The dental profession is experiencing growth and change in many areas, and the methods used to educate both dental students and active practitioners must adapt to new technologies, materials, clinical techniques, and research findings. One dental school that is taking a bold leap forward in terms of its teaching methods and curriculum objectives is the University of Maryland Dental School. To learn more about the university’s new approach and the reasons why dramatic changes are being made, Dentistry Today conducted an exclusive interview with Christian S. Stohler, DMD, Dr. Med. Dent., dean of the school, Mark Reynolds, DDS, PhD, chairman of the Department of Periodontics, and Ashraf Fouad, BDS, DDS, MS, chairman of the Department of Endodontics, Prosthodontics, and Operative Dentistry.
Christain S. Stohler, DMD, Dr. Med dent.
Mark Reynolds, DDS, PhD
Ashraf Fouad, BDS, DDS, MS
Dr. Stohler: Although small changes in dentistry have been observed in the past 10 years, groundbreaking progress has been made in related areas that will shape the future of dentistry in the years ahead. It is not what has happened within the field of dentistry within the past 10 years that defines the trajectory of the dental discipline; it is the influence of powerful external pressures outside dentistry that have emerged in the past 10 years that will define the course of our profession.
Dr. Reynolds: From my perspective, the most significant changes that have emerged in dentistry relate to dental implants, digital radiography, and evidence-based dental practice. Dental implants have dramatically changed the way we treatment plan and enhance our ability to meet the needs of the community. Advances in digital radiography and computed tomography, for example, permit more accurate diagnosis and treatment planning. Evidence-based practice reflects a significant paradigm shift in dentistry and medicine. The expectation is that clinicians will provide care based on a careful integration of clinically relevant scientific evidence, together with their clinical expertise and the patient’s treatment needs and preferences.
Dr. Fouad: In the last 10 years, there have been major advances in the hierarchical classification of evidence and the promotion of the concept of evidence-based practice. There have been a number of major innovations in the areas of implant dentistry, bonded restorations, and fiber-reinforced composites that have made a significant impact on the practice of dentistry. We have a much better understanding of the relationship between oral and systemic diseases. In the field of endodontics, there have been numerous technological advances that have allowed clinicians to be more efficient and render more technically precise treatment that is biologically based and less traumatic for the patient. Examples include the advent of multifrequency apex locators, various landed and nonlanded rotary instruments, numerous antimicrobial irrigants, thermoplasticized root canal filling systems, digital radiography, intraosseous anesthesia, and bonded resin-based root filling materials, among other technologies.
However, perhaps more important are the advances in our understanding of the disease processes that we are treating and the variables that are significant in determining treatment outcomes. We are starting to learn more about the association of endodontic pathosis and systemic disease. Endodontic and periodontal diseases share a lot of commonalities, including similar microbial flora, inflammatory changes, and host responses. Moreover, endodontic pathosis can result in severe disseminating infections if left untreated.
Finally, the last decade saw a tremendous increase among practitioners as well as in dental schools in the appreciation of the importance of electronic oral health records. Clinicians see the tremendous value in effectiveness, efficiency, and tracking that electronic systems can provide. Furthermore, the understanding of the inter-relationship of oral diseases, as well as their relationship to systemic diseases, is greatly enhanced with the use of electronic systems. Advances in network architecture and speed, security of digital resources, input devices, and robust databases are making this a reality.
Dr. Linda Otis takes 3-D panoramic images of a young orthodontic patient.
First-year dental students Justin Whiting and Zahra Omar at work in the school's Clinical Simulation Lab.
The advanced simulation lab gives students a realistic setting to hone their pre-clinical skills before transitioning to live patients in the clinics.
View from the school's main atrium. The new environment provides a welcoming atmosphere for everyone who visits and works in the school.
DT: Patients are increasingly looking for more aesthetic solutions. Are you poised to accommodate those needs?
Dr. Stohler: Comfort, convenience, and quality of life will increasingly turn out to be significant considerations for the segment of the population that has access to care. In fact, lifestyle-altering interventions have already transformed the practice of medicine in significant ways. One can assume that parallel societal pressures by those who can afford it will influence the manner by which dental care will be delivered. Comfort during the actual dental procedure is only one of the many requests that will be dictated. Dental education has to be sensitive to these emerging trends.
Dr. Reynolds: Major advances have been made in the areas of implant placement, implant site development, and periodontal plastic procedures to optimize aesthetic outcome. Tremendous clinical progress, for example, has been made in strategies for immediate implant placement and restoration that predictably preserve natural gingival contours. Surgical microscopes have been increasingly used to perform periodontal plastic procedures to enhance the predictability of aesthetic out-comes. We also are involved in ongoing clinical research programs examining dental implants and periodontal and bone regeneration.
Dr. Fouad: There are numerous advances in dentistry today in the area of aesthetics. In fact, cosmetic dentistry is a hot area because of the high demand for cosmetic procedures. At Maryland, we are in the planning phases of establishing a Center of Excellence in Esthetic Dentistry. This effort involves faculty recruitment, shaping our curriculum, and planning continuing education programs in aesthetic dentistry.
While there are trends that show a reduction in dental caries in industrialized countries at present, people are becoming more active in sports and other physically demanding activities. These activities result in an increase in the incidence of accidental trauma to teeth. We see a fair number of fractures or luxations of anterior teeth, as well as discoloration that follows traumatic injuries, particularly in a large metropolitan area like Baltimore. We emphasize in our curriculum realignment and splinting of teeth and internal bleaching, as well as the use of contemporary bonded restorations to repair fractured teeth.
DT: How are you making the transitions from classroom to clinic to professional more seamless for students?
Dr. Stohler: It is critical that we think of better strategies to transition our dental students from the academic teaching environment into the real world of dentistry. Currently, our dental students are forced to transition on their own. We need to allow the private sector to interface with dental students and engage representatives of academic disciplines in healthy discussions with their real-world colleagues. We also can adopt a hospital model in dental schools that is no longer managed by the academic disciplines, similar to the relationship between a medical school and its affiliated hospital—a step undertaken at Maryland. Clearly, the academic community needs to seriously face the societal expectation of “softening the landing” of our graduates.
Dr. Reynolds: We are facilitating the transition from classroom to clinic by incorporating technology-based clinical experiences that develop skills and reinforce key elements of the curriculum. Greater emphasis is also being placed on interactive, small-group, case-based discussions on evidence-based dental practice. The goal is to center learning on the student using technology to facilitate learning on demand, within an environment and at a time chosen by the student. In periodontics, the curriculum is also being modified to include computer and Web-based interactive learning modules that focus on the classification, diagnosis, and treatment of periodontal diseases. A clear educational challenge will be to develop a dynamic curriculum that is responsive to the increasingly rapid advances in diagnostics and therapeutics.
Dr. Fouad: In the last few years, we have introduced simulation exercises to students as an intermediary stage between preclinical exercises and clinical practice. These include operative exercises on typodonts with teeth that have simulations of enamel and dentin, as well as areas of dental caries. Most recently we have introduced exercises in endodontics in which the students treat model teeth mounted in mannequin heads, with the dental dam in place, and with the same aseptic technique they are expected to use on patients.
In the new dental school building, we have a state-of-the-art simulation facility. This will introduce the students to this simulated practice at an even earlier stage and allow most of their practice to mimic direct patient care. The simulation facility even has the same computer hardware and software—including digital radiography—that the clinics are using. All these changes allow us to make the shift from preclinical to clinical education much more seamless than it has been in the past.
DT. Technology has changed every profession, including dentistry. How are you managing to stay ahead of the curve?
Dr. Stohler: By believing that I can do it!
Dr. Reynolds: The doubling time for scientific information is short. Keeping ahead of the curve is arguable, but the effort nonetheless requires a significant investment of time, including ongoing participation in research meetings and continuing education courses in clinical practice. An increasingly greater reliance also is placed on agencies and services such as PubMed, a service of the National Library of Med-icine and the National Insti-tutes of Health, which enable rapid access to the scientific literature. Efforts to stay abreast of the technology also have been facilitated through ongoing seminars and in-service training programs, with the latter often sponsored by corporate partners.
Dr. Fouad: There are many new technologies available today in dentistry. Indeed, it is difficult to stay current with the constant stream of innovations that find their way to the dental marketplace. We try to stay current through methodical and systematic review of the literature, which we do routinely in our postgraduate programs and have introduced in our senior year predoctoral curriculum. We also have significant interactions with vendors of dental supplies and equipment, attend exhibits at national and international meetings, perform evaluations of selected technologies that would benefit our patients, and interact with colleagues in other dental schools to learn of novel ways of using technologies and incorporating them into the curriculum.
DT: What about those who graduated 20+ years ago? How are you keeping older professionals connected to the latest technologies?
Dr. Stohler: If I can do it, anybody can!
Dr. Reynolds: We are developing continuing education programs that focus on contemporary clinical concepts and skills that incorporate the underlying scientific basis for these procedures. Two basic strategies are being adopted to keep our graduates abreast of emerging technologies. The first strategy is through clinical programs that permit laboratory and clinical training, including patient care. The second approach is to maximize the educational promise of the Internet through the development and delivery of Web-based courses that will enable graduates to access knowledge and to learn in new and different ways.
Dr. Fouad: Fortunately, the state of Maryland is among the many states that have a continuing education requirement for renewal of the dental license. Our dental school is now in the planning phases for capitalizing on the technologies and space available in the new building to provide a number of continuing education courses for community dentists. We also have a ro-bust Dean’s Faculty program, in which a large number of dentists in private practice teach in the school on a part-time basis. They bring in their expertise and time, but they also have an opportunity to attend seminars, explore new technologies, and participate in shaping our new educational strategies.
DT: How has digital (versus pneumatics) changed the standard of dental education?
Dr. Stohler: Digitally controlled processes turn “checkers” into smart teachers. At Maryland, we are at the door-step of abandoning 911-teaching styles that consist of checking and fixing-type interventions. For example, smart data loggers will allow tracking of instrument use and sequencing. Individual competency enforcement and procedure authorization will be implemented by control codes to respective instruments, etc, moving toward an individualized, competency-driven learning environment that is quite different from the lockstep thinking that has dominated dental education for the past 167 years. For the first time in dental education, we will have a control system by which personal achievements and not class membership drive the progress of the individual student. This is the single most exciting thing ever to happen in dental education.
Dr. Reynolds: Digital technologies have affected multiple facets of clinical care in dentistry. The most notable example is digital radiography, which has profoundly affected clinical care by reducing patient exposure to radiation and enabling more accurate diagnostic evaluation and treatment planning. Other imaging technologies, for example, computed tomography, provide 3-D images of sufficient accuracy to permit the fabrication of surgical guides for placement of dental implants.
These same imaging technologies also have advanced research and teaching. This technology, for example, enables the precise dimensional analysis of bony defects for the fabrication of grafts and volumetric analysis of new bone formation, which have advanced research in tissue engineering. Three-dimensional imaging and software systems present new opportunities for the dentist to plan, execute, and assess the outcomes in patients undergoing cosmetic and reconstructive procedures.
Dr. Fouad: The introduction of digital technologies in the dental office is reshaping the model for patient care, teaching, and research. We currently have dental chairs that communicate with a computer-based management program to track data that include optimal patient positioning, the number of times that handpieces and other unit equipment are used, as well as speed, torque, and auto-reverse/auto-forward functions of the electric handpieces. This results in a reduction of equipment in the operatory, because the electric handpiece is able to provide the entire spectrum of speeds and features needed for restorative dentistry and endodontics. The unit also provides ultrasonic capabilities for periodontics and endodontics, a curing light, and intraoral imaging. This all serves the patient better, as it facilitates the delivery of dental care. It also allows the faculty to record and evaluate the actions and behavior of dental students during the delivery of care. Therefore, there is now the opportunity to emphasize and assess not only the product that students deliver, but also the process by which they provide the care. This model of education emphasizes principles of infection control, aseptic technique, ergonomics, and patient-doctor behavior. Finally, the presence of a comprehensive oral health record that communicates with dental chair and dental unit actions provides a powerful tool for research into basic treatment outcomes as well as optimal educational and practice strategies.
DT: What do the next 10 to 20 years hold for the profession?
Dr. Stohler: More than ever, the next generation of dentists will demand integrated solutions that capitalize on the digital revolution that has influenced their learning and actions since the introduction of the IBM PC in 1982. Air-controlled and pneumatic systems will rapidly become obsolete and will be replaced by digital motors, affecting all processes in dentistry. The digitalization of dentistry will fire up the excitement in the discipline, creating momentum as we have seen with the fluoridation efforts of the 1960s, where the dental discipline realized the largest public health impact ever in medicine.
However, it is not only the digital revolution that will electrify dentistry. The paradigm shift in medicine that calls for redirecting care from average to personalized medicine, enabled by huge advances in fundamental understanding, including the genome project and biotechnologies, will change the course of the dental discipline. Many surgical procedures will be replaced by medical interventions that are selected on the basis of unique molecular fingerprints. The line in the sand between dentistry and medicine will be redrawn—close realignment between these professions is in the
Dr. Reynolds: The future prom-ises to usher in a new generation of technologies for the profession in managing conditions and disorders affecting the oral and craniofacial complex. Significant advances are highly likely in genomics, im-aging, biomimetics, robotics, drug delivery, regenerative biology, and tissue engineering. Genomic databases, for example, provide extraordinary opportunity for innovations in areas of diagnostics, preventive dentistry, and therapeutics. Biological agents such as growth factors, and drug delivery systems will undoubtedly take on an increasingly greater role in enhancing ther-apeutic outcomes, such as alveolar ridge augmentation and periodontal regeneration. Gains in therapeutic efficacy, in turn, will likely enable the treatment of a broader range of patients. Finally, the interface of clinical dentistry with medicine will continue to strengthen as research clarifies the dynamic, reciprocal relationship between oral and systemic health.
Dr. Fouad: The most important short-term innovations include establishing a comprehensive oral health record, expanding magnification technologies to general dentistry, advances in diagnosis of dental caries and pulpal and periradicular disease, better 3-D imaging using cone-beam computer tomography (CT) and possibly clinical application of high-resolution micro CT, and the widespread use of dental implants for unrestorable or missing teeth and to support dentures.
In the long term, technologies are on the horizon that could revolutionize diagnostic and treatment modalities in dentistry. These include nanotechnology to deliver drugs or develop novel biomaterials; stem cells used to regenerate dental pulp, the tooth form, as well as bone; saliva as a diagnostic and monitoring tool for many systemic diseases and conditions; microarrays for rapid microbiological analyses of periodontal or endodontic pathogens; and the delivery of effective, rather than empirical, antimicrobial therapies.
Finally, in the area of dental education, advances in the areas of robotics and haptics will allow us to develop intelligent simulators for students to have a more enriching educational experience that better simulates the patients and the disease processes that they are learning to manage. This would affect not only the effectiveness of the learning process, but also the assessment of competency by licensure and other regulatory bodies.
The authors would like to acknowledge Regina L. Davis, MA, who contributed to this article.