European Journal of Dental Education ISSN 1396-5883
Current trends and status of continuing professional development in implant dentistry in Europe T. C. Ucer1, D. Botticelli2, A. Stavropoulos3 and N. Mattheos4 1 2 3 4
Oaklands Hospital, Salford, UK, ARDEC, Ariminum Odontologica, Rimini, Italy, € University, Malmo €, Sweden, Faculty of Odontology, Malmo Faculty of Dentistry, The University of Hong Kong, Hong Kong, China
Keywords continuing professional development; implant dentistry; postgraduate dental education. Correspondence Cemal Ucer Dental Implantology Oaklands Hospital 19 Lancaster Road Salford M6 8AQ, UK Tel.: +44 1612371842 Fax: +44 1612371844 e-mail: [email protected] Accepted: 18 November 2013 doi: 10.1111/eje.12080
Abstract Introduction: Previous surveys have shown that newly graduated dentists, in most European countries, do not obtain adequate theoretical knowledge and, especially, clinical skills in implant dentistry (ID) through their undergraduate education and must therefore acquire knowledge and develop competencies through further postgraduate study. Moreover, clinicians, in general, need to continue to maintain the currency of their competence by undertaking ongoing continuing professional development (CPD). This seems particularly important in ID as techniques, and materials develop rapidly due to advances in biomedical technology. Despite recent developments, CPD in ID remains poorly organised with little standardisation or harmonisation across Europe. The objective of this survey was to explore the current status and trends within CPD education in ID in Europe. Materials and methods: Stakeholders and opinion leaders associated with ID education were invited by email to fill an online questionnaire (closing date: 30th April 2013). Two hundred and forty-seven questionnaires were distributed, and two separate reminders were sent to participants in 38 European countries. The survey contained 14 multiple-choice questions, and the data were collected using SurveyMonkey© software, exported in SPSS (Inc, Chicago, IL, USA) format and analysed using descriptive statistics. Results: Two hundred respondents working in 24 countries replied to the survey (response rate of 81% of invitees and 63% of countries surveyed). The results demonstrated a wide divergence in the content and structure of CPD in ID in Europe. Conclusions: Dentists need CPD to develop their skills and to maintain their competence in ID. There is an urgent need for structured and accredited CPD, which should be readily available to all dentists practising ID. It should have pre-determined learning objectives, delivered by accredited CPD providers and educators, and have assessable outcome measures to ensure the best possible impact on clinical practice and patient safety.
Introduction Continuing professional development (CPD) is now recognised as an essential professional activity for dentists (i) to maintain their clinical skills and to keep these up to date with new developments in scientific knowledge and technology and (ii) to integrate these techniques into clinical practice safely (1–6). 52
Previous surveys (3) have shown that newly graduated dentists, in most European countries, do not obtain adequate theoretical knowledge and particularly clinical skills in implant dentistry (ID) through their undergraduate education and must therefore acquire knowledge and develop competencies through further postgraduate study. Clinicians need to continue to maintain the currency of their competences in ID as knowledge, techª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 52–59
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Current trends and status of CPD
niques and materials develop fast due to rapid technological advances. By keeping dentists’ knowledge and skills up to date, CPD enhances safe practice and aims to improve quality of care. In general, excepting structured degree programmes leading to an academic title and/or specialty, there are three types of CPD activity commonly available to dentists: (i) reading professional journals; (ii) attending lectures, courses or study clubs and (iii) undertaking short-term or modular training courses to learn new techniques (7–9). To have any real impact on clinical practice, CPD activity should be systematically planned and structured in relation to the specific learning needs of the individual clinician and not selected arbitrarily according to ease of access or convenience. In this respect, the personal development plan (PDP) is seen as a useful self-appraisal and evaluation tool as it encourages reflection on own clinical skills and helps to enhance the impact of CPD on clinical practice by identifying strengths and weaknesses in own knowledge or skills (10). In a recent European-based survey (DentCPD), it was reported that although CPD education was available from a wide range of sources, it was generally unregulated and there was considerable variation in the level/quality of the CPD activity in Europe (10). In general, university dental schools and professional dental associations were found to be the most common CPD providers, which reportedly provided the best quality of teaching. The need for harmonisation of CPD across Europe to support the safe management of patients and promote mobility of practitioners was recommended on the basis of the findings of the DentCPD survey (9, 10). Implant dentistry does not seem to be an exemption from the above; however, there is no structured information available on CPD in implant dentistry in Europe at present, as the DentCPD survey did not specifically address this discipline (10). Thus, the aim of the present study was to collect information on the emerging trends in CPD activity in implant dentistry across Europe to contribute to the current discussion, including information about providers, programme/course structure, quality assurance and accreditation criteria, and possible barriers to CPD, and to assess the opinion of European stakeholders. The specific objectives of the study were to: Collect information on the emerging trends in CPD activity in implant dentistry. Explore how CPD education in implant dentistry is delivered or structured in Europe. Identify the quality assurance criteria used (if any) for CPD education in implant dentistry. Investigate the barriers to CPD education in implant dentistry in Europe. Use the data to contribute to current discussions on structuring of CPD activity in implant dentistry in Europe.
course providers, representatives of national and international scientific associations related to implant dentistry were invited by email to fill in an online questionnaire hosted by SurveyMonkey©. The invitees were identified through the network of the ADEE and member directories of national and international scientific associations or foundations related to implant dentistry, for example, European Association for Osseointegration (EAO), European Federation of Periodontology (EFP), International Team for Implantology (ITI) and Osteology Foundation. Websites of major implant companies were also consulted, and persons appearing responsible for educational events were invited to participate. In total, 247 individuals in 38 European countries (including all EU countries and candidate states) were invited to participate in the survey. The survey contained 14 multiple-choice questions constructed on the basis of the DentCPD (10) questionnaire, but was adapted and amended with questions specific to implant dentistry and in accordance with the specific objectives of this study. Within the framework of the current questionnaire, a structured CPD course was defined as a ‘sequential CPD programme leading to predetermined learning outcomes’, whilst unstructured CPD included ‘conferences, meetings, stand-alone (unlinked) CPD lectures or learning activities’. The questionnaire was first piloted amongst a group of experts in implant dentistry education, and the email invitation – including a brief explanation of the purpose of the survey – was issued on 14 March 2013, and the survey was closed on 30 April 2013. Responses were collected using the SurveyMonkey© software (surveymonkey.com) with the system set to disallow multiple responses per email address, but to allow the participants to reenter the survey and update their responses at a later date. Data were exported in SPSS (Inc, Chicago, IL, USA) format and analysed as a whole and by country using descriptive statistics.
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Responses were received from 200 invitees working in 24 countries, that is, response rates of 81% and 63%, respectively (Fig. 1). Seven invitees opted out of the survey, and 12 emails were returned undelivered, whilst no response was received from invitees in 14 countries despite two reminders. 29% of the respondents worked in a capital city, whereas 39% worked in a large city (self-reported), 25% in a medium size city and 7% in a rural location. The respondents included university teaching stuff (41%), implant clinicians/experts (31%), private course providers and representatives of commercial implant/biomaterials companies and of national and European level implant associations (Fig. 2). Two countries (UK and Turkey) were represented with significantly more respondents. Consequently, at certain parts, results are reported for the whole sample and also excluding Turkey and UK respondents.
Methods
Implant dentistry in undergraduate education
A group of European stakeholders with an interest in implant dentistry education, including the participants of the Association for Dental Education in Europe (ADEE) European Workshop on Implant Dentistry University Education (Budapest, 2013), selected academic teachers and opinion leaders/experts,
Seventy-three per cent of the respondents (66% excluding Turkey and the UK) did not think that newly graduated dentists acquired the necessary surgical skills in the undergraduate curriculum to provide straightforward surgical implant treatment, but 41% per cent (54% excluding Turkey and the UK) indi-
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Results
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Fig. 1. Distribution of the respondents according to country of work.
Fig. 2. Respondents’ position/interest in implant dentistry.
cated that newly graduated dentists obtained skills during their undergraduate education to treat straightforward prosthodontic cases. Only a very small minority was of the opinion that newly graduated dentist gained adequate clinical skills needed to provide surgical (5%) or prosthodontic implant treatment (8%) in advanced or complex categories (SAC classification; 11). A large majority of respondents (76% of all respondents or 83% excluding UK and Turkey), from the European countries surveyed, reported that no additional degrees were currently required for a licensed dentist to practise implant dentistry in their region/country. Fifty-seven per cent of all respondents 54
(58% excluding UK and Turkey) said that dentists gained clinical skills in implant dentistry by attending CPD courses run by universities or professional organisations, however not leading to an academic degree or formal recognition.
Current trends in CPD activity in implant dentistry In general, the vast majority of respondents (71%) reported the availability of well-structured CPD courses in implant dentistry in their countries/regions; however, only a few of these courses ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 52–59
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were said to be accredited. A limited number of respondents (4%) stated that only ‘product training’ was available in their region (Fig. 3). Twenty per cent of the participants (16% excluding UK and Turkey) believed that CPD in implant dentistry needed urgent development and structuring.
Quality control of CPD in implant dentistry in Europe Respondents reported that there was some quality assurance of CPD in implant dentistry, but this was generally limited (Fig. 4).
Types of CPD activity in implant dentistry in Europe Product training organised by commercial companies, short 1–2 day courses (with no predetermined learning outcomes) and study club meetings were ranked as the three most common forms of CPD education in implant dentistry in Europe, whilst verifiable e-learning was reported to be the least common. Figure 5 shows the organisations that provide regular CPD in implant dentistry in Europe. Most of the accredited CPD was delivered by universities and national organisations, which were also more likely to provide the necessary core competencies in implant dentistry. Courses run by the industry were
Fig. 4. Structure and quality of the existing continuing professional development in implant dentistry.
Fig. 3. What is the current status of continuing professional development education in implant dentistry in your city/region?
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 52–59
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tions or the Ministry of Health provided most of the accreditation for CPD courses in implant dentistry.
Role of mentoring and clinical audit in CPD Forty per cent of all respondents used PDPs to identify and guide their learning needs in implant dentistry, whilst 70% mentioned that they gained clinical skills under the supervision of an experienced colleague (e.g. a mentor) showing that not all CPD in Europe is theoretically based.
Importance of PDPs, mentoring, the logbook and national register of implants: A large majority of the respondents thought that PDP (65%), keeping a logbook of implant activity to document clinical cases (i.e. auditing; 80%), gaining clinical experience under mentor supervision (85%) and setting up a national register of dental implants/complications (70%) were very important.
Barriers to CPD education Fig. 5. The organisations that provide regular continuing professional development in implant dentistry.
reported to provide the core competencies only partly and were less likely to be accredited.
Quality assurance criteria and accreditation of CPD in implant dentistry With regard to quality assurance of CPD courses in implant dentistry, respondents rated ‘teaching experience and formal qualification of the speakers’ as the most important criterion (Table 1). Accreditation of the CPD providers and speakers, predetermined learning objectives, participant feedback and formal end-of-course assessments were also ranked as important determinants of the quality of CPD education. Moreover, the respondents reported on the accreditation of CPD in implant dentistry stating that universities, national level dental organisa-
TABLE 1. Quality assurance criteria of continuing professional development (CPD) activities
Answer choices
Rank
Responses %
Teaching experience and formal qualifications of speakers Appropriate learning environment or facilities Participants’ feedback Formal assessment of participants upon completion of the course Predetermined learning objectives Accreditation of CPD providers Official recognition or accreditation of speakers External audit and quality control
1
86
2 (2) (2)
58 58 58
3 4 5 6
56 54 52 47
56
Lack of incentives, time and cost concerns and lack of patient awareness or appreciation of the importance of CPD for dentists were the three most commonly cited barriers to CPD education in implant dentistry.
Respondents’ opinion on implant dentistry as a specialisation and CPD providers Sixty per cent of the respondents (62% excluding UK and Turkey) ‘agreed’/‘strongly agreed’ that implant dentistry should be recognised as a speciality on a European level. Whilst 52% (59% excluding UK and Turkey) agreed/strongly agreed that CPD education in implant dentistry should only be provided by universities or accredited organisations, a large majority (85%; 89% excluding UK and Turkey) on the other hand thought that effective CPD could be delivered by a variety of recognised providers including experienced clinicians. Seventy-five per cent of the respondents (74% excluding UK and Turkey) believed that CPD in implant dentistry should be accredited at a central (national or European) level. There was overwhelming agreement that CPD providers/educators should publically declare any conflicts of interest.
Discussion Due to the absence of any specific registers of CPD providers/educators in implant dentistry, the study surveyed the opinion of a wider group of stakeholders with a known interest in implant dentistry education in Europe including academic teachers, clinicians with or without a specialist background, opinion leaders within scientific and professional dental associations, providers of CPD (e.g. EU institutions, universities, national implant associations, commercial company representatives, course providers and relevant scientific societies [e.g. European Federation of Periodontology (EFP), European Association for Osseointegration (EAO), etc.]. The addressees were also invited to forward the online link to ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 52–59
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the survey to their colleagues with a known interest in CPD in implant dentistry. A good response rate was achieved for the current survey from a total of 24 countries. The two largest groups of respondents consisted of university teaching staff (41% of all respondents and 45% excluding the data from UK and Turkey) and implant clinicians/experts (31% and 28% excluding UK and Turkey) representing the two main sectors of education providers in ID – thus reducing the risk of distortion of the results. Although two electronic reminders had been circulated, no response was received from some of the EU states. It is possible that at least some of the non-respondents may have failed to receive the initial email invitation or the reminders due to interception by their antispam software. This is an inherent shortcoming of any electronic survey by email. To prevent duplication or distortion of data, the electronic questionnaire system (SurveyMonkey©) was set up to exclude multiple responses from a single email address or a PC. A methodological weakness of this survey that might affect its validity is the risk of bias that may have been caused by sampling error. This could have occurred as the recipients had been targeted because of their known interest/expertise in implant dentistry education. Moreover, there was a wide variation in response rate from different European countries; therefore, a direct comparison of the results between different European countries was not considered appropriate. A higher rate of participation from the UK could be explained, at least partly, by the availability of several formal university based postgraduate diploma and master’s programmes in the UK (at least eight university master’s programmes in implant dentistry). A unique situation also exists in the UK that dentists are required to undertake structured implant education and training under mentor supervision before they can provide implant dentistry (12, 13). Therefore, there is a strong interest and involvement in postgraduate CPD implant activity in the UK by educators and providers as well as by dental professionals. Another weakness of the study relates to the fact that the results depended on self-reported data based on the subjective opinion of the respondents. Despite its shortcomings, this survey has demonstrated that there was a wide variation in CPD education in implant dentistry in Europe with little consistency, structure or regulation. The data showed that although well-structured CPD courses were available in some European countries, relatively few of these were regulated or accredited. This demonstrated the need for availability of structured CPD activity in implant dentistry in Europe. The reported lack of standardisation or regulation of CPD is consistent with the results of previous surveys of general CPD activity in Europe (10). A comprehensive survey of stakeholders reported the availability of compulsory CPD in dentistry only in approximately 50% of the EU states (10). In about a quarter of the rest of the EU countries, an official regulated CPD system was available, but this was voluntary rather than a compulsory system. Nevertheless, there appear to be a trend, in recent years, towards a regulated and accredited dental CPD in the EU states to help dentists to maintain their knowledge and competence (10). To our knowledge, this is the first comprehensive survey that has attempted to elicit the opinion of stakeholders in Europe ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 52–59
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on the current trends in CPD activity in implant dentistry. Our data have shown that although most European countries have some CPD activity in implant dentistry, the structure of these courses seems to be less than ideal from an educational point of view. This survey has shown that no additional degrees were currently required for a licensed dentist to practise implant dentistry in Europe. However, when questioned if implant dentistry should be made a speciality in Europe, interestingly, a majority of all respondents of the current survey agreed/strongly agreed that it should be. Notwithstanding this opinion, the respondents agreed that clinical skills and competence in implant dentistry can be acquired from well-structured CPD courses and effective CPD can be delivered by a variety of recognised providers including experienced clinicians. Presumably, if specialisation in implant dentistry was to be recognised, these specialist would treat highly complex cases including complications, whilst non-specialist practitioners with special interest in implant dentistry could confine their work to mainly straightforward the cases (SAC classification; 11). Although this is consistent with the results of a recently conducted survey (14), this point needs to be clarified in future surveys. The respondents rated lack of incentives, time and cost concerns and lack of patient awareness or appreciation of the importance of CPD for dentists as the three most commonly cited barriers to CPD education in implant dentistry. Future CDP courses should therefore be designed to minimise such barriers and to ensure that CPD activity in implant dentistry is designed to produce quantifiable clinical benefits for the dentists and patients alike. The results of the current survey also showed that the use of PDPs and logbooks, as tools of reflective learning, would be highly desirable for identifying individual learning needs and planning CPD activity in implant dentistry. The efficiency of lifelong learning depends on the individual’s ability to continuously and critically appraise and reflect on his/her professional knowledge, skills and actions and use these to guide his/her learning needs. Thus, an effective CPD requires a strong element of selfassessed and self-directed learning activity. In this respect, the use of PDP has been recommended as an invaluable tool that could allow the identification of professional strengths and weaknesses as well as the factors that affect the acquisition of new knowledge or skills (3). Similarly, auditing one’s clinical activity by keeping detailed clinical records or a logbook is seen as an important tool in highlighting clinical areas of weaknesses or problems. The use of the PDP is not yet a common practice in dentistry in Europe although a recent survey revealed that formal appraisal or PDP meetings were compulsory in general dentistry in a minority of countries for private and non-private dentists (10). In this respect, there was widespread support for introduction of a European register of implants and complications. This very interesting proposition should be investigated in future surveys to see how such national or European registers of implant activity could contribute to CPD. Product training organised by commercial companies, short 1–2 day courses (with no predetermined learning outcomes) and study club meetings were ranked as the three common forms of CPD education in implant dentistry in Europe. Interestingly, despite the increasing popularity of the internet, verifiable 57
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e-learning (e.g. online courses/webinars) was reported to be the least common type of CPD education in implant dentistry. Although accreditation was not commonplace in Europe, a number of organisations were identified as the principle professional bodies accrediting CPD courses in implant dentistry. These were national/professional dental organisations, universities and the Ministry of Health in descending order. There was a strong agreement that CPD in ID should be accredited at a national or European level and that implant manufacturers or commercial companies should provide product training only. The latter is consistent with the conclusions of the ADEE 1st workshop in implant dentistry education (Prague, 2008; 3). There was a general agreement that the undergraduate education, in the majority of the European countries, does not equip dentists with the clinical skills needed to implement the full spectrum of implant dentistry expected in a modern general practice. This finding is consistent with previous reports (3, 15), although there has been a recent increase in undergraduates gaining experience in straightforward implant prosthetics (14). A dental graduate relies on attending CPD courses either to acquire and develop his/her initial core knowledge and skills in implant dentistry or to keep these up to date as part of his/ her lifelong learning activity. Therefore, it is evident that CPD in implant dentistry is needed irrespective of whether implant dentistry is taught in the undergraduate curriculum or competences in ID are achieved as part of formal postgraduate education or training.
Conclusion Implant dentistry has evolved to become a highly technical and multidisciplinary branch of dentistry, which requires constant update of knowledge and clinical competence in restorative as well as surgical sciences. With rapid advances in materials and techniques, dentists who provide any aspect of implant dentistry, irrespective of their initial undergraduate or postgraduate level of training or expertise, need to maintain and update their knowledge and skills through a well-structured, lifelong CPD activity. This applies to all members of the team who are involved in delivery and maintenance of implant treatment from the general practitioner with special interests in implant dentistry to the specialist level. The undergraduate curriculum in Europe does not yet universally provide dentists with the competence required to practise implant dentistry, although there has been an increasing trend towards this direction as the ADEE 1st European Consensus workshop on implant dentistry university education in 2008 (14). Therefore, CPD in implant dentistry should be an integral and essential part of a career of any healthcare professional who is involved in implant practice. This would ensure that dentists continue to maintain the currency of their competence within the area of their clinical activity. The current survey has demonstrated that, in most European countries, there is some CPD activity in implant dentistry ranging from product training by the industry to accredited university courses (excluding formal qualifications). However, currently, this is mostly unregulated, poorly structured with no 58
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recommended hours of study or accreditation in most countries. Our data demonstrated the important role of CPD and support the following conclusions: Standardisation of CPD in implant dentistry with a view to achieving closer harmonisation across Europe is highly desirable. This would increase the standard of care in implant dentistry and ensure that dental health practitioners are competent and up to date within the area of their clinical activity. Furthermore, this would facilitate mobility of healthcare professionals as well as patients seeking initial or follow-up treatment across Europe. To be educationally effective, CPD in implant dentistry should be highly structured and accredited either at a national level or desirably at a European level. CPD should be clinically applicable, and courses should match the different learning needs of practitioners working at different levels of complexity of treatment. CPD should be readily available, with as little barriers as possible, in modular, transparent format with tangible benefits and quality assurance of its educational outcomes by regulatory authorities (e.g. Ministry of Health), universities or academic institutions. Most importantly CPD in implant dentistry should match the individual needs of the practitioners and be applicable to their practice. In this respect, the use of logbooks and PDPs is highly desirable as tools of self-appraised and self-directed lifelong reflective learning activity. Continuing professional development could be provided by a variety of sources including universities, academic institutions or individual experts provided that it is structured with clear educational objectives at each level of clinical competence (or complexity) and should incorporate the following quality assurance elements: Predetermined learning objectives. Assessment of learning outcomes (16) both summative and formatively and feedback from learners. Accreditation by a national or European organisation. Blended teaching with a good mix of theory with practice. Clinical experience at the workplace under supervision of clinical mentors (using objective clinical assessment tools). Transferrable credits that can be accumulated towards a tangible learning outcome or recognition of CPD activity. Course providers and educators should be recognised by a national or European body. Course providers and tutors/educators in implant dentistry should declare any conflicts of interest prior to teaching. Courses should be held in an environment that is conducive to efficient teaching and learning activity. Implant industry should confine their teaching to product training only. Finally, it is recommended that the academic community should establish clear guidelines on CPD and training standards in implant dentistry.
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Conflicts of interest Professor Ucer is involved in delivery of postgraduate university degree courses and CPD courses in implant dentistry in the UK. Professor Botticelli is involved in delivery of postgraduate private courses for continuing education in implant dentistry. No other conflicts of interest have been declared. ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 52–59
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References 1 Schleyer T, Eaton KA, Mock D, Barac’h V. Comparison of dental licensure, specialization and continuing education in five countries. Eur J Dent Educ 2002 Nov: 6: 153–161. 2 Sanz M, Saphira L. Competencies in implant therapy for the dental graduate. Appropriate educational methods. Eur J Dent Educ 2009: 13 (Suppl. 1): 36–43. 3 Mattheos N, Albrektsson T, Buser D, et al. Teaching and assessment of implant dentistry in undergraduate and postgraduate education: a European Consensus. Eur J Dent Educ 2009: 13 (Suppl. 1): 10–17. 4 Tseveenjav B, Vehkalahti MM, Murtomaa H. Attendance at and self-perceived need for continuing education among Mongolian dentists. Eur J Dent Educ 2003: 7: 130–135. 5 Department of Health. A first class service: quality in the new NHS. London: Department of Health, 1998. 6 Bullock A, Firmstone V, Fielding A, Frame J, Thomas D, Belfield C. Participation of UK dentists in continuing professional development. Br Dent J 2003: 194: 47-51. 7 Buck D, Newton T. Continuing professional development amongst dental practitioners in the United Kingdom: how far are we from lifelong learning targets? Eur J Dent Educ 2002: 6: 36–39. 8 Polyzois I, Claffey N, Attstrom R, Kelly A, Mattheos N. The role of the curriculum and other factors in determining the medium- and long-term attitude of the practicing dentist towards life-long learning. Eur J Dent Educ 2010: 14: 84–91.
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9 Barnes E, Bullock AD, Bailey SE, Cowpe JG, Karaharju-Suvanto T. A review of continuing professional development for dentists in Europe. Eur J Dent Educ 2012: 16: 166–178. 10 Bullock A, Bailey S, Cowpe J, et al. Continuing professional development systems and requirements for graduate dentists in the EU: survey results from the DentCPD project. Eur J Dent Educ 2013: 17: e77–e81. 11 Dawson A, Chen S, eds. The SAC classification in implant dentistry. Berlin: Quintessence, 2009. 12 General Dental Council. Continuing professional development. Available at http://www.gdc-uk.org/Dentalprofessionals/CPD/ Documents/GDC%20CPD%20booklet.pdf last accessed 2.11.2013 13 Training Standards in Implant Dentistry. FGDP 2012. Available at http://www.fgdp.org.uk/_assets/pdf/publications/policy% 20documents/implant%20training%20stds%20jun%2012.pdf last accessed on 2.11.2013 14 Koole S, Vandeweghe S, Mattheos N, De Bruyn H. Implant dentistry education in Europe: 5 year after the ADEE consensus report. Eur J Dent Educ 2014: 18 (Suppl. 1): 43–51. 15 Donos N, Mardas N, Buser D. An outline of competencies and the appropriate postgraduate educational pathways in implant dentistry. Eur J Dent Educ 2009: 13 (Suppl. 1): 45–54. 16 Mattheos N, Ucer C, Van de Velde T, Nattestad A. Assessment of knowledge and competencies related to implant dentistry in undergraduate and postgraduate university education. Eur J Dent Educ 2009: 13 (Suppl. 1): 56–65.
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Current trends and status of continuing professional development in implant dentistry in Europe T. C. Ucer1, D. Botticelli2, A. Stavropoulos3 and N. Mattheos4 1 2 3 4
Oaklands Hospital, Salford, UK, ARDEC, Ariminum Odontologica, Rimini, Italy, € University, Malmo €, Sweden, Faculty of Odontology, Malmo Faculty of Dentistry, The University of Hong Kong, Hong Kong, China
Keywords continuing professional development; implant dentistry; postgraduate dental education. Correspondence Cemal Ucer Dental Implantology Oaklands Hospital 19 Lancaster Road Salford M6 8AQ, UK Tel.: +44 1612371842 Fax: +44 1612371844 e-mail: [email protected] Accepted: 18 November 2013 doi: 10.1111/eje.12080
Abstract Introduction: Previous surveys have shown that newly graduated dentists, in most European countries, do not obtain adequate theoretical knowledge and, especially, clinical skills in implant dentistry (ID) through their undergraduate education and must therefore acquire knowledge and develop competencies through further postgraduate study. Moreover, clinicians, in general, need to continue to maintain the currency of their competence by undertaking ongoing continuing professional development (CPD). This seems particularly important in ID as techniques, and materials develop rapidly due to advances in biomedical technology. Despite recent developments, CPD in ID remains poorly organised with little standardisation or harmonisation across Europe. The objective of this survey was to explore the current status and trends within CPD education in ID in Europe. Materials and methods: Stakeholders and opinion leaders associated with ID education were invited by email to fill an online questionnaire (closing date: 30th April 2013). Two hundred and forty-seven questionnaires were distributed, and two separate reminders were sent to participants in 38 European countries. The survey contained 14 multiple-choice questions, and the data were collected using SurveyMonkey© software, exported in SPSS (Inc, Chicago, IL, USA) format and analysed using descriptive statistics. Results: Two hundred respondents working in 24 countries replied to the survey (response rate of 81% of invitees and 63% of countries surveyed). The results demonstrated a wide divergence in the content and structure of CPD in ID in Europe. Conclusions: Dentists need CPD to develop their skills and to maintain their competence in ID. There is an urgent need for structured and accredited CPD, which should be readily available to all dentists practising ID. It should have pre-determined learning objectives, delivered by accredited CPD providers and educators, and have assessable outcome measures to ensure the best possible impact on clinical practice and patient safety.
Introduction Continuing professional development (CPD) is now recognised as an essential professional activity for dentists (i) to maintain their clinical skills and to keep these up to date with new developments in scientific knowledge and technology and (ii) to integrate these techniques into clinical practice safely (1–6). 52
Previous surveys (3) have shown that newly graduated dentists, in most European countries, do not obtain adequate theoretical knowledge and particularly clinical skills in implant dentistry (ID) through their undergraduate education and must therefore acquire knowledge and develop competencies through further postgraduate study. Clinicians need to continue to maintain the currency of their competences in ID as knowledge, techª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 52–59
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niques and materials develop fast due to rapid technological advances. By keeping dentists’ knowledge and skills up to date, CPD enhances safe practice and aims to improve quality of care. In general, excepting structured degree programmes leading to an academic title and/or specialty, there are three types of CPD activity commonly available to dentists: (i) reading professional journals; (ii) attending lectures, courses or study clubs and (iii) undertaking short-term or modular training courses to learn new techniques (7–9). To have any real impact on clinical practice, CPD activity should be systematically planned and structured in relation to the specific learning needs of the individual clinician and not selected arbitrarily according to ease of access or convenience. In this respect, the personal development plan (PDP) is seen as a useful self-appraisal and evaluation tool as it encourages reflection on own clinical skills and helps to enhance the impact of CPD on clinical practice by identifying strengths and weaknesses in own knowledge or skills (10). In a recent European-based survey (DentCPD), it was reported that although CPD education was available from a wide range of sources, it was generally unregulated and there was considerable variation in the level/quality of the CPD activity in Europe (10). In general, university dental schools and professional dental associations were found to be the most common CPD providers, which reportedly provided the best quality of teaching. The need for harmonisation of CPD across Europe to support the safe management of patients and promote mobility of practitioners was recommended on the basis of the findings of the DentCPD survey (9, 10). Implant dentistry does not seem to be an exemption from the above; however, there is no structured information available on CPD in implant dentistry in Europe at present, as the DentCPD survey did not specifically address this discipline (10). Thus, the aim of the present study was to collect information on the emerging trends in CPD activity in implant dentistry across Europe to contribute to the current discussion, including information about providers, programme/course structure, quality assurance and accreditation criteria, and possible barriers to CPD, and to assess the opinion of European stakeholders. The specific objectives of the study were to: Collect information on the emerging trends in CPD activity in implant dentistry. Explore how CPD education in implant dentistry is delivered or structured in Europe. Identify the quality assurance criteria used (if any) for CPD education in implant dentistry. Investigate the barriers to CPD education in implant dentistry in Europe. Use the data to contribute to current discussions on structuring of CPD activity in implant dentistry in Europe.
course providers, representatives of national and international scientific associations related to implant dentistry were invited by email to fill in an online questionnaire hosted by SurveyMonkey©. The invitees were identified through the network of the ADEE and member directories of national and international scientific associations or foundations related to implant dentistry, for example, European Association for Osseointegration (EAO), European Federation of Periodontology (EFP), International Team for Implantology (ITI) and Osteology Foundation. Websites of major implant companies were also consulted, and persons appearing responsible for educational events were invited to participate. In total, 247 individuals in 38 European countries (including all EU countries and candidate states) were invited to participate in the survey. The survey contained 14 multiple-choice questions constructed on the basis of the DentCPD (10) questionnaire, but was adapted and amended with questions specific to implant dentistry and in accordance with the specific objectives of this study. Within the framework of the current questionnaire, a structured CPD course was defined as a ‘sequential CPD programme leading to predetermined learning outcomes’, whilst unstructured CPD included ‘conferences, meetings, stand-alone (unlinked) CPD lectures or learning activities’. The questionnaire was first piloted amongst a group of experts in implant dentistry education, and the email invitation – including a brief explanation of the purpose of the survey – was issued on 14 March 2013, and the survey was closed on 30 April 2013. Responses were collected using the SurveyMonkey© software (surveymonkey.com) with the system set to disallow multiple responses per email address, but to allow the participants to reenter the survey and update their responses at a later date. Data were exported in SPSS (Inc, Chicago, IL, USA) format and analysed as a whole and by country using descriptive statistics.
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Responses were received from 200 invitees working in 24 countries, that is, response rates of 81% and 63%, respectively (Fig. 1). Seven invitees opted out of the survey, and 12 emails were returned undelivered, whilst no response was received from invitees in 14 countries despite two reminders. 29% of the respondents worked in a capital city, whereas 39% worked in a large city (self-reported), 25% in a medium size city and 7% in a rural location. The respondents included university teaching stuff (41%), implant clinicians/experts (31%), private course providers and representatives of commercial implant/biomaterials companies and of national and European level implant associations (Fig. 2). Two countries (UK and Turkey) were represented with significantly more respondents. Consequently, at certain parts, results are reported for the whole sample and also excluding Turkey and UK respondents.
Methods
Implant dentistry in undergraduate education
A group of European stakeholders with an interest in implant dentistry education, including the participants of the Association for Dental Education in Europe (ADEE) European Workshop on Implant Dentistry University Education (Budapest, 2013), selected academic teachers and opinion leaders/experts,
Seventy-three per cent of the respondents (66% excluding Turkey and the UK) did not think that newly graduated dentists acquired the necessary surgical skills in the undergraduate curriculum to provide straightforward surgical implant treatment, but 41% per cent (54% excluding Turkey and the UK) indi-
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Results
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Fig. 1. Distribution of the respondents according to country of work.
Fig. 2. Respondents’ position/interest in implant dentistry.
cated that newly graduated dentists obtained skills during their undergraduate education to treat straightforward prosthodontic cases. Only a very small minority was of the opinion that newly graduated dentist gained adequate clinical skills needed to provide surgical (5%) or prosthodontic implant treatment (8%) in advanced or complex categories (SAC classification; 11). A large majority of respondents (76% of all respondents or 83% excluding UK and Turkey), from the European countries surveyed, reported that no additional degrees were currently required for a licensed dentist to practise implant dentistry in their region/country. Fifty-seven per cent of all respondents 54
(58% excluding UK and Turkey) said that dentists gained clinical skills in implant dentistry by attending CPD courses run by universities or professional organisations, however not leading to an academic degree or formal recognition.
Current trends in CPD activity in implant dentistry In general, the vast majority of respondents (71%) reported the availability of well-structured CPD courses in implant dentistry in their countries/regions; however, only a few of these courses ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 52–59
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were said to be accredited. A limited number of respondents (4%) stated that only ‘product training’ was available in their region (Fig. 3). Twenty per cent of the participants (16% excluding UK and Turkey) believed that CPD in implant dentistry needed urgent development and structuring.
Quality control of CPD in implant dentistry in Europe Respondents reported that there was some quality assurance of CPD in implant dentistry, but this was generally limited (Fig. 4).
Types of CPD activity in implant dentistry in Europe Product training organised by commercial companies, short 1–2 day courses (with no predetermined learning outcomes) and study club meetings were ranked as the three most common forms of CPD education in implant dentistry in Europe, whilst verifiable e-learning was reported to be the least common. Figure 5 shows the organisations that provide regular CPD in implant dentistry in Europe. Most of the accredited CPD was delivered by universities and national organisations, which were also more likely to provide the necessary core competencies in implant dentistry. Courses run by the industry were
Fig. 4. Structure and quality of the existing continuing professional development in implant dentistry.
Fig. 3. What is the current status of continuing professional development education in implant dentistry in your city/region?
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tions or the Ministry of Health provided most of the accreditation for CPD courses in implant dentistry.
Role of mentoring and clinical audit in CPD Forty per cent of all respondents used PDPs to identify and guide their learning needs in implant dentistry, whilst 70% mentioned that they gained clinical skills under the supervision of an experienced colleague (e.g. a mentor) showing that not all CPD in Europe is theoretically based.
Importance of PDPs, mentoring, the logbook and national register of implants: A large majority of the respondents thought that PDP (65%), keeping a logbook of implant activity to document clinical cases (i.e. auditing; 80%), gaining clinical experience under mentor supervision (85%) and setting up a national register of dental implants/complications (70%) were very important.
Barriers to CPD education Fig. 5. The organisations that provide regular continuing professional development in implant dentistry.
reported to provide the core competencies only partly and were less likely to be accredited.
Quality assurance criteria and accreditation of CPD in implant dentistry With regard to quality assurance of CPD courses in implant dentistry, respondents rated ‘teaching experience and formal qualification of the speakers’ as the most important criterion (Table 1). Accreditation of the CPD providers and speakers, predetermined learning objectives, participant feedback and formal end-of-course assessments were also ranked as important determinants of the quality of CPD education. Moreover, the respondents reported on the accreditation of CPD in implant dentistry stating that universities, national level dental organisa-
TABLE 1. Quality assurance criteria of continuing professional development (CPD) activities
Answer choices
Rank
Responses %
Teaching experience and formal qualifications of speakers Appropriate learning environment or facilities Participants’ feedback Formal assessment of participants upon completion of the course Predetermined learning objectives Accreditation of CPD providers Official recognition or accreditation of speakers External audit and quality control
1
86
2 (2) (2)
58 58 58
3 4 5 6
56 54 52 47
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Lack of incentives, time and cost concerns and lack of patient awareness or appreciation of the importance of CPD for dentists were the three most commonly cited barriers to CPD education in implant dentistry.
Respondents’ opinion on implant dentistry as a specialisation and CPD providers Sixty per cent of the respondents (62% excluding UK and Turkey) ‘agreed’/‘strongly agreed’ that implant dentistry should be recognised as a speciality on a European level. Whilst 52% (59% excluding UK and Turkey) agreed/strongly agreed that CPD education in implant dentistry should only be provided by universities or accredited organisations, a large majority (85%; 89% excluding UK and Turkey) on the other hand thought that effective CPD could be delivered by a variety of recognised providers including experienced clinicians. Seventy-five per cent of the respondents (74% excluding UK and Turkey) believed that CPD in implant dentistry should be accredited at a central (national or European) level. There was overwhelming agreement that CPD providers/educators should publically declare any conflicts of interest.
Discussion Due to the absence of any specific registers of CPD providers/educators in implant dentistry, the study surveyed the opinion of a wider group of stakeholders with a known interest in implant dentistry education in Europe including academic teachers, clinicians with or without a specialist background, opinion leaders within scientific and professional dental associations, providers of CPD (e.g. EU institutions, universities, national implant associations, commercial company representatives, course providers and relevant scientific societies [e.g. European Federation of Periodontology (EFP), European Association for Osseointegration (EAO), etc.]. The addressees were also invited to forward the online link to ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 52–59
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the survey to their colleagues with a known interest in CPD in implant dentistry. A good response rate was achieved for the current survey from a total of 24 countries. The two largest groups of respondents consisted of university teaching staff (41% of all respondents and 45% excluding the data from UK and Turkey) and implant clinicians/experts (31% and 28% excluding UK and Turkey) representing the two main sectors of education providers in ID – thus reducing the risk of distortion of the results. Although two electronic reminders had been circulated, no response was received from some of the EU states. It is possible that at least some of the non-respondents may have failed to receive the initial email invitation or the reminders due to interception by their antispam software. This is an inherent shortcoming of any electronic survey by email. To prevent duplication or distortion of data, the electronic questionnaire system (SurveyMonkey©) was set up to exclude multiple responses from a single email address or a PC. A methodological weakness of this survey that might affect its validity is the risk of bias that may have been caused by sampling error. This could have occurred as the recipients had been targeted because of their known interest/expertise in implant dentistry education. Moreover, there was a wide variation in response rate from different European countries; therefore, a direct comparison of the results between different European countries was not considered appropriate. A higher rate of participation from the UK could be explained, at least partly, by the availability of several formal university based postgraduate diploma and master’s programmes in the UK (at least eight university master’s programmes in implant dentistry). A unique situation also exists in the UK that dentists are required to undertake structured implant education and training under mentor supervision before they can provide implant dentistry (12, 13). Therefore, there is a strong interest and involvement in postgraduate CPD implant activity in the UK by educators and providers as well as by dental professionals. Another weakness of the study relates to the fact that the results depended on self-reported data based on the subjective opinion of the respondents. Despite its shortcomings, this survey has demonstrated that there was a wide variation in CPD education in implant dentistry in Europe with little consistency, structure or regulation. The data showed that although well-structured CPD courses were available in some European countries, relatively few of these were regulated or accredited. This demonstrated the need for availability of structured CPD activity in implant dentistry in Europe. The reported lack of standardisation or regulation of CPD is consistent with the results of previous surveys of general CPD activity in Europe (10). A comprehensive survey of stakeholders reported the availability of compulsory CPD in dentistry only in approximately 50% of the EU states (10). In about a quarter of the rest of the EU countries, an official regulated CPD system was available, but this was voluntary rather than a compulsory system. Nevertheless, there appear to be a trend, in recent years, towards a regulated and accredited dental CPD in the EU states to help dentists to maintain their knowledge and competence (10). To our knowledge, this is the first comprehensive survey that has attempted to elicit the opinion of stakeholders in Europe ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 52–59
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on the current trends in CPD activity in implant dentistry. Our data have shown that although most European countries have some CPD activity in implant dentistry, the structure of these courses seems to be less than ideal from an educational point of view. This survey has shown that no additional degrees were currently required for a licensed dentist to practise implant dentistry in Europe. However, when questioned if implant dentistry should be made a speciality in Europe, interestingly, a majority of all respondents of the current survey agreed/strongly agreed that it should be. Notwithstanding this opinion, the respondents agreed that clinical skills and competence in implant dentistry can be acquired from well-structured CPD courses and effective CPD can be delivered by a variety of recognised providers including experienced clinicians. Presumably, if specialisation in implant dentistry was to be recognised, these specialist would treat highly complex cases including complications, whilst non-specialist practitioners with special interest in implant dentistry could confine their work to mainly straightforward the cases (SAC classification; 11). Although this is consistent with the results of a recently conducted survey (14), this point needs to be clarified in future surveys. The respondents rated lack of incentives, time and cost concerns and lack of patient awareness or appreciation of the importance of CPD for dentists as the three most commonly cited barriers to CPD education in implant dentistry. Future CDP courses should therefore be designed to minimise such barriers and to ensure that CPD activity in implant dentistry is designed to produce quantifiable clinical benefits for the dentists and patients alike. The results of the current survey also showed that the use of PDPs and logbooks, as tools of reflective learning, would be highly desirable for identifying individual learning needs and planning CPD activity in implant dentistry. The efficiency of lifelong learning depends on the individual’s ability to continuously and critically appraise and reflect on his/her professional knowledge, skills and actions and use these to guide his/her learning needs. Thus, an effective CPD requires a strong element of selfassessed and self-directed learning activity. In this respect, the use of PDP has been recommended as an invaluable tool that could allow the identification of professional strengths and weaknesses as well as the factors that affect the acquisition of new knowledge or skills (3). Similarly, auditing one’s clinical activity by keeping detailed clinical records or a logbook is seen as an important tool in highlighting clinical areas of weaknesses or problems. The use of the PDP is not yet a common practice in dentistry in Europe although a recent survey revealed that formal appraisal or PDP meetings were compulsory in general dentistry in a minority of countries for private and non-private dentists (10). In this respect, there was widespread support for introduction of a European register of implants and complications. This very interesting proposition should be investigated in future surveys to see how such national or European registers of implant activity could contribute to CPD. Product training organised by commercial companies, short 1–2 day courses (with no predetermined learning outcomes) and study club meetings were ranked as the three common forms of CPD education in implant dentistry in Europe. Interestingly, despite the increasing popularity of the internet, verifiable 57
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e-learning (e.g. online courses/webinars) was reported to be the least common type of CPD education in implant dentistry. Although accreditation was not commonplace in Europe, a number of organisations were identified as the principle professional bodies accrediting CPD courses in implant dentistry. These were national/professional dental organisations, universities and the Ministry of Health in descending order. There was a strong agreement that CPD in ID should be accredited at a national or European level and that implant manufacturers or commercial companies should provide product training only. The latter is consistent with the conclusions of the ADEE 1st workshop in implant dentistry education (Prague, 2008; 3). There was a general agreement that the undergraduate education, in the majority of the European countries, does not equip dentists with the clinical skills needed to implement the full spectrum of implant dentistry expected in a modern general practice. This finding is consistent with previous reports (3, 15), although there has been a recent increase in undergraduates gaining experience in straightforward implant prosthetics (14). A dental graduate relies on attending CPD courses either to acquire and develop his/her initial core knowledge and skills in implant dentistry or to keep these up to date as part of his/ her lifelong learning activity. Therefore, it is evident that CPD in implant dentistry is needed irrespective of whether implant dentistry is taught in the undergraduate curriculum or competences in ID are achieved as part of formal postgraduate education or training.
Conclusion Implant dentistry has evolved to become a highly technical and multidisciplinary branch of dentistry, which requires constant update of knowledge and clinical competence in restorative as well as surgical sciences. With rapid advances in materials and techniques, dentists who provide any aspect of implant dentistry, irrespective of their initial undergraduate or postgraduate level of training or expertise, need to maintain and update their knowledge and skills through a well-structured, lifelong CPD activity. This applies to all members of the team who are involved in delivery and maintenance of implant treatment from the general practitioner with special interests in implant dentistry to the specialist level. The undergraduate curriculum in Europe does not yet universally provide dentists with the competence required to practise implant dentistry, although there has been an increasing trend towards this direction as the ADEE 1st European Consensus workshop on implant dentistry university education in 2008 (14). Therefore, CPD in implant dentistry should be an integral and essential part of a career of any healthcare professional who is involved in implant practice. This would ensure that dentists continue to maintain the currency of their competence within the area of their clinical activity. The current survey has demonstrated that, in most European countries, there is some CPD activity in implant dentistry ranging from product training by the industry to accredited university courses (excluding formal qualifications). However, currently, this is mostly unregulated, poorly structured with no 58
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recommended hours of study or accreditation in most countries. Our data demonstrated the important role of CPD and support the following conclusions: Standardisation of CPD in implant dentistry with a view to achieving closer harmonisation across Europe is highly desirable. This would increase the standard of care in implant dentistry and ensure that dental health practitioners are competent and up to date within the area of their clinical activity. Furthermore, this would facilitate mobility of healthcare professionals as well as patients seeking initial or follow-up treatment across Europe. To be educationally effective, CPD in implant dentistry should be highly structured and accredited either at a national level or desirably at a European level. CPD should be clinically applicable, and courses should match the different learning needs of practitioners working at different levels of complexity of treatment. CPD should be readily available, with as little barriers as possible, in modular, transparent format with tangible benefits and quality assurance of its educational outcomes by regulatory authorities (e.g. Ministry of Health), universities or academic institutions. Most importantly CPD in implant dentistry should match the individual needs of the practitioners and be applicable to their practice. In this respect, the use of logbooks and PDPs is highly desirable as tools of self-appraised and self-directed lifelong reflective learning activity. Continuing professional development could be provided by a variety of sources including universities, academic institutions or individual experts provided that it is structured with clear educational objectives at each level of clinical competence (or complexity) and should incorporate the following quality assurance elements: Predetermined learning objectives. Assessment of learning outcomes (16) both summative and formatively and feedback from learners. Accreditation by a national or European organisation. Blended teaching with a good mix of theory with practice. Clinical experience at the workplace under supervision of clinical mentors (using objective clinical assessment tools). Transferrable credits that can be accumulated towards a tangible learning outcome or recognition of CPD activity. Course providers and educators should be recognised by a national or European body. Course providers and tutors/educators in implant dentistry should declare any conflicts of interest prior to teaching. Courses should be held in an environment that is conducive to efficient teaching and learning activity. Implant industry should confine their teaching to product training only. Finally, it is recommended that the academic community should establish clear guidelines on CPD and training standards in implant dentistry.
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Conflicts of interest Professor Ucer is involved in delivery of postgraduate university degree courses and CPD courses in implant dentistry in the UK. Professor Botticelli is involved in delivery of postgraduate private courses for continuing education in implant dentistry. No other conflicts of interest have been declared. ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 52–59
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