Abstract
The purpose of this study was to obtain information about education in substance use and dependence that appears in the predoctoral curricula of U.S. and Canadian dental schools. Sixty-eight deans were sent a twenty-item survey requesting information about when in the curriculum these subjects were taught, what instructional methods were used, and whether behavior change instruction was included to address these issues in clinical interactions. The survey had an 81 percent response rate. The topics of alcohol use and dependence, tobacco use and dependence, and prescription drug misuse and abuse were reported in over 90 percent (N=55) of responding schools’ predoctoral curricula. The topic of other substance use and dependence was reported in only 72.7 percent (N=40) of these schools. The primary instructional method reported was the use of lecture. Less frequently used methods included small-group instruction, instruction in school-based clinic, community-based extramural settings, and independent study. As future health professionals, dental students are an important source for patients concerning substance use, abuse, and treatment. Our investigation confirmed that alcohol, tobacco, and prescription drug abuse is addressed widely in predoctoral dental curricula, but other substance use and dependence are less frequently addressed.
Keywords: predoctoral dental curriculum, behavioral education, substance use and abuse, alcohol use and dependence, tobacco use and dependence, prescription drug misuse and abuse
Between 2002 and 2008, the number of persons in the United States with substance dependence or abuse remained virtually unchanged (22.0 million in 2002 and 22.2 million in 2008).1 In 2008, 23.1 million persons in the United States aged twelve or older needed treatment for an illicit drug or alcohol use problem (9.2 percent of persons aged twelve or older). Of these, 2.3 million received treatment at a specialty facility. Thus, nearly 21 million persons needed treatment for an illicit drug or alcohol use problem, but did not receive treatment at a specialty substance abuse facility in the past year.1 In addition, more than 95 percent of individuals who did not receive treatment felt they did not need it. These data suggest that many individuals will not seek treatment on their own. The National Institute on Drug Abuse (NIDA) has noted that these statistics, coupled with the significant and extensive range of health consequences affected by drug use, illustrate the need for drug abuse education as a component of comprehensive medical education.2
The extent to which substance use and dependence education appears in current predoctoral dental curricula has not been investigated recently. Twenty-five years ago, in May 1986, Sandoval et al. surveyed academic deans of all dental schools in the United States and Canada.3 The primary motivation for their investigation was the prevalence of impaired dental practitioners and estimates of the incidence of recreational drug use by future practitioners. Their survey addressed the presence and level of instruction in drug abuse and/or alcoholism. The survey also requested information about the number of hours of instruction, the sponsoring department, and the involvement of rehabilitated individuals in the instruction process. They found that approximately one-fourth of the schools responding did not offer instruction in substance abuse topics; consequently, they called for an increase in the number of hours of instruction and the “incorporation of a more meaningful educational format” that might include small-group discussions and the participation of rehabilitated dentists.
One year later, in May 1987, the American Dental Association (ADA) Commission on Dental Accreditation shared a statement with all U.S. dental school deans encouraging them to include education on substance use, misuse, and addiction in predoctoral and postdoctoral dental curricula.4 At least one institution, the University of California, Los Angeles (UCLA) School of Dentistry, responded to this call for education about addiction, warning signs in patients, and effective treatment approaches. In January 1990, the UCLA School of Dentistry introduced a ten-hour course on substance abuse.4 This course was developed using the Curricular Guidelines in Chemical Dependency approved by the Advisory Committee on Chemical Dependency Issues, Council on Dental Practice of the ADA. The course included lectures on the causes of addiction, the disease concept, pharmacology, diagnosis and recognition, and treatment methods. In 1992, five North Carolina schools, including the University of North Carolina School of Dentistry, initiated a four-year project to provide dental and medical students with skills for prevention, identification, intervention, and management of individuals affected by alcohol, tobacco, and other drug abuse or dependence.5 All these schools engaged in a common curriculum development process, but individual schools designed, implemented, and evaluated their own substance abuse curricula tailored to their students’ needs.
More recently, tobacco and methamphetamine education have been the focus of calls for substance use instruction in predoctoral dental education. A 2001 survey of fifty-four dental schools found that forty-five of them provided some tobacco education, but that content and evaluation varied widely.6 Gordon et al. called for incorporating tobacco treatment education in the dental curriculum and offered steps to overcome barriers to implementation, such as web-based learning, PDA modules, and faculty development.7 In 2006, the American Dental Education Association (ADEA) published Curriculum and Clinical Training in Oral Health for Physicians and Dentists: Report of a Panel of the Macy Study. This report recommended that, by graduation, dental students should be able to demonstrate knowledge of the clinical presentation of major diseases and conditions (including oral manifestations) of substance abuse, including “alcohol, tobacco, drugs, and related oral conditions, e.g., ‘meth mouth.’” The report also called for dentists to develop skills to be competent to “provide patient education and health counseling (e.g., use motivational interviewing or other techniques for patient behavioral change in nutrition, substance use, or oral hygiene habits).”8 In 2008, the ADEA House of Delegates approved Competencies for the New General Dentist including three that pertain to substance abuse identification and treatment. The competencies state that graduates must be competent to recognize and manage substance abuse; provide prevention, intervention, and educational strategies (for health promotion); and apply psychosocial and behavioral principles in patient-centered health care.9
To our knowledge, no comprehensive survey of substance use and dependence education in predoctoral dental curricula has been conducted since 1986. The medical school at our university is a National Institute on Drug Abuse (NIDA) Center of Excellence for Physician Information and has developed educational resources on substance use and dependence for medical students. In light of this area of focus and the lack of information about educational offerings and needs in predoctoral dental education, we proposed a new investigation. The purpose of this study was to obtain information about the predoctoral dental curriculum devoted to substance use and dependence in the United States and Canada. Specifically, we were interested in learning about the amount of curriculum time allotted and instructional methods used to teach predoctoral dental students about alcohol, tobacco, prescription drug, and other substance use and dependence. We also sought information about behavior change instruction offered in this education.
Methods
Study invitations were sent via e-mail to all dental school deans in the United States and Canada (N=68) beginning in November 2009. The invitation described the purpose of the study and included contact information and a link to the online twenty-item survey. The survey requested information as to when in the predoctoral dental curriculum substance abuse and dependence was addressed, what instructional methods were used, and whether behavior change instruction was included. In February 2010, hardcopy versions of the survey were sent to those who had not yet responded to the online survey. Follow-up e-mails were also sent.
Respondents were required to select their dental program from a drop-down list to begin the survey and had the option of providing contact information at the end. The survey also included definitions of substance dependence and abuse, along with common synonyms, to ensure response accuracy and promote study validity.
This study was reviewed and granted exempt status by the Creighton University Institutional Review Board. Descriptive statistics were used to analyze the survey data with PASW 17.
Results
Responses were received from fifty-five of the sixty-eight (80.9 percent) dental schools in the United States and Canada. The results are 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.
Alcohol Use and Dependence
Fifty schools (90.9 percent of those responding) reported that their curriculum addresses alcohol use and dependence. Coverage of this topic is distributed across the four years: 62 percent address this topic in the first year, 60 percent in year two, 56 percent in year three, and 40 percent in year four. Table 1 shows that the total time in contact hours per year varies from a mean of 2.63 hours in the third year to a mean of 4.44 hours in the fourth year.
Table 1.
Amount of time and instructional methods used for alcohol use and dependence education in U.S. and Canadian dental schools across four years of the curriculum, as reported by survey respondents
| First Year | Second Year | Third Year | Fourth Year | ||
|---|---|---|---|---|---|
| Number of Schools Addressing These Topics, by Year | 31 | 30 | 28 | 20 | |
| Amount of Time, in Contact Hours | Mean | 4.33 | 3.06 | 2.63 | 4.44 |
| Median | 2 | 2 | 2 | 2 | |
| SD | 5.7 | 3.18 | 2.36 | 5.1 | |
| Minimum | 0.5 | 1 | 1 | 1 | |
| Maximum | 28 | 16 | 10 | 18 | |
| Instructional Methods | |||||
| Lecture | n | 29 | 28 | 20 | 11 |
| % | 94% | 93% | 71% | 55% | |
| Small group | n | 12 | 5 | 7 | 8 |
| % | 39% | 17% | 25% | 40% | |
| Instruction in school-based clinic | n | 1 | 1 | 7 | 8 |
| % | 3% | 3% | 25% | 40% | |
| Community-based extramural setting | n | 3 | 1 | 1 | 4 |
| % | 10% | 3% | 4% | 20% | |
| Independent study, not online | n | 0 | 0 | 0 | 2 |
| % | 0 | 0 | 0 | 10% | |
Note: Respondents could select all years and all methods in which instruction occurred.
Table 1 also shows the instructional methods used, with more schools reporting use of the lecture in all four years than any other method including small-group instruction, instruction in school-based clinic, community-based extramural settings, and independent study (not online). Respondents were invited to list any additional instructional methods. Responses included sessions with recovering addicted patients who present their personal experiences, personal case study, guest speakers, problem-based learning (PBL) exercise, trips to an addiction hospital, large-group discussion, readings, objective structured clinical examination (OSCE), and a panel of substance-abusing dentists.
Tobacco Use and Dependence
Fifty-one schools (92.7 percent of those responding) reported that their curriculum addresses tobacco use and dependence. Here again, coverage of the topic is distributed across the four years: 51 percent address this topic in the first year, 70.6 percent in year two, 47.1 percent in year three, and 41.2 percent in year four. Table 2 shows the total time in contact hours per year, which varies from a mean of 3.11 hours in the first and second years to a mean of 4.41 hours reported for the fourth year.
Table 2.
Amount of time and instructional methods used for tobacco use and dependence education in U.S. and Canadian dental schools across four years of the curriculum, as reported by survey respondents
| First Year | Second Year | Third Year | Fourth Year | ||
|---|---|---|---|---|---|
| Number of Schools Addressing These Topics, by Year | 26 | 36 | 24 | 21 | |
| Amount of Time, in Contact Hours | Mean | 3.11 | 3.11 | 4.1 | 4.41 |
| Median | 2 | 2 | 3 | 2 | |
| SD | 3.69 | 2.05 | 4.4 | 3.95 | |
| Minimum | 0.5 | 1 | 1 | 1 | |
| Maximum | 18 | 9 | 18 | 16 | |
| Instructional Methods | |||||
| Lecture | n | 22 | 33 | 17 | 9 |
| % | 85% | 92% | 71% | 43% | |
| Small group | n | 9 | 11 | 7 | 4 |
| % | 35% | 31% | 29% | 19% | |
| Instruction in school-based clinic | n | 2 | 3 | 11 | 12 |
| % | 8% | 8% | 46% | 57% | |
| Community-based extramural setting | n | 2 | 0 | 2 | 2 |
| % | 8% | 0 | 8% | 10% | |
| Independent study, not online | n | 1 | 0 | 0 | 1 |
| % | 4% | 0 | 0 | 5% | |
Note: Respondents could select all years and all methods in which instruction occurred.
Table 2 also provides an overview of the instructional methods used, with more schools reporting use of the lecture in the first, second, and third years and instruction in school-based clinic in the fourth year. The other instructional methods included small-group instruction, community-based extramural settings, and independent study (not online). Again, schools were invited to list any additional instructional methods, and responses included videotaping, computer case studies, simulation, virtual patients, clinical instruction, and readings.
Prescription Drug Misuse and Abuse
Fifty-two schools (94.5 percent of those responding) reported that their curriculum addresses prescription drug misuse and abuse. Coverage of this topic is also distributed across the four years: 42.3 percent address this topic in the first year, 51.9 percent in year two, 61.5 percent in year three, and 40.4 percent in year four. Table 3 shows the total time in contact hours per year, which varies from a mean of 1.38 hours in the first year to a mean of 2.33 hours reported for the second year.
Table 3.
Amount of time and instructional methods used for prescription drug misuse and abuse education in U.S. and Canadian dental schools across four years of the curriculum, as reported by survey respondents
| First Year | Second Year | Third Year | Fourth Year | ||
|---|---|---|---|---|---|
| Number of Schools Addressing These Topics, by Year | 22 | 27 | 32 | 21 | |
| Amount of Time, in Contact Hours | Mean | 1.38 | 2.33 | 1.78 | 1.93 |
| Median | 1 | 2 | 2 | 2 | |
| SD | 0.65 | 2.17 | 1.02 | 1.1 | |
| Minimum | 0.5 | 1 | 0.5 | 1 | |
| Maximum | 3 | 10 | 4 | 4 | |
| Instructional Methods | |||||
| Lecture | n | 17 | 23 | 24 | 15 |
| % | 77% | 85% | 75% | 71% | |
| Small group | n | 5 | 3 | 6 | 5 |
| % | 23% | 11% | 19% | 24% | |
| Instruction in school-based clinic | n | 1 | 1 | 3 | 3 |
| % | 5% | 4% | 9% | 14% | |
| Community-based extramural setting | n | 2 | 0 | 0 | 1 |
| % | 9% | 0 | 0 | 5% | |
| Independent study, not online | n | 0 | 0 | 0 | 0 |
| % | 0 | 0 | 0 | 0 | |
Note: Respondents could select all years and all methods in which instruction occurred.
Table 3 also provides an overview of the instructional methods used, with more schools reporting use of the lecture in all four years than any other method including small-group instruction, instruction in school-based clinic, and community-based extramural settings. There was no use of independent study (not online). The use of a panel of abusing dentists was a suggested instructional method that could be used.
Other Substance Use and Dependence
Only forty schools (72.7 percent of those responding) reported that their curriculum addresses other substance use and dependence (e.g., methamphetamine, marijuana, cocaine, inhalants). As with other areas, coverage of this topic is distributed across the four years: 55 percent address it in the first year, 45 percent in year two, 57.5 percent in year three, and 40 percent in year four. Table 4 shows the total time in contact hours per year, which varies from a mean of 2.03 hours in the first year to a mean of 3.08 hours reported for the second year.
Table 4.
Amount of time and instructional methods used for other substance use and dependence (e.g., methamphetamine, marijuana, cocaine, inhalants) education in U.S. and Canadian dental schools across four years of the curriculum, as reported by survey respondents
| First Year | Second Year | Third Year | Fourth Year | ||
|---|---|---|---|---|---|
| Number of Schools Addressing These Topics, by Year | 22 | 18 | 23 | 16 | |
| Amount of Time, in Contact Hours | Mean | 2.03 | 3.08 | 2.56 | 2.45 |
| Median | 1 | 2 | 1 | 2 | |
| SD | 2.58 | 3.75 | 3.99 | 1.3 | |
| Minimum | 1 | 1 | 1 | 1 | |
| Maximum | 10 | 12 | 18 | 4 | |
| Instructional Methods | |||||
| Lecture | n | 18 | 15 | 17 | 10 |
| % | 82% | 83% | 74% | 63% | |
| Small group | n | 5 | 2 | 3 | 3 |
| % | 23% | 11% | 13% | 19% | |
| Instruction in school-based clinic | n | 2 | 0 | 4 | 3 |
| % | 9% | 0 | 17% | 19% | |
| Community-based extramural setting | n | 1 | 2 | 2 | 2 |
| % | 5% | 11% | 9% | 13% | |
| Independent study, not online | n | 0 | 0 | 0 | 0 |
| % | 0 | 0 | 0 | 0 | |
Note: Respondents could select all years and all methods in which instruction occurred.
Table 4 also provides an overview of the instructional methods used, with more schools reporting use of the lecture in all four years than any other method including small-group instruction, instruction in school-based clinic, and community-based extramural settings. There was no use of independent study (not online). Suggested additional instructional methods included guest speakers, cases, panel discussion, and readings. This topic was noted to be more meaningful for those students who participated at an extramural site with a significant methamphetamine use patient base.
Behavior Change Education
Thirty-five schools (64.8 percent of those responding) reported that their curriculum addresses behavior change education (e.g., Prochaska’s stages of change model). A mean of 5.63 total contact hours of instruction was reported regarding this topic across the four years. While lectures and class discussions are used to address this topic, schools employ additional instructional methods such as PBL cases, roleplay, motivational interviewing simulation, videos, student case presentations, Alcoholics Anonymous (AA) meeting visits, and application of behavioral change strategies in community activities and OSCEs. One respondent indicated that the school is currently developing a curriculum to address addiction issues and will include motivational interviewing techniques in it.
Discussion
As future health professionals, dental students are an important source for patients concerning information about substance use, abuse, and treatment. Our investigation confirmed that alcohol, tobacco, and prescription drug abuse is addressed widely in predoctoral dental curricula in the United States and Canada, but other substance use and dependence receive less coverage. We speculate there may be regional differences in education because schools may have responded to local practice needs or crises (e.g., methamphetamine use in the Midwest). Lectures are the predominant instructional method although multiple interactive and experiential activities are used for behavior change instruction. Small-group discussion may be absent from many educational programs due to a lack of small-group rooms, insufficient number of faculty members, and limited time in the academic schedule. The continued call for education on substance use, abuse, and behavior change instruction suggests there is a need for instructional materials and faculty development on teaching substance use issues to predoctoral dental students.
We acknowledge that the predoctoral dental curriculum is expected to address many topics, but there appears to be growing consensus on the need for substance use, abuse, and behavior change education. Our investigation found that lectures remain the primary mode of instruction, and this suggests a need for curricular innovation. For example, only one school reported using online instruction; however, new technology, often already provided and supported by universities, could facilitate the development of online materials such as videos or case scenarios. Likewise, faculty members might welcome a set of publicly available (e.g., via MedEdPORTAL) curriculum resources tailored for predoctoral dental students. Fostering active engagement with lecture material has been found to promote learning gains, so it may be useful to consider using new resources to enhance existing lectures.10 Similarly, new curricular resources could prepare students for workplace learning, i.e., the experiential learning process they will encounter in clinical settings. Workplace learning is improved when students participate in authentic activities, so current strategies like lectures may be less effective than strategies that simulate clinical activities or occur within a clinical setting.11
This study is not without limitations. As with any survey, the accuracy and completeness of the results are limited to the responses from the participants. Also, this survey did not include responses from thirteen (19.1 percent) schools, so it is possible there are additional examples of substance use and dependence instruction yet to be described. However, this study does provide a current glimpse at substance use and dependence education in the predoctoral dental curriculum in U.S. and Canadian dental schools.
Acknowledgments
Support for this study was provided by the National Institute on Drug Abuse (NIDA).
Funding from the National Institute on Drug Abuse (NIDA) Centers of Excellence for Physician Information program supported the data analyses and manuscript development under National Institutes of Health Contract No. HHSN271200900021C (Prime contractor: JBS International, Inc.; Subcontractor: Creighton University). The results of the survey will be used to guide the development of curricular resources for dental education.
Contributor Information
Dr. Kathryn N. Huggett, Office of Medical Education, School of Medicine, Creighton University.
Dr. Gary H. Westerman, Department of Community and Preventive Dentistry, School of Dentistry, Creighton University.
Dr. Eugene J. Barone, Department of Family Medicine, School of Medicine, Creighton University.
Ms. Amanda S. Lofgreen, Office of Medical Education, School of Medicine, Creighton University.
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