Undergraduate orthodontics in Belfast: 12 years on

Eur \ Dent Educ 1997; I: 133-137 Printed in Denmark. All rights resenled

Copvght 0 Munksgaard 1997

t l X , l P t l \ J U I . H \ A I ,I,

Dental Education ISSN 1396-5883

Undergraduate orthodontics in Belfast: 12 years on Andrew Richardson

Division of’ Orfhodontics, Sckool qf C h c n l Drrltistry, The Queen’s Unizvrsity of Belfast,Belfast, Northern Ireland, UK

The British and European Community recommendations for teaching orthodontics in the undergraduate curriculum from 1963 UP to the present day are reviewed. 12 years experience of the Course introduced in Belfast in 1984 is reviewed and some Of the difficulties are identified. Modifications in the course to meet these difficulties are described.

Key words: orthodontics - undergraduate course - official recommendations - problems and solutions.

0 Munksgaard, 7997 Accepted for publication 3 June 1997

F ALL THE DENTAL specialities, orthodontics fits 0 least happily within the framework of undergraduate education. It has normal growth and development (rather than pathology) as its basic science, it has discrete manipulative skills involving wire, screws, and elastic materials, it is practised largely on children, and most importantly, orthodontic treatment demands regular supervision of the patient over long periods of time.

Under the Dentists Act enacted by the British Government in 1957, the General Dental Council (GDC) was given responsibility for promoting high standards of professional education among dentists. In their ‘Recommendations concerning the dental curriculum’ published in 1963 (1) the GDC stated ‘The course should include lectures or demonstrations and clinical instruction in the prevention and treatment of malocclusion as carried out in general dental practice’.

Dental educators seemed to agree that undergraduate students must assimilate a knowledge of facial growth and the development of occlusion in order to practise dentistry on any child patient but orthodontic treatment ‘as carried out in general dental practice’ was another matter. Most orthodontic specialists were forthright in the view that orthodontic treatment was a postgraduate subject and that undergraduate students should be allowed to do no more than observe the complexities of mechanotherapy carried out by a properly trained specialist. The opposite opinion ex- pressed by general dental practitioners and their rep- resentatives was that regular attendance at a dental practice by patients was the best milieu for longitudi-

nal observation of the developing occlusion and that the knowledgeable generalist was strategically placed to implement interceptive measures or early treatment if required. Consensus does not and probably never will exist on the question of how much orthodontic treatment should be carried out by the general dental practitioner, but the reduction in dental caries, the consequent change in the pattern of general practice and the swing of public interest from dental comfort to dental aesthetics are potent factors in favour of general practice orthodontics.

In the past, undergraduate courses in orthodontics have been described as ”existing in isolation” by Behrents & Keim, (2) and by the British Orthodontic Standards Working Party (3) as leading to a poor awareness of orthodontics among British general practitioners. The significant report to the Nuffield Foundation (4) recommended that the undergraduate student should be able to recognise irregularities at the earliest possible stage and should be able to undertake simple treatment. The Report of the Dental Strategy Review Group, set up by the British Govern- ment and published in 1981 (S), stated ’There is a clear need for an improvement in education and training in orthodontics....’. These criticisms by individuals and committees were met by the GDC recommendation of May 1985 (6). ’In orthodontics, students should carry out the continuing care of a small number of patients requiring simple removable appliance treatment. Stu- dents should also receive instruction and demonstrations in the diagnosis and treatment of more complex problems, including those requiring fixed appliance therapy’. These recommendations were taken to

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satisfy article no. 1 of the second Dental Directive of the European Economic Community (7).

The GDC recommendations of 1987 were modified in May 1990 (8) in that the treatment carried out by undergraduate students need not specifically involve removable appliances and the more complex problems need not necessarily include fixed appliances. The spirit of these recommendations is reflected in the report of The Advisory Committee on the Training of Dental Practitioners set up by the European Com- mission (9) which states that undergraduate training should include ’Carrying out orthodontic corrections of minor occlusal problems’ and, in recognition of the orthodontic specialist, ’knowing when to refer patients with more complex problems’. The recent GDC document ’The First Five Years’ (10) also favours the specialist in the statement: ‘A major objective is that the student should be able to apply the principles of orthodontics in general practice and to recognise the limitations that exist in that situation’, while preserv- ing ’Students should carry out the continuing care of patients requiring simple appliance therapy’.

In anticipation of the 1985 GDC recommendation, a new undergraduate course in orthodontics was implemented in Belfast which some reviewers have re- garded as innovative (2) The distribution of student time is shown in Table 1. The key feature of the new course was the introduction of longitudinal dresserships with students moving round the specialities on a daily or sessional basis which fitted the longitudinal demands of orthodontic care. The impli- cation was that all other departments in the dental school would have to change to a longitudinal system as well. Due to the goodwill of colleagues in other departments, some of whom could see benefits in a longitudinal dressership for their own speciality, the decision to change to a longitudinal system was made, a rather complicated timetable of rotations worked out, and the new scheme implemented in 1984.

12 years later, the time may have come to review the new course and to highlight the difficulties for the benefit of others moving in the same direction.

TABLE 1 . Under,mdunte student contact hours

2nd Year 3rd year 4th Year 5th Year

lectures 14 0 16 0 tutorials 3 6 6 7 laboratory 33 30 0 0 clinical treatment 0 30 30 0 clinical diagnosis 0 0 30 0

Experiences with the new curriculum Our objective is to produce a graduate who can sup- ply an efficient yet empathetic service for his/her patients and who can take a balanced view of orthodontic treatment within the concept of total and holistic dental care. The graduate should have a clear concept of developing normal occlusion so that deviations from normal can be detected at an early stage. S/He should be aware of all treatment possibilities including a full range of fixed appliances and orthognathic surgery. S/He should be in a position to undertake interceptive treatment and most treatments with removable or functional appliances supported where necessary by Consultant advice. Students have their first exposure to orthodontics in the 2nd year of study, following courses in the basic sciences during the 1st year.

Second year The aim of the course in the 2nd year is to produce a student who has sufficient orthodontic knowledge and technical experience to start clinical practice at the beginning of 3rd year.

The course commences with 15 informal introduc- tory lectures at weekly intervals and 11 3-h sessions on laboratory techniques. Students are expected to make 12 removable appliances to a satisfactory standard. These appliances are assessed under an OSCE system by the students themselves as self-assessment, by the Professor and by the Technician who teaches the course. The marking is done in open forum with all members of the tutorial group present. This does not seem to embarrass the students and is seen as a rather jolly occasion. Although contrary to the prin- ciple of anonymous marking, the object in this forma- tive examination is to allow candidates to learn by their own shortcomings and by the mistakes of others. The marks are used as part of the 4th year clinical examination.

Since students will have their first experience of clinical work at the beginning of the 3rd year, they attend an orientation course of 3 hours duration which explains the working systems of the department, deportment and dental chair manipulation.

Third year The aim by the end of 3rd year is to have refreshed, extended and tested material given in 2nd year, and to have introduced students to personal clinical and laboratory practice. At the beginning of the third year of study’ students meet the patients for whom they will provide orthodontic treatment on a monthly basis

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up to the time of the 4th-year clinical examinations, Some 20 months in the future. Students attend monthly for clinical treatment and have a monthly laboratory session for appliance fabrication.

The requirement of 6 cases either completed or showing substantial improvement is comfortably ex- ceeded by almost all students. The wirework for appliances is made by the students, and it is an inviol- able rule that wirework must be handed in to the pro- duction laboratory at least 1 week before the patient’s next visit for processing of the baseplate. Effectively, therefore, students have 3 weeks to complete the wirework. Technical advice is available at all stages. Fears regarding the quality of appliances and of ensuring that appliances are ready on time have proved groundless due to the responsible attitude of students, close laboratory supervision, and discipline where required.

Each student treats at least one patient needing pro- clination of upper incisors, one class 11 division 1 case, one case of crowding to be treated by extraction of premolars or molars, and fits at least one functional appliance and one appliance from a miscellaneous category including arch expansion, space maintainers and habit deterrents. The academic deparhnent in Belfast is fortunate in that it is also the hospital refer- ral centre for the area of the Eastern Health and Social Services Board (pop. 639,000) which ensures sufficient patients for academic purposes. The aim is to have all initial appliances inserted within the first 3 months of the 3rd year and at this stage, the laboratory sessions are replaced by tutorials and sessions for the prepara- tion of essays. There is no formal classroom work in the 3rd year, but students receive tutorials which in- troduce X-ray cephalometry and supplement material covered in the formal lectures.

Early in the 3rd year, each student is given a list of essay subjects and must submit essays on 4 of these topics before the end of the academic year. Library work and literature searches are encouraged. All essays are marked by the Professor as part of the 4th year clinical examination.

In a recent survey, students complained that they received patients for whom a treatment plan had al- ready been formulated and that they would have lik- ed to have more lectures and tutorials during this year.

Fourth year After the end of the 4th year of study, students undertake elective periods together with attachments out- side the dental school which would disrupt the con- tinuous care of orthodontic patients. Accordingly, we

plan to have treatments completed before the end of the 4th year as far as possible. The aim during the 4th year is to have given students first-hand experience of orthodontic treatment, diagnosis, treatment planning and laboratory practice and to have refreshed, extended and tested material given in the 2nd and 3rd years. Apart from case presentations which have been introduced in the 5th year, the orthodontic course is completed by the end of the 4th year, and the objectives are virtually the same as the course as a whole.

During the 4th year, there is an advanced course of 12 lectures. Students continue to care for the patients they are treating, and attend sessions set aside for the diagnosis of new patients and for patients on review. Students are required to diagnose and plan treatment for at least 20 new patients. Students state that they would like to have more tutorials during the 4th year especially on treatment planning.

Fijth year Since 5th-year students are not constantly available, the treatment of patients is discontinued as far as the students are concerned at the end of 4th year and students have little contact with the orthodontic department during the 5th year. Exceptions are 7 sessions during which presentation of more complex cases, which invariably involve fixed appliances and often surgical procedures, are presented by members of staff. Emphasis is placed on the distinction between simple malocclusions which are amenable to intercep- tion or treatment with removable or functional appliances and the more challenging cases which should be referred to a specialist.

Exam inat ions Following the report to the Nuffield Foundation (4) section 5.34: “..,.too much emphasis has been laid on judging the performance of students in technical procedures under the artificial conditions of an examination setting”. Efforts have been made to remove the make or break cup-final atmosphere from examinations. Students complete a 4th-year clinical examination which comprises scores for the technique course in 2nd year, the essay scores in the 3rd year and, in the 4th year, presentation of a patient they have treated. For the 5th year clinical examination, students prepare a diagnosis and treatment plan for a patient they have selected in the 4th year, together with a viva voce examination in 5th year. Apart from the viva voce examination, none of these tests takes a student by surprise and they are greatly favoured by the students themselves. The examination structure is shown in Table 2.

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TABLE 2. Examination structure

4th year clinical examination 5th Year clinical examination Final examination

technique viva specialist written examination essays treated case presentation

diagnosidtreatment planning case presentation possible written, oral questions and case presentation as part of general examination

TABLE 3. Problems and solutions

Problem Solution

longitudinal nature of orthodontic treatment inadequate laboratory space new laboratory quality of appliances appliances ready on time patients for treatment with previously formulated treatment plan too many formal examinations students start treatment before having experience of diagnosis no sessions for appliance construction in 4th year

treatment changes with complex appliances too slow for

students unable to fulfil appointments on account of other

longitudinal dresserships

laboratory quality control responsible attitude of students discipline as required treatment plan revised and presented for discussion revised examination structure no solution no formal solution because the need for 2nd and 3rd appliances

demonstrations of patient records and slide material

appointments fulfilled by members of staff

unpredictable; students use unallocated time

demonstration purposes

commitments

Initially, students presented records of their best treatment in the final examination, but this has been discontinued on the grounds that it placed overemph- asis on orthodontics in the overall examination structure. In the current final examination, students sit a written paper of 3 h duration, shared with Paediatric Dentistry, and may present an orthodontic patient in the case presentation section. Questions with orthodontic relevance are frequently asked in the general viva voce examinations which are part of the final examinations.

Throughout the course, the numbers of patients treated, diagnosed and demonstrated to the students, are carefully noted and these data used as part of con- tinuous assessment scores.

Problems The problems arising in running the course and the solutions are listed in Table 3.

Discussion We have been unable to find an answer to the criticism that the course chronologically puts treatment before diagnosis and treatment planning. The confines of the undergraduate course and the longitudinal nature of orthodontic treatment are such that students must be introduced to the patients they are to treat at the earliest possible stage. Bearing in mind that students need the skills of appliance construction gained

in the 2nd year in order to treat patients, the beginning of the 3rd year is the earliest possible time to start treatment. Likewise, students and their patients can not reap the full benefit of a diagnostic procedure unless students have completed at least the introduc- tory course of lectures. Thus, the beginning of the 3rd year seems the earliest stage to begin diagnosis. Treat- ment and diagnosis could be commenced concur- rently in the 3rd year, but this would necessitate a sizeable increase in the 3rd-year timetable space given to orthodontics as against the conflicting demands of other specialities. Accordingly, clinical diagnosis is taught in the 4th year.

In the 4th year, there are no sessions set aside for appliance construction, because it is impossible to pre- dict when 2nd and 3rd appliances will be required for the patients under treatment. 4th-year students continue to make the wirework for these appliances and find time during uncommitted sessions and lunch hours for this purpose.

Another problem has been meeting the GDC recommendation that students should receive demonstrations of more complex malocclusions treated with fixed appliances. Initially, students attended monthly sessions to observe complex treatments, but this proved troublesome and unproductive. Some of the more junior members of staff complained that the presence of an audience was a distraction when they were busy and wished to concentrate on the treatment of the patient. Students found the placement of

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brackets and archwire changes unexciting after they had seen it done on several occasions and orthodontic treatment is too slow for students to gain an overview of treatment changes when taught this way. These clinical sessions have now been replaced by case presentations demonstrating complex treatment during the 5th year of the course.

Close clinical supervision is provided by all grades of staff with a student/staff ratio which never exceeds 61 and at best is 5:2. This commitment of staff to running the course is heavy and there is little room for manoeuvre in fulfilling other functions expected of academic staff and an academic department.

Occasionally, student holidays, conferences and courses which must be run on a block system, have clashed with the on-going commitment of students to their patients. Members of staff have to be accommo- dating in seeing patients when students have other commitments. The enthusiasm of students for the course has been a great encouragement and it is re- warding to see how many newly-qualified practitioners are recognising and treating malocclusions in practice.

The orthodontic capabilities of graduates fall far short of a fully trained orthodontist who has under- taken a postgraduate course of instruction, but graduates seem to achieve the stated objectives of the course. We believe that they are in a position to recognise developing malocclusions and are capable of providing reliable interceptive treatment and most treatments with removable, or functional appliances, supported where necessary by Consultant advice. It is, however, pertinent to question the standards achieved in the light of criticism levelled at the standard of treatment in the National Health Service of the UK (11). The quality of treatment provided by the students has been analysed using the IOTN and PAR indices and the results published (12). It was reassuring to find that when all indices were applied, the improvement rate was 80% and that there were valid reasons, such as failure of the patient to complete treatment or a planned 2nd

phase of treatment with fixed appliances, in the re- maining 20%.

References 1. The General Dental Council. Recommendations concerning

the dental curriculum General Dental Council, Wimpole St. London 1963.

2. Behrents RG, Keim RG. Education, research and personnel needs in orthodontics. Current Opinion in Dentistry 1991: 1: 652-656.

3. British Orthodontic Standards Working Party. Orthodontic aspects of vocational training. Br J Orthod 1986: 13: 165-173.

4. The Nuffield Foundation. An inquiry into dental education. The Nuffield Foundation, Regent’s Park, London NWl4RS. 1980.

5. Department of Health and Social Security. Towards better dental health - guidelines for the future. Report of The Den- tal Strategy Review Group. DHSS, London, 1981.

6. The General Dental Council. Recommendations concerning the dental curriculum. General Dental Council, Wimpole St. London, 1985.

7. European Economic Community. Dental Directives 78/687/ EEC. Br Dent J 1978 17 (suppl).

8. The General Dental Council. Recommendations concerning the dental curriculum. General Dental Council, Wimpole St, London, 1990.

9. European Commission. Report and recommendations concerning clinical proficiencies required for the practice of dentistry in the European Union. Report of The Advisory Com- mittee on the Training of Dental Practitioners, XV/E/8316/ 8/93. Brussels, 1993.

10. General Dental Council. The first five years. The undergraduate dental curriculum. General Dental Council, Wimpole St, London, 1997.

11. Richmond S. Shaw WC, Stephens CD, Webb WG, Roberts CT, Andrews M. Orthodontics in the general dental service of England and Wales: a critical assessment of standards. Br Dent J 1993: 174: 315-329.

12. Burden DJ, Richardson A. PAR for the course. Orthodontic Audit Working Party Newsletter. RCS England, 1992: 2: 3-4.

Address: Andrew Riclrardsorl Division of Ortliodontics school of Clinical Derrfistry a f the Royal Victoria Hnspifals

Belfast Northerti 1rt.larid BTl2 6BP UK

and Dental Hospital Trust

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Undergraduate orthodontics in Belfast: 12 years on