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Magnification in Dental Practice and Education: Experience and Attitudes of a Dental School Faculty

Key words: questionnaires, dental education, vision, perception, magnification

Submitted for publication 01/11/08; accepted 03/14/08

	Abstract

Top Author information Abstract Methods Results Discussion Conclusions References

 
The routine use of magnification and enhanced lighting by oral health care providers, educators, and students is growing, but there is little consensus regarding its implementation and use. Many students and faculty at the Temple University Kornberg School of Dentistry elect to use some form of magnification in their real and simulated patient care activities, even though the school does not mandate or suggest standards for its utilization. A questionnaire was administered to the clinical faculty to assess two parameters: experience with magnification, and attitudes concerning the value of enhanced vision. Eighty-two out of 124 eligible participants completed the questionnaire successfully for a 66 percent return rate. Sixty-one percent of respondents reported their primary practice or teaching activities as "general dentistry or restorative/prosthodontics." The remainder of the respondents represented a cross-section of other departments and specialists. All endodontists and periodontists who completed the survey and 56 percent of the general/restorative dentists indicated they use magnification. This group accounted for 91 percent of all magnification users. Thirty-nine percent in the magnification users group indicated that they avoid using magnification for some procedures. Faculty magnification users are not in full agreement about the value of enhanced vision in a dental education program. Nearly one-quarter of all magnification users indicated it is unlikely they would use magnification in the teaching environment, even though they may use it in private practice. Various explanations were given for this inconsistency. Only 61 percent of magnification users indicated they make a point to talk to students about the uses and benefits of magnification. While 91 percent of users said that magnification offers significant benefits, only 73 percent believe it should be a program requirement, and 61 percent think it should be required beginning in the first year of the curriculum. The findings of this survey suggest that educational institutions would be wise to address faculty concerns and reasons for resistance before moving to the mandated use of magnification.

Visual acuity must be regarded as an asset, but how well a dentist needs to see in order to perform at an acceptable level is uncertain. Traditionally, the use of magnification and enhanced lighting has been viewed as an aid to failing vision for older or otherwise visually impaired practitioners, but the benefits may be more far-reaching. Unfortunately, performance standards for dentistry remain somewhat ill-defined, which complicates any effort to measure objectively the effects of magnification on treatment outcomes.

The potential ergonomic benefits of magnification to dental clinicians have been discussed extensively in the literature and were reviewed recently.^1,2 The perception that magnification promotes good posture and thereby reduces musculoskeletal stress (and perhaps even the risk of debilitating injury) remains a prominent marketing approach for manufacturers of surgical telescopes. On the other hand, relatively few well-designed, peer-reviewed, scientific studies have been published that relate visual acuity or magnification to quality of care,^3,4 and from these, little evidence has emerged to prove the intuitive position that enhanced vision leads to better dentistry.^5–9 Even in endodontology, in which the use of operating microscopes has become routine in postdoctoral education and clinical practice, a search of the literature yields very few controlled clinical studies designed to test the effect of magnification on outcomes of conventional and surgical therapy (tooth retention, post-operative pain, patient satisfaction, etc.).^10,11

In spite of the lack of scientific evidence proving its benefits, the use of magnification within the dental community appears to be growing.^3,12 The use of magnification as high as 20X by dental laboratory technicians is not uncommon.¹³ Presumably, many practicing dentists, dental educators, dental hygienists, and students also believe magnification offers significant benefits. Others may not share this view. In dental education, the perceptions and attitudes of the faculty impact institutional policymaking, sway curriculum decisions, and shape the learning experience of dental students in the most fundamental ways. Therefore, understanding these attitudes represents a preliminary step for those who may wish to deliberate the advantages and disadvantages of incorporating magnification into an existing dental education program.

The purpose of this study was to gauge the experience of a dental school faculty regarding magnification and assess their attitudes concerning the value of enhanced vision in dental treatment and education.

	Methods

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All individuals who serve on the faculty of the Temple University Maurice H. Kornberg School of Dentistry part-time (at least one-half day per week) or full-time, hold a D.M.D., D.D.S., or similar dental degree, and have teaching responsibilities in at least one clinical science course that has a laboratory or clinical component were identified as subjects of the study. A total of 124 faculty members met the inclusion criteria and were invited to participate. The use of voluntary human subjects had been approved previously by the university’s Institutional Review Board. An investigational administrator was employed to manage data returns and to maintain the objectivity of the investigators. The investigators were blind to the identity of the respondents.

A questionnaire with twenty-five items was designed to investigate the respondents’ general experience with magnification, magnification and lighting preferences, and feelings about the potential benefits of magnification to patients and practitioners, as well as to collect limited biographical information. Several questions were directed specifically to those participants who have never used magnification or have discontinued its use, including the reasons for those choices. The survey was constructed and distributed using a commercial web-based survey software (Survey Monkey, www.surveymonkey.com). In order to beta-test the data collection instructions and procedures, the survey was administered to five residents (nonparticipants) in the school’s Advanced Education in General Dentistry program. Their comments led to several minor changes in the preference settings and slight modification of the survey content before launching the study.

One week prior to the launch of the survey, the investigators sent an alert to all eligible participants by conventional and electronic mail explaining the goals of the study. In an effort to maximize the return rate, the questionnaire was then made available electronically on the Internet and also in paper form for those individuals without easy access to email. A four-digit survey code number was randomly assigned to every eligible participant and used by the investigational administrator to validate returned questionnaires and identify any duplicate submissions.

In addition to several mass email reminders from the investigators, the administrator hand-delivered printed reminders to those individuals who were specifically identified as having failed to return a questionnaire. To consolidate information, one of the investigators (MM) entered all data submitted by paper questionnaire into the web database, and the other investigator (JN) reviewed those entries for transcriptional error. The survey was closed after a total elapsed running time of twenty-five days.

	Results

Top Author information Abstract Methods Results Discussion Conclusions References

 
Eighty-two out of 124 eligible participants completed the questionnaire successfully, for a net return rate of 66 percent. Ten questionnaires submitted via the Internet had to be disqualified because of procedural errors—mainly missing, duplicate, or invalid survey code numbers. Fifty respondents (61 percent) reported their primary practice or teaching activities as "general dentistry or restorative/prosthodontics." The other 39 percent were divided among numerous specialty disciplines and departments (Figure 1).

View larger version (59K): [in this window] [in a new window]   Figure 1. Primary practice or teaching activities of respondents, by percentage of total respondents

The data revealed that faculty members who described themselves as endodontists, general/restorative dentists, or periodontists commonly used magnification. One hundred percent of the endodontists (seven), 100 percent of the periodontists (five), and 56 percent (twenty-eight of fifty) of the general/restorative dentists who responded indicated that they "presently use magnification in [some] form or frequency for teaching and/or patient treatment." In contrast, the use of magnification by faculty members in other dental specialty areas (oral medicine/pathology/radiology, oral surgery, orthodontics, and pediatric dentistry) appears to be relatively uncommon. Only one respondent in each of those specialties indicated they use magnification—a total of four out of twenty individuals.

Of the forty endodontists, general/restorative dentists, and periodontists who identified themselves as magnification users, 82.5 percent (thirty-three) indicated it is very likely (70 percent) or somewhat likely (12.5 percent) that they would "use magnification during a typical patient visit in a private practice setting." Five others in this group of forty revealed that they have no private practice, essentially lowering the number of potential respondents to thirty-five for this survey item. Using this adjusted total, the percentage would be 94.3 very or somewhat likely to use magnification in private practice.

Twenty percent of respondents (nine) indicated they are more likely to use magnification in their private practice settings than for their teaching activities. Explanations for that predisposition are listed in Figure 2. Fewer respondents reported they are very likely to use magnification for teaching purposes compared to private practice. Of the thirty-two who are very likely to use magnification in their private practices, twenty-five (78 percent) indicated they would be equally likely to use it in their teaching activities. Four of those thirty-two indicated it is somewhat or very unlikely that they would use magnification while teaching in the dental school.

View larger version (40K): [in this window] [in a new window]   Figure 2. Respondents’ reasons for being more likely to use magnification in private practice than in teaching

No respondent indicated that he or she is more likely to use magnification for teaching compared to private patient care, but nineteen who said they are as likely to use magnification for teaching as for private practice offered various comments, including these: "Need magnification for all patients"; "I see better detail, and can teach and perform procedures with greater precision"; and "I feel I am a better practitioner with magnification."

A total of twenty-eight of the forty-four magnification users answered this open-ended question: "If you are more likely to use magnification EITHER for teaching OR private practice, briefly explain why." Nine respondents who treat private patients reported a tendency to use magnification more in the private practice than the educational setting. Six offered reasons for this preference. One individual reported a logistical problem: "Forget to bring to school." Another cited a concern about the perceived risks of overusing magnification: "I try to give my eyes a break from magnification when possible." The remaining four respondents expressed the opinion that magnification is not as important to them in their teaching roles: "Have not found need [for it in] teaching situations"; "Teaching is less demanding due to mostly supervisory role"; "Not necessary in teaching restorative removable"; and "Have not felt the need for magnification in teaching activities."

Approximately 39 percent (seventeen) of faculty members in the magnification users group indicated that they "avoid using magnification for some procedures in private practice or teaching." Nine indicated that "unaided vision is satisfactory for some procedures," and eleven responded that "magnification hinders my ability to perform some tasks."

Within the magnification non-users group, 87 percent reported that they had never used magnification. Several of the most common reasons given for non-use appear to be discipline-specific. Two pediatric dentists offered the following explanations: "Pediatric patients don’t hold still, making focusing a problem. Additionally, it may frighten them"; and "Need to see the whole child and not focus only on tooth." A respondent in the specialty Oral Medicine/Radiology noted: "Not needed for soft tissue exam/biopsy." An orthodontist asserted that magnification "would not really apply to orthodontic treatment." An oral surgeon indicated that he tried magnification but "had trouble with the size of the field of magnification"—perhaps implying that some surgical procedures require a broader view of the oral cavity.

Sixty-one percent (twenty) in the non-user subgroup indicated that they have considered using magnification but have not taken the initiative to institute it. The factors holding these individuals back are shown in Figure 3. Included in the "other" category are several issues about the safety of magnification and a few discipline-specific concerns, such as frightening very young patients. The remainder of the magnification non-users group (13 percent) who stated that they had at one time tried magnification but no longer utilize it often complained of difficulty adapting or overcoming the "learning curve."

View larger version (202K): [in this window] [in a new window]   Figure 3. Factors given by respondents for not using magnification, by percentage of total non-users

View larger version (23K): [in this window] [in a new window]   Figure 4. Level of agreement with statements about the value of magnification, by number of respondents in the users group

	Discussion

Top Author information Abstract Methods Results Discussion Conclusions References

While approximately three out of four magnification users do not distinguish between office and school working environments, a substantial number of faculty members in this sample appear to have minimal motivation to serve as magnification role models in the educational setting. Their reasoning deserves careful attention, because it could undermine any effort to encourage or require magnification as part of a dental school curriculum.

Based on respondents’ comments, it is recommended that faculty dentists who maintain extramural practices should have at least two pairs of eyewear to eliminate the risk of losing telescopes or forgetting to transport them where and when they are needed. Institutions that are interested in easing the transition to mandatory magnification use by faculty (and students) could address this concern by absorbing or subsidizing the cost of purchasing loupes for faculty dentists. Any number of assistance options, including prorated benefits based on teaching hours per week, can be envisioned.

A Medline search of the scientific literature failed to produce any single scientific study related to the potential short- or long-term ill effects of routine magnification use by health care professionals. This is rather surprising in view of the fact that physicians have used devices providing enhanced vision for many decades. Concerns cited by a few respondents that properly fitted and adjusted magnification devices might cause unwanted dependency, eye strain, or other ill effects do not appear to be evidence-based.

Perhaps the most intriguing reason mentioned for avoiding magnification in the educational setting is that the "need" is not clear. Anecdotal comments from dental students and practitioners who either do not purchase surgical telescopes or buy them and fail to use them suggest that many believe they see well enough with unaided vision. As previously discussed, little scientific evidence is available to refute this position. However, the avoidance of magnification in the educational setting by those who use magnification in a private practice setting is more difficult to understand and substantiate.

Nine of ten respondents who said they use magnification in private practice but usually do not for their teaching responsibilities described themselves as general/restorative dentists. All faculty members who hold a D.M.D., D.D.S., or similar degree in the Department of Restorative Dentistry teach in a clinical simulation laboratory or an actual clinical environment. Their duties include demonstrating skills related to comprehensive oral evaluation, diagnosis, tooth preparation, impression-making, installation of restorations, and so on. It is very unlikely that avoidance of magnification in the teaching environment can be explained by a set of teaching duties that are substantially different than the procedures performed in the typical private practice setting. A possible exception may be noted for those faculty members who teach a set of skills for which magnification is commonly avoided, even by routine magnification users. For example, removable prosthodontics was cited by one respondent as an area where magnification is not necessary.

It appears that, among magnification users, there are certain clinical situations in which magnification is viewed as a detriment to proper treatment. Three respondents for whom it is "very likely" they would use magnification in both private practice and teaching environments identified specific situations for which they would avoid magnification. A pediatric dentist stated that "it tends to scare young patients, especially at new patient visits." One may presume that this specialist believes the fear-inducing potential of surgical telescopes can be managed in a population of children, much like other fears typically exhibited by inexperienced dental patients. An endodontist expressed a preference for giving local anesthesia with unaided vision. A respondent identified as a general/restorative dentist indicated that he or she would not use magnification while observing the patient during interviews, implying that an unobstructed view of the entire person is important at the beginning of a patient visit. It is apparent that many routine magnification users also rely on unaided vision for certain tasks because of habit or preference. It might be difficult to reach a consensus on a comprehensive list of those tasks, and it was not a goal of this study to do so.

Ninety-one percent (forty) of the magnification users group either agreed or strongly agreed with the statement "magnification offers significant benefits for dental health care providers and patients." There was slightly less support for the statement "magnification improves the overall quality of the dental services I provide" and less support still for the contention that "magnification allows me to maintain good posture and reduces my risk for fatigue and injury" (Figure 4). While the lack of scientific evidence linking magnification with quality of dental care has already been discussed, several papers have been published that claim an ergonomic benefit.^1,2 Apparently, almost one-third of the respondents who use magnification were not convinced about ergonomic benefits.

The data suggest there is a greater tendency among the faculty to use magnification than to preach its use. Only 61.4 percent (twenty-seven) of magnification users agreed or strongly agreed with the statement "I make a point to talk to students about the uses and benefits of magnification in dentistry" (Figure 4). When faced with the many other technical demands during a typical clinical encounter with a student and patient, it is possible that some teachers simply don’t think to ask students about their magnification decisions. Usage data presented here, however, suggest that dental school teachers are themselves less likely to use magnification in the dental school environment compared to a private practice setting.

It is far more difficult to explain why some teachers who extol the virtues of magnification are less likely to agree that magnification should be required in the D.M.D. curriculum. While 90.9 percent (forty) of the users feel that magnification offers significant benefits to dentists and dental patients, only 72.7 percent (thirty-two) believe it should be a program requirement, and fewer still, 61.4 percent (twenty-seven), think it should be required beginning in the first year of the D.M.D. program, when formative skills in clinical dentistry are taught in laboratory simulations (Figure 4). Only one of forty-four magnification users (2.3 percent) disagreed with the statement that magnification offers significant benefits. Three respondents (6.8 percent) indicated they were not sure. Five magnification users (11.1 percent) said they either disagreed or strongly disagreed that magnification should be required in the D.M.D. program or that it should be instituted in the first year. These data suggest that some teachers who use magnification because they think it is beneficial don’t believe students should be required to do the same.

Other teachers are not especially opposed to the required use of magnification by students, but they are not convinced it is necessary. Seven respondents (15.9 percent) indicated they don’t know if magnification should be required, and twelve (27.3 percent) said they don’t know if it should be required in the first year. For both questions, the number of respondents who took a neutral position exceeded those who took a negative stance. These findings indicate that open discussion with the faculty would be helpful to encourage a better understanding of the complex issues related to magnification use in a D.M.D. curriculum.

	Conclusions

Top Author information Abstract Methods Results Discussion Conclusions References

 
Dentists who are experienced magnification users can often be overheard making statements such as these: "I could never go back to practicing without telescopes" or "I feel blind without my loupes." Intuitively, one might expect the dental community to immediately embrace any technological advance that enhances visual perception, as long as the costs and learning curves are reasonable. Yet the results of this survey, which reports the behaviors and attitudes of a typical American dental school faculty, suggest that many educators may be slow to accept assisted vision as a standard mode of practice.

Educational institutions that envision moving to the mandated use of magnification, high intensity auxiliary lighting, or even operating microscopy would be wise to recognize the faculty as primary stakeholders who must ultimately buy into the goals of the initiative and then serve as role models for the student body. Mandating magnification for students without first addressing faculty concerns and reasons for resistance is bound to be met with some disappointment.

"Buying in" to the principles and merits of assisted vision would be easier if the evidence base were stronger. Accordingly, the following clinical questions merit further scientific investigation:

• Is it possible for an experienced dentist to perform at a higher level with the help of magnification?
  
• If dentists perform at a higher level, will their patients benefit significantly as evidenced by enhanced outcomes, such as diseases diagnosed at an earlier stage, longer-lasting restorations, or fewer surgical errors?
  
• How do age-dependent changes (e.g., failing vision) affect the ability of a dentist to render satisfactory dental services?
  
• Can a novice learner (a dental student) develop competence at a faster rate with enhanced vision?
  
• Are there any undesirable side effects, either in provider health or treatment outcomes, with routine use of magnification?
  

	Acknowledgments

 
The authors gratefully acknowledge the contribution of Nancy L. Etsell, who served as the investigational administrator on this project. Mrs. Etsell is Administrative Coordinator of the Department of Restorative Dentistry, Temple University Kornberg School of Dentistry.

	Author Information

Top Author information Abstract Methods Results Discussion Conclusions References

 
Dr. Meraner is Associate Professor, and Dr. Nase is Adjunct Associate Professor, Department of Restorative Dentistry, Temple University Kornberg School of Dentistry. Direct correspondence and requests for reprints to Dr. Mark Meraner, Temple University Maurice H. Kornberg School of Dentistry, 3223 N. Broad Street, Philadelphia, PA 19140; 215-707-3996; mmeraner{at}temple.edu.

	REFERENCES

Top Author information Abstract Methods Results Discussion Conclusions References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Meraner, M. Articles by Nase, J. B. Search for Related Content PubMed PubMed Citation Articles by Meraner, M. Articles by Nase, J. B.