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.

Dr. Richard ValachovicIn this month’s Charting Progress, Dr. Rick Valachovic shares what’s on the minds of ADEA’s Canadian members and discusses the trends that are reshaping dental education in Canada.

To celebrate ADEA’s recent launch of a legislative advocacy portal for Canadian members, I decided to call some Canadian colleagues to find out what’s on their minds. Not surprisingly, many of their concerns overlap with those of their U.S. peers, but Canadian dental education also operates in a uniquely Canadian context, with advantages and challenges all its own.

The country has 10 dental schools—all affiliated with public universities—and the tuition at most of them is relatively low when compared with most schools in the United States. Admission is extremely competitive, with more than seven applicants for every first-year dental school slot. As a result, many Canadians go abroad to study dentistry, and not just to the United States. In recent years, Canada has also developed reciprocity agreements with dental schools in Australia, New Zealand and Ireland.

The impact of these developments has been striking. Prior to 2010, three-quarters of newly licensed dentists in Canada had graduated from Canadian schools. Today, less than half of new dentists are educated in Canada, and the expectation is that number will continue to decline.

Reciprocity is only partially responsible for this trend. Add to that a separate national policy decision to welcome professionals of all stripes to Canada, and you have the makings for an increasingly globalized Canadian dental profession.

Since 2011, internationally educated dentists from countries without reciprocity have had a new pathway to practice dentistry in Canada: taking an equivalency assessment to establish their eligibility for Canadian licensure. The National Dental Examining Board of Canada (NDEB) Equivalency Process has proven to be popular. Jack Gerrow, D.D.S., Executive Director and Registrar at the NDEB, estimates that in 2014 alone, 150 to 200 international dentists obtained licenses through the process. Factor in the 200 dentists made eligible through reciprocal agreements, and 90 international dentists who attended qualifying (also known as advanced standing) programs, and it’s easy to see why the 450 Canadians who graduated from the country’s traditional predoctoral programs in 2014 are now in the minority.

Does the diversity of routes to licensure or the mismatch between supply and demand for Canadian dental education matter? Do these factors have a bearing on the availability of dental care? The answers to those questions depend on your point of view.

Benoit Soucy, D.M.D., M.Sc., is among those Canadians who have expressed concern that the influx of international dentists may be contributing to an emerging surplus of dentists in some areas of Canada. Benoit is Director of Clinical and Scientific Affairs at the Canadian Dental Association (CDA), which represents most of the provincial dental associations in Canada. Benoit told me that regulators are not receiving more complaints about international dentists than about graduates of accredited programs. Yet despite this good news, he expressed concern that internationally trained dentists, who are unfamiliar with the Canadian practice environment, will necessarily face additional challenges in their integration into the job market.

Daniel (Dan) Haas, D.D.S., Ph.D., FRCD(C), Dean of the University of Toronto Faculty of Dentistry, shares Benoit’s desire to see international dentists spend time becoming acculturated to North American dental practice. He would prefer that international dentists enter the workforce though the qualifying process that has been in place since 1997, and he believes the dental education community shares that view. Meanwhile, these advanced standing programs are currently at capacity and admit about 90 students a year. Again, limited supply meets considerable demand.

“Restrictive enrollment has not actually worked to stem the tide of new dentists in Canada,” Dan told me. He used this argument to win approval to increase Toronto’s enrollment by 25% a few years ago. “Many Canadian applicants do not get into dental schools in Canada, and then turn to U.S. schools, which is totally fine, but if Canadians want to be dentists, why don’t we train a few more of them here in Canada?” he argued.

Dan’s institution is the largest dental school in Canada, and one of the few with the wherewithal to expand. All of the dental schools in Canada are part of public universities that, like their U.S. counterparts, are being asked to do more with declining government funding. Making up for these financial losses is no easy feat given that the government also regulates how much tuition schools can charge.

Dan asks, “How will we do what we’re supposed to do: great research, create knowledge and at the same time have great educational programs? Because financially, we’re strapped. For all of us, that’s the biggest challenge, to balance our budgets, not just to survive but to be great schools.”

“Part of the financial problem for dental programs in Canada is that we have 10 small dental schools,” observes Jack Gerrow. He told me that for the past 20 years he has been promoting institutional cooperation models that could increase efficiency, but he has found few takers. Nevertheless, he is excited by some faculty-level initiatives, including a removable-prosthodontics curriculum—created at the Dalhousie University Faculty of Dentistry—that is reaching thousands of users via YouTube.

Another initiative coming out of that institution is the Network for Canadian Oral Health Research (NCOHR). The network was established in 2012 with funding from the Canadian Institutes of Health Research and other partners, and includes researchers from all of the nation’s dental schools. NCOHR’s goal is to build capacity for oral health research by connecting people across disciplines and across institutions and by giving them the skills they need to compete for research funding.

Debora Matthews, D.D.S., Dip. Perio., M.Sc., Assistant Dean for Research at Dalhousie, received the grant that first established the network, and she serves as its director. In a few short years, Debora told me the network has hosted a series of well-attended workshops and institutes, and its individual members have established relationships that are bearing fruit. Ph.D. candidates have connected with mentors, scientists have co-authored peer-reviewed papers and newly formed research teams have competed successfully for funding.

In a recent vote of confidence, the Association of Canadian Faculties of Dentistry (ACFD), ADEA’s sister organization in Canada, and the Canadian Association for Dental Research agreed to fund the network for another three years. That’s good news for the network and for two of its most prominent teams, one focused on orofacial pain and the other looking for sustainable ways to reduce oral disease in Canada’s First Nations, Inuit and Métis people.

What many in the States may find most surprising about our neighbor to the north is that Canada also has a significant access-to-care problem when it comes to oral health. The Medical Care Act, which established the country’s publicly funded health system in 1966, excluded dental care, and the Canada Health Act, which further clarified the system in 1984, was equally mum when it came to oral health. (If you’re interested in learning why, take a look at this paper.)

Today, 95% of Canadian dental care is paid for out-of-pocket or through private insurance. As this year’s ADEA/Sunstar Americas, Inc./Harry W. Bruce, Jr. Legislative Fellow, Greg Olson, D.D.S., M.S., put it, “Even though Canadians as a whole tend to be more socially conscious and community minded, they are struggling with the challenge of integrating dental care with general health care.”

Greg is an Associate Professor at Loma Linda University School of Dentistry and Canadian by birth. He shares the concern held by many in his native land that the government should be doing more to address its access-to-care problem.

To get a better sense of where the issue stands, I contacted Paul Allison, B.D.S., Ph.D., Dean at McGill University Faculty of Dentistry. Paul chaired a national panel on improving access to dental care for vulnerable populations. The following were among the key findings of the panel’s 2014 report:

  • Many low- and even middle-income Canadians suffer from pain, discomfort, disability and loss of opportunity because of poor oral health.
  • Approximately six million Canadians avoid visiting the dentist every year because of the cost.
  • Private sector dentistry—which provides good quality dental care for a majority of people living in Canada—does not serve as a good model of health care provision for the vulnerable groups who suffer the highest levels of oral health problems.

The report’s proposed remedies for improving access are both multifaceted and incremental. How could they be otherwise, given its finding that “There is no consensus on standards of dental care provision among federal, provincial, territorial and municipal governments in Canada,” any more than there is the United States? But Paul himself has a bolder vision, which he shared with me last month.

“We need to fundamentally rethink how we deliver dentistry,” he contends. “People really struggle to get to us for all sorts of very good reasons. We should set up and test new models of care that take dentistry to them, whether it be mobile dentistry, teledentistry or putting care in unusual settings.”

Paul would like to see dental schools in the forefront of not only developing these models of care but also training students and residents to implement them. He says that’s what came out of the report for him.

One way dental education might become a laboratory for new models of care would be through the development of a fifth-year residency program—an idea that emerged in informal conversations at this year’s meeting of the ACFD. While discussions are still preliminary, they signal that the desire to see dental education evolve to remain relevant to society at large is as vigorous in Canada as in the United States.

John O’Keefe, M.Dent.Sc., M.B.A., is an exemplar of this and other Canadian trends. His lilting accent reveals his Irish origins, and his current title, Director of Knowledge Networks, signals his evolving role at the CDA. Until 2010, he served as Editor-in-Chief of the association’s journal. Today he strives to facilitate dialogue among CDA members. He oversees CDA Oasis, a virtual “campfire” where dentists are invited to share their stories and their expertise, and to learn from others. John has also helped to create the Canadian Oral Health Round Table, a national forum focused on improving Canadians’ oral health.

“For the first time in my memory, we’ve got an annual symposium in which we bring together associations within dentistry with other professions like teachers, social workers and government groups,” John told me. “It’s baby steps, but we’ll have 30 organizations coming back for a third year in a row to talk about addressing oral health promotion for the most vulnerable groups in Canadian society. I think that’s something to be celebrated.”

So do I, and I wish John well in his quest to inspire members of the Canadian dental profession to come together around the virtual campfire to share their experiences and discuss their collective future. This activity can only enhance the profession, the dental education community and the oral health of those they serve.

Dr. Richard ValachovicIn this month’s Charting Progress, Dr. Rick Valachovic examines the promise of Big Data and its potential to enhance dental diagnosis, treatment and research.

In 2011, IBM’s Watson computer captivated the public when it challenged two legendary Jeopardy! champions on the iconic television quiz show. With access to more than 200 million pages of information and algorithms for sorting through this enormous quantity of data to identify the most likely responses to Jeopardy! clues, Watson outscored both human competitors.

Since this public demonstration of the power of what is referred to as “Big Data,” IBM engineers have focused on honing Watson’s skills in several new realms, including medical diagnosis. I don’t have to tell you that the amount of information available to clinicians now grows at a rate that far outstrips an individual’s ability to absorb it. A computer, on the other hand, is ideal for sifting through large amounts of data and looking for patterns. Watson takes this power one step further with a unique capacity for natural language processing and applying cognitive reasoning to analyze information and work with the clinician. In other words, Watson can understand a question posed in plain English, sort through massive amounts of data for potentially relevant answers, and communicate these to a clinician—in a matter of seconds—using what sounds like human speech.

Collaborators at the Cleveland Clinic and elsewhere have already provided Watson with a foundational medical “education.” This year, IBM announced that it is partnering with 14 major cancer centers to train Watson to analyze genetic data that can guide cancer therapy for individual patients. IBM has also invested heavily in acquiring health-related data sets to enhance Watson’s knowledge. These include large banks of images, which are pushing Watson’s programmers to equip “him” with a new set of skills in visual analysis.

A clinical world in which Watson and his successors provide seamless automated decision-support to clinicians may be some years down the road, but such a world no longer seems like the stuff of science fiction. Whether dentistry will benefit from these developments depends on our willingness to adopt a tool that has been remarkably controversial: dental diagnostic codes. In 2006, the ADEA House of Delegates passed a resolution declaring its support for the development and implementation of such codes to facilitate clinical research and assist in developing best practices for dental care delivery. Dentistry as a whole has been historically slow to take up this charge, and most dental schools are no exception. Fortunately, that situation has started to change.

Today, the Big Data revolution has finally given our community the incentive it needed to adopt diagnostic coding. Nearly all ADEA member schools now use electronic health records (EHRs); several dozen schools have introduced diagnostic codes into their EHR systems; and a small but growing subset of our institutions has banded together to create the first oral health database—BigMouth Dental Data Repository—developed from partially de-identified EHR data.

Six dental schools are currently participating in BigMouth, which resides on secure servers at the University of Texas School of Dentistry (UTSD) at Houston. BigMouth is a project of the Consortium for Oral Health Research and Informatics (COHRI), and researchers who want to query the data can submit a project proposal to a COHRI review committee for consideration. The database currently holds more than 2 million records, and already a few researchers have accessed the data to examine adherence to treatment protocols and the associations between several systemic and oral health conditions.

Muhammad Walji, Ph.D., Associate Dean for Technology Services & Informatics at the University of Texas School of Biomedical Informatics at Houston, leads the project. When we spoke recently, Muhammad told me that the project is now looking to expand the number of participating schools, standardize the way they collect data and, now that initial government grants have been spent, develop a financial sustainability plan. BigMouth is currently able to accept data from any institution that uses an axiUm EHR, but organizers are discussing plans to incorporate data from clinics using other systems in the future.

“We want the database to be as diverse as possible,” Muhammad told me, “especially geographically, so we can get a better understanding of what’s happening to patients throughout the country. We also want to reach outside of dental schools. We’re interested in having other institutions—such as large group practices—participate because they may be serving different types of patients.”

The creation of BigMouth was one of the driving forces behind the creation of the Dental Diagnostic System (DDS), previously known as EZCodes. DDS is currently in use at 16 dental schools and one dental support organization. An additional 16 dental institutions have loaded the DDS in their EHRs as a first step toward implementation of the terminology. Elsbeth Kalenderian, D.D.S., M.P.H., Ph.D., Chair, Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, working with other Harvard and UTSD colleagues along with the University of California, San Francisco, School of Dentistry and ACTA (Academisch Centrum Tandheelkunde Amsterdam1) in the Netherlands, developed the DDS terminology in 2009.

More than two decades ago, the American Dental Association (ADA) recognized the need for a dental diagnostic coding system and began working to develop a separate system known as the Systematized Nomenclature of Dentistry (SNODENT®). Its codes are an official subset of the Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT®), a comprehensive set of medical terms that are recognized around the globe. SNODENT uses the same format as the International Classification of Diseases (ICD) codes that are the standard for health care reimbursement. The system offers a high level of detail; for example, it contains 25 ICD codes for different types of tooth decay. Yet the rollout of SNODENT has been periodically interrupted, and the dental community has been slow to adopt it.

“The initial development of SNODENT wasn’t ready for prime time,” explains David Preble, D.D.S., J.D., Vice President of the recently created ADA Practice Institute, “and the EZCodes (now DDS) were created to fill the gap.”

I called David to get an update on SNODENT and the acceptance of dental diagnostic coding generally. “People who are not informed still talk as though dentistry doesn’t have diagnostic codes,” David told me. “We do have codes; they’re just not widely implemented,” he emphasized.

Why has dentistry as a whole been resistant to diagnostic coding? In David’s view, the reticence is related to cost and culture. In an environment of decreasing reimbursement from insurers and fewer self-paying patients coming in for care, dental offices already feel under pressure to create efficiencies. Practitioners may see the introduction of EHRs and diagnostic codes as costly disruptions to the work flow that bring few benefits. But as he points out, “In the academic and large group practice environments, using diagnostic codes and electronic health records hasn’t turned out to be the workflow issue dentists fear.”

At dental schools, the desire to take part in Big Data initiatives such as BigMouth or others under way at the National Institutes of Health should serve as a motivator to adopt diagnostic coding. According to David, a handful of dental schools are already using SNODENT, and more are likely to join them. In the past year, the coding system was officially recognized by the American National Standards Institute (ANSI), and the ADA is now working with DDS code users and other stakeholders to develop an integrated coding system that can serve everyone’s needs.

David envisions that many future SNODENT users may want to begin by adopting smaller reference sets of SNODENT codes rather than working with the full 7,000+ terms contained in the system. While the specificity of SNODENT makes it an ideal system for research, David estimates that a clinician practicing general dentistry might only need 200 of those codes to document 99% of the diagnoses made in his or her practice.

Indeed, the more manageable size of the DDS system is one of its reported attractions. In the words of its creators, the DDS serves as an “interface terminology” whose terms are organized in a user friendly and meaningful manner for chairside use. SNODENT’s designers recognize the value of the DDS and have already incorporated about two-thirds of the DDS codes into the larger system.

Next month, the ADA will convene a meeting with stakeholders to address compatibility issues between the two coding systems. Then the ADA plans to put the revised version of SNODENT back on the ANSI ballot for approval. The goal is to ensure that the first ANSI-recognized version of SNODENT provides a solid foundation for future iterations of the nomenclature.

Elsbeth and Muhammad believe that delivering a unified diagnostic coding system for the dental profession by this fall will be a tall order; however, they are excited about working to harmonize the two systems. Meanwhile, everyone agrees that the adoption of diagnostic coding marks a turning point for our profession. How soon we will see universal adoption is harder to say, but there’s no doubt that it is the critical next step in fully realizing the potential of Big Data.

It’s also worth mentioning that Big Data is making some traditional researchers nervous. The National Institute of Dental and Craniofacial Research is trying to be sensitive to these concerns as it considers the creation of possible funding streams to support research based on EHR data. Where Big Data excels is in mining very large sets of existing data to establish correlations. A need will still exist for controlled trials that seek to establish causation.

Meanwhile, the desire to preserve today’s best quality research shouldn’t deter us from pursuing the new opportunities afforded by Big Data. As David points out, “Data alone will not replace traditional research, but there is a dearth of evidence for many things that happen in dentistry and a finite amount of money for controlled trials, and there are some trends you’re not going to see in a controlled trial no matter how many people you enroll.”

There’s no question that Big Data can enhance dental research and the care we provide, but even Big Data enthusiasts—such as Muhammad—caution against overzealousness.

“It’s not the answer to all of our questions,” he told me. “Big Data are inherently messy, so we need a team approach—clinicians, informaticians, researchers, statisticians, epidemiologists—and I think we have to be quite careful with what questions we ask of these systems as well.”

1 The English translation of the name is “Academic Center for Dentistry, Amsterdam.”

Dr. Richard ValachovicIn this month’s Charting Progress, Dr. Rick Valachovic explores how dental schools can enrich their IPE programs and improve the care they provide by establishing collaborations outside the health professions.

Last fall, I ventured north of our offices in Washington, DC, to spend a day at the University of Maryland, Baltimore (UMB). From the office of UMB President Jay Perman, M.D., I looked out over the streets of West Baltimore. Many Americans associate this community with poverty, rioting and police violence, but Jay views this corner of the city quite differently. He sees it as a laboratory, one where students can learn about the social determinants of health—safe neighborhoods, walkable streets, access to nutritious foods and health services—and one where interprofessional education (IPE) can thrive.

Jay is a pediatric gastroenterologist with a passion for IPE and a strong belief that public universities must serve their communities. To that end, he chairs the board of the Downtown Partnership of Baltimore and serves on the boards of a local foundation, a regional business association and a public-private partnership dedicated to advancing the health, safety and success of Baltimore’s youth. In 2013, he established the Center for Community-Based Engagement and Learning to enhance UMB’s involvement with local children and families. And he wants all of the university’s students to develop a similar appreciation for the potential of West Baltimore.

That’s where IPE and its changing face come in. UMB may not be unique, but it certainly is unusual. Its schools of the health professions—dentistry, nursing, medicine and pharmacy—and its graduate programs in the health sciences are situated on a health and human services campus that includes schools of social work and law. As a result, these professions, not usually thought of as “health” professions, are easily integrated into UMB’s interprofessional activities.

“It’s great,” says Jacquelyn Fried, RDH, M.S., Associate Professor, Director of Interprofessional Initiatives and Acting Graduate Program Director at the University of Maryland School of Dentistry. “It really takes the patients from soup to nuts. When you’re looking at a geriatric case, you’re looking at legal issues such as advanced directives and disability rights; and with social work, you’re looking at quality-of-life issues, the family dynamics. It adds a really nice element to the whole experience.”

These diverse schools have always shared a campus, and some previously offered courses in geriatrics, human sexuality and other topics that cross professional lines. But collaborations that span the entire campus are relatively new. IPE figures prominently in UMB’s 2011–2016 strategic plan, and the establishment of the Center for Interprofessional Education in 2013 cemented IPE’s importance within the university. Today, UMB strives to educate all its students to take a team-based approach to providing high-quality, affordable health care and human services.

Students take part in a variety of classroom and community initiatives, from an annual IPE day, during which interprofessional teams of students collaborate to solve a complex case using standardized patients, to participation in the JACQUES Initiative,1 a 12-year-old effort both to serve Baltimore residents living with HIV and to combat the spread of the virus. Rounding out the program are a University of Maryland School of Pharmacy case competition, opportunities for community-based team exercises in long-term care and in emergency-department settings, and courses such as Health Care Law, which encourage interprofessional enrollment.

Ten years ago, UMB brought its various schools together to create a Master of Public Health Program by capitalizing on existing offerings within the university’s profession-specific schools. At that time, Susan Wozenski, J.D., M.P.H., was offering a course in program planning and evaluation within the University of Maryland School of Nursing. She is now director of the dual M.S./M.P.H. program at the nursing school, and the program planning and evaluation class has become a core component of that degree.

“It was a great class,” she told me, but with the introduction of M.P.H. students from other professions, “it became an even better class.”

Susan is an attorney who says she sees health challenges through the lens of policy change, legislative issues and regulation. For example, when it comes to helping people with addictions, she thinks of using drug courts, which combine supervision, testing, sanctions and incentives to promote adherence to clinical treatments. This diversity of perspectives is also evident in her classroom, where the students tackle real-world problems that range from reducing Type 2 diabetes in Baltimore’s school children to combatting cholera in Haiti.

“No one profession has all the tools and resources to solve these large problems,” she observed. “Knowing what other disciplines can contribute gives you a tremendous advantage when problem solving.”

Because Jay Perman couldn’t agree more, he created UMB’s President’s Clinic. Every Tuesday, he invites a team of students from UMB’s seven professional schools to work with him and colleague Elsie Stines, RN, M.S., CPNP, a nurse practitioner, on an actual case with interprofessional dimensions. Students conduct thorough medical histories and physical exams, engage in dialog with patients and their families, and consult with one another to develop a plan of care. The presence of social work and law students makes the health professions students aware of social issues that may underlie a health complaint and of barriers to care that may impede effective treatment. Above all, students come to appreciate the value of treating the whole patient rather than simply focusing on the disease. Jay hopes that this exposure to team-based care delivery will prime students for practicing collaborative care once they are out in the field.

Of course, UMB is not alone in venturing beyond the health professions to enhance IPE and improve care delivery. The award-winning CARES2 program at the University at Buffalo School of Dental Medicine is one of several initiatives that incorporate social work students or professionals in dental school clinics to better resolve patient needs that can interfere with care. On other campuses, the more distantly related fields of architecture and engineering are also part of the IPE mix.

Larry Schnuck, AIA, is Vice President and Team Leader for medical education at design firm Kahler Slater, an ADEA corporate member known for its expertise in designing health professions schools. Larry tells me that IPE and collaborative care have been drivers in all the firm’s recent projects. (You can read about two of these in the March 2014 issue of Charting Progress.)

The firm recently designed new facilities for the University of Wisconsin-Madison School of Nursing. Among other features, the new space will support collaboration among experts from the schools of nursing, computer science, public health and engineering who are seeking environmentally based ways to improve human health. The building will contain the Center for Aging Research and Education (CARE), which will feature a full-scale and fully instrumented mock apartment to introduce students to the latest technologies that can improve the safety and efficiency of care delivery in the home.

Such exciting new learning environments not only promote collaboration, they also result from collaboration, a process that Kahler Slater routinely employs.

“Not unlike what we’re trying to do through our designs,” Larry told me, “we encourage collaboration here at the firm. It’s not one person, it’s a team that works together, along with the client and even some of their stakeholders in the community, to design these facilities.”

This summer, UMB announced that it had received funding for a new Interprofessional Education Center Facility that will likely be housed in a vacant building in its West Baltimore neighborhood. The facility will include simulated clinical space and become the new home of the President’s Clinic.

It’s clearly time for schools that want to grow their IPE programs to look beyond the health professions for partners that can help prepare students to address the social, cultural and environmental dimensions of health. Even though care occurs at the individual level, it’s critical to remember that other forces also influence our patients’ health and well-being. Getting the perspective of nonhealth professionals can remind us that addressing family dynamics, living environments and even public policy may be just as important for improving patients’ health as the clinical care we provide.

As IPE evolves to include a broader range of professions, it is also worth noting that this approach to professional development can benefit other professions. Faculty from the College of Social Sciences, Health, and Education at Xavier University, a Jesuit institution in Cincinnati, have been among the most active participants in the faculty development institutes run by the Interprofessional Education Collaborative. Health fields account for a minority of the college’s 11 undergraduate programs, but Doug Olberding, Ed.D., sees IPE as a “unifying bridge” that can help the disparate programs within his college develop a stronger identity within the university and a collective sense of purpose. Doug, who is Chair of the Department of Sports Studies, was charged with facilitating a year-long reimagining of the college in 2014.

“In academia, we’re so siloed. That’s the basic problem in health, but it’s an issue for any profession,” Doug believes. “When you can communicate outside your own discipline, you learn so much more.”

His colleagues agree. They have proposed a new name—the College of Professional Sciences—and a new college-wide focus: IPE.

1 Joint AIDS Community Quest for Unique and Effective Treatment Strategies
2 Counseling, Advocacy, Referral, Education and Service

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.


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