Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic reflects on his 22 years at ADEA and shares his plans for life after ADEA.

When I started in 1997 as Executive Director at the Association of American Dental Schools (as we were known before we became ADEA in 2000), my plan was to stay for about five years and then return to academic dentistry. While I am someone who normally sticks to a plan, each year I kept uncovering more to do.

From the very first day, I had my work cut out for me. At the time, six dental schools had closed in the previous decade, one more was yet to close, and seven other schools risked a similar fate. Dental Education at the Crossroads, an aptly titled report released by the Institute of Medicine two years earlier, captured the difficult choices dental education faced. As I launched my term, I was eager to chart a more auspicious course, but my initial five-year plan proved insufficient. As each new challenge emerged, I saw opportunities to continue to move dental education toward a more innovative, inclusive and stable place.

While there is still much to do, today the dental professions have attained considerable standing—not only within the oral health community, but also alongside our colleagues in higher education and our partners in other health professions such as medicine, nursing, pharmacy and public health. Dental education is now part of federal and global policy discussions. We have made progress in connecting the mouth to the rest of the body. And with these allies across the health professions and higher education, we are working to realize a vision for health care where the entire care team, including dental professionals, is educated together to serve the whole person.

Our Association has also blossomed into an organization with over 20,000 individual members representing the multiple institutional and individual member communities within dental education. Internally, our organization has grown from a staff of 10 to a staff of 75 and from a $3 million budget to one of almost $30 million, with $25 million held in investment, reserve and ADEAGies Foundation® portfolios.

But these accomplishments are not mine alone. It has been a privilege to lead a capable and committed staff and to be part of a vibrant community of scholars and clinicians dedicated to improving the dental and overall health of all people. Without the individuals in our community who gave their time selflessly and without compensation to serve in the leadership roles at ADEA, none of this would have been possible. The work has been challenging at times but always rewarding, and it has been an honor to play my part.

So what’s next? The time is right for our new President and CEO to carry the new ADEA strategic plan forward, and it’s not too soon to begin planning for 2023, when we will celebrate the 100th anniversary of the founding of our Association. When that event occurs, my wife Mary Kay and I will be in the front row.

As for me, in recent months I’ve often heard the voice of Pete Seeger in my head singing, “To everything there is a season, and a time to every purpose under heaven.” I plan to take the summer to refresh and think about ways to continue playing a meaningful role in this complex world we live in. I know many opportunities await, but few can rival the rich experience I’ve had over the past two plus decades. For that—and to the many people who made it possible—I will be forever grateful.


Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic explains the meaning of RPSA and reveals nine other ideas that have guided his actions during 22 years as ADEA President and CEO.

From my seat within our Association, I’ve had a rare vantage point these past 22 years. I’ve been privileged to serve as ADEA’s Chief Executive Officer in a time of transition—from an organization primarily serving dental schools to a member-driven association representing the multiple communities within dental education. Over the years, I’ve gained insights that have guided my stewardship during this period. Here are 10 of them, captured in mantras, maxims and musings that I hope may prove useful in informing ADEA’s journey ahead.

1. Oral health is a national security issue.

Oral health is rarely the first thing that comes to mind when people think about national military readiness. But the reality is, if you can’t eat, you can’t fight—and no one in harm’s way should be distracted by dental pain.

Dental conditions, including not having enough teeth, have been among the most common medical reasons for deferment from military service since the American Civil War. In fact, the label “4-F” to denote a medical deferment originated back in the days when recruits needed (and often lacked) four front teeth with which to bite down on a gunpowder cartridge so they could tear it open with one hand.

Loading today’s weapons no longer relies on the users’ dentition, yet even in the 21st century, dental readiness remains a concern. The deployment of National Guard and Army Reserve troops to Iraq and Afghanistan revealed significant deficits in their oral health, prompting changes in military regulations aimed at improving the dental readiness of our citizen soldiers. That’s good news, but we must remain vigilant to ensure that the nation’s oral health doesn’t become a threat to its national security.

2. The mouth really is a part of the body.

Shortly after the American Civil War, medical schools made it clear that they didn’t want to have anything to do with dental education. They saw the profession as mechanical in nature, dealing mostly with pain and extracting teeth. Ironically, dentistry’s historical isolation from medicine has, in some ways, worked to our advantage. We were forced to take the lead in developing our professions.

Yet over time, something counterfactual occurred: The mouth became separated from the rest of the body, almost as though it lacked nerves, blood vessels and other connecting anatomical structures.

You may have heard me joke that the oral cavity could be defined as the anatomy between the lips and the tonsils that other health professionals rarely examine, but in truth, this separation is no laughing matter. Fortunately, 150 years later, health care educators and providers have come to recognize the oral cavity for the anatomical organ that it is and advocate for integrating dental and medical care. ADEA’s work as an equal partner with organizations representing educators in other health professions shows our commitment to a future based on interprofessional education and collaborative practice.

3. The face of dentistry is changing.

When I graduated from the University of Connecticut School of Dental Medicine, 80% of dentists were white and men. That is no longer the case, and the change has been dramatic. In 2016, for the first time, the majority of applicants to dental school were women. In 2018, for the first time, the majority of applicants to dental school were non-white. These are milestones in the dental profession and it validates the work we’ve been doing to recruit a more diverse pool of applicants.

Dentistry has always been a first profession for many families. In my youth, a lot of people like me (of Eastern European descent) were entering dentistry. Today, a quarter of dental school applicants have roots in Asian countries. Through efforts such as the Summer Health Professions Education Program, which we lead with the Association of American Medical Colleges supported by funding from the Robert Wood Johnson Foundation, we continue to strive for even greater diversity in our workforce. Having reached the current tipping point in the dental school applicant pool, we’re on course to create a dental workforce that one day will reflect America’s soon-to-be minority-majority makeup.

4. This year’s graduates will still be practicing in 2060.

I completed my pediatric dental residency at the Children’s Hospital Medical Center in Boston in 1979. Had I remained a full-time practicing pediatric dentist, what I learned then would pretty much have carried me through my entire 40-year career. Some dental materials have changed since then, but overall, I could have practiced the way I learned in my program and had a successful career. Four decades later, that’s quite remarkable.

Today’s graduates, whether from dental schools or allied dental programs, face a far different future. Changes are already on the horizon—in areas such as robotics, biomaterials, digital dentistry and artificial intelligence—that will transform dental practice in unforeseen ways. The knowledge and skills our graduates acquire in 2019 will not be enough to sustain their careers through 2060. In this context, preparing our students for lifelong learning has taken on enormous importance. We’ve made strides in transforming our curriculum from what was sometimes a hollow exercise in memorization to a meaningful way of equipping practicing professionals with the ability to acquire up-to-date knowledge and skills. That said, we have a long way to go to ensure that our graduates are prepared to keep learning throughout their careers.

5. Success or failure in dentistry is measured in tenths of millimeters.

Those of us in the dental professions have reputations for being painstakingly detailed. That may not be the most desired trait in social settings, but our patients are almost universally grateful for our perfectionism. A gap of more than a tenth of a millimeter between the margin of a tooth and a restoration can result in recurrent decay, and none of us wants to think about what happens when an implant perforates a mandibular canal.

The procedures we perform require extreme precision. We have no choice but to teach and practice to tenths of millimeters. Unfortunately, it’s not always easy for students to perform to such exacting standards. In recent years, we’ve come to publicly acknowledge the stresses inherent in preparing for our professions—and in practicing the professions as well. Recent conversations about well-being and resilience have put us on a path toward a more humanistic approach to educating students. Those discussions are a vital first step, but we must put our words into action. We must “walk the walk.”

6. In today’s world, you have to have an engaging smile.

For much of the last century, you could get a good job making steel or cars or lumber, and no employer thought twice about your teeth. Not so in today’s service-oriented economy. To get most jobs, you must have an engaging smile, and any reluctance to show off one’s pearly whites can severely affect a person’s self-esteem.

The effect is even greater in the social sphere, where a vast number of people use apps to vet the appearance of potential mates before they have a chance to compete for love on personality or other criteria. These concerns, while essentially cosmetic, have created a greater appreciation for the value of dental health. A radiant smile relies on healthy gums, strong enamel, and proper spacing of the teeth—conditions that allow for pain-free use of the oral cavity in essential activities such as eating and speaking. Access to proper dental hygiene and restorative care can assure these functions and give people a critical tool for economic and social success.

7. Dental schools need to be part of the trunk of the academic tree.

Between 1986 and 2000, seven dental schools closed and another seven almost met the same fate. What distinguished these two groups? The ones that closed thought that dental schools were different from other units of their parent institutions and positioned themselves “out on a limb” on the academic tree, making it easy for the parent institution to cut them off.

The schools that survived had made themselves part of the trunk of the academic tree. They were engaged with the main campus, their faculty served on university committees, and their strategic plans were consistent with those of their parent institutions. To thrive, all of our schools and programs must be integral to their parent institutions and serve these institutions’ missions and goals. That’s a lesson we can’t afford to ignore.

8. If you’ve seen one dental school, you’ve seen one dental school.

I often hear people make sweeping statements about dental education. While they usually contain a grain of truth, we need to stop painting with such a broad brush, especially when it comes to describing our perceived shortcomings. Each dental school has a unique blend of strengths and challenges.

While accrediting bodies in the United States and Canada ensure that all dental schools meet national standards, for the moment, at least, we’ve managed to remain flexible and innovative. In fact, most dental schools are taking astonishing steps to differentiate themselves from one another. Many are exceptionally innovative—whether in research, community-based education, integration of technology, interprofessional learning environments, or some other area. Many dental schools are now thought of as the “front porch” of their universities through their teaching clinics and their presence in federally qualified health centers and mobile vans. Unlike McDonald’s franchises, you won’t find the same things on the menu no matter where you go, and that’s one of dental education’s strengths.

9. Where you stand depends on where you sit.

Most human endeavors have a political dimension, and dental education is no different. After years of advocating for change inside the Beltway, in Chicago and elsewhere, I’ve come to realize that you can’t make progress unless you understand where those with differing views are coming from.

I mean that quite literally. Whether negotiations are occurring at the federal level, state level or within or among our academic and professional organizations, each person at the table has to go home and justify his or her actions. If you can help make a case that will satisfy your opponent’s constituents, that’s half the battle.

ADEA’s recent progress on the licensure front exemplifies the value of this approach. For years, we rubbed up against the competing interests of students, educators, practicing clinicians and those charged with protecting the public’s welfare. But over the last two years, we mentally put ourselves in each other’s shoes and quickly discovered that we shared considerable common ground. It’s a lesson worth remembering as we take on new challenges.

10. Relentlessly pursue strategic alliances.

In all our Association’s initiatives, the relentless pursuit of strategic alliances, or RPSA (I pronounce it “rip saw”), has been my mantra. Why? As the academic branch of a relatively small profession, dental education has always risked being marginalized.

When I arrived at ADEA 22 years ago, I quickly discovered that we had incredibly weak relationships with outside organizations whose concerns overlapped with our own. We had next to no interaction with most of these groups and spent little energy and few resources on fostering collaborations. But as most of you know, I soon challenged our Association to turn these potential allies into strategic partners. We forged ties with organized dentistry, with education organizations representing the other health professions, and with national associations focused on higher education. We successfully deepened our relationships with a growing number of corporate partners. And then we reached beyond our borders to pursue stronger global ties, which have blossomed in recent years. Along the way I learned that a hearty laugh and a sense of humor can make all the difference in getting others to engage.

Thanks to RPSA, we are now integral to the intraprofessional, interprofessional and globalized future that is shaping both health professions education and health care delivery. I hope you will agree that RPSA has served us well.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic looks at how military service can prepare dentists for encore careers as dental educators.

About 10 years ago, I had the honor of participating in a national educators’ tour sponsored by the U.S. Army Medical Field Service School at Fort Sam Houston in San Antonio, TX. I met uniformed health professionals of all kinds and came to more fully appreciate their commitment to the needs of both healthy soldiers and those who had returned from conflicts with injuries. Impressively, all the dentists with whom I interacted were either already board certified or on the path to board certification in general dentistry or a dental specialty program. But what struck me most was how the entire health care team was focused on its mission: keeping service personnel healthy and ready to deploy.

Oral health is rarely the first thing that comes to mind when people think about national readiness, but dental conditions, including not having enough teeth, have been among the most common medical reasons for deferment from military service since the Civil War. In fact, the label “4-F” to denote a medical deferment originated back in the days when recruits needed (and often lacked) four front teeth with which to bite down on a gun powder cartridge so they could tear it open with one hand.

Loading today’s weapons no longer relies on the users’ dentition, yet even in the 21st century, dental readiness remains a concern. When the army called up members of the National Guard and Army Reserve to deploy to Iraq in the early- to mid-2000s, roughly 50% of these citizen soldiers had dental problems that made them unfit to serve overseas. Like many other Americans, guardsmen often lacked dental insurance or the means to pay for routine dental care. A change in Army regulations in 2010 reminded reserve troops that they are responsible for their own dental readiness and charged commanders with ensuring the dental readiness of the troops they lead, incentivizing everyone to promote and maintain better oral health.

In contrast, active-duty service personnel can receive dental care at little or no cost, thanks to a robust corps of military dental officers. ADEA Senior Scholar in Residence Leo Rouse, D.D.S., FACD, was one of them, and he ultimately served as Commander of the U.S. Army Dental Command.

“When you have a unit with poor dental readiness, you can’t deploy,” Leo told me, or as he likes to say, “If your troops can’t eat, they can’t fight.” When Leo was stationed in Germany, he made this case with Norman Schwarzkopf, who was then a one-star general. “Just imagine,” he told him, “if one of the folks who operate these tanks has an acute episode of dental pain. It could affect how they operate the equipment.”

If the name Schwarzkopf is not familiar to you, he became a four-star general and then a household name when he commanded coalition forces during the Persian Gulf War. Fortunately, he and others in the military shared Leo’s views, and over the decades, the services have established a series of dental centers and postgraduate programs where service members can receive excellent care.

The Dean of the Boston University (BU) Henry M. Goldman School of Dental Medicine, Jeffrey W. Hutter, D.M.D., M.Ed., attended one of these programs at the National Naval Dental Center (now the Navy Postgraduate Dental School) in Bethesda, MD. Before graduating from the University of Pennsylvania School of Dental Medicine, he sought a commission as a lieutenant in the U.S. Navy Dental Corps. The position came with a two-year service obligation, and he and his wife soon discovered that they liked the military lifestyle and the educational opportunities the Navy offered. “You were a naval officer first, then you were a Dental Corps officer,” he recalls, which was a far cry from the private practice existence he envisioned for himself while still in dental school.

Jeff was eager to specialize in endodontics, but before he could apply for an advanced education program, he needed to complete a shipboard or foreign duty tour. Choosing to “go to sea,” he served on a destroyer tender that maintained naval vessels in the Mediterranean. “We were fixing the sailors’ teeth while the tender was fixing the ships themselves,” he told me, and there was plenty of care to be provided. “It didn’t take long to realize that our mission was to keep the sailors, marines and soldiers ready to deploy or go to war at any time.”

Following his specialty training, Jeff was sent to the Naval Dental Center in Pearl Harbor, HI, where he says working with junior dental officers gave him his first taste of what being an educator might be like. He asked to serve next at the National Naval Dental Center in Norfolk, VA, home of the world’s largest naval base. There he ran the endodontics department and developed a one-year fellowship program in endodontics. After four years at that duty station, Jeff began to see himself as an educator, a reality that was confirmed by his next posting as chair of the department of endodontics and director of the Advanced Specialty Education Program in Endodontics at the National Naval Dental Center in Bethesda. “I went from being a resident in the program to now running the program itself,” he recalls happily.

By the time Jeff retired in the summer of 1996, he knew he wanted to stay in education, and his rise through the ranks at BU confirms that academia has been an excellent fit for this retired military officer. That comes as no surprise to Leo Rouse, who made the same transition himself and eventually served as the Dean of Howard University College of Dentistry.

“If you want an outstanding faculty member, you can’t do better than someone from the military,” Leo believes. Why? To have a successful military career, you must be a good officer as well as a good dentist, he says, and the qualities that officers possess work well in an academic environment. Collegiality, strategic thinking and the ability to plan, evaluate, manage and budget can be especially valuable as faculty members rise through the ranks. Leo began his academic career as a faculty member in the Dental Science Division at the Army Medical Department Center and School (AMEDDCS) at Fort Sam Houston. When he retired from the Army in 1997 and transitioned to an academic position at Howard University, he was able to advance to the roles of Associate Dean for Clinical Affairs and Chair of the Department of Clinical Dentistry. As Leo put it, “People saw I could walk and chew gum at the same time.”

John Valenza, D.D.S., Dean at the University of Texas School of Dentistry at Houston (UTSD), sees something similar in the military veterans who make up as much as 10% of UTSD’s faculty. “Military veterans have a unique experience that prepares them well for an academic environment,” he told me. “It’s not just how they lead as faculty. It’s also how they work with students. They bring insight to helping others learn and advance, an ability that translates well in teaching roles.”

As John points out, retired military dentists also understand structure, learning curves and advancement processes, knowledge that prepares them well for the rigors of promotion and tenure. And because the military attracts a diverse cross-section of Americans, recruiting faculty from the veteran population also helps make dental schools more diverse. That’s important at a public institution such as UTSD, John says, that wants faculty, students and staff to reflect the population of the state.

During my visit to the Medical Field Service School at Fort Sam Houston, and more recently through my service on the Veterans Administration National Academic Affiliations Council, I’ve also come to appreciate that veterans bring another invaluable asset to academic dental institutions: knowing how to function as part of a team. Military health professionals are focused on the mission, and that focus is key to their ability to dismantle the barriers that have traditionally stood in the way of interprofessional education and collaborative care. What better group could we look to for future faculty than these board-certified dentists for whom interprofessional collaboration is the norm?

The challenge is making the connection between military service and academic dental careers. Most military dentists have only worked in military environments. We need to provide them with opportunities to become acquainted with civilian academic culture, so they can see how easily they might fit in.

As Jeff Hutter’s experience illustrates, military service is imbued with educational opportunities that provide an excellent foundation for future academic careers, and officer training provides leadership experiences that would be hard to come by in the civilian dental world. “The Navy gave me the tools to be a leader and to work with students, residents, faculty and staff as a team,” Jeff told me. He is grateful for that experience, and we should be, too. It’s a privilege to welcome retired military dentists to our academic institutions, and I hope we will be welcoming more of them soon.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic highlights digital technologies that are transforming the way we live and the way we provide clinical care.

The hype around IBM’s Watson and the computer’s failure to revolutionize medical diagnosis since making its debut on the game show Jeopardy! have left many observers reluctant to jump on the next big technological bandwagon. You may be among them, and with good reason. Acquiring new technology can be costly and time-consuming, and it can take fortitude to persevere through the pain that often comes with learning to use it properly, especially when you have to bring others along for the ride.

Does that mean we should shrink from the opportunities before us? Hardly. We just need to do more to prepare for what lies ahead.

That’s why Mary Truhlar, D.D.S., M.S., Dean of the Stony Brook University School of Dental Medicine and Chair of the ADEA Council of Deans, chose to focus this year’s ADEA Deans’ Conference on the technological challenges faced by dental schools. Over the course of several days in California, deans and their colleagues learned from one another about successfully integrating new technologies in the past and heard from outside experts about what’s coming down the road.

“There is so much going on in the clinical realm that is absolutely breathtaking,” said Bruce Lieberthal, Chief Innovation Officer at Henry Schein, Inc., who spoke about health care technology at the conference.

Since 2015, Bruce has headed the innovation group at Henry Schein, an ADEA Corporate Member and a distributor of dental equipment and supplies. He shared descriptions of what’s taking place in the health care innovation landscape and explained the role that artificial intelligence (AI) is playing as a facilitator of this progress.

The dream of getting computers to think has been around since the 1950s, but the ability to realize that dream has only been possible in the wake of six recent developments.

  • The dramatic increase in computing power. Today’s desktop computers have 1.3 million times more brute computing power than the computer that took NASA’s Apollo 11 mission to the moon and back.
  • The increase in communication speed and the decrease in latency, the delay before a transfer of data begins. With the introduction of 5G communications, that speed will increase to the point where a surgeon guiding an operation remotely and the robot making incisions act at essentially the same time.
  • The ability to miniaturize computer chips to embed powerful processors in smaller and smaller devices.
  • The creation of artificial neural networks that simulate how the human mind works.
  • The accumulation of sufficient data sets to facilitate computer learning.
  • The advent of deep learning, the process by which computers apply neural networks to the analysis of diverse data to solve complex problems.

AI has been key to the development of the Internet of Things (IOT). I suspect you are familiar with IOT through the boom in smart devices for the home. With 5 billion IOT devices in the world today, many of us are regulating our thermostats or operating home security systems through our smartphones. I’ve noticed many of you wearing devices that track your steps and other data, and these “wearables” become more sophisticated every year. The latest Apple Watch can generate an electrocardiogram in just 40 seconds. Meanwhile, in the realm of dentistry, smart toothbrushes are tracking how long and how well people brush.

These devices represent just the most visible manifestations of the use of IOT in the health care arena. Implantable devices, such as electrodes that stimulate the brain, and ingestible sensors aimed at tracking medication use are the next frontier in remotely managing chronic conditions. More than 40% of Americans have one or more of chronic diseases, which account for an estimated 75% of all health care spending. Being able to monitor these conditions outside of health care settings—before they become acute—is a crucial strategy for keeping people healthy and keeping down costs.

What will these technologies mean for the dental office? Imagine walking into a practice and activating the lights, the computers and the compressor by simply saying, “Good morning.” The thermostat setting moves up or down depending on the time of year, and music starts to flow through the sound system. During your first appointment, your assistant returns from the supply closet with the materials you will be using that day, and before you even employ them, your inventory control program, thanks to sensor technology, has already placed orders for those that are running low.

IOT technologies also have the potential to substantially improve the patient experience. As individuals are ushered into separate operatories, music can put them at ease by changing in accordance with the preferences stored in their health records. As patients exit from the practice, postoperative instructions can appear on their smartphones along with coupons for the drugs they need to purchase.

Another ADEA Deans’ Conference speaker, Larry Emmott, D.D.S., also anticipates advances in genetics and big data playing a growing role in diagnosis, with digital lab-on-a-chip devices taking center stage. Larry writes about digital technology in his Emmott on Technology blog, and he has made it his mission to help dental professionals make good technology choices. Larry attributes much of the expanded use of digital technologies in diagnosis to what he calls “these little miracles in our pockets,” our smartphones. One example he told us about: a $5 test for the human immunodeficiency virus made from a specialized chip and a 3D printed interface that can be attached to a smartphone.

On the treatment side, Larry foresees advances in dentistry that are “just mind-boggling.” He expects that robotic surgery and the use of lasers will improve the precision and the experience of care. So will 3D printing, which is already transforming the construction of dental restorations. Others are using bio-plotters to custom build teeth and pieces of bone from human cells. And Bruce knows of at least one company that is seeking FDA approval for the use of nanotechnology to embed antimicrobial properties in dental restorative materials. Mind-boggling, indeed!

These tools could be revolutionary—in part because they may ultimately allow people to diagnose and treat many conditions themselves well before entering a dental office or other health care setting.

“Eventually, a professional dentist will have to intervene to do some things,” Larry believes, “but 50 years down the road, these technologies will enable us to deliver health care quickly and cheaply at a very high degree of quality.”

While clearly enthusiastic about the power of the digital revolution, Larry is also well aware of the barriers that may continue to impede progress in these areas for some time to come. For starters, he notes that a lack of data security and privacy concerns are holding back the spread of technologies that rely on the Internet to store and share data. Second, he says that dentistry is “plagued by proprietary systems,” which prevent information sharing in ways that would allow for significant advances in research and clinical care. Third, the absence of standards for interoperability that stakeholders honor and adhere to—not just in dentistry but in medicine as well—continues to stymie progress. Fourth, state licensure requirements and other regulations stand in the way of innovations such as telehealth. Finally, our own dental culture is likely holding many of us back.

As Larry rightly points out, dental professionals as a group are rule-oriented, and we value precision. We are taught to follow step-by-step procedures and are loath to deviate from what we know. Too often, when we do embrace a new technology, we don’t adapt our practices to take full advantage of its capabilities. “If dentists don’t have a vision of what they’re trying to accomplish, they can spend a lot of money on technology and get very little benefit,” Larry observed.

Too often this has been the case, but informative programs, such as the conference the deans enjoyed this fall, can do a great deal to inform our vision of the future and help us successfully integrate technology into our schools and practices. Ultimately, smart devices are about much more than convenience. When creatively deployed, these groundbreaking technologies can also make people healthier, and they might even reduce preventable morbidity and mortality.

I have no doubt that technological advances in health care have a bright future, but the challenge we face now as dental educators is to prepare our students for a more digitally assisted clinical environment while also teaching them to function in the world as it currently exists. Truly, there is much to ponder about how we meet this challenge.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic shares key findings from a landmark report that describes the reasons change is needed in dental licensure and sets a pathway forward.

Monty MacNeil, D.D.S., M.Dent.Sc., 2018-19 Chair of the ADEA Board of Directors, has been concerned about the dental licensure process since his days as Academic Dean at the University of Connecticut School of Dental Medicine.

“I watched students struggle to prepare for their clinical licensure exams. The process influenced their decision-making and professional judgment, enticing them to make decisions counter to their contemporary training and good, evidence-based patient care,” Monty recalls. “I also saw the outcomes of those exams, and there didn’t seem to be any rhyme or reason when it came to which students were successful and which were unsuccessful.”

Eliminating the use of single encounter, procedure-based examinations on patients as part of the licensure process has been official ADEA policy since 2011. The American Dental Association (ADA) embraced this position even earlier, in 2005. And now, in partnership with the American Student Dental Association (ASDA), a joint task force of our three organizations—the Task Force on Assessment of Readiness for Practice (TARP)—has authored a landmark report that calls upon state dental boards to replace these exams with ethically grounded clinical assessments that provide a more valid and reliable measure of graduates’ readiness for practice.

“The ‘live patient’ exam always had a stigma around it, but it was the only game in town,” says Joe Crowley, D.D.S., ADA Past President. Thankfully, during the past decade, several pioneering states have been early adopters of alternative ways of assessing clinical competency for initial licensure. These include mandatory accredited advanced dental education, portfolios, curriculum-integrated format exams and the Objective Structured Clinical Exam (OSCE), first used for licensure in Canada. One state, Colorado, accepts all pathways to licensure.

To scale these efforts nationally, in 2016 the ADA committed to developing an OSCE for U.S. dental licensure, and our Association took on the task of creating a compendium of clinical competency assessments that would build on the California Hybrid Portfolio, which is now a recognized pathway to licensure in that state. Once these two new assessments are in place, the challenge will be to convince additional states to adopt them as pathways to licensure and eliminate the use of single encounter, procedure-based examinations.

That will be a heavy lift in states where vocal defenders of the status quo are still convinced that traditional clinical exams are the best way to protect the public, despite evidence to the contrary. (To debunk the myth of a connection between the skills tested on the exam and the infractions that lead dentists to face reprimands from their state dental boards, I highly recommend David Chambers’ study of disciplined dental licenses in the spring 2018 issue of the Journal of the American College of Dentists.)

In the meantime, our best strategy for convincing states to modernize the initial dental licensure process may be to start by focusing on the second goal articulated by the Task Force: license portability. The TARP Report urges states to update the laws and rules governing licensure by credentials so a license to practice dentistry in one state becomes “portable,” allowing dentists to practice in any state of the union.

“That’s really tough to argue against because U.S. dental graduates are all trained on the same standards and come from schools that are accredited the same way by the same accrediting body,” Monty says. “What is the distinguishing aspect from one state to another that would justify restricting license portability?”

The Federal Trade Commission (FTC) has raised similar concerns, and in recent years, the agency has argued against restrictions on professional licensure on anti-competitive grounds. A White House report takes a similar stance, and a separate paper from the Hamilton Project and The Brookings Institution comes to the same conclusion.

“When designed and implemented appropriately, licensing can benefit practitioners and consumers through improving quality and protecting public health and safety,” the paper states. However, licensing restrictions are often “inconsistent, inefficient, and arbitrary,” the paper adds, restricting mobility across states and increasing the cost of services to consumers.

Colorado made history in 2016 by deciding to accept all ways of assessing clinical competency (alternative as well as traditional) as pathways to Colorado licensure for dentists and dental hygienists. Currently, a small minority of states accept one or more alternative pathways, 10 states accept only two or three of the traditional regional exams, and four states accept only one exam. The Task Force calls upon dental boards in all states to go the way of Colorado until the report’s two larger goals have been met.

When it comes to license portability, Joe tells me he sees the proverbial “light at the end of the tunnel. I truly believe many of today’s D1s will be practicing in states with license portability.” Monty is also optimistic: “I think state boards are recognizing that there is a concern at the federal level about these issues, and they will be hesitant to amplify that further.”

Monty’s optimism also springs from the unprecedented level of unity achieved by the Task Force organizations. “There is a strong opinion across the country that change is necessary, and it’s not a fringe opinion,” he says. “It’s across the practicing community, it’s across the educational community and it’s across the student/trainee community. That’s very powerful and very hard to ignore.”

And ignoring this consensus will soon become even harder. News of the Task Force report was well received in the trade press.

What’s next?

  1. ADEA will develop a compendium of clinical competency assessments that are valid and reliable in demonstrating that our graduates are competent to enter practice.
  2. The ADA will complete development of its dental licensure OSCE and begin testing the new exam in late 2019. Several schools have already expressed a strong interest in taking part in the pilot, and more details will be available by the time of the 2019 ADEA Annual Session & Exhibition in March.
  3. At the same time, the newly established Coalition for Reform in Dental Licensure will begin creating an infrastructure to advocate for change across the states. Representatives from ASDA, the ADA and ADEA have already been chosen.
  4. The Coalition is currently reviewing the perceived readiness of various states to consider changes in their initial licensure and portability rules. The next step will be to establish state-focused coalitions to advocate for change in 2019.

The experience in Colorado has shown that students, residents and fellows are incredibly effective in the advocacy arena, and I anticipate that as informed advocates who stand ready to “vote with their feet,” they will play key roles in the next phase of this endeavor across the states.

As ADEA Chief Policy Officer Denice Stewart, D.D.S., M.H.S.A., points out, “ADEA, ADA and ASDA have come out against the single encounter, procedure-based examinations on patients. These exams place a significant burden on students, schools and programs; they are expensive, time-consuming and stressful. If students can choose any pathway to licensure, they may be less likely to choose traditional exams.” Once that occurs, we will likely find ourselves at a tipping point, where states still following a 20th-century licensure model will feel greater pressure to change.

The Task Force report makes one other observation that is vital to consider if we hope to hasten the pace of change. The handful of states in which new and additional pathways to licensure have been adopted share a common attribute: a high degree of trust among the state dental board, the state dental association and the dental schools located within the state. That trust was built on long-standing relationships and also on knowledge—of how and why education works, and how CODA accreditation ensures that a competent dentist is the end result of a dental education. Much of that knowledge was gained through exposure—something ADEA members can encourage by inviting dental board members to observe accreditation site visits and other important events in the life of a dental school.

“The more we can get representatives of state boards and licensing agencies to come to our schools, to see what we’re doing, the more trust that develops,” says Cecile (Ceil) Feldman, D.M.D., M.B.A, Dean of Rutgers, The State University of New Jersey, School of Dental Medicine, who has spent considerable time advocating for licensure modernization. “Developing trust is not just about them coming to our schools. It’s also about educators going to their meetings. We need to remember, they’re not trying to create obstacles for our students. They have a very significant and serious role to play and we need to appreciate their side of things.”

When I spoke with examiners last year for an earlier column on this topic, they expressed a number of valid concerns about the licensure process, including a desire for third-party oversight of licensure assessments conducted in dental schools. Members of the Coalition have expressed their openness to third-party engagement, and Ceil agrees that this would be a welcome development.

“I’d love to see some meetings where we sit down and think jointly about what kind of assessment documentation would give state boards and examiners confidence in what dental schools are doing,” she says. Given developments related to licensure at the national level, it’s urgent that we do so.

“Just as all politics is local, all licensure is local,” Ceil points out, “at least until the FTC or some other group steps in.” She hopes it won’t get to that point, believing it’s better for our community to find our own solutions than to have them thrust upon us. I agree, and I’m confident we will be able to find common ground with the state boards and the examining community, just as we have with ASDA and the ADA.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic explores what the 2018 ADEA Survey of Dental School Seniors reveals about ADEA’s work in five key areas.

Each year the annual ADEA Survey of Dental School Seniors offers a contemporary snapshot of the most recent graduating class and provides insights on how we are doing as dental educators. We’ve yet to fully digest this year’s data, but I’ve had a chance to study the numbers we’ve gathered. The data are telling with regard to a few of ADEA’s recent priorities, so I thought I’d give you an early look at what this year’s senior survey reveals about our work in these areas.

Cultivating future faculty

The creation of ADEA Chapters on campuses is our latest initiative aimed at defining the value and appeal of academic careers. Just two years since their official launch, 48 ADEA Chapters now exist across the U.S (47) and Canada (1)—strong growth from 36 chapters at the start of 2018.

Student involvement in the chapters appears to have become mainstream; about a third of respondents indicated that they had participated in their campus ADEA Chapter in some way and most seniors reported that they had attended a chapter event. Other good news: A healthy 10% of respondents reported having held a leadership position, organized an event, or both, with membership on the rise within the ADEA Council of Students, Residents and Fellows.

It is important to thank ADEA Chair of the Board Monty MacNeil for some of this recent progress. Growing the number of ADEA Chapters was one of his top priorities in 2018-19, a message he has delivered far and wide across the ADEA community, and one he underscored at the ADEA Deans’ Conference this past week. Earlier this year, at his direction, ADEA launched a yearlong promotional effort by naming October “ADEA Chapter Month” and providing resources to schools to help them form chapters and support students interested in learning about academic careers. Key resources that support ADEA Chapter Month include a chapter toolkit and a policy brief that articulates the value of the chapters and describes financial programs for students and residents ready to pursue academic dentistry.

Cultivating future faculty is, of course, a primary goal of these activities. Are ADEA Chapters bringing us closer to our objective? The survey data reveal encouraging news—53% of the students who told us about their intentions said they “definitely” or “probably” plan to teach at some point in their careers. Among that subgroup, 95 respondents said they plan to teach immediately after graduation. If this many graduates joined the faculty ranks each year, we’d be well on our way to solving a persistent problem with faculty vacancies, numbering between 200 and 400 since 2005.

For more on this ADEA priority, visit these pages on the ADEA website:
ADEA Chapters for Students, Residents and Fellows
ADEA Academic Dental Careers Fellowship Program (ADCFP)


ADEA has invested considerable effort in recent years advocating for changes to the way U.S. dentists and hygienists are licensed, and our Association is not alone. Some individual schools, educators and partner organizations also have taken bold steps to develop new pathways to licensure that would eliminate the need for single-encounter, procedure-based examinations on patients and enable greater mobility for licensed dentists.

Those of you who have been following this critical topic closely will remember that the yearlong postgraduate residency (PGY1) option; Curriculum Integrated Format (CIF) exam; the Objective Structured Clinical Exam (OSCE), adopted from Canada for use in Minnesota; and the California Portfolio Exam (CPE) were initially greeted with skepticism. They remain controversial in some quarters, but today each of these pathways to licensure is well established in at least one state, and a growing number of states accept one or more of these alternatives. With California and New York—two populous states, each with multiple dental schools—in the mix, it’s easy to see why new pathways to licensure impact more and more dental school seniors each year.

As a result, the 2018 survey contains several new questions that reflect these changes in the licensure landscape. What do the answers reveal? While the various single encounter, procedure-based exams administered at the state or regional level continue to represent 75% of the licensure pathways pursued by this year’s graduates, a substantial minority of the class of 2018 pursued or planned to pursue an alternative pathway. Because some individuals seek licensure through more than one pathway, it’s hard to share precise numbers. The survey suggests, however, that as many as 1,500 seniors may have taken advantage of alternatives to regional and state exams in 2018.

That would not have been possible a decade ago, but the survey also tells us that much remains the same. A full 89% of respondents said the second most influential factor in their choice of pathway was that the chosen exam was the only one accepted in the state where they intend to practice.

For more on this ADEA priority, be sure to read next month’s Charting Progress, which will discuss how the Report of the Task Force on Assessment of Readiness for Practice released in September creates a roadmap for change in dental licensure.


For the first time, this year’s survey included 16 questions related to student well-being, a topic I addressed in Charting Progress in July 2017. At the time, ADEA was taking steps to respond to rising concerns about burnout, depression and suicide among health professionals and a possible precursor to these problems: student stress.

I’m pleased to report that responses to the well-being questions were high—and encouraging. Almost 90% of responding students indicated that they “always find new and interesting aspects” of their dental school experience, and more than 90% indicated they usually can manage their dental school workload and cope with the attendant pressures.

At the same time, similar numbers of students sometimes feel overwhelmed, and a smaller majority of students report that they often feel “worn out and weary” or “emotionally drained” at the end of the day. These findings suggest that our recent emphasis on student wellness is well placed, and that continued efforts to boost student resilience and well-being are warranted. ADEA remains engaged in this work, through the ADEA Commission on Change and Innovation in Dental Education, through various ADEA councils and as an inaugural sponsor of the Action Collaborative on Clinician Well-Being and Resilience at the National Academy of Medicine.

For more on this ADEA priority, see the American Dental Education Association (ADEA) Statement on Commitment to Clinician Well-being and Resilience.

Serving the underserved

The survey also reveals continued engagement in two areas of perennial concern to ADEA: preparing students to practice interprofessionally and care for underserved populations. Schools have taken a number of steps to enhance student preparation in both these areas, and the survey respondents indicated that those efforts are paying off.

More than 90% of seniors expressed confidence in the preparation they received in the areas of cultural competency, behavioral and social determinants of health, and dental care for LGBTQ and racially, ethnically or culturally diverse groups—populations that are often underserved. Despite feeling well-prepared to take on this effort, only 61% of respondents said they planned to work in an underserved area at some point in their careers. It’s probably worth exploring why the remaining respondents have ruled out this avenue for practice. On a more encouraging note, 645 students indicated they planned to work in an underserved area immediately after graduation.

For more on this ADEA priority, visit these pages on the ADEA website:
Children’s Health Insurance Program (CHIP)
Medicaid Dental Services
ADEA Student Diversity Leadership Program

Interprofessional education (IPE)

Most ADEA members know that we’ve spent much of the last decade encouraging IPE as a means to prepare dental students for collaborative practice. As a founding member of the Interprofessional Education Collaborative (IPEC), we’ve helped define the nature of IPE and support a series of IPEC Faculty Development Institutes and other events that have helped our members implement IPE on their campuses.

Given this investment, it’s not surprising that 82% of this year’s seniors reported taking part in a wide variety of IPE experiences that helped them gain a better understanding of the roles of other health professions in caring for patients.

The survey indicated that 68% of dental students in the class of 2018 interacted with nursing students, 64% with pharmacy students and 44% with medical students during their dental education. Although seniors reported that classroom activities predominated, the survey also showed that more than a third of IPE activities were clinical, and some involved research. Seniors also indicated that they had ample opportunities to engage in volunteer activities with students from other professions. The vast majority of seniors, 83%, agreed that they had benefited from working with other health professions students.

For more on this ADEA priority, visit these pages on the ADEA website:
20 Years Beyond the Crossroads: The Path to Interprofessional Education at U.S. Dental Schools
All Together Now: Realizing IPE at Academic Health Centers
What jumps out at me from the review of data is that a sizable portion of the students who plan to pursue careers in teaching or serving the underserved are ready to implement their career plans. I don’t want to infer too much from the survey findings, but might they suggest that our efforts to move beyond simple exposure to create immersive educational experiences in these areas is giving students the confidence to take the road less traveled?

Dental students’ desire to engage in these pursuits immediately after graduation is heartening. Of course, this will take time; it will be a few years before these graduates have all embarked on their careers, as many of their fellow seniors have moved on to advanced dental education programs. I’m eager to see how the entire class of 2018 takes on the world.
It’s worth noting that this year we piloted a customized version of the ADEA Survey of Dental School Seniors with students at Canadian dental schools. Each Canadian school has its own exit survey, so it may be some time before response rates on the new ADEA survey allow us to gain clear perspective on seniors’ experiences north of our common border. Nevertheless, our Canadian colleagues have expressed a desire to continue working with us to create a fuller picture of dental education in North America. The annual senior survey is one valuable tool in that pursuit.

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.”