Paediatric dentistry in outreach settings: an essential part ofundergraduate curricula?M. L. Hunter1 and U. Chaudhry2

1 Applied Clinical Research and Public Health Group, Cardiff University School of Dentistry, Cardiff CF14 4XY, UK,2 Paediatric Dentistry Unit, University Dental Hospital of Manchester, Manchester M15 6FH, UK

Introduction

Undergraduate teaching in paediatric dentistry focuses onprevention, behaviour management and the treatment of dentalcaries. For newly qualified dentists to be competent to providecomprehensive oral health care from birth through adolescence,curricula must provide students with the opportunity to gainknowledge and skills in all three areas.

In the learning process, there is no substitute for clinicalexperience and repetition of techniques confers both compe-tence and confidence. A lack of appropriate undergraduate clin-

ical experience can have negative consequences on the abilityand confidence of newly qualified dentists to provide essentialdental care to children. Crucially, this may result in anincreased number of referrals to already pressurised specialistservices.

In the USA, it has already been recognised that lack of prep-aration of dental students is one aspect of a disparity in accessto paediatric dental care (1). A number of factors contribute tothis lack of preparation. One is a declining workforce in paedi-atric dental education, compounded by a mean 10 percentincrease in the number of dental students. Another is the

Keywords

undergraduate education; paediatric dentistry;

placement learning.

Correspondence

M. L. Hunter

Applied Clinical Research and Public Health

Group

Cardiff University School of Dentistry

Heath Park

Cardiff CF14 4XY

UK

Tel: +442920748277

Fax: +442920746489

e-mail: hunterml@cf.ac.uk

Accepted: 27 January 2009

doi:10.1111/j.1600-0579.2009.00574.x

Abstract

Introduction: Although placements in primary care settings remote from dentalschools are becoming a common feature of undergraduate dental curricula, little evi-dence is available regarding the experience of paediatric dentistry gained in this way.

Materials and methods: Treatment logs relating to salaried primary care placementsundertaken by the Class of 2007 at Cardiff University School of Dentistry were exam-ined, particular attention being paid to paediatric-specific procedures.

Results: Forty-nine logs relating to placements undertaken in South East Wales and51 relating to those in North Wales were retrieved. In South East Wales, 90% ofstudents gained experience of primary tooth restoration, 61% carrying out primaryendodontics. Sixty-three percent of students undertaking placements in South EastWales and 69% of those placed in North Wales gained experience of primary toothextraction under local anaesthesia. All but three students gained experience of adminis-tering inhalation sedation.

Discussion: The findings of this study should go some way towards reassuring thosewho have expressed concern that recruitment difficulties within dental schools inevita-bly lead to increasing numbers of students qualifying without clinical experience ofpaediatric dental procedures considered to be within the remit of a newly qualifieddental practitioner. However, there remains wide variation in the breadth and depth ofexperience of individual students and it is still possible for some students to graduatewithout what might be considered core experience in paediatric dentistry.

Conclusion: Salaried primary care settings are ideally placed to provide students withexperience of paediatric-specific procedures. Clinical education in paediatric dentistryshould, therefore, incorporate the strengths of dental school and placement education.

European Journal of Dental Education ISSN 1396-5883

Eur J Dent Educ 13 (2009) 199–202 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Munksgaard 199

growing tendency for Paediatric Dentistry to be taught by non-specialists (2). These trends are recognisable as also occurringwithin the United Kingdom.

Changing patterns of dental disease also contribute todecreased undergraduate experience. As caries in the permanentdentition continues to decline, so also does the population of‘teaching patients’ old enough and sufficiently co-operative fordental students to provide restorative or surgical treatmentunder local anaesthesia in a university setting. In the UnitedKingdom, the decline in caries prevalence in the child popula-tion has made it increasingly difficult for dental schools torecruit child patients who require preventive and restorativecare, but whose behaviour is not so challenging that specialistmanagement is indicated. In the early 1990s, Rodd (3) sug-gested that, as a result, students were gaining little practice ineven basic paediatric clinical procedures; there is no recentevidence to suggest that this situation has changed.

The responsibility to provide students with the requisiteexperience in Paediatric Dentistry lies with the dental schools.Regrettably, dental school clinics are notoriously inefficient, anunproductive clinical environment being perceived as the pri-mary weakness of this setting (4). Thus, placements in primarycare sites remote from dental schools are becoming a commonfeature of undergraduate dental curricula in the United King-dom. Such placements allow students to acquire practical expe-rience over and above that available within dental schools andmay enhance their preparedness for modern practice (5).

For more than 20 years, year 5 (final year) undergraduatestudents of the School of Dentistry, Cardiff University havebeen required to complete two outreach placements in salariedprimary care settings; the first of these is based in South EastWales (in selected clinics in Bro Taf and Gwent) and the sec-ond in North Wales (at Wrexham Dental Centre). These place-ments enable students to gain experience of treating childpatients in an environment away from the School of Dentistryand also familiarise them with the range of patients treatedwithin salaried primary care services. The South East Walesplacement is of 8 days duration whilst that in North Wales is10 days long; in both cases, each day equates to approximately6 h of clinical practice during which students are exposed tothe role of the salaried primary care service in providingemergency and routine dental care to children up to the age of16 years.

A previous publication (6) has shown that the majority ofstudents are, overall, more confident following experience inoutreach settings than they were on completion of their allo-cated paediatric dentistry sessions in the School of Dentistry.At the time of that study, however, no information was avail-able as to the quantity of additional clinical experience cur-rently gained through this form of placement learning. (Indeed,the publication of any data relating to the clinical exposure ofdental students to paediatric-specific procedures is a rare occur-rence). This study, therefore, aims to make good this deficit.

Materials and methods

In salaried primary care settings, student clinical activity isrecorded by means of a paper log; this documents both quan-tity and quality of work undertaken. In both centres, student

activity in relation to the following items of treatment isrecorded: history and examination, treatment plan, acclimati-sation, review, topical fluoride application, fissure sealant app-lication, oral hygiene instruction, diet analysis and advice,prescription, scaling and polishing, temporary restoration,radiographic examination, local anaesthesia, intracoronal resto-ration (primary/permanent), preformed metal crown, endodon-tic treatment (primary/permanent), extraction (primary/permanent), impressions. In addition, logs of clinical activity atWrexham Dental Centre include data relating to the adminis-tration of inhalation sedation.

For the purposes of this study, logs relating to the Class of2007 were retrieved. Quantitative data relating to the comple-tion of operative and non-operative interventions in salariedprimary care settings in South East Wales and Wrexham wereentered into two Microsoft Excel spreadsheets for analysis.

Results

The Class of 2007 comprised 55 students. One year after gradu-ation, it was possible to retrieve 49 logs relating to placementscompleted in South East Wales and 51 related to placementscompleted at Wrexham Dental Centre.

Table 1 illustrates the number of procedures completedby students undertaking placements in salaried primary care

TABLE 1. Number of procedures per student (n = 49) completed during

SE Wales salaried primary care placement

Mean Mode Range

No. (%) of

students

with experience

of procedure

History/examination 18.1 7 1–40 49 (100)

Treatment plan 7.4 0 0–40 43 (88)

Review 0.2 0 0–3 8 (16)

Acclimatisation 0.4 0 0–2 11 (22)

Topical fluoride 0.8 0 0–3 25 (51)

Fissure sealant 4.6 0 0–19 39 (80)

OHI 1.1 0 0–7 29 (59)

Diet analysis/advice 0.3 0 0–7 11 (22)

Prescription 0.9 0 0–4 23 (46)

Scale/polish 3.3 1 0–15 37 (76)

Temporary dressing 1.9 0 0–11 35 (71)

Radiographic examination 5.6 3 0–19 42 (86)

LA 5.5 6 1–16 49 (100)

Intracoronal restoration

(primary)

3.1 2 0–14 44 (90)

Intracoronal restoration

(permanent)

5.2 4 0–12 46 (94)

Preformed metal crown 0 0 0 0 (0)

Endodontic treatment

(primary)

1.4 0 0–7 30 (61)

Endodontic treatment

(permanent)

0.3 0 0–2 7 (14)

Extraction (primary) 1 0 0–6 31 (63)

Extraction (permanent) 0.3 0 0–3 18 (37)

Impressions 0.3 0 0–3 9 (18)

OHI, oral hygiene instruction; LA, local anaesthesia.

Undergraduate experience in paediatric dentistry Hunter & Chaudhry

200 Eur J Dent Educ 13 (2009) 199–202 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Munksgaard

settings in South East Wales. Table 2 illustrates the number ofprocedures completed by students undertaking placements inNorth Wales.

Discussion

A recent study (7) examined similar data from the Class of2007 at Ohio State University College of Dentistry (OSUCD).The authors reported that outreach settings provided a signifi-cant contribution to overall paediatric dental education.Students performed more clinical procedures during outreachplacements and also performed procedures deemed central topaediatric dental treatment. Whilst the university-based systemprovided more patient contacts and core procedures per stu-dent, these were heavily skewed towards diagnosis and preven-tion. Significantly, the school-based clinic could not supplyeven one procedure per student in a substantial number ofrestorative categories. In contrast, the outreach centres, pro-vided multiple treatment experiences.

Within the School of Dentistry at Cardiff University, stu-dents gain limited experience of providing operative care tochild patients until the penultimate year of their course. Duringyear 2, they complete an operative techniques (phantom head)course which includes procedures relevant to the restoration of

the primary and young permanent dentitions. Clinical sessionsin year 3 are largely devoted to the development of skills inrelation to behaviour management and individual prevention.During year 4, two groups of between 10 and 12 studentsrotate through the paediatric clinic on one half-day per week.The first hour of each session is devoted to problem-basedlearning, whilst the remaining 2½ h are devoted to patient con-tact and ‘hot review’. On each session, one group of studentsoperates, whilst their colleagues provide chairside assistance;students can expect to act as operators on between 15 and 17sessions during the year. Supervision is provided by two clinicalteachers (one paediatric dentist and one orthodontist) and stu-dents are scheduled to see one paediatric dentistry patient andone orthodontic patient in each session. They will, therefore,have only 15–17 one-hour slots in which to treat child patientsduring the academic year. Assistance from trained dentalnurses, though usually available on request, is limited, no morethan two normally being available.

Child patients treated by undergraduate students areselected on the basis that the treatment needs of the formermatch the educational needs of the latter. However, it issomewhat inevitable that many of those who find their wayonto undergraduate clinics will previously have been managedunsuccessfully in a primary care setting. Others will have pre-sented at a late stage in the natural history of their dental dis-ease, either because the referring dentist has attempted toprovide treatment over a long period or, regrettably, becausethe clinical need has been overlooked or managed in a casualmanner. Sadly, for such children, initial management of dentaldisease will not infrequently have involved recourse to theextraction of several teeth under general anaesthesia. Under-graduate students, therefore, can expect to gain limited experi-ence of more extensive paediatric-specific restorativeprocedures during their clinical sessions within the School ofDentistry. For example, they are rarely presented with theopportunity to carry out primary endodontics or place a pre-formed metal crown. Likewise, a minority of students will gainexperience of extracting a primary or permanent tooth underlocal anaesthesia.

The two salaried primary care placements allow students tobenefit from working in a more intimate environment withtrained nursing support and immediately available individualsupervision from an experienced clinician. Perhaps mostimportantly, undergraduate students are provided with compli-ant child patients selected from those for whom the respectivesalaried primary care service provides primary dental care.

Given the foregoing comments regarding the relative paucityof previous experience available within the School of Dentistryin relation to operative procedures for the primary dentition,the results presented in Tables 1 and 2 are encouraging. Inparticular, it should be noted that:l 90% of placements in South East Wales clinics providedexperience of primary tooth restoration; 61% of studentscarried out primary endodontics.l 63% of placements in South East Wales and 69% of thosein North Wales provided experience of primary tooth extrac-tion under local anaesthesia.l All but three students gained experience of administeringinhalation sedation.

TABLE 2. Summary statistics for procedures per student (n = 51)

completed during North Wales salaried primary care placement

Mean Mode Range

No. (%) of

students with

experience of

procedure

History/examination 4.6 4 0–11 46 (90)

Treatment plan 2.1 0 0–8 43 (84)

Review 0.6 0 0–4 28 (57)

Acclimatisation 0.9 0 0–6 26 (51)

Topical fluoride 0.7 0 0–6 19 (37)

Fissure sealant 2.3 0 0–11 38 (75)

OHI 1.1 0 0–8 25 (49)

Diet analysis/advice 0.4 0 0–5 12 (24)

Prescription 1.5 0 0–6 34 (67)

Scale/polish 0.9 1 0–4 32 (63)

Temporary dressing 1.8 2 0–7 38 (75)

Radiographic examination 3.2 0 0–16 40 (78)

LA 10.9 0 0–27 43 (84)

Intracoronal restoration

(primary)

1.7 0 0–8 36 (71)

Intracoronal Restoration

(permanent)

11.7 9 4–24 51 (100)

Preformed metal crown 0 0 0–1 1 (2)

Endodontic treatment

(primary)

0.2 0 0–3 8 (16)

Endodontic treatment

(permanent)

0.9 1 0–3 31 (61)

Extraction (primary) 1.5 0 0–7 35 (69)

Extraction (permanent) 3.8 1 0–18 44 (86)

Impressions 1.8 1 0–7 39 (76)

Inhalation sedation 8.3 7 0–22 48 (94)

OHI, oral hygiene instruction; LA, local anaesthesia.

Hunter & Chaudhry Undergraduate experience in paediatric dentistry

Eur J Dent Educ 13 (2009) 199–202 ª 2009 The Authors. Journal compilation ª 2009 Blackwell Munksgaard 201

Significantly, only one student gained experience of placing apreformed metal crown on a primary molar. This is a notuncommon finding in undergraduate dental education. Only20% of those graduating from King’s Dental Institute, London,between 1997 and 2001 had experience of providing this typeof restoration (8). Likewise, Rodd (3) found it necessary toexclude preformed metal crowns from her examination ofchanges in undergraduate experience in clinical paediatric den-tistry as so few were performed. In both cases, the totality ofundergraduate clinical experience in paediatric dentistry hadbeen gained in the university setting. From our study, it is clearthat even salaried primary care settings are unable to providethe requisite experience. This observation might, therefore,prompt clinical teachers to question whether this procedure isrequired of primary care practitioners or whether it might bereasonable to regard it as being non-essential clinical experiencefor the undergraduate. Alternatively, it might prompt universitydepartments to consider adopting and promulgating therecently described ‘Hall technique’ (9) as a means of increasingthe provision of this effective and durable restoration.

Our findings should be seen as going some way towardsreassuring those who have expressed concern that recruitmentdifficulties within dental schools lead to increasing numbers ofstudents qualifying without clinical experience of paediatricdental procedures historically considered to be within the remitof a newly qualified dental practitioner. However, even in awell-established outreach programme such as this, there is widevariation in the breadth and depth of experience of individualstudents and it still remains possible for some students tograduate without what might be considered core experience inPaediatric Dentistry.

In comparison with similar programmes in the USA, out-reach placements at Cardiff are of relatively short duration. Forexample, the Class of 2007 at OSUCD spent approximately60 days (on a longitudinal basis) in community-based outreachclinics and their experience of paediatric-specific proceduresreflects this. At Cardiff, expansion of placement learning, withits introduction at an earlier stage in undergraduate education,is a long-term aim. In the interim, however, the final year pro-gramme has been amended to provide a longitudinal attach-ment of 1 day/week for 8 weeks to local salaried primary caresettings. It is hoped that this will give students the opportunityto provide continuity of care to a smaller number of patients,thereby increasing the ratio of restorative vis a vis preventiveprocedures.

Conclusion

The experience that students are able to gain during what iscurrently a comparatively short time demonstrates the impor-tant role of outreach placements in paediatric dentistry. It isour view that clinical education in paediatric dentistry shouldincorporate the strengths of both dental school- and outreach-based education. The principles of paediatric dental care andbasic clinical procedures are best taught within the dentalschool, ideally early in the undergraduate years and under thesupervision of specialists in paediatric dentistry. This experiencecan then be augmented by placements in appropriate primarycare settings where competencies can be assessed in a morerealistic environment.

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