Dentistry As an Effective Entry Into Primary Care: The Dental School–Community Health Center Collaboration

The maldistribution of dentists nationally has complicated the ability of the dental profession to meet the oral health needs of many rural communities. To produce graduates who are inclined to serve the underserved, dental schools must select individuals who are predisposed to working with "at-risk" populations, by virtue of their previous commitment to community service. This is an important part of the "social mission of dental education." As Fitzhugh Mullan, MD, recently wrote, "…Social mission is about making health not only better, but fairer-more just, reliable, and universal."¹ Some schools emphasize health disparity reduction in their missions, such as the colleges of medicine and dentistry at the Mesa, Arizona campus of A.T. Still University (ATSU).¹

Since its creation, Arizona School of Dentistry & Oral Health (ASDOH) has based much of its educational model on the visionary idea of selecting students from rural areas and collaborating with local community health centers (CHCs) to nominate applicants who they believe will return to their communities to serve. Known as the "Hometown Program," this effort encourages CHCs to recommend applicants who would support the "social mission" of returning to and possibly practicing at their CHC. This program assures that the CHC's nominee will receive an interview.

The ASDOH model also requires fourth-year students to spend about half of their clinical experience/education in local CHCs throughout the United States. These 4- to 5-week rotations enable the student to participate in a "real-world" setting and be exposed to the integrated models of care that are foundational to providing care in the CHCs. This exposure to rural communities seems to positively influence student attitudes about treating underserved populations.² In addition, dentists from rural areas are much more likely to return to rural areas to practice.³

It appears that the formation of dental school-community health center partnerships to improve health and well-being is becoming more widespread across the United States, with ATSU/ASDOH taking the lead role in initiating and fostering these partnerships. This collaborative approach is effective because many different CHCs are addressing similar issues and serving similar populations. Collaboration creates an opportunity to align efforts, reduce duplication, optimize financial resources, and, ultimately, improve the overall health and well-being of communities.

Lack of access to oral healthcare contributes to profound and enduring oral health disparities in the United States. The US healthcare system is able to provide acute care but continues to struggle with the need for ongoing care, especially for vulnerable populations. CHCs help by providing services to uninsured, low-income, and underserved populations.

The issues of oral health and the underserved have been addressed in a policy paper, Oral Health for All: Policy for Available, Accessible, and Acceptable Care.⁴ This paper makes recommendations regarding the integration of oral health services into healthcare delivery.⁵ In 2011 the Institute of Medicine published two reports. The first explored ways to promote the use of preventive oral health interventions to improve oral health literacy.⁶ The second report focused on access to oral healthcare for vulnerable populations.⁷

CHCs have served as the largest primary care network in the United States for 50 years. The nation's safety net of more than 1,300 CHCs operates over 10,000 clinics, caring for 27 million individual patients. Committed to improving the health of their communities, these nonprofit organizations are governed by the patients they serve. A passion for those "most in need" puts CHCs in the frontlines of the strive for social justice, according to Gary Cloud, PhD, Vice President, Strategic University Partnerships at ATSU, in an email communication with the authors August 2017.

At the Policy & Issues Forum at the National Association of Community Health Centers meeting in 2014, Vice President Joe Biden said, "This country has always been about possibilities…and the kind of work you have been doing reflects that belief. Community health centers are the indispensable resource for so many people who are underserved and under-insured. Thank you so much for what you've done, not for us, but for the American people."⁸

NACHC and ATSU have a unique partnership, one that is intent on addressing a portion of the nation's need for high-quality, community-minded, culturally competent, compassionate healers. The partnership began with the opening of a health center-focused dental school (ASDOH), and moved forward to a health center-focused medical school (ATSU-School of Osteopathic Medicine in Arizona [SOMA]), followed by a second health center-focused dental school (ATSU-Missouri School of Dentistry & Oral Health [MOSDOH]).

The success of the ASDOH clinical collaboration with CHCs is due to a number of opportunities that are part of the clinical experience of ASDOH fourth-year students. These include working in an interprofessional environment that promotes whole-person health and experiencing social justice firsthand by providing care to many rural, poor, elderly, and intellectually developmentally disabled patients. Often this is the student's first opportunity to venture into new geographically underserved areas. After seeing how satisfying the experience can be, many of the students choose to accept residencies and employment at these CHCs.

ASDOH received a major Health Resources & Services Administration (HRSA) grant to work with a CHC to enhance its interprofessional curriculum while adding teledentistry to the learning experience. ASDOH students, working alongside medical students and staff at a CHC, are modeling a learning experience that will further enhance whole-person health efforts. The integration of oral health into primary healthcare is becoming a cornerstone of healthcare reform and the efforts to improve health.

Research has shown that after the cost of dental care, low oral health literacy is a major reason why people do not visit the dentist, even if they have dental insurance, transportation, and a ready-and-willing provider, and more than 35% of Americans fall into this category.⁹ Technology, social media, and existing dental staff must be utilized to make positive changes in this area. Health insurers must fully understand that oral health impacts overall health-especially chronic diseases-and can easily be managed by integrating oral health into primary care while reducing costs. The abundance of research, such as Jeffcoat et al's study examining emergency room visits for oral health,¹⁰ continues to demonstrate the increased cost in both dollars and health status caused by failure to fully integrate oral health into primary care.¹¹

The successful adoption of the ASDOH collaboration with CHCs by other dental schools will greatly enhance the awareness of future dental graduates in developing partnerships with medical, behavioral, and other healthcare providers. Registered dental hygienists (RDHs), for example, are extremely well-qualified to provide the needed "patient education" and many would undoubtedly gladly do so if compensated for their time. The sharing of oral, nutritional, and other health-related information by an RDH or other dental professionals should be a normal part of the dental visit.

CHCs are well-equipped to provide this type of patient education, and, in fact, many of them do. ASDOH has partnered with some CHCs to help them introduce the ASDOH-developed app Text2Floss to their patients to increase oral health literacy. The successful use of this app in a CHC was documented in a research project reported in the Journal of Public Health Dentistry.¹²

Over the past 11 years, more than 30% of ASDOH graduates entering the dental profession are working either at CHCs or the military. This is the highest percentage of graduates nationwide and demonstrates how the experience of students working in these communities can positively impact the critical issue of maldistribution of dentists. The constructive experiences ASDOH students have during these rotations are documented in their weekly reflections. These experiences underscore the importance of dental schools collaborating with local community clinics and rural CHCs.

Leonard B. Goldstein, DDS, PhD
Assistant Vice President for Clinical Education Development, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona; The ATSU Center for the Future of the Health Professions

Jack Dillenberg, DDS, MPH
Dean Emeritus, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona; The ATSU Center for the Future of the Health Professions