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Perspectives |
Key words: dental education, dental curriculum, research, scholarship, science integration
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Abstract |
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New science and technologies are already making their way into all aspects of dental practice and have changed traditional approaches to diagnostics, risk assessment, prevention, and many procedures in clinical dentistry. These new science advances are primarily directed toward connective tissue biophysics/ mechanics, tissue engineering, and the large areas of biotechnology (gene therapy, drug delivery, transport dynamics), molecular engineering (macromolecular structure, protein structure, and molecular therapies), informatics (patient management/record systems, data mining/management applications, and simulation/computer-assisted learning environments), and biomaterials (biocompatibility, bioengineering applications of polymers, biomimetics, implant materials, and nanotechnology of dental materials).
For example, there are now commercially available kits related to diagnosis, risk assessment, and prognosis for caries/periodontal disease based on genetic polymorphisms, biomarkers, and principles of cell biology.1,2 In fact, the recent development of saliva as a diagnostic medium has placed dentistry at the forefront of monitoring systemic health and disease.3 The application of genomics/proteomics to diagnostic tests and preventive measures requires that students and practitioners receive the necessary knowledge related to microbial/human genetics and the current principles of molecular medicine.4 Given the current lack of genetics instruction in dental education, this will require significant restructuring of dental curricula and faculty development programs.5 Within the field of restorative dentistry, the tremendous advances in biomaterials research have led to the current availability of esthetic posterior adhesive restorations, ushering the profession into the "postamalgam era."6 It has been clearly established that this new biomimetic approach to restorative dentistry is possible through the use of composite resins/porcelains and the generation of a hard tissue bond. The development of these nanomaterials has moved nanotechnology from its theoretical foundations into mainstream practice, and there are now many examples of commercially available products demonstrating the scope of further applications of such technology.7
In the area of dental informatics, the application of computer and information sciences to improve dental research, education, and practice has been particularly noteworthy. Many dental schools have developed sophisticated simulation laboratories that take advantage of virtual reality technologies to teach preclinical skills, and the use of electronic teaching tools and learning environments (CD-ROM or web-based) has increased dramatically.8,9 Although today’s dental students are entering the educational program with unprecedented computer literacy, many dental faculty require significant training in order to take full advantage of current computer-aided simulation and instruction capabilities.10,11 Most dental schools have already implemented some form of electronic paperless records, patient management systems, and digital imaging techniques. Although this technology has the ability to revolutionize patient care through rapid and efficient management of large amounts of clinical information, for it to be useful, the technology must be understood by the end users (students, faculty, and practicing clinicians). At the present time, many practitioners do not exhibit a high degree of computer literacy and are not using currently available informatics technologies to their full potential.12
The use of computer and imaging technology is rapidly changing the practice of orthodontics through computer-assisted appliances for tooth movement (InvisalignTM computer-generated therapy).13 Newly available digital imaging methods that reveal minute details and enhance discrimination have added a sophisticated level of reliability/predictability to implant procedures.14,15 Recent improvements in computer-aided design (CAD) and computer-aided manufacturing (CAM) for indirect restorations now provide for replication and digitization of the complex topography of tooth structure.16 Over the last several years, CAD-CAM techniques have transitioned from the domain of the unreliable to mainstream practice, providing better mechanical properties, improved marginal integrity, and enhanced esthetics compared to traditional indirect techniques. Today’s more reliable CAD-CAM techniques, some of which may reduce the number of patient visits, are available for the production of a wide range of ceramic restorations.
Scientific and technological advancements that generate new knowledge will continue to occur at unprecedented rates. Future advances will be made possible through emerging interdisciplinary collaborations and thought processes. Thus, significant curricular changes will be necessary to educate a new group of dental professionals who will effectively use interdisciplinary research findings to solve clinical problems and apply new technological advances to the oral health environment. In order to maintain its status as a respected scientifically based health profession, dentistry must appreciate and incorporate these advances within its education and patient care systems. The continued evolution of the dental profession will depend on the discipline’s ability to translate the new science into integrated interdisciplinary services in clinical settings.17 To ensure the continued viability of the profession, it is the responsibility of the dental education sector to facilitate the development of institutional infrastructures that are responsive to and supportive of scientific and technological advances. At the very least, faculty and students must become sophisticated consumers of research and utilize scholarly approaches to evidence-based paradigms in their clinical patient management.
Those outside of dental education may assume that such health professions education/training programs regularly transfer new knowledge and clinical applications of new technologies into their curricula; however, those within dental education realize that scientific advances usually experience a slow assimilation into the dental curriculum.18,19 Dental education in the United States has traditionally been characterized by discipline-based, lecture-style teaching that emphasizes technical expertise,20,21 with insufficient attention paid to the development of critical thinking/problem-solving skills and redesign of content/teaching approaches, thus resulting in a stagnant, overcrowded curriculum.22,23 Furthermore, graduates do not have an appreciation for the application/importance of research and discovery to patient care activities and are not adequately prepared to embrace interdisciplinary technology-based education/training and informational resources critical to lifelong learning and professional growth.24–26
There are a variety of opinions regarding the future role of new science and research/scholarship in dental education.25–30 Some contend that current curricula and research/scholarly training experiences maintain an adequate number of research/scholarly enterprises to develop new knowledge, disseminate new advances/technologies, and translate that information into patient care. However, recent approaches have maintained narrowly focused definitions of the perceived importance of research/scholarly activity, the purpose of research, strategies for increasing the number of future dental researchers/educators, and methods for producing graduates who incorporate evidence-based philosophies into their practices.26,30 Furthermore, most would admit that some potentially serious problems have developed including insufficient 1) numbers of current and future research/ scholarly dental faculty; 2) integration of dental research into the larger world of science; 3) application of new science to clinical practice settings; and 4) acceptance/ownership of research findings by the dental community.25–30 To date, there are no data available to determine the degree to which the current educational system has contributed to these problems.
Historically, approaches to support new science and research/scholarship have favored accomplished investigators and established infrastructures within research-intensive institutions.26,29,30 Dental schools designated as research non-intensive are usually associated with smaller universities, have institutional missions emphasizing teaching/service, often lack resources required for developing an infrastructure that supports elite research programs, and are unable to sustain a critical mass of experienced faculty actively engaged in research and scholarly pursuits. Within these cultures, faculty have limited time to pursue scholarly activities because a faculty-intensive teaching curriculum dominates the environment.31 As a result, research endeavors at these schools have been largely ignored, creating a large cadre of disenfranchised faculty and students with no ability or desire to contribute to the overall agenda related to the infusion of science and discovery into the dental curriculum and patient care activities.
The present paradigm of dental education severely limits the ability to restructure the process to support infusion of new science due to an overcrowded curriculum, lack of integration of biomedical/clinical sciences, and a clinical component that operates in an environment completely removed from research/scholarly enterprises.26,30 Within this context, new advances/technologies and the overall activity of research/scholarship become an afterthought or an arena reserved for a cloistered group of designated academic faculty. This traditional model must experience a paradigm shift, not only to increase the number of participants in science/scholarship, but also to enhance access, acceptance, and applicability of the science/scholarship. For the profession to advance, every dental school must play a role in establishing a culture that attaches value to research/discovery, evidence-based practice, and the application of new knowledge/technologies to patient care.32
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Recent Models for Integration of New Science into the Dental Curriculum |
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TopAbstractRecent models for integration...ConclusionsReferences |
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Marquette University School of Dentistry
The Marquette University School of Dentistry (MUSoD) began the process of completely restructuring its dental curriculum in 1999. Over the last eight years, this process has resulted in significant changes that have produced a dynamic, nontraditional educational program that continues to evolve.32,33 The first phase of the transition involved 1) elimination of outdated or repetitive content; 2) reduction of traditional lecture-based, discipline-specific courses; 3) integration of basic biomedical, behavioral, and clinical sciences content into appropriately sequenced four-year educational tracks; 4) implementation of case-based rounds and facilitated discussions using clinical and biomedical correlates for continuous reinforcement of key concepts; and 5) establishment of early clinical experiences and community-based experiential learning opportunities. This comprehensive effort was partially funded by the United States Department of Education through the Fund for Improvement of Post-Secondary Education (DOE FIPSE program).33
The second phase of the transition involved development of a dedicated curricular track providing continuous exposure to new science concepts and applications as well as student research/scholarly activity throughout all four years of dental education. This track represented mandatory hours of didactic time exposing students to topics not traditionally included in dental curricula. Additionally, students were provided with customized flexible schedules to participate in elective "hands-on" mentored research/scholarly experiences at local, national, and international sites including linkages to certificate, M.S., and Ph.D. programs. New curricular elements were designed to foster an appreciation of research/ discovery, an interest in academic/research careers, and the application of new knowledge and biomedical/clinical advances to patient care. This effort was partially supported by the National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH) R25 Oral Health Research Curriculum Grant.32
The present-day MUSoD curriculum is illustrated in Figure 1
. MUSoD maintains a relatively small faculty (forty-five full-time faculty for a class size of eighty students) and is a traditional research non-intensive institution with a prominent teaching and community service mission along with a teacher-scholar faculty model. To increase the emphasis on research/scholarship, enable the application of new advances to clinical practice, and create the conditions for such a significant change to occur in the educational program, the faculty needed to be prepared and trained to support the new curriculum. Thus, it is important to note that DOE and NIDCR funding was also used to support a wide array of faculty development activities that provided skill sets required to deliver integrated biomedical/clinical content; research-oriented, evidence-based approaches to dental education; and translational case-based teaching methods emphasizing the application of new science/technologies to patient care.
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The highlight of this component of the curriculum track is an interinstitutional D.D.S.-Ph.D. program developed with the University of Rochester Center for Oral Biology. This unique program allows Marquette dental students to begin their Ph.D. studies with three-month research rotations each summer. During these summer rotations, students are also able to complete clinical activities, so that they maintain their class standing and complete the D.D.S. program within the normal four-year period. The entire fourth year of dental school is completed at Rochester with concurrent Ph.D. coursework, research, and clinical activity. Students graduate with their dental class and return to Rochester for an additional one to two years to complete the Ph.D. Financial incentives are provided throughout the program including $6,000 for each summer, fourth-year tuition coverage, and a $22,000 stipend for each additional Ph.D. year. The funding sources for stipends and tuition support are derived from the Marquette R25 and Rochester T32 NIH-NIDCR grant awards.
Development and implementation of a comprehensive faculty development initiative were related to critical components of the overall curriculum reform and MUSoD-designed and -delivered faculty development activities that support the new curriculum. The first phase was designed to provide programming that allowed the faculty to identify and appreciate key scientific, biomedical, behavioral, and clinical concepts that should be included in the curriculum tracks and needed to be reinforced through inclusion in case-based rounds and one-on-one teaching opportunities on the clinic floor. Introduction of the concepts involved in utilizing evidence-based decision-making strategies were included in this phase of the faculty development activities. The training was delivered interactively using group learning activities based on actual clinical dental cases; this provided an opportunity for faculty to review the biomedical and clinical science concepts that are crucial to an adequate diagnosis/treatment plan. These modules were supplemented with seminars using unique cases and interactive discussions concerning critical scientific concepts present in the cases that were influential in diagnosis/treatment planning decisions. Additionally, behavioral sciences and interdisciplinary considerations that impacted comprehensive patient management were incorporated into the cases, along with discussions of complex medical histories and treatment settings as well as use of patient scenarios featuring varying levels of debilitation/function, social/socioeconomic circumstances, and ethnic/cultural considerations.
The second phase of faculty development activities consisted of opportunities to develop instructional/teaching skills in research-oriented areas. These opportunities consisted of 1) development of skills necessary to effectively lead small group, case-based seminars involving use of an evidence-based protocol including specifically how to conduct/facilitate an effective dental rounds session; 2) use of technology in teaching and development of electronic learning environments including instruction on utilizing PowerPoint presentations, preparing and delivering courses through use of Internet tools/software packages, and using web-based information resources for instruction; 3) one-on-one teaching skills to enhance clinical learning, including appropriate questioning strategies designed to prompt students to recognize and solve patient treatment issues applying appropriate biomedical, behavioral, and clinical science concepts; and 4) development/ implementation of assessment approaches for case-based, practically applied research/scholarly curriculum track components. Thus far, this training has comprised twenty-eight formal activities consisting of self-study modules combined with seminars and workshops. A detailed listing of the faculty development activities completed during the curriculum reform process is provided in Table 2.
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The new MUSoD curriculum model significantly changed the culture of a research non-intensive dental school, creating a supportive environment for research/scholarship, increasing academic productivity, and altering the attitudes of faculty/students with regard to new science and its place in dental education and practice. Significant increases were demonstrated in 1) number of students participating in research/scholarship, attending national meetings, acquiring research awards, publishing manuscripts, pursuing advanced training/degrees, and expressing interest in academic/research careers; 2) number of faculty participating in development activities, publishing manuscripts, and mentoring students; and 3) institutional credibility within the university, supportive infrastructure for research/scholarship, and cultural expectations for academic excellence. Table 3 illustrates some comparisons made using baseline data prior to the new curriculum and data collected in 2006.
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The Biodontics program promotes innovations in oral health through a specific educational program focused on the research and development of products, technologies, and equipment. At the dental student level, the material is delivered through presentations/ discussions scheduled within the curriculum, along with a special eight-week elective summer course. The Biodontics material is provided by faculty, business leaders, entrepreneurs, management executives, scientists, architects, and dental manufacturers. This course is also open to dental students from other schools. At the graduate level, a structured fellowship provides opportunities for interaction with research faculty, representatives of the dental industry, entrepreneurs, and practitioners including hands-on experience with state-of-the-art technologies. As part of the program, fellows develop educational, translational research, and clinical trials programs designed to integrate basic science discoveries with clinical applications. New technologies such as probiotics, dental lasers, and electronic patient record systems were included in the program to offer a wide range of experiences.
The highest level of instruction within the Biodontics program is a formal residency that provides a certificate after two years of training, including advanced coursework in health management, public policy, integrated biological sciences (biotechnology, bioinformatics, bioethics, and genetics), methods of health research, technology transfer processes, technological innovations and technology commercialization strategies, and leadership/entrepreneurship. The goal of the Biodontics residency is to uniquely integrate basic and clinical research findings with clinical training and incorporate contemporary developments in biotechnology (molecular biology, genomics, informatics, bioengineering, and nanotechnology) with clinical dentistry.
Assessment of the impact of the UConn Biodontics program has demonstrated that incorporating new science concepts within the context of activities that can be translated to clinical practice is effective in stimulating students, residents, and faculty to use thought processes that apply new knowledge and discovery to patient care.34 The need for educational approaches that emphasize the application of research to patient care and facilitate student entry into clinical research training programs has recently been documented.35–38
University of Texas Health Science Center at San Antonio Dental School
The University of Texas Health Science Center at San Antonio Dental School recently initiated a curriculum redesign project intended to infuse an appreciation of new science at all levels of the curriculum (Dr. John Rugh, personal communication). The approach involves preparation of Critically Appraised Topic summaries (CATs)39 by students, residents, and faculty for clinical questions that arise pertinent to patient care and the development of a searchable online database (library) of high-quality, informative CATs that have been subjected to a peer review process. A CAT is a critical assessment of the available evidence that addresses a clinical question.40–43
The CATs database will be regularly reviewed and updated by a panel of reviewers comprised of dental school faculty and alumni practitioners under coordination of a CATs library manager and will be used to disseminate evidence-based information and promote transfer of research findings into patient care at the dental school and in the community. The CATs contain the basic foundational and evidence-based information that applies new science to clinical practice. A key component of the program is the collaborative involvement of dental students, graduate residents, faculty, and private practitioners in CATs preparation and review. This provides a mechanism to expose students, faculty, residents, and practicing dentists to recent scientific discoveries and the best clinical research on issues of high clinical relevance. Dental students write CATs in 75 percent of the clinical courses pertinent to various types of oral health problems and therapeutic approaches; residents also write CATs in six postgraduate dental education programs. The project includes a formal faculty development program on evidence-based practice emphasizing the preparation and use of CATs. The overarching goal is to promote an appreciation of new science and increase the probability that this information will be integrated into the dental curriculum and private practice settings. The searchable CATs database will be made available to all practicing dentists and ultimately to the public to help increase the rate of new science transfer to patient care.
To institutionalize the CATs curriculum component, course objectives in all four years of the curriculum have been revised to include competency in preparing CATs (asking focused questions, searching for the best evidence, critical appraisal, writing summaries, and integrating new knowledge into clinical care decisions) and other facets of evidence-based practice. The CATs curriculum component will also be coordinated with existing advanced dental student training and predental student outreach programs to enhance interest in dental research and increase the flow of students into these programs and potentially into academic careers in the oral health sciences. It is anticipated that the new curricular element will stimulate a deeper appreciation of new science, enhance skills associated with critical appraisal of the literature, promote evidence-based approaches to patient care, and foster more rapid integration of research findings into both the dental education program and private dental practice. Assessment strategies will include evaluating the impact of the project on 1) student, resident, and faculty attitudes regarding evidence-based practice; 2) student, resident, and faculty ability to utilize skills associated with CATs and implement evidence-based practice approaches; and 3) clinical instruction strategies used by faculty when working with students.
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Conclusions |
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TopAbstractRecent models for integration...ConclusionsReferences |
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The models described here also introduce a "hidden curriculum" that supports research/scholarly activity and the inclusion of new science in the daily fabric of the educational experience. It is important to note that, within these models at three U.S. dental schools, the hidden curriculum has received strong support from clinical and part-time faculty—role models who have a tremendous influence on dental students. A systematic review of the evidence related to strategies for teaching critical appraisal and evidence-based practice concepts by Coomarasamy and Khan in 2004 indicates that learner mastery of these skills occurs most effectively in the clinical context, not in the classroom, and that provider role modeling is essential.49 The significance of the hidden curriculum on student attitudes and behaviors has been previously reported, and the influence of clinical and part-time faculty cannot be overestimated within this context.50 Previous reports have emphasized the need for dental schools to integrate new science and research/scholarship into the curriculum so that they produce future leaders for the profession. It has been estimated that dental schools must engage 20 percent of their best and brightest students with enriched academic curricula for 20 percent of their educational program in order to accomplish this goal.48 Since the primary mission of most dental schools is to train competent clinicians, it is important to note that the Marquette model was developed in a research non-intensive institution that has historically focused on its educational mission.
Each dental school possesses unique characteristics and has differing resources that can be focused on the broad area of curriculum reform and incorporation of new science into the educational program. However, to support a national/international agenda related to maintaining the status of the dental profession, every dental school should play a part in establishing an infrastructure that attaches value to new science, research/scholarship, evidence-based practice, and the application of new knowledge and technologies to patient care.32 In order to accomplish this task, researchers, educators, and clinicians will have to work closely together. Thus, the true measure of success for all of these constituencies should be to continue to provide curricular models that demonstrate how all faculty can combine their efforts to address one of the most important current issues in dental education.
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Acknowledgments |
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Footnotes |
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This article is one in a series of invited contributions by members of the dental education community that have been commissioned by the ADEA Commission on Change and Innovation (CCI) in Dental Education to address the environment surrounding dental education and affecting the need for, or process of, curricular change. This article was written at the request of the ADEA CCI but does not necessarily reflect the views of ADEA, the ADEA CCI, or individual members of the CCI. The perspectives communicated here are those of the author.
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REFERENCES |
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