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Suggested Guidelines for the Provision and Assessment of Orthodontic Education in Europe. A Report from the Professional Development Group of the EURO-QUAL BIOMED II Project

Eastman Dental Institute for Oral Health Care Sciences, University College London, 256, Gray's Inn Road, London WC1X 8LD, UK
Department of Orthodontics, University of Athens, Athens, Greece
Centre for Postgraduate Dental Education, University of Edinburgh, Edinburgh, UK
Specialist Practice, Erding, Germany
Department of Orthodontics, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland

Abstract

The suggested guidelines for the provision and assessment of Orthodontic education in Europe, which are introduced, set out, and discussed in this paper, resulted from the work of the Professional Development Group (PDG) of the EURO-QUAL BIOMED II project. They were published in the final report of the project, after comments had been received from a range of national and European bodies and societies, including the British and the European Orthodontic Societies, Royal Colleges, and the General Dental Council.

Key words: Europe, Guidelines, Provision and assessment of orthodontic education.

Introduction

The quality of any healthcare depends, in part, on the quality of the education and training received, at the beginning and throughout the working lives of those who provide it. The content and duration of undergraduate dental education, and of specialist training in Orthodontics and Oral Surgery within the member states of the European Union (EU) and European Economic Area (EEA) are prescribed by EC Directives (78/686/EEC and 78/687/EEC). However, the Directives merely lists topics to be covered during training and make no attempt to suggest the level of competence that individuals should achieve before qualifying as dentists or specialist orthodontists, or to suggest how they should maintain their level of competence throughout their working lives. This has been left to the discretion of individual member states and, in some cases, ‘provinces’ or universities within member states. A basic principle of EC law is that of the right of individual citizens of the EU (and EEA) to work in their trade or profession anywhere within the EU (and EEA). This principle presupposes that training standards reach a safe and acceptable level and that there will be a degree of harmonization (but not total uniformity) in all member states. Unfortunately, some 20 years after Directives (78/686/EC and 78/687/EEC) came into effect, there is little evidence of harmonization of standards in either undergraduate or specialist training in orthodontics.

The European Commission's Advisory Committee on the Training of Dental Practitioners has tried to establish an informal, voluntary system of peer review for dental schools within the EU and has recommended competencies for both undergraduate education and specialist orthodontic training. However, in the past many dental schools have declined or ignored requests to become involved in peer review. The concept of competencies is being further developed within the DENTED project (Scott, 1999). It is to be hoped that this project will further stimulate the interest in the convergence of training standards for dentistry in Europe.

In the past, Orthodontic Societies and University departments have agreed the Erasmus syllabus as a voluntary, pan-European guideline for specialist orthodontic training. Alternatives have been under discussion. Some wish to see the establishment of a pan-European examination (assessment) to mark the completion of specialist training.

Apart from perceived difficulties with the quality of training at undergraduate and specialist level, there are also wide variations in the employment and training of non-dentist support staff in orthodontics within the EU and EEA. There were also concerns about the continuing education of dentists and orthodontics, and of their training in communication skills.

The EURO-QUAL BIOMED II project was not restricted to quality issues in the provision of orthodontic care in EU and EEA countries, and included representatives from several eastern European.

During the last 3 years, the PDG of Euroqual has worked against this background to formulate a set of guidelines, which could be accepted throughout Europe, with a view to harmonizing the quality and basic content of the different educational programmes in all aspects of Orthodontics in Europe.

Suggested Guidelines for Orthodontic Education in Europe

The guidelines relate to the quality of training and education. However, members of the Group were unanimous in the opinion that quantity was also an issue. In this respect, the Group suggests that as all orthodontists who are nationals of member states of the European Union (EU), have the legal right to work anywhere in the EU and the EU is likely to expand again in the relatively near future, National Governments need to work together to plan the size of the European orthodontic workforce on a pan-European basis.

Undergraduate Education

1. Orthodontics should be included in the undergraduate curriculum.
   
2. On graduation all dentists should be competent to recognize malocclusion and treatment need, and be aware of the general principles of orthodontic treatment. If necessary, they should be able to provide interceptive and prophylactic care.
   

Postgraduate (Specialist) Education

1. Training should take place under the auspices and supervision of organizations approved by the competent authority of the country concerned (as required by the EC training directives) and occur in an approved establishment which fulfils the following criteria:

   (i) an adequate and varied patient flow;
   

   (ii) adequate facilities, equipment, and infrastructure;
   

   (iii) appropriate numbers of proficient and assessed teaching staff;
   

   (iv) the opportunity for elective student exchange.
   

   
   
2. Teaching should be of sufficient breadth and depth to equip all students to diagnose, and treat a wide range of malocclusions to agreed treatment goals.
   
3. Teaching should take place in an environment that stimulates and promotes critical, scientific thinking.
   

Examinations and the Assessment of Specialists

1. All trainee specialists should undertake an agreed pan-European final assessment at the end of their training.
   
2. This assessment should be carried out by an independent multi-national body and include the following elements:

   (i) the candidate's diagnostic and patient handling skills assessed on actual patients at the time of the assessment;
   

   (ii) the presentation of cases treated personally by the candidate;
   

   (iii) an oral examination;
   

   (iv) an assessment of the candidate's critical scientific thinking skills.
   

   
   
3. Candidates should normally be assessed in their own national language.
   
4. The assessors (examiners) should include at least one external assessor who is a national of and who holds a specialist orthodontic qualification from a country other than the country in which the assessment is taking place.
   

Continuing Professional Education (CPE)

1. All providers of orthodontic care should undertake regular CPE throughout their working lives.
   
2. CPE should include all aspects of professional life such as clinical skills, and patient and practice management.
   
3. The CPE activities of orthodontic care providers should be independently assessed on a regular basis.
   

Orthodontic Auxilliaries Training
The use or otherwise of orthodontic auxilliaries is a matter of personal choice and the laws of individual countries. However, for those countries whose laws permit the employment of orthodontic auxilliaries:

1. Training and CPE should be to an agreed pan-European level.
   
2. The clinical activities of orthodontic auxilliaries (and their CPE) must be the responsibility of a supervising qualified dentist on site.
   

Communication Skills

1. Communication skills training should be included at all levels of orthodontic training.
   
2. Communication skills training should enable providers of orthodontic care to communicate effectively with patients, practice staff, and professional colleagues.
   
3. It should also equip them to communicate effectively with other individuals, and public and private organizations.
   
4. All those who teach, lecture, or examine should undergo formal training in these skills, periodically update the skills, and be independently assessed on a regular basis. The rationale for these guidelines is discussed in the final section of this report.
   

Discussion

The results of the surveys performed by the PDG indicate that there are wide variations in both the quality and quantity of orthodontic training at all levels in Europe. Differences occur between countries and within countries from one dental school to another. There may well be good reasons relating to geographical, social, and legal reasons for some variations, e.g. if the law in a country restricts the practice of dentistry and orthodontics to dentists only then there can be no involvement of orthodontic auxilliaries in that country. It is also desirable that teaching takes place in a liberal environment and that there will be disagreement over the merits of different techniques between clinicians, which will be reflected by variations in teaching philosophies from dental school to dental school. However, patients in all countries have a right to expect that the clinicians that treat them have been adequately trained, and maintain their skills and knowledge throughout their working lives. As EC law enables the free movement of labour throughout the EU and EEA, and several Eastern European countries are likely to join the EU in the foreseeable future, it seems reasonable to suggest the implementation of basic quality guidelines for orthodontic training in Europe in an effort to harmonize, but not homogenize training standards.

The PDG are aware that the guidelines that they have suggested are unlikely to be enshrined in EC law. At best, they could be supported by a majority of dental schools and other training institutions in Europe, by orthodontists and those providing orthodontic care, by Dental Associations, by Governments, and other funding and legislating bodies, and perhaps most importantly, by patients. Well over 20 countries were involved in the EURO-QUAL project and its members came from a variety of backgrounds, both within and without orthodontics. Responses to the suggested guidelines have been generally positive. The guidelines are broad and seek to establish principles, which the majority of those involved with the teaching and organization of orthodontics could subscribe to. There appears to be a wide range of opinion and interests amongst those groups. It is therefore not surprising that there have been some comments, from those who consider training standards in some countries to be unsatisfactory, that the guidelines are too weak. However, others have commented that the guidelines are too prescriptive and should be couched using the conditional tense (‘could’ rather than ‘should’). The PDG consider that it has taken a middle path and suggested quality guidelines, which can be acceptable to the majority of those for whom they are intended.

References

European Council Directive Number 78/686/EEC (1978) Official Journal of the European Communities, 21, L233.

Scott, J. (1999) Convergence in dental education in the DENTED project, European Journal of Dental Education, 3, 1–2

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