Reimagining Dental Education in Canada

In 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.