Translation of the shortened dental arch research into clinical practice: a stakeholder mapping approach

The shortened dental arch (SDA) concept, originally described by Käyser, proposes that a functional dentition can be maintained with 20 occluding anterior and premolar teeth. The approach, also termed the posteriorly reduced dental arch (PRDA), may be particularly beneficial in resource-constrained settings such as South Africa (SA). The World Health Organization recognized the concept in 1982, and SA adopted it into policy in 1994; however, contextual evidence supporting its benefits for the SA population was initially lacking and, despite subsequent global and local high-quality evidence, the concept remains largely absent from clinical practice and minimally represented in teaching. In SA dental schools, curricula have traditionally emphasized restoring arches to 28 teeth, with minimal explicit instruction on SDA/PRDA. Although SDA content was briefly introduced in the 4th year of one program, students became confused about indications and clinical requirements. This paper addresses the gap between evidence generation and clinical adoption by focusing on stages beyond diffusion and passive dissemination, emphasizing an active, stakeholder-focused strategy to implement SDA/PRDA in curricula and practice and to engage non-academic stakeholders to improve evidence-based patient care.

Global research on SDA/PRDA includes clinical trials, long-term follow-ups, observational studies, economic evaluations, and synthesis research. Evidence addresses oral function, patient satisfaction, periodontal conditions, temporomandibular joint impact, and oral health-related quality of life (OHRQoL). High-level evidence from RCTs and systematic reviews (including 10-year follow-ups) supports functional adequacy and patient-centered outcomes with SDA/PRDA. In the South African context, studies assessed clinician and student knowledge and attitudes, clinical functioning with SDA, patient satisfaction, OHRQoL, and synthesized global evidence (systematic review and RCT). Despite strong evidence at the apex of the evidence pyramid, translation into curricula and clinical practice has been limited. The literature also underscores that only rigorous, high-quality evidence should drive curricular change and clinical protocols, and that KT requires targeted strategies beyond publication and conference presentations to influence practitioner behavior.

Design: Stakeholder mapping/analysis to identify participants who can influence translation and implementation of SDA/PRDA evidence into clinical practice. Ethical considerations followed the Declaration of Helsinki; no additional participant contact occurred that could affect prior ethics approvals. Tools: Stakeholder map and stakeholder communication plan; narrative analysis and synthesis of collected information. Steps: (i) Identify stakeholders involved in teaching, clinical implementation, policy, reimbursement, and those receiving care (patients). (ii) Prioritize stakeholders by their influence and interest regarding SDA/PRDA in academic and non-academic settings (teaching, clinical practice, policy). (iii) Develop a communication plan detailing who to engage, when, by whom, and via which media. The process was iterative and non-linear, allowing concurrent or staged engagement and reflection to adjust strategies.

• Stakeholder identification: Key groups included academics (lecturers, clinical teachers, researchers), policymakers (government, oral health insurers), practitioners (general dentists, prosthodontists; public and private), dental technicians/auxiliaries, media, dental organizations, and patients. These were further organized into four primary groups: Academics, Policymakers, Practitioners, and Patients. - Prioritization and influence-interest mapping: Academics, practitioners, and patients were identified as high-influence/high-interest stakeholders requiring close management and frequent engagement. Oral health insurers and media also wield notable influence. Government policymakers showed lower observable interest despite policy inclusion, indicating need for targeted engagement. Supportive stakeholders (e.g., dental technicians, auxiliaries) should be monitored and kept informed. - Communication plan: Tailored strategies were outlined for each stakeholder (e.g., face-to-face departmental meetings and seminars for academics; CPD meetings, conferences, and social media for practitioners; emails/infographics and meetings for policymakers/insurers; public education via media for patients). Engagement frequency and responsible persons were specified to guide implementation. - Early implementation experience: After consultation with the head of department, a 4th-year lecture on SDA was introduced but later abandoned due to student confusion about indications and clinical requirements; the plan shifted to teaching in 5th year, aligning with readiness for clinical application and graduation. Departmental and faculty-level alignment (including clinical requirements) remains necessary. - Overall, the mapping highlighted stakeholders not initially engaged (notably policymakers and insurers), clarified their roles in implementation, and provided a structured plan to move from evidence to practice.

The mapping underscores that passive dissemination (publications, conference presentations) is insufficient for practice change. Despite robust global and local evidence supporting SDA/PRDA, clinicians remain reluctant to adopt it, often due to traditional training models, misalignment of curricular requirements, and perceived financial disincentives. CPD alone appears inadequate to change behavior; curricular integration at tertiary institutions is pivotal. Policy inclusion without stakeholder engagement does not ensure implementation, as seen in SA where SDA/PRDA is in policy but not standard practice. The stakeholder approach clarifies whose support is critical, how to tailor messages to adult learners and different audiences, and how to leverage influential actors (academics, practitioners, patients, media, insurers) to catalyze change. Addressing financial concerns directly (e.g., evidence from economic evaluations, emphasizing long-term follow-up care and potential revenue via maintenance) is vital to mitigate resistance. Iterative, theory-informed implementation strategies (e.g., Grol’s stages of change) alongside the communication plan can facilitate adoption and improve patient access to evidence-based, cost-conscious prosthodontic care.

Stakeholder mapping identified and organized key actors whose engagement is essential to implement the SDA/PRDA concept in both curricula and clinical practice. Targeted, staged communication with high-influence stakeholders (academics, practitioners, patients, insurers) should proceed to align clinical practices with evidence and national policy. Continued engagement is needed to address misconceptions, financial concerns, and curricular alignment, thereby enabling broader delivery of evidence-based care. Future efforts should deepen policymaker and insurer involvement, finalize curricular integration (e.g., 5th-year placement and clinical requirements), and evaluate implementation outcomes.

Major limitations include limited government involvement despite policy recognition of SDA/PRDA; lack of engagement with oral health insurers; and potential bias from the practitioner-researcher perspective regarding behavior change and clinical workflows. The absence of direct stakeholder engagement during the mapping phase (to preserve prior ethics approvals) may also limit immediate implementation insights.