Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic shares the results of a recent study and strategies that schools are employing to keep dental education costs in check.

Last month, the American Dental Association (ADA) House of Delegates received the results of a study that should be of particular interest to the dental education community. It hasn’t received much fanfare, but the report—which classifies dental education models, examines revenues and expenses, and evaluates the community’s preparedness to engage in research—stands apart as the first research-based effort to get a handle on what is driving the cost of dental education.

At the request of the ADA House of Delegates, Cavanaugh Hagan Pierson & Mintz, a management consulting firm with a strong focus on the health professions, teamed with ADEA to analyze which factors contribute to the cost of dental education and to see if there might be steps that dental schools could take to keep costs in check.

The ADA Study on Approaches to and Implications of Alternative Dental Education Models found that many of the variables that predict dental school expenditures mirror those that predict expenditures in higher education generally: the size of the faculty, the number of students and the cost of living in any particular school’s locale. But to the disappointment of some, the analysis found no “magic bullet” that all schools could seize to improve their efficiency. In other words, it found no correlation between curricular models and costs.

“The unique design and delivery of predoctoral education at every school means that each has to figure out how to deal with cost on its own,” said ADA Trustee Robert Bitter when we spoke last month.

Bob represented the ADA on the joint ADA-ADEA Study Group that helped to inform the research effort. As a periodontist who joined the faculty at Southern Illinois University School of Dental Medicine two years ago, and as the father of a recent medical school graduate, Bob is concerned about the cost of professional education. But the study convinced him that there are no simple solutions to the cost conundrum.

“What will work for each school depends on its mission, its location and how it chooses to engage in research,” Bob said.

Nader Nadershahi agrees. You may know him as the Dean of the University of the Pacific, Arthur A. Dugoni School of Dentistry. He is also a member of the ADA House of Delegates, and in that capacity, he represented that association on the ADA-ADEA Study Group.

“I was hoping if we looked, there would be one or two models of efficiency that stood out,” Nader told me, “but the cost of delivering care in an educational setting is very high and very inefficient.”

Few would argue that point, but just because dental education is inherently expensive, it doesn’t mean individual schools can’t take steps to reduce costs and increase revenues.

At Rutgers, The State University of New Jersey, School of Dental Medicine (RSDM), the Dean and Chair of the ADEA Board of Directors, Cecile Feldman, has focused on keeping her school fiscally sound through revenue diversification. She also served on the ADA-ADEA Study Group, and before that, on the 2012–2013 ADEA Presidential Task Force that looked at the cost of higher education and student borrowing, so she is very familiar with the issues.

“Before ADEA undertook the cost and borrowing study,” she told me, “some people believed that dental schools didn’t care about cost but that’s contrary. It’s something we are extremely sensitive of. We want to do right by students. We’re constantly striving to bring in more revenue to keep costs as low as possible.”

Cecile has managed to augment and diversify her school’s income streams by keeping an eye on opportunities at the federal and state levels. She and her colleagues have also had a hand in creating some of those opportunities. For example, RSDM, ADEA and others advocated for the inclusion of dental schools as eligible entities in the federal program that subsidized the adoption of electronic health records. RSDM acquired $3 million in federal funds from that source alone, and another $26 million in state funds for capital improvements.

“If you’re not paying attention to what’s going through Congress or your state legislature,” Cecile says, “you’ll miss things you can really use and leverage to help move things forward.”

RSDM has also gotten managed care companies to improve their fee schedules and has dramatically grown its continuing education program—two other ways that schools can increase revenues.

Nader also has some bold ideas to add to that mix. He sees curriculum sharing as one way to lower costs for all dental schools. “If we were all collaborating,” he told me, “schools could shoulder a small percentage of the cost of developing high-quality content but have access to 100% of it.”

He’d also like to see government provide greater support for the safety-net care that dental schools deliver. “If all dental school clinics were identified as federally qualified health centers and had a per-encounter reimbursement rate,” he believes, “that would be a game changer.”

Bob Bitter also thinks government has a role to play, and he points to the steady disinvestment of states in higher education as one source of today’s educational-cost woes. What can the ADA do about that?

“We’ve advocated on behalf of our students for debt relief and lower interest rates on their educational loans,” Bob told me. “We need to begin advocating for our institutions as well.”

The ADA’s recent report provides an excellent basis for such efforts. By assembling data to inform a discussion that previously consisted of anecdotes and sometimes outdated assumptions, that association has already made a major contribution and given us a fresh look at the cost conundrum.

 

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic previews a groundbreaking overseas meeting and describes other milestones in ADEA’s journey to advance global cooperation in dental education.

Question: What do Uganda, Sri Lanka and Peru have in common?

Answer: You can find Journal of Dental Education (JDE) readers in all three countries—not to mention in scores of others around the globe.

In a single week this past August, JDE articles were downloaded or viewed online more than 100 times in Finland, Turkey and Malaysia. JDE articles were accessed more than 1,000 times in Australia, India and Germany—and thousands more times across another 90 countries. If these statistics don’t confirm the JDE’s role as a vehicle for disseminating knowledge internationally, I don’t know what would.

As impressive as the numbers may be, they represent just one facet of ADEA’s current strategic commitment to “[s]erve as a collaborative partner in the global effort to improve oral and overall health.” In fact, ADEA began looking outward long before these words were enshrined in our strategic directions. In 2005, ADEA cofounded the International Federation of Dental Educators and Associations (IFDEA), and in 2007, our Association met with colleagues from 66 nations at an IFDEA summit in Dublin, Ireland, to launch a new era of international collaboration. Today, that global effort—temporarily slowed by the economic impacts of the recession—is going strong, and dental educators from around the world are looking to ADEA as a valued resource and partner.

In an era of increasing globalization, it comes as no surprise that U.S. dental educators are contributing to change and innovation at both established and newer dental schools on every continent (see the Spring 2015 ADEA CCI Liaison Ledger). Many large U.S. universities now have satellite programs abroad, and a few of these include global outposts of their dental schools. An association known as the Consortium of Universities for Global Health has grown exponentially in recent years, and its Global Oral Health Interest Group was one of the first special interest groups to be approved by that organization.

ADEA is also actively engaged in a wide range of activities that benefit our international colleagues and enlarge our own understanding of dental health and education. We can boast three global initiatives in 2016 alone and a groundbreaking event planned for 2017. Let’s start there, because I hope I can entice some of you to join us in London next spring for ADEE/ADEA 2017—the first joint meeting of ADEA and the Association for Dental Education in Europe (ADEE).

This highly interactive meeting will focus on four themes and give participants an opportunity to take part in shaping the future of dental education. How? Up to six hours of protected discussion time has been set aside so that attendees can engage in substantive discussion and work to develop a consensus around best practices related to four areas: 

Senior faculty from both continents will serve as chairs and facilitators for each working group, and a handpicked cadre of junior faculty will serve as rapporteurs, assisting the workshop facilitators in two ways: by participating in the literature review process that will precede the meeting and by writing four position papers that will capture the attendees’ views. These papers are intended to help guide ADEA and ADEE members in responding to the challenges and opportunities that lie ahead for dental education, and I, for one, am excited to see what writing them collaboratively will reveal.

We anticipate that representatives from around the world will attend the meeting, scheduled for May 8–9, 2017. In addition to the working sessions, the meeting will feature:

  • A keynote address by medical futurist, university lecturer and widely published author Bertalan Meskó, M.D., Ph.D.
  • A reception in the magnificent Governors Hall of St. Thomas’s Hospital in the heart of London.

The call for posters is now open, and registration for the meeting will open by early December. I hope to see many of you there.

The joint meeting builds on our longstanding close relationship with ADEE and the conscious effort we have made for decades to reach out to the global dental education community. In 2016 alone, we added a feature to the JDE website allowing readers to translate the html text of articles into 90 languages—vastly increasing their accessibility to our overseas readers. We hosted a three-day ADEA CareerCon—an online gathering designed with foreign-trained and North American dentists in mind. And we entered into a Memorandum of Understanding with our sister association in Japan, the Japanese Dental Education Association (JDEA). The JDEA represents all 29 Japanese dental schools, and we look forward to sharing our expertise and developing joint initiatives to advance the mission, vision and objectives of each organization.

Where else has this global journey taken us? In recent years, ADEA members and staff have traveled to international meetings in Riga, Latvia; Szeged, Hungary; Bangkok, Thailand; and Poznań, Poland, to name a few. We’ve hosted five ADEA International Women’s Leadership Conferences in Canada, Sweden, France, Brazil and, most recently, in Barcelona, Spain—where we collaborated with ADEE to sponsor an international workshop on global standards for dental education.

Closer to home, we’ve been busy contributing to a thriving virtual community of educators hungry for materials to build or enhance the curricula used to prepare new dentists for practice in their home countries. These educators can avail themselves of a host of free online teaching, learning and assessment resources and materials through:

  • MedEdPORTAL®, our open-access curricular collaboration with the Association of American Medical Colleges.
  • ADEA weTeach®, a user-friendly gateway—launched this past year—providing teaching, learning and assessment resources.
  • The ADEA Curriculum Resource Center, a web portal that, in addition to containing high-quality learning materials (curriculum guides, slide decks, bibliographies, case studies and handouts designed to be easily incorporated into faculty-developed courses), also supports the work of dental educators abroad.

As mentioned before, our journal, the JDE, plays a central role in extending ADEA’s global reach. In addition to publishing several dozen articles in recent years that focus on global health, the JDE also provides content specifically aimed at its international readers. Two examples: A 2013 Perspectives piece by two Australian dental educators provides guidance for international authors on scholarly research and writing, and a 2014 paper describes U.S. career pathways for foreign-educated dentists.

While U.S. authors continue to lead in JDE submissions, the journal has seen a steady flow of manuscripts from other shores. Indian and Brazilian authors have averaged 85 and 32 submissions a year, respectively, since 2010, and our colleagues from Canada, Iran, Turkey, China, Australia and Malaysia also have an impressive record of submitting manuscripts for consideration. Submissions from Saudi Arabia have grown at an especially rapid rate—from six in 2010 to 38 in 2015.

ADEA also serves students from other countries through ExploreHealthCareers.org. A leading resource for individuals seeking information about health careers, the website has logged over 340,000 visitors from outside the United States in the year ending August 2016.

Of course, international collaboration lies at the heart of our Association in a fundamental way that we sometimes overlook. Because ADEA represents both Canadian and U.S. dental schools and programs, we are continually prompted to view the issues that confront us through an international lens. Given the position the United States holds in the world, sustaining that outlook can be a challenge for many of us. Fortunately, cooperative agreements and frequent interaction with our sister associations around the world remind us to look outside our borders and engage with colleagues who bring an international perspective to our discussions. I look forward to experiencing this interchange firsthand in London and seeing where our global journey takes us next.

Related content from previous issues of Charting Progress

The Personal Becomes Political: A Global Phase Down of Dental Amalgam
A Small Step for Global Health With Big Implications for Dental Education
Dental Education: An Expanding Universe 
A Warm Day in Adelaide

Dr. Richard ValachovicIn this month’s Charting Progress, Dr. Rick Valachovic reflects on the remarkable progress made by those who have championed interprofessional education and where this effort stands today.

Last month, many of us woke to the sad news that Harrison Spencer, my counterpart at the Association of Schools and Programs of Public Health (ASPPH), had died. If you were not privileged, as I was, to know Harrison, this tribute will give you some sense of the extent of our loss. Harrison had a stellar clinical and research career before devoting himself full time to academic public health. In that capacity alone he leaves a rich legacy, including as a champion of interprofessional education (IPE).

Alongside ADEA and four other sister associations, ASPPH was one of the founding members of the Interprofessional Education Collaborative (IPEC). IPEC has seen tremendous growth since its inception in 2009, and its influence in establishing IPE as an integral part of health professions education has become more marked with each passing year. In 2012, the IPEC founders helped sponsor two influential workshops on IPE, organized by the Global Forum on Innovation in Health Professional Education at the National Academy of Medicine (formerly the Institute of Medicine). In 2014, the independent educational accreditation bodies of the six health professions represented within IPEC formed the Health Professions Accreditors Collaborative to further facilitate the ability of our schools to prepare graduates for collaborative practice. Last month, the National Center for Interprofessional Practice and Education recognized IPEC with  a Pioneer Award for creating the IPEC Core Competencies for Interprofessional Collaborative Practice. And this coming year, the Summer Medical and Dental Education Program will become more broadly interprofessional, engaging the schools and students of other health professions under a new name: the Summer Health Professions Education Program. (If you aren’t familiar with this outstanding preparatory program for students who are underrepresented in the health professions, take a look at this earlier issue of Charting Progress.)

Last month I spoke to Lucinda Maine, Ph.D., RPh, Executive Vice President and CEO of the American Association of Colleges of Pharmacy, another IPEC founder, to take stock of where we stand with IPE.

“I believe IPE is at the tipping point,” she said, invoking author Malcolm Gladwell. “Students like it, our accrediting bodies say we will do it, and selectively employers are telling us they need more team-ready clinicians to hire. The demand side will pull us further and further along the path.”

Indeed, that demand is growing, and the progress we’ve made to date suggests we will be able to meet it. Our schools no longer view IPE as an optional luxury, and the proof is that required IPE learning experiences are rapidly supplanting elective ones. A full 92% of medical schools reported having a mandatory IPE experience in 2014, and that same year, 69% of dental schools reported requiring IPE. That is double the figure from just two years earlier.

Other professions have taken note, and they are eager to join us in this endeavor. IPEC responded this year by expanding its ranks to include an additional nine institutional members, most of which had been supporting members of the collaborative since 2011. We held our inaugural Council meeting in June, and the level of engagement was remarkable, reminding me of the energy we founding members felt at the start of this journey.

Back then, two ADEA Past Presidents, Sandra Andrieu, M.Ed., Ph.D., and Leo Rouse, D.D.S., FACD, carried the IPE torch for our Association. Both were involved in drafting the IPEC Core Competencies, which have become the gold standard for developing IPE initiatives since they were published in 2011. To ensure this influential document’s continued relevance, IPEC recently revised it to organize the competencies within a single domain of Interprofessional Collaboration and broaden them to better achieve the Triple Aim framework that is guiding health care reform.

The competencies have been instrumental in firmly grounding IPE in the curricula of numerous health professions schools, but we have another IPEC initiative as well to thank for recent progress. Since 2012, the collaborative has been hosting a series of IPEC Institutes, where teams from participating schools develop curricular ideas they can implement when they return home. To date, these teams have included members from an almost unimaginable diversity of professions—60 at last count—which speaks yet again to the enthusiasm we’re seeing for interprofessional collaboration. (If you’re curious about the non-health professions among our IPE collaborators, see The Changing Face of IPE and Collaborative Care.)

Another ADEA Past President, Ron Hunt, D.D.S., M.S., has been to so many IPEC workshops that the organizers call him a “frequent flier.” His attendance at six workshops in four years says a lot about the challenges of getting IPE off the ground and about the ability of the IPEC Institutes to jumpstart the process.

As Associate Dean for Academic Affairs, Midwestern University College of Dental Medicine-Arizona, Ron was on the first interprofessional team his university assembled in 2012. With an IPE accreditation standard “pointing the way,” the then Dean of the College of Pharmacy funded the expedition of Midwestern senior administrators to attend an IPEC Institute that fall. Ron told me they returned with plans for a first-year course that were “overly ambitious” and soon scuttled when the representative of the medical faculty left the university.

Following a subsequent institute, plans were derailed yet again. The creation of a new college at Midwestern-Arizona and the adoption of a new university accreditation theme shifted university priorities and resources, leaving IPE with limited institutional support. Nevertheless, the pressure on the College of Pharmacy and others to address IPE-related program accreditation standards propelled the process forward.

At a third IPEC Institute, Ron and his colleagues finally hit on a winning idea they could sell back home. The IPE module they developed fit neatly into an existing introduction to the health professions course, and after a successful pilot, the module was expanded to include all entering students on campus.

Building on this initial success, Midwestern sent three more teams to IPEC Institutes. They have developed an IPE experience that brings pharmacy students into the dental clinic to consult with dental students on patient care, and an innovative elective on patient safety that combines online, classroom and community-based learning.

“We could not have done it without the IPEC workshops,” Ron told me. “You get the expertise of the keynote speakers, but probably even more important, you get the concentrated, unobstructed time to work with your team. There are no distractions from students or anything else. Each of the times we attended, we got a lot accomplished.”

The IPEC Institutes are still going strong, with the next one scheduled to begin on October 5.

These developments all suggest that IPE has indeed reached a tipping point. Nevertheless, realizing our collective vision of a flourishing IPE enterprise throughout health professions education will take more time, energy, thoughtful action and resources.

“Many institutions have done a good job of creating classroom and simulation-based interprofessional learning opportunities, but we need to do more to assess IPE and make sure it is relevant to students,” says Jeff Stewart, D.D.S., M.S., Associate Professor in the Department of Pathology & Radiology at the Oregon Health & Science University School of Dentistry. Jeff chaired OHSU’s Interprofessional Initiative Steering Committee for the past five years, and he believes the next push will be to provide more clinical opportunities for interprofessonal learning through patient care.

In October, Jeff will be joining ADEA as Senior Director for Institutional Innovation and Development. In that capacity, he wants to play a role in ensuring that dental and allied dental education remain prominent participants and leaders in the future evolution of IPE, a goal I share.

When I asked Lucinda about the challenges before us, she pointed out that at most of our institutions, the responsibility for IPE still rests on the backs of willing volunteers. “Upper-level administrators need to see IPE as a mission-related activity that requires financial and human resources to sustain over time,” she said.

I couldn’t agree more. Meanwhile, champions like Lucinda, Jeff, Ron, Leo, Sandra and Harrison have been critically important in bringing us to where we stand today. With students, employers and accreditors as our allies, full IPE implementation is no longer a matter of if, but of when.

Related content from previous issues of Charting Progress

The Changing Face of IPE and Collaborative Care
Interprofessional Collaboration Benefits ADEA and Its Partners
Recent Developments on the IPE Front
IPE Is Here to Stay
Paving the Road to Interprofessional Practice
Crossing the Interprofessional Divide 
Interprofessional Practice Can Play Leading Role in an Academic Setting 

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic discusses the U.S. Supreme Court’s recent decision regarding the use of race as one factor in holistic admissions decisions at the University of Texas at Austin.

June has come and gone, and universities around the country are breathing a collective sigh of relief. The Supreme Court has finally ruled on the role of race in admissions in higher education.

During the just concluded term, the Court revisited the case of Fisher v. University of Texas at Austin (Fisher II) and ruled that the race-conscious admissions program used by the university was lawful under the Equal Protection Clause of the 14th Amendment. The University of Texas at Austin (UT) instituted a holistic admissions program, which allowed the consideration of race as one of many factors in the admissions process. Although the approach to college admissions used at UT is unique, the Court’s decision signaled that the higher education community stands on solid ground when using race as one factor in holistic admission programs.

The Court first heard Fisher (now known as Fisher I) in 2013 but declined to render a decision. Instead, the justices remanded the case to a lower court to determine whether UT’s admissions policy met the standard of “strict scrutiny.” In other words, the justices wanted the lower court to determine whether the use of race-conscious policies achieved a level of diversity in practice that the university could not achieve through race-neutral policies alone. (For a fuller history of the original case, see my August 2013 Charting Progress.) In 2015, the lower court held that the university had indeed met the strict scrutiny standard, and once again, the case went back to the Supreme Court.

In Fisher II, the most recent decision, the Court affirmed earlier rulings that recognized the value of diversity in educational settings. Justice Anthony Kennedy, writing for the majority, stated, “[T]he compelling interest that justifies consideration of race in college admissions is not an interest in enrolling a certain number of minority students, but an interest in obtaining ‘the educational benefits that flow from student body diversity,’” a phrase quoted from the Fisher I decision.

ADEA views the Supreme Court’s ruling as critical to acknowledging the unique value that diversity brings to students, staff and faculty throughout dental education. ADEA demonstrated its commitment to diversity in higher education by signing onto three amicus briefs that were submitted to the Supreme Court in the case (No. 11-345 in 2012, No. 09-50822 in 2013 and No. 14-981 in 2015). Our Association is proud of its leadership role in championing access, diversity and inclusion, most visibly through the promotion of holistic review—a balanced assessment of each candidate’s experiences, attributes and metrics—in admissions to our academic dental institutions.

Since 2005, we have been offering training and technical assistance to member schools in how to implement this approach to screening applicants, and our efforts have had a measurable impact. A noteworthy 93% of dental schools reported that they used holistic review in a 2014 survey of schools of the health professions, and other health professions educators are looking to learn from our example.

In the past year, ADEA staff and holistic review trainers from our member institutions have presented at both nursing and pharmacy education conferences and at schools of veterinary medicine. We will embark on a new chapter in our diversity efforts in October, when we will host two sessions focused on unconscious bias at the ADEA Fall Meetings. In 2017, the University of Michigan and the University of Florida will also pilot unconscious bias workshops modeled after those developed by the Association of American Medical Colleges Learning Lab. These workshops will be customized for our schools and programs and, if the pilot goes well, we hope to make this training widely available by next summer.

The CODA Predoctoral Accreditation Standards include three dimensions of diversity:

  • Structural or compositional diversity, which refers to the makeup of the student body, faculty and staff at a program or institution.
  • Curricular or classroom diversity, which refers to the presence of content that promotes the integration of skills, insights and experiences from diverse groups in academic settings.
  • Institutional or interactional diversity, which focuses on each school’s climate or environment and whether it values diversity and provides opportunity for informal learning among diverse peers.

There is still much work to be done on all three of the fronts designated in the CODA standards, and the Fisher II ruling made clear that the Court will be watching to see whether institutions go about that work in ways that are consonant with their missions and “narrowly tailored” to meet precise goals. Justice Kennedy concludes, “The court’s affirmance of the University’s admissions policy today does not necessarily mean the University may rely on that same policy without refinement. It is the University’s ongoing obligation to engage in constant deliberation and continued reflection regarding its admissions policies.”

Over time, these decisions affect not only our schools, but also the ability of all people, including the uninsured and economically disadvantaged, to access dental care from dental providers from varied cultural backgrounds. These issues are important, within our community and beyond.

Related content from previous issues of Charting Progress

Preparing to Lead in the Post-Fisher Era
Diversifying the Dentist Workforce, One Cohort at a Time
Number of American Indian Dentists Experiences Amazing Growth Spurt
Can a Girl From the Caribbean Find Happiness in Nebraska? Tales from the AAMC/ADEA Summer Medical and Dental Education Program
Math Literacy: A New Civil Right for an Information Age
Getting the Whole Story: A Holistic Admissions Process
Today’s Students-Tomorrow’s Colleagues

 

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic, ADEA President and CEO, shares new evidence of sugar’s harmful health effects and asks how the dental education community might capitalize on growing public interest in limiting sugar intake.

Public willingness to address the health effects of sugar may be reaching a tipping point. Last month, the city of Philadelphia passed a tax on sugar-sweetened beverages, becoming the first major U.S. city to overcome resistance to such a measure. Berkeley, California’s residents passed a comparable tax in 2014, but according to the New York Times, this liberal enclave’s success was unique. Forty other municipal and state government attempts to pass similar measures all failed—until now.

Philadelphia’s soda tax—which proponents framed not as a public health measure but as a revenue generator for universal preschool—has given hope to advocates who are alarmed about the nation’s obesity epidemic and the growing body of scientific evidence linking excess sugar consumption to a range of systemic ills.

The World Health Organization (WHO); celebrity chef Jamie Oliver; and former Mayor Michael Bloomberg, who attempted to ban the sale of large-size sugar-sweetened beverages in New York City, have all brought much-needed attention to the hazards of sugar consumption, but no one has beaten the anti-sugar drum quite so steadily as Robert Lustig, M.D., M.S.L., a Professor of Pediatrics in the Division of Endocrinology and a member of the Institute for Health Policy Studies at the University of California, San Francisco. Dr. Lustig authored the best-selling book Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease and now serves as President of the Institute for Responsible Nutrition, a nonprofit organization dedicated to reducing the nation’s appetite for sugar.

This past April, Dr. Lustig gave the opening keynote address at the National Oral Health Conference. The title of his presentation was “Tooth Decay and Liver Decay: The Nexus Between Doctors and Dentists.” You can find his slides online if you want a more detailed explanation, but the bottom line is this—added sugars in our diets cause both dental caries and liver disease.

Dr. Lustig doesn’t mince words about the severity of sugar’s impact on human health. In his view, sugar is a “toxic” substance every bit as dangerous as alcohol. He believes public policies should limit the availability of the first just as they do the availability of the second.

I’ll leave it to our endocrinologist colleagues to evaluate Dr. Lustig’s assertions about liver disease, but his points about caries are more than familiar. I saw the effects of sugar first hand as a pediatric dental resident at Children’s Hospital in Boston. It’s hard to imagine now, but the city lacked community water fluoridation at that time, and we saw high levels of childhood caries as a result.

Jessica Lee, D.D.S., M.P.H., Ph.D., Chair and Director of Research for the pediatric dentistry department at the University of North Carolina at Chapel Hill (UNC) School of Dentistry, is outspoken about the need to address sugar’s causal role in tooth decay. She and Beau Meyer, D.D.S., pediatric dental resident, co-authored a commentary in the October 2015 issue of the Journal of Dental Research calling on policymakers to “be courageous” in developing policies to curb sugar intake and urging the scientific community to raise its voice in support of evidence-based policies.

I reached out to get their thoughts on what the dental education community should be doing to raise awareness among students about the effects of sugar on both dental and overall health. Beau, who is currently pursuing a Master of Public Health degree at UNC, told me they would like to see more emphasis on advocacy in the predoctoral curriculum.

“That goes beyond telling students they need to be advocates and meet with their Congressmen,” Beau said. “I’d like to see something that gets down to the nuts and bolts.” He envisions interprofessional workshops, field experiences and informal opportunities to “lunch and learn” that would teach students how to interact with a legislator, make that first phone call, find appropriate resources and build on established relationships between the state dental society and state legislators. But his vision extends beyond these practical concerns.

“Learning how to see beyond the patient in your chair and look at your practice and how it fits into the community as a whole—it’s a different way of thinking,” he told me, “and it’s a challenging way to think.”

Jonathan Shenkin, D.D.S., M.P.H., couldn’t agree more. Jonathan is Clinical Associate Professor in the Departments of Pediatric Dentistry and Health Policy & Health Services Research at the Boston University Henry M. Goldman School of Dental Medicine.

“When I talk to dental students, I beg them not to think of their futures as treating the patients who walk through the doors,” Jonathan told me. “Being able to change policies so you can improve the health of everyone, not just the people who pay you—it’s the most critical thing we teach students.”

Not surprisingly, Jonathan is excited by the implementation of the soda tax in Philadelphia, and believes such measures will begin catching on around the country. He sees an opportunity for dental professionals to join in this effort to curb sugar consumption and hopes it will have the same impact that tobacco taxes had on smoking.

“We have parallel etiology—sugar—for obesity and for tooth decay. This is a great opportunity to engage the public health and medical communities in helping our patients address the obesity crisis and the oral health crisis at the same time. It can only be positive,” Jonathan believes.

I agree, but given all the attention currently focused on sugar’s contributions to obesity and other aspects of overall health, the challenge may be to keep tooth decay in the conversation. There’s no doubt that it deserves the attention of the dental community. In the same issue of the Journal of Dental Research mentioned earlier, two London-based researchers remind readers that “free sugars” (those found in processed foods, syrups and juices) are the principal (and in their view, the only) cause of caries. They argue that our focus on the other factors—fluoride, bacteria—that mitigate and feed the disease, have taken our eye off the primary culprit. The authors conclude, “Dental caries is a diet-mediated disease,” and they add that “to stress the multifactorial effects on the sugars-induced causal process muddies our understanding and misdirects policy.”

Might it also suggest that we need to reevaluate the role of nutrition and its relationship to the oral-systemic connection in our curricula? I called Rebecca Wilder, B.S.D.H., M.S., another Professor at the UNC School of Dentistry who serves as Director of both Faculty Development and Graduate Dental Hygiene Education. She and her colleagues conducted a survey of North Carolina dentists and dental hygienists to ascertain their knowledge, attitudes and practice behaviors related to oral-systemic disease. They found that respondents were generally knowledgeable but often fell short when it came to putting their knowledge into practice.

“In dental hygiene, we’ve observed these connections for years,” Rebecca told me. “To finally have some science to say yes, these connections have been validated, has been a relief in some respects. Now the challenge is figuring out how to incorporate this into patient care.”

She is encouraged by the recent willingness of pediatric dentists to counsel the parents of their overweight patients about the risks associated with obesity, and she sees room in the curricula to encourage similar efforts for oral-systemic disease.

“I could envision an interprofessional course on oral-systemic disease where sugar is discussed extensively. Students would learn about its detrimental effects—not only orally, but systemically—so they could collaborate on patient care and patient education in the future. Once we have evidence-based knowledge, we have to take the onus as professionals to be assertive and talk to our patients about these issues.”

This fall, I’ll be attending a conference sponsored by a coalition of oral health and pediatric groups with support from the Robert Wood Johnson Foundation. The goal of this meeting is to engage the oral health community in efforts to prevent childhood obesity. Judging from the preliminary agenda, sugar-sweetened beverages will take center stage.

As for the value of soda taxes, it’s too soon to know what their impact will be on the residents of Berkeley or Philadelphia, but we might infer a few things from our neighbor south of the border. Mexico leads the world in soda consumption, and its rates of obesity and diabetes are similar to those in the United States. After Mexico instituted a tax on sugar-sweetened beverages at the start of 2014, researchers at UNC and Mexico’s National Institute of Public Health found a 6% drop in soda purchases compared with previous years. Mexican cola bottlers begged to differ, citing rising sales, but the researchers are sticking by their methodology and offer even brighter news for 2015. They say soda sales were 8% lower than pre-2014 averages, and bottled water purchases were up 4%. In the years ahead, I’ll be watching to see whether the incidence of caries falls as well.

Related content from previous issues of Charting Progress

Setting the Record Straight on Fluoride
Managing Caries Risk: A Paradigm for the 21st Century? 

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic, ADEA President and CEO, looks at two trends that are paving the way for individualized learning—virtual reality and serious games.

If you subscribe to The New York Times, you may have recently received something curious in the mail: a sturdy cardboard box with oddly shaped cutouts, strategically placed Velcro tabs and two plastic lenses. The Google Cardboard viewer is remarkably similar to the 3-D viewers that have been around since the dawn of photography, but with one important distinction: Instead of a slot for slides, the box contains a space for a smart phone. Download a virtual reality app such as NYT VR, call up a video on your smart phone and you can use the box to immerse yourself in a virtual world. Look right. Look left. Gaze up. Gaze down. Turn around, and your view continues seamlessly in every direction. Not only is the image before you three-dimensional, your view has no boundaries, like the world itself.

In education, we’ve been using the term “virtual reality” for years to describe artificially created experiences that simulate real-world conditions and allow learners to practice their skills. Role-playing activities of all sorts—even those that were merely text-based or incorporated only still images—once earned this moniker, but as time has passed, we increasingly use the term to denote digital technologies, especially those that strive to replicate the look and sound and even the tactile sensations of an experience.

In 2003, Second Life—the web-based world where many universities and a few dental schools established virtual outposts—began allowing users to log in from their computers and socialize, learn and conduct business with people across the globe. Today, if you’re willing to spend some serious money, the Oculus Rift and its Touch controllers will give you a much more engaging virtual-reality experience. Although the technology is primarily used to play video games at present, some observers predict that its widespread educational applications will not be far behind. According to Fortune magazine, the U.S. military, a pioneer in the use of educational simulation and gaming, is already employing the Oculus Rift to train soldiers to use the Patriot air defense system.

While I don’t know of any ADEA members currently working with this particular virtual reality technology (if you are, please let me know), I just learned that Meharry Medical College School of Dentistry and the Case Western Reserve University School of Dental Medicine have been approved as developer sites for the Microsoft HoloLens holographic simulation technology, which may someday help students visualize anatomic structures and surgical techniques. I’ll be keeping my eyes on that project, slated to begin later this year.

Meanwhile, the use of nonholographic simulation is well-established in dental education and in recent years has become more sophisticated. DentSim—manufactured by ADEA Corporate Member Image Navigation Ltd.—and the other augmented-reality dental-training simulators on the market introduced computer visualization and assessment to traditional preclinical learning. These systems provide precise and immediate feedback—during a procedure and after it is completed—freeing up faculty and allowing students to perform more preparations than they would otherwise be able to. Since practice makes perfect, the advent of computer-assisted simulation represents a major advance over working on typodonts unaided.

The introduction of haptics—the science of integrating the sense of touch into computer applications—has added yet another dimension to simulation in the preclinical arena. ADEA Corporate Member MOOG—working with Academisch Centrum Tandheelkunde Amsterdam (ACTA), a Netherlands-based dental school—was the first to harness this technology for dental education. Their Simodont® Dental Trainer creates a simulated learning environment in which students can practice a wide range of psychomotor skills and procedures while receiving the same type of feedback provided by earlier virtual-reality simulators. Working with Novint Technologies, our colleagues at the Harvard School of Dental Medicine (HSDM) have developed an advanced prototype for another haptic simulator, the Virtual Reality Dental Training System, which may also be widely available one day.

Haptic simulators represent a significant step forward in simulation fidelity and efficiency. They eliminate the need for typodonts and manikin heads, and most everyone who has tried these systems is wowed by their ability to replicate the feel of dental instruments interacting with different types of human tissue. While some evidence suggests that students trained using haptic devices perform better than their peers, the body of research supporting the use of haptics in clinical education remains limited, and they face another barrier to widespread adoption: their upfront costs.

To get a read on this issue and other advances in learning technology, I called Elise Eisenberg, D.D.S., M.A., Senior Director of Informatics at New York University College of Dentistry, who has been following these developments for years.

“Schools want to know if a given technology will enable more efficient and effective pedagogies,” Elise told me. “Will they improve the economics of delivering education and the potential for student success?”

Even though digital simulation systems obviate the need for purchasing typodonts and other disposable items and reduce the number of faculty needed to assess preclinical performance, they are not widely perceived as affordable—at least that’s the impression of several people with whom I spoke. Issues of cost aside, Elise sees a compelling reason to bring virtual reality into preclinical and specialty education: The generation of students just now entering dental school is seeking a different type of education.

“Generation Z’s approach to learning is much more personalized, not as prescriptive,” Elise says, “and virtual reality allows for that type of learning.”

Generational learning preferences are even more salient in the latest pedagogical trend: gamefication. If you’re not familiar with the concept, this infographic provides a quick introduction. In a nutshell, gamefication is about applying the elements of game play—entertainment, competition, rewards and such—in other contexts. In the educational arena, some innovators are taking inspiration from a medium that the current generation has been steeped in almost since birth: video games.

As early as 2009, ADEA Corporate Member Nobel Biocare USA, LLC worked with a company called Breakaway Games and the Dental College of Georgia at Augusta University to release a role-playing video game called the Virtual Dental Implant Trainer (V-DIT). The game involves both interviewing patients to determine whether an implant would be appropriate and simulating implant placement, giving students a chance to practice dental implant decision-making.

In 2014, our colleagues at the American Association of Colleges of Pharmacy (AACP) undertook an even more ambitious project: the creation of a massively multiplayer online role-playing game (MMORPG) that health professions students can play to develop interprofessional competencies. Mimycx, as the game is called, places students in a futuristic health care setting. Players choose avatars to represent them on screen, and game play resembles what you would find in World of Warcraft or Grand Theft Auto. But the goal—to seek information from the right health professional at the right time to make better patient-care decisions—is decidedly rooted in the world of health care.

“Mimycx is an educational tool to meet students where they are now,” says AACP Associate Executive Vice President Ruth Nemire, Pharm.D., Ed.D., “so they can learn 24/7, so they can learn from each other and so they have a safe environment in which to learn.”

AACP created the game in partnership with the Virginia Serious Games Institute (VSGI), based at George Mason University. Three schools are currently using Mimycx on a research basis, and the partners hope to market it widely, offering it to schools via an enterprise license or directly to students in the same way electronic textbooks are sold. According to VSGI Founding Director Scott Martin, “What we hope is that as more students have access to the game, they will find teammates anywhere in the world who are using it at the same time, just as they would with standard MMORPGs.”

Social interaction is a key element in games, as Elise Eisenberg pointed out when we spoke, so it makes sense to create virtual environments where learners can engage with one another. “I don’t know of anyone currently creating MMORPGs specifically for dental education,” Elise told me, “but it’s not far away.”

In the meantime, I know of at least two dental schools that are harnessing the appeal of digital games to help their students with knowledge acquisition and review. One of these is the University of Pittsburgh School of Dental Medicine, where Associate Professor of Oral & Maxillofacial Pathology Elizabeth Bilodeau, D.M.D., M.D., M.S.Ed., has developed the University of Pittsburgh Dental School Pathology Game. As with most inventions, this game was developed to solve a problem. Elizabeth observed that students typically performed poorly on image-based exams. Their inability to distinguish conditions by their appearance suggested to her that many students would have difficulty applying their oral-pathology knowledge in a clinical setting.

In response, she created a digital oral pathology atlas, working from a colleague’s rich trove of 2×2 slides that no one was using anymore. To get students to take advantage of this resource, she turned the atlas into a game, with a leader board listing top scorers to motivate players to practice and improve their scores.

“I think there’s a lot of promise in gamefication,” Elizabeth told me, “but I’ve learned it’s incredibly challenging to do it well.”

She says creating the pathology game has been a labor of love, and with students handling the programming, it has also required time and patience. Nevertheless, she remains upbeat about the potential of games and other digital initiatives.

“These tools create a safe environment that simulates the clinical environment,” Elizabeth observes. “Students can fail, and you can actually let them fail. There’s a lot to be said for that.”

Michelle Robinson, D.M.D., M.A., is also enthusiastic about the potential of digital games to enhance dental education. The Associate Professor and Associate Dean for Health Information and Business Systems at the University of Alabama at Birmingham (UAB) School of Dentistry recently developed a game for residents in periodontics. Using the Kaizen (Japanese for “continuous improvement”) platform developed at the UAB medical school, Michelle created an online knowledge-review game to prepare the residents for a mock standardized exam. New content was released each morning, and students who played the game daily were rewarded with extra points. The students’ regular practice appears to have paid off. Michelle told me the program director was “floored” by the improvements he saw in exam scores and plans to use the game again next year.

Michelle and her colleagues are analyzing the data they’ve collected and plan to publish it, so I’ll let them share the details with you later, but I want to mention one other observation she made. Students’ use of the game eliminated the need for faculty to conduct general review sessions prior to the exam. As a result, faculty could spend review time answering questions that arose when students played the game.

As Michelle put it, “If technology means your face-to-face time is more valuable, then that’s even better.” Makes sense to me.

Will digital games and virtual reality bring us closer to a future in which learning can occur anywhere at any time, and effectively prepare our students for clinical practice? The jury is still out, but it certainly appears that we’re headed in that direction, and forthcoming research will help us determine how far away that future lies and what types of detours we may take along the way.

Meanwhile, I applaud our colleagues—in industry as well as academia—who are investing their time and energy in breaking new ground. Only through experimentation, bringing new technologies to market and vigorous research can we learn whether it is possible to realize the promise of virtual reality and gaming.

Related content from previous issues of Charting Progress

New Buildings Support the Use of 21st Century Tools

Is Dental Education Ready for MOOCs?

Perhaps Old Dogs Can Learn New Tricks 

The Not So Distant Future: Dental Education in 2050

Catching the Waves of e-Learning and Distance Education

See also the Spring 2014 ADEA CCI Liaison Ledger: eLearning

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic, ADEA President and CEO, offers four strategies, seven steps and a few reflections on ways dental schools can build a culture of research and scholarship.

We’ve talked a lot in recent years about the need for academic dental institutions to pursue research and scholarship. Most of us agree this pursuit is essential if we want dentistry to sustain its status as a learned profession. Yet, building a research enterprise can be challenging. It takes leadership and commitment, and history shows that it also requires patience, even at institutions that make research a top priority.

Those of us who have been around for a while remember that before John Greene, D.M.D., led a transformation that turned the dental school at the University of California, San Francisco into a research powerhouse, the school had been known for its excellence in restorative procedures, especially those using gold alloys. We can also recall that the dental schools at New York University, the University of Michigan and the University of Texas in San Antonio had limited research portfolios before Michael (Mike) Alfano, D.M.D., Ph.D.; J. Bernard (Bernie) Machen, D.D.S., M.S., Ph.D.; and Dominick (Dom) DePaola, D.D.S., Ph.D., respectively, were appointed to deanships. We take for granted that these institutions, among many others, are now research-focused, but it took years—even decades—for them to achieve that status.

Today, Nova Southeastern University College of Dental Medicine (NSU CDM)—the first of the crop of schools that began graduating dental students in the 21st century—is undergoing a similar transformation, now under the leadership of Dean Linda Niessen, D.M.D., M.P.H., M.P.P. “We’d love to be on the list of the top 10 [National Institute of Dental and Craniofacial Research] NIDCR-funded schools,” Linda told me, “and we’re working to get there.”

This quest aligns with Nova Southeastern University’s current investments in research and scholarship. These include the construction of a hospital and the opening of an M.D.-granting medical school that should attract more research-focused specialists to the campus. The university will also open a Center for Collaborative Research later this year and has recruited 20 scientists from the prestigious Karolinska Institutet in Sweden.

At the dental school, Linda is employing several related strategies to foster research and scholarship. First, she is seeking new faculty who are interested in and capable of conducting research. Second, in recognition that research is a collaborative enterprise, she is looking to develop partnerships—both within the university and with outside groups. Third, she is focused on training the next generation—encouraging not only predoctoral students to do research but also faculty to mentor them and each other. Fourth, she is hosting faculty development seminars with leading researchers who can share their expertise.

“That doesn’t mean it’s easy to build to a research program,” Linda told me, “even for established schools. Sometimes people are intimidated by research. Clinicians are often overwhelmed.”

I also spoke with Terri Dolan, D.D.S., M.P.H., former Dean of the University of Florida College of Dentistry (UF COD), and now Chief Clinical Officer and Vice President at Dentsply Sirona. UF COD has been a top 10 recipient of NIDCR funding for more than a decade. Terri said that when she was a junior faculty member at Florida, “There was always a nagging tension between the researchers and the clinicians about who was more important, who was more valuable, and who received more recognition.”

When Terri became Dean, one of her goals was to show how a culture of research and scholarship supports all three legs of the academic stool—teaching, research and service.

In Terri’s view, a successful dental school has a balanced culture and mutual appreciation across the three missions. As Dean, she supported the development of this culture through several strategic initiatives—including the appointment of an Associate Dean for Faculty Affairs—to ensure that faculty were well mentored and took advantage of the National Institutes of Health’s (NIH) Research Career Development Awards and other similar opportunities. During her tenure, the dental school also benefited from an NIDCR Research Enhancement Infrastructure Award. That support provided key resources that got the school “over the hump,” Terri explained.

“There’s no question that it takes resources to establish a top research program,” says Cecile Feldman, D.M.D., M.B.A., Dean of the School of Dental Medicine at Rutgers, The State University of New Jersey. Cecile is making fostering a culture of research and scholarship a priority during her term as the Chair of the ADEA Board of Directors.

Since 2004, extramural research funding through NIDCR has been essentially flat, despite a FY16 increase. The same is true for the other 20 NIH institutes and centers that fund dental research. While other federal agencies, including the National Science Foundation and the U.S. Department of Defense, also provide dental schools with research support, the finite nature of government research dollars makes it difficult for dental schools to grow their research programs.

While some of the newer dental schools are making notable strides in building their research capacity, very few have been successful in obtaining substantial research funding, and many older schools struggle to obtain funding as well.

“NIH does a great job with the peer-review process,” says Cecile, “but it’s hard to argue that there isn’t any bias in the system.” The review panels often have limited expertise in oral health, she points out, and the process is not blinded. “Even if it were,” Cecile adds, “the nation’s top researchers know what is going on around the country. We need to improve the process to make sure the best science is funded.”

Dr. Feldman counsels that dental schools need to wear a policy “hat” when they develop their research projects if they want to be successful in receiving research awards. “Especially when it comes to research funding from government agencies, it’s always about affecting policies, which will improve our nation’s health,” she says.

All aspects of dental education—clinical care, public health, pedagogical techniques—lend themselves to research and scholarship when looked at from the right vantage point. Whether you are a clinician taking part in a National Dental Practice-Based Research Network study for community-based preventive care, or an educator looking for better ways to assess student learning, “You have to train yourself to say, ‘Why did that work? Why didn’t that work? What did I learn from this experience? And what would help us do this better in the future?’” as Dr. Dolan put it when we spoke.

She sees a number of affordable ways schools can reinforce this spirit of inquiry. She suggests they start by putting their electronic health records’ data to work through participation in BigMouth (see the September 2015 Charting Progress).

“It’s not a matter of money,” she says. “The data are there. It’s a matter of faculty time, focus and commitment.”

Terri also recommends taking part in one of many programs designed to expose students to research. Perhaps the best known of these is SCADA, The International Association of Student Clinicians/American Dental Association, which has been funded by DENTSPLY International, Inc. (now Dentsply Sirona) since 1959.

As a former SCADA participant myself, I can speak firsthand to the benefit of these experiences. I am where I am today in my academic career because of the interest in research that my participation in the SCADA program sparked when I was a dental student at the University of Connecticut.

Industry provides another avenue for financing research, as Terri knows well: “There’s an important role for partnerships with industry on university campuses, but people don’t always understand how to make that work. Small Business Innovation Research grants are underused in dentistry, and can be one way to help commercialize inventions and often spin them off or sell them to a company. That’s all scholarship, and it is critical to advancing patient care.”

Cecile agrees, adding that academic institutions seeking industry research dollars need to be strategic. “It’s not about a single project but about a research agenda,” she says. “Schools need to sit down with corporations, think about the future and develop strategic partnerships.”

So what are some other steps that any academic dental institution can take to foster a culture of research and scholarship?

  1. Make clear that the school or program values research and scholarship by incorporating these pursuits in its mission statement.
  2. Get to know others in the university community and develop collaborative partnerships.
  3. Hire research faculty and make sure their presence is visible in both the dental school laboratories and the classroom.
  4. Encourage students to take part in research projects and competitions that expose them to the broader research community.
  5. Collaborate with local chapters of the American Association for Dental Research.
  6. Take advantage of NIDCR grant programs to build the research infrastructure and to educate and support the next generation of dental researchers.
  7. Use sabbaticals and exchange opportunities to keep faculty fresh.

“We also need to think about collaborations between the highly research-intensive schools and the new schools,” Linda Niessen suggests. “There are opportunities for mentoring and partnerships among the schools that we haven’t leveraged to any extent.”

I agree that we could be doing more to help one another, and if we do, I suspect everyone will benefit. As Terri put it, “Observing, asking questions and then working hard to answer them—that’s the fun part of being at a university. When it all clicks, it’s engaging and that’s where you want to be.”

Related content from previous issues of Charting Progress

What Big Data Could Mean for Dental Education

Harnessing the Potential of Saliva

Evidence-Based Dentistry: Time to Extend the Curve

Our Commitment to Research: Past, Present, and Future

When Opportunity Knocks, An Energized Dental Research Community Answers

See also the Fall 2015 ADEA CCI Liaison Ledger: Research—From the Ground Up