Adequacy of Patient Pools to Support Predoctoral Students Achievement of Competence in Pediatric Dentistry in U.S. Dental Schools

Predoctoral Dental Education Adequacy of Patient Pools to Support Predoctoral Students Achievement of Competence in Pediatric Dentistry in U.S. Dental Schools Paul S. Casamassimo, DDS, MS; N. Sue Seale, DDS, MSD Abstract: The aim of this study was to characterize the current status of predoctoral pediatric dentistry patient pools in U.S. dental schools and compare their status to that in 2001. A 2014 survey of school clinic-based and community-based dental patient pools was developed, piloted, and sent to pediatric predoctoral program directors in 57 U.S. dental schools via SurveyMonkey. Two follow-up contacts were made to increase the response rate. A total of 49 surveys were returned for a response rate of 86%. The responding program directors reported that their programs patient pools had declined in number and had changed in character with more diversity and fewer procedures. They attributed the changes to competition, cost, and location of the dental school. The respondents reported that community-based dental education clinical sites continued to provide additional service experiences for dental students, with contributions varying by the nature of the site. A large number of the respondents felt that their graduates lacked some basic pediatric dentistry clinical skills and were not ready for independent practice with children. The results of this study suggest that the predoctoral pediatric dentistry patient pool has changed and general dentists may be graduating with inadequate experiences to practice dentistry for children. Dr. Casamassimo is Professor and Chair, Division of Pediatric Dentistry and Community Oral Health, College of Dentistry, The Ohio State University; Dr. Seale is Regents Professor, Department of Pediatric Dentistry, Texas A&M University Baylor College of Dentistry. Direct correspondence to Dr. Paul S. Casamassimo, Division of Pediatric Dentistry and Community Oral Health, The Ohio State University College of Dentistry, 305 West 12 th Avenue, Suite 4126, Columbus, OH 43210; 614-722-5651; Casamassimo.1@osu.edu. Keywords: dental education, pediatric dentistry, dental school clinics, clinical education, community-based dental education, competence Submitted for publication 10/2/14; accepted 11/23/14 Recent increases in dental caries in children in the United States 1 suggest the need for a careful assessment of the level of preparedness of general dentists to treat young child patients. Garg et al. reported in 2013 that general dentists in practice in one city treated children selectively, 2 a phenomenon identified a decade earlier in our previous study. 3 These are mainly children older than four years of age who are well behaved, with minimal dental caries, and not supported by Medicaid. Paradoxically, dental care for children, especially children from low-income families, is increasingly being delivered by general dentists, often having recently graduated from dental school and in some corporate settings and community-based treatment programs in underserved areas. The implementation of the Affordable Care Act (ACA) provides coverage with pediatric oral health benefits for increased numbers of families with children through private insurance or Medicaid expansion. 4 One of the essential benefits mandated by the ACA is for pediatric services, including oral and vision care, and plans provided through the exchanges offer options for dental insurance for children. The general dentist may become the gatekeeper for dental benefits to children as well as a major provider. Preventive services by non-dentists to counter the surge in early childhood caries such as those offered by pediatricians and family practice physicians in well-child visits lag, even after a decade of emphasis. 5 Pediatric dentists account for only a small percentage of the dentist workforce and may be too few in number to accommodate the rise in dental caries or the expected increase in demand as a result of the ACA. School-based care by dentists or new 644 Journal of Dental Education Volume 79, Number 6

provider types will take years to be implemented and will reach only a segment of the population even at full capacity. These changes support a current assessment of the capacity and readiness of the general dental workforce to care for children. One concern is whether general dentists are being adequately prepared during dental school to assume an increased role in providing dental care to children, many of whom will present with complex treatment challenges. A variety of factors such as dental school location, patient payment requirements, faculty shortages, and new, more diffuse accreditation standards 6 have all been suggested as having a role in the changing preparedness of general dental graduates to care for children. A survey of predoctoral pediatric dentistry program directors conducted in 2001 found students were prepared in dental school to take care of children four years of age or older, who are well behaved, and who have low levels of dental disease. 7 A companion survey of general dentists revealed that, not surprisingly, those are the children they treat, strengthening the potential association between predoctoral education and subsequent practice patterns. 3 Recent anecdotal evidence indicates dental school predoctoral pediatric dentistry programs are having difficulties recruiting sufficient pediatric patients to meet program competencies. 8 An update of predoctoral pediatric dentistry programs to determine the adequacy of their patient pools to provide the education general dentists need to provide dental care to children is timely. The aim of this study was therefore to survey U.S. predoctoral pediatric dentistry program directors to determine the current status of their clinical programs with specific focus on patient populations, the procedures their students are performing, the location of the clinical experiences students receive, and the nature of student supervision. Methods This investigation received prior review and approval by the Institutional Review Board of The Ohio State University and was conducted in March 2014. A list of predoctoral pediatric dentistry program directors for all U.S. dental schools was obtained from the American Academy of Pediatric Dentistry. The survey was a revised version of a previously validated instrument we used in the 2001 study; it consists of 27 questions divided into three categories: patient pool and clinical experiences, competence of graduates, and faculty workforce. 7 Questions about patient pool inquired about adequacy, factors affecting it, and changes in patient characteristics over the past ten years. Questions about clinical experiences inquired about presence and location of these experiences and barriers to on-campus clinical experiences and external rotations. Additional questions sought answers about where various types of clinical experiences occurred, patient characteristics, payer sources in these locations, and supervision of students while treating patients in various locations. Questions about competence of graduates asked the respondents to identify essential pediatric dentistry skill sets for newly graduated general dentists, how the clinical experiences were provided, and their perceived readiness of the students to provide care for children upon graduation. The respondents were also asked about numbers of procedures students performed and whether patient care was comprehensive or single-visit encounters. Faculty workforce questions inquired about size and qualifications of program faculty, time allocation, and workforce changes over the past five years. The survey was pilot tested for clarity with ten full-time pediatric dentistry educators who would not be participating in the final survey. Their comments were incorporated into the final revised survey. The final survey was sent to predoctoral program directors in all 57 U.S. dental schools via SurveyMonkey. The identity of the respondents, based on school location, was maintained initially to allow contact with nonrespondents. A second mailing was made seven days following the initial email to all nonrespondents. Finally, a telephone call or personal e-mail contact was made to program directors not responding to the second email by the co-principal investigators. The surveys were de-identified when all responses were received, and all analyses were conducted without knowledge of the identity of the program providing data. Responses are reported using descriptive statistics and reported as frequencies. Results Surveys were received from 49 of 57 possible respondents for an 86% response rate after three contacts. Some respondents declined answering some questions and parts of questions. We report June 2015 Journal of Dental Education 645

the number of positive responses as the numerator and the number responding to that question as the denominator (i.e., positives/respondents). Patient Pool and Clinical Experiences Of the 49 responding program directors, 33 reported their pediatric patent pool was inadequate to provide predoctoral students sufficient patients to achieve program competencies and gave reasons such as inadequate numbers of pediatric patients to screen (29/33), location of dental school (18/32), and lack of patients requiring restorative care (16/31). Comments reported under an other choice as reasons for inadequate patient pools included competition with well-marketed, locally available, and efficient offices (corporate and private); traditional issues related to care provided within a dental school (e.g., lengthy appointments, parking, and inadequate curriculum time); and Medicaid state rules governing how families are assigned to providers. Reported changes over the past ten years in school-based predoctoral patient pools included fewer available patients (28/45), less decay (13/45), and greater racial diversity (18/45). Among the respondents, 70% (35/49) reported having external rotations for pediatric patient care for predoctoral students outside the dental school (Table 1). Those responding said these rotations occurred most frequently in community health centers (FQHCs), city/public health clinics, and mobile clinics. Other locations reported included (in de- creasing order of frequency) school-based programs, hospitals, clinics for patients with disabilities or special needs, private practices, women, infants, and children s (WIC) clinics, and Indian reservations. Of the 49 responding programs, 39 directors said they had an advanced education program in pediatric dentistry that competed with the predoctoral program for patients. Supervision of predoctoral students in external rotations depended on the type of clinic (Table 1). As might be expected, pediatric dentists supervised more frequently in hospital clinics, but also in private practices, mobile clinics, and school-based programs. General dentists were more likely than pediatric dentists or residents to be the supervising dentist in community health centers and city/public health clinics and, surprisingly, in clinics for patients with disabilities or special needs. Issues/challenges that precluded taking predoctoral dental students to off-site locations for pediatric patent experiences were reported by 17 of the 48 respondents to this question. Almost all of these 17 reported that lack of faculty supervision (16/17) and funding (14/15) prevented them from taking students off campus. Other oft-cited reasons included location/distance to travel, loss of income to school, not enough faculty full-time equivalents (FTEs), transportation, and lack of off-site locations. Respondents were asked to identify where, either in the dental clinic located within the dental school or in the community-based clinic, each of a list of pediatric patient experiences occurred (Table Table 1. Types of external rotations, frequency of use, and type of supervision, by number of respondents reporting each rotation type Supervision in Clinics by External Rotation Type Pediatric Dentists General Dentists Residents City/public health clinics N=25 9 15 2 Women, infants, and children s clinics N=12 4 2 0 Hospital clinics N=18 10 5 7 Community health centers (FQHCs) N=24 11 18 5 Private practice N=13 6 5 1 Indian reservation N=11 0 4 10 Clinics for patients with disabilities or special needs N=27 6 7 2 Mobile clinics N=29 9 7 4 School-based programs N=28 8 7 2 N=total number of participants responding to that item Note: Respondents could choose all supervision options that applied. 646 Journal of Dental Education Volume 79, Number 6

2). Treatment of Medicaid patient populations was more likely to occur in the dental school clinic than in the community clinic. Higher volume patient care occurred much more frequently in community-based clinics compared to dental school clinics. Experiences with infant oral exams, sedated patients, operating room/general anesthesia, and more advanced behavior management occurred slightly more frequently in community-based clinics than in dental school clinics. Special needs patients and children with high levels of caries were slightly more likely to be seen in the dental school compared with the community-based clinic. Children seen in the dental school clinic and the community-based clinic tended to be similar in mean age (8.0 and 8.1 years of age, respectively). Supervision of students during clinical experiences in the dental school was always provided by pediatric dentists (100%), with general dentists participating in supervision in less than one-third of the programs responding. Faculty members were reported as simultaneously supervising residents and predoctoral dental students in about half of the programs. Payer sources in the dental school differed from payer sources in the community clinics (Table 3). Cash, private insurance, and Medicaid were reported by 100%, 85%, and 94% of respondents, respectively, for the dental school patients compared with 74%, 65%, and 84%, respectively, for patients in the community-based clinics. Sliding scales and flat fee-per-visit were more frequently reported for the community-based clinics than the school-based clinics. No-pay patients were similar in the schoolbased clinics and the community-based clinics. Competence of Graduates We were interested in the impact of the patient pool on students achievement of competence, particularly in consideration of new accreditation standards of the Commission on Dental Accreditation (CODA) 6 since the last survey. Respondents were asked to choose from a list those competencies they deemed essential pediatric dentistry skill sets for newly graduated general dentists. These were procedures commonly used in pediatric oral health care (Table 4). The only skill sets not chosen by more than 90% of the respondents were behavior management techniques of voice control and protective stabilization, use of nitrous oxide, management of dental and alveolar trauma, and treatment of special needs patients. Respondents were also asked to identify how clinical experiences were provided to students in any of the following forms: live patient encounter, simulation and/or prepared cases, and observation of treatment. A choice of no clinical teaching in this area (didactic only) was also offered. Table 4 reports two of these choices (live patient encounters and Table 2. Types of pediatric dental clinical experiences by clinic location, by percentage and number of respondents reporting yes on each item Pediatric Patient Experience Dental School Clinic Community-Based Clinic Infant oral exams 61%/30 63%/26 N=49 N=41 Children with high caries levels 83%/39 78%/31 N=47 N=40 Medicaid patient populations 94%/46 74%/31 N=49 N=42 Operating room/general anesthesia 21%/10 23%/9 N=48 N=40 Sedated pediatric patients 23%/11 24%/10 N=48 N=41 Advanced behavior management 34%/16 37%/15 N=47 N=41 Special needs patients 60%/29 56%/23 N=48 N=41 Higher volume patient care 16%/7 53%/21 N=43 N=40 N=total number of participants responding (yes/no) to that item June 2015 Journal of Dental Education 647

Table 3. Payer sources reported for predoctoral dental care by clinic location, by percentage and number of respondents reporting yes on each item Payer Source Dental School Clinic Community-Based Clinic Cash 100%/47 74%/26 N=47 N=35 Private insured 85%/39 65%/22 N=46 N=34 Medicaid/CHIP 94%/44 84%/31 N=47 N=37 Sliding scale 21%/9 53%/18 N=44 N=34 Flat per visit fee 16%/7 24%/8 N=45 N=34 No pay (free care) 33%/15 29%/10 N=45 N=34 N=total number of participants responding (yes/no) to that item Table 4. Dental procedures respondents reported as essential for general dentist competence, for which their graduates were prepared, and how their students were prepared, by percentage and number of respondents to each item Essential Prepared for Live No Clinical Competence for Independent Patient Teaching Procedure General Dentists Practice Encounter in Area Diagnosis and treatment planning 100%/48 96%/47 100%/49 2%/1 Caries risk assessment 100%/48 89%/44 100%/49 2%/1 Restorative dentistry 100%/48 92%/45 100%/49 2%/1 Stainless steel crowns 94%/44 59%/29 86%/42 0 Pulp therapy 94%/44 57%/28 84%/41 2%/1 Radiographic techniques 100%/48 96%/47 100%/49 4%/2 Infant oral examination 92%/43 71%/34 83%/40 13%/6 N=47 N=48 N=48 N=48 Preventive treatments of prophylaxis and sealants 100%/48 98%/48 100%/49 4%/2 Tell, show, do form of behavior management 100%/48 98%/48 100%/49 4%/2 Voice control form of behavior management 62%/28 39%/19 53%/26 14%/7 N=45 N=49 N=49 N=49 Protective stabilization form of behavior management 27%/12 18%/9 20%/10 37%/18 N=44 N=49 N=49 N=49 Nitrous oxide/oxygen analgesia behavior management 75%/35 63%/31 74%/36 14%/7 N=47 N=49 N=49 N=49 Management of dental and alveolar trauma 83%/39 47%/22 49%/24 14%/7 N=47 N=47 N=49 N=49 Special needs patients 74%/34 42%/20 68%/32 3%/6 N=46 N=48 N=47 N=47 Space management 91%/42 71%/34 84%/41 8%/4 N=46 N=48 N=49 N=49 N=total number of participants responding (yes/no) to that item 648 Journal of Dental Education Volume 79, Number 6

no clinical teaching). Among the respondents, 86% reported live patient encounters for stainless steel crowns, 84% for pulpotomies, 83% for infant oral examination, and 74% for nitrous oxide/oxygen analgesia. More advanced forms of behavior management were reported much less frequently for live patient encounters with protective stabilization at 20% and voice control at 53%. In the area of protective stabilization, 37% of responding programs reported no clinical teaching (didactic only). When asked if their dental students were ready to provide care to children upon graduation as a general dentist for the listed procedures, 59% of the respondents said their students were ready to provide stainless steel crowns (SSCs) and 57% for pulp therapy. Fewer than three-fourths said they were ready to provide infant oral exams (71%) or space management (71%), and fewer than two-thirds said they were ready to use nitrous oxide/oxygen analgesia (63%). Only 47% reported believing their students were ready to treat dental alveolar trauma and 42% ready to treat special needs patients. Finally, respondents were asked to identify the numbers of sealants, simple restorations, pulp therapy, SSCs, space maintainers, and nitrous oxide experiences their students would have accomplished upon graduation in both the dental school clinics and community-based clinics. Experiences with sealants and simple restorations were reported to be greater in the community-based clinics. It was disappointing to note the more complex procedures of pulp therapy and SSC were at approximately the same low numbers in the community-based clinics as in dental school clinics. Table 5 reports the number of procedures performed by dental students according to location. Discussion This study assessed the status of predoctoral clinical education in pediatric dentistry in view of increases in dental caries in children, impending increase in care-seeking by families as a result of the pediatric oral health mandate in the ACA, anecdotal reports of deteriorating patient pools in dental schools, emergence of community-based training as an alternative to dental school-based training, and changes in accreditation standards related to predoctoral dental competencies. The most significant and ominous findings of this study were confirmation that two-thirds of respondents indicated their patient pools were inadequate to provide experiences necessary to train a general dentist to care for children and the assessment by predoctoral program directors of their graduates inability to perform certain basic pediatric dentistry procedures and services. A high response rate adds credibility to these findings and suggests that this is a significant problem in U.S. dental education. These results provide an opportunity to compare similar survey data obtained in 2001 7 with the responses in 2014. Major changes were noted in the program directors perceptions about the adequacy of patient pools for students to meet program competencies and in the reasons for the inadequacy. From 2001 to 2014, a 62% increase had occurred in the number of program directors who did not believe their patient pools were adequate (67% in 2014 vs. 42% in 2001). Reasons for this inadequacy had changed as well. Insufficient faculty and high clinic fees no longer appeared to have the same magnitude as problems (14% in 2014 vs. 29% in 2001 and 23% vs. 41%, Table 5. Number of procedures performed by graduating dental students in both dental school and community-based sites, by average and range reported by responding program directors (N=49) Dental School Clinic Community-Based Clinic Procedure Average Range Average Range Sealants 18.0 0-50 26.0 4-100 Simple restorations 8.7 0-20 14.5 0-50 Stainless steel crowns 2.1 0-10 2.1 0-10 Pulp therapy 1.1 0-10 1.7 0-10 Nitrous oxide/oxygen analgesia behavior management 2.3 0-20 1.8 0-5 Space management 2.0 0-10 0.5 0-2 June 2015 Journal of Dental Education 649

respectively). Shortage in numbers of patients to screen and location of dental schools were reported by nearly twice as many in this recent survey (85% in 2014 vs. 47% in 2001and 56% in 2014 vs. 39% in 2001, respectively) as contributing to insufficient patient pools. Dental schools have historically been the safety net for low-income populations, but with increased numbers of group practices accepting Medicaid and CHIP, families now have alternatives that may provide shorter appointments and better accommodate work schedules. Dental schools are often located remotely from patients and have insufficient parking, both of which may have increased these issues as perceived barriers. External rotations provide an alternative source of patients for students educational experiences, and dependence on them has increased slightly in the 12 years between these studies (71% in 2014 vs. 65% in 2001). Descriptions of rotations have changed somewhat, with greater participation in community health centers (76% in 2014 vs. 60% in 2001). Twothirds of the programs still use city/health clinics. A substantial drop occurred in the use of women, infants, and children s (WIC) clinics (18% in 2014 vs. 33% in 2001), hospital clinics (40% in 2014 vs. 63% in 2001), private practice (25% in 2014 vs. 33% in 2001), and Indian reservations (15% in 2014 vs. 20% in 2001). External rotations provide students with educational experiences, some of which may be difficult to provide within the dental school. Comparison of responses from the two surveys indicated differences over the past 12 years in what kind of experiences these rotations provide. The current program directors depended more on external rotations for training in infant oral exams (63% in 2014 vs. 48% in 2001) and special needs patient experiences (56% in 2014 vs. 42% in 2001), but were less dependent on them for training in more advanced behavior management (37% in 2014 vs. 54% in 2001) and high volume patient care (53% in 2014 vs. 89% in 2001). Advanced behavior management may be used less today, due to changes in guidelines, to account for decline in that area. The percentage of respondents reporting problems in taking predoctoral students off-site remained constant at 65%. In the earlier survey, lack of faculty supervision and not enough FTEs were problems identified by 100% of the program directors; and both factors continued to be major issues, receiving 94% and 71% positive responses, respectively, in the 2014 survey. Funding (94%), location/travel distance (79%), and loss of clinic income to the dental school (75%) appeared to have risen in importance in 2014, compared with 12% who identified these as problems in 2001. The need for alternative locations has become much greater, as directors reported insufficient numbers of patients in dental schools. To address this challenge, dental school administrations need to work with program directors to decrease barriers and facilitate use of community-based pediatric clinical education. Changes in responses about who supervised students while they were providing care in external clinical sites paralleled the most frequently given reasons as barriers to external rotations of lack of faculty supervision and not enough FTEs. That is, the 2014 survey found that clinic location and pediatric dentist supervision as barriers ranged from 60% to 33% depending on the location, but averaged about 47%, a substantial drop from the 87% reported in 2001. General dentists were reported to supervise from 17% to 72% of the time depending on the clinic location, but averaged 47%, which again is a decrease from the 61% reported in 2001. Supervision by residents ranged from 10% to 41% depending on location, and they only supervised in seven of the locations listed. Their coverage averaged to be 20%, which is a drop from the 56% reported in 2001. Major differences emerged in patient availability and amount of decay in patients over the thirteen years. The 2001 survey found that only 13% of the respondents thought the number of available patients had decreased in the previous ten years compared with over half of the 2014 respondents. Caries was thought to have increased by only 7% of the 2001 respondents compared with 29% in 2014. This transition may be indicative of an increase in caries, particularly in the more diverse population noted in the 2014 survey. Improvements in educational experiences for dental students were reported regarding infant oral exams, with 83% of program directors responding in 2014 that their students had live patient encounters compared with only 27% in 2001. Though not as dramatic, improvements were also reported for students experiences with children with special health care needs: up from 48% in 2001 to 68% in 2014. Live patient encounters with pulpotomies and SSCs, however, had dropped from 98% in 2001 to 84% and 86%, respectively, in 2014. Our comparison of the results of two similar studies over a decade apart showed a lingering and in 650 Journal of Dental Education Volume 79, Number 6

some cases worsening problem. Inadequacy of predoctoral patient pools identified in the current study involves structural problems within dental education to deal with environmental changes: competition by community-based treatment programs and changing care-seeking practices of patients. The numbers of patients seeking care in school-based dental clinics has declined, as has the amount of treatment needed by these patients. This is a decades-long deterioration, noted much earlier in the last century. 9 Dental school location was reported to be a problem in this study. These responses suggest that families are less willing to seek care outside their community. The Institute of Medicine has recommended that educational programs move to community-based settings to reach patients, 10 a sentiment echoed across several decades by expert panels and thought leaders in education and the professions. 11,12 A large percentage of programs responding to this study noted the addition of community-based clinical care to supplement on-campus experiences, yet reported problems with faculty coverage and financial issues that complicated the shift to communitybased care. It is not clear whether these problems speak to real obstacles to community placement of students or reluctance by institutions, even after decades of declining patient pools, to evolve to a more community-based educational model as is used in medical and other professional education. Some traditional institutions have embraced communitybased pediatric dentistry education with success, as in the program at The Ohio State University College of Dentistry, 13 and the newest generation of dental education programs, oft-termed the osteopathic model, rely heavily on community-based clinical education to provide student experiences. Paradoxically, dental visits by children have increased over the last decade, with governmentfunded programs showing the most growth. 14 Further confounding the plight of predoctoral dental education is the noted increase in early childhood caries at the turn of the twentieth century. 1 Families appear to be seeking pediatric dental services, and children increasingly need procedures but just not in traditional dental school settings. Ironically, in this study, respondents reported that their patient pools were now more diverse, suggesting that those with most dental need should be seeking care in the schools. With assurance of access to care in the ACA and Medicaid expansion, but with families facing economic challenges, limited work opportunities, and geographic distance from university campuses, it may be that alternative closer-to-home sites are more desirable. Limitations of this study include the structure of questions, which forced responses and may not have included all factors affecting these findings. For example, we used pulp therapy rather than listing types of pulpal therapy. We also did not conduct further analysis to determine association of variables to explain findings. Our purpose was primarily to reassess change in predoctoral education rather than to seek explanations and to be able to use the previous study 7 as a comparison to identify changes. Conclusion These results suggest a further deterioration of the educational value of dental school-based patient pools since 2001 as well as continued reliance on off-campus sites to provide students with relevant and adequate experiences. Further, this study suggests that the quality of graduates skills in basic pediatric dentistry procedures may be compromised by continued campus-based emphases in their education. Further research is needed to determine whether improved quality and quantity of experiences will result in a shift toward a more robust general dentist response to the need for pediatric dental care in the future. Acknowledgments This study was supported in part by the Pediatric Oral Health Policy Research Center of the American Academy of Pediatric Dentistry, Chicago, IL. The authors wish to recognize the assistance of Mr. Scott Dalhouse in development and administration of the study instrument. REFERENCES 1. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-94 and 1999-2004. Vital Health Stat 2007;11(248):1-92. 2. Garg S, Rubin T, Jasek J, et al. How willing are dentists to treat young children? A survey of dentists affiliated with Medicaid managed care in New York City, 2010. J Am Dent Assoc 2013;144(4):416-25. 3. Seale NS, Casamassimo PS. Access to dental care for children in the United States: a survey of general practitioners. J Am Dent Assoc 2003;134:1630-40. 4. Implications of the Affordable Care Act for dental care in the United States. Chicago: American Dental Association, 2013. June 2015 Journal of Dental Education 651

5. Lewis CM, Boulter S, Keels MA, et al. Oral health and pediatricians: results of a national survey. Acad Pediatr 2009;9(6):457-61. 6. Commission on Dental Accreditation. Accreditation standards for dental education programs. Chicago: American Dental Association, 2010. 7. Seale NS, Casamassimo PS. Pediatric dentistry predoctoral education in the United States: its impact on access to dental care. J Dent Educ 2003;67(1):23-30. 8. Gillette J. Survey results from predoctoral pediatric dentistry program directors meeting. Presentation at American Academy of Pediatric Dentistry Annual Session, Orlando, FL, May 2013. 9. McTigue DJ, Lee MM. Patient availability in undergraduate pedodontic programs. Pediatr Dent 1983;5(2): 135-9. 10. Institute of Medicine and National Research Council. Improving access to oral health care for vulnerable and underserved populations. Washington, DC: National Academies Press, 2011. 11. Pyle M, Andrieu SC, Chadwick G, et al. The case for change in dental education. J Dent Educ 2006;70(9):921-4. 12. Field MJ, ed. Dental education at the crossroads: challenges and change. An Institute of Medicine Report. Washington, DC: National Academy Press, 1995. 13. Thikkurissy S, Rowland ML, Bean CY, et al. Rethinking the role of community-based clinical education in pediatric dentistry. J Dent Educ 2008;72(6):662-8. 14. Nasseh K, Aravamudhan K, Vujicic M, Grau B. Dental care use among children varies widely across states and between Medicaid and commercial plans within a state. Research Brief. Chicago: American Dental Association Health Policy Resources Center, October 2013. 652 Journal of Dental Education Volume 79, Number 6