In this month’s letter, ADEA President and CEO Dr. Rick Valachovic explains why dental schools need to take a serious look at whether they are adequately preparing students to apply genetics in clinical care.
Ready or Not, the Era of Personalized Dentistry Is Here
30,000. That’s the estimated number of people in the United States whose genomes had been sequenced as of 2011. I am not one of them, but I have an interesting related story to tell. Five years ago, I attended the annual TedMed gathering in San Diego. There I heard a presentation from Anne Wojcicki, the founder of 23andMe, a privately held personal genomics company whose direct-to-consumer personal genome test was named Invention of the Year by Time magazine in 2008. The company offered attendees at the meeting analysis of their DNA. I accepted out of idle curiosity, and since then, I’ve gained a sneak peek into the era of personalized medicine—and personalized dentistry—that lies ahead.
In 2003, the Human Genome Project completed its map of the full sequence of genes that make up the human genome. This knowledge and subsequent discoveries have deepened our understanding of what causes diseases and given us new insights into treating diseases and avenues for preventing them prior to their onset.
Today the ready availability of genetic testing and genome sequencing, and their relative affordability, have brought genetic knowledge into the clinical arena, allowing physicians and dentists to personalize the care they provide to individual patients. It doesn’t take much imagination to envision how knowing about the gene variants that affect the function of a particular patient’s pain receptors and analgesic absorption could be useful in a dental office. Taken a step further, it is easy to see how the clinical application of genetics is on the cusp of transforming care.
Ten years ago, Francis Collins, M.D., Ph.D., then Director of the National Human Genome Research Institute, and Larry Tabak, D.D.S., Ph. D., then Director of the National Institute of Dental and Craniofacial Research, published a paper calling for increased genetics education for dental health professionals. Why? “Because education is about the future, not the past, and we are now entering the era in which genetics and genomics will play a vital role in both oral health research and dental practice,” they answered.
The Collins and Tabak paper speaks of salivary diagnostics, salivary gland gene transfer, tissue engineering and the use of stem cells as just a few of the scientific advances that need to be incorporated into dental education so that genomic research outcomes can be translated into improved clinical outcomes for patients. Since then, a decade of new discoveries related to the architecture, function and coding of human genes makes this call all the more urgent. Until recently, genetics was an area of interest for a few, but it won’t be long before all dentists will need to be versed in human genetics if they want to continue to provide high-quality care. (For more on this topic, see a recent guest editorial by Hal Slavkin, D.D.S., Professor Emeritus and Dean Emeritus at the Herman Ostrow School of Dentistry at the University of Southern California, in The Journal of the American Dental Association.)
A 2001 survey conducted by Tom Hart, D.D.S., Ph.D., and researchers at the University of Pittsburgh revealed that only eight dental schools provided a formal course in human genetics at that time, and most of the remaining schools did not have plans to create one. These institutions reported that genetics education was integrated into courses such as pathology, biochemistry and microbiology, with considerable variation in the amount of time devoted to genetics and the topics each school covered.
When I spoke to Tom earlier this month, he told me he suspects there may be even fewer stand-alone courses in human genetics at dental schools today. “Those courses often came about because of the passion of individual faculty members,” he told me, “and some of them have since retired.”
Tom, who is currently a Professor at the University of Illinois at Chicago College of Dentistry, is one of three dentists serving on the Inter-Society Coordinating Committee for Practitioner Education in Genomics, more commonly referred to as ISCC. The committee is charged with improving the genomic literacy of physicians and other healthcare providers and enhancing the effective use of individual patients’ genomic results in their clinical care. The means to this end is the development and sharing of educational competencies and resources that professional societies, specialty boards and others—including associations such as our own—can modify to support the educational needs of their members.
Karen Novak, D.D.S., M.S., Ph.D., is representing ADEA on the ISCC. Karen is Associate Dean for Professional Development and Faculty Affairs at The University of Texas School of Dentistry at Houston where a genetic counselor is working with others at the dental school to assess genetic content in the current curriculum and propose ways to better integrate the topic so it has relevance for the type of personalized clinical care graduates will soon be expected to provide.
One of ISCC’s stated goals is to collaborate with provider education groups to “standardize approaches, competencies, and knowledge base for all health workers.” While the committee’s mandate is to improve genetic literacy of the practice community, ADEA is committed to seeing that the committee’s work also benefits the education community so, as Karen put it, we’re not playing catch up. I am grateful for the way in which Karen is representing all of us on this committee.
This federal initiative is occurring none too soon. According to an article that appeared earlier this summer in the New England Journal of Medicine, several thousand physicians have already ordered clinical genome sequencing or its less expensive abridged version, exome sequencing, for their patients. The paper’s authors anticipate that about 10,000 of these tests will be ordered in 2014, and that the number will only grow as the cost continues to decrease dramatically. The consumer demand will also broaden from individuals with difficult to diagnose conditions to healthy individuals who are curious about their genetic risk factors, ushering in the use of genomic information for preventive as well as diagnostics purposes. As Tom put it, “Today, the problem is not acquiring genetic information, but what to do with it.”
Dental educators are not immune to this problem of appropriately handling genetic information. Tim Wright, D.D.S., M.S., Director of Strategic Initiatives at the University of North Carolina at Chapel Hill School of Dentistry, has a longstanding interest in genetics and represents the American Association for Dental Research on the ISCC. Tim and I both attended dental school in the 1970s, before the field of genetics came into being. While it is increasingly obvious that all health professionals who diagnose and treat disease will need a grounding in this science, Tim fears that most dental educators are disinterested in genetics and ill prepared to help their students gain competency in this area. He sees faculty development as an essential first step.
“Faculty need to know about the clinical implications of genetics, why it is important in terms of cancer predisposition, oral craniofacial anomalies, or to be a good diagnostician,” Tim told me. “Most dental schools don’t even teach how to do a good family history. That’s a key component as a foundation for genetics, and it’s going to be critical for helping our patients achieve optimal health.”
I agree. If dentists and dental educators don’t become schooled in this area, the risks could be substantial for our patients and our practices. We need to know when genetic testing does and does not have value for clinical care, and we need to understand the legal and ethical dimensions that come into play when the information revealed by testing could have health implications for an individual’s entire family. Meanwhile, professional societies representing geneticists have voiced serious concerns about the potential harms that may accrue from the commercialization of genetic testing and its marketing to healthy individuals. Not only is the quality of the testing at issue—how the results are interpreted is also a concern. If a finding shows a 50% increase in a risk factor for a specific condition, a clinician will convey that information differently depending on whether the original risk was 2% or 60%, but will a testing company do that? We will have to wait and see.
“Regulation of genetic testing is not what dentists believe it to be,” Tom Hart told me. “Tests are not necessarily clinically valid or clinically useful. That’s my greatest concern—this lack of understanding—and it won’t go away until we have comprehensive genetics education at dental schools.”
Tom is optimistic that ISCC can start to remedy this situation. He has confidence in the group’s leadership and sees dentistry’s participation as a tremendous opportunity to be at the table with a truly interprofessional group of scientists and healthcare providers whose work will help translate genetics into clinical care. He believes this inclusive approach will go a long way to circumvent problems for patients by reducing disparities in the way different clinical disciplines use genetic information.
Tim Wright is equally enthusiastic about the interprofessional makeup of the ISCC and the resources it is creating. The group is building competencies that each discipline can adapt and creating resources, including a bank of unfolding case studies that educators can use in their classrooms. But Tim cautions that the ISCC will only be part of the solution.
“There is currently no funding for it,” he points out. “It’s a voluntary effort, and if it’s all just people like myself, each putting in one scenario, it’s probably not going to be as robust a national resource as it could be.”
Tim points out that curriculum revision is not a small or insignificant task, especially when most faculty are not versed in the subject matter and the geneticists who are, are focused on research. He suggests that the Commission on Dental Accreditation standards for predoctoral dental education be used to move the ball forward. “It would be very helpful to have the word ‘genetics’ in there,” he observes. “That is what drives institutions to say, this is important and we need to do it.”
Meanwhile, ADEA stands to gain from participating in the ISCC. In addition to sharing and helping to develop resources, we are learning how the healthcare professions can collaborate to optimize health care through a shared understanding of the issues that impact health across our professions and disciplines. And we also have talent and resources of our own to bring to the table, starting with the report of the 2007 Josiah Macy Jr. Foundation study on genetics and its implications for education and practice.
So how has the advent of personalized medicine affected me? The fortunes of 23andMe changed last year, and the company currently offers only ancestry-related information derived from its DNA analysis for new customers. But for those of us who got in on the ground floor, the company continues to send regular updates on breakthroughs in genetic knowledge that might be relevant to our health. I have yet to share this knowledge with my healthcare team, but under the right circumstances I will, and those circumstances could arise at any time. New knowledge of human genetics is created every day, revolutionizing our understanding of diseases, their treatments and ourselves. It’s not too soon to prepare for this future.