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Orthodontics around the World |
1 Orthodontic Department, Dresden, Germany
2 Department of Dental Health and Development, Cardiff, UK
3 Orthodontic Department, Brescia
R. Oliver, Department of Dental Health & Development, Dental School, Heath Park, Cardiff CF14 4XY, UK
Abstract
As a result of a European Union funded project (DentEd), a programme of visits to dental schools throughout Europe has been underway since 1998. This report describes the philosophy behind DentEd, gives a brief description of the features of a visitation, and covers the orthodontic and paediatric dentistry teaching as reported in 26 different dental schools in 16 different countries. It is based on a report submitted to DentEd from a small working group that looked at various aspects of educational provision within the two disciplines across Europe. The value of this information to teachers within the two disciplines and to the wider dental community is briefly discussed. The report recommends the adoption of an integrated course for orthodontics and paediatric dentistry. The main objectives are that the student should be able to understand orofacial and psychosocial growth and development of the child, recognize aberrant growth and development, and manage the behaviour of the child, their straightforward preventive, restorative and occlusal needs, and to make appropriate and timely referral.
Key words: Undergraduate Education, Europe
Introduction
DentEd is one of approximately 40 Thematic Network Projects that are funded by the European Union's Directorate on Education and Culture. The aims of the Thematic Network Projects are to disseminate good practice, promote partnerships, and to provide a forum for debate and exchange of ideas and information. The rationale for the DentEd project centred on concerns regarding the variable standards of undergraduate dental education across Europe, the variety of assessment methods controlling entry to the profession, the level of skills and competences possessed by new graduates, and the consequent impact that the free movement of dentists within Europe might have.
At the start of the project in 1997, there were 20 schools from around Europe who agreed to take part in the project. The project finished at the end of September 2000, by which time 28 schools had been visited in 16 different countries, of whom seven are non-EU members and a further 10 schools were scheduled to be visited.
The DentEd project is based mainly on a 5-day visitation to a dental school by an international team of academics actively involved in dental undergraduate education. The visiting team consisted of a chairperson, rapporteur, and a minimum of three other people. It attempted to be representative of all dental disciplines (including basic science) and from a range of countries, one of which should have a similar political and educational background to the country of the school hosting the visit.
The school is asked to prepare a Self-Assessment Report (SAR) that should be sent to each member of the visiting team prior to the visit. The SAR has 22 sections that cover all aspects of the dental school and course. Within each section related to the course, factual details are given, e.g. number of hours of instruction and pedagogical methods (theory, practical, laboratory), and the timing of each element within the course, followed by a list of their perceived strengths, weaknesses innovations, and best practice. This paper is based on Section 9 of the SAR—Orthodontics and Paediatric Dentistry—and summarizes the views of a working group that met in plenary session at a meeting in Stockholm in September 2000. The original report from which this paper is derived and reports from other sections may be seen on the DentEd web page (www.dented.org).
General Description
Within dental schools, Orthodontics and Paediatric Dentistry are traditionally taught by two distinct departments, despite the extensive common ground between the two. Whilst there are advantages to having two departments, it does make the concept of a holistic ‘Dentistry for the Child’ approach difficult to achieve. Some dental schools are now moving towards an integrated approach in both teaching and clinical practice, and amending the title of their course to ‘Dentistry for the Child and Adolescent’. This is motivated partly by a pedagogical desire to improve the student experience, partly as a result of scarce resource and partly a tacit acceptance of the difficulty in defining the boundaries of responsibility of Paediatric Dentistry.
Two points in this section should be taken under particular consideration:
). These arrangements are influenced by the local environment of organization and administration in the dental schools of the various European countries.
General Organizational Structure
The number of departments in the schools varies from 4 to 20. Orthodontics is a distinct department in the majority of schools and is joined with Paediatric Dentistry as a single department only in four schools. Public Dental Health and/or Prevention is integrated with Paediatric Dentistry in two schools, and in two other schools Orthodontics and Paediatric Dentistry are together with Dental Public Health as one department. In three German schools Paediatric Dentistry is part of the Department of Operative Dentistry. This is a historical anomaly that is gradually disappearing.
The European Orthodontic Society (EOS) and the European Federation of Orthodontic Specialists Associations (EFOSA) declare within the ERASMUS-programme, for specialist practice, postgraduate education should be compulsory and should have a minimum duration of 3 years. Orthodontics is a recognized specialty in all the European countries that have been visited, although the duration of postgraduate education varies. All countries apart from Germany and the UK have a 3-year training programme that is university based. In the UK, to become a hospital consultant a further two years of training after basic speciality training are necessary. The ‘3 + 2’ training programme is linked to an academic orthodontic unit (although the ‘2’ may not be in the same institution as the basic ‘3’). In Germany, the training programme requires a year to be spent in an academic institution, and a further 2 years in a recognized specialist practice or continuation at the university
This arrangement has relevance because, in countries with postgraduate education, undergraduate education is directed at basic knowledge with priority given to growth, development, and diagnosis, but in countries without postgraduate education the student will require additional skills and knowledge in treatment.
Nevertheless, in all countries, the generalist treats 20–50 per cent of the orthodontic cases (Schneider et al., 1998). Therefore, additional to the points above, topics such as (interceptive) orthodontic prevention and treatment of simple malocclusions should be included in the undergraduate educational programme.
The timing of undergraduate entry to clinics to treat child patients varies considerably between schools and between the two disciplines (Tables 1, 2). Similarly, the number of hours in the curriculum varies between orthodontics and paediatric dentistry, as does the balance between the theoretical and clinical elements of the course. In a small number of schools students have no personal practical orthodontic experience and learn by observation at the chairside. In schools where paediatric dentistry is part of operative dentistry, the quality and quantity of experience of dentistry for children is variable.
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Orthodontics
The primary aims in most schools are that the graduate should be able to understand and recognize normal and abnormal craniofacial growth, eruption pattern, and occlusal development, should evaluate the need of treatment, and assess the proper time for treatment or referral for treatment. They should be able to undertake the treatment of common types of malocclusion such as simple Class II division 1 and crossbite at an early stage with the help of the supervisor.
The objectives of lessons, seminars, and the practical training in the majority of schools are the following:
The nature of practical training varies. In some schools, students treat their own orthodontic patients in a separate or comprehensive practical training in dentistry for children and adolescents. In the other schools, students learn diagnostic procedures in seminars and assist the supervisor during treatment, without gaining personal experience in the day-to-day management of an orthodontic case. This may well reflect the challenging nature of cases referred to the department.
Paediatric Dentistry
Paediatric Dentistry is an independent department in 14 schools. It is a sub-specialty of Operative Dentistry in three schools, and linked to either behavioural science or preventive dentistry in a further three schools. The number of hours is about a third that of Orthodontics (Table 2
). The primary aims of the paediatric dentistry curriculum are to prepare the student for the management and general preventive and restorative dental care of infants, children and adolescents, and to assess the appropriate time of referral of a child for specialist care.
The objectives of lessons, seminars and practical training are the following:
Important Regional Differences and Potential Consequences
There exists a difference in philosophical approach to dental undergraduate courses, with mainly ‘western’ schools favouring an odontological approach, whereas many ‘eastern’ schools retain a stomatological approach. There are a number of schools that are in a transitional phase towards odontology. In general, the stomatological approach leaves less time in the course for the clinical dental disciplines and this must have some impact on the clinical competence of new graduates from different schools throughout the area of ‘Europe’.
The resource allocated to the Dental Course by different universities will impact on the overall quality of graduate. However, there is some evidence in the reports provided that Orthodontics suffers from a shortage of staff because, contrary to many other dental disciplines, staff have both undergraduate and postgraduate educational duties to fulfil. Also, where Paediatric Dentistry is a sub-specialty of Operative Dentistry, whilst there may be no lack of resource, the message that children are just small adults is unhelpful.
The small resource allocated by governments (usually former Soviet Union countries) to higher education, and dentistry in particular is also a substantial handicap leading to lack of funds for crucial things such as books, journals, computers, and clinical consumables, as well as refurbishment of clinics. This impacts on the overall quality of teaching environment and will inhibit the development of modern adult educational methods such as problem-based learning. In addition, the lack of funds to support staff activities and travel leads to prolongation of professional isolation with its consequent impact on staff morale, and their continued professional education and development.
Yet another problem faced by small countries with limited resources available is the availability of up-to-date information in the native language. Any dental course within ‘Europe’ today needs a staff and student body who are capable of understanding written English and preferably also spoken English.
A positive aspect of the regional differences is the knowledge that the majority of graduates will not move out of the country in which they live and train, and the training programme will have prepared them for practice within that country. The converse, that undergraduate training programmes should equip students to work in any ‘European’ country is unsustainable, although the DentEd drive to bring about some harmonization of courses is to be recommended. Furthermore, the parochialism that inevitably follows professional isolation will be a major contributor to the stagnation of ideas and techniques to the detriment of undergraduate courses.
Integration
Experience shows that the only real way to bring about a properly integrated course is for the departments to be merged, or for there to be one head of department who is prepared to delegate authority and responsibility to the different sections.
If integration is accompanied by a merging of departments, whilst sending correct messages to the students about Dentistry for the Child, there can be repercussions. A reduction of departments within a school may weaken the overall position of the Dean within the university. It automatically reduces the opportunities for individuals to become a head of department, affecting promotion pathways. The sensitivities of staff in the combined department must be addressed, so that the affiliation of the head of department is not perceived to favour one or other specialty.
The major advantage of integration is the subliminal message of holistic care of the child. Other advantages are:
Another distinct and important issue is the extent of orthodontic instruction at undergraduate level. This is influenced by a range of issues.
In those countries in which orthodontics is considered the province of the specialist, undergraduate instruction should be essentially the teaching of recognition of normal and abnormal craniofacial and occlusal development, and timely and appropriate referral. The limited amount of time within the curriculum available to orthodontics will restrict all but a cursory exposure to fixed appliances (which are recognized as the means of production of high quality orthodontic results; Richmond et al., 1993). Indeed, undergraduates should not be encouraged to consider themselves competent to use such a powerful tool as a fixed appliance. Furthermore, many would argue that only the most able students can approach competence in the management of removable appliances.
A final part of the equation lies in the staff resource available. Low staff numbers will inevitably impact upon the quality and quantity of orthodontic instruction. This may affect staff morale that, in turn, can have a malign influence on students' perceptions of the specialty.
Paediatric Dentistry
The main differences are in the department structure. In the small number of schools where they work together with the Orthodontic Department, all teaching is directed at the same age group of patients. This focus at a developmental stage is more suitable for comprehensive treatment of the growing child. Links with Dental Public Health and Prevention are found in a small number of schools. This concept helps to broaden the intellectual base of the specialty, but the risk that these linked disciplines are seen as entirely the province of dentistry for children can lead to difficulty.
In a minority of schools, Paediatric Dentistry is linked to a well structured Behavioural Science course that prepares the student for the varying levels of psychosocial development that they will encounter in their child patients.
Best Practice and Innovations
The following list gives the examples of Best Practice that were offered by the different schools in their SAR. There has been some editorial activity to eliminate duplication and to simplify the list for ease of reading. The list is divided into Orthodontics and Paediatric Dentistry. The innovations are more generic in nature and are not divided by discipline.
Orthodontics
Paediatric Dentistry
Innovations
PBL. Integrated cases of Orthodontics, Paediatric Dentistry, Oral Surgery, Restorative Dentistry, Behavioural Science, Preventive Dentistry, and General Dentistry.
Integrated course for Orthodontics and Paediatric Dentistry.
Lessons by students in kindergarten an schools on Dental Health.
Screening of schoolchildren for dental disease observed by students.
Competence as an assessment method.
Reflective log book for clinical practice.
Individual learning goals agreed between tutor and student.
Extra-mural (outreach) clinical experience in a primary care and Dental Public Health environment.
Mentoring by senior students and use of postgraduate students for undergraduate instruction.
Electronic capture of clinical data.
Video used as a teaching tool.
Pro-active discussion in protected time prior to the start of a clinical session of cases to be treated.
Hot review of cases treated during the session, i.e. protected time discussion at the end of a clinic of things that have gone well, things that have not gone well (and how they were handled), and unusual or interesting cases seen.
Conscious sedation ± general anaesthesia for management of the anxious child.
Special needs children treated by undergraduates.
Teamworking. This may be with dental nurses, hygienists, therapists, and dental technicians as part of the immediate dental team, but expanding to include wider teams such as those found in the interdisciplinary care within dentistry, and broader still in the management of children with cleft lip and palate.
Recommendations
The recommendations that follow are culled from the details of courses given within the schools' SAR, and from the Best Practices and Innovations.
These are features of the orthodontic and paediatric dentistry curricula that the working group felt should be included or excluded from the undergraduate course. Those for inclusion were considered to have the potential for enhancing the student learning experience, whereas those for exclusion were considered to have little relevance in a modern undergraduate dental course.
Orthodontics
Paediatric Dentistry
Conclusions
In broad terms, there is not a great deal of disharmony in the approach of different dental schools to the teaching of Orthodontics and Paediatric Dentistry.
All aim to ensure that students understand general and orofacial growth and development of the child, are able to recognize malocclusion, and to manage occlusal development. Paediatric Dentistry aims, in addition, to ensure that graduates have the necessary child management skills, together with appropriate restorative skills for primary teeth and traumatized immature permanent teeth. Both disciplines also include appropriate and timely referral skills.
The amount of theoretical and clinical time available to the two disciplines varies considerably, as does the timing of first exposure to child patients.
There are manpower problems in some schools that curtail the amount of student contact time and also, presumably, influence the amount of research that may be performed.
Some schools have to overcome problems of the unavailability of dental textbooks, and other important literature and sources of information in their native language.
There is a wide variety of pedagogical approach from stomatologically-based courses to odontological courses. There are varying degrees of penetration of Problem Based Learning ranging from none at all to total use of PBL throughout the entire course. Use of competence as an assessment method is limited. There is a minority of schools where Orthodontics and Paediatric Dentistry are fully integrated.
The recommendations given above are designed to complement the common elements already described. Whilst it is accepted that the undergraduate course should prepare the student to be able to safely and competently undertake those procedures that the GDP will perform, it must be remembered that the practice profile of the GDP will alter with increasing postgraduate experience. Hence, the ‘typical’ GDP work pattern is difficult to define.
Acknowledgments
The full membership of the working group comprised: Therese Garvey, Ilga Urtane, Antanas Sidlauskas, Elizabeth Davenport, Claus Munk, Lasi Alvesalo, M Spyropulis, Giuliano Falcolini, Liam Convery, Ilza Akota. The work was supported by the DentEd grant from the EU Thematic Network programme. Particular thanks go to Professor Derry Shanley who has led the project from its inception and has been instrumental in its success. A similar paper is being submitted to the International Journal of Paediatric Dentistry.
References
O'Brien, K. (1997) Undergraduate orthodontic education: what should we teach rather than what can we teach? Guest Editorial, British Journal of Orthodontics, 24, 333–334.[Medline]
Richmond, S., Shaw, W. C., Stephens, C. D., Webb, W. G., Roberts, C. T. and Andrews, M. (1993) Orthodontics in the General Dental Service of England and Wales: a critical assessment of standards, British Dental Journal, 174, 315–329.[Medline]
Schneider, M., Hofmann, U. and Biene-Dietrich, P. (1998) Der Bedarf an Fachzahndrzten für die Kieferorthopd in der vertragszahnärztlichen Versorgung, Bundesverband der Deutschen Kieferorthopäden, Augsburg, 3–33.
This article has been cited by other articles:
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  W. J. S. Kerr Letter to the Editor J. Orthod., December 1, 2001; 28(4): 322 - 322. [Full Text] [PDF]
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