C.E. Credit. Global Health in Dental Education: Establishing a Framework for Global Health Engagement Among Future Dental Practitioners

ABSTRACT

Background

The COVID-19 Pandemic highlighted global health inequities, put a pause on short-term experiences in global health (STEGH’s), and emphasized new virtual modalities of international collaboration. In light of these new modes of collaboration, this article will reflect on and suggest changes to the current landscape of global health education in US dental schools.

Results

The authors suggest that existing global oral health engagements, which are predominantly STEGH’s, can be improved through adherence to guiding principles, such as those of the Brocher Declaration. Further, the authors argue that implementing global health didactics and internationalization of education into dental school curriculums would more optimally prepare students for participation in global health.

Conclusions

In summary, a shift in the introductory global health educational modality in dentistry, from the current STEGH-dominated model to a combination of formal didactics, internationalized education, and collaborative, sustainable, and interprofessional clinical experiences would strengthen both the future of global oral health and the field of dentistry altogether.

Continuing Education Credit Available

The practice worksheet is available online in the supplemental material tab for this article. A CDA Continuing Education quiz is online for this article: https://www.cdapresents360.com/learn/catalog/view/20.

KEYWORDS:

• World health
• teaching
• teaching materials
• global health
• oral health
• internationalization of dental education

Introduction

The field of global health, defined as an “area for study, research, and practice that places a priority on improving health and achieving equity for all people worldwide”, has experienced dramatic expansion since the new millennium.¹ There is increasing push for the inclusion of oral health as an important player in the larger scale goals of global health, as highlighted in a landmark Lancet Oral Health series.² Dental disease affects a staggering 3.5 billion people.² Dental caries is the most common noncommunicable disease, and periodontitis affects nearly 10% of the global population.² These statistics focus attention to the wide reach of oral disease, which necessitates that global health cannot be addressed without intentional attention toward oral health. Dentists must commit to prioritizing and improving oral health for all.

A definition of global oral health was proposed as: “oral health for all people and elimination of global health inequities through health promotion, disease prevention, and appropriate oral care approaches that consider common determinants and solutions and acknowledge oral health as part of overall health.”³ Notably, in acknowledging common determinants and solutions, this definition frames oral health as a public health matter. The dentist has a duty to promote public welfare,⁴ and local public health issues are inextricably linked with global health. Thus, it becomes clear that to follow its duty to beneficence, the dental community must have a footprint in global oral health.

The dental profession’s commitment to reducing global disease burden is evident through our longstanding history of service to communities worldwide.⁵ The COVID-19 pandemic suspended many of these efforts but offered a unique opportunity to reflect upon our current global health practices and identify areas for improvement. For example, the restrictions on in-person interactions revealed the capabilities of virtual platforms in expanding both healthcare and health education.^6,7 Similarly, virtual platforms may offer great potential for assistance in global health efforts. In addition, the COVID-19 pandemic highlighted the role of interdisciplinary collaboration to promote community health, such as how half of US states permitted dentists to administer COVID vaccinations.⁸ Such solutions provoke discussion for future interdisciplinary collaboration that can work toward a common goal of improving global access to oral and systemic healthcare.

Inspired by these reflections, the authors propose three possible avenues the dental community can take to cultivate improved global health practices and instill a foundational framework for global health engagement among future oral health practitioners— (1) ensure the sustainability of existing institutional and governmental partnerships for global collaboration in science, clinical practice, and dental education, (2) establish formal global health didactics, and (3) adopt the internationalization of dental education.⁹

STEGHs – Revisiting the Current Landscape of Global Oral Health Education

The term “global health” in dental education is often associated with short-term experiences in global health (STEGHs). A national survey of U.S. dental students found that 83% of respondents were interested in participating in an international dental service trip while in school.¹⁰ Similarly, mission trips were the most common form of formal global health opportunity offered by dental schools as of 2020.¹¹ STEGH’s come in many different forms with different types of sponsoring organizations. Lasker notes a few main types of these organizing entities, ranging from faith-based and non-faith-based non-governmental organizations, to educational institutions (e.g. dental schools), to corporate sponsored groups.¹² The underlying mission and non-clinical activities related to each STEGH can vary considerably from organization to organization.¹²

The Commission on Dental Accreditation (CODA), responsible for establishing and implementing the minimum standards for dental education in the United States, does not require any standards specific to global health.¹³ However, CODA does require have standards relevant to global health. For example, CODA requires that graduates demonstrate competence in managing diverse patient populations and possess the necessary skills to thrive in a multicultural work environment (Standard 2–17).¹⁴ Another CODA standard, Standard 2–26, mandates that dental education programs provide opportunities and encourage students to engage in service-learning experiences and/or community-based learning experiences.¹⁴ These standards were implemented with the intention of cultivating dental professionals for a culturally competent workforce adept to serve an increasingly multidimensionally diverse society.

STEGHs have the potential of offering pathways to these CODA objectives, as they can allow students to witness healthcare across borders, nurture cultural competency, and compare global public health issues and strategies. However, drawbacks surrounding STEGHs can include limited communication and cultural understanding, undermining of local expertise, lack of oversight and accountability by sponsor organizations, and unlawful practices by volunteer participants.^15,16

STEGHs often face challenges in language barriers and cultural sensitivity.¹² For example, interviews with Ghanaian health care workers found that language barriers and undermining of local knowledge and expertise were the most cited challenges related to STEGHs.¹⁵ Another concern is participant adherence to standard clinical practices, such as appropriate documentation and record keeping. This standard is not always maintained by volunteer practitioners in low- and middle-income countries (LMICs). Mantey et al. highlights this concern, pointing to the lack of available data on outcomes related to STEGHs in Ghana.¹⁵ This trend is exacerbated by a lack of oversight, as there are no formal regulatory bodies evaluating the outcomes of STEGH’s.¹⁷

Concerns about documentation go hand-in-hand with concerns about training requirements for volunteer health care providers. In instances of inadequate oversight, STEGHs can involve inadequately trained, or even untrained, parties delivering healthcare.¹⁸ This again illustrates STEGH-related risks to human dignity and demonstrates the need for guiding ethical principles in global health engagement. Further, STEGH’s can also be “volunteer-centric,” focusing disproportionately on offering a positive and fun experience to volunteers rather than on providing high-quality care to the patients and community they are engaging with.^12,16,19

According to CODA, educational institutions should facilitate the development of “core professional attributes” in its students, which include “altruism, empathy, and social accountability.”¹⁴ STEGHs are intended to nurture these qualities in their participants. However, a STEGH-centered model of global health education may inadvertently perpetuate a relatively informal, non-standardized, and unidirectional approach to global health engagement, where students inaccurately learn global health as “patchwork” care voluntarily provided by high-income countries (HICs) to LMICs in order to address immediate need.^12,20 Unsustainable practices in short term health engagements will not be resolved by simply outlining downsides – it is necessary to shift the conversation toward a solution-oriented approach. To instill the core professional attributes expected from dental professionals effectively, it is essential to recognize that ethical operation and management of these programs are necessary.

Guiding Principles for STEGHs: The Brocher Declaration

The ADA endorses five fundamental principles that constitute the ADA Code of Ethics: Patient Autonomy, Nonmaleficence, Beneficence, Justice, and Veracity.⁴ These principles are meant to advise dentists in their interactions with patients. In parallel, the Brocher Declaration is a statement of ethical principles to advise STEGHs. A comparison of the Brocher Declaration and other guiding documents relevant to the dental profession are seen in Figure 1. The Brocher Declaration is an evidence-based reference for guiding, planning, and implementing global health efforts to ensure conscientiousness and intentionality. The declaration outlines six key principles for best practice in global health engagement¹⁶:

Figure 1. Venn diagram illustrating the common objectives between the Brocher Declaration,¹⁶ American Dental Association (ADA) code of Ethics,⁴ and commission on Dental Accreditation (CODA) standards for predoctoral Programs.¹⁴

1. Mutual partnership with bidirectional input and learning - There must be both recognition and empowerment of the fact that host country health professionals possess valuable experience and expertise. Educators from HIC’s have as much knowledge to gain from their colleagues in LMIC’s as they have to impart.

2. Empowered host country and community define needs and activities - The host country guides the healthcare work to provide the most targeted and sustainable health outcomes. As Rosenbaum et al states, “STEGH programs should be developed because a host partner wants the dental school’s partnership and collaboration, not because the dental school wants to travel to a certain location.”²¹

3. Sustainable programs and capacity building - Important needs are addressed and met, as well as intentionally strengthened to reap long-term benefits.

4. Compliance with applicable laws, ethical standards, and code of conduct - Ensure compliance with both traditional laws of clinical care as well as ethical principles that advocate for social justice, social contract, utilitarian principles. The legal framework of the host community cannot be violated.

5. Humility, cultural sensitivity, and respect for all involved - Remain cognizant of cultural humility practices while acknowledging limitations of understanding due to role as non-community members.

6. Accountability for actions - Commit to consistent effort to ensure that unintended consequences are not occurring or excused as allowable behaviors.

These principles coincide with the priorities expressed by host countries.^22–26 These principles can also guide students in achieving competencies relevant to CODA standards such as 2–17 and 2–26.¹⁴ Specific oral health programs demonstrating these principles can help better understand how the Brocher Declaration can be applied in practice²⁷:

1. University of Colorado (CU) School of Dental Medicine’s Global Health Program – Through partnership with family-owned Guatemalan banana and palm oil agro-business Agro-America (principle 1), CU operates and provides primary care, maternal care, and comprehensive dental care via a community health clinic in rural Guatemala.²⁸ Students providing care are overseen by faculty who are registered with the Guatemalan dental board (principle 4), and US regulations for charting, sterilization, and clinical protocols are followed (principle 6). By traveling to this clinic 3-4 times a year, CU not only fills the need for dental care in the community, but also participates in development of community and school oral health education programs (principle 3). Strong local partnership allows for a community-centered approach that ultimately enables community members to give input on and benefit from these efforts (principles 2, 5), better supporting a positive long-term effect on the community.

2. UCSF Global Oral Health Community Partnership – This program involves faculty-mentored global health research projects in 12 countries.^27,29 With a strong emphasis on addressing the structural causes of poor oral health domestically and abroad, fellows must both formally present and disseminate project findings via publication and international conference participation. By focusing on structural causes of oral health inequities rather than acute treatment of disease, this program encourages students to develop sustainable long-term solutions (principle 3)

3. HSDM/CISG Global Health Extension Course: Perspectives from Costa Rica – Following a foundational didactic course, Harvard students spend an immersive week in Costa Rica learning from local professionals about social determinants of health, health systems and policies, integration of oral and systemic healthcare, and sustainable community partnership.^27,30 Upon return, Harvard students reflect on their experiences and use what they’ve learned to propose potential solutions to the challenges they witnessed. This short-term field experience does not directly provide oral healthcare and instead utilizes Brocher principles to foster cultural sensitivity, a “learn-first” attitude (principle 5), and globally-oriented thinking at an interdisciplinary level.

Overall, institutions of dental education (and any other organizations participating in global health) are encouraged to design global health programs with the Brocher declaration in mind, and the existing programs that demonstrate these principles are applauded.

Education Beyond STEGHs

Global Health Curriculum

The literature on the current state of global health education in US dental schools is relatively sparse. Currently, many dental schools lack a formal global health curriculum. A 2016 study found that only 44% of responding schools offered global health courses, and only 43% had a faculty member with a position dedicated to global health.³¹ However, 62% offered STEGHs, and 89% reported their students participate in STEGHs offered by nonprofit or non-governmental organizations outside of the school.³¹ Similarly, Sung and Gluch report that as of 2016, only 12% of responding schools have an independent course covering global health, although 83% of respondents did report that certain global health topics (e.g., social determinants of oral health, working with patients with low health-literacy) were covered as a part of other courses.³² The authors also found areas of coverage gaps, with under 50% of responding schools covering certain topics such as global dental infrastructure (27%), data collection methods (31%), and identification of stakeholders (46%).³² Further, only 41% of schools planned to further develop their global health curriculum.³²

It is unclear how global health curriculum has developed since these studies occurred. There is limited literature investigating global health education in dental schools, and much of the existing literature focuses on global health opportunities broadly (including extracurricular activities and STEGH’s) rather than specifically on formal curriculum in global health.^10,11,13,33 This is not to say that global oral health curriculum has not advanced since these publications, but that if it has, it has not been documented. More research is needed in this area. The concern still exists, however, that interested students are more likely to be introduced to global health through clinical outreach than through formal, structured coursework. Sung and Gluch’s data brings this notion to light, with 69% of responding institutions offering elective overseas health experiences, while less than half (43% of offering institutions) provide pre-travel preparatory courses.³² These authors express the concern that “such trips may often become those participants’ model for addressing disease in underserved populations, rather than an organized approach to sustainable oral health care systems developed in collaboration with the host country.”³²

While clinical experience is an important component of global health education, it is important not to overshadow the knowledge base that didactic foundations provide. Like other disciplines within dentistry, there is great benefit in educating students about the principles underlying a topic before having them apply those principles in the clinical setting. In the same way that students are taught the caries classification system and cavity preparation design before operative practice in the teaching clinic,³⁴ there is benefit in teaching students about topics such as bidirectional input and cultural humility before sending them into clinical global health experiences. The WHO has brought attention to this notion in its recently adopted “Global Strategy on Oral Health’’ and corresponding “Global Oral Health Action Plan” (GOHAP).³⁵ Action item 49 of the GOHAP focuses specifically on reform at the dental school level, calling for countries to “improve oral health workforce curricula and training” by incorporating competency-based education in concepts like public health, disease prevention and evidence-based medicine. Formal incorporation of global health didactics and corresponding summative evaluations into dental school curriculum allows for this action item to be accomplished. These components will ultimately provide students with the conceptual framework necessary for optimal engagement with global health efforts.

Students who choose to embark on a STEGH are generally motivated to do so by an already present interest in global health. Formal global health didactics, in addition to providing a conceptual framework for global health engagement, may also provide an avenue to spark and nourish this interest in students who would be otherwise unaware of it. An example of such curriculum is the Global Health Starter kit (GHSK) developed by the Harvard School of Dental Medicine and the Global Oral Health Interest Group of the Consortium of Universities for Global Health (CUGH).²⁷ This competency-based, modular curriculum covers foundational topics including global burden of disease, the history and development of global health, the role of oral health in primary care, social determinants of health, and the ethical considerations that come with global health engagement. This curriculum includes materials designed for both teachers and learners, and could be of great use in addressing action 49 of the GOHAP and increasing the presence of formalized global health education at US dental schools. Additionally, the GHSK is free and publicly available, thus alleviating (at least in part) the burdens of financial cost and curriculum development that come with the expansion of global health opportunities in dental schools. Further, implementation of the GHSK does not require the same amount of time, networking, and infrastructure development that are necessary to build international partnerships. Its accessibility and readiness to use allow the GHSK to serve as a great starting point for schools interested in expanding their global health curriculum.

Lee et al. assesses the successes and challenges among early adopters of the GHSK, finding that users felt the content was sound, with 100% of respondents being either moderately or extremely satisfied with its quality.¹³ However, barriers to implementing the GHSK were faced both at the instructional and institutional level.¹³ Some interviewees cited a lack of global health experience and a lack of dedicated global health faculty as barriers to instruction of students using the GHSK.¹³ Others cited difficulties in finding time to incorporate the GHSK into an already busy curriculum.¹³ This struggle is compounded by the fact that there is no CODA requirement specific to global health education.¹³ Further implementation of the GHSK will require faculty development and institutional investment in formal global health curriculum.

Internationalization of Dental Education

In an increasingly globalizing world, the valuable lessons that can be gained from the exchange of ideas across cultures and countries must be recognized. CODA recognizes this, stating that “a significant amount of learning occurs through informal interactions among individuals who are of different races, ethnicities, religions, and backgrounds.”¹⁴ In line with this acknowledgment, CODA has instituted standards aimed at fostering structural, curricular, and interactional diversity within dental schools. One such standard is 1–4, which mandates that dental schools must have policies and practices that include: creating an environment that supports diversity as a core value and provides opportunities for informal learning among diverse peers.¹⁴ Internationalization of Higher Education (IHE) is an exceptional way to put this standard into practice.

IHE, often defined as “the process of purposefully integrating international, intercultural, or global dimensions into medical education in order to enhance its quality and prepare all graduates for professional practice in a globalized world,”³⁶ can aid in bridging cultural and transnational barriers. Three educational formats are predominant in IHE: (1) global partnerships, (2) student mobility, and (3) internationalization “at home” programs.³⁶ Institutional partnerships, often with the intention of establishing student exchange programs, currently appear to be the most conventional format.⁹ These partnerships appear amenable to the longer term, bidirectional global health efforts recommended by the Brocher Declaration. Establishment of international partnerships – between any combination of high-, middle-, and low-income countries – encourages multidirectional dissemination that leads to improvements in cultural competency, clinical practice among providers, and personalization of patient care in all involved countries.

Most recently, growing attention has been focused on curricula promoting internationalization “at home” (IaH). Among other modalities (international content teaching, internationalization of local campus activities or international faculty exchanges) this format utilizes remote learning and video conferencing platforms to connect students around the world, allowing them to develop cultural competence and global perspectives in oral healthcare regardless of their ability to travel abroad.

One example of an IaH program is the “International Collaboration Exchange Program (ICEP)” founded at Columbia University.³⁷ ICEP is a two semester-long networking program that utilizes video conferencing to connect health professions students, early in their careers, from around the globe. It is structured like a traditional curriculum-based course on global health with monthly lectures featuring interdisciplinary faculty speakers, politicians, and journalists.³⁸ Speakers present their lectures live through video conferencing, discussing various topics from international health systems and cultural competency, to food and nutrition and planetary health. Students at ICEP are also grouped into small teams to collaborate on a final presentation about a global health topic of their choice. These teams are intentionally diverse, both culturally and professionally, consisting of participants from partner universities around the world pursuing various professions in healthcare including medicine, dentistry, pharmacy, and health sciences. As such, ICEP not only sets up a sustainable platform for students to network on an international and interprofessional level but also enables them to do so at an early stage in their professional education.

IaH programs like ICEP not only promote curricular and interactional diversity as supported by CODA, but also address Action 48 from the WHO’s GOHAP, which encourages “[reforming] intra- and inter-professional oral health education” to prepare students for the integration of oral health into primary care and promotes “equitable access to oral health professional education.” Because IaH removes the need for physical relocation, it broadens the diversity of students who have access to such opportunities, including those with disabilities and those who may identify with marginalized gender orientations or ethnic or religious backgrounds that render overseas travel as potentially unsafe. Furthermore, it creates less of an administrative and financial burden, and is easier to establish, more environmentally sustainable, and safer at times of natural disasters, wars, and political conflicts.*³⁷

IaH can also be taken on as an initiative by student clubs and extracurricular activities. Student-led global health interest groups can host seminars from international lecturers, as well as virtual meet and greets with students from different countries. For example, the Global Surgery Student Alliance is a student-led group that has hosted multiple virtual “Global Surgery Symposiums” with speakers and attendees from countries and institutions around the world.^39–41 Perhaps institutions can foster adoption of IaH by supporting these student-led clubs. Integration of IaH into dental education is a promising next step in global dental health education. It has the potential to broadly increase global health interest and cultural humility among a greater diversity of dental students while promoting collaboration across borders and disciplines.

Conclusion

The status of global health education in US dental schools is relatively unclear. More research must be done to evaluate its current condition. Nevertheless, dental education stands to benefit from formal global oral health curricula and internationalization of dental education as a whole. The global health starter kit can be used as a starting point for institutions wishing to pursue these goals. Future efforts that will support these developments may include workforce training and institutional support for the implementation of global health curriculum. Research and development of competency assessments in order to evaluate the quality of global health education will also be of great benefit.

The future of global oral health is dependent upon the training of future global oral health leaders. A shift in the introductory global health educational modality in dentistry, from the current STEGH-dominated model to a combination of formal didactics, globalized education, and collaborative, sustainable, and interprofessional clinical experiences would strengthen both the future of global oral health and the field of dentistry altogether.

Acknowledgments

Dr. Brittany Seymour for her expert teaching and guidance in the generation of this perspective piece

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/19424396.2024.2330583

Additional information

Notes on contributors

Noah Brady

Noah Brady, BS, is a fourth year DMD student at the Harvard School of Dental Medicine. He will be entering residency in Oral and Maxillofacial Surgery at Mayo Clinic in Rochester, MN starting in July of 2024.

Rachel Utomo

Rachel Utomo, BA, is a fourth year DDS candidate at Columbia University College of Dental Medicine. She is an international student from Indonesia and will be working as a general dentist after graduation.

Aiysha Amjad

Aiysha Amjad, BS, is a second year DMD student at the Harvard School of Dental Medicine with interests in oral and maxillofacial surgery and global health.

Anette Wu

Anette Wu, MD, MPH, PhD, is an associate professor in the Department of Pathology and Cell Biology at the Vagelos College of Physicians and Surgeons at Columbia University. Dr. Wu was trained in Transplantation and General Surgery in Hannover, Germany and at the Massachusetts General Hospital/Harvard University in Boston, MA. USA. Her current research interest is in educational research in internationalization of medical education, and she is the director of the “International Collaboration and Exchange Program” at the Vagelos College of Physicians and Surgeons.