DentalEDU.tv has hundreds of registered professional dental users earning Continuing Education credits through its live and on-demand video course offerings. While the site’s exceptional video quality is enough to differentiate DentalEDU.tv, its supporting capabilities enable its effectiveness as an educational platform. The site’s custom video player automatically detects the viewer’s bandwidth and selects between HD or lower-resolution versions of the video accordingly. The player tracks the minutes of each chapter – or of the entire production in the case of a live event – that are watched by the user, ensuring that the viewer is meeting the minimum requirements for certification of completion of the course.

A StreamZHD encoding system, supplied by Digital Rapids reseller Trock Media, is used to capture, encode and stream live HD productions from 1MediaProduction’s multi-camera studio. The StreamZHD encoder is also used to transcode edited media files from Apple® Final Cut Pro® into formats ready for on-demand Web distribution. A TouchStream portable encoding and streaming appliance, configured with HD-SDI input, provides a second live streaming channel – allowing users to switch between multiple streams – while giving 1MediaProduction increased flexibility in live production at remote sites. Encoded outputs are delivered in the H.264 compression format for playback through DentalEDU.tv’s video player, powered by Adobe® Flash® technology.

“Digital Rapids encoding systems enabled us to realize our vision of bringing dental education to the Web in high definition,” said Dr. Bradley J. Engle, founder of DentalEdu.tv. “As we continue to increase the quality and sophistication of our online offerings to include live events from multiple camera angles and mobile delivery such as the Apple iPhone, the roles of TouchStream and StreamZHD in our operations will expand even further.”

“We’re very pleased that 1MediaProduction has chosen our systems as the backbone of DentalEdu.tv,” said Brent Ross, Director of Sales for the Americas at Digital Rapids. “The ability to deliver high definition content over the web is enabling a wide range of innovative new video-based services, and the superior quality, flexibility and cost-effectiveness of TouchStream and StreamZHD make them ideal solutions to power these applications.”

StreamZHD continues to raise the bar for high-definition encoding solutions, delivering multi-format video ingest, encoding, transcoding and live streaming in a versatile configuration that integrates easily into any media environment. TouchStream appliances deliver Digital Rapids’ renowned streaming video quality and reliability in a fully self-contained, portable form factor with an intuitive touch-screen interface for unparalleled ease of use.

StreamZHD, TouchStream and the complete range of Digital Rapids solutions will be showcased in booth number SL6010 at the 2010 NAB Show, April 12-15 in Las Vegas. For more information about Digital Rapids, please visit www.digital-rapids.com.

About Digital Rapids Corporation – Digital Rapids provides the leading hardware and software solutions for transforming and delivering media, enabling the multi-platform experiences that are changing how audiences view content. Scaling from standalone appliances to global workflows, Digital Rapids solutions enable media professionals to maximize their productivity, quality, and the value of their content. Recipient of a coveted IBC Innovation Award and four prestigious Frost & Sullivan honors for encoding and transcoding leadership, Digital Rapids combines innovative technology with proven expertise to help our customers to expand their audiences, increase their media revenues and reduce their costs. Digital Rapids Corporation (www.digital-rapids.com) is headquartered in Ontario, Canada with offices in the United States, the UK, Australia, Argentina and Hong Kong.

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Copyright 2010 Digital Rapids Corporation. All rights reserved.  Digital Rapids, the Digital Rapids logo and StreamZHD are trademarks or registered trademarks of Digital Rapids Corporation. All other trademarks are the property of their respective holders. Features, pricing, availability and specifications are subject to change without notice.

Press Contact (Americas)

Mike Nann

Director of Marketing/Cmns

Digital Rapids Corp.

(905) 946-9666 Ext. 135

mike.nann@digital-rapids.com

Press Contacts (Europe/Asia)

Kerr Duffy

Marketing Manager

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DentalEDU.TV is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership credit. Approval does not imply acceptance by the state or provincial board of dentistry. The current term of approval extends from February 1, 2009 to January 31, 2012
http://www.dentaledu.tv
dental education continuing dental education dental schools online dental school online dental education

Bradley J Engle, DMD MHS
5659 Naples Blvd
Naples, FL 34109
http://www.engleimplantdentistry.com

engleimplantdentistry.com
Tel: (239) 593-2178
Fax: (239) 593-2179
Email: info@engleimplantdentistry.com

This article specifically does not consider the upcoming 2008 national elections and the potential for a universal single-payer health plan that may or may not encompass dental benefits or how such a system might be implemented. The sequence of this article is to

• examine the changing dental disease burden in the United States and hence the need for dental services;
• provide an overview of the system of dentistry since the system defines the players that may influence dental education;
• identify a number of the influencers on dental care delivery and the education system processes; and
• from these perspectives, opine on the potential impacts these influencers will have on dental education.

First and foremost, this article is meant to stimulate thoughtful discourse about our evolving health care system and dentistry’s role therein. I have no lock on the truth about the future. If this perspective engenders discussion amongst dental educators regarding curriculum, staffing, facilities management, etc., it will have performed its intended purpose.

Severe dental diseases were once pandemic in the U.S. population.¹ As a result, even though the average life span was significantly shorter than today,² edentulism was quite high, and suffering dental pain was common. Paintings of the first U.S. president with a scar on his cheek left by a fistula, reportedly of dental origin, are reminders of how far dental science has come in two hundred and thirty years.

As a pandemic, dental diseases affected virtually our entire population. This had impacts on much of our society and our health care concerns as a nation. Congress initially formed the National Institute of Dental Research, now National Institute of Dental and Craniofacial Research (NIDCR), in 1948 partially as a response to the dental condition of young men being conscripted into World War II’s armed forces.³ Many conscripts could not meet the minimum dental standard of the day of having six opposing teeth with which to “masticate a ration” and were “4-F” because of this dental condition.⁴ Dental diseases were ubiquitous and crossed most socioeconomic lines.

Today we no longer face this degree of disease penetration.⁵ Dentistry’s two primary diseases, dental caries and periodontal diseases,⁶ are no longer evenly distributed in the population. Some population segments still have epidemic disease penetration, while other sectors of society have an endemic disease distribution. In many U.S. population segments, dental diseases progress at significantly slower rates than in the past, while, in others, rapid progression is still the norm. This is not to suggest that other disease processes are not found in the orofacial structures. It is not the intent of this article to avoid those diseases and conditions. Rather, it speaks to the impacts of the two primary diseases on the work burden in daily practice and on the teaching of dental skill sets that address these areas. Treating the etiology, prevention, diagnosis, restoration, and management of these two diseases, their clinical sequela, and the cosmetic needs of patients still commands the greatest time and returns the greatest revenue within the general practice of dentistry.

The influence of this changing distribution of dental diseases on the dental health care system is that clinicians need to be not only astute diagnosticians but also must acquire significant skills in risk assessment. That is, they should have the skill sets to be able to predict who in their patient census is at higher risk for acquisition or progression of dental diseases. Unless a practitioner is treating one of the remaining highly diseased U.S. populations, it is no longer acceptable to treat all individuals in a practice as being at equal risk for disease acquisition and progression. At the same time, it is not acceptable to spend time and resources performing risk assessment in a setting where dental diseases are pandemic. A one size fits all strategy overtreats some and significantly undertreats others and may not improve health outcomes, all while consuming scarce resources. Being able to know the differences between pandemic, epidemic, and endemic distributions of diseases in our populations and which population a practice is treating is critically important. It should modulate the diagnostic, preventive, and therapeutic strategies the clinician employs. Health systems recognize this distribution issue and are taking steps to constrain the inappropriate expenditure of resources. This will be an influence on dental practices and delivery systems and hence will impact dental education.

Both of dentistry’s primary diseases are reasonably well characterized chronic biofilm-contained bacterial infections with significant influences from the patient’s immune system and lifestyle. Until relatively recently, dentistry treated these infections by principally using surgical models of care. For dental caries, this surgical model is somewhat cynically described as “drill, fill, and bill.” For periodontal diseases, it was scale, root planing, and surgery. When these mechanisms ran their course, extractions occurred, and fixed or removable prostheses replaced the lost teeth/tooth structure. In most cases, these models of practice represented our “best current evidence.” That we have developed new models, procedures, and practices is normal and expected in a science-based profession; this development is continuously changing health care systems.

These new models emphasize more and more risk assessment and disease management often without surgical interventions. This mirrors the expectations for other health system entities. Science from within and outside our profession is making available new tools for practitioners to better recognize and predict different risk levels in our patient populations. When surgical interventions are required, many new materials and methods are available. “Minimally invasive” is not a term that originated in dentistry. It is a common term and a developing practice in medicine as well. Health systems recognize the myriad of benefits that accrue from less traumatic or atraumatic interventions.

The demographic of the U.S. population is also changing. The U.S. Census Bureau projects almost straight-line population growth with a national negative birthrate.⁷ Both immigration and an aging population contribute to this growth, and both bring unique practice issues to health care systems that impact dental education.

For each of these developing areas, the health care system is adapting and evolving. Health care systems examine these emerging demographics, trends, sociopolitical influences, techniques, and technologies with the goal of providing the most efficient and effective diagnostics, preventives, and therapeutics in the populations they serve. Dentistry and dental education will need to align with these shifts.

The system of dentistry includes not only health care providers like dentists and hygienists and dental schools and other entities acting as primary and tertiary treatment facilities, but also consumers (patients), payers (public, private, and patients), medical health care systems, regulatory bodies, political entities (including dental associations), manufacturers of dental products, and more. No player in the system operates independently of the others. The system of dentistry, like other parts of the health care system, represents a complex interplay of interests, influences, and influencers. To cite an example, dental education is influenced by the regulatory agencies that license dental practitioners. The regulatory body is influenced by the political winds and the emerging science of dentistry, as well as by the dental practitioner community. The practitioner community is influenced by the economy and its effect on purchasers’ or patients’ willingness to fund the delivery of dental services and at what level. Changes to payment coverage may be influenced by negotiated labor agreements that are also economically influenced.

This influence chain is highly branched, and this example is not intended to carve out other influences at any level. It is important to recognize that changes to one element of the health care system influence many others and that the entire symphony of players represents the health care system. Influences on the system of dentistry include the following.

Health Care Costs.
The influence of total health care costs on the emerging health care system, including dentistry, is substantial. Dentistry accounts for approximately $80 billion per year in a $1.75 trillion U.S. health expenditure economy. The United States is currently spending somewhere near 15 percent of its gross domestic product on health care. This is more than most other first world nations, and the result of this spending is openly criticized and debated. This debate and its consequences are shaping the future health care system. These expenditures are from public sources like Medicaid and Medicare services, from private employer-based payment systems, and from patients themselves (whether as copayments or as self-funding activities). Surveys show that 29 percent of health care consumers skip prescribed or needed health care services because of cost. For 18 percent of Americans, health care costs are the biggest monthly expense they pay after mortgage or rent.⁸ These costs influence the emerging health systems and, consequently, dental education. One of the principal influences of interest here is the cost of health care on the pricing of U.S. products in increasingly competitive world markets.

Global Economy.
We are part of an emerging and continuously morphing world economy. High health care costs, at their current rates, can contribute to making U.S. products less competitive both domestically and abroad. Demanding a higher price for an equal quality product generally results in lower sales of the higher priced product, which can lead to lower corporate profits or corporate losses. In either a stagnant or a loss position, management of shareholder organizations is then likely to consider a number of cost control measures. One of the options is how it compensates its workers.

Health Care Benefits.
In the United States, a major portion of our health care system evolved as an employment-based system. Health care benefits are a form of indirect employment compensation. Historically, this appears to have been at least partially the result of the wage freezes imposed on most sectors of the economy during World War II. In order to attract and retain workers in scarce labor markets in which wages were frozen, employers began using health care benefits as a way to influence workers’ choice of employers.

Consumerism.
Today, those employers who are purchasing health care benefits are becoming much more aggressive consumers of health care plans and services in an effort to constrain costs and keep their products competitive. These purchasers are demanding proof of value for their health care expenditures. This is the same demand on their products being requested by their customers. The choices for increasing value are either to lower prices or to increase quality. Whether an employer or a health care system, this generally leads to demand for “effective” practices. “Efficacy” is the ability to produce the desired amount of the desired effect within the system. Within health care, the principal focus of these efforts has been concentrated on medicine. But it is now being extended to dentistry, vision, pharmacy, nursing, and other allied health services. The impact on dental education will be on teaching practices that are effective in specific clinical situations. Dental education is rising to this challenge through its participation in evidence-based practices. This includes the research and publication aspect of dental education as well as the teaching and service components.

Total Health Care Costs.
This search for lower total health care expenditures has helped drive the search for cause and effect between dental diseases and systemic diseases or condition and outcomes of dental interventions. Clearly, if you can perform a $70 dental prophylaxis and reduce the number of $80,000 pre-term low birth weight babies while also improving the quality of life of the child and family, you will follow that practice (assuming there are not other harms induced by the interventions). If dental interventions consistently show total health care savings, the evolving health care system will make provisions for these services. The delivery system for effective services is still being determined in health care systems. For example, if it is both health- and cost-effective to provide four periodontal maintenance visits to periodontally affected diabetic patients, health systems may co-locate hygienists in internal medicine or endocrinology clinics to provide these services.

Evidence-Based Health System Demands.
There are a number of other manifestations of this consumerism. For example, the brokers and consultants for dental benefits are directing their sophisticated purchasers to demand evidence-based plan designs. They are seeing some successes with these practices in medicine and are beginning to demand similar proofs in dentistry. They are demanding to know what coverage for specific benefits gets them in improved health care outcomes for their employees and for the future costs for health services. The focus and scope of the phrase “evidence-based” used here is different from the American Dental Association’s clinical definition of evidence-based decision making (EBD) that is justifiably focused on the treatment of individual patients. This “evidence” is about what is best for specific covered populations. How are diseases distributed in the population that will be “insured,” and what’s the most effective way to maximize the population’s health while minimizing the costs? As an example, a cogent question is: if the risks for dental diseases are not evenly distributed, then why does everyone systematically get two bite-wing radiographs every year? This diagnostic practice may have made sense in 1950 when cavities and periodontal disease were pandemic, but it does not make sense now in specific populations.

Research and development in this area are ongoing by a number of interested parties including many dental schools. Development is impeded by the lack of commonly agreed on and used diagnostic codes. Such codes have the potential to significantly improve outcomes research and are used throughout the general health care system. To the great credit of the American Dental Education Association (ADEA) and a number of the Association’s constituent schools, there is real effort being expended now to remove this impediment in an open and public process.

Litigation.
The U.S. culture of litigation also influences health care consumerism and the emerging health care systems. Hospital systems and health plans have been and are being sued for permitting practices that were knowingly not effective or actually harmful. One way to manage this kind of risk is to develop guidelines or practice parameters. These guidelines or practice parameters are employed to constrain practices that consistently fall outside a reasoned (evidence-based) set of options. In the case of individual practitioners, they may lose their privileges or may be dropped from payment systems if their practice is deemed to be inappropriate, ineffective, or harmful. This is a different form of risk assessment being practiced within the health care system.

Dental education may be indirectly affected by these activities. The key for most practitioners and health systems is the development of critical thinking among the system’s participants. This has been an articulated goal of dental education for many years, but without much tangible emphasis in curriculum competencies (knowledge, skills, and values of dental school graduates) distributed by ADEA or the accreditation process for dental schools implemented by the Commission on Dental Accreditation. Critical thinking has a much more prominent emphasis in the revised version of curriculum competencies that ADEA is in the process of ratifying for distribution to dental schools in 2008. Whether critical thinking will become a greater focus of examining and regulatory bodies remains to be seen. This skill set is crucial for staying current in a health care industry with a rapidly changing science base. The knowledge that students and practitioners acquire today may be obsolete in the not-too-distant future. Transitioning to new practice mechanisms requires the ability to assess and think critically about that science and its sequela.

P4P (Pay for Performance).
Consumers (public and private insurers, individual patients, and patient advocacy groups) are demanding proof of outcomes in medicine. They are beginning to pay differentially for those individuals and systems that perform above defined values. This includes systems where public funds are expended on health services. The Veterans Administration is one of the groups taking the lead in examining outcomes and rewarding superior performance.^9,10 The Academy of Internal Medicine, in a proactive move, is judiciously examining whether an increasing portion of an internal medicine practitioner’s compensation should be determined based on outcomes of care.¹¹ This is one of the reactions to practice variation in diagnosis, prevention, and treatment. Our health care literature is replete with examples of trying to control this variation when it reaches the point where patients are being harmed.^12,13 Recently, health and cost outcomes for over treatment are beginning to drive this pay for performance equation. Dentistry will not escape this process because it operates in health care markets and the control of variation is an emerging consumer expectation.

Public Disclosure of Outcomes.
External entities are also rating providers of care and posting these ratings on websites and other publicly available media. Some of these are subscription systems where, for a fee, you can examine the ratings of a practitioner’s performance,¹⁴ while others are provided as a public service.¹⁵ Some of these ratings services are publicly funded entities. In all of these, performance is judged against a normative standard. Without belaboring the point, risk adjustment of these results is critical to having valid ratings. This too is driven by consumerism. If there were no markets for these ratings, there would be no business. Dental education would seem to have a role in participating in the development of these normative standards.

Transformational Technologies
Finally, the biggest wild card influencer for the dental health system is the unanticipated advent of one or more transformational technologies that directly affect dental practice and hence dental education. Transformational technologies are defined by the buggy-whip scenario. Buggy whips, once in high demand, are now novelty items or functional items for a limited market. The automobile was the transformational technology that delimited the value of the buggy whip and the buggy whip-making service. One such scenario for dental health care is that science develops an inexpensive way to diagnose who is at risk for cavities or discovers a cure for cavities in treated populations. If such a technology is simple and easily used, who will do this? Will it be so simple that it is dispensed over the counter? For those who have been around dental research for many years, this “cure” has been “just around the corner” for years. Looking at our current health research papers at the International Association for Dental Research and American Association for Dental Research, the reality seems closer than it has been before. Health systems will respond to these transformational technologies as they have previously. Vaccines and numerous other preventive technologies are now regularly employed whereas, in previous decades, patients received extensive treatment in the offices of practitioners. Dentistry is particularly vulnerable because we are medical specialists, and if one of the specialty diseases strongly associated with the practice of dentistry is virtually eliminated, the health system will change. This would also be true for a permanent restorative material that meets the aesthetic demands of patients or elimination of recurrent caries. Dental education would be significantly impacted by such a change. The salient questions, as noted above, are 1) when will this occur? 2) what will be the training required for transitional dentists as the diseases traditionally addressed by the dental profession wash out of the system? and 3) what will be the training and nature of practice for follow-on dentists when there is no new disease?

DentalEDU.TV is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership credit. Approval does not imply acceptance by the state or provincial board of dentistry. The current term of approval extends from February 1, 2009 to January 31, 2012
http://www.dentaledu.tv
dental education continuing dental education dental schools online dental school online dental education

Bradley J Engle, DMD MHS
5659 Naples Blvd
Naples, FL 34109
http://www.engleimplantdentistry.com

engleimplantdentistry.com
Tel: (239) 593-2178
Fax: (239) 593-2179
Email: info@engleimplantdentistry.com

There are no easy solutions to these financial problems. Federal and state funding for dental education is unlikely to increase substantially in the next five to ten years. Federal funding is already declining (either reduced rate of increase or absolute cuts) for biomedical research,⁵ Medicaid,⁶ safety net clinics,⁷ and underrepresented minority health professional student scholarships.⁸ Further, the large and growing national debt and rapidly rising health care expenditures will continue to strain public budgets. We doubt that large increases in public resources will become available for health professions education within the foreseeable future.

Although most schools are likely to continue to increase tuition by 5 to 6 percent a year and raise more funds from gifts, this will not solve the financial problems of most state-supported schools because tuition and gifts account for only a relatively small percentage of total revenues.

Since the majority of total school expenditures is related to the operation of clinical programs, schools have tried to operate their clinics more efficiently. State-supported schools have made some progress, increasing net revenues from patient care, but expenses have increased at almost the same rate (1994 to 2003).⁹

In this article, we examine two other options for increasing the net revenues available to dental schools. First, building on the experience of the Pipeline, Profession, and Practice: Community-Based Dental Education program,¹⁰ we estimate the financial impact of having senior dental students receive their general dentistry (or comprehensive care) clinic experience in community clinics and practices. In this model, community sites are not owned or managed by dental schools, and they have no financial risk in their operation. Likewise, schools receive no payment from the sites for revenues generated by students but are expected to lower their operating costs.

Second, we estimate the financial impact of transforming clinics owned and managed by schools into patient-centered operations, where faculty practice as they supervise residents and students. In this model, faculty and residents provide care using multiple operatories, staffed with types and number of allied dental health and administrative staff similar to private practices.

These two models are not mutually exclusive, and many schools may employ both strategies. However, in this study, we examine each model separately in its steady-state configuration. The transition costs, especially for patient-centered delivery systems, will be substantial and are only briefly discussed here.

This section presents a brief description of the two models and reviews the limited literature on their effectiveness in meeting educational objectives, achieving financial goals, and providing care to underserved populations.

Community-Based Education
Almost all dental schools assign senior students to rotate through community clinics as part of their education; in 2003–04, we estimate that the median time senior students spent in these community rotations was eleven to fifteen days.¹¹ (The American Dental Association’s most recent survey of predoctoral education reports that the total median hours of extramural patient care for junior and senior students was 179 hours. Assuming an eight-hour day, this comes to twenty-two days in total or eleven days for seniors.) The rationale behind these community assignments varies among schools, but is mainly educational: providing opportunities for students to treat a more diverse patient population in terms of age, income, race/ethnicity, medical/dental conditions, geography, etc. Some schools also use community assignments to supplement their available numbers of dental chairs and faculty.¹²

The University of Colorado was the first dental school to make community-based education an integral part of its program. Colorado senior dental students spend at least six months of the year in community rotations in both clinics and private practices.¹³ Likewise, for many years, Harvard University dental students have spent most of their senior year doing clinical rotations in Boston area community clinics.¹⁴

In 2002, the Robert Wood Johnson Foundation and the California Endowment granted funds for a demonstration project on the impact of community-based dental education on reducing disparities in access to dental care. Some fifteen schools are now participating in this program, the objective of which is to have senior students (and General and Pediatric Dentistry residents for the California schools) average sixty days in community clinics and practices, treating low-income patients.¹⁰ The rationale for this objective is that students are three to four times more productive in community clinics and practices than in dental school clinics. This is because they have access to trained dental assistants and administrative staff, and perhaps more importantly, the primary goal of community sites is the efficient delivery of high-quality patient care. This is decidedly different from most dental school clinics, which are organized as teaching laboratories, where students seldom see more than two or three patients a day and generate relatively little income annually. These clinics are very expensive to operate and require large subsidies.¹⁵

Based on the Pipeline experience and other published reports, we can conclude that 1) many community sites will accept senior students and provide them the necessary clinical resources to provide care efficiently; 2) most senior students are more productive in these settings, averaging six to eight patients a day, during a multiple-week rotation; 3) community clinic dentists are able to provide adequate supervision of one or two students while treating a full panel of patients, if the student rotations are for at least a few weeks’ duration; 4) students report having positive experiences and are more self-confident and clinically productive when they return from the rotations; 5) community clinic dentists, staff, and patients are positive about having senior students; and 6) large numbers of underserved patients receive dental care.^{12,13,16–24}

Patient-Centered Care Education System
In this form of education, the primary goal of dental school clinics is patient care, and faculty practice in an integrated system with residents and senior students, following a private practice model. Medicine, nursing, and pharmacy have always educated their residents and students in patient-centered delivery systems. This is also the predominant system for training residents in oral and maxillofacial surgery.²⁵

A few dental schools have specialty faculty and residents practice together in patient-centered clinics. Faculty generate substantially more clinical income than in traditional faculty practices, and reportedly, residents receive an excellent educational experience.²⁶

In a historical examination of patient-centered clinics in dental education, Formicola et al. reported that the University of Pennsylvania ran an experimental clinic in the 1980s in which faculty, residents, and students practiced together.²⁷ This experiment was successful educationally and was more cost-effective than traditional dental school clinics, but for complex reasons was not extended to the entire school. Several other schools have tried different strategies to operate their clinics more efficiently, but none has had faculty, residents, and students practice together, following the patient-centered model.

The methods used to estimate the financial impact of community-based dental education and patient-centered clinics are described as follows.

Community-Based Education Assessment Methodology
For this model, our financial estimates are based on the assumption that 70 percent of senior student clinical educational experiences are devoted to general dentistry and that all general dentistry training takes place in community clinics and practices. We expect that students will continue to receive specialty training in school-run specialty clinics, since few community sites provide specialty services.

To estimate the financial impact of senior students spending 70 percent of the year in community rotations, we used aggregate data from the 2003–04 ADA financial survey.²⁸ Complete data was available on fifty-four schools.

Using the survey data, we determined clinic operating and clinic instructional expenses for residents (specialty graduate students and AEGD/GPR residents) and junior and senior students for each school. We assumed that these expenses were essentially the same for all three groups and obtained the average expense per provider. We multiplied expense per provider times the number of senior students and, then, multiplied this number by 70 percent. This calculation gave the reduction (savings) in clinic operating and instructional expenses when seniors spend 70 percent of their senior year in community rotations.

We determined the revenues generated by senior and junior students (excludes revenues from residents and faculty) and allocated 59 percent of these revenues to senior students, since seniors are known to generate more revenue than juniors.²⁹ This number was multiplied by 70 percent. This estimate gave the expected loss of clinic revenues when senior students spend 70 percent of the year in community sites. We then subtracted the revenue loss from the estimated reduction in operating and clinic instructional expenses to get the net savings per school. This value was divided by total school expenses to get the percent net savings per school.

To determine the factors that explain the net savings per school, we used ordinary least squares regression. The dependent variable was net dollar savings per school, and the independent variables were total number of dental student equivalents (control for school size), public versus private (and private state-related) schools (the two types of schools have well-known differences in staffing patterns and operating efficiency),³ and the number of specialty residents and general dentistry residents (residents contribute to clinic operating and instructional expenses).

Patient-Centered Care Education Systems Assessment Methodology
The financial estimates are based on several assumptions about the operation of a patient-centered delivery system in a dental school clinical environment. We assume that one faculty member heads a team of two residents and two senior students. Working out of four operatories, faculty members treat patients while supervising residents and students. The faculty member is supported by one hygienist and four dental assistants. We further assume that the two residents work closely with the faculty member and have access to the same number of operatories and allied dental health personnel. Also, as part of the core team, the two senior students each have one operatory and one dental assistant.

Since 50 percent of the clinical faculty are specialists in the average dental school, we assume that ten of the twenty teams of faculty, residents, and senior students are led by specialists. The facilities and allied health staff used per team member are portrayed in Table 1.

The average dental school has eighty students, forty-eight residents (excluding oral surgery and dental public health), sixty FTE clinical faculty (excluding oral surgery and dental public health), and 280 operatories allocated to residents and senior students.^30–32 The number of FTE faculty assigned to third-year students is about twenty, leaving forty FTE faculty to supervise senior students and residents. Faculty have other responsibilities, so we assume that only 50 percent of their time is spent in clinical practice/teaching. This leaves twenty FTE faculty for clinical teaching. Likewise, we estimate that students and residents spend 30 percent of their time on activities outside the dental clinic. This leaves thirty-four FTE residents and fifty-six FTE students available to work in patient-centered clinics run by the school.

Within these physical and staffing constraints, twenty teams can operate at the same time. Open for at least 250 days per year, this means that twenty FTE clinical faculty (general dentists and specialists), forty FTE residents, and forty FTE senior students are needed to operate the system. We assume schools will increase the number of residents to meet this staffing requirement. We also assume that seniors will spend some time in community clinic and practice rotations, since they can not all be accommodated in patient-centered dental school clinics. Some schools may have adequate facilities, faculty, residents, and staff to operate additional teams and could accommodate all the senior students in the patient-centered clinics. Finally, because seniors are in school for about eight months, they will not be present for all 250 days of clinic operations.

The expected net revenues generated per team FTE faculty member are a percentage of the revenues generated by private general dentists. In 2002–03, general practitioners had an average net income of $174,350. With an overhead of 68 percent, their gross income was $550,920.³³ In the same year, specialists had gross and net incomes of $778,630 and $291,250, respectively, and overhead costs of 63 percent. Based on discussions with experienced clinical faculty, we estimate that faculty can generate 85 percent of the net income of full-time community practitioners with the same training. We assume that the remaining 15 percent is spent on instruction. This may underestimate faculty revenues, since in the Pipeline program, community dentists reported no loss of income when they supervised one or two senior students or residents, providing the rotations were for three or four weeks’ duration. Finally, we assume there is no separate faculty practice independent of residents and seniors.

The revenues generated by residents are calculated the same way. We assume that residents are 65 percent as productive as private practitioners in a given type of generalist or specialty office and that their productivity will be reduced by 10 percentage points because they assist in the supervision of senior dental students (one student per resident). Thus, on average, residents will be 55 percent as productive as private practitioners.

Senior students working with an assistant are expected to treat seven patients per day and generate an average of $40 per hour for a total of $280 per day. On an FTE basis, this comes to about $45,000, which should come close to covering the marginal expenses per FTE student, including the salary of a dental assistant, supplies, laboratory charges, etc.

This analysis assumes that faculty and residents treat full-pay patients. That is, patients are charged usual and customary fees for the geographic area whether services are provided by faculty members or residents. In contrast, we assume that senior student fees are reduced by about 50 percent from faculty/resident fees.

For the purpose of comparison with the traditional model of clinical dental education, we calculated the reported revenues of faculty (intramural practice), residents, and predoctoral students in the average dental school from the ADEA 2002–03 survey data. As previously noted, we allocated 59 percent of predoctoral revenues to seniors.²⁹ Expenses for intramural practice are reported separately, but clinic operating and instructional expenses are reported collectively for residents, seniors, and juniors. To estimate resident and senior expenses, we divided aggregate expenses by provider and multiplied by the number of residents and seniors.

The financial models presented in this article are limited by the amount and quality of data available. The annual surveys of dental school financial and educational operations obtained from the ADA and ADEA surveys have well-known problems. Specifically, schools may not respond to the survey questions the same way, and no effort is made by the survey group to assess the validity of the data reported by schools. Also, schools receive different types of cross-subsidies from their universities, and these are difficult to describe, measure, and allocate. For all these reasons, financial comparisons among schools must be drawn cautiously.

These limitations notwithstanding, the data used in the financial models is the only fiscal information on dental schools available. Also, using aggregate values across all schools provides more accurate and stable estimates of school financial operations than those based on any one school. Therefore, the results are probably reasonable estimates of the financial impact of the two new educational models.

The analyses indicate that the savings from community-based education are significant, but the overall financial impact is rather modest. The average school generated a net savings of $2.7 million; this represents an 8.1 percent gain in net revenues. The variation among schools in net savings was substantial. State-supported schools had greater savings on average than private schools ($0.8 million) because the former schools have higher operating costs than the latter schools. As expected, larger schools had larger absolute savings than smaller schools. The number of specialty and general dentistry residents did not have a significant impact on savings.

Relative to the magnitude of the financial challenges facing most dental schools, community-based dental education does not offer a total solution. That is, the annual increase in net revenues, $2.7 million, is not large enough to meet the growing revenue needs of the average dental school. This is especially true as the gap between private practitioner and faculty incomes continues to widen.

This strategy could be more financially attractive to schools if they received some payment for the services provided by senior students in community clinics. A few schools have negotiated payments from federally qualified health centers (FQHCs) when residents and senior students are involved in the rotations.³⁴ The feasibility of having partnerships between dental schools and FQHCs is now being explored with the U.S. Health Resources and Services Administration, since both schools and FQHCs could benefit from the association. With about 603 FQHCs nationally that provide dental care in 2004, these clinics could be an important training site for dental students and residents.³⁵

In contrast, the development of patient-centered clinics owned and operated by dental schools showed considerable financial promise. The estimated increase in total net revenues averaged about $14 million per school. Although there will be many demands on these funds, increasing support for full-time clinical faculty is critically important. Based on discussion with several medical and dental school deans, we believe that schools need to raise clinical faculty salaries to 70 percent of the incomes of comparable private practitioners. This is necessary to recruit and retain a full-time clinical faculty member who is adequately prepared, clinically and scientifically, for an academic career in a major research university. Based on 2002–03 data, sixty full-time clinical faculty need an additional $4 million in salary support to bring their incomes to 70 percent of comparable private practitioners. With an average clinical faculty (specialist and generalist average) income of $97,000 in 2002–03, the addition of $4 million per school would increase the average salary of full-time clinical faculty to $163,000.

We also suggest that schools cover the stipends ($40,000) and fringe benefits ($8,000) of residents. For forty FTE residents this comes to $1.9 million. Of course, in many schools GPR/AEGD and oral and maxillofacial surgery residents already have GME support, and in a few other schools, all specialty residents are covered by GME funds. In these schools, residents would not need additional support, and the funds could be used for other purposes.

Beyond faculty and residents, schools will have many other demands on new net revenues. Previous reports indicate that schools need to make greater investments in learning resources, physical facilities, and the curriculum and in moderating tuition increases.

Even though the $14 million is a large increase in total resources, schools that need more net revenues can increase the percentage of time clinical faculty spend providing care and teaching from the base of 50 percent used in this financial model. This strategy has obvious limits, since schools need faculty to cover other teaching assignments and committee activities and to have adequate time for their research and other scholarly activities.

Schools could also employ some dentists on a clinical (non-tenure) track and have them spend most of their time in patient care and clinical teaching. The net revenues generated by these faculty may be large enough to use a portion of it to cross-subsidize school programs. This strategy has been used by medical schools for many years. Close to 35 percent of medical school revenues come from patient care programs.³⁶

Thus, even though patient-centered clinics staffed by full-time faculty, residents, and senior students show considerable promise to address the financial challenges faced by most dental schools, variants of the proposed model program may be needed to further increase net revenues.

While financially promising, the capacity of schools to convert their existing patient care operations to patient-centered clinics is a large unknown. A few schools do have some experience with this model, but most involve teams of specialty faculty and residents working together. To our knowledge, none have integrated senior students into their operations or established patient-centered programs to deliver general dental care.

This suggests that the average school would require considerable effort to convert to a patient-centered clinical education model for seniors, residents, and faculty. Further, the increases in net revenues presented in the financial models represent an upper boundary estimate and is what could be achieved under ideal conditions. We would be surprised if many schools achieve the level of clinical operational efficiency reported in this article.

In addition, there are substantial capital costs to transition to a patient-centered model. Based on discussions with practice management consultants and dental school financial officers, we estimate that it may take from $500,000 to $1 million in capital investment per team to convert traditional dental school clinics into patient-centered practices. However, we also believe that about 14 percent of overhead costs generated in patient-centered clinics are available for long-term capital investment. This is about the percentage of private practice overhead used for capital investments and, therefore, should be available to schools. Also, schools can begin slowly to make this conversion, starting with a few faculty, resident, and senior student teams and, then, over a period of ten years, fully implement the model.

Some of the barriers that schools face in converting to a patient-centered delivery system are easy to predict. They include convincing faculty and staff of the need to change to a new educational model, dealing with the constraints of state and/or university human resource policies that provide little flexibility in hiring and managing staff, recruiting faculty and staff who have experience running patient-centered delivery systems, having adequate numbers of full-pay patients, and dealing with concerns from local stakeholders such as community organizations and private practicing dentists. Of all these barriers, changing the mind-set of faculty and staff may be the most challenging.

Another important caveat concerns how increases in net revenues from the successful operation of patient-centered dental clinics are allocated. We assume that the additional funds will be used to strengthen dental school educational, research, and service programs. The reality is that declines in academic health center budgets are expected because of the slow growth in Medicaid and Medicare reimbursement rates. In this fiscal environment, any financial gains made by dental schools could be used to subsidize the operation of other health professional clinical and educational programs. Further, some dental schools may have to pass the additional funds on to their parent universities. This is especially true for the few dental schools that are investor-owned.

Finally, this study has focused on the financing of dental education. Of equal importance is the impact of these models on the quality of educational programs. There is substantial evidence that well-run community-based dental education programs do provide excellent clinical experiences. As previously noted, many schools now have senior students spend from three to eight months in community clinic rotations.

Little is known about the impact of dental school patient-centered care programs on the quality of resident and senior student clinical education. However, since many other health professions and oral and maxillofacial surgery use patient-centered teaching programs, there is some reason to believe that dental schools would be successful, both educationally and financially, in converting to this new model of dental education. Indeed, the education of students and residents may be significantly better in a patient-centered model. In contrast to the current clinical education system, they will work with a team of experienced allied dental health personnel and administrators, learn how to deliver care in a real delivery system, and perhaps most importantly, have the opportunity to model their own clinical performance on clinical faculty who provide high-quality care efficiently that meets or exceeds patient expectations.

New science and technologies are already making their way into all aspects of dental practice and have changed traditional approaches to diagnostics, risk assessment, prevention, and many procedures in clinical dentistry. These new science advances are primarily directed toward connective tissue biophysics/ mechanics, tissue engineering, and the large areas of biotechnology (gene therapy, drug delivery, transport dynamics), molecular engineering (macromolecular structure, protein structure, and molecular therapies), informatics (patient management/record systems, data mining/management applications, and simulation/computer-assisted learning environments), and biomaterials (biocompatibility, bioengineering applications of polymers, biomimetics, implant materials, and nanotechnology of dental materials).

For example, there are now commercially available kits related to diagnosis, risk assessment, and prognosis for caries/periodontal disease based on genetic polymorphisms, biomarkers, and principles of cell biology.^1,2 In fact, the recent development of saliva as a diagnostic medium has placed dentistry at the forefront of monitoring systemic health and disease.³ The application of genomics/proteomics to diagnostic tests and preventive measures requires that students and practitioners receive the necessary knowledge related to microbial/human genetics and the current principles of molecular medicine.⁴ Given the current lack of genetics instruction in dental education, this will require significant restructuring of dental curricula and faculty development programs.⁵ Within the field of restorative dentistry, the tremendous advances in biomaterials research have led to the current availability of esthetic posterior adhesive restorations, ushering the profession into the “postamalgam era.”⁶ It has been clearly established that this new biomimetic approach to restorative dentistry is possible through the use of composite resins/porcelains and the generation of a hard tissue bond. The development of these nanomaterials has moved nanotechnology from its theoretical foundations into mainstream practice, and there are now many examples of commercially available products demonstrating the scope of further applications of such technology.⁷

In the area of dental informatics, the application of computer and information sciences to improve dental research, education, and practice has been particularly noteworthy. Many dental schools have developed sophisticated simulation laboratories that take advantage of virtual reality technologies to teach preclinical skills, and the use of electronic teaching tools and learning environments (CD-ROM or web-based) has increased dramatically.^8,9 Although today’s dental students are entering the educational program with unprecedented computer literacy, many dental faculty require significant training in order to take full advantage of current computer-aided simulation and instruction capabilities.^10,11 Most dental schools have already implemented some form of electronic paperless records, patient management systems, and digital imaging techniques. Although this technology has the ability to revolutionize patient care through rapid and efficient management of large amounts of clinical information, for it to be useful, the technology must be understood by the end users (students, faculty, and practicing clinicians). At the present time, many practitioners do not exhibit a high degree of computer literacy and are not using currently available informatics technologies to their full potential.¹²

The use of computer and imaging technology is rapidly changing the practice of orthodontics through computer-assisted appliances for tooth movement (Invisalign^TM computer-generated therapy).¹³ Newly available digital imaging methods that reveal minute details and enhance discrimination have added a sophisticated level of reliability/predictability to implant procedures.^14,15 Recent improvements in computer-aided design (CAD) and computer-aided manufacturing (CAM) for indirect restorations now provide for replication and digitization of the complex topography of tooth structure.¹⁶ Over the last several years, CAD-CAM techniques have transitioned from the domain of the unreliable to mainstream practice, providing better mechanical properties, improved marginal integrity, and enhanced esthetics compared to traditional indirect techniques. Today’s more reliable CAD-CAM techniques, some of which may reduce the number of patient visits, are available for the production of a wide range of ceramic restorations.

Scientific and technological advancements that generate new knowledge will continue to occur at unprecedented rates. Future advances will be made possible through emerging interdisciplinary collaborations and thought processes. Thus, significant curricular changes will be necessary to educate a new group of dental professionals who will effectively use interdisciplinary research findings to solve clinical problems and apply new technological advances to the oral health environment. In order to maintain its status as a respected scientifically based health profession, dentistry must appreciate and incorporate these advances within its education and patient care systems. The continued evolution of the dental profession will depend on the discipline’s ability to translate the new science into integrated interdisciplinary services in clinical settings.¹⁷ To ensure the continued viability of the profession, it is the responsibility of the dental education sector to facilitate the development of institutional infrastructures that are responsive to and supportive of scientific and technological advances. At the very least, faculty and students must become sophisticated consumers of research and utilize scholarly approaches to evidence-based paradigms in their clinical patient management.

Those outside of dental education may assume that such health professions education/training programs regularly transfer new knowledge and clinical applications of new technologies into their curricula; however, those within dental education realize that scientific advances usually experience a slow assimilation into the dental curriculum.^18,19 Dental education in the United States has traditionally been characterized by discipline-based, lecture-style teaching that emphasizes technical expertise,^20,21 with insufficient attention paid to the development of critical thinking/problem-solving skills and redesign of content/teaching approaches, thus resulting in a stagnant, overcrowded curriculum.^22,23 Furthermore, graduates do not have an appreciation for the application/importance of research and discovery to patient care activities and are not adequately prepared to embrace interdisciplinary technology-based education/training and informational resources critical to lifelong learning and professional growth.^24–26

There are a variety of opinions regarding the future role of new science and research/scholarship in dental education.^25–30 Some contend that current curricula and research/scholarly training experiences maintain an adequate number of research/scholarly enterprises to develop new knowledge, disseminate new advances/technologies, and translate that information into patient care. However, recent approaches have maintained narrowly focused definitions of the perceived importance of research/scholarly activity, the purpose of research, strategies for increasing the number of future dental researchers/educators, and methods for producing graduates who incorporate evidence-based philosophies into their practices.^26,30 Furthermore, most would admit that some potentially serious problems have developed including insufficient 1) numbers of current and future research/ scholarly dental faculty; 2) integration of dental research into the larger world of science; 3) application of new science to clinical practice settings; and 4) acceptance/ownership of research findings by the dental community.^25–30 To date, there are no data available to determine the degree to which the current educational system has contributed to these problems.

Historically, approaches to support new science and research/scholarship have favored accomplished investigators and established infrastructures within research-intensive institutions.^26,29,30 Dental schools designated as research non-intensive are usually associated with smaller universities, have institutional missions emphasizing teaching/service, often lack resources required for developing an infrastructure that supports elite research programs, and are unable to sustain a critical mass of experienced faculty actively engaged in research and scholarly pursuits. Within these cultures, faculty have limited time to pursue scholarly activities because a faculty-intensive teaching curriculum dominates the environment.³¹ As a result, research endeavors at these schools have been largely ignored, creating a large cadre of disenfranchised faculty and students with no ability or desire to contribute to the overall agenda related to the infusion of science and discovery into the dental curriculum and patient care activities.

The present paradigm of dental education severely limits the ability to restructure the process to support infusion of new science due to an overcrowded curriculum, lack of integration of biomedical/clinical sciences, and a clinical component that operates in an environment completely removed from research/scholarly enterprises.^26,30 Within this context, new advances/technologies and the overall activity of research/scholarship become an afterthought or an arena reserved for a cloistered group of designated academic faculty. This traditional model must experience a paradigm shift, not only to increase the number of participants in science/scholarship, but also to enhance access, acceptance, and applicability of the science/scholarship. For the profession to advance, every dental school must play a role in establishing a culture that attaches value to research/discovery, evidence-based practice, and the application of new knowledge/technologies to patient care.³²

DentalEDU.TV is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership credit. Approval does not imply acceptance by the state or provincial board of dentistry. The current term of approval extends from February 1, 2009 to January 31, 2012
http://www.dentaledu.tv
dental education continuing dental education dental schools online dental school online dental education

Bradley J Engle, DMD MHS
5659 Naples Blvd
Naples, FL 34109
http://www.engleimplantdentistry.com

engleimplantdentistry.com
Tel: (239) 593-2178
Fax: (239) 593-2179
Email: info@engleimplantdentistry.com

By all outward signs, our profession is in great shape. Dentist incomes continue to rise, exceeding those of primary care physicians.^3,4 Professional journals advertise numerous practice and employment opportunities, and approximately 97 percent of dental graduates are employed or otherwise professionally active in dentistry at one year after graduation.⁵ Anecdotally, dentists are very positive about the profession and, to date, feel somewhat insulated from the ills of a broken health care system that plagues other health professions.

Symptoms of a looming crisis in dental education suggest that the status quo cannot be sustained unless significant steps are taken to address the challenges facing dental education.⁶ Pyle et al. have described these challenges: declining financial support in the face of high, escalating costs; high student debt; faculty shortages; an outdated, irrelevant curriculum; and a frustrating environment for learning and patient care, among others.² From the viewpoint of practitioners, there have been additional signs: the perceived commercialization of dental education,⁷ the opening of new dental schools in non-research-oriented institutions,⁸ and recent dental school cheating scandals.^9–12 Finally, despite the evidence that many Americans enjoy very good oral health, there are constant reminders of the changing demographics and health status of our society and the significant number of individuals who continue to lack access to care.¹³

The ADEA CCI’s strategy to involve stakeholders, including representatives from the ADA, offers an ideal opportunity for the practice community to become engaged in a process for securing our vision for the future.¹⁴ Practitioners and leaders in organized dentistry care deeply about the profession and want to have a voice in the education of their future colleagues. Opportunities for collaboration in this endeavor are important to ensure support rather than obstruction of evolving change by alumni and local dental communities. A partnership between dental education and dental practice will ensure that the proposed changes in dental education result in new graduate competencies that are realistic and relevant. The principles proposed by the ADEA CCI to shape the dental education environment represent critical concerns of the profession and important points of leverage in transforming the dental curriculum and ultimately new graduates.

A critical focus for change must be the culture and environment of dental education. With few exceptions, the current generation of dental practitioners remember their own dental education experiences as highly frustrating. What were the sources of student disdain? Course content or assignments that were irrelevant or never put in context. A perception that some techniques and procedures were outdated or not relevant to contemporary dental practice. A mismatch between what was published as curricular requirements and what was really required to survive and succeed, sometimes referred to as the “hidden curriculum.” Intimidating methods of clinical and preclinical instruction. Faculty who didn’t seem to know how to teach or test. An inefficient, complex, and convoluted patient care system that compromised patient welfare and dignity. Recent studies confirm persistent concerns and support the need for a humanistic environment that fosters collegial, professional interactions and promotes learning as a positive growth experience.^15,16 Providing an appropriate emotional climate beginning in the freshman year and doing more to show faculty and administrative support for students and nurturance during their clinical years are areas that may need more attention. Students need to be treated with the respect of professional colleagues from the time they enter dental school and understand the associated obligations of ethical conduct and professional responsibility.

The current generation of student looks at work-life issues very differently from the way mature practitioners do, and faculty must account for these differences in their approach to working with students and preparing them for their professional obligations. The demands of dental practice, the economic environment, and societal expectations will present tremendous challenges to students. Dental school is an important and appropriate setting for students to learn, understand, and adopt the concept of professionalism. This is the time for students to understand their responsibilities for competence, integrity, and respect and compassion for patients; to understand their obligations to society and the profession; and to develop a commitment to excellence and lifelong learning. Although dental schools may consider professionalism to be integral or inherent to the dental curriculum, more emphasis is needed in this area. The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project provides an excellent example of how teaching and assessment of professionalism can be more systematically incorporated into the curriculum.¹⁷

A second overriding concern of the practice community relates to a changing perception of the mission of the dental school and its role and relationship to its parent institution. Observations of directions taken by new dental schools and existing schools impacted by diminishing financial support raise concerns about the potential for dental schools to maintain a strong research mission. Despite the important contributions to dentistry by pioneers of the profession, we can no longer count on the opinions of experts as the basis for oral health care. Dentistry must be evidence-based. The profession needs to be able to depend on a cadre of academic dentists and their colleagues to conduct university-based research, free of commercial influence, that will generate new knowledge and technology to support future dental practice. It is a concern to see so few dentists participating in dentist-scientist programs or choosing an academic career that includes full engagement in research and scholarship. Dental schools must find a way to take full advantage of funding opportunities to support the development of research-capable academicians and ensure that these individuals receive the mentoring and sustained support to assume leadership roles in dental research.

By the same token, dental faculty who engage in research must be able to share their findings and support the translation of research into practice. The instruction of dental students should not be isolated from the research function of the dental school, and students should benefit from the opportunity to understand and adopt the critical thinking and problem-solving processes that are the foundation of research activity. Regardless of whether students have opportunities to participate in original dental research, all should have the experience and ability to critically appraise clinical research and interpret the validity of findings. This exposure should enhance their awareness of the areas of new knowledge and developing technology that could potentially impact the direction of future practice. Instead of relying on the set of knowledge and techniques acquired from their dental curriculum to support their entire careers, students should be prepared to anticipate, evaluate, and adopt new information and technology. Many practitioners take the cookbook approach to practice and rely on the wisdom of experts from the lecture circuit and throw-away journals because they were conditioned in dental school to emulate sage clinicians rather than to understand, analyze, and work through a problem using appropriate resources and problem-solving skills.

From the perspectives of both students and practitioners, dental curricula do not appear to be cutting edge, and dental schools are often the last places that practitioners consider when looking for continuing education. Why is this? Are dental schools wisely skeptical of the latest new gadget or technique that is likely unproven in superiority or effectiveness? Is there a lack of curiosity, creativity, and entrepreneurial initiative to support clinical trials of new products and techniques? Is it a lack of resources to purchase the latest equipment and materials? Is the curriculum too crowded with traditional areas of knowledge and techniques that are irrelevant, outdated, or no longer important or consistent with patient oral health conditions and needs? Even if students are too inexperienced to master multiple techniques or approaches to clinical problems, they need to be exposed to emerging areas of science and treatment modalities in an environment that includes a process for quality assessment and control so that they will be prepared to evaluate and implement new approaches in their own practices without undue hesitation or harm to patients. Recent news of significant partnerships between dental schools and industry offer a sign of hope that availability of equipment and materials will be less of a limitation.¹⁸ However, these relationships carry the burden of additional vigilance in managing commercial influence and bias in evaluating clinical effectiveness. Community-based clinical experiences, such as those promulgated by the Robert Wood Johnson Foundation’s Pipeline, Profession, and Practice Program and the Macy Study, may offer exposure to a greater variety of clinical practices, materials, and techniques in addition to achieving other objectives.^19,20

Many dental practitioners wonder if they could pass Part I of the National Board Dental Examination today, let alone a final examination from a current dental school course. This calls into question the idea that a circumscribed set of facts or knowledge can serve the needs of a dental practitioner throughout his or her career. When considered in conjunction with previous thoughts, it appears that the dental curriculum could benefit from some aggressive pruning as well as a review of the methods of assessment. Although a small set of basic principles and associated technical vocabulary may be needed as a foundation for learning, more emphasis must be placed on critical thinking and self-directed learning as recommended by the CCI. Instead of passively sitting through hours of lecture, students need to be engaged in learning in a way that requires them to learn in context and be able to access the knowledge that is pertinent to the situation. Understanding basic biomedical sciences will continue to be a necessity for comprehension of clinical sciences and emerging advances in areas such as molecular biology and genetics that may ultimately change the approach to oral health care, but schools should continue to evaluate the level of detail, as well as the appropriate time and source of instruction, e.g., predental versus predoctoral. Many schools, for example, have reconsidered the amount of time devoted to various topics and laboratory assignments in areas such as gross anatomy and histology, freeing up time for other purposes.

In considering what courses or content to include in the curriculum, dental schools should be encouraged to use a more evidence-based approach, instead of relying on internal discussion and recommendations of faculty who may naturally tend to promote the importance of their own content areas. Important sources of data that should inform curricular decisions include information on research topic areas sponsored or conducted by the National Institute of Dental and Craniofacial Research, the ADA Research Agenda, surveys on dental services rendered, data from the National Health and Nutrition Examination Surveys (NHANES) and other epidemiologic studies, and individual state oral health needs assessments. Shuler’s article on the adoption of emerging scientific advances identifies sources of information that can contribute to decision making about directions for curricular change.²¹ For public schools, focus groups of dental practitioners within the state can provide more locally relevant guidance on decisions about whether there is a need to change the amount of time and/or competencies for such topics as complete dentures. Engaging other health professionals may also prove valuable. The ADA, for example, has learned through discussion with the American Academy of Pediatrics of the need for general dentists who are fully capable of providing services for children in the very young age group from birth to three years. This information is also consistent with data on oral health disparities.^22,23 Data on the trends in distribution of dental services show significant changes in proportion of services in different categories, with dentists delivering almost twice as many diagnostic and preventive services in 1999 as in 1959.^24,25 This suggests that significantly more curricular attention should be devoted to developing the diagnostic capabilities of dental graduates. This direction is further supported by data on the demographic and medical characteristics of dental patients—an aging population with complex medical histories. In addition, changing scopes of practice for allied dental personnel suggest that the role of the dentist may continue to evolve with greater emphasis on diagnosis and overall patient management than on routine preventive and basic restorative services.

It has become evident that mastery of basic biomedical, behavioral, and clinical sciences is not sufficient for ensuring a successful dental practice. Today’s practitioner must be able to effectively operate and manage a small business in a highly competitive economic environment. Whether practice owner, associate, or employee, today’s dentist’s success depends on substantial understanding and competence in basic business principles: accounting, marketing, insurance and reimbursement mechanisms, and human resources management, for example. In addition, he or she must have a working knowledge of basic legal principles, recordkeeping, and the legislative and regulatory requirements that impact health care practice. Students should not be expected to learn these principles and best practices by trial and error or by osmosis during a period of association with a mature practitioner. While some dental educators may consider courses in these areas to lack substance in comparison to the basic biomedical sciences, these business topics are the foundation for undergraduate and graduate programs in business administration and provide the know-how that allows other small business leaders to compete for the public’s spending dollar and to achieve success in the community business environment.

In addition to didactic learning experiences that provide a foundation in these topics, practical learning experiences within the dental school or a community-based clinical setting are essential. Again, the concepts of ethical professional conduct must be an integral part of this instruction. It is as important for students to be confronted with challenging business decisions in a guided learning environment as it is for them to receive feedback to guide self-assessment on the quality of a restoration. Our future practitioners must have the critical thinking and clinical skills necessary to provide quality oral health care for the public and must graduate with a clear understanding of the tools needed to thrive in the world of small business as well.

Several examples and suggestions in this article have advanced the importance of community-based learning activities for dental students. Community-based programs serve important purposes, not only for the student, but for the dental school, the profession, and the public. ADEA’s 2003 policy statement, “Improving the Oral Health Status of All Americans: Roles and Responsibilities of Academic Dental Institutions,” clearly describes the role of the dental school in preparing students to meet their professional and social responsibilities of providing competent care for a diverse population and improving the oral health of all groups of society with special attention to those who are vulnerable and underserved.²⁶ Student assignments to off-site clinics can provide needed care to the underserved; teach students about their professional obligation to serve the public good; help students better understand the complex needs of the underserved and develop the skills for delivering culturally competent care; and provide opportunities for interaction with other health care providers and community leaders. Community-based clinical experiences should include exposure to private dental practices. Such arrangements could provide important opportunities for collaboration with the practicing community. Developing closer relationships among students, community practitioner mentors, and dental schools allows dentists in the practicing community to learn from students about advances in science, technology, and clinical techniques, as well as the critical thinking approach to practice, and diminishes the potential for a future profession at odds with itself because of diverging approaches to patient care. Engaging members of the practice community in various roles, such as mentor to students, adjunct faculty, or advisory committee members, can help to keep dental education well grounded and facilitate the growth of the profession through the integration of new ideas into practice and the adoption of evidence-based dentistry. Further, such relationships can help with the daunting challenge of ensuring that students graduate with the breadth and depth of technical competence necessary to meet the current oral health needs of the public while preparing both students and practitioners for a much different, but unknown, future. As the dental education curriculum is transformed, it would be valuable to allow community dentists to have access to current course materials. New technology and the use of electronic teaching materials and methods should make access to components of the dental curriculum feasible and could expand lifelong learning opportunities for practitioners.

Today’s students are not only tomorrow’s practitioners but the leaders of the profession. Ensuring the future of the profession is a leadership challenge that must be shared by both dental educators and the practice community. The process of becoming a dentist is much akin to that of a leader—an arduous journey of continuous learning and self-development. The last and most important leadership test is sharing what you have learned with the next generation.²⁷

DentalEDU.TV is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership credit. Approval does not imply acceptance by the state or provincial board of dentistry. The current term of approval extends from February 1, 2009 to January 31, 2012
http://www.dentaledu.tv
dental education continuing dental education dental schools online dental school online dental education

Bradley J Engle, DMD MHS
5659 Naples Blvd
Naples, FL 34109
http://www.engleimplantdentistry.com

engleimplantdentistry.com
Tel: (239) 593-2178
Fax: (239) 593-2179
Email: info@engleimplantdentistry.com

“The art of progress is to preserve order amid change and to preserve change amid order.”— Alfred North Whitehead

To meet the changing needs of society, there have been many calls for change in the way that dental students are educated. International and national attention has focused on the need for curriculum reform in health care education, including dental education, in order to address existing inadequacies, such as an increasing focus on high tech procedures to the detriment of a more humanistic, holistic, and evidence-based approach to health care. If an individual dental school chooses to engage in change, regardless of the magnitude, in addition to focusing on what to change, focusing on managing the process—how to change—will enhance success in achieving change that is comprehensive and sustainable.

The current dental education literature contains multiple presentations of the rationale for curricular reform.^1–4 Recommendations for curriculum content and educational strategies have been published as curriculum models, pedagogical techniques, and examples of best practices.^5–11 But despite the articulation of compelling rationales and substantive recommendations for educational reform, there are relatively few studies of the change process itself in dental education. Kassebaum et al. conducted a survey that resulted in a cross-sectional view of predoctoral curricula and curriculum evaluation strategies, as well as recently implemented and planned changes in North American dental schools.¹² Although that study did not address the change process itself, a method for managing curriculum revision was described that involved an ideal curriculum committee comprised of faculty who could be counted upon to take a “wide view” and focus on the best interests of the entire school versus parochially defending departmental/disciplinary turf. With regard to the curriculum change process itself, Kassebaum et al. summarized the responses to survey questions about process as “the tortuous and emotionally laden path to educational reform.” Currently, a targeted inquiry into dental schools that have recently planned or implemented changes, with emphasis on process issues during the initiation phase of the planning, is under development (a proposed project of Dr. Karen Novak, 2008 ADEA/William J. Gies Foundation Education Fellow). A transformational change in the curriculum at a private Midwest school of dental medicine, with particular emphasis on the architecture of the change process, has recently been reported,¹³ and a theoretical analysis of the organizational change process in one public U.S. dental school that has recently undergone significant curriculum and clinic changes is also under way (“Qualitative Analysis of the Organization Change Process in Dental Education: A Case Study,” my dissertation project). Two articles in the December 2007 issue of the Journal of Dental Education highlighted the importance of faculty development to successful change and emphasized issues germane to the process of implementing curriculum reforms.^14,15 Finally, Dharamsi et al. studied the curricular change process at the University of British Columbia School of Dentistry by exploring its social constructs.¹⁶ These examples demonstrate that whereas many schools are involved with changes, relatively few authors have chosen to bring focus to particular aspects of the change process itself or have published their experiences in the dental education literature.

In contrast, beyond dental education, there is a great deal written about the change process in organizations in general^17,18 and in educational institutions in particular, especially in higher education.^19–23 These and other studies investigated the organizational and educational reform processes in various settings and reached the conclusion that change initiatives are as likely to be derailed over disagreements about process as they are about substance. Further, it was found that when individuals paid attention to and were personally comfortable with the process/procedural aspects of the reform effort, greater success resulted.

This article was invited by the American Dental Education Association (ADEA) Commission on Change and Innovation in Dental Education (CCI) in order to present information about the organizational change process with a focus on factors that may be unique to the academic environment. Utilizing established knowledge about change and innovation in other educational and non-educational organizations as a framework, the purpose of this article is to raise awareness of these processes and, in particular, to espouse the perspective that change and innovation are processes that can and should be managed systematically to ensure success. It should be acknowledged that all dental schools, as with all organizations, experience ongoing changes of various magnitudes, sometimes as a consequence of calculated, purposeful planning to achieve targeted modifications and sometimes as a result of reactive and spontaneous response to unexpected events and undesired outcomes (“firefighting”). Many dental schools have probably experienced impressive change and innovation in both content (what was changed) and process (how the change was accomplished) without reporting these outcomes and strategies in the literature. Still, a cursory review of salient features that emerge from the organizational change literature, particularly in that of higher education and in professional education, may be of interest to those who are in the midst of or in the planning or reflective stages of change.

The type of change being called for in dental education (change that cultivates critical thinking, evidence-based practice, and lifelong learning, for example) is deemed “transformational” and is to be distinguished from 1) “unplanned” change that arises in response to some unforeseen situation and 2) “superficial” change that reflects a new way of doing the same old thing. Rather, transformational change is systemic (deeper), is pervasive (more widespread), and may involve the altering of the beliefs and understandings held by individuals within the organization. The American Council on Education (ACE) conducted the Project on Leadership and Institutional Transformation, which included a six-year study on change in higher education involving twenty-six universities.^19–23 (A synopsis of the report is posted on the ADEA CCI website at www.adea.org/adeacci/Documents/SynopsisACE.pdf.) The authors of this landmark study defined the characteristics of transformational change in the following ways: 1) it alters the culture of the institution by changing select underlying assumptions and institutional behaviors, processes, and products; 2) it is deep and pervasive, affecting the whole institution; 3) it is intentional; and 4) it occurs over time. These authors defined “successful” change not only in terms of outcomes, but as a modification that is sustained without reversion to a previous state even though the details of reform may indeed be modified over a period of time as the new way of doing business is merged into the culture of the institution.

The “process” of change refers to how and why a change is initiated, implemented, evaluated, and sustained. “Innovation” in organizations refers to the initiation and adoption of new ideas and practices and is often considered concomitant with change. Although change and innovation are separate processes, unless otherwise noted, innovation will be implied within the organizational change process in this article.

To apply what is known about organizational change to dental education, it is useful to begin with a perspective that views organizations as entities that exist within unique external and internal environments. Although this perspective is seemingly intuitive, this was not always the case as will be described in the next section. A brief historical overview of formal thought about organizations is presented to provide a foundation for further discussion of factors that influence organizational change. Knowledge about the broader organizational framework, in addition to a focus on individual member behavior, increases the likelihood that successful change will occur.

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The curtailment of federal and state support has created a financial challenge for public dental education.^2,5–10 Dental education is one of the most expensive health professions education programs on a per student basis. The estimated marginal cost of financing physician training at a U.S. public school is $251,085 per student, compared to $312,040 for educating a dental student.^4,11 A revealing cliché frequently repeated by university advancement and development administrators reflects diminishing state support for higher education: “public universities,” they say, “were state-supported, then they were state-assisted, and now they are state-located.” The drastic decline in public support has been linked to critical issues currently facing dental education, such as increases in tuition and fees with a corresponding increased student debt load and less money to pay faculty, adding to faculty shortages or increased teaching workloads with associated declines in research and scholarship.^8,12–14 Additional problems still exist, such as the high cost of clinic operations, aging dental school infrastructure, and lack of funds to continue incorporating information technology into the dental curriculum.

There is justified concern that these financially driven resource issues, besides adversely affecting day-to-day operations of dental schools, might have more long-term negative effects on schools’ ability to sustain an adequate research base, educate a diverse workforce, and prepare graduates to deliver dental services to underserved patient populations; hence, the esteem of the overall dental profession may be in jeopardy. In light of these challenges, the objectives of this article are to review current dental education financial issues and management models and present innovative strategies for addressing these issues in the future. Our collective investigation of this topic was part of the learning experience we had as fellows, along with our mentor, Dean Williams, in the American Dental Education Association (ADEA) Leadership Institute class of 2008.

Financial Challenges to Dental Education 

Tuition and Student Debt
From 1991 to 2000, average state support for dental education dropped from approximately 45 to 32 percent of a school’s annual budget. Even though this average suggests schools receive approximately one-third of their funding from state support, this level varies, so that a significant number of state or state-related schools (private schools that receive a per capita enrollment subsidy from the state, such as the Maurice H. Kornberg School of Dentistry at Temple University and the University of Pittsburgh School of Dental Medicine⁴) are functioning almost like private schools due to the minimal state support they receive.⁵ Many state/state-related schools now have to generate 70 percent or more of their operating budgets from tuition, extramural support (grants), revenues derived from clinical services, and charitable donations.

A common response by dental schools to the decline in state funding has been to increase tuition and fees, approximately 7 to 10 percent per year since 1993.^5,7 Consequently, student debt at graduation has grown dramatically.^6,12,14–17 Between 2000 and 2006, educational debt at graduation increased 38 percent. Average indebtedness for all dental school graduates was reported to be $145,465 in 2006, with public school graduates averaging $124,700 and private/state-related graduates averaging $174,241.¹⁸ Even with the rising cost of tuition and fees and the resulting higher student debt level, to date, dental schools are still attracting many well-qualified applicants to fill their classes due to dentistry’s high private practice income potential.^8,18

However, one outcome of the increasing tuition is that the number of enrollees from higher income families has increased substantially. From 1998 to 2006, the number of students with parental incomes of $100,000 or greater increased from 35.1 to 44.2 percent, while the number of students with parental incomes less than $50,000 declined from 32.4 to 25.8 percent.¹⁸ Furthermore, current dental school enrollment of African Americans and Hispanic/Latinos at 4.7 and 5.3 percent, respectively, does not reflect the equivalent representation of those minorities in the overall population of the United States (12.4 and 15 percent, respectively).^19,20 Thus, it would appear that tuition and fee increases are contributing to the factors discouraging talented students from lower income families and underrepresented minorities from pursuing dental careers.

As the student debt load has increased, the number of students receiving financial assistance in the form of loans has increased from 82.3 percent in 1990–91 to a range of from 89.5 to 90.8 percent, depending upon whether the school is private, private/state-related, or public, with public school students receiving the most financial assistance.¹⁵ The amount of financial assistance needed continues to exceed tuition and fees, since it also covers living expenses and the cost of books and other supplies and materials. Because the cost of obtaining a dental education is no longer covered by low-cost government loan programs, students are increasingly finding it necessary to obtain loans from private sources with higher, non-fixed interest rates. However, many students, because they have no credit history or a history of bad credit, have a difficult time qualifying for private loans.^15,21 Many students are, therefore, concerned with how to finance their dental education; this is especially true for students from disadvantaged backgrounds.¹⁵

In addition to high tuition levels affecting student diversity, graduates’ career and practice decisions may be impacted. For example, a high debt load makes it less likely that a graduate will choose to practice in a community health center or provide care in underserved areas.^14,18 Perhaps, the increased debt level and its subsequent effect on dental practice might be related to the increased focus on the business of dentistry, as recently reported in the New York Times.²² Critics have blamed dentists’ interest in money for the access to care issues in the country, going so far as to imply that the profession’s resistance to a two-tiered level of care system is based on financial interests. Continually rising dental school tuition, absent a plan to contain costs, might provide justification for this criticism.

Faculty Shortages
Dental school budget cuts have also had a negative effect on faculty salaries. By 2000, the private practice general dentist annually earned $86,000 more than his or her dental school faculty counterpart, and the private practice specialist earned $170,000 more than his or her faculty counterpart.⁸ By 2015, Bailit et al. have projected that this annual difference will increase to $278,000 and $454,000, respectively.⁸ With the growing discrepancy between faculty and private practice income, it is not surprising that many faculty members are leaving academia.²³ Moreover, dental school graduates with a high debt level are not likely to choose academic dentistry over the more profitable private practice. This fact was recently confirmed by the ADEA survey of the 2006 graduating class, which found that less than 1 percent of the responding graduates were even considering an academic career.¹⁸ Collectively, these factors have led to an ever-increasing faculty shortage.^13,17,24 There are currently 406 vacant faculty positions, which averages to approximately seven vacancies per dental school.²⁵

Beyond filling the vacancies, there is concern about schools’ ability to attract and retain faculty members noted for excellence, research, and recognized scholarly activity with current faculty compensation. With the extreme faculty shortage, institutions might be tempted or forced to increase teaching or service workloads, thereby reducing release time for scholarly efforts and minimizing the importance of research and scholarship, leading to the erosion of the profession to the point that dentistry is considered a vocation rather than a learned profession.¹⁴

Clinic Operations and Facilities
The high cost of clinical operations is another factor for consideration when attempting to understand the cost of dental education.¹⁰ In medical education, most clinical learning and patient care experiences take place in hospital facilities during the third- and fourth-year clerkships and then in residencies after graduation. The costs of the medical school clerkships are to some extent shared between the school (which provides faculty who double as attending physicians and who are often compensated by both school and hospital) and the teaching hospital through a variety of mechanisms. The expenses for residency education are almost wholly underwritten by the hospital and the federal government, through a combination of revenue sources including clinical fees generated by the residents’ provision of patient care. In contrast, the majority of dental clinical instruction takes place in non-hospital clinics operated by the schools. Between 1990 and 2000, patient care expenses in public dental schools increased approximately 35 percent.²⁶ However, predoctoral student-generated clinic income does not cover the costs of operation, because dental school clinics operate as teaching laboratories with students seeing no more than two or three patients per day at substantially reduced fees to compensate for the additional time required for care.⁷ On average, clinical income covers only approximately 32 percent of the school’s costs of clinic instruction and operation.⁴

Another issue related to clinic operations and facilities is the fact that most universities’ investment in the extensive patient care facilities within dental schools (essentially an ambulatory care, outpatient clinic that is larger than found in major hospital systems) and supporting infrastructure has not kept pace with the routine maintenance and replacement expenses associated with operating such a facility. This is a major concern when the physical plants of many schools, including the so-called “new” schools started in the 1970s, are thirty to forty years old.⁸ As a result, dental schools typically cannot afford to incorporate technological advancements in patient assessment and treatment into the curriculum, so students graduate with limited knowledge of current technology and equipment that is standard in dental practices.²⁰

Current Models to Address Financial Challenges

Clinical Education Models
New revenue strategies must be explored to find alternatives to the reliance on tuition increases and associated student debt load. While dental education is not a for-profit business, with increasing clinic operation costs and rising tuition, sound business management principles should be considered.²⁷ One example of this approach is implementation of a model using private practice principles to increase senior dental student production. In one dental school during the 2003–04 academic year, a private practice model was implemented and resulted in a 63 percent increase in revenue, more care for more patients, and expanded educational opportunities for students in the business aspect of dentistry.²⁸

Community-based and patient-centered education/delivery systems have been recommended as potential alternate approaches to dental clinical education;⁷ most recently, this paradigm shift in dental education has also been recommended as part of the Macy Study report.²⁹ Community-based education usually incorporates community-based rotations into the senior dental curriculum, with the primary goal of these programs being the efficient delivery of high-quality patient care. Additional advantages are increased student productivity and the fact that, in many situations, underserved patients benefit by receiving oral health care that might not otherwise be available. The University of Colorado was the first to implement community-based rotations in both community clinics and private practices as an integral part of its program.³⁰

In addition to community-based education, the Macy Study also proposed that the patient-centered education/delivery model should be used within the dental school rather than teaching clinics that resemble preclinical laboratories with patients replacing the mannequins.²⁹ Within the proposed patient-centered system, a comprehensive care approach is used in which faculty members treat patients while supervising students, who gain experience as part of the team of providers. Each clinical team would typically consist of a small core of faculty members, junior and senior students, dental assistants, and patient care coordinators.

Bailit et al. calculated how community-based or patient-centered education could potentially increase revenues.⁷ Outcomes related to community-based education predicted a net savings per school of $2.7 million, or 8.1 percent of total school expenses. Patient-centered care would potentially generate $27.7 million in gross revenues, of which there would be $18.6 million in overhead for net revenue over expense of $9 million. In either case, these outcomes are significant, since the average dental school had approximately a $5 million deficit from clinical operations in 2003.⁷ However, it’s important to note that, with Bailit et al.’s proposed patient-centered model, the analysis assumes that patients are charged usual and customary fees for care provided by the faculty, while there is a 50 percent fee reduction for treatment provided by the students.

While the patient-centered education and delivery system has been more commonly incorporated into oral surgery and specialty clinics,^7,24 it is only in the last five to ten years that some dental schools adopted a patient-centered model. Although not exactly the same as the proposed model in the Macy Study, a faculty practice-team approach is used within some predoctoral clinics.²⁹ While faculty members do not treat patients, this clinic model incorporates a comprehensive care approach, so that the patient’s needs come first, rather than students treating patients only to meet their educational requirements. Three dental schools (University of Maryland, Columbia University, and University of Louisville) that reorganized their clinics to implement patient-centered delivery were evaluated as part of a case study that reported that increased efficiency and student patient billings occurred following the reorganization.³¹ However, despite the implementation of patient-centered delivery in these schools, with only students providing care, the clinics are still not self-supporting. As reported by Formicola, there are some lessons to be learned from the schools in that study.²⁹ The culture of teaching clinics is difficult to overcome, for example, since faculty members are resistant to becoming active practitioners. In addition, the patient mix, school location, and opposition to potential competition from local practitioners may also make transitioning to a patient-centered model in which faculty also treat patients more difficult.

Another model incorporating outsourced clinical education is used by A.T. Still University’s Arizona School of Dentistry and Oral Health, where a portion of students’ clinical education is conducted in outlying clinics. In addition, didactic education is outsourced via adjunct visiting professors, who teach one- to two-week modules in their area of expertise.³² However, in most situations, other more traditional dental schools are subsidizing the true costs of providing instruction in the modular format by allowing their faculty to serve as visiting professors and not recovering the full costs of ongoing faculty benefits and time away from the university. Despite the major infrastructure cost savings at A.T. Still, where the dental school does not incur the legacy costs of maintaining a large full-time faculty, the students’ yearly tuition, excluding fees, is currently estimated at $39,860.³² Thus, this model does not appear to alleviate high tuition or student debt problems considering that the national average for predoctoral tuition and fees for 2005–06 was $25,490.³³ However, the model does address the faculty shortage issue by having only nineteen full-time faculty available for a class size of sixty students. On the other hand, this methodology for staffing a dental school also makes it more difficult to maintain dentistry as a learned health science profession with so few dental faculty members able to contribute to research and scholarship.

Moreover, with the shift to adjunct faculty in outlying clinics and the creation of the non-tenure clinical educator track in many schools, these faculty members are typically not required, encouraged, or given release time to be involved in scholarly or research activities.^14,34 With the increasing faculty shortages²⁵ at most dental schools, the clinical faculty spend the majority of their time involved with clinical instruction.

Dental School Faculty for the Future
If dentistry is going to remain aligned with the research university system, the ongoing faculty shortage must be addressed. As discussed, the combination of high student debt and the discrepancy between academic and private practice income is a prohibiting factor to dental graduates considering dental education as a career. As a result, dental schools tend to tap retired dentists, including retired military dentists, as a source for faculty. However, as pointed out in a recent article by Bertolami,³⁵ what retirees offer to dental education is sometimes limited to clinical supervision. It is not likely that baby boomer (aged fifty-five to sixty-five) faculty members will support or participate in efforts to introduce new teaching and learning methods into the curriculum, figuring that they are relatively short-term employees in the interval between closing their practices and full retirement. This recruitment model for dental school faculty also sends the message to students that academics is not a first choice, but rather something to do when you retire from your primary career.³⁶

Perhaps dental education should be considered as a discrete category of dentistry, since practicing dentistry is very different from teaching dentistry. Anyone pursuing dentistry as a career, whether for private practice or academics, must be willing to incur significant direct educational expenses; forgo other income while in dental school; undertake grueling classwork, training, and examination; anticipate a future that begins with debt reduction; and face uncertainty about the amount and course of future earnings.³⁷ It has been suggested that dental students who would consider academics might be a distinct subset of dental students.^35,38 For example, many students accepted into dental school have a higher sense of entrepreneurship and are willing to put their own financial assets at risk in order to develop a business-based dental practice, in return for significant economic gain.³⁵ In contrast, there are others who would rather be employed as dentists rather than filling the role of dental practice owner/proprietor. When comparing the lifetime income of employed dentists versus full-time faculty, the income differential is small because typically, as an employee, there is no production-based mechanism for increasing salary as is the case with clinical practice.³⁷ Dental schools should consider identifying and accepting some of those applicants who might prefer positions as employees and, accordingly, develop a pool of students who could be groomed for an academic career. The recruitment of such applicants should be included not only in the admissions process but also occur prior to admissions. One early opportunity for such recruitment could be through meetings with preprofessional health science groups such as predental and premedical college organizations. Despite the recommendation, there are currently no tested criteria or mechanisms that could be used to identify these students.

Even with identifying a pool of dental students better suited for careers in dental education, faculty compensation must also be addressed if dental schools hope to recruit and retain excellent academicians. It has been recommended that dental education consider the model of compensation policies typically employed in medical education.²⁴ Academic physicians bill for the patient care services that they provide while they simultaneously supervise and assist trainees. Although this might be difficult to implement initially, dental school faculty would receive extra income based on student productivity, or their own productivity, because faculty will undoubtedly provide more direct patient care if an approximation of the medical model is pursued within a dental school-operated treatment facility. In addition to increasing faculty compensation via supplementary income derived from patient care billing, several medical schools have implemented performance-based compensation for teaching, research, and academic service activities.^39–41 Survey evaluations of these programs indicate that the majority of respondents are satisfied with the incentive system and the associated income bonus. Utilizing these compensation plans in dental education could improve the financial benefits of an academic career and potentially increase the number of applicants for faculty positions.

Another way the dental profession has tried to address the faculty shortage problem is by instituting the D.D.S.-Ph.D. dual degree program. It was hoped that these programs would attract students with a genuine interest in an academic career, but the reality is that many of these individuals leave academics due to the burden of high debt, the lure of high income, or both.³⁵

There has been an increasing interest in having the Commission on Dental Accreditation (CODA) of the American Dental Association (ADA) provide accreditation for international dental schools.^42,43 The most commonly cited reason for exporting accreditation is legislative pressure to import dentists to increase access to care;⁴² on the other hand, imported dentists might also help relieve the faculty shortage. However, with no requirement as to where these dentists should practice, international accreditation may not address access to care or faculty shortages. Currently, most internationally trained dentists integrate themselves into the U.S. system by earning a D.D.S. or D.M.D. in one of the advanced-standing programs available at thirty-seven of the fifty-six U.S. dental schools.⁴² Dental schools might use these advanced standing training programs as part of a faculty recruitment and hiring package for foreign-trained dentists. For example, qualified internationally trained dentists could be recruited for faculty positions and then allowed to participate at no charge in a modified advanced standing program, while serving as an active faculty member. To address retention following program completion, the faculty member would be required to sign documentation agreeing to remain at the school for some period of time. If they left prior to the agreed period, they would be required to reimburse the school for the tuition costs of the advanced standing program.

The advanced education or specialty programs are another significant source of new faculty. In the last two years, 21 percent of new faculty were individuals who had just graduated from such a program.²⁵ Another potential benefit of the advanced education programs is that, while in the residency, these individuals could be involved with teaching predoctoral students to help ease the faculty shortage.

Collaborations with Private Industry
Previously, there was an arm’s length model between dental education and industry due to concerns about commercialism.^44,45 In spite of posing potential ethical risks, partnership models have evolved into mutually beneficial relationships, with dental school partnerships with private industry increasing.⁴⁵ Examples of such partnerships include donations for capital projects, endowed professorships, symposia, continuing education courses, educational materials, scholarships, fellowships, research funding, and access programs.^44,46 Another common example of corporate support for dental schools is dental suppliers providing products and equipment at a significantly reduced cost to the schools. While corporate support reduces clinic operation costs, it also exposes students to the various companies and their products.

Many schools also have educational grants from implant companies. Besides providing students with the opportunity to place and restore implants in patients who might not ordinarily be able to afford them, the programs also establish student familiarity with particular implant systems. In addition, these implant grants might be related to the continuing decline in the percentage of graduating seniors reporting inadequate implant education, down from 50 percent in 2001 to 38.7 percent in 2006.¹⁸ Other potential areas of corporate support would be access to newer technologies such as digital impressions and associated computer-based systems such as CAD/ CAM for generating indirect restorations.

Another mechanism for generating revenue, the selling of naming rights by secondary schools and local governments, is increasing.^47–50 We could find only one example in dental education: Nobel Biocare AB of Sweden awarded $4 million to Tufts University School of Dental Medicine to name the Oral and Maxillofacial Surgery Clinic and further develop the study of dental implant applications.⁵¹ Financing dental education through naming rights may not be feasible for some dental schools and will be debated within the context of dental education and its institutions.

A novel example of private industry partnering with a dental school is the case of Nara Bank and the University of California, Los Angeles (UCLA), School of Dentistry. Nara Bank provided funding and facilities support for community-based health fairs, established a special loan program to enable low-income patients to receive dental treatment, and extended lines of credit to UCLA dental graduates to help them establish or buy practices in underserved areas.⁵² The concept of a public-private partnership of dissimilar business entities offers the possibility of a new means of support for dental schools. This partnership is a shift from largely top-down public funding to a combination of public/private/corporate funding. This approach has been proposed throughout higher education and continues to be explored in many different settings.⁵³

An additional corporate partnership approach was recently developed to finance orthodontic specialty programs sponsored by a for-profit company. The corporate/orthodontic graduate program was implemented within three universities, one private and two public.⁴⁴ However, within three years, the corporation had filed for bankruptcy, and the partnership is no longer in existence. Despite the fact that the university officials expressed surprise and stated the corporation appeared to be stable and well run, it was reported there were repeated warnings about the company that went unheeded.⁵⁴ This example points to the need for exercising extreme care in the development of education-industry partnerships.

The potential conflict of interest in the interactions of academics with industry and health professionals with pharmaceutical companies is being highly scrutinized. Stringent regulations are now enforced in many academic centers, so that, for example, academicians/health professionals do not accept products, gifts, meals, or payment to attend meetings.^55–57 The intent of these regulations is to eliminate any industry influence or motivational factors that would bias the selection of a product that may affect patient care.

Besides direct dental education-industry partnerships, the ADA Foundation has initiated Dental Education: Our Legacy, Our Future, a collaborative effort of partner organizations, such as dental schools, specialty associations, and other dental organizations, to raise awareness of the challenges facing dental education and promote philanthropy within dentistry to address these issues. It is estimated that, by 2014, these partner organizations will have raised $500 million to address issues facing the future of dental education.^20,58 These funds should be available for scholarships, fellowships, and loan forgiveness programs, in addition to supporting innovative educational technology efforts. However, despite these lofty goals, there will likely be limitations associated with this program.

Other Innovations to Address the Economics of Dental Education

Regardless of the numerous strategies that have been implemented, the current model of public dental education economics is not sustainable. To date, the fiscal problems have predominantly been addressed by increasing revenues via tuition increases and education models that potentially increase clinic income. However, to remain viable, the dental education system must adopt transformational actions to address its fiscal problems for the long term. In short, public dental education must re-engineer itself in order to be sustainable for the future. The proposed re-engineering might begin by exploring the following three ideas: 1) redesign the educational process, 2) reduce and redistribute time in dental school, and 3) develop a regional curriculum.

Application of Business Principles to Achieve Savings
Dental education and the curriculum have not changed much during the past century.^14,59 By radically examining all aspects of the dental education process with an emphasis on quality, delivery, cost, and innovation, there is reason to believe that cost savings can be made. In FY2005, the overall dental education enterprise represented a $2.4 billion operation.³³ By re-engineering a 10 or 20 percent savings in the entire enterprise, $240 to $480 million could be freed up for reinvestment, reduction in tuition, or improvement in faculty salaries. Business principles such as Total Quality Management (TQM)⁶⁰ or Kai-zen⁶¹ among others should be explored on a pilot basis to determine feasibility and then implemented at those dental education institutions whose culture would support a major redesign process. Planning for new dental schools should incorporate the most efficient use of resources possible and subscribe to a continuous quality improvement philosophy.

Reduction in Education Time
Undergraduates utilize advanced placement (AP) courses and are able to test out of various courses to gain course credit, thus reducing their total instructional time in college. This happens in dental education with advanced placement students such as those internationally trained dentists who enroll in U.S. degree programs. What if dental students could take challenge exams or AP courses and thus reduce their total enrollment time in dental school? The ability of a student to reduce one semester or up to a full year would save up to 25 percent of the total tuition costs for a traditional four-year program. The key is having students certified as being competent in equivalent courses. This would force a restructuring of the first year of dental school, but could prove more useful and less costly for students. The savings might also translate to dental education programs as a result of the reduction of the instructional costs for providing the courses. However, to realize this savings, all students within a dental school class would have to participate in the AP program for particular courses; otherwise, if only a portion of the students opt out, the course would still have to be offered. Thus, although the advanced placement scenario might have merit, there are unanswered feasibility questions that would need to be addressed.

Restructuring across the dental school curriculum to eliminate redundancies and outdated methodologies along with the increased use of information technology could conceivably open up more time in the curriculum. This could be extremely important since most dental students feel overwhelmed in their first two years and would allow the dental school curriculum to remain at four years. Dental education in North America has historically been resistant to change.^62,63 However, in 2005, the ADEA Board of Directors appointed an oversight committee, the Commission on Change and Innovation in Dental Education, to provide oversight to systemic, collaborative innovative change in general dentistry education.⁶³ A series of white papers has been developed to detail the case for change and associated strategies for curricular and other areas of change.^14,64,65

Regional Education
Another redesign idea for dental education is to create a consortium of regional educational centers that prepare dental students for the biomedical, behavioral, and preclinical sciences curriculum. Institutions would share the cost of faculty and curriculum in this model. The regional facilities would be used efficiently by operating twelve months a year at a minimum of forty hours per week, unlike the utilization at current educational facilities, which often have minimal educational activities for ten to twelve weeks annually, especially in the summer. The use of costly teaching technology and preclinical simulation could be spread across a number of participating schools to reduce the high per student cost of instruction. For example, a $60,000 simulator shared by four schools would only cost each school $15,000 initially along with an annual maintenance fee. A 100-station preclinical lab would cost $6 million for the simulators, but each school would only need to pay $1.5 million to participate. An alternative to this purchase model could be a lease arranged by a dental school to spread the costs over time. In either financial arrangement, the major benefit of a regional consortium is sharing costs, thus lowering an individual dental school’s costs for instruction in the biomedical, behavioral, and preclinical sciences curriculum and more efficient use of educational facilities. However, in either situation, schools would need to consider the annual cost of transporting students and faculty to where the simulator is housed and the impact on the anticipated savings.

Thomas Friedman in his book The World Is Flat describes how technology has been instrumental in changing the way we interact and interface with businesses and individuals across the world.⁶⁶ Utilizing these technologies can expand dental education from the traditional brick and mortar dental school to greater regional, national, and even international collaborations. It is not inconceivable for a lecture or symposium at one site to be teleconferenced worldwide. In addition, making didactic materials available to students 24/7 through the use of technology would allow for less time in the classroom and more in the lab or clinic.⁴³ The problem in implementing these innovations can be twofold: the lack of information systems infrastructure, and faculty inertia and resistance to change.

For the foreseeable future, a return to the federal government capitation grant program of the 1960s and 1970s is not anticipated. By considering some re-engineering initiatives, however, dental school leaders can begin to think and perhaps function differently. The ideas suggested to address the financial challenges facing dental education support the intent to continue to educate adequate numbers of dentists at a reasonable cost both to the student and the institution, while maintaining the position of dentistry as a learned profession. Failure to explore and implement new ways of educating dental students in a more cost-effective manner may result in less than desirable outcomes for the profession of dentistry in the future.

DentalEDU.TV is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership credit. Approval does not imply acceptance by the state or provincial board of dentistry. The current term of approval extends from February 1, 2009 to January 31, 2012
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Bradley J Engle, DMD MHS
5659 Naples Blvd
Naples, FL 34109
http://www.engleimplantdentistry.com

engleimplantdentistry.com
Tel: (239) 593-2178
Fax: (239) 593-2179
Email: info@engleimplantdentistry.com

An informal meeting in the fall of 2003 took place at New York University School of Dentistry to discuss what could be done to increase the number of patients being treated with dental implants. All members agreed that, although there is a large number of patients who would benefit from implant therapy, particularly patients who are edentulous, few actually receive implants and implant prosthodontics.

Out of this preliminary meeting came the concept that increasing the hands-on implant dentistry knowledge imparted to dental students would increase the number of patients benefiting from dental implants. It was felt that if a student did not perform clinical implant care on a live patient, he or she was less likely to perform that care in practice. The dental literature indicates that there is a strong correlation for recent graduates between offering and restoring implants in their practice when an implant course was taken as part of their dental school curriculum.^5–8

Towards that end, those involved agreed to assemble an implant workshop involving all deans of U.S. and Canadian dental schools, as well as representatives of their surgical and prosthodontic faculty. At this workshop, action ideas for schools were to be generated across the various clinical disciplines and school boundaries to improve the care of fully and partially edentulous patients by increasing implant therapy. The results of this workshop will be published in a separate report.

Other goals of the ADEA Implant Workshop were to share instruction methods for predoctoral implant dentistry programs, including predoctoral curriculum information that would better facilitate additional training in implant prosthodontics while students are still in dental school. This report presents the results of an implant survey sent to the deans in advance of the workshop. The survey was intended to identify the then-current status of implant education and, particularly, the predoctoral students’ clinical experience with implant treatment.

Bradley J Engle, DMD MHS
5659 Naples Blvd
Naples, FL 34109

http://www.engleimplantdentistry.com
Tel: (239) 593-2178
Fax: (239) 593-2179
Email: info@engleimplantdentistry.com

The pursuit of lifelong learning-whether to enrich our lives, follow a new dream, or simply challenge ourselves, is certainly something that appeals to many of us. For some professionals, however, ongoing training in their fields of expertise is more important than for others. Individuals working in the medical and dental fields are entrusted with the safety and comfort of others on a daily basis. Should they choose to rely upon their initial training indefinitely, ignoring ongoing developments and technological advances, they would be putting their practices at legal risk and jeopardizing the health and welfare of their patients. In these fields, it’s simply not an option to assume that there is nothing more to learn.

Dental continuing education is essential for anyone working within the dental field. As in the medical field, technological advances in the field come at a rapid-fire pace, and staying abreast of the latest research, tools and treatment methods is crucial. Ongoing training for dental professionals is so important that most states require that dentists and hygienists complete a certain number of dental continuing education activities each year in order to remain licensed to practice. These requirements vary from state to state, and in some cases also apply to dental assistants.

Pursuing continued education in the dental field can be beneficial in several ways. For a dentist who is currently in practice, ongoing continuing education ensures that his or her patients have access to the latest diagnostic, preventative and treatment methods. For an individual just beginning a career in the dental field, dental continuing education can open new career pathways, provide opportunities for advancement and improve earning power.

A wide variety of dental continuing education activities are available for both working and non-working individuals. If your goal is simply to stay informed about new research findings and updated industry best practices, there are plenty of low-cost, self-paced online courses that can help you to meet your state’s continuing education requirements and enhance your ability to perform your current job role. If you are interested in furthering your formal education, however, in order to advance your career in the dental field, you may wish to pursue a degree or certificate program. For example, a dental assistant may discover that she is interested in pursuing a career as a hygienist-whether to earn a higher salary or simply to experience more personal fulfillment in her job role. In this case, she would need a degree from an accredited dental hygiene school in order to obtain her license.

Regardless of the pathway you choose, as a dental professional you should consider your pursuit of education to be a lifelong endeavor. Doing so will not only better position you to advance within your chosen field; it will also ensure that you’re able to provide the best possible care for your patients.

DentalEDU.TV is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership credit. Approval does not imply acceptance by the state or provincial board of dentistry. The current term of approval extends from February 1, 2009 to January 31, 2012
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A dentist will need to have taken a good amount of courses for getting one’s degree in dentistry. The first part of this education will come through going to a college to study dental health studies and various concerns involving teeth. This is a necessity because many dental schools require college degrees for admission.

The dental school a dentist goes to will be an important thing to see. This school is one that covers various dental procedures and practices that one will have to work with on a daily basis as a dentist. A typical student will need to spend four years at one of these schools.

After graduating from a dental school a dentist will receive a DDS degree. This refers to being a Doctor of Dental Surgery. This degree is a requirement for people who want to be legally allowed to practice dental procedures in a particular area.

In some cases a dentist may want to become a specialist. This can include working as an orthodontist, oral surgeon or pediatric dentist. Someone who wants to get into one of these fields will need to go to another dental school for up to five years to study in one of these subsets. This can only be done after a dentist officially get a DDS degree.

A program that works for becoming a specialist will be one that is offered by a typical dental school. It will also be one that is fully approved and supported by a major legislative body for dentistry like the American Dental Association.

Finally a dentist will have to work with continuing education over time. This is used to help with educating dentists about new procedures and tools in the field of dentistry. Various schools offer continuing education courses. These courses can also be found at the annual ADA meeting.

When finding dentists it will help to see what education processes are used for helping to become a certified dentist. A dentist will work with years of education to become one and much more in order to be a specialist in some field. The education used will work to help with getting to be certified to practice dentistry.

DentalEDU.TV is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership credit. Approval does not imply acceptance by the state or provincial board of dentistry. The current term of approval extends from February 1, 2009 to January 31, 2012
http://www.dentaledu.tv