This position paper has been peer-reviewed by the participants of Group A: “Undergraduate Education in Implant Dentistry”

Group A consisted of the following: Chair Chair Reviewer

Professor Professor Dr. Professor Professor Professor Professor Mr. Professor Dr. Dr. Professor Professor

Soren Hugo Sebastiaan Philippe Matteo Cecilia Klaus Torsten Katalin Anders Ioannis Wilfried Damien

Jepsen De Bruyn Koole Bouchard Chiapasco Christersson Gotfredsen Meyer-Elmenhorst Nagy Nattestad Polyzois Wagner Walmsley

European Journal of Dental Education ISSN 1396-5883

Contemporary undergraduate implant dentistry education: a systematic review S. Koole1 and H. De Bruyn1,2 1 2

Faculty of Medicine and Health Sciences, Department of Periodontology and Oral Implantology, Dental School, Ghent University, Ghent, Belgium € University, Malmo €, Sweden Faculty of Odontology, Department of Prosthodontics, School of Dentistry, Malmo

Keywords implant dentistry; undergraduate education; systematic review. Correspondence Sebastiaan Koole Ghent University Dental School De Pintelaan 185, 1P8 9000 Ghent Belgium Tel: +32 9 332 4017 e-mail: [email protected] Accepted: 7 November 2013

Abstract Introduction: Consensus reports recommend that students upon graduation should possess a significant level of knowledge and competence in implant dentistry, including basic competences in diagnostics, treatment planning, restorative, straightforward surgical and maintenance procedures. In response, undergraduate curricula need to integrate implant dentistry. This narrative review explores educational programmes in terms of competences, related research and barriers or reflections, regarding implementation in undergraduate curricula. Materials and methods: Publications (2008–2013) were searched systematically in WoS, PubMed and ERIC and screened independently by two authors in four stages: removal of duplicates, title screening, abstract screening and full-text reading. Inclusion criteria encompassed implant dentistry in undergraduate education.

doi: 10.1111/eje.12076

Results: Finally, 37 of 420 papers were included. Detailed information regarding programme content, number of participants, staff input, logistics/funding issues is scattered. Theoretical education is predominant, and pre-clinical/clinical training is offered minimally, often carried out in elective programmes. However, selected straightforward cases treated by undergraduates yield positive outcomes with low failure rates, few complications, high patient satisfaction and student appreciation. Barriers to implementing implant dentistry in the undergraduate curriculum include funding issues, limitations in time or staff availability/competence and lack of suitable patients. Overcoming these barriers is worthwhile as experience-based implant education affects future practice as well-informed students propose more restorative alternatives to their patients. Conclusion: Although implant dentistry is increasingly integrated in undergraduate curricula, challenges remain in developing strategies to implement existing competence profiles and the extent of experience-based education. To support further advancement, universities should report comprehensively on their implant programmes to allow comparison and reproduction in other environments.

Introduction Patients consider dental professionals as clinical experts and expect them to establish the correct diagnosis for a given problem as well as to offer the best possible treatment that fulfils their needs and demands. Dentists are supposed to take morbidity, longevity, costs and benefits of a certain treatment into consideration. Often legislation requires them to present alternatives to treatment proposals, especially in the context of 12

restorative dentistry. To transform students into competent and skilful dental practitioners, it is important that undergraduate education follows the pace of innovations and stays well attuned with everyday professional practice (1). To remain relevant, education has to permanently monitor clinical practice, integrating any new developments in the domain of dentistry. Over the last decades, implant dentistry has continuously grown in importance for dental rehabilitation. As patients grow older, the prevalence of full and partial edentulism increases ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 11–23

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(2–4). Continuous improvement in implant materials, surgical protocols and prosthetic techniques has made implant therapy a valuable and predictable treatment alternative in reconstructive dentistry (5, 6). For single-tooth replacements, the cost of implant-borne restorations is comparable to that of conventional fixed prosthetics (7). However, the latter requires damage to the natural tooth substance. Hence, also from a biological standpoint, an implant is the first treatment choice for singletooth replacements (8). Consequently, the delivery of implant therapy is expected to increase. Whereas implant dentistry was mainly performed by specialists with emphasis on surgery, the growing demand and applicability have led to a wider adoption of implants in clinical practice. General dental practitioners have undertaken additional training, gaining the necessary prosthetic skills and competences to promote implant dentistry in their practice. Also, more clinicians strive to perform holistic care for their patients by performing all aspects of implant placement, including surgery and restorative procedures. Currently, the practice of implant dentistry is no longer considered as solely belonging to the specialist domain. Academic institutions have recognised their leading role in education and in preparing graduates to make independent evidence-based clinical decisions (8, 9). Future dental professionals should possess certain competences within implant dentistry, such as to identify the indications, provide patients with correct information and refer or even treat patients themselves to the extent of their competence. Consequently, there is an increase in time spent on implant-related topics in undergraduate curricula (10, 11). Some countries have even by law requested that dental schools include competences related to implant prosthetics in their curriculum (12). In support of this process, in 2008, academic leaders invited by the Association of Dental Education in Europe (ADEE) reached a consensus on implant education. Guidelines, including the rationale for implant dentistry, theoretical knowledge and competences at the undergraduate and postgraduate level as well as methods of assessment in dental education were described to facilitate further development of implant dentistry education in Europe (13). In 2011, Kroeplin and Strub (14) performed a literature review, to evaluate the integration of implant dentistry in undergraduate curricula worldwide. They included publications between 1974 and 2009, describing undergraduate implant education in the last decades. Results demonstrated implant dentistry as part of the undergraduate curricula, predominantly taught by theoretical courses in the form of lectures (1–20 h). Implant therapy integrated in preclinical and clinical training was less apparent and differed greatly between curricula. In line with these initiatives, the current review explores in a systematic manner recent reports on undergraduate oral implantology education in literature, since the ADEE workshop in 2008. This study aims to analyse the reported programmes and educational outcomes, specific instructional methods, competences, research about implant dentistry in undergraduate curricula and reported barriers to and/or reflections about the integration of implant dentistry in undergraduate education. To structure this review, four research questions (RQ) were posed. RQ1: What is the current status of undergraduate implant education, in terms of content, complexity and accessibility? ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 11–23

Undergraduate implant dentistry education

RQ2: What competences for undergraduate implant dentistry education have been reported? RQ3: What research has been reported concerning clinical outcome, patient satisfaction and student perspective? RQ4: What are the barriers and/or reflections reported about the integration of implant dentistry in undergraduate education?

Materials and methods A systematic search strategy was used in response to the research questions, investigating the initiatives related to contemporary undergraduate implant dentistry education. Web of Science (WoS), PubMed and the Education Resources Information Centre (ERIC) were searched, using combinations of the following search terms: implant dentistry; undergraduate education; predoctoral education; implant* and curriculum. PubMed search was complemented with Medical Subject Headings (MeSH) terms: dental education; dental implants; dental students; dental schools and dental implantation, and endosseous. Results were limited to publications of the last 5 years (2008– 2013) and written in English. Due to the explorative character of the review, all publication types, including original studies, review articles, consensus documents, reports and commentaries were included in the literature search. The total of publications was augmented by one additional article, that was in press at European Journal of Dental Education at the time of the literature search and was provided by the associate editor. The screening process was conducted in four stages as depicted in Fig. 1. First, all duplicate publications were removed. Subsequently, all articles were screened and selected if they met the three inclusion criteria. They included

Web of Science: 143 publicaƟons

PubMed: 268 publicaƟons

Total of 419 publicaƟons +1* 183 duplicates excluded 237 publicaƟons included for Ɵtle screening

62 publicaƟons remained for abstract screening

ERIC: 8 publicaƟons

Excluded: Non-implant denƟstry 49 Non-educaƟon 79 Non-undergraduate level 47 Excluded: Non-implant denƟstry 6 Non-educaƟon 4 Non-undergraduate level 1

51 publicaƟons remained for full-text screening

AŌer evaluaƟon of full texts 37 publicaƟons met inclusion criteria

Excluded: Non-implant denƟstry 3 Non-educaƟon 1 Non-undergraduate level 9 No informaƟon 1

* addiƟonal publicaƟon provided by associate editor European Journal of Dental EducaƟon

Fig. 1. Used search strategy: the initial literature search in three databases and the excluded publications as a result of the screening process (title, abstract and full-text screening).

13

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publications about (i) implant dentistry and (ii) focused on education (iii) at an undergraduate level. The selection process was based on the consecutive screening of titles, abstracts and full articles. The screening process was performed independently by the two authors. Disagreement was discussed until consensus was reached. When there was any remaining doubt about selecting an article, this article progressed to a more extensive level in the screening process. Finally, after the screening process, the remaining articles that met the inclusion criteria were independently reviewed by both authors. For each of the included articles, data were extracted, including country of origin, publication type, year of publication and information related to the research questions.

Results The initial literature search yielded 420 publications. First, 183 duplicate publications were removed. After the screening process, an additional 200 publications were excluded, leaving 37 recent publications (2008–2013) to meet the inclusion criteria. Excluded publications as a result of full-text screening are listed in Table 1. The characteristics of the included publications are summarised in Table 2.

RQ1: What is the current status of undergraduate implant education, in terms of content, complexity and accessibility? In general, two types of publications about undergraduate implant education could be identified: first, those dealing with a single programme (15–27) and second, descriptive studies including multiple programmes (14, 28–31). A common trend in the last decades is a steady increase in undergraduate schools, offering some kind of implant-related education up to the point that at present around 100% of the programmes included the scientific basis for implant dentistry in their curriculum (14, 29). Notwithstanding this wide integration of implantology at an undergraduate level, consistency between offered programmes is lacking (14, 28, 29).

Three didactic components in implant education can be identified. Basic theoretical education is by far the most common; pre-clinical exercises have a lesser frequency, and clinical education in the context of assisting or self-performing implant-related treatment is only offered in a limited amount of programmes (14, 15, 20–22, 24, 25, 30). Theoretical education is offered to provide students with the knowledge of the basic principles of implant dentistry or is taught in a line of learning to ground pre-clinical and clinical education. Taught implant-related topics are diverse, including (i) general aspects such as historic review (21, 29) or generalised introduction to implant dentistry (21, 22); (ii) indications and contraindications (14, 22, 29); (iii) biological aspects of osseointegration (21, 29), soft tissue management (14) or biocompatibility (22, 29); (iv) implant-related aspects concerning material science (22, 29), implant types (29), implant surface topography (29); (v) implant survival and success rates (21, 22, 29); (vi) clinical aspects related to patient information/education (29), treatment planning (14, 16, 21, 22, 29), maintenance (14, 22), restoration (14, 29), prosthetic complications (29), treatment of failing patients (14, 21); (vii) surgical aspects in general (21, 29), pre-surgical assessment (21, 29), surgical techniques (14), navigated surgery (22), introduction to bone grafting (14, 22, 29), sinus grafting (22, 29), suturing techniques (22), immediate loading (29), complications (29), post-surgical care (21, 29); (viii) also the inclusion of modern technology, using CBCT scans and 3D modelling for case planning and virtual dental implant planning software in undergraduate education, was reported (22, 32). To deliver these knowledge elements, multiple didactical approaches have been proposed, including e-learning (9, 21, 24, 28, 29), self-directed learning (9, 25), problem-based learning (9, 25), tutorial-based learning (27) and student–teacher-centred education (19). The educational resources used in support of implant education were selected literature (17, 21, 27, 28), videos/DVDs (28), internet-based information (28) and textbooks (31). Pre-clinical education provides students with a controlled environment in which to learn implant-related skills and to become familiar with implant procedures, materials and instruments.

TABLE 1. Overview of excluded publications as a result of full-text screening process Excluded publications

Reason for exclusion

Focus of publication

Andreana et al. (54) Azari and Nikzad (55) Baehni and Tonetti (56) Bickel et al. (57) Christensen (58) €e and Lynch (59) de Oyagu Gallucci et al. (60) Jokstad (61) Judy (62) Jung et al. (63) Junges et al. (64) Mattheos and Ivanovski (65) €nwetter et al. (66) Scho Stone (67)

Non-undergraduate education Non-educational Non-undergraduate education Non-undergraduate education Non-undergraduate education Not implant dentistry related Non-undergraduate education Non-undergraduate education Non-undergraduate education Non-undergraduate education Not implant dentistry related No information Not implant dentistry related Non-undergraduate education

Implant success rate in graduate clinic Evolution of rapid prototyping Consensus report on periodontology Introduction of implant dentistry in Fiji Opinion on the future of dentistry Teaching of removable partial dentures in Spain New postgraduate programme at Harvard Postgraduate education in Canada and Scandinavia Editorial on implant education triage EAO summer camp report Curriculum development in Brazil Introduction of an Australian consensus report Competence development and education New examination in implant dentistry

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TABLE 2. Characteristics of included publications and their main conclusions Year

Publication

Country

Type

Main conclusions

2008

Addy et al. (28)

UK/Ireland

Study curriculum survey

Blum et al. (29)

UK

Study curriculum survey

Jahangiri & Choi (15)

USA

Description programme + study student survey

Kronstrom et al. (16)

Canada

Study clinical outcome

Maalhagh-Fard and Nimmo (17) De Bruyn et al. (30)

USA Europe

Description programme + study clinical outcomes Study curriculum survey

Harrison et al. (43)

Ireland

Study patient survey

Hicklin et al. (38)

Europe

Consensus report

Kido et al. (18)

Japan

Lang & De Bruyn (8)

Europe

Description programme + study student survey Consensus report

Mattheos et al. (68)

Europe

Consensus report

Mattheos et al. (13)

Europe

Consensus report

Nicolas et al. (44)

France

Study student survey

Sanz & Saphira (37)

Europe

Consensus report

Aragon et al. (69)

Canada

Study clinical outcome

Bonde et al. (34)

Denmark

Study clinical outcome

€th et al. (19) Gu

Germany

Farino et al. (20)

USA

Description programme + study student survey Study clinical outcome

Mattheos et al. (39) Mattheos et al. (40)

Australia Australia

Consensus report Consensus report

Majority of schools provide implant education, mainly lecture-based or pre-clinical training. Clinical training is limited. Increase in implant education is anticipated in near future All schools provide implant dentistry to some extent, but there are large variations in content and teaching modalities Implant programme should be fully integrated into entire dental curriculum, including biomedical concepts, simulation and patient care. Experience appeared to influence students’ perceptions of curriculum coverage Clinical outcome of implant treatment by undergraduate students (limited to treatment planning and prosthodontics) is similar to that reported by experienced surgeons or periodontists An elective implant programme, including 159 implants placed over an 11-year period, yielded a survival rate of 93.7% Significant diversity exists in undergraduate implant education in Europe; barriers are present, and guidelines are needed to optimise education Patients demonstrated high overall satisfaction with received treatment (limited to restorative procedures by undergraduate students after implant placement performed by postgraduate students) Recommended knowledge for undergraduate students included biological prerequisites and related clinical procedures Two-day simulation-based training was effective to alter student perceptions towards implant treatment Demographic changes and implant therapy as cost-effective treatment imply the integration of implant dentistry in curricula. Results from an academic consensus Assessment should be integrated in all educational levels, reflecting learning outcomes (Miller pyramid) Implant dentistry should be integrated in the undergraduate curriculum, based on the consensus guidelines on knowledge, competencies and assessment methods Assessment of the curriculum at Clermont-Ferrand dental school (France) revealed implantology-related skills are under-represented and future changes are anticipated Based on the ADEE and DentEd framework, competencies were defined to ground competence-based implant education with a strong emphasis on interdisciplinarity and integration Performance of dental students when fabricating a mandibular twoimplant overdenture is not different from that of a conventional denture, perceived by patients and prosthodontists Implant-supported single-tooth replacements performed by undergraduate students have high survival rates and few biological and technical complications A simulation-based pre-clinical implant surgery course was perceived positively by undergraduate participants Implants placed by residents and restored by undergraduate students yielded a 98% survival rate Key competencies to clarify curricula endpoints Required competency domains in implant dentistry are described related to: diagnostic procedures and treatment planning stage; surgical placement; prosthetic reconstruction; maintenance; diagnosis and appropriated treatment of biological or technical complications during maintenance

2009

2010

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Table 2. Continued Year

Publication

Country

Type

Main conclusions

2010

McAndrew et al. (9)

UK

Consensus report

Tarica et al. (45)

USA

Study curriculum survey

Wilcox et al. (21)

USA

Description of programme

Atashrazm et al. (31)

Worldwide

Study curriculum survey

Chowdhary & Chowdhary (41)

India

Review

Kroeplin & Strub (14)

Germany

Review

Kroeplin & Strub (22)

Germany

Lee et al. (23)

USA

Description programme + study clinical outcome Study clinical outcome

Yuan et al. (24)

USA

Study student survey

Zimmermann & Hendricson (25)

USA

Description programme + study student survey

Calvert et al. (33)

UK

Study patient survey

Jalbout et al. (26)

USA

Description programme + study clinical outcome

Moghadam et al. (36)

USA

Study patient survey

Nkenke et al. (32)

Germany

Study student survey

Wolleb et al. (42)

Switzerland

Study clinical outcome

Ariani et al. (35)

Indonesia

Study student survey

Moest et al. (27)

Germany

Description programme

Staff training, financial resources and patient recruitment issues have been identified amongst others as barriers and challenges for undergraduate implant education Despite the wide variation of materials and techniques used for cement-retained implant-supported crowns, there are common trends in USA dental schools Creighton University offers voluntary clinical implant participation to all dental students including both surgical placement and prosthetic restoration Majority of schools have included implant dentistry in their undergraduate curriculum, with large variations amongst programme elements. Curriculum guidelines were absent in 50% of schools The introduction of implant dentistry as part of the compulsory undergraduate curriculum is suggested in India to manage problems related to a high prevalence of edentulism Undergraduate curricula teach implant dentistry by lectures and laboratory courses, but level of clinical experience varies extensively Survival rates for dental implants placed and restored by students are comparable to those by experienced dentists Three-year clinical outcome of patients receiving implant-retained mandibular overdentures or single-tooth implants in an undergraduate programme (restoration by undergraduate students and placement by residents) identified a 99% survival rate with few complications Pre-patient care laboratory exercises influence students’ future plans to provide implant therapy A strategy of faculty development and case selection grounding an elective surgical implant course is beneficial to both students and faculty Undergraduates achieve similar levels of improvement as experienced prosthodontists in the provision of implant-supported mandibular overdentures In an honours programme, reporting on performance of only seven students placing in total 52 implants, surgical problems were reported such as lack of initial implant stability or direction problems Patients are highly satisfied about received implant-retained crowns in undergraduate programme Virtual dental implant planning software is accepted by undergraduate dental students High survival rates and few complications were found in tooth and implant-supported fixed dental prostheses treated in the undergraduate curriculum Undergraduate students are aware of implant therapy as a restorative treatment option and plan to include implants in their future practice; nevertheless, they considered implant dentistry insufficiently covered in the current curriculum I-lect tutorial, providing practical experience in implant dentistry at an early stage of the curriculum, was positively perceived by the participating undergraduate students

2011

2012

2013

Reported exercises include implant planning (22), implant osteotomy preparation on pig heads (22), training on simulated models (18, 22), surgical drills (24). Students are closely supervised in pre-clinical exercises and often participate in live demonstration by the instructor (19). These exercises also have a preparatory function for dental students as they enter clinical training. 16

During their learning and training activities, undergraduate students mostly participate in treatment planning, restorative care of easy cases and clinical maintenance. This includes history taking (22, 23), clinical examination to assess clinical parameters necessary to make a proper diagnosis and appropriate treatment plan (16, 22, 23), pre-surgical care (23), tooth ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 11–23

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extractions (22), restoration of implants (16, 22, 23, 28) or assisting in restorative procedures undertaken by residents or staff members (18, 33). Actual placement of implants by students was only allowed in a limited number of programmes (21, 22). By and large, one can conclude that in most programmes students’ tasks are limited to observation (18, 22, 24, 28) or chair-side assisting (16, 22, 23). Close supervision of undergraduate students is an important aspect in clinical training. Supervisors are often described as experienced faculty members in implant dentistry. Zimmerman and Hendricson (25), however, described a train-the-trainer programme in three phases. First, faculty members attended a three-day course on restorative and surgical aspects of implant dentistry, mainly based on theoretical sessions, followed by hands-on training. In a second phase, experience was gathered in implant placement under guidance of specialists and from their peers. In a last phase, they provided peer training for new faculty members in the training programme. Literature reveals that only straightforward patient cases are selected for treatment by undergraduates (8, 14). The definition of a simple case seems to be quite diverse but also broad. Specific procedures described can go from the following: edentulous or partially edentulous patients with adequate bone width and height not requiring bone grafting (16, 22, 25); no more than two adjacent implants in one quadrant (16); implant placement only in healed sockets and excluding immediate placement in extraction sockets (16); mandibular overdentures on two implants (14, 20, 24); one- to four-unit FPDs (14); single-unit cases (20, 24, 28); multiple-unit cases (20); implantsupported single crowns in incisor, canine and premolar regions (34); removable overdentures (28) molar and premolar restorations (16); not medically compromised (25) and patients with low aesthetic demands (25). Undergraduate training programmes also apply strict exclusion criteria related to specific implant locations or bone condition. For instance, treatment in second and third molars (23) of anterior implants (20) in the aesthetic zone is excluded (23). High-risk patients were excluded such as patients with complex restorative needs (17), heavy smokers (17). One study (34) excluded patients with a history of irradiation of the head and neck region, chemotherapy, HIV-infected, substance-addicted cases, autoimmune or bone metabolic disease, uncontrolled diabetes, poor oral hygiene, progressive periodontitis, pregnant and breast-feeding women and immunosuppression. In undergraduate curricula, implant-related education is usually taught to students in the mid or final stages of their training (18, 20, 28, 31, 34, 35), although some programmes provide theoretically based introductory courses in the initial years of the curriculum (14). By and large, theoretical knowledge is taught to all students. Some elective programmes, directed to offer (additional) clinical experience to (selected) small groups of undergraduate dental students, are often based on voluntary participation or on pre-selection (16, 17, 21, 25–27). Selection criteria that have been reported include previous grade ranking (16, 17), multiple-questions examination (16), pre-attendance at certain seminars, participation in pre-clinical hands-on sessions and chair-side assistance activities (16, 23, 26), curriculum vitae or letters of recommendation and personal motivation (25). In exceptional circumstances, some ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 11–23

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undergraduate curricula offer clinical experience in restoration and/or surgery to all students (15, 22, 36).

RQ2: What competences for undergraduate implant dentistry education have been reported? Undergraduate curricula have to educate students that are able to cope with the implant-related demands in professional practice. In the first ADEE workshop on implant dentistry education in Europe, academic leaders in implant dentistry have consented on the competences a graduated dentist should have acquired. Dental students are considered able to include the indication of oral implants in their treatment planning (8). As a result, Sanz and Saphira (37) have identified implant dentistry involved competencies in seven domains: professionalism; communication and interprofessional skills; knowledge base, information handling and critical thinking; clinical information gathering; diagnosis and treatment planning; establishment and maintenance of oral health; and health promotion. The aim of these competencies is to enable trained graduates to practice implant therapy independently and safely. In support, Hicklin et al. (38) have described the underlying knowledge base undergraduate students should attain. These include aspects of implant treatment overview; osseointegration of dental implants; soft tissue interface with dental implants; clinical and diagnostic information; treatment planning considering dental implants; aesthetic considerations; fixed dental prosthesis on teeth vs. implant reconstruction; materials for dental implants; surgical procedures; surgical complications; management of bone and soft tissues for implant site development; prosthetics; biomechanics of implant-supported reconstructions; aetiology, pathogenesis, prevention and therapy of peri-implantitis; and long-term results of implant-supported reconstructions. In Australia, a similar consensus report on competencies for the graduating dentist has been developed based on the six stages of implant treatment: (i) diagnostic procedures and information gathering and analysis; (ii) comprehensive, restorative-driven, patient-centred treatment planning; (iii) surgical stage, placement of implants; (iv) prosthodontics stage, restoration of occlusion function and aesthetics; (v) maintenance stage and; (vi) diagnosis and treatment of biological or technical complications (39, 40). A consensus report from the UK is less descriptive concerning learning outcomes, but states that graduates should have acquired sufficiently assessed basic competences in implant dentistry from the clinic to the laboratory, acting as a foundation for possible future expansion (9). A review report from India concludes that undergraduate students should have attained the knowledge and understanding of implant dentistry and adequate clinical experience to independently cope with clinical problems (41). The referred competence models, however, are instruments that only prove their worth when they are used as standards for curriculum development and benchmarking. Wilcox et al. (21) have described six educational goals that were used to ground a successful undergraduate implant programme in the 17

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United States. They encompassed (i) knowledge of physical and physiological mechanisms, impacting implant success; (ii) competence in evaluating and maintaining implants/prostheses that have already been placed and restored; (iii) competence in evaluating treatment suitability and advising patients seeking implant placement/restoration; (iv) competence in restoring simple implant cases; (v) competence in managing patients who will undergo implant placement; and (vi) familiarity with the special surgical protocols used when placing an implant. In conclusion, the reported competence models for undergraduate implant dentistry education share common grounds in targeting all treatment aspects of implant therapy, including diagnostics, treatment planning, surgical placement of implants, prosthodontics, maintenance and biological or technical complications. Upon graduation, these competencies should enable dental professionals to include implant dentistry into their practice and provide the foundation to develop more advanced competencies in postgraduate training. Future reports need to focus on the integration of these competence profiles to establish their usefulness as a benchmark for undergraduate implant education.

RQ3: What research has been reported concerning clinical outcome, patient satisfaction and student perspectives? Multiple programmes report to offer undergraduate students the ability to acquire clinical experience in restoration and placement of implants (30). Survival rate of oral implants is an important indicator of the positive outcome of therapy and is in the order of 92–100% (16, 20–23, 34, 42). In the majority of these undergraduate clinics, students are responsible for treatment planning in addition to the actual implant placement, performed by an experienced faculty member. At Creighton University, undergraduate students acquire extended experience in implant surgery, which resulted in a respective three- and five-year survival rate of 97% and 95% (21). The undergraduate programme at the University of Kentucky reported a success rate of 93% when implants placed by postgraduate residents were restored by students (20). Success was identified as the absence of pain or mobility and patient satisfaction with function, appearance and surgical experience. In an elective programme at the University of Detroit (17), 6.3% of the implants failed in 10% of the patients. By and large, one can conclude that the outcome obtained in these programmes, provided there are strict inclusion criteria and proper case selection, yields a clinically acceptable outcome. An honours programme at New York University (26) provided seven selected students (of approximately 350) the opportunity to place implants under close supervision. In total, 47 surgeries were performed, to place 52 posterior implants (length 10 mm, diameter 3.5–5 mm), of which three failed to achieve the desired initial stability (35 Ncm insertion torque). Ten implants required drill direction modifications at time of initial pilot drill at 8 mm depth. All direction adjustments were successfully executed by students (n = 7) and staff (n = 3) to end up in implant placements. Biological conditions relative to peri-implant health were reported on single-tooth replacements performed by undergrad18

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uate students at Aarhus University in Denmark (34). This was reflected by a mean probing depth of 4.8 mm, a mean bleeding on probing score of 0.57 and mean bone level change of 0.14 and 0.16 mm after one and 10 years of loading. Wolleb et al. (42) found a plaque control rate at follow-up of 22.8% and a mean value for bleeding on probing of 21.5% in patients treated in the undergraduate programme at the University of Zurich. Biological complications related to implant treatment by undergraduate students were scarce but reported to occur. These included soft tissue inflammation (23, 34, 43), fistula over two implants (34). Similarly, technical complications have occurred such as screw loosening (17, 34), screw fracture (17) and porcelain fractures (17, 34), damaged prosthetic parts (23) and repair/remaking of definitive prosthesis (23). These findings are common in implant therapy with experienced clinicians. Patients’ satisfaction is an additional important parameter to determine the quality of treatment. Table 3 summarises the various aspects of studied patient satisfaction in the reported studies. In general, high satisfaction rates have been reported. Furthermore, Calvert et al. (33) have demonstrated that undergraduate students making implant-supported overdentures achieved similar increase in patient satisfaction and quality of life than experienced prosthodontists. Implant education is aimed to develop implant-related competences in students. Hence, their perception is an important indicator for further curriculum development. At ClermontFerrand dental school (France), students in the final 2 years of the undergraduate curriculum and previously graduated dental practitioners (n = 170) were questioned about the appearance of 52 items in the current curriculum (44). Students indicated a need for more thorough training in relation to implant dentistry. This included the competence to perform common periodontal surgical procedures, implant surgery as well as the whole range of implant-borne prosthetic procedures. Undergraduate students (year 4–5) at the University of Indonesia were questioned about their perceptions on implant treatment, current implant curriculum and future plans (35). Implant therapy was considered as the first treatment option for the replacement of mandibular first molars and maxillary anterior teeth. For restoring an edentulous mandible, however, the first choice was a conventional approach with a complete removable denture. Students indicated that implant education at present was insufficiently covered in the curriculum. They suggested theoretical education, simulated practical exercises and clinical observation of cases. Furthermore, students reported the intention to include implant treatment in their future practice and to pursue additional postgraduate training. To increase the number of undergraduate students with restorative experience, New York University introduced an integrated implant programme in 2005 (15). To evaluate this programme, students were asked to identify the amount of implant dentistry in the curriculum as excessive, satisfactory, fair or inadequate. Between 2005 and 2008, the proportion of the answer ‘inadequate’ decreased in favour of an increase in responses ‘satisfactory’ and ‘fair’. In conjunction, the percentage of students with restorative experience increased from 3% to 92%. In line with this finding, at the University of Texas undergraduate dental students, after applying and being admitª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 11–23

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TABLE 3. Summary of reported patient satisfaction rates as a result of treatment by undergraduate (UG) students Author

University

Treatment

Satisfaction rate

Farino et al. (20)

University of Kentucky College of Dentistry

Implant placement: residents in periodontology and maxillofacial surgery Restoration: UG students

Moghadam et al. (36)

New York University College of Dentistry

Restoration: UG students

Harrison et al. (43)

Dublin Dental School and Hospital

Wolleb et al. (42)

University of Zurich

Implant placement: postgraduate periodontal students Restoration: UG students Implant placement: faculty members Other procedures: UG student

Overall: 94.4% Appearance: 94.8% Function: 95.6% Surgical experience: 99.2% Appearance: 86% Speech: 95% Chew: 96% Overall comfort: 91% Decision implant treatment: 98% Treatment experience: 90% Recommend treatment to others: 97% Overall: 90% Treatment again: 95% Recommend treatment to others: 90% Overall: 97.8%

ted to a selective course in implant dentistry to promote clinical experience, reported the course increased their understandings of oral implantology and contributed to their awareness of implant therapy as a treatment option (25). Pre-clinical education is also valued by undergraduate students. Kido et al. (18) reported on a 2-day pre-clinical exercise on simulation models, directed to teach incision and flap management, implant bed preparation, actual implant placement and suturing. After training, positive opinions towards integrating training in the curriculum increased, technical aspects were perceived as less difficult than anticipated, and more students preferred implant-related therapy over conventional fixed toothborne prosthetics when restoring missing first mandibular molars. Similarly, at Ludwig-Maximilians University (Germany), students received pre-clinical training, targeting interdisciplinary planning for a two-implant-retained overdenture treatment. This included the use of drilling and guiding templates, and placement of two ball attachments into a pre-existing full denture (19). Overall, students were highly positive, scoring 1.7 on a 6-point scale (1 = excellent to 6 = unsatisfactory). Aspects that were rated particularly high were live demonstration (1.3) and supervision (1.4). Students at University of Illinois at Chicago (24) perceived implant dentistry as important in the curriculum after attending pre-clinical exercises. Strong associations were found between students’ preparedness from the exercises and future plans to provide implant-related care. The latter was specified as making proper diagnosis and treatment planning, restoration of single-tooth implants and restoration of implant-retained overdentures. At the University of Erlangen-Nuremberg (Germany) (32), students’ opinions towards the implementation of virtual dental planning software in the undergraduate curriculum were assessed. For this purpose, a questionnaire about perceived usefulness, ease of use, behavioural control, subjective norm, attitude and behavioural intention was applied. Findings indicate a positive perception of virtual dental planning software in the undergraduate curriculum, although perceived as difficult. ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 11–23

In general, it can be concluded that clinical outcome of treatment by undergraduate students, albeit on highly selected cases, is acceptable and comparable to implants placed and restored by experienced dental practitioners. The majority of patients are satisfied with the treatment received in undergraduate clinics. Implant education is positively attained by students and all the aforementioned studies suggest that pre-clinical education influences students’ future plans to consider implant therapy as treatment alternatives to conventional prosthetics.

RQ4: What are the barriers and/or reflections reported about the integration of implant dentistry in undergraduate education? Despite the acknowledged significance of implant dentistry, it is evident that at present universities at large experience difficulties in fully integrating implant dentistry within their programmes. Multiple barriers have been suggested as explanatory reasons. Difficulty in integrating an additional programme in an already overcrowded curriculum is often referred to as an argument for absence of focus on implant dentistry in undergraduate education (9, 14, 28, 30, 31, 40). Some institutions may not consider implant therapy as a priority (29) or regard implantology as an advanced topic, which should be taught solely in postgraduate education (14, 31). The introduction of clinical education requires sufficient patients with straightforward needs as suitable learning content for undergraduate students (9, 15, 25, 34, 40, 43). Available patients for implant therapy are also being targeted by competing treatments such as conventional removable and fixed prosthodontics as well as other postgraduate or continuous education programmes (36). Complexity of the patient case is often used to allocate a patient in an undergraduate or other programme (25). Afterwards, it is also important to follow up patients in a maintenance programme (15, 34). Close supervision is a prerequisite for creating a safe learning environment for both students and patients (9, 14, 26, 29–31, 19

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40). Faculty members have to be trained in treatment modalities and patient management and should be calibrated in relation to the defined learning outcomes (15, 28, 34, 36, 43). Benefits of using residents to supervise undergraduate students are for them the opportunity to acquire additional teaching experience, apart from the surgical training (23). Training of supervisors, infrastructure and the possibility to provide patients with incentives to be treated by undergraduate students require considerable financial resources (9, 14, 22, 29– 31, 36, 40, 43). The implant industry often supports educational programmes financially and/or with the provision of implant components and logistics in terms of training. In that way, they are contributing considerably to the programmes’ funding (26, 28, 40, 43). Before entering clinical training, students should have had sufficient theoretical education and pre-clinical exercises. Preparatory simulation itself is essential for students’ performance in clinical training (17). Furthermore, using one implant system is beneficial from a practical and organisation point of view because it simplifies training protocols and benefits inventory demands (17, 20, 26). Nevertheless, educational programmes have reported working with more than one company and some schools have included up to 11 in their programmes (45). Another possible benefit of implant education is that working with different surgical disciplines such as oral surgery, periodontics and prosthodontics and other faculty members creates a multidisciplinary context, which provides an additional learning opportunity for the participating students (23). Elective programmes could provide students with sufficient competence and experience in preparation for future clinical practice. To familiarise students, not in elective programmes, with implant dentistry, it was suggested to include implant therapy as a component of the regular clinical placement in the curriculum, organising an implant rotation (17). However, authors have also indicated that this initiative would require considerable additional resources. In conclusion, implant-related education has been demonstrated to impact future intentions of undergraduate students to consider and apply implant therapy as a treatment alternative (24, 25, 35). Nevertheless, multiple barriers have been identified that may counteract the actual integration of implant dentistry in undergraduate education. Each curriculum has to balance the benefits and barriers to determine the extent of integration of implant dentistry, within a country’s specific context of politics and legislation (29, 30).

Discussion As the integration of implant dentistry in daily dental practice progresses, academic institutions increasingly incorporate implant-related education into their undergraduate curricula. The literature included in the systematic review demonstrates considerable progress in this domain over the last 5 years. Furthermore, the broad range of countries involved in the publications suggests the integration of implant dentistry in undergraduate education as a worldwide phenomenon, despite variations in local context, educational resources, patient characteristics, protocols or standards of care and legislative issues (46, 47). 20

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Disparity of undergraduate implant education has been reported previously (10, 14, 30, 48). Nevertheless, implant dentistry education could be identified by an incremental line of learning from theoretical to pre-clinical and clinical education. Theoretical courses are the baseline of implant education and seem to be part of each reported programme. They are used to teach the fundamentals of oral implantology to undergraduate students and the knowledge base needed in pre-clinical and clinical training. Programmes solely based on lectures and seminars provide graduates with a basic set of knowledge on implant dentistry, but it could be questioned whether this is enough to prepare students to work in the daily clinical practice. Profiles for the graduating dentist in both Europe (37) and Australia (40) have suggested the development of competences that requires at least some (pre-)clinical education. Preclinical training is offered to familiarise students with various implant-related procedures, instruments and materials. Furthermore, it provides a safe environment for students to develop a certain skill set, before encountering real patients. Clinical education is the last training phase to demonstrate competence in a real clinical context. In the majority of programmes, clinical training includes undergraduate students providing restorative treatment on implants placed by faculty members, oral surgeons or residents. Only a few programmes provide students with the opportunity to actually acquire surgical experience. Although theoretical education on surgical aspects and pre-clinical training of surgical skills has been reported, it remains unclear to what extent these aspects of implant dentistry are currently taught in programmes with and without surgical training. Patients treated by undergraduate students are referred to as straightforward cases. Nevertheless, a wide range of procedures with multiple exclusion criteria are used to define these cases, and it is often unclear whether it refers to the StraightforwardAdvanced-Complex (SAC) classification system in implant dentistry (49). The SAC system enables the classification of restorative and surgical cases into three levels of complexity, which could also be used to standardise the inclusion of adequate patient cases for the various levels of implant dentistry education as has been suggested by Sanz and Saphira (37). Installing pre-clinical and clinical training requires a considerable amount of time and funding to train supervisors, organise infrastructure and logistics and recruit sufficient and suitable patients. With an over-congested dental curriculum, all the aforementioned issues form serious barriers that have to be overcome. Hence, the question appears whether extensive experience should be offered to all students. The studies of Maalhagh et al. (50) and Huebner (51) have demonstrated that preclinical and clinical experience offered to students during an implant programmes will positively influence their involvement in implant therapy after they graduated. Nevertheless, considering the extensive costs, it could be argued to only offer advanced clinical training to a selected group of highly motivated students in addition to a compulsory basic training for all students. Reported clinical outcomes in undergraduate clinics were comparable to treatment performed by experienced clinical practitioners (16, 20, 22, 34). These results, however, should be interpreted prudently. Students in the majority of the ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 11–23

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programmes were involved in the restorative treatment of an implant that was actually placed by an experienced professional. Furthermore undergraduate clinical programmes only provide treatment to straightforward patient cases, which could also have affected survival rates, in comparison with experienced clinicians (52). Nevertheless, undergraduate education in clinical environments appears to be positive, with high patient satisfaction and student appreciation. The information provided on contemporary undergraduate implant dentistry in this review maybe is incomplete. Data extraction was often difficult, due to incomplete description, vagueness or generalisation, lacking detailed information on programme content and practical implementation. A similar finding was observed in the review of Kroeplin and Strub (14) where an important part of the extracted information was labelled as ‘not reported’. Hence, in support of the further development of implant education, it is advised that future publications on implant programmes should include a comprehensive disclosure on the educational approach provided, enabling reproduction to others and comparison for the purpose of research. Description of implant programmes should include information about the learning goals, content, methods of teaching (format, assessment and dedicated hours) and targeted student population (year in the curriculum and compulsory/elective/selective course). Moreover, strategies used to implement programmes, barriers encountered and coping mechanisms are extremely valuable information in the current educational context, where consensus guidelines have been formulated, but there are questions over implementation. Illustrative is the discrepancy between the published competence profiles for graduated dentists and the lack of reports on programmes that have actually included these profiles as learning outcomes. Experiences of the implementation of these competence models and their impact on graduated dentists coping with the demands of professional practice will establish their value as a benchmark. Furthermore, it will contribute to the evolution of competence profiles as they have to be reviewed regularly (40). As implant materials and procedures keep evolving, education needs to remain well attuned to equip students with the latest developments in the domain. Progression in CBCT scanning technology and 3D modelling has influenced implant case planning and consequently has been introduced in undergraduate education as well. A systematic approach is needed to identify new developments in implant dentistry and define the appropriate level of education in which it should be implemented. Undergraduate implant education requires the development of efficient and skilful clinically oriented supervisors. The majority of publications have identified close supervision as an important aspect of (pre-)clinical training. Most supervisors are identified by their clinical expertise as experienced clinicians, faculty members or surgeons. Close supervision in undergraduate clinics is needed for patient treatment, because despite proper planning and preparatory sessions, adjunctive help of staff members may be required to compensate for inexperience. Supervision, however, also requires additional teaching skills to create a optimal learning environment for students (53). Hence, train-the-trainer sessions are important to continuously train ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 11–23

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supervisors in their task to demonstrate, guide, provide feedback, stimulate reflective learning and even assess dental student in (pre-)clinical training. This aspect of implant education is currently underexposed in literature, considering its pivotal role in experience-based implant education.

Conclusion Although implant dentistry is increasingly integrated in undergraduate curricula, challenges remain in developing strategies to implement existing competence profiles and the extent of experience-based education. In support of further advancement, universities should report comprehensively and in a structured way on their implant programmes to allow comparison and reproduction.

Conflicts of interest Professor De Bruyn reports on behalf of Ghent University, educational collaboration agreements with BIOMET 3i and DENTSPLY Implants and additional research collaboration agreements with Southern Implants, BIOMET 3i and DENTSPLY Implants. No other conflicts of interest have been declared.

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