M. A. I. (Lex) MacNeii, DDS Assistant Professor Assistant Dean, Ctinical Affairs M, I. MacEntee. PhD, LDStI), Dip Prostb, FRCDiO opinions of Dentists on an Professor and Chair Division of Proithodonlics Integrated Fixed and Department of Clinical Dental Sciences Removable Prosthodontic Faculty of Dentistry University of British Columbia Curriculum Vancouver, British Columbia, Canada

Dentists in practice from 3 to 5 years who were exposed to an integrated fi>;ed and removable prosthodontic curriculum as students al the tjniversity of British Columlîia responded to a survey on the relevance of their prosthodontic education to current dental practice. The majority of the respondents reported fhat the integrated curriculum prepared them adequately for general dental practice, although many felt fhat they would have benefited from a greater emphasis on specific treatments, mosf notably cast metal , all-ceramic restorations, and implant-supported prostheses. In! I ProsthodonI 1997,10:14-18.

he Commission on Dental Accreditation in 9. Single-unit ceramic and metal ceramic resto- TCanada uses the Curriculum Guidelines devel- rations oped by the American Association of Dental 10. Fixed partial Schools to assess and approve the quality of dental 11. Restoration of nonvital teeth professional education in Canada.^ The guidelines 12. Partial denture abutments for state that students "must under- 13. Resin-bonded restorations stand and demonstrate competence in "a wide 14. Implant-supported fixed prostheses (when range of procedures, from to available). various intracoronal and extracoronal restorations." Graduates must demonstrate competence in: Graduates must also have an understanding of:

1. Complete dentures 1. Attachments for removable prostheses 2. Removable partial dentures 2. Principles ol restorations witb dental implants 3. Immediate complete dentures and immediate complete overdentures These guidelines were established in 1980, and 4. Complete dentures opposing removable partial they remain unaltered apart from a recent refer- dentures ence to overdentures, implants, and resin-bonded 5. Single complete dentures and all-ceramic restorations. 6. Interim and/or transitional dentures The educational goals of an accredited program 7. Relining, rebasing, and repairing a removable imply that a new dentist must be able to examine prosthesis and manage patients requiring any of these prosthe- 8. Single-unit cast-gold restorations (partial or ses. However, a survey of dentists in British complete coverage) Columbia about 15 years ago found that a large pro- portion of the respondents, educated in Candida or Reprint requests: Dr M, A. /. (Lex) MacNeil, Faculty of DanUitry,the United States, provided few complete oi imme- University of Brifish Coiumbia, 2199 Wesbrook Mill, Van- diate dentures, and they did not adhere to ih(^^ re- couver. Briusfi Caiurr)bÍ3, Cenaría V6T !Z3. movable prosthodontic principles taught in dental

The Irlernalional lourna! of Prosl 14 Volume 10, Number 1,1997 Opinions o( Denlisis on Prosliindonlic Curricuium schools.-' For example, nearly two thirds of the re- Table 1 Prosthodontic Services Offered Frequently spondents admitted ihai they did nol use a dental by Recent Denfai Graduates surveyor, and about one quarter of ihe dentisis did Percentage nol provide a detailed prescription lo a dental tech- distribution Sen/ice (n = 55) nician when designing removable partial dentures. In fact, about half of the respondents said ihat they Cast metai and meial ceramic crowns 95- Restoralions ol endodonficaily Irealed teeth 80- routinely accepted designs developed solely by den- Partial dentures tal technicians. hxed 66- removable About 25 years ago there was a move in post- Mainfenance procedures (eg, denture reiine) 611 graduate dental education in North America to im- Compiete dentures prove the scope of specialty services by combining sefs 33t fixed and removable prosthodontic programs. In singie 311" Cast mefal inlays/onlays 24 keeping with this move, and because of the re- immediate denf ures/overd enture s 19 sponse to a 1980 survey of dentists in British Ceramic crowns/in i ays/on lays/veneers ^2 Columbia, the Faculty of Dentistry at the Implan t-supporfed prostheses 2 University of British Columbia (UBC) integrated the "Combined dislributior = 53%. tCombirea disiriButior ^ 24%. fixed and removable undergraduate prosthodontic programs.'' The integration drew from the mixture of clinical and nonclinical sciences as specified by the accreditation guidelines.' This paper presents the opinions of dentists who graduated from the integrated program 3 lo 5 years previously to identify: (1) the scope of prosthodon- tic services they felt competent to provide; ¡2) the were allowed to choose to remain anonymous. The change in practice that they anticipated in the fore- response rate was improved by randomly accessing seeable future; and (3> their feelings about the potential participants who did nol respond on first prosthodontic education they received. The 51 responses were reviewed upon return Methods and divided into two groups: those from dentists who identified themselves (n = 23); and ihose from The authors developed a structured questionnaire demists who did not (n - 28). Subsequently, a ran- in three sections and tested it on a small group of dom selection was made from the combined pool dentists to reduce ambiguity. Section One focused of 28 anonymous respondents and 54 nonrespon- on practice characteristics, year of graduation, and dents to yield an additional 49 potential partici- prosthodontic training since graduation. Section pants. Telephone conlaci was made with 39 of Two addressed the current and anlicipated scope those anonymous respondants or nonrespondenls, of prosthodontics in practice, and requested an as- of whom 14 said that they had returned the ques- sessment of the prosthodontic education received. tionnaire anonymously, another 14 offered to an- Section Three asked for a self-rating of prosthodon- swer the questionnaire and return it hy mail, while tic skills, and an assessment of the prosthodonlic the remaining 11 answered an abbreviated form of education as a basis for further learning. Responses the questionnaire directly on ihe telephone. This to the questionnaire slatements were solicited on a strategy produced an additional seven question- 10-point scale indicating the extent of agreement naires, providing for a total of 58 written responses or disagreement. and 11 verbal responses, for a combined response One hundred seventeen dentists graduated from rateof ñ6%of the 105 available graduates (Fig 1). University of British Columbia between 1989 and Measurements on the 10-point scale were trans- 1991, and the questionnaire was maiied lo the 105 formed into dichotomous (agreement/disagree- who were in general practice and who could be ment) scores with an arbitrary cut-off between five contacted (Table 1). The survey was restricted and six to produce a reasonably balanced distribu- to graduates from this 3-year period because it tion of the data for further analyses. Bivariale tables seemed reasonable that dentists with 3 to 5 years in and chi-square tests were constructed to compare practice would have the experience necessary to respondents with nonrespondents, and to test for judge the significance and practical impact of the associations between opinions on the integrated educational program, and that they would respond.-' prosthodontic program and the scope of prostho- Return postage was provided, and the respondents donlic practice.

, Numbcri, 1997 15 The lnlerr)alional loiirnal of Proslhodontk Graduates (117)

.(12) Available (105)

Response (51] No response (54) J

Unidentified (28)

I Not randomly Randomly selected (49) selected (33)

Contact by phone (39) No contact (10)

(43) Previous Interview Offered response by response telephone (14) Previous No response response

Response No response

Fig 1 Selection of respondents. 'Total respondents = 69. "Tolal nonrespondents = 48.

Results The change anticipated in the demand for prosthodontic services was highest for single- Characteristics of the Sample restorations, fixed partial dentures, and, most no- tably, for implant-supported dentures, accompanied Response rales from the three graduating years var- by a drop in demand for complete and immediate ied considerably (39% from 1989; 31% from 1990; dentures or overdentures (Table 2). 26% from 1991; and 4% unknown), but, as ex- Almost two thirds (62%) of the respondents were pected, the majority (70%) of the 58 respondents satisfied with both the didactic and clinical educa- practised in a large metropolis. Over half (53%) of tion they received for crowns and fixed and remov- the 58 respondents provided crowns, fixed partial able partial dentures in contrast to intracoronal and dentures, and endodontic post/cores as frequent ser- implant-related restorations (Table 3). They felt vices in practice, whereas less than one quarter competent to plan and perform most treatment in- (24%) of them offered complete and removable par- volving dentures alone or combined with other tial dentures frequently (Table 1). However, nearly prostheses, but they were less confident in chang- everyone (91 %) reported that they used a dental sur- ing the or providing dentures on im- veyor to design removable partial dentures. There plants (Table 4), Overall, respondents felt that the was substantially less involvement in cast metal or integrated prosthodontic program offered a sound ceramic intracoronal restorations, immediate den- basis for future learning, and there was ,i wide- tures, overdentures, and implant-supported-den- spread response that curricular time devined to tures. prosthodontics should be maintained.

I of Proslhodonlii 16 Volume 10, Number 1, 1997 MacNeil/MacCntec Opinions of Dentisti on Prosiliodontit Cjfriculun

Table 2 Anticipated Change in Demand for Table 3 Assessment by Recent Dental Graduates of Prosthodontic Services Over the Next 2 Years an Integrated Prosthodontic Program (Percentage Percentage distribution Distribution of Positive Assessment) of anticipated change (n = 55) Sen/ice Didactic Clinical Both No No Cast metal and metal 97 97 95 Service Increase Decrease change opinion ceramic crowns Cast rnetal and metal 60 3 28 9 Partial dentures ceramic crowns fixed 93 78 78 Ceramic crowns 48 3 17 31 removable 97 80 74 inlay s/onlays/veneers Restorations ol endo- Fixed partial dentures 47 5 35 14 dontically treated teeth 74 65 55 Implant-supported 40 3 28 29 Complete denture prostheses sets 84 85 62 Cast metal inlays/oniays 38 10 24 28 singie 71 60 50 Restorations ol endo- 29 3 41 30 Maintenance procedures dontically treated teeth (eg, denture reiine) 70 65 55 Removable partial 16 12 50 23 Immediate Qentures/ dentures overdenture s 66 51 36 Maintenance procedures Cast metal inlays/onlays 36 14 9 (eg, denture reline) 12 9 45 35 Ceramic crowns/inlays/ Immediate dentures/ 5 31 30 35 oniays/veneers 12 14 5 overdentures Impiant-supported Complete denture: prostheses 5 4 0 sets 5 50 30 18 single 3 17 45 35

Discussion Table 4 Self-assessed Ability of Dentists to Plan and Provide Prosthodontic Treatments (Percentage Others who surveyed recent dental graduates typi- Distribution) cally have found that about half of those surveyed Treatment Ability to plan Ability to provide responded.^•^-" The authors were encouraged to Complete dentures 86 66 find that the sampling strategy which focused on a Fixed or removabie partiai dentures 85 90 random selection of the non respondents raised the Combined fixed and final response to a higher level of confidence. removable dentures 74 74 Integrating fixed and removable prosthodontics in Changes to horizontai or an undergraduate curriculum has many advantages vertical dimensions of occlusion 30 12 and, as this survey showed, very few disadvantages. Implant-supported Emphasis can be placed on the preclinical and clin- prostheses 14 7 icai knowledge common to both forms of treat- ment, care of patients can be managed efficiently and comprehensively without fragmenting the re- sponsibility for supervision of treatment, and change can be accommodated with greater ease the results should interest prosthodontic educators and control. Unfortunately, there are relatively few generally. dental faculties with a completely integrated pros- Overall, the respondents felt positively disposed thodontic curriculum, and even fewer that have a toward the integrated program as preparation for prolonged experience of integration. Thirty years general dental practice, particularly if the scope of ago, almost 95% ot tbe dental schools in North the experience broadens to meet the anticipated de- America listed fixed and removable prosthodontics mand for intracoronal cast and ceramic restorations, as separate disciplines in tbe undergraduate cur- and for dentures over implants. It was evident that riculum.'' Since then there has been considerable the positive attitudes toward removable prosthodon- change towards integration. Currently, nearly three tics in the program did little to increase the use of quarters (71%¡ ofthe dental schools in Canada and these services in practice. A similar observation has the USA report that they have departments of been reported previously with an explanation that prosthodontics or restorative dentistry, rather than the decreasing number of edentulous patients and separate departments of fixed and removable the role of denturists in British Columbia probably prostbodontics.^^ Therefore, although this survey was limits the demand for complete dentures.'^•^'' The restricted to graduates of one integrated program. interest in cast metal inlays and onlays is consistent

ne TO, Number I, 1997 17 The liiiemarlonai lournai of Prosthodomics Opinions of DenlisiB on Proslhodomi i I/Mac Ente

with the widespread enthusiasm for cast and direct 6. Diane |W, Rrchler D, Stoskopf C. Improved '"^P"'^''°'L^. gold restorations in the Pacific Norlhwest,'^ and it non-responses to mallback questionnaires. StJt Me'' l^ ' contrasts with the declining popularity of cast 12:283-288. restorations in other regions." However, the current 7. Emhree BG, Whitehead PC. Validity and reli;'hil'iV "' ^e"''^' ported drinl(ing behavior: Dealing with the ¡inà^'-'«^ "f '^• vigorous promotion of "esthetic" restorations has nol sponse bias. J Slud Alcohol 1993;54;334-344. gone unnoticed by the recent graduates."' None- 8. Poulin C, MacNeil P, Mitic W. The validity of .i I'rcvince- theless, most dental educators aro reluctant to en- wide drug use survey: Lessons in design. Can | Publ Health dorse all-ceramic restorations, apart from anterior 1993;84:259-264. ceramic veneers,'' because of inadequate informa- 9. Eltinger RL, McLean H, lakobsen |. Effect of a geriatric educa- tional experience on graduate activities and attitudes. | Dent tion on the success of this service."'"-'^ In addition, Educl990;S4:273-278. clinical experience with oral implants received very ¡Q. Stewart BL, Ralph WJ, Macmillan CH. Survey of dental prac- little attention in the undergraduate dental curri- tice/dental education in Victoria, Part V. One-year follow-up culum, although there seems to be a general move survey of 1988 graduating class. Aust Dent J ]992;37: over the last few years to involve all dental students 217-221. 11. Goodacre C|. Review of the literature—Predoctoral fixed in the design, fabrication, and maintenance of im- prosthodontics education. J Prosthet Dent 1990;64:3I9-325, plant-supported prostheses. t2. American Association of Dental Schools. 1994-1995 Di- Finally, the authors are encouraged by the re- rectory of Institutional Members and Association Officers. sponse that the integrated program offers a sound Washington, DC: AADS, 1995. basis for future professional learning. New legisla- 13. MacEntee Ml. Denturists and oral health in tbe aged. | Prosthet Dent 1994;72:437-491. tion in many jurisdictions requires all self-governing 14. MacEntee Mi. Clinical epidemiológica I concerns and the geri- professions to have guidelines relating to practice atric prosthodontic patient. I Prosthet Dent 1994;7I: standards, quality assurance, and continued com- 487-491. These results show also that most new 15. Tucker RV. Class 2 inlay cavity procedures. Oper Dent 1982; petency. 7:50-54. graduates do not feel competent in all areas of 16. MacEntee Ml, Belser U. Fixed restorations produced by com- prosthodontics. Therefore, continuing education mercial dental laboratories m Vancouver and Geneva. J Oral must be an integral part of professional life, and it Rehabil 198ñ;16:301-305. might be appropriate to consider some restrictions 17. Rucker LM, Richter WA, MacEntee Ml, Richardson AS. on the practice of new graduates, particularly in Clinical evaluation of porcelain and resin veneers. ] Am Dent Assoc 1990;I21:594-596. view of quality assurance directives and rapid tech- 18. Walton |N. Esthetic alternatives for posterior teeth: Porcelain nological advances. and I a bora tory-processed composite resins (review). J Can Dent Assoc 1992;58:82O-823. Conclusion 19. Denissen HW, Wijnhoff CE, Veldhuis AA, Kalk W. Five year study of all-porcelain fixed partial dentures. | Prosthet Dent 1993;69:464-468. This survey demonstrates that an integrated under- 20. Thordrup M, Isidor F, Horsted-Binds lev P. A one-year clinical graduate prosthodontic curriculum provides a study of indirect and direct composite and ceramic inlays. sound basi5 for general practice. Scandl Dent Res ]994;102:186-192. 21. Government of British Columbia. Bill 71, Health Professions Statutes Amendment Act. Royal Assent, British Columbia References Legislature, luly 29, 1993. 22 Boyd MA. Curriculum focus: Traditional dental education 1. American Association of Dental Schools. Curriculum guide- confronts the new biology and social responsibility. I Dent lines for removable prosthodontics/Curriculum guidelines for Educ1993;57:340-342 . J Denl Educ 1993;57:45-55. 23. Harris IB. New expectations for professional competence. In: 2. MacEntee Ml, Pierce CA, Williamson MF. Removable Curry L, Wergin |F (eds). Educating Professionals- prosthodontic services by dentists in British Columbia. | Can Responding to New Expectations for Competence and Dent Assoc 1980;46:764-767. Accountability. San Francisco: fossey-Bass, 1993;17-52. 3. MacEntee Ml, Williamson MF. Attitudes of dentists in British 24. Cavanaugh SH. Connecting education and practice. In: Curry Columbia to dental technicians, dental mechanics and remov- L, Wergin |F (edsl. Educating Professionals—Responding to able prosthodontics. | Can Dent Assoc 1960:46:768-771. New Expectations for Competence and Accountability. San 4. MacEntee MI. Integration of fixed and removable prosthodon- Francisco: Jossey-Bass, 1993:107-127. tics in an undergraduate dental curriculum. J Dent Educ 25. Welker WA. The dental curriculum: Is it relevant to dental 198t;45:204-206. practiced Prosthodont 1992;1:47-50. 5. Haug SP, Brown DT, Goodacre Ci, Cerimele B|. Recent grad- uates and current dental students' evaluation of their prostho- donlic curriculum. I Prosthet Dent 1993;70:361-37l.

al of ProslhodonlK 18 no. Number 1, 1997