A Clinically Oriented Complete Denture Program for Second-Year Dental Students

Transcription

1 A Clinically Oriented Complete Denture Program for Second-Year Dental Students Ales Obrez, D.M.D., Ph.D.; Damian J. Lee, D.D.S.; Anna Organ-Boshes, D.D.S.; Judy Chia-Chun Yuan, D.D.S., M.S.; G. William Knight, D.D.S., M.S., M.S. Abstract: The traditional preclinical complete denture prosthodontic curriculum relies predominantly on the laboratory (e.g., bench-type) component of the complete denture fabrication process. In most cases, this involves a passive model of student knowledge acquisition utilizing lectures and low-fidelity laboratory exercises. A recently implemented program in the College of Dentistry at the University of Illinois at Chicago challenges this educational paradigm by introducing an active learning environment for second-year students based on significant clinical exposure with patients. The result is a major shift of emphasis, first, from a purely technical/laboratory aspect of the discipline to patient-centered education and, second, from mastering individual phases of denture fabrication to understanding the entire process of edentulous patient care. To compare student outcomes in the new program with those in the traditional program, their performance overall and in three components of the final examination for each program were statistically compared. The results of the one-way ANOVA analysis show statistically significant improvement in the students total score in the new program, including their performance on the written, practical, and OSCE portions of the final examination. This article describes the rationale, logistics, challenges, and advantages of the new educational model of the complete denture prosthodontics curriculum. Dr. Obrez is Associate Professor; Dr. Lee is Clinical Assistant Professor; Dr. Organ-Boshes is Clinical Assistant Professor; Dr. Yuan is Clinical Assistant Professor; and Dr. Knight is Assistant Dean for Clinical Education all at the Department of Restorative Dentistry, College of Dentistry, University of Illinois at Chicago. Direct correspondence and requests for reprints to Dr. Ales Obrez, Department of Restorative Dentistry, College of Dentistry (MC 555), University of Illinois at Chicago, 801 South Paulina Street, Room 204K, Chicago, IL ; phone; fax; aobrez@uic.edu. Keywords: innovation, dental educational methodology, predoctoral prosthodontics curriculum Submitted for publication 5/1/09; accepted 7/21/09 A major teaching and learning objective of the preclinical curriculum in complete denture removable prosthodontics is to introduce students to the fundamental laboratory and clinical steps involved in the fabrication and delivery of complete dentures. The subject is traditionally taught during the second year of dental education, with a major emphasis on the laboratory component. 1-4 This laboratory emphasis is one of the major deficiencies of this model. 5 Students spend a majority of their time in the laboratory, with minimal or no patient contact. Teaching dental students clinical procedures in the laboratory setting requires that students gain an abstract understanding of the process of denture fabrication, rather than creating a process that involves alternating sequences of clinical and laboratory procedures found in clinical practice. Though some schools have introduced manikin heads into the laboratory setting, a majority of programs still rely on the edentulous dentoform to simulate the patient. Alternatively, the clinical and laboratory procedures are presented by using prerecorded video demonstrations. 2 However, none of these educational methods adequately replaces live patient demonstrations and students active engagement in both the laboratory and clinical environments. Only one school has reported no laboratory component of the course, instead opting for an entirely patient-based curriculum. 6 If the primary objective of the preclinical curriculum is to provide dental students with the knowledge and skills to successfully initiate patient care, the traditional curriculum in removable complete denture prosthodontics falls short of adequately preparing students for this transition in their education. 7 Furthermore, the average lag time between completion of preclinical education and actual patient treatment ranges from six to nine months. The lecture format is still the most widely used didactic educational method for the transfer of knowledge. But without purposeful planning, lectures tend to be passive experiences from a student point of view and have questionable learning outcomes. All of these shortcomings of the traditional curriculum have been previously identified in reports from the Institute of Medicine 8 and the American College of Prosthodontists. 5 As part of a major, ongoing curriculum revision in the College of Dentistry of the University of Illinois at Chicago since 2002, 9 including course 1194 Journal of Dental Education Volume 73, Number 10

2 evaluation data collected from students and faculty, the Department of Restorative Dentistry took a significant step forward by introducing a new curriculum in complete removable prosthodontics. This program is characterized as a small-group, asynchronous model of education that introduces a clinical component into the traditional bench-type curriculum. The program is supported with Internet-based transfer of knowledge that allows substitution of traditional lectures with grand-rounds-like discussions. This article describes this innovative high-fidelity approach to prosthodontic curriculum delivery. The Restructured Program The overarching objective of this curriculum revision was to introduce dental students to the clinical and laboratory aspects of complete denture prosthodontics as early as possible and in the most clinically relevant manner. The summer semester of student transition from the first year to the second was identified as the place to start the program. The existing preclinical course had been taught as a traditional laboratory course in the dental technique laboratories during the fall semester of the second year. The specific objectives of the project were to 1) develop a curriculum in which students would experience clinical practice as part of their pre-patient curriculum, helping them to transition seamlessly into clinical practice; 2) provide a way for students to participate in small-group discussions related to the subject of complete removable prosthodontics; 3) provide background information for students through the Internet-based educational platform (Blackboard Academic Suite, 2009); and 4) vertically integrate this program with the newly implemented predoctoral implant program. General Outline of the Program This twenty-one-week program was introduced in It is offered one day per week to the firstyear dental students as they transition into the second year (summer and second-year fall semesters). The program is divided into two half-day sessions, splitting the class of approximately ninety students in two groups. Each session consists of a didactic and clinical or laboratory assignment, depending on the step within the sequence of denture fabrication and care process (Figure 1). As part of the didactic component, each student is expected to review the assigned material prior to the session (available on the Blackboard site and in the required reading), answer the review questions received a week earlier, and attend structured summary discussions prior to each clinic or laboratory session (Figure 2). The topics for each discussion session are narrowly focused and related to the rationale, technique, sequence of the steps, and possible difficulties expected during the laboratory or clinical procedures that immediately follow. This discussion session is also dedicated to clarifying any questions students may have regarding any laboratory or clinic procedure related to their understanding of Figure 1. Schematic of the clinically oriented preclinical complete denture curriculum October 2009 Journal of Dental Education 1195

3 Review Session Clinic/Laboratory Session 0.5 Hour 2.5 Hours Figure 2. Example of a typical session (total three hours) in the complete denture curriculum the material or to their patient care activity. With the expectation that they will be prepared for the session, students are challenged to actively participate in all aspects of the review of the topic. The faculty member s traditional role of lecturer is replaced with the role of a facilitator of discussions. In the clinic and the laboratory, each student is assigned to a team consisting of eight students working with one edentulous patient and one faculty member. Each team is responsible for completing management of the edentulous patient, including fabrication and delivery of a complete denture with all the necessary interim and post-delivery care. In this clinical and laboratory work, each student has an opportunity to experience the individual steps and procedures that are necessary during the process of complete denture therapy/care. Most of the laboratory work for the patient s dentures, including processing, is performed by a commercial laboratory. If the individual clinical session requires more time, the team s faculty member decides whether to extend the clinical assignment into the following session. For some teams, this may necessitate lengthening the entire program. Each team of students, therefore, proceeds through the clinical component of the program at its individual pace (asynchronously). However, teams are required to complete their didactic requirement by the time of the program s final examination, usually given during the final week of the fall semester. Patients receive complete dentures that are a combined result of the faculty member s direct involvement through his or her clinical demonstrations and supervision, students active participation, and the commercial laboratory s work. While most of the laboratory work on patients dentures is performed by a commercial laboratory, the students experience various aspects of the laboratory steps and procedures using class-wide standardized maxillary and mandibular edentulous master casts. The casts are mounted on a semi-adjustable articulator (Hanau WhipMix articulator, WhipMix Corp., Louisville, KY) in an ideal maxillo-mandibular relationship using mounting indices. The laboratory sessions are scheduled during the time the patient s prosthesis is in the commercial laboratory. The student s simulated complete denture projects are evaluated at the wax try-in stage Journal of Dental Education Volume 73, Number 10

4 Patient Selection Patients for the program are recruited from within the pool of existing edentulous patients who have already been treated in the College of Dentistry. They are treatment-planned for denture reline, denture repair, or a remake of their existing dentures. All prospective patients are carefully screened by the program director using criteria that follow the Prosthodontic Diagnostic Index (PDI) classification. 10 Only those patients classified as Class I (e.g., having minimal alveolar ridge resorption, adequate attached gingival, ideal maxillo-mandibular relationship) are selected to participate in the program. Patients who agree to participate are given the detailed schedule of approximately nine clinic appointments and a letter of understanding stating that, if they keep all the scheduled appointments, they will receive the new set of dentures at no cost. All of the patients accepted into the program are also encouraged to participate in the predoctoral implant program. Patients who agree to receive two mandibular implants to support the newly fabricated mandibular denture are followed by the same group of students, further augmenting student learning. Didactic Material The background material necessary for the students to prepare for the individual laboratory and clinical sessions, as well as for the final examination, is posted either on the dedicated Blackboard site or provided in the required reference book 11 and the college-generated program manual. It is mandatory that each student review the appropriate material before each didactic and clinical or laboratory session. Each student answers the review questions received a week earlier and turns the completed huddle sheet in before starting the discussion, which ensures student preparedness for the session. The students are encouraged to take notes in their manuals on all comments regarding the discussed material and to keep it for their future clinical practice. The program manual thus provides for the students a repository for information acquired in the program. In addition to checking the program manuals, the program director is responsible for maintaining the Blackboard site by providing content material in the form of PowerPoint presentations 12 and handouts. The PowerPoint presentations cover all steps involved in fabrication of complete dentures (evaluation of edentulous patient, custom tray fabrication, border molding and final impressions, record base and wax rim fabrication, maxillo-mandibular records, selection and setting of denture teeth, concepts of complete denture occlusion, and complete denture delivery). The program director also meets with the faculty mentors to provide course updates and to review each team s progress. Student Evaluation In the current course, prior to the final examination the student is to 1) complete team management of the edentulous patient consisting of all the required clinical steps in the process of complete denture fabrication; 2) attend and actively participate in the review sessions; 3) complete and turn in the huddle sheets prior to each discussion; and 4) complete his or her laboratory work (custom tray, record base with wax rims, mounting the casts on semi-adjustable articulator, setting anatomic denture teeth in bilateral balance articulation, final wax contouring) using standardized edentulous casts. The final examination consists of a written part in the form of multiple-choice questions, a station-to-station problem-based examination (an objective structured clinical examination, OSCE), and a practical examination consisting of setting maxillary denture teeth against a mounted cast of an existing mandibular denture. The final practical examination is an open-book type and requires students to follow accepted criteria of setting the anatomic teeth in bilateral balanced articulation. Passing this program is one of the prerequisites for students to advance into patient care. Student and Faculty Perceptions of the Program Upon completion of the program each year, each student completes a survey regarding perceptions about the content, logistics, and role of faculty in this program. Comparison of student responses to the same survey given prior to the introduction of the new curriculum illustrates their perceptions of its main strengths and weaknesses. This information is analyzed by the program director and used for appropriate changes. Student evaluation from the previously delivered courses cited excellent organization, informative and useful lectures, and a supportive course manual as strengths. Weaknesses noted centered on the questionable usefulness of the artificial (simulated) patients. Students identified the use of casts from unknown patients, the arbitrary articulator mount- October 2009 Journal of Dental Education 1197

5 ings, and the lack of facial characteristics for mold selection and tooth arrangement. The major identified strength of the new program is its early introduction of the student to the patient, while the major perceived weakness has tended to be a desire for more structured discussion sessions. This concern has been addressed by addition of a focused review of the topic, presented by the designated faculty member with the intention of provoking active discussion among students. The faculty members who have experience in both the old and new curricula have expressed their opinions that students have generally performed better and seemed to be working at or above the level of competence with the new curriculum. They have also said they felt that students would benefit even more if the group size was smaller. Objective Evaluation of the Program To assess overall student academic achievement in the revised curriculum and compare it to that of students in the old program, their final performance was analyzed. Since there has not been any change in the final assessment of students upon completion of both types, the outcome measures of the study were the results on individual components of the programs final examination. The latter consisted of 1) a written multiple-choice examination, 2) an OSCE, and 3) a practical examination consisting of setting denture teeth. The data used in the study had been originally collected for educational purposes only, archived and retained for legal purposes. The use of the data and the analysis itself were reviewed and approved by the Institutional Review Board at UIC (Research Protocol # ). After removal of the identifiers, the data were pooled by the type of the curriculum and statistically compared using one-way ANOVA (SPSS version 16.0; SPSS, Chicago, IL). The results of the analysis are presented in Table 1. The results show significant improvement in students overall performance in the program, including on each of the components of their final examination. Discussion Clinical Exposure in the Preclinical Curriculum The traditional pre-patient complete denture curriculum places major emphasis on laboratory techniques, with minimal or no exposure or relation to patient care. Due to time constraints in most dental curricula, even the teaching of technique procedures has often been reduced to student observations rather than direct involvement. 3 A study published in 2003 examineded the predoctoral complete denture curriculum in forty-three U.S. dental schools. In combination with other educational approaches, thirty schools (71 percent) reported using an edentulous dentoform for preclinical laboratory, twenty-one schools (50 percent) were using manikin heads as a substitute for the patient, and only one dental school (2 percent) reported having no laboratory component but rather teaching complete removable prosthodontics in its entirety in the clinic. 2 That school, the University of Colorado School of Dentistry, and its transition clinic integrated major pre-patient courses and students clinical experiences. 6 One of the courses that was significantly changed and successfully incorporated into its curriculum was a complete denture prosthodontics program. Though the program was entirely clinically based and without significant student laboratory exposure, the initial report of the outcomes measured (decreasing lag time between the Table 1. Results of one-way ANOVA comparing academic achievement of students in the old and new curricula Total Points Achieved in the Final Written Final Practical Program Examination OSCE Examination Curriculum Old New Old New Old New Old New Number of students Mean score SD F ratio Significance Journal of Dental Education Volume 73, Number 10

6 conclusion of the pre-patient course and the students first clinical experience, student satisfaction, etc.) supported continuation of that program. 6 Teaching removable prosthodontics with the complex interaction of the laboratory and clinical phases requires careful balance. 13 Focusing these early student experiences entirely on one of the two components of the process (i.e., the laboratory) can easily translate into ignoring important roles of the diagnostic process and patient-clinician relationship. 14 Another benefit of managing patients in a curriculum designated as being pre-patient or preparatory to actual patient care is the elimination of the lag period between the didactic/laboratory portion of student learning and students actual exposure to clinical care. The students apply the newly acquired clinical and laboratory concepts promptly and without the need to memorize the procedures in abstract form. 13 Entering the clinical environment early is also overwhelmingly favored by dental students, as expressed in their answers to recent surveys, and objectively supported by the number of completed clinical procedures during their remaining clinical training (Table 2); similarly, it has been reported that dental school graduates rank early clinical exposure as the factor most important in preparing them for clinical practice Finally, vertically integrating our program with the predoctoral implant program provides students an opportunity to follow the same patient through the entire process of delivering implant-supported mandibular overdentures, recognized as a first choice option of care for most edentulous patients. 18 Active Learning Progress in development of information technology has allowed significant changes with respect to the structure of curriculum delivery. 19,20 Traditional learning methods in the form of lectures, combined with self-study by using textbooks and course manuals, are considered to be passive with respect to students participation in the learning process. Using information technology as a platform to provide background information to students not only changes the role of faculty, but also provides the student with unlimited access to the needed information. As a result, students have the opportunity to expand the scope of inquiry while pacing themselves according to their individual needs regarding learning facts. 21 Instead of maintaining the traditional role of the lecturers, faculty members become responsible for ensuring the information is available to students and for guidance in the learning process. 16 In addition, faculty members maintain student contact as facilitators of small-group discussions and, as shown in our program, with no need to increase their number. Although 28 percent of North American dental schools have reported the expanded use of instructional technology in their core curricula, 2 there is no report regarding a follow-up with small-group discussions. Having the pertinent background information available in advance and requiring students to come to discussion sessions prepared and with questions related to the reviewed material add relevance to the session. Participation in small groups gives students an opportunity to actively discuss issues re- Table 2. Mean number of clinical experiences per student for graduating classes (new program was introduced in 2005) Graduating Year n=number of students n=64 n=68 n=67 n=60 n=66 n=62 Total Total Total Total Total Total (mean per (mean per (mean per (mean per (mean per (mean per Procedure student) student) student) student) student) student) Maxillary complete denture (2.22) (2.78) (2.46) (2.80) (3.65) (3.42) Mandibular complete denture (1.39) (1.74) (1.64) (1.87) (2.65) (2.29) Maxillary immediate denture (0.47) (0.44) (0.76) (0.92) (1.02) (0.90) Mandibular immediate denture (0.23) (0.25) (0.37) (0.43) (0.71) (0.63) Total procedures (4.31) (5.21) (5.24) (6.02) (8.03) (7.24) October 2009 Journal of Dental Education 1199

7 lated to the already familiar clinical and/or laboratory scenario. The student thus assumes the role of active learner. 7 Consequently, this educational model allows each group facilitator to highlight clinical relevance, encourage critical thinking, and integrate biomedical and clinical sciences. 5,17 This vertical integration became part of the newly implemented curriculum at our dental school, allowing existing knowledge to be progressively supplemented by new information. 8 Active learning has also been shown to have a positive effect on the student with respect to the quality of the learning process and the learning environment itself. 16,22 Significantly, small-group learning provides an opportunity for each student to participate, while eliminating the likelihood of segregation of the group into smaller subsets of students. In addition, this learning environment charges the student with the responsibility for learning and checking themselves through self- and peer evaluation. Students participating in early versions of the program expressed a desire for more organized and moderated discussions. By presenting an abbreviated synopsis of the material first, followed by the discussion, a successful compromise between the lecture and discussion formats was achieved. Potential Shortcomings of the Curriculum One of the potential shortcomings of this new method of learning is its heavy dependence on patient compliance and student motivation. If the patient fails to make an appointment, the planned clinical procedure is delayed, and the expected experience for faculty and students has to be replaced with a didactic and/or laboratory session. This may impede the flow of learning. In addition, the new proposed curriculum places heavy dependence on a student s personal motivation to learn the material and to be prepared in advance of the laboratory or clinical sessions. In spite of the abbreviated review of the subject, unless the student comes to the sessions prepared, smallgroup discussions may not be productive. To ensure positive discussion outcomes, contingencies must be addressed in advance. 16 Conclusions In our dental school, a clinically based prepatient curriculum in complete removable prosthodontics has recently replaced a traditionally taught laboratory-based course. The revised curriculum introduces each student to the clinical experience early in the preclinical curriculum, allowing the student to practice high-fidelity pre-patient care and to seamlessly transition to clinical practice. Use of an Internet-based educational platform as a source for pertinent clinical and laboratory information has allowed the introduction of small-group discussions, in which the student becomes an active participant while the faculty member has the simultaneous opportunity to assess and evaluate the student s understanding of the required information. Finally, the new curriculum has not only significantly improved students academic achievement, but has also enabled vertical and horizontal integration with the rest of our revised curriculum. Acknowledgments We thank Dr. Stephen D. Campbell, Professor and Chair, Department of Restorative Dentistry, College of Dentistry, University of Illinois at Chicago, for making helpful and very valuable suggestions on the manuscript. REFERENCES 1. Petropolous VC, Rashedi B. Complete denture education in U.S. dental schools. J Prosthod 2005;14(3): Rashedi B, Petropolous VC. Preclinical complete denture survey. J Prosthod 2003;12(1): Weintraub AM, Weintrub GS. The dental student as technician: an 18-year follow-up of preclinical laboratory programs. J Prosthod 1997;6(3): Huang SP, Brown DT, Goodacre CJ, Cerimele BJ. Recent graduates and current dental students evaluation of their prosthodontic curriculum. J Prosthet Dent 1993;70(4): Diaz-Arnold AM, Langenwalter EM, Andres CJ, Lloyd PM, Nimmo A, Cronin RJ. The Institute of Medicine study of dental education: issues affecting prosthodontics. J Prosthod 1996;5(2): Lang LA, Holmes DC, Passon C, Trombly RM, Astroth JD, Tavel AF. Introducing dental students to clinical care: the Complete Denture Prosthodontics Transition Clinic. J Prosthod 2003;12(3): Sukotjo C, Thammasitboon K, Howell H, Karimbux N. Students perceptions of prosthodontics in a PBL hybrid curriculum. J Prosthod 2008;17(6): Field MJ, ed. Dental education at the crossroads: challenges and change. An Institute of Medicine Report. Washington, DC: National Academy Press, Crawford JM, Adami G, Johnson BR, Knight GW, Knoernschild K, Obrez A, et al. Curriculum restructuring at a North American dental school: rationale for change. J Dent Educ 2007;71(4): Journal of Dental Education Volume 73, Number 10

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