Admittedly, I am not an unbiased observer. I have made my professional career in dentistry as a translational/clinical scientist, and I still regularly see patients within my (unofficial) specialty of oral medicine. However, my career path was not planned; it just happened, and my views on the roles of the biological sciences and medicine within dentistry have evolved accordingly.

	THE DEVELOPMENT OF AN UNOFFICIAL SPECIALIST

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I entered dental school in 1967 fully intending to practice general dentistry. I had a minimal interest in biology (my bachelor of arts degree is in history), and, although I wanted to enter a health care profession and help people, I clearly wanted to avoid treating seriously ill patients and taking calls at all hours of the night. Dentistry seemed like a perfect career choice for me, and indeed it has been. Dentistry has allowed me enormous career flexibility, extraordinary professional satisfaction and a good life. So why do I still struggle over this issue? The reason is that I care about dentistry. I think dentistry, while an important component of health care during my professional career, risks being marginalized if dental schools fail to provide students with more practical training in medicine and the biological sciences. Serendipitously, as I worked on this essay, the most recent issue of the ADA News was headlined, "Dental Education: Our Legacy—Our Future," with a subhead reading "Securing the future of dentistry."⁷ The "Our Legacy—Our Future" program is a nationwide collaborative initiative involving the input and participation of hundreds of dental stakeholders and partners that include the ADA Foundation and the American Dental Education Association. It was developed to raise awareness of the needs of U.S. dental education.⁷ The story reminds all of us that the future of our profession is our collective responsibility.

My circuitous professional path has taken me from the innocent ambitions of a 21-year-old entering dental school, to wanting to spend most of my time at a laboratory bench discovering new scientific facts, to becoming a more "mature" professional who consciously began targeting my research to make a difference in people’s lives. The latter has been my professional operating mode for 20 years, and I have tried to make my science useful in managing specific and significant oral health problems.

I have had the inordinate good fortune to spend most of my career at the National Institutes of Health (NIH) and, since 1982, to work in arguably the finest clinical research center in the world, the NIH Clinical Center. Surrounded by luminaries in the world of biological sciences and academic medicine, I unequivocally recognize the relevance of oral health to a patient’s general health and quality of life. However, while I have successfully avoided the primary responsibilities of caring for seriously ill patients, I have not avoided caring for many patients with significant medical problems. Through a colleague in graduate school who worked on salivary proteins, and my military service assignment in the U.S. Naval Medical Research Institute, where I was asked to study salivary proteins, I became interested in salivary glands and saliva. Also, my first permanent NIH position was in the National Institute on Aging. As a consequence of these circumstances, my research became directed toward clinical problems affecting salivary glands in middle-aged and elderly adults.

Not surprisingly, many people with these demographic characteristics have one or more significant systemic diseases. To conduct clinical studies and provide care for these patients, I realized that I needed to know more about their diseases, as well as how the diseases were monitored and treated. In essence, I needed to know some basic general medicine. The way I met this need primarily was through the generosity of colleagues, in both formal and informal situations. I asked lots of questions, and I learned on the job. Was this unorganized approach appropriate? I doubt it, but it was the best I could do. My informal medical "education" was minimal, but thanks to my NIH colleagues and the environment in which I work, I was able to conduct high-quality studies and, I hope, make some useful contributions. I believe few people are as lucky.

	PUTTING SOME ‘MEDICAL’ INTO DENTAL EDUCATION

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What does all of this have to do with dental education? Can a single person’s career path and experiences be broadly relevant or instructive? I believe so. It is my thesis that dental students need to know enough medicine to treat their patients who have chronic systemic illnesses, a population that continues to increase in size.⁸ Dental education in the United States ensures that students have a fundamental background in the basic biological sciences. Unfortunately, in general, United States dental schools do little to build on this foundation.^3,5,6,9 I have long asked why dental schools require such extensive training in the biological sciences if, for the most part, it has little practical outcome and is primarily an intellectual exercise for dental students.^1–6 Certainly, dentists use much of their training in anatomy and pharmacology, and some of their training in microbiology, but my experience suggests that little of their education in biochemistry, physiology and immunology is applied in the dental operatory. All medical students have a minimum requirement for training in general internal medicine, something that helps them appreciate their training in these three biological science disciplines as being intrinsic to patient care. I sincerely believe dental students have a similar need.

It is difficult to determine precisely how much training U.S. dental students receive in general internal medicine, but it seems to be limited. For example, the ADA’s 2003–04 Survey of Predoctoral Dental Education¹⁰ has two subject listings in which general medical training for students likely might be incorporated: general medical emergencies and hospital dentistry. Only five of 55 U.S. dental schools spend more than 1.0 percent of their instructional time on general medical emergencies, while 10 schools spend 1.5 percent or more of their course time providing training related to hospital dentistry.¹⁰ I think it is fair to ask why organized dentistry and the dental education community have not addressed the issue of providing more substantive general internal medicine training for dental students, given existing demographic trends. From my perspective, there could be many reasons (Box 1), and I comment on several below.

Another type of cost is that to the student. I understand how expensive dental education is, and I recognize how much time students already spend in preparing to practice their profession. However, students should experience little increased cost, in either time or money, for such a curriculum change. Certainly, the institutional and student costs depend on the type of training provided, which could vary widely (see below). The time is right for organized dentistry to join with the dental education community⁷ and make a serious effort to determine a useful cost-benefit ratio for providing dental students with some substantive general internal medicine training. I hypothesize that the benefits will be much greater than the costs.

Is the dental curriculum too crowded to accommodate medical training? A third reason for the relative absence of training for dental students in general internal medicine is an existing view that the dental school curriculum already is overcrowded. This argument generally states that because many other important issues need to be addressed in dental education, and there already is not enough curriculum time, training in internal medicine must take a back seat. I accept the fact that dental school curricula are overcrowded. However, it is difficult for me to accept the concept that all additions to curricula require the elimination of other subjects. Unfortunately, the standard at most dental schools is the addition/elimination method of program modification, a patchwork approach of curriculum development (see below) that ultimately could paralyze the continued evolution of dentistry and dental education.

The basic structure of current curricula in U.S. dental schools originated with Geis’¹³ report in 1926. Certainly, many changes have been made since then, but the basic design and approach remain the same. While dental education and the U.S. public profited enormously from the Geis report, we should be mindful that it was written a full 80 years ago. At that time, the biological sciences were much more primitive and phenomenological, the population had very different kinds of dental problems, and the proportion of middle-aged and older adults in U.S. society was dramatically smaller than it is now. I have argued that the Institute of Medicine (IOM) report on dental education,¹⁴ which was published more than 10 years ago, provided dentistry with a substantive step in the evolution of the dental school curriculum from that outlined in the Geis report.² In 1996, I wondered in print,² paraphrasing the title of a contemporary editorial in Annals of Internal Medicine,¹⁵ whether the IOM report would result in "tinkering or real reform" for dental education.

Unfortunately, after more than a decade, only tinkering has occurred. Key recommendations in the IOM report, including calls for more links between dentistry and medicine, have gone unheeded. From my perspective, that of a concerned dentist who admittedly does not function within a dental school, the patchwork approach to dental curricula has outlived its usefulness. I suggest that it is time for organized dentistry and the dental education community to take a hard look at where dentistry wants to be in 2030 and to design comprehensive curricula to achieve that goal. If that view does not include being an integral member of the health care community that is able to provide optimal care for middle-aged and elderly patients who are medically compromised, then it is fine not to provide dental students with substantive training in general internal medicine. However, if it is otherwise, then we need to design new curricula with meaningful core competencies for the next generation of dentists, rather than apply patches to our existing ones. The demographic data are quite clear^8,16; future dentists will be asked to care for greater numbers of ambulatory elderly patients who have significant medical concerns. Crowded curricula or not, dentistry must respond to this fact.

Would substantive training in medicine for dental students take too much effort? To address this question, it is necessary first to define what level of practical internal medicine training dental students require. From my perspective, there are several possibilities, such as training at the level of a nurse practitioner or a podiatrist. However, the model that I favor, and on which I will comment, is that of a third-year medical student. Whatever the type of training, it should provide students with the means of assessing a patient’s medical status and suitability for dental treatment—that is, it should be practical. Dental students could function in a hospital for a two-to three-month general medical rotation at the level of a third-year medical student with only modest additional academic effort. Third-year medical students in general medical rotations observe senior clinicians evaluating patients, listen to senior clinicians discuss patients, read independently to help them understand what they have seen and heard, and provide limited supervised patient care. This might include writing clinical notes that are countersigned by more senior clinicians and entering patient orders. They learn how to take an accurate history and perform a physical examination. Importantly, they typically do nothing that is irreversible. The level of institutional supervision and responsibility is equivalent to that required for a third-year dental student who is evaluating and planning treatment for a patient receiving comprehensive dental care.

The course of preclinical study in biological sciences is almost identical for U.S. dental and medical students. Indeed, some schools have joint medical/dental biological science coursework. Therefore, a dental student likely would need to take only one or two additional short courses, perhaps one in physical diagnosis and another in the basics of common diseases (such as diabetes and hypertension), to function as a third-year medical student. Similar coursework is included in many postgraduate dental education programs, so this notion should be neither foreign nor especially difficult to implement for many dental schools. Physical diagnosis, albeit not a complete examination, is relevant to general dental practice, especially for the treatment of patients with many of the conditions listed in Box 2. The courses would not cost dental schools much to provide and would require relatively little extra energy from dental students. As noted above, this is the type of training in general medicine that I favor, but it is not the only way, and there certainly are no data to suggest it is the best way. If dentistry accepts the notion that practical training in general internal medicine should be a core competency for dental students, there are many ways in which this goal can be accomplished.

I suspect that the major efforts required to make internal medicine training possible for dental students likely would be political and administrative. Almost all dental schools in the United States are affiliated with a university that includes a medical school. My arguments are addressed to these schools. (Dental schools without medical school affiliations would have additional, but not insurmountable, difficulties, which I will not address here.) Approval for dental students to spend time in internal medicine wards typically would come from the chief of medicine at the associated university hospital. This person primarily will be concerned that the students are prepared adequately (addressed above); act professionally (a nonissue); and not be present in numbers so large as to diminish the training of medical students or hinder the function of the attending clinicians. Thus, it is unlikely that a dental school class of 80 students could be accommodated at a single hospital in a single block of time. To accomplish this endeavor doubtless would take some bargaining, but most medical schools have affiliations with multiple hospitals, and adding one or two dental students to various medical teams should present no major problem, especially for larger medical schools. There certainly would be logistical challenges, but there should be no absolute impediment.

I believe that by far the biggest difficulty, requiring the most administrative and political effort, would be in overcoming the angst about such a change that would arise in some dental school faculty members. This could occur in at least two major forms. Certainly, some faculty members would be rightly concerned about the effects the "loss" of time to general medical training would have on students’ ability to achieve core dental surgical competencies. Although I hypothesize that this would not be a problem, this concern is valid and can be addressed readily by objective double-blind testing between different student cohorts. Additionally, typical faculty members at any professional school know much more than their students about all phases of their professional discipline. Training dental students substantively in general internal medicine would alter this balance in a dramatic way, albeit in a focused area. This circumstance could make some faculty members uncomfortable, and it is an imbalance that should be addressed substantively. Faculty members will need to be counseled, reassured and supported. Additionally, and ideally, they should be provided with continuing education in physical diagnosis and major medical concerns for ambulatory dental patients, something that also would benefit their own practices.

	CLOSING ARGUMENTS

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Although I have long argued that dental students should have training in general internal medicine, I believe the necessity for this is even more pressing today. Predictions made 30 years ago about the aging of our society have come true, and clearly there are more ambulatory dental patients who have lived longer than was the case in former years. Importantly, this trend is continuing, and it is anticipated that the proportion of the U.S. population 65 years and older will increase from 12.4 percent in 2000 to 19.6 percent in 2030, an approximate 60 percent increase.⁸ In absolute terms, this is an actual doubling of people in this age group—from approximately 35 million to more than 70 million.⁸

In addition to there being more elderly people who are ambulatory, many of them will have common, significant systemic diseases. The table provides information about recent trends in the prevalence of some common diseases and morbid conditions in the United States. All of these show an increased prevalence,^17–22 and many affect older people significantly. For example, the prevalence of all types of diabetes in 1990 was 4.9 percent, while in 2005 it was approximately 7.0 percent,¹⁷ an increase of about 43 percent. Furthermore, from 1997 to 2004, the prevalence of all cancers in the United States increased by 10.7 percent, hypertension by 11.6 percent and stroke by 13.4 percent.¹⁸ Impressively, 13 percent of all patients receiving allogeneic bone marrow transplants in 2002 were older than 50 years, while in 1984, this percentage was less than 1.¹⁹ Also, as shown in the table, the number of people receiving organ transplants in the United States increased by 5.8 percent,²⁰ and the prevalence of age-adjusted obesity has increased by more than twofold among all adults between 1976 and 2002.²¹

Additionally, and implicit in demographic predictions of increased longevity in the United States, progress in the biological sciences has been and continues to be dramatic. Many novel biologically based treatments have been and continue to be approved for use with multiple common diseases. These include use of monoclonal antibodies and recombinant protein biologicals^23,24 and—likely soon—stem or progenitor cells,²⁵ tissue engineering²⁶ and gene therapy.²⁷ In particular, novel therapies for patients with many conditions (such as cancer, autoimmune diseases, hematopoetic disorders) have a strong basis in targeting specific biochemical or immunological mechanisms that have gone awry. To understand how these new biological therapies affect oral health or patients’ responses to dental treatments, dentists need to understand, in a practical sense, the mechanisms involved.²⁴ Another testable hypothesis is that training in general internal medicine will reinforce a dental student’s understanding of key biological mechanisms involved in major common diseases. Dental students are much more likely to be exposed to novel therapeutics, and their mechanisms of action, on a hospital ward than in a typical university dental clinic.

As I noted earlier, citing the immediate past editor of JADA,¹¹ if dentistry fails to provide the training that enables most general dentists to offer dental care to patients with complex medical conditions, it will lose its current status as a valued health care profession and become marginalized. I do not think that the vast majority of dentists want this outcome. To make the necessary course correction, it will take the combined efforts of many—including deans, curriculum committees, licensing agencies, regional board examiners and the ADA’s leadership—as well as changes in the national board examinations and in dental school accreditation programs. It may not be easy, but it is needed—and it is the right thing to do.