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

Dr. Richard ValachovicIn this month’s letter, ADEA President & CEO Dr. Rick Valachovic shares what you might have missed at the 2016 ADEA Annual Session & Exhibition.

It’s hard to believe that just one month ago, I was a mile above sea level, conversing with many of you, celebrating the progress we’ve made on so many fronts and gathering fresh perspectives on the future challenges and opportunities that await dental education

As always, this year’s ADEA Annual Session & Exhibition offered a chance to learn about and discuss myriad topics. These included calibration, communication, collaboration, cultural competency, comprehensive care, course design and CODA accreditation—and that’s just the Cs! Interprofessional education, dental assisting and dental hygiene, evidence-based dentistry and primary care also took center stage. No matter what your areas of interest, you can find links to session descriptions on the 2016 ADEA Annual Session & Exhibition electronic Program Planner. By logging onto the site with your email and Annual Session registration ID, you can also obtain a wealth of presentation materials.

Meanwhile—to give you a taste of the event itself—here are a few standouts:

Most Eye-Catching Attendee: The Big Blue Bear, a 40-foot high sculpture that has been peering into the Colorado Convention Center since its installation as part of a public art program in 2005.

Most Incongruous Sensation: The warmth of the sun that greeted us on Friday and the snow visible on the Rocky Mountain peaks about 60 miles to the west. (We didn’t know how lucky we were. A week later, a blizzard with 20 inches of snow slammed into the Denver Metro Area and Colorado’s Front Range, knocking out power, closing schools and shutting down Denver International Airport.)

Most Unexpected Sight: The parade of young dancers making their way, with parents and costume trunks in tow, to the dance competition at the other end of the convention hall.

Most Rude Awakening: The clock jumping forward an hour Sunday morning.

Most Pleasant Surprise: Only a few marijuana jokes, and one serious presentation—How Marijuana Legislation Is Shaping Tomorrow—on the drug’s oral health impacts.

Biggest Blast From the Past: The reprinted 1924 Annual Session program, distributed at the Opening Plenary.

Most Entrepreneurial Moment: When start-up the Safe-D-Needle (one of eight new vendors to exhibit this year!) took its first order in the Exhibition Hall.

Most Glamorous Event: The 2016 William J. Gies Awards for Vision, Innovation and Achievement, which was accompanied by Tin Brother, a jazzy bluegrass string band that received rave reviews.

Most Awe-Inspiring Talk: Allison Levine’s description at the Opening Plenary of the first American women’s expedition to Mount Everest.

Most Empowering Session: Brenda Allen’s interactive Q&A during the Evening Plenary on Gender Issues.

Most Partisan Moment: The ADEA Political Spotlight, during which Karl Rove and Howard Dean talked about the Affordable Care Act. Rove wants the future to look like Medicare Part D; Dean says the future will look like Massachusetts, with insurers and health systems coming together to function as one.

Most Amusing Remark: That’s a tough one, but I think all the contending lines were uttered by Karl Rove.

Most Tech-Savvy Location: The ADEA Tech Expo, launched as the Technology Fair in 1999, now in its 18th year!

Most Information Conveyed Per Minute: The ever-popular Short Talks session on using emerging technologies to enhance teaching and learning.

Most (Virtual) Distance Traveled: A discussion of best practices for creating high-quality online education for novice learners, graduate students and practicing professionals.

Most Motivating Suggestion: “If we want to drive the best outcomes for our patients, we need to think of ourselves as innovators.” Tuesday’s Plenary speaker Josh Linkner.

Most Gracious Participants: The folks at the University of Colorado School of Dentistry, who offered visitors a terrific tour of their new facility followed by a delicious lunch, and the visitors who waited patiently while staff arranged alternative transportation to the site.

Most Moving Moment: Ron Rupp’s remarks upon receiving the 2016 ADEA Distinguished Service Award. I’ve known Ron for nearly 20 years and already knew how losing the full use of his right hand in a skiing accident changed the course of his career. But hearing him share that story and the joy he has received through his affiliation with ADEA reminded me of how fortunate we are in dental education to have people with so much passion for the well-being of our profession and our community.

Most Globally Cooperative Occurrence: Too many to choose from here. On Monday, ADEA signed a Memorandum of Understanding with one of our sister organizations, the Japanese Dental Education Association, marking an important moment in our effort to expand our collaborations with our international colleagues. There was also a well-attended session discussing dental therapy practices in Rwanda and Minnesota. I must also give a shout-out to our Association for Dental Education in Europe colleagues, who joined us to continue planning for the first joint ADEA/ADEE meeting, to be held in London in May 2017.

Best Glimpse of the Future: Once again, too many contenders in this category for a single pick. The awarding of scholarships to students pursuing preventive dentistry or academic careers? Discussion of an interprofessional clinic run by students at the University of Colorado? Students explaining their posters in the Exhibition Hall? ADEA Student Diversity Leadership Program participants organizing themselves for a group photo on the stairs of the convention center? All these moments were nothing short of inspiring. If these young people are any indication, the future of dental education looks exceedingly bright!

Most Summative Moment: I was with ADEA Past Chair of the Board Lily Garcia Monday evening, and she recounted an experience that captures the essence of our annual gatherings. Over the weekend, she ran into a former dental student. She was delighted to learn that he had matured into a family man and returned to dental school—this time as an educator. As a first-time ADEA Annual Session attendee, he was overwhelmed by the abundance of opportunities, so she guided him to a seminar designed specifically for new faculty. “That’s what it’s all about,” she told me. “Being able to get new faculty the tools they need, keeping mid-level faculty engaged, and keeping the seasoned folks like us energized and involved.” I couldn’t agree more.

Greatest Regret: That not every ADEA member could be with us in Denver. I hope this brief recap inspires you to join us next year in Long Beach, California, where we will endeavor to move Beyond Boundaries.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic, ADEA President and CEO, previews the unique opportunities that await attendees at the 2016 ADEA CCI Liaisons Summer Meeting in New Orleans.

Have you ever thought about dropping an egg from a 24-story building? Have you wondered how you might construct a package to land it safely on the ground?

From time to time, students at the Massachusetts Institute of Technology (MIT) get together, not just to ponder these questions, but to devise and test contraptions that can keep an egg intact when it is dropped from a great height. Given the countless innovations that have emerged from MIT, I think they’re on to something—and so do management gurus, elementary school teachers and others who want to encourage innovative thinking.

This summer, ADEA will take a page out of the Great Egg Drop book when we host the 10th ADEA CCI Liaisons Summer Meeting in New Orleans. This annual gathering brings together faculty who have been appointed by their deans to be agents of change on their campuses. To celebrate the start of a second decade of innovation in dental education and accelerate the pace of change, this meeting will break the mold. Rather than learning about innovation, the Liaisons will take part in the process itself.

The best way to learn is experiential, and this meeting will give the Liaisons the kind of interactive experiences that can position them to better lead change initiatives at their home institutions, including:

  • Taking part in several interactive workshops.
  • Receiving direct feedback on current projects or ideas percolating on their campuses.
  • Having both time and support to refine their ideas.
  • Creating roadmaps for future action.

ADEA Chief Learning Officer Anthony Palatta, D.D.S., Ed.D., who has been working with the meeting planning committee to structure the event, sees the new format as a response to the Liaisons’ request to be engaged in projects throughout the year. That request gave birth to a novel idea: inviting Liaisons who attend the June meeting to present posters representing actual or aspirational projects on their campuses.

These posters will not only expose the Liaisons to some of their colleagues’ best ideas, they will also serve as a vehicle for learning how to innovate and how to evaluate innovation.

The competition will occur in three stages that mirror developmental concepts within innovation:

  • In Round 1, Learning How to Assess Innovation, each Liaison will be given a rubric and asked to grade each of the posters.
  • In Round 2, Making Your Case for Innovation, the 10 teams whose posters receive the most votes will prepare and make five-minute oral presentations, giving attendees a fuller view of their plans. Once again, attendees will decide which of these projects truly breaks new ground.
  • In Round 3, Thinking Innovatively, three teams of finalists will engage in a contest that will hone their innovative thinking skills. (No word yet on whether or not this round will involve eggs.)

If you are a Liaison, and the thrill of competition or the opportunity to get your creative juices flowing still hasn’t motivated you to clear your calendar in early June, then perhaps the lure of funding will. The winners of the poster contest will go home not just with their peers’ admiration, but with some seed money they can use to translate their ideas into action or take established projects to the next level.

The process of planting seeds and taking them to fruition will be further explored in a session that kicks off the meeting on Tuesday. The Going Green Model applies the vocabulary of gardening to the process of change. Speaker Jones Loflin will share his views on:

  • Creating environments that enable change to grow and thrive.
  • Cultivating routines that support new actions and behaviors.
  • Celebrating “harvest moments” that motivate additional growth.

The timing of the Going Green presentation will coincide with the closing day of the 2016 ADEA Allied Dental Program Directors’ Conference, also being held in New Orleans in June. This is the third year the two meetings have held a joint overlap session with the goal of building bridges between the allied dental and dental education communities; however, this is the first time the session will be interactive.

The next day, the Liaisons will be in for another treat: a workshop on transformational leadership led by veteran Liaison Frank Licari, D.D.S., M.P.H., M.B.A. Frank authored a seminal ADEA CCI White Paper on the importance of faculty development in supporting curriculum change, and he has more than two decades of experience putting these ideas into practice. While at the University of Illinois at Chicago College of Dentistry, he established a faculty committee and charged it with developing a new curriculum. He has since held leadership roles at two new dental schools: Midwestern University College of Dental Medicine-Illinois and Roseman University of Health Sciences College of Dental Medicine – South Jordan, Utah, where, in his role as Dean, he is continuing to shake up dental education.

In his current position, Frank has drawn on the expertise of executive consultant Barry Pogorel to conduct interactive workshops with Roseman dental school faculty, most of whom are new to academia. At the June meeting, Frank will lead a reflection exercise drawn from these workshops to give Liaisons a taste of the process he is using to help his faculty adapt to new challenges.

“As I was hiring faculty,” Frank recently told me, “the most frequent thing I heard was, ‘I want to teach students what I know,’ and I told them, ‘It’s really not about that. It’s about teaching them what they need to know for the next 20, 30 and 40 years.’”

So far, Frank has put 51 faculty and staff through transformational leadership training, and he believes it has opened their minds and given them a much better understanding of why the traditional lecture format used when they were in dental school is not as effective as case-based learning and other newer pedagogical techniques.

On the last day of the meeting, Geralyn “Geri” D. Crain, D.D.S., Ph.D., Assistant Dean for Educational Support and Faculty Development and Clinical Associate Professor at East Carolina University School of Dental Medicine (ECU SDM) will hold a workshop on how to translate ideas into reality. She knows this area well, having focused her doctoral research on developing a framework for managing change.

Geri first became involved with ADEA CCI while she was working on her doctorate in organizational development and change. Since joining the faculty at ECU SDM as it opened its doors in 2011, she has served as an ADEA CCI Liaison representing that institution. She recently accepted the position of ECU Interim Assistant Vice Chancellor for Interprofessional Collaboration for the Division of Health Sciences, a post that will give her new opportunities to lead and transform her institution.

Like the schools mentioned above, ECU SDM is a beacon of innovation, and its faculty have been exemplary when it comes to executing all manner of novel initiatives—from a groundbreaking model of community-based dental education to the sophisticated use of digital technologies to support active learning and assessment. Geri will have plenty of first-hand experience to draw on as she leads the Liaisons in creating roadmaps for their own innovation initiatives.

Could this process have positive outcomes for every one of our dental schools? We’d like to think so, but the results depend on participation. We’re hoping every school will send its Liaisons to New Orleans in June. This unique gathering is one your school will not want to miss.

Related content from previous issues of Charting Progress:

ADEA CCI: Curricular Change and Then Some

Jumping Into the Water With Both Feet

New Accreditation Standards Affirm a New Direction for Dental Education

The Not So Distant Future: Dental Education in 2050

Preparing Now for the Future of Dental Education

Commission on Change and Innovation in Dental Education

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic, ADEA President and CEO, describes ADEA’s current leadership development programs, plans for future opportunities and the reasons these investments matter.

If you could spend a few days looking at the world through the eyes of a theoretical physicist, exploring the virtues of courage and hope, reflecting on your own personal development and gathering the collective wisdom of your peers on a thorny problem at work, would you seize that opportunity?

Leadership development may sound abstract and impersonal, but it is anything but. Well-designed programs offer an immersive experience that challenges participants both personally and professionally, and the results are impressive. ADEA’s decades-long investment in leadership development has yielded a cadre of dental educators who are extraordinarily well-prepared to lead our institutions. These individuals have also been influential in guiding our Association and the course of dental education. As we seek to navigate the challenges of training the next generation of dental professionals for 21st-century practice, the value of investing in leadership cannot be overstated.

“Everyone has to lead at some point, so it strengthens dental education when we prepare our members to lead and to see themselves as leaders,” says Diane Hoelscher, D.D.S., M.S., ADEA’s Senior Vice President for Professional Development. In that position, Diane oversees a continuum of leadership programs tailored to meet the needs of dental educators of all kinds at every stage of their careers.

I hope by now most of you have heard of the ADEA Leadership Institute, our flagship professional development program for faculty who are ready to enter the senior leadership ranks. The institute started in 1999, when multiphase, yearlong programs for health professions educators were few and far between. The program’s duration is important, because research indicates that the best way to change adults’ behavior is to work with them over an extended period of time.

“A yearlong program requires a great deal of commitment from the participants as well as the Association,” says N. Karl Haden, Ph.D., a former ADEA staffer and current President of AAL, which has contributed to the design and implementation of the institute since its inception. According to Karl, 75% of ADEA Leadership Institute alumni say that the program had a significant or highly significant impact on their careers, and 99% say they would recommend the institute to their peers.

In recent years, ADEA has also developed programs tailored to early- and mid-career faculty:

I should also note that over the years, ADEA has partnered with others on two programs with a long record of achievement. Starting in 2004, ADEA teamed up with the W.K. Kellogg Foundation® to offer grants to 11 universities through the ADEA W.K. Kellogg Foundation Minority Dental Faculty Development (MDFD) Program. To meet the program’s goal of diversifying the community of dental educators, MDFD supported leadership development for underrepresented minority and low-income individuals recruited to faculty positions. The latest phase of the program builds on lessons learned and provides diversity leadership training and skills development for academic/community partnerships to improve access to both careers and health care for underserved communities.

In 1997, ADEA also partnered with the Hedwig van Ameringen Executive Leadership in Academic Medicine® (ELAM®) Program for Women to give dental faculty access to this exemplary program. This collaboration is at least partially responsible for the remarkable rise in the number of women who are dental school deans—13 as of today—or who hold higher positions within their universities.

But our Association is not resting on these accomplishments. Since mid-2014, an ADEA Commission on Change and Innovation (ADEA CCI) in Dental Education workgroup with the American Dental Hygienists’ Association (ADHA) has been helping to create a leadership course for dental hygiene educators. It combines a single two-day, face-to-face session with online networking and instruction to make the course both affordable and accessible. Still in development, the ADEA CCI workgroup with the ADHA will begin piloting the 12-week course in August.

Although ADEA leadership development programs are open to all members, allied dental educators often lack the institutional financial support that facilitates participation in leadership programs that require travel or a major time commitment. This new offering aims to fill that gap.

Meanwhile, just last month, 20 ADEA members traveled to Florida to take part in the inaugural programming for the ADEA Leadership Institute Phase V—an opportunity for institute alumni to reinforce networks, strengthen relationships and engage in further leadership development. Participants had high praise for the three sun-filled days they spent exploring the nature of the physical universe, contemplating virtues that can guide leadership, discussing colleagues’ professional challenges and envisioning their own personal pathways.

Looking ahead, ADEA staff are working on creating a cutting-edge program specifically for new dental school deans. A growing number of dental educators are taking unconventional paths to their leadership positions, and many have requested additional professional development and support.

ADEA also offers less formal ways for its members to develop their leadership skills. As Diane Hoelscher put it when we spoke recently, “The ADEA Leadership Institute gave me what I needed to move into a position as a chairperson, but ADEA also provided me with a great opportunity to lead in the Association.”

Diane first became involved with an ADEA Special Interest Group and served on its board. Seeing that leadership positions within the Association were both “very doable and rewarding” whetted her appetite for more. She was elected as a representative to the ADEA Council of Faculties, served on the Council’s administrative board and eventually became Board Director for Faculties. She found that experience unusually rewarding and instructive. “When you’re doing it, you’re learning by doing,” she observes, “and you’re learning in a way that sticks with you.”

Experience has also been a powerful teacher for ADEA Senior Scholar in Residence Leo Rouse, D.D.S., FACD. Most of you know Leo from his service as President of the ADEA Board of Directors. What you may not know is that Colonel Rouse had a distinguished 25-year career in the U.S. armed forces and served as Commander and Chief Operating Officer of the U.S. Army Dental Corps before becoming a civilian dental educator.

No one is more passionate about the value of leadership than Leo. The former Dean of the Howard University College of Dentistry puts that passion to work by mentoring a cohort of ADEA Leadership Institute fellows, an experience he calls one of the greatest of his professional life.

“Leadership is about the two Cs, communication and collaboration,” Leo says, “and how you look for the good in every person, especially those who may feel they don’t have the requisite skills to do certain things.”

When I asked Leo what lessons about leadership dental education could take from the military, he was quick to focus on mission.

“In academe,” Leo told me, “you have two missions: to educate students and to provide quality, safe patient health care. But faculty and administrators don’t always focus on the macro picture. Often times we think in terms of silos.”

Leo attributes his success as Dean to encouraging faculty to keep the college’s larger mission in view, and he urges other dental educators to keep an eye on the big picture, too. I share that view. No matter where each of us stands in our careers, leadership means remembering that we are part of a larger whole. Whether that entity is our class, our department, our program, our college or our university, we need to ask how we are contributing to the well-being of that whole and how our actions might influence its trajectory moving forward.

As Diane put it, “Leadership is important because of where we want to go and what we want to see happen. Change is a reality in life, but we want to be leading change in the right direction. The more leaders we have in the ranks of dental schools and allied programs, the more capacity we will have to realize our vision for the future.”

I couldn’t have said it better myself.

Next month, many of us will meet at the 2016 ADEA Annual Session & Exhibition in Denver to collaborate on “Shaping Tomorrow, Together.” I hope to see you there.

Related content from previous issues of Charting Progress:
– Who Will Teach The Next Generation?
– Wanted: Jack of All Trades and Master of Many
– From 0 to 13 in 13 Years: ELAM’s Impressive Track Record in Preparing Women for Leadership
– Tomorrow’s Leaders: Made, not Born

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic shares principal findings from an encouraging recent analysis of student indebtedness and considers the study’s implications for dental education.

Hold on to your hats. When it comes to student indebtedness, the picture may be far less bleak than we’ve been led to believe.

“[T]ypical borrowers are no worse off now than they were a generation ago,” write Beth Akers and Matthew Chingos in a 2014 report published by the Brown Center on Education Policy at the Brookings Institution. Beth, a Fellow in the institution’s Center on Children and Families and at the Brown Center on Education Policy, spoke about the report, Is a Student Loan Crisis on the Horizon?, at the ADEA Deans’ Conference last fall. What she had to say was both startling and reassuring.

The report’s findings (updated) upend the conventional wisdom that is bandied about in the popular media—that increased levels of student indebtedness for all types of students are condemning the current generation to a bleak future. Accounts of excessive borrowing and personal hardship give the impression that all of today’s students are suffering. Beth’s research tells a far different story.

Using 1989–2010 data from the Survey of Consumer Finances administered by the Federal Reserve Board, she and her co-author looked at how educational borrowing levels and incomes evolved within households led by adults aged 20 to 40. Not surprisingly, the authors found a significant rise in the level of student loan debt these households carried and a considerably smaller increase in annual household incomes. But while many people look at these data and jump to the conclusion that today’s holders of student debt are worse off, Beth and her colleague conclude that, “Increases in debt may be a benign symptom of increasing expenditure on higher education.”

“The right way to think about debt,” Beth told me, “is that debt is used to finance an investment that pays off over the lifetime. Your debt may have increased by $5,000 and your income by only $1,000 a year, but when you add it up over a lifetime, that additional income swamps the increase in debt you’ve taken on.”

When it comes to dental education, this finding supports a view I have long held: that dental education is an excellent investment despite its high cost. There’s no question that debt-to-income ratios have been rising in dentistry and other high-income professions in recent years. A paper published in the Journal of the American Dental Association (JADA) in November found that the average educational debt held by dental graduates was 103% of median income in 2011, up from 70% in 1996. But while this percentage represents a significant increase, it doesn’t negate the bigger point made by the Brookings study: that increases in average lifetime earnings have “more than kept pace” with increases in student borrowing.

Indeed, the Brookings report finds that about one-quarter of the rise in student debt over the two decades studied is attributable to the fact that more Americans are seeking higher education and that more of those individuals are pursuing graduate degrees.

“Prior to this paper, people were looking at debt burden in terms of the debt-to-income ratio, but to me the burden of debt is much more appropriately measured by looking at how much you have to pay in a given month to service that debt versus how much you have to spend on consumption,” Beth explains. “That’s the debt payment-to-income ratio that we published. The popular narrative would have you believe that households are being swamped by these payments, but on average, people are spending about 4% of their monthly earnings on debt repayment.”

According to Beth, that number has not increased over time. In fact, the data would suggest it may have decreased, further strengthening her conclusion that on average, educational borrowing is as sound an investment today as it has been in the past, and not just for dentistry. From time to time we hear that some dental hygiene graduates are struggling to find employment, but that appears to be a localized phenomenon. The Bureau of Labor Statistics reports that employment of dental hygienists is projected to grow 19% from 2014 to 2024, much faster than the average for all occupations, and U.S. News & World Report ranks dental hygiene number five on its 100 Best Jobs list.

At this point, I’m guessing there may be skeptics among you who remain unconvinced. You might be asking: Even if today’s average monthly student loan payment represents the same portion of income as it did 20 years ago, what about the fact that borrowers are taking almost twice as many years to pay off their debt? Doesn’t that constitute an increased burden?

Mert Aksu, D.D.S., J.D., M.H.S.A., Dean of the University of Detroit Mercy School of Dentistry, raised this very point with me and others after hearing Beth speak in October. Mert is concerned that dentists who are still paying off their loans will find it harder to fund their retirements, and he is particularly concerned about how this possibility might affect those who choose employment over owning their own practices. Historically, Mert pointed out, the dental practice itself has constituted the largest asset a dentist possessed at the time of retirement.

The Brookings study does not address the issue of retirement savings, but Beth told me the longer repayment period is not a cause for concern when looked at in strictly financial terms. From this perspective, lifetime earnings still outweigh the cost of student borrowing today just as they did in the past.

All that said, there may be less tangible costs associated with increased student indebtedness. One recent study using 1997 data found a small but significant inverse relationship between student debt and psychological well-being. In a posting on the Brookings website, Beth acknowledges that “It may be the case that debt imposes emotional costs,” but tempers that scenario by adding, “the treatment of student debt by the popular media has almost certainly caused some borrowers to worry about their debts more than they would have otherwise.”

In Mert’s view, changes in the market for dental care should also be factored in when considering the potential burden of indebtedness on our current and future graduates. He rightly points out that much of the growth in the dental market is occurring in Medicaid and other less well-reimbursed sectors. Mert speculates that, over time, this trend could depress those lifetime earnings the Brookings study is banking on.

Much of the discussion within our community about the growth of dental student indebtedness has centered on a related concern: whether high levels of educational debt might discourage newly minted dentists from providing care in underserved communities. To get a perspective from the practice community on this and other issues, I called Marko Vujicic, Ph.D., Chief Economist and Vice President of the American Dental Association (ADA) Health Policy Institute. Marko is one of the authors of the JADA paper I mentioned above, which looked at the effect of educational debt on dentists’ career choices.

According to Marko and his colleagues, their research indicates that high debt levels do influence some career decisions, but that gender and race are much better predictors of where dentists choose to practice and whether they choose to treat Medicaid patients or provide charity care.

“To the extent that you accept our results,” Marko told me, “you should explore interventions outside of debt relief if you want to influence career choice.”

Marko’s comments raise the question of whether current policy proposals aimed at lowering student debt levels are well designed to achieve larger societal goals. Beth is concerned that some proposed policies would benefit those who are most able to meet their debt obligations and do little for those who truly need help.

“Policymakers need to recognize that debt is not a bad thing,” she argues. “Debt without a means to pay is the thing that we need to be worried about.”

Beth points out that policies such as student loan refinancing at lower interest rates would disproportionately benefit people with large outstanding debt—the very people, research shows, who tend to earn high incomes.

“Things like income-driven repayment plans, which we’ve seen expanded in the last two years, are really a step in the right direction,” Beth believes. “These plans ensure that those who have made investments in higher education that didn’t pay off won’t be stuck with unaffordable monthly debt payments.”

Marko also warns that poorly conceived policies can create as many problems as they solve. He told me some economists oppose providing student debt relief because it takes the onus off schools to address rising tuitions. Likewise, in economic terms, the availability of federally subsidized student loans artificially lowers the cost of preparing for a professional career, potentially stifling the development of innovations that would reduce the cost of higher education.

“It comes back to what you’re trying to achieve,” Marko said. “Broad-brush policies can reduce the cost of education for everyone in America, but if we want to achieve different societal objectives, such as getting dentists to practice in underserved areas, a more targeted set of loan forgiveness policies would be more effective in achieving this end.”

When I asked Marko if the dental education data conform to Beth’s assessment that increased student debt reflects a largely positive development—increased investment in higher education—he responded, “Absolutely. Look, your dental education is an investment, and it’s a privilege to have an earnings stream as a dentist. You have to look at these questions in that context.”

I couldn’t agree more.

Related content from previous issues of Charting Progress
August 2014, A Dental Education Remains an Attractive Investment
September 2013, Getting a Handle on Educational Costs and Borrowing
February 2012, Student Debt: Cause or Symptom of Current Ills?
December 2009, Dental Hygiene Program Capacity: Finding the Right Balance
September 2006, Paying the Price


Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic celebrates a decade of Charting Progress with a look back at some of his own observations as well as words shared by thought leaders and others in our community.

The clock is swiftly ticking toward the start of 2016—the year that will mark the 10th anniversary of this publication. The inaugural, May 2006 issue of Charting Progress, which was conceived as a vehicle for exploring topics of importance to ADEA members, focused on the challenge of changing demographics.  I wrote about the need to recruit talented individuals into academic dentistry as large portions of the faculty approached retirement age, the importance of enrolling underrepresented minority students to beneficially impact the quality of education and patients’ access to care, and the values of the millennial generation and its potential to positively reshape the access-to-dental-care landscape.

Next year I plan to revisit these and other topics—to reflect on what has occurred during the past decade and share fresh insights on where we stand today. Although much has changed and we’ve seen progress on many fronts, it is almost startling to note how relevant the topics discussed in these pages remain—two, five, even 10 years later.

With that in mind, I thought you might like to join me in looking back at some of the ideas expressed in this letter. The context or the timing of some of the quotes below may come as a surprise, but most of them seem as apt today as they were when first written. Mixed in with a few thoughts of mine, you may find some words of your own, although your title or affiliation may have changed. Do your comments still ring true? Has your perspective changed? I’d love to hear your current views as I prepare to revisit these topics in 2016.

Richard W. Valachovic, D.M.D., M.P.H.
President and CEO

“What usually happens in dental education is somebody goes out on a limb, and everybody says well, we’ll watch and see how that works for a while before we dip our toes in that water. The fact is I don’t think we can wait any longer. Schools are going to have to start taking some educational risk and implementing things faster.”
– Dr. Todd Watkins, Assistant Dean for Dental Education and Informatics, East Carolina School of Dental Medicine. Jumping Into the Water with Both Feet, January 2012.

“Terror is a great motivator. When I was academic dean, I could always count on getting things done two years before a site visit.”
– Dr. Marilyn Lantz, Professor of Periodontics and Oral Medicine, University of Michigan School of Dentistry and Associate Director for Education, Career Development, and Mentoring, Michigan Institute for Clinical and Health Research. ADEA CCI: Curricular Change and Then Some, July 2012.

“As the Dr. Marcus Welbys of the world gradually disappear, it seems only logical to ask whether private practice dentistry will follow suit.”
– Dr. Rick Valachovic. From Bungalow to Big Box? How DSOs Could Change the Face of Dentistry, June 2014.

“Dental hygiene has to start focusing on public health. That’s where we started, working with children in the schools. Then we entered private practices, and now we are coming full circle.”
– Dr. Colleen Brickle, Dean of Health Sciences at Normandale Community College. Dental Hygiene Education Responds to an Evolving Oral Health Workforce, August 2011.

“I get feedback every time,” he told me, “from someone who says, ‘This has changed the way I do my practice. It’s changed the way that my patients behave, and it’s changed their oral health.’”
– Dean John Featherstone, University of California, San Francisco, School of Dentistry. Managing Caries Risk: A Paradigm for the 21st Century?, November 2013.

“There’s always the question of what are you going to do with your life, but then you wonder, am I capable of doing it? The program has given me a lot of clarity about where I’m going and confidence that I can do the work.”
– Dele Ajagbe, Summer Medical and Dental Education Program alum. Today’s Students—Tomorrow’s Colleagues, August 2007.

“These students can come in on a level playing field and perform at the level of our other students. The programs are effective. They work!”
– Dr. Ernestine Lacy, Director of the Office of Student Development, Texas A&M University Baylor College of Dentistry. Diversifying the Dentist Workforce, One Cohort at a Time, June 2012.

“Unless kids get math concepts earlier, they have nothing to build on. I’d like to see our schools become involved in the pipeline at an earlier age, middle school at least.”
– Dr. Jeanne Sinkford, ADEA Associate Executive Director for Equity and Diversity. Math Literacy: A New Civil Right for an Information Age, December 2008.

“Part of the demand for accelerated programs will come from students themselves. They are so adapted to controlling their lives and using information technology to get what they need quickly.”
– Dr. Steve Shannon, President/CEO, American Association of Colleges of Osteopathic Medicine. Just a Matter of Time? Maybe Not., March 2012.

“The information literacy of young people has not improved with the widening access to technology. In fact, their apparent facility with computers disguises some worrying problems.”
– Dr. Heiko Spalleck, Associate Dean for Faculty Development and Associate Professor at the Center for Informatics at the University of Pittsburgh School of Dental Medicine. Perhaps Old Dogs Can Learn New Tricks, March 2011.

“I see faculty using the same devices their students employ. They are exploring the Web, file sharing, using Twitter, and the like with equal enthusiasm.”
– Dr. Elise Eisenberg, Senior Director of Informatics, New York University College of Dentistry. Perhaps Old Dogs Can Learn New Tricks, March 2011.

“It’s the right thing educationally. As one of my colleagues puts it, if your mother or father asked, I can see a dentist who just graduated from dental school, or I can see a dentist who just finished his residency, which one would you recommend?”
– Dr. Todd Thierer, Director, General Practice Residency Program, University of Rochester. Where Does PGY-1 Fit In?, August 2008.

“There seems to be a misconception that all dental students are vehemently opposed to a postgraduate year.”
– Dr. Rishi Popat, ADEA Vice President for Students. Where Does PGY-1Fit In?, August 2008.

“People who are not informed still talk as though dentistry doesn’t have diagnostic codes. We do have codes; they’re just not widely implemented.”
– Dr. David Preble, Vice President of the ADA Practice Institute. What Big Data Could Mean for Dental Education, September 2015.

“There is still a desire on the part of some faculty to get to the answer, to tell students the right way of doing things or at least what they perceive to be the right way. That’s good for today, but what about tomorrow?”
– Dr. Frank Licari, Professor and Associate Dean of Academic Affairs, Midwestern University College of Dental Medicine-Illinois. A Visit to the Flipped Classroom, October 2012.

“We’ve been talking about change for almost 100 years. Let’s use these new schools as learning laboratories: Implement the best practices, document what we do, measure the outcomes, and see what works and what doesn’t.”
– Dr. Jim Koelbl, Founding Dean, Western University of Health Sciences College of Dental Medicine. Opportunities Abound for New Dental Schools. How Will We Seize Them?, August 2009.

“Even though we talk nuts and bolts and wires and so forth, the question you keep coming back to is function, what do you want to do? The purpose is to engage, whether it’s your patients, your students, your faculty or your staff, and in the best tradition of a university, to engage ideas.”
– Dean David Johnsen, University of Iowa College of Dentistry. New Bricks and Mortar Bring Welcome Change to Our Campuses, November 2012.

“Regardless of specialty, all residency programs should inculcate their residents with a sense of responsibility, a sense of diligence regarding the gamut of their patients’ oral health needs. That is the foundation of patient-centered care.”
– Dr. Bob Berkowitz, Chair of the Division of Pediatric Dentistry at the University of Rochester School of Medicine and Dentistry. Holding Ourselves to the Highest Standard: Doing What’s Best for Patients, October 2010.

“I worry that in those dental offices that are more production oriented, the patient-centered aspect of care sometimes may not be treated with the respect it deserves.”
– Dr. Ellen Grimes, Program Director of Dental Hygiene at Vermont Technical College. Holding Ourselves to the Highest Standard: Doing What’s Best for Patients, October 2010.

“I think most dentists are trying to do the right thing, especially pediatric dentists who I’ve found to be the most patient-oriented, but sometimes the risk-benefit balance gets lost in the hustle and bustle of taking care of lots of people every day.”
– Dr. Alan Lurie, Professor and Chair, Division of Oral and Maxillofacial Diagnostic Sciences, University of Connecticut School of Dental Medicine. How Gently Do You Image?, June 2015.

“I tell students, ‘You don’t want the best image. You want the worst image you can get away with.’”
– Dr. Bernard Friedland, Oral Maxillofacial Radiology faculty member at the Harvard School of Dental Medicine. How Gently Do You Image?, June 2015.

“Students used to turn to us and say, tell me if this is good enough. Now we ask them to think it through and evaluate their own work before the faculty give their appraisals.”
– Dean Ron Hunt, Virginia Commonwealth University School of Dentistry. Move Over, Multiple Choice. There Are New Assessments in Town, February 2010.

“Fifty boards require some type of CE, but you can ski in the morning and take a course in the afternoon. There’s no outcome assessment. Perhaps CE is a way to maintain your competency, but it is not a way to demonstrate your competency.”
– Dr. James Cole II, former officer of American Association of Dental Boards and the Western Regional Examination Board, and former Chair of the Commission on Dental Accreditation. Making Waves, One State at a Time, July 2011.

“When you have an ill person you care about, and you go from provider to provider and see that they don’t have a common language, and that the patients really suffer, it gives you the impetus and the drive to make [interprofessional collaborative practice] a priority.”
Dr. Sandra Andrieu, Associate Dean of Academic Affairs at the Louisiana State University School of Dentistry. Paving the Road to Interprofessional Practice, February 2011.

“While interprofessional education is good and saves money, the magic in this revolves around the fact that there are about 40 million people in the United States who regularly access dental care but not other health care.”
– Dr. Michael Alfano, NYU Executive Vice President, New York University. Interprofessional Practice Can Play Leading Role in an Academic Setting, February 2009.

“Every year I get letters from people with high blood pressure saying, ‘Thank you. That dentist or that dental hygienist saved my life!’”
– Dean Leo Rouse, Howard University College of Dentistry. Paving the Road to Interprofessional Practice, February 2011.

“Opening a dental school every time some legislator or university administrator wants to serve an underserved group is the least efficient way of providing care to poor people that I can think of.”
– Dean Jerry Goldberg, Case School of Dental, and Interim Provost at Case Western Reserve University. New Dental Schools: Proceed, But Appreciate That They Are Only One of Many Answers to Our New Challenges, May 2008.

“It’s a house of cards, and Medicaid money is the key card. If we have to, we’ll offer certain treatments for free to be sure our students have the exposure.”
– Dean Mert Aksu, University of Detroit Mercy School of Dentistry. Troubled Assets? Perhaps, but Dental Education Is Holding Its Value in the Higher Education Portfolio, June 2009.

“It is startling to see how the job has changed even in the last six months. Most deans are looking at cuts to their budgets anywhere between 5% and 35% for the 2010 fiscal year.”
– Dr. Karl Haden, President, Academy for Academic Leadership. Wanted: Jack of All Trades and Master of Many, March 2009.

“For all of us, that’s the biggest challenge, to balance our budgets, not just to survive but to be great schools.”
– Dean Daniel Haas, University of Toronto Faculty of Dentistry. Reimagining Dental Education in Canada, October 2015.

“How supportive will the administration be if the number of applicants declines and alumni have difficulty finding work?”
– Prof. Phyllis Spragge, Director of the Dental Hygiene Program and Interim Dean of Biology and Health Sciences at Foothill College. Looking for Silver Linings Among Economic Storm Clouds, August 2010.

“It’s one thing to persuade campus leadership and the Board of Trustees that an idea has merit, but state-supported institutions also need to gain the approval of their Boards of Regents and their state legislatures. The political dimensions become immense, and every layer of bureaucracy can bring on a case of heartburn.”
– Dean Kenneth Kalkwarf, University of Texas Health Sciences Center at San Antonio Dental School. Communication→Trust→Collaboration→ Regionalization? July 2010.

“Our school will remain a good value for students even with the higher tuitions, and the board recognizes this.”
Dean Huw Thomas, University of Alabama at Birmingham School of Dentistry. Troubled Assets? Perhaps, but Dental Education Is Holding Its Value in the Higher Education Portfolio, June 2009.

“The new campus allows us to be as efficient as we can be with the infrastructure for research, education, and clinical practice. We don’t duplicate, we collaborate.”
– Dean Denise Kassebaum, University of Colorado Denver School of Dental Medicine. Troubled Assets? Perhaps, But Dental Education Is Holding Its Value in the Higher Education Portfolio, June 2009.

“It always comes back to this: Is clinical education a byproduct of patient care, or is patient care a byproduct of clinical education?”
– Dr. John Reinhardt, former Dean, University of Nebraska Medical Center College of Dentistry. Dental Clinic Finances: Lessons From the Big Ten and an Innovative Five, March 2015.

“You are either at the table, or you are on the menu.”
– Dr. Larry Tabak, Principal Deputy Director, National Institutes of Health. Our Commitment to Research: Past, Present, and Future, October 2011.

“Most of our AADR members were busy writing grants in March and April. Even if many of these are not funded, the work that’s been done can be applied to future R01 and other grant applications. This is a tremendous opportunity that will pay dividends for years to come.”
– Dr. Chris Fox, Executive Director for the International and American Associations for Dental Research. When Opportunity Knocks, an Energized Dental Research Community Answers, July 2009.

“Everything is in flux. Nothing is predictable.”
– Jack Bresch, ADEA Associate Executive Director and Director, ADEA Center for Public Policy and Advocacy . Putting Some “Teeth” in Health Care Reform Bills, October 2009.

“The favorable alignment of current political realities with ADEA’s commitment to support policies that promote and enhance access to care creates an unprecedented opportunity for us.”
– Dr. Rick Valachovic. Policy and Politics: Necessary Bedfellows, December 2007.

“In our judgment, the benefits that our fellow citizens will accrue from this legislation certainly outweigh its imperfections.”
– 2011 ADEA Statement on the Affordable Care Act. Pediatric Dental Benefits—Less “Essential” Than Previously Thought, February 2014.

“We have over all pretty sluggish growth in demand…[s]o the key question for the dental education community is, are you training the ‘right’ kind of dentists? Are you training your graduates so that they can work in settings where the demand for dental care will grow?”
– Dr. Marko Vujicic, Chief Economist and Vice President of the Health Policy Institute at the American Dental Association. A Dentist Shortage? Maybe, Maybe Not., May 2014.

“Anyone who applies here understands this intent and emphasis in the curriculum. To the extent that there was any prior hesitancy, students asking, ‘why do we need to do this,’ those types of expressions are no longer heard.”
– Dr. Caswell Evans, Associate Dean for Prevention and Public Health Sciences, University of Illinois at Chicago College of Dentistry. Reaping the Rewards of Community-Based Education, September 2012.

“Every one of my students, 360 of them a year, graduate saying, ‘What do you mean fluoride for adults isn’t the norm?’ We’re changing it.”
– Dr. Mark Wolff, Professor and Chair of the Department of Cariology and Comprehensive Care and Associate Dean for Predoctoral Clinical Education at New York University College of Dentistry. Managing Caries Risk: A Paradigm for the 21st Century?, November 2013.

“Today, the problem is not acquiring genetic information, but what to do with it.”
– Dr. Tom Hart, Professor, University of Illinois at Chicago College of Dentistry. Ready or Not, the Era of Personalized Dentistry Is Here, September 2014.

“I came to recognize that the most significant advantage a dental school-based education program has is its ability to train to a single standard of care, thus ensuring public trust and the respect of the profession.”
– Dean Patrick Lloyd, University of Minnesota School of Dentistry. Absent a Dentist, What’s the Alternative?, May 2009.

“As the field of dentistry evolves, and as we become more integrated into the health care system overall, this is the direction we need to be heading.”
– Dean Cecile Feldman, Rutgers School of Dental Medicine. The Dental Office: A Portal to Primary Care, December 2013.

“From our current vantage points, none of us can truly see the shape of our profession 50 years from now. What we can be sure of is that there will be change.”
– Dr. Rick Valachovic. Commission on Change and Innovation in Dental Education, August 2006.

“There are very few schools that want to say, look, we need more American Indian dentists, so let’s make accommodations for them to succeed in school.”
– Dr. George Blue Spruce, Jr., Assistant Dean for American Indian Affairs, Arizona School of Dentistry & Oral Health. Number of American Indian Dentists Experiences Amazing Growth Spurt, December 2012.

“For me, it’s personal. I feel fortunate to have been given an opportunity to become a dentist, and I want to give that opportunity to my scholars.”
– Dr. Rosa Chaviano-Moran, Acting Director of Admissions for the predoctoral program and SMDEP Dental Program Director, University of Medicine and Dentistry of New Jersey. Can a Girl From the Caribbean Find Happiness in Nebraska? Tales From the AAMC/ADEA Summer Medical and Dental Education Program, January 2010.

“We want to make sure that people from all backgrounds have an opportunity to bring a range of perspectives to health care so they really reflect the diversity of our nation and benefit all Americans down the road.”
– Andrea Daitz, Program Associate, Robert Wood Johnson Foundation. Diversifying the Dentist Workforce, One Cohort at a Time, June 2012.

“The quality of your student body changes when you’re admitting people who are really engaged.”
– Dr. Venita Sposetti, Assistant Dean for Admissions and Financial Aid at the University of Florida College of Dentistry. Getting the Whole Story: A Holistic Admissions Process, March 2008.

“Education should be out in front of change, but too often it is struggling to keep pace and move forward as professional practice evolves.”
– Ms. Ann Battrell, Executive Director of the ADHA. Dental Hygiene Education Responds to an Evolving Oral Health Workforce, August 2011.

“You are so far ahead of the curve. You’ve had discussions that most of us are just beginning to have.”
– Dr. Bryan Cook, Director of the Center for Policy Analysis at the American Council on Education. ADEA CCI: Curricular Change and Then Some, July 2012.

“Ideas are transformative only when people grab hold of them and put them into practice.”
– Dr. Rick Valachovic. It Takes Ideas and Then Some to Spark Lasting Change, July 2008.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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