Guest Editorial: Dentistry-Some Thoughts for the Future University coursework and professional training pose a number of challenges, requiring a review of educational priorities and expectations. The thoughts below address a number of concerns and suggest an approach to planning for the future. Priorities and expectations for dental education. This decade is critical for dental education to ensure a correct mix of traditionally accepted information and new information and techniques that must be incorporated into any program that focuses on the needs of a modern preventive-oriented, minimal-intervention-type clinical practice. The dilemma is compounded by a wealth of new information: new restorative materials, dental implants, acute and chronic oro-facial pain, general medicine, oral medicine and pathology, management of immuno-suppressed patients, and gerodontics. As well, there is the question of resources and facilities for the prioritizing of educational needs. Educators faced with limited time for didactic and clinical coursework and declining resources need to have realistic expectations of what can be achieved in an undergraduate program. Our aim ought to be primarily educational and secondarily vocational. Primary goals should be the development of a knowledge base for problem solving, the fostering of an enquiring mind, and a critical appreciation of new developments. Secondary goals would include knowledge of human behavior, skills in patient management, in assessment, diagnosis, and treatment planning, and in specific clinical procedures. The clinician should be able to manage problems as they arise, cope with new circumstances, and be competent to adapt to future demands.

Basic and biological training and student selection.

Traditionally, dental students have either shared aspects of basic and biological science courses with medical students, or attended specific dental courses in these fields. This dichotomyis inappropriate, and similar basic and biological science training for dental and medical students is desirable. The specific clinical sciences are then developed on a broad biological base. The highly technical nature of clinical dentistry and the focus on technical components of laboratory procedures have been the backbone of dental education. This must, however, be viewed as part of our evolutionary history, and modern training cannot provide the same focus on technical aspects of dentistry that were important 50 years ago. There is a range of requirements for students in dentistry: a knowledge ofand appreciation forthe responsibilities ofhealth care professionals, manual skills, intellectual ability, a sympathetic and caring attitude, and appropriate communication skills for management of patients and interfacing with professional colleagues. Students should be selected on the basis of these criteria. This is most easily done if students have already completed some university coursework before commencing dentistry. Secondary school results should be only a component of assessment. In Britain and Australia, the majority of dental students progress directly from secondary school to university; in North America, all dental schools

require their students to complete some science coursework. An interview should be an integral part ofassessment. How else is it possible to gain a feeling for each student's appreciation of dentistry, his or her aptitude for it and interests in it? It is morally irresponsible not to provide an opportunity to advise and redirect students at the earliest possibility following interview, should they believe that dentistry is not what they imagined it to be. An interview would also provide the opportunity to assess communication skills and language comprehension. Assessment of manual skills is important as a guide to students' ability to cope with the 1944

highly practical nature of dental coursework. Students need not be gifted in manual skills, but they need to display not only an appropriate level of ability over a period of coursework (minimum, one semester) but also, equally importantly, an interest in manual skill development. The difficulty with these assessments is resource-based, and they would be achievable onlyifthey were carried out on a relatively small number of students, rather than on the larger number completing their secondary schooling. If dentistry coursework was a double or combined degree, the first degree in science would provide basic and biological science training andthe opportunity for more comprehensive selection procedures. In these circumstances, students would gain experience in tertiary studies, would be older and more independent, and would have a tertiary academic record to assist selection. It would allow time for more comprehensive assessment, and provide an opportunity for students to rethink their priorities. It would also provide an exit point for students who findthat theymight wish to follow a different career path. To satisfy these requirements, it would be desirable for students to major in the appropriate biological science subjects. During the second and third years, science options as dental prerequisites would allow for manual skills assessment in the second year (through a course such as biomaterials science) and an oral health course in the third year (as an introduction to clinical dentistry). Students who satisfactorily complete the dental options would progress to dentistry, followingthe science course. Studentswho did not pass the dental options and who could not manage the manual skills component would have an exit point with a science degree which would provide opportunities for teaching and research. Such a program would allow students to re-assess their interests and gain maturity and enable the Faculty to make more appropriate selections for clinical dentistry. A three-year clinical dentistry program would be conducted over an extended clinical year of 42 weeks (i.e., three semesters or six terms). The specific biological science material for dentistry, which would not have been covered in the science course, could be integrated with the clinical sciences. Additional material for specific practice needs not covered in the clinical program could be offered through additional graduate diplomas.

Clinical competence The expectation of competence in all clinical and technical procedures, given time and resource constraints, is unrealistic. It is important for theoretical information to be understood, but there is

inadequatetimetoexpectcompetencyinthebroadvarietyofclinical procedures that are required in practice. It is clear that in the prioritization of requirements, which should be linked with marketplace demands, time and resource constraints will dictate limits for both didactic and clinical coursework. The development of shortterm graduate diploma programs (over six to 12 months part-time), to supplement essential core material presented during undergraduate coursework, needs to be considered. With this opportunity, dentists with specific practice needs would be able to acquire skills through graduate diploma programs to respond to the real needs of the community in which they practice. The alternative is an internship year before registration, following the completion of university coursework. In medicine, this situation exists in many countries and forms the backbone of hospital service. It is unlikely that this opportunity would be possible in dentistry, since resources for clinical positions and infrastructure support (for dental assistants, etc.) are not available, and for such an internship program to be accepted, all students would require a similar opportunity. On the other hand, clinical

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Vol. 71 No. 12

DENTISTRY-SOME THOUGHTS FOR THE FUTURE

dental practice is highly variable from city to country areas, and within large cities. It seems more appropriate to provide a basic program and to offer graduate diplomas to answer specific community needs of new practitioners. The following examples illustrate the point: First, how much complete-denture teaching is necessary or appropriate for current undergraduate programs? The dental curriculum of the past focused on removable prosthodontics, since it was the basis of community dental needs. In most Western countries, this situation no longer exists, although there remains a considerable backlog of complete-denture requirements. Many practices, particularly in city areas, have few complete-denture patients. This variation in community demand is best addressed by including a component of removable prosthodontics in undergraduate coursework, but where practice demands are great, a graduate diploma in this field would allow the new graduate to develop the competence and confidence to offer this service. Second, the question of dental implants. The last decade has provided clinical and scientific evidence that predictable dental implant treatment is a reality. Bone biology research, the meticulous development of implant design and instrumentation appropriate for their use, a defined surgical protocol, and long-term followup of treated cases have been progressively developed by Professor P.-I. Branemark (University of Gothenburg, Sweden) and his team since the late 1950's. Implant treatment following this technique began in 1965, and more recently the international dental community has embraced this surgical protocol. Universities and dental associations now accept that the use of dental implants provides a much-needed and unique approach for the treatment of tooth loss. There are currently more than 30 different implant systems available, and many are being studied systematically and assessed for long-term predictability. Should undergraduate dental programs contain a comprehensive implant course? What undergraduate coursework should be excluded to provide time? The question of costs and resource implications provide a further dilemma. However, a graduate

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diploma on dental implants, to follow a basic undergraduate course, would provide the expertise and a confidence to offer this service in practice. Registration Boards have a moral obligation to expect such training as a mandatory requirement before new graduates are tempted to provide this service without adequate knowledge or skills. These examples provide a mechanism for both broad clinical training related to specific practice demands and the acceptance of an appropriate level of clinical competency at the completion of undergraduate training. This may then be extended by providing a variety of graduate diploma programs in specific areas, to extend the fields that cannot be adequately covered during the undergraduate course. This proposal is distinct from continuing education, since graduate diplomas are to provide an acceptable level of competence to allow the clinician to offer a service at the appropriate level of clinical expertise. Continuing education, on the other hand, is an ongoing process which allows clinicians to update their theoretical knowledge and practical skills on a foundation of long-term clinical practice. This is a continual need, and the question of Registration Boards requiring continuing education as mandatory for re-registration has met with divided opinion. It would seem that Registration Boards have an obligation to ensure that the clinical competence of their registrants is appropriate for community needs, and continuing education, as a mandatory requirement for re-registration, seems the best mechanism. The difficulty is to ensure that a range of courses at an appropriate academic and clinical level is available and that such courses are attended. -Professor Iven Kineberg Dean, Faculty of Dentistry University of Sydney Professorial Unit Level 3 Westmead Hospital Dental Clinical School Westmead, NSW 2145 Australia

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Dentistry--some thoughts for the future.

Guest Editorial: Dentistry-Some Thoughts for the Future University coursework and professional training pose a number of challenges, requiring a revie...
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