CDA Journal - January 2022: Dental Student Research

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January 2022 Teledentistry Hybrid Learning Case-Based Discussions Community-Based Education

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Dental Student Research Mariela Padilla, DDS, M.Ed

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Jan. 2022

C D A J O U R N A L , V O L 5 0 , Nº 1

d e pa r t m e n t s

5 Guest Editorial/Ethics Should Fit the Scope of Practice 7 Farewell to Dr. Shue 9 Impressions 65 RM Matters/Handle With Care: Minimizing Risk With Short-Term and Traveling Patients

68 Regulatory Compliance/The Road to E-Prescribing 70 Tech Trends f e at u r e s

13 Dental Student Research An introduction to the issue.

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Mariela Padilla, DDS, M.Ed C.E. Credit

17 Evolution of Patient Care Post-Pandemic: Teledentistry the New Norm, a Narrative Review This review provides an overview of the history, legality, billing and infrastructure needed for teledentistry service. Antranig Mesrobian, MS; Karam Korya, BS; and Kamal Al-Eryani, DDS, PhD

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Impact of Hybrid Learning on Students’ Performance in Biomedical Sciences During COVID-19 Pandemic This study compared in-person to hybrid instructional delivery methods for acquiring biomedical sciences knowledge and critical thinking skills of first- (D1) and second-year (D2) dental students. Oussama Hefnawi, BS; Xi Chen, DPPD, MPA; and Mahvash Navazesh, DMD

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Efficacy of Virtual Asynchronous Didactic Delivery and Case-Based Discussions for Predoctoral Orthodontic Education The purpose of this research is to evaluate the efficacy of virtual didactic delivery and CBL discussions for a predoctoral orthodontics course using a pilot study of “coded discussions” and contrasting student course evaluations with a previous traditional in-person lecture iteration of the same course. James Chen, DDS, PhD, MPH; Brandon Zegarowski, DDS; and Mandy Lam, DDS

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Dental Student Community Clinic Placement in Australia and the United States: Systematic Review and Case Study This review examined community clinic rotations and their impact on dental students’ level of competence in Australia and the United States. Anna Doan Bowers, DDS; Ove A. Peters, DMD, MS, PhD; Paul Subar, DDS, EdD; Sandra March, BDSc; and Christine I. Peters, DMD

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C D A J O U R N A L , V O L 5 0 , Nº 1

Journa C A L I F O R N I A

published by the California Dental Association 1201 K St., 14th Floor Sacramento, CA 95814 800.232.7645 cda.org

CDA Officers Ariane R. Terlet, DDS President president@cda.org John L. Blake, DDS President-Elect presidentelect@cda.org

D E N TA L

Management Peter A. DuBois Executive Director Carrie E. Gordon Chief Strategy Officer Alicia Malaby Communications Director

Editorial Kerry K. Carney, DDS, CDE Editor-in-Chief Kerry.Carney@cda.org Ruchi K. Sahota, DDS, CDE Associate Editor

Carliza Marcos, DDS Vice President vicepresident@cda.org

Marisa K. Watanabe, DDS, MS Associate Editor

Max Martinez, DDS Secretary secretary@cda.org

Gayle Mathe, RDH Senior Editor

Steven J. Kend, DDS Treasurer treasurer@cda.org Debra S. Finney, MS, DDS Speaker of the House speaker@cda.org Judee Tippett-Whyte, DDS Immediate Past President pastpresident@cda.org

Volume 50 Number 1 January 2022

A S S O C I AT I O N

Jack F. Conley, DDS Editor Emeritus

Permission and Reprints

Journal of the California Dental Association Editorial Board

Robert E. Horseman, DDS Humorist Emeritus

Andrea LaMattina, CDE Publications Manager Andrea.LaMattina@cda.org 916.554.5950

Charles N. Bertolami, DDS, DMedSc, Herman Robert Fox dean, NYU College of Dentistry, New York

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February/ Post-Pandemic Assessment March/General Topics April/Pregnancy

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Mariela Padilla, DDS, M.Ed Guest Editor Andrea LaMattina, CDE Publications Manager Kristi Parker Johnson Communications Manager Blake Ellington Tech Trends Editor

The Journal of the California Dental Association (ISSN 1942-4396) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. The California Dental Association holds the copyright for all articles and artwork published herein.

Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental Medicine, Pomona, Calif. Mina Habibian, DMD, MSc, PhD, associate professor of clinical dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles Robert Handysides, DDS, dean and associate professor, department of endodontics, Loma Linda University School of Dentistry, Loma Linda, Calif. Bradley Henson, DDS, PhD , associate dean for research and biomedical sciences and associate professor, Western University of Health Sciences College of Dental Medicine, Pomona, Calif. Paul Krebsbach, DDS, PhD, dean and professor, section of periodontics, University of California, Los Angeles, School of Dentistry Jayanth Kumar, DDS, MPH, state dental director, Sacramento, Calif. Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral health education, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Nader A. Nadershahi, DDS, MBA, EdD, dean, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry Michael Reddy, DMD, DMSc, dean, University of California, San Francisco, School of Dentistry

The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor do advertisements constitute endorsement or approval of advertised products or services.

Avishai Sadan, DMD, dean, Herman Ostrow School of Dentistry of USC, Los Angeles

Copyright 2022 by the California Dental Association. All rights reserved.

Brian J. Swann, DDS, MPH, chief, oral health services, Cambridge Health Alliance; assistant professor, oral health policy and epidemiology, Harvard School of Dental Medicine, Boston

Visit cda.org/journal for the Journal of the California Dental Association’s policies and procedures, author instructions and aims and scope statement.

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Harold Slavkin, DDS, dean and professor emeritus, division of biomedical sciences, Center for Craniofacial Molecular Biology, Herman Ostrow School of Dentistry of USC, Los Angeles

Richard W. Valachovic, DMD, MPH, president emeritus, American Dental Education Association, Washington, D.C.


Guest Editorial

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Ethics Should Fit the Scope of Practice David W. Chambers, EdM, MBA, PhD

W ■

hich of the following is a definition and which is a characterization?

Humans have dignity, individual and collective rights and may not be harmed. Humans are featherless bipeds (Aristotle).

The first is more attractive: It says nice things about humans. It also characterizes seagulls, religious and fraternal organizations, the redwoods and the U. S. Constitution. But the function of definitions is to sort things into examples and nonexamples. Aristotle’s rule would pretty accurately get all the humans in one pile and all the nonhumans in another. Dentistry is evolving, and recently there has been interest in defining oral health or even health generally to accommodate these changes. Consider the following: ■  World Health Organization (WHO) definition: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. ■  American Dental Association (ADA) definition: Oral health is a functional, structural, aesthetic, physiologic and psychosocial state of well-being and is essential to an individual’s general health and quality of life. ■  FDI World Dental Federation definition: Oral health is multifaceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through

The ethical challenge comes in claiming to be addressing community needs by only responding to individual needs.

facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex. There is a bit of circularity in the WHO definition since one of the dictionary definitions of “well-being” is “a state of health.” The second part just says that other definitions are incomplete. The ADA “definition” is also circular, but positive in the set of characterizations that are enumerated: “Functional, structural and aesthetic” features are traditional criteria for judging the work of dentists. But it is not traditional to hold dentists responsible for psychosocial thriving. Dentists would not have their licenses disciplined for failure to do so in a “complete” fashion. The FDI definition is a little stronger. It lists a set of operations relative to the oral complex that “healthy” individuals are capable of without undesirable limitations. The trouble here is that health is defined by a standard of disease. It is the old question of whether the patient has a temperature. Yes, everyone does, but is it too low to be consistent with life or so high that it represents a threat? In a way, these “definitions” are telling us where to look and when to feel satisfied but not whether we have found what we are looking for. It is as clear as can be that dentistry has succeeded and beyond anything that could have been imagined even a few years ago. Master clinicians of 100, 50

and perhaps even fewer years ago lacked the know-how, technology and delivery systems to accomplish what is now expected of the average recent graduate. Americans expect that long-lasting, painless, beautiful smiles can be had by those who want them. At the same time, school districts across the country are forgoing hundreds of thousands of dollars annually in lost per capita attendance reimbursement because children are absent with oral pain. Rural America is being left behind by the consolidation of dental business and its technology boom that depends on a concentration of paying customers. Dental visits are up slightly for the young and the old, but down for the majority of the population. Dentists are the least trusted of the health professionals while at the same time dentistry is regarded as one of the top “jobs.” The progress of dentistry depends to some extent on how dentistry is defined. We are tangled in confusions over means and ends, individuals and communities, opportunities and obligations and the assumption that what is legally and economically justified is also ethical. Many of the exciting recent developments in dentistry, especially those of a highly technical and interdisciplinary nature, serve real needs, but for a small segment of the population. Sometimes the prospect of mastering a new JANUARY 2 0 2 2

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GUEST EDITORIAL C D A J O U R N A L , V O L 5 0 , Nº 1

technology skews treatment patterns. The greatest concern among dentists and patients alike now is overtreatment: Technically acceptable treatment that is not needed. Both dentistry (the means) and oral health (the outcome) must be ethically sound. Questionable procedures justified by good intentions fail the test of ethics. So does wanting to be a technique star at the expense of patients’ health broadly speaking. The WHO, ADA and FDI definitions are open on the question of whether oral health is an individual or a general good. Would a community with a basically adequate level of dental functioning be healthier than one with a few “show-off” mouths and many in oral distress? There is much to be said on both sides of this issue. We can hardly fault patients who want the best for themselves or criticize dentists for responding more readily to those who are willing to pay for the best. There are large cohorts of individuals who place low value on oral health, are demanding and difficult to treat (if they even show for a scheduled appointment) and detract from the capacity to serve others. Governments and insurance exist for the very purpose of balancing individual and group needs. Professional organizations have the double responsibility of representing the well-being of members and assuring the public that the profession (in the collective sense) is responding to the needs of the public (in the collective sense). The ethical challenge comes in claiming to be addressing community needs by only responding to individual needs. There is ample evidence in the technology literature that periods of rapid change coincide with and contribute to periods of increasing disparities in income and health. The category-creating feature of definitions advances claims about who is entitled to do what. As statements about 6 JANUARY

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scope of practice, they define markets. Expanding the scope of dentistry has both positive and negative features. Claims on larger markets will lead inevitably to conflicts with other professions and with payers. Scope implies responsibility. Using CBCT images is a market builder. It also represents a liability because the visual area available for review, and thus for which a practitioner is responsible for acting knowledgeably on, is increased. Failure to diagnose, especially relatively low-paying areas of periodontal disease and oral cancer, is one of the leading reasons for malpractice

The greatest concern among dentists and patients alike now is overtreatment: Technically acceptable treatment that is not needed.

suits and actions against dentists’ licenses. This is case selectivity. Broadening the scope of practice means increasing the level of training. The tension between expanding the market and expanding the training necessary can be gauged by comparing the profession’s budget for lobbying and indemnity programs with its support of education. The ethical issue associated with itching to enlarge scope at the higher end is that in order to be financially sustainable, resources will have to go to fewer patients paying higher fees for more advanced (or different) needs. This is entirely a legal or economic consideration, except in cases where a profession attempts to prevent others from servicing needs that are unattractive to the profession. Then it is an ethical issue.

Some tentative definitions … Oral health: Optimal attainable function and appearance and prevention and repair of diseases and damage to the orofacial complex, including conditions that interact with it. ■  Dentistry: The profession that accepts responsibility for oral health outcomes as its essential and primary reason for existing. ■  Dental market: Range of activities dentists have an economic and legal right to perform. n ■

David W. Chambers, EdM, MBA, PhD, is a professor of orthodontics and former associate dean for academic affairs and scholarship at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco. He is also the editor of the American College of Dentists and published over 650 papers, including a monthly Journal column on ethics. Dr. Chambers received the American Dental Education Association Gies Award for Achievement in 2018. Reprinted with permission from the Journal of the American College of Dentists.


C D A J O U R N A L , V O L 5 0 , Nº 1

CDA Journal thanks Dr. Shue for his service, welcomes new associate editor Dr. Watanabe The staff of the Journal of the California Dental Association expresses its deep gratitude to Brian K. Shue, DDS, CDE, for his dedication to producing an exceptional journal experience for our readers. Over his 12 years as associate editor, Dr. Shue contributed thoughtful and sometimes provocative commentary, challenging readers to consider topics and concerns relevant to the profession. His very personal editorial “The Dis Ease of Microaggressions” was reprinted in the Journal of the American College of Dentists and the SDDS Nugget. He also served as guest editor for the May 2009 issue of the Journal “Serving the Underserved,” which was used by the American Dental Association to help inform its leadership. Dr. Shue is the dental director of a federally qualified health center and is a certified dental editor. He served as president of the American Association of Dental Editors and Journalists (AADEJ),

managing to successfully navigate through some very rough existential seas and bring the organization to a safe harbor. Dr. Shue was also the editor of the San Diego County Dental Society for 15 years. His quiet, unassuming manner belies his steadfast and dependable self. We are grateful for his professionalism and his perennially positive attitude. We are excited to welcome our new associate editor, Marisa K. Watanabe, DDS, MS. Dr. Watanabe is an associate dean for community partnerships and access to care in the College of Dental Medicine at Western University. Dr. Watanabe, who has worked with dental publications throughout her educational career, has been a frequent reviewer as well as a guest editor for the Journal. We are pleased Dr. Watanabe has agreed to join the Journal team and look forward to her contributions. n

The Journal welcomes letters We reserve the right to edit all communications. Letters should discuss an item published in the Journal within the last two months or matters of general interest to our readership. Letters must be no more than 500 words and cite no more than five references. No illustrations will be accepted. Letters should be submitted at editorialmanager.com/ jcaldentassoc. By sending the letter, the author certifies that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publication elsewhere, and the author acknowledges and agrees that the letter and all rights with regard to the letter become the property of CDA.

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Impressions

C D A J O U R N A L , V O L 5 0 , Nº 1

How Countermarketing Can Reduce SSB Consumption Public health messages designed to reduce parents’ purchases of sugarsweetened beverages marketed as fruit drinks for children convinced a significant percentage of parents to avoid those drinks, according to a study by researchers at the University of Washington and the University of Pennsylvania. The UW-led study published in the American Journal of Public Health set out to assess the effect of culturally tailored countermarketing messages on drink choices, similar to stark antismoking campaigns, and involved more than 1,600 Latinx parents who participated by joining Facebook groups. Study authors focused on this demographic because Latinx children have a high rate of sugary drink consumption, and the beverage industry intentionally targets the Latinx community, said James Krieger, MD, MPH, lead author and clinical professor of health systems and population health in the UW School of Public Health. To design their study, researchers consulted focus groups involving dozens of Latinx parents from across the country to get their perceptions of how marketing works, how they think about what they are buying for their children and how to culturally tailor messages that would resonate in their community. That industry marketing led parents to believe fruit drinks are healthy beverages by creating a “halo of health” around the product. With information from those focus groups and the aid of a Latinx marketing firm, the researchers created countermarketing graphics and messages in Spanish and English designed to elicit outrage, fear of the harmful effects on children and other negative emotions. The researchers then enrolled 1,628 Latinx parents — predominantly female and from lower-income households — to participate in Facebook groups for six weeks to study the impact of countermessages on those parents’ beverage choices and fruit drink perceptions. The study divided parents into three groups. The two “intervention” groups were those who received fruit drink countermessages only and those receiving a combination of countermessages plus water promotion messages. The third group, the control group, saw safety messages about car seats. Using a simulated online store that offered fruit drinks, soda, water, milk or 100% fruit juice, parents from all three groups chose a drink for their kids and received money they could use to buy the drink in a real store. The researchers found that parents who saw countermarketing messages alone or combined with pro-water messages were less likely to buy a fruit drink and more likely to buy water. Specifically, parents in the fruit-drink countermarketing group decreased their virtual purchases of these drinks by 31% compared to the control group and by 43% by the group receiving the combined messages. Learn more about this study in the American Journal of Public Health (2021); dx.doi.org/10.2105/AJPH.2021.306488. n

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IMPRESSIONS C D A J O U R N A L , V O L 5 0 , Nº 1

Primary Teeth May Help Identify Kids at Risk for Mental Disorders Optics Device Shines Light on Dental Imaging One day soon, a patient might be able to find cavities long before they appear on a dental X-ray and early enough that the decay can be stopped in its tracks. All it would take is an instrument similar to an electric toothbrush fitted with a camera and a light-emitting diode instead of a brush. The patient would rinse with a special mouthwash, run the instrument over their teeth, then look at their smartphone to see which areas show signs of acid eating away at the tooth enamel. The patient would share the images with their dentist, who would then prescribe a highly concentrated fluoride solution to be carefully applied to the danger spots. That is the vision of Eric Seibel, PhD, director of the University of Washington’s Human Photonics Laboratory in Seattle. He has filed a patent on this technique and is searching for a medical device company interested in building such an instrument, according to an article published on Nature.com. Dr. Seibel is one of several researchers developing optical-imaging techniques for dentistry using light instead of X-rays to examine teeth for cavities and cracks. Light in the near-infrared spectrum can penetrate the outer enamel layer, the underlying dentin, the pulp at the center and even the gum tissue. Part of the motivation is to reduce patients’ exposure to ionizing radiation, even though the risk from dental X-rays is extremely low. The UK National Health Service says that the lifetime increase in 10 JANUARY

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The thickness of growth marks in primary teeth may help identify children at risk for depression and other mental health disorders later in life, according to a groundbreaking study published in the JAMA Network Open. A research team analyzed 70 primary teeth collected from 70 children enrolled in the “Children of the 90s” study based at the University of Bristol. Parents donated primary teeth (specifically, the canines) that naturally fell out of the mouths of children aged 5 to 7. The width of the neonatal line (NNL) was measured using microscopes. Mothers completed questionnaires during and shortly after pregnancy that asked about four factors that are known to affect child development: stressful events in the prenatal period, maternal history of psychological problems, neighborhood quality (whether the poverty level was high or it was unsafe, for instance) and level of social support. Several clear patterns emerged. Children whose mothers had lifetime histories of severe depression or other psychiatric problems, as well as mothers who experienced depression or anxiety at 32 weeks of pregnancy, were more likely than other kids to have thicker NNLs. Meanwhile, children of mothers who received significant social support shortly after pregnancy tended to have thinner NNLs. These trends remained intact after the researchers controlled for other factors that are known to influence NNL width, including iron supplementation during pregnancy, gestational age and maternal obesity. It is unknown what causes the NNL to form, but it’s possible that a mother experiencing anxiety or depression may produce more cortisol, the “stress hormone,” which interferes with the cells that create enamel. Systemic inflammation is another candidate. The researchers say the results of this study could one day lead to the development of a much-needed tool for identifying children who have been exposed to early-life adversity, which is a risk factor for psychological problems, allowing them to be monitored and guided toward preventive treatments, if necessary. Learn more about this study in JAMA Network Open (2021); doi:10.1001/ jamanetworkopen.2021.29129. Primary incisor from a 2- month-old child. The NNL is darker than the surrounding enamel due to a lower content of minerals. (Credit: Semantic Scholar)

risk of a fatal cancer from each standard dental X-ray is one in a few million. However, for children, alternatives to X-rays would be especially welcome, both because the radiation dose is larger relative to their body size and because children’s teeth change rapidly enough that more frequent imaging could be

useful. Dentists and dental assistants, who might be near X-rays on a daily basis and thus face a higher risk of exposure than most people, could also benefit. But the main reason for the interest in optical imaging is that it can visualize problems that X-rays can’t. Read more of this article on nature.com.


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Filtration Devices Could Increase Health Safety in Dental Offices In a new study using 3D holographic imaging, University of Minnesota Twin Cities researchers tested the effectiveness of three filtration devices that can mitigate the spread of aerosols during ultrasonic scaling. The findings could increase health safety in dental offices

during the COVID-19 pandemic. The researchers found that two of the devices — a high-volume evacuator (HVE) and an extraoral local extractor (ELE) — were very successful at reducing aerosol spread. This is one of the first studies to use advanced

U.S. Dentists Still Prescribe Opioids Despite Effective Alternatives A survey of dentists in the U.S. revealed that an overwhelming majority of those who responded believe nonsteroidal anti-inflammatory drug (NSAID)-acetaminophen combinations are as effective or more effective in managing dental pain as opioids; however, almost half say they still prescribe opioids. The results of the survey, conducted by PharmedOut with undergraduate students at the Georgetown University School of Nursing and Health Studies, were published in the Journal of the American Dental Association. Previous studies found that dentists comprise 15.8% of opioid prescribers and prescribe 8.6% of opioid medications in the U.S. Dentists are the highest prescribers of opioids to patients aged 18 and younger. “We know that the first exposure to opioids for many people occurs in their teens and early 20s following common dental procedures like third molar extractions,” said Nkechi Nwokorie, who conducted the work as an undergraduate at Georgetown. “This is a particularly vulnerable population for misuse.” The Georgetown researchers received 291 survey responses and analyzed 269 completed surveys. Although 84% of respondents reported believing that NSAIDacetaminophen combinations are equally as effective or more effective than opioids, 43% of respondents also reported regularly prescribing opioid medications. “This underscores the need for more education about the harms of opioids and the need for national guidelines to align clinical practice with current evidence,” said Adriane Fugh-Berman, MD, a professor in the departments of pharmacology and physiology and family medicine at the Georgetown University Medical Center. Learn more about this study in the Journal of the American Dental Association (2021); doi.org/10.1016/j.adaj.2021.07.018.

engineering imaging techniques to map the size, distribution and mitigation of aerosols in dental offices. The paper was published in the Journal of the American Dental Association. In the study, the researchers looked specifically at aerosol generation during ultrasonic scaling. Using a dental manikin and thermoplastic teeth — and with real dental hygienists performing the procedure — the researchers used holographic imaging to map the size and distribution of aerosols released. Then the researchers tested three devices that aim to filter the aerosols from the air. These included a saliva ejector, an HVE and an ELE. They found that the ELE and HVE were most effective at filtering out the particles, reducing the number of aerosols by 96% and 88%, respectively. The researchers also found that using combinations of the different devices doesn’t necessarily lead to better particle removal. For example, using the ELE alone is more efficient than combining it with the saliva ejector or the HVE. The researchers hope that their findings can guide dental professionals on what strategies they can use to keep COVID-19 from spreading in their offices. Learn more about this study in the Journal of the American Dental Association (2021); doi.org/10.1016/j. adaj.2021.06.007.

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introduction C D A J O U R N A L , V O L 5 0 , Nº 1

Dental Student Research Mariela Padilla, DDS, M.Ed

GUEST EDITOR Mariela Padilla, DDS, M.Ed, is the director of Online Programs and Telehealth and an associate professor of clinical dentistry at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported.

E

very year, the Journal of the California Dental Association sets aside an issue for dental students, and their mentors, to share their academic findings. It has been a great pleasure to support those who are publishing in this issue and to see firsthand the role of mentors in shaping the next generation of dental practitioners. A successful professional can be recognized by different achievements or capacities — such as diagnostic accuracy, skillful procedure execution, financial sustainability and public recognition — but also as someone who maintains an appropriate balance between technical competencies and essential social skills. These “soft” skills prioritize communication, emphasizing respect, professionalism, ethics and an understanding of diversity. Soft skills include personal values and interpersonal skills, and some specific examples are communication, leadership, critical thinking and problem-solving.1 The ability to communicate assertively and effectively is one of the most important attributes in the dental profession. Studies have demonstrated that effective providerpatient communication is an asset in getting the required information and developing rapport.2 Furthermore, good communication skills increase dental patients’ satisfaction and treatment outcomes.3 Communication skills in the health care environment are to be continuously cultivated and nurtured, and clinicians should always look for opportunities to do so by identifying and

taking advantage of opportunities to educate and promote oral health. Leadership skills are key as the discipline moves into the interprofessional model of care, where each discipline contributes to understanding the needs of a patient in a more comprehensive fashion.4 Critical thinking in dentistry may relate to exploring different perspectives that a practitioner must consider, facilitating the resolution of complex problems and fostering professional behaviors.5 To improve these skills, clinicians might benefit from discussions with colleagues, attending professional meetings and reading current literature.6 Evolutions in science, new understanding of diseases and technological innovations have changed the professional practice of dentistry. Thirty years ago, having an electrical dental amalgamator was considered an innovation. Guidelines and protocols are important, but best practices have to be adapted, and clinicians must find ways to stay current in this field of continuous evolution. Thus, other soft skills that need to be cultivated include adaptability and flexibility in an ethical and responsible environment. The only way to adapt to changes is to recognize them, and if possible, the clinician should look to anticipate changes by identifying developments in the environment. When the context changes, a flexible response to the new demands is desirable, and the clinician will benefit from the ability to adjust to JANUARY 2 0 2 2

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introduction C D A J O U R N A L , V O L 5 0 , Nº 1

situational shifts.7 The best strategies to foresee potential changes and to respond in a timely fashion are to participate in continuous education and current literature reviews, to identify trends and to analyze if the science supports updating a clinical practice. The clinician has the responsibility to incorporate evidence-based guidelines, using solid scientific bases for generating trustworthy recommendations.8 By understanding the state of the art in the discipline and communicating with others respectfully and effectively, the decision-making process regarding diagnosis, treatment planning and execution will follow professional ethics and responsibility. This issue features clear examples of the application of soft skills to respond to the great disruptive event of our time, a pandemic. The California dental schools have adapted, showing flexibility when facing a changing reality. The leadership looked into solutions for complex situations and innovated with hybrid models, both

for teaching and for care provision. In addition, the basic research needed to understand the disease’s mechanisms and potential therapeutic targets continued, ensuring that the training of creative minds and the discovery journey did not stop. New protocols came into play, and as the science moved forward with data, academia was able to implement safe environments to ensure the continuity of the learning process and the training of the next generation of dental professionals. The examples chronicled here provide ample evidence that, behind that kind gaze we see in the eyes of our administrators, faculty, students, staff and patients, there are moving forces that are ready to meet and adapt to even the most difficult circumstances. n RE FE RE N CE S 1. Gonzalez MA, Abu Kasim NH, Naimie Z. Soft skills and dental education. Eur J Dent Educ 2013 May;17(2):73–82. doi: 10.1111/eje.12017. Epub 2013 Jan 10. PMID: 23574183.

2. Tseng W, Pleasants E, Ivey SL, Sokal-Gutierrez K, Kumar J, Hoeft KS, Horowitz AM, Ramos-Gomez F, Sodhi M, Liu J, Neuhauser L. Barriers and facilitators to promoting oral health literacy and patient communication among dental providers in California. Int J Environ Res Public Health 2020 Dec 30;18(1):216. doi: 10.3390/ijerph18010216. PMID: 33396682; PMCID: PMC7795206. 3. Ayn C, Robinson L, Nason A, Lovas J. Determining recommendations for improvement of communication skills training in dental education: A scoping review. J Dent Educ 2017 Apr;81(4):479–488. doi: 10.21815/JDE.016.003. PMID: 28365612. 4. Grocock R. Leadership in dentistry. Br Dent J 2020 Jun;228(11):882–885. doi: 10.1038/s41415-020-1633-4. PMID: 32541752. 5. Martin D. A guide to critical thinking: Implications for dental education. Br Dent J 2020 Jul;229(1):52–53. doi: 10.1038/ s41415-020-1648-x. PMID: 32651522. 6. Feller L, Lemmer J, Nemutandani MS, Ballyram R, Khammissa RAG. Judgment and decision-making in clinical dentistry. J Int Med Res 2020 Nov;48(11):300060520972877. doi: 10.1177/0300060520972877. PMID: 33249958; PMCID: PMC7708710. 7. Pruessner L. A cognitive control framework for understanding emotion regulation flexibility. Emotion 2020 Feb;20(1):21–29. doi:10.1037/emo0000658. 8. Djulbegovic B, Guyatt GH. Progress in evidencebased medicine: A quarter century on. Lancet 2017 Jul 22;390(10092):415–423. doi: 10.1016/S01406736(16)31592-6. Epub 2017 Feb 17. PMID: 28215660.

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teledentistry C D A J O U R N A L , V O L 5 0 , Nº 1

C.E. Credit

Evolution of Patient Care Post-Pandemic: Teledentistry the New Norm, a Narrative Review Antranig Mesrobian, MS; Karam Korya, BS; and Kamal Al-Eryani, DDS, PhD

abstract Background: The start of the new decade brought an inconceivable affliction. In the first quarter of 2020, humanity faced an invisible enemy, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), known infamously as COVID-19. The virus left every facet of life in a state of disarray, and as we adjust to the new normal, the necessary changes are evident. Results: Through synchronous or asynchronous interactions, the efficiency, convenience and costeffectiveness of telehealth remain unparalleled. Therefore, as society attempts to move past the pandemic, the progression of patient care and management will be a catalyst in the transformation of health care systems. Practical implications: Considering the precedent set by teledentistry during the pandemic, the widespread incorporation of this digital medium will benefit both patients and dentists. Keywords: Teledentistry, pandemic, COVID-19, telehealth, technology, patient care, dental care

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AUTHORS Antranig Mesrobian, MS, is a DDS candidate, class of 2024, at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported. Karam Korya, BS, is a DDS candidate, class of 2024, at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported.

Kamal Al-Eryani, DDS, PhD, is an assistant professor of clinical dentistry, division of diagnostic sciences at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported.

S

evere acute respiratory syndrome coronavirus-2 (SARS-CoV-2) disease, or what the world knows as COVID-19, has left its mark on humanity. Life came to a screeching halt as the entire world mobilized to take precautions against a virus that has revealed itself to be an enigma. Two years later, the scientific community continues to learn and adapt ways in which humanity can persevere against this unknown enemy and has learned to cope with the substantial amount of loss and devastation.

Technology is a part of virtually every aspect in health care, including education, patient care and communication.

SARS-CoV-2 left public health, our economy and our way of life in a state of disarray. The novel coronavirus pandemic has spawned four intertwined health care crises that reveal and compound deep underlying problems in the health care system of the United States.1 Failure to mobilize an effective response compounded with the inability to provide care to all those affected revealed efficiency and capacity as the apparent Achilles heels’ of our health care infrastructure. Current efforts need not look very far in finding a solution in creating a more efficient form of health care delivery, because the foundation already exists. The requisite infrastructure for connectivity is widely available at both ends of the clinical encounter, most readily through the ubiquitous smartphone.2 18 JANUARY

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Technology has transformed everyday life, from our professional lives to daily tasks at home. In essence, it has brought a certain level of efficiency and convenience for the user. Technology is a part of virtually every aspect in health care, including education, patient care and communication. In addition, technology has proven to be beneficial in reaching patients via remote access, known as telemedicine. “Most health care systems in private and public sectors have already deployed electronic health records, thereby ensuring continuity of care for their patients. A sizeable proportion of outpatient visits in various settings can be clinically managed effectively from a distance, that is, patients with nonurgent conditions can be triaged to telemedicine service without compromising their health or quality of care.”2 The pandemic impacted all facets of health care; dentistry, in particular, came under scrutiny due to aerosolgenerating procedures. However, as time went on, recommendations from the Centers for Disease Control and Prevention (CDC) and the American Dental Association (ADA) allowed dental offices to provide “essential” services to patients because health cannot take a backseat to anyone or anything. “Oral health is an integral component of systemic health and explains dentistry is essential health care because of its role in evaluating, diagnosing, preventing or treating oral diseases, which can affect systemic health.”3 “Teledentistry refers to the delivery of dental advice, care and treatment to patients remotely by exploiting the power of telecommunication, all the while avoiding person-person interaction.”4 Therefore, from the beginning of the pandemic, the ADA updated its teledentistry policy to better serve dentists who rely on this technology


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to care for patients, emphasizing the standard that consultations and treatments through teledentistry must be consistent with how they would be delivered in person. Almost two years into the pandemic, teledentistry continues to be a vital tool in reducing the burden on our health care infrastructure while simultaneously being an effective tool in screening, consultations, diagnosing and referring. Moving forward, dental health care personnel (DHCP) will need to increasingly integrate technology to provide a more efficient and comprehensive form of care. “While the use of teledentistry is already an established function in oral medicine, periodontal conditions and oral surgery, patient care in the post-COVID-19 era will need to leverage technology to offer the best possible treatment outcomes and access to care for all.”4 The reader may be wondering, if everything is ready to go, why is it not being applied? Well, that is because it is always a work in progress. “Effective teledentistry requires significant investment in data privacy, adequate training and access to the internet.”4 Concomitantly, there must be uniformity in confidentiality, ethical standards and the manner in which the medium is utilized between patients and the DHCP. “Automated screening algorithms can be built into the intake process, and local epidemiologic information can be used to standardize screening and practice patterns across providers.”5 These separate facets coming together through the use of technology and integrating into the health care infrastructure will bring about a more productive outcome. With an unprecedented opportunity to learn from our shortcomings, there is no time like the present to reassess,

evaluate and apply the necessary changes needed to make sure teledentistry works. Taking the necessary actions to ensure the expansion of access to care while maintaining patient privacy protocols will ensure a brighter future for the American people regarding health care. “Leaders in health care, business and technology work collaboratively to disrupt the status quo and chart a new course for our country’s health system — a system that is affordable, efficient and accessible for everyone.”6

Almost two years into the pandemic, teledentistry continues to be a vital tool in reducing the burden on our health care infrastructure.

Materials and Methods

This narrative review utilized articles analyzing the scope of teledentistry in regard to history, legality, services, insurance, reliability, infrastructure and treatments. PubMed and Google Scholar databases were searched from their inception to May 2021. An English-only filter was placed for the included papers. These articles are cited within this paper to convey the critical nature of teledentistry.

Results History of Telemedicine

Telehealth has been used in one way or another since the 1950s, where it was utilized for neurological exams and group therapy sessions. An exponential boom ensued in the following decades as federal agencies such as the U.S. Department

of Health, Education, Welfare (now known as the Department of Health and Human Services) and Massachusetts General Hospital launched their telehealth program, thus proliferating the widespread use of technology as a medium for providing services. The 1980s saw telemedicine expand globally, as countries such as Russia, Australia and Armenia formed joint operation partnerships with the United States to provide telehealth services to those in need.7 With the global framework settled, the advent of the technology boom in the 1990s led to telemedicine expanding from a handful of disciplines to a means of delivering multiple disciplines of health care. Almost immediately, telehealth became a component of health care that all major institutions, academic or otherwise, added to their repertoire. With the widespread proliferation of this “new” service, federal, state and medical regulatory bodies were established to oversee and fund numerous established programs. Today, telehealth is a tool that improves the health of the population, enhances the patient care experience, provides education to future providers and ultimately allows for many patients to receive care when needed. Telehealth encompasses numerous facets of health care and, concerning dentistry, has reduced the cost of services provided, improved access to dental specialists (i.e., oral surgeons, endodontists, etc.) and increased efficiency through reduced travel times, thus proving to be revolutionary.7,8

History of Teledentistry

Oral health is an integral part of general well-being. Technical advances in dental care have documented early diagnosis, preventive treatments and early intervention to prevent or reduce most oral diseases’ progress. JANUARY 2 0 2 2

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Radiology was the first discipline (1959) to utilize telehealth to diagnose/ treat patients, and other disciplines followed suit. The various benefits telehealth provided led the U.S. military and the Department of Defense to establish a dental informatics system. “The U. S. Army’s Total Dental Access (TDA) project is seen as being at the frontier of teledentistry, which had begun in 1994. TDA is the teledentistry project within the department of defense that enables referring dentists from the U.S. Armed Forces to consult with specialists at a medical center about the status of a patient.”9 Additionally, TDA aimed to increase access to dental care for patients who lived in rural areas, improving the cost-effectiveness of dental treatments, streamlining dentist-to-laboratory communications and improving dental education.8 The success of the TDA was undeniable, as it led to a proliferation of teledentistry in the private sector. “By providing dentists with easy, costeffective access to specialists, it is possible to improve the quality of care by facilitating better and timely information to dentists for better decision-making and better communication between them and their patients.”10 With the current pandemic in mind, it is clear how critical teledentistry has been in achieving continuity of care for patients worldwide. The aerosol-producing dental procedures were a significant source of concern regarding the spread of SARS-CoV-2 in the early days of the pandemic. The potential transmission to patients and doctors alike led to a recommendation by the ADA on March 16, 2020, to postpone dental procedures deemed as nonemergency or “elective.”11 Examples of nonemergency procedures include but are not limited to extraction of asymptomatic teeth, restorative dentistry 20 JANUARY

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including treatment of asymptomatic carious lesions, aesthetic dental procedures, initial or periodic oral examinations and recall visits, including routine radiographs, routine dental cleaning and other preventive therapies.12 Nonetheless, teledentistry flourished, as it allowed for continuity of care between dentists and their patients during these troubling times. “Online conversations allow the exchange of several types of data like written or voice messages for diagnostic doubts as well as therapeutic suggestions, video messages for a better evaluation of

California has some of the most extensive teledentistry laws, with patient rights being the focal point.

a patient’s requirements and descriptions of problems in their own words.”13 The evolution of teledentistry is solely dependent on the evolution of existing technologies. The progression of the latter will inadvertently expand the former. That being said, when expanding any aspect of patient care, consideration must be given to the legal protections for both provider and patient.

Legality of Teledentistry

Technology has afforded dentists the ability to communicate with their patients and other dental specialists through various avenues. According to the ADA, teledentistry allows dental professionals to reach a larger patient population, and by doing so, increases access to care. More so, teledentistry

must conform to the same legal standards as in-person office visits.14 Laws regulating teledentistry vary from state to state. California has some of the most extensive teledentistry laws, with patient rights being the focal point. Prior to the delivery of telehealth, the dental professional must inform the patient that teledentistry may be used and obtain verbal or written consent. Failure to do so will result in unprofessional conduct pursuant to Business and Professions Code 2290.5.15 Examinations and interventions must follow proper documentation, summary of services, appropriate follow-up care and referral to the emergency department as needed.14 Regardless of the medium used, interactions between clinicians and patients must always meet the standards by which prescriptions may be issued. The common practice of prescribing medication before the COVID-19 pandemic was that a physician could issue a prescription only after an appropriate examination had been performed and a medical indication for the prescription had been determined. Moreover, Business and Professions Code section 2242.1 prohibits individuals from prescribing, dispensing or furnishing dangerous drugs on the internet without an appropriate prior examination and medical indication, unless under exceptional circumstances.16 However, due to the current public health emergency, a special ordinance allowed the dispensing of controlled substances via telehealth to patients for whom they have not conducted an in-person medical evaluation provided: ■  The prescription is used for a legitimate purpose. ■  The practitioner is acting in accordance with federal and state laws. ■  The interaction with the patient occurs via a two-way, real-time audiovisual communication system.


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TABLE 1

Forms of Teledentistry Variations of Teledentistry

This special ordinance designated by the Secretary of Health and Human Services and the Drug Enforcement Agency will remain in effect for as long as SARS-CoV-2 is deemed a public health emergency.17

Teledentistry Services

Teledentistry enables clients to access preventive services completed on-site through different technologies. Patients consult with the dentist via websites, patient portals or phone calls. The use of teledentistry enables hygienists to provide a patient with educational tools required to avoid diseases and which treatment is needed before the patient’s needs progress. It provides portable equipment to hygienists, enabling them to make a treatment room in essentially any area. This enhances access to care in any interior locations, such as schools, nursing homes and conference rooms, which can be changed into a private treatment room. Furthermore, patients who have obligations during normal business hours (i.e., work, child care, etc.) can still connect with their oral health care provider and receive the necessary care. Ultimately, dentists can prevent diseases in patients in remote areas and those with limited resources and elevate the practice of medical providers. Through teledentistry, dentists and hygienists in remote areas can connect to specialists in larger communities. For example, orthodontists can utilize teledentistry as a cost-effective approach to supervising treatment options for patients in remote areas (i.e., tracking the progress of a patient’s dental movements). Modern information support works in teledentistry such that it helps to increase the dentist’s performance in the diagnosis and treatment of patients’ oral health problems. Teledentistry can separate treatments done remotely from those

Definition

Synchronous

• Live: Two-way, real-time encounter. • Occurs in patient’s home or designated site. • Interactive.

Asynchronous

• Store and forward: Scheduled for a later date. • Convey health history to clinician/specialist.

Remote patient monitoring

• Clinical evaluations for chronically ill patients utilizing either synchronous or asynchronous methods.

done clinically by utilizing existing screening software and evaluating the intensity of the issue and the ability of the patient to manage the problem according to the instructions (FIGURE 1 ). Home monitoring devices work in teledentistry because they help save client data and provide a channel and network to participate in the process. From reducing health disparities in areas with limited physical access to eliminating transportation costs, it is clear that telehealth has found its place within the health care system. Additional benefits telehealth can provide in the future include but are not limited to improving health literacy, reducing hospital readmissions, immediate access to physicians, medication adherence and a host of others.18

Synchronous vs. Asynchronous

Telehealth delivery in general falls under three forms: synchronous, asynchronous and remote patient monitoring. Synchronous delivery indicates a live, two-way interaction between the patient and dental care provider. The real-time interaction allows for a live discussion and delivery of care, whether this occurs at the patient’s home or at a designated site (such as in facilitated virtual visits).18 Asynchronous telemedicine, also known as “store and forward,” refers to the collection of diagnostic records and medical history, which is forwarded to the health care professional for diagnosis and treatment recommendation. Asynchronous teledentistry is often touted for its efficiency,

as it does not require meeting at a specified time, thus being more convenient for both patient and provider.18 Lastly, remote patient monitoring consists of clinical evaluation of patients outside of traditional health care settings, i.e., home, an assisted living facility, a remote area, etc.17 Remote patient monitoring is helpful for patients with chronic illnesses who choose to maintain their independence and live in their preferred environment (TA BLE 1 ). Besides the factor of live versus store and forward, synchronous and asynchronous telehealth also differ in the manner in which they are classified and coded by insurance. Therefore, appropriate codes must be used for the type of telehealth provided so that insurance reimbursement for services provided is made at the same rate and accuracy as in-person services.

Insurance

While teledentistry reduces the cost burden for health care providers and patients alike, the service is not without its limitations, especially as it relates to reimbursements. Medicaid tends to offer reimbursement for synchronous care. However, numerous criteria must be met, such as limited access to care, location of the patient, etc.18 Medicare, which is health care offered by the federal government for persons ages 65 and older, usually does not cover teledentistry. Private insurance companies show significant variability when reimbursing for teledentistry services, as they are governed by the states in which they operate. JANUARY 2 0 2 1

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Gender

Age

Location of problem

Algorithm generates potential conditions (based on symptoms described)

Request consultation

Indicate pattern, frequency, character, potential cause, your chief complaint(s)

Problem is located in my upper jaw (maxilla)

Problem is located everywhere in my mouth (generalized)

Problem is located in my lower jaw (mandible)

Select your chief complaint (i.e., serious headache, swollen glands, tooth pain, numbness, tingling, etc.)

Self-examination utilizing instructions put forth by algorithm

Rate your chief complaint(s) on a scale from 1 to 10

Briefly describe your symptoms

FIGURE 1. Example of an automated screening algorithm utilized by orofacial pain specialists that standardizes screening and practice patterns across providers and allows for increased efficiency.

The imbalances between insurance reimbursements are considered significant barriers for teledentistry. However, as COVID-19 engulfed our reality and teledentistry became the most viable option, immediate action was taken to rectify these obstacles. On March 18, 2020, the California Department of Managed Health Care (DMHC) issued an all-plan letter instructing health plans to take immediate steps to allow people to obtain health care via 22 JANUARY

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telehealth.19 Furthermore, the California Department of Health Care Services (DHCS) proposes implementing broad changes with the DHCS Telehealth Proposal to extend these additional benefits for Medi-Cal recipients postpandemic when medically appropriate. During the pandemic, dental insurance became more flexible in covering teledentistry for initial and follow-up visits. Services were covered as if they were provided in person;

however, insurance reimbursement regulations vary widely state by state, and a dentist must check with the patient’s insurance prior to performing services. As indicated earlier, teledentistry billing must follow the same rate and accuracy as in-person services. Providers who engage in synchronous encounters must indicate CDT code D9995 in addition to other services provided, i.e., diagnostic, treatment planning, etc. CDT coding for asynchronous encounters must


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TABLE 2

Most Common CDT Codes Used in Teledentistry

be indicated by code D9996 and submitted accordingly. Patient encounters must also include the diagnostic and evaluative procedures completed during each session, such as D0191 (patient assessment), D0140 (limited oral evaluation — problem focused), etc.19 (TA BLE 2 ).

Telehealth Exam Accuracy/Validity

The telehealth examination is important as it reduces the chances of patients getting infected with the virus. The patients do not have to meet with the dentists and other health professionals for health services, reducing interactions with individuals who might be infected with COVID-19. Telehealth examinations help health practitioners attend to patients in different locations and diagnose their issues without having to meet physically. helping patients protect themselves against threats in post-pandemic care by reducing instances of traveling to receive care.20 Teledentistry is accurate and produces valid responses to patients through examination. The patients can perform various medical tests in their homes with the right tools getting instructions from the dentist. The results obtained can be validated by the dentist to provide dental care while increasing patient safety. In teledentistry, the specificity and sensitivity of oral pathology diagnosis is very high, where both percentages exceed 90% in most settings, making teledentistry a very competent method for oral pathology diagnosis.21

Teledentistry Limitations

Teledentistry successfully connects and transfers electronic information, remote consultations, assessment and evaluation of patients’ needs. Be that as it may, teledentistry is limited in the types of procedures that can be performed. Any treatment plan that requires operations,

Teledentistry Billing Codes

Definition

D9995

Synchronous: real-time encounter

D9996

Asynchronous: store and forward

D0140

Limited oral evaluation

D0170

Reevaluation

D0171

Reevaluation: postoperative visit

crown placements, extractions or alignments must be carried out in person, because teledentistry can only be used in functions that do not require the dentist to be present with the patient to render care.9

Health Insurance Portability and Accountability Act Requirements

The U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects medical records and other personal data. These guidelines extend to any health care provider who is transmitting digital data and cover teledentistry and any related communication, so one should comply with the guidelines when implementing telehealth. The two essential pieces that HIPAA defines on teledentistry are how to handle communication and how the information is stored. HIPAA governs the software used for teledentistry. Under HIPAA, a HIPAA business associate agreement is considered to be an official contract between a HIPAA-covered entity and a HIPAA business associate or downstream business associate. The contract is mainly intended to protect personal health information and abide by HIPAA guidelines. Also, for hygienists to comply with HIPAA guidelines, teledentistry needs to ensure that communication between the client and their provider is encrypted. Rules are provided to ensure the safety of teledentistry data and how providers should handle such information. For example, information must be transmitted over an encrypted connection. This means that third parties should not access data in transit.22 Therefore, the software made to transfer medical data should

have encryption built into the system. All company stores are required to store the client’s personal information on their encrypted servers. Encrypting information is the best practice for cybersecurity and a requirement for any health care provider that stores information. To ensure that ethics are not violated in a nontraditional area, high clinical standards of protection, efficiency and sterilization should be used. The services must be tracked using cloud-based software and sent to the patient’s insurance provider directly. The Department of Health and Human Services conducts periodic evaluations to ensure that certain laws are followed. Companies that fail can face hefty fines and public relations issues, so most teledentistry businesses make sure they follow all of the rules (FIGURE 2 ). According to the ADA, teledentistry can be an important way of expanding dental practitioners’ reach by reducing the impact of distance barriers, which increases access to treatments. Teledentistry can extend the scope of the dental practice to a population within reasonable geographical distances by offering necessary dental treatment. Thus, the ADA provided compliance guidelines for teledentistry. The services must be provided in the same way as in-person services to achieve this objective.23 Examinations and subsequent procedures performed via teledentistry must focus on the same quality of information as those performed in-person. It is the legal duty of the dentist to ensure that all documents collected for diagnosis and treatment are suitable for the dentist. Patients who receive telehealth care need to JANUARY 2 0 2 1

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Patient information, such as current treatments, medical history and intraoral imaging, is reviewed

Patient’s contact information is acquired from the appointment made earlier

• Communication is established via phone call or Zoom • The patient is given informed consent verbally including the purpose, risks, benefits, alternatives and rights Synchronous communication: • Patient and dentist interact in real time via video call • Only the scheduled observation is done in a specific setting •Postoperative visits are documented

Asynchronous communication: • Patient sends their data to dentist for remote evaluation • Evaluation is limited to a specific complaint • Postoperative visits are documented

• Audio communication takes place between patient and dentist • Diagnostic procedures rendered during service • Patient’s need for dental services determined

• Reported documentation and evidence is used to determine appropriate treatment • Necessity of follow-up is determined

FIGURE 2 . The necessary HIPAA steps that dentists must abide by when utilizing teledentistry to treat patients.

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Patient is assisted in making decisions regarding oral health care coordination, types of providers and treatment areas and system of payment


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be tracked appropriately, including a description of the patient’s services. To provide satisfactory follow-up treatment for patients during the telehealth experience, a dentist who uses telehealth must be familiar with the availability and scope of local dental services.

Technological Infrastructure and Software Requirements

The ADA developed an online database known as the systemized nomenclature of dentistry that enables efficient communication of patient data by health providers within the electronic health records (EHRs). This technology is required when practicing telehealth. EHRs are a computerized, systematic array of electronic health data. They allow numerous clinicians to access the same patient record, resulting in improved interprofessional communication and more efficient patient care. Patients may also be educated about proposed interventions and potential results. Teleconsults can also happen via live video, collection of secure encoded data or remote patient monitoring. Therefore, innovative technologies are required, like website monitoring applications, kiosks, mobile devices apps and videoconferencing, which engage patients via connective health apps. These technologies ensure care is provided by allowing real-time, interactive communication between patients and the provider located at a distant site. They can also be used to send messages for encouraging healthy behaviors.

Conclusion

Dentistry is an integral part of our health care system, and teledentistry is a functioning component of that system. Once considered impractical, teledentistry proved its worth during the pandemic.

By limiting in-office, aerosol-generating procedures, the virtual medium of teledentistry allowed continuity of care between dental care providers and their patients. The sky is the limit for future teledentistry applications as consultations, treatment planning, preoperative instructions, treatments, postoperative care and a host of other services integrate into this form of dental care delivery. Whether it will increase access to care, reduce unnecessary visits or create a more efficient health care model, it is clear that the virtual doctor’s office is here to stay. n RE FE RE N C E S 1. Blumenthal D, Fowler EJ, Abrams M, Collins SR. COVID-19 — implications for the health care system. N Engl J Med 2020 Oct 8;383(15):1483–1488. doi: 10.1056/ NEJMsb2021088. Epub 2020 Jul 22. 2. Bashshur R, Doarn CR, Frenk JM, Kvedar JC, Wooliscroft JO. Telemedicine and the COVID-19 pandemic, lessons for the future. Telemed J E Health 2020 May;26(5):571–573. doi: 10.1089/tmj.2020.29040.rb. Epub 2020 Apr 8. 3. Versaci MB. Dental Practices Remain Open Amid COVID-19 Surge. ADA News Dec. 1, 2020. 4. Abbas, Beenish et al. Role of Teledentistry in COVID-19 Pandemic: A nationwide comparative analysis among dental professionals. Eur J Dent 2020 Dec;14(S 01):S116–S122. doi: 10.1055/s-0040-1722107. Epub 2020 Dec 31. 5. Hollander JE, Carr BG. Virtually perfect? Telemedicine for COVID-19. N Engl J Med 2020 Apr 30;382(18):1679– 1681. doi: 10.1056/NEJMp2003539. Epub 2020 Mar 11. 6. Madara JL. America’s Health Care Crisis Is Much Deeper Than COVID-19. 7. Ford DW, Valenta SR. Telemedicine: Overview and Application in Pulmonary, Critical Care, and Sleep Medicine. 1st ed. Cham, Switzerland: Springer Nature; 2021. 8. Jampani ND, Nutalapati R, Dontula BS, Boyapati R. Applications of teledentistry: A literature review and update. J Int Soc Prev Community Dent 2011 Jul;1(2):37–44. doi: 10.4103/2231-0762.97695. 9. Arora PC, Kaur J, Kaur J, Arora A. (2019). Teledentistry: An innovative tool for the underserved population. Digital Medicine 2019;5(1):6–12. doi: 10.4103/digm.digm_13_18. 10. Rocca MA, Kudryk VL, Pajak JC, Morris T. The evolution of a teledentistry system within the Department of Defense. Proc AMIA Symp 1999;921–4. 11. Burger D. ADA recommending dentists postpone elective procedures. American Dental Association March 16, 2020. 12. Solana K. ADA develops guidance on dental emergency, nonemergency care. American Dental Association March 18, 2020. 13. Deshpande S, Patil D, Dhokar A, Bhanushali P, Katge F. Teledentistry: A boon amidst COVID-19 lockdown — a narrative review. Int J Telemed Appl 2021, 8859746. doi. org/10.1155/2021/8859746. 14. American Dental Association. ADA Policy on Teledentistry.

15. CDA Practice Support. Teledentistry Consent and Notice. 16. Medical Board of California. Internet Prescribing. 17. U.S. Department of Justice Drug Enforcement Agency. COVID-19 information page. 18. Mechanic OJ, Persaud Y, Kimball AB. Telehealth Systems. 19. California Dental Association. Dental Billing and Telehealth/Teledentistry. 20. Alabdullah JH, Daniel SJ. A systematic review on the validity of teledentistry. Telemed J E Health 2018 Aug;24(8):639–648. doi: 10.1089/tmj.2017.0132. Epub 2018 Jan 5. 21. Queyroux A, Saricassapian B, Herzog D, et al. Accuracy of teledentistry for diagnosing dental pathology using direct examination as a gold standard: Results of the tel-e-dent study of older adults living in nursing homes. J Am Med Dir Assoc 2017 Jun 1;18(6):528–532. doi: 10.1016/j. jamda.2016.12.082. Epub 2017 Feb 22. 22. Irving M, Stewart, R, Spallek H, Blinkhorn A. Using teledentistry in clinical practice as an enabler to improve access to clinical care: A qualitative systematic review. J Telemed Telecare 2018 Apr;24(3):129–146. doi: 10.1177/1357633X16686776. Epub 2017 Jan 16. 23. Giudice A, Barone S, Muraca D, et al. Can teledentistry improve the monitoring of patients during the COVID-19 dissemination? A descriptive pilot study. Int J Environ Res Public Health 2020 May 13;17(10):3399. doi: 10.3390/ ijerph17103399. T HE CORRE S P ON DIN G AU T HOR , Antranig Mesrobian, MS, can be reached at amesrobi@usc.edu.

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teledentistry C D A J O U R N A L , V O L 5 0 , Nº 1

C .E. CREDIT QUESTIONS

January 2022 Continuing Education Worksheet

1.

This worksheet provides readers an opportunity to review C.E. questions for the article “Evolution of Patient Care Post Pandemic: Teledentistry the New Norm, A Narrative Review” before taking the C.E. test online. You must first be registered at cdapresents360.com. To take the test online, please click here. This activity counts as 1.0 of Core C.E.

1. Teledentistry can be used for which types of patient care? a. Consultation b. Assessment c. Treatment d. All of the above

2. True or False: ADA’s teledentistry policy recognizes the challenges to providing care via teledentistry and emphasizes differing standards for care rendered through teledentistry and care delivered in person.

3. Effective teledentistry requires knowledge and use of which of the following? (mark all that apply) a. Electronic health records b. Data privacy c. Uniformity of ethical standards d. Confidentiality

6. The U.S. Army’s TDA project stands for: a. Today’s Dental Army b. Teledentistry Access c. Total Dental Access d. None of the above

7. True or False: Though some states require a dental professional to inform the patient that teledentistry may be used and obtain consent, verbal or written, prior to the delivery of telehealth services, this is not required in California.

8. True or False: A “special ordinance” designated by the federal secretary of Health and Human Services and the Drug Enforcement Agency permits the dispensing of controlled substances via telehealth to patients for whom an in-person medical exam has not been conducted, if certain conditions are met, for as long as SARS-CoV-2 is deemed a public health emergency.

4. The technology boom helped telemedicine expand from a handful of disciplines to a means of delivering multiple disciplines of health care in which decade? a. 1970s b. 1980s c. 1990s d. 2000s

5. True or False: Radiology was the first discipline to utilize telehealth to diagnose/treat patients.

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9. Telehealth may be delivered in which of the following ways? a. Asynchronously b. Synchronously c. By monitoring the patient remotely d. a and b e. All of the above

10. True or False: The specificity and sensitivity of oral pathology diagnosis exceeds 90% in most settings, making teledentistry a very competent method for oral pathology diagnosis.


hybrid learning C D A J O U R N A L , V O L 5 0 , Nº 1

Impact of Hybrid Learning on Students’ Performance in Biomedical Sciences During COVID-19 Pandemic Oussama Hefnawi, BS; Xi Chen, DPPD, MPA; and Mahvash Navazesh, DMD

abstract Background: The COVID-19 pandemic forced educators to rapidly adopt hybrid distance-learning instructions. Objective: This study compared in-person to hybrid instructional delivery methods for acquiring biomedical sciences knowledge and critical thinking skills of first- (D1) and second-year (D2) dental students at the Herman Ostrow School of Dentistry of USC fall trimester 2019 through fall 2020. Methods: Participants were coded by instructional methods (in-person versus hybrid). Independent t tests were performed to compare overall biomedical course scores of two consecutive cohorts of students receiving different instructional methods. Chi-square analyses examined the relationship between letter grade distribution and instructional methods. Then, paired t tests further assessed performance of the same cohort of students between instructional methods on three subcomponent exams of course grades: multiple choice question (MCQ), computer-based objective test (COMBOT) and triple jump (T3). A survey on instructional methods was also incorporated. The study design including deidentified grades collection was approved by the Institutional Review Board (IRB). Results: Students’ overall course performance in biomedical sciences in D1 and D2 was similar between the two instructional delivery methods (⍴ [D1] < 0.05, n = 288; ⍴ [D2] < 0.05, n = 284). Student scores on MCQ, COMBOT and T3 exams from hybrid instructions were slightly higher than their scores from in-person instructions (⍴ [MCQ], ⍴ [COMBOT], ⍴ [T3] < 0.0001, n =144). Students (n = 144) preferred taking problem-based learning sessions (94%) and T3 exams (80%) via Zoom or Blackboard over in person.

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hybrid learning C D A J O U R N A L , V O L 5 0 , Nº 1

Conclusion: A hybrid instructional method is effective for learning foundational biomedical knowledge and developing critical thinking skills and is preferred by dental students. Keywords: COVID-19 pandemic, instructional delivery method, hybrid learning, biomedical sciences, integrated curriculum, dental education, learning outcomes, problem-based learning

AUTHORS Oussama Hefnawi, BS, is a fourth-year dental student at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported. Xi Chen, DPPD, MPA, is the academic program manager in the Office of Academic Affairs at the Herman Ostrow School of Dentistry of USC. Her work focuses on program management, academic proposal development and learning outcome assessments. Conflict of Interest Disclosure: None reported.

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Mahvash Navazesh, DMD, is executive associate dean for academic, faculty and student affairs and a professor of diagnostic sciences in the department of diagnostic sciences, anesthesia and emergency medicine at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported.

T

he COVID-19 pandemic has had an immense impact on all aspects of life including the education sector. In many cases, in-person learning halted, and students had to adapt to remote or distance learning. Dental students experienced many changes to their routine educational experiences including canceled direct patient care and the adaptation of virtual rotations, lectures and seminars due to safer-athome orders. The sudden necessity to switch from traditional to distance learning caused by the pandemic has led to a great deal of anxiety among dental students.1 They experienced increasing stress and expressed concerns over their suffered clinical education.2 Haridy et al. (2020) studied the viewpoint of dental faculty through responses from 212 dental educators. Among them, 135 agreed that there were negative implications of COVID-19 on all dental disciplines, and 123 thought these implications would last a long time and that an action plan was needed.3 Deery (2020) reviewed the impact of COVID-19 on 67 dental schools in the United States.4 The author suggested that dental schools should incorporate sustainable adaptation of distance learning in curricula as well as learning assessments and teaching methodologies.4 The profession of dentistry lacks preparedness in dealing with emergency crises; therefore,

protocols should be put in place to better respond to potential future crises.4,5 According to the Commission on Dental Accreditation (CODA), dental schools must incorporate didactic and clinical technologies to support dental education.6 Additionally, dental graduates should have the competency to apply in-depth biomedical knowledge in the provision of patient care.6 To meet CODA standards and adhere to federal and local mandates for the prevention of COVID-19 spread, dental schools had to find creative methods to deliver the same quality education. A sundry of learning modalities including online, blended and hybrid were thus adopted by dental educators globally to overcome challenges put forth by the pandemic.3–5,7–10 Although hybrid learning or blended learning is not a new concept, it has become a popular focus of educational research in light of the pandemic. Amir et al. (2020) studied students’ perspective of classroom and online learning during the pandemic and found that dental students agreed that blended learning of the two delivery methods could be manageable and useful.10 In a comprehensive literature review, Barabari and Moharamzadeh (2020) discussed virtual reality simulation for manual dexterity skills development in dentistry.9 Several studies reported that dental students’ performance and perception have been the same or improved with


C D A J O U R N A L , V O L 5 0 , Nº 1

TABLE 1

University of Southern California and Herman Ostrow School of Dentistry COVID-19 Chronology in Spring 2020

hybrid or blended learning as compared to conventional teaching methods.11–13 Farah-Franco et al. (2020) used a preclinical online hybrid learning model and investigated its impact on dental student learning outcomes while looking at student and faculty feedback. Their hybrid curriculum consisted of an online didactic aspect (videos, audio, diagrams and an assessment question) and content reinforcing methods (collaborative group projects and application of the online didactic aspects). They compared data from five multidisciplinary courses (comprehensive care clinical dentistry), and a health sciences reasoning test was used to measure critical thinking. They found that dental student educational outcomes remained steady or were improved with the hybrid learning. Hybrid learning in this case promoted critical thinking, self-motivation and clinical preparedness.11 A study investigated the impact of blended learning by having 253 fourth-year dental students undergoing the new curriculum and comparing it to the previous traditional method of teaching. Assessments used online and written exams, assignments, quizzes and online discussion forums.12 Blended learning cohorts scored higher grade point averages and students’ perceptions were positive. Another study assessed blended learning in a preclinical endodontic course and reported that the studied cohort performed better root canal procedures than the traditional cohort.13 To our knowledge, the impact of hybrid learning on an integrated holistic biomedical sciences curriculum in dental school during the COVID-19 pandemic has not been examined yet. Therefore, we aimed to make a contribution through an assessment of student performance on biomedical sciences curriculum in its entirety with a large class size of 144 students per cohort. This study compared

Time

Events

March 2-6

Dental school midterm exam week (regular classroom/lab exams).

March 9

University-issued guidance for schools to prepare for online teaching.

March 10

University informed that didactic classes would be held online March 14-29 and would use March 10-13 as a training period for use of online instructional tools.

March 9-13

Intensive efforts were undertaken by and for USC faculty, staff and students to transition didactic classes to Zoom; numerous workshops were given by the USC Center for Excellence in Teaching and support and training services were also provided by the dental school’s Offices of Academic Affairs, Information Technology and Enterprise Applications.

March 14

Didactic classes taught exclusively online.

March 19

Los Angeles County and Los Angeles city jointly issued a “Safer at Home” order, effective midnight.14

March 23

Norris Dental Science Center closed to all students, residents, faculty and staff.

April 10

Los Angeles County extended “Safer at Home” order through May 15, 2020.14

April 13-17

Final exams for spring 2020 trimester administered online using ExamSoft, Blackboard and Zoom.

in-person to hybrid instructional delivery methods for students’ acquisition of foundational biomedical knowledge and critical thinking skills during the first (D1) and second (D2) year of dental school. The results may help to shape future instructional modalities in dental schools beyond the pandemic.

Methods Context

In spring 2020, the University of Southern California (USC) and the Herman Ostrow School of Dentistry of USC had to quickly adapt to the pandemic circumstances and make a series of changes to teaching and learning (TA BLE 1 ). As shown in TA BLE 1 , didactic classes moved into an exclusive online mode immediately after the midterm exam week; therefore, the spring 2020 trimester was split in half between the in-person and hybrid instructional methods. While clinic and lab activities have gradually resumed since August 2020 to a limited operational capacity, the biomedical curriculum and its exams have remained fully online since spring 2020 at the dental school. Based on the context

reviewed, the study selected the following four trimesters as the study period to compare student performance between the in-person and the hybrid instructional methods: fall 2019, spring 2020, summer 2020 and fall 2020 (TA BLE 2 ).

Instructional Delivery Methods

The in-person instructional delivery method in this study refers to small-group learning with a faculty facilitator in the classroom twice per week. The hybrid instructional method in this study refers to an exclusive online pedagogy with no in-person physical meetings. Yet, the learning is interactive and collaborative, using mixed virtual instructional methods including Zoom sessions, Blackboard, a virtual learning management system, Osmosis, a video stream learning aid, chatrooms, online problem-based learning (PBL) cases and the online school library. These methods can be used synchronously or asynchronously. Apart from adjustments to the instructional delivery method (inperson versus hybrid) and examination setting (classroom versus Zoom or Blackboard), there were no changes to the biomedical sciences curriculum JANUARY 2 0 2 2

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TABLE 2

Instructional Delivery Methods for Biomedical Courses Fall 2019, Fall 2020 Trimester

Months

Instructional Method

Fall 2019

August to December

In person

Spring 2020

January to mid-March

In person

Spring 2020

Mid-March to April

Hybrid

Summer 2020

May to August

Hybrid

Fall 2020

August to December

Hybrid

content and sequence, coursework, faculty facilitators and grading criteria.

Study Design

Student participants (N = 428) were coded by the instructional method (inperson versus hybrid) they received in a trimester and class cohorts. Learning outcomes were measured through student performance on two comprehensive and integrated courses that build the biomedical sciences curriculum in D1 and D2 at the Herman Ostrow School of Dentistry of USC: Human Structure and Human Function.15 The performance indicators used in this study are overall course score points, course letter grades and the two courses’ graded activities and subcomponent exams, including participation in problem-based learning (PBL) sessions, a multiple-choice questions (MCQ) exam, a computer-based objective test (COMBOT), a triple-jump exam (T3) and a problem-solving exam (P3). Following a learner-centered curricular principle, performance indicators measure students’ acquisition and application of biomedical sciences knowledge. The PBL participation grades measure students’ learning, reasoning, teamwork and feedback skills demonstrated in the PBL case sessions. Each PBL group normally includes eight students and one faculty facilitator. For each hypothetic patient case, students are expected to work collaboratively to first identify the facts (what they know), establish a set of hypotheses (what they think) based upon these facts and then determine their learning needs (what they need to know) to evaluate their 30 JANUARY

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hypotheses. The MCQ and COMBOT exams are based on fundamental knowledge learned in PBL cases. T3 and P3 exams assess students’ critical thinking skill development and application. A T3 exam functions as both a learning exercise and assessment that includes three steps: 1) draft an analysis of a hypothetical patient by identifying major problems and establish reasonable questions and hypotheses (one hour); 2) search scientific evidence to test hypotheses; and 3) on the next day, report findings and conclude whether the hypotheses should be accepted or rejected during a 30-minute oral presentation to two faculty evaluators.16,17 In the P3 examination, students are required to review a hypothetical patient scenario, establish a list of differential diagnoses, list supporting evidence and identify a prioritized list of tests and procedures to help make a final diagnosis. An overall course score is the sum of each graded component multiplied by its respective percentage assigned in the course syllabus (TA BLE 1 ). The letter grades use the following scale: A = 90%-100%, B = 80%-89%, C = 70%-79% and F = 0-69%. The grading components of biomedical courses in D1 and D2 (TA BLE 3 ) include PBL participation, MCQ, COMBOT, T3 (D1 only) and P3 (D2 only). The relationship between instructional delivery methods and student performance was assessed twofold. First, the study compared the performance of two consecutive cohorts of dental students on the same curriculum, with one cohort receiving in-person instruction before the pandemic and the other cohort

receiving hybrid instruction during the pandemic. Secondly, the study compared the performance of a same class cohort of dental students on biomedical courses taught in-person before the pandemic and then through hybrid instruction during the pandemic. The four comparisons of student performance on biomedical courses between instructional delivery methods are listed below. Two-consecutive-cohort comparisons: ■  Overall course scores and distribution of letter grades in D1 trimester I. Cohort (inperson instruction) in fall 2019 versus Cohort (hybrid instruction) in fall 2020. ■  Overall course scores and distribution of letter grades in D2 trimester IV. Cohort (inperson instructions) in fall 2019 versus Cohort (hybrid instructions) in fall 2020. Same-cohort comparisons: ■  Exam scores of MCQ, COMBOT and T3 earned by the same cohort of D1 students on inperson midterm exams versus hybrid final exams (via Zoom or Blackboard) in spring 2020. ■  Average scores of three inperson T3 exams versus average scores of three hybrid T3 exams (via Blackboard) earned by the same cohort of D1 students fall 2019 through summer 2020. The study also incorporated a recent survey in spring 2021 to this cohort of dental students, who are now in their D2 year, about their preference of instructional and assessment methods in learning biomedical sciences (hybrid versus in person). This survey was part of the school’s routine outcomes assessment


C D A J O U R N A L , V O L 5 0 , Nº 1

TABLE 3

Grading Components of Biomedical Sciences Courses in D1 and D2

D1

PBL case Human Structure I participation a,b,c 20%

MCQ midterm 15%

MCQ final 15%

COMBOT midterm 15%

COMBOT final 15%

Triple-jump (T3) midterm 10%

Triple-jump (T3) final 10%

PBL case participation 20%

MCQ midterm 15%

MCQ final 15%

COMBOT midterm 15%

COMBOT final 15%

Triple-jump (T3) midterm 10%

Triple-jump (T3) final 10%

PBL case Human Structure II participation a,b,c 20%

MCQ midterm 15%

MCQ final 15%

COMBOT midterm 15%

COMBOT final 15%

P3 midterm 10%

P3 final 10%

PBL case participation 20%

MCQ midterm 15%

MCQ final 15%

COMBOT midterm 15%

COMBOT final 15%

P3 midterm 10%

P3 final 10%

Human Function I a,b,c

D2

Human Function II a,b,c

measures managed by the Ostrow School’s Office of Academic Affairs with the assistance of student leadership.

Data Collection

The study design and data collection were approved as coded-data research by the USC Institutional Review Board, #UP-21-00272. The grades of the biomedical courses in D1 (Human Structure I and Human Function I) and D2 (Human Structure II and Human Function II) from fall 2019 through fall 2020 were collected for the study. The deidentified grades were obtained from the grading database managed by the Office of Academic Affairs, which included overall course scores, letter grades and scores of PBL session participation, MCQ, COMBOT, T3 and P3 exams. Student participants were coded by the instructional delivery mode each cohort received in a given trimester: either in-person or hybrid. Student participants consisted of three class cohorts and 428 dental students at the Herman Ostrow School of Dentistry of USC. In the four comparisons discussed in this study, each cohort of student participants refers to all students in the class (N1 = 143, N2 = 144, N3 = 141). The N1 cohort had 144 students in trimester I but one student dropped during D1. Therefore, the number of students in the N1 cohort read 144 when referring to D1, but 143 when referring to D2.

Statistical Analysis

Independent t tests were performed to compare the averages of overall course scores of biomedical courses in D1 and D2 between in-person and hybrid instructional delivery methods. Chi-square analyses of independence, with 2 x 3 contingency tables, were performed to examine the relationship between the distribution of letter grades and instructional delivery methods. Because the biomedical curriculum was delivered in person during the first half of the spring 2020 trimester but through hybrid instructions for the second half of the trimester, paired t tests were performed to compare student performances on the midterm and final of the MCQ, COMBOT and T3 exams. Lastly, a paired t test was performed to compare students’ average performance on the three inperson T3 exams and three Blackboard T3 exams in D1. For all t tests and chi-square analyses in this study, the significant level (alpha) was .05.

Results

1. Students’ overall course performances of biomedical courses in D1 and D2 were similar between the two instructional delivery methods. There was no significant difference in overall course scores of biomedical courses in D1 trimester I between two consecutive cohorts of dental students, with one cohort receiving in-person instructions in fall

2019 (N1 = 144) and the other cohort (N2 = 144) receiving hybrid instructions in fall 2020. (FIGURE 1 , ⍴-value = 0.235 > 0.05, t critical two-tail = 1.968, t stat = 1.191.) The distributions of letter grades earned by the two consecutive class cohorts of students are listed in TA BLE 4 . Chi-square analysis reported similar grades distributions between the in-person (N1 = 144) and hybrid (N2 = 144) instructional methods in D1 trimester 1 (FIGURE 2 ). In other words, there was no significant relationship between instructional delivery methods and distribution of letter grades, at ⍺ = 0.05. (Result: χ2 [df = 2, n = 288] = 2.938, p > 0.05.) The independent t test and the chi-square analysis performed for two consecutive cohorts of dental students in D2 trimester IV suggested the same findings as the analyses in D1 trimester I. Student performance, by overall course scores and distribution of letter grades, were similar between the in-person (N1 = 143) and hybrid (N3 = 141) instructional delivery methods in D2 trimester IV. (Results: ⍴-value 0.153 > 0.05, t critical two-tail = 1.969, t stat = 1.434; χ2 [df = 2, n = 284] = 3.927, p > 0.05.) 2. Student scores on final MCQ, COMBOT and T3 exams from hybrid instructions were slightly JANUARY 2 0 2 1

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hybrid learning C D A J O U R N A L , V O L 5 0 , Nº 1

T Distribution DF: 286

f(x) 0.4

higher than their performance from in-person instructions on the respective midterm MCQ, COMBOT and T3 exams in D1 trimester II, spring 2020 (TA BLE 5 , N1 = 144).

0.3

0.2

0.1

α =0.025

α =0.025

0 –4

–2

0

t Stat 1.191

x

Critical Value = –1.968

4

2 Critical Value = 1.968

FIGURE 1. T distribution — overall course grades. TABLE 4

Letter Course Grades Distribution in D1 Trimester 1 Letter Grade Distribution: Trimester 1, Fall 2020 vs. Fall 2019 Instructional delivery method

A

B

C

Mean

SD

In-person

29 (20%)

104 (72%)

11 (8%)

85.87

4.49

Hybrid

41 (28%)

95 (66%)

8 (6%)

86.49

4.31

TABLE 5

Paired T-Test Results of MCQ, COMBOT and Triple Jump Exams in D1 Trimester II Paired T-Test Results, a = 0.05 Hybrid final exam vs. in-person midterm exam

T-stat

T-critical P-value

DF

Mean difference

Standard error

MCQ

6.723

1.656

< 0.0001

143

0.519

0.077

COMBOT

13.649

1.656

< 0.0001

143

1.112

0.081

Triple-jump (T3)

5.577

1.656

< 0.0001

143

0.221

0.040

3. Students’ average performance on the three triple-jump (T3) exams given via Blackboard was better than their average performance on the other three T3 exams given in person in D1 (FIGURE 3 , N1 = 144). The three in-person exams were the T3 midterm and final in fall 2019 and the T3 midterm in spring 2020. The other three Blackboard exams were the T3 final in spring 2020 and the midterm and final of T3 in summer 2020. The study calculated an individual student’s average score of three in-person exams and their average score of three Blackboard exams, and then used the two arrays of average scores to perform a paired t test (N1 = 144). (Results: ⍴-value 1.91568E-10 < 0.05), t critical onetail = 1.656, t stat = 6.728.) As a supplementary note, the survey we mentioned earlier to this cohort of dental students (100% participation) reported 94% of students preferred the small-group PBL sessions remaining via Zoom. Students strongly agreed and/or agreed that they learned very well via Zoom (82%) and preferred taking T3 exams remotely via Zoom or Blackboard over in person (80%).

Discussion

The results of this study indicated that a hybrid instructional method is effective for learning fundamental knowledge of biomedical sciences and developing critical thinking skills. Despite the pandemic, students in both D1 and D2 receiving hybrid instruction were able 32 JANUARY

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C D A J O U R N A L , V O L 5 0 , Nº 1

Chi-Square Distribution - Letter Grades DF: 2 P (X ≥ 5.991) = 0.05

f(x) 0.5 to perform at a similar level as compared to their respectively immediate previous cohort receiving in-person instruction. Further, tests on the same cohort of D1 students reported slightly better performance on MCQ, COMBOT and T3 exams from hybrid instructions than in-person instructions. Our findings confirmed information reported in the literature that hybrid instruction in a digitally engaging learning environment can result in equal or enhanced student performances, and in many cases, students’ reactions were positive toward hybrid instructions.11–13 The incorporated survey outcomes revealed learners’ preference of distance hybrid instructions for conducting problem-based learning sessions and remote exams, which added a student perspective to our findings. This study’s contributions to the literature lie in the assessment of student performance on the PBL biomedical sciences curriculum in its entirety with a large class size of 144 students per cohort. Our integrated biomedical curriculum design makes it easy to conduct a holistic review on learning outcomes beyond a single subject such as anatomy and physiology. Other recent studies on dental students’ outcomes from hybrid or blended learning reported comparable outcomes; however, they mostly focused on skill development in preclinical (laboratory) and clinical sciences instead of PBL integrated biomedical sciences. Farah-Franco et al. (2020) found that the hybrid learning group either performed the same or better than the traditional group and showed increased self-motivation, independence and critical-thinking skills.11 The sample size was approximately 70 students in each of the four groups of participants. Similarly, the study from Jordan on fourth-year dental students found that the blended learning group scored

0.4 0.3

Chi-Square Test Stat 2.938

0.2 0.1 0 0

5

10

5.991

15

FIGURE 2 . Chi-square distribution — letter grades.

f(x)

T3 Exams T Distribution (DF:143) P (X ≥ 1.656)=0.05

0.4

0.3

0.2 T Stat X = 6.728

0.1

0 –4

–2

0 x

2

4

1.656

FIGURE 3 . T distribution of the triple-jump (T3) exams.

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higher scores in assignments, quizzes and clinical assessments compared to their control counterparts (354 in the control group and 253 in the blended learning group).12 Another study on 81 students’ performance in a preclinical endodontic course reported that the blended learning cohort performed better root canal procedures than the traditional cohort.13 This study reported here is among the early steps of a systematic plan to explore the effectiveness and sustainability of hybrid instructional methods at the Herman Ostrow School of Dentistry. We chose to first focus on biomedical sciences because, unlike virtual clinical rotations and the temporary halt of patient care forced by the pandemic, there were no interruptions in the biomedical sciences learning. Except for the change in the instructional delivery methods (in person versus hybrid), there were no changes to the biomedical sciences curriculum content and sequence, coursework, faculty facilitators and grading criteria. Our future focus will be on the assessments of students’ application of biomedical sciences knowledge learned and critical-thinking skills developed from hybrid instructions to their everyday practice of dentistry in the third and fourth years of dental school. There were several limitations to our study. First, it focused exclusively on student performance indicators. Future studies on hybrid instructional methods should incorporate comprehensive student and faculty feedback, such as student motivation and faculty encouragement of student participation. Second, our problem-based learning pedagogy and learner-centered environment may potentially limit the generalizability of our results to other dental schools that have different types of pedagogy or learning philosophy. Third, it is worth noting that inequity in access to 34 JANUARY

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advanced technologies and school services in a more diverse and larger sample size may impact the hybrid learning outcomes differently. For example, at the Ostrow school, spaces with COVID-19 safety measures were provided for dental students who needed accommodations for Zoom exams or classes due to unstable internet or background noise at home. Frequent faculty calibration sessions were held for virtual teaching, proctoring exams and student counseling. Faculty and staff members from the offices of academic affairs, enterprise applications and facilities management made tremendous efforts to facilitate a smooth transition from in-person to distance hybrid learning. The availability of these supportive services could contribute to steady or better student performance and their positive experience of a hybrid instructional method.

Conclusion

A hybrid distance instructional method is effective for learning fundamental biomedical knowledge and developing critical-thinking skills for dental students. It is preferred by students over the traditional model. n RE FE RE N CE S 1. Iyer P, Aziz K, Ojcius DM. Impact of COVID‐19 on dental education in the United States. J Dent Educ 2020 Jun;84(6):718–722. doi: 10.1002/jdd.12163. Epub 2020 Apr 27. 2. Hung M, Licari FW, Hon ES, Lauren E, Su S, Birmingham WC, Wadsworth LL, Lassetter JH, Graff TC, Harman W, Carroll WB, Lipsky MS. In an era of uncertainty: Impact of COVID-19 on dental education. J Dent Educ 2021 Feb;85(2):148–156. doi: 10.1002/jdd.12404. Epub 2020 Sep 13. 3. Haridy R, Abdalla MA, Kaisarly D, Gezawi ME. A cross-‐ sectional multicenter survey on the future of dental education in the era of COVID‐19: Alternatives and implications. J Dent Educ 2021 Apr;85(4):483–493. doi: 10.1002/jdd.12498. Epub 2020 Dec 1. PMCID: PMC7753345. 4. Deery C. The COVID-19 pandemic: Implications for dental education. Evidence-based dentistry. Evid Based Dent 2020 Jun;21(2):46–47. doi: 10.1038/s41432-020-0089-3. 5. Haroon Z, Azad AA, Sharif M, Aslam A, Arshad K, Rafiq S. COVID-19 era: Challenges and solutions in dental education. J Coll Physicians Surg Pak 2020 Oct;30(10):129–131. doi:

10.29271/jcpsp.2020.supp2.129. 6. American Dental Association. Accreditation standards for dental education programs. 7. Prieto D, Tricio J, Cáceres F, Param F, Meléndez C, Vásquez P, Prada P. Academics’ and students’ experiences in a Chilean dental school during the COVID-19 pandemic: A qualitative study. Eur J Dent Educ 2021 Nov;25(4):689–697. doi: 10.1111/eje.12647. Epub 2021 Jan 6. 8. Desai BK. Clinical implications of the COVID‐19 pandemic on dental education. J Dent Educ 2020 May;84(5):512. doi: 10.1002/jdd.12162. Epub 2020 Apr 26. PMCID: PMC7267231. 9. Barabari P, Moharamzadeh K. Novel coronavirus (COVID-19) and dentistry — a comprehensive review of literature. Dent J (Basel) 2020 Jun;8(2):53. doi: 10.3390/ dj8020053. 10. Amir LR, Tanti I, Maharani DA, Wimardhani YS, Julia V, Sulijaya B, Puspitawati R. Student perspective of classroom and distance learning during COVID-19 pandemic in the undergraduate dental study program Universitas Indonesia. BMC Med Educ 2020 Dec;20(1):1–8. doi.org/10.1186/ s12909-020-02312-0. 11. Farah‐Franco SM, Hasel R, Tahir A, Chui B, Ywom J, Young B, Singh M, Turchi S, Pape G, Henson B. A preclinical hybrid curriculum and its impact on dental student learning outcomes. J Den Educ 2021 May;85(5):679–689. doi.org/10.1002/ jdd.12517. 12. Qutieshat AS, Abusamak MO, Maragha TN. Impact of blended learning on dental students’ performance and satisfaction in clinical education. J Dent Educ 2020 Feb;84(2):135–142. doi: 10.21815/JDE.019.167. 13. Maresca C, Barrero C, Duggan D, Platin E, Rivera E, Hannum W, Petrola F. Utilization of blended learning to teach preclinical endodontics. J Dent Educ 2014 Aug;78(8):1194– 204. 14. County of Los Angeles Department of Public Health. Safer at Home Order for Control of COVID-19, Order Revised April 10, 2020. 15. Navazesh M, Rich S, Tiber A. The rationale for and implementation of learner-centered education: Experiences at the Herman Ostrow School of Dentistry of the University of Southern California. J Dent Educ 2014 Feb;78(2):165–80. 16. Navazesh M, Rich SK, Keim RG. Triple jump examination evaluation of faculty examiners by dental student examinees. J Dent Educ 2014 May;78(5):714–22. 17. Navazesh M, Rich S, Bahari-Chopiuk N, Keim R. Triple jump examinations for dental student assessment. J Dent Educ 2013 Oct;77(10):1315–20. T HE CORRE S P ON DIN G AU T HOR , Oussama Hefnawi, BS, can be reached at hefnawi@usc.edu.


case-based learning C D A J O U R N A L , V O L 5 0 , Nº 1

Efficacy of Virtual Asynchronous Didactic Delivery and Case-Based Discussions for Predoctoral Orthodontic Education James Chen, DDS, PhD, MPH; Brandon Zegarowski, DDS; and Mandy Lam, DDS

abstract Background: Case-based learning (CBL) has been widely accepted as an integral part of active learning in dental curriculums. An all asynchronous didactic and CBL model for orthodontic education was developed out of necessity during the COVID-19 pandemic. The purpose of this research is to evaluate the efficacy of virtual didactic delivery and CBL discussions for a predoctoral orthodontics course using a pilot study of “coded discussions” and contrasting student course evaluations with a previous traditional in-person lecture iteration of the same course. Materials and methods: Using the concept of “discussion coding,” a numerical rubric can be used to individually evaluate a student’s experience in a virtual forum. The data gathered include the quantity and timing of student posts as well as metrics evaluating student engagement via post quality, post type and discussion-generating characteristics of posts based on topics across each of the four themed module discussions. Student course evaluations from 2018 were then contrasted to the evaluations from 2020 with the virtual format. Results: The discussion data showed high levels of student engagement in clinically relevant topics with quantity and timeliness of posts exceeding the course minimum requirements. When compared to previous course evaluations with solely passive learning, the educational outcomes and student satisfaction of virtual courses appear to be similar in nature. Conclusion: Pairing short asynchronous passive learning lectures and in-depth active learning online case discussions, based on student feedback, offers a method to create immersive learning experiences that are not just a product of modern necessity. Keywords: Virtual, case based, discussions, predoctoral, orthodontic education, asynchronous, outcomes

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case-based learning C D A J O U R N A L , V O L 5 0 , Nº 1

AUTHORS James Chen, DDS, PhD, MPH, is an assistant professor in the department of orthodontics at the University of the Pacific, Arthur A. Dugoni School of Dentistry. Conflict of Interest Disclosure: None reported. Brandon Zegarowski, DDS, is a recent graduate of the University of the Pacific, Arthur A. Dugoni School of Dentistry. He is pursuing a Master of Science in dentistry in the orthodontics and dentofacial orthopedics program at the Oregon Health and Science University in Portland. Conflict of Interest Disclosure: None reported.

Mandy Lam, DDS, is a recent graduate of the University of the Pacific, Arthur A., Dugoni School of Dentistry. She is now serving the U.S. Navy Dental Corps at the Great Lakes Naval Station in Chicago. Conflict of Interest Disclosure: None reported.

D

ental education in the U.S. has long been based on passive learning, with didactic material being presented to students in lecture format. Over the past decades, more dental programs have implemented active learning modules to improve the overall educational experience for dental students through problem-based learning (PBL) or casebased learning (CBL).1 Research has shown that proper implementation of PBL and CBL learning modules has significantly improved the overall

Case-based learning has been instrumental in medical education for decades.

educational experience of dental students.2 Subtle differences exist between PBL and CBL, with the latter requiring some level of knowledge prior to the case discussions. Case-based learning has been instrumental in medical education for decades. The use of formative didactic learning as a base from which students engage in clinical case problem-solving has shown to be a good adjunct to traditional lectures.3 CBL is collaborative, hence the faculty member is directly involved in the experience and learning. This style of education lends itself perfectly toward virtual learning, as both the didactic and case information can be delivered directly to the students. Richards et al. concluded that case-based teaching may encourage dental students to focus on their patients’ cultural background and whole complexity 36 JANUARY

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when assessing treatment decisions.4 This would encourage collaboration with other disciplines within the predoctoral curriculum, though at the same time could cause issues with the limited time a course instructor would have to devote to small groups. Historically, CBL has been a strain on faculty time and has required additional resources; however with the use of the education technology, asynchronous learning can offer flexibility to both the faculty and students, leading to positive educational outcomes.1 Predoctoral orthodontic education in U.S. dental programs has primarily been based on some combination of passive learning, faculty lectures and clinic rotations. Unlike other dental specialties, orthodontic treatment typically lasts one to three years, which in the context of three- to four-year dental programs offers very few opportunities to apply didactic information to first-hand clinical experiences. While clinic rotations are helpful, they are often a snapshot of the whole treatment. Yang et al. described the challenges faced by orthodontic educators, in that “limited curriculum time and clinical probation is difficult in creating a meaningful learning experience and makes students have rare exposure to a broad range of existing clinical situations.”5 Yang et al. further poses the challenges orthodontic faculty face in attempting to present a large amount of information to students with little clinical exposure to facilitate closure of the information loop.5 In their article, Yang et al. showed implementation of case-based learning modules was both well received and helped improve student understanding of problem lists, diagnosis and treatment planning.5 Due to the COVID-19 pandemic, many dental programs had to move most, if not all, of their current courses from in-person to some combination of remote learning. At the University of


C D A J O U R N A L , V O L 5 0 , Nº 1

the Pacific, Arthur A. Dugoni School of Dentistry, a rapid shift occurred within the biomedical and clinical didactic curriculum, transitioning to a combination of Zoom and Canvas for certain classes that formerly consisted of solely in-person lectures. With the postCOVID-19 transition, faculty increased the application of Canvas and in some cases used it to actively interact with students in lieu of in-person meetings.6 Using a virtual model developed by the University of California at Berkeley Online Master of Public Health program, the predoctoral orthodontic courses implemented a unique combination of asynchronous passive learning modules and asynchronous active learning through CBL online discussion forums.7 Yang et al. has shown the value of CBL modules in orthodontic education in predoctoral education. The COVID-19 pandemic forced educators to combine previously successful educational formats such as CBL with utilizing online educational platforms. The null hypothesis of this pilot study is for dental students at the University of the Pacific, Arthur A. Dugoni School of Dentistry, passive and active learning modules newly developed in the predoctoral orthodontic curriculum do not differ fundamentally from previous in-person passive learning. To test this hypothesis, the following specific aims were constructed: 1) Compare student course evaluations between the new asynchronous passive and active learning format to previous in-person passive learning only format and 2) collect and analyze discussion data and to determine the efficacy and quality of virtual asynchronous delivery of the course. To achieve this aim, a standardized “Discussion Forum Coding Guide” was developed through which every post in the course was manually quantified and qualified.

Methods Overall Course Evaluation

This project was completed with IRB approval (IRB2021-101). Aggregate student course evaluations for the introductory orthodontic course (OR244) from 2018 at the University of the Pacific, Arthur A. Dugoni School of Dentistry were compiled and compared to the compilation of student course evaluations after conclusion of the OR244 class in 2020 (TA BLE 1 ). A major course difference between these years is in 2018, OR244 was delivered in person with lectures

Students were presented different clinical cases with specific questions that related back to the weekly course content.

while 2020 saw the transition to an online format with the new inclusion of asynchronous didactic content delivery and use of discussion forums on Canvas. In both these years, a digital questionnaire was distributed to students who successfully completed the course.

Course Layout

The basic structure of the online class was to separate the course material into easily digestible weekly modules with asynchronously recorded lectures of 20 to 40 minutes each for passive learning, and case-based discussions modules were a critical piece of student engagement in terms of active learning. For each discussion section, students were divided into 10 groups (two groups with 16 students and eight groups with

17 students). Of the seven modules of content in the course, only modules 2, 3, 4 and 7 had discussion forums in the format evaluated in this study. Each of these modules lasted one week, and within that time, students were given the first three days to post their answers to the case of their choice along with four days to post a reply to a classmate’s original post. Students were presented different clinical cases with specific questions that related back to the weekly course content. Each student was asked to choose a case they thought was interesting to them, answer the associated questions and then respond to another classmate’s post. The course director was actively engaged in making sure to respond to each student’s post and questions in an environment where right or wrong answers were not as important as the dialogue generated by their discussion posts.

Discussion Assessment

Data was collected after completion of the orthodontics course, and as such, it is retrospective cross-sectional data in nature. All student identifiers and demographics were removed to have purely deidentified data. The quality and quantity of the discussion posts for this new orthodontic didactic delivery system were evaluated though designing a coding system for each discussion post (APPENDI X 1 ). Each discussion response was coded into a numerical value to allow for statistical analysis of each module (discrete numerical values ranging from 0–4 depending on the criteria). Seven specific categories to measure quantity, timing and quality of each response were developed. These categories were assessed by two research graders and input into Microsoft Excel documents. The researchers spent three hours prior to collecting data evaluating test posts together as a way of standardizing the “Discussion Forum JANUARY 2 0 2 2

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case-based learning C D A J O U R N A L , V O L 5 0 , Nº 1

TABLE 1

Course Evaluation for 2018 Compared to 2020: Orthodontic 244 Course Evaluation 2018 Disagree

Strongly disagree % of total evaluations

N

% of total evaluations

N

Agree

N

% of total evaluations

Strongly agree

N

Total

% of total evaluations

Course requirements were clear.

5.7%

3

11.3%

6

37.7%

20

45.3%

24

53

Assessments (exams, quizzes, other) were fair and representative of course content.

7.5%

4

3.8%

2

45.3%

24

43.4%

23

53

Presentations were clear and to the point.

5.7%

3

24.5%

13

34.0%

18

35.8%

19

53

This course was well organized.

5.7%

3

13.2%

7

43.4%

23

37.7%

20

53

Faculty appeared interested in my learning the material.

3.8%

2

5.7%

3

43.4%

23

47.2%

25

53

The pace of material presented in this course was appropriate.

7.5%

4

5.7%

3

35.8%

19

50.9%

27

53

The difficulty of the material in this course met my expectations for a course at this level.

3.8%

2

5.7%

3

45.3%

24

45.3%

24

53

The format of this course (lecture, lab, seminar, case study, independent study, etc.) helped me learn.

3.8%

2

17.0%

9

41.5%

22

37.7%

20

53

Please use the four-point scale to answer the following questions about your orthodontics didactic course.

Mean rating

Count N

Course requirements were clear.

3.2

53

Assessments (exams, quizzes, other) were fair and representative of course content.

3.2

53

Presentations were clear and to the point.

3.0

53

This course was well organized.

3.1

53

Faculty appeared interested in my learning the material.

3.3

53

The pace of material presented in this course was appropriate.

3.3

53

The difficulty of the material in this course met my expectations for a course at this level.

3.3

53

The format of this course (lecture, lab, seminar, case study, independent study, etc.) helped me learn.

3.1

53

Ratings are as follows (Strongly agree-4, Agree-3, Disagree-2, Strongly disagree-1)

Coding Guide” metrics. The first two categories involved the quantity and timing of student posts in the discussion forum. Both categories were based on the instructions given to the students in the course syllabus regarding a minimum of one original response to a case and one reply to a peer or instructor as well as a first post due date on Monday at 11:59 p.m. and a second post due on Thursday at 11:59 p.m. of the module week. Posts were then assessed for the case topic they were in response to as well as whether it was an original response to the assigned case or a reply 38 JANUARY

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to a peer or instructor. To determine the level of student interaction via discussion, individual posts were evaluated for the type of response elicited (peer, instructor or none) as well as the inclusion of a follow-up question or novel material in the post to elicit further discussion. The individual posts were also evaluated for quality based on a standard rubric seen in the “Discussion Forum Coding Guide” in A P P E N D I X 1 . There were no course requirements for the quality or discussion-generating nature of a post; the only two requirements were the quantity and timing of the posts.

Discussion Coding Calibration

The discussion coding primarily focused on objective assessments of each discussion post such as times and frequency of posts. One subjective assessment focused on quality of the discussion post. To assess the calibration between the two graders, the kappa statistic for agreement for this subjective measure was measured in Module 2 with both individual graders completing the quality data collection for the entire module independently. Module 2 quality measure had an agreement level of 98% compared to the expected 44%


C D A J O U R N A L , V O L 5 0 , Nº 1

TABLE 1, CONTINUED

Course Evaluation for 2018 Compared to 2020: Orthodontic 244 Course Evaluation 2020 N

Strongly disagree

Disagree

N

N

Total

Strongly agree

% of total evaluations

% of total evaluations

% of total evaluations

Agree

N

% of total evaluations

Course requirements were clear.

1.6%

1

7.9%

5

55.6%

35

34.9%

22

63

Assessments (exams, quizzes, other) were fair and representative of course content.

3.2%

2

1.6%

1

60.3%

38

34.9%

22

63

7.9%

5

15.9%

10

42.9%

27

33.3%

21

63

I could fully engage with classmates 6.3% and the course director.

4

9.5%

6

44.4%

28

39.7%

25

63

Presentations were clear.

3.2%

2

4.8%

3

52.4%

33

39.7%

25

63

This course was well organized.

0.0%

0

12.7%

8

49.2%

31

38.1%

24

63

Faculty appeared interested in my learning the material.

0.0%

0

4.8%

3

41.3%

26

54.0%

34

63

The pace of material presented in this course was appropriate.

3.2%

2

12.7%

8

49.2%

31

34.9%

22

63

The difficulty of the material in this course met my expectations for a course at this level.

1.6%

1

14.3%

9

47.6%

30

36.5%

23

63

The online course was effective.

9.5%

6

12.7%

8

42.9%

27

34.9%

22

63

I would have preferred face-to-face class meetings.

4.8%

3

28.6%

18

20.6%

13

46.0%

29

63

The online format of this course supported my learning.

Please use the four-point scale to answer the following questions about your spring quarter online orthodontics didactic course.

Mean rating

Count N

Course requirements were clear.

3.2

63

Assessments (exams, quizzes, other) were fair and representative of course content.

3.3

63

The online format of this course supported my learning.

3.0

63

I could fully engage with classmates and the course director.

3.2

63

Presentations were clear.

3.3

63

This course was well organized.

3.3

63

Faculty appeared interested in my learning the material.

3.5

63

The pace of material presented in this course was appropriate.

3.2

63

The difficulty of the material in this course met my expectations for a course at this level.

3.2

63

The online course was effective.

3.0

63

I would have preferred face-to-face class meetings.

3.1

63

Ratings are as follows (Strongly agree-4, Agree-3, Disagree-2, Strongly disagree-1)

along with a kappa value of 96.5%. These values show both grades were well calibrated to the most subjective assessment tool in the discussion coding.

Statistical Analysis

Microsoft Excel was used as the primary form of data entry along with

basic data analysis (Microsoft Corp., Seattle) and data was transferred to Stata for further statistical analysis (Stata, StataCorp LLC, College Station, Texas). Basic descriptive analysis was used to evaluate quantity and time (mean and SD) for each post. Qualitative measures were primarily focused on within module

differences as opposed to between module differences due to the statistical complexity of looking for differences among different groupings of topics. Within each module, the focus remained on the relationship between the type of case or topic and the quality of the posts. The primary comparison measure was the JANUARY 2 0 2 1

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case-based learning C D A J O U R N A L , V O L 5 0 , Nº 1

APPENDIX 1: DISUSSION FORUM CODING

1. Student – Quantity (minimum: 1 original response, 1 reply) ■  0 – Missing post, incomplete ■  1 – Minimum posts per student ■  2 – 1 additional post above minimum ■  3 – 2+ additional posts above minimum 2. Student – Time (how many are doing it at last minute and early — dates: first post due Monday 11:59 p.m., reply post due Thursday 11:59 p.m.) ■  N/A – Not completed ■  0 – Late ■  1 – < 24 hours before (on due date) ■  2 – 24–48 hours before (1 day early) ■  3 – > 48 hours before (2 or more days early) 3. Post – Quality (low, medium, high) ■  1 - Low – Comment or question stating personal opinion or anecdotal evidence without further developing idea. ■  2 - Medium – Comment or question using primary sources of information from course material or basic internet search to further develop idea. ■  3 - High – Comment or question using secondary/tertiary sources: peerreviewed journals, articles with citations, etc., to further develop idea. 4. Post – Case topic (distribution of favored/unfavored cases) ■  1 – Case 1 ■  2 – Case 2 ■  3 – Case 3 ■  4 – Case 4 5. Post – Post type (original case response or reply) ■  1 – Original response to assigned case ■  2 – Reply/response to peer or instructor 6. Post – Discussion generation frequency (discussion behavior – how many posts elicited discussion (%)) ■  0 – If no questions or comments with novel material are made within the post to elicit further discussion. ■  1 – If follow-up questions or comments are made within the post to receive feedback or introduce novel material eliciting further discussion. 7. Post – Response frequency (how many posts were responded to by nobody, by peers w/wo instructors versus solely instructors (%)) ■  0 – If no response and left open-ended. ■  1 – If response by peer comment with/without instructor comment. ■  2 – If response by instructor comment only.

type of case within each module. The type of case is classified as nominal form of data, and as such, nonparametric tests were used for statistical analysis. The Kruskal-Wallis test was used to assess if there were any statically significant differences in quality based on the topics for within each module. The types of cases varied among all the 40 JANUARY

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modules, which limited the individual comparisons compared to a broader analysis. All student identifiers were removed prior to evaluating the discussion response, therefore differences in demographics such as age, sex and dental program (DDS compared to international dental student) were unable to be assessed. Furthermore, each module

had a varying degree of responses both in total and per student making it difficult to directly compare between modules.

Results Overall Course Evaluation

First, the overall student evaluations from 2018 (pre-COVID-19) were compared to this current 2020 (during COVID-19) course (TA BLE 1 ). The comparison showed that for all course criteria the new format was similar in quality to that of the 2018 course. When looking at the average scoring for course quality, both formats were almost identical, except for a slight difference in “faculty appeared interested in my learning the material.” While numerically similar in overall course evaluation, several noticeable differences arose in the open-ended questions given at the end of the course evaluation. Due to the large number of open-ended responses, just a few will be highlighted to illustrate what was noticed. The positive responses for the traditional format centered on lecture content specifically focusing on Invisalign. The negative open-ended responses primarily focused on the delivery of the lecture material and some requests for more in-depth case discussion. In contrast, the positive open-ended responses for this new format centered on class organization, quality of the learning from discussion forums, interaction with faculty and peers and case presentation. Some examples of positive response are: “I thought this was the most effective online class we had spring quarter. I felt like my learning was very active and the courses/cases presented were both informative and enjoyable to watch from home. I also believed all the faculty were online and interested in helping us at any hour. Great job!” and “The content of this course is pretty complex and there was a steep learning curve but once I started to


C D A J O U R N A L , V O L 5 0 , Nº 1

APPENDIX 2 : QUALIT Y OF DISCUSSION POSTS ( MODULES 2 AND 3 )

Module 2 Mixed Dentition Case*

learn more about orthodontics I could logic my way through different treatment plans. The most useful parts of this course were the discussion boards because we got to see the thought processes of our peers and learn from them.” The negative responses for the new format focused on logistics of the course and the amount of material provided at one time. Some examples of these negative responses are: “There was way too much thrown at us at once. I had a hard time following along and had to do outside research to be able to answer the discussion questions” and “The amount of material this course presented us with was extensive. It often took me more than eight hours each Friday to get through the material and I often needed two days to work through the materials.”

Module Discussion Evaluation

For each discussion group, there was a minimum number of posts ranging from 32 to 34 depending on which group had more or less students. When all 10 groups were combined, the minimum expected number of posts/reposts amounted to 321 per module. TA BLE 3 shows that the average number of total posts (minus all instructor posts) was 409 (range of 365–430). This indicates that more than just the minimum number of posts were occurring for each module. Though this result is not an ideal proxy for student engagement, it does give a picture of the different levels of participation within each module. Both the quantity and timing of each post for all modules were assessed as well. On average, each module generated between the minimum to at least one additional post (APPENDI X TA BLE 2 ) with Module 4 being the only module with closer to the minimum number. The initial post by students in the first two modules was completed generally one day before the due date, but in the last two modules, that average moved closer to the due date (APPENDI X TA BLE 2 ).

Response type

Anterior crossbite

Moderate Severe crowding crowding

Open bite Deep bite

Total

No response

39

28

20

51

12

150

Response by peer

34

33

20

59

10

156

Response by instructor

23

22

24

27

11

107

Total

96

83

64

137

33

413

Discussion generation frequency

Anterior crossbite

Moderate Severe crowding crowding

Open bite Deep bite

Total

No discussion

60

55

41

91

26

273

Follow-up discussion

36

28

23

46

7

140

Total

96

83

64

137

33

413

Post type

Anterior crossbite

Moderate Severe crowding crowding

Open bite Deep bite

Total

Original post

41

33

25

54

16

169

Response

55

50

39

83

17

244

Total

96

83

64

137

33

413

Module 3 Adolescent Cases Post quality

Protrusion

Impaction

Root resorption

Orthodontic staging

Total

Low

44

58

66

12

180

Medium

52

52

58

20

182

High

7

22

31

5

65

Total

103

132

155

37

427

Discussion generation frequency

Protrusion

Impaction

Root resorption

Orthodontic staging

Total

No discussion

51

68

98

23

240

Follow-up discussion

52

64

57

14

187

Total

103

132

155

37

427

Post type

Protrusion

Impaction

Root resorption

Orthodontic staging

Total

Original post

43

44

68

14

169

Response

60

88

87

23

258

Total

103

132

155

37

427

The student reposts to their colleagues were consistently posted at least one day before the due date (APPENDI X TA BLE 2 ). The criteria pertaining to the level of engagement of students in the discussion forum was also evaluated. The quantity of

posts generating discussion were evaluated with 540 of 1,635 evaluated posts across all groups and modules eliciting further discussion, which was an average of 33%. Across all modules, the total responses elicited by peers were the most common JANUARY 2 0 2 2

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case-based learning C D A J O U R N A L , V O L 5 0 , Nº 1

APPENDIX 2 : QUALIT Y OF DISCUSSION POSTS ( MODULE 4 ) , CONTINUED

Module 4 Adult/Invisalign Response type

Incisor impaction

Perio missing teeth

Class III malocclusion

Invisalign difficulty

Total

No response

30

54

29

22

135

Response by peer

27

49

37

25

138

Response by instructor

20

30

25

17

92

Total

77

133

91

64

365

Post quality

Incisor impaction

Perio missing teeth

Class III malocclusion

Invisalign difficulty

Total

Low

41

62

41

24

168

Medium

35

67

43

33

178

High

1

4

7

7

19

Total

77

133

91

64

365

Discussion generation frequency

Incisor impaction

Perio missing teeth

Class III malocclusion

Invisalign difficulty

Total

No discussion

59

102

66

38

265

Follow-up discussion

18

31

25

26

100

Total

77

133

91

64

365

Post type

Incisor impaction

Perio missing teeth

Class III malocclusion

Invisalign difficulty

Total

Original post

32

64

39

32

167

Response

45

69

52

32

198

Total

77

133

91

64

365

form of response as well, with 589 of 1,635 posts eliciting a response solely by a peer in the same group, for an average of 36%. Lastly, the quality of each student post and repost sorted by topic was evaluated. The comparison was just within modules as opposed to the cross-comparison of modules due to the significant differences in the range of contents between the modules along with the varied number of individual posts. There were no major differences within each module across different types of clinical cases (TA BLE 3). Two quality measures showed a statistical significance (P < 0.05), Module 2 response quality and Module 3 response type. The P-value for Module 2 response quality was 0.03 which is below the classical P < 0.05 threshold, but if one considers the number of comparisons 42 JANUARY

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within each module, this value is most likely due to random chance (TA BLE 3 ). However, for the response type in Module 3, the P-value was 0.0001, and in the face of multiple comparisons, this value appears to be more realistic (TA BLE 3 ). This module is unique in that it is the only module with one case that is not clinically relevant (orthodontic staging), and as such it had the lowest number of posts. The quality of the posts was further evaluated by assessing the percentage of posts that had high, medium and low quality. When graphically evaluating the percentages, a few specific topics were noted that had 50% or higher of medium to high quality of responses (FIGURE 1). Modules 2 and 3 presented with the greatest number of topics of quality posts having a medium quality designation.

Discussion

The COVID-19 pandemic has significantly impacted dental education specifically when it pertains to educational content given in person. While there is no clear substitute for clinical training, traditionally passive learning courses such as orthodontics had an opportunity during the mandated shutdown to attempt and assess different teaching methods. This study focused on the implementation of a fully asynchronous orthodontic curriculum with both a passive and active learning component. A point of interest was to see how this new curriculum fared both with student satisfaction and grasping of important fundamental orthodontic knowledge. The analysis methods were developed after the course had completed, thus this study was conducted as a pilot with limited data available. The results of this pilot study showed similarities between an in-person passive learning-only course (prior to COVID-19) and the new asynchronous passive and active-learning course (during COVID-19) based on student feedback. Course ratings were not expected to be significantly higher in the new model compared to the old learning model because the general material of the course was the same. However, similar course evaluation would indicate that students fundamentally enjoyed the asynchronous environment the same as the passive learning environment. While quantitatively similar, this online teaching modality produced more student feedback and open-ended questions. Students reported to benefit from the increased level of engagement, particularly from the unique engagement with faculty and colleagues in a virtual open learning space. This difference is most likely attributed to the direct interactions the course director had with students in small group online discussion forums under the new format.


C D A J O U R N A L , V O L 5 0 , Nº 1

APPENDIX 2 : QUALIT Y OF DISCUSSION POSTS ( MODULE 7) , CONTINUED

Module 7 Surgery

Beyond the course evaluations, an additional point of focus was the quality aspect of each asynchronous CBL module. The setup of the discussion modules was twofold, one to increase the opportunity of students viewing more than just one case and to encourage professional interaction they would experience in private practice. Quality was assessed through metrics evaluating the engagement level of each discussion module. With approximately a third of posts eliciting further discussion and peer responses, the level of student engagement was more than satisfactory given that no course requirements defined quality of posts or discussion generation metrics, thus all the peerto-peer interaction occurred naturally without course grade incentive. Data did not show any module or topic stood out as “more” engaging, however, topics that were not clinically relevant did not garner as much interest (orthodontic staging) compared to clinically relevant ones. Specifically, modules 2 and 3 tended to induce a higher percentage of quality posts. It is possible that the quality of posts was much higher earlier in the quarter than later on in the course. These results, while not surprising, highlight the importance of understanding what the interests are of students when designing CBL modules. Similar to the Buelow et al. study, identifying course content that attracts a higher level of interest is a way that programs can encourage and support online students’ learning engagement.8 Some common concerns with live-discussion forums are the unequal distribution of participation. With in-person discussions, one would expect a bell-shaped curve with a few students extremely eager and a few shy in expressing their thoughts. While the study was conducted after the course was completed, online discussion forums offer a unique space for students to be

Response type

Class III surgical

Class III Nonsurgical

Class II surgical

Class II nonsurgical

Total

No response

38

23

25

19

105

Response by peer

43

21

28

21

113

Response by instructor

83

44

44

41

212

Total

164

88

97

81

430

Post quality

Class III surgical

Class III nonsurgical

Class II surgical

Class II nonsurgical

Total

Low

78

38

58

42

216

Medium

73

48

34

35

190

High

13

2

5

4

24

Total

164

88

97

81

430

Discussion generation frequency

Class III surgical

Class III nonsurgical

Class II surgical

Class II nonsurgical

Total

No discussion

121

69

71

56

317

Follow-up discussion

43

19

26

25

113

Total

164

88

97

81

430

Post type

Class III surgical

Class III nonsurgical

Class II surgical

Class II nonsurgical

Total

Original Post

66

34

32

35

167

Response

98

54

65

46

263

Total

164

88

97

81

430

*Each cell represents the number of discussion posts and totals represent the total of discussion posts by category. Grading criteria can be found in Appendix 1. TABLE 2

Discussion Post Quantity and Timing Quantity mean (SD)*

Time for first post mean (SD)**

Time for second post mean (SD)**

Module 2

1.41 (SD 0.63)

1.96 (SD 0.89)

2.22 (SD 0.83)

Module 3

1.40 (SD 0.66)

1.79 (SD 0.84)

2.38 (SD 0.82)

Module 4

1.18 (SD 0.55)

1.26 (SD 1.22)

2.19 (SD 0.93)

Module 7

1.45 (SD 0.66)

1.11 (SD 0.54)

2.03 (SD 1.02)

*Quantity (minimum: 1 original response, 1 reply): 0 = Missing post, incomplete, 1 = Minimum posts per student, 2 = 1 additional post above minimum, 3 = 2+ additional posts above minimum **Time (how many are doing it at last minute and early — dates: first post due Monday 11:59 p.m., reply post due Thursday 11:59 p.m.): N/A = not completed, 0 = Late,1 = < 24 hours before (on due date), 2 = 24–48 hours before (1 day early), 3 = > 48 hours before (2 or more days early)

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case-based learning C D A J O U R N A L , V O L 5 0 , Nº 1

Module 2: Mixed Dentition Response Quality 70% 60% 50% 40% 30% 20% 10% 0% Anterior Crossbite Moderate Crowding Low %

Severe Crowding Medium %

Open Bite B

Deep Bite

High %

Module 3: Adolescent Response Quality 60% 50% 40% 30% 20% 10% 0% Protrusion

Impaction Low %

Root Resorption Medium %

Orthodontic Staging

High %

FIGURE S 1

curious and comfortable that their posts will be discussed without judgement.9 Discussions moderated by faculty further instill this curiosity and development through personal engagement. In this particular discussion-forum design, the goal was to elicit both quality posts relating to each case as well to facilitate professional interactions between peers. Anecdotally, in reviewing each response, we were pleased to see students being both encouraging and supportive of each other. The findings in this study 44 JANUARY

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help to encourage this modality of teaching and education in predoctoral orthodontics for future courses. The active learning component of the new orthodontic curriculum sets up an open environment for improved learning, but the passive learning aspect of the course faced several pitfalls. The biggest concern with a purely asynchronous online passive learning model is procrastination or a potential for a lack of self-motivation to keep up with the material. A study by Landrum at

the University of Dallas examined how online learning may increase a student’s academic confidence.10 Surprisingly, some students do not learn as effectively when given the freedom to set their own pace of learning. This is relevant to Cheng’s concern that virtual learning may lead to procrastination and lower educational outcomes.11 Compared to mandatory in-person attendance, some students reported feeling overwhelmed by the extent of lecture material provided when asked to respond to challenging discussion prompts. The course directors addressed this issue with personal responses to each student in the discussions to help guide them to the proper train of thought. Active participation by the course directors in the discussion forum could be the catalyst for students who are not as self-motivated as others and needs to be studied further. Another important aspect is reducing intimidation of discussing topics that students are not familiar with. To accomplish this, the expectations of discussion can be communicated more clearly, such that the quality of discussion is more important than the accuracy of student’s responses. A focus on developing an open area where students feel comfortable making mistakes is important in promoting their understanding of the material. Case-based learning (CBL) has long been recommended as a promising tool for medical and dental professionals and has been proposed to be further integrated into dental curriculums.9 A study conducted by Cutinan et al. with regard to predoctoral operative dental education demonstrated that case-based activities increase students’ comfort levels by bridging the theory-practice gap between didactics and clinic.12 CBL has been shown to promote small-group learning as well as engaging students and facilitating deeper learning,13 through structured


C D A J O U R N A L , V O L 5 0 , Nº 1

Module 4: Adult Invisalign Response Quality 60%

activities linked to realistic clinical practice scenarios.14 The use of virtual platforms allows greater accessibility by the instructor to the students, allowing for high-quality discussion and problemsolving in an asynchronous manner that is beneficial to both students and faculty.15 By evaluating student discussion habits with relation to certain case topics via the application “discussion coding,” conclusions can be made regarding which topics are more interesting to students, and adjustments can be made in course material to improve student engagement. With regard to orthodontic course material, studies have shown teleeducation to be as effective as traditional teaching methodologies.16 As the shift back to the classroom occurs across the country, it is vital to acknowledge the benefit virtual case-based discussions and asynchronous didactic delivery have in predoctoral dental education outcomes. This pilot cross-sectional study has several potential limitations. The first is this project did not take into consideration how the students may be personally and mentally impacted by the COVID-19 pandemic and how that affects their learning abilities. A study conducted at the University of Jordan during the pandemic by Hattar et al. concluded that though there is appreciation for new learning methods, students still acknowledge missing many educational experiences and do not believe it to be effective enough as a substitute for clinical practice.17 Dental school is a heterogeneous population of students with different ages and backgrounds, and additionally, there are students with no dental education and others with international dental education. Moving forward, a prospective cohort study would be an ideal method to assess how demographics and education level affect both interest and quality of a new

50% 40% 30% 20% 10% 0% Incisor Impaction

Perio Missing Teeth Low %

Class III Malocclusion

Medium %

Invisalign Difficulty

High %

Module 7: Surgery Response Quality 70% 60% 50% 40% 30% 20% 10% 0%

Class III Surgical

Class III Non-Surgical Low %

Class II Surgical

Medium %

orthodontic curriculum. Several students noted they preferred the traditional form of passive learning during the open-ended and anonymous course evaluations. Another potential confounder to the study could be the level of technology experience of students because those with a strong understanding of new technology might perform better than those without. All of this key demographic information will need to addressed in a long-term prospective study. In comparing two types of education delivery methods, another potential weakness in this

Class II Non-surgical

High %

project is the lack of long-term data on this new format of learning, and further studies looking at students’ ability to translate didactic information into clinical practice are needed. Further research is needed regarding different topics and disciplines within dentistry to evaluate the efficacy of virtual learning for differently themed content.

Conclusion

These findings enhance the quality of education by taking into consideration how this generation learns best, JANUARY 2 0 2 2

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oral health literacy C D A J O U R N A L , V O L 5 0 , Nº 1

TABLE 3

Quality of Discussion Posts:* Module 2, Mixed Dentition Case** Post q

Anterior crossbite

Moderate crowding

Severe crowding

Open bite

Deep bite

Total

Low

32

35

21

66

8

162

Medium

52

42

34

66

22

216

High

12

6

9

5

3

35

Total

96

83

64

137

33

413

Statistically significant P = 0.030 (Kruskal Wallis Test)

Quality of Discussion Posts:* Module 3, Adolescent Cases Response type

Protrusion

Impaction

Root resorption

Orthodontic Total staging

No response

34

26

58

6

124

Response by peer

41

56

70

15

182

Response by instructor

28

50

27

16

121

Total

103

132

155

37

427

Statistically significant P = 0.0001 (Kruskal Wallis Test) *Each cell represents the number of discussion posts and totals represent total discussion posts by category. Grading criteria can be found in Appendix 1. **Refer to Appendix 2 for the remainder of the modules 2–3 discussion evaluation and modules 4–7.

such that participating in a virtual learning space may increase a student’s academic confidence and choosing topics of interest can encourage online students’ learning engagement.1 Developing a curriculum where students have smaller but more frequent lectures coupled with an open environment for case-based learning strongly stimulated students’ interest. Virtual case-based discussions allow for ample student/faculty interaction with high-quality levels of discourse. The findings of this orthodontics course study offer insight on how to leverage online educational tools and programs to progress the needs of our generation and adapt to the ever-changing climate of health care education both currently and moving forward in post-pandemic settings. Further research is needed regarding different topics and disciplines within dentistry to evaluate the efficacy of virtual learning for differently themed content. n RE FEREN CE S 1. Nadershahi N A, Bender DJ, Beck C, Lyon C, Blaseio A. An overview of case-based and problem-based learning

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methodologies for dental education. J Dent Educ 2013 Oct;77(10):1300–5. 2. Nerali J, Telang L, Telang A, Chakravarth P. Problem-based learning in dentistry, implementation and student perceptions. Saudi J Oral Sci 2020; 7(3)194–198. doi: 10.4103/sjos. SJOralSci_15_20. 3. Williams, Brett. Case based learning — a review of the literature: Is there scope for this educational paradigm in prehospital education? Emerg Med J 2005 Aug;22(8):577– 81. doi: 10.1136/emj.2004.022707. PMCID: PMC1726887. 4. Richards PS, Inglehart, MR. An interdisciplinary approach to case‐based teaching: Does it create patient‐centered and culturally sensitive providers? J Dent Educ 2006 Mar;70(3):284–91. 5. Yang Z, Ding Y, Jin F. Student Perceptions of Effectiveness of Case-Based Learning in Orthodontic Education. Open Med 2015; 2:48–52. doi: 10.2174/1874220301401010048. 6. Zheng M, Louie K. Promoting student engagement and online interaction with cloud-based technology. J Dent Educ 2021 Apr 24. doi: 10.1002/jdd.12628. Online ahead of print. 7. UC Berkeley School of Public Health. General Information of Online MPH Programs. 8. Buelow JR, Barry T, Rich LE. Supporting Learning Engagement With Online Students. Online Learning 2018; 22(4):313– 340. doi: dx.doi.org/10.24059/olj.v22i4.1384. 9. Regier DS, Smith WE, Byers HM. Medical genetics education in the midst of the COVID-19 pandemic: Shared resources. Am J Med Genet Part A 2020 Jun;182(6):1302–1308. doi: 10.1002/ajmg.a.61595. Epub 2020 Apr 23. PMCID: PMC7264783. 10. Landrum B. Examining Students’ Confidence to Learn Online, Self-Regulation Skills and Perceptions of Satisfaction and Usefulness of Online Classes. Online Learning 2020; 24(3):128–146. doi: dx.doi.org/10.24059/olj.v24i3.2066. 11. Cheng SL, Xie K. Why college students procrastinate in online courses: A self-regulated learning perspective. Internet High Educ 2021 Jun;(50):100807. doi.org/10.1016/j.

iheduc.2021.100807. 12. Chutinan S, Kim J, Chien T, Meyer HY, Ohyama H. Can an interactive case‐based activity help bridge the theory‐ practice gap in operative dentistry? Eur J Dent Educ 2021 Feb;25(1):199–206. doi: 10.1111/eje.12591. Epub 2020 Oct 13. 13. Hofsten A, Gustafsson C, Häggström E. Case seminars open doors to deeper understanding — Nursing students’ experiences of learning. Nurse Educ Today 2010 Aug;30(6):533–8. doi: 10.1016/j.nedt.2009.11.001. Epub 2009 Dec 16. 14. Thistlethwaite, JE, Davies D, Ekeocha S, Kidd JM, MacDougall C, Matthews P, Clay D. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teach 2012;34(6):e421–44. doi: 10.3109/0142159X.2012.680939. 15. Zheng M, Spires H. Teachers’ interactions in an online graduate course on Moodle: A social network analysis perspective. Meridian 2011, 13(12). 16. Lima MS, Tonial FG, Basei E, Brew MC, Grossmann E, Haddad AE, Bavaresco, CS. Effectiveness of the distance learning strategy applied to orthodontics education: A systematic literature review. Telemed J E Health 2019 Dec;25(12):1134–1143. doi: 10.1089/tmj.2018.0286. Epub 2019 Sep 30. 17. Hattar S, AlHadidi A, Sawair FA, Abd Alraheam I, ElMa’aita A, Wahab FK. Impact of COVID-19 pandemic on dental education: Online experience and practice expectations among dental students at the University of Jordan. BMC Med Educ 2021 Mar 8;21(1):151. doi: 10.1186/s12909-02102584-0. T HE CORRE S P ON DIN G AU T HOR , Brandon Zegarowski, DDS, can be reached at bzegarowski@gmail.com.


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communit y-based education C D A J O U R N A L , V O L 5 0 , Nº 1

Dental Student Community Clinic Placement in Australia and the United States: Systematic Review and Case Study Anna Doan Bowers, DDS; Ove A. Peters, DMD, MS, PhD; Paul Subar, DDS, EdD; Sandra March, BDSc; and Christine I. Peters, DMD

abstract Background: Community-based dental education is increasingly integrated in dental school curricula to promote educational enrichment, to accommodate larger class sizes and to expose students to a broader patient demographic. This review examined community clinic rotations and their impact on dental students’ level of competence in Australia and the United States. Methods: A systematic review identified pertinent literature between 2005 and 2021 from databases including PubMed, SCOPUS and the Cochrane Library. It was limited to studies involving dental student placement at community-based dental clinics and the impact of the community-based dental rotation on clinical competency. Two case studies present data from identical surveys addressing final-year dental students. Results: Nineteen articles met the inclusion criteria out of an initial 51 titles identified. Eleven articles addressed community-based dental education (CBDE) in the U.S and five related to Australia. Overall, there was a positive effect following students’ rotation across all outcomes, including treatment planning, diagnosis, time management, clinical skills, productivity and communication/interpersonal skills. In addition, students were found to be more likely to consider employment in rural/underserved areas following these clinic outplacements. These findings were in line with feelings and observation by the selected cohorts of students in Australia and the U.S.

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communit y-based education C D A J O U R N A L , V O L 5 0 , Nº 1

Conclusion: Community clinic rotations resulted in evident gains in competency for students across multiple competencies. The current literature suggests that a longer outplacement program with more patient encounters offers increased benefits. Moreover, placement to clinics in underserved regions may encourage students to practice in these locations, mitigating the maldistribution of the dental workforce in rural areas. Keywords: Dental health education, community clinic, clinical competence, U.S. dental education, Australian dental education

AUTHORS Anna Duan Bowers, MS, DDS, is a first-year postgraduate endodontics resident at the University of the Pacific, Arthur A. Dugoni School of Dentistry where she also obtained her dental degree with honors. She is a member of the American Association of Endodontists and the Northern California Academy of Endodontics. Conflict of Interest Disclosure: None reported. Ove A. Peters, DMD, MS, PhD, is the discipline lead and a professor of endodontics as well as the academic director of the Oral Health Alliance at the University of Queensland, School of Dentistry. He has held faculty positions in Heidelberg, Germany, Zurich, Switzerland at the University of California and the University of the Pacific. He was the founding director of the postgraduate endodontic program at the UOP. Conflict of Interest Disclosure: None reported.

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Paul Subar, DDS, EdD, is a professor, and the chair of the department of diagnostic sciences and director of the special care clinic/hospital dentistry program at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco. He also holds a faculty appointment as a clinical professor, department of family medicine, University of California, San Francisco, School of Medicine. Conflict of Interest Disclosure: None reported.

Sandra March, BDSc, is a lecturer in the University of Queensland School of Dentistry where she received her dental degree. Dr March’s practice interests are centered on prevention and endodontics. Conflict of Interest Disclosure: None reported. Christine I. Peters, DMD, is a senior lecturer in endodontics at the University of Queensland School of Dentistry. She was an assistant professor in the department of prosthetic dentistry and in the division of endodontics at the University of Zurich Dental School and an assistant professor and professor of endodontology at the University of the Pacific, Arthur A. Dugoni Dental School in San Francisco. Conflict of Interest Disclosure: None reported.

C

ommunity-based dental education (CBDE) is increasingly incorporated in dental education.1–3 Placement of dental students at community clinics allows interfacing with and caring for a diverse patient pool and varied populations and enriches and improves clinical learning. Furthermore, educators and public health officials hope that this experience will promote a life-long participation in community service, especially in underserved geographic areas.1,3 In Australia, dental students typically rotate through urban and rural community clinics, as determined by the dental curriculum of each university. At the University of Queensland School of Dentistry (UQ) in Brisbane, Australia, rotations are integrated within the final year of the curriculum, where students spend four days per week performing clinical practice activities either at an external placement or internally at the dental school clinic. In the U.S., the Commission on Dental Accreditation (CODA) requires that dental education programs provide opportunities and assist students in engaging in servicelearning experiences and/or communitybased learning experiences.4 Student-centered teaching in outreach clinics enhances confidence


C D A J O U R N A L , V O L 5 0 , Nº 1

TABLE 1

Keyword Search Strategy Used in PubMed, SCOPUS and the Cochrane Library

and clinical competency and may be more effective than dental school training alone in teaching treatment planning.5–8 Community clinic stays increase the number of student-patient encounters and are rewarding and encouraging for the students involved.5,9 Recently, Formica et al.10 published a strategic analysis and recommendations for future dental education. The authors emphasize a changing practice environment, with graduates choosing larger group clinics rather than solo practices. To avoid preparing dental students for a single-practice scenario that many new dentists will not work in, they advise moving clinical education to community-based clinics. Patients benefit from affordable dental treatment rendered by a larger number of clinicians. Students, on the other hand, learn to manage adult and pediatric patients with more complex health and dental needs.10 Challenges for dental students include balancing and reconciling their private lives with high tuition fees, full study schedules and demanding academic assessments. International students leave their family support and navigate a new culture.11,12 In CBDE, students describe increased comfort, better time management and an enjoyable and positive experience.8,13,14 For example, participants in a survey by Johnson and colleagues1 reported their time spent in a community clinic as the best part of their dental education. In this study, the change in students’ overarching competence before and after community clinic rotations at particular dental schools in the United States and Australia is systematically reviewed in the literature. The selfreported impact of CBDE in terms of component competencies on students at the University of Queensland (UQ) and at the University of the Pacific (Dugoni) are compared and evaluated.

Materials and Methods

The review section of this article is based on a search for suitable literature between 2005 and 2021 from databases including PubMed, SCOPUS and the Cochrane Library by one independent reviewer. The following terms and their various combinations were used in the initial search strategy: dental education, dental community clinic, clinical competency, dental students, community clinic rotation and rural placement (TA BLE 1 ). An evaluation of the titles and abstracts was undertaken for all identified articles. Duplicates and articles nonpertinent to the review topic were removed, leaving 51 articles for further review (FIGURE 1 ). The following inclusion criteria were used to identify appropriate literature: dental education studies in the United States or Australia and placement at community dental clinics and its impact on clinical competency (self-reported or evaluated). Excluded were studies conducted outside of the United States or Australia, editorials, abstracts, news and policy briefs and studies not investigating change in competencies before and after rotation. The final sample included 16 publications, five of which addressed CBDE in Australia1,15–17,32 and the remaining 11 dealt with CBDE in the U.S.2,18–25,30,31

1

Community-based dental education (535)

2

1 AND dental student (206)

3

2 AND competency (93)

4

2 AND United States (133)

5

2 AND Australia (4)

6

3 AND United States (62)

7

3 AND Australia (3)

8

Community clinic AND dental student (1139)

9

8 AND competency (304)

10

9 AND United States (110)

11

9 AND Australia (24)

12

Rural clinical placement AND dental (36)

13

12 AND United States (4)

14

12 AND Australia (21)

15

dental external clinical placement (122)

16

15 AND United States (0)

17

15 AND Australia (3)

18

Rural dental rotation (28)

Studies selected after screening, inclusion and exclusion criteria applied: Berg,18 Coe,22 DeCastro,19 Johnson,1 Johnson,15 Johnson,16 Lalloo,17 Mascarenhas,24 Mashabi,25 Mathieson,20 McFarland,21 Piskorowski,23 Simon,2 Habibian,30 Rohra31 and Koedyk32

Details for the characteristic and data collected from the studies included in the systematic review are in TA BLE 1 . There was a high degree of heterogeneity among the type of placement as well as the approach to collecting the information. The following describes the findings for both locations.

employed reflective journaling and open-ended questions,16,17 interviews,1,20 assessment of productivity24,25 and direct performance assessments,19 such as licensing exam performance scores. Five studies used pre- and postrotation evaluations,2,15,16, 25,30 while others gathered postrotation metrics only.1,17–22,24,31,32 Sample sizes varied among the studies, from less than 50 to more than 200 (TA BLE 2 ). Key outcomes assessed in the studies included treatment planning, diagnosis, time management, clinical skills, productivity, provider confidence, critical thinking, professionalism and interpersonal and communication skills.

Data Collection Methods

Duration of Placement

Results

Twelve of the 16 studies collected data with questionnaires or surveys.1,2,15–18,21–23,30–32 Others

The placement length reported in the Australian studies was in the one month or less range1,15–17 in all studies JANUARY 2 0 2 2

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communit y-based education

Identification

C D A J O U R N A L , V O L 5 0 , Nº 1

Records identified through database searching limited from 2005-2021(n = 1581)

Additional records identified through other sources (n = 0)

Screening

Duplicates removed: (n = 1500)

Records screened by title and/or abstract (n = 1530)

Eligibility

Full-text articles assessed for eligibility (n = 51)

Studies included in review (n = 16)

Records excluded by title (n = 1272) Records excluded by abstract (n = 177)

Full-text articles excluded, with reasons No clinical competency assessment (n = 23) Review article (n = 2) No assessment of change before/ after or with/without CBDE (n = 5) Not CBDE based (e.g., hospital rotation) (n = 2) Not U.S./AU (n = 1) Abstract only (n = 2)

Included

U.S. articles included (n = 11) Australian articles included (n = 5)

FIGURE 1. A PRISMA flow diagram of literature search and selection methodology.

except one.32 In contrast, the studies conducted at schools in the U.S. tended to cover a longer placement duration, with the majority of the studies describing an assignment of longer than five weeks and three studies lasting longer than 12 weeks.18–20 52 JANUARY

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Impact on Treatment Planning

CBDE rotation enhanced students’ ability to treatment plan. On a scale of 1 to 5, with 5 being the highest score, Berg et al.18 reported a postrotation change from 74.6% to 82.5% in students who gave themselves self-assessment scores

of 4 to 5 in treatment planning and associated competencies. Likewise, Johnson et al.15 noted that prerotation self-assessed treatment planning skills improved from a mean score of 3.4 ± 0.5 to 3.8 ± 0.3, compared to no improvement in students who did not


C D A J O U R N A L , V O L 5 0 , Nº 1

TABLE 2

Key Outcomes Following Community-Based Dental Education (CBDE) Rotation, Supported by Literature Parameter

Publication

Citation number (total = 16)

United States

Berg,18 Coe,22 DeCastro,19 Mascarenhas,24 Mashabi,25 Mathieson,20 McFarland,21 Piskowrowski,23 Simon,2 Habibian,30 Rohra31

11

Australia

Johnson,1 Johnson,15 Johnson,16 Lalloo,17 Koedyk32

5

Location

Data collection Questionnaire/Survey

Berg,18 Coe,22 Johnson,1 Johnson,15 Johnson,16 Lalloo,17 McFarland,21 Piskorowski,23 Simon,2 12 Habibian,30 Rohra,31 Koedyk32

Reflective Journal/Open Ended Questions

Johnson,16 Lalloo17

Interview/Transcript

Johnson,1 Mathieson20

Productivity

Mascarenhas, Mashabi

2

Performance Assessment

DeCastro19

1

Prerotation and Postrotation

Johnson,15 Johnson,16 Mashabi,25 Simon,2 Habibian30

5

Postrotation Only

Berg,18 Coe,22 DeCastro,19 Johnson,1 Lalloo,17 Mascarenhas,24 Mathieson,20 McFarland,21 Rohra,31 Koedyk32

10

2

24

2 25

Collection timing

Sample size 0-50

Johnson,15 Johnson,16 Mascarenhas,24 Mashabi,25 Simon2

5

50-100

Johnson,1 Lalloo,17 McFarland,21 Piskowrowski23

4

101-200

Coe,22, Mathieson,20 Koedyk32

3

> 200

Berg,18 DeCastro,19 Habibian,30 Rohra31

4

Rotation length Less than 2 weeks

0

2 to 4 weeks

Johnson, Johnson, Johnson, Lalloo, McFarland

5 to 12 weeks

Coe, Mascarenhas, Mashabi, Piskorowski, Simon, Habibian, Koedyk

7

> 12 weeks

Berg,18 DeCastro,19 Mathieson20

3

Range by Year

Rohra

1

1

16

22

15

24

17

25

5

21

23

2

30

32

31

Outcomes (improvements) Treatment Planning

Berg,18 Johnson,15 McFarland,21 Simon2

4

Diagnosis

Berg,18 Coe,22 DeCastro,19 Johnson,15 McFarland21

5

Time Management

Johnson, Johnson, Koedyk

3

Clinical Skill

Berg,18 Coe,22 DeCastro,19 Johnson,1 Johnson,15 Johnson,16 Lalloo,17 Mathieson,20 Piskowrowski,23 Simon,2 Habibian,30 Rohra,31 Koedyk32

13

Productivity

DeCastro,19 Mascarenhas,24 Mashabi25

3

Communication/Interpersonal Skills

Berg,18 Johnson,15 Johnson,16 Lalloo,17 Mathieson,20 McFarland,21 Simon2

7

16

15

32

Intent to practice rural/underserved areas Improved Decreased

Johnson,1 Johnson,15 Johnson,16 Lalloo,17 Koedyk,32 Piskorowski,23 Simon2

7 0

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communit y-based education C D A J O U R N A L , V O L 5 0 , Nº 1

attend a rural placement rotation. Simon et al.2 found that students agreed significantly more with the statement “I feel competent in developing different treatment plans for my patient.” McFarland et al.21 saw improved assessment, diagnosis and treatment planning in two investigated cohorts.

Impact on Diagnosis

Self-reported diagnostic ability improved after CBDE. Berg et al.18 described 77.6% versus 83.1% of 4 to 5 grades in students’ ability to “identify and record patient’s oral problems.” Examination and evaluation of patients improved from 79.1% to 86.4%. Coe et al.22 found that 61% of their students became more confident in providing exams, prophylaxis and fluoride treatments to pediatric patients following their CBDE rotation. DeCastro et al.19 saw returning students produced almost three times the clinical points compared to students who did not attend that rotation. Johnson et al.15 stated that postrotation, students reported their diagnostic ability as a strength compared to preplacement where it was reported as a weakness. McFarland et al.21 saw improvement in assessment, diagnosis and treatment planning following rotations.

Impact on Time Management

While time management and clinical efficiency was a common self-reported weakness of students prior to their rotation through a rural placement program, a four-week placement window turned speed and clinical adeptness into strengths of the students.16 Students were “pleased with the clinical experience provided, with increased time management skills and clinical confidence emphasized.”16 In a separate study, Johnson et al.15 noted that students perceived an increase in self-reported time management skills from 54 JANUARY

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3.2 ± 0.7 to 3.6 ± 0.6 postplacement, compared to students who did not attend and noted no improvement (3.6 ± 0.6 to 3.6 ± 0.7). Koedyk et al.32 noted “improved time management” mentioned by students. All studies were conducted at an Australian dental school. None of the U.S. studies reported metrics on time management.

Impact on Clinical Skills

The highest impact (13 of 16 studies) of CBDE rotations was noted relative to clinical skills. All included

The highest impact (13 of 16 studies) of CBDE rotations was noted relative to clinical skills.

Australian studies1,15–17,32 and eight out of the 11 U.S. studies described improvements in this metric.2,18–20,22,23,30,31 Prior to the rotation, students listed extractions, restorations and scaling as strengths, while postrotation, detecting caries and crown preparations were also listed as strengths, indicating improved skills in these areas.16 Treatment skills and clinical ability improved in participating versus nonparticipating students.15 Similarly, Lalloo et al.17 described “clinical skills improved” alongside “social and life skills,” with 32% strongly agreeing and 52% agreeing that they “developed clinical operative skills in a primary care environment.” However, due to poor patient flow, some locations were found to be “not very beneficial to learn clinical skills.”17

Berg et al.,18 in a study conducted at a United States dental school, noted a moderate or large enhancement of confidence in students’ clinical skills. Prior to their rotation, 74.6% of students rated their ability to “treatment plan and be able to provide majority of required care” as a 4 to 5 compared to 86.4% of students postrotation. Coe et al.22 found that 78% of students became more confident giving local anesthesia, 69% in providing simple restorative treatments, 100% in performing stainless steel crown procedures, 89% in delivery of pulp therapy treatment and 69% in performing extractions. Mathieson et al.20 noted that higher patient volume on clinical placement brought a “substantial increase in their speed and technical skill.” Northeast Regional Board restorative exam pass rates improved after CBDE, as did scores with simulated patients.19 Highly significant increases in confidence “as a clinician in terms of efficiency, clinical skills and competence” were noted in another study;2 specifically, rotations advanced the students’ ability to “manage dental emergencies.” Rohra et al.31 reported that 80% of their respondents agreed or strongly agreed with improving their clinical skills through the community-based education, and Habibian et al.30 found a high level of satisfaction with clinical experience and students stating an increase in confidence as well as becoming “more independent and working autonomously.” Indeed, it was described that the proportions of students perceiving excellent skill levels in treating underserved patients more than doubled.23

Impact on Productivity

Three U.S. studies directly assessed productivity as a metric. Students who were placed on rotation scored an average of 1,946.54 ± 472 clinical points compared to a significantly lower mean


C D A J O U R N A L , V O L 5 0 , Nº 1

in nonparticipating students who scored 1,082.45 ± 187.58 points.19 In these combined points across oral diagnosis, endodontics, prevention, periodontics, general dentistry, fixed prosthodontics, removable prosthodontics and oral surgery, CBDE resulted in nearly doubling student productivity. Mascarenhas et al.24 noted that longer clinical externships resulted in even greater productivity. Students who were placed on a 10-week rotation performed 35% more procedures than those on the six-week rotation over the course of the rotation.24 Clinical revenue increased by more than onethird, and students accomplished more procedures per month postexternship compared to preexternship.25

Impact on Communication/ Interpersonal Skills

The second most commonly assessed CBDE metric was on students’ communication and interpersonal skills. The proportion of students’ self-grading of 4 or 5 in “utilizing patient management and interpersonal skills” rose from 91.0% to 96.5%.18 Students’ ability to “educate patients on etiology and control of oral diseases/conditions” improved from 83.6% to 91.2% postrotation.18 Students initially noted “patient communication” as both a strength and also an area where they hoped to improve.16 Postplacement, “patient management” and “communication skills” were commonly reported strengths with many students indicating improvement. Students receiving CBDE saw their communication ability improve from 3.9 ± 0.7 to 4.3 ± 0.4 compared to students who did not receive CBDE, whose ability only changed from 4.3 ± 0.5 to 4.4 ± 0.5.15 Lalloo et al.17 found a strong agreement or agreement with the statement “I developed skills of patient management including communication

skills” 32% and 49% of the time. Interpersonal factors remained a common theme, with students experiencing positive interactions with dental patients from various socioeconomic statuses, but no numerical metric was assigned to improvements.20 McFarland et al.21 reported increased communication and interpersonal skills in two consecutive student cohorts. Finally, students were more likely to “feel comfortable in presenting and discussing sequence of treatment, estimated fees, payment plans, timetable and patients’ responsibilities

A hope in CBDE is that students develop an intent to practice in a rural/ underserved area after their rotations.

for treatment” and 27 out of 35 students reported that “building meaningful relationships with patients” was the most rewarding part of their rotation.2

Impact on Intent To Practice in a Rural/Underserved Area

A hope in CBDE is that students develop an intent to practice in a rural/ underserved area after their rotations. All three Johnson et al.1,15,16 studies found that students were more likely to practice in a rural setting after their rotation experience. Initially, only 57% of students were “likely to work in a rural setting after graduation” compared with 97% postrotation.16 A second study15 found that prior to their placement, 54.8% of students considered working in a rural location, compared to 96.9% postrotation.

Students not on rotation considered rural work only 35.5% of the time. One of the top 15 graduate feedback responses was that rural clinical placement rotation “influenced me to work rurally.”1 Lalloo et al.17 noted after rotations, 8% of students strongly agreed and 25% of students agreed with the statement “I am now more likely to choose a career in the public sector,” and 15% of students strongly agreed and 25% of students agreed with the statement “I am now more likely to work in a rural and remote setting” after their rotations. Koedyk et al.32 reported that following rural placement, most students would consider rural practice after graduation. It appears choosing to work in community clinics is a function of how many weeks students spent on rotations in community clinics.23 In 2005, where the rotations were three weeks in length, 6.1% wanted to work in a rural area versus 16.5% in 2010, where rotations were eight weeks in length.23 Simon et al.2 found that students increasingly agreed with the statement “I am interested in incorporating community health and outreach work into my practice to be a provider for the underserved” following rotations. In conclusion, practical implications for teaching institutions with limited clinic capacity include easing space constraints by transferring students into extramural sites. This might allow admission of a higher number of students. From the standpoint of dental education providers, learning in public health clinics teaches real-life dentistry, participation in community service, genuine public health, applied professional ethics and communication with populations outside of the known setting of their dental school.13 Interestingly, while studies demonstrate similar revenue generated in community sites and in dental school clinics,14 production increases JANUARY 2 0 2 2

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SURVEY QUESTIONS

Demographics: Gender: Male/Female/Other; Age; Status: A current student/A recent graduate 1. Have you participated in extramural clinic placement? Yes/No 2. How many weeks was the approximate total length of your extramural program(s) excluding your clinical experience at the school of dentistry (please enter full number)? 3. Please describe the settings of the extramural placement (multiple selections allowed): Rural/Urban 4. When did the extramural placement occur? First and second quarter/third and fourth quarter 5. From your log, please estimate the number of individual patient encounters that occurred during your extramural program (please enter full number). 6. Please rate your experience in the outplacement program in the following areas: Time for clinical teaching was sufficient. Patient care was relevant and made me better understand treatment needs and ethics of the population served. ■  Methods of the dental school and community clinic were calibrated. ■  The mentor-student collaboration worked well. ■  The mixture of patients and treatments was satisfying. ■  The number of treatments rendered was appropriate. ■  I feel more confident in patient interaction after the rotation. ■  I feel more confident in diagnosis and treatment planning after the rotation. ■  I feel more efficient during treatment hours after the rotation (better time management, greater number of procedures rendered). ■  I feel more productive in clinical treatment after the rotation (more weighted occasions of service generated for the clinic). 7. Please rate your ability in each of the following BEFORE the outplacement. ■  ■

8. Please rate your ability in each of the following AFTER participating in the outplacement. Critical thinking. Professionalism. ■  Communication and interpersonal skills. ■  Health promotion. ■  Practice management and informatics. ■  Patient care: Assessment, diagnosis and treatment planning. ■  Patient care: Establishment and maintenance of oral health. 9. How many extramural clinic sites did you attend? One/two/more than two 10. In your experience, were there noticeable differences between the outplacement settings? ■  ■

■  ■  ■

Similarly helpful instructors? Differences in patient exposure? Similar settings?

11. On the sliders below, assign yourself two numerical overall competency grades in dentistry, one BEFORE and one AFTER external placement, where 100% is your personal maximum achievable. Self-assigned grade before placement/ self-assigned grade after placement. 56 JANUARY

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postexternship.13 The benefits of CBDE appear to increase as rotation time lengthens, allowing multiple appointments for more complex clinical procedures.26 Thus, placing dental students into community-based clinic rotations or community-based dental education (CBDE) has various advantages, not only students, but also to patients, public health organizations and dental schools.17

Case Study

To our knowledge, no direct comparison exists between a U.S. and an Australian dental school regarding the benefits of community-based dental education for students’ competencies. The aim of this case report addressed the following questions: (i) what were the similarities and differences in observations and self-reported impact of community clinic rotation on clinical treatment self-confidence between dental students at the two participating schools; and (ii) what were the self-rated levels of competency before and after rotation. The UQ Health and Behavioral Sciences Faculty Ethics Committee granted approval for the survey (HABS approval # 2017001568), and the Institutional Review Board (IRB) at Dugoni permitted a cooperative research agreement (IRB protocol review # 2017001568). The study was conducted at the University of Queensland, School of Dentistry, a public dental school in Herston, Qld, Australia, and at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco. At both universities, senior students in their final year of dental education and students who had graduated the previous year were invited to participate. A total of 36 out of 132 eligible UQ students or graduates and 38 out of 290 eligible Dugoni students or graduates responded to a survey (27% and 13% response


C D A J O U R N A L , V O L 5 0 , Nº 1

rates, respectively), with a distribution of 44% female respondents at UQ and 56% female respondents at Dugoni. The average participant age was 26 at UQ and 27.5 at Dugoni. Of the responding students, 76% at Dugoni and 54% at UQ were recent graduates, and 24% at Dugoni and 46% of the students at UQ were current students; 73% of UQ students were situated in rural community clinics, while only 21.4% of Dugoni students were placed in nonurban clinic rotations.

Data Collection

Students at both universities were invited to take identical online surveys related to their community clinic rotation experiences, influence of rotations on self-reported confidence in clinical treatment and self-reported levels of component competencies and overall clinical competency after rotations. The survey consisted of 11 questions starting with demographics such as gender, age and whether respondents were recent graduates or current students (SURV E Y Q UE S TIONS ). The second section of the survey questioned students about their experiences in community clinic rotation. This part of the survey included a set of 5-point Likert-scale items that asked students to report whether the rotation resulted in increased self-confidence in clinical treatment. The last survey segment asked students to rate their skill levels prior to and after community clinic rotations by assigning themselves “before” and “after” grades for several component competencies in the Competencies for the New General Dentist by the American Dental Education Association (ADEA).27 In addition to these component competencies, students were asked to rate their overall clinical competency on a sliding scale of 0–100, with 100 representing a personal optimum.

Data Analysis

The underlying hypothesis was that there would be differences in skills acquisition between the two dental schools evidenced by community clinic rotation experiences, self-reported changes in clinician confidence, component competencies and overall competency before and after rotation. Data were either continuous (timeframes, numbers of patients or self-reported competency) or proportions. Continuous data were consistent with normal distributions. Hence, students’ t-tests and chi square tests were used; the level of significance was set at 0.05.

Community Clinic Rotation Experiences

The setting in dissimilar clinic locations, such as urban versus rural sites, caused no significant difference in the learning experience in outplacement programs. Students at UQ, however, consistently rated their experience significantly better than those at Dugoni (TA BLE 3 ). Students at UQ worked 21.2 ± 6.5 (mean ± SD) weeks. This was a significantly (p < 0.0001) longer time in the outplacement program than for students at Dugoni, who spent 3.2 ± 1.9 weeks in community clinics. Consequently, students at UQ had a higher overall number of patient encounters (UQ 373.4 ± 130.5 versus Dugoni 41.3 ± 23.8). If calculated by week, however, the difference was not statistically significant: 19 weekly patient treatments took place at Dugoni venues and 17 patients were treated at UQ-associated clinics per week. The percentage of students somewhat or strongly agreeing that the time spent was sufficient varied from 93.9% of the students at UQ versus 74.3% of students at Dugoni. All responding students at UQ agreed that patient care was relevant; it resulted

in better understanding of treatment needs and ethical considerations of the served population. This percentage was significantly higher (p = 0.002) than the 80% of students at Dugoni feeling the same way. Students´ perception on calibration regarding treatment methods between the dental school and community clinic showed no significant differences between both institutions. Overall, the mentor/student relationship was constructive and encouraging. No student at UQ disagreed; however, 20% of students at Dugoni did not think the collaboration between mentor and student worked well (p < 0.0001). In the same line of perception, 23% of students at Dugoni were not satisfied with the mixture of patients and treatments and only 3% of students at UQ (p = 0.018) voiced this concern. In fact, 67% of students at UQ strongly agreed that the number of treatments rendered was appropriate as opposed to 37% of students at Dugoni (p = 0.014).

Self-Reported Confidence in Clinical Treatment After Rotation

In terms of self-confidence, all surveyed students at UQ reported that they felt more confident in both the interaction with patients and in diagnosis and treatment planning after the rotation, a significantly higher percentage than the approximately 70% of Dugoni students (TA BLE 3 ). Furthermore, students at UQ felt they had learned better time management, a greater number of procedures rendered or being more productive in clinical treatment.

Self-Reported Changes in Component Competencies

Before outplacement rotations, perception among students on their component competencies before CBDE contrasted significantly between the two JANUARY 2 0 2 2

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TABLE 3

Responses on Experience in the Outplacement Program Given by New Graduates and Current Dental Students Pacific

Strongly disagree N (%)

UQ

Disagree N (%)

Neither agree nor disagree N (%)

Agree N (%)

Strongly agree N (%)

P value

5 (14.3)

2 (5.7)

14 (40)

12 (34.3)

p = 0.022

13 (39.4)

18 (54.5)

10 (28.6)

18 (51.4)

5 (15.2)

28 (84.8)

Time for clinical teaching was sufficient

2 (5.7)

Patient care was relevant and helped understand treatment needs and ethics

1 (2.9)

Methods of the dental school and community clinic were calibrated

2 (5.7)

The mentor-student collaboration worked well

1 (2.9)

The mixture of patients and treatments was satisfying

6 (17.1)

2 (5.7) 1 (3)

2 (6.1)

11 (33.3)

19 (57.6)

The number of treatments rendered was appropriate

4 (11.4)

3 (8.6)

3 (8.6)

12 (34.3)

13 (37.1)

2 (6.1)

2 (6.1)

7 (21.2)

22 (66.7)

I feel more confident in patient interaction after the rotation

3 (8.6)

3 (8.6)

3 (8.6)

7 (20)

19 (54.3)

4 (12.1)

29 (87.9)

I feel more confident in diagnosis and 3 (8.6) treatment planning after the rotation

6 (17.1)

11 (31.4)

15 (42.9)

4 (12.1)

29 (87.9)

I feel more efficient during treatment hours after the rotation

2 (5.7)

3 (8.6)

2 (5.7)

7 (20)

21 (60)

1 (3)

3 (9.1)

29 (87.9)

I feel more productive in clinical treatment after the rotation

2 (5.7)

3 (8.6)

8 (22.9)

22 (62.9)

5 (15.2)

28 (84.8)

2 (6.1) 5 (14.3)

1 (2.9)

7 (20)

3 (8.6)

16 (45.7)

7 (20)

5 (15.2)

2 (6.1)

17 (51.5)

9 (27.3)

6 (17.1)

2 (5.7)

12 (34.3)

14 (40)

1 (3)

5 (15.2)

27 (81.8)

2 (5.7)

10 (28.6)

15 (42.9)

p = 0.002

n.s. p < 0.0001 n.s. p = 0.014 p < 0.001 p < 0.001 p = 0.007 P = 0.013

Darker shaded areas represent Dugoni students, and lightly shaded areas represent UQ students.

institutions. In general, students at Dugoni rated their prerotation level of competency significantly higher than students at UQ. Concerning critical thinking, 77.1% of students at Dugoni felt reasonably or strongly competent before the rotation. No student at UQ felt strongly competent and only 33.3% felt reasonably competent (p < 0.0001). In patient care, assessment, diagnosis and treatment planning before the rotation at UQ, no student felt strongly competent, but 33.3% of the cohort felt reasonably competent. Meanwhile, 20% and 57.1%, respectively, felt strongly and reasonably competent at Dugoni (p = 0.001). Spending time in communitybased education considerably changed opinions among students in both institutions regarding their component competencies. Participants from both 58 JANUARY

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institutions recorded improvement in all ADEA competencies, including health promotion and practice management, and perceived their abilities as similarly high after the outplacements in all competencies tested.

Self-Reported Overall Competency Before and After Rotation

A sliding scale from 0–100, with 100 reflecting the personal best, provided overarching self-reflective grades. In this respect, self-assigned grades before placement were significantly higher (p = 0.005) for students at Dugoni (65.7 ± 18.1) than for those at UQ (53.9 ± 14.7). The increase in the self-grade after the placement was significantly higher (p < 0.0001) for students at UQ (22.4 ± 10.6) than for those at Dugoni (5.4 ± 20.3).

Discussion

This study reviewed community clinic rotations and their impact on dental students’ level of competence in Australian and U.S. dental schools and reported two cases aimed to compare community clinic rotations and their impact on student clinical competency and self-perceived confidence. There were a limited number of studies limited to the U.S. and Australia that assessed students’ competency in relation to community clinic rotations. Ultimately, 16 studies were identified with five addressing community clinic rotations in Australia and 11 addressing them in the U.S. In all the key outcomes identified for review in this study, there was an improvement when comparing prerotation to postrotation metrics. In terms of treatment planning, four of


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the 13 studies addressed that there was an improvement in students’ ability to treatment plan following their participation on rotation. Five of the 13 studies noted an improvement in diagnosis ability of students following rotation and three studies directly addressed improvement in time management. Of the studies that directly addressed time management, all were conducted at schools in Australia, although the three studies addressing improvement in productivity were from the U.S. One can ascertain that if there is improvement in productivity, consequently there is also likely improvement in time management of students during their procedures. The two categories that were most studied were those addressing improvement in clinical skill and communication/ interpersonal skills. Thirteen of the studies saw that students improved in their clinical skills, whether self-assessed or assessed through other metrics such as regional clinical exam performances, and seven studies found that students saw an improvement in communication/ interpersonal skills. It seemed that more of the Australian studies were interested in students’ future employment plans, with all five of the Australian studies having some metric on whether there was a positive correlation with rotation placement and consideration of the rural working locations postgraduation. All of the Australian studies found that postrotation, students were more likely to choose a rural location for employment. As Australia continues to struggle with poor distribution of dental professionals in rural locations, exposing students to a rural setting through these rural placement programs in the hopes of encouraging students to eventually practice in a rural setting can help address this rural shortage.1 In U.S. dental schools, a period of at least four weeks is the norm.23 It was

found that augmenting CBDE time to eight weeks increased the graduates’ willingness to serve in community clinics after graduation.23 In addition, rotation length is critical in allowing conclusion of multiple-appointment treatments. Procedures that require several appointments necessitate a suitable length of clinic presence to bring a treatment to completion. In a study on CBDE practices in 33 U.S. dental schools, Mays et al.26 stated that “shorter rotations will limit the type of patient encounters and impact the student’s experience.”

Differences in setting did not however impact the students’ learning experience in outplacement programs.

Rotation times in U.S. schools was found to generally be longer than those in Australian schools with the majority of the U.S. rotations lasting five weeks or longer and Australian rotations generally being about four weeks in length. A survey of recent graduates and current students at UQ and Dugoni before and after community clinic rotations investigated differences and similarities between the schools. The self-reported impact of community clinic rotation on clinical confidence was assessed, as were self-graded component competencies and overall competency. In the first section of this survey on demographics, there were no significant differences between Dugoni or UQ dental schools concerning age, gender or whether participants had already

graduated or were still enrolled. About three times as many students at UQ worked in rural community clinics, in comparison to Dugoni students, who mainly completed rotations in urban clinics. Differences in setting did not however impact the students’ learning experience in outplacement programs in either rural or urban clinics. Students at UQ consistently rated their experience significantly better than those at Dugoni. One possible reason for the positive results with UQ students could be the significant difference in time spent on clinical learning on rotation. Students at UQ spent about 21 weeks in the outplacement program while Dugoni students spent much less time, about three weeks, on rotation. As a result, UQ students treated nine times as many patients as Dugoni students; almost 94% of students at UQ somewhat or strongly agreed that their community clinic time spent was adequate, while a quarter of students at Dugoni felt the time given for rotations was not sufficient. If calculated by week, however, this difference did not lead to significantly less studentpatient encounters for Dugoni students. The survey results show that component competencies students felt lacking in improved more for students at UQ, leading to a similar self-reported final achievement in both institutions. Perceived changes were not as evident in students at Dugoni, as demonstrated by student ratings on the overall outplacement experience itself. At both dental schools, survey participants were asked to grade themselves in ADEA competencies.27 A “competency” encompasses an indispensable set of behaviors or skills that sustain unsupervised, selfregulated dental practice. Further, competencies include comprehension, critical thinking and problemJANUARY 2 0 2 2

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solving skills, professional behavior, experience, ethics and hand skills.27 Populations outside the dental school differ from the more closely defined patient pool inside an education institution. In a community clinic, dental education gains aspects of private practice, such as engagement with realistic dentistry, community service, exposure to the public health system, applied ethics and interpersonal and interprofessional communication with populations outside of the known environment of their dental school.13 Perhaps as important, studies point out similar revenue in community sites and in dental school clinics and an increase of production postexternship.14,25 In this survey, students at Dugoni felt more self-confident before the outplacement and gave themselves significantly better initial grades for seven ADEA competencies than survey participants at UQ. This difference leveled out to similar scores for both institutions after CBDE. In terms of critical thinking, there was a significant difference, with more than three-quarters of students at Dugoni feeling reasonably or strongly competent before the rotation. No student at UQ felt strongly competent and only a third felt reasonably competent. None of the Dugoni students or new graduates thought they were still developing competence at professionalism before CBDE. All Dugoni students felt strongly, reasonably or at least just competent, while significantly more students at UQ felt they were still developing professionalism. Students at Dugoni also felt significantly more accomplished and strongly competent in communication and interpersonal skills than students at UQ. The disparity could be based in the different programs, UQ accepting some undergraduate students 60 JANUARY

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trial on effects and costs of different modes of survey administration, Scott et al.28 noted an online response rate of 12.95% in medical GPs. Cook et al.29 conducted a randomized experiment with a physician survey that included low-cost nonmonetary incentives, a formal reminder letter and a postcard and only 8.5% of practitioners completed the questionnaire. To the contrary, Pit at al.13 stated in their systematic review that postal surveys were costly but more effective than telephone or email surveys and that monetary or nonmonetary incentives increased participation. In this survey, three email reminders were sent, but no compensation or reward was offered, which may have influenced the response rate. Participants from Dugoni Another potential limitation of and UQ recorded the review is that the protocol was not noticeable improvement in registered with the PROSPERO database. While not mandatory, such registration all ADEA competencies. is beneficial to avoid duplication and to enable comparison of already reported review methods with what is planned. However, due to the sequencing of UQ students compensated any previous the survey and review portions, this lack of self-confidence and resulted in the was not done in the present study. same final perception on competency and Regardless, collectively the reviewed similar self-grades as students at Dugoni. studies demonstrated that studentLastly, students assigned themselves centered teaching in outplacement an overarching grade on a sliding scale clinics enhances confidence and clinical from 1–100. These final, self-reflective competency. Likewise, CBDE can lead grades started out significantly higher to better treatment-planning skills.5–7,9 for Dugoni than UQ students. The end The number of treated patients increases results were similar, with a significantly and in turn provides a greater quantity higher increase in grades after CBDE of rendered clinical work. Spending for students taking the survey at UQ. part of their dental training outside This study had certain limitations; for of the routine and familiarity of their example, only one university per country dental school considerably changed was assessed and the results represent survey students’ perceptions in a positive way, data only, not institutional grading. Despite in both institutions. Participants from multiple efforts to remind participants, it Dugoni and UQ recorded noticeable accomplished a comparatively low response improvement in all ADEA competencies. rate. The latter finding mirrors research Patient treatments in community on survey response rates. In a randomized clinics are a fulfilling and confidencestraight out of high school, as opposed to college graduates, with potentially more mature life skills at Dugoni. In patient care, assessment, diagnosis and treatment planning before the rotation, more than three-quarters of Dugoni students felt strongly competent, while slightly more than a third felt reasonably competent at UQ. These differences among students in both institutions in competency lost significance after community-clinic rotation. The results seem to indicate that a longer stay in CBDE programs and the higher number of patients available for


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building experience for participating students.5–7,9 With enhanced clinical learning outcomes in CBDE and future directions in dentistry indicating mostly large group practices rather that individual practices, dental education might take steps to decrease dental school clinic presence and increase time spent in community clinics. Therefore, it may be recommended to not only make CBDE a significant component of dental education but also to enhance it in the final year of education specifically at Dugoni.

Conclusions

Collectively, literature suggests that community-clinic rotations lead to gains in competency for students across multiple metrics including treatment planning, diagnosis, time management, clinical skill, productivity and communication/interpersonal skills. Similarly, our case report regarding UQ and Dugoni shows improved clinical confidence and self-reported skills in the ADEA competencies of critical thinking, professionalism, communication and interpersonal skills, health promotion, practice management and informatics as well as patient care in assessment, diagnosis, treatment planning and establishment and maintenance of oral health. Students gained higher selfreflective grades. Positive changes after rotations suggest increased benefits of longer outplacement programs with considerably more patient encounters. In addition, exposure to rural clinic placements/clinics in underserved regions can help expose students to other career possibilities following graduation and hopefully encourage them to consider practicing in areas where there is a dental health professional shortage, mitigating the maldistribution of the dental workforce in rural or underserved areas. n

RE FE RE N C E S 1. Johnson G, Wright FAC, Foster K. A longitudinal evaluation of the Rural Clinical Placement Program at the University of Sydney Dental School. Eur J Dent Educ 2019;23(1):e59–e70. doi: 10.1111/eje.12401. Epub 2018 Nov 16. 2. Simon L, Shroff D, Barrow J, Park SE. A reflection curriculum for longitudinal community-based clinical experiences: Impact on student perceptions of the safety net. J Dent Educ 2018;82(1):12–19. doi: 10.21815/JDE.018.004. 3. Gordon S, Warren AC, Wright WG. Influence of Community-Based Dental Education on Practice Choice: Preliminary Data from East Carolina University. J Dent Educ 2019;83(9):1000–11. doi: 10.21815/JDE.019.101. Epub 2019 May 27. 4. Commission on Dental Accreditation CODA. Accreditation standards for dental education programs. Chicago:2018. 5. Abuzar MA, Burrow MF, Morgan M. Development of a rural outplacement programme for dental undergraduates: students’ perceptions. Eur J Dent Educ 2009;13(4):233–9. doi: 10.1111/j.1600-0579.2009.00581.x. 6. Elkind A, Watts C, Qualtrough A, et al. The use of outreach clinics for teaching undergraduate restorative dentistry. Br Dent J 2007;203(3):127–32. doi: 10.1038/bdj.2007.681. 7. Smith M, Lennon MA, Brook AH, et al. A randomised controlled trial of the effect of outreach placement on treatment planning by dental students. Br Dent J 2006;Suppl:27–31. doi: 10.1038/sj.bdj.4814069. 8. Smith M, Lennon MA, Robinson PG. Students’ clinical experience on outreach placements. Eur J Dent Educ 2010;14(1):7–11. 9. Smith M, Lennon MA, Brook AH, Robinson PG. A randomized controlled trial of outreach placement’s effect on dental students’ clinical confidence. J Dent Educ 2006;70(5):566–70. 10. Formicola AJ, Bailit HL, Weintraub JA, Fried JL, Polverini PJ. Advancing dental education in the 21st century: Phase 2 report on strategic analysis and recommendations. J Dent Educ 2018;82(10):eS1–eS32. doi: 10.21815/JDE.018.109. 11. Elani HW, Allison PJ, Kumar RA, et al. A systematic review of stress in dental students. J Dent Educ 2014;78(2):226–42. 12. Stormon N, Ford PJ, Eley DS. Exploring personality in Australian dentistry students: Implications for coping with a challenging degree. Eur J Dent Educ 2019;23(1):8–13. doi. org/10.1111/eje.12368. 13. Major N, McQuistan MR, Qian F. Association of community-based dental education components with fourthyear dental students’ clinical performance. J Dent Educ 2014;78(8):1118–26. 14. Bean CY, Rowland ML, Soller H, et al. Comparing fourthyear dental student productivity and experiences in a dental school with community-based clinical education. J Dent Educ 2007;71(8):1020–6. 15. Johnson G, Blinkhorn A. Assessment of a dental rural teaching program. Eur J Dent 2012;6(3):235–43. 16. Johnson GE, Blinkhorn AS. Student opinions on a rural placement program in New South Wales, Australia. Rural Remote Health 2011;11(2):1703. Epub 2011 May 18. 17. Lalloo R, Evans JL, Johnson NW. Dental students’ reflections on clinical placement in a rural and indigenous community in Australia. J Dent Educ 2013;77(9):1193–201. 18. Berg R, Call RL, Maguire K, et al. Impact of the University of Colorado’s Advanced Clinical Training and Service (ACTS)

program on dental students’ clinical experience and cognitive skills, 1994–2006. J Dent Educ 2010;74(4):423–33. 19. DeCastro JE, Bolger D, Feldman CA. Clinical competence of graduates of community-based and traditional curricula. J Dent Educ 2005;69(12):1324–31. 20. Mathieson KM, Gross-Panico ML, Cottam WW, Woldt JL. Critical incidents, successes and challenges of communitybased dental education. J Dent Educ 2013;77(4):427–37. 21. McFarland KK, Nayar P, Ojha D, et al. Impact of community-based dental education on attainment of ADEA competencies: Students’ self-ratings. J Dent Educ 2016;80(6):670–6. 22. Coe JM, Brickhouse TH, Bhatti BA, Best AM. Impact of community-based clinical training on dental students’ confidence in treating pediatric patients. J Dent Educ 2018;82(1):5–11. doi: 10.21815/JDE.018.002. 23. Piskorowski WA, Stenafac SJ, Fitzgerald M, Green TG, Krell RE. Influence of community-based dental education on dental students’ preparation and intent to treat underserved populations. J Dent Educ 2012;76(5):534–9. 24. Mascarenhas AK, Freilich S, Henschaw M, et al. Evaluating externship programs: Impact of program length on clinical productivity. J Dent Educ 2007;71(4):516–23. 25. Mashabi S, Mascarenhas AK. Impact of community externships on the clinical performance of senior dental students. J Dent Educ 2011;75(10 Suppl):S36–41. 26. Mays KA. Community-based dental education models: An analysis of current practices at U.S. dental schools. J Dent Educ 2016;80(10):1188–95. 27. ADEA Competencies for the New General Dentist: (As approved by the 2008 ADEA House of Delegates). J Dent Educ 2017;81(7):844–47. 28. Scott A, Jeon SH, Joyce CM, et al. A randomised trial and economic evaluation of the effect of response mode on response rate, response bias and item nonresponse in a survey of doctors. BMC Med Res Methodol 2011;11:126. doi. org/10.1186/1471-2288-11-126. 29. Cook DA, Wittich CM, Daniels WL, et al. Incentive and reminder strategies to improve response rate for internet-based physician surveys: A randomized experiment. J Med Internet Res 2016;18(9):e244. doi: 10.2196/jmir.6318. PMCID: PMC5045523. 30. Habibian M, Elizondo L, Mulligan R. Dental students’ attitudes toward homeless people while providing oral health care. J Dent Educ 2010 Nov;74(11):1190–6. PMID: 21045223. 31. Rohra AK, Piskorowski WA, Inglehart MR. Communitybased dental education and dentists’ attitudes and behavior concerning patients from underserved populations. J Dent Educ 2014 Jan;78(1):119–30. PMID: 24385531. 32. Koedyk C, Satur J, Vaughan B. What do dental students value about their rural placements — Is clinical experience enough? Aust J Rural Health 2021 Oct;29(5):670–677. doi: 10.1111/ajr.12780. Epub 2021 Oct 1. PMID: 34595796. T HE CORRE S P ON DIN G AU T HOR , Christine I. Peters, DMD, can be reached at c.peters@uq.edu.au.

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Handle With Care: Minimizing Risk With Short-Term and Traveling Patients TDIC Risk Management Staff

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ou likely have invested considerable time and money in a marketing plan that attracts new patients to your office, along with energy and resources to ensure those patients are retained. Building a thriving practice and growing your patient base is even more rewarding when new patients are referred to you from satisfied existing patients or other trusted health care providers and peers. Some of these patients come with baggage — quite literally! A variety of situations can prompt patients who are not local to seek dental care while they are temporarily visiting or residing in your area. Some may have an established provider in their primary residential area but are experiencing an unexpected dental emergency or trauma. Others may be attempting to maintain an established treatment plan or receive preventive care while temporarily living away from their regular dentist. These patients may include: ■  Business travelers who are on extended work trips in your city. ■  Students at local colleges, universities or boarding schools. ■  “Snowbirds” or others who live in one area seasonally then return to their permanent residence for the rest of the year. As the “emergency” general dentist, you may be handling more difficult procedures but are unable to ensure continuity of care, follow-up treatment and maintenance once the patient leaves your office. An additional complication is that you have not had the opportunity yet to build a climate of trust with this short-term patient — an important step in the provider-patient relationship that increases communication and improves

outcomes. So how can you care for temporary or traveling patients while protecting your practice from elevated risk factors? The Dentists Insurance Company’s dedicated Risk Management analysts provide guidance to inform complex decision-making and help you navigate patient selection and documentation.

A case study in treating an out-of-town patient

A phone call received by TDIC’s Risk Management Advice Line involved

a retiree patient who enjoyed spending summers in the milder coastal climate of Northern California but preferred spending the winter months in Arizona. The patient did not disclose this information about her sun-seeking lifestyle to the dentist she saw in California. When she began experiencing tooth pain, the California dentist treated her and placed a provisional crown, advising the patient to return in two weeks for a permanent restoration. The patient failed to return until months later; by that time, the tissue

answers

From one-on-one risk management advice by phone to informed consent forms to expert-led seminars, we’re here to help you practice with confidence. We are The Dentists Insurance Company. Learn more at tdicinsurance.com/rm

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JANUARY 2022

RM MAT TERS C D A J O U R N A L , V O L 5 0 , Nº 1

around the tooth was inflamed and the tooth had developed slight mobility. The dentist advised the patient of the tooth’s guarded prognosis during this second appointment. The patient chose to have the previously fabricated crown placed, but the crown did not fit and needed to be remade. Upon hearing the news that this would extend the treatment time, the patient stated she would soon be leaving town. The treating dentist asked the lab to rush the case so the patient’s treatment could be completed prior to her departure. A few weeks after the permanent crown had been delivered, the California dentist heard back from the patient, who was now living in Arizona. She reported that the tooth had fractured at the gumline. With the patient living so far away, limiting her return for followup care, the dentist sought advice from TDIC’s Advice Line for how to handle the situation ethically and effectively. The Risk Management analyst advised the dentist on the importance of patient and case selection as well as spending more time with patients during initial visits to gain knowledge about their dental history and lifestyle. Recognizing that the patient’s difficulty with receiving continuity of care from his practice was overlooked in previous visits, the dentist was willing to offer the patient a partial refund to offset the cost of care. The analyst reviewed guidelines for offering the patient a refund and reminded the dentist to encourage the patient to establish care with a dentist in her current location as soon as possible. Such a reminder should be offered in writing to establish a body of evidence.

The importance of patient selection

As much as you want to welcome new patients, remember that dentists are not obligated to accept all patients into 64 JANUARY

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their practice (barring discrimination). Those you do select to make up your patient base should generally be those with whom you can form productive, healthy provider-patient relationships. When patients come to you on an as-needed basis and you are not in the position to perform routine exams or radiographs, it is difficult for you to ensure continuity of care, proper diagnoses, treatment and maintenance — all factors that increase risk. With that in mind, you may sometimes choose to weigh the benefits

Dentists are not obligated to accept all patients into their practice (barring discrimination).

of temporary patient care against those known risks. Potential patients may warrant extra consideration when they have been referred to you by current patients or trusted colleagues. Providing care to these patients promotes a positive working relationship between you and the referrer and ensures you will continue to get referrals from them on an ongoing basis — not all of which will be temporary. Online reputation management is another factor that should be considered when deliberating accepting a temporary patient. If the patient reached out to your office due to positive provider reviews discovered online, they are more likely to leave a review of their own. Such reviewers have been known to leave negative feedback

based on their interaction with office staff when initially seeking care. Because your office staff are the first point of contact with any potential patient, they should be trained to offer thoughtful, compassionate service to anyone who requests an appointment. If you choose to accept emergency or short-term patients on a case-by-case basis, be sure your office staff understands the process for case review and how to communicate that process to those seeking emergency care. The ethical standard for emergency services for patients who are not patients of record is to make “reasonable arrangements for their emergency care,” according to the ADA Principles of Ethics and Code of Professional Conduct. To facilitate meeting this standard, TDIC suggests maintaining a list of phone numbers of clinics and dental societies to provide to emergency patients who don’t have an established dental provider.

Considerate communication and documentation

Respectful communication and careful documentation at all points of service protect your practice’s reputation and mitigate risk. Questions on your intake forms are a good place to begin this documentation. Asking “What is the reason for your visit today?” and “When was your last dental visit and what was the name of the dentist?” are appropriate ways to identify short-term patients. Should you decide to accept a short-term or traveling patient, here are an additional five critical points of communication and documentation: ■  Whether or not the patient has a regular dentist. If they do, make every effort to consult directly with that provider. Request any recent notes or radiography that pertain to the current treatment. ■  The patient‘s detailed medical and


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dental histories. This is particularly important if you are unable to obtain records from another dentist on behalf of the patient. Document past medical and dental procedures, current diagnoses and any medications. ■  The patient‘s lifestyle. To get a complete picture of health, inquire about and document aspects of the patient’s lifestyle that may impact their care. This includes travel plans and any impediments to consistent access to care. ■  Informed consent. As with all patients, informed consent is a discussion, not just a form. Acknowledge their understanding and consent before offering any treatment. Short-term patients should also be notified of the risks posed by postponing follow-up care. ■  The length of treatment. If an outof-town patient presents with a particularly complex case, it’s best not to get involved beyond palliative care. Patients who are visiting or living temporarily in your area may not have the opportunity to complete treatment under your care. Explain the importance of continuous care to the patient and encourage them to schedule a consultation with their primary dentist. Treating “snowbirds,” college students or patients who present only on an emergency basis can be challenging, especially when another general dentist is their primary care provider. As the “secondary” general dentist, you have more liability exposure than the dentist who is performing their routine dental care. Again, the best defense is good communication between the dentist and patient and between the two treating dentists. Be sure to proactively explain to the patient the importance of continuous care with one practitioner. And if the

situation becomes too complex, ask the patient to choose who will be their primary dentist. If the patient is unwilling to do so, then it’s best to consider terminating care. Trust your instincts and have the confidence to say no to cases that make you uncomfortable. If you find yourself facing a challenging or uncertain patient care situation, consult an experienced TDIC Risk Management analyst. n

The Dentists Insurance Company’s Risk Management Advice Line is a benefit available at no cost to CDA members, as well as to policyholders protected by TDIC. To schedule a consultation, visit tdicinsurance.com/RMconsult or call 800.733.0633.

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PRACTICE SALES • VALUATIONS/APPRAISALS • TRANSITION PLANNING • PARTNERSHIPS • MERGERS • ASSOCIATESHIPS NORTHERN CALIFORNIA EAST BAY AREA PEDO: Well-established with 8 Ops, Digital, plumbed for Nitrous, and high NP count. Associate-driven with Delta PPO. 2019 GR $832K on 3-4 days/wk., 2020 Production $560K. #CA2523 FAIRFIELD AREA: High traffic area, 7 Ops Digital, Pano/CB, 23+ NP/mo. with 8+ Hyg. days/wk. Room to grow with specialties. 2019 GR $1.7M and 2021 on track to exceed 2019. #CA1824 FREMONT ORAL SURGERY: New Listing! 34 yr history, diverse high-tech community. 4 Ops Digital, 7-10 y/o equipment, Pano. 2019 GR $548K on 3.5 days/wk. #CA2754 GREATER SONORA AREA: Rural lifestyle GP/Real Estate, 5 Ops, Dentrix, Strong hyg prog in stable community. 2019 GR $698K. #CA1713 HAYWARD: Great neighborhood practice +RE opportunity. 4 Ops, digital, updated. 2019 GR $730K. #CA2771 LAKE TAHOE AREA: 4 Ops, 37+ yrs Goodwill. Rural lifestyle GP in growing resort community. 2019 GR $760K. #CA1715 LAKE TAHOE AREA: 5 Ops w/ 6th Open, Operatory views of Lake Tahoe, only 34 Delta Premier patients, 2,100 sf. 2019 GR $579K on 22 avg. Dr. hrs/wk. #CA608 MILLBRAE: New Listing! Great practice in the heart of the peninsula with 60 yrs goodwill. 5 Ops. 2019 GR $1M+ on 4 days/ wk. and 6 Hygiene days. Owner will work back for a short time for transition. Digital, Pano, Waterlase & Periolase. #CA1139 NAPA COUNTY: New Listing! 7 Ops, stand-alone building. Gross Revenue over $1M+ with 7 Days of Hygiene. Computerized and Digital. Established in the community for over 37 years. #CA2912 NORTHERN SACRAMENTO: Busy location, Paperless, 3 Ops+4th shared, CEREC, Digital Pano. 2019 GR $671K on 24-32 hrs/wk. #CA1745 OAKLAND: New Listing! Pill Hill area, walk to BART, 2019 GR $473K and postCOVID recovery to $595K in 12 months since reopening. 3 Ops, Digital x-days and Pano. #CA2839 PLEASANTON: New Listing! 7 Ops, 5 Equipped, Dentrix, Digital, Laser, Digital Pan, no need to add $, this practice has everything. GR $1.3M. Won’t last. #CA2891 REDDING AREA: Price reduced by $100K under valuation price! Modern office with 5 Ops, 4 Eq., Digital, Newer CEREC, 23 NP/ mo with no marketing. Strong Hygiene, specialties referred. 2019 GR $558K. #CA1742 ROCKLIN/GRANITE BAY: New Listing! High-end 4 Op GP/Cosmetic practice in affluent area. Paperless, digital, iTero scanner, 8+ hyg. Days/wk. 2019 GR $1.6M+, 2021 Prod projected at $2M+. RE for sale with practice. #CA2793 ROSEVILLE/CITRUS HTS: New Listing! 6 Ops, high traffic area, 13 yrs goodwill, Digital, lasers, 26 NP/mo, 5 days Hygiene, specialties referred. Seller will work back. #CA2749

ORANGE COUNTY: 4 Ops in soughtMODESTO AREA: Est. area with 60+ yrs. ROSEVILLE/ROCKLIN: New Listing! after area. 34 yrs Goodwill, many hi-end goodwill. 5 Ops, 2019 GR $1.1M+ on 3 7 Ops, hi-end practice in desirable area. procedures done in-house but room to grow days/wk. Dental Condo also available for Digital, CAD/CAM, lasers, Pano. 10+ hyg. other specialties. Digital. FFS/Cash. purchase or lease, Seller may consider days/wk, 2019 GR $2.3M, 2021 projected #CA2704 $2.5M. Lease with purchase option. #CA2770 financing. #CA635 PALM DESERT: 4 Ops 27 yrs Goodwill. MONTEREY: 4 Ops, Paperless, Digital, SAN FRANCISCO: New Listing! 4 Ops, Strong hyg prog w/ hi-end patient base of Pano. 2019 GR $1.1M with Adj. Net over Financial District, SoftDent, Digital sensors locals/snowbirds. 2019 GR $809K on only $450K. Post-COVID revenue has grown and Pan. FFS/PPO, GR $1.6M+. Delta PPO 16 days/mo. with low overhead. Call today! even more! RE for sale, non-Delta Premier Practice with over 70 NP/mo. #CA2934 #CA691 office, FFS and some PPOs. #CA2614 SAN JOSE: Est for 35 yrs, 2019 GR of PALMDALE/LANCASTER: 7 Op office SANTA CRUZ: New Listing! 4 Ops, $1.3M with Adj. Net of 38%. 6 Ops, Digital in fast-growing community. Paperless with Minutes to beach! Digital, CEREC, Pano, X-rays and Pan, CAD/CAM, Laser. Upscale Dentrix, digital X-rays, 8 days of hyg./week building near shopping. Seller can stay on P/T. CBCT. Bread and butter practice-room to and dedicated staff. Room to grow with grow with specialties. FFS and Delta PPO #CA1140 specialties! #CA2612 only. #CA2938 SAN MATEO: Price Reduction! 5 Ops, SAN BERNARDINO: New Listing! 6 Ops, Digital, iTero Scan, CEREC, Laser, Paperless, SANTA CRUZ COUNTY: New Listing! established 33 years, cash, HMO, Denti-Cal 4 Ops, near beach, in strip center. Digital Microscope. Seller-owned stand-alone in a busy area with parking. 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Ops, FFS/PPO. Eaglesoft, Digital, M11 and for a 4th. Dentrix, digital, refers most Est 22 yrs with 5 star Google reviews, Digital Pano. RE potentially for sale also. specialties with low overhead and high net. Paperless with CEREC, Scope, Laser, Strong Doctor selling for health reasons highly GR $600K. #CA2815 Hyg. Retiring seller. 2019 GR $782K with motivated. #CA2945 good post-COVID recovery. #CA2594 TORRANCE: New Listing! 3 Ops, retiring BAKERSFIELD: 6 Ops, 40 yrs Goodwill, seller with 34 yrs goodwill. Ready to take to SONOMA COUNTY: New Listing! 4 Ops great reputation in the area. 6 hyg ds/wk and the next level with technology of your with room to expand into suite next door. GR choosing. Amazing location in desired area. over $1M for last 3 yrs. Est. 30+ years. Strong most specialty work referred. Digital pano, digital X-rays. 2019 GR $600K. RE also for 2019 GR of $300K with low expenses, a hygiene, digital, space available to lease or sale. #CA1274 wonderful opportunity to grow. #CA2807 buy. #CA2790 BAKERSFIELD: New Listing! 6 Ops, 5 SONORA AREA: New Listing! 5 Ops, SAN DIEGO Equipped, Digital, 2020 Collections $1M+ Producing $825K in a renovated suite. RE for with 6 days hygiene and 2 P/T associates. sale w/practice. Strong Hyg program. Digital, CARLSBAD: New Listing! 5 Ops, modern #CA2587 Laser, and Digital Pano. #CA2850 design, suburban growing area. Digital Pan, BURBANK: Big opportunity for large Digital sensor, Laser, Paperless. 30 NP/mo. S. SACRAMENTO-GREENHAVEN: New practice merger, 6 Ops, Digital, seller retiring. Room to grow with marketing and specialties. Listing! Associate in place. 4 Ops, Digital, 6 days of hygiene, specialties referred. Seller #CA2933 Cone Beam, Digital Pano, Specialties referred. will transition, open to financing options. 2019 Not a Delta Premier Provider. 2021 projected DEL MAR: New Listing! 4 Ops, Digital, GR $918K. #CA2632 $800K+. #CA2741 Open Dental, Conservative Practitioner who COASTAL ORANGE COUNTY: refers out specialties. 4 days of hygiene per VACAVILLE AREA: Price Reduced over New Listing! 5 Ops, 4 Equipped, Digital Pano week. Seller is eager for a quick sale. $35K! Seller will work back for up to 6 mo. and X-rays, well-established neighborhood, Excellent opportunity in a very desirable Centrally-located & hi-traffic location with location. #CA2724 25+ yrs goodwill. 5 Ops in 1,700 sf. 2019 GR very desired area. 2019 GR over $1M. #CA2787 $556K on 32 hrs/wk. #CA645 ENCINITAS: New Listing! 5 bright Ops, strip mall location. Digital Pan, Laser, Digital VACAVILLE AREA: 4 Ops, 3 equipped, 45 HUNTINGTON BEACH: New Listing! 5 Ops, established 30 yrs. RE ownership X-rays, Paperless. 25 NP/mo. Grow with years goodwill, Digital, paperless, most available. PPO with specialties referred - room specialties. #CA2935 specialties referred. 2019 GR $723K on 30 to grow. High net income in sought-after area. hour week. #CA2748 ESCONDIDO: New Listing! 6 Ops, hi-prod, #CA2937 CBCT, Scanner, Scope, Laser. Off main road, CENTRAL CALIFORNIA LONG BEACH: RE Ownership an option! refers out most specialties. #CA2946 Upper middle-class residential practice est. in N. SAN DIEGO INLAND FACILITY: CENTRAL VALLEY/MODESTO: 1950. Existing 4 Ops, 3 Equip, Digital, Easy New Listing! 8 Ops, high visibility retail, expansion next door to add 3 Ops, 2 are equip. New Listing! 5 Ops, 4 equipped plus a 4 chair ortho bay. Excellent space for GP looking to Open 20+ yr, Digital, soft/hard tissue lasers, Most Specialty referred. Strong post-COVID expand or specialist. #CA2840 3,300+ active pts., 24+ NP/mo., 4 hyg days/ production. 2019 GR $696K. #CA671 wk., 18.5 hour Dr. work week. 2019 GR MONTEBELLO: New Listing! 3 Ops in busy POWAY: New Listing! 6 Ops, Dentrix, $852K, 2020 84% of 2019. #CA2721 strip center location with 2 Associates, Digital Dexis, CBCT, laser, solid foundation. Main road location with free parking. #CA2932 FRESNO AREA: New Listing! 6 Op Valley X-rays, and all specialty work referred out. gem, great staff in desirable area. Paperless, #CA2786 SAN DIEGO: New Listing! 4 Ops, desirable/ Trios Scanner, Digital Pan/Ceph, Lasers and ORANGE COUNTY: New Listing! 8 Ops, 6 affluent community. CEREC, CBCT, Digital, 12 days of hyg/wk. 2019 GR $1.4M, 2021 Dentrix, Paperless. Room to grow with projected at $1.4M again. Seller may consider equipped, room to bring in specialists! Digital, specialties. #CA2896 BioLase, iTero, Digital Pan, beautiful office, option to purchase RE. #CA2004 modern and clean. Premium strip center SAN DIEGO: New Listing! Rare GREATER MODESTO: New Listing! 7 location. GR $590K. #CA2926 opportunity, seller retiring, 4 Ops in desirable Ops, Desirable area, Dentrix, Digital, Laser, location with good cash flow. High quality Digital Pano. RE for sale w/practice. Not a work. Digital, Dentrix. #CA2851 Delta Premier provider. 2020 GR $615K and 2021 should exceed it. #CA2795

Northern California Office

800.519.3458

Henry Schein Corporate Broker #01230466

www.HenryScheinDPT.com

Southern California Office

888.685.8100


Regulatory Compliance

C D A J O U R N A L , V O L 5 0 , Nº 1

The Road to E-Prescribing CDA Practice Support

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alifornia prescribers had to switch to electronic prescribing by Jan. 1, 2022, as did prescribers in Utah, Nebraska, New Hampshire, Michigan and Maryland. California is now part of a majority of states that require the use of e-prescribing. In 2011, Minnesota was the first to require it, and in 2016, New York was the first to impose penalties.1 In addition to state mandates, the Centers for Medicare and Medicaid Services (CMS) are set to implement a rule requiring that Medicare Part D prescriptions for schedule II, III, IV and V controlled substances be prescribed electronically.2 Although the move to e-prescribing seems swift, it began in 2003 when the Medicare Modernization Act required the establishment of standards for e-prescribing.3 This was followed by the publication of a 2006 Institute of Medicine report, which found that medication errors are the most common medical errors and the cost of treating related injuries was over $3.5 billion annually. The report included among its many recommendations that all prescriptions be written electronically by 2010.4 Not long after the release of that report, the California Healthcare Foundation published in 2008 an issue brief on the status of e-prescribing in the state. The brief included recommendations to get health care payers, pharmacies and health care providers on board to adopt e-prescribing.5 The DEA’s adoption of an e-prescribing regulation in 2010 was one of the necessary steps to standardizing the e-prescribing process. The DEA

regulation establishes standards for ensuring that only authorized prescribers can prescribe controlled substances. Although CMS established in 2005 the first e-prescribing standards, it has since adopted the SCRIPT standard established by the National Council for Prescription Drug Program (NCPDP), a nonprofit, multistakeholder organization. The NCPDP standard facilitates the transfer of prescription data between prescribers, pharmacies, payers, health

care facilities and intermediaries. E-prescribing software applications must comply with both of these standards. The country’s opioid crisis was declared a public health emergency in 2017 and led policymakers to lean on e-prescribing to reduce drug diversion and protect against drug misuse.6 The California legislation, which established the e-prescribing requirement, cites that e-prescribing for controlled substances would “significantly reduce,

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if not eliminate paper-based fraud and forgery while creating electronic records of controlled substance transactions, thereby strengthening surveillance and drug monitoring program in California.”7 Assembly Bill 2789 was enacted in 2018 to require e-prescribing for controlled and noncontrolled substances except in specified circumstances. It also requires pharmacies to be able to accept e-prescriptions. At the request of impacted stakeholders, the effective date of the requirements was set for Jan. 1, 2022, three years after the legislation’s passage. Other legislation approved in 2018 and later tightened the security of controlled substances prescription forms used in the interim before the e-prescribing mandate began. The legislation led prescribers to change their forms more than once to ensure the forms had all required elements. Even with mandated e-prescribing, prescribers should retain their forms in a secure location for use in situations when e-prescribing is not available or required, as described in the law. E-prescribing can help reduce medication errors and improve patient safety. For example: ■  Pharmacists no longer need to struggle to read a prescriber’s handwriting. ■  Prescribers have access to a patient’s prescription history. ■  The availability of builtin alerts, for example, for potential drug interactions. E-prescribing reduces drug diversion through fake prescriptions and allows for improved monitoring of controlled substance prescriptions. Applications can integrate with state prescription drug 68 JANUARY

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monitoring programs. However, recent studies suggest that the actual impact of e-prescribing on opioid prescriptions is not yet clear.8,9 Medication errors can still occur with e-prescribing. Because drug names can look similar, such as Celebrex and Celexa, prescribers should double-check that they have selected the correct drug. The Institute for Safe Medication Practices maintains a list of these confused drug names. In 2020, industry media reported 66% of all prescriptions were e-prescribed in 2017 and 80% in 2019.10 With more states mandating e-prescribing in the coming years, the percentage of prescriptions that are e-prescribed will rapidly increase. E-prescribing resources are available on cda.org: Prescribing and Dispensing Q & A and Electronic prescribing for controlled and uncontrolled substances becomes mandatory in California in January 2022. n RE FE RE N CE S 1. ID.me. A guide to state and federal EPCS requirements and deadlines. Accessed Oct. 15, 2021. 2., Centers for Medicaid and Medicare Services. E-prescribing. Accessed Nov. 2, 2021. 3. Bell D, Friedman M. E-prescribing and the Medicare modernization act of 2003, abstract. Health Aff (Millwood) Sep–Oct 2005;24(5):1159–69. doi: 10.1377/ hlthaff.24.5.1159. 4. The National Academies of Sciences, Engineering and Medicine. Medication errors injure 1.5 million people and cost billions of dollars annually; report offers comprehensive strategies for reducing drug-related mistakes. 5. California Healthcare Foundation. Getting connected: The outlook for electronic prescribing in California. 6. Office of the National Coordinator for Health Information Technology. Opioid epidemic and health IT. Accessed Nov. 2, 2021. 7. AB 2789 Senate Business, Professions and Economic Development analysis. Accessed Nov. 3, 2021. 8. Abouk R, Powell D. Can electronic prescribing mandates reduce opioid-related overdoses? Econ Hum Biol 2021

Aug;42:101000. doi: 10.1016/j.ehb.2021.101000. Epub 2021 Apr 9. 9.Everson J, Cheng A, et al. Association of electronic prescribing of controlled substances with opioid prescribing rates. JAMA Netw Open 2020 Dec 1;3(12):e2027951. doi: 10.1001/jamanetworkopen.2020.27951. PMCID: PMC7753903. 10. Jason C. What is e-prescribing and why is it vital for providers, patients.

Regulatory Compliance appears monthly and features resources about laws that impact dental practices. Visit  cda.org/ practicesupport  for more than 600 practice support resources, including practice management, employment practices, dental benefit plans and regulatory compliance.


Tech Trends

C D A J O U R N A L , V O L 5 0 , Nº 1

A look into the latest dental and general technology on the market

Sceptre 34-Inch Curved UltraWide LED Monitor ($349.97, Sceptre) Large monitors have been the domain of gamers; however, office users are turning to this deceptively useful piece of hardware to increase productivity. The extra screen space allows for more magnification of images, more information to be displayed and more windows to be opened. In a practice where space is at a premium, these advantages must be weighed against a large monitor’s cost, capabilities and size. Sceptre, a Chinese electronics company, has made it its mission to offer affordable monitors with incredible specifications. This review focuses on the Sceptre 34-inch curved 100Hz ultrawide LED monitor tested with a Lenovo Thinkpad P15 connected through HDMI on a USB-C laptop dock. For those who have not used a large monitor before, first impression out of the box is that a 34-inch monitor is comically huge. Thankfully, it is not comically heavy, as it weighs 16 pounds, but its creaks and groans cast doubt on its durability and build quality. The monitor is easy to set up: Just plug it in and go. It comes with VESA-compatible mounts for those looking to mount it on a wall. The screen can comfortably fit two windows at near full size, allowing for enhanced multitasking. The display is crisp and does not have motion artifacts until pushed by video-game-level graphics. While the 100Hz is a decent specification to boast about, it is not truly noticeable in productivity applications where images are not moving quickly (e.g., looking at CBCTs, typing, intraoral photographs, 4k videos). Two unexpected but welcomed features are its antiflicker and blue light shift technologies that can combine to reduce eye fatigue. From a pure price-to-performance standpoint, the Sceptre 34-inch monitor is a rare product that boasts an impressive handful of features for an affordable price. — Alexander Lee, DMD

Journal, Microsoft Garage (free, Microsoft) An abundance of apps is available for tablets and touchscreen laptops that integrate a digital ink pen for handwritten notes and drawings. Many of these apps make use of typing as the primary method of input and are supplemented with pen markups. Journal, a Microsoft Garage app for Windows, provides an ink and touch experience for tablets and two-in-one devices that uniquely combines handwritten digital pen input with gestures and AI technology to take journaling and productivity to another level. Journal interacts with users taking notes through digital pen input only. The home screen displays a simple interface where users can create journals customized by name, color and icon. Inside each journal, users can choose different page styles and spacing of lines and/or dots for every page. Users can choose from pen, highlighter or pencil input tools with customizable tip sizes and colors. There is also an eraser tool to correct mistakes. Page scrolling is easily accomplished with a finger swipe. Beyond basic notetaking features, Journal utilizes ink and touch gestures to enhance its use. Users can select their handwritten text or drawings by simply tapping on it with their finger. Tapping on the selection again increases the size of the field. Similarly, users can also lasso with the digital pen to select their ink. Once selected, users can choose to copy the ink as displayed or copy a text transcription to the clipboard for pasting in their favorite applications. Selected content can also be dragged by finger or pen to other pages or applications. Users can import images or PDF documents into journal pages for markup. Headings in pages can be created by underlining ink, which users can organize and search for within a journal. Bulleted lists are automatically detected for quick reference. Items can also be flagged for search by drawing a star next to it. Microsoft 365 work or school users can mention people in their organization in a page by drawing an @ symbol, which pulls up a person picker. Mentioned users do not get shared access to the note, but are simply used as a reference for search. Users can search for any keyword or filter within a journal, but cannot search all journals combined. Additionally, drag and drop of selections between applications may vary based on compatibility. — Hubert Chan, DDS

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