The publication in 2000 of Oral Health in America: A Report of the Surgeon General appeared to forecast a new era of importance for dentistry. The report's findings emphasized leading-edge technologies and research that could be brought to bear on maintaining and restoring health; the need to alleviate the burden of oral diseases and disorders in the nation as a whole; and actions to be undertaken to improve oral health across the life span.
Consistent with these findings, the report envisioned a biomedical research workforce of sufficient quantity, skill, and commitment to fulfill, with supportive infrastructure, the promise of diminished oral disease and the attendant benefits that improved oral health brings to general health.
Yet, just one decade later, a terrible irony has emerged. Recent evidence suggests a reverse trend, a gradual de-emphasis on research within those traditional incubators of potential oral heath researchers—our nation's dental schools. What has gone wrong?
Today, US dental schools are not competing effectively for available research dollars in the oral health sciences in comparison with other kinds of academic institutions. Indeed, between 1993 and 2008, the percentage of NIH funding going to dental schools decreased from almost 70 percent to less than 50 percent, despite an overall increase in dollars awarded for dental research by the National Institute of Dental and Craniofacial Research (NIDCR). As the dental research pie has increased, the piece going to dental schools has gotten smaller. Moreover, between 1982 and 2000, seven dental schools—none having a significant research portfolio—closed, and since 2000, four dental schools have opened. The new schools are presumed to be non-research-intensive because they do not appear to be investing in research-oriented faculty and are nested within parent universities that are themselves not known to be research-intensive. When these data are viewed in aggregate, it appears that a redirection of dental education away from its historic mission of research, teaching, and service toward a more limited and exclusive focus on teaching may be taking place.
One likely explanation for this trend is the substantial increase in the compensation of practicing dentists in recent years. This development has led to a greater demand for dental education from an expanded pool of academically outstanding dental applicants for whom high compensation is a key driver in the selection of an occupation, and to the emergence of additional dental schools to meet this demand.
One interpretation has been that new schools are not just new, but rather that they embody a new style of dental education as well, one founded on a simple, tuition-based financial plan, often in non-research-intensive universities, and for which research may not be a driving priority. Although the Commission on Dental Accreditation (CODA) has an explicit standard for accreditation requiring that research must (emphasis theirs) be an integral component of the purpose/ mission, goals, and objectives of a dental school, it is hard to envisage a dental school being cited because of an insufficient research program or losing its accreditation because of an inadequate research environment.
In principle, it is certainly possible for a dental school to exist without supporting a large resident faculty, tenure, or basic scientists. It is even possible for dentistry to be taught without a significant preclinical educational infrastructure, including large (often money-losing) student clinics or research laboratories. In fact, both the newly emerging dental schools and long-established dental schools (many of which are, in truth, non-research-intensive) have attempted varying blends of these diverse survival strategies. But whether a dental school is among the crop of the newly established or not, what is quite clear is that society as a whole genuinely values dental research. This is evidenced by a continued increase in funding for research in the oral health sciences over recent years. Yet, as funding for oral health research has increased, the percentage going to dental schools has declined.
This outcome cannot be placed at the feet of new, less research-oriented dental schools—they haven't been around long enough to have an impact one way or another. More importantly, no matter how many non-research-intensive dental schools might be formed, this could never explain why the research-intensive ones have become so much less competitive in securing funding from an increased pool of research dollars. Rather, the decline of dental education's competitiveness in the research arena is the predictable outcome of years of de-emphasizing the importance of dental research in dental education institutions in general (whether new or old) and, perhaps, because of an ambiguity in the minds of dental practitioners themselves about the relative importance of research as the foundation of a learned profession.
In the abstract, practicing dentists presume that dental research is going on someplace by somebody, and they guess that it must be happening in dental schools. It isn't. As a consequence, research in the oral health sciences has been taken up by non-dental academic institutions, including medical schools, engineering schools, and hospitals, with the added research funding—and more—being absorbed by these institutions for which dental research, astonishingly, has a higher priority than it does for US dental schools.
If a trend away from fostering a robust oral health research infrastructure is a manifestation of a change in the mission of existing dental schools and/or a reflection of new dental schools whose long-term institutional commitment coalesces around teaching the technical aspects of dentistry while minimizing research as the foundation of dental practice, a diminishing research scenario could well continue over an extended period. The result, to my mind, would be to undercut the pipeline of potential research scientists coming from US dental schools, decreasing further the amount of research conducted within dental schools, and weakening the nation's oral health infrastructure.
Equally important is the impact of this trend on the dental education process. Much of professional education entails learning to cultivate sophisticated tastes and nuanced satisfactions. Acquiring the taste for complex issues, for problems, and for problem solving comes naturally to some people; for others, it needs to be cultivated. This, more than anything else, is what higher education is supposed to accomplish. All dental schools without exception need to help students acquire this taste—though there may be more than one way of doing so.
An education colored by research is one way of achieving the objective of intellectual rigor and of helping to cultivate in students an appreciation for complexity. But this may not be the only way to do it. It's quite possible for dental schools that lack a research focus to still cultivate an emphasis on critical thinking. While not contributing original research themselves, they may still educate students to understand that a scientific literature exists; where to find it; how to read that literature and understand it; to critique it; to segregate the scientifically valid from the invalid; and to take what is valid and adapt it to the care of patients. Whatever the mechanism employed, one thing is certain: All the discussion of evidence-based practice (EBP) will be irrelevant if dental graduates are scientifically illiterate and if the language and syntax of modern biological research are unintelligible to dentists.
Implicit in the discussion is the unstated assumption that the risk of slipping into vocationalism is great for dentistry. This risk entails a mindset that says: “Just tell me what I need to know technically and nothing more; keep everything snappy, practical, and up-to-date, with nothing theoretical or irrelevant.” The problem with such an approach is that it encourages acceptance of flawed assertions as true and tends, in the long run, to move one away from truth, rather than toward it.
Dental educators, like everyone else, fear the unknown. Accordingly, it's not just the thought of new schools, but of new kinds of schools, that has provoked an anxiety—possibly irrational—over a new and unwelcome direction for dental education and practice. This anxiety recently crystallized around a meeting of deans from research-intensive dental schools held at the University of Michigan. A positive outcome may well be a tremendous increase in consciousness in the minds of practitioners and educators alike of the diminished state of dental research in US dental schools as a whole.
This issue of Global Health Nexus offers a window into the current debate regarding the implications of the trend away from an emphasis on research within dental education. We are privileged to have among our guest authors Dr. Michael C. Alfano, Executive Vice President of NYU and a former dean of NYUCD; Dr. Peter Polverini, Dean of the University of Michigan School of Dentistry; Dr. Dominick P. DePaola, Associate Dean for Academic Affairs at Nova Southeastern University College of Dental Medicine; and Dr. Richard I. Vogel, Executive Vice Dean of NYUCD.
This issue also celebrates a number of major faculty research achievements, including the selection of Dr. Timothy Bromage as the recipient of the 2010 Max Planck Research Award, one of the most prestigious awards in the world for scientists working in the natural sciences; the recruitment of several immensely talented new faculty members, including Dr. Brian Schmidt, who has been appointed the new Director of the Bluestone Center for Clinical Research; and the work of nursing professor Dr. Joyce Anastasi to help chronically ill cancer patients manage symptoms. You'll also find a number of articles on the increasing strides that NYUCD is making in providing sustainable oral health care in remote regions of the world, and on the consistent rise in philanthropy to NYUCD, including a $3.5 million gift in honor of Dr. Schmidt's work and a multimillion dollar, multiyear commitment by Henry Schein Cares, the Henry Schein company's global responsibility program, to support global student outreach at NYUCD.
I am also pleased to call your attention to a story about the induction of the inaugural members of the NYU College of Dentistry Academy of Distinguished Educators, which speaks to the importance of recognizing outstanding teaching at the College. To underscore the importance of the Academy to the life of the University, NYU President John Sexton was present to officially induct the inaugural members.
In all, this is an issue filled with stories that we believe you will find both provocative and enlightening.