Connecticut; it emphasized school- rather than office-based services. Two years later, Connecticut became the first state to authorize hygienists to provide services under a dentist's supervision. In 1916, the same year that a New York court found no law preventing the provision of care by hygienists, Columbia University founded the first university-based hygiene program, a step that shortly thereafter stimulated the founding of the dental school itself (Orland, 1992). The American Dental Hygienists' Association (ADHA) was founded in 1923, the same year as the American Association of Dental Schools (AADS). In 1947, the ADHA and the ADA set forth the first accreditation standards for dental hygiene programs. Today, accredited programs range in length from two to four years and lead to either an associate or a baccalaureate degree. Education Reform The Flexner Report Early in this century, the Carnegie Foundation for the Advancement of Teaching funded a series of reports on professional education in the United States. The publication of the fourth report, Abraham Flexner's 1910 study of medical education, was a landmark event (Flexner, 1910; Vevier, 1987; Wheatley, 1988). More than 80 years later, the Flexner report still shapes medical—and dental—school curricula. The report reflected and reinforced several themes or innovations in medical education including the mobilization against proprietary medical schools; the rationalization of the relationship between universities and professional schools; the creation of higher standards for medical school admissions and for better-qualified, full-time faculty; and the movement toward education grounded in scientific research and thinking. 6 6 Flexner's promotion of full-time research-oriented medical faculty was attacked by many respected physicians. For example, William Osler foresaw "the evolution throughout the country of a set of clinical prigs, the boundary of whose horizon would be the laboratory ... forgetful of the wider claims of a clinical professor as a trainer, a leader in the multiform activities of the profession, an interpreter of science to his generation, and a counsellor in public and in private of the people, in whose interests after all the school exists" (quoted in Wheatley, 1988, p. 69.)
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--> The Gies Report The tenth in the series of Carnegie reports, which was published in 1926, focused on dental education. Its author, William Gies was a Columbia University biochemistry professor with a particular interest in dental research. The report, which took five years to research and write, consisted of 250 pages of text plus more than 400 pages of appendixes, including lengthy descriptions and evaluations of the existing dental schools, each of which was visited by Gies. Table 2.2. presents Gies' basic conclusions. His commentary on his five conclusions was essentially as follows. First, dental schools deserved earnest attention by universities. They should not be regarded as trade schools and profit centers, whose profits were to be funneled to the medical schools. Dentistry can be appropriately regarded as the oral specialty of medicine, albeit an autonomous rather than a conventional specialty because of its mechanical emphasis. Indifference to research or graduate study as avenues to productive scholarship and leadership should not be acceptable. Libraries should be upgraded as a sign of credibility. TABLE 2.2. Conclusions of the Gies Report on Dental Education, 1926 In universities, dentistry, an independent division of health service and, in effect, the oral specialty of the healing art, should receive the quality of consideration and support now deservedly accorded to medicine. In dental schools, teaching and research should be as effectual as the best in a good university, and the status of dental teachers should be raised accordingly. The preparatory education of dentists should be equivalent, in general character, to that of physicians, which now includes at least two years of approved work in an accredited academic college after graduation from a four-year high school. The undergraduate curriculum in dentistry should be devised for intensive preparation for the duties of general practice only, and should be so organized that earnest and competent students could complete the training in three years. An optional full-year graduate curriculum, separate or combined, including dispensary and hospital experience as well as opportunity and encouragement in research, should be provided for all types of specialization in oral science and art, especially those of practice, public health administration, teaching, and investigation. SOURCE: Gies, 1926, p. 179.
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--> Second, the sincere commitment of the university to dental education would be demonstrated most meaningfully by elevating the status of the dental teacher and supplying sufficient remuneration to attract full-time committed educators. Schools should not be allowed to retain successful practitioners whose teaching is "uninstructive or even farcical" and who subordinate their teaching duties to practice. Endowments should be established as further evidence of university commitment. Such endowments would discourage schools from maintaining programs that were "intended in many cases primarily to keep themselves alive and to prolong the residence of students" (Gies, 1926, p. 206). Third, to underscore that dentistry is not a trade, predental and premedical collegiate education should be comparable, and predoctoral medical and dental curricula should be similar and shared insofar as possible. A liberal preprofessional education stimulates the spirit of inquiry and scientific thinking and helps prepare dental students to be the intellectual peers and colleagues of medical students. Better predental education would allow transfer of some courses from the predoctoral to the predental level and encourage better teaching of the basic sciences at the predoctoral level. Gies and the president of the Carnegie Foundation also urged that medical students be better trained in oral health. Fourth, if some coursework could be transferred to the preprofessional level, if the great amount of both duplication and minutiae in classes could be eliminated, and if instruction in the mechanical aspects of dentistry could be reduced, then a three-year rather than a four-year program (nine to ten months per year) should be sufficient for training general practitioners. The curriculum could still be expanded to achieve greater "correlation" with clinical medicine. Given the continuing advancements in technique and knowledge, Schools should concentrate on helping students "to teach themselves" and to be able "to learn and grow in proficiency" (Gies, 1926, pp. 190, 191). Specialization should be reserved for postdoctoral education. Gies tersely condemned the shortfall between these aspirations and the reality as follows. "Although most of the schools are integral parts of universities, few enjoy income from endowment or the equivalent, and . . . a majority subsist on fees, pay small salaries for instruction, have few whole-time teachers, are deficient in library facilities, offer no opportunity for graduate work, ignore research, are not intimately associated educationally with medical schools or hospitals, give no financial assistance to students, and make no systematic effort to guide their graduates into communities in need of dental service" (Gies, 1926, p. 246).
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--> assistance of the AADS; an ADA critique of the preceding report (ADA, 1980); and, in the 1980s, a series of conference proceedings published in the AADS Journal of Dental Education. Other relevant studies include the 1980 study of Advanced Dental Education sponsored by the W.K. Kellogg Foundation (AADS and W.K. Kellogg Foundation, 1980) and the 1993 report of the Pew Health Professions Commission. These reports document the development of the dental curriculum and the continuation or emergence of many of the problems discussed further in Chapter 4 of this report. Their sponsorship reflects the important role that private foundations have played and continue to play in encouraging critical thinking and change in dental education. The Struggles Over Educational Standard Setting The development of professions, in which the establishment of membership standards is a central element, has its roots in St. Benedict's sixth century description of the ''profession" of adherence to the standards of the monastic community. Today, professional standards reflect both community interest and self-interest, and the professions' interest in the education of their prospective members derives from these sometimes, but not always, compatible objectives. The drive by many educators and practitioners to institute more stringent admission and graduation requirements, eliminate proprietary schools, develop formal assessment mechanisms, and set other standards for dental schools reflected triple desires: to protect the public from ill-trained practitioners, to discourage some competitors, and to improve the stature of the profession. The various objectives behind the drive for professionalization in general and educational standards in particular are sources of both tension and harmony between the practice and the education communities. The National Association of Dental Examiners (NADE), organized in 1883, put pressure on the dental schools to improve standards for accepting students and granting degrees, and it criticized the weakness of the major association of dental educators, the National Association of Dental Faculties (NADF).8 The latter organization, which was created in 1884, took most of the propri- 8 Unless otherwise indicated, this discussion relies primarily on McCluggage, 1959.
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--> etary schools as members. Their strength within the organization kept it from developing rigorous standards for schools, although it did lengthen the dental curriculum to three years in 1891 and four years in 1917. (A high school diploma was not required for dental school admission until 1916 [Ward, 1972].) Echoing the split between institutional and preceptor models of dental education in the late nineteenth century, the American Dental Association (then called the National Dental Association) split in the early part of this century between the supporters of university-based education and those who supported and typically were products of proprietary schools. Debates over educational standards and sponsorship were occasionally ill-tempered. In 1909, in an effort at cooperation, the NADE and the NADF proposed that a council on dental education be created somewhat along the lines of the Council on Medical Education, an organization established in 1904 as a standing committee of the American Medical Association. The Dental Educational Council was, however, set up as an independent body composed of representatives of the NADE, the NADF, and the ADA (with the university-based faculty organization left out). The Dental Educational Council initially focused on surveys of dental education, inspection of schools, and advice on policy and curricula, but within its first decade it also began rating dental schools, using a highly controversial rating system. Gies criticized it for allowing schools not affiliated with universities to get "A" ratings, a practice that the council dropped in 1924 (McCluggage, 1959). The 1920s and 1930s saw substantial changes in dental education. These included the formation in 1923 of the American Association of Dental Schools (a consolidation of four separate groups that William Gies helped negotiate) and the 1926 Gies report. The AADS, which was not troubled by a strong proprietary school contingent in its membership, received Carnegie Foundation support in 1930 for a curriculum study (Sissman, 1971), and the ADA undertook a major curriculum study at about the same time (McCluggage, 1959). During this period, the leadership of the American Dental Association (as the National Dental Association renamed itself in 1922) became increasingly restive about the independence of the Dental Educational Council, and it sought to bring educational standard setting under ADA control. In 1938, the council became the Council on Dental Education), "the agency of the ADA" in dental education (McCluggage, 1959, p. 385). The council's board provided equal representation for the ADA, the AADS, and the
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--> NADE. In 1948, the CDE took on the role of accrediting dental schools and approving specialty boards, internships, and residencies. In 1974, the council was succeeded by the Commission on Dental Accreditation, which is technically independent but is funded, staffed, and housed by the ADA. The ADA was also interested in national educational standards as a step toward reciprocity in state licensure. Reciprocity has been described as a "treaty" between two states to accept each other's licensing procedures (McCluggage, 1959, p. 388). The issue of uniform licensing standards raised—and still raises—potent political controversies over states' rights and freedom of movement that spill over to the educational realm. Initially, the battle over uniform standards focused on the development of a uniform written national examination that dealt with knowledge of the basic sciences and certain clinical matters. The National Board of Dental Examiners was created in 1928 amidst intense controversy over the initiation and control of such a uniform examination.9 It administered the first nationwide written examinations in 1933 and 1934, but by 1958, only 32 states accepted the national examination certificates as a full or partial substitute for a state written examination (Damiano et al., 1992). Today, all states do. Controversy now focuses on continued testing of clinical competency through a varied set of state and regional examinations. Regional cooperation in clinical examinations began in 1967 when New York and the District of Columbia administered a single examination, a step that led to the creation of the first regional board, the Northeast Regional Board. Three other regional boards have since been developed, and more than half the states participate in one or more of these boards. Dentistry and dental hygiene are among the very few health professions requiring direct assessment of clinical skills using real patients. Chapter 8 discusses more recent developments and issues in standard setting. 9 The depth of feeling was illustrated by one dentist's claim that "Cleopatra had her asp; Hamilton had his Aaron Burr; Caesar had his Brutus; and Christ, his Judas Iscariot. Dentistry has its National Board of Dental Examiners" (McCluggage, 1959, p. 392)
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--> Building A Research Base In The University Before 1948 Dental research—inside and outside university-based dental schools—was relatively slow to establish itself. In the 1930s, William Gies, at the behest of several prominent New York dentists, suggested that "various biological researches be conducted at different dental schools," but the responses indicated that "neither inclination, facilities or abilities were available" [quoted in Orland, 1992, p. 207). Like early dental education, early dental research, at least in its applied aspects, was troubled by disputes about commercialism. Particularly fierce battles pitted organized dentistry against practitioners seeking patents on dental crowns and inlays (McCluggage, 1959). On a related front, just as he criticized proprietary dental schools, Gies criticized commercial writing about innovations in dentistry. In introducing the Journal of Dental Research in 1919, he cited the "dominant trade journalism . . . for commercial efficiency, professional obtundity, and unlimited superficiality . . . [that] demoralized the spirit and impoverished the imagination of dentistry" (Gies, 1919, reprinted in Orland, 1992, p. 73). According to Harris (1989), university-based research in the 1920s was concentrated in 10 dental schools—California, Louisville, Harvard [with the Forsyth Infirmary cooperating), Illinois, Michigan, Minnesota, Northwestern, Pennsylvania, Rochester, and Western Reserve. During this period, the ADA encouraged university research with grants administered through a committee of the National Research Council [McCluggage, 1959).10 In the early decades of this century, the ADA also promoted research initiatives by various agencies of the federal government including the Public Health Service and the Bureau of Standards. These agencies, in turn, supported dental research in some universities, although they con- 10 In her discussion of the National Research Council [NRC], the administrative arm of the National Academy of Sciences, Harris (1989) notes the low esteem in which dental research was held by medicine at the time Gies conducted his study. Although the NRC was one of the first federally supported bodies to support dental research, its division of medical sciences was relatively hostile. The chair of the division is recorded in 1920 with these comments: "Of course, they [dentists] can't do any real investigating ... on their own, but in a cooperative thing I think we can make use of them ... [and] eventually ... [gain] control of the whole thing" (Christian quoted in Harris, 1989, p. 29).
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--> ducted much research in their own laboratories. By 1948, however, only 18 institutions—not all dental schools—were conducting dental research with newly available National Institutes of Health (NIH) funds (Harris, 1989). Even though the 1941 standards of the ADA's Council on Dental Education (created in 1938) required that dental schools conduct research, only 21 of the 40 dental schools even applied for the new funds. Since 1948 With the creation of the National Institute for Dental Research in 1948, the federal government initiated a focused—albeit still modest—effort to promote research in oral health problems. In addition to organizing NIDR's own research laboratories, the first director, H. Trendley Dean, proposed to promote dental research by ''(1)[expanding] the training of dental researchers, (2)[encouraging] all the country's forty dental schools and certain graduate schools to expand dental research through research grants-in-aid, and (3) [establishing] some small research studies in universities coordinated and administered by NIDR" (Harris, 1989, p. 96). The emphasis on research training by NIDR reflected the conclusion that a shortage of qualified dental researchers hampered serious applied and basic research.11 A similar conclusion is reflected in a 1955 tribute to Gies that argued that many of the advances in dental practice had come not from dental schools but from medical schools and private industry (Rosebury, 1955, reprinted in Orland, 1992). In 1954, after finding a paucity of "good" dental research applications, members of an NIDR planning committee attempted to assess the research potential of the dental schools, and their site visits to schools may have acted as an additional stimulus for dental research (Harris, 1989). Since its founding in 1948, NIDR has undertaken a number of more formal initiatives to encourage dental research and research training (Harris, 1989). Some of the programs are aimed at schools, others at individuals. They include the following: The extramural research program continued and built on the small preexisting base of NIH dental research grants. From 1956 11 Federal government support for the training of health scientists began in 1937 with programs authorized by the National Cancer Act (IOM, 1990d).
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--> to 1959, the percentage of dental schools participating increased from 50 to 94. The extramural program established special sections for training and research grants in 1962. The fellowship program also built on existing Public Health Service (PHS) and other programs for training researchers at government facilities. One, funded by the ADA, started in 1941 and continued until 1970. The research centers program, initiated elsewhere at NIH in 1959 and in dentistry in 1962, provided support for comprehensive investigation of specific oral health problems or general disease conditions. The first support went to the University of Pittsburgh Cleft Palate Center. The NIDR created a Dental Research Institutes and Centers program in 1965 that awarded grants for five regional centers in 1967. The NIDR contracted with the ADA in 1964 for an information center to collect and make available dental research data that could be used in designing and developing research and training programs. In 1974, the National Research Service Award Act created a separate congressional authorization for research training, after the Nixon administration had impounded all NIH training funds and proposed elimination of all federally supported research training (IOM, 1990d). The act restricted student support to those pursuing research careers and included a service or payback obligation for those receiving training. The Dentist Scientist Award, created in 1984, supported individuals in a five-year program of dental specialty training and research training leading to a Ph.D., generally in a basic science. Health Status And Epidemiological Research Until the 1950s, when the National Health and Nutrition Examination Survey (NHANES) was launched, data on oral health status were limited largely to community and special surveys undertaken by a variety of public health, educational, and professional groups (Harris, 1989). The historical importance of even small-scale dental epidemiological research should be noted. Although dental practitioners individually were all too aware of the prevalence of tooth decay and other problems, their testimony did not provide the compelling evidence needed to achieve broad public recognition and action to attack the problems. One starting point was data amassed from the physical examinations of mili-
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--> tary draftees and recruits beginning as early as the Civil War and from the records that the Marine Hospital Service began to collect in the 1870s. Limited though these data were, the widespread problems of decay, tooth loss, and poor function that they identified did stimulate incremental steps to improve oral health services, training, and research (Harris, 1989). At the community level, the first dental inspection of schoolchildren began in 1906 in Rochester, New York. These inspections were undertaken primarily as part of an oral hygiene movement. This movement also included the founding of children's dental clinics with funding from George Eastman in Rochester and the Forsyths in Boston (McCluggage, 1959). Both clinics evolved into leading centers of dental research and postgraduate education. The data collected from inspections of school children in dozens of cities helped build understanding of the high prevalence of tooth decay. States also began school-based service programs and data collection efforts. As of 1936, 14 states provided by statute that "Vincent's infection" (trench mouth) be reported to the state health department (U.S. Department of the Treasury, 1936). In the 1920s, surveys conducted by the Division of Child Hygiene in the PHS focused on dental fluorosis [permanent discoloration of teeth) and the possible influence of diet and climate on caries. Fluorosis was first viewed purely as a dental defect. Its role in caries prevention was only later suspected. In the 1930s, the PHS in cooperation with the ADA sponsored two national surveys, one polling state health departments and institutions and the other examining 1.5 million children aged 6 to 14 in 26 states (McCluggage, 1959; Harris, 1989). Nothing comparable was done again until the first NHANES study. Unfortunately, variability in examiners' recording of caries led to a probable underestimate of caries prevalence. Nonetheless, the geographical variation in caries experience was regarded as one piece of evidence linking fluorosis with the control of tooth decay (Harris, 1989). Data on oral health status began to improve substantially in the 1960s and 1970s. As discussed further in Chapter 3, these data are still limited in important respects. In light of their generally limited involvement in research at midcentury, it is not surprising that dental schools figure little in the most important oral health research of that period, that is, investigation of the oral health effects of fluoride (Rosebury, 1955, reprinted in Orland, 1992; McNeil, 1957; McClure, 1970; Harris,
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--> 1989). That research was the culmination of a process that began in the early 1900s with the observations and persistence of a Colorado dentist, Dr. Frederick McKay, who was fascinated by the problem of mottled enamel. He caught the attention of Dean G.V. Black of the Northwestern University Dental School, who collaborated in some studies to understand the problem. Another dental school dean, H.E. Friesell of the University of Pittsburgh, tried unsuccessfully to get federal funding to study the same problem, which had been noted by a Pittsburgh graduate practicing in Arizona. Instead, researchers at the University of Arizona Agricultural Experiment Station linked mottled enamel to drinking water containing fluoride. In 1931, the PHS agreed to investigate mottled enamel and brought in Dr. H. Trendley Dean to lead the work. The eventual result was the major trial of artificial fluoridation in Grand Rapids, Michigan. (Dean was later named the first director of NIDR.) The effectiveness of this and later trials in reducing caries led to strong public health support of community fluoridation. This support, however, was soon countered by fierce opposition from an unusual combination of forces including Christian Scientists, skeptical scientists and clinicians, chiropractors, health food advocates, and right-wing groups that viewed fluoridation as a Communist conspiracy to usurp individual rights and impose socialized medicine (McNeil, 1957; McClure, 1970). Chapter 3 examines the current status of fluoridation. Other Controversies Clinic Services In addition to disagreements about the process and substance of accreditation and licensure, other bones of contention between educators and practitioners should be noted. From time to time, for example, controversy has focused on dental school clinics as a source of competition for practitioners and a form of "corporate dental practice," akin to the prepaid group practices that provoked the opposition of physicians from their earliest days. When the dean of the dental school at Columbia University proposed early in this century to offer dental services "at a moderate charge to persons in moderate circumstances," rather than only low-cost preventive and medical services, he was strongly criticized (Orland, 1992, p. 102). The committee's site visits and other meetings indicated that initiatives by dental schools to establish faculty
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--> practices or otherwise to expand clinical services can still provoke resistance by area practitioners. More generally, the financing of dental services has incited bitter debate since at least the 1920s. One starting point was the work of the private Committee on the Costs of Medical Care. With funding from several foundations, the committee set out to collect data on the cost and availability of health services. Its five-year investigation generated 27 field studies and a controversial final report (Anderson, 1968; Starr, 1982; IOM, 1993b). One part of this investigation was a survey of the incidence of dental disease and of the cost and availability of dental services (McCluggage, 1959). These studies found that 12 percent of health care spending went to dental services versus 30 percent to physician services and 24 percent to hospitals. The proportion of dentists to population varied from 1:500 to 1:4,000 for the population generally, but it was 1:8,500 among the segregated black population. The committee's proposals for change, which included group practice and voluntary private insurance, were strongly opposed by both the medical and the dental professions. The controversy discouraged the Roosevelt administration from including health coverage as part of its social security proposals. In the 1940s, a series of government actions almost inadvertently encouraged employers to expand nonwage compensation to their employees (Somers and Somers, 1963; Starr, 1982). Substantial growth in private, employment-based health insurance was one major consequence, although dental insurance specifically did not really begin to grow until the 1970s. Less than 2 percent of the population was covered by private dental insurance in 1965 compared to over 25 percent in 1978 (IOM, 1980). When the Medicare program was established in 1965, it excluded dental services—and that exclusion remains in place. Although required to cover some services for children, most state Medicaid programs pay relatively little for dental care, especially for adults IOTA, 1990). Today, not quite half the U.S. population has some form of public or private coverage for dental services (Keefe, 1994). Controversy has also surrounded other steps to extend access to dental services. In 1970, Congress established the National Health Service Corps (NHSC; P.L. 91-623) to improve health services in underserved areas. Although the focus was on areas with shortages of health personnel, the legislation also included provisions for partly or fully subsidized care to those who could not afford to pay. In most cases, local medical or dental societies as well as local governments had to agree to designations of shortage areas. Opposition by dental groups was apparently more frequent
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--> than medical society opposition (Carnegie Council on Policy Studies in Higher Education, 1976). Later legislation established a scholarship program for selected health professions students. In return, the recipient was required to provide one year of service in the NHSC or the Public Health Service for each year of scholarship support. The current status of this program is discussed in Chapters 4 and 9. Dental School Enrollments Yet another source of controversy involves the fundamental questions of how many dental schools are needed and how many students they should enroll. The 1950s and 1960s saw a growing—but not undisputed—sentiment that there was a shortage of physicians and some other health professionals (Somers and Somers, 1963; Coggeshall, 1965; Fein, 1987). One early response came in the Health Professions Educational Assistance Act of 1963 (P.L. 88-129), which provided for construction and expansion grants to schools and for loans to students. In 1970, the report of the Carnegie Commission on Higher Education, Higher Education and the Nation's Health, reflected widespread agreement that the nation had a shortage of physicians, dentists, and certain other health professionals. It encouraged expansion in health professions education, warned against overspecialization, supported training of physician and dentist assistants, and proposed creation of a national health service corps. The Comprehensive Health Manpower Act (P.L. 92-157) of 1971, like its 1963 predecessor, provided loan and scholarship money as well as funds for both new and expansion construction and operating costs. It provided an even more powerful incentive for growth by linking schools' eligibility for funds to increases in first-year enrollments—10 percent for schools with 100 or fewer first-year students and S percent (or 10 students, whichever was greater) for larger institutions. Funding for dental schools (excluding research and postgraduate programs) increased from $64 million in 1970-1971 to $80 million in 1971-1972 but dropped back to $57.8 million in 1974-1975 (Carnegie Council on Policy Studies in Higher Education, 1976). Between 1971 and 1975, six new dental schools were established.12 Then, just six years after the 1970 Carnegie 12 Other provisions in the 1971 legislation encouraged medical and dental schools to move from a four- to a three-year curriculum. Sixteen schools made the change, but when funding ended, all but the University of the Pacific returned to
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--> report, a report by a successor organization warned that too many medical schools were being established and that the increased supply of physicians was not eliminating geographic disparities (Carnegie Council on Policy Studies in Higher Education, 1976). The report suggested, however, that enrollments in some dental schools should be expanded and that new schools were needed in Arizona and probably in Florida. Today, Arizona still has no dental school, and Florida continues to have a single school as it did in 1976. Congress reacted to the changing view of the health care supply question (particularly the view that there was a ''physician glut") by reducing direct support for health professions education, including dental schools. The whipsaw effect of adopting and then removing a significant stimulus for enrollment growth had disruptive effects on both educators and practitioners that still persist in debates about the size, distribution, and composition of the dental work force and the appropriate number and size of dental schools. As noted in Chapter 1, six Schools have closed since 1985, and the overall enrollment drop is equivalent to closing about 20 average-sized schools (Consani, 1993). Chapter 9 examines the dental work force today. Summary The twentieth century opened for dental education with an abundance of proprietary schools, a trade not fully transformed into a profession, and a primitive regulatory structure. The population was beset by serious dental disease, resigned to tooth loss, and limited in the treatments available to it. The science and research base was minuscule. During the twentieth century, dental practice, education, and regulation have been transformed. Proprietary schools have vanished amidst a series of educational reforms, and a significant—albeit still limited—research capacity has emerged. The next chapter focuses on the trends in oral health that have greatly diminished the incidence and severity of dental disease. the four-year schedule. Earlier, most dental schools had adopted year-round three-year programs during World War H but only the University of Tennessee continued that pattern after the war (Santangelo, 1981).
Representative terms from entire chapter: