Message from the Herman Robert Fox Dean
Dentistry: Circle Back? Circle the Wagons?
Or Circle the Moment?
- Dr. Michael C. Alfano

By Michael C. Alfano, DMD, PhD Executive Vice President, New York University; Former Dean, NYU College of Dentistry

I assumed a new role at New York University four years ago, and for the first time in more than 40 years, the profession of dentistry has not been a part of my daily life. Nevertheless, I continue to follow the development of the profession because I care deeply about its future. Alas, my observations on some aspects of recent developments in dentistry and dental education have not been encouraging. My concerns prompt me to express a few thoughts about the troubling trend lines that are developing.

Circle Back?
Let's start where the profession 'begins' - with education. Dentistry can be proud of its long march to an ever-improving educational system. Beginning with its origins as an apprentice-based trade, dental education has risen from the era of the barber surgeons, through the period of proprietary schools of dentistry, to university-affiliated colleges and schools, many of which have strong research programs. Indeed, if I were to try to identify the signature event that moved dentistry from a trade to a profession, it would be the alignment of the dental education system within universities, especially research universities, early in the 20th century.

Related developments have certainly helped to enhance both the quality and esteem of the profession along the way, including the founding of the ADA, AADS (ADEA), NIDR (NIDCR), CODA, and the Regional Board System - especially as this Board system has become more progressive in recent years. In addition, we should always be mindful and thankful for the innovations of our colleagues in academic and corporate research labs that have led to the development of diagnostics, instrumentation, therapeutics, preventives, and materials-based advances that the barber surgeons never dreamed about.

So, why worry? I am very concerned that the dental profession is losing esteem, struggling to find leaders who are up to the task, and possibly even circling backward. One reason is the potential long-term impact of the new dental schools that have opened, or are scheduled to open, in the near term. While I am not familiar with all of the schools in the queue, those that I do know, taken individually, should contribute well to educating a diverse array of talented new colleagues. For example, one school has a strong emphasis on recruiting and serving Native Americans; another will integrate the education of dentists with other health professionals; and a third will try to reduce educational costs, while increasing access to care, by utilizing broad community-based clinical education. What is not to like about such creative approaches to dental education? In fact, it is this very willingness to experiment with different models of dental education that makes the profession strong. Moreover, some very talented leaders have been recruited to guide these institutions forward. Therefore, I am not concerned about any individual new dental school.

My concern arises from the fact that not one of these new schools is nested within the structure of a research-intensive university. In fact, I believe the last dental school to be sited at a major research university was at the University of Florida in 1972. Why is this? Moreover, why have some research universities elected to close their dental schools? Why have institutions like Harvard, Penn, and Michigan welcomed dental schools in the past, but universities like Stanford, Chicago, and Yale will not consider them now? What will replace the contributions of research-based dental schools in the advancement of dental care?

Comprehensive answers to these questions are beyond the scope of this short article, but the present situation is already causing worrisome developments. For example, 27 research-oriented dental schools recently concluded a meeting in the Midwest to discuss what to do to foster more research on oral health and to address the added costs of running a research dental school and its consequent impact on the 'sticker price' of dental education. This strikes me as a worthy goal, but why aren't all dental schools at the table to discuss this topic? Does this mean that non-research-intensive dental schools need an alliance of their own? Have we lost the ability to focus on tough topics as a collective? Will the absence of non-research-intensive schools in the debate reduce chances of creating research consortiums by which research-intensive schools partner with non-research-intensive schools to enhance the educational experience of the students and advance the profession? How far will such subdivisions set back the brilliant move of ADEA a few years ago in pulling all aspects of dental education together by welcoming all components of the profession to membership? Surely these issues warrant open discussion at the highest levels of the profession.

Circle the Wagons?
While dental education might be in danger of circling back, our colleagues at the ADA seem content to circle the wagons, at least in one important area. To be sure, there have always been 'crises' of sorts within the organization of the ADA - tripartite membership; professional advertising; expanded function dental auxiliaries (EFDAs); denturism. However, in previous eras, the Association seemed to be able to initiate dialogue or to identify leadership that helped the organization to evolve positively - perhaps slowly - but positively nonetheless. The situation today seems different to me.

For example, ADA staff leadership has been dismissed under a cloud pierced only by the cognoscenti; current staff leadership is under duress in similar secrecy; rumors of federal oversight circulate; trustees and delegates snipe at each other; and the Association seems consumed by what it is against rather than what it supports. As this dysfunction, as many are calling it, continues, the two defining dental care issues of our time - healthcare reform, which has the potential to add 10 million additional children to the rolls of dental insurance, and the launch of the "new dental practitioners" (community dental care coordinators, dental therapists, or advanced dental hygiene practitioners) are proceeding with inadequate discussion and reflexive as opposed to insightful thinking. Thus, it would seem that the ADA, in failing to study and understand the mistakes it made in Alaska with respect to the dental therapist model, is doomed to repeat them.

On Alaska, I remember a discussion with a highly placed leader of the ADA in which I called to inquire about the ADA's stand on adoption of the New Zealand model of dental therapists by settlements of native Alaskans. It went something like this:

  • Let me understand this. The ADA is going to sue the native Alaskans who are trying to adopt a system of dental care that has been proven to work for 90 years for use in remote sites that currently have no dental care? (Short answer: Yes.) And do I further understand correctly that in addition to paying lawyers large sums of money to conduct the litigation, you are going to spend equally large sums of money on a PR campaign to ameliorate the concerns of the public about access to dental care? (Short answer: Yes). Why? (Short answer: This is what the Board wants.) So, why don't you spend all of that money to actually hire dentists to go to Alaska to deliver the care? If you do this, the PR will take care of itself, and the headline will be, "Dentists dig deep into their own pockets to ensure dental care for rural Alaskans." (Short answer: The Board won't buy it; it wants to nip this approach in the bud.)

The rest, as they say, is history.

Fast forward a decade or so, and note where we are:

  1. Minnesota has passed legislation allowing for the development of mid-level dental practitioners.
  2. Several other states are considering such legislation.
  3. A group of a dozen or so state dental organizations are obliged to meet privately (without ADA participation) to determine the best approach to introduce and license mid-level practitioners. This group of state dental associations understands both the passion of the citizenry for better access to care and the importance of participating in the process to ensure that the enabling legislation in their states improves access to care without risking the health of the population or undermining the high quality of dental practice in those states.
  4. In contrast, a second group of state dental organizations was recently organized to fight the development of mid-level dental practitioners. Thus, more than half the state dental societies in the country are at odds with each other.
  5. The ADA was not invited to participate in two high-level federal committees studying the delivery of dental care in the United States. Imagine that! The ADA, which considers itself the leading institution on dental care in this country, was not invited to the table to discuss the signature dental health issue of the day.
  6. Efforts by a foundation-supported group of educators to write curriculum guidelines for the dental therapist model have been hampered - but not stopped - by the concern of some invitees that they will be ostracized by 'organized' dentistry.

The resistance to new models of practice by dentists is not unique to the dental therapist discussions of today. For example, the first efforts to establish a dental hygiene school in Ohio in 1910 were fiercely resisted by local dentists, resulting in the school's closing after a couple of years. Similarly, the establishment of the Fones School of Dental Hygiene in 1913 in Connecticut was bitterly opposed by local dentists; but fast forward 100 years and there are now about 300 dental hygiene programs in the United States.

Periodic tiffs between dental and dental hygiene organizations notwithstanding, few would argue that the public and the dental profession have not benefited enormously from the establishment and growth of the dental hygiene profession. Perhaps the dental profession can once again rise above its natural state of resisting any intrusion on the status quo to have an open discussion on how the public and the profession might once again benefit from new treatment paradigms like the dental therapist. Alternatively, we can circle the wagons and await the inevitable outcomes of the failure to learn from our past mistakes.

Circle the Moment?
Often a signature event can catalyze important change. Think of the individual who survives a myocardial infarct, but then begins an exercise program; closer to home, reflect on the tragic dental infection-caused death of Deamonte Driver, which galvanized Congress to pay attention to the need for more funding for dental care. Is it possible that the growth in the numbers of non-research-intensive dental schools can catalyze the first meaningful collaborations among dental schools of different types? Would such collaborations make dental education better…more efficient… more respected? Will alumni of research-oriented dental schools 'dig deeper' to support an educational model with inherently higher operating costs to preserve research in dental schools?

On the practice side of the ledger, will the rise of these new dental practitioners create models that change the dental profession in important, positive ways? ADA policy states that the dentist must remain the leader of the team. Is the profession aware that the proposed "dental therapist" being educated at the University of Minnesota School of Dentistry will work in a private practice under the supervision of the dentist? Can practicing dentists accept that dental therapists can effectively deliver certain clinical procedures - but certainly not all dental therapies? Will the arrival of these new dental professionals enable dentists to evolve in ways that more fully utilize the breadth of the scientific education that was part of their dental curriculum?

Will these evolving dentists focus more exclusively on diagnosis, treatment planning, and complex cases; and will they promote the expansion of dentistry as a primary healthcare discipline? Can they rise in service to a country with an inadequate primary healthcare system to lead teams of hygienists, therapists, nurse practitioners, and other health professionals in creating not only better access to health care, but simply earlier and better health care? Will they recognize that there are 30 to 40 million Americans who get regular dental care, but not regular medical care? And will they arrange through their general healthcare colleagues working with them in their expanded primary care dental practices to diagnose and manage the millions of cases of diabetes, hypertension, and hyperlipidemia, among other conditions which today go both undiagnosed and untreated until it is too late, and too expensive?

Finally, let me note that I worked for eight years in a non-research- intensive dental school, and for an additional eight years in a research-intensive school. Each made important contributions, and there is need for both types of schools. My concern is that the balance is beginning to shift away from the research-intensive schools, which I think is a serious mistake in the evolution of dentistry and dental care. Indeed, I fear this trend will accelerate in the near future, and dental education will founder with a diminished research base, and the profession of dentistry will decline in synchrony with its educational arm.

I also practiced dentistry privately for some time and have been an ADA member for 40 consecutive years, including a 16-year period when I worked in the corporate world. I have had the privilege to consult for the ADA on numerous occasions, and although I have often disagreed with ADA policy, I never considered dropping out of the Association. I will not drop out now, even though the Association is disappointing me greatly at the moment. Nevertheless, I will write about these issues as opportunities, such as this invitation to write for Global Health Nexus, present themselves. I encourage you, whatever your views, to do the same.

Wake up, dentistry!