The Challenge of Access to Care

Can an innovative dental education model help address the access issue? The answer is yes—making it happen is another thing. Access to care has dominated the dental care delivery discussion for quite a while and is more complex than most of us have realized. For example, even if a patient has transportation, motivation to see a dentist, and some form of insurance to pay for it, there has to be a ready, willing, and able dentist to provide the care. If a patient is lacking the transportation, insurance, or motivation, access to care becomes more difficult and requires more than a dental education solution. Then there’s the person with a severe intellectual or physical disability or a complex medical condition who may not know that he or she needs dental care. These individuals rely on the knowledge and motivation of their caregivers, their ability to pay for needed dental services, and dental providers willing and able to treat them to help them maintain good oral health. Additionally, it has become apparent that those having the most difficult time in accessing dental care have significant oral health needs. This includes the poor, those living in rural areas, and those with special healthcare needs. These cases often also in-clude the medically complex, intellectually disabled, and elderly. What does all this mean to the challenge of improving access to quality oral healthcare?

Professional Environment
Dentistry, as a profession, has gone through significant changes since its beginnings. The Gies report and the emergence of sophisticated dental interventions, new technology, and dental materials have catapulted the dental profession to the status of a major healthcare provider throughout the world. With this elevation of status came additional responsibilities that the profession has been slow to embrace and has had a difficult time adapting to. These include its role in dealing with the HIV issue, tobacco use cessation, interprofessional practice with other healthcare providers, care of special needs patients, etc.
The recent economic downturn has to be factored into the mix when examining and addressing the access to oral healthcare issue. Public funding for dental services has virtually “evaporated” from all sectors and underserved groups. Dentists themselves are feeling the impact with the reduction of dental insurance benefits, and patients postponing or refusing care as other competing priorities are impacting their families. Dentists who have contemplated retirement have put it off, and many who were providing free or donated services have had to cut back to generate more practice revenue. As the economy recovers, and it will, these issues will one day be a bad memory. In the meantime, how are we as a profession going to help assure the improvement of the oral health of our nation? How can it be done for the long haul, in a way that promotes the highest quality care delivered in a caring and compassionate manner to all?

Dental Education Response
Dental education has a unique and critical opportunity to step up and adjust to these compelling issues. The entire educational model—from who is accepted, how they are trained, the integration of “community mindedness,” and interprofessional practice—is essential in the development of dental leaders/providers. They are needed to solve the access to care issue that lingers and will continue, unless changes are made. If we continue to do what we have always done, we will only get what we have always gotten. The solo private practice model of dental care delivery has to morph into a model that is relevant to the social changes that are emerging in response to the increasing health needs, physical and behavioral, that are facing all Americans. It’s no longer just about teeth; it’s about the person attached to the tooth, the family attached to the person, and ultimately the community attached to the family! This is the perspective that the dentist of the future needs in order to solve the access issue.
General acceptance of the dental profession comprising oral healthcare providers who are comfortable managing the growing numbers of medically complex and intellectually disabled patients is very challenging and difficult to achieve, but it is necessary. Developing an educational environment that is successful in preparing dentists to meet this need is daunting, given all that is required in the traditional dental education model. Dental schools have to continue their efforts to develop innovative interprofessional practice clinical models and curricula to align with the evolving healthcare system.
Specifically, the traditional dental education model has relied upon recruiting bright, analytical individuals with good manual dexterity and an affinity for the biological sciences. Dental schools take pride in accepting students with very high GPAs and dental aptitude test scores. The dental curriculum is very rigorous, compressed, and heavily weighted with the basic sciences and preclinical dental laboratory exercises. Opportunities for community dentistry patient clinical experiences are limited. Developing leadership skills through implementing dentistry in community projects, obtaining formal education in public health culminating in a certificate in public health, and providing clinical care to special needs patients are not common to all dental schools.
Dental education has become very expensive, and full-time faculty are difficult to find and retain while students graduate with an enormous debt load. How do we effectively meet the challenges and needs of the increasing underserved population while improving the dental education model?

An Innovative Approach to Dental Education
About 12 years ago, a group of innovative dental educators, dental industry leaders, public health folks, and the leadership of A. T. Still University came together in Scottsdale, Ariz, as a “blue ribbon” panel to think about and propose a dental education model that could address the societal needs for improved oral health utilizing an innovative collaboration with community health centers while educating caring, compassionate dentists who would be community leaders in a cost-effective way without compromising the clinical excellence needed to provide the highest quality care. The discussions included the establishment of core values/principles, student recruitment, community-based clinical educational experiences, and emphasis on public health with a commitment to both didactic and hands-on dentistry in the community experiences.
To emphasize the commitment to a public health and to a whole person health philosophy, the name selected for the school—Arizona School of Dentistry and Oral Health (ASDOH)—was important and is the first dental school to in-clude “oral health” in its name. In order to graduate dentists with a strong commitment to serve the underserved, the panel believed that it was es-sential to select applicants who had demonstrated a significant amount of community service prior to arriving at dental school. Community service was not limited to volunteer dental-related experiences and could include working as a volunteer for a nonprofit or community agency or being employed in a community health center. It was felt that selecting students with this experience would en-hance the chance that they would move into a community service setting after graduation. There were no guarantees, but these students definitely would have a propensity for community service after graduation. During the past decade, this has emerged as a core principle of the ASDOH model and has proven to be an important element in the extraordinarily high percentage of ASDOH graduates working in community settings or the military.
Additionally, ASDOH wanted to produce leaders in communities while teaching students to be great dentists. To help achieve this and assure that they would understand the total “health picture” of their community, each student is required to complete a certificate in public health during dental school. They would, if they choose, be able to roll those courses into a full master’s of public health, which would be awarded at their graduation. This year’s graduating class had 26 students graduate with dual degrees (DMD and MPH).
Since its inception, 36% of all ASDOH graduates are working in community settings or the military. Many are dental directors of not-for-profit organizations and actively engaged in providing care to the underserved. Additionally, this year’s graduating class had 6 American Indians (the largest cohort of American Indians to ever graduate from a dental school). All 6 of these wonderful graduates have returned to Indian communities to practice.
Yes, innovative, community-minded, interprofessional-oriented dental education models can help address the access to care issues facing the underserved in America. Let’s have the vision, courage, and commitment to create them.


Dr. Dillenberg is the inaugural dean of A. T. Still University’s Arizona School of Dentistry and Oral Health. He received his master’s degree in public health from the Harvard School of Public Health and completed his dental education at New York University College of Dentistry. He is a board member of the American Association of Developmental Medicine and Dentistry, the Association for Prevention Teaching and Research, the Caplin Family Foundation, and the Center for Oral Health, and is he the vice chair for First Things First Southeast Maricopa Region. He is also a member of the ADA, the American Association of Public Health Dentistry, the American Dental Education Association, and many others. He can be reached at (480) 219-8165 or at jdillenberg@atsu.edu.

Disclosure: Dr. Dillenberg reports no disclosures.

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