By Linda G. Levin, D.D.S., Ph.D.
As an educator for over 20 years I was involved in clinical and didactic proficiency assessments on many levels. None were as informative as what I experienced in 2005 when I went into full-time clinical practice. It was there that I could observe the real-life competency of my students. I remember reviewing a case for retreatment in which the primary treatment was "less than adequate" and thinking, "Who taught this person that this was acceptable?" Then I had an astounding revelation - it was me! How could this be? I taught at a CODA- and ADA-accredited school. Our curriculum was approved. We complied with every requirement. Furthermore, we had a renowned postgraduate program in endodontics with the same faculty. My conclusion was that we teach two standards of endodontic practice: one to endodontic residents and another, much lower, standard to predoctoral students.
Our residents were instructed in microscopy and three-dimensional imaging, and they were given a solid underpinning of the literature and biology pertaining to our specialty. In contrast, our predoctoral students were exposed to a minimum and arbitrary number of cases, many of which were accessed previously in the emergency clinic. They were also screened for difficulty by the faculty, so case selection was largely hidden from them. The amount of time for didactic lecturing at the predoctoral level was shrinking so more time could be devoted to other disciplines. Was my school different from others? After reviewing surveys taken at predoctoral directors' conferences, I realized we were the norm, not the exception.
In most institutions today we teach predoctoral students the same techniques we taught in the 1980s. The exception is that most teach some form of rotary instrumentation (which evolved in the 1990s). We are heavily dependent on two-dimensional radiographs and "feel-o-dontics" that uses an explorer to find anatomy rather than a microscope. There are valid reasons for this and most stem from a lack of resources at many institutions for the predoctoral students. But we have to ask ourselves, is this in the best interest of the student and, most importantly, the patients that they will treat? Are we exposing future general dentists to state-of-the-art endodontics or are we leaving them with the impression that performing molar endodontics is no more involved or specialized than an MOD restoration?
In the Fall 2014 issue of the AAE's ENDODONTICS: Colleagues for Excellence, we outlined the Standard of Practice in Contemporary Endodontics. This tome described the skill set and knowledge base necessary for the current standard of clinical practice. It is the standard that the legal community uses when evaluating the competency of endodontic care. The general dentist who performs an endodontic procedure is expected to perform at the same level as the specialist, but how can they if they are not taught to do so? In a recent survey of our predoctoral educators the overwhelming opinion was that our current system of predoctoral education does not provide the resources to educate students adequately to practice state-of-the-art endodontics. Eighty-nine percent of faculty felt that students are not competent to perform molar endodontic procedures. This is concerning since they will be licensed to do so when they graduate - with or without sufficient training.
Can we rely on external controls to ensure adequate endodontic education for the predoctoral student? The CODA and ADEA requirements for endodontic teaching are deliberately vague. The revised CODA predoctoral education standards simply state that the student must be exposed to "pulpal therapy," which allows for a wide range of interpretations by those who develop the predoctoral curriculum and by the deans who allocate resources. These nonspecific guidelines have resulted in huge heterogeneity in the endodontic competency of dental graduates. The AAE is aware that this is of great concern to stakeholders like group practices, insurance carriers, dental service organizations, the various branches of government service and especially patients, who rely on a certain level of proficiency from new dentists, regardless of the school from which they matriculated.
So what do we do about it? First, we must examine how we measure competency. There are several levels of evaluation at the predoctoral and licensure levels. All are fraught with a lack of consistency and validity. Does the ability to perform endodontic treatment on an acrylic tooth equate with the clinical competency required to treat patients? Many schools and boards feel that it is, or they have simply conceded to external pressures to produce licensed dentists. The AAE is taking action to address competency in endodontics, recently appointing a special committee to study this issue and make recommendations as to how we can better judge a student's ability to be a "safe starter" in endodontics. It is a complex topic that demands our immediate attention.
As specialists in endodontic care, it is our responsibility to lead the charge in making sure our predoctoral students receive a sound and consistent foundation in our specialty. We must teach one standard of practice to all of our students. The present educational system gives the false impression that the student is prepared to practice at the same level as the endodontist. We need to use the allotted time in the predoctoral curriculum to provide a firmer foundation in the biologic basis of disease, diagnosis, treatment planning and prognosis. For students interested in clinical competency in simple endodontics, schools must offer "selectives" so the student can have adequate exposure to care. We know this is possible because predoctoral programs like Virginia Commonwealth University and the University of Texas Health Science Center at San Antonio have accomplished this. Lastly, we have to make competency examinations meaningful. We must be able to confirm that that the skill set and knowledge base necessary for good endodontic practice has been mastered.
It has been argued that teaching predoctoral students at the same level that we teach our residents will result in fewer referrals to the endodontist. But this is contrary to the experience of many of our "flagship" educational programs. In programs that teach to a higher standard, we see that dentists refer more as they understand the complexity and expertise involved in endodontic care. I firmly believe that the majority of our general dental colleagues truly want what is best for their patients. We must teach them what endodontics in 2016 looks like. We owe it to our students and, most importantly, to their patients.