Michael C. Alfano, DMD, PhD, Dean

Nearly eight decades after the publication of the Gies Report in 1926, dental education is in danger of becoming irrelevant. Despite amazing advances in science and technology, the dental school curriculum continues to reflect the premises of the Gies Report and therefore the thinking of the last century. I submit to you that if dental education and dentistry are to thrive in the 21st century, we must begin now to rethink the entire dental education process: prerequisites, curriculum, program size, national and regional boards, costs, and continued competency.

The Danger of Preserving the Status Quo
Nearly a decade ago, the Institute of Medicine report, Dental Education at the Crossroads, raised the alarm when it stated that:

The problem in reforming dental education is not so much achieving consensus on directions for change but difficulty in overcoming obstacles to change. Agreement on educational problems is widespread. The curriculum is crowded with redundant or marginally useful material and gives students too little time to consolidate concepts and to develop critical thinking skills. Comprehensive care is more an ideal than a reality in clinical education, and instruction still focuses too heavily on procedures rather than on patient care. Linkages between dentistry and medicine are insufficient to prepare students for a growing volume of patients with more medically complex problems and an increase in medically-oriented strategies for prevention, diagnosis, and treatment.

In 2002, the ADA’s Future of Dentistry Report expressed similar concerns. That report pointed out that “expansion of oral and craniofacial science, changes in disease patterns, advances in dental materials, coupled with technological advances, are competing with the traditional elements of dental education for curriculum time.”

The problem was further crystallized in the Surgeon General’s Report on Oral Health, published in 2000. Calling oral diseases a “silent epidemic,” the Report documented that oral and systemic problems are often associated and that oral diseases and disorders can compromise health and well being over a lifetime. But the Report also concluded that solutions to these problems are hindered by issues involving oral health disparities, the relative inability of the public to benefit from scientific advances, the tenacity of barriers to care for growing segments of the population, and the erosion of the dental workforce by aging and retirements.

The Biggest Challenge for Dental Education Today
Dental schools are in a position to attack these problems, but the current dental education system is threatened by escalating educational costs, mounting student indebtedness, and myriad other problems.

The biggest challenge of all, however, is to keep the curriculum relevant; otherwise, we’re cheating our students. Since 1926, we have continued to teach the traditional basic sciences in lock-step sequence with or without integration depending on the school. As a result, the amount of hours students should be getting in other areas is inadequate. Future discoveries in disease prevention, diagnosis, and treatment are almost certain to come from the sciences of genomics, proteomics, microbial genetics, biometrics, and pharmacogenomics. But we do not teach enough pharmacology, nor have we expanded the time we allocate in the curriculum for oral medicine, implant dentistry, and aesthetics. In short, we have not been very effective in matching hours of instruction with an optimized curriculum which meets patient expectations and modern quality standards.

We know that not all the topics we teach are absolutely relevant to the development of quality dental practitioners; but we have been reluctant to take things out of the curriculum in order to make room to allot more hours for newer educational needs. The reason is simple: entrenched interests resist change. Some faculty are comfortable teaching what they have always taught. Also, the National Boards, which are very fair in design, do not reflect the science that is most relevant for practice. Even though there is an active mechanism to update the “boards,” I submit that it is not effective. So we add huge amounts of new materials in some areas, while shortchanging our students in other areas. The result is a baggy monster, a bloated dental curriculum that does not reflect the potential of a dynamically evolving healthcare environment.

To dimensionalize the problem, I recently jotted down the following list of additions to the curriculum over the past 30-plus years since I graduated from dental school. Within the same period, only four topics have been deleted.

A review of the subjects we teach, how we teach, and how we test, is long overdue.

The Choice Before Us: Hedge Our Bet or Trim Our Hedge
In May 2004, New York State passed a bill known as “PGY1,” which, beginning in 2007, requires all New York State dental school graduates to complete a clinically based ADA Commission on Dental Accreditation (CODA)-approved postdoctoral general practice or specialty dental residency program of at least one year as a prerequisite for initial licensure in New York State. This new legislation eliminates the clinical exam as a requirement for licensure in New York.

There was great bipartisan support for this legislation, whose stated goal is to elevate the level of training of the profession so that it more closely follows the medical model for licensure. But implicit within this reasoning, I believe, is an acknowledgement that dental educators find it difficult to teach students all they need to know to become competent dental graduates within the four-year dental curriculum as it is presently structured. This thought occurred to me during a discussion with a longtime NYUCD faculty member. “Mike,” he said, “why are you supporting all this PGY1 stuff? Can’t the darn dental schools get it done in four years now? What are you doing, hedging your bet?”

Yes, I thought, we have placed ourselves in a position where we are forced to do that. I would argue that PGY1 can be much more than a hedge; it can be a year of vital service and learning. It can be a period that enables new graduates to transition from competency to proficiency; to develop deeper experience treating patients with special needs or the medically compromised; to interact with an expanded set of faculty, mentors, and other health professionals; to learn new approaches to treatment; to investigate practice and education opportunities; and to provide increased access to the underserved.

But PGY1 shouldn’t allow us to balance our system failure and access problem on the backs of new, debt-laden graduates. We must bring the curriculum into balance by shrinking some areas of the curriculum and expanding others. The emphasis should be shifted to knowledge and skills that will likely be relevant to new practitioners with projected careers of 40 years. One way to do that would be to transfer some of the first-year dental school requirements to the baccalaureate level. This may mean not only that sciences like biochemistry are reduced in curriculum time in order to add more pharmacology and genomics, but also that certain clinical sciences, such as full denture technique, could be reduced to allow more time for newer techniques like implant dentistry to be taught. Although there will be a need for full dentures for the foreseeable future except in certain areas of the country, full denture construction will likely become so rare that the dentures required by the public could be handled by specialists. We have to be strong enough to say, “We’re not dumbing down. We’re doing what is necessary to keep the curriculum relevant.”

Look at what is happening today. We are graduating dentists who are so overwhelmed by advances in pharmacology, and so intimidated by their insufficient preparation in that area, that they are afraid to write prescriptions. To seize the advances that are occurring every day in pharmacology, clinicians will certainly need to write prescriptions, inject biologicals into their patients, AND understand the plethora of drugs that patients may be taking. But the prospects for dentists to perform these services under the present training system are worrisome. We must do a better job in using our prescription-writing skills to maximize our effectiveness as a profession. If we do not, it is possible that physicians will apply some of these advances in oral disease management. To the extent that such physician involvement helps patients, society is served; but the dental profession may be marginalized in the process. As the great former editor of JADA, Larry Meskin, once said in an editorial on a related topic, “Use it or lose it!”

Other areas in the curriculum also reflect failures to match value to cost. For example, when prosthodontics and periodontics specialty programs went from two years to three years in length several years ago, it seemed like a good idea at the time. Certainly the extra year could be used to enhance the educational experience. However, dental graduates determined that it was not worth three years of their life to specialize in these areas and applications to these two programs plummeted. It is past time to add the same kind of price/value assessments to higher education that the corporate world uses.

New Vistas
There are some encouraging developments on the horizon. The ADEA is beginning to be interested in rethinking the entire dental education enterprise and the ADA also appears receptive to working with dental educators to do something about our overgrown “hedge.” Also, we have the benefit of lessons learned about mismatched price/value relationships. Most exciting of all are technological efficiencies that dental education is only now beginning to embrace. For example, in teaching anatomy, these include videos, 3D modeling, and plastination (see article), versus traditional methods of dissection that have been mostly unchanged for more than 300 years.

We can continue to “hedge our bet” by playing catch up with the present, tweaking the curriculum, while knowing that we’ll never really get the problem under control. Or we can take the kind of drastic action required to organize a dental education enterprise designed to stay ahead of changing times. At NYUCD and elsewhere (see Santa Fe Group Salon Special Report), we are working hard to “trim our hedge.”

Additions to the dental curriculum:
composites (anterior and posterior)
cadcam
glass ionomers
implants
veneers
molecular genetics
systemic interactions:
    preterm birth, lung disease,
    MI’s, diabetes, stroke
terrorism preparedness
sinus lifts
barrier membranes
biologicals
    P15®; Emdogain®
bonding agents
Invisalign®
management of special needs patients
pharmacotherapy
    10x increase in new chemical entities
    Periostat®, Amlexanox®
    Triclosan®
rotary endodontics
lasers
whitening
informatics
new disease entities
    HIV/AIDS, HPV
Cytokines*
cultural competence
ethics
diagnostics:
    Oral Cdx®
    toluidine blue
    intraoral cameras
    Diagnodent®

Deletions from the curriclum:
gold foils
denture processing
silicate cement
endodontic cultures

*Imagine this. Since I graduated in 1971, almost one new immunologically active molecule has been discovered every month!

Recent Educational Innovations at NYUCD
2000:
NYUCD makes the decision to scrap its old curriculum. Work begins on an entirely new curriculum emphasizing health promotion through prevention. The old curriculum consisted of 5,000 hours. Despite adding many new elements and expanding selected areas, the new curriculum consists of 4,500 hours – a 10 percent reduction in time. Highlights of the new curriculum follow.

NYUCD introduces the first completely digitized dental school curriculum.

2001:
A state-of-the-art clinical simulation and laboratory technology center opens.

Predoctoral implant education is expanded.

Digital radiography techniques are introduced into the curriculum.

2002:
A four-year continuing education course on “Assessing the Professional Literature” is added to the predoctoral curriculum.

2003:
The Invisalign® technique is introduced.

NYUCD broadcasts its first international, interactive dental videoconference.

NYUCD becomes the first U.S. dental school to mandate bioterrorism preparedness training for predoctoral students.

An elective in teaching skills gives third-year students the opportunity to teach lab procedures to freshmen.

2004:
NYUCD partners with The Levin Group to design clinical practice management training programs.

Plastination is introduced into anatomy education.

Ergonomic training is mandated for all DDS students.

Diagnodent® technology is introduced.