Education in maxillofacial prosthetics Joe B. Drane, D.D.S.” The University
of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute,
A
review of the educational program in Maxillofacial Prosthetics at The University of Texas at Houston Dental Branch and The M. D. Anderson Hospital demonstrates the effectiveness of the maxillofacial prosthetic educational program in the past 23 years and the changes and modifications which may be indicated for its improvement in the future. Fifty-five dentists have been registered in the maxillofacial prosthetic program. Thirty-one completed two years of training; twenty-one completed one year of training; two did not complete the program; and one died during his training program (Table 1). The fifty-two dentists who completed the maxillofacial prosthetic program entered into various types of practice (Table II). Twenty-three dentists have entered into institutional practice of maxillofacial prosthetics. These maxillofacial prosthodontists are staffing programs either in medical centers, cancer hospitals, or dental schools. The largest group (14) includes those. sent for training by the various federal services-3 in the Navy, 3 in the Air Force, 1 in the Army, and 7 in the Veterans Administration. The next largest group (8) entered into a combined private practice and institutional part-time teaching program. Four dentists continued their education in order to obtain their Master’s Degree, and three dentists entered into private practice. There has been a decrease in dentists entering institutional practice and a shift to increased numbers of dentists in private practice and a combination of institution and private practice. Presented at The Academy of Maxillofacial Prosthetics, San Diego, Calif. *Head, Department of Dental Oncology; Director, Regional Maxillofacial Restorative Center; Chief, Dental Service, The University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute; and Professor, Maxillofacial Prosthetics, The University of Texas Health Science Center Dental Branch, Houston, Texas.
CO&3913/78/
110583
+ 04$00.40/O
Q 1978 The
C
V. Mosby
Co.
Houston. Texas
A review of the l-year and 2-year trainees (Table III) showed that the largest group in the I-year program went to federal service practice, while the largest group in the 2-year program went into institutional practice. At the present time (Table IV) there has been a shift in the number from institutional and federal practice to private practice and combined practice, with the greatest chang? taking place among the trainees from the Z-year program. Of further interest is the fact that 48 of the 55 dentists who started the program are still practicing maxillofacial prosthetics either full time or part time. Their geographic distribution following completion of training is 16 in Texas, 29 in other states in the United States, and 8 who have returned to their countries of origin outside of the United States-Nicaragua, India, Brazil, Mexico, Canada, and Puerto Rico (Table V). SELECTION
OF TRAINEES
In the early days of the maxillofacial prosthetic program there were few requirements for admission into the program other than a degree in dentistry and an application which included a curriculum vitae and a biographical data sketch. These requirements were adequate at that time, since only one resident was being admitted each year for 2 years of training, and full time could be devoted to the supervision of the student’s clinical work. As the program evolved to encompass a full curriculum which included clinical, didactic, and research activities, more stringent requirements and a closer review of the applicants became desirable and necessary. Since the time allotted for maxillofacial training in most programs is limited to 1 or 2 years, and since there is so much to be covered if the trainee is to become competent in all phases of maxiiiofacial prosthetics, there is simply no time available during this period to train students in routine dental techniques and procedures.
Therefore,
it is required
THEJOURNALOFPROSTHE~CDENTISTRY
that
583
DRANE
Table I. Maxillofacial
Table III. Type of practice immediately following training, 19.53-1976
trainees, 1953-1976
Years of training 1 Year of training Dropped out during training Deceased during training Total 2
31
21 2
I 55
Table II. Type of practice following
training,
1953-1976 Practice Institution
Private practice Combination Federal service Continued education Deceased Dropped out of training TOtdl
Immediate
Present
23 3
16 9
8 14 4 1 2 5.5
13 12 I 2 2 55
they have a good background of the English language in order to receive instruction adequately and be able to express themselves accurately to patients and other staff members. It is required and expected that they be competent as dentists and be able to carry out routine prosthodontic procedures upon admisson to the training program. It is required that they submit three letters of recommendation, which are thoroughly evaluated by the Dean of Graduate Studies and the Head of the Department of Dental Oncology. It is required that they submit a statement from a physician certifying that they are in good health and a recent chest radiograph. They must submit a transcript of their college records, and it is desirable to have a personal interview with each selected resident prior to final acceptance and appointment. From our previous experience, the final requirement is of prime importance both to the trainee and to the program. Three applicants who were accepted for the program later found that they either were not aware of the involvements of maxillofacial prosthetics and the types of patients that need care or were simply not psychologically suited to practice this type of dentistry. One applicant chose not to enter the program following a personal visit and discovering what was involved. This caused problems due to late timing in filling the position with an alternate candidate. Another of the three candidates was accepted for training, stayed 10 days or 2 weeks, and
!584
I-y-01 trainee
Practice Institution Private practice Combination Federal service Continued education Dropped out of training Deceased Total
7 I
Z-year
trainee 16 2 8 I 4
13 2 1 24
31
then left without notice. He simply could not work with disfigured patients. The third trainee came into the program with an excellent background, was very competent in carying out prosthodontic procedures, and had excellent letters of recommendation which indicated no problems, yet his personality absolutely prevented him from being able to work with supporting personnel or take instruction from the teaching staff. I believe, following these experiences, that personal interviews are highly desirable so that the applicants may be fully aware of all that is involved in this highly specialized work before starting in the program, and also so that applicants who are not psychologically suitable may be screened out. Unfortunately, letters of reference all too often only say good things about the person and do not point out potential problems. In addition to the requirements for admission, an applicant should have completed at least 1 year in a rotating dental internship program, or 1 or more years in general practice. It is also recommended that all applicants for this comparatively long-term training attend a short course in maxillofacial prosthetics so that they may be fully
aware of all that will
be
involved in their future dental practice. LENGTH OF CURRICULUM The length of curriculum
must necessarily depend
upon all of the factors involved
in the selection
of
trainees. in general, 1 year for technician training and 2 years for maxillofacial prosthodontic training is recommended. Only six technicians have trained over a 2-year period, but it became apparent that prior formal training in a technological course for 2 years did not provide a satisfactory background to enter maxillofacial technology training. Practical experience in a commercial dental laboratory or a
NOVEMBER
1978
VOLUME
40
NUMBER
5
EDUCATION
IN MAXILLOFACIAL
PROSTHETICS
Table IV. Present type of practice, 1953-1976 Practice
l-year trainee
Institution
6 2 2 11
Privatepractice Combination Federal service Continued education Dropped out of training Deceased Total
2 1 24
Table V. Additional information maxillofacial trainees, 1953-1976
Z-year trainee
1 31
Nukz 48 of 55 are still practicing full or part time.
It is extremely difficult to assessthe national needs for maxillofacial prosthodontists and technicians, since until recently they have not been included in the personnel tables of organizations of dental schools or hospitals. So far almost all trainees, upon completion of their program, have had one or more positions offered to them. As maxillofacial prosthetic services become more recognized in major medical centers, trained specialists, both professional and supportive, will be more in demand throughout the country. Support activities in the form of maintenance of maxillofacial prostheses and prosthetic rehabilitation of cancer patients will become more and more the responsibility of the prosthodontist, and therefore many of them will need additional training in maxillofacial prosthetics. I do favor the concept of regional maxillofacial rehabilitation centers. As pointed out by Boucher’ in “Guidelines for Advanced Prosthodontic Education,” “ the residency program, like the postgraduate program, should be designed to provide clinical competence,” and this can best be done through the center concept. In a center setting there is more clinical material concentrated in a single area and there are more associated clinical and didactic facil-
OF PROSTHETIC
DENTISTRY
No.
Texas Other States in U.S. Foreign countries Deceased Total
NATIONAL NEEDS
THE JOURNAL
Prefient location
10 7 11 1 1
private dental office should be a requirement. As for recruiting maxillofacial prosthetic technicians, the dental laboratory field is the logical source. The maxillofacial prosthetic technician is expected to be competent in all types of maxillofacial laboratory procedures-intraoral removable and fixed prostheses, implant prostheses, irradiation and surgical treatment prostheses, and facial prostheses. If the technician is only expected to be involved in facial prostheses, then recruitment from artists and sculptors would be in order.
regarding
16 29
H 2 55 maxillofacial
ities available to be utilized education, and research.
ADMMM’RATIVE
prosthetics either
both in patient care,
STRUCTURE
Many different administrative structures are used in the various maxillofacial prosthetic programs across the nation. At The University of Texas, in Houston, there is both a hospital-based activity and a dental school activity. In the past, there was a conventional organizational structure of the dental service at the hospital which included maxillofacial prosthetics, oral surgery, and general dental support for radiation therapy patients. The dental service was under the Section of Head and Neck Surgery in the Department of Surgery. This structure was barely adequate in the early days of the program, since it gave little visibility to dentistry in the hospital and made it subservient to the Department of Surgery, which allowed for very little representation in the activities of the hospital. At the School of Dentistry there was a section of maxillofacial prosthetics in the Department of Prosthodontics which was very active in the clinical management of trauma and congenital patients but had very little input in teaching oncology to the undergraduate dental students, dental hygiene students, etc. Most of the cancer teaching was done by the Department of Pathology, which provided little interaction with the clinical faculty. In an attempt to correct these problems, over a 2-year planning period, a structure made up of a separate Department of Dental Oncology at the hospital with a section of maxillofacial prosthetics, oral surgery, and general dentistry was instituted. At the dental school, the section of maxillofacial prosthetics has been retained in the Department of Prosthodontics, but an additional Department of Dental Oncology has been established in order to
585
coordinate the undergraduate cancer teaching, set up cancer screening programs, and expand basic research cancer projects. This combined administrative structure will allow for many improvements in the overall staffing, patient care, educational activities, and both basic and clinical research programs.
REFERENCE 1.
Boucher, L. J.: Guidelines for advanced prosthetic rducation. J PROSTHET DENT 23:104, 1970.
Reprint requeststo: DR. JOE B. DRANE M. D. ANDERSON HOSPITAL AND TUMOR TEXAS MEDICAL CENTER HOUSTON, TEXAS 77030
N~VEMBERW~~
INSTITUTE
VOLUME40
NUMBER 5
of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute,
A
review of the educational program in Maxillofacial Prosthetics at The University of Texas at Houston Dental Branch and The M. D. Anderson Hospital demonstrates the effectiveness of the maxillofacial prosthetic educational program in the past 23 years and the changes and modifications which may be indicated for its improvement in the future. Fifty-five dentists have been registered in the maxillofacial prosthetic program. Thirty-one completed two years of training; twenty-one completed one year of training; two did not complete the program; and one died during his training program (Table 1). The fifty-two dentists who completed the maxillofacial prosthetic program entered into various types of practice (Table II). Twenty-three dentists have entered into institutional practice of maxillofacial prosthetics. These maxillofacial prosthodontists are staffing programs either in medical centers, cancer hospitals, or dental schools. The largest group (14) includes those. sent for training by the various federal services-3 in the Navy, 3 in the Air Force, 1 in the Army, and 7 in the Veterans Administration. The next largest group (8) entered into a combined private practice and institutional part-time teaching program. Four dentists continued their education in order to obtain their Master’s Degree, and three dentists entered into private practice. There has been a decrease in dentists entering institutional practice and a shift to increased numbers of dentists in private practice and a combination of institution and private practice. Presented at The Academy of Maxillofacial Prosthetics, San Diego, Calif. *Head, Department of Dental Oncology; Director, Regional Maxillofacial Restorative Center; Chief, Dental Service, The University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute; and Professor, Maxillofacial Prosthetics, The University of Texas Health Science Center Dental Branch, Houston, Texas.
CO&3913/78/
110583
+ 04$00.40/O
Q 1978 The
C
V. Mosby
Co.
Houston. Texas
A review of the l-year and 2-year trainees (Table III) showed that the largest group in the I-year program went to federal service practice, while the largest group in the 2-year program went into institutional practice. At the present time (Table IV) there has been a shift in the number from institutional and federal practice to private practice and combined practice, with the greatest chang? taking place among the trainees from the Z-year program. Of further interest is the fact that 48 of the 55 dentists who started the program are still practicing maxillofacial prosthetics either full time or part time. Their geographic distribution following completion of training is 16 in Texas, 29 in other states in the United States, and 8 who have returned to their countries of origin outside of the United States-Nicaragua, India, Brazil, Mexico, Canada, and Puerto Rico (Table V). SELECTION
OF TRAINEES
In the early days of the maxillofacial prosthetic program there were few requirements for admission into the program other than a degree in dentistry and an application which included a curriculum vitae and a biographical data sketch. These requirements were adequate at that time, since only one resident was being admitted each year for 2 years of training, and full time could be devoted to the supervision of the student’s clinical work. As the program evolved to encompass a full curriculum which included clinical, didactic, and research activities, more stringent requirements and a closer review of the applicants became desirable and necessary. Since the time allotted for maxillofacial training in most programs is limited to 1 or 2 years, and since there is so much to be covered if the trainee is to become competent in all phases of maxiiiofacial prosthetics, there is simply no time available during this period to train students in routine dental techniques and procedures.
Therefore,
it is required
THEJOURNALOFPROSTHE~CDENTISTRY
that
583
DRANE
Table I. Maxillofacial
Table III. Type of practice immediately following training, 19.53-1976
trainees, 1953-1976
Years of training 1 Year of training Dropped out during training Deceased during training Total 2
31
21 2
I 55
Table II. Type of practice following
training,
1953-1976 Practice Institution
Private practice Combination Federal service Continued education Deceased Dropped out of training TOtdl
Immediate
Present
23 3
16 9
8 14 4 1 2 5.5
13 12 I 2 2 55
they have a good background of the English language in order to receive instruction adequately and be able to express themselves accurately to patients and other staff members. It is required and expected that they be competent as dentists and be able to carry out routine prosthodontic procedures upon admisson to the training program. It is required that they submit three letters of recommendation, which are thoroughly evaluated by the Dean of Graduate Studies and the Head of the Department of Dental Oncology. It is required that they submit a statement from a physician certifying that they are in good health and a recent chest radiograph. They must submit a transcript of their college records, and it is desirable to have a personal interview with each selected resident prior to final acceptance and appointment. From our previous experience, the final requirement is of prime importance both to the trainee and to the program. Three applicants who were accepted for the program later found that they either were not aware of the involvements of maxillofacial prosthetics and the types of patients that need care or were simply not psychologically suited to practice this type of dentistry. One applicant chose not to enter the program following a personal visit and discovering what was involved. This caused problems due to late timing in filling the position with an alternate candidate. Another of the three candidates was accepted for training, stayed 10 days or 2 weeks, and
!584
I-y-01 trainee
Practice Institution Private practice Combination Federal service Continued education Dropped out of training Deceased Total
7 I
Z-year
trainee 16 2 8 I 4
13 2 1 24
31
then left without notice. He simply could not work with disfigured patients. The third trainee came into the program with an excellent background, was very competent in carying out prosthodontic procedures, and had excellent letters of recommendation which indicated no problems, yet his personality absolutely prevented him from being able to work with supporting personnel or take instruction from the teaching staff. I believe, following these experiences, that personal interviews are highly desirable so that the applicants may be fully aware of all that is involved in this highly specialized work before starting in the program, and also so that applicants who are not psychologically suitable may be screened out. Unfortunately, letters of reference all too often only say good things about the person and do not point out potential problems. In addition to the requirements for admission, an applicant should have completed at least 1 year in a rotating dental internship program, or 1 or more years in general practice. It is also recommended that all applicants for this comparatively long-term training attend a short course in maxillofacial prosthetics so that they may be fully
aware of all that will
be
involved in their future dental practice. LENGTH OF CURRICULUM The length of curriculum
must necessarily depend
upon all of the factors involved
in the selection
of
trainees. in general, 1 year for technician training and 2 years for maxillofacial prosthodontic training is recommended. Only six technicians have trained over a 2-year period, but it became apparent that prior formal training in a technological course for 2 years did not provide a satisfactory background to enter maxillofacial technology training. Practical experience in a commercial dental laboratory or a
NOVEMBER
1978
VOLUME
40
NUMBER
5
EDUCATION
IN MAXILLOFACIAL
PROSTHETICS
Table IV. Present type of practice, 1953-1976 Practice
l-year trainee
Institution
6 2 2 11
Privatepractice Combination Federal service Continued education Dropped out of training Deceased Total
2 1 24
Table V. Additional information maxillofacial trainees, 1953-1976
Z-year trainee
1 31
Nukz 48 of 55 are still practicing full or part time.
It is extremely difficult to assessthe national needs for maxillofacial prosthodontists and technicians, since until recently they have not been included in the personnel tables of organizations of dental schools or hospitals. So far almost all trainees, upon completion of their program, have had one or more positions offered to them. As maxillofacial prosthetic services become more recognized in major medical centers, trained specialists, both professional and supportive, will be more in demand throughout the country. Support activities in the form of maintenance of maxillofacial prostheses and prosthetic rehabilitation of cancer patients will become more and more the responsibility of the prosthodontist, and therefore many of them will need additional training in maxillofacial prosthetics. I do favor the concept of regional maxillofacial rehabilitation centers. As pointed out by Boucher’ in “Guidelines for Advanced Prosthodontic Education,” “ the residency program, like the postgraduate program, should be designed to provide clinical competence,” and this can best be done through the center concept. In a center setting there is more clinical material concentrated in a single area and there are more associated clinical and didactic facil-
OF PROSTHETIC
DENTISTRY
No.
Texas Other States in U.S. Foreign countries Deceased Total
NATIONAL NEEDS
THE JOURNAL
Prefient location
10 7 11 1 1
private dental office should be a requirement. As for recruiting maxillofacial prosthetic technicians, the dental laboratory field is the logical source. The maxillofacial prosthetic technician is expected to be competent in all types of maxillofacial laboratory procedures-intraoral removable and fixed prostheses, implant prostheses, irradiation and surgical treatment prostheses, and facial prostheses. If the technician is only expected to be involved in facial prostheses, then recruitment from artists and sculptors would be in order.
regarding
16 29
H 2 55 maxillofacial
ities available to be utilized education, and research.
ADMMM’RATIVE
prosthetics either
both in patient care,
STRUCTURE
Many different administrative structures are used in the various maxillofacial prosthetic programs across the nation. At The University of Texas, in Houston, there is both a hospital-based activity and a dental school activity. In the past, there was a conventional organizational structure of the dental service at the hospital which included maxillofacial prosthetics, oral surgery, and general dental support for radiation therapy patients. The dental service was under the Section of Head and Neck Surgery in the Department of Surgery. This structure was barely adequate in the early days of the program, since it gave little visibility to dentistry in the hospital and made it subservient to the Department of Surgery, which allowed for very little representation in the activities of the hospital. At the School of Dentistry there was a section of maxillofacial prosthetics in the Department of Prosthodontics which was very active in the clinical management of trauma and congenital patients but had very little input in teaching oncology to the undergraduate dental students, dental hygiene students, etc. Most of the cancer teaching was done by the Department of Pathology, which provided little interaction with the clinical faculty. In an attempt to correct these problems, over a 2-year planning period, a structure made up of a separate Department of Dental Oncology at the hospital with a section of maxillofacial prosthetics, oral surgery, and general dentistry was instituted. At the dental school, the section of maxillofacial prosthetics has been retained in the Department of Prosthodontics, but an additional Department of Dental Oncology has been established in order to
585
coordinate the undergraduate cancer teaching, set up cancer screening programs, and expand basic research cancer projects. This combined administrative structure will allow for many improvements in the overall staffing, patient care, educational activities, and both basic and clinical research programs.
REFERENCE 1.
Boucher, L. J.: Guidelines for advanced prosthetic rducation. J PROSTHET DENT 23:104, 1970.
Reprint requeststo: DR. JOE B. DRANE M. D. ANDERSON HOSPITAL AND TUMOR TEXAS MEDICAL CENTER HOUSTON, TEXAS 77030
N~VEMBERW~~
INSTITUTE
VOLUME40
NUMBER 5
