An investigation of complete denture teaching in the UK: part 2. The DF1 experience

Key Points

• Surveys of undergraduate teaching in complete denture treatment have raised concerns that newly qualified graduates entering vocational training are deskilled in complete denture techniques.

• Reports that the confidence that the DF1s had in their abilities with complete denture treatment as expressed in the answers to the survey was at odds with their subsequent comments.

Abstract

Aim This paper, the second in a series of two (see BDJ 2013; 215: 177–181), investigates the opinions of a cohort of dental foundation year 1 (DF1) practitioners regarding their skills and competence in relation to their educational background in complete dentures.

Materials and methods With the permission of the Dean of the London Deanery a questionnaire was emailed to the ten London Foundation year 1 training schemes for distribution to approximately 100 DF1s. Five schemes responded with total of 56 completed questionnaires (56%).

Results The average number of complete dentures made as undergraduates was three. Forty-six percent had no experience in making copy dentures. An average of 2 (median 2.05) immediate replacement dentures were made; only 10% made 8-15 dentures. None had experience in implant-supported dentures. Thirty-five percent enjoyed their undergraduate training whereas 45% did not. Thirty-seven percent felt that their training had given them experience and confidence in complete dentures but 32% were of the opposite opinion. Sixty-three percent felt complete dentures were an important or very important aspect of dentistry. Six percent completely disagreed. The majority were confident in making impressions while 39% lacked confidence in registering jaw relations. Thirty-five percent were confident with chairside adjustments at the intermediary treatment stages but 28% were not. Sixty-three percent were confident in the fitting of new dentures and 64% with the after-care. There was no significant gender difference in the responses. There was a significant difference between the London and non-London trained DF1s. The London trained respondents made significantly fewer dentures than the non-London trained cohort. The latter also rated complete denture treatment as being more important. The comments section revealed that 43% felt that they had a lack of experience; only 5% were confident, 16% thought that complete denture treatment would become obsolete and only 5% recognised the continuing importance of complete denture treatment.

Conclusion There is a disparity between the comments which indicate a lack of confidence in complete denture treatment and the response to the questionnaire. Other authors have commented on the lack of experience that has resulted in new graduates entering vocational training with little confidence in complete denture techniques. This report has highlighted these difficulties with respect to a current cohort of DF1s.

Introduction

In a paper looking forward to the twenty-first century, Seward¹ commented on the General Dental Council's (GDC 's) First five years² stating, that 'to adopt the status quo for any of the educational developments would be to abnegate our responsibility'. Since then several reports have highlighted the real and potential lack of competencies in the list prescribed by the GDC.^3,4,5,6,7 In a series of articles, Clark et al. brought to our attention what he termed a crisis in complete denture treatment in the UK.⁷ This culminated in an investigation into the undergraduate complete denture curriculum throughout the UK. The authors found that there is no mechanism in place to ensure that UK dental schools teach to the level expected by the GDC.

Seward considered the one-year period of mandatory vocational training (VT) (now referred to as dental foundation year 1, DF1, training) to be an outstanding educational success.¹ However, Cabot found little evidence to support this claim.⁸ His investigation of two successive cohorts of vocational dental practitioners (VDPs) found that vocational training (VT) produced practitioners capable of independent practice but that it could be better. In particular there was a need for the trainers to progress in parallel with the VDPs, undergoing their own skills progression.

Patel et al. compared the views of new VDPs with those of their trainers regarding how undergraduate dental education had prepared them for vocational training.⁹ The study also set out to identify areas of weakness in undergraduate education that could influence the future training needs of vocational trainers. With reference to removable prosthodontics, most trainers (68%) scored undergraduate training in construction of immediate dentures to be 'poor', compared to the majority of VDPs (82%) who were content with their training in this field. Overall, the majority of VDPs believed that they were prepared adequately at dental school for the construction of removable prostheses in general practice. Similarly in the field of complete dentures a large majority of the VDPs (94%) and trainers (88%) felt that it was covered well or very well. In conclusion, they confirmed that there were definite areas of the undergraduate course in which there was a perceived lack of training and that those areas should be targeted for extra tuition during their vocational training year.

Clark et al. referred to the illogicality of reducing the teaching of complete dentures in response to the reduction in the number of edentulous patients, to the point that removable prosthodontics is now considered one of the weakest areas for vocational trainers.⁷ A lack of experience has resulted in the new graduate entering vocational training with little confidence in denture techniques and unable, sometimes unwilling, to undertake these procedures.

The second part of this overall study was undertaken to investigate the opinions of a cohort of DF1s regarding their skills and competence in relation to their educational background in complete dentures. It should be considered in the light of a concurrent survey of the existing teaching of the complete denture curriculum in the UK.⁷ Added to the data of other studies it showed the lack of experience in complete dentures that undergraduates can suffer during their years in dental school.

To date, there has not been a specific study of the views of the graduates as they go into general practice, faced with the clinical reality of providing complete dentures for the general public. Hence this survey will consider the responses of a cohort of recently qualified dentists working as dental foundation year 1 (DF1s), concerning their experience in dental school and their self-perceived levels of competency in complete denture construction in general practice.

Methods

VDP questionnaire

The London Deanery consists of 15 individual dental foundation training schemes, each of which has approximately 10-15 DF1s. Each scheme has its own advisor and an administrator. A questionnaire was formulated to be circulated among the DF1s. A general review of the project headed the questionnaire and the questionnaire itself comprised of several sections. The respondents remained anonymous throughout the study.

With permission from the Dean of the London Deanery, each advisor was emailed the questionnaire, with a request that the administrator would print, distribute and collect the questionnaire while the DF1s were attending the day-release programme at their postgraduate centre. The completed questionnaires were then returned by post.

A pilot questionnaire was tested on a group of colleagues including a DF1 practitioner and amendments were made according to the feedback received. It was then submitted for statistical evaluation after which further amendments were made.

The definitive questionnaire was sent by email to all the London Dental Foundation year 1 training schemes (10) for distribution to the DF1s (approximately 100). Five schemes responded with a total of 56 completed questionnaires (56% response rate). Among the graduates 11 dental schools were represented, of which two were from abroad. All the respondents had qualified within the last two years. Seventeen (30%) were male and 39 (70%) female. Thirty-three (60%) of the DF1s qualified at the two London dental schools, 20 (36%) from the other UK dental schools and two (4%) from overseas.

The results of the DF1 questionnaire were collated and numerically evaluated. In the study, the median values of each of the group of responses were compared as this gave a true indication of the level in each group. The data were statistically analysed in order to detect any significant differences.

The numerical data produced from the individual questions suggested that most of the variables had a non-normal distribution (that is, skewed), as the mean value and the median value were not similar. For this reason the group comparisons were carried out using a non-parametric hypothesis test, the Mann-Whitney test. In this study the null hypothesis was that there is no median difference between the two groups (male/female and London/non-London trained).

Results

1. Several questions looked at the different types of denture produced during undergraduate studies

(i) Complete dentures

See Figure 1 and Table 1.

Figure 1

Complete dentures

Table 1 Complete dentures

The average (median) number of complete dentures made was 3.05, with the majority of DF1s making 2-3 complete dentures during their undergraduate years. A minority made up to ten and others as few as one. All had received some relevant clinical experience in this area.

(ii) Copy dentures

See Figure 2 and Table 2.

Figure 2

Copy dentures

Table 2 Copy dentures

Forty-six percent had no experience in this technique but a minority (approximately 26%) had made from two to four copy dentures.

(iii) Immediate replacement dentures

See Figure 3 and Table 3.

Figure 3

Immediate replacement

Table 3 Immediate replacement

The average (median 2.05) number of immediate replacement dentures made was two, with many (37%) clearly having very little (n = 1 immediate replacement denture) or no experience. A minority (10%) received more experience (n = 8-15 immediate replacement dentures) in this field.

(iv) Implant supported dentures

None of the DF1s had no experience in this field.

2. Questions based on a Likert Scale

The following analyses refer to those questions requiring responses using a Likert scale on the DF1 questionnaire.

(i) I enjoyed my undergraduate training in complete dentures

See Figure 4 and Table 4.

Figure 4

Enjoy undergraduate training

Table 4 Enjoy undergraduate training

DF1s who enjoyed their undergraduate complete denture course (35%) were fewer compared to those who did not enjoy it (44%).

(ii) I feel that my training has given me sufficient experience and confidence to offer this treatment in general practice

See Figure 5 and Table 5.

Figure 5

Experience and confidence

Table 5 Experience and confidence

The number of DF1s who felt confident in the overall procedure of making complete dentures (37%) was only slightly more than the number who had low confidence in the procedure (32%).

(iii) How do you rate the importance of complete dentures in modern general practice?

See Figure 6 and Table 6.

Figure 6

Importance

Table 6 Importance

The large majority (63%) of DF1s felt that complete dentures were an important or very important aspect of dentistry. However, there was a minority indicating total disagreement.

(iv) Complete denture procedures: how confident do you feel when undertaking the following procedures relating to complete dentures?

(a) Impressions

See Figure 7 and Table 7.

Figure 7

Impressions

Table 7 Impressions

The majority (69%) of DF1s were confident in this procedure. A small minority (4%) admitted to being less confident.

(b) Jaw relations

See Figure 8 and Table 8.

Figure 8

Jaw relations

Table 8 Jaw relations

Many (39%) DF1s did not feel confident in registering the horizontal and vertical relationships compared to 30% who expressed confidence.

(c) Adjustment of laboratory wax-up

See Figure 9 and Table 9.

Figure 9

Adjust wax-up

Table 9 Adjust wax-up

Thirty-five percent of DF1s felt confident with chair-side adjustment at the wax up stage, compared to 28% who did not.

(d) Fitting of dentures

See Figure 10 and Table 10.

Figure 10

Fitting

Table 10 Fitting

The majority (63%) of DF1s were confident in fitting new dentures.

(e) After-care and adjustment

See Figure 11 and Table 11.

Figure 11

Aftercare

Table 11 Aftercare

Most (65%) of the DF1s felt largely confident in making denture adjustments.

3. Male/Female differences

A further analysis was carried out to determine whether there was any significant difference in the responses between the sexes in the answers to any of the questions. The grouped median value of both the male and female respondents in all of the questions were then compared and statistically analysed for any significant differences using the Mann-Whitney test. Two questions identified significant differences between the sexes; with respect to the procedure of fitting dentures (p-value 0.043) and aftercare (p-value 0.015), males were significantly more confident than females. There were no other significant differences between the sexes in their responses.

4. London/Non-London division

The two undergraduate London dental schools contain the largest cohort of students in the UK compared to the other undergraduate dental schools. Most of the graduates attempt to find a dental foundation training scheme in the area where they qualify; consequently a significant number of respondents in this survey were London trained (n = 21, 38%). However, the London dental foundation training schemes attract applications from all UK graduates and the remaining respondents (n = 33, 59%) were a cross-section of the other UK dental schools.

The cohort was divided between the London and non-London trained graduates and the results analysed to discover if there were any significant differences between the two groups with respect to the responses given to any of the questions. The grouped median values of each cohort were obtained and the Mann-Whitney test was applied. Three questions showed evidence of a significant difference between the London trained and non-London trained respondents:

(i) The number of complete dentures undertaken during undergraduate studies

Group median scores for London 2.61/non-London 4.75 (p-value 0.001).

(ii) The number of copy dentures undertaken during undergraduate studies

Group median London 0.34/non-London 1.83 (p-value 0.000).

(iii) How do you rate the importance of complete denture treatment in modern general practice?

Group median London 2.53/non-London 1.88 (p-value 0.002).

London trained respondents had made significantly fewer dentures and copy dentures than the non-London cohort.

Non-London trained respondents rated the importance of complete dentures in modern general dental practice significantly greater than the London trained cohort.

The finding that most of the DF1s were less confident in the recording of jaw relationships is not surprising as this procedure is more dependent on experience than the more technical aspects of treatment.

5. Comments

The comments section of the questionnaire was studied and a coding assigned after identifying and categorising the various responses (Table 12).

Table 12 Categorisation of comments section responses

The following is a selection of these comments. More than one comment was expressed by many DF1s. Some did not comment.

Lack of practical experience/lack of confidence

DF1 9: Find them hard – do not get enough practice.

DF1 17: Need more experience to become more confident.

DF1 18: I feel there is not enough undergraduate training in providing good sets of complete dentures.

DF1 22: Although we were taught the principles of C/C dentures, I feel that I have limited experience and confidence when dealing with such cases in practice. This is due to the limited number of cases taken on as an undergraduate. C/C dentures are heavily operator dependent so more importance should be given to this area of the dental undergraduate course.

DF1 23: Not enough theory or practical.

DF1 32: Compared to other aspects of dentistry (eg restorations, extractions) I feel I have had very limited exposure regarding complete dentures.

DF1 33: No undergraduate training in complete dentures is sufficient to provide enough confidence to carry out treatment in general practice. I have needed my trainer's help in providing complete dentures for my patients in practice.

DF1 35: I feel I could have had more cases.

DF1 39: I don't think I learnt a whole lot as the demonstrator always did it for you.

DF1 42: But basic experience which must be improved with seeing a greater number of cases.

DF1 44: Would rather deal with other cases.

DF1 45: The experience I gained at university was not sufficient to give me confidence to complete dentures in practice.

DF1 51: I feel that although provided with good academic and clinical training, we still require more clinical time spent together with demonstrators to be more confident treating patients requiring C/C or C/P.

DF1 52: Limited undergraduate experience means we are not fully prepared for any difficulties in practice.

Confidence

DF1 5: I felt confident in complete dentures on leaving university.

DF1 16: It is essential to understand the principles behind the clinical and technical aspects of complete denture provision. I think my undergraduate training prepared me very well for this.

DF1 46: I feel that I have learned the practical side to C/C during VT.

Procedures lacking in confidence

DF1 6: Complete dentures are always a challenge, particularly in establishing the OVD without causing any TMJ dysfunction/problems.

DF1 13: Good undergraduate training but still very unsure of bite registration stage. Never know whether laboratory errors or mine when problems.

DF1 18: More emphasis should be put on how to take good impressions and jaw registration.

DF1 24: Waxing up laboratory skills really helped but not many skills learnt at university for adjusting acrylic so that you can't see adjustments made especially when there is no laboratory on site to re-polish after.

Undergraduate studies

Favourable comments

DF1 12: Undergraduate training provides a sound foundation for the field of prosthodontics.

DF1 13: Good undergraduate training

DF1 15: My undergraduate studies were good as our dean was a prosthodontist.

DF1 16: I feel that complete dentures are an important service in general dental practice and it is essential to understand the principles behind the clinical and technical aspects of complete denture provision. I think my undergraduate training prepared me very well for this.

DF1 43: I believe that the core knowledge was provided at university.

DF1 54: I feel my training in dental school was adequate to understand the theory behind complete dentures.

Unfavourable comments

DF1 21: Although I felt that my lectures/tutorials on complete dentures were not very good, I learnt most of my knowledge on completes by being on clinics and carrying out the procedures.

DF1 33: No undergraduate training in complete dentures is sufficient to provide enough confidence to carry out treatment in general practice.

DF1 55: I think that our teaching was poorly organised at dental school such that we were making them before we got theory teaching.

DF1 56: I feel my undergraduate teaching was poor and presented in an uninteresting way. I feel I lacked understanding in the area when I left school.

General dental practice is different from dental school

DF1 4: I feel impression stages are being compromised by lack of appropriate time under NHS conditions.

DF1 20: Time constraints and amount of visits available to make complete dentures in practice is very limited compared to hospital.

DF1 24: Handling simple cases is fine when carrying out all the stages, very tempting to skip steps now, especially with nurse pressure, different materials, principal ethics. Taking over from previous VDP difficult. Hard to be as thorough in GDP – no surveyor/design sheets. There is no laboratory on site to re-polish after.

DF1 30: Undergraduate studies more difficult cases as referrals from GDPs. GDP is easier.

DF1 55: Also, dental school teaches the ideal method which is not always possible in practice.

In future complete denture treatment will become obsolete

VDP 1: I think that the teaching of complete dentures is still required, but in modern dental practice the provision of such cases is reducing, with patients keeping their teeth for much longer. For the future I think that GDPs can easily become deskilled through the lack of cases and may need to refer such cases to specialist care.

VDP 5: Due to the advent of implants and patients retaining their teeth I feel conventional complete dentures will become increasingly obsolete, with the exception of implant supported dentures.

VDP 8: Only one C/C case so far in VT as patients retaining their teeth longer.

VDP 25: I think C/C are becoming fewer in number and maybe soon only specialists will be doing.

Continued importance

VDP 52: There will still be a need for complete dentures even with advancements in implants.

VDP 53: I think this aspect of dentistry is very important for the future, as people are living longer and requiring dentures.

VDP 54: I still think it will be an important part of dentistry for some years to come.

Discussion

Despite the reduction in the number of edentulous persons in the UK population, an increase in life span will probably offset this reduction. It has been predicted that there will always be a need for the construction of complete dentures and the continued physiological reduction of the alveolar ridge with increasing age will make complete denture construction even more difficult in the future.¹⁰

Some of the DF1s' comments were oblivious to these predicted outcomes, as they see complete dentures becoming increasingly obsolete. This view could be regarded as wishful thinking engendered by a lack of experience.

Regional variation

The Adult Dental Health surveys of 1998¹¹ and 2010,¹² while confirming the decline in the edentulous population as a percentage of the total, also highlighted a regional variation in the UK, with a higher percentage of edentulous individuals in northern regions. This regional variation manifests itself in the clinical experience of many of the undergraduates. The London dental schools cited a lack of sufficient complete denture patients as a reason for the low clinical experience of their undergraduates. They also commented that they have integrated the subject into the general prosthodontic curriculum.

As reported in Part 1, generally the number of complete dentures expected to be made is extremely low, one to three, in most schools with an exception of eight reported at a northern school.

According to this study London dental school graduates make fewer dentures than their regional colleagues, which may go some way to explaining the significant difference between the two cohorts in their rating of the importance of complete dentures in general practice.

Some authors^13,14 have commented that in a stretched curriculum it is impossible to devote adequate time to complete dentures and have advocated simplified techniques such as copy dentures as a compromise solution. It would appear that this view has not had any influence on undergraduate training since within the present cohort of DF1s on average they only completed one such treatment.

There is often a perceived discrepancy between undergraduate dental training and the requirements of general practice and this was reflected in comments highlighting that the traditional curriculum, as taught in the dental schools, is not adequate preparation for general dental practice. The danger of this view is that if the graduate lacks sufficient competence and confidence in their theoretical and clinical background, perforce, compromises might be made that are not in the patient's best interests.

Implants

Implants, it is argued, will certainly have an impact on the future of clinical decision making when a clinician is faced with a complete denture patient. Contrary to the expectations mentioned in a recent report⁶ and despite promotion in the literature and the York Consensus statement,¹⁵ the undergraduates were getting very little experience in implant supported dentures. In fact patients were not taking this option in great numbers due the perceived costs and fear of surgery. Downturns in the economy make it very unlikely that extensive use of implants will develop either in the National Health Service or private practice. Certainly, from their comments DF1s seemed to be unaware of the limitations of this treatment option.

Competence

The GDC requires dental graduates to be 'competent at designing effective indirect restorations and complete and partial dentures'.¹⁶

'Competent' is defined in the GDC document as 'having a sound theoretical knowledge and understanding of the subject together with an adequate clinical experience to be able to resolve clinical problems encountered, independently, or without assistance'.

The comments which reflect a lack of confidence in complete denture treatment are at odds with the results of the Likert scale based questions where apart from the recording of jaw relationships many DF1s expressed high to moderate levels of confidence. Patel et al.⁹ noted a similar response in their cohort of DF1s.

Conclusion

Clark et al.⁷ commented on the lack of experience that has resulted in the new graduate entering vocational training with little confidence in denture techniques and unable, sometimes unwilling, to undertake these procedures.

This report has highlighted these difficulties with respect to a current cohort of DF1s. A previous paper¹⁰ confirmed the apparent downgrading of complete dentures as a curricular subject in many of the UK dental schools. Clark's letter¹⁷ referring to his own findings did not appear to elicit a response from the relevant authorities. It would be of interest to investigate the overall expectations of the skills required by new graduates, particularly during their first year post graduation and to evaluate whether the current DF1 trainees meet these expectations. It is hoped that treatment of the edentulous patient will feature highly in such a study.