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December 2003 ■ Journal of Dental Education 1327

Oral Health Disparities Among the Elderly:Interdisciplinary Challenges for the FutureMarsha A. Pyle, D.D.S., M.Ed.; Eleanor P. Stoller, Ph.D.Abstract: The elderly, like other population groups, have experienced varying levels of oral health among their diverse demo-

graphic subgroups. For those in poverty, experiencing social isolation, residing in long-term care institutions, and with complex

medical illness, oral health care may be unreachable. Various models of training, education, and community, public, and

professional collaboration have been proposed, yet few strategies have been implemented. Interdisciplinary approaches that

bring interested partners together as equal stakeholders may create faster tracks in improving access to health care for those

geriatric patients who lack it. This article explores past and present recommendations for interdisciplinary collaborations, reviews

the current and future needs of the geriatric population, discusses educational models and content, and expresses the need for

leadership to address oral health disparities in the elderly. Finally, strategies for making improvements in the existing oral health

disparities are discussed.

Dr. Pyle is Associate Dean for Academic Affairs, School of Dental Medicine, and Dr. Stoller is Selah Chamberlain Professor of

Sociology, Department of Sociology—both at Case Western Reserve University. Direct correspondence and requests for reprints

to Dr. Marsha A. Pyle, Associate Dean for Academic Affairs, Case Western Reserve University School of Dental Medicine,

10900 Euclid Avenue, Cleveland, OH 44106-4905; 216-368-3968 phone; 216-368-3204 fax; [email protected].

Submitted for publication 7/23/03; accepted 10/14/03

The first ever Surgeon General’s Report (SGR)

on Oral Health in 20001 brought to the fore-

front the idea of oral health as a part of gen-

eral health. Despite advances in oral health across

the lifespan, the report identified segments of the U.S.

population that have not benefited from these ad-

vances. The geriatric population is as a group often

at risk of disease and often experiencing limited ac-

cess to oral health care because of place of residence,

economic factors, complex medical illness, social

isolation, and other individual and social factors

(Table 1). The projected aging of the U.S. popula-

tion heightens the urgency of addressing needs for

the increasingly dentate elderly who are at risk for

dental disease and oral health decline.1,2 The SGR

presented strategies to engage communities of inter-

est in creating new educational models for both pro-

fessional and community settings. It focused dialogue

on public and private collaborations to improve oral

health and address identified disparities,3-6 including

oral health for the elderly.

The purpose of this article is to discuss the need

for greater interdisciplinary training in geriatrics to

help resolve disparities in oral health care for the eld-

erly. We examine historical policy recommendations

in education, curriculum implications for dentistry

and medicine, and strategies to increase interdisci-

plinary training. This review reveals a discrepancy

between past educational recommendations and the

current approach to preparing oral health profession-

als to care for the future burgeoning elderly popula-

tion.

Background: Needs of theElderly

Since 1900, the proportion of the U.S. popula-

tion over the age of sixty-five has grown from 4 per-

cent to 12.7 percent.7 Increasingly, cohorts of the eld-

erly are aging with natural dentition. In the 1988-91

Third National Health and Nutrition Examination

Survey (NHANES), nearly 72 percent of adults aged

sixty-five to seventy-four were dentate, with an av-

erage of more than eighteen teeth.8 Dentate individu-

als therefore remain at risk for dental disease, espe-

cially caries and periodontal disease, as well as soft

tissue pathology. A growing population of older pa-

tients who have more teeth presents a combination

that impacts dental needs. A lifetime of dental dis-

ease experience, partial tooth loss, medical condi-

tions, and medications adds to the complexity of treat-

ing these patients. The elderly, as well as disabled

and medically compromised populations, have a dis-

proportionate amount of oral disease.9

Today’s older individual is also a more frequent

utilizer of dental care services than previous cohorts.

Reports from the 1960-70s characterized the elderly

as infrequent users of oral health care.10,11 More re-

1328 Journal of Dental Education ■ Volume 67, Number 12

cently, according to the 1987 National Health Inter-

view Study, the mean number of dental visits annu-

ally for senior citizens exceeded that of younger age

groups.12 Meskin and Berg examined the impact that

older adult patients have on private practices. They

found that the “percentage of office visits, services

provided, and expenditures attributed to patients 65

years of age or older exceeded the percentage of the

population in that age group.”13 Over a ten-year pe-

riod, a 30 to 64 percent increase in the number of

older adults seen in dental practices13 demonstrates

the growing influence that senior adults will continue

to have on oral care service utilization.

While Meskin and Berg investigated patients

in private practice, the vast majority of whom live

independently, the accessibility of oral care for indi-

viduals needing assistance with activities of daily

living and those institutionalized is often extremely

limited.14 Approximately 5 percent of the population

over sixty-five reside in long-term care settings

(LTC). An additional 5 to 10 percent of this popula-

tion group is homebound.15 There is little data about

homebound patients,16,17 but data affirms that oral

health of individuals in LTCs is consistently

poor.14,18,19

Linkages of oral health and general health have

received increased public attention since the publi-

cation of the SGR and research suggesting oral-sys-

temic health relationships. Periodontal disease has

been associated with cardiovascular disease, athero-

sclerotic lesion formation, increased risk of ischemic

stroke, and all-cause mortality.20-23 There is increas-

ing evidence linking an oral infection-inflammation

pathway.24 Previously established associations be-

tween leukemia and gingival enlargement,25 oral

manifestations of systemic diseases,26,27 relationships

between diabetes and wound healing, diabetes and

aspiration pneumonia,28,29 and medication and oral

side-effects/consequences26,30 also underscore why it

is important for dentists to understand these relation-

ships in order to provide competent care to the eld-

erly population.

Therefore, based on the numbers and propor-

tion of the aging population, their dentate status, the

impact of chronic medical conditions and treatment

on oral health, and the suggested relationships of

dental disease to general health, students of tomor-

row must be prepared to face the unique challenges

of an aging patient group in the practice of general

dentistry. To increase the degree of understanding of

the medical complexity of these patients, interdisci-

plinary training that considers the whole patient will

be required. New models of curricula in dentistry,

medicine, and allied health professions must emerge.

Current Shortfalls inPreparation for Care ofthe Elderly

A complex set of factors has contributed to the

magnitude of oral health disparities in older popula-

tions. Factors include health and educational policy

and fiscal implications, insufficient evidence-based

research, and failure to examine nontraditional edu-

cational models in the health professions.

Educational PolicyA recent overview of oral health in the United

States31 documented concentrations of dental disease

and oral health decline among older Americans, par-

ticularly those who are disadvantaged by race/

ethnicity and socioeconomic status. Objectives for

improving access to quality health services and oral

health are listed in Healthy People 2010, the com-

prehensive, nationwide health promotion and disease

prevention agenda.32 Two overarching goals of

Healthy People 2010—to increase quality and years

of healthy life and to eliminate health disparities—

are directly applicable to resolving the inequities of

oral health in diverse aging populations. Dental edu-

cational agendas should address these important dis-

parities.

Table 1. Summary points from surgeon general’sreport related to geriatric oral health care

• Disparities remain for access-limited groupsdespite oral health improvement for manyAmericans.

• Dentists have the opportunity to play anexpanded role in the interdisciplinary team.

• Integration of general and oral health programsis insufficient.

• Public health structure is insufficient to meet theneeds of access-limited groups.

• Medically necessary oral health care remainslimited especially for those most likely to need it(elderly).

• New dentist practice choices may reflect thelevel of debt-load at graduation.

• Nursing homes have limited capacity to deliverneeded oral health care services.


A variety of important reports in the last de-

cade indicated that dental schools remain isolated

from interaction with other health care institutions.

In the early 1990s, the Pew Health Professions Com-

mission noted that dental care delivery has changed

little over the last several decades and that “dentists

have relatively little direct interaction with other

types of health care providers.”2 The Pew report cited

dental education’s inability to respond to demo-

graphic trends, changes in care delivery, and tech-

nology due to inflexible curricula. Clinical dental

education also provides little opportunity for inter-

disciplinary work in health care teams. It is time for

a new model of dental education that is more inte-

grative with a variety of patients, health care provid-

ers, and individuals who are involved in health care

management and interdisciplinary health care.

Within dental education, progress has been

monitored in the growth of didactic and clinical train-

ing in geriatrics. The most recent study33 reported the

results of a survey of all U.S. dental schools. Although

there has been consistent growth in didactic curricula

among dental schools, growth in both intramural and

extramural clinical experiences has not increased to

the same level.33 To date, no surveys have investi-

gated the level of interdisciplinary training or suc-

cesses achieved. This is likely due to the fact that

this educational format is challenging and rarely used

or reported in predoctoral dental education.

The Institute of Medicine’s (IOM) report Den-

tal Education at the Crossroads also underscored the

need for changes in dental education, citing the need

for preparation of students to care for the increasing

numbers of medically complex, dentate elderly. The

report suggested that dental education should become

more closely integrated with medicine on multiple

levels.34,35 Nearly a decade later, there has been slow,

limited progress in developing and implementing

new models of education that address these issues.

Fiscal ImplicationsThe lack of inclusion of oral care services in

Medicare may have contributed to the preservation

of the dental profession’s independence, yet it has

also contributed to the access to care problem for

many older adults. Only 14.5 percent of patients over

the age of sixty-five retain dental insurance,36 requir-

ing most people to pay for dental care with “out of

pocket” dollars. For individuals with Medicaid ben-

efits, the scope of services varies by state, as this

program is a federal-state shared responsibility pro-

gram. Recent state budgetary demands have impacted

the continuation of programs in some states and

caused the termination of various levels of benefits

in some, often the adult programs. The oral health

needs of the elderly and the demographic changes in

the U.S. population warrant a reassessment of the

role of oral care services in federal health programs

such as Medicare and revision of policies for Med-

icaid administration.

Likewise, dentists’ lack of willingness to serve

Medicaid patients and patients of LTC facilities, re-

gardless of payment method, has contributed to the

access problem as well.37 Expanding professional-

ism and ethics curricula to include topics regarding

the right vs. privilege of oral health care could serve

to develop a greater sense of service to humankind

among dental students. Incorporating service learn-

ing programs as an integral part of clinical experi-

ences would also help to internalize institutional

value systems that honor the professional and ethi-

cal obligations of dentistry to society.

Research NeedsThe role of interdisciplinary collaboration is

apparent in reports addressing research needs. In

2000, the American Dental Education Association

(ADEA), responding to the American Dental

Association’s Report on the Future of Dentistry

Project,38 noted the need for dental education to be

sensitive to changing population demographics, dis-

ease patterns, and health care delivery and empha-

sized the need for more research opportunities for

students. The need for interdisciplinary collabora-

tion in basic and clinical dental and craniofacial re-

search was emphasized, especially where studies

could lead to increased interdisciplinary interaction

and practice. There is also a need for greater value to

be placed on educational research to identify effec-

tive training models that can contribute to contem-

porary educational practices.

The National Institute of Dental and Craniofa-

cial Research (NIDCR) 2002 report on elimination

of dental health disparities39 discussed that popula-

tion subgroups, including older Americans, have poor

oral and general health but cautioned that good re-

search data is often nonexistent. Dental education

can play an important role in fostering research on

educational and health promotional strategies appro-

priate to the social and cultural frameworks that char-

acterize these subgroups. Cooperation among re-

searchers in basic science, clinical science,


demography, and social science will be required to

effectively reduce oral health disparities. In the

NIDCR Health Disparities Plan outlined in the re-

port, educational initiatives were not overtly de-

scribed, yet the context in which the research needs

are described is amenable to all types of research in

educational institutions. The plan acknowledges that

there is often a gap between research knowledge and

practice, an important emphasis for overcoming oral

health disparities.

Interdisciplinary EducationalImplications

More recently, the IOM convened an interdis-

ciplinary summit in 2002 to develop recommenda-

tions for reform of health professions education. The

goal of the summit was to facilitate discussion on

change in education that would enhance patient care

quality and safety. The report of that summit40 called

for approaches related to oversight, training environ-

ment, research, public reporting, and leadership.

Table 2 outlines the five competency areas identi-

fied by the summit as key elements for all health

professions education. This report again highlighted

the necessity for interdisciplinary training among the

health professions to address our country’s chang-

ing demographics characterized by aging, ethnic and

racial diversity, chronic illness, and a population with

a need for access to health care information. Unfor-

tunately, dentistry was not represented at this impor-

tant summit that considered how health professions

education must change.

Despite recurring evidence that leaders in edu-

cation and health care policy have long seen a vision

of interdisciplinary training and collaboration among

medicine, dentistry, and other health professions,

there has been slow progress in developing demon-

stration projects and implementing best practices

from successful programs. A review of interdiscipli-

nary training involving dentistry and other health

professions reveals that most of these collaborative

efforts do not involve dentistry. A literature search

of “interdisciplinary teams and dental” terms since

1990 netted only ten articles, none of which related

to geriatric training and only four dealt with educa-

tional models. Another search of “geriatric interdis-

ciplinary teams and dental” found no matches since

1990. Of the articles that did describe collaborative

training models, most involved medicine and social

work, allied health, nursing, pharmacy, nutrition,

chiropractic, occupational therapy, or other health

professions.

Interdisciplinary ModelsInterdisciplinary or multidisciplinary teaching

teams have been utilized to help educate health pro-

fessions students in geriatrics for years.42-50 These

programs have used a diverse group of educational

models to link various health professions (not includ-

ing dental students) and community service agen-

cies to academic institutions for training in care of

the elderly and to address ethical issues training for

the purpose of stimulating educational collaboration.

Programs such as these report improvement in stu-

dent attitudes towards the elderly and in skills in as-

sessing patients’ decisionmaking capacity, negotiat-

ing care plans, and appreciating the broad range of

elderly patient life experiences.51 There has been little

effort to study and report on programs that include

dental professionals in interdisciplinary team learn-

ing units. The historical isolation in dental educa-

tion has not fostered collaborations in joint projects

to train more health professions’ students together.

A recent literature review indicated that there

are few medical journal articles that point to the need

for interdisciplinary training or “cross-education”

involving dental professionals. Increasing sugges-

tions of oral-systemic health interactions clearly in-

dicate the need for interdisciplinary training models

to enhance the ability of health professionals to treat

the ever-growing population of elderly. With more

medically complex patients and limited oral health

information within medical education,52 new initia-

tives to redesign predoctoral medical and dental cur-

ricula seem timely.

One of the most visible examples of interdis-

ciplinary training involving postdoctoral dentistry has

Table 2. IOM competencies for all health professionseducation

“Competencies are the habitual and judicious use ofcommunication, knowledge, technical skills, values, andreflection in daily practice.”

• Provide patient-centered care• Work in interdisciplinary teams• Employ evidence-based practice• Apply quality improvement• Utilize informatics

Source: Hundert EM, Hafferty F, Christakis D. Characteris-tics of the informal curriculum and trainees’ ethicalchoices. Acad Med 1996;71(6):624-42.


been the Faculty Training Projects in Medicine, Den-

tistry, and Behavioral and Mental Health, which is

funded by the Health Resources and Services Ad-

ministration (HRSA).53 This federal program is an

interdisciplinary postdoctoral geriatrics training pro-

gram that educates physicians and dentists together.

Originally mandated in 1986, geriatric psychiatry was

added to this federal program in 1992. The program

supports physicians who have completed residencies

in family medicine or internal medicine, mental

health professionals such as psychiatrists, and den-

tists who have completed residency programs or spe-

cialty training for two-year geriatric fellowships and/

or one-year geriatric retraining for faculty with pre-

vious interests in this area. The Bureau of Health

Professions (BHPr)-supported program is unique,

allowing an integrated program that is not limited to

single clinical sites and has flexibility in affiliations

and curriculum. The programs are organized around

interdisciplinary didactic instruction in all aspects of

geriatric care and clinical training concentrated in

the fellow’s discipline, with cross-participation in

clinics to the extent appropriate. Dentistry is always

included as a team member. The programs include

training in administration, teaching, research, and

clinical care. This is the only faculty training pro-

gram of its kind in the United States that supports

training in geriatric dentistry. The number of pro-

grams and fellows trained are outlined in Table 3.

There are currently nine funded programs.

Early in the 1990s, the fellows completing these

programs were tracked to determine how many re-

mained in academic settings, but this tracking mecha-

nism has not continued. While there is no current

data on the status of fellows previously trained

through this program, it is likely that the dental fel-

lows trained in this venue serve as the current core

of academic leaders training current dental students.

Yet, with expected needs for physicians specially

trained to serve the elderly estimated to be in the

thousands, the need for additional training would

seem evident for all health professions serving the

elderly.54 It is unlikely that the numbers of the el-

derly requiring health care will be matched by suffi-

cient numbers of adequately trained physicians, den-

tists, and other health professionals in the near future,

unless expansion of programs or new programs are

instituted. Other geriatrics training programs

(master’s level) exist in dentistry, but do not share

the same emphasis on interdisciplinary training as

the BHPr program.

In summary, progress in effecting change in

the current mechanisms of training in the care of the

elderly has been slow. Recommendations from policy

sources to enhance interdisciplinary training have

been made without concomitant increases in train-

ing programs. There is a lack of sufficient training

mechanisms for predoctoral and postdoctoral pro-

grams. There is a critical need for educational re-

search on models of training to prepare health pro-

fessionals to care for the elderly. In many cases,

training does not address the critical issues of cul-

tural competence, communication, and understand-

ing patient value systems. Finally, dental education

and medical education remain isolated from each

other.

Future Needs in DentalEducation

Need for LeadershipIt is critical to identify leaders who have the

skill and passion for making greater advances in ge-

riatric interdisciplinary training including curriculum

revision. While dental educators have been consid-

ering ways to make that happen, the suggestions for

this change are more than ten years old. Dealing with

slow professional and institutional change can be

discouraging. A certain level of grassroots movement

and knowledge is required from the different health

professions. Medical, dental, and allied health edu-

cation should collaborate with professional organi-

zations, national testing organizations, accrediting

bodies, and licensing organizations to create efficient,

high-quality educational programs that will be re-

Table 3. Number of programs funded by year: facultytraining projects in geriatric medicine, dentistry, andbehavioral and mental health

Funding Year No. of Programs No. of Fellows(five-year funding, Funded Trainedexcept 1988 and 1991,which are three-year)

1988 23 1151991 16 741994 9 1352000 5 Data pending2001 2 Data pending2002 2 Data pending


sponsive to the changing demographics of the soci-

ety. Otherwise, educational innovators will be pe-

nalized for their leadership, creativity, and efficiency

by oversight groups who are unable to change at the

same pace when new educational models are insti-

tuted. A shared vision for change will be required.

The health professions should educate themselves

to understand, in concert, the needs of contempo-

rary oral and general health care related to the eld-

erly.

There is an opportunity for dental education

and organized dentistry to take the lead to address

the access to care issue from the grassroots level. If

local level activities are a link to facilitating greater

access to dental care for the elderly, then associa-

tions with strong lobbies such as the ADA and its

constituents (state level), as well as other national

agencies advocating for senior citizens, could be

important assets for securing new resources for train-

ing, research, and care.

Strategies for ChangeChange is often viewed negatively by individu-

als unaccustomed to innovation, but careful planning

can minimize risk and uncertainty. First, compelling

evidence must exist to make the change. As previ-

ously discussed here, multiple reports already exist

to support new thinking about interdisciplinary col-

laborative training. Second, specific required ele-

ments must be identified early to guarantee that ad-

equate time, knowledge, space, and resources are

available to effect change. Finally, there is a need

for motivated, visionary leaders who think

collaboratively, who are calculated risk-takers, who

realize a better game plan must be nurtured, and who

are willing to provide the opportunity for new ideas

to reach fruition. This suggests the need for interdis-

ciplinary leadership training programs in geriatrics

and health professions education to develop the vi-

sionary talents of individuals who have the skill,

perspective, passion, and desire to lead the way. Cov-

eted demonstration programs should be developed

that are interdisciplinary in nature and universally

recognized and supported. Opportunities for future

leaders to collaborate could assist the development

of emergent leaders who will facilitate educational

change that is responsive to the societal needs of an

aging population.

In times of lean economics, it makes great sense

to look for innovative opportunities to capitalize on

existing resources. For example, in one midwestern

city, the university bought the property of an 800-

bed acute care hospital that had closed five years

earlier. The dean of a midwestern school of dental

medicine proposed the facility be used as an inter-

disciplinary training facility. A former dean of medi-

cine was appointed to oversee the development of

this facility where a model of interdisciplinary out-

patient care could occur. One year after the sugges-

tion, the project remains an idea. Likely, many ob-

stacles lie ahead in making this vision a reality, yet

this innovation shows genuine dental-medical col-

laboration and creative leadership.

Need for a Core CurriculumThere is clear evidence that medical, dental,

and health professions education must change in or-

der to address health disparities among the aging

population.1,2,32,34,35,38,40 The reports reviewed contend

that the nature of medical, dental, and other health

professions education must change to better prepare

future practitioners to deal with health disparities

among the elderly. Federal funding could leverage

training opportunities in geriatrics. Since comprehen-

sive working examples of interdisciplinary training

that include dentistry do not exist for predoctoral

dental curricula, there is a compelling need to estab-

lish demonstration projects that model medicine and

dentistry together. Many dental students do not

choose additional formal training beyond their den-

tal school program, so adequate training to interact

with other health professionals in order to provide

quality care to the elderly must occur during dental

school. Medical and dental education must develop

a core curriculum that all students could share, with

interdisciplinary experiences beginning with the first

day of class.

While a number of new models of dental edu-

cation have been proposed and several have been

implemented,55 a high priority is developing strate-

gies for allowing more institutions to implement

change and overcome the obstacles encountered by

the experiences of the first wave of curriculum inno-

vators. Greater efficiency and lessons learned could

help other institutions attempting to implement new

projects in health professions education. Likewise, a

fresh look at existing programs, such as advanced

training in general dentistry residencies, could cre-

ate a view of mainstreaming what we currently call

“special needs populations” within the realm of gen-

eral dentistry. If core curricula included geriatric di-

dactic and clinical experiences, then a new cadre of


practitioners could be prepared to serve the needs of

the elderly.

Teaching to the Needs of ElderlyPatients

Within the discipline of dentistry, educational

change must occur in didactic and clinical formats

in predoctoral and graduate training. Developing

teachers of geriatrics, research initiatives for appli-

cations in clinical practice, and developing a cadre

of practitioners who have the knowledge, skills, and

values and are willing to commit their time in ser-

vice to the underserved elderly would be important.

Approaches that recognize diversity and address cul-

tural competency in our programs have been advo-

cated.56 Sensitivity to understanding and valuing

other belief systems are also important concepts, in

addition to diversity issues, in general.57

Dental education’s approach to treatment plan-

ning education, for example, has traditionally evolved

around ideal treatment planning from the provider’s

perspective, focusing on relatively healthy, average

patients. Yet treatment plans for frail elderly may be

complicated by barriers to care, disease, uncertainty

about risks and benefits, and inadequate knowledge

about patient preferences.58 There are few references

to understanding patient preference and value sys-

tems in oral care treatment decisionmaking.59 How-

ever, frail older patients at risk for dental disease of-

ten have significant medical, psychosocial, and

economic complications that impact their ability to

get care. Life situations define how they may make

oral care decisions about their preferences. Further-

more, both well and frail elderly patients may ex-

hibit variation in the priorities they attach to differ-

ent dimensions of oral health and dental treatment.60

A study of dental students confirmed that students’

perception of the preferences and values of elderly

patients about oral health do not always agree with

those of elderly patients.61 Older patients’ oral health

goals may be framed by the context of the situation.

For example, in painful dental situations, patients

may know the strategy that is in the best interest of

their oral health, yet external factors may influence

their decisionmaking approach, derailing the best-

choice decision.62

Better understanding of patient value systems,

preferences, behaviors, and confounding life circum-

stances may help prepare students to communicate

with the elderly and to appreciate and work within

their belief systems. In doing so, greater opportunity

to address the needs of the elderly patient may be

achieved. A recent student report in Special Care in

Dentistry noted that factors such as these are critical

for the ability of students to effectively deal with

treatment planning complex older patients.63

Need to Define CompetenciesA set of educational principles and competen-

cies should be developed to help define key broad

educational principles that will allow students of the

twenty-first century to meet the needs of the aging

population. A set of core competencies specific to

oral health care and dental education have been pro-

posed through a Delphi study conducted by Dolan

and Lauer. Their contemporary detailed statements

of knowledge and skills across dental disciplines64

could serve as the basis for updating previously

(1989) published curriculum guidelines in geriatric

dentistry.65

However, a broader approach to competency

development in special care topics should be framed

to encompass educational objectives amenable to

both dental and medical education. The broad com-

petencies could be framed within special patient care

to address the needs of the general patient popula-

tion. These should be a part of all predoctoral dental

programs and are not unlike those proposed in the

IOM Summit summary.40 (See Table 4.) Defining the

educational outcomes will require additional study

and refinement, as will articulating the evaluation

strategies that will measure the level of quality and

accomplishment necessary. The competencies are

proposed as a beginning discussion of the definition

of the knowledge, skills, and values contemporary

Table 4. Competencies for geriatric oral care inpredoctoral programs

Graduates must be competent to collaborate in interdisci-plinary teams to facilitate special patient care.

Educational outcomesStudents must:

• Function within an interdisciplinary healthcare team providing special patient care.

• Integrate medical, dental, psychosocial, andeconomic factors impacting patient care.

• Prescribe treatment plans that are sensitiveto patient values and belief systems.

• Demonstrate effective communication withspecial care patients.


students of dentistry will need to function in the

health care system that will be caring for the increas-

ingly older, more complex patient.

SummaryDespite compelling recommendations from

diverse sources that suggest dental education can and

should revise its mode of delivery and philosophy to

broaden interdisciplinary training venues, little

progress has been made in this area. The rationale

for increased interdisciplinary training in geriatrics

is evident in the demographics of the aging society

we live in. While a model interdisciplinary training

program exists, additional and expanded programs

that include predoctoral education will be required

to develop adequate numbers of health care provid-

ers to care for the elderly. Meeting this need will

demand new levels of leadership among individu-

als, the public and private sectors, educational insti-

tutions, professional organizations, and oversight

groups. New value for educational research will also

be important to facilitate the necessary changes.

Table 5 highlights proposed strategies for im-

proving the health professions’ ability to diminish

geriatric oral health disparities. Dental education

leaders must work to ensure that dentistry is invited

to the table when the IOM committee meets, when

curriculum committees of universities convene, and

when professional organizations join together. Over-

views of health disparities that fail to incorporate oral

health are incomplete.

The educational rationale for increasing inter-

disciplinary training has existed for a decade. The

next step is to identify visionary leaders who have

Table 5. Strategies for improving health professions’ ability to diminish geriatric oral health disparities

• Take advantage of working interdisciplinary educational models that currently involvedentistry: craniofacial teams.

• Remove barriers to interdisciplinary care of the elderly.— Work to include “special care” patients in mainstream care.

◆ Expand curricula and clinical experiences in general dentistry residency programs.◆ Expand predoctoral didactic and clinical experience.

— Remove financial impediments.— Increase advocacy in an era of diminishing public assistance.

◆ Revamp Medicaid system to remove dependency on optional state funding.◆ Partner with private and public groups, professional lobby groups.

▲ ADA, AARP▲ Engage constituent and component dental societies.

◆ Reassess oral health role in Medicare.— Increase federal funding for interdisciplinary models of education that include geriatrics.

◆ Expand HRSA-BHPr geriatric training program.— Find new systems to fund oral health care for special care patients.

• Create incentives to develop new integrated curricula in dentistry, medicine, and alliedhealth professions.— Create efficiencies by pooling resources.— Develop interdisciplinary RFPs for interdisciplinary curriculum models for predoctoral

education.• Create interdisciplinary training laboratories as a standard training format.

— Create clinical space and educational opportunity for training health professionsstudents together as a usual format.

• Create and publicize outcomes from demonstration projects and best practices. For example:— Senior living communities that include interdisciplinary health care facilities as training

sites for tomorrow’s practitioners .• Update allied health professions schools competency documents to reflect:

— the importance of ability to be prepared for care of the elderly.— the need for interdisciplinary training as a part of necessary skills.

• Assist accrediting and licensing bodies in incorporating new competencies into theirvalues and policies.


the expertise and passion to make innovative cur-

riculum revision in health professions education hap-

pen, so that the educational system improves and oral

health disparities for the elderly can be overcome.

AcknowledgmentThe authors wish to express their gratitude to

L. Dahlstrom for editorial assistance with the manu-

script.

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