Dr. Richard ValachovicIn this month’s Charting Progress, Dr. Rick Valachovic looks at the debate over teaching the placement of dental implants in predoctoral and specialty curricula.

This past summer, the Commission on Dental Accreditation (CODA) adopted revised accreditation standards for advanced education programs in prosthodontics, ending one of the longest and most contentious standard review processes in recent memory.

At issue was the inclusion of standards related to dental implant placement. Although historically the surgical procedure has not been associated with prosthodontics, prosthodontists began placing implants in the early 1980s. A decade later, prosthodontics programs were lengthened to accommodate the introduction of implant therapy.

“Prosthodontics used to be defined as, ‘You do dentures; you do crowns,’” says Lily Garcia, D.D.S., M.S., FACP, Associate Dean for Education at the The University of Iowa College of Dentistry & Dental Clinics and Immediate Past Chair of the ADEA Board of Directors. “No,” she responds on behalf of her specialty, “we treat and restore patients based on a diagnosis of their conditions.”

Lily says 2003 was pivotal for prosthodontics. That is the year when the American College of Prosthodontists adopted a new definition—one that made clear that implant placement, as well as implant restoration, fell within the specialty’s scope. A 2013 survey showed that 90% of prosthodontics residency programs were already training residents in implant placement. The new CODA standards go a step further: They ensure accountability by making the training a requirement for all advanced programs in the specialty.

Given that the standards largely ratified the on-the-ground reality, why did their adoption take so long to approve? Since researchers at the 1982 Toronto Osseointegration Conference in Clinical Dentistry validated the placement of implants as a long-term alternative to bridges and dentures, many dental specialties have laid claim to one part or another of implant dentistry.

“Periodontists and oral surgeons took on placing implants, prosthodontists took on restoring implants, orthodontists use a type of implant for anchoring, endodontists are placing implants and want to include this as part of their specialty, and periodontists want to include the name ‘implant dentist’ in their specialty’s name in the near future. The public is confused about who should be doing this.” That’s the assessment of John Da Silva, D.M.D., M.P.H., Sc.M., Vice Dean of the Harvard School of Dental Medicine and President of the American Academy of Implant Dentistry (AAID), which offers a 300-credit-hour certification program. John has limited patience with what he calls the “underlying battle going on among all the specialties about who should own implant dentistry.” His association represents 5,000 general dentists and specialists, and he says that general dentists appear to be placing more implants than are specialists.

“Some general dentists refer out to specialists, and some don’t have access to specialists in their communities. Those folks tend to go out and learn how to do implant dentistry, and many of them do it well,” he told me.

“I think a motivated and well-trained general dentist is ideal for implant placement,” says Mark Latta, D.M.D., M.S., Dean at Creighton University School of Dentistry. Creighton does not have advanced education programs, so Mark feels passionately that implant dentistry should be a core competency for general dentists—not just the treatment planning, but understanding the concepts involved in the surgery and hands-on knowledge of the restoration.

“What we’re trying to articulate to our students is that the restoring dentist has to be at least an equal partner with the dentist who places the implant to achieve the best success,” Mark told me. So is it feasible in Mark’s view to include implant placement in the predoctoral curriculum?

“If we followed the IOM [Institute of Medicine] recommendation that the dental doctoral degree be a five-year degree,” Mark responded, “then in that fifth year, there would be an opportunity to teach more complicated dental therapies, including implant surgery. But the reality is, we have so many areas in which we have to get our graduates to minimal competency, that implant placement is probably a bridge too far.”

Many would agree with Mark, but not everyone. How much dental students should learn about implant placement, what is more appropriate for residency training and which specialties should be involved remain open questions and the source of considerable debate. Implants have become the first choice of care for a majority of patients with missing teeth, and it’s not clear if dentistry will be able to meet future demand for this treatment if implant placement remains a strictly advanced-level competency.

Leila Jahangiri, B.D.S., D.M.D., M.M.Sc., Clinical Professor and Chair of Prosthodontics at New York University College of Dentistry, has dedicated the last 14 years of her career to seeing that implant dentistry becomes integrated in the predoctoral curriculum. In her view, “No dental student should graduate in 2015 only knowing theoretical aspects of implant dentistry.”

At the direction of her former Dean, Mike Alfano, D.M.D., Ph.D., and with the support of her current Dean, Charles Bertolami, D.D.S., D.M.Sc., Leila has taken the lead in developing the implant dentistry curriculum at NYU for the past decade. She has also trained faculty at 48 schools in the United States and abroad, helping them establish their own implant curriculum.

Leila feels strongly that dental schools should take responsibility for educating their students and alumni in this area rather than leaving implant training to implant manufacturers, and she advocates starting at the predoctoral level because, she says, “There aren’t enough specialists in the country to handle the load.”

Leila’s views have been challenged by others who perform surgical procedures, who argue that today’s graduating dental students are not as well surgically trained as their peers were 20 years ago, and are therefore unprepared to learn implant placement. All students do not necessarily have the same experiences in periodontal surgery or flap surgery for extractions, her surgeon colleagues tell her. “I agree with that,” she responds, and she offers as a solution putting more surgical training in the curriculum.

Another objection also dogs proponents of predoctoral education in implant placement: the potential for competition between advanced dental education and predoctoral programs when it comes to finding patients. To get a handle on this issue, I called Mike Reddy, D.M.D., D.M.Sc., Dean at the University of Alabama at Birmingham School of Dentistry. Mike has researched bone regeneration, implant site development and abutments, and he considers implants one of the major health care innovations of the last 30 years.

“Where some schools may struggle,” he told me, “is in finding the volume of patients, but at UAB, access to patients hasn’t been a problem. We are seeing tremendous demand for implants from complex patients who come to us for our expertise.”

Dr. Jahangiri also thinks that fears about access to adequate numbers of patients are misplaced. She points out that 40% of Americans over the age of 65 are edentulous in at least one arch, and she says 120 articles discuss the beneficial impact of a simple two-implant overdenture for the lower jaw on the general health of older adult patients.

“The medical community and insurers don’t know about the value of this,” she told me, “that this procedure can reduce the cost of care to the elderly.”

Once these benefits are more widely known, Leila believes this patient population—along with others—will supply more than enough training opportunities for dental schools. In her view, there are bigger issues. These include the high cost of implants—which are covered by some private, but no public, insurers—and outmoded educational requirements that inappropriately influence which prosthodontic care choices students recommend.

“The students need to ask, ‘What is the best option for the patient?’ That’s what should determine the treatment, and in an academic dental setting, the cost of bridgework and implants should be made equal so treatment cost is not a deciding factor for the patient.”

Meanwhile, the biggest hurdle of all, Leila says, is the need for faculty training. She recommends a combination of the following before faculty attempt implant placement themselves:

  • Didactic education that can be accessed online
  • Opportunities for independent simulation learning (so faculty can take all the time they need with the instrumentation and materials without pressure from their colleagues)
  • Multiple side-by-side surgical observations with a trained expert

She also advocates for annual reviews of problems that have occurred to give faculty an opportunity to reflect, discuss challenges and refresh their skills

At least in the academic dentistry community, there seems to be a consensus that dentists of all stripes can and will continue to be engaged in implant dentistry, and that all dentists must learn to collaborate in this endeavor for the sake of their patients. A 2015 survey published in the Journal of Dental Education confirmed that more than 90% of dental schools are teaching restorative procedures related to implants, most often in the third year.

Mike Reddy would like to see the implant curriculum integrated earlier on. “Implants should be taught with treatment planning, perio, prosthodontics and oral surgery, not just in a separate course. It makes for better treatment planning if students start thinking about it from the time they come in.”

While John Da Silva does not advocate the categorical exclusion of general dentists or specific specialty groups from implant placement, he is concerned that everyone who practices implant dentistry be thoroughly trained and that the field has the opportunity to evolve and mature. To encourage progress in these areas, he and his fellow AAID members are working toward creating an implant dentistry specialty through the American Board of Dental Specialties. John says a separate specialty would allow dental schools to establish formal implant dentistry programs, which would build a critical mass of dentists who understand the full scope of implant treatment—including ancillary surgical procedures.

“A specialty would create a group of people who can go beyond the routine and simple things and become a resource for the dental community. To me, that’s how you move a profession forward—by having experts you can rely on to drive the frontier further,” he says.

John anticipates resistance to AAID’s proposal, and his worries may be well founded. But within academic dentistry, there appears to be considerable common ground. Leila told me that she would like to see all predoctoral students educated in implant dentistry, but she added, “I don’t see this as an opportunity for general dentists to do it all. I see this as an opportunity to sift through the cases and identify the ones that are simpler to treat versus those that require interdisciplinary care by specialists.”

Similarly, in reflecting on her specialty’s recent experience with the revision of its advanced education program standards, Lily asked, “Should an isolated clinical procedure be used to define boundaries between specialty and general dentistry? Are we truly at odds, or can we learn something from this about working better together, capitalizing on our strengths for the patients we all serve?”

I have no doubt we can, and that the dental education community will show the way in doing so.

Dr. Richard ValachovicIn this month’s Charting Progress, Dr. Rick Valachovic shares what’s on the minds of ADEA’s Canadian members and discusses the trends that are reshaping dental education in Canada.

To celebrate ADEA’s recent launch of a legislative advocacy portal for Canadian members, I decided to call some Canadian colleagues to find out what’s on their minds. Not surprisingly, many of their concerns overlap with those of their U.S. peers, but Canadian dental education also operates in a uniquely Canadian context, with advantages and challenges all its own.

The country has 10 dental schools—all affiliated with public universities—and the tuition at most of them is relatively low when compared with most schools in the United States. Admission is extremely competitive, with more than seven applicants for every first-year dental school slot. As a result, many Canadians go abroad to study dentistry, and not just to the United States. In recent years, Canada has also developed reciprocity agreements with dental schools in Australia, New Zealand and Ireland.

The impact of these developments has been striking. Prior to 2010, three-quarters of newly licensed dentists in Canada had graduated from Canadian schools. Today, less than half of new dentists are educated in Canada, and the expectation is that number will continue to decline.

Reciprocity is only partially responsible for this trend. Add to that a separate national policy decision to welcome professionals of all stripes to Canada, and you have the makings for an increasingly globalized Canadian dental profession.

Since 2011, internationally educated dentists from countries without reciprocity have had a new pathway to practice dentistry in Canada: taking an equivalency assessment to establish their eligibility for Canadian licensure. The National Dental Examining Board of Canada (NDEB) Equivalency Process has proven to be popular. Jack Gerrow, D.D.S., Executive Director and Registrar at the NDEB, estimates that in 2014 alone, 150 to 200 international dentists obtained licenses through the process. Factor in the 200 dentists made eligible through reciprocal agreements, and 90 international dentists who attended qualifying (also known as advanced standing) programs, and it’s easy to see why the 450 Canadians who graduated from the country’s traditional predoctoral programs in 2014 are now in the minority.

Does the diversity of routes to licensure or the mismatch between supply and demand for Canadian dental education matter? Do these factors have a bearing on the availability of dental care? The answers to those questions depend on your point of view.

Benoit Soucy, D.M.D., M.Sc., is among those Canadians who have expressed concern that the influx of international dentists may be contributing to an emerging surplus of dentists in some areas of Canada. Benoit is Director of Clinical and Scientific Affairs at the Canadian Dental Association (CDA), which represents most of the provincial dental associations in Canada. Benoit told me that regulators are not receiving more complaints about international dentists than about graduates of accredited programs. Yet despite this good news, he expressed concern that internationally trained dentists, who are unfamiliar with the Canadian practice environment, will necessarily face additional challenges in their integration into the job market.

Daniel (Dan) Haas, D.D.S., Ph.D., FRCD(C), Dean of the University of Toronto Faculty of Dentistry, shares Benoit’s desire to see international dentists spend time becoming acculturated to North American dental practice. He would prefer that international dentists enter the workforce though the qualifying process that has been in place since 1997, and he believes the dental education community shares that view. Meanwhile, these advanced standing programs are currently at capacity and admit about 90 students a year. Again, limited supply meets considerable demand.

“Restrictive enrollment has not actually worked to stem the tide of new dentists in Canada,” Dan told me. He used this argument to win approval to increase Toronto’s enrollment by 25% a few years ago. “Many Canadian applicants do not get into dental schools in Canada, and then turn to U.S. schools, which is totally fine, but if Canadians want to be dentists, why don’t we train a few more of them here in Canada?” he argued.

Dan’s institution is the largest dental school in Canada, and one of the few with the wherewithal to expand. All of the dental schools in Canada are part of public universities that, like their U.S. counterparts, are being asked to do more with declining government funding. Making up for these financial losses is no easy feat given that the government also regulates how much tuition schools can charge.

Dan asks, “How will we do what we’re supposed to do: great research, create knowledge and at the same time have great educational programs? Because financially, we’re strapped. For all of us, that’s the biggest challenge, to balance our budgets, not just to survive but to be great schools.”

“Part of the financial problem for dental programs in Canada is that we have 10 small dental schools,” observes Jack Gerrow. He told me that for the past 20 years he has been promoting institutional cooperation models that could increase efficiency, but he has found few takers. Nevertheless, he is excited by some faculty-level initiatives, including a removable-prosthodontics curriculum—created at the Dalhousie University Faculty of Dentistry—that is reaching thousands of users via YouTube.

Another initiative coming out of that institution is the Network for Canadian Oral Health Research (NCOHR). The network was established in 2012 with funding from the Canadian Institutes of Health Research and other partners, and includes researchers from all of the nation’s dental schools. NCOHR’s goal is to build capacity for oral health research by connecting people across disciplines and across institutions and by giving them the skills they need to compete for research funding.

Debora Matthews, D.D.S., Dip. Perio., M.Sc., Assistant Dean for Research at Dalhousie, received the grant that first established the network, and she serves as its director. In a few short years, Debora told me the network has hosted a series of well-attended workshops and institutes, and its individual members have established relationships that are bearing fruit. Ph.D. candidates have connected with mentors, scientists have co-authored peer-reviewed papers and newly formed research teams have competed successfully for funding.

In a recent vote of confidence, the Association of Canadian Faculties of Dentistry (ACFD), ADEA’s sister organization in Canada, and the Canadian Association for Dental Research agreed to fund the network for another three years. That’s good news for the network and for two of its most prominent teams, one focused on orofacial pain and the other looking for sustainable ways to reduce oral disease in Canada’s First Nations, Inuit and Métis people.

What many in the States may find most surprising about our neighbor to the north is that Canada also has a significant access-to-care problem when it comes to oral health. The Medical Care Act, which established the country’s publicly funded health system in 1966, excluded dental care, and the Canada Health Act, which further clarified the system in 1984, was equally mum when it came to oral health. (If you’re interested in learning why, take a look at this paper.)

Today, 95% of Canadian dental care is paid for out-of-pocket or through private insurance. As this year’s ADEA/Sunstar Americas, Inc./Harry W. Bruce, Jr. Legislative Fellow, Greg Olson, D.D.S., M.S., put it, “Even though Canadians as a whole tend to be more socially conscious and community minded, they are struggling with the challenge of integrating dental care with general health care.”

Greg is an Associate Professor at Loma Linda University School of Dentistry and Canadian by birth. He shares the concern held by many in his native land that the government should be doing more to address its access-to-care problem.

To get a better sense of where the issue stands, I contacted Paul Allison, B.D.S., Ph.D., Dean at McGill University Faculty of Dentistry. Paul chaired a national panel on improving access to dental care for vulnerable populations. The following were among the key findings of the panel’s 2014 report:

  • Many low- and even middle-income Canadians suffer from pain, discomfort, disability and loss of opportunity because of poor oral health.
  • Approximately six million Canadians avoid visiting the dentist every year because of the cost.
  • Private sector dentistry—which provides good quality dental care for a majority of people living in Canada—does not serve as a good model of health care provision for the vulnerable groups who suffer the highest levels of oral health problems.

The report’s proposed remedies for improving access are both multifaceted and incremental. How could they be otherwise, given its finding that “There is no consensus on standards of dental care provision among federal, provincial, territorial and municipal governments in Canada,” any more than there is the United States? But Paul himself has a bolder vision, which he shared with me last month.

“We need to fundamentally rethink how we deliver dentistry,” he contends. “People really struggle to get to us for all sorts of very good reasons. We should set up and test new models of care that take dentistry to them, whether it be mobile dentistry, teledentistry or putting care in unusual settings.”

Paul would like to see dental schools in the forefront of not only developing these models of care but also training students and residents to implement them. He says that’s what came out of the report for him.

One way dental education might become a laboratory for new models of care would be through the development of a fifth-year residency program—an idea that emerged in informal conversations at this year’s meeting of the ACFD. While discussions are still preliminary, they signal that the desire to see dental education evolve to remain relevant to society at large is as vigorous in Canada as in the United States.

John O’Keefe, M.Dent.Sc., M.B.A., is an exemplar of this and other Canadian trends. His lilting accent reveals his Irish origins, and his current title, Director of Knowledge Networks, signals his evolving role at the CDA. Until 2010, he served as Editor-in-Chief of the association’s journal. Today he strives to facilitate dialogue among CDA members. He oversees CDA Oasis, a virtual “campfire” where dentists are invited to share their stories and their expertise, and to learn from others. John has also helped to create the Canadian Oral Health Round Table, a national forum focused on improving Canadians’ oral health.

“For the first time in my memory, we’ve got an annual symposium in which we bring together associations within dentistry with other professions like teachers, social workers and government groups,” John told me. “It’s baby steps, but we’ll have 30 organizations coming back for a third year in a row to talk about addressing oral health promotion for the most vulnerable groups in Canadian society. I think that’s something to be celebrated.”

So do I, and I wish John well in his quest to inspire members of the Canadian dental profession to come together around the virtual campfire to share their experiences and discuss their collective future. This activity can only enhance the profession, the dental education community and the oral health of those they serve.

Dr. Richard ValachovicIn this month’s Charting Progress, Dr. Rick Valachovic examines the promise of Big Data and its potential to enhance dental diagnosis, treatment and research.

In 2011, IBM’s Watson computer captivated the public when it challenged two legendary Jeopardy! champions on the iconic television quiz show. With access to more than 200 million pages of information and algorithms for sorting through this enormous quantity of data to identify the most likely responses to Jeopardy! clues, Watson outscored both human competitors.

Since this public demonstration of the power of what is referred to as “Big Data,” IBM engineers have focused on honing Watson’s skills in several new realms, including medical diagnosis. I don’t have to tell you that the amount of information available to clinicians now grows at a rate that far outstrips an individual’s ability to absorb it. A computer, on the other hand, is ideal for sifting through large amounts of data and looking for patterns. Watson takes this power one step further with a unique capacity for natural language processing and applying cognitive reasoning to analyze information and work with the clinician. In other words, Watson can understand a question posed in plain English, sort through massive amounts of data for potentially relevant answers, and communicate these to a clinician—in a matter of seconds—using what sounds like human speech.

Collaborators at the Cleveland Clinic and elsewhere have already provided Watson with a foundational medical “education.” This year, IBM announced that it is partnering with 14 major cancer centers to train Watson to analyze genetic data that can guide cancer therapy for individual patients. IBM has also invested heavily in acquiring health-related data sets to enhance Watson’s knowledge. These include large banks of images, which are pushing Watson’s programmers to equip “him” with a new set of skills in visual analysis.

A clinical world in which Watson and his successors provide seamless automated decision-support to clinicians may be some years down the road, but such a world no longer seems like the stuff of science fiction. Whether dentistry will benefit from these developments depends on our willingness to adopt a tool that has been remarkably controversial: dental diagnostic codes. In 2006, the ADEA House of Delegates passed a resolution declaring its support for the development and implementation of such codes to facilitate clinical research and assist in developing best practices for dental care delivery. Dentistry as a whole has been historically slow to take up this charge, and most dental schools are no exception. Fortunately, that situation has started to change.

Today, the Big Data revolution has finally given our community the incentive it needed to adopt diagnostic coding. Nearly all ADEA member schools now use electronic health records (EHRs); several dozen schools have introduced diagnostic codes into their EHR systems; and a small but growing subset of our institutions has banded together to create the first oral health database—BigMouth Dental Data Repository—developed from partially de-identified EHR data.

Six dental schools are currently participating in BigMouth, which resides on secure servers at the University of Texas School of Dentistry (UTSD) at Houston. BigMouth is a project of the Consortium for Oral Health Research and Informatics (COHRI), and researchers who want to query the data can submit a project proposal to a COHRI review committee for consideration. The database currently holds more than 2 million records, and already a few researchers have accessed the data to examine adherence to treatment protocols and the associations between several systemic and oral health conditions.

Muhammad Walji, Ph.D., Associate Dean for Technology Services & Informatics at the University of Texas School of Biomedical Informatics at Houston, leads the project. When we spoke recently, Muhammad told me that the project is now looking to expand the number of participating schools, standardize the way they collect data and, now that initial government grants have been spent, develop a financial sustainability plan. BigMouth is currently able to accept data from any institution that uses an axiUm EHR, but organizers are discussing plans to incorporate data from clinics using other systems in the future.

“We want the database to be as diverse as possible,” Muhammad told me, “especially geographically, so we can get a better understanding of what’s happening to patients throughout the country. We also want to reach outside of dental schools. We’re interested in having other institutions—such as large group practices—participate because they may be serving different types of patients.”

The creation of BigMouth was one of the driving forces behind the creation of the Dental Diagnostic System (DDS), previously known as EZCodes. DDS is currently in use at 16 dental schools and one dental support organization. An additional 16 dental institutions have loaded the DDS in their EHRs as a first step toward implementation of the terminology. Elsbeth Kalenderian, D.D.S., M.P.H., Ph.D., Chair, Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, working with other Harvard and UTSD colleagues along with the University of California, San Francisco, School of Dentistry and ACTA (Academisch Centrum Tandheelkunde Amsterdam1) in the Netherlands, developed the DDS terminology in 2009.

More than two decades ago, the American Dental Association (ADA) recognized the need for a dental diagnostic coding system and began working to develop a separate system known as the Systematized Nomenclature of Dentistry (SNODENT®). Its codes are an official subset of the Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT®), a comprehensive set of medical terms that are recognized around the globe. SNODENT uses the same format as the International Classification of Diseases (ICD) codes that are the standard for health care reimbursement. The system offers a high level of detail; for example, it contains 25 ICD codes for different types of tooth decay. Yet the rollout of SNODENT has been periodically interrupted, and the dental community has been slow to adopt it.

“The initial development of SNODENT wasn’t ready for prime time,” explains David Preble, D.D.S., J.D., Vice President of the recently created ADA Practice Institute, “and the EZCodes (now DDS) were created to fill the gap.”

I called David to get an update on SNODENT and the acceptance of dental diagnostic coding generally. “People who are not informed still talk as though dentistry doesn’t have diagnostic codes,” David told me. “We do have codes; they’re just not widely implemented,” he emphasized.

Why has dentistry as a whole been resistant to diagnostic coding? In David’s view, the reticence is related to cost and culture. In an environment of decreasing reimbursement from insurers and fewer self-paying patients coming in for care, dental offices already feel under pressure to create efficiencies. Practitioners may see the introduction of EHRs and diagnostic codes as costly disruptions to the work flow that bring few benefits. But as he points out, “In the academic and large group practice environments, using diagnostic codes and electronic health records hasn’t turned out to be the workflow issue dentists fear.”

At dental schools, the desire to take part in Big Data initiatives such as BigMouth or others under way at the National Institutes of Health should serve as a motivator to adopt diagnostic coding. According to David, a handful of dental schools are already using SNODENT, and more are likely to join them. In the past year, the coding system was officially recognized by the American National Standards Institute (ANSI), and the ADA is now working with DDS code users and other stakeholders to develop an integrated coding system that can serve everyone’s needs.

David envisions that many future SNODENT users may want to begin by adopting smaller reference sets of SNODENT codes rather than working with the full 7,000+ terms contained in the system. While the specificity of SNODENT makes it an ideal system for research, David estimates that a clinician practicing general dentistry might only need 200 of those codes to document 99% of the diagnoses made in his or her practice.

Indeed, the more manageable size of the DDS system is one of its reported attractions. In the words of its creators, the DDS serves as an “interface terminology” whose terms are organized in a user friendly and meaningful manner for chairside use. SNODENT’s designers recognize the value of the DDS and have already incorporated about two-thirds of the DDS codes into the larger system.

Next month, the ADA will convene a meeting with stakeholders to address compatibility issues between the two coding systems. Then the ADA plans to put the revised version of SNODENT back on the ANSI ballot for approval. The goal is to ensure that the first ANSI-recognized version of SNODENT provides a solid foundation for future iterations of the nomenclature.

Elsbeth and Muhammad believe that delivering a unified diagnostic coding system for the dental profession by this fall will be a tall order; however, they are excited about working to harmonize the two systems. Meanwhile, everyone agrees that the adoption of diagnostic coding marks a turning point for our profession. How soon we will see universal adoption is harder to say, but there’s no doubt that it is the critical next step in fully realizing the potential of Big Data.

It’s also worth mentioning that Big Data is making some traditional researchers nervous. The National Institute of Dental and Craniofacial Research is trying to be sensitive to these concerns as it considers the creation of possible funding streams to support research based on EHR data. Where Big Data excels is in mining very large sets of existing data to establish correlations. A need will still exist for controlled trials that seek to establish causation.

Meanwhile, the desire to preserve today’s best quality research shouldn’t deter us from pursuing the new opportunities afforded by Big Data. As David points out, “Data alone will not replace traditional research, but there is a dearth of evidence for many things that happen in dentistry and a finite amount of money for controlled trials, and there are some trends you’re not going to see in a controlled trial no matter how many people you enroll.”

There’s no question that Big Data can enhance dental research and the care we provide, but even Big Data enthusiasts—such as Muhammad—caution against overzealousness.

“It’s not the answer to all of our questions,” he told me. “Big Data are inherently messy, so we need a team approach—clinicians, informaticians, researchers, statisticians, epidemiologists—and I think we have to be quite careful with what questions we ask of these systems as well.”

1 The English translation of the name is “Academic Center for Dentistry, Amsterdam.”

Dr. Richard ValachovicIn this month’s Charting Progress, Dr. Rick Valachovic explores how dental schools can enrich their IPE programs and improve the care they provide by establishing collaborations outside the health professions.

Last fall, I ventured north of our offices in Washington, DC, to spend a day at the University of Maryland, Baltimore (UMB). From the office of UMB President Jay Perman, M.D., I looked out over the streets of West Baltimore. Many Americans associate this community with poverty, rioting and police violence, but Jay views this corner of the city quite differently. He sees it as a laboratory, one where students can learn about the social determinants of health—safe neighborhoods, walkable streets, access to nutritious foods and health services—and one where interprofessional education (IPE) can thrive.

Jay is a pediatric gastroenterologist with a passion for IPE and a strong belief that public universities must serve their communities. To that end, he chairs the board of the Downtown Partnership of Baltimore and serves on the boards of a local foundation, a regional business association and a public-private partnership dedicated to advancing the health, safety and success of Baltimore’s youth. In 2013, he established the Center for Community-Based Engagement and Learning to enhance UMB’s involvement with local children and families. And he wants all of the university’s students to develop a similar appreciation for the potential of West Baltimore.

That’s where IPE and its changing face come in. UMB may not be unique, but it certainly is unusual. Its schools of the health professions—dentistry, nursing, medicine and pharmacy—and its graduate programs in the health sciences are situated on a health and human services campus that includes schools of social work and law. As a result, these professions, not usually thought of as “health” professions, are easily integrated into UMB’s interprofessional activities.

“It’s great,” says Jacquelyn Fried, RDH, M.S., Associate Professor, Director of Interprofessional Initiatives and Acting Graduate Program Director at the University of Maryland School of Dentistry. “It really takes the patients from soup to nuts. When you’re looking at a geriatric case, you’re looking at legal issues such as advanced directives and disability rights; and with social work, you’re looking at quality-of-life issues, the family dynamics. It adds a really nice element to the whole experience.”

These diverse schools have always shared a campus, and some previously offered courses in geriatrics, human sexuality and other topics that cross professional lines. But collaborations that span the entire campus are relatively new. IPE figures prominently in UMB’s 2011–2016 strategic plan, and the establishment of the Center for Interprofessional Education in 2013 cemented IPE’s importance within the university. Today, UMB strives to educate all its students to take a team-based approach to providing high-quality, affordable health care and human services.

Students take part in a variety of classroom and community initiatives, from an annual IPE day, during which interprofessional teams of students collaborate to solve a complex case using standardized patients, to participation in the JACQUES Initiative,1 a 12-year-old effort both to serve Baltimore residents living with HIV and to combat the spread of the virus. Rounding out the program are a University of Maryland School of Pharmacy case competition, opportunities for community-based team exercises in long-term care and in emergency-department settings, and courses such as Health Care Law, which encourage interprofessional enrollment.

Ten years ago, UMB brought its various schools together to create a Master of Public Health Program by capitalizing on existing offerings within the university’s profession-specific schools. At that time, Susan Wozenski, J.D., M.P.H., was offering a course in program planning and evaluation within the University of Maryland School of Nursing. She is now director of the dual M.S./M.P.H. program at the nursing school, and the program planning and evaluation class has become a core component of that degree.

“It was a great class,” she told me, but with the introduction of M.P.H. students from other professions, “it became an even better class.”

Susan is an attorney who says she sees health challenges through the lens of policy change, legislative issues and regulation. For example, when it comes to helping people with addictions, she thinks of using drug courts, which combine supervision, testing, sanctions and incentives to promote adherence to clinical treatments. This diversity of perspectives is also evident in her classroom, where the students tackle real-world problems that range from reducing Type 2 diabetes in Baltimore’s school children to combatting cholera in Haiti.

“No one profession has all the tools and resources to solve these large problems,” she observed. “Knowing what other disciplines can contribute gives you a tremendous advantage when problem solving.”

Because Jay Perman couldn’t agree more, he created UMB’s President’s Clinic. Every Tuesday, he invites a team of students from UMB’s seven professional schools to work with him and colleague Elsie Stines, RN, M.S., CPNP, a nurse practitioner, on an actual case with interprofessional dimensions. Students conduct thorough medical histories and physical exams, engage in dialog with patients and their families, and consult with one another to develop a plan of care. The presence of social work and law students makes the health professions students aware of social issues that may underlie a health complaint and of barriers to care that may impede effective treatment. Above all, students come to appreciate the value of treating the whole patient rather than simply focusing on the disease. Jay hopes that this exposure to team-based care delivery will prime students for practicing collaborative care once they are out in the field.

Of course, UMB is not alone in venturing beyond the health professions to enhance IPE and improve care delivery. The award-winning CARES2 program at the University at Buffalo School of Dental Medicine is one of several initiatives that incorporate social work students or professionals in dental school clinics to better resolve patient needs that can interfere with care. On other campuses, the more distantly related fields of architecture and engineering are also part of the IPE mix.

Larry Schnuck, AIA, is Vice President and Team Leader for medical education at design firm Kahler Slater, an ADEA corporate member known for its expertise in designing health professions schools. Larry tells me that IPE and collaborative care have been drivers in all the firm’s recent projects. (You can read about two of these in the March 2014 issue of Charting Progress.)

The firm recently designed new facilities for the University of Wisconsin-Madison School of Nursing. Among other features, the new space will support collaboration among experts from the schools of nursing, computer science, public health and engineering who are seeking environmentally based ways to improve human health. The building will contain the Center for Aging Research and Education (CARE), which will feature a full-scale and fully instrumented mock apartment to introduce students to the latest technologies that can improve the safety and efficiency of care delivery in the home.

Such exciting new learning environments not only promote collaboration, they also result from collaboration, a process that Kahler Slater routinely employs.

“Not unlike what we’re trying to do through our designs,” Larry told me, “we encourage collaboration here at the firm. It’s not one person, it’s a team that works together, along with the client and even some of their stakeholders in the community, to design these facilities.”

This summer, UMB announced that it had received funding for a new Interprofessional Education Center Facility that will likely be housed in a vacant building in its West Baltimore neighborhood. The facility will include simulated clinical space and become the new home of the President’s Clinic.

It’s clearly time for schools that want to grow their IPE programs to look beyond the health professions for partners that can help prepare students to address the social, cultural and environmental dimensions of health. Even though care occurs at the individual level, it’s critical to remember that other forces also influence our patients’ health and well-being. Getting the perspective of nonhealth professionals can remind us that addressing family dynamics, living environments and even public policy may be just as important for improving patients’ health as the clinical care we provide.

As IPE evolves to include a broader range of professions, it is also worth noting that this approach to professional development can benefit other professions. Faculty from the College of Social Sciences, Health, and Education at Xavier University, a Jesuit institution in Cincinnati, have been among the most active participants in the faculty development institutes run by the Interprofessional Education Collaborative. Health fields account for a minority of the college’s 11 undergraduate programs, but Doug Olberding, Ed.D., sees IPE as a “unifying bridge” that can help the disparate programs within his college develop a stronger identity within the university and a collective sense of purpose. Doug, who is Chair of the Department of Sports Studies, was charged with facilitating a year-long reimagining of the college in 2014.

“In academia, we’re so siloed. That’s the basic problem in health, but it’s an issue for any profession,” Doug believes. “When you can communicate outside your own discipline, you learn so much more.”

His colleagues agree. They have proposed a new name—the College of Professional Sciences—and a new college-wide focus: IPE.

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Dr. Richard ValachovicIn this month’s Charting Progress, Dr. Rick Valachovic describes the rise of salivary diagnostics and the field’s potential to enhance dentistry’s role in primary care.

Imagine a day when, during a routine dental recall examination, you undergo screening for a variety of oral and systemic diseases. Thanks to point-of-care technologies, before the end of your visit, your dentist shares the results. She is pleased to let you know that your A1C levels are under control and that you are at low risk for periodontitis, but the screening has also detected a biomarker for oral cancer. This is cause for concern, but because the disease has been caught early—before the onset of symptoms—your prognosis is excellent.

Such a scenario may not be far off. Researchers are discovering new biomarkers in saliva every year and clinical trials have already put a number of these to the test. Technological advances are rapidly bringing us closer to the day when screening in the dental office for systemic and oral diseases could become commonplace.

The future I’m describing reflects the promise of the maturing field of salivary diagnostics. Most of us naturally produce a liter of saliva each day, opening the door for clinicians and researchers to obtain a diverse array of biological information in a way that is painless, noninvasive and essentially risk-free. More importantly, the range of biomarkers found in this abundant fluid appears to be every bit as great, if not greater, than the range found in blood. Whether we want to diagnose a disease, engage in screening and early detection, or use saliva to monitor disease progression, patient compliance with treatment or treatment effectiveness, we can achieve these goals by harnessing the potential of saliva.

As early as the 1990s, researchers used saliva to measure cortisol, the hormone whose presence indicates stress. Today, saliva can be tested for many more microscopic components, including:

  • Bacteria, including those linked with cariogenic activity.
  • Metabolites, a diverse group of chemicals produced by the cells of living organisms.
  • Drugs, whether therapeutic or recreational.
  • Proteins, including those linked to periodontitis.
  • DNA and RNA linked to viruses, bacteria and cancers.

These and other biomarkers have been found for a number of systemic diseases, including HIV, hepatitis, diabetes, Alzheimer’s disease and several cancers.

We have the National Institutes of Health, and specifically the National Institute of Dental and Craniofacial Research (NIDCR), to thank in large part for supporting the researchers responsible for these discoveries. Beginning in 2002, the NIDCR started investing tens of millions of dollars to address two challenges: identifying the salivary proteome and developing new technologies that clinicians could employ to detect salivary biomarkers. This work included cataloging more than 1,100 of the proteins that make up the salivary proteome and identifying the gene transcripts, metabolites, microbes and micro-RNAs that are found in human saliva. In 2010, NIH funded two new studies aimed at identifying salivary biomarkers for early oral cancer detection and proteomic and genomic biomarkers for primary Sjogren’s Syndrome. Today, the NIH continues to fund multiple grants focused on salivary diagnostics.

Among the dental researchers who took part in the initial round of NIDCR research is David Wong, D.M.D., D.M.Sc., Associate Dean of Research at the University of California, Los Angeles (UCLA), School of Dentistry and Director of the UCLA Center for Oral/Head and Neck Oncology. David continues to operate a lab at UCLA that is actively engaged in this research. He and his colleagues have made significant contributions to cataloging the salivary proteome and developing diagnostic technologies. More recently, they have been working on detecting extracellular RNAs—genetic material released by cells and carried throughout the body in blood and saliva—to improve the diagnosis and treatment of a range of disorders.

“When the journey started,” David recalled when we spoke last month, “the scientific understanding was that whatever is in blood is also in saliva. Ten years later, we know that there is also a unique presence of bodily information in saliva that is nowhere else in the body. Our recent discovery that certain non-coding RNAs are uniquely present in saliva, but not in blood, echoes this revelation.”

Despite saliva’s rich diversity of biological information, biomarkers found in saliva exist at lower concentrations than they do in blood. This initially made it difficult to access the information, but the advent of miniaturization technologies and discoveries in other scientific fields have overcome this challenge. Today, a number of extremely sensitive salivary diagnostic tests produce rapid and highly accurate results, and the development of platforms that can screen for dozens of different biomarkers at once is now well underway. These platforms are being incorporated in portable point-of-care devices that could soon find homes well outside the confines of the lab—in community settings, remote areas such as battlefields, and, of course, in dental offices.

David’s latest work centers on the development of saliva- and blood-based liquid biopsies that could determine the genomic fingerprint of a cancer noninvasively. Current research shows that tumor cells shed their genetic information into our bodily fluids in the form of circulating DNA and RNA. The ability to easily tap that information could be tremendously useful in treating diseases that stem from cancer gene mutations.

“What we’re talking about is personalized medicine,” said Jed Jacobson, D.D.S., M.S., M.P.H., Chief Science Officer and Senior Vice President at Delta Dental of Michigan, Ohio, Indiana, and North Carolina. (You can find more on the potential of personalized medicine in my September 2014 Charting Progress).

I called Jed to ask why he has become a public booster of salivary diagnostics, and to get his take on the potential role salivary diagnostics can play in targeting health care dollars where they will have the greatest benefit. In 2013, Jed wrote an article in the Journal of the California Dental Association predicting that one day consumers could benefit from the presence of salivary diagnostics in every dental office in the United States.

When we spoke, Jed used the example of periodontal disease to convey the economic value of salivary diagnostics. “Salivary biomarkers move right into that space where we are looking at the genetic makeup of individuals to see if they are at a greater risk, and if they are, then we would deploy further preventive services in those individuals. Even though it would cost more, we would prevent the disease from happening in the first place, which in the long run is a cost savings.”

Delta Dental has been involved in research exploring salivary biomarkers in dental caries, periodontitis and oral cancer and in pilot projects evaluating the dental office as an opportunistic screening site for chronic medical conditions. He believes that if the use of salivary diagnostics for early screening became routine, the technology could position dental offices as a cornerstone of primary care. After all, 60% of the U.S. population visits the dentist annually, creating major opportunities for dentists to screen for a wide range of diseases. With nearly 90% of respondents to a 2010 national sample survey of U.S. general dentists indicating they would be willing to perform salivary diagnostics in their practices, it’s not hard to imagine the dental office being transformed into a one-stop diagnostic destination.

The utility of salivary diagnostics for a variety of applications seems assured, but their value may be most pronounced in two particular situations. In the first, genetic information allows clinicians to ascertain early the presence of a disease, when it is most amenable to treatment. Because oral cancers are hard to spot clinically in their early stages, diagnosing these diseases from saliva has been a major focus of academic research. Just last month, the Johns Hopkins University School of Medicine announced that its researchers had joined the ranks of those who have identified markers associated with oral and orapharyngeal cancer—in this case, tumor DNA—both in blood and saliva. The two media yielded different results, leading the researchers to conclude that “combining blood and saliva tests may offer the best chance” of finding cancer in the mouth and throat.

Secondly, the value of salivary diagnostics may also be enhanced when genetic information plays a major role in guiding treatment. David Wong gave me the example of EGFR gene mutations, which are associated with 60% of lung cancers in Asia. Drugs that target these mutations have been shown to prolong life up to two years, but determining whether a patient has the mutations currently requires a tumor biopsy, which may not be possible if the patient is frail or living in a remote area of the world.

David’s team studied saliva from 44 people in Taiwan who had been diagnosed with non-small cell lung carcinoma and had these gene mutations. “The concordance of saliva reflecting these mutations in the lungs was almost 100%,” David told me.

The researchers have since validated their findings in a second blinded study in mainland China funded by the National Cancer Institute. David believes the concept can be generalized to all human cancers with a genetic component. If so, salivary diagnostics could radically facilitate and transform clinicians’ ability to better target therapies for their patients.

We are still several years from that reality, despite the remarkable progress made in the last decade. A handful of tests for a very limited number of biomarkers are currently on the market, but none of these tests can be performed at the point-of-care, and researchers question whether they can be relied on to work as advertised.

Spencer Redding, D.D.S., M.Ed., is among those who have expressed concern about commercializing these technologies too soon. The Chair of the Department of Comprehensive Dentistry at the University of Texas Health Science Center at San Antonio School of Dentistry has been involved with salivary diagnostics and the development of point-of-care technologies on the patient recruitment side since 2007. He shares David Wong’s view that review by the U.S. Food and Drug Administration (FDA) is the best way to ensure that salivary diagnostic tests deliver on their promise, and he pointed out several additional hurdles that need to be overcome.

“In the traditional laboratory diagnosis arena,” he reminded me, “there are specific quality control measures employed. With point-of-care testing, you have to come up with another paradigm to make sure that testing is accurate.”

Despite his caution, I heard echoes of David’s and Jed’s enthusiasm when Spencer and I talked. He is following the work of Theranos, a disruptive upstart in the diagnostic market, which is using finger stick blood tests, transparent pricing and direct-to-consumer marketing to test for conditions—including a few cancers—before symptoms appear. As for so-called lab-on-a-chip point-of-care devices, Spencer is convinced that they will one day revolutionize how we diagnose disease. But, he adds, where this will occur and what medium will be used remain to be seen. Saliva, blood and even epithelial cells have all shown their merit. Cells gathered with brush biopsies are the current medium of choice in the research group—led by John McDevitt, Ph.D., Chair of Biomaterials and Biomimetics at New York University College of Dentistry—to which Spencer belongs.

“I think the big question for our profession is, are we going to be involved in this? I hope we are,” Spencer concluded.

I hope so, too, and I’m confident we will be. In just a few years, I expect to see courses on salivary diagnostics become a mainstay of the dental curriculum and to find our students learning to use devices the size of a smart phone to screen their patients for all manner of conditions and disease. The promise of point-of-care diagnostics and their potential to advance personalized medicine is undeniable, and there’s every reason to believe that saliva—and dentistry—will be part of the mix.

Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic shares the latest news on dental school application trends and other indicators confirming that the profession remains an attractive one.

Four years ago, I used June’s Charting Progress to discuss emerging concerns surrounding the use—and potential misuse—of cone-beam computed tomography (CBCT) in dentistry. As Bernard Friedland, B.Ch., M.Sc., J.D., a colleague of mine on the faculty at the Harvard School of Dental Medicine, pointed out at the time, CBCT technology had made its way into the hands of clinicians who had only a minimal understanding of how to select patients appropriately for CBCT imaging or lacked the knowledge to interpret CBCT images correctly. Those concerns still exist, but since that time, members of the diagnostic imaging community have stepped up to address them in meaningful ways. These dental educators are working to promote the safe and appropriate use of CBCT and to reduce the total amount of radiation exposure that patients—especially children—receive from radiographs of all types during dental care.

We can achieve these objectives by following the ALARA principle. The acronym stands for “as low as reasonably achievable” and represents the idea that exposure to ionizing radiation should not exceed the minimum amount needed to produce a diagnostically useful image.

Today, leading dental associations—ADEA included—are on record supporting the use of the ALARA principle to guide diagnostic imaging. Under the auspices of The Alliance for Radiation Safety in Pediatric Imaging, of which ADEA is a member, organizations have joined together to support the Image Gently® campaign. Launched last fall, the campaign is promoting an approach to diagnostic imaging that helps limit children’s exposure to ionizing radiation in dental settings.

The campaign’s Six-Step Plan recommends the following:

  1. Select radiographs based on each individual’s need.
  2. Use the fastest image receptor possible.
  3. Collimate the X-ray beam to expose only the area of interest.
  4. Always use thyroid collars.
  5. Childsize the exposure time.
  6. Use CBCT only when essential for diagnosis and treatment planning.

The alliance also wants to ensure that every member of the imaging team knows how to determine when imaging is appropriate and how to set the appropriate exposure when imaging children.

It’s hard to quantify the exact amount of exposure reduction that would accrue to a child if all of the protocols above were followed, but researchers estimate that exposure could be reduced by as much as 90%. Even if that number overshoots the mark, it is a stark reminder that when we fail to adhere to the ALARA principle, we are exposing children to far more radiation than is needed to diagnose and treat their conditions. This exposure occurs in part because not everyone appreciates that children are not simply small adults. Children are far more sensitive to ionizing radiation than adults are, and because their life expectancies surpass the 30- to 40-year latency period during which many cancers develop, children’s risk of dying from radiation-induced cancer is three to five times higher than that of adults.

X-ray examinations used in dental practice are the most common form of ionizing radiation exposure to the head and neck, giving our community unique opportunities to reduce the amount of radiation our youngest patients receive in this region of the body. So why do so many of us fall short of the ALARA ideal?

I asked Alan Lurie, D.D.S., Ph.D., a mentor of mine at the University of Connecticut School of Dental Medicine. His response: “The risk from radiation exposure in dentistry is very small, so it is very easily dismissed when you’re looking for disease that can injure a patient badly. You slowly start to forget about the risks of the technology because the benefits are right in front of you and the risks are based on evaluation of epidemiologic data. That’s a big separation for a clinician.” Alan and I published an article on the risks and benefits of X-ray exposure in pediatric dentistry many years ago.

Alan reminded me that the tools to limit exposure have been around for a long time. Rectangular collimation was available in the 1960s, and thyroid collars have been around even longer. By the late 1970s, F-speed film was being tested. From Alan’s perspective, it is simply inexcusable that the slower D-speed film is still being manufactured. “There is no reason to use D-speed film right now, absolutely zero,” he said. “There have been numerous tests, clinical and laboratory, of the ability to diagnose caries and periodontal disease and periapical lesions on F- versus D-speed film, and F is the equal or the superior to D in every test.”

The fact that some clinical licensure exams explicitly require that pre- and post-treatment images be obtained using D-speed film also perpetuates the use of this outdated modality. The requirement is a holdover from earlier days when this film speed was the standard. As Image Gently gains traction, and more people commit to following the ALARA principle, perhaps this requirement will finally be revised. That said, change occurs slowly. It is equally possible that the elimination of live-patient licensure exams, which has gained steam in recent years, will achieve the same end first.

“I think most dentists are trying to do the right thing, especially pediatric dentists who I’ve found to be the most patient-oriented,” Alan said, “but sometimes the risk-benefit balance gets lost in the hustle and bustle of taking care of lots of people every day.”

Christos Angelopoulos, D.D.S., M.S., agreed. Christos is President of the American Academy of Oral and Maxillofacial Radiology (AAOMR). The organization, which has published position papers on the use of CBCT in implants, endodontics and other specialties, is committed to alerting people throughout the profession about when it is—and is not—appropriate to use this powerful new imaging modality.

“CBCT is such a great tool that dentists may use it without asking, ‘Can I get the same diagnostic information using something else?’” Christos told me. While no one doubts the value of CBCT as a diagnostic tool for major skeletal anomalies such as cleft palate, facial trauma, and occlusal discrepancies, he says there is no evidence to support its routine use under other circumstances.

Several years back, AAOMR collaborated with the American Association of Endodontists (AAE) to produce a position paper that introduced guidelines for the use of CBCT by that specialty. Although following guidelines is voluntary, AAE has asked for an update, slated for release later this year. The request suggests that AAE members are finding the guidelines useful. In 2014, AAOMR issued a separate position paper on the use of CBCT in orthodontics, which affects large numbers of pediatric patients. That document commends the added value of CBCT in diagnosis, but recommends avoiding its use for routine orthodontic assessment, especially when alternate modalities are available. The paper also encourages dentists to use the ALARA principle to determine whether CBCT’s benefits exceed its risks.

When it comes to CBCT, implementing the ALARA principle is easier said than done—not because doing so is technically difficult, but because so few dentists in private practice have advanced training in oral and maxillofacial radiology. Dr. Friedland suspects that in many offices, CBCT units are used with the default settings, whether or not these are appropriate for the task at hand or the patient being imaged. This practice is especially problematic in multispecialty groups, where the defaults may be set for the types of images needing the highest resolution and widest field of view, needlessly exposing many patients, and possibly staff, to excess radiation.

We all get into routines, but when scientific evidence no longer supports our practices, it’s imperative that we consider other ways of doing things. Unfortunately, changing practice habits typically takes a full generation. Are there ways to pick up the pace? Perhaps, but not necessarily.

“States could make the Image Gently practices mandatory,” Bernard suggested. “Insurance companies could decide not to reimburse for radiographs taken without rectangular collimation. These things could be relatively easily solved in many countries, but the United States is resistant to regulation.”

Christos is optimistic that dental schools, at least, will provide fertile ground for the spread of the Image Gently approach. “Dental schools are open and familiar with the requirement of having evidence behind any decision that is being made,” he pointed out, “so these guidelines should be easier to apply in a dental school environment.”

Today, customary practices around diagnostic imaging vary considerably from school to school. The Commission on Dental Accreditation standards for both dentistry and dental hygiene require that schools have policies and procedures in place for the safe use of radiographic equipment. Determining what constitutes safe use is left to each program. At Harvard, Bernard has made it his mission to set clear parameters and make sure students understand them.

“Since we acquired CBCT 10 years ago,” Bernard told me, “I tell students, ‘You don’t want the best image. You want the worst image you can get away with.’“ In other words, once a scan is of high enough quality to enable a diagnosis, the additional information is of no value. Reminding everyone that clinicians are responsible for interpreting abnormal findings on the entire image—and liable if they do not—might also encourage more careful consideration of when to image and how to limit the field of view.

Bernard also teaches his students how to reset the machine for various types of scans, a process that typically takes just a few clicks of a mouse. If this type of education were more widely dispensed—to practicing clinicians as well as to future dentists and allied dental professionals—we would start to see the ALARA principle regularly put into action.

Today’s technologies allow us to produce diagnostic images of unprecedented clarity, but we must not let our capacity to create more detailed radiographs cloud our judgment about what’s best for our patients. To image responsibly, we must base our decisions on the available evidence and ask whether more detailed radiographs will have an impact on treatment outcomes.

Fortunately, several systematic reviews looking at the use of CBCT have appeared in the last year, giving members of our community access to new evidence on which to base their imaging practices. Additional information is available on the Image Gently website, and recent American Dental Association guidance can be found on the U.S. Food and Drug Administration website.

Looking to the future, promising imaging modalities are in development that do not use radiation, but these are far from ready for clinical application. For the present, radiographic imaging remains an essential tool in our diagnostic arsenal. Our best course of action is to focus on using current imaging modalities responsibly.

“We need to encourage people to do the right thing, to make radiographs when needed and not routinely,” Christos emphasized. “That will make a huge, huge difference.”

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic explains how ADEA has expanded the reach of its premier program for encouraging students to consider academic dental careers.

“In dental school, one of my professors pulled me aside one day after class and said, ‘Have you thought about teaching? You’re great with your hands, and you’re always helping people.’ I said, ‘Thanks so much,’ but I thought he was crazy.”

Yun Saksena, B.A.Sc., M.M.Sc., D.M.D., Associate Professor at Tufts University School of Dental Medicine, shared this anecdote with me when we spoke last month. Although I haven’t conducted a survey on the matter, I suspect her reaction would resonate with most students today. They see themselves headed in one direction—toward practice—and the idea of an academic dental career seems foreign at best. “People come in with blinders on, not realizing they have options,” Yun observes. “I’d like people to explore.”

Exploration is a big part of the ADEA Academic Dental Careers Fellowship Program (ADEA ADCFP), which has been encouraging dental and allied dental students and residents to consider academic careers by engaging them in research, teaching and one-on-one mentoring. The program, begun in 2006 with grant support from the ADA Foundation and initially cosponsored by the American Association for Dental Research and the ADEAGies Foundation, has provided over 100 students from 27 U.S. and Canadian institutions insight into academic or research careers.

That experience has been good for those individuals—and it would ultimately benefit the schools and programs where they may teach—but the program has done little to address an underlying culture that doesn’t support academic and research careers as much as it does clinical dentistry. That situation is about to change.

This year, ADEA relaunched the program with more ambitious goals. Anthony Palatta, D.D.S., Ed.D., who now serves as ADEA’s Senior Vice President for Institutional Capacity Building, led the redesign. I have heard Anthony call educators and researchers the “silent heroes” of our profession, the ones who make it possible for the vast majority of dentists to practice to the best of their abilities, so I wasn’t surprised by his eagerness to expand the reach of the ADEA ADCFP.

As we thought about the program, we considered several fundamental questions:

  • Rather than serving a few individual students each year, how do we increase the capacity of our academic dental institutions to engage and nurture future faculty?
  • What if we used the program’s resources and the wealth of experience among faculty members to create an environment in which any student with an interest in teaching or research would have access to information and support at his or her institution?
  • Could we create a critical mass of students on campus with an interest in academic careers?
  • Would their increased numbers elevate the value of teaching and research among their peers?

All good questions, which we are currently striving to answer. The literature confirms that the major reason students pursue academic careers is because a faculty member takes an interest in them. For this reason, the program has been transformed into a professional development initiative that equips faculty with resources they can use to help create a community of future academics and researchers at participating institutions.

At the ADEA Annual Session & Exhibition in March, the ADEA ADCFP held a two-day training for this year’s faculty mentors. Some were new to the program; others have been involved for years. They exchanged ideas about how they might structure the ADEA ADCFP programming at their institutions, learned about mentoring best practices and received guidance on recruiting students and other faculty mentors.

The new program—launched this month—retains many of the elements that distinguished the former version. The hope is that innovative ways of mentoring will emerge from each institution. In addition to regular contact with a faculty mentor, students take part in both a research and a teaching practicum. They conduct interviews with faculty and administrators who are at various points in their academic careers. The students, who have access to several webinars on teaching and research, also keep a monthly journal, write reflective essays about their experiences and maintain an ADEA ADCFP portfolio.

Former program guidelines required students and their mentors to attend the ADEA Annual Session & Exhibition, making sponsorship of more than one student–mentor pair cost-prohibitive for some schools. The new guidelines encourage students to create posters and present their research at the meeting, but since attendance (and therefore travel) is no longer required, more students can participate in the program.

The ADEA ADCFP was initially conceived during a time of concern about a faculty shortage. A shortfall still exists, but it is not as acute as it was a decade ago. The new program focuses on academic development and promotes the rewards that come with teaching and research. Even without as much pressure to fill faculty vacancies, it’s still important to combat the widely held notion that the academy is mainly a place to spend one’s end-of-career years.

“Typically, students don’t want to come back to teach immediately,” says Michelle Wheater, Ph.D., Associate Professor and Director of Research and Student Academic Leadership Development at the University of Detroit Mercy School of Dentistry (UDM SOD), “but we’re shifting to a culture where academia is considered a viable career option.”

Michelle is one of those educators who jumped at the opportunity to bring the ADEA ADCFP to her dental school. She and her colleague, Kathi Shepherd, RDH, M.S., Associate Professor and Director of Educational Development and Outcomes Assessment, had already worked on the development of a program at UDM SOD, entitled Explorations in Dentistry, to encourage students to pursue teaching careers, but Michelle appreciated the additional dimensions the ADEA ADCFP had to offer. Her students find the faculty interviews especially enlightening.

“I think it was an eye opener for a lot of students to see what faculty did on a daily basis,” she told me. Thanks to the Explorations program, which serves as UDM SOD’s teaching component within the ADEA ADCFP, students get to experience the faculty role as well. Dental and dental hygiene students learn how to prepare a course of six modules, which they then present to undergraduates who are interested in attending dental school. “It gives them a view of what goes on behind the scenes: preparing lectures, understanding new material, deciding the best way to teach this material, or determining how to assess the material appropriately.”

When it comes to the low number of graduates who choose to pursue academic careers directly out of the gate, Michelle is pragmatic. She points out that most graduates carry a lot of educational debt, and they know that practice is likely to be more lucrative, but perhaps not meet the needs of those who aspire to a career in academics. “Now if I could come up with something like a tuition reimbursement program for future faculty…” she muses.

Yun Saksena’s initial reluctance to pursue an academic career had less to do with money (although she acknowledges that salary is an important factor to consider) and more to do with questions of identity.

“I thought, most of these professors are old white guys. Why would I want to be like them?” she told me. Today her perspective is 180 degrees away from her initial assessment. While a teaching assistant at Tufts, she discovered that she loved teaching—so much so that she stayed on part time after graduating and moving into practice. Today she is full time on the Tufts faculty and actively engaged at her institution and through ADEA in promoting mentoring, academic careers and the ADEA ADCFP. She wishes she had realized sooner in her career how fulfilling she would find her current career in teaching and research. She’s also eager to see the Tufts version of the ADEA ADCFP evolve over time—maybe into a formal honors track for dental students with academic ambitions.

“I like academia much better than private practice and find it more fulfilling,” she says. “I feel I’m doing more. When you’re teaching, you’re affecting so many more people, and some of the people I’ve taught are faculty now.”

Visit ADEA’s website for more information on the ADEA Academic Dental Careers Fellowship Program.


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