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Dentistry is changing
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Dentistry is changing: Leaders needed Howard Bailit JADA 2014;145(2):122-124 10.14219/jada.2013.29 The following resources related to this article are available online at jada.ada.org (this information is current as of June 28, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/2/122
This article cites 12 articles, 4 of which can be accessed free: http://jada.ada.org/content/145/2/122/#BIBL Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx
Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly prohibited without prior written permission of the American Dental Association.
Downloaded from jada.ada.org on June 28, 2014
Commentaries
Guest editorial
Dentistry is changing Leaders needed Howard Bailit, DMD, PhD
T
he dental education and delivery systems face several long-term challenges that are related to changes in the prevalence of oral diseases, innovations in science and technology, and market forces. In this guest editorial, I examine these trends and raise several issues that the dental profession needs to address. The future of the profession depends on how these issues are resolved. Trends
Oral disease. In the United States, the incidence of caries and the prevalence of untreated dental caries have declined dramatically as a result of water fluoridation, preventive services provided by dentists and better personal preventive behaviors. This trend has affected people in all income and education groups and is certain to continue.1 Older cohorts (such as those older The dental education and practice communities may face some difficult years ahead as they adapt to a changing world.
than 60 years) who did not have the full benefits of fluoride are declining in numbers. Younger cohorts have much less disease. Furthermore, most untreated disease is concentrated in lower income groups. This is not because the incidence of caries is that much higher in this segment of the population.2 Rather, it is the result of large disparities in financial access to care. Lower-income populations (approximately 100 million people) have the highest prevalence of untreated caries but account for less than 20 percent of dental care expenditures.3 In contrast, people in the upper one-third of the income distribution have relatively little untreated disease but account for 53 percent of dental care expenditures.3 These trends have implications for private dental practice. Namely, the effective demand for restorative care, the financial mainstay of most general practices, is declining. In 1950, about 40 percent of private practitioners’ 122 JADA 145(2) http://jada.ada.org February 2014 Copyright © 2014 American Dental Association. All Rights Reserved.
Downloaded from jada.ada.org on June 28, 2014
Commentaries
services involved restorations; in 2005, that had decreased to 12 percent.4,5 Although there are other oral diseases that require treatment, and more elderly people are dentate and visiting dentists than in previous generations, this new demand does not offset the decrease in restorations. As restorative care declines, dentists are becoming more dependent financially on providing diagnostic and preventive services. Specialty services remain a relatively small and declining component of the average general dental practice.4 The current dental education and delivery systems were organized to provide care to a population with rampant caries. This is no longer the case, and the trends are clear—less caries, especially in upper income groups. Science and technology. No one person can predict the scientific developments in each major area of biomedical research that will affect the future practice of dentistry. It is possible to make some general predictions. The billions of dollars spent each year on biomedical research by governments and private industry in developed
practices and may advocate for changes in dental practice acts to permit ownership by someone other than a dentist. It also is reasonable to predict that some dentists in group practices will try to contract directly with employers to deliver care to employees and their dependents. This will put group practices in competition with insurers. A major unresolved issue is the interest of large medical care systems (for example, accountable care organizations) in owning dental practices. Implications
The evidence suggests that the population is getting healthier, and the large investment in biomedical research is expected to accelerate improvements in oral health. At the same time, the organization of the delivery system is moving from solo to group practices. What impact will these trends have on dental education and practice? Dental education. Dental schools are facing major challenges because public support is declining11 and educational debt soon may reach unsustainable levels.12 At
As restorative care declines, dentists are becoming more dependent financially on providing diagnostic and preventive services.
countries will lead to more effective diagnostic, preventive and treatment methods. This will result in new and improved preventive methods at the community and practice levels that will further reduce the incidence of caries and periodontal disease.6 More treatments will be available that do not require doctoral-level education and can be delegated to other personnel.7 At the same time, some new treatments (for example, stem cell– derived tooth transplants) will require advanced scientific education.8 Delivery system. Twenty years ago, solo practices represented approximately 80 percent of private-practice dentists.9 Now, group practices are increasing and solo practices decreasing. The reasons for this trend are not fully understood but probably are related to efficiencies associated with a larger practice (for instance, more effective management of personnel and technology and better access to capital). Another factor is the availability of many dental graduates who do not have the resources to purchase their own practices.10 In 10 or so years, group practices are likely to become a significant component of the dental delivery system in many local markets. Because of different financial incentives, group and solo practitioners may come into conflict over selected issues. For example, group practices are better positioned to gain from the employment of different types of allied dental personnel. Likewise, dentists in group practices will want larger organizations to buy their
the same time, the numbers of schools and graduates are increasing,10 whereas the demand for dental care is decreasing.13 Other professions, such as law, recently have faced similar challenges, and they experienced dramatic declines in applicants.14 This may well occur in dentistry, as graduates find it increasingly difficult to pay back hundreds of thousands of dollars in educational debt. If this does happen, can all dental schools survive downsizing, or will some close? On the basis of a similar supply-and-demand imbalance in the 1980s, the latter outcome is most likely. The next five to 10 years may be a difficult period for the dental education community and will lead to some basic questions: dHow many dentists are needed to provide care to an increasingly healthy population? Although it is true that one-third or more of the American people do not have adequate financial access to dental care,3 this is not because there are too few dentists. The access problem will not be solved until American taxpayers decide to adequately fund public dental insurance for low-income groups, build a larger system of community safety-net clinics or both. dWhat is the appropriate level of dental school education in the biomedical and clinical sciences? Research will produce new therapies that require a strong science background, and more patients will have related oral and systemic diseases. dShould graduates be required to have a residency JADA 145(2) http://jada.ada.org February 2014 123
Copyright © 2014 American Dental Association. All Rights Reserved.
Downloaded from jada.ada.org on June 28, 2014
Commentaries
education so that they are well prepared to provide most dental services and to work efficiently with a full array of clinical and administrative personnel and advanced technology? dIs dentistry a learned profession (like law and medicine) or a doctoral-level technical occupation (like optometry)? If it is the former, most dentists must be educated in research-intensive universities at which tenure-track faculty members spend significant time doing research and generating new knowledge. Practice. Practicing dentists, as well as dental educators, face serious challenges. At the national level, dental care utilization rates and per-person dental care expenditures began to decline five years before the 2007-2008 economic recession, and these declines are reflected in lower practitioner incomes.13 At the same time, dentists are faced with a greater supply of dental services, resulting from a greater number of graduates, a later age of dentists’ retirement and the greater use of auxiliaries. How will the majority of dentists who are still in solo practices respond to these challenges? dSimilar to physicians in the 1980s, will they form independent practice associations (IPAs) to compete with large dental groups and to increase their negotiating leverage with payers?15 Some evidence suggests that dental IPAs are being formed.16 dWill many solo dentists decide to form or join group practices? The past 20 years has seen a marked decline in solo medical practice; the great majority of physicians are now in some form of group practice.17 Next Steps
The dental education and practice communities may face some difficult years ahead as they adapt to a changing world. But planned change is difficult because there is no central dental organization that can develop and implement new policies. Control of dentistry is dispersed widely among many different organizations. At the national level, the Commission on Dental Accreditation (CODA) has the legal authority to determine dental school educational standards.18 Can CODA—which is composed of 30 members from different organizations— develop a consensus among its members and make politically difficult decisions to move dental education in new directions? Other national organizations (such as the American Dental Association and the American Dental Education Association) do not have direct control over local dental schools or practices. In fact, dentistry is regulated primarily at the state level through state dental practice acts. Other health professions have faced these types of challenges, and the change process usually involved the formation of an informal coalition of leaders from different segments of the profession.19 The informal groups develop a consensus and then work with accred-
iting bodies and states to implement the needed changes. Will leaders of the dental profession come together and address these problems? The future of the profession depends on it. n doi:10.14219/jada.2013.29 Dr. Bailit is a professor emeritus, University of Connecticut Health Center, 263 Farmington Ave., MC 6325, Farmington, Conn. 06030-6325, e-mail [email protected]. Address correspondence to Dr. Bailit. Disclosure. Dr. Bailit did not report any disclosures. 1. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat 2007;11(248):1-92. 2. Broffitt B, Levey SM, Warren J, Cavanaugh JE. Factors associated with surface-level caries incidence in children aged 9 to 13: the Iowa Fluoride Study (published online ahead of print July 26, 2013). J Public Health Dent 2013;73(4):304-310. doi:10.1111/jphd.12028. 3. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey. Table 3: dental services—median and mean expenses per person with expense and distribution of expenses by source of payment: United States, 2011. http://meps.ahrq.gov/data_stats/tables_compendia_hh_interactive.jsp?_ SERVICE=MEPSSocket0&_PROGRAM=MEPSPGM.TC.SAS&File=HCFY2 011&Table=HCFY2011_PLEXP_B&VAR1=AGE&VAR2=SEX&VAR3=RAC ETH5C&VAR4=INSURCOV&VAR5=POVCAT11&VAR6=MSA&VAR7=RE GION&VAR8=HEALTH&VARO1=4+17+44+64&VARO2=1&VARO3=1&VA RO4=1&VARO5=1&VARO6=1&VARO7=1&VARO8=1&_Debug=. Accessed Jan. 7, 2014. 4. American Dental Association. 2005-06 Survey of Dental Services Rendered. Chicago: American Dental Association Survey Center; 2007. 5. Moen BD, Poetsch WE. More preventive care, less tooth repair: survey of dental services rendered, 1969. JADA 1970;81(1):25-36. 6. Milgrom P, Zero DT, Tanzer JM. An examination of the advance of science and technology of prevention of tooth decay in young children since the surgeon general’s report on oral health. Acad Periatr 2009;9(6):404-409. 7. Glassman P, Subar P, Budenz AW. Managing caries in virtual dental home using interim therapeutic restorations. J Calif Dent Assoc 2013;41(10):745-752. 8. Yamaza T, Ren G, Akiyama K, Chen C, Shi Y, Shi S. Mouse mandible contains distinctive mesenchymal stem cells. J Dent Res 2011;90(3):317-324. 9. American Dental Association. Survey of Dental Practice 2012: Table 1, employment status of general practitioners from 1990-2012. Chicago: American Dental Association Survey Center; 2013. 10. American Dental Education Association. ADEA Dean’s Briefing Book 2013. www.nxtbook.com/ygsreprints/ADEA/g37461_adea_briefbook2013/. Accessed Dec. 8, 2013. 11. American Dental Association. The rising cost of dental education. In: ADA Health Policy Resources Center. A Profession in Transition: Key Forces Reshaping the Dental Landscape. Chicago: American Dental Association; 2013. www.ada.org/sections/professionalResources/pdfs/Escan2013_ADA_ Full.pdf. Accessed Dec. 8, 2013. 12. Asch DA, Nicholson S, Vujicic M. Are we in a medical education bubble market? N Engl J Med 2013;369(21):1973-1975. 13. Vujicic M, Lazar V, Wall T, Munson B. An analysis of dentists’ incomes, 1996-2009. JADA 2012;143(5):452-460. 14. Rampell C. Law school applications decline, especially from graduates of elite colleges. The New York Times. Aug. 23, 2013. http://economix.blogs. nytimes.com/2013/08/23/law-school-applicants-decline-especially-amonggrads-of-elite-colleges/. Accessed Dec. 8, 2013. 15. Robinson JC, Cassalino LP. Vertical integration and organizational networks in health care. Health Aff (Millwood) 1996;15(1):7-22. 16. Bailit HL. Group practice in a changing business environment. Discussion presented at: American Dental Association 2013—America’s Dental Meeting; Oct. 31, 2013; New Orleans. 17. Moses H III, Matheson DH, Dorsey ER, George BP, Sadoff D, Yoshimura S. The anatomy of health care in the United States. JAMA 2013;310(18): 1947-1963. 18. Formicola AJ, Bailit HL, Beazoglou TJ, Tedesco LA. The interrelationship of accreditation and dental education: history and current environment. J Dent Educ 2008;72(2 suppl):53-60. 19. Buerki RA. In search of excellence: the first century of the American Association of Colleges of Pharmacy, part 4—planning for tomorrow. Am J Pharm Educ 1999;63(fall suppl):12-13.
124 JADA 145(2) http://jada.ada.org February 2014 Copyright © 2014 American Dental Association. All Rights Reserved.
Dentistry is changing: Leaders needed Howard Bailit JADA 2014;145(2):122-124 10.14219/jada.2013.29 The following resources related to this article are available online at jada.ada.org (this information is current as of June 28, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/2/122
This article cites 12 articles, 4 of which can be accessed free: http://jada.ada.org/content/145/2/122/#BIBL Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx
Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly prohibited without prior written permission of the American Dental Association.
Downloaded from jada.ada.org on June 28, 2014
Commentaries
Guest editorial
Dentistry is changing Leaders needed Howard Bailit, DMD, PhD
T
he dental education and delivery systems face several long-term challenges that are related to changes in the prevalence of oral diseases, innovations in science and technology, and market forces. In this guest editorial, I examine these trends and raise several issues that the dental profession needs to address. The future of the profession depends on how these issues are resolved. Trends
Oral disease. In the United States, the incidence of caries and the prevalence of untreated dental caries have declined dramatically as a result of water fluoridation, preventive services provided by dentists and better personal preventive behaviors. This trend has affected people in all income and education groups and is certain to continue.1 Older cohorts (such as those older The dental education and practice communities may face some difficult years ahead as they adapt to a changing world.
than 60 years) who did not have the full benefits of fluoride are declining in numbers. Younger cohorts have much less disease. Furthermore, most untreated disease is concentrated in lower income groups. This is not because the incidence of caries is that much higher in this segment of the population.2 Rather, it is the result of large disparities in financial access to care. Lower-income populations (approximately 100 million people) have the highest prevalence of untreated caries but account for less than 20 percent of dental care expenditures.3 In contrast, people in the upper one-third of the income distribution have relatively little untreated disease but account for 53 percent of dental care expenditures.3 These trends have implications for private dental practice. Namely, the effective demand for restorative care, the financial mainstay of most general practices, is declining. In 1950, about 40 percent of private practitioners’ 122 JADA 145(2) http://jada.ada.org February 2014 Copyright © 2014 American Dental Association. All Rights Reserved.
Downloaded from jada.ada.org on June 28, 2014
Commentaries
services involved restorations; in 2005, that had decreased to 12 percent.4,5 Although there are other oral diseases that require treatment, and more elderly people are dentate and visiting dentists than in previous generations, this new demand does not offset the decrease in restorations. As restorative care declines, dentists are becoming more dependent financially on providing diagnostic and preventive services. Specialty services remain a relatively small and declining component of the average general dental practice.4 The current dental education and delivery systems were organized to provide care to a population with rampant caries. This is no longer the case, and the trends are clear—less caries, especially in upper income groups. Science and technology. No one person can predict the scientific developments in each major area of biomedical research that will affect the future practice of dentistry. It is possible to make some general predictions. The billions of dollars spent each year on biomedical research by governments and private industry in developed
practices and may advocate for changes in dental practice acts to permit ownership by someone other than a dentist. It also is reasonable to predict that some dentists in group practices will try to contract directly with employers to deliver care to employees and their dependents. This will put group practices in competition with insurers. A major unresolved issue is the interest of large medical care systems (for example, accountable care organizations) in owning dental practices. Implications
The evidence suggests that the population is getting healthier, and the large investment in biomedical research is expected to accelerate improvements in oral health. At the same time, the organization of the delivery system is moving from solo to group practices. What impact will these trends have on dental education and practice? Dental education. Dental schools are facing major challenges because public support is declining11 and educational debt soon may reach unsustainable levels.12 At
As restorative care declines, dentists are becoming more dependent financially on providing diagnostic and preventive services.
countries will lead to more effective diagnostic, preventive and treatment methods. This will result in new and improved preventive methods at the community and practice levels that will further reduce the incidence of caries and periodontal disease.6 More treatments will be available that do not require doctoral-level education and can be delegated to other personnel.7 At the same time, some new treatments (for example, stem cell– derived tooth transplants) will require advanced scientific education.8 Delivery system. Twenty years ago, solo practices represented approximately 80 percent of private-practice dentists.9 Now, group practices are increasing and solo practices decreasing. The reasons for this trend are not fully understood but probably are related to efficiencies associated with a larger practice (for instance, more effective management of personnel and technology and better access to capital). Another factor is the availability of many dental graduates who do not have the resources to purchase their own practices.10 In 10 or so years, group practices are likely to become a significant component of the dental delivery system in many local markets. Because of different financial incentives, group and solo practitioners may come into conflict over selected issues. For example, group practices are better positioned to gain from the employment of different types of allied dental personnel. Likewise, dentists in group practices will want larger organizations to buy their
the same time, the numbers of schools and graduates are increasing,10 whereas the demand for dental care is decreasing.13 Other professions, such as law, recently have faced similar challenges, and they experienced dramatic declines in applicants.14 This may well occur in dentistry, as graduates find it increasingly difficult to pay back hundreds of thousands of dollars in educational debt. If this does happen, can all dental schools survive downsizing, or will some close? On the basis of a similar supply-and-demand imbalance in the 1980s, the latter outcome is most likely. The next five to 10 years may be a difficult period for the dental education community and will lead to some basic questions: dHow many dentists are needed to provide care to an increasingly healthy population? Although it is true that one-third or more of the American people do not have adequate financial access to dental care,3 this is not because there are too few dentists. The access problem will not be solved until American taxpayers decide to adequately fund public dental insurance for low-income groups, build a larger system of community safety-net clinics or both. dWhat is the appropriate level of dental school education in the biomedical and clinical sciences? Research will produce new therapies that require a strong science background, and more patients will have related oral and systemic diseases. dShould graduates be required to have a residency JADA 145(2) http://jada.ada.org February 2014 123
Copyright © 2014 American Dental Association. All Rights Reserved.
Downloaded from jada.ada.org on June 28, 2014
Commentaries
education so that they are well prepared to provide most dental services and to work efficiently with a full array of clinical and administrative personnel and advanced technology? dIs dentistry a learned profession (like law and medicine) or a doctoral-level technical occupation (like optometry)? If it is the former, most dentists must be educated in research-intensive universities at which tenure-track faculty members spend significant time doing research and generating new knowledge. Practice. Practicing dentists, as well as dental educators, face serious challenges. At the national level, dental care utilization rates and per-person dental care expenditures began to decline five years before the 2007-2008 economic recession, and these declines are reflected in lower practitioner incomes.13 At the same time, dentists are faced with a greater supply of dental services, resulting from a greater number of graduates, a later age of dentists’ retirement and the greater use of auxiliaries. How will the majority of dentists who are still in solo practices respond to these challenges? dSimilar to physicians in the 1980s, will they form independent practice associations (IPAs) to compete with large dental groups and to increase their negotiating leverage with payers?15 Some evidence suggests that dental IPAs are being formed.16 dWill many solo dentists decide to form or join group practices? The past 20 years has seen a marked decline in solo medical practice; the great majority of physicians are now in some form of group practice.17 Next Steps
The dental education and practice communities may face some difficult years ahead as they adapt to a changing world. But planned change is difficult because there is no central dental organization that can develop and implement new policies. Control of dentistry is dispersed widely among many different organizations. At the national level, the Commission on Dental Accreditation (CODA) has the legal authority to determine dental school educational standards.18 Can CODA—which is composed of 30 members from different organizations— develop a consensus among its members and make politically difficult decisions to move dental education in new directions? Other national organizations (such as the American Dental Association and the American Dental Education Association) do not have direct control over local dental schools or practices. In fact, dentistry is regulated primarily at the state level through state dental practice acts. Other health professions have faced these types of challenges, and the change process usually involved the formation of an informal coalition of leaders from different segments of the profession.19 The informal groups develop a consensus and then work with accred-
iting bodies and states to implement the needed changes. Will leaders of the dental profession come together and address these problems? The future of the profession depends on it. n doi:10.14219/jada.2013.29 Dr. Bailit is a professor emeritus, University of Connecticut Health Center, 263 Farmington Ave., MC 6325, Farmington, Conn. 06030-6325, e-mail [email protected]. Address correspondence to Dr. Bailit. Disclosure. Dr. Bailit did not report any disclosures. 1. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat 2007;11(248):1-92. 2. Broffitt B, Levey SM, Warren J, Cavanaugh JE. Factors associated with surface-level caries incidence in children aged 9 to 13: the Iowa Fluoride Study (published online ahead of print July 26, 2013). J Public Health Dent 2013;73(4):304-310. doi:10.1111/jphd.12028. 3. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey. Table 3: dental services—median and mean expenses per person with expense and distribution of expenses by source of payment: United States, 2011. http://meps.ahrq.gov/data_stats/tables_compendia_hh_interactive.jsp?_ SERVICE=MEPSSocket0&_PROGRAM=MEPSPGM.TC.SAS&File=HCFY2 011&Table=HCFY2011_PLEXP_B&VAR1=AGE&VAR2=SEX&VAR3=RAC ETH5C&VAR4=INSURCOV&VAR5=POVCAT11&VAR6=MSA&VAR7=RE GION&VAR8=HEALTH&VARO1=4+17+44+64&VARO2=1&VARO3=1&VA RO4=1&VARO5=1&VARO6=1&VARO7=1&VARO8=1&_Debug=. Accessed Jan. 7, 2014. 4. American Dental Association. 2005-06 Survey of Dental Services Rendered. Chicago: American Dental Association Survey Center; 2007. 5. Moen BD, Poetsch WE. More preventive care, less tooth repair: survey of dental services rendered, 1969. JADA 1970;81(1):25-36. 6. Milgrom P, Zero DT, Tanzer JM. An examination of the advance of science and technology of prevention of tooth decay in young children since the surgeon general’s report on oral health. Acad Periatr 2009;9(6):404-409. 7. Glassman P, Subar P, Budenz AW. Managing caries in virtual dental home using interim therapeutic restorations. J Calif Dent Assoc 2013;41(10):745-752. 8. Yamaza T, Ren G, Akiyama K, Chen C, Shi Y, Shi S. Mouse mandible contains distinctive mesenchymal stem cells. J Dent Res 2011;90(3):317-324. 9. American Dental Association. Survey of Dental Practice 2012: Table 1, employment status of general practitioners from 1990-2012. Chicago: American Dental Association Survey Center; 2013. 10. American Dental Education Association. ADEA Dean’s Briefing Book 2013. www.nxtbook.com/ygsreprints/ADEA/g37461_adea_briefbook2013/. Accessed Dec. 8, 2013. 11. American Dental Association. The rising cost of dental education. In: ADA Health Policy Resources Center. A Profession in Transition: Key Forces Reshaping the Dental Landscape. Chicago: American Dental Association; 2013. www.ada.org/sections/professionalResources/pdfs/Escan2013_ADA_ Full.pdf. Accessed Dec. 8, 2013. 12. Asch DA, Nicholson S, Vujicic M. Are we in a medical education bubble market? N Engl J Med 2013;369(21):1973-1975. 13. Vujicic M, Lazar V, Wall T, Munson B. An analysis of dentists’ incomes, 1996-2009. JADA 2012;143(5):452-460. 14. Rampell C. Law school applications decline, especially from graduates of elite colleges. The New York Times. Aug. 23, 2013. http://economix.blogs. nytimes.com/2013/08/23/law-school-applicants-decline-especially-amonggrads-of-elite-colleges/. Accessed Dec. 8, 2013. 15. Robinson JC, Cassalino LP. Vertical integration and organizational networks in health care. Health Aff (Millwood) 1996;15(1):7-22. 16. Bailit HL. Group practice in a changing business environment. Discussion presented at: American Dental Association 2013—America’s Dental Meeting; Oct. 31, 2013; New Orleans. 17. Moses H III, Matheson DH, Dorsey ER, George BP, Sadoff D, Yoshimura S. The anatomy of health care in the United States. JAMA 2013;310(18): 1947-1963. 18. Formicola AJ, Bailit HL, Beazoglou TJ, Tedesco LA. The interrelationship of accreditation and dental education: history and current environment. J Dent Educ 2008;72(2 suppl):53-60. 19. Buerki RA. In search of excellence: the first century of the American Association of Colleges of Pharmacy, part 4—planning for tomorrow. Am J Pharm Educ 1999;63(fall suppl):12-13.
124 JADA 145(2) http://jada.ada.org February 2014 Copyright © 2014 American Dental Association. All Rights Reserved.