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PREFACE
INTRODUCTION
Dentistry as a serious medical science is required to evolve. This evolution is
driven by scientific research, population needs and economics, and has to be
reflected in the undergraduate dental curriculum.
The curriculum therefore has to evolve to reflect these changes to enable new
young graduates to be up to date in their knowledge and skilled technically to
provide this service to the public.
The dental curriculum has, to some extent, evolved over the years and has
attempted to provide the graduate with an overview of dentistry in all its
aspects, but with more experience and hence skills concentrated in certain
aspects.
The general dental curriculum has become more theoretical and less practical
overall. Dental quotas for practical experience required by graduates have
fallen and clinical experience has moved from the traditional techniques to the
modern, perhaps less invasive techniques of bonding materials and
composite restorations etc,
In 199? Dental vocational training became mandatory and despite its
undoubted educational value, it was and is perceived as the practical
experience ‘faculty’ of the undergraduate dental schools.
Dental trainers, employed by the Dental Vocational Deanery, see first hand
the level of skills of the new graduates and whilst academic and knowledge
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based skills and good, however, in certain areas there is a clear lack of
confidence.
One traditional aspect of dentistry that in which this is evident - is prosthetics,
and particularly the prescription of complete dentures.
This area of dentistry has seen a significant reduction in dental curriculum
hours, both in clinical teaching and laboratory experience.
Whilst in former days, many hours were spent in the laboratory, now all work
is out sourced to commercial laboratories. Clinical teachings and actual
patient experience is very limited.
This results in the new graduate entering general practice with little
confidence in these techniques and unable and even unwilling to undertake
these procedures.
However, is this just the view of the ‘older’ or ‘more experienced’
practitioners?
Are these skills relevant to today’s modern practice?
Is it a necessary skill for a graduate to have in today’s population where the
edentulous trend is declining?
Should complete dentures be officially recognised as no longer being in the
sole domain of the general practitioner but also in the hands of the Clinical
Dental Technician, with the added skills of specialists for the difficult cases?
Should we go the way Orthodontics has gone with almost all treatment now
being undertaken by specialists?
Or-are we losing a skill that every graduate should have in his repertoire to
offer comprehensive dental treatment to the general public.
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How will this impact on the practitioners overall skills, and indeed if we deskill
our graduates in this field who we will we attract into the speciality and who
will train the specialists?
During the forthcoming pages I intend to provide a background to the present
situation regarding Complete Denture provision and its future implications.
LITERATURE REVIEW
John A Hobkirk (Hobkirk J 2005) presents an overview of the historical
development of Prosthodontics from its early beginnings of the craft guilds in
the 16th Century England.
Research and technical developments in Victorian times led to significant
advances in dentistry and the emergence of dental specialities. Amongst the
developing specialities was prosthetics. With increased understanding if oral
function, techniques and material for restoring diseased tooth tissue and the
development of a teamwork approach between the physician and technician,
all ensured the prominence of the speciality and its importance to the general
population.
In the 20thCentury, there were significant developments in dentistry and a
further increase in specialisations in various countries. Hobkirk in his article
relates the average number of dental specialists per million of the population
according to the per capita gross domestic product (in 2000). Although he
admits the data may be subject to different interpretation, it is nevertheless
noteworthy that there us a correlation between the national wealth and the
range and number of dental specialists.
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In the late 20th Century there was a significant change in the perceived
importance of the various contingent aspects of prosthetics and Hobkirk
shows this clearly by comparing the number of publications on different
aspects of prosthodontics from 1966-2004. This shows the significant
reduction in publications relating to complete dentistry and the concomitant
increase in publications relating to dental implants.
In 2002, both in the USA and UK, eminent researches were beginning to ask
and reflect on the future of complete denture fabrication by general dental
practitioners, Douglas C W (Douglas C, Shih A, Ostry L, 2002)) estimated
that, in the USA, edentulism was falling by 10% every decade and this has led
to the discussion amongst educators about the future need for complete
dentures on the undergraduate curriculum. However, he points out, that
despite the decreasing edentulous trend, there will be an increase in the older
population, which will offset this trend. Therefore, speculating into 2020 he
finds that there will be significant minority of the population that will require
complete dentures and that if training in this aspect of prosthodontics is
eliminated from the dental curriculum, millions of patients will be forced to
seek dental services from alternative providers.
In the UK, 2002, the same questions are being asked, but perhaps
precipitated by different circumstances.
Clark (Clark R K F 2002) in an opinion paper initiated the discussion. He
highlights the gradual reduction in curriculum time devoted to the teaching of
complete denture construction and its failure to educate the undergraduate in
its shortened and truncated form. He suggests that patients can be split in to
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general groups, those that can manage with dentures and those that have
difficulty.
He suggests that with the advent of the new specialist lists those of the
second group should be treated by specialists only, and general practitioners
should at least be able to treat the first group. He therefore goes on to
recommend that the undergraduates should at least be taught the basics to
be able to treat the first group of patients within the time constraints of the
present curriculum. He describes the type of ‘hybrid’ course that was adopted
in Hong Kong, in which the student became familiar with the techniques
involved in making dentures without becoming expert, and time was saved by
out-sourcing laboratory work to dental technicians.
He concludes that there will always be a need for complete dentures to be
made in the UK, and until the time that all of these dentures can be made by
Specialists the undergraduate training must give the student at least
competence to undertake the treatment of less difficult patients.
The inherent difficulty in Clark’s proposition is his division of patients into the
two groups. Surely the difficult patient of one group could be converted into
the manageable patients of the other group by well made dentures and the
first group will be converted into the second group by inadequately made
dentures!!
It also failed to address the problem of recruiting specialists from the general
dental practitioners who will be unskilled and consequently unmotivated to go
further in this field.
McCord (McCord J F 2003) discusses the anatomical and psychological effect
of tooth loss and edentulism, and their long term implications to the patient.
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The physiological changes are well documented and the importance of the
clinician to empathise with the patient is essential.
However, he points out that new graduate are now less well able and
equipped to carry out the necessary reconstruction for the edentulous patient
with complete dentures. He shows in unpublished data that dental schools
devote less time to complete denture prosthodontics than previously and the
amount of laboratory hours the graduate is required to attend has reduced by
one fifth in 2000 as compared to 1960. The consequence of these changes
has resulted in the minimum requirement of complete dentures for a dental
student to sit final examinations to be greatly reduced from the requirement in
1960. These factors have led to the undergraduate developing a negative
attitude to complete denture prosthodontics and he suggests that the overall
manner of teaching this subject should change in that - “a student is taught to
treat a patient who has no teeth rather than to provide dentures for an
edentulous mouth.”
However McCord in the above paper does not present any solution for the
problem.
At the Manchester BDA conference 2003, McCord elaborated on this
problem, highlighted in his report to the conference (McCord J F 2003). He
repeats the fact that the new graduates are less well equipped to diagnose,
treatment plan and effectively treat the edentulous patient.
He suggests that this problem is compounded by the NHS regulations and
remuneration, as well as the negative stereotype that is associated with
treating the elderly patient. He quotes the study of Morrow et al (Morrow LA
Burke FJT McCord JF 1995) that indicates that the journal space devoted to
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complete denture prothodontics had fallen by more than the percentage of
people becoming edentulous in the UK.
The continuous resorption of the edentulous ridge as highlighted by Tallgren
(Tallgren A 1966) will still necessitate clinicians to supply new complete
dentures in the future, and by its nature the re-treatment will become more
complicated.
He suggests that there must be an appreciation of the fact that successful
complete dentures are a paradigm of science and art.
At the moment there is little evidence-based science and the ‘art’ is far from
the level of the aesthetic dental world.
CLINICAL DENTAL TECHNICIANS
In March 2006, at the annual conference of the British Society for the Study of
Prosthetics Dentistry (BSSD), the subject of undergraduate training in
removable prosthodontics, was discussed.
The group questioned the level of competency achieved by undergraduates,
considering the amount of clinical and technical experience currently available
on the undergraduate course.
Various factors, including the decrease in the number of suitable patients for
inexperienced students and the changing demographics of patients requiring
removable prosthetics, all contribute to a worrying trend.
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It also highlighted the reduced number of specialist clinical academics in the
field, which increases the burden on fewer teachers and reduces the
effectiveness.
The number of Dental Technician training posts and Instructor Technicians
has also decreased.
This has also resulted in reducing the quota of cases for the dental students
due to the lack of technical support.
It also reported that new graduates felt that their prosthodontic skills had
decreased, rather than improve, during their Vocational Training year.
The report ended by the group proposing further formal detailed survey of the
teaching of removable prosthodontics in UK Dental Schools and to make
recommendations for the future.
This report was printed verbatum in the Editorial of the British Dental Journal
(Aug 2006) without any further comment.
In an opinion paper in the British Dental Journal (June 2007), Wilson, points
out the significance of the publication of this report of the BSSPD in the BDJ,
on this date.
He points out that 31st July 2006 was a momentous day for the dental
profession in that it was the day that the GDC legalised Clinical Dental
Technicians and gave them the right to practice as independent clinicians,
rather than part of a “dental team”.
The impact on the general prosthodontic teaching problem, that CDTs will
have, was not mentioned in the Editorial or the BSSPD report.
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Wilson cites the lack of training, competency and regulation of CDT, as further
regression in the provision of prosthodontics for our patients. This is being
encouraged by the GDC. He rather wryly notes that, with the advert of the
CDTs those concerned will no longer have to worry about the dwindling
education of complete denture prosthodontics, as it will only be a matter of
time before this topic is completely removed from the undergraduates
curriculum.
However, Wilson ends his piece by sincerely hoping that CDTs will join the
ranks of the specialist prosthodontics, rather than keeping to themselves, and
will work together with the profession to raise standards of care.
Ideally he would like to see CDTs trained alongside undergraduate dental
students, but feels that there is no desire for this from the Deans of the Dental
Schools.
Further research into the activity and education of UK CDT’s was carried out
by Ross(2007).
In a questionnaire sent to 128 members of CDTA, he sought to get an idea of
the current training of CDT’s and their attitude to their future registration as
DCP’s with the GDC.
A large majority of the CDT’s had obtained their education via George Brown
College, Toronto, Canada.
This course is 90% distance learning, and the small clinical component is
undertaken in Canada.
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It was pointed out that the GDC document - Developing the Dental Team -
stipulates that potential students should already hold a recognised
qualification in dental technology.
However at that time there was no existing training courses in the UK to
undertake this extra programme of CDT education.
There appears to be between 500-1000 CDT’s in employment in the UK, but
due to the fact that it was officially illegal practice prior to 2006, it was difficult
for this survey to illicit detailed historical information from the CDT’s.
One of the main objections to the CDT, from the prosthodontic world,
especially in UK, is the inadequate training. However after assessment of the
training by the FGDP of the RCS, a “top-up” course has been developed, with
examination and registration by successful candidates. Statutory registration
has been welcomed by CDT’s, and once registered qualified CDT’s would
hold professional indemnity, which would increase patient protection.
The author does see the eventual role of the CDT to broaden the availability
of the provision of complete dentures. However the NHS fee structure would
have to be made more attractive to entice CDT’s out of their private practice
as well a change in NHS regulations.
An important difference, however, was pointed out, between CDT’s and the
recognized DCP’s, for example Dental Hygienist and Therapists. The CDT is
able to treat patients directly and undertake the diagnosis and treatment
planning, without requiring a referral from a dentist. This is not able to be done
with the DCP.
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The CDT’s, which were previously illegal, have suddenly become professional
clinicians, despite the vast difference in education and experience between
them and other DCP’s.
The UK has been resistant to changes, however in other countries, notably
New Zealand and Canada, the CDT or denturist has been a legal profession
for many years.
In New Zealand the Dental Act of 1988 legalized the denturist to deal directly
with the public, taking away, what was viewed as “monopoly rights” of the
dentist.
Devlin (1994) carried out research into the economic effects of denturism, in
New Zealand, in its competition with dentists.
It was found that, in fact, there was not a marked change in the market
response after the opening of competition. This could be explained by the fact
that legalisation did not change the nature of provision of dentures, from the
pre-legalisation days.
It was also pointed out, that although it may have been a “hot topic” in the
dental world, the consumers lacked information about the changes. This may
have been different to the changes in Canada, which was driven by
consumers.
The perception of consumers in the difference of quality of care offered by
dentists as opposed to CDT, might also explain the fact that dentist’s fees did
not change remarkably.
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In a later survey in New Zealand, Egan (2008) found a significant professional
fee differential for prosthodontic services supplied by denturists and dentists.
Denturists’ lower fees provide a more economic option and they were even
making inroads into the implant overdenture market.
MacEntee (J Prosthetic Dentistry 1994) charted the historical and political
establishment of Denturists in Canada. He mentions that is was stronger
political opposition from the BDA and its close association with the medical
profession that prevented the development of denturists in the UK.
By 1979 there were only two Canadian states in which denturists were still
illegal, and since then denturists have established a role within Canadian
society.
Nevertheless the dentists of Canada were still rather skeptical of the role of
denturists and surveys indicated that they did not approve of their education,
and strongly disapproved of denturists treating mouths with natural teeth.
MacEntee continues by reviewing the literature around the Oral Health of the
Elderly. He concludes that Oral Health in old age is influenced to a large
extent by complete dentures and that mucosal inflammation and hyperplasia
Is associated with inadequate dentures.
As well as being able to examine and diagnose for the presence of oral
cancer, the dentist has an essential role In the treatment of the elderly.
Denturists have little or no training in pathology or diagnosis of soft tissue
lesions. Hence in some areas the patient is required to attend a dentist and be
passed orally fit, before attending a denturist. However this protocol has been
widely opposed by the denturists.
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MacEntee also cites the economic benefit of competition between dentists
and denturists, which has been shown to have reduced the increase in the
cost of complete dentures, relative to the increase in cost of other items of
dental treatment. This was not supported by the Office of Fair Trading in the
UK, who decided not to support denturists as there was little justification for
this additional service. This was the position also taken by the Irish Restrictive
Practice Commission.
There have been various studies comparing the quality of dentures provided
by the dentists and denturists. Tuominen R (J of Oral Rehabilitation 2003)
concludes, after a study of 242 denture wearing subjects that the provision of
dentures by denturists and dental technicians seems to be related to a
decrease in clinical quality as compared to those produced by dentists.
Clark (Clark R K F Radford D R Fenlon M R 2004) develops his idea
proposed in his paper quoted above (Clark R 2002) regarding a changed
curriculum to give the undergraduate a basic knowledge of the subject in the
time constraints applied by the dental schools. He suggests that, perhaps,
students should be taught replacement denture or copy denture techniques as
a substitute for the traditional course. The particular technique he suggests
would involve less clinical time and introduce the student to complete denture
construction, educating them to a level that may encourage some to take the
discipline further and others to treat routine cases with this technique and the
difficult cases refer to specialists or clinical dental technicians.
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The technique he admits has its flaws, as indeed the whole concept of the
copy denture being more easily tolerated is not based on any research.
Indeed it may be the duplication of the denture faults that make it acceptable
to patients. New dentures would be likewise acceptable should they be made
to the correct parameters.
Clark is just adding to the debate on the issue. He accepts the fact of the
reduction in clinical awareness of the new graduate and is suggesting we alter
the course to produce a less skilled practitioner but adequate for his purpose.
Ettinger ( Ettinger R L 2004) quotes the Douglas et al (2002) epidemiological
survey of edentulism in USA, and his prediction for 2020, previously
mentioned. He also highlights the detrimental effect poor dentures can have
on the patient, forcing them to eat a poorly nutritious diet, putting them at a
higher risk of disease. Psychological factors play a great role in the
dissatisfaction of dentures by their wearers. In fact, this factor may be more
influential on success than anatomical conditions or denture quality. Ettinger
also points out that complete denture success is more dependent on
experience rather than evidence-based science. This clinical mentoring has
been traditionally the method of teaching and it is this cycle that is being
broken by the revised undergraduate curriculum.
Students are faced with diminishing number of patients to treat and those that
are treated are the more demanding and difficult patient. This, in turn, puts
the novice student in difficulty and initiates a negative approach to complete
denture restoration for the rest of their career.
Some countries have introduced clinical dental technicians to care for the
edentulous but these technicians do not posses the medical knowledge to
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asses the overall health and medication of their patients and the training to
diagnose and treat the 30% of patients with denture induced soft tissue
lesions.
Other countries have shifted the care for persons who cannot afford private
prosthodontics to the salaried services.
In conclusion he urges dental schools to rethink their curriculum and train
dentists to have the skills to care for the potential 16.4 million older adults who
will need complete dentures in 2020.
In 2005 R T Hawkinson, in a letter (Hawkinson RT 2005) appeals to the dental
world to go back to basics. He posits that it is not feasible to restore a
dentition on implant supported prosthesis, unless the practitioner has a sound
education and experience in restoring the edentulous mouth with complete
dentures. The knowledge of the correct tooth and soft tissue potion can only
be gained with an understanding of the complete denture. This is full mouth
rehabilitation.
If graduate students are unable to make dentures without help from a
laboratory they are unable to even plan implant rehabilitation.
However, an opposing view was penned by McGarry (McGarry T J 2005). He
urged dental educators to move away from ‘traditional’ thinking about teeth
replacement with removable prosthodontics; and to fully embrace education
and training in implant therapy. He refers to this mode of treatment as
minimal invasive prosthetic therapy (MIPT). Implant placement, in the partially
dentate mouth, would eliminate the need for healthy adjacent tissues to
support conventional prosthetic therapies.
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He calls for the extension of implant surgical training into the undergraduate
dental curriculum in the USA.
Carlsson (Carlson G E Ridwann O 2006) reviewed the current trends in
prosthodontics generally, in which the osseo-integrated implant has
revolutionised the treatment of the partially and totally edentulous patients.
Whilst the distinct advantages of these treatments are evident, nevertheless
the cost of such treatments serves as a constraint to the wider use by the
public, even in the wealthiest countries.
He quotes a further study of Medline research using the term ‘prosthodontis’
which indicates that the growth in literature on conventional prosthetics was
rapid in 1960’s, reaching a peak in the 1990’s after which a gradual decrease
occurred. The number of paper’s relating to implants, however, dramatically
increases in the last decade up to 2004.
Such advances in implant technology and research as well as the
development of dental materials ensure that these are the prime driving forces
in prosthodontics today. It has even been proposed (McGill Consensus
Conference 2002) that implant supported overdentures should become the
standard of care for the edentulous patient, particularly in the mandible.
But at the end of the day, even in the wealthiest countries, conventional
prosthodontic treatment, including removable dentures will continue to play an
essential role in everyday dentistry.
Waldman ( Waldman H B Perlman S P Ling X 2007)) considers the actual
number of dentures that would still have to be provided in 2020 in the USA.
His predictions, based on other extensive research papers estimate that in
2020 there would be 61 million edentulous arches. Assuming that demand for
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dentures would be one quarter of that number, it would still mean that each
professionally active prosthodontist would be responsible for approximately
4600 dentures!!
Given this scenario and the calls for elimination of unnecessary course and
curriculum hours, it is no wonder that the prediction is that millions of patients
will be forced to seek denture services from alternative providers. – the
denturists. Therefore, he strongly challenges the view that the preparation of
the next generation of dentists to provide complete dentures is “unnecessary.”
The sheer numbers of the future treatment need dictate that this is an
essential in the dental curriculum. This is in addition to the fact that this
subject gives the dentist an appreciation of a wide variety of dental issues,
including occlusion, which is useful in all aspects of dental care.
He concludes by saying that we have no choice but to prepare the next
generation of practitioners with the necessary didactic prosthetic course and
clinical experience in their undergraduate training years.
As previously mentioned – Clark R., in an opinion paper in BDJ (2002), put
forward the suggestion of an abridged prosthetic course, teaching just the
basics of the subject to the undergraduate students.
What impact will this have on patient satisfaction?
Hakestaun Uet al(1997) examined a small (42) group of patients who had
undergone extensive general prosthodontic treatment.
They found that technical quality is associated with patient satisfaction.
However when focusing on complete denture prosthetics the results are
different.
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Kawai Y at al (2005) compared the quality of conventional
complete dentures fabricated with two different techniques - the traditional
technique and the simplified technique.
In a random controlled study the two groups were compared. It was found that
the quality of complete dentures, which was measured by patient ratings for
overall satisfaction, does not suffer when manufacturing techniques are
simplified to save time and materials.
Heydecke G (2008) compared the patient ratings of denture satisfaction
between a denture comprehensively manufactured with that of a denture
made with a simplified technique.
This was a random crossover trial, with each patient scoring both dentures.
After 3 months of wearing each of the dentures, the patients rated their
general satisfaction, of each of the dentures.
It was concluded that a comprehensive method for manufacturing of complete
dentures does not appear to positively influence patient ratings of denture
satisfaction when compared to simple procedures.
Sutton AF, Glenny AM , McCord JF (2005) researched the evidence for
the assumption that the occlusal scheme of complete dentures has a direct
influence upon their success. Their conclusion was that there is weak
evidence to suggest that it be advantageous to provide posterior teeth with
cusps compared to providing cuspless teeth.
However they recommended further well conducted trials to provide further
evidence.
Carlsson GE, (2006) mentions that there is poor correlation between
quality of dentures and patient satisfaction, and no evidence that a more
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complex fabrication technique results in a better clinical outcome.
Balanced occlusion / articulation is not necessary for successful complete
dentures, and the quality of materials only have a minor influence on patient
satisfaction.
However he concludes that psychological factors, i.e. a good relationship
between dentist and patient are more important than prosthodontic factors for
a positive outcome.
Fenlon M.R, Sherriff M, (2004) investigated whether the clinical quality of the
new complete dentures predicts the patient satisfaction of those same
dentures two years after insertion. In a large study (417) it was found that
there was no significant association between aspects of new denture quality
and patient satisfaction after two years, compared to the three months ratings
from the same patients who demonstrated significant association between
new denture quality and satisfaction with use of new complete dentures.
The conclusion being that initial clinical quality of new dentures is not a
significant factor in determining long-term satisfaction.
Undergraduate Training
The General Dental Council’s, The First Five Years (2008) suggests a number
of competencies that must be achieved by the dental undergraduate prior to
qualification. It lists”…… be competent at designing effective indirect
restorations and complete and partial dentures…”
Youngson CC. et al (2007) studied the requirements in restorative
dentistry that undergraduate dental students have to fulfil in order to sit the
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final examination in the UK and Ireland, and compare those requirements
with competencies stipulated by the GDC above. In an anonymised
questionnaire sent to each of the undergraduate schools, it was apparent that
there were fundamental differences between the schools as to how to
ascertain that their student had reached “competency”. Some schools
explained that they do not have “requirements” but provide general guidelines
as to what should be achieved. Other institutions had numerical targets e.g.
direct placement restorations - varied from 50 to 160.
Five institutions did not have numerical requirements for dentures – complete
or removable.
In conclusion it was recommended that this wide disparity between institutions
should be remedied. Requirements should be similar between institutions and
should be closely mapped by the GDC’s required outcome for UK dental
institutions.
Patel J. (2006) compared the views of new vocational dental practioners
(VDP) and their trainers regarding how undergraduate dental education has
prepared them for vocational training (VT). It also aimed to identify areas of
weakness in undergraduate education that could influence future training
needs of vocational trainers.
A structured postal questionnaire was completed by VDP’s and their trainers
from five deaneries (186). It covered all aspects of dentistry and highlighted
areas in which undergraduate education covered the topic “well” or ”very well”,
e.g. treatment planning, history taking, diagnosis, to areas rated “poor” e.g.
molar endodontics and surgical extractions.
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With reference to removable prosthodontics, most trainers (68%) perceived
undergraduate training in construction of immediate dentures to be “poor”,
compared to the majority of VDP’s (82%) who were content with their training
in this field.
Overall the VDP’s believed they were prepared adequately at dental school
for the construction of removable prostheses in general practice.
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