ACADEMICS AND EDUCATION

Introducing Dental Students to Clinical

Patient Care: The Complete Denture
Prosthodontics Transition Clinic
Lisa A. Lang, DDS, MS,
1
David C. Holmes, DDS, MS,
2
Craig Passon, DDS, MS,
3
Robert M. Trombly, DDS, JD,
4
Jeffrey D. Astroth, DDS, MSPH,
5
and Arnold F. Tavel, DMD
6
Using complete denture treatment as an introduction to clinical patient care for dental students,
the purposes of the Complete Denture Prosthodontics Transition Clinic at the University of Colorado
School of Dentistry are to reduce the time lapse between the preclinical complete denture prosth-
odontics course and the rst denture patient experience, and to encourage development of student
self-condence and skills. In the 2002 spring semester, faculty at the University of Colorado School
of Dentistry initiated the Complete Denture Prosthodontics Transition Clinic for DS-II (second-
year) dental students, as an introduction to clinical patient care. Each patient was assigned to a team
of two dental students. Three Division of Prosthodontics faculty members staffed each clinic session,
providing a student-to-faculty ratio of approximately 6.6:1 and a patient-to-faculty ratio of approx-
imately 3.3:1. All DS-II students in the Class of 2004 delivered their rst complete dentures no later
than 8 months (average, 184 days) after the last day of the preclinical complete denture prosthodon-
tics course. The time from the diagnostic appointment through the denture placement appointment
averaged 39 days for patients treated in this program, compared with an average of 98 days or more
for previous classes. The program was successful in achieving the goal of reducing the time lapse
between the preclinical complete denture prosthodontics course and the rst denture patient
experience.
J Prosthodont 2003;12:206-210. Copyright 2003 by The American College of Prosthodontists.
INDEX WORDS: dental education, removable prosthodontics, curriculum, new educational pro-
grams, dental students
I
N 1970, Dr. John J. Sharry observed that a few
dental school administrators believe that com-
plete and partial edentulousness will disappear
from the scene within the passage of a decade or
two.
1
More than 3 decades have passed since Dr.
Sharrys report, and the prophecy of those few
administrators certainly has not been fullled. In
fact, Douglass et al
2
recently predicted that in the
United States, the adult population in need of 1 or
2 complete dentures will increase from 33.6 million
in 1991 to nearly 37.9 million in 2020.
Clearly, edentulism still persists in the United
States, and the prospects for its eradication in the
near future seem unlikely. Dental education pro-
grams must prepare their students to address these
continuing patient needs.
In this era of an increasingly overcrowded dental
school curriculum, educators are constantly chal-
lenged to develop programs that afford efcient use
of precious curricular hours. Some authors have
proposed that providing students with denture pa-
tient contact during the rst or second year could
shorten the time spent with basic laboratory tech-
niques, as well as increase student interest and
enthusiasm toward complete denture prosthodon-
From the School of Dentistry, University of Colorado Health Sciences
Center, Denver, CO.
1
Assistant Professor and Chair, Division of Prosthodontics.
2
Associate Professor and Chair, Division of Comprehensive Care.
3
Associate Professor and Chair, Department of Restorative Dentistry.
4
Associate Professor and Associate Dean of Clinics.
5
Associate Professor, Division of Prosthodontics.
6
Assistant Clinical Professor, Division of Prosthodontics.
Accepted April 6, 2003.
Correspondence to: Lisa A. Lang, DDS, MS, Division of Prosthodon-
tics; School of Dentistry, University of Colorado Health Sciences Center,
4200 East Ninth Avenue; Campus Box C-284, Denver, CO 80262.
E-mail: Lisa.Lang@UCHCS.edu
Copyright 2003 by The American College of Prosthodontists
1059-941X/03/1203-0000$30.00/0
doi:10.1016/S1059-941X(03)00052-4
206 Journal of Prosthodontics, Vol 12, No 3 (September), 2003: pp 206-210
tics.
3,4
Other authors have argued for the elimina-
tion of preclinical manikin procedures in complete
denture prosthodontics.
5,6
Although it seems that most dental school ad-
ministrators recognize that the content and process
of the dental school curriculum must be revised,
there is no general agreement on precisely what
changes should be made.
7
In 1998, prosthodontic
educator members of the American College of
Prosthodontists (ACP) published recommendations
for prioritizing curricular elements of the prosth-
odontic curriculum.
8
Components of the prosth-
odontic curriculum were evaluated in relation to
the levels of skill and knowledge that a graduating
dental student should achieve. Exposure and
competency were the 2 skill levels identied,
whereas familiarity and understanding were
the 2 stages assigned to the knowledge level. The
joint ACP and American Dental Education Associ-
ation meeting recommended that the dental stu-
dent should achieve a skill level of competency
with a knowledge level of understanding in treat-
ing patients with ACP class I and II
9
(ie, less-
complicated treatment needs) complete edentu-
lism.
Background and Rationale for the
Program
One of the most exciting, yet frightening, times in
a dental students career is the transition from
preclinical dentoform-based procedures to clinical
patient-based procedures.
10
Sophisticated dental
patient simulation systems are currently used at
several dental schools,
11
and it has been reported
that students are enthusiastic about the learning
environment and educational approach of the sim-
ulation clinic, preferring it to traditional preclinical
laboratory instruction.
12
Nonetheless, an early in-
troduction to actual dental patients was favored by
dental school graduates in a recent alumni survey.
13
Since 1992, the University of Colorado School of
Dentistry has implemented a unique clinical pro-
gram beginning in the middle of the DS-II (second
year dental student) year, the Operative Dentistry
Transition Clinic. The objectives of the Operative
Dentistry Transition Clinic are to create comfort-
able rst operative dentistry clinic experiences, to
provide treatment for patients with limited needs,
and to emphasize, through practical experience,
the fundamental clinical skills needed for inde-
pendent performance.
14
The Operative Dentistry
Transition Clinic has proven to be an effective,
procient, and comfortable introduction to clinic
patient care. Other clinic programs at the Univer-
sity of Colorado School of Dentistry have gradually
adopted this format of early clinic experience with
oral diagnosis and periodontics now fully integrated
into the DS-II Transition Clinic.
In the fall of 1996, the University of Colorado
inaugurated a Comprehensive Care Program span-
ning 6 semesters as the primary intramural clinical
curriculum for all predoctoral dental students. In
the spring of 1998, traditional numerical proce-
dural clinical requirements were replaced by a
more general, competency-based set of clinical ex-
pectations. As reported earlier, numerical require-
ments are not necessary to ensure dental student
productivity; in fact, students can complete more
clinical procedures in a comprehensive care clinical
environment without numerical requirements.
Dental students in the Class of 1999 each com-
pleted an average of 8.38 complete dentures (range,
4 to 16), and those in the Class of 2000 each
completed an average of 9.58 complete dentures
(range, 6 to 14).
15
For many years, the preclinical complete den-
ture prosthodontics course at the University of Col-
orado School of Dentistry has been a 64-hour lec-
ture/laboratory course that meets for 1 4-hour
session per week for 16 consecutive weeks spanning
the spring and summer semesters of the DS-I year.
Before 2002, the rst complete denture prosth-
odontics patient experience was not scheduled until
after students had begun treating their assigned
patients in the Comprehensive Care Clinic in the
summer semester of the DS-II year. Even for those
students who began treating a complete denture
patient early in the Comprehensive Care Clinic, a
full year had passed since they had completed the
preclinical complete denture prosthodontics course.
Some students did not initiate their rst denture
patient experience until later in the DS-III year, as
much as 2 years or more (Table 1) after completion
of the preclinical complete denture prosthodontics
course. Recognizing this time lapse between the
preclinical course and the rst denture patient ex-
perience as a potential shortcoming of the educa-
tional program, faculty began exploring mecha-
nisms for reducing this delay.
207 September 2003, Volume 12, Number 3
Program Description
In discussions at faculty meetings and curriculum
committee meetings in 2001, it was proposed that
complete denture therapy offered an appropriate
treatment challenge for providing the dental stu-
dents rst clinical patient experiences. It was rec-
ognized that although complete denture therapy
provides its own characteristic challenges, several
potential advantages could also be identied:
1. The procedures involved are typically noninva-
sive and reversible, thereby lending themselves
to demonstration by faculty, followed by re-
peated performance by 1 or more students.
2. The stress associated with administering anes-
thetic injections is typically not a factor.
3. The anxiety associated with the possibility of
causing the patient to experience pain is less of
an inuence in the studentpatient relationship.
4. Appointment management can be more
straightforward.
5. A properly extended preliminary impression
technique can be mastered before study casts
are used for diagnosis of dentate cases.
6. The concepts of occlusal plane analysis, esthetic
proportion, and patient body image can be intro-
duced before the student is presented with ab-
normal dentate problems.
7. The use of gross motor skills in complete den-
ture fabrication obviates the need for students to
struggle with developing the ne motor skills
required for operative dentistry. More time can
be devoted to understanding human factors and
the needs of the total patient.
8. Students are better able to develop communica-
tion skills and assess psychological proles and
patient expectations throughout the treatment.
9. The student must learn to identify unfavorable
human factors that may produce maladaptive
responses to treatment; examples include lack of
trust in the dentist, previous negative experi-
ences with dentists, unrealistic expectations, re-
sistance to change, anxiety, inadequate tissue
tolerance, chronic dissatisfaction, and the wish
to fail.
16
Before the start of the DS-II spring semester,
dental students at the University of Colorado
School of Dentistry, in preparation for beginning
clinical patient care, have completed Basic Life
Support (BLS) certication, didactic instruction in
clinic protocol, and skill development exercises in
4-handed dentistry techniques. In the 2002 spring
semester, faculty initiated the Complete Denture
Prosthodontics Transition Clinic for DS-II students
(Dental Class of 2004). This programnow preceded
the Operative Dentistry/Periodontics/Oral Diagno-
sis Transition Clinic, and would be the introduction
to clinical patient care for this entire class of dental
students.
In January 2002, the DS-II class of 39 members
was divided into 18 2-student teams and 1 3-student
team. For scheduling purposes, 1 group (20 stu-
dents, 10 teams) was assigned to a morning sched-
ule for the Complete Denture Prosthodontics Tran-
sition Clinic, and the other group (19 students, 9
teams) was assigned to an afternoon schedule.
The unique educational needs of the Complete
Denture Prosthodontics Transition Clinic were
taken into account in patient recruitment and se-
lection. For this introduction to clinical patient care
for dental students, faculty believed that it was
important that the patients not be excessively chal-
lenging in terms of either the technical or psycho-
logical aspects of their oral health care needs. A list
of totally edentulous patients who had been previ-
ously treated in the University of Colorado School
of Dentistry was generated from clinic records.
Patients from this list were contacted and recruited
for a screening appointment. These patients were
Table 1. First Patient Experiences in Removable Complete Prosthodontics at the University of
Colorado School of Dentistry: Range of Initiation and Placement Dates by Class
Dental
Student
Class of
Final Date of
Preclinical
Removable Complete
Prosthodontics
Course
Initiation of First Denture Placement of First Denture Average Time
Between Preclinical
Course and
Initiation of
First Denture (Days)
Average Time
From Initiation
Until Placement of
First Denture (Days)
Earliest
Start
Date
Average
Start
Date
Latest
Start
Date
Earliest
Placement
Date
Average
Placement
Date
Latest
Placement
Date
1999 7/17/96 08/26/97 12/07/97 07/06/98 10/13/97 03/18/98 11/05/98 508 98
2000 7/23/97 06/23/98 11/27/98 05/26/99 07/22/98 02/20/99 11/03/99 492 114
2001 7/22/98 06/08/99 12/24/99 09/11/00 07/19/99 04/14/00 11/10/00 520 143
2002 7/21/99 09/08/00 02/01/01 07/25/01 11/03/00 05/04/01 11/26/01 561 126
2003 7/19/00 06/05/01 11/30/01 04/16/02 09/13/01 02/07/02 05/09/02 499 99
2004 7/18/01 01/16/02 01/18/02 01/30/02 02/20/02 02/25/02 03/20/02 184 39
208 Complete Denture Prosthodontics Transition Clinic Lang et al
told that if they qualied for participation in this
program and attended all scheduled appointments,
then complete dentures would be fabricated by a
team of faculty and students at no charge. Patients
were screened by 1 of 2 Division of Prosthodontics
faculty members in 2 3-hour sessions. Patients who
qualied at the screenings were informed that par-
ticipation in the program required their agreement
to attend all appointments listed on 1 of 2 prede-
termined appointment schedules (a Wednesday
morning sequence with 1 Thursday morning ap-
pointment, or a Wednesday afternoon sequence
with 1 Thursday afternoon appointment). Nineteen
patients were selected to participate in the pro-
gram: 10 patients for the morning appointment
sequence and 9 patients for the afternoon appoint-
ment sequence.
Each patient was assigned to a team of dental
students. Appointments were scheduled on the
morning or afternoon track as listed in Table 2.
Each clinic session was staffed by 3 Division of
Prosthodontics faculty members, yielding a stu-
dent-to-faculty ratio of approximately 6.6:1 and a
patient-to-faculty ratio of approximately 3.3:1.
Each student/patient team was assigned to 1 of
the 3 prosthodontists for the entire course of treat-
ment. At the beginning of each clinic session, the
group met in the clinic, and the prosthodontic
faculty reviewed the procedure to be preformed
during that session. Before initiating the clinical
procedure, a faculty member demonstrated the
technique on 1 patient in the group. During this
time, faculty questioned the students regarding
procedural techniques, dental materials, and pa-
tient management. After the demonstration was
completed, the student teams returned to their own
patients to provide treatment. The improved stu-
dent/patient-to-faculty ratio allowed faculty time to
provide more individualized instruction to students.
The complete denture prosthodontic techniques
taught in the predoctoral programat the University
of Colorado School of Dentistry are consistent with
those most frequently reported in a 1996 survey of
North American dental schools.
17
The technique
uses irreversible hydrocolloid for preliminary im-
pressions, modeling plastic compound for border
molding of the nal impression tray made of Triad
custom tray material (Dentsply, York, PA), polysul-
de rubber (Permalastic; Kerr, Romulus, MI) for
nal impressions, and Triad tray material for
record bases. Although the students are exposed to
anatomic and nonanatomic occlusal schemes, lin-
gualized occlusion is primarily emphasized.
Students were evaluated daily on a 4-point grad-
ing scale. The evaluation was based on student
team preparedness, clinical performance, and pa-
tient management.
Review of the Pilot Program
Between January 16, 2002 and March 20, 2002, 19
completely edentulous patients received compre-
hensive upper and lower denture therapy in the
pilot Complete Denture Prosthodontics Transition
Clinic. At completion of the program, all DS-II
students in the Class of 2004 had performed their
rst complete denture patient service, from initia-
tion through placement, within 8 months of the last
day of the preclinical complete denture prosthodon-
tics course (see Table 1). The program was success-
ful in reducing the time lapse between the preclin-
ical complete denture prosthodontics course and
the rst denture patient experience. The three
Division of Prosthodontics faculty members who
staffed the clinic in this program reported that the
DS-II students in this program were at least as well
prepared for the rst complete denture patient
experience as were the students from any previous
class.
The time from the diagnostic appointment
through the denture placement appointment aver-
aged 39 days for patients treated in this program.
For previous classes of dental students, this average
time had been 98 days or more for their rst
denture patients (see Table 1). The three Division
of Prosthodontics faculty members who staffed the
clinic in this program all believed that accelerating
the completion of treatment enhanced the continu-
Table 2. Appointment Sequence for the 2002
Complete Denture Prosthodontics Transition
Clinic
Appointment Date Procedure(s) Planned
1 1/16/02 Oral examination and
diagnostic records
2 1/23/02 Border mold and nal
impression
3 1/30/02 MM records
4 2/6/02 Tooth try-in
5 2/20/02 Denture placement
6 2/21/02 Follow-up (24 hours)
7 2/27/02 Follow-up (7 days)
209 September 2003, Volume 12, Number 3
ity of care, resulting in a better learning experience
for the students and a better service for the pa-
tients.
The University of Colorado School of Dentistry
plans to continue the Complete Denture Prosth-
odontics Transition Clinic as the introduction to
clinical patient care for dental students. The initial
success of this program raises several interesting
questions that have not yet been fully investigated:
1. Will students who had their rst complete den-
ture patient experience earlier complete more
complete dentures in the Comprehensive Care
Clinic than their predecessors?
2. Will students who had their rst complete den-
ture patient experience earlier achieve compe-
tency in complete denture prosthodontics earlier
than their predecessors?
3. Will students who had a complete denture pa-
tient experience as their introduction to patient
care be better prepared for the Operative Den-
tistry/Periodontics/Oral Diagnosis Transition
Clinic, and subsequently for the Comprehensive
Care Clinic?
These questions provide exciting topics for
further investigation.
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210 Complete Denture Prosthodontics Transition Clinic Lang et al