November 2008 ■ Journal of Dental Education
1231
Critical Issues in Dental Education
Is Dentistry at Risk? A Case for
Interprofessional Education
Rebecca S. Wilder, B.S.D.H., M.S.; Jean A. O’Donnell, D.M.D.; J. Mark Barry,
D.M.D., M.B.A.; Dominique M. Galli, M.S., Ph.D.; Foroud F. Hakim, D.D.S., M.B.A.;
Lavern J. Holyfield, D.D.S.; Miriam R. Robbins, D.D.S., M.S.
Abstract: The goal of interprofessional education (IPE) is to bring various professional groups together in the educational envi-
ronment to promote collaborative practice and improve the health care of patients. Interest in IPE has been sparked by several
factors in the health care system, including the increased awareness of oral-systemic connections, an aging population, the shift
of the burden of illness from acute to chronic care, and lack of access to basic oral care. Increasingly, since the publication of the
U.S. surgeon general’s report in 2000, the dialogue surrounding IPE in dentistry has escalated. But how has dentistry changed
regarding IPE since the report was released? This position paper argues that little has changed in the way dental students are
taught and prepared to participate in IPE. The authors contend that academic dentistry and organized dentistry must take the lead
in initiating and demanding IPE if dental students are to be prepared to work in the health care environment of the twenty-first
century. Included are reasons why IPE is necessary and why dentistry must lead the conversation and participate in the solution to
the oral health care crisis. It explores existing models and alternate approaches to IPE, barriers to implementation, and proposed
strategies for academic institutions.
Prof. Wilder is Associate Professor, Director of Faculty Development, and Director of Graduate Dental Hygiene Education, Uni-
versity of North Carolina at Chapel Hill School of Dentistry; Dr. O’Donnell is Assistant Professor and Vice Chair, Department of
Restorative Dentistry and Comprehensive Care, University of Pittsburgh School of Dental Medicine; Dr. Barry is Associate Dean
of Clinical Administration, Medical University of South Carolina; Dr. Galli is Associate Professor, Department of Oral Biology,
Indiana University School of Dentistry; Dr. Hakim is Assistant Professor and Curriculum Director, Department of Restorative
Dentistry, University of the Pacific Arthur A. Dugoni School of Dentistry; Dr. Holyfield is Director of Faculty Development and
Assistant Professor, Baylor College of Dentistry; and Dr. Robbins is Associate Chair, Department of Oral and Maxillofacial
Pathology, Radiology, and Medicine, New York University College of Dentistry. Direct correspondence and requests for reprints
to Prof. Rebecca S. Wilder, University of North Carolina at Chapel Hill School of Dentistry, CB#7450, Room 3280, Chapel Hill,
NC 27599-7450; 919-966-8221 phone; 919-966-6761-fax; Rebecca_wilder@dentistry.unc.edu.
This article was written in partial fulfillment of completion of the 2007–08 ADEA Leadership Institute.
Key words: dental education, interprofessional education, curriculum reform, predoctoral education, interdisciplinary education
Submitted for publication 3/17/08; accepted 7/23/08
T
he phrase “the mouth is a mirror” has been
used to illustrate what can be detected and
ultimately diagnosed from examining oral
tissues, including the detection of microbial infec-
tions, hematological diseases, and some cancers.
As the challenge of providing health care to all
Americans is growing, so is the disconnect between
the dominant pattern of practice of the dental profes-
sion and the oral health needs of the nation.
1
In fact,
dental disease is so widespread that the U.S. surgeon
general’s report on oral health referred to it as the
“silent epidemic.”
2
Concern over such oral health issues as the
prevalence of dental disease, the relationship between
oral health and general health, and the limited avail-
ability of dental health professionals to meet the
oral health care needs of U.S. citizens is escalating.
We submit that if dental health professionals are to
remain the vanguard of oral health care, it is impera-
tive that they implement strategies to address the oral
health needs of the population. One such measure that
has been suggested to achieve this goal is interprofes-
sional collaboration, a cross-disciplinary approach to
patient care across various professions.
The report Oral Health in America critically
reviewed the relationship among oral health, general
health, and well-being.
2
This report called for the
development of a National Oral Health Plan that will
“improve quality of life and eliminate health dispari-
ties by facilitating collaborations among individuals,
health care providers, communities, and policymak-
ers at all levels of society and by taking advantage of
1232
Journal of Dental Education ■ Volume 72, Number 11
existing initiatives.” To be included in this oral health
plan, the dental profession must be vigilant in efforts
to prepare itself for collaborative care. This will be
difficult to accomplish if health care providers have
not been trained to work in interprofessional teams,
a process that commences with the incorporation of
interprofessional education into the dental education
curriculum.
The term “interprofessional education” (IPE)
(also known as interdisciplinary education) is defined
as an educational process that provides health profes-
sions students “with experience across professional
disciplinary lines as they acquire knowledge and
skills in subject areas required in their respective
educational programs.”
3
While there are documented
instances of institutions across the nation and across
multiple health care disciplines that engage in IPE, it
is the premise of this position paper that participation
by dental institutions in these efforts is insufficient
and that nondental entities are proceeding with and
without the input or influence of the dental profes-
sion.
4,5
Further, we submit that unless the current phi-
losophy of dental education and practice is changed,
future oral health care providers will be excluded
from interprofessional care.
6-8
In 2002, for example, 150 leaders and experts
from various health professions convened at the
Institute of Medicine (IOM) Health Professions Edu-
cation Summit to discuss strategies for restructuring
clinical education to be congruent with principles of
the current and future health care system. The sum-
mit was followed by a report, Health Professions
Education: A Bridge to Quality,
4
which emphasized
that physicians, nurses, pharmacists, and other health
care professionals are not being adequately prepared
to provide the highest quality of care nor is there
adequate attention to assessing the professionals’
continued proficiency. The report laid out five core
competencies that all clinicians should possess to
achieve the level of care needed in the twenty-first
century. The proposed competencies were 1) provide
patient-centered care; 2) work in interdisciplinary
teams; 3) practice evidence-based medicine; 4) focus
on quality improvement; and 5) utilize information
technology. Represented at the summit were physi-
cians, pharmacists, nurses, physician assistants, and
allied health professionals. Dentistry had no repre-
sentation on any level of the planning committee nor
among attendees at the summit.
5
In 2004, Zwarenstein et al. reported on a
Cochrane review to assess the effectiveness of IPE
interventions compared to education interventions
in which groups of students from various profes-
sions learn separately from one another.
9
At that
time, no studies fulfilled the inclusion criteria for the
systematic review process. More recently, Reeves et
al. reported on the results of a follow-up Cochrane
review on IPE.
10
Several health and social profes-
sionals were included in the criteria for selection:
physicians, nurses, midwives, pharmacists, dentists,
and others. Six studies met the inclusion criteria. Of
those studies, several showed positive results of IPE
in areas including patient satisfaction
11
and collabora-
tive team behavior.
12
Unfortunately, dentistry was not
studied in any of the investigations.
In 2006, Rafter et al. reported on the status
of IPE in U.S. academic health centers that include
schools of dentistry.
5
Of the academic health centers
investigated, several reported attempting to develop
IPE programs but none of them included dental stu-
dents. While reasons cited for dentistry not partici-
pating in IPE vary (lack of time, resources, interest,
administrative support), if academic dentistry does
not make a concerted effort to incorporate IPE into
the dental curriculum and participate in the plan-
ning and implementation of IPE, the profession will
remain left behind.
A Wake-Up Call
Concern for the nation’s oral health is escalat-
ing. Issues include access to care for low-income and
underserved minority groups, oral diseases related to
tobacco use, chronic facial pain, craniofacial birth
defects and trauma, and the emergent health needs
of an aging population that will need services in
new locations and in new forms.
1
A recent article in
the New York Times highlighted oral health dispari-
ties,
13
reporting that while dentists are experiencing
a financial boom, millions of Americans are without
access to care. This article was just one attempt to
capture the attention of the American public; but it
should also serve as a wake-up call for the profession
to accept that change is needed. In essence, the dental
profession can no longer continue business as usual
in the delivery of patient care.
One approach that should be considered in the
delivery of oral health care is collaboration with other
members of the medical team. The perception that
oral health is separate from and less important than
general health has been ingrained in the American
consciousness.
Private practice settings and isolation
from other health services have helped create the
November 2008 ■ Journal of Dental Education
1233
impression that oral health is not part of one’s overall
health
but rather a luxury available only to those who
have access through employee coverage and/or the
ability to pay for services. However, oral health and
general health are inseparable.
Routine dental visits are an important aspect
of patient health. Dentists are often the first line of
defense in the prevention, early detection, and treat-
ment of both oral and systemic diseases and there-
fore must become more involved in assessing and
ensuring the overall health of their patients through
screening, diagnosis, and referral.
Moreover, a col-
laborative network among dentists and other medi-
cal professionals would be even more beneficial to
patients as well as to other health care providers. This
collaboration begins with the preparation of dental
students to work effectively in alliances with other
health professionals and will require support at all
levels of dental education, beginning at the highest
levels of administration.
The need for interprofessional health care is
made more acute by the insufficient number of avail-
able dental professionals in rural and underserved
areas to address the needs of the general population.
IPE is an innovative measure that can resolve prob-
lems resulting from the lack of access to care.
14-18
Clearly, an improvement in the accessibility of trained
oral health professionals is warranted; however,
because of the inequitable distribution of the dental
workforce, it is unlikely that this shortage will be
remedied by dentists alone. Despite this fact, attempts
by others such as the dental therapists in Alaska or
expanded-duty dental hygienists to augment the oral
health team have not been generally well received by
the dental profession. This lack of acceptance pre-
vails despite the presence of clear and documented
successes by allied dental health professionals like
the long-standing dental therapists of New Zealand.
While the incidence of decayed, missing, and filled
teeth (DMFT) of children in New Zealand is roughly
comparable to that of children in the United States,
the existence of school-based dental clinics led
by dental nurses has led to essentially decay-free
mouths for school-aged children in New Zealand
when epidemiological studies are done at the end
of the school year.
19
In the United States, alternate
approaches to meeting oral health care needs have
included expansion of the dental team through allied
oral health care professionals such as the advanced
dental hygiene practitioner
(ADHP) introduced by the
American Dental Hygienists’
Association (ADHA)
20
and the oral preventive assistant (OPA).
21
Recently,
the American Dental Association (ADA) introduced
the concept of a community dental health coordina-
tor (CDHC), a new team member who would be
specifically trained to help organize community
programs and function in remote locations and other
underserved areas.
21
Expanding the roles and decreasing the limita-
tions placed on the scope of practice of non-dentist
members of the oral health care team would likely
be an effective strategy, particularly in rural areas or
locations where there is a shortage of dentists. While
a more empowered oral health team would be benefi-
cial, we contend that the introduction of physicians
or other strategic members of current general health
care teams is just as important to meeting the overall
health care needs of the public. A two-way stream
of collaboration between dental and medical teams,
fostered by educational staging (IPE in all units of the
health sciences) as well as the redesign of physical
premises departing from the trend of separate dental
and medical offices and clinics, must ultimately lead
to more effortless exchange of information between
medical and dental health care settings. Such col-
laboration might include referrals, labs, treatment
requests, and precautions; more comprehensive prac-
tice of dentistry and medicine; and earlier detection
of both oral and systemic diseases—all leading to
decreased national health care costs.
This emphasis on IPE needs to occur while the
dental student is being educated. Providing a class-
room and clinical environment where collaborative
behaviors can be modeled and practiced by students
would offer a means to help reinforce concepts and
model appropriate patient care and interprofessional
collaboration. Utilizing community sites that serve
at-risk populations would also help to address the
disparities in health care highlighted by the surgeon
general’s report
2
and the National Call to Action to
Promote Oral Health issued by the National Institutes
of Health.
22
A series of articles by Mouradian et al.
and other authors called for dental-medical collabo-
ration as a way to address these needs.
23-29
A number
of promising models are described; often missing,
however, are the dental student and a strong leader-
ship role from dental education to train our future
professionals to work collaboratively as part of an
interprofessional health care team.
Understandably, the shift toward IPE will
require modification of some aspects of the dental
education curriculum. In July 2007, the American
Dental Education Association (ADEA) Commis-
sion on Change and Innovation in Dental Education
1234
Journal of Dental Education ■ Volume 72, Number 11
(CCI), through an ADEA-Commission on Dental
Accreditation (CODA) Task Force, distributed a
document containing recommendations for changes
to the predoctoral accreditation standards. Among
them are additions under Standard 5, Patient Care
Services. The recommended additions and their intent
are as follows:
30
• Students must be competent to collaborate with
other health care providers in providing patient
care. Intent: Oral health is fundamental to sys-
temic health. Effective patient care requires col-
laboration and communication among health care
providers. To the extent possible, students should
have educational experiences, particularly clinical
experiences, that involve working with other health
professions students and practitioners.
• Dental education programs must make available
sufficient opportunities and encourage students
to engage in structured learning experiences that
combine community service with preparation
and reflection (service-learning). Intent: Students
should learn professional responsibility to address
the needs of the community, particularly those not
served and underserved. To assist and encourage
students to participate in service-learning, dental
schools should seek partnerships in their com-
munities with private practice dentists and other
health care professionals to provide patient care
through faculty and students.
These recommendations appear to be a good
starting point or common denominator across dental
education. Even so, we must ask if such standard
changes would materially affect the culture of dental
education. This idea of cultural change or evolution
was discussed by Cohen when he postulated that,
over time, dentistry will integrate completely with
medicine based on convergent cultural evolutionary
trends.
31
Still, if this integration is inevitable, then
dentistry must be at the forefront of any initiative
leading to such change.
Barriers to Implementation
Educating students to interact as an interdisci-
plinary health care team is a major challenge for the
health care professions. Historically, medical, dental,
nursing, and allied health programs have provided
very little direct, collaborative, interdisciplinary
education for their students. Health professionals
are trained in isolation, with long-standing inter-
professional and intraprofessional rivalries. Most
faculty teach in a cloistered environment and are
not adequately prepared to teach skills needed to
foster interdisciplinary collaboration and joint deci-
sion making.
32,33
A lack of knowledge and skills of
other disciplines fuels interdisciplinary rivalry. Fears
that professional identity and power may be diluted
through an interdisciplinary focus can manifest as
a lack of cooperation, with disciplines defending
their authority at the expense of the overall process.
34
Furthermore, a lack of financial incentives and limita-
tions makes it difficult to obtain consistent funding
streams to sustain core programs or model innova-
tions in education and practice.
35
Nonetheless, vari-
ous attempts have been made to cross-train students
from different health professions. Indeed, examples
of programs within the domain of IPE in the United
States have been described in the literature since at
least the 1940s.
36
The disciplines involved have var-
ied by program, as have content and sites in which
programs have been conducted. Much of the early
literature on programs in both the United States and
abroad is descriptive in nature and describes pilot pro-
grams only. Programs ended when funding stopped
and/or they lacked outcome information.
With respect to dentistry’s role as part of
comprehensive health care teams, a review of the
literature shows only limited inclusion of oral health
care professionals as members of interdisciplinary
teams.
8,23,24,37-41
The fact that many dental profession-
als do not perceive urgency in the call for IPE should
come as no surprise to those involved with dental
education. Rather than integrating dentistry within
a comprehensive interdisciplinary health care educa-
tion system, most of academic dentistry has contin-
ued to opt for an isolated, insular approach to training
future dentists.
42
This silo approach to education, a
distinct professional code of ethics, and the drawing
of boundaries around professional knowledge all
undermine respectful awareness of the knowledge
and skills of other disciplines.
43
Furthermore, with
an already saturated curriculum, professional educa-
tors in dentistry object to further intrusions of a “new
subject area” into their curricula. Although a growing
push for dental education reform has resulted in some
curricular changes,
43-47
nearly 90 percent of North
American dental schools surveyed in 2002 operated
a traditional discipline-based (silo) curriculum, and
only a handful reported interdisciplinary curriculum
organization.
48
Reasons cited were that the process
of curriculum modification is “slow and difficult,”
“departments remain territorial,” and “change is a
slow and humbling process.” In the same survey,
November 2008 ■ Journal of Dental Education
1235
respondents were asked what curricular innova-
tions they had planned for the next four years. Only
48 percent of the schools planned more curricular
emphasis on medical problems, and only 52 percent
planned to increase educational collaborations with
other schools on campus.
48
IPE is often viewed as a fad by educators and
not perceived as a high priority. Admittedly, the lack
of scientific evidence of the effectiveness of IPE
and the absence of outcome studies showing that
interdisciplinary teams result in better care
9,10
make
it hard to justify the time and effort needed to widely
implement IPE.
46
Despite these barriers, if we, as
dental educators, do not place sufficient value on
integrating oral health within the context of primary
health,
8
we cannot expect our graduates to do so in
their practices. If we do not provide, as an integral
part of the dental curriculum, opportunities for our
students to collaborate with other health profession-
als, we should not expect them to value collaboration
after graduation.
Changing the Culture of
Dental Education
If we accept the need to incorporate IPE within
the dental education curriculum as a means to help
address the nation’s oral health crisis, the inevitable
question is how this can be accomplished given the
wide array of barriers and new paradigms to adopt.
It is our firm belief that in order to implement IPE
in the dental curriculum the following strategies
must occur:
• Faculty Development: First and foremost, the
importance and value of IPE must be conveyed
to the academic community of dental educators.
It is unrealistic to expect that all faculty members
will eagerly engage in this process unless faculty
development programs designed to educate and
enlighten are initiated at each academic institution.
The proposed recommendations of the ADEA-
CODA Task Force working in conjunction with the
ADEA CCI place considerably more emphasis on
professional development of the faculty as a core
responsibility of the dental school and describe
the critical role of faculty to the cultivation of an
academic environment that supports and sustains
innovation. For example, the proposed changes
to the predoctoral standards under Standard 5,
Patient Care Services emphasized the need for
dental students to be competent to collaborate with
other health care providers.
30
Faculty development,
initiated and required by academic institutions,
is necessary to cultivate the necessary skills and
experiences for faculty members, so they can then
teach and model these behaviors and skills with
their students.
• IPE Initiatives: Many institutions have existing
interprofessional initiatives that involve multiple
colleges and disciplines. Dental school leaders
need to ensure complete and proactive participa-
tion in these activities. Universities and health
science centers that do not have such programs
should create the opportunity for dental schools
to take the lead and develop campus-wide inter-
professional teams and activities. Those schools
not affiliated with academic health centers can
partner with community centers to identify sites
and methods for students and faculty to work with
multiple professions in providing care to under-
served populations.
• Curricular Changes: The biggest challenge—in-
corporating IPE into the dental curriculum—would
necessitate recommendations for both didactic
and clinical changes and would further require
collaboration with multiple professions. Ideally,
course material on IPE would begin as early as the
first year and continue throughout the curriculum
to include appropriate content and competencies.
Content for the curriculum should acknowledge
the historical role dentistry has played in important
preventive measures such as fluoridation, sealants,
and oral hygiene. Topics integral to dentistry that
cross interprofessional lines (for example, the
aging population, special needs, craniofacial de-
fects, pediatrics, medical/dental therapeutics, and
identification of risk factors for oral and systemic
disease) would highlight the connections between
oral health and general health. Students must be
able to develop and present models of interpro-
fessional practice that emphasize the benefits of
a multidisciplinary approach and address these
complex health issues. The values promoted in
formal courses must also be reflected in clinical
practice settings.
9
The access to care problem and
health care crisis that drive the move toward IPE
provide a logical starting point to identify commu-
nity centers attempting to address the needs of the
underserved. Existing facilities, frequently staffed
(or understaffed) by medical and nursing person-
nel, offer a venue for dental students and faculty
to teach, learn, and serve collaboratively. Rotations