Journal of Public Health Dentistry . ISSN 0022-4006

How can dental public health competencies be addressed at the undergraduate level? Mario A. Brondani, DDS, MSc, MPH, PhD; Komkham Pattanaporn, DDS, MPH, DrPH; Jolanta Aleksejuniene, DDS, MSc, PhD Faculty of Dentistry, Department of Oral Health Sciences, University of British Columbia, Vancouver, BC, Canada

Keywords dental education; public health dentistry; community services; self-reflections; competency-based education; dental public health; health workforce. Correspondence Dr. Mario A. Brondani, Faculty of Dentistry, Department of Oral Health Sciences, University of British Columbia, 2199 Wesbrook Mall, Vancouver, BC V6T1Z3, Canada. Tel.: 604-822-6562; Fax: 604-822-3562; e-mail: [email protected]. Mario A. Brondani, Komkham Pattanaporn, and Jolanta Aleksejuniene are with the Faculty of Dentistry, Department of Oral Health Sciences, University of British Columbia. Received: 4/22/2013; accepted: 7/22/2014. doi: 10.1111/jphd.12070 Journal of Public Health Dentistry 75 (2015) 49–57

Abstract Objectives: To discuss the extent to which an undergraduate dental module addresses dental public health competencies via its different learning pedagogies and to explore the relevance of students’ written reflections on these dental public health competencies. Methods: This article uses a literature review to situate the extent to which dental public health competencies are addressed by the University of British Columbia undergraduate dental module entitled “Professionalism and Community Services” (PACS). It also uses students’ written individual self-reflections (between 100 and 500 words) on community service learning activities to critically illustrate how dental public health competencies support their learning. Results: The PACS dental module is delivered to undergraduate students in all 4 years, more than 190 in total, and addresses six dental public health competencies, including oral health promotion, ethics, and evidence-based practice. The multifaceted pedagogical approach employed to discuss aspects of dentistry related to dental public health includes guest lectures, community activities, small group activities, self-reflection, and reports. Conclusions: Given the falling number of dental public health professionals in North America, the discussed undergraduate pedagogy aims to sensitize future dentists to a career focused on dental public health. Through reflections, students pondered ideas related to dental public health; they also engaged in developing meaningful activities in various underserved communities. Further studies are needed to evaluate the influence of this community-based curriculum upon students’ practice choice.

Introduction Dental public health is a nonclinical specialty that focuses on assessing the oral health needs and improving the dental health of populations rather than individuals (1-3). This is done by educating the public about oral health and by applying evidence-based research for community-based prevention and control of oral and dental diseases (1,2). A dental public health professional must possess broad knowledge and skills in administration, research methods and oral health assessment, prevention and control of oral diseases and oral health promotion, and delivery and financing of oral health care (2,4). In 2008, the Canadian Association of Public Health Dentistry released the Discipline Competencies for Dental Public Health in Canada, outlining the essential knowledge, skills, and attitudes necessary for the practice of dental public © 2014 American Association of Public Health Dentistry

health (4). This document provides the building blocks for effective dental public health, listing competencies in tune with the American accreditation standards in dental public health (2), which fall within the scope of public health as a whole (3,5,6). Such competencies remain suitable for teaching undergraduate dental students about the role of the discipline of dental public health in the oral health of the population at large.

The need for undergraduate education in dental public health In Canada, disparities in oral health and inequities in access to oral health care not only persist but have increased in the past few years (7). Released in 2011, Cycle II of the Canadian Health Measure Survey revealed that approximately 40.36 49

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million hours per year were lost from work, school, or normal activities due to dental sick days/dental visits from 2007 to 2009. Hence, almost 50% of lower-income earners required some form of dental treatment, but only a fraction of them had access to proper care (8). The situation is worse among Canadian First Nations and Aboriginal peoples (9-11). Similarly, the 2000 U.S. Surgeon General’s report on oral health highlighted that“while the majority of North Americans have adopted safe . . . means of maintaining oral health . . . many still experience needless pain and suffering [at] financial and social costs that significantly diminish the quality of life”(12). The Canadian and American reports attest to the existence of a gap between research findings and public health practices. In the hope of narrowing this gap, some dental schools in the United States offer dual-degree programs combining the DMD and Master of Public Health degrees (13). In fact, the World Dental Federation has emphasized that a positive attitude toward dental public health could be developed through undergraduate dental education (14). As such, community-based learning activities and health promotion programs would address the needs of the public at large and help to counteract the public image of some dentists as “drill and fill merchants” (15). This article aims a) to discuss the extent to which the University of British Columbia (UBC) undergraduate dental curriculum addresses dental public health competencies via its different learning pedagogies and b) to explore the relevance of students’ written reflections on these dental public health competencies to their dental education.

Methods This article uses a literature review to provide background information on dental public health competencies and to situate the extent to which these competencies are addressed by the UBC undergraduate dental module entitled “Professionalism and Community Services” (PACS). It also uses some examples of students’ written reflections, gathered since the PACS module was introduced in 2007, in a descriptive inquiry to critically illustrate how dental public health competencies support students’ learning, as well as students’ perspectives on the value of the activities described. These reflections are not analyzed qualitatively for their thematic content because we have already provided such analysis elsewhere (16-18). Our paper is structured in the following sequence: We first present the multifaceted pedagogical approaches we have employed to directly and indirectly discuss aspects of dentistry related to dental public health. We proceed by illustrating the extent to which these approaches address the dental public health competencies for the new graduate in dentistry outlined by the Association of Canadian Faculties of Dentistry (ACFD) and the American Association of Public Health Dentistry (AAPHD) (2,19) (Table 1). As an 50

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undergraduate curriculum for graduate general dentists, the UBC Faculty of Dentistry dental program is not meant to explicitly cover the AAPHD competencies or any of the other specialties in their entirety. We utilize selected community feedback to illustrate community views on students’ engagement in dental public health issues. We conclude the article with recommendations and implications for certification in the profession while calling on other dental schools to join a dialogue about the need for undergraduate training focused on dental public health.

Dental public health competencies and the PACS undergraduate dental module In the fall of 2007, we formally introduced the PACS module at the UBC Faculty of Dentistry. This community servicebased undergraduate dental education module spans all 4 years of the DMD curriculum, from 24 weekly 3-hour sessions in year 1 to five consecutive 8-hour full days in year 4 (16). Community-based dental education is supported by the principles of experiential learning pedagogy (20). The PACS module encourages students in all 4 years1 of the DMD curriculum to think critically about the community as their patient while discussing the social determinants of oral health through a dental public health lens. It also focuses on six domain competencies out of the 47 that are necessary for a new graduate in dentistry according to the ACFD (19) (Table 1). These six competencies were purposefully selected because they address, directly or indirectly, some of the dental public health competencies suggested by Brothwell (13), and although they are listed as separate competencies in Table 1, their objectives and related activities might overlap. PACS combines small-group activities related to community services, such as teaching, learning, and reflection. with preclinical and clinical initiatives in various communities, mentored by a licensed and experienced dentist or dental hygienist with a faculty appointment (16,20). These activities aim to enrich students’ learning experiences, encourage their lifelong community engagement, and strengthen communities (21). In our previously published work (16,17,20), the various activities involved in the PACS module have been discussed in terms of their relevance to dental public health, as we aim to do here. With the aim that meaningful community service should also foster interest in and engagement with dental public health, the relationship 1

Annual enrolment at the UBC Faculty of Dentistry varies.Years 1 and 2 can have between 45 and 50 students each, while years 3 and 4 may have between 50 and 65 each, given the addition of students from the international dental degree completion program. The total number of students in a given year varies between 180 to 220 for all academic years combined.

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Professionalism, Competency #4 Communicate effectively with patients, parents or guardians, staff, peers, other health professionals and the public

Professionalism, Competency #45

Communication skills

Ethics/professionalism

† Examples are given only for selected pedagogies.

* These objectives are addressed in all four years of the PACS module.

patients, society and the profession

Demonstrate professional behavior that is ethical, supersedes self-interest, strives for excellence, is committed to continued professional development and is accountable to individual

Apply accepted principles of ethics and jurisprudence to maintain standards and advance knowledge and skills Professionalism, Competency #47

Professionalism, Competency #3 Evaluate the scientific literature and justify management recommendations based on the level of evidence available

Evidence-based practice

Health Promotion, Competency #25

Health promotion and

Provide education regarding the risks and prevention of oral disease and injury to encourage the adoption of healthy behaviors

Health Promotion, Competency #1 Recognize the determinants of oral health in individuals and populations and the role of dentists in health promotion, including the disadvantaged

Determinants of health

education

ACFD competency (19)*

Domain

self-interest, strives for excellence, is committed to professional development, and is accountable to individual patients, society, the

Competency IV.1 Applying the acceptable principles of ethical behavior and professional conduct (professionalism)

profession, and to the public

Recognize and demonstrate professional behavior that is ethical and lawful, supersedes

with the public

Communicate effectively, both orally and in writing, with colleagues, practitioners, staff, patients, and

health of individuals, families and groups in the community Provide care that emphasizes prevention of oral disease, and supports the maintenance of existing systemic and oral health for patients of all ages Acquire, synthesize and apply information in a scientific, critical and effective manner and apply to improve health of vulnerable populations

Assume a role for improving the

Recognize the wider social factors (determinants) that affect health and oral health in individuals and populations

PACS objectives

Competency IV Incorporate ethical standards in oral health programs and activitie

health issues

Competency VII Communicate and collaborate with groups and individuals on oral

Competency II.8 Serving as a resource for professional and community groups concerning evidence for the effectiveness of preventive and treatment interventions and the rationale for their use

Develop resources, implement and manage oral health programs for populations

Competency III

Competency I.2 Assessing oral health status, needs and demands, and their determinants in a community

AAPHD competency (2)

the complaint department from the local licensure college

Year 1: Standardized patients, small group learning, self-reflection Year 4: In-class discussion using real cases from

Year 4: Clinical care in the community and interprofessional communication

guest lecture on conflict management and communicating with dementia patients Year 3: Guest lecture and hands-on behavior management of children

Year 1: Individual volunteer patient interview, FIFE technique, self-reflection Year 2: Individual patient interview (life history),

Years 1 to 4: Lectures, small group leaning, computer lab (searching strategies), evidence-based report

planning, implementation, and evaluation, with a final report Year 3: Hands-on evaluation of preventive activities in inner-city schools

clinics and hospitals Year 1: Hands-on oral health promotion

Year 4: Provision of clinical care in community

Year 3: Lectures, self-reflection, preventive activities in inner-city schools

Year 1: Lectures, small group learning, in-class activities, self-reflection, oral health promotion projects in community organizations Year 2: Lectures, small group learning, workshops, self-reflection, oral health promotion, and pre-clinical activities in long-term care facilities

PACS year and pedagogies used†

Table 1 Dental Public Health Knowledge Domains for the Public Dental Health Fellowship Exam and Competencies Addressed in the “Professionalism and Community Services” Module

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between the public health competencies and the PACS module is presented and discussed below. Determinants of health Didactic components that address health determinants are included in all 4 years of the PACS module using different pedagogies, and some from selected years are presented below. Year 1 The first hour of a 3-hour inaugural session involves students in small groups examining extracted teeth while thinking aloud about the following questions:“Why do you think these teeth had to be removed? What are the determinants of health and how do they impact each community similarly and differently? What is the main role of a dental professional in the community?” The main goal of this activity is to enable students to recognize the reasons for tooth extraction while critically considering the variation in oral health and disease patterns in different communities. Year 3 Third-year students learn about social and cultural determinants affecting the oral health of children from underserved communities. Students visit inner-city elementary schools and engage in face-to-face encounters with children between the ages of 5 and 13 years from different ethnic and cultural backgrounds. Students further develop their communication skills and understanding of how sociocultural determinants influence oral health of children and their families. In another rotation based on community service, students meet children under 2 years old. mainly from working poor or immigrant families, and their parents. On this particular rotation, students have the opportunity for first-hand experience of sociocultural determinants of health, including language barriers, low socioeconomic status, and culturally relevant beliefs and practices. As advised by Brill and colleagues (22) and others (23), community-focused activities like these can sensitize students to social determinants of health and health disparities. Education and health promotion

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evidence-based practice to assess the needs of a community and plan, implement, and evaluate a community-based health education program at their assigned site over a 9-week period (20). On a smaller scale, these activities also mirror the dental public health competency that involves the ability to “plan oral health programs for populations” (2). The learning objectives of this community service are to encourage students to understand the challenges that vulnerable segments of the population face and to enable them to learn about and experience first-hand some of the social determinants of health (20) as suggested by Kwan and collaborators (24) and Horowitz and Frazier (25). Year 2 Students in groups of eight provide preclinical oral care for the institutionalized elderly (26), such as caries-control procedures and denture marking and cleaning. Students also engage in educational activities with care aides that involve denture cleaning and assessing activities of daily living (27), as described by Brondani et al. (28). More importantly, students are encouraged to reflect on care for the elderly that is humanistic, interdisciplinary, and interactive with family members and with care aides and other health-care professionals (18). While considering the impact of aging within the public health care system, students learn that tooth retention in old age can impact dental care utilization, but the lack of dental public health programs tailored to this cohort of the population leave seniors on society’s margins (29). Evidence-based practice Evidence-based practice (EBP) is understood as the conscientious, explicit, and judicious use of current evidence in making decisions about the care of individual patients and/or communities (30). The principles of EBP are taught throughout all four years of the PACS module incrementally, using different individual and group activities. Year 1 Students learn the basic principles of evidence-based practice, including how to develop questions under the PICO framework (Patient/Population, Intervention, Comparison, Outcomes) for literature searches for the best evidence. Students also learn how to assess the credibility of information sources.

Year 1 For purposes of oral health promotion, groups of eight students each are assigned to a community site: an inner-city elementary school, a community center, or a not-for-profit organization. Under the supervision of a tutor and module coordinator, students apply principles of public health and 52

Years 2 to 4 EBP skills are further practiced as students prepare and implement different community-based oral health promotions and preclinical and clinical care based on the best available evidence. © 2014 American Association of Public Health Dentistry

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Communication skills Didactic components that address competency in communication skills are also threaded throughout the 4 years of PACS.

Year 1 As a key element in successfully interacting with the public, the ability to communicate efficiently is discussed during a 3-hour session covering the principles of effective communication. During this session, students role-play individually in an 8-minute interview scenario with a volunteer patient, usually a faculty or staff member. The scenario focuses on obtaining the medical and dental history while the others in the group observe. Students are introduced to the FIFE (Feelings, Ideas, Function, Expectations) technique, to be employed during the role play (31). Following the role play, a discussion takes place among the students, the volunteer patient, and the group tutor, the latter providing constructive feedback and talking about the interviewing process as a whole.

Year 2 Students have an interactive 2-hour session with a speech– language pathologist who discusses communication techniques for older adults with dementia and their family members. In another session, students are exposed to tactics of conflict management in which they learn how to recognize different stages in conflict, how to identify a number of situations where conflict might occur, and how to develop strategies to deal with conflict. Conflict resolution is an integral part of public health leadership and health care management and utilization (32,33).

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with regard to the ethical principles of autonomy, nonmaleficence, beneficence, and justice (17). Year 4 The ethics theme is wrapped up with real cases provided by the complaint department of the College of Dental Surgeons of British Columbia. The goal of this fourth-year session is to explore how senior students react to real ethical scenarios that portray issues of complaints and conflicts in dentistry, many of which they might have experienced while providing clinical care in their final undergraduate year. Professionalism Year 1 Although the discussion of professionalism is integrated into all 4 years of PACS, its core principles are introduced in the very first session of this module in year 1, before the activity with the extracted teeth described above. During this session, students discuss the article series entitled “Is dentistry a profession?” (34-36), which ponders the meaning and implications of professionalism within the social contract between the public and dental professionals beyond the “drill-fill-bill” philosophy (14). Students also discuss the UBC professional standards document,2 which they read, discuss, and sign while revisiting some of the ethical content and the ethics/ professionalism issues they may encounter in the course of practicing their profession. We strongly believe that ethics and professionalism not only overlap but also complement one another, as acceptable professional conduct will be expected to embrace ethical behavior.

Results Ethics Ethics, as an integral part of the profession, is explored longitudinally in PACS.

Year 1 Two intensive sessions with standardized patients roleplaying different ethical scenarios take place to present and discuss ethics as fully described by Brondani and Rossoff, with emphasis on the principles of autonomy, nonmaleficence, beneficence, and justice (17). The first session starts with a 1-hour seminar to discuss the principle of ethics among students, tutors, and representatives from the American College of Dentists. Following the ethics role play, students are provided with the Code of Professional Conduct and discuss in their small groups the relevance of such a code © 2014 American Association of Public Health Dentistry

Throughout PACS, we encourage students to self-reflect on a continual basis (37). Reflection is one of the didactic assessment tools we use to bring significance to what is learned and allow students to question and ponder issues that still need to be addressed or further explored (17,37). As we have published elsewhere, reflections are conducted individually, either typed on a computer or handwritten (100 to 500 words per entry, two to six entries per year per student), and the group tutor motivates further thinking by giving constructive feedback on each reflection individually in a formative manner; no grades are given (16-18). We have gathered more 2

This document was developed by the UBC Faculties of Medicine and Dentistry. Learners and faculty are required to demonstrate expected behaviors and to meet expectations of professional conduct within the following areas: honesty, respect to others, confidentiality, and responsibility.

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than 1,000 individual reflections since 2007, when the PACS module was first introduced. This article focuses on reflections provided by students that directly or indirectly address the dental public health competencies outlined in Table 1, reproduced with permission from the Behavioural Research Ethics Board of the University of British Columbia as with our previous articles (16-18). Excerpts from some of these reflections from students in different years are presented to illustrate the extent to which students have pondered the six dental public health competencies, while community feedback is employed to demonstrate the value of such community service activities. The reflections are not used to evaluate how well students learned the different dental public health competencies. Rather, they are used to illustrate the impact of the UBC undergraduate dental module upon students’ learning within the objectives of the PACS module. Other forms of assessments are used as outcome measures throughout the PACS module but are not presented here.

Determinants of health For a fourth-year student in 2010 going to a not-for-profit organization that provides nonmedical resources to HIVpositive clients, the determinants of health were illustrated by one of the organization’s members, who shared the story of his battle with HIV: We were introduced to a member who told us about his situation, from how he found out he was HIV positive while still working to being homeless and at society margins. It really brought home the message that working conditions, housing, and social ties are not only determinants of your health, but also of who you are. In 2009, a second-year student going to a long-term care facility reflected on the diversity of this population and on the need to respect them individually, while recognizing the limitations of health assessments performed in a public health field: The most impactful moment was to realize how diverse the elderly population is . . . I was puzzled by the subjectivity of health assessments. The first person I saw was a male in his mid-seventies, very active and cognizant, and yet his chart showed a score on an index of independence of 1, implying dependency in almost all levels. I questioned if that was an accurate measurement or if his independency fluctuated with time. This student questioned the value of measuring health status as static when, as discussed by Allison et al. (38), it fluctuates over time. Equally importantly, this reflection challenges the use of such measures as the sole basis for assessment of health and quality of life when the sociocultural context is not always acknowledged (39,40). For a first-year student going to a community center in 2011, the health promotion aspect of the activities offered a 54

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moment for reflection regarding positive feedback and impact on the residents: It was challenging to receive criticism in front of the participant . . . I was brushing his teeth with too much toothpaste [which could have caused further burning on his already dry mucosa]. But the tutor brought up great points and got me thinking.

Health promotion The reflections on this competency attest to the fact that oral health promotion can improve knowledge and even oral hygiene performance but may have only a limited impact on caries experience and long-term behavior change (41). In fact, students from different years of PACS concluded that their oral health initiatives might provide knowledge and information but have yet to modify attitude and change behavior as advised by Freedman and Ismail (42) and others (28). For a first-year student going to not-for-profit organization in 2008, the message learned was prioritization and awareness: While we are dental professionals, sometimes we forget that people have different priorities in life, and brushing teeth might not be the first one. If parents do not see the value of taking care of their own teeth, how can we expect them to care for their children? The above reflection concurs with Watt’s recommendations to focus effort on the interrelationships of personal, socioeconomic, and cultural factors when planning for long-term and sustainable improvements in oral health (43). For a thirdyear student going to a community center in 2010 to talk to young adults about the risks posed by tobacco smoking to oral and general health, the implications of smoking to the public health care system were presented to engage participants, as discussed by Saywell and colleagues (44) and others (45): When our group shifted the presentation from “tobacco is not good for you” to explaining that the money spent in hospitals to treat tobacco-related diseases could be used [for] something else in their communities, we got their attention. In fact, preaching about quitting smoking under only the argument that it is detrimental to health has been proven to be insufficient for behavior change (39,46,47).

Evidence-based practice Throughout the 4 years of PACS, EBP helps students to focus their efforts when conducting literature reviews and synthesizing information for other modules. For a student who was in the second year in 2011, the relevance of EBP principles discussed in year 1 came in handy for delivery one of the module assignments, a report on the guidelines for © 2014 American Association of Public Health Dentistry

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performing oral care during a flu outbreak in long-term care, for which the student received praise: When I first had a lecture on the EBP principles, I found myself a bit lost. They were not readily applicable. But now, for this assignment, it was much easier to focus on that particular piece of evidence and evaluate effectively the existing claims.

Communication skills Good communication is relevant to any educational process or setting at individual, group, or population level. According to a first-year dental student going to a community center to develop a dental health educational project in 2010, proper communication can be hindered by language barriers: Some participants were not comfortable asking us questions about their own oral health probably because you could see they were not understanding everything. Healthcare professionals should perhaps spend more time with each patient and really ask questions so they don’t leave the offices feeling like their doctor or dentist didn’t really explain everything. When discussing public health leadership, Olson (48) concluded that communication skill development is indeed an integral part of exemplary practice. For one activity, students’ leadership attempts were observed by a community site coordinator who provided feedback to the first author (MB): I was impressed by one of the student’s efforts in making sure the participants were understanding what was being presented as most of your clients are non-Englishspeakers. She took a leadership role in using draws and body language but without dominating the presentation. In a multicultural and diverse society such as North America, more than half of public health care workers encounter patients and communities with limited English proficiency (49), and the use of non-English language skills might be necessary to communicate successfully.

Ethics and professionalism The teaching pedagogy employed to discuss ethics in PACS has been extensively presented in Brondani and Rossoff (34); thus, the focus on competency #45 in this article serves to illustrate how “the approach to dental ethics presented does not profess to make an otherwise unethical dentist ethical, but it can give all students the tools to recognize when a dilemma exists . . . and ultimately make a good decision.” Students are given tools to act ethically and professionally, but it is their responsibility to “walk the walk.” The reflections on professionalism have been informative to us, as they have demonstrated students’ growth and personal development. They have also shown that the impact of © 2014 American Association of Public Health Dentistry

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the PACS community experience as a whole can vary. It can be positive for some, as for a third-year student going to an inner-city school in 2011: I love children and was considering specializing in pediatric dentistry [and] this experience was exactly what I needed to get a first taste of working with children. However, for others, such as a second-year student going to a long-term care facility in 2009, it can be questionable. I did not necessarily enjoy the activities with the residents. The facility had a general ‘depressing’ atmosphere that made me think . . . I would never like to be living there or go there as a dentist.

Discussion The four years of the PACS module involve integrated teaching of six competencies related to dental public health. Nonetheless, the actual impact of the PACS module upon newly graduated students’ choice of professional career remains unknown. In contrast to Altman et al. (50), we cannot guarantee that our community service learning curriculum has influenced students’ choice of practice, either as volunteers in the community or as full-time public health dentists. We do expect that by exposing students to dental public health core values (i.e., competencies), undergraduate modules like PACS can enable future dentists to readily apply such principles in their future careers or inspire them to pursue advanced education in the field.

Conclusion We believe that dental modules such as PACS can nurture an interest in dental public health and engage students with meaningful activities in various underserved communities. However, follow-up studies involving UBC graduating classes that have experienced all 4 years of PACS are needed to explore the extent to which this community-based education has impacted young professionals’ attitudes towards dental public health and how well the students have fulfilled the domains and competencies presented. Nevertheless, it remains naïve to think that all students and dentists would necessarily be willing to work outside a private practice model to attend to the needs of the public. As reflected by a student in 2009 who was asked about the role of dentistry in addressing oral health disparities: Perhaps it is not a “one size fits all” approach, but a combination of public services and private workforce. Either way, much of the profession of dentistry remains a business involving private enterprise; we concur with Leake that “the low and falling number of qualified active dental public health specialists represents a severely compromised capacity” (7). Given the constraints of an undergraduate training focused on graduating competent general dentists, 55

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the falling number of specialists could be counteracted by recognizing dental public health training from nontraditional and perhaps nondental public health programs that still meets the requirements for board examinations. Perhaps our specialty has to be flexible, while still maintaining the professional standards for fellowship and board certification, to produce enough qualified dental public health workers and faculty members with knowledge and skills to conduct practice of and examinations in dental public health. Unless this occurs, the trend observed by Leake will get worse, and dental public health initiatives will have insufficient numbers of advocates and certified fellows. Accordingly, we would like to invite dental schools worldwide to join a dialogue about undergraduate training focused on dental public health and its impact upon future dental professionals, given that, as outlined by the Lalonde report 40 years ago (51), an increase in service availability and access does not necessarily equate to higher utilization or better (oral) health.

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5. 6.

7. 8.

9.

10.

Acknowledgments The authors are grateful to the students who provided their reflections, to their respective tutors who guided them, and to the site coordinators, volunteers, and community guests who participated in this module. Special thanks go to Drs. Larry Rossoff and Bill Brymer for their commitment to the PACS module and students’ learning and to the anonymous reviewers who gave us insightful ideas and suggestions on this article. The authors are grateful to Adrian Carney and Ingrid Ellis for their insights and ideas on the style of this article. This publication is based on an oral presentation entitled “Public health dentistry within an undergraduate dental curriculum: Is community service learning the answer?” that was presented during the 2012 meeting of the Canadian Association of Public Health Dentistry in Prince Edward Island, September 21-23. References 1. Canadian Association of Public Health Dentistry. Discipline competencies for dental public health in Canada. Release 4.0. 2008. 2. American Association of Public Health Dentistry. Competency statements for dental public health. Springfield, IL: American Association of Public Health Dentistry, 1998 [cited 2013 Aug 17]. Available from: http://www.aaphd.org/ default.asp?page=competencies.htm. 3. Public Health Agency of Canada. Core competencies for public health in Canada: Release 1.0. Ottawa: Public Health Agency of Canada, 2007 [cited 2012 Nov 13]. Available from: www.phac-aspc.gc.ca/core_competencies. 4. American Dental Association. Accreditation standards for advanced specialty education programs in dental public

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How can dental public health competencies be addressed at the undergraduate level?

To discuss the extent to which an undergraduate dental module addresses dental public health competencies via its different learning pedagogies and to...
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