The Evolution of Dental Education
Francis G. Serio, DMD, MS, MBA
Dentistry and dental education have changed immensely since 1976 when I entered school. Many of these changes were deliberate, whereas others occurred due to outside forces. When I was in school, we labored under the weight of clinical "requirements" that mandated we complete a specific number of procedures in each discipline. As far as I know, there was no particular science behind the numbers beyond the faculty's arbitrary determination of what procedure necessary to effectively train new general dentists. In the 1990s, clinical education gravitated toward the development of competencies, and the idea of requirements became a banished concept among the dental cognoscenti. The thought was that once a student successfully demonstrated competency, further repetition of a specific procedure was not necessary. This concept has always bothered me. I believe, perhaps incorrectly, that clinical dentistry is a psychomotor discipline that requires repetition to master. Golfers do not stop practicing after hitting one drive down the center of the fairway, but dental students often stop practicing a procedure after successfully challenging a competency/skills assessment exam, and this is tacitly supported by clinical faculty.
A side effect of this, as well as many other curricular and economic changes, is that students perform many fewer procedures than they did under the requirement-based system. Are students better trained under the competency-based/reduced experiences system than they were previously? No one knows for sure because there is no comparative research. But for the past 20 years or so, dental educators have maintained that this is a better system. Another blow, in my opinion, to the comprehensive clinical training of dental students is the adoption of the general dentistry model by many programs. To be sure, some schools can do this well. However, it has been both my direct and anecdotal experience that in some schools the specialties are marginalized. Most faculty members of programs employing the general dentistry model are primarily restorative dentists. Students may have some contact with the specialties, but it is much less than in the past. One untoward consequence of this is that dentists graduate with less of an understanding of when to refer patients for specialty care. Another is that students develop less of an appreciation for what each specific discipline can do to save natural teeth. Having multidisciplinary, super-generalist faculty members is a nice idea that is lacking in execution due to a dearth of these clinicians in dental schools.
For good reasons, many dental schools place students on extramural rotations for extensive amounts of time. This makes it difficult to maintain continuity of care and complete time-consuming, complex procedures on a single patient. Some schools have remedied this by decreasing the clinical expectations (ie, requirements). Other schools utilize a points system wherein students earn points for specific steps within a procedure, even if those steps are completed on different patients or outside of the mouth. In some schools, it is possible to graduate without doing a single crown from start to finish on the same patient. In others, it is possible for students to graduate having only done an endodontic procedure on an extracted tooth. Why? Because that is the way that the clinical expectation and competency systems are set up.
Another major influence is the cost of care in dental schools. All schools are under enormous financial pressure, and fees have necessarily increased. Unfortunately, it is not uncommon for a crown to cost $400 to $500 in a school program. This is still a significant discount when compared with a private practice fee, but many dental school patients would be hard-pressed to come up with the $1,500 needed for a 3-unit bridge, let alone the money needed for an implant-supported crown or other complex procedure.
All of these issues greatly affect the quality of dental education, and I have not even mentioned the impact of graduate programs on predoctoral education. With the increasing complexity of treatment modalities and the critical importance of comprehensive treatment planning, are we best serving our future colleagues and the public at large by diminishing clinical training? I don't think so.
About the Author
Francis G. Serio, DMD, MS, MBA, is a diplomate of the American Board of Periodontology and maintains a private practice in Bayboro, North Carolina.