Table of Contents

Cover Story
Practice Building
Roundtable
Continuing Education
  • Opioid Prescribing in Dentistry Stephanie Golubic, DMD, MBE, Paul A. Moore, DMD, PhD, MPH, Nathaniel P. Katz, MD, George A. Kenna, PhD, RPh, Elliot V. Hersh, DMD, MS, PhD
Endodontics
Esthetics
Restorative

Inside Dentistry

June 2011, Volume 7, Issue 6
Published by AEGIS Communications

Richard W. Valachovic, DMD, MPH

The executive director of the American Dental Education Association (ADEA) describes the state of dental education and the oral health work environment.

Interview by James B. Bramson, DDS

INSIDE DENTISTRY (ID): A lot has happened since you became the executive director of ADEA in 1996. What's been the biggest challenge for you in leading the organization that represents America's dental academic community?

Richard Valachovic (RV): I think that the challenge of leading ADEA is, at the same time, also one of our greatest strengths. Unlike other organizations, we're a major umbrella organization for all of dental education. Our membership includes all of the dental schools in the United States and Canada; we also have institutional members in the dental hygiene programs, dental assisting programs, and laboratory technology programs, and we represent advanced education programs within dental schools and programs that reside in hospitals or other institutions outside of dental schools. Plus, we have a whole corporate membership. Perhaps it would be easier in many ways if we just represented one of those groups. We represent all of them.

ID: With all of those diverse constituencies, how do you find consensus for the organization?

RV: I think there is consensus around the educational issues. We certainly don't always agree, but ADEA acts as the common element in providing an opportunity for all of the voices in the academic community to be heard and, hopefully, we get to the point where we get some consensus. I think in the things we've been dealing with—addressing new models of teaching and learning, issues around distributive education, online learning, community-based education, interprofessional education—we actually have been able to come to consensus pretty well, using ADEA as the common approach.

ID: What would you consider to be the major challenges for academic dental institutions?

RV: I think many of the challenges right now are addressing these new models of learning and teaching, and having new generations come in that learn differently than many of the teachers who are there, so we're trying to Figure all of that out. But clearly the real challenges are the financial ones, particularly for our public institutions, during this difficult time with funding. Also, we continue to have a huge issue with our faculty. We currently have about 400 open positions across the country, and we are not filling those as quickly as we would like. Right now there's a real opportunity out there for folks who want to join the academic ranks.

ID: Are those vacancies primarily due to discrepancies between academic and private practice salary opportunities?

RV: It used to be. Twenty years ago, the two major sources of new faculty were graduates of an advanced education program, or the military. Before the recession hit, the lure of private practice was quite strong, especially to young dentists who were finishing either dental school or an advanced education program and were faced with huge loan repayments. Now, by far, the major sources of new faculty—approximately 60%—are dentists who have had a career and been successful in private practice. This is wonderful for filling the clinical slots, even if, as it very often is, it's on a part-time basis. The major need right now is in some of the basic sciences and for full-time academics—people who have clinical experience and training and research backgrounds and other forms of scholarship. Filling those spots is critical to maintaining dentistry as a profession.

ID: How has the role of the dental educator changed over the past decade, and how has the role of the dental school changed?

RV: In its essence, not all that much has changed. Educators are educators, for the most part. What's different now is that the modalities of education are changing. I think that the role of technology and simulation has become much more important in the educational process. The educator is no longer the "sage on the stage." It's not the teacher standing up in front of a class for a defined hour and holding forth. The teacher is much more of a facilitator now of learning among groups of students. Sometimes in problem-based learning or case-based learning, opportunities are presented in other ways, so that the educator becomes more of a facilitator of student learning, as opposed to being the expert and giving out information that students had to learn and assimilate. Not all education occurs just in lectures anymore.

ID: Has the mission of the schools changed?

RV: It has. Schools have become much more involved in being safety net providers where they are. And that's true not just of the dental schools, but also dental hygiene programs and advanced education programs that are outside the dental school. One of the phrases we used during one of our leadership summits at ADEA was that the school is the "front porch" of the university. There's much more community-based education going on out there. It used to be that all clinical education was conducted inside the dental clinics of the school. Now much more of it is being provided in settings outside of the dental school—after students have shown basic competency—in community health centers and clinics, nursing homes, and other kinds of places.

ID: Let's talk about the students for a minute. ADEA administers the student application service. What are the trends right now in numbers and quality of the applicant pool to dental schools?

RV: We are enjoying a tremendously robust applicant pool. There are 2.5 applicants for every first-year slot in dentistry, and 2.3 applicants per first-year slot in allopathic medicine. This may be the first time that, even though the applicant pools aren't the same size, the ratios of applicants to first-year slots is different—this is the first time that we can say, "well, if you can't get into dental school, I guess you'll have to go to medical school."

Let me give you some particulars. From 2000 to 2010, the size of the dental school applicant pool increased more than 50%, from 7,700 in 2000 to more than 12,000 applicants now. We peaked in 2007 with about 13,000 applicants, and between 2007 and 2010, our applicant pool averaged about 12,500, and it has been relatively stable at that number.

In 2000, the average overall GPA of the applicant pool was 3.2. By 2010, it had gone up to 3.35. But even more dramatic is the GPAs for enrolled students. In 2000 it was 3.35, and in 2010, it's up to 3.53. Those are very highly qualified students. While this is great news, one of the problems that it does raise is that it's easy to accept a class based solely on good GPAs and good DAT scores. One of the issues for ADEA is ensuring that both applicants and matriculated students are not just those who are good test-takers. You want to have an applicant pool and a student body that's a little more reflective and representative of the country itself.

ID: What are some of the other current demographic trends that you're witnessing in dental school application and enrollment?

RV: When I went to dental school in the 1970s, the percentage of women in dental school was under 5%. In 2000, the applicant pool was 40% women, and the first-year class was about 40% women. In 2010, the applicant pool was 46% women, and our first-year class overall was about 46% percent women. So a lot of the growth that has occurred in the applicant pool has come from the growing number of women who are applying to dentistry. Otherwise, in general, the average age of the applicants, the pre-dental majors of the applicants, those have not changed dramatically in the past decade. The geographic distribution has changed only slightly. We're seeing maybe a 3% to 5% increase in applicants from the Southeast, but that's where the demographic growth of the country has occurred as well.

ID: You alluded earlier to some ethnic diversity issues. Why hasn't dentistry been successful in moving the needle with underrepresented minorities, and are there new programs being developed to help change this?

RV: I think that what we have seen over the past 5 years especially are significant increases in the number of African-Americans and Hispanics who are applying to dental schools. What we haven't seen yet is a correspondingly proportionate increase in the number of enrollees from these groups. I think that we can attribute the growth in the underrepresented minority applicant pool to a variety of factors, including more underrepresented minorities having completed college and being ready to enter dental school. Also, the Robert Wood Johnson Foundation and the California Endowments Pipeline project have helped to not only put the dental students out into the community, but focused on recruiting underrepresented minorities into dentistry. Also important has been a large grant from the Robert Wood Johnson Foundation that we have with the Association of American Medical Colleges to support the Summer Medical and Dental Education Program.

Another initiative that ADEA has been engaged in on this front is running a group of admissions committee workshops, which is also funded by the Robert Wood Johnson Foundation. In these workshops, we go in and try to help admissions committees understand how to take what we call a more holistic or full-file review of the applicant pool. Not everyone who has been successful in college—who has obtained the high GPAs and DAT scores—is necessarily going to make a good care provider. We're interested in the entire picture a student presents. There are many things to look at when evaluating applicants other than the traditional markers for success in dental school, such as grades and DAT scores. In schools where we have conducted these workshops, we are seeing increases in the number of underrepresented minorities being accepted.

ID: Let's talk a little bit about the workforce. What are some of the latest trends?

RV: Well, there are some inescapable mathematics to deal with here. In the late 1970s, we had 6,300 dental school graduates per year. After we closed dental schools and consolidated the class sizes of some of the larger dental schools, we dropped down to 3,900 graduates per year by 1980. We're back up to around 4,800 now, but that cohort of graduates from the 1970s and early 1980s is now thinking about retirement, and there is a much smaller group to replace it. We try to educate the dentists to be as productive as they can be, but I think we're going to go through a period of time, especially while the economy continues to turn around, where we're going to see the number of dentists retiring outpacing the number of dentists entering the profession.

ID: You mentioned that several schools closed. Several new ones have opened since then, with others, we understand, in the planning stages. What's the current state of affairs for the new schools as well as the others that might be planned?

RV: Seven schools closed between 1982 and 2000. Since then, five new schools have opened and most of them have graduated students already. Right now there are four more new dental schools that have deans in place, have applied for accreditation status, and are expecting to admit students this year or next. The opening of these new schools should bring, by 2020, 5,500 to 6,000 graduates per year, which is pretty consistent with the recent ADA workforce modeling report.

ID: If we look at the workforce disparities we've been talking about, and demand for care is still a little weak in this economy, what effect do you think this is going to have on the success of any of the proposed new auxiliaries?

RV: Well, the reality is we've still got an access to care problem, and I think everyone acknowledges that. We're not trying to propose any new workforce model—midlevel provider or anything else, but roughly 25% to 35% of 310 million Americans are not getting quality dental care. So one of the things that we're seeing with the models of dental therapists that are coming out, is that hopefully, if utilized appropriately, dental therapists might allow a dental office to provide more care than it is providing now. What that means is not only could productivity increase, but also in the process of getting to that point of increased productivity, we're going to need to think about what that means for educating the dentists. If you're not doing the procedures yourself but supervising others who are providing care, those are two different things. Our focus is ensuring the quality of the education of those dentists being put into supervisory roles, and ensuring that our dental students are being educated to become leaders of the dental team.

ID: ADEA was instrumental in advocating for dental curriculum reform, through its Commission on Change and Innovation in Dental Education (CCI). How much of CCI's work is being embraced by the education community?

RV: It's really been remarkably successful in a number of ways. We have established a group of liaisons representing nearly all of the dental schools in the United States and Canada, and these liaison groups are actively engaged in the work of the ADEA CCI through their own projects that focus in their own institutions on curriculum evaluation and modification, curriculum integration, electronic patient records, problem-based learning, critical thinking skills, etc. Each year these liaisons come together to share best practices, and we're seeing how well they're integrated into the curricula throughout the country.

A survey of dental schools in the spring of 2009 asked about actions taken in relation to the ADEA competencies for the new general dentists. What was interesting was that 74% had already charged their curriculum committees to review the school's existing competencies, and another 20% were getting ready to take action. So with nearly 100% of dental schools taking the ADEA competencies for the new general dentist under consideration, we feel that we're having an impact. We're not trying to create a nationwide curriculum; what we're trying to do is facilitate best practices across the country.

ID: Another one of your initiatives at ADEA was to forge a lot of new strategic alliances for the organization. What have been the outcomes of that advocacy for ADEA?

RV: When I came into this role as executive director in 1996, there was a great deal of tension within the entire dental community. There were conflicts between general dentists and specialists, there were conflicts between dental educators and the practicing community. Also, we had gone through the experience of closing the seven dental schools and having others at risk. One of the things that I certainly noted was that the schools that closed were all private, and they all had missions that were somewhat different than the parent institution. There wasn't mission synthesis. In addition, dentistry had been somewhat isolated from the other health professions. We weren't working as closely with medicine, nursing, pharmacy, public health, particularly those on the academic side in those communities, as we might have. So as a mantra of my work early on, I took on what I call the relentless pursuit of strategic alliances, and I think that we've been really successful at engaging the practicing community at all levels. The ways ADEA interacts with the other associations now is much more positive and forward-looking. We're much more involved with higher education in general—for example, I'm a member of the Washington Higher Education Secretariat and I've been very active with the Federation of Associations of Schools of the Health Professions, a group that represents all of the associations that represent health professions from the academic perspective. I think that all of those alliances were meant to enhance the perception that dentistry is part of the higher education system, it's not just isolated on a dental-school part of the campus.

ID: In this light, where do you see dentistry being most vulnerable these days?

RV: As a profession, we are most vulnerable to external forces. There is a perception out there that there's an access to care problem in dentistry, and if we can't find an answer to the problem ourselves, governments and foundations are going to find answers that we may not want. So I think that all of us in the dental community—on the practicing side, on the education side, on the research side—everybody needs to get together to find solutions for the future that we develop and implement instead of having others impose their answers on us, which may not be in the best interest of our patients or our profession.

ID: If you could change one thing about dental education in the United States, what would it be?

RV: More research would be high on that list. The National Institute for Dental and Craniofacial Research distributes a large amount of money to support research, and we've got a number of corporations that are supporting research and development, but I think that we need to ensure a robust research foundation to our profession. Allied with that is addressing the faculty shortage, and finding ways to ensure that we have a talented faculty that is educated as academicians in appropriate ways for each type of faculty position for the future.

ID: You give a lot of commencement addresses at dental schools. What kind of advice about the profession's future are you giving today's graduates?

RV: What I focus on is the fact that in being given this degree, you are being given an incredible opportunity that very few others in this country are given. You're one of only 5,000 people this year who are going to be eligible to get a license to practice dentistry. That's a huge responsibility. What you need to do as a young dentist is understand that your license to practice dentistry is a right and a privilege. You need to be part of the answer to the challenges that we're going to face in the future, including access to care, evidence-based dentistry, the introduction of new technologies. All of these things you need to take responsibility for, and not just sit in your operatory and treat patients. You need to be ready for a lifetime of learning and using the critical thinking skills that you were taught during your 4 years of dental school.

About Dr. Valachovic

In addition to his post as Executive Director of ADEA, Dr. Valachovic also served as the Executive Director of the International Federation of Dental Education Associations (IFDEA), which represents eleven associations of dental schools and educators throughout Asia, Africa, Europe, the Middle East, North America, and Central America, and also as the President of the Federation of Associations of Schools of the Health Professions. He is a member of the Washington Higher Education Secretariat. Previously he was an associate professor at the Harvard School of Dental Medicine, and served there as Dean for Clinical Affairs, Dean for Government and Community Relations, and Director of Postdoctoral Education. Dr. Valachovic has also served as Chief of the Dental Service at the Harvard University Health Services, and has served on the boards of three foundations and a national museum.