Comment
Implant Education in the Dental Curriculum
Perry R. Klokkevold, DDS, MS
Copyright 2001 Journal of the California Dental Association.
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The success of osseointegrated dental implants has forever changed dentistry and, thus, undergraduate dental education. With the tremendous clinical acceptance and increased patient demand for dental implants, dental school educational programs must prepare students to treat patients with this modality. The purpose of this article is to provide an overview of the predoctoral dental implant educational program at the University of California at Los Angeles School of Dentistry.
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Dental implant therapy is an essential part of dentistry. Research has established the biological basis for and documented the long-term predictability of dental implants, which has promoted the acceptance of their clinical use. The success of osseointegrated dental implants has forever changed dentistry and, thus, undergraduate dental education. It has changed the perspective of clinicians and educators on many aspects of dental therapy. Dentists have witnessed a paradigm shift from the practice of saving teeth at all cost to one that considers extraction of compromised teeth to improve the esthetics, function, and long-term prognosis of the entire dentition with the application of this technology. For some cases, such as the missing single tooth, implant therapy is becoming the standard of care because it is predictable and often more conservative than a conventional crown and bridge.1 Additionally, patients have become educated and appreciate how implants can benefit their oral health, esthetics, and function. As a result, more and more patients are seeking dental implant therapy. According to a recent American Dental Association survey, the number of dental implant procedures being done in the United States tripled from 1986 to 1997; and this trend is expected to continue.2
In July 1990, 62 faculty members from 49 U.S. dental schools gathered in Chicago to review, revise, and approve curriculum guidelines for predoctoral implant dentistry.3 This conference was a joint effort by the American College of Oral Implantologists, the University of Pittsburgh School of Dentistry, and the American Association of Dental Schools.4 The curriculum guidelines established at the conference were embraced by many dental schools, which have used them to design their implant educational programs.5 The guidelines suggested that upon completion of the dental school program, dental students should be able to identify and discuss aspects of implant dentistry, including a historical background and current trends in dental implantology. With this knowledge, students would be expected to describe both surgical and prosthetic procedures used to provide implant therapy. The proceedings of this conference made no recommendations for laboratory and/or clinical experience in the predoctoral curriculum guidelines. The guidelines recommended that dental students be given lecture format instruction in implant dentistry and that courses should be taught to the level that achieved exposure and understanding.
In an article written for the Journal of the California Dental Association nearly a decade ago, Dr. Howard Landesman stated, "A student graduating in 1996 should have a background in implant dentistry which permits him/her to use this treatment option in any individual who is partially or totally edentulous."6 He was referring to the need for a curriculum in implant dentistry, as part of the predoctoral curriculum, that conferred competence greater than that of exposure and understanding. Obviously, with the tremendous clinical acceptance and increased patient demand for dental implants, dental school educational programs must prepare students to be able to assess for, plan for treatment with, and treat patients with dental implants.
Clearly, there is a need for dental implant education in the predoctoral curriculum of dental students. In response to this need, most North American dental schools have implemented some form of dental implant education.7-9 However, incorporating new dental implant courses into an existing dental school curriculum has not been without challenge. The most commonly cited challenges include:
* A lack of adequately trained faculty to teach courses;
* Not enough time in an already overfilled dental school curriculum; and
* Scarce financial resources.9-11
Today, many specialists have been trained; thus, the first challenge should not be an issue. The second challenge remains because of the difficulty in eliminating more-traditional aspects of dental school education curriculum in order to accommodate an implant educational program. The financial challenge has been addressed in some cases with the aid of implant companies.11
The purpose of this article is to provide an overview of the current predoctoral dental implant educational program offered at the University of California at Los Angeles School of Dentistry. The dental implant educational program within this institution evolved as an extension of the advanced prosthodontic courses. It is structured to provide dental students with a basic learning experience in implant dentistry, including hands-on laboratory sessions and opportunities to provide implant therapy for patients.
Didactic Educational Program
Implant dentistry is a multidisciplinary therapy comprising surgical and restorative requirements. For this reason, dental implant education is typically taught in segments, with specialists teaching within their respective domains. Implant education began with specialists teaching only their respective (surgical or prosthetic) areas of implant dentistry to dental students as part of their specialty departmental courses. However, the separation of surgical and restorative aspects of implant dentistry sends the wrong message to dental students. To teach the concept that the surgical procedures are performed to achieve a restorative goal, a more-integrated approach has been created. Teaching different aspects of implant dentistry in separate courses unnecessarily segments the treatment concepts into separate entities. Since implant therapy always results from a surgical procedure followed by a restorative procedure, it is more logical and effective to teach these different aspects as part of a continuous course. Furthermore, teaching courses that are separated by specialty results in an unnecessary repetition of certain subjects, such as history and treatment planning.
The primary concept being taught at the UCLA School of Dentistry is that treatment plans are primarily driven by restorative needs. That is, the restorative plan ultimately determines the surgical needs. For this reason, the dental implant curriculum at UCLA has been developed to bring specialists together with a unifying curriculum designed to teach students in a continuous series of courses. This curriculum, which emphasizes the prosthetic/restorative aspects of implant dentistry, is an extension of the advanced prosthodontic courses with lectures given primarily by the prosthodontic specialists and restorative faculty augmented with lectures given by the periodontal and oral and maxillofacial surgery faculty. Lecture presentations cover topics including but not limited to:
* The biologic and scientific basis of osseointegration;
* Patient evaluation, diagnosis, and treatment planning;
* Basic implant surgery procedures along with postoperative patient management;
* Basic implant prosthodontic procedures; and
* Implant maintenance protocols.
The predoctoral didactic educational program in advanced prosthodontics and implant dentistry at UCLA consists of 30 hours of lecture over two quarters with a minimum of four hours of laboratory hands-on experience. The Section of Removable Prosthodontics teaches the primary core course in implant dentistry for predoctoral dental students with prosthodontists providing most of the didactic educational program. Surgical specialists (periodontists and oral surgeons) provide instruction on the surgical aspects of implant dentistry as part of this core educational course. The Sections of Periodontics and Oral and Maxillofacial Surgery continue to teach some aspects of surgical implant therapy as part of their respective specialty courses. This facilitates their ability to stress the importance of implant surgery in their courses.
The course format consists of a series of lecture presentations, laboratory hands-on experience, and Internet access to study materials. The didactic course begins with a historical perspective on dental implants from subperiosteal implants to the current status of osseointegrated endosseous dental implants. The biological basis for osseointegration is supported with evidence from the literature. Patient assessment, diagnosis, and treatment planning for the various types of implant cases are emphasized as a major part of the course. Evidence from the literature is used to support the concepts being taught. Procedures used in implant therapy are presented in detail with follow-up laboratory sessions in which students participate. Tables 1 and 2 list the behavioral objectives and lecture topics for the UCLA predoctoral series of dental implantology courses.
Recently, the Internet has been utilized effectively as a means of providing study materials to students. Lecture materials prepared by faculty are accessible to students via the Internet. A password-protected Web site has been established, which makes available the entire course lecture material as given in class with photos, figures, and text. The Web site offering of this course is intended to give students unlimited access to lecture material for study and review rather than as a substitute for class attendance. Class attendance is required, and a written final examination is given at the end of each quarter to test competence in learning course materials.
Laboratory Hands-on Experience
As part of the dental implant education, dental students participate in both surgical and prosthetic hands-on sessions in the laboratory. In the surgical hands-on session, students prepare and place multiple screw-type, cylindrical implants in a prefabricated edentulous mandible model. Clinical slides and a video presentation are shown prior to the exercise to stress the importance of gentle surgical techniques, irrigation for cooling, and the use of surgical guides for the proper "prosthetically driven" implant placement. The hands-on exercise teaches the proper use of sequential drilling with an emphasis on precise management of the osteotomy site. Figure 1 illustrates the preparation and placement of two implants in an edentulous mandible model simulating the positions for an implant-assisted overdenture.
The prosthetic hands-on experience enables students to become familiar with a variety of implant restorative components. Students apply both direct and indirect impression-taking techniques to externally hexed implants in a plastic model. Several abutment choices are fitted on the model with explanations for the use of each type. Students practice taking impressions with the various impression copings and use implant analogs to pour working models of the simulated implant case. These prosthetic hands-on sessions are completed in conjunction with a treatment planning discussion of real patient cases. The faculty-to-student ratio for these sessions is 1-to-4 so that each student gets ample attention and has the opportunity to ask questions. Figure 2 illustrates the models used for the simulation of impressions and abutment placement in a partially edentulous patient with an implant-supported fixed partial denture. The laboratory hands-on experience serves to familiarize dental students with the various components and procedures for implant dentistry in an environment that is conducive to learning without patients.
Clinical Experience
In addition to the required didactic and laboratory aspects of the implant educational program, dental students are encouraged to treat patients with implants. The current curriculum does not require dental students to complete dental implant cases as part of their graduation requirements, but they are given extra-credit incentives to seek and complete implant cases. Students are highly encouraged to do some simple implant cases as part of their restorative and removable prosthodontic experience. The types of implant cases that students are encouraged to do include implant-assisted overdentures, single-implant restorations, and simple multi-unit fixed restorations. The most common type of case students treat is the mandibular implant-assisted complete overdenture. Figure 3 demonstrates a typical dental student case with two mandibular implants used to retain a lower denture with a bar and Hader clip design.
Dental students have the opportunity to gain clinical experience with the surgical aspects of implant therapy by assisting and observing cases performed by postgraduate residents and faculty in the periodontal and oral and maxillofacial surgery programs. This experience allows students to observe implant surgery first hand and provides ample opportunity to ask questions. Extra credit is given for assisting, but it is not required as part of the dental implant experience for predoctoral students.
Perhaps more important than any actual experience with dental implant procedures, students are taught to think about dental implant treatment options as part of their diagnostic work-up and treatment planning for patients. All potential implant patients are taken through an advanced treatment planning session with several faculty representing each of the specialty sections. In preparation for the advanced treatment planning session, students take a complete history, examine the patient, prepare mounted study models, and request appropriate diagnostic radiographs. At the advanced treatment planning appointment, the dental student presents his or her case to the faculty. Each faculty member examines the patient and provides his or her respective specialist view on the problems that present. As an interactive learning experience, the student is asked questions that stimulate thoughts about the treatment options. Ultimately, a treatment plan is developed for the patient with consideration for patient desires and all presenting problems, including finances. This interactive treatment-planning session allows faculty to teach patient-driven concepts to students on an individual basis and facilitates the development of ideal treatment plans for patients.
Conclusion
Nearly three decades of evidence supports the use of osseointegrated dental implants, and it is now considered a predictable means of replacing missing teeth with long-term success. More and more patients are becoming educated about dental implants and seeking implant solutions. Dental school curriculums need to continue to evolve with implant dentistry to prepare dental students in the assessment, treatment planning, and restorative aspects of dental implant therapy. This article has outlined the current status of dental implant education at the predoctoral level taught at the UCLA School of Dentistry. Future directions for dental implant education at the predoctoral level will likely include interdisciplinary applications, more clinical experiences for dental students, and computer-simulation experience.
Acknowledgments
The author would like to acknowledge and thank Dr. E.B. Kenney (professor and chair, UCLA Periodontics), Dr. John Beumer (professor and chair, UCLA Removable Prosthodontics), and Dr. Earl Freymiller (clinical associate professor and chair, UCLA Oral and Maxillofacial Surgery) for their review of and advice on the preparation of this manuscript.
Author
Perry R. Klokkevold, DDS, MS, is an associate professor and the clinical director of the postgraduate periodontics residency at the University of California at Los Angeles School of Dentistry in the Division of Associated Specialties, Section of Periodontics.
1. Newman MG, The single-tooth implant as a standard of care -- editorial. Int J Oral Maxillofac Implants 14(5):621-2, 1999.
2. Dental Implants Nearly Triple Over 10-Year Period: ADA Survey. May, 1999. Available at: http://www.ada.org.
3. Ismail JYH, Predoctoral curriculum guidelines in implant dentistry. Int J Oral Implant 7(1):67-9, 1990.
4. Simons AM, Bell FA, et al, Undergraduate education in implant dentistry. Implant Dent 4(1):40-3, 1995.
5. The American Association of Dental Schools, Curriculum guidelines for predoctoral implant dentistry. J Dent Educ 55(11):751-3, 1991.
6. Landesman HM, Dental implants in the predoctoral curriculum. J Calif Dent Assoc 20(5):58-9, 1992.
7. Arbree NS, Chapman RJ, Implant education programs in North American dental schools. J Dent Educ 55(6):378-80, 1991.
8. Wilcox CW, Huebner GR, et al, Placement and restoration of implants by predoctoral students: the Creighton experience. J Prosthodont 6(1):61-5, 1997.
9. Weintraub AM, Seckinger R, et al, Predoctoral implant dentistry programs in U.S. dental schools. J Prosthodont 4(2):116-21, 1995.
10. Seckinger RJ, Weintraub AM, et al, The status of undergraduate implant education in dental schools outside the United States. Implant Dent 4(2):105-9, 1995.
11. Taylor TD, Dental students and dental implants: what's the right combination? -- editorial. Int J Oral Maxillofac Implants 16(1):19-20, 2001.
To request a printed copy of this article, please contact/Perry R. Klokkevold, DDS, MS, UCLA School of Dentistry, Box 951668, Los Angeles, CA 90095-1668 or pklok@ucla.edu.
Table 1. Behavioral Objectives for Predoctoral Dental Implantology Courses Taught at UCLA
1. With respect to osseointegration, students will understand:
a. The relationship between subperiosteal implants, and bone and the enveloping soft tissues;
b. The definition of osseointegration;
c. The unique biocompatibility of titanium;
d. The influence of temperature generated during bone preparation on osseointegration;
e. The importance of the delay of occlusal loading after placement of osseointegrated implants;
f. The relationship between oral mucosa and osseointegrated implants;
g. Bone repair mechanisms around implants;
h. Implant biomechanics;
i. Nature of the bone-implant interface; and
j. Nature of bone repair around implants with different surface morphology.
2. Students will become familiar with the prosthodontic and surgical components and the terminology used to describe them.
3. With respect to the placement of osseointegrated implants, the students will understand:
a. The means of patient selection with respect to hard and soft tissues in both edentulous and partially edentulous patients;
b. The medical contraindications;
c. The basic surgical procedures used in implant placement;
d. The basic surgical procedures used at second-stage surgery; and
e. The fabrication of templates used during implant placement.
4. When fabricating a fixed edentulous bridge, students will be familiar with:
a. The management of the soft tissues surrounding the implants;
b. The methods of making impressions;
c. The means of fabricating record bases;
d. The method of making centric-relation records;
e. The method for determining cantilever length;
f. Determining the occlusal scheme; and
g. The procedure used during processing, delivery, and follow-up.
5. When fabricating implant-assisted or -supported overlay dentures, the student will be familiar with:
a. The criteria for patient selection;
b. Design principles regarding implant-supported prostheses vs. implant-assisted prostheses;
c. The attachment employed and the rationale for choosing them;
d. Impression methods;
e. Means of making and fabricating record bases;
f. The methods used in making centric-relation records;
g. Developing an appropriate occlusal scheme; and
h. Methods employed in processing, delivery, and follow-up.
6. When constructing fixed partial dentures for partially edentulous patients, students will learn:
a. The principles of patient selection and workup;
b. The use of surgical templates in implant placement;
c. The basic biomechanics and occlusal principals employed;
d. The clinical and laboratory steps used in fabrication of these restorations;
e. The rationale, design, and application of abutment selection; and
f. The indications of single-tooth implants in the anterior and posterior quadrants.
7. With regard to periodontal considerations, students will be familiar with:
a. The importance of attached mucosa around implants;
b. Microbiology of the implant-gingiva interface;
c. The differences between the implant-bone interface and the periodontal ligament;
d. The methods of follow-up and maintenance; and
e. The treatment of peri-implantitis.
Table 2. Lecture Topics for Predoctoral Dental Implantology Courses Taught at UCLA
1. Historical perspective on implant dentistry
2. Biologic basis of osseointegration
3. Patient selection and treatment planning
a. Edentulous
b. Partially edentulous
4. Stage I surgery -- implant placement
a. Edentulous maxilla
b. Edentulous mandible
c. Partially edentulous
d. Role of bone grafting
5. Stage II surgery -- implant exposure
a. Edentulous patients
b. Partially edentulous
c. Special soft-tissue considerations
6. Prosthodontic components and nomenclature
a. Implant analogues
b. Impression copings
c. Abutments
d. Abutment analogues
7. Prosthodontic procedures
a. UCLA abutments
b. Conical abutments
c. Custom abutments
8. Restoration of the posterior quadrants/partially edentulous patients
a. Provisionals
b. Occlusal factors
c. Cusp angles
d. Width of occlusal table
e. Materials
f. Hygiene access
9. Implant restorations in the esthetic zone
a. Single-tooth restorations (bone and soft-tissue contours)
b. Multiple-tooth restorations (bone and soft tissue contours)
c. Prosthodontic procedures
10. Restoration of the edentulous maxilla
a. Implant-assisted overlay dentures
b. Hader, ERA design
c. Implant-supported overlay dentures
d. Milled bars
e. Porcelain-fused-to-metal fixed edentulous bridges
11. Restoration of the edentulous mandible
a. Implant-assisted overlay dentures
b. Hader, ERA design
c. Implant-supported overlay dentures
d. Milled bars
e. Porcelain-fused-to-metal fixed edentulous bridges
12. Hands-on session (surgical)
a. Sequential drilling procedure
b. Osteotomy preparation
c. Placement of threaded implants
13. Hands-on session (prosthetic)
a. Impressions
b. Record bases
c. Records
d. Implant-assisted bar designs
Legends
Figure 1. Laboratory hands-on experience in the surgical preparation and placement of screw-type, cylindrical dental implants in a plastic jaw.
Figure 2. Laboratory hands-on experience in the restorative aspects of implant dentistry, including impression taking.
Figure 3. Clinical view of typical dental student implant case of an implant-assisted overdenture.
Figure 4. Clinical experience in the surgical aspects of implant
therapy is gained by assisting residents and faculty in Periodontics and
Oral and Maxillofacial Surgery.
