The Role of Science and Technology in Shaping the Dental Curriculum

Edward F. Rossomando, D.D.S., Ph.D.; Mathew Moura, B.A.

Abstract: In this article, we explore the role of science and technology as a force shaping the dental curriculum throughout history. This force is examined from a historical perspective, ranging from 1840 at the Baltimore College of Dentistry to 2007. We divide the history of dental education into two eras: the germ theory era from 1840 to 1953, and the genomic theory era from 1953 to 2007. We have chosen 1953 as the beginning of the genomic era as this is the year of publication of the structure of DNA. Based on our analysis of science and technology as a force acting on dental education throughout the two eras, we recommend a format for the basic science curriculum that emphasizes products and technologies as a means to teach the biosciences and to promote the translation of these technologies into dental practice. Dr. Rossomando is Professor and Director, and Mr. Moura is Assistant for Educational and Special Programsboth at the Center for Research and Education in Technology Evaluation, Department of Craniofacial Sciences, School of Dental Medicine, University of Connecticut. Direct correspondence and requests for reprints to Dr. Edward F. Rossomando, 12 West Fairway Ave., Westerly, RI 02891; 860-679-2622 phone; 860-679-1920 fax; erossomando@uchc.edu. Key words: dental education, Gies report, dental curriculum, research, oral health care access, science integration, biological sciences Submitted for publication 6/14/07; accepted 10/10/07

he reform of dental education is again on the agenda of many dental organizations and the subject of articles in dental periodicals.1-4 Recently, several dental organizations have appointed committees to revisit the topic.5 The reform effort has been ongoing since the Gies report of 1926, but the pace of interest in reform has intensified during the past decade: beginning with the Institute of Medicine (IOM) report of 1995, then the U.S. surgeon generals report of 2000, and the American Dental Associations future of dentistry report in 2001.6-9 These numerous attempts at reform suggest agreement among some dental educators on a need for change. Some of these educators have voiced the concern that dental schools graduate professionals with inadequate exposure to biological science and understanding of its future applicability.3,10 Other dental educators argue that the ADA accreditation guidelines do not call for sufficient mastery of the scientific progress of the last ten to twenty years, particularly in areas such as genomics, proteomics, and phenotyping technologies, the microbiome, and epigenetics.3,4,9 Still others argue that, as diagnosis and treatment shift from a germ theory to a theory for disease processes based on mutation and faulty functioning of our genes, it will be imperative that dental graduates have the intellectual framework to incorporate genomic-based diagnostics and treatments into their practice.9 These considerations have not been fully acted upon by dental schools, which suggests that all parties have not agreed on the direction and magnitude of
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such changes and how to accomplish them. In this article, we explore the role of science and technology as a force that has shaped the dental curriculum from 1840, when the Baltimore College of Dentistry matriculated its first class of students, until 2007. Dental history is divided into two eras: the germ theory era from 1840 to 1953, and the genomic theory era from 1953 to 2007. We designated 1953 as the beginning of the genomic era because that is the year of publication of the structure of DNA.11 By analyzing science as a force acting on dental education throughout the two eras, we will make recommendations that might be useful for dental curriculum reform today. We will argue that technology advances were a catalyst that helped establish dentistry as a learned profession in the early decades of the twentieth century and infused scientific concepts into the curriculum. A similar potential exists today for a scientifically driven reform of dental education and, ultimately, dental practice to help the profession evolve and mature in a new era of rapid technological transformation.

The Germ Theory Era: 18401953

1840: The Introduction of Science into the Dental Curriculum
Diseased teeth have been treated for centuries by a variety of healers. Until the mid-nineteenth
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century, the education of dentists was by apprenticeship. It was not until 1840 that the first dental school in the world opened in Baltimore, Maryland; it would not be until 1867 that the first dental school would be attached to a university.12 Prior to the opening of the Baltimore College of Dentistry, licensure was granted with little regard for ones scientific background.13 Once dental training was placed within the sphere of education, the teaching of dentistry became based on scientific understanding and research. The first curriculum included subjects such as anatomy, chemistry, and physiology for a total of about 200 hours of science.6 Through the last half of the nineteenth century and into the early twentieth century, scientific discoveries justified an increase in scientific content. Following the publication of the Gies report in 1926 and until the 1950s, basic science courses accounted for approximately 500 hours of the overall curriculum in U.S. dental schoolsroughly 10 percent of students coursework.13 This increase was accommodated by increasing the number of years for a dental degree from two to three years in U.S. dental schools in the years directly following the Gies report. When Gies recommended increasing the number of science hours, there was unanimity among dental educators at the then forty-three dental schools to do so. Why? There appear to be three reasons: 1) the increase in scientific knowledge between 1840 and 1953 was readily evident to educators; 2) the dental profession recognized that the scientific method being taught in universities was a reasonable paradigm to use as methodology for diagnosis and treatment and should be taught in dental schools; and 3) the acquisition of a body of knowledge and a method for its transfer in teaching enabled dentistry to join medicine as a learned profession.

The Increase in Scientific Knowledge from 1840 to 1953

From 1840 to 1953, first in Europe and then in the United States, scientific knowledge and technological advances poured from academic, governmental, and industrial laboratories. Many of these technological advances, including the electric light, the model T automobile, and the airplane, not only had a profound effect on everyday life, but also affected the way Americans viewed science and technology. Dentistry and the dental profession were not immune to these scientific, technological, and cultural changes. One of the most important advances was the research of W.D. Miller. In 1890, Miller published his seminal

work linking microbes to the decay process, thereby disproving the miasma theory of dental disease and extending the germ theory to dental caries.14 In 1898, William Hunter introduced the term oral sepsis to the profession, thereby applying Millers work to dentistry and, particularly, bringing attention to the contamination potential of then current prosthetic procedures.15,16 Throughout the early 1900s, several published findings would finally make explicit the importance of oral infection to the practice of dentistry.17 Given the positive view of science in American culture throughout the 1900s, it should not be a surprise that the academic dental community recognized and agreed with Gies that, in order to apply these scientific findings to dental practice, science courses were an absolute necessity for dental students. Also, dentistswho at home were enjoying music from Thomas Edisons Victrola and converting their gas lights to electricwere eager to introduce the latest technology into their practice, not only to provide the best oral health care but to show their colleagues and patients they had the latest and best. Whether it was a radio, the new flying machine, or racing cross country in Pullman railcars with steam engines, Americans, including dentists, realized a new era was unfolding because of science, and they knew that an understanding of that science was vital to enjoy these advancements. To have a modern dental office, a scientific education was not only necessary but critical. Many dentists of the early twentieth century, for example, desired to incorporate radiography into their practices, just as physicians were doing, and therefore applied pressure on dental schools to add this new technology to the curriculum. In those days, technology transfer was rather slow. X-rays were discovered in 1895 by Wilhelm Roentgen and were utilized as early as 1896 by C. Edmund Kells for diagnosis.18 However, because training in dental radiology was not introduced into the dental school curriculum until 1918, x-ray machines would not become a fixture in dental practices until the early 1930s.19,20

Science in Nineteenth and Early Twentieth-Century America and Its Effect on the Dental Curriculum
A second reason dental academicians might have encouraged the teaching of the basic sciences was the popularity of the scientific method of systematic inquiry based on hypothesis-driven data collection and analysis in the late nineteenth and early twentieth centuries. Although the scientific method
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is well entrenched as a standard approach to the exploration of unknowns and problems today, it was an exciting new concept 100 years ago. There was great enthusiasm at that time for the concept of scientific inquiry and acceptance of its methods for uncovering facts and providing explanations for everyday occurrences from thunder and lightning to the causes of disease. By 1926, the scientific way of thinking had entered many aspects of contemporary life. The publication of Darwins Origin of Species in 185921 established the power of scientific reasoning; for any well-informed American wishing to demonstrate to friends and colleagues a level of erudition, there was no better way to do it than to quote the latest scientific findings. Not to be left behind, it would have been logical to expect that leaders of the dental profession, eager to keep up with their colleagues in medicine and to differentiate their activities from those of faith healers and phrenologists of the day, would want the public to know the practice of dentistry was grounded in the scientific methodand that the diagnoses and treatments recommended by dentists were discovered through laboratory research and clinical trials.

Dentistry Becomes a Learned Profession

There might have been a third reason science was encouraged. Between 1840 and 1953, dentistry acquired a body of knowledge and codified an educational curriculum for transmitting this knowledge. With the addition of an oath in which individuals professed commitment to do no harm, a code of conduct, and the necessary organization to enforce this code, dentistry had assembled most if not all of the elements that defined a learned profession.22 Clearly, the incorporation of science into the education of practitioners and advocacy of a systematic approach to investigating unknowns and problems were integral parts of this definition, and they would not be readily abandoned.

The Genomic Era: 19532007

Increase in Scientific Knowledge and the Genomic Revolution
By the onset of the twentieth century, the success of the scientific method in finding causes and
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treatments for human diseases had been established. In medicine, the method was applied dramatically and effectively to the etiology of cholera and tuberculosis.23,24 As a result of the application of the scientific method, the germ theory of disease was firmly established, displacing the miasma theorythe theory that diseases were caused by noxious airand allopathic medicine was able to displace the panoply of faith healers who practiced medicine until the early 1900s.25 By the time of World War II (the 1940s), just fifteen to twenty years after the Gies report, dentistry had established a scientific tradition, incorporated the scientific method as a way for transmitting knowledge, and joined medicine in becoming a learned profession. As the century reached its half-way point, a scientific discovery that would test their ability to adapt was about to shatter the tranquility and complacency of both the medical and dental professions. This discovery, coupled with many more to be made during the remainder of the century, was so disruptive that both professions ability to adapt, change, and grow would be severely tested. In 1953, the structure of DNA was published,11 and in 2001, only forty-eight years later, the sequence of the human genome was published.26 These two events not only affected what science could do and how, but influenced American culture as well. Everything from the political debate on stem cells to the making of sci-fi movies in Hollywood was affected by what is usually called the genomic revolution.27 The late twentieth century produced other technological surprises. In the 1970s, Bill Gates and Paul Allen were writing code for something called the computer, a technology that would change how we work and play. By 2000, Americans had entered the digital age, with the wireless age to follow a few years later. With the introduction of cell phones with photographic and wireless capabilities, America was on its way to experiencing a revolution in communication of similar magnitude to that experienced by Americans in the 1900s with the introduction of radio and the telephone. The medical and dental professions were expected to keep up. During the late twentieth century, the number of basic science curriculum hours increased substantially in dental school from 500 hours prior to World War II to an average of 840 hours in 1994, or from about 10 percent of the curriculum to approximately 18 percent.6,7,13 Scientific and technological advances continued after 1994, which stimulated recommendations within dental education for incorporation of more science hours into the dental school curricu-

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lum. However, a curriculum survey by the American Dental Association (ADA) showed that, in 200304, the number of science hours remained at about 840.28 This suggests that dental schools were having a difficult time deciding whether to increase the total amount of curriculum hours in order to incorporate more for science, to eliminate certain courses and replace them with others, or to add basic science lectures to clinical courses when relevant in order to teach new material.29 Dental schools in 200708 are attempting to deal with the last half-centurys increase in scientific bioknowledge, but the environment is very different from that in 1926. In 1926, when Gies recommended increasing the number of science courses, dental schools made room by increasing dental school from two to three years and then, soon after, to four years. While there was a brief flirtation by some schools with a fifth year, competition from the traditional four-year schools and profound questions about financing an extra year of dental school quickly ended consideration of this experiment. Unable to expand the curriculum beyond the four years, dental schools today are faced with few options for dealing with an already crowded curriculum. One option, as summarized in the following section, is to alter teaching strategies in an effort to better instill basic sciences in the curriculum without changing the amount of curriculum hours.

Using Innovative Technology for Teaching Bioscience

Given the constraints on curriculum expansion and faculty reluctance to make hard choices about content to keep or delete, the most viable option may be to change the format for teaching bioscience. For example, it could be argued that there is already sufficient basic science in the curriculum to build students understanding of new bio-based diagnostic and treatment technologies that are soon to emerge from the developmental pipeline. This argument is rarely stated but is apparent from a reading of dental schools mission statements. For those dental schools whose mission is to teach xenodonticsa term introduced to refer to the use of metals, plastics, and other materials foreign to the human body for the repair, replacement, and restoration of diseased and missing teethit might not be necessary to increase the science hours.30 Indeed, because of the introduction of new equipment such as CAD/CAM technologies

and lasers, new products such as composites, and new procedures such as implants, an argument can be made that a better use of the time would be to ensure mastery of these technologies and products. In 200708, using the lack of availability of clinical diagnostic or treatment technology as a reason not to teach a subject should come as no surprise. This same argument was used by dental educators in the 1900s. In the absence of a technology for clinical use, the dental professional is often reluctant to endorse the incorporation of science that underlies this technology. Again the parallel between 1900 and 2000 is striking. Historians have noted that it was not until after the availability of the first commercial dental x-ray in 1913 that dental radiography became a central diagnostic tool for the dental profession.18 Before 1913, not a single dental school in the United States taught the subject of radiography.18-20 Though physicians had made use of x-rays for many yearsa Philadelphia physician had even presented a lecture to that citys dental society in 1906 entitled The Advantages of X-rays in Dentistryit would not be until after 1926 and the Gies report that dental schools would teach radiography courses.31 The fact that bio-based diagnostic and treatment technologies are not on the market should not preclude their introduction to dental students. Introducing innovations into the dental curriculum, prior to the technology based on the innovation reaching market, offers several advantages to the learning of both science and clinical treatments. First, if these innovations are introduced within the science curriculum, they can be used as examples of the relevance of science material. Introducing biomimetic tissue engineered from stem cells for the replacement of dental and craniofacial structures can be useful in teaching basic science subjects from histology and embryology to the molecular biology of growth factors.32 Introducing emerging diagnostics that use saliva for the detection of risk of caries and periodontal disease and for various cancers would demonstrate the relevance of topics from immunoassays, molecular biology assays, polymerase chain reaction, and chip technology. Lectures that incorporate recent progress on vaccines for dental caries and periodontal disease would of necessity contain the science of vaccine biology including immunology, virology, and pathology.33-35 Introducing bio-based dental diagnostics and treatments might be one way to include genomic science content without an increase in the number of science hours.

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Conclusions
In this article, we explored the role of science and technology as a force for previous reform of the dental curriculum. Between the 1850s and 1920s, there were a significant number of advances in physics and chemistry, some of which resulted in technological improvements in areas such as communications and transportation. Scientific discoveries in the area of microbiology, in particular, the work of W.D. Miller, led to a better understanding of the etiology of dental caries. By 1926, the force generated by these scientific advances led to a report by William Gies that recommended the inclusion of additional science courses in the dental curriculum. His recommendations were readily accepted, and the dental curriculum was changed. In 1953, the structure of DNA was published, leading science and society into the genomic era. While this discovery produced a significant change in scientific circles, the dental curriculum remained relatively unchanged through the 1960s and into the 1990s. By 2000, the force of the discovery of the structure of DNA and the bioscience information accumulated in the intervening forty years had produced a genomic theory of disease. As this theory gained momentum in the medical community, there were those in the dental community who began to think about incorporating this bioscience into the dental school curriculum. This concern was included, in one form or another, in reports recommending changes in dental education in 1995, 2000, and 2001.6-9 The fact that curriculum reform is again on the agenda of dental organizations suggests that many recommendations remain to be implemented. Taking 1895, the discovery of x-rays, as a starting point, it took about thirty years for the major scientific and technological advances made in the last half of the nineteenth century and early twentieth century to produce sufficient force to influence the dental profession. The 1926 Gies report can be seen as a response to that force. We suggest that the rapid and universal acceptance of the Gies recommendations for increasing the amount of science in the curriculum occurred because of the flexibility to expand dental school from two to four years. In our view, another factor prompting the acceptance of scientific advances in the years following the Gies report was the availability of technology and products in the schools dental clinics. The use of these products required knowledge of the science underlying the

technology. For instance, to use the x-ray machine required knowledge of the science of radiation. It is our opinion that the educational reform recommendations over the past ten years that proposed better integration of bioscience into the dental school have not been immediately accepted because the dental curriculum today remains overcrowded and the biosciences have not yet been translated into technologies and products. Any attempt to reform the curriculum must overcome these two difficulties. In 2008, many bio-based diagnostics and therapeutics are emerging from the discovery pipeline and entering the marketplace. As they do, diagnosis and treatment will shift from a germ theory to a theory for disease processes based on epigenetics.36 Clearly, to have a successful practice in the twenty-first century, dental graduates will need the intellectual framework to incorporate genomic bio-based products and technologies into their practices. Only if this intellectual framework is incorporated into the dental curriculum will dental schools be able to graduate professionals with adequate exposure to biological science and understanding of its importance. Of course, any curriculum changes should be reinforced by changes in the ADA accreditation guidelines. These must be updated to evaluate mastery of the scientific progress of the last ten to twenty years, particularly mastery of areas such as genomics, proteomics, and phenotyping technologies, the microbiome, and epigenetics.

Recommendations
As discussed above, a number of reports on the status of dental education over the past ten to fifteen years have concluded, to varying degrees, that the explosion of new bioscience information that has occurred since the 1950s necessitates an alternative approach to the teaching and learning of the sciences in the dental school curriculum.6-9 These reports have recommended better integration of basic science and clinical concepts, more casebased (patient-based) teaching and assessment, deletion of basic science material of peripheral relationship to the practice of general dentistry, and increased emphasis on new scientific breakthroughs (e.g., genomics and diagnostics). As the addition of more hours to the curriculum may not be an option, dental schools have experimented with changing teaching strategies. At the University of Connecticut

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School of Dental Medicine, an educational program was developed based on this idea. The format for this experimental program, which has been called Biodontics, introduces innovative bio-based technology and products for diagnosis and treatment and then presents the biosciences needed to use and interpret data from these technologies.30,37 For example, an extensive knowledge of bioscience is needed to understand how saliva can be used as a diagnostic tool, how stem cells can be used to bioengineer tooth replacements or bio-scaffolds for bone replacement, how salivary glands can be used for drug delivery, or how blood tests can be used for periodontal risk determination. We recommend a format for the basic science curriculum that emphasizes products and technologies as a means to teach the biosciences, demonstrates the relevance of bioscience to clinical dentistry, and links the biosciences to clinical dental practice.

Acknowledgments

The authors wish to thank Dr. Bernard W. Janicki for his thoughtful comments and helpful suggestions. The University of Connecticut School of Dental Medicines Biodontics program is supported in part by a grant from theNational Institute of Dental and Craniofacial Research(DE01628).

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33. Smith DJ, Akita H, King WF, Taubman MA. Purification and antigenicity of a novel glucan binding protein of streptococcus mutans. Infect Immun 1994;62:254552. 34. Moharamzabeh K, Brook IM, Van Noort R, Scutt AM, Thornhill MH, et al. Tissue-engineered oral mucosa: a review of the scientific literature. J Dent Res 2007;86(2):11524.

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