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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic shares what you may have experienced or might have missed at this year’s ADEA Annual Session & Exhibition in Boston.

When we chose the venue for this year’s annual gathering, we never anticipated that Boston would be making headlines this winter—not just for its famed sports teams but for its unprecedented snowfall—a record 110 inches as of late March.

Yet, despite the mounds of snow still hemming in parked cars and filling empty lots, the city welcomed ADEA members with clear sidewalks, comfortable temperatures and mostly sunny skies. As CNN senior political analyst Gloria Borger commented at the start of Monday’s Political Spotlight, it felt good to get out of Washington, DC, which ironically was hit with a winter storm that stopped the city in its tracks while many of us (including me) were trying to get out of town. But all that was quickly forgotten as this year’s ADEA Annual Session & Exhibition unfolded.

The meeting achieved its goal of “Igniting Minds, Unlocking Potential” right from the start, thanks to the phenomenal success of this year’s ADEA GoDental Workshop and Recruitment Fair for Predental Students and Advisors. A record 500 students, advisors and parents from the United States, Canada and Puerto Rico traveled to Boston to gain insight into the application process and meet admissions officers from more than 40 dental schools and representatives from other related organizations. Attendees—whether teens from local colleges, international students or adults pursuing a second career—mobbed the advisors, sought guidance from current dental students and posed for countless photographs.

Boston’s status as college town extraordinaire gets some of the credit for the uniquely high turnout at this year’s recruitment fair—more than double what we’ve seen in previous years—but credit for the electrifying energy in the convention hall rests squarely with the organizers. They introduced two new features that made this year’s event especially memorable: an inspiring keynote address by forensic pathologist Dr. Joye Carter, the first African American physician to be appointed Chief Medical Examiner in the United States, and one-on-one consultations with our colleague Paul Garrard, whose annual presentation on financing a dental education is always a big hit.

Saturday also featured a full roster of activities for ADEA members who were in town for the main event. Attendees who wanted to venture offsite were faced with the difficult choice of which outstanding dental school to tour: Harvard’s, Tufts’ or Boston University’s. From what I overheard in the halls later that day, visitors to each of these schools were seriously impressed.

Many also arrived early to take part in the 2015 ADEA Signature Series Program, which once again received rave reviews from participants. The discussion centered around the role institutional climate plays in fostering professional development, and representatives of two exemplary faculty development programs—one at Boston University and the other at New York University—shared their strategies for staving off what Harvard researcher Dr. Kiernan Mathews dubbed “post-tenure stress disorder (PTSD).”

The symposium was the first of several events that helped spread the word about creative approaches to faculty development. Saturday’s Faculty Development Marketplace lit a fire under presenters, who had five short minutes to explain what is happening on their campuses. Listeners could also feel the heat on Sunday as more than 100 people squeezed in for Mentoring Best Practices for Early Career Faculty during a dynamic New Ideas Session.

The main action kicked off on Sunday morning, with the Opening Plenary featuring an engineer from NASA’s Jet Propulsion Laboratory. Adam Steltzner, who led the team charged with landing the Curiosity rover on Mars, talked about innate human curiosity as a driver of education. As expected, he wowed the audience with images of Mars and tales of overcoming the technical challenges facing his team to create a successful landing. But the most amazing revelation in Steltzner’s presentation was rooted in the far more familiar terrain of academia.

Steltzner explained that his journey to earning a Ph.D. was not propelled by high school courses in advanced math or the other academic pursuits we normally associate with high achievers in the sciences. Steltzner left high school intending to make a life as a rock musician, but the movement of the stars piqued his curiosity and literally changed the course of his life. He enrolled in community college and eventually found himself on the path to a Ph.D., thanks to a professor who conferred what Steltzner called “a glee at the prospect of being able to understand the universe.”

“Curiosity is the spark. Exploration, the fire that burns from it,” he told the audience, reminding any of us who might have forgotten that the connections that form between students and teachers can make all the difference when it comes to igniting minds and unlocking potential.

Not surprisingly, the other plenaries also proved to be highlights of this year’s Annual Session. ESPN SportsCenter anchor Linda Cohn drew a large audience to the Evening Plenary on Gender Issues: Discourse and Dessert. Although her talk focused on her professional journey as a woman breaking into the top echelons of a male-dominated field, her advice spoke to everyone in the room. She stressed the importance of being genuine and true to oneself, especially in environments that tempt people to compromise their values in order to get ahead.

“If you can work at a place where you’re smiling and laughing—not all the time, but more than you are stressed out and feeling sick to your stomach—that’s a win,” she said with characteristic candor.

During the Q and A that followed, ADEA Chair of the Board of Directors, Dr. Lily Garcia, asked Cohn what makes her want to mentor young people. “I’m moved when I see that fire,” she said, echoing this year’s theme.

CNN’s Gloria Borger delivered the signature blend of humor and insight we’ve come to expect from the Political Spotlight, but without a partisan bent and with a high ratio of optimism to cynicism. She asserted that presidential campaigns are fundamentally about hope, suggested that Hillary Clinton would benefit from a good primary opponent, and elicited laughs with a joke (attributed to Sen. Dianne Feinstein) about Jeb Bush’s run for the presidency. “Now we know what the Bush family means by No Child Left Behind,” she quipped.

Speaking about the new Republican majority in Congress as Democrat Barack Obama finishes his second term, Borger admitted that she was one of those people—“Call me Pollyanna”—who thought divided government would motivate both sides to work together to prove they could govern. Her prescription for getting around partisan gridlock? “The American public needs to say, ‘We want to elect people differently,’ and vote people out of office who don’t want to do that,” she asserted. She pointed to the California and Louisiana primary systems as examples of how states could make elections more competitive. “Everybody [regardless of party affiliation] is thrown into the same bucket and you see who survives,” she said.

The Closing Plenary was perhaps the most thought provoking. Cultural historian Sarah Lewis, who is currently a W. E. B. DuBois Research Institute Fellow at Harvard, shared some of the insights she has gained from studying what common factors allow individuals to accomplish exceptional things. I won’t try to summarize her research here, but suffice it to say their paths were neither obvious nor easy. If you are an educator interested in how people learn from their failures or in how to create environments where students feel safe taking risks and persisting toward mastery, you will want to read her book, The Rise: Creativity, the Gift of Failure and the Search for Mastery. Given the long line at the book signing following her talk, I suspect many of you are doing just that.

The ADEA Annual Session Program Committee, chaired by Dr. Sharon Siegel of Nova Southeastern University College of Dental Medicine, also did a remarkable job of assembling a cornucopia of educational offerings. The topics presented ran the gamut. We learned about avatars and anatomy, implants and IPE, primary care and problem solving, global and women’s health, as well as OSCEs, professionalism, lasers and social media—and believe me when I say this just scratches the surface! Sessions on admissions practices, Graduate Medical Education (GME), electronic health records, changes to documenting diversity, and the Affordable Care Act (ACA) were also available, thanks to the efforts of staff at the ADEA Policy Center and others. With a Supreme Court case that could gut the health care law very much in the news this winter, the ACA session, always popular, was packed.

Attendees also had exciting opportunities for hands-on learning. They used video to refine their communication skills and hi-fidelity manikins to practice responding to clinic emergencies. They also received targeted advice on practical matters such as how to submit high quality manuscripts to the Journal of Dental Education or session abstracts for next year’s meeting. (Please do so here before June 1!)

Turnout was excellent for the 2015 William J. Gies Awards for Vision, Innovation and Achievement, whose awardees exemplify what can happen when the potential within our individual and institutional members is unlocked. The annual awards ceremony gives our community a chance to honor those who dedicate their careers to educating students and work to create a new health care norm where oral health is inextricably linked to overall health. The Procter & Gamble Company was the premier sponsor of this year’s awards, one of which went to our very own Jeanne Craig Sinkford, D.D.S., Ph.D., Senior Scholar-in-Residence at ADEA, for her outstanding vision as a dental educator.

The dental hygiene community appeared especially energized by this year’s meeting, in part thanks to the presence of Esther Wilkins, RDH, D.M.D. Some of you may not be acquainted with Esther, but rest assured, she is known to all who have studied dental hygiene. The Tufts University School of Dental Medicine graduate made an indelible mark on the profession by authoring Clinical Practice of the Dental Hygienist. This foundational text, first published in 1959, is currently in its 11th edition. The book is so widely used that dental hygienists identify their educational cohort not by graduation year, but by the color of the cover that adorns their edition of Esther’s book!

Presentations on curricular change as part of a session on Transforming Dental Hygiene Education also generated excitement. The American Dental Hygienists’ Association, in collaboration with AAL, has initiated a pilot program to develop innovative learning domains and curricula that could serve as transformative models for dental hygiene programs throughout the country. Judging from the presentations by program directors from Miami-Dade College, which prepares students for traditional private practice employment, and Eastern Washington University, whose curriculum is geared to the broader scope of practice allowed within that state, curricular change and innovation in dental hygiene may be as diverse as it has been in dentistry.

Ample food for thought was also offered by three Chair of the ADEA Board of Directors Symposia—one of which focused on self-directed group learning, another on faculty mentoring, and a third on financing dental education. I caught part of this last symposium, where Drs. Nader Nadershahi, Cecile Feldman and Mike Alfano explained the challenges that lie before us. Nader provided a thorough overview of where we stand today; Cecile put our challenges in the broader context of higher education, academic medicine and biomedical research; and Mike supplied some provocative ideas for everyone’s consideration. Mike believes the current model of dental education is not sustainable, a quandary he framed by asking, “Are we like Kodak?” Kodak was a wonderfully innovative company for decades, Mike noted, but filed for bankruptcy protection in 2012. “They had the knowledge to invent the future of images…but Kodak missed the opportunity to reinvent itself.”

I sincerely hope the answer to Mike’s question about dental education is “no,” and believe that discussions such as those that occur at ADEA meetings are key to avoiding such a fate. Indeed, as I explained in my address to the ADEA House of Delegates, there is much to be proud of and much to look forward to in dental education.

As many of you know, each year during the Opening of the House of Delegates, we observe a moment of silence for ADEA members who have passed away. This year, we were especially sad to note the passing of two dental students. Jiwon Lee was a talented student at Columbia University. She served as President of the American Student Dental Association, and we all thought that one day she would help to lead our profession. The killing of Deah Barakat, a student at the University of North Carolina in Chapel Hill, along with his wife and her sister, also shook our community to the core. Deah left a legacy through the fund he helped create to support a dental relief mission for Syrian refugees. I was pleased to tell the House of Delegates that more than half a million dollars had been donated to the fund as of early March. Despite the profound grief that accompanies these tragedies, I am left with a feeling of gratitude that young people of this caliber are choosing dentistry as their profession.

At the Closing of the House of Delegates, Lily Garcia shared highlights of her year as Chair and told us that these experiences confirmed her belief in the importance of what we do as educators. If you have had the pleasure of meeting Lily, it won’t surprise you to hear that she enlivened this year’s meeting with her legendary wit. She frequently went off script, telling us that no one has better comedic timing than her predecessor, Dr. Steve Young, and informing the crowd that her Dean at Iowa, Dr. David Johnsen, would be giving dance lessons in the exhibition hall. She also did a terrific job of acknowledging the generosity of our event sponsors. “It’s all about relationships,” she said in speaking of ADEA’s corporate partners. “You can’t thank these people enough.”

We also heard from incoming Chair of the Board Dr. Huw Thomas, Dean of the Tufts University School of Dental Medicine. In his address to the House of Delegates, Huw regaled us in Welsh (his native tongue), told us he has a passion for rugby and raised some of the issues he would like to explore during his term. These included the growth of group practices and corporate dentistry, new workforce models, student debt and third-party reimbursement. Regarding this last item, he advised, “Let’s not let the next train leave the station.”

I’m sure we will consider these and many other issues when we meet next year in Denver to explore the theme “Shaping Tomorrow, Together.” I look forward to seeing you there.

Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic shares lessons from a 2014 ADEA Dean’s Conference presentation on ways that innovative dental schools are devising financially strong and educationally sound clinical education programs.

As promised last month, this Charting Progress will look at emerging practices that are helping schools maximize clinic revenue, improve their overall financial pictures and enhance clinical education in the process. Once again, we have a speaker at the 2014 ADEA Dean’s Conference last November to thank for the information I am about to share. John Reinhardt, D.D.S., who recently stepped down from his deanship at the University of Nebraska Medical Center College of Dentistry to rejoin the dental school faculty, told us what he learned from the research he conducted during his experience as the 2014 ADEA William J. Gies Foundation Education Fellow.

Using his connections with other dental school deans in the Big Ten athletic conference, John collected and compiled the kind of data that dental schools use to measure the financial health of their clinical programs. Dental schools generally do not share this type of data with other dental schools. However, these Big Ten schools have a history of sharing data with one another while maintaining confidentiality, which, John says, gives each institution strong evidence on which to chart its own individual path to improvement. Why might other dental schools want to share data? In John’s view, “Unless schools know how their clinical programs compare to others financially, those schools don’t know whether or where to seek improvements.”

John was surprised by the remarkable differences among schools his survey revealed, and so were those of us who heard his presentation. His survey looked at both dental residents and D3 and D4 students and asked about the number of clinic hours assigned, the average annual and hourly revenue collected per student and the fees for 20 key procedures. Here is a sample of what he learned about the nine schools.

  • Annual clinic hours for D3 and D4 students (combined) ranged from 1,500 hours to 2,700 hours, a difference of 80%.
  • Average hourly collections for D3 students ranged from $9 to $23, even though overall the fees charged by all schools were similar.
  • The highest fees charged for seven procedures commonly performed by dental students were more than double the fees at the schools that charged the least; for example, a complete removable maxillary denture ranged from $393 to $999.
  • Annual revenues per dental resident ranged from $29,000 to $194,000 for advanced education programs in pediatric dentistry and from $53,000 to $290,000 for advanced education programs in oral and maxillofacial surgery.

While there may be good explanations for the magnitude of these differences, they seem extreme given how much the Big Ten dental schools—all large, research-focused public universities—have in common. As John put it, “There’s something happening here that we need to explore.”

Fortunately for us, John plans to continue his research. This year he will invite all of our dental schools to participate in a survey to collect revenue-related data on a broader scale. Given adequate participation, the results should provide compelling evidence about which practices are effective and should help dental schools make informed decisions about clinical education and clinic management.

In the meantime, John has already gathered information on five innovative dental schools that others can look to as they contemplate how best to shape clinical education in the future. You can learn more from looking at John’s slides, but here, in a nutshell, are some of the lessons John learned about maximizing dental clinic revenue.

Missouri School of Dentistry & Oral Health (MOSDOH)

MOSDOH has eliminated its reliance on an in-school dental clinic by establishing a novel public–private partnership with Grace Hill Health Centers, a federally qualified health center (FQHC). MOSDOH, which just opened its doors to students in 2013, assumed responsibility for constructing a new dental education and oral health clinic in an area of high dental need in St. Louis and will retain ownership of the building. Grace Hill will be responsible for maintenance, supplies and clinical operations, with the two partners sharing revenue and risk.

Students will complete their initial didactic education in Kirksville, MO before relocating in their junior years to pursue clinical education at the Grace Hill facility. Senior students will spend about six months in externships at other community health clinics. The MOSDOH model has many advantages, including shared financing, access to enhanced Medicaid reimbursements and additional financial support under the Public Health Service Act. The facility also gives MOSDOH access to clinical faculty and helps the school fulfill the university’s mission to serve the community.

East Carolina University School of Dental Medicine (ECU SDM)

ECU SDM has retained its use of a campus clinic, but like MOSDOH, ECU SDM has transferred a large portion of clinical education to the community. The school has built eight 16-chair Community Service Learning Centers in underserved areas across the state, where each senior dental student spends three rotations of two months duration. Each center has a local partner, such as an FQHC, public health department, hospital or community college. To reduce costs and simplify management, all eight buildings have the same floor plan and use axiUm software. In addition, because ECU is a public school, it received state support for the construction, equipping and maintenance of the new clinical facilities.

The model also offers several educational advantages. Students gain experience managing business operations at a small multi-dentist clinic, and ease of data collection through axiUm creates opportunities for community-based research. The ability to collect and compare data will also allow ECU SDM to examine financial performance, productivity and health outcomes across the eight sites to further refine the school’s clinical education model.

University of Maryland School of Dentistry

The University of Maryland modified its approach to clinical education without building independent facilities. In 1985, the dental school spun off its clinic operations as a tax-exempt professional corporation, or a 501(c)(3). Although named the University of Maryland Faculty Dental Service Plan, the nonprofit encompasses all of the school’s clinics whether staffed by students, faculty and/or residents. Separating clinic operations from the university allows for greater business flexibility, making it easier for managers to hire, adjust work assignments, revise job descriptions, modify work hours and reward outstanding employees. The corporate model also encourages fiscal responsibility and streamlines purchasing by bypassing state approval for some purchases and bidding processes. Departments are allowed to retain half of the net revenues they generate, creating an incentive for clinics to increase income.

Virginia Commonwealth University School of Dentistry (VCU SOD)

VCU SOD also uses a 501(c)(3), VCU Dental Care, to manage its clinical operations and market its services to the public. VCU Dental Care was first formed in 1995 to oversee its faculty practice but has since evolved, incorporating residents in 2001 and dental and hygiene students in 2009. Like the University of Maryland, VCU Dental Care has more flexibility in handling business challenges. For example, the ability to hire outside state salary requirements and offer employee incentives makes VCU Dental Care a more competitive employer. The corporate system’s financial data reporting system also simplified VCU Dental Care’s ability to gather information needed to apply for federal Electronic Health Record incentive payments, which the clinics received. The corporation’s separate 501(c)(3) status has also allowed VCU Dental Care to earn money for its clinics by investing its reserve funds. Perhaps most impressive, VCU SOD has established a system of clinical performance incentives. Through its Variable Clinic Earnings incentive plan, VCU Dental Care contributed $2 million to faculty salaries in 2014.

Midwestern University College of Dental Medicine-Arizona

Midwestern University’s Arizona campus has taken, to my knowledge, a unique approach to clinical education that appears to be enhancing learning, patient care and the clinic’s bottom line. The school pairs its D3 and D4 students to work together side by side for a year with one serving as dental care provider and the other as a chairside assistant. The students switch roles as the complexity of their work dictates. When the D4 student graduates, his or her D3 partner is paired with a new student, and the team continues to serve the same cohort of patients in the year ahead.

This arrangement has multiple advantages over more traditional clinics in which students often operate without dental assistants. Patients benefit from continuity of care and receive more efficient service. Patients feel more secure since treatment is overseen by three sets of eyes (those of the student provider, the student assistant and the faculty supervisor). Students benefit from constant peer review, collaborative learning and the steady presence of a dental assistant. And finally, the clinic can operate more efficiently because it requires fewer chairs, fewer faculty and (since more treatment can be provided per visit) fewer disposable supplies to educate its students.

In comparison to the Big Ten schools, Midwestern-Arizona does well financially. Its fees fall in the average range for the Big Ten, yet they collect $62,000 per D3-D4 student pair annually on average, far more than the comparable Big Ten average of roughly $40,000. This amounts to $10 more collected per hour at Midwestern—no small accomplishment.

Each of these models is tailored to the specific needs, circumstances and goals of five very different dental schools.

“It always comes back to this: Is clinical education a byproduct of patient care, or is patient care a byproduct of clinical education?” John noted during his presentation. “It has to be a little bit of both, but how you look at that issue is what really determines clinical models, how dental care is delivered, and how dentistry is taught.”

It’s exciting to realize there are so many creative strategies available to dental schools looking to enhance clinical revenue and make changes to their curricula in ways that will improve the long-term financial prospects and educational strength of their programs. The willingness of the Big Ten schools and these five innovators to share information about their programs gives other dental schools an excellent basis for evaluating the many approaches to improving clinical revenue. Although each school will pursue its own unique course, the dental education community benefits from the availability of information on how other schools have tackled common challenges, and we appreciate John’s efforts to collect and share it.

John’s 2015 ADEA survey will provide us with a much larger evidence base that we can use to pinpoint problems and identify best practices. This may be critical if we are to overcome the economic challenges discussed in last month’s Charting Progress.

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

It seems as though a day doesn’t pass without our hearing another story—often alarmist—about the skyrocketing cost of higher education. Even when the news is more measured, critics and supporters alike are increasingly asking hard questions about what students and taxpayers are getting in return for their tuition dollars.

While dental education has some unique strengths that should sustain it in the midst of this turmoil, our community is still part of the larger world of higher education and shares many of the same vulnerabilities. That’s why we asked Jane Wellman to speak at the 2014 ADEA Deans’ Conference last November about what is driving educational costs and shaping public perceptions of the value provided by our institutions. Jane is the Executive Director of the National Association of System Heads and Founding Director of the Delta Dental Project on Postsecondary Costs, Productivity and Accountability. A leader with experience in both government and nonprofit spheres, Jane has long immersed herself in public policy discussions surrounding postsecondary education. As expected, she was able to give us a nuanced and multi-dimensional explanation of how higher education is financed and some of the challenges we face. I am sharing that with you now.

While there appears to be consensus that the business model for higher education is broken, few critics truly understand that business model or appreciate the need to balance the four factors that make up what Jane called the “quadratic equation” for business success: value, resources, cost and processes. As a result, there is a lot of confusion and misinformation about what factors drive educational cost.

Jane argued that the public’s perception of the value of higher education is seriously “out of whack.” Until the 1980s, we associated the quality of higher education with the prestige of the institution, the money it attracted and the selectivity of its admissions. Jane called this an “input notion of quality” that conflates the business model elements of value (as perceived by consumers and investors) and resources (such as money, prestige, demand and personnel). In the 1980s and ‘90s, public opinion shifted to a notion of quality that focused on learning and outcomes. In this more practical, consumer-oriented view, value and resources were separated and a new mission emerged for colleges: to impart measurable skills.

This shift in how we measure value has coincided with a significant expansion in the portion of the U.S. population attending college and a parallel shift in how the public views the mission of this particular educational institution. Only 39% of Americans currently believe the purpose of college is to help people grow personally and intellectually. A majority of Americans now hold a more utilitarian view—college should be about getting a career and increasing earnings. While a college degree will still increase a person’s earning power in the long run, that value hasn’t increased at the same rate as tuition, and personal income is in decline. As a result, the benefit of getting a college degree relative to its cost is diminishing, and price has become a flashpoint for criticism. Many in the public are convinced that our schools are spending money on the wrong things—or at least on things that don’t tangibly contribute to the public’s new expectations regarding higher education output.

Jane took issue with this analysis, arguing that there are a variety of factors responsible for the rise in tuition prices that go well beyond the perceived spending problem that dominates public opinion. First, she directly attributed rising tuition rates to falling state appropriations to public universities even though, on their surface, some of the basic facts appear to contradict this assertion.

  • Nationwide, state appropriations for higher education more than tripled between 1987 and 2011.
  • Yet, when adjusted for inflation and enrollment, this tripling represented an increase of only 21%.
  • The result: When looking only at state general fund appropriations, adjusted for enrollments and spending, state funding for higher education declined between 1987 and 2011 by 20%—far higher than declines in funding for any other state function.

It’s no wonder there’s confusion. As Jane pointed out, all these statements are true.

I discussed state disinvestment in higher education in the February 2012 issue of Charting Progress, pointing out the inverse relationship that exists between state and local funding and student and family spending on tuition. In 2009, state and local governments were contributing only 38% of the cost of higher education, down from a high of 60% in 1975, and families were picking up more than half of the cost.

This phenomenon also affects our community. With fewer state dollars available, more of the burden of paying for dental education has shifted to the individual, leading to rises in both tuition and student debt.

Jane also provided data on the substantial increase in demand for higher education. While K-12 education grew by 21% between 1985 and 2010, postsecondary public education grew by 60%, private education grew by 102% and graduate education grew by 85%. Not only are more students seeking out higher education, Jane explained, they are doing so in more expensive fields. Thirty years ago, the majority of students sought degrees in the lower-cost humanities or social sciences. Now students flock to degrees such as business and engineering, which cost more to deliver.

Meanwhile, as prices have gone up, the growing practice of tuition discounting has driven college revenue down. Current CFOs find this practice, in particular, unsustainable. While universities have a variety of other revenue sources such as private gifts, endowment income, or revenue from auxiliary enterprises, most of the funds from these sources are not fungible. In other words, money from the building fund cannot be used to reduce tuition, meaning higher education institutions can’t always control how they spend their own money.

In the face of these challenges, Jane explained, higher education must also manage the use of cross subsidies instead of profit to cover the cost of varied programs. Because we lack transparency in pricing in education overall, the disconnect between cost and price becomes lost on the public. The typical consumer doesn’t see the way revenues from low-cost programs subsidize higher cost programs, or the way undergraduate programs subsidize graduate programs. This is especially true now that state subsidies have all but disappeared.

When looking for a culprit to explain increased price and cost, the public often looks to faculty salaries. In reality, spending on faculty amounts to less than half of spending in higher education. In fact, with the shift from tenured and tenure-line faculty to contract or adjunct positions, such significant cuts have been made that we should have concerns about how they affect quality. Faculty, meanwhile, blame increased costs on bloated administrations. While Jane acknowledged that some institutions have overhead costs that can’t be explained, she pointed to the cost of benefits—a cost outside institutional control—as the “smoking gun,” if indeed one exists.

Finally, Jane believes that the fourth element in her equation—processes for conducting business in higher education—is failing us. Jane asserted that traditions of shared governance, boards, accreditation, licensure and a budget-making process that cycles from year-to-year are not suited to resolving the complex challenges facing higher education. Among the evidence she cited: the fact that even the Association of Governing Boards acknowledges the need to address governance problems.

Despite this bleak outlook, Jane ended on a positive note. She believes we can find solutions to these problems if we remember the four components of our business model: value, resources, cost and process. Approaching it this way, she says, is “like solving a quadratic equation.” She doesn’t advocate for simply persuading the public that things are okay when clearly they are not. Rather, she urged us to address the accuracy of public perceptions while developing better processes, gathering more data, improving governance, examining cost structures and, of course, never giving up on revenue.

As promised at the outset of her talk, Jane’s presentation did a great deal to arm us with the concepts, language and data we will need to lead a more constructive conversation about our community’s financial future. You can find additional detail about her various points here.

We are fortunate in dental education that demand for our programs and our graduates’ earnings remain strong. Nevertheless, these strengths must be measured against a continuing rise in dental student debt and our relentless battle to ensure that economically disadvantaged students are not discouraged from entering our professions. Last year, ADEA conducted a survey of dental school deans’ perceptions of cost and borrowing, the results of which will appear later this year in the Journal of Dental Education. It revealed that our institutional members are taking an impressive range of measures to keep costs down and lower student borrowing.

One underappreciated cost driver in our community is the need to build and maintain clinical facilities in which to train our students. The pace of technological change in recent decades has only added to the costs associated with this enterprise. Next month, I will write about emerging practices that are helping schools maximize clinic revenues to improve this portion of the economic picture.

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

In 2010, ADEA surveyed advanced education program directors and asked them to list the top qualities that are important to them in selecting candidates for their programs. Here are the attributes that ranked in the top five:

  • Team player
  • Assumes responsibility
  • Integrity
  • Interpersonal/communication skills
  • Reliability

When the responses of each dental specialty were looked at individually, critical thinking and clinical skills, or both, typically made their way into the top five as well. All but one specialty (more on that later) ranked academic talent dead last.

This finding may sound counterintuitive, but it shouldn’t be surprising. Academic talent is essentially a given among applicants to advanced dental education programs. Only high achievers make it into dental school to begin with, and no one graduates by being an academic slouch. But two developments—the decision in 2008 by the Joint Commission on National Dental Examinations (JCNDE) to move to pass/fail licensure exams in 2012 and the increased number of program applicants coming from dental schools that employ pass/fail grading—have raised difficult questions for advanced education programs accustomed to using National Board scores, grade point averages and class rank to help them screen and select candidates.

In anticipation of these challenges, ADEA created the ADEA Future of Advanced Dental Education Admissions (ADEA/FADEA) Project in 2009 to identify the best ways to review, compare and select candidates for advanced dental education programs. The project’s first activity was to conduct the 2010 survey and the results revealed a clear disconnect between the qualities program directors said they most valued, and the tools they were using to identify them. When the survey asked the directors to name the top factors they found most useful in evaluating candidates, letters of evaluation topped the list; but the three factors that followed—class rank, NBDE Part I scores and dental school GPA—indicated the difficulties that lay ahead. Come 2012, these numerical scores would no longer be available for some or all candidates, and perhaps more importantly, many in our community openly questioned their value in predicting professional success.

I wrote about the reasoning behind pass/fail grading in last month’s Charting Progress. In a nutshell, more and more students are choosing to go to dental schools that do not provide a GPA or class rank because they find the pass/fail grading environment more conducive to learning. And when it comes to scores on National Board exams, there is no evidence to support the notion that differences within the range of passing scores reflect meaningful differences in knowledge and ability among test takers, despite the common use of the exams to make these distinctions in the past. Furthermore, the inability of National Board scores to predict success in advanced education programs is borne out by program directors who tell us that struggling students rarely lack academic skills. Rather, their problems stem from a lack of interpersonal or communication skills, or an inability to function well in teams.

These qualities are the focus of the ETS® Personal Potential Index (ETS PPI), a web-based system that evaluates applicants on personal characteristics in six areas: knowledge and creativity, communication skills, teamwork, resilience, planning and organization, and ethics and integrity. Considering these personal characteristics alongside traditional metrics such as scores and grades is at the crux of holistic review, an approach to admissions that ADEA member schools have widely embraced in selecting their predoctoral students. In fact, according to a recent report by Urban Universities for HEALTH, a project that aims to increase health equity by diversifying the health care workforce, dental schools lead among the health professions in their use of holistic admissions.

ADEA began piloting the ETS PPI as part of the ADEA Postdoctoral Application Support Service (ADEA PASS℠) application in 2012, and program directors report that they like having a standardized tool to assess many of the variables linked to success in graduate, business or professional school. They also say the ETS PPI is becoming more helpful with each passing year, in no small measure because we have been working to clarify the instructions for employing the tool and encouraging faculty to make full use of the comment fields to fill in any gaps that may exist in a student’s letters of reference. These letters remain a vital part of every student’s application package, but they can be as varied as the individuals who write them. Moving forward, we will be working with deans and others to make sure that letters of evaluation are comprehensive and demonstrate a genuine knowledge of each student’s strengths and weaknesses to give candidates and program directors their best possible shot at finding matches that will work for them both.

Since the creation of ADEA/FADEA, the project has collaborated with the ADEA Council of Hospitals and Advanced Education Programs (ADEA COHAEP) to host two collaborative summits on advanced education admissions. The first summit allowed ADEA members to discuss the findings of the 2010 survey. The second, held in 2013, brought program representatives together to learn about new tools within the ADEA PASS application and gain a better understanding of how pass/fail dental schools evaluate their students. Seven of the eight schools that currently use pass/fail grading attended and shed light on the systems they have in place to distinguish outstanding students from good students in their academic environments.

The 2013 summit also touched on the use of multiple mini-interviews (MMI), the practice of having applicants work through short, structured problems with a series of faculty members. I first wrote about this technique in a 2008 issue of Charting Progress, which looked at ways of assessing student professionalism. Today, more schools and programs are using MMIs to reveal many of the characteristics that faculty most value. (For more on MMIs and other topics related to admissions, see the April 2014 Journal of Dental Education (JDE).)

Last fall I learned that some of our colleagues in medicine are using a proprietary online personality assessment tool to gather similar information in a slightly different way. Residency Select purports to reveal candidates’ behavioral attributes in three areas: usual tendencies, stress tendencies and drivers. Programs customize the instrument so that each candidate assessment profile reflects the program’s particular screening criteria. According to the company behind Residency Select, no dental residency programs are currently using the tool, but it is available to them. It will be interesting to see how this assessment instrument works for medical residency programs on some of our campuses and to consider whether it might be useful for some of our programs as well.

One group of programs that might welcome a tool of this type is oral and maxillofacial surgery (OMS) residencies. If you haven’t already guessed, OMS is the specialty that ranked academic talent highly in the 2010 ADEA/FADEA survey. In fact, this group of specialists placed academic talent at the top of their list and chose “National Board score above 90” as the fifth most desirable quality they sought in applicants. Why did the results for this specialty diverge so much from the findings for other groups of advanced education programs?

To find out, I called David Shafer, D.M.D., Associate Professor and Chair of the Division of Oral and Maxillofacial Surgery at the University of Connecticut School of Dental Medicine. Dave has been a member of COHAEP for more than a decade and is now the ADEA Board Director for Hospitals and Advanced Education Programs so he is well versed in the concerns of his peers. He is also in an unusual position. Situated in a school that uses pass/fail grading and in a specialty that values high-stakes standardized exams, he is willing to defend both.

“There’s no reason to suspect that at pass/fail schools, the students aren’t being taught to a very high level,” he told me when I asked about the reluctance of some programs to consider candidates from these institutions. “I’d argue that some of the pass/fail schools are some of the hardest schools in the country to get into.”

He also shared praise for the ETS PPI and its role in bringing more standardization to the appraisal of candidates. “We’ve had the PPI for three cycles now,” David observed, “and people are getting better at writing comments that are useful.”

But for some of the more competitive programs, Dave says that determining high academic achievement remains an important part of the mix. For his specialty in particular, strong exam scores are essential for entering the profession.

“The problem we run into in oral and maxillofacial surgery is that we need to know students can perform well on a high-stakes exam because they’re going to have to take other ones. Many of our students go on to get an M.D., which requires an ability to pass Step 1 and Step 2 of the Medical Boards, and then they have to take their oral maxillofacial surgery boards. I need that data. I need to know who can perform.”

To address this reality, OMS programs began requiring scores from the National Board of Medical Examiners Comprehensive Basic Science Examination (CBSE) when NBDE scores ceased to be available. The CBSE is considered a statistically valid, in-depth examination of basic medical science knowledge, and the test seems to be a good fit for these specialty programs.

As I wrote last month, the American Dental Association is developing an admissions test for advanced dental education programs in 2016. At a minimum, the exam will expand the admissions tools available to advanced education programs, but these programs are diverse, and one exam is unlikely to suit them all. Personally, I’m not concerned. Each year, dental schools manage to evaluate applicants from 1,800 different colleges and universities seeking admission to their predoctoral programs. If we can do that, I’m confident we will figure out graduate admissions in a pass/fail environment as well.

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