Predoctoral substance use disorders curricula: A survey analysis and experiential pedagogy

Abstract

Substance Use Disorders (SUD) are chronic health conditions with heritability characteristics, environmental influences, long-term management considerations and they cooccur. The US opioid epidemic is a crisis of both prescription and nonprescription opioid use. Clinicians now have access to evidence-based practices but the evolving trends require continuous attention including curriculum initiatives for dental schools. The purpose of this study was to obtain information about the content and educational strategies of current SUD curricula, beneficial educational products for a standardized curriculum and perceived barriers toward standardization. Invitations were sent to 64 US dental schools describing the purpose of this study and a link to complete the survey was provided. Fully completed responses were received from 32 (50.0%) of the schools. Descriptive statistics was used to analyze the data. Most dental schools surveyed (81.3%) have a curriculum for SUD with classroom lectures being the most commonly used teaching method (96.2%), followed by online modules (42.3%). About 30% of the responding schools provided additional educational experiences. Instruction occurred mostly in second (73.1%) and third (77.0%) academic years. Opioids, alcohol, nicotine, and marijuana were the most frequently taught substance classes. Curriculum standardization with online modules (81.3%), case-based exercises (59.4%), and simulation with standardized patients (43.8%) was considered desirable to improve student competency in the management of patients with SUD. Lack of time (62.5%), space (56.3%), and faculty (50.0%) were cited as the most common barriers to curriculum initiatives. Experiential and achievable options for improving SUD curriculum were highlighted.

1. INTRODUCTION

Substance Use Disorders (SUD) are chronic mental health conditions with heritability characteristics, environmental influences, long-term management considerations and relapse rates comparable to other chronic medical conditions.¹ SUD include Alcohol Use Disorder (AUD), Tobacco Use Disorder (TUD), Opioid Use Disorder (OUD), and Cannabis Use Disorder (CUD). As of 2018, 19.3 million people living in the United States have SUD with 16.3 million for AUD and 2.4 million for OUD.² TUD causes close to 500,000 deaths per year³ and the risk for CUD has increased since marijuana was legalized for recreational use in some states.⁴

Binge and heavy drinking increases the risk for AUD and current US data show that 25.8% of people ages 18 or older reported binge drinking in the past month and 6.3% of people 18 or older reported heavy drinking in the past one month⁵ while the economic burden of alcohol misuse rose from about $167.7 billion in 2006 to about $249.0 billion in 2010.⁶ Although smoking has declined from 20.9% in 2005 to 14.0% in 2019, about 34 million Americans still smoke and smoking rates remain high in certain groups such as men, persons with disabilities and individuals living below poverty level.⁷ More than 2 million Americans need treatment for OUD⁸ and two thirds of the 70,000 deaths from drug overdose in 2017 involved opioids.⁹ The rate of opioid overdose deaths in the United States has increased by 500% since 1999 and despite the availability of treatment, opioid mortality rate has now surpassed that of AIDS at its peak in the early 1990s.¹⁰ Synthetic opioids are now driving the US epidemic¹¹ as prescription opioid is being replaced by heroin adulterated with fentanyl and its analogues.¹² In reality, the US opioid epidemic is now fueled by nonprescription opioid use. In addition, majority of adults who met the criteria for one of the SUD also met the criteria for additional SUD based on the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria¹³ and cooccurring alcohol and drug use are an important factor to consider when screening individuals for SUD.¹⁴

In the 1980s, empirical knowledge fueled the opioid crisis with a mistaken belief that opioids had low addictive potential among those suffering from pain¹⁵ but more recent information has highlighted the importance of carefully weighing potential benefits against the risks of adverse events¹⁶ as well as the perils of inaccurate citation.¹⁷ Equipped with new guidelines, clinicians now have access to evidence-based best practices for prescribing controlled substances. Among dentists, opioid prescribing, used primarily to alleviate pain following surgical procedures such as third molar extractions, has begun to taper off.¹⁸ The American Dental Education association (ADEA) has emphasized by policy brief, the pivotal role of dental educators in minimizing and controlling substance prescription misuse including a collaborative, multifaceted approach to curtailing the devastating impact of all SUD and that continuous attention from dental stakeholders including curriculum initiatives at dental schools where future dentists are trained is desirable.¹⁹

Historically, delivery of SUD content occurred in several areas of dental curricula.^20,21,22 More recently, to improve SUD education and to underscore its relevance, several initiatives have been reported in scientific literature. In a 2012 publication, a tobacco cessation counseling project using Motivational Interviewing (MI) techniques was implemented in a dental setting, resulting in a 20% quit rate among patients after 6 months.²³ An online alcohol-related curriculum for dental students was reported in 2014 and its five learning modules resulted in significant improvements in students’ behavioral skills for screening and brief intervention with standardized patients.²⁴ A cross-institutional collaboration to enhance training in pain assessment and opioid management through the adoption of core competencies along primary, secondary and tertiary prevention domains was published in 2017.²⁵ Training and resources for managing patients with TUD have been available to dental students and practitioners since 2019.²⁶ A model for integrating Screening, Brief Intervention and Referral to Treatment (SBIRT) along the continuum of dental curriculum was successfully implemented and published in 2020.²⁷ SBIRT is an evidence-based model for managing individuals with or at risk for SUD.²⁸ It entails universal screening for alcohol misuse, tobacco use, misuse of opioid prescription, or use of illicit drugs.

For promoting and monitoring the continuous quality and improvement of dental educational programs, the Commission on Dental Accreditation (CODA) revised Standard 2–23e to Standard 2–24e. CODA Standard 2–16 also has mandates that are applicable. The intent of these two standards include ensuring ability of graduates to “evaluate, assess and apply current and emerging science and technology and possess the basic knowledge, values and skills to practice independently at the time of graduation” as well as to facilitate education in basic principles of cultural competency, recognition of health disparities, importance of meeting health care needs of underserved and development of professional attributes in altruism, empathy and social accountability.²⁹

It has also been noted that professionalism hinges on communication. The use of sensitive language is a key component of medical and dental training in cultural competency and the type of language used with reference to SUD can perpetuate stigma and diminish the quality of care.³⁰ In addition, it is critical that dental schools implement educational strategies that provide learning on a range of themes such as SBIRT, prescribing practices, interprofessional approaches and electronic data systems.³¹ Accordingly, the content, language and design of a SUD curriculum can steer learners toward competency and impact the quality of care and as such, curriculum initiatives that are evidence-based, offering a deeper understanding of individuals with SUD are needed.³² The content should link didactic knowledge with clinical skills. The language of interpersonal communication needs to be nonjudgmental, nondominating, noncondescending, nonstigmatizing and increase help seeking. Multifaceted pedagogical methods will allow for immersion, integration and application along the continuum of the curriculum. Some of the current curriculum initiatives are anchored on core competencies and curriculum integration and offer a pathway to standardization with formalized content, appropriate design format, essential elements, baseline requirements along accreditation guidelines and there is awareness that dental curricula, being dynamic, and especially for a difficult subject with a national focus, such as SUD, will imply that standardization is desirable. Additionally, alternate pedagogies that can foster transformative understanding have been identified, developed, delivered and evaluated in a dental and dental hygiene setting.³³ Thematic analysis of this initiative indicated that reflective exercises, interactive sessions and community-driven open dialogue had a positive impact on student learning and promoted a deep dive into issues of equity, diversity, learning environment and inclusion beyond what is offered through simply classroom didactics.

A 1988 survey had found SUD education in dental schools to be minimal and passive relative to the significance of the subject and recommended a significant increase in teaching hours including the incorporation of more meaningful learning strategies (small group discussions, involvement of rehabilitated dentists).³⁴ In 2011, the results of a survey of SUD curricula were presented under five topics (alcohol use and dependence, tobacco use and dependence, prescription drug misuse and abuse, other substance use and dependence, and behavior change education).³⁵ While confirming that alcohol, tobacco and prescription drug abuse is widely addressed in dental curricula, it recognized that some educational methods such as small group discussions may be absent from many programs and suggested that there is a need for instructional material and faculty development. Results from the 2019 ADEA opioid dental school survey indicated that a significant number of US dental schools have undertaken changes to their curriculum and clinical protocols to combat the epidemic and that more research is necessary to ascertain the success of the changes implemented so far and the factors causing these results.³⁶

The purpose of this study was to obtain information about some of the characteristics of current SUD curricula at US dental schools and to analyze the responses to the survey. Specifically, we wanted to find out about the educational strategies currently being implemented and the most beneficial educational products for a standardized curriculum. We were also interested in the perceived barriers toward a standardized curriculum.

2. MATERIALS AND METHODS

2.1. Preparation

Our interdisciplinary team consisting of a dentist, psychiatrists, and research project managers worked collaboratively on this funded project. The New York State Psychiatric Institute Institutional Review Board (NYSPI-IRB) granted this study an exempt status (IRB project # 5792). We obtained and reviewed the listing of accredited predoctoral dental education programs³⁷ and we decided to survey 64 US dental schools excluding any newly established school.

2.2. Development of survey instrument

Our team developed a new survey instrument, being fully aware of new accreditation requirements, dearth of citable survey instruments and evolving developments in SUD knowledge. The survey sought information regarding seven characteristics in a SUD curriculum: (1) educational strategies currently implemented, (2) substance classes addressed in curriculum, (3) dental school year(s) receiving instruction, (4) location of training, (5) instructors for training, (6) most beneficial educational products, and (7) perceived barriers to implementation (Table 1). Preset response options were provided in a check box format and responders were allowed to check off more than one box. Furthermore, free-text response options were offered to responders who wished to provide additional information.

TABLE 1.

Characteristics of current SUD curriculum

	%Yes
SUD curriculum	(n = 26)	SD
1. SUD educational strategies currently implemented:
Classroom lectures	96.2	0.192
Online webinars	0.0	0.000
Online modules	42.3	0.494
Standardized patient simulation	34.6	0.476
Clinical practice at dedicated site	30.8	0.462
Other	7.7	0.267
2. Substance classes addressed in SUD curriculum:
Alcohol	92.3	0.27
Nicotine	92.3	0.27
Marijuana	80.8	0.39
Stimulants (cocaine, methamphetamine)	73.1	0.44
Benzodiazepines	69.2	0.46
Opioids	96.2	0.19
Inhalants	50.0	0.50
Hallucinogens	46.2	0.50
Other	7.7	0.27
3. Dental school year(s) receiving the SUD curriculum:
1st Year	65.4	0.48
2nd Year	73.1	0.44
3rd Year	77.0	0.42
4th Year	38.5	0.49
4. Location of the SUD curriculum:
Onsite	100.0	0.00
Offsite	7.7	0.27
5. Instructors for SUD curriculum:
Dental faculty	88.5	0.31
Psychiatry faculty	15.4	0.36
Addiction medicine faculty	3.85	0.19
Other	57.7	0.49

In order to ascertain the validity of the survey instrument, we invited 10 educational researchers from within our institution to review the survey instrument and determine whether, on the face of it, the survey instrument was an accurate measure of the concept being investigated. The face validity questionnaire had 10 items with a dichotomous response scale (Yes/No).³⁸ The 10 items were: (1) Generally, does this US dental school survey instrument look like what survey instruments should look like? (2) Is this survey useful for analyzing SUD curriculum in US dental schools? (3) Were the survey questions clearly written? (4) What is your opinion about the number of questions in the survey? (5) Do you believe that the survey questions comprehensively cover all aspects of SUD curriculum that need to be investigated? (6) Does the instrument measure what it is supposed to measure? (7) Does this survey instrument need to be improved on? (8) Are you a physician in the field of addiction psychiatry? (9) Do you believe that SUD education is important for dentistry? (10) Are you satisfied with the amount of time it took to complete this evaluation? We then calculated the percentage of agreement and the Gwet’s Agreement Coefficient³⁹ of their responses.

2.3. Survey process

Beginning in April 2019, invitations were sent by e-mail to the academic deans of 64 schools asking them to complete our survey. In the invitation, we described the purpose of our study and we included a link to the survey. We also provided our contact information and the IRB approval status. Follow-up emails and phone calls were made approximately every other week from April to September 2019 to those schools that had not yet responded.

2.4. Data collection and analysis

Data were collated using Microsoft Excel and descriptive analysis was used to summarize the data. The summarized responses are presented and discussed under three categories: (1) presence of SUD curriculum, (2) characteristics of current SUD curriculum, and (3) standardization of SUD curriculum, responses to CODA mandate, and barriers to SUD curriculum.

3. RESULTS

Fully completed responses were received from 32 (50%) of the 64 US dental schools surveyed. There were no partially completed responses. We report on the 32 responses.

3.1. Face validity of survey instrument

From the 10 educational researchers that validated the survey instrument, 100% agreed that instrument was useful in analyzing SUD curriculum in US dental schools. 90% agreed that the instrument looked like what a survey instrument should look like, had appropriate number of questions and was clearly written. 80% agreed that it captured the goal of the instrument. 70% agreed that it was comprehensive. Overall, percentage of agreement was 87% and the Gwet’s Agreement Coefficient for the first six items on the face validity questionnaire was 0.68.

3.2. Presence of SUD curriculum

26 (81.3%) (SD = 0.39) of the 32 US dental schools that responded to our survey reported currently implementing a SUD curriculum. Several responders explained further with free text comments that their curriculum effort could be in the form of formal SUD course(s) or embedded in other courses with pharmacology being mentioned quite often.

3.3. Characteristics of current SUD curriculum

Data about the characteristics of current SUD curricula were for the 26 schools that indicated having a SUD curriculum. Classroom lectures were the most common strategy (96.2%) with 42.3% using online modules, 34.6% utilizing simulation, 30.8% providing clinical practice, and 0% offering online webinars. Opioids (96.2%), alcohol (92.3%), nicotine (92.3%), and marijuana (80.8%) were the most frequently taught substances. Inhalants (50.0%) and hallucinogens (46.2%) and “Designer drugs” listed as “Other” substance class (7.7%) was also taught. SUD are most commonly taught during the 2nd and 3rd academic years (73.1% and 77.0%, respectively) while the 4th academic year was the least common (38.5%). All US dental schools that responded indicated that their SUD curriculum was taught on-site with 7.7% reporting that part of their training also occur at an off-site location, relative to the dental school, such as a medical or pharmacy school. With respect to faculty, 88.5% responded that faculty from their dental school teach their curriculum and 57.7% also indicated that nondental faculty does some teaching out of which 15.4% were from psychiatry/addiction psychiatry and 3.8% were from nonpsychiatry (Behavioral health, School of Nursing, Department of Pharmacology) (Table 1).

3.4. Standardization of SUD curriculum

Almost all the responding dental schools (93.8%) indicated that a standardized SUD curriculum would help them meet the new CODA Standard 2–24e. Furthermore, 75% of responders indicated that they are planning to modify/update their SUD curriculum in response to the new CODA mandate. With respect to what SUD educational products surveyed schools would find most beneficial, 81.3% indicated online modules, 59.4% expressed interest in receiving instructors’ manual for case-based learning in small groups, 43.8% identified with simulation with standardized patients, and 40.6% were for classroom lectures. 15.6% of responders considered clinical practice at a dedicated site as being beneficial (Figure 1). Preference for online modules was statistically significant over other options except instructors’ manual for case-based exercise and preference for instructors’ manual was statistically significant over clinical practice at dedicated sites (Table 3).

FIGURE 1.

Opinions about the most beneficial educational product for a standardized curriculum

TABLE 3.

Differences in proportion and P values of most beneficial SUD educational products for a standardized curriculum

Educational product	% Selected	Individual study guide	Instructors’ manual for case-based small groups	Online webinar	Online modules	Simulation with standardized patient	Clinical practice at dedicated site
Classroom lectures	40.63	d = 6.3%  (P = 0.6048)	d = −18.8%,  (P = 0.1267)	d = 9.4%  (P = 0.4320)	d = −40.6%  (P = 0.0003)*	d = −3.1%  (P = 0.8004)	d = 25.0%  (P = 0.0206)
Individual study guide	34.38		d = −25.0%  (P = 0.0385)	d = 3.1%  (P = 0.7896)	d = −46.8%  (P < 0.0001)*	d = −9.4%  (P = 0.4403)	d = 18.8%  (P = 0.0760)
Instructor’s manual for case-based small groups	59.38			d = 28.1%  (P = 0.0185)	d = −21.9%  (P < 0.0486)	d = 15.6%  (P = 0.2053)	d = 43.8%  (P < 0.0001)**
Online webinar	31.25				d = −50.0%  (P < 0.0001)*	d = −12.5%  (P = 0.2976)	d = 15.6%  (P = 0.1335)
Online modules	81.25					d = 37.5%  (P = 0.0008)*	d = 65.6%  (P < 0,0001)*
Simulation with standardized patient	43.75						d = 28.1%  (P = .00097)
Clinical practice at dedicated site	15.63

Note: Based on Bonferroni correction, P < 0.0024 would be significant between two proportions.

^*Preference for online modules was statistically significant over other options except instructors’ manual for case-based exercise.

^**Preference for instructors’ manual was statistically significant over clinical practice at dedicated sites.

Perceived barriers to implementing a standardized SUD curriculum were lack of time (62.5%), lack of space (56.3%), lack of faculty (50.0%), insufficient funding (37.5%), and lack of institutional buy-in (15.6%) (Table 2, Figure 2). Lack of time, space, and faculty were statistically significant over lack of institutional buy-in (Table 4).

TABLE 2.

Standardization of SUD curriculum

	%Yes
SUD curriculum	(n = 26)	SD
Responses to CODA mandate
Standardized curriculum would help meet CODA Standard 2–24e	93.8	0.24
Characteristics of standardized of SUD curriculum
6. Most beneficial educational products:
Classroom lectures	40.6	0.49
Individual study guide	34.4	0.48
Instructors’ manual for case-based small groups	59.4	0.49
Online webinars	31.3	0.46
Online modules	81.3	0.39
Standardized patient simulation	43.8	0.50
Clinical practice at dedicated site	15.6	0.36
Other	3.1	0.17
7. Perceived barriers to SUD curriculum:
Lack of faculty to teach curriculum	50.0	0.500
Too time intensive	62.5	0.481
Lack of space in overall predoctoral dental curriculum	56.3	0.496
Insufficient funding	37.5	0.484
Lack of institutional buy-In	15.6	0.363

FIGURE 2.

Perceived barriers to implementing a standardized SUD curriculum

TABLE 4.

Differences in proportion and P values of perceived barriers to a standardized SUD curriculum

Perceived barrier	% Selected	Lack of space	Lack of faculty	Lack of funding	Lack of institutional buy-in
Lack of time	62.50	d = 6.3%  (P = 0.6100)	d = 12.5%  (P = 0.3096)	d = 25.0%  (P = 0.0389)	d = 46.9%  (P < 0.0001)*
Lack of space	56.25		d = 6.3%  (P = 0.6157)	d = 18.8%  (P = 0.1260)	d = 40.6%  (P = 0.0002)*
Lack of faculty	50.00			d = 12.5%  (P = 0.3096)	d = 34.4%  (P = 0.0017)*
Lack of funding	37.50				d = 21.9%  (P = 0.0409)
Lack of institutional buy-in	15.63

Note: Based on Bonferroni correction, P < 0.005 would be significant between two proportions.

^*Lack of time, space, and faculty were statistically significant over lack of institutional buy-in.

4. DISCUSSION

The percentage of agreement from the ten academic researchers who looked at the curriculum survey instrument was substantial³⁸ and the calculated Gwet’s Agreement Coefficient of 0.68 was within a good range. Within the survey instrument itself, the frequency of free text comments is indicative of the dynamism of dental curricula, the reality of SUD education. This position is supported in literature⁴⁰ and educators understand that current best practices require synthesis of dental and medical knowledge and skills and that competency in managing patients with SUD will best be achieved by minimizing the wall between courses and by cross-pollination of content across courses.

Our investigation showed that 81.3% of US dental schools that responded to our survey are providing SUD instruction either with dedicated courses or embedding it in other courses. This is a modest increase over the 75% reported in 1988,³⁴ is comparable to the 72.7%−94.5% reported in 2011³⁵ and is related to the 87% indicated for curricular changes in response to the opioid epidemic as seen in the 2019 report.³⁶ While the absence of 100% reporting from dental schools is a concern, it is logical to believe that the remaining dental schools are in the throes of SUD curriculum updates in response to CODA mandates of 2019. However, there is a shortage of studies examining the curricular content of SUD in predoctoral dental education.⁴⁰ As such, an appropriate inquiry is to seek to understand the characteristics of current curricula and which instructional methods have been employed so far, where and when. Apropos to that is to ascertain what pedagogical options remain deployable as well as the obstacles to implementation.

We established in this survey that opioids, alcohol, nicotine, and marijuana are the four most commonly taught substances as apparently, these are the most frequently encountered substances in the dental setting although the data indicated that a broad spectrum of SUD are being addressed. There is a wide berth in the availability of faculty with dental and nondental faculty being utilized depending on individual school circumstances. Teaching facilities were essentially on site.

We found that most responders to our survey checked off that new features of a SUD curriculum should include online training, case-based exercises, and simulation with standardized patients and classroom lectures. Our understanding of this evidence is that academic leaders aspire for a SUD curriculum that optimizes the traditional classroom, invigorates the contemporary training methods, and introduces innovative pedagogy that translates concepts into clinical experiences and are anchored on standardization. We deduced that there is a concern about a gap between the foundational knowledge and clinical skills and a desire to close the loop.

Institutional buy-in was not considered a major barrier as most responders felt that a standardized SUD curriculum would be beneficial in meeting accreditation mandates. Institutional buy-in may have been facilitated by the revision of CODA standards. Spatial and temporal densities of curricula as well as scarcity of faculty were the principal concerns of academic leaders. Lack of training has already been identified as a major barrier affecting dentists’ attitudes toward persons with SUD⁴¹ and there is knowledge that successful foundational training in SBIRT in the early years²⁷ can serve as a bedrock to propel additional experiences through the life cycle of the curriculum. There is also good evidence that training should be reinforced at regular intervals depending on the choice of available resources.⁴²

As further research continues, more options for closing the loop in predoctoral SUD curriculum have become available. Although there is no working definition of standardization, curriculum approaches such as vertical and horizontal integration as well as using technology are often mentioned.⁴³ Technology as a value proposition has synergistic effect, can clear logistical barriers, delivering analog, digital and mixed-method educational experiences although high-fidelity solutions can be challenging. Therefore, innovating curriculum with technology can help find the time, space, and rubric for translational SUD instruction. Building alliances for multidisciplinary practice and interprofessional education might also be pursued as a long-term strategy.⁴⁴

An online, standardized core curriculum in SUD and SBIRT, designed for dental schools, permits learners to proceed sequentially through three modules (foundational knowledge, case-based and an Objective Structured Clinical Examination [OSCE] with an opioid narrative).⁴⁵ In this approach, the didactic content is synonymous with the foundational knowledge which includes the neuroscience of SUD, guidelines about substance use and abuse, SUD in population health and dental medicine, SBIRT, safe prescribing among others. The value of SUD management can be gleaned from case studies in small group exercises where cultural and language sensitivity can be learned and appropriate encounter behaviors demonstrated and developed. Because case-based learning is effective for students who have already acquired the foundational knowledge and it can be used in multiple ways, especially to move from siloed curriculum to a multidisciplinary approach, it has been recommended for teaching oral health knowledge, dispositions and skills.⁴⁶ Therefore, case-based exercises are the bridge connecting the didactic with the clinical and they can be organized to accommodate role-play and reflective exercises. Reflective assignments and guest lectures by individuals, especially clinicians in recovery, have also been utilized as pedagogical approaches.⁴⁰ Clinical skills including motivational interview techniques, collaborative practice, and continuation of dental care are best practiced and assessed during simulation with standardized patients and actual clinical practice. The utility and achievability of a formative 1-station OSCE for SUD has been demonstrated.⁴⁷ The 1-station OSCE was the third of a three-tiered (SBIRT seminar, case-based exercises and OSCE) incremental approach to a standardized SUD curriculum that aligned and integrated SBIRT knowledge, value and skills both horizontally and vertically along the continuum of curriculum. A self-paced online course with the goal of developing SBIRT knowledge, skills, and abilities is available for all oral healthcare learners (preferably faculty).⁴⁸ This platform enables the learner to assimilate the nuances of SBIRT through interactive games, case scenarios and quizzes and it offers institutions a chance to have their own version.

These aforementioned initiatives in SUD and SBIRT education are experiential and they are derivatives of interdisciplinary synergy. They were supported by federal grants and interested dental schools can pursue funding opportunities through the National Institute of Mental Health, Substance Abuse and Mental Health Services Administration (SAMHSA), Health Resources & Services Administration (HRSA) among others.

As noted by the ADEA, their 2019 opioid dental school survey was a stepping stone toward further research into this line of inquiry. Our investigation adds value to the ADEA study by extending the conversation to include other substance classes, exploring further the issue of standardization, and contributing scientific evidence pertaining to barriers toward SUD curriculum. Furthermore, we provided literature on very recent curricular initiatives that have been evaluated for success.

This study has some limitations. The survey questionnaire can be improved on to cover assessments, clinical protocols for pain management and communication training. The data analysis was based on a 50% survey response rate and as such, accuracy of the data is limited to the responses provided. We also did not consider the class sizes or how the regional distribution of dental schools could affect responses. The cohort of dental schools that cotrain with medical schools especially in the foundational years could be a confounding factor. More research would be welcomed to investigate the design and content of case-based exercises including the use of rehabilitated professionals, self-reflections, and community involvement activities. What we have learnt from this study is that US dental schools have developed the capability to provide instruction in SUD even as they recognize the need to increase their capacity through the provision of additional immersive training.

5. CONCLUSION

Evidence showed that predoctoral education in SUD is a truism and dental schools are providing SUD instruction but there is a need to close the loop in the training. New curriculum initiatives such as online modules, case-based exercises, and simulation with standardized patients are desirable to improve student competency in the management of patients with SUD and there are realistic, experiential, and achievable options available.