changing the face of basic science teaching in dental

Dharini van der Hoeven, MSc, PhDLincoln Edwards, DDS, PhD

The University of Texas Health Science Center‐School of Dentistry

Bruce D. Gitter, MS, PhDIndiana University School of Dentistry

Changing the face of basic science teaching in dental education

Learning Objectives

• Describe different pedagogic approaches that can be utilized to make basic science learning interesting to students

• Discuss approaches utilized to integrate pharmacology into clinical disciplines

• Exhibit practical ways of demonstrating importance and relevance of basic sciences to clinical practice

• CODA STANDARD 2‐11: “Biomedical science instruction in dental education must ensure an in‐depth understanding of basic biological principles consisting of a core of information on the fundamental structures, functions, and interrelationships of the body systems”

Why this is so important?

• CODA STANDARD 2‐14: “Graduates must be competent in the application of biomedical science knowledge in the delivery of patient care”

• Provide a solid foundation for life‐long learning

• A necessary obstacle they have to “survive” before embarking on the more important clinical sciences

• Basic sciences are less important for dental practice

• There is no need to learn as many biomedical facts as possible before entering clinical practice

• Basic sciences are irrelevant for dental practice

• Basic sciences are boring

A dental student’s perception of basic sciences

Learning Objective 1

Describe different pedagogic approaches that can be utilized to make basic science learning

interesting to students

Making basic science learning exciting, engaging and relevant

Use of classroom response systems• Numerous benefits in classes, including……

• improved student engagement•enhanced formative feedback for instructors•easy quizzing tools•a means to take attendance


Multimedia instruction• Integrating varying formats such as lecture, text, graphics, audio, video, and web resources increases motivation, alertness, and can improve the quality of student responses.


An example of the use of video in instruction• When teaching the “Singer and Nicolson Fluid Mosaic Model of Membranes”,

instead of trying to explain how the membrane proteins can move laterally on the plane of the membrane, show it in real‐time.


An example of the use of web resources in instruction• When teaching the different web resources available for obtaining drug information, rather than simply listing them, navigate the websites and show students how to obtain information


Incorporate as many dental relevance as possible (and try to incorporate latest research findings)

Armed to the teeth with αvβ6 integrin• Tooth enamel is the hardest mineralized tissue in the body and is produced by cells called

ameloblasts.

• During the secretory stage of amelogenesis, enamel proteins such as amelogenin are secreted into the enamel matrix, which is in direct contact with the ameloblast plasma membrane.

• A recent study shows that integrin αvβ6 is expressed in ameloblasts where it regulates deposition of amelogenin and subsequent enamel biomineralization.

• In mice deficient in αvβ6 integrin (Itgb6−/−), the researchers found chalky rounded incisors, with a significantly reduced mineral‐to‐protein ratio, whereas the molars of these mice show reduced mineralization and severe attrition.

Slide from lecture on “Extracellular Matrix and Integrins”, Biomedical Sciences Core, Fall 2015

Teeth from 6-month-old Itgb6−/− mice show severe attrition.

Leila Mohazab et al. J Cell Sci 2013;126:732-744

©2013 by The Company of Biologists Ltd

Slide from lecture on “Extracellular Matrix and Integrins”, Biomedical Sciences Core, Fall 2015


Student‐centered learning activities during lecture

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ACROSS1 An oral adverse effect that could be produced by anticholinergics6 Primary neurotransmitter released by postganglionic sympathetic fibers 7 Sympathetic activity causes bronchial smooth muscle ________ 8 There is normally a _______ in the autonomic nervous system that can be increased or decreased 9 Neurotransmitter between pre‐ and post‐ganglionic nerves 10 In autonomic efferent innervation, this fiber originates in the CNS and ends in a synapse

DOWN2 Another name for sympathetic division3 Most preganglionic fibers of this division are short and postganglionic fibers are long 4 Primary function of this division is conservation of body processes and maintenance of organ function 5 Response produced by parasympathetic division

Example: Cross‐word puzzle

Slide from lecture on “Introduction to Autonomics”, Principles of Pharmacology, Summer 2015

Classification of agonists

Increased response

Decreased response

Constitutive response

Receptors are constitutively active

Slide from lecture on “Pharmacodynamics I”, Principles of Pharmacology, Summer 2014

Example: Small group discussion

Full Agonists

Increased response

Decreased response


Drugs that bind to receptors and activate the receptor‐effector systems to the maximum extent of which the system is capable


Partial Agonists

Increased response

Decreased response


Drugs that bind to receptors and activate them but do not evoke as great a response, no matter how high the concentration


Inverse Agonists

Increased response

Decreased response


Drugs that bind to receptors and decrease activity of the receptor‐effector system


Inverse Agonists are different from Antagonists

Increased response

Decreased response


• Antagonists bind to receptors but do nothing ‐ they neither increase or decrease receptor response

• Antagonists merely block the binding of agonists• Competitive antagonists bind to the agonist binding site and prevent the binding of

agonists Slide from lecture on “Pharmacodynamics I”, Principles of Pharmacology, Summer 2014

Inverse Agonists are different from Antagonists

Increased response

Decreased response


Allosteric antagonists bind allosterically and change the conformation of the agonist binding site and thereby prevent agonist binding


Pharm Fun!

• Break up into groups of three

• Discuss the questions for a total of 2 minutes

• Be prepared to come to the front and explain the answer!!Slide from lecture on “Pharmacodynamics I”, Principles of Pharmacology, Summer 2014

Full agonist

If the dose response effect for a full agonist is as shown below…..

For the same receptor, what will the dose response curve look like for a1. Partial agonist2. Antagonist3. Inverse agonist


Relationship between drug concentration and effect


How do I know this approach works?


Exhibit practical ways of demonstrating importance and relevance of basic sciences to clinical practice

• Exhibit practical ways of demonstrating importance and relevance of basic sciences to clinical practice–An understanding of the basic sciences is needed to identify specific targets for selective inhibition.

–Clinically, an understanding of the mechanism of action of drugs can help to explain drug selection and treatment strategies.

Introduction

• BP > 160/100 no invasive dental treatment• Knowledge of physiology of SNS, kidney, RAS• Understanding of mechanism of elevated BP• Development of many and effective drugs• Hypertension is now controllable

Importance of Basic Science to the Treatment of Hypertension

Importance of Basic Science to the Treatment of Hypertension

Hypertension, VoL 8, No 4, APRIL 1986

Effect of Clonidine on Blood Pressure

http://rx‐metronidazole.net/work.html

1. Mechanism of Action of Metronidazole2. Spread of odontogenic infections

Importance of Basic Science to the Treatment of Infection

A 21‐year‐old woman had condylar resorption after orthognathic surgery. History, examination, and blood work showed that the patient did not produce estrogen. The condylar resorption occurred over a 34‐month period and resulted in a Class II occlusion with anterior open bite. Sagittal TMJ slices and lateral cephalometric radiographs obtained before surgery (A), 7 months after orthognathic surgery (B), and 34 months after orthognathic surgery (C) are shown.

Gunson, Arnett, and Milam. Pharmacologic Control of Condylar Resorption. J Oral Maxillofac Surg 2012.

Importance of Basic Science to the Treatment of Condylar Resorption

Gunson, Arnett, and Milam. Pharmacologic Control of Condylar Resorption. J Oral Maxillofac Surg 2012.


Journal of Oral and Maxillofacial Surgery, Volume 70, Issue 8, 2012, 1918 - 1934


A. Steroid withdrawalB. Pregnancy

Importance of Hypothalamic‐Pituitary‐Adrenal Axis to Clinical Practice

Prednisone Prednisolone

Matthael et al. (2000) Endocrine .Reviews. 21(6):585-618

Importance of Basic Science to the Treatment of NIDDM

Treatment of hypoglycemia with glucose or glucagon

• Aspirin and Ibuprofen• Antibiotics and oral contraceptives• Warfarin and NSAIDs• Tramadol and SSRI• Macrolides and Statins• Benzodiazepines and grapefruit juice• Metronidazole and alcohol

Importance of Basic Science to Drug Interactions

Student Evaluations

Essentials in Medicine II, Fall 2015 (DS3)

Medical Pharmacology, Spring 2014 (DS3)


Discuss approaches utilized to integrate pharmacology into clinical disciplines

Approaches to Integrate Pharmacology into Clinical Disciplines

• Pharmacology education in dental school is an integral part of basic medical sciences education and is critical to the clinical training and successful practice careers of future dentists

• Students must pass NBDE Part II for licensing

High Level Rationale

Deeper Dive Rationale (but still obvious)

• Dentists use and prescribe drugs

– Local anesthetics– Post procedure pain– Sedation/Anxiety– Infection/Inflammation– Caries prevention– Xerostomia– Smoking cessation– Emergency drugs

The Complete Dental Patient

• Obtaining and understanding comprehensive medical histories, including current medications and allergies, are critical to providing excellent and effective dental care

• Patients often take multiple prescription/non‐prescription drugs and nutraceuticals that may or may not influence dental treatment plans and outcomes

• Typical patients:• ~ 50% are taking at least 1 prescription med

• 10‐11% take 5 or more prescription meds

(not just a mouth with teeth)

Integrating Pharmacology Into Clinical Disciplines: Key Dental Education Goal

• Though classroom and clinical training, students should learn to integrate patient’s medical (including drug) history as part of their overall treatment strategy

• Certain conditions, particularly those resulting in a medically compromised patient, have significant effects on oral health and dental treatment plans

How do we insure and determine if students integrate their pharmacology training into clinical practice?

• Start in the classroom • In addition to traditional basic pharmacology instruction in the D1‐D3 years, incorporate advanced pharmacotherapeutics into D1 and D2 SABS courses (Systems Approach to Biomedical Sciences)

– Anatomy, histology, physiology, and pharmacology of (modular) systems

D1• Immunology• Endocrinology• Neuromuscular• Respiratory• Cardiovascular• Gastrointestinal

D2• Hematology• Reproductive/

Urinary• Musculoskeletal• Dermatology

Add case‐based pharmacology assignments for each modulethat focus on the integration of pharmacology into clinical practice

Evaluate and Train

• Start with an investigation of how students collect and document patient medical history, including current medications– Design baseline study to assess

student’s perception and performance

• Perception via survey• Performance criteria:

– Proper drug name and spelling

– Class– Dose/frequency– Indication– Potential oral effects– Medication‐condition

consistency– Individual and overall drug

% complete

• Clinical Education– Investigate status and develop best practices

A Complete Medication History Contains:

• Proper drug name– Correct spelling

• Drug class– e.g. ACE inhibitor, statin, sulfonylurea,

bisphosphonate

• Indication– Often inferred from the medical history;

need to confirm

• “why are you taking this drug?”

• Medication‐condition consistency– critical to understanding patient’s

overall medical history

• Dose and frequency– Confirm with patient (for

example, did you inject your insulin dose this morning? How much? Have you taken your asthma meds today?)

• Potential oral effects and dental care issues– Interactions– Contraindications– Treatment plan concerns

• Individual and overall drug % completion– Provides quantitation for

statistical analyses

• Analopril– Vasotec (enalapril)

• Lumagin– Lumigan (bimatoprost)

• Sytomel– Cytomel (liothyronine, T3)

• Karafat– Carafate

• Adver– Advair (salmeterol/fluticasone)

• Flowvent– Flovent (fluticasone)

• Pravostatin– Pravachol (pravastatin)

• Atenola– Tenormin (atenolol)

Gems: Proper drug name and spelling

• Nexus– Nexium (esomeprazole)

• Naproxin– Naproxen

• Tyleonol– Tylenol (acetaminophen)

• Perocta– Percoset (oxycodone/acetaminophen)

• Reyatz– Reyataz (atazanavir)

• Vatrex– Valtrex (valacyclovir)

• Amoldepine/BenAZP– Amlodipine/benazepril

• Dicloflonate– Diclofenac

Gems: Examples of patient‐reported current medications

• “Another drug for HTN” • “Prostata”

–No reported conditions• “Patient unsure”

–Reported type 2 diabetes, emphysema, triple bypass 22 yrs ago

Current Study Status

• Collaboration with D2 Student, Wesley Burcham and Dr. Laura Romito (IUSD)

• Baseline study underway to assess D3/D4 student’s perception and performance–After data collection and analysis, design and implement mitigation strategy

–Repeat study in 2‐3 years to measure effects of mitigation strategy.

–Present/publish results

Time for Questions

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changing the face of basic science teaching in dental

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