INSTITUTIONAL ISSUES
A R T I C L E
Oral Health Care in the 21st Century: Implications for
Dental and Medical Education
William D. Hendricson, MS, and Peter A. Cohen, PhD
ABSTRACT
The past decade has been turbulent for dental education,
marked by debate about the future directions of the cur-
riculum and the profession itself. The bulk of the dental
school curriculum is still devoted to tooth restoration or
replacement techniques, although the need for these pro-
cedures has declined. Some dental educators now advo-
cate an oral physician model as the desired direction for
the profession, with expanded training in systemic disease
pathophysiology and a practice scope that extends beyond
exclusive focus on the teeth and supporting structures.
Proponents of this model contend for curriculum time
with faculty who desire to maintain a technical focus.
The outcome of this curricular tug-of-war has implica-
tions for medical education, because many oral health
problems now fall into the overlapping educational and
patient care environments of physicians, dentists, and
other health care providers. Will physicians perceive the
I
n 1971–1972, a World Health Organization commis-
sion assessed health professions education throughout
the world, including the United States. The commis-
sion concluded that education is inextricably interwo-
ven with the health service system, and when questions arise
about the delivery of service, questions about the training of
health care providers follow soon after.1 And, indeed, in the
30 years since that prophetic report, a torrent of questions
Mr. Hendricson is director, Division of Educational Research and Devel-
opment, The University of Texas Health Science Center at San Antonio,
San Antonio, Texas, and is associate editor, Journal of Dental Education.
Dr. Cohen is dean, College of the Health Professions, Wichita State Uni-
versity, Wichita, Kansas.
Correspondence and requests for reprints should be addressed to Mr. Hen-
dricson, Division of Educational Research and Development, The University
of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive,
San Antonio, TX 78229-3900; telephone: (210) 567-2813; e-mail:
具hendricson@uthscsa.edu典.
ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
new dentist as an encroachment on territory or as a re-
source to enhance patient care? Within dentistry, the
traditions of tooth restoration and prosthodontics shape
the profession’s culture. Are dental educators ready to re-
configure a curriculum that is deeply intertwined with the
professional identity of 150,000 U.S. dentists practicing
today?
To stimulate thinking about these issues, the authors
analyze the responses of dental education to changes in
the public’s oral health and to calls for curricular reform,
propose strategies for modifying the way dentists are pre-
pared for their professional responsibilities, and explore
the sociology of change in academic institutions, because
elements of dental education targeted for reform are re-
vered components of school culture.
Acad. Med. 2001;76:1181–1206.
has been unleashed in the United States about the way med-
ical care is provided for the public, leading to a still-evolving
reconfiguration of the health care landscape and, as pre-
dicted, scrutiny of the way health care providers are prepared
for their professional roles in society.2–5 In this article, we
focus on dentistry, a profession that has similar public service
roles and shares a common biomedical science foundation
with medicine, but which has been differentiated into dif-
ferent pathways for education, licensure, and scope of prac-
tice for a variety of complex historical, economic, political,
and philosophical reasons. (For more about our goals for this
article, see the later section entitled ‘‘Purpose of This Arti-
cle.’’)
WINDS OF CHANGE
Winston Churchill said that ‘‘the winds of change are
blowing and we lean into them with equal measures of an-
1181
 21ST-CENTURY ORAL HEALTH CARE,
ticipation and dread’’ to capture the conflicting emotions
that arise when established institutions and methods are
questioned.6 The winds of change have been blowing since
the 1980s in U.S. health professions education. The 1984
report of the Association of American Medical Colleges
(AAMC) panel on the general professional education of the
physician (the ‘‘GPEP report’’) and the reports of the Pew
Health Professions Commission a decade later were catalysts
for curricular introspection in medical schools and other
health professions schools.7–9
The dental education community embarked on an analysis
of its own curricular health approximately ten years ago.
This introspection led to the 1995 Institute of Medicine
(IOM) report entitled Dental Education at the Crossroads:
Challenges and Change, which proposed reform of curriculum
content and modernization of teaching and learning meth-
ods.10 Both before and after that IOM study, there was agi-
tation for change among elements of the dental school fac-
ulty and administration. Catalysts for change in dental
education include projections of faculty shortages counter-
balanced by projections of increased public need for oral
health providers and services, particularly in large under-
served populations; desire at the administrative level and
among some faculty to play a more proactive public health
role by extending student education and patient care services
into the community; advances in genetics and molecular bi-
ology with implications for patient care and thus for curric-
ulum content; faculty desire to upgrade the scientific basis
of the clinical curriculum; and resource-driven evaluation of
long-standing educational and patient care practices in the
dental school clinic that may no longer be educationally or
economically viable.
At the core of the debate over future directions is what
has been called the ‘‘surreal duality’’ of dental education and
the profession.11 At one end of the spectrum, a large portion
of the curriculum is devoted to mechanical techniques
taught and evaluated in fine-grain detail, for example, plac-
ing a class II amalgam restoration or constructing a remov-
able partial denture. At the other end, dentists are expected
to be accomplished diagnosticians capable of assessing and
managing a multitude of oral pathologies (i.e., oral physi-
cians, with expanded focus beyond the teeth and supporting
structures) and knowledgeable about sophisticated biomedi-
cal science concepts—for example, the roles of carcinogens
such as benz-pyrene and tobacco-specific nitrosamines in the
production of DNA adducts such as 06 methyl guanine,
which interfere with DNA replication; or the genotypes of
interleukin-1 that are associated with adult periodontal dis-
ease. The biomedical science component of this duality has
been brought into sharp focus by two recent events: the Hu-
man Genome Project12 and the Surgeon General’s report on
the oral health of America.13 This duality has created ten-
1182 ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
sion within dental schools as proponents of an expanded
biomedical emphasis and a broader concept of the dentist’s
health care role aggressively contend for curriculum time
with faculty who desire to maintain the traditional technical
focus (e.g., the traditional tooth-doctor role). Efforts to ac-
commodate both components of this duality have produced
excessively dense curricula at most dental schools.
PURPOSE OF THIS ARTICLE
A preliminary version of this article was developed by in-
vitation for the 75th Anniversary Leadership Summit Con-
ference of the American Association of Dental Schools
(AADS), conducted in October 1998. Fifty dental school
deans participated in that meeting and were accompanied
by the chancellors of their parent academic health science
centers. The purposes of the conference were to stimulate
thinking about the future directions of dental education
within the broader purview of health professions education
and to assess the role of the dental school within the aca-
demic health center. The early version of the present article
was read by the summit conference participants and debated
in small-group sessions. Based on encouragement and feed-
back from conference participants, a revised manuscript was
made available to the dental education community through
the AADS Web site in December 1998. A further modified
version, incorporating feedback from individuals who had
read the on-line version, was published in the conference
proceedings, Leadership for the Future: The Dental School in
the University, in the summer of 1999.14 Additional feedback
from a variety of individuals and the authors’ own critical
reflections led to the present version. The authors are edu-
cation specialists who are not dentists but who have more
than 50 years of combined experience as consultants for two
thirds of the dental schools in North America. We also have
worked for more than 100 medical, pharmacy, nursing, and
allied health schools, residency programs, and medical spe-
cialty associations.
Our goal for this article is to stimulate dialog among med-
ical and dental educators about the scope, structure, and
content of the training provided for dentists as we enter the
21st century. To accomplish this goal, we first review the
publics’ evolving oral health status since World War II as an
indicator of curriculum priority and content. In the second
section, we consider the extent to which dental schools re-
sponded to the changes in oral health over the past 50 years
and to calls for curricular reform. In the third section, we
examine three institutional strategies we believe can make
a difference in the way dentists are prepared for their pro-
fessional responsibilities: (1) developing a curriculum based
on competency-based techniques, (2) blending the educa-
tion of oral health specialists into the broader system of
 21ST-CENTURY ORAL HEALTH CARE, CONTINUED

Table 1

Comparison of Characteristics of U.S. Dental and Medical School Education Programs, Late 1990s

Characteristic Dental Medical

Duration
Curriculum flexibility
Philosophy
Focus
Outcome
Curriculum structure
Nature of courses
Biomedical sciences
Preclinical preparation
Clinical education
Location of clinical educa-
tion
Four years (53 of 54)
Almost totally lock-step
Competency-based assessment
Primary emphasis on the dentition until recently
Prepare student to function as unsupervised entry-
level general practitioner on the day of graduation
Primarily departmentally-based courses throughout;
less than 20% have multi-disciplinary basic science
courses; limited cross-disciplinary learning in pre-
clinical/clinical curricula
Most schools have 60–80 distinct courses; many 1–
2-credit courses with less than 40 clock hours; nu-
merous lecture courses in clinical years; students
do not have clerkship-type rotations in 3rd year;
instead, work on skills in several areas simultane-
ously; more schools are devoting 4th year to pri-
mary care
Typically 800–1,000 clock hours
Major curriculum focus; lab technique courses oc-
cupy much of 1st and 2nd years; limited lab in-
struction for patient interview and exam skills, but
extensive ‘‘learn by doing’’ in 3rd and 4th years;
detailed assessment of techniques used for tooth
restoration/replacement
Historically, based on completion of in-mouth proce-
dural requirements (technique repetitions); exten-
sive hands-on learning; patients assigned directly
to students, not faculty; faculty serve as coaches
and graders
In most schools, primarily occurs in school’s on-
campus clinic; recent recognition of value of com-
munity-based experience
Almost all are four years
Primarily lock-step until 3rd year
Movement toward competency-based assessment
General review of human structure, function, and
pathophysiology
Prepare student to enter residency training; expose
student to medical specialties; develop student’s
foundation patient care skills
Eclectic—two thirds have some multidisciplinary
courses in 1st and 2nd years; Primarily specialty-
based in 3rd and 4th years, although many
schools have multidisciplinary primary care rota-
tions
Most schools have 15–20 total courses in years 1
and 2, each with substantial clock hours/course
credits; 3rd year: 6–8 multi-week rotations; 4th
year: several multi-week rotations and substantial
electives; very few lecture courses in years 3 and 4
Typically 1,500–1,800 clock hours
Limited to physical assessment (H & P) courses; less
than 10% of curriculum; procedural skills mostly
learned during clerkships or later in residency
training; in many schools procedural skills beyond
H and P are not defined or systematically assessed
in a school-wide program
Still based on the team-ladder model with students
on lowest rung of ladder; much observation of res-
idents and attendings; students exposed to wide
spectrum of disease, do work-ups and practice ar-
ticulating diagnoses during case presentations
Students receive experiences in many patient care fa-
cilities as they move among rotations; most
schools now have rotations in community clinics
and practitioners’ offices

health professions education, and (3) expanding public
health and prevention training for dental school graduates.
We used these three strategies to create a description of a
prototype 21st-century dental school curriculum, which ap-
pears in the appendices. We hope this prototype will stim-
ulate the discussion and establishment of alternative models
for the oral health component of health professions educa-
tion. In the fourth section, we explore the sociology of
change in medical and dental schools. To orient medical
educators to the dental school environment, Table 1 pro-
vides a synopsis of some of the principal similarities and dif-
ferences between educational programs leading to the MD
and DDS/DMD degrees.
I: ORAL HEALTH IN AMERICA —1945 TO 2000:
IMPLICATIONS FOR CURRICULUM PRIORITIES
It is often stated that oral disease is the most common dis-
ease of mankind and quite possibly the one disease that all
humans have in common, yet the parameters of what con-
stitutes oral health, and conversely oral disease, are often
vaguely defined. What is oral health? Mouradian defines oral
health as ‘‘encompassing all the immunologic, sensory,
neuromuscular and structural functions of the mouth and
craniofacial complex. Oral health influences and is related
to nutrition and growth, pulmonary health, speech produc-
tion, communication, self-image and societal functioning.’’ 15

ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001 1183

 21ST-CENTURY ORAL HEALTH CARE,
Mouradian also proposes that oral health is intertwined with
‘‘all aspects of a child’s developmental processes, genetic po-
tential and environmental circumstances.’’
In the years immediately following World War II in the
United States, dental caries and periodontal disease were
widespread, with high percentages of patients experiencing
rampant caries, periapical abscesses, and advanced periodon-
titis, all of which produced a high degree of endentulism.
Because physical removal of caries and tooth extraction were
the primary treatments available, the primary foci of the
dental school curriculum were teaching students to extract
teeth, physically remove decay, replace the excavated tooth
structure with various materials, including gold, stainless
steel, and amalgam, and create prosthetic devices to replace
missing teeth.
However, several decades of research into the biologic
causes and mechanisms of dental infection, leading to en-
hanced preventive and therapeutic regimens; the widespread
use of fluoride as a prophylactic mechanism; and aggressive
patient education have substantially reduced tooth loss and
the incidence of caries in child, adult, and geriatric age
groups.16 Further progress in prevention and therapy is an-
ticipated as we expand our understanding of the genetic basis
of oral diseases and from advances in cell and molecular
biology, immunology, and pharmacology. As we enter the
21st century, oral health is better than ever for the majority
of Americans. The remarkable reduction in oral disease and
accompanying sequelae is one of the more dramatic success
stories in U.S. public health and one that should be a source
of considerable pride for the dental profession. However, sig-
nificant challenges remain, especially at opposite ends of the
age spectrum—for children and the elderly—and in a large
and still-growing underserved population composed primar-
ily of ethnic minority groups and the economically disad-
vantaged.
Oral Health Problems in 2001
A curriculum for health care professionals-in-training should
prepare entry-level practitioners to provide prevention, as-
sessment, and treatment services for the most pressing cur-
rent and predictable future health care problems of society.
What does the oral health of Americans in 2001 tell us
about curricular directions for dental school? Large segments
of the public still have significant oral health care needs in
a variety of areas (discussed in more detail in later para-
graphs): chronic facial pain and impaired jaw-joint function,
craniofacial birth defects, craniofacial trauma including
physical violence inflicted on children, dental caries and as-
sociated health problems—particularly among children,
head and neck cancers, periodontitis, tobacco-related dis-
ease, and the evolving oral health needs of our rapidly ex-
panded elderly population.
1184 ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
Three other factors will strongly influence dental care and
dental education in the 21st century: (1) research exploring
potential interrelationships among oral disease and disorders
classically defined as medical problems, including diabetes,
perinatal problems, and cardiovascular disease; (2) the in-
creasingly multicultural fabric of our society; and (3) access-
to-care issues, particularly for the young, the elderly, and the
economically disadvantaged. Of course, there are many other
oral health problems—including oral candidiasis, particu-
larly as an early sign of HIV infection; herpesvirus infections,
as related to bidirectional genital–oral herpes and associated
sexually transmitted diseases; numerous anomalies of cranial
bones and teeth, and Sjögren’s syndrome—but they are not
discussed here because they are less frequently observed by
the dental practitioner.
Chronic facial pain and impaired jaw-joint function.
More than 20% of adults experience chronic facial pain, the
effects of which can profoundly effect quality of life. Facial
pain may emanate from tooth-related infections or mucosal
sores and irritations, and also includes burning sensations in
the mouth, temporomandibular joint pain, and generalized
pain across the face or cheek. More than ten million Amer-
icans experience pain and dysfunction related to the tem-
poromandibular joint, including musculature pain and diffi-
culty opening the mouth, with accompanying problems in
chewing, headaches, and pain emanating from the ear.
Women report both generalized facial pain and temporo-
mandibular joint pain at substantially higher rates than men
do.17,18 A number of research centers around the world are
now investigating the frequently-observed co-existence of
temporomandibular pain disorders, fibromyalgia, and chronic
fatigue syndrome, and dentists are involved on many of these
research teams.19
Craniofacial birth defects. More than 150,000 infants are
born each year in the United States with congenital mal-
formations, and these conditions can affect facial appear-
ance, speech, and various quality-of-life indices, including
self-esteem. Defects affecting the orofacial complex, includ-
ing cleft lip and palate, are the most common, resulting in
more than one billion dollars of expenditures annually for
the extensive surgical, medical, and rehabilitative interven-
tions needed to repair these defects, and for prosthetic de-
vices.20 Maternal cigarette smoking has been identified as a
significant risk factor for oral clefts.21
Craniofacial trauma. There are more than 20 million vis-
its per year to emergency departments for craniofacial trauma
involving injuries to the jaw, dentition, or soft tissues of the
oral cavity. An additional six million head and neck injuries
annually are treated by dentists in their offices.22 Overall,
25% of all children and adults will experience a traumatic
injury to one or more anterior teeth.23 In the National
Health Care Survey of Emergency Rooms, violence (physical
 21ST-CENTURY ORAL HEALTH CARE,
assaults) and falls each accounted for 31% of visits related
to head and face injuries. Two thirds of the physical abuse
experienced by children is head and neck trauma.24,25
Dental caries and associated health problems. In spite of
the dramatic reduction in caries in the overall population
since World War II, the most common chronic childhood
disease is still dental caries, which afflicts 57 million of our
children, making it five times more common than asthma
and one of the most common causes of missed school days.
The incidence of caries, 50% in mid-childhood, has re-
mained the same for a number of years despite the avail-
ability of recognized preventive measures.26 One in four chil-
dren in the United States live in conditions of poverty
normally associated with an impoverished developing nation
rather than an industrial power; not surprisingly, the inci-
dence of oral disease is disproportionately represented among
children from low-income households.27 Seventy-five per-
cent of all childhood dental problems occur in 25% of chil-
dren, primarily those of low-income and minority status.28
One third of all Head Start preschoolers and 50% of Native
American children have early childhood caries (ECC),
which is clinically correlated with compromised oral func-
tion, poor nutrition, and diminished height and weight at-
tainment.29 In all children, regardless of ethnicity and eco-
nomic situation, dental caries is typically a comorbid
condition with other indicators of poor health status, and in
particular is strongly associated with nutritional deficiencies
that underlie a number of childhood health problems.15 Oral
health is also intertwined with childhood diseases, including
asthma and cystic fibrosis. Asthmatic children have more
decay affecting permanent teeth, poorer periodontal status,
and more loss of tooth surface than do their non-asthmatic
peers.30,31 The higher incidence of caries in children with
restricted airway disease is thought to be associated with
their use of beta-2 agonists, which contribute to reduced
salivary flow, as well as to mouth breathing and esophageal
reflux, which are common in this population. The poor oral
health of children with chronic respiratory and gastrointes-
tinal infections has also been associated with long-term use
of liquid medications containing carbohydrates and sugar.32
Head and neck cancers. One American per hour dies
from oral, pharyngeal, or nasopharyngeal cancer, which is
now the sixth most common form of cancer, behind lung,
stomach, breast, colon, and rectum/cervix cancers.33 In 1997
in the United States, there were 21,000 new cases of oral
cancer among men, with 5,600 deaths, and approximately
10,000 new cases and 2,800 deaths among women. The
overall five-year survival rate for people with oral and pha-
ryngeal cancers is only 52%, which is worse than the rates
associated with cancers of the prostate, rectum, uterus, co-
lon, breast, bladder, and larynx in both black and whites.34
The number of deaths from oral cancer has increased year
ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
by year over the past 25 years.33,35 Tobacco use, heavy al-
cohol consumption, and poor diet are the primary etiologic
factors for more than 90% of head and neck cancers, with
tobacco use alone representing 80% of the risk factors.36,37
Periodontal disease. Sixty percent of adults in the United
States will have periodontal disease in their lifetimes, and it
is a significant contributing factor to the loss of more than
12 teeth that the average American experiences by the age
of 50. Aside from caries, periodontal infection is the most
common reason for dental visits, and in advanced forms can
require extended, unpleasant, and costly therapy, including
surgical interventions.
There is a strong association between smoking and peri-
odontal disease. Approximately 50% of periodontitis cases
are caused by smoking, and the outcomes of periodontal
therapy are adversely affected by smoking.36 A recent lon-
gitudinal study of 900 male and female teenagers found that
smokers are nearly three times as likely as their nonsmoking
peers to have periodontitis in their mid-20s and resulting
loss of periodontal attachment, which is the bony and soft-
tissue support for the teeth.38 In addition, the preponderance
of research has established an association between diabetes,
either type 1 or type 2, and periodontal diseases to the ex-
tent that periodontitis has been called the ‘‘sixth compli-
cation of diabetes.’’ 39 People with diabetes experience gin-
gival inflammation, loss of periodontal ligament attachment,
abscesses, alveolar bone loss, and tooth loss more frequently
and with greater severity than do those in non-diabetic pop-
ulations. Sixteen million people in the United States have
type 1 or type 2 diabetes, and the medical complications of
this disease represent the seventh leading cause of death.40,41
There has been considerable research to determine whether
periodontal infection effects glycemic control. The results
suggest a relationship, but are not conclusive.
Tobacco-related diseases. Tobacco use is the single most
preventable source of death and disability in modern society.
Fifty percent of regular cigarette smokers will die from a to-
bacco-related disease, and one third of these smokers will die
early, losing on average 20 years of life. Worldwide, there
are now four million tobacco-related deaths annually, and
such deaths are projected to increase to more than eight
million by 2020, when tobacco-related deaths will account
for one in six deaths from all causes. In the United States,
there are 500,000 deaths associated with tobacco use each
year. Thirty percent of all cancer is linked to tobacco use.42,43
Tobacco is also a significant risk factor for other diseases of
the mouth: ulcers, periodontal disease, cleft lip and palate,
and caries, and tobacco use delays healing of wounds.36,43
Odor, tooth staining, poor hygiene, and telltale oral dis-
ease make tobacco use obvious to dentists and dental hy-
gienists. The typical dental appointment is considerably
longer than modern medical appointments, affording oppor-
1185
 21ST-CENTURY ORAL HEALTH CARE,
tunity for dentist–patient discussion of tobacco use and its
consequences. However, Tomar reported that only 24% of
current smokers received advice from their dentists to quit
using tobacco.44 Dolan found that just 30% of dentists of-
fered tobacco-use cessation services to patients, and fewer
than one in five felt they were adequately trained to help
their patients stop smoking.45 Dentists do not provide to-
bacco-use cessation services for three reasons: they do not
perceive such services to be part of their responsibility, they
fear that they may alienate patients, and they lack confi-
dence in their ability to provide such assistance to their pa-
tients. In contrast, dental patients now expect their dentists
to help them stop smoking, and the dental or dental hygiene
appointment may provide a powerful opportunity for cessa-
tion education, particularly when precancerous lesions and
other undesirable sequelae of smoking are evident in the
patient’s mouth.46 Yet, in 1999, only 11 U.S. dental schools
provided instruction in tobacco-use cessation or prevention
techniques.47
Changing oral health of the elderly population. Ameri-
cans 65 years old and older are the fastest-growing segment
of our population. In 1900, the median age in the United
States was 23 years, and only 4% of Americans were 65 years
of age or older. By 1995, 13% of the population were aged
65 or older, and by 2050, more than 20% of the population
will be 65 years old or older.48 Further, by the year 2020, it
is projected that 60% of hospital admissions and one third
of all medical outpatient practice will be devoted to geriatric
patients.
Estimates of geriatric patients currently in dental practices
range from 25% to 30%. Because of technologic advances
in diagnosis and treatment, many people who in the past
would have succumbed at earlier ages to cancer, cardiopul-
monary disease, immunologic disorders, and trauma are liv-
ing longer, but with an array of chronic medical problems
complicated by physical limitations, mental disabilities, and
polypharmacy. Because senior citizens are losing fewer teeth
prematurely, they conversely will be more at risk for caries
and periodontal disease later in life, leading to less reliance
on the full denture and greater need for other forms of oral
health care to address the needs of the partially edentulous
patient.49 As the over-65 population grows, there will be a
concurrent growth in the number of home-bound frail el-
derly and those living in long-term care facilities. More than
40% of the elderly already reside in long-term facilities at
some point in their lives.50 These individuals will pose a new
challenge for dentists and other health care professionals.
A number of studies have documented a high incidence
of oral disease among home-bound, nursing home, and hos-
pice patients, with almost 20% requiring emergency dental
care.13 Kiyak and McIntyre found that 70% of patients in
long-term care facilities had unacceptably poor oral hy-
1186 ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
giene.51,52 Nurses and nursing auxiliaries in long-term care
facilities are not trained to provide oral hygiene care or to
recognize problems, which is complicated by the fact that
oral hygiene for the elderly is considered an unpleasant task
and thus may be neglected.
Oral Disease–Systemic Disease Relationships
The mouth is a productive incubator for bacteria, viruses,
parasites, and fungi. More than 500 bacterial strains have
been identified in the oral cavity, and 150 strains have been
identified from infections of tooth pulp.53 In spite of im-
munologic mechanisms, pathogens from the mouth can en-
ter the bloodstream or the lymphatic system. Researchers are
now exploring possible relationships between oral infections
and other medical disorders. In addition to the periodontal
infection–diabetes relationship, the two potential oral–sys-
temic relationships that have received the most attention
are those in perinatal morbidity and cardiovascular disease.
Perinatal morbidity. Infant mortality has decreased over
the past 20 years, but the incidence of low-birth-weight in-
fants has not declined despite emphasis on prenatal care.
Approximately four million low-birth-weight infants are
born annually, both preterm and full-term, resulting in a sig-
nificant level of perinatal morbidity, untold emotional dis-
tress among family members, and resource expenditures in
the billions of dollars. Preterm birth and/or low birth weight
is the principal factor in 60% of infant mortality.54 Oral in-
fection has been proposed as a potential cause of prematurity
or low birth weight, perhaps as a sequela of toxins form oral
pathogens that reach the placenta and disrupt fetal growth
and development. Several case–control investigations indi-
cate that pregnant women who have severe periodontal dis-
ease are at higher risk to deliver preterm and/or low-birth-
weight newborns. In one of the few studies to control for
causal factors such as smoking, alcohol use, nutrition, age,
ethnicity, and gastrointestinal tract infection, Offenbacher
found a sevenfold increase in risk for mothers with perio-
dontal disease.55,56 However, more controlled studies are
needed before definitive conclusions can be developed.
Cardiovascular disease. For years, evidence from uncon-
trolled studies, retrospective reviews of national health da-
tabases, case reports, and anecdotal evidence have indicated
that the risks of heart disease may be substantially higher for
persons who have periodontal disease.57 Research interest
has increased in the past decade; for example, the National
Heart, Lung and Blood Institute of the National Institutes
of Health is sponsoring studies of the role played by biofilm-
forming bacteria (which colonize the mouth) in the release
of pro-inflammatory mediators by white blood cells, which
may, in turn, trigger stroke and heart disease. In studies that
adjusted for risk factors such as smoking, hypertension, obe-
 21ST-CENTURY ORAL HEALTH CARE,
sity, diabetes, elevated cholesterol, and family history, there
have been consistent findings that patients with periodontal
disease are 1.5 to 2.0 times more likely to develop cardio-
vascular disease or experience a stroke.58–60 However, a study
that monitored 8,032 subjects in the National Health and
Nutrition Examination Survey Epidemiological Follow-up
Study for 20 years did not identify an independent relation-
ship between periodontal disease and coronary heart dis-
ease.61 A number of investigations of the relationship of oral
infection to heart disease are in progress around the world,
and understanding of that relationship should improve in
the next few years.
Multicultural Environment for Oral Health Care
Dentists in the 21st century will serve the oral health needs
of an increasingly multicultural public as the percentages of
Hispanic, African-American, Asian, and other patients con-
tinue to grow in relation to the Anglo (i.e., non-Hispanic
Caucasian) population. Overall, the growth rate of the U.S.
population had slowed to an all-time low of 10% growth per
decade in the 1990s, compared with 19% in the baby
boomer period of 1946–1966, 15% from 1900 to 1940; and
30% per decade in the 1800s. The net increase in the U.S.
population since 1990 was 19 million, and 67% of this
growth was accounted for by minority populations.48 By
2020, if current birth and mortality rates continue, 40% of
the children and adolescents in the United States will be
members of minority groups, versus approximately 25% in
1980.62,63
Accordingly, many patients will enter the dental office
with different health care beliefs, motivations, and expec-
tations than those held by previous generations of patients,
and providers will experience differences in disease preva-
lences as the patient pool diversifies. For example, African
Americans experience nearly twice the morbidity and mor-
tality from oral cancer that Anglos do.16,64 A variety of stud-
ies have revealed that members of minority populations ex-
perience greater risk for overall health morbidity, including
oral disease, due to language barriers, lack of geographic
proximity to health care facilities, lack of reliable transpor-
tation, lack of health insurance, and particular culturally-
based beliefs about health and illness.65–67 The economic
status of U.S. families is also projected to decline over the
next 50 years. Murdock estimates that the average household
income in 2050 will be $2,000 less than that in 1990 (mea-
sured in 1990 constant dollars). Further, the current income
differences between Anglo, African-American, and Hispanic
households (Anglo = $39,000; African-American = $23,500;
Hispanic = $25,000) will continue to spread over the next
50 years.48 Disparities in dental health between the Anglo
population and elements of the Hispanic, African-American,
ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
and Native American populations and between the econom-
ically advantaged and disadvantaged, without regard to eth-
nicity, parallel the disparities evident in other areas of med-
ical care.13
Access to Dental Care
Overall, in the early 1990s, 9% of the U.S. population,
or 22 million people, reported unmet dental care needs in a
study by the Project Hope Center for Health Affairs, based
on the 1994 National Access to Care Survey by The Robert
Wood Johnson Foundation.68 Eight million more people re-
ported unmet oral health needs than reported medical care
needs that were not met. Seventy-four percent of the indi-
viduals reporting unmet dental care needs considered their
problems to be serious. Ethnicity and socioeconomic status
were strongly associated with the lack of dental care. Twice
as many African Americans (15%) reported unmet oral
health needs as did Caucasians (7.4%). Among those who
wanted dental care but did not get it, 72% reported it was
because they could not afford it, had no insurance, or could
not find a dentist who would accept their insurance.
In the United States, utilization of oral health care ser-
vices and the incidence of oral disease are strongly linked to
dental insurance coverage, particularly for children. Sixty
percent of children have medical insurance coverage
through their parents’ workplace health plans, but only 30%
have dental insurance through their parents’ employers.69,70
Only 20% of Medicaid-eligible children receive any type of
dental care, and only a handful of oral health care services
that might benefit children are eligible for Medicare reim-
bursement.28 Parents report that dental needs are the most
common of all unmet health care needs for their children.71
For adults, dental plans are available from about 60% of
employers, and the majority of these plans are fee-for service.
About 30% of employees receive dental benefits from pre-
ferred provider or health maintenance organizations. The el-
derly typically lose dental insurance benefits when they re-
tire; thus dental care is primarily an out-of-pocket expense
for senior citizens, which may become a significant public
health issue as more and more of our elderly live into their
80s and beyond with their dentition largely intact. Finally,
a critical oral health access issue is availability of a fluori-
dated public water supply. Approximately 60% of Americans
live in communities that provide fluoridated drinking water,
but over 100 million Americans live in communities that
do not, including several large metropolitan areas with sub-
stantial Hispanic and African-American populations and
many rural communities with low-income families that are
underserved by dentists and physicians. The disease-preven-
tion objectives of Healthy People 2010 include increasing
the percentage of Americans with access to fluoridated pub-
lic water supplies to 75% by the end of this decade.72
1187
 21ST-CENTURY ORAL HEALTH CARE,
Oral Health: Summing Up
In summary, the oral health of Americans has improved dra-
matically in the past 50 years thanks to the impressive efforts
of the dental profession and fluoridated water supplies. Yet,
in 2001, substantial dental problems exist in a sizable group
of children, living primarily but not exclusively in low-in-
come communities. We say ‘‘not exclusively’’ because dental
services still account for 25% of all health care expenditures
for children aged 6–18.73 At the opposite end of the spec-
trum, a rapidly growing cohort of elderly patients is con-
fronting dentists and physicians with intertwined dental and
medical problems. Many of the elderly will have no dental
insurance and will reside in extended care facilities that his-
torically have not provided good oral health care services.
For all age groups, child/adolescent, adult, and elderly, dis-
parities in dental status and utilization of oral health care
services are profound between the economic haves and have-
nots of our society.
Education Implications of Contemporary Oral Health
From our perspective as educators, contemporary oral health
in America has four implications for the medical education
and dental education communities:
䡲 The most pressing oral health problems and issues in 2001
are no longer purely dental in nature; they fall into the
overlapping educational and patient care environments of
physicians, dentists, and other health care providers.
䡲 In the 21st century, providing high-quality dental care and
improving the oral health for all segments of society will
be intertwined with public health policy, resource alloca-
tion, and care delivery/access issues. The dental profession
will need to decide whether it wants to become a more
integrated component of the overall health care system
versus continuing the ‘‘splendid isolation’’ tradition of
dental practitioners functioning in relative isolation from
physicians and other health care providers. The dental
profession will also need to decide whether a better foun-
dation in public health policy will provide practitioners
with a broader societal perspective on health care and
more firmly establish prevention as a key role. In one of
the very few office-based observational studies of activities
and services in dental practices, only 2% of the dentists’
time and 6% of the hygienists’ time was devoted to pre-
vention counseling.74
䡲 Tobacco use plays a profound role in many oral health
problems and is the primary contributor to other high-
morbidity diseases. Dentists and dental hygienists are in an
ideal position to play an important role in tobacco-use
prevention and cessation, but have not done so aggres-
1188 ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
sively, in part because of concerns about scope of practice,
infringement on physicians’ responsibilities, and lack of
training.
䡲 The evolving perception of oral health as an integrated
component of overall wellness will exacerbate the dental
profession’s surreal-duality dilemma and fuel the current
debate over curricular emphasis. Should the profession
fully commit to an oral-physician concept or continue to
promote the traditional tooth-doctor role? The bloated
dental school curriculum indicates that both ends of the
duality cannot be accommodated equally. The oral-physi-
cian concept implies an expanded scope of practice beyond
tooth restoration and replacement that may test the
boundaries of professional turf in the head and neck region
with several medical specialties. Will medical professionals
and educators view the oral-physician role as an infringe-
ment on practice or as a resource that can enhance patient
care? On the dental education side of the fence, the tech-
nical and aesthetic traditions underlying restorative den-
tistry and prosthodontics are for many dentists the heart
and soul of the profession and shape the culture of den-
tistry as a unique enterprise. Are dental educators ready to
reconfigure aspects of the curriculum that are deeply in-
tertwined with both the professional identity and the per-
sonal identities of hundreds of thousands of dentists
trained in the United States since the 1950s?
II. DENTAL EDUCATION’S RESPONSE
TO CHANGES IN ORAL HEALTH AND
CURRICULAR-REFORM RECOMMENDATIONS
How has the dental education community responded to the
evolution of oral health over the past 50 years? Tedesco75
documented dental education’s response based on a chrono-
logic review on numerous reports of curricular reforms, be-
ginning with the pivotal 1926 Gies Report, which proposed
recommendations similar to those of the Flexner Report. Te-
desco’s conclusion? The dental education community has re-
sponded to the winds of change with ‘‘some growth, and
little change.’’ The typical dental school curriculum in
1997–98 primarily emphasized caries removal, restoration of
excavated tooth structure, and creation of prosthetic devices
to replace missing or defective teeth in adults, just as it did
in 1950.76
But there is a well-developed agenda of reform. In addi-
tion to competency-based assessment, which is now man-
dated by the accreditation standards of the Commission on
Dental Accreditation, the dental school reform agenda con-
sists of ten recommendations similar to those advocated for
medical schools:
䡲 Decompress the curriculum by eliminating outdated and
peripherally relevant material.
 21ST-CENTURY ORAL HEALTH CARE,
䡲 Increase educational collaboration between dentistry and
the other health professions, featuring more curricular em-
phasis on the interaction of dental and medical problems.
䡲 Redirect basic science course work toward disease patho-
physiology taught by problem-based techniques.
䡲 Expose students to patients and their oral health and sys-
temic medical problems from the first days of the curric-
ulum to the last.
䡲 Revitalize the science underlying clinical decision making
via evidence-based approaches.
䡲 Organize group-practice teams in the clinical years to pro-
mote more continuity in faculty–student relationships and
expand peer teaching by students working together in clin-
ical teams.
䡲 Increase the use of community-based clinics as training
sites for students.
䡲 Include in the final year of the curriculum, or in a post-
graduate internship year, a clinical experience that repli-
cates the comprehensive care environment of the general
dental practitioner.
䡲 Utilize computer-based and Web-based information tech-
nology to enrich students’ learning.
䡲 Rededicate dental school clinics to serving the oral health
needs of the public rather than primarily viewing patients
as educational material for students.
For the most part, these reforms represent ideas advocated
for many years but sporadically implemented. The IOM
study of dental education concluded that
the problem in reforming dental education is not so much
consensus on directions for change but difficulty in overcom-
ing obstacles to change. Agreement on educational problems
is widespread. The curriculum is crowded with redundant or
marginally useful material and gives students too little time
to consolidate concepts or develop critical thinking skills.
Comprehensive care is more an ideal than a reality in clinical
education, and instruction still focuses too heavily on proce-
dures rather than on patient care.10
The dental education reform recommendations, taken col-
lectively, argue for a learning environment that encourages
students to learn collaboratively, provides students with op-
portunities early in the curriculum to practice application of
newly acquired biomedical information by solving patient
problems, fosters longitudinal contact between instructors
and small groups of students, and provides learners with con-
tinuous contact with patients and their health problems
throughout the educational program. These concepts are
consistent with contemporary educational theory and are
based on the inquiry-driven learning that students use to
convert unorganized static information (i.e., data ‘‘sponged’’
from a text or a lecture) into the interlinked chains of net-
ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
worked knowledge (i.e., information that has meaning, utility,
priority, and interconnections to other data) that experts
access to solve problems (see Figure 1).77,78
Advances in PET (positron emission tomography) scan
studies, fMRI (functional magnetic resonance imaging), and
SQUID (superconducting quantum interference device)
have provided neurophysiologists with technology capable of
mapping how the brain functions during complex cognitive,
perceptual, and psychomotor tasks.79 These studies indicate
that expert practitioners (whose knowledge structure is rep-
resented in the bottom panel of Figure 1) have integrated
neural networks that facilitate instantaneous retrieval of
chains of knowledge relevant to task performance or problem
assessment. The novice (whose knowledge structure is rep-
resented in the top panel of Figure 1), confronted with the
same task or problem, struggles in a trial-and-error manner
to assemble isolated bits of information (represented by the
various symbols within the columns) because he or she lacks
Figure 1. How novices and experts mentally structure information they
have acquired from various sources and experiences. Novices’ information,
represented by the top panel, is vertical and compartmentalized. When con-
fronted with a new problem, novices struggle in a trial-and-error manner to
assemble isolated bits of information, represented by the various symbols
within the columns, because they lack pre-existing networks that allow fast
retrieval of pertinent information. Experts, on the other hand (see the bot-
tom panel), have dense interlinking that allows pattern recognition and
rapid retrieval of chains of knowledge relevant to problem solving. This is
known as horizontally networked knowledge. These two structures are also
descriptive of contrasting approaches to health professions education, as
explained in the text. Source: Hendricson WD, Kleffner JH. Curricular and
instructional implications of competency-based dental education. J Dent
Educ. 1998;62:183–96. Used by permission.
1189
 21ST-CENTURY ORAL HEALTH CARE,
pre-existing knowledge chains. Problem-centered, collabo-
rative learning is a strategy that helps novices develop the
knowledge networks needed for expert function.80,81 There is
also a growing belief among cognitive scientists that the
structure and sequencing of information presented to stu-
dents should parallel the way expert practitioners configure
this information for on-the-job performance (e.g., experts
access integrated webs of interrelated data).82
A substantial literature pertinent to the dental education
reform agenda has emerged in the past ten years, including
advocacy papers and implementation reports for compe-
tency-based assessment,83,84 reorganizing the basic science
curriculum,85 evidence-based health care,86,87 problem-based
learning,88–87 information technology,98–100 reforming clinical
education,101–103 and the dentist’s role in the overall health
care system.104,105 The focal point for reform in both dental
and medical education has been problem-based learning
(PBL), particularly for reorganization of basic science con-
tent into multidisciplinary modules based on the organ sys-
tems, blending of clinical and basic science instruction to
enhance relevance, and infusion of active learning into the
curriculum. Assessment of dental education’s response to
PBL suggests why this strategy (which embodies several
items on the reform agenda) and other educational initia-
tives have made only modest inroads.
The literature on PBL in the health professions is exten-
sive, including comprehensive reviews of learning out-
comes.106–110 PBL has a four-decade record of successful im-
plementation, and the ability of students to learn effectively
in well-orchestrated PBL programs is no longer debated by
individuals familiar with the literature. Students in PBL pro-
grams cite the energy of intellectual exchange, sense of per-
sonal involvement, and stimulation of discovery as they col-
laborate to solve the health mysteries of the patient
portrayed in the case. These are expressions of excitement
about learning that stand in stark contrast to commentary
about the tedious monotony of the lecture hall.111,112 Win-
ston Churchill’s commentary on his own education captures
the positive attributes of PBL for many students: ‘‘I hate to
be taught, but I love to learn.’’ 6 Yet, PBL has not captured
the imagination of dental educators to the extent it has been
embraced by medical school faculty.
Four factors may contribute to PBL’s failure to make sig-
nificant inroads.
䡲 First, PBL emphasizes the formulation of a broad-spectrum
differential diagnosis, followed by data collection to rule
out pathogenic options. At its heart, PBL is a detective
game designed to help students identify problems, retrieve
data, and ultimately solve the mystery. The purposes of
PBL are to help students learn to play this diagnostic de-
tective game, learn the normal structure and function of
1190 ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
the human body, and learn the pathogenesis of abnormal-
ities. The detective format of PBL, focusing on diagnosis,
is not ideally suited to the traditional dental school cur-
riculum, which emphasizes the other end of the spectrum
—surgical and restorative treatment.
䡲 The second factor relates to how PBL is used in the dental
curriculum, which, from our perspective, is the most dense
(i.e., numbers of courses and clock hours) and stressful
(i.e., numbers of exams, deadlines and requirements) of all
health professions curricula. Frequently, PBL is added to
the curriculum as a correlation course to help students tie
together basic science and clinical concepts. No free time
is created for students to do research between tutorials;
thus students perceive PBL to be an extra burden.
䡲 Faculty concerns about effort-effectiveness constitute the
third implementation barrier. To strengthen research pro-
grams and offset stagnation in state appropriations, dental
schools are converting teaching positions into research-
oriented positions that hopefully will generate state, fed-
eral, and private funding. The remaining teaching faculty
are expected to devote more of their time to laboratory
and clinical courses. Consequently, department chairs are
hesitant to commit dwindling teaching resources to PBL,
which is perceived to be faculty-intensive.
䡲 The fourth factor relates to the nature of PBL itself. The
back-and-forth, sometimes unfocused dialog that charac-
terizes a dynamic PBL group can appear unproductive to
faculty, who may prefer simply to tell students how to solve
the problem rather than watch them flounder. Faculty dis-
comfort with the facilitator role is evident in all health
professions. But from our experience, it is more prevalent
in dental education because few dental faculty have ex-
perienced PBL as students. The seemingly unstructured dy-
namics of PBL may not fall within the typical dental fac-
ulty member’s concept of learning. In contrast, most
medical school faculty educated in the past 25 years prob-
ably encountered PBL at some point in their training.
Summary of Implementation Barriers to Dental
Education Reforms
The response to PBL mirrors factors contributing to ‘‘some
growth, but little change’’ for other dental education re-
forms. These factors include hesitancy to deviate from the
technical focus of dentistry’s duality, narrow conceptualiza-
tion among administrators and faculty as to what constitutes
learning and teaching, lack of familiarity with alternatives
to traditional lecture/lab instruction, unsuccessful efforts to
add teaching and learning innovations as extra components
to already jam-packed curricula, and perception among fac-
ulty with heavy teaching loads that these reforms represent
extra work for the already overworked. In relation to work-
 21ST-CENTURY ORAL HEALTH CARE,
load, concerns about faculty shortages have escalated to the
point that school administrators are pondering whether they
can continue doing business as usual. Fifty percent of dental
school faculty are more than 50 years old and 40% of the
11,000 full- and part-time faculty will retire by 2010. The
$60,000 income differential between private practice and ac-
ademia has limited the number of new graduates who pursue
university employment and has induced many young faculty
to depart for economically greener pastures. It is estimated
that academic dentistry needs to recruit 150–200 new fac-
ulty per year to maintain pace with current attrition, but in
the past decade an average of only 80 of the 4,100 annual
graduates (2%) have joined dental school faculties each
year.113,114
If this trend continues, dental schools will need to develop
more efficient ways to implement the curriculum, develop
new models of education such as geographic approaches that
pool school resources in a region, identify alternative sources
of faculty such as community practitioners, or scale back the
size of dental education nationally by reducing enrollment
or closing schools.
III. FUTURE DIRECTIONS IN DENTAL EDUCATION
In this section, we review three directions for dental edu-
cation that we predict can enhance the education of dental
students: (1) developing a competency-based curriculum
that may provide a more educationally sound learning en-
vironment and make more efficient use of faculty, (2) blend-
ing dental education into the mainstream of health profes-
sions education by increasing opportunities for clinical
training in multidisciplinary environments, and (3) provid-
ing dental students with stronger training in public health.
Competency-based Curriculum
Stimulated by the adoption of competency-based assessment
as an accreditation standard in 1995, dental schools have
done an admirable job of identifying competencies that stu-
dents should acquire, and many schools are creating evalu-
ation processes to measure these competencies.
However, few dental schools, if any, have attempted to
restructure the curriculum and student learning methods
around actual competency-based principles. From our per-
spective, developing a competency-based learning system is
an important next step in the evolution of dental education.
Hendricson and Smith described the three questions that
faculty must answer to develop a competency-based health
professions education curriculum:
䡲 What knowledge, skills, and professional/personal values
should the student possess at the time of graduation so he
ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
or she will be ready for the next level of training (e.g., a
postgraduate year one) or be prepared to serve as an in-
dependently functioning entry-level general practitioner?
䡲 What learning experiences will enable students to acquire
these competencies?
䡲 How do faculty know whether students have attained
these competencies—what proof, or evidence, is needed
to establish that a student has attained competency? 115,116
A competency-based curriculum (CBC) has three features
that are different from what most health professions educa-
tors have experienced: (1) top-down planning based on anal-
ysis of contemporary and predicted future health care needs
of the public and the associated responsibilities of practi-
tioners in the field, (2) a readiness-based model in which
students advance through the curriculum at different rates
from each other based on their individual capabilities, and
(3) a horizontal curriculum structure in which students pro-
gress through competency modules hierarchically sequenced
by difficulty level, and characterized by tight time proximity
between laboratory learning and clinical experience. A num-
ber of developing nations employ the hierarchical structure
of competency-based education to provide common path-
ways for training health care providers. For example, the
modular curriculum of the School of Oral Health, Fiji
School of Medicine, provides a competency-based ladder
that prepares a student to function as a dental hygienist after
two years, a dental laboratory technician after three years, a
dental therapist capable of performing general dentistry ser-
vices (e.g., tooth restoration, crowns, bridges) after four
years, and a dental surgeon after five years.117
Top-down Planning
Grussing used the term ‘‘top-down planning’’ to convey the
idea that competency-based curricula are derived from the
roles, responsibilities, and frequently performed tasks carried
out by practitioners to address the health care needs of the
public.118 Grussing visualized the public’s health problems
and the associated roles and responsibilities of the care pro-
vider as the top, or pinnacle, of the educational mountain.
Top-down planning leads to what is called a needs-based
curriculum. For example, the Arizona School of Health Sci-
ences, affiliated with the Kirksville College of Osteopathic
Medicine, is planning to open a new needs-based dental
school to address oral disease in Arizona, where 31% of chil-
dren have never been to a dentist and 400,000 children have
rampant tooth decay. As depicted in Figure 2, faculty de-
velop the curriculum by working down from practitioner
tasks and responsibilities to create an interlinked sequence
of learning activities and assessments that prepare students
for these responsibilities. The goal of top-down planning is
1191
 21ST-CENTURY ORAL HEALTH CARE,
to create an efficient pathway for the student that links com-
petencies to subject matter and learning experiences, which,
in turn, are linked to evaluations that measure performance
of these competencies. The outcome is a series of hierarchi-
cally-arranged learning modules that start with universal
foundation material (e.g., the building blocks for all subse-
quent learning) and progress sequentially through more so-
phisticated competencies.
In contrast, most faculty in health professions education
are familiar with only bottom-up planning, which has been
the standard operational model for 20th-century higher ed-
ucation. In bottom-up planning, certain pre-matriculation
courses are accepted by tradition as being suitable prereq-
uisites for entry into the professional program. Various
courses are superimposed on top of these prerequisites, with
each discipline building its own column of courses indepen-
dent of other specialty areas, resulting in a silo curriculum
that resembles the top panel of Figure 1. In the silo curric-
ulum, basic science, behavioral science, and clinical disci-
plines train students independently (e.g., operate their own
autonomous mini-curricula) with no planned cross-fertiliza-
tion. When all courses in each of the discipline-based silos
1192 ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
Figure 2. Contrasting approaches to curriculum
planning used in competency-based education (the
top-down panel) and discipline-based education
(the bottom-up panel). Sources: Grussing PG. Cur-
ricular design: competency perspective. Am J
Pharm Educ. 1987;51:414–9. Hendricson W, Cohen
P. Future directions in dental school curriculum,
teaching and learning. In: Leadership for the Fu-
ture: The Dental School in the University. Washing-
ton, DC: Center for Educational Policy and Re-
search, American Association of Dental Schools,
1999.
are passed, the student graduates. The assumption is that
students, by their own devices, will assimilate, retain, and
integrate the information from all these courses, and thus
become competent, with minimal outside assistance.
Looking at health professions education overall, the silo
approach is the prevailing model. At most academic health
centers, each of the individual professions autonomously op-
erate curricula with minimal planned interaction (although
students from different programs may bump into each other
by accident because they happen to be assigned to the same
facility). The Institute of Medicine–National Academy of
Science report, To Err is Human: Building a Safer Health Care
System, examined the reasons for preventable patient-care
errors and accidents that contribute to 50,000–100,000
deaths and several hundred thousand near-misses annually
within health care facilities.119 Among many contributing
factors, four educational conditions were identified: (1) the
silo curriculum model does not provide multidisciplinary
training that reflects workplace realities (IOM recommen-
dation: ‘‘Train in teams those who will work in teams’’); (2)
because of reliance on memorization during training, health
professions education produces entry-level practitioners with
 21ST-CENTURY ORAL HEALTH CARE,
poor knowledge integration, poor vigilance for potential er-
rors, and inadequate coping skills when problems occur; (3)
entry-level practitioners lack training in information man-
agement systems and thus rely on memorization when on
the job; and (4) there is a lack of opportunity to practice
problem solving during training and on the job.
In summary, bottom-up planning, which typically pro-
duces a silo curriculum, helps faculty answer the question,
What do we want to teach students about our respective
areas of specialization? In contrast, top-down planning en-
courages faculty to answer these questions: What must our
graduates be able to do so they can function as entry-level
general practitioners without direct supervision and coach-
ing? Or, what must our graduates be able to do so they can
provide patient care at the next level of professional train-
ing, and benefit from educational experiences at the next
level?
Readiness-based Model
In a traditional time-based curriculum, it is assumed that
spending a fixed number of years in training will ensure com-
petency. In the readiness-based model of the CBC, students
proceed through the educational program at different rates
depending on individual capabilities. No arbitrary fixed time
in training is set in the CBC. In other words, a student
remains in training until he or she has successfully satisfied
the requirements of competency assessments that document
the ability to use designated skills in patient care without
assistance. In the CBC, students and instructors jointly de-
termine student readiness for competency assessments during
which students perform without coaching and assistance by
faculty. One student could be ready after two or three patient
encounters, while another may require six or seven learning
experiences to fine-tune the necessary patient care skills, as-
sisted by the coaching, feedback, and modeling of faculty.
A CBC is also not repetition-based. In contrast to a read-
iness-based approach, in the traditional model of dental ed-
ucation, as evidence of clinical competence students are re-
quired to successfully complete within calendar deadlines
required numbers of repetitions of a wide range of dental
procedures, involving various types of amalgam, gold, and
composite restorations, crowns, dentures, root canals, ex-
tractions, quadrants of periodontal scaling, etc. In this sys-
tem, students’ behaviors in the dental school clinic often
revolve around finding patients who have oral health prob-
lems that allow them to perform required repetitions of the
designated dental procedures. The requirement system has
been criticized for creating an environment in which stu-
dents are encouraged to place their own training needs
ahead of patients’ health care needs (e.g., talking a patient
into undergoing a procedure the student needs to perform,
but the patient may not need).120 However, several studies
ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
have demonstrated that dental students operating without
requirements are just as productive as or more productive
than peers in a requirement-driven system, receive an
equally diverse clinical experience, perform as well or better
on various indices of clinical performance, and report lower
levels of stress.101,121–124 The use of absolute numbers of pro-
cedure repetitions as a marker of students’ competence, and
equating time in training with readiness to practice, are an-
tithetical to competency-based assessment.
Horizontal Curriculum Structure
Competency-based curricula are structured differently from
discipline-based curricula. A bird’s-eye view of a traditional
discipline-based dental or medical curriculum looks like the
top panel of Figure 1, a series of silos representing the courses
of autonomous disciplines. In contrast, Figure 3 depicts a
bird’s-eye view of a competency-based curriculum, derived
from training models in the military and industry.125 In a
CBC, students are evaluated before matriculation for their
adaptability to the learning and assessment methods em-
ployed in a competency-based program. After matriculation,
students participate in additional assessments to pinpoint the
appropriate starting point for each student.
Most but not all students begin with a foundations phase
where they learn patient care skills and biologic science con-
cepts that serve as the universal underpinnings for all other
areas of performance. Students have opportunities to apply
these foundations by working with patients during the foun-
dations phase.
The foundation biologic sciences courses for a compe-
tency-based health professions curriculum should be struc-
tured differently from traditional discipline-based basic sci-
ence courses. In the process of consulting with dental and
medical schools over the past ten years, the senior author
(WDH) has interviewed more than 200 community practi-
tioners and analyzed survey data from hundreds of residents
who were requested to look back at their education. Prac-
titioners and residents have a consistent vision of how they,
from an educational consumers’ perspective, would like to
see the biomedical sciences structured. This vision is dra-
matically different from that reflected by the educations
these individuals received. In the traditional silo curriculum,
course directors organize their courses chronologically, topic
by topic, from day one to the final examination (e.g., ver-
tically) to introduce the subject matter to students in a log-
ical progression for that particular topic. And indeed, most
courses are well organized within the contexts of their par-
ticular silos in the overall curriculum. However, students ex-
perience the curriculum in a different manner as they try to
make sense of information communicated in four to six con-
current courses taught back to back, hour by hour, in a single
1193
 21ST-CENTURY ORAL HEALTH CARE, CONTINUED

Figure 3. Structure of a com-

petency-based curriculum for a
health professions education
program. Source: Hendricson
W, Cohen P. Future directions
in dental school curriculum,
teaching and learning. In:
Leadership for the Future: The
Dental School in the University.
Washington, DC: Center for Ed-
ucational Policy and Research,
American Association of Dental
Schools, 1999.

day (e.g., horizontally, across discipline silos). To illustrate
this point, here is a list of the topics students encountered
on a single day during the freshman year at a well-respected
dental school with a discipline-based curriculum.
䡲 From 8 to 9 AM: Pharmacology—diuretics
䡲 From 9 to 12 AM: Gross anatomy—neuroanatomy of basal
ganglia
䡲 From 1 to 3 PM: Physiology—gastrointestinal motility
䡲 From 3 to 4 PM: Microbiology—specific immunity
䡲 From 4 to 5 PM: Biomaterials—metallurgy
Each course was well organized internally, but what is the
impact on the learners as they attempt to make sense of
fragmented and uncoordinated bits of information from five
or more courses, each conducted independently? And this
process occurs day after day throughout the curriculum.
In contrast to the approach depicted above, dental school
graduates prefer what they frequently called a ‘‘lined-up’’ cur-
riculum that coordinates morphology, anatomy, physiology,
pathology, and treatment both for the head and neck region
(craniofacial) and for the organ systems of the human body.
Such a curriculum is arranged horizontally by broad related
topics; for example, development (growth); structure (what
is it? where is it?); function (how does it work?); pathology
(what goes wrong?); and therapy (how to treat it?).126 This
lined-up approach to curriculum organization is conceptually
similar to the knowledge networking (often described as hor-
izontal linkage) that apparently serves as the underpinning
for the development of expertise.

1194 ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001

 21ST-CENTURY ORAL HEALTH CARE,
The 1999–2000 AAMC Curriculum Directory indicates
that more than 100 U.S. medical schools (roughly 70%)
have implemented an approximation of the horizontally
lined-up model (e.g., thematically integrated versus purely
discipline-based courses) for either the first year or the sec-
ond year, or the bulk of both years. In contrast, integrated
basic science curricula in North American dental schools are
rare. Forbes found that 90% of the associate deans for aca-
demic affairs endorsed the concept, but only ten schools op-
erated curricula that blended basic science courses to-
gether.127
After completion of competency tests to certify acquisi-
tion of the biological and clinical foundations, CBC students
move through a hierarchy of learning modules that provide
learning experiences and assessment for increasingly com-
plex competencies, in a building-block approach. An im-
portant feature of the hierarchical CBC model is that inter-
related preclinical experiences (e.g., developing basic
technical skills in a laboratory) and clinical experiences with
patients both occur within learning modules throughout the cur-
riculum rather than via the traditional system of limiting lab-
oratory work to the first half of the educational program and
clinical work to the third and fourth years.
Thus, it is possible that even students in the final phase
of the curriculum may spend time learning new skills in a
laboratory. On the first day of the laboratory, students are
assembled into learning teams (often called learning
‘‘squads’’ per the squad concept in military applications of
CBC) of six to eight students led by an instructor (team
leader) who is assisted by one or more senior students who
serve as teaching assistants (TAs). The squad of students,
instructor, and TAs work together every day in the lab and
also move together from the laboratory into the clinic to
ensure continuity of learning between laboratory and clinic.
The key to the horizontal CBC format is the continuous
relationship of an expert practitioner with a small group of
novice learners in the tradition of the artisan–apprentice
training model perfected during the 15th- and 16th-century
Renaissance by the masters of various craft guilds. When
students test out of the laboratory phase of the module, they
move into the clinic and perform the procedure on patients,
with coaching and feedback from the team leader and TAs,
within days of passing the laboratory competency examina-
tion. Competency assessment in the clinical phase of the
module is accomplished by the triangulation method, which
consists of three measurements of different aspects of com-
petence: assessment of the student’s ability to perform pro-
cedural skills, a case-based written assessment of the student’s
ability to use knowledge to make patient care decisions, and
the team leader’s overall assessment of the student’s perfor-
mance, including patient management, ability to commu-
nicate biomedical knowledge, technical skills, and profes-
sional demeanor.
ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
Upon successful demonstration of competency, students
enter a new module where they are reorganized into new
learning squads, meet new instructors and TAs, and repeat
the process. However, in some CBC formats, the learning
squad remains intact for several competency modules, de-
pending on the expertise of the team leader. Students who
do not demonstrate competency repeat the module. The ul-
timate layer of the curriculum is an extended period of com-
prehensive practice, involving all competencies. To gradu-
ate, during the final curriculum layer students must
successfully complete competency examinations that mea-
sure key skills and the ability to demonstrate professional
values when interacting with patients.
An educational advantage of the CBC is the tight time
relationship between laboratory simulation and use of these
skills during patient care. In the traditional dental curricu-
lum, six to 12 months may elapse between a student’s lab-
oratory experience and performance of the learned proce-
dures in the clinic. The literature on acquisition and
maintenance of complex procedural skills indicates that per-
formance erodes within several weeks if the skill is not con-
tinuously practiced and fine-tuned by self-assessment and in-
structor coaching.128 The CBC learning squad structure
would also alter the management of patients within the
clinic. In most dental school clinics, patients are assigned
directly to students, not to clinicians serving as faculty. Fac-
ulty basically serve as evaluators who inspect the students’
work at various points in the treatment process and assign
grades. Thus, dental students primarily encounter clinicians
as checkers rather than as mentors and rarely observe faculty
in a care-provider role. Instead of seeing faculty as role mod-
els and teachers, dental students have historically focused on
the gatekeeper (grader) role of clinician faculty. This pro-
duces a higher level of guarded, hunkered-down behavior
among dental students than we have observed among stu-
dents in other health professions education programs. In
contrast, the faculty leader of each CBC learning squad
would assume responsibility for patient management and
would coordinate the diagnostic and therapeutic activities of
the squad, providing some care also, especially early in the
module, and assigning other tasks to students and/or the se-
nior TAs working with the squad.
Competency-based Curriculum: Time and
Resource Efficiencies
A competency-based format may alleviate two other prob-
lems in dental education: escalating student indebtedness
and faculty shortages. Research on the CBC indicates that
the readiness-based model allows learners to proceed through
training faster than does the traditional time-based ap-
proach.80,129 Some medical residency programs have adopted
the readiness-based CBC and report faster learner pro-
1195
 21ST-CENTURY ORAL HEALTH CARE,
gression toward competence. For example, neurosurgery
residents at Johns Hopkins mastered a variety of complex
competencies from three to 18 months faster after imple-
mentation of a CBC format.130 Implementing a training sys-
tem in which students can graduate in a shorter time frame
will obviously ease the students’ financial burden and pro-
vide resource economies for the institution.
Because of the squad-continuity concept, competency-
based programs typically do not use the FTE (full-time
equivalent) coverage approach in which several instructors
fill one faculty slot in the clinic during the week. In the
CBC, one faculty member is assigned full-time to each learn-
ing squad that moves as a unit through the clinical modules.
Senior students provide the primary instructional support for
the team leaders rather than faculty. For example, a CBC
class of 100 would consist of approximately 14 teams and
require full-time teaching commitment from 14 instructors
plus a couple of rovers. In our experience, a typical clinic
week for 100 students in a traditional curriculum might be
staffed by up to 25 different faculty from the various de-
partments. Because of the full-time dedication of one in-
structor to a squad of students, CBC staffing is lean and
mean in comparison with conventional approaches. Of
course, the down side is that certain faculty are designated
as full-time teachers and have no time for other academic
activities. Therefore, the CBC requires modification to the
triple-threat approach to promotion and tenure to avoid
placing competency team leaders in jeopardy.
A 21st-century Curriculum Model for Dental Education
A number of medical schools structure their curricula in the
AM – PMformat (i.e., morning and afternoon), which is a
Table 2
Thematically-based Biological Science Units in Proposed 21st-century Dental School Curriculum
Biological Science Thematic Units
Development, structure, function, and abnormalities of cells, tissues,
and organs
Normal and abnormal development, structure, and function of the oro-
facial complex
Normal and abnormal biology of oral cavity (pathogens and immune
response)
Assessment, prevention, and treatment of abnormalities of the orofacial
complex, including oral–systemic disease links
Pharmacologic agents
Source: Hendricson W, Cohen P. Future directions in dental school curriculum, teaching and learning. In: Leadership for the Future: The Dental School in the University.
Washington, DC: Center for Educational Policy and Research, American Association of Dental Schools, 1999.
1196 ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
viable format for the foundations phase of a competency-
based dental school curriculum.131 In the AM – PM model,
eight of the ten half-day blocks during the week are sched-
uled for learning experiences and two half days are unsched-
uled. In the morning, thematically integrated basic science
courses are conducted four days a week (blocks 1–4). During
two afternoons, students meet in PBL groups from 1 to 3 PM
to analyze cases that require application of concepts derived
from the biologic science instruction (blocks 5–6). The re-
mainders of these afternoons are unscheduled so students can
research questions arising during the PBL sessions. On a
third afternoon, students participate in a physical assessment
lab to learn patient examination pertinent to an anatomic
area or pathologic mechanism addressed at that point in the
curriculum (block 7). Students spend a half day per week at
a clinical site assisting third- or fourth-year students with
patient examinations (block 8).
In our vision of the 21st century dental school curriculum,
four half-day blocks in the morning will be devoted to the
biologic science units depicted on the left side of Table 2.
The titles of the numerous courses that traditionally com-
prise these thematic units are indicated on the right side of
the table. Each thematic unit will employ an integrated
cross-disciplinary approach based on the lined-up horizontal
structure. The four half-day PM blocks will be devoted to a
PBL integration session (block 5) to help students pull to-
gether biologic principles and three blocks devoted to foun-
dation patient care skills (blocks 6–8; 12 hours per week).
In addition to learning foundation dental skills, we recom-
mend that dental students also learn how to take a full med-
ical history and conduct a comprehensive head-to-toe phys-
ical examination. Patients with oral disease and common
medical comorbidities such as arthritis, cancer, cardiovas-
Dental School Courses That Traditionally Comprise Each Thematic Area
Gross anatomy, microscopic anatomy, neuroanatomy, general pathol-
ogy, physiology (pathophysiology), biochemistry
Gross anatomy/embryology, growth and development, dental anatomy,
pediatric dentistry, occlusion, orthodontics, TMD, craniofacial abnor-
malities, oral diagnosis, radiographic interpretation
Microbiology, biochemistry, cariology, oral pathology, immunology, peri-
odontics, nutrition, prevention, endodontics, oral diagnosis
Oral diagnosis, oral pathology, preventive dentistry, community den-
tistry, public health, clinical medicine, periodontics, other clinical spe-
cialties
Pharmacology, neuroscience, biochemistry
 21ST-CENTURY ORAL HEALTH CARE,
cular disease, and diabetes should serve as physical assess-
ment subjects. Interviewing and examining individuals who
have active disease, at the same time as taking pathophy-
siology course work, will allow dental students to see the
clinical presentations of medial conditions and demonstrate
the intermingling of dental and medical problems. By the
middle of the spring semester, first-year students should assist
upperclassmen two half days a week and have a weekly half-
day preceptorship in a hospital-based dental clinic where the
interplay of patients’ medical and dental problems is evident
and students can encounter a primarily geriatric patient pop-
ulation.
As depicted in Appendix A, we recommend dividing each
clinical year into four ten-week competency modules, with
two-week mini-modules scheduled after modules one and
three for focused pursuit of elective topics. Two of the six
mini-modules in the second, third, and fourth years should
address health services research and require the student to
conduct an evidence-based investigation of an oral health
topic. For the remaining four mini-modules, the student can
choose from an additional research topic, clinical experi-
ences in dental or medical subspecialties, comprehensive
dentistry in a community setting, or a rotation in the
school’s walk-in emergency clinic. One of the ten-week com-
petency modules should be devoted to pubic health, with a
community service component and completion of an evi-
dence-based research project. Fourth-year students will also
serve one day per week as TAs in the foundation skill labs
for first-year students or as TAs in lower-level competency
modules. The competency modules in the second, third, and
fourth years should be arranged in a stairstep continuum that
allows the student to progress through basic skills underlying
many areas of clinical care before progressing to more com-
plex competencies. To stimulate thought, particularly among
dental educators, a hypothetical clinical module sequence is
proposed in Appendix B.
Blending Dental Education into the Mainstream
of Health Professions Education
The IOM Report on Dental Education recommended that
‘‘dental educators should work with their colleagues in med-
ical schools and academic health centers to require and pro-
vide for dental students at least one rotation, or clerkship,
or equivalent experience in relevant areas of medicine, and
offer opportunities for additional elective experience in hos-
pitals, nursing homes, ambulatory care clinics, and other
settings.’’ 10 The IOM report also recommended that dental
school faculty should have sufficient experience in clinical
medicine that they—and not just physicians—could impart
core medical knowledge to dental students and be clinical
role models to students in regard to recognition and appro-
priate responses to medical disorders in patients.
ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
Our view is that the dentist is a health care provider who
has received specialized training in assessment and treatment
of diseases and abnormalities of the orofacial complex, an
anatomically and functionally-defined region similar to the
anatomic or functional parameters that establish practice do-
mains for other medical specialties and subspecialties. The
key question is: Should the education of the orofacial spe-
cialist be better assimilated with the training for students
preparing for careers in other areas of medical specialization?
A number of factors indicate to us that the answer is ‘‘yes.’’
As we have seen, numerous high-morbidity diseases and ab-
normalities of the orofacial complex can benefit from mul-
tidisciplinary prevention and treatment. For example, ad-
vances in microbiology suggest that reducing maternal
reservoirs of mutant streptococci, preventing transmission of
bacteria from mothers to infants, and enhancing the child’s
resistance to bacterial implantation are viable approaches to
primary caries prevention.29 Implementing those preventive
measures and educating the public about the infectious
transmission of caries requires teamwork between pediatri-
cians, dentists, and public health workers.
In addition, the growth in the number of elderly patients,
with medical and dental comorbidity, will place dentists and
physicians in more frequent collaboration to coordinate
treatment for this population. Research in molecular biology
and investigation of the genetic basis of disease have tran-
scended traditional disciplinary boundaries, blending the ef-
forts of dental and medical investigators with the expertise
of basic scientists. Access to the Internet and other sources
of health information has enhanced public awareness of dis-
ease processes, medications, non-pharmacologic therapies,
diet and fitness, and alternative medicine, which places pres-
sure on all health care providers to stay abreast of develop-
ments across a broad spectrum of biomedical knowledge.
And finally, academic health centers (AHCs) are strug-
gling to determine the winning combination that will enable
them to compete in the marketplace. Many AHCs hope to
entice patient enrollment by assembling attractive packages
of multidisciplinary service teams. Given the uncertainties
of core financing for university-operated clinics, dental
school administrators now understand the need to demon-
strate the value-added potential of the dental school clinic,
within an overall spectrum of health care services.132 The
Blue Ridge Academic Health Group, a component of the
University of Virginia Health Policy Center, which consists
of academic health professionals, sociologists, economists,
and businessmen, advises AHC administrators who are re-
configuring organizational structures to enhance economic
viability. The Blue Ridge Group recommends that ‘‘AHCs
must base their management structures and programs on the
collective enterprise. Individual components of AHCs that
perceive themselves as independent and isolated must come
1197
 21ST-CENTURY ORAL HEALTH CARE,
to view themselves as an integral part of a common enter-
prise, and must commit to collaborative accomplishment of
common goals and objectives.’’ 133
If there are substantial reasons for blending the education
of dentists with that of physicians-in-training, how can this
be accomplished? The IOM recommendation to add a med-
ical clerkship to the dental curriculum is problematic. Clerk-
ship directors are hard pressed to locate training sites and
adequate numbers of university-based or community physi-
cians for their own students, so adding dental students to
the clerkship mix is doubtful. However, there are other ways
to diversify the dental students’ clinical experience and in-
crease interaction with other health professionals. The 21st-
century curriculum proposed in this article has three mech-
anisms to accomplish these goals.
䡲 First, the whole-body physical assessment in the founda-
tions phase will alert students to the interplay of oral and
systemic diseases while they are learning about pathophy-
siologic mechanisms and will encourage students to view
patient health holistically, not just from the perspective of
the oral cavity.
䡲 Second, the 21st-century curriculum should include a ten-
week multidisciplinary health care module in the second
year that focuses on five areas where dentists and other
health care professionals will increasingly interact in the
future: ear, nose, and throat; oncology; hospital-based den-
tistry; pediatrics; and geriatrics (two-week rotations in
each area). It is particularly important to provide dental
students with experiences in the hospital environment and
with elderly patients early in the curriculum. Many dental
schools already have rotations in hospital dental clinics,
but usually at the end of the curriculum. An early hospital
rotation will provide students with patient care experi-
ences that blend oral health and internal medicine. The
hospital dental service is also the environment in which
students are most likely to observe dentists functioning in
an oral-physician role. The geriatrics rotation should in-
clude home visits with the elderly. For example, first-year
medical students at the University of Texas Health Sci-
ence Center at San Antonio meet ‘‘senior professors’’ who
are geriatric volunteers willing to share their life experi-
ences and medical histories with students.134 During years
three and four of clinical training, dental students should
also provide care to elderly patients at long-term care fa-
cilities.
䡲 The third mechanism for diversifying the dental students’
education comprises the mini-modules, which can provide
cross-disciplinary experiences in many areas: genetically-
based craniofacial anomalies, maxillofacial prosthetics, dis-
orders of the temporomandibular joint, reconstructive sur-
gery for facial trauma, HIV infection, substance abuse,
1198 ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
psychosocial–behavioral issues, and community-based pre-
vention services.
Although it is not the focus of this article, we believe that
residents in the medical primary care disciplines, particularly
pediatrics and family medicine, should receive expanded
training in oral health assessment and prevention. Pediatri-
cians and family physicians see children regularly, but they
typically receive rudimentary training in oral health issues
in their residency programs.135 The situation is complicated
by the fact that there are only 3,500 pediatric dentists in
the United States, and most general dentists practicing today
received very limited training in providing dental care for
infants and young children.15 To address this gap in oral
health care for children, Mouradian recommends that phy-
sicians training to be primary care providers should learn oral
health assessment techniques, learn how to provide caries
prevention counseling to children and parents, and learn
basic techniques for caries control such as applying fluoride
varnishes.15 We recommend that the third-year family med-
icine clerkship include a rotation in an oral diagnosis screen-
ing clinic where medical students can work up patients (who
typically have plenty of systemic disease) in conjunction
with dental school peers. The third-year pediatrics clerkship
should include a module on oral health, and medical stu-
dents should learn how to assess a child’s oral health status
as part of the routine physical assessment protocol.
Building Alliances for Multidisciplinary Education
Medical–dental school alliances exist now, which suggests
that the obstacles are not insurmountable. Medical school
anesthesia and surgery departments cooperate with oral sur-
gery in support of predoctoral and graduate training, includ-
ing DDS—MD dual-degree programs. Dental and medical
faculty collaborate in the research and teaching activities of
federally-funded geriatrics education centers and provide
joint staffing for university-operated extended-care centers.
Clinical research centers for craniofacial disorders and max-
illofacial prosthetics include dentists and physicians. Several
dental schools provide four- to six-week hospital externships
for their students.
From our perspective, four strategies for cross-disciplinary
alliance building are available: (1) cross-appointment of den-
tal and medical school faculty in areas with overlapping in-
terests such as pediatric dentistry with medical pediatrics,
general dentistry–community dentistry with family and com-
munity medicine, and periodontics with internal medicine;
(2) budget re-direction in which schools purchase the ser-
vices of other AHC components, a model already used by
dental and medical schools to implement the basic science
curriculum; (3) collaboration of medical and dental schools
 21ST-CENTURY ORAL HEALTH CARE,
in recruitment of dual-degree faculty who have the breadth
of training and experience to teach in both schools; and (4)
service exchanges in which departments support each other’s
educational program in repayment for clinical services. For
example, the dental school provides staffing and equipment
for the medical school’s mobile health vans in exchange for
the medical school’s providing slots for dental students in
clinical electives, or vice versa.
Expanded Focus on Public Health and Tobacco-use
Prevention–Cessation
During the third year of the 21st-century curriculum, stu-
dents should complete a public health competency module
that features field investigation of community health prob-
lems, training in evidence-based literature review, and pre-
sentation of an evidence-based research report. The nature
of oral disease in the 21st century and the demographics of
populations in greatest need of dental services suggest to us
that the dental education community should carefully con-
sider the long-term value-added potential for the profession
and for the public of providing more joint DDS–MPH de-
gree tracks at dental schools, and also perhaps establishing
a national goal to graduate a certain percentage of students
with the DDS–MPH package (for example, 25% of gradu-
ates by 2025). With proper scheduling, a student should be
able to complete a dual degree in five years with summer
work, especially if a readiness-based CBC is implemented.
Dental students should receive enhanced education about
tobacco use and its associated health problems and receive
training in tobacco prevention and cessation techniques.
The American Dental Association has advocated a more
proactive role in tobacco prevention and cessation for its
members, and models have been developed for education of
dentists-in-training and community practitioners.136–138 Be-
cause of the dentist’s focus on the oral cavity, where signs of
smoking are obvious and effects are profound, it seems to us
that the dental profession can be a first line of defense
against this insidious practice, a new and critically important
disease prevention role for the profession.
IV. SOCIOLOGY OF CHANGE IN HEALTH
PROFESSIONS EDUCATION
After assessing the wreckage of a failed attempt to revise the
curriculum, a medical school dean captured the challenge of
reform, ‘‘It is not enough to have good ideas. Other factors
are much more powerful.’’ 139 Goffee, Berquist, and Schein
studied university culture and faculty values as the basis for
analyzing adaptability to change.140–142 They observe that
university faculty value independence and autonomy, do not
value collaboration, but have a strong need for job security
ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
and insulation from risk. Goffee envisions the organizational
culture of an institution as a matrix with two axes, a vertical
one representing solidarity (cohesiveness of purpose among
organization components), and a horizontal one representing
sociability (interpersonal relationships among persons in the
organization). The levels of solidarity and sociability can be
high (strong solidarity and much sociability) or low (weak
solidarity and minimal effort at sociability). Goffee con-
cludes that ‘‘university faculty, identifying more strongly with
their disciplines than with the university itself, typically lack
solidarity. Their interpersonal relationships (sociability) may
be distant as well, placing the university low on both soli-
darity and sociability,’’ thus making the university culture
particularly resistant to change.140
Dentists have been described as cautious, conservative,
valuing order and conformity, with a desire to control
events.143 Not surprisingly, the independent yet cautious na-
ture of the faculty is reflected in the organizational structure
of dental schools, most of which operate under a decentral-
ized states’-rights philosophy that encourages autonomous
action by departments, an organizational structure similar to
that of most medical schools. Ebert and Ginzberg describe
medical schools as a confederation of semi-autonomous fief-
doms that seemingly exist to compete with each other for
treasure (institutional resources), territory (office, laboratory,
and clinic space), and political influence (curriculum
time).144 Just as when Julius Caesar observed, as he stood on
the banks of the Rhine gazing at the first bridge to span the
river from Germania into Gaul (France), that ‘‘most cer-
tainly, commerce will follow this means of transportation,’’
so also curriculum most certainly follows the school’s orga-
nizational chart.145
Given these factors, resistance to change in the university
environment is the norm rather than the exception. Dental
education is not alone in its inability to institute meaningful
reforms. Samuel Bloom’s classic discussion of resistance to
change in medical schools reviewed the myriad efforts since
1920 to improve medical education and observed that the
process was characterized by ‘‘reform without change.’’ 146
This conclusion was echoed by Christakis, who assessed the
marginal impact of 19 national-level efforts to reform med-
ical education.147 Bloom and Christakis both identified or-
ganizational structure and the cultural environment of the
institution as the major barriers to educational revitalization.
The process by which educational institutions respond to
changes in policy, resource allocation, or structure is pre-
dictable. Reform efforts in institutions with complex infra-
structures proceed through the following phases:
䡲 Denial: A self-protective state to avoid being overwhelmed
䡲 Resistance: Mourning and distress; passive-aggressive resis-
tance
1199
 21ST-CENTURY ORAL HEALTH CARE, CONTINUED

䡲 Acceptance: Inevitability of impending change is recog-
nized
䡲 Bargaining: Attempts to piecemeal or sequester the new
plan
䡲 Exploration: Future-focused thinking about how to inte-
grate the new plan into the mainstream of the institution
䡲 Commitment: Proactive efforts to make the new plan work
effectively
䡲 Comfort: The plan is no longer ‘‘new’’ but is perceived as
routine and ‘‘our way’’ 148,149
Most reforms fail to move beyond the denial or resistance
stages, particularly when they are not provoked by a galva-
nizing event that reflects poorly and publicly on the insti-
tution (for example, poor board scores, a high student attri-
tion rate, or media reports of faculty unhappiness). Reforms
may reach the bargaining stage if leadership persistently fo-
cuses attention on the problem and articulates a viable so-
lution (e.g., a new organizational reality), a process known
as reality framing.150 Levine identified enclaving and piece-
mealing as particularly effective and frequently-used bargain-
ing strategies that block educational innovations.149 Reforms
often are enclaved, or quarantined, as detached programs
that sequester reformers away from conventionally-minded
faculty, and limit disruption of standard operations. Quar-
antined programs typically wither when reformers depart or
assume new responsibilities. In piecemealing, departments
adopt only the components of reform packages they can live
with and ignore less agreeable aspects. Departments will en-
clave and piecemeal until they reduce reforms to small com-
ponents that have negligible impact on departmental struc-
ture and operations, a minimalization process leading to
reform without change.
Noer developed a model to assess the likely response of
an organization to a reform initiative.151 Noer’s response-fac-
tor model categorizes organizations along two dimensions—
capacity for change and comfort with change. Dental schools
can best be described as ‘‘entrenched’’ organizations, with
high capacity for change, but low comfort with change. En-
trenched organizations respond to change by blaming and
complaining, acknowledging the need to change but resist-
ing efforts to modify philosophy, structure, and operations,
working harder at previously successful behavior patterns,
and riding it out until things return to normal. We believe
dental schools must aspire to become what Noer categorizes
as ‘‘learning’’ organizations, which have high capacity for
implementing change and high comfort with the processes
necessary to support and maintain innovation. Learning or-
ganizations respond quickly to challenges and deficiencies by
developing new strategic directions, focusing on solving
problems rather than casting personal blame, and accepting
short-term setbacks in exchange for long-term enhancement
of operations. As Peter Drucker states, ‘‘One cannot manage
change. One can only be ahead of it.’’ 152
The literature on organizational change in health profes-
sions education indicates that the chief executive officer
(CEO) is ‘‘the straw that stirs the drink.’’ Bland and col-
leagues reviewed the literature reporting curricular change
strategies and outcomes in higher education and identified
35 factors that contribute to successful reform.153 Bland
grouped these success factors into 13 categories such as or-
ganizational structure, scope of the innovation, and leader-
ship. Of these factors, leadership stood out. ‘‘Leadership
comes up again and again as critical to the success of cur-
ricular change because the leaders control or substantially
influence nearly all the features essential for success.’’ With-
out strong CEO leadership, clear vision of a different but
desirable future, persistent promotion of the vision, excellent
behind-the-scenes organization, and willingness to face
down obstructionists, true reform is not likely to occur.
Deans must resist what Lencioni refers to as leadership temp-
tations, with the foremost temptations being (1) the equa-
tion of personal popularity with successful management and
(2) focusing on personal achievements rather than organi-
zational results as indicators of performance.154 Instead, Len-
cioni contends that CEOs should make institutional out-
comes the most important measure of their own personal
success, organize and manage faculty in ways needed to
achieve desired results, work for the long-term respect of
faculty as opposed to their affection, and take decisive ac-
tion. The associate deans who work with the dean must
share these leadership abilities and wholeheartedly support
the vision. Several universally respected faculty leaders must
also share the vision, have the same passion for making im-
provements, and be willing to stick their necks out among
peers to endorse what may be unpopular recommendations.
Evaluation of curricular innovation projects at eight medical
schools funded by The Robert Wood Johnson Foundation
indicates that a bookends approach to leadership (dean and
associate deans on one side; respected faculty leaders on the
other) is vital to success.155,156
CLOSING OBSERVATIONS
Faculty development and reconsideration of organizational
structure will be key ingredients in whatever direction dental
and medical education take in the next 20 years, indepen-
dently or jointly.
Faculty Development
Most dental schools have operated discipline-based curricula
for decades (year 1 = basic science lectures with a few pre-
clinical labs; year 2 = preclinical labs, a few basic science

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 21ST-CENTURY ORAL HEALTH CARE,
courses, and a get-ready-for-clinic experience; years 3 and 4
= primarily clinical, divided into specialty and generalist-
focused components). Few dental school faculty have expe-
rienced educational programs that are not close approxima-
tions of this model. This is a limiting factor when seeking
new approaches because teachers ‘‘like what they know best’’
and ‘‘teach the way they were taught.’’ Consequently, re-
sources must be devoted to professional development pro-
grams that prepare faculty for different roles in new curric-
ulum formats. The outcomes of the Robert Wood Johnson
curriculum-innovation projects and evaluations of other re-
form efforts in medical education demonstrate that preparing
faculty to assume new academic responsibilities is vital to
successful conceptualization, implementation, and mainte-
nance of the reform.153,157–159
Organizational Development
Bloom and Magill observed that the discipline-based struc-
ture of health professions education institutions is a direct
descendent of the organizational structure of the German
research university in the mid-19th century.146,160 In 1850,
subdividing university resources along purely disciplinary
lines made sense because cross-disciplinary research was not
even a consideration, given the dim awareness of biologic
mechanisms underlying disease and the unsophisticated
technology available to investigate biologic questions. Now
that we are in the 21st century, does the organizational struc-
ture of the 19th-century German research university still
provide the most appropriate environment for educating
health care professionals? Academic administrators in both
dentistry and medicine will need to address this question.
We conclude with a reminder from the 16th century:
There is nothing more difficult to take in hand, more perilous
to conduct, or more uncertain in its success, than to take the
lead in the introduction of a new order of things—because
the innovator has for enemies all those who have done well
under the old conditions . . . but only lukewarm defenders in
those who may do well under the new.
NICCOLO MACHIAVELLI, The Prince 161
REFERENCES
1. The Sociology of Professional Training and Health Manpower: Sum-
mary Report. Geneva, Switzerland: World Health Organization,
Working Panel on Professional Training, 1972.
2. MacArthur JH, Moore FD. The two cultures and the health care rev-
olution. JAMA. 1995;277:985-9.
3. Findlay, S. HMOs told to be more open and flexible. USA Today.
December 18, 1996;1A:4A.
4. Kertesz L, Weissenstein E. Patient-protection rift: Kaiser group calls
for federally enforced standards. Modern Healthcare. 1997;September
29:6.
ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
5. Eklund SA, Pittman JL, Smith RC. Trends in dental care among in-
sured Americans: 1980 to 1995. J Am Dent Assoc. 1997;128:179–80.
6. Blake R, Louis WR (eds). Churchill: A Major New Assessment of His
Life in Peace and War. New York: W. W. Norton, 1993.
7. Mueller S (chair). Physicians for the 21st century: report of the project
panel on the general professional education of the physician and col-
lege preparation for medicine. J Med Educ. 1984 Nov;59(11 Pt. 2).
8. Pew Health Professions Commission. Health Professions Education for
the Future: Schools in Service to the Nation. San Francisco, CA:
UCSF Center for the Health Professions, 1993.
9. Pew Health Professions Commission. Critical Challenges: Revitalizing
the Health Professions for the Twenty-first Century, San Francisco,
CA: UCSF Center for the Health Professions, 1995.
10. Field MJ (ed). Dental Education at the Crossroads: Challenges and
Change. Washington, DC: National Academy Press, 1995.
11. Tabak L. Enhancing student research and the training of future aca-
demicians: a solutions-based approach. Paper presented at ADEA/
AADR Joint Symposium, Chicago, IL, March 7, 2001.
12. Venter CJ, Adams MD, Myers EW, et al. The sequence of the human
genome. Science. 2001;291:5507.
13. U.S. Department of Health and Human Services (USDHHS). Oral
Health in America: A Report of the Surgeon General. Washington,
DC: U.S. Department of Health and Human Services, 2000.
14. Hendricson W, Cohen P. Future directions in dental school curricu-
lum, teaching and learning. In: Leadership for the Future: The Dental
School in the University. Washington, DC: Center for Educational
Policy and Research, American Association of Dental Schools, 1999:
37–62.
15. Mouradian WE. The face of the child: children’s oral health and den-
tal education. J Dent Educ. 2001;65:821–31.
16. White AB, Caplan DJ, Weintraub JA. A quarter century of changes
in oral health in the United States. J Dent Educ. 1995;59:19–60.
17. Lipton JA, Ship JA, Larach-Robinson D. Estimated prevalence and
distribution of reported orofacial pain in the United States. J Am Dent
Assoc. 1993;124:115–21.
18. Carlsson GE, LeResche L. Epidemiology of temporomandibular dis-
orders. In: Sessle B, Bryant PS, Dionne RA (eds). Temporomandibular
Disorders and Related Pain Conditions. Seattle, WA: IASP Press,
1995:211–26.
19. U.S. Department of Health and Human Services (USDHHS), Public
Health Service, National Institutes of Health. Agenda for Research
on Women’s Health for the 21st Century. A Report of the Task Force
on the NIH Women’s Health Research Agenda for the 21st century.
Vol. 2. Bethesda, MD: National Institutes of Health, 1999.
20. Schulman J, Edmonds LD, McClearn AB, Jensvold N, Shaw GM.
Surveillance for and comparison of birth defect prevalences in two
geographic areas—United States, 1983–88. MMWR. 1993;42:1–7.
21. Wyszynski DF, Duffy DL, Beaty TH. Maternal cigarette smoking and
oral clefts: a meta-analysis. Cleft Palate Craniofac J. 1997;34:206–10.
22. Kaste LM, Gift HC, Bhat M, Swango PA. Prevalence of incisor
trauma in persons 6–50 years of age: United States, 1998–1991. J
Dent Res. 1996a;75:696–705.
23. McDonald AK. The National Electronic Injury Surveillance System:
a tool for researchers. Washington, DC: U.S. Consumer Product
Safety Commission, 1994.
24. Needleman HL. Orofacial trauma in child abuse: types, prevalence,
management and the dental profession’s involvement. Pediatr Dent.
1986;8:71–80.
25. Mathewson RJ. Child abuse and neglect: the dental profession’s re-
sponsibility. Compendium. 1993;14:658–62.
26. U.S. Public Health Service. Healthy People 2000 Progress Report on
Oral Health. Washington, DC: U.S. Department of Health and Hu-
man Services, 1995.
1201
 21ST-CENTURY ORAL HEALTH CARE,
27. Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution
of pediatric dental caries: NHANES III, 1984–1994. J Am Dent As-
soc. 1998;129:1229–38.
28. Valachovic RW, Weaver RG, Sinkford JC, Haden NK. Trends in den-
tistry and dental education. J Dent Educ. 2001;65:539–61.
29. Edelstein BL. Evidence-based dental care for children and the age 1
dental visit. Pediatr Ann. 1998;27:569–74.
30. McDerra EJC, Pollard MA, Curzon MEJ. The dental status of asth-
matic British school children. Pediatr Dent. 1998;20:281–7.
31. Ryberg M, Moller C, Ericson T. Effect of beta-2 adrenoceptor agonists
on saliva proteins and dental caries in asthmatic children. J Dent Res.
1987;66:1404–6.
32. Maguire A, Rugg-Gunn AJ, Butler TJ. Dental health of children tak-
ing antimicrobial and non-antimicrobial liquid oral medications long-
term. Caries Res. 1996;30:16–21.
33. Johnson N. Tobacco use and oral cancer—a global perspective. J Dent
Educ. 2001;65:328–39.
34. Ries LA, Kosary CL, Hankey BF, Miller BA, Clegg L, Edwards BK
(eds). SEER Cancer Statistics Review, 1973–1996. Bethesda, MD:
National Cancer Institute, 1999.
35. Marshall JR, Graham S, Haughey BP, et al. Smoking, alcohol, den-
tition and diet in the epidemiology of oral cancer. Eur J Cancer Oral
Oncol. 1992;28B:9–15.
36. Winn D. Tobacco use and oral disease. J Dent Educ. 2001;65:306–
12.
37. Blot WJ, McLaughlin JK, Winn DM, et al. Smoking and drinking in
relation to oral and pharyngeal cancer. Cancer Res. 1988;48:3282–7.
38. Hashim R, Thomson WM, Pack ARC. Smoking in adolescence as a
predictor of early loss of periodontal attachment. Community Den-
tistry and Oral Epidemiology. 2001;29:130–5.
39. Löe H. Periodontal disease—the sixth complication of diabetes mel-
litus. Diabetes Care. 1993;16:329–34.
40. National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK). Diabetes Statistics. Bethesda, MD: National Institutes of
Health; NIH Pub. no. 99-3892, 1999.
41. Murray CGL, Lopez AD. Global mortality, disability and the contri-
bution of risk factors: global burden of disease study. Lancet. 1997;
349:1436–42.
42. U.S. Department of Health and Human Services. Reducing Tobacco
Use: A Report of the Surgeon General. Atlanta, GA: U.S. Depart-
ment of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention and
Health Promotion, Office on Smoking and Health, 2000.
43. Wald NJ, Hackshaw AK. Cigarette smoking: an epidemiological over-
view. Br Med Bull. 1996;52:3–11.
44. Tomar SL, Husten CG, Manley MW. Do dentists and physicians ad-
vise tobacco users to quit? J Am Dent Assoc. 1996;127:259–65.
45. Dolan TA, McGorray SP, Grinstead-Skigen CL, Mecklenburg R. To-
bacco control activities in U.S. dental practices. J Am Dent Assoc.
1997;128:1669–79.
46. Severson HH, Andrews JA, Lichtenstein E, Gordon J, Barckley MS.
Using the hygiene visit to deliver a tobacco cessation program: results
of a randomized clinical trial. J Am Dent Assoc. 1999;129:993–9.
47. Barker GJ, Williams KB. Tobacco use cessation activities in U.S. den-
tal and dental hygiene student clinics. J Dent Educ. 1999;63:828–38.
48. Murdock SH, Hogue MN. Current patterns and future trends in the
population of the United States: implications for dentistry and the
dental profession in the twenty-first century. J Am Coll Dentists.
1998;65:29–35.
49. Douglass CW, Ostry L, Shih A. Denture usage in the United States:
a 25-year prediction. J Dent Res. 1998;77:209[abstract 829].
50. Murtaugh C, Kemper P, Spillman B. The risk of nursing home use in
later life. Med Care. 1990;28:952–62.
1202 ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
51. Kiyak HA, Grayston MN, Crinean CL. Oral health problems and
needs of nursing home residents. Community Dent Oral Epidemiol.
1993;12:49–52.
52. McIntyre RT, Jackson M, Shosenburg JW. Dental health status and
treatment needs of institutionalized seniors. Ont Dent. 1986;63:12–
4, 18–23.
53. Kroes I, Lepp PW, Relman DA. Bacterial diversity within the human
subgingival crevice. Proc Natl Acad Sci USA. 1999;96:14547–52.
54. Gibbs RS, Romero R, Hillier SL, Eschenbach DA. A review of pre-
mature birth and subclinical infection. Am J Obstet Gynecol. 1992;
166:1515–8.
55. Offenbacher S, Katz V, Fertik G, et al. Periodontal infection as a
possible risk factor for preterm low birth weight. J Periodontol. 1996;
67(10 suppl):1103–13.
56. Offenbacher S, Jared HL, O’Reilly PG, et al. Potential pathogenic
mechanisms of periodontitis associated pregnancy complications. Ann
Periodontol. 1998;3:233–50.
57. Mattila KJ, Asikainen S, Wolf J, Jousimies-Somer H, Valtonen VV,
Nieminen M. Age, dental infections, and coronary heart disease. J
Dent Res. 2000;79:756–60.
58. Genco RJ. Periodontal disease and risk for myocardial infarction and
cardiovascular disease. Cardiovasc Rev Rep. 1998;19:34–40.
59. Genco R, Chadda S, Grossi S, et al. Periodontal disease is a predictor
of cardiovascular disease in a Native American population. J Dent
Res. 1997;76:14–519 [abstract 3158].
60. Beck JD, Offenbacher S, Williams R, Gibbs P, Garcia R. Periodontics:
a risk factor for coronary heart disease? Ann Periodontol. 1998;3:127–
41.
61. Hujoel PP, Drangsholt M, Spiekerman C, DeRouen TA. Periodontal
disease and coronary heart disease risk. JAMA. 2000;284:1406–10.
62. Kehrer BH, Burroughs HC. More Minorities in Health. Menlo Park,
CA: Henry J. Kaiser Family Foundation, 1994.
63. Easterlin L. HHANES results reveal first big picture of Hispanic
health. Urban Med. 1988;3:12–15.
64. Wingo PA, Ries LAG, Giovino GA, et al. Annual report to the na-
tion on the status of cancer, 1973–1996. with a special section on
lung cancer and tobacco smoking. J Natl Cancer Inst. 1999;91:675–
90.
65. Guendelman S, Schwalbe J. Medical utilization by Hispanic children.
How does it differ from black and white peers? Med Care. 1986;24:
925–40.
66. Drury TF, Garcia I, Adesanya M. Socioeconomic disparities in adult
oral health in the United States. In: Adler NE, Marmot M, McEwen
BS, Stewart J (eds). Socioeconomic Status and Health in Industrial
Nations. Ann NY Acad Sci. 1999;896:322–4.
67. Pamuk E, Makuc D, Heck K, Rueben C, Lochner K. Socioeconomic
Status and Health Chartbook. Health, United States, 1998. Hyatts-
ville, MD: National Center for Health Statistics, 1998.
68. Mueller CD, Schur CL, Paramore LC. Access to dental care in the
United States. J Am Dent Assoc. 1998;129:429–37.
69. Simpson G, Bloom B, Cohen RA, Parsons PE. Access to health care.
Part I. Vital Health Stat. 1997;197:1–47.
70. American Dental Association (ADA), Edelstein BL. Oral Health Ser-
vices in the Child Health Insurance Program, Children’s Dental
Health Project, Washington, DC, and the American Dental Associ-
ation Task Force on CHIP Resource Packet. Chicago, IL: ADA, 1998.
71. Newacheck PW, Hughes DC, Hung YY, et al. The unmet health needs
of America’s children. Pediatrics. 2000;284:2625–31.
72. U.S. Department of Health and Human Services (USDHHS).
Healthy People 2010. Washington, DC: U.S. Department of Health
and Human Services, 2000.
73. Lewit EM, Monheit AC. Expenditures on health care for children and
pregnant women. US Health Care for Children. 1992;2:96–114.
 21ST-CENTURY ORAL HEALTH CARE,
74. Wotman S, Lalumandier J, Nelson S, Stange K. Dental education and
the general practice of dentistry: implications for dental education of
a practice research network by a school of dentistry. J Dent Educ.
2001;65:751–9.
75. Tedesco LA. Issues in dental curriculum and change. J Dent Educ.
1995;59:97–147.
76. American Dental Association. Survey of Predoctoral Dental Educa-
tional Institutions 1997/1998. Curriculum. Vol 4. Chicago, IL: Amer-
ican Dental Association, 1999.
77. Bransford JD, Brown AL, Cocking RR (eds). How People Learn:
Brain, Mind, Experience and School. Washington, DC: National
Academy Press, 1999.
78. Regehr G, Norman GT. Issues in cognitive psychology: implications
for professional education. Acad Med. 1996;71:988–1001.
79. Harrier RJ, Siegel BV, MacLachlin A, Soderling E. Regional glucose
metabolic changes after learning a complex visual–spatial/motor task:
a positron emission tomographic study. Brain Res. 1992;570:134–43.
80. Druckman D, Bjork RA (eds). In the Mind’s Eye: Enhancing Human
Performance. Washington, DC: National Academy Press, 1991.
81. Ericsson KA. Expert performance: its structure and acquisition. Am
Psychol. 1994;49:725–47.
82. Jensen E. Teaching with the Brain in Mind. Alexandria, VA: ASCD
Press, 1998.
83. McCann AL, Babler WJ, Cohen PA. Lessons learned from the com-
petency-based initiative at Baylor College of Dentistry. J Dent Educ.
1998;62:197–207.
84. Chambers DW, Geissberger M. Toward a competency analysis of op-
erative dentistry techniques. J Dent Educ. 1997;61:795–803.
85. Valchovic RW. Making science clinically relevant. J Dent Educ. 1997;
61:434–6.
86. Guyatt G. Evidence-based health care: a new approach to teaching
the practice of health care. J Dent Educ. 1994;58:648–53.
87. Sutherland SE. The building blocks of evidence-based dentistry. J Can
Dent Assoc. 2000;66:241–4.
88. Clark CD, Harrison RL, MacNeil MAJ, et al. The new dental curric-
ulum at the University of British Columbia: integrating with medi-
cine. J Dent Educ. 1998;62:718–22.
89. Login GR, Ransil BJ, Meyer M, et al. Assessment of preclinical prob-
lem-based learning versus lecture-based learning. J Dent Educ. 1997;
61:473–9.
90. Townsend G, Winning TA, Wetherell JD, et al. New PBL dental
curriculum at the University of Adelaide. J Dent Educ. 1997;61:374–
87.
91. Rohlin M, Petersson K, Svensater G. The Malmo model: a problem-
based learning curriculum in undergraduate dental education. Eur J
Dent Educ. 1998;2:103–14.
92. Fincham AG, Baehner R, Chai Y, et al. Problem-based learning at
the University of Southern California School of Dentistry. J Dent
Educ. 1997;61:417–25.
93. Forrest AS, Walsh LJ, Isaacs G, et al. PBL as a tool for integrating
anatomy into the dental curriculum. J Dent Educ. 1998;62:685–92.
94. Matlin KS, Libert E, McArdle PJ, et al. Implementing the problem-
based curriculum at Harvard School of Dental Medicine. J Dent Educ.
1998;62:693–708.
95. Shuler CF, Fincham AG. Comparative achievement on National
Board Examination Part I between dental students in problem-based
learning and traditional educational tracks. J Dent Educ. 1998;62:
666–70.
96. Pau AK, Collinson S, Croucher R. Dental students’ evaluation of 2
community-oriented PBL modules. Eur J Dent Educ. 1999;3:159–66.
97. Fincham AG, Shuler CF. The changing face of dental education: the
impact of PBL. J Dent Educ. 2001;65:407–22.
ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
98. Cohen PA, Forde ED. A survey of instructional technology in dental
education. J Dent Educ. 1992;56:123–7.
99. Willis DO, Smith JR, Golden P. A computerized business simulation
for dental practice management. J Dent Educ. 1997;61:821–8.
100. Johnson L, Thomas G, Dow S, Stanford C. An initial evaluation of
the Iowa dental surgical simulator. J Dent Educ. 2000;64:847–54.
101. Dodge WW, Dale RA, Hendricson WD. A preliminary study of the
effect of eliminating requirements on clinical performance. J Dent
Educ. 1993;57:667–72.
102. Cameron CA, Phillips SL, Chasteen JE. Outcomes comparison of
solo-practitioner and group practice models. J Dent Educ. 1998;62:
163–71.
103. Frankle SN, Boustang FG, Fournier DM. New directions in the evolv-
ing design of an experiential education program. J Dent Educ. 1997;
61:746–52.
104. Nash DA. The oral physician: creating a new oral health professional
for a new century. J Dent Educ. 1995;59:587–97.
105. Mulvihill JE. Insights on a new era under a reforming health care
system. J Dent Educ. 1995;59:620–27.
106. Schmidt HG, Dauphinee WD, Patel VL. Comparing the effects of
problem-based and conventional curricula in an international sample.
J Med Educ. 1987;69:656–62.
107. Albanese MA, Mitchell S. Problem-based learning: a review of the
literature on its outcomes and implementation issues. Acad Med.
1993;68:52–81.
108. Vernon DTA, Blake RL. Does problem-based learning work? A meta-
analysis of evaluative research. Acad Med. 1993;68:550–63.
109. Saarinen-Rahiika H, Binkley JM. Problem-based learning in physical
therapy: a review of the literature and overview of the McMaster
University experience. Phys Ther. 1998;78:195–207.
110. Berkson L. Problem-based learning: have the expectations been met?
Acad Med. 1993;68(10 suppl):S79–S88.
111. Adams RS. Making doctors—a new approach. Teach Learn Med.
1989;1:62–6.
112. Kaufman DM, Mann KV. Students’ perceptions about their courses in
problem-based learning and conventional curricula. Acad Med. 1996;
71:852–4.
113. American Association of Dental Schools. Future of Dental School
Faculty: Report of the President’s Task Force. Washington, DC: Amer-
ican Association of Dental Schools, 1999.
114. Haden K, Beemsterboer PL, Weaver RG, Valachovic RW. An update
on future dental school faculty. J Dent Educ. 2000;64:657–73.
115. Hendricson WD, Kleffner JH. Curricular and instructional implica-
tions of competency-based dental education. J Dent Educ. 1998;62:
183–96.
116. Smith SR, Dollase R. AMEE Guide No. 14: outcome-based education.
Part 2: planning, implementing and evaluating a competency-based
curriculum. Med Teach. 1999;21:15–22.
117. Tuisuva J, von Doussa R, Dimmer A, et al. The sequential modular
curriculum for oral health personnel: an evaluation of the Fijian ex-
perience after five years. Community Dental Health. 1999;16:97–101.
118. Grussing PG. Curricular design: competency perspective. Am J Pharm
Educ. 1987;51:414–19.
119. Kohn LT, Corrigan JM, Donaldson MS (eds). Committee on Quality
of Health Care in America. To Err Is Human: Building a Safer Health
Care System. Washington, DC: National Academy of Sciences, In-
stitute of Medicine, 2000.
120. Ismail AI. Dental education and the primary oral health care clinic
model. J Dent Educ. 1996;60:520–3.
121. Hicks JL, Dale RA, Hendricson WD, et al. Effects of reducing senior
clinical requirements. J Dent Educ. 1985;49:169–75.
122. Nowlin T, Dodge W, Hendricson WD. Results of a pilot patient-cen-
tered clinical education program. J Dent Educ. 1998;62:106.
1203
 21ST-CENTURY ORAL HEALTH CARE,
123. Stacey MA, Morgan MV, Wright C. The effect of clinical targets on
productivity and perceptions of clinical competence. J Dent Educ.
1998;62:409–14.
124. Evangelidis-Sakellson V. Student productivity under requirement and
comprehensive care systems. J Dent Educ. 1999;62:407–13.
125. Friedlander P. Competency-driven, component-based curriculum ar-
chitecture. Performance and Instruction. 1996;35:14–21.
126. Hendricson WD. Basic science integration: why shake-up the curric-
ulum? Paper presented at the Biomedical Sciences Section Program,
American Dental Education Association, Chicago, IL, March 4, 2001.
127. Forbes WC. Integrating basic sciences and problem-based learning in
the basic sciences. J Dent Educ. 2001;65:34.
128. Johnson P. The acquisition of skill. In: Smyth MM, Wing AM (eds).
The Psychology of Human Movement. London, U.K.: Academic
Press, 1984.
129. Ben-Yoseph M, Ryan P, Benjamin E. Retention of adult students in a
competence-based individualized degree program: lessons learned. J
Cont Higher Educ. 1999;47:24–30.
130. Long DM. Competency-based residency training: the next advance in
graduate medical education. Acad Med. 2000;75:1178–83.
131. A Baylor Blend: Curriculum Guide for 1996–97. Houston, TX: Baylor
College of Medicine, Office of the Curriculum, 1996.
132. Anderson AW. The challenges facing dental schools and academic
health centers. J Dent Educ. 1995;59:628–30.
133. Hildick S, Kohler PO. The future of U.S. health care and its effect
on health care education. J Dent Educ. 1998;62:376–80.
134. Senior professors help train medical students. The News. University
of Texas Health Science Center at San Antonio, September 11, 1998;
31:1–2.
135. Lewis CW, Grossman DC, Domoto PK, Deyo RA. The role of the
pediatrician in the oral health of children: a national survey. Pediat-
rics. 2000;106:1–7.
136. Christen AG. Tobacco cessation, the dental profession and the role
of dental education. 2001;65:368–74.
137. Benson W, Christen AG, Crews KM, Madden TE, Mecklenburg RE.
Tobacco-use prevention and cessation: dentistry’s role in promoting
freedom from tobacco. J Am Dent Assoc. 2000;131:1137–45.
138. Gordon JS, Severson HH. Tobacco cessation through dental office
settings. J Dent Educ. 2001;65:354–63.
139. Hendricson WD, Payer AF, Rogers LP, et al. The medical school cur-
riculum committee revisited. Acad Med. 1993;68:183–8.
140. Goffee R, Jones G. What holds the modern company together? Har-
vard Bus Rev. Nov–Dec 1996;74:133–48.
1204 ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001
CONTINUED
141. Berquist WH. The Four Cultures of the Academy. The Jossey-Bass
Higher and Adult Education Series. San Francisco, CA: Jossey-Bass,
1992.
142. Schein EH. Three cultures of management: the key to organizational
learning. Sloan Management Rev. 1996;380:9–20.
143. Grandy TG, Westermann GH, O’Canto RA, Erskine CG. Predicting
dentists’ career choices using the Myers–Briggs type indicator. J Am
Dent Assoc. 1996;127:253–8.
144. Ebert R, Ginzberg E. Reform of medical education. Health Aff. 1988;
(7 suppl):5–38.
145. Caius Julius Caesar. Debello Gallico (Gallic Wars): Book 4. Translated
by WA McDevitte and WS Bohn. New York: Harper Brothers, 1869.
146. Bloom SW. Structure and ideology in medical education: an analysis
of resistance to change. Med Educ. 1989;23:228–41.
147. Christakis NA. The similarity and frequency of proposals to reform
U.S. medical education: constant concerns. JAMA. 1995;274:706–11.
148. Hendricson WD, Katz MS, Hoy LJ. Survey on curriculum committees
at U.S. and Canadian medical schools. J Med Educ. 1988;63:762–74.
149. Levine A. Why Innovations Fail. Albany, NY: State University of
New York Press, 1980.
150. Smircich L, Morgan G. Leadership: the management of meaning. J
Applied Behav Sci. 1982;18:257–73.
151. Noer DM. Breaking Free: A Prescription for Personal and Organiza-
tional Change. San Francisco, CA: Jossey–Bass, 1997.
152. Drucker PF. Management Challenges for the 21st Century. New York:
Harper Business, 1999.
153. Bland CJ, Starnaman S, Wersal L, et al. Curricular change in medical
schools: how to succeed. Acad Med. 2000;75:575–94.
154. Lencioni P. The Five Temptations of a CEO. San Francisco, CA:
Jossey–Bass, 1998.
155. Kaufman A. Leadership and governance. Acad Med. 1998;73(9
suppl):S11–S15.
156. Mennin SP, Krackov SK. Reflections on relevance, resistance and re-
form in medical education. Acad Med. 1998;73(9 suppl):S60–S64.
157. Bland CJ, Stritter FT. Characteristics of effective family medicine fac-
ulty development programs. Fam Med. 1988;20:282–8.
158. Irby DM. Faculty development and academic vitality. Acad Med.
1993;68:769–73.
159. Rubeck RF, Witzke DB. Faculty development: a field of dreams. Acad
Med. 1998;73:(9 suppl):S32–S37.
160. Magill MK, Catinella P, Haas L, et al. Cultures in conflict: a challenge
to faculty of academic health centers. Acad Med. 1998;73:871–5.
161. Hariman R. Political Style: The Artistry of Power. Chicago, IL: Uni-
versity of Chicago Press, 1995.
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APPENDIX A

Schematic of Proposed 21st-century Competency-based Dental School Curriculum

*Units on development, structure, function, and abnormalities of cells, tissues, and organs (except the orofacial complex), metabolism and
nutrition, and infectious processes/host response.
†Two-week rotations in ENT (ear, nose, and throat clinic), oncology, hospital dentistry, pediatrics, and geriatrics.

Modules Ten weeks duration; students devote approximately 30 hours per week to module theme.
MM Two-week mini-module for clinical or research electives.
CPD (Clinical Practice of Dentistry) = 2–3 hours per week.
CCC (Comprehensive Care Clinic) = one day per week.

APPENDIX B

Proposed Sequence of Clinical Competency Modules

Second Year

䡲 Diagnosis, prevention, and treatment of periodontal disease, including an interdisciplinary rotation on surgical skills
䡲 Restoration of dentition
䡲 Management of dysfunction/abnormalities of the craniofacial complex (a multidisciplinary module addressing growth and development
abnormalities from childhood to adulthood)
䡲 Multidisciplinary health care—ENT (ear, nose and throat), oncology, pediatrics, hospital dentistry, geriatrics (two weeks each; total of
ten weeks)

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 21ST-CENTURY ORAL HEALTH CARE, CONTINUED

䡲 Two mini-modules for clinical or research electives (two weeks each)

䡲 Clinical Practice of Dentistry (CPD) = two–three hours per week devoted to: (1) Pain Management and Clinical Pharmacology and
(2) Economic Basis of Health Care Systems

Third Year

䡲 Endodontics and inter-arch restorations

䡲 Removable restorations (partial and complete dentures)
䡲 Public health including a community field-work project and an evidence-based project
䡲 Primary dental care (comprehensive care)
䡲 Two mini-modules for clinical or research electives (two weeks each)
䡲 Clinical Practice of Dentistry (CPD) = two–three hours per week devoted to (1) Clinical Pathology Conferences, (2) Clinical Phar-
macology, and (3) Dental Informatics

Fourth Year

䡲 Oral surgery, management of trauma and emergencies, and dental walk-in clinic
䡲 Implant dentistry and esthetic dentistry (five weeks each)
䡲 Primary care (including a two-week hospital dentistry rotation)
䡲 Primary care (including a two-week practice management preceptorship/project)
䡲 Two mini-modules for clinical or research electives (two weeks each)
䡲 Clinical Practice of Dentistry (CPD) = two–three hours per week devoted to: (1) Dentist in Society, (2) Professional Ethics and
Jurisprudence, and (3) Dental Practice Management

Module Scheduling

A hypothetical class of 80 is divided into four groups of 20 students who rotate among the modules. Patient treatment in junior year
competency modules that may extend beyond the confines of a ten-week rotation (for example, multi-unit fixed bridges or partial dentures)
can be completed during the weekly comprehensive care days scheduled throughout the year and/or during the Primary Care Module,
depending on the student’s rotation schedule.

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