Dr. Richard ValachovicIn this month’s Charting Progress, Dr. Rick Valachovic takes a second look at a disruptive force in the dental marketplace and asks what it means for dental schools and programs as they prepare students for practice.

Are we doing enough to prepare students for the shifts occurring in the business of dentistry? Should we be doing more to help our students evaluate their opportunities both as employees and as entrepreneurs?
A lot has happened since I asked those questions in 2014 as part of a column titled “From Bungalow to Big Box? How DSOs Could Change the Face of Dentistry”. At the time, there was even some lingering disagreement about what term to use to describe dental support organizations (DSOs)—businesses that offer a range of nonclinical support services to affiliated dental practices.

DSOs vary, but affiliates are typically group dental practices that have outsourced their marketing, billing and IT functions to the DSO and adopted its corporate branding. From a consumer perspective, these practices appear to be part of a chain, and they are sometimes called “corporate practices” to distinguish them from the solo and small group practices that have long dominated dentistry.

Today, the term DSO is well established, and these once marginal players have gained a strong foothold in the marketplace for dental services. In an age of increasing consolidation among health care delivery entities, this shouldn’t be surprising. Nevertheless, the rise of DSOs represents a remarkable cultural shift.

Why is the appeal of these entities growing? Simply put, they fill a need by addressing a number of the stressors faced by today’s dental practices. Whether a practice struggles to market its services online and through social media; decipher ever-changing insurance contracts; maintain an electronic health record; or finance the acquisition, installation and maintenance of sophisticated digital equipment, DSOs offer a range of services that free up affiliated dentists to focus almost exclusively on the clinical aspects of their profession.

This proposition has proven especially attractive to millennials. By 2015, nearly 12% of dental school graduates entering private practice were choosing to work for corporate practices affiliated with DSOs. This year’s ADEA Survey of Dental School Seniors showed that 16% were making this career choice. Some older dentists have also jumped on board, eager to avail themselves of the ready-made solutions that DSOs offer to the increasingly complex challenges of running a mature practice.

“The days of just sending out a postcard or putting a sign out on the street are over,” says Michael Bileca, President of the Association of Dental Support Organizations. “Patients are ultimately in charge of their choices, and there’s a plethora of information in front of them to make that choice.”

According to Michael, DSOs have evolved to help practices adapt to the new health care landscape by developing different competencies for different affiliates. Some DSOs have strong marketing and branding capabilities and primarily build practices from scratch. Other DSOs focus on technology or on a dental specialty, such as prosthodontics. In recent years, he estimates, DSOs have experienced double-digit growth—in the number of practices supported, the number of dentists supported, and the number of patients seen in DSO-affiliated practices. “Year in, year out, I’ve seen continued growth in the ability and competency of the DSOs to create more value for their supported practices and dentists,” Michael said.

There’s no question that DSOs have a lot to offer, but for those of us educated in an era when independent, solo practice was the norm, practicing dentistry in a corporate environment requires a cultural shift not all of us are ready to embrace. That’s partially due to the unfortunate checkered history of a few corporate practices, a history that has fueled skepticism about the quality of care provided by all such practices.

“From what we hear, in a DSO there is pressure to produce from the start and not necessarily the mentorship where the doctor/owner has a vested interest in seeing that treatment is done properly,” says Gary Badger, D.D.S., M.S., who recently retired as Professor, Chair and Program Director of the Department of Pediatric Dentistry at the University of Texas School of Dentistry at Houston. He is especially concerned that new dentists who work in corporate practices will be less inclined to take the time they need to seek advice when they are unsure about a procedure. “They get the message that if they don’t produce, they are not needed,” he says.

Gary fears these expectations can create an ethical quandary for inexperienced dentists, especially those who graduate with high amounts of debt. In Gary’s view, “It boils down to ethics, critical thinking and how students will perform under pressure.”

Michael agrees that the transition to practice is challenging for new dentists—in any environment—but he disputes the idea that DSOs are responsible for poor clinical decision-making by employed dentists. “Clinical decision-making is the responsibility of the practice owners,” he says, whereas the DSO is responsible for the business support services. “The more we can support the business of dentistry in the areas of marketing, IT, insurance contracting and the like, the more it leaves the supported practices able to focus on clinical care, and that in and of itself is a tremendous value.”

Gary acknowledges that all corporate practices are not alike. He thinks students can—and should—vet all potential employers as they make their post-graduation plans. He wants students to find out about an organization’s reputation before signing on and scrutinize contracts to make sure they leave room for decision-making based on ethical principles rather than financial goals.

Helping students formulate appropriate questions for future employers is one recommendation that Gary and his co-authors put forth in a 2015 paper in the Journal of Dental Education. They urged dental schools to enhance their practice management curricula in four ways:

  1. Explain shifts that occur in the business of dental practice.
  2. Provide a clear understanding of the legal structure of the corporate practice of dentistry and the dentist’s rights and responsibilities in this practice model and others.
  3. Review time allotted in the dental curriculum for inquiry into the corporate dentistry practice model, and assist students in developing the appropriate questions to make an educated decision regarding this and other practice options.
  4. Develop interactive and engaging experiences that give students the opportunity to explore various types of practice models that include interprofessional experiences.

I agree it is incumbent on us to educate students to make informed decisions about their employment options after graduating and to better prepare them for the transition to practice. On the most fundamental level, our graduates need to understand that, as Gary and his co-authors put it, “[T]here are no circumstances…that absolve dentists from responsibility for the treatment of their patients.” That may be harder to appreciate in a corporate environment than in a small private practice setting—or not.

Many DSOs offer mentoring and formal continuing education (CE) programs structured to help recent graduates transition to practice. Heartland Dental, the largest DSO in the United States, invests heavily in professional development, offering 200 hours of supported CE courses to its dentists each year. Patrick Ferrillo, Jr., D.D.S., a past president of ADEA who served as dean of three dental schools and, until recently, sat on the Heartland board of directors, told me that Heartland even incentivizes CE with significant financial bonuses, some of which are large enough to pay off a dentist’s student loans. That financial benefit aside, he says the reason DSOs sponsor professional development programs is to cultivate better dentists. “If you are better educated, better prepared, your practice is only going to flourish,” he says.

Pat joined the Heartland board at the request of a former student at the Southern Illinois University School of Dental Medicine: Heartland founder Rick Workman, D.D.S. At the time, Pat recalls, DSOs were highly controversial. Although he had moved to the University of Nevada, Las Vegas, by then, Pat knew his former colleagues in Illinois didn’t like the idea of a large corporate practice competing with their alumni for patients. Nevertheless, he was curious. “I saw this as a new opportunity for our graduates to consider, and I knew Rick was very conscientious, that he cared about the quality of care, so I decided to be engaged,” Pat told me.

After 12 years serving on Heartland’s board, Pat has concluded that the overall concept of DSOs is positive, and that there’s a reason they are experiencing such rapid growth. “It’s an attractive alternative for graduates coming out of dental schools and for those who are thinking of slowing down, so to speak, and want to sell their practices,” he told me. Part of that attraction is that DSOs allow dentists to practice dentistry and enjoy a better work/life balance than those who own their own practices.

In Pat’s observation, dentists at Heartland were happy, especially the younger practitioners. He characterized their perspective as “‘I want to work, I want to have a good life, I want to have a great income and I’ve got to pay off my student debt.’ They seem to be very content with that.”

So how would he like to see dental education evolve to better prepare students for the changing practice environment? Pat would like faculty who are sending a message to students not to consider DSOs to keep an open mind and let students decide what is right for them.

I agree. One size does not fit all, and now that DSOs are part of the mainstream, we should do more to help students explore all of their career options. As Gary stated, that means helping our graduates to ask the right questions.

Pat recommends these two:

  • Will the DSO I join support me in my personal career development?
  • As a dentist, will I drive the decision-making when it comes to patient care?

If the answers to both questions are yes, then DSOs appear to be a career option well worth considering.

Dr. Richard ValachovicIn this month’s Charting Progress, Dr. Rick Valachovic urges caution in adopting workforce models and projections that predict a massive oversupply of dentists in 2040, citing the risk and impact of doing so.

Earlier this summer, I was invited to take part in a webinar on the dental workforce hosted by the American Dental Association (ADA). The occasion was the release of a new ADA Health Policy Institute (HPI) brief that presents HPI’s latest estimates of the future supply of U.S. dentists. The study—conducted with the scientific rigor we’ve come to expect from HPI Chief Economist and Vice President Marko Vujicic, Ph.D., and his team—makes an important contribution to the debate about how we, as a dental community, can sustain the dental profession and deliver care to everyone who needs it.

The event provided an opportunity to discuss concerns raised by some in our community about the number of dentists needed for the future. On the one hand, federal workforce projections as late as 2015 concluded that increases in supply would not meet the national demand for dentists in 2025, exacerbating an existing shortage. This assessment, combined with projections about future demand for care, was a factor in the opening of 13 new dental schools and the expansion of many others that we’ve witnessed since 1997.

On the other hand, two of our colleagues in dental education, Howard Bailit, D.M.D., Ph.D., and Stephen “Steve” Ekland, Dr.P.H., D.D.S., M.H.S.A., have predicted a dentist surplus of between 32% and 110% by the year 2040. Writing in the Journal of Dental Education, the authors cite several factors that suggest a decline in demand for dental services and a major increase in the number of people each dentist will be able to serve. While acknowledging the uncertainties in their assumptions, the authors conclude, “[A] large and growing surplus of dentists in 2040 is expected.”

So how do we reconcile these opposing views on the size of the future dental workforce capable of meeting anticipated future demand for care? The authors of the landmark 1995 Institute of Medicine (IOM) report, Dental Education at the Crossroads: Challenges and Change, offered an alternative perspective.

“After reviewing workforce models and projections and their underlying assumptions,” the committee stated, it found “no compelling case that the overall production of dentists will prove too high or too low to meet public demand for oral health services. Accordingly, it found no responsible basis for recommending that the total dental school enrollment should be pushed higher or lower.”

In my view, this assessment is still relevant today and speaks to an essential truth, perhaps best expressed by the inimitable Yogi Berra: “It’s tough to make predictions, especially about the future.”

Yogi was right. Predicting the future is difficult, and we do so at our peril. We don’t know the social, political, technological and other changes that might occur in the near- and long-term future, so any predictions we make are based on uncertain assumptions. Think of the changes that have occurred since 1990—in information technology, genetic engineering and international affairs, to name just a few domains. I chose 1990 because that date was 28 years ago—the same number of years between 2018 and 2040.

What particularly concerns me is the suggestion Howard and Steve make that dental schools should reduce the number of dentists they graduate rather than wait for market forces to reduce the dentist supply. “With a current graduating class of about 6,000 (and growing),” they write, “there is already a substantial surplus of dentists, and this surplus would continue for years to come. Importantly, the longer the current number of graduates continue (or grow), the smaller future classes would have to be to correct the imbalance.”

This statement, like opposing views based on predictions of a dentist shortage, assumes that there is a “guiding hand” able to control with precision the number of dental schools and their class sizes. That may have existed in the health and education ministries in Moscow during the Soviet era, but no government agency or organization has that sweeping influence in the United States. It is a mistake to think that any forces other than market forces can impact these numbers.

Nevertheless, despite the perils of prediction, university presidents and governing boards must make choices about the opening or closing of dental schools, their class sizes and a host of other matters. It seems prudent to me to base those decisions on what we know today about the current state of oral health and the provision of dental services. According to data from the Centers for Disease Control and Prevention, nearly half of all American adults who have teeth have periodontal disease, and nearly half of children under age 19 have experienced dental caries. These numbers are even higher in low-income and minority communities. We could alleviate some of this disease with universal community water fluoridation, but only about 70% of Americans benefit from fluoridated public drinking supplies, and each year some communities vote to remove fluoride from their water. Against this context, for the foreseeable future, we anticipate an ongoing need for dental care.

Public sentiment appears to be bullish on the dental profession. In 2018, U.S. News & World Report placed dentistry number two in its 100 Best Jobs ranking, and number one in its ranking of health care jobs. Our application services data reflect this strong interest in the profession. ADEA currently processes 20 applications for each first-year dental student slot, an impressive ratio that has held consistent for the past six years. We now graduate almost 6,000 dentists annually to serve a U.S. population of 327 million. Contrast that with the mid-1970s, when 6,300 dental graduates went on to serve a U.S. population tallied in 1980 at 226 million. Not surprisingly, no U.S.-licensed dentist who wants to practice his or her profession lacks employment opportunities.

Those who predict doom and gloom for the future of dental education often cite the level of graduating dental student debt as a harbinger of a change in dental education’s fortunes and dentistry’s attractiveness as a career, but we know that there is another story. Dentists have among the lowest default rates on their student loans, and the majority pay off their loans in seven years.

Economic forecasting is an imprecise science at its best. At its worst, it can lead us to set policies that are not in our community’s best interest. Over the decades, we have seen pendulum swings with the opening and closing of dental schools and increases and decreases in the number of dental school graduates. I do not see any evidence that we should try to force the pendulum to one side or the other.

So how do we move forward? The 1995 IOM committee’s conclusion that there is “no responsible basis for recommending that the total dental school enrollment should be pushed higher or lower” strikes me as a solid point of departure. To send a different message to the the university presidents and governing boards of the 66 U.S. dental schools is misguided, in my view. Such a message is also unfair to those current and future applicants to dental school who aspire to a career in dentistry.

As we consider dental school enrollments moving forward, let’s keep the perils of prediction in mind. A world with less dental disease and a need for fewer dentists is well worth aspiring to, but it is far from clear that such a reality is at hand. Intervening to reduce the number of future dental school graduates could harm the millions of Americans with dental disease by impeding the care future graduates could provide. Are we willing to take that risk?

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic looks at how an international treaty on mercury is prompting a shift in the treatment of dental caries.

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Closer to a Crossroads

With everything going on in the world, a recent move by the European Parliament may have escaped your notice. On July 1, Europe’s latest regulation on mercury went into effect, limiting the use of dental amalgam in questionable ways.

While the move was applauded by some, it was not without controversy (I’ll get to that in a moment). Nevertheless, the rule marks an important milestone in Europe’s compliance with the Minamata Convention, an international treaty negotiated by the United Nations Environment Programme for the purpose of reducing mercury pollution from a wide range of sources, including dental amalgam.

Dental amalgam was one of the products initially slated to be banned under the 2013 agreement, which went into force a year ago. Thanks to a unified effort by the international dental community to make delegates aware of the safety and value of the material, the final document called for a phase down in its use rather than a ban.

In some countries, that phase down is progressing rapidly, in large part due to consumer preferences for alternative materials. At least one nation, Norway, has phased out amalgam use entirely. A few other nations are not far behind, and many others are well on their way to meeting the treaty’s requirements on dental amalgam. According to Benoit Soucy, D.M.D., M.Sc., Director of Clinical and Scientific Affairs at the Canadian Dental Association, Canada was already in compliance with the Minamata Convention even before the country became a signatory. As for the United States, the Environmental Protection Agency issued a final rule on the handling of dental amalgam last summer, with all U.S. dental practices required to achieve compliance by July 2020.

In light of these developments, it’s not surprising that back in 2013, I said I could “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.”

I recently asked Christopher Fox, D.M.D., D.M.Sc., Chief Executive Officer at the American and International Associations for Dental Research, if he shares that view. He does, and he takes it a step further. “If we ramp up preventive approaches, we will reduce the need, not just for amalgam, but for any restorative material,” he recently told me.

A May 2018 editorial in the Bulletin of the World Health Organization echoes that view.

We are in a period of transition from a conventional model of restorative dentistry, one largely based on the use of dental amalgam, to an oral health model oriented towards health promotion and integrated disease prevention. The phase down of the use of dental amalgam can become a catalyst to renew and revitalize dentistry and tackle the health, social and economic burden of oral disease by prioritizing oral health as part of the global health agenda.

Margherita Fontana, D.D.S., Ph.D., Professor at the University of Michigan School of Dentistry, spoke with me about Caries Management by Risk Assessment (CAMBRA) in 2013. She and others within the ADEA Section on Cariology have since devised a U.S. Cariology Curriculum Framework that outlines the many options now available for preventive and nonsurgical therapies and emphasizes the need for evidence-based clinical decision-making when treating individuals.
Newer approaches—sealants, varnishes, gels, silver diamine fluoride, high-fluoride toothpastes, glass ionomer fillings and nutritional counseling—give us a range of tools for restoring and maintaining healthy teeth. Of course, it takes time to disseminate new practices widely, and it can be difficult absent corresponding policy change around reimbursement and the like. Nevertheless, we can start by educating our students and current practitioners about the full extent of what’s in today’s dental treatment toolbox.

In October, the American Dental Association (ADA) will be issuing guidelines on nonrestorative approaches to treating caries. These guidelines, along with forthcoming ones on prevention and on the surgical treatment of caries, will provide us with a valuable resource—one that can also contribute to phasing down the use of amalgam.

Last month, I spoke with Marcelo W. B. Araujo, D.D.S., M.S., Ph.D., Vice President of the ADA Science Institute, a project of the ADA Council on Scientific Affairs. Marcelo is eager to see dentistry move in a more preventive direction and is hoping the ADA clinical practice guidelines will contribute to the profession’s progress. The guidelines cover the full gamut of available tools, including advocacy for public health initiatives such as community water fluoridation as a means of preventing caries.

“We need to change the mindset of the professional to see that prevention is also part of practicing dentistry,” Marcelo emphasized. “I’m hoping our clinical practice guidelines will help change that mindset.”

Marcelo is not alone. A growing community of dentists is looking for innovative and more effective ways to prevent and manage caries. Last year, they met in California at the International Conference on Novel AntiCaries and Remineralizing Agents 3 (ICNARA 3). (You can learn more about their proceedings in Advances in Dental Research, an e-supplement to the Journal of Dental Research. For those who are interested in learning more about one of these agents, silver diamine fluoride, Oral Health America is hosting a webinar on the topic later this month.)

Given these developments, is dentistry at a crossroads where the amalgam “pathway” is no longer needed to ensure that everyone can achieve good oral health? Within the research and academic communities at least, there seems to be a consensus that complete caries removal is no longer an evidence-based treatment. Instead, the goal of dental treatment has shifted to preserving the natural tooth structure and remineralizing teeth whenever possible, and some minimally invasive techniques for managing dental caries are gaining ground. Nevertheless, the absence of safe and reliable amalgam replacement materials that work under similar conditions at a similar price remains a barrier to a phase down in less-resourced settings with high levels of dental disease.

In recognition of this need, some manufacturers have been investing in new dental materials, and so has the U.S. government. The National Institute of Dental and Craniofacial Research awarded $2.8 million for six research grants aimed at developing a long-lasting composite polymer capable of replacing current restorative materials and outlasting current commercial materials by at least a factor of two. Those grants end this summer, so it shouldn’t be long before we learn what progress researchers have made toward achieving those goals.

That’s a long way of saying we’re not at a crossroads yet, but advances in materials science, the availability of alternative treatments and renewed emphasis on prevention are certainly bringing us closer. Political pressures are also accelerating the march toward a future where disease prevention and tooth preservation should make the need for restoration less common, which brings me back to the European regulation that just went into effect. Although it allows for exceptions, the rule effectively prohibits the use of dental amalgam in deciduous teeth, in children under age 15 and in pregnant and nursing women.

Why restrict the use of amalgam in these populations?

“The Europeans have made a political recommendation, not an evidence-based recommendation,” Marcelo points out. Indeed, the final rule reflects the political clout of those who oppose the use of amalgam based on spurious claims related to its impact on human health, rather than on any change in the scientific consensus. The ADA still considers amalgam a safe dental material with wide applicability, Marcelo says, especially where low-cost treatments are needed, and will continue to support amalgam’s use in any person needing dental care.

“Everyone agrees that we want to get mercury out of the environment,” Chris Fox adds, “but we don’t want to get rid of dental amalgam as a choice for professionals and patients based on erroneous information about its direct health effects. Dental amalgam is safe for human health.”

In fact, Chris is concerned that the same level of scrutiny amalgam has received may not be applied to newer restorative materials. When we spoke, he emphasized the need to ensure that any replacement product has a strong safety profile.

“We can’t forget that there are other health hazards out there. Everything is on a continuum of risk, and we need to balance all those in terms of both human health and the environment,” he emphasized.

It may take some time to find that balance, but there’s no question that we have the scientific and public health know-how to reach the prevention-oriented future we envision. Amalgam restorations may be with us for some time to come, but I believe we are well on our way toward a more conservation-oriented dental practice that preserves both the environment and our teeth.

Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic considers the evolution of ADEA’s centralized application service and where the application process stands today.

In 1972, I applied to dental school. I was one of many young people whose interest in pursuing a dental career created an unprecedented surge in the number of dental school applicants—from about 9,000 at the start of the decade to a peak of almost 16,000 in 1975, before falling back to roughly 10,000 by 1980.

In 1979, 6,301 students enrolled in dental school, the highest number on record. Today, about 12,000 individuals apply to dental school each year, and with the addition of 10 new schools and the expansion of class sizes over the last 20 years, institutional enrollments have increased about 50%. With 6,122 first-time, first-year enrollees in 2017, enrollments may soon exceed their historical peak.

1972 was also the year that ADEA, then the American Association of Dental Schools (AADS), launched its centralized application service for predoctoral programs—AADSAS®—freeing participating schools from much of the up-front work that goes into the admissions process. Centralizing the application process was a bold step, and we can be proud that dentistry was one of the first health professions to take it. Applications were printed on paper, filled out by hand and mailed to AADSAS. The service photocopied the forms and distributed them to dental schools. That process was in still in effect when I arrived at ADEA in 1997, and I knew it was time for a change.

Later in 1997, we engaged George Haddad of Liaison International, a Boston-based tech firm that is now a leader in online application services. Outsourcing some of the more cumbersome tasks streamlined operations at ADEA, but George and his team had their work cut out for them. “At first, we continued to print the applications and send them to schools every week,” George recalls. “We had stacks of paper applications.”

In the early years, we used a hybrid process that integrated floppy disks (remember those?). Applicants filled out their applications on paper and ADEA sent the information to a data entry firm to transcribe. Meanwhile, ADEA staff collected transcripts and verified coursework and credits. Because schools still wanted to read the applications on paper, Liaison International was printing and mailing reams of paper as late as the 2010–2011 application cycle.

It quickly became apparent that moving AADSAS to the web was the right solution. To accomplish this, Liaison International developed a secure platform that ultimately allowed us to move the entire application process online and into the 21st century. ADEA was the first health professions association to launch a web-based application service, a pioneering move that other associations have since emulated.

Since 2012, the pace of progress has been dizzying. Applicants submit all information online, including letters of recommendation. DAT scores are automatically reported to the service. Paper has been entirely eliminated from the process—schools now log in to the service to access applications electronically. In 2013, ADEA reached another milestone: becoming the first health professions association to boast that all of its U.S. schools participated in its predoctoral application service. Over the years, we introduced three more application services: ADEA PASS®, for advanced education programs; ADEA CAAPID®, for programs designed for dentists with degrees earned outside the United States or Canada; and ADEA DHCAS®, for dental hygiene programs.

When I spoke recently with George, he confirmed that ADEA was among the first health professions organizations to outsource the management and operations of the application process and the technology needed to run the service. Turning this function over to his firm has reduced our Association’s costs by saving space and eliminating the need to hire and train seasonal staff. Meanwhile, the most important outcome of this transformative change is that we’ve improved the experience for applicants. Applicants now have a “one-stop shop” where they can access information and complete the entire application process.

The application’s content has also been modernized. We changed how we ask about race and ethnicity, introduced socioeconomic-status variables and provided schools the opportunity to ask questions that are not part of the standard application. We’ve also encouraged the use of new interviewing techniques, such as the multiple mini interviews, which allow schools to evaluate skills such as critical thinking, ethical decision-making and effective communication.

All of this provides ample evidence that ADEA’s application services are up-to-date and have kept pace with today’s ever-changing times. In fact, we’ve been ahead of the curve, leading the way for many of our sister associations. But putting aside whatever pride we may feel in these accomplishments, it’s fair to ask, “Why does this matter? How does it advance our mission?”

I think George sums it up well when he says, “Centralized application services allow associations to market their professions as a whole, so recruitment happens on a national level, eliminating redundancy while preserving the uniqueness of each school’s admissions process. The platform gets all the schools around the table. They share best practices and create requirements for the profession.”

I couldn’t agree more, and the results are evident in the changes we’re seeing in admissions practices and the applicant pool. The widespread adoption of holistic admissions, particularly by dental schools, allows applicants to “tell their stories” and articulate why they have what it takes to be a caring, competent health care professional. While admission to dental school remains extremely competitive, we are seeing a wider range of grade point averages and DAT scores, suggesting that schools are more willing to consider a broader range of attributes when evaluating applicants.

One of the most interesting trends has been the rise in the number of re-applicants, those who apply to dental school for a second or third time. These individuals typically work hard to gain additional education and experience to achieve their goals. They now represent one-third of our applicant pool, demonstrating just how attractive a dental career remains.

The increased presence of women in our incoming classes is another striking example of how things have changed since I applied to dental school. In 1972, women accounted for 14% of the applicant pool. Mirroring other economic and social trends during this period, women now account for 51% of dental school applicants.

ADEA has also invested considerable effort in attracting underrepresented students to the profession. One important ADEA priority is the Summer Health Professions Education Program, an academic enrichment program for educationally and socioeconomically disadvantaged students seeking to enter dentistry or another health profession. In addition, to promote diversity and ensure that all students have the opportunity to present a complete picture of their qualifications during the admissions process, we are working across our membership to help train faculty and staff in the use of holistic review, consistent with federal case law. Most recently, we established an ADEA Centralized Application Service Working Group to analyze trends and give us a better sense of our applicants and enrollees. We still have a long way to go in creating a dental workforce that truly reflects our nation’s diversity, but I am optimistic that our investments will pay off.

This year, we introduced a “soft launch” of the application, which allowed applicants to prepare their applications three weeks before the site opened for submissions. More than half of anticipated applicants took advantage of this head start, and George was not surprised in the least that this student population is first out of the gate. “Dental students are among the first to apply,” he told me. “They are very diligent.”

So, what’s next? I don’t have any pronouncements to make, but rest assured, as technology advances and social norms and expectations shift, ADEA will continue to embrace change. Our operational goal is to always be able to say, “We are actively simplifying the process of applying to dental school,” with all signs appearing to indicate that our motivated pool of applicants will continue to “seize the moment.”


Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic asks tobacco-cessation educators how their work has changed with the advent of vaping and some states’ legalization of recreational marijuana use.

You may recall the title of my May letter, “A Matter of Life and Death.” I could easily have used the same title this month, but whereas deaths from pediatric sedation (last month’s topic) are extremely rare and occur in a matter of minutes, deaths related to tobacco use remain all too common and occur over the course of decades. Will the availability of new, smokeless nicotine delivery systems reduce smoking-related deaths or introduce a new generation to the tobacco habit? Will the legalization of marijuana in more and more states introduce a new contaminant to people’s mouths and lungs or simply decriminalize a hidden behavior?

The research into these questions is incomplete and contradictory, but we have several reasons to be concerned about new practices that complicate the effort to reduce tobacco use. Smoking marijuana poses similar risks to smoking tobacco and may be responsible for some additional oral health effects. As an ADA topic page points out, THC, an appetite stimulant, encourages snacking, which may explain why using marijuana is associated with higher numbers of caries.

Vaping, which delivers nicotine without the smoke, has been heralded by some as a welcome alternative to tobacco use. In fact, the United Kingdom embraces the practice in its effort to help smokers quit.

“It’s part of the National Health Service’s treatment plan for those who want to quit to incorporate e-cigarettes and vaping,” says self-described tobacco nerd Joan Davis, RDH, Ph.D., Director of Research, Special Projects & Initiatives at the A.T. Still University Missouri School of Dentistry & Oral Health. “On the other hand, the CDC is 110% against it.”

Why are scientists at the Centers for Disease Control and Prevention concerned? You can get the full CDC assessment of e-cigarettes on the agency’s website and a summary of the evidence on the public health consequences of using them in a 2018 report from the National Academy of Sciences, Engineering, and Medicine. In a nutshell, while e-cigarette vapor typically contains fewer toxins than tobacco smoke, it is far from harmless.

  • The primary ingredient, nicotine, is highly addictive and affects the developing brain.
  • Vaping liquids contain flavorings and other chemical additives, some of which are linked to cancer and other serious diseases.
  • The process of converting liquids into an inhalable vapor involves heat, which can damage cells in the mouth, potentially increasing the risk of such oral conditions as infection, inflammation and gum disease.
  • Perhaps of most concern is the popularity of vaping among young people, leading many observers to fear that the practice may induce users to start smoking and expose them to all its attendant harms. (A recent issue of The New Yorker offers a vivid portrait of the phenomenon in affluent high schools.)

As we consider these risks, our experience with tobacco may be instructive. It took decades of concerted effort with substantial government support to bring smoking rates down to the current level, roughly 15% in the United States and Canada. Nevertheless, one in five deaths is still linked to tobacco use, a habit that also contributes to tooth loss, periodontal disease and oral cancer among the living.

“Somehow this problem has not gone away,” Joan points out, “and the most addicted populations are those who are poor, have limited education or are mentally ill.”

CDC statistics corroborate this statement. Almost a third of adults with less than a high school degree smoke cigarettes, as compared with 10.4% of college-educated adults. This disparity explains why many highly educated people think smoking is no longer an issue, despite the fact that 480,000 people die from it each year.

The good news is that smoking-cessation interventions work, and dental professionals are well positioned to deliver them effectively. A 2012 Cochrane review of 14 studies found that interventions conducted by oral health professionals roughly doubled the rate of tobacco abstinence at six months or longer. Unfortunately, the treatment of tobacco dependence continues to be inconsistent in many dental practices, suggesting a growing role for dental and other health professionals who are ready and willing to talk with their patients about what they are inhaling.

Joan would like to see everyone receive a tobacco-cessation intervention at every appointment, but she acknowledges that several barriers stand in the way. She told me many dentists don’t think tobacco-cessation counseling falls within their purview. Others lack the necessary skill set, and based on their limited experience, they believe that counseling doesn’t work. Joan attributes these failures to a lack of understanding about motivational interviewing and health behavior change.

“You need to ask open-ended questions as opposed to, ‘Did you quit yet?’” she says, and work in questions about tobacco and other substance use with routine questions about brushing and flossing. Many dentists are also pressed for time.

That’s certainly true for dental educators, who, research shows, also have a mixed record when it comes to preparing new providers to help their patients kick the tobacco habit. Joan and several colleagues have surveyed U.S. and Canadian dental schools and U.S. dental hygiene and dental assisting programs about tobacco dependence education (TDE). Among the researchers’ findings:

  • As of 2016, TDE had not been consistently integrated into predoctoral education.
  • At dental schools, 90% of respondents indicated that faculty members were “confident” to “extremely confident” in teaching tobacco-related pathology, but only 49% reported the same level of confidence in teaching students how to help patients quit.
  • Three-quarters of dental hygiene programs reported expecting their graduates to be competent in a moderate-level tobacco-cessation intervention, but only one quarter reported having a formal competency that encompassed the U.S. Public Health Service’s Clinical Practice Guidelines for such an intervention.
  • Almost all dental assisting programs addressed oral and systemic diseases related to tobacco use, but less than 30% of programs covered key topics related to tobacco cessation.

All dental providers should be versed in TDE, according to Laura Romito, D.D.S., M.S., M.B.A., Associate Professor at the Indiana University School of Dentistry (IUSD), Director of its Nicotine Dependence Program, and Associate Director for Faculty Development and Curriculum at the IU Interprofessional Practice & Education Center.
“Patients may share more readily with a dental assistant or a dental hygienist than with the dentist, so we advocate for tobacco interventions to involve the entire oral health team,” she says. “It’s one of the things that makes Indiana unique.”

IUSD has been a leader in tobacco research, education and cessation since Arden Christen, D.D.S., M.S.D., M.A., started the school’s first programs in these areas in 1980. Historically, the university’s Nicotine Dependence Program has ranked among the most successful in the field. According to a 2001 paper in the Journal of Dental Education, the program’s one-month quit rate was 58% and its one-year quit rate was 33%, well above the national averages for intensive interventions.

IUSD continues to be among a handful of schools that do an exemplary job when it comes to TDE. Led by Pamela Rettig, M.S., IUSD’s dental hygiene TDE program requires all students to work on their communication skills and to develop a personalized quit plan for a friend or family member. The dental assisting program makes sure students graduate with knowledge of tobacco’s oral health effects, various tobacco products, and behavioral and pharmacological interventions, enabling graduates to advance the oral health care team’s tobacco-dependence treatment efforts.

Dental students learn to:

  • Take a social history that captures the use of tobacco, e-cigarettes and marijuana.
  • Educate patients on the oral health implications of continued use of these substances, advise them of the benefits of quitting and gauge whether they are interested in doing so.
  • Connect patients who want to reduce their tobacco use with resources, such as the state’s quitline, or providers who can prescribe pharmacotherapy for tobacco cessation.

Students may also choose to counsel patients themselves. During a clinical elective, which Laura supervises, students develop a behavioral and pharmacological treatment plan and initiate counseling. They seek to identify the triggers that influence each patient’s substance use and the barriers that discourage them from quitting. Laura then evaluates students on a range of competencies.
“Can they assess patients’ use of these substances? Can they develop a cessation treatment plan? Can they communicate effectively with the patient using the motivational interviewing techniques that they’ve been taught?” Laura asks.

In Joan Davis’s view, this assessment piece is key. If the Council on Dental Accreditation made evidence-based tobacco-cessation counseling a graded clinical competency, she believes it would be a game changer. “Schools would have to back it up with didactic education, make time in the curriculum and provide faculty with training,” she says. “A lot of schools teach students about tobacco using nongraded case studies. These don’t demonstrate students’ interpersonal skills, which are essential for tobacco cessation.”

Schools and programs that want to bolster their tobacco education will find a ready-made, open-access resource in Tobacco Free! Curriculum©, which includes learning objectives, student activities and assessments. Joan designed the curriculum while on the faculty at Southern Illinois University Carbondale well before vaping and marijuana legalization were on everyone’s radar screens, but she believes it’s premature to change the fundamentals of tobacco cessation education until more definitive research emerges about how use of these additional substances influences people’s efforts to quit.

“Honestly, I think educators and clinicians need to just keep doing what they’re doing and up their game to provide more comprehensive treatment,” she says. “If everybody at least asks if people use tobacco products and encourages them to quit and gets them to a quitline, that’s good. It would be even better if they could work on motivating them to quit.” (A quitline is a tobacco cessation service available through a toll-free telephone number. Quitlines are staffed by counselors trained specifically to help smokers quit.)

One of the challenges of addressing tobacco use in today’s more complex social environment, Laura says, is identifying the practice in the first place. People who vape, or go to a hookah bar on the weekends, don’t always think of themselves as smokers. “They need to understand why we’re asking,” she says, “and that using these products may have oral health ramifications.”

As science sheds additional light on newer nicotine delivery systems and marijuana use, the principles underlying tobacco-dependence treatment will likely remain relevant, she says. At IUSD, they are currently studying the feasibility of integrating a clinical decision support system in the electronic health record that would trigger tobacco-cessation counseling. “This should help to standardize student oral health provider’s messaging,” Laura says, “and hopefully make their interventions more effective.”

Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic hears from experts in pediatric sedation about efforts to reduce adverse events in the dental office.

You’ve read the headlines or heard them on TV, and if you’re like me, the stories seem surreal. How, you wonder, could this happen again?

While deaths in the dental office are exceedingly rare, they do occur, and it’s especially troubling when a child’s life is lost. The good news is, we know a lot about why this happens, and we can do a great deal to prevent future tragedies.

I recall the bygone days when hospitalization and general anesthesia were often required to treat the youngest patients. The ability to sedate children in the dental office was a major advancement, but it is not without serious associated risks. Studies show a low but persistent rate of life-threatening respiratory events induced by sedation, and the size of children’s airways makes them especially vulnerable to complications that can end in death.

A 2013 study revealed 44 media reports of such events between 1980 and 2012. How does that compare with the number of children sedated for dental procedures during those decades or today? No one knows for sure, but observers agree that the use of pediatric sedation is on the rise.

One such observer is Stephen Wilson, D.M.D., M.A., Ph.D., Chief Dental Officer at Blue Cloud Pediatric Surgery Centers and author of the first textbook solely devoted to pediatric sedation for dental procedures. Steve also served for three years on the ADEA Board of Directors. He published a study in 2001 on the use of procedural sedation (referred to as “conscious sedation” to reflect that patients remain more responsive compared with an unresponsive state when under general anesthesia). He found an increased use of procedural sedation compared with the preceding decade, a trend that he believes continues to this day. Why? A multitude of reasons—early childhood caries are on the rise, with parents eager for treatment; many preschool-aged children are ill equipped to sit still for dental procedures; some school-aged children are paralyzed by fear and anxiety in the dental setting; and more.

“I think sedation is increasing to meet a need that’s out there, and that’s appropriate,” Steve told me. The occurrence of adverse events, he believes, boils down to inadequate training—in both sedation and rescue techniques.

“General practitioners receive very little if any didactic or clinical sedation experiences in dental schools,” Steve told me. “When they graduate and go out into practice, they’re basically using sedation for the first time on their own. They’re essentially self-taught, so they may not be aware of guidelines or procedures or even basic pharmacology, and consequently, they get into trouble.”

To make matters worse, when trouble occurs, providers may not be prepared to intervene effectively while they wait for emergency services to arrive.

“We have this model in dentistry where the person doing the surgery is also the person who is supposed to be providing the anesthesia and monitoring the patient’s safety. You really can’t do both safely,” says Paul Casamassimo, D.D.S., M.S., Professor Emeritus in the Division of Pediatric Dentistry at The Ohio State University College of Dentistry.

In recent years, Paul and Steve have been involved in developing and editing the pediatric sedation guidelines jointly issued by the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD). Paul also led the task force that revised the Accreditation Standards for Advanced Specialty Education Programs in Pediatric Dentistry about a decade ago. In 2017, the Commission on Dental Accreditation reissued those standards, which now require students and residents to complete a minimum of 50 patient encounters in which sedative agents other than nitrous oxide are used. In at least half of those cases, residents must act as the sole primary operator. Observing sedative procedures doesn’t count.

These requirements represent vastly more preparation than the typical general dentist receives in a weekend CE course on sedation, no matter how high the quality may be, and Paul feels it’s warranted.

“Someone who might be mildly sedated can go into moderate to deep sedation just because of their physiology, and dentists have to be able to handle those types of unexpected effects,” Paul told me.

He is pleased that the sedation standards for pediatric dental residents have been strengthened, and he praises the sedation training oral and maxillofacial surgeons receive. But Paul notes with concern that sedation training is not a standard feature of most general practice residencies, nor is it included in the typical predoctoral curriculum. Meanwhile, the practice standards for dentists who use sedation vary substantially from state to state.

There are exemplars, including Paul’s state of Ohio. The state’s dental board lays out stringent criteria that dentists must meet before receiving a permit to provide deep sedation or general anesthesia. Requirements include completing accredited graduate-level training and passing an onsite facility evaluation to ensure that appropriate personnel, drugs and equipment are in place to monitor and rescue patients.

States can also help ensure patient safety by requiring dental offices to become certified through the American Association for Accreditation of Ambulatory Surgery Facilities and by bolstering their Medicaid programs. Low reimbursement rates for publicly funded pediatric dental visits make it difficult for families to find willing providers, Steve says, let alone dentists who are well trained in sedation and skilled in managing young children.

This is an art in and of itself, as anyone who has worked with very young children can tell you. In Paul’s view, detailed in a 2015 article in the Journal of Dental Education, problems associated with pediatric sedation arise in part from how little exposure most dentists and dental students have to treating very young children, especially those with complex needs. “If you’re going to practice family dentistry,” Paul believes, “you’ve got to be able to take care of kids from one year of age and people with special needs, and the training needs to reflect that.”

He thinks raising the training standards for specialty programs and for dentists who want to provide sedation is probably the best avenue for improving safety. As far as predoctoral students are concerned, he’d like to see elective opportunities that meet state dental board criteria for those who want to provide sedation. Absent that training, he recommends communicating that sedation is not in the realm of general dental care and putting “the fear of God, so to speak,” in future dentists who see sedation as a simple procedure.

I appreciate Paul’s sentiments. In an ideal world, all children who need sedation would be referred to highly trained specialists, but there simply aren’t enough of those specialists to go around. And the alternative—general anesthesia in a hospital operating room—comes with its own set of problems as I learned firsthand during my pediatric residency at Children’s Hospital Medical Center in Boston. I, for one, am glad that we now have the option of sedating children who need care in outpatient settings. The question is, what more can we do to ensure that providers are well trained in sedation and in rescue techniques?

Steve has given a lot of thought to what comprehensive training might look like. On the didactic side, he would like all dental schools to give predoctoral students a common foundation by:

  • Familiarizing them with the AAP/AAPD pediatric sedation guidelines.
  • Having them review morbidity and mortality case studies to understand that almost all sedation-related cases involve the respiratory system or overdosing with local anesthetics.
  • Teaching them about physiologic monitoring devices, such as pulse oximeters and capnographs.
  • Emphasizing the need to have a person in the operatory whose only task is to monitor patients during deeper levels of sedation and intervene to rescue if problems arise.
  • Explaining the implications of the sedation routes (oral, intranasal, intravenous).
  • Offering simulation training in advanced life support and rescue.

This last item is costly and time-consuming, but has been shown to be more effective than didactic education alone, and on most of our campuses, simulation centers are already in place. At present, general practitioners and some specialists receive very minimal training in this area, sometimes as little as a basic course in CPR.

Steve acknowledges the challenge of adding to an already packed curriculum, but he points out that “Sedation is the one aspect of dentistry we do that can be life-threatening to the patient.”

Can sedation emergencies be eliminated? Probably not, but we can prepare ourselves better to deal with them when they happen. We can start by considering curricular changes such as Steve suggests, by supporting legislative and regulatory efforts that would improve safety and by reducing barriers to care that allow children’s dental problems to become acute.

Paul tells me that the AAP, AAPD and other dental and medical specialty organizations are working in concert to eliminate deaths from pediatric dental sedation. It’s time for the dental education community to seriously consider what more we can do to ensure that providers are well-trained in sedation and rescue techniques.

Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic makes clear why you should plan ahead now to attend next year’s ADEA Annual Session & Exhibition.

The one complaint we hear following every ADEA Annual Session & Exhibition is a happy problem to have: There are simply too many sessions people want to attend and no way they can physically attend all of them.

While we haven’t found a magic potion that allows dental educators to be in two places at once, this year in Orlando we did introduce a media-rich environment that led attendees to experience more of the meeting than ever before. Meet ADEA TV, our latest communications venture, which debuted to rave reviews. Five monitors became hubs in the convention hall where people gathered throughout the day to view Annual Session highlights. The production team did a stellar job making the videos feel interactive. As one person I spoke with commented, it felt as though the people on screen were talking directly to you. But as the infomercials say, don’t take my word for it. Visit the website to see for yourself!

We also upped our social media game this year with the help of Western University of Health Sciences College of Dental Medicine (WU CDM) Assistant Dean for Clinical Education, Hubert worked with the ADEA Division of Communications and Membership to organize a Social Media Squad comprised of members of the ADEA Council of Students, Residents and Fellows and WU CDM students. Together, they chronicled each day’s events under the hashtag #ADEA2018, posting 500 messages that reached ADEA’s 10,000 Twitter followers and thousands more via Twitter, Facebook, Instagram and Snapchat.

The Annual Session mobile app featured something new as well: ADEA Quest. While not quite Pokémon Go, the game succeeded in sending players throughout the Exhibit Hall on a hunt that spurred conversations among attendees, exhibitors and ADEA staff. Players collected points as they went and could enter raffles to win prizes. Following many sessions, we also introduced ADEA TouchPoll™ surveys to get an instant read on how members viewed select events. Respondents were entered into a raffle, and one lucky third-year student, WU CDM’s Katie Oates, went home with the grand prize—complimentary registration and round-trip airfare to next year’s Annual Session in Chicago.

One highlight of every ADEA Annual Session & Exhibition is the ADEA Political Spotlight. It is always entertaining, but this year it also was genuinely educational, combining both substance and style. Roll Call reporters Mary C. Curtis and Patricia Murphy shared the filters they use to distinguish news from noise as they cover U.S. politics and policy. For example:

  • Hope Hicks leaving the White House?
  • Congress voting to repeal the Affordable Care Act for the 69th time?
  • Anything that happens on the Hill between now and the midterm elections?

All noise, but luckily for us, the information shared at this year’s Annual Session was most definitely news, and welcome news at that.
ADEA members are taking seriously the need to prepare for the road ahead, and in session after session, they were eager to share the myriad individual ways they are gearing up for the challenges that lie around the corner. This year’s theme, Vision 2030, amplified those efforts by putting them into a larger context and challenging ADEA members to imagine how our community can continue to thrive in a rapidly changing environment. As Leon Assael, D.M.D., now Immediate Past Chair of the ADEA Board of Directors, is fond of pointing out, 2030 is a mere 12 years away, so we have no time to lose in getting ready for the sweeping changes coming to dental education.

Three Chair of the Board symposia explored the specific challenges dental education will confront in the years ahead, while the Opening Plenary speaker, futurist Mike Walsh, offered a big-picture perspective. He issued a wake-up call for all of us to reinvent, reimagine and redesign the oral health ecosystem, urging us to “think big,” “ask dangerous questions” and consider what roles automation, artificial intelligence and algorithms can play in our teams.

The Closing Plenary speaker, Natalie Kogan, also addressed the need for a cultural shift, but reassured us that “It is okay not to feel okay about change.” Her upbeat presentation on striving for emotional health and resilience in the workplace seemed to strike a chord with an audience all too cognizant of the stresses associated with preparing for and practicing our professions. Our community cares deeply about student well-being, as evidenced by the overflow crowd at a separate session on student happiness.

A palpable feeling of calm and camaraderie permeated this year’s gathering. The Gaylord Palms Resort & Convention Center provided a tropical oasis where attendees could feel close to nature. Under a giant glass dome, hotel guests watched alligators and turtles bask in sunlit pools. The adjacent convention center was easy to navigate, with lots of nooks that encouraged people to sit and converse, and more than once, I overheard people talking about collaborating on proposals for next year’s Annual Session.

The programming also put people at ease. For the second year in a row, we hosted a Find Your Tribe event, during which first-time attendees received guidance on how to get the most out of the meeting from a volunteer Army of Connectors. Roughly 140 newcomers took part, double last year’s attendance. Over in the Exhibit Hall, a steady stream of members kept staff at the professional development booth busy explaining which of ADEA’s various educational offerings might be right for them. Meanwhile, the introduction of electronic media was seamless, with people of all generations gathering around screens and interacting comfortably as though they were digital natives.

If this year’s gathering went off without a hitch, it was no accident. Keith Mays, D.D.S., M.S., Ph.D., Associate Dean for Academic Affairs at University of Minnesota School of Dentistry, and the rest of the Annual Session Planning Committee did a phenomenal job pulling together this year’s programming, and ADEA staff members worked diligently to address member feedback from past gatherings. Under Krisa Haggins’ leadership, the ADEA Meetings, Conferences and Education Technology team stepped up to provide an exceptional experience. Members told me they felt listened to and heard.

Because we were looking to the future, it seems only right that students, residents and fellows had a strong presence this year. These young people who come through our doors are the most important part of what we do and why we do it. On Monday, we hosted the inaugural ADEA Summit for National Student Leaders, which brought representatives of seven associations supporting dental students together to form a strategic alliance in pursuit of common goals. The ADEA Student Diversity Leadership Program drew another 53 students who left with individual leadership plans and a new vision for their program’s future, one focused around reducing health disparities and promoting student well-being.

The allied dental community, including dental therapists and a record number of students, was also well-represented this year, and the entire allied community was moved to see Dr. Colleen Brickle, RDH, RF, Ed.D., Dean of Health Sciences at ‎Normandale Community College and one of Minnesota’s dental therapy pioneers, receive an ADEA Presidential Citation award.

There are so many more moments I’d love to describe:

  • The remarkably moving acceptance speeches given at this year’s William J. Gies Awards for Vision, Innovation and Achievement.
  • The meeting of the ADEA Women Liaison Officers’ Group—now 45 strong including Canadian members—and their plans to work toward becoming an ADEA Special Interest Group.
  • The presence of our colleagues from Europe and beyond, with whom we made plans for two future international conclaves.
  • Three outstanding sessions presented by our Advocacy and Government Relations staff examining Medicare funding for Graduate Medical Education, health care reform and select cases before the U.S. Supreme Court.
  • Timely presentations on licensure, prescription drug abuse and augmented reality.
  • And, of course, the 2018 ADEA GoDental Recruitment Event, which brought people from all over the country to meet face-to-face with admissions officers. One look at the rapt expressions on the faces of prospective dental students during a staged mock interview and the critique session that followed, and you were both proud of our profession and reinvigorated.

For me personally, it was a special pleasure to reconnect with a classmate of mine from my time at Harvard University, Alexia Antczak-Bouckoms, D.M.D., Sc.D., M.P.H., who spoke during the “In the Mix” Plenary. Since a 1996 spinal cord injury changed the course of her life, this dental educator has focused on raising her children and raising millions of dollars for spinal cord research.

“A person is a person,” she said, sharing her vision of inclusiveness. “It doesn’t matter what they can or can’t do. You just have to recognize the spirit of them and include them in any way that you can.” I was especially pleased to see that attending Annual Session has sparked her interest in renewing her engagement with dental education.

So what’s next for the other attendees? In March 2019 we’ll gather again—this time in Chicago to celebrate our collaborative spirit. In the meantime, I’ve no doubt we’ll be hard at work—in our Sections and SIGs, in our Councils and workgroups, in our sister associations and at individual schools—processing all that we heard and experienced in Orlando and thinking intently about how we can prepare for tomorrow. As Mike Walsh pointed out, it won’t be enough to simply invest in technology. Successful organizations also invest in their cultural “operating systems.”

“How easy is it for the next generation of leaders and professionals to share and act on their vision of the future?” he asked. “All the answers you may need are inside your organization. Question is, ‘Are you listening to these people?’”

That’s a great reminder to keep our ears—and our minds—wide open.