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Trends in Behavioral Sciences Education in Dental Schools, 1926 to 2016

Linda Centore, PhD, ANP

Abstract: This article outlines the journey of behavioral sciences education from a multidisciplinary array of topics to a discipline with a name, core identity, and mission in dental schools’ curricula. While not exhaustive, it covers pivotal events from the time of the Gies report in 1926 to the present. Strengths and weaknesses of current behavioral sciences instruction in dental schools are discussed, along with identification of future opportunities and potential threats. Suggestions for future directions for behavioral sciences and new roles for behavioral sciences faculty in dental schools are proposed. This article was written as part of the proj- ect “Advancing Dental Education in the 21 st Century.”

Dr. Centore is Health Sciences Clinical Professor and Chair, Division of Behavioral Sciences and Community Dental Education, University of California, San Francisco School of Dentistry. Direct correspondence to Dr. Linda Centore, Division of Behavioral Sciences and Community Dental Education, University of California, San Francisco School of Dentistry, 707 Parnassus Avenue, Box 0758, San Francisco, CA 94143; 415-502-6301; Linda.Centore@ucsf.edu.

Keywords: dental education, behavioral sciences, curriculum, dental curriculum, doctor-patient relations, communication

Submitted for publication 1/27/17; accepted 3/15/17 doi: 10.21815/JDE.017.009

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T his article aims to broadly review the history

of teaching behavioral sciences in dental

curricula as an aspect of the current state of

dental education (Figure 1). It was written as part of the project “Advancing Dental Education in the

21 st Century.”

Revolutionary guidelines for dental education emerged in the early 20 th century as a result of Wil- liam J. Gies’s Report on Dental Education in the United States and Canada. 1 As dentistry defined itself as a closely aligned but separate profession from medicine and proposed higher education require- ments to doctoral level education, a new standard was created. This included newly desired qualities, characteristics, and expectations for dentists. Gies described the conscientious dentist as one who is

mentally, emotionally, and socially mature with qualities of “self-control, attention, courtesy, kind- liness, sympathy, tact, and good will.” While this proposal was empowering for dentistry, achieving agreement among the schools took time. The 41 member schools of the American Association of Den- tal Schools (AADS; now American Dental Education Association, ADEA) endorsed these progressive recommendations, but several decades passed before they were fully accepted. 2 The Gies report planted the seeds for new behavioral expectations for dentists. In addition to competence in technical restorative skills, the report stated that dentists should be caring and compas-

sionate clinicians. Gies believed that a well-rounded dental education would humanize dentists and lead to better patient care. “Behavioral science,” a term coined in 1951, is defined as a “branch of science (i.e., psychology, sociology, or anthropology) that includes human interaction and provides generalizable prin- ciples about human behavior in society.” 3 This new branch of science gave a designation to a collection of topics relevant to understanding human behavior deemed important in educating dental professionals. By the 1970s, these topics had coalesced and gained a solid presence in dental curricula. Dworkin, a signifi- cant contributor to that development, saw the need to incorporate multiple disciplines and include relevant aspects of psychology, anthropology, sociology, pub- lic health, epidemiology, statistics, and economics. 4 In the beginning, dental faculty members called on colleagues in psychiatry, psychology, or sociol- ogy to teach behavioral sciences to dental students. Well-intentioned, non-dental faculty members could not fully comprehend dentistry’s patient manage- ment challenges and struggled with which aspects of human behavior or social sciences to teach. 4,5 Content did not immediately translate into relevance for dental students or positively impact patient care. Initial attitudes toward behavioral sciences by dental faculty and students could be described as ambivalent at best. A new perspective was needed to connect human behavior and patient management skills to the relevant clinical context in dentistry.

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Figure 1. Timeline of the development of behavioral sciences in dentistry and dental education From

Figure 1. Timeline of the development of behavioral sciences in dentistry and dental education

From the 1970s to the 1990s, Dworkin and other notable behavioral scientists succeeded in creating a map for behavioral sciences instruction and promoted what it could offer dentistry. Further evidence of the increasing significance of behavioral sciences was its new presence in dental education research. Proposals requesting funding for research in this new field of behavioral sciences flowed into the National Institute of Dental Research (NIDR; now National Institute of Dental and Craniofacial Research, NIDCR). However, the authors of those proposals came from such diverse educational back- grounds that NIDR staff were confused regarding who should review them. 6 During the mid-1990s, dental educators agreed that behavioral sciences content would improve the dentist’s ability to successfully interact with patients. Dworkin identified two formidable obstacles to educating dental students to internalize humanistic attitudes in dental school: the pressured dental cur- riculum with little time for personal growth, and the narrow faculty focus on teaching hand skills. 4 He declared that self-awareness, reflection, the student-

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doctor-patient relationship, and working with other health care professionals and the community were essential. 7 Dworkin and Gershen were pioneers who implemented active and experiential learning methods to assist dental students in increasing their awareness of patients’ emotional experience of the doctor-patient relationship and treatment. 7,8 Educated and trained as dentists and psychologists, these in- novators brought relevance to the field of behavioral sciences and moved the field forward by virtue of their interprofessional lenses.

Teaching Behavioral Sciences: The Path to Relevance

While gaining traction, behavioral sciences instruction was by no means unanimously accepted in dental schools. In a 1969 survey, Jetterson discov- ered that 60% of U.S. dental schools did not have formal instruction in behavioral sciences. 9 He learned

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that 85% of dental students initially reported they believed behavioral sciences courses would be valu- able to their education; however, after taking their coursework, this dropped to 66%. Negative student opinion was related to choice of content and teaching methods. These findings underline the challenge of teaching behavioral sciences: identifying the knowl- edge and skill sets needed for patient management, and integrating it with the relevant basic sciences and clinical dental sciences in a relevant context. Furthermore, Dworkin and other behavioral sciences faculty members realized behavioral sciences instruc- tion lacked a set of clear educational objectives. 7,8 In 1984, the first curriculum guidelines for be- havioral sciences instruction in dental schools were established. 10 In 1993, the Curriculum Guidelines Committee of the Section on Behavioral Sciences of the AADS (now ADEA) published new guidelines for behavioral sciences content. 11 The accrediting and regulatory bodies who influenced these guidelines included the AADS, American Dental Associa- tion (ADA), Commission on Dental Accreditation (CODA), and Institute of Medicine (IOM). These guidelines provided didactic and clinical skill-based teaching recommendations in areas captured broadly as ethics; professional socialization; stress and pain; self-awareness; communication and interviewing; developmental needs of the child, adolescent, adult, and older adult; patients with special needs; cultural awareness; management of anxiety; and practice management. These guidelines were aimed at stan- dardizing this aspect of dental curricula. In a survey of behavioral sciences hours (didactic and clinical) published in 1993, 39 U.S. dental schools reported an average of 41 total curriculum hours of interpersonal skills instruction, 49 hours of behavior management instruction, and 27 hours of anxiety and pain control instruction in behavioral sciences teaching, with 7-14 hours teaching these topics in clinic. 12 Schools varied widely in behavioral sciences teaching hours. Some integrated behavioral sciences topics into clinical general dentistry or specialty courses, and others offered stand-alone courses. The 1995 IOM report Dental Education at the Crossroads provided guiding principles and objec- tives for dental education. Two objectives from the IOM report were especially important to behavioral sciences: 1) reducing disparities in oral health status by disadvantaged economic, racial, and other groups; and 2) encouraging prevention at both the individual and community level. 13 Similarly, the 2000 surgeon general’s report on oral health re-emphasized the

integration of dentistry with medicine and described oral health disparities. 14 The report suggested cre- ating messages sensitive to language and culture to change public perceptions about prevention. A stronger message came from the surgeon general’s 2003 national call to action requesting culturally informed and linguistically accessible messages about the importance of regular oral health care to improve health literacy. 15 These influential reports raised awareness of the importance of personal and cultural health beliefs as they affect comprehension of need for preventive services. Additionally, they made clear the need for dental schools to go out to the community to serve those in need. Beginning in 2002, the Robert Wood Johnston Foundation funded Pipeline, Profession, and Prac- tice: Community-Based Dental Education grants to assist dental schools in providing clinical education in community clinics and to inspire dental students to choose community clinics as a career path. 16 Schools with pre-existing community-based pro- grams expanded them, and those without developed new community partnerships. Behavioral sciences instruction was developed to increase students’ cul- tural sensitivity to prepare them to work with diverse patient populations. Community-based dental educa- tion, now a CODA requirement, provides students with experience treating diverse populations of vulnerable and underserved patients. Despite some residual faculty ambivalence about students’learning dentistry at externship sites, students reported satis- faction in their reflective essays. 17 When surveyed, students reported positive experience with exposure to challenging clinical presentations, sociocultural issues (e.g., substance abuse, domestic violence, poverty, mental illness), and self-esteem-building experiences with patients, staff, and site dentists. 18 Donate-Bartfield and Lausten showed that provid- ing culturally sensitive patient care to reduce health disparities required an understanding of the patient’s perception, appreciation of cultural practices, good communication skills, and ethical reasoning. 19 They differentiated the need to understand cultural beliefs from attempting to “manage” or manipulate patient behavior, as health beliefs and behavior are a true reflection of culture. With all these developments, teaching inter- personal communication skills became a cornerstone of behavioral sciences teaching. Communicating ef- fectively and managing diverse patient populations involve sophisticated interpersonal skills. The novice clinician needs doctor-patient relationship skills such

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as creating a safe environment for disclosure, asking non-judgmental questions, active listening, the ability to empathize, clarifying and asking follow-up ques- tions, providing patient education in plain and simple words, and performing a teach-back for informed consent. Richards and Inglehart found that case- based, small-group teaching methods that brought together dental and behavioral sciences faculty in- creased dental students’ awareness of the importance

of psychosocial and cultural factors. 20 Influencing cli- nician attitudes and values in the service of increasing communication skills and cultural humility requires teaching methods that invite clinicians to examine their own behavior in the doctor-patient relationship. Simulation is required with demonstration/modeling, deliberate practice, and self- and peer assessment. The use of standardized patient actors or real pa- tients as teachers for dental students brings social, linguistic, and cultural traditions to life with imme- diacy and clinical relevance. Wagner et al. found that dental students who interacted with mock patients trained to present challenging social histories and cultural characteristics showed increased sensitivity to cultural differences on post-program surveys. 21 If dental students do not possess an understanding of cultural traditions and oral health beliefs, the patient is at high risk for making a decision that could be misperceived as “being non-compliant.” New skills were also needed for dentists to motivate patients with low oral health literacy to improve their oral hygiene and engage in preven- tive practices. Donate-Bartfield et al. advocated for

a multidisciplinary philosophy that could bring be-

havioral sciences, ethics, and public health together to create a broader context for teaching culturally sensitive patient care. 22 Examining assumptions, us- ing reflective listening, and showing empathy were

defined as essential tools. This approach develops cultural sensitivity and is aligned with the ethical

and public health responsibility of dentists. In addi- tion, motivational interviewing has brought dentistry

a counseling method that is superior in motivating

behavioral change when compared to conventional education 23 and provides dentists with a tool to im- prove preventive oral hygiene practices and increase compliance with caries management by risk assess- ment (CAMBRA) interventions. A paradigm shift has occurred in our under- standing about how to teach novice adult learners.

Ambrose et al. stated that “learning is a process, not

a product

something students themselves do.” 24 Behavioral

and is not done to students but rather

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sciences faculty members realize it is critical to identify learner motivation as it fuels their interest and informs their priorities for learning. Ambrose et al. stated that component skills, such as communica- tion skills, need practice and benefit from targeted feedback. Active listening, empathetic responses, interviewing skills, assessment and management of dental fear, and identification of oral health beliefs and oral health literacy level are component skills that need to be addressed. Teaching dental students to counsel patients in a simulated environment allows behavioral faculty to evaluate novice clinician inter- personal skills. Often dental students do not realize the value of interpersonal skills until they graduate and interact with patients in a practice setting. I have seen this confirmed in exit interviews when students rate whether content received during predoctoral education was adequate. The challenge for faculty members in behavioral sciences has consistently been how to focus selectively on the most critical skills given resource limitations. Over 90 years after the Gies Report, we have high expectations for the professional development of dentists and for the faculty teaching dental students and contributing to their professional socialization. While it varies by institution, behavioral sciences faculty members are accountable for teaching key parts of the content required in the CODA standards (Table 1). 25 Prioritization is often necessary due to time, personnel, and competing priorities. These pressures challenge the best-intentioned behavioral sciences faculty members to comprehensively ad- dress the 2016 standards.

Responding to a New Oral Health Care Horizon: The Path to Shape-Shifting

Behavioral sciences instruction sits at the dynamic intersection of acceptance, relevance, and integration for the purpose of achieving excellent communication and interpersonal skills in future den- tal graduates who must treat a diverse population. The more seamless the integration of behavioral sciences with basic and dental sciences, the more likely these skills will be perceived as relevant and be practiced. Routine oral health screening, evaluation, and treat- ment require tolerance of mild discomfort, accep- tance of intrusion into an orifice (the oral cavity), and perceptions about body image. The art and technique

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Table 1. 2016 CODA accreditation standards for predoctoral education that pertain to behavioral sciences

Dimensions of Diversity: relates to the curriculum, but may also involve aspects of structural and institutional climate diversity.

Principles of the Educational Environment: should involve comprehensive patient-centered care, critical thinking, self-di- rected learning, a humanistic environment, scientific discovery and the integration of knowledge, evidence-based care, assessment, application of technology, faculty development, collaboration with other health care providers, and diversity.

Humanistic Environment: relates to humanistic pedagogy that includes respect, tolerance, understanding, and concern for others and is fostered by mentoring, advising, and small-group interaction with respectful professional relation- ships between and among faculty and students that establishes a context for the development of interpersonal skills necessary for learning, for patient care, and for making meaningful contributions to the profession.

Diversity: relates to recognition that a significant amount of learning occurs through informal interactions among indi- viduals who learn directly and indirectly learn from their differences, and need to reexamine assumptions about themselves and their world. Programs must create an environment that ensures an in-depth exchange of ideas and beliefs across gender, racial, ethnic, cultural, and socioeconomic lines.

Curriculum Management 2-6 Biomedical, behavioral, and clinical science instruction must be integrated and of sufficient depth, scope, timeliness, quality, and emphasis to ensure achievement of the curriculum’s defined competencies.

Self-Assessment 2-10 Graduates must demonstrate the ability to self-assess, including the development of professional competen- cies and the demonstration of professional values and capacities associated with self-directed, lifelong learning.

Behavioral Sciences 2-15 Graduates must be competent in the application of the fundamental principles of behavioral sciences as they pertain to patient-centered approaches for promoting, improving, and maintaining oral health. 2-16 Graduates must be competent in managing a diverse patient population and have the interpersonal and com- munication skills to function successfully in a multicultural environment.

Ethics

2-20 Graduates must be competent in the application of the principles of ethical decision making and professional responsibility.

Clinical Sciences 2-22 Graduates must be competent in providing oral health care within the scope of general dentistry to patients in all stages of life. 2-25 Dental education programs must make available opportunities and encourage students to engage in service- learning experiences and/or community-based learning experiences.

Faculty and Staff 3-2 The dental school must show evidence of an ongoing faculty development process.

Source: Commission on Dental Accreditation. Accreditation standards for dental education programs. Chicago: American Dental Association, 2016.

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of the doctor-patient relationship require both its own place in the curriculum and integration in the con- text of general dentistry. Relevant behavioral skills assessments include creating a safe environment to disclose health history information; communicat- ing empathy and compassion when discussing bad news; assessing and successfully managing dental and injection fear; addressing unrealistic expecta- tions; assessing health literacy in patient teaching; and coaching patients to adapt to a prosthesis (e.g., partial or full denture) or accept complex treatment (e.g., scaling and root planing, periodontal surgery, extractions, or implants).

With an increasing population of patients with more complex medical, cognitive, and psychiatric conditions and multiple medications, dental stu- dents need high-level medical and psychological history-taking skills. Students need more training to assess, manage, and monitor cognitive capacity for giving informed consent for health care, as well as assessing controlled and uncontrolled conditions that may require modifications for treatment (e.g., patients with diabetes, dementia, traumatic brain injury, heart failure, chronic obstructive pulmonary disease, cancer, or major depression). There will be a need for enhanced knowledge and critical thinking

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about pharmacology and psychopharmacology along with a deeper understanding of how aging affects the absorption, distribution, metabolism, and elimination of medications. The dentist of tomorrow needs more patient management skills including sophisticated communication and interpersonal skills to interact with patients and all members of the health care team. Increasingly, interprofessional education and practice will immerse dentists in the medical environment and bring much-deserved respect to dentists who complete the health care team. Behavioral sciences instruction must dem- onstrate flexibility to meet challenges ahead as the landscape changes. What would Gies say about dentistry in the 21 st century? He would likely com- ment that the profession has evolved from a cottage industry to a profession with evidence-based guide- lines. He might recommend an open-minded stance for dentists who fear change in health care delivery models or a loss of autonomy from interprofessional collaboration or mid-level providers. He would likely advise re-envisioning dental education to prepare future dentists for practice settings that currently do not exist. Behavioral sciences faculty members are partners in educating the dentists of tomorrow. As we work together toward that goal, it is important to keep in mind the strengths, weakness, opportunities, and threats (SWOT) to behavioral sciences instruc- tion in dental schools today. I provide my SWOT analysis in Table 2.

Discussion

The dentist of tomorrow must be compassion- ate, evidence-based, highly skilled, and ready to collaborate with and be part of an interprofessional health care team. Communicating effectively with other health care professionals is essential. In a rap- idly changing population, the dentist of tomorrow needs to be comfortable with communicating with diverse populations. The Cultural and Linguistically Appropriate Services (CLAS) Guidelines recom- mended by the U.S. Office of Minority Health will likely have a greater impact on dental practice in the future. 26 With a shift toward non-white major- ity cultures, 27 Limited English Proficiency (LEP) patients and those who prefer oral health care infor- mation in their first language will expect that dental professionals provide professional interpreters in all dental practice settings and provide translated patient education materials, treatment plans, and

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consent forms in all languages representing 5% or more of the surrounding demographic. Schools will need to move toward professional interpreting sys- tems or create options for oral certification exams for students, staff, and faculty. At the same time baby-boomers are aging and living longer, requiring an expansion of care in geriatric dentistry, we do not have a sufficient number of dentists to treat the oral health needs of children. 28 Behavioral sciences content is therefore needed to expand the graduating dentist’s competence in treating diverse populations. One could predict that dentistry will eventually ac- cept mid-level practitioners as medicine has with nurse practitioners and physicians’ assistants. New roles require clarity, communication skills, and team function. Behavioral sciences faculty members are poised to provide education to address these needs.

Conclusion

Behavioral sciences faculty members are highly valuable interprofessional colleagues who contribute significantly to the professional social- ization of dentists. Behavioral sciences education humanizes the novice learner by providing knowl- edge, influencing attitudes, and teaching patient management skills. As partners and resources, behavioral sciences faculty members stand ready to educate dentists in new roles. Gies would be pleased to see how far we have come in human- izing dentists to create compassionate, caring oral health care providers. With the needs of aging and diverse populations and an insufficient number of dentists to treat children, new roles, and health care delivery models, dentistry will need all of its health care colleagues, including the behavioral sciences faculty. Imagine a health care home where the dentist is a colleague welcomed and part of the health care team. We have already moved from an emphasis on interprofessional education to thinking about the infrastructure and mechanisms needed to create a health care home where dentistry practices alongside medicine, nursing, pharmacy, and mental health in providing comprehensive care. There are many changes occurring in our health care system. Dental curricula will need to shape-shift to meet the needs of the public for greater access to care, to address changes in both the dental and health care practice environment, and to advance with sci- ence as new developments impact oral health. As the silo environment of solo private practice sunsets, a

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Table 2. Strengths, weaknesses, opportunities, threats (SWOT) analysis of the behavioral sciences curriculum today

Strengths

1. Behavioral sciences curriculum is a key component in dental curricula and required by the Commission on Dental Accreditation (CODA). Most behavioral sciences faculty are faculty with at least a master’s degree and more often a doctoral degree in clinical or educational psychology, social work, or nursing.

2. Behavioral sciences curriculum content adapts to changes in CODA competencies for dental school curricula. It is taught by faculty with a working knowledge of dentistry or co-taught with dentists for increased relevance to actual practice.

3. Behavioral sciences faculty have been fully integrated into dental schools with some holding clinical, administrative, or research positions such as division chairs, department chairs, or deans and are leaders within their institutions.

Weaknesses

1. Behavioral sciences curriculum is often the primary responsibility of one or two full- or part-time faculty members. Given competing academic demands, faculty members must make choices about content and emphasis based on available curriculum time, dental faculty colleague availability for content relevance, resources, and expertise.

2. Achieving basic competence in communication and interpersonal skills in order to serve a diverse population requires the iterative process of experiencing, reflecting, thinking, and acting. Teaching and assessing these skills are time- and labor-intensive and, as such, require additional faculty, space, and simulation time and resources similar to the development of other performance skills.

3. Succession planning for behavioral sciences faculty in dental schools requires identifying candidates with expertise in multiple areas: psychological assessment and intervention skills, educator training, and working knowledge of patient care issues in dentistry.

Opportunities

1.

A

doctoring and professionalism course brings together topics related to professional socialization and identity and

patient management skills in the service of developing an emotionally mature clinician. Skills would include inter- viewing and medical/dental/psychosocial history taking; managing ethical dilemmas in clinic; determining capacity and obtaining informed consent; dental anxiety/fear assessment and management; motivational interviewing; conflict resolution; determining a good faith relationship; dismissing a patient; and documentation skills.

2.

Establish a pipeline for behavioral sciences teaching succession planning by creating continuing education courses, certificate programs, or postdoctoral fellowships in behavioral dentistry for psychology, social work, and nursing

doctoral-level graduates to attract new candidates. Having these graduates rotate through clinical dentistry as part of

a

behavioral health rotation may inspire interest.

3.

Behavioral sciences teaching is offered by both clinical and research behavioral sciences faculty. Behavioral clinical faculty members add significant value to predoctoral and postdoctoral education with their clinical expertise. They are an asset to clinic directors, faculty, and students in clinic and could be considered for leadership positions such as dean of student affairs or dean of diversity and inclusion.

4.

Behavioral research faculty add significant value to predoctoral and postdoctoral education in mentoring students and residents on research projects and theses, respectively. They are an asset to the research enterprise and scholarly infrastructure in dental schools and could be considered for positions such as directors of predoctoral or postdoctoral educational assessment or deans of research.

5.

Virtual, simulation, and standardized patients used in OSCEs could be shared among health professions programs, both for purposes of sharing resources and for interprofessional education.

Threats

1.

As new technology, discoveries, procedures, and materials emerge in dentistry, there will be increased competition for curriculum time. Behavioral sciences may face challenges in retaining hours for didactic instruction and simula- tion experiences.

2.

As the expense of dental education rises, schools will look to save money on their most expensive item: faculty salaries. This might lead to moving more content online and creating more interprofessional courses. As this occurs,

it would be important to make sure dentistry’s unique patient management issues are included.

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new and more collaborative form of dentistry dawns, and behavior sciences will be there to help.

Acknowledgments

The author wishes to acknowledge the follow- ing individuals who made incisive comments that improved the clarity of ideas and flow of thinking:

Susan Hyde, DDS, MPH, PhD, Associate Professor, Department of Preventive and Restorative Dental Sci- ences, School of Dentistry, University of California,

San Francisco; Anne Koerber, DDS, PhD, Professor, Department of Oral Medicine and Diagnostic Sci- ences, College of Dentistry, University of Illinois at Chicago; George Taylor, DMD, MPH, DrPH, Profes- sor, Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of Cali- fornia, San Francisco; and Evelyn Donate-Bartfield, PhD, Professor, Department of Dental Developmental Sciences/Behavioral Sciences, College of Dentistry, Marquette University.

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Editor’s Disclosure

This article is published in an online-only supplement to the Journal of Dental Education as part of a special project that was conducted indepen- dently of the American Dental Education Association (ADEA). Manuscripts for this supplement were reviewed by the project’s directors and the coordina- tors of the project’s sections and were assessed for general content and formatting by the editorial staff. Any opinions expressed are those of the authors and do not necessarily represent the Journal of Dental Education or ADEA.

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