The Future of Prosthodontics by Nay Aung

The Future of Prosthodontics

Prosthodont Res Pract 5 : 2-9, 2006

REVIEW ARTICLE

The Future Value of Prosthodontics Yasumasa Akagawa

President of Japan Prosthodontic Society

To achieve greater recognition for prosthodontics in academia and among the general public as a vital health science specialty for the 21st century, and to advance this specialty’s contributions to society, the Japan Prosthodontic Society has become a corporate juridical person. Today, our organization stands ready to accept the responsibility for leadership in developing initiatives to improve prosthodontic education, research, and treatment. This article examines the future prospects for our discipline in the context of current trends and prospects.

Today’s trends

Today in Japan we face unprecedented developments. These trends include: the rapid aging of the population together with a declining birth rate and a resulting overall population decrease (Fig.1 and 2); the advance of globalization; and the development of a knowledge-based society grounded in the continuing rapid advancement of information technology. Remarkable progress in the natural sciences, including brain research, regenerative medicine/regenerative therapy, genome/post genome science and nanotechonology is taking place in the fields associated with medicine and dentistry. At the same time, dental schools are downsizing due to the overproduction of dentists. As members of the scientific community, we must recognize our responsibility to address the problems that our prospective future holds.1 Recently, the Japanese government has developed a vision of the future, projecting to the year 2030 and titled “Japan’s 21st Century Vision”.2 This vision involves (1) establishment of free flow of people, goods, and information, (2) encouraging development of a society in which individuals enjoy good health and an average life expectancy Corresponding to: Oral Health Association of Japan 1-43-9 Komagome, Toshima-ku, Tokyo 170-0003, Japan Tel: +81-3-3947-8891, FAX: +81-3-3947-8341 E-mail: hensyu7@kokuhoken.or.jp

（×1000） 140,000 High Variant

120,000

Low Variant

100,000

Medium Variant

80,000 60,000 40,000 Real Value

Estimated Value

20,000 0 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 （year）

Fig. 1 Estimated future population of Japan. In 2003, the population of Japan was reported to be 128 million; it is estimated that by 2100, it will have declined to 64 million. (National Institute of Population and Social Security Research homepage) （%） 35 Low Variant

Medium Variant

High Variant

25 20 15 10 Real Value

Estimated Value

5 0 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 （year）

Fig. 2 The aging of Japan. Japan’s population is aging rapidly. It is estimated that 30% of the population will be classiﬁed as elderly in 2030 in comparison with 19% in 2005. (National Institute of Population and Social Security Research homepage)

of 80 years, and (3) organization of a small but effective government. For our part, to help achieve this vision we, as prosthodontists, must clarify our responsibilities as a discipline as we redefine the broad value of prosthodontics to our society. In previous years, the goal of prosthodontic care has been defined as the improvement of oral function and the resolution of aesthetic problems. Today, that goal has been defined more explicitly. The goal of prosthodontic care that we

Future Value of Prosthodontics

1987

1993

1999

Number of residual teeth

0 40~44

44~49

50~54

55~59

60~64

65~69 70~74

75~79

80~84

85~ （year）

Fig. 3 Average number of residual teeth for the population in 1987, 1993 and 1999. The number of residual teeth has increased over the last 6 years. However, among those 65 years and older, many have 20 or fewer teeth.

seek today is to enrich the quality of life of each patient by solving problems caused by disturbances of occlusion, chewing, swallowing and appearance. To ensure that goal is to enhance the value of prosthodontics. In other words, our discipline seeks to maintain proper dentition in children and adults, to restore dentition in edentulous adults of all ages, and to enrich and/or improve the quality of life of a population with an average life expectancy of 80 years. A timely report from the Science Council of Japan (National Committee for Sciences of Oral Function) has provided a report entitled “Healthy long life expectancy created by sound occlusion and mastication”3 and this report has been summarized by the Union Council of Japan Dental Societies. The report seeks to promote a better understanding of the importance of adequate mastication based on sound occlusion to a healthy long life expectancy.

Table 1 Distribution of comparative studies on implant

and removable partial denture treatment between 1980 and 2005 by literature review. A few articles provides evidence are present for the last 25 years.

234 Case report Clinical comparative study 19 Meta-analysis 5 Restrospective study 3 Prospective-cohort study 4 Within cross-over study 2 Randomized controlled clinical trials 15

odontic needs7 show that the number of bridges needed by the elderly will increase 2.0 times (2.2~1.1 times, with 95% confidence) and the number of dentures needed by 1.5 times (1.8~1.0 times) over the next 20 years, then reach a plateau in the subsequent 10 years. Higher rates will prevail among elderly with disabilities, with bridges increasing 2.7 times (3.2~1.0 times) and dentures 1.8 times (2.2~1.0 times), over the next 25 years. Prosthodontic patients can be categorized into 2 groups, those who are independent and those with disabilities. The prosthodontic care provided to these different groups can be quite different. Currently prosthodontic care has been offered primarily to the independent elderly, but in the near future, such care must also be offered to disabled elderly to reduce the cost of nursing care. One of the great values of prosthodontics lies in the extension of such care to the disabled elderly.

Evidence of the value of prosthodontics

Future prospective on the need for prosthodontic care

Changes in the number of residual teeth among populations are shown in Figure 3. The average number of residual teeth has increased at each of the survey times from 19874 to 19935 and 1999.6 On the other hand, many people over 65 years old still have fewer than 20 teeth. Prosthodontic care can offer more assistance to these individuals. In other words, existing dentition must be maintained in individuals who are less than 65 years and lost dentition must be restored in more elderly populations. Projections of future prosth-

Evidence-based clinical care has recently been widely discussed in the contexts of both medicine and dentistry. Evidence-based care is defined as the provision of treatment based on a combination of the highest quality relevant research findings, the clinician’s skills, and the patient’s particular needs. The quality and quantity of relevant research are not always sufficient however. For example, a review of the literature regarding comparative evaluations of implant therapy and removable partial denture treatment for the 25 years between 1980 and 2005 shows few articles on this topic. Thus, we lack evidence supporting the theory and treatment modalities of 3

Denture wearers

Rate of penetration （Person）

Akagawa, Prosthodont Res Pract 5 : 2-9, 2006

Non-denture wearers

Survival rate

1.0 0.8 0. 6 0 .4

Penetration(+)

Penetration(-)

＊

8 0 20 Dentate

0.2

E de n t u l ou s w i th d e n t u r e s

E d en tu l o u s w it h o u t d e n t u r e s ＊：P＜0.05

0 0

100 （month）

Fig. 4 Cumulative survival rate of elderly with/without

dentures for occlusal support. Over the past 8 years, elderly with no dentures have had a signiﬁcantly lower survival rate than those with dentures or remaining natural occlusion (P <0.05). (Yoshida et al11)

Fig. 5 Rate of penetration of pharynges in the elderly with

more than 20 teeth and edentulous jaws. Signiﬁcantly higher rates are seen in elderly with edentulous jaws and no prosthesis (P <0.05). (Yoshikawa et al13 ) 8020 dentate: The elderly of 80 years with more than 20 teeth.

prosthodontic care (Table 1). Not only the impact of prosthodontic care on physical well being but also on the psychological, economic and social aspects of life must be further elucidated. Because of the lack of such evidence, the success or failure of prosthodontic care has never been well defined. The criteria for success are normally understood in terms of biological effects, prostheses survival rates, and patient satisfaction. However, Carlsson8 reported at the International Symposium Osaka 2000 that the success of complete denture treatment depends primarily on psychosocial factors in the patient and the patient-dentist relationship rather than on the treatment techniques themselves. This interpretation has caused us to change our attitude toward prosthesis-oriented prosthodontic care. In this regard, the relationship between effective prosthodontic treatment and a healthy life expectancy is gradually coming into clear view. For example, research has shown that independent elderly with more than 16/20 teeth live signiﬁcantly longer.9, 10 Those elderly whose lost teeth and impaired occlusion have not been restored with dentures have a signiﬁcantly lower rate of survival than those whose lost teeth and occlusion have been restored11 (Fig. 4). Recently, the Japanese government has expressed its concerns relating to the heavy burden of nursing home costs and to the need to promote better health among the elderly. Pneumonia associated with dysfunctional swallowing is a primary cause of death among the elderly receiving nursing assistance. The incidence of such pneu4

Number of falls per year （%）

With occlusal support

With dentures

Without occlusal support

100

More than 2

Less than 1

Fig. 6 Number of falls per year among elderly with demen-

tia with varying level of occlusal support. Demented elderly without occlusal support have signiﬁcantly higher incidence of falls (P ＜0.0001). (Yoshida et al16 )

monia, caused by inadvertent swallowing of oral microorganisms, can be decreased by improving oral care among nursing home residents.12 Loss of occlusion contributes to dysfunctional swallowing. In fact, the incidence of penetration of pharynges is significantly higher when the edentulous elderly person removes his or her dentures13 (Fig. 5). Moreover, good occlusion contributes to enhancement of quality of life (QOL) and may affect other activities of daily living. Good QOL is highly related to the enjoyment of eating, and elderly with well-ﬁtting dentures have been shown to have higher QOL than those whose dentures are ill-fitting or who are edentulous but do not wear dentures.14 A significant relationship has been found between good occlusal support and physical balance/muscle strength in the lower

Future Value of Prosthodontics

legs. 15 Frequent falls (more than twice in one year) among elderly with dementia has been shown to be associated with a lack of occlusal support16 (Fig. 6). Although ﬁrm evidence is still lacking as to the possible contributions of good prosthodontic care to the reduction of nursing expenses, clearly such care contributes to maintaining a good quality of life for our elderly citizens.

Osseointegrated implants

The introduction of osseointegrated implants by Brånemark in 1965 marked a new era in prosthodontic care. Today, implants are placed in the jaws of many partially or totally edentulous patients. The market for implant products in Japan has expanded in the past few years and expansion is expected to continue in the near future with an increase of a billion Japanese YEN per year. Well-designed studies on implant surface modiﬁcation, guided bone regeneration, and immediate/early loading must be performed to obtain further evidence to enhance clinical applications. However, it must be acknowledged that implant therapy is not yet recognized as a top priority treatment modality for partially/totally edentulous patients. Even in Sweden where osseointegrated implants were born, less than 10 % of potential patients receive the benefit of implant therapy. In fact, most of our patients prefer conventional bridge/denture works. Although it seems advisable to extend the application of implant therapy to more patients to enrich their QOL, more evidence is also needed comparing the effectiveness and efﬁcacy of implants to conventional prosthodontic treatment to ensure that the best and most appropriate prosthetic care is provided.

Strategy to increase the value of prosthodontics

Strategic planning is taking place, including sharing the mission of our society among members, structuring the new prosthodontics through the reform of scientific meetings of our society, ensuring the quality of prosthodontic care by accrediting specialist prosthodontists, promoting globalization to contribute to the solution of

Present procedure Ex ami nation Consultation

Di a gnos is Treatment planning

Treatment

Maintenance Repair

Future procedure Examination Consultation

D i a g no s i s Treatment planning

Treatment

Maintenance Repair

Fig. 7 Future prosthetic treatment procedure based on the future value of prosthodontics. Diagnosis, treatment planning and maintenance / repair will be more important aspects of future prosthodontic treatment based on advances in the discipline.

Asian problems, and participating in society through disclosure of information. Such strategic planning will create additional value in prosthodontics. To more fully share the mission of our society among members will help us to clarify the role of prosthodontics care. In this effort, we need to change our way of thinking about and acting on the future. We must structure the new prosthodontics not only by improving traditional prosthodontic treatment including the development of new materials and clinical techniques, but also through the evolution of a creative prosthodontics associated with the advancement of such related areas as brain science, regenerative medicine, nanotechnology, bioinformatics, sleep science and nutrition science. Further, we must have strong leadership in this organization to enhance evidence-based approaches to prosthodontic care especially through epidemiological studies. For example, bioinformatics is a breakthrough area that has emerged with the completion of the Human Genome Project. Our individual differences are explained by just 0.1 % of the total sequence of nucleotides, called single nucleotide polymorphisis (SNPs). It has been suggested that genetic diagnosis using SNPs may provide a novel opportunity for differentiating among edentulous patients, allowing development of an even more personalized prosthodontic care.17 Recommendation of the prosthodontic treatment option with the greatest potential beneﬁt based on such genetic diagnosis is a possible way to increase the value of prosthodontics. 5

Akagawa, Prosthodont Res Pract 5 : 2-9, 2006

Occlusion/ Function

Dentures Materials Crown/ Bridge Implants Others

30 20

Classification of articles (%)

JPD

IJP

J JP 2000

2001

2002

2004

2003

10 5 0 gy lo io em / id n Ep ctio n fu ion w us Ja ccl / o e on a wb os Ja uc m gy lo io em / id n Ep ctio n fu ion w us Ja ccl e/ o n o a wb os Ja uc m gy lo io em / id n Ep ctio n fu ion w us Ja ccl e/ o on a wb os Ja uc m gy lo io em / id n Ep ctio n fu ion w us Ja ccl e/ o on a wb os Ja uc m

Rate of Articles （%）

10 0 1958

1968 1978

1 9 88

1998

20 04

Fig. 10 Classiﬁcation of articles published in major interFig. 8 Articles published in the Journal of Japan Prosthodontic Society (JJP) over 46 years. Many articles in the last 46 years were on occlusion and function.

JPD

Classification of articles (%)

IJP

JJP 2000

2001

2002

2004

Development of such a CAD/ CAM system is another way to increase the value of prosthodontics.

2003

New prosthodontics from the global viewpoint

10 5 0 t an pl Im e ur nt De r ・B

t an pl Im e ur nt De r ・B

Fig. 9 Classiﬁcation of articles published in major international prosthodontic journals during the last 5 years. Increase is seen in number of articles on implants in the three major journals. However, this tendency is not seen in JJP. JPD: The Journal of Prosthetic Dentistry, JP: Journal of Prosthodontics, IJP: The International Journal of Prosthodontics, JJP: The Journal of Japan Prosthodontic Society.

CAD/CAM for crown / bridge work offers another example. CAD/CAM processing with the light impression technique can dramatically reduce several routine procedures, enhancing effective work methods, reducing the prevent consumption of impression, modeling, investing and casting materials. The use of titanium may prevent risks associated with rare metals used in gold-silver palladium alloys, which have been most common in Japan. Thus, CAD/CAM technology may induce a signiﬁcant paradigm shift. Prosthetic care procedures can be shifted to diagnosis, treatment planning and maintenance routines as treatment time is reduced (Fig. 7). 6

national prosthodontic journals during the last 5 years. In JJP, the number of articles on jaw function / occlusion is remarkable compared with articles in the three major journals. JPD: The Journal of Prosthetic Dentistry, JP: Journal of Prosthodontics, IJP: The International Journal of Prosthodontics, JJP: The Journal of Japan Prosthodontic Society.

Creative prosthodontics must be continuously developed in Japan. From a global viewpoint, our direction should be evaluated in the context of related activities in other industrialized countries. Articles published during the last 40 years in the Journal of Japan Prosthodontic Society (JJP) were classiﬁed into categories by Kobayashi,18 with the consequent classiﬁcation of articles published between 1958 and 2004 shown in Figure 8. Articles on occlusion and jaw function are predominant. It is quite proper in the evaluation of research trends to compare the subject matter of these articles to that of articles published in leading international journals, such as the Journal of Prosthetic Dentistry (JPD), Journal of Prosthodontics (JP) and the International Journal of Prosthodontics (IJP). Articles in these journals were classified into categories such as crown/bridge, dentures, implant, jaw bone/mucosa, jaw function/occlusion and epidemiology (Fig. 9, 10). These journals all publish quite similar numbers of articles in the various categories, except for articles on implants. An increase in articles on implants is seen in the three English language journals, with no clear comparable in-

Future Value of Prosthodontics Psychology

Sociology

Biology

Economics

Review

JPD

Material / technology

5.5%

89%

86%

IJP

11% 7%

12%

68?ﾋ

52%

8% 16%

2004

2005

Fig. 11 Comparison of speciﬁc ﬁelds represented in arti-

cles published in the International Journal of Prosthodontics and the Journal of Prosthetic Dentistry in 2004 and 2005. In 2004, most articles were on materials / technology for both IJP and JPD. There is no apparent difference. In contrast, fewer articles on materials / technology and increase of articles to 30% on the biological, psychological, economic, and social impacts of prosthodontic care on patients were published in IJP in 2005, while JPD published the same large number as in 2004. JPD: The Journal of Prosthetic Dentistry, IJP: The International Journal of Prosthodontics.

crease in JJP. On the other hand, a remarkable rate of articles on jaw function/occlusion was found in JJP, with fewer articles on clinical epidemiology. It must be pointed out that evidence-based research on prosthodontic theories and techniques is insufficient. In addition, the biological, psychological, economic and social impacts of prosthodontic care on patients have yet to be fully clarified. A comparison of IJP and JPD for 2004 and 2005 (until April) reveals a new trend (Fig. 11). No clear difference between JPD and IJP in category ratio appears in 2004 but, in 2005, JPD continues with the same category ratio, with more than 80 % of the articles on materials and technologies in traditional prosthodontics, while in IJP nearly 30 % of articles examined biological, psychological, economic, and social impacts of prosthodontic care. This tendency is quite interesting, although it may depend in part on the Editor’s initiative. In any case, clarification of the impact of prosthodontic care on patients, based on clinical epidemiological studies, is a top prior-

ity. Therefore, the Japan Prosthodontic Society (JPS) must take the initiative in encouraging and developing related research projects. Several years ago, JPS began two research projects on denture treatment outcomes. These multi-center studies involved several prosthodontic departments nationwide, and the findings thus far indicate the need to encourage and continue such projects. Moreover, JPS has recently made the decision to publish our journal in English. Prosthodontic Research and Practice appears in four volumes, beginning in January 2006. Members and foreign colleagues are encouraged to submit manuscripts on their research or clinical products. This new policy will definitely support our application for inclusion in the MEDLINE database and our efforts to achieve strong impact factors. International exchanges between foreign prosthodontic societies and JPS should be actively pursued. JPS has already begun scientific exchanges with the Korean Academy of Prosthodontics and the Asian Academy of Prosthodontics. The second joint meeting with the Greater New York Academy of Prosthodontics is scheduled for Tokyo in 2007. In the near future, close communication with prosthodontic specialist organizations in Europe and the USA, as well as prosthodontic societies in China and India are expected to develop. In particular, JPS should direct more attention toward solving prosthodontic problems in Asia, and cooperation with Asian organizations will make Japanese prosthodontics a conspicuous presence throughout the Asian region.

Newly restructured scientiﬁc meetings to activate prosthodontic research and practice

In 2006, we abandone our policy of two annual meetings; only one national scientific meeting will be held each year with nine simultaneous branch meetings nationwide. It is imperative to share the inherent functions of scientific meetings with the branch meetings. We hope that scientiﬁc and clinical papers based on our daily activities will be discussed at the annual meeting, along with research and education programs, such as table clinics and small group workshops to foster the next generations of prosthodontic researchers and clinicians. Such efforts will be focused on the development of a new creative 7

Akagawa, Prosthodont Res Pract 5 : 2-9, 2006

prosthodontics. Clinical discussions on updated materials and technologies provided to general practitioners will help them to provide the best prosthodontic care in their daily practice.

JPS policy to respond to community needs more closely

JPS has a responsibility to conduct nonprofitable public benefit activities. These activities involve science-transfer programs and proposed solutions to community problems, to be provided in the form of citizen forums, leaflets, homepages and other media exposure. We expect that conducting these activities steadily will help our society grow to be more public policy-oriented with a closer and higher-profile relationship to the local community.

Offering best quality prosthodontic care; developing specialist programs

To assure high quality prosthodontic care is one of the top priorities of JPS. To do so, strong specialist prosthodontist training programs must be developed. Specialist Prosthodontist must be defined as “performing prosthodontic care based on evidence-based treatment planning and most appropriate techniques to restore function and appearance in difficult cases and to maintain longterm care for the enrichment of quality of life for all patients.” To pursue these objectives, we must: 1. Share fully information relating to solutions to difficult prosthodontic problems. 2. Screen prosthodontists referred for difficult prosthodontic care. Through these procedures, it is expected that the quality of prosthodontic care will be much improved. Today the classification of clinical cases based on degree of difficulty has been developed into 4 categories; Level 1: cases suitable for care in undergraduate clinics, Level 2: cases for residents and general practitioners, Levels 3: and 4: cases for specialized prosthodontist clinics. To provide greater benefit to more people, the creation of clinical treatment guidelines for prosthodontic care is an urgently necessary task. These guidelines should be discussed from the viewpoint of justice and safe care. Guidelines will be of great help in standardizing the quality of 8

prosthodontic care for all patients. Initiatives to reform the social insurance system for dental care should be undertaken by the leadership of dental academic societies. The scientiﬁc community is duty-bound to provide maximum benefit to the public based on scientiﬁc results. Our program of science transfers to disseminate clinical technologies is a must for the public.

Closing

The future value of prosthodontics has been discussed in relation to strategic planning. These planning sessions must be held regularly. Only through the dedicated efforts of all JPS members will we accomplish our plans and create new values for society and the public in the 21st century. Based on these activities, the contribution of prosthodontics to extended healthy life expectancy under optimal conditions will be clearly demonstrated. The Japan Prosthodontic Society must recognize this huge responsibility, and make even more dedicated efforts to serve society and the public. The discipline of prosthodontics can look forward to an exciting future with continued improvement in the performance of our daily activities and recognition of our signiﬁcant role in improving dental health.

References 1. Japan Perspective, Science Council Japan, Tokyo, 2002. 2. Japan’s 21st Century Vision, Cabinet office, The Government of Japan, Tokyo, 2005. 3. Healthy long life expectancy created by sound occlusion and mastication, National Committee for Sciences of Oral Function, Science Council of Japan, Tokyo, 2004. 4. Report on the Survey of Dental Disease (1987), Health Policy Bureau Ministry of Health and Welfare Japan, Tokyo, Oral Health Association of Japan, 1987. 5. Report on the Survey of Dental Disease (1993), Health Policy Bureau Ministry of Health and Welfare Japan, Tokyo, Oral Health Association of Japan, 1993. 6. Report on the Survey of Dental Di-sease (1999), Health Policy Bureau Ministry of Health and Welfare Japan, Tokyo, Oral Health Association of Ja-

Future Value of Prosthodontics

pan, 1999. 7. Kanatani M, Watanabe K, Miyakawa O. Number projections of bridges and dentures for elderly and department elderly people. J Jpn Prosthodontic Soc 45:227-237, 2001. 8. Carlsson GE．Principles and management strategies of prosthodontics beyond 2000. Proceeding of International Symposium Osaka 2000, 8-9, 2000. 9. Appollonio I, Carabellese C, Frattola A et al. Dental status, quality of life, and mortality in an older community population: A multivariate approach. J Am Geriatr Soc 45: 1315-1323, 1997. 10. Hamalainen P, Meurman JH, Keskinen M et al. Relationship between dental health and 10-year mortality in a cohort of community-dwelling elderly people. Eur J Oral Sci 111: 291-296, 2003. 11. Yoshida M, Morikawa H, Yoshikawa M et al. Eight year mortality associated with dental occlusion and denture use in community-dwelling elderly persons. Gerodontology 22: 234-237, 2005. 12. Yoneyama T, Yoshida M, Mukaiyama H et al. Oral care reduces pneumonia of elderly patients in nursing homes. J Am Geriatr Soc 50:430-433 2002.

13. Yoshikawa M, Yoshida M, Nagasaki T et al. Inﬂuence of aging and denture use on liquid swallowing in healthy dentulous and edentulous elderly. J Am Geriatr Soc (in press). 14. Yoshida M, Sato Y, Akagawa Y et al. Correlation between quality of life and denture satisfaction in elderly complete denture wearers. Int J Prosthodont 14: 77-80, 2001. 15. Yamaga T, Yoshihara A, Yoshitake Y et al. Relationship between dental occlusion and physical ﬁtness in an elderly population. J Gerontol A Bio Sci Med Sci 57A: 616-620, 2002. 16. Yoshida M, Morikawa H, Kanehisa Y et al. Functional dental occlusion may prevent falls in elderly individuals with dementia. J Am Geriatr Soc 53:1631, 2005. 17. Nishimura I, Garrett N. Impact of human genome project on treatment of frail and edentulous patients. Gerodontology 21: 3-9, 2004. 18. Kobayashi Y. Overview of prosthodontics in health science. Proceeding of 100th Anniversary Meeting of the Japan Prosthodontic Society, 27-35, Tokyo, Oral Health Association of Japan, 1999.

Prosthodontics Themed Issue

CLINICAL

Tooth bleaching

Bleaching update and the future impact on prosthodontics Van B. Haywood*1 and Fadi Al Farawati1

Key points Provides an updated review of tray bleaching.

Demonstrates changes in prosthodontic treatment due to the impact of bleaching.

Introduces relatively new techniques for single dark teeth, caries control, and improving gingival health with carbamide peroxide.

Abstract Bleaching has changed the way the world looks at teeth, with lighter teeth becoming the norm due to the ease and simplicity of tray bleaching. The resultant lighter teeth have changed prosthodontics in that there is less need for some types of restoration, less aggressive preparation design, as well as new techniques for shade selection, caries control and managing gingival health.

Introduction Approximately 30 years ago, bleaching became more readily available to patients, by almost all dentists, through the introduction of tray bleaching with 10% carbamide peroxide (CP).1 Since that time, many variations on the process have been introduced and there has also been a resurgence in the older in-office bleaching techniques. 2 Due to the ever increasing popularity of bleaching and the resultant changed smile for patients, many ‘over-thecounter’ products have also been introduced, as well as different products proposed for bleaching. However, the most cost-efficient, safest and most easily used technique which works very well in many different situations has remained the tray bleaching technique with 10% carbamide peroxide (Figs 1 and 2). Many areas of the tray technique have been researched and explored. Carbamide peroxide has been found to penetrate intact enamel and travel through the dentine to the pulp in 5–15 minutes.3 The colour of the tooth is found primarily in the dentine, and the dentine is changed by bleaching.4 This easy passage

Augusta University, Restorative Sciences, Dental College of Georgia, Augusta, Georgia, United States. Correspondence to: Van Haywood Email: vhaywood@augusta.edu

of peroxide also accounts for the sensitivity some patients experience.5 Teeth darkened by age or genetically discoloured generally take from three nights to six weeks of nightly treatment to be bleached to their maximum lightest colour. However, not every patient will achieve the same endpoint; teeth vary

Fig. 1 Discolouration of maxillary teeth creates an unsightly smile. Image reproduced with permission from Quintessence Publishing

in their response to bleaching, both in how fast they change colour as well as the final outcome of the colour change. Teeth stained by nicotine may take one to three months of overnight treatment (Figs 3 and 4), while teeth discoloured by tetracycline ingestion can take from two to six months of nightly treatment

Fig. 2 Bleaching with 10% carbamide peroxide in a custom tray for two to six weeks nightly creates a much more natural appearance. Image reproduced with permission from Quintessence Publishing

Refereed Paper. Accepted 7 January 2019 DOI:10.1038/s41415-019-0314-7

Fig. 3 Pipe smoker for many years with nicotine stains has dark teeth from internal and external staining. Image reproduced with permission from Quintessence Publishing

Fig. 4 Three months of nightly bleaching with 10% carbamide peroxide in a non-scalloped, no-reservoir tray removes nicotine stains. Image reproduced with permission from Quintessence Publishing

BRITISH DENTAL JOURNAL | VOLUME 226 NO. 10 | May 24 2019 © The Author(s), under exclusive licence to British Dental Association 2019

753

CLINICAL

Tooth bleaching

prosthodontics. Some of the changes in prosthodontic treatment from the impact of bleaching are described as follows.

Bleaching avoids unnecessary veneers or crowns when only a colour change of the teeth is needed Fig. 5 Tetracycline staining is one of the most difficult stains to remove, with grey being the hardest colour; fortunately the gingival third is not grey. Image reproduced with permission from Quintessence Publishing

Fig. 6 Six months of nightly bleaching with 10% carbamide peroxide in a custom tray removes most of the tetracycline stains, which are bound tightly in the dentine. Image reproduced with permission from Quintessence Publishing

Fig. 7 Dark canines can detract from a smile. Courtesy of Dr Amber Lawson

Fig. 8 Bleaching all the teeth with 10% carbamide peroxide can bring the canines to within half a shade of the lateral incisor and first premolar, the ideal prosthodontic shade distribution. Courtesy of Dr Amber Lawson

Fig. 9 Comparison of the maxillary teeth to the mandibular teeth demonstrates the discolouration of the maxillary. Image reproduced with permission from Quintessence Publishing

Fig. 10 After bleaching nightly with 10% carbamide peroxide in a tray for several weeks, the maxillary is now lighter than the mandibular teeth. Bleaching one arch at a time helps with compliance and monitoring of outcomes. Image reproduced with permission from Quintessence Publishing

(Figs 5 and 6).6 Higher concentrations of CP have more side effects, and once the rate of change of the tooth has been reached the additional percentages merely contribute to tooth sensitivity and gingival irritation.7 Tray design has varied from the original nonscalloped no-reservoir design, which works well for 10% CP, to scalloped trays with reservoirs for higher concentrations. Ten percent CP is made to go on to tissue and gingival health improves during bleaching; however, higher concentrations will tend to burn the tissue causing sensitivity, so a different tray design is used. Sensitivity to the teeth is related to the easy

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passage of the peroxide to the pulp, creating a reversible pulpitis. The higher the concentration, the greater the sensitivity. This sensitivity is best treated with potassium nitrate (PN), which also penetrates enamel and dentine in approximately 30 minutes.8 The PN can be included in the bleaching material, used independently before and after bleaching or applied in a toothpaste. Not only has the increased popularity and use of tray bleaching impacted patients, it has also impacted other dental treatments as well. One area that has been affected is

A uniform colour of all the visible teeth is generally more aesthetically pleasing than having some teeth darker than other teeth. Generally, the maxillary incisors are the same colour and match the colour of the first premolar, with the canine being at most a half shade darker. When the canine is significantly darker by several shades than the premolar and lateral incisor it detracts from a natural smile. Bleaching such that the canine more closely matches the adjacent teeth provides a more natural smile. Bleaching the canines also demonstrates that bleaching is changing the genetic colour of the tooth by changing the dentine (Figs 7 and 8). The first case of bleaching reported in the literature was to avoid preparing six anterior teeth for porcelain veneers when the teeth only needed a colour change. With the advent of bleaching, much tooth structure has been saved from preparations to improve colour. Veneers are indicated for form or function as well as certain aesthetic situations, but a simple colour change of a tooth should first be addressed with bleaching. Since enamel is designed to last a lifetime and all restorative materials have some finite life, the more tooth structure that is retained by conservative bleaching the more long-lasting the teeth will be (Figs 9 and 10). A successful restoration will demonstrate an ability to perform as expected over a certain observation period. Systematic reviews showed an estimated five-year survival rate of 94.4% for conventional tooth-supported FDPs,9 93.3% for all ceramic single crowns and 95.6% for metalceramic single crowns.10 Furthermore, a 12-year retrospective study showed survival rate of 94.4% for laminate veneers.11 On the other hand, maintaining tooth structure is fundamental in the choice a restoring dentist would consider when addressing the patient’s aesthetic concerns. In a study to measure the amount of tooth structure removed for metal-ceramic crowns and traditional veneers,12 the authors found the preparation removed up to 72.1% of the coronal tooth structure to receive a metal-ceramic crown and 16.6% for a veneer. The patient can always proceed to the more aggressive preparations if needed, but never can go back, so the first treatment of choice should be bleaching.

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It is not necessary to crown a single dark anterior tooth that has received endodontic therapy, so it can be bleached

Fig. 11 The crown is scheduled for replacement due to aesthetics and margins, but other teeth are also discoloured. Image reproduced with permission from Quintessence Publishing

Fig. 12 Bleaching with 10% carbamide peroxide nightly in a custom tray lightens the natural teeth to a more acceptable shade for replacement of the crown. Image reproduced with permission from Quintessence Publishing

Fig. 13 An endodontically treated anterior tooth is dark for unknown reasons, but would not require a crown otherwise. Courtesy of Dr Leigh Anne Fortney

Fig. 14 Debridement of the pulp chamber and internal bleaching with 20% carbamide peroxide provides a proper colour match with no need for a crown or veneer. Courtesy of Dr Leigh Anne Fortney

Fig. 15 A single dark tooth is bleached first using a ‘single dark tooth tray’ design, where the teeth moulds on either side of the dark tooth are removed so the adjacent teeth do not change colour. Image reproduced with permission from Quintessence Publishing

Fig. 16 The single dark right central incisor has reached its maximum lightening from bleaching, so the other teeth are not bleached in order to avoid a mismatched smile. Image reproduced with permission from Quintessence Publishing

Bleaching will harmonise tooth colour before the restoration of an adjacent tooth with a crown

placing restorations provides a simpler colour matching option. For porcelain veneers, a thickness of 0.3 mm is required for each shade change, so bleaching will allow for a lighter substrate and less removal of enamel to alter the colour.13 Also, when a single tooth needs to be crowned, it is best to bleach the adjacent teeth first to provide the best outcome for the shade match of the crown (Figs 11 and 12).

When porcelain veneer or composite resin restorations are indicated over discolorations or mismatched teeth, the restorative will mimic the natural tooth structure better if the underlying tooth is as light as possible. Bleaching before

One of the major shifts in dental treatment is the determination that anterior endodontically treated teeth no longer need a crown because of endodontic treatment. While posterior teeth that have received endodontic therapy should have a crown to avoid fracture, the anterior teeth survive just as long without a crown as with a crown. In a retrospective study 14 which looked into the survival rate of 1,273 endodontically treated teeth (range 1–25 years), it was significantly evident that endodontically treated posterior teeth should receive full coverage crowns but this is not necessary for anterior teeth with enough dentine support or relatively sound anterior teeth.15 The reasons are related to occlusion, anatomy and position in the mouth. The posterior teeth have occlusal forces three times that of anterior teeth, and are directed down the long axis of multi-rooted teeth, so they are prone to fracture or split. The anterior teeth have single roots, with occlusal forces one third that of posterior teeth and directed laterally. What determines the success or fracture of an anterior tooth is the amount of remaining dentine. If the tooth is reduced for an aesthetic crown in addition to the endodontic therapy, the tooth is significantly more weakened than not providing a crown, so it is better to bleach than to crown, unless the tooth needs a crown regardless of the endodontic therapy. Anterior teeth now differ from posterior teeth concerning the need for prosthodontic treatment, with more internal and external bleaching indicated rather than crowns (Figs 13 and 14).

A single dark tooth which has not received a root canal does not need endodontic therapy in order to bleach it A single dark tooth that does not need a root canal, as in the case of calcific metamorphosis, can be bleached from the ‘outside-in’ using a single-tooth bleaching tray.16 Since the peroxide passes through intact enamel and dentine to the pulp in 5–15 minutes, there is no need to create a pulp chamber or perform endodontic therapy to obtain access to the inside of the tooth. The tooth can be bleached just as easily from the ‘outside-in’ as from the ‘inside-out’. The bleaching technique for the tray fabrication is similar to a full tray but a

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special ‘single-tooth’ tray is fabricated that only allows the bleaching material to contact the single dark tooth without changing the colour of the adjacent teeth. The tray design would extend onto tissue and require a low 10% concentration of carbamide peroxide. If the dark tooth does not lighten sufficiently to match the adjacent teeth, the adjacent teeth would not be bleached. If the dark tooth bleaches lighter than the adjacent teeth, then a conventional tray can be used to slowly titrate the colour of the adjacent teeth to match the single dark tooth (Figs 15 and 16).

Bleaching will restore teeth darkened by age that were originally matched to adjacent PFM crowns to the original shade to match the crowns One aesthetic challenge is that over time the teeth will darken, both from ageing as well as diet and lifestyle habits. Smoking, coffee, wine and other food stuffs, alongside the deposition of more yellow secondary dentine, will darken teeth. Ceramic crowns, teeth or plastic teeth on a removable partial denture will not change colour, so eventually there is a mismatch in the shade of the prosthesis from the original colour of the tooth. With bleaching, the adjacent natural teeth can be re-lightened to the original shade of the crowns. This is especially helpful if the teeth were originally bleached before the crown or removable partial denture (RPD) shade selection, because the endpoint for bleaching is known. Even if the teeth were not bleached originally, bleaching the darkened teeth will still be a benefit. Care must be taken to titrate the bleaching process back to the unbleached shade. Occasionally, the potential for having overall lighter teeth will prompt a patient to bleach to the maximum lightening, then replace the now darker appearing crown (Figs 17, 18, 19, 20).

Bleaching can lighten teeth under veneers if the existing shade of the veneer is too dark, which may avoid replacing the veneers One of the goals of a porcelain veneer is to have the ‘life-like’ translucency of the natural tooth. This means there is a certain amount of transparency in the veneer to avoid a ‘dead’ look. The problem when the original tooth colour is dark is that discoloration is transmitted through the veneers to make the veneers darker. If the veneers were placed over

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Fig. 17 The crown on the lateral incisor does not match the remaining dentition. It is unclear whether the crown matched originally. Image reproduced with permission from Quintessence Publishing

Fig. 18 Bleaching with 10% carbamide peroxide overnight brings the natural teeth more in line with the colour of the crown. Image reproduced with permission from Quintessence Publishing

Fig. 19 When the two cantilever porcelains fused to metal lateral incisors were inserted, the natural central incisors matched. Now the natural teeth have darkened over the 17 years since insertion. Image reproduced with permission from Quintessence Publishing

Fig. 20 Bleaching nightly with 10% carbamide peroxide brings the natural teeth back to the shade which more closely matches the PFM crowns, thus extending the aesthetic life of the fixed partial dentures. Image reproduced with permission from Quintessence Publishing

dark teeth, then the teeth can be bleached from the lingual, with the tray application of 10% carbamide peroxide.17 Bleaching will not have an effect on the ceramic veneer nor on the resin cement, but as the tooth lightens the veneer will appear to lighten, providing a more aesthetic outcome (Figs 21 and 22). Should the teeth relapse over time, they can be re-bleached from the lingual to the original shade making the veneers the original shade.

Bleaching can provide a supplement to good oral hygiene and supportive periodontal care in maintaining gingival health, avoiding root caries and stopping recurrent decay at the crown margins, especially in a full-mouth restoration patient Often an indication for a full-mouth reconstruction with crowns and fixed partial dentures is the extensive decay a patient may have experienced over their lifetime. However, their tendency to get decay, as well as the advancing age and resultant medications

causing dry mouth, can result in recurrent decay at the margins of otherwise excellent restorations. Dentine and cementum are more susceptible to decay than enamel, with dentine dissolving at pH 6.8 and enamel dissolving at pH 5.5. In order to maintain a full-mouth reconstruction, a bleaching tray with 10% carbamide peroxide can be used every night to elevate the pH above which tooth decay can occur in dentine or enamel, reduce the plaque from the teeth, and kill some of the bacteria that cause decay.18,19,20,21,22,23,24,25 ,26,27 The application of peroxide gel through a tray as an adjunct to scaling and root planning during periodontal follow-up appointments significantly reduced bleeding on probing for 66 refractory patients.28 Carbamide peroxide can be considered an effective and affordable alternative to topical antibiotic application in periodontal refractory cases, in patients with good oral hygiene who maintain regular recalls of professional periodontal care. It is for this reason that an oxidising gel of 1.7% hydrogen peroxide (Perio Gel, QNT Anderson, Bismarck, ND) was

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developed to be delivered intraorally using a closed tray. In a randomised clinical trial for six months, Putt and Proskin found clinical improvement in pocket depth reduction and bleeding index when a 1.7% hydrogen peroxide gel was used with scaling and root planning comparing to SRP alone.29 There is no impact on the prosthesis or cements, and there is an improvement on the gingival health as well, since 10% carbamide peroxide was originally used as an oral antiseptic for wound healing. In all the bleaching research that evaluated gingival health as well as tooth colour change, there is improvement during bleaching. However, it is necessary to stress the importance of meticulous oral hygiene and maintaining regular recalls, as this will be the only way to ensure plaque removal and the detection of gingival/periodontal deterioration.

Bleaching will irrigate and clean tissue around implants to avoid peri-implantitis Longitudinal studies of 22 years show implant survival rates from 87%–99.2%.30 This high percentage of survival dose not hide the high percentage of peri-implant mucositis (43%) (Fig. 23) and peri-implantitis (22%) (Fig. 24) in a recent meta-analysis.31 There is strong evidence supporting the idea that regular recalls for periodontal supportive therapy will reduce the chance of developing periimplantitis.32 Recalls are particularly important in patients with a history of treated aggressive periodontitis, due to the high susceptibility of this patient’s category to develop periodontal and peri-implant diseases.33 Ten percent carbamide peroxide has a long history of use as an oral antiseptic to improve gingival health.34 When the implant-surrounding soft tissues develop an inflammatory lesion due to plaque accumulation, an early nonsurgical intervention is important to avoid the

Fig. 23 Severe peri-implant mucositis shows erythema, oedema and spontaneous bleeding

Fig. 21 Porcelain veneers were placed over tetracycline stained teeth without prior bleaching and project a greyish colour due to their translucency. Image reproduced with permission from Quintessence Publishing

progression of the disease into the supportive bone. In addition to the regular non-surgical methods of scaling and polishing, systemic and local antibiotics, and air-powder jets, the clinician can utilise the additional benefit of using tray application of carbamide peroxide 10% as it has been proven that teeth whitening improves gingival health.35 Curtis et al. found a reduction in plaque index when carbamide peroxide was compared with a placebo gel.36 This could be explained by the bacterial (Streptococcus mutans and Lactobacilli) inhibitory effect of 10% carbamide peroxide when applied for two hours.37 More longitudinal randomised clinical trials are necessary to prove the additional benefit of using carbamide peroxide, along with good oral hygiene.

Fig. 22 Bleaching the tetracycline-stained teeth from the lingual with 10% carbamide peroxide does not affect the colour of the porcelain or resin cement, but because the tooth is now lighter the veneers appear lighter. Image reproduced with permission from Quintessence Publishing

actinomycetemcomitans (AA).39 The impact of 10% hydrogen peroxide in conjunction with antibiotics was studied to clean implant surfaces under flap procedure,40 the study showed a 58% drop in gingival bleeding for five years following-up (Fig. 25).

Bleaching teeth before veneering or crowning will allow the use of more translucent aesthetic materials instead of opaque materials in discoloured teeth

Hydrogen peroxide (HP) as an oxidising agent is considered as one of the implant surface detoxification agents.38 When used for subgingival irrigation, HP was efficient in suppressing the growth of Actinomyces

All-ceramic restorations provide a wide range of value and translucency, more than porcelain fused to metal (PFM) restorations.41 This ability gives all-ceramic restorations the ability to mimic natural teeth. However, different ceramic systems provide various degrees of translucencies.42 Glass ceramics are more translucent than the strong and opaque polycrystalline ceramics (aluminaand zirconia-based restorations). This feature makes glass ceramics (such as lithium disilicate and feldspathic glass) a preferred choice when restoring anterior teeth. To

Fig. 24 Advanced peri-implantitis, the implant had notable mobility. The treatment of choice for this case was to remove the infected implant and bone graft the resultant bony defect

Fig. 25 Moderate case of peri-implantitis, notice the bacterial plaque accumulation. Modern rough implant surfaces make the disinfection of the infected surfaces a complicated and unpredictable procedure

Bleaching can disinfect exposed titanium surfaces to treat peri-implantitis

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Fig. 26 Polarised light photography of two all-ceramic preparations demonstrate how one shade will need to be lighter to compensate for the darker preparation form. A ‘stump form’ shade would need to be taken also. Courtesy of Dr David Urbanawiz

understand the effect of tooth shade on the final aesthetics of the dental restoration, we can refer to the importance of communicating the stump shade of the prepared tooth to the lab technician, since the stump shade may affect the chroma and value of the produced restoration if a translucent material is used.43 This phenomenon could be adjusted by bleaching the teeth which will be restored, which will increase the value and reduce the chroma of the teeth, allowing the use of the highly aesthetic glass-ceramic restorations instead of trying to mask the colour of dark teeth with opaque systems like metal-ceramics and polycrystalline ceramics (Fig. 26).

With the advent of bleaching, we no longer are required to teach chairside ‘stain and glaze’ to match cracks and older teeth in the dental school curriculum Traditional prosthodontic teaching involves staining and glazing porcelain fused to metal crowns to match aged or disfigured teeth. Chairside staining is a tedious process which has been made more difficult with the infection control procedures needed in clinic. Now a more reasonable approach would be to bleach first to minimise defects, then provide a lighter crown without the aging effects.

Because of bleaching, ceramic shade choices for porcelain materials and denture teeth are now lighter than B1 (Vita classic shade guide) Hands and teeth tend to reveal a person’s age, so an adult may look ten years younger with lighter teeth. The influence of television and

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Fig. 27 Denture teeth are now being made lighter than conventional denture teeth due to patient demands. Image reproduced with permission from Quintessence Publishing

Fig. 28 Patient request of all ceramic restorations lighter than B1. Image reproduced with permission from Quintessence Publishing

Fig. 29 When the patient prefers a lighter denture tooth colour, the natural mandibular teeth may not match. Image reproduced with permission from Quintessence Publishing

Fig. 30 Bleaching the mandibular arch with 10% carbamide peroxide can provide a more uniform match between the denture and the nature teeth. A single arch bleaching fee is needed. Image reproduced with permission from Quintessence Publishing

Fig. 31 A provisional restoration fabricated with bis-acryl in a patient on chlorohexidine can leak and create a black stain on the margins of the preparation. Image reproduced with permission from Quintessence Publishing

movies on the world is to create a desire for lighter teeth; since those people with lighter teeth are perceived to be more intelligent, attractive and fun to be around.44 With the population having lighter teeth worldwide, there is not as much demand for the darker A4-type shades in ceramics or in denture teeth. Patients desire lighter teeth, so the companies have begun to produce shade tabs and porcelains as well as denture teeth lighter than B1 for many people’s desires (Figs 27 and 28). This may also result in the need to bleach natural teeth to match the lighter denture tooth shades (Figs 29 and 30).

Fig. 32 Ten percent carbamide peroxide, which is an oral antiseptic, can be used to gently clean the margins without damaging tissue or compromising the bond strength of the all-ceramic crown to be bonded in place. Image reproduced with permission from Quintessence Publishing

Because of lighter teeth from bleaching and more translucent all ceramic crowns, fibre posts are replacing metal posts Teeth that require restorations after bleaching will require a lighter shade ceramic. Also, teeth that are bleached retain their natural translucency and vitality, so more translucent ceramic shades and materials are being used for anterior teeth. As all ceramic restorations

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are becoming more popular and able to replicate the translucency of teeth, there is the possibility of the colour of the preparation or post/core showing through to alter the colour of the crown. In order to minimise the show through of metal posts under all-ceramic crowns, more fibre posts are being used. The main advantage of a fibre post over a metal post is the aesthetics as well as the avoidance of any dark metal altering the shade of the translucent ceramic restoration.

Utilise tray bleaching as a diagnostic shade tool before major oral reconstructions In aesthetically demanding cases where the patient is not clear about the final tooth shade desired, tray bleaching could be utilised as a conservative diagnostic tool to bleach the natural teeth to the desired tooth shade before initiating the rehabilitation. This bleaching approach will be more reliable than using mock-ups with PMMA or BIS-GMA, as these materials has different shade values than the definitive ceramic prosthesis. Also, if the patient is in a PMMA provisional restoration during bleaching, the PMMA may turn yellow.45

Bleaching materials will remove chlorhexidine staining around provisional restorations before cementation of crowns

no prosthetic material changes colour from bleaching, the process would cause a mismatch of the older crown with the now whiter teeth, indicating a new crown needed for aesthetic balance. This would also occur if the bleaching material was used for caries control around existing crowns.47 The need for new crowns incurs much expense. Even if the patient has the finances to replace all their crowns to a lighter shade, sometimes the removal of an old crown that was on a cracked tooth or had a post may jeopardise the success of the new crown. Generally, patients with extensive fixed prosthetics, especially on cracked or compromised teeth, are not good candidates for bleaching. When they need a replacement crown, the darker shades would be required to avoid replacing all their crowns.

Conclusions Bleaching has changed the way the world looks at teeth, with lighter teeth becoming the norm due to the ease and simplicity of tray bleaching. The resultant lighter teeth have changed prosthodontics in that there is less need for some types of restoration, less aggressive preparation design, as well as new techniques for shade selection, caries control and managing gingival health.

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The use of newer bis-acryl provisional materials, especially when used for porcelain veneer provisional restoration, can result in occasional leakage at the margins. If the patient was using chlorohexidine to improve tissue health, further staining can occur. Using a cotton swap with 10% carbamide peroxide to clean the preparation before cementation of veneers or crowns has been show to easily clean without damaging tissue and without compromising bond strengths of the resin cements (Figs 31 and 32).46

A word of caution about bleaching In spite of the benefits of bleaching and the impact on conventional prosthodontics, there is at least one contraindication to bleaching involving prosthodontics. When older patients already have crowns in place that match their adjacent discoloured teeth, they may be interested in bleaching to look younger. Since

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BRITISH DENTAL JOURNAL | VOLUME 226 NO. 10 | May 24 2019 © The Author(s), under exclusive licence to British Dental Association 2019

RESEARCH AND EDUCATION

Leadership education in prosthodontics: Development and impact of the Future Leaders in Prosthodontics (FLIP) workshops Sreenivas Koka, DDS, MS, PhD, MBA,a M. Murat Mutluay, DDS, PhD,b Neal Garrett, PhD,c David Felton, DDS, MS,d and Limor Avivi-Arber, DDS, MSc, PhDe According to the American ABSTRACT Dental Association, the number Statement of problem. The effectiveness of leadership education for prosthodontists is unknown. of dentists per capita in the Purpose. The purpose of this survey study was to evaluate the self-perceived impact a 2- to 2.5-day United States is higher than it leadership education workshop in prosthodontics had on participants’ professional, leadership, and has ever been and is projected to management development. continue growing until at least Material and methods. Participants who attended a leadership workshop for future leaders in 2035.1 Increased competition prosthodontics (FLIP) were surveyed to assess their self-reported improvements in different among dentists can be expected leadership domains. The survey was administered to 89 participants using an online survey tool, as they compete for patients and demographic data about participants were also collected. Results were tabulated for seeking care. Simultaneously, descriptive presentation. Where applicable, the Spearman correlation coefficients were calculated. university budgets have been Results. Seventy-two individuals responded to the invitation for a response rate of 80.9%. diminishing in relative terms, a Improvement in all 11 leadership capabilities assessed in the survey was noted by over 75% of phenomenon exacerbated by respondents. Over 90% of respondents reported improvement in overall leadership, career the global recession of 2008 to management, team management, self-awareness, problem-solving, and conflict resolution. No 2 2009. Greater reliance on significant (P>.13) relationships were found among demographic data such as age, sex, home limited research funding, faculty continent, or primary career focus (academics or private practice). entrepreneurship, and philanConclusions. Within the limitations of this survey study, participants in a leadership workshop thropy as sources of revenue in noted improvement in a variety of leadership capabilities. (J Prosthet Dent 2019;-:---) academic settings has ensued. It is against these backdrops of increasing competition and Commission on Dental Accreditation (CODA) stanfinancial pressure that practicing and academic dentists are dards with regard to practice management and challenged to make sound leadership business decisions in recognizing that leadership and management are order to be successful. different things, the bulk of dental school curricula Dental training programs at the predoctoral level revolves around dental knowledge and the technical routinely include only minimal exposure to education application of dental skills.3 However, some dental in leadership. While dental schools strive to meet schools offer combined DDS/MBA programs that

Clinical Professor, Advanced Prosthodontics, Loma Linda University School of Dentistry, Loma Linda, Calif; Private practice, San Diego, Calif; Lecturer, Advanced Prosthodontics, UCLA School of Dentistry, Los Angeles, Calif; CEO, Career Design in Dentistry, San Diego, Calif. b Clinical Professor and Chair in Prosthodontics, Institute of Dentistry, University of Eastern Finland, Kuopio, Finland and Chief Dentist, Department of Oral and Maxillofacial Diseases, Kuopio University Hospital, Kuopio, Finland; Senior Researcher, Adhesive Dentistry Research Group, Department of Restorative Dentistry and Cariology, Institute of Dentistry University of Turku, Turku, Finland. c Professor Emeritus, Advanced Prosthodontics, UCLA School of Dentistry, Los Angeles, Calif. d Dean, University of Mississippi Medical Center School of Dentistry, Jackson, Miss. e Assistant Professor, Prosthodontics, Faculty of Dentistry, University of Toronto, Toronto, Canada.

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Clinical Implications Clinical, practice, and academic success rely on sound career development choices. Pursuit of education in leadership is a choice that can provide participants with an array of decision-making and team-leading skills. In this way, clinicians and academics can enhance their individual success and the success of the teams they lead.

include leadership education to prepare dental students to lead. In prosthodontic residency programs, although CODA standards also require practice management education, leadership education is not a specific focus.4 This may result in prosthodontic graduates with limited preparation for leadership roles as they enter the private practice or academic workforce. Such graduates are unable to appreciate the myriad short- and long-term leadership and business challenges they are about to experience. In the academic arena, leaders of programs, divisions, departments, sections, and centers, as well as assistant/associate deans and deans, are usually selected from the faculty pool. Yet, leadership training generally is not considered a key piece of the faculty development model during the early career years. For those beyond formal dental education, there are different ways to develop leadership capabilities. Some are informal such as finding a mentor who has the experience and willingness to pass along their wisdom or reading leadership literature and watching online videos. Both the American Dental Association (ADA)5 and the American Dental Educators Association (ADEA)6 provide development opportunities through programs offering content from a variety of relevant experts. More formal ways are through online courses from universities via platforms such as EdX or Coursera or in-person coursework in community colleges or universities. Universitybased programs might culminate in a degree with the Masters in Business Administration (MBA). In prosthodontics, where does one turn to learn leadership capabilities? Recognizing that new prosthodontic faculty in the early years of their career in academics often have limited access to formal education in leadership in their institutional environment, a novel workshop series titled Future Leaders in Prosthodontics (FLIP) was conceived by 2 of the authors (S.K., N.G.) in 2012. A specific goal of this program was to introduce select fundamentals of leadership science and practice to a group of 20 to 25 aspiring future leaders in academic prosthodontics. A key element of the FLIP workshop program was to expose participants to the science and art of leadership. Beginning with THE JOURNAL OF PROSTHETIC DENTISTRY

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the third workshop, the curriculum expanded to include sessions addressing leadership challenges in private practice. Another key element of FLIP was to build a global network of future leaders and established leaders in prosthodontics, including leadership coaches. The first two workshops, FLIP1 and FLIP2, were hosted by the Mayo Clinic Section of Prosthodontics in 2013 and 2014, and subsequent workshops have taken place at other locations (Table 1). In addition, the first FLIP reunion workshop for FLIP1 to FLIP6 alumni took place in May 2017 in the United States immediately before the Academy of Prosthodontics Centennial Scientific Session. FLIP8 took place in Bangkok, Thailand, in March 2019, further expanding FLIP as a global initiative. Support for the FLIP programs has come from a variety of sources including the Academy of Prosthodontics Foundation, the Academy of Prosthodontics, Nobel Biocare, and each of the host institutions (Table 1). FLIP4 and FLIP7 were additionally cosponsored by the Editorial Council of the Journal of Prosthetic Dentistry. Since FLIP3, the workshops have been conducted by Career Design in Dentistry, a nonprofit corporation dedicated to providing education in leadership and management for those in private practice and academia. Participants can be nominated to attend an FLIP workshop by anyone involved in prosthodontics, most frequently by individuals from the sponsoring partners or by alumni of FLIP workshops. The principle eligibility criterion is that nominees be within 3 years (before or after) their first major leadership position. Diversity in participant education requires they have a significant interest in prosthodontics; a participant does not have to be a dentist or prosthodontist to participate. The number of alumni that can attend an FLIP workshop again is capped at 5 to ensure that new participants form a significant majority. A typical FLIP workshop lasts 2 to 2.5 days and consists of lectures and action learning exercises. Lectures are given by established leaders in prosthodontics as well as by experts in elements of leadership. Each FLIP workshop has been unique in terms of overall content, covering topics such as negotiations, team building, conflict resolution, creativity, budgets, building an outstanding practice, building an outstanding clinical career, being a dean/chair, neuroscience of leadership, leadership theory, effective decision-making, philanthropy, mental resilience, and leading in professional organizations. The personal development of leadership traits has also been explored, such as those promoted by Goleman in his teachings on “emotional intelligence,”7 traits that women appear to manifest more than men.8,9 This content is predominantly foundational and is complemented by action learning exercises. Action learning exercises allowed for small group interactions and fostered team-building dynamics.10 In this regard, Koka et al

2019

Table 1. Dates, locations, host institutions, and sponsors of FLIP workshops Workshop

Workshop Dates

Location

FLIP1

October 27-29, 2013

Rochester, Minnesota, USA

Mayo Clinic

Host Institution

William R. Laney Endowment for Prosthodontic Education, Academy of Prosthodontics Foundation

Co-sponsors

FLIP2

October 25-27, 2014

Rochester, Minnesota, USA

Mayo Clinic

William R. Laney Endowment for Prosthodontic Education, Academy of Prosthodontics Foundation

FLIP3

May 14-15, 2016

Rochester, New York, USA

Eastman Institute for Oral Health

Academy of Prosthodontics Foundation, Nobel Biocare USA, Career Design in Dentistry

FLIP4

March 11-12, 2017

London, United Kingdom

Kings College London, Guys Hospital

Academy of Prosthodontics Foundation, Academy of Prosthodontics, Nobel Biocare AG, Editorial Council of the Journal of Prosthetic Dentistry, and Career Design in Dentistry

FLIP5

May 19-21, 2017

Jackson, Mississippi, USA

University of Mississippi School of Dentistry

Academy of Prosthodontics Foundation, Nobel Biocare USA, Career Design in Dentistry

FLIP6

February 10-12, 2018

Yorba Linda, California, USA

Nobel Biocare USA Traning Center

Academy of Prosthodontics Foundation, Nobel Biocare USA, Career Design in Dentistry

FLIP7

September 7-9, 2018

London, United Kingdom

Kings College London, Guys Hospital

Academy of Prosthodontics Foundation, Academy of Prosthodontics, Nobel Biocare AG, Editorial Council of the Journal of Prosthetic Dentistry, and Career Design in Dentistry

FLIP8

March 4-5, 2019

Bangkok, Thailand

Chulalongkorn University

Academy of Prosthodontics Foundation, Academy of Prosthodontics, Nobel Biocare AG, Editorial Council of the Journal of Prosthetic Dentistry, and Career Design in Dentistry

FLIP, future leaders in prosthodontics.

FLIP workshops have aligned well with leadership development programs for physicians.11,12 In addition, networking among participants and between participants and faculty was encouraged through long breaks between sessions. Social connections were promoted through these interactions as well as a workshop dinner. While informal conversations with participants and faculty during and after the workshops have indicated that participants enjoyed their experience, the impact of attending an FLIP workshop is best assessed over time and in a manner where feedback can be provided anonymously. Two ways to assess workshop impact would be at the organizational level and the individual level. This article reports individual participant’s perceptions of the impact an FLIP workshop had on their professional, leadership, and management navigation.

skills (questions 2, 6, 9, and 10). The remainder of the 11 questions focused on general leadership qualities including overall leadership, time management, career management, and decision-making. Finally, 2 open-ended questions asked participants to describe key learnings from FLIP and to describe additional leadership/management topics of interest (questions 15, 16). The survey was administered online, and the question order in each survey was randomized. The same IP address was limited to 1 survey submission to eliminate duplicate submissions. Responses to the survey were anonymous. The Spearman rank correlation coefﬁcients were used to determine whether correlations existed in responses based on participants’ sex, age, primary career focus, number of workshops attended, and home continent (a=.05).

MATERIAL AND METHODS The UCLA Ofﬁce of the Human Research Protection Program determined that the project did not meet the deﬁnition of human subject research. A total of 89 individuals (33.7% women, 66.3% men) who attended FLIP1, FLIP2, FLIP3, FLIP4, and FLIP5 were invited to participate in the survey, which was disseminated using the online portal, SurveyMonkey, and a reminder email was sent 48 hours later. The survey contained a total of 18 questions (Table 2). Participant demographic data were captured in 5 questions (questions 12, 13, 14, 17, and 18). Eleven multiple choice questions (questions 1 to 11) focused on participant’s perception of whether and to what degree attending FLIP had changed their leadership/management skills. Five of these 11 questions asked participants to assess their development in some of Goleman’s 5 components of emotional intelligence4: selfawareness (question 5), empathy (question 3), and social Koka et al

RESULTS A total of 72 FLIP workshop participants completed the survey for a response rate of 80.9%. The sex distribution of the survey respondents was 36.1% women and 68.9% men. Participants’ age categories ranged from 30 to 34 to 50 to 54 years (Fig. 1A). The geographic distribution of participants (Fig. 1B) indicated the majority were from North America (59.7%), followed by Europe (19.4%) and Asia (15.3%). Most participants identiﬁed a primary career focus (Fig. 1C) in academics (54.2%), followed by private practice (31.9%) and hospital practice (13.9%). The majority (73.6%) of the participants had only attended 1 FLIP workshop, 22.2% had attended 2 workshops, and 4.2% more than 2 workshops. The impact of attending 1 or more FLIP workshops on the respondents’ self-perceived improvement (signiﬁcantly THE JOURNAL OF PROSTHETIC DENTISTRY

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Table 2. Survey instrument containing 18 questions Thank you for taking this survey to help us learn where FLIP has been able and unable to help you with your career and your daily lives. FLIP Impact Survey 1. As a direct result of attending one or more FLIP workshops, how would you describe your overall leadership skills?

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Table 2. (Continued) Survey instrument containing 18 questions 10. As a direct result of attending one of more FLIP workshops, how would you describe your conﬂict-resolution skills? Signiﬁcantly improved Slightly improved Unchanged

Signiﬁcantly improved

Worse

Slightly improved

11. As a direct result of attending one of more FLIP workshops, how would you describe your career management skills?

Unchanged Worse

Signiﬁcantly improved

2. As a direct result of attending one or more FLIP workshops, how would you describe your social skills?

Slightly improved Unchanged

Signiﬁcantly improved

Worse

Slightly improved

12. How many total FLIP workshops have you attended as a participant or faculty?

Unchanged Worse

3. As a direct result of attending one or more FLIP workshops, how would you describe your empathy for others?

Signiﬁcantly improved

Slightly improved

4 5

Unchanged

13. What is your gender?

Worse 4. As a direct result of attending one or more FLIP workshops, how would you describe your time management skills?

Female Male 14. Which of the following do you view as your current primary career focus?

Signiﬁcantly improved Slightly improved

Private practice

Unchanged

Academics

Worse

Hospital dentistry

5. As a direct result of attending one or more FLIP workshops, how would you describe your self-awareness? Signiﬁcantly improved

Military 15. Please describe 1 or 2 speciﬁc ways or interactions where attending an FLIP workshop has helped you.

Unchanged

16. Please describe leadership or management where you would like additional education/training.

Worse

17. What is your home continent where you work?

Slightly improved

6. As a direct result of attending one or more FLIP workshops, how would you describe your communication skills?

North America Europe

Signiﬁcantly improved

South America

Slightly improved

Africa

Unchanged

Australia Asia

Worse 7. As a direct result of attending one or more FLIP workshops, how would you describe your problem-solving skills?

18. What is your age? (y) 25-29

Signiﬁcantly improved

30-34

Slightly improved

35-39

Unchanged

40-44

Worse

45-49

8. As a direct result of attending one or more FLIP workshops, how would you describe your decision-making skills? Signiﬁcantly improved Slightly improved Unchanged Worse 9. As a direct result of attending one or more FLIP workshops, how would you describe your team management skills? Signiﬁcantly improved Slightly improved Unchanged Worse (continued on next column)

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or slightly improved) in leadership capabilities is seen in Table 3. Almost all (96.2%) respondents reported improvement in overall leadership, and over 90% reported improvement in career and team management, self-awareness, problem-solving, and conﬂict resolution. Social skills, time management, and empathy were the elements showing the least percentages of improvement, yet more than 75% of the participants indicated improvement in these leadership capabilities and all the other tested capabilities.

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Table 3. Rank order of leadership capabilities by percentage of respondents scoring “Signiﬁcantly improved” or “Slightly improved”

25-29 30-34

Rank

35-39 40-44 45-49 50-54 0

20%

40%

60%

80%

100%

Percentage of Respondents Answering “Signiﬁcantly Improved” or “Slightly Improved”

Leadership Capability

Overall leadership

Career management

96.2 95.8

Team management

94.5

Self-awareness

94.4

Problem-solving

91.7

Conﬂict resolution

90.3

Communication

88.7

Decision-making

87.5

Empathy

80.6

Time management

77.8

Social skills

76.1

North America Europe South America Africa Australia Asia 0

20%

40%

60%

80%

100%

B Private Practice

Individual comments to the open-ended questions were reviewed and grouped based on general content area. Among the speciﬁc ways in which attending FLIP has helped the participants develop their leadership capabilities, the most commonly cited topics were the impact of networking and developing professional relationships, understanding leader-follower dynamics, gaining a better perspective on leadership in academics, and how to strategically grow a private practice. Regarding areas of interest for future leadership training, the most commonly cited areas were conﬂict resolution, business development, motivating others, and navigating organizational politics and behavior. DISCUSSION

Academics Hospital Dentistry Military 0

20%

40%

60%

80%

100%

C Figure 1. A, Age distribution of survey respondents. B, Home continent distribution of survey respondents. C, Primary career focus distribution of survey respondents.

The Spearman correlation coefﬁcients between the respondents’ age (Table 4) or sex (Table 5) and the respondents’ answers to questions focusing on their perception of changes in their leadership or management skills were relatively weak (r<0.2) and not statistically signiﬁcant (P>.13). Furthermore, none of the other demographic variables (primary career focus, number of workshops attended, or home continent) were correlated with the respondents’ answers to the survey questions. Koka et al

The noted leadership and management expert and educator, John Maxwell, stated that “The single biggest way to impact an organization is to focus on leadership development. There is almost no limit to the potential of an organization that recruits good people, raises them up as leaders and continually develops them.”13 Unfortunately, dental schools spend more resources on training good researchers, good educators, and good clinicians than they do on training good leaders, whether it be for academic or private practice settings. Indeed, education in leadership often is offered only to those who have been identiﬁed as high potential leaders based on achievements in research, education, and clinical care, as if being excellent in one or more of those areas is a prerequisite for becoming a leader. This is despite examples from the business and sports worlds where the most successful leaders, coaches, or team managers are not necessarily exceptional at speciﬁc business tasks or the sport they coach.14 Leadership is an entity and a skill set all to itself. Leadership is harddeven for those who have training in leadership. How can those who have no or limited training be helped? Where do they turn? As noted THE JOURNAL OF PROSTHETIC DENTISTRY

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Table 4. Spearman correlation coefﬁcients of participants’ response to change in leadership capability relative to participant age

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Table 5. Spearman correlation coefﬁcients of participants’ response to change in leadership capability relative to participants’ sex

Spearman Correlation Coefﬁcient

Overall leadership

-0.08

.50

Overall leadership

Problem-solving

-0.18

.13

Time management

-0.09

.43

Conﬂict resolution

0.04

Leadership Capability and Age

Spearman Correlation Coefﬁcient

-0.04

.76

Problem-solving

0.08

.50

Time management

0.03

.79

.75

Conﬂict resolution

0.02

.87

Leadership Capability and Sex

Career management

-0.02

.86

Career management

0.01

.95

Team management

-0.09

.46

Team management

0.01

.95 .98

Communication

0.05

.70

Communication

-0.00

Decision-making

-0.12

.30

Decision-making

0.05

.68

Self-awareness

-0.01

.94

Self-awareness

0.05

.70

Social skills

-0.03

.84

Social skills

Empathy

-0.12

.31

Empathy

previously, ADEA and ADA have leadership development programs, as do some US state dental associations. If one goal is to develop certain leadership capabilities, such as strategic decision-making or negotiating, an interested person could seek executive education at a business college. For those with greater interest, pursuit of an MBA is also an option, and a choice would need to be made between a general MBA and one that focuses on health care. However, investing in developing a skill or capability takes resources and time, and early-career academicians and clinicians are often unable to commit the time and resources for extensive leadership training. At the same time, if the same leadership mistakes are made repeatedly, with budgetary and career implications, does it matter that one is an excellent clinician, educator, or researcher? When it comes to leadership, direction is more important than speed. Heading in the right direction slowly is better than heading in the wrong direction quickly. Learning and acquiring leadership capabilities to lead oneself, and a group for which one is responsible, in the right direction is an important investment. FLIP offers participants an opportunity to experience a relatively brief intervention designed to allow them to appreciate the breadth and depth of the leadership topics and resources available. Although it is merely an introduction to the vast fields of leadership, management science, and practice, it is encouraging that almost all (97.2%) respondents reported improvement in overall leadership and that over 90% reported improvement in career and team management, self-awareness, problemsolving, and conflict resolution (Table 3). Indeed, over 75% of the participants reported at least some improvement in all the 11 areas of leadership capability assessed in the survey. These data indicate that the participants perceived benefit from attending a leadership workshop. Following on, and based on participants’ comments, it was clear the participants perceived the benefits of networking and making new friends as THE JOURNAL OF PROSTHETIC DENTISTRY

-0.07

.57

0.08

.49

significant. In today’s global environment, the fact that every workshop had participants from 4, and sometimes 5, continents is important for establishing friendships that yield global collaboration. Furthermore, participants’ comments demonstrated their desire to learn more about conflict resolution, motivating others, business development, and the challenges brought forth by organizational politics. These topics represent 3 routine matters with which academics and private practitioners struggle daily and that are based on relationship. Business development requires long-term thinking, which suggests future workshops should focus on elements such as vision setting, strategy, marketing, and innovation. None of the responses to any of the 11 questions were correlated with the respondents’ sex or age. With regard to sex, the survey questions were designed to include some elements of emotional intelligence: empathy, social skills, and self-awareness. A sex difference could have manifested here as women are thought to be better at appreciating and showing the traits associated with emotional intelligence.11,12 However, no difference between the sexes was found in terms of improvement in these 3 elements of emotional intelligence. Perhaps, because the women and men attending the workshop had been nominated for showing good leadership skills and potential, their skill sets were solid a priori, or perhaps all participants perceived an improvement in these capabilities regardless of the level at which they began the workshop. With regard to age, there was a broad distribution of age among the participants. Again, considering that the eligibility criteria for the workshops were related to leadership experience, the age distribution is not surprising as different people seek or are chosen for leadership positions independently of age. However, none of the areas examined in the survey were influenced by the participants’ age. It may be that the criteria selected for individuals who were in a narrow range of leadership experience (within 3 years of their first major leadership Koka et al

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position), and hence, the effect of age was negated given the content of the workshop and the way the survey was designed. Also, because the workshops focused on the fundamentals of leadership, the effect of age may be less than if the workshops focused on more advanced leadership theory and practice for more seasoned, and presumably older, participants. Overall, these results indicate that leadership education may benefit people across the age spectrum. Measuring the impact of leadership training is difficult. How any leadership-specific outcome has been impacted by any single training experience is almost impossible to measure objectively because many other factors can influence leadership performance. A 2- to 2.5day workshop all by itself is unlikely to have a unique impact. Rather, it is best viewed as one piece of a large educational puzzle where numerous factors in an individual’s leadership development capabilities are in play. Perhaps workshop participants volunteered to attend because they realized the importance of cultivating leadership skills. Being nominated for and being willing to participate in an FLIP workshop shows they accept the need for the education. The fact that many FLIP alumni are moving into prominent leadership positions may be a self-fulfilling prophecy. Indeed, FLIP alumni may exemplify Steven Covey’s response when he was asked if leaders are born or made: “Are leaders born or made? This is a false dichotomydleaders are neither born nor made. Leaders choose to be leaders.”15 FLIP alumni may do well as leaders because they have chosen to be leaders, and attending an FLIP workshop is simply a manifestation of their choice. CONCLUSIONS Within the limitations of this survey study, the following conclusions were drawn: 1. Attending a leadership workshop is valued and appreciated by survey participants, who reported improvement in all areas identified as important for successful leadership.

Koka et al

2. These self-reported improvements are independent of a participant’s age, sex, primary career focus, or home continent. REFERENCES 1. American Dental Association. Health Policy Institute. Number of practicing dentists per capita in the United States will grow steadily 2016. Available at: http://www.ada.org/w/media/ADA/Science%20and%20Research/HPI/Files/ HPIBrief_0616_1.pdf. Accessed August 20, 2018. 2. Mitchell M, Leachman M, Masterson K. A lost decade in higher education funding. Center on Budget Policy Priorities. Available at: https://www.cbpp. org/research/state-budget-and-tax/a-lost-decade-in-higher-educationfunding. Accessed December 1, 2018. 3. Commission on Dental Accreditation, Standards 2-18, 2-19 and 2-20. Available at: https://www.ada.org/w/media/CODA/Files/pde.pdf?la=en. Accessed December 1, 2018. 4. Commission on Dental Accreditation, Standard 4-15. Available at: https:// www.ada.org/w/media/CODA/Files/prostho.pdf?la=en. Accessed December 1, 2018. 5. American Dental Educators Association, ADA Leadership Institute. Available at: http://www.adea.org/LeadershipInstitute/. Accessed August 20, 2018. 6. American Dental Educators Association, ADEA Leadership Institute. Available at: http://www.adea.org/LeadershipInstitute/. Accessed August 20, 2018. 7. Goleman D. Emotional intelligence. 1st ed. New York: Bantam; 1995. 8. Curci A, Lanciano T, Soleti E, Zammuner VL, Salovey P. Construct validity of the Italian version of the Mayer-Salovey-Caruso emotional intelligence test (MS CEIT) v2.0. J Pers Assess 2013;95:486-94. 9. Wojciechowski J, Stolarski M, Matthews G. Emotional intelligence and mismatching expressive and verbal messages: a contribution to detection of deception. PLoS One 2014;9:e92570. 10. Kelliher F, Byrne S. The thinking behind the action (learning): reﬂections on the design and delivery of an executive management program. J Work Applied Mgmt 2018;10:35-49. 11. Frich JC, Brewster AL, Cherlin EJ, Bradley EH. Leadership development programs for physicians: a systematic review. J Gen Intern Med 2015;30: 656-74. 12. Steinert Y, Naismith L, Mann K. Faculty development initiatives designed to promote leadership in medical education. A BEME systematic review: BEME guide no. 19. Med Teach 2012;34:483-503. 13. Maxwell JC. The 17 irrefutable laws of teamwork. 10th anniversary ed. Nashville, Tennessee: Thomas Nelson; 2001. p. 185. 14. Schempp PG, McCullick BA, Grant MA, Foo C, Wieser K. Professional playing experience does not lead to professional coaching success. J Coaching Educ 2010;3:72-82. 15. Covey S. The 8th habit: From effectiveness to greatness. New York: Free Press; 2004. p. 62. Corresponding author: Dr Sreenivas Koka Koka Dental Clinic 8031 Linda Vista Rd, Suite 210 San Diego, CA 92111 Email: skoka66@gmail.com Copyright © 2019 by the Editorial Council for The Journal of Prosthetic Dentistry. https://doi.org/10.1016/j.prosdent.2019.03.006

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IN BRIEF

• The GDC sets a dangerous precedent in allowing Clinical Dental Technicians independent practice.

• Academic Heads of Departments are responsible for the decline in standards of undergraduate teaching.

• Specialist societies, especially the BSSPD, should have had more input into the training of CDTs.

The future for removable prosthodontics in the UK – a personal opinion J. Wilson1 In allowing Clinical Dental Technicians (CDTs) to practise complete denture prosthodontics independently the General Dental Council (GDC) has set a dangerous precedent that could threaten the future integrity of the ‘dental team’. In bemoaning the decline in standards for undergraduate teaching of removable prosthodontics the academic specialists, and the BSSPD, only have themselves to blame. It can only be hoped that, once established, Clinical Dental Technicians will raise the woefully low standard of removable prosthodontics in the UK.

I read, with mixed emotions, (anger, sadness, bewilderment) the editorial on the Teaching of removable prosthodontics in the UK (Br Dent J 2006; 201: 129) and wondered whether the timing was deliberate rather than coincidental. The mentioned British Society for the Study of Prosthetic Dentistry (BSSPD) conference took place in March 2006. 31 July 2006 was a momentous date for the dental profession. On that day the GDC not only legalised CDTs but also gave them the right to practise as independent clinicians, rather than as members of the much vaunted ‘dental team’. It seemed that the GDC had fi nally caved in to pressure from the denturists without and the Dental Care Professionals (DCPs) within. However, as for its assertion that it consulted ‘widely’ I would like to know where, when and with whom? Surely with the

Senior Lecturer/Honorary Associate Specialist in Restorative Dentistry, Member of the GDC Specialist List in Prosthodontics, 164 Albany Road, Roath, Cardiff, CF24 3RW Correspondence to: Mr Jeff Wilson Email: jeffrey.wilson@ntlworld.com

Refereed Paper Accepted 2 February 2007 DOI: 10.1038/bdj.2007.478 © British Dental Journal 2007; 202: 653-654

BSSPD, the recognised specialist body concerned with removable prosthodontics; or perhaps with the British Prosthodontic Conference; or even with the 360 (approx.) members of the GDC Specialist List in Prosthodontics? Did the GDC consult directly with all registered general dental practitioners, who are most likely to be affected by these legislative changes? If it did I am not aware of any such consultation having occurred. Where was the publicity or communication? In my opinion the GDC acted irrationally, irresponsibly and without proper consultation. I then wondered where the editor and all those worthy people in the so called ‘representative group’ from the BSSPD had been hiding all this time. The editorial appeared in the fi rst edition of the BDJ following the date for registration of all DCPs, but nowhere did the editorial mention CDTs – who will now, presumably, have the opportunity to lead the study and practice of removable prosthodontics to higher levels of competence and excellence! Those concerned academics will no longer need to worry about teaching complete denture prosthetics as it should only be a matter of time before this topic is removed from the undergraduate dental curriculum. Forgive me for saying it,

BRITISH DENTAL JOURNAL VOLUME 202 NO. 11 JUN 9 2007

but the editorial was riddled with inaccuracies, non-sequiturs and, in my humble opinion, nonsense! I then assumed that the editorial may have been based on a report from the representative group – in which case I may owe the BDJ editor an apology. However, this would imply that the BDJ editor is more privileged than the ordinary BSSPD members who have not yet had the opportunity to read such a report from this group. The editorial concludes with this representative group vowing to lessen any negative impact on undergraduate teaching in the future. The cry goes up ‘too late – the horse has already bolted, the damage already done!’ Who were the members of this representative group? They were none other than the academic ‘Heads of Departments’ of the prosthetics teachers in the (mainly) undergraduate dental schools. But why are these leading members of academe suddenly bemoaning the decline in the standard of undergraduate removable prosthodontic teaching when they, themselves, must be held responsible for that very teaching and, by implication, the decline? I was a delegate attending the AGM of that BSSPD conference. Some delegates suggested that perhaps the BSSPD, 653

OPINION including the academic Heads of Departments, had suddenly woken up to the fact that CDTs were almost upon us and we should be doing something about it. Where have they all been hiding too, I wondered? When a suggestion from the floor was made that the BSSPD should make representations to the GDC in this respect I was shocked by the response of the Chairman when he responded that he was ‘not minded to do so’! I place the blame for the lack of involvement of the specialist societies squarely with the presidents of those societies, who have obviously done little or nothing to involve themselves or their societies in this debate – which has been going on for several years. With respect to the CDTs – and one must admire them for their persistence – I have absolutely no problem in welcoming them as DCPs, but only if they are properly trained, competent and regulated. Badly made complete dentures can, after all, cause harm. As I understand it (from anecdotal information gained from technician colleagues, some of whom are practising denturists in the UK), the clinical training for UK denturists of the ‘George Brown School’ consists of three weeks spent in Canada making complete dentures for one or two people. This is hardly comparable with the three or so clinical years spent by most dental undergraduates in the UK. Granted, they do not spend all that time managing edentulous patients, but do gain an enormous amount of clinical experience compared with only three weeks. I also feel strongly that, as DCPs, CDTs should be part of the dental team with the dentist as team leader and taking overall responsibility. The dental team and team working is one of the fundamental aims of the current GDC, so I wonder why the ability for CDTs to practise independently was ‘sneaked in’, as it was never part of the original proposals. In my opinion some form of clinical examination (similar to the International Qualifying Examination for foreign dentists) to validate the clinical training of CDTs should have been instituted. Unfortunately this

ability to practise independently sets a very dangerous precedent, for it will only be a matter of time before CDTs are pressing to be allowed to make partial dentures independently, then possibly even more. Following such a lead, other DCPs would, no doubt, want to practise independently as hygienists and therapists. The irony is that some practising denturists do not carry out their own technical work but send their clinical work to a technical laboratory. What about the NHS? Will enabling legislation be passed to allow CDTs to charge edentulous patients the NHS fee for making a set of complete dentures? Will Primary Care Trusts contract local CDTs to make a number of complete dentures? I doubt it, as practising denturists seem to charge as much, if not more than their dentist colleagues on a private basis. Even under the new contract’s remuneration scheme, I would suggest that it is not really worth trying to make a set of dentures on the NHS. Apparently, the GDC will not allow CDTs to practise in the UK until they are deemed competent to do so. This means they will have to obtain a ‘diploma’ after following a course of study to be organised by the Kent Deanery and regulated by the Faculty of General Dental Practitioners of the Royal College of Surgeons of England. I would like to know where this was all set up. Who was involved/ consulted and what qualifies these particular ‘experts’ to certify the CDTs? When asked what topics will be taught on this diploma does more clinical experience feature? No - everything else but clinical experience. To prepare CDTs for independent clinical practice they will be taught the theory of radiology, governance and cross infection control. I would argue that there is nothing more important than clinical experience. However, this also adds to the danger of the precedent in that it gives CDTs the right to diagnose with virtually no clinical experience whatsoever. The GDC has therefore devalued removable prosthodontics but, more importantly, is showing disregard for

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the oral health of the edentulous. It has also insulted recognised specialists in removable prosthodontics, especially the members of its own prosthodontics specialist list. Why has it done this – to satisfy a demand for complete dentures in the UK? Hardly, at a time when the specialists are saying that there is a dwindling number of edentulous, that the average age of edentulism is increasing and that the difficulty of managing the edentulous patient is increasing. And what for the future? I sincerely hope that CDTs will join (and be welcomed by) the specialist societies rather than keeping themselves to themselves, will want to participate in raising the standards of removable prosthodontics and will work with dentists and the dental team rather than working in isolation. However, I doubt this will happen. Since originally penning this article I attended the 2007 conference of the American Prosthodontic Society under the presidency of our own Professor Harold Preiskel (the fi rst non-American president of this society). At their AGM they formally admitted Dental Technologists as full members of the Society. The European Prosthodontic Association has always welcomed as members anyone with an interest in prosthodontics. Let us hope that the BSSPD will now be proactive in encouraging dental technologists and especially CDTs to join its ranks. In my opinion, the best place to train CDTs would have been alongside their undergraduate dental student and dental technician colleagues in dental schools and hospitals. However, it seems that there is little will for this either on the side of the CDTs or, regrettably, on the side of the deans of dental schools (with the notable exception of Sheffield). 31 July 2006 was a sad day for dentists, prosthodontists, and especially the edentulous, thanks to the GDC. My only hope is that our new CDT colleagues will start to raise the declining standard of complete denture prosthetics in the UK.

OBSERVATIONS

GORDON J. CHRISTENSEN, D.D.S., M.S.D., PH.D.

PROSTHODONTICS IS IN YOUR FUTURE Several decades ago, prostho-

dontic procedures dominated dentistry. Teeth were extracted on a routine basis and artificial dentures were made for patients when natural teeth could have been saved using the techniques of today. Removable complete prosthodontics was prominent. Preventive dentistry, including better patient education about oral hygiene, fluoride application and proper diet, has since started to be promoted by the dental profession. Saving teeth instead of extracting them became popular and was valued by the public. Removable complete prosthodontics was less needed than in the past. The life expectancy of the American public increased from 45 years in 1930 to nearly 80 years in 2000. The retention of natural teeth increased from 7.4 teeth at age 65 in 1960, to about 20 teeth at age 65 in 2000.1 Removable complete dentures are now encountered only infrequently in youth. With the increase in life expectancy and the retention of natural teeth, fixed, implant and removable partial prosthodontics are now a major part of dentistry. It is estimated that this trend will continue as people live longer, retain even more natural teeth and have a

greater desire for more elective esthetic procedures. The practice of dentistry has shifted heavily from treating young people to treating mature adults, and prosthodontics is in heavy demand again. However, todayâ&#x20AC;&#x2122;s prosthodontics is a different type of prosthodontics from that of the past. What does the future hold for prosthodontics, general dentists and prosthodontists? Prosthodontics is one of nine recognized specialties in dentistry. As with several of these nine specialties, most of prosthodontics is accomplished by general practitioners. What is the role that prosthodontists and general dentists have in prosthodontic therapy in the United States? The following information represents my views after practicing, teaching and researching in prosthodontics for 40 years.

public now demands esthetically acceptable crown coverage of discolored, carious, broken or periodontally disfigured teeth, and dentists of today can provide these necessary services. As is the case for most of endodontics, periodontics, pediatric dentistry, and oral and maxillofacial radiology, the majority of prosthodontic therapy is provided by general practitioners. Oral surgical and orthodontic procedures are accomplished less frequently by general practitioners than they are by specialists. Prosthodontists have significant in-depth background in the complex technical, biological and esthetic aspects of fixed prosthodontics. They are capable of providing clinical support, treatment planning and educational information to general practitioners in the complex aspects of fixed prosthodontics.

FIXED PROSTHODONTICS

REMOVABLE PARTIAL PROSTHODONTICS

It has been estimated that more than 40 million crowns were placed in the United States last year.2 That is about 25 units of fixed prosthodontics per general practitioner per month, or more than one-third of the average gross income of a general dentist (based on ADA typical average gross income estimates). The

In the past, many people elected to have all of their teeth removed instead of having removable partial dentures. However, currently many natural teeth remain in most mature people, and when long-term retention of teeth is unknown because of periodontal disease, removable

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CHRISTENSEN partial dentures are often a more desirable therapy than fixed or implant Dr. Christensen is prostheses. co-founder and senior consultant of In my expeClinical Research rience teachAssociates, 3707 N. ing removable Canyon Road, Suite No. 7A, Provo, Utah partial pros84604, and is a thodontics to member of JADA’s editorial board. He mature generhas a master’s deal dentists, gree in restorative this area of dentistry and a doctorate in education education in and psychology. He dentistry is board certified in prosthodontics. could use sigAddress reprint renificant upquests to Dr. grading. There Christensen. is a general lack of understanding of the need for planning removable partials, as well as of clasp design, semiprecision and precision attachments, differences among artificial teeth types, metals for frameworks, denture base resins, occlusion on natural and artificial teeth, and other topics. Additionally, many dental laboratories have only minimal knowledge of these topics. Although thousands of removable partial dentures are made in the United States each year, their quality could be significantly improved. Prosthodontists have special expertise in this area, and most are pleased to be consulted when difficult cases are encountered. IMPLANT PROSTHODONTICS

This complex area of prostho-

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dontics has made major strides in the past 10 years. However, the difficulty encountered in planning and constructing implant prostheses, as well as the laboratory expertise and interaction necessary for success, have discouraged some dentists from becoming involved with implant prosthodontics. Education and experience are required to provide long-term successful implant prosthodontic therapy. Prosthodontists have special education in implant prosthodontics. They are a valuable resource for general practitioners, both in treatment planning and providing therapy. I predict that implant prosthodontics will continue to increase in need and demand, become more refined clinically, and become a part of more general practices. MAXILLOFACIAL PROSTHETICS

Making artificial replacements for the face, ears and other parts of the body is a less commonly encountered aspect of prosthodontics and is usually accomplished by prosthodontists. It requires optimum interaction with most dental specialties and several medical specialties. General dentists should have an understanding of the type of therapy available and how to refer patients to prosthodontists for treatment. AVAILABILITY OF PROSTHODONTISTS

There are approximately 1,000 prosthodontists certified by the

American Board of Prosthodontics. They are located in all areas of the United States. Prosthodontists are willing and eager to help general dentists in treatment planning their cases or, if requested, to perform the prosthodontic therapy themselves. CONCLUSIONS

Prosthodontics was officially established as a specialty of dentistry in 1947. It has grown and matured to be a resource of highly qualified and skilled practitioners who can provide prosthodontic therapy for all types of complex clinical situations. As with several other dental specialties, most of prosthodontic therapy is accomplished by general practitioners. Prosthodontists are assisting the profession in treatment planning and in providing treatment for the most complex fixed, removable and implant prosthodontic cases, as well as in maxillofacial prosthetics. I know that my colleagues are eager to help general practitioners and other specialists in this growing and complex area of dentistry. ■ The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association. Educational information on topics discussed by Dr. Christensen in this article is available through Practical Clinical Courses and can be obtained by calling 1-800-223-6569. 1. Douglass CW. Future needs for dental restorative materials. Adv Dent Res 1992; 6:4-6. 2. Melnitchenko E. Dental industry overview. Vital Points 1999;10:2.

RESEARCH SECTION

AND EDUCATION

EDITOR

LOUIS J. BOUCHER

The future D. A. Atwood,

M.D.,

of prosthodontics D.M.D.*

Harvard School of Dental Medicine, Boston, Mass.

uring the past 10 to 15 years, much has happened both in and out of the profession of dentistry that has had an impact on the practice of prosthodontics.

EFFECT OF MANPOWER

Increase/

CHANGES

Prosthodontic Society Presented at American Vegas. NW. *Professor and Head of Prosthetic Dentistry. tOwen, T.: Personal communication, 1982.

ratio --..

1970

At the initiative of the dental profession, the U.S. government contributed over $800 million to dental education, including approximately $300 million for capitation grants, $100 million for specific educational projects and programs, and $252 million for dental school construction grants.+ Eleven new dental schools have been established since 1965 (an increase of 22%).’ The number of first-year dental students increased from 3,806 in 1965 to 6,030 in 1980 (an increase of 58%)‘; and the number of professionally active dentists increased from 95,990 in 1965 to 134,226 in 1980 (an increase of 39%).’ In the 1 l-year period from 1970 to 1980, it was documented that the civilian population of the United States grew from 203 to 220 million (an increase of 8%), while the number of civilian dentists increased 34%, a rate of growth more than four times that of the population (Table I).* As a result, the civilian dentistto-population ratio rose from 47.1:100,000 to 58.6:100,000.2 As the ratios increase, the number of persons per dentist decreases. U.S. civilians per dentist dropped from 2,123 in 1970 to 1,707 in 1980.2 The distribution of dentists varies in different parts of the United States.’ In 1980 in Massachusetts there were 69.9 dentists to 100,000 civilians (or 1,430 civilians per dentist), which is more than twice the ratio in Mississippi (32.5 dentists to 100,000 persons or 3,075 persons per dentist).’ A decreased ratio of potential patients to dentists can lead to increased competition among dentists.

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Table I. Dentist-to-population

meeting,

Las

Civilian dentists Civilian population Dentist-topopulation ratio Persons per dentist

decrease (%I

19430

95,680

129,064

+34

203 million

220 million

47: 100,000

58.6:100,000

+24

1,707

-19

2,123

Table II. National

expenditures 1970 (billions of dollars)

Nominal Adjusted for inflation

4.6 3.9

for dental care

1980 (billions of dolla&

Increase (%)

18 7.2

291 84 -_-____-

Table III. Adjusted per dentist

dental expendihzfes

1970

1980

$37,990

$53,640

IWNWS! 41% --

EFFECT OF IMFLATION As a result of increased numbers of dentists, increased population, increased proituctitiizy, and i&ation, national expenditures for dental care increased 291% from approximately $4.6 billion in 19702 to $18 billion in 1980 (Table II).’ In order to reduce the effect of inflation, which caused the Consumer Price Index (CPI) to rise 112% and the Dental Fee Index to rise 101% during these 11 years, it is helpful to adjust these dollar figures to constant 1967 dollars (CFl = 1OO).3In these terms the dental expenditures in 1980 were really

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$7.2 billion (instead of $18 billion), or an increase of 84% over inflation-adjusted 1970 expenditures. If the inflation-adjusted expenditures are divided by the number of professionally active dentists, the increase in the real dental expenditures per dentist can be calculated to show a rise from $37,990 per dentist in 1970 to $53,640 per dentist in 1980 (+41%) (Table III).” The difference gives a rough measure of the increase in productivity adjusted for inflation and number of professionally active dentists. An increase in the productivity of dentists can increase the competition among dentists. EFFECT OF CHANGES PRACTICE

IN DENTAL

The nature of dental practice has been changing as life expectancy of the population increases, as the prevalence of dental caries decreases, and as the effects of preventive and conservative dentistry and patient education have gradually taken hold.‘s4 Furthermore many patients are now demanding more sophisticated and costly dental treatment. From 1976 to 1978 the Research Triangle Institute conducted a national study of 485 private general dentistry practices and gathered extensive data on services rendered, professional time expended, and gross income per week.‘z6 For purposes of analysis the types of service were divided into three major categories: (1) prevention; (2) basic services, which consisted of diagnosis, operative dentistry, removable prosthodontics, and oral surgery; and (3) reconstructive services, which consisted of fixed prosthodontics, periodontics, endodontics, and orthodontics. From the 21,299 dental services rendered during 13,883 patient visits over a 2-week on-site observation period, certain trends were observed. Overall, fixed prosthodontics was the third most frequent reason for a visit to a general dentist (13.5%) (Table IV).s (It should be noted that in previous national surveys 1.9% to 3.9% of visits were for treatment with fixed prosthodontics.‘) Of the 485 private practices, 177 consisted of one dentist, 131 two dentists, 110 three or four dentists, and 67 five or more dentists (Table V).’ The smaller practices leaned toward more preventive and basic services and larger practices toward more reconstructive services, including more patient visits, more time spent, and larger gross income from fixed prosthodontics. Although there is a trend toward a decreased percent of edentulism and there are 1.6 fewer missing teeth per person in all adults 18 to 79 years of age, because of the large number of patients who are 60 years of age or

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Table IV. Primary Type

reason for visit (1977)

of service

% 13.1

Prevention Basic services Fillings (including inlays) Oral diagnosis/radiology Removable prosthodontics Oral surgery

32.0 16.1 8.2 5.7 62.0

Reconstructive services Crowns and bridges Endodontic treatment Orthodontic treatment Periodontal treatment

Table V. Percent

13.5 5.2 2.5 1.6 22.8

of dentist

services

No. of dentists Type

of service

Prevention Basic Reconstructive

in the practice

3 or 4

5 or more

19.8 68.5 11.8

16.4 67.6 16.0

13.7 64.9 21.3

11.3 66.1 22.7

older and partially or completely edentulous, there is a documented need for prosthodontic treatment. This prompted Douglass6 to predict that “the stage is set for a bull market in the delivery of prosthodontic services.” EFFECT

OF DEMAND

VS. NEED

It is well known that the demand for dental services rarely approaches the need,‘s4 even when the economic barrier is removed or reduced by government or private dental insurance. The number of persons insured by some sort of dental benefit plan increased to about one third of all U.S. citizens (87 million) by 1981 and undoubtedly contributed to the previously described increase in annual expenditures for dental care.’ However, if the present economy with double-digit unemployment and continued inflation persists, there could be a reduction in both the disposable income available for dental care and the rate of growth in the number of persons covered by dental insurance. Furthermore, there could be a reduction in certain forms of thirdparty coverage. For example, 11 of 41 states (26%) with dental benefits in their Medicaid programs in 1974 had dropped the adult benefits by 1981.’ Such external economic factors can have considerable impact on the demand for dental care in dental practices individually as well as nationally, because in economi-

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tally stringent times many persons postpone having necessary dental care, especially prosthodontic and other costly treatment. This is another factor that tends to increase competition among dentists.

ROLE OF PROSTHODONTIC ORGANIZATIONS The question, Have we produced too many dentists? is inseparable from the question, What will be the state of the economy? The demand for the services rendered by dentists is determined by a host of complex factors that are far beyond the capacity of the individual dentist to analyze, to make conclusions from, or to influence. To help cope with the enormous problems that face individual dentists, the profession has organized itself in democratic fashion into national, state, and local societies representing most dentists. The American Dental Association (ADA) has done a tremendous job through its various councils: gathering data, making analyses, preparing position papers, and making recommendations. During 1982 the ADA was in the midst of an historic study of “The Future of Dentistry,” a study that inevitably will have a significant impact on the future of dentistry.’ In an ideal democracy individuals with special expertise and interests have both the right and the responsibility to seek to influence such deliberations in a democratic way. To try to provide significant input in prosthodontic matters, 18 national, regional, and specialty prosthodontic groups (plus two Canadian groups) have combined their various talents and efforts through the Federation of Prosthodontic Organizations (FPO). Through meetings of the House of Delegates, Executive Committee, Officers Committee, and various other working committees of the FPO, important issues involving prosthodontic matters are discussed and deliberated. In addition, FPO position papers are developed for the protection of the public, and appropriate recommendations are submitted to the ADA for consideration. With the FPO Central Office located in the ADA building, effective two-way communication has developed progressively over the years and prompted the Associate Executive Director of the ADA to remark: “The Federation is absolutely essential to the field of prosthodontics. If the Federation did not exist, we would have to invent it.“* Two recent examples of the work of the FPO are the position papers that were prepared in response to the Interim Report of the Special Committee on the Future of Dentistry and to the Draft Proposal of the ADA Council on Dental Education relative to criteria for Recognition of Specialties.“~‘” In addition, the FPO

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through the leadership of the Committee on Education and Research conducted a workshop on Advanced Postdoctoral Education Programs in Prosthodontics. The FPO House of Delegates approved the Consensus Report of the workshop and submitted it to the ADA Commission on Dental Accreditation.” These documents are some of the fruits of the cooperative efforts of many people wiorking in the best interests of the public. Any or all of the documents could have an effect on the future of prosthodontics. Several steps still remain in the ADA deliberations. The people who comprise the united voice of prosthodontics must always remain vigilant and active.

ROLE OF PROSTHODONTIC

EDUCATION

As prosthodontists find themselves in the political arena of public policy, the economic arena of government programs with huge appropriations, or the public health arena of demographic and epidemiologic analysis of trends in oral disease, many of us become acutely aware of the inadequacies of our preparation to leave the womblike security of our dental offices to go out into the world of politics or public health. Yet whom can we send to speak for prosthodontics? Do we want to send a person who is not a clinician experienced in prosthodontics? I think not, because who can know better the clinical aspects of these national problems than someone who is trained and experienced clinically in patient care? Yet, how much material, experience, or study about public policy or public health can be squeezed into already overcrowded doctoral or advanced prost hodontic programs? Very little. Reality requires that even in a 2-year advanced prosthodontic program, the clinical program consumes at least 2 years if a quality prosthodontist is to be produced. If significant biomedical research or study of public policy or public health is to be achieved without sacrificing the quality of the clinical program, then reality demands additional time. Recognizing, these circumstances, the Harvard School of Dental Medicine has developed a variety of programs in each of the dental specialties, including prosthodontics, which offers the highly motivated student expanded opportunities to achieve excellence in a number of potential careers.” The Biomedical Research Track combined with clinical training is the oldest of these combined programs. Significant research under the direction of a qualified research sponsor, relevant course work, and thesis defense require 1 additional year in the Master of Medical Science program or 2 (or more) years in the Doctor of Medical Science program. The objective of

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the programs is to educate clinical scholars who will combine patient care, teaching, and research in an academic environment. The Health Care Delivery Track is designed to prepare dentists who, in addition to becoming excellent prosthodontists, will also be able to interact effectively in health administration situations and in public policy debates and decisions that are shaping the future of prosthodontics. A variety of opportunities exists within the Health Care Delivery Track. One is a collaborative program with the Harvard School of Public Health that leads to a Master of Public Health degree on successful completion of course work, a health care delivery research project, and thesis defense. The goal of this 3-year program is to train excellent prosthodontists to gain additional expertise that will help them address various dental care delivery problems related to prosthodontics in either the public or private arena. Another program in the Health Care Delivery Track in association with the Harvard School of Government leads to a Master of Public Policy degree after 2 additional years of course work, research, and thesis defense. The objective of this 4-year program is to educate an excellent prosthodontist with the potential for significant impact in the area of public policy. Obviously, these rigorous programs require an extraordinary degree of commitment and are not for everyone for a variety of reasons, not the least of which is inflation. The cost of going to dental school has risen dramatically, and mean indebtedness on graduation of dental students increased from $16,000 in 1978 to $24,650 in 1981, a 54% increase in only 3 years.’ The number of applicants to dental schools has dropped from 14,900 in 1975 to 8,200 in 1981 along with a drop in the applicant-to-acceptance ratio from 2.6:1 to 1.4: 1.’ Whether this dramatic reduction in the dental school applicant pool is related to a reduction in the “rate of return to dentistry,” the implication of these trends relative to the quality of future dental students and the possible lowering of standards is a matter of considerable concern to dental educators.‘3, I4 The Committee on the Future of Dentistry states that the existence of sufficient numbers of adequately qualified applicants constitutes one of the most critical matters confronting dental education today.’ We must avoid a “retrenchment to eminent mediocrity.“15 These threats to the quality of dental students are coming at a time when a major premise of the Committee on the Future of Dentistry is that dental graduates will be broadly competent dentists and that

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there will be less need for specialists.’ The FPO position paper challenges the Committee to document that premise relative to prosthodontics because of the reduced predoctoral curriculum and clinical experience in prosthodontics over the past decade. As competition for patients increases, there could be a tendency for general practitioners to attempt complex treatments that would be better referred to specialists. This is done not only at risk to the patient but in today’s litigious society at risk to the practitioner as well. Maintenance of current competence in any area of practice depends on previous education and experience, continuing education, personal motivation, preference and skills, and adequate continuity of practice in the discipline. For 35 years the dental profession has recognized the need and value of specialists in prosthodontics to provide leadership in dental education and research as well as superior services to patients. The important contribution to this process by accredited advanced specialty education cannot be denied. At the request of the ADA, the American Board of Prosthodontics was established in 1947 to certify the competency of individuals in the specialty of prosthodontics. The Board continues to accomplish this mandate through didactic and clinical examinations. Because the types of services required for the maintenance of good oral health vary from simple to complex, various categories of health care providers are required from auxiliaries to specialists. The important questions are, What should be the “mix” of the various categories? and Is the correct mix determined by controlled access, by a free and open market, or by some combination of the two? These are the kinds of public policy questions that persons inside and outside the dental profession are currently addressing. Solving today’s and tomorrow’s problems will take leaders with the best education possible, not only in prosthodontics but also in health care administration and public policy. President Derek C. Bok of Harvard University stated: “. . . the greatest challenge facing American higher education in this generation is to provide professional preparation of the highest quality for able men and women who will provide leadership roles in public service. . . .“‘6

FUTURE

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For decades dental caries has been rampant in many parts of the United States. At last the epidemic of dental caries seems to be coming under control, thanks to the efforts of the dental profession through basic research, promotion of fluoridation, education of the public, and care of patients. In the midst of an

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epidemic, compromises on quality are sometimes necessary. Cost restraints may prevent doing all procedures that are usually performed in the best manner known. It its continuing battle with dental caries, the dental profession has scarcely been able to keep up with the demand, let alone the need. As the rate of caries declines, the profession will have time to raise the quality of care to new heights. The emphasis will be more on quality than on quantity; but with today’s and tomorrow’s new materials, techniques, and equipment, and with better dental care administration to improve our productivity, we will be able to provide high quality oral health care to more people than ever.“.‘* Whether we achieve these worthy goals will depend in part on whether our society as a whole is prepared to demand and fund dental research and dental care adequately.” As discussed in this article, there are several factors impacting on dentistry and prosthodontics that tend to increase competition. Some fear this. Personally, I believe that competition can be good. Competition in a free enterprise system has helped to make the United States a great nation. It can promote the development and maintenance of competence, industriousness, creativity, efficiency, productivity, and quality, as well as a desire to please the consumer. Competition discourages complacency, monopolistic price fixing, and inadequate concern for the consumer. Typically, the individuals entering the profession of dentistry have been solo entrepreneurs who want to help people, like to work with their hands, and want to be their own boss. That combination has provided a professional type of competition that has brought U.S. dentistry to an increasingly high level of performance and has made it available to an increasingly greater percent of U.S. citizens. Over the last 20 years a variety of systems for delivering dental care has evolved to serve the perceived needs of the people. 2o Competition will refine these systems. Some will fail and disappear while others will evolve and succeed. In this pluralistic nation a number of systems may coexist, each providing for the needs of different groups of individuals within society overall. A monolithic system that eliminates competition need not and, in my opinion, should not be the goal. Who can predict the future ? Certainly not I, anymore than I predicted the now-historic inflation over the past 11 years, which has had a profound effect on every aspect of prosthodontics: education, research, administration, and practice. However, I do believe that certain fundamentals will affect the future of prosthodontics. Through research we must develop improved pre-

266

ventive, diagnostic, and treatment methods and materials. Through education we must develop and maintain the best possib1.e competence. Through administration we must provide leadership for guiding the United States the way it should go on prosthodontic matters. Through practice we must provide appropriate services with concern for the individual. The need to accomplish these goals will continue for many years. I believe the prosthodontic community has the resilience, the commitment, the competence, the creativity, and the organization to influence the future for the good of the public. Let’s do it! REFERENCES 1.

4. 5.

7. 8.

IO.

I I.

12.

13.

Interim Report of the American Dental Assoctation’s Special Committee on the Future of Dentistry: issue Papers on Dental Research, Manpower, Education, Practice. and Public and Professional Concerns. September 19R2. Special Committee to Study the Future of Dentistry: Resource Papers on Dental Research, Dental Education, Dental Practice, Dental Manpower, and Public/Professional Concerns. Based on data available June 1981. American Dental Association. (Unpublished data.) Dentists’ fees and inflation. Joint report of the Bureau of Economic Research and Statistics and the Bureau of Public Information. J Am Dent Assoc 93:129. 1976 Douglass, C. W., and Cole, K. 0.: Utilization of dental services in the United States. J Dent Educ 43:223, 1979. Nash, K. D., Douglass, C. W., and Wilson, .J.: Economies of Scale and Productivity in Dental Practices. Research Triangle Institute, Center for Health Studies, Contract No. 231”750430. U.S. E’ublic Health Service. Final Report. August 1979. Douglass, C. W.: The role of specialists and general practitioners in provision of prosthodontic services. J I’kos’rn~r hN1 58844, 1983 Morn. B. D., and Poetsrh, W. E.: More preventive care, less tooth repair. J Am Dent Assoc 81:25, 1970. Cinley, T.: Remarks to the Executive Committee of the Federation of Prosthodontic Organizations meeting, I&. 16. 1980, Chicago, Ill. (Unpublished data.) Response of Federation of Prosthodonti~ Organizations to Request from ADA Special Committee on the Future of Dentistry for (Comment on Interim Rep(vt. (IJnpublished data.) Response 01 Federation of Prosthodontn Oryanizations to Request from ADA Council on Dental Eduratuon for Comment on Proposed Revision of (Xrcrta “‘II~ Recogmtion of Specialty Areas. (Unpublished data.) Proposed Guidelines for Postdoctoral Programs in Prosthodontics. Final Report of Workshop for Director of Postdoctoral Programs in Prosthodontics. (Unpublished data.) Committee on Postdoctoral Education, Ifnrvard School of Dental Med:cine: Opportunities for Postdoctoral Education. Boston. 198 I, Ifarvard School of Dental Medicine. Bureau of Economic and Behavioral Revarch, American

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14. 15.

16. 17.

Dental Association: The dental school applicant pool and the rate of return to dentistry. J Am Dent Assoc 105t271, 1982. Solomon, E., and Pait, C.: Impact of the applicant decline. J Dent Educ 45~812, 1981. Mulvihill, J. E.: Financing dental education from the viewpoint of the academic health center: Retrenchment of mediocrity or enhancement for excellence. J Dent Educ 36:307, 1982. Bok, D. C.: Excellence in governance. Harvard Magazine 85~25, 1982. Sozio, R. B., and Riley, E. J.: The shrink-free ceramic crown. J PR~STHET

18.

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DENT

49:182,

1983.

Apotheker, H., and Jako, G. J.: A microscope dentistry. J Microsurg 3:1, 1981.

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for

use in

19.

20.

Goldhaber, P.: Has organized dentistry failed to meet the dental needs of the American people? An educatorâ&#x20AC;&#x2122;s perspective. J Dent Educ 46:579, 1982. Gondela, L.: The delivery of dental care. An assessment of five alternative systems. J Am Dent Assoc 105:431, 1982.

Reprint requests to: DR. DOUGLAS A. ATWOOD HARVARD UNIVERSITY SCHOLL OF DENTAL MEDICINE 188 LONGW~~D AVE. BOSTON,

02115

267

RESEARCH AND EDUCATION SECTION

EDITOR

LOUIS J. BOUCHER

Procompetition health of prosthodontics H. L. Bailit,

D.M.D.,

Ph.D.,*

policies

and the future

and J. E. Grasso, D.D.S., M.S.**

Lrniversity of Connecticut School of Dental Medicine, Farmington, Conn.

he American health care system has undergone unprecedented growth during the past 30 years. Dentistry has participated in this growth, and dentists now enjoy a higher level of affluence and prestige than ever before in their 200-year history as a profession. There is substantial evidence that this period of rapid growth is coming to an end and that the 1980s will see a decreased rate of private and public investment in medical and dental care. Further, as the dentist-to-population ratio increases with the graduation of more dentists, it is obvious that there will be considerable economic pressure on dental practitioners. Within this period of constrained resources, a new administration that advocates greater competition and less regulation in the marketplace for health services is in Washington. To date, this ideology has been expressedin the dismantling of severalfederal agencies previously involved in regulating the health care system. Legislation to promote greater competition in the delivery of health care can be expected in the next few years, To a large extent, the specialty of prosthodonticshas not beeninfluenced by past changesin national health policies. Most government health insurance programs do not cover the more advancedand expensiveprosthodontic services,and asprofessionalsin a predominantly non-hospital-based discipline, private practitioners of prosthodonticsdo not comeunder the purview of most public regulatory agencies. This era may also be coming to an end. Indications are that some of the proposed modifications in the financing and organization of the health care system presently being consideredby the Reagan administration could affect the practice of prosthodontics.

Presented at the American College of Prosthodontics, St. Louis, MO. *Professor and Head, Department of Behavioral Sciences and Ckxmm.mity Health. **.lssociate Professor, Department of Restorative Dentistry

0022.1013,

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1975

Fig. 1. National health expenditures: total and percent of grossn,ational product, 1960-1.981.

The purpose of this article is to examine the procompetition policies of the federal government and to considerhow thesepolicies will influence the practice of prosthodontics. This seemsto be an especially appropriate time to look at theseissuesbecausethere is substantial evidence that, for other reasons, prosthodontics is in a period of transition. This article is organized into two major sections. The first section examines the health care delivery systemand the procompetition policies of the Reagan administration. With this introductory material as background information, the second section considers the potential effect of procompetition legislation on the practice of dentistry, with specialreference to prosthodontics. It is within this context that the future of prosthodonticsas a dental specialty is discussed. THE

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LEGEND

Private

*All h9alth 9xpmdlture4 ““.. ~~ttospltal charge4 -----Phyrlclan’4 ,999 - -‘-‘Dentle.t’a leea

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Fig. 2. National health expenditures according to type of expenditure in current dollars, U.S. fiscal years 1965-1980.

STATEMENT

OF THE PROBLEM

It will not surprise most people that the primary problem being addressedin the procompetition legislation is rising expenditures for health care and, more particularly, the large public subsidy for these expenditures. Fig. 1 showsthe percent of the grossnational product (GNP) that has beendevoted to health care for the past 20 years.’ From a 1960 baselineof 5.3%, it is now approaching 10%. Within the sametime period expenditures have gone from $25 billion to almost $300 billion, doubling about every 5 years. If present trends continue, by 1985 from $500 to $600 billion will be spent on health care in the United States. This rate of increase is not the samefor all health services; Fig. 2 demonstratesthat it is hospital costs that have increasedmost rapidly.’ Fees paid to physicians have increasedmuch lessrapidly and dental fees have risen less than the consumer price index. Although the general public may not believe it, dental feesare actually lower now in noninflated dollars than they were in 1967. Fig. 3 indicates the sources of funds for health services.2 In 1965 public sector contributions began a rapid increase with the start of Medicare and Medicaid, so that now they constitute 40% of all expenditures. Specifically, 56% of hospital and nursing home costs are paid for with public funds.’

256

Fig. 3. Percent distribution of health care expenditures by source of funds. In contrast, public funds pay for only 5% of dental care expenditures, primarily in the Medicaid program. What do all thesefigures mean?First, it is clear that health care is consumingan ever larger percent of our total national income and there does not appear to be any end in sight. While there is nothing inherently wrong with spending 10% of the GNP on health, this nation hasmany other priorities besideshealth, suchas a strong military and the control of crime. These legitimate needswill not be met if more and more funds go into health care. Another problem with increasing health expenditures is that there is little direct evidencethat the nation is becoming healthier as a result of these allocations. Further, other countries with similar populations spend much less of their national income for health care and appear to be equally healthy. An example is Canada, which spendsonly 7% of its GNP on health care.3Thus, the question arises,Are we gaining better health with more outlays for health care? If we are not getting healthier, can we afford to spend so much money in this one area? Finally, should the government be responsiblefor 40% of the health care bill? While the public contribution has remained at the 40% level for the past 5 years, the absolute dollar amount has been increasing. Certainly any serious attempt to reduce federal and state expenditures will require reducing Medicaid and Medicare expenditures. With the election of President Reagan and many

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new fiscally conservative congressmen, a new perspective has been brought to the problem of health care costs. The general position of the Reagan administration is antiregulatory and procompetition; it is these procompetition policies that we will examine next. PROCOMPETITION

HEALTH

POLICIES

The Reagan administration has no clearly defined public position on health care. That is, the administration has not formally introduced legislation to deal with the problem of controlling expenditures. However, several key members of the Reagan administration, namely David Stockman, Director of the Office of Management and Budget, and several leading Republican congressmen, have submitted procompetition health legislation that represents the general philosophy of the new administration. The procompetition position has been presented in an interesting book entitled Health Plan by a leading conservative economist from Stanford University, Alain Enthoven.4 It is important to first understand Enthoven’s explanation for the reasonswhy health care expenditures are out of control.

Causes of increased

spending

Enthoven claims that the fee-for-service method of paying doctors rewards the provision of more services and more expensive servicesbut doesnot assigndoctors any economic responsibility for the consequencesof their decisions. Likewise, hospitals are paid on the basis of their costs so that higher costslead to more revenue. This means that doctors and patients who make the decision to use hospitals and other services have no reason to be cost consciousbecausethe bill is paid by insurance companiesor government agencies. Enthoven4 goeson to note that other factors have reinforced the insured fee-for-service system.Tax laws have put the control of employeehealth insurance into the handsof employers by making employer contributions to health insurance tax free. Becauseemployee health benefits are not taxed, the indirect government subsidy to the private sector delivery system last year was about $25 billion. A related problem is that employeesare either forced to accept the one health plan negotiated by their employers or, if more than one plan is available to them, they have no financial incentive to pick the less expensive plan. Becausethe employer usually pays the full premium for either plan, the employee naturally tends to select the more expensive plan. Enthoven4 argues that the only realistic option for dealing with this incentive system,which fostersgreat-

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er expenditures, “is to create a system of fair economic competition among alternative financing and delivery systems in which the successful ones will be those that produce the best value for consumers, including the control of costs.“’ Enthoven suggests further that more competition is most in keeping with the traditions and institutions of the American people - . and. therefore, is most likely to succeed. In the next sectionthe basicfeatures of the Enthoven proposal, the Consumer Choice Health Plan (CCHP), will be presented. The plan restructures the health care system in the United States to make it more competitive.

Consumer

Clmoice Health

Plan

Rather than discussconfusing detail, only the major features of the CCHP will be considered. 1. Health insurance would be independent of job status. Everyone, whether employed or not, would be covered by the health plan. 2. Tax incentives would be provided to encourage the health care system to be made up predominantly, but not exclusively, of physicians and dentists organized into competitive groups. In this systemphysicians would accept responsibility for providing comprehensive health care serviceslargely on a capitation basis, which would put them at financial risk. 3. The present tax subsidy for health insurance would be replaced by refundable tax credit equal to 60% of the health care costsof an average family ( of certain age and size). A tax credit is a flat amount subtracted from the family’s tax liability that is refunded. This means that if a family chose a less expensive plan they would receive a cashrefund at the end of the year. If, on the other hand, they chosea more expensive plan that exceededthe tax credit, they would have to pay for it with after-tax dollars. Finally, all people would have to join somehealth plan to receive the tax credit. The poor and elderly would receive a government-supported voucher to enable them to purchasea health plan. 4. Individuals and families would be able to choose from amongthree or more competing health plans. All plans would be required to offer at least a basic set of health services that would be determined by the government. Dentistry would probably not be included in the basic set of services. Of course the more expensive plans would offer more extensive benefits and might incmde dentistry. However, the more expensive plans would be paid for, in part, with outof-pocket, after-tax dollars. The cost of this plan would initially be the sameas

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that of the existing system, although more would come from government. Over time, however, the rate of increase in health care expenditures is expected to decline dramatically. Further, Enthoven stresses that the “CCHP would make the government’s contribution to personal health services a ‘controllable” expenditure that could be set at a level in balance with other priorities, instead of today’s open commitment. . . .“4 With respect to acceptance by the medical and dental professions, Enthoven4 states that “the medical profession is going to have to live by the rules of competition accepted by American business in general.” The next issue is, What could the CCHP mean to dentistry? This is somewhat difficult to predict without having the full details on the specific plan that may be enacted; nevertheless, some speculations are possible.

Implications

of CCHP for dentistry

There are several potential effects of the CCHP on the practice of dentistry. First, if the minimal set of services required for all health plans excluded dental care, it is very likely that families would have to buy dental insurance with after-tax dollars. While it is impossible to estimate what percent of families would choose dental insurance under these circumstances, there is little question that the present growth rate of dental insurance would decline. The loss of revenue to dental practices would be substantial. Dental insurance now pays for 25% to 30% of all dental care, some $6 billion annually. As an estimate, perhaps $3 to $4 billion and possibly more would be lost to the dental care system. Second, if dentists had to form competing groups to survive economically and were at financial risk to provide care for a fixed amount of money under a capitation system, there would likely be a marked decrease in the use of expensive elective services. This means that utilization of prosthodontics, periodontal surgery, and some types of endodontic and oral surgical services could be expected to decline. As such, the need for specialists would be reduced. By the same token, general dentists who are competent to handle a broad range of services such as advanced periodontics, prosthetics, and endodontics would be in demand. Third, the quality of dental care might be reduced. In an effort to become more competitive financially, dental groups would be likely to spend less time with patients, to offer fewer elective and expensive services, and to see patients less frequently. These behaviors should theoretically be counterbalanced by the need for dental groups to keep their patients satisfied so that

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they would continue to enroll in the group. The key then would be in convincing patients that they are receiving adequate care. Before the effects of procompetition policies on prosthodontics are discussed in greater detail, the political future of this legislation should be considered.

Political

feasibility

There is major opposition to the CCHP by several powerful organizations: the American Dental Association (ADA), the American Medical Association, and the American Hospital Association. Organized labor is also against the Enthoven plan. On the opposite side are equally powerful advocates, including the business community, the proprietary hospital industry, and, most of all, several well-known conservative politicians, including the Secretary of Health and Human Services, Richard Schweiker. Thus, the opposing forces are formidable and a major political battle can be predicted if the Reagan administration goes ahead with the CCHP.S The arguments against the CCHP mainly concern the fact that the health care industry has had little experience with the type of competitive health care system just described.6 It is not clear that it would reduce expenditures and at the same time maintain an acceptable level of quality. Further, there are serious doubts about the willingness of physicians and dentists to form competing groups, or of the willingness of patients to accept care in a predominantly capitation health system. Other critics note that the restructuring of the health care system required by the CCHP would be massive, leading to the development of as many federal regulations and as large a bureaucracy as the administration claims it is trying to eliminate.6 The best information we are able to obtain is that the administration will not submit procompetition health legislation to Congress during the next 12 months. However, consideration is being given to one part of the CCHP, that of putting a cap on the amount of money that can be spent on health insurance premiums without taxation. As previously noted, this could have a substantial financial impact on dentistry. Certainly it must also be concluded that even without new legislation the present emphasis on competition within dentistry will be encouraged by the Reagan administration. This means that advertising, the development of capitation dental plans, retail dentistry, industrial-based dental clinics, and other alternate delivery systems will continue to expand.

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The final section of this article will consider the future of prosthodontics in the context of increased competition. PROSTHODONTICS Prosthodontics, one of the oldest specialties of dentistry, has several serious problems. As stated by Sharry,’ one of the outstanding prosthodontic educators of this century: “Prosthetic dentistry is facing a turmoil which is unprecedented in its history.” From a review of the prosthodontic literature and a discussion of these issues with many professional colleagues, there appears to be four related problems that should be overcome if prosthodontics is to grow and prosper. These problems are briefly discussed and placed in the context of the procompetition environment of dental practice that is likely to predominate for at least the next several years.

Issues 1. Prosthodontic graduate programs are unable to attract a large number of well-qualified students. According to a 1976 survey of graduate programs, almost 40% of prosthodontic positions could not be filled.” Further, many trainees are dentists from the Veterans Administration (VA) or armed services. Evidently dental graduates do not consider prosthodontics an attractive career when they have to invest their own funds to pay tuition and to support themselves for 2 years. 2. The general population does not seem to be as aware of the specialty of prosthodontics as it is of oral surgery or orthodontics. This recognition is important since it relates to the frequency of self-referrals for care and the willingness to pay the higher fees associated with specialty care. 3. Related to patient acceptance of prosthodontics as a specialty, insurance carriers do not recognize the special expertise of Board-eligible or qualified prosthodontists and pay them the same fees as general dental practitioners.* In part this results from the method of determining fees under the Usual, Customary and Reasonable (UCR) payment system. For a particular service, fees are determined from the distribution of fees (up to the ninetieth percentile) submitted by all dentists. Claims in services such as periodontal surgery or orthodontics are submitted mainly by specialists, so that fee levels are high. In contrast, the majority of claims for dentures or crowns are sent in by general *Ihvnes.

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practitioners, keeping prosthodontists’ fees artificially constrained by the ninetieth percentile rule. 4. General dentists who do not have advanced prosthodontic training provide many of the sameprosthetic services ;as prosthodontists and seldom refer patients to prosthodontists.* All these problems are probably interrelated. That is, the primary :reasonthat more dental graduates are not attracted to a career in prosthodonticsmay be the relatively poor return on the cost of their specialty education. A 1971 ADA survey showed that prosthodontists have one of the lowest incomes of dental specialistsand learn only marginally higher incomes than the average general dentist.’ The main reason that prosthodontists’ incomes are not higher is clue to the competition from general dentists who provide the same types of services. Any differencesin thme quality of servicesoffered by prosthodontistsare apparently not recognizedby patients, and this keeps prosthodontists’ fees relatively low. It is difficult to seeany solution to this problem that does not involve clea:rly establishingthe quality advantages of receiving care from a prosthodontist. Unfortunately it is difficult to be optimistic. The competition from general dentistsis likely to increaseas dental incomescontinue to decline in terms of noninflated dollars, as they have for the past several years. Fewer dentists will be willing to refer patients to prosthodontistsbecauseit would mean further lossesto their income. Competition from general dentistswill also increase with the growing numbersof dental graduateswho are taking 1- or 2-year general dentistry residencies.These dentists will be better prepared to treat more complex prosthodontic patients. At present 20%to 30%of dental graduates enroll in general residency training and the percent can be expected to increasesubstantially in the next 5 years.“’ Another negative factor for prosthodontists is the growth of capitation programs. Even without the implementation of the CCHP, the number of dental capitation programs is starting to increaserapidly. In states such as Michigan and Wisconsin with large numbersof United Auto Workers members,capitation programs are the fastestgrowing segmentof the dental care delivery system. In capitation programsa primary way of controlling costs is reducing the utilization of expensive elective prosthodontic services.This means that as capitation programs becomemore common, the utilization of the more complex prosthetic servicesmay decrease.Like-

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wise, to minimize operating costs, the prosthetic services that are received will tend to be provided by general dentists rather than by prosthodontists. Thus it seems clear that capitation dental programs will not advance the specialty of prosthodontics. While the future of prosthodontics may not seem promising, positive measures that may improve the situation can be taken. This article concludes with a brief discussion of some of the more important options. POTENTIAL

SOLUTIONS

The basic problem is establishing the recognition of the superior ability of formally trained prosthodontists to treat patients requiring complex reconstructive procedures. With this recognition by general dentists, the public, and insurance carriers, prosthodontic fees will increase, making it a more attractive specialty to dental graduates. Several long- and short-term approaches to achieving this objective would include the following.

Long-term

solutions

Research. The basic reason for specialties within dentistry (or medicine) is that the body of knowledge and skills associated with the treatment of a particular part of the body cannot be, or are not, mastered in the 4 years of undergraduate dental education. A comparison of undergraduate and graduate curricula in prosthetics suggests that the basic biologic and physical science knowledge that underlies the practice of prosthodontics is taught in the 4 years of dental school and that undergraduate students are at least introduced to most prosthetic procedures. What most dental students lack at graduation are the advanced clinical skills and experience to effectively apply this basic knowledge to the treatment of patients. But, for the motivated dentist these skills can be acquired in time, and some dentists who have not had graduate training in prosthodontics become proficient in this discipline of practice. Further, once in practice perhaps all general dentists improve their prosthetic skills, providing real competition to Board-eligible or qualified prosthodontists. There are two obvious long-term solutions to this problem. The first, which we believe is unacceptable, is to reduce the time spent in prosthodontics during the 4 years of dental school so that dental graduates would not be prepared to deal with any but the most elementary prosthetic procedures. An example of this strategy is seen in orthodontics; little basic information on the science and techniques of orthodontics is offered

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in most dental schools.* As a result, few general dentists provide orthodontic services and, in turn, compete with orthodontists. A more acceptable solution is to make major advancements in the basic and clinical sciences related to prosthodontics so that only dentists with advanced formal training in prosthodontics would be eligible to undertake certain complicated procedures. This strategy will not be successful without some restructuring of departments of prosthodontics. That is, much greater effort must be made to involve prosthodontic faculty in fundamental research related to the practice of their discipline. Most prosthodontic departments are not noted for their research efforts, and the research that is being done relates mainly to dental materials. While this work in the materials sciences should be encouraged, greater emphasis should be placed on biologic research. Major breakthroughs that will eventually have a significant influence on the practice of dentistry are taking place in biology. Prosthodontics needs to participate in this research and create a body of advanced scientific knowledge unique to this subdiscipline of dentistry. Combining the specialties of prosthodontics, periodontics, and endodontics. Another long-term strategy involves merging prosthodontics, periodontics, and endodontics into one specialty. It is becoming apparent that periodontists and endodontists are beginning to have some of the same problems as prosthodontists. As more dentists graduate from dental school with better training in periodontics and endodontics and as more of these graduates take advanced training in general dentistry, the competition between periodontists and endodontists and general dentists is likely to increase. Although it is bound to be controversial, perhaps it is time to take a hard look at the present structure of specialty programs in dentistry. There is a growing concern that dentistry is fragmented into too many small specialty groups. We believe that a strong case can be made for combining advanced training in periodontics, endodontics, and prosthodontics. With a merger of the three disciplines a more rational organization of patient care might result and a unique body of specialty-level knowledge and skills could be defined. These two long-term strategies may have little reality for the immediate problems facing prosthodon*This statement does not imply any conscious attempt by the orthodontic profession not to teach orthodontics to dental students. Rather, orthodontics has always been a graduate-level program.

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tics. Further, they are certain to raise major opposition both from within prosthodontics and from other dentists. Still, we believe that they may offer the best hope for the prosthodontic profession and should receive seriousconsiderationby the leadersand membersof the recognized prosthodontic organizations. Short-term

solutions

The short-term solution offered relates to establishing that Board-qualified and eligible prosthodontists provide superior quality prosthodontic treatment compared to nonspecialists. Three options have been identified for gaining public recognition of the expertise acquired in prosthodontic specialty educations. 1. Prosthodontics should become the first dental specialty to develop a national standard examination for dentists completing their graduate program in prosthodontics.This examination should be a rigorous test of knowledge and skill that clearly establishesthe clinical competenceof dentistscompleting an advanced prosthodontic program. While all prosthodontic programs are accredited through a formal review system, there may still be considerable unevenness in the quality of different programs. The national examination should serveto improve the weaker programs, and it will allow the leadersof the professionto emphasize the importance of the biologic and clinical sciencesin the training of prosthodontists. A precedent for the strategy is seenin several medical specialties,such as orthopedic surgery and family practice.* 2. Prosthodontics should become the first dental specialty to develop a national standard examination for recertification as a Board-qualified prosthodontist. This examination, both didactic and clinical, might be given every 5 to 7 years. Several specialtiesof medicine have establishedsuch an examination, indicating their commitment to excellence in clinical care.* 3. Research should be conducted to investigate the variation in quality of care among prosthodontistsand general dentists.If the care provided by prosthodontists is clearly superior, it must be documented.Further, the implications of any quality difference to oral health and dental expenditures need to be examined. Unless prosthodontists can show that their care results in a more efficient use of dental care dollars, that is, more oral health is produced for the dollars

spent, it will be difficult to demand higher feeson the basisof superior quality. CONCLUSIONS It is clear that the 1980swill be a period of change for the health professions.The rapid expansion in the demand for services that accompaniedthe growth of public and private health insurance in the 1960s and 1970smay soonbe coming to an end. In addition to the relative decline in resourcescommitted to health care, medical and dental practitioners are faced with the competition of large numbers of new graduates. A further complicating factor in this changing health care sceneis a palitically conservativeadministration in Washington that intends to promote more competition among health providers and institutions. It is within this environment that the specialty of prosthodontics must deal with its immediate problem of increased competition from general dentists. A critical challenge for individuals or organizations is knowing when circumstancesrequire that they take the initiative and move in new directions. The leaders of prosthodonticsare now faced with such a challenge. The fundamental problem is defining a unique body of clinical knowledge, both at the basic science and technical levels, that provides prosthodontists professional and societalrecognition for their specialqualifications. In the long run this unique body of knowledge can only come from basic and applied research. It is apparent that departments of prosthodontics must assumerespons:lbility for this research, and graduate studentsin prosthodonticsneed to receive their education in research-oriented clinical programs. These students repre:sent the future leadership of the profession. In the short term some steps can be t.aken to give prosthodontistsgreater visibility for their expertise, but whether or not these steps will have any significant effect is not clear. What is clear is that maintaining the status quo offers little promise. As Sharryâ&#x20AC;&#x2122; said in 1977: â&#x20AC;&#x153;So, there are problems, and there are constant and serious attempts to solve them. My worry is that the pace of work may not match the urgency of the need.â&#x20AC;? REFERENCES 1.

2. *American 19Al.

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Ibard

of Medical

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Specialties:

Personal

DENTISTRY

communication,

Freeland, Ll. S., and Schendler, C, E. Kauonal health expenditures: Short-term outlook and Ion!;-:rrm projections. Health Care Financ Rev 2:97, 198 1. Freeland. hl , Calat, G., and Schendkr, C. E. Prelections of national health expenditures, 19890, 1985 snd 1990. Health Care Financ Rev l:l, 1980.

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4. 5. 6.

Donabedian, A., Axelrod, S. J., and Wyszewianski, L.: Medical Care Chartbook, ed 7. Ann Arbor, Mich., 1980, Health Administration Press. Enthoven, A.: Health Plan. Reading Mass., 1980, AddisonWesley Publishing Co. Inglehart, J. K.: Special report: Drawing the lines for the debate on competition. N Engl J Med 305~291, 1981. Brown, L. D.: Competition and health cost containment: Cautions and conjectures. Milbank Mem Fund Q 59~145, 1981. Sharry, J. J.: The need for reappraisal in prosthodontics. J PROSTHET DENT 37~83, 1977.

8. 9. 10.

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Brewer, A. A.: Recruiting students for advanced education programs in prosthodontics. J PROSTHET DENT 35:43, 1976. Annual Survey of Dental Education Institutions. J Am Dent Assoc 88:931, 1974. Advanced Dental Education: Recommendations for the â&#x20AC;&#x2122;80s. Chicago, 1980, American Association of Dental Schools.

Rtymnt requests to: DR. HOWARD L. BAILIT DEPARTMENT OF BEHAVIORAL UNIVERSITY OF CONNECTICUT FARMINGTON, CT 06032

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SCIENCES AND COMMUNITY HEALTH CENTER

1983

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NUMBER

REMOVABLE LOUIS

PROSTHODONTICS

BLATTERFEIN,

The future

ROBERT

M. MORROW,

of complete

Dayton D. Krajicek, D.D.S.* Veterans Administration Hospital,

S. HOWARD

PAYNE,

Section editors

prdmdmtics

Kerrville,

Texas

rosthodontics is that branch of dentistry which is concerned with the diagnosis, planning, fabrication, and placement of artificial devices to replace one or more teeth and associated tissues. Prosthodontics may be divided into four sections: complete, removable partial, fixed partial, and maxillofacial prostheses. The first three always include the replacement of missing teeth; maxillofacial prosthesis may or may not include this phase of treatment. Dentistry is a profession requiring long, continued academic preparation, special knowledge, and postacademic study. It is a calling, a strong impulse to serve people. Dentistry, like most other professions, seeks to make itself unnecessary. In pursuing this worthy goal, dentistry has embarked upon an intensive campaign of preventing disease. This is not new. Dental literature has always advocated preventive techniques.l More recent years have seen a tremendous emphasis on prevention. TOOTH

MORTALITY

In the main, tooth “mortality” arises from two almost universal diseases, dental caries and periodontal disease. Dental caries begins early in life. If left untreated, the patients become candidates for prostheses. Periodontal disease also begins early in life.2 With time and neglect, the disease progresses and loss of teeth follows. The prevention of dental caries represents dentistry’s most successful public health effort. Fluoride therapy, dietary restrictions, food supplements, and pit and fissure sealants have greatly reduced the caries attack rate. It is impossible to calculate the number of people who are benefiting from the fruits of caries prevention. The etiology of periodontal disease is baffling; factual information is meager.’ Since prevention depends, in a large measure, on home care, efforts to inspire this type of prevention on a mass scale have been unsuccessful.” Professional therapy awaits more precise information on the nature of periodontal disease.” As more Read

before

*Director.

126

the American

Prosthodontic

Society,

Las Vegas,

NW.

VoIume Number

Table

37 â&#x20AC;&#x2DC;2

The

I. Edentulous

future

complete

prosthodontics

127

persons

Year

Populalion

No. of edentulow persons

Per cent

1957-58 1971 1975

173,619,OOO 202,360,OOO 211.925.000

21,900,OOO 22,600,OOo 24,200,OOO

12.6 11.2 11.4

teeth are spared from dental caries, we may anticipate that they will become victims of periodontal disease. Prevent+ of tooth-destroying diseases would decimate prosthodontics if not relegate it to history. This would be in keeping with our professional destiny; such fancy is not immediately impending. There is little prospect that the number of patients requiring prosthodontic therapy will decline in the near future. Prevention of periodontal disease must advance to the stage of caries prevention before the need for prosthodontics declines. SOURCES

OF INFORMATION

The judgments made in this report were based on three sources of information. The Bureau of the Census, the National Center for Health Statistics of the Department of Health, Education and Welfare, and the Bureau of Economic Research and Statistics of the American Dental Association. Data were not always available for matching years. In some instances, averages provided acceptable information. In others, percentages derived from existing data provided acceptable projections, making possible the coordination of total populations, numbers of edentulous persons, numbers of people with dental prostheses, and numbers of active dentists for the appropriate years. PROJECTIONS The Bureau of the Census issues four projections of future populations based on several assumptions. The data used in this report are from the third projection was 72 (Series E) , next to the lowest projection. 4 In 1974, manâ&#x20AC;&#x2122;s life expectancy years5 Immigrants in 1974 numbered 360,000 persons, and this number is not expected to decline. 5 The 1974 fertility rate of 1.86 is the lowest in history.5 Nevertheless, the population of the United States is expected to rise at a rate of about 2,500,OOO persons per year up to 1985. For the year 2000, the estimated population is 264,430,OOO (Series E). If present conditions continue, the United States is expected to reach a population of 277,000,OOO and zero growth during the 21st century.6 The American Dental Association has also projected the number of active dentists up to the year 1985.1 Information on the projected numbers of edentulous persons for future years was unavailable from any source. The percentage of edentulous persons ranged from 12.6 in 1957-58 to 11.2 in 1971 to 11.4 for 1975.7, 8 The mean for these 18 years was 11.7 per cent (Table I). This report arbitrarily placed future

128

.I. Prosthet. Februaly.

Krajicek

Table II. Denture

wearers,

1975-estimated

population,

Dent. 1977

211,445,OOO

No.of edentulous persons

Cutegory

Complete denture Removable partial denture Fixed partial denture Complete fixed partial denture Complete removable partial denture Fixed removable partial denture Denture-wearing population Edentulous population

Table III. Edentulous

*Projected

Per cent

23,000,OOO 13,000,000 4,000,000 400,000

10.8

2,500,000 600,000 44,000,ooo 24,200,OOO

I.2 0.3 20.8 11.4,

6.3 2 0.2

persons and replacements

Year

No. of edentulow persons

1958 1971 1975 19txo* l985* 1990* 2000;

21,900,OOo 22,600,000 24,200,oOO 24,656,OOO 25,827,OOO 27,130,OOO 28.100.000

Replacement 3,056,ooo 3,164,oOo 3,388,OOO 3,452,OOO 3,716,OOO 3,798,OOO 3.934.000

at 11 per cent.

projections at 11 per cent, which represents a reasonable and conservative estimate. Reduction in percentage does not imply a reduction in numbers since projections on population growth indicate continued increases until some time in the 21st century. Therefore, the judgments presented in this report are based, in part, on existing data and projections presented by reliable agencies. The number of edentulous persons is projected on the basis of past experience of the author.

EDENTULOUS PERSONS Denture wearers include those people with fixed partial, removable partial, or complete dentures and with combinations of all three. In 1975, they numbered 44,000,OOO persons or 20.8 per cent of the population (Table II) .* This report will concentrate only on the number of edentulous persons and complete denture wearers. Past trends in the edentulous population in the United States suggest an increased need for complete dentures. The 1957-58 survey estimated the number of edentulous persons at 21,900,OOO or 12.6 per cent of the population. In 1971, the edentulous population was estimated at 22600,000 or 11.2 per cent of the populations Both the percentage and number increased in the 4 year period of 1971 to 1975 (Table I). Of the 24,200,OOO edentulous persons estimated in 1975, 1,200,OOO were without dentures.8 In 1971, l,lOO,OOO persons had no dentures. In addition, 1,700,OOO persons (8 per cent) did not use their dentures and 6,500,OOO(30 per cent) indicated a need

22T:râ&#x20AC;&#x153;2â&#x20AC;&#x2122; Table

The

IV. Population

and patient/dentist

future

of complete

prosthodontics

129

ratio No. of

Year

Pooulation

practicing dentists

1958 1971 1975 1980* 1985;

173,619,OOO 202,360,OOO 211,925,OOO 224,138,OOO 235,701,OOO

88,000 100,500 121,150 122,000 138,650

Patient/ dentist ratio 1,848 2,013 1,927 1,726 1,624

*Projected.

for new dentures.7 The three categories-those use their dentures, and those who indicated per cent of the edentulous population, or prosthodontic therapy. These figures compare complete dentures for 239 patients who had dentures at no cost. Of these patients, 29.7 poor quality and 7.7 per cent of the patients to masticate efficiently.g DENTURE

with no dentures, those who do not a need for new dentures-represent 39 9,400,OOO persons, needing complete favorably with a critical evaluation of the opportunity to replace ineffective per cent had dentures judged to be of with good-quality dentures were unable

REPLACEMENT

The useful, effective life span of complete dentures has not been established. There have been suggestions that complete dentures should be relined or remade at 5 or 6 year intervals. â&#x20AC;&#x153;3 I1 In the 1975 data, the 40 to 49 year age group presented 2,200,OOO complete denture wearers. In the 50 to 59 year age group, there were 4,400,000, and at 60 years and over, there were 11,900,000.8 Based on the life expectancy of 72 years and these data, it is projected that 3,500,OOO denture patients in addition to those who become edentulous will require denture relines or new dentures each year (Table III). The number of persons requiring replacement dentures increases the potential number of denture patients by 14 per cent. These data strongly suggest the need for a systematic recall system for complete denture patients. PROJECTED

NUMBER

OF DENTISTS

The increase in population and the vast number of persons not receiving dental treatment stimulated the effort to increase the number of practicing dentists. For the next 10 years, the number of practicing dentists will increase more rapidly than the population. Since 1956, the number of practicing dentists has been based on those younger than 68 years of age. An additional 3,500 have been placed in the category of related professions, such as administrators, teachers, and investigators, or in dental industry.4 The continued increase in the number of practicing dentists will reduce the patient/dentist ratio. Table IV lists the population, number of active dentists, and patient/dentist ratio for the United States.4 The ratio reached a peak in 1971 and then declined as the number of dentists increased.4 The projected decrease in patient/dentist ratio after 1975 is approximately 1.6 per cent per year. These promising projections augur professional dental care for more persons.

J. Prosthet. February,

130

Krajicek

Table

V. Estimated

complete

denture

patient/dentist

Year

No. of dentists

1958 1971 1975 1980 1985

88,000 100,500 121,150 122,000 138,650

Dent. 1977

ratio Potential denture

complete patients 249 259 218 197 182

It is more difficult to project the ratio of dentists to edentulous persons. The projected number of dentists includes specialists such as oral surgeons, orthodontists, periodontists, and pedodontists who do not practice complete prosthodontics. From 1958 to 1985, the number of dentists will increase by 57 per cent or 2.1 per cent per year for the 27 years. The number of denture wearers during this period will increase by 18 per cent or 0.7 per cent per year. The result will be a reduction in potential complete denture patients, resulting in a reduction in denture patient: dentist ratio of about 2.5 per cent per year (Table V) . GEOGRAPHIC

DISTRWJTION

The geographic distribution and growth trends portend further imbalance of the patient/dentist ratio. In 1974, over two thirds of the population lived in metropolitan areas. However, the largest metropolitan areas have shown the least growth since 1970.5 The central cities of metropolitan areas have actually lost population since 1970. There has been a corresponding increase in population in rural areas. The population of the United States is concentrated in the Middle Atlantic, East North Central, and South Atlantic regions. These areas constitute 17 per cent of the land mass of the United States and contain 53 per cent of the population, including 54 per cent of complete denture wearers and 53 per cent of the active dentists. However, the population is not static. The population in the southwestern states is increasing more rapidly than that in the northeastern states.4T â&#x20AC;&#x2122; The economic basis of families combined with the size of households is also a factor in contemplating the future of prosthodontics. Families averaging 2.8 persons with a yearly income of less than $15,000 represent 47 per cent of the population. They also constitute 85 per cent of the complete denture wearers. The per-capita income of persons living in areas of the greatest concentration of population and the highest percentage of complete denture wearers is 11.4 per cent higher than that of the remainder of the stateside population. Since the population is shifting toward the southwestern states and away from the northeastern states, the complete denture patient/dentist ratio should increase and decrease in these areas in similar fashion. DENTURIST

SURVEY

A 1976 survey by the Oregon Dental Association presents the opinions of dentists in a state close to the Canadian border where denturism is practiced. The questionnaire was answered by less than half of the dentists in the state, of whom 2 per cent were prosthodontists and 83 per cent general dentists. One must assume that the general dentists practiced complete denture therapy.

ypn&7

The

future

of complete

prosthodontics

131

The practice of dentistry by nondentists did not alarm the dentists, although the patient/dentist ratio in Oregon is 23 per cent below the national average. While the dentists thought their practices had not suffered and would not suffer, they considered denturism a threat to oral health. Almost half of the respondents (49 per cent) reported that the number of patients receiving removable prosthodontic therapy was decreasing. No explanation for the decrease was sought in the survey. The decrease in the number of patients requiring removable prostheses is in keeping with the trend suggested by the projected data on the general population, population of dentists, and number of edentulous persons. It is obvious that as the patient/dentist ratio decreases, the need for nonprofessional personnel to engage in dental practice should also decrease.

DISCUSSION AND CONCLUSIONS The dental profession cannot find joy in the prospect of continuing mortality of teeth. Nevertheless, the exigencies of health care demand prostheses to maintain good health and happiness. Prosthodontics has provided successful function and emotional well-being to millions of people. Projections of population, numbers of dentists, and edentulous persons must be taken with circumspection. Untoward and unforseen factors may alter the anticipated relationships. Nevertheless, projections indicate a trend. It is in this sense that the conclusions are drawn. The projections reported in this article counsel continued prosthodontic therapy. Until the rate of tooth mortality radically declines, the need to maintain and even promote a superior service manifests professional integrity. With 38 per cent of the complete denture-wearing public expressing dissatisfaction, the answer lies in research to improve both the useful life span and the function of dentures. This can come only from those persons who have undertaken the continued academic preparation, have special knowledge, and have the professional outlook of dentists. In addition, practicing dentists have the training and ability to understand and interpret contributions to research. To relegate the professional obligations to less trained and less competent dental ltboratory technicians holds promise of reducing the quality of oral health care for edentulous patients and increasing the percentage of dissatisfied patients. The shift in population from large metropolitan to rural areas and from the Northeast to the Southwest may cause further disruption in local areas and in patient/dentist ratios. Patients, especially retirees, face few problems in moving. Dentists face many. The individual state Board requirements confine dentists to states where they are licensed. There will be a need for reciprocity to maintain a healthy patient/dentist ratio. Prosthodontics has a promising future. This highly successful therapy will continue to serve the public with functional substitutes for missing dental organs. With continued research, prosthodontics will improve its service and look to the future with pride.

I thank M. Cristol of the Bureau of Economic providing information used in this report.

Research

and

Statistics

of the

ADA

for

132

J. Prosthet. February.

Krajicek

Dent. 1977

References 1. Hunter, J.: The Natural History of the Human Teeth, London, 1778, Printed for J. Johnson, p. 124. 2. Taichman, N. S.: Some Perspectives on the Pathogenesis of Periodontal Disease, J. Periodontol. 45: 361-363, 1974. 3. Greene, J. C.: The Ease for Preventive Periodontics, J. Dent. Child. 42: 24-27, 1975. 4. Bureau of Economic Research and Statistics, ADA: Growth in Population and Number of Dentists to 1985, J. Am. Dent. Assoc. 87: 901-903, 1973. 5. World Almanac, New York, 1976, Newspaper Enterprise Association, Inc. 6. Statistical Abstracts of the United States, United States Department of Commerce, Social and Economic Statistics Administration, Bureau of the Census, Washington, D. C., 1974. 7. Edentulous Persons Publication M. (HRA) 74-1516, United States Department of Health, Education and Welfare, National Center for Health Statistics, Rockville, Md., 1974. 8. Bureau of Economic Research and Statistics, ADA: Survey of Denture Wearers, 1976. 9. Yoshizumi, D. T.: An Evaluation of Factors Pertinent to the Success of Complete Denture Service, J. PROSTHET. DENT. 14: 866-878, 1964. 10. Craddock, F. W.: Prosthetic Dentistry, ed. 3, London, 1956, Henry Kimpton, p. 411. Il. Schlosser, R. 0.: Complete Denture Prosthesis, Philadelphia, 1940, W. B. Saunders Company, p. 290. VETERANS

ADMINISTRATION

KERRVILLE,

TEXAS

HOSPITAL

78028

IADR A new

RTV silphenylene

PROSTHODONTIC maxillofacial

D. H.

Lewis, D. R. Cowsar, Institute, Birmingham, Ala.

A. C. Tanquary,

ABSTRACT

prosthetic

material

and

R. Tarwater.

Southern

Research

An improved elastomer with an optimum balance of mechanical properties, processability, environmental stability, colorability, and esthetics, for use in fabricating extraoral maxillofacial prostheses, was sought. An arylene silicone polymer, polytetramethylsilphenylenesiloxanedimethylsiloxane, was synthesized and formulated as a pourable, viscous, room-temperature-vulcanizing liquid. Silphenylene polymers are colorless and will accept either intrinsic or extrinsic coloration. When mixed with conventional catalysts, the silphenylene vulcanizates can be easily and reliably cast in closed dental stone molds to give prostheses that are strong and tough yet soft and pliable. Typical values for tensile strength, elongation at break, modulus at 100% elongation, and hardness are, respectively, 1400 psi, 1000 psi, 50 psi, and 35 (Shore A). Since the arylene linkages in the silphenylene polymers impart unusually high values of surface energy to these silicone elastomers, they have an excellent tactual as well as visual resemblance to skin, and they adhere well to tapes and adhesives. A preclinical toxicologic evaluation has been completed, and the materials are currently undergoing clinical evaluation. This

study

was supported

Reprinted from the editor, and the American

Journal Dental

by NIH-NIDR

of Dental Association

Contract Research (copyright

No. NOI-DE-42435. with permission holder).

of the

author,

the

Expanded-duty

dental

auxiliaries

and

prosthodontics

of the future William

A. Welker, D.D.S., M.S.D.*

USAF Medical

Center,

Wright-Patterson

AFB, Ohio

lhe Journal of the American Dental Association indicates that, by use of the expanded-duty dental auxiliary (EDDA), the dentist can reduce the number of hours he works and can still increase the number of patients seen in his office.= Furthermore, he can increase the number of restorations placed, as well as the secondary preventive services he provides to his patients. With proper utilization of EDDAs, all of this can be accomplished with better utilization of operating expenses and without any significant reduction in the quality of treatment provided to the patient. With that in mind, this article will outline how the EDDA program functions in the United States Air Force dental service.

REQUIREMENTS First of all, to be considered for the Air Force expanded-duty dental auxiliary program, candidates must be high school graduates and must score in the top 20 per cent on their entrance aptitude test. Second, they must be experienced chair-side assistants or dental hygiene technicians. Third, they must be on their second or subsequent enlistment and serving in a grade of from E-4 to E-9. Fourth, they must have obtained a grade of 14 or higher on the chalk carving test (20 is the maximum possible score). Fifth, high school or college credits in general science, biology, anatomy, and chemistry are desired, but not mandatory. Sixth, they must be honest, dependable, and of good moral character. Each application is screened by the director of base dental services, by the command dental surgeon, and at the military where the final determination as to selection or rejecpersonnel center HQ/USAF, tion is made.

THE COURSE It is a 26 week course and includes instruction in ( 1) oral anatomy and physiology, (2) head and neck anatomy, (3) oral pathology, (4) fundamentals of microbiolThe views expressed herein are those of the author and do not necessarily the United States Air Force or the Department of Defense. Read before the Carl 0. Boucher *Colonel, USAF (DC). 348

Prosthodontic

Conference,

Columbus,

Ohio.

reflect

those of

ghm&

“3”

Expanded-duty

auxiliaries

for

the future

349

ogy, (5) dental medicines, (6) four-handed dentistry, (7) placing, carving, and finishing both temporary and permanent restorations, (8) making impressions for diagnostic casts, (9) placing temporary crowns and temporary fixed partial dentures, ( 10) irrigating and medicating root canals, (11) placing and removing periodontal dressings, ( 12) removing sutures, and ( 13) desensitizing teeth. The course is divided into two parts. Phase I is taught at the School of Health Care Sciences, Sheppard AFB, Texas. Phase II is conducted at the Dental Clinic, USAF Hospital, Sheppard AFB, Texas. Phase I is given over an 18 week period and consists of 708 hours of technical training in the subjects listed above; 148 of these hours are didactic or classroom oriented, while 560 hours involve laboratory work or student participation. Phase II is conducted for 8 weeks and is a clinical preceptorship, with 232 hours spent in restorative dentistry and 80 hours divided among the dental specialties. The time spent in each of the specialties varies depending upon the patient load and the nature of the treatments required by those patients. The student performs reversible procedures of treatment under clinical conditions along side base dentists, although his supervision is maintained by the staff of the School of Health Care Sciences.

UTILIZATION Upon successful completion of the course, the EDDAs are assigned to Air Force dental clinics. To date, there are approximately 57 EDDAs at 18 Air Force dental clinics in the United States. In those clinics, they work under the direct supervision of a dentist at all times. Since July, 1974, we have had an EDDA assigned to the Department of Prosthodontics at Wright-Patterson USAF Medical Center. He has practiced under the direct supervision of Dr. Donald Kramer and myself, both of whom are Diplomates of the American Board of Prosthodontics. When he was assigned, we assumed .he knew nothing of the practice of prosthodontics (which of course was not true) and gave him instruction in all of the procedures he was to perform. That instruction was conducted in the following manner: (1) we discussed the procedure and slides were shown; (2) he observed the procedure in our office at least three times; (3) he performed the procedure in his oflice with one or both of us present for assistance and instruction; and (4) when he had become proficient in the procedure, we were present in the clinic only to check certain steps and the final product. He now accomplishes the following procedures for us: makes impressions for diagnostic (study) casts; mounts those casts on an articulator; screens patients with broken prostheses and other prosthodontic “troubles” to insure that the correct records and forms are present before we examine the patient; polishes rest preparations and teeth for final impressions of removable partial dentures; and cements temporary crowns and temporary fixed partial dentures.

DISCUSSION Information collected by the United States Public Health Service and published in the Journal of the American Dental Association tells us that, by the end of 1972, some expanded functions had been authorized for dental auxiliaries in 32 states. The

350

Welker

J. Prosthet. Dent. March. 1976

extent of such authorization varied from minimal functions to comparatively extensive procedures. Ten additional states have passed legislation authorizing expanded functions, but the dental boards in those states have not issued the necessary rules and regulations to implement this legislation.* Thus, it would seem that it is no longer a matter of whether or not we will have EDDA utilization, To a great extent, we already have it. It now becomes a matter of proper implementation. Although many states have modified their dental practice acts to permit expansion of auxiliary duties, there are relatively few auxiliaries qualified to perform those duties. There are some 24,000 certified dental assistants and 16,000 hygienists in this country. The total number of practicing dentists is around 100,000. Even if all 40,000 of the auxiliaries were trained expanded-duty assistants, some dentists could not employ one. A recent editorial stated, “It is doubtful that the majority of dentists are currently well prepared technically or psychologically to utilize a well-trained auxiliary to the maximum extent allowable by the more liberal dental practice acts.“3 No doubt a skilled EDDA under the supervision of a dentist may work more efficiently than the dentist who works alone. However, we must never lose sight of the fact that the most significant consideration in the utilization of EDDAs is quality service and treatment for our patients. Thus, we must insure that auxiliaries do not provide unacceptable dental treatment because of poor training or supervision.

GUIDELINES FOR USING EXPANDED-DUTY AUXILIARIES The following guidelines should be incorporated into successful utilization of EDDAs. 1. Careful selection of personnel, both those to receive training as EDDAs and those who are to be their instructors. 2. Extensive, concentrated training by qualified instructors in an academic setting. 3. After graduation, utilization of auxiliaries under the direct supervision of dentists who are fully qualified in the disciplines they are supervising. (Above all, the supervising dentist must possess technical excellence in that discipline.) 4. Establishment of a continuing education program for the EDDAs by the American Dental Association at some level-local, state, national, or a combination of the three. The dental community of the future will make extensive use of expanded-duty dental auxiliaries, but we should approach that future with careful reflection upon what has happened in the past. We should assess critically the way we have utilized the dental laboratory technician, considering the reasons for the development of such terms as: bootleg dentistry, denture clinic, the denturist, the denturist society, and the illegal practitioner of dentistry. We surely do not want to open Pandora’s box for the rest of our dental auxiliaries.

CONCLUDING COMMENTS Let us reflect for a moment. Is the use of any dental auxiliary, including the expanded-duty dental assistant, a right granted to the dentist upon graduation or successful completion of a state board examination or is it a privilege to be earned? It makes little difference which it is as long as we, as doctors, accept the responsibilities that go with the use of auxiliaries. They include the proper training, super-

Volume 35 Number 3

Expanded-duty

auxiliaries

for

the

future 351

vision,and

utilization of auxiliaries. Only if we accept and execute these responsibilities can we fulfill our most important duty, the proper care of all our patients at all times. At present, I do not think the most important issue is whether or not we believe in the use of expanded-duty dental assistants. Rather, it is that we show an active interest in the matter of their utilization by the profession, for the greatest danger in the use of dental auxiliaries is apathy toward their performance of duties. Regardless of your stand on the EDDA issue, become involved in the making of policy that will determine their utilization. By your involvement, you invest in the future of our profession and help determine the way prosthodontics will be practiced in that future. References in 1. Redig, D., Snyder, M., Nevitt, G., and Tocchini, J.: Expanded Duty Dental Auxiliaries Four Private Dental Offices: The First Yearâ&#x20AC;&#x2122;s Experience, J. Am. Dent. Assoc. 88: 969-984, 1974. 2. News of Dentistry: Public Health: Expanded Functions Summarized by State, J. Am. Dent. Assoc. 88: 310-311, 1974. 3. Butts, H. C., Editorial: Expanding Auxiliary Duties: Proceed Cautiously, J. Am. Dent. Assoc. 89: 751-752, 1974. 4053 FOREST RIDGE BLVD. OHIO 45424

DAYTON,

ARTICLES TO APPEAR IN FUTURE ISSUES Curriculum

curtailment

John J. Sharry,

in prosthodontic

The measurement of personality tion with complete dentures Mary

Smith,

B.D.S., L.D.S.R.C.S.,

Accuracy of six elastic partial dentures Jean-Pierre D.h.c.

education

D.M.D.

Stauffer,

D.M.D.,

traits and their relation

to patient

satisfac-

MS.

impression Jean-Marc

materials Meyer,

used for complete-arch D.S.C.,

and Jean-Noel

Nally,

fixed D.M.D.,

Prosthodontics-Past, W. 6. love, D.&D., University

present,

and

future

M.Sc.*

Manitoba,

Faculty

Dentistry,

Winnipeg,

Manitoba,

Canada

lhe practice of prosthodontics is a challenging endeavor. It requires a broad background of information, knowledge, and skill to carry out successfultreatment. It is through training and education that a practitioner’s abilities are developed. Included are predental programs and the undergraduate (doctoral) courseleading to a D.M.D. or D.D.S. degree, graduate or postgraduate (postdoctoral) programs, and finally continuing education programs. These programs teach the application of prosthodontic treatment principles. They involve much exposure to didactic information and also allow time to acquire a background of clinical experience. PRESENTSITUATION Unfortunate alterations have been made and are being made in many university curricula. The results of these actions are twofold--less time is available to impart didactic information and even lesstime remains to develop the necessary clinical skills to practice prosthodontics. Consequently, the quality of training becomesquestionable and high standards are not easily maintained. New teaching methods can be applied for more efficient dissemination of theoretical information, but there is no substitute for the time needed to develop adequate clinical experience, At the same time, the public is placing many demands on the dental profession. A wide scope of low-cost treatment is now considered a basic right. The quality of treatment is of secondary concern. Some individuals will seek treatment according to price, not quality. Because of these facts, the illegal practice of prosthodontics has grown enormously. We may not agree with these trends, but obviously a need is being fulfilled. Unfortunately, the quality of treatment is not a debatable point, even though the quality might be subject to speculation. The fact is that the public demands and is receiving this type of service. Also, legislators look favorably upon the public’s demand for such service. Therefore, a trend of the times is being borne out in our profession. Legislation is passedfor what is seemingly “in the interests of,” but not “in the best interests of,” Presented *Rrofessor,

at The

Carl

Department

Boucher

of Rehabilitative

Prosthodontic Dental

Conference,

Columbus,

Ohio.

Science.

261

262

Loue

J. Ptosthet. September,

Dent. 1976

the public! In many instances, legislation is passed which is in the best interests of the legislators or for political expediency-such is the legislation that has legalized practice by dental mechanics in six of the ten provinces in Canada. Dental mechanics are known by many names in different regions-dental technicians, dental therapists, dental technologists, etc. In the province of Manitoba, which lies directly north of North Dakota and Minnesota, legislation was passed in the fall of 1972 to legalize treatment of the public directly by dental mechanics. At the present time, 40 to 50 per cent of all complete denture services in Manitoba are performed by licensed dental mechanics. They make dentures for persons seeking and expecting low-cost treatment. There are dentists who openly refer their patients to dental mechanics. Because dental mechanics lack adequate education and training, their ability to perform competent prosthetic services is limited. Patients with difficult anatomic, physiologic, or psychologic problems cannot be treated by this group. In fact, licensed dental mechanics will refer patients they are unable to treat more readily than many dentists. They send these patients to either competent dentists who are prepared to treat them or the Faculty of Dentistry at a university. The dental mechanics are, in effect, carrying out a screening process. On the professional side, many dentists are eliminating removable prosthodontics from their practices. Their reasons for doing so are not clear. Either they are unable to treat patients due to lack of training, or because of the complexities of treatment, the time factor involved, and the need for much attention to detail, this category of treatment is no longer a lucrative form of practice. Because of these factors, it seems clentists are frequently willing to relinquish removable prosthodontic treatment. The more difficult patients, however, are put in a quandary, because few dentists are willing to treat them. Consequently, many patients are not receiving treatment at all. The Faculty of Dentistry at the University of Manitoba is able to accept a few of these patients for treatment, but only with a careful screening before final selection. Here is the unsatisfactory state of affairs at the present time. (1) Prosthodontic training in the dental curricula has been cut back. (2) There is a lack of dentists qualified to provide prosthodontic service. (3) Dentists are unable to cope with patients being referred by dental mechanics or by their own confreres. This is not a very promising picture. FUTURE

SITUATION

What does the future hold? This is a question that is easily asked but extremely difficult to answer. We can only speculate as to what will happen. There are many factors at work. One is public demand, another is legislation. As time goeson, legislation is bound to be introduced and subsequently passed in other regions of the North American continent. Not to accept this fact is folly. Admittedly, bills for legislation may be stalled for a period of time, but becauseof public demand plus the inability of organized dentistry to cope with the vast scope of the problem, the number of laws permitting some form of practice by dental mechanics will increase.

Volume 36 Number 3

Prosthodontics-Past,

present, and future

263

There is likely to be a continual plucking of hours from other disciplines in undergraduate dental curricula as has indeed occurred with removable prosthodontics. Further erosions must be halted. It is not sufficient to maintain current course-hour allocations. Time that has been lost must be regained so that more didactic information and clinical experience will be a reality for future graduates. This point is particularly important, because future dentists are the ones who must meet the challenge of treating the difficult prosthetic patients. Currently, patients are being screened and often are treated by dental mechanics who have no more than â&#x20AC;&#x153;tradeâ&#x20AC;? training to practice prosthetic dentistry. There is an increasing demand for dentists who limit their practice to prosthodontics-that is, those who, by virtue of postdoctoral training or continuing education programs, have increased their knowledge in this field. Furthermore, organized dentistry cannot at this time fulfill what I consider to be its obligation to the public, namely, treating difficult patients. The dental profession recognizes the many difficulties peculiar to prosthetic patients and the time as well as the attention required by the seemingly limitless details of treatment: We recognize the standards of treatment which must be maintained for our patients, and we honor standards. We recognize all these factors, but the general population does not and is not interested in them. The public is interested in getting the necessary, minimal treatment at the lowest possible cost. These are the demands that the general population is placing on the services which the dental profession must provide and that prosthodontists in particular must try to meet. But, groups with less training are being ever more widely utilized to fulfill these demands. The future of prosthodontics will require that some revamping of the concepts of delivery of prosthodontic services take place. Present and future demands will not be met by dentists taught by dental faculties as they function today. The trends I have outlined may not be totally bad. It seems that todayâ&#x20AC;&#x2122;s graduates are unable, for whatever reason, to cope with the demands being thrust upon them. Consequently, the challenges ahead will be directed to dentists who have acquired training beyond their basic dental degrees. They will have to treat problem patients. Admittedly, it is only through extensive didactic training and advanced clinical experience that such challenges will be met. SUMMARY 1. The geographic areas served by licensed dental mechanics will increase in number and size in the future. 2. There will be increasing difficulties in supplying dental graduates of a high caliber from our faculties of dentistry to serve adequately in the field of prosthodontics. 3. More graduate (postdoctoral) programs will be needed to train dentists to treat difficult prosthetic patients. The need for prosthetic services is still with us and will continue to grow. Only go with progressive thought and aggressive action can organized prosthodontics forward to meet its challenges. A battle is not won on defense alone, for such has

264

J. Prosthet. Dent. September, 1976

Love

been the game plan to date. Currently, dentists have a reasonable way to deliver an important health service to the population at large. However, only with a rapid advancement in the concept of delivery of total prosthodontic care can the best interests of the public be maintained. Finally, the highest standards of practice and ethics must be the guiding principles to any future changes in the delivery of prosthodontic services to the public. UNIVERSITY OF MANITOBA FACULTY OF DENTISTRY WINNIPEG R3E OWE, MANITOBA CANADA

ARTICLES

APPEAR

IN FUTURE

ISSUES

Restorative occlusion utilizing a custom incisa! guide table Thomas J. Balshi, D.D.S., Ernest B, Mingledo& D.D.S., Bernard H. Olbrys, D.D.S., and Stephen J. Cantor, D.D.S. Porcelain shade stability after repeated firing Nasser Barghi, D.D.S., and Joel Goldberg, D.M.D. The neutral zone in complete dentures Victor E. Beresin, D.D.S., and Frank J. Schiesser, D.D.S. The use of intraoral cores to repair complete prostheses Ali Bolouri, D.M.D., and Joe D. Bell, D.D.S.

and partial

removable

Alloplastic tooth implants Louis J. Boucher, Ph.D., D.D.S. A review of concepts of silver amalgam retention Charles F. Bouschor, D.D.S., and Jobe R. Martin, D.M.D. Microstructure of amalgam surfaces Kai Chiu .Chan, D.D+S., M.S., John W. Edie, M.Sc., Ph.D., and Daniel B. Boyer, D.D.S., Ph.D. A dinical evaluation of semiprecious alloys for dowels and cores John W. Dale, B.D.S., D.D.S., M.D.%, F.R.A.C.D.S., and John Moser, M.S., Ph.D.

The future

of the American

John J. Sharry,

D.&D.*

Board

of Prosthodontics

Medical University of South Carolina, School of Dental Medicine, Charleston, S. C.

he American Board of Prosthodontics has over the last several decades examined and certified hundreds of American dentists as specialists in prosthodontics. In the main, this task was carried out extremely well, but the traditions set in the 1940’s and 50’s no longer fit the 1970’s. On that account, the Board itself and many others ,who are earnestly concerned about the future of prosthodontics realize the need for constant reappraisal of the Board certification process. That the need exists is not *argued; what may be arguable is the speed with which reforms must be accomplished. The structure of the Board at present is determined by that tradition which was established in the 1940’-that is, examiners are men of some reputation in prosthodontics who have demonstrated a willingness to serve. Today, we must ask better credentials of Board examiners than we have in the past. All those who would be icandidates for the examiner’s chair must demonstrate a national reputation as a currently active clinician or scholar. Certainly, we should demand that every examiner exhibit a personality which includes a balanced sense of justice so that both the public and the profession are properly served. That sense of justice should include kindness and compassion. We cannot support the irascible or arrogant examiner, for we know that through his tyranny, he may very well disarm a perfectly capable and skillful individual who is unable to withstand his assaults. As a further credential, we should ask that anyone willing to stand for election to an examiner’s post undergo a written test prior to announcing his candidacy. This is extremely important for we, as prosthodontists, delegate to examiners very serious rights, privileges, and judgments. Certainly, we should ask that a candidate for the examiner’s post be willing to demonstrate his own wide knowledge of prosthetics before participating in such an adversative proceeding. Such a test can be devised by a special committee of the Federation of Prosthodontic Organizations ; a committee which might consist of as many as 30 or 40 memPresented *Professor,

to the Federation of Prosthodontic Department of Prosthodontics.

Organizations

Workshop,

Rochester,

N. Y.

Sharry

J. Prosthet. January,

Dent. 1976

bers, but which should insure that a knowledge of all current concepts of diagnosis and treatment will be part of an examiner’s background. Next, we should ask that the candidate for an examiner’s post be willing and prepared to defend openly his reasons for giving a failing grade to any candidate. We can no longer afford the practice, in which we have so long engaged, of denying candidates their right to know why they failed. The membership of the Board, in my judgment, should consist of three individuals whose forte is in fixed prostheses, three members whose forte is in removable prostheses, and three whose forte is in maxillofacial prostheses. Furthermore, the term of a Board member should be reduced so that no examiner serves for more than three years. (However, a prior year as an observer could be helpful.) This reduction in time would bring about two benefits. In the first place, it might attract more people who are willing to serve as Board members. Many now find the term of seven years to be too demanding. Second, it could make lighter the burden on the Board if an examiner turns out to be a blight on all whom he examines and on all with whom he serves. In addition to the clinical members, the Board should include adjunctive members to serve special purposes. For example, a lawyer should be retained by the Board for legal advice at all times. He should be skillful in the particular areas of law relevant to the Board’s work and be employed on an annual retainer. In addition, one or more educationists, with either a Ph.D. in educational psychology or a doctorate in education, should be maintained on contract to provide advice in the examining process and to devise evaluating mechanisms which will add to the defensibility of the examination. Further, the Board should consider employing an executive secretary who, in addition to the usual duties, will keep the Board current on all matters regarding specialty examinations and practices in medicine and dentistry and will ease the substantial workload of the Board’s member Secretary. These adjunctive members could be financially supported partly by Board revenues and partly by the Federation of Prosthodontic Organizations. The willingness to support such activities would certainly be a test of earnestness on the part of the Federation. Last is the matter of Board accountability, so very tightly connected with the matter of Board evaluation. Presently, accountability is indirect and cumbersome. 1 suggest that it be made more immediate and more easily accomplished. Certainly, reducing the length of service on the Board would, in the long run, make Board actions more responsive to the electorate. The Board has always been and will of course continue to be responsible under the law. The Spector of litigation has risen over the profession increasingly during the last several years, and while in some instances it diminishes the work of many responsible individuals and organizations, it has in other circumstances improved procedures. Perhaps we can forestall the negative aspects of litigation by setting up an appeal body for those who are dissatisfied with the judgments of the American Board of Prosthodontics. That appeal group can be a committee of Fellows from the American College of Prosthodontists which, presently, is the only constituent organization of the FPO in which disappointed candidates could have confidence.

Volume Number

35 1

The future

of the ABP

An appeal body could review the records of the examination and issue an advisory opinion which would be binding neither on the Board nor the candidate, but .would represent an unbiased opinion in a matter which most Americans would con:sider adversative. In closing, I am compelled to note that the content of the examination should be reconsidered. I find it difficult to defend intellectually an examination which demands treatment of a patient at the site of the examination. Certainly, all of the pressures of any examination are magnified by the variables inherent in the personality and physiology of a particular patient. If neurosurgeons, cardiovascular disease surgeons, and others can develop examinations which do not include treatment of the patient, how can we say that we must have a. patient treated on the spot. What kind of real defense can we offer? I submit that it is fragile indeed for us to argue that it is the only way we can know whether a prosthodontist has the skills or not. Certainly, some prosthodontists who are obviously skillful may find the examination circumstance unnerving and, therefore, may not perform as they ordinarily would. These notes will, I hope, be argued profitably by prosthodontists, for I do not pretend that they are supported by sufficient â&#x20AC;&#x153;behind the scenesâ&#x20AC;? knowledge to suggest their adoption. I submit them because they are, in my opinion, timely in attitude if not in detail. MEDICAL SCHOOL

UNIVERSITY OF DENTAL

80 BARRE CHARLESTON,

DF SOUTH MEDICINE

ST. S. C.

29401

CAROLINA

FUTURE

OF PROSTHODONTICS

The future

of prosthodontics

S. Howard Payne, D.D.S.* State Uniuersity of New York at Buflalo,

School

Dentistry,

Buffalo,

N. Y.

eorge Washington would have given anything for a scientifically made, comfortable set of dentures. Now, a skilled dentist, using modern materials can make excellent, virtually undetectable restorations. Many people think this is easy. Many curriculum committees think so too! Some technicians and illegally practicing laboratory technicians are ready to take over the field, because they think dental school training is not necessary to make dentures. We are at the crossroads! An article published 13 years ago warned of the dismal future of removable prosthodontics and the dangers of the denturist m0vement.l Removable prosthodontics has been de-emphasized in most schools. One college of dentistry in *New York state has reduced its preclinicai hours to 90, another to 110. Periodontists are predicting that dental disease and loss of teeth ,will soon be problems in the past. It is obvious that many deans and curriculum committees concur. How unfortunate that it is not true! Ignorance, fear, andâ&#x20AC;&#x2122;procrastination are the enemies of good preventive dentistry. Too many patients visit the dentist after they have become dental cripples. Stress is the primary reason that no magic cures are in sight. The tension and emotional turmoil of modern living are great health destroyers. The stress component has recently been identified as a major cause of heart disease, cancer, cerebrovascular incidents, and lung disease. To these can be added periodontal disease, osteoporosis, and hypersensitive oral mucosa. These disease entities create problem denture wearers who comprise the major part of a prosthodontistâ&#x20AC;&#x2122;s practice. Few physicians are aware of these problems, because they have little dental orientation in their medical education. Aged patients constitute another group in need of good prosthodontic service. The problems related to geriatric patients are multiple and involve all workers in the health professions. A factor of increasing costs affects the future of both prosthodontics and periodontics. How many people can or will spend $25.00 for scaling and polishing the teeth or $100.00 a quadrant for gingivectomies ? Those who believe dentures will be a thing of the past are not being very realistic! Presented to the Federation of Prosthodontic *Clinical Professor of Prosthodontics.

Organizations

Workshop,

Rochester, N. Y. 3

Payne

J. Prosthet. Dent. January, 1976

What about the future of fixed prosthodontics? Even now, only well-to-do persons can afford it. At the checkout counter in a supermarket, observe the number of missing upper premolars in young adults. Ask someone why. “What! Five-hundred dollars to replace a single tooth!?” Ridiculous for a young family? Perhaps not, but they think so. They have their eyes on a new car or a color television set. Unless a much cheaper substitute for gold is found, fixed prosthodontics will be out of reach for many patients. This may increase the demand for good removable partial dentures. However, the average dental student does not have enough preclimcal training and practice in school to adequately design a removable partial denture. The young dentist does not design removable partial dentures, thus relinquishing his legal responsibility according to most dental practice acts. The laboratory technician may be able to design a framework as a geometric figure but not according to physiologic principles and esthetic factors. For example, clasps are often placed completely around upper canines, marring the patient’s appearance and potentially increasing the destructive forces on the teeth. A common error is the locating of lingual and buccal clasp arms at different heights on the teeth which can exaggerate lateral stresses during function and during the insertion and removal of the denture. Another error is the placement of the clasp arms too far from the gingivae when the teeth could have been surveyed and the clasps positioned closer. Add to these errors such things as frameworks which have had the occlusal rests cut off because the dentist failed to check the opposing occlusion or those mandibular removable partial dentures designed without any rests at all, and we can understand the frustration of many patients with removable partial dentures. What about the future of complete dentures? Dentists already delegate too much of the construction of dentures to the commercial laboratories. How, then, can we criticize the laboratory people when they think they are doing most of the work and getting the short end of the fee? But they do not know the whole story! One Canadian dentist said of the denturists in Ontario, “They don’t know what they don’t know!” He should have explained further. They do not know much about oral disease or about tissue behavior in nutritional and pathologic deficiencies. They do not know about psychologic health and mental disease, an understanding of which is necessary to making a prognosis in problem denture wearers. They do not know much about determining the correct vertical dimension of occlusion. It is not enough for the denturist merely to be able to fabricate the materials that make up a set of dentures, nor is it right for the dentist to abdicate his own responsibilities. There will be a definite need for more specialists in prosthodontics. Wealthy and educated people still demand the best care, and older people will need special attention. The number of dissatisfied denture wearers will increase as more dentures are made by less competent people. Peer review will be increasingly necessary, and more prosthodontists will be needed as consultants.

CONCLUSIONS The need for complete dentures will increase. No breakthrough in periodontics have a significant effect on the people because of cost, fear, ignorance, and stress. Unless a cheaper substitute for gold and ways to improve the appearance of restorations are discovered, fixed prosthodontics may not be in great demand.

will

‘Volume Number

The

35 1

future

prosthodontics

We should be concerned when dental students pick up artificial teeth from the (clinic floor and put them back in the wax-up or talk on the phone and fail to wash before treating a patient. How much information on microbiology and other basic fsciences do they really assimilate? There are many other instances of the failure of fstudents to respect clinical cleanliness. The primary purpose of a dental school should be to train dentists for the prac1:ice of dentistry. Deans and curriculum committees must realize that you cannot practice dentistry in the mouth, even though a few try! We have to restore clinic and laboratory time so that a dentist will become manually competent and will have enough clinical experience to do general dentistry. If this cannot be done, then a hospital or clinic internship should be mandatory. Elective courses which do not contain clinical components should be discontinued. ISpecialization should be confined to postgraduate and graduate or residency training. There is too much clinical dentistry to learn in a short time to allow didactic elec1:ives as substitutes. Deans and curriculum committees should re-evaluate curriculum time, recognize the need for a return to the clinical practice of dentistry, and employ qualified clinical teachers. A student forgets too much theory unless he can put it to practice. We should, as specialists, constantly teach and emphasize that when all the teeth are gone, replacing the entire dentition is a difficult and complex task. The modern dental graduate is not well trained to do this, and the denturist is not capable of doing it: fabricating materials-yes; restoring the stomatognathic system-no! Third-party payments and industrial health insurance pose danger signs to the practice of dentistry as we know it. Those who pay the bills call “the shots,” and the wedge has already been driven. As costs increase, clinics may have to be formed. Unless we can do something, prosthetic dentistry as we know it will be a thing of the past, and we as dentists will have nobody to blame but ourselves! References

1. Payne, S. H.: The 812-816, 21. Lamott, Putnam’s

1962. K.: Escape Sons, Inc.

396

AVE.

PORTER

BUFFALO,N.Y.

School,

14201

From

the

Practitioner,

Stress-How

and

to Stop

the Killing

Denturist, Yourself,

J. PROSTHET. New

York,

DENT.

1974,

12:

G. P.

The journal of

PROSTHETIC DENTISTRY JANUARY,

The Future

House

1976

VOLUME

of Prosthodontics-A

35, NUMBER

Prosthodontic

t the 1974 annual meeting of the Federation of Prosthodontic of delegates adopted the following resolution:

Workshop

Organizations,

the

Resolved, that a conference of representatives from the Federation, directors of advanced education programs in prosthodontics, directors of undergraduate programs in prosthodontics, and the American Board of Prosthodontics be held as early as feasible to discuss the problems of mutual concern related to prostbodontic education, Board certification, and the general state of the specialty.

To implement the action proposed in this resolution, Dr. Daniel H. Gehl, President of the FPO, appointed a committee charged to develop a format for a Prosthodontic Workshop to be held in Rochester, N. Y., in June, 1975. Participants included representatives from the United States and Canada from all groups mentioned in the above resolution. Position papers were written on the various topics to be discussed in the workshop sessions, and they are printed in this issue of the JOURNAL. ]. C. H.

Practice

of prosthodontics:

Past, present,

and

future

Douglas Allen Atwood, M.D., D.M.D.* Harvard School of Dental Medicine, Boston, Mass.

hroughout our society there is a widespread and increasing trend toward specialization in all phases of life. In order to obtain a proper perspective for a specific examination of the specialty practice of prosthodontics, it is helpful to examine first the inherent advantages and disadvantages of specialization in any area.

ADVANTAGES OF SPECIALIZATION There is little argument today that there has been a knowledge explosion in this century and that even a broadly educated and highly intelligent person cannot be equally expert in all areas of life simultaneously. Specialization provides an individual with an opportunity to acquire special knowledge, special skill, and special experience above and beyond that which he could acquire if he did not specialize. Similarly, the tools and equipment which have been devised in this century have become more specialized, each designed for a very specific purpose. In those instances where such equipment is expensive or difficult to use or service, practical facts of life will place such equipment only where it will do the most good. Some of the greatest advances of this century have been the direct results of efficient production methods. One needs only to think of the automobile or the television receiver to understand the importance of efficient production. Important ingredients of successful production include sound planning, wise investment in and careful layout of equipment and facilities, thorough training of personnel, fair labor practices, good standard operating procedures, and competent management. Specialization also requires marketing research to assess the need and the demand for the special product or service, public relations to relate the product or service to the need, and distribution methods to satisfy the demand. As a result of increased â&#x20AC;&#x153;know-how,â&#x20AC;? more efficient production methods, and other factors, specialization should result in more and better products or services at less cost. Read *Assistant

before

the Workshop

Clinical

Professor

on Advanced of Prosthetic

Prosthodontic

Education,

Chicago,

Ill.

Dentistry.

393

394

f. Pros. Dent. April, 1969

Atwood

DISADVANTAGES

OF SPECIALIZATION

That this desirable goal does not always result can he attributed to several reasons. First, specialization is not necessarily synonymous with greater efficiency. Inefficient methods, poor equipment, inadequate planning, lack of trained personnel, unfair labor practices, and incompetent management help neither a generalist nor a specialist. Specialization creates only an opportunity for greater efficiency in a given area. Second, specialization may tend to create a monopoly situation with all its attendant inequities---a situation which the people of this country have repeatedly overthrown whether in public or in private doma.in. Much of the success of America has been due to the checks and balances of a competitive free enterprise system where the people have the ultimate control through both the dollar and the ballot box. In the last analysis, the professions must answer to the people. Third, specialization may result in fragmentation of a coherent subject, creation of artificial barriers to communication. and lack of understanding of the interrelations of the parts of a whole. Fourth, specialization may lead to inappropriate adulation of the product or service. The American marketplace is loaded with products which fill no need, which are pretentiously packaged and advertised, and which lack contact with the real needs of millions of Americans. Similarly, some services are so inappropriately glorified that the fees charged for these services lack all contact with the real world, and the real needs are not even remotely met. There are many inconsistencies in our society where entertainers and ball players may earn far more than college professors. Increased demand may temporarily raise prices, but prudent businessmen try not to price themseltres out of business. Specialization magnifies the problem of putting a fair price on such intangible, yet highly significant cost factors as education, quality, imagination, creativity, skill, and experience in contrast to such tangible cost factors as material costs, labor costs, utilities, and taxes. A nation which neglects or devalues educators and professionals will pay a grievous price in the long run. TRENDS

IN MEDICAL

SPECIALIZATION

The development of a specialty depends on both a need and a demand. An American today would not want his gallbladder removed by a general practitioner if he could have it done by a general surgeon; he would not want an operation performed on his heart by a general surgeon if he could have it done by a cardiac surgeon. If he has no money and no insurance, he might accept less than his first choice, but if money is no problem, he wants the best he can get. How does a layman know which physician to choose? How does he pay for the best? There are problems with 110 easy answers, but by evolution, three answers are emerging: ( 1) specialty board certification, (2) group practice, and (3) health insurance. The solo general practitioner of medicine who takes care of all medical and surgical problems from birth to death has been disappearing from the scene over the past quarter century. As men have specialized, they ha\re automatically grouped together in various ways in clinics, medical buildings, and hospitals, because they could not practice a specialty in isolation. The layman has come to recognize

Volume Number

21 4

Practice

prosthodontics

395

that board certification, though it may be imperfect as a measure, is at least a starting point in accepting a physician. Both the patient and the physician are in a sense the victims and the beneficiaries of the success of medical specialization. As medical practice has become more specialized and more expert, it has become more expensive. Techniques, facilities, and equipment have come a long way from t,he doctor’s little black bag. The long, thorough, present-day education of the physician has cut significantly into his productive years. The regular sharing of medical costs through health insurance, both private and public, has made this tremendous improvement in quality of medical care economically possible. These three trends have not yet solved one of medicine’s greatest problems: the maldistribution of medical manpower. Human nature being what it is, the physician has tended to gravitate toward the best sources of good patients. Cronkhitel has defined the good patient as one who has a little money, is clean, does not smell very bad, is articulate, understands the lingo that physicians and dentists use, does not argue very much, is not hostile, comes back when he is told, does what he is told, takes his medicine regularly, and always thanks you. Because there has been a need and a demand for medical services in areas of “good patients,” many large areas of “bad patients” have been virtually vacated by private medical practitioners “in search of the good life.” Cronkhite states that the medical profession is unable to meet the new demands suddenly released by the governmental guarantees of medical care made under the provisions of Medicare and Medicaid legislation. TRENDS

IN DENTAL

SPECIALIZATION

My father was a general dentist who practiced conservative preventive and restorative dentistry on a group of “good patients” from 1917 to 1957. After a few months of practicing at Forsyth Dental Infirmary and after a two-year association with an older dentist whose specialty was periodontics, he established his own practice. From the very beginning, he employed a hygienist, and this greatly improved his productivity. He also referred all his patients requiring oral surgery and orthodontics to specialists with whom he frequently consulted. This was somewhat unusual in those days, but he felt very strongly that his patients benefited by these basic policies. Today, specialization within dentistry is increasing at a rapid pace. It is not uncommon for a “general practitioner” of dentistry to refer to specialists all those patients requiring oral surgery, orthodontics, periodontal surgery, endodontics, and involved bridgework. Those patients who are “denture neurotics” are usually referred to * specialists. Perhaps an even better indication of the trend toward specialization in dentistry is the ever-increasing number of graduates who enter specialty training programs. This is what happened in medicine twenty years ago, partly because the graduates themselves realized that they could not become expert in all phases of medicine. The same advantages and disadvantages of specialization apply to dentistry as to other areas. Dentists too are overwhelmed by the knowledge explosion. They wish to acquire special knowledge, special skill, and special experience in order to become expert in at least one area. They wish to buy and use all the latest and

396

Atwood

J. Pros. Dent. April, 1969

best equipment but soon realize that they would have neither the room nor the capital to possess all the equipment presently available, let alone the new things which come out every year. Dentists are also discovering that if they carefully plan their offices, thoroughly train and adequately pay their personnel, set up standard operating procedures, and competently manage all these factors, they accomplish more and perform better dentistry. All of these tasks are simplified if there is at least some specialization. However, as with any specialization, dentists must avoid inefficiency, they must avoid either the fact or the appearance of oppressive monopoly, they must fight fragmentation which creates interdisciplinary barriers, and they must be on guard against inappropriate self-adulation leading to inordinate fees and neglect of those unable to pay the fee. Each of the dental specialties in a sense takes away something from the general dentist. In most instances, these are things which he gladly gives away for one reason or another, e.g., difficulty, dislike, or inefficiency. Yet there remains a core of dentistry which will keep the general dentist busy for years to come. This core is itself a specialty consisting of preventive dentistry, restorative dentistry, routine fixed and removable prosthodontics, simple endodontics, and minor oral surgery. Such an individual serves an important role in our society which is neither more nor less significant or challenging than that of a specialist. Such a person must be well educated in order that he may be able to adjust readily to future advances in dentistry made possible through findings in research whether immunologic (such as a vaccine) , technical (such as a new filling material) , or pharmacologic (such as a new drul:) . The backbone of American dentistry has been the solo practitioner who is usually a rugged individualist who chose dentistry because he likes the personal doctor-patient relationship, he likes to work with his hands, and he wants to be his own boss. However, most solo entrepreneurs have been discovering of late that if they hire a hygienist, a chairside assistant, and a secretary, they can produce more and perform better dentistry at less cost. Only then do they begin to get the feel for a certain degre of managerial skills-for being the captain of a team. Perhaps one of the paradoxes of dental practice is that the executive, the â&#x20AC;&#x153;boss,â&#x20AC;? is also the piece worker. When the dentist checks a prophylaxis performed by his hygienist or the radiographs taken by his dental assistant or the wax occlusion rims constructed by his laboratory technician, he is an executive, but when he fills the tooth or makes the impression, he is both the worker and the manager. As certain of the managerâ&#x20AC;&#x2122;s duties are delegated to properly trained personnel, he becomes more productive while still maintaining sup&vision of and responsibility for their actions. A good example of the increased efficiency of specialization is related to the hiring of a laboratory technician. It is generally true that a dentist has more control over his own laboratory technician than over a commercial laboratory. Yet if he does not specialize in one area, such as prosthodontics or orthodontics, it may be inefficient to hire a technician. Similarly, the members of a group practice are more able to hire additional auxiliary personnel (such as an ofice manager) which a solo practitioner cannot do. One of the great strengths of America has been its diversity. A wide diversity

Volume 21 Number4

Practice

of prosthodontics

397

exists in methods of dental practice-solo, private group, public and school clinic, dental school clinic, hospital outpatient care, and hospital and nursing home inpatient care. It seemslikely that this diversity will continue, and perhaps it is proper that it should becauseof the wide variety of social and economic factors throughout the land. Yet it also seemslikely and proper that more dental specialization and more group practices will develop throughout America especially, but not exclusively, in the more populated areas. Also, it seemslikely that as medical groups form in and about hospitals dental groups should do likewise. At the Centennial Conference on Oral Health at the Harvard School of Dental Medicine,2 a challenge was hurled at American dentistry by eminent world leaders in dentistry, from this country and from abroad, to face up to providing comprehensive dental care and services to all who need them. A similar challenge was offered at a recent workshop.3 The need is there; the demand is increasing. It is evident that the dental profession, like the medical profession, is suddenly faced with fantastic increasesin demand for its services to meet needs which have long been lying dormant. Government is committed to help to meet these needs. As both governmental and professional leaders have clearly stated, there must be a cooperative partnership between government and dentistry. Neither can go it alone. THE SPECIALTY OF PROSTHODONTICS There are three major subdivisions in the specialty of prosthodontics-fixed, removable, and maxillofacial. However all three are intimately interrelated. Fixed and removable can be practiced without maxillofacial prosthodontics, but not vice versa. Usually there is much overlap between fixed and removable prosthodontics although a few practice only fixed prosthodontics and a few only complete removable prosthodontics. Traditionally, it has been difficult for a solo practitioner to practice fixed and removable prosthodontics without also doing some other types of dentistry (such as prophylaxis, fillings, crowns on abutment teeth, oral surgery, and endodontics) becauseof a lack of qualified specialistsand a lack of efficient cooperation between dentists. As more specialists become available and as more groups form, more prosthodontists are able to limit their practice to those phasesfor which they are best qualified, but they must be well informed about all phasesof clinical dentistry. A survey on what a prosthodontist actually does in his office will be presented at this workshop. Without anticipating what this survey will show, it is safe to say that the type of practice, whether solo, group, hospital, or military, will influence the results. â&#x20AC;&#x153;The goal of prosthodontic service is not simply the production of prostheses, but rather the restoration of the function and appearance of a vital body part and the maintenance of the patientâ&#x20AC;&#x2122;s health. It must be remembered that the health service aspect of prosthodontics is of paramount importance.â&#x20AC;&#x153;4 To achieve this goal, Payne5 has emphasized the importance of doctor-patient rapport, diagnostic intuition, clinical skill and judgment, artistic ability, mechanical ingenuity, and empathy. Many prosthodontic leaders have earnestly sought to determine what knowledge and skills a prosthodontist should have and how he should acquire them. However, the answer to these questions must be qualified by two

398

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other questions: What is the extent of the prosthodontic need in America, and how is the dental profession to meet that riced. 2 The extent of the need may well influence the methods of meeting the neccl. I17 o give a small measure of the extent of the prosthodontic needs, let US 100k at only one aspect: In 1962, there were over 20 million totally edentulous individuals in America.” The needs of each edentulous person cannot be met by a single operation to cure his prosthetic problems for the rest of his life. Several longitudinal studies’-Y have shown that resorption of residual ridges under dentures is usually a continuing process resulting in loss of Lertical face height, changes in jaw and tooth relations, and chronic discomfort and irritation from dentures which no longer fit because of changes in the shape of the ridgrs. It is a well-accepted prosthodontic practice lo that all denture patients should be examined at least once a year and that dentures should be relined or remade before such changes cause irrevocable damage. The multimillion dollar business devoted to do-it-yourself denture additives and adhesives is blatant evidence of the tremendous need for more prosthodontic services in this country. The scientific evidence showing the destructive results of such self-treatment is accumulating.“-” ‘Ihe number of totall)- cdentulous patients has been rising steadily with the steady increase in population and longevity. In 1958, there were 206 diplomates certified by the American Board of Prosthodontics’“; in 1967, there were 320, of whom 80 (27 p er cent) were in the military service, and a few were in retirement.14 A very strong case can be made that America desperately needs 100 times that number now. Not only are well-trained, experienced prosthodontists needed to treat the difficult. problems of prosthodontir patients. but they are needed to carry a large part of the brlrden of treatment imposed by the great need. They must not limit their treatment to only a relatively frw high-fee patients each year; rather, they must plan and equip their offices, train their personnel, standardize their procedures, and competently manage in suclr a way as to allow treatment of rnany more patients in an efficient but sympathetic and professional manner. They must relate themselves to other dental and medical specialists so that they can function harrnoniously and naturally to the best interests of the patients. Ebert15 stated, “It makes no sense to call for ever-increasing amounts of money and manpower if the system in which they are required to operatr is inherently inefficient..” The major point is not that all prosthetic dentistry will be performed by prosthodontists. On the contrary, general dentists will continue to do much of the prosthetics just as they will continue to do much of the oral surgery and much of the periodontal care. Many parts of this tremendous country will need to be served by competent all-around general dentists, but wherever the need and the demand are great, the dental profession mujt organize into the most efficient units to produce the most and the best dentistry possible. Specialization makes possible special arrangrmerits for more efficient handling of special prohlema.

SOURCESOF CANDIDATES FOR BOARD EXAMINATION Where can large numbers come from? Only a relative

of candidates for prosthodontic board certification few can come from existing prosthodontic training

Volume Number

21 4

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programs approved by the American Dental Association (perhaps 100 per year) .I6 This source needs to be dramatically and rapidly increased. On the full-time and part-time faculties of many dental schools, there must be many potential candidates. Likewise, among the 100,000 practicing dentists, there must be many eligible candidates. It is completely unrealistic and unnecessary to expect such persons with great clinical and/or teaching experience to take off two years to qualify for board examinations. There must be alternate routes to make such persons eligible for consideration and examination as soon as possible. The time is short. ALTERNATIVES In considering alternatives, one must be specific. Certification by a clinical board means recognition of a proved competence to perform in a certain specialized clinical area in a manner above the average level. It does not signify infallibility; it does not imply perfection or even total knowledge. Rather it means professional commitment to a specialized area. Such a commitment implies and leads to special study, special experience, special “know-how,” special facilities, special equipment, and special efficiency in handling problems in this clinical area. It does not necessarily imply research or teaching in the area. Such experiences may (or may not) be additional assets. Clinical examining boards must use a certain amount of discretion in evaluating alternative professional backgrounds. Otherwise, why have a board? In clinical prosthodontics, fifteen years of conscientious practice with repeated efforts at continuing education, as evidenced by participation in postgraduate courses and prosthetic meetings or by active teaching of prosthetic dentistry in graduate or undergraduate dental schools, surely help to qualify a mature dentist as well as or better than some two-year graduate programs would help an inexperienced recent graduate. Perhaps each candidate’s credentials could be examined, his strong and his weak points determined, and a realistic study program designed to prepare him for examination. SPECIALTY

BOARD

MEMBERS

Most specialty boards are conducted by sincere dedicated professional men who have almost unbelievable commitments in teaching, research, administration, writing, and professional organizations. It would seem that the day has arrived when specialty boards need some full-time professionals to conduct the business of the boards under the supervision of part-time directors. No board can do all the following tasks on a part-time basis: ( 1) encourage and supervise the development of graduate programs of prosthodontics throughout the country; (2) organize and conduct board examinations several times a year in different parts of the country; (3) evaluate the educational backgrounds of prosthodontic “late bloomers” and outline individual postgraduate programs to complete requirements for examination; (4) organize and conduct periodic reviews of the continuing education of each diplomate; and (5) encourage the development of a variety of continuing education courses. If this workshop comes up with imaginative but realistic alternatives to the arbitrary rigid two-year requirement, then the future of the specialty practice of prosthodontics is bright indeed. If, however, the present situation is allowed to drift with-

400

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out affirmative leadership and action, then dentistry will obvious and most pressing responsibilities--the adequate millions of totally and partially edentulous citizens who to realize the significance of the term “patient power.“l’

J. Pros. Dent. April, 1969

be failing one of its most professional treatment of have only recently begun

SUMMARY 1. Throughout our society there is a widespread and increasing trend toward specialization in ail phases of life. 2. As a result of increased “know-how,” more efficient production methods, and other factors, specialization should result in more and better products or services at less cost. 3. A high degree of medical specialization has developed because of the desire of both the profession and the patients. 4. From a practical standpoint, medical specialization has been made possible by the development of specialty board certification, group practice, and health insurance. Similar trends are evident within dental practice. 5. The demand for medical and dental services has been increasing, but the supply of these services has not been increasing rapidly enough. 6. The health professions must be careful not to price their services out of the reach of either the patients or the nation. On the other hand, professional services must be recompensed fairly or otherwise both quality and quantity of services rendered will decline. 7. Professional specialization should provide more and better medical and dental services at less cost. 8. There is an urgent need for a vast increase in the number of board-certified prosthodontists who, because of their increased “know-how” and because of specialized practice, should provide more and better prosthodontic services in areas of high demand at less cost to the patient but with appropriate recompense for services rendered. References 1. Cronkhite, L. W., Jr.: The Delivery of Medical Care: A Look Into the Future, Harvard D. Alum. Bull. 28: 42-45, 1968. 2. Goldhaber, P., et al.: Oral Health, Facts, Figures, and Philosophy, Harvard D. Alum. Bull., Special suppl., Nov., 1968. 3. American College of Dentists, Workshop on Dental Manpower: Meeting Dental Needs in the 1970’s, J. Am. Coll. Dentists 35: 100-237, 1968. 4. Lytle, R. B., Atwood, D. .4., and Beck, H. 0.: Minimum Standards of Adequate Prosthodontic Service, J. PROS. DENT. 19: 108-110, 1968. .5. Payne, S. H.: Knowledge and Skills Necessary in the Practice of Prosthodontics, J. PROS. DENT. 20: 255-257, 1968. 6. United States Public Health Service Publication: Total Loss of Teeth in Adults: United States 1960-62, United States Government Printing Office, 1967, Washington, D. C. 7. Atwood, D. A.: A Cephalometric Study of the Clinical Rest Position of the Mandible. Part II. The Variability on the Rate of Bone Loss Following the Loss of Occlusal Contacts, J. PROS. DENT. 7: 544-552, 1957. 8. Talgren, A.: The Reduction in Face Height of Edentulous and Partially Edentulous SubActa odont. scandinav. 24: 195-239, 1966. jects During Long-Term Denture Wear,

Volume 21 Number 4 9. 10. Il. 12. 13. 14. 15. 16. 17.

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Carlsson, G. E.: Changes in the Jaws and Facial Profile After Extractions and Prosthetic Treatment, Tr. Roy. Schools Dent. Stockholm & UmeH 2: 12, l-29, 1967. The Academy of Denture Prosthetics: Principles. Concepts, and Practices in Prosthodontics-1967, J. PROS. DENT. 19: 180-198, 1968. Woelfel, J. B., Berg, T., Mann, A. W., and Krieder, J. A.: Documented Reports of Bone Loss Caused by Use of a Denture Reliner, J. A. D. A. 71: 23-34, 1965. Woelfel, J. B., Winter, C. M., and Curry, R. L.: Additives Sold Over the Counter Dangerously Prolong Wearing Period of Ill-Fitting Dentures, J. A. D. A. 71: 603-613, 1965. Commission on the Survey of Dentistry in the United States: The Survey of Dentistry. The Final Report, American Council on Education, Washington, D. C., 1961. Beck, H. 0.: American Board of Prosthodontists, J. PROS. DENT 18: 589-600, 1967. Ebert, R. H.: Medical Care: Reform the System, Harvard Today, Spring, 1968. Council on Dental Education, American Dental Association: Accredited Advanced Dental Education Programs for the Preparation of Specialists. Jan., 1968. Baumgartner, L.: On the Future of Patients and Physicians, Harvard Today. Spring, 1968. 110 FRANCIS ST. BOSTON. MASS. 02215

MISCELLANEOUS

RESEARCH AND THE FUTURE JOHN

OF PROSTHODONTICS

W. KNUTSON, D.D.S., DR. P.H.*

Washington, D. C. HE CURRENT STATUS OF DENTAL RESEARCH and particularly research relating to prosthodontics will be considered here. In doing so, I shall be discussing an activity which engages each of you in varying degrees. I use the term â&#x20AC;&#x153;researchâ&#x20AC;? in its broadest sense. Research is simply the habit of testing and correcting concepts by their consequences in experience. It is difficult to conceive of a successful prosthodontist who is not engaged in testing and correcting concepts by their consequences in experience. On the other hand, those who regard research as a very limited, profound, and even awesome activity engaged in by a few strange individuals vi11 participate as learners who have discovered the values of being intelligently ignorant. After all, those in the profession who put knowledge remedially to account are as indispensable to the human enterprise as are researchers who bring new truths to light. Certainly no one will disagree with the concept that learning by doing creates its own obsolescence.

FINANEIAL

SUPPORT

FOR RESEARCH

Learning by doing, innovating, and developing were the principal avenues for progress in dentistry in this country until a decade ago when the Congress first appropriated funds specifically for dental research. In 1950, the Congress appropriated $200,000 to enable the National Institute of Dental Research to provide grant support for approximately twenty research projects in dental schools and in other research institutions. A total of $35,000 was appropriated for the training of research workers- enough to support eight to twelve fellows. In retrospect, the pitifully small and woefully inadequate financial support of dental research in this country in 1950 reflected a strange conundrum. Although the American people were spending more than $1,500,000,000 a year for dental services-almost one-sixth of their total health dollar-less than 0.1 per cent of that amount was being expended in efforts to discover methods to prevent dental Read before the Greater New York Academy of Prosthodontics, New York, N. Y. *Assistant Surgeon General, Chief Dental Officer, u. S. Public Health Service, Department Health, Education, and Welfare. 375

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diseases or to improve control procedures. The comparable figure for the medical aspects of health is nearly 4 per cent. Progress in gaining financial support of dental research during the decade of the fifties is reflected by a comparison of today’s budget of the National Institute of Dental Research with that of 1950. Funds available for grants for dental research projects in dental schools and other research institutions throughout the country have increased from the 1950 figure mentioned earlier, $200,000, to more than $6,000,000. The number of projects supported has increased from twenijr to more than 400. Support for research fellowships has increased twenty fold iron] $35,000 in 19.50to $760,000 in 1960. III addition, almost $3,000,000 is currently available for grants to support a variety of training activities in dental schools. These include graduate research training programs and part-time student research fellowships for eight dental students in each of the dental schools and two students in each of the schools of public health. This year $800,000 was budgeted to support training units in dental schools to teach dental students to use chairside assistants effectively and effi&ntly. During this same decade, the Congress has increased the appropriation for the direct operation of the Kational Institute of Dental Research from $276,000 in 1950 to slightly more than $3,250,000 in 1960. .111 of us can find reason for being pleased with this support of dental research. The support, however, is still in its infancy, since a large part of it was tnade available in 1957 for the first time-just 3 years ago. It is still much too little and it is only roughly 0.5 per cent of the $2,000,000,000 now being expended by the public for dental health services. I am confident that the public is willing to spend more and that the financial support required to engage the ever-increasing number of dental research trainees in challenging research and teaching careers will he provided. Surely, a public which spent more than $17,000,000 for denture adItekes and denture cleansers in 1957 will be willing to spend substantially more for the research which could result in far more effective methods of prevention and contra j! of dental diseases than those available now.

l<ven a summary review of projects and lx-ogress under this greatly expanded dental research program would be beyond the scope of this article. However, more than forty projects supported (roughly one-tenth of the total number of projects recriving support today) can be classified in the prosthodontic area. included among these projects are such titles as “Stress Patterns in the Edentulous Human Mandible and Maxilla as Tnflucnced by Complete Denture Forms,” “Investigation of Magnetic Implant Dentures, ” “Study of the Morphologic Changes in the Jaws I-‘ollowing the Loss of Teeth,, ” “The Effect of Tooth Forms on Denture Efficiency,” Evalua‘“Vclopharyngeal Action in Consonant Articulation, ” “Cinderadiographic tion of Dental Speech Rids, ” “Evaluation of Resin Denture Bases,” “CinefluorogStudies on Musraphv of Temporomandibular Articulation, ” “Electromyographic

“N%L~ ‘,’

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cles of Mastication, ” “Measurement of Lateral Muscular Forces on the Teeth,” “Oral Myometric Pressures, ” “Dental Function and Structure in Older Persons,” “Alveolar Ridge Reconstruction With Alloplastic Implants,” and “Relationship Between Chewing Efficiency and Dietary Habits in Older Persons.” Research in the areas suggested by the project titles just listed has done much to improve prosthetic service in all its aspects. Better materials have been produced, new techniques have been developed, and a better understanding of the oral mechanism, including neural and muscular anatomy, physiology, and function, has been fostered. With the general tendency toward longer life and the continuing increase in size of the older portion of our population, the need for research leading to improvements in prosthodontic services becomes more and more pressing. The Report of the National Health Survey1 shows that 22 million persons (13 per cent of the population) are edentulous. The percentage increases with age from about 1 per cent in the 15 to 24 years age group to 67 per cent in the 75 years and older age group. This survey revealed too that only 7 per cent of all edentulous persons 65 years of age and over had seen a dentist within the previous year. This finding suggests that we are failing to motivate edentulous persons to visit their dentist at regular intervals and that they are not active participants in a program of oral health maintenance. Mandibular Movement.-An ever-increasing amount of research is being directed toward establishing a better. understanding of muscle actions and extending our knowledge concerning mandibular movements. One might well ask why this stress on muscle action and mandibular movement. The invention of the first articulator in 1805 started a long procession of modified instruments with one common function-that of reproducing mechanically the movements of the mandible. None have fully achieved this common goal. It is not difficult, however, to rationalize failure to reproduce precisely the mandibular movements, the most complicated movements of any of the body units. Perhaps the best an articulator can be expected to do is to approximate mandibular movement and provide a guide to its inclinations and paths. Returning, then, to the question “Why should so much stress be placed on research in muscle action and mandibular movement ?” it can be answered by saying that the more thoroughly we understand the physiologic, biologic, and neuromuscular aspects of the oral mechanism, the more readily we can adapt to and compensate for the recognized inadequacies of our instruments. It is thus that we increase our capability of constructing a satisfactory and functional prosthodontic appliance. Because controversy persists over whether or not there is a true hinge movement of the mandible, much research has been centered on the temporomandibular joint. Apparently, there is general agreement that there is a hinge axis movement for at least a short distance prior to occlusal contact. If this is true, the hinge axis determination should be useful in establishing centric occlusion. Other records, however, become necessary for the establishment of proper tooth form and contour to accommodate harmonious mandibular movement laterally, protrusively, or retrusively, for then the hinge is no longer the predominant factor.

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Through active research, the numerous forces concerned with mandibular action can be more clearly defined. Then we can adapt our thinking to fit the new findings and, recognizing the limitations of ourselves and our instruments, perhaps we can more nearly approach normal function. 7’~mporolnandibzlZar Joint.--The temporomandibular joint itself is probably the most sensitive reactor to occlusal disharmonies of the oral mechanism. It reflects defects in occlusal harmony in varying degrees, ranging from little or no effect other than an occasional click, through middle ear difficulties, to excruciatingly painful symptoms in the head and neck. Kelly and (;oodfriend” reported that 70 per cent of patients with verified vertigo had occlusion-joint conditions as the cause, through a transfer of the occlusion-joint conditions to the vestibular syst.cm of the ear. Research of this sort enalJes us not only to define problems but to develop remedies and preventive measures. Koc,llt!/elro!/rnphic- .Sf~iirs.-- -Recent studies have sl~own, too, that as many as 25 per cent of edentulous patients ha\~ some form of positive roentgenographic findings. such as eml~edtletl root tips, impacted or unerupted teeth, and cysts, and that as high as 10 per cent have pathosis, wch as radioluscent areas about root tips, residual cysts, sequestra, and malignancy. Iii view of the results of studies such as these, it is unthinkable that anyone wc~uld attempt the construction of a denture without first making a thorough examination of the patient. i‘onrlition O! .S14P/wl-til1f~~‘~s.sIIL~.s.--Increasing attention is being given to the condition of the supporting structures and tissues--their health or, if injured, their re>toratitrn to health. Many abnormal conditions of the ridges, supporting structurns, and tissues have beer1 successfully treated through the simple procedure of providing rest. \‘itamin therapy and e.wrcise of the musculature arc among the other means being studied for the treatment of abnormal ridges and tissues. f znpressio~f. T~~chiqz~tx--- ~Itnpressio~~techniques continue to receive considerablr attention. Each technique appears to have its advantages as well as its disadvantages. These are verifiable through study and research. I:ndoubtedly, the continuing search for a universal impression technique has engendered a tendency to adapt one technique to every patient. Certainly, the needs of the individual patient and the ability of the dentist will continue to l)e important factors in the selection, modification, and use of several tecliniquc3. Kctcution pi I)wfwrs.~ --The mechanical retention oi dentures has been a fawrrtl study area. The range cstends from suction cups to the implantation of natural teeth. Currently, the implantation of magnets for retention is being developed and refined. The use of epoxy resins and allied substances for the implantation of natural teeth has created visions of tooth banks being evolved through which replacements ior missing teeth might la: made from previously collected and storc(1 sterile natural teeth. \I’hether or not any of these approaches will 1)~ dcwlopctl as effective and practical dental procedures will depend upon further research on tissue tolerance, retentive ability, and the capability of the replacements to withstand the forces of masticatioll. Tooth Forms.- -Tn the area of tooth form, opinions differ as to whether or rmt cuspless teeth should be employed and, if cusped teeth are to be used, what

EX%Z â&#x20AC;&#x2DC;,â&#x20AC;&#x2122;

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height cusps are best. The answer probably lies in the judicious use of each within the indications of the individual case. A recent report concluded that anatomic tooth forms cause more bone deformation over a larger area than nonanatomic tooth forms and that heavy bone structure is more resistant to deformation per unit force than average or light bone structure. On the other hand, another report concluded that patient preference is for 20 degree posterior teeth rather than for Hallâ&#x20AC;&#x2122;s posterior teeth and that the latter produce more soreness during the adjustment period. BACKGROUND

KNOWLEDGE

AND

SKILLS

It is studies such as these (although the findings seem contradictory) that will lead to ultimate understanding of the basic problems and principles underlying satisfactory prosthodontic services. The characterization and staining of teeth and denture-base materials comprise another continuing effort to more nearly satisfy the individual needs of patients. All in all, it is increasingly clear that treatment with a prosthodontic appliance requires more than Imechanical skills. It requires a solid background of knowledge of the basic sciences-anatomy and pathology, histology and physiology, physics and chemistry, neurology and psychology. In addition, it requires a high order of skills in eliciting, understanding, and influencing the habits, attitudes, and values of each patient. CHALLENGES

Although research is increasing our scientific and technical knowledge and competence in the area of prosthodontics, intelligent application of that knowledge appears to require of us a broader and deeper understanding of the biologic sciences than we have had before. If we believe this, it seems clear that the next decade will present great and exciting challenges. First, the population increases projected for this country greatly exceed any scheduled plan for a similar increase in the number of dentists, so that the ratio of dentists to population will become less adequate within the next 10 years. Second, the development and expansion of prepayment and postpayment plans for dental health services will be accelerated and will markedly increase the proportion of our population that can afford dental services. Third, economic projections indicate that the population increases will be accompanied by an increased median income and will broaden the base of participation in available dental health services. Fourth, the trend toward urbanization will continue and will increase the demand for dental services, Fifth, increases in the level of education of future populations will greatly extend appreciation of and the demand for dental health services. In other words, relatively fewer dentists and an increased demand for dental health services mean that all of us will be challenged by opportunities greater than ever before to make our services more efficient and to make them available to an increasing number of patients.

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Den. 1961

OPPORTUh-ITIES

If challenges in the next decade represent opportunities for leadership in solving emerging problems, those with competence in the area of prosthodontics will be especially favored. Much evidence supports this conclusion. First, the 19.57 National Wealth Survey reveals that there are 22 million ptlentulous persons in this country. This means that 1 out of every S persons is edentulous. This is an amazingly high figure. Nevertheless, it does not include the large number \vho have only one edentulous jaw or who are partially edentulous ;~nd in need of 1)rosthodontic services. Second, the population increases projected for the 1960s will add 5,000,OOO more persons to the age group 6.5 and over, so that we will have a total of 20 million in this group. Third, the 1960 amendments to the Social Security Act changed Title I from “Old Age i\ssistance” to ‘Y;rants to States for Old .4ge Assistance and .‘\lt:dical Assistance for the Aged” and provided that a subcategory of citizens 05 :‘iws oi age and over, potrntially numbering several million, may receive medical ;iAtance, including dental services. The groul) to benefit is aged persons \vho :w not. eligible to receive old age assistance payments and who are considered to 1~’ unable to meet the cost of needed health services. Increased federal matching ljcrcentages of old age assistance funds is expected to make an additional $13?,!W1,000 a year available to the states. IVnder this program, there is a ceiling on the lwr caipta expenditure which will be matched by the Federal government. I-lowever, thrre is no ceiling for amounts expended under medical assistance to the aged. V&ml matching contributions under this new program will range from 50 to SO per cent depending on the per capita income of the state, but the actual amount cli money provided is limited only bv the state allocation of funds for matching JurJxw~s. Fourth, in 19.59 bills which would authorize “denturists,” or “denturologists,” tci make clcntures directly for patients were introduced for legislative consideration :t!id action in seven states-California, Georgia, Illinois, Michigan, Sevada, Oklx1~tnla, and ~~~asliington. in brief, these four items indicate that the actual and potrntial need for prosthotlontic scr\Gs is very large ant1 is growing larger at an accelerated pace; that the health service requirements of tlte needy aged, including dental health services, will be provided through federal and state assistance programs J and that some dwtal technician groups are actively engaged in initiating action which woultl 1wrmit them to employ merchandising methods in exploiting those in need of l~rr~~tliodontic services. --Perhaps by paraphrasing a common complaint of wlfarc w&crs. the implications of these four items can be brought into better focus: ‘.c irw of our most frustrating health service problems is our unsuccessful and iruitless efiorts to secnrc dental health services, and particularly dentures for our wlfnre clients. Provisions are made for supplying all other kinds of health services, excepting dentures. Is there anything we can do about it I” Before considering our answer to this question, it may he worth noting that the needy aged and medically indigent, although a minority group, probably exert a greater influence on political

E”,‘G‘2’

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and legislative action and on the results of public referenda than do the great majority of prosthodontic patients who can and are willing to pay for health services. LEADERSHIP

Now, what can you do to engage in the leadership opportunities reflected by these facts and trends ? First, from the philosophic standpoint, the positive rather than the negative and defensive approach to the problem must be adopted. You must be actively identified with the conscience rather than with the fears of your community. Second, you must be prepared to present your profession’s values in situations where they are contested. Third, if prosthodontic dental services are considered essential to physical and mental health, you must insist that they be made available to those who cannot afford to pay for them. If your community’s health program for the needy does not include prosthodontic services, you should initiate organized constructive efforts to get them included, for in priority listings of essential dental services for the aged, dentures are second only to emergency relief of pain and infection. Fourth, you must provide professional guidance to ensure that only qualified dentists are designated to supervise prosthodontic service programs and that provisions are made for continuing education of these dentists. You must also see to it that expert and consultative services are always available so that the services offered will be of high quality. In short, you must engage in those activities which will ensure that needy patients receive modern, effective prosthodontic health services. It is through such leadership activities that you will enhance the stature of your profession and maintain the respect of a grateful public. You will be engaging, indeed, in that humanistic quality of the Athenians, “The art of making gentle the life of mankind.” REFERENCES

1. Loss of Teeth. Health Statistics From the U. S. National Health Survey, Series B, No. 22, Washington, 1960, Department of Health, Education, and Welfare, U. S. Public Health Service. 2. Kelly, H. T., and Goodfriend, D. J. : Medical Significance of Equilibration of the Masticating Mechanism, J. PROS. DEN. 10:496-515,1960. U. S. PUBLIC DEPARTMENT WASHINGTON

HEALTH SERVICE OF HEALTH, EDUCATION,

25, D. C.

AND WELFARE

Harold D. Sgan-Cohen, DMD, MPH Department of Community Dentistry, Hebrew University Hadassah Faculty of Dental Medicine Jerusalem, Israel E-mail: harolds@cc.huji.ac.il

Complete Tooth Loss USA adults (1999-2004) aged 65+ yrs 44.20%

26.90%

below poverty level

References

above poverty level

1. Sgan-Cohen HD, Mann J: Health, oral health and poverty. JADA 138:1437-1442, 2007. 2. World Bank: International Comparison Program. Poverty PPPs Available at: http://go.worldbank.org/OPQO6VS750. Accessed Aug 2007. 3. World Health Organization: WHO Oral Health Country/Area Profile Programme. WHO Headquarters Geneva, Oral Health Programme Available at: http://www.whocollab.od.mah.se/. Accessed Aug 2007. 4. Hobdell MH, Oliviera ER, Bautista R, Myburgh NG, Lalloo R, Narendran S, Johnson NW: Oral diseases and socio-economic status (SES). Brit Dent J 194:91-96, 2003. 5. Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, Eke PI, Beltrán-Aquilar ED, Horowitz AM, Li CH: Trends in oral health status: United States, 1988-1994 and 1999-2004. National Center for Health Statistics. Vital Health Stat 11(248): 1-92, 2007. 6. World Health Organization: Declaration of Alma Ata. International Conference on Primary Health Care, Alma Ata, USSR, September, Geneva: WHO, 1978. 7. Oral health in America: A report of the Surgeon General. Rockville Md: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. NIH publication 00-47132000.

% complete tooth loss

Fig 6.—Complete tooth loss: USA adults (1999-2004) aged 65þ years.

less likely to benefit from dental care than their richer and insured counterparts. Poverty is a scourge of mankind and is prevalent among developing countries. Regrettably developed countries are also often characterized by significant class inequality and social disparities between the privileged and the underprivileged. Dentists should be actively involved in social attempts aimed at reducing and eradicating poverty. By adopting this role, we can fulfill our obligation to society and improve our status as health professionals.

The future of prosthodontics Background.—The discipline of prosthodontics is no longer limited to Western nations. With the global access to cutting-edge technology, even foreign dental labs can compete. In addition, these labs offer the advantage of less costly labor rates, which is a distinct threat to their Western competitors. Adding in the cost of dental supplies, which may follow the oil market price increases, those countries with higher labor expenses will experience increasing pressure from the cost of doing business. Prosthodontic incomes are currently favorable, but the integration age that is upon us indicates that health care providers who have the best available science, the best training, and the best economic preparation will have the most advantages in delivering prosthodontic services. Prosthodontic ‘‘Ages’’.—Various eras in the prosthodontic specialty can be identified. Each was decisive

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and absolutely needed for the current state of prosthodontics to develop. Included would be the eras of tooth replacement techniques, of organizations and journals, of temporolmandibular joint disorders, of education and symposia, of adhesive porcelain, of implants, of science and the best evidence, and, currently, of leadership and stewardship. The points that mark these eras include the formation of organizations designed to promote prosthodontic education, the development of a glossary of acceptable and commonly used terms, the rise of peerreviewed journals, the adoption of national certifying specialty exams and performance verification standards, and the scheduling of symposia and workshops that promote consensus and collective purpose among practitioners. Evidence-based practice in dentistry has promoted the best available science for treatment decision-making and empowered researchers to look into prosthodontic

topics. The age that awaits prosthodontists will see the end of our right to define our own specialty. The ability to apply scientifically rigorous methods and research findings to knowledge-based diagnoses will be balanced with service accompanied by added value. Coming Changes.—The changes needed to bring forth this new era will require that prosthodontists quit clinging to what are now the old ways and take hold of new and challenging opportunities. Instead of maintaining the status quo, prosthodontists will need to recognize their own personal role as stewards of their profession. This will entail not just letting go of what is no longer useful but also developing new strategies as the need arises. Leading by example and mentoring fellow prosthodontic colleagues will help the specialty grow. It is vital to correlate diagnoses and treatment protocols with the best science currently available, which requires that rigorous research be conducted. Prosthodontists will take on the role of researcher, teacher, and clinician as well as master of diagnosis and treatment. The focus will be on providing a wide range of care advantageous to the patient.

When change is needed, we must be flexible enough to embrace new ideas. Think of the possibilities if stem cell implants could be used instead of titanium endosseous implants, requiring no mechanical interlocking components or gold retaining screws. This is the future for which prosthodontists must be preparing themselves.

Clinical Significance.—While directed at the specialty of prosthodontics, Dr. Wiens’ comments relate to all of dentistry. Advancements in all the various disciplines of our profession in the past 25 years have dramatically changed the scope of what we, as dentists, have to offer to society. With this evolution comes the need for us all to grow as individual practitioners in concert with our profession as a whole.

Wiens JP: Leadership, stewardship, and prosthodontic’s future. Int J Prosthodont 20:456-458, 2007 Reprints available from JP Wiens; e-mail: jonatwiens@aol.com

EXTRACTS NUTS TO STRESS According to Penn State nutritionists, munching pistachios each day can keep your blood pressure lower in stressful situations. Eating about 11⁄2 ounces (about a handful) daily for 1 month provided the lower blood pressure; eating 3 ounces increased artery relaxation and eased the heart’s workload. The 11⁄2 ounce serving delivers 240 calories and 10 g of fat. [Nuts That Soothe Your Nerves. Prevention, August 2007]

EXTRACTS ANOUNCE OF PREVENTION Researchers at 14 US medical centers are testing oral insulin to see if it can prevent Type 1 diabetes among individuals at risk. For some people with islet cell antibodies in their blood, oral insulin may delay the development of Type 1 diabetes for as long as 4 years. [Oral Insulin May Prevent Diabetes. AGD Impact, September 2007, p 29]

Volume 53

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2008

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Foundation restorations in fixed prosthodontics: Current knowledge and future needs Steven M. Morgano, DMD,a and Susan E. Brackett, DDS, MSb Faculty of Dentistry, Kuwait University, Safat, Kuwait, and Oklahoma City, Okla. Purpose. The Ad Hoc Committee on Research in Fixed Prosthodontics established by the Academy of Fixed Prosthodontics publishes a yearly comprehensive literature review on a selected topic. The subject for this year is foundation restorations. Methods. Literature of various in vitro and in vivo investigations that included technical and clinical articles was reviewed to provide clinical guidelines for the dentist when selecting methods and materials for restoration of structurally compromised teeth. Topics discussed and critically reviewed include: (1) desirable features of foundation restorations, (2) foundations for pulpless teeth, (3) historic perspectives, (4) cast posts and cores, (5) role of the ferrule effect, (6) prefabricated posts, (7) direct cores, (8) foundation restorations for severely compromised teeth, (9) problems and limitations, (10) future needs, and (11) directions for future research. Conclusion. This comprehensive review brings together literature from a variety of in vitro and in vivo studies, along with technique articles and clinical reports to provide meaningful guidelines for the dentist when selecting methods and materials for the restoration of structurally compromised teeth. (J Prosthet Dent 1999;82:643-57.)

CLINICAL IMPLICATIONS The topic of foundation restorations involves many materials and techniques used in everyday dental practice. This article comprehensively reviews the dental literature on this subject to provide clinically relevant guidelines for the dentist. Limitations in knowledge are discussed, and suggestions for future research to improve the professionâ&#x20AC;&#x2122;s understanding of the clinical performance of foundation restorations are made.

he Ad Hoc Committee on Research in Fixed Prosthodontics established by the Academy of Fixed Prosthodontics is dedicated to sustaining academic excellence and interest in fixed prosthodontics. The goal of the committee is to disseminate knowledge relevant to fixed prosthodontics with a yearly publication of a comprehensive literature review on a selected topic. The subject for this year is foundation restorations.

PURPOSES OF FOUNDATION RESTORATIONS Successful fixed prosthodontic treatment depends on the ability of cemented cast restorations to resist dislodgment from tooth preparations. The interaction of 3 primary factors appears to influence potential for dis-

Presented to the American Academy of Fixed Prosthodontics Ad Hoc Committee, Chicago, Ill., February 1999. aAssociate Professor of Prosthetic Dentistry and Dental Materials Science, Faculty of Dentistry, Kuwait University. bPrivate practice, Oklahoma City, Okla. DECEMBER 1999

lodgment: (1) design of the tooth preparation, (2) fit of the casting, and (3) nature of the cement. This review will concentrate on methods to improve the design of tooth preparations for structurally compromised teeth by using foundation restorations. Tooth preparations must possess retentive and resistance form to ensure long-term serviceability of fixed prosthodontic restorations. Retention will prevent dislodgment of a casting along a path parallel to the path of insertion of a restoration and resistance will prevent dislodgment along any other path (Fig. 1). The dentition is subjected to a 180-degree field of force vectors (Fig. 2), so resistance form is considered to be more critical than retentive form. However, it is impossible to separate these 2 features.1,2 Resistance has been associated with the degree of taper of a tooth preparation.3 Wiskott et al2 suggested a linear relationship between height or diameter of the preparation and resistance. Grooves have also been shown to enhance the resistance form especially in molars,4 and a recent clinical study of cast restorations indicated a lack of resistance form to the tooth preparations of dislodged castings.5 THE JOURNAL OF PROSTHETIC DENTISTRY 643

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Fig. 2. During function, artificial crown is subjected to 180degree field of force vectors.2

all height of the final cast restoration.6 A foundation restoration made from a restorative material is often indicated when inadequate coronal tooth structure remains to permit development of retentive and resistance form. Shillingburg et al7 advocated the placement of a core reconstruction or foundation restoration when one half or more of the coronal tooth structure is missing, and pins can be used to augment the retention of the foundation restoration.8 After the restorative core material is secured, the tooth with its core reconstruction can be prepared following accepted guidelines for tooth preparations of intact teeth.9

DESIRABLE FEATURES OF FOUNDATION RESTORATIONS

Fig. 1. A, Retention prevents dislodgment of restoration along path of insertion. B, Resistance prevents dislodgment of restoration by forces directed in apical, oblique or horizontal direction.

It is the responsibility of the dentist to incorporate retention and resistance form in the design of the tooth preparation that will receive a cast restoration. Nevertheless, cast restorations are commonly placed on damaged teeth with substantial loss of tooth structure. Retention and resistance form became compromised as the height of the prepared tooth is reduced in relation to the width of the preparations and over644

Foundation restorations replace coronal tooth structure that was lost as a result of dental caries, previous restorations or tooth fracture and may be fabricated from various restorative materials. The desirable features of the foundation restoration vary depending on clinical conditions. Minute depressions or undercuts may be present in a tooth preparation. If adequate retentive and resistance form can be developed from natural tooth structure, strength of the foundation restoration is less critical, and these minor irregularities can be restored with the adhesive restorative materials such as glass ionomer, resinmodified glass ionomer, or compomer cements.10 A foundation restoration that does not contribute to the overall retention and resistance form of the tooth preparation is commonly described as a base. When the foundation restoration augments the retention and resistance provided by the remaining tooth structure, it is usually described as a core reconstruction. VOLUME 82 NUMBER 6

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Physical properties of a core reconstruction become more important as residual intact tooth structure decreases.10 Some desirable features of a core material include adequate compressive strength to resist intraoral forces,11 sufficient flexural strength to prevent flexure of the core during normal intraoral functions,11 biocompatibility,12 resistance to leakage of oral fluids at the core/tooth interface,13,14 ease of manipulation,15 ability to bond to remaining tooth structure,16-18 thermal coefficient of expansion and contraction similar to tooth structure,13 dimensional stability,19 minimal potential for water absorption,20-22 and inhibition of dental caries.23 When retentive and resistance features are derived primarily from the core material, the strength of a foundation restoration and the retention of a core can directly influence survival of the artificial crown. Certain core materials may lack the inherent strength to support a complete crown. A tooth that must serve as an abutment to a fixed or removable prosthesis is subjected to increased stress, and the overall mechanical properties of the core must be adequate to resist these forces. Posterior teeth will be exposed to higher force thresholds than anterior teeth and the direction of the force differs. Therefore, required compressive and flexural strength may differ, depending on the location of the tooth in the dental arch. In addition, a foundation restoration that supports a translucent all-ceramic crown should not adversely effect the esthetic qualities of the final restoration.24

FOUNDATION RESTORATIONS FOR PULPLESS TEETH Historical perspectives The concept of using the root of a tooth for retention of a crown is not new.25 In the 1700s Fauchard inserted wooden dowels in canals of teeth to aid in crown retention.26 Over time the wood would expand in the moist environment to enhance retention of the dowel until, unfortunately, the root would often fracture vertically.25 Additional efforts to develop crowns retained with posts or dowels in the 1800s were limited by the failure of the “endodontic” therapy of the era. Several of the 19th century versions of dowels also used wooden “pivots,” but some dentists reported the use of metal posts favored by Black27 in which a porcelain-faced crown was secured by a screw passing into a gold-lined root canal. A device developed by Clark in the mid-1800s was extremely practical for its time because it included a tube that allowed drainage from the apical area or the canal.28 The Richmond crown was introduced in 1878 and incorporated a threaded tube in the canal with a screwretained crown. The Richmond crown was later modified to eliminate the threaded tube and was redesigned as a 1-piece dowel and crown.29,30 One-piece dowelDECEMBER 1999

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crowns became unpopular because they were not practical. This was evident when divergent paths of insertion of the post-space and remaining tooth structure existed, especially for abutments to fixed partial dentures (FPDs). One-piece dowel-crown restorations also presented problems when the crown or FPD required removal and replacement. These difficulties led to development of a post-and-core restoration as a separate entity with an artificial crown cemented over a core and remaining tooth structure. With the advent of scientific endodontic therapy in the 1950s, the challenges increased for restorative dentistry. Teeth that were commonly extracted without hesitation were successfully treated with predictable endodontic therapy, and a satisfactory restorative solution was necessary, especially for teeth with severe damage. Cast posts and cores became routine methods for restoration of endodontically treated teeth.

CAST POSTS AND CORES The development of cast dowel cores was a logical evolution from the Richmond crown. For endodontically treated anterior teeth with moderate to severe destruction, cast posts and cores have been described as the restorative method of choice.31 Conversely, molars often perform satisfactorily with direct cores retained by engaging the pulpal chamber and a portion of the root canals,32,33 and retention of the core can be augmented by placement of 1 or more prefabricated intraradicular posts. Premolars may be restored with either custom cast posts and cores or prefabricated post(s) with direct cores.

Methods of fabricating cast posts and cores A reliable method for fabricating a custom dowel core is direct fabrication of the pattern.34 The tooth is prepared for the crown after the existing restorations, dental caries, and weakened tooth structure are removed; the post space is then prepared. Guidelines for the length of the post include a length equal to the length of the clinical crown of the final restoration,35 and two thirds or three quarters the length of the root in bone.36 In vivo studies have suggested that clinical success of posts is directly proportional to their lengths; so it is rational to prepare a post channel as long as it is consistent with anatomic limitations while maintaining 4 to 5 mm of apical gutta percha seal.37-40 A shorter post is undesirable because it is less retentive and can produce unfavorable leverage and shear stresses within the root canal that may predispose the root to fracture.41,42 The width of the post is also an important consideration because arbitrarily widening the diameter of the post will reduce the thickness and strength of the radicular dentin.43 Thickness of remaining dentin is critical. The post space should provide resistance to rotation of the dowel core. If the configuration of the prepared 645

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canal is circular in cross section, it will not provide this resistance to rotation. A keyway should be placed within the canal.44 A positive seat for the core at the opening of the post-space is desirable to prevent overseating of the dowel, which may wedge the root and cause vertical fracture.44 Numerous materials have been described for fabrication of the dowel-core pattern. These materials included: wax with a plastic rod as a carrier and support,34,36,45 wax with a dental bur,44 and acrylic resin with a solid plastic sprue.35,46-49 Another method developed a core of acrylic resin with an endodontic file coated with wax that adapted to the prepared canal.50 A variation of the direct custom dowel core incorporated a prefabricated plastic pattern manufactured to correspond to the diameter and configuration of a specific reamer. With this method, the desired reamer was used to instrument the canal, and the matching plastic pattern was inserted into the post channel. Acrylic resin was then adapted to the coronal surface of the post pattern and contoured to the desired form. These prefabricated plastic patterns can be divided into 2 types: (1) precision parallel dowels and (2) precision tapered dowels. Custom cast dowel cores require 2 visits. A primary disadvantage of the direct method of fabricating posts and cores is the chair time to fabricate the pattern. The indirect method conserves chair time by delegating the pattern for the post and core to a dental laboratory technician. Nevertheless, an accurate impression of the prepared post space that extends deeply in the canal of an endodontically treated tooth is a challenge. Success of the indirect method depends on the accuracy of the impression replicating the internal surface of the prepared root canal. Impression material may be injected in the post space and distributed by a spiral paste filler to capture the internal morphology of the canal.51 A rigid object is inserted in the canal before the initial set of impression material to strengthen this impression and minimize potential for distortion. Suggested reinforcement mechanisms include toothpicks,52 wire,53,54 paper clips,55,56 and plastic sprues.57 Prefabricated precision metal posts58 and fit-sized plastic patterns59 offer an alternative approach that uses a pick-up impression. The post space is prepared with the appropriate instruments to conform to the preselected pattern, and the pattern is inserted in the canal with a substantial extension beyond the coronal tooth finish line. An impression is made that picks up the pattern that is transferred to the working cast, and the dowel core can be fabricated by a dental laboratory technician.

Alloys for cast posts and cores Traditionally, custom dowel cores were cast in a gold alloy comparable to the alloys used for complete crowns. For decades the US government maintained a 646

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gold standard that resulted in a fixed, inexpensive price for gold. When this regulation for the price of gold was removed, the cost of gold elevated dramatically in the 1970s. With the cost of gold at unprecedented levels, there was an incentive to develop alternative alloys for cast restorations, and included dowel cores. Base metal alloys traditionally used to cast frameworks for removable partial dentures (RPDs) were suggested as logical alternatives to gold alloys, and their use for dowel cores was advocated.47,60 A major disadvantage of base metal alloys was their hardness because these castings were ground and contoured chairside. Alternative alloys were later introduced to resolve the problems of contouring and finishing posts and cores fabricated from base metal alloys. Dowel cores made from silver-palladium alloys were more easily adjusted chairside and were suitable castings.61 Many properties of these silver-palladium alloys are similar to those of gold casting alloys, and they offer an economical and satisfactory alternative for custom-cast posts and cores.

Cast posts and cores as a method of restoring pulpless teeth Cast dowel cores have been reported to provide excellent service for endodontically treated teeth with moderate-to-severe damage. A 6-year retrospective study of 96 endodontically treated teeth with extensive loss of tooth structure and restoration with the use of cast dowel cores indicated a 90.6% success rate.62 Cast posts are best applied to single-rooted teeth, especially incisors and canines; and the use of custom cast dowel cores, fabricated directly or indirectly, remains an integral component of prosthodontic treatment. A recently reported national survey investigated dentistsâ&#x20AC;&#x2122; philosophies and techniques of restoring endodontically treated teeth. The results indicated that the majority of dentists in the United States used either cast posts exclusively or both cast posts and prefabricated posts in their practices.63

ROLE OF THE FERRULE EFFECT A post and core in a pulpless tooth can transfer occlusal forces intraradicularly with resultant predisposition to vertical fracture of the root.64,65 The role of the final cast restoration in protection of the dowelrestored pulpless tooth has been discussed for decades. In 1959 Frank66 indicated the importance of protective coronal coverage of pulpless teeth, and Rosen44 suggested that the â&#x20AC;&#x153;hugging actionâ&#x20AC;? of a subgingival collar of cast metal provided extracoronal bracing that could prevent fracture of tooth structure. Eissman and Radke67 used the term ferrule effect to describe this 360-degree ring of cast metal and recommended extension of the definitive cast restoration at least 2 mm apical to junction of the core and remaining tooth structure (Fig. 3). VOLUME 82 NUMBER 6

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Fig. 3. Occlusal forces (OF) are transmitted to center of root through post as spreading forces (SF) that can cause vertical fracture of root. If artificial crown extends 2 mm apical to junction of core and tooth, ferrule effect (FE) will resist these spreading forces. Post and core in combination with artificial crown provide coronoradicular stabilization.

In vitro studies by Barkhorder et al68 and Hemming et al69 reported an improved resistance to fracture when encircling collars or ferrules were used with posts. Assif et al70 examined in vitro the effect of post design on the fracture resistance of pulpless premolars restored with cast crowns. Their results indicated that the design of the post did not influence resistance to fracture if the core was covered with a complete cast crown that extended 2 mm apical to the finish line of the core. An in vitro study by Isidor et al71 evaluated the effects of post length and ferrule length on the resistance to dynamic loading of bovine teeth restored with artificial crowns. Resistance to failure was greatest for the group restored with a combination of the longest posts (10 mm) and the longest ferrules (2.5 mm). Libman and Nicholls72 evaluated in vitro the effects of ferrules on the integrity of the cement seal of cast crowns, and reported improved resistance to fatigue failure of the cement seal of a crown when the crown margin extended at least 1.5 mm apical to the margin of the core. Another study indicated that failure of the DECEMBER 1999

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Fig. 4. Pulpless maxillary first premolar with post in buccal root. Occlusal force (large arrow) can produce tensile stresses at lingual aspect of crown margin (small arrow) that may jeopardize integrity of marginal seal of crown.

cement seal of the artificial crown occurred first on the tension side of the tooth, especially when the ferrule was small and the post was off-center (Fig. 4).73 Loss of the cement seal of the coronal restoration is insidious and clinically undetectable initially. Nevertheless, leakage will occur between the crown margin and the tooth surface and may extend into the post space, which could lead to dental caries and potential loss of the tooth.74 A clinical study by Torbjรถrner et al75 retrospectively evaluated the survival and failure characteristics of teeth restored with posts and artificial crowns, and their results indicated a higher potential for fracture of the post when the cemented crowns did not provide a ferrule effect (Fig. 5). Cementation of a post with a dentinal bonding system could theoretically provide internal bracing of the root that substitutes for the extracoronal ferrule. Two recent in vitro studies have suggested this possibility.76,77 Clinical studies to corroborate the internal reinforcement of roots with dentinal bonding systems are lacking. Thus, there is no compelling evidence to suggest abandonment of the classic extracoronal ferrule. 647

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Fig. 5. When ferrule is absent, occlusal forces are concentrated at junction of post and core, and post may fracture.

Shillingburg et al78 have advocated a contrabevel in the tooth preparation for a cast post and core to produce a core with a collar that serves as a secondary ferrule, independent of the ferrule provided by the cast crown. However, Sorensen and Engleman79 reported no advantage to this contrabevel and collar when a crown was cemented over the core. Their results indicated that the ferrule effect was obtained from nearly parallel walls of intact tooth structure coronal to the finish line for the artificial crown and not from the contrabevel on the core preparation.79 They also reported that a 1-mm beveled finish line for a complete crown preparation without additional tooth structure coronal to the bevel did not improve the fracture resistance of the root.79 Loney et al80 conducted an analysis of stresses developed in photoelastic-resin models of maxillary canines restored with cast cores. Half the specimens contained cores with a 1.5-mm collar to provide a ferrule as a component of the core itself, and half omitted this collar. Their results indicated substantially higher mean stresses with the collared cores and suggested that incorporation of a ferrule with a cast core may be undesirable. Milot and Stein81 investigated the ability of beveled tooth preparations to improve the resistance to fracture 648

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of plastic tooth analogs restored with three different post systems. Substantial tooth structure remained coronal to a rounded-shoulder finish line for complete crowns, and a 1-mm bevel was added to half the specimens. The results of their in vitro study indicated an appreciable increase in mean failure thresholds when the length of the ferrule was increased by the addition of a 1-mm bevel to the finish line.81 Despite the well-intended recommendation to develop a cast ferrule as a component of the cast core, there is little evidence to support the contrabevel and ferrule as integral components of a cast core.39,82 Preparation of a contrabevel for the core requires the removal of sound coronal tooth structure and may compromise the ferrule effect from the cemented artificial crown. This design to the post-and-core preparation also results in a final casting with both intracoronal and extracoronal components, which complicates compensation for thermal contraction of the alloy during investing and casting. Finally, this ferrule as a part of the cast core cannot be developed with any of the direct core materials. However, failure of teeth restored with direct core reconstructions has not been associated with the lack of a ferrule effect from the core material when the cemented artificial crown provides a ferrule. Current knowledge has confirmed that the dentist should retain as much coronal tooth structure as possible when preparing pulpless teeth for complete crowns to maximize the ferrule effect. A minimal height of 1.5 to 2 mm of intact tooth structure above the crown margin for 360 degrees around the circumference of the tooth preparation appears to be a rational guideline for this ferrule effect. Surgical crown lengthening83 or orthodontic extrusion84 should be considered with severely damaged teeth to expose additional tooth structure to establish a ferrule. If these provisions for developing a ferrule are impractical, extraction of the tooth and replacement with conventional or implantsupported prosthodontics should be considered.

PREFABRICATED POSTS Prefabricated posts have become more popular, and there is a variety of systems available. A recent nationwide survey of dentists indicated that 40% of general dentists used prefabricated posts most of the time, and the most popular prefabricated post was the parallelsided serrated post.63 The use of prefabricated posts with a direct core reconstruction is often regarded as the restorative method of choice for restoration of pulpless molars with substantial loss of tooth structure.31 These commercially available posts are supplied in various shapes with numerous surface configurations. They may be parallel-sided or tapered. Some parallel-sided posts are tiered, whereby parallelism is maintained but their diameters are narrowed in their apical VOLUME 82 NUMBER 6

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portions where the root is generally thinner. Some prefabricated posts are passive, and others actively engage tooth structure with threads.85,86 Active posts are more retentive, but can generate unfavorable stresses and predispose the root to fracture.87-89 The most retentive passive post is a long, parallel-sided post with a roughened surface, but a parallel-sided post will often require removal of substantial radicular dentin to achieve the desired length.39,41,90-92

Carbon-fiber reinforced epoxy resin posts Most prefabricated posts are metallic, but there are several newer nonmetallic systems available. A post fabricated from a carbon-fiber reinforced epoxy resin was developed in France by Duret and Renaud, and became commercially available in Sweden in 1992.93 Carbonfiber reinforced epoxy resin is a recently introduced dental restorative material composed of unidirectional carbon fibers that are 8 Âľm in diameter embedded in a resin matrix and supporters claim the physical properties are similar to those of natural dentin.94-99 The material is radiolucent and appears to be biocompatible based on cytotoxicity tests reported by TorbjĂśrner et al.99 Two in vitro studies have indicated that these carbonfiber posts possessed inferior strength compared to metal posts.100,101 Nevertheless, an in vitro study of carbonfiber reinforced epoxy resin posts that used bovine teeth suggested that these posts were less likely than metal posts to cause fracture of the root at failure.102 A retrospective short-term clinical study of 236 teeth restored with carbon-fiber reinforced epoxy resin posts reported no failures attributable to the posts after a period of 2 to 3 years of service.103 These posts are manufactured in several configurations (Fig. 6) and are used with composite cores and resin luting agents. Nevertheless their ability to bond to adhesive dental resins appears unremarkable, and their bond can be improved with mechanical retention such as serrations.98,104 At this time the long-term effects of restoring pulpless teeth with these posts are unknown. Although the stiffness of these posts has been reported to be similar to human dentin, Purton and Payne98 reported a transverse modulus of elasticity for these posts that exceeded the values recorded for stainless steel posts. Because of the parallel arrangement of the reinforcing carbon fibers, these posts displayed anisotropic behavior whereby their physical properties differ depending on the loading angles.98 Furthermore, even if the elastic modulus of the post were comparable to human dentin, this property will not ensure similar clinical behavior for the post and radicular dentin. The root is essentially a hollow tube, and the thin rod-shaped post is within this hollow tube surrounded by an intervening layer of composite resin luting agent. The radically different configurations of the root compared with the post combined with the interposed composite resin lutDECEMBER 1999

Fig. 6. Various configurations of commercially available carbon-fiber reinforced epoxy resin posts.

ing material suggest that the flexibility of the post will not match the flexibility of the root. Another in vitro study indicated that the form of the post would influence its rigidity and reported that smooth posts were less flexible than serrated posts.104 A flexible post can be detrimental especially when there is little remaining natural tooth structure between the margin of the core and the gingival extension of the artificial crown. When the ferrule is absent or extremely small, occlusal loads may cause the post to flex with eventual micromovement of the core, and the cement seal at the margin of the crown may fracture in a short time (Fig. 7). Marginal leakage with recurrent dental caries will ensue, but the deterioration will be unnoticed until substantial destruction of tooth structure occurs.74

Zirconia posts With recent advances in ceramic technology, the allceramic crown has become more popular. However, restoring a pulpless tooth with a metal post and core in combination with an all ceramic crown is a challenge. The underlying metal from the post and core can alter the optical effects of a translucent all-ceramic crown and compromise the esthetics. In response to the need for a post that possesses optical properties compatible with an all-ceramic 649

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Fig. 8. Commercially available post made from zirconium oxide.

Fig. 7. Flexible post may allow micromovement of core (small arrow) under occlusal load (large arrow) when ferrule is small or absent with resultant fracture of cement seal at crown margin (curved arrow).

core was formed over the prefabricated zirconia post to develop a post and core that was entirely ceramic. Clinical trials are lacking with this new all-ceramic post, and the ability of these posts to resist intraoral forces are unknown. Ceramics are tough materials with high compressive strengths, but are brittle when subjected to shearing forces.117,118 An alternative to this all-ceramic post is a cast post and core made from a metal ceramic alloy. Opaque porcelain can be fused to the core portion to provide a durable post and core that will disguise the graying effect that can occur with conventional cast metal posts and cores when combined with all-ceramic crowns.119

Woven-fiber composite materials crown, an all-ceramic post has been developed (Fig. 8).24,105-108 This post is composed of zirconium oxide, a material that has been used in medicine for orthopedic implants. Animal studies have indicated stability after long-term aging of this ceramic material without evidence of degradation.109,110 The post is made from fine-grain, dense tetragonal zirconium polycrystals (TZP),111,112 and the zirconia post has been reported to possess high flexural strength and fracture toughness.113 This radiopaque material is biocompatible with some physical properties similar to steel.113-115 The zirconia post was designed for use with an adhesive resin cement, and one in vitro study has recorded poor resin-bonding capabilities of this post to radicular dentin after dynamic loading and thermocycling.116 These posts were also designed for use with a composite core material, but a large composite core may not be sufficiently rigid to support a brittle all-ceramic crown.11,20 Sorensen24 described a method of combining this post with IPS Empress pressed-glass technology to compensate for the disadvantages of a composite core for an all-ceramic restoration. A custom glass-ceramic 650

The manufacturer of a cold-glass plasma-treated polyethylene woven-fiber has suggested this material in a resin composite to provide coronoradicular stabilization for pulpless teeth.120,121 The fibers are multidirectional and developers of the material have suggested a number of uses.122 An in vitro study of this material with extracted human teeth indicated that woven-fiber composite posts and cores were significantly weaker than cast metal posts and cores.123 Nevertheless, when this woven-fiber composite was reinforced with a smaller-diameter prefabricated post, the strength of the system increased significantly.123 These prefabricated posts embedded in the woven-fiber composite were not as strong as cast posts and cores, but were less likely to cause fracture of the roots when subjected to failure loads.123

CEMENTS AND CEMENTATION OF POSTS Dental cements Dental cements lute the post to radicular dentin, and properties such as compressive strength, tensile strength, and adhesion of the cement are commonly VOLUME 82 NUMBER 6

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described as predictors for success of a cemented post. Other factors such as potential for plastic deformation, microleakage, water imbibition, behavior of the cement during the setting process, and handling characteristics can also influence the survival rate of a cemented post. There are several luting agents currently available to the dentist and they include: zinc phosphate, polycarboxylate, glass ionomer, resin-modified glass ionomer, compomer, and resin cements. These different classes of cements represent a variety of products by a number of dental manufacturers. There are distinct advantages and inherent disadvantages to each product. Zinc phosphate cement is the standard cement used for decades to lute dental restorations, and this cement has been extremely successful. The primary disadvantages of zinc phosphate cement are solubility in oral fluids and lack of true adhesion. Polycarboxylate and glass ionomer cements provide a weak chemical bond to dentin.124,125 Polycarboxylate cements have been reported to undergo plastic deformation after cyclic loading and may be less retentive than zinc phosphate and glass ionomer cements.126 Glass ionomer cement has been reported to release fluoride127-129; nevertheless the ability of glass ionomer cement to inhibit dental caries in dentin has not been clearly demonstrated.130 Resin-modified glass ionomer cements possess similar chemical properties and also can leach fluoride131,132; however, objective proof of the clinical benefit of this fluoride release is also lacking.133 Adhesive resins are essentially insoluble and provide better retention in vitro compared with nonadhesive resins and conventional cements.134 There are peculiarities to the handling characteristics and clinical behavior of each class of cement. Glass ionomer cement requires several days135 or even several weeks136 to reach its maximal strength, so it is unsuitable as a luting agent for posts. Any recontouring of the core with a dental handpiece soon after cementation of the post will cause vibration of the post that may weaken the immature cement film and contribute to eventual retentive failure of the post. Resin-modified glass ionomer cement has become popular for cementation of complete crowns, and its use has been suggested for cementation of posts.137,138 However, this class of cement imbibes water and expands with time,139,140 and there is anecdotal evidence that volumetric expansion of this cement will fracture all-ceramic crowns relatively soon after cementation.141 If this cement can fracture all-ceramic crowns, its expansion will likely cause vertical fracture of roots if selected to cement posts. Therefore, it appears at this time that resin-modified glass ionomer cements should be avoided for cementation of posts. Resinous cements have been studied extensively, and several investigations have evaluated the ability of adhesive resins to retain intraradicular posts. Some studies DECEMBER 1999

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Fig. 9. Study of pulpless premolars restored with MOD silver amalgam restorations (A), resin-bonded MOD inlays (B), and MOD onlays cemented with zinc phosphate cement (C) indicated best fracture resistance with onlays.

have reported significantly greater retention for posts cemented with adhesive resins,142-145 whereas others have reported conflicting results.146-148 One factor that has a detrimental effect on resinous cements is eugenol contamination of dentin. The setting process of dental resins occurs by free-radical addition polymerization, and this process can be inhibited by phenolic compounds, such as eugenol (2-methoxy-4-allyphenol).146 Most endodontic sealers contain eugenol, and the obturation of the root canal occurs by condensation of the gutta percha filling material under pressure to force the eugenol-containing liquid sealer into the dentinal tubules and lateral canals. After eugenol has penetrated dentin, it is difficult to remove, and the presence of eugenol in the radicular dentin can explain the inconsistent results reported for posts cemented with adhesive resins.142,146,148,149 The ability of resins to bond to dentin and restorative materials can enhance retention, but this increased retention may not ensure resistance to dislodgment of the post with normal clinical conditions. One study has reported extremely high retentive values for an unfilled 4-META resinous cement,142 but this cement is relatively weak and has been reported to undergo plastic deformation that will likely lead to fatigue failure in vivo.150 Adhesive resin cements are also technique sensitive, and Mendosa and Eakle147 have reported difficulty in manipulating a resinous cement in vitro. For example, some posts did not seat completely in their post channels because of premature setting of the resin. Resin cements have also been suggested as a method to reinforce pulpless teeth. One study evaluated the ability of inlays cemented with resin bonded procedures in posterior pulpless teeth to bond together the remaining tooth structure and eliminate the need to cover and surround the cusps with a cast restoration. This study compared the fracture resistance of extracted endodontically treated premolars restored with MOD silver amalgam restorations, resin-bonded MOD inlays, and MOD onlays cemented with zinc phosphate cement (Fig. 9). The greatest resistance to fracture was 651

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of the available cements possess physical properties that are capable of compensating for problems commonly associated with a poorly designed post. A short, wide, overly tapered post combined with an artificial crown lacking an adequate ferrule is more likely to fail regardless of cement. If a post is fabricated consistent with sound biomechanical principles, following guidelines in a standard prosthodontic text, conventional cements such as zinc phosphate cement are satisfactory.

DIRECT CORES Core materials

Fig. 10. Cement was placed on post only. As post is seated (large arrow) entrapped air within canal (small arrows) escapes through liquid cement, creating voids in cement film.

recorded for MOD onlays cemented with zinc phosphate cement.151

Cementation of posts If cement is placed on the post only when it is cemented, air will be trapped deeply in the prepared canal, and as the post is seated the air will travel through the liquid cement to create voids that will compromise the physical properties of the cement film (Fig. 10). Filling the canal with cement before seating the post will avoid air entrapment and ensure a dense uniform cement lute.152 Nevertheless few dental cements provide adequate working time to introduce cement into the canal before the post is seated, and resin cements are especially prone to premature setting if this procedure is attempted. Tjan et al146 have demonstrated substantial voids with an adhesive resin cement, and suggested that these voids were responsible for the unexpected low retentive values for posts luted with the resin cement. Zinc phosphate cement is especially well suited for placement of the cement in the canal before seating of the post because of its extended working time.152 To date, there have not been any long-term clinical trials of cemented posts that demonstrate the superiority of a specific cement, and most dentists will select a cement empirically. Studies have confirmed that none 652

The three basic direct core materials are silver amalgam, composite, and glass ionomerâ&#x20AC;&#x201C;based core materials. There have been numerous in vitro experiments that have investigated the physical properties of these core materials. Some studies have been conducted with crowns cemented over cores to more appropriately mimic clinical conditions, and others have loaded the core materials directly to determine their strengths. Conclusions often differ depending on the design of the study, and factors such as applied loading angle have been shown to substantially alter the results.153 Properties that are important predictors of the clinical behavior of a core material include compressive, shear and tensile strengths, along with rigidity.154,155 Silver amalgam has been reported to perform best as a core material under simulated clinical conditions because of its high compressive strength and rigidity.11,156 Conversely, a number of studies have indicated that materials derived from glass ionomer cement perform poorly as a load-bearing core material.155-160 Composite has a strength intermediate between silver amalgam and glass ionomer core material and is more flexible than silver amalgam.11 It appears that composite is an acceptable direct core material when substantial coronal tooth structure remains,155,157-161 but less desirable when there is limited supporting dentin.11 Composite is also difficult to condense adequately in the tooth preparation, and a syringe technique has been reported to produce a denser core compared with a bulk-insertion technique.162 Several composite core materials contain a fluorosilicate inorganic filler similar to the aluminum fluorosilicate glass in glass ionomer cements. Consequently, these composites release trace amounts of fluoride that may continue for up to 5 years.163,164 Nevertheless, as with the fluoride leached from glass ionomer cements, clinically relevant cariostatic properties have not been established with these fluoride-containing composite core materials.

Bonded cores Contemporary adhesive dentistry allows for the bonding of cores to the remaining tooth structure.16,17,165-167 Bonding techniques will augment the VOLUME 82 NUMBER 6

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mechanical retention of a core, but should not be used as the sole means of retention.18,165,168 The high fracture strength of silver amalgam can be improved in vitro with the use of an amalgam bonding agent, although the clinical relevance of the effect of the bonding procedure after prolonged intraoral function are unknown.17 Amalgam bonding techniques result in an adhesive resin at the interface between the tooth and the silver amalgam, and marginal leakage has been reported after in vitro aging for 30 days.169 However, leakage at the core margin should not be a problem when amalgam bonding agents are used because the margins of the artificial crown completely cover the core/tooth interface.

FOUNDATION RESTORATIONS FOR SEVERELY COMPROMISED TEETH In the past pulpless molars were resected and restored with complex restorative techniques as a method to retain compromised teeth and avoid the need for removable prosthetic restorations.170 These restorative procedures are technically demanding and expensive. A failure rate ranging from 32% to 38% within the first 10 years of service has been reported for resected molars,171,172 although teeth that survived 10 years appeared to have a better long-term prognosis.173 Construction of a foundation restoration to retain a complete crown is especially difficult with a resected tooth, and a relatively high percentage of failures appeared to be the result of restorative failures and faulty resective procedures.174 With the advent of predictable osseointegrated implants to support and retain prosthetic restorations,175-179 the practice of retaining severely compromised teeth has diminished substantially. Often it is in the best interest of the patient to extract teeth with a poor prognosis and replace the compromised teeth with implant-supported artificial crowns or FPDs.

CURRENT PROBLEMS AND LIMITATIONS Despite the large volume of published research on foundation restorations, major gaps exist in the professionâ&#x20AC;&#x2122;s current knowledge on this topic. There are numerous in vitro studies of different approaches to foundation restorations, primarily involving methods of restoring pulpless teeth; but data from these in vitro investigations are frequently conflicting and not always applicable clinically.31 Several retrospective clinical studies of restored pulpless teeth have been reported in the literature.28,37,180-185 Nevertheless, the results of these studies are also conflicting, and it is difficult to formulate meaningful clinical guidelines based on diametrically opposed results. With any retrospective study, there are problems with control of the treatment methods, and the proceDECEMBER 1999

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dures provided are commonly biased. For example, it can be assumed that the dentists who provided treatment for the patients surveyed in a retrospective study used clinical judgment to select the method of treatment. Teeth with minimal remaining coronal dentin may have been restored with custom cast posts and cores, and those with substantial residual tooth structure may have received prefabricated posts or foundation restorations without posts. Consequently, with this hypothetical treatment protocol, the teeth restored with cast posts would be at a higher risk of failure not because of any inherent problems with the procedure but because the dentists selected cast posts and cores for teeth with the least supporting dentin and the poorest prognosis.

FUTURE NEEDS With the advent of new materials and techniques, additional in vitro and in vivo studies are required to fully evaluate the efficacy of these recent developments. The carbon-fiber reinforced epoxy resin post and zirconia post, as well as recently introduced cements and bonding techniques, are among these new materials and procedures. Currently, there is sparse scientific knowledge relative to the long-term prognosis of teeth restored with these approaches. Further improvements in direct core materials would also be welcome. Silver amalgam is the most mechanically sound core material, but health concerns about its mercury content continue.186 A silver amalgam core is eventually totally covered with a complete artificial crown and not exposed to the oral environment; thus, a silver amalgam core is unlikely to contribute any systemic mercury to the patient. Nevertheless, the day may come when silver amalgam is not available in dentistry for any purposes, and a suitable substitute for direct cores will be necessary. Composite core materials can provide favorable mechanical results when there is adequate remaining supportive dentin, but the flexibility of current formulations limit their use when extensive coronal tooth structure is missing. Reinforcement with silanized glass fibers or polymer-impregnated fibers has been suggested as a method of improving the flexural strength of dental resins. This approach may improve the physical properties of resin-based core materials.187 In addition, health related issues may also arise with composites. Organic constituents have been reported to leach from dental composite resins, and the biologic effects of these eluded organic materials are unknown.188-191

SUGGESTED DIRECTIONS FOR FUTURE RESEARCH Randomized controlled clinical trials would provide the most reliable data on the prognosis of teeth restored with foundation restorations, but these studies 653

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are prohibitive, and data relative to long-term success rates would be unavailable for many years. Retrospective clinical studies are more cost-effective, and if well executed, can serve as reasonable alternatives to randomized controlled clinical trials. The dental profession needs more high-quality retrospective clinical studies on this topic, and investigations of patients treated in a relatively controlled environment such as a dental school would likely provide more valid results than those reported from the currently available retrospective investigations. For maximal reliability and validity, retrospective data should be collected from large groups of patients, with records chosen randomly by chance from a pool of patients who received treatment that is consistent with recommended procedures found in standard texts.

SUMMARY The topic of foundation restorations involves many materials and techniques used daily in dental practice. This comprehensive article reviewed literature from various in vitro and in vivo investigations in addition to technical and clinical reports to provide meaningful guidelines for selection of methods and materials for restoration of structurally compromised teeth. Limitations in current knowledge of this topic and directions for future research were also suggested. We thank Dr Nadim Baba and Mr Bruce Spector for the photography of Figures 6 and 8.

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46. Bartlett SO. Construction of detached core crowns for pulpless teeth in only two sittings. J Am Dent Assoc 1968;77:843-5. 47. DeDomenico RJ. Technique for the fabrication of a cast post and core with nonprecious metal. J Am Dent Assoc 1977;94:1139-41. 48. Rosenberg PA, Antonoff SJ. Gold posts. Common problems in preparation and technique for fabrication. NY State Dent J 1971;37:601-6. 49. Stern N. A direct pattern technique for posts and cores. J Prosthet Dent 1972;28:279-83. 50. Miller AW. Direct pattern techniques for post and cores. J Prosthet Dent 1978;40:392-7. 51. Sall HD. Restorative techniques for endodontically treated teeth. Dent Surv 1977;53:45-7. 52. Michnick BT, Raskin RB. A multiple post-core technique. J Prosthet Dent 1978;39:622-6. 53. Dooley BS. Preparation and construction of post-retention crowns for anterior teeth. Aust Dent J 1967;12:544-50. 54. McLean JW. The alumina tube post crown. Br Dent J 1967;123:87-92. 55. Baraban DJ. The restoration of pulpless teeth. Dent Clin North Am 1967;Nov:633-53. 56. Fellman S. Indirect technique for gold core and crown restoration for non-vital teeth. Dent Surv 1964;40:41-3. 57. Mazzuchelli L. Post and core construction. R I Dent J 1972;5:11-5. 58. Rosentiel E. Impression technique for cast core preparations. Br Dent J 1967;123:599-600. 59. Chiche GJ, Mikhail MG. Laminated single impression technique for cast posts and cores. J Prosthet Dent 1985;53:325-8. 60. Pinkley VA, Morris DR. Use of nonprecious metal for cast dowel and core. J Prosthet Dent 1974;32:78-9. 61. Dale JW, Moser J. A clinical evaluation of semiprecious alloys for dowels and cores. J Prosthet Dent 1977;38:161-4. 62. Bergman B, Lundquist P, Sjogren U, Sundquist G. Restorative and endodontic results after treatment with cast posts and cores. J Prosthet Dent 1989;61:10-5. 63. Morgano SM, Hashem AF, Fotoohi K, Rose L. A nationwide survey of contemporary philosophies and techniques of restoring endodontically treated teeth. J Prosthet Dent 1994;72:259-67. 64. Guzy GE, Nicholls JI. In vitro comparison of intact endodontically treated teeth with and without endo-post reinforcement. J Prosthet Dent 1979;42:39-44. 65. Trope M, Maltz DO, Tronstad L. Resistance to fracture of restored endodontically treated teeth. Endodont Dent Traumatol 1985;1:108-11. 66. Frank AL. Protective coverage of pulpless teeth. J Am Dent Assoc 1959; 59:895-900. 67. Eissman HF, Radke RA. Postendodontic restoration. In: Cohen S, Burns RC, editors. Pathways of the pulp. 4th ed. St Louis: CV Mosby; 1987. p. 640-3. 68. Barkhordar RA, Radke R, Abbasi J. Effect of metal collars on resistance of endodontically treated teeth to root fracture. J Prosthet Dent 1989;61: 676-8. 69. Hemmings KW, King PA, Setchell DJ. Resistance to torsional forces of various post and core designs. J Prosthet Dent 1991;66:325-9. 70. Assif D, Bitenski A, Pilo R, Oren E. Effect of post design on resistance to fracture of endodontically treated teeth with complete crowns. J Prosthet Dent 1993;69:36-40. 71. Isidor F, Brondum K, Ravnholt G. The influence of post length and crown ferrule length on the resistance to cyclic loading of bovine teeth with prefabricated titanium posts. Int J Prosthodont 1999;12:78-82. 72. Libman WJ, Nicholls JI. Load fatigue of teeth restored with cast posts and cores and complete crowns. Int J Prosthodont 1995;8:155-61. 73. Fan P, Nicholls JI, Kois JC. Load fatigue of five restoration modalities in structurally compromised premolars. Int J Prosthodont 1995;8:213-20. 74. Freeman MA, Nicholls JI, Kydd WL, Harrington GW. Leakage associated with load fatigue-induced preliminary failure of full crowns placed over three different post and core systems. J Endod 1998;24:26-32. 75. Torbjörner A, Karlsson S, Ödman PA. Survival rate and failure characteristics for two post designs. J Prosthet Dent 1995;73:439-44. 76. Saupe WA, Gluskin AH, Radke RA Jr. A comparative study of fracture resistance between morphologic dowel and cores and a resin-reinforced dowel system in the intraradicular restoration of structurally compromised roots. Quintessence Int 1996;27:483-91. 77. Mendoza DB, Eakle WS, Kahl EA, Ho R. Root reinforcement with a resinbonded preformed post. J Prosthet Dent 1997;78:10-4. 78. Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamen-

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tals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997. p. 204. 79. Sorensen JA, Engleman MJ. Ferrule design and fracture resistance of endodontically treated teeth. J Prosthet Dent 1990;63:529-36. 80. Loney RW, Kotowicz WE, McDowell GC. Three-dimensional photoelastic stress analysis of the ferrule effect in cast post and cores. J Prosthet Dent 1990;63:506-12. 81. Milot P, Stein RS. Root fracture in endodontically treated teeth related to post selection and crown design. J Prosthet Dent 1992;68:428-35. 82. Hunter AJ, Hunter AR. The treatment of endodontically treated teeth. Curr Opin Dent 1991;1:199-205. 83. Smukler H, Chaibi M. Periodontal and dental considerations in clinical crown extension: a rational basis of treatment. Int J Periodontics Restorative Dent 1997;17:464-77. 84. Kocadereli I, Tasman F, Guner SB. Combined endodontic-orthodontic and prosthodontic treatment of fractured teeth. Case report. Aust Dent J 1998;43:28-31. 85. Kurer PF. The Kurer anchor system for the post crown restoration. J Ont Dent Assoc 1968;45:57-60. 86. Musikant BL, Deutsch AS. A new prefabricated post and core system. J Prosthet Dent 1984;52:631-4. 87. Standlee JP, Caputo AA, Holcomb J, Trabert KC. The retentive and stressdistributing properties of a threaded endodontic dowel. J Prosthet Dent 1980;44:398-404. 88. Standlee JP, Caputo AA, Holcomb JP. The Dentatus screw: comparative stress analysis with other endodontic dowel designs. J Oral Rehabil 1982;9:23-33. 89. Standlee JP, Caputo AA. The retentive and stress distributing properties of split threaded endodontic dowels. J Prosthet Dent 1992;68:436-42. 90. Standlee JP, Caputo AA, Hanson EC. Retention of endodontic dowels: effects of cement, dowel length, diameter and design. J Prosthet Dent 1978;38:400-5. 91. Johnson JK, Sakumura JS. Dowel form and tensile force. J Prosthet Dent 1978;40:645-9. 92. Standlee JP, Caputo AA. Effect of surface design on retention of dowels cemented with a resin. J Prosthet Dent 1993;70:403-5. 93. Duret B, Reynaud M, Duret F. A new concept of corono-radicular reconstruction: the Composipost (2). [in French] Chir Dent Fr 1990;60:69-77. 94. Yazdanie N, Mahood M. Carbon fiber acrylic resin composite: an investigation of transverse strength. J Prosthet Dent 1985;54:543-7. 95. Malquarti G, Berruet RG, Bois D. Prosthetic use of carbon fiber-reinforced epoxy resin for esthetic crowns and fixed partial dentures. J Prosthet Dent 1990;63:251-7. 96. King PA, Setchell DJ. An in vitro evaluation of a prototype CFRC prefabricated post developed for the restoration of pulpless teeth. J Oral Rehabil 1990;17:599-609. 97. Vigule G, Malquarti G, Vincent B, Bourgeois D. Epoxy/carbon composite resins in dentistry: mechanical properties related to fiber reinforcements. J Prosthet Dent 1994;72:245-9. 98. Purton DG, Payne JA. Comparison of carbon fiber and stainless steel root canal posts. Quintessence Int 1996;27:93-7. 99. Torbjörner A, Karlsson S, Syverud M, Hensten-Pettersen A. Carbon fiber reinforced root canal posts. Mechanical and cytotoxic properties. Eur J Oral Sci 1996;17:599-609. 100. Sidoli GE, King PA, Setchell DJ. An in vitro evaluation of a carbon fiberbased post and core system. J Prosthet Dent 1997;78:5-9. 101. Martinez-Insua A, da Silva L, Rilo B, Santana U. Comparison of the fracture resistances of pulpless teeth restored with a cast post and core or carbon-fiber post with a composite core. J Prosthet Dent 1998;80:527-32. 102. Isidor F, Odman P, Brondum K. Intermittent loading of teeth restored using prefabricated carbon fiber posts. Int J Prosthodont 1996;9:131-6. 103. Fredriksson M, Astbäck J, Pamenius M, Arvidson K. A retrospective study of 236 patients with teeth restored by carbon fiber-reinforced epoxy resin posts. J Prosthet Dent 1998;80:151-7. 104. Love RM, Purton DG. The effect of serrations on carbon fibre posts— retention within the root canal, core retention, and post rigidity. Int J Prosthodont 1996;9:484-8. 105. Myenberg KH, Luthy H, Scharer P. Zirconia post: a new all-ceramic concept for non-vital abutment teeth. J Esthet Dent 1995;7:73-80. 106. Pissis P. Fabrication of a metal-free ceramic restoration utilizing the monobloc technique. Prac Periodontics Aesthet Dent 1995;7:83-94. 107. Zalkind M, Hochman N. Esthetic considerations in restoring endodontically treated teeth with posts and cores. J Prosthet Dent 1998;79:702-5.

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108. Zalkind M, Hochman N. Direct core buildup using a preformed crown and prefabricated zirconium oxide post. J Prosthet Dent 1998;80:730-2. 109. Akagawa Y, Ichikawa Y, Nikai H, Tsuru H. Interface histology of unloaded and early loaded partially stabilized zirconia endosseous implant in initial bone healing. J Prosthet Dent 1993;69:599-604. 110. Cales B, Stefani Y, Lilley E. Long-term in vivo and in vitro aging of a zirconia ceramic used in orthopaedy. J Biomed Mat Res 1994;28:619-24. 111. Gubta TK, Lange FF, Bechtold JH. Effect of stress-induced phase transformation on the metastable tetragonal phase. J Mat Sci 1978;13:1464-70. 112. Schweiger M, Frank M, Rheinburger V, Holand W. New sintered glassceramics based on apatite and zirconia. Proceedings of the International Symposium on Glass Problems. Istanbul, Turkey. ICG 1996;2:229-35. 113. Hulbert SF, Morrison SJ, Klawitter JJ. Tissue reaction to three ceramics of porous and non-porous structure. J Biomed Mater Res 1972;6:347-74. 114. Porter DL, Heuer AH. Mechanism of toughening partially stabilized zirconia ceramics (PSZ) J Am Ceram Soc 1977;60:183-4. 115. Ichikawa Y, Akagawa Y, Nikai H, Tsuru H. Tissue compatibility and stability of a new zirconia ceramic in vivo. J Prosthet Dent 1992;68:322-6. 116. Dietschi D, Romelli M, Goretti A. Adaptation of adhesive posts and cores to dentin after fatigue testing. Int J Prosthodont 1997;10:498-507. 117. Jones DW. The strength and strengthening mechanisms of dental ceramics. In: McLean JW, editor. Dental ceramics: proceedings of the first international symposium on ceramics. Chicago: Quintessence; 1983. p. 83141. 118. Ban S, Anusavice KJ. Influence of test method on failure stress of brittle dental materials. J Dent Res 1990;69:1791-9. 119. Hochstedler J, Huband M, Poillion C. Porcelain-fused-to-metal post and core: an esthetic alternative. J Dent Tech 1996;13:26-9. 120. Ribbond Inc. Constructing a Ribbond composite-laminate endo post and core. In: Ribbond bondable reinforcement ribbon: instruction manual. Seattle: Ribbond, Inc; 1992-1997. p. 21-6. 121. Karna JC. A fiber composite laminate endodontic post and core. Am J Dent 1996;9:230-2. 122. Rudo DN, Karbhari VM. Physical behaviors of fiber reinforcement as applied to tooth stabilization. Dent Clin North Am 1999;43:7-35. 123. Sirimai S, Riis DN, Morgano SM. An in vitro study of the fracture resistance and the incidence of vertical root fracture of pulpless teeth restored with six post-and-core systems. J Prosthet Dent 1999;81:262-9. 124. Smith DC. A new dental cement. Br Dent J 1968;124:381-4. 125. Wilson AD, Prosser HJ, Powis DM. Mechanism of adhesion of polyelectrolyte cements to hydroxyapatite. J Dent Res 1983;62:590-2. 126. Oilo G. Luting cements: a review and comparison. Int Dent J 1991; 41:81-8. 127. Scoville RK, Foreman F, Burgess JO. In vitro fluoride uptake by enamel adjacent to a glass ionomer luting cement. ASDC J Dent Child 1990; 57:352-5. 128. Rezk-Lega F, Ogaard B, Rolla G. Availability of fluoride from glassionomer luting cements in human saliva. Scand J Dent Res 1991;99:603. 129. Marcushamer M, Garcia-Godoy F, Chan DC. Caries protection after orthodontic band cementation with glass ionomer. ASDC J Dent Child 1993;60:300-3. 130. Staninec M, Giles WS, Saiku JM, Hattori M. Caries penetration and cement thickness of three luting agents. Int J Prosthodont 1998;1:259-63. 131. Musa A, Pearson GJ, Gelbier M. In vitro investigation of fluoride ion release from four resin-modified glass polyalkenoate cements. Biomaterials 1996;17:1019-23. 132. Chung CK, Millett DT, Creanor SL, Gilmour WH, Foye RH. Fluoride release and cariostatic ability of a compomer and a resin-modified glass ionomer cement used for orthodontic bonding. J Dent 1988;26:533-8. 133. Kreulen CM, de Soet JJ, Weerheijm KL, van Amerongen WE. In vivo cariostatic effect of resin modified glass ionomer cement and amalgam on dentine. Caries Res 1997;31:384-9. 134. Tjan AH, Li T. Seating and retention of complete crowns with a new adhesive resin cement. J Prosthet Dent 1992;67:478-83. 135. Mojon P, Hawbolt EB, MacEntee MI, Ma PH. Early bond strength of luting cements to a precious alloy. J Dent Res 1992;71:1633-9. 136. Matsuya S, Maeda T, Ohta M. IR and NMR analyses of hardening and maturation of glass-ionomer cement. J Dent Res 1996;75:1920-7. 137. Hunt PR, Gogarnoiu D. Evolution of post and core systems. J Esthet Dent 1996;8:74-83. 138. Mitchell CA, Orr JF. Comparison of conventional and resin-modified glass-ionomer luting cements in the retention of post-crowns by fatigue loading. J Oral Rehabil 1998;25:472-8.

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139. Small IC, Watson TF, Chadwick AV, Sidhu SK. Water sorption in resinmodified glass-ionomer cements: an in vitro comparison with other materials. Biomaterials 1998;19:545-50. 140. Irie M, Nakai H. Flexural properties and swelling after storage in water of polyacid-modified composite resin (compomer). Dent Mater J 1998;17: 77-82. 141. Miller MB. The reality of nonscience-based newsletters. Quintessence Int 1996;27:655-6. 142. Standlee JP, Caputo AA. Endodontic dowel retention with resinous cements. J Prosthet Dent 1992;68:913-7. 143. Leary JM, Holmes DC, Johnson WT. Post and core retention with different cements. Gen Dent 1995;43:416-9. 144. Duncan JP, Pameijer CH. Retention of parallel-sided titanium posts cemented with six luting agents: an in vitro study. J Prosthet Dent 1998;80:423-8. 145. Junge T, Nicholls JI, Phillips KM, Libman WJ. Load fatigue of compromised teeth: a comparison of 3 luting cements. Int J Prosthodont 1998;11:558-64. 146. Tjan AH, Nemetz H. Effect of eugenol-containing endodontic sealer on retention of prefabricated posts luted with an adhesive composite resin cement. Quintessence Int 1992;23:839-44. 147. Mendoza DB, Eakle WS. Retention of posts cemented with various dentinal bonding cements. J Prosthet Dent 1994;72:591-4. 148. Schwartz RS, Murchison DF, Walker WA 3rd. Effects of eugenol and noneugenol endodontic sealer cements on post retention. J Endod 1998;24:564-7. 149. al-Wazzan KA, al-Harbi AA, Hammad IA. The effect of eugenol-containing temporary cement on the bond strength of two resin composite core materials to dentin. J Prosthodont 1997;6:37-42. 150. White SN, Yu Z. Physical properties of fixed prosthodontic, resin composite luting agents. Int J Prosthodont 1993;6:384-9. 151. Costa LC, Pegoraro LF, Bonfante G. Influence of different metal restorations bonded with resin on fracture resistance of endodontically treated maxillary premolars. J Prosthet Dent 1997;77:365-9. 152. Jacobi R, Shillingburg HT Jr. Pins, dowels, and other retentive devices in posterior teeth. Dent Clin North Am 1993;37:367-90. 153. Huysmans MC, Van Der Varst PG, Peters MC, Plasschaert AJ. The Weibull distribution applied to post and core failure. Dent Mater 1992:8:283-8. 154. Yaman P, Thorsteinsson TS. Effect of core materials on stress distribution in posts. J Prosthet Dent 1992;68:416-20. 155. Levartovsky S, Kuyinu E, Georgescu M, Goldstein GR. A comparison of the diametral tensile strength, the flexural strength, and the compressive strength of two new core materials to a silver alloy-reinforced glassionomer material. J Prosthet Dent 1994;72:481-5. 156. Russell MD, Masood M, Cunningham L. The behavior of post-retained core materials supported by coronal tooth structure in vitro. Int Endod J 1997;30:408-12. 157. Cohen BI, Deutsch AS, Condos S, Musikant BL, Scherer W. Compressive and diametral tensile strength of titanium-reinforced composites. J Esthet Dent 1992;4(suppl):50-5. 158. Cohen BI, Condos S, Deutsch AS, Musikant BL. Fracture strength of three different core materials in combination with three different endodontic posts. Int J Prosthodont 1994;7:178-82. 159. Cohen BI, Pagnillo MK, Condos S, Deutsch AS. Four different core materials measured for fracture strength in combination with five different designs of endodontic posts. J Prosthet Dent 1996;76:487-95. 160. Cohen BI, Pagnillo MK, Newman I, Musikant BL, Deutsch AS. Cyclic fatigue testing of five endodontic post designs supported by four core materials. J Prosthet Dent 1997;78:458-64. 161. Sornkul E, Stannard JG. Strength of roots before and after endodontic treatment and restoration. J Endod 1992;18:440-3. 162. Mentink AG, Meeuwissen R, Hoppenbrouwers PP, Kayser AF, Mulder J. Porosity in resin composite core restorations: the effect of manipulative techniques. Quintessence Int 1995;26:811-5. 163. Cohen BI, Deutsch AS, Musikant BL. Fluoride release from four reinforced composite resins: a one year study. Oral Health 1995;85:78,10,13-4. 164. Cohen BI, Pagnillo MK, Deutsch AS, Musikant BL. A five year study. Fluoride release of four reinforced composite resins. Oral Health 1998;88:81-6. 165. Ruzickova T, Staninec M, Marshall GW, Hutton JE. Bond strengths of the adhesive resin-amalgam interface. Am J Dent 1997;10:192-4. 166. Staninec M, Marshall GW, Lowe A, Ruzickova T. Clinical research on

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bonded amalgam restorations. Part 1: SEM study of in vivo bonded amalgam restorations. Gen Dent 1997;45:356-62. 167. Staninec M, Marshall GW, Lowe A, Ruzickova T. Clinical research on bonded amalgam restorations. Part 2: Further studies and clinical techniques. Gen Dent 1997;45:361-2. 168. Ianzano JA, Mastrodomenico J, Gwinnett AJ. Strength of amalgam restorations bonded with Amalgambond. Am J Dent 1993;6:10-2. 169. Saiku JM, St Germain HA Jr, Meiers JC. Microleakage of a dental amalgam alloy bonding agent. Oper Dent 1993;18:172-8. 170. Newell DH, Morgano SM, Baima RF. Fixed prosthodontics with periodontally compromised dentitions. In: Malone WF, Koth DL, Cavazos E, Kaiser DA, Morgano SM, editors. Tylman’s theory and practice of fixed prosthodontics. 8th ed. St Louis: Ishiyaku EuroAmerica; 1989. p. 87-111. 171. Langer B, Stein SD, Wagenberg B. An evaluation of root resections. A tenyear study. J Periodontol 1981;52:719-22. 172. Bühler H. Evaluation of root-resected teeth. Results after 10 years. J Periodontol 1988;59:805-10. 173. Carnevale G, Pontoriero R, di Febo G. Long-term effects of root-resection therapy in furcation-involved molars. A 10-year longitudinal study. J Clin Periodontol 1998;25:209-14. 174. Newell DH. The role of the prosthodontist in restoring root-resected molars: a study of 70 molar root resections. J Prosthet Dent 1991;65:715. 175. Zarb GA, Schmitt A. The longitudinal clinical effectiveness of osseointegrated dental implants: the Toronto study. Part I: surgical results. J Prosthet Dent 1990;63:451-7. 176. Zarb GA, Schmitt A. The longitudinal clinical effectiveness of osseointegrated dental implants: the Toronto study. Part II: the prosthetic results. J Prosthet Dent 1990;64:53-61. 177. Zarb GA, Schmitt A. The longitudinal clinical effectiveness of osseointegrated dental implants: the Toronto study. Part III: problems and complications encountered. J Prosthet Dent 1990;64:185-94. 178. Bahat O. Treatment planning and placement of implants in the posterior maxillae: report of 732 consecutive Nobelpharma implants. Int J Oral Maxillofac Implants 1993;8:151-61. 179. Cordioli G, Castagna S, Consolati E. Single-tooth implant rehabilitation: a retrospective study of 67 implants. Int J Prosthodont 1994;7:525-31. 180. Sorensen JA, Martinoff JT. Intracoronal reinforcement and coronal coverage: a study of endodontically treated teeth. J Prosthet Dent 1984; 51:780-4.

181. Sorensen JA, Martinoff JT. Endodontically treated teeth as abutments. J Prosthet Dent 1985;53:631-6. 182. Weine FS, Wax AH, Wenckus CS. Retrospective study of tapered, smooth post systems in place for 10 years or more. J Endod 1991;17:293-7. 183. Vire DE. Failure of endodontically treated teeth: classification and evaluation. J Endod 1991;17:338-42. 184. Hatzikyriakos AH, Reisis GI, Tsingos N. A 3-year postoperative clinical evaluation of posts and cores beneath existing crowns. J Prosthet Dent 1992;67:454-8. 185. Creugers NH, Mentink AG, Kayser AF. An analysis of durability data on post and core restorations. J Dent 1993;21:281-4. 186. ADA council on Scientific Affairs. Dental amalgam: update on safety concerns. J Am Dent Assoc 1998;129:494-502. 187. Vallittu PK. Flexural properties of acrylic resin polymers with unidirectional and woven glass fibers. J Prosthet Dent 1999;81:318-26. 188. Olea N, Pulgar R, Perez P, Olea-Serrano F, Rivas A, Novillo-Fertrell A, Pedraza V, et al. Estrogenicity of resin-based composites and sealants used in dentistry. Environ Health Perspect 1996;104:298-305. 189. Nathanson D, Lertpitayakun P, Lamkin MS, Edalatpour M, Chou LL. In vitro elution of leachable components from dental sealants. J Am Dent Assoc 1997;128:1517-23. 190. Hamid A, Hume WR. A study of component release from pit and fissure sealants in vitro. Dent Mater 1997;13:98-102. 191. Sÿderholm KJ, Mariotti A. BIS-GMA—based resins in dentistry: are they safe? J Am Dent Assoc 1999;130:201-9. Reprint requests to: DR STEVEN M. MORGANO FACULTY OF DENTISTRY KUWAIT UNIVERSITY JABRIYA PO BOX 24923 SAFAT 13110 KUWAIT FAX: (965)532-6049 E-MAIL: smorgano@hsc.kunix.edu.kw Copyright © 1999 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/99/$8.00 + 0. 10/1/102934

Bound volumes available to subscribers Bound volumes of The Journal of Prosthetic Dentistry are available to subscribers (only) for the 1999 issues from the publisher at a cost of $92.00 ($106.00 international) for Vol. 81 (January-June) and Vol. 82 (July-December). Shipping charges are included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Volumes 79 and 80 are also available. Payment must accompany all orders. Contact Mosby, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA; phone (800)453-4351, or (314)453-4531. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.

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Foreign-Trained Dentists in Advanced Education in Prosthodontics Programs in the United States: Demographics, Perspectives on Current Training, and Future Goals Zeyad H. Al-Sowygh, BDS, DMSc1 & Cortino Sukotjo, DDS, MMSc, PhD2 1

Keywords Foreign-trained dentists; characteristics; academic and career expectations. Correspondence Cortino Sukotjo, Department of Restorative Dentistry, Comprehensive Dental Implant Center (CDIC), University of Illinois at Chicago, College of Dentistry, 801 S. Paulina St., Chicago, IL 60612. E-mail: csukotjo@uic.edu

Accepted March 17, 2010 doi: 10.1111/j.1532-849X.2010.00658.x

Abstract Purpose: This study investigated the perspectives of foreign-trained dentists (FTDs) in comparison with US-trained Dentists (USTDs) in Advanced Education in Prosthodontics (AEP) programs on their current clinical training and future goals. Materials and Methods: This study was conducted by analyzing data from previously published literature. When appropriate, Chi-square statistical analysis was conducted to determine the influence of where the AEP residents earned their DMD/DDS degree (FTDs/USTDs) on all variables. Only results that yielded significant differences were discussed. Results: A majority of both FTDs and USTDs were male. Most USTDs were married, while most FTDs were single. Most FTDs were not US citizens and most originated from Asia, followed by the Middle East, South America, and Europe. Significantly more FTDs had higher ranks in their dental schools, had more advanced degrees, and spent more time practicing before entering the AEP programs. In selecting AEP programs, FTDs placed significantly higher values on a programâ&#x20AC;&#x2122;s reputation and research opportunities. During their AEP training, FTDs paid significantly higher tuition and received lower stipends, but obtained more financial support from families. On the other hand, USTDs received significantly more financial aid and earned income from part-time work, but had significantly higher total educational debts. USTDs showed a significantly higher interest in becoming a student member of the American College of Prosthodontists and participated actively in prosthodontics organizations. USTDs were more interested in becoming maxillofacial prosthodontists, while FTDs were more interested in pursuing academic careers. Conclusion: FTDs differed from USTDs in several ways. Because of their interests in academics and research, FTDs may potentially have a positive impact on the development of the prosthodontics discipline. This information may be beneficial for AEP program directors in accommodating the needs of FTDs, and for FTDs in better preparing for their AEP training.

The US attracts many foreign students seeking advanced training as healthcare professionals, either in medicine or dentistry. In the field of medicine, foreign-trained doctors, or international medical graduates (IMGs), make up a substantial part of the US physician workforce.1 Moreover, data indicate that 70 to 75% of IMGs stay in the United States after the completion of their graduate medical education.2 Numerous studies have examined the performance and characteristics of IMGs during and after

finishing their residency training.3-8 Some studies suggest that the presence of IMGs had a positive impact on the medical field by covering healthcare needs in medically underserved areas, contributing to the academic and research environment, and enriching the US medical system.6-8 However, others suggest different views. For example, IMGs were perceived as having inferior clinical training levels in comparison with United States medical graduates (USMGs). They also faced cultural barriers,

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Figure 1 Percentage of foreign-trained dentists entering different advanced dental education programs in 2007/2008. Data retrieved from the American Dental Association.

Figure 2 Enrollment rate of foreign-trained dentists in Advanced Education in Prosthodontics programs over the past 18 years. Data retrieved from the American Dental Association.

Materials and methods

which could negatively shape their doctor-patient relationships and reduce the quality of their medical care.4,7,8 In dentistry, upon completion of their dental training, many foreign-trained dentists (FTDs) enter international dental studies (IDS) or advanced dental education (ADE) programs in the United States. The total number of FTDs entering ADE varies over the years.9 Many FTDs in ADE are considered talented, knowledgeable, and highly motivated individuals who perform well during their training. Upon finishing their advanced studies, many FTDs return to their home countries, but some stay in the United States to practice or teach.10 Many studies have analyzed the performance of FTDs in IDS10-13 ; however, none could be identified in the ADE programs. Without understanding their background and expectations, residency programs may not adequately support FTDs and may even impact them negatively. Prosthodontics is the sixth largest of the nine recognized dental specialties.14 In 2001, there were 3237 professionally active prosthodontists practicing in the United States, 78.6% of whom were private practitioners.14 Compared to other specialties, advanced education in prosthodontics (AEP) programs have the highest percentage of enrolled (Fig 1) and graduated FTDs.9 The FTD enrollment rate has fluctuated over the last 18 years. It peaked in 2000/2001, declined slightly in 2005/2006, and rose again in 2007/2008 (Fig 2). A recent survey of AEP program directors conducted by the American College of Prosthodontists (ACP) in 2002/2003 indicated that the number of FTD residents in AEP programs reached nearly 50%.15 Due to the high percentage of FTDs joining the specialty, it is important to know their expectations and perceptions of AEP programs; however, no report in the literature has addressed this important issue. The purpose of this study was to investigate FTDs’ perspectives of their current prosthodontics clinical training and future goals and compare these perspectives to those of USTDs. Demographic data between FTDs and USTDs were also compared and presented. 162

The study was performed using data from a previously published study, representing approximately 48% of all prosthodontic residents in the United States.16 Data regarding FTDs in AEP programs were retrieved from the American Dental Association (ADA).9 A 52-item survey, approved by the Internal Review Board (IRB) office at the Harvard Medical School Office for Research Subject Protection (IRB Approval #M14529–101), was distributed to prosthodontic residents in the United States. The survey had three parts: Part A assessed the residents’ demographic information; Part B assessed the prosthodontic programs; Part C assessed the residents’ future goals. The only identifiers in the survey were gender, age, marital status, level of education, citizenship (US or other), and whether the respondent earned a DDS/DMD degree from a US or non-US Dental School. Participants were also asked to state their academic ranks if available. Space was allotted for additional comments. Data collected were entered into Microsoft Excel 2003 (Microsoft, Seattle, WA) and analyzed using SPSS V15.0 (SPSS Inc, Chicago, IL). The means and standard deviations for each response were calculated and ranked. Data were analyzed by both descriptive and analytic statistics. Chi-square test was conducted to determine the association of where the degrees were earned (FTDs vs. USTDs) on all variables. A significance level of 0.05 was used.

Results Demographic

The response rate was 43% (191/450), representing approximately 48% of all prosthodontic residents in the United States (Table 1). From the total respondents (191), 85 were FTDs, representing 48% of the total FTDs in AEP population (176, excluding Canadian). A majority of the FTDs and USTDs were male. The mean age of USTDs and FTDs was 30.96 ± 4.58 and 30.89 ± 4.30, respectively. A majority of FTDs were not US citizens (p = 0.00), and they came mostly from Asia, followed by the Middle East, then South America, and Europe (Table 2). A majority of USTDs were married, whereas the majority of

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Table 1 Number of responding residents based on gender and foreigntrained dentists/US-trained dentists (FTD/USTD)

USTD FTD Total

Male

Female

Total

68 (64.1%) 53 (62.3%) 121 (63.3%)

38 (35.8%) 32 (37.6%) 70 (36.6%)

106 (100%) 85 (100%) 191 (100%)

FTDs were single (Table 3). There were significantly higher percentage of FTDs holding master’s (FTDs 14%, USTDs 4.7%, p = 0.02) and PhD (FTDs 8%, USTDs 1%, p = 0.01) degrees. Before entering the program, FTDs spent more time working (> 5 years: FTDs 36.4%, USTDs 9.4%, p = 0.00; 0 year: FTDs 0.08%, USTDs 60.3%, p = 0.00) either in private practice (FTDs 62%, USTDs 17%, p = 0.00) or pursuing other education (FTDs 13%, USTDs 1.8%, p = 0.00). FTDs also had significantly higher dental school academic ranks (Top 5%: FTDs 30%, USTDs 14.1%, p = 0.00; Top 5–10%: FTDs 32.1%, USTDs 16.1%, p = 0.00). Perception of current training and programs

A significantly higher percentage of FTDs placed a higher value on the importance of a program’s reputation (Most Important: FTDs 48.2%, USTDs 31.4%, p = 0.00) and research opportunities (FTDs 76.4%, USTDs 42.8%, p = 0.00). FTDs also presented a significantly higher interest in conducting research (FTDs 76.4%, USTDs 42.8%, p = 0.00), publishing research (FTDs 82.3%, USTDs 57.8%, p = 0.00), and publishing clinical cases (FTDs 72.6%, USTDs 50.4%, p = 0.00). On the other hand, USTDs showed a significantly higher interest in becoming student members of the ACP (USTDs 98%, FTDs 89.4%, p = 0.01). FTDs paid significantly higher tuitions (>$40,000: FTDs 33.3%, USTDs 18.2%, p = 0.00), received significantly lower stipends during their first ($0: FTDs 62.5%, USTDs 29.5%, p = 0.00), second ($0: FTDs 66.6%, USTDs 31.8%, p = 0.00), and third ($0: FTDs 66.6%, USTDs 33.3%, p = 0.00) year of training. FTDs received significantly more financial support from family (FTDs 56.4%, USTDs 37.1%, p = 0.00). On the other hand, USTDs received significantly more financial aid (USTDs 32.3%, FTDs 15.2%, p = 0.00), and earned selfsupporting income from part-time work (USTDs 10.5%, FTDs 1.1%, p = 0.00). USTDs had a significantly higher total educational debt than did FTDs ($151–200,000: USTDs 18%, FTDs

Table 2 Number of foreign-trained dentists based on their nationalities Nationality Asia Middle East South/Central America Europe/Eastern Europe Canada Other/not mentioned Total

Total 26 (30.5%) 16 (18.8%) 9 (10.5%) 9 (10.5%) 2 (2.3%) 23 (30.5%) 85 (100%)

Table 3 Number of responding residents based on marital status and FTD/USTD

USTD FTD Total

Single

Married

Divorced

Total

50 (47.1%) 44 (51.7%) 94 (49.3%)

54 (50.9%) 37 (43.5%) 91 (47.6%)

2 (1.8%) 4 (4.7%) 6 (3.1%)

106 (100%) 85 (100%) 191 (100%)

11.25%, p = 0.00), a likely factor restricting them from becoming full-time academics. Educational debts, however, did not restrict FTDs from pursuing full-time academic careers (USTDs 70.2%, FTDs 46.1%, p = 0.00). Future goals

FTDs showed significantly higher interests in planning an academic or research career (FTDs 31.7%, USTDs 12.7%, p = 0.00) and becoming full-time academicians if income were to improve (FTDs 70.5%, USTDs 51.4%, p = 0.00). On the other hand, USTDs showed a significantly higher interest in becoming maxillofacial prosthodontists (USTDs 9.4%, FTDs 2.3%, p = 0.04) and being active in prosthodontics organizations (USTDs 86.6%, FTDs 72%, p = 0.01).

Discussion Demographics

Total enrollment of FTDs in AEP programs declined from 2002 until 2006 and recently increased again to a total of 176, which represented 41% of all AEP residents.9 The respondent ratio of FTDs/USTDs (55%/44%) in this study was similar to the AEP residents’ demographic information retrieved from the ADA (FTDs/USTDs: 53%/46%).9 The FTD respondents from this study were from many different continents. This trend followed the results shown in the most recent study on FTDs licensed to practice in the United States.10 In that study, the authors explored the origins of FTDs seeking licensures in the United States by looking at the data received from the ADA Department of Testing Services. Their study showed that the greatest number of potential US licensees were primarily from Asia, the Middle East, and South America.10 Another study also showed that foreign-born IMGs most frequently graduated from schools in South Asia, followed by the Middle East.3 Foreign doctors and dentists who graduate from countries that use English as a second language, such as India and the Philippines, might have greater advantages during the application and matriculation processes in entering the United States educational and healthcare systems. Unlike USTDs, a majority of FTDs were single; however, a previous study reported a different finding.17 IMG residents at six Baltimore Internal Medicine residency programs were significantly more likely to be married and have children than USMGs.17 Another recent study showed that the married applicants reported a significant spousal influence in their program choice.18 It remains unclear why such a discrepancy exists between our finding and the current literature.

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A significantly higher percentage of FTDs held more advanced degrees than USTDs in this study. Studies from medical journals also noted a similar pattern: that IMGs were more likely to have higher degrees than were USMGs.17 Considering the competitiveness of entering US residency programs, only top foreign students could be selected; however, due to extreme variations in educational and grading systems worldwide, academic ranks may not represent an objective indicator to determine students’ performance in their previous training.4,11 Although having a higher degree might indicate an academic engagement and could be considered favorable by program directors, similar to research and scholarly activities, attainment of an advanced degree does not predict the resident’s performance or future career in academics.19 Perceptions of current training and programs

Like IMGs, some FTDs return to their countries of origin upon graduation10 and become prominent members in academics or the profession because of their advanced education.20 Therefore, reputation of the institution is an important factor for FTDs. FTDs’ higher interest in performing research and publishing might reflect their intention to pursue academic careers. This is in agreement with previous studies demonstrating that IMGs had significantly more scholarly works than did USMGs.3,8 Because USTDs could get government loans, they were more likely to have higher educational debts than FTDs. In addition, USTDs could receive additional sources of funding, such as from military scholarships or the National Health Service Corps.8 A similar trend was observed in USMGs;17 however, this situation did not apply to FTDs. FTDs need to attain different sources of funding, such as from their government or an international agency such as the Fulbright Program (http:// fulbright.state.gov/). The application process to residency programs in the United States is long, meticulous, exhausting, and often takes many years to prepare. Knowing that the admission process is highly competitive, some prospective students may spend extra time after graduation preparing for the admission process by improving their TOEFL score, continuing their education to graduate level, or working in private practice to gain more experience. Our study showed that before entering their residency program, FTDs spent significantly more time working in private practice, partly in preparation for the high educational expenses in the United States. By doing so, they were more likely to have some savings to pay for their future educational expenses. This also explains why FTDs have more clinical experience than USTDs. It had been suggested that these experiences might benefit US training programs by adding diversity, maturity, and different perspectives on healthcare;3,8 however, one study showed that having dental licenses from foreign countries did not predict students’ success in US dental programs.11 FTDs paid significantly higher tuition than USTDs. When entering US public institutions, FTDs are charged with higher out-of-state tuition or nonresident fees. It might also be that a higher proportion of FTDs attended private institutions. One study found that many IMGs were more likely to seek training in urban settings where most private schools were located, because 164

urban settings were typically more diverse, and patients, staff, and community might be more accepting of FTDs’ different cultural backgrounds.3 Future trends

In comparison with USTDs, a lower proportion of FTDs became ACP student members and participated in prosthodontics organizations. This may indicate their plans to return to their home countries upon graduation and, as such, they see minimal benefit in becoming members of these organizations. Compared to USTDs, a significantly lower proportion of FTDs showed an interest in continuing their studies in maxillofacial fellowship programs. Some possible explanations for this trend might include the different perception of maxillofacial prosthodontics training by FTDs and the even more limited funding for them to pursue such a specialty. In addition, this study found that a higher proportion of FTDs was more likely to choose an academic or research career. If FTDs decide to stay in the United States, they may potentially serve as clinical faculty members or researchers. It has been noted that many IMGs have made significant contributions to the improvement of clinical practices, biomedical research, and undergraduate or postgraduate education.6,20 Contribution to our profession

The presence of FTDs in AEP programs may potentially positively impact patients, AEP programs, and dental communities. The education of immigrant health professionals and their interest in practicing in the United States could provide muchneeded personnel to deliver care to various ethnic groups. A substantial number of the residents come from the native countries of certain minority or ethnic population groups in the United States, where access to healthcare is often identified as a problem due to cultural, attitudinal, language, and other nonfinancial barriers.10,21 In addition, FTDs can also be recruited to fill the rising numbers of vacant prosthodontist positions in US dental schools.22 Many of these FTDs are internationally recognized experts and highly qualified professionals. Many prominent positions in US dental schools, such as department chairs, AEP program directors, prosthodontic faculty, and researchers, were held by foreign-trained dentist AEP program graduates. In addition, FTDs who return to their countries usually become prominent members in academics or community practices, and by doing so, may disseminate the philosophy of US healthcare and education to other parts of the globe.4 Despite their positive contributions, a recent study showed that many foreign-trained healthcare professionals were experiencing problems when entering residency programs.23 Poor residency performance of IMGs has been reported. It was suggested that the reasons included inadequate command of the English language, cultural differences, a low level of basic medical knowledge, different attitudes, poor time management and multitasking techniques, and lack of understanding of technological development and procedures unique to the US healthcare system.4 Therefore, more research is warranted to explore the journey of FTDs to ADE programs, particularly in prosthodontics.

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Finally, to the best of the authors’ knowledge, this is the first study examining the roles of FTDs in ADE, particularly in AEP programs. By understanding FTDs’ expectations, perceptions, and limitations, program directors may support them better academically in the future. To effectively ensure a positive experience for FTDs in AEP programs in the United States, further research in several areas is needed, including academic and cultural adjustment, academic performance comparison between FTDs and USTDs, as well as AEP program directors’ perceptions of their FTDs residents.

Foreign-Trained Dentists in Prosthodontics Programs

Limitations of this study

The available literature on this topic is limited, and it is difficult to compare and contrast our finding with the current literature. Therefore, some subjective or speculated statements were made to provide explanation and rationale to support our finding. The data achieved may serve as a baseline for future studies regarding this issue. Additionally, data from this study were self-reported, and the response rate was <50%, which might not represent the opinion of the majority of FTDs in AEP programs. We also acknowledge some additional questions could have been asked to improve this study, thus providing more insight to the profession.

Conclusion FTDs’ demographics, perspectives on clinical training, and future goals were presented. FTDs differed from USTDs in several ways. Because of their interest in academics and research, FTDs might positively impact the prosthodontics discipline. This information may be beneficial for AEP program directors considering FTDs as their future residents and in raising awareness in their expectations or limitations. It may also help FTDs in better preparing for their advanced training.

Acknowledgment The authors wish to thank Dr. Stephen Campbell, Judy Yuan, Damian Lee, and Dewi Susanti for reviewing and providing input on the article.

References 1. Norcini JJ, van Zanten M, Boulet JR: The contribution of international medical graduates to diversity in the U.S. physician workforce: graduate medical education. J Health Care Poor Underserved 2008;19:493-499 2. Mullan F, Politzer RM, Davis CH: Medical migration and the physician workforce. International medical graduates and American medicine. J Am Med Assoc 1995;273:1521-1527 3. Schenarts PJ, Love KM, Agle SC, et al: Comparison of surgical residency applicants from U.S. medical schools with U.S.-born and foreign-born international medical school graduates. J Surg Educ 2008;65:406-412 4. Horvath K, Pellegrini C: Selecting international medical graduates (IMGs) for training in US surgical residencies. Surgery 2006;140:347-350 5. Boulet JR, Swanson DB, Cooper RA, et al: A comparison of the

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characteristics and examination performances of U.S. and non-U.S. citizen international medical graduates who sought Educational Commission for Foreign Medical Graduates certification: 1995–2004. Acad Med 2006;81:S116-S119 Thind A, Freeman T, Cohen I, et al: Characteristics and practice patterns of international medical graduates: how different are they from those of Canadian-trained physicians? Can Fam Physician 2007;53:1330-1331 Leon LR Jr, Villar H, Leon CR, et al: The journey of a foreign-trained physician to a United States residency. J Am Coll Surg 2007;204:486-494 Leon LR Jr, Ojeda H, Mills JI Sr, et al: The journey of a foreign-trained physician to a United States residency: controversies surrounding the impact of this migration to the United States. J Am Coll Surg 2008;206:171-176 2006–07: Survey of Advanced Dental Education. Chicago, American Dental Association, January 2008 Sweis LE, Guay AH: Foreign-trained dentists licensed in the United States: exploring their origins. J Am Dent Assoc 2007;138:219-224 Itaya LE, Chambers DW, King PA: Analyzing the influence of admissions criteria and cultural norms on success in an international dental studies program. J Dent Educ 2008;72:317-328 Stacey DG, Whittaker JM: Predicting academic performance and clinical competency for international dental students: seeking the most efficient and effective measures. J Dent Educ 2005;69:270-280 Komabayashi T, Raghuraman K, Raghuraman R, et al: Dental education in India and Japan: implications for U.S. dental programs for foreign-trained dentists. J Dent Educ 2005;69:461-469 2002 Survey of Dental Practice: Prosthodontists in Private Practice. Chicago, American Dental Association, 2002 Nash KD: Postgraduate program directors survey, 2002–2003. Organizational and operational characteristics of prosthodontic program. Millican, TX, Nash & Associates, Inc. October 2004. http://www.prosthodontics.org/pdf/survey-results-2002–03.pdf. Accessed on September 24, 2010 Al-Sowygh ZH, Sukotjo C: Advanced education in prosthodontics: residents’ perspectives on their current training and future goals. J Prosthodont 2010;19:150-156 Gozu A, Kern DE, Wright SM: Similarities and differences between international medical graduates and U.S. medical graduates at six Maryland community-based internal medicine residency training programs. Acad Med 2009;84:385-390 Blissett R, Lee MC, Jimenez M, et al: Differential factors that influence applicant selection of a prosthodontic residency program. J Prosthodont 2009;18:283-288 Lee AG, Golnik KC, Oetting TA, et al: Re-engineering the resident applicant selection process in ophthalmology: a literature review and recommendations for improvement. Surv Ophthalmol 2008;53:164-176 Cohen JJ: The role and contributions of IMGs: a U.S. perspective. Acad Med 2006;81:S17-S21 Berthold P, Lopez N: PENN PASS: a program for graduates of foreign dental schools. J Dent Educ 1994;58:849-854 Chmar JE, Weaver RG, Valachovic RW: Dental school vacant budgeted faculty positions, academic years 2005-06 and 2006-07. J Dent Educ 2008;72:370-385 Horvath K, Coluccio G, Foy H, et al: A program for successful integration of international medical graduates (IMGs) into U.S. Surgical residency training. Curr Surg 2004;61:492-498

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Advanced Education in Prosthodontics: Residents’ Perspectives on Their Current Training and Future Goals Zeyad H. Al-Sowygh, BDS, DMSc1 & Cortino Sukotjo, DDS, MMSc, PhD2, 3 1

Assistant Professor, Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia Assistant Professor, Department of Restorative Dentistry, Comprehensive Dental Implant Center (CDIC), University of Illinois at Chicago, College of Dentistry, Chicago, IL 3 Formerly, Instructor, Department of Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental Medicine, Boston, MA 2

Keywords Survey; prosthodontics; resident; perspective; training; future goals. Correspondence Cortino Sukotjo, Department of Restorative Dentistry, Comprehensive Dental Implant Center (CDIC), University of Illinois at Chicago, College of Dentistry, 801 S. Paulina St., Chicago, IL 60612. E-mail: csukotjo@uic.edu

Accepted: January 12, 2009 doi: 10.1111/j.1532-849X.2009.00537.x

Abstract Purpose: The purposes of this study were to identify current prosthodontic residents’ demographics and to document prosthodontic residents’ perspectives on their clinical training and future goals. Materials and Methods: A 52-item survey was created and distributed to prosthodontic residents in the United States on February 8, 2007. The data collected were analyzed; the means and standard deviations were calculated and ranked. Statistical analysis was conducted using Chi-square and Mann-Whitney analysis (p = 0.05). Results: A 43% response rate was achieved, representing approximately 48% of the total population of prosthodontic residents in the United States. The majority of residents ranked clinical education as the most important factor in selecting their programs, were satisfied with their training, and planned to pursue the certification of the American Board of Prosthodontics. When asked how often they planned to work, 4 days a week was the most common answer. Conclusion: This is the first report identifying current prosthodontic residents’ demographics and their perspectives on their clinical training and future goals. Several trends were identified, indicating a bright future for the specialty. By knowing the students’ perceptions regarding their training and future goals, the American College of Prosthodontists and/or program directors will be able to use this information to improve residency programs and the specialty.

There are approximately 400 residents enrolled in 46 Advanced Education in Prosthodontics (AEP) programs in the United States.1 They are one of the main sources of information on how to improve our specialty and residency programs. Surveys of graduate prosthodontic students have been proposed since 1976;2 however, unlike other specialties,3-7 limited publications have reported on AEP, and none reported on the residents’ perspectives on their current clinical training. The majority of the studies on prosthodontic education have been performed at the predoctoral level.8-14 Studies related to AEP have been based on surveys of program directors, deans, and practicing prosthodontists.15-19 A recent study for the first time surveyed AEP residents on which factors might influence residents in choosing prosthodontics as their specialty.20 The study reported that residents considered the complexities and challenges of treatment planning and execution of prosthodontic treatment to be the most important factors in deciding to specialize in prosthodontics. The role of mentors also strongly 150

influenced the students in choosing prosthodontics as their career. The purposes of this study were to identify current prosthodontic residents’ demographics and to document prosthodontic residents’ perspectives on their clinical training and future goals. In addition, we also hypothesized that gender might influence perspectives on training and future goals.

Materials and methods Based on Bruner et al,7 a 52-item survey (Appendix) was created with some modifications and was approved by the IRB office at the Harvard Medical School Office for Research Subject Protection (IRB Approval #M14529–101). Questions were multiple choice, closed ended, numerical priority scale (a reverse Likert-type scale), and anonymous. The survey comprised three parts: Part A, a 10-item questionnaire assessing resident demographics; Part B, a 31-item questionnaire assessing prosthodontic program-related information; and Part C,

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a 10-item questionnaire assessing the residents’ future goals. Current residents from all prosthodontic programs in the United States were contacted by e-mail, mail, and/or through the program directors. Mailing address information (N = 347) was obtained from the American College of Prosthodontists (ACP) Central Office. The surveys were distributed to prosthodontic residents in the United States on February 8, 2007. A second mailing/reminder was distributed on April 2, 2007. Of all mailed questionnaires, only responses returned within 1 month of the second mailing were accepted for analysis. The only identifiers on the survey were gender, age, marital status, level of education, and citizenship (US or other). Marital status was defined as “single,” “married,” or “divorced.” Participants were also asked to state their National Board Dental Score Part I, and academic rank if available. Space was allotted for additional comments. The data collected were entered into Microsoft Excel 2003 (Microsoft, Seattle, WA) and analyzed using SPSS V15.0 (Chicago, IL). The means and standard deviations for each response were calculated and ranked. Descriptive statistics were used to describe the study population. Statistical analysis was conducted using Chi-square and Mann-Whitney analysis (p = 0.05).

eral practice residency (GPR), Periodontics, etc]. Of the respondents, 55.5% received their dental degree from a US dental school, and the mean score on the National Board of Dental Examination-part I was 87.52 ± 4.91, with a range of 76 to 98. In regards to their dental school ranking, 21.3% ranked within the top 5% of their class, 23.5% ranked between 6% and 10%, 30.6% ranked between 11% and 25%, 16.4% ranked between 26% and 50% in their class, and 8.2% did not report their rank, either because their dental school does not use a ranking system or because they did not recall their position. Nearly 37.5% of the respondents entered prosthodontic training immediately after dental school, 21.9% began 1 to 2 years after their graduation, 19.3% started 3 to 5 years later, and 21.4% entered more than 5 years after graduation. Of the respondents who did not enter prosthodontic training immediately, 43.8% were in private practice, 12.3% were in the military, 27.2% were completing other residencies [e.g., advanced education of general dentistry (AEGD) or GPR, etc.], 8% were completing other formal educational degrees (master’s or PhD), and 8.6% were doing other activities. The number of men who were in the military before entering their program was significantly higher than women (p = 0.01). Program specifics

Results Of the 450 distributed surveys, 192 were completed and returned, corresponding to a response rate of 43%. The completed surveys represented approximately 48% of the total population of prosthodontic residents in the United States. Demographics

Table 1 describes the demographic characteristics of the survey correspondents; 63.5% were men and 36.5% were women. The mean age of prosthodontic residents was 31 years, which varied slightly with gender (men were about 1.5 years older than women). Approximately 53% of men were married, whereas only 37% of women were; around 56% of women were unmarried, compared to 46% of men. Women showed a significantly higher divorced rate of about 7%, compared to men who showed only a 1% divorce rate (p = 0.01). Nearly two-thirds (64%) of the married men had children, while only 40% of the married women had children. There were slightly more US citizen respondents (54.7%) than non-US citizens (45.3%). The respondents’ level of education was 8.9% master’s degree, 4.2% PhD, and 16.1% with another certificate [e.g., gen-

The distribution of residents surveyed was 69 first-year (36.6%), 58 second-year (30.5%), and 63 third-year residents (33.2%). They reported a mean of 3.83 ± 1.56 residents per class (a range of 1 to 8 residents). The mean number of programs they applied to was 3.38 ± 2.84, where they received 2.69 ± 2 interview invitations and attended 2.08 ± 1.39 interviews. Of interest to note, 96 residents (50%) attended only one interview and got accepted in their chosen program. Residents rated the importance of several factors when selecting their prosthodontics residency program (Table 2). “Clinical education” was ranked most frequently as the most important, while the “where they went to dental school” factor was ranked as the least important. Of the respondents, 54% reported they were satisfied with their training program, and 38% reported that they were very satisfied, whereas 8% reported that they were unsatisfied. Around 75% of the respondents reported that their programs specifically prepared them to obtain the American Board of Prosthodontics (ABP) Certification; 54.2% reported their programs required them to take Part I of the ABP during their

Table 2 Most important reasons for selecting prosthodontic program Table 1 Demographic characteristics of prosthodontic residents surveyed in 2007

Number Age Single Married Divorced Non-US citizens

Male

Female

Total

122 (63.5%) 31.54 ± 4.5 56 (45.9%) 65 (53.3%) 1 (0.8%) 53 (43.3)

70 (36.5%) 29.85 ± 4.2 39 (55.7%) 26 (37.1%) 5 (7.1%) 34 (46.8%)

192 (100) 30.93 ± 4.4 95 (49.5%) 91 (47.4%) 6 (3.1%) 87 (45.3%)

Clinical education Reputation Cost Location Laboratory work training Research opportunities Where I went to dental school

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Median response

Ranked as most important

Ranked as least important

5 4 4 4 4 2 2

64.7% 38.7% 32.8% 28.1% 18.3% 12.6% 7.9%

2.6% 2.6% 15% 12.5% 5.8% 31.4% 49.7%

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Table 3 Residents’ response regarding the adequacy of education their program provides them in different fields of prosthodontics

Fixed prosthodontics Removable complete prosthodontics Removable partial prosthodontics Dental implants prosthodontics Maxillofacial prosthodontics Occlusion Temporomandibular disorders Dental materials

Didactic

Clinical

Stipend

90.0% 92.1% 82.1% 88.4% 54.5% 85.8% 56.8% 80.0%

94.7% 94.7% 78.4% 93.7% 41.8% 80.4% 47.1% N/A

$0 <$5,000 $5,000–$10,000 $11,000–$15,000 $16,000–$20,000 $21,000–$30,000 >$30,000

residency. Approximately 90% of the respondents said they were required to take the Mock Board Part I exam during their residency, while 77% reported that they were encouraged to complete one of the patient-care parts of the ABP examination during their residency. Of the respondents, 88.5% said they had adequate numbers of patients with a diversity of complexity. Table 3 shows the respondents’ opinions when asked if their program provided them with adequate knowledge in the different subjects of prosthodontics. The majority of the respondents reported that they had adequate knowledge in basic didactic and clinical prosthodontics, with the exception in few areas. Of the respondents, 82.8% reported their programs offered advanced degrees (master’s or PhD), where 67.9% of them were pursuing a master’s degree, 8.2% were pursuing a PhD degree, and 23.9% were not in any degree program. Only 32.3% of the programs required their residents to complete a degree program as part of the program’s requirements; however, 74.5% required their residents to do research as part of the program. When asked about their interests to do research regardless of whether it was required, 57.6% of the respondents reported they were interested; 69.1% planned on publishing their research in a refereed journal, while 60.6% planned to publish their clinical care in a refereed journal. Men showed a significantly higher interest in publishing their clinical cases in a refereed journal than women did (p = 0.02). The reported median of the number of faculty teaching in the respondents’ programs with full-time academic appointments was 3 to 4 faculty, whereas part-time academic appointments was 3 to 5 faculty. The number of board-certified faculty teaching in their program (full and part-time faculty) was 3 to 4 faculty. Of the respondents, 94.2% reported they were student members of the ACP. The respondents reported that their programs encouraged them to join and participate in the ACP during their residency. When asked to estimate their programs’ tuition each year, 21.2% reported they did not pay tuition, 10.1% reported they paid between $1,000 and $5,000, 9% reported they paid between $6,000 and $10,000, 13.8% reported they paid between $11,000 and $20,000, 6.3% reported they paid between $21,000 and $30,000, 16.4% reported they paid between $31,000 and $40,000, and 23.3% reported they paid more than $40,000. 152

Table 4 Reported stipend amount received each year during prosthodontic residency 1st

2nd

3rd

43.3% 5.8% 14.0% 13.5% 7.0% 2.3% 14.0%

45.7% 4.6% 11.3% 9.3% 9.9% 5.3% 13.9%

46.1% 2.8% 12.8% 9.9% 9.2% 5.7% 13.5%

Year

Table 4 shows the respondents’ reports on the stipend they received during prosthodontic residency; 43% to 46% received no stipends during their residency programs. The respondents’ reports on additional financial support received while in prosthodontic residency was: 28.1% received support from family, where women showed a significantly higher number than men (p = 0.01); 15.5% financial aid; 14.2% bank loans; 13.5% federal subsidized loans; 14.2% savings; 3.9% part-time work; and 10.6% other means of additional support. When asked to estimate their debts at the time of graduation from prosthodontic residency trainings, 38.7% reported they would have no debt, 10.1% reported their debt was less than $25,000, 9.7% reported their debt between $25,000 and $50,000, 13.5% reported their debt between $51,000 and $100,000, and 26.8% reported their debt to exceed $100,000. They also estimated their total educational debt: 23.1% had no debt at all, 10.8% had debt less than $50,000, 15.1% between $51,000 and $100,000, 28% between $100,000 and $200,000, while 23.1% had debt exceeding $200,000. Around 60% of the respondents reported that their educational debts restricted them from pursuing fulltime academics after graduation. Future trends

Following graduation, the majority of respondents (56%) indicated their plans to enter private practice, where 21.3% planned to work as associates (men showed a higher number than women in their plans to work as associates, p = 0.05), 18.9% in a partner setting, and 15.8% in a solo practice. Of the respondents 17.8% planned to continue their advanced education, where 13.7% planned to enter an implant fellowship program, and 4.1% planned to enter a maxillofacial prosthodontic residency program. Of the respondents, 13.4% stated their plans to pursue academic and/or research careers, and 3.8% reported their plans for the military, where men showed a higher number than women in their plans to join the military (p = 0.05). Only 1% stated plans to work in an HMO setting, and 7.9% had different plans or were undecided on the future plans. When asked about their interests in becoming full-time academicians, 60.2% stated they would be interested if the income for teaching were to improve. In addition to private practice, 92.7% reported an interest in becoming part-time academicians. Almost 80% of the respondents stated that they would recommend the specialty of prosthodontics to their colleagues, students, and family members. Of the respondents, 63.5% said they plan to limit their practice to prosthodontics only.

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When asked about their 10-year plans after graduation, 48.1% stated that they plan to work 4 days a week, while 41.7% said they plan to work 5 days a week, and only 10.1% reported that they would work 3 days a week. Most of the respondents (47.8%) expected to earn annually between $200,000 and $400,000, 20.9% expected to earn between $400,000 and $600,000, 15.9% reported they expect to earn more than $600,000, and 15.4% expected to earn between $100,000 and $200,000. Men expected to work significantly more days per week (p = 0.01), and to earn significantly more annually than women (p = 0.001). Nearly 80% stated their plans to pursue the ABP certification. The majority of the respondents (73.5%) reported that they would contribute to the prosthodontic programs in which they were trained, from which 41.1% stated they would begin making their contributions 5 or more years after graduation. With respect to the amount of their contributions, 53% said that 1% to 3% of their annual income would be reasonable to contribute, 14% stated that 4% to 6% of their annual income would be reasonable, and only about 5% of the respondents said they would contribute more than 7% of their annual income. On the other hand, 25.5% of the respondents said they would not give any contribution to the programs in which they were trained, and 3.5% did not respond to this question. Approximately 54% of the respondents stated their plans to contribute to the ACP Education Foundation. Nearly 80% of the respondents stated that they would become active in prosthodontic organizations following their graduation.

Discussion Unlike other specialty programs,3-7 reports on prosthodontics residents’ demographics and education is scarce. There are only limited references with which to compare these data. This is the first study describing prosthodontics residents’ perspectives on their current training and future goals and can serve as the foundation for future studies. Demographics

The demographic data of the residents surveyed in 2007 showed similar characteristics to the previous survey in 2006.20 This might be because the distribution time of the surveys was too close to each other. Interestingly, although the sample size was small, we noted that female students had a significantly higher divorce rate and had fewer children compared to male respondents. Recent studies have shown that family issues such as pregnancy, marriage, and motherhood had more impact on female residents.21,22 The majority of the respondents did not enter their programs immediately after graduation. Of those who did not enter immediately after graduation, 43.8% were in private practice. This could be due to high debts carried by new graduates, family financial responsibilities, and the small number of prosthodontic residency training programs that provide stipends or give tuition reductions. On the other hand, after generating income from private practices and overcoming family financial responsibilities, young dentists might have difficulty in returning to residency programs. The financial burden might not apply to the

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foreign-trained dentists, as most of their previous and current dental education might be supported by their families.

Program specifics

The majority of the respondents reported that their programs prepared them to obtain ABP certification either by taking Mock Board Part I, or to complete a patient-care part. Although a majority of the students reported they were encouraged to complete one of the patient-care parts during their training, perhaps in the future this recommendation can become mandatory. By completing the patient care parts during their training, the residents can take all the benefits that may not be available in their private practices. In addition, in 2008, a substantial change was made to the oral ABP examination process, which may necessitate programs to modify their board preparation curricula accordingly. Of the students/class, 20% to 28% received stipends between $5,000 and $15,000, and 13% to 14% received stipends of more than $30,000. This finding was in agreement with a previous report that in dental school-based programs, the mean stipend was approximately $11,000, while in non-dental school-based programs the mean was $35,000 to $39,000.19 The authors also emphasized that the mean stipends and tuition almost balanced out across all 3 years of training. Regarding the residents’ responses on the adequacy of their education in different fields of prosthodontics, the majority of students reported having adequate training in basic prosthodontics with the exception of clinical Removable Partial Dentures (RPDs), maxillofacial prosthodontics, and TMD. Although the cohort for the partially edentulous patient was still high,23 and the patients could have been treated with RPDs, a majority of patients received dental implant care as opposed to RPD therapy. This trend may be due to information on implant dentistry becoming more available to patients through media technology such as the Internet. In addition, to address the demands for implant treatment in patient care and to enhance surgical implant knowledge, the ACP in 2005 added placement of implants to its Accreditation Standards for Advanced Specialty Education Programs in Prosthodontics.17 It is expected that students will act as first assistant and/or primary surgeon for some of their own patients. In respect to TMD, recent accreditation standards for AEP programs mandated that instructions must be provided at the understanding level in TMD and orofacial pain, and students must be competent in the prosthodontic management of patients with TMD and/or orofacial pain.24 Therefore, the programs should grant their residents more exposure to didactic and clinical TMD. The majority of students ranked clinical education as the most important factor, and research opportunity/original dental school as the least important factor in selecting prosthodontic programs. This finding was in agreement with our previous data.20 In this article, we demonstrated that applicants placed a high emphasis on clinical education, their impressions of the program directors, advice from predoctoral mentors, their impressions of residents’ satisfaction and happiness, and the opportunity to place dental implants when selecting their prosthodontic programs. The factors of least importance

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are climate and opportunities to moonlight, teach, and conduct research. In this study, it was also noted that the majority of prosthodontic programs (74.5%) required their residents to do research as part of their program requirements. In addition, a majority of students were interested in doing research and publishing their research in a refereed journal; however, only a few programs (32.3%) required their residents to participate in formal graduate training, either master’s or PhD programs. In the future, to increase the quality of research, more participation in formal graduate training may be necessary. Future trends

When asked about their plans after graduation, few students (13.4%) showed an interest in academics and/or research careers; however, 60.2% reported they would be interested if the income for teaching was improved; 92.7% reported their interests in becoming part-time academicians in addition to their private practices. It was clear that despite their interest in becoming prosthodontic educators, the low income of academicians, exacerbated in some cases by high debt, discouraged them from becoming full-time educators. With the expected normal attrition of full-time faculty, this inclination might result in a low number of full-time faculty with full-time appointments in the future. A more thorough assessment of the impact of different reasons preventing graduates from joining academics is necessary. Evaluating their 10-year plans, most of the respondents (48.1%) planned to work 4 days a week, and 41.7% planned to work 5 days a week with a median annual income goal between $200,000 and $400,000. In addition, male prosthodontists expected to work significantly more days per week and to earn significantly more than their female counterparts. Our finding was in agreement with previous data. Nash and Pfeifer18,19 showed that the average earnings for prosthodontists in private practices were estimated to be $213,742 ± $167,488; male prosthodontists earned 30% more than female prosthodontists, and the mean earnings grew as prosthodontists gained more experience. One of the most significant findings was the high satisfaction of the residents with their future career. Nearly 80% of the respondents would recommend the specialty to their colleagues, students, and family members. The majority of respondents were planning to limit their practices to prosthodontics. Of the respondents, 80% planned to pursue ABP certification, which might be attributed to the ACP’s effort to encourage students to attain board certification. Of the respondents, 80% also reported their plans to become active in prosthodontic organizations in the future. Future study is needed in 10 years to follow up and determine whether the responding residents accomplished these goals. There are some limitations to this study. First, the data are indicative of 48% of the AEP resident population, which may not be representative of the total prosthodontic resident population. Second, from our survey, we learned that additional questions could have been asked to provide the profession with valuable information, such as the faculty (full- /part-time/board-certified faculty members) and student ratio in the program. Another question that could have been asked would be if research men154

tors were available in the departments, what kind of research facilities they had, and how they got financial support in performing their research. We should also have asked the residents where they intended to practice, to teach, or both, to estimate the number of future prosthodontists in the United States.

Conclusion This is the first report identifying current prosthodontic residents’ demographics, perspectives on their clinical training, and future goals. These findings can serve as a foundation for future studies. Several trends were identified and showed a promising future for the specialty. One of the most significant findings was the high satisfaction of the residents with their future career. The findings of this study have important implications for AEP programs. By knowing the students’ perceptions regarding their training and future goals, the ACP and/or program directors will be able to use this information to improve the programs and the specialty itself.

Acknowledgments The authors would like to acknowledge Drs. Stephen D. Campbell and Kent Knoernschild for reviewing and giving suggestions regarding the manuscript. The authors wish to thank all residents who generously devoted their time and effort to completing our survey. We also thank Dewi Susanti for editing the manuscript.

References 1. American Dental Association: 2004/2005 Survey of Advanced Dental Education. Chicago, American Dental Association, 2006. 2. Aborn PS: Advanced prosthodontic education: survey of graduate students. J Prosthet Dent 1976;35:47-48 3. Keim RG, Sinclair PM: Orthodontic graduate education survey, 1983–2000. Am J Orthod Dentofacial Orthop 2002;121:2-8 4. Rudolph DJ, Sinclair PM: Orthodontic graduate education survey 1983–1994. Am J Orthod Dentofacial Orthop 1997;112:418-424 5. Sinclair PM, Rudolph DJ: Orthodontic graduate education survey 1983 to 1989. Am J Orthod Dentofacial Orthop 1991;100: 465-471 6. Sinclair PM, Alexander RG: Orthodontic graduate education survey. Am J Orthod 1984;85:175-181 7. Bruner MK, Hilgers KK, Silveira AM, et al: Graduate orthodontic education: the residents’ perspective. Am J Orthod Dentofacial Orthop 2005;128:277-282 8. Duncan JP, Taylor TD: Teaching an abbreviated impression technique for complete dentures in an undergraduate dental curriculum. J Prosthet Dent 2001;85:121-125 9. Taylor TD, Aquilino SA, Jordan RD: Prosthodontic laboratory and curriculum survey. Part IV: fixed prosthodontic curriculum survey. J Prosthet Dent 1985;53:267-270 10. Petropoulos VC, Arbree NS, Tarnow D, et al: Teaching implant dentistry in the predoctoral curriculum: a report from the ADEA Implant Workshop’s survey of deans. J Dent Educ 2006;70: 580-588 11. Petropoulos VC, Rashedi B. Removable partial denture education in U.S. dental schools. J Prosthodont 2006;15:62-68

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12. Petropoulos VC, Rashedi B: Complete denture education in U.S. dental schools. J Prosthodont 2005;14:191-197 13. Lim MV, Afsharzand Z, Rashedi B, et al: Predoctoral implant education in U.S. dental schools. J Prosthodont 2005;14:46-56 14. Geerts GA, Stuhlinger ME, Nel DG: A comparison of the accuracy of two methods used by pre-doctoral students to measure vertical dimension. J Prosthet Dent 2004;91:59-66 15. Wright RF, Dunlop RA, Kim FM, et al: A survey of program directors: trends, challenges, and mentoring in prosthodontics. Part 1. J Prosthodont 2008;17:69-75 16. Wright RF, Dunlop RA, Kim FM, et al: A survey of deans: trends, challenges, and mentoring in prosthodontics. Part 2. J Prosthodont 2008;17:149-155 17. Sukotjo C, Arbree NS: Prosthodontic program directors’ perceptions regarding implant placement by prosthodontic residents: a 2004 survey conducted by the Educational Policy Subcommittee of the American College of Prosthodontists. J Prosthodont 2008;17:662-668 18. Nash KD, Pfeifer DL: Prosthodontics as a specialty private practice: net income of private practitioners. J Prosthodont 2006;15:37-46 19. Nash KD, Pfeifer DL: Private practice and the economic rate of return for residency training as a prosthodontist. J Am Dent Assoc 2005;136:1154-1162 20. Blissett R, Lee MC, Jimenez M, et al: Differential factors that influence applicant selection of a prosthodontics residency program. J Prosthodont 2009;18:283-288 21. Jain S, Ballamudi B: Women in U.S. psychiatric training. Acad Psychiatry 2004;28:299-304 22. Woodside JR, Miller MN, Floyd MR, et al: Observations on burnout in family medicine and psychiatry residents. Acad Psychiatry 2008;32:13-19 23. Douglass CW, Watson AJ: Future needs for fixed and removable partial dentures in the United States. J Prosthet Dent 2002;87: 9-14 24. Commission on Dental Accreditation: Accreditation Standards for Advanced Specialty Education Programs in Prosthodontics. Chicago, American Dental Association, July 26, 2007

Appendix. Survey of prosthodontic residents A. Please answer the following DEMOGRAPHIC questions: 1. Gender: Male Female 2. Age: ________ 3. Marital Status: Single Married Divorced 4. Number of Children: ________ 5. Citizenship: US Other: _____________ 6. Level of Education, check all that apply: DDS/DMD/BDS Master PhD Certificate: ________ 7. Did you earn your DDS/DMD Degree from a US or Canadian Dental School? Yes No 8. How many years after dental school graduation did you begin your prosthodontic residency? 0 years 1–2 years 3–5 years > 5 years 9. What did you do during that time? (Check all that apply) N/A Private Practice Military Residency_____________

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Other education (MS, PhD, etc.) ______________ Other_________________

10. What was your National Board Dental Examination Part I score? ____________ N/A, Non-US graduate 11. What was your academic rank in dental school? Top 5% 6–10% 11–25% 26–50% Other: _________ B. Please answer the following PROGRAM related questions: 1. How many programs did you apply to? 1 2 3 4 5 6 7 Other: _________ 2. How many interview invitations did you receive? 1 2 3 4 5 6 7 Other: _________ 3. How many interviews did you attend? 1 2 3 4 5 6 7 Other: _________ 4. In what year of residency are you currently in? 1st year 2nd year 3rd year 5. Number of residents per class: 1 2 3 4 5 6 7 Other: _________ What is the total number of residents? _____________ 6. How important were each of the following when selecting your prosthodontic program? Not Important (1) Most Important (5) Reputation 1 2 3 4 5 Location 1 2 3 4 5 Cost 1 2 3 4 5 Clinical education 1 2 3 4 5 Laboratory work training 1 2 3 4 5 Where I went to dental school 1 2 3 4 5 Research opportunities 1 2 3 4 5 7. How satisfied are you with your prosthodontic residency training program? Unsatisfied Satisfied Very Satisfied 8. Does your program specifically prepare you to obtain the American Board of Prosthodontics Certification? Yes No 9. Does your program require you to take part I of the American Board of Prosthodontics during your residency? Yes No 10. Does your program require you to take the MOCK Board part I exam during your residency? Yes No 11. Does your program encourage you to complete one of the patient care parts of the American Board of Prosthodontics during your residency? Yes No 12. Do you think you have adequate numbers of patients with different complexity? Yes No 13. Do you think your program provides you with adequate didactic knowledge in the following subjects? Fixed Prosthodontics Yes No Complete Denture Prosthodontics Yes No Removable Partial Denture Prosthodontics Yes No Dental Implants Prosthodontics Yes No Maxillofacial Prosthodontics Yes No Occlusion Yes No

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Temporomandibular Disorders Yes No Dental Materials Yes No 14. Do you think your program provides you with adequate clinical training in the following subjects? Fixed Prosthodontics Yes No Complete Denture Prosthodontics Yes No Removable Partial Denture Prosthodontics Yes No Dental Implants Prosthodontics Yes No Maxillofacial Prosthodontics Yes No Occlusion Yes No Temporomandibular Disorders Yes No 15. Does your program offer an advanced degree? Yes No If yes, are you pursuing a: Master’s PhD Other ____________ 16. Are students required to do research as part of the program requirements? Yes No 17. Are students required to complete a degree program (Master’s or PhD) as part of the program requirements? Yes No 18. Are you interested in doing research whether or not it is required? Yes No 19. Do you plan to pursue publishing your research in a refereed journal? Yes No 20. Do you plan to pursue publishing any of your completed patient care in a refereed journal? Yes No 21. Estimate the number of faculty teaching in your program that have full-time academic appointments in your school: 0 1–2 3–4 5–6 >7 22. Estimate the number of faculty teaching in your program that have part-time academic appointments in your school: 0 1–2 3–5 6–8 9–11 12–14 > 14 23. Estimate number of board-certified faculty teaching in your program (full and part-time faculty): 0 1–2 3–4 5–6 >7 24. Are you a student member of the ACP? Yes No 25. Are you encouraged to join and participate in the ACP, the prosthodontic specialty organization, during your residency? Yes No 26. Estimate the tuition for your program each year: $0 $1–5K $6–10K $11–20K $21–30K $31–40K >$40K 27. If you receive a stipend, how much is it? 1st year: $0 <$5K $5–10K $11–15K $16–20K $21–25K >$25K 2nd year: $0 <$5K $5–10K $11–15K $16–20K $21–25K >$25K 3rd year: $0 <$5K $5–10K $11–15K $16–20K $21–25K >$25K 28. What additional financial support have you received while in your prosthodontic residency?

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(Check all that apply) Family Financial Aid Bank Loans Federally Subsi-

dized Loans Savings P/T Work Other______________ 29. Estimate your debt at the time of graduation from prosthodontic residency training from prosthodontic residency only: $0 <$10K $10–25K $26–50K $51–75K $76–100K >$100K 30. Total educational debt: $0 <$25K $25–50K $51–75K $76–100K $101–150K $151–200K > $200K 31. Do you feel that your educational debt restricts you from pursuing full-time academics after graduation? Yes No C. Please answer the following questions about your FUTURE GOALS: 1. What are your plans following graduation? Associate Partner Solo Practice HMO Military Academics/Research Implant Training/Fellowship Maxillofacial Prosthodontics Undecided/Other 2. Would you be interested in full-time academics if the income for teaching was improved? Yes No 3. Are you interested in part-time academics combined with private practice? Yes No 4. Would you recommend choosing Prosthodontics as a specialty/profession to your colleague/student/family member? Yes No 5. Are you planning to limit your practice to Prosthodontics only? Yes No 6. Realistically, ten years after graduation I plan to: Work weekly: 1 day 2 days 3days 4 days 5 days Earn annually: $100–200K $201–400K $401–600K $601–800K >$800K Obtain American Board of Prosthodontics Certification: Yes No 7. How many years after graduation will you begin making a financial contribution to the residency in which you trained? 0 years 1–2 years 3–4 years 5+ years Never 8. After reaching financial stability, what percentage of income do you think is reasonable to contribute annually? 0% 1–3% 4–6% 7–10% >10% 9. Have you or are you planning on contributing to the American College of Prosthodontists Education Foundation (ACPEF)? Yes No 10. Do you plan on becoming active in prosthodontic organizations following your graduation? Yes No

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Journal of Prosthodontics Implant, Esthetic, and Reconstructive Dentistry Official Journal of The American College of Prosthodontists Volume 15

Number 6

November-December 2006

GUEST EDITORIAL Reframing the Future of Prosthodontics

ROSTHODONTICS has made great strides in recent years, demonstrated by a long litany of accomplishments: the opening of new programs, an improved applicant pool, an expanded scope of Prosthodontics, the launch of the ACP’s new website, public relations successes, a revitalized central office, the development of a more nimble governance structure, the ACP Education Foundation, and much more. As recently reported on MSN.com, we are sixth in the ranking of America’s highest paying jobs (U.S. government’s salary data, Department of Labor’s Bureau of Labor Statistics). This is ahead of all business careers and almost all other medical and dental careers. While things have dramatically improved, we need to continue to make things better to attract the best and brightest. We are poised to continue the successes for Prosthodontics and our patients; however, this requires careful planning. On June 11–12, 2006 a group of 20 dental and prosthodontic leaders gathered to consider the future of Prosthodontics. The intent was for key leaders to collaborate and identify the critical strategic issues facing prosthodontics and our graduate educational programs. An external facilitator was used as part of a structured brainstorming session to develop a series of propositions and strategic goals and plans. This involved the assimilation of a large amount of background information. Some of this was available from previous surveys or the dental literature.

Excerpts from this column were published in the Fall 2006 ACP Messenger.

Much of it was newly developed information from surveys and contact with the other specialties. The materials included: • • • • •

Need for Care and Patient Demographics Private Practice Educational Programs and Environment Science and Technology Information on the Other Dental Specialties

A series of core questions was used to direct the discussions. For example, “Do Prosthodontics and our Advanced Prosthodontic Programs need to grow? What role does developing science and technology play in the future of Prosthodontics?’’ The knowledge base was enlightening for those who participated in the summit. For example, there are approximately 90 graduates from our Prosthodontic Programs staying in the United States each year. This is inadequate by any measure. It is less than one-half of the other core specialties, and inadequate to meet the demands for care. We need to act now. A formal summary for the summit is in development. This will be shared with all communities of interest as soon as it is available. The core conclusions include: • There is an urgent need to transform and grow the field of prosthodontics within the next ten years. • The numbers of prosthodontists and advanced training programs need to grow. • Science and technology will be the driving forces in this transformational growth.

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• The culture of prosthodontics needs to change to leading the specialties and educational environment in restorative, implant, esthetic, and reconstructive dentistry. • Patient advocacy efforts must be increased.

• Recommendation 7 – Be leaders in dental school curriculum reform • Recommendation 8 – Continue efforts to increase the public and professional awareness of the specialty of prosthodontics

There was overwhelming recognition of the need to grow prosthodontics. This growth needs to encompass: (1) the number of prosthodontists, (2) the size and number of our specialty educational programs, (3) our presence in the academic environment, (4) continuing education offerings, (5) the organization and membership, and (6) our resources. In addition, there is a need to focus on establishing prosthodontics as the science and technology leader. The participants developed a series of visions and prioritized strategies to address the key issues. The list of recommendations was long. The top eight were: Workforce: The expanded prosthodontic workforce will support growth and innovation in practice, education, and research.

The summit outcomes will be the driving force behind two subsequent invitational meetings with key stakeholders in the field of prosthodontics to be convened by the ACP in early 2007. The two invitational follow-up meetings—one for corporate partners and one for the Prosthodontic Forum organizations—will serve as venues for review of the summit recommendations, where strategies for collaboration with stakeholder groups can be developed. Through the lens of the summit, I see the most incredible future for prosthodontics! The vision is so clear. I see the future of a growing prosthodontic community. I see an organization and foundation that embrace our core value of improving the quality of life through prosthodontics. I see a future of an active and strong membership, an organization of 4,000 members, a Central Office equaled by none. I see a future of widespread public awareness and the best continuing education programs. I see a new organizational structure that will position us to be nimble and responsive to our membership and the demands of the environment—a structure that will help us realize our future. I see a future of the top students from every dental school pursuing prosthodontics, a future of more and larger Prosthodontic Programs, providing leadership in the educational and patient care environments. I see a future of 200 new prosthodontists graduating every year; not just numbers, but the best and brightest the specialty has ever seen. I see a future of patients in need seeking the expertise we offer, a public that benefits from the best of care and the growth of our specialty. A series of task forces will be established in the coming months to further develop and realize the series of visions and actions defined by the summit. Please become involved. It will take each and every one of us.

• Recommendation 1 – Increase the number of trained prosthodontists • Recommendation 2 – Grow ACP membership Science and Technology: Prosthodontics will lead the use and innovation of new science and technologies to improve the quality of life and the position of the specialty; promote the integration of new technologies into educational, research, and patient care programs; and lead the generation of new knowledge. • Recommendation 3 – Be at the forefront of science and technology as inventors, beta testers, and early adopters • Recommendation 4 – Increase prosthodontic competency in science and technology through Centers of Excellence • Recommendation 5 – Integrate new science and technologies to the UG and PG dental school curricula • Recommendation 6 – Leverage new technologies for educational advances Patient Care, Treatment Standards, and Education: Prosthodontists will be creators and purveyors of the prosthodontic knowledge base for patient care.

Stephen D. Campbell, DDS, MMSc President Elect American College of Prosthodontists

Journal of Prosthodontics Official Journal of The American College of Prosthodontists Volume 9

Number 3

September 2000

Spread the News, the Future Looks Bright for Prosthodontics

or those who have been in the trenches, it may not come as a surprise that “the primary dental need for older adults is fixed prosthodontics.”1 It simply reaffirms what many in prosthodontics have said and written for years. Still, it’s satisfying to read it in print. In a recent Journal of the American Dental Association article, Meskin and Berg1 reported the results of a 10-year follow-up survey investigating the impact of older adults on the practices of a random sample of dentists in 5 states. Comparing data from their initial 1988 survey with data collected 10 years later, they noted an increase in the percentage of activity attributable to older adults at all levels (number of office visits, services provided, and patient expenditures). Further, every percentage exceeded the percentage of older adults in the general population. Several findings were particularly relevant to the future of prosthodontics. 1. Fixed prosthodontic treatments accounted for the highest patient expenditure. For older adult patients, it was by far the greatest service expense, according to results of both the initial and follow-up surveys. 2. Periodontal treatments were second on the list of service dollars expended by older adults. These services showed the most growth during the 10-year period. 3. Removable prosthodontics ranked third. 4. Other high-consumption services included operative dentistry and endodontics. Let’s consider prosthodontic treatments first. Although Meskin and Berg1 considered fixed prosthodontic treatments among older adults to be “more complex and challenging for dentists to provide,” Copyright © 2000 by The American College of Prosthodontists doi:10.1053/jpro.2000.21774

they were reluctant to specify which group of dentists might be best able to provide these services or exactly how dentists should prepare themselves to meet these clinical challenges. Possibly the most logical solution would be advanced training in prosthodontics. Secondly, the authors did not define exactly what type of periodontical therapies were rendered. Because periodontal disease among this population exhibits a relatively low prevalence, it could therefore be argued that these treatments were likely to have been mostly routine dental prophylaxes and surgical measures to enhance restorative treatments. Although the percentage of removable prosthodontic treatments attributable to complete denture versus partial denture treatments was not indicated, a third-place ranking among all dental care expenditures provides further evidence that the need for prosthodontic care is high. It also foretells potential opportunities to offer implant prosthodontics. Finally, both operative dentistry and endodontics ranked high and have serious implications for prosthodontics. One might suspect that the operative treatment needs, like the prosthodontic treatments, were “complex and challenging.” Under a different classification structure, they might even be considered prosthodontic rather than operative. In the case of endodontic treatments, the probability that these treated teeth will require full coverage restorations is high, making prosthodontic care an important part of meeting the needs of older dental patients. Considered by itself, the 1988/98 data presented by Meskin and Berg is remarkable and exciting. These data take on even greater significance, however, when considered in light of current population predictions for our older adults. For instance, to-

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dayâ&#x20AC;&#x2122;s over-65 age group accounts for approximately 12.6% of the US population, or over 34.5 million citizens.2 This promises great opportunities for prosthodontists to provide much-needed care to older adults. With growth projections of 20% (or 70.3 million), we can predict a long and healthy future for prosthodontics for many years to come. Spread the news, the future looks great for prosthodontics. But heed the advice offered by Meskin and Berg, and reevaluate your practice to ensure that it is accessible to older adults and that it appeals directly to their needs and preferences. As prosthodontists, we are prepared clinically, both in knowledge and expertise, but our awareness and appreciation for the special psychological, ergonomic, and societal conditions may be less than desirable. The opportunities ahead for prosthodontics are nearly limitless and are probably better than ever

Lloyd

before. The magnitude and quality of our success, then, will depend on our ability to capitalize on our strengths while striving to understand and accommodate the particular needs of our older patients. Cordially,

Patrick M. Lloyd, DDS, MS Editor-in-Chief, Journal of Prosthodontics The American College of Prosthodontists

References 1. Meskin L, Berg R: Impact of older adults on private dental practices, 1988-1998. J Am Dent Assoc 2000;131:1188-1195 2. United States Census Bureau, Population Division, Populations Projections Program: Population Projections of the United States by Age, Sex, Race, Hispanic Origin and Nativity: 1999 to 2100. Washington, DC, U.S. Census Bureau, 2000

EDITORIAL

Precision Prosthodontics Personalized or precision medicine involves the customization of healthcare with medical decisions, practices, and products designed for the patients’ genetic composition, environment, and lifestyle.1 In 2012 Kornman and Duff2 asked the question about personalized medicine, “Will dentistry ride the wave or watch from the beach?” In this issue Drs Puri, Kattadiyil, Puri, and Hall3 answer, “Yes. The era of personalized prosthodontics has arrived.” In their exciting research, Puri et al3 discovered that elevated levels of bone turnover markers, measured with a single blood draw, were associated with increased frequency of denture relines. They state, “Serum bone turnover markers may predict individuals at risk of frequent relines due to rapid alveolar bone resorption.” As far as we are aware, this is the ﬁrst time prosthodontists have been given the tools to help patients with edentulism evaluate their individual risk for future bone loss. Such knowledge will impact treatment decision making.

THE JOURNAL OF PROSTHETIC DENTISTRY

Puri et al3 are opening the door to a future with improved dental care because of the ability of dentists to make decisions based on biochemical markers in their patients. I expect to see more manuscripts that focus on improved and better-targeted diagnostics in the future. Welcome to the era of precision prosthodontics! Stephen F. Rosenstiel Editor-in-Chief REFERENCES 1. Matsumoto T, Ohno M, Azuma J. Future of pharmacogenetics-based therapy for tuberculosis. Pharmacogenomics 2014;15:601-7. 2. Kornman KS, Duff GW. Personalized medicine: will dentistry ride the wave or watch from the beach? J Dent Res 2012;91(7 Suppl):8S-11S. 3. Puri S, Kattadiyil MT, Puri N, Hall SL. Evaluation of correlations between frequencies of complete denture relines and serum levels of 3 bone metabolic markers: A cross-sectional pilot study. J Prosthet Dent 2016; XXX:XXX-XX. Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.