- Email: [email protected]
What a prosthodontist does
What
a
P. Kenneth
Morse,
Ph.D.,*
and Louis J. Boueher,
Ph.D., D.D.S.**
Medical College of Georgia, School of Dentistry, Augusta, Ga.
I
n planning for graduate and postgraduate programs in prosthodontics, it is important to bear in mind what a prosthodontist does. The day-to-day activities of a prosthodontist must inevitably bear some relationship to the clinical understanding, technique, and basic science taught in the advanced education program, While no one would suggest that we have reached the ultimate state of the art in prosthodontics, it is nevertheless important that the candidate for a specialty practice master the present state of the art. In view of these considerations, it was deemed important to obtain an indication oft the day-to-day activities of prosthodontists. Accordingly, a mail survey of prosthodontists was conducted. giving them an opportunity to describe their daily activities. SAMPLE Questionnaires were sent to all of the 320 prosthodontists who were listed as diplomates in 1967 by the American Board of Prosthodontics. Of these, 274 r‘rsponded and 196 of the responses were usable (i.e., indicating one or more direct services to patients on the survey day). Of the 78 persons indicating no services to patients, 34 were teachers and/or researchers, 21 were administrators, 21 were retired, and 2 did not identify their present status. METHOD F&h prosthodontist selected by the survey was asked to list each cate how many minutes The covering letter dontist to “. . . list the
Read
before
the
was asked to report his activities for a single day, which was staff and specified on the survey form. The prosthodontist prosthodontir procedure which he accomplished and to indiit took. explained the purpose of the survey, and asked each prosthoclinical and laboratory procedures you performed on the sur-
Workshop
on Advancrd
*Associate
Professor,
Dental
**Associate
Dean
and Professor
402
Prmthodontic
Education. of Prosthodontirs.
Education.
C:hicaql,
I11
Volume Number
21 4
What
a prosthodontist
does
403
vey date indicated on the upper right hand corner of the attached form. If this was your day off, or for some reason or other it was not a typical day in your office, please use the next working day following the day indicated.” The letter closed with ranging from a reminder to “. . . list only activities in the field of prosthodontics examinations to adjustments.”
SELECTION OF SURVEY PERIOD Because some prosthodontists may tend to concentrate certain types of activity at the beginning, middle, or end of the week, a five-day working period was used with 20 per cent of the prosthodontists in the survey assigned to each of the days. Since the activities of the prosthodontist may be somewhat dependent upon the proximity of key national holidays, the first week in October was selected as a typical week. All persons not responding to the first request were sent a second letter assigning a comparable survey day from the first week of December.
METHOD OF ASSIGNING SURVEY DAYS The diplomates of the American Board of Prosthodontics were stratified on the basis of civilian or military employment, with 20 per cent of each group assigned to each of the five survey days. While the assignment to each of the five survey days was not strictly a random assignment, the only possible bias would come from variables correlated with the alphabetical order of the states in which the diplomates reside.
CODING OF RESPONSES Because the responding prosthodontists were asked to describe their activities in their own terms, it was necessary to code these responses for data processing. Twenty-two classifications for patient-related procedures were established, and each specific procedure reported by an individual prosthodontist was classified from the description of the procedure and from the context as either (1) fixed prosthodontics, (2) removable prosthodontics, or (3) unclassified prosthodontics (i.e., indeterminate as to fixed or removable prosthodontics). Maxillofacial prosthetics and cleft palate procedures were included with fixed, removable, and unclassified prosthodontics. All judgments were made by a diplomate of the American Board of Prosthodontics. Although the respondents had been requested to list only activities in the field of prosthodontics, a total of 2,071 minutes spent on procedures involving general dentistry were also included in the reports. This information was deleted from the reports before analysis.
ANALYSIS OF DATA Each timed patient-related procedure was tabulated by type of procedure and by type of classification. The 22 different procedures and 3 classifications account for 66 different combinations of procedure and classification. For each such combination, the survey sought to determine (1) how many minutes were spent in the activity described by this procedure and this classification and (2) how many different prosthodontists spent time in this combination of procedure and classification.
404
Morse
and
Bouchel
J. Ptos. Dent. April, 1969
The time entry for each combination of procedure and classification was calculated as a percentage of the total time recorded for all reported procedures. The number of prosthodontists reporting activity in each procedure with each type of classification was calculated as a percentage of the total number of prosthodontists (N = 196) reporting one or more timed patient-related procedures.
RESULTSAND DISCUSSION Table I presents information about the per cent of the 196 practitioners who performed each specific procedure. Because the same person could conceivably have performed each of the 22 procedures under each of the 3 classifications, it therefore is not appropriate to calculate the total from the percentages of the various entries. The best interpretation of the entries in Table I would be that on any given day “X” per cent of the prosthodontic practitioners will perform this procedure at least once.
Table 1. Per cent of 196 practicing
prosthodontists
Kemov-
Unclassi-
able proxthodontics
fied prosthodontics
Examination and diagnosis Survey and design Consultation (M.D. or D.D.S.) Impressions for study casts Postinsrrtion check
10.2 -._
17.9 7.1 x.2 1 .5 x.2
47.4 2.6
Preparation
42.3
6fi.X
13.3
21.9
4.1 2.0
21.9 3x.3 12.8
Procedure
II
and impression
III
Laboratory
IV
Jaw relation records and face-bow transfer Jaw relation records Face-bow transfer and adjust articulator
V
x71
VII
VIII
TX
specific procedures
Fixed prosthodontics
Group I
performing
Try-in and reset teeth Try-in and centric check-bite Set teeth Try-in and adjust occlusion Insert and refinc~ occlusion I nser’t Refine occlusion .4djustment Repair Tissue Rpbase
1.5
9.2 1 ..5
16.3 21.9 15.3
2.0 12.2
--~.. .~
24.5 23.0
2.0 6.6
61.7 10.2
----
9.7 in.7
---
treatment or reline
or more
-----
7.7 34.7 5.6
Miscellaneous One
10.2
2.0 procedures
58.0
94.9
54.6
Volume Number
21 4
What
a prosthodontist
does
405
Virtually all (94.9 p er cent) practicing prosthodontists surveyed engaged in one or more procedures that could be classified as removable prosthodontics. Well over half (58.0 per cent) engaged in one or more procedures that could be classified as fixed prosthodontics. The great majority of the practitioners (54.6 per cent) who performed one or more unclassified prosthodontic procedures were in the category “Examination and diagnosis.” This information provides few clues as to what percentage of subsequent treatment may be classified as fixed or removable prostheses. Table II presents the number of minutes reported for each prosthodontic procedure in each classification, and this time is expressed as a percentage of total
Table II. Per cent of time spent procedures
by 196 practicing
Procedure
Group I
II
IX
fied prosthodontics
Total*
14.06
17.65
-
31.70
2.19
2.94
-
5.13
0.50
3.91 5.52
-
3.91 6.02
0.1%
1.17
-
1.35
Try-in and reset teeth Try-in and centric check-bite Set teeth Try-in and adjust occlusion
1.09 0.32 0.19
2.87 3.21 2.97 -
-
3.96 3.53 2.97 0.19
Insert Insert Refine
1.67 6.41 0.72
2.15 3.94 2.95
-
3.82 10.36 3.67
Adjustment Repair
0.16 0.55
5.71 0.78
-
5.87 1.34
Tissue Rebase
-
1.19 1.06
-
1.19 1 .OE
-
-
0.41
0.41
29.15
63.11
Preparation
and impression
Jaw relation records and face-bow transfer ,Jaw relation records Face-bow transfer and adjust articulator
VIII
Unclassi-
0.13
IV
VII
in specific
2.41 0.83 1.00 0.11 0.72
Laboratory
VI
Removable prosthodonticr
0.97 --
Examination and diagnosis Survey and design Consultation (M.D. or D.D.S.) Impressions for study casts Postinsertion check
III
V
Fixed prosthodontics
prosthodontists
and refine
occlusion
occlusion
treatment or reline
Miscellaneous Total*
*Totals do not represent a sum of the percentages centage computed directly from the raw totals.
in a row
or column,
6.36 0.25 -
9.75 1.08 1 .oo 0.84 0.84
0.73 -
7.75 but
100.00 rather
a per-
404
Morse
and
.I. Pros: Dent. Apd, 1969
Boucher
Table ill. Proportionate time spent on specific procedures fixed prosthodontics and removable prosthodontics
I
II
Fixed prosthodontics (pm cent)
Procedure
Group
Examination
and diagnosis Survey and design Consultation (M.D. or D.D.S.) Impressions for study casts Postinsertion check
Preparation
and
given separately
within
Removable prosthodontics (per cent)
3.33
3.82 1.32 1.59 0.18 1.13
_-0.43
impression
48.23
‘7.96
III
Laboratory
7.52
4.65
IV
Jaw relation records and face-bow transfer Jaw relation records Face-bow transfer and adjust articulator
1.71 0.62
6.20 8.75 1.85
v
VI
VII
VIII IX
Try-in and reset teeth Try-in and centric check-hite Set teeth Try-in and adjust occlusion Insert Insert Refine
and refine
3.7 5 1.11
4.55 5.09 4 71
0.65
occlusion
5.73 22.01 2.45
occlusion
3.41 6.25 4.68
Adjustment Repair
0.5.5 I .90
9.05 1 .2 4
Tissue treatment Rebase or reline
.-
1.88 1.68
Miscellaneous
100.00
Total*
*Totals were percentagized
directly
from
the raw
100.00
totals.
prosthodontic time. Each entry may be interpreted as follows: On the survey day, “x“ per cent of all time reported was spent on this procedure and/or in this classification. Of the time reported, more man-hours were devoted to removable prosthodontics (63.11 per cent) than to fixed prosthodontics (29.15 per cent). Virtually all of the unclassified prosthodontic time was represented in the category “Examination and diagnosis” for reasons indicated above. In Group II, the procedure “Preparation and impression” accounted for almost one third (31.70 per cent) of all prosthodontic time reported. Other groups of procedures which accounted for at least 10 per cent of all prosthodontic time included Group I ( 13.51 per cent), Group IV ( 11.28 per cent) ? Group V ( 10.65 per cent), and Group VI ( 17.85 per cent). One of the interesting findings in Table II was that only 5.13 per cent of all prosthodontic time was spent on laboratory procedures. This suggests that the
P%ez ” 2a
What
a prosthodontist
does
407
typical prosthodontist has most of his laboratory work done by a commercial laboratory or by his own laboratory technician. This raises the question of how much time in the advanced curriculum should be devoted to laboratory techniques. It should be noted that the procedure of setting teeth was not included with the laboratory procedures. Two associated findings of interest were the low percentages of time devoted to rebasing and relining dentures (1.06 per cent) and to repairing dentures (1.34 per cent). This is difficult to explain, because these procedures are frequently needed and are beneficial to the patient. While improvements in dental materials could lessen the demand for repairs due to breakage of dentures, such improved materials could not reduce the amount of rebasing necessary because of changes in the mouth. Apparently many new dentures were made when the old dentures could have been repaired or rebased. Since most patients are referred to prosthodontists and since most prosthodontists do not rebase or reline dentures made by other dentists, this may explain why so low a percentage of time was spent in relining or rebasing dentures. Table III indicates the relative distribution of time spent on procedures classified as fixed and removable prosthodontics. Several of these findings may be relevant to planning advanced curricula in these two special fields of prosthodontics. Within the classification of removable prosthodontics, the small amount of time expended in tissue treatment procedures (Group VIII, 1.88 per cent) is surprising. Considering the length of time necessary for the average tissue treatment regimen for one patient, one would expect that tissue treatment would account for a higher percentage of all time spent in removable prosthodontics. Since tissue treatment materials have been on the commercial market for only about a decade, this may suggest that many prosthodontists are not yet using this procedure. Short courses on tissue treatment may be needed to brin g these practitioners up to date. Because of the many types of accidental damage that occur to removable dentures, it was expected that the proportion of time spent on repairs (Group VII) within removable prosthodontics would be substantially higher than that spent for fixed prosthodontics. If anything, slightly more time was spent proportionately on repairs in fixed prosthodontics. However, repairs of removable prostheses may be more frequently delegated to a laboratory technicion or to commercial laboratories and thus not show up as time spent by the prosthodontist. Although there was little difference in Group VI in the proportion of time spent on the combined procedure of “Insert and refine occlusion,” “Insert” occupied relatively almost four times as much time in fixed prosthodontics while “Refine occlusion” occupied relatively almost twice as much time in removable prosthodontics. Insertion of a fixed prosthesis automatically involves the refinement of the occlusion. In the case of the removable prosthesis, however, it is less obvious upon insertion that refinement is needed. Occlusal problems associated with removable prostheses were probably not immediately noticeable and required refinement at later separate appointments. It seems reasonable that greater attention to detail at the time of insertion of both fixed and removable prostheses would result in fewer adjustments later. Substantially greater emphasis in Group VII on adjustments in removable prosthodontics lends further credence to this reasoning.
408
Morse
and Boucher
J. Pros. Dent. April, 1969
An analysis of Table III reveals that jaw relation records are much more prominent in removable prosthodontics (14.95 per cent for two procedures combined) than in fixed prosthodontics (1.71 per cent). This is reasonable, because with edentulous patients, the prosthodontist often must establish such records without guides such as the teeth and the periodontal membranes which may not be present. It is also reasonable that the prosthodontist who treats patients with removable prostheses would have more of his time taken up in the try-in procedure. This procedure is often more time-consuming in removable prosthodontic procedures because of the hard and soft tissue changes resulting from extraction of teeth. The tissue changes associated with fixed prostheses are not usually manifested in dramatic changes in facial contours and do not require extensive try-in procedures.
SUMMARY A mail survey of 320 diplomates of the American Board of Prosthodontics produced responses from 274, Of these, 196 reported one or more patient-related procedures on the survey day. The responses were analyzed by type of procedure and by prosthodontic classification of the problem (fixed, removable, or unclassified). More than 63 per cent of all prosthodontic time reported was classified in the category of removable prosthodontics. Virtually all prosthodontists surveyed (94.9 per cent) reported at least one procedure classified as removable prosthodontics. A majority (58.0 per cent) also reported one or more procedures classified as fixed prosthodontics. Unexpected concentrations of time and failures to produce expected concentrations of time were identified, and the implications for advanced education were discussed. Different patterns of time concentration in fixed and removable prosthodontics were also identified which suggest possible curricular differences for these subspecialties. MEDICAL SCHOOL AWUSTA,
COLLEGE
OF GEORCHA
OF DENTISTRY
GA. 30902
a
P. Kenneth
Morse,
Ph.D.,*
and Louis J. Boueher,
Ph.D., D.D.S.**
Medical College of Georgia, School of Dentistry, Augusta, Ga.
I
n planning for graduate and postgraduate programs in prosthodontics, it is important to bear in mind what a prosthodontist does. The day-to-day activities of a prosthodontist must inevitably bear some relationship to the clinical understanding, technique, and basic science taught in the advanced education program, While no one would suggest that we have reached the ultimate state of the art in prosthodontics, it is nevertheless important that the candidate for a specialty practice master the present state of the art. In view of these considerations, it was deemed important to obtain an indication oft the day-to-day activities of prosthodontists. Accordingly, a mail survey of prosthodontists was conducted. giving them an opportunity to describe their daily activities. SAMPLE Questionnaires were sent to all of the 320 prosthodontists who were listed as diplomates in 1967 by the American Board of Prosthodontics. Of these, 274 r‘rsponded and 196 of the responses were usable (i.e., indicating one or more direct services to patients on the survey day). Of the 78 persons indicating no services to patients, 34 were teachers and/or researchers, 21 were administrators, 21 were retired, and 2 did not identify their present status. METHOD F&h prosthodontist selected by the survey was asked to list each cate how many minutes The covering letter dontist to “. . . list the
Read
before
the
was asked to report his activities for a single day, which was staff and specified on the survey form. The prosthodontist prosthodontir procedure which he accomplished and to indiit took. explained the purpose of the survey, and asked each prosthoclinical and laboratory procedures you performed on the sur-
Workshop
on Advancrd
*Associate
Professor,
Dental
**Associate
Dean
and Professor
402
Prmthodontic
Education. of Prosthodontirs.
Education.
C:hicaql,
I11
Volume Number
21 4
What
a prosthodontist
does
403
vey date indicated on the upper right hand corner of the attached form. If this was your day off, or for some reason or other it was not a typical day in your office, please use the next working day following the day indicated.” The letter closed with ranging from a reminder to “. . . list only activities in the field of prosthodontics examinations to adjustments.”
SELECTION OF SURVEY PERIOD Because some prosthodontists may tend to concentrate certain types of activity at the beginning, middle, or end of the week, a five-day working period was used with 20 per cent of the prosthodontists in the survey assigned to each of the days. Since the activities of the prosthodontist may be somewhat dependent upon the proximity of key national holidays, the first week in October was selected as a typical week. All persons not responding to the first request were sent a second letter assigning a comparable survey day from the first week of December.
METHOD OF ASSIGNING SURVEY DAYS The diplomates of the American Board of Prosthodontics were stratified on the basis of civilian or military employment, with 20 per cent of each group assigned to each of the five survey days. While the assignment to each of the five survey days was not strictly a random assignment, the only possible bias would come from variables correlated with the alphabetical order of the states in which the diplomates reside.
CODING OF RESPONSES Because the responding prosthodontists were asked to describe their activities in their own terms, it was necessary to code these responses for data processing. Twenty-two classifications for patient-related procedures were established, and each specific procedure reported by an individual prosthodontist was classified from the description of the procedure and from the context as either (1) fixed prosthodontics, (2) removable prosthodontics, or (3) unclassified prosthodontics (i.e., indeterminate as to fixed or removable prosthodontics). Maxillofacial prosthetics and cleft palate procedures were included with fixed, removable, and unclassified prosthodontics. All judgments were made by a diplomate of the American Board of Prosthodontics. Although the respondents had been requested to list only activities in the field of prosthodontics, a total of 2,071 minutes spent on procedures involving general dentistry were also included in the reports. This information was deleted from the reports before analysis.
ANALYSIS OF DATA Each timed patient-related procedure was tabulated by type of procedure and by type of classification. The 22 different procedures and 3 classifications account for 66 different combinations of procedure and classification. For each such combination, the survey sought to determine (1) how many minutes were spent in the activity described by this procedure and this classification and (2) how many different prosthodontists spent time in this combination of procedure and classification.
404
Morse
and
Bouchel
J. Ptos. Dent. April, 1969
The time entry for each combination of procedure and classification was calculated as a percentage of the total time recorded for all reported procedures. The number of prosthodontists reporting activity in each procedure with each type of classification was calculated as a percentage of the total number of prosthodontists (N = 196) reporting one or more timed patient-related procedures.
RESULTSAND DISCUSSION Table I presents information about the per cent of the 196 practitioners who performed each specific procedure. Because the same person could conceivably have performed each of the 22 procedures under each of the 3 classifications, it therefore is not appropriate to calculate the total from the percentages of the various entries. The best interpretation of the entries in Table I would be that on any given day “X” per cent of the prosthodontic practitioners will perform this procedure at least once.
Table 1. Per cent of 196 practicing
prosthodontists
Kemov-
Unclassi-
able proxthodontics
fied prosthodontics
Examination and diagnosis Survey and design Consultation (M.D. or D.D.S.) Impressions for study casts Postinsrrtion check
10.2 -._
17.9 7.1 x.2 1 .5 x.2
47.4 2.6
Preparation
42.3
6fi.X
13.3
21.9
4.1 2.0
21.9 3x.3 12.8
Procedure
II
and impression
III
Laboratory
IV
Jaw relation records and face-bow transfer Jaw relation records Face-bow transfer and adjust articulator
V
x71
VII
VIII
TX
specific procedures
Fixed prosthodontics
Group I
performing
Try-in and reset teeth Try-in and centric check-bite Set teeth Try-in and adjust occlusion Insert and refinc~ occlusion I nser’t Refine occlusion .4djustment Repair Tissue Rpbase
1.5
9.2 1 ..5
16.3 21.9 15.3
2.0 12.2
--~.. .~
24.5 23.0
2.0 6.6
61.7 10.2
----
9.7 in.7
---
treatment or reline
or more
-----
7.7 34.7 5.6
Miscellaneous One
10.2
2.0 procedures
58.0
94.9
54.6
Volume Number
21 4
What
a prosthodontist
does
405
Virtually all (94.9 p er cent) practicing prosthodontists surveyed engaged in one or more procedures that could be classified as removable prosthodontics. Well over half (58.0 per cent) engaged in one or more procedures that could be classified as fixed prosthodontics. The great majority of the practitioners (54.6 per cent) who performed one or more unclassified prosthodontic procedures were in the category “Examination and diagnosis.” This information provides few clues as to what percentage of subsequent treatment may be classified as fixed or removable prostheses. Table II presents the number of minutes reported for each prosthodontic procedure in each classification, and this time is expressed as a percentage of total
Table II. Per cent of time spent procedures
by 196 practicing
Procedure
Group I
II
IX
fied prosthodontics
Total*
14.06
17.65
-
31.70
2.19
2.94
-
5.13
0.50
3.91 5.52
-
3.91 6.02
0.1%
1.17
-
1.35
Try-in and reset teeth Try-in and centric check-bite Set teeth Try-in and adjust occlusion
1.09 0.32 0.19
2.87 3.21 2.97 -
-
3.96 3.53 2.97 0.19
Insert Insert Refine
1.67 6.41 0.72
2.15 3.94 2.95
-
3.82 10.36 3.67
Adjustment Repair
0.16 0.55
5.71 0.78
-
5.87 1.34
Tissue Rebase
-
1.19 1.06
-
1.19 1 .OE
-
-
0.41
0.41
29.15
63.11
Preparation
and impression
Jaw relation records and face-bow transfer ,Jaw relation records Face-bow transfer and adjust articulator
VIII
Unclassi-
0.13
IV
VII
in specific
2.41 0.83 1.00 0.11 0.72
Laboratory
VI
Removable prosthodonticr
0.97 --
Examination and diagnosis Survey and design Consultation (M.D. or D.D.S.) Impressions for study casts Postinsertion check
III
V
Fixed prosthodontics
prosthodontists
and refine
occlusion
occlusion
treatment or reline
Miscellaneous Total*
*Totals do not represent a sum of the percentages centage computed directly from the raw totals.
in a row
or column,
6.36 0.25 -
9.75 1.08 1 .oo 0.84 0.84
0.73 -
7.75 but
100.00 rather
a per-
404
Morse
and
.I. Pros: Dent. Apd, 1969
Boucher
Table ill. Proportionate time spent on specific procedures fixed prosthodontics and removable prosthodontics
I
II
Fixed prosthodontics (pm cent)
Procedure
Group
Examination
and diagnosis Survey and design Consultation (M.D. or D.D.S.) Impressions for study casts Postinsertion check
Preparation
and
given separately
within
Removable prosthodontics (per cent)
3.33
3.82 1.32 1.59 0.18 1.13
_-0.43
impression
48.23
‘7.96
III
Laboratory
7.52
4.65
IV
Jaw relation records and face-bow transfer Jaw relation records Face-bow transfer and adjust articulator
1.71 0.62
6.20 8.75 1.85
v
VI
VII
VIII IX
Try-in and reset teeth Try-in and centric check-hite Set teeth Try-in and adjust occlusion Insert Insert Refine
and refine
3.7 5 1.11
4.55 5.09 4 71
0.65
occlusion
5.73 22.01 2.45
occlusion
3.41 6.25 4.68
Adjustment Repair
0.5.5 I .90
9.05 1 .2 4
Tissue treatment Rebase or reline
.-
1.88 1.68
Miscellaneous
100.00
Total*
*Totals were percentagized
directly
from
the raw
100.00
totals.
prosthodontic time. Each entry may be interpreted as follows: On the survey day, “x“ per cent of all time reported was spent on this procedure and/or in this classification. Of the time reported, more man-hours were devoted to removable prosthodontics (63.11 per cent) than to fixed prosthodontics (29.15 per cent). Virtually all of the unclassified prosthodontic time was represented in the category “Examination and diagnosis” for reasons indicated above. In Group II, the procedure “Preparation and impression” accounted for almost one third (31.70 per cent) of all prosthodontic time reported. Other groups of procedures which accounted for at least 10 per cent of all prosthodontic time included Group I ( 13.51 per cent), Group IV ( 11.28 per cent) ? Group V ( 10.65 per cent), and Group VI ( 17.85 per cent). One of the interesting findings in Table II was that only 5.13 per cent of all prosthodontic time was spent on laboratory procedures. This suggests that the
P%ez ” 2a
What
a prosthodontist
does
407
typical prosthodontist has most of his laboratory work done by a commercial laboratory or by his own laboratory technician. This raises the question of how much time in the advanced curriculum should be devoted to laboratory techniques. It should be noted that the procedure of setting teeth was not included with the laboratory procedures. Two associated findings of interest were the low percentages of time devoted to rebasing and relining dentures (1.06 per cent) and to repairing dentures (1.34 per cent). This is difficult to explain, because these procedures are frequently needed and are beneficial to the patient. While improvements in dental materials could lessen the demand for repairs due to breakage of dentures, such improved materials could not reduce the amount of rebasing necessary because of changes in the mouth. Apparently many new dentures were made when the old dentures could have been repaired or rebased. Since most patients are referred to prosthodontists and since most prosthodontists do not rebase or reline dentures made by other dentists, this may explain why so low a percentage of time was spent in relining or rebasing dentures. Table III indicates the relative distribution of time spent on procedures classified as fixed and removable prosthodontics. Several of these findings may be relevant to planning advanced curricula in these two special fields of prosthodontics. Within the classification of removable prosthodontics, the small amount of time expended in tissue treatment procedures (Group VIII, 1.88 per cent) is surprising. Considering the length of time necessary for the average tissue treatment regimen for one patient, one would expect that tissue treatment would account for a higher percentage of all time spent in removable prosthodontics. Since tissue treatment materials have been on the commercial market for only about a decade, this may suggest that many prosthodontists are not yet using this procedure. Short courses on tissue treatment may be needed to brin g these practitioners up to date. Because of the many types of accidental damage that occur to removable dentures, it was expected that the proportion of time spent on repairs (Group VII) within removable prosthodontics would be substantially higher than that spent for fixed prosthodontics. If anything, slightly more time was spent proportionately on repairs in fixed prosthodontics. However, repairs of removable prostheses may be more frequently delegated to a laboratory technicion or to commercial laboratories and thus not show up as time spent by the prosthodontist. Although there was little difference in Group VI in the proportion of time spent on the combined procedure of “Insert and refine occlusion,” “Insert” occupied relatively almost four times as much time in fixed prosthodontics while “Refine occlusion” occupied relatively almost twice as much time in removable prosthodontics. Insertion of a fixed prosthesis automatically involves the refinement of the occlusion. In the case of the removable prosthesis, however, it is less obvious upon insertion that refinement is needed. Occlusal problems associated with removable prostheses were probably not immediately noticeable and required refinement at later separate appointments. It seems reasonable that greater attention to detail at the time of insertion of both fixed and removable prostheses would result in fewer adjustments later. Substantially greater emphasis in Group VII on adjustments in removable prosthodontics lends further credence to this reasoning.
408
Morse
and Boucher
J. Pros. Dent. April, 1969
An analysis of Table III reveals that jaw relation records are much more prominent in removable prosthodontics (14.95 per cent for two procedures combined) than in fixed prosthodontics (1.71 per cent). This is reasonable, because with edentulous patients, the prosthodontist often must establish such records without guides such as the teeth and the periodontal membranes which may not be present. It is also reasonable that the prosthodontist who treats patients with removable prostheses would have more of his time taken up in the try-in procedure. This procedure is often more time-consuming in removable prosthodontic procedures because of the hard and soft tissue changes resulting from extraction of teeth. The tissue changes associated with fixed prostheses are not usually manifested in dramatic changes in facial contours and do not require extensive try-in procedures.
SUMMARY A mail survey of 320 diplomates of the American Board of Prosthodontics produced responses from 274, Of these, 196 reported one or more patient-related procedures on the survey day. The responses were analyzed by type of procedure and by prosthodontic classification of the problem (fixed, removable, or unclassified). More than 63 per cent of all prosthodontic time reported was classified in the category of removable prosthodontics. Virtually all prosthodontists surveyed (94.9 per cent) reported at least one procedure classified as removable prosthodontics. A majority (58.0 per cent) also reported one or more procedures classified as fixed prosthodontics. Unexpected concentrations of time and failures to produce expected concentrations of time were identified, and the implications for advanced education were discussed. Different patterns of time concentration in fixed and removable prosthodontics were also identified which suggest possible curricular differences for these subspecialties. MEDICAL SCHOOL AWUSTA,
COLLEGE
OF GEORCHA
OF DENTISTRY
GA. 30902