Among the many recent technological innovations

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1 Use of Technology in Dental Education Implementation of New Technologies in U.S. Dental School Curricula Sheri A. Brownstein, DMD; Aseel Murad, BDS, DMD; Ronald J. Hunt, DDS, MS Abstract: With dentistry rapidly evolving as new technologies are developed, this study aimed to identify the penetration of emerging dental technologies into the curricula of U.S. dental schools and to explore whether certain school characteristics affected adoption of these technologies. A 19-question survey was sent to the academic deans of all 62 U.S. dental schools. In addition to questions about characteristics of the school, the survey asked respondents to indicate where in their curricula the technology was incorporated: preclinical didactic, preclinical laboratory, clinical didactic, and/or clinical patient experience. Of 62 eligible schools, 33 useable responses were received, for a 52% response rate. The results showed that the greatest overall penetration of dental technologies was in preclinical didactic courses and the lowest was in the preclinical laboratory. Specific technologies implemented in the largest percentage of responding schools were digital radiography and rotary endodontics. The technologies with the lowest penetration were CAD/CAM denture fabrication and hard tissue lasers. These results suggest that the incorporation of technology into dental schools is following that of private practice as the most widely adopted technologies were those with the greatest acceptance and use in private practice. Among the respondents, factors such as class size and age of the school had greater impact on incorporation of technology than funding source and geographic location. Dr. Brownstein is Assistant Professor, College of Dental Medicine-Arizona, Midwestern University; Dr. Murad is Assistant Professor, College of Dental Medicine-Arizona, Midwestern University; and Dr. Hunt is Professor and Associate Dean of Academic Affairs, College of Dental Medicine-Arizona, Midwestern University. Direct correspondence to Dr. Sheri A. Brownstein, Midwestern University, College of Dental Medicine-Arizona, North 59th Ave., Glendale, AZ 85308; ; sbrown1@midwestern.edu. Keywords: dental education, dental technology, educational technology, curriculum Submitted for publication 6/16/14; accepted 8/9/14 Among the many recent technological innovations in the field of dental medicine are computer-assisted design/computerassisted manufacturing (CAD/CAM)-fabricated indirect restorations, digital impressions, and cone beam imaging. Dental product manufacturers are now marketing directly to the public, and today s patients have information about dental technologies readily available via the Internet; as a result, they demand state-of-the-art dental care. New practitioners must be prepared to respond to that demand, so exposing dental students to emerging patient care technologies may contribute to their future success. As Iacopino noted, It is generally accepted that most new practitioners use the technologies that they were exposed to and worked with in their dental training and postgraduate residencies (451). 1 Most dental students today belong to the millennial generation, 2 which adapts quickly to emerging technologies and uses them frequently in both educational and personal settings. 3 Social media, e-books, and interactive lectures are commonplace in current dental curricula, 4,5 and teaching strategies have evolved to accommodate the needs of this generation of learners. 1 To facilitate their students learning, dental faculty members now routinely incorporate technologies such as Turning Point, videos, and social media into their lectures. Beyond those educational technologies, dental educators must also keep current on new developments in their industry in order to give students access to and experience with newer technologies and techniques to ensure their ability to give patients the highest quality of care. As mandated by Commission on Dental Accreditation (CODA) standards, all dental schools must provide faculty development programs to help educators keep abreast of new technologies. 6 Different dental schools, though, adopt technology at different rates. This variability can be due to the fact that evidence-based dentistry and professional standards of care must be used to make informed decisions regarding curriculum change and patient care. Most educators agree that new technologies, materials, and techniques must be supported by evidence of clinical success before incorporating them into the curriculum. 7 This requirement helps explain March 2015 Journal of Dental Education 259

2 why dental schools may be cautious in changing from techniques with long-term evidence of clinical success to more recent technologies. Although many reports have been published about the incorporation of technologies at individual dental schools, little is known regarding the extent to which emerging dental technologies have been incorporated into the curricula of dental schools across the United States or the degree to which students are being exposed to them. The aim of this study was to identify the penetration of emerging dental technologies into the curricula of U.S. dental schools and to explore some school characteristics that may affect adoption of these technologies. In addition, the study sought to test the hypotheses that dental schools that have smaller class sizes, are newer, or are privately funded would adopt more emerging technologies. Methods The Midwestern University Institutional Review Board deemed the study exempt from full review and determination. To determine the penetration of 12 dental practice technologies into U.S. dental curricula, we developed a nineteen-question survey and distributed it via SurveyMonkey to the academic deans of all 62 U.S. dental schools. addresses of the academic deans were obtained from the American Dental Education Association (ADEA) institutional directory. The survey link was embedded within an addressed to each individual. Each school was assigned a randomly generated identification code known only to the primary researchers. The survey was field tested for ease of use, time required to complete, and understanding of the content by two Midwestern University College of Dental Table 1. Numbers and response rates to survey of U.S. dental schools by primary funding source and geographic region All Number Response Schools Responding Rate Total % Primary funding source Private % Public % Geographic region West % Northeast % Southeast % Medicine-Arizona (CDMA) associate deans and five CDMA faculty members. Some minor adjustments were made to the survey before the final version was distributed. The initial was followed by up to two reminders for nonrespondents. The s were sent from January to April The survey asked the academic deans to indicate which of 12 dental practice technologies had been incorporated into their school s dental education program. The technologies were 1) CAD/CAM for fabricating indirect restorations (e.g., Cerec or E4D); 2) CAD/CAM for fabricating dentures (e.g., Dentca or Avadent); 3) digitally aided orthodontic appliances (e.g., Invisalign or Clear Align); 4) digital radiography (e.g., Gendex or Dexis); 5) cone beam technology; 6) virtual models for implant surgical stent fabrication; 7) rotary endodontic handpieces and files; 8) reciprocating endodontic handpieces and files; 9) warm gutta percha obturation (e.g., Obtura); 10) digital caries detection devices (e.g., DIAGNOdent, DIFOTI, Canary); 11) soft tissue lasers (e.g., Diode, YSGG, CO2); and 12) hard tissue lasers (e.g., YSGG). The academic deans also were asked to indicate where in their curricula the technology was incorporated: preclinical didactic, preclinical laboratory, clinical didactic, and/or clinical patient experience. Preclinical was defined as being in the first- and second-year curricula, and clinical was defined as being in the third- and fourth-year curricula. The respondents were given a choice of other with the option to make any additional comments. The survey also included several questions about characteristics of the school. We hypothesized that schools that had smaller class size, had operated for fewer years, and were privately funded would demonstrate greater penetration of the technologies into their curricula. Results Of the 62 eligible dental schools, 33 useable responses were received (Table 1), for a 52% response rate. The response rate differed little by the school s primary funding source (public: 54% vs. private: 52%) and only slightly by geographic region (West: 50% vs. Northeast: 48% vs. Southeast: 65%). The greatest overall penetration of dental technology among the responding dental schools was in preclinical didactic courses (62% average penetration), and the lowest was in the preclinical laboratory (36%) (Table 2). The specific technologies implemented in the largest percentages of these 260 Journal of Dental Education Volume 79, Number 3

3 Table 2. Percentages of responding U.S. dental schools reporting use of dental technologies by part of curriculum (N=33) Clinical Patient Technology Preclinical Didactic Preclinical Laboratory Clinical Didactic Experience CAD/CAM indirect restorations 76% 55% 48% 58% CAD/CAM dentures 39% 9% 30% 3% Digital orthodontics 64% 24% 33% 30% Digital radiography 90% 79% 79% 91% Cone beam technology 73% 27% 73% 85% Virtual stents, implant placement 55% 30% 42% 30% Rotary endodontics 85% 85% 76% 79% Reciprocating endodontics 45% 27% 30% 30% Warm gutta percha 64% 42% 63% 36% Digital caries detection 63% 21% 36% 30% Soft tissue lasers 52% 24% 55% 39% Hard tissue lasers 36% 12% 36% 12% Overall average 62% 36% 50% 44% schools were digital radiography (85%) and rotary endodontics (81%). The technologies with the lowest penetration were CAD/CAM denture fabrication (20%) and hard tissue lasers (24%). For clinical patient experience, six of the 12 technologies listed were used in 30% or less of the schools clinics. Dental schools with larger class sizes (over 100 students) tended to incorporate fewer of the new technologies into their curricula (Table 3). Similarly, schools older than 60 years were less likely to have incorporated technologies than newer schools (Table 4). There were no significant differences between publicly funded schools and privately funded schools in the implementation of the technologies (Table 5). Discussion Among the many challenges in implementing new technologies into a dental school curriculum is appropriate preparation of the faculty. According to Hendricson et al., As the demands on faculty continue to expand, it is now recognized that preparing health professions faculty for their teaching responsibility is a necessary function of academic institutions (p. 1518). 8 Most new faculty recruits are in the 55 to 60 years of age range and are changing their career paths from private practice, military service, or public health positions. 9,10 While most of Table 3. Percentages of responding U.S. dental schools reporting use of dental technologies by curriculum location and class size (N=19 with <100 students per class; N=14 with ê100 students per class) Preclinical Preclinical Clinical Clinical Patient Didactic Laboratory Didactic Experience Technology < < < < CAD/CAM indirect restorations 84% 64% 63% 43% 47% 5% 63% 5% CAD/CAM dentures 58% 14% 16% 0 26% 36% 5% 0 Digital orthodontics 63% 64% 21% 29% 26% 43% 26% 36% Digital radiography 1% 79% 89% 64% 84% 71% 1% 79% Cone beam technology 89% 5% 21% 36% 74% 71% 95% 71% Virtual stents, implant placement 58% 5% 37% 21% 37% 51% 37% 21% Rotary endodontics 89% 79% 89% 79% 74% 79% 89% 64% Reciprocating endodontics 53% 36% 37% 14% 37% 21% 42% 14% Warm gutta percha 74% 5% 53% 29% 58% 71% 42% 29% Digital caries detection 79% 43% 21% 21% 37% 36% 37% 21% Soft tissue lasers 63% 36% 32% 14% 68% 36% 58% 14% Hard tissue lasers 37% 36% 16% 7% 42% 29% 16% 7% Overall average 62% 39% 41% 30% 51% 46% 43% 30% March 2015 Journal of Dental Education 261

4 Table 4. Percentages of responding U.S. dental schools reporting use of dental technologies by curriculum location and age of school (N=14 <60 years; N=19 ê60 years) Preclinical Preclinical Clinical Clinical Patient Didactic Laboratory Didactic Experience Technology <60 60 <60 60 <60 60 <60 60 CAD/CAM indirect restorations 93% 63% 79% 37% 50% 47% 71% 47% CAD/CAM dentures 71% 16% 21% 0 21% 37% 7% 0 Digital orthodontics 71% 58% 29% 21% 29% 37% 21% 37% Digital radiography 100% 84% 100% 63% 93% 68% 100% 84% Cone beam technology 86% 63% 14% 37% 64% 79% 86% 84% Virtual stents, implant placement 64% 47% 36% 26% 29% 53% 36% 26% Rotary endodontics 93% 79% 93% 79% 93% 63% 100% 63% Reciprocating endodontics 50% 42% 29% 26% 43% 21% 43% 21% Warm gutta percha 79% 53% 64% 26% 64% 63% 57% 21% Digital caries detection 71% 58% 21% 21% 29% 42% 36% 26% Soft tissue lasers 64% 42% 43% 11% 71% 42% 64% 21% Hard tissue lasers 43% 32% 21% 5% 43% 32% 21% 5% Overall average 74% 53% 46% 29% 52% 49% 54% 36% Table 5. Percentages of responding U.S. dental schools reporting use of dental technologies by curriculum location and funding source (N=20 publicly funded; N=13 privately funded) Preclinical Preclinical Clinical Clinical Patient Didactic Laboratory Didactic Experience Technology Public Private Public Private Public Private Public Private CAD/CAM indirect restorations 73% 82% 55% 55% 55% 36% 59% 55% CAD/CAM dentures 32% 55% 9% 9% 23% 45% 5% 0 Digital orthodontics 59% 73% 23% 27% 32% 36% 23% 45% Digital radiography 91% 91% 77% 82% 82% 73% 91% 91% Cone beam technology 73% 73% 23% 36% 82% 55% 91% 73% Virtual stents, implant placement 46% 73% 23% 45% 41% 45% 27% 36% Rotary endodontics 82% 91% 82% 91% 77% 73% 73% 91% Reciprocating endodontics 42% 55% 27% 27% 27% 36% 27% 36% Warm gutta percha 64% 67% 41% 46% 64% 64% 36% 36% Digital caries detection 64% 64% 18% 27% 36% 36% 27% 36% Soft tissue lasers 55% 46% 23% 27% 55% 55% 41% 36% Hard tissue lasers 32% 46% 14% 9% 32% 45% 14% 9% Overall average 59% 68% 35% 40% 50% 50% 43% 45% these practitioners have vast clinical experience, few have adequate knowledge of teaching strategies, philosophies, and general expectations and policies of an academic setting. As a result, most faculty development topics deal with teaching methodologies, techniques, and advancement. 8 This faculty development time then competes with courses concerning emerging clinical technologies. It also may be challenging for full-time dental school faculty members to keep up with emerging technologies while maintaining full-time academic responsibilities. Dental school instructors must also be calibrated with each other in the content of their courses to provide students a consistent learning environment. As the curriculum content should be uniformly taught by all faculty members, time and effort are required to evaluate, develop, and calibrate educators to a new protocol, technology, technique, or concept. These are some of the hurdles faced by today s dental educators and administrators regardless of faculty size, which may explain the slower acceptance and integration of newer technologies. 262 Journal of Dental Education Volume 79, Number 3

5 The greatest overall integration of technology among the responding dental schools in our study was in the preclinical didactic courses. This could be a result of the ease with which a new concept or material may be implemented at the didactic level, where content can be readily modified. Adding a laboratory or clinical component, by contrast, may be complicated by the acquisition of new materials and supplies that require the allocation of additional funds and administrative approval. Further, when new technologies are added, conventional exercises may be displaced because a limited number of laboratory hours are available for instruction. As faculty members routinely update their lectures yearly to ensure they remain current and relevant, it is uncomplicated to add new technologies to the didactic curriculum. The incorporation of technology into U.S. dental school curricula tends to follow that of private practice. The one exception discovered in this study was the high penetration of cone beam computed tomography (CBCT) into dental curricula, whereas most private dental practices do not own a CBCT scanner. This discrepancy could be due to the fact that universities have access to funding for purchase of such expensive equipment. Since dental practitioners do routinely send patients to imaging centers for CBCT diagnostics in implant treatment planning, learning about this technology while in dental school is useful. This study also found that the specific technologies most implemented in these U.S. dental schools are digital radiography and rotary endodontics. Digital radiography was introduced to dentistry in the mid-1980s by Francis Mouyen and is widely accepted and used in clinical practice. 11 Similarly, according to a recent survey of general dentists, 74% used NiTi rotary files for cleaning and shaping root canals. 12 These technologies have been proven successful and have been widely incorporated into private dental practices around the United States. In contrast, CAD/CAM denture fabrication, which Dentca Inc. claims to have been the first to develop, has been around fewer than ten years and is not yet widely used in private practice. 13,14 Likewise, although hard tissue lasers developed for dentistry have been reported in the literature since 1988, they are also not commonplace in private practice due to their limited clinical applications. 15,16 Our study found correlations between incorporation of new technologies and both class size and age of school. In our results, the schools with larger classes tended to incorporate fewer technologies. As more resources are required to implement new items into the curriculum, it may be more difficult for schools with larger classes to effect change. As well as financial considerations, implementing changes in the curriculum takes time. The more students who must become competent in a task, the longer the instruction will take. This does not, however, take into account other factors such as teaching methodologies and modalities. The correlation of older schools with fewer technologies may be a reflection of the point that newer schools tend to accept changes more willingly and therefore may incorporate new technologies and materials more readily as their curricula are still evolving. As schools mature, policies and curriculum may become more established and resistant to change. Dental schools are responsible for educating future dentists about new technologies. Especially considering the high cost of dental education, incorporating new technologies into the curriculum gives students a greater return on their academic investment one that will ultimately affect their future practices and patient care. To continue learning after dental school, students must also be taught how to read and analyze journal articles, evaluate research data and scientific evidence, and choose among options for continuing education in order to make educated, informed decisions about patient care. Therefore, dental faculty members must not only strive to expose students to new and proven technologies, but also give them the tools with which to make evidence-based decisions about technologies after graduation. This exposure improves the quality of the curriculum by keeping students current with the rest of the dental community during dental school and for the rest of their careers. As with all surveys, our research results are limited to the knowledge and recall of the respondents, which may be incomplete. The academic deans surveyed may not have been cognizant of all specifics of their curricula, and some may have spent more time consulting department heads than others. In addition, the number of U.S. dental schools and the response rate of the schools limited the sample size. This study investigated only the penetration of technologies into dental curricula. More research should be conducted into the reasons why specific technologies that have been adopted in many dental practices have not been incorporated into dental school curricula. Follow-up surveys could monitor the future penetration of these dental technologies. March 2015 Journal of Dental Education 263

6 Conclusion As the field of dental medicine continues to incorporate new technologies, dentists must stay current by participating in continuing education courses and reading and analyzing the appropriate literature. Dental educators must also stay current with emerging technologies as they are developed and implemented in order to provide the most comprehensive education to their students. This study was conducted to identify which technologies are currently incorporated into U.S. dental schools predoctoral programs as well as to determine factors that may affect the incorporation of these technologies. The results showed that the incorporation of technology into dental schools follows that of private practice as the technologies that were adopted the most were those with the greatest acceptance and use in private practice. Factors such as class size and age of the dental program were found to have a greater impact on the incorporation of technology than funding source and geographic location. Acknowledgments The researchers would like to extend their gratitude to the faculty and administrators who took the time to respond to this survey. Disclosure The authors did not receive any funding or benefits from industry or elsewhere to conduct this study. REFERENCES 1. Iacopino A. The influence of new science on dental education: current concepts, trends, and models for the future. J Dent Educ 2007;71(4): Evans L, Hanes PJ. Online cultural competency education for millennial dental students. J Dent Educ 2014;78(6): DiLullo C, McGee P, Kriebel RM. Demystifying the millennial student: a reassessment in measures of character and engagement in professional education. Anat Sci Educ 2011;4: Bahner DP, Adkins E, Patel N, et al. How we use social media to supplement a novel curriculum in medical education. Med Teach 2013;34: Ditmer MM, Dye J, Guirguis N, et al. Electronic vs. traditional textbook use: dental students perceptions and study habits. J Dent Educ 2011;76(6): Commission on Dental Accreditation. Accreditation standards for dental education programs. Chicago: American Dental Association, Hendricson W, Cohen P. Future directions in dental school curriculum, teaching, and learning. In: Leadership for the future: the dental school in the university. Washington, DC: Center for Educational Policy and Research, American Association of Dental Schools, 1999: Hendricson WD, Anderson E, Andrieu SC, et al. Does faculty development enhance teaching effectiveness? J Dent Educ 2007;71(12): Chmar J, Weaver R, Valachovic RW. Dental school vacant budgeted faculty positions, academic years and J Dent Educ 2008;72(3): Bertolami C. Creating the dental school faculty of the future: a guide for the perplexed. J Dent Educ 2007;71(10): Van der Stelt PF. Filmless imaging: the uses of digital radiography in dental practice. J Am Dent Assoc 2005;136: Savant GM, Sannah W, Sedgley CM, Whitten B. Current trends in endodontic treatment by general dental practitioners: report of a United States national survey. J Endod 2014;40(5): Bidra AS, Taylor TD, Agar JR. Computer-aided technology for fabricating complete dentures: systematic review of historical background, current status, and future perspectives. Prosthet Dent 2013;109(6): About Dentca. At: dentca.com/aboutus.asp. Accessed 6 June Husein A. Applications of lasers in dentistry: a review. Arch Orofac Sci 2006;1: Verma SK, Maheshwari S, Singh RK, Chaudhari PK. Lasers in dentistry: an innovative tool on modern dental practice. Natl J Maxillofac Surg 2012;3(2): Journal of Dental Education Volume 79, Number 3