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Features Section |
1 Chesterfield, UK
2 Maastricht, The Netherlands
H. S. Duterloo, Eijsendaalweg 3, 6231RS Meerssen, The Netherlands. Email: dutortho{at}euronet.nl
Abstract
The background to the formation of the European Board is given and the necessary procedures for obtaining certification of the European Board of Orthodontists (EBO) are described. An example case report is included to give the reader an indication of the type of detail required for each and every case presented. Recommendations are given for prospective candidates who might consider attempting EBO certification in the future.
Introduction
The purpose of this article is to encourage participation in the EBO examination by providing information about the requirements and presenting an example of case report.
History
In the western world orthodontic treatment was available on a very limited scale in the first part of the last century, and then only to a select part of the population. During the second part of that century orthodontics developed into a thriving branch of the health industry and is now provided on mass scale. The number of orthodontists and the amount of orthodontic treatment provided has grown immensely.
Originally issues to check and improve the quality of care did come to the fore. Latterly and certainly over the past decade or so, self-audit, clinical governance, and peer review have become major issues in all branches of the health industry. Fundamental to these issues is the assessment of quality by peer review.
In orthodontics several systems have developed and have been adapted for specific purposes. On a population scale, where statistical procedures are essential, standards, and indices were designed and applied to measure quality. In the last decade the need, effectiveness, and efficiency of orthodontic treatments provided by various groups of care providers became a popular field of research.1–
4 Recently, in the Netherlands, structured, systematic visitation of orthodontic practices by peers has been implemented.
Certification by Board examination is another way of promoting high standards of care. The aim is to improve the professional performance of the individual clinician by careful and extensive evaluation of all aspects of actual patient treatments.
In the United States of America such a system was formulated in 1929 when the American Board of Orthodontics (ABO) was set up. The ABO introduced a voluntary examination and standards of excellence were gradually established by consensus of the chosen experts of the day. There are, to date, almost 2000 American Board certified orthodontists. To be a diplomat of the ABO became an important career asset for academics and leading clinicians in the United States of America.5 James Vaden, past President of the ABO has listed the reasons for putting oneself forward for Board exams as:6
In Europe, the development of orthodontic specialties was rather more haphazard throughout the 20 century. Although orthodontics is now recognized as a specialty of dentistry in most countries of Western Europe, large differences still exist between the various public health systems in these countries. This has had a major impact on the way orthodontics is provided and practised, and also on what portion of the population has access to the service.
Orthodontic specialist education, mostly at academic institutions, is provided in most European countries. A standard curriculum was designed and has been adopted by many European universities.7 In view of the developments indicated above, the European Orthodontic Society, in 1996, initiated the European Board of Orthodontists.
Objectives
The objectives of the European Board of Orthodontists are described in the constitution of the EOS (Table 1).
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). During this time national boards have also been set up. Though many similarities exist, all the examinations (American, European, Italian, French, etc.) differ in various aspects as regards content, requirements, organization and judgement systems.
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Eligibility
To be eligible to participate in the examination the candidate must be a recognized specialist in their own country. Cases to be presented must be diagnosed and treated solely by, and under the full responsibility of the candidate. Cases treated during basic training as a specialist or cases treated by different clinicians in a group practice are therefore unacceptable for submission as EBO cases. An examination fee must be paid well in advance of the examination and the candidate must sign an agreement that decisions of the Examination Board will be accepted as final.
Examination regulations
Categories of cases
The comprehensive instructions to candidates are provided on disc, and they describe explicitly and specifically the eight categories of malocclusions that have to be presented in prescribed format (Table 3). No doubt whatsoever exists as to what type of cases and what clinical records are required. The extent of ‘write up’ of the case is also dictated by the sizes of the boxes on the forms, again enormously helpful to the aspiring candidate.
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Case presentations require initial pre-treatment records. These include a written explanation of the clinical examination, as well as colour facial and intra-oral photographs, dental casts, radiographs (dental tomogram and cephalogram), cephalometric tracings and accompanying assessment, a written treatment plan and explanation justifying that particular plan. Similar requirements apply to the second set of records after completion of treatment, with a description of the progress of treatment and its result. The third set of records (at least 1 year after completion of retention) does not include radiographs. The final text is a description of the findings, and a final evaluation of the treatment result and the long-term prognosis.
Superimposition of cephalometric tracings is not mandatory; however, it is recommended as a great deal of information can be gained about growth and treatment from relevant superimpositions. Additional records are encouraged if they enhance the overall case presentation and can be added as appendices.
Oral examination
The language for the oral examination is usually English; however, other major European languages can be used provided the candidate has indicated this at application. The reason for this is to make sure that examiners speak and understand that language to ensure the examinee has a fair chance.
Candidates are confronted with two unseen cases, often cases treated by the examiners and after having spent 1 hour examining the clinical records, they have 30 minutes to present, explain, and discuss their diagnoses and treatment plans.
Evaluation and judgement
The Council of the European Orthodontic Society nominates examiners. The examiners do not know the identity of any of the candidates prior to meeting them during the viva examinations.
For all parts of the examination a score of at least 65% is required for a pass. A case evaluation form is used with a sequence of marks for each case (see Table 4). No more than 10 per cent of the marks can be gained from the quality of the records. There is little possibility for compensation of marks within a case, or between cases and the oral examination. The difficulty of a case is given due consideration when assessing the marks. The use of the case evaluation form helps the examiners to calibrate, to be systematic and objective. It also allows the possibility to give balanced weighting to all aspects of the case and not just single out, for instance, purely the post-treatment occlusion. The texts, therefore, play a major role in the evaluation, as this is where the candidate can explain the rationale for clinical decisions and actions, or describe difficulties encountered during treatment or may express doubts or self-criticism on particularly controversial aspects of the treatment provided.
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Candidates are usually established orthodontic specialists with at least 5 years of independent clinical experience. To select the most suitable cases for each category, together with the required documentation, requires systematic and organized collection of clinical records. Therefore, the time needed to select and prepare the suitable cases should not be underestimated. The time needed to produce the case presentation binders and the dental casts is estimated at about 12–15 hours per case. The use of computers is recommended as it improves the quality of the presentation and is a real time-saver. As the texts are to be in English, extra time may be needed for the preparation. The use of an editor or other helper with a good working knowledge of written English is highly recommended.
Example of successful case report
In this section a successful case report is presented and this is illustrated in Figures 1–3. The purpose of is to demonstrate specific aspects of the case presentation. It is to indicate the type and quality of records that should lead to successful presentation of cases.
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The first clinical page comprises a resume of the entire case and the following page gives all the diagnostic information in specific categories with a maximum amount of information specified by virtue of the size of the boxes and the font size specified. It is therefore essential to be as brief and concise as possible, but still to include the salient point.
Routine records are taken for every patient at three stages: pre- and post-treatment, and at least 1 year out of treatment. The routine records comprise dental casts, colour facial photographs, colour intra-oral photographs, a dental tomogram, and a lateral cephalogram with tracing and a table including numerical values of the cephalometric assessment.
A page is then devoted to the treatment plan outlining the objectives of treatment and breaking down the treatment in stages to aid easy comprehension of the clinical approach of that particular patient. The following pages includes a resume of all treatment, concisely listing what was performed each stage, perhaps giving details of arch-wire changes or particular mechanics used.
Following treatment a standard set of records is included once again, which is almost identical to the pre-treatment records. If possible it is useful to place the facial and intra-oral shots in similar positions to those contained in the pre-treatment records, to allow the examiners to make direct comparisons between the two. A second table is included in the post-treatment records listing the pre- and post-treatment cephalometric values side by side to enable changes to be quickly assessed.
The candidate is then given the opportunity to describe the results achieved, perhaps highlighting any problems in treatment and describing any particularly interesting aspects of the treatment. A post-treatment evaluation is also required, as well as some justification of the retention regime chosen.
A further set of records is provided, at least 1 year post-treatment, although at this stage a dental tomogram is not required. If available, once again, the cephalometric morphological assessment is carried out to allow assessment of any dentoalveolar tipping and/or skeletal changes that may have occurred after the end of active treatment.
A final half-page is then requested to allow the candidate to give a final assessment of the case and point out any aspects of treatment, tooth movement or skeletal change, which are of particular note. If there are any aspects of treatment that could be improved upon or, with the benefit of hindsight, may have been differently treated, it would be worth alluding to these at this stage.
Candidates have the opportunity to include appendices to their presentation and things worth including might be any in-treatment photographs taken at particular milestones in treatment, super-impositions of the cephalometric tracings or perhaps photo’s showing a fully functional occlusion at the end of treatment. Often photographs will be taken of adjunctive appliances used to achieve the clinical result, such as functional appliances and is always of interest to see the occlusion at the end of the functional phase before fixed appliances are placed. In addition, photos will often have been taken up particular stages in treatment such as the change of arch-wires. Following the progress through various arch-wire changes can shed light on the efficiency with which the treatment progressed.
In addition to the cephalometric morphological assessment presented, pictorial representation of the dentoalveolar and skeletal changes, by virtue of super-imposition of post-treatment tracings on pre-treatment tracings, can offer an examiner a significant insight into the changes achieved during treatment. It is also of benefit to superimpose the final green tracings on the previous two tracings to monitor any dentoalveolar changes occurring after the end of active treatment.
Demonstration of a fully functional occlusion showing right lateral excursion with absence of non-working side contacts, left lateral excursion with absence of non-working side contacts and, finally, incisal guidance in protrusion with gentle posterior disclusion will all contribute to a positive assessment of the case by the examiners.
Discussion
The procedure, which has evolved over the past few years, is felt to work well. It is also felt that the examination is of very high standard, and the assessment and appraisal of the candidates, and their material, objective and fair. Despite this apparently satisfactory process it is appropriate that the current procedure is constantly reappraised for potential weaknesses and areas that lend themselves for improvement. The success of the EBO is totally dependant on the brightest and best clinicians putting themselves forward for and successfully passing the assessment.
To date there is insufficient scientific evidence to support inclusion of each and every section of the clinical requirements and some details of the judgement system might not withstand close scrutiny. Examples of difficulties faced is the use of end of treatment dental tomograms to judge the proper mesio-distal angulation of teeth8 or the impact of inherent method errors in cephalometric evaluations9 and possible limitations in record taking.10
A problem of different order is the uncertainty surrounding malocclusions prone to relapse such as closure of open bites.11 Such situations are likely to prevent candidates including such a case in their presentation.
The examining Board regularly adapts requirements, regulations, and assessment systems due to changing circumstances, or scientific and clinical viewpoints. Some of the changes or adaptations appear to make the examination more easy, while others have the opposite effect. It is also apparent that striving for perfection is behind some of the requirements. However, also for that aspect actions should as much as possible be ‘evidence based’. Candidates should bear in mind that a relentless pursuit of such perfection, is not in the interest of all patients. An acknowledged balance between clinical excellence and the best overall interests of the patient is important. Recognition of when each patient has reached the goals appropriate to them is a desirable characteristic of the competent and mature clinician.
The recently released British Orthodontic Society guidelines on radiography state that radiographs are only justified when that particular patient will benefit from the results of that specific radiograph. As a result, lateral cephalograms are taken before debond when there is still some space to close. The EBO regulations state that a lateral skull radiograph at the end of treatment, whilst useful, is not mandatory. The same applies to the ‘C’ records taken at a later stage. Providing a full and complete explanation and justification of treatment is provided, accompanied by acceptable documentation, photographs, and radiographs, there should be no problems having these cases accepted.
Though the EBO examiners regularly calibrate their judgement to be as objective as possible, some subjectivity is unavoidable. On the other hand, clinical procedures, perfectly applied and accurately described, together with intelligent, elegant solutions to complex orthodontic problems effectively show abilities and treatment results that can be reliably identified as excellent. It is obvious that candidates select the very best available material, but it is unlikely that the presented cases would be unrepresentative of the professional standard of that clinician. It is therefore our opinion that the successful candidate is probably an excellent clinician. Candidates usually find the examination a tremendous professional challenge and for most of them, after many months of painstaking preparation, it is an enormously rewarding if somewhat stressful day. The successful candidates are quite rightly proud of their achievement and we have yet to meet a successful candidate who didn’t think the EBO was a very worthwhile pursuit of clinical excellence.
Conclusion
For the individual clinician, who wants to have their clinical work appraised and assessed alongside some of the best clinical cases in Europe the EBO is for them. It affords the opportunity to scrutinize and then hopefully improve the quality of their own clinical practice from which all their future patients will benefit.
Further information about the EBO can be obtained from the European Orthodontic Society, Flat 20, 49 Hallam Street, London W1W6JN, UK. Tel/Fax: 44 (0) 207935 2795 (email: eoslondon{at}compuserve.com).
References
Shaw WC, O’Brien KD, Richmond S, Brook P. Quality control in orthodontics: indices of treatment need and treatment standards. Br Dent J 1991; 170: 107–112.[Medline]
Richmond S, O’Brien KD, Buchanan IB, Burden D. 1994 An Introduction to Occlusal Indices, 2nd edn. Mandent Press,.
Prahl-Andersen B. Quality development in the orthodontic practice. In: Carels C, Willems G (Eds) The Future of Orthodontics. Leuven: Leuven University Press, 1998.
Al Yami EA, Kuypers-Jagtman A-M, van’t Hof MA. Stability of orthodontic treatment outcome: follow-up until 10 years post retention. Am J Orthod Dentofac Orthop 1999; 115(3): 300–304.[CrossRef][Medline]
Vaden JL, Kokich VG. 1999 The American Board of Orthodontics. Past, Present, and Future. Available at: http://www.americanboardortho.com/history/ppf.htm
Vaden JL The American Board of Orthodontics Am J Orthod Dentofac Orthop Gazette 2000.
Van der Linden FP, Bolender C, Canut JA. Three years postgraduate programme in Orthodontics. The final report of the Erasmus project. Eur J Orthod 1992 14: 85–94.
McKee IW, Glover KE, Williamson PC, Lam EW, Heo G, Major PW. The effect of vertical and horizontal positioning in Panoramic Radiography on mesiodistal tooth angulations. Angle Orthod 2001; 71: 442–452.[Medline]
Kamoen A, Dermaut L, Verbeek R. The clinical significance of measurement error in the interpretation of treatment results. Eur J Orthod 2001; 23: 569–579.
10 Isaacson KG, Thom AR. Orthodontic Radiographs: guidelines. London: British Orthodontic Society, 2001.
11 Fischer K, von Konow L, Brattstrom V. Open bite: stability after bimaxillary surgery—2-year treatment outcomes in 58 patients. Eur J Orthod 2000; 22(6): 711–718.
Received February 14, 2002; accepted February 20, 2002
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  J. R. Sandy Northcroft Memorial Lecture 2006 The future of specialist training J. Orthod., September 1, 2007; 34(3): 177 - 184. [Abstract] [Full Text] [PDF]
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