Undergraduate experience of clinical procedures in

paediatric dentistry in a UK dental school during

1997—2001

R. P. SeddonDepartment of Paediatric Dentistry, Guy’s, King’s and St Thomas’ Dental Institute, London, UK

Abstract The aim of this study was to determine the clinical

experience of undergraduate students in paediatric dentistry.This was a prospective study in a clinic teaching paediatric

dentistry to undergraduates within a UK dental school. Studentswho graduated between 1997 and 2001 at King’s Dental

Institute, London, were required to complete a quantitativerecord of their clinical activity. The mean undergraduate intake

for the 5-year period was 58. Thirty-six (36) sessions each of2—2 1

2 h duration were available in the course for the clinical

treatment of children (one half day per week), a total of 81 h.The undergraduates assessed and planned treatment for 13.4

patients, 3.6 emergency patients and administered 10.4 localanalgesics. The mean number of inhalation sedation adminis-

trations increased (1.5—3.3) per student during the 5-yearperiod. The mean number of procedures performed by under-

graduates for primary teeth was 8.1 restorations in glassionomer or compomer and 1.9 in amalgam, 1.6 pulpotomies

and 0.2 preformed crowns. The mean number of procedures forpermanent teeth was 24.5 fissure sealants, 2.6 preventive resin

restorations, 1.5 amalgams, 1.7 composites, 1.4 incisal edge

restorations and 0.8 root canal treatments. For permanent

teeth, the trend was towards an increase in the number ofpreventive resin restorations (1.9—2.8) and composite restora-

tions (1.4—1.9) but a decrease in the number of amalgamrestorations (2.1—0.9) during the 5-year period. Individual

students’ clinical experience was very variable. Procedures thatwere performed more than 10 times were experienced by every

student. A procedure performed on average two to four timeswithin a year group would be experienced by only 80—90% of

the group and less frequently performed procedures would onlyhave been experienced by a minority of graduates. A large

number of patients failed to attend or cancelled appointmentsrepresenting a loss of 21 h of clinical treatment time per

student, about 25% of the total time available for the treatmentof children in the clinical course.

Key words: undergraduate education; paediatric dentistry.

ª Blackwell Munksgaard, 2004Accepted for publication 1 March 2004

Introduction

T he General Dental Council (GDC) of the UK

has stated that the aim of dental education is to

produce a caring, knowledgeable, competent and

skilful dentist (1). During the 5 years of the dental

undergraduate curriculum, the emphasis changes

from a didactic course towards greater clinical

involvement with patient contact. The final year

undergraduate will spend a large proportion of their

time in clinical practice, planning and delivering

treatment. It is accepted that dentistry is a ‘hands on’

occupation and that patient contact is essential to

develop the practical skills, communication and

patient management skills needed.

The GDC identified three levels of expertise for the

new dental graduate. They should be competent at

a procedure, defined as having sound theoretical

knowledge and understanding with adequate clinical

experience to resolve clinical problems without assist-

ance. They should have knowledge of a procedure,

defined as having sound theoretical knowledge but

with limited clinical or practical experience. And

finally they should be familiar with a procedure,

defined as having a basic understanding of the subject

but without having had direct clinical experience.

Within the speciality of paediatric dentistry, caries

diagnosis and planning non-operative care, fissure

sealing, preventive resin restorations, pit and fissure

restorations, approximal and incisal tip restorations

were all identified as procedures at which the new

graduate should be competent. Pulp therapy and

preformed crowns in primary molars, the role of

sedation for the young patient and the management of

trauma were identified as areas where the graduate

should have knowledge (1).

172

Eur J Dent Educ 2004; 8: 172–176All rights reserved

CopyrightªBlackwell Munksgaard 2004

european journal of

Dental Education

Throughout the 1980s a number of reports from the

USA identified changes in the availability of child

patients suitable for undergraduate teaching that was

attributed primarily to the decline in caries experience

(2, 3). The problem was not a shortage of patient

numbers but shortages of patients in need of restorat-

ive procedures appropriate for teaching. Increases in

the number of preventive measures, fissure sealing and

preventive resin restorations undertaken by students

have been generally reported. However, this coincided

with decreases in the total number of restorations,

particularly amalgams (3–8). Although this trend is

beneficial for the dental health of the child population

and underlines the success of preventive measures, the

consequences for undergraduate dental education may

be an excess of ‘minimal care’ patients (5). Concern has

been expressed at the increasing difficulties in ensuring

that each student has experience of every type of

operative procedure that would have been previously

regarded as an essential part of an undergraduates’

education (2, 4, 7). A report from Israel identified a

similar trend of increases in the number of fissure

sealants and preventive resin restorations with a

decrease in the number of amalgam restorations (8).

It has been suggested that changes in restorative

philosophy and the recognition that preventive resin

restorations have proved superior to amalgam for

initial occlusal lesions may also have contributed to the

changing pattern of undergraduate clinical experience.

A common theme in many of these reports was the fear

that recent graduates have had less clinical experience

than their predecessors, particularly with the more

extensive restorative procedures (4, 5, 7–9). For exam-

ple, in 1980, 95% of new graduates from the school in

Jerusalem had performed a pulpotomy in a primary

molar but this had reduced to 71% of graduates a

decade later (8). In the only comparable UK study in

Sheffield, Rodd similarly found that an increase in the

number of fissure sealants and preventive resin resto-

rations accompanied a dramatic 83% reduction in the

number of one-surface amalgam restorations. A pilot

study had indicated that the number of primary molar

preformed crowns and endodontic procedures in

permanent teeth performed by undergraduates were

so few that they did not warrant inclusion in the study

(10).

Since the ‘Poswillo Report’ over a decade ago there

has been increasing interest in the provision of

inhalation sedation in the UK dental curriculum (11).

Poswillo identified wide variations between dental

schools in the UK, particularly in the practical

training and experience of sedation, and he encour-

aged the wider use of nitrous oxide sedation within

the undergraduate curriculum. The GDC’s guidelines

governing the use of general anaesthesia in dentistry

may herald a decline in its use and an increase in the

need for sedation (12). In the UK, direct experience of

the treatment of extensive caries in children under

general anaesthesia is usually considered the remit of

the specialist practitioner and beyond the scope of

undergraduate education. However, the new graduate

would be expected to be familiar with the indications

for general anaesthesia and the guidelines for referral.

In the light of changing dental disease patterns and

the recently revised recommendations of the GDC, The

First Five Years – A Framework for Undergraduate

Education, this study reports on the clinical experience

and procedures performed by fourth and fifth year

undergraduates in a clinic teaching paediatric dentis-

try within a UK dental school for intakes graduating

between 1997 and 2001.

Method

In September 1991 students were admitted to a new

5-year Bachelor of Dental Surgery course at King’s

Dental Institute, London, due to graduate in 1996.

Within the speciality of paediatric dentistry, a per-

centage of the undergraduates’ in-course assessment

was determined according to a quantitative record of

clinical procedures undertaken during the fourth and

fifth years. The bulk of the clinical work with children

was undertaken during the first two terms of the final

year. During these terms the students rotated through

the Department of Paediatric Dentistry on one half

day per week. The first hour of each session was

devoted to a tutorial on an aspect of paediatric

dentistry and the remaining 2—2 12 h was devoted to

a clinical treatment session with patient contact. At the

end of each clinical session the undergraduates were

required to complete a record itemising the clinical

procedures performed for that session which was

countersigned by the member of the teaching staff

responsible for supervising the work. During the first

intake of the 5-year course graduating in 1996, data

collection was piloted and some modifications were

made. For the intakes graduating during 1997—2001,

data was comparable and the results are presented in

Tables 1 and 2.

Results

Undergraduates who qualified during the 5 years

1997—2001 attended an average of 36 clinical treatment

Clinical experience of undergraduates

173

sessions (83 h). A large number of patients failed to

attend or cancelled appointments (a mean of 17 failed

appointments per student each of 1.25 h duration). This

represented a loss of over 21 h of clinical treatment time

for each student, about 25% of the total time available

for the treatment of children in the clinical course

(Table 1).

The mean number of ‘new’ patients (previously

unseen by the student) who were examined and

treatment planned was 13.4, although the students

would not necessarily have completed treatment for

all of these patients. The mean number of local

analgesics was 10.4 and inhalation sedation adminis-

trations increased (1.5—3.3) per student during the

5-year period (Table 2).

For primary teeth, undergraduates performed a

mean of 10 intra-coronal restorations, 8.1 with comp-

omer or glass ionomer type materials and 1.9 in

amalgam. Undergraduates performed a mean of 1.3

pulpotomy (stages) but only 62% of undergraduates

had direct clinical experience of the primary molar

pulpotomy procedure. Individual student’s experi-

ence of preparing and fitting a preformed crown was

less. A mean of 0.2 crowns per student meant that only

20% of the intake had experience of providing this

very effective and durable restoration. For permanent

teeth, the trend was towards an increase in the

number of preventive resin restorations (1.9—2.8)

and composite restorations (1.4—1.9) but a decrease

in the number of amalgam restorations (2.1—0.9)

during the 5-year period. An increase in the number

of fractured incisal edge restorations (0.9—1.8) and

root canal treatment (0.3—1.1) could be attributed to

deliberate efforts by the teaching staff to expose the

undergraduates to the consequences of dental trauma.

Table 2 presents the mean number of procedures

per student but for clarity does not show the full

extent of the variation between individual students’

experience. For less frequently performed procedures,

a considerable proportion of the undergraduate intake

TABLE 1. Undergraduate intake numbers and attendance by students and patients during 1997—2001

Graduation year 1997 1998 1999 2000 2001 1997—2001 mean

Undergraduate intake 49 61 52 61 52 55Clinical sessions 33.9 36.7 37.0 35.7 37.7 36.2Clinical hours 76.3 82.6 83.3 80.3 94.3 83.3Undergraduate absence (sessions) – 2.3 2.7 2.1 3.6 2.6Patient DNA (appointments) 16.6 19.2 17.2 16.4 15.5 17.0

TABLE 2. Clinical procedures performed by undergraduates in paediatric dentistry during 1997—2001

Graduation year

Mean number of procedures per student (and the percentage ofthe intake with experience of that procedure) Weighted mean

1997 1998 1999 2000 2001 1997—2001

Assessment, prevention and managementExamination and treatment plan 12.3 12.3 14.7 14.6 12.9 13.4Recall examination 1.4 3.5 4.6 4.7 6.7 4.2Emergency patient 2.5 (82) 4.2 (93) 4.2 (96) 2.8 (92) 4.5 (98) 3.6 (91)Preventive advice 9.8 11.6 17.8 17.7 17.3 14.9Fissure sealant 23.2 23.7 27.2 23.8 24.8 24.5Local analgesia 7.9 9.2 10.8 13.0 10.9 10.4Inhalation sedation 1.5 (59) 1.4 (67) 1.8 (71) 3.0 (92) 3.3 (90) 2.2 (77)

Primary tooth restorationsCompomer/glass ionomer restoration 6.5 (96) 8.0 (98) 9.5 (100) 7.7 (98) 8.7 (98) 8.1 (98)Primary amalgam restoration 1.9 (84) 2.1 (77) 1.8 (81) 2.1 (84) 1.6 (65) 1.9 (78)Vital formocresol pulpotomy 0.7 (47) 0.4 (31) 0.5 (33) 0.5 (33) 0.7 (47) 0.5 (38)Non-vital pulpotomy stage 1 0.8 (47) 0.9 (51) 0.6 (42) 0.6 (34) 0.7 (47) 0.7 (43)Non-vital pulpotomy stage 2 0.4 (22) 0.3 (28) 0.3 (25) 0.5 (33) 0.7 (47) 0.4 (27)Preformed crown primary molar 0.3 (22) 0.3 (25) 0.2 (21) 0.1 (11) 0.1 (8) 0.2 (20)

Permanent tooth restorationsPreventive resin restoration 1.9 (69) 2.5 (80) 2.6 (87) 2.9 (84) 2.8 (71) 2.6 (80)Amalgam (one surface) 1.4 (57) 1.0 (54) 1.0 (56) 1.1 (61) 0.6 (35) 1.0 (53)Amalgam (two surface) 0.7 (45) 0.8 (39) 0.4 (31) 0.5 (31) 0.3 (22) 0.5 (34)Composite (class 2 and 3) 1.4 (57) 1.4 (56) 2.0 (69) 1.8 (75) 1.9 (69) 1.7 (65)Incisal edge restoration 0.9 (49) 1.3 (66) 1.7 (73) 1.2 (61) 1.8 (71) 1.4 (64)Root canal therapy 0.3 (14) 0.7 (41) 1.1 (52) 0.9 (33) 1.1 (43) 0.8 (37)IRM dressing 7.0 (96) 7.4 (98) 8.0 (100) 9.3 (100) 11.2 (100) 8.6 (99)Extraction primary – – – 2.0 (75) 2.5 (75) 2.2 (75)Extraction permanent – – – 0.2 (16) 0.1 (6) 0.2 (11)

Values within parentheses are expressed as percentage.

Seddon

174

had not experienced a procedure at all at the time of

graduation. Figure 1 shows the relationship between

the frequency of a procedure performed within the

student intake as a whole (mean number of proce-

dures per student) and the percentage of students who

experienced the procedure at least once (percentage

with experience) derived from the combined results

for the 5 years (Table 2).

Procedures that were performed on average more

than 10 times within the intake were experienced by

every student. Administering a local analgesic and

fissure sealing are examples. If a procedure was

performed on average more than 10 times, then all

students would have had some experience of the

procedure, although that experience was uneven

throughout the intake, some students having per-

formed the procedure once or twice only, while others

might have performed the same procedure as much as

20 times. Procedures that were performed on average

two to four times within the intake would be familiar to

most but unfamiliar to 10—20% of graduates at the

time of qualification. Amalgam restorations in primary

teeth, preventive resin restorations, nitrous oxide

sedation and assessing an emergency patient came

into this category. Significant gaps appeared in stu-

dents’ clinical experience for less frequently performed

procedures such as primary molar pulp therapy and

only a minority of undergraduates had experience of

preparing and fitting a preformed crown.

Discussion

Clinical instruction in paediatric dentistry seems

broadly similar in many dental schools in the United

States and elsewhere (6, 8, 10). The clinical manage-

ment of children occurs predominantly during the

final year before graduation, usually preceded by an

operative technique course. Reports of the number of

hours devoted to the clinical management and treat-

ment of children has varied. Ripa quoted 260 h in

New York (which combined both orthodontic and

paediatric dentistry) (3), to 90 h in Jerusalem (8), 42 h

in Kansas (9), 90 h in Sheffield, UK (10) and in this

report 83 h at King’s Dental Institute, GKT. Patients

who failed to attend for appointments reduced the

time for the treatment of children by 25%, which is of

concern when the time available for undergraduate

treatment within a crowded curriculum is limited.

Again, this is a problem that has adversely affected

patient availability in other schools (13).

Table 3 compares undergraduate experience of some

common paediatric dental procedures reported from a

number of schools, although the time periods to which

the reports refer vary considerably. The mean number

of primary molar pulpotomies performed by students

at King’s was 1.3 compared with San Francisco (1.7),

New York (3.4), Georgia (1.2), Florida (2.2), North

Carolina (3.0), Iowa (1.1 and 0.7) and Jerusalem (2.4). In

a number of these reports the fear has been expressed

that the reduction of caries has led to a decline in the

number of children requiring restorative work, partic-

ularly of an extensive nature (2–5, 8, 9). Clearly, many

Mean number of procedures per student

Per

cent

age

wit

h ex

peri

ence

0

10

20

30

40

50

60

70

80

90

100

0 5 10 15

Fig. 1. Relationship between the mean number of procedures perstudent and the proportion of the intake that had experienced aprocedure at least once (percentage with experience).

TABLE 3. Undergraduate experience of procedures in paediatric dentistry. A comparison amongst schools in the United States, Israel andthe United Kingdom

SanFrancisco(2)

New York(3)

Georgia(4)

Florida(4)

NorthCarolina(4)

Iowa,1983—89(7)

Iowa,1990—97(7)

Jerusalem(8)

Sheffield,UK, 1984(10)

Sheffield,UK, 1993(10)

King’s,UK

Fissuresealant

5.9 52.9 37.8 10.3 1.0 32.8 28.6 6.4 10.0 16.0 24.4

Primarypulpotomy

1.7 3.4 1.2 2.2 3.0 1.1 0.7 2.4 0.5 0.6 1.3

Preformedcrown

3.1 5.2 2.2 4.8 6.0 2.4 2.0 5.5 – – 0.2

Clinical experience of undergraduates

175

schools have experienced difficulties in providing all

undergraduates with sufficient clinical experience in

some paediatric dental procedures (13). If a particular

clinical skill is no longer required of dentists it might be

reasonable to regard that procedure as non-essential

clinical experience for the undergraduate (4). However,

many clinical teachers in paediatric dentistry may be

uncomfortable with the knowledge that increasing

numbers of undergraduates might qualify without

clinical experience in procedures that once were con-

sidered to be within the remit of the general dental

practitioner (10). Solutions to such difficulties in the

USA have included undergraduates sharing patients,

involving students in satellite clinics, providing free

treatment for children of lower income families, provi-

ding school buses or more emphasis on non-clinical

teaching to compensate for the lack of clinical experi-

ence (4, 7, 13).

Within the King’s clinical course there was an

increase in the number of inhalation sedations per-

formed by students from 1.5 to 3.5 so that inhalation

sedation (as an operator/sedationist rather than as an

observer or assistant) was experienced by 90% of

undergraduates qualifying in the year 2001. No

mention was made in reports from the USA of

undergraduates’ experience of nitrous oxide or inha-

lation sedation. A recent report investigated the

teaching of inhalation sedation in the UK and Ireland

and found that considerable variation between schools

in the teaching of inhalation sedations still existed (14).

All but one school offered hands-on experience of

inhalation sedation, usually within a paediatric dental

setting and the average number of cases treated per

student was 2.6. If this is taken as the national average

then this falls very short of the target of 10 inhalation

sedation cases per student that was proposed by

Poswillo, which is perhaps an unrealistic high expec-

tation in the current climate (11). The GDC’s recom-

mendation was that the new graduate should have

knowledge of inhalation sedation rather than be

competent (1). Perhaps it should be accepted that a

new graduate is unlikely to have treated a sufficient

number of inhalation sedation cases as an undergra-

duate and that further knowledge and experience of

sedation should be gained during post-graduation

through continued professional education.

Conclusions

This paper has confirmed trends in undergraduate

education in paediatric dentistry within a UK dental

school that have been previously identified in reports

from the USA. It seems likely that undergraduates

who qualify in the future will have treated more

children, provided more preventive care and minimal

restorations and will have treated more children with

inhalation sedation but have performed fewer amal-

gam restorations, pulpotomies and preformed crowns

on primary teeth.

References

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4. Walker J, Pinkham J, Jakobsen J. Pediatric patient yield in1978 and 1983. J Dent Educ 1986: 50: 614–615.

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11. Poswillo DE. General anaesthesia, sedation and resuscita-tion in dentistry: Report of anExpertWorkingParty for theStanding Dental Advisory Committee. London: Depart-ment of Health, publication PL/CDO, 1990: 18, 19, 22.

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Address:

R. P. Seddon

Department of Paediatric Dentistry

Guy’s, King’s and St Thomas’ Dental Institute

Denmark Hill Campus

Caldecot Road

London

UK

Tel: 020 7346 3375

Fax: 020 7346 4074

e-mail: robert.seddon@kcl.ac.uk

Seddon

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