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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What’s next?

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

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

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

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

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

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

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

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

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

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

Cultivating future faculty

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

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

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

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

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

Licensure

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

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

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

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

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

Well-being

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

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

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

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

Serving the underserved

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

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

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

Interprofessional education (IPE)

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

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

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

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

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

Dr. Richard ValachovicIn this month’s Charting Progress, Dr. Rick Valachovic takes a second look at a disruptive force in the dental marketplace and asks what it means for dental schools and programs as they prepare students for practice.

Are we doing enough to prepare students for the shifts occurring in the business of dentistry? Should we be doing more to help our students evaluate their opportunities both as employees and as entrepreneurs?
A lot has happened since I asked those questions in 2014 as part of a column titled “From Bungalow to Big Box? How DSOs Could Change the Face of Dentistry”. At the time, there was even some lingering disagreement about what term to use to describe dental support organizations (DSOs)—businesses that offer a range of nonclinical support services to affiliated dental practices.

DSOs vary, but affiliates are typically group dental practices that have outsourced their marketing, billing and IT functions to the DSO and adopted its corporate branding. From a consumer perspective, these practices appear to be part of a chain, and they are sometimes called “corporate practices” to distinguish them from the solo and small group practices that have long dominated dentistry.

Today, the term DSO is well established, and these once marginal players have gained a strong foothold in the marketplace for dental services. In an age of increasing consolidation among health care delivery entities, this shouldn’t be surprising. Nevertheless, the rise of DSOs represents a remarkable cultural shift.

Why is the appeal of these entities growing? Simply put, they fill a need by addressing a number of the stressors faced by today’s dental practices. Whether a practice struggles to market its services online and through social media; decipher ever-changing insurance contracts; maintain an electronic health record; or finance the acquisition, installation and maintenance of sophisticated digital equipment, DSOs offer a range of services that free up affiliated dentists to focus almost exclusively on the clinical aspects of their profession.

This proposition has proven especially attractive to millennials. By 2015, nearly 12% of dental school graduates entering private practice were choosing to work for corporate practices affiliated with DSOs. This year’s ADEA Survey of Dental School Seniors showed that 16% were making this career choice. Some older dentists have also jumped on board, eager to avail themselves of the ready-made solutions that DSOs offer to the increasingly complex challenges of running a mature practice.

“The days of just sending out a postcard or putting a sign out on the street are over,” says Michael Bileca, President of the Association of Dental Support Organizations. “Patients are ultimately in charge of their choices, and there’s a plethora of information in front of them to make that choice.”

According to Michael, DSOs have evolved to help practices adapt to the new health care landscape by developing different competencies for different affiliates. Some DSOs have strong marketing and branding capabilities and primarily build practices from scratch. Other DSOs focus on technology or on a dental specialty, such as prosthodontics. In recent years, he estimates, DSOs have experienced double-digit growth—in the number of practices supported, the number of dentists supported, and the number of patients seen in DSO-affiliated practices. “Year in, year out, I’ve seen continued growth in the ability and competency of the DSOs to create more value for their supported practices and dentists,” Michael said.

There’s no question that DSOs have a lot to offer, but for those of us educated in an era when independent, solo practice was the norm, practicing dentistry in a corporate environment requires a cultural shift not all of us are ready to embrace. That’s partially due to the unfortunate checkered history of a few corporate practices, a history that has fueled skepticism about the quality of care provided by all such practices.

“From what we hear, in a DSO there is pressure to produce from the start and not necessarily the mentorship where the doctor/owner has a vested interest in seeing that treatment is done properly,” says Gary Badger, D.D.S., M.S., who recently retired as Professor, Chair and Program Director of the Department of Pediatric Dentistry at the University of Texas School of Dentistry at Houston. He is especially concerned that new dentists who work in corporate practices will be less inclined to take the time they need to seek advice when they are unsure about a procedure. “They get the message that if they don’t produce, they are not needed,” he says.

Gary fears these expectations can create an ethical quandary for inexperienced dentists, especially those who graduate with high amounts of debt. In Gary’s view, “It boils down to ethics, critical thinking and how students will perform under pressure.”

Michael agrees that the transition to practice is challenging for new dentists—in any environment—but he disputes the idea that DSOs are responsible for poor clinical decision-making by employed dentists. “Clinical decision-making is the responsibility of the practice owners,” he says, whereas the DSO is responsible for the business support services. “The more we can support the business of dentistry in the areas of marketing, IT, insurance contracting and the like, the more it leaves the supported practices able to focus on clinical care, and that in and of itself is a tremendous value.”

Gary acknowledges that all corporate practices are not alike. He thinks students can—and should—vet all potential employers as they make their post-graduation plans. He wants students to find out about an organization’s reputation before signing on and scrutinize contracts to make sure they leave room for decision-making based on ethical principles rather than financial goals.

Helping students formulate appropriate questions for future employers is one recommendation that Gary and his co-authors put forth in a 2015 paper in the Journal of Dental Education. They urged dental schools to enhance their practice management curricula in four ways:

  1. Explain shifts that occur in the business of dental practice.
  2. Provide a clear understanding of the legal structure of the corporate practice of dentistry and the dentist’s rights and responsibilities in this practice model and others.
  3. Review time allotted in the dental curriculum for inquiry into the corporate dentistry practice model, and assist students in developing the appropriate questions to make an educated decision regarding this and other practice options.
  4. Develop interactive and engaging experiences that give students the opportunity to explore various types of practice models that include interprofessional experiences.

I agree it is incumbent on us to educate students to make informed decisions about their employment options after graduating and to better prepare them for the transition to practice. On the most fundamental level, our graduates need to understand that, as Gary and his co-authors put it, “[T]here are no circumstances…that absolve dentists from responsibility for the treatment of their patients.” That may be harder to appreciate in a corporate environment than in a small private practice setting—or not.

Many DSOs offer mentoring and formal continuing education (CE) programs structured to help recent graduates transition to practice. Heartland Dental, the largest DSO in the United States, invests heavily in professional development, offering 200 hours of supported CE courses to its dentists each year. Patrick Ferrillo, Jr., D.D.S., a past president of ADEA who served as dean of three dental schools and, until recently, sat on the Heartland board of directors, told me that Heartland even incentivizes CE with significant financial bonuses, some of which are large enough to pay off a dentist’s student loans. That financial benefit aside, he says the reason DSOs sponsor professional development programs is to cultivate better dentists. “If you are better educated, better prepared, your practice is only going to flourish,” he says.

Pat joined the Heartland board at the request of a former student at the Southern Illinois University School of Dental Medicine: Heartland founder Rick Workman, D.D.S. At the time, Pat recalls, DSOs were highly controversial. Although he had moved to the University of Nevada, Las Vegas, by then, Pat knew his former colleagues in Illinois didn’t like the idea of a large corporate practice competing with their alumni for patients. Nevertheless, he was curious. “I saw this as a new opportunity for our graduates to consider, and I knew Rick was very conscientious, that he cared about the quality of care, so I decided to be engaged,” Pat told me.

After 12 years serving on Heartland’s board, Pat has concluded that the overall concept of DSOs is positive, and that there’s a reason they are experiencing such rapid growth. “It’s an attractive alternative for graduates coming out of dental schools and for those who are thinking of slowing down, so to speak, and want to sell their practices,” he told me. Part of that attraction is that DSOs allow dentists to practice dentistry and enjoy a better work/life balance than those who own their own practices.

In Pat’s observation, dentists at Heartland were happy, especially the younger practitioners. He characterized their perspective as “‘I want to work, I want to have a good life, I want to have a great income and I’ve got to pay off my student debt.’ They seem to be very content with that.”

So how would he like to see dental education evolve to better prepare students for the changing practice environment? Pat would like faculty who are sending a message to students not to consider DSOs to keep an open mind and let students decide what is right for them.

I agree. One size does not fit all, and now that DSOs are part of the mainstream, we should do more to help students explore all of their career options. As Gary stated, that means helping our graduates to ask the right questions.

Pat recommends these two:

  • Will the DSO I join support me in my personal career development?
  • As a dentist, will I drive the decision-making when it comes to patient care?

If the answers to both questions are yes, then DSOs appear to be a career option well worth considering.

Dr. Richard ValachovicIn this month’s Charting Progress, Dr. Rick Valachovic urges caution in adopting workforce models and projections that predict a massive oversupply of dentists in 2040, citing the risk and impact of doing so.

Earlier this summer, I was invited to take part in a webinar on the dental workforce hosted by the American Dental Association (ADA). The occasion was the release of a new ADA Health Policy Institute (HPI) brief that presents HPI’s latest estimates of the future supply of U.S. dentists. The study—conducted with the scientific rigor we’ve come to expect from HPI Chief Economist and Vice President Marko Vujicic, Ph.D., and his team—makes an important contribution to the debate about how we, as a dental community, can sustain the dental profession and deliver care to everyone who needs it.

The event provided an opportunity to discuss concerns raised by some in our community about the number of dentists needed for the future. On the one hand, federal workforce projections as late as 2015 concluded that increases in supply would not meet the national demand for dentists in 2025, exacerbating an existing shortage. This assessment, combined with projections about future demand for care, was a factor in the opening of 13 new dental schools and the expansion of many others that we’ve witnessed since 1997.

On the other hand, two of our colleagues in dental education, Howard Bailit, D.M.D., Ph.D., and Stephen “Steve” Ekland, Dr.P.H., D.D.S., M.H.S.A., have predicted a dentist surplus of between 32% and 110% by the year 2040. Writing in the Journal of Dental Education, the authors cite several factors that suggest a decline in demand for dental services and a major increase in the number of people each dentist will be able to serve. While acknowledging the uncertainties in their assumptions, the authors conclude, “[A] large and growing surplus of dentists in 2040 is expected.”

So how do we reconcile these opposing views on the size of the future dental workforce capable of meeting anticipated future demand for care? The authors of the landmark 1995 Institute of Medicine (IOM) report, Dental Education at the Crossroads: Challenges and Change, offered an alternative perspective.

“After reviewing workforce models and projections and their underlying assumptions,” the committee stated, it found “no compelling case that the overall production of dentists will prove too high or too low to meet public demand for oral health services. Accordingly, it found no responsible basis for recommending that the total dental school enrollment should be pushed higher or lower.”

In my view, this assessment is still relevant today and speaks to an essential truth, perhaps best expressed by the inimitable Yogi Berra: “It’s tough to make predictions, especially about the future.”

Yogi was right. Predicting the future is difficult, and we do so at our peril. We don’t know the social, political, technological and other changes that might occur in the near- and long-term future, so any predictions we make are based on uncertain assumptions. Think of the changes that have occurred since 1990—in information technology, genetic engineering and international affairs, to name just a few domains. I chose 1990 because that date was 28 years ago—the same number of years between 2018 and 2040.

What particularly concerns me is the suggestion Howard and Steve make that dental schools should reduce the number of dentists they graduate rather than wait for market forces to reduce the dentist supply. “With a current graduating class of about 6,000 (and growing),” they write, “there is already a substantial surplus of dentists, and this surplus would continue for years to come. Importantly, the longer the current number of graduates continue (or grow), the smaller future classes would have to be to correct the imbalance.”

This statement, like opposing views based on predictions of a dentist shortage, assumes that there is a “guiding hand” able to control with precision the number of dental schools and their class sizes. That may have existed in the health and education ministries in Moscow during the Soviet era, but no government agency or organization has that sweeping influence in the United States. It is a mistake to think that any forces other than market forces can impact these numbers.

Nevertheless, despite the perils of prediction, university presidents and governing boards must make choices about the opening or closing of dental schools, their class sizes and a host of other matters. It seems prudent to me to base those decisions on what we know today about the current state of oral health and the provision of dental services. According to data from the Centers for Disease Control and Prevention, nearly half of all American adults who have teeth have periodontal disease, and nearly half of children under age 19 have experienced dental caries. These numbers are even higher in low-income and minority communities. We could alleviate some of this disease with universal community water fluoridation, but only about 70% of Americans benefit from fluoridated public drinking supplies, and each year some communities vote to remove fluoride from their water. Against this context, for the foreseeable future, we anticipate an ongoing need for dental care.

Public sentiment appears to be bullish on the dental profession. In 2018, U.S. News & World Report placed dentistry number two in its 100 Best Jobs ranking, and number one in its ranking of health care jobs. Our application services data reflect this strong interest in the profession. ADEA currently processes 20 applications for each first-year dental student slot, an impressive ratio that has held consistent for the past six years. We now graduate almost 6,000 dentists annually to serve a U.S. population of 327 million. Contrast that with the mid-1970s, when 6,300 dental graduates went on to serve a U.S. population tallied in 1980 at 226 million. Not surprisingly, no U.S.-licensed dentist who wants to practice his or her profession lacks employment opportunities.

Those who predict doom and gloom for the future of dental education often cite the level of graduating dental student debt as a harbinger of a change in dental education’s fortunes and dentistry’s attractiveness as a career, but we know that there is another story. Dentists have among the lowest default rates on their student loans, and the majority pay off their loans in seven years.

Economic forecasting is an imprecise science at its best. At its worst, it can lead us to set policies that are not in our community’s best interest. Over the decades, we have seen pendulum swings with the opening and closing of dental schools and increases and decreases in the number of dental school graduates. I do not see any evidence that we should try to force the pendulum to one side or the other.

So how do we move forward? The 1995 IOM committee’s conclusion that there is “no responsible basis for recommending that the total dental school enrollment should be pushed higher or lower” strikes me as a solid point of departure. To send a different message to the the university presidents and governing boards of the 66 U.S. dental schools is misguided, in my view. Such a message is also unfair to those current and future applicants to dental school who aspire to a career in dentistry.

As we consider dental school enrollments moving forward, let’s keep the perils of prediction in mind. A world with less dental disease and a need for fewer dentists is well worth aspiring to, but it is far from clear that such a reality is at hand. Intervening to reduce the number of future dental school graduates could harm the millions of Americans with dental disease by impeding the care future graduates could provide. Are we willing to take that risk?

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic looks at how an international treaty on mercury is prompting a shift in the treatment of dental caries.

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Closer to a Crossroads

With everything going on in the world, a recent move by the European Parliament may have escaped your notice. On July 1, Europe’s latest regulation on mercury went into effect, limiting the use of dental amalgam in questionable ways.

While the move was applauded by some, it was not without controversy (I’ll get to that in a moment). Nevertheless, the rule marks an important milestone in Europe’s compliance with the Minamata Convention, an international treaty negotiated by the United Nations Environment Programme for the purpose of reducing mercury pollution from a wide range of sources, including dental amalgam.

Dental amalgam was one of the products initially slated to be banned under the 2013 agreement, which went into force a year ago. Thanks to a unified effort by the international dental community to make delegates aware of the safety and value of the material, the final document called for a phase down in its use rather than a ban.

In some countries, that phase down is progressing rapidly, in large part due to consumer preferences for alternative materials. At least one nation, Norway, has phased out amalgam use entirely. A few other nations are not far behind, and many others are well on their way to meeting the treaty’s requirements on dental amalgam. According to Benoit Soucy, D.M.D., M.Sc., Director of Clinical and Scientific Affairs at the Canadian Dental Association, Canada was already in compliance with the Minamata Convention even before the country became a signatory. As for the United States, the Environmental Protection Agency issued a final rule on the handling of dental amalgam last summer, with all U.S. dental practices required to achieve compliance by July 2020.

In light of these developments, it’s not surprising that back in 2013, I said I could “imagine a future in which we will be able to manage without amalgam, even in the procedures where it is currently the restorative material of choice.”

I recently asked Christopher Fox, D.M.D., D.M.Sc., Chief Executive Officer at the American and International Associations for Dental Research, if he shares that view. He does, and he takes it a step further. “If we ramp up preventive approaches, we will reduce the need, not just for amalgam, but for any restorative material,” he recently told me.

A May 2018 editorial in the Bulletin of the World Health Organization echoes that view.

We are in a period of transition from a conventional model of restorative dentistry, one largely based on the use of dental amalgam, to an oral health model oriented towards health promotion and integrated disease prevention. The phase down of the use of dental amalgam can become a catalyst to renew and revitalize dentistry and tackle the health, social and economic burden of oral disease by prioritizing oral health as part of the global health agenda.

Margherita Fontana, D.D.S., Ph.D., Professor at the University of Michigan School of Dentistry, spoke with me about Caries Management by Risk Assessment (CAMBRA) in 2013. She and others within the ADEA Section on Cariology have since devised a U.S. Cariology Curriculum Framework that outlines the many options now available for preventive and nonsurgical therapies and emphasizes the need for evidence-based clinical decision-making when treating individuals.
Newer approaches—sealants, varnishes, gels, silver diamine fluoride, high-fluoride toothpastes, glass ionomer fillings and nutritional counseling—give us a range of tools for restoring and maintaining healthy teeth. Of course, it takes time to disseminate new practices widely, and it can be difficult absent corresponding policy change around reimbursement and the like. Nevertheless, we can start by educating our students and current practitioners about the full extent of what’s in today’s dental treatment toolbox.

In October, the American Dental Association (ADA) will be issuing guidelines on nonrestorative approaches to treating caries. These guidelines, along with forthcoming ones on prevention and on the surgical treatment of caries, will provide us with a valuable resource—one that can also contribute to phasing down the use of amalgam.

Last month, I spoke with Marcelo W. B. Araujo, D.D.S., M.S., Ph.D., Vice President of the ADA Science Institute, a project of the ADA Council on Scientific Affairs. Marcelo is eager to see dentistry move in a more preventive direction and is hoping the ADA clinical practice guidelines will contribute to the profession’s progress. The guidelines cover the full gamut of available tools, including advocacy for public health initiatives such as community water fluoridation as a means of preventing caries.

“We need to change the mindset of the professional to see that prevention is also part of practicing dentistry,” Marcelo emphasized. “I’m hoping our clinical practice guidelines will help change that mindset.”

Marcelo is not alone. A growing community of dentists is looking for innovative and more effective ways to prevent and manage caries. Last year, they met in California at the International Conference on Novel AntiCaries and Remineralizing Agents 3 (ICNARA 3). (You can learn more about their proceedings in Advances in Dental Research, an e-supplement to the Journal of Dental Research. For those who are interested in learning more about one of these agents, silver diamine fluoride, Oral Health America is hosting a webinar on the topic later this month.)

Given these developments, is dentistry at a crossroads where the amalgam “pathway” is no longer needed to ensure that everyone can achieve good oral health? Within the research and academic communities at least, there seems to be a consensus that complete caries removal is no longer an evidence-based treatment. Instead, the goal of dental treatment has shifted to preserving the natural tooth structure and remineralizing teeth whenever possible, and some minimally invasive techniques for managing dental caries are gaining ground. Nevertheless, the absence of safe and reliable amalgam replacement materials that work under similar conditions at a similar price remains a barrier to a phase down in less-resourced settings with high levels of dental disease.

In recognition of this need, some manufacturers have been investing in new dental materials, and so has the U.S. government. The National Institute of Dental and Craniofacial Research awarded $2.8 million for six research grants aimed at developing a long-lasting composite polymer capable of replacing current restorative materials and outlasting current commercial materials by at least a factor of two. Those grants end this summer, so it shouldn’t be long before we learn what progress researchers have made toward achieving those goals.

That’s a long way of saying we’re not at a crossroads yet, but advances in materials science, the availability of alternative treatments and renewed emphasis on prevention are certainly bringing us closer. Political pressures are also accelerating the march toward a future where disease prevention and tooth preservation should make the need for restoration less common, which brings me back to the European regulation that just went into effect. Although it allows for exceptions, the rule effectively prohibits the use of dental amalgam in deciduous teeth, in children under age 15 and in pregnant and nursing women.

Why restrict the use of amalgam in these populations?

“The Europeans have made a political recommendation, not an evidence-based recommendation,” Marcelo points out. Indeed, the final rule reflects the political clout of those who oppose the use of amalgam based on spurious claims related to its impact on human health, rather than on any change in the scientific consensus. The ADA still considers amalgam a safe dental material with wide applicability, Marcelo says, especially where low-cost treatments are needed, and will continue to support amalgam’s use in any person needing dental care.

“Everyone agrees that we want to get mercury out of the environment,” Chris Fox adds, “but we don’t want to get rid of dental amalgam as a choice for professionals and patients based on erroneous information about its direct health effects. Dental amalgam is safe for human health.”

In fact, Chris is concerned that the same level of scrutiny amalgam has received may not be applied to newer restorative materials. When we spoke, he emphasized the need to ensure that any replacement product has a strong safety profile.

“We can’t forget that there are other health hazards out there. Everything is on a continuum of risk, and we need to balance all those in terms of both human health and the environment,” he emphasized.

It may take some time to find that balance, but there’s no question that we have the scientific and public health know-how to reach the prevention-oriented future we envision. Amalgam restorations may be with us for some time to come, but I believe we are well on our way toward a more conservation-oriented dental practice that preserves both the environment and our teeth.

Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic considers the evolution of ADEA’s centralized application service and where the application process stands today.

In 1972, I applied to dental school. I was one of many young people whose interest in pursuing a dental career created an unprecedented surge in the number of dental school applicants—from about 9,000 at the start of the decade to a peak of almost 16,000 in 1975, before falling back to roughly 10,000 by 1980.

In 1979, 6,301 students enrolled in dental school, the highest number on record. Today, about 12,000 individuals apply to dental school each year, and with the addition of 10 new schools and the expansion of class sizes over the last 20 years, institutional enrollments have increased about 50%. With 6,122 first-time, first-year enrollees in 2017, enrollments may soon exceed their historical peak.

1972 was also the year that ADEA, then the American Association of Dental Schools (AADS), launched its centralized application service for predoctoral programs—AADSAS®—freeing participating schools from much of the up-front work that goes into the admissions process. Centralizing the application process was a bold step, and we can be proud that dentistry was one of the first health professions to take it. Applications were printed on paper, filled out by hand and mailed to AADSAS. The service photocopied the forms and distributed them to dental schools. That process was in still in effect when I arrived at ADEA in 1997, and I knew it was time for a change.

Later in 1997, we engaged George Haddad of Liaison International, a Boston-based tech firm that is now a leader in online application services. Outsourcing some of the more cumbersome tasks streamlined operations at ADEA, but George and his team had their work cut out for them. “At first, we continued to print the applications and send them to schools every week,” George recalls. “We had stacks of paper applications.”

In the early years, we used a hybrid process that integrated floppy disks (remember those?). Applicants filled out their applications on paper and ADEA sent the information to a data entry firm to transcribe. Meanwhile, ADEA staff collected transcripts and verified coursework and credits. Because schools still wanted to read the applications on paper, Liaison International was printing and mailing reams of paper as late as the 2010–2011 application cycle.

It quickly became apparent that moving AADSAS to the web was the right solution. To accomplish this, Liaison International developed a secure platform that ultimately allowed us to move the entire application process online and into the 21st century. ADEA was the first health professions association to launch a web-based application service, a pioneering move that other associations have since emulated.

Since 2012, the pace of progress has been dizzying. Applicants submit all information online, including letters of recommendation. DAT scores are automatically reported to the service. Paper has been entirely eliminated from the process—schools now log in to the service to access applications electronically. In 2013, ADEA reached another milestone: becoming the first health professions association to boast that all of its U.S. schools participated in its predoctoral application service. Over the years, we introduced three more application services: ADEA PASS®, for advanced education programs; ADEA CAAPID®, for programs designed for dentists with degrees earned outside the United States or Canada; and ADEA DHCAS®, for dental hygiene programs.

When I spoke recently with George, he confirmed that ADEA was among the first health professions organizations to outsource the management and operations of the application process and the technology needed to run the service. Turning this function over to his firm has reduced our Association’s costs by saving space and eliminating the need to hire and train seasonal staff. Meanwhile, the most important outcome of this transformative change is that we’ve improved the experience for applicants. Applicants now have a “one-stop shop” where they can access information and complete the entire application process.

The application’s content has also been modernized. We changed how we ask about race and ethnicity, introduced socioeconomic-status variables and provided schools the opportunity to ask questions that are not part of the standard application. We’ve also encouraged the use of new interviewing techniques, such as the multiple mini interviews, which allow schools to evaluate skills such as critical thinking, ethical decision-making and effective communication.

All of this provides ample evidence that ADEA’s application services are up-to-date and have kept pace with today’s ever-changing times. In fact, we’ve been ahead of the curve, leading the way for many of our sister associations. But putting aside whatever pride we may feel in these accomplishments, it’s fair to ask, “Why does this matter? How does it advance our mission?”

I think George sums it up well when he says, “Centralized application services allow associations to market their professions as a whole, so recruitment happens on a national level, eliminating redundancy while preserving the uniqueness of each school’s admissions process. The platform gets all the schools around the table. They share best practices and create requirements for the profession.”

I couldn’t agree more, and the results are evident in the changes we’re seeing in admissions practices and the applicant pool. The widespread adoption of holistic admissions, particularly by dental schools, allows applicants to “tell their stories” and articulate why they have what it takes to be a caring, competent health care professional. While admission to dental school remains extremely competitive, we are seeing a wider range of grade point averages and DAT scores, suggesting that schools are more willing to consider a broader range of attributes when evaluating applicants.

One of the most interesting trends has been the rise in the number of re-applicants, those who apply to dental school for a second or third time. These individuals typically work hard to gain additional education and experience to achieve their goals. They now represent one-third of our applicant pool, demonstrating just how attractive a dental career remains.

The increased presence of women in our incoming classes is another striking example of how things have changed since I applied to dental school. In 1972, women accounted for 14% of the applicant pool. Mirroring other economic and social trends during this period, women now account for 51% of dental school applicants.

ADEA has also invested considerable effort in attracting underrepresented students to the profession. One important ADEA priority is the Summer Health Professions Education Program, an academic enrichment program for educationally and socioeconomically disadvantaged students seeking to enter dentistry or another health profession. In addition, to promote diversity and ensure that all students have the opportunity to present a complete picture of their qualifications during the admissions process, we are working across our membership to help train faculty and staff in the use of holistic review, consistent with federal case law. Most recently, we established an ADEA Centralized Application Service Working Group to analyze trends and give us a better sense of our applicants and enrollees. We still have a long way to go in creating a dental workforce that truly reflects our nation’s diversity, but I am optimistic that our investments will pay off.

This year, we introduced a “soft launch” of the application, which allowed applicants to prepare their applications three weeks before the site opened for submissions. More than half of anticipated applicants took advantage of this head start, and George was not surprised in the least that this student population is first out of the gate. “Dental students are among the first to apply,” he told me. “They are very diligent.”

So, what’s next? I don’t have any pronouncements to make, but rest assured, as technology advances and social norms and expectations shift, ADEA will continue to embrace change. Our operational goal is to always be able to say, “We are actively simplifying the process of applying to dental school,” with all signs appearing to indicate that our motivated pool of applicants will continue to “seize the moment.”

 

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic asks tobacco-cessation educators how their work has changed with the advent of vaping and some states’ legalization of recreational marijuana use.

You may recall the title of my May letter, “A Matter of Life and Death.” I could easily have used the same title this month, but whereas deaths from pediatric sedation (last month’s topic) are extremely rare and occur in a matter of minutes, deaths related to tobacco use remain all too common and occur over the course of decades. Will the availability of new, smokeless nicotine delivery systems reduce smoking-related deaths or introduce a new generation to the tobacco habit? Will the legalization of marijuana in more and more states introduce a new contaminant to people’s mouths and lungs or simply decriminalize a hidden behavior?

The research into these questions is incomplete and contradictory, but we have several reasons to be concerned about new practices that complicate the effort to reduce tobacco use. Smoking marijuana poses similar risks to smoking tobacco and may be responsible for some additional oral health effects. As an ADA topic page points out, THC, an appetite stimulant, encourages snacking, which may explain why using marijuana is associated with higher numbers of caries.

Vaping, which delivers nicotine without the smoke, has been heralded by some as a welcome alternative to tobacco use. In fact, the United Kingdom embraces the practice in its effort to help smokers quit.

“It’s part of the National Health Service’s treatment plan for those who want to quit to incorporate e-cigarettes and vaping,” says self-described tobacco nerd Joan Davis, RDH, Ph.D., Director of Research, Special Projects & Initiatives at the A.T. Still University Missouri School of Dentistry & Oral Health. “On the other hand, the CDC is 110% against it.”

Why are scientists at the Centers for Disease Control and Prevention concerned? You can get the full CDC assessment of e-cigarettes on the agency’s website and a summary of the evidence on the public health consequences of using them in a 2018 report from the National Academy of Sciences, Engineering, and Medicine. In a nutshell, while e-cigarette vapor typically contains fewer toxins than tobacco smoke, it is far from harmless.

  • The primary ingredient, nicotine, is highly addictive and affects the developing brain.
  • Vaping liquids contain flavorings and other chemical additives, some of which are linked to cancer and other serious diseases.
  • The process of converting liquids into an inhalable vapor involves heat, which can damage cells in the mouth, potentially increasing the risk of such oral conditions as infection, inflammation and gum disease.
  • Perhaps of most concern is the popularity of vaping among young people, leading many observers to fear that the practice may induce users to start smoking and expose them to all its attendant harms. (A recent issue of The New Yorker offers a vivid portrait of the phenomenon in affluent high schools.)

As we consider these risks, our experience with tobacco may be instructive. It took decades of concerted effort with substantial government support to bring smoking rates down to the current level, roughly 15% in the United States and Canada. Nevertheless, one in five deaths is still linked to tobacco use, a habit that also contributes to tooth loss, periodontal disease and oral cancer among the living.

“Somehow this problem has not gone away,” Joan points out, “and the most addicted populations are those who are poor, have limited education or are mentally ill.”

CDC statistics corroborate this statement. Almost a third of adults with less than a high school degree smoke cigarettes, as compared with 10.4% of college-educated adults. This disparity explains why many highly educated people think smoking is no longer an issue, despite the fact that 480,000 people die from it each year.

The good news is that smoking-cessation interventions work, and dental professionals are well positioned to deliver them effectively. A 2012 Cochrane review of 14 studies found that interventions conducted by oral health professionals roughly doubled the rate of tobacco abstinence at six months or longer. Unfortunately, the treatment of tobacco dependence continues to be inconsistent in many dental practices, suggesting a growing role for dental and other health professionals who are ready and willing to talk with their patients about what they are inhaling.

Joan would like to see everyone receive a tobacco-cessation intervention at every appointment, but she acknowledges that several barriers stand in the way. She told me many dentists don’t think tobacco-cessation counseling falls within their purview. Others lack the necessary skill set, and based on their limited experience, they believe that counseling doesn’t work. Joan attributes these failures to a lack of understanding about motivational interviewing and health behavior change.

“You need to ask open-ended questions as opposed to, ‘Did you quit yet?’” she says, and work in questions about tobacco and other substance use with routine questions about brushing and flossing. Many dentists are also pressed for time.

That’s certainly true for dental educators, who, research shows, also have a mixed record when it comes to preparing new providers to help their patients kick the tobacco habit. Joan and several colleagues have surveyed U.S. and Canadian dental schools and U.S. dental hygiene and dental assisting programs about tobacco dependence education (TDE). Among the researchers’ findings:

  • As of 2016, TDE had not been consistently integrated into predoctoral education.
  • At dental schools, 90% of respondents indicated that faculty members were “confident” to “extremely confident” in teaching tobacco-related pathology, but only 49% reported the same level of confidence in teaching students how to help patients quit.
  • Three-quarters of dental hygiene programs reported expecting their graduates to be competent in a moderate-level tobacco-cessation intervention, but only one quarter reported having a formal competency that encompassed the U.S. Public Health Service’s Clinical Practice Guidelines for such an intervention.
  • Almost all dental assisting programs addressed oral and systemic diseases related to tobacco use, but less than 30% of programs covered key topics related to tobacco cessation.

All dental providers should be versed in TDE, according to Laura Romito, D.D.S., M.S., M.B.A., Associate Professor at the Indiana University School of Dentistry (IUSD), Director of its Nicotine Dependence Program, and Associate Director for Faculty Development and Curriculum at the IU Interprofessional Practice & Education Center.
“Patients may share more readily with a dental assistant or a dental hygienist than with the dentist, so we advocate for tobacco interventions to involve the entire oral health team,” she says. “It’s one of the things that makes Indiana unique.”

IUSD has been a leader in tobacco research, education and cessation since Arden Christen, D.D.S., M.S.D., M.A., started the school’s first programs in these areas in 1980. Historically, the university’s Nicotine Dependence Program has ranked among the most successful in the field. According to a 2001 paper in the Journal of Dental Education, the program’s one-month quit rate was 58% and its one-year quit rate was 33%, well above the national averages for intensive interventions.

IUSD continues to be among a handful of schools that do an exemplary job when it comes to TDE. Led by Pamela Rettig, M.S., IUSD’s dental hygiene TDE program requires all students to work on their communication skills and to develop a personalized quit plan for a friend or family member. The dental assisting program makes sure students graduate with knowledge of tobacco’s oral health effects, various tobacco products, and behavioral and pharmacological interventions, enabling graduates to advance the oral health care team’s tobacco-dependence treatment efforts.

Dental students learn to:

  • Take a social history that captures the use of tobacco, e-cigarettes and marijuana.
  • Educate patients on the oral health implications of continued use of these substances, advise them of the benefits of quitting and gauge whether they are interested in doing so.
  • Connect patients who want to reduce their tobacco use with resources, such as the state’s quitline, or providers who can prescribe pharmacotherapy for tobacco cessation.

Students may also choose to counsel patients themselves. During a clinical elective, which Laura supervises, students develop a behavioral and pharmacological treatment plan and initiate counseling. They seek to identify the triggers that influence each patient’s substance use and the barriers that discourage them from quitting. Laura then evaluates students on a range of competencies.
“Can they assess patients’ use of these substances? Can they develop a cessation treatment plan? Can they communicate effectively with the patient using the motivational interviewing techniques that they’ve been taught?” Laura asks.

In Joan Davis’s view, this assessment piece is key. If the Council on Dental Accreditation made evidence-based tobacco-cessation counseling a graded clinical competency, she believes it would be a game changer. “Schools would have to back it up with didactic education, make time in the curriculum and provide faculty with training,” she says. “A lot of schools teach students about tobacco using nongraded case studies. These don’t demonstrate students’ interpersonal skills, which are essential for tobacco cessation.”

Schools and programs that want to bolster their tobacco education will find a ready-made, open-access resource in Tobacco Free! Curriculum©, which includes learning objectives, student activities and assessments. Joan designed the curriculum while on the faculty at Southern Illinois University Carbondale well before vaping and marijuana legalization were on everyone’s radar screens, but she believes it’s premature to change the fundamentals of tobacco cessation education until more definitive research emerges about how use of these additional substances influences people’s efforts to quit.

“Honestly, I think educators and clinicians need to just keep doing what they’re doing and up their game to provide more comprehensive treatment,” she says. “If everybody at least asks if people use tobacco products and encourages them to quit and gets them to a quitline, that’s good. It would be even better if they could work on motivating them to quit.” (A quitline is a tobacco cessation service available through a toll-free telephone number. Quitlines are staffed by counselors trained specifically to help smokers quit.)

One of the challenges of addressing tobacco use in today’s more complex social environment, Laura says, is identifying the practice in the first place. People who vape, or go to a hookah bar on the weekends, don’t always think of themselves as smokers. “They need to understand why we’re asking,” she says, “and that using these products may have oral health ramifications.”

As science sheds additional light on newer nicotine delivery systems and marijuana use, the principles underlying tobacco-dependence treatment will likely remain relevant, she says. At IUSD, they are currently studying the feasibility of integrating a clinical decision support system in the electronic health record that would trigger tobacco-cessation counseling. “This should help to standardize student oral health provider’s messaging,” Laura says, “and hopefully make their interventions more effective.”