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Dominick P. DePaola, DDS, PhD
Dominick P. DePaola accepts the Gies Award for Outstanding Achievement as a Dental Educator. Dr. DePaola was one of nine recipients of the prestigious prize at the 2009 ADEA Annual Session and Exhibition.
The president emeritus of The Forsyth Institute talks about what it was like to lead one of the most prominent dental research organizations in the profession.
INSIDE DENTISTRY (ID): How did you first become interested in dentistry, and what kind of key challenges did you face?
Dominick P. DePaola (DD): When I was growing up in New York City, I had the benefit of having parents who wanted their son to become a doctor, and they pushed me toward studying medicine or dentistry. I started my career in medical school, in Bologna, Italy, which was interesting. My parents were living in Brooklyn, and I had expected to be in Italy for a number of years. Unfortunately, my father became very ill, and couldn't sustain my being abroad. Which is fine—you have to do what you have to do.
When I looked at some other alternatives, dentistry seemed to me to be the most exciting possibility. I had some friends who were in the business, so to speak, and they really encouraged me. That's how I became interested. So I came back, and decided dentistry is probably a better career for me. Because, as you know, dentistry has one tremendous advantage in that you can graduate from dental school in four years, and if you pass the licensure exam, you can practice or do whatever you want. The other profession in which I was interested—medicine—is a much longer journey.
Then when I got into dental school, I really became interested in the profession, because I ended up being one of the people serving as a liaison for the dental school to the American Dental Association. I got caught up in the whole area of dentistry and where it was going in the future.
ID: You've had a long and quite varied history in the dental world: dean of several dental schools and president of Forsyth, the research institute. Which part of your background do you think had the most influence on you, and how did it shape your perspective?
DD: First was the college I graduated from—a small liberal arts college in New York City called St. Francis College. They instilled in us the importance of really understanding critical thinking. They also imbued us with these wonderful principles of not only learning, but also how to integrate our learning with our faith, as well as with the kinds of careers that we wanted to pursue. Essentially, they made it clear that we had a lot of opportunities ahead of us in life, and one of them could be caring for people. So that experience pushed me into thinking about what kind of profession I wanted to go into.
Then, when I was a resident at Beth Abraham Hospital, a chronic disease hospital, the consulting neurologist at the time was the now-famous author Oliver Sacks. He created the L-dopa treatments for patients with postencephalitic Parkinson's disease—this was featured in the movie “Awakenings.” This was really fortunate for me, because I was the only oral medicine resident in the hospital. Therefore, I did all the rounds with him, and I treated every single one of those patients. That experience fueled me to look beyond just practicing—which is a wonderful thing to do, of course, but I wanted to do something more than that. Sacks and another colleague (whom I believe was the medical director of the entire hospital) said to me, “You know what you need if you really want to go into academics and do research? You need the union card.” Frankly, I didn't even know what the union card was—it's a PhD. These people influenced me a great deal, in terms of what academics can do.
ID: In your opinion, what barriers, other than language, impede more international research and education collaboration?
DD: What I really think impedes collaboration is the whole area of uneven education systems across the globe. There are some very fine universities all over the world, obviously, and a lot of great research takes place. But in terms of universities and their requirements, particularly in our field, they're really uneven.
People go into those partnerships and collaborations with an almost jaundiced, non-trusting view, and we have to sort of work our way through that—which is a lot of effort. Therefore, what I think happens is that people tend to gravitate toward those they know, and they end up staying more at home, so to speak. However, there have been a number of initiatives over the years that have really opened up this area. One is the program originally called Dent Ed, where they tried to fashion—and it's still working—an international curriculum set of principles to be applied across the globe. That program has made a big difference.
People are thinking a little differently about those kinds of collaborations and what they could mean. Also, science knows no boundaries. If somebody makes a discovery in the Czech Republic, as long as the science is good, it can have applications anywhere in the world. I see more and more people collaborating internationally on all kinds of scientific frontiers. Also, I believe more people are beginning to understand that countries like Scandinavia, especially in our field of oral health, led the world for a long time in the prevention of oral disease. So we have lessons to learn from them—maybe they got it right.
I think collaboration stimulates us to seek some common ground. In fact, I have had an opportunity, since I was the dean of two Texas schools, to spend a considerable amount of time in Mexico, building international programs with my Mexican colleagues and neighbors. It's amazing the kind of things you can envision while you're in an institution that has a different mindset than your own.
ID: How does the area of nutrition as it relates to oral health and disease fit within the dental curriculum and the lifelong learning needs of today's dental practitioners?
DD: I've spent my career on this—I could talk about it for hours. The truth of the matter is, this area has been deemphasized in the undergraduate curriculum. And that's unfortunate, because the future of our profession, as well as the future of medicine in general, is really related to chronic disease—that's what's emerging now as the 21st century health challenges. Nutrition has a role to play in a lot of oral diseases—not only caries, but also periodontal disease, because of its influence on the immune response. Nutrition has a great influence on inflammation, and also on the major problem that society faces now, which is obesity. For the aging population, whether they have intact dentition or not makes a difference in how they chew and what kind of nutrients they get. In addition to what I've already mentioned, nutrition has a great role to play in the development of oral tissues, and even in preventing some craniofacial anomalies such as cleft lip and palate.
Also, in my view at least, the whole issue of nutrition underpins the increasing necessity to deal with prevention of disease. Prevention is where the future is. Frankly, if we don't start with nutrition, I'm not sure where we should start, especially for chronic diseases. I think we need to integrate nutrition more fully in the curriculum: It needs to be not just a part of the nutritional biochemistry course, but integrated in other programs and courses. It has to be a part of the clinical assessment that students do on patients.
The problem has always been that there are dentists and physicians who believe in nutrition, and sometimes they've translated these beliefs into less-than-credible ideas of what nutrition can do. Nutrition really isn't a magic bullet; it's a way of feeding yourself so that you get the right nutrients at the right time.
It's important that for the lifelong learning needs of practitioners, they have to be—I'd say—reeducated about what nutrition is these days, relative to when some of us graduated dental school. Frankly, I thought nutrition was the most boring course I'd ever taken, because all it dealt with was sugar and cavities—but nutrition is way beyond that now. To me, it's really underutilized and underemphasized. We have to start using it as an integrative science—to combine the principles of nutrition and basic sciences with clinical practice. Today the science of neutagenomics portends an entirely new approach to nutrition and personalized preventive medicine.
ID: Is there an increased emphasis on nutrition by individual schools, or is there more of a macro movement toward a realization of adjusting the curriculum?
DD: I wish I could tell you it was a macro movement, but I don't think it is. I think it's individual schools and individual programs. Part of the problem we've always had with nutrition is that we don't train enough people—particularly people with oral health backgrounds—to go into the field. So it's been one of those situations where there's limited, let's say, qualitative faculty who can deliver this science. At some schools, they can tap into the great resources in their health science centers, where usually there's a community of bona fide nutritionists, nutritional biochemists, or dieticians. However, we have not been growing our own, and it's one of the training programs that, frankly, NIDCR doesn't get a lot of call for. That's unfortunate.
ID: When you were at Forsyth, there was a lot of cutting-edge research going on. What new discoveries can dentists expect in the next 10 years or so, and how will they affect day-to-day practitioners?
DD: There's no question that was maybe the most exciting place for research I've ever worked, because scientists are always caught up in breakthroughs. It was not unusual to have conversations about exciting new findings, and we had the benefit of seminars there all the time.
I don't have a crystal ball about what we can expect in the future, but I think there are a couple of real possibilities. One is the area of salivary diagnostics—there's no doubt that's going to continue to grow. In fact, it's a broader field than just salivary diagnostics; it's basically oral fluid diagnostics. We're trying to create molecular fingerprints, so that people can really participate in personalized medicine. Simply explained, you could compare your fingerprint (normal versus disease state) and try to figure out how to return to the normal state. It's an unbelievably explosive and exciting field, and it's based on the findings from the great genome project, which continues to grow.
Also, we will see a number of new technologies coming out of the nanotechnology field. Tissue engineering regeneration will become even more prevalent than it is now. When I was at Forsyth, we had a program to try to regenerate a tooth. There's still people working on that, and every day they get closer. Scientists at Massachusetts General Hospital and many other institutions across the country are creating novel ways to regenerate a host of organ systems, including livers and kidneys. The regeneration phenomenon is astonishing. It won't be too long before somebody will figure out how to regenerate tissues to make a real tooth. Even when we were doing that at the most fundamental level at Forsyth, the phone used to ring off the hook in my office with people asking if they could be on the list to get a tooth like that rather than through traditional tooth replacements such as implants or prostheses.
ID: What about a caries vaccine?
DD: That was next on my list—I think it's still viable. There's no doubt that one would work. The biggest problem we have right now is convincing people to fund a vaccine for a non-life-threatening disease. I think that's a problem that some in the industry have created. Not just industry, even NIDCR has had that as one of their positions. However, there are other diseases, like mumps, that are not life-threatening, for which we have vaccines. I think that whole area needs to be rethought. Frankly, the problem has been that industry—which really needs to fund this kind of activity because of the extensive clinical trial testing—hasn't been willing to make that investment.
I believe we're going to see more and more vaccine biology moving in that direction. It may not be a vaccine in a traditional sense; it might be more of a passive immunity vaccine. But whatever it is, it's definitely on the horizon.
ID: Could you describe the award-winning community-based school oral health initiative that Forsyth also developed?
DD: That's really what Forsyth is about—the official name is the Forsyth Dental Infirmary for Children. During the first 50 years, they've treated approximately 500,000+ children for free. Over time, they realized that all the disease in the population couldn't be treated away. Therefore, Forsyth morphed into a great research institution, but somehow it lost its way a little bit by downplaying the treatments for children. Of course, society has changed over the years—children can't just be bused into schools any more, the way they were around the turn of the century.
When I arrived at Forsyth with a number of my colleagues, we decided to beef up the health program for kids. Essentially, we created a school-based community oral health program, delivering preventive services to children in their own setting. It started out very simply—brushing, flossing, sealants, fluoride, and education. We involved the school nurses, and we got informed consent from the parents. Then it caught on—the community, parents, and teachers all liked it. It didn't take very much time, traveling to the schools to get it done. Fortunately, Forsyth gained some financial support for that program.
Now it's expanding into its next phase. They have a new director who's taking it in an even more exciting direction. It really is a school-based oral health prevention program designed to target children who are underserved, whom we identify through their participation in school lunch programs. What's made it really amazing is that we've been assessing their health on a longitudinal basis to some extent, although that's really difficult to do. But we've been pulling out some longitudinal data to try to Figure out, if we intervene, what does it mean as the children get older? Does it actually reduce caries? And it sure does.
ID: In one of your papers, you wrote about revitalizing education based on new principles. Could you outline your vision for us?
DD: I think the vision is that students have to become critical thinkers, lifelong learners, and problem solvers. We need to integrate sciences—and not just basic science, by the way, but also behavorial, epidemiology, and population-based science. We have to understand how to apply science-based evidence to clinical practice. In my view, in the future, the most important thing is to have students function as primary care providers as part of interdisciplinary health teams. The entire emphasis in a curriculum and clinical practice—and also, frankly, in the examinations—should be to assume roles in prevention, risk assessment, and early detection of disease. That's where these students should be—on the front line of those activities. It's a big-picture approach. What we have to do is create a new dental graduate, unlike any of us now, who can be prepared to practice for some unknown future. It has to be somebody who has attained different skills.
ID: In thinking about dental education, do you see changing roles for the schools with respect to lifelong or continuing education?
DD: There's no question they're going to have to increase their ability and capacity to provide lifelong learning. I'll use a parallel here—in medicine, physicians are tied to a university or a hospital somehow, or a health science center. Essentially, they can't practice any other way—for example, they need to have some kind of affiliation to hospitalize patients. One of the problems in dentistry is that there is nothing to tether the practitioner to the health science center or dental school. Therefore, we have to create ways for that to happen—for example, by designing some genuinely novel and exciting programs of lifelong learning and continuing education.
The practice-based research network (PBRN) model that's emerging now might be helpful. It includes some very good possibilities to engage practitioners in the kind of academic activities that will not only enhance their practices and give them a different mindset on how to evaluate information, but might also provide some opportunities for them to become part of the education system.
More and more of these programs are going to emerge, and there are people working on creating these new kinds of missions. I really do think it's going to grow, and I think it's necessary. The necessity for the schools and the profession to improve access to and utilization of care is another critical area where education and the profession will intersect.
ID: You're a member of the Santa Fe Group, which is a think tank for dental policy and advocacy. What is that group hearing these days when it puts its ear to the ground?
DD: Certainly the workforce is a huge issue. The geriatric and special needs populations are also major concerns. In addition, education reform and community-based education are important. I also think trying to understand community support, and gain community capacity for people to help themselves is an area that the group has been involved with. We're also trying to make some inroads in health literacy.
Then there's another program that we're probably going to roll out next year, called Connect the Docs (I have to credit Raul Garcia with the name). I think it's a futuristic concept—we want to create a situation in which patients will ultimately understand that the comprehensive care that they're going to achieve has the necessary input of all different kinds of healthcare professionals. One of the problems is that, although we've received a lot of good comments about interdisciplinary and transdisciplinary care, we don't really see it operationally—even in the Federally Qualified Health Centers and the community health centers. We need to create transdisciplinary education programs and clinical models, in a sense connecting all the different docs to provide the assessment, prevention, care, and evaluation of a population that's changing demographically.
ID: What kind of advice are you giving new graduates?
DD: Train to be careful, critical thinkers. They have to understand lifelong learning and be prepared for the unexpected, because change is imminent and continuous. They also need to really care about the health of the public. In addition, they need to be the type of person who understands science, who is willing to address changing issues and embrace new ideas—beyond the skills and knowledge that they graduated with.
And finally, I think they really need to embrace the idea of being part of a healthcare team. In fact, I wanted to comment on this earlier—one of the things we're missing as a profession is that we have not embraced maybe our most important allied health professional as well as we should, and that's the dental hygienist. We should be working closely with them and dental assistants—and frankly with other healthcare professionals such as nurses and pharmacists. The hygienists are so important to our profession, and I don't think we've done a good job of building a good relationship, other than with individuals in practice. But at the professional level, it's been a huge disappointment, and, I think, a missed opportunity.
About the Interviewee
Dominick P. DePaola, DDS, PhD, is President Emeritus of The Forsyth Institute. A former dean of the Dental School at the University of Texas Health Science Center at San Antonio and of the Dental School at the University of Medicine and Dentistry of New Jersey, he also served as President and Dean of the Baylor College of Dentistry of the Texas A&M University System. Currently, DePaola is Academic Dean at Nova Southeastern University College of Dental Medicine. The first person to have served as the President of both the ADEA and AADR, DePaola is a frequent consultant to the National Institutes of Health, the food and pharmaceutical industry, the American Dental Association, and the American Society of Nutrition (ASN). In 2001, he was awarded an Honorary Membership to the American Dietetic Association (ADA), the only dentist ever to receive this honor. He has also been the 2009 recipient of the William J. Gies Award for Outstanding Acheivement as an educator.