European Journal of Dental Education ISSN 1396-5883
Implant dentistry education in Europe: 5 years after the Association for Dental Education in Europe consensus report S. Koole1, S. Vandeweghe1,2, N. Mattheos3 and H. De Bruyn1,2 1 2 3
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 Faculty of Dentistry, Department of Prosthodontics, School of Dentistry, University of Hong Kong, Hong Kong, China
Keywords implant dentistry; dental curriculum; undergraduate education; postgraduate education. Correspondence Sebastiaan Koole Dental School Ghent University De Pintelaan 185, 1P8 Ghent 9000 Belgium Tel: +32 9 332 4017 Fax: +32 9 332 3851 e-mail: [email protected] Accepted: 22 November 2013 doi: 10.1111/eje.12084
Abstract Introduction: To promote consensus on implant dentistry university education in Europe, a workshop amongst university teachers and opinion leaders was organised in 2008. As a result, guidelines on both under- and postgraduate education were issued. This study aims to investigate the current status of university teaching of implant dentistry and the impact of the recommendations for teaching and assessment, 5 years after the first consensus. Finally, this report attempts to identify future directions in education within the discipline. Materials and methods: An online survey was distributed amongst 105 academic leaders in implant education in Europe, and 52 questionnaires were returned (response rate 50%). Results: The average amount of implant dentistry in undergraduate curricula has increased to 74 h, compared to 36 h in 2008, and the inclusion of pre-clinical and clinical education has increased. No change occurred with regard to the aimed competence levels. It was suggested that certain implant procedures including surgery should be provided by dentists after attending additional courses, whilst complex treatments will still require specialist training. The 2008 workshop guidelines have been implemented to a varying extent (25–100%) in under- and postgraduate education. Main reported implementation barriers included limited time availability in the curriculum and limited financial/material resources. Future discussions about implant dentistry in Europe should be focused towards integration in current dental curricula, approaches to overcome barriers and the relations with and role of industrial partners. Conclusion: Implant dentistry is increasingly integrating in undergraduate dental education. Development of the consensus guidelines in 2008 may have facilitated this process. Nevertheless, further progress is needed on all educational levels to align training of professionals to the growing treatment needs of the population.
Introduction Implant dentistry is a rapidly evolving area within oral health care. As procedures become more predictable and efficient, and cost–benefit ratios improve, implant therapy reaches a growing part of the population as an important treatment alternative in reconstructive dentistry (1–3). The major indications for implant placement include restoration of oral function and ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 43–51
chewing comfort, preservation of dental elements and reconstructions and the replacement of missing teeth (4). The initial provision of implant dentistry was limited to specialised professionals, but today, straightforward implant procedures have become more and more mainstream and, consequently, are increasingly performed by non-specialists (5). To keep up with this development, universities face the challenge to develop and implement implant dentistry education at 43
Implant dentistry education in Europe
all levels (under-, postgraduate and continuing professional development) to prepare dental professionals with sufficient competences to fulfil the patient demands and treatment needs of today. At an undergraduate level, dentists have to be prepared to include oral implants in the treatment planning of their patients and also to maintain patients with implants. This implies competence with the indications and limitations of implant therapy, related pathology, maintenance and treatment of straightforward cases (1, 6). Postgraduate education has to prepare graduates to perform highly specialised implant treatment, often for compromised cases. Regarding continuing professional development and lifelong learning, both clinicians and specialists need to constantly update their knowledge and skills to provide the best possible state-of-the-art dental care for their patients. To promote a consensus on guidelines for teaching and assessment of implant dentistry in Europe, the Association for Dental Education in Europe (ADEE) organised a first workshop on implant dentistry university education in 2008. Academic leaders agreed on the recommendation that implant dentistry should be taught in undergraduate education (1). It should include the fundamental principles of implant therapy, enabling graduates to integrate implant treatment into an overall concept of comprehensive care, to identify indications and contraindications and to inform patients about the treatment options (7). The educational approach used should be in line with modern insights about curriculum development, for example, competence-based education, student-centred, evidence-based, interdisciplinary, case-based and/or problembased learning (5). Postgraduate competences were identified in four domains: (i) clinical, (ii) management and leadership, (iii) communication and (iv) professionalism and ethics, at different levels of clinical practice (straightforward, advanced and complex) according to the need of general practitioners to specialists (8). These guidelines are one of many educational initiatives, reflecting the focus on implant dentistry worldwide, including guidelines and consensus reports (6, 9, 10), surveys (11–14), reviews (15, 16) and reports about curriculum development (17–19) and innovative approaches to education (20–23). In preparation of the first ADEE workshop on implant dentistry education in 2008, a survey study was executed to identify the status of implant dentistry university education in Europe (24). Five years later, in preparation for the second consensus workshop, a similar questionnaire was distributed. The aim was to describe the present status of implant dentistry education in Europe, to monitor any trends since the first workshop and to draft suggestions for future directions. The study performed was structured by four research questions (RQ): RQ1. What is the current environment of implant dentistry in under- and postgraduate education in Europe? RQ2. Which changes have occurred since the first workshop on implant dentistry education in Europe? RQ3. Which were the common strategies used to implement implant dentistry in undergraduate and postgraduate education? RQ4. What are the future directions of implant dentistry education in Europe? 44
Koole et al.
Materials and methods The questionnaire was sent to the 73 participants of the first ADEE consensus workshop. Additionally, 32 other leading academics involved in implant dentistry in European universities were selected to participate, based on their presence and influence in implant dentistry education since the first workshop. In total, 105 participants were invited to fill in an online questionnaire. After one reminder, 52 questionnaires were completed and returned, resulting in a 50% response rate. This questionnaire contained identical items from the first European survey on implant education (24) for comparison purposes, which were supplemented with additional questions to comply with the research questions in this study. The content of the questionnaire was pre-tested for face validity in a panel of experts within the field of implant dentistry education and encompassed 22 questions grouped into four categories: ‘Implant dentistry in undergraduate education’, ‘Implant dentistry in postgraduate education’, ‘Necessary competences in implant dentistry’ and ‘Impact of the 2008 consensus on teaching and assessment of implant dentistry in Europe’. Data were analysed using descriptive statistics and all analyses were performed utilising SPSS 20.0 (SPSS Inc., Chicago, IL, USA). All percentages of respondents are presented in round off figures. For comparison reasons, some results are depicted in relation to the findings reported in the 2009 publication on implant dentistry education in Europe (24).
Results Results are based on the completed questionnaires by respondents from 20 European countries. Table 1 illustrates the number of respondents per country and institution that answered the 22 questions in the survey. Some respondents were from the same country, but from different institutions, or had different fields of expertise.
Implant dentistry in undergraduate education Forty-four of 52 respondents (85%) reported that their affiliated institution has an undergraduate dental curriculum. The average number of students in the final year is 69, ranging from 7 to 200 students. Almost all respondents (98% – 43/44) indicated that some form of implant dentistry is taught to their undergraduate students. In 34% (15/44), this is a separate course, and in other cases, implant dentistry is being taught as part of another discipline. Reported disciplines are multidisciplinary courses based on oral and maxillofacial surgery, prosthetic dentistry, periodontology, restorative dentistry and orthodontics; material science and integral care. Respondents reported an average total time of 74 h in the undergraduate curriculum, spent on implant dentistry related topics, ranging from 4 to 288 h, compared to 36 h (3–120 h) in 2009. Table 2 displays the reported instructional methods that are used for implant dentistry in undergraduate education. Notable differences from the results of 2009 include a higher number of reported spent hours on implant-related education and the use of more pre-clinically and clinically orientated instructional methods. ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 43–51
Koole et al.
Implant dentistry education in Europe
TABLE 1. Number of respondents per country and institution Country
Respondents
Institutions
Belgium Bulgaria Denmark Egypt Estonia Germany Hungary Iceland Israel Italy Lebanon The Netherlands Portugal Republic of Ireland Romania Spain Sweden Switzerland Turkey United Kingdom Total
3 1 1 1 1 8 2 1 1 5 1 3 2 1 1 6 4 2 1 7 52
2 1 1 1 1 7 2 1 1 5 1 3 2 1 1 5 2 2 1 6 46
TABLE 2. Instruction methods for implant dentistry in undergraduate education, number of respondents (%) compared to the results of the 2009 publication (24)
Instruction method Theoretical Pre-clinical Assisting others – implant surgery Assisting others – implant prosthetics Clinical (own patients) Other1
2013 respondents (%)
2009 respondents (%)
41/44 (93) 34/44 (77) 32/44 (73)
43/43 (100) 28/43 (65) 22/43 (51)
29/44 (66)
19/43 (44)
23/44 (52) 8/44 (18)
12/43 (28) 8/43 (19)
1
Other reported instruction methods: (i) rare clinical experiences only in selected cases, (ii) hands-on courses with different systems, (iii) surgical procedure on jaws from animal cadavers, (iv) introduction to different systems by ‘industrial implant partners’, (v) inserting implants under supervision, (vi) clinical prosthetic treatment of own patients – prosthetic only and (vii) implantology workshops for all students.
Clinical experience in implant-supported prosthetic restorations within the undergraduate curriculum Thirty-three of 44 respondents (75% vs. 70% in 2009) reported that undergraduate students in their institution gathered clinical experience in prosthetic restorations of dental implants. This experience is acquired in 76% (25/33 vs. 57% in 2009) by assisting others, 73% (24/33 vs. 50% in 2009) by treating patients on an individual basis under guidance and 3% (1/33) reported that students only acquired experience in very selected cases. ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 43–51
Implant prosthetic restoration procedures undertaken by undergraduate students individually The implant prosthetic restoration procedures executed by undergraduate dental students are summarised in Table 3. Almost a quarter of the respondents (23% vs. 56% in 2009) and in 26% of the institutions, students are not allowed to perform any clinical procedure. Procedures that are allowed to be performed by students in the remaining institutions include most often straightforward cases in the non-aesthetic zone (molars and bicuspids), implant overdenture on two non-connected implants and a simple 2–4 unit free-standing fixed partial dentures. Compared to 2009, undergraduate curricula provide more opportunities for dental students to gather experience in implant prosthetic restorations. There is a general increase in prosthetic procedures performed by students and a decrease in the number of curricula not allowing any clinical procedures at all. Clinical experience in surgical implant procedures within the undergraduate curriculum According to 64% of the respondents (28/44 vs. 53% in 2009), students acquired clinical experience in surgical implant procedures in their institution. This includes 64% by assisting others (28/44 vs. 40% in 2009), 25% by treating patients individually under guidance (11/44 vs. 5% in 2009) and 7% by other approaches (3/44). Other approaches were reported as (i) videotape on demand in e-learning system, (ii) surgery using TABLE 3. Overview of implant prosthetic procedures performed by undergraduate dental students, compared to 2009
Respondents (%)
Corrected for institutions (%)
Procedure
2013
2009
2013
2009
No clinical procedure allowed Single-tooth bicuspid Single-tooth molar Implant overdenture in mandible on two non-connected implants Simple 2–4 unit free-standing fixed partial denture (bridge) Single-tooth aesthetic zone Implant overdenture with two implants and a bar No limits Other1 Full-arch bridge
10/44 (23)
24/43 (56)
10/38 (26)
16/32 (52)
20/44 (45) 18/44 (41) 16/44 (36)
14/43 (33) 12/43 (28) 10/43 (23)
18/38 (47) 16/38 (42) 14/38 (37)
10/32 (31) 8/32 (25) 8/32 (25)
13/44 (30)
7/43 (16)
11/38 (29)
6/32 (19)
8/44 (18)
7/43 (16)
8/38 (21)
5/32 (16)
8/44 (18)
4/43 (9)
8/38 (21)
4/32 (13)
3/44 (7) 1/44 (2) 0/44 (0)
2/43 (5) 1/43 (2) 0/43 (0)
3/38 (8) 1/38 (3) 0/38 (0)
2/32 (6) 1/32 (3) 0/32 (0)
1
Other procedure reported that the clinical instructor decides according to patient’s dental treatment needs.
45
Implant dentistry education in Europe
Koole et al.
animal cadavers and (iii) in very few selected cases. Overall, there is an increase in undergraduate students gathering experience in surgical implant procedures, compared to 2009.
TABLE 5. Barriers for including implant surgery in undergraduate education
Education of implant dentistry through optional courses
Barriers
2013
No barriers No interest Investment costs Limited funding Insufficient patient flow Limited patients’ demand (financial barrier) Limited staff/personnel Limited time in curriculum Government regulations Liability/insurance regulations Other1
15/44 3/44 15/44 11/44 10/44 12/44 17/44 9/44 7/44 3/44 7/44
Sixteen of 44 respondents (36% vs. 23% in 2009) indicated their institution offered optional courses about implant dentistry in the undergraduate curriculum. On average, 67% of the students participate in the elective courses, ranging from 10% to 100%. The offered courses are based on solely prosthetics (2/16), surgery (2/16), both prosthetics and surgery (10/16) and other (3/16). The latter included (i) basic informative course on dental implantology, including historical data, implant terminology and classification, materials, implant surfaces, osseointegration and bone to implant interface, patient assessment, planning of implant treatment, implant surgery and implant prosthetics, (ii) guided bone regeneration techniques on a training model in the pre-clinical part of the studies and (iii) periodontology. Barriers for including implant dentistry in the undergraduate dental curriculum Table 4 depicts the barriers, respondents’ encounter, to include implant prosthetics in the undergraduate dental curriculum in their institution. Sixteen respondents (36% vs. 72% in 2009) reported the presence of barriers. Costs related with the necessary infrastructure and limited availability for funding were the most mentioned. Table 5 summarises the barriers for including implant surgery in the dental curriculum. Twenty-eight respondents (65% vs. 88% in 2009) reported the presence of barriers in their institution. Most identified barriers included costs related with the necessary infrastructure and staff/personnel shortage.
TABLE 4. Barriers for including implant prosthetics in undergraduate education Respondents (%) Barriers
2013
No barriers No interest Investment costs Limited funding Insufficient patient flow Limited patients’ demand (financial barrier) Limited staff/personnel Limited time in curriculum Government regulations Liability/insurance regulations Other1
34/44 2/44 10/44 10/44 6/44 7/44 6/44 1/44 4/44 3/44 2/44
1
2009 (77) (5) (23) (23) (14) (16) (14) (2) (9) (7) (5)
12/43 2/43 17/43 14/43
(28) (5) (40) (33)
9/43 18/43 21/43 0/43 2/43 4/43
(21) (42) (49) (0) (5) (9)
Other barriers suggested the followings: Patients pay a considerable amount of money for implant-supported dental prostheses. If beginners should perform the treatment, a considerable reduction in treatment cost is necessary for the recruitment of willing patients.
46
Respondents (%) 2009 (34) (7) (34) (25) (23) (27) (39) (20) (16) (7) (16)
5/43 4/43 18/43 12/43
(12) (9) (42) (28)
10/43 22/43 23/43 0/43 9/43 7/43
(23) (51) (53) (0) (21) (16)
1
Other barriers included (i) Postgraduate programme is 3 years and 4400 h. That does not fit an undergraduate training programme, (ii) implant surgery should be performed by specialists, no time for training in undergraduate programme and (iii) inadequate surgical competence of undergraduates.
In general, less barriers were reported in both implant prosthetics and surgery, compared to 2009. More respondents indicated that there are no barriers and those that were reported decreased in frequency. Government regulations as a confounding factor are a notable exception.
Implant dentistry in postgraduate education In 67% of the questionnaires (35/52), respondents reported that their institution offered a postgraduate educational programme, leading to a higher degree or specialty, which includes implant dentistry procedures. Table 6 summarises the reported educational programmes. Oral and maxillofacial surgery Postgraduate programmes of oral and maxillofacial surgery have an average length of 3.6 years of study, ranging from 1 to 9 years. These programmes have on average 150 European credit transfer system (ECTS) credits, ranging from 64 to 180, and respondents reported on average 4.7 students (range 1–12) in the final year of study. Fourteen of 20 respondents (70%) acknowledged that oral and maxillofacial surgery is a recognised specialty in their country, and 75% of the respondents (15/ 20) reported that the postgraduate programme has an official university recognition. Periodontology Postgraduate programmes of periodontology have an average length of 2.8 years of study, ranging from 1 to 4 years. These programmes have on average 167 ECTS credits, ranging from 50 to 600. Respondents reported on average 6.0 students (range 1–24) in the final year of study. Sixteen of 24 respondents (67%) acknowledged that periodontology is a recognised specialty in their country, and 79% of the respondents (19/24) ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 43–51
Koole et al.
Implant dentistry education in Europe
TABLE 6. Overview of postgraduate educational programmes related to implant dentistry
Respondents (%)
Corrected for institutions (%)
Programme
2013
2009
2013
2009
No Programme Oral and maxillofacial surgery Periodontology Prosthodontics/ restorative dentistry Independent implant dentistry programme Implant dentistry included in other programmes1
17/52 (33) 20/52 (38)
5/49 (10) 28/49 (57)
16/46 (35) 17/46 (37)
5/35 (14) 18/35 (51)
24/52 (46) 20/52 (38)
36/49 (73) 27/49 (55)
21/46 (46) 19/46 (41)
23/35 (66) 19/35 (54)
11/52 (21)
19/49 (39)
11/46 (24)
14/35 (40)
5/52 (10)
4/49 (8)
5/46 (11)
4/35 (11)
that their institution offered CPD courses with a short duration (
Implant dentistry education in Europe: 5 years after the Association for Dental Education in Europe consensus report S. Koole1, S. Vandeweghe1,2, N. Mattheos3 and H. De Bruyn1,2 1 2 3
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 Faculty of Dentistry, Department of Prosthodontics, School of Dentistry, University of Hong Kong, Hong Kong, China
Keywords implant dentistry; dental curriculum; undergraduate education; postgraduate education. Correspondence Sebastiaan Koole Dental School Ghent University De Pintelaan 185, 1P8 Ghent 9000 Belgium Tel: +32 9 332 4017 Fax: +32 9 332 3851 e-mail: [email protected] Accepted: 22 November 2013 doi: 10.1111/eje.12084
Abstract Introduction: To promote consensus on implant dentistry university education in Europe, a workshop amongst university teachers and opinion leaders was organised in 2008. As a result, guidelines on both under- and postgraduate education were issued. This study aims to investigate the current status of university teaching of implant dentistry and the impact of the recommendations for teaching and assessment, 5 years after the first consensus. Finally, this report attempts to identify future directions in education within the discipline. Materials and methods: An online survey was distributed amongst 105 academic leaders in implant education in Europe, and 52 questionnaires were returned (response rate 50%). Results: The average amount of implant dentistry in undergraduate curricula has increased to 74 h, compared to 36 h in 2008, and the inclusion of pre-clinical and clinical education has increased. No change occurred with regard to the aimed competence levels. It was suggested that certain implant procedures including surgery should be provided by dentists after attending additional courses, whilst complex treatments will still require specialist training. The 2008 workshop guidelines have been implemented to a varying extent (25–100%) in under- and postgraduate education. Main reported implementation barriers included limited time availability in the curriculum and limited financial/material resources. Future discussions about implant dentistry in Europe should be focused towards integration in current dental curricula, approaches to overcome barriers and the relations with and role of industrial partners. Conclusion: Implant dentistry is increasingly integrating in undergraduate dental education. Development of the consensus guidelines in 2008 may have facilitated this process. Nevertheless, further progress is needed on all educational levels to align training of professionals to the growing treatment needs of the population.
Introduction Implant dentistry is a rapidly evolving area within oral health care. As procedures become more predictable and efficient, and cost–benefit ratios improve, implant therapy reaches a growing part of the population as an important treatment alternative in reconstructive dentistry (1–3). The major indications for implant placement include restoration of oral function and ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 43–51
chewing comfort, preservation of dental elements and reconstructions and the replacement of missing teeth (4). The initial provision of implant dentistry was limited to specialised professionals, but today, straightforward implant procedures have become more and more mainstream and, consequently, are increasingly performed by non-specialists (5). To keep up with this development, universities face the challenge to develop and implement implant dentistry education at 43
Implant dentistry education in Europe
all levels (under-, postgraduate and continuing professional development) to prepare dental professionals with sufficient competences to fulfil the patient demands and treatment needs of today. At an undergraduate level, dentists have to be prepared to include oral implants in the treatment planning of their patients and also to maintain patients with implants. This implies competence with the indications and limitations of implant therapy, related pathology, maintenance and treatment of straightforward cases (1, 6). Postgraduate education has to prepare graduates to perform highly specialised implant treatment, often for compromised cases. Regarding continuing professional development and lifelong learning, both clinicians and specialists need to constantly update their knowledge and skills to provide the best possible state-of-the-art dental care for their patients. To promote a consensus on guidelines for teaching and assessment of implant dentistry in Europe, the Association for Dental Education in Europe (ADEE) organised a first workshop on implant dentistry university education in 2008. Academic leaders agreed on the recommendation that implant dentistry should be taught in undergraduate education (1). It should include the fundamental principles of implant therapy, enabling graduates to integrate implant treatment into an overall concept of comprehensive care, to identify indications and contraindications and to inform patients about the treatment options (7). The educational approach used should be in line with modern insights about curriculum development, for example, competence-based education, student-centred, evidence-based, interdisciplinary, case-based and/or problembased learning (5). Postgraduate competences were identified in four domains: (i) clinical, (ii) management and leadership, (iii) communication and (iv) professionalism and ethics, at different levels of clinical practice (straightforward, advanced and complex) according to the need of general practitioners to specialists (8). These guidelines are one of many educational initiatives, reflecting the focus on implant dentistry worldwide, including guidelines and consensus reports (6, 9, 10), surveys (11–14), reviews (15, 16) and reports about curriculum development (17–19) and innovative approaches to education (20–23). In preparation of the first ADEE workshop on implant dentistry education in 2008, a survey study was executed to identify the status of implant dentistry university education in Europe (24). Five years later, in preparation for the second consensus workshop, a similar questionnaire was distributed. The aim was to describe the present status of implant dentistry education in Europe, to monitor any trends since the first workshop and to draft suggestions for future directions. The study performed was structured by four research questions (RQ): RQ1. What is the current environment of implant dentistry in under- and postgraduate education in Europe? RQ2. Which changes have occurred since the first workshop on implant dentistry education in Europe? RQ3. Which were the common strategies used to implement implant dentistry in undergraduate and postgraduate education? RQ4. What are the future directions of implant dentistry education in Europe? 44
Koole et al.
Materials and methods The questionnaire was sent to the 73 participants of the first ADEE consensus workshop. Additionally, 32 other leading academics involved in implant dentistry in European universities were selected to participate, based on their presence and influence in implant dentistry education since the first workshop. In total, 105 participants were invited to fill in an online questionnaire. After one reminder, 52 questionnaires were completed and returned, resulting in a 50% response rate. This questionnaire contained identical items from the first European survey on implant education (24) for comparison purposes, which were supplemented with additional questions to comply with the research questions in this study. The content of the questionnaire was pre-tested for face validity in a panel of experts within the field of implant dentistry education and encompassed 22 questions grouped into four categories: ‘Implant dentistry in undergraduate education’, ‘Implant dentistry in postgraduate education’, ‘Necessary competences in implant dentistry’ and ‘Impact of the 2008 consensus on teaching and assessment of implant dentistry in Europe’. Data were analysed using descriptive statistics and all analyses were performed utilising SPSS 20.0 (SPSS Inc., Chicago, IL, USA). All percentages of respondents are presented in round off figures. For comparison reasons, some results are depicted in relation to the findings reported in the 2009 publication on implant dentistry education in Europe (24).
Results Results are based on the completed questionnaires by respondents from 20 European countries. Table 1 illustrates the number of respondents per country and institution that answered the 22 questions in the survey. Some respondents were from the same country, but from different institutions, or had different fields of expertise.
Implant dentistry in undergraduate education Forty-four of 52 respondents (85%) reported that their affiliated institution has an undergraduate dental curriculum. The average number of students in the final year is 69, ranging from 7 to 200 students. Almost all respondents (98% – 43/44) indicated that some form of implant dentistry is taught to their undergraduate students. In 34% (15/44), this is a separate course, and in other cases, implant dentistry is being taught as part of another discipline. Reported disciplines are multidisciplinary courses based on oral and maxillofacial surgery, prosthetic dentistry, periodontology, restorative dentistry and orthodontics; material science and integral care. Respondents reported an average total time of 74 h in the undergraduate curriculum, spent on implant dentistry related topics, ranging from 4 to 288 h, compared to 36 h (3–120 h) in 2009. Table 2 displays the reported instructional methods that are used for implant dentistry in undergraduate education. Notable differences from the results of 2009 include a higher number of reported spent hours on implant-related education and the use of more pre-clinically and clinically orientated instructional methods. ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 43–51
Koole et al.
Implant dentistry education in Europe
TABLE 1. Number of respondents per country and institution Country
Respondents
Institutions
Belgium Bulgaria Denmark Egypt Estonia Germany Hungary Iceland Israel Italy Lebanon The Netherlands Portugal Republic of Ireland Romania Spain Sweden Switzerland Turkey United Kingdom Total
3 1 1 1 1 8 2 1 1 5 1 3 2 1 1 6 4 2 1 7 52
2 1 1 1 1 7 2 1 1 5 1 3 2 1 1 5 2 2 1 6 46
TABLE 2. Instruction methods for implant dentistry in undergraduate education, number of respondents (%) compared to the results of the 2009 publication (24)
Instruction method Theoretical Pre-clinical Assisting others – implant surgery Assisting others – implant prosthetics Clinical (own patients) Other1
2013 respondents (%)
2009 respondents (%)
41/44 (93) 34/44 (77) 32/44 (73)
43/43 (100) 28/43 (65) 22/43 (51)
29/44 (66)
19/43 (44)
23/44 (52) 8/44 (18)
12/43 (28) 8/43 (19)
1
Other reported instruction methods: (i) rare clinical experiences only in selected cases, (ii) hands-on courses with different systems, (iii) surgical procedure on jaws from animal cadavers, (iv) introduction to different systems by ‘industrial implant partners’, (v) inserting implants under supervision, (vi) clinical prosthetic treatment of own patients – prosthetic only and (vii) implantology workshops for all students.
Clinical experience in implant-supported prosthetic restorations within the undergraduate curriculum Thirty-three of 44 respondents (75% vs. 70% in 2009) reported that undergraduate students in their institution gathered clinical experience in prosthetic restorations of dental implants. This experience is acquired in 76% (25/33 vs. 57% in 2009) by assisting others, 73% (24/33 vs. 50% in 2009) by treating patients on an individual basis under guidance and 3% (1/33) reported that students only acquired experience in very selected cases. ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 43–51
Implant prosthetic restoration procedures undertaken by undergraduate students individually The implant prosthetic restoration procedures executed by undergraduate dental students are summarised in Table 3. Almost a quarter of the respondents (23% vs. 56% in 2009) and in 26% of the institutions, students are not allowed to perform any clinical procedure. Procedures that are allowed to be performed by students in the remaining institutions include most often straightforward cases in the non-aesthetic zone (molars and bicuspids), implant overdenture on two non-connected implants and a simple 2–4 unit free-standing fixed partial dentures. Compared to 2009, undergraduate curricula provide more opportunities for dental students to gather experience in implant prosthetic restorations. There is a general increase in prosthetic procedures performed by students and a decrease in the number of curricula not allowing any clinical procedures at all. Clinical experience in surgical implant procedures within the undergraduate curriculum According to 64% of the respondents (28/44 vs. 53% in 2009), students acquired clinical experience in surgical implant procedures in their institution. This includes 64% by assisting others (28/44 vs. 40% in 2009), 25% by treating patients individually under guidance (11/44 vs. 5% in 2009) and 7% by other approaches (3/44). Other approaches were reported as (i) videotape on demand in e-learning system, (ii) surgery using TABLE 3. Overview of implant prosthetic procedures performed by undergraduate dental students, compared to 2009
Respondents (%)
Corrected for institutions (%)
Procedure
2013
2009
2013
2009
No clinical procedure allowed Single-tooth bicuspid Single-tooth molar Implant overdenture in mandible on two non-connected implants Simple 2–4 unit free-standing fixed partial denture (bridge) Single-tooth aesthetic zone Implant overdenture with two implants and a bar No limits Other1 Full-arch bridge
10/44 (23)
24/43 (56)
10/38 (26)
16/32 (52)
20/44 (45) 18/44 (41) 16/44 (36)
14/43 (33) 12/43 (28) 10/43 (23)
18/38 (47) 16/38 (42) 14/38 (37)
10/32 (31) 8/32 (25) 8/32 (25)
13/44 (30)
7/43 (16)
11/38 (29)
6/32 (19)
8/44 (18)
7/43 (16)
8/38 (21)
5/32 (16)
8/44 (18)
4/43 (9)
8/38 (21)
4/32 (13)
3/44 (7) 1/44 (2) 0/44 (0)
2/43 (5) 1/43 (2) 0/43 (0)
3/38 (8) 1/38 (3) 0/38 (0)
2/32 (6) 1/32 (3) 0/32 (0)
1
Other procedure reported that the clinical instructor decides according to patient’s dental treatment needs.
45
Implant dentistry education in Europe
Koole et al.
animal cadavers and (iii) in very few selected cases. Overall, there is an increase in undergraduate students gathering experience in surgical implant procedures, compared to 2009.
TABLE 5. Barriers for including implant surgery in undergraduate education
Education of implant dentistry through optional courses
Barriers
2013
No barriers No interest Investment costs Limited funding Insufficient patient flow Limited patients’ demand (financial barrier) Limited staff/personnel Limited time in curriculum Government regulations Liability/insurance regulations Other1
15/44 3/44 15/44 11/44 10/44 12/44 17/44 9/44 7/44 3/44 7/44
Sixteen of 44 respondents (36% vs. 23% in 2009) indicated their institution offered optional courses about implant dentistry in the undergraduate curriculum. On average, 67% of the students participate in the elective courses, ranging from 10% to 100%. The offered courses are based on solely prosthetics (2/16), surgery (2/16), both prosthetics and surgery (10/16) and other (3/16). The latter included (i) basic informative course on dental implantology, including historical data, implant terminology and classification, materials, implant surfaces, osseointegration and bone to implant interface, patient assessment, planning of implant treatment, implant surgery and implant prosthetics, (ii) guided bone regeneration techniques on a training model in the pre-clinical part of the studies and (iii) periodontology. Barriers for including implant dentistry in the undergraduate dental curriculum Table 4 depicts the barriers, respondents’ encounter, to include implant prosthetics in the undergraduate dental curriculum in their institution. Sixteen respondents (36% vs. 72% in 2009) reported the presence of barriers. Costs related with the necessary infrastructure and limited availability for funding were the most mentioned. Table 5 summarises the barriers for including implant surgery in the dental curriculum. Twenty-eight respondents (65% vs. 88% in 2009) reported the presence of barriers in their institution. Most identified barriers included costs related with the necessary infrastructure and staff/personnel shortage.
TABLE 4. Barriers for including implant prosthetics in undergraduate education Respondents (%) Barriers
2013
No barriers No interest Investment costs Limited funding Insufficient patient flow Limited patients’ demand (financial barrier) Limited staff/personnel Limited time in curriculum Government regulations Liability/insurance regulations Other1
34/44 2/44 10/44 10/44 6/44 7/44 6/44 1/44 4/44 3/44 2/44
1
2009 (77) (5) (23) (23) (14) (16) (14) (2) (9) (7) (5)
12/43 2/43 17/43 14/43
(28) (5) (40) (33)
9/43 18/43 21/43 0/43 2/43 4/43
(21) (42) (49) (0) (5) (9)
Other barriers suggested the followings: Patients pay a considerable amount of money for implant-supported dental prostheses. If beginners should perform the treatment, a considerable reduction in treatment cost is necessary for the recruitment of willing patients.
46
Respondents (%) 2009 (34) (7) (34) (25) (23) (27) (39) (20) (16) (7) (16)
5/43 4/43 18/43 12/43
(12) (9) (42) (28)
10/43 22/43 23/43 0/43 9/43 7/43
(23) (51) (53) (0) (21) (16)
1
Other barriers included (i) Postgraduate programme is 3 years and 4400 h. That does not fit an undergraduate training programme, (ii) implant surgery should be performed by specialists, no time for training in undergraduate programme and (iii) inadequate surgical competence of undergraduates.
In general, less barriers were reported in both implant prosthetics and surgery, compared to 2009. More respondents indicated that there are no barriers and those that were reported decreased in frequency. Government regulations as a confounding factor are a notable exception.
Implant dentistry in postgraduate education In 67% of the questionnaires (35/52), respondents reported that their institution offered a postgraduate educational programme, leading to a higher degree or specialty, which includes implant dentistry procedures. Table 6 summarises the reported educational programmes. Oral and maxillofacial surgery Postgraduate programmes of oral and maxillofacial surgery have an average length of 3.6 years of study, ranging from 1 to 9 years. These programmes have on average 150 European credit transfer system (ECTS) credits, ranging from 64 to 180, and respondents reported on average 4.7 students (range 1–12) in the final year of study. Fourteen of 20 respondents (70%) acknowledged that oral and maxillofacial surgery is a recognised specialty in their country, and 75% of the respondents (15/ 20) reported that the postgraduate programme has an official university recognition. Periodontology Postgraduate programmes of periodontology have an average length of 2.8 years of study, ranging from 1 to 4 years. These programmes have on average 167 ECTS credits, ranging from 50 to 600. Respondents reported on average 6.0 students (range 1–24) in the final year of study. Sixteen of 24 respondents (67%) acknowledged that periodontology is a recognised specialty in their country, and 79% of the respondents (19/24) ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 43–51
Koole et al.
Implant dentistry education in Europe
TABLE 6. Overview of postgraduate educational programmes related to implant dentistry
Respondents (%)
Corrected for institutions (%)
Programme
2013
2009
2013
2009
No Programme Oral and maxillofacial surgery Periodontology Prosthodontics/ restorative dentistry Independent implant dentistry programme Implant dentistry included in other programmes1
17/52 (33) 20/52 (38)
5/49 (10) 28/49 (57)
16/46 (35) 17/46 (37)
5/35 (14) 18/35 (51)
24/52 (46) 20/52 (38)
36/49 (73) 27/49 (55)
21/46 (46) 19/46 (41)
23/35 (66) 19/35 (54)
11/52 (21)
19/49 (39)
11/46 (24)
14/35 (40)
5/52 (10)
4/49 (8)
5/46 (11)
4/35 (11)
that their institution offered CPD courses with a short duration (
