dental care in the United States is the fear of pain.1 ... cology andl Oral Surgery, medical College of. Virginia .... ment of medical emergencies was wide- spread ...
Survey of the Teaching of Pain Control at the Predoctoral Level* A
Ravmond A. Dionne, D.D.S., M.S.t William L. Dewey, Ph.D.+ t Edwin Joy, D.D.S.tt t A major obstacle to the acceptance of dental care in the United States is the fear of pain.1 Recognition of this fact has led to rene,wed interest in the teaching of pain anid anxiety conitrol in dental schools. This paper reports the results of a survey of the teaching of pain and anxiety control in dental schools at the predoctoral level. The ol)iectives of the survey wvere to detennine the current status of paini control education and the implementation of the Guidelines fur Teaching the Corn prehensive Control of Pain and Anxiety in Dentistry.' These Guidelines 'were developed and published in 19 1 through the joint efforts of the American Denital Society of Anesthesiology, the American Association of Dental Schools aind the Aimerican Denital Association. The purpose of the Guidelinies "-as to delineate the scope of pain and anxiety control and to set acceptable standards for the teaching of this subject at the predoctoral, graduate. anid continuinig education levels. Tv-o pre%ious studies: -4 have examined w-hich departmenits and personnel are responisible for teaching pain control at the predoctoral level. The present study attemps to examine the content of the pain control curriculumii at the preclinical and 'This stutdy wvas supported in part by U.S.P.H.S. Training Grant 5T-22 DE 0016. A preliminary report wvas made at American Association of Dental Schools 'Meeting, MIiami, MIarch 1976. tPostdoctoral Trainee, Departments of Pharmacology andl Oral Surgery, medical College of Virginia, Richmond, VA 2.3220. tIProfessor of Pharmacology, Medical College of V'irginia, Richmond, VA 2-3220. f fIChairman, Department of Oral Surgery, Medical College of Georgia, Augusta, Georgia 309092.
152
clinical levels, and to make an estimate of the success of these programs. Methods A survey fonn was developed using the criteria outlined in the Guidelines for the teaching of pain control at the predoctoral level. Clinical pharmacology, hypnosis and acupuncture were included as a matter of general interest. The survey form consisted of 25 questions and was examined for clarity and objectivity within our institution. This questionnaire was mailed to 55 dental schools in the U.S. A second copy of the questionnaire was mailed to those schools which did not initially respond. A total of 40 (71%) completed questionnaires wvere returned and the results compiled. Results The data accumulated were divided into three categories. A summary of the results regarding preclinical experience is presented in Table 1. All the schools reporting .2ECL:NICAL EXPERIEN4CE
Yes 2. 3
4. 5. 6. 7. B. 9. 10.
heories of Pair P'rocess Local Anesthesia Co7rs c i sus Seda t i on
1
Nitrous Qidie I Sedation Genes-al Anesthesia General Ptarmacolo og Clinical Pharnacol logy Physical Diagxosis Behavioral ScienceIs
ypiosis, Acupu.ct.ure
Mnagwient of Oner aefcies
(;
*
Mean Hours
100
4
100
17-4 14.9
95
1_
S-C 83 65
Range
Gui el i nes
1-30 5-34 1-40
12 24
2-16 16-1X0
12
--
--
6-5 52.3
10 50
--
72.5 60
21.1 37.3
32.5
---
130
1-60 4-200
TABLE 1
offer some form of preclinical instruction on the theories of the pain process, local anesthesia, conscious sedation, general pharmacology and the management of medical emergencies. Approximately twothirds of the schools also offer some type of instruction in general anesthesia, physical diagnosis and behavioral science. The range in the number of hours reported is wide,
ANESTHEsiA PROGRESs
being as varied as fifty fold for some categories. There are three areas where the Guidelines contain specific recommendations for the number of hours of instruction to be devoted to a specific topic. It is recommended that local anesthesia be taught at least one hour a week for one quarter, or a total of approximately 12 hours. The mean number of hours for the sample was 17.4 hours with a range of 5 to 34 hours. Twenty-six of the schools had courses which were greater than or equal to the recommended time, while 3 were less and 11 did not supply an answer. The total time recommended for teaching sedation techniques was 24 hours. The mean number of hours reported was 14.9 with a range of 1 to 40 hours. Fourteen of the schools reporting had courses greater than or equal to the recommended time, 13 were less than this figure and 12 did not answer or did not have such courses. The third specific recommendation is a general anesthesia course of at least 12 hours duration. The mean number of hours reported was 6.5 hours with a range of 2 to 16 hours. Only 4 schools reported courses vhich satisfied the recommendation, while 9 schools reported courses less than the recommended length. However 27 schools failed to supply an answer to this item. The data gathered on clinical teaching experience is summarized in Table 2. TeachII.
deonstration
Yes (X)
# Hours
Range
80 55
12.0 12.2
1-45 1-25
95 90
3.2 6.6
1-16 1-20
82.5 62.5
2.5 4.6
1-10 1-20
demonstration
participation
65 17.5
3.3
1-8
demDnstration
92.5 67.5
4.6 4.5
1-24 1-24
Managemnt of Emergencies
participation
TABLE 2
ing by demonstration was the most com-mon mode used for nitrous oxide sedation: (95%), intravenous sedation (82.5%), and general anesthesia (65%). The participation of the students was prevalent in nitrous oxide, less so for intravenous sedation and
SEPTEMBER-Oc-OBER, 1976
No
Other
1. Nitrous Oxide
60
27.5
12.5
2. I.V. Sedation
27.5
55
17.5
65
TABLE 3
participation I.Y. Sedation demDnstration participation 4. General Anesthesia 5.
SELF-ASSESSMENT Yes
Mean
1.
3.
III.
3. Research Program 35
CLINICAL EXPERIENCE
Physical Diagnosis demnstrati on participation 2. Nitrous Oxide Sedation
negligible for general anesthesia. Instruction in physical diagnosis and the management of medical emergencies was widespread, but only 55% of the schools allowed student participation in physical diagnosis, 67.5% for the management of medical emergencies. Again the variation in the time allocated ranged widely between different institutions. The Guidelines are not as specific in this area but do recommend that the student have sufficient experience to become proficient in the use of oral, intravenous and inhalation techniques of sedation. The average amount of clinical time reported for nitrous oxide instruction was 3.2 hours for demonstration and 6.6 hours for participation. This is a total of approximately 10 hours. The clinical time allocated to intra'venous sedation was reported as 2.6 hours for demonstration and 4.6 hours for participation, for a total time of 7 hours. It is not clear from this information whether the intent of the Guidelines is being realized. The last part of the survey consisted of a self-assessment by the respondents of their
programs. Sixty percent of the schools reported that their graduates could perform nitrous oxide sedation safely and competently. Only 27% of the schools felt that their graduates could perform intravenous sedation safely and competently. An active research program in pain control was reported to be in existence at 35% of the institution. Discussion The questionnaire method of gathering information has many inherent weaknesses. However, the size of the sample and the objective nature of the questions do offer confidence in drawing certain conclusions. First, there exists a wide diversity in the quantity of instruction at the preclinical 153
leveL As an example, the total number of hours allocated to the predinical teaching of conscious sedation techniques varied by as much as forty-fold among different institutions. Secondly, the majority of the institutions failed to satisfy the minimum criteria outlined in the Guidelines for instruction in conscious sedation and general anesthesia at the predoctoral leveL Thirdly, only one-quarter of the schools reported that their graduates were capable of safely using both nitrous oxide and intravenous sedation. Realizing that self-assessment is a liberal standard, it is probable that a more rigid set of criteria would lower this figure substantially. Lastly, the number of hours devoted to clinical instruction appears to be inadequate. This problem is compounded by the reliance on demonstrations alone at many institutions. There is little questioning of the need for training dental practitioners in the various techniques of pain and anxiety controL The necessity of making dental care available to that portion of the population which now avoids it due to anxiety is a public health problem which confronts denfistry. The results of this survey indicate that teaching in this area at the predoctoral level is inadequate. A significant cause of this may be the paucity of individuals who are primarily responsible for teaching this topic. Two previous reports34 have indicated that the teaching of pain control is largely under the jurisdiction of the Oral Surgery faculty. This is often a secondary responsibility and may result in inadequate attention to the teaching of pain and anxiety control. The establishment of a department or a division to have responsibility for all aspects of the curriculum relevant to pain control would likely result in greater emphasis and coordination of the subject matter. Such a department would also facilitate the inservice taining of faculty members to supervise students in the use of pain control techniques. Another problem is the lack of an organization to deal with the teaching of this subject at the predoctoral leveL While the impact of the ADSA has been noteworthy in the area of postdoctoral general anesthesia training, it has yet to alter significantly the traditional neglect of pain control 154
in the undergraduate curriculum. This is evidenced by the relatively small number of schools who reported that their graduates were capable of using the techniques of conscious sedation safely. A possible solution to this problem would be the establishment of a program by the ADSA to assist dental schools in developing departments or divisions of pain controL Such a program could develop specific guidelines for the content of predoctoral programs, establish criteria for evaluating clinical competence and disseminate information on educational techniques relevant to pain control training. Such a program would not only elevate the level of instructions in pain control at the predoctoral level but also emphasize its importance in the dental curriculum. References 1. Rayner, J. F. Pain control as a factor in preventive health care. Presented at American Association for the Advancement of Science Meeting. January 1975. 2. American Dental Association, Council on Dental Education: Guidelines for the comprehensive control of pain and anxiety in Dentistry. May 1971. 3. Douglas, B. L. Report of survey on teaching anesthesia in dental schools. J Dent Educ 28:211, 1964. 4. Laskin, D. Mf. Progress in pain control? J Oral Surg 31:423, 1973.
ANNOUNCOUNT The Department of Anesthesia at the Hospital of the University of Pennsylvania is offering a 2 and 3 year Dental Pain Control Program, sponsored by the National Institutes of Health. The program consists of clinical and research training in all phases of anesthesia with special emphasis on dental outpatient anesthesia and pain control. The program will commence July 1, 1977. Candidates are encouraged to have had previous hospital experience and be interested in academic careers. Those interested should contact Jeffrey G. Garber, D.M.D., Director of Dental Anesthesia, Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, PA 19104. ANESTHFSJ PFOGR
