Dr. Richard Valachovic
In this month’s letter, ADEA President & CEO Dr. Rick Valachovic shares what you may have missed at this year’s ADEA Annual Session & Exhibition in San Antonio.

Right from the start, that most complex of human organs—the brain—dominated this year’s ADEA Annual Session & Exhibition with the ambitious theme: The Science of Learning.

“As far as we can tell, we’re the only species on the planet that has grown so sophisticated that we’ve thrown ourselves headlong into deciphering our own programming language.”That was the assessment of David Eagleman, Ph.D., the year’s Opening Plenary speaker, who energized a packed house with a fascinating talk on the brain—in his words, “the most complicated device we’ve found in the universe.” Dr. Eagleman argued that educators need to focus more on cultivating cognitive flexibility in their students, and he shared his ideas on how to create a “brain-compatible” classroom where students feel engaged and inspired to learn.

Three symposia programmed by the Chair of the ADEA Board of Directors, Steven Young, D.D.S., M.S., further explored the science of learning.

The first of these, Urban Legend or Brain Fact: The Truth About Learning, busted myths about the brain that have been successfully used to market a range of well-known products (Coca-Cola was one of the first!), most of which have unproven benefits, and some of which can even harm cognitive performance. What truly boosts learning and memory? Prior experience (learning is context-dependent), pictures (vision dominates the other senses) and practice (spaced learning is better than massed learning).

The second symposium, Drilling Down on LD & ADHD: Understanding and Accommodating Students with Disabilities, also dispelled a few myths while exploring the social and emotional challenges that can further hamper these students’ academic performance. This session also discussed strategies for accommodating students’ needs and the legal obligations of schools.

The last of the symposia, Engaging the Brain: Art and The Science of Dentistry, explored the value of training in art appreciation to enhance three skill sets: close observation, unbiased analysis and clear, empathetic communication. The presenters described a phenomenally successful elective course developed by The University of Texas School of Dentistry at Houston and the Museum of Fine Arts, Houston. The course capitalizes on the brain’s preference for visual learning, creates opportunities for repeat practice and takes place in the sort of enriched, “brain-compatible” environment that Dr. Eagleman described as conducive to learning. Is it any wonder that the course has a waiting list?

As you can see, brains ruled at this year’s Annual Session, but it was far from dry or academic in the less flattering understanding of that word. In addition to food for thought, the gathering provided nourishment for the senses and opportunities to connect with colleagues in a festive environment. The conference hotel and the adjacent convention center sit alongside San Antonio’s famous River Walk, a meandering system of canals and bridges flanked by grand hotels, historic structures and inviting restaurants. This year’s opening reception was held at the water’s edge, where an all-woman mariachi band serenaded the crowd. I don’t know how many of us were able to enjoy the guacamole and ceviche before heading out to dinner that night, but I can tell you that more than 2,200 ADEA members attended at least some of the conference events, making this our most highly attended meeting to date.

The next morning, it was business as usual: another dynamic plenary speaker to jump-start the day and dozens of educational sessions on topics as diverse as cultural competency, tobacco cessation, dental service organizations, the Supreme Court’s most recent ruling on college admissions and, yes, more brainy topics, including neurobiology. Some of these sessions represented unique partnerships between ADEA Sections and Special Interest Groups. This growing trend toward collaboration was evident in several joint ADEA Council meetings as well.

The one complaint I hear consistently each year is that there are so many good sessions, it is impossible to attend everything. In that sense, my annual recap is as much for those who attended as it is for those who were unable to join us. Here are a few vignettes and sound bites to give you a taste of what else you may have missed, whether or not you made it to San Antonio.


Chair-elect of the ADEA Board of Directors Lily Garcia delivers part of her speech in Spanish at the Opening of the ADEA House of Delegates. She tells the story of her grandmother who grew up in South Texas at a time of segregation. The older woman’s love of education had a lasting legacy: Every one of her 17 grandchildren earned a university degree. Her impact on Lily is clear when she announces her primary focus for the coming year: to be a strong, positive influence on the next generation of health professionals.

Earlier in the day, college students don white coats at the ADEA GoDental Workshop and Recruitment Fair for Predental Students and Advisors. More than 250 participants take advantage of this opportunity to consult health professions advisors and admissions officers from more than 50 dental schools.

Current dental students convene for the launch of the ADEA Student Diversity Leadership Program, which will train and mentor students with an interest in academic careers.

Out-of-towners visit the University of Texas Health Science Center at San Antonio Dental School for a tour of the current facility. They also get a glimpse of the new state-of-the-art facility under construction where faculty and students will soon conduct research and clinical trials to advance innovation and patient care.

Quotes of the Day:

“All things are possible with money, software and time.”
R. Todd Watkins, Jr., D.D.S., Assistant Dean for Dental Education and Informatics at East Carolina University School of Dental Medicine, speaking during the ADEA Signature Series on disruptive innovation in health care education.

“Thank you for speaking up for us.”
Nina Godiwalla, speaker at the Evening Plenary on Gender Issues and author of Suits: A Woman on Wall Street, quoting an eye-opening remark from a reader of her book with whom she had previously thought she had little in common.


The Exhibit Hall opens. It takes a long walk and three escalator rides to get there, but the products on display, the poster sessions, the ADEA TechExpo, the New Idea Sessions and the ever-popular free lunch make it well worth the trip.

Now you see it, now you don’t. The timer is set and each presenter has only five minutes to update the audience on a new teaching practice or instructional technology during Teaching and Learning With Emerging Technologies and Informatics: Short Talks. This rapid-fire session comes to a close at noon. Two hours later, folks are at it again. The topic this time: teaching innovations in the biomedical sciences.

Attendees pack the room to learn about the latest ADEA Trends in Dental Education and leave with three take-aways:

  • The 2014 dental school applicant pool is slightly down with the greatest decline among minority students.
  • We have a new tool to identify promising students from low socio-economic backgrounds, which should help us to recruit more of these students.
  • With many new schools established and others likely to open in the next few years, we have built the educational capacity to welcome these promising students.

Quotes of the Day:

“I wish we could come to a consensus and put everybody on an equal footing.”
Questioner during a session titled Understanding the Selection Criteria for Residency Programs in the Climate of Pass/Fail.

“The team at ADEA has taken a small insular organization concerned with maintaining dental schools to a dynamic organization that, along with our strategic partners, is creating the future of our profession.” 
Kenneth L. Kalkwarf, D.D.S., M.S., Dean Emeritus of the University of Texas Health Science Center at San Antonio Dental School, and recipient of the ADEA Distinguished Service Award.

“What will the next generation of dental hygienists look like, because they’re in your hands? What role will they play—are you preparing them for any and all roles? What skill sets will they need and how will you change your systems to provide them with those skills? Will a new curriculum be needed if we’re going to be viewed as integrated into the health care system?”
Ann Battrell, M.S.D.H., Executive Director of the American Dental Hygienists’ Association speaking at a session titled Transforming Dental Hygiene Education: Recommendations for the Future.

“When my grandfather came to this country in 1900, he was part of the 1% that came from Latin America. In 2012, 48% of immigrants came from Latin America and the Caribbean. These are the shifts that are taking place.”
Ricardo Romo, Ph.D., President of The University of Texas at San Antonio, speaking at the ADEA Commission on Change and Innovation in Dental Education (ADEA CCI) College President’s Symposium.


An impressive turnout of (dare we hope?) future candidates listens eagerly to the advice of current leaders during a session titled Will the Next Dean Please Stand Up? The United States currently has only two dental school deans from underrepresented minority groups. Many leave this session encouraged that a more diverse group of deans may emerge in the future.

A fortunate few tour the Center for the Intrepid, a state-of-the-art U.S. Army medical facility that is providing rehabilitation to service members and others who have sustained amputations, burns or functional limb loss. The facility’s efforts to return patients to the highest levels of physical, psychological and emotional well-being leave the visitors both awed and inspired.

With the sun starting to sink in the West, elegantly clad attendees make their way to the Lone Star Ballroom for the 2014 William J. Gies Awards for Vision, Innovation and Achievement. As in previous years, the accomplishments of this year’s recipients speak volumes about the ingenuity and dedication of our community.

Quotes of the Day

“I have had the privilege of excellent mentors, who became collaborators, colleagues and friends. … At all times I keep the earliest lessons from my mentors and from ADEA in mind and heart—continuing to ask, what do our institutions and our communities need from us?”
Lisa Tedesco, Ph.D., Vice Provost for Academic Affairs – Graduate Studies and Dean of the James T. Laney School of Graduate Studies at Emory University and winner of a 2014 Gies Award for Outstanding Achievement, making her acceptance speech.

“Remember, site visitors are our friends. They’re us. You want to make their job as easy as you can.”
William Dodge, D.D.S., Dean, University of Texas Health Science Center at San Antonio Dental School, one of three schools that shared their experiences using the new Commission on Dental Accreditation standards to prepare their accreditation Self-Study Reports.

“In the midst of great geopolitical, demographic and economic changes, our country has to make a decision: Are we going to turn to each other, or on each other?”
Van Jones, cohost of CNN’s Crossfire, speaking at the Political Spotlight plenary session.


With their bags packed for a midday departure, many attendees make their way to the theater for the Closing Plenary. They hear from Rishi Desai, M.D., an infectious disease physician who traded in his job as an epidemiologist with the Centers for Disease Control and Prevention to be part of the revolution in online learning at the Khan Academy. In the hours that follow, some head for home while others take in one last educational session or seize the opportunity to chat with colleagues they rarely see.

In the late afternoon, members of ADEA’s governing bodies make their way to the third floor of the convention center for the Closing Session of the ADEA House of Delegates. The results of the vote for the new Chair-elect are announced (it’s Tufts’ Dental Dean Huw Thomas, B.D.S., M.S., Ph.D.), and outgoing Chair Steve Young gives his final address. His words bring to mind two people who made their presence felt in San Antonio, not through proximity, but through the power of their ideas. The first is Clayton Christensen, D.B.A., M.B.A., M.Phil. Dr. Christensen was mentioned by Steve in passing during his speech and by several other speakers earlier in the session. Dr. Christensen’s concept of disruptive innovation took center stage at this year’s ADEA Signature Series and appears to have played a role in drawing a record 200 people to San Antonio a day prior to the meeting’s official opening to explore this powerful idea in the context of health professions education.

The other individual is John Medina, Ph.D. I can’t tell you how many times I heard people mention last year’s Opening Plenary speaker and his book Brain Rules: 12 Principles for Surviving and Thriving at Work, Home, and School. Apparently those of you who bought the book also read it and were excited by the prospect of hearing this year’s speakers further explore this fascinating topic.

I could say more, but I think I’ve conveyed just how rich and rewarding the ADEA Annual Session & Exhibition can be. If I haven’t motivated you to join us in 2015 in my adopted hometown of Boston, perhaps the theme of next year’s gathering will: Igniting Minds, Unlocking Potential. Hope to see you there.

Dr. Richard Valachovic
In this month’s letter, ADEA President and CEO Dr. Rick Valachovic looks at the role new brick and mortar facilities play in transforming learning through the use of educational technologies.

Up-to-date buildings are changing the ways we treat patients and the ways our students learn, not only in the classroom, but also in the clinic and in new preclinical labs. These new facilities retain familiar elements but hint at a substantially different future. Simulation is beginning to marginalize the traditional classroom—and even the clinic—as an educational site, and technologies developed to enhance patient care have started to transform learning.

To give you a glimpse into this future, I spoke with the deans of four dental schools. In 2006, the University of Maryland School of Dentistry (UMSOD) became the first of these four to move into a new state-of-the-art building. UMSOD left behind a dark warren of classroom and clinic spaces encased in a concrete shell—a 1970s design aimed at conserving energy. In contrast, the new facility emphasizes natural light and open spaces, prized for their social as well as visual benefits, and it incorporates a variety of educational technologies. These include lecture-capture capabilities that give students the freedom to view lectures when, where and as often as they wish. The technology also allows faculty to demonstrate techniques remotely so that rather than crowding around a demonstration station, every student has a clear view, courtesy of a video screen.

Some of UMSOD’s most dramatic innovations have occurred in the simulation lab (sim lab) and in the clinic where the use of electronic health records, digital imaging, electric hand pieces, CAD/CAM systems and, in some specialty clinics, microscopy and video capture is becoming routine. While these technologies were primarily developed to advance patient care, they are also having a profound impact on teaching and learning.

“The dilemma we have in the current clinical model of teaching is that the students generally have to stop and move away from the patient so the faculty can provide instruction,” Mark Reynolds, M.A., D.D.S., Ph.D., Interim Dean of UMSOD, told me when we spoke last month. “Streaming video from the microscope to a 32-inch monitor overcomes many teaching obstacles, allowing an attending to provide real-time feedback and instruction during the delivery of care.”

Other digital technologies in place at UMSOD are also impacting learning, and in Mark’s view, their greatest value lies in the ability they give schools to teach in the absence of patients. Take, for example, electronic health records (EHRs). These are transforming how all of the four schools I recently “visited” by phone are using their simulation labs. As John Valenza, D.D.S., Dean of The University of Texas School of Dentistry at Houston (UTSD), put it, “Students don’t just prepare plastic teeth in the simulation clinic. They treat virtual patients.”

Thanks to the introduction of networked computers at each workstation, UTSD students can access the EHRs of virtual patients as they work through simulated cases. These run the gamut from medical management to drug interactions to ethical issues, and each concludes with an intense debriefing with faculty modeled on the practice of medical educators.

Over in the patient-care clinic, the EHR continues to take center stage. “We wanted to bring the EHR into the circle of care with the patient and the provider,” John told me. “When faculty in the operatory talk with the patient and student, having the computer there to show and tell is so powerful.”

To facilitate this interaction, UTSD designed its operatories so that only one thing is attached to the dental chair: a computer with a 20″ touch screen monitor that can be drawn in close if the student wants to manipulate images while explaining a procedure or if the patient needs to sign a consent form. The monitor can also be pushed away when students need to search for information or take notes.

“We sometimes refer to the computer as the third person in the treatment room,” John said. “That can be good, or that can be bad. Some providers aren’t the strongest communicators, and having a computer in the room sometimes makes them worse.”

Carol Lefebvre, D.D.S., M.S., who was recently named Dean of the Georgia Regents University College of Dental Medicine (GRU CDM), echoed this concern. “I’ve experienced it myself when I go to my physician,” Carol told me. “They’re looking at the computer screen and entering data, and there’s no contact with me except verbally. Our students face the same issue. How do you maintain that personal connection with all that technology?”

GRU CDM moved its clinical operations to its remarkable new building in 2011, and the school is about to move its classrooms as well. It will share an Education Commons containing classrooms, simulation space and student lounges with the medical school. Like the dental schools in Texas and Maryland, GRU has also brought EHRs into its simulation lab, introduced CAD/CAM for milling crowns and restorations, and installed ceiling-mounted microscopes in its endodontic clinic.

The move to the Education Commons will allow the college to more efficiently engage in small-group, team-based learning. A tiered dental classroom has been structured with two rows of seats on each level so that students can turn around and interact with one another. A second, nontiered classroom, dedicated for use by the dental school, is wired for laptops, and large video screens will hang on each of its four walls for maximum flexibility. The room can be configured in various ways, but initially it will be arranged with tables for groups of eight to 10 students. Video from the dental operatories can be streamed into both classrooms and conference rooms. This capability will immediately allow the school to expand its continuing education courses to more practicing dentists, and may ultimately play a role in predoctoral dental education as well.

GRU CDM will also benefit from gaining access to the medical school’s many standardized patients in a simulation area of the Education Commons dedicated to interprofessional education. In this space, design may play a bigger role than technology. Two large open bays with beds that can be curtained off line the walls, and tables in the center of the room give students from different professions a place to congregate while they develop diagnoses and treatment plans. An additional 24 single-patient examination rooms provide separate areas to observe patient and student interactions.

Carol expressed excitement about the opportunity GRU students have to become skilled in using the latest technologies, but she raised interesting questions about how they will transfer these abilities to the practice arena.

“These technologies—CAD/CAM units, intraoral scanners, digital radiography, microscopes—are very expensive for private practitioners. There are still practices that are using film,” she observed. “As educators, we have to find a balance. We have to expose students to all these technologies, but we have to also teach them traditional methods.”

Finding this balance will be one of Carol’s mantras as GRU CDM embarks on its first significant curriculum reform in 10 years.

Meanwhile, back in Maryland, UMSOD is preparing to take the next step in its digital dentistry adventure: harnessing the technologies it has in place to radically change how clinical skills are taught and assessed. CAD/CAM currently allows users to convert an intraoral photo into a 3-D rendering that can be used to design a dental prosthesis. Three-dimensional images of the prosthesis can then be sent wirelessly to a milling machine, as occurs at UMSOD, or to a 3-D printer, either of which can fabricate the finished product.

Soon the school expects to acquire an evaluation program, which will work within the CAD/CAM system. The software can consistently and reliably scan a student’s tooth preparation and compare it to a faculty-determined standardized preparation, allowing students to evaluate their own performances. As Mark Reynolds pointed out, the software will enable an iterative process of learning through which students can systematically perfect their clinical skills.

John Valenza expressed similar enthusiasm for using software to assess students, but for different reasons.

“These new technologies will enable us to redefine the metrics we use for assessment,” he asserted, “and they are independent of clinical judgment.”

Indeed, computers have the potential to evaluate student work in a way that is consistent, reliable and unquestionably objective. Computer-assisted evaluation would obviate the need for faculty calibration (at least in the areas that lend themselves to digital assessment). With its potential to reduce some of the burden of grading, this type of evaluation should be especially welcome at schools where faculty are stretched thin.

Even where faculty are plentiful, the use of digital technologies can enhance assessment. At UTSD, for instance, John Valenza has observed that the simulation clinic—by providing a consistent experience to students—has had an unintended benefit.

“It is a fabulous way to calibrate faculty,” he told me. “They collaborate to build and deliver the cases, and every student in the class takes part in the simulation exercise. Whether the focus is on standards of care, materials or a medical management question, it puts everyone on the same page.”

Miles away on the West Coast, I had the opportunity to attend the ribbon cutting for the new University of the Pacific Arthur A. Dugoni School of Dentistry (Pacific Dugoni) building in downtown San Francisco earlier this month. As in Maryland, Pacific Dugoni’s new building emphasizes community spirit and more open space where faculty, staff and students can come together. No one has private offices, including the dean, although private rooms are available for private conversations. Not surprisingly, the new facility will have fewer large classrooms and more networked spaces where students and faculty can access technology to engage in case-related learning.

“We have multiple goals for the building,” Dean Pat Ferrillo, D.D.S., told me. “We want to create flexibility, a new learning environment and a new practice model, as well as a sense of community, and finally to move much closer to our patient population. We know the technology is going to be a major part of learning for the next generations. We need to be sure we have the “infostructure” to support what we know today and what we don’t know about tomorrow.”

The centerpiece of Pacific Dugoni’s new facility is a state-of-the-art simulation lab. Its operatories, like those in several other newly built or renovated schools, will precisely replicate those that students will find in private practice. The space will also house a new generation of mannequin that exhibits more life-like facial features, a full tongue, saliva flow and anatomically correct teeth. Pacific Dugoni developed the mannequin head in partnership with its manufacturer, KaVo Kerr Group, to give students the feeling that they are treating human beings when they practice on the mannequins rather than simply preparing plastic teeth.

The innovations taking place at these four schools and at many other ADEA member institutions are truly impressive. Yet in the end, technology is a tool—a means to an end—and it is not the only tool in the toolbox. The open designs that foster collaboration at Pacific Dugoni and at UMSOD, the opportunity to work interprofessionally at GRU CDM and the intense debriefing with faculty following simulation at UTSD all underscore the importance of other factors in achieving our educational goals.

That said, time has shown again and again that technologies that appear optional today often become essential in the future. Can we still teach without them? Of course, but those schools on the cutting edge will be better positioned to meet the next wave of innovation when it arrives.

Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic clears up some of the confusion surrounding the expansion of pediatric oral health coverage under the ACA.

These past six months should have been a time to celebrate for those who care about children’s oral health. The Affordable Care Act (ACA), which seemed to hold out the promise of universal pediatric dental coverage, had reached a milestone in its implementation. The federal government and some states were finally launching the health exchanges intended to bring affordable health coverage to millions of Americans previously priced out of the insurance market. But just as the problematic roll out of the HealthCare.gov website caught supporters of the law off guard, the interpretation of “essential” as it applies to pediatric oral health benefits has left many in our community scratching their heads.

ADEA was part of a coalition that raised its voice in the halls of Congress and at the White House in support of health care reform. After much negotiation, the law that emerged did not include oral health benefits for everyone, but the ACA did include pediatric oral health services among the 10 “Essential Health Benefits” that private insurers would be required to include in the policies they offered through the new health exchanges. This victory—although partial—was seen as a major step toward universal dental coverage for all Americans.I recently revisited a 2012 policy brief on pediatric dental benefits under the ACA, produced by the nonprofit Children’s Dental Health Project (CDHP) and the Georgetown University Health Policy Institute Center for Children and Families. The brief contains a graphic that clearly lays out how children were expected to access dental benefits under the law.

Children in families with the lowest incomes would continue to receive coverage through Medicaid or the Children’s Health Insurance Program (CHIP). Children in families with employer-sponsored medical insurance who were eligible for CHIP could receive dental-only supplemental coverage in those states that offered it. Families in other states and at higher income levels would be eligible to purchase dental insurance for their children through the new health exchanges that opened last fall. If a family’s income met or fell below 400% of the federal poverty level, the family would receive a subsidy in the form of a tax credit.

On the surface, this still describes the state of pediatric oral health coverage today, but in substantial ways, the rules governing how pediatric oral health benefits are made available under the ACA stretch the common understanding of the word “essential.” These benefits are essential only in so far as the health exchanges must offer at least one plan that contains them. Consumers, meanwhile, are not obligated to purchase plans that contain dental benefits, and families that purchase stand-alone dental plans may pay a hefty price for the privilege.

In 2012, ADEA signed on to a letter sent to the Centers for Medicare & Medicaid Services (CMS), which has been responsible for writing the rules that govern how the ACA is implemented. The letter, drafted by CDHP, expressed concern that proposed rules on the treatment of stand-alone dental plans might undermine the ACA’s intent by creating barriers to coverage, especially in the area of affordability. This is precisely what appears to have occurred:

  • First, lower-income consumers who are eligible for subsidies to help them pay their medical insurance premiums will typically not receive subsidies for their purchase of a dental plan. The specific rules governing the calculation are too complex to detail here. Suffice it to say that the IRS has interpreted the law to limit the agency’s ability to factor in the full cost of stand-alone dental plans in determining the tax credits families receive to help them pay for coverage.
  • Second, stand-alone dental plans have their own separate out-of-pocket maximums (limits on what consumers are expected to pay for care in a given year). While these are supposed to be “reasonable,” the current limits in plans offered through the federal health exchanges ($700/child and $1,400 for families with two or more children) are decidedly pricey for many consumers. Additionally, states can set their own maximums for stand-alone dental plans, and some have proposed setting limits higher.
  • Third, while the ACA states that dental plans must offer access to an “adequate” number of providers, the law does not provide specific guidance about what constitutes adequacy. Given that an estimated 45 million Americans live in dental shortage areas, observers fear that some consumers who purchase dental insurance will find it necessary to travel long distances or face long wait times in order to make use of their dental coverage.

Those who struggled long and hard to obtain a pediatric dental benefit under the ACA are understandably disappointed by these developments, and many are hesitant to challenge the rules related to the pediatric dental benefit while so many members of Congress are still actively looking for opportunities to repeal the entire law. In a few states, however, efforts are underway to mitigate some of the law’s shortcomings.

In California, for instance, consumers may see improved options for dental coverage through the state’s Covered California health exchange, perhaps starting in 2015. Currently the state offers pediatric dental benefits only through stand-alone plans, but the state has committed to giving stakeholders a second chance to shape policy in this area and commissioned a report, which details a number of options for improving pediatric dental coverage issued through the exchange. Covered California has also conducted a survey of the state’s insurers, eight of which indicated their willingness to develop a health plan with embedded dental benefits. Consumers who purchase this type of policy benefit in two ways: they have a single out-of-pocket maximum to meet, and the IRS automatically includes the cost of dental benefits in calculating their tax credit.

California is also debating whether to make pediatric dental coverage mandatory for state residents. The purchase of pediatric dental coverage is currently mandatory in three states: Kentucky, Nevada and Washington state. Like California, Washington state’s health exchange currently offers pediatric dental benefits only through stand-alone plans, and the state is discussing the idea of offering medical plans with embedded dental coverage in the future.

Even at the federal level, there is hope in some quarters that implementation of the ACA can be modified to increase the number of children with access to dental coverage and lower its cost to consumers. CDHP, the American Dental Association and representatives of the insurance industry, including Delta Dental and the National Association of Dental Plans, are leading efforts to modify the law in two ways. These entities have sent a letter to U.S. Treasury Secretary Jack Lew asking that the IRS revisit its interpretation of the law and calculate tax credits based on the purchase of both medical and dental plans (when families purchase both) rather than on the cost of purchasing the medical plan alone.

CDHP has also asked CMS to cap the out-of-pocket maximums consumers pay at the level set for a family purchasing a medical plan with embedded dental benefits. It’s unlikely that this will occur, but CMS has proposed new lower out-of-pocket maximums for dental plans beginning in 2015. Should these rules be adopted, the out-of-pocket cost to families with stand-alone dental plans would drop to $300 for one child and $400 for two or more children, potentially saving consumers hundreds of dollars.

What does all this mean for dental education? It would be hard to argue that the implementation of pediatric dental benefits under the ACA will have any direct impact on our community. Nevertheless, it’s clear that our profession has a stake in how these events continue to unfold. I can’t help feeling that failings in the ACA’s implementation of these benefits are symptomatic of dentistry’s historic isolation within health care. We must overcome this legacy, not only in the interest of achieving universal access to oral health care, but also to assure the health and longevity of our profession.

The American Dental Association has reported that in recent years, the utilization of dental care has declined among adults, and dental spending has flattened out or even declined. With the advent of the health exchanges under the ACA, we’ve also seen a movement among some large employers—traditionally the biggest purchasers of dental insurance—toward offering their employees a stipend to purchase health coverage independently. Whether those adults will choose to purchase dental coverage remains unknown, but given the influential role dental benefits play in driving adults to seek care, we should be concerned. Recent events suggest that there’s a very real possibility that we’ll see a further decline in utilization in the years ahead.

When I first wrote about the ACA in this letter in 2011, I quoted from a statement about its passage by then ADEA President Dr. Sandra Andrieu on ADEA’s behalf. The statement read, “In our judgment, the benefits that our fellow citizens will accrue from this legislation certainly outweigh its imperfections.”

I believe that statement still holds true, even if obstacles in the path forward loom larger today than they did three years ago. It may be some time before opposition to the ACA cools to a point where supporters of oral health coverage feel comfortable taking up the charge for universal dental coverage once again, but comfort may be a luxury we cannot afford.

Dr. Richard Valachovic
In this month’s letter, ADEA President and CEO Dr. Rick Valachovic describes how partnering with foundations has amplified ADEA’s influence and strengthened dental education.

The relentless pursuit of strategic alliances. If you’ve heard me say it once, you’ve probably heard me say it dozens of times. RPSA (or “ripsaw” as I’ve come to refer to it) has been my longstanding mantra. Why? You need only look at what ADEA has accomplished in the last decade for your answer. It’s no exaggeration to say that through our alliances, we have transformed good ideas into effective practices and helped to spread them throughout our community and beyond.

ADEA has forged invaluable partnerships with professional associations, corporations, advocacy groups, the research community and a group of visionary foundations. ADEA’s partnerships with these foundations provide perhaps the best example of how strategic alliances further our work, and it’s the example I want to focus on in this month’s letter.

By now, I hope you are familiar with at least two of the foundations—the Robert Wood Johnson Foundation (RWJF) and the W.K. Kellogg Foundation (Kellogg)—that have underwritten several of our most far-reaching programs. These two entities have made a sustained commitment to support our efforts to recruit and foster a healthy pipeline of future dentists, dental hygienists and faculty members, and their investments in our Association have paid incredible dividends.

Let me start with RWJF and its ambitious mission: to improve the health and health care of all Americans. Early in its 40-year history, the foundation determined that building the health care workforce was one important means of achieving its overall goal. Since 1972, the foundation has financed a series of scholarship programs in a variety of health professions, some of which continue to this day. In fact, I currently sit on the national advisory committee for New Careers in Nursing (NCIN), a scholarship program of RWJF and the American Association of Colleges of Nursing (AACN).

In keeping with the foundation’s goal of reducing disparities in access to care, many RWJF scholarship programs target minority and low-income students, and some of them have been available to dental students. While RWJF continues to fund scholarships, it concluded early on that it needed to do more to grow and diversify the health professions workforce. Following the release in 2000 of the first report on oral health by a U.S. surgeon general, the foundation began developing a strategy on oral health. They were impressed by a program that Columbia University College of Dental Medicine was running in Harlem at that time and came to see dental education as part of the solution to the problem of access to health care services for underserved populations.

Working with Dr. Allan Formicola, then Dean at Columbia, the foundation championed a national initiative to expand community-based education that became known as the Dental Pipeline program. The national program office was established at Columbia University and Dr. Howard Bailit of the University of Connecticut School of Dental Medicine was tapped to join Allan in leading the effort. In its initial phase, the program awarded $19 million in grants to dental schools to develop community-based clinical education programs and recruit underrepresented minority and low-income students to dentistry.

Despite the magnitude of the funding, the foundation was not able to fund every school that wanted to take part. RWJF reached out to folks at The California Endowment, which shared the foundation’s interest in expanding access to care in underserved communities. The endowment stepped in to support the effort by funding four California dental schools to participate alongside the University of California, San Francisco School of Dentistry (UCSF SOD), which had received an award from RWJF.

ADEA was enlisted as an early partner in the Dental Pipeline program and charged with administering a complementary $1 million scholarship program funded by Kellogg to the 15 participating schools. Then in 2008, RWJF opened a second round of funding to replicate the Dental Pipeline’s best practices, and another eight schools received grants to focus on either community-based education or student recruitment.

Today, several dozen more schools stand to benefit from the Dental Pipeline program through the National Learning Institute, funded by RWJF and jointly overseen by the University of the Pacific Arthur A. Dugoni School of Dentistry and ADEA. The institute is providing training, technical assistance and financial support to dental schools that want to develop new community partnerships to further their educational and recruitment goals.

While the first cohort of Dental Pipeline grantees made significant progress in establishing community-based clinical education programs, it became apparent early on that progress in diversifying their student bodies had stalled. An analysis of applicant data indicated that more students from the targeted groups were applying to dental school, but that minority and low-income enrollments remained flat. In response, RWJF turned its attention to admissions committees and asked what they could do differently to ensure that more of these desirable candidates would gain admission.

The Dental Pipeline national program office recruited a cadre of student affairs/admissions officers, including Dr. Charles Alexander of UCSF SOD, Dr. Dennis A. Mitchell of Columbia and Dr. Dave Brunson, then of the University of North Carolina at Chapel Hill School of Dentistry, to pilot a workshop for admissions committees. The goal was to help committees move away from their sometimes sole reliance on test scores and grades and start evaluating candidates holistically.

The workshop generated much enthusiasm, and prompted RWJF to consider ways to sustain it over the long term. The foundation invited ADEA to submit a proposal to run a train-the-trainer workshop to enlist others in presenting admissions committee workshops, and later funded ADEA’s creation of an online resource where schools could access workshop content at will. Under the leadership of Dave Brunson, who had become Associate Director for ADEA’s Center for Equity and Diversity, and Dr. Anne Wells, Senior Vice President for Educational Pathways, 36 admissions workshops were conducted between 2004 and 2012.

The trust engendered in the course of working on these projects led to a third collaboration with RWJF in 2006 that I have written about many times in this letter: the Summer Medical and Dental Education Program (SMDEP). The foundation first established a summer program for medical students in 1988 with a goal of preparing students from underrepresented minority groups to successfully compete for admission to medical school. In 2005, the program was opened to predental students on a pilot basis, and when the foundation decided to institute the program’s predental component more widely, RWJF enlisted ADEA to work with the Association of American Medical Colleges (AAMC), which has administered the summer premedical program since the start.

Currently, nine dental schools host the SMDEP program. Since the program began accepting predental students in 2006, 1,644 have participated. Data gathered primarily from the classes that have completed their undergraduate studies indicate that, to date, a quarter of SMDEP’s predental graduates have been accepted to dental school.

While a full evaluation of the program is still in its early stages, we can conclude that our strategic alliance with AAMC, like our partnership with RWJF, continues to bear fruit. Our joint work on SMDEP laid a strong foundation on which to build another collaborative venture, the inclusion of dental curricular resources on the online MedEdPORTAL site, first created by AAMC. We have also been stalwart allies in promoting interprofessional education (IPE), and last year we collaborated to produce the AAMC/ADEA Dental Loan Organizer and Calculator, which is helping our students better manage their debt.

It is striking to me that foundations, which could invest in improving oral health in many ways, have chosen to make multi-year, multi-million dollar investments in dental education—supporting the role our schools play as safety net providers and our efforts to diversify the workforce.

“Foundations have been sensitive to the need for greater diversity within dental schools in order to achieve our mutual goal of serving the oral health needs of vulnerable communities,” Dr. Jeanne Sinkford, ADEA’s Senior Scholar in Residence, has observed.

Jeanne has worked with me over the years to cultivate ADEA’s relationships with several foundations. In a recent conversation she expressed her gratitude that the resulting partnerships have been instrumental in furthering our diversity and inclusion agenda. “These partnerships have allowed ADEA to be visionary in how it influences schools to create more diverse academic environments,” she said, and I agree.

The W.K. Kellogg Foundation may be best known at present for its leadership role in advancing innovative, community-based solutions to addressing oral health disparities, but for more than a decade it has been funding a different strategy with the same aim: creating an oral health workforce that reflects the diversity of society as a whole. Toward this end, in 2004 the foundation put its muscle behind a major effort to improve access by diversifying the academic workforce.

The ADEA Minority Dental Faculty Development (ADEA MDFD) program has assisted dental schools and allied dental programs in developing academic and community partnerships that are changing the cultural climate on our campuses and gradually enlarging the presence of underrepresented minorities in the faculty ranks. A “grow-your-own” philosophy, which encourages institutions to look within their own communities and cultivate talent, undergirds this collaborative effort.

The multi-faceted MDFD program engages students in high school, college and professional programs with a range of opportunities that deepen their knowledge of the oral health professions and develop the skills they will need to pursue academic careers. Exposure programs and career clubs, academic support and enrichment, research opportunities, leadership training and, above all, mentoring are some of the tools grantees have employed to strengthen the academic pipeline.

MDFD is emblematic of the long view that Kellogg and ADEA’s other foundation partners have taken in addressing the access issue. The program, which has created living laboratories on many of our campuses where recruitment and faculty development strategies can be tested, is now in its ninth year, and current funding will continue until 2015. Through MDFD’s dental school initiatives alone, the program has identified 358 potential faculty members. More recently, grants have focused on developing faculty for allied programs and careers in research.

In the mid-2000s, several other foundations also provided generous gifts to support two other ADEA programs aimed at diversifying the workforce. The Josiah Macy Jr. Foundation, which dedicates its resources to advancing health professions education, funded the creation of a flexible seven-year dental curriculum through a program entitled Moving Forward: Bridging the Gap. The Macy grant allowed three regional consortia of minority-serving undergraduate institutions and nearby dental schools to develop innovative programs to speed the entry of underrepresented minority students into dentistry.

The ADA Foundation provided the funds to launch the Academic Dental Careers Fellowship Program. In its first two years, 22 U.S. and Canadian students attending dental schools or allied dental programs completed fellowships and indicated their intention to pursue academic careers. In 2007, the American Association for Dental Research, along with the newly created ADEAGies Foundation, stepped in to continue funding the program.

For decades, the Gies Foundation, which honors the legacy of dental education pioneer Dr. William J. Gies, was a small, private entity based in New York City. Although respected for its grant making, the foundation had limited impact or visibility outside of New York. In 2002, the foundation’s directors were looking for a way to extend their grant making to the larger dental education community. They approached ADEA, and we agreed to partner with the Gies Foundation to form a public charity, the ADEAGies Foundation, which now serves as the philanthropic arm of our Association.

In addition to hosting the prestigious William J. Gies Awards for Vision, Innovation and Achievement, the ADEAGies Foundation awards scholarships, fellowships and project grants that recognize, support and encourage a wide range of educational, research and leadership activities related to dental education.

All of the collaborations described above have generated an enormous amount of good will, which in turn has yielded over $40 million dollars in direct and collaborative funding for many of our community’s vital endeavors during the past decade. While this financial capital has given a huge boost to our Association and its members, it’s hard to calculate the full value of ADEA’s foundation partnerships, which equals far more than the cumulative dollar value of the individual gifts received. ADEA’s strategic alliances with foundations have acted as (to borrow a term from the military) a force multiplier, magnifying the impact of our initiatives many times over. Individual schools have always done some of these things well, but by allowing us to refine and disseminate effective policies and practices, our grant-funded initiatives are reshaping the culture of dental education.

I want to mention one more program that exemplifies the synergies that can occur when our Association works in partnership with others. Almost a decade ago, a small group of forward-looking individuals came up with the idea to create a website that would acquaint minority students with careers in the health professions. This brainchild took shape as ExploreHealthCareers.org, but early on, the site’s survival was in doubt. A source of solid funding to build its content resources had yet to be identified; then a change of leadership at its parent association threatened to leave the site without a home

Fortunately for everyone, the Macy Foundation and ADEA came to the rescue, with one providing sufficient funds to develop the website’s content and the other taking responsibility for providing it with a home. Since then, both RWJF and Kellogg have contributed to the site’s expansion, as did the Institute for Oral Health, and today the site is alive and flourishing. It showcases information about scores of careers in the health professions, receives an average of almost 15,000 visitors each day and ranks number one in searches of health career information on the Web.

The power of these relationships also resonates in the work ADEA and its sister health professions associations have done to advance IPE through the Interprofessional Education Collaborative (IPEC). IPE is a strategic priority of both RWJF and Macy, and both foundations have been cheerleaders for the collaborative’s initiatives.

Thanks to the hard work of our members and staff, foundations see that ADEA can be counted on to sustain the initiatives it has taken under its umbrella and that ultimately, these become part of the fabric of our Association. As we move forward, I anticipate that the bonds we have formed with our supporters, and the bonds they have formed with one another, will continue to multiply the impact of our work in the years ahead.

Dr. Richard Valachovic
In this month’s letter, ADEA President and CEO Dr. Rick Valachovic explores opportunities for dentistry in the evolving primary care delivery system.

As promised in November’s Charting Progress, I want to continue exploring the intersection of dentistry and medicine by focusing this month on dentistry’s role within primary care. Those of you who attended the 2013 ADEA Deans’ Conference last month in Savannah heard and talked a great deal about this topic, and I know that many of you have been contemplating the dentistry/primary care relationship for much longer than that.

Dr. Monty MacNeil, Dean of my alma mater, the University of Connecticut School of Dental Medicine, published an essay at the beginning of 2013 that posed this question: Should dentists assume a more active role in the provision of primary (medical) care services to the patients we treat? Monty believes that dentists’ expertise and network of delivery points could be better harnessed, especially given the current and projected shortages of primary care providers. As he suggests in his essay, “This just might be our opportunity as a profession to demonstrate that we are an essential part of health care by providing a carefully selected ‘slice’ of medical services that fit with and reinforce the importance of oral health and quality dental care.”

Monty is not alone in his views. I’ve talked with many who believe that dentistry can and should become a portal to primary care. Just to be clear, we are not talking about medical diagnosis and treatment, which are—appropriately—the province of other health professions. We are talking about monitoring health risks, expanding preventive services, screening for specific conditions and, where appropriate, taking a role in their management. For example, we are experts at giving injections, so offering vaccinations might make sense. We also take medical histories, so if our patients tell us they haven’t seen a primary care provider in a while, certain screenings may be in order. We also know how to provide nutrition counseling and guidance on smoking cessation, and we know how to assess risk. I’m not just talking about caries risk assessment, which I discussed last month, but the risk of cardiovascular disease, diabetes and other chronic conditions that can impinge on our ability to treat oral diseases.

“As the field of dentistry evolves, and as we become more integrated into the health care system overall, this is the direction we need to be heading,” said Dr. Cecile (Ceil) Feldman, Dean of the Rutgers School of Dental Medicine, when we spoke last month. “I don’t think dentists should be managing chronic conditions. That’s not our training, but doing everything we can to match patients with someone who does have the training is appropriate and should be in our purview.”

Leveraging the expertise of other health professionals through referral is a central feature of collaborative practice, and preparing our students for an environment in which collaborative care delivery has become routine is the primary goal of interprofessional education (IPE). Interprofessional Education in U.S. and Canadian Dental Schools: An ADEA Team Study Group Report, published by the Association in 2012, discusses this topic. Dr. Allan Formicola, Dean Emeritus of the Columbia University College of Dental Medicine (Columbia CDM), served as lead author on the report, so I called him to hear his views on dentistry’s role in primary care.

“Up until 2000, when the Surgeon General’s report stated emphatically that oral health was essential to general health, most people looked at dentistry as a separate profession that took care of the mouth,” Allan told me. “When research studies started to demonstrate the effect of oral disease on systemic disease and vice versa, and when caries were recognized as the leading chronic disease in children, people started to think differently.”

Not surprisingly, the ADEA Team Study Group’s report reflects this evolution in how dentistry is perceived. The first rationale the report offers for IPE calls dentistry “a critical component of the primary care system,” the practitioners of which “must be able to communicate effectively with other primary care providers.” The second rationale points to the impact of chronic health conditions, such as diabetes, on patients’ oral health (and vice versa) and states that, “Such patients require coordination of care between dentistry and the other health professions.”

These principles are on display at the University at Buffalo School of Dental Medicine (UB SDM), where Dean Michael Glick has intensified the school’s commitment to IPE to support his vision of the dental office as a portal to primary care. In addition to taking medical histories, students are expected to take blood pressure readings and offer their patients screening for diabetes and HIV. Michael sees chair-side screening as a positive but insufficient step toward engaging dentists more fully in primary care.

“My problem with the screening process is: Does the dentist know what to do with that information?” he told me.

To ensure that the dentist (or the dental student) does know, UB SDM has engaged a pharmacist to help students and faculty interpret patients’ medical and medication histories, and Michael has placed a librarian on the clinic floor to help clinicians retrieve and appraise the scientific literature. Michael shared one impressive result of employing this interprofessional approach to reviewing patients’ medications: “We have actually detected potential major side effects that could have occurred that the patient was completely unaware of.”

Michael has also created a web-based program that students can use at the point of care to access up-to-date information on multiple medical conditions and how they impact dental care. Using a typical health questionnaire as a starting point, the Medical Support System for Oral Health Care Professionals guides users through appropriate follow-up questions and provides information on how to interpret different answers and test results. The program contains dental protocols for various medical disorders, including alerts when treatment might produce adverse events. The program also provides links to reliable sources of information on drug interactions, evidence-based dentistry and medical and statistical topics. You can see a demonstration video and learn about how to acquire the software, which Colgate-Palmolive Company will make available to dental schools free of charge for use by senior dental students.

The potential public health impact of using the dental office as a portal for primary care has been studied in relation to a rapidly growing health concern: diabetes mellitus. Dr. Ira Lamster, Allan’s successor in the dean’s office at Columbia CDM and currently Professor of Health Policy and Management at Columbia University Mailman School of Public Health, has devoted years to developing and testing a method for identifying patients with unrecognized diabetes or prediabetes in a dental setting. He conducted two studies to determine if the method could successfully identify diabetes or prediabetes in adult patients with at least one of four self-reported risk factors for the disease.

The study protocol included a periodontal examination and a point-of-care HbA1c test of the patient’s blood sugar. The results of the two studies varied slightly, but in both cases, Ira’s team was able to identify—using periodontal screening alone—approximately three quarters of patients with abnormal blood sugar. These results were equivalent or better than the use of the point-of-care blood test alone. Together, the screening and the test identified approximately 90% of those patients with diabetes or prediabetes.

The Centers for Disease Control and Prevention estimate that one in four cases of diabetes is undiagnosed. Given the serious and potentially life-threatening consequences of this disease when left untreated, the benefit of screening at-risk patients in the dental office seems undeniable. The question becomes, could we—and should we—make this screening the routine standard of care?

Ira’s answer is an emphatic, “Yes!” He argues that we need this information in order to effectively treat oral diseases, and conducting point-of-care testing while gathering data on a patient’s oral health increases the likelihood of identifying those at risk. As the population ages, this information will be all the more important.

“The population will be presenting with more noncommunicable chronic diseases including diabetes mellitus,” Ira points out. “One in 12 patients now has the disease. If dentists in the future are unable or uncomfortable managing these patients, that’s a significant deficiency.”

Ira believes it is incumbent on dental schools to be aware of these trends and teach in greater depth both about the oral complications of diabetes and about appropriate screening tools. Monty MacNeil agrees. In his view, academic health centers and their community-based partners are in a unique position to experiment with delivering some primary care services in the dental office while the larger practice community waits for reimbursement and other issues to be sorted out.

“Let’s not make the lack of reimbursement the barrier right now,” he told me. “We know that prevention and early identification of medical risk are keys to controlling rising health care costs. If we can demonstrate better health outcomes in partnerships like this with medicine, I think we’ll see reimbursement systems evolve around us.”

Ira also sees as a potential barrier the uncertainty around scope-of-practice boundaries, and he has made a formal request to the U.S. Department of Education for clarification on whether dentists can conduct screening for diabetes in the dental office. Ira told me that roughly 50% of the states have a scope-of-practice statement containing language similar to the American Dental Association’s scope-of-practice definition. This statement contains broad language that effectively acknowledges that in-office blood sugar testing falls within the dental scope of practice. In addition, all dentists adhere to the Clinical Laboratory Improvement Amendments regarding the use of in-office diagnostic tests, and know that when a positive test result is obtained, a referral to a medical provider is essential. Nevertheless, I imagine that many dental practices will welcome a clear statement by the government sanctioning diabetes screening in the dental office.

Assuming the aforementioned barriers can be surmounted, there remains a cultural question: Are patients and their oral health providers ready for this step? One study titled, “Dentists’ attitudes toward chair-side screening for medical conditions,” published in 2010 by a group at the Rutgers School of Dental Medicine (then the New Jersey Dental School), reported that 90% of dentists believe it is somewhat or very important to screen for specific medical conditions, with three quarters of respondents including diabetes mellitus.

Two additional studies, one by the same research team and another using data gathered by the Dental Practice-Based Research Network, found that patients also overwhelmingly accepted the idea of diabetes screening in the dental office. What’s more, most of them were willing to pay a modest amount out-of-pocket to have the screening done.

As we contemplate the role of dentistry in primary care, let us not forget that the practice of general dentistry is primary care. Unfortunately, as Michael Glick reminded me, we have not done a good enough job of communicating that to our colleagues in the other health professions. In the long run, IPE should make a major contribution to changing those misperceptions.

As Ceil Feldman put it, “It’s a two-way street. As dentists become more sensitive to and actively involved in identifying patients who need a medical home, physicians who see oral disease will start moving their patients to the dental side.”

Ceil went on to ask whether the medical home and the dental home will co-exist or eventually merge into one. That’s a question for another day, but as far as what occurs when all the professions collaborate in the delivery of primary care, I agree with Ceil’s conclusion: “The patients win out.”

Consciously working at the intersection of dentistry and medicine represents a new frontier in improving our patients’ health. Not only will doing so allow us to guide our patients toward appropriate care. It should also instill in our medical, nursing and pharmacy colleagues a better understanding of the care we can offer their patients.

Dr. Richard Valachovic
In this month’s letter, ADEA President and CEO Dr. Rick Valachovic considers a movement among oral health professionals that favors prevention and the medical management of dental disease.

Last month, two events—the launch of government-run health insurance exchanges and efforts in Congress to delay and defund other aspects of the Affordable Care Act—focused my attention once again on ways that our professions’ roles in the health care system are changing. Not all—or even most—of that change comes in response to the evolution taking place in the U.S. health care system. Nevertheless, recent events reinforce what we have known for some time: that the oral health professions will look markedly different in the 21st century than they did in the 20th.

While some aspects of what lies ahead remain hard to predict, it’s apparent that greater integration of the health professions—of education, research and practice—and of the body, the mind and the oral cavity are well underway. As a result, I’ve decided to focus the next two issues of Charting Progress on practices that are bridging the historic divide between dentistry and other health professions. This month, let’s start by looking at a medical approach to managing oral health using caries risk assessment. By now, this term should be familiar to most in our community. A 2009 survey of dental schools indicated that 90% of responding institutions had a caries risk assessment program in place for their predoctoral students, and 59% listed caries risk assessment as a graduation requirement. Nearly all dental hygiene programs also teach their students to assess caries risk. These numbers are even higher today according to Dr. Margherita Fontana, Associate Professor in the Department of Cariology, Restorative Sciences and Endodontics at the University of Michigan School of Dentistry. Margherita helped conduct a more recent survey of caries risk assessment in the predoctoral dental curriculum. She told me that all schools now say they teach the practice, but there is significant variation in how they do it.

“One of the challenges has been to make sure that caries risk assessment is consistently implemented with every patient who comes to the dental school setting,” said Margherita. “Even in the schools that are most committed to caries risk assessment, there are still a number of patient charts that might not have the required assessment forms completed.”

As you may know, Margherita has been a leader in the ADEA Section on Cariology, and she is a leading proponent of caries risk assessment, although she readily admits there is still some confusion among oral health professionals about caries risk assessment generally and about CAMBRA specifically. The CAMBRA acronym stands for Caries Management by Risk Assessment, which is both a philosophy and a method for managing the disease of dental caries. The term also applies to a survey tool for discovering what puts patients at risk of developing dental caries and to treatment approaches that aim to reduce that risk.

“The strategies we choose and the frequency with which we monitor patients is based on each patient’s risk,” Margherita explained. “And if we have to intervene restoratively, we’re going to try and preserve as much tooth structure as possible.”

This view stands in stark contrast to the concept of “extension for prevention” pioneered by Dr. G.V. Black, the founder of modern operative dentistry. Anyone who has studied restorative dentistry is familiar with Dr. Black’s seven steps for restoring carious lesions. Step seven, “performing the toilet of the cavity,” is especially memorable since his cleaning procedure long outlived the colorful phrase he used to describe it.

Dr. Black’s “extension for prevention” idea, conceived in the late 19th century and promulgated in textbooks throughout the 20th, was that carving away healthy portions of the tooth adjacent to the decay would prevent future carious involvement. This seemed to make sense at a time when acid was deemed to be the primary cause of dental caries, but remarkably, Dr. Black’s approach to restoration continued to persist in the second half of the 20th century despite our growing understanding of the bacterial genesis of caries and the ability of fluoride and other agents to fortify tooth enamel. In other words, our surgical orientation to treating the problem remains firmly entrenched in many, if not most, dental offices.

That said, in the 1990s, things started to change. A group of researchers led by Dr. John Featherstone, Dean of the University of California, San Francisco, School of Dentistry (UCSF SOD), conducted research that put to rest any lingering notion that placing restorations cured the disease of caries. Their multi-year randomized clinical trial of caries management by risk assessment found that the use of a chlorhexidine rinse following the restoration of teeth with carious lesions reduced the bacterial load in the mouths of adults, whereas placing restorations alone did not.

It wasn’t long before these same researchers and other California dental educators came together to act on these findings. With the support of the California Dental Association, they formed a coalition to promote the routine use of the caries risk assessment and treatment protocols they had named “CAMBRA.” Starting from the premise that caries should be managed medically, they focused on controlling the microflora of the mouth and remineralizing those teeth with weakened enamel. To determine the best way to achieve this for each patient, they developed a CAMBRA assessment form that documents the factors contributing to a patient’s risk of developing caries. (You can see the most recent version of the form incorporated in an iPhone app called MyCAMBRA, which UCSF SOD launched earlier this fall.)

Over the years, a number of other caries risk assessment forms have been developed or adapted in North America and Europe, where caries risk assessment is also gaining ground. I asked Margherita what distinguishes them from one another.

“The forms are all basically measuring the same variables,” she told me. “It’s how they word the questions and how they weight the answers that is different. The reason you have those differences is because there’s not a lot of evidence around how to use the majority of existing forms. It’s primarily based on expert opinion and data on the predictive ability of individual risk factors.”

In other words, the jury is still out on which forms and protocols are most effective in assessing risk and guiding effective preventive treatment. Margherita told me that very few questions on the forms have been shown to be predictive, and those that have been confirm what we already know from the literature: that a patient’s past experience of caries is the best predictor of future caries risk. So why not just assess caries risk based on a patient’s caries experience?

According to Margherita—who received a highly prestigious Presidential Early Career Award for Scientists and Engineers last year, which she is using to develop a caries risk assessment form that can be used by patients rather than clinicians—the forms are as much about managing caries risk as they are about predicting it. The information they gather—about dietary habits, knowledge of oral hygiene, access to fluoridated water and the like—sheds light on a range of factors that are germane to a patient’s dental treatment plan. This information allows for the customization of care, which has the potential to more effectively engage the patient in a preventive oral health regimen than the one-size-fits-all advice to brush and floss.

In the United States, the CAMBRA movement has grown beyond its West Coast roots. Eastern and Central U.S. CAMBRA coalitions came into existence a few years ago, and the formation of a nationwide CAMBRA Coalition is underway. In 2010, CAMBRA Coalition members were also among those who formed the ADEA Section on Cariology to discuss and enhance teaching in this area. The section’s former Councilor is Dr. Mark Wolff, Professor and Chair of the Department of Cariology and Comprehensive Care and Associate Dean for Pre-doctoral Clinical Education at New York University College of Dentistry (NYUCD). He has been influential in seeing that caries risk assessment is performed by both dental and dental hygiene students for all patients who pass through the NYUCD clinic. From what I hear, performing caries risk assessment is not yet routine in some dental school clinics, but the bigger challenge, in Mark’s view, is customizing preventive strategies for adults. He notes that prevention efforts have largely been limited to children, and he’s not satisfied with this.

“Every one of my students, 360 of them a year, graduate saying, ‘What do you mean fluoride for adults isn’t the norm?’” Mark told me, adding proudly, “We’re changing it.”

This advance is laudable, but fluoride at all ages is not the same as providing the type of customized treatment that Mark and others advocate. One obstacle to achieving their vision is a lack of strong evidence on adult preventive care, and as Mark points out, such evidence is urgently needed.

“We have yet to see the real high-risk group in dental caries arrive on the scene: elderly people of limited means,” Mark observed. “Their dexterity is decreasing, their prescription drug use (which in many cases causes dry mouth) is increasing and they still have their teeth with lots of repair done on them. That’s a formula for disaster, so managing their caries risk starts to become very important.”

Perhaps, but effectively managing caries risk for the majority of our patients will require a cultural change on our part, and that never comes easily.

“People who have learned an intensive, detailed skill set like dentistry don’t really want to change and do something different,” John Featherstone remarked when we spoke earlier this fall. As a result, he focuses most of his energies on his current students with the hope that the next generation of oral health professionals will view caries risk assessment as the norm. Meanwhile, he hasn’t given up on current practitioners entirely. John offers a lot of continuing education courses on CAMBRA. (You will be able to read about his recent MOOC, or massive open online course, on the topic in a future issue of the ADEA CCI Liaison Ledger.) And he is seeing some positive results.

“I get feedback every time,” he told me, “from someone who says, ‘This has changed the way I do my practice. It’s changed the way that my patients behave, and it’s changed their oral health.’”

If the experience of these practitioners can be widely replicated, we may start to see the power of prevention begin to transform our approach to combating dental disease. Overcoming another obstacle—the lack of reimbursement for most preventive services—is already being explored by several forward-looking insurers. In one pay-for-performance pilot, reimbursement for caries risk assessment drove the use of risk assessment to 98%! The American Dental Association is also paving the way for insurance reimbursement by introducing three new dental procedure codes in 2014: one each for low, moderate and high caries risk.

Should managing caries risk dominate the practice of dentistry and dental hygiene in the century ahead? Regardless of your answer to that question, we must rethink the way we approach patients, both as individuals and from a community perspective. We cannot simply follow the status quo if we want to be effective in promoting oral health. When it comes to patients, we need to look at their diets and oral health beliefs as well as their oral hygiene. As for communities, we must consider demographics, cultural traditions and infrastructure (from water fluoridation to the availability of healthful food) if we want to reduce the future incidents of caries. Gathering this data through caries risk assessment, regardless of the specific protocol, appears to be a promising way of committing ourselves to intervening with individually tailored preventive strategies before caries recur. Such action is all to the good.

Dr. Richard Valachovic
In this month’s letter, ADEA President and CEO Dr. Rick Valachovic spotlights how a global treaty on mercury appears to be accelerating the development of new restorative materials and prompting discussion within academic dentistry about dental amalgam’s place in the curriculum.

Think about the teeth in your mouth. If you are old enough to have had a tooth restored before 1980, it is highly likely that the material used was dental amalgam. In the unlikely event you had a tooth restored in the 1990s or later, you were probably given a choice between amalgam and resin composite.

Today, composite is pretty much considered the default restorative material in North America, although amalgam remains in use and continues to serve a vital purpose. Ten years from now, I suspect most dental offices and clinics will no longer stock amalgam—mostly in response to this long-term trend, but also because of a new environmental treaty that aims to make amalgam (and other products containing mercury) less available in the years ahead.

The Minamata Convention on Mercury represents four years of negotiation among 140 nations under the auspices of the U.N. Environment Programme (UNEP). Named for a Japanese city where inhabitants were seriously harmed by mercury pollution, the treaty calls on nations to reduce the use of mercury in small-scale gold mining, to control its release from coal-fired power plants and to ban the production, import and export of many mercury-containing products by 2020.

Dental amalgam was initially slated to be among those banned products. At the start of the negotiations, groups who view amalgam as a human health risk—despite a lack of credible scientific evidence to validate their claims—generated considerable support for a ban. A year later, two nongovernmental organizations, the International Association for Dental Research (IADR) and the Worldwide Dental Federation (FDI), joined the negotiations, bringing their scientific understanding of dentistry and human health to a political discussion framed largely by environmental concerns. The presence of a unified voice for organized dentistry turned the negotiations around. In the end, UNEP delegates agreed to a phase down—rather than a ban—of the use of dental amalgam, with no fixed date for its elimination.

For an insider’s perspective on what brought about this evolution in the delegates’ thinking, I called Dr. Dan Meyer, Senior Vice President, Division of Science and Professional Affairs at the American Dental Association (ADA). Dan acted as an ADA advisor to IADR and FDI and personally attended four of the five international meetings held to negotiate the Minamata Convention. According to Dan, many who attended the UNEP Intergovernmental Negotiating Committee meetings, especially those from countries where dentists are a rarity, were unaware of the complexities of the dental issues at stake.

“To me that’s a tragedy,” Dan said. “These representatives didn’t understand the oral health implications of limiting the use of or trying to phase out dental amalgam. They didn’t realize what a huge detriment that would be to the oral health care of the individuals they were trying to represent and protect.”

Dan dismissed many of the anti-amalgam groups’ claims as misrepresentations and misinformation not supported by science, but he told me that refuting these allegations proved a formidable task. Nevertheless, over time, he and others representing the oral health professions conveyed the message that retaining amalgam as a restorative option benefits both patients and providers.

To those of us who have been using amalgam for decades, its value as a tried and true material that is durable, affordable and less sensitive to moisture than the alternatives may be self-evident. (Those of you who are not fully acquainted with the differences between dental restorative materials can learn more from this primer.)

That said, I can also imagine a future in which we will be able to manage without amalgam, even in the procedures where it is currently the restorative material of choice. My recent conversations with researchers and materials scientists, who for decades have been following the debate surrounding amalgam use, have led me to wonder whether imminent advances in materials science, recent revelations about existing materials and shifting political priorities might not coalesce to eliminate most amalgam use in just a few years’ time.

Amalgam is touted for being less costly and more durable than other restorative materials. Those distinctions certainly held true in the past, but perhaps the time has come to re-evaluate our assumptions in light of new research and some promising developments. First, let’s consider cost.

A study published in Public Health Reports in 2007 estimated that a ban on amalgam in the United States would increase the cost of each dental restoration by $52, or nearly 20%. While those figures appear to give amalgam a clear cost advantage, they do not reflect the cost of implementing best management practices (BMPs) aimed at dealing with amalgam waste.

The use of BMPs was just beginning to take hold in the mid-2000s when the study data were collected. I can remember an earlier time when most of us routinely disposed of excess amalgam in the trash. Today our clinics recover the vast majority of that waste amalgam. Recovery protects the environment but also raises the cost of using the material.

The other commonly cited benefit of amalgam is its durability, which has traditionally been viewed as far superior to that of resin composites. Recent research suggests that this perceived advantage has also been overstated. I know many of you will beg to differ, but at least one 2010 study from the Netherlands supports this contention. The study found that, after 12 years, composite survival rates exceeded those of amalgam restorations, except in cases involving three-surface restorations in high-risk patients. Additionally, few dentists wait for a restoration to fail before replacing it. This tendency may be significantly reducing the lifespan of many restorations and skewing the data about their longevity.

So, do these re-appraisals of the cost of amalgam use and the durability of composites mean that our community can dispense with dental amalgam today? No, not yet. But the day when we can may not be far off.

Last month, the National Institutes of Dental and Craniofacial Research announced the award of $2.8 million in research grants for the development of a long-lasting composite polymer capable of replacing current restorative materials. The six groups receiving these awards are expected to work cooperatively and share data and resources to achieve the goal of developing a material with a clinical service life exceeding current commercial materials by at least a factor of two. The hope is that this collaboration will produce a viable alternative material within five years or perhaps even sooner.

Even if that timeline is overly optimistic, there’s little doubt that the use of amalgam will continue to decline. In addition to efforts to reduce its presence in the waste stream, consumers—when given the choice—are opting for materials that mimic the appearance of natural teeth.

I recently discussed this trend with Dr. Mark Wolff, Professor and Chair of the Department of Cariology and Comprehensive Care and Associate Dean for Predoctoral Clinical Education at the New York University College of Dentistry (NYUCD). He told me that at NYUCD, amalgam represents less than 20% of the restorations placed in the dental clinic, and that figure has been declining. This trend results largely from patient preferences but also from NYUCD’s decision to eliminate the requirement that students place a certain number of amalgam restorations prior to graduation. Mark believes students should still learn how to place amalgam, but he considers it unethical to force the material on patients who don’t want it.

“We still teach amalgam—in the lab,” he told me. “In the clinic, a bonded restoration is the default because we can do it more conservatively.”

Of course the most conservative approach is prevention, a strategy for reducing the use of amalgam that the Minamata Convention advocates and that everyone can agree upon. As Dan Meyer points out, “No dental restorative material is as beneficial to oral health as preserving the intact, natural tooth structure, and with the emphasis on prevention, sealants, fluoride toothpaste and public water fluoridation, we can reduce the use of all dental restoratives to a greater extent in the future.”

Next month, I’ll talk more about prevention and discuss Caries Management by Risk Assessment, better known as CAMBRA. Meanwhile, a diplomatic conference was held in Japan last week where the Minamata Convention was opened for signature. Canada was one of 92 nations to sign the document, and other nations are expected to follow suit in the year ahead. One of the implications for our schools and programs is clear. Although the time we spend teaching the placement of amalgam will continue to diminish, we will still need to teach our students how to deal with the amalgam restorations already in circulation. Some estimates put their number around 900,000, and as these fail, dentists will need to know how to recover and recycle the resulting waste.

The most recent ADA survey, completed in 2010, indicated that half of private dental practices that place amalgam restorations were using amalgam separators. In states that have enacted voluntary recycling incentives or regulatory mandates, that percentage is much higher today. So once again, politics is playing a role in the transition to the next generation of safe, effective, affordable, durable—and environmentally friendly—restorative materials.

Completing this transition may require continued political involvement. Traditional regulatory processes add years to the time it takes to bring a new product to market. If dental professionals are eager to conclude the phase down of amalgam in short order, they will need to think about advocating for the acceleration of the approval process for whatever amalgam substitute emerges.


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