Commentary: Necessity of Blending Dental Education Into the Mainstream of Medical Education as a Specialty Area: Advocating for a Reform Idea Aiming to Promote the Health System Performance in Iran

Abstract

With the knowledge we have today about the concept of health and its complexities and determinants, the separation between medical and dental education (DE) does not seem reasonable anymore. Dentistry has mainly developed based on a mechanical approach to treat the related problems. This makes the efforts for reorientation of dental care (DC) toward a preventive approach, relying upon dentists as the chief oral health (OH)-related workforce, inefficient. This is while effective strategies have been identified for prevention, as the key to simultaneously control the burden and costs of the ubiquitous oral diseases, at both individual and population levels without dentists. We think that approaching OH as an integral part of the general well-being requires fundamental changes in the structure of OH system including a substantial revision in the current situation of dentistry as an autonomous health profession with a separate education from the main body of the medicine. In this short article, we briefly discuss the necessity of blending DE into the mainstream of medical education and actual consideration of dentistry as a medical specialty area. After discussing the subject at two levels (health-care system and national levels), the next sections draw attention to some complementary issues.

Keywords

dental education health policy health system reform dentistry medical specialty oral health integration dental professions

Dental caries and periodontitis are the main diseases of the orodental complex. They, along with their consequences, constitute more than 95% of the burden of oral diseases (Murray & Lopez, 1996). According to the Global Burden of Disease 2010 Study, though untreated dental caries and severe periodontitis are the first and sixth prevalent diseases, respectively, they, combined with severe tooth loss, accounted for approximately 0.6% of all disability-adjusted life years (a summary measure of the disease burden) worldwide (Marcenes et al., 2013). Nevertheless, dental care (DC) costs were estimated to account for a significant share of about 4.6% of the global health expenditures in 2010 (Listl, Galloway, Mossey, & Marcenes, 2015). Meanwhile, because of the low ability of the dental sector to compete with other health areas for a greater share of limited public resources, out-of-pocket payments by patients play a pivotal role in financing DC in most countries (M. Jadidfard, Yazdani, & Khoshnevisan, 2013).

Although currently dentists are the main (and, more or less, exclusive) providers of dental services in Iran and most countries, the contribution of the common practice of dentistry in improving the generally accepted oral health (OH) indices has been questionable at least over the recent half-century (Nadanovsky & Sheiham, 1995; Pinilla & González, 2009). One important reason is that the dentistry and its related competencies have mainly developed based on a mechanical approach to treat the problems of oral cavity (Fejerskov, Escobar, Jøssing, & Baelum, 2013), and this inherent characteristic makes the efforts for reorientation of DC toward a preventive approach, relying upon dentists as the chief OH-related workforce, inefficient. Therefore, the adoption of policies of increasing the dentist/population ratio and specialization in dentistry in order to promote access to quality DC seems incompatible with the goal of establishing a preventive-oriented system and, so, exhibits a mismatch between the goals and the policies that, in addition to raise the costs, is unable to basically address the problem. This is while effective strategies have been identified for prevention, as the key to simultaneously control the burden and costs of oral diseases, at both individual and population levels without dentists (Fejerskov et al., 2013; Sheiham, 2005).

Historically, there have been two broad approaches for dental education (DE): odontology and stomatology (Scott, 2003). In stomatology model, education in dentistry requires a general medical degree as any other medical specialty area. In odontology model, DE is totally separated from the education of general medicine from the beginning. Each model has its own pros and cons. Compared to stomatology, it is claimed that odontology results in dentists more competent in performing clinical dental procedures but lacking adequate understanding of the general health issues and so unable to efficiently manage the medical conditions of their clients (Tanaka, Honda, & Kitamura, 2008). DE in Iran has followed the odontological tradition. Many countries with stomatological model, especially European ones in the recent decade, has moved toward odontological curriculum mainly due to considering equivalency of DE across the members of the EU as a requirement for joining countries (Banoczy, 1993). Despite the mentioned trend toward odontological model, in this article, we advocate in favor of a modified form of the stomatological model for Iran.

The Iranian oral healthcare system (OHCS) has been described and critiqued elsewhere (M.-P. Jadidfard, Yazdani, & Khoshnevisan, 2012). High levels of unmet needs, high levels of out-of-pocket payments (∼90%) in significant and increasing dental expenditures, and a dramatic increase of the dental schools in order to train general and specialist dentists in the recent decade are among its notable and rather paradoxical features. We, the authors, believe that one of the root causes for this unfavorable performance relates to dental workforce planning and education system and, specifically, the separation of DE from the main body of the medical education. Considering the historical background of the establishment and evolvement of the dentistry as a profession, even if the separation between dental and medical education was acceptable till a few decades ago (Simon, 2016), with the knowledge we have today about the concept of health and its complexities and determinants it does not seem reasonable anymore. If the profession’s reliance on practical aspects along with the high prevalence of oral diseases has been used to justify the DE autonomy, then such reasoning can be employed to legitimate the separation of other medical specialties with similar conditions. In this short article, we briefly discuss the necessity of blending DE into the mainstream of medical education and actual consideration of dentistry as a medical specialty area. After discussing the issue at two levels, the last section draws attention to some crucial and complementary strategies.

First Level: (Oral) Health-Care System

Approaching OH as an integral component of general health is one of the emphasized recommendations reiterated by the leading international OH-related organizations (Glick et al., 2012; Petersen, 2003). The increase in general health topics, as a main theme in the revisions of dental curriculums in order to promote the general medical knowledge of dental students, has been a strategy used for this purpose during the recent decades (Scott, 2003). Aside from the extent to which this educational intervention has been successful, we believe that viewing OH as an integral part of the general well-being requires more fundamental changes in the structure of OH system including a serious revision in the current situation of dentistry as an autonomous health profession with a separate education from the main body of the medicine. We think that this separation prevents the real integration of OH into the general health and, until DE is considered as a specialty area of the medicine, meaningful success in such integration cannot be expected through interventions such as medicalization of the DE (saturation of DE with general medical content). The independence of DE per se conveys strong signal to dental students—as future DC providers—to feel little need, if any, to general health issues and to suppose themselves independent from other HC areas.

Also in this regard, it seems that the increase in dental specialties in different countries is a consequence of this separation; particularly, when we know that this increase has been mainly due to the professional interests—with the dental schools and associations playing the main role—rather than being subjected to a precise need assessment at the community level (Widström & Eaton, 2006). Accordingly, dental specialties include a wide range of variety among countries recognizing specialization in dentistry (Sanz, Widström, & Eaton, 2008; Schleyer, Eaton, Mock, & Barac’h, 2002). Currently, 12 dental specialties (including two PhD courses) are established in Iran, a situation comparable with some developed countries with the highest degree of specialization in dentistry. This does not seem to be in accordance with the real OH needs of the population. More importantly, we think that disproportionate increase of dental specialists may have unfavorable effects on general DE and OHCS.

The rather narrow range of services in most clinical dental specialties may incentivize the specialist members of the dental faculties to, either formally or informally, foster general graduates who are less competent compared to their earlier cohorts, particularly in the practical aspects of the dental practice, in order to ensure a greater share of DC market. The result would likely be more referrals to the specialists for services formerly provided by the general dentists at an acceptable quality and lower costs.

In addition, DE autonomy potentially provides a possibility to disproportionately increase the intake of workforce compared to other medical specialties (a potential source of inefficiency through supplier-induced demand). Meanwhile, the unusual increase in dental schools in Iran (from less than 20 to around 60 over the recent decade), in the absence of appropriate strategies for workforce planning (including effective mechanisms for the distribution of graduates) and efficient structures for organizing and financing DC, does not promise a desirable prospect for DC provision in forthcoming years. Considering DE as a postgraduate medical education program can have the ancillary advantage of curbing the situation because, despite the current decision makers’ desire, there are many barriers against reversing the trend.

Moreover, another factor reinforcing the necessity of this reform in DE—as a pivotal strategy for the real integration of OH into the general health—is the population aging as a remarkable demographic transition occurring in varying degrees in almost all countries, including Iran. The complexity of the elderly’s health problems requires dentists to be capable of optimal management of these patients (Tanaka et al., 2008). The proposed reform in DE will likely ensure achieving this objective.

Second Level: From a Human Capital Perspective at the National Level

Compared to general medicine, the length of general education in dentistry is shorter (on average, 6 vs. 7.5 years in Iran) resulting in an equivalent degree. This general dental degree gives the graduates the opportunity to earn incomes comparable with many medical specialties—with at least 11–12 years of medical education. This relative advantage of return on investment motivates many of the top-ranked students in Iran’s annual university entry exam to choose dentistry as their future career.

On the other side, we know that the majority of the routine dental services require moderate levels of skill. Accordingly, from a macro perspective, a concern is raised about whether dentistry is a suitable choice for many of its applicants in terms of the realization of their potential capabilities and intellectual capacities. This inconsistency between individuals’ capacities and their occupation’s requirements create the possibility of underemployment and thus a waste of human capital at the national level.

If the government could provide conditions to encourage such students to pursue potentially more innovative fields such as basic sciences, they could likely play more active roles in the development of the society. Considering DE as a medical specialty can provide more possibility for these elite students to make an informed decision about their lifelong career in the light of a deeper understanding of their abilities, away from the economic attractions of the dentistry.

Complementary Strategies

Like any other strategy, to achieve its goals, the proposed reform in DE requires a precise design and appropriate implementation of complementary strategies in different health system functions, including workforce planning. Particularly, there is an urgent need for an efficient type of mid-level providers at the primary level of health-care system (PHC) in order to harness the prevalence of common oral diseases, especially dental caries. According to the current evidence and the experiences of different countries, we think that an “expanded-duty dental hygienist” (authorized to perform simple restorations) would be a suitable choice.

For the optimal management of the DC delivery system after reorganization, modern technologies, such as teledentistry, can be employed to connect these first-level providers to those at the second level (dentists/oro-dental specialists). Besides, basic OH knowledge and competencies must be included in the general medical curriculum (Nash, 1995). Also, dental specialties—after probable revisions in their types and scopes of practice according to appropriate criteria, including community HC needs and implications for education and research—can be considered as subspecialties (tertiary DC) for this new medical specialty: Oro-Dental Health/Medicine.

The Influences of the Reform on the Medical and Dental Practice

The advocated change will certainly affect the current practice of both dentistry and medicine toward enhancing interprofessional care and the real integration of OH/OHC into the general health/HCS. Primarily, we think that this change will minimize the untoward effects of traditional dentistry—as discussed throughout this article—as an autonomous profession with hundreds of annual graduates equipped with an inherent therapeutic mechanical and costly approach for completely preventable OH problems. Furthermore, like other medical specialists, the general medical education will actually empower future oro-dental specialists with a holistic view of health and make them capable to better manage the medical conditions of their more likely complicated future patients (Beier, Kapferer, Burtscher, Ulmer, & Dumfahrt, 2012); this particularly matters in the context of an aging population.

From the other hand, general physicians equipped with appropriate OH knowledge and competencies during their formal education will be able to contribute more actively in managing the OH of the population. This will especially be the case when appropriate mid-level OHC providers are employed in the PHC teams led by a family/general physician.

If the complementary strategies are properly implemented, the advocated change will locate the common practice of dentistry at its right place as a second-level HC area. This allows prevention to be more rationally and efficiently addressed at PHC level in favor of the considerable OH benefits for the whole population.

In terms of DC financing, the structural integration of OH into the general health through treating DE/dentistry as a medical specialty (as well as the complementary strategies mentioned earlier) will pave the way for dental services to be more efficiently funded by general resources particularly under insurance plans (either public or private). Recent evidence suggests that embedding dental insurance within the general health plans could significantly promote financial protection against DC expenditures (Vujicic & Yarbrough, 2017). This would be of high importance in many countries where out-of-pocket payments are the prevailing way of financing DC including Iran and, especially, countries with a pluralistic HCS model like United States where insurance companies play an eminent role in HC financing. Of course, the details of such coverage need to be further investigated in order to make its dental-component responsive to real OH needs of the population. Considering dental diseases/infections as those in any other part of the body, redefining the basic benefit package of health services according to appropriate criteria with the consideration of DC and direct payment to mid-level OHC providers as the PHC agents of OH are among the issues that should be taken into account in this regard.

The implications of the proposed idea for the research community are considerable and crucial in order to provide robust supportive evidence for any decision made under the new paradigm. We believe that the most prioritized research area basically includes studies seeking to map the concept and define the contemporary role of the “dentist” as well as the coproviders of OHC including the mid-level providers and specialists (as the primary and tertiary DC providers, respectively) in a reorganized system. Meanwhile, studies are required to help establish a common and globally accepted framework for dental subspecialties (current dental specialties) based on appropriate criteria.

The proposed reform in DE is a result of a new paradigm in OH and dentistry, and so its implementation will certainly face barriers in the current structures and, perhaps more importantly, will entail challenges in convincing the main stakeholders, especially the dental community, about its necessity as an upstream strategy to optimize the DC/HC delivery system performance.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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