European Journal of Dental Education ISSN 1396-5883

Evaluation of the implant-related restorative undergraduate programme at ACTA, the Netherlands. Part I: students’ satisfaction C. Fijnheer, F. R. Langhorst and D. Wismeijer Department of Prosthodontics and Oral Implantology, Academic Centre for Dentistry Amsterdam (ACTA), the Netherlands, Amsterdam

keywords implant dentistry; dental curriculum; undergraduate education; implant prosthetics; student satisfaction. Correspondence Christianne Fijnheer Dentist, department of Prosthodontics and Oral Implantology, Academic Centre for Dentistry Amsterdam (ACTA), Gustav Mahlerlaan 3004, 1081 LA Amsterdam the Netherlands Tel: +31 20 5980 412 Fax: +31 20 5980 333 e-mail: [email protected] Accepted: 5 March 2015 doi: 10.1111/eje.12145

Abstract Introduction: Due to the increasing use of dental implants, many future dentists will encounter implant-related procedures in general practice. Over the past decade, implant dentistry is more and more often included in undergraduate curricula. Very little is known about students’ satisfaction regarding implant-related undergraduate programmes, as minimal analyses are performed. In particular, a lack of information exists regarding programmes where undergraduates restore implants. This study describes an evaluation of the students’ satisfaction regarding the implant-related restorative undergraduate programme at ACTA, the Netherlands. Material and methods: After clinical examination and establishment of the treatment plan, undergraduates were required to assist postgraduate implantology students during surgery. All patients received Straumann (Basel, Switzerland) implants. The restorative phase of the treatment was subsequently performed by the undergraduates. A students’ questionnaire was developed. All questions were exclusively on the restorative part of the implant-related programme. Results: In total, 90 patients were treated by 78 undergraduates. 146 Straumann implants were restored with 121 restorations. The most common restoration was a single crown (80.2%), followed by three-unit fixed partial dentures (12.4%). The questionnaires showed a high rate of students’ satisfaction concerning the restorative implant programme. Students replied they think they can manufacture an implantsupported crown or FDP without supervision after following the programme. In their opinion, the existence of the restorative programme should definitely be continued. Conclusion: According to positive student perceptions, an implant-related restorative programme should be recommended for implementation in undergraduate dental curricula. The programme at ACTA could be used as a template for other universities.

Introduction The use of oral implants has developed into a predictable treatment option for partially dentate and completely edentulous patients (1–3). Probably, the indication of a three-unit fixed dental prosthesis (FDP) on natural abutments will more and more often be replaced by an implant-supported single crown. Due to the popularity of this option, more dental practitioners will encounter implant dentistry-related procedures in their

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everyday practice. Therefore, undergraduate curricula should adequately prepare dental students by teaching basic theoretical knowledge and providing the opportunity for (pre-)clinical practice (4–7). It has been shown that there is an increase of implant therapy in general practice when undergraduate students received an implant course in their dental school curriculum (8, 9). Over the past decade, an increasing number of schools throughout Europe and the USA included implant dentistry into their undergraduate curriculum (7).

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Evaluation implant-related undergraduate programme

Competencies for dental students in implant dentistry should be defined to promote a consensus on guidelines (6, 10, 11). Hence, the Association for Dental Education in Europe (ADEE) organised workshops in 2004, 2008 and 2013, respectively. Guidelines and competencies were made for basic theoretical knowledge and clinical procedures, as well as required didactic skills (10, 12). However, there is a great variety in the approach by different universities (6, 7, 11, 13–15). The benchmarks stated by the ADEE in 2008 have not yet been achieved, and the diversity between universities remains extensive (16). By extending the dentistry education from 5 to 6 years in the Netherlands, more capacity became available for extensive teaching in endodontology, periodontology, restorative dentistry and implantology in the undergraduate curriculum. Since September 2011, the Academic Centre for Dentistry Amsterdam (ACTA) has also included an implant dentistry programme in the fifth year, of their 6-year curriculum. This undergraduate programme contains (i) advanced lectures, (ii) workshops based on patient cases, (iii) digital implant and prosthetic planning procedures, (iv) pre-clinical experiences such as (guided) surgery, suturing and impression taking, (v) assisting during implant placement and (vi) restoring implants. This last component is called ‘the implant-related restorative undergraduate programme’ (Fig. 1). Worldwide, most implant-related undergraduate programmes offer lectures. Moreover, pre-clinical and clinical workshops

fifth year curriculum

(restoring implants) are less common part of these undergraduate curricula. However, these percentages have increased over the years (13, 17). For example, in 2002, only 37% of European schools gave their students the opportunity to gain clinical experience in restoring implants (6). According to a recent survey, this percentage increased to 73% in 2014 (17). The most common implant-supported prosthetic treatment performed by undergraduates is a single crown, followed by mandibular overdentures and small-unit fixed partial dentures (7, 14). Not only clinical outcomes (for instance survival and success rates) of prosthetic implant treatment performed by undergraduates are important. An evaluation of the patients’ and students’ satisfaction regarding the implant-related restorative undergraduate programmes is necessary to fine tune the curricula to the needs in general practice (18). Few surveys focus on patients’ opinions, of which the majority deals with edentulous patients. Likewise, there are minimal analyses on students’ satisfaction regarding implant-related restorative undergraduate programmes. Due to a lack of information concerning the evaluation of implant-related restorative undergraduate programmes, the purpose of this study is ‘Evaluation of the implant-related restorative undergraduate programme at ACTA, the Netherlands. Part 1: Students’ satisfaction’. Hence, this first article only describes an evaluation of the students’ satisfaction and exclusively focuses on that component of the undergraduate programme in which students restore implants.

1. Lectures

2. Workshops

Basic principles

Thorough principles Patient cases

3. Digital planning workshops Guided Surgery

4. Pre-clinical workshops (Guided) Surgery Suturing Analog and digital impressions

Written examination

end of fifth year curriculum / sixth year curriculum

Selection clinical patient

No suitable own patient

Suitable own patient

Contact postgraduate students Random surgery patient

Partially dentate patients Establishing treatment plan Contact postgraduate students Intake and final treatment plan

5. Assisting during surgery Implant placement by postgraduate students Second stage surgery

6. Restoring implants called "implant-related restorative undergraduate programme"

Undergraduate treats own patient Implant-supported single crown Implant-supported fixed dental prosthesis

Fig. 1. Flowchart of the implant-related undergraduate programme at ACTA.

ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 84–93

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Material and methods After following the lectures, workshops, digital planning workshops and pre-clinical workshops, the undergraduates undergo an examination and the selection of clinical implant patients starts. During the fifth year curriculum, students treat ACTA patients in all disciplines. In some patient cases implantology is indicated. These patients are treated during the whole implant course by their own student. The students’ duties during the implant course include a clinical examination and establishment of the treatment plan both surgically and prosthetically. After intake, the final treatment plan is discussed with and then determined by a postgraduate implantology student. The postgraduate implantology students perform the surgical treatment, in which undergraduate students are required to assist the surgeon during the implant placement. All patients receive Straumann (Basel, Switzerland) implants. Subsequently, the undergraduates restore the implants during the implant-related restorative undergraduate programme (Fig. 1). This restorative phase generally includes implant-supported single crowns and small-unit fixed partial dentures (FDPs) in partially edentulous posterior maxillae and mandibles. During the restorative programme, one clinical teacher from the oral implantology department is available for six students every Tuesday, although mostly less than six implant patients are treated at the same time. Generally, a total of three appointments are scheduled per patient (Fig. 2). During the workshops and pre-clinical workshops, the undergraduates are informed about restoring implants; however, extensive clinical manuals (‘Impression taking’, ‘Crown/FDP placement’ and ‘Aftercare’) are available for each step of the restorative process. The first restorative appointment includes impression taking with alginate (Cavex Impressional, Cavex Holland BV) for the fabrication of an individual impression tray. During the second treatment, a final impression is taken using the individual impression tray and soft polyether impression material (ImpregumTM PentaTM, 3M ESPE). The third appointment consists of placing the crown or FDP. During the restorative phase, two radiographs are taken. The first radiograph is taken prior to the final impression (checking the connection of the impression coping) and the second at the time of prosthetic delivery. The second radiograph is also used for a baseline examination. Hygiene instructions are provided during the final appointment (Fig. 2). The aftercare is managed by a dedicated dental hygienist at the oral implantology department. Due to a lack of information regarding evaluations of implant-related restorative undergraduate programmes, questionnaires were developed for patients and students. An explaining letter with the purpose of the study was enclosed. Through filling in their last name on the explaining letter, patients and students gave permission for inclusion in the

study. Only the students who have restored implants and their patients, who have been treated in this programme, were included in the study. One of the authors (CF) has also treated patients and was subsequently excluded from the study. Two students have treated also three patients, and six students have treated two patients. Because these eight students have treated more patients, it can be expected that the results can be significantly affected by them being questioned twice and thrice. Therefore, only the students’ questionnaires related to their first implant patient are included in the study. The students’ questionnaire contained 6 categories with in total 61 statements. Statements about (i) appointments, (ii) manuals, (iii) student/patient relation, (iv) student/teacher relation, (v) outcome of the restorative treatment and (vi) final evaluation of the implant-related restorative undergraduate programme were defined (Fig. 3). Also, age and gender were assessed in the questionnaires. All the statements were on the implant-related restorative undergraduate programme, and previous implant-related appointments (such as the intake and the surgery) were not included in the evaluation. The statement design varied from yes/no to qualified statements. The possible answers of the qualified statements were transferred into a fivegrade categorising scale; strongly disagree (=1), disagree (=2), neutral (=3), agree (=4) and strongly agree (=5). The students’ questionnaires were sent by e-mail or personally given by one of the authors (CF) after the third appointment. Subsequently, the students returned the questionnaires to the clinical teacher. The online students’ questionnaire was distributed through an html link sent by e-mail. The patients’ questionnaire contained five categories with in total 37 statements. Statements about (i) appointments; (ii) patient/student relation, (iii) patient/teacher relation, (iv)

The students’ questionnaire contained 6 categories with statements. 1. Appointments 2. Manuals 3. Student/patient relation 4. Student/teacher relation 5. Outcome of the treatments 6. Final evaluation of the implant-related restorative undergraduate programme

The patients’ questionnaire contained 5 categories with statements. 1. Appointments 2. Student/patient relation 3. Student/teacher relation 4. Outcome of the treatments 5. Final evaluation of the implant-related restorative undergraduate programme

Fig. 3. Questionnaires about the undergraduate programme at ACTA.

Appointment 1

Appointment 2

Appointment 3

Alginate impressions Fabrication individual impression tray

Radiograph impression coping Impregum ® impression Bite registration

Placing crown/FDP Second radiograph Hygiene instructions

implant-related

restorative

Fig. 2. Flowchart of the implant-related restorative undergraduate programme at ACTA.

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Evaluation implant-related undergraduate programme

outcome of the restorative treatment and (v) final evaluation of the implant-related restorative undergraduate programme were defined (Fig. 3). Also, age and gender were assessed in the questionnaires. Likewise, the statement design varied from yes/no to qualified statements. The patients’ questionnaires were distributed by mail, together with self-addressed envelopes. In some cases, questionnaires were given by one of the authors (CF) at the next-scheduled appointment and directly returned or returned by mail (self-addressed envelopes were enclosed). Also, questionnaires were given after the third restorative appointment and returned directly or by mail. Data management was conducted using Excel (Microsoft, Redmond, WA, USA), and data analysis was performed by SPSS (version 21.0 for Windows, Chicago, IL, USA). All questionnaires were collected, recorded and analysed by one person (CF). Descriptive statistics were used to analyse the patients’ and students’ questionnaires. Because of the aim of this study, only the results of the students’ questionnaires will be considered.

The answers to the yes/no statements are shown by frequencies and percentages (%), as well as the answers to the qualified statements (transferred into a five-grade categorising scale 1–5).

Appointments Most students either agreed or strongly agreed (65.2%) it was easy to make appointments regarding the implant-related restorative treatments. The majority of the students (87.0%) replied they personally made the appointments with the patient. Less students (55.1%) responded that they made the appointments at the reception and few students (17.4%) asked the call centre to contact the patient. Their experiences with regard to the number of treatments and the duration of the total treatment period were quite similar to their expectations, as the majority of the students agreed or strongly agreed (76.8%, and 65.2%, respectively) to these statements (Table 2).

Results

Manuals

Between February 2013 and April 2014, 90 patients were treated by students in the restorative part of the undergraduate implant programme. There were 53 male patients (58.9%) and 37 (41.4%) female patients, with a mean age of 56.7 years. They received in total 146 Straumann implants, of which one failed before loading. The implants were restored with 121 restorations: 97 (80.2%) single crowns, 6 (4.9%) splinted crowns, 15 (12.4%) three-unit FDPs and 3 (2.5%) four-unit FDPs. The majority of the restorations were screw-retained (89.3%), 10.7% was cement-retained (Table 1). In total, 78 students participated in the implant-related restorative undergraduate programme. Thirty (38.5%) of them were men, and 48 (61.5%) were women. The average age of the students was 26.2 years (range 23–39 years). One of the authors (CF) treated three patients and was, as mentioned before, subsequently excluded from the study. Because eight students have treated more patients, only the students’ questionnaires related to their first implant patient are included in the study. Therefore, 77 questionnaires were distributed. Sixty-nine questionnaires were returned, giving a response rate of 89.7%.

Most students either agreed or strongly agreed that they knew what was expected of them (84.0%) and which proceedings they had to carry out during the treatments (85.5%). Many students claimed they did read the available manuals before the treatments. A total of 97.1% prepared themselves by reading ‘Impression taking’ and 98.6% by reading the second manual ‘Crown/FDP placement’. However, less students did read the manual ‘Aftercare’ (79.7%). During the treatments, the first two manuals were frequently used (88.4% and 89.9%, respectively). The manual ‘Aftercare’ was less used during the treatments (60.9%). The clarity of the manuals was confirmed by the answers to these statements. A total of 86.9% agreed or strongly agreed the clarity of the manual ‘Impression taking’, 88.4% the clarity of the second manual ‘Crown/FDP placement’. The manual ‘Aftercare’ was less read and used; however, 71.0% of the students either agreed or strongly agreed the clarity (Table 3).

TABLE 1. Type of restoration and Screw retained versus Cement retained Restoration

Amount

%

Single crown Screw retained Cement retained Splinted crowns Screw retained Cement retained Three-unit FDP Screw retained Cement retained Four-unit FDP Screw retained Cement retained Total

97 95 2 6 4 2 15 6 9 3 3 0 121

80.2 78.5 1.7 4.9 3.3 1.7 12.4 5.0 7.4 2.5 2.5 0.0 100

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Student/patient relation Regarding the communication between the student and the patient, 79.7% of the students replied they did inform the patient about the costs of the treatments. A total of 65.2% answered that their patient had signed an informed consent. A total of 79.7% replied they did inform the patient about the number of treatments and 78.3% of the students responded they did inform the patient regarding the duration of the treatments (Table 4).

Student/teacher relation The majority of the students replied they were in a position to ask for feedback after the treatments, 87.0% agreed or strongly agreed the statement. A total of 75.4% of the students replied the teacher has given sufficient feedback. Most of the students agreed or strongly agreed (66.6%) they have carried out all proceedings during the restorative treatments although, some of them replied the teacher also carried 87

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TABLE 2. Statements ‘Appointments’ Yes/No statement Y (%) 1. It was easy to make the appointments 2. I personally made the appointments with my patient 3. I made the appointments with my patient at the reception 4. I asked the call center to contact my patient for making appointments 5. The number of treatments was similar with regard to my expectations 6. The duration of the total treatment period was similar with regard to my expectations

N (%)

Qualified statement NA (%)

M (%)

60 (87.0)

9 (13.0)

0 (0)

0 (0)

38 (55.1)

30 (43.5)

0 (0)

1 (1.4)

12 (17.4)

57 (82.6)

0 (0)

0 (0)

1 (%)

2 (%)

3 (%)

4 (%)

5 (%)

NA (%)

M (%)

1 (1.4)

9 (13.0)

14 (20.3)

22 (31.9)

23 (33.3)

0 (0)

0 (0)

1 (1.4)

4 (5.8)

11 (15.9)

28 (40.6)

25 (36.2)

0 (0)

0 (0)

2 (2.9)

9 (13.0)

12 (17.4)

22 (31.9)

23 (33.3)

0 (0)

1 (1.4)

Y, Yes; N, No; NA, not applicable; M, Missing; 1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree.

TABLE 3. Statements ‘Manuals’ Yes/No statement Y (%) 7. I knew what was expected of me during the treatments 8. I knew which proceedings I had to carry out during the treatments 9. I did read the manual ‘Impression taking‘ before the treatments 10. I did read the manual ‘Crown/FDP placement‘ before the treatments 11. I did read the manual ‘Aftercare‘ before the treatments 12. I have used the manual ‘Impression taking‘ during the treatments 13. I have used the manual ‘Crown/FDP placement‘ during the treatments. 14. I have used the manual ‘Aftercare‘ during the treatments 15. The manual ‘Impression taking‘ is clear 16. The manual ‘Crown/FDP placement‘ is clear 17. The manual ‘Aftercare‘ is clear

N (%)

Qualified statement NA (%)

M (%)

67 (97.1)

1 (1.4)

1 (1.4)

0 (0)

68 (98.6)

1 (1.4)

0 (0)

0 (0)

55 (79.7)

14 (20.3)

0 (0)

0 (0)

61 (88.4)

8 (11.6)

0 (0)

0 (0)

62 (89.9)

7 (10.1)

0 (0)

0 (0)

42 (60.9)

27 (39.1)

0 (0)

0 (0)

1 (%)

2 (%)

3 (%)

4 (%)

5 (%)

NA (%)

0 (0)

4 (5.8)

7 (10.1)

35 (50.7)

23 (33.3)

0 (0)

0 (0)

0 (0)

5 (7.2)

5 (7.2)

36 (52.2)

23 (33.3)

0 (0)

0 (0)

0 (0)

1 (1.4)

7 (10.1)

29 (42.0)

31 (44.9)

1 (1.4)

0 (0)

0 (0)

1 (1.4)

7 (10.1)

30 (43.5)

31 (44.9)

0 (0)

0 (0)

0 (0)

1 (1.4)

7 (10.1)

25 (36.2)

24 (34.8)

12 (17.4)

M (%)

0 (0)

Y, Yes; N, No; NA, not applicable; M, Missing; 1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree.

out procedures (47.8%). Nevertheless, the majority of the students (86.4%) replied they were in a position to work independently (Table 5).

Considering the design and height of the crown or FDP, lower percentages of satisfaction (76.8% and 75.3%, respectively) were reported (Table 6).

Outcome of the treatments

Final evaluation of the implant-related restorative undergraduate programme

With a high percentage of 97.1%, most students replied they were satisfied with the final result of the treatments. Regarding the substatements, the students were most satisfied with the function (94.2%) and colour (85.5%) of the restoration. 88

The students answered they have learned much about prosthetics and oral implantology by following the restorative implant programme (89.8%). A higher percentage was found with regard to ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 84–93

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Evaluation implant-related undergraduate programme

TABLE 4. Statements ‘Student/patient relation’ Yes/No statement

18. 19. 20. 21.

I did inform the patient about the costs of the treatments My patient had signed an Informed Consent I did inform the patient about the number of treatments I did inform the patient about the duration of the treatments

Y (%)

N (%)

NA (%)

M (%)

55 45 55 54

9 19 12 13

5 5 2 2

0 0 0 0

(79.7) (65.2) (79.7) (78.3)

(13.0) (27.5) (17.4) (18.8)

(7.2) (7.2) (2.9) (2.9)

(0) (0) (0) (0)

Y, Yes; N, No; NA, not applicable; M, Missing; 1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree.

TABLE 5. Statements ‘Student/teacher relation’ Qualified statement 1 (%) 22. I was in a position to ask the teacher for feedback after the treatments 23. I think the teacher has given me sufficient feedback 24. I have carried out all proceedings during the treatments 25. The teacher carried out proceedings 26. I was in a position to work independently

2 (%)

0 (0) 0 1 9 0

3 (%)

2 (2.9)

(0) (1.4) (13.0) (0)

3 4 12 1

5 (7.2)

(4.3) (5.8) (17.4) (1.4)

12 18 13 7

(17.4) (26.1) (18.8) (10.1)

4 (%)

5 (%)

NA (%)

M (%)

26 (37.7)

34 (49.3)

2 (2.9)

0 (0)

22 29 22 32

30 17 11 29

2 0 2 0

0 0 0 0

(31.9) (42.0) (31.9) (46.4)

(43.5) (24.6) (15.9) (42.0)

(2.9) (0) (2.9) (0)

(0) (0) (0) (0)

Y, Yes; N, No; NA, not applicable; M, Missing; 1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree. TABLE 6. Statements ‘Outcome of the treatments’ Qualified statement

27. 28. 29. 30. 31.

I I I I I

am am am am am

satisfied satisfied satisfied satisfied satisfied

with with with with with

the the the the the

final result colour of the crown/FDP design of the crown/FDP height of the crown/FDP function of the crown/FDP

1 (%)

2 (%)

3 (%)

4 (%)

5 (%)

NA (%)

M (%)

0 0 0 1 0

0 4 3 6 1

2 6 12 10 1

25 26 27 23 35

42 33 26 29 30

0 0 1 0 2

0 0 0 0 0

(0) (0) (0) (1.4) (0)

(0) (5.8) (4.3) (8.7) (1.4)

(2.9) (8.7) (17.4) (14.5) (1.4)

(36.2) (37.7) (39.1) (33.3) (50.7)

(60.9) (47.8) (37.7) (42.0) (43.5)

(0) (0) (1.4) (0) (2.9)

(0) (0) (0) (0) (0)

Y, Yes; N, No; NA, not applicable; M, Missing; 1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree.

the gained practical knowledge (91.3%) in contrast with gained theoretical knowledge during the programme (62.3%). The majority of the students (89.8%) either agreed or strongly agreed there was sufficient time available for the treatments. Remarkably, few students replied they have treated enough implant patients (36.2%). A total of 95.6% of the students replied they think the implant-related restorative programme is an important part of their study, and almost all students (97.1%) agreed or strongly agreed to continue the existence of the programme in the future. With regard to the importance of making an implant-supported crown or FDP as a dentist, a large number of students (98.6%) either agreed or strongly agreed to the statement. A total of 72.6% of the students replied they think they can manufacture an implant-supported restoration without supervision due to following the implant-related restorative programme. Also, the majority of the students (89.9%) replied they would like to be educated in making a full prosthesis on implants. Because all students became familiar with the Straumann system, many of them (49.2%) would probably use this system in the future. However, the majority (72.4%) either agreed or

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strongly agreed they would like to become familiar with other implant systems as well (Table 7).

Discussion Implant-related undergraduate programmes worldwide Since the increased usage and predictability of oral implants, implant dentistry has become part of the majority of undergraduate curricula worldwide. A study by Atashrazm et al. (14) in 2011 shows that an increasing number of dental schools have incorporated implantology into their undergraduate curriculum. Also, Kroeplin and Strub (7) found, based on previous studies (6, 13), that the percentage of universities that included implant dentistry has increased throughout the years. However, a recent survey by Mattheos et al. (16) shows that the benchmarks stated by the ADEE workshop in 2008 are not achieved today. Also, this workshop in 2013 shows that the diversity between undergraduate implant programmes worldwide remains as large as it was in 2008.

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TABLE 7. Statements ‘Final evaluation of the implant-related restorative undergraduate programme’ Qualified statement 1 (%) 32. I have learned a lot about Prosthetics and Oral Implantology by following the restorative implant programme 33. I have gained a lot theoretical knowledge by following the restorative implant programme 34. I have gained a lot practical knowledge by following the restorative implant programme 35. I think there was sufficient time available for the treatments 36. I think I have treated enough implant patients 37. I think the restorative implant programme is an important part of my study 38. I think the existence of the programme has to be continued in the future 39. I think it is important making an implant-supported crown or FDP as a dentist 40. I think I can manufacture an implant-supported restoration without supervision due to following the restorative implant programme 41. I would like to be also educated in making a full prosthesis on implants 42. I think I would probably use the Straumann system in the future 43. I would like to become familiar with other implant systems as well

2 (%)

0 (0)

0 (0)

0 (0)

2 (2.9)

0 (0)

0 (0)

0 (0) 3 (4.3) 0 (0)

2 (2.9) 18 (26.1) 1 (1.4)

3 (%)

4 (%)

5 (%)

NA (%)

M (%)

7 (10.1)

31 (44.9)

31 (44.9)

0 (0)

0 (0)

23 (23.3)

26 (37.7)

17 (24.6)

1 (1.4)

0 (0)

6 (8.7)

25 (36.2)

38 (55.1)

0 (0)

0 (0)

3 (4.3) 19 (27.5) 2 (2.9)

31 (44.9) 12 (17.4) 31 (44.9)

31 (44.9) 13 (18.8) 35 (50.7)

2 (2.9) 3 (4.3) 0 (0)

0 (0) 1 (1.4) 0 (0)

0 (0)

0 (0)

2 (2.9)

21 (30.4)

46 (66.7)

0 (0)

0 (0)

0 (0)

0 (0)

1 (1.4)

26 (37.7)

42 (60.9)

0 (0)

0 (0)

0 (0)

4 (5.8)

8 (11.6)

34 (49.3)

23 (23.3)

0 (0)

0 (0)

1 (1.4) 1 (1.4) 0 (0)

1 (1.4) 2 (2.9) 1 (1.4)

5 (7.2) 29 (42.0) 17 (24.6)

28 (40.6) 25 (36.2) 25 (36.2)

34 (49.3) 9 (13.0) 25 (36.2)

0 (0) 3 (4.3) 1 (1.4)

0 (0) 0 (0) 0 (0)

Y, Yes; N, No; NA, Not Applicable; M, Missing; 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree.

Implant-related restorative undergraduate programmes worldwide The level of clinical experience gained, as part of an implantrelated undergraduate programme, differs worldwide (6, 7, 11, 13, 14, 19). Compared to a study in 2009 (13), Koole et al. (17) stated that more undergraduate students are in a position to gain clinical restorative implant experience nowadays (73% vs. 50% in 2009). Some undergraduate curricula do not contain patient treatment, and in some situations, students were not able to gain clinical experience due to a small patient pool (11). Likewise, in the implant-related restorative programme at ACTA not all students have treated an implant patient. On the other hand, several students have restored more than one implant patient, and frequently multiple implants per patient. According to Atashrazm et al. (14), most students restore implant-supported single crowns, overdentures and fixed partial dentures. In this ACTA programme, the most common restoration is the single crown, followed by the three-unit FDP. Overdentures are not part of the restorative undergraduate programme at ACTA. However, the majority of the students report that they would like to be educated in making an implant-supported full prosthesis. Based on a study by Calvert et al. (20), there is no significant difference regarding patients’ satisfaction and quality of life whether the overdenture treatment is delivered by students or prosthodontists. Maalhagh-Fard et al. (21), Kronstrom et al. (22), Bonde et al. (23), Kroeplin (24), Parrish et al. (25) and Vandeweghe et al. (26) reported acceptable clinical outcomes of implantrelated treatments performed by undergraduates. Also, a recent literature review by Koole and De Bruyn (19) shows that patient treatment by undergraduates appears to be positive.

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Students’ satisfaction Some studies (25–30) have investigated students’ opinions with regard to their implant curriculum. However, none of these students’ evaluations contain an exclusive research regarding implant-related restorative treatments in an undergraduate programme. Therefore, the aim of this study was to evaluate the students’ opinions regarding the implant-related restorative programme at ACTA. Only students who have treated an implant patient in this programme were included in the study. As multiple students have treated more patients, only the questionnaires related to their first implant patient were reported. Appointments Most students replied they personally made the appointments with the patient. Usually, in other patient treatment programmes at ACTA, the call centre is authorised to make patient appointments. Probably, due to the possibility to call the patient themselves and the opportunity to determine the appointment dates, more students chose this option. The students’ experiences with regard to the number of treatments and the duration of the total treatment period were quite similar to their expectations. However, the complexity of the patient case and additional appointments like a try-in of the implant-supported restoration prior to final placement would possibly influence these results. Manuals The majority of the students claimed they did read the available manuals before and during the treatments; nevertheless, their

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answers could be questioned. Probably, students are more leaning towards answers they think are expected of them (18). Regarding the statement about the ‘Aftercare’ manual, few students replied they did read and used the manual. Apparently, the importance of aftercare is not clearly considered and that is why it should be more emphasised. Also, due to the fact that a dedicated dental hygienist of the oral implantology department manages the aftercare, students were possibly less inclined to study this subject. The clarity of the manuals was highly confirmed by the students. Therefore, extensive manuals can guide undergraduates before and during implant-related restorative treatments. However, during the (pre-clinical) workshops, the subject ‘restoring implants’ was also comprehensively clarified. Student/patient relation The importance of informing the patient about the costs of the treatment is mandatory at ACTA. However, not all students replied they did inform the patient and less students answered that their patient had signed an informed consent. Probably, a previous student has already completed this requirement. Student/teacher relation Not every student wants feedback and asks for an evaluation of their performance. However, the results of the questionnaires showed that the students found themselves in a position to ask for feedback. The statements related to carrying out the proceedings should rather be replaced by yes/no statements instead of qualified statements. It seems to be difficult for the students to differentiate the level of assistance they have received from the teacher. Also, the answers could be questioned with reference to some questionnaires were the student replied he or she has carried out all proceedings although they claimed the teacher has also carried out some procedures. Possibly, these students did not read the questionnaire accurately or they did not understand the separation of the statements. Like most European dental schools, ACTA offers their implant-related programme in the fifth year of the undergraduate curriculum. Due to prolonged implant healing times, some students were already sixth year students when they made the implant-related restoration. With regard to the independence of students, sixth year students would probably claim they could work more independently in contrast to fifth year students. Due to their level of experience, sixth year students deem themselves to be more competent. Outcome of the treatments The overall satisfaction regarding the final result of the treatments is higher than the percentages of the substatements (colour, design, function and height of the crown or FDP). Probably, the sum of substatements determines the overall satisfaction. Some students replied they were not satisfied with the height of the crown or FDP. At ACTA, the students were instructed to attempt a lighter occlusion and articulation pattern of the implant-supported structure in relation to natural teeth. Possiª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 84–93

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bly due to an imperfection during the bite registration or due to a miscommunication with the dental technician, the height of some crowns or FDPs needed adjustment. Final evaluation of the implant-related restorative undergraduate programme The students replied they gained more practical knowledge by following the restorative programme. The statement about gaining theoretical knowledge showed a lower percentage. These results are explicable, because the students performed the patient treatments themselves and experienced therefore a domination of practical knowledge. According to the students, there was sufficient time available for the treatments; however, not every student works at the same speed. Also, the difference between a fifth and sixth year student could be a reason for discrepancy. Due to the fact that only students who have treated an implant patient were included in the study, there is a lack of information regarding students who do not have any clinical implant-supported restorative experience. Remarkably, students who have treated an implant patient replied they do not agree they have treated enough implant patients. In all probability, students without any clinical experience are also likely to treat more implant patients. Not every dental student will graduate with implant-supported restorative experience or even attend an implant surgery. Likewise, according to the study of Petropoulos et al. (11), not all students were in a position to treat an implant patient. This problem could be solved if students work together during the implant treatments. A disadvantage could be that they subsequently reply they gained less practical knowledge due to sharing the proceedings with their colleague. During the whole undergraduate implant programme at ACTA, the students were educated using the Straumann implant system. ACTA is supported by Straumann by free components such as implants, discounts in prosthetic component costs and demonstration kits for hands-on workshops. Stated by Petropoulos et al. (11), Atashrazm et al. (14) and Kroeplin and Strub (7), many universities indicate they get support by implant companies. Apart from ITI/Straumann, also Nobel Biocare is frequently used. Probably, with this assistance and collaboration, less patients will decline implant treatment due to financial limitations. Due to a comprehensive patient pool, more students will subsequently be in a position to restore implants. At ACTA, some of the students replied they think they would probably use the Straumann implant system in the future. Apparently, due to becoming familiar with this system, they will continue its use and acquired knowledge after graduation. However, they also replied they would like to become familiar with other implant systems. In this study, almost all students either agreed or strongly agreed that they think it is important to be able to make an implant-supported crown or FDP as a dentist. Based on several studies, it is to be expected that those students probably offer and restore more implants after graduation. Huebner (8) found that dentists with undergraduate implant experiences place and restore more implants than dentists who were not educated in 91

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implantology during their study. Even dentists who only received laboratory training during their undergraduate curriculum include significantly more implant dentistry in their practices. Also, Maalhagh-Fard et al. (9) showed a correlation between dentists who had participated in an undergraduate implant programme and performed more implant-related treatments after graduation. Despite the fact many students replied they think they have not treated enough implant patients, the majority of the students think they can manufacture an implant-supported restoration without supervision due to following the restorative implant programme at ACTA. Also, the statements regarding the importance of this restorative implant programme and that the existence of the programme has to be continued in the future show that the students were very satisfied with the programme. According to the students, the development of this programme and including it in the undergraduate curriculum is a great success with numerous positive responses.

Limitations The results of the students’ evaluation cannot be considered conclusive due to a limited sample size. This study evaluates only the students’ satisfaction regarding the implant-related restorative undergraduate programme. Patient-related opinions are also important to extend and develop the implant-related undergraduate programme. A subsequent article will emphasise on patients’ satisfaction.

Conclusion The article describes an evaluation of the students’ satisfaction regarding the component of the implant-related undergraduate programme where students restore implants. This study demonstrates that: 1 implant-related restorations (in this programme crowns and FDPs) made by undergraduates give satisfactory outcomes according to students’ perceptions. However, this can also be viewed as the ability of undergraduates to achieve the clinical objective of restorative treatment. 2 most undergraduates experience they get a lot of practical knowledge by following an implant-related restorative programme. 3 by following an implant-related restorative programme, students think they can manufacture an implant-supported crown or FDP without supervision. 4 apart from the education of an implant-supported crown or FDP, students at ACTA replied making a full prosthesis on implants should also be included in an undergraduate programme. 5 students acknowledge the importance of making an implantsupported crown or FDP as a future dentist. 6 students experience the implant-related restorative implant programme at ACTA as an important part of their undergraduate curriculum, and the existence of the programme should definitely be continued in the future according to these participating students.

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Due to high levels of students’ satisfaction, an implantrelated restorative programme should be recommended for the implementation in undergraduate dental curricula. The restorative programme at ACTA could be used as a template for other universities.

Acknowledgements The authors would like to thank Straumann (Basel, Switzerland) for their support and funding of this program.

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