Undergraduate teaching of periodontology in UK dental schools

Eur 1 Dent Educ 1998; 2: 172-1 77 Printed tn Denmark. A// nghts resewed

CopVnghI 0 Munkspnrd 1998

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Dental Education ISSN 1396-5883

Undergraduate teaching of periodontology in UK dental schools

P. A. Heasman* Restorative Dentistry, The Dental Schwi , University of Newcastle upon Tyne, NE2 4BW, UK

A questionnaire survey of dental schools in the United Kingdom was undertaken to evaluate the teaching of periodontology and the extent to which the curricula correlate with the guidelines Set by the European Federation of Periodontology (EFP) in 1996. The questionnaire sought details regarding the basic structure and content of courses, the manpower for teaching the subject, methods of assessment and evaluation, and extra-curricula opportunities linked to periodontology. The responses show that there is considerable consistency between the UK schools in

teaching periodontology and that the curriculum content largely fulfils EFP guidelines. The survey has also established an extensive database on information in this area of undergraduate dental education.

Key words: periodontology; undergraduate curricula.

0 Munksgaard, 7998 Accepted for publication 7 July 1998

HE EXPANSION and recognition of postgraduate T specialty programmes in periodontology throughout Europe enables the successful graduate to specialise in periodontics in any member state of the European Union. These developments were foreseen by the European Federation of Periodontology (EFP) which was formed to oversee and co-ordinate stan- dards of training in periodontology in Europe. Curric- ula guidelines for undergraduate and postgraduate programmes were published (1, 2). These were not proposed as inflexible precepts for periodontal education, but rather as a way of ensuring minimum stan- dards are achieved at all levels of education in periodontology (Table 1).

In the UK, periodontology remains an important and integral component of the undergraduate curriculum. In 1980, the Teachers’ Section of the British Society of Periodontology published a document which outlined attitudinal, didactic and clinical goals for teaching periodontics in the UK (3). It is reason- able to suppose that these objectives will have served as a useful foundation when curricula at individual schools were subsequently developed, modified or streamlined. The need to maintain a degree of independent emphasis, however, based upon the skill

‘ Chairman o f Teachers’ Section, British Society of Periodonto- logy.

base, resources and needs of each school, is clearly recognised.

The primary aim of this questionnaire survey was to evaluate all aspects of the teaching of periodontology in UK dental schools. Secondary objectives were to determine the extent to which UK curricula correlate with the EFP guidelines, and also to identify for discussion, those aspects of teaching which show some variation between individual schools.

Method A structured questionnaire was sent to named indi- viduals (BSP contacts or Heads of Periodontal Depart- ments/Units) at each of the 14 Dental Schools in the UK. The closed sections of the questionnaire sought specific information on all aspects of curricula in periodontology under the broad headings of; structure and content of the course, manpower, assessment and evaluation, and extracurricular opportunities. The questionnaire also included open sections, permitting the responders to provide considerable detail of the individual courses at each school.

The information was collected and collated manually and then compared and contrasted with the principal recommendations of the EFP guidelines. Following the analysis, 3 questions were raised for further discussion by the Teachers’ section of the BSP at its annual meeting in 1997. The questions were as follows:

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Teaching of periodontology in UK dental schools

TABLE 1 . Eurmean Federation of Periodontolom. Curricular guidelines for underaraduate periodontal education

Overview Periodontology should be taught as:

an independent core subject co-ordinated with basic sciences and other clinical disciplines a subject matter course and clinical practice, mostly in the form of comprehensive dental practice seminars, tutorials, group discussions and assigned individual work pre-clinical and clinical courses on diagnosis, treatment planning and instrumentation

Global objectives Undergraduates must achieve

a broad knowledge of sciences basic to periodontology a broad knowledge of interactions between Periodontal and Systemic diseases, and periodontal management of the medically Compromised a broad knowledge of periodontal epidemiology an intensive knowledge of clinical periodontics a clinical expertise in the presentation, diagnosis and management of early and moderate periodontitis clinical expertise in the presentation and diagnosis of advanced periodontitis

Time allocation seminars and tutorials 50-90 h preclinicdclinics 150-1 80 h comprehensive therapy 150-1 80 h

Evaluation Students should be assessed

on their knowledge and clinical performance by written examination at the end of the course by proficiency tests of diagnosis and instrumentation techniques

To what extent should periodontal surgery be cov- ered in the undergraduate curriculum? To what extent should the undergraduate dental course in periodontology be integrated with the course in dental hygiene?

odontology ? How should undergraduates be evaluated in

The conclusions from these discussions will be included in the Discussion section of this paper.

Results A completed questionnaire was received from each of the 14 dental schools in the UK. The mean number of dental undergraduates/school/year was 58 (range 30-90). 9 schools had between 50-65 students/year.

TABLE 2. Meor1 riuniber of hoirrs of periodolIto!ogy teaching in each of the 5 years of the curriculunt in 14 UK Dental Schools

Year of course Hours of teaching

1st 2nd 3rd 4th 5th total

lectures 1 6 8 8 3 2 6 Seminars 1 5 13 10 3 32 phantom head 0 4 9 13 1 27 clinical 0 16 44 63 38 161

7 schools had modified their periodontal curriculum after considering the EFP guidelines. There had, however, been no major restructuring of any course, and all the implemented changes were considered to be minor. All schools believed that their courses in periodontology now broadly complied with the EFP guidelines.

Structure and content of teaching Periodontology is taught principally as a core subject in 6 schools, exclusively as one component of the integrated restorative dentistry in none, and both as a core subject together with an integrated approach in 8 schools. The majority of the core didactic and clinical teaching is taught in the 3rd and 4th years of the 5 year curriculum. In 8 schools, the core teaching is introduced in the 2nd year of the course with lectures, seminars and phantom-head-based instrumentation courses. The core teaching extends into the final year of the course in 5 schools, and in only 3 is the subject taught over 4 years of the 5-year curriculum.

An overview of the mean number of teaching hours allocated to core teaching of periodontology in each year of the course is shown in Table 2. The didactic content of lectures and seminars was exhaustive, and in all cases complied well with the outlined subject matter in the EFP guidelines (not shown). In a number of schools, some topics not listed in the guidelines, are addressed in lectures, almost certainly because of the specific interests of staff. These subjects were:

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Heasman

dentine hypersensitivity HIV diseases cross-infection in clinical periodontics when to refer for specialist treatment markers of disease activity oral hygiene products surgical versus non-surgical management.

The association between oral implantology and periodontology is recognised in 4 schools where the subjects are taught as part of the same course. In a further 8 schools, implantology is included in the undergraduate curriculum but is not part of the periodontology course.

Undergraduates at all schools undertake a pre-clinical course in periodontal instrumentation using jaw- models and phantom heads. The mean length of this course is 7.5 h. The majority of schools (10) devote between 6 and 10 h to pre-clinical instrumentation, with an overall range of 3-18 h.

Periodontal surgery is practised using models or pigs jaws in 9 schools, and for an average of 3 h/ student. In only one school, however, is periodontal surgery a requirement for all students. Elsewhere, there are opportunities to observe periodontal surgery

with only a minority of students having the chance to undertake a procedure themselves.

The opportunity for students to use or experience more ‘modem’ learning methods of the subject is somewhat limited. Both problem-based and com- puter-assisted learning techniques are practised/ available in 5 schools, whereas one method or the other is available in a further 5 centres. Neither method is available (for periodontology teaching) in 7 schools.

Each school was asked to list the essential and optional textbooks which are recommended to their students. The texts which are considered to be essential or optional at more than one school are shown in Table 3. It can be seen that the core of essential reading comprises just 4 principal texts. A further 8 texts (to those shown in Table 3) were recommended as optional, each by only one school. Optional reading tended to be much more broad based and partly re- flected loyalty to the authors (members of staff) at each school.

Manpower Table 4 shows the staffing resources available for teaching clinical periodontology at each school (A-N).

TABLE 3. Essential and optional textbooks recommended for undergraduates at more than one UK dental school

Textbook Number of Schools

essential optional

Textbook of clinical periodontology (Lindhe) Outline of periodontics (Manson & Eley) Pathology of periodontal disease (Williams et al.) Guide to periodontics (Jenkins & Allan) Atlas of periodontology (Strahan & Waite) Drugs, diseases and the periodontium (Seymour & Heasman) Colour atlas of periodontology (Rateitschak) Glickman’s clinical periodontology Colour atlas of oral medicine (Rateitschak)

TABLE 4. Manpower responsible for teaching clinical periodontology at each dental school (A-N for anonymity): UG - undergraduate; wte - whole time equivalent

STAFF

Full-time university lecturers with principal duties in periodontology Full-time university lecturers whose teaching duties include periodontology NHS consultant staff whose clinical duties include teaching in periodontology (wte) Specialist training grade staff (restorative) who contribute to UG teaching (Me) Tutor/staff hygienists who contribute to UG teaching General dental practitioners who contribute to teaching (wte) Specialist dental practitioners who contribute to teaching (wte)

A B C

2 3 4 1 0 1

1 0 0

0 0 1

0 2 1 0 0 2.3 0 0 1

D

0 8

1

1

0 1.5 0

- E F G H I J K L M N

2 3 2 2

1 2

0 0

3 3 0.2 0.1 0 0

5 1

1

2

0 0 3.2

3 3 2 2 3 4 1 0 8 0 0 0 1 2

0 . 3 3 1 0 1 0 0

0 0 1 0.1 0.1 1 1

2 1 1 0 0 0 0 0 0 0.2 0.6 0.5 1 2 0 . 1 0 0 0 0 1 0

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The contributions made to the periodontal curriculum by both clinical, non-periodontal teachers, and by basic scientists are outlined in Table 5. Conversely, in 9/13 schools, the full-time lecturers whose principal duties are in periodontology also have input into clinics and courses additional to those in periodonto-

All 14 dental schools have an associated hospital with both hygienist staff and a School of Dental Hy- giene. Integration of training of dental students and dental student hygienists is, however, very limited. Combined training of both groups (in periodontology) is undertaken for 12 months in just 2 schools. In a further 4 schools, the links are more tenuous with staff and tutor hygienists having some input into phantom head instrumentation courses, teaching oral hygiene measures and designing and constructing handouts. In 6 schools, dental students have the opportunity to observe dental hygienists at work.

logy.

TABLE 5. Contribution (by school) to undergraduate teaching of periodontology by clinics] (non periodontal) teachers and basic scientists

Basic scientists Clinical discipline Number ot schools

oral pathologists 8 microbiologists 9

oral biologists 7 anatomists 4 physiologists 3 epidemiologists 3

radiologists 3 paedodontists 2 prosthodontists 2

immunologists 2

TABLE 6. Student eztaliiation in periodontology

Method of student assessment NO. schools

grading of clinical sessions 14

case reports 10

log diaries of treatment 5 Project work 4

cIass/term examinations (non-professional) 13

essays 8

TABLE 7. Resrarcll Opporfunifies for u?ldergradlrates in periodonto-

Opportunity No. schools

British Society of Periodontology

Intercalated degrees (6 Med sCi/BsC)

'om

presentations at dental research meetings and

periodontology based 'elective' project 12

1 1

6

Assessment and evaluation methods In all schools, periodontology is assessed during the final year of the undergraduate course. Most frequently, this is carried out in the final degree examination either as a 'stand alone' discipline, or as part of the wider discipline of restorative dentistry. Methods used for continuous assessment during the course are shown in Table 6.

Ext ra-cu rricular opportunities Undergraduates at all schools are encouraged to at- tend postgraduate lectures and symposia, and thus have the opportunity to hear speakers of national and international reputation. In no instance, however, was the frequency of such occasions described as being more than 'very occasional'.

Opportunities to carry out research projects (elec- tives), intercalated degrees (BSc, B Med Sci) and to present papers at national and international meetings are outlined in Table 7. Such activity can only be described as regular in 2 schools. In one school, 4-6 students/ year researched a periodontal topic to present as a dissertation. In the other school, 4 or 5 students/ year selected a periodontal project to undertake as part of their elective period of study.

Discussion This questionnaire survey succeeded in establishing an extensive database of information for curriculum content in periodontology in UK dental schools.

It is very clear that in all curricula, the detailed subject matter provided to undergraduates in the form of lectures and/or seminars correlates closely with the 45 topics listed in the EFP guidelines (1). Furthermore, the didactic content is supplemented in each instance by a short list of textbooks which showed remarkable consistency between schools. This suggests that the information base for teaching (and learning) periodontology demonstrates considerable uniformity through the UK.

An overview of the time allocation for teaching periodontology also confirms that there is broad agreement with EFP recommendations, at least with respect to lectures, seminars, pre-clinical and periodontal patient clinics (Table 2). It was also evident that in the majority of schools, periodontology is included in comprehensive therapy clinics (restorative dentistry). It was not possible to establish the specific time allocation to periodontics in such clinics, mainly because the recorded unit of assessment is the out- come of treatment rather than the time spent under- taking the restorative procedure. Indeed, it is difficult

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Heasman

to envisage how this information can be obtained ac- curately. In summary, with respect to teaching hours recommended in the EFP guidelines, 9 schools fulfil the academic criteria, 10 fulfil the clinical criteria, and 5 fulfil both.

The exposure of undergraduates to periodontal surgery is largely restricted to observing procedures undertaken by senior staff. From open comments, it was clear that an insufficiency of staff for 1:l supervision on a regular basis was the main reason for students not being able to undertake procedures themselves. A reduction in surgical experience is also likely to have been determined by a change in disease pat- terns and the evidence-based efficacy of non-surgical therapies. It is of interest to compare the UK situation with that in the United States where pre-doctoral students perform periodontal surgery (gingivectomy, modified Widman flap, gingivoplasty, apically reposi- tioned flap and distal wedges) in almost 100% of schools. Indeed, 70% of schools have a minimum requirement for periodontal surgery (4). This difference in experience of periodontal surgical techniques is, at least in part, likely to reflect a difference in the under- lying treatment approach to periodontal disease between the USA and the UK. Nevertheless, it would be interesting to determine the extent to which the manpower and close support available for teaching surgery varies in dental schools in the two countries. In the UK, there is total agreement amongst teachers that, whilst recognising the limitations in manpower, periodontal surgery should be taught in the undergraduate curriculum. Although few students may perform surgery themselves, clinical observation and the use of videos or video-links might enable students to be exposed to a much wider range of procedures than is presently the case.

It is seen from Table 4 that the manpower for teaching clinical periodontology is derived from full-time university lecturers who specialise in the subject. (The one school (D) with no such staff at the time of the survey has since appointed 2 full-time periodontists.) It is also apparent that there is considerable additional teaching input (at all schools) from a variety of staff grades including NHS consultants, specialist trainees, tutor and staff hygienists, general and specialist dental practitioners. This structuring of teaching must be encouraged to ensure that the undergraduates are exposed not just to academics, but also to those periodontal service providers at all levels. It should be acknowledged however that for NHS consultant and training grades, general and specialist practitioners, the questionnaire asked for whole time equivalents (wtes) for manpower input. The responses suggest

that in some instances (for example specialist practitioners at school H) the question may have been mis- interpreted, thus leading to an overall overestimate of the input of these staff grades.

It is also well-recognised that the practice of periodontology is based upon biological principles and that the undergraduate curriculum will inevitably overlap with other clinical disciplines and biological sciences (5). It is therefore reassuring to observe that both basic scientists and teachers of other clinical disciplines have an input into the periodontal curriculum (Table 5). Conversely, lecturers in periodontology, in the majority of schools, also have timetabled duties in restorative dentistry clinics. This will ensure that the students are aware of the important relationship between periodontics and the broader restorative discipline.

In North America, the teaching, particularly of pre- ventive periodontal therapy, is enhanced and supplemented by dental hygienists who work in conjunction with (and under supervision of) a full-time faculty member (6). Hygienists have a teaching r81e in 7 of the 14 UK schools, although the overall input is somewhat limited. There is also minimal integration between the teaching of dental students and student dental hygienists. Whilst there may well be logistic difficulties with integration of the academic and phantom head (pre- clinical) components of the two courses, the periodontal management of individual patients could be planned to involve both groups and is educationally favourable. The dental student would gain experience in writing prescriptions for the hygienist, and would therefore become more familiar with the scope of treatments undertaken, and would acquire the ability to constructively supervise treatment undertaken by dental auxiliaries. The student dental hygienists would learn to appreciate their own contribution to the dental team and increase their knowledge of patient management in the wider, restorative discipline.

EFP recommendations for the assessment of students in periodontology are certainly fulfilled, with the majority of schools using clinical grading, term examinations and case reports as methods for evaluation. Open comments and further discussion established that essays are the most popular method through which attainment of academic knowledge is tested, and although multiple choice questions offer the opportunity to examine a wider range of knowledge, these are used much less frequently. Clinically, although the use of diaries to log student activity is by no means widespread (5/14 schools), their use is becoming increasingly popular for monitoring the range of completed treatments. There is not, however,

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a clear-cut consensus regarding the best method to as- sess clinical competency. Simply logging the number of hours of attendance on clinics (as stated in the EFP guidelines) does not necessarily correlate with the eventual competency of an undergraduate. Setting minimal targets for any one procedure to be undertaken may well help to attain a uniformity of experience, but this will not necessarily ensure that each individual student will achieve competency in the procedure or technique. The (target) number of times a procedure should be performed for a student to become competent may vary considerably between indi- viduals, and hence fixing the same target for all students can be largely counterproductive. Ln contrast to EFP guidelines, clinical proficiency tests in scaling, root planing, diagnosis and treatment planning are undertaken in only 4 schools. The need for close and regular modtoring of clinical performance is therefore only too apparent as is the need for further research into the development of effective and validated assessment methods.

Concluding remarks The teaching and curriculum content of periodontology in the UK shows consistency between schools and largely fulfils the EFP guidelines on undergraduate education. It is hoped that the findings of this questionnaire survey which have been circulated to all UK dental schools, will enable teachers to evaluate their own courses in comparison to those at all other schools. This information may be invaluable as modem education principles based upon self-directed and

problem-based learning methods are introduced and developed in the undergraduate dental curriculum.

Acknowledgements I wish to thank Claire Grainger for the preparation of the manuscript and Anne Hallowes for preparing the questionnaire. I am also grateful to all my colleagues who completed and promptly returned the ques- tionnaires.

References 1. European Federation of Periodontology, Curricular Guide-

lines in Undergraduate Periodontal Education, 1996. 2. European Federation of Periodontology, Graduate pro-

gramme in Periodontology, 1994. 3. Cowley GC, Ashley P. Undergraduate education in period-

ontology. Br Dent J 1980: 149: 297. 4. Radentz WH, Caffesse RG. Surgical procedures in predoc-

toral periodontics programs. J Dent Educ 1991: 55: 589- 591.

5. Anonymous. Curriculum guidelines for periodontics. J Dent Educ 1985: 49: 611-615.

6. Johnson JD, Scheetz JP, Abbott LJ, Showfety KJ. Dental hygienists as instructors in periodontics. J Dent Educ 1987 51: 109-110.

Address: P. A. Heasman Restorative Dentistry The Dentuf School University of Newcastle upon Tynr NE2 4BW UK

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Undergraduate teaching of periodontology in UK dental schools