The Current Status of Infant Oral Health Instruction Within Predoctoral Dental Education.

2.1 Data Collection

Following an extensive literature review, a 25-item questionnaire was developed specifically for this survey. Question types included multiple choice, multiple selection, and fill-in-the-blank. They were adapted from previous literature examining pediatric dentistry curricular time, dental student experiences treating pediatric patients, and dental school graduate preparedness to treat pediatric patients [6–10, 12, 21]. Questions were selected if they asked participants about the number of clock hours in the pediatric dentistry curriculum, specific educational practices and clinical tasks performed during an IOH visit, and clinical sites where experiences occur. Clinical tasks for children 0–36 months included examining children, providing toothbrush prophylaxis, applying fluoride varnish, assessing fluoride status/intake, providing oral hygiene instructions, providing nutritional counseling, assigning caries risk status, providing counseling about teething and non-nutritive habits, recommending use of fluoride toothpaste at the time of first tooth eruption, and recommending the first dental visit by age 12 months.

Additional questions were added to assess clinical operations about workflows for infant patients. To update previous studies, the questionnaire also included questions about methods of instruction and specific competency assessments directly or indirectly related to an IOH visit, such as an IOH exam, diet or nutritional counseling, fluoride varnish application, and silver diamine fluoride application. The questionnaire was pilot tested for content validity by members of the AAPD Council on Pre-Doctoral Education. The final version of the questionnaire was converted to REDCap to facilitate data collection and analysis [22], and a copy is available as Appendix 1.

The questionnaire was administered electronically via an email distribution list maintained by the AAPD Educational Program Manager that includes pediatric dentistry faculty contacts at all dental schools. Among the 75 accredited dental schools in the United States, 9 were excluded since they had not yet graduated their first class by the time of questionnaire administration, leaving 66 eligible schools. The data collection window was from March 15, 2024, through May 31, 2024. Potential participants were sent email reminders approximately 2, 4, and 8 weeks following the initial introductory email about the questionnaire. A final, in-person reminder to respond to the survey was made at the AAPD Annual Session Joint Academic Day in May 2024. Potential participants were given information about the study’s purpose, potential risks and benefits of participation, and an assurance of confidentiality. The primary author’s contact information was provided to participants if they had any questions about the study or their participation.

2.2 Statistical Analysis

Descriptive statistics were reported for each questionnaire item as counts and percentages or means and standard deviations based on the type of data each item represented. This was a descriptive study without planned hypothesis testing. Missing data was included as its own category. All analysis was performed in STATA (version 16.0, STATA Corp. LLC, College Station, TX, USA).

4.1 Summary and Interpretation of Results

This study provides a comprehensive evaluation of the dedicated pediatric clock hours and the current state of IOH education within U.S. predoctoral dental school curricula. Substantial variability was identified in both didactic and clinical components. The findings align with previous research describing discrepancies in IOH training, particularly the number of clinical experiences and the methods used to assess competency [6, 10, 11]. By offering an updated summary of IOH education, this study extends existing literature and identifies critical gaps in clinical exposure and curricular integration. These findings underscore the persistent challenge of aligning dental education practices with established professional guidelines, such as the recommendation for a child’s first dental visit by age 1 [12, 13].

4.2 Importance of Results

Nearly 25% of 2–5 year-old children have dental caries, a percentage that has not changed appreciably over the past four decades [23, 24]. Rates of untreated decay have improved, suggesting that access to dental care is improving [23]; however, trends in preventing the disease altogether are stagnant [24]. Few children have a dental visit by their first birthday in the United States [13, 14]. The average child has a first dental visit closer to age 3 [13], where disease is often present and likely at advanced stages requiring expensive and extensive treatment [25]. Reimbursement policies and innovative care delivery models that support earlier access to dental care hold promise at improving IOH utilization. However, the role of training the new dental workforce cannot be overlooked.

The availability of an adequate number of infant patients for clinical training limits a dental student’s ability to be prepared to treat infant patients upon graduation. This disconnect between professional guidelines and what is currently achieved in predoctoral curricula, specifically for IOH, represents a significant opportunity for dental educators to think differently about dental care delivery systems beyond traditional clinical operations [10, 11]. Students are not adequately prepared to deliver IOH [26]. A number of strategies could be implemented in the predoctoral curriculum to enhance IOH training and prepare graduates to provide these services upon graduation (Table 4). In addition to making sure the content is covered in didactic instruction, clinical operations could be modified to support IOH clinical experiences, which generally require fewer resources than other preventive or treatment visits. Modifications might include changes to scheduling templates, visit locations, and instrument kits. Developing simulated cases that use either basic pediatric mannequins (Figure 1) or standardized patient parents, depending on the specific objective, could be useful adjuncts in lieu of or in preparation for clinical experiences. Calibrating faculty on what is specifically defined within the IOH visit would align expectations for students.

Community-based education could bridge gaps in both clinical exposure and access to care. Community rotations and partnerships with Early Head Start school-based centers or Women, Infants, and Children (WIC) clinics could provide an opportunity to enhance students’ clinical competencies while simultaneously expanding access to IOH care for underserved populations [12, 13]. Care delivery models such as medical–dental integration, particularly for infants and toddlers at well-child medical visits [27, 28], could provide additional learning opportunities and clinical pathways for more infants to be examined by dentists and dental students. From an accreditation standards perspective, one way to strengthen the profession’s commitment to IOH could be an intent statement added to predoctoral standard 2-23 [11], specifically mentioning preventive care for vulnerable life stages including infancy.

State level policies may influence how different dental schools are able to implement IOH experiences. A Current Dental Terminology code (D0145) exists and was designed to facilitate IOH appointments [29]. However, various administrative hurdles and state-by-state variations have been identified with respect to its implementation [30]. As an example, in Texas, providers enrolled in the state Medicaid program, including board-certified pediatric dentists who learn IOH during their residency training, must take an online certification course to be able to bill for the code [31]. Another factor is that some state Medicaid programs may utilize D0145 as a bundled code [32]; this means that the infant oral examination, prophylaxis, fluoride vanish application, and anticipatory guidance are bundled together and only the D0145 code needs to be completed. Other states may require separate code completions for each component of the IOH visit [30]. These nuances in insurance-based utilization of the IOH code are typically not covered in dental education and may become an additional barrier preventing dental graduates from adopting these procedures in practice.

4.3 Limitations and Strengths

This study has several limitations. First, its reliance on self-reported data has the potential for response bias, as participants may have either overestimated or underestimated aspects of their curricula, particularly regarding clinical exposure and competency assessments. However, to mitigate this concern, the survey instrument was validated in collaboration with subject-matter experts, ensuring clarity and relevance. In addition, the consistency of our findings with previous literature on IOH education supports the reliability of the data [6, 10].

Second, while the study achieved a 59% response rate—comparable to or exceeding similar national surveys in dental education—the possibility remains that non-responding schools may differ in ways that could influence the overall findings. As a result, generalizability has limitations. However, the diversity of responding institutions, spanning various geographic regions, institutional types, and program structures, strengthens the applicability of the results to broader discussions on predoctoral IOH education [9, 11].

A third limitation is the study’s cross-sectional design, which provides a snapshot of current educational practices but does not allow for the assessment of longitudinal trends. While a longitudinal approach would yield deeper insights into how IOH education evolves over time, the primary objective of this study was to establish a contemporary baseline of IOH instruction and clinical exposure. These findings serve as a foundation for future research that can track changes and evaluate the long-term impact of curricular modifications.

Last, this study did not incorporate perspectives from predoctoral dental students, whose firsthand experiences could offer valuable insights into the effectiveness of IOH education and their preparedness to provide IOH care upon graduation. While faculty members are best positioned to provide accurate curricular data, student perceptions of the adequacy of their training would complement these findings and provide a more comprehensive evaluation. Future research should incorporate student perspectives through surveys or qualitative interviews to gain a broader understanding of IOH education.

Despite these limitations, this study has several notable strengths. It is among the few recent efforts to systematically evaluate both didactic and clinical components of IOH education across U.S. dental schools. The survey instrument was developed with input from educational experts in the specialty, ensuring that the collected data accurately reflects current curricular practices. By identifying the disconnect between professional guidelines and the clinical realities of predoctoral training, this study provides critical insights that can inform curricular improvements. The results support actionable recommendations, such as expanding community-based education and incorporating simulation-based training, both of which have the potential to enhance IOH education and improve patient outcomes. Adding an intent statement to CODA Predoctoral Standard 2-23 could strengthen the professions commitment to IOH.

4.4 Future Directions and Recommendations

Based on the findings of this study, several recommendations can be made to advance IOH education and its impact on pediatric oral health outcomes. First, dental schools should prioritize the development of community-based education programs. Partnerships with community clinics, mobile dental units, and school-based health programs can provide students with the clinical exposure necessary to develop proficiency in IOH care while addressing disparities in access to care for underserved populations [12, 13].

Second, innovative educational technologies, such as simulation-based training and standardized patients, should be explored as supplementary tools for IOH education. These technologies can bridge the gap created by limited patient pools, offering students consistent opportunities to practice clinical skills in a controlled, realistic environment [10, 11]. Costs may preclude schools from being able to engage in-person standardized patients; but alternatives such as virtual standardized patients or avatar patients generated by artificial intelligence platforms using large language modeling may provide more cost-friendly alternatives.