The Trajectory of Pharmacology Education in Dentistry: Is a Course Correction Needed?
Frederick A. Curro, DMD, PhD; Mahmood S. Mozaffari, DMD, PhD; Roy L. Stevens, DDS; and William Warner, PhD
In effort to stem the opioid epidemic, the authors of this editorial urge reforms for dental training by returning to the basics. This near abandonment of foundational sciences by stakeholders is at a high price: compromised patient safety and health
Through research and development, dentistry, like other healthcare-related fields, has improved the nation’s oral and general health. Despite such success, the general decline in the quality of higher education described by Bloom1 has continued, and this trajectory has made its way to dental schools teaching pharmacology, to which this editorial is directed. This problem is manifested particularly in many dental practitioners’ understanding and appreciation of the science and clinical application of pharmacology. We, the authors of this editorial, have become concerned about an educational gap in knowledge of the basics and applications of pharmacology in contemporary dental education and practice. We believe this is largely due to the substitution of a therapeutics approach for the science of pharmacology in the dental curriculums. Because pharmacology is dynamic and continuously evolving, this replacement has far-reaching consequences. The US Food and Drug Administration approves each year an average of 60 drugs, which poses new challenges of potential drug interactions and adverse effects for the prescribing clinician. At the same time, a growing number of systemic disorders, such as diabetes mellitus, are now managed with polypharmacy and considered to be chronic diseases, thereby complicating medical histories and the consequent risks for dental practitioners administering or prescribing medication. The manifestation of this educational decline is seen in the reported cases of mortalities in dental offices as a result of inappropriate use of medications to achieve sedation and general anesthesia and in the clinical use of opioids for postoperative pain management. Dentistry is not the only healthcare profession identified with having a decreased emphasis on the science of pharmacology in dental-school curriculums. A recent policy statement released from the American College of Clinical Pharmacology reported similar findings in medical and nursing schools.2
The misuse and abuse of opioids leading to addiction and increased death rates in the United States is now a national concern. Although the cause is multifaceted, a major issue can be linked to an increasing de-emphasis of the foundational-science curricula and the general attitude of students who view the learning of basic sciences as obstacles, rather than needed tools, for engaging in the delivery of dental care.
A History of Pharmacology Education
Pharmacology has traditionally been taught starting with general principles of pharmacokinetics and pharmacodynamics and progressing through the classes of drugs, with in-depth pharmacology of the prototypical agent from each class being stressed. This was to limit memorization of the many drugs available but require the student to remember the differences of each drug as compared to the prototypical agents. For example, a whole host of opioid agents can be compared and contrasted to the prototypical opioid agent, morphine, to discern their proper use and dosages. As new drugs become available in the marketplace, the reference drug becomes important clinically. This is to avoid having to assess the drug’s effects each time a drug is prescribed.
Pharmacology and Therapeutics
Therapeutics is the branch of medicine concerned with the treatment of disease and the action of remedial agents. Pharmacology is the science of drugs and their pharmacokinetics, pharmacodynamics, and pharmacotherapeutics, or their use in the treatment of diseases. Indeed, a thorough understanding of pharmacology is a prerequisite for proper therapeutic use of drugs, hence, the genesis of the term pharmacology and therapeutics. Inadequate appreciation of such distinctions and requirements has created a gap in the understanding of drugs and their use by clinicians. This is reflected in clinicians’ “drugs of choice,” the inadequacy of information dissemination to the patient, and, in the case of opioids, the lack of sufficient attention to their addictive potential, potential drug interactions and health hazards (including mortality), early manifestation of dependence and tolerance, and proper use and disposal. In an attempt to increase student clinic time, curricula have progressively de-emphasized foundational sciences and some schools would prefer to have certain aspects of basic sciences relegated as part of the predoctoral admission requirements or have guest lecturers rather than full-time qualified faculty teach foundational sciences. That, in and of itself, weakens the knowledge base for pharmacology, which is undoubtedly dependent on other foundational-science disciplines. One consequence would be that the school might lose control over course content and undermine the students they graduate. This turn of events is unfortunate and problematic because pharmacology is the obvious link between foundational and clinical sciences and embodies the term doctor, which allows a clinician to prescribe a medication while also assuming the responsibility of its effect and side effects.
Dental education can be weakened by a lack of prioritization of what is important to practice. Curricula are overburdened by content that can distract students from courses that have malpractice consequences and that create audit liability. The mission of professional schools must be to educate a knowledgeable clinician who can navigate specific topics affecting patient outcomes. Pharmacology is a core course requiring its well-deserved place in the curricula and to be reinforced by lifelong learning. The academic mission of many schools has become increasingly blurred, and an educational process defining a professional for many years forward has been somewhat misdirected.
Case-Based Therapeutics
Dental schools subscribe to certain metrics. For a science such as pharmacology, the metric is the performance on the National Board Dental Examinations (NBDE). Previously, NBDE included 100 questions about pharmacology. Today, the pharmacology component is comprised of 31 questions, only 5 of which are dedicated to analgesic medications. In addition, pharmacology is a small part of a comprehensive examination for which the knowledge base in pharmacology has minimal impact on a passing grade. Consequently, both students and programs have de-emphasized this important component of dental education, favoring a shift toward case-based therapeutics (CBT). Often in CBT, meaningful assessment of pharmacologic properties of medications is essentially overlooked, along with the essentials of proper dosing based on pharmacokinetics. Such shortcomings can be manifested in various ways, including the wrong choice of medication and inappropriate medication regimens resulting in suboptimal therapeutic responses or toxic reactions. With respect to pain management, dental practitioners’ main concern is to alleviate pain and many may have a propensity to use opioids without due considerations of the physiologic basis of maxillofacial pain and discomfort.
The authors believe CBT is an important supplementary component of dental education but not an acceptable substitute for the science of pharmacology, the primary armamentarium that a clinician has for treating pain in a patient. An oversimplified presentation of pharmacology, CBT was initiated as an attempt to integrate basic sciences with clinical sciences early in the curricula and to respond to students’ complaints of “relevancy of the subjects being taught.” But one cannot present enough cases to make a student knowledgeable about the many aspects of drugs. Rather than teach the science of pharmacology, the courses have shifted to therapeutics. This shortchanges the students’ abilities to build on their education in the future, producing inadequate skills in students to enable them to navigate the complexity of the literature and define what is important. Consequently, dental-school graduates may have to rely heavily on the pharmacist for a proper course of medication therapy. However, this is a misguided approach, for it is the clinician who has knowledge of the medical history of the patient and the patient’s procedural-based needs. Only the clinician has the privilege to prescribe medication but also bears the responsibility for it.
Whose Responsibility Is It?
In this brief communication, we have opined on the national crises of opioid misuse and addiction and focused on the inadequate knowledge base of clinicians regarding the science of pharmacology as a primary culprit. As alluded to above, our contention is further supported by the recent reports of mortalities involving sedation and anesthesia procedures in dental offices, which is suggestive of a dire need to identify all contributing factors and address them properly. We believe the responsibility lies at several levels, including dental schools, dental educators, students, dental practitioners and patients. Clearly, the responsibility and accountability should be proportional to the role of the individual and/or academic centers in the challenges we face in this arena. With respect to academic education, we hope the ongoing attempts to revise dental-school curricula would be considered as an opportune time to strengthen foundational sciences, including pharmacology, rather than further downsizing them. Students must also assume the responsibility for their own education and demand meaningful offerings of foundational sciences. Patients must be informed of relevant aspects of therapeutic agents and adhere to clinicians’ instructions. The use of opiates and opioids dates to ancient cultures, and these substances have played a valuable role throughout history. Yet, we are now faced with an epidemic of opioid misuse and abuse that we know stems from lack of due consideration of their properties and how to properly utilize them for their therapeutic effects while avoiding adversities to the individual and the larger society.
Conclusion
While the authors acknowledge the advancements in dentistry, challenges remain, one aspect of which is the focus of this communication. We hope this editorial will lead to a frank and informed discussion among all stakeholders with the ultimate objective of helping to prevent inappropriate use of medications in dentistry, especially opioids. Vertical or horizontal integration of a science such as pharmacology requires, first, a core knowledge base to even discuss the integration at a clinical level and any other interpretation under the guise of exposing the students to an early clinical experience has only weakened their knowledge base. As dental educators and clinicians, we firmly believe that the educational opportunities provided to future clinicians should be strengthened to better achieve our objective of graduating doctors of dental medicine and surgery.
References
1. Bloom A. The Closing of the American Mind. New York, NY: Simon and Shuster; 1987.
2. Wiernik PH; for the Public Policy Committee of the American College of Clinical Pharmacology. A dangerous lack of pharmacology education in medical and nursing schools: a policy statement from the American College of Clinical Pharmacology. J Clin Pharmacol. 2015;55(9):953-954.
Disclaimer
The authors of this editorial are senior academics and/or practicing clinicians, each having decades of experience either in clinical practice and/or directing pharmacology courses in dental schools. The views described in this communication are solely those of the authors, and not of their respective institutions/affiliations.
Acknowledgment
The authors wish to honor the memory of their colleague and friend, Dr. William Brockman (University of Missouri—Kansas City), with whom they had several fruitful conversations on the focus on this editorial.
