Looking Back
I graduated from the University of Washington School of Dentistry in 1999. Overall, my dental school experience was very positive. I had tremendous mentors who trained me well, establishing the foundation upon which I have built my career. I remained a perpetual student and continued my efforts to grow professionally. My alma mater fulfilled its essential functions: It prepared me to transition into clinical practice, to be adaptable to changes, to think critically, and to be a life-long learner.
Roseman College of Dental Medicine: Looking Forward
Recently, I had the opportunity to visit Roseman University of Health Sciences College of Dental Medicine (CODM) in South Jordan, Utah, to train its clinical faculty in the Bioclear Method for posterior composites. In 2015, Roseman adopted the method for its preclinical curriculum. The Bioclear Method was chosen for its relative simplicity, predictability, and quick skill acquisition by novice learners. The baton was now being passed to the clinical faculty who would continue teaching the method to students transitioning into clinic.
Roseman CODM is committed in its mission to prepare students by teaching them modern techniques within a rich learning environment fostered by an egalitarian relationship between faculty and students. Accepting the trend for direct posterior restorations in clinical practice, the school shifted its curriculum to focus on composite resin over amalgam. Reflecting upon this, I realized that I very rarely place amalgam restorations anymore. Although I received minimal training for the few posterior composites I placed in dental school, my skills adapted and grew with the gradual changes within my practice.
How Well Have Operative Curriculums Adapted to Clinical Trends?
The steady decline of amalgam restorations, in favor of composite resin in posterior restorations, is undeniable. The 2006 ADA Procedure Recap Report showed that 70% of direct restorations were composite resin. This has been spurred by patient demands for aesthetic options, fear of mercury exposure, mercury disposal concerns, the trend toward less invasive procedures, and improvements in resin composites, adhesives, and techniques for placement. Despite assurances of amalgam safety and the technique challenges associated with properly placing composite resins, composite is here to stay. It causes one to wonder if amalgam will eventually fade away completely.
With my recent experience at Roseman, I began to ponder how well our schools adapted/changed to prepare students for the clinical demands of a modern practice. A survey of dental schools in the United Kingdom, Ireland, Canada, and the United States concluded that US schools were lagging behind in their curriculum for posterior composites compared to other schools.1 Other studies compared curriculum time versus clinical procedures performed for amalgam and composite restorations. The findings revealed the number of posterior restorations filled with composite exceeded amalgam, although relative curriculum time allotted for composite and amalgam were similar.2,3
Curiosity prompted me to investigate current dental licensure requirements for operative dentistry. Since schools must ensure students are basically trained to meet licensure requirements, I surmised that this would offer reasonable insight into what the schools are teaching. I discovered all of the exams have similar requirements for Class II restorations. The preparation can be either a traditional G.V. Black prep or slot prep for alloy or the same preparation (with minor modifications) for composite. More than a century later, we are still basically teaching G.V. Black cavity prep designs while using amalgam and composite almost interchangeably for direct posterior restorations. But is a century-old mortise and tenon joint cavity prep design appropriate for modern adhesive materials?
Amalgam Versus Composite Technique Instruction
Amalgam and composite are very different materials with different technical requirements. Composite resin placement technique has more components to master than are required to place an amalgam restoration.
G.V. Black contributed much to our profession by standardizing amalgam prep design and technique, but such standardization is actually lacking for composite resin. Schools must teach restorative skills to a basic level of competency. Without a universal standard for composite resin, what should schools teach, how do they assess progress, and how successful are they? The University of Texas Health Science Center at San Antonio Dental School scrutinized failure rates of resin restorations in its student clinics. It was found that Class II composite replacements greatly exceeded Class II amalgam replacements by a factor of 10:1.4 It was acknowledged that composite technique has more points for potential failure than amalgam; thus improved instruction and supervision of novice students would be necessary.
Is Maintaining the Status Quo Sufficient?
Our patients are living longer and keeping more of their teeth. We should be able to deliver modern, conservative options to repair teeth. New graduates must have basic competency in this fundamental skill. If we accept the growing trend for posterior composite restorations, we must ensure graduates are fully and properly trained in the procedure. Considering the greater technical challenges associated with the placement of composite resin restorations, perhaps a curriculum overhaul is due that would allow more time and resources to nurture student competency with the associated techniques. I appreciate that tension must exist between licensing agencies and dental schools to ensure that new graduates are acquiring basic skills necessary to enter practice; however, are current licensing standards holding schools back from modernizing their operative curriculum, or vice versa? What is the best way to move the profession forward?
The following guest comments are by David S. Howard, DDS, the assistant professor and pre-clinical co-director of Roseman CODM:
I heard Tony Robbins once say the only humans that like change are wet babies. Whenever we consider change, a cautionary limbic activation makes us hesitant to follow through. Hence, the old adage “the more things change, the more they stay the same” is all too often a reality. Especially in a health science like dentistry, where a certain standard is expected and required, this adage holds true. As practitioners, we can ill afford monumental failures from trying to effect change. Furthermore, for dental schools or dental licensing organizations, such failures would potentially be more damaging and forever tarnish their reputations. The dental schools and licensing organizations take their position of superintending standards for the public very seriously. With this great responsibility, it is understandable that these administering agencies would lean toward safety of the known past and effect change with extreme caution.
Review of scientific literature revealed such high failure rates for posterior composite restorations that we, at Roseman, truly felt we had nothing to lose in our search for a better system. We looked at our curriculum and found our time invested in pre-clinic was divided 50/50 for composite/amalgam. However, the relative percentage of restorations being produced in clinic was 99/1 for composite/amalgam. We realized that we were experiencing a poor return on investment of our pre-clinic curriculum time in clinic. We felt very strongly that we needed to invest more curriculum time teaching and preparing students to provide restorative services that the patients desired with greater competency, predictability, efficiency, and productivity.
We investigated the Bioclear system and found that it effectively attends to all 3 consternating sciences that dentists must manage: physics, biology, and chemistry. Throughout the years, massive changes in bonding chemistry still failed to produce significant longevity of posterior composite restorations. We believe this is because the physics and biology involved have been largely ignored. The Bioclear Method addresses all 3 sciences in a very sensible way. Equally important is the fact that Bioclear is a method that can be quickly and easily mastered by novice learners, thus helping to decrease progression time toward competency, efficiency, and productivity. We will be releasing research data in support of this. We have no doubts or reservations that incorporating Bioclear into our curriculum was the absolute right thing to do at this time!
Closing Comments
Dental schools seem to have maintained an operative curriculum similar to my training years. They have limited curriculum time and resources to develop hand skills, basic techniques, and critical thinking.
Newly minted graduates are taught the basics and then left to self-navigate the many resin technique options available. All of this is understandable. However, current practice trends mean graduates will likely use technique-sensitive composite resin as the restorative material of choice. Furthermore, the changing practice model, group practices, and more transient dentist/patient relationships will potentially decrease opportunities for self-critique and concomitant skill maturation. I have to wonder: Is my G.V. Black-centered operative curriculum still adequate to train future graduates? Is Roseman CODM blazing the trail to meet the new demand?
References
- Lynch CD, McConnell RJ, Wilson NH. Teaching the placement of posterior resin-based composite restorations in U.S. dental schools. J Am Dent Assoc. 2006;137:619-625.
- Ottenga ME, Mjör I. Amalgam and composite posterior restorations: curriculum versus practice in operative dentistry at a US dental school. Oper Dent. 2007;32:524-528.
- Rey R, Nimmo S, Childs GS, et al. Curriculum time compared to clinical procedures in amalgam and composite posterior restorations in U.S. dental schools: a preliminary study. J Dent Educ. 2015;79:331-336.
- Overton JD, Sullivan DJ. Early failure of class II resin composite versus class II amalgam restorations placed by dental students. J Dent Educ. 2012;76:338-340.
Dr. Kim is co-director and full faculty of Bioclear Learning Center (BLC) International. She actively teaches and develops new curriculum for BLC. She also maintains a full-time patient practice in Tacoma and Bellevue, Wash. She can be reached via email at jihyonkim@bioclearmatrix.com.
Disclosure: Dr. Kim reports no dislosures.
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