To what extent is prevention addressed in dental education?
It is that time of the year when students are busy finishing their semester at the dental school. For first-semester students, the next five to six years will be filled with courses on anatomy, pharmacology, radiology, and all aspects of dental restorative methods and treatments. While endodontics, periodontics and oral surgery remain important, one area in dental education has seemingly increased in relevance: preventive dentistry. European and North American universities are beginning to include proper oral hygiene techniques in their dental curricula. Dental students will therefore focus more on prophylaxis, but probably not in the near future.
Since the introduction of dentistry as an academic field, the focus has naturally been on restoring damage to the soft and hard tissue. However, an increasing number of departments of preventative dentistry are studying the means and methods of oral disease prevention, the oral health status of the population, as well as knowledge, attitudes and behaviour regarding oral health. In addition, growing research in biological science and epidemiology within the last decades has enhanced understanding of disease prevention. However, some of the research on oral health and its consequences for systemic health has yet to find its way into today’s textbooks. Furthermore, preventative dentistry in the curriculum of most European universities constitutes only two credits. At British and American universities, however, some dental faculties have begun to recognise the central role of prevention.
“There has been an increase in curriculum time on prevention,” said Prof. Gary Cheung, Associate Dean and Clinical Professor in Endodontology at the University of Hong Kong’s Faculty of Dentistry in China. “A few years ago, we added about 12 hours of prevention clinic and consolidated and formed a cariology course of about 15 hours that has a strong focus on caries prevention. Throughout the dental school’s curriculum, seminars on health promotion teach disease prevention.” Referring to the situation at the University of Michigan’s School of Dentistry in the US, Dr Carol Anne Murdoch-Kinch, Associate Dean for Academic Affairs said: “We have always stressed the importance of prevention in our dental education programs. Our students have been taught the importance of fully understanding the etiology of dental disease, in order to practice primary, secondary and tertiary prevention for all oral diseases. Because this is so important, principles of prevention are integrated fully within all of our courses in our curriculum, and our students must demonstrate competency in applying these principles during patient assessment, diagnosis and treatment planning and treatment provision. Disease risk assessment is a relatively new competency introduced over the past two decades and is now taught for all the common and important diseases in dentistry.”
Education in preventative dentistry has indeed become an integral part of the dental curriculum. In 2012, researchers at the Henry M. Goldman School of Dental Medicine at Boston University published an article titled “The paradigm shift to prevention and its relationship to dental education”. In their paper, the authors remarked, “[D]espite the explosive growth in high-quality scientific evidence, it may be surprising to recognize the extent to which evidence-based preventive practices have yet to be successfully disseminated and fully implemented”. Apart from this initial paradigm shift, a coherent transition to a true prevention-based practice has not been realised. For evidence-based preventative approaches to become reality in the long term, the dental education community would need to increasingly use technology transfer and disseminate new practice models. Clearly, the surgical model of corrective and reparative treatment will not switch immediately to an approach that concentrates on diagnosis, early intervention and prevention, but this new paradigm will eventually be accepted and recognised as part of daily practice in modern dentistry. According to the authors, “The dental education community is ideally poised to take a leadership role in shifting the practice paradigm to prevention.”
Prevention in European education
Prevention has been an integral focus of the Association for Dental Education in Europe. Already in 1983, the annual meeting discussed the impact of prevention on dental education, as well as new teaching concepts in preventative dentistry. In 1990, the meeting in Budapest in Hungary discussed basic sciences in dental and medical education, as well as changing aspects of preventative dentistry in dental education. During the 2016 meeting in Barcelona in Spain in August, association secretary general Dr Maria Cristina Manzanares explained: “The future dental practitioner will play an essential role not only in the prevention of dental pathologies, such as caries and oral cancer, but also as a member of multidisciplinary teams caring for the general health of our populations. Prevention, diagnosis and treatment of global health problems, such as non-communicable diseases and rare diseases, require the competencies of dental professionals.”
A number of posters on preventative education were shown at the Barcelona event. Among these was one from the University of Bucharest titled “Changes of oral health-related knowledge after an interactive education lesson led by dental students”. It discussed the impact of dental students explaining the risk of protective factors against tooth decay and proper toothbrushing techniques to 14-year-olds. A questionnaire before and after the lesson concluded that knowledge of proper toothbrushing increased from less than 5 per cent to 63 per cent. A similar increase in knowledge was observed regarding the role of fluoride toothpaste. However, knowledge of the importance of dental appointments and the role of toothbrushing did not change significantly (82 per cent vs 85 per cent and 81 per cent vs 94 per cent, respectively). Whether this knowledge is adequate to effect behavioural change is not known.
Mechanical plaque control and change of habits
A special interest group workshop, hosted by Swiss oral health care products’ manufacturer Curaden, sought to provide answers in this regard. Under the title “A different approach: A hands-on preventive dentistry curriculum”, two speakers discussed examples of education in preventative dentistry in dental schools and, more importantly, ways of achieving long-term behavioural change in oral hygiene habits. Dr Isabel Martínez Lizán, a professor at the University of Barcelona, spoke about the necessity of oral hygiene knowledge among dental students. “We have situations when patients think that the oral health of dentists is excellent, but it is actually not. Dentists know the best tools, practise the best technique and seem to clean all their tooth perfectly, but they increasingly have gingival recession, abrasion and hypersensitivity.” One major reason for this has been the current dental curriculum, which is focused on restorative techniques. Lectures deliver the knowledge, but only a culture of self-directed learning will be successful in today’s society, said Martínez Lizán.
What does self-directed learning mean exactly? “The content of the dental curriculum should address today’s needs in dentistry. We need to have more hands-on workshops which focus on individual training. Schools should also ensure that the curriculum is based on scientific evidence and best practices. Early contact between patients and first- to second-year students should take place,” said Martínez Lizán.
She then highlighted that prevention should be applied in all aspects of dental education and include hands-on training, which has to be repeated and assessed. “Prevention needs to be trained. At university, it is important to learn clinical competencies. We have to try to find the best tools for learning and practising good oral hygiene—and this starts with the student. Academics and students sometimes do not think about their own oral health. They might not like or recommend the interdental brush just because they have never practised with it. When you learn from books, you cannot learn by touch, but once you feel it, and repeat it, you understand it.”
Currently, Martínez Lizán offers two seminars on preventative and community dentistry, which she integrated into the university’s curriculum. The courses include biofilm structure, oral hygiene tools and techniques, and patient motivation. Her students explore interdental spaces with interdental brushes and clean their own teeth and their interdental spaces. First-semester students are asked to attend the courses again in two years and examine the brushing technique of at least two patients. In her department, students have been eager to learn about prevention. “Oral hygiene is key to preventing oral disease and ensuring good oral health. Oral hygiene means mechanical plaque control, disruption of biofilm and acquisition of good habits,” she explained and added, “First, you have to do it very well before showing it to others.”
The teaching of prevention would be more effective if early clinical exposure was incorporated, Martínez Lizán continued. First-year dental students would be in contact with patients, thereby enhancing learning about health, illnesses and diseases. Whether in the classroom or hospital, these patient encounters could lead to early understanding of diseases among dental students. Through early clinical exposure, dental students could acquire a more thorough understanding of disease prevention and the promotion of health. Once students have met stroke patients, they will understand the necessity of preventing periodontal inflammatory disease from affecting the cardiovascular system or possibly also the cranial nerves. “Early contact between patients and dental students should take place. You take all students into account: from the first to the last semester. First- and second-semester students are excited to see the patient close to them, but they are also afraid. This should not be the case.”
Prevention means education
Dr Jiri Sedelmayer, the second speaker at the workshop, lectured at the University of Hamburg from 1982 until 2011. Before and during his academic career, he provided emergency dental services in hospitals. “I had a lot of patients at night, normal people such as teachers and lawyers with rotten teeth. Children were crying because of pain. As representatives of a medical field, how can we allow that to happen?” He continued that few, if any, textbooks on dentistry state that a toothbrush has to have a small head with dense and soft bristles in order to be acceptable to patients and non-traumatic to the gingivae. Furthermore, in this regard, only individual training, repetition and motivation can lead to long-term success.
Sedelmayer advocates that his long-term strategy, called individually trained oral prophylaxis, be introduced into the dental curriculum in order to achieve correct mechanical plaque control and a change in oral hygiene habits. Implementing this approach in dental education will take time. Furthermore, according to him, examinations on prevention should be a prerequisite in order to graduate in dentistry. “Just as you need good periodontists and endodontists for the basic and advanced courses, instructors for preventative dentistry too need to be trained to examine students,” he stated. Currently, he offers a six-week training course at Charles University in Prague in the Czech Republic. First-year students practise oral hygiene every Wednesday. In the seventh week, his students have to pass a test in order to complete the course.
In summary, prevention means education. Individual care and motivation of each patient and dental student should be the focus of dental education. As the scientific evidence on preventative measures and their cost-effectiveness grows, prevention will help meet the challenge of chronic (oral) disease. How long it will take for the curriculum to devote more hours to preventative dentistry is unknown, but what is clear is that future dentists will learn more about the relationship between oral health and systemic health. They will learn more about the billions of oral bacteria that are hidden in interdental spaces. They will learn more about the association between periodontitis and cardiovascular disease, as well as diabetes, asthma, low birth weight and osteoporosis. Future dentists will recognise that an oral wound should be treated in the same way as other wounds. With this knowledge, dentists will be able to motivate themselves and their patients in order to achieve prevention.”