Implementation of a patient-centered approach to clinical dental education: a five-year reflection.

The intent of the redesign of the clinical component of the Harvard School of Dental Medicine (HSDM) curriculum from a traditional numerical procedures-based system to a patient-based comprehensive care system was to improve both patient care and student learning. The aim of this retrospective cohort study was to evaluate the outcomes of and students' perspectives on this patient-centered comprehensive care model introduced in 2009. Data were obtained from the school's Office of Dental Education for a study sample consisting of 205 fourth-year dental students in the graduating classes of 2009 through 2014 at HSDM. The results showed that students were completing more than the required number of comprehensive patient cases on average. A survey given to the Class of 2014 found that the respondents (35 of 36 students) were generally satisfied with the new curriculum and the clinical experience in relation to continuation of care and perceptions of comprehensive care. The results of this study suggest that the redesigned patient-centered assessment model of the clinical component of the curriculum helped improve patient care and student learning.

Implementation of a flipped classroom educational model in a predoctoral dental course.

This article describes the development and implementation of a flipped classroom model to promote student-centered learning as part of a predoctoral dental course. This model redesigns the traditional lecture-style classroom into a blended learning model that combines active learning pedagogy with instructional technology and "flips" the sequence so that students use online resources to learn content ahead of class and then use class time for discussion. The dental anatomy portion of a second-year DMD course at Harvard School of Dental Medicine was redesigned using the flipped classroom model. The 36 students in the course viewed online materials before class; then, during class, small groups of students participated in peer teaching and team discussions based on learning objectives under the supervision of faculty. The utilization of pre- and post-class quizzes as well as peer assessments were critical motivating factors that likely contributed to the increase in student participation in class and helped place learning accountability on the students. Student feedback from a survey after the experience was generally positive with regard to the collaborative and interactive aspects of this form of blended learning.

Impact of the NBDE grading change on postgraduate admissions processes.

The aim of this study was to assess the effect of discontinuing the reporting of National Board Dental Examination (NBDE) Part I numerical scores on postgraduate program directors' admissions selection processes. This cross-sectional survey-based study collected information about two admissions cycles (2012-13 and 2013-14) from directors of American Dental Education Association Postdoctoral Application Support Service (ADEA PASS(SM)) programs in all postdoctoral training disciplines; the response rate was 54.5%. According to the 2012-13 cycle results, these program directors rated an NBDE Part I score the third most important part of an application, behind grade point average (GPA) and class rank (ranked first and second, respectively). In the 2013-14 cycle, in the absence of an NBDE Part I score, almost all other parts of the application increased in importance for the responding directors, but the relative rank of factors remained almost unchanged. Significantly, 71% of the directors reported that it was now more difficult to select interview candidates, and 76% said they wanted some form of national, numerically scored exam. No significant change was noted between the two years in the number of applications or interviews offered per resident position, although the standard deviation of the number of interviews offered increased in both pediatric dentistry and postdoctoral general dentistry.

The impact on dental students of changes to the National Board Dental Examination grading system.

The purpose of this study was to assess how the change to pass/fail grading of the National Board Dental Examination (NBDE) Part I has impacted dental students' study habits and their perspectives on pursuit of postdoctoral specialty education. This cross-sectional survey-based study included over 75 percent of U.S. dental schools and a total of 1,843 responses. This sample was 18.5 percent of all potentially eligible U.S. dental students. Participating schools distributed the electronic survey to their last class to take the NBDE Part I for a numerical score and the first class to take the NBDE Part I pass/fail. Respondents who took the exam for a numerical score and were interested in a specialty reported studying the most (average 167 hours) compared to respondents who took the exam pass/fail (average 114 hours). Respondents who took the exam pass/fail and reported feeling that this change decreased their chances of getting into a specialty program outnumbered those who thought the change increased their chances (3:1). This study observed a correlation between the recent grading changes to the NBDE Part I and decreased reported study time. Eighty percent of the respondents preferred a standardized, objective measure to help differentiate them when applying to specialty programs, and the majority reported feeling that the change in grading practices negatively affected their chances of pursuing a specialty.

Perceptions and practices of U.S. dental schools regarding curriculum integrated format and traditional format licensure exams.

The dental licensure exam in the United States has evolved over the past ten years, and two formats-the traditional format and curriculum integrated format-are now available for students to satisfy licensure requirements. The objective of this study was to examine the differences and relative merits of the two formats. A twenty-five-question survey was distributed to the fifty-seven U.S. dental schools at the time. The survey included both quantitative and discrete variables and followed a strategic sequential order. The first set of questions sought to determine what type of board preparatory/mock exam each dental school offered, and the next set of questions asked which licensure exam each school formally offered. The final questions were qualitative in nature and aimed to determine the school representatives' opinions about the curriculum integrated format versus traditional format. Of the fifty-seven schools contacted, thirty-seven agreed to participate (response rate=64.9 percent). Fourteen schools reported that they administer the traditional format only and twelve administer the curriculum integrated format only, while eleven offer both. Thirty-two schools offered mock board exams to their graduating students, and twenty-four of those said their mock exams were identical in format to the actual qualifying clinical exams offered at their institution. The respondents reported no significant advantage to preparing for the curriculum integrated format examination as compared to the traditional format examination with regards to number of clock hours taken from regular curriculum time. In reporting on this study, this article provides an overview of the relative advantages and disadvantages of the two examination formats used for the dental licensure process in the United States.

Does a case completion curriculum influence dental students' clinical productivity?

The purpose of this study was to evaluate the effects of a new clinical curriculum on dental student productivity as measured by number of procedures performed in the student teaching practice. Harvard School of Dental Medicine adopted a new clinical education model for the predoctoral program in summer 2009 based upon a Case Completion Curriculum (CCC) rather than a discipline-based numeric threshold system. The two study groups (threshold group and case completion group) consisted of students who graduated in 2009 and 2010. Clinical performance was assessed by clinical productivity across five major discipline areas: periodontics, operative dentistry, removable prosthodontics, fixed prosthodontics, and endodontics. The relationships between the two study groups with regard to number of procedures performed by category revealed that the case completion group performed a significantly higher number of operative and removable prosthodontic procedures, but fewer periodontal and endodontic procedures (p≤0.03). No statistically significant difference in number of procedures was observed with fixed prosthodontic procedures between the two groups. Clinical productivity as a result of redesigning the clinical component of the curriculum varied in selected disciplines. The CCC, in which the comprehensive management of the patient was the priority, contributed to achieving a patient-based comprehensive care practice.

Association between students' dental admission test scores and performance on comprehensive clinical exams.

This study examined the association between Dental Admission Test (DAT) scores and the comprehensive exams conducted at Harvard School of Dental Medicine. The authors hypothesized that students who scored high on the DAT would also perform well on the comprehensive examinations. Sixty-six students from the graduating classes of 2005 and 2006 were included. The outcome variable of interest was the final composite grade obtained by the students in the three comprehensive examinations. The main independent variable of interest was the individual component scores on the DAT. Multivariable logistic regression analysis using the maximum likelihood methods was used to examine the association between comprehensive exam grades and DAT scores. Effects of age, gender, and race/ethnicity were adjusted in the regression models. On the first comprehensive examination, seventeen students obtained an Honors grade, while thirteen did so on the second comprehensive examination and fifteen on the third comprehensive examination. None of the DAT component scores were significantly associated with Honors grades on the first comprehensive examination. On the second comprehensive examination, quantitative reasoning scores (OR=2.48, 95 percent CI=1.09-5.68, p=0.03) and total science scores (OR=14.17, 95 percent CI=1.89-106.80, p=0.01) were significantly associated with Honors grades. Reading comprehension score was associated with increased odds of obtaining Honors grade on the third comprehensive examination (OR=1.81, 95 percent CI=1.13-2.92, p=0.01). Students who scored well on the quantitative reasoning, total science, and reading comprehension sections of the DAT had higher odds of receiving an Honors grade on the second and third comprehensive examinations. These factors may be associated with the problem-solving/critical thinking components in the school's PBL curriculum.

A case completion curriculum for clinical dental education: replacing numerical requirements with patient-based comprehensive care.

The aim of this article is to describe the development and implementation of a case completion curriculum as a new clinical education model for the predoctoral program at Harvard School of Dental Medicine. In this innovative model, students conduct patient-based comprehensive care and complete assigned patient cases on which their performance is assessed, in contrast with a traditional model based on procedural numerical requirements. In our new model, senior tutors, who are full-time faculty members, act as group leaders responsible for patient assignment, treatment planning, monitoring of student performance, and verification of patient care. The number of completed patient cases in this new comprehensive care system increased from a previous average of 12.8 cases per student prior to graduation to 22.8 cases. Additionally, the number of patients who had to be transferred due to outstanding or pending treatment when their student provider graduated or because of students' need to fulfill discipline requirements has decreased from an average of 16.4 to 4.6.

Evaluation of a new assessment tool in problem-based learning tutorials in dental education.

The Harvard School of Dental Medicine (HSDM) uses a hybrid problem-based learning (PBL) approach to teaching in the D.M.D. curriculum. Each tutorial group at HSDM is made up of eight to ten students. The objective of this study was to examine the performance of the students in the tutorial sessions as assessed by the tutor. A total of ten tutorial blocks led by twenty-four tutorial leaders were completed at HSDM between summer 2008 and fall 2009. All of the tutors were calibrated to a new assessment system that was developed for student assessment in the tutorials. The students were assessed on three major domains: knowledge acquisition, problem-solving and analytical thinking skills, and personal and interpersonal development. The tutors evaluated the students assigned to their group after the end of each block. Students also filled out a self-assessment form. Simple descriptive statistics were used to summarize the evaluations of the tutors. A total of 290 student evaluations from ten tutorial blocks were available for analysis. Tutors reported that 64 percent of the students preferred to communicate verbally without prompting and 68 percent of students submitted written reports to the groups during tutorial sessions. Tutors reported that a majority of students brought new information to each tutorial session (86.5 percent), brought information that facilitated others' learning (88.7 percent), integrated newly acquired knowledge with previous knowledge (92.7 percent), applied knowledge from self-study to explain issues during case discussions (91.7 percent), asked appropriate questions to stimulate discussions (87.3 percent), generated hypotheses to explain problems under discussion (83.8 percent), evaluated the hypotheses in light of available evidence (85.5 percent), defined and took responsibility for learning goals and objectives (89.3 percent), responded well to criticism (91.7 percent), took a leadership role (74.5 percent), and demonstrated sensitivity to psychosocial issues (88.6 percent). Student communication that tended to take over the group process in a non-contributory manner was reported in only 2 percent of the evaluations. Overall, students participating in PBL tutorial sessions appear to exhibit problem-solving and analytical thinking skills and personal and interpersonal attributes.

Association Between National Board Dental Examination Part II Scores and Comprehensive Examinations at Harvard School of Dental Medicine.

Harvard School of Dental Medicine (HSDM) uses a hybrid problem-based approach to teaching in the predoctoral program. The objective structured clinical examination (OSCE) is a formative examination designed to assess the performance of students in the problem-based learning (PBL) curriculum. At HSDM three comprehensive examinations with OSCE components are administered during the third and fourth years of clinical training. The National Board Dental Examination (NBDE) Part II is taken in the final year of the predoctoral program. This study examines the association between the NBDE Part II and the comprehensive exams held at HSDM. Predoctoral students from the HSDM classes of 2005 and 2006 were included in this study. The outcome variable of interest was the scores obtained by students in the NBDE Part II, and the main independent variable of interest was the performance of students in the comprehensive exams (honors, pass, make-up exam to pass). The Mann-Whitney U-test was used to examine the association between the grades obtained in the each of the three comprehensive exams and the NBDE Part II scores. Multivariable linear regression analysis was also used to examine the association between the NBDE Part II scores and the comprehensive exam grades. The effect of potential confounding factors including age, sex, and race/ethnicity was adjusted. The results suggest that students who performed well in the comprehensive exams performed better on the NBDE Part II, even after adjusting for confounding factors. Future studies will examine the long-term impact of PBL on postdoctoral plans and career choices.

The effect of aspirin on gingival crevicular fluid levels of inflammatory and anti-inflammatory mediators in patients with gingivitis.

BACKGROUND: Inflammatory and anti-inflammatory mediators may play a significant role in patients with gingivitis. The purpose of this study was to assess the short-term effects of the systemic administration of two different concentrations of aspirin (81 and 325 mg/day, by mouth) on clinical periodontal parameters and gingival crevicular fluid (GCF) levels of 15-epi-lipoxin A4 (15-epi-LXA4), lipoxin A4, leukotriene B4 (LTB4), prostaglandin E2 (PGE2), and interleukin (IL)-6 and -1beta in a sample of naturally occurring gingivitis patients. METHODS: At day 0, after initial screening for entry, baseline periodontal parameters, including bleeding on probing (BOP), periodontal probing depths (PDs), and plaque index (PI) were measured, and GCF was sampled from 12 intrasulcular sites with filter paper strips for the measurement of six types of inflammatory and anti-inflammatory mediators using competitive enzyme immunoassay and enzyme-linked immunosorbent assay (prevalues). Forty-seven subjects were assigned randomly to one of three treatment groups: placebo (15 subjects); aspirin, 81 mg (16 subjects); and aspirin, 325 mg (16 subjects) once daily. On day 7, subjects were recalled for the measurement of periodontal parameters and collection of GCF samples for the measurement of six types of mediators (postvalues). RESULTS: Changes in inflammatory and anti-inflammatory mediator levels were not statistically significant for any of the three treatment groups. However, when pre- and postvalues were compared in the subjects receiving aspirin, 325 mg, there was a negative trend in the relationship between 15-epi-LXA4 and PGE2, whereas the relationship between LTB4 and PGE2 was not as strong. This might indicate that the subjects responding to aspirin-mediated PGE2 suppression effects produced higher 15-epi-LXA4 in GCF than non-responders. No statistically significant differences in PD and PI between pre- and postvalues were found for any of the three treatment groups. However, the results demonstrated a significant increase in BOP when aspirin, 325 mg was compared to placebo (P <0.001) and aspirin, 81 mg (P = 0.001). CONCLUSIONS: Aspirin can have an affect on BOP in naturally occurring gingivitis patients. Although most of the inflammatory mediators did not show significantly detectable changes after aspirin treatment for 7 days, the trend of aspirin-associated increases of 15-epi-LXA4 implied that this recently discovered aspirin-dependent eicosanoid may be associated with the increased incidence of BOP observed in the subjects who received aspirin therapy.

Dental Admission Test scores and performance on NBDE Part I, revisited.

The purpose of this study was to examine the relationship between performance on the Dental Admission Test (DAT) and Part I of the National Board Dental Examination (NBDE Part I) for students at the Harvard School of Dental Medicine (HSDM). This study was a retrospective cohort study, examining HSDM students over an eight-year period. Data regarding DAT and NBDE Part I scores were obtained from the Office of the Registrar. Descriptive statistics were computed for all study variables. Multiple linear regression analyses were subsequently computed to examine the relationship between DAT subtest scores and performance on NBDE Part I subtests. Goodness of fit for the models was evaluated using the R-squared value. Statistically significant associations were those with p-value =0.05. Data were available for 244 students who matriculated at HSDM during the period of 1995-2002. DAT reading comprehension scores were statistically significantly associated with performance on all four subsections of the NBDE Part I. DAT general and organic chemistry scores were associated with performance on the microbiology and pathology subtest of NBDE Part I. Performance on the perceptual ability test was associated with performance on the dental anatomy and occlusion subtest. Performance on the DAT reading comprehension subtest was the most reliable predictor of performance on the NBDE Part I. However, the variability in NBDE Part I scores is not accounted for significantly by variability in DAT scores.

Randomized study evaluating recombinant human bone morphogenetic protein-2 for extraction socket augmentation.

BACKGROUND: Conventional dentoalveolar osseous reconstruction often involves the use of grafting materials with or without barrier membranes. The purpose of this study was to evaluate the efficacy of bone induction for the placement of dental implants by two concentrations of recombinant human bone morphogenetic protein-2 (rhBMP-2) delivered on a bioabsorbable collagen sponge (ACS) compared to placebo (ACS alone) and no treatment in a human buccal wall defect model following tooth extraction. METHODS: Eighty patients requiring local alveolar ridge augmentation for buccal wall defects (> or =50% buccal bone loss of the extraction socket) of the maxillary teeth (bicuspids forward) immediately following tooth extraction were enrolled. Two sequential cohorts of 40 patients each were randomized in a double-masked manner to receive 0.75 mg/ml or 1.50 mg/ml rhBMP-2/ACS, placebo (ACS alone), or no treatment in a 2:1:1 ratio. Efficacy was assessed by evaluating the amount of bone induction, the adequacy of the alveolar bone volume to support an endosseous dental implant, and the need for a secondary augmentation. RESULTS: Assessment of the alveolar bone indicated that patients treated with 1.50 mg/ml rhBMP-2/ACS had significantly greater bone augmentation compared to controls (P < or =0.05). The adequacy of bone for the placement of a dental implant was approximately twice as great in the rhBMP-2/ACS groups compared to no treatment or placebo. In addition, bone density and histology revealed no differences between newly induced and native bone. CONCLUSION: The data from this randomized, masked, placebo-controlled multicenter clinical study demonstrated that the novel combination of rhBMP-2 and a commonly utilized collagen sponge had a striking effect on de novo osseous formation for the placement of dental implants.

Problem-based learning and research at the Harvard School of Dental Medicine: a ten-year follow-up.

Dental students at the Harvard School of Dental Medicine (HSDM) are required to pursue and complete research projects in order to obtain the doctor of dental medicine (D.M.D.) degree. The purpose of this study was to evaluate the effect of curriculum changes on a set of measurable outcomes related to research pursuits. This study was designed as a retrospective analysis of outcomes data from the period 1992-2002. The predictor variable was program format (non-PBL vs. PBL); the outcome variables were the percentage of students listed as authors on an IADR/AADR abstract during their tenure at HSDM and the percentage of students listed as first and/or presenting authors. Univariate statistics were computed for each class, and independent samples t-tests were used to compare the study groups with regard to our outcomes. For the majority of our outcomes, there was no statistically significant difference between the PBL and non-PBL groups, possibly due to sample size limitations. While the implementation of PBL at HSDM has not universally increased student productivity in research, it has not had an adverse effect either. It is possible that students in the PBL curriculum are nurturing other interests, such as community service, while retaining productivity in research.

Measuring the efficacy of rhBMP-2 to regenerate bone: a radiographic study using a commercially available software program.

This radiographic study evaluated the efficacy of different concentrations of rhBMP-2 to regenerate bone in alveolar defects in the anterior maxilla. The study was performed using reasonably standardized CT examinations and the Simplant program. The radiographic measurements were further refined by careful standardization of the measured regions of interest. There was a statistically significant difference in bone formation between subjects treated with a concentration of 1.5 mg/mL rhBMP-2 compared with each of the other groups. There was no statistically significant difference in bone volume between any of the other groups. None of the groups showed a loss in bone volume.

Problem-based learning: effects on standard outcomes.

Dental students at the Harvard School of Dental Medicine (HSDM) participate fully in the first two years of the curriculum with the Harvard Medical School (HMS) while also taking parallel dental classes. HSDM students were first exposed to problem-based learning (PBL) in 1987 when the "New Pathway" curriculum was introduced at HMS in the first two years of the medical school curriculum (the HSDM courses remained traditional lecture-based classes). In 1994, HSDM incorporated PBL into the first, second, and third (clinical year) year dental courses, and the curriculum shifted from a five-year curriculum to a four-year curriculum. The purpose of this study was to evaluate the effect of PBL and program length on measurable outcomes for dental education: NBDE Part I scores, attrition and graduation rates, and percentage of graduates entering postdoctoral training programs. This study was designed as a retrospective analysis of outcomes data from 1980 to 2002. Univariate linear regressions were computed for each measure against each outcome. Subsequent bivariate regression analyses revealed that the implementation of PBL has markedly affected NBDE Part I scores, graduation rates, attrition rates, entrance into postdoctoral plans, and percentage of graduates entering GPR/AEGD programs, while program length has had an effect on graduation rates, attrition rates, entrance into postdoctoral programs, and percentage of graduates entering GPR/AEGD programs. The findings of this report suggest that the implementation of PBL combined with a change in program length has been successful for all outcomes measured and that PBL alone has contributed to the rise in NBDE Part I scores among HSDM graduates.

Blocking Periodontal Disease Progression with Anti-Inflammatory Agents.

Recent advances in the identification of specific immuno-inflammatory pathways of periodontal disease have encouraged investigators to attempt to modulate some of these host responses in an attempt to slow the periodontal disease process. Some of the best known mediators of these immuno-inflammatory pathways are prostaglandins. The action of prostaglandins can be inhibited through the use of non-steroidal anti-inflammatory drugs (NSAIDs). This review examines research over the last two decades during which the effect of several NSAIDs on the progression of gingival inflammation and alveolar bone loss was explored. J Periodontol 1993; 64:828-833.