Dental Student Perceptions of Predoctoral Implant Education and Plans for Providing Implant Treatment

Transcription

1 Dental Student Perceptions of Predoctoral Implant Education and Plans for Providing Implant Treatment Judy Chia-Chun Yuan, D.D.S., M.S.; Linda M. Kaste, D.D.S., Ph.D.; Damian J. Lee, D.D.S., M.S.; Rand F. Harlow, D.D.S.; Kent L. Knoernschild, D.M.D., M.S.; Stephen D. Campbell, D.D.S., M.M.Sc.; Cortino Sukotjo, D.D.S., Ph.D., M.M.Sc. Abstract: This study aims to identify dental students perceptions of pre-patient care laboratory exercises (PCLEs) and clinical experiences that influence their future plans for providing implant care. One of two questionnaires was administered to dental student classes at one dental school (D2: Survey 1; D3 and D4: Survey 2). Future plans as graduates to provide implant diagnosis and treatment planning (DxTP), restoration of single-tooth implants (STIs), and implant-retained overdentures (IODs) were cross-sectionally assessed along with potential influences such as PCLE, clinical experiences, gender, and class. The majority of students planned to provide implant services after graduation (DxTP 68.9 percent; STI 61.2 percent; IOD 62.1 percent). Bivariately, males reflected more preparedness from PCLEs than females (p=.002) and the D2 students more than D3 and D4 students (p<.001). Multivariate models revealed the perceived preparedness from PCLEs generally had the strongest association with future plans for performing implant therapy. However, this varied by gender and class. These findings indicate that PCLEs are important for their influence on students future plans to provide implant therapy. However, further studies are needed to validate actual PCLEs and clinical implant practices (both longitudinally and for other schools) and to determine educational interventions to optimize the provision of implant care. Dr. Yuan is Clinical Assistant Professor, Department of Restorative Dentistry, College of Dentistry, University of Illinois at Chicago; Dr. Kaste is Associate Professor, Department of Pediatric Dentistry, College of Dentistry, University of Illinois at Chicago; Dr. Lee is Clinical Assistant Professor, Department of Restorative Dentistry, College of Dentistry, University of Illinois at Chicago; Dr. Harlow is Clinical Assistant Professor and Director of Predoctoral Implant Program, Department of Restorative Dentistry, College of Dentistry, University of Illinois at Chicago; Dr. Knoernschild is Associate Professor and Director of Advanced Prosthodontics, Department of Restorative Dentistry, College of Dentistry, University of Illinois at Chicago; Dr. Campbell is Professor and Head, Department of Restorative Dentistry, College of Dentistry, University of Illinois at Chicago; and Dr. Sukotjo is Assistant Professor, Department of Restorative Dentistry, University of Illinois at Chicago, College of Dentistry. Direct correspondence and requests for reprints to Dr. Cortino Sukotjo, Department of Restorative Dentistry, College of Dentistry (MC 555), University of Illinois at Chicago, 801 South Paulina Street, Room 365B, Chicago, IL ; phone; fax; Keywords: dental implants, dental students, dental education, perception, intention Submitted for publication 10/25/10; accepted 12/29/10 Dental implant-supported care has become a desirable treatment option 1,2 due to predictability and high success rates, 3-5 increased patient interest, 6 increased patient acceptance, 7 conservation of adjacent tooth structure, 3 preservation of the alveolar bone, and resistance to carious lesions. 8 Despite an estimated decline in the agespecific rates of edentulism, the unmet need for complete dentures will continue to increase as the baby boomer generation matures. 9,10 The demand for prosthodontic treatments has been projected to exceed the provider supply through ,10 Though most prosthodontists treat patients requiring implantsupported prostheses, 11 general dentists must also be prepared to incorporate dental implant philosophy to meet best practices, patient needs, and demands. 12 With increased patient awareness and expectations, 13 dental graduates must recognize the indications for implant care and provide predictable treatment. Evidence continues to support the rationale that integration of dental implants into predoctoral dental education is imperative since dentists exposed to implant therapy as students are more likely to provide implant care for their patients. 14,15 Implant dentistry has been incorporated into predoctoral curricula worldwide In the United States, thirty-two schools report that implant education is part of the requirement in the predoctoral curriculum. 23 In addition, Commission on Dental Accreditation (CODA) standards for dental education programs have mandated that, effective July 1, 2013, graduating dentists must be competent in providing dental implant 750 Journal of Dental Education Volume 75, Number 6

2 prosthodontic therapy for their patients. 24 Student learning experiences through a well-organized curriculum will directly affect clinical decision making. Student perceptions of those dental implant learning experiences may directly affect how well they learn and incorporate implant treatment options into their daily clinical practice. Two studies 21,22 have investigated students perceptions of the implant curriculum, although most published studies on predoctoral implant education have concerned the curriculum s development, structure, teaching philosophy, 14,15,19-21,23,25-27 and clinical outcomes. 26,28,29 Students perceptions may provide important information in identifying potential areas for improvement in educational curricula. 30 For example, a recent study of student perceptions following preclinical exercises suggested that students stress levels associated with prosthodontics exercises were greater than those in endodontics and operative dentistry. 31 Another study found that the majority of students surveyed felt stressed during fixed prosthodontic and complete denture courses, but not in removable partial denture laboratory exercises. 32 The University of Illinois at Chicago College of Dentistry (UIC-COD) Predoctoral Implant Program was developed on a foundational belief that 1) dental implants must be fully integrated into predoctoral student learning experiences and 2) the learning model must best fulfill the students learning needs for effective clinical practice that incorporates the fundamentals of patient diagnosis, treatment planning, and dental implant therapy. With the evolution of the program, opportunities arose for outcomes assessment to ensure that students were receiving the appropriate learning experiences and gaining confidence in meeting patients needs with dental implants. Analyzing student perceptions may help educators convey the educational concepts, 30 knowledge, skills, and behaviors needed to provide patients with optimal dental implant therapy and to identify factors that may affect their future plans for providing implant-supported care. Therefore, the objectives of this study were to 1) identify student perceptions of their pre-patient care laboratory exercises and clinical curriculum, 2) relate these perceptions to any future plans to treat patients requiring implant care, and 3) investigate any differences between gender and educational level in the survey responses. The following provides an overview of the UIC predoctoral implant program, methods used for assessment of students perceptions of their experiences, and the reported student outcomes from the learning experiences. UIC Predoctoral Implant Program In 2000, a Comprehensive Dental Implant Clinic was initiated at UIC that includes predoctoral and postdoctoral components. The philosophy of the program is to provide a prosthetically driven, patient-centered, and competency-based education for every student. The UIC Predoctoral Implant Program was developed to ensure that every dental student receives didactic, hands-on, pre-patient care laboratory exercises (PCLEs) and clinical learning experiences including patient treatment in order to develop the necessary knowledge and skills to provide single tooth implant (STI) supported restorations and twoimplant retained mandibular overdentures (IODs). The goal of this program is to provide student competence in aspects of prosthetic restoration for partially edentulous patients and for rehabilitation with implant-retained overdentures for completely edentulous patients. Competence for restoration of STIs and IODs was defined as the following: students must be able to independently diagnose and treatment plan from radiographs and clinical examination, and students must be able to independently fabricate a surgical guide, communicate with the surgeon, and provide implant-supported restorations for patients. The didactic portion of the program is presented in a traditional lecture format, with the aid of the Internet-based educational platform (Blackboard Academic Suite, 2010). The importance of proper patient selection and specialty referral is strongly reinforced through the dental implant therapy team approach. The hands-on component of the training is divided into STI restoration and IOD treatment modules. Prior to each laboratory exercise, a live demonstration is presented to the students. Students learn the proper sequence of instrumentation and implant placement with surgical drills, followed by the restorative phase using the appropriate implant components. The implants, drilling units, surgical drills, and various implant parts are provided by Astra Tech (Astra Tech, Inc., Waltham, MA) and Nobel Biocare (Nobel Biocare, Sweden). June 2011 Journal of Dental Education 751

3 Materials and Methods Two surveys were developed based on Sukotjo et al. 31,32 with modifications. All D2 students ( of 2011, n=65) received Survey 1 at the end of the pre-patient care implant curriculum in May Survey 1 asked D2 students for their perceptions of the importance of implant education, how well the PCLEs prepared them for patient care, and whether these experiences might influence their future plans to perform implant therapy. They were also asked about their perceptions of the pre-patient care implant curriculum. A second survey (Survey 2) was distributed to the D3 students ( of 2010, n=66) and D4 students ( of 2009, n=64) in April 2009 near the completion of their third/fourth-year clinical experience. In addition to similar questions from Survey 1, Survey 2 also assessed students perceptions of their stress levels, competence, preparedness, clinical experiences, and productivity. Both questionnaires were administered using an Internet-based survey engine (SurveyMonkey, Menlo Park, CA). The research protocol received exempt status from the Office for the Protection of Research Subjects and Institutional Review Board, University of Illinois at Chicago (protocol # ). Participation in the study was voluntary, and the anonymity of the respondents was assured. Data were entered into a software database (Microsoft Excel 2003; Microsoft, Seattle, WA). Statistical software (Statistical Package for the Social Sciences, version 17.0; SPSS Inc., Chicago, IL) was used for the statistical analyses. The data were analyzed with both descriptive and inferential statistics. Frequencies and percentages were used to provide an overview of the demographic data. Cross-tabulations were constructed, and the Fisher s exact test, Kruskal- Wallis test, ANOVA, and independent t-test were conducted to examine the relationships between variables. Several variables were recoded to be dichotomous, based on thresholds in the data. Logistic regression models were constructed for multivariate analysis. First, the variables available for all three classes were assessed for the contributions towards the three outcomes of future plans for implant care by perceived preparedness from the PCLEs, gender, and class. The three outcomes of future plans were plans to provide diagnosis and treatment planning (DxTP), plans to restore STI restorations, and plans to restore IODs. The associations of independent variables with all three classes, gender, and individual classes were studied. A second group of logistic equations provided further assessment for clinical experiences from Survey 2 conducted with the third- and fourthyear students. These variables included stress, competence, productivity, and preparedness, in addition to the above-mentioned independent variables. The relationship of these variables was evaluated for both the D3 and D4 classes, by gender and class. Similar modeling was conducted for Survey 1. Results A high response rate was achieved for both surveys: 95 percent for Survey 1 (D2) and 89 percent for Survey 2 (D3 and D4). The vast majority of the respondents (99 percent) felt that implant training in predoctoral dental education was important or very important. Regarding the level of instructor feedback, the majority of respondents (D2: 87.1 percent, D3: 55.6 percent, D4: 68.3 percent) felt it was just right. The distribution of respondents by gender and dental class is presented in Table 1. The gender distribution was similar both overall and by class (p=0.368 and p=0.577, respectively). Each class contributed about one-third of the responses. More than half of the respondents (104, 58.4 percent) felt that implant PCLEs had adequately prepared them for treating patients. respondents (56.7 percent) felt more prepared from the laboratory exercises than their female counterparts (43.3 percent) (p=0.002). The distribution across class for perceived adequate preparedness from PCLEs varied, with the highest being reported by the D2s (p<0.001). When asked to describe overall experiences in performing STI and IOD care in the clinic, D4s felt more competent than D3s on the composite competency index on STI and IOD procedures (STI: 7.4 D4s vs. 3.5 D3s, p<0.001; IOD: 4.5 D4s vs. 1.7 D3s, p<0.001) (data not shown on table). D4s reported performing significantly more STI and IOD procedures than D3s (STI: 4.9 D4s vs. 2.5 D3s, p<0.001; IOD: 3.6 D4s vs. 1.2 D3s, p<0.001) (data not shown on table). In general, STI procedures were performed 1.6 times more frequently than IODs. The most common and least common procedures performed were consultation and restorative procedures for both treatment modalities, respectively. The majority of the responding students from all classes reported planning to provide DxTP (68.9 percent), STI (61.2 percent), and IOD restorations (62.1 percent) after graduation (Table 2). s 752 Journal of Dental Education Volume 75, Number 6

4 Table 1. Distribution by class and gender for respondents to implant education and future plans questionnaires: Survey 1 (D2) and Survey 2 (D3 and D4), AprilMay 2009 Surveys 1 (D2) and 2 (D3 and D4) Total N N (%) Female N (%) P-value D2 N (%) D3 N (%) D4 N (%) P-value (46.6%) 95 (53.4%) (51.6%) 24 (42.1%) 27 (32.5%) (35.2%) 57 (31.8%) 59 (33.0%) Laboratory exercise adequately Yes (56.7%) 45 (43.3%) 0.002* 51 (49.0%) 23 (22.0%) 30 (29.0%) <0.001* Plan to DxTP Yes (48.8%) 63 (51.2%) (35.8%) 39 (31.7%) 40 (32.5%) Plan to restore STIs Yes (53.2%) 51 (46.8%) 0.040* 38 (34.9%) 35 (32.1%) 36 (33.0%) Plan to restore IODs Yes (51.8%) 53 (48.2%) (35.5%) 35 (31.8%) 36 (32.7%) Survey 2 (D3 and D4) Stress during STI treatment Yes (41.0%) 51 (59.0%) (44.8%) 48 (55.2%) Stress during IOD treatment Yes (40.0%) 50 (60.0%) (46.0%) 45 (54.0%) Preparedness in STI treatment Yes (47.0%) 39 (53.0%) (46.0%) 40 (54.0%) Preparedness in IOD treatment Yes (48.0%) 40 (52.0%) (49.0%) 39 (51.0%) *P-values less than June 2011 Journal of Dental Education 753

5 (69.9 percent) were significantly more likely to plan to restore STIs than females (53.7 percent; p=0.040). For the total, the majority of the respondents felt that adequate preparedness from laboratory exercises significantly influenced their future plans to provide DxTP (p=0.004), STIs (p=0.006), and IOD restorations (p=0.010). The perceived stress during treatments did not show any significant association with any future plans. Logistic regression models estimating the indicators of future plans in implant-supported care for all classes are presented in Table 3, using only the common variables assessed in Survey 1 (D2) and Survey 2 (D3 and D4). To assess the influences in different conditions, total and separate regressions for male, female, D2, D3, and D4 groups were conducted. Three sets of outcomes of DxTP, STIs, and IODs were assessed. For each of these three, model A observed the preparedness from the PCLE only, and model B observed the preparedness from the PCLE adjusting for gender and class. For the total sample, the point estimate for the preparedness from PCLE experience varied little with the inclusion of gender and class. When assessing gender separately, male respondents consistently showed a stronger association between the perceived preparedness from the PCLE alone when controlling for class than did the females in the female-only models. D3 students were the only class to demonstrate a strong association between perceived preparedness from the PCLE and plans to practice implant dentistry, where statistical significance was reached. Table 4 presents the indicators of future plans to provide implant care from Survey 2 for D3s and D4s only, for the consideration of the additional factors assessed. For the total sample, the point estimate for the preparedness from the PCLE increased with gender and class. The point estimate decreased when the additional factors were added for the DxTP model, but remained relatively constant across the additional factors for the STI and IOD models. When modeling gender separately, male respondents Table 2. Bivariate analysis of students perceptions of future plans for performing implant care: Survey 1 (D2) and Survey 2 (D3 and D4), AprilMay 2009 Surveys 1 (D2) and 2 (D3 and D4) Plan to diagnosis and treatment plan % Yes P-value Plan to restore STI % Yes P-value Total 68.9% 61.2% 62.1% : Female 72.3% 66.3% % 53.7% Plan to restore IOD % Yes P-value 0.040* 68.7% 55.8% : D2 D3 D4 71.0% 68.4% 67.8% % 61.4% 61.0% % 61.4% 61.0% Laboratory exercise adequately Yes No 77.9% 56.8% 0.004* 70.2% 48.6% 0.006* 70.2% 50.0% 0.010* Survey 2 (D3 and D4) Stress during STI treatment Stress during IOD treatment Preparedness in STI treatment Preparedness in IOD treatment Yes No Yes No Yes No Yes No *P-values represent values less than NA represents non-relevant comparisons. 65.5% 82.6% 66.7% 74.1% 77.0% 53.7% 74.0% 58.3% % 73.9% NA NA NA NA 59.5% 66.7% 0.017* 64.9% 56.1% NA NA NA NA 64.9% 55.6% Journal of Dental Education Volume 75, Number 6

6 Table 3. Logistic regression models for indicators of future plans to provide implant care by total, gender, and class: from data restricted to being available from both Surveys 1 (D2) and 2 (D3 and D4), AprilMay 2009 Total Female D2 D3 D4 I. Do you plan to provide implant diagnosis and treatment planning to your patients after graduation as a result of your training? Model A. Laboratory exercise adequately Model B. Laboratory exercise adequately 2.7 (1.4, 5.2)* 3.3 (1.2, 9.2)* 2.2 (0.9, 5.4) 2.4 (0.6, 9.3) 5.3 (1.3, 21.1)* 2.3 (0.8, 7.1) 2.8 (1.4, 5.6)* 1.0 (0.5, 2.1) 1.1 (0.7, 1.7) 3.3 (1.1, 9.8)* 1.0 (0.5, 1.9) 1.2 (0.7, 2.1) 1.2 (0.7, 2.1) 2.1 (0.5, 8.3) 1.8 (0.6, 5.8) 7.0 (1.5, 31.9)* 0.5 (0.1, 1.7) 2.3 (0.7, 7.1) 1.1 (0.4, 3.4) II. Do you plan to provide single tooth implant restorations to your patients after graduation as a result of your training? Model A. Laboratory exercise adequately Model B. Laboratory exercise adequately 2.5 (1.3, 4.6)* 2.7 (1.0, 7.4)* 1.9 (0.9, 4.4) 0.9 (0.3, 3.4) 15.0 (3.0, 74.5)* 2.2 (0.7, 6.3) 2.4 (1.2, 4.7)* 1.7 (0.9, 3.2) 1.2 (0.8, 1.7) 3.0 (1.0, 8.7)* 1.2 (0.6, 2.2) 2.1 (0.9, 4.8) 1.2 (0.7, 2.0) 0.7 (0.2, 2.7) 2.8 (0.9, 8.2) 17.6 (3.2, 96.7)* 0.7 (0.2, 2.6) 2.0 (0.7, 5.9) 1.9 (0.6, 5.8) III. Do you plan to provide overdenture implant restorations to your patients after graduation as a result of your training? Model A. Laboratory exercise adequately Model B. Laboratory exercise adequately 2.4 (1.3, 4.4)* 3.2 (1.2, 8.7)* 1.6 (0.7, 3.7) 1.0 (0.2, 3.7) 15.0 (3.0, 74.5)* 1.6 (0.6, 4.7) 2.3 (1.2, 4.4)* 1.5 (0.8, 2.8) 1.1 (0.7, 1.7) 3.6 (1.2, 10.5)* 1.2 (0.7, 2.2) 1.7 (0.7, 3.9) 1.1 (0.6, 1.8) 0.7 (0.2, 3.1) 2.4 (0.8, 7.0) 22.6 (3.7, 136.7)* 0.4 (0.1, 1.7) 1.5 (0.5, 4.3) 2.0 (0.7, 5.9) *Reflects significant odds ratios where the 95% CI does not include the null value of 1. June 2011 Journal of Dental Education 755

7 Table 4. Logistic regression model for indicators of future plans in implant care by total, gender, and class: data restricted to being available from Survey 2 (D3 and D4), AprilMay 2009 I. Do you plan to provide implant diagnosis and treatment planning to your patients after graduation as a result of your training? Total Female D3 Only D4 Only Model A. Laboratory exercise adequately 3.2 (1.4, 7.5)* 3.6 (1.1, 12.5)* 3.2 (0.9, 11,1) 5.3 (1.3, 21.1)* 2.3 (0.8, 7.1) Model B. Laboratory exercise adequately Model C. Laboratory exercise adequately Stress during STI treatment Stress during IOD treatment Competent in performing STI treatment (mean) Competent in performing IOD treatment (mean) Productivity in STI treatment (mean) Productivity in IOD treatment (mean) Preparedness in STI treatment Preparedness in IOD treatment 3.5 (1.4, 8.4)* 0.8 (0.3, 1.8) 0.9 (0.4, 1.9) 1.9 (0.6, 6.4) 1.1 (0.4, 3.1) 0.3 (0.1, 1.4) 0.4 (0.1, 2.5) 1.6 (0.3, 8.6) 1.1 (0.8, 1.5) 0.9 (0.7, 1.2) 0.9 (0.6, 1.3) 1.6 (1.0, 2.3) 1.9 (0.5, 6.7) 0.8 (0.2, 2.5) 3.6 (1.1, 12.6)* 1.2 (0.3, 4.1) 0.6 (0.1, 7.0) 0.7 (0.0, 14.8) 0.4 (0.0, 16.0) 3.1 (0.1, 95.4) 0.9 (0.4, 2.2) 0.9 (0.5, 1.8) 1.0 (0.5, 2.5) 1.5 (0.8, 2.9) 8.9 (0.6, 130.7) 0.6 (0.0, 10.0) 3.5 (1.0, 12.4) 0.7 (0.2, 2.0) 2.9 (0.6, 14.2) 0.2 (0.0, 2.1) 0.4 (0.0, 6.3) 0.8 (0.1, 7.8) 1.2 (0.8, 1.7) 1.0 (0.7, 1.4) 0.8 (0.5, 1.5) 1.6 (0.9, 3.0) 1.1 (0.2, 5.3) 0.9 (0.2, 4.3) 7.0 (1.5, 31.9)* 0.5 (0.1, 1.7) 2.7 (0.5, 14.9) 0.7 (0.1, 3.9) 0.6 (0.0, 10.9) 1.2 (0.1, 15.6) 0.8 (0.5, 1.3) 1.0 (0.6, 1.6) 1.2 (0.7, 2.0) 1.4 (0.7, 2.7) 2.4 (0.4, 15.1) 0.9 (0.1, 5.7) 2.3 (0.7, 7.1) 1.1 (0.4, 3.4) 0.9 (0.1, 7.9) 1.1 (0.2, 4.9) 0.5 (0.0, 7.3) 2.1 (0.2, 22.4) 1.6 (1.0, 2.5) 1.0 (0.7, 1.4) 0.7 (0.3, 1.5) 1.6 (0.9, 2.9) 2.6 (0.3, 21.1) 0.9 (0.1, 6.4) II. Do you plan to provide single tooth implant restorations to your patients after graduation as a result of your training? Model A. Laboratory exercise adequately 4.5 (2.0, 10.2)* 3.6 (1.1, 12.5)* 4.8 (1.5, 15.4)* 15.0 (3.0, 74.5)* 2.2 (0.7, 6.3) Model B. Laboratory exercise adequately Model C. Laboratory exercise adequately Stress during STI treatment Competent in performing STI treatment (mean) Productivity in STI treatment (mean) Preparedness in STI treatment 4.3 (1.8, 10.1)* 1.3 (0.6, 3.0) 0.8 (0.4, 1.8) 5.5 (1.8, 6.2)* 1.3 (0.5, 3.2) 0.5 (0.1, 1.6) 0.6 (0.2, 1.8) 1.1 (0.9, 1.4) 1.1 (0.8, 1.5) 0.5 (0.2, 1.4) 3.6 (1.0, 12.6)* 1.2 (0.3, 4.1) 2.6 (0.5, 15.2) 1.0 (0.1, 7.0) 2.5 (0.6, 11.4) 1.1 (0.7, 1.8) 0.8 (0.4, 1.5) 1.3 (0.2, 8.7) 5.4 (1.6, 17.9)* 0.6 (0.2, 1.8) 9.4 (1.9, 47.4)* 0.4 (0.1, 2.2) 0.1 (0.0, 1.3) 1.1 (0.8, 1.5) 1.1 (0.7, 1.9) 0.3 (0.1, 1.3) 17.6 (3.2, 96.7)* 0.6 (0.2, 2.6) 18.9 (2.7, 135.0)* 0.7 (0.2, 3.3) 0.6 (0.1, 3.5) 0.9 (0.6, 1.4) 1.2 (0.7, 2.0) 0.4 (0.1, 2.1) 2.0 (0.7, 5.9) 1.9 (0.6, 5.8) 1.9 (0.4, 9.1) 1.5 (0.4, 4.8) 0.8 (0.1, 3.6) 1.3 (0.9, 1.8) 0.9 (0.5, 1.7) 0.9 (0.2, 4.7) 756 Journal of Dental Education Volume 75, Number 6

8 III. Do you plan to provide overdenture implant restorations to your patients after graduation as a result of your training? Model A. Laboratory exercise adequately 3.8 (1.7, 8.5)* 4.4 (1.3, 15.1)* 3.1 (1.0, 9.5)* 15.0 (3.0, 74.5)* 1.6 (0.6, 4.7) 1.5 (0.5, 4.3) 2.0 (0.7, 5.9) 22.6 (3.7, 136.7)* 0.4 (0.1, 1.7) 3.5 (1.1, 11.0)* 0.6 (0.2, 1.7) 4.4 (1.3, 15.4)* 1.5 (0.4, 5.1) 3.7 (1.6, 8.6)* 1.2 (0.5, 2.6) 0.8 (0.4, 1.9) Model B. Laboratory exercise adequately 1.2 (0.3, 5.3) 3.7 (1.0, 14.7) 1.8 (0.4, 7.6) 1.0 (0.7, 1.4) 1.8 (1.1, 2.8)* 1.0 (0.2, 5.0) 22.1 (3.0, 161.1)* 0.4 (0.1, 2.4) 0.2 (0.0, 1.5) 0.9 (0.6, 1.5) 1.4 (0.8, 2.5) 0.4 (0.1, 2.0) 3.7 (1.0, 14.5) 0.2 (0.0, 1.1) 0.5 (0.1, 2.3) 1.0 (0.7, 1.4) 1.6 (1.0, 2.5) 0.7 (0.2, 2.5) 4.0 (0.8, 20.7) 0.9 (0.1, 9.1) 1.3 (0.3, 6.1) 0.8 (0.5, 1.3) 1.6 (1.0, 2.6) 0.6 (0.1, 4.3) 3.8 (1.4, 10.5)* 1.6 (0.6, 4.0) 0.3 (0.1, 1.2) 0.8 (0.3, 2.4) 0.9 (0.7, 1.2) 1.6 (1.2, 2.2)* 0.5 (0.2, 1.5) Model C. Laboratory exercise adequately Stress during IOD treatment Competent in performing IOD treatment (mean) Productivity in IOD treatment (mean) Preparedness in IOD treatment *Reflects significant odds ratios where the 95% CI does not include the null value of 1. showed a stronger association between the perceived preparedness from the PCLE alone and adjusting for class factor only for the DxTP and IOD models. Female respondents showed a stronger association between the perceived preparedness from the PCLE adjusting for other measured factors for the DxTP and STI models. When modeling classes separately, respondents in the D3 class demonstrated a stronger association between the perceived preparedness from the PCLE and plans, where statistical significance was reached. A logistic regression model for D2 respondents was constructed to assess the relationship of various independent variables with future implant care measured in Survey 1. None of the measured variables reached statistical significance (data not shown). Although there were no significant differences between the genders among D2 respondents in suggesting future plans, males were more likely to report the intent to provide implant care than females. Discussion Outcomes from this study indicated that students benefited from their pre-patient care education and experiences. Student perceived preparedness from PCLEs and showed a strong association for providing implant care, such as DxTP, STIs, and IOD restorations for all three classes. This observation confirmed the importance of PCLEs and was an encouraging indicator of effectiveness for the predoctoral implant learning experience at UIC COD. This finding was consistent with previous studies 21,22 in that implant training has been reported to be effective in enhancing students education. Kido et al. 22 reported that students have positive opinions toward implant treatment after their training. Conversely, Jahangiri et al. 21 suggested that students were more satisfied when they had more exposure to clinical implant dentistry. Based on prepatient care and clinical experiences, UIC students would be competent as new graduates in providing comprehensive implant care described in this study to their future patients. Patient contact is critical in the predoctoral clinical experience for students to gain confidence in providing therapy with implants. 22 Among all three dental classes in our study, variations in the perceived preparedness from the laboratory exercises for treating patients were assessed. More D2s, followed by D4s and D3s, reported being adequately prepared June 2011 Journal of Dental Education 757

9 from the laboratory exercises for treating patients. The questionnaires were distributed to D2 students immediately after the pre-patient care course. Although they had participated in clinical implant rotations, no actual clinical experience in treating implant care patients had occurred for the D2s. Some studies have suggested that female students were more likely to report stress than males, whereas others reported contradictory results Our study found no statistically significant difference in the perceived stress level between the genders and was consistent with a recent study that examined five categories of stressors (academic performance, faculty relations, patient and clinic responsibilities, personal life issues, and professional identity) between male and female medical and dental students. 38 Various factors may contribute to this finding. The number of women faculty members involved in the UIC COD predoctoral implant curriculum has increased over the years. The presence of more female faculty members may provide a less stressful learning atmosphere than the traditionally male-dominated dental learning environment. 38 The D4s reported being slightly more stressed in performing STI and IOD procedures than D3s. One would expect the D4s to have less perceived stress in performing implant procedures due to their higher level of exposure and experiences. A recent study reported that higher study level was associated with lower performance pressure and interpreted this as an improvement with the progression in the dental curriculum. 34 Some possible reasons that D4s on the contrary reported higher stress could be the pressure to complete patient care in time, greater expectations from instructors, concerns about not completing their implant competency portfolio prior to graduation, or fear of employment after graduation. 36,37 Others have reported inconsistency of feedback from faculty to be one of the top stressors for dental students. 38,40 This study did not further investigate the specific causes or sources of stress in the clinic; therefore, no definitive reasons may be provided at the present time. Our study found that, among D3s and D4s, males were more likely to perform IOD procedures and females more likely to perform STI procedures than their counterparts regarding their future patients. One study reported that female dentists were more likely to refer to specialists and implant care than males. 41 The authors of that study stated that the gender differences reflected the service rendered and practice patterns. The D3s in our study consistently showed significant association in the three future plans compared to D2s and D4s. One possible explanation may be that D2s have not had enough clinical exposure and experience in planning to provide implant care for their future patients. As for D4s, it could be that as they gain more clinical experience, they have a better handle on future plans when they graduate. In addition, it could be that the future practice pattern may dictate the involvement of implant care, as some specialties do not incorporate implant therapy into their care. Several limitations exist in interpreting the findings of our questionnaires. First, information regarding students potential dental career choices was not acquired. Students future career direction may influence whether implant dentistry would be an expected therapy component in their practice, as some dental specialties, such as orthodontics or pedodontics, do not include implant therapy. Additional questions about future plans for implant care could have provided more complete information. In addition, the study design was a cross-sectional survey with information collected at one point in time. Longitudinal surveys to observe student trends and perceptions as they progress through their dental education and beyond as health care providers would be beneficial. A longitudinal follow-up questionnaire for the same class to identify the extent and indicators of providing implant care for their patients is planned. Conclusions Within the limitations of this study, the following conclusions were drawn: 1. Pre-patient care laboratory exercises are important in predoctoral implant education and preparation for students providing dental implant therapy in the future. 2. The majority of students plan to provide diagnosis and treatment planning, single-tooth implant restorations, and implant-supported overdentures for their future patients. 3. Differences existed between male and female students in their perceived preparedness and future plans. 4. D4 students reported higher stress levels when providing implant-related care than D3 students. 758 Journal of Dental Education Volume 75, Number 6

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