A survey on education in cariology for undergraduatedental students in EuropeA. G. Schulte1, W. Buchalla2, M.-C. D. N. J. M. Huysmans3, B. T. Amaechi4, F. Sampaio5,G. Vougiouklakis6 and N. B. Pitts7

1 University of Heidelberg, Heidelberg, Germany2 University of Zurich, Zurich, Switzerland3 Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands4 University of Texas Health Science Center at San Antonio, San Antonio, USA5 Federal University of Paraiba, Joao Pessoa, Brasil6 University of Athens, Athens, Greece7 University of Dundee, Dundee, UK

Introduction

In many European countries, medical faculties have started todevelop a written curriculum for the education of their medicalor dental students. Some national organisations in the medicalor dental field also have written down guidelines for the educa-tion of medical or dental students in specific areas. Further-more, with an increasing emphasis on globalisation, andincreasing free movement of health care professionals withinthe European setting, there is a growing need for determiningthe basic competences expected of those health care profession-als (1). While documents defining curriculum requirementsreleased from specific European Organisations now exist in thefields of: Endodontology, Gerodontology, Implantology, Pedod-ontology and Periodontology (2–6), to date, no attempt hasbeen made to develop either a national or a European CariologyCurriculum. There are many important reasons to close thisgap. Caries prevalence is still high among the general popula-tion in many European and non-European countries. Even by

acknowledging considerable success of numerous caries preven-tive actions in several European countries, it has to be statedthat, especially, children and adolescents aged between 6 and15 years have profited from these efforts (7, 8). Continuousefforts provided by the dental profession are required to main-tain this success. Furthermore, dental caries becomes moreunevenly distributed across populations of both children andadults within countries but also among countries. Thus, dentalcaries continues to be responsible for significant health, socialand economic impacts and imposes the necessity to deliver aprofound education in cariology for dental students.

In 2010, the European Organisation for Caries Research(ORCA), together with the Association of Dental Education inEurope (ADEE), organised a workshop with the aim todevelop, in consensus, a European Core Curriculum in Cariolo-gy (9). In preparation of this effort, a survey was conducted,with the aim to gather relevant information about undergradu-ate education in cariology. Collecting information from asmany European dental schools as possible was also deemed

keywords

undergraduate education; pre-clinical

education; clinical education; dental curriculum;

cariology; erosion; non-erosive wear.

Correspondence

Prof Dr Andreas G. Schulte

Department of Conservative Dentistry

University of Heidelberg

Im Neuenheimer Feld 400

69120 Heidelberg

Germany

Tel: +49 6221 566024

Fax: +49 6221 565074

e-mail: andreas.schulte@med.uni-heidelberg.de

Accepted: 29 August 2011

doi:10.1111/j.1600-0579.2011.00708.x

Abstract

The aim of the survey was to collect relevant information about education in cariologyfor dental undergraduate students in Europe. The ORCA/ADEE cariology curriculumgroup prepared a questionnaire that was mailed in 2009 to 179 European dentalschools. One hundred and twenty-three dental schools (72%) from 32 countries com-pleted and returned the questionnaires. In most of these schools, education in cariologyis delivered by at least two different units. The units mainly involved are PaediatricDentistry, Conservative Dentistry, Restorative Dentistry or Operative Dentistry. Theo-retical education in cariology is delivered by practically all responding dental schools,and in 96% of these schools, it starts within the first 3 years. Pre-clinical exercises areoffered by 98% of the schools starting mainly in the third or fourth year. In 97% ofthe schools, clinical exercises are carried out, and this occurs mainly in the fourth andfifth year. In nearly all dental schools (88%), education in cariology comprises not onlycaries but also dental erosion and non-erosive wear. The vast majority of the respond-ing dental schools (89%) supported the idea of developing a European Core Curricu-lum in Cariology.

European Journal of Dental Education ISSN 1396-5883

Eur J Dent Educ 15 (Suppl. 1) (2011) 3–8 ª 2011 John Wiley & Sons A/S 3

desirable to give the schools an opportunity to participate inthis process.

Materials and methods

The ORCA/ADEE cariology curriculum committee developed aquestionnaire on education in cariology in Europe, which wasmailed to 179 dental schools in 35 European countries inspring 2009. Most of them were institutional members ofADEE, and their addresses were provided by ADEE. The com-mittee added some missing schools from their own knowledge.In eight cases, the letters came back undeliverable. In summer2009, the first reminder was sent to the schools that had notresponded, and in winter 2009, a second reminder was mailedto the schools still missing. The letters containing the question-naire were sent to the Deans of the Dental Schools, who wereasked to forward this to the person(s) in charge for the educa-tion in cariology.

At the top of the first page of the questionnaire, the definitionof cariology as provided in the scope of ORCA was presented:‘Scientific understanding of the aetiology, pathogenesis, preven-tion and clinical control or management of dental caries. Healthoutcomes related to dental caries are also of interest, as are otherdisorders of dental hard tissues, such as dental erosion’.

The questionnaire comprised 12 questions related to differentfields of education in cariology. These questions are presentedin the next paragraph together with the results.

Results

Completed questionnaires were returned from 123 of the 171European dental schools that had received the questionnaire.Thus, the response rate was 72%.

In Table 1, the countries with the number of dental schoolsand number of responding institutions are listed.

Question 1: Specific Cariology Curriculumavailable in dental schools?

Seventy-five per cent (n = 92) of the 123 respondents reportedhaving defined a specific curriculum, delivered through one ormore departments.

Question 2: Availability of Cariology Curriculumin written form

Fifty-five per cent (n = 70) of the 123 respondents said thatthis overall cariology curriculum was available in written form.

Question 3: Departments of dental schoolsresponsible for education in cariology

Education in cariology is delivered with great variability inEuropean countries. In most dental schools, two (n = 56), three(n = 10) or more than three (n = 4) units are involved, whilein 44 schools, only one unit is responsible. The units men-tioned frequently are Paediatric Dentistry (n = 50), Conserva-tive Dentistry (n = 30), Restorative Dentistry (n = 25),Operative Dentistry (n = 22), Preventive Dentistry (n = 11)

and Community Dentistry/Public Health (n = 7). Units whoseinvolvement was less often mentioned were as follows: Anat-omy, Biological Sciences, Biochemistry, Biomaterials, Biomedi-cine, Clinical Odontology, Dental Pathology, GeriatricDentistry, Histology, Oral Infections Diseases, Oral Medicine,Oral Microbiology, Oral Pathology, Orthodontics, Pre-clinicalDentistry, Prosthetic Dentistry or Radiology.

Questions 4 and 5: Name of courses wherecariology is taught

In 86% of the dental schools (n = 106), the word cariology ispart of the name of lecture series or course units where cariology

Table 1. List of 34 European countries with dental schools where the

questionnaire about a European Core Curriculum in Cariology was mailed

to

Country

Number of

schools on the

mailing list1

Number of

schools

responding

Austria 4 3

Bosnia-Hercegovina 1 1

Bulgaria 1 1

Belgium 6 4

Croatia 2 2

Czech Republic 5 4

Denmark 2 2

Estonia 1 0

Finland 3 3

France 14 12

Germany 29 16

Greece 2 2

Hungary 2 2

Iceland 1 1

Ireland 2 1

Italy 12 4

Latvia 1 1

Lebanon 1 1

Lithuania 2 2

Former Yugoslavian

Republic of Macedonia

1 1

Malta 1 1

Netherlands 3 3

Norway 3 3

Poland 8 4

Portugal 5 5

Romania 6 4

Serbia 3 1

Slovak Republic 1 1

Slovenia 1 1

Spain 10 4

Sweden 4 4

Switzerland 4 4

Turkey 13 12

United Kingdom2 17 13

Total 171 123

1This list does not include the eight dental schools where the question-

naire was undeliverable.2Including post-graduate institutes.

Survey on cariology education Schulte et al.

4 Eur J Dent Educ 15 (Suppl. 1) (2011) 3–8 ª 2011 John Wiley & Sons A/S

is taught, while in 17 dental schools, this is not the case. Inthese 17 schools, cariological contents are presented in coursesnamed Conservative Dentistry, Conservative Odontotherapy,Dental Pathology, Oral Pathology or Paediatric Dentistry.

Questions 6, 7 and 8: Different types ofeducation in cariology

Education in cariology is delivered in theoretical, pre-clinicaland clinical courses. Practically, all responding schools offertheoretical education, and nearly all schools reported offeringpre-clinical and/or clinical courses (Table 2).

Theoretical education in cariology starts already in the firstyear in 25% of the responding schools, but in the majority ofdental schools, this type of education starts in the second orthird year (Table 3). The start of pre-clinical exercises using

phantom heads, extracted teeth, etc. was reported to be mainlyin the second or third year, but in 15% of the schools, theseexercises are available already in the first year (Table 3). Withregard to clinical education, 85% of the schools reported tostart this in the third or fourth year (Table 3).

Theoretical education is offered in a wide variety of timeranging between one and 4 years (Table 4). The majority ofschools offer pre-clinical education for 1 year, but about one-third offers this for 2 years (Table 4). Clinical education takesplace mainly for two or 3 years, but some schools report tohave this type of education only for 1 year (Table 4). Table 5shows in which year what type of education is offered. Educa-tion in cariology is offered mainly in the second to fifth year.

Question 9: Education in cariology includes alsoerosion of dental hard tissues

In 89% of the dental schools (n = 110), education on erosionof dental hard tissues is delivered within the cariology lecturesand course units.

Question 10: Education in cariology includes alsodefects of dental hard tissues like abrasion orattrition

In 88% of the dental schools (n = 108), educational coursesrelated to cariology also include dental hard tissue defects apartfrom carious defects and dental erosion like hypo-mineralisa-tion, abrasion, attrition, etc.

Table 2. Instruction methods for cariology in undergraduate education

Kind of

instruction

method

Number of

responding

dental schools

Number and

proportion of dental

schools offering

education

Theoretical 123 122/99%1

Pre-clinical 123 120/98%1

Clinical 123 119/97%1

1Not all responding 123 dental schools answered the questions about

kind of instruction methods.

Table 3. Start of different types of education in cariology within the undergraduate education

Kind of instruction

method

Start in

1st year

Start in

2nd year

Start in

3rd year

Start in

4th year

Start in

5th year

Start in

6th year Total

Theoretical 30 53 36 2 0 1 1221

Pre-clinical 18 53 47 2 1 0 1201

Clinical 3 12 46 55 3 0 1191

1Not all responding 123 dental schools answered the questions about kind of instructions methods.

Table 4. Duration of different types of education in cariology within the undergraduate education

Kind of instruction

method

Within

1 year

Within

2 years

Within

3 years

Within

4 years

Within

5 years

Within

6 years Total

Theoretical 33 26 28 28 6 1 1221

Pre-clinical 69 41 9 2 0 0 1201

Clinical 21 49 37 12 0 0 1191

1Not all responding 123 dental schools answered the questions about kind of instruction methods.

Table 5. Availability of education in cariology in the undergraduate curriculum of European dental schools (n denotes number of dental schools)

Kind of instruction

method

Education in

1st year, n

Education in

2nd year, n

Education in

3rd year, n

Education

4th year, n

Education in

5th year, n

Education in

6th year, n

Theoretical 30 76 93 68 37 6

Pre-clinical 18 67 87 10 2 0

Clinical 3 13 57 109 94 2

Schulte et al. Survey on cariology education

Eur J Dent Educ 15 (Suppl. 1) (2011) 3–8 ª 2011 John Wiley & Sons A/S 5

Question 11: Support for development of aninternational Core Curriculum in Cariology

One hundred and nine of 123 dental schools declared theirwillingness to support a European Core Curriculum in Cariolo-gy. This means not only that 89% of the responding Europeanschools are in favour of such a curriculum but also that themajority of all European dental schools support the develop-ment of a European Core Curriculum in Cariology.

Question 12: Fields to be included in CariologyCurriculum

The questionnaire presented 27 items related to cariology anderosion, which the respondents could tick to express theiragreement (Table 6). For twelve items, more than 90% of therespondents expressed support, and for the other items, theproportion of support ranged between 70% and 89%.

Furthermore, the opportunity was offered to indicate addi-tional items deemed necessary by the educators. Several of thesefree-text suggestions fitted to the items that were presented onthe questionnaire, but additional items were also noted. Theindividual suggestions are grouped to related main items. Inmost cases, items were suggested by single or only a fewrespondents. Suggestions marked with an asterisk (*) weremade more than once.

The following items 1–7 were mentioned in the question-naire, but for many educators, these items appeared too gen-eral, and thus they indicated subitems. The items are presentedin alphabetical order.

1. Dental Hard Tissues: Developmental defects*; hereditarytooth defects and anomalies*; appearance of non-cariousdefects; molar-incisor-hypo-mineralisation; biophysics ofdental hard tissues; tooth wear with erosion included; min-eralisation disturbances; tooth whitening.

2. Diet: Sugar Alcohols; sugar substitutes.3. Aetiology: Differences in pathogenesis between coronal and

root caries; aetiology of dental attrition; aetiology of dentalabrasion; aetiology of dentine sensitivity; tooth defencemechanisms against caries; factors affecting progression ofcaries; pathologies of dental caries and dental erosion.

4. Plaque Removal: Antibacterial mouth rinses, toothpastes.5. Plaque and Saliva: Microbiological analysis of plaque;

microbiological analysis of saliva*; buffer capacity of sal-iva*; chair-side saliva tests; calcium ion management.

6. Prevention: General preventive aspects; prevention of dentalerosion; immunisation and gene therapy; immunology ofdental caries; communication skills; social aspects; visualaids for better communication with the patient.

7. Risk Assessment and Diagnostics: Methods to test cariogenicpotential; how to diagnose caries; differential diagnosticsbetween erosion and attrition and abrasion; types of caries

Table 6. Support for 27 items to be included in a European Core Cariology Curriculum and presented in the questionnaire

Item

Number of

supporting schools

Percentage of

supporting schools1

Anatomy and histology of dental hard tissues 111 90

Aetiology of dental caries 120 98

Aetiology of dental erosion 105 85

Microbiology 116 94

Diet 117 95

Saliva and salivary glands 110 89

Dental plaque 117 95

Behavioural sciences 86 70

Special aspects of early childhood caries 102 83

Descriptive and analytical epidemiology of dental caries 111 90

Descriptive and analytical epidemiology of dental erosion 92 75

Clinical and histological appearance of dental caries lesions 120 98

Clinical and histological appearance of dental erosion 100 81

Clinical detection of carious lesions 119 97

Radiological detection of carious lesions 120 98

Non-radiological tools for detection of carious lesions 116 94

Remineralisation of dental hard tissues affected by caries 117 95

Removal of dental hard tissues affected by caries 109 89

Atraumatic restorative treatment of carious defects in dental hard tissues 102 83

Caries risk assessment 118 96

Caries prevention in patients (monitoring) 110 89

Caries prevention in populations 106 86

Professional and individual plaque removal 98 80

Chemical and mechanical plaque removal 97 79

Role of fluorides in caries prevention 116 94

Role of fluorides in prevention of dental erosion 97 79

Aspects of fluoride toxicity 102 83

1Percentage calculated in relation to the total number of 123 responding dental schools

Survey on cariology education Schulte et al.

6 Eur J Dent Educ 15 (Suppl. 1) (2011) 3–8 ª 2011 John Wiley & Sons A/S

such as radiation caries or rampant caries or arrested cariesor root caries; classification of caries lesions*; root caries;caries risk factors; risk patients for dental caries and dentalerosion*; how to take relevant dental and medical history.The following items 8–15 were not mentioned on thequestionnaire, but were deemed relevant for a CariologyCurriculum by the educators completing the questionnaires.These items are also presented in alphabetical order.

8. Caries and Erosion Control: Future means of caries control;caries control of individual patients in daily practices; inac-tivation of carious lesions; role of fluorides in caries anderosion control; caries balance; managing caries by a medi-cal approach; common risk factor approach.

9. General Health and Caries: Systemic diseases and dental car-ies*; relationship between caries and medical pathologies;pharmacology and caries incidence; links to special needsdentistry; caries in ageing populations; special aspects of car-ies in elderly patients; drug dependences and caries profiles.

10. Materials: Remineralising agents; dental materials and risksof secondary caries; knowledge about materials used in ca-riology; chlorhexidine in cariology; dental biomaterials;adhesive techniques; laser treatment of hard tissues.

11. Non-invasive/least invasive Treatment Options: minimuminterventions*; sealants for early childhood caries; pit andfissure sealants*; minimal invasive treatment techniques*;caries infiltration; non-operative treatment of the patholo-gies linked to the dental hard tissues.

12. Public Health: management of dental public health; preven-tion programmes during childhood.

13. Pulp: pulp health maintenance; pulp response on pathogenicstimuli; dental pulp pain in response to caries*; indirect pulpcapping; endodontics; biological rationale for stepwise exca-vation.

14: Research: evidence-based dentistry and cariology; clinicalresearch in cariology.

15. Restorative Treatment/Operative Treatment: Operative treat-ment of the pathologies linked to the dental hard tissues;principles of cavity preparation according to restorativematerials, role of restorative dentistry in caries control; linkbetween cariology and operative dentistry, restorative den-tistry and cariology; restoration of caries lesions*; biologicalrationale for operative treatment.

Discussion

The information gained from this survey provided invaluableinput and support for the preparation of the first ORCA/ADEEworkshop on the development of a European Core Curriculumin Cariology, which took place on 28–30 June 2010 in Berlin,Germany.

Tables 2–5 show indisputably that cariology is recognised asone of the key items of dental education in Europe. All dentalschools offer theoretical, pre-clinical and clinical education incariology. Although there is considerable variation about com-mencement and duration of the different types of education incariology, on average, this is part of the dental curriculum ofall dental schools, mainly in the second, third, fourth and fifthyear (Table 5). Taking these figures into account, we maywonder that neither a European nor any national curriculum

in cariology was presented prior to the present activities ofORCA and ADEE. However, the proportion of dental schoolshaving completed the questionnaire is very high and there wasnearly unanimous support for the development of a Europeancore curriculum in cariology. It should be underlined that thissupport is based on the reactions of not less than 109 dentalschools from 32 European countries. This underscores the sup-port for the curriculum project as not only the majority of theresponding dental schools but also the majority of all Europeandental schools were in favour.

The survey clearly shows that undergraduate education in ca-riology is not confined to aspects related to caries in the strict-est sense of the word but also comprises education in erosionand non-erosive wear in nearly all European countries. Theinterest in dental erosion and non-erosive wear has only devel-oped to a substantial degree over the past 15 years, so prior tothis investigation, it could be doubted to what degree the sub-ject had entered the undergraduate education. With nearly 90%of the responding dental schools reporting erosion and non-erosive wear as a relevant subject to cariology, it may be con-sidered an established subject.

There is a broad consensus about the 27 main areas thatshould be taught in cariology courses. For half of these items,the rate of support was 90% or higher, and for the other items,the rate of support was at least 75% (Table 6) with one excep-tion regarding behavioural sciences. This item was deemed nec-essary by only 70% of the responding dental schools. As 90%of the schools agree that education should comprise caries pre-vention, and caries prevention can hardly be envisaged withoutapproaches including patient education, motivation and behav-iour modification, this is rather surprising.

In contrast to the previous observations showing a high levelof agreement, a large diversity was observed with regard to thenumber of units responsible for education in cariology. Onlyone-third of the schools reported to have one unit beingresponsible for education in cariology. In many schools, thiseducation is shared between conservative/operative/restorativedentistry and paediatric dentistry. In addition, in severalschools, this education is delivered by even more units. Thismay well explain why an integrated cariology curriculum fornational or European use has not been produced earlier, and itimplies the need for communication between many groups toachieve such an integrated curriculum. We hope that a Euro-pean Core Curriculum in Cariology will offer a framework tosupport communication among units involved in its teachingand will enable many schools to decide more easily on therespective responsibilities.

Conflict of interests

The authors confirm no conflicts of interests.

References

1 Cowpe J, Plasschaert A, Harzer W, Vinkka-Puhakka H, Walmsley

AD. Profile and competences for the graduating European Dentist –

update 2009. Eur J Dent Educ 2010: 14: 210–214.

2 European Society of Endodontology. Undergraduate Education in

Endodontology. Int Endod J 2001: 34: 57–580.

Schulte et al. Survey on cariology education

Eur J Dent Educ 15 (Suppl. 1) (2011) 3–8 ª 2011 John Wiley & Sons A/S 7

3 European Academy of Pediatric Dentistry. A guideline framework

for undergraduate education in Paediatric Dentistry. Eur Arch Pae-

diatr Dent 2009: 10: 114–119.

4 Hicklin SP, Albrektsson T, Hammerle CHF. Theoretical knowledge

in implant dentistry for undergraduate students. Eur J Dent Educ

2009: 13(Suppl. 1): 24–35.

5 Kossioni A, Vanobbergen J, Newton J, Muller F, Heath R. European

college of Gerodontology: undergraduate curriculum guidelines in

Gerodontology. Gerodontology 2009: 26: 165–171.

6 Sanz M, Meyle J. Scope, competences, learning outcomes and meth-

ods of periodontal education within the undergraduate dental cur-

riculum: a Consensus report of the 1st European workshop on

periodontal education – position paper 2 and consensus view 2.

Eur J Dent Educ 2010: 14(Suppl. 1): 25–33.

7 Schulte AG, Momeni A, Pieper K. Caries prevalence in 12-year-old

children from Germany. Results of the 2004 national survey. Com-

munity Dent Health 2006: 23: 197–202.

8 Steiner M, Menghini G, Marthaler TM, Imfeld T. Changes in dental

caries in Zurich school-children over a period of 45 years. Schweiz

Monatsschr Zahnmed 2010: 120: 1084–1104.

9 Schulte AG, Pitts NB, Huysmans MC, Splieth C, Buchalla W.

European Core Curriculum in Cariology for European

Undergraduate Dental Students. Eur J Dent Educ 2011: 15 (Suppl.

1): 9–17.

Survey on cariology education Schulte et al.

8 Eur J Dent Educ 15 (Suppl. 1) (2011) 3–8 ª 2011 John Wiley & Sons A/S