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The Role of the Dental School in Increasing the Emphasis on Preventive Dentistry in Dental Practice
The role of the dental sch o o l in increasing th e em p h asis on preventive dentistry in dental p ractice
Robert B. Shira, DDS, Boston Jam es E. Cassidy, DMD, DPH, Washington, DC
D entistry’s goal—the attainment and maintenance of oral health— is being presented to dental stu dents as treatm ent o f disease. Disease prevention, which is equally as im portant as disease treat ment, must receive greater emphasis in the cur riculum s of dental schools.
The armed forces continuously face the prob lems of dealing with the massive oral disease of the American populace as represented by a cross section of its youth. So perhaps we are more acutely aware of the magnitude of the na tion’s oral disease epidemic than some o f our colleagues in civilian practice who do not see this broad sampling of the populace. A survey that was completed within the past year among men entering active duty in the Army showed that a mean minimum requirement o f 8.2 hours of professional care per man was required to correct existing pathoses. This poor state o f oral health among young men entering the Army reflects the poor state of oral health among Americans. Men entering the armed forces, after all, are among the healthiest of America’s youth who, despite their deplorable state of oral health, still are healthier than their elders. The question then, made ever more cogent by the increasingly probable advent o f some form of national health program is: What are we to do about the situation? The courses of action most often suggested are to increase dental manpower; to increase productivity of dental manpower; and to prevent or control oral diseases at least to the extent 1068 ■ JADA, Vol. 84, May 1972
that requirements for corrective and restorative care are reduced to a more readily manageable level. For the present at least, all three courses of action are needed. However, unless ways are found to shift the emphasis to effective disease prevention, the future of the nation’s oral health and of the dental profession appears bleak. N o nation can afford the cost of providing restorative care to a population in which the rate o f oral disease progresses as it does at present in this country. If the restorative approach to national dental care is taken, the nation eventually will be faced with a choice between reducing dental benefits or reducing other socially desirable pro grams. If historical examples from other nations that are faced with a similar choice are noted, the choice seems obvious. In addition to recognizing the economic neces sity for effective disease preventive and control programs on a national basis, we also should reemphasize that the complete absence of oral disease is much more desirable than the avail ability of even the highest quality restorative care. The basic problem to be faced, then, is how the dental profession can become more effective in the prevention and control o f oral disease. The purpose of this paper is to explore the role of the dental schools in this effort. Because we recognize that the schools do not operate in isolation from the practicing profes sion, we will make reference to the reciprocal influences between schools and practitioners.
Army experience with graduates Much of the responsibility for the attainment of optimum oral health for the population and for individual patients rests with the dental schools. They have the expertise and faculties to train students adequately in techniques of restorative dentistry and the treatment of oral
disease. They also should have the capacity to teach preventive dentistry. There are indications, however, that instruction in preventive dentistry has not successfully conferred a competence that is equivalent to that attained by students in the diagnosis and treatment o f oral disease. Because the Army Dental Corps commissions from 800 to 1,000 dental graduates each year and works with these young dentists for two or more years, we are in an ideal position to eval uate what the dental student has learned about preventive dentistry. This is what we have seen, and it does not make us happy. In 1967, the graduating dental student had little concept of what was meant by preventive dentistry. This understanding has improved, but it still is not adequate. Most students have heard of preventive dentistry but many are vague about exactly what it is, and most are not con vinced it will work— at least in their hands. Consequently, it is given a low priority in their thinking and practice. Many think it is nonproductive compared with restorative dentistry. Furthermore, most grad uating dentists are not convinced that preven tive dentistry is economically sound and that patients will pay a reasonable charge for pre ventive procedures. Most graduates are eager to improve their skills in periodontics, oral surgery, prosthodontics, and crown and bridge, and do not wish to devote time to preventive dentistry, or even much time to operative dentistry. M ost graduates have not been taught specific techniques for initiating an effective preventive program, and many have little idea about how to incorporate preventive dentistry successfully into general practice. For the most part they do not know how to communicate with patients to interest them in preventive programs. They know little about the basic problems of changing the behavioral patterns of the dental profession or the popu lation, although solutions are necessary for a successful preventive dentistry program. More over, they know little about the community aspects of preventive dentistry. Because o f these attitudes, most dentists think that their time is wasted if they are asked to serve as the preventive dentistry officer at their station or to devote any appreciable time to clinical preventive dentistry practice. As the nation approaches the initiation of some form o f national health program, the health pro fessions are challenged to provide comprehensive health care for a total population. From the
point of view of health and fiscal reality, the only feasible approach to such a program is one that emphasizes disease prevention. The Army has faced this challenge and has elected an approach that is based on prevention. Because we must rely mainly on recent dental graduates to carry out our preventive programs and because we have found them wanting in required knowledge and skills, we believe that we are in a position to comment on needed changes in dental education.
Changing goals of dental schools Dental schools exert a profound influence on the type of practice their graduates will conduct once they leave the school. If preventive den tistry is to become a way o f life for the prac ticing dentist, a greater emphasis on this sub ject is essential in the curriculum so that the profession can offset its historically derived preoccupation with restorative dentistry. In this way students will become better prepared to meet the demands o f contemporary and future clinical practice. Such a change in emphasis does not imply a downgrading of the importance of sound restorative dentistry, but it does require the up grading of preventive dentistry in the scale of educational values. Unless the dental schools and their faculties accord preventive dentistry a higher degree of representation in the curriculum and especially in clinical instruction, and unless they accept and foster the concept o f prevention rather than restoration as the ultimate goal of dentistry, stu dents will continue to regard the development of knowledge and skills in prevention as secondary in importance to acquisition of skills in re storative dentistry. Furthermore, if students are not exposed to the philosophy and clinical techniques of prevention while they are under graduates, it is unlikely that they will acquire and practice these skills after they graduate. A dental school or any other institution must have clearly stated goals. In fact, these goals should be stated so specifically that the degree to which they are attained is readily measured. In dentistry, this measurement applies first to the behavior o f dentists— what they do and how they do it. Ultimately the degree of goal at tainment should be measurable in terms o f the results of the dental profession’s efforts among those it serves.
Shira—Cassidy: THE DENTAL SCHOOL AND PREVENTIVE DENTISTRY ■ 1069
The proper goal for dentistry is easy enough to state: To attain and maintain optimal oral health among those served. Health o f the society is a proper goal for the profession as a whole, and health o f individual patients is proper for the practitioner. Such a goal, or a similar one, seems to be intellectually acceptable to most members o f the profession. However, is the re sulting behavior appropriate to such a goal? The answer appears to be no. The question then is, why? Unfortunately, the professional perspective that foreordains the behavioral goal of the ma jority o f dentists is one of oral health care. The word, care, affects the behavioral role of the profession because it connotes after-the-fact treatment of disease. Some may wish to argue this point semantically; however, it is a be havioral pattern that is well demonstrated. The outstanding example is that restorative dentistry is given preponderant emphasis in requirements for graduation from many o f our dental schools and for passing many of the state boards. Thus, a goal dichotomy has developed. Although our stated goal is optimum oral health for all, our behavioral goal is oral health care for a few. The fact that the behavioral goal of health care applies to only a few is, of course, not surprising, given the current treatment capability of the profession. Why has this situation developed? Mainly, it comes from behavioral patterns that were es tablished in dental school where emphasis on restorative dentistry as the major thrust of den tal practice appears to have become institu tionalized. The institutionalization of restorative dentistry is reasonably understandable when one understands the historical roots o f dentistry’s emphasis on postdisease care. At one time postdisease treatment of diseaseproduced lesions was the only available, scientif ically supported approach to care. A s a result, appropriate technical procedures for such treat ment were given primary emphasis in dental schools. Properly then, technical procedures become the norm for a judgment of professional compe tence and, additionally, become the basis for professional remuneration. Generations of den tists have accepted this norm and they how exert influence on the schools to continue the emphasis on the development of technical skills. Thus the interrelated influence of school-practitioner-school comes full cycle. 1070 ■ JADA, Vol. 84, May 1972
The cycle from the practitioners’ perspective is reinforced by a feeling o f incapability to change the mode of practice. The cycle is reinforced by the dental educators’ perspective of considerations of power and prestige related to departmentalized areas of dental practice.
Overcoming institutionalization Many of the major problems that face our pro fession and our society at large are attributable to the phenomenon of institutionalization. The first step toward institutionalization is habituation. A s a person or organization finds that, within the context of available knowledge, certain procedures work effectively, these pro cedures become habitualized. There is nothing wrong with habitualization in itself because it is natural to the maturational process necessary for efficiency o f operation. If the decision-making process is necessary every time repeated ac tivities are carried out, not much will happen. In dental schools as in other institutions, much is established by deliberate choice because cer tain procedures are found to be relevant to the attainment o f established goals. H owever, as time passes and personnel change, habitualized procedures tend to become institutionalized as ends in themselves, losing their identity as means. As the organization grows and becomes more complex, there is a tendency to specialization in which both the overall goal and related subgoals are lost. What is passed on to new comers in the organization is knowledge of pro cedures that, in the absence o f knowledge of pertinent goals, have become goals in themselves. In addition people have a tendency to remain with what is familiar, fearing the new or dif ferent. At this point the organization has become procedure-oriented rather than goal-oriented. Such trite statements as: “ We do it this way because it is our policy,” and “ D on ’t ask ques tions; that’s the way it is done,” become com monplace. (An excellent example of the phe nomenon of institutionalized procedure was the placement of horsewhip holders on early auto mobiles.) When this happens, procedures have become institutionalized and are difficult to change. Another effect of institutionalization relates to goals as well as to procedures. A s time passes,
changes occur in the environment in which an organization operates. G oals and procedures that once were appropriate becom e outdated in light o f new knowledge. Adherence to these outmoded goals and procedures often becomes a serious block to needed change. Obsolescent goals block change by keeping attention focused on activities no longer ap propriate by themselves for doing all that could be done in solving a given problem. Thus, in dentistry the failure to establish health rather than health care as a viable goal has resulted in continued nearly exclusive emphasis on tech nical procedures related to disease treatment. What is needed at this time is a balance in emphasis between disease treatment and disease prevention— a balance appropriate to the current state of knowledge of oral disease etiology and to the current and potential health of the public. What is needed ultimately, however, is not simply an updating of our repertoire of proce dures to include prevention. What is needed is a system and methodology for continuous evalu ation of where we are headed and how we are doing. Are our goal statements still valid? Is behavior consistent with stated goals? Are teach ing and practice procedures based on all avail able knowledge relevant to accomplishing our goals? If the answer is “ no” to any of these questions, what actions can we take? What we need is a continuous evaluation of what we are doing in the light o f what we could be doing and in the context of what we hope to do. Therefore, we need a methodology for break ing down institutionalization and then preventing it from redeveloping. Another facet with which we must deal is that of institutionalized thinking among our students. This problem is generic to all facets of human society, and therefore one which has affected most of our students in many ways by the time they enter dental school. There is hope, how ever, that this situation can be remedied rath er readily. We know from cultural anthropological and psychological studies that early experiences greatly affect subsequent behavior. This applies generically to experiences early in life, and spe cifically to experiences early in a new field of endeavor. Therefore, it is probable that prop erly structured early experiences in dental school can encourage students to develop a more appropriate perspective of dental practice. There are at least two major steps needed
to bring this about. First, we must define the goals o f dental education in terms o f the qual ities, characteristics, and behavior patterns we wish to see in our graduates and then contin uously evaluate our educational efforts in terms of how well we are accomplishing these goals. Secondly, we must shift the emphasis in edu cation from one of teaching to one o f learning.
From teaching to learning Until we properly define our educational goals in terms of graduates, there is no way to eval uate the effectiveness in real life. Furthermore, there is no way to determine the relative over all value of the many specialized areas of knowl edge and skills currently included in curriculums. Without this kind o f definition and evaluation, we quickly institutionalize procedures so that their effectiveness is evaluated in terms of how many procedures are accomplished, rather than in terms of their contribution to goal achieve ment. We are then in a position somewhat like that of the man who, on discovering he is lost in the woods, doubles his speed without know ing where he is going. For a properly goal-oriented approach to cur riculum evaluation to be effective, behaviorally measurable goals must be established within teaching departments and interdepartmental sup port for overall educational goals must be de veloped. This will require de-institutionalization among some faculty members who tend to judge their own importance in terms of the number of hours allocated their departments rather than in terms of their contribution to the develop ment o f a comprehensively competent graduate. It is hoped that this can be done through edu cation o f faculties to evaluate student perfor mance in regard to behavioral com petence rather than in terms of hours spent or numbers of procedures done, and in light of overall edu cational goals as well as departmental subgoals. Should this not work, the long-term solution appears to lie in the establishment o f new criteria for the future selection of faculty. Regarding the educational process itself, our reason for bringing out the need for shifting the focus from teaching to learning is that it is the only approach for developing the type o f dental practitioner who is expected to continue to grow throughout his professional life. Emphasis placed
Shira—Cassidy: THE DENTAL SCHOOL AND PREVENTIVE DENTISTRY ■ 1071
on teaching leads to the impression that authori tative answers are always available to all ques tions, so all that is needed is to seek out the proper authority for the correct answer. A corol lary impression is that knowledge is a func tion o f position. Teaching, which usually amounts to a process of spoon-feeding information to students for them to memorize, may appear to be an efficient ap proach to education when measured over the short range in terms of ability to produce the in formation on demand. H owever, it is not effec tive as a means for long-term retention or as a means for integration of information into conceptual-behavioral patterns essential for the ap plication of knowledge to practical problems or as a basis for fuiure learning. Rather than having information fed to them, students should seek it out for themselves. Teachers should provide guidance and reinforcement for stu dents’ efforts. A s time passes, the need for teacher guidance will diminish as the student becom es increasingly self-directed. Through this approach the student in essence becomes his own teacher and becomes prepared to conduct his own lifelong educational program. In ad dition, the satisfaction gained from personal dis covery has the potential for stimulating the dis coverer to go beyond existing knowledge. A fundamental goal o f dental education should be to graduate a practitioner who has learned to learn. Such a person has the potential to be a lifelong learner, a seeker after knowledge, the kind o f person who will stay abreast o f new knowledge in his profession and related fields, who is capable o f integrating this knowledge into personal concepts and behavior, and who possi bly will become a participant in the advance ment o f knowledge.
Catalysts for change The changes that are needed in dental education are related to fundamental problems facing our society. The failure of dentistry to capitalize on available preventive knowledge is but a manifestation of the more general problems of institutionalization. U nless we address ourselves to these problems, our solutions will amount only to a temporary covering over of the symp toms o f disease while the underlying disease progresses unchecked. In this context, dentistry has the opportunity to play a vital role in up1072 ■ JADA, Vol. 84, May 1972
grading the quality of life in our society: Spe cifically by developing systems and methodol ogies for bringing optimum oral health to all people, and generically by providing a model for others to follow in revitalizing organizations, institutions, and professions. The dental schools are in an ideal position to act as catalysts for needed change. I f den tistry is to attempt meaningfully to meet the upcoming challenge of bringing optimum oral health to the total population, w e must find new ways of delivering health services. The den tal schools would seem legitimately to have a dual role in this attempt. Their research capa bilities can help develop the new knowledge and methodologies needed. Their educational pro grams can ensure that dental graduates not only are prepared to practice in the most advanced way possible, but also are oriented to remain up to date throughout their professional lives, and possibly even to participate in the search for more effective ways for preventing and con trolling oral diseases. The proper role of the dental school then is not merely one of catching up to the present by increasing the emphasis placed on prevention within the curriculum. Properly, it is also one of preparing for the future— taking action so that ten or twenty years hence we will not have to discuss how we are going to do what already should have been done. In conclusion, we believe that a reorientation in the thrust and methodology o f our schools of dentistry can lead to the development o f a self-generating, self-regenerating profession cap able o f growth and development toward ac complishment of the profession’s proper ultimate goal of optimal oral health for all people. In doing this, we will have developed a model for dealing with the problem of institutionali zation which so greatly hampers individuals and organizations trying to cope with the realities of our ever more rapidly changing world.
This paper was presented at the Second Conference on Prac tice A dm inistration: Emphasis Prevention in Practice, Sept 910, 1971. Dr. Shira is dean of the Tufts University School of Dental Medicine, Boston, 02111. He form erly was Assistant Surgeon Gen eral fo r Dental Services and C hief of the A rm y Dental Corps, w ith the rank of m ajor general. Dr. Cassidy is chief of pro fessional services in the O ffice of the Chief o f the Arm y Dental Corps, O ffice of the Surgeon General, Departm ent of the Army, W ashington, DC 20314.
Robert B. Shira, DDS, Boston Jam es E. Cassidy, DMD, DPH, Washington, DC
D entistry’s goal—the attainment and maintenance of oral health— is being presented to dental stu dents as treatm ent o f disease. Disease prevention, which is equally as im portant as disease treat ment, must receive greater emphasis in the cur riculum s of dental schools.
The armed forces continuously face the prob lems of dealing with the massive oral disease of the American populace as represented by a cross section of its youth. So perhaps we are more acutely aware of the magnitude of the na tion’s oral disease epidemic than some o f our colleagues in civilian practice who do not see this broad sampling of the populace. A survey that was completed within the past year among men entering active duty in the Army showed that a mean minimum requirement o f 8.2 hours of professional care per man was required to correct existing pathoses. This poor state o f oral health among young men entering the Army reflects the poor state of oral health among Americans. Men entering the armed forces, after all, are among the healthiest of America’s youth who, despite their deplorable state of oral health, still are healthier than their elders. The question then, made ever more cogent by the increasingly probable advent o f some form of national health program is: What are we to do about the situation? The courses of action most often suggested are to increase dental manpower; to increase productivity of dental manpower; and to prevent or control oral diseases at least to the extent 1068 ■ JADA, Vol. 84, May 1972
that requirements for corrective and restorative care are reduced to a more readily manageable level. For the present at least, all three courses of action are needed. However, unless ways are found to shift the emphasis to effective disease prevention, the future of the nation’s oral health and of the dental profession appears bleak. N o nation can afford the cost of providing restorative care to a population in which the rate o f oral disease progresses as it does at present in this country. If the restorative approach to national dental care is taken, the nation eventually will be faced with a choice between reducing dental benefits or reducing other socially desirable pro grams. If historical examples from other nations that are faced with a similar choice are noted, the choice seems obvious. In addition to recognizing the economic neces sity for effective disease preventive and control programs on a national basis, we also should reemphasize that the complete absence of oral disease is much more desirable than the avail ability of even the highest quality restorative care. The basic problem to be faced, then, is how the dental profession can become more effective in the prevention and control o f oral disease. The purpose of this paper is to explore the role of the dental schools in this effort. Because we recognize that the schools do not operate in isolation from the practicing profes sion, we will make reference to the reciprocal influences between schools and practitioners.
Army experience with graduates Much of the responsibility for the attainment of optimum oral health for the population and for individual patients rests with the dental schools. They have the expertise and faculties to train students adequately in techniques of restorative dentistry and the treatment of oral
disease. They also should have the capacity to teach preventive dentistry. There are indications, however, that instruction in preventive dentistry has not successfully conferred a competence that is equivalent to that attained by students in the diagnosis and treatment o f oral disease. Because the Army Dental Corps commissions from 800 to 1,000 dental graduates each year and works with these young dentists for two or more years, we are in an ideal position to eval uate what the dental student has learned about preventive dentistry. This is what we have seen, and it does not make us happy. In 1967, the graduating dental student had little concept of what was meant by preventive dentistry. This understanding has improved, but it still is not adequate. Most students have heard of preventive dentistry but many are vague about exactly what it is, and most are not con vinced it will work— at least in their hands. Consequently, it is given a low priority in their thinking and practice. Many think it is nonproductive compared with restorative dentistry. Furthermore, most grad uating dentists are not convinced that preven tive dentistry is economically sound and that patients will pay a reasonable charge for pre ventive procedures. Most graduates are eager to improve their skills in periodontics, oral surgery, prosthodontics, and crown and bridge, and do not wish to devote time to preventive dentistry, or even much time to operative dentistry. M ost graduates have not been taught specific techniques for initiating an effective preventive program, and many have little idea about how to incorporate preventive dentistry successfully into general practice. For the most part they do not know how to communicate with patients to interest them in preventive programs. They know little about the basic problems of changing the behavioral patterns of the dental profession or the popu lation, although solutions are necessary for a successful preventive dentistry program. More over, they know little about the community aspects of preventive dentistry. Because o f these attitudes, most dentists think that their time is wasted if they are asked to serve as the preventive dentistry officer at their station or to devote any appreciable time to clinical preventive dentistry practice. As the nation approaches the initiation of some form o f national health program, the health pro fessions are challenged to provide comprehensive health care for a total population. From the
point of view of health and fiscal reality, the only feasible approach to such a program is one that emphasizes disease prevention. The Army has faced this challenge and has elected an approach that is based on prevention. Because we must rely mainly on recent dental graduates to carry out our preventive programs and because we have found them wanting in required knowledge and skills, we believe that we are in a position to comment on needed changes in dental education.
Changing goals of dental schools Dental schools exert a profound influence on the type of practice their graduates will conduct once they leave the school. If preventive den tistry is to become a way o f life for the prac ticing dentist, a greater emphasis on this sub ject is essential in the curriculum so that the profession can offset its historically derived preoccupation with restorative dentistry. In this way students will become better prepared to meet the demands o f contemporary and future clinical practice. Such a change in emphasis does not imply a downgrading of the importance of sound restorative dentistry, but it does require the up grading of preventive dentistry in the scale of educational values. Unless the dental schools and their faculties accord preventive dentistry a higher degree of representation in the curriculum and especially in clinical instruction, and unless they accept and foster the concept o f prevention rather than restoration as the ultimate goal of dentistry, stu dents will continue to regard the development of knowledge and skills in prevention as secondary in importance to acquisition of skills in re storative dentistry. Furthermore, if students are not exposed to the philosophy and clinical techniques of prevention while they are under graduates, it is unlikely that they will acquire and practice these skills after they graduate. A dental school or any other institution must have clearly stated goals. In fact, these goals should be stated so specifically that the degree to which they are attained is readily measured. In dentistry, this measurement applies first to the behavior o f dentists— what they do and how they do it. Ultimately the degree of goal at tainment should be measurable in terms o f the results of the dental profession’s efforts among those it serves.
Shira—Cassidy: THE DENTAL SCHOOL AND PREVENTIVE DENTISTRY ■ 1069
The proper goal for dentistry is easy enough to state: To attain and maintain optimal oral health among those served. Health o f the society is a proper goal for the profession as a whole, and health o f individual patients is proper for the practitioner. Such a goal, or a similar one, seems to be intellectually acceptable to most members o f the profession. However, is the re sulting behavior appropriate to such a goal? The answer appears to be no. The question then is, why? Unfortunately, the professional perspective that foreordains the behavioral goal of the ma jority o f dentists is one of oral health care. The word, care, affects the behavioral role of the profession because it connotes after-the-fact treatment of disease. Some may wish to argue this point semantically; however, it is a be havioral pattern that is well demonstrated. The outstanding example is that restorative dentistry is given preponderant emphasis in requirements for graduation from many o f our dental schools and for passing many of the state boards. Thus, a goal dichotomy has developed. Although our stated goal is optimum oral health for all, our behavioral goal is oral health care for a few. The fact that the behavioral goal of health care applies to only a few is, of course, not surprising, given the current treatment capability of the profession. Why has this situation developed? Mainly, it comes from behavioral patterns that were es tablished in dental school where emphasis on restorative dentistry as the major thrust of den tal practice appears to have become institu tionalized. The institutionalization of restorative dentistry is reasonably understandable when one understands the historical roots o f dentistry’s emphasis on postdisease care. At one time postdisease treatment of diseaseproduced lesions was the only available, scientif ically supported approach to care. A s a result, appropriate technical procedures for such treat ment were given primary emphasis in dental schools. Properly then, technical procedures become the norm for a judgment of professional compe tence and, additionally, become the basis for professional remuneration. Generations of den tists have accepted this norm and they how exert influence on the schools to continue the emphasis on the development of technical skills. Thus the interrelated influence of school-practitioner-school comes full cycle. 1070 ■ JADA, Vol. 84, May 1972
The cycle from the practitioners’ perspective is reinforced by a feeling o f incapability to change the mode of practice. The cycle is reinforced by the dental educators’ perspective of considerations of power and prestige related to departmentalized areas of dental practice.
Overcoming institutionalization Many of the major problems that face our pro fession and our society at large are attributable to the phenomenon of institutionalization. The first step toward institutionalization is habituation. A s a person or organization finds that, within the context of available knowledge, certain procedures work effectively, these pro cedures become habitualized. There is nothing wrong with habitualization in itself because it is natural to the maturational process necessary for efficiency o f operation. If the decision-making process is necessary every time repeated ac tivities are carried out, not much will happen. In dental schools as in other institutions, much is established by deliberate choice because cer tain procedures are found to be relevant to the attainment o f established goals. H owever, as time passes and personnel change, habitualized procedures tend to become institutionalized as ends in themselves, losing their identity as means. As the organization grows and becomes more complex, there is a tendency to specialization in which both the overall goal and related subgoals are lost. What is passed on to new comers in the organization is knowledge of pro cedures that, in the absence o f knowledge of pertinent goals, have become goals in themselves. In addition people have a tendency to remain with what is familiar, fearing the new or dif ferent. At this point the organization has become procedure-oriented rather than goal-oriented. Such trite statements as: “ We do it this way because it is our policy,” and “ D on ’t ask ques tions; that’s the way it is done,” become com monplace. (An excellent example of the phe nomenon of institutionalized procedure was the placement of horsewhip holders on early auto mobiles.) When this happens, procedures have become institutionalized and are difficult to change. Another effect of institutionalization relates to goals as well as to procedures. A s time passes,
changes occur in the environment in which an organization operates. G oals and procedures that once were appropriate becom e outdated in light o f new knowledge. Adherence to these outmoded goals and procedures often becomes a serious block to needed change. Obsolescent goals block change by keeping attention focused on activities no longer ap propriate by themselves for doing all that could be done in solving a given problem. Thus, in dentistry the failure to establish health rather than health care as a viable goal has resulted in continued nearly exclusive emphasis on tech nical procedures related to disease treatment. What is needed at this time is a balance in emphasis between disease treatment and disease prevention— a balance appropriate to the current state of knowledge of oral disease etiology and to the current and potential health of the public. What is needed ultimately, however, is not simply an updating of our repertoire of proce dures to include prevention. What is needed is a system and methodology for continuous evalu ation of where we are headed and how we are doing. Are our goal statements still valid? Is behavior consistent with stated goals? Are teach ing and practice procedures based on all avail able knowledge relevant to accomplishing our goals? If the answer is “ no” to any of these questions, what actions can we take? What we need is a continuous evaluation of what we are doing in the light o f what we could be doing and in the context of what we hope to do. Therefore, we need a methodology for break ing down institutionalization and then preventing it from redeveloping. Another facet with which we must deal is that of institutionalized thinking among our students. This problem is generic to all facets of human society, and therefore one which has affected most of our students in many ways by the time they enter dental school. There is hope, how ever, that this situation can be remedied rath er readily. We know from cultural anthropological and psychological studies that early experiences greatly affect subsequent behavior. This applies generically to experiences early in life, and spe cifically to experiences early in a new field of endeavor. Therefore, it is probable that prop erly structured early experiences in dental school can encourage students to develop a more appropriate perspective of dental practice. There are at least two major steps needed
to bring this about. First, we must define the goals o f dental education in terms o f the qual ities, characteristics, and behavior patterns we wish to see in our graduates and then contin uously evaluate our educational efforts in terms of how well we are accomplishing these goals. Secondly, we must shift the emphasis in edu cation from one of teaching to one o f learning.
From teaching to learning Until we properly define our educational goals in terms of graduates, there is no way to eval uate the effectiveness in real life. Furthermore, there is no way to determine the relative over all value of the many specialized areas of knowl edge and skills currently included in curriculums. Without this kind o f definition and evaluation, we quickly institutionalize procedures so that their effectiveness is evaluated in terms of how many procedures are accomplished, rather than in terms of their contribution to goal achieve ment. We are then in a position somewhat like that of the man who, on discovering he is lost in the woods, doubles his speed without know ing where he is going. For a properly goal-oriented approach to cur riculum evaluation to be effective, behaviorally measurable goals must be established within teaching departments and interdepartmental sup port for overall educational goals must be de veloped. This will require de-institutionalization among some faculty members who tend to judge their own importance in terms of the number of hours allocated their departments rather than in terms of their contribution to the develop ment o f a comprehensively competent graduate. It is hoped that this can be done through edu cation o f faculties to evaluate student perfor mance in regard to behavioral com petence rather than in terms of hours spent or numbers of procedures done, and in light of overall edu cational goals as well as departmental subgoals. Should this not work, the long-term solution appears to lie in the establishment o f new criteria for the future selection of faculty. Regarding the educational process itself, our reason for bringing out the need for shifting the focus from teaching to learning is that it is the only approach for developing the type o f dental practitioner who is expected to continue to grow throughout his professional life. Emphasis placed
Shira—Cassidy: THE DENTAL SCHOOL AND PREVENTIVE DENTISTRY ■ 1071
on teaching leads to the impression that authori tative answers are always available to all ques tions, so all that is needed is to seek out the proper authority for the correct answer. A corol lary impression is that knowledge is a func tion o f position. Teaching, which usually amounts to a process of spoon-feeding information to students for them to memorize, may appear to be an efficient ap proach to education when measured over the short range in terms of ability to produce the in formation on demand. H owever, it is not effec tive as a means for long-term retention or as a means for integration of information into conceptual-behavioral patterns essential for the ap plication of knowledge to practical problems or as a basis for fuiure learning. Rather than having information fed to them, students should seek it out for themselves. Teachers should provide guidance and reinforcement for stu dents’ efforts. A s time passes, the need for teacher guidance will diminish as the student becom es increasingly self-directed. Through this approach the student in essence becomes his own teacher and becomes prepared to conduct his own lifelong educational program. In ad dition, the satisfaction gained from personal dis covery has the potential for stimulating the dis coverer to go beyond existing knowledge. A fundamental goal o f dental education should be to graduate a practitioner who has learned to learn. Such a person has the potential to be a lifelong learner, a seeker after knowledge, the kind o f person who will stay abreast o f new knowledge in his profession and related fields, who is capable o f integrating this knowledge into personal concepts and behavior, and who possi bly will become a participant in the advance ment o f knowledge.
Catalysts for change The changes that are needed in dental education are related to fundamental problems facing our society. The failure of dentistry to capitalize on available preventive knowledge is but a manifestation of the more general problems of institutionalization. U nless we address ourselves to these problems, our solutions will amount only to a temporary covering over of the symp toms o f disease while the underlying disease progresses unchecked. In this context, dentistry has the opportunity to play a vital role in up1072 ■ JADA, Vol. 84, May 1972
grading the quality of life in our society: Spe cifically by developing systems and methodol ogies for bringing optimum oral health to all people, and generically by providing a model for others to follow in revitalizing organizations, institutions, and professions. The dental schools are in an ideal position to act as catalysts for needed change. I f den tistry is to attempt meaningfully to meet the upcoming challenge of bringing optimum oral health to the total population, w e must find new ways of delivering health services. The den tal schools would seem legitimately to have a dual role in this attempt. Their research capa bilities can help develop the new knowledge and methodologies needed. Their educational pro grams can ensure that dental graduates not only are prepared to practice in the most advanced way possible, but also are oriented to remain up to date throughout their professional lives, and possibly even to participate in the search for more effective ways for preventing and con trolling oral diseases. The proper role of the dental school then is not merely one of catching up to the present by increasing the emphasis placed on prevention within the curriculum. Properly, it is also one of preparing for the future— taking action so that ten or twenty years hence we will not have to discuss how we are going to do what already should have been done. In conclusion, we believe that a reorientation in the thrust and methodology o f our schools of dentistry can lead to the development o f a self-generating, self-regenerating profession cap able o f growth and development toward ac complishment of the profession’s proper ultimate goal of optimal oral health for all people. In doing this, we will have developed a model for dealing with the problem of institutionali zation which so greatly hampers individuals and organizations trying to cope with the realities of our ever more rapidly changing world.
This paper was presented at the Second Conference on Prac tice A dm inistration: Emphasis Prevention in Practice, Sept 910, 1971. Dr. Shira is dean of the Tufts University School of Dental Medicine, Boston, 02111. He form erly was Assistant Surgeon Gen eral fo r Dental Services and C hief of the A rm y Dental Corps, w ith the rank of m ajor general. Dr. Cassidy is chief of pro fessional services in the O ffice of the Chief o f the Arm y Dental Corps, O ffice of the Surgeon General, Departm ent of the Army, W ashington, DC 20314.