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Abstract: Introducing new technology in the dental school
curriculum may face some uphill challenges navigating through
university-level bureaucracy, financial ramifications, and
influencing the mindset of certain faculty. A dental school that
relies heavily on teaching traditional restor- ative procedures may
particularly face many challenges to embrace new technology. The
restorative department at a US dental school created a division of
computer-aided design and computer-aided manufacturing (CAD/CAM)
dentistry to introduce the concept of digital dentistry to dental
students and faculty. This article describes methods that were
adopted to improve acceptance and increase the productivity of
chairside CAD/CAM restorations for both students and faculty at the
dental school in US.
Keywords; CAD/CAM, curriculum, digital dentistry, US dental
school
Introduction
Although the fundamental motives behind restorative dentistry have
not changed, the production, materials, and delivery methods for
restorations have significantly improved due to the introduction of
digital dentistry [1]. The Commission on Dental Accreditation
(CODA) standards require all dental schools to provide faculty
development programs to help educa- tors keep up to date with new
technologies [2]. Recognizing the value of digital dentistry for
dental education, Oregon Health & Science University (OHSU)
School of Dentistry (Portland, OR, USA) decided to introduce
education on chairside computer-aided design and computer-aided
manu- facturing (CAD/CAM) systems in the curriculum. The goals were
to update the restorative curriculum and provide the students with
experience and understanding of chairside CAD/CAM systems.
The purpose of this short communication is to describe successful
development and implementation of a chairside CAD/CAM restorative
curriculum at a US dental school. The hope is that the details of
the US example can serve as guidance on how chairside CAD/CAM
systems can be introduced into the curriculum of Japanese dental
schools.
Each phase of CAD/CAM implementation in clinics Phase 1:
Introduction of chairside CAD/CAM to the school for faculty and
students revitalizing the CAD/CAM dentistry program The curriculum
of the chairside CAD/CAM restorative program started as an elective
program, which was conducted after regular school hours as a study
club from around 2010. First and second year students received
introductory training with the CEREC Red and Blue Cams (Dentsply
Sirona, Charlotte, NC, USA) in their preclinical education, but no
faculty or students were using it in the clinic.
The school then acquired eight intraoral scanners (CEREC Omnicam,
Dentsply Sirona) and ten milling machines (CEREC inLab MC XL,
Dentsply Sirona) in summer 2017. Two intraoral scanners, designated
only for restorations, and two milling machines were assigned to
two operators for clinic use in December 2017. The challenge in
this phase was that the initial utilization was very low, as
faculty, and senior students did not fully accept the equipment.
Due to the minimal utilization of the CAD/CAM system, the
Restorative Dentistry Department restructured the chairside CAD/CAM
program in the 1st quarter of 2018.
Methods for increasing awareness and improving acceptance The
initial step was to make chairside CAD/CAM restorations more
appealing by providing the patients with a financial incentive. The
fee for CAD/CAM restorations was approximately 25-35% lower
compared to porcelain fused metal and gold metal restorations
(Table 1). In addition, a CAD/CAM study club for faculty with
varying levels of experience was created. The monthly meeting
offered a lecture presentation and hands-on for every attendant.
The lecture presentation included basic information on using the
equipment, such as making a patient profile, selecting a tooth, and
selecting the CAD/CAM material for the restoration.
The program director developed a chairside CAD/CAM curriculum for
the clinic, with the approval of the dean of clinical affairs, in
which two dental operatories in the clinic were reserved
exclusively for these types of procedures. The director also met
with the clinical group leaders and encouraged the group leaders to
promote chairside CAD/CAM restorations among the students and help
identify teeth that can benefit from these types of
restorations.
Phase 2: Introduction of CAD/CAM to preclinical education
Preclinical experience with CAD/CAM systems The chairside CAD/CAM
restorative education for students and faculty are summarized in
Table 2. In the preclinical curriculum, 1st year students have an
opportunity to experience chairside CAD/CAM systems in dental
anatomy course, and learn about digitally designed tooth
morphology. In the 2nd year course, students utilize these units to
learn about treatment planning, and restorative procedures. After
that, the 2nd year students take an intensive 8-week CAD/CAM course
before matriculating into the clinic. In this CAD/CAM course, they
are asked to prepare typodont teeth with 7 different restoration
designs. They prepare each type of restoration thrice, with
self-evaluations for each one, in a stipulated amount of time.
Faculty that are interested in learning more about CAD/CAM
procedures are encouraged to participate in this course so that
they can enhance their knowledge base. The challenge in this phase
was to modify the curriculum in order to include CAD/CAM courses
for 1st and 2nd year dental students.
Phase 3: Introduction of CAD/CAM to clinical education clinical
experience with CAD/CAM systems For clinical sessions, faculty and
students are encouraged to schedule patients for an entire day in
order to start and finish the restoration in a single visit, as
followed by regular clinical digital workflow (Fig. 1). Ideally,
during the morning session, the student prepares the tooth and cap-
tures an intra-oral scan. Using a part of the lunch break, they
complete the laboratory procedures, including designing, milling,
and crystallization. The students have the opportunity to seek the
assistance of an in-house certified dental technician for the
laboratory phase. When the patient
Journal of Oral Science, Vol. 63, No. 4, 358-360, 2021
Short Communication
Successful development and implementation of a digital dentistry
curriculum at a US dental school Carlos A. Jurado1), Akimasa
Tsujimoto2), Amit Punj3), Natsuko Aida4), Masashi Miyazaki5), and
Hidehiko Watanabe6)
1) Texas Tech University Health Science Center, Woody L. Hunt
School of Dental Medicine, El Paso, TX, USA 2) Department of
Operative Dentistry, University of Iowa College of Dentistry, Iowa
City, IA, USA 3) Division of Prosthodontics, Montefiore Medical
Center Department of Dentistry, Bronx, NY, USA 4) Department of
Biochemistry, Tokyo Dental College, Tokyo, Japan 5) Department of
Operative Dentistry, Nihon University School of Dentistry, Tokyo,
Japan 6) Department of Restorative Dentistry, Oregon Health &
Science University School of Dentistry, Portland, OR, USA
(Received February 12, 2021; Accepted August 10, 2021)
Correspondence to Dr. Akimasa Tsujimoto, Department of Operative
Dentistry, University of Iowa College of Dentistry, 801 Newton Rd,
Iowa City, IA 52242, USA Fax: +1-319-355-7267 E-mail:
[email protected]
J-STAGE Advance Publication: September 9, 2021 Color figures can be
viewed in the online issue at J-STAGE.
doi.org/10.2334/josnusd.21-0070 DN/JST.JSTAGE/josnusd/21-0070
359
returns for the afternoon appointment, the restoration is ready for
delivery. Students are also encouraged to prepare teeth and remove
old restorations under rubber dam isolation. The rubber dam is
removed for the scanning phase and for the delivery phase they are
mandated to re-apply the rubber dam for bonding procedures. The
challenge in this phase was to first select the ideal clinical
faculty that were competent mentoring students on doing chair-side
CAD/CAM restorations on real patients and to organize the new
clinical workflow for CAD/CAM restorations.
Phase 4: Maintenance and expansion of CAD/CAM education outcomes
after two years The methods of phase 1-3 were implemented to
increase utilization and acceptance of chairside CAD/CAM
restoration. By the end of 2018, the strategies mentioned above
were coming to fruition. The dental students and faculty members
with limited experience using the chairside CAD/ CAM system felt
more comfortable using it and were very satisfied due to
the continual training. The assignment of dedicated clinic chairs
for CAD/ CAM procedures and a more confident mindset among both the
faculty and students in embracing this technology helped
tremendously. The culmina- tion of these strategies increased
CAD/CAM utilization almost three-fold in 2019, compared to 2018.
Although all types of restorations increased in number from 2018 to
2019, the production of chairside CAD/CAM restorations increased
sharply (Fig. 2). The challenge in this phase was to encourage
students to maintain the high production of chair-side CAD/ CAM
restorations.
Phase 5: Application of CAD/CAM systems for comprehensive treatment
At present, the school is continuing educational programs to enable
dental students and faculty to employ chair-side CAD/CAM
restorative treat- ments as a more comprehensive treatment method.
In addition, through the provision of new information in the study
club as it becomes available,
Table 1 Chairside computer-aided design and computer-aided
manufacturing (CAD/CAM) education for students and faculty
Student education Preclinical (1st and 2nd year students) Clinical
(3rd and 4th year students) 1st year students:
• CAD/CAM clinic 10 half day sessions/week • 2 CAD/CAM chairs • 4
CAD/CAM supervising instructors • 20 or more clinical instructors
trained for diagnosis and
treatment planning of CAD/CAM restorations
• Digital wax up using CAD/CAM machines (2 sessions) 2nd year
students:
• Introduction of CAD/CAM in indirect restoration course (1
session) • CAD/CAM project (scan and design) in a treatment
planning course (1 session) • Scan and design of implant
restorations (2 sessions) • CAD/CAM course (8 sessions)
Faculty education Monthly study club meetings
• Hands-on • Live patient • Case presentations
Participation in student chairside CAD/CAM courses • Access to
student lecture materials/videos
Table 2 School fee, estimated production cost, and profit of
chairside computer-aided design and computer-aided manufacturing
(CAD/CAM), porcelain fused to metal (PFM), and gold restorations at
OHSU
Restorations School fee Estimated production cost Profit
Chairside CAD/CAM restoration $ 450.00 $ 23.00 $ 427.00
Porcelain fused to metal restoration $ 600.00 $ 258.46 $
341.54
Gold metal restoration $ 525.00 $ 228.34 $ 296.66
Fig. 1 Typical clinical workflow of chairside CAD/CAM restoration
in a single visit by senior students. A: Pre-operative condition of
tooth #35; B: After removal of old restoration and caries lesion
with rubber dam; C: Core build-up using resin composite followed by
preparation for ceramic crown with rubber dam; D: Computer aided
design using CEREC; E: Bonding of CAD/CAM crown with rubber dam; F:
Post- operative condition immediately after removal of rubber dam
and occlusal adjustments
360
both dental students and faculty are enabled to remain up to date
with the latest technology. The school is also continuing
educations that promote not only the chairside CAD/CAM system, but
also restorations using an intraoral scanner and in-lab CAD/CAM
systems, for a broad use of digital dentistry.
Discussion
The current generation of students are quick learners of digital
dentistry, as compared to dentists who were trained in a different
era [3]. Thus, it is challenging for senior faculty to change their
clinical workflows in order to adapt themselves to new technology.
Different approaches to training in digital dentistry, keeping in
mind how different generations learn, are essential. Once faculty
feel confident that this technology yields success- ful
restorations, it becomes easier for them to recommend and teach it
to dental students.
In the statistics for production of restorations in the restorative
depart- ment at OHSU on 2018 and 2019, production of chair-side
CAD/CAM restorations increased year on year. This increase was
clearly related to the chairside CAD/CAM restorative training for
the faculty, and thus achieve- ment of this initial goal is shown
to be important in Phases 1-3. It is true that this kind of faculty
development does not lead to acceptance of the technology by every
faculty member, but it does appear to be possible to carry out
effective chairside CAD/CAM restorative training by continuing to
work patiently to have as many faculty as possible change their
behavior in line with the initial goal.
However, it is also true that there remain obstacles to the
continued expansion of this CAD/CAM education. The financial cost
can be a barrier to increasing the number of machines in the
clinic. It is extremely difficult to ensure that large numbers of
machines are available in both the simula- tion clinic and clinic
at all times. Some schools may be able to resolve this problem
through donations from alumni, but another approach, which may be
applied in parallel, is to rely on cooperation with manufacturers.
Of course, the role that industry can play in promoting chairside
CAD/CAM education in dental schools has already been
recognized.
Although, in Phases 4 and 5, manufacturers can also play an
important role in providing up-to-date information in the study
club and offering the new technologies and machines. Such a
collaboration between dental school education and the manufacturers
is a win-win situation for the further development of CAD/CAM
education. If students become more familiar with CAD/CAM dentistry,
they will move in that direction, and thus are likely to purchase
such equipment when they go into private practice. Further, the
spread of CAD/CAM dentistry is likely to lead to technological
developments and a reduction in the cost of equipment, so that
digital dentistry will become more democratic. Of course, this
educa- tional development will also be very beneficial for
patients.
There are many universities that have introduced chairside CAD/CAM
system in response to the changing environment and government
requests, but that are unsure how to build on the basic courses
that they provide in order to offer a fully satisfactory grounding
in digital dentistry. Faculty who are taking the lead in CAD/CAM
education in the US are addressing this problem in many different
ways [4]. In this report, the steps taken at OHSU, the persistence
of the faculty who have carried out the whole process have been
introduced, and the importance of support not only from the
university have been shown, but also from manufacturers. This
report will be helpful in launching or improving digital dentistry
in Japan, as the technique takes the lead in the field of
restorative dentistry.
Conflict of interest The authors have no conflict of interest to
declare.
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