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  • Dr. David Alfaro

So I have graduated, now what?

I am sure that I have been boring the non-dentites with my recent streak of dental related articles. Well, being a nerdy dentist, dental education seems to be a topic that is frequently on my mind.

The Canadian Dental Association publishes articles online that are relevant to our profession, and a recent one caught my eye, one that is very related to what I have been writing about lately. Those who have been following along will surely notice that I place a big emphasis on the importance of formal advanced training in dentistry, including post graduate residencies and specialty programs.

Nobody graduates from dental school a master in his/her craft.

An article was recently published online in the Journal of the Canadian Dental Association, which evaluated the future career goals of graduating dental students of the University of Alberta. It lists the preliminary results of a five-year study, and makes comparisons to trends in Canada and the United States.

So what are these trends?

Find out here:

Let us talk about what dental students do after graduation.

What do graduating dentists plan on doing after they complete their programs?

It would be great to have up to date national statistics on this, but unfortunately this one study was limited to students from one university in Canada. In the US of A, however, graduating students have to take exit surveys that are administered by the American Dental Education Association (ADEA) before picking up their diplomas. This offers dental educators feedback on the experiences and future plans of graduating dentists on a yearly basis, with the accepted biases of survey based information collection.

Although I looked and looked, I could not find similar data from Canada from the last decade, so if anyone knows of a good resource, please let me know!

The aforementioned article states that almost 90% of the dental students in Alberta (2012-2014) planned to go directly into private practice without any further residency or specialization. Only one student in the three years surveyed was enrolling in a specialty program right out of dental school.

In comparison, ADEA research on students who graduated from American programs in 2013 indicate that only 48% of students were planning on entering private practice right away, with 30% of students surveyed believing that a 1 year residency should be MANDATORY. 49% of graduating students in the USA in 2013 applied to residency programs!

Read more here:

I went to Columbia and right from day one, we were being exposed to specialty dentistry. We were expected to volunteer in oral surgery when our patients cancelled, we had mandatory assists in periodontics and endodontics, and we had a full day a week in fourth year at a hospital based residency somewhere in New York. Advanced education was force fed to us, and as a result, we realized that dentistry is hard, and that complex dentistry requires advanced training.

It is not uncommon for over 95% of the students graduating from Columbia to enter into a residency program right away, many directly into top specialty programs across the US and Canada.

So why the discrepancy between US and Canada?

This is a question that perplexed me when I returned back from the big apple and began my residency at the local university. Part of my program was to teach in the undergraduate dental clinic, and as I got to know the students, I encouraged them to get involved in the specialty programs, and recommended that they consider applying for residencies, just as the graduate students at Columbia did for me. I even organized seminars to introduce students to the various specialties, and for them to meet the residents, in hopes of planting a seed. But very few of the local students expressed any interest; many preferred to move to a small town and do as much work as possible instead of pursuing a formal advanced training in general dentistry.

The JCDA article referred to a 2006 study where UBC graduates of the 2003 class (about 30 of them) were surveyed to see what their career goals were, and compared them to students in Japan and Thailand. Only 25% of the UBC grads were interested in advanced education, again, lower than US numbers, but higher than what is currently happening in Alberta.

Is it because students feel ready to get out there?

Both in Canada and the United States, all accredited dental programs have strict regulations and monitoring to ensure that their students are finishing their educations competent to practice general dentistry upon graduating. Dental students should feel ready to get out there and work after dental school.

And indeed they do.

Of the over 4370 outgoing students in the 2013 ADEA survey, less than 10% of respondents felt either somewhat underprepared, or underprepared, in key areas of dentistry including diagnosis, treatment planning, basic restorative (fillings) and fixed prosthodontics (crown and bridge).

So yes, students do not feel underprepared in skills required of a general dentist.

But what about complex dentistry such as dental implants, orthodontics or endodontics?

These are complicated topics that are really just introduced to students during dental school. Student dentists are just learning how to use handpieces (drills), how to work using mirrors, how to work using proper posture, and then focus on basic procedures such as fillings, cleanings, dentures, and basic oral surgery. Many only get to do a dozen crowns, and maybe a bridge, and if they are lucky, an implant crown during the entirety of their education. Yes, students finish a couple of root canals, so they are introduced to endodontics, but they definitely do not get competent in the use of microscopes. Most programs do not have the students treating complex orthodontic cases at all.

The result is that graduating dentists do not feel so competent in advanced aspects of dental care.

Respondents in that same 2013 ADEA survery indicated that 17.4% felt underprepared, and 32% felt somewhat underprepared in implant dentistry, 6.7% and 21.3% in endodontics, and 30.3% and 32% in orthodontics, respectively.

That means that almost 50% of graduating dentists from American programs do not feel comfortable with implant dentistry, almost 25% for root canals, and over 60% for braces. This could be a major reason why students pursue formal advanced education in the United States at a much higher rate than in Canada.

Do Canadian students feel better prepared?

A plausible explanation would be that Canadian students feel better prepared in complex dentistry than graduates from American programs.

Again, I could not find Canadian data as reliable as the ADEA information, but if we refer back to the original article that I was talking about, only 62-76% of the U of A students felt that school had provided them with sufficient knowledge.......yet....89% go straight in to private practice. If we look at similar data in the 2006 article about the 2003 UBC grads, over 80% of the students who responded to the survey felt that dental school was too short of a period of time.

Nobody graduates dental school a master! Students from Canadian universities still feel underprepared in certain aspects of dentistry, just like their counterparts from American programs. It is nothing to be ashamed of, complex dentistry is difficult. Too difficult for novice dentists.

What kind of advanced training is available for dentists?

Going into a residency is not just about becoming a specialist. There are many excellent dental residencies that are geared toward general dentists. Some are hospital based (General Practice Residencies: GPRs), where dentists get the opportunity to work in operating rooms and deal with medically compromised patients, learn proper emergency management, learn proper sedation techniques, and gain advanced training in surgical care. Many students do a GPR year prior to applying to a specialty, especially for surgical programs.

There are also more academic, private practice style residencies geared toward students who want formal advanced training for the general dentist (Advanced Education in General Dentistry: AEGD). AEGD programs offer students formal education in dental implantology, dental ceramics, endodontics, oral surgery, and even practice management.

Furthermore, there are 1 year oral surgery and dental implant fellowships that can be taken if dentists really want to learn more about a specific topic.

If general dentists are interested in including advanced treatments in their clinical repertoire, there are excellent opportunities for them to acquire these skills in formal, accredited, university level programs. Yes, they may have to move away for a year and have to take a dock in pay, but the experience is invaluable, and anyone who has taken a program will come out years ahead of students who spent their first year out of dental school struggling to get used to the pace of private practice.

So why is Canadian student participation in advanced education so low?

Maybe we are broke after dental school?

We all graduate with mega debt, so that can be a major factor. But most of the residencies pay a stipend, and realistically no first year graduate is going to be killing it straight out of dental school. Especially in a saturated market like Vancouver.

Maybe students don't realize how complex advanced dentistry really is? Very few dental schools in Canada have a full compliment of dental specialties, so students do not get exposed to these types of advanced cases, and even if there are specialty programs, there has to be a strong interaction between the graduate and undergraduate programs for the students to really experience complicated dentistry.

Perhaps students think that continuing education is enough?

Like I have said a billion times, yes, while there are some great CE courses that can be taken to improve skills in advanced techniques, nothing replaces a formal dental residency or specialty training program.

It is not enough to take a CE course in sedation and feel that it suffices. Dentists really should have hospital based training if they plan on sedating people.

Dental Implants? Is a 30, or 60 hour course enough time to really learn dental implantology? No way. Many programs are weekend deals where you work on pig bones....what is stopping someone from drilling a couple of implants in a pig jaw and calling it a day. Course taken. I feel qualified.

No. Not acceptable.

Invisalign study club? Moving teeth with clear aligners is still orthodontics, and orthodontics is still complicated, even if a computer is doing all of the work for you. If you recall, 60% of students did not feel comfortable with orthodontics upon graduating, yet I see Invisalign posters in every office......

There are many great formal opportunities for dentists to get advanced training in Canada and the United States, yet our graduates are choosing to skip out. Moving to a small town to "gain experience" under a mentor is an excellent opportunity, depending on the mentor, but it will never replace the education that is given in a residency, under the guidance of many mentors, often specialists in their field.

Nobody graduates dental school an expert, but completing a residency sure helps build confidence in the right way.

Thanks for reading,

Dr. Dave


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