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The Revitalization of U.S. Dental Education

	Abstract

Top Abstract The problem Drivers of change Education Science and Technology Consumerism and Industry Economics Disconnects that form barriers... The high ground Educational commons and thinking... Unifying vision: the continuum How to move forward? Recommendations Conclusion References

 
Executive Summary

(Delivered at the Macy Study Convocation)

Revitalization of dental education in the United States is an imperative, but it depends mainly on the willingness of dental school faculty to make great changes. My remarks address a system of education of dental professionals in relation to other health professionals whose vision seems at times to have surpassed ours. I advocate for a revitalization of our profession in order to stand at the fore when it comes to ensuring the health and well-being of the public. Thanks to advances in molecular medicine, health care is being transformed from a system of treating disease to one that provides predictive, preemptive, and personalized care. This presentation makes recommendations for rethinking the current system of dental education in order to elevate dentistry to its rightful place as a vibrant health care leader. Dental education needs to be a source of new knowledge, discovery, and innovation to sustain its legacy as a learned profession. Graduates must be lifelong learners who can critically evaluate science and technology for the good of their patients.

Future dentists should be providers of primary care, yet data suggest that the organizational structure to support this vision is lacking. The accreditation system, interrelated with licensure and National Boards, needs to set a better floor. While independence is an admirable goal, I see too much variation in the accreditation system. We must overcome fears and politics to upgrade the profession as pharmacy did when it introduced the Pharm.D. degree. With that came a change in the entire system of pharmacy education and clinical practice and recognition of pharmacists as members of an interdisciplinary health care team.

Dentistry and dental education are doing a lot that is good, but we must and can do even better if the profession is to thrive as a respected member of the health professions delivering high-quality, evidence-based care to the public. Dental students, faculty, and practitioners must have command of new and coming scientific advances and technologies that will have a profound impact on the practice of dentistry. We must take the long view in educating our students so they will, as practitioners, be able to expertly evaluate and use new technologies throughout their careers. With regard to technologies, three examples may help clarify their future importance in dentistry: 1) oral fluids and tissues are natural tools for health surveillance; 2) within the next five to ten years, microarrays of all 700 bacterial species will be available for diagnostic purposes as will treatment tied to this diagnostic tool; and 3) biomarkers of inflammation will continue to develop into chair-side technologies with appropriate treatments. These three examples—along with spectacular advances in imaging, materials science, stem cell biology, and regenerative medicine—signal the need for rigorous change in dental education and practice.

If we desire twenty-first century clinicians, we are obligated to teach students to "learn how to learn." We must teach them to practice evidence-based dental medicine. We must teach them to operate as members of interdisciplinary, primary health care teams. Moreover, we must ensure that the face of the profession—its practitioners—reflects the rich diversity of the community. Attendees at the Macy convocation are in a position to provide leadership, to work with appropriate organizations, and to enable Pharm.D.-like consensus. It behooves us to agree on a unified vision for revitalizing dental education. The vision should be based on a set of principles, either those originally laid out by W.J. Gies in 1926 or ones that may be a better fit with this day and age. The following are several recommendations for transformative change in dental education. In my view, based on my experience as a dental professional and leader, and by looking beyond our educational boundaries to places like MIT, I believe that they may be the most promising: 1) think BIG!; 2) involve students in hands-on learning experiences from day one; and 3) provide students and the profession with the tools to tackle major biomedical, clinical care, and societal issues including access to care, cost of care, HIV, emerging infectious diseases, elder care, and many others.

In fact, I believe that we already know what to do to upgrade the dental profession. We need to make it happen. We need to act as catalysts for change. We understand that change is necessary but continue to struggle with implementing sustained curriculum reform and regulatory reform. Why? Partly because we have not convinced the dental profession and the education community that a crisis really exists. "Crisis" may sound to the uninformed like crying wolf, especially in a climate in which dentists in private practice are doing exceedingly well. Further, we have not provided a compelling vision for the future. Transformation will require a profound reexamination of what we are doing today and what is necessary for survival and sustained growth. We must keep pace with new knowledge and methods of teaching—unless, of course, we choose to subscribe to the facetious message of W. Edwards Deming, who is credited with rebuilding the Japanese economy after World War II: "It is not necessary to change. Survival is not mandatory."

Dental education should be at the hub of this transformation from surgical to medical management and to preemptive medicine. Dental education should be the singular place where change is embraced and where new models for education, clinical care, accelerated technology transfer, and lifelong learning are tested and validated. Although dental education does many things correctly, it has not been proven to produce graduates who readily embrace science-based findings and who look to dental education, the faculty, and the academic health centers or universities as the primary source of information regarding contemporary clinical practice. Unfortunately, the current model of dental education creates "schizophrenic adaptors" of change. On the one hand, there is sufficient evidence to demonstrate that practicing dentists readily embrace new technologies that provide increased practice income or that improve technical skills, business practice, and efficiency. On the other hand, practicing dentists, by and large, do not appear to adopt rapidly new diagnostics, preventives, and therapeutics based on advances in science and technology. Unlike medicine, dental practitioners do not have a prima facie link to the dental school.

Adoption of the rapidly advancing science breakthroughs and the realization of the promise of molecular medicine will require huge changes in mindset, educational structure, and leadership. The purpose of this article is to examine the "system" of dental education (Figure 1) and to proffer some recommendations on rethinking the current system in order to move dentistry to its rightful place as a vibrant leader in the public’s health and well-being and to ensure dental education is at the forefront as the trusted source of science, technology, and clinical information.

View larger version (76K): [in this window] [in a new window]   Figure 1. The system of dental education

	The Problem

Top Abstract The problem Drivers of change Education Science and Technology Consumerism and Industry Economics Disconnects that form barriers... The high ground Educational commons and thinking... Unifying vision: the continuum How to move forward? Recommendations Conclusion References

• changing age and ethnic/culturally related population demographics,
  
• patient/population desires, needs, and expectations,
  
• changing health system expectations,
  
• evolving interdisciplinary expertise and practice requirements,
  
• new scientific discoveries, and
  
• integration of emerging technologies.
  

Perhaps most importantly and as a consequence, dental education has not been aligned with the core values and central mission of the research-intensive universities where most of them are housed. ADEA’s Commission on Change and Innovation in Dental Education (CCI)⁵ articulated a number of points that are relevant to the issue of revitalization of dental education, concluding that a curriculum change, thus reform and revitalization, is compelling for a number of reasons:

• Financing of dental education at all levels remains a significant challenge.
  
• Recruitment and retention of faculty in an era of diminishing resources are seriously problematic.
  
• The curriculum in many dental schools is based on a model of education delivery that is at best fifty years old.
  
• Emerging science, technology, and disease patterns promise to change oral health significantly.
  
• Dental education and practice are facing an increasingly ethnically and racially diverse population.
  
• There are questions and concerns about the ability to sustain a "learned" profession while contributing to new knowledge in the university or academic health center setting.
  
• There is a chasm that exists between the principles of dental education and the core values that define the profession.
  
• While complexity of diseases across all populations continues to grow, the profession is evolving towards promotion of high-end specialized dental services.
  
• The role of dentistry in primary care is diminished and magnified at the same time sciences are uncovering oral-systemic health relationships.
  

Meeting these and other challenges facing dental education, including 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 and system, including changes in prerequisites, admissions, credentialing, financing, and quality assurance.⁸

It has become increasingly clear that dentistry needs to be the primary source of new knowledge, discovery, and innovation to sustain our legacy as a learned profession and that graduates must be lifelong learners who can critically evaluate science and technology. At this point of our evolution, it is debatable at best as to whether or not dental education is meeting these critically important objectives. Perhaps the single hallmark that defines dental education at this point in its evolution is the "silo" approach to curriculum development, education, and evaluation.⁹ This has led to an isolated, insular approach to training future dentists rather than an educational system in which dentistry is embedded within a comprehensive, interdisciplinary health care and training system (see Figure 1). Thus, dental schools have created a gap between new scientific and technical advances and incorporation of these advances into dental education and clinical practice. Perhaps the greatest challenge dentistry faces is keeping the curriculum as relevant as possible so that future applications of risk assessment, disease prevention, diagnosis, and treatment—which are almost certain to come from the biomedical sciences such as proteomics, cell biology, microbial and molecular genetics, biometrics, and pharmacogenomics—are allocated sufficient curriculum time to meet changing patient needs, demands, and expectations.¹⁰

Nearly a decade ago, the IOM report Dental Education at the Crossroads raised the alarm regarding dental education when it stated that

the problem in reforming dental education is not so much achieving consensus on directions for changes 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 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.¹

Even though this alarm was raised more than ten years ago and there has been some movement in the direction of having a more integrated approach to dental education, it is clear that significant obstacles remain, including escalating educational costs, resistance to change, a graying faculty, insufficient funds to revitalize the physical plant, insufficient funding to invest in new faculty and new technology, insufficient commitment to advancing research into the fabric of dental education, and continuing difficulty of building bridges between the dental education institutions and other health care professionals as well as with the community of practitioners. All of these observations underscore the notion that the need for curriculum and dental education revitalization is necessary now and must be approached with the clear understanding that, while no one model will work for all dental schools, the outcomes of the educational process should be similar. As stated earlier, the status quo is no longer desirable or acceptable! Rather, closer integration with medical education and training is essential, collaboration among the health professions is more important than ever, and dentists should be leaders in the health care community. In fact, a new generation of leaders in dentistry needs to be developed, and mechanisms to overhaul the credentialing process—especially national and regional board examinations—must be adopted that result in a more relevant credentialing process that links the modern practice of dentistry to scientific and technological advances and to societal needs and expectations.^4,10 This is a daunting challenge, which will require effective leadership and a shared vision of the outcomes of the education process that are embraced by dental education’s stakeholders.

	Drivers of Change

Top Abstract The problem Drivers of change Education Science and Technology Consumerism and Industry Economics Disconnects that form barriers... The high ground Educational commons and thinking... Unifying vision: the continuum How to move forward? Recommendations Conclusion References

 
At this point, we are armed with a virtual consensus regarding the necessity for reform in dental education, but with no clear consensus on how to move the reform forward to achieve a transformation effect. Thus, it is important to understand the drivers of change, as well as the disconnects that must be overcome (see next section) to create a more significant and contemporary educational system. The primary drivers of change are demographics, the media, science and technology, economics, public policy, industry, consumerism, the regulatory environment (OSHA, FDA, accreditation, boards, licensure), and education.

It would be beyond the scope of this article to describe every one of those drivers and their impact on the dental education system in detail. However, here we will consider four critical drivers that are important to consider: education, science and technology, economics, and consumerism. It is important to keep in mind that all these drivers in one way or another are not isolates but are interdependent. That is, if one is tweaked, it could resonate with or impact other drivers.

	Education

Top Abstract The problem Drivers of change Education Science and Technology Consumerism and Industry Economics Disconnects that form barriers... The high ground Educational commons and thinking... Unifying vision: the continuum How to move forward? Recommendations Conclusion References

 
Unfortunately, on the education front, dental education has more often than not reacted to change rather than initiated change. There are multiple examples in which outside influences including so-called hotel room continuing education courses have had a greater influence on technologies that have ultimately made their way into the dental curriculum than through the technologies derived from science in the education environment. Indeed, Tedesco in 1995 made the provocative comment that stands today that "the dental education community has responded to the winds of change with some growth and little change."¹¹ The 1995 IOM report reached two important conclusions that must be considered on the education front.¹ First, dental education should be closely integrated with medicine and other relevant health professions. Second, dental education should be immersed in the totality of the academic health center described recently by Bertolami as a tectonic interface between disciplines and professions, where the silos disappear and the result is an agglomeration of virtual schools.¹² Intellectual capital drives the complex integration of the dental school within the health center and with the communities it serves (Figure 2). Unfortunately, despite all these recommendations and observations, a survey of the current structure, recent innovations, and planned changes in dental education revealed that only 7 percent of schools (four schools) reported that their entire curriculum was organized around themes of interrelated topics, whereas the great majority of schools (forty-three schools) indicated that only a few courses with interrelated subjects were in the curriculum.⁷ Although there have been recent successes in breaking the silo paradigm and in developing more integrative, thought-provoking models of education, the traditional lockstep biomedical and dental disciplines remain entrenched in many schools. So, on the education front, it seems clear that education is not a significant driver of change for many schools. The lack of sustained reform begs the question "are we headed toward a two-tier system of dental education and clinical practice?"

View larger version (20K): [in this window] [in a new window]   Figure 2. Current models of dental education Source: Modified from Bertolami CN. Presentation at the American Dental Education Association’s Council of Deans Annual Meeting, La Jolla, CA, November 2006.

	Science and Technology

Top Abstract The problem Drivers of change Education Science and Technology Consumerism and Industry Economics Disconnects that form barriers... The high ground Educational commons and thinking... Unifying vision: the continuum How to move forward? Recommendations Conclusion References

• acute to chronic diseases,
  
• aging population,
  
• health disparities,
  
• emerging infectious diseases,
  
• biodefense,
  
• regenerative medicine and stem cell biology,
  
• diagnostics tied to treatment,
  
• personalized medicine—realizing the promise of the genome project and molecular medicine,
  
• and more.
  

Although the scientific horizon is filled with great promise and expectations, Keusch¹⁴ pointed out, at an International Association for Dental Research (IADR) Plenary Session in 2004, that in addition to advancements in science and clinical care in the twentieth century, there have also been disappointments, which continue to this day. These disappointments include the following:

• disparities in health increasing,
  
• increasing disparities in health research,
  
• knowledge does not directly lead to solutions,
  
• more neglected disease (largely of the poor),
  
• failure to effectively use technology, and
  
• profit-based drug/medical device development—avoids diseases of the poor and creates major problems of access, availability, and affordability.
  

Thus, there is a need to transform health and medicine for the twenty-first century in a preemptive manner relative to twentieth-century medicine. Zerhouni recently articulated these transformative notions, shown in Table 1.¹³

Science is producing unbelievable breakthroughs that can improve health, save lives, and reduce the cost of care. So, the question remains: what will it take for these breakthroughs to make their way into dental education and clinical practice? This is the reason for the need to attack dental education reform NOW, so that dentistry is on the cutting edge not the dull edge of science and technology. The entire science base of dental education needs considerable rethinking, and new models of an integrated science curriculum, coupled with new clinical practice paradigms, need to be proffered and tested. Baum has argued that dental students should be provided more biological sciences and medicine, which are necessary to sustain the learned profession and practice as more medically minded practitioners and scholars.¹⁵ Donoff and others have offered similar calls for significant changes to dental education’s core science and medicine base.¹⁶ However, no matter what new material is added or integrated, if the students and faculty do not use the information in patient care, it will result in a return to the status quo or worse!¹⁷

Unfortunately, although the potential for science and technology to be a major change agent is palpable, there is little evidence that dental education feels the universal urgency to embrace twenty-first century science and inculcate it into the curriculum and thus to patient care. Other health professions, including physicians and nurse practitioners, could conceivably manage oral diseases and disorders, so if dental education does not change, it could run the danger of losing its place as the gatekeeper for oral health.

	Consumerism and Industry

Top Abstract The problem Drivers of change Education Science and Technology Consumerism and Industry Economics Disconnects that form barriers... The high ground Educational commons and thinking... Unifying vision: the continuum How to move forward? Recommendations Conclusion References

 
Consumers have the greatest capacity to drive change! Perhaps the best example is the now old story of the patient, Kimberly Begalis, who allegedly contracted AIDS from a dental office. Following exposure of the issue on both 60 Minutes and 20/20, the obvious question the consumer asked the dentist was "how come you’re not wearing gloves?" Consumer demand for dental professional change was so powerful that in 1986, after one year, dentists wearing gloves went from 25 percent to 90 percent!¹⁸ This is an illustration of the power of consumer-driven demand. Similar observations could be made about aesthetic dentistry: consumers are demanding whiter teeth and more beautiful smiles. As a result, the dental profession and the dental industry are responding to their demands by introducing new products including teeth whiteners and invisible orthodontic procedures, among others.

Educators, scientists, and the dental industry must establish some novel and creative partnerships to create, market, and distribute contemporary technologies to the practicing dentist, the health professions education system, and the consumer. In this regard, industry is in a quandary regarding how to move from making products that are successful in today’s environment to new products generated from contemporary discovery science without suffering economic loss and market share. There may be unprecedented opportunity to those industry leaders who are willing to partner with the science, education, and other appropriate communities of interest to both move dentistry to the forefront of the new health care system while establishing exciting new products, devices, and markets.

The recent movement by the insurance industry to pay for preventive and periodontal services is based on the emerging science linking oral infections to systemic health. Importantly, the insurance industry appears to acknowledge that its willingness to provide these consumer services to selected populations will not only address oral health issues but has the capacity to reduce the overall cost of medical care. If this continues, we may enter an era in which consumer demand for dental services will grow even faster as the demands for care will transcend cosmetics.¹⁹

	Economics

Top Abstract The problem Drivers of change Education Science and Technology Consumerism and Industry Economics Disconnects that form barriers... The high ground Educational commons and thinking... Unifying vision: the continuum How to move forward? Recommendations Conclusion References

 
In terms of economics, Bailit et al.,^20,21 as well as Brown and Meskin,²² have described the high cost of dental education and the decline in revenue to state-related dental schools. At the same time, there is a flattening of NIH support and a clear need to upgrade substantially the investment in dental education and research infrastructure and, in particular, faculty recruitment and retraining. Dental education is on the precipice of a crisis in which costs are escalating, revenues are declining, student indebtedness is at an all time high, and tuition is climbing to unprecedented and, perhaps, unsustainable levels. The net result is that most schools are expanding fundraising efforts and increasing clinical income to cope with the changing economic picture.

Given the macro environment surrounding dental education, it is unlikely that future revenues will increase substantially, and thus the ability to maintain the quality of the educational offerings and the ability to meet the research mission of the university will be compromised. Bailit et al.²¹ conducted an extensive financial analysis of the models of dental education and concluded that clinical income could be substantially increased if there were a shift in philosophy to a patient-centered clinical care model in which teams of faculty, residents, and students provide care to patients. This model is similar to that employed by medicine in teaching hospitals. If these data prove to be accurate, dental schools could have a ready source of income that could be reinvested in infrastructure and faculty recruitment. The barriers to implementing this approach in dental education are considerable, but the model should be tested and validated. At the very least, this concept illustrates the powerful impact that finances could have as a driver of change in dental education.

	Disconnects That Form Barriers to Change

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In addition to these important drivers of change, it is important to understand that there are at least five crucial disconnects that are barriers to curriculum reform and revitalization of the dental education system that must be addressed. These are as follows:

1. The teaching of science and its use in the clinical setting form the first disconnect. It is not a matter of what should be taught in terms of incorporating new courses and content in the curriculum or whether there is a vertical or diagonal model; rather, the question is how can the dental education system be more effective so that students and faculty can work together to apply science to clinical care at every level.
   
2. National boards, licensure, and reimbursement remain a barrier to innovation and creativity. There is an overwhelming need for board and licensure reform to accompany educational reform. There needs to be flexibility in boards, licensure, accreditation, and reimbursement systems to enable new models of dental education to be tested and validated.
   
3. The promise of new technology is incredibly exciting, but there are very few drugs, devices, and products to apply to the clinical setting at this time, so what can we offer practicing dentists that would make them want to change their practice today? Indeed, the current linkage between diagnostics and therapeutics is weak.
   
4. The cottage industry mentality of the dental profession is another disconnect—in particular, the lack of an umbilicus to the health care system and to the dental school, which is the antithesis of the medical model. This disconnect contributes in a major way to the isolation of the dental office and is a significant barrier to implementing a truly integrated model of dental education and clinical practice. The advent of the Practice-Based Research Networks (PBRNs) can be helpful in this regard, but even they represent an important but insufficient method to ensure that practices are linked to advances in science and technology and that practitioners are contributors to both knowledge and improved patient health outcomes.
   
5. Diversity and sociodemographics represent a seriously problematic disconnect among dental education, the dental profession, and society. In spite of numerous initiatives to stimulate a more robust applicant pool from the underrepresented and underserved cohorts of the population, the enrollment of minorities in dental education remains abysmal. At the same time, the overall applicant pool is expanding rapidly, and the demographics of the nation’s population are shifting dramatically towards a more ethnically and culturally diverse society. Without a continuous and serious commitment to expand the pool of practitioners so that it reflects the nation’s changing population, the profession could be in danger of creating a lasting society/dental practice disconnect. If this trend is not reversed rapidly, access to care will continue to worsen, and the profession will march on to elitism.
   

	The High Ground

Top Abstract The problem Drivers of change Education Science and Technology Consumerism and Industry Economics Disconnects that form barriers... The high ground Educational commons and thinking... Unifying vision: the continuum How to move forward? Recommendations Conclusion References

 
The dilemma faced by dental education is to continue to graduate competent practitioners to meet the present needs of the population, while preparing students for a radically different kind of practice in the future—one that emphasizes predictive, personalized, and participatory medicine. As stated earlier, the great majority of schools continue to use the lockstep approach to basic and clinical science instruction with little integration of science underpinnings at the clinical level and with continuing metastatic, irregular additions to the curriculum. It continues to be easier to base a curriculum on what was necessary to teach in the past rather than what will be necessary to learn in the future. So, given these dilemmas and the complexity of both the problems dental education faces and the drivers of change and the disconnects that exist, what is the high ground? That is, what are the expectations of graduates for the future? The following^4,5 are considered to be the expectations that the ideal dental education would provide for its graduates:

• a relentless sense of curiosity and inquiry;
  
• critical thinkers;
  
• problem solvers;
  
• lifelong learners;
  
• individuals who have been taught how to learn;
  
• students and graduates who know how to access information;
  
• students and graduates who know how to distinguish fact from fiction and evaluate science;
  
• students, graduates, and practitioners who can apply science-based evidence to clinical practice in a variety of clinical settings;
  
• integration of science, behavioral, and population knowledge;
  
• ability to function as a primary care provider in interdisciplinary settings;
  
• graduates and practitioners who have the capacity to function as either an independent scientist or a member of a practice-based translational research team;
  
• competent to assume new roles in prevention, risk assessment, and early detection of disease; and
  
• men and women of science.
  

These high-ground expectations of graduates in the future are not new nor are they novel, but they represent the kind of practitioner for the twenty-first century that many in the academic community and in professional organizations like the American Dental Association, the American Dental Education Association, the American Association for Dental Research, the private sector, the National Institute of Dental and Craniofacial Research, and many of dentistry’s stakeholders would like to be the result of dental education. So the question becomes: how do we move dental education from its relatively asynchronous and insular focus to one that is truly integrative across an entire system of health professions education?

	Educational Commons and Thinking Big

Top Abstract The problem Drivers of change Education Science and Technology Consumerism and Industry Economics Disconnects that form barriers... The high ground Educational commons and thinking... Unifying vision: the continuum How to move forward? Recommendations Conclusion References

 
Perhaps an interesting lesson could be learned from the Massachusetts Institute of Technology (MIT).²³ In its recent extensive rethinking of an MIT education, the dean of the School of Science, Robert Sibley, wrote: "It is impossible for us in four years to give students everything they need for life—one of the fundamentals is that students should leave MIT with a passion for learning." This is the essence of what the dental education community needs to embrace. In order to move to the next level of dental education, it appears that we have two issues that must be addressed. One is that we need to create what can be termed a dental "educational commons," that is, a consensus amongst stakeholders that students in the system of dental education should be provided with a shared set of ideas, common concepts, values, skills, attitudes, competencies, and arguments whose merits they can debate.²³ The underpinnings of this educational commons are a science core of a new or novel array of cross-disciplines whose objective is to get the students and the faculty to think bigger earlier in their education.²³ In essence, the think-bigger approach could result from:

• stressing the cross-disciplinary interactions needed to address all aspects of a particular problem, including the use of science, population, behavioral, social, and engineering concepts to address emerging society issues;
  
• introducing students from the first moment they enter dental education to the day-to-day life of science, education, and clinical practice—the hands-on learning approach;
  
• thinking big, which means looking well beyond the school and the university;
  
• equipping students to tackle some of the big, pressing problems like health care disparities, access to care, quality of care, cost of care, and AIDS; and
  
• equipping students with uncommon intensity, curiosity, and excitement.
  

The net result should be for dental education to provide a structure and sequence of offerings at every level that result in the nurturing of cosmopolitan, creative thinkers. Creating an educational commons whose objective ultimately is to graduate people who are bigger thinkers could result in the profession remaining relevant in an ever-changing world. In this regard and if we look once again at the MIT model, in recent years they have had two remarkable initiatives, which I believe can be translated to dental education. The first is the creation of a new department of biological engineering, which is made up of faculty from a wide range of disciplines spanning biological sciences, medicine, genetics, computational biology, engineering, and social sciences and where leaders are educated at the interface of this complex array of disciplines—in effect, creating a new discipline. The bottom line is to produce a graduate who represents a new discipline and who is unlike any one of the existing faculty in this new biological engineering program. This is a profound objective, which in essence is what dental education reform is all about—that is, to produce a new graduate and practitioner who is unlike any of us but who can function in the complex, exciting environment that the twenty-first century demands.

The second learning experience from MIT that is applicable to dental education lies in the open curriculum model, which MIT has fostered.²⁴ That is, MIT has put online virtually every course they offer in every discipline, which is available to the public for free! Since that time, over 120 institutions have joined an open courseware consortium. Why not dental education? The information cannot be used to obtain a degree, but it speaks to the freedom of movement of content and it speaks to something that has been missing in dental education and that is the ability to access information from a variety of experts across the nation, if not the globe, who could provide contemporary knowledge to the dental education environment and which can be accessed online. The objective here would be for dental education to consider this open curriculum model, but extend it further by accessing expert content from disciplines derived from any university, industrial, or federal source. Thus, specific programs could be developed for which students would get credit and essentially create what amounts to a new system of dental education—that is, a virtual dental school in the context of the health professions education system. In essence, the creation of a virtual "World Dental School" is a notion that is synergistic with the need for educational reform and also ensures state of the science content and could decrease the cost of education. The obstacles to establishing a world school are considerable, but isn’t this a model that dental education should advocate and test?

Dental education is at a momentous time in its evolution. Notwithstanding all of the problematic issues articulated earlier in this article, the applicant pool is at its highest peak in many years and the quality of the applicants is superb. Therefore, dental education has an obligation to provide a curriculum and clinical care model that stimulates this incredible student body to be motivated and not "de-motivated." This is the time to define what dentistry should be and what dental education can really achieve in the complex environment in which it exists. Essentially, dental education needs the leadership to advocate for a more systems-oriented approach to integrating biology, molecular medicine, dental medicine, and clinical care across an entire spectrum and continuum of dental and health professions disciplines.

	Unifying Vision: The Continuum

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The second major issue that must be addressed beyond the thinking-big education commons notion is that dental education must adopt a unifying vision for the future. In 2004,⁴ DePaola and Slavkin proffered the vision that dental education should be a continuum that leads from predoctoral science and clinical education, moving into professional training in the clinical, biomedical, and behavioral sciences, and extending into lifelong learning in dentistry. In amplifying this notion of a unifying vision, it has become clear that the continuum, which represents the dental education system, should extend from a primary and secondary education pipeline through undergraduate education to dental and health professions education to the possibility of offering joint degrees where new discipline interfaces can occur and to lifelong learning orchestrated through a variety of mechanisms including the PBRNs, continuing education, and virtual grand rounds, among others (Figure 3). The latter has the potential to create linkages between the practicing community and the academic health center. This continuum also enables integration with other health professions so that dentistry functions as a part of a primary health care team. If nothing else is apparent, it is without question that the dental education system is complex, and if one part is tweaked or adjusted, it will have significant effects on other components (Figure 1). Real reform can occur only when the system is understood. Finally, it is important to note that sustained future curriculum changes require a strategic partnership with all stakeholders, including all other health professionals. Most importantly, to move from the status quo to a new level of dental education will require risk-taking and provocative leadership that is effective and efficient and results in a shared vision!

View larger version (68K): [in this window] [in a new window]   Figure 3. The dental science education continuum Source: Adapted from: Cox M, Harvard Medical School, 2003; and DePaola DP, Slavkin HC. Reforming dental health professions education: a white paper. J Dent Educ 2004;68(11):1139–48.

	How to Move Forward?

Top Abstract The problem Drivers of change Education Science and Technology Consumerism and Industry Economics Disconnects that form barriers... The high ground Educational commons and thinking... Unifying vision: the continuum How to move forward? Recommendations Conclusion References

• It may be too expensive and time-consuming to either acquire new resources or redeploy existing resources to change. In this regard, dental education works on a thin margin with little excess fiscal capacity. So without an infusion of additional resources, the status quo or tweaking of the status quo prevails. Some institutions and their leaders are comfortable with the current education system and have difficulty seeing how any real change will pay off. That is, where is the incentive to change? Are any new resources coming to the dental school from the university? Other than threats of closure, what is the real incentive for change? In addition, some may take comfort in a more vocational rather than academic direction to the education of students, given the resources and time it takes to add scholarship and research to the fabric of education.
  
• It is quite difficult to change dentistry without changing medicine and other components of the health professions system. The system of health professions education is complex, so when one segment is changed, there is an impact on the entire system. An example is the problem with turning out dentists whose primary care function is directed to health promotion and disease prevention. Unfortunately, the reimbursement and licensure systems are still geared to procedure-based dentistry rather than preventive initiatives, threatening the livelihood of a different type of practitioner.
  
• The politics associated with change are enormous and are a potential deterrent to change. For example, the exploration of a new practitioner model creates a firestorm of concern among organized dentistry.
  
• Leadership must be effective in order to execute transformational change. Leadership in dental education must be able to work in an environment that enables the leader to lead. This has not always been the case in dental education.
  
• Thinking big and thinking globally are requirements for transformational change and, in many ways, are the antithesis of the insular approach that characterizes many dental education institutions.
  
• Perhaps we have been approaching change from the wrong direction. Rather than start with education, perhaps we should try to effect change in the standards (boards, licensure, accreditation) that have a powerful impact on dental education and could lead to systemic change. Certainly, when the pharmacy degree was changed to a Pharm.D. and there was recognition that pharmacists could become valuable members of an interdisciplinary health care team, the entire system of pharmacy education and clinical practice changed.
  
• Perhaps there is too much inertia in the system to expect anything more than incremental change.
  
• Most importantly, in order for transformative change to occur, two things must take place. First, dental education and the profession must acknowledge that a crisis exists. Second, dental education and the profession must embrace a new vision for the future. It is evident that we have failed to articulate the immediacy of the crisis facing dental education and have not put forth a compelling vision of the future.
  

	Recommendations

Top Abstract The problem Drivers of change Education Science and Technology Consumerism and Industry Economics Disconnects that form barriers... The high ground Educational commons and thinking... Unifying vision: the continuum How to move forward? Recommendations Conclusion References

 
Over the past decade or so, dental educators have used a variety of approaches to improving dental education, ranging from decompression of the curriculum to problem-based learning to developing the competency-based curriculum. The array of initiatives is truly mind-boggling as can be seen in Figure 4. Unfortunately, as Kassebaum et al.⁷ pointed out in their survey of dental education, very few schools have taken on the task of organizing a curriculum around interrelated topics and, most likely, none have addressed the provocative issue of integrating their course offerings throughout one continuum of dental education, including clinical integration with the range of health professional schools. Donoff in 2006 made some provocative recommendations for reforming dental education.¹⁶ Some of Donoff’s observations are synergistic with the following recommendations for revitalizing the dental education system:

View larger version (87K): [in this window] [in a new window]   Figure 4. The array of recent initiatives in dental education

1. Develop new models to finance dental education or to address costs of education. These models can include:
   • asynchronously distributed, web-based models of curriculum content,²⁵
     
   • distance education models in which degrees and courses can be offered online,
     
   • faculty taking responsibility for patient care,²¹
     
   • part-time dental education coupled with a "residency" requirement, and
     
   • exploration of the adaptability of the "Arizona Model" to other institutions.
     
   
   
2. Commit to the acquisition and utilization of appropriate resources to reinvest in academic quality integrated with the parent university or academic health center. Ensure reinvestment in academic enrichment, technology, and research infrastructure, and, in concert with other schools within the health center, recruitment of the next generation of faculty and the retraining of existing faculty. In this context, it is important for dental education to recruit new research faculty from sources outside dentistry, thus avoiding a zero sum game.
   
3. Build new workforce models designed to increase access to care and reduce the cost of care:
   • create the pediatric oral health therapist,²⁶
     
   • create the comparable physician assistant and nurse practitioner model for the dental profession,
     
   • develop fully the utilization of the nurse practitioner in leading oral health risk assessment, health promotion, and disease prevention in the multidisciplinary health care setting, and
     
   • explore and test the feasibility of a new practitioner working at the interface of medicine, dentistry, nursing, and pharmacy.
     
   
   
4. Taking the lead from the University of Washington, establish a vigorous program to educate other health care professionals about oral health. Create a web-based oral health and wellness program that can be utilized by other health professionals.
   
5. Invigorate a new approach to interdisciplinary research such that research is embedded in the fabric of the continuum of the dental education system. In concert with the National Institute of Dental and Craniofacial Research (NIDCR), other federal health institutes, and the private sector, test novel approaches to train Ph.D.-level scientists to translate science to clinical medicine. For example, provide training in medicine and dental medicine to selected Ph.D. students so that they are conversant about dentistry and medicine from the clinical perspective and, thus, can lead a new generation of translational science transcending the dental education system.²⁷ Continue to fund the U24 Model of "jump starting" research at selected dental institutions. These current U24s appear to be having an impact on the energy to change and the infrastructure to change. In particular, they appear to be having an impact on the recruitment of faculty who can be integrated into clinical decision making.
   
6. Some schools, like Case School of Dental Medicine, are utilizing students early in the first year to provide a hands-on sealants experience to children in school-based settings. Can we push this envelope so that dental students are placed in multidisciplinary health care settings from day one? This notion has the capacity to fundamentally alter dental education, such that a seamless curriculum spanning basic sciences to clinical care is apparent. In this model, students can progress from observers to questioners to collecting data, to assisting in differential diagnosis, to developing research projects, to understanding how basic, translational, and clinical information is used and integrated in patient care. This model can also create a nurturing environment for all disciplines to gain respect for the patient and for other health care providers. A critical outcome is to engage a new faculty role model for students, one who is not simply a "checker" but one who is a true man or woman of science and one who inculcates in the student the evidence-based approach to clinical decision making and clinical care through the span of dental education. A critical component of this approach is to design a physical plant to facilitate the realization of a continuum of education, research, and clinical practice. In this regard, a core curriculum specifically designed to support interdisciplinary education and clinical practice must provide the framework for this model, which, in turn, can be evaluated regularly for program improvement.
   
7. Explore the basis for the success of nursing and pharmacy, which have developed courses of study in which students utilize the information derived from the "sciences" in clinical settings.
   
8. Taking a page from the novel New York University experience, develop a multidisciplinary wellness clinic focusing on primary care and an integrative approach to prevention, risk assessment, and therapy. This approach could provide the basis for evidence-based, multidisciplinary courses to train translational research faculty, who become role models for interfacing between patients and student-clinicians.
   
9. Integrate the education of predoctoral dental and dental hygiene students with postdoctoral trainees, similar to the Columbia University pathophysiology and physical diagnosis model. The novel twist would be to include medical residents, nursing students, and pharmacy students in the same environment, creating a side-by-side interdisciplinary model of primary care.
   
10. Create incentives for regional sharing and consolidation of student, faculty, and curricular resources to make dental education more efficient and financially sound.
    

There are many more initiatives that could be developed to transform dental education. In order for any of the above to succeed, as well as any others being tried in dental education today, a number of "drivers" must be in play. These include provocative and effective leadership; willingness to take calculated risks and even begin a creative revolution; funding to support innovations and creativity (either new funds or redeployment of funds); flexibility in credentialing and reimbursement systems so that current credentialing is not a barrier for transformation; willingness to engage other health professions schools and disciplines; willingness to engage the consumer; an absolute commitment to scientific discovery coupled with translating science and technology into clinical practice; continuous documentation of clinical skills, knowledge, and attitudes; commitment to critical thinking, problem solving, information management, leadership, and teamwork; lifelong learning using interdisciplinary and experiential settings; commitment to an evidence-based approach to clinical decision making; and an absolute commitment to Thinking Big.

	Conclusion

Top Abstract The problem Drivers of change Education Science and Technology Consumerism and Industry Economics Disconnects that form barriers... The high ground Educational commons and thinking... Unifying vision: the continuum How to move forward? Recommendations Conclusion References

 
We are on the brink of a remarkable transformation of dental education. The only question that remains is this: do we have the will and leadership necessary to tackle the obstacles and move dentistry and dental education to become an ever more respected member of the health care team? Clearly, dental education has had some successes, and there is an increasing array of best practices aimed at improving dental education. However, there is much more to do. Academic institutions, like dental education, have always stood at the gate between the past and the future, attempting to prepare the next generation of leaders for a world that is new technologically and culturally. Unfortunately, education institutions today are among the most conservative forces in our society, out of touch with society’s needs to create learning communities.²⁸ The transformation we are seeking will require a profound re-examination of what we are doing today and what is necessary to do in the future. We must accept the pace at which new knowledge is being generated. We must be a part of knowledge generation and must recognize that the current methods of mastering dental education are outmoded, but that learning how to learn represents today’s essential knowledge. Perhaps the words attributed to W. Edwards Deming are important to remember: "It is not necessary to change. Survival is not mandatory."²⁹

	Footnotes

 
Dr. DePaola is President Emeritus of The Forsyth Institute in Boston. He has served on the faculty of Tufts University School of Dental Medicine, Medical College of Virginia/Virginia Commonwealth University, Fairleigh Dickinson University School of Dentistry, University of Texas Health Science Center at San Antonio, University of Medicine and Dentistry of New Jersey, Baylor College of Dentistry, and Harvard School of Dental Medicine/Harvard Medical School. He has also served as Dean of the Dental School, University of Texas Health Science Center at San Antonio, where he was also Acting Dean of the Graduate School of Biomedical Sciences; Dean of the University of Medicine and Dentistry of New Jersey-New Jersey Dental School; President and Dean of Baylor College of Dentistry; and President of The Texas A&M University System Baylor College of Dentistry. Dr. DePaola has received many awards for his leadership and scholarship and is widely regarded as an expert on nutrition as it relates to health promotion/disease prevention activities and to oral disease, diagnosis, etiology, and therapy. He is the only dentist who has an honorary membership in the American Dietetic Association and the only dentist elected President of both the American Association for Dental Research and the American Dental Education Association. The American Dental Education Association presented him with a Presidential Citation for outstanding contributions to the organization and the profession of dentistry in 2003 and a Distinguished Service Award in 2005. He received his D.D.S. degree from New York University and his Ph.D. degree in Nutritional Biochemistry and Metabolism from the Massachusetts Institute of Technology. Direct correspondence to him at 144 Coventry Place, Palm Beach Gardens, FL 33418; ddepaola{at}forsyth.org.

	REFERENCES

Top Abstract The problem Drivers of change Education Science and Technology Consumerism and Industry Economics Disconnects that form barriers... The high ground Educational commons and thinking... Unifying vision: the continuum How to move forward? Recommendations Conclusion References

 

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