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The significance of complete denture prosthetics in the dental school curriculum today, and in 1976
Miscetlcmeous
The si@ficunce the dental Alvin College
1. Morris,
of co
schooi
cusrictclum
dentwe
p
today,
and
its in in 1976
D.D.S., Ph.D.*
of Dentistry,
University
of Kentucky,
Lexington,
Ky.
1 t is appropriate and essential that all in dentistry prepare for the challenges of the exciting days ahead by focusing attention on the future. Congratulations are due those who planned this section of the Scientific Session for their foresight and their recognition of the timeliness of the theme for this forum. Because of my enthusiasm for the subject being discussed, I wish to express my appreciation for the privilege of being included as an essayist. I feel especially honored since my assignment could well have been given to a nuiuber of well-known dental school administrators who have prosthodontics as their clinical background. Since the primary aim of the dental school curriculum is the preparation of the decision of what to teach is directly related to students for future practice, I am going to speak the question of what will constitute practice. Consequently, briefly on the future of prosthetics as I see it. This will be followed by a review of the curriculum today and in 1976. Attention will then be directed to the various conflicts with which it seems we are inevitably destined to be confronted.
COMPLETE DENTURE PROSTHETICS IN FUTURE PRACTICE This is an intriguing time to be viewing the future of prosthetics, in that there appear to be opposing forces in operation. One force should result in a relative decrease and one in a relative increase in the amount of prosthetic services which dentists will be asked to provide. The most important factors which will affect the eventual outcome will be time, and the result of federal legislation related to health care. L4t the opening ceremonies of the Seattle World’s Fair in April, 1962, a “time capsule” was buried at the foot of the Space Needle, beneath a stone tablet, requesting that the capsule be opened on April 21. 2000 A.D.~ A citizen’s committee had been charged with the responsibility of selecting for the capsule articles which they Presented at the Scientific Session of the annual tion, Dallas. Texas, November. 1966. *Dean.
80
meeting of the American
Dental
Asswia-
Prosthetics
and the dental
school curriculum
81
believed would be extinct by the 21st century. Among the articles buried and judged to be extinct 38 years later are included a typewriter, a telephone book, an umbrella, and a set of dentures. Though one might disagree with the judgement of Seattle’s Citizens’ Committee, I firmly believe that complete denture prosthetic service 50 years from today will constitute a small proportion of dental practice. This change will reflect the preventive measures already available, and those yet to be developed. Today, dental caries essentially can be controlled through the multiple use of fluoride as a preventive agent. The greatest difficulty yet to be overcome is the development of better methods for bringing the full benefits of prevention to more people. Earlier and more complete treatment of the carious lesions which do develop in our younger population can be expected. Preventive or interceptive orthodontic care will be an important part of general practice. Dentists will be spending increasing proportions of their time preventing and controlling periodontal disease. Reaching old age with the benefits of natural teeth will become the reasonable expectation of most Americans. TODAY
AND
1976
In contrast to what was stated above concerning the more distant future, it is my belief that in the next decade an increased emphasis on complete dentures in practice can be anticipated. It is staggering to realize that half of the American citizens over 50 years of age are without natural teeth and that, on an average, 20 dentures must be provided for every 100 young men inducted into military service today. That the need for complete denture prosthetic services currently exists cannot be denied. That the demand for such services is going to increase drastically is, in my opinion, an inevitability. Permit me to support this latter conclusion by reviewing pertinent federal legislation and the trends which have been demonstrated. When Public Law 89-97, the Social Security Amendments of 1965, was passed, the greatest attention was given to Title XVIII, popularly known as Medicare. Of perhaps equal importance, however, is Title XIX, known as Medicaid, which has major ramifications for health services. Medicare is essentially a federally-administered insurance program providing for total compulsory contributions with benefits as entitlement for all people 65 and over. Title XIX is a medical assistance program for people of any age on a basis of need, and is administered by the state in cooperation with the federal government, which contributes financial support on a matching basis. At the present time, Medicare does not include dentistry, except some oral surdoes provide for dental care? including some prosthetic gery ; while Medicaid services. That the involvement of complete denture prosthetic services in these two programs is destined to increase markedly seems almost certain. One can anticipate that both the age group covered and services rendered under Title XVIII will increase, as the definition of the needy under Title XIX increases. The only question is which will first have the greatest impact on dentistry. The year 1972 has been set as the target date for states to provide total care for all eligible persons under Medicare, and there are many who expect this care to include complete
82
Morris
denture services. Eligibility for Medicaid has now been increased to include the indigent and the medical needy of all ages who are dependent to some degree because of advanced age, disability or blindness, or because of a particularly heavy economic burden caused by an episode of illness. The state of New York has now so defined medical indigency under Title XIX that 40 per cent of its population are eligible for benefits. Twenty-one million dollars have been given to the California Dental Service Corporation to provide complete dental care for the medically indigent of that state. Some may say that merely providing financial support will have little effect on the rate at which the public demands complete denture services. Recent events in Kentucky have demonstrated the fallacy of such thinking. When the U.S. Public Health Service opened a new patient care facility in the city of Louisville, 28,000 indigent people of all ages were eligible for treatment. According to the Director of the project, 75 per cent of all patients coming to that clinic during the first few months of operation requested complete denture service. It is my opinion that one of the most important challenges facing dentistry in the immediate future will be that of providing complete dentures at the rate demanded by the public. Even in the “Great Society,” limitation of financial resources of the federal government may slow the rate at which our edentulous citizens are offered dental treatment. The pressure for such treatment may, therefore? not peak as early as 1976, but it will be in evidence. In summarizing my comments on the future, two forces are recognized. C>ne will markedly increase the relative demand for complete denture services and will undoubtedly dominate the immediate future. The other force will result in a very significant decrease in the demand for such service that will be conspicuously evident
hy 2000
A.1).
PROSTHETl,CS IN THE DENTAL
CURRJCULUM
TODAY
It is my opinion that the emphasis on complete denture prosthetics in the dental curriculum today reflects the past. Currently, there is a recognized ferment in dental education, and almost all in the profession agree that curriculum alterations are in order. The faculty of many schools can now articulate what the characteristics of a new program in dental education should be, but rarely have the curriculum changes necessary to implement new programs being accomplished. The result is that, in general, our curricula are outdated. The point that prosthetics in the present curriculum reflects the past rather than the future is supported by a review of what has occurred since The Red Book on dental curriculum was published in 1935.’ It was originally recommended in The Red Book that 23.3 per cent of the curriculum should be devoted to prosthetics. (It should be noted that the figures cited refer to both complete and partial denture prosthetics.) A survey in 1941 revealed that, at that point in history, prosthetics accounted for an average of 25.9 per cent of the curriculum in schools throughout the countrys3 The Survey of Dentistry* revealed that in 1958, the time devoted to prosthetics in the nation’s schools averaged 26.1 per cent. Based upon the nature of dental practice in 1934, perhaps The Red Book’s recommendation was logical. The logic of 26.1 per cent in 1958 must be questioned, however, since the Survey revealed
Volume 19 Number 1
Prosthetics
and the dental
.school curriculum
83
that only 13 per cent of general dental practice was devoted to prosthetics at that time.+ In an effort to ascertain the status of today’s curricula, the 1966 bulletins of 12 dental schools were examined. Four schools each from the east, mid-west, and west were selected. Information obtained from bulletins may be misleading, and is not presented in such a way to make detailed analysis possible. This informal review, however, failed to indicate that any significant change in the relative role of prosthetics in the average curriculum has occurred since 1958. A review of current dental school bulletins also suggested that few changes have been introduced in the manner in which complete denture prosthetics is organized within the curriculum. In most instances, it is presented as a separate technique course offered in the second, or perhaps the first year. This is followed by additional independent courses in the third and fourth years which usually include both lectures and clinical work. Clinical teaching of prosthetics frequently occurs in a separate facility, which serves to further emphasize the independent nature of this clement of patient care. It is suggested that this approach to teaching complete denture prosthetics is essentially the pattern by which the subject has been taught for many years. It is my conclusion, therefore, that the emphasis on complete denture prosthetics in the curriculum today reflects little change over the past 30 years. In general, a rather large segment of the total curriculum is devoted to this subject. Further, there appears to be little change in the approach to teaching in that the related subject matter is usually taught as an independent body of knowledge, with little emphasis on correlation with other clinical sciences. PROSTHETICS
IN THE DENTAL
CURRICULUM-l
976
,4s curriculum revision continues in our dental schools, complete denture prosthetics is destined to receive a great deal of attention. It is my opinion that the attitude will prevail in most schools that the curriculum time committed to this subject is greater than it should be, and that the present time allottment is not appropriate for today or the future. In the process of up-dating our eduactional programs, the relative emphasis on complete denture prosthetics as expressed in curriculum hours must be decreased. This is understandably a difficult fact for all to accept. What must be emphasized is that this predicted decrease will not reflect a decrease in the importance of complete denture prosthetics. It will merely reflect the inevitable tides of change as they affect the emphasis of dental education and dental practice. SHIFTS IN EMPHASIS Changes in emphasis within the dental curriculum are delicate matters to discuss, but are of such vital importance that they must be squarely faced. New information is continually evolving in our changing profession. Certain fields of dentistry or areas of practice are receiving greater attention, and certain others less. It is a difficult task for a faculty to decide which new material is vital and important to an educational program tuned to the future. It seems inevitable, however, that if only four years are to be devoted to the predoctoral program in dentistry, then as new material is added to the curriculum, something must be eliminated.
84
Morris
One of the characteristics of a dynamic society is that its frontiers arc always chang-ing. The frontiers of today become the familiar territory of tomorrow. The frontiers of dentistry and dental education are changing. Some aspects of the field which were so much at the forefront at one point in history are no longer there. Admittedly, this is difficult to accept, particularly if a great part of one’s life has been devoted to one of the fields no longer in the forefront. Hut realism is essential to progress. An example of what we are discussing can be taken from the basic science areas of anatomy and biochemistry. There was a time in the professional schools when anatomy was tlw basic science. Anatomists were the most renowned of all people in the scientific community. Currently it seems the biochemists are riding at the top of the heap. There has been a change, and further change can bc anticipated. A similar example can be cited in the clinical fields. It is rccognizcd that WC are experiencing a changing emphasis from the replacement to the preservation of the dentition. A shift has been occurring in which periodontics is receiving more emphasis. This shift does not imply that prosthetics is unimportant, nor does it imply that it should not be taught well. It does it imply that the graduates in the 1970’s need not he prepared to offer good complete denture prosthetic service to their patients. lt does not mean that the talents possessed by the prosthodontist arc unimportant or unappreciated. It must be recognized that judgments of differences in talents arc not judgments of differences in human worth. The frontiers of 0111. dynamic profession are changing, and it is essential that those who plan the dental curriculum accommodate these changes. Another point which deserves attention when discussing reaction to ~1 dccreased relative emphasis on prosthetics is the fact that a decrease in curriculum hours does not automatically imply a decrease in quality of instruction. A IWM’ and shorter course, developed after a critical review of what and how material is being presented, will frequently permit one to realize his teaching objectives equally well or better than before. Such has been our experience at the University of Kentucky in sc\cral fields. The full potential for educational television to improve the cfficicncy and effectiveness of our teaching has yet to he realized. The same nray bc said regarding computer science, programmed instruction, packaged 8 mm. rllovics. individual slide sets, and other self-study media. I predict that. in 1976, our teachingprograms will place less emphasis on the lecture, and more on newer pedagogical techniques. RELATIVE
EMPHAStS
A decade from now the teaching of complete denture prosthetics will be more closely related to other courses in the curriculum. The prosthodontist and portions of his rnaterial will be included in conjoint efforts, such as a comprehensive course in occlusion. Cooperative teaching in dental materials will be common. Better integration of prosthetics with other programs of the school will he encouraged by the fact that fewer schools will have physically separate prosthetic clinics. As in other clinical disciplines, prosthetic techniques will be taught in the clinical setting rather
Volume 19 Number 1
Prosthetics and the dental school curriculum
85
than the laboratory, in order that the transfer of technical skills to the care of patients may be facilitated.” There will be a significant decrease in the emphasis and time devoted to the purely technical aspects of complete denture fabrication. Less time will be spent teaching laboratory skills to the student. Technicians within the school will do the laboratory work related to patient care. A trend toward this latter approach is already evident in several schools. This decreased emphasis on laboratory procedures will save many curriculum hours, and at the same time, prepare the student to utilize the technician more effectively, as he must in practice. Many dental schools may have Technician Utilization Programs similar to the Dental Assistant Utilization programs which exist in most schools today. Emphasized in these programs will be the role of the technician in the private group practice setting, in which the student of today is destined to practice. SIMPLIFICATION
AND
STANDARDIZATION
Another curriculum change which is predicted for 1976 will be a tendency toward simplification and standardization of the techniques used in providing complete denture service. The “Battle of the Articulators” will be de-emphasized, and more effort will be devoted to work simplification and prosthetic practice efficiency. A new emphasis in the curriculum of the future will provide demonstration for the potential contribution of complete denture prosthetics in preventive dentistry and preventive medicine. The early diagnosis of oral cancer in the denture patient will be stressed. As the future dentist becomes one of the chief agents for referral to the physician, oral medicine, as it relates to edentulous patients, will receive increased attention. In addition, the importance of liaison between the prosthodontist and the behavioral scientist will be more fully appreciated, as the psychic problems of the edentulous patient are more clearly related to his oral problems. I predict that, in 1976, complete denture prosthetics will be taught in a shorter time, utilizing newer teaching methods to present material which will be significantly different. In many ways, material related to prosthetics will be correlated with other courses in the curriculum. RESPONDING
TO CONFLICTS
As one considers the material which has been presented thus far, several statements or concepts can be identified which appear to be in conflict. It is possible that these conflicts merely reflect my personal confusion, but I suggest that they represent honest dilemmas which we must be prepared to face. An effort will be made to respond to some of these conflicts with the hope that they can be viewed with more understanding. What about the conflict inherent in the view that less curriculum time should be devoted to complete denture prosthetics during a period in which it is predicted a greater demand for prosthetic services will exist ? Is not a greater demand for such service justification for more rather than less curriculum time? The answer to this latter question would be “yes,” were it not for the fact that prosthetic dentistry does not stand alone in the complex arena of academic dentistry. Many social, political, scientific, and professional forces are at work which are having a profound impact
J. Pros. Dent. Jmwy,
1%8
on many fields. President Johnson announced in Texas, last April, that he had instructed Secretary Gardner to develop recommendations for a dental care pro,gram for the children of the nation. At the 1966 annual session of the American Dental Association, our profession will take action on a proposed National Dental Health Program for Children. Both of these events are destined to place significantly-increased emphasis on preventive dentistry, pedodontics, and orthodontics. The current trend to ,give increased attention to p(ariodontics was alluded to earlier. The curricula of many schools aheady inclrlde a serious commitment to community or social dentistry. With the reminder that one cannot equate quantity of curriculum time with quality of teaching, I am convinced those who teach prosthodontics in the futurtb can and will meet their responsibilities to their students effectively. The solution IO the increased demand for prosthodontic stxrvices must be met through improved methods for their delivery. It is possible that when such improvements are developed, which I feel must occur, their ultimate impact may be a reduction of pressure for curriculum time. It was stated that a great emphasis on the role of the dental laboratory technician in the teaching and practice of complete denture prosthodontics is indicated. Some will feel that this concept is in conflict with the recommendation that less time be spent in teaching the student techniques related to the construction of dentures. It is frequently stated that a dentist cannot properly suljervix his technician unless he is trained and skilled in technical procedures. In support of this view, the students in many schools are required to do their own laboratory work. It is implied that such experience will qualify the student throughout his professional career to serve as a consultant to the technician on how to wax dentures. or pack and polish acrylic resin. Such an argurnent has always betan difficult for me to understand. 7’herc is every reason to expect and hopca that the technician will be more proficient than the dentist in carrying out routine laboratory procedures. Whether the dentist constructed one or ten dentures as a student will not changt, this fact. The student can be taught how to rearrange anterior teeth in order to improve esthetics, and posterior teeth in order to acquire a better-balanced occlusion, without spending many curricular and extracurricular hours setting up teeth.?‘hc dentist who knows what the proper design of the lower impression tray should be will have no difficulty in communicating his requirements to the technician. Whether or not he can construct such a tray as quickly as a technician is immaterial. It is c3sential only that the student be taught to recognize and drmand an acceptable piece of technical work. It is my opinion that this aim or educational Koal can be achirveci without requiring the student to carry out repeated ttxchnical cscrcises. There are those who justify large expenditures of curriculum time in teaching laboratory procedures on the basis that some day the dentist may wish to do his own laboratory work. Although such procedure is rarely necessary and should be discouraged: the dentist could become proficient in the necessary techniques with little effort. This is certainly true in thta case of the recent graduate. Others would probably require a similar arnount of cfrort. regardless of how much experience they had as students. Currently. we are in a discoura+lg cara of poor relationships between the dental
“N;r:r‘;”
Prosthetics
and the dental
school curriculum
87
llrofession and the dental laboratory industry. This is highlighted by various actions taken by the National Association of Certified Dental Laboratories. It is my opinion that the ultimate and best solution to this chronic and vexing problem will be achieved when all aspects of dentist-technician relationships are approached in a candid and realistic manner in the dental school curriculum. To provide the student with an unrealistic view regarding either his own or his laboratory technician’s role will merely perpetuate the present status. STANDARDIZED
APPROACH
An additional conflict which deserves attention is contained in the statement that a less complex and more standardized approach to denture construction is predicted during a period when the scientific basis of dental practice is being espoused. The prediction is based upon the previously described expectation that we are destined to experience a mounting demand for more complete denture service. Iluring a time when the profession is exerting great efforts to demonstrate that it can meet its responsibilities to the edentulous public, the use of complex procedures requiring extra patient appointments will be placed under critical scrutiny. Unless it can be proved through careful clinical research that such procedures result in a superior level of patient care, they will be abandoned. It is expected that an increased number of clinical investigations will be conducted by the nation’s prosthodontists as they seek the techniques, based o’n sound biological principles, which will provide the best level of patient care through the most efficient approach possible. It is predicted that national conferences will be convened for the purpose of discussing the best approach for providing a greater volume of complete denture service. The ccpts held dear by some of our most distinguished clinicians being discarded, unless result will be a trend toward a more standard technique, with the conflicting contheir validity can be established through clinical research. In conclusion, I wish to state that my comments have been intended to be provocative but not negative. The role of the prosthodontists in our profession and our dental schools will continue to be an exrtemely important one. They will be looked to for critical leadership as we meet the challenges which lie ahead. Increasing sophistication will be demanded of prosthodontists in the area of maxillofacial prosthetics, as they seek to provide care for the increasing number of patients who are suffering from cancer, congenital defects, and facial trauma. The attention of this forum has been focused upon one field within our profession. As we view the future, our orientation should be a broad one with each field considered in its relationship to the profession at large. For, to paraphrase a portion of the 12th Chapter of 1st Corinthians, the profession does not consist of one member but of many. We should be so adjusted that there may be no discord in the profession: but that the members may have the same cares for one another. If one member suffers, all suffer together; if one member is honored, all rejoice together. References 1. Master plan for the School of Dentistry-1966-1980, Report of the Committee on Goals and Objectives, School of Dentistry, University of Southern California, 1966. (Mimeo.) 2. American Association of Dental Schools: A Course of Study in Dentistry: Report of the Curriculum Survey Committee, Chicago, 1935, American Association of Dental Schools.
88
Morris
J. Pros.
Dent.
January, 1968
3. Horner, H. H.: Dental Education Today, Chicago, 1947, University of Chicago Press. 4. American Council on Education: The Survey of Dentistry; The Final Report, Washington, D. C., 1960. 5. Hickey, ,J. C.: Combined Course in Technical and Clinical Complete Dentures Prosthodontics, J. Dent. Ed. 29: 155-161, 1965. MEIXCAL CEXTER COLLEGE OF DENTISTRY UNIVERSITY OF KENT~~CKY LEXINGTON, KY. 40506
The si@ficunce the dental Alvin College
1. Morris,
of co
schooi
cusrictclum
dentwe
p
today,
and
its in in 1976
D.D.S., Ph.D.*
of Dentistry,
University
of Kentucky,
Lexington,
Ky.
1 t is appropriate and essential that all in dentistry prepare for the challenges of the exciting days ahead by focusing attention on the future. Congratulations are due those who planned this section of the Scientific Session for their foresight and their recognition of the timeliness of the theme for this forum. Because of my enthusiasm for the subject being discussed, I wish to express my appreciation for the privilege of being included as an essayist. I feel especially honored since my assignment could well have been given to a nuiuber of well-known dental school administrators who have prosthodontics as their clinical background. Since the primary aim of the dental school curriculum is the preparation of the decision of what to teach is directly related to students for future practice, I am going to speak the question of what will constitute practice. Consequently, briefly on the future of prosthetics as I see it. This will be followed by a review of the curriculum today and in 1976. Attention will then be directed to the various conflicts with which it seems we are inevitably destined to be confronted.
COMPLETE DENTURE PROSTHETICS IN FUTURE PRACTICE This is an intriguing time to be viewing the future of prosthetics, in that there appear to be opposing forces in operation. One force should result in a relative decrease and one in a relative increase in the amount of prosthetic services which dentists will be asked to provide. The most important factors which will affect the eventual outcome will be time, and the result of federal legislation related to health care. L4t the opening ceremonies of the Seattle World’s Fair in April, 1962, a “time capsule” was buried at the foot of the Space Needle, beneath a stone tablet, requesting that the capsule be opened on April 21. 2000 A.D.~ A citizen’s committee had been charged with the responsibility of selecting for the capsule articles which they Presented at the Scientific Session of the annual tion, Dallas. Texas, November. 1966. *Dean.
80
meeting of the American
Dental
Asswia-
Prosthetics
and the dental
school curriculum
81
believed would be extinct by the 21st century. Among the articles buried and judged to be extinct 38 years later are included a typewriter, a telephone book, an umbrella, and a set of dentures. Though one might disagree with the judgement of Seattle’s Citizens’ Committee, I firmly believe that complete denture prosthetic service 50 years from today will constitute a small proportion of dental practice. This change will reflect the preventive measures already available, and those yet to be developed. Today, dental caries essentially can be controlled through the multiple use of fluoride as a preventive agent. The greatest difficulty yet to be overcome is the development of better methods for bringing the full benefits of prevention to more people. Earlier and more complete treatment of the carious lesions which do develop in our younger population can be expected. Preventive or interceptive orthodontic care will be an important part of general practice. Dentists will be spending increasing proportions of their time preventing and controlling periodontal disease. Reaching old age with the benefits of natural teeth will become the reasonable expectation of most Americans. TODAY
AND
1976
In contrast to what was stated above concerning the more distant future, it is my belief that in the next decade an increased emphasis on complete dentures in practice can be anticipated. It is staggering to realize that half of the American citizens over 50 years of age are without natural teeth and that, on an average, 20 dentures must be provided for every 100 young men inducted into military service today. That the need for complete denture prosthetic services currently exists cannot be denied. That the demand for such services is going to increase drastically is, in my opinion, an inevitability. Permit me to support this latter conclusion by reviewing pertinent federal legislation and the trends which have been demonstrated. When Public Law 89-97, the Social Security Amendments of 1965, was passed, the greatest attention was given to Title XVIII, popularly known as Medicare. Of perhaps equal importance, however, is Title XIX, known as Medicaid, which has major ramifications for health services. Medicare is essentially a federally-administered insurance program providing for total compulsory contributions with benefits as entitlement for all people 65 and over. Title XIX is a medical assistance program for people of any age on a basis of need, and is administered by the state in cooperation with the federal government, which contributes financial support on a matching basis. At the present time, Medicare does not include dentistry, except some oral surdoes provide for dental care? including some prosthetic gery ; while Medicaid services. That the involvement of complete denture prosthetic services in these two programs is destined to increase markedly seems almost certain. One can anticipate that both the age group covered and services rendered under Title XVIII will increase, as the definition of the needy under Title XIX increases. The only question is which will first have the greatest impact on dentistry. The year 1972 has been set as the target date for states to provide total care for all eligible persons under Medicare, and there are many who expect this care to include complete
82
Morris
denture services. Eligibility for Medicaid has now been increased to include the indigent and the medical needy of all ages who are dependent to some degree because of advanced age, disability or blindness, or because of a particularly heavy economic burden caused by an episode of illness. The state of New York has now so defined medical indigency under Title XIX that 40 per cent of its population are eligible for benefits. Twenty-one million dollars have been given to the California Dental Service Corporation to provide complete dental care for the medically indigent of that state. Some may say that merely providing financial support will have little effect on the rate at which the public demands complete denture services. Recent events in Kentucky have demonstrated the fallacy of such thinking. When the U.S. Public Health Service opened a new patient care facility in the city of Louisville, 28,000 indigent people of all ages were eligible for treatment. According to the Director of the project, 75 per cent of all patients coming to that clinic during the first few months of operation requested complete denture service. It is my opinion that one of the most important challenges facing dentistry in the immediate future will be that of providing complete dentures at the rate demanded by the public. Even in the “Great Society,” limitation of financial resources of the federal government may slow the rate at which our edentulous citizens are offered dental treatment. The pressure for such treatment may, therefore? not peak as early as 1976, but it will be in evidence. In summarizing my comments on the future, two forces are recognized. C>ne will markedly increase the relative demand for complete denture services and will undoubtedly dominate the immediate future. The other force will result in a very significant decrease in the demand for such service that will be conspicuously evident
hy 2000
A.1).
PROSTHETl,CS IN THE DENTAL
CURRJCULUM
TODAY
It is my opinion that the emphasis on complete denture prosthetics in the dental curriculum today reflects the past. Currently, there is a recognized ferment in dental education, and almost all in the profession agree that curriculum alterations are in order. The faculty of many schools can now articulate what the characteristics of a new program in dental education should be, but rarely have the curriculum changes necessary to implement new programs being accomplished. The result is that, in general, our curricula are outdated. The point that prosthetics in the present curriculum reflects the past rather than the future is supported by a review of what has occurred since The Red Book on dental curriculum was published in 1935.’ It was originally recommended in The Red Book that 23.3 per cent of the curriculum should be devoted to prosthetics. (It should be noted that the figures cited refer to both complete and partial denture prosthetics.) A survey in 1941 revealed that, at that point in history, prosthetics accounted for an average of 25.9 per cent of the curriculum in schools throughout the countrys3 The Survey of Dentistry* revealed that in 1958, the time devoted to prosthetics in the nation’s schools averaged 26.1 per cent. Based upon the nature of dental practice in 1934, perhaps The Red Book’s recommendation was logical. The logic of 26.1 per cent in 1958 must be questioned, however, since the Survey revealed
Volume 19 Number 1
Prosthetics
and the dental
.school curriculum
83
that only 13 per cent of general dental practice was devoted to prosthetics at that time.+ In an effort to ascertain the status of today’s curricula, the 1966 bulletins of 12 dental schools were examined. Four schools each from the east, mid-west, and west were selected. Information obtained from bulletins may be misleading, and is not presented in such a way to make detailed analysis possible. This informal review, however, failed to indicate that any significant change in the relative role of prosthetics in the average curriculum has occurred since 1958. A review of current dental school bulletins also suggested that few changes have been introduced in the manner in which complete denture prosthetics is organized within the curriculum. In most instances, it is presented as a separate technique course offered in the second, or perhaps the first year. This is followed by additional independent courses in the third and fourth years which usually include both lectures and clinical work. Clinical teaching of prosthetics frequently occurs in a separate facility, which serves to further emphasize the independent nature of this clement of patient care. It is suggested that this approach to teaching complete denture prosthetics is essentially the pattern by which the subject has been taught for many years. It is my conclusion, therefore, that the emphasis on complete denture prosthetics in the curriculum today reflects little change over the past 30 years. In general, a rather large segment of the total curriculum is devoted to this subject. Further, there appears to be little change in the approach to teaching in that the related subject matter is usually taught as an independent body of knowledge, with little emphasis on correlation with other clinical sciences. PROSTHETICS
IN THE DENTAL
CURRICULUM-l
976
,4s curriculum revision continues in our dental schools, complete denture prosthetics is destined to receive a great deal of attention. It is my opinion that the attitude will prevail in most schools that the curriculum time committed to this subject is greater than it should be, and that the present time allottment is not appropriate for today or the future. In the process of up-dating our eduactional programs, the relative emphasis on complete denture prosthetics as expressed in curriculum hours must be decreased. This is understandably a difficult fact for all to accept. What must be emphasized is that this predicted decrease will not reflect a decrease in the importance of complete denture prosthetics. It will merely reflect the inevitable tides of change as they affect the emphasis of dental education and dental practice. SHIFTS IN EMPHASIS Changes in emphasis within the dental curriculum are delicate matters to discuss, but are of such vital importance that they must be squarely faced. New information is continually evolving in our changing profession. Certain fields of dentistry or areas of practice are receiving greater attention, and certain others less. It is a difficult task for a faculty to decide which new material is vital and important to an educational program tuned to the future. It seems inevitable, however, that if only four years are to be devoted to the predoctoral program in dentistry, then as new material is added to the curriculum, something must be eliminated.
84
Morris
One of the characteristics of a dynamic society is that its frontiers arc always chang-ing. The frontiers of today become the familiar territory of tomorrow. The frontiers of dentistry and dental education are changing. Some aspects of the field which were so much at the forefront at one point in history are no longer there. Admittedly, this is difficult to accept, particularly if a great part of one’s life has been devoted to one of the fields no longer in the forefront. Hut realism is essential to progress. An example of what we are discussing can be taken from the basic science areas of anatomy and biochemistry. There was a time in the professional schools when anatomy was tlw basic science. Anatomists were the most renowned of all people in the scientific community. Currently it seems the biochemists are riding at the top of the heap. There has been a change, and further change can bc anticipated. A similar example can be cited in the clinical fields. It is rccognizcd that WC are experiencing a changing emphasis from the replacement to the preservation of the dentition. A shift has been occurring in which periodontics is receiving more emphasis. This shift does not imply that prosthetics is unimportant, nor does it imply that it should not be taught well. It does it imply that the graduates in the 1970’s need not he prepared to offer good complete denture prosthetic service to their patients. lt does not mean that the talents possessed by the prosthodontist arc unimportant or unappreciated. It must be recognized that judgments of differences in talents arc not judgments of differences in human worth. The frontiers of 0111. dynamic profession are changing, and it is essential that those who plan the dental curriculum accommodate these changes. Another point which deserves attention when discussing reaction to ~1 dccreased relative emphasis on prosthetics is the fact that a decrease in curriculum hours does not automatically imply a decrease in quality of instruction. A IWM’ and shorter course, developed after a critical review of what and how material is being presented, will frequently permit one to realize his teaching objectives equally well or better than before. Such has been our experience at the University of Kentucky in sc\cral fields. The full potential for educational television to improve the cfficicncy and effectiveness of our teaching has yet to he realized. The same nray bc said regarding computer science, programmed instruction, packaged 8 mm. rllovics. individual slide sets, and other self-study media. I predict that. in 1976, our teachingprograms will place less emphasis on the lecture, and more on newer pedagogical techniques. RELATIVE
EMPHAStS
A decade from now the teaching of complete denture prosthetics will be more closely related to other courses in the curriculum. The prosthodontist and portions of his rnaterial will be included in conjoint efforts, such as a comprehensive course in occlusion. Cooperative teaching in dental materials will be common. Better integration of prosthetics with other programs of the school will he encouraged by the fact that fewer schools will have physically separate prosthetic clinics. As in other clinical disciplines, prosthetic techniques will be taught in the clinical setting rather
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than the laboratory, in order that the transfer of technical skills to the care of patients may be facilitated.” There will be a significant decrease in the emphasis and time devoted to the purely technical aspects of complete denture fabrication. Less time will be spent teaching laboratory skills to the student. Technicians within the school will do the laboratory work related to patient care. A trend toward this latter approach is already evident in several schools. This decreased emphasis on laboratory procedures will save many curriculum hours, and at the same time, prepare the student to utilize the technician more effectively, as he must in practice. Many dental schools may have Technician Utilization Programs similar to the Dental Assistant Utilization programs which exist in most schools today. Emphasized in these programs will be the role of the technician in the private group practice setting, in which the student of today is destined to practice. SIMPLIFICATION
AND
STANDARDIZATION
Another curriculum change which is predicted for 1976 will be a tendency toward simplification and standardization of the techniques used in providing complete denture service. The “Battle of the Articulators” will be de-emphasized, and more effort will be devoted to work simplification and prosthetic practice efficiency. A new emphasis in the curriculum of the future will provide demonstration for the potential contribution of complete denture prosthetics in preventive dentistry and preventive medicine. The early diagnosis of oral cancer in the denture patient will be stressed. As the future dentist becomes one of the chief agents for referral to the physician, oral medicine, as it relates to edentulous patients, will receive increased attention. In addition, the importance of liaison between the prosthodontist and the behavioral scientist will be more fully appreciated, as the psychic problems of the edentulous patient are more clearly related to his oral problems. I predict that, in 1976, complete denture prosthetics will be taught in a shorter time, utilizing newer teaching methods to present material which will be significantly different. In many ways, material related to prosthetics will be correlated with other courses in the curriculum. RESPONDING
TO CONFLICTS
As one considers the material which has been presented thus far, several statements or concepts can be identified which appear to be in conflict. It is possible that these conflicts merely reflect my personal confusion, but I suggest that they represent honest dilemmas which we must be prepared to face. An effort will be made to respond to some of these conflicts with the hope that they can be viewed with more understanding. What about the conflict inherent in the view that less curriculum time should be devoted to complete denture prosthetics during a period in which it is predicted a greater demand for prosthetic services will exist ? Is not a greater demand for such service justification for more rather than less curriculum time? The answer to this latter question would be “yes,” were it not for the fact that prosthetic dentistry does not stand alone in the complex arena of academic dentistry. Many social, political, scientific, and professional forces are at work which are having a profound impact
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on many fields. President Johnson announced in Texas, last April, that he had instructed Secretary Gardner to develop recommendations for a dental care pro,gram for the children of the nation. At the 1966 annual session of the American Dental Association, our profession will take action on a proposed National Dental Health Program for Children. Both of these events are destined to place significantly-increased emphasis on preventive dentistry, pedodontics, and orthodontics. The current trend to ,give increased attention to p(ariodontics was alluded to earlier. The curricula of many schools aheady inclrlde a serious commitment to community or social dentistry. With the reminder that one cannot equate quantity of curriculum time with quality of teaching, I am convinced those who teach prosthodontics in the futurtb can and will meet their responsibilities to their students effectively. The solution IO the increased demand for prosthodontic stxrvices must be met through improved methods for their delivery. It is possible that when such improvements are developed, which I feel must occur, their ultimate impact may be a reduction of pressure for curriculum time. It was stated that a great emphasis on the role of the dental laboratory technician in the teaching and practice of complete denture prosthodontics is indicated. Some will feel that this concept is in conflict with the recommendation that less time be spent in teaching the student techniques related to the construction of dentures. It is frequently stated that a dentist cannot properly suljervix his technician unless he is trained and skilled in technical procedures. In support of this view, the students in many schools are required to do their own laboratory work. It is implied that such experience will qualify the student throughout his professional career to serve as a consultant to the technician on how to wax dentures. or pack and polish acrylic resin. Such an argurnent has always betan difficult for me to understand. 7’herc is every reason to expect and hopca that the technician will be more proficient than the dentist in carrying out routine laboratory procedures. Whether the dentist constructed one or ten dentures as a student will not changt, this fact. The student can be taught how to rearrange anterior teeth in order to improve esthetics, and posterior teeth in order to acquire a better-balanced occlusion, without spending many curricular and extracurricular hours setting up teeth.?‘hc dentist who knows what the proper design of the lower impression tray should be will have no difficulty in communicating his requirements to the technician. Whether or not he can construct such a tray as quickly as a technician is immaterial. It is c3sential only that the student be taught to recognize and drmand an acceptable piece of technical work. It is my opinion that this aim or educational Koal can be achirveci without requiring the student to carry out repeated ttxchnical cscrcises. There are those who justify large expenditures of curriculum time in teaching laboratory procedures on the basis that some day the dentist may wish to do his own laboratory work. Although such procedure is rarely necessary and should be discouraged: the dentist could become proficient in the necessary techniques with little effort. This is certainly true in thta case of the recent graduate. Others would probably require a similar arnount of cfrort. regardless of how much experience they had as students. Currently. we are in a discoura+lg cara of poor relationships between the dental
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llrofession and the dental laboratory industry. This is highlighted by various actions taken by the National Association of Certified Dental Laboratories. It is my opinion that the ultimate and best solution to this chronic and vexing problem will be achieved when all aspects of dentist-technician relationships are approached in a candid and realistic manner in the dental school curriculum. To provide the student with an unrealistic view regarding either his own or his laboratory technician’s role will merely perpetuate the present status. STANDARDIZED
APPROACH
An additional conflict which deserves attention is contained in the statement that a less complex and more standardized approach to denture construction is predicted during a period when the scientific basis of dental practice is being espoused. The prediction is based upon the previously described expectation that we are destined to experience a mounting demand for more complete denture service. Iluring a time when the profession is exerting great efforts to demonstrate that it can meet its responsibilities to the edentulous public, the use of complex procedures requiring extra patient appointments will be placed under critical scrutiny. Unless it can be proved through careful clinical research that such procedures result in a superior level of patient care, they will be abandoned. It is expected that an increased number of clinical investigations will be conducted by the nation’s prosthodontists as they seek the techniques, based o’n sound biological principles, which will provide the best level of patient care through the most efficient approach possible. It is predicted that national conferences will be convened for the purpose of discussing the best approach for providing a greater volume of complete denture service. The ccpts held dear by some of our most distinguished clinicians being discarded, unless result will be a trend toward a more standard technique, with the conflicting contheir validity can be established through clinical research. In conclusion, I wish to state that my comments have been intended to be provocative but not negative. The role of the prosthodontists in our profession and our dental schools will continue to be an exrtemely important one. They will be looked to for critical leadership as we meet the challenges which lie ahead. Increasing sophistication will be demanded of prosthodontists in the area of maxillofacial prosthetics, as they seek to provide care for the increasing number of patients who are suffering from cancer, congenital defects, and facial trauma. The attention of this forum has been focused upon one field within our profession. As we view the future, our orientation should be a broad one with each field considered in its relationship to the profession at large. For, to paraphrase a portion of the 12th Chapter of 1st Corinthians, the profession does not consist of one member but of many. We should be so adjusted that there may be no discord in the profession: but that the members may have the same cares for one another. If one member suffers, all suffer together; if one member is honored, all rejoice together. References 1. Master plan for the School of Dentistry-1966-1980, Report of the Committee on Goals and Objectives, School of Dentistry, University of Southern California, 1966. (Mimeo.) 2. American Association of Dental Schools: A Course of Study in Dentistry: Report of the Curriculum Survey Committee, Chicago, 1935, American Association of Dental Schools.
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3. Horner, H. H.: Dental Education Today, Chicago, 1947, University of Chicago Press. 4. American Council on Education: The Survey of Dentistry; The Final Report, Washington, D. C., 1960. 5. Hickey, ,J. C.: Combined Course in Technical and Clinical Complete Dentures Prosthodontics, J. Dent. Ed. 29: 155-161, 1965. MEIXCAL CEXTER COLLEGE OF DENTISTRY UNIVERSITY OF KENT~~CKY LEXINGTON, KY. 40506