The Reporter: June 1996, Vol.7, No.3
Reshaping Dental Education for the 1990s and Beyond

Columbia's School of Dental and Oral Surgery has made great progress during what can best be described as difficult and challenging times. On the national scene, dental education has contracted. Six U.S. dental schools have closed for a variety of reasons over the past decade. The impact of managed care on the dental profession and the school's education and patient care missions is still unknown. At the local level, the school felt the loss of state aid, which dropped from more than 26 percent of the school's revenues to less than 3 percent.

Those realities could have been considerable barriers to progress, but the school refused to consider them as such. The recent American Dental Association's Middle States Report on the Fall 1995 Columbia site visit summarized that although SDOS had a number of significant challenges to overcome, including cuts in state funding and large numbers of faculty retirements, "Columbia has done a very fine job of dealing successfully with these challenges."

This report describes SDOS's strengths and outlines its preparations for the next century. Faculty The basic science faculty members, internationally recognized for their research endeavors, take pride in their teaching efforts-a commitment for which the 1995 site visitors commended SDOS. In 1995, the full-time clinical faculty grew to 52 highly qualified individuals from 35 in 1987. The school attracted 25 assistant professors from varied backgrounds, more than doubling the 11 assistant professors of 1987. Full-time, on-site faculty are assisted by an extensive and well-prepared group of 17 full-time, off-site faculty located mainly at the Harlem Hospital, the Bronx Veterans Administration Hospital, and the Helen Hayes Hospital. Those facilities provide strong educational support for the dental school. Contracts are maintained with 23 affiliated hospitals and 48 attending staff who also serve as faculty mentors for students. The Commission on Dental Accreditation (CODA) 1995 site visit report stated that, "Individual students assigned to this clinic [Harlem Hospital] received an education that must be considered an exemplary achievement of the public service and educational goals of SDOS." More than 100 part-time faculty members augment the full-time faculty and most serve on a voluntary basis. Contributing to the faculty luster are members of a dedicated group of emeritus professors. In short, as the 1995 accreditation report stated, "the qualifications of the faculty as to their knowledge and experience were a strength of the institution."

Students and the Curriculum

The current predoctoral student body numbers 280. Demand for enrollment is at an all-time high and the success of graduates gaining acceptance into a limited number of postdoctoral training programs has never been better. The 1,800 applications for 1995-96 represented a 21 percent increase over the previous year's cycle and an increase of 360 percent over five years ago. That 360 percent increase compares with a 70 percent increase nationwide.

Dr. Marlene Klyvert, associate professor of clinical dentistry, with first-year students in her oral histology course, which she co-teaches with Dr. Letty Moss-Salentijn, associate dean of academic affairs.

One immediate measure of the success of SDOS graduates is their acceptance into postdoctoral training programs. The Class of 1996 was particularly successful in attaining postdoctoral placement as all but one has been accepted into either specialty or general practice programs. That placement of 99 percent-compared with the approximately 35 percent of D.D.S. graduates nationally who do any postdoctoral education-indicates that the directors of the programs recognize the extraordinary preparation of Columbia graduates in the biomedical sciences, their clinical competence, and their understanding of high standards in patient care.

The Predoctoral Course of Study Both the basic science and clinical science faculty have directed major attention to curriculum review and revision during the past seven years. A curriculum to maintain excellence needs continuous updating, but its general goals should reflect the strengths of the institution. The SDOS course of study takes advantage of the school's close ties to P&S and an excellent network of affiliated hospitals in the New York metropolitan area.

The Curriculum of SDOS Dentists of the next century will have to be health professionals who can work confidently with members of the medical profession and participate optimally in a practice setting, the nature of which is rapidly changing through scientific, technological, and socioeconomic advances.

Columbia has made a significant commitment to a strong biomedical sciences curriculum. During the first two years, many courses educate medical and dental students together. Dental students are encouraged to think of them- selves as specialists who have, at an earlier stage than their medical colleagues, made a decision to enter a specialty.

Students develop the necessary technical skills to become good dental practitioners in a state-of-the-art preclinical simulation laboratory in the first two and one-half years of the curriculum. During the two "clinical years," students continue to apply those skills both in the school's dental clinics and in the weekly rotations at affiliated hospitals during the final year of study. Because of this experience, Columbia dental graduates are well-prepared to treat the more complex cases requiring special handling between medical and dental practitioners. Third- and fourth-year students provide comprehensive care to a group of patients after passing the first stages of competency in a group-practice setting while working alongside graduate dentists and members of the faculty and after demonstrating mastery of predetermined competencies.

One of the most innovative programs the school offers is the Area of Concentration Program, which allows third- and fourth-year students the opportunity to pursue a particular area of interest and learn in-depth about an aspect of dentistry that cannot be covered in the standard core curriculum. Approximately half of the students select concentrations in the dental specialties while the other half select opportunities to earn a master's degree in public health in addition to a D.D.S. degree, to pursue research in one of the many outstanding research laboratories at CPMC, or to pursue unique interests such as speech pathology or veterinary dentistry. Some enter the dental educator track, which enables them to acquire the pedagogical skills necessary to become professional educators.

For a select group of students who show particular promise in research or teaching, the school has 10 predoctoral research and teaching assistant positions available each year. Some of the students continue their research after graduation by enrolling in Ph.D. programs.

The 1995 visiting committee's comments on the curriculum stated it well: "Strengths of the program included a strong, diverse and dedicated faculty; effective integra-tion of the various subjects throughout the curriculum and a wide variety of traditional and innovative teaching modalities."

Postdoctoral Programs

The two types of postdoctoral training programs at CPMC are University postdoctoral training programs and Presbyterian Hospital residency programs.

University Postdoctoral Specialty Programs-Post-doctoral specialty programs at Columbia in endodontics, orthodontics, pediatric dentistry, periodontics, and prosthodontics have attracted an applicant pool of top-notch candidates from all over the United States and abroad for a limited number of positions for those highly competitive programs. A carefully constructed and continually evolving core curriculum of basic and applied sciences prepares graduate dentists to take their places as leaders in patient care, education, and research in their respective fields. Divisional courses focusing on the clinical sciences help produce specialists who will function at the top of their fields.

The master of arts degree is offered in conjunction with the certificate programs to a limited number of students who qualify and have an interest in pursuing careers in education and research. Programs in periodontics and prosthodontics have been extended to three years because of increasing curriculum requirements, particularly in the area of implant dentistry.

In addition to regular specialty programs, fellowship programs have been established in pediatric dentistry and orthodontics, and a residency program has been established in maxillofacial prosthodontics. Those programs have helped integrate the specialty programs with the work of the newly established Center for Craniofacial Reconstruction and Rehabilitation. The center, established under the auspices of the oral and maxillofacial surgery, orthodontics, and prosthodontics divisions, is composed of a multi-disciplinary group of dental and medical practitioners concerned with the treatment of patients with genetic, developmental, or acquired craniofacial defects who require a team approach to treatment. Hospital Residency Programs-The oral and maxillofacial surgery (OMS) residency training program at CPMC has the reputation as one of the most desirable OMS training programs in the country. Of the 361 applicants who participated in the 1996 oral and maxillofacial surgery residency national match program, more than 100 applied for the two positions at Columbia. In 1986 the OMS residency curriculum was expanded to incorporate study that leads to a medical degree from P&S and training in general surgery at Presbyterian Hospital. All residents have completed medical school, most with honors. Of the graduates of the program eligible to take board exams, 100 percent have passed on the first attempt.

Five full-time, one half-time, and 23 voluntary attending faculty form the OMS active staff. The faculty are known internationally for work on temporomandibular joint disease, salivary gland disease, craniofacial and dentofacial surgery, and medical management of the surgical patient. Members of the faculty have been board examiners and members of the Commission on Dental Accreditation, NIH study panels, journal editorial boards, and numerous specialty organization committees. During CODA's recent site visit, the program received full approval, with the faculty listed as one of the program's strengths.

The pediatric dentistry residency program is one of the most active in the United States. Special pediatric patients, including children with cleft lips and palates and other maxillofacial defects, approximately 50 cardiac transplant patients, and a significant number of other organ transplant recipients are given care through the pediatric dental service. The Division of Pediatric Dentistry also provides educational programs in the local public schools and is actively engaged with the Women, Infants, and Children (WIC) Program of northern Manhattan. A special patient care fellow, who is already a pediatric dentist, sees a large number of HIV-positive children as part of a special grant to the school.

The general practice residency program offers recent dental graduates the opportunity to evaluate and treat severely medically compromised and physically challenged individuals, whose special needs make it difficult to receive general dental care within the community. The program activities include performing comprehensive dentistry in the operating room, taking emergency room call, and serving as consultants to the organ transplant team. In addition, rotations in anesthesiology and emergency medicine are scheduled.

The Advanced Education in General Dentistry (AEGD) Fellowship Program serves as the primary care center of SDOS, providing comprehensive dental care to patients of all ages. Within SDOS clinics, emphasis is placed on educating clinically competent general practitioners who can treat patients in the context of family, culture, and community.

The AEGD fellowship program was expanded with the help of a U.S. Public Health Service training grant. Fellows rotate to eight affiliated community health centers in the New York metropolitan area, the SDOS DentCare Project at the public school primary care clinics in Washington Heights-Inwood, and an SDOS-affiliated family practice location. Four or five of the 20 first-year fellows are selected to continue into a second year, which gives more experience in treating complex general dentistry cases.

The goal of the AEGD program is to train general practitioners who are competent and committed to practicing in any setting, including community health centers serving minority and low-income populations.

Research

William Gies, one of SDOS's founders, was a biochemist who early on in the history of the school encouraged a spirit of inquiry. The school has a distinguished record in contributing new knowledge to areas of dental disease such as the pathogenesis of periodontal disease and caries, oral pathology, and salivary chemistry. Last year, for example, the faculty and students presented eight research papers and six pedagogical presentations at the 1996 meetings of the International Association of Dental Research and the American Association of Dental Schools. D.D.S. and postdoctoral students presented 21 table clinics at the spring 1996 Research Day activities at the school.

Keeping research continually viable is more difficult in the 1990s than it was in past decades as competition for the shrinking research dollar has become greater. The school has adopted an ambitious research plan to continue emphasizing its research mission. Part of the strategy includes increasing collaborative studies with colleagues in the basic and clinical medical sciences.

Members of the Division of Periodontics have been examining oral manifestations of HIV infection in cohorts of at-risk groups. Those studies are conducted in collaboration with investigators in the HIV Center for Clinical and Behavioral Research at the New York State Psychiatric Institute and Harlem Hospital Center. The Division of Oral Surgery has been examining biochemical mediators of inflammation in the temporomandibular joint in a collaborative project with the Department of Orthopedics, and the Division of Prosthodontics has been studying mechanical properties of dental and implant materials.

Dr. John Zimmerman, SDOS assistant dean for information resources and assistant professor of dentistry, demonstrates state-of-the-art computer software that coordinates and records patient data-such as charts, X-rays, and clinical appearance-in one location.

With the success of initial collaborative efforts between SDOS and P&S investigators, other projects, such as the interaction between diabetes and periodontal disease, have been identified. In conjunction with this new focus, the school has adopted an ambitious research plan to further strengthen its research mission. Highlights of the plan include the addition of six D.D.S.-Ph.D. investigators to the SDOS faculty to increase federally funded research at SDOS, as well as identification of additional research mentors and funding to increase the number of students who can participate in research while attending SDOS.

The senior practice clinic-a modernized dental operatory-with new dental units, cabinetry, storage, and chairs.

Community, National, World Issues

The school has continued to focus on expanding its community outreach. One of SDOS's most successful outreach programs is STEP-Science & Technology Entry Program. The school is a charter member of a group of institutions that has received STEP grants to address the dearth of underrepresented minorities in the licensed professions in New York.

SDOS has formed partnerships with the School of Public Health for other community programs. One example is the Northern Manhattan Women's and Children's HIV Demonstration Project, the largest federally funded pediatric AIDS program in the country. Under a grant to the School of Public Health from the AIDS Institute of New York State, SDOS provides dental care for HIV- and AIDS-infected children in Presbyterian Hospital and assists the dental staff in four other hospitals to do the same. In another collaboration, the school embarked on a new community outreach program to bring preventive dental services to children in two Washington Heights intermediate schools.

In 1988, the dental school and Harlem Hospital Center collaborated to develop the minority specialty program, which addresses the paucity of African-American specialists in dentistry. Since that time, the program has educated more minority specialists than any other program in the nation.

Recognizing that the missions of the University and the school go beyond even national borders, the school entered into a formal agreement with the National Taiwan University to provide exchanges of faculty and students. Each year, approximately 10 dental students and visiting faculty from around the world study at SDOS for periods ranging from one to 12 months.

Patient Care

Patient care programs at the school have taken, and will continue to take, great strides toward comprehensive patient care. That focus has created great increases in the offering of oral health care in the Washington Heights-Inwood and Harlem communities. In 1991-92, the clinics registered 51,000 visits. By 1994-95, visits increased to 65,000 and that number is expected to exceed 70,000 in the 1995-96 academic year.

SDOS programs have expanded to meet increasing demands. That expansion has moved the school into the managed care arena. A practice at the Morningside campus of Columbia University provides care to more than 10,000 student-health enrollees and a network of faculty in the greater metropolitan area offers dental care to more than 1,200 officers enrolled in the University's dental plan.

Physical plant improvements reflect curricular improvements. All undergraduate dental units have been replaced with state-of-the-art operatories. The senior practice clinic simulates a private setting. The junior clinic is now adjacent to the AEGD I practice clinic. Both the seventh and eighth floors are supported by a new central sterilization unit designed for use with a student/university-owned instrument management system. The system, the only one of its kind in the country, offers optimal control of sterilization while allowing students control and maintenance of their own instruments. The last two phases of change will focus on the redesign and construction of the postdoctoral and oral and maxillofacial surgery areas.

The Future

As the year 2000 approaches, and as the school prepares to educate oral health care providers in the new century, SDOS has positioned itself with the strongest educational programs, the best possible clinical programs, and a greatly renewed clinical faculty.

The school approaches today's challenging environment as an opportunity to make major advances. Managed care is a challenge that gives the school an opportunity to reform the patient care delivery system. Tight funding for research presents an opportunity to recruit D.D.S./Ph.D.-prepared faculty suited to compete for research funding. And finally, the challenge of preparing graduates for a practice environment that more heavily relies on computer technology, managed care, and population-based solutions to oral health problems gives the school an opportunity to create a community-based system of care that views the health of the community as central to the mission of the care system, linking it to the school by a computer network and using it as a setting for education.

At the ribbon-cutting ceremony of the new SDOS preclinical lab are, from left, Dr. Norman Kahn, the Robinson Professor of Dentistry and professor of pharmacology; Dr. Herbert Pardes, vice president of Health Sciences; and Dr. Allan J. Formicola, SDOS dean

Those challenges could possibly cause major dislocations to the school's three missions of research, teaching, and patient care. For each opportunity, however, the school has already established a planning process to convert the opportunity into productive programs.

Circumstances and environments may change, but the cornerstones of the school-a well-prepared faculty, an in-depth education, excellent students, and dedicated alumni-will ensure continued success.