Association of Canadian Faculties of Dentistry Educational Framework for the Development of Competency in Dental Programs.

The Association of Canadian Faculties of Dentistry (ACFD) recently developed a proposal that reflects its evolving understanding of competency-based dental education. The ACFD proposal was developed into an Educational Framework for the Development of Competency in Dental Programs and has been adopted by all ten Canadian dental schools as the basis for their ongoing curriculum development and assessment. This framework identifies five global competencies that provide a big picture of the complex skills, knowledge, and behaviors that dental graduates must demonstrate. Detail for clarification and illustration is provided by more comprehensive "components" of each area that elaborate on the global statement and by a new dimension that assists with assessment: "indicators" of the specific knowledge, skills, and behaviors that can be measured as steps towards developing competence. In the information supporting understanding and assessment of the five key areas are both the existing national competency statements to facilitate the use of the framework by other stakeholders and a parallel set of knowledge, skills, and abilities statements developed by the National Dental Examining Board of Canada (NDEB) as the starting point for updating its examination blueprints. This article outlines the development, structure, and contents of the ACFD Educational Framework in the hope that it can serve as the foundation for a new Canadian national competencies document serving all national stakeholders.

Dental Students' Interpretations of Digital Panoramic Radiographs on Completely Edentate Patients.

The ability of dental students to interpret digital panoramic radiographs (PANs) of edentulous patients has not been documented. The aim of this retrospective study was to compare the ability of second-year (D2) dental students with that of third- and fourth-year (D3-D4) dental students to interpret and identify positional errors in digital PANs obtained from patients with complete edentulism. A total of 169 digital PANs from edentulous patients were assessed by D2 (n=84) and D3-D4 (n=85) dental students at one Canadian dental school. The correctness of the students' interpretations was determined by comparison to a gold standard established by assessments of the same PANs by two experts (a graduate student in prosthodontics and an oral and maxillofacial radiologist). Data collected were from September 1, 2006, when digital radiography was implemented at the university, to December 31, 2012. Nearly all (95%) of the PANs were acceptable diagnostically despite a high proportion (92%) of positional errors detected. A total of 301 positional errors were identified in the sample. The D2 students identified significantly more (p=0.002) positional errors than the D3-D4 students. There was no significant difference (p=0.059) in the distribution of radiographic interpretation errors between the two student groups when compared to the gold standard. Overall, the category of extragnathic findings had the highest number of false negatives (43) reported. In this study, dental students interpreted digital PANs of edentulous patients satisfactorily, but they were more adept at identifying radiographic findings compared to positional errors. Students should be reminded to examine the entire radiograph thoroughly to ensure extragnathic findings are not missed and to recognize and report patient positional errors.

Panoramic radiographs made before complete removable dental prostheses fabrication: A retrospective study of clinical significance.

STATEMENT OF PROBLEM: The value of digital panoramic radiographs to screen for problems before fabricating conventional complete dentures is unclear. PURPOSE: The purpose of this retrospective study was to examine the influence of pretreatment digital panoramic radiographs on the clinical management of patients receiving complete removable dental prostheses. MATERIAL AND METHODS: The clinical records, including panoramic radiographs, of 169 patients seeking new complete removable dental prostheses over a 6-year period were interpreted independently by both a prosthodontist and an oral and maxillofacial radiologist to identify radiographic findings that influenced clinical patient management. A 95% confidence interval and an observed proportion of agreement were used to interpret the results. RESULTS: Sixty percent of the 169 radiographs examined had 1 or more abnormal or positive radiographic findings; however, only 6 (<4%) of 165 abnormalities detected influenced patient management, and 3 of them were identified during the clinical examination. CONCLUSIONS: Pretreatment digital panoramic radiographs revealed very few abnormalities that influenced the treatment of patients requiring complete removable dental prostheses. Furthermore, the digital images in this study revealed positive findings at a rate similar to those found in studies assessing analog radiographs, reinforcing current guidelines that recommend against radiographic screening of patients who seek new complete removable dental prostheses.

Critical Thinking Disposition and Skills in Dental Students: Development and Relationship to Academic Outcomes.

Critical thinking is a key element of complex problem-solving and professional behavior. An ideal critical thinking measurement instrument would be able to accurately predict which dental students are predisposed to and capable of thinking critically and applying such thinking skills to clinical situations. The aims of this study were to describe critical thinking disposition and skills in dental students at the beginning and end of their first year, examine cohort and gender effects, and compare their critical thinking test scores to their first-year grades. Volunteers from three student cohorts at the University of British Columbia were tested using the California Critical Thinking Disposition Inventory and California Critical Thinking Skills instruments at the beginning and end of their first year. Based on the preliminary findings, one cohort was retested at graduation when their final-year grades and clinical advisor rankings were compared to their critical thinking test scores. The results showed that students who entered dental school with higher critical thinking scores tended to complete their first year with higher critical thinking scores, achieve higher grades, and show greater disposition to think critically at the start of the program. Students who demonstrated an ability to think critically and had a disposition to do so at the start of the program were also likely to demonstrate those same attributes at the completion of their training. High critical thinking scores were associated with success in both didactic and clinical settings in dental school.

Reaching Consensus on Essential Biomedical Science Learning Objectives in a Dental Curriculum.

This article describes how the University of British Columbia Faculty of Dentistry reached consensus on essential basic biomedical science objectives for DMD students and applied the information to the renewal of its DMD curriculum. The Delphi Method was used to build consensus among dental faculty members and students regarding the relevance of over 1,500 existing biomedical science objectives. Volunteer panels of at least three faculty members (a basic scientist, a general dentist, and a dental specialist) and a fourth-year dental student were formed for each of 13 biomedical courses in the first two years of the program. Panel members worked independently and anonymously, rating each course objective as "need to know," "nice to know," "irrelevant," or "don't know." Panel members were advised after each round which objectives had not yet achieved a 75% consensus and were asked to reconsider their ratings. After a maximum of three rounds to reach consensus, a second group of faculty experts reviewed and refined the results to establish the biomedical science objectives for the renewed curriculum. There was consensus on 46% of the learning objectives after round one, 80% after round two, and 95% after round three. The second expert group addressed any remaining objectives as part of its review process. Only 47% of previous biomedical science course objectives were judged to be essential or "need to know" for the general dentist. The consensus reached by participants in the Delphi Method panels and a second group of faculty experts led to a streamlined, better integrated DMD curriculum to prepare graduates for future practice.

Graduating dental students' views of competency statements: importance, confidence, and time trends from 2008 to 2012.

Competency documents are used in dental education as both an educational framework and an accreditation instrument. The aim of this study was to analyze the perceptions of graduating dental students at the University of British Columbia (UBC) regarding the importance of each competency statement, as well as to assess their confidence in their abilities associated with each statement. The instrument was based on the survey developed by Schönwetter et al. at the University of Manitoba using the Association of Canadian Faculties of Dentistry competency document. The current study surveyed UBC graduating students in the years 2008 through 2012. The response rates ranged from 66.7% to 95.9%, averaging 77.5% across all five years. The results showed that, overall, the students rated all the competencies as important, but they rated their confidence lower than the perceived importance. Correlation coefficients averaged a moderate correlation of 0.376 for all competency statements except the five with the greatest discrepancy between perceived importance and confidence. The competencies the students perceived as most important tended to be associated with tasks frequently performed during predoctoral dental education. The instrument used in this study can help other academic dental institutions identify patterns of students' perceived competency importance and confidence to inform allocation of teaching time and resources and adopt new methodologies to address identified areas of need.

Who is teaching what, when? An evolving online tool to manage dental curricula.

There are numerous issues in the documentation and ongoing development of health professions curricula. It seems that curriculum information falls quickly out of date between accreditation cycles, while students and faculty members struggle in the meantime with the "hidden curriculum" and unintended redundancies and gaps. Beyond knowing what is in the curriculum lies the frustration of timetabling learning in a transparent way while allowing for on-the-fly changes and improvements. The University of British Columbia Faculty of Dentistry set out to develop a curriculum database to answer the simple but challenging question "who is teaching what, when?" That tool, dubbed "OSCAR," has evolved to not only document the dental curriculum, but as a shared instrument that also holds the curricula and scheduling detail of the dental hygiene degree and clinical graduate programs. In addition to providing documentation ranging from reports for accreditation to daily information critical to faculty administrators and staff, OSCAR provides faculty and students with individual timetables and pushes updates via text, email, and calendar changes. It incorporates reminders and session resources for students and can be updated by both faculty members and staff. OSCAR has evolved into an essential tool for tracking, scheduling, and improving the school's curricula.

Faculty and student perceptions of the success of a hybrid-PBL dental curriculum in achieving curriculum reform benchmarks.

The dental education literature identifies eleven benchmark reform agenda curriculum qualities. The purpose of this study was to determine the extent to which the University of British Columbia D.M.D. curriculum was perceived by students and faculty as achieving these benchmarks and to note any differences in perceptions within and between the student and faculty groups. A WebEval survey consisting of twenty-one questions was delivered online in November 2007 to faculty members and D.M.D. students. The response rate was similar (~60 percent) for both students and faculty members. Comparisons were made between faculty members and students as well as within each group. For the faculty, we looked at the influence of appointment, focus, and teaching experience. For students, we looked at the influence of the year in the program, gender, and program track. Some differences (p<0.05) were identified within the faculty and student groups; however, there were many more differences between the faculty and the students, especially in areas related to curriculum redesign, collaborations with other health professions, preparation for independent practice, and creating a trust-based clinic environment. Faculty members were more optimistic about curriculum progress than were students. Improved communication of curriculum goals and explicit efforts at creating a safe and supportive learning environment could diminish these differences over time.

Fracture incidence in mandibular overdentures retained by one or two implants.

STATEMENT OF PROBLEM: While 2 to 4 implants are preferred to retain and stabilize an implant overdenture, some reports suggest a single implant is adequate to retain an overdenture. Denture fracture is one of the common complications with overdentures; however, there is no information on the incidence of fractures when dentures are retained by 1 implant. PURPOSE: The purpose of this study was to compare the fracture incidence of mandibular overdentures retained by 1 and 2 implants. MATERIAL AND METHODS: The records of 85 subjects enrolled in the Vancouver Implant Prosthesis (VIP) clinical trial between 2003 and 2008 and followed up for at least 17 months were reviewed retrospectively. From the clinical records, subjects who had experienced a fractured overdenture were identified. A fracture was considered as either a visible crack in the acrylic resin or complete separation of the denture parts. The same clinical records listed 3 denture fracture sites: over the implant, elsewhere, or unknown. A chi-square test was used to compare the incidence of fracture (alpha=.05). Kaplan-Meier and log rank tests were used to compare the survival rate of overdenture or "time to fracture" (alpha=.05). RESULTS: Forty-two subjects received a single implant, and 43 received 2 implants. In total, there were 17 fractures recorded for 13 subjects. Nine single-implant subjects experienced 11 denture fractures, while 4 double-implant subjects experienced 6 fractures. There was no significant difference in the incidence of denture fractures in prostheses retained by 1 or 2 implants. When denture fractures did occur, they were found most frequently in areas adjacent to the implant(s). CONCLUSIONS: The incidence of denture base fractures was not significantly different between overdentures retained by 1 implant and those retained by 2 implants. When fractures did occur, they tended to be in areas adjacent to implants.

Questionnaire-based study on sleep-disordered breathing among edentulous subjects in a university oral health center.

The aim of this study was to evaluate the prevalence of sleep-disordered breathing (SDB) and its relationship with nocturnal denture wear in edentulous subjects. Sixty-two edentulous subjects completed questionnaires to ascertain their risk for SDB; 25 subjects wore dentures during sleep. The prevalence of SDB was 40.3% based on the results of the Berlin Questionnaire. There was no significant difference between high- and low-risk groups with respect to age, Body Mass Index, or denture use, except for a history of self-reported high blood pressure. The prevalence of suspected SDB in edentulous subjects was higher than in the general population.

A randomized clinical trial comparing patient satisfaction and prosthetic outcomes with mandibular overdentures retained by one or two implants.

PURPOSE: This randomized clinical trial tested hypotheses that there are no differences in patient satisfaction, component costs, or treatment and maintenance times when mandibular overdentures are retained by one or two implants. MATERIALS AND METHODS: Subjects wearing conventional complete dentures were randomized to receive either one midline or two bilateral mandibular implants followed by a mandibular denture reline to incorporate implant retention. They indicated on a visual analog scale satisfaction with their dentures before implants and at 2 months and 1 year after implant retention. Satisfaction outcomes between the two groups were compared using the Wilcoxon/Mann-Whitney nonparametric rank test, while changes within each group were analyzed using signed-rank tests. Component costs and times for surgery, prosthodontic treatment, and maintenance were compared using nonparametric and t tests. RESULTS: Eighty-six subjects enrolled in this study and 85 completed the 1-year follow-up, at which median satisfaction was 93 (maximum 100) in the single-implant group and 94 in the two-implant group (P > .5). Within each group, median improvement in satisfaction was similarly dramatic (approximately 44) and significant (P < .001). Prosthodontic maintenance time was similar for both groups (P > .37), but the single-implant group had significantly lower component costs (P < .001) and lower times for surgery (P = .002), postsurgical denture maintenance (P = .021), and denture reline (P < .001). Five implants failed in four subjects, all in the two-implant group and all before denture reline. CONCLUSION: Lower component costs and treatment times, with comparable satisfaction and maintenance time over the first year, indicate that a mandibular overdenture retained by a single midline implant may be an alternative to the customary two-implant overdenture for maladaptive denture patients.

Screening and enrolling subjects in a randomized clinical trial involving implant dentures.

PURPOSE: When planning and budgeting for a clinical trial, researchers have few references to help them estimate how many volunteers will need to be screened, how long the screening process may take, and how much it may cost to enroll sufficient qualified subjects. The purpose of this study was to analyze the time and costs involved in recruiting, screening, and enrolling subjects for a randomized clinical trial examining patient satisfaction with mandibular dentures retained by 1 or 2 implants. MATERIALS AND METHODS: Data collected included age and sex of volunteers, recruiting sources, length of time and costs of recruiting and screening volunteers, and reasons for inclusion or exclusion. Results were analyzed using Pearson chi-square tests. RESULTS: We estimated that we would need to screen 180 volunteers over a period of 4 years at an estimated total cost of CAN$47,664.00 to enroll 86 subjects. Instead, we had to screen 220 volunteers at a direct cost of $63,324.81. We excluded 28% of volunteers, while 32% declined participation and 40% agreed to participate in the study. Volunteers were most commonly excluded because of technical problems with their existing dentures, while they were most likely to decline participation because of perceived surgical risks with implants. Those who agreed to participate most commonly cited anticipation of a more secure mandibular denture as their reason for enrolling. CONCLUSION: We had to screen more volunteers at a higher cost than anticipated, with only 40% of those screened meeting inclusion criteria and agreeing to participate in the trial.

The burden of debt for Canadian dental students: part 4. The influence of debt on program and career decisions.

In the 3 previous papers of this 4-part series, we explored the issue of debt among dental students in Canada to analyze the factors influencing levels of debt. The information was obtained from a national survey of all dental students enrolled in Canadian dental schools during the 2003-2004 academic year. The aims of this fourth paper were to investigate the influence of debt upon career decisions after graduation and to comment on future directions for research into the impact of the rising costs of dental education and dental students' increasing debt levels. The results show that almost half of respondents found the costs of dental programs significantly higher than they anticipated. One-third of the respondents indicated that their anticipated debt level upon graduation had influenced their choice of career path within dentistry. Although this study provides baseline information about the degree of and influences on the indebtedness of students currently enrolled in dental programs across Canada, much remains to be learned about the impact of the higher costs of dental education on potential applicants to dental school and the effect of increased educational debt on practising dentists.

The burden of debt for Canadian dental students: part 3. Student indebtedness, sources of funding and the influence of socioeconomic status on debt.

In recent years, tuition fees at most universities across Canada have increased substantially, particularly in professional programs such as dentistry. Anecdotal evidence suggests that these increases have a significant adverse impact on the educational experience of dental students. In January 2004, students at Canada's 10 dental schools were invited to participate in a survey on costs, debt and other factors related to attending dental school in Canada. This third article in a series of 4 examines the effects of funding sources and socioeconomic status (SES) on dental students' debt. The survey provided key information about the costs of attending dental school and the levels of debt among dental students across Canada. Choice of school and year of study had a significant effect on the overall costs of attending dental school, and dental students' costs were largely financed by private loans or other forms of debt. Canadian dental students' average debt varied between 24,000 to 26,000 dollars per annum, depending on their year of study. Key determinants of borrowing included type of residence, SES, total costs, and number of dependents. Students who lived at home or with relatives borrowed significantly less than those who were renting. Parents' SES was related to students' access to forms of educational funding that result in no debt burden. SES also played a role in determining the likelihood of a student pursuing further professional education.

The burden of debt for Canadian dental students: part 2. A report on survey participants and an analysis of dental education costs.

There are many anecdotes, but few facts about the issue of dental students' debt in Canada. This second of a 4-part series about dental students' debt attempts to remedy this situation. In January 2004, students at Canada's 10 dental schools were invited to participate in a survey on costs, debt and other factors related to attending dental school in Canada. The survey provided previously inaccessible demographic information about levels of debt amongst dental students. A typical dental student respondent had completed 4 years of post-secondary education, was in first year of dental school, was single with no dependents, did not work outside of classes, lived in rented accommodation and walked to school. Reported costs to attend dental school varied widely among Canadian dental schools. Choice of school and year of study had a significant effect on overall costs of attending dental school.

The burden of debt for Canadian dental students: part 1. Review of the literature.

Debt among Canadian university graduates is increasing, while money apportioned to federal and provincial needs-based student assistance programs has been decreasing since the 1990s. Dental students have had to absorb increased tuition fees at both the undergraduate and post-baccalaureate levels. Existing debt and high tuition fees may adversely influence a potential candidate"s decision to enroll in dental school. Likewise, debt incurred during the minimum 2 years of pre-dental education adds to the future debt load of dental graduates. It seems that few dental students can remain debt-free during their dental education, although data are lacking about the extent of debt among dental students and its impact on their career decisions. Government statistics focus primarily on tuition costs for baccalaureate-degree students. Tuition and clinic-related fees constitute a significant proportion of costs for dental students; moreover, university administrations perceive dentistry as an expensive curriculum. This first article of a 4-part series examines debt among dental students, both nationally and internationally.

Choosing or refusing oral implants: a prospective study of edentulous volunteers for a clinical trial.

PURPOSE: Little is known about why people accept or refuse oral implant treatment. The purpose of this study was to assess edentulous subjects' acceptance or refusal of free implants to retain mandibular dentures, and to evaluate factors that might predict those who are more likely to choose implants. MATERIALS AND METHODS: One hundred one volunteers completed questionnaires about their background, satisfaction with conventional dentures, oral health-related quality of life, and preference for implants. Results were analyzed using Pearson chi-square tests and logistic regression. RESULTS: While 79% of volunteers accepted and 21% refused an initial offer of free implants, a number of them changed their minds, leaving 64% who wanted implants and 36% who did not want them. The most common reason for choosing implants was anticipation of improved mandibular denture stability or security (73%), while the most common reason for refusal was concern about surgical risks (43%). A logistic regression model identifying those who complained of poor chewing function, poor speech, pain, and dissatisfaction with appearance improved the prediction of those who wanted implants from 64% to 80%. CONCLUSION: When cost was removed as a factor, more than one third (36%) of the older, edentulous participants in this study ultimately refused an offer of free implants to retain their mandibular dentures. Poor chewing function, poor speech, pain, and dissatisfaction with appearance were the most important factors in predicting who would choose implants.

A clinical trial of patient satisfaction and prosthodontic needs with ball and bar attachments for implant-retained complete overdentures: three-year results.

STATEMENT OF PROBLEM: Few prospective trials of implant-retained mandibular dentures have evaluated the increase and duration of patient satisfaction, costs of denture maintenance in relation to different methods of attaching overdentures to implants, or the use of a reinforced framework. PURPOSE: This report evaluates subjects' satisfaction and prosthodontic maintenance during a 3-year randomized clinical trial of implant-retained mandibular complete dentures, whether reinforced or not with a cast framework, and attached by bar-clip or 2.25-mm ball-spring matrices to endosteal dental implants. MATERIALS AND METHODS: One hundred edentulous subjects, each having at least 1 year's experience with conventional complete dentures, were selected from respondents to a university dental clinic's request for volunteers. Candidates were examined to verify adequate mandibular bone and medical suitability for implants. Subjects then received 2 implants in the anterior mandible before being stratified by mandibular bone height and gender and assigned randomly to 1 of 4 treatment groups. Every subject received a new maxillary complete denture in addition to an implant-supported mandibular complete denture, with or without a reinforcing framework, connected to implants by either a bar-clip or a ball-spring patrix and matrix. The dentures were adjusted and repaired as needed. Subjects indicated on a visual analogue scale (VAS) satisfaction with conventional dentures prior to the study and then with new dentures at 1 month, 1 year, and 2 years. The results reported here are from the first 68 subjects observed for 3 years after receiving new dentures (19 subjects received new dentures less than 3 years before this analysis, and another 13 subjects were lost to follow-up). VAS scores are presented in simple tables and graphs, and results for different groups were compared using 2-sided nonparametric rank tests and repeated measures ANOVA. With respect to costs and maintenance, t tests were used to compare group means. Sample size and other design considerations used a .05 significance level. RESULTS: After receiving new dentures with mandibular implant supports, improved satisfaction "within subject" was prompt, durable, substantial, and statistically significant, regardless of the attachment mechanism, and with or without a reinforcing framework. In contrast, there were no notable satisfaction differences between the 2 attachment mechanisms, or with the presence or absence of a reinforcing framework, either at specific intervals after receiving the new dentures, or in repeated measures ANOVA. For both attachment groups, most denture adjustments occurred during the first year. This accounted for 81% of total adjustments during 3 years, when the 34 subjects in the ball-spring group and the 34 in the bar-clip group were combined. The mean numbers of adjustments per subject and associated clinical times did not differ significantly between the 2 groups. Conversely, denture repairs declined more slowly than adjustments. Almost all repairs (90%) occurred in the ball-spring group to correct problems with the attachments, 39% in the first year, and tapering off only slightly in the following 2 years. Over 3 years of follow-up, mean numbers of repairs per subject differed significantly between groups: 6.7 repairs per person in the ball-spring group, compared to 0.8 in the bar-clip group ( P<.001), and mean time per appointment was greater for repairs in the ball-spring group: 18.9 minutes compared to 16.9 ( P<.01). The cast framework had no influence on the satisfaction expressed or on adjustments and repairs. CONCLUSION: Subjects were very satisfied with the new dentures, although the ball-spring attachment tested in this trial required substantially more repairs.

A randomized clinical trial comparing two mandibular implant overdenture designs: 3-year prosthetic outcomes using a six-field protocol.

PURPOSE: This clinical trial tested the null hypothesis that there would be no difference in prosthetic maintenance for two-implant mandibular overdentures retained by either a bar-clip mechanism or ball attachments. Prosthetic outcomes are reported over 3 years using a six-field protocol. MATERIALS AND METHODS: One hundred edentulous participants received new maxillary complete dentures and a mandibular two-implant overdenture (IOD), with random assignment to either a bar and metal clip or two ball attachments (titanium alloy matrix and spring) for retention. Eighty-seven subjects were available for follow-up after 3 years. RESULTS: Almost three times as many bar-clip dentures (63%) were rated successful compared to the ball attachment design. Two percent of the participants in each group died over the course of the study, while 15% of the bar-clip and 8% of the ball IOD subjects were lost to follow-up. More than three times as many ball attachment IODs (60%) required retreatment in the form of excessive repairs, and twice as many of the ball attachment design (8%) required replacement. The ball attachment IOD was significantly more likely to require patrix tightening or matrix replacement, while the bar-clip design was more likely to require activation of the matrix. CONCLUSION: Using the criteria of a six-field protocol for implant overdenture outcomes, the bar-clip IOD was a significantly more successful prosthesis, requiring less maintenance than the titanium alloy matrix and spring ball attachment IOD employed in this study. The null hypothesis was therefore defeated.

One-year prosthetic outcomes with implant overdentures: a randomized clinical trial.

PURPOSE: This randomized clinical trial examined implant overdenture (IOD) fabrication and maintenance time and costs, adjustment and repair incidence, and patient satisfaction after 1 year. MATERIALS AND METHODS: Sixty-four patients received 2 mandibular implants and an IOD with either a bar with 2 clips or 2 ball attachments for denture retention. RESULTS: Fabrication time, number of appointments, and chair time for adjustments were similar for the 2 denture designs. The most common adjustments for both types were to the IOD contours. Ball-attachment dentures required about 8 times longer for repairs than bar-clip prostheses. Approximately 84% of patients with ball-attachment dentures needed at least 1 repair, versus 20% of those with a bar-clip mechanism. The most common repairs were replacement of the cap spring or cap for the ball-attachment IOD and replacement of a lost or loose clip for bar-clip dentures. DISCUSSION: Patients were equally and highly satisfied with the improvements in function, comfort, and appearance with both types of IOD compared to their original conventional dentures. CONCLUSIONS: Given equivalent levels of patient satisfaction with either method of retention and a much higher repair rate for the ball attachment, it is suggested that a bar-clip design be used rather than the particular ball attachment utilized in this study.