The Necessity for Major Reform in Dental Education

Impending Crisis in Oral Health Care Prompts Look at Dental Education

In late August, a group of about 60 leaders in dentistry, other healthcare professions, public policy, and the corporate sector met in San Francisco for two days under the auspices of the Santa Fe Group to focus on an impending crisis in oral healthcare education in the United States and to plan strategies that will enable major change and reform to avert the crisis. The salon was designed as an important first step in the journey toward a broad-based national effort to overhaul American dental education.

The rationale for the salon was twofold: 1) Changing societal needs resulting from such factors as immigration, aging and associated chronic diseases have increased disparities in health and in access to care, creating a need for a new type of dentist. Consequently, dental schools must change to reflect these new realities; and 2) Meeting the challenges facing dental education and embracing the astonishing advances in genomics, proteomics, pharmacotherapy, and systems biology will require not simply a change in curriculum, but a reform of the entire dental education process, including changes in prerequisites, admissions, credentialing, and quality assurance.

Calling the salon the beginning of a “revolution from within,” Santa Fe Group President Dr. Larry Meskin explained that “the Santa Fe Group’s objective is to act as a catalyst to influence change by providing a forum in which healthcare professionals, policy leaders, and decision makers from multidisciplinary backgrounds can come together in a neutral environment to share opinions freely, without concern about institutional loyalties and constraints.”

Highlights of the salon proceedings follow.

Why Reform Dental Education?
A white paper, “Reforming Dental Health Professions Education,” coauthored by Dr. Dominick P. DePaola, President and CEO of The Forsyth Institute, and Dr. Harold Slavkin, Dean of the University of Southern California School of Dentistry, framed the issues for discussion.

Drs. DePaola and Slavkin noted that because contemporary dental education remains rooted in training models developed nearly a century ago, dental schools are not providing the kind of education modern practitioners need to function competently in today’s biologically, pharmacologically, and technologically driven healthcare environment. The result is a dental delivery system that cannot keep pace with nor be responsive to shifting population demographics, changing patient expectations, evolving inter- disciplinary practice requirements, emerging technologies, and demands for quality improvement.

“The fact that 80 percent of dental disease occurs in 20 percent of the population, that 110 million Americans lack dental insurance, and that there is a growing shortage of dentists to treat certain populations, especially children, obligates us to move quickly toward reform,” said Dr. Slavkin, as he urged participants to begin implementing change strategies in their home institutions and organizations. To guide the implementation process, Drs. DePaola and Slavkin presented a series of critical assumptions, shown in the box at the end of this article.

Potential Dental Education Models
Participants reviewed five models for dental education from which improvements might be derived, and many other equally intriguing approaches were discussed at the salon. A summary of the formal models follows.

Dr. Jack Dillenberg, Dean of the Arizona School of Dentistry and Oral Health, presenting “Community-based Education: A View From the Trenches,” concluded that dentistry must get students more engaged in communities where they are needed, and that students need to become more representative of the populations they serve.

“The Pipeline Project and Social Engagement,” by Dr. Allan Formicola, former Dean of the Columbia University School of Dental and Oral Surgery, documented ongoing efforts to engage dental education in promoting social needs by increasing the time that senior students and residents spend providing care to underserved patients in patient-centered community clinics and practices; revising the dental school curriculum to support community-based education programs; and increasing recruitment and retention of underrepresented minority and low-income students.

“Technology and Distributed Education,” by Mr. James F. Galbally, Principal, The Presidential Practice, King of Prussia, PA, focused on the high potential of a more technology-based curriculum, which can be widely distributed via electronic methods, but noted that content must determine the extent to which technology is used.

Dr. Howard Landesman, Dean of the University of Colorado School of Dentistry, presented “Corporate Partnerships,” which addressed the importance of seeking more creative relationships with corporate America in order to improve the education of dental students in new and innovative ways; create an enhanced standard of excellence for graduates; and develop a more diverse healthcare workforce.

“Medical-Dental Models in Dental Education," by Dr. David A. Nash, William R. Willard Professor of Dental Education and Professor of Pediatric Dentistry and Bioethics at the University of Kentucky Medical Center, focused on the importance of integration with medicine, nursing, and other health professions education models, either completely, or in hybrid versions.

A common theme running through the papers was that the current dental education system is not serving all of the public, and that the single most important factor responsible is the “silo” approach that has traditionally been the hallmark of the dental education curriculum. By opting for an isolated, insular approach to training future dentists, rather than for integration of dentistry within a comprehensive, interdisciplinary healthcare education and training system, dental schools have created a gap between new scientific and technological advances and incorporation of these advances into dental education and clinical practice.

Other factors cited for this gap were an insufficiently diverse workforce, lack of evidence-based learning and critical thinking/problem solving in the curriculum, lack of a focus on the whole patient/overall health and on integration with and utilization of the larger health professions workforce, a continuing emphasis on surgical/technical skills, and the failure of many continuing education programs in dental schools to become centers of excellence.

Participants noted the need to integrate a number of major topics into the curriculum, including medical approaches, risk assessment/ management training, biopsychosocial models and behavior/communication skills, and interdisciplinary care and team approaches, as well as to close gaps in the curriculum, with specific regard to the needs of children, the elderly, and special populations. Moreover, there was consensus on the point that while no one model will work for all dental schools, the outcomes should be similar.

Consensus also emerged that the status quo is no longer desirable or acceptable; that closer integration with medical education and training is essential; that collaboration among the health professions is more important than ever; that dentists should be leaders in the healthcare community; that leaders in dentistry need to be developed, and that a mechanism is required to make the credentialing process, especially national and regional board examinations, more relevant to the modern practice of dentistry, to scientific and technological advances, and to societal needs and expectations.

The Mission of Dental Education
Looking to the future, participants articulated their vision of an “ideal” oral health education system:

The mission of the oral health education system of the United States is to serve society by educating and training a diverse workforce capable of meeting the nation’s need for oral health care. Members of this workforce should variously be engaged in clinical oral health care, public health practice, biomedical and health services research, education, and administration. Oral health professionals should also contribute to the fields of ethics, law, public policy, government, business, and journalism. The education system will meet its unique responsibilities to educate and train highly competent clinical practitioners by ensuring that they acquire, and sustain throughout their careers, the knowledge, skills, attitudes, and values needed for practice within interdisciplinary healthcare teams. These skilled healthcare providers must have the ability to provide complex, integrative, high-quality care for patients, families, and communities. To do less is an abrogation of the professional covenant extended to dentistry by society.

Recommendations by Participants
The salon concluded with the following recommendations for both short- and long-term strategic actions:

Short-term Actions:

• A pediatric oral health “summit” should be convened to address the shortage of pediatric dental faculty and to develop new models for pediatric oral healthcare delivery, including assessment of the benefits of utilizing oral healthcare providers in medical practices.
• Use more technology in dental education to achieve greater efficiencies.
• Reclaim continuing dental education to enable dental schools to enhance revenue and improve quality.
• Expand best business practices including quality assurance standards within the dental education environment; and continue to look for ways to collaborate with business that leverage both the economic and knowledge capital of business with-out compromising the integrity of the educational process.
• Develop a fund to support ongoing innovation in dental education; for example, the creation of a uniformly implemented risk assessment model for pediatric oral health.
• Create incentives for regional sharing and consolidation of student, faculty, and curricular resources to make dental education more efficient.

Long-term Strategic Actions:

• The provider pool must be expanded through the creation of links between dentistry and other health professions, especially with regard to pediatric oral health.
• Continue to explore other models of dental education including integration or hybrid models with medicine, nursing and other health professions.
• Establish selected, evidence-based, multidisciplinary centers to train translational-research faculty, who will become role models for interfacing between patients and student-clinicians, thereby helping to improve the speed with which science is translated into practice.
• Carefully evaluate the benefits and risks of the extreme timelines for dental education including the three calendar year program used effectively at the Arthur A. Dugoni School of Dentistry at the University of the Pacific, and the new approach in New York State that requires a mandatory PGY1 year as a requirement for licensure and replacement for clinical board examination.
• Redefine credentialing of dental professionals: by building national board examinations which are more relevant to the skill set required to practice dentistry at graduation and in the future; by continuing development of a Part III National Board focused on clinical skills; by evaluating alternate modes of qualifying dentists including PGY1; and by building a system to ensure that there is continuing competence in dental professionals throughout their professional careers.
• Make the faculty member, not the student, responsible for clinical care.
• A new level of practitioner should be created, one who can expand access to care, especially pediatric dental care.
• Accreditation standards should include diversity in order to help solve the national oral health disparity gap.
• Internal dental school changes should be developed in recognition of community needs and in collaboration with other healthcare professions.

For more information and periodic updates, visit the Santa Fe Group Web site at www.santafegroup.org.

Santa Fe Group Board of Directors
Lawrence H. Meskin, President Professor of Dentistry University of Colorado
Richard W. D’Eustachio, Vice President Past President American Dental Association
Steven W. Kess, Secretary/Treasurer Vice President, Corporate Development Henry Schein, Inc.
Michael C. Alfano Dean, College of Dentistry New York University
Dominick P. DePaola President and CEO The Forsyth Institute
Arthur A. Dugoni Dean, Arthur A. Dugoni School of Dentistry University of the Pacific
Raul I. Garcia Professor and Chair Department of Health Policy and Health Services Research Boston University
Wendy E. Mouradian Director, Regional Initiatives in Dental Education Clinical Professor of Pediatrics, Pediatric Dentistry University of Washington
Linda C. Niessen Vice President, Clinical Education DENTSPLY International
Harold Slavkin Dean, College of Dentistry University of Southern California
David O. Born, Executive Director

Salon Participants
Kathryn Ann Atchison Professor & Associate Dean for Research UCLA Dental Public Health
Joel H. Berg Professor & Chair University of Washington, School of Dentistry Department of Pediatric Dentistry
Charles Bertolami Dean University of California- San Francisco School of Dentistry
Yolanda Bonta Associate Director of Technology Colgate-Palmolive Co. Global Oral Health Policy
Laurence Brody Chief Executive Officer ConsoliDent
Richard Buchanan Professor and Dean School of Dental Medicine SUNY/Buffalo
Greg Chadwick Past President American Dental Association
David Chambers Associate Dean Arthur A. Dugoni School of Dentistry University of the Pacific
Peter Cohen Dean, Health Professions Wichita State University
Pam Den Besten Professor University of California- San Francisco Department of Growth & Development
Jack Dillenberg Dean Arizona School of Dentistry and Oral Health
Teresa A. Dolan Dean University of Florida College of Dentistry
R. Bruce Donoff Dean Harvard School of Dental Medicine
Chester W. Douglass Professor Harvard School of Dental Medicine, Oral Health Policy and Epidemiology
Samuel F. Dworkin Professor Emeritus University of Washington, School of Dental and Oral Surgery Department of Oral Medicine
Caswell Evans Associate Dean University of Illinois at Chicago College of Dentistry
Allan Formicola Former Dean Columbia University School of Dental and Oral Surgery
Kent Fletcher President GC America, Inc.
Christopher Fox Executive Director International Association for Dental Research
Pete Frechette Chairman and CEO Patterson Dental Company
Paula K. Friedman Associate Dean Goldman School of Dental Medicine
Terry Fulmer Division Head and Professor NYU Steinhardt School of Education Division of Nursing
James F. Galbally, Jr. Principal The Presidential Practice
Paul Glassman Associate Dean Information & Educational Technology Arthur A. Dugoni School of Dentistry University of the Pacific
Jerry Goldberg Dean and Professor of Oral and Maxillofacial Surgery Case Western Reserve University School of Dentistry
Charles J. Goodacre Dean Loma Linda University School of Dentistry
Lynette E. Kagihara Director, AEGD Program and Associate Professor of Clinical Dentistry School of Dentistry University of Southern California
Robert Klaus President and CEO Oral Health America
Dushanka Kleinman Deputy Director NIDCR-NIH
Gary Kunkle Vice Chairman and CEO DENTSPLY International
Howard Landesman Dean University of Colorado School of Dentistry
R. Ivan Lugo Associate Dean, Financial Administration & Institutional Relations Temple University School of Dentistry
Beth Mertz UCSF Center for the Health Professions
David A. Nash University of Kentucky Medical Center
M. Elaine Neenan Associate Dean, External Affairs University of Texas Health Sciences Center at San Antonio
Laura Neuman Associate Executive Director American Dental Association Division of Education
Kathy O’Loughlin President Delta Dental Plan of Massachusetts
Barkley Payne Senior Director American Dental Association Foundation
Gary Price President and CEO American Dental Trade Association
Eugene Sekiguchi Immediate Past President American Dental Association
Chuck Shuler Associate Dean, Academic Affairs University of Southern California School of Dentistry
Douglas M. Simmons Associate Professor, Restorative Dentistry University of Texas, Houston
Martha Somerman Dean University of Washington School of Dentistry
Mike Sudzina Director, Professional & Scientific Relations The Procter & Gamble Company
Henri Treadwell Director, Community Voices Morehouse School of Medicine National Center for Primary Care
Helena Gallant Tripp President American Dental Hygienists Association
Richard W. Valachovic Executive Director American Dental Education Association
Anthony Volpe Vice President, Clinical Dental Research Colgate-Palmolive Co.
Don Waters President & CEO Brasseler USA
Jane Weintraub Professor Community Dentistry and Oral Epidemiology UCSF, School of Dentistry
Ken Zachariasen Associate Dean & Chair University of Alberta Department of Dentistry

Also participating from the Santa Fe Group:
Michael C. Alfano
David O. Born
Dominick P. DePaola
Arthur A. Dugoni
Raul I. Garcia
Steven W. Kess
Lawrence H. Meskin
Wendy E. Mouradian
Linda C. Niessen
Harold Slavkin

Dr. DePaola’s and Dr. Slavkin’s Assumptions for Implementing Change Strategies
Assumption 1: Reform of oral health professional education is critical to enhancing the quality of health and well-being for all people in the U.S.
Assumption 2: Academic environments of most health professions education (dentistry, medicine, pharmacy, nursing, allied health sciences) all too often are not inter-disciplinary, whereas healthcare clinical practice and clinical research often require explicit interdisciplinary efforts.
Assumption 3: There is no one model or template for dental education that will suffice for all dental schools.
Assumption 4: There must be a unifying vision of what dental education “could be” and what a 21st century practitioner “could be.”
Assumption 5: Adequate resources must be allocated to realize the vision of dental education.
Assumption 6: A common language and core competencies across health professions have not yet been achieved.
Assumption 7: The competencies for dental school graduates and practitioners for the 21st century must be well defined and renewed throughout a lifetime of professional activities.
Assumption 8: Evidence-based core competencies should be established across all health professions and integrated with clinical care services.
Assumption 9: Dental education must enable individuals to learn, to re-invent, and to attain contemporary competencies over a lifetime.
Assumption 10: The collaborative role of allied health professionals (dental assistants, dental hygienists, dental technologists) must be expanded significantly, holding open the possibility of developing pediatric oral health therapists, among other new “reconfigurations” of providers.
Assumption 11: Integrative biomedical, population, behavioral, social, and economic sciences must be incorporated into the curriculum at every level.
Assumption 12: There must be regular assessment of curricula and pedagogical outcomes and continual documentation of clinical skills.
Assumption 13: Scientific discovery, coupled with translating science and technology into clinical practice, must be a core value of dental education.
Assumption 14: Critical thinking, problem solving, information management, leadership and teamwork, and lifelong learning must be integral to all dental education models.
Assumption 15: Humanism, professionalism, and communication skills must underpin the education process.
Assumption 16: Innovation, creativity, and the nurturing of ideas must permeate dental education and clinical practice.
Assumption 17: “It will take a village” to reform dental education, including individual faculty members, organized dentistry, industry leaders, funding agencies, insurers, patient advocates, the media, public health advocates and practitioners, regulators, leaders from research, education, and government, state and national licensing boards, accreditation agencies, and the public.
Assumption 18: This conference cannot be the end; it must be a beginning. We must articulate concrete steps and “walk the talk”; we must begin and sustain the journey.