Since the discovery of osseointegration, the use of dental implant therapy has notably increased as partly and completely edentulous patients seek a conservative, predictable and potentially esthetic treatment option for tooth replacement.1-3 Implant therapy is attractive to both clinicians and patients alike because of its relatively high success rate,4-7 improvements in patient quality of life measures following implant restoration8-10 and its long-term cost-effectiveness compared with other prosthetic options.11-14 Such factors have contributed to the widespread use of dental implants as an approach to tooth replacement in cases ranging from a missing single tooth to partial and even complete edentulism.
As a result of changing population demographics in both Canada and the United States,15 aging patients with a favourable socioeconomic standing, who have preserved the majority of their dentition and require tooth replacement or are looking to reconstruct a debilitated dentition, are increasing the demand for implant therapy. Subsequently, there has been an increase in demand for clinicians who are adequately trained and competent to provide this service. These trends have resulted in a need for both European16 and Canadian dental academic institutions and their representative organizations17 to include comprehensive dental implant curricula at both the postdoctoral and predoctoral levels. At the postdoctoral level, the focus is purposefully on surgical management and preparation of sites for oral implants, as well as complex, implant-borne prosthetic rehabilitation. However, at the predoctoral level, single-tooth implant and implant overdenture therapies are feasible and, thus, promote this standard of care among contemporary general dentists. As a result, most academic institutions in Europe, the United States and Canada have established predoctoral dental implant programs.
The rate of incorporation of oral implantology into predoctoral dental curricula has been relatively conservative compared with clinical adoption rates in the private sector, where implants have been in use for over 4 decades. In 1974, only 33% of U.S. dental schools reported implant therapy as part of their predoctoral curriculum.18 By 2004, a survey investigating predoctoral implant education at U.S. and Canadian dental institutions revealed that, although 97% of schools reported their students received didactic training, only 51% of students actually received any clinical experience restoring implants.17 Despite the apparent substantial increase in predoctoral implant education, national evaluations of graduating predoctoral dental students in the United States show a significant deficit in concurrence between inclusion of implant-based curricula and acquisition of proficient clinical skills.17 Surveys of graduating predoctoral students reveal that the 2 most common responses in relation to implant therapy education are "inadequate time" in the curriculum to master concepts (38.7% of respondents) and, consequently, a lack of "preparedness" (43% of respondents).19,20 Over time, the percentage of graduating students reporting inadequate time has declined (from 50% in 200121), yet the percentage currently reporting lack of preparedness remains consistent with earlier surveys.19,20
These more recent queries of graduating dental students should not be overlooked, as dental graduates who are exposed to implant therapy in formal didactic modalities (i.e., lectures, seminars, case series reviews) and preclinical simulations in the laboratory and who are engaged in the clinical management of implant patients at the predoctoral level are overwhelmingly more adept and confident in providing implant therapy as a general practitioner. 22 Adequate instructional experiences at the predoctoral level have been shown to result in dentists restoring more implants after graduation, referring more patients to surgical specialists and having a continuing desire to broaden their education in implant dentistry once in practice.23,24 This stands in stark contrast with graduates of programs that lack a formal implant curriculum.
Although previous surveys have evaluated the prevalence of implant curricula in U.S. and Canadian dental schools in the early 2000s,17 few data address Canadian dental institutions' current predoctoral implant program content and preferences. Recent findings of such a study of U.S. predoctoral implant programs revealed significant curricular and clinical heterogeneity between regions, despite predoctoral implant program director demographics that were more homogeneous.25
The objective of this study was to survey predoctoral implant program directors of schools accredited by the Commission on Dental Accreditation of Canada (CDAC) to assess current didactic and clinical preferences in the provision of implant therapy at the predoctoral level and compare the findings with those from U.S. institutions. Such data on current clinical instructional preferences are of value, as in 2015 all CDAC-accredited Canadian dental schools introduced implant therapy into predoctoral curricula. Canadian dental institutions looking to modify predoctoral implant programs may also use this information to help augment their programs.
Methods
Predoctoral implant program directors were identified for the 10 CDAC-accredited dental schools in Canada.26 The appropriate contacts were identified by searching the web site of each institution's dental school. Contact was made via email to verify the person's position as the predoctoral implant program director.
A draft survey was developed to query program directors in terms of demographics, diagnosis, treatment planning, restorative techniques, preferences and trends in dental implant therapy. After review and revision by faculty members at the University of Iowa College of Dentistry, a final version of the survey was accepted. An online survey tool called Qualtrics (Provo, Utah, USA) was used to create the survey and collect data from respondents.
The survey included 15 questions on demographics. Some, such as "Please select from the categories below any specialty for which you have certification" were contingent on the participant answering "Yes" to an earlier question, i.e., "Do you have specialty training?" Following the demographic section, the survey contained 12 questions relating to the predoctoral implant program's educational methods, diagnosis, treatment planning, restorative techniques, preferences and trends in dental implant therapy. Finally, program directors were asked what they feel is the most beneficial instructional method in preparing students to provide implant therapy on graduation and whether they feel their program prepares students adequately to provide routine dental implant therapy for tooth replacement on graduation.
A letter detailing the objective of the study and containing a link to the survey was emailed to each predoctoral implant director on 12 August 2013. If a survey response or email message was not received from the institution, a follow-up email was sent 3 weeks later and every 3–4 weeks until 5 November 2013. Following compilation and investigation of the results, we noted multiple incomplete responses. Thus, directors with incomplete responses were contacted again by email on 6 January 2014. All participants were able to opt out by responding to any of the emails indicating that they did not wish to be contacted or by simply not completing the survey. In addition, after beginning the survey, participants had the option of not answering any 1 or all of the questions.
Data were imported into a SPSS dataset. Simple descriptive statistics were used to present the data and information was summarized using SPSS version 22.0 (IBM Inc., New York, NY). Because the sample size was small (10 schools), no statistical tests for associations were conducted.
This study was approved by the University of Iowa Institutional Review Board (#201307759).
Results
Predoctoral implant program directors from all 10 Canadian schools participated in the study (100% response rate). Most program directors were men (80%), aged ≥ 51 years (60%) and had practised for at least 21 years (80%) (Table 1). All program directors had undergone specialty training, with 90% certified in prosthodontics and 10% in oral and maxillofacial surgery. Of the 5 program directors who responded to the question on board certification, 4 were certified in prosthodontics and 1 was certified in oral and maxillofacial surgery. With regard to implant therapy training, 70% indicated that they had formal training. Forty percent (40%) of program directors had worked for more than 20 years in the same institution and 30% had served as predoctoral implant program directors for 5–6 years.
Table 1 Characteristics of participants.
| Characteristic (n = 10) | % of respondents |
|---|---|
| *Note: 5 of the 10 directors reported board certification. | |
| Sex | |
| Male | 80 |
| Female | 20 |
| Age range, years | |
| 20–30 | 0 |
| 31–40 | 10 |
| 41–50 | 30 |
| ≥ 51 | 60 |
| No. years practising dentistry | |
| < 1 | 0 |
| 1–2 | 0 |
| 3–4 | 0 |
| 5–6 | 0 |
| 7–10 | 10 |
| 11–15 | 0 |
| 16–20 | 10 |
| ≥ 21 | 80 |
| Specialty training | |
| Yes | 100 |
| No | 0 |
| Specialty certification | |
| Dental public health | 0 |
| Endodontics | 0 |
| Oral and maxillofacial pathology | 0 |
| Oral and maxillofacial radiology | 0 |
| Oral and maxillofacial surgery | 10 |
| Orthodontics | 0 |
| Pediatric dentistry | 0 |
| Periodontics | 0 |
| Prosthodontics | 90 |
| Board certification (5)* | |
| Dental public health | 0 |
| Endodontics | 0 |
| Oral and maxillofacial pathology | 0 |
| Oral and maxillofacial radiology | 0 |
| Oral and maxillofacial surgery | 10 |
| Orthodontics | 0 |
| Pediatric dentistry | 0 |
| Periodontics | 0 |
| Prosthodontics | 40 |
| Implant therapy training | |
| Yes | 70 |
| No | 30 |
| No. years working in this institution | |
| 0–5 | 20 |
| 6–10 | 20 |
| 11–20 | 20 |
| ≥ 21 | 40 |
| Number of years served as predoctoral implant program director | |
| 0–2 | 20 |
| 3–4 | 10 |
| 5–6 | 30 |
| 7–8 | 10 |
| 9–10 | 10 |
| 11–15 | 10 |
| 16–20 | 10 |
| ≥ 21 | 0 |
In terms of institutional characteristics (Table 2) most program directors were affiliated with the prosthodontics department (70%). The various departments involved in the predoctoral implant program included: prosthodontics (90% of all schools), oral and maxillofacial surgery (90%), periodontics (60%), oral and maxillofacial radiology (50%), restorative dentistry (40%) and orthodontics (20%). The predoctoral program was integrated into the first year (10%), second year (50%), third year (90%) and fourth year (70%) of the dental school curriculum.
Table 2 Institutional characteristics of Canadian predoctoral dental implant programs.
| Characteristic (n = 10) | % of respondents |
|---|---|
| Department affiliated with | |
| Dental public health | 0 |
| Endodontics | 0 |
| Oral and maxillofacial pathology | 0 |
| Oral and maxillofacial radiology | 0 |
| Oral and maxillofacial surgery | 10 |
| Orthodontics | 0 |
| Pediatric dentistry | 0 |
| Periodontics | 0 |
| Prosthodontics | 70 |
| Restorative dentistry | 20 |
| Departments involved in predoctoral implant program | |
| Dental public health | 0 |
| Endodontics | 0 |
| Oral and maxillofacial pathology | 0 |
| Oral and maxillofacial radiology | 50 |
| Oral and maxillofacial surgery | 90 |
| Orthodontics | 20 |
| Pediatric dentistry | 0 |
| Periodontics | 60 |
| Prosthodontics | 90 |
| Restorative dentistry | 40 |
| Years of the dental curriculum in which the predoctoral implant program is integrated | |
| First | 10 |
| Second | 50 |
| Third | 90 |
| Fourth | 70 |
Half of the program directors said that they used 2 implant systems in their program, 30% used 3 systems and 20% used only 1 system (Table 3). Apart from didactic components, both simulation exercises (without direct patient care) and direct patient care under supervision were implemented in 90% of predoctoral implant programs. The most frequently taught restorative implant methods were posterior single-implant-supported single crown (100%), mandibular implant-tissue-supported overdenture (90%), anterior implant-supported single crown (60%) and posterior 3-unit implant-supported bridge (50%). All programs required their students to prepare surgical guides before implant placement.
Students at all schools routinely used guided surgery planning software in their undergraduate implant curriculum (Table 4). Fixture-level impression methods were taught most often (90% of schools). Open-tray impression techniques were used in 70% of schools and the closed-tray technique was used in 30% of schools. The most frequently used abutment type was a custom abutment (60%). Titanium (100%) and zirconia (60%) were the most frequently used abutment materials. The screw-retention fixation method (60%) was slightly favoured over cement retention (40%).
Half of the program directors "disagreed" that the predoctoral program adequately prepared students to provide routine dental implant therapy for tooth replacement after graduation (Table 5). Only 20% "strongly agreed" and 30% "agreed" that the program adequately prepared students for this work. A vast majority of program directors (90%) responded that direct supervised patient care is the most beneficial instructional method.
Table 3 Characteristics of Canadian predoctoral dental implant programs.
| Characteristic (n = 10) | % of respondents |
|---|---|
| Number of implant systems to which predoctoral students are exposed | |
| 1 | 20 |
| 2 | 50 |
| 3 | 30 |
| 4 or more | 0 |
| Aside from the didactic component, exercises included in implant program | |
| Simulation exercise (not direct patient care) | 90 |
| Direct patient care under supervision | 90 |
| Restorative implant methods taught in clinic | |
| Posterior single-implant-supported single crown | 100 |
| Anterior implant-supported single crown | 60 |
| Mandibular implant-tissue-supported overdenture | 90 |
| Maxillary implant-tissue-supported overdenture | 20 |
| Posterior 3-unit implant-supported fixed partial denture | 50 |
| Anterior 3-unit implant-supported fixed partial denture | 30 |
| Others | 0 |
| Are students required to prepare a surgical guide or a set of surgical guides before surgical implant placement? | |
| Yes | 100 |
Table 4 Implant techniques taught in Canadian dental schools.
| Technique (n = 10) | % of respondents |
|---|---|
| Impression modalities primarily taught | |
| Fixture level | 90 |
| Abutment level | 10 |
| Impression technique primarily taught | |
| Closed tray | 30 |
| Open tray | 70 |
| Abutment type used primarily in program | |
| Stock | 40 |
| Custom | 60 |
| Abutment materials used | |
| Titanium | 100 |
| Zirconia | 60 |
| Abutment materials used Fixation modality primarily taught | |
| Noble metal | 30 |
| Others | 0 |
| Screw retained | 60 |
| Cement retained | 40 |
Table 5 Opinions of directors about the effectiveness of the predoctoral dental implant program taught at their school.
| Viewpoint (n = 10) | % of respondents |
|---|---|
| Predoctoral program adequately prepares students to provide routine dental implant therapy for tooth replacement upon graduation | |
| Strongly agree | 20 |
| Agree | 30 |
| Disagree | 50 |
| Strongly disagree | 0 |
| Instructional method that is most beneficial | |
| Didactic | 0 |
| Preclinical on a bench top | 10 |
| Preclinical on a simulated patient | 0 |
| Direct, supervised patient care | 90 |
Discussion
In this cross-sectional survey, the characteristics of predoctoral dental implant programs at all 10 Canadian institutions were assessed from the responses of the institutions' predoctoral implant program directors, which provide a comprehensive overview of current trends in Canadian predoctoral implant education. Assessment was based on program director demographics, curricular content and preferences and program directors' perceptions of graduating students' preparedness to provide dental implant therapy on graduation. In a similar survey of predoctoral dental implant programs in the United States, program and curricular heterogeneity was observed between regions.25 As Canada has fewer dental schools (10), our findings show less heterogeneity among institutions or regions. Whether such relative uniformity among Canadian institutions is intentional or conditional is indiscernible at this time.
Demographically, Canadian predoctoral implant program directors are predominantly men, aged 51 or older, have specialty training in prosthodontics and have been practising clinical dentistry for 21 or more years. Such characteristics are in line with those of U.S. predoctoral implant program directors, where a clear majority are men, older than 51 years of age, have specialty training in prosthodontics and have been practising dentistry for 21 or more years.25 Program directors in Canada are also predominantly affiliated with restorative, rather than surgical, disciplines in their institution, and a predominant majority have received formal training in oral implantology, which also mirrors U.S. data. A likely cause for this observed trend is that implant dentistry is fundamentally a restorative treatment approach, supported by surgical protocols. In addition, most predoctoral implant learning has been focused on treatment planning and restoration of implants, rather than surgical management of the implant patient. As implant dentistry continues to become more pervasive and surgical protocols diffuse into the predoctoral curriculum,27 one may predict an increase in program directors with surgical backgrounds in the future.
Almost half of Canadian predoctoral implant program directors have been working at their institution as a faculty member for more than 21 years, with an even distribution of remaining program directors in 0–5 year, 6–10 year and 11–20 year ranges. Compared with their counterparts in the United States, on average, Canadian predoctoral implant program directors appear to have longer tenure as faculty at their institution; however, the number of Canadian directors is much smaller than in the United States. Despite a "greying" of Canadian implant program directors, many have only been program directors for 6 years or less, which also directly correlates with U.S. program director demography. Faculty turnover as a result of retirement or transition into private practice, as well as promotion of mid/late-career faculty, are potential factors that could be influencing the observed trend.28
Because of the complexity and interdisciplinary nature of implant-based treatment approaches, it is not surprising that most Canadian dental schools choose to incorporate implant curricula into the third and fourth years of dental school, a trend also seen in the United States. The need for sufficient didactic, clinical and laboratory skills to facilitate implant therapy is a likely a reason for this observed timing.
One aspect of curriculum decisions that appears to differ between Canadian and U.S. institutions is the fact that Canadian institutions seem to favour heterogeneity in implant-systems exposure, with most Canadian institutions exposing predoctoral students to 2 or 3 systems. In contrast, U.S. institutions clearly favour the use of a single system at an institution. Whether such preferences are based on class size or the preferences of the program directors themselves is difficult to establish and a limitation of this study. However, many U.S. dental schools receive subsidized or donated implant componentry from manufacturers, which defrays costs for patients and incentivizes treatment among predoctoral students. Such agreements between manufacturers and institutions in the U.S. could be contributing to these observations.
Aside from didactic elements, the overwhelming majority of Canadian predoctoral implant programs offer both simulated, as well as direct patient care experiences, to their students. Posterior single-tooth implant-supported restorations and mandibular implant-tissue-supported overdentures are the predominant restorative methods taught. In addition, anterior single-tooth implant-supported restorations, as well posterior 3-unit implant-supported fixed partial dentures have a significant presence in Canadian predoctoral implant curricula. Complete unanimity exists among Canadian institutions with regard to the requirement for predoctoral students to prepare a surgical guide or a set of surgical guides before placement of the implant fixture. These practices are identical to those in U.S. predoctoral implant program curricula.
Comparing technical protocols favoured in Canadian and U.S. dental schools reveals the greatest philosophical differences. Although both U.S. and Canadian implant program directors overwhelmingly favour fixture-level, as opposed to abutment-level impression modalities, Canadian curricula tend to favour open-tray impression techniques whereas U.S. institutions favour closed-tray techniques. U.S. institutions are currently split with regard to teaching primarily stock or custom abutments in predoctoral curricula. Canadian institutions appear to be slightly in favour of abutment customization. This observation could be explained by the fact that Canadian institutions seem to prefer screw retention (which often requires custom componentry), whereas U.S. institutions seem to favour cement retention as the primary fixation method for fixed-implant restorations. When considering abutment biomaterials, Canadian and U.S. institutions are identical, with 100% employing titanium, 60% employing zirconia and 30% employing noble metal (cast) abutments.
Most Canadian program directors feel that direct, supervised patient care is th e most useful instructional method in terms of student growth, learning and progress in the area of oral implantology. This view parallels the observations of U.S. program directors. With regard to student preparedness, U.S. data show that most predoctoral implant program directors feel positive about the level of preparedness of graduating dental students to provide implant therapy in practice. However, only half of Canadian program directors feel positive about this outcome measure. Why half feel negative about the preparedness of graduating students to perform implant therapy remains in question and should be the topic of a follow-up investigation. The results of this study are generalizable as all 10 dental schools in Canada participated in the survey. However, because of the limited sample size (resulting in lack of adequate power to conduct meaningful analyses), no statistical tests for associations between implant curriculum and school characteristics were conducted.
Conclusion
The results of this study demonstrate many parallels between Canadian and U.S. dental schools pertaining to predoctoral implant program director demographics, as well as institutional curriculum preferences. However, several areas of divergence exist: Canadian institutions show greater implant curriculum homogeneity, preferences for incorporation of guided surgery software during case planning, open-tray impressioning, abutment customization and screw retention, compared with U.S. institutions. Of potential concern to Canadian institutions, however, is why half of predoctoral implant program directors feel their students are inadequately prepared to provide routine dental implant therapy on graduation.
THE AUTHORS
 |
Dr. Barwacz is assistant professor, Craniofacial Clinical Research Center, The University of Iowa College of Dentistry, Iowa City, Iowa. |
 |
Dr. Avila-Ortiz is assistant professor, department of periodontics, The University of Iowa College of Dentistry, Iowa City, Iowa. |
 |
Dr. Allareddy is associate professor, department of orthodontics, The University of Iowa College of Dentistry, Iowa City, Iowa |
 |
Ms. Tamegnon is a graduate student, department of biostatistics, The University of Iowa College of Public Health, Iowa City, Iowa |
 |
Dr. Hoogeveen is a graduate resident, department of pediatric dentistry, The University of Iowa College of Dentistry, Iowa City, Iowa |
Correspondence to: Dr. Christopher A. Barwacz, The University of Iowa College of Dentistry, Department of Family Dentistry, Craniofacial Clinical Research Center, W425 Dental Science Bldg., Iowa City, IA 52242-1010, USA. Email: chris-barwacz@uiowa.edu
The authors have no declared financial interests in any company manufacturing the types of products mentioned in this article.
This article has been peer reviewed.
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