What’s Going on in Dental Schools?

Anne L. Koch, DMD
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Background
For the past 2 years, I have had the pleasure to travel around North America presenting endodontic courses. The majority of these courses have a hands-on component, and I thoroughly enjoy teaching endodontics to young dentists. However, there is a very noticeable trend that should be of great concern to the profession, and that is the apparent lack of clinical endodontic experience for many students while in dental school. Many young dentists I speak with have completed fewer than 3 clinical endodontic cases (while in dental school), and it is not unique to find a recent graduate who has never completed a clinical case. This does not even meet the minimal CODA requirements! This problem is strictly an undergraduate issue, as all postdoctoral endodontic programs are doing well. In addition, this does not apply to all dental schools, but it does apply to a significant number of them. So what’s going on here?

A Lack of Clinical Experience in Undergraduate Endodontics
Running a dental school in the year 2020 is not an easy task; in fact, it is enormously challenging. The budgets are huge, the incomes generated from both clinical and research sectors vary greatly, and the curriculum itself seems jam-packed with all kinds of corollary courses. This op-ed article is not designed to address all these myriad issues. Rather, let’s concentrate on the lack of clinical endodontic experience of a typical undergraduate dental student and how recent graduates can improve their endodontic skills after graduation.

It has been my experience that many dental schools are accepting far too many students to allow for a thorough clinical experience. In fact, numerous dental schools have developed programs or externships that “ship out” students to environments where they can do very little. An example would be a third-year dental student “observing” in a practice setting but not having the clinical skills nor the authority to do much. It also must be noted that some externship programs can be very beneficial to students: for example, by providing the opportunity to gain clinical experience. Unfortunately, there seems to be great variation among these programs, and sometimes their merits are questionable. However, what all these programs do achieve is that they get the students out of the school so others may be accepted, and more tuition money is generated.

New Technology Is Not a Panacea
Furthermore, new technology is sometimes being promoted as the magic elixir to make up for the lack of clinical experience. In my opinion, this is also misleading. Yes, of course I can embrace new technology, but the sim-lab manikins don’t grab the handpieces and don’t have bleeding problems, and, most assuredly, getting good anesthesia is not a problem! My suggestion is to not worship at the altar of technology. Going forward, the key is to combine the latest technology with long-established evidence-based principles. This is how we move the specialty of endodontics forward.

Some Relevant Observations
My willingness to bring light to this problem is not based on animus directed toward any particular school or individuals. This is just what I am seeing across the country when I do hands-on endodontic courses, and it is a common refrain among older dentists after they have hired recent graduates as associates. I honestly believe that all the dental school deans are trying to make the education experience in their respective dental schools the best possible for the students. Perhaps there are some new solutions to this dilemma of reduced clinical experience for undergraduate dental students.

I have heard both school administrators and students complain about the lack of patients. My response is hustle! For example, many non-surgical endodontic cases already exist in the Panorex films of dental school patients. I used to have my second- and third-year endodontic residents course in the main clinic, examining patients’ Panorex radiographs, and in doing so, the students would discover many endodontic cases, both non-surgical and surgical. Students routinely protect their patient charts as they are concerned that, if other disciples (such as endo) commence treatment, they may somehow lose the patient. This is a major concern, especially if the patient has a prosthodontic treatment plan in place that will help the student meet his or her graduation requirements. Obviously, reaching out to hospitals, community clinics, and other outreach programs can also be beneficial in generating more patients.

I also had a very simple rule with my postdoctoral residents. Before they could take over an undergraduate’s endodontic case (a retreatment or surgical case, for example), they had to find a replacement case for that student. When I first mentioned this to my residents, they couldn’t believe that I created this rule. Consequently, they questioned me. I had a simple reply: “They also pay tuition!” Furthermore, it usually takes an endodontic resident only 15 to 30 minutes to find a replacement case in the emergency area. But what happens when a student graduates from dental school and they have had minimal clinical experience in a discipline such as endodontics? The answer is to take quality continuing education courses that include a realistic hands-on component. Unfortunately, these are becoming more difficult to find, and they do involve another tuition.

Maximizing Hands-on Postgraduate Courses in Endodontics
Assuming the recent graduate finds an appropriate hands-on course in endodontics, how can he or she maximize his or her experience? There are 4 suggestions that come to mind. The first suggestion is as follows: If you are taking a hands-on course at a large dental meeting, please attend the lecture that discusses the technique, whether it is the day or morning before your hands-on. Recently, I conducted a hands-on session at a major dental meeting, and the good news was that it was completely sold out. But the bad news was that only one person had attended my lecture the previous day. You save significant time and get much more from a hands-on session if you make the effort to attend the accompanying lecture.

The second suggestion involves real teeth. If at all possible, try to bring sterilized, extracted, accessed teeth. Please check state regulations concerning this issue, but if you are in a location where you can bring extracted, sterilized teeth, they add much more value to the clinical experience. There are some good model teeth available, but there is nothing like a real tooth for learning a new endodontic technique.

The third suggestion involves the simple advice of spending 15 minutes the evening before the hands-on portion reading up on the technique and materials that you will be using the following day. This type of advance preparation will maximize your hands-on experience.

My fourth and final suggestion is to bring with you the endodontic shaping system or technique that you are currently using so that you may compare it to the new system that is being touted at the hands-on session. This makes great sense to me and will help you make an informed decision.

CLOSING COMMENTS
The lack of clinical endodontic experience while in dental school is very disturbing. Friends tell me, “Annie, get over it! It’s just like ortho!” I strongly disagree. In orthodontic treatment, if someone loses an elastic or breaks a wire, this is principally an inconvenience. However, if a recent dental graduate sees a patient with cellulitis in the canine fossa region that obliterates the nasolabial fold, which is a real dental emergency, the clinician treating this patient needs to be both experienced and knowledgeable.

In summary, we can say that the reduction in clinical experience at dental schools presents a significant challenge. We need to find ways to allow students to gain more clinical expertise and experience in all phases of dentistry. Concerning endodontics specifically, more of an effort should be made in teaching endodontics at the undergraduate level, not just focusing on postdoctoral programs. The dental students deserve this; the individuals paying the tuition bills deserve this; and, ultimately, our patients deserve this.


Dr. Koch received both her DMD degree and Certificate in Endodontics from the University of Pennsylvania. She is also the founder and past director of the Postdoctoral Program in Endodontics and Microsurgery at the Harvard School of Dental Medicine. Following her clinical and academic career, Dr. Koch formed her own successful technology and development company, Real World Endo, of which she was CEO and President. Dr. Koch is the holder of multiple patents and the author of more than 150 articles in her specialty field. She maintains a faculty position at the Harvard School of Dental Medicine. She can be reached via email at annelaurenkoch@gmail.com.

Disclosure: Dr. Koch reports no disclosures.

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