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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 21st 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;
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

his article aims to broadly review the history sionate clinicians. Gies believed that a well-rounded
of teaching behavioral sciences in dental dental education would humanize dentists and lead
curricula as an aspect of the current state of to better patient care. “Behavioral science,” a term
dental education (Figure 1). It was written as part coined in 1951, is defined as a “branch of science (i.e.,
of the project “Advancing Dental Education in the psychology, sociology, or anthropology) that includes
21st Century.” human interaction and provides generalizable prin-
Revolutionary guidelines for dental education ciples about human behavior in society.”3 This new
emerged in the early 20th century as a result of Wil- branch of science gave a designation to a collection
liam J. Gies’s Report on Dental Education in the of topics relevant to understanding human behavior
United States and Canada.1 As dentistry defined itself deemed important in educating dental professionals.
as a closely aligned but separate profession from By the 1970s, these topics had coalesced and gained a
medicine and proposed higher education require- solid presence in dental curricula. Dworkin, a signifi-
ments to doctoral level education, a new standard cant contributor to that development, saw the need to
was created. This included newly desired qualities, incorporate multiple disciplines and include relevant
characteristics, and expectations for dentists. Gies aspects of psychology, anthropology, sociology, pub-
described the conscientious dentist as one who is lic health, epidemiology, statistics, and economics.4
mentally, emotionally, and socially mature with In the beginning, dental faculty members called
qualities of “self-control, attention, courtesy, kind- on colleagues in psychiatry, psychology, or sociol-
liness, sympathy, tact, and good will.” While this ogy to teach behavioral sciences to dental students.
proposal was empowering for dentistry, achieving Well-intentioned, non-dental faculty members could
agreement among the schools took time. The 41 not fully comprehend dentistry’s patient manage-
member schools of the American Association of Den- ment challenges and struggled with which aspects
tal Schools (AADS; now American Dental Education of human behavior or social sciences to teach.4,5
Association, ADEA) endorsed these progressive Content did not immediately translate into relevance
recommendations, but several decades passed before for dental students or positively impact patient care.
they were fully accepted.2 Initial attitudes toward behavioral sciences by dental
The Gies report planted the seeds for new faculty and students could be described as ambivalent
behavioral expectations for dentists. In addition to at best. A new perspective was needed to connect
competence in technical restorative skills, the report human behavior and patient management skills to
stated that dentists should be caring and compas- 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 the 1970s to the 1990s, Dworkin and doctor-patient relationship, and working with other
other notable behavioral scientists succeeded in health care professionals and the community were
creating a map for behavioral sciences instruction essential.7 Dworkin and Gershen were pioneers
and promoted what it could offer dentistry. Further who implemented active and experiential learning
evidence of the increasing significance of behavioral methods to assist dental students in increasing their
sciences was its new presence in dental education awareness of patients’ emotional experience of the
research. Proposals requesting funding for research doctor-patient relationship and treatment.7,8 Educated
in this new field of behavioral sciences flowed into and trained as dentists and psychologists, these in-
the National Institute of Dental Research (NIDR; novators brought relevance to the field of behavioral
now National Institute of Dental and Craniofacial sciences and moved the field forward by virtue of
Research, NIDCR). However, the authors of those their interprofessional lenses.
proposals came from such diverse educational back-
grounds that NIDR staff were confused regarding
who should review them.6 Teaching Behavioral
During the mid-1990s, dental educators agreed
that behavioral sciences content would improve the Sciences: The Path to
dentist’s ability to successfully interact with patients.
Dworkin identified two formidable obstacles to Relevance
educating dental students to internalize humanistic While gaining traction, behavioral sciences
attitudes in dental school: the pressured dental cur- instruction was by no means unanimously accepted
riculum with little time for personal growth, and the in dental schools. In a 1969 survey, Jetterson discov-
narrow faculty focus on teaching hand skills.4 He ered that 60% of U.S. dental schools did not have
declared that self-awareness, reflection, the student- formal instruction in behavioral sciences.9 He learned

August 2017 Supplement  ■  Journal of Dental Education eS67

that 85% of dental students initially reported they integration of dentistry with medicine and described
believed behavioral sciences courses would be valu- oral health disparities.14 The report suggested cre-
able to their education; however, after taking their ating messages sensitive to language and culture
coursework, this dropped to 66%. Negative student to change public perceptions about prevention. A
opinion was related to choice of content and teaching stronger message came from the surgeon general’s
methods. These findings underline the challenge of 2003 national call to action requesting culturally
teaching behavioral sciences: identifying the knowl- informed and linguistically accessible messages
edge and skill sets needed for patient management, about the importance of regular oral health care to
and integrating it with the relevant basic sciences improve health literacy.15 These influential reports
and clinical dental sciences in a relevant context. raised awareness of the importance of personal and
Furthermore, Dworkin and other behavioral sciences cultural health beliefs as they affect comprehension
faculty members realized behavioral sciences instruc- of need for preventive services. Additionally, they
tion lacked a set of clear educational objectives.7,8 made clear the need for dental schools to go out to
In 1984, the first curriculum guidelines for be- the community to serve those in need.
havioral sciences instruction in dental schools were Beginning in 2002, the Robert Wood Johnston
established.10 In 1993, the Curriculum Guidelines Foundation funded Pipeline, Profession, and Prac-
Committee of the Section on Behavioral Sciences of tice: Community-Based Dental Education grants to
the AADS (now ADEA) published new guidelines assist dental schools in providing clinical education
for behavioral sciences content.11 The accrediting and in community clinics and to inspire dental students
regulatory bodies who influenced these guidelines to choose community clinics as a career path.16
included the AADS, American Dental Associa- Schools with pre-existing community-based pro-
tion (ADA), Commission on Dental Accreditation grams expanded them, and those without developed
(CODA), and Institute of Medicine (IOM). These new community partnerships. Behavioral sciences
guidelines provided didactic and clinical skill-based instruction was developed to increase students’ cul-
teaching recommendations in areas captured broadly tural sensitivity to prepare them to work with diverse
as ethics; professional socialization; stress and pain; patient populations. Community-based dental educa-
self-awareness; communication and interviewing; tion, now a CODA requirement, provides students
developmental needs of the child, adolescent, adult, with experience treating diverse populations of
and older adult; patients with special needs; cultural vulnerable and underserved patients. Despite some
awareness; management of anxiety; and practice residual faculty ambivalence about students’ learning
management. These guidelines were aimed at stan- dentistry at externship sites, students reported satis-
dardizing this aspect of dental curricula. In a survey faction in their reflective essays.17 When surveyed,
of behavioral sciences hours (didactic and clinical) students reported positive experience with exposure
published in 1993, 39 U.S. dental schools reported an to challenging clinical presentations, sociocultural
average of 41 total curriculum hours of interpersonal issues (e.g., substance abuse, domestic violence,
skills instruction, 49 hours of behavior management poverty, mental illness), and self-esteem-building
instruction, and 27 hours of anxiety and pain control experiences with patients, staff, and site dentists.18
instruction in behavioral sciences teaching, with 7-14 Donate-Bartfield and Lausten showed that provid-
hours teaching these topics in clinic.12 Schools varied ing culturally sensitive patient care to reduce health
widely in behavioral sciences teaching hours. Some disparities required an understanding of the patient’s
integrated behavioral sciences topics into clinical perception, appreciation of cultural practices, good
general dentistry or specialty courses, and others communication skills, and ethical reasoning.19 They
offered stand-alone courses. differentiated the need to understand cultural beliefs
The 1995 IOM report Dental Education at the from attempting to “manage” or manipulate patient
Crossroads provided guiding principles and objec- behavior, as health beliefs and behavior are a true
tives for dental education. Two objectives from the reflection of culture.
IOM report were especially important to behavioral With all these developments, teaching inter-
sciences: 1) reducing disparities in oral health status personal communication skills became a cornerstone
by disadvantaged economic, racial, and other groups; of behavioral sciences teaching. Communicating ef-
and 2) encouraging prevention at both the individual fectively and managing diverse patient populations
and community level.13 Similarly, the 2000 surgeon involve sophisticated interpersonal skills. The novice
general’s report on oral health re-emphasized the clinician needs doctor-patient relationship skills such

eS68 Journal of Dental Education  ■  Volume 81, Number 8 Supplement

as creating a safe environment for disclosure, asking sciences faculty members realize it is critical to
non-judgmental questions, active listening, the ability identify learner motivation as it fuels their interest
to empathize, clarifying and asking follow-up ques- and informs their priorities for learning. Ambrose et
tions, providing patient education in plain and simple al. stated that component skills, such as communica-
words, and performing a teach-back for informed tion skills, need practice and benefit from targeted
consent. Richards and Inglehart found that case- feedback. Active listening, empathetic responses,
based, small-group teaching methods that brought interviewing skills, assessment and management of
together dental and behavioral sciences faculty in- dental fear, and identification of oral health beliefs
creased dental students’ awareness of the importance and oral health literacy level are component skills
of psychosocial and cultural factors.20 Influencing cli- that need to be addressed. Teaching dental students
nician attitudes and values in the service of increasing to counsel patients in a simulated environment allows
communication skills and cultural humility requires behavioral faculty to evaluate novice clinician inter-
teaching methods that invite clinicians to examine personal skills. Often dental students do not realize
their own behavior in the doctor-patient relationship. the value of interpersonal skills until they graduate
Simulation is required with demonstration/modeling, and interact with patients in a practice setting. I have
deliberate practice, and self- and peer assessment. seen this confirmed in exit interviews when students
The use of standardized patient actors or real pa- rate whether content received during predoctoral
tients as teachers for dental students brings social, education was adequate. The challenge for faculty
linguistic, and cultural traditions to life with imme- members in behavioral sciences has consistently been
diacy and clinical relevance. Wagner et al. found that how to focus selectively on the most critical skills
dental students who interacted with mock patients given resource limitations.
trained to present challenging social histories and Over 90 years after the Gies Report, we have
cultural characteristics showed increased sensitivity high expectations for the professional development
to cultural differences on post-program surveys.21 If of dentists and for the faculty teaching dental students
dental students do not possess an understanding of and contributing to their professional socialization.
cultural traditions and oral health beliefs, the patient While it varies by institution, behavioral sciences
is at high risk for making a decision that could be faculty members are accountable for teaching key
misperceived as “being non-compliant.” parts of the content required in the CODA standards
New skills were also needed for dentists to (Table 1).25 Prioritization is often necessary due to
motivate patients with low oral health literacy to time, personnel, and competing priorities. These
improve their oral hygiene and engage in preven- pressures challenge the best-intentioned behavioral
tive practices. Donate-Bartfield et al. advocated for sciences faculty members to comprehensively ad-
a multidisciplinary philosophy that could bring be- dress the 2016 standards.
havioral sciences, ethics, and public health together
to create a broader context for teaching culturally
sensitive patient care.22 Examining assumptions, us- Responding to a New Oral
ing reflective listening, and showing empathy were
defined as essential tools. This approach develops Health Care Horizon: The
cultural sensitivity and is aligned with the ethical
and public health responsibility of dentists. In addi- Path to Shape-Shifting
tion, motivational interviewing has brought dentistry Behavioral sciences instruction sits at the
a counseling method that is superior in motivating dynamic intersection of acceptance, relevance, and
behavioral change when compared to conventional integration for the purpose of achieving excellent
education23 and provides dentists with a tool to im- communication and interpersonal skills in future den-
prove preventive oral hygiene practices and increase tal graduates who must treat a diverse population. The
compliance with caries management by risk assess- more seamless the integration of behavioral sciences
ment (CAMBRA) interventions. with basic and dental sciences, the more likely these
A paradigm shift has occurred in our under- skills will be perceived as relevant and be practiced.
standing about how to teach novice adult learners. Routine oral health screening, evaluation, and treat-
Ambrose et al. stated that “learning is a process, not ment require tolerance of mild discomfort, accep-
a product . . . and is not done to students but rather tance of intrusion into an orifice (the oral cavity), and
something students themselves do.”24 Behavioral 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
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.
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.
2-20 Graduates must be competent in the application of the principles of ethical decision making and professional
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.

of the doctor-patient relationship require both its own With an increasing population of patients with
place in the curriculum and integration in the con- more complex medical, cognitive, and psychiatric
text of general dentistry. Relevant behavioral skills conditions and multiple medications, dental stu-
assessments include creating a safe environment to dents need high-level medical and psychological
disclose health history information; communicat- history-taking skills. Students need more training
ing empathy and compassion when discussing bad to assess, manage, and monitor cognitive capacity
news; assessing and successfully managing dental for giving informed consent for health care, as well
and injection fear; addressing unrealistic expecta- as assessing controlled and uncontrolled conditions
tions; assessing health literacy in patient teaching; that may require modifications for treatment (e.g.,
and coaching patients to adapt to a prosthesis (e.g., patients with diabetes, dementia, traumatic brain
partial or full denture) or accept complex treatment injury, heart failure, chronic obstructive pulmonary
(e.g., scaling and root planing, periodontal surgery, disease, cancer, or major depression). There will be
extractions, or implants). a need for enhanced knowledge and critical thinking

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about pharmacology and psychopharmacology along consent forms in all languages representing 5% or
with a deeper understanding of how aging affects the more of the surrounding demographic. Schools will
absorption, distribution, metabolism, and elimination need to move toward professional interpreting sys-
of medications. The dentist of tomorrow needs more tems or create options for oral certification exams
patient management skills including sophisticated for students, staff, and faculty. At the same time
communication and interpersonal skills to interact baby-boomers are aging and living longer, requiring
with patients and all members of the health care team. an expansion of care in geriatric dentistry, we do
Increasingly, interprofessional education and practice not have a sufficient number of dentists to treat the
will immerse dentists in the medical environment oral health needs of children.28 Behavioral sciences
and bring much-deserved respect to dentists who content is therefore needed to expand the graduating
complete the health care team. dentist’s competence in treating diverse populations.
Behavioral sciences instruction must dem- One could predict that dentistry will eventually ac-
onstrate flexibility to meet challenges ahead as the cept mid-level practitioners as medicine has with
landscape changes. What would Gies say about nurse practitioners and physicians’ assistants. New
dentistry in the 21st century? He would likely com- roles require clarity, communication skills, and team
ment that the profession has evolved from a cottage function. Behavioral sciences faculty members are
industry to a profession with evidence-based guide- poised to provide education to address these needs.
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 Conclusion
collaboration or mid-level providers. He would likely
advise re-envisioning dental education to prepare Behavioral sciences faculty members are
future dentists for practice settings that currently do highly valuable interprofessional colleagues who
not exist. Behavioral sciences faculty members are contribute significantly to the professional social-
partners in educating the dentists of tomorrow. As ization of dentists. Behavioral sciences education
we work together toward that goal, it is important to humanizes the novice learner by providing knowl-
keep in mind the strengths, weakness, opportunities, edge, influencing attitudes, and teaching patient
and threats (SWOT) to behavioral sciences instruc- management skills. As partners and resources,
tion in dental schools today. I provide my SWOT behavioral sciences faculty members stand ready
analysis in Table 2. 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
Discussion diverse populations and an insufficient number
The dentist of tomorrow must be compassion- of dentists to treat children, new roles, and health
ate, evidence-based, highly skilled, and ready to care delivery models, dentistry will need all of its
collaborate with and be part of an interprofessional health care colleagues, including the behavioral
health care team. Communicating effectively with sciences faculty. Imagine a health care home where
other health care professionals is essential. In a rap- the dentist is a colleague welcomed and part of the
idly changing population, the dentist of tomorrow health care team. We have already moved from an
needs to be comfortable with communicating with emphasis on interprofessional education to thinking
diverse populations. The Cultural and Linguistically about the infrastructure and mechanisms needed to
Appropriate Services (CLAS) Guidelines recom- create a health care home where dentistry practices
mended by the U.S. Office of Minority Health will alongside medicine, nursing, pharmacy, and mental
likely have a greater impact on dental practice in health in providing comprehensive care.
the future.26 With a shift toward non-white major- There are many changes occurring in our health
ity cultures,27 Limited English Proficiency (LEP) care system. Dental curricula will need to shape-shift
patients and those who prefer oral health care infor- to meet the needs of the public for greater access to
mation in their first language will expect that dental care, to address changes in both the dental and health
professionals provide professional interpreters in care practice environment, and to advance with sci-
all dental practice settings and provide translated ence as new developments impact oral health. As the
patient education materials, treatment plans, and 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

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
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.
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.
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.
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.

new and more collaborative form of dentistry dawns, San Francisco; Anne Koerber, DDS, PhD, Professor,
and behavior sciences will be there to help. Department of Oral Medicine and Diagnostic Sci-
ences, College of Dentistry, University of Illinois at
Acknowledgments Chicago; George Taylor, DMD, MPH, DrPH, Profes-
The author wishes to acknowledge the follow- sor, Department of Preventive and Restorative Dental
ing individuals who made incisive comments that Sciences, School of Dentistry, University of Cali-
improved the clarity of ideas and flow of thinking: fornia, San Francisco; and Evelyn Donate-Bartfield,
Susan Hyde, DDS, MPH, PhD, Associate Professor, PhD, Professor, Department of Dental Developmental
Department of Preventive and Restorative Dental Sci- Sciences/Behavioral Sciences, College of Dentistry,
ences, School of Dentistry, University of California, Marquette University.

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