Orthodontic Postgraduate Education: a Global Perspective

Orthodontic Postgraduate Education: A Global Perspective

Theodore Eliades, DDS, MS, Dr Med Sci, PhD, FRSC, FIMMM, FRSM, FInstP Professor and Director Clinic of Orthodontics and Paediatric Dentistry Center of Dental Medicine Un iversit y of Zu rich Zu r ich , Sw it zerlan d Formerly Associate Professor, Department of Orthodontics, School of Dentistry, Aristotle University of Thessaloniki, Greece Editor-in-Chief, Journal of Dental Biomechanics Associate Editor, American Journal of Orthodontics and Dentofacial Orthopedics Associate Editor, European Journal of Orthodontics Associate Editor, Progress in Orthodontics

Athanasios E. Athanasiou, DDS, MSD, Dr Dent Acting Dean, Professor, and Program Director in Orthodontics Hamdan Bin Mohammed College of Dental Medicine Mohammed Bin Rashid University of Medicine and Health Sciences Un ited Arab Em irates Professor Department of Orthodontics, Faculty of Dentistry School of Health Sciences Aristotle University of Thessaloniki Th essalon iki, Greece Former Dean, School of Dentistry, Aristotle University of Thessaloniki Former Chair and Program Director, Department of Orthodontics, School of Dentistry, Aristotle University of Thessaloniki Past President, National Academic Recognition Information Center, Hellenic Ministry of Education Immediate Past President, World Federation of Orthodontists Past President, European Federation of Orthodontics Past President, Greek Orthodontic Society Honorary Editor, Hellenic Orthodontic Review

32 illustrations

Th iem e Stuttgart • New York • Delhi • Rio de Janeiro Librar y of Congress Cataloging-in -Publication Data Im port an t n ote: Medicine is an ever-changing science undergoing continual development. Research and clinical Orthodontic postgraduate education : a global experience are continually expanding our knowledge, in perspective / [edited by] Theodore Eliades, particular our knowledge of proper treatment and drug Athanasios E. Athanasiou. therapy. Insofar as this book mentions any dosage or p. ; cm . application, readers may rest assured that the authors, Includes bibliographical references. editors, and publishers have made every effort to ensure ISBN 978-3-13-200401-6 (alk. paper)—ISBN 978-3-13- that such references are in accordance with the state of 200411-5 (eISBN) kn owledge at th e tim e of production of th e book. I. Eliades, Theodore, editor. II. Athanasiou, Athanasios Nevertheless, this does not involve, imply, or express E., editor. any guarantee or responsibility on the part of the publis- [DNLM: 1. Orthodontics—education. 2. Education, hers in respect to any dosage instructions and forms of Dental, Graduate. 3. Internationality. W U 18] applications stated in the book. Every user is requested RK78.5 to examine carefully the manufacturers’ lea ets accom- 617.6′430071—dc23 panying each drug and to check, if necessary in consul- 2015018457 tation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at w w w.thiem e.com on the product description page. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though speci c reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public dom ain.

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Forew or d ...... vi Preface ...... viii Co n t r ib u t o r s ...... x 1 Historical Aspects of Postgraduate Orth odon tic Curricu lu m Form u lation : Preceptorsh ips an d Sch ool Curricu la ...... 1 Jam es L. Vaden and Jackie Hittner 2 Con tem porar y Orth odon tic Postgraduate Program s as Related to th e Rest of Den tal Specialt y Advan ced Edu cation ...... 9 Henry W. Fields 3 Con tem porar y Orth odon tic Postgraduate Edu cation as Related to Un dergraduate Orth odon tic Program s ...... 17 Pertti Pirttiniem i 4 Orth odon tic Specialt y Edu cation in Eu rope ...... 23 Stavros Kiliaridis and Anne-Marie Kuijpers-Jagtm an 5 Specialt y Level Edu cation in Orth odon tics in th e Un ited Kingdom ...... 34 Susan J. Cunningham 6 Postgradu ate Orth odon tic Edu cation in th e Un ited States ...... 42 Peter Ngan and Christina DeBiase 7 Orth odon tic Specialt y Edu cation in Can ada ...... 52 W illiam A. W iltshire 8 Orth odon tic Specialt y Edu cation in Latin Am erica ...... 59 Julia F. de Har n 9 Orth odon tic Specialt y Edu cation in East an d South east Asia, w ith a Particular Focu s on Ch in a ...... 66 Jiu-Xiang Lin, Yan-Heng Zhou, Tian-Min Xu, and Xue-Dong Wang 10 Orth odon tic Specialt y Edu cation in Ocean ia ...... 73 Alexandra K. Papadopoulou, Oyku Dalci, and M. Ali Darendeliler 11 Orth odon tic Specialt y Edu cation in th e Middle East an d Africa ...... 83 Abbas R. Zaher and Hassan Kassem 12 Orth odon tic Specialt y Edu cation in th e In dian Subcon tin en t...... 88 Om P. Kharbanda 13 Th e Education al Role of Orth odon tic Boards arou n d th e World ...... 112 Mauro Cozzani and Frank Weiland 14 Stru cture an d Organ ization of Den tal Specialt y Edu cation in th e Un ited Kingdom ...... 117 Fraser McDonald, G. How ard Moody, and Dirk Bister 15 International Guidelines of the Erasmus Project and the World Federation of Orthodontists ...... 125 Athanasios E. Athanasiou and Theodore Eliades 16 Th e Role of New Tech n ologies in Orth odon tic Specialt y Edu cation ...... 128 Shazia Naser-Ud-Din 17 Th e Role of Con tin u ou s Profession al Developm en t in Orth odon tic Edu cation ...... 144 Athanasios E. Athanasiou 18 Th e Role of Scien ti c Journ als in Orth odon tic Specialt y Edu cation ...... 147 David L. Turpin 19 Th e Role of Research in Orth odon tic Specialt y Edu cation ...... 162 Kee-Joon Lee and Young-Chel Park 20 Advan ced Orth odon tic Edu cation : Evolu tion of Assessm en t Criteria an d Meth ods to Meet Futu re Ch allenges ...... 182 Theodore Eliades and Athanasios E. Athanasiou Ap p e n d ix ...... 191 In dex ...... 219

v Foreword: Consideration on Wishes and Reality

The dental profession was developed to solve problems in the literature. However, the biggest impact of this related to teeth. These had earlier been taken care of by development is seen in the marketing of appliances on the blacksmith, the barber, or the village doctor. From the Internet. The patients are promised “short invisible general dentistry several specialties have been defined, treatment,” the general dentists “easy gains in income” orthodontics and oral surgery being among the first. The w ith th ese ap p lian ces, an d th e specialist s “less ch air t im e reason was clearly that with the development of the pro- – more income.” Quality and long-term results are, on fession, the teaching within basic dental education was the other hand, rarely mentioned. The dominance of the considered inadequate with respect to these disciplines. product-related aspect of orthodontics is also expressed The performance of an orthodontic treatment required in the reduced interest in teaching and research, as the more knowledge and manual training than general den- academic positions render less than half the incom e of a tal training could include. The present book provides the private well-functioning clinic. reader with all aspects of graduate training within ortho- Th e develop m ent of materials facilitating orthodon- dontics, including guidelines for continuous education; t ics h as resu lted in several con sequ en ces: (1) “Ap plian ce- in other words, an updated version of the state of the art market driven orthodontics” has to a large degree erased of orthodontic education in 2015. the need for wire bending and producing of custom- The first schools of orthodontics were opened in St. made appliances; (2) the prefabricated appliances can be Louis, Missouri, m ore than 100 years ago; 20 years la- acquired by anyone; and (3) the fascination of being in ter a considerable number of dental schools had started the academic environment has become less attractive: a structured graduate program in orthodontics. On the less salary and minor impact on the clinical reality, hence other hand, it was not unt il 1961 that the m inimum edu- a lack of dedicated academ ic staff. cational requirements for the specialty were formulated Th e p r e s e n t b o o k e xp r e ss e s n ot o n ly t h e r e a lit y, b u t t o in the United States. Meanwhile, dentists in other parts an even larger degree the dream. The authors are explai- of the world started developing graduate programs and ning the rules, but also adm itting a concern regarding the defining necessary rules for recognition of a specialist increasing invasion of non-specialists into our reserve. In title. In Europe, the Erasmus project guidelines were spite of this development the importance of a profound pub licized in 1992 and an update was published in 2014. basic and continuing education cannot be overestimated, Although many countries have proclaimed that they but even the surveys of the profession are classifying the fulfill the requirements stated in the Erasmus program, orthodontist according to technique. Treatment should diversity is still considerable and an unbiased uniform be goal-oriented and patient-focused and not bound to a validation is generally missing. Recognizing the diversity, specific technique. Graduate education should therefore t h e Eu rop ean Fed erat ion of Or t h od on t ic Sp e cialist s (EFO- include training and practice within several treatment SA) has suggested standardization of the exam s. approaches and the treatment plan should be based on a The orthodontic specialty comprised a theoretical solid knowledge of both biology and biomechanics. The and a practical part, of which wire bending was an im- focus on income and outsourc ing evaluated by question- portant component. With the introduction of the straight naires used to evaluate the professionals by income and w ire philosophy based on prescription brackets and pre- technique is reflecting how deeply the specialty, which form ed wires, the need for bending has, according to the was developed on the premises that appliances were

companies, becom e superfluous.1,2,3 This also applied produced to generate a specific tooth movement, is being when aligners, another alternative to wire bending, was replaced by “fast food orthodontics.” Levelling of the up- presented. The possibility of outsourcing changed the ap- per “social six” may satisfy the patient imm ediately, but pliances used to generate tooth displacement from being could have a detrim ental influence on the long-term de- “force-driven” to being “appliance-driven.” The prescrip- velopm ent of the dentition. tion brackets can be bonded indirectly and standard or The specialist’s training requires, according to the custom-made wires can be delivered. Consequently, all authors of this book, continuous upgrading. As the or- dentists had to do was to insert the prescribed sequence thodontic clientele is changing from an almost entirely of the wires; this may also be done by non-orthodontists. young growing population to adult patients, who to a The fact that these appliances can be purchased by any large degree require orthodontics as part of rehabili- dentist, even non-dentists, has changed the profession tation, the orthodontist should possess knowledge on from a scientifically based to a market-driven profes- biology, including the aging processes and the influence sion. The increasing importance of making treatment of general diseases on the periodontium and the bone. faster and with reduced chair time is clearly reflected Tr e a t m ent of the aging population has to be individua- vi Foreword vii lized and the standard appliances will rarely deliver a one technique. We cannot claim that orthodontics is only maintainable result. Teamwork with other specialties as for specialists but the differential diagnosis should be re- well as interdisciplinary treatment in relation to other spected also by the non-specialist who should be able to disciplines performed by gnathologists, surgeons, im- recognize, as we all should, our limitations. The present plantologists, and prosthodontists, are necessary. Indivi- book outlines the state of the art of the education and dual treatment plans have to be agreed upon and “fast the possibilities and wishes around the world, but the orthodontics” is rarely a valid option. Interaction with attitude toward the patient is of the utmost importance other specialties is crucial and as one of the authors, an d th e m an ufact urers’ progress sh ould be ben eficial not Professor Fields, explains in Chapter 2, overlapping w ith only for the orthodontist but also for the patient. neighboring specialties will increase. One question rem ains. What can the profession do to Birte Melsen, DDS, Dr Odont remain a research-based specialty? First: A good educa- Professor tion is surely one component. Second: Dedication of col- Aarhus University, Denmark leagues to support a continuous development, not only Past President, European Orthodontic Society with donation of money but also with time. What makes you happier, an increase in income or the satisfaction References gained when a really difficult problem is solved? Third: To generate a campaign informing the population of the 1. Andrews LF. The straight-wire appliance. Explained difference between “fast food appliance-driven ortho- and compared. J Clin Orthod 1976;10:174-95. dontics” and patient-oriented goal-driven orthodontics. 2.Andrews LF. The straight-wire appliance, origin, con- There should be a difference. Whereas a large number of troversy, commentary. J Clin Orthod 1976;10:99-114. minor problems can be solved by non-specialists by pre- 3. Engel GA. Preform ed arch w ires: reliability of fit. Am J fabricated appliances, the specialist should m aster all of Orthod 1979;76:497-504. the different treatment approaches and not be limited by

Preface

Postgraduate orthodontic education has thrived from its review a large set of independent materials to retrieve initial development by means of preceptorship programs responses to queries. The void on a concise, updated, in the early 1900s to the 21st century’s organized m ulti- and thorough source of postgraduate orthodontic pro- perspective training curricula, which blend both clinical gram structures around the globe calls for a book, w hich and basic sciences. The evolution curve of postgraduate would: programs after the definition of objectives of orthodon- 1.serve as a reference source of the variation of ortho- tic specialty education demonstrates a remarkable pat- dontic education worldwide, presenting the individu- tern, characterized by alternating peaks of activity fol- al characteristics of various program curricula; lowed by quiescent periods of stationary grow th. 2.include the updated international, regional, or nation- In it ially, th e p rogress w as based on th e in t rodu ct ion of al guidelines on recognition or accreditation criteria novel appliances and treatment methods, and the science of health authorities, professional organizations, and part of curricula was limited to fundamentals of osteolo- scientific societies; gy and medical subjects such as anatomy. However, with 3.list all major objectives for postgraduate orthodontic the introduction of the biological basis of orthodontics education and orthodontic specialty recognition; and and the emphasis on the mechanisms of growth and de- 4. feature a self-assessment guide for internal accredita- velopment, this model was altered. As a result, organized tion based on previous published work. courses on various subjects extending from molecular biology to genetics have been included in the curricula The title of the book was selected with dental stu- of many programs. This swift change in the structure of dents or dentists seeking postgraduate education in education was accompanied by the introduction of sem i- orthodontics primarily in mind. Currently, there are nars on epidem iology, statist ics, m echanics, and m aterials hundreds of programs available in the English lan guage science initially in the orthodontic and at a later stage in in Europe, North America, Asia, the Middle East, and organized graduate core course curricula. Depending on Oceania. Many postgraduate programs in non-English the direction and areas of interest of academic faculty, speaking countries seek to promote their profile in the the level of involvem ent of postgraduate students varies prospective postgraduate student market while at the from a superficial knowledge to cover the basics up to the same time offering programs in the English language. competence level of performing independent research on This wealth of inform ation is now, w ith this publication, the subject, which often found its way to print in highly available to this group of colleagues who are interested in ranked biomedical periodicals. Consequently, the struc- pursuing specialty education in orthodontics, as well as ture, with emphasis on research and academic curricula to orthodontic specialists, m ainly academ ics, research- as well as orthodontic clinical training, shows a high vari- ers, and clinical faculty, who are interested in acquiring abilit y am ong program s even in the sam e country; suffice knowledge on the subject and familiarizing themselves it to mention that this variation may reach substantial le- with the current state of orthodontic advanced educa- vels w hen different countries are considered. tion worldwide. The foregoing differences may be worth reviewing With regard to the latter group of potential readers, from many perspectives including that of (1) a dental the book also relates advanced orthodontic education student or dentist but prospective postgraduate ortho- with the rest of dental specialty programs, as well as dontic program applicant, (2) orthodontic faculty inquir- undergraduate orthodontic curricula, and addresses the ing on the structure and function of programs in other relevant educational roles of new technologies, conti- countries, and (3) organizations seeking an overview of nuous professional development, scientific journals, and the status of postgraduate orthodontic education. research. Resources providing facts about the educational Finally, academics, organizations, societies, and systems and structures, and organizational aspects of groups functioning in the wider field of organized den- orthodontic specialty/board/fellowship exam inations, tistry would also find in this text a valuable reference are st r ikingly lacking. Th erefore, profession als in th e aca - guide on the topic. demia or candidates seeking information on the differ- The contents of such a publication could not be all- ent trends and policies followed around the globe must inclusive with regard to the presentation of existing

viii Preface ix high-level advanced orthodontic programs in the various ever, the authorship of all high-merit chapters by the countries around the w orld. However, the editors believe prominent and internationally recognized experts de- that the regions, countries, organizations, and institu- serves the expression of deep gratitude and sincere tions presented by the extremely qualified and promi- appreciation by the editors. nent contributors of the various chapters surely provide a very representative global perspective. Theodore Eliades, DDS, MS, Dr Med Sci, It should be kindly acknowledged that the trust and PhD, FRSC, FIMMM, FRSM, FInstP commitment to the aims of this publication by Thieme Athanasios E. Athanasiou, DDS, MSD, Dr Dent made possible the materialization of this project. How-

Contributors

At h an asios E. Ath an asiou , DDS, MSD, Dr Den t Director of Education , British Orthodontic Societ y Acting Dean, Professor, and Program Director in Honorary Secretary, European Orthodontic Society Orthodontics Form er Chair of the Specialt y Advisor y Com m it tee for Hamdan Bin Mohammed College of Dental Medicine Orthodontics in United Kingdom Moham m ed Bin Rashid Universit y of Medicine and Health Sciences Oyk u Dalci, DDS, Ph D United Arab Emirates Senior Lecturer, Discipline of Orthodontics Professor, Departm ent of Orthodontics, Facult y of Dent istr y Universit y of Sydney, Facult y of Dentistr y School of Health Sciences, Aristotle Universit y of Sydney, Australia Thessalon iki Thessaloniki, Greece M. Ali Dar en deliler, DDS, Ph D, Dip. Or t h ., Cer t if. Form er Dean, School of Dentistr y, Aristotle Un iversit y Or t h ., DDSc, PD, FICD, MRACDA (Or th) of Thessaloniki Professor and Chair, Head of Departm ent, Discipline of Form er Chair and Program Director, Departm ent Orthodontics of Orthodontics, School of Dentistr y, Aristotle Facult y of Dentistr y, Universit y of Sydney University of Thessaloniki Sydney, Australia Past President, National Academ ic Recogn ition Inform ation Center, Hellen ic Min istr y of Education Ch r ist in a B. DeBiase, MA, EdD Im m ediate Past President, World Federation of Professor and Associate Dean for Academ ic and Orthodontists Postdoctoral Affairs Past President, European Federation of Orthodontics School of Dentistry, West Virgin ia Universit y Past President, Greek Orthodontic Societ y Morgantow n, West Virgin ia, United States Honorary Editor, Hellenic Orthodontic Review Th eodore Eliades, DDS, MS, Dr Med Sci, Ph D, FRSC, Dirk Bister, MA, FDS (RCSEdin), FDSOr th , MOr t h FIMMM, FRSM, FIn stP (RCSEdin), MSc, Dr. m ed . den t ., Dr. m ed ., FHEA Professor and Director, Clin ic of Orthodontics and Consultant in Orthodontics Paediatric Dentistry Guy’s and St. Thom as’ Foundation Trust Center of Dental Medicine, Universit y of Zurich

London, United Kingdom Zurich, Switzerland Form erly Associate Professor, Departm ent of Mau ro Cozzan i, DMD, CAGS, MScD Orthodontics, School of Dentistry, Aristotle Professor of Orthodontics and Gnathology University of Thessaloniki, Greece Un iversit y of Cagliari, School of Dental Medicine Editor-in-Chief, Journal of Dental Biom echanics Cagliari, Italy Associate Editor, Am erican Journal of Orthodontics Diplom ate, Am erican Board of Orthodontics and Dentofacial Orthopedics Mem ber, European Board of Orthodontists Associate Editor, European Journal of Orthodontics President, European Board of Orthodontists Associate Editor, Progress in Orthodontics President, International Scientific Com m it tee UOC Odontoiatria Hen r y W. Fields, DDS, MS, MSD “Istituto Giannina Gaslini” and “Galliera Hospital,” Professor and Vig/William s Endow ed Division Chair in Genoa, Italy Orthodontics Past President, Italian Association of Specialists in Ohio State University, College of Dentistry Orthodontics Chief, Section of Orthodontics, Department of Dentistry Past President, Italian Academ y of Orthodontics Nationwide Children’s Hospital Past President, Italian Board of Orthodontics Colum bus, Ohio, Un ited States Form er Dean , Oh io State Universit y, College of Dentistr y Su san J. Cu n n in gh am , Ph D, BCh D, FDSRCS(Or t h), MSc, Form er Vice Chair of the Com m ission on Dental MOrthRCS, FHEA Accr e d it a t ion Professor/Honorary Consultant in Orthodontics Form er Chair of the Council on Governm ent Affairs, Program m e Director MClin Dent in Orthodontics American Dental Association Un iversit y College London, Eastm an Dental Instit ute London, United Kingdom x Contributors xi

Ju lia F. de Har fin , Ph D Mem ber of the Council of the Net w ork of Erasm us Professor and Chair, Orthodontic Departm ent Based European Orthodontic Programs Maimonides University Councillor of the World Federation of Orthodontists Buenos Aires, Argentina Editor-in-Chief, Orthodontics and Craniofacial Research Past President, Argentine Societ y of Orthodontists Form er Chair, Departm ent of Orthodontics and Past President , Lat in Am erican Associat ion of Ort hodont ists Craniofacial Biology, Radboud University Medical Form er Mem ber of the World Federation of Center Orthodontists Executive Committee Form er Head, Cleft Palate Craniofacial Centre Radboud University Medical Center Jackie Hit t n er, MA, MBA Past President, European Orthodontic Societ y Library Ser vices Manager, Charles R. Baker Mem orial Past President, Dutch Association for the Study of Lib r a r y Orthodontics American Association of Orthodontists Past President , Dutch Cleft Palate Craniofacial Associat ion St. Louis, Missouri, Un ited States Past Chair, Central Board for Dental Specialists in the Im m ediate Past President, Midcontinental Chapter of Netherlands the Medical Librar y Association Past President, St. Louis Medical Librarians Kee-Joon Lee, DDS, MS, Ph D Professor, Department of Orthodontics Hassan Kassem, BDS, MSc Yonsei Universit y, College of Dentistr y Assistant Lecturer, Department of Orthodontics Seou l, Sout h Korea Alexandria University Secretary, Korean Association of Cleft Lip and Palate Alexandria, Egypt Editor-in-Chief, Journal of Korean Dental Science

Om P. Kh arban da, BDS, MDS, MOr th RCS Edin , MMed , Jiu -Xian g Lin , DDS, MS, Ph D FDS RCS Edin Hon , FAMS Professor, Department of Orthodontics Professor and Head, Department of Orthodontics and Peking Universit y, School and Hospital of Stom atology Dentofacial Deformities Beijing, China Centre for Dental Education and Research, All India Past Vice-President, Peking Universit y Institute of Medical Sciences Past President, Ch inese Orthodontic Societ y New Delhi, India Fellow Indian Board of Orthodontics, Hon Causa Fraser McDon ald, BDS, MSc, MA, Ph D, MOr th , FDSRCS

President Elect, Indian Societ y for Dental Research/ (Edin bu r gh & En glan d), CSci, CBiol, FSB International Association of Dental Research India Head, Department of Orthodontics Division King’s College London Dental Institute Consultant Editor, Journal of Indian Orthodontic Society London, United Kingdom Past Chief Editor, Journal of Indian Orthodontic Societ y Exam ination Lead, Facult y of Dental Surger y Past President, Indian Orthodontic Society Royal College of Surgeons of Edinburgh Past President, Indian Cleft Lip Palate and Craniofacial Edinburgh, United Kingdom Association G. How ard Moody, BDS, FDSRCSEd, Ph D, FRC Pat h , St avros Kiliar idis, DDS, Odon t Dr/Ph D DFM, FRCSEd (adh om in em) Professor and Chairm an , Departm ent of Orthodontics Faculty Adviser University of Geneva Bahrain Postgraduate Dental College Geneva, Switzerland Adilya, Bahrain Form er Professor and Chairm an, Departm ent of Consultant Oral Pathologist (retired) and Forensic Orthodontics, Universit y of Athens, Greece Odontologist to the Crown Office, Scotland Mem ber of the Council of the Net w ork of Erasm us Former Vice-Dean, Secretary, Examination Convener, Based European Orthodontic Program s Chair of SAB in GDS and Mem ber of Council, Royal College of Surgeons of Edinburgh An n e Mar ie Ku ijpers-Jagt m an , DDS, Ph D, FDSRCSEn g Professor Em eritus of Orthodontics, Departm ent of Sh azia Naser-Ud-Din , Ph D, MSc, BDS, CFD, DPHDen t , Orthodontics and Craniofacial Biology FICCDE, DCPSP-HPE, MOr th RCSEdin Radboud University Medical Center Assistant Professor of Orthodontics Nijmegen, The Netherlands Ham dan Bin Moham m ed College of Dental Medicine Deputy Professor Moham m ed Bin Rash id Universit y of Medicine and Universitas Indonesia, Faculty of Dentistry Health Sciences Jakarta, Indonesia Dubai, Un ited Arab Em irates xii Contributors

Form er Discipline Lead Orthodontics, School of Xu e-Don g Wan g, SMD, Ph D Dentistry, University of Queensland, Australia, Orthodontic Specialist and Research Assistant, Brisbane, Queensland, Australia Department of Orthodontics Peking Universit y, School and Hospital of Stom atology Peter Ngan , DMD Beijin g, Ch in a Professor and Chair, Departm ent of Orthodontics School of Dentistr y, West Virginia Universit y Fran k Weilan d, DMD, Ph D Morgantow n, West Virginia, Un ited States Associate Professor, Departm ent of Orthodontics Medical Universit y of Vienna Alexan d ra K. Papadop ou lou , DDS, MSc, Dip. Or t h , Ph D Vienna, Austria Sen ior Lect urer, Discipline of Orthodontics Im m ediate Past President, European Board of Facult y of Dentistry, Un iversit y of Sydney Orthodontists Sydney, Australia William A. Wilt sh ire, BCh D, BCh D(Hon s), MDen t , You n g Ch el Park, DDS, Ph D MCh D(Orth), DSc, FACD, FRCD(C) Professor Emeritus of Orthodontics Professor and Head, Departm ent of Preventive Dental Yonsei University, College of Dentistry Science Seoul, South Korea Professor, Head and Program Director, Division of Form er Dean, Yonsei Un iversit y, College of Dentistry Orthodontics Former President, Korean Association of Orthodontists Universit y of Manitoba, College of Dentistr y Form er President, World Im plant Orthodontic Winnipeg, Manitoba, Canada Association Former Professor and Head, Department of Orthodontics Universit y of Pretoria, Facult y of Dentistr y Per t t i Pir t t in iem i, DDS, Ph D, Dr Or th od Johannesburg, Republic of South Africa Professor and Chair, Departm ent of Oral Developm ent Chair, Canadian Council of Graduate Orthodontic and Orthodontics Program Directors Dean, Division of Oral Health Research Chair, Council on Orthodontic Education of the Medical Facult y, Universit y of Oulu American Association of Orthodontists Chief Dentist President, Societ y of Orthodontic Educators of the Medical Research Center, Universit y Hospital of Oulu American Association of Orthodontists Oulu, Finland

Mem ber of the Council of the Net w ork of Erasm us Tian Min Xu , DDS, Ph D Based European Orthodontic Programs Professor, Department of Orthodontics Former Dean, Institute of Dentistry, University of Oulu Peking Universit y, School and Hospital of Stom atology Past President, Orthodontic Section of Finn ish Dental Beijin g, Ch in a Societ y Vice Secretary General, Chinese Stomatological Association David L Tur pin , DDS, MSD Past President, Chinese Orthodontic Society Moore/Riedel Professor, Department of Orthodontics University of Washington, School of Dentistry Abbas R. Zah er, BDS, MS, Ph D Seattle, Washington, United States Professor and Chairm an , Departm ent of Orthodontics Editor Em erit us, Am erican Journal of Orthodontics and Facult y of Dentistr y, Alexandria Universit y Dentofacial Orthopedics Alexandria, Egypt Past Editor, Angle Orthodontist Form er Vice-Dean, Facult y of Dentistr y, Alexandria Member, World Federation of Orthodontists Executive University, Alexandria, Egypt Com m it t e e President, Egyptian Orthodontic Society Im m ediate Past Vice-President, World Federation of Jam es L. Vaden , BA, DDS, MS Orthodontists Professor and Form er Chairm an , Departm ent of Orthodontics Yan -Hen g Zh ou , DDS, Ph D University of Tennessee Health Science Center Professor and Chairm an , Departm ent of Orthodontics Memphis, Tennessee, United States Peking Universit y, School and Hospital of Stom atology Beijin g, Ch in a President, Chinese Orthodontic Society Historical Aspects of 1 Postgraduate Orthodontic Curriculum Formulation: Preceptorships and School Cu rric u la

James L. Vaden and Jackie Hittner

Formal dental education began in America and was the rst to recognize that success- in 1839. The Baltimore College of Dental ful orthodontia lies in retention. He advo- Surgery was established, the rst periodi- cated a broader education for dentists.4 cal devoted to dentistry w as published, and The rst textbook on orthodontia the American Society of Dental Surgeons appeared in 1889, when Simeon H. Guil- was organized—all in 1839.1 ford,5 at the request of the National Asso- Chapin A. Harris lectured on irregu- ciation of Dental Faculties, w rote a book for larities of the teeth at the Baltimore Col- the student, not for the practitioner. Guil- lege of Dental Surgery, but it was not until ford was at the time teaching orthodontia after 1857 that orthodontia was taught as a to students of the Philadelphia Dental Col- special subject at the college.2 Henry Bliss lege. The course at Philadelphia Dental Col- Noble, an 1857 graduate of the Baltimore lege was entirely didactic and included no

College of Dental Surgery, although a gen- clinical work. eral practitioner of dentistry, in some small As the dental colleges continued their measure made a specialty of correcting interest in orthodontia, more men became irregularities of the teeth, and he became interested in the eld, and more papers a special lecturer on the subject at the col- on the regulation of the teeth appeared lege and also in the dental department of in the literature. In 1888, Eugene S. Talbot Colum bia University.3 published a book entitled Irregularities The orthodontia that was to become of the Teeth and Their Treatment,6 which a specialty did not emerge until Norman went through several editions and became Kingsley, known as the father of orthodon- a standard textbook. Talbot dwelt on the tia, began in 1858 to publish occasional causes of malocclusion and went so far as papers on regulating the teeth. As early as to say that, without knowledge of etiology, 1872, he lectured to students on the causes no one could successfully correct deformi- and correction of m alocclusion, stressing ties of the jaws. the functional as well as the aesthetic value In 1886, Edward Hartley Angle read a of orthodontic treatment. His greatest con- paper, “Irregularities of the Teeth,” before tribution to the advancement of orthodon- the Minneapolis Dental Society.1 In 1888, tia as a science was that he gathered up all he read another paper, “The Angle System the loose ends of orthodontia and placed of Regulating Teeth,” before the Ninth Inter- them on a rmer basis. Kingsley made national Medical Congress. In the same year, extensive use of vulcanite plates as retain- the rst edition of his book, Malocclusion of ers. He stressed the importance of ne the Teeth, was published.4 The book went models, claiming rightly that they carry through seven editions; the last one pub- more conviction than any amount of talk, lished in English appeared in 1907.7 1 2 Orthodontic Postgraduate Education: A Global Perspective

An gle w en t to t h e Nat ion al Den t al Asso- students. Lectures were given during the ciation meeting at Niagara Falls in 1899. At senior year, but little of a technical nature that meeting, he succeeded in getting four was taught. In some schools, simple cases young men to spend three weeks with him were treated in the clinic. For the most part, in his o ce in St. Louis. There, he was able the courses were inadequate, and the stu- to divorce himself from the handicaps of dents still looked upon them as a necessary the dental colleges and to surround him- evil. Progress was m ade, but it was slow.8 self with young men who were willing to In 1922, New York University and study orthodontia in the broad and thor- Columbia University, both in New York City, ough manner that he had outlined for began teaching graduate orthodontics—at them. This was the humble beginning of Columbia under the leadership of Leuman the Angle School of Orthodontia.4 It was M. Waugh (1877–1972), who was also a the rst postgraduate school to be estab- founder of the dental school itself. A self- lished. From that tim e, Dr. Angle conducted taught orthodontist from Canada, Waugh a school every year until 1911. As a result, had an illustrious career in teaching and there were, in 1911, approximately 150 dental politics. He headed the orthodontic men devoting their time to the practice of department from 1917 to 1945. He helped orthodontia. found the International Association of Den- Each year, Dr. Angle added to his course tal Research (1920), of which he was later such subjects as he thought important to the president. As president of the American students of orthodontia. He was aided by Society of Orthodontists (1935), he was his close friend, Edmund Wuerpel, an art- instrumental in organizing the association ist and teacher of renown. Former students into constituent societies.9 w ho showed special abilities were added to Three more schools opened in 1923. his sta . Within a few years, he was receiv- Each was associated with an important ing more applicants for his course than he person in orthodontic history. A. LeRoy w as able to accept . So great w as th e in terest Johnson (1881–1967; Angle School, 1909) in orthodontia that in 1911, he had received wrote “Basic Principles of Orthodontics,” more than 300 applications for his course which was considered one of the best expo- and could accept only 23 of them . Ill health sitions of orthodontic biology of its time. It caused him to discontinue his courses in uenced schools to limit undergraduate after 1911. However, when he regained his education to the fundamentals of occlu- health, he again started to teach. He m oved sion, diagnosis, etiology, and classi cation. to Pasadena, California, and restarted the Many schools closed their orthodontic clin- Angle College of Orthodontia.1 ics. Also as a result of this article, Johnson After the success of the Angle School, was asked to open one of the rst master’s several other postgraduate schools of orth- program s in orthodontics, at the Universit y odontia were established. The Interna- of Michigan, where he was appointed pro- tional School of Orthodontia was founded fessor of orthodontics. As such, he became in Kansas City, Missouri, and in 1912, Mar- the rst full-time orthodontic teacher.10 tin Dewey, an early student of Dr. Angle’s, John V. Mershon (1867–1953; Angle started the Dewey School of Orthodontia School, 1908) was head of orthodontics at in St. Louis, Missouri. Both of these schools the University of Pennsylvania from 1916 to more or less followed the pattern of the 1925. When he took over the newly formed Angle School. graduate department, he tried to present Beginning about 1907, the in uence of orthodontics from the biological rather than the many men who had attended the post- the mechanical viewpoint. His extensive graduate schools began to be felt in the 50 teaching, including at the Dewey School, or more dental schools in the country. One was done gratuitously. His study of the by one, they added men trained in orth- relapse phenomenon led to his memorable odontia to their faculties, and full courses quote, “You can move teeth to where you in orthodontia were o ered to the dental think they belong; nature will place them 1 Historical Aspects of Postgraduate Orthodontic Curriculum Formulation 3 where they will best adapt themselves to to Angle in in uencing the development of the rest of the organism.”11 The third school, orthodontics on the West Coast.15 Northwestern University, opened its gradu- However, Spencer R. Atkinson (1886– ate department under Charles R. Baker 1970; Angle School, 1920) was chosen to (1880–1970), an orthodontist in Evanston, head the new department. Orthodontist, Illinois, who also gained recognition as a teacher, inventor, innovator, anatomist, and writer, historian, editor, and librarian. His skilled photographer, Atkinson was origi- library became the nucleus of the American nally a children’s dentist. After studying Association of Orthodontists’ library that anatomy and anthropology, he was invited now bears his name.12 to teach anatomy at the Angle School in The impetus to establish a graduate Pasadena, where he became a student and department in the College of Dentistry at then superintendent. Atkinson’s interest in the University of Illinois campus in Chicago the growth and development of the head came from Frederick B. Noyes (1872–1961; led to a collection of some 1,400 skulls, Angle School, 1908). In 1929, as dean of the which are now housed at the University dental college, Noyes sought to establish of the Paci c School of Dentistry. He origi- a department that would carry on Angle’s nated the term key ridge.16 ideals. The Angle College had closed two The American Association of Ortho- years earlier, and the profession’s leaders— dontists was founded in 1900 by a small concerned about the future of orthodon- group of ve dedicated men. By 1953, it tics—were asking, “How can we keep the had grown to nearly 1,400 members. The study of our specialty out of the hands of parent association was divided into eight the mechanistic ‘diploma mills’”?13 constituent societies with names indicative The answer, as far as Noyes was con- of their geographic areas. Membership in cerned, was to place the department under the association was by election at the con- the leadership of Allan G. Brodie (1897– stituent society level, and each society set 1976; Angle College, 1927), one of Angle’s its own requirem ents and quali cations. last graduates and one of his favorites As a consequence, American Association of (An gle a n d close fr ie n d s calle d h im “St eve ”). Orthodontists membership varied consid- Brodie had been out of school only two erably throughout the entire organization. years, but his writing and speaking abili- It included those who had received graduate ties and his grasp of the edgewise appli- or postgraduate training at the university ance had catapulted him to the position of level and others whose training consisted spokesman for the “new mechanism” and of instruction in proprietary schools or in placed him at the forefront of orthodontic short-term preceptorships. There was also education.14 the “self-trained” orthodontist and occa- The rst graduate orthodontic pro- sionally the one whose only evidence of gram on the West Coast began in 1934 competence was his statement that he was at the University of Southern California an orthodontist. If pressed, he would pro- School of Dentistry, the only dental school duce his professional card or letterhead as in southern California at the time. Since “proof” of his status.17 1910, an undergraduate department had As the association grew in numbers, existed there under the direction of Profes- it became more mature, and with this sor of Orthodontics and Radiology James D. maturity there came a realization that the McCoy (1884–1965; Angle School, 1905). requirements for membership should be He and his brother, John, pioneered orth- standardized. With this in mind, the Great odontic o ce design in their showcase Lakes Society of Orthodontists introduced o ce on Wilshire Boulevard in Los Angeles, the following resolution at the 1953 meet- installing one of the rst X-ray units (1908). ing of the association’s board of directors in McCoy wrote two textbooks and more Dallas: than 100 articles. A dynamic, sought-after RESOLVED: That the Executive Coun- speaker and raconteur, he was second only cil of the American Association of Ortho- 4 Orthodontic Postgraduate Education: A Global Perspective

dontists be urged to appoint a special or This was to become e ective two years standing committee to study methods of after the date of adoption. It was read at training orthodontists and to make sug- the 1954 general meeting of the associa- gestions to Constituent Societies which tion, but to comply with the bylaws, it had would lead toward uniformity of training to be postponed for nal action at the next and the raising of standards of require- session of the association. It was therefore ments for membership in the Constituent scheduled for the San Francisco meeting in Societies, and also be instructed to rec- 1955. ommend additions or alterations to the At the rst general business meeting constitution (bylaws) calling for higher of the association in 1955, the amend- requirem ents for m em bership from tim e ment proposed at the previous meeting to time.18 in 1954 was presented for consideration. The committee was duly appointed, After lengthy discussion, a vote was taken with each constituent society represented. and the amendment, as introduced, was The seed for a supervised preceptorship adopted. But there were many who were program had been planted; germination not completely content with the amend- would be a long, adventurous, and at tim es m e n t . At it s n ext m e et in g t w o d ays lat e r, t h e hazardous process. board of directors accepted a new motion that a special committee be appointed to again consider educational requirements 1.1 Seeking a Solution for membership in the American Associa- to Training Programs for tion of Orthodontists. The report of this special committee More Orthodontists was presented at a general business meeting of the association in Boston in 1956. The After a year of intensive work and extensive portion applicable here reads as follows: correspondence, the report of the commit- Five years in exclusive practice of te e w as p rese n te d at t h e rst m e et in g of t h e orthodontics, at least three consecutive board of directors in Chicago in 1954. Dis- years of which shall have been in the

cussion continued throughout the morn- o ce of, and in full time association with, ing and afternoon. No conclusion could a practicing member of the American be reached. The meeting adjourned with Association of Orthodontists. This prac- the request that the committee renew its ticing member shall have been an active e orts in an attempt to arrive at an accept- member of the American Association of able solution. The second meeting of the Orthodontists not less than eight years. board of directors was almost a repetition The applicant must be recommended by of the rst. Finally, after listening to both two active members of the Constituent a majority and a minority report from the Society in whose jurisdiction he intends committee, the board voted to submit the to practice.18 following amendment to the bylaws at the This report was adopted in the form of next general m eeting of the association: an amendment to the bylaws, and as such RESOLVED: A person who has been was referred for nal action to the 1957 in the exclusive practice of orthodon- session of the association. The business tics for at least three years, and who has meetings of the 1957 American Associa- successfully completed an orthodontic tion of Orthodontists general assembly in course of a minimum of 1,500 hours in New Orleans are still remembered as pos- an approved dental school, and who is sibly the most contentious in the history a member in good standing in his local, of the association, because when the 1956 state, and national organization, may be amendment was referred to the 1957 ses- elected to active membership through sion for n al act ion , each sid e w as fu lly p re- the Constituent Society. He must be rec- pared to defend its position. ommended by two active members.18 1 Historical Aspects of Postgraduate Orthodontic Curriculum Formulation 5

1.2 Could the Schools to acquire a basically sound foundation in 18 clinical orthodontics. Both the national and Meet the Demand? constituent society committees realized that only through intensive supervision of Discussion was intense, vigorous, and force- his training could the preceptee be assured ful. A review of the arguments shows that that, upon the successful completion of his advocates of t h e p olicy of lim it in g m em ber- course, he would be a competent ortho- ship to university-trained m en believed (1) dontist eligible to apply for membership in that orthodontics had achieved such rec- the American Association of Orthodontists ognition as a specialty that the American and certi cation by the American Board of Association of Orthodontists could no lon- Orthodontics. ger a ord to accept as members applicants who had not received formal training at the university level and (2) that su cient interest was being shown by the dental schools 1.3 Uniform Standards so that, in a short time, there would be a Set for All Constituent balance between supply and demand. 18 Those who favored the acceptance of Societies preceptorship training m aintained (1) that there were not enough orthodontists to From the beginning, the committees recog- satisfy the demand and that, if past history nized that upon completion of their train- was any criterion, it would be many years ing, preceptees would theoretically have before the schools would be of much help a clinical advantage over their university- and (2) that there were many competent trained contemporaries, but that the latter dentists who wanted to enter the specialty would have a more intimate knowledge of but who could not meet the time require- the basic sciences that are so fundamental ments of the graduate schools. These men to the scienti c progress of orthodontics. were also worthy of, and entitled to, our To facilitate the work of the constitu- consideration. ent society qualifying com mittees, it was

As the vote was taken and the ballots essential that there be an established proce- counted, the result was in favor of formal dure that would be followed by all qualify- training by the narrow margin of 189 to ing com m ittees and that there be m inim um 186. At the second meeting of the asso- curricular requirements that would be ciation, two days later, a vote for recon- common and acceptable to all constituent sideration was successful, and American societies. It was to be two years before the Association of Orthodontists members national committee could report that all of favoring a supervised preceptorship as a the constituent societies had arrived at the satisfactory educational requirement were “standard level of acceptance” demanded the victors by a m ajority of 166 to 43. by the American Association of Orthodon- The 1957 board of directors delegated tists board of directors. After this had been the responsibility for developing this newly accomplished, the board authorized the accepted program to a national “master” granting of certi cates to those who had qualifying committee. The members of this successfully completed their training in the committee were to be the chairmen of the supervised preceptorship program. regional qualifying com m ittees of the eight The rst class to qualify nished in 1961, constituent societies. In retrospect, a signif- and the last in 1970. There were a total of icant contributing factor to the success of 266 graduates of the program, with the fol- the program was the relative permanence lowing distribution at the constituent soci- of the personnel of the master committee ety level: Southwestern Society 76, Paci c over the next 12 years. Coast Society 30, Southern Society 53, Mid- The principal objective of this con- western Society 23, Middle Atlantic Society trolled educational experiment was to pro- 32, Great Lakes Society 17, Northeastern vide an opportunity for those participating Society 31, and Rocky Mountain Society 4. 6 Orthodontic Postgraduate Education: A Global Perspective

1.4 Preceptorship qualifying committee of the American Association of Orthodontists, and (3) the Program of the board of directors of the American Asso- American Association of ciation of Orthodontists, whose decision shall be nal. Orthodontists: Outline of G. The preceptor will be permitted to have Procedure and Minimum only one preceptee in training at any Requirements for All given time. 19 H. The preceptor shall le with the qualify- Constituent Societies ing committee a detailed outline of the course of instruction that he proposes 1.4.1 Procedure to give the preceptee. This outline must be approved by the qualifying commit- A. The preceptor must be an active mem- tee of the constituent society. ber of the American Association of Or- I. The preceptee shall spend full time in thodontists, which membership must the exclusive practice of orthodontics have been continuous for the previous under the personal supervision of his eight years, and he must have been ap- preceptor (by “personal supervision” proved by the qualifying committee to is meant that the preceptor shall be act as a preceptor. present in the same o ce at all times B. The preceptor must be an active mem- that the preceptee is engaged in clinical ber of the constituent society within practice) except during sickness of the whose geographical area he maintains latter or while he is on vacation. Should a full-time practice. Should the precep- su ch sickn ess or vacat ion be for a p er iod tor have o ces within the jurisdiction longer than two continuous weeks, the of more than one constituent society, qualifying committee shall be so noti- by mutual consent of these societies he ed. At no time shall the preceptee en- m ay m ake a choice. gage in any other type of practice, nor C. Both the preceptor and the preceptee shall he practice orthodontics outside shall make a form al application to the the o ce of his preceptor. qualifying committee for permission to J. The clinical and laboratory work of the engage in this program. preceptee shall be open to inspection D. Upon receipt of this application, a stan- by the com m ittee at all tim es. dard questionnaire shall be sent to both K. Should either the preceptor or the pre- the preceptor and the preceptee. The ceptee become dissatis ed with their questions listed in the two form s are association, either or both shall have such as to give the com mittee the basic the privilege of presenting their case to information that it will require in deter- the qualifying committee. mining the tness of each applicant to L. The qualifying committee shall in no act in his respective capacities. These case insist upon instruction in any questionnaires are not nal, nor do they certain type of appliance or method of preclude the committee from using treatment but shall put emphasis upon other m ethods of seeking inform ation. general orthodontic knowledge. E. Upon acceptance, both the preceptor M. The preceptee, upon successful comple- and the preceptee shall be noti ed in tion of eighteen months of training, writing of the o cial date of the incep- shall be eligible for associate member- tion of the preceptorship. ship in the constituent society under F. Should the qualifying committee of the whose jurisdiction he is being trained. constituent society refuse either appli- N. Upon successful completion of the pre- cant, said applicant shall have the right ceptorship program, both the preceptor of appeal, in the following order, to (1) and the preceptee shall be so noti ed in the board of directors or other governing writing. body of the constituent society, (2) the 1 Historical Aspects of Postgraduate Orthodontic Curriculum Formulation 7

1.4.2 Minimum Requirements latter to the extent given in current textbooks. The course of instruction as submitted by 4. A w ritten review of the literature on a the preceptor and approved by the quali- subject of the preceptee’s choice. fying committee shall serve as the basic guide for the instruction of the preceptee. 5.Outline of thesis. The preceptee shall be examined by the Note: De nite progress should be evi- qualifying committee at the end of each year dent at this tim e. It is the critical stage in of his preceptorship. The results of these the preceptee’s development. examinations are to be sent to both the pre- Third-year examination to include: ceptor and the preceptee with any recommendations deemed essential to the welfare 1. Comprehensive examination by of the program . the qualifying committee sitting as The requirements listed herein are min- an exam ining board plus w ritten imum requirements, and no revision of this exam ination to be based on anything program sh all be allow ed w h ich is less th an pertaining to orthodontics, with special those incorporated herein. reference to the literature of the last 15 First-year examination to include: years. 1. Subm ission of a typodont w ith 2.Thesis. This should be submitted an appliance of choice, including su ciently in advance to allow time auxiliaries for the treatm ent of for reading by each m em ber of the malocclusions for which the appliance committee. is most suitable. 3. Resubm ission of 10 cases previously 2. Submission of ve cases started by the show n, w ith complete records to date, preceptee showing progress to date. together with ve additional cases treated by the preceptee, with complete 3. A w ritten review of the literature in a records to date. subject of the preceptee’s choice.

Note: Records of all cases submitted 4. An oral or w ritten exam ination, or should include a complete case analy- both, to show a knowledge of the basic sis, outline of treatment, and retention. fundamentals of orthodontics. All cases shown by the preceptee should 5. General idea and title of a proposed be named and numbered when rst pre- thesis, w hich m ust be acceptable to the sented. A record of these cases should be qualifying committee. kept by the committee. The preceptorship program served its Second-year examination to include: purpose. It trained dentists to be specialists in orthodontics. The program was discon- 1. Subm ission of typodont w ith a second tinued by the American Dental Association appliance of choice. The preceptee House of Delegates, but not before it had is to dem onstrate a sound working added specialists who could successfully knowledge of this appliance. correct the malocclusions of America’s chil- 2. Resubm ission of the original ve cases d r e n . Th e p r o g r a m w a s a r a g in g s u cce s s . Ev i- shown with complete records showing dence is the following statem ent, which is progress to date. Submission of ve an excerpt from the Report of Com m ittee B additional cases under treatment by (Advanced Education and Specialties), pre- the preceptee with complete records to sented at the December 8–9, 1966, meeting date. of the Council on Dental Education: 3. Oral or written examination, or both, to The board of directors of the Ameri- show advanced knowledge of clinical can Association of Orthodontists takes orthodontics and basic sciences, of the de nite pride in the success achieved 8 Orthodontic Postgraduate Education: A Global Perspective

by the supervised preceptorship pro- 9. Porter LJ. In memoriam. Leuman Maurice gram of the American Association of Waugh (1877-1972). Am J Orthod 1972; Orthodontists; however, it acquiesces 62(5):535–537 to the ruling of the House of Delegates 10. Cope O, Greep RO, Shaw JH, Thompson of the American Dental Association GE, Van Leewen MJ. Memorial tribute for that no new preceptorship program be A. LeRoy Johnson (1881-1967). Am J Orthod approved after January 1, 1967.20 1968;54(4):291–295 11. Waugh LM. Orthodontic pro les: John V. Mershon. Am J Orthod 1958;44:699–706 References 12. Graber TM. Obituary: Charles R. Baker. Am J Orthod 1970;58:514–517 1. Lewis SJ. The development of orthodon- 13. Frederick B. Noyes. Obituary. J Am Dent As- tic education. J Am Dent Assoc 1934; soc 1961;63:440 27(7):1157–1158 14. Kloehn JS. Portrait of a giant. Angle Orthod 2. Harris CA. The Principles and Practice of 1990;60(2):129–134 Dental Surgery. 4th ed. Philadelphia, PA: 15. Pollock HC Sr. Orthodontic pro les: James Blakiston; 1845 D. McCoy. Am J Orthod 1964;50:918–921 3. Simon W. History of the Baltimore Col- 16. Gawley RJ, Stoller AE. In memoriam: Spen- lege of Dental Surgery. In: Transactions cer Roane Atkinson (1886-1970). Am J Or- of the Fourth International Dental Con- thod 1971;59(5):516–519 gress. Vol 3. Press of the “Dental Cosmos”; 1905:290–293 17. Wahl N. Orthodontics in 3 millennia. Chap- ter 3: The professionalization of ortho- 4. Tweed CH. Men and Their In uence on the dontics. Am J Orthod Dentofacial Orthop History of Orthodontia. Unpublished manu- 2005;127(6):749–753 script. Between 1950–1959. American As- sociation of Orthodontists, Charles R. Baker 18. Hahn GW. The story of the AAO-super- Mem orial Library, St. Louis, MO vised preceptorship program. Am J Orthod 1971;60(2):189–195 5. Guilford SH. Orthodontia or Malposition of the Human Teeth: Its Prevention and Rem- 19. Preceptorship program of the American edy. 4th ed. Philadelphia, PA: Spangler & Association of Orthodontists: Outline of procedure and minimum requirements

Davis; 1893 for all constituent societies. Am J Orthod 6. Talbot ES. Irregularities of the Teeth and 1963;49(3):215–221 Their Treatment. 1st ed. Philadelphia, PA: Blakiston; 1888 20. American Dental Association. Council on Dental Education (1966, December 8–9). 7. Angle EH. Treatment of Malocclusion of the Meeting of Committee B, Advanced Educa- Teeth and Fractures of the Maxillae. 7th ed. tion and Specialties. Excerpt of Report from Philadelphia, PA: S. S. White Dental Manu- Comm ittee B. American Association of Or- facturing Company; 1907 thodontists, Charles R. Baker Memorial Li- 8. Weinberger BW. Historical resume of the brary, St. Louis, MO evolution and growth of orthodontia. J Am Dent Assoc 1934;23:2001–2021 Contemporary Orthodontic 2 Postgraduate Programs as Related to the Rest of Dental Specialty Advanced Education

Henry W. Fields

The goal of this chapter is to provide a con- usually in the later years of school. Because text for and raise issues related to orth- of the limited number of specialists and odontic postgraduate education, in contrast restricted time in predoctoral curricula, to postgraduate education in other dental orthodontics, and certainly clinical ortho- specialties. The focus is largely on the U.S. dontics, was not a serious factor in dental environment, although it is acknowledged schools. Some schools included laboratory- that a vibrant system of guidelines exists in based exercises, and at best, clinical obser- Europe through the Network of Erasmus- vation and demonstration occurred in the Based European Orthodontic Postgradu- third or fourth year of school.2 ate Programmes (NEBEOP).1 The material At about the same time, Edward Angle is organized into the following sections: began lecturing and writing, with the “Background and Early Predoctoral and notion that orthodontics should be part of

Specialty Education,” “Comparison w ith the predoctoral and graduate curricula. He Other Selected Areas of Dental Specialty was unsuccessful but subsequently devel- Education,” “Special Challenges to Orth- oped his own Angle School of Orthodontia odontic Specialty Programs,” “Turf Wars,” around the turn of the century. Students and “The European Approach to Program spent weeks to months at the proprietary Quality and Consistency.” schools that emerged, where singular g- ures were advocates of particular methods and philosophies. Most notable was the Angle school in which resident stu- 2.1 Background and Early dents and a more diverse faculty advocated strongly for the non-extraction approach. Predoctoral and Specialty Disciples of Angle taught in his school, and Ed u c a t i o n others opened additional schools.2 Orga- nized orthodontics began in 1900 as the In the mid-1800s, interest in orthodontic Society of Orthodontics, which was the education was lim ited, with some emerg- precursor of the American Association of ing practitioners trained mostly in in-o ce Orthodontists (AAO), established in 1935. preceptorships. As greater interest devel- Although Harvard–Forsyth o ered a oped, more lectures were sporadically pre- graduate program in orthodontics for sev- sented at dental meetings. eral years in the early 1900s, New York City In the late 1800s, orthodontics was was the site of the rst two sustainable introduced into predoctoral curricula. programs, at Columbia University and New Instruction began as didactic o erings, York Universit y, in 1922. In the next several 9 10 Orthodontic Postgraduate Education: A Global Perspective

years, more programs opened and spread one teacher and one pupil. All these devel- to the Midwest and West Coast. The head of opments and methods hinged on singular each program was a luminary in the grow- gures with a point of view. Although some ing eld.3 tried to reinforce and advocate for the sci- On the West Coast, an innovative pred- enti c basis of orthodontics, the tradition octoral program that included a strong began and continues today that a strong orthodontic component was begun to bol- personality with new or renewed ideas can ster care for children. This was “Curricu- alter t h e cou rse of t h e p rofession in p osit ive lum II,” which lasted from 1929 to 1969 at and negative ways. Even today, continuing the University of California, San Francisco education speakers recommend new meth- (UCSF) School of Dentistry. In this pro- ods, some unproven and often underwrit- gram, the nal three years of dental school ten by orthodontic supply companies, to emphasized pediatric dental and orthodon- practitioners eager for better methods of tic didactics and clinical care. The gradu- treatment. The advocate claims that the ates were eligible to sit for the California methods are successful, but that there is State Board examination, and most went inadequate time for documentation and directly into orthodontic specialty prac- evaluation. By the time the evidence is tice.4 Curriculum II, a predoctoral program in hand, the advocate has moved on and with graduate content, was an anomaly in adopted another new method. specialty education with a unique niche. Science has had a tough time acquir- Specialty education took several ing a foothold, and this has been so for the forms—graduate programs, postgraduate entirety of the profession. If this were not programs, and preceptorships. The gradu- the case, orthodontics would not redis- ate program s o ered didactic and clinical cover old ideas with new vigor after they education and led to a degree. The post- h ad been d iscred ited years before. How else graduate programs provided an ongoing can we account for the pendulum swing in sequence of education, on less than a full- controversies regarding extraction versus time basis in some instances, and awarded nonextraction, early versus late treatment, a certi cate upon completion. A new con- and growth modi cation versus dental cept in orthodontic education developed in movement?2 If we truly learned from sci- the 1950s, which was designed to produce ence and our experiences, the extent of the more well-trained orthodontists until the pendulum swing would be reduced, and we university-based training capacity was suf- would gradually see the pendulum begin cient to meet demand. The AAO precep- to hover over the central truth and not be tor program prepared clinical candidates kick-st ar ted again by t h e m ere breat h of t h e from 1961 to 1970, and orthodontists were same argument years later. This may also trained in private practitioners’ o ces in explain why many of the advances we have a prescriptive three-year program with made have been technical and mechanical exacting protocols.5 rather than biological. When one considers the history of Good science is complex, often leaving the evolution of orthodontic education, it some ambiguity regarding its generalizabil- becomes clear how a profession could grow, it y an d fu r t h er qu est ion s, so t h at t h ere is an ow, and t urn w ith the ideas and view s of a opening for the acceptance of “what works selected few individuals. Early formal edu- in my hands” rather than what routinely has cation struggled. Strong gures entered the been proved to work after rigorous scien- picture, lled the void, and founded pro- ti c scrutiny. Acquiring an understanding prietary schools centered around one per- of evidence-based care, even with a central sonality. When graduate programs began place in the advanced education guidelines, in universities, only one strong gure was in a specialty that currently has a dearth of required to bring the program recognition. high-quality studies, takes careful thought The preceptor programs that followed to and consideration and is not uniquely an ll the practitioner void revolved around orthodontic dilemma. 2 Orthodontic Postgraduate Programs for Dental Specialty Advanced Education 11

After much debate and discussion, the and orthodontics are two of the special- American Dental Association (ADA) Council ties generally based in outpatient clinical on Dental Education proposed that dentists settings. who wanted to declare themselves special- Since 1997, the program directors for ist s in on e of t h e areas ap p roved by t h e ADA all types of education must be board cer- be required to complete two or more years ti ed.10–13 Before this, in 1988, pediatric of advanced education “as speci ed by the dentistry required ve years of clinical certifying boards.” The ADA House of Del- experience for a program director, as well egates passed such a resolution at the 1961 as formal education in teaching for resi- annual session, although the requirement dents in preparation for their encounters did not take e ect until 1965.6 The earli- with predoctoral students (and possibly est such guidelines speci c to orthodontics, later as faculty members).14 This showed dated 1963, were prepared and issued by great foresight because in a number of the AAO Council on Orthodontic Education, institutions, titular board-certi ed clini- created in 1962.7 cians were installed as program directors From 1974 to 1984, the ADA Commission to meet the letter of the new standard. on Dental Accreditation (CODA) produced Unfortunately, board certi cation did not and issued general program requirements speak to the organizational, educational, applicable to all advanced specialty pro- curricular, or academic quali cations of a grams, to which the curriculum guidelines program director. After 2008, orthodontics authorized by each specialty board were did rule that before becoming a program appended to make them speci c to that director, the candidate must have two years specialty. The rst such ADA-issued guide- of teaching experience.15 There is little lines for orthodontics on le in the ADA or no evidence that this requirement for archives are dated 1975.8 The boilerplate board certi cation upgraded program per- preambles were speci c regarding facili- formance or outcomes because the clinical ties, teaching responsibilities, research, expertise spoken to by board certi cation a liated institutions, resident evaluation, is shared by many in the clinical environ- and admissions. After 1984, CODA adopted ment, although program administration is educational requirements for curricula shared by few and not addressed by this devised by each specialty, and individual requirement. Even today, clinicians and advanced education requirements were the scientists in dentistry spend 6 to 10 years pattern for the future.9 gaining technical pro ciency, but essentially days, if that, preparing for educational instruction and program administration. Oral and maxillofacial surgery accredi- 2.2 Comparison with tation guidelines mention the temporo- Other Selected Areas mandibular joint area in the 1970s and orthognathic surgery in the 1980s. Ortho- of Dental Specialty dontics was not far behind in the 1980s, Ed u c a t i o n but periodontics arrived later.9,16,17 Many of these newer inclusions take a decade Orthodontic advanced specialty education to become mainstream in education, after h as evolved on a t im et able sligh t ly d i eren t being introduced earlier in the practice set- from that of some of the other specialties. ting. Although it seem s to indicate resis- A brief comparison with several other spe- tance to change, the lag provides time to cialties is presented here. Oral and maxillo- ascertain that the newly de ned scope has facial surgery routinely operates in hospital scienti c underpinnings. This is probably and outpatient settings; pediatric dentistry as it should be. has a similar setting, depending upon the Periodontics and pediatric dentistry locat ion of t h e p rogram , bu t u su ally is m ore are the two disciplines that speci cally centered on outpatient care. Periodontics note a need for some level of expertise in 12 Orthodontic Postgraduate Education: A Global Perspective

orthodontic treatment.18,19 Concerns about Orthodontics has embraced a broaden- this overlap have rarely been voiced rela- ing of the basic sciences to include biostatis- tive to periodontics. On the other hand, the tics, epidemiology, genetics, biomechanical interface with pediatric dentistry has been tenets, and research methods. There is now uneven. This controversy usually becomes a recognition that complex, interdisciplin- evident when the pediatric dentistry ary treatment is often necessary, with mul- guidelines periodically undergo revision. tiple clinicians required. Evidence-based The intensity of the discussions has been methods have recently taken root with the m itigated in recent years by the foresight of recognition of randomized controlled stud- both groups. Preliminary drafts have been ies, systematic reviews, and meta-analyses shared by the groups, which then engage as the top tier of rigor. Unfortunately, most in joint conferencing with a focus on care- orthodontic clinical science does not pass ful word choices that describe sound treat- muster as robust and unbiased, as men- ment. Coincidentally, the preventive and tioned previously, leading some to conclude restorative needs of pediatric patients have mistakenly that any approach is justi ed stabilized, with an intractable patient group because none has great science behind it. requiring continued attention. Addition- ally, this young and disadvantaged group of patients is part of the only expanding segment of the population gaining access 2.3 Special Challenges through public funding.20 Because of this growth, the pressure to nd alternatives to Orthodontic Specialty to restorative care to supplement pediatric Programs practices, as was the notion in the 1980s, has been reduced. The expansion of CODA to include all spe- It appears that oral and maxillofacial cialties enlarged the com mission and surgery has been a monitor of the number changed its focus and strength from pri- of cases and procedures of speci c types for marily general dentistry/predoctoral issues years. Pediatric dentistry and periodontics to the specialties.22 Previously, the mem- have come to document treatment numbers of the commission (ADA appointed) bers and maintain case logs for di erent had been from the educational, dental types of treatment more recently.11,12,16 This examining, and dental practice communi- method provides assurance of adequate ties, supplemented by public members. The educational experience. Orthodontics has balance of the commission and its focus stressed ensuring that diversity of treat- changed dramatically when all special- ment types be emphasized but has never ties were included because the specialties been prescriptive regarding case numbers then accounted for a larger percentage of an d t yp es of care p rovid ed . Given t h e diver- the members than any other constituency sity of programs, movement in the direction grou p s. Th is ch ange ad ded a p olit ical at m o- of more accountability may be reasonable. sphere to the deliberations. Pediatric dentistry and orthodontics To illustrate, after the specialty groups led the way in making research a “must” were included, they caucused on issues requirement for advanced specialty educa- before meetings so that their positions tion in 1988 and 1992, respectively.14,21 In would be assured. This development was 1997, pediatric dentistry required that the never the intention of those who broad- experience be data based.11 It is clear that ened the base for discussion and decision oral and maxillofacial surgery has been making. In fact, orthodontics was a major clinically based, whereas periodontics has player in the attempt to direct the delibera- expanded its educational programs based tions regarding issues. on disease with basic science premises CODA h a s a n d co n t in u e s t o st r u ggle w it h (microbiology and immunology). issues of consistency among examiners. 2 Orthodontic Postgraduate Programs for Dental Specialty Advanced Education 13

Orthodontics has left the standards open This seems to be most popular with new to the interpretation of the site visitor, with programs and those undergoing dramatic guidance from the evaluators’ checklist and changes. Orthodontics as a whole must face CODA sta . Some specialties have gone to this issue as the number of programs con- numeric procedure counts in an attempt to tinues to expand. reduce the site visitor’s discretion—a direc- Another issue that orthodontics and tion orthodontics should consider. possibly even dentistry as a whole must Orthodontics faced a critical change in face is that of the workforce. As mentioned advanced education when corporate sup- earlier, orthodontics is viewed as a prized port was lent to programs and residents specialty profession. It attracts more pro- in exchange for access to training facili- spective students than there are positions ties and future practitioners. Initially, the for education, and dental and nondental battle was waged on the basis of the tness educational institutions are opening proof nontraditional institutions to sponsor grams to capitalize on this high demand. programs and on con icts of interest, but CODA and the accreditation process must lost on the grounds of site visit–demon- hold the line for program quality. strated equivalent educational experience As a matter of public policy, public insti- and outcomes. This resulted in standards in tutions can make determinations regarding orthodontics that scrutinize the sources of program size based on the appropriate use noninstitutional funding and its in uence of public funds. Private and nondental insti- on programs and the options of students tutions more likely make their determina- following graduation 23—a fundamental test tions based on the potential for demand of the accreditation process. and on revenue. For every public position Another dilemma is the acceptance of closed, a private one can open. Institutions residents into the programs. Clearly, there must provide only evidence of resources to are public and private programs with long support a program to justify program size and short heritages and at high and low to CODA, not need. points in their histories. Orthodontics can There is no responsive and timely eco- be portrayed as a prized specialty with n om ic syste m in p lace to react to t h e su p p ly unlimited personal and professional poten- of and demand for orthodontic or dental tial for those seeking admission. Following practitioners. Oversupply can readily occur interviews, programs can choose either to and take a decade to remedy, with interim participate in the match system used by deleterious impact on new and old prac- medicine and a number of the other den- titioners and their practices along with a tal specialties or to choose and commit negative external view of the profession as prospective students independently. The it tries to grapple with the situation. match simply follows the rules of an algo- The circumstances described here rithm to place students depending upon are not unique to orthodontics; they also student and program ranking preferences. apply to dentistry. Especially at a time The match was originally put in place of increased scrutiny of dentistry by the to standardize the sequence of events and Federal Trade Commission, it is di cult to reduce deal making between programs manage the workforce in an ethical, legal, and applicants. This was especially help- and responsible manner. The outcomes of ful because the applicants were in high- a workforce that has become deleterious stakes, high-pressure situations and unsure to the practition ers can readily be seen in of their chances for successful accep- veterinary medicine. When current and tance. Preying on the uncertainty of the future needs were evaluated against the naïve appeared unethical and unseemly. status quo, the increase in graduates of new Although the match initially helped corral programs, and other potential scenarios, questionable behavior, more schools have a gross and growing oversupply of practi- embraced independence from the match in tioners was predicted.24 Orthodontics and an e ort to gain an advantage in recruiting. dentistry will need to face this challenge. 14 Orthodontic Postgraduate Education: A Global Perspective

2.4 Turf Wars properly. Orthodontists are now placing tem porar y an ch orage devices an d perform - ing laser surgery for soft-tissue problems, All s p e c ia lt ie s h a ve fa ce d t u r f w a r s t o p r o t e c t both of which procedures were originally or expand their scope of practice. Oral and the domain of the oral and m axillofacial maxillofacial surgery has long interfaced surgery and periodontal communities. with both otolaryngology (the specialty Some orthodontists claim expertise in dealing with diseases of the ear, nose, and occlusal and temporomandibular joint- throat) and plastic surgery regarding areas related problems and are diagnosing and of the face where the specialties would be treating airway and sleep disturbances. separate or would coexist. In m any institu- The scope of practice of each area gradually tions, all cover the maxilla and associated becomes de ned as the specialty organi- soft tissues, while the mandible is usually zations incorporate training requirements reserved for oral and maxillofacial surgery. into the educational accreditation guide- Minor facial surgery and some major cos- lines. This is an ongoing process, with a metic surgery are now practiced by otolar- response that is by nature slow and mea- yngology, oral and maxillofacial surgery, sured. As new technology appears to make and plastic surgery – based, it is hoped, previous interventions simpler, this trend on adequate training and documentation, toward increasing the scope of dental spe- which most hospitals require for speci c cialties will continue. privileges to practice. Dental schools are only recently using this strategy. The con icts previously noted regarding the scope of practice occur among dental 2.5 The European an d m ed ical sp ecialt ies, an d t h ere are m any legendary con icts of this nature related to Approach to Program medicine. Orthopedics, neurosurgery, and Quality and Consistency osteopathy practitioners routinely compete for opportunities to treat the back. The NEBEOP, founded in 2009, comprises a

Psychiatrists, psychologists, and social group of European orthodontic educators workers have competing interests, as do who largely focus on orthodontic advanced ophthalmologists and optometrists. Anes- specialty education.1 As one of their activi- thesiologists and certi ed registered nurse ties, they revised the original “Three Years anesthetists continue to joust. Currently, Postgraduate Programme in Orthodontics: when competing therapies are advocated, The Final Report of the Erasmus Project,” clinical trials address successful outcom es which was originally funded by the Eras- as the true measure of the preferred treat- mus Bureau of the European Cultural Foun- m ent and further scope of practice. dation in 1989 and nalized in 1992.25 Dentistry has always claimed that any The document describes curricular general practitioner can perform any pro- guidelines for a three-year program with cedure within the scope of dentistry if he associated minimum curriculum hours. The or she is trained and experienced and if the guidelines are comprehensive and include procedure will bene t the patient. As new overall objectives, guidance for operations technologies appear, this is becoming an and conditions, objectives for didactic edu- even m ore ch allenging area to n avigate, an d cation, and then competencies for all areas the internal dental boundaries of practice of education. are not clear. Surgical implant placement Interestingly, besides providing topics is completed by oral and maxillofacial sur- and hourly guidance, the guidelines also geons, periodontists, endodontists, prosth- provide recommendations regarding the odontists, and general practitioners. Teeth necessity of a stipend, minimum number are uncovered by oral and maxillofacial of hours per week in clinical contact, mini- surgeons and periodontists, and both can mum number of patient starts, faculty-to- perform dental transplants when trained st u d en t rat ios, lim it at ion s on t h e am ou n t of 2 Orthodontic Postgraduate Programs for Dental Specialty Advanced Education 15 student laboratory work, a 10% cap on resi- References dent teaching, required research, and nal assessment for all courses and the com- 1. Huggare J, Derringer KA, Eliades T, et al. pleted program. The graduates are assessed The Erasmus programme for postgradu- and also present 10 completed cases to ate education in orthodontics in Europe: an update of the guidelines. Eur J Orthod a committee with at least one external 2014;36(3):340–349 examiner. Clearly, this is a more detailed 2. Wahl N. Orthodontics in 3 millennia. Chap- and broader educational exposure than is ter 3: The professionalization of ortho- required in the United States. dontics. Am J Orthod Dentofacial Orthop All programs are directed by registered 2005;127(6):749–753 orthodontists with at least ve years of spe- 3. Lewis SJ. The development of orth- cialty experience. The guidelines recognize odontic education. J Am Dent Assoc that those headed for education or research 1934;21:1152–1165 will require even more education. Quite 4. Dougherty HL Sr. The curriculum II orth- notably, this document was agreed upon by odontic program at the University of Cali- educators from 15 countries. Even though fornia at San Francisco School of Dentistry it is comprehensive, it is advisory, and the from 1929 until 1969. Am J Orthod Dentofa- requirements of national boards supersede cial Orthop 1999;115(5):595–597 the suggestions in the document, which do 5. Hahn GW. The story of the AAO-super- not have the initial force of law unless they vised preceptorship program. Am J Orthod are adopted by the individual nations. 1971;60(2):189–195 6. American Dental Association Council on Dental Education. Specialists, specialties and specialization: association policies and 2.6 Conclusion actions (1946–1961) II. J Am Dent Assoc 1962;64:888–890 Orth odontics has had a long histor y of edu- 7. American Association of Orthodontists Council on Orthodontic Education. Ortho- cation begun by steadfast individuals w ith dontics: Principles and Policies, Educational singular viewpoints. Som e of that person- Requirements, Organizational Structure. St. ality-driven evangelism is still seen today. Louis, MO: American Association of Ortho- The specialty of orthodontics continues to dontists; 1963 seek the truth and scienti c underpinnings 8. American Dental Association Com mission in an evidence-based world. It faces unique on Dental Accreditation. Orthodontics: Re- challenges in the future regarding scope quirements and Guidelines for Advanced of practice, workforce, and accreditation Specialty Education Programs. Chicago, IL: accountability. Borrowing insights from American Dental Association; 1975 our European colleagues may prove helpful. 9. American Dental Association Com mission on Dental Accreditation. Requirements for Advanced Specialty Education Programs in Orthodontics. Chicago IL: American Dental Acknowledgements Association; 1984 10. American Dental Association Com mission The author would like to thank Karen Hart, on Dental Accreditation. Standards for Ad- vanced Specialty Education Programs in Senior Director, Education Operations and Oral and Maxillofacial Surgery. Chicago, IL: Director, Council on Dental Education and American Dental Association; 1997 Licensure; Andrea Matlack, American Den- 11. American Dental Association Com mission tal Association archivist; and Jackie Hittner, on Dental Accreditation. Standards for Ad- American Association of Orthodontists vanced Specialty Education Programs in librarian, for their assistance with resources Pediatric Dentistry. Chicago, IL: American for this chapter. Dental Association; 1997 12. American Dental Association Com mission on Dental Accreditation. Standards for Ad- 16 Orthodontic Postgraduate Education: A Global Perspective

vanced Specialty Education Programs in 19. American Academy of Pedodontics. Guide- Periodontics. Chicago, IL: American Dental lines for Advanced Education in Pedodon- Association; 1997 tics: Principles and Policies—Educational 13. American Dental Association Com mission Requirements. Chicago, IL: American Acad- on Dental Accreditation. Standards for Ad- emy of Pedodontics; 1969 vanced Specialty Education Programs in 20. Wall TP, Vujicic M, Nasseh K. Recent trends Orthodontics. Chicago, IL: American Dental in the utilization of dental care in the United Association; 1997 States. J Dent Educ 2012;76:1020–1027 14. American Dental Association Com mission 21. American Dental Association Com mission on Dental Accreditation. Standards for Ad- on Dental Accreditation. Standards for Ad- vanced Specialty Education Programs in vanced Specialty Education Programs in Pediatric Dentistry. Chicago, IL: American Orthodontics. Chicago, IL: American Dental Dental Association; 1988 Association; 1992 15. American Dental Association Com mis- 22. American Dental Association Com mission sion on Dental Accreditation. Accreditation on Dental Accreditation. Supplemental Re- Standards for Advanced Specialty Education port 2: Revision of th e Rules of th e Com m is- Programs in Orthodontics and Dentofacial sion on Dental Accreditation. Chicago, IL: Orthopedics. Chicago, IL: American Dental American Dental Association; 1997 Association; 2008 23. American Dental Association Com mission 16. American Dental Association Com mission on Dental Accreditation. Advanced Spe- on Accreditation. Oral Surgery: Require- cialty Education Program s in Orthodontics ments and Essentials for Advanced Specialty and Dentofacial Orthopedics. Chicago, IL: Education Programs. Chicago, IL: American American Dental Association; 2002 Dental Association; 1975 24. Dall TM, Forte GJ, Storm MV, et al. Execu- 17. American Dental Association Com mission tive summary of the 2013 U.S. Veterinary on Dental Accreditation. Standards for Ad- Workforce Study. J Am Vet Med Assoc vanced Specialty Education Programs in 2013;242(11):1507–1514 Periodontics. Chicago, IL; American Dental 25. van d er Lin d en FPGM. Th re e years p ostgrad- Association; 1994 uate programme in orthodontics: the nal 18. American Dental Association Com mission report of the Erasmus Project. Eur J Orthod on Dental Accreditation. Requirements for 1992;14(2):85–94

Advanced Specialty Education Programs in Periodontics. Chicago, IL: American Dental Association; 1986 Contemporary Orthodontic 3 Postgraduate Education as Related to Undergraduate Orthodontic Programs

Pertti Pirttiniemi

3.1 Current Level of dent can bond brackets and x arch wires in several patients under supervision. On the Postgraduate Orthodontic other hand, opinions have been expressed Education in Relation to that at the undergraduate level, for example, the construction of orthodontic appliances Undergraduate Education in a laboratory should not be included in the curriculum.4 It is a known fact that the current volume, When compared with undergraduate as well as the contents, of undergraduate education, current contemporary post- orthodontic teaching is highly variable, both graduate orthodontic programs are well internationally1 and nationally.2,3 The num- balanced, lasting typically three years and ber of lectures and hours devoted to ortho- providing a good professional basis for the dontics is generally much m ore variable

future specialist. It can be concluded that at the undergraduate level4 in comparison the theoretical and systematic approaches with those typically reported or set as a goal of most orthodontic postgraduate pro- in postgraduate education.5,6 The reported grams make them unique in comparison mean (standard deviation [SD]) of curriculum with specialist training in other elds. hours devoted to orthodontics is about 110 (86),4 which is approxim ately 6% of the num - ber of curriculum hours typically included in three years of postgraduate orthodontic training. At maximum, the number of hours 3.2 General Aims of in Europe is 360 at the undergraduate level, Orthodontic Education which is more than three times the average and nearly 20 times more than the number The present aims of postgraduate orth- of hours in schools with the least number odontic education have been formulated of orthodontic curriculum hours. Therefore, clearly in th e 2009 pu blicat ion of th e World there is an extremely large variation in the Federation of Orthodontists task force,5 and volume of undergraduate orthodontic curri- further updated in the Erasmus program cula. The large variation in hours is re ected (European Community Action Scheme in the contents of the teaching. In all schools, for the Mobility of University Students) orthodontic diagnostics is taught, and in guidelines, published in 2014.6 The ortho- most schools at least observing simple orth- dontist shall be competent to diagnose and odontic treatments is possible. In the schools treat all orthodontic problems and cases with the most extensive orthodontic cur- and to work in groups, when needed. Fur- riculum at the undergraduate level, the stu- thermore, the orthodontist must possess a 17 18 Orthodontic Postgraduate Education: A Global Perspective

wide knowledge of craniofacial grow th and It is clear that in many respects these many other associated factors. ADEE competencies are relatively broad The aims of undergraduate teaching are and demanding, and even di cult to reach. much more vague and are lacking in gen- However, they may provide a good basis eral agreement. Hobson et al7 formulated for an individual dental school to develop the aim s of education as follows: its own aims and plans suitable for the environment. The newly quali ed dentist should be able to access the general orthodontic needs of every patient. They should be able to recognize and describe mani- fest and developing m alocclusions. In 3.3 Di erent Vie w s addition, they should also be able to Concerning the Contents undertake a limited number of rela- of Undergraduate tively simple procedures in which they are competent, whilst recognizing Orthodontic Education those cases that should be referred for specialist treatment. Although the aims of undergraduate orthodontic education are relatively constant, In this respect, Chadwick et al8 take when it comes to diagnostic skills, or the a di erent approach as they stress more ability of a general dentist to refer patients knowledge and less clinical training: to specialists, or to act during emergency Dental graduate should provide a sound situations, the views regarding the need knowledge of craniofacial growth and for orthodontic manual skills vary widely. occlusal development; to provide the This is to a large extent based on the fact knowledge and skills to be able to that in many countries, virtually all orth- make a clinical orthodontic diagnosis; odontic xed appliance treatment is done to provide the knowledge and skills by specialists, and therefore it has been to be able to design and construct a questioned whether the general practitioner should be trained in xed orthodon- removable orthodontic appliance to correct simple occlusal features. tics at all. It is noteworthy that most lists of competencies in undergraduate ortho- The Association of Dental Education dontics have been formulated in the United in Europe (ADEE)4 describes the aims of Kingdom. It is interesting that in a survey undergraduate orthodontic education of United Kingdom dental schools concern- based on competencies. The ADEE speci- ing the undergraduate orthodontic cur- es that on graduation, “a dentist must be riculum, Derringer3 noticed a large variety competent at managing limited develop- of subjects being taught and also a shift in mental or acquired dento-alveolar, growth- content from removable appliances to xed related and functional abnormalities of the appliances. primary, mixed and permanent dentition.” However, this is not the case in many The ADEE also lists a variety of support- countries. One reason m ay be a sm all num - ing competencies, including diagnostic and ber of specialists, or the fact that the spe- laboratory skills, especially those related to cialty may not be recognized at all. Also, removable appliances. In addition, the list in some sparsely populated countries, the includes competency in managing emer- specialist m ay act as a consulting ortho- gency situations, identifying unhealthful dontist, and treatment may at least partly oral habits and preventing them, assessing be administered by a general practitioner. facial form and deviations in it, determin- It is n at ural th at in this kin d of sit uat ion th e ing a patient’s aesthetic requirements and demand for the manual skills of the general how they can be met, and carrying out an practitioner is much higher, and this sets orthodontic assessment. di erent requirements for the undergradu- 3 Orthodontic Postgraduate Education for Undergraduate Orthodontic Programs 19 ate orthodontic curriculum. Therefore, it the e cacy of computer-assisted learning may be feasible that the undergraduate (CAL) in comparison with traditional m eth- curriculum be locally adjusted to meet the ods of learning in orthodontic education. demands of the surrounding society. This They found that the e cacy of CAL was does not, however, alter the increasing greater, and they identi ed a knowledge need for the coordination of undergradu- gain favoring CAL. In Belgium, Aly at al12 ate orthodontic education as a result of studied the use of an interactive multi- the increasing international movement of media package developed for orthodontics working dentists. teaching and intended to provide undergraduate and postgraduate dental students with an interactive tool for self-study and self-evaluation. The majority of under- 3.4 Developments and graduate and postgraduate students in the Trends in Teaching study were very satis ed with this form of educational approach because it was felt to Dentistry has been greatly involved in the be very helpful in enabling them to under- rapid development of undergraduate teach- stand the orthodontic curriculum more ing and learning during the last decades. e ciently. In the United Kingdom, Bains et One of the most frequent topics of discus- al13 compared the e ciency of e-learning, sion in this respect has been the introduc- face-to-face learning, and blended learning tion of problem -based learning (PBL) into and students’ attitudes toward them. In a the orthodontic curriculum. Because PBL randomized trial, four di erent groups of is no longer new, experiences have been students received the same cephalomet- described and opinions expressed both for ric tutorial but were allocated to di erent and against it. The use of PBL in orthodon- modes of learning. The students’ attitude tics has been studied, and it has been found toward each learning method was positive, that traditional teaching with lectures and but blended learning was signi cantly the seminars provides a student with better most accepted and face-to-face learning coverage of the curriculum in comparison the least accepted. Also, e-learning was sig- w ith PBL. With PBL, h ow ever, th e long-term ni cantly less preferred in comparison with recollection of learned subjects appears to blended learning. be better.8,9 It has also been pointed out that traditional assessment methods favor traditional teaching methods. Experience with PBL in postgraduate 3.5 Evaluation of Learning education is much less common than in undergraduate education. Bearn and Chad- Partly because of new teaching methods, wick10 studied the use of PBL in postgradu- but also because of new trends in evalua- ate orthodontic teaching, ant they noted tion in general, new methods of evaluation that although initial expectations of the have recently been developed, particularly method were high, it eventually proved in undergraduate education. This is related disappointing. PBL led to tension between to the fact that undergraduate classes are individuals or within groups, and fear of so large that individual assessment is not failure was common. The current trend always possible. It is natural that the teach- appears to be a decrease in the use of PBL. ing methods used strongly in uence the Very popular in orthodontics teaching, assessment methods used. Thus, in con- at both the undergraduate and postgradu- ventional teaching with lectures and semi- ate levels, has been the use of e-learning nars, w ritten essays are a com m on m ethod or multimedia tasks. An application is of assessment. However, assessment is blended learning, which is a mixture of always necessary, regardless of the method traditional learning and e-learning. Al- of teaching. Clinical skills are in most cases Jewair et al11 conducted a meta-analysis of assessed by clinical teachers, but prefer- 20 Orthodontic Postgraduate Education: A Global Perspective

ably in a structured manner and with a modalities, the years spent in postgradu- tested method. In this respect, we have ate education may be too limited. In turn, seen a movement toward the evaluation this sets new requirements for the under- of competencies instead of the testing of graduate curriculum. It would be bene cial pure knowledge. The rationale for testing if new postgraduate students had the best competence is described by Chambers14: possible quali cations in basic orthodontic “The behavior that is expected of the inde- knowledge. The question then becomes: pendent practitioner at the beginning. Is it better for postgraduate education if This behavior incorporates understand- undergraduate education stresses theo- ing, skills and values in a response to the retical issues or clinical aspects? In many full range of circumstances encountered in cases, postgraduate education does not general practice.” In its best form, the test- take place in the same location as under- ing of competence can be done so that the graduate education. When the curriculum test situation mimics the authentic clini- is analyzed, it can often be seen that the cal situation within real circum stances. A teaching of the theoretical and diagnostic good way in both undergraduate and post- parts of the curriculum is relatively con- graduate learning is the use of log books. stant from school to school. In regard to the Students record their learning experiences, orthodontic mechanics of xed or remov- and they can easily be checked afterward able appliances, the curriculum is in m any when an evaluation is performed. cased highly variable. Thus, from the point Regardless of the teaching method, of view of postgraduate education, it most the chosen assessment method should likely would be bene cial if the theoretical be objective, reliable, and justi ed. It also basis of orthodontic teaching or diagnos- should be relatively easy to perform and tic skills were increased and at the same repeat, and naturally it should re ect the time coordinated. This would make the ini- contents of the subject. tiation of postgraduate orthodontic education somewhat easier. In many cases, this kind of development is not easy because the undergraduate orthodontic curriculum may be pressured to include other 3.6 Demands That expanding subjects, and the administra- Current Postgraduate tion m ay be pressured to limit the num ber Education Places on of teaching personnel for various economic reasons. This is why orthodontic subjects Undergraduate Education in some schools have been limited, or the method of teaching has been changed to The orthodontic profession is a highly a simpler form when fewer teachers are demanding one, and therefore special- available. Another relevant factor of impor- ist education is requested by and popular t an ce is t h e ch ron ic lack of acad em ic teach - among dentists. It has been estim ated that ers of orthodontics in many countries. in the United States, there are more postgraduate students in orthodontics than in any other discipline.15 It is also noteworthy that the European Union o cially recog- 3.7 Increasing International nizes only orthodontics and oral surgery as specialties in dentistry. In most dental Movement and the schools or orthodontic programs, post- Contents of Orthodontic graduate education lasts from two to four Undergraduate Education years, a three-year program being typical. Because the subjects that must be taught Orthodontics, like dentistry in general, is a during the postgraduate period are con- very international profession. It has always stantly increasing, as a result of the devel- been easy for a dentist to change his or her opment of new diagnostic and treatment location or country of practice if the local 3 Orthodontic Postgraduate Education for Undergraduate Orthodontic Programs 21 regulations or laws allow. For decades, the are continually tested and monitored. The European Union has set the free movement educational eld is very dynamic, not the less of the workforce as a clear and important so because of new technology or theories of goal. Therefore, the European Union has learning. At the same tim e, the clinical eld implemented standards for undergraduate is changing with new treatment methods teaching in dentistry. For the undergraduate and materials. Working with patients has orthodontic curriculum, the requirements become more demanding as their aware- of the European Union are relatively broad. ness of di erent treatment alternatives and This may be related to the fact that when aesthetic requirements has increased. new countries were accepted into the Euro- Perhaps the biggest challenges to the pean Union, some compromises had to be learning environment in orthodontics are made. Possibly for this reason, the DentEd the lack of teaching personnel and the eco- project was initiated in the European Union, n om ic con st ra in t s t h at m ay m a ke t h e d evel- in which teaching in dentistry in more than opment of the teaching unit di cult. The 20 European Union countries was evaluated best way to deal with the lack of teachers during site visits, and the results of these in both undergraduate and postgraduate visits were published.1 In parallel with the education is to increase the amount of sci- undergraduate project, a project directed at enti cally oriented teaching at the under- the coordination of postgraduate orthodontic graduate level. Indeed, it has been shown education was initiated (Erasmus program that any exposure to teaching or research for postgraduate education in orthodontics during dental studies may increase a grad- in Europe).6 As well, the European Union uate’s interest in an academic career.16 A launched a visitor program for university mandatory research experience during the students and teachers in Europe, in which undergraduate years may result in a larger teachers of orthodontics could easily make number of graduates hoping to incorpo- site visits to other European universities and rate research in their careers. This, in turn, share teaching. Together, these programs may further the scienti c development of have clearly had a coordinating e ect on the dental profession. Naturally, the same both undergraduate and postgraduate teach- is true for postgraduate education. There- ing. In addition, the relatively long site visits fore, in the recently updated recommenda- of numerous students, both undergraduates tions of the Erasmus guidelines, a separate and postgraduates, to other European univer- period of research is included in the post- sities have undoubtedly in uenced teaching graduate curriculum.6 This research leads, at both the sending and receiving universities. in an optimal situation, to the publication It must be remembered that the orth- of a scienti c report of the project. In turn, odontic specialists working in the United students graduating with a postgraduate States and Canada, for example, are not in degree m ay wish to maintain their scien- many cases native citizens and have been ti c contacts and pursue a scienti c career educated, at least at the undergraduate level, and teaching activities. abroad. It is quite clear that the trend in the It is clear that all procedures that aim direction of more international teaching and for or lead to a greater coordination of learn ing is p erm an en t an d can be con sid ered undergraduate teaching in orthodontics positive in nature. This developm ent inevita- are bene cial in many respects. The con- bly results in a requirem ent for further coor- sequences will facilitate the movement of dination of teaching in all countries. dentists and enable them to work in different environments. The other advantage relates to postgraduate education. The more consistent the competencies of new 3.8 Future Perspectives postgraduate students, the easier the task of teachers in postgraduate education. This Undergraduate orthodontic teaching, as well can be especially bene cial in theoretical as postgraduate education, is constantly fac- subjects and in diagnostic skills, but also in ing new challenges. New teaching methods scienti c skills and basic orientation. 22 Orthodontic Postgraduate Education: A Global Perspective

References 9. Bearn DR, Chadwick SM, Jack AC, Sackville A. Orthodontic undergraduate education: 1. Harzer W, Oliver R, Chadwick B, Paganelli C. assessment in a modern curriculum. Eur J Undergraduate orthodontic & paediatric den- Dent Educ 2002;6(4):162–168 tistry education in Europe—the DentEd proj- 10. Bearn DR, Chadwick SM. Problem-based ect. J Orthod 2001;28(1):97–102 learning in postgraduate dental edu- 2. Rock WP, O’Brien KD, Stephens CD. Orth- cation: a qualitative evaluation of stu- odontic teaching practice and undergradu- dents’ experience of an orthodontic ate knowledge in British dental schools. Br problem-based postgraduate programme. Dent J 2002;192(6):347–351 Eur J Dent Educ 2010;14(1):26–34 3. Derringer KA. Undergraduate orthodon- 10.1111/j.1600-0579.2009.00588.x tic teaching in UK dental schools. Br Dent J 11. Al-Jewair TS, Azarpazhooh A, Suri S, Shah PS. 2005;199(4):224–232 Computer-assisted learning in orthodontic 4. Oliver R, Hingston E. Undergraduate clinical education: a systematic review and meta- orthodontic experience: a discussion paper. analysis. J Dent Educ 2009;73(6):730–739 Eur J Dent Educ 2006;10(3):142–148 12. Aly M, Willems G, Van Den Noortgate 5. Athanasiou AE, Darendeliler MA, Eliades T, et W, Elen J. E ect of multimedia informa- al; World Federation of Orthodontists (WFO) tion sequencing on educational outcome Guidelines for Postgraduate Orthodontic Edu- in orthodontic training. Eur J Orthod cation. World J Orthod 2009;10:153–166 2012;34(4):458–465 10.1093/ejo/cjr036 6. Huggare J, Derringer KA, Eliades T, et al. The 13. Bains M, Reynolds PA, McDonald F, Sher- Erasmus programme for postgraduate edu- ri M. E ectiveness and acceptability of cation in orthodontics in Europe: an update face-to-face, blended and e-learning: a ran- of the guidelines. Eur J Orthod 2014;36(3): domised trial of orthodontic undergradu- 340–349 10.1093/ejo/cjt059 ates. Eur J Dent Educ 2011;15(2):110–117 10.1111/j.1600-0579.2010.00651.x 7. Hobson RS, Carter NE, Gordon PH, Mattick CR. Undergraduate orthodontic teaching in 14. Chambers DW. Competencies: a new the new millennium —the Newcastle model. view of becoming a dentist. J Dent Educ Br Dent J 2004;197(5):269–271 1994;58(5):342–345 8. Chadwick SM, Bearn DR, Jack AC, O’Brien 15. Burk T, Orellana M. Assessment of graduate orthodontic programs in North America. J KD. Orthodontic undergraduate education: developments in a modern curriculum. Eur Dent Educ 2013;77(4):463–475 J Dent Educ 2002;6(2):57–63 16. Nalliah RP, Lee MK, Da Silva JD, Allareddy V. Impact of a research requirement in a dental school curriculum. J Dent Educ 2014;78(10):1364–1371 Orthodontic Specialty 4 Education in Europe

Stavros Kiliaridis and Anne Marie Kuijpers-Jagtman

The history of orthodontic specialty educa- torical background. Notwithstanding the tion in Europe spans a period of 80 years. birth of the European Economic Commu- It started in 1935, when ve German and n it y (EEC) in 1957, w h ich w as t h e p re d eces- two Austrian universities o ered students sor of the European Union (EU) as we know the opportunity to specialize in orthodon- it today, each of the 28 member states still tics by working as assistants in their orth- has its own national laws, regulations, and odontic clinics. Other countries in Europe administrative provisions when it comes to followed, but formal training based on an dental specialist education. The same holds agreed curriculum did not yet exist.1 On th e true, of course, for the countries that do not other side of the ocean, the rst graduate belong to the EU. orthodontic departments had been open In this chapter, we start with a short from the early 1920s on, and a structured introduction to legislation at the EU level course program in orthodontics had been regarding specialist education and rec- established by Dr. Allan Brodie at the Uni- ognition. First in regard to the recogni- versity of Illinois in Chicago in 1930.2 This tion of professional quali cations are the program served as a model for orthodon- relevant EU directives. However, the EU directives do not include any description tic specialty education in the United States and in uenced orthodontic education in of the required study content of postgrad- Europe as well. In the 1950s, the specialty uate programs. Because the EU functions of orthodontics was o cially recognized as a single market, it becam e urgent to lay in a few countries, mainly in the northern down a statement about the contents of part of Europe. The Netherlands, the Scan- postgraduate education in orthodontics to dinavian countries, and Switzerland were guarantee the quality of orthodontic spe- among the rst to organize their postgrad- cia list s a ll ove r Eu rop e . Th is w a s t h e re a son uate programs in orthodontics, avored by for the initiation of the Erasmus program the American model.1 In the United King- (European Community Action Scheme for dom, the Royal Colleges assumed a role the Mobility of University Students) in comparable to the one that already existed 1989 and the start of the Network of Eras- for the medical specialties (see Chapters 5 mus-Based European Orthodontic Post- and 14). In the year 2015, most European graduate Programs (NEBEOP) in 2008.3 We countries have recognized orthodontic spe- also describe brie y the role of the Euro- cialists and have implem ented specialty pean Federation of Orthodontic Specialist education programs. Associations (EFOSA), which unites orth- However, there is still a wide diversity odontic specialist organizations in Europe in the structure and contents of specialist and maintains a register of the state of education programs in Europe. Typically, a airs regarding the specialty in di erent this rather complicated situation has a his- countries in Europe.

23 24 Orthodontic Postgraduate Education: A Global Perspective

4.1 European Union so many times that they had become unworkable. Directives Directive 2005/36/EC,7 on the recognition of professional quali cations, came The EU is an economic and political union into force on October 20, 2007. It has been of 28 countries. Its internal market allows amended 11 tim es since its publication the free movement of goods, capital, ser- (latest amendment dated December 28, vices, and people between the member 2013), and two corrigenda were published. states. The European Economic Area (EEA) A consolidated version of the directive and includes EU countries and also Iceland, its annexes is available on the EU Web site Liechtenstein, and Norway. It allows them (consolidated version of Directive 2005/36/ to be part of the EU’s single market. Swit- EC7 of 20.11.2013). Article 35 of the direc- zerland is neither an EU nor an EEA mem- tive concerns specialist dental training, and ber but has been part of the single market the following requirements are listed: since 2002 by a series of bilateral agree- 1.Admission to specialist dental training ments. An overview of relevant EU legis- shall be contingent upon completion lation regarding orthodontic specialists is and validation of basic dental training given in Ta b l e 4 . 1 . referred to in Article 34, or possession The rst EU directive, “concerning the of the docum ents referred to in Articles mutual recognition of diplomas, certi cates 23 and 37. and other evidence of the formal quali cations of practitioners of dentistry, including 2.Specialist dental training shall comprise measures to facilitate the e ective exercise theoretical and practical instruction of the right of establishment and freedom in a university center, in a treatm ent to provide services,” dates from 1978.4 teaching and research center, or, where In Article 4, it is stated that each member appropriate, in a health establishment state shall recognize the diplom as of dental approved for that purpose by the practitioners specializing in orthodontics competent authorities or bodies. and oral surgery of other member states in

accordance with Articles 2 and 3 of Direc- 3.Full-time specialist dental courses tive 78/687/EEC.5 In Article 2 of Directive shall be of a m inim um of three years’ 78/687/EEC, a further speci cation is given duration and shall be supervised by the of the minimum requirements that the competent authorities or bodies. They training leading to a form al quali cation shall involve the personal participation as a dental specialist should meet.5 One of of the dental practitioner training to the entrance criteria is that the specialist be a specialist in the activity and in the should rst be a dentist having completed responsibilities of the establishment a ve-year full-time theoretical and practi- concerned. cal course in dentistry. In the Annex of the Basically, the requirements are the latter document,5 an overview is given of same as those in the EU directives of 1978. the subjects required in such a ve-year In Annex v.3, the subjects for the den- full-time course leading to a diploma in tal curriculum are listed, which have also dentistry. However, the contents of a spe- remained, amazingly enough, unchanged cialist ed u cat ion st u dy p rogram in regard to compared with those in the version that professional knowledge, skills, and compe- was published 27 years earlier! Again, spe- tencies are not speci ed. In 2001, in Direc- cialist knowledge, skills, and competencies tive 2001/19/EC,6 amendments were made are not included in the current directive. to the general system for the recognition of The existing diversity among countries in professional quali cations, including the Europe regarding specialist education and two earlier directives of 1978 on the profes- the wish to provide the same high-quality sion of dental practitioner. Finally, in 2005, orthodontic care for all European nation- a new directive7 was composed because als called for international collaboration to the relevant directives had been amended formulate guidelines for the education of 4 Orthodontic Specialty Education in Europe 25

Ta b l e 4 . 1 Overview of European Union legislation regarding orthodontic specialists

EU document Contents Remark

Council Directive 78/686/ Concerns mutual recognition Amended by Directive EEC of 25 July 1978 of diplomas, certi cates, and 2001/19/EC and replaced by other evidence of the formal Directive 2005/36/EC quali cations of practitioners of dentistry, including measures to facilitate the e ective exercise of the right of establishment and freedom to provide services

Council Directive 78/687/ Concerns the coordination Amended by Directive EEC of 25 July 1978 of provisions laid down 2001/19/EC and replaced by by Law, Regulation, or Directive 2005/36/EC Adm inistrative Action in respect of the activities of dental practitioners

Directive 2001/19/EC of the Amends Council Directives Replaced by Directive European Parliament and of 89/48/EEC and 92/51/EEC on 2005/36/EC the Council of 14 May 2001 the general system for the recognition of professional quali cations and Council Directives 77/452/ EEC, 77/453/EEC, 78/686/EEC, 78/687/EEC, 78/1026/EEC, 78/1027/EEC, 80/154/EEC, 80/155/EEC, 85/384/EEC, 85/432/EEC, 85/433/EEC, and 93/16/EEC concerning the professions of nurse responsible for general care, dental practitioner, veterinary surgeon, m idwife, architect, pharmacist, and doctor (text with EEA relevance)

Directive 2005/36/EC of the Concerns the recognition of 11 amendments until European Parliament and of professional quali cations 28 December 2013; the Council of 7 September (text with EEA relevance) consolidated version of 2005 Directive 2005/36/EC of 20.11.2013 on the EU Web site

Abbreviations: EC, European Council; EEA, European Economic Area; EEC, European Economic Com- munity; EU, European Union. 26 Orthodontic Postgraduate Education: A Global Perspective

orthodontic specialists. This gave rise to the minimum duration for an orthodontic spe- start of several initiatives: the Erasmus pro- cialist education program was set at three gram in 1989, EURO-QUAL II as part of the years full time (4,800 scheduled hours). It Biomed 2 program in 1995,8 and NEBEOP in was proposed to reserve 25% of the curricu- 2008.3 lu m h ou rs for elect ives. Th e m ain p ar t of t h e report contains a detailed description of the objectives of obligatory courses, the competency levels that should be reached, and the 4.2 Erasmus num ber of hours for each speci c topic. For more than two decades, this report The freedom of exchange of orthodontists contributed signi cantly to the strength- within the EU and the EEA made a con- ening of the level of postgraduate training sensus of educational standards an urgent in orthodontics in Europe and fueled the matter. As previously outlined, the EU debate about quality enhancement and directives provide only general guidelines quality control. Many programs in Europe for specialist education, and they are not used the guidelines outlined in the report speci c enough to form the basis of a well- as their gold standard for the education de ned curriculum for the education of of future orthodontists. After the original orthodontic specialists. About 25 years ago, publication, however, the eld of orthodon- in 1989, an initiative arose, funded by the tics changed substantially. New diagnostic Erasmus Bureau of the European Cultural tools and treatment techniques became Foundation of the Commission of the Euro- available, and there was a major change pean Com munities, to develop guidelines from mono-disciplinary orthodontics to to arrive at a comm on curriculum for post- interdisciplinary treatment approaches. graduate education in orthodontics. The Moreover, new insights into adult learn- main reason for developing such an exam- ing had their impact on teaching, not only ple curriculum was to establish guidelines at the undergraduate but also at the post- that could serve as baseline criteria for the graduate level. development of an orthodontic postgradu- In the meantime, NEBEOP was initiate program in each country in Europe. It ated in 2008.3 The network participants was anticipated that this would contribute strongly advised that the 1992 guidelines to reducing the diversity in the contents be updated. Therefore, in 2010, a task force, and duration of the existing programs and chaired by Professor Jan Huggare of Swe- would assist countries about to embark on d en , w as for m ed to com e u p w it h p rop osals the postgraduate training of specialists in for an update. In 2012, after several rounds orthodontics. of amendments, the nal revision was A committee of 15 program directors approved by the NEBEOP assembly, and the representing 15 European countries (Aus- nal report about the updated guidelines tria, Belgium, Denmark, Finland, France, was published in 2014.10 Germany, Greece, Ireland, Italy, the Neth- The postgraduate orthodontic program erlands, Norway, Spain, Sweden, Switzer- objectives, general and speci c conditions, land, United Kingdom) was set up for this and distribution of hours remained largely project. The nal results were published the same as those in the guidelines of 1992. in 1992, entitled “Three Years Postgradu- The most important general and speci c ate Programme in Orthodontics: the Final conditions in the Erasmus guidelines9,10 Report of the Erasmus Project.”9 In the fol- are summarized in Table 4.2. The theoreti- lowing years, it became widely known as cal contents are divided into eight themes, the Erasmus program for specialty educa- which were rede ned and modernized. An tion in orthodontics. overview of the updated guidelines for the The committee formulated main objec- theoretical contents of the program and the tives and general and speci c conditions for distribution of hours is given in Ta b l e 4 . 3 . specialty education in orthodontics. The Furthermore, in the 2014 guidelines, essen- 4 Orthodontic Specialty Education in Europe 27 tial competency levels were de ned for • Encouraging the evaluation of uni- the skills and competencies that residents versities and other o cially recog- should have acquired at the end of their nized institutions for the training of postgraduate education. orthodontic specialists within the EU It should be noted that the revision of EFOSA m ade an important contribution the Erasmus program should be used as a to identify and understand the huge diver- guideline to assist in the development and sit y of the European education program s in maintenance of high-quality postgraduate orthodontics as the rst step before trying education in orthodontics. The Erasmus to advance with their coordination. This program is not part of EU legislation, and e ort was partially achieved because each NEBEOP, w hich took the initiative to update country in Europe has a specialist associa- the guidelines, is not a legal authority that tion that has access to all inform ation about can override the EU directives or national the education, recognition, and registration laws and regulations. Nevertheless, the of specialists. An e ort was made by van guidelines can serve as a useful model der Linden1 to present the situation regard- for good-quality postgraduate training in ing the education of orthodontic specialists orthodontics and have had proven impact in 20 European countries, as well as Israel in m any countries in Europe. and Turkey, based on the information collected through a survey performed by EFOSA in 2002 of the national orthodon- 4.3 European Federation tic specialist organizations. The collected information dealt with the existing oppor- of Orthodontic Specialists tunities in each country for postgraduate Asso ciatio ns training, the content of the specialty education programs, the em bedding of specialist In 1977, the European Federation of Orth- education within universities or elsewhere, odontic Specialists Associations (EFOSA) the existence of an examination at the end was founded by national orthodontic spe- of the program, and last but not least the cialists associations from Belgium , Den- evaluation of the level of the training. m ark, England, France, Germ any, Ireland, Based on this survey, Cyprus, Iceland, Italy, and the Netherlands, and in 1998, and Luxembourg did not report special- after changes in the EFOSA bylaws, other ist education facilities in orthodontics. All European national associations joined the other countries mentioned three-year EFOSA. Am on g t h e aim s st ated in t h e EFOSA specialty education program s except Bel- constitution, the following deal with spe- gium, France, the Netherlands, Poland, cialty education: and Switzerland, where four years of education was requested. All programs were • Improving the contents and quality of full time except in France. The represen- education for orthodontic specialists tatives of most of the countries claimed by means of formulating proposals that orthodontic specialist education in geared toward de ning and coordinat- their countries adhered to the guidelines ing the teaching of orthodontics at the of the Erasmus program, and that it took university and post-university level place exclusively at universities with one • Standardizing European examina- exception, Germany, where “the general tions at the end of specialist training requirement is at least one year’s univer- programs in orthodontics sity experience and up to two years’ preceptorship within a privately practicing Furthermore, the EFOSA Web site orthodontic specialist, approved for that (www.efosa.eu) provides a list of tasks and purpose by the State Dental Organisation.” responsibilities: Large variations existed in the format • Prom oting a high level of training of of the nal examination, if there was one. orthodontic specialists within the EU The examiners were mainly university 28 Orthodontic Postgraduate Education: A Global Perspective

Table 4.2 Erasmus guidelines for the theoretical contents of postgraduate education in orthodontics

Part/hours Contents

A General biological and medical subjects 310 hours A1 Pe d ia t ric s A2 Anatomy and embryology of craniofacial structures A3 Ge n e t ic s A4 Cell and molecular biology, immunology, and microbiology A5 Oral pathology and medicine A6 Pharmacology A7 Ear–nose–throat and speech A8 Craniofacial syndromes A9 Psychology of the child, adolescent, and adult A10 Research methodology and biostatistics B Basic orthodontic subjects 325 hours B1 Development of the dentition (normal and abnormal) B2 Facial growth (normal and abnormal) B3 Physiology and pathophysiology of the stomatognathic system B4 Aspects of tooth movements and dentofacial orthopedics B5 Oral and maxillofacial radiology and other imaging techniques

B6 Cephalometric radiography B7 Orthodontic materials B8 Orthodontic biomechanics C General orthodontic subjects 340 hours C1 Etiology and epidemiology of malocclusions C2 Need and demand for orthodontic treatment C3 Diagnostic procedures C4 Orthodontic diagnostic assessment, treatment objectives, and treatment planning C5 Growth and treatment analysis C6 Long-term e ect of orthodontic treatment C7 Iatrogenic e ects of orthodontic treatment C8 Orthodontic literature 4 Orthodontic Specialty Education in Europe 29

Part/hours Contents

D Orthodontic techniques 195 hours D1 Removable appliances D2 Functional appliances D3 Extra-oral appliances D4 Part ial xed appliances D5 Fixed labial and lingual appliances D6 Retention appliances D7 Skeletal anchorage devices, temporary anchorage devices D8 Oral devices for obstructive sleep apnea treatment E Interdisciplinary treatment procedures 125 hours E1 Adult orthodontics E2 Treatment of patients with orofacial clefts and craniofacial anomalies E3 Orthodontic–surgical treatment E4 Orthodontic–periodontal treatment E5 Orthodontic–restorative treatment E6 Craniomandibular disorders F Management of health and safety 25 hours F1 Management of oral health F2 Health and safety in orthodontic practice F3 Multicultural health and health care behavior G Practice management, administration, and ethics 45 hours G1 O ce management G2 Communication G3 Ergonomics G4 Legislation G5 Professional ethics H Extramural educational activities elective Participation in activities like m eetings and congresses of (inter) national orthodontic societies, Distinguished Teacher lectures, and postgraduate courses of the European Orthodontic Society Source: Huggare J, Derringer KA, Eliades T, et al. The Erasmus programme for postgraduate education in orthodontics in Europe: an update of the guidelines. Eur J Orthod 2014;36(3):340–349. 30 Orthodontic Postgraduate Education: A Global Perspective

Table 4.3 Summary of the general and speci c conditions speci ed in the updated guidelines of the Erasmus program for postgraduate education in orthodontics

Program

• Structured program

• Minimum of 3 years’ full-time equivalent

• Delivered in universities or institutes with an academ ic a liation

Clinical activity

• Clinical activity (chair-side time): minimum of 16 hours per week (approximately 2,000 hours over the 3-year program)

• Treatment of at least 50 new cases with a variet y of malocclusions

• Clinical supervision by an orthodontic specialist

Theoretical education

• Based on a prede ned structured program

• Lectures and seminars equivalent to at least 5 hours per week (minimum of 600 hours over the 3-year program) distributed over the entire educational period

• Treatment planning or treatment evaluation seminars or discussions equivalent to at least 3 hours per week

• Assessment of knowledge within the educational period and a summative nal exam ination

Research

• Protected research time must be included with the provision of clear academic guidance.

• The research should be of su cient quality to lead to a publication or a congress presentation.

Source: Huggare J, Derringer KA, Eliades T, et al. The Erasmus programme for postgraduate education in orthodontics in Europe: an update of the guidelines. Eur J Orthod 2014;36(3):340–349. 4 Orthodontic Specialty Education in Europe 31 professors, sometimes reinforced by exter- founded in November 2008, after three nal examiners or by government-assigned years of preparation, according to the boards. In the United Kingdom and Ireland, principal demand raised and approved by the examinations were held by the Royal more than 60 participants of the European Colleges. Although orthodontic education Orthodontic Teachers’ Forums in 2006, in most countries took place exclusively 2007, and 2008. In the founding meeting at universities, as required by the Erasmus in Geneva, 36 attendees were present from program, the contents of the courses of 17 countries. During the founding meet- study were not veri ed. A major problem ing, th e NEBEOP bylaw s w ere discu ssed an d encountered in evaluating this aspect was approved to establish a format for function- that the information obtained in the sur- ing of the network.3 vey of 2002 failed to reveal adequate infor- Thus, the network comprises a group mation about the individual educational of orthodontic postgraduate training pro- institutions and the extent of the Erasmus grams represented by program directors or program implementation. orthodontists assigned by institutions that deliver a structured program in orthodontics. The primary concern of the network is education that is speci c to the specialty 4.4 Network of Erasmus- of orthodontics, and its main purpose is Based European the advancement of orthodontic post- Orthodontic Programs: graduate training in Europe. The network consists of full members and provisional External Assessment of members. The provisional members must Postgraduate Programs have previously completed a self-assessment form indicating that their program In 2006, the rst European Orthodon- broadly ful lls the requirements for mem- tic Teachers’ Forum took place after the bership according to the Erasmus program. authors of this chapter’s initiative. The goal To maintain and improve the quality of of this event, which was supported by the advanced education in orthodontics, a European Orthodontic Society, was to pro- periodic external assessment of the educa- vide a forum in which orthodontic teachers tional process and structure of each post- could meet one another to exchange infor- graduate program in orthodontics is part of mation, opinions, and ideas on undergradu- the quality assurance guidelines of NEBEOP ate and postgraduate teaching and research. and a requirement for full membership The organizing committee identi ed and in NEBEOP. This external periodic review invited representatives of approximately process includes a self-assessment of the 260 orthodontic postgraduate programs in program and a site evaluation by external Europe, m any of them in eastern Europe. assessors. The purpose of the site visit is The idea of NEBEOP was born as a result to obtain in-depth information concerning of the demand of the participants of the all educational and administrative aspects rst Teachers’ Forum, who pointed out the of the program. The site visit veri es and problem of the diversity of the European supplements the information contained in educational programs in orthodontics. It the comprehensive self-assessment docu- was seen to be necessary to establish some ment completed by each institution before common feasible standards to be used as the site evaluation. guidelines for European postgraduate edu- A program director applies on a vol- cation in orthodontics. The ambition was untary basis to have the program of his that in a reasonable period of time, the or her institution assessed against certain majority of the institutes providing orth- prede ned minimum criteria of quality odontic education in Europe would be able that have been developed by NEBEOP in the to meet the standards of the updated guide- past. In the assessment procedure for full lines of the Erasm us program . NEBEOP was membership, the backing of the university 32 Orthodontic Postgraduate Education: A Global Perspective

is compulsory because interviews with the 4.5 Discussion program director and the dean or head of the dental school, am ong others, are part of In their discussion on the ndings of a the procedure. Europe-wide survey into the state of orth- To guarantee the objective assessment odontic education, the professional devel- of postgraduate programs, in the initial opment group of EURO-QUAL II of the period until June 2014, only external asses- Biomed 2 Project stated, “One of the joys sors who were not involved in NEBEOP of living in Europe is the cultural diversity were invited to perform site visits. Once within a relatively small geographical area. 12 programs have been approved for full It would appear that this diversity also membership in NEBEOP, representatives of manifests itself in the postgraduate special- these programs will have the obligation to ist orthodontic training within Europe.”11 perform the site visits. This wide diversity still exists 15 years later, The standards by which the evalua- and it is unlikely that it will disappear in tion committee evaluates a postgraduate the near future. Nevertheless, the coordina- program are based upon the NEBEOP self- tion of standards in specialist education is assessment guide. The self-assessment an issue that a ects the quality of care and guide sets forth the standards for educa- that depends, at least partly, on the educational content, clinical training, research, tion and training that orthodontists receive evaluation and assessment, program an d t h e com p ete n cies t h ey h ave ach ieve d at director and teaching sta , facilities and the beginning of their careers. resources, and quality assurance that post- The EU directives do not de ne and will graduate programs in orthodontics should probably never de ne the required con- meet according to the updated version of tents for an educational program because the Erasmus guidelines.10 Thus, one of the this is left to the authority of the member major tasks of NEBEOP is to assess whether states. Therefore, a bottom-up approach these guidelines have been implem ented was seen as the best way forward. NEBEOP during site visits and other activities of the was not born as a result of bureaucratic organization.

requirements; rather, it was developed by At the moment, the network has 70 a group of European educators interested European program directors as provisional in high-quality postgraduate education in or full members. It should be stressed that orthodontics in Europe. Some of the pro- NEBEOP is not an o cial authority for grams wanted to go one step further by accrediting schools or certifying programs. opting for a voluntary objective quality Most countries in Europe have their own assessment to let them know where they accreditation system, and NEBEOP is not are. This bene ts even programs that do overruling any of the national regulations. not yet ful ll the criteria because they are NEBEOP provides guidelines on the struc- made aware of the areas where improve- ture and contents of a program that pro- ment can be attempted in accordance with mote the quality of postgraduate education the NEBEOP guidelines. in countries building their postgraduate This feasible approach to coordinate program in orthodontics, or in those w here the levels of specialist education beyond the specialty is not yet recognized. In con- the borders of the EU member states gives clusion, NEBEOP is a network of European hope that gradually, in a reasonable period programs that are attempting to comply of time, the majority of the institutions with the Erasmus guidelines.3 The mem- providing orthodontic education in Europe bers have agreed on a voluntary system of will be able to meet the standards of the assessment against the standards set by Erasmus programme. This e ort demands NEBEOP as the qualit y of their postgraduate an external evaluation to guarantee the program is their main goal. implementation of these guidelines. An 4 Orthodontic Specialty Education in Europe 33 organization like NEBEOP can be of bene t 5. 78/687/EEC: Council Directive 78/687/ for those programs that require external EEC of 25 July 1978 concerning the coor- accreditation and quality assessment based dination of provisions laid down by Law, on peer-review standards. When this pro- Regulation or Administrative Action in cess proceeds, the bene ts will be seen in respect of the activities of dental practitioners. O cial Journal of the European all countries as Europe continues to func- Communities L233, 1978;21:10–14. http:// tion as a single m arket and m obility among eur-lex.europa.eu/legal-content/EN/ educated professionals, such as orthodon- ALL/?uri=CELEX:31978L0687 t ist s, in creases. It is clear t h at in m any Eu ro - 6. 2001/19/EC: Directive 2001/19/EC of the pean countries, there is a well-functioning European parliament and of the Council of external review system, and therefore those 14 May 2001 amending Council Directives universities do not need an extra assess- 89/48/EEC and 92/51/EEC on the general sys- ment procedure. On the other hand, an tem for the recognition of professional qual- important number of European postgradu- i cations and Council Directives 77/452/ ate programs do not have external assess- EEC, 77/453/EEC, 78/686/EEC, 78/687/ m en t p roced u res, an d an evalu at ion of t h eir EEC, 78/1026/EEC, 78/1027/EEC, 80/154/ program s sim ilar to the evaluation of those EEC, 80/155/EEC, 85/384/EEC, 85/432/EEC, 85/433/EEC and 93/16/EEC concerning the with high standards will be a driving force professions of nurse responsible for gen- to increase the education standards of our eral care, dental practitioner, veterinary specialty. surgeon, midwife, architect, pharmacist The interest in educational issues shared and doctor. O cial Journal of the European by the “academic” NEBEOP and the profes- Communities L206/1, 2001;44:1–51. http:// sional organization EFOSA provides hope eur-lex.europa.eu/legal-content/EN/TXT for a promising collaboration and comple- /?qid=1431800969100&uri=CELEX:3200 m entary actions of these two groups. 1L0019 7. 2005/36/EC: Directive 2005/36/EC of the European Parliament and of the Council of 7 References September 2005 on the recognition of professional quali cations. O cial Journal of the

1. van der Linden FPGM. Orthodontic special- European Union L255, 2005;48:22–142. Con- ists education in Europe: past, present and solidated document with amendments and future. Prog Orthod 2005;6(1):14–35 corrigenda of 20.11.2013 at the EU Web site. 2. Wahl N. Orthodontics in 3 millennia. http://ec.europa.eu/internal_market/quali- Chapter 3: The professionalization of or- fications/policy_developm ents/legislation/ thodontics. Am J Orthod Dentofac Orthop index_en.htm. Accessed January 26, 2015 2005;127(6):749–753 8. Original Report Series. Series of reports on 3. Network of Erasmus Based European Orth- European orthodontics. The EURO-QUAL odontic Postgraduate Programmes. Bylaws. Biomed 2 Project. Original report series. J http://www.eoseurope.org/useful_links/ Orthod 2000;27(1):83–84 NEBEOPBylaws- nal.pdf. Published May 9. van d er Lin d en FPGM. Th re e years p ostgrad- 2009. Accessed January 26, 2015 uate programme in orthodontics: the nal 4. 78/686/EEC: Council Directive 78/686/EEC report of the Erasmus Project. Eur J Orthod of 25 July 1978 concerning the mutual rec- 1992;14(2):85–94 ognition of diplomas, certi cates and other 10. Huggare J, Derringer KA, Eliades T, et al. evidence of the form al quali cations of The Erasmus programme for postgradu- practitioners of dentistry, including mea- ate education in orthodontics in Europe: sures to facilitate the e ective exercise of an update of the guidelines. Eur J Orthod the right of establishment and freedom to 2014;36(3):340–349 provide services. O cial Journal of the Eu- 11. McDon ald JP, Adam idis JP, Eaton KA, Seeh ol- ropean Communities L233, 1978;21:1–9. zer H, Sieminska-Piekarczyk B. A survey of http://eur-lex.europa.eu/legal-content/EN/ postgraduate (specialist) orthodontic edu- ALL/?uri=CELEX:31978L0686 cation in 23 European countries. J Orthod 2000;27(1):92–98 Specialty Level Education in 5 Orthodontics in the United Ki n g d o m

Susan J. Cunningham

5.1 Postgraduate Membership in Orthodontics (MOrth) examination of the Royal College of Sur- Specialty Level Training geons. At the time of the writing of this in Orthondontics and the chapter, there are two MOrth examinations: one is a bi-collegiate exam ination run General Dental Council jointly by the Royal College of Surgeons of Curriculum England and the Royal College of Physicians and Surgeons of Glasgow, and the other Postgraduate specialty level training in is run by the Royal College of Surgeons of orthodontics in the United Kingdom fol- Edinburgh. Some universities o er a two- low s the General Dental Council (GDC) cur- year stand-alone master’s degree program, riculum, the most recent version of which but this does not give eligibility to take the can be found on the GDC Web site (https:// MOrth examination. www.gdc-uk.org/Dentalprofessionals/ The purpose of the three-year curricu- Specialistlist/Documents/OrthodonticCur- lum is to enable trainees in orthodontics to riculum.pdf). Training to specialty level achieve the level of competence expected requires three years of full-tim e instruc- to provide appropriate care for the group

tion (or the part-time equivalent) and of patients normally seen by a specialist in involves both clinical and academic learn- orthodontics. There are currently 34 mod- ing; the academic element usually consists ules in the curriculum, and trainees must of undertaking a university postgraduate show competence in all of these areas for degree alongside the clinical training, and successful completion of the program. The this can be at a master’s or taught doctor- ways in which this may be achieved for ate level. Individual universities o er dif- each individual module are detailed in the ferent degree programs, so it is important curriculum. The modules are divided into that applicants investigate them to apply “Generic Knowledge, Skills and Attitudes” for a program that meets their personal (9 modules) and “Orthodontic Specialist requirements. Speci c Knowledge, Skills and Attitudes” The GDC curriculum includes the (25 modules). features of the European Erasmus pro- The curriculum prepares trainees to gram 1 and fulfills the requirements of undertake and maintain a contemporary the directives of the Commission of the evidence-based approach to orthodontic European Communities on Dental Edu- practice, and therefore trainees are expected cation regarding the education of ortho- to undertake personal research training and dontists2 and the World Federation of experience. This can be achieved either by Orthodontists guidelines for postgradu- preparing a research dissertation or through ate orthodontic education.3 two papers in appropriately peer-reviewed Upon successful completion of the cur- journals submitted on work undertaken riculum, trainees are eligible to take the during the training period. The research 34 5 Specialty Level Education in Orthodontics in the United Kingdom 35 component of the program must ful ll the that the list does not include all teaching minimum master’s level requirements of methods used): the Quality Assurance Agency. In the United • Clinical practice, including personal Kingdom currently, the vast m ajorit y of spe- treatment with chair-side teach- cialty trainees pursue a master’s (or taught ing and attendance at new patient doctorate) level postgraduate degree at a clinics United Kingdom university to ful ll the aca- • Practical and technique courses demic requirements of the curriculum. • Lectures Specialty level training in orthodon- • Seminars and problem-solving tics in the United Kingdom takes place sessions within hospital departments, linked to • Online learning the following recognized universities for the academic and research components of training: Barts and The London (Queen Mary University), Birm ingham, Bristol, Car- 5.2.1 Clinical Practice di , Dundee, Edinburgh, Glasgow, King’s Training takes place within hospital depart- College London, Leeds, Liverpool, Manches- ments, where orthodontists work in teams. ter, Newcastle, She eld, and UCL Eastman This hospital setting ensures close super- Dental Institute. Queen’s University Belfast vision of all clinical work. Clinical practice does not currently run a program but may includes personal treatment sessions dur- do so again in the future. Not all universi- ing which trainees undertake treatment ties have programs every year, and the planning and hands-on treatment of their number of programs and trainees depends own patients under the close supervision on workforce needs. All programs work to of senior clinical supervisors. There is also a nationally agreed-upon, balanced timeta- attendance at new patient clinics and a ble of clinical sessions, research, academic range of multidisciplinary clinics; the clin- teaching, personal study, administration, ics available may vary among hospitals. and audit. The aim of clinical training is to provide

trainees with the skills and competence required for the independent practice of orthodontics, and the skills necessary to use 5.2 Teaching Methods di erent appliance systems to treat patients with a wide range of malocclusions. All Di erent universities vary in their teaching program s teach the use of rem ovable, func- methods; for example, some programs are tional, and xed appliance system s. Pro- traditional and relatively didactic in their grams in the United Kingdom provide good approach, whereas others focus on student- clinical exposure, and chair-side teaching centered methodologies, such as problem- form s an essential elem ent of the program s. based learning (PBL), in which trainees learn Each hospital takes this important fact into about a particular area through their expe- account and ensures that the appropriate rience of problem solving. Applicants are personnel are available to provide this level advised to research the methodologies used of teaching and supervision. Training is led in the programs for which they are apply- by consultant level sta who have under- ing, to ensure that they meet their personal taken at least ve years of training: three requirements. Additionally, some universi- years of specialist training and an additional ties provide all of their teaching “in house,” period of at least two years of advanced whereas in other cases, teaching is shared training to consultant level. Many of those among several universities in the same geo- providing teaching and supervision also graphic area. have formal teaching quali cations. Con- The teaching methods vary from pro- sultants m ay be employed by the National gram to program, but those most com- Health Service or by the university and have monly used are the following (please note honorary consultant status. 36 Orthodontic Postgraduate Education: A Global Perspective

5.2.2 Practical and Technique senior clinicians or academics in the United Kingdom, and they include information on Co u rs e s a particular topic, suggested references for that topic, and also interactive questions so These courses play an important part in that trainees can test their ow n knowledge. developing practical skills. Trainees are The modules are all contemporary and required to attend several courses during updated on a regular basis. their training, including wire-bending and typodont courses in which speci c appliance techniques are taught. Typodont courses are extrem ely useful in the early stages of train- 5.3 Assessments and ing because they allow practical skills to be Examinations acquired before such skills are used in the clinic. All orthodontic specialty program s incorporate assessments and examinations. Assessments are both formative and sum- 5.2.3 Lectures mative, and those commonly used in the United Kingdom include the follow ing Lectures are still used in m any program s to (please note that the list does not include allow the basic principles of orthodontics all assessment methods used, and methods to be imparted to a group of trainees. vary among programs): • Written assessments 5.2.4 Seminars and Problem- • Practical assessments Solving Sessions • Treatment planning assessments/ diagnostic tests/structured clinical Small-group seminars are often used to dis- reasoning cuss a speci c type of clinical problem or a • Case presentations certain topic from the curriculum. Trainees • Objective structured clinical exami-

will usually be given a reading list before nations (OSCEs) the seminar so that they come prepared • Workplace-based assessments with a certain background level of knowl- (WBAs) edge. The session may be led by a member • Presentation of a research thesis/ of sta or by the trainees themselves if the dissertation program uses PBL. 5.3.1 Written Assessments 5.2.5 Online Learning These may include essays, multiple short- Most universities in the United Kingdom answer questions, multiple-choice ques- have their own virtual learning environ- tions, and/or extended matching questions. ments (VLEs). These provide lectures, reading lists, timetables, and other information relevant to individual programs. Addition- 5.3.2 Practical Assessments ally, the British Orthodontic Society (BOS) These may include, for example, assess- has funded the development of a national ments of wire-bending skills under timed VLE that includes modules mapped to conditions. Trainees m ay be asked to un der- the GDC curriculum, and this informa- take the wire bending required for xed tive resource is available to those enrolled and/or removable appliances in speci ed in United Kingdom training programs. clinical situations. The individual m odules are all written by 5 Specialty Level Education in Orthodontics in the United Kingdom 37

5.3.3 Treatment Planning improvement. Observers provide in-depth feedback to the trainee; the trainee and Assessments/Diagnostic trainer then discuss potential areas that could Tests/Structured Clinical be worked on to enhance the trainee’s future Re a s o n i n g clinical practice. The WBAs currently used in orthodontic training are the following: These assessments are usually centered on • Direct observation of procedural the clinical records of an unseen patient. skills (DOPS) Trainees are given su cient time to study • Case-based discussions (CBD) the records, following which they undergo • Clinical evaluation exercises (CEX) an oral examination. They are expected to • Multiple-source feedback (MSF) show an understanding of the main issues related to that patient and to discuss appro- DOPS: A trainee is observed performing priate treatment strategies. a certain practical procedure (e.g., a bond- up, the placement of an arch wire, the t- ting of a functional appliance); the observer 5.3.4 Case Presentations then provides constructive feedback at the end of the clinical episode. In a case presentation, the trainee writes a CBDs are structured interviews designed comprehensive case report for a patient under to assess a trainee’s professional judgment his or her care. This is usually followed by an regarding the management of a patient for oral examination to allow the examiner(s) w hom he or she has responsibilit y. The dis- to assess the trainee’s understanding of the cussion of the patient’s treatment is based salient features of the case, understanding of on evidence in the case notes; the patient the treatment plan and treatment mechanics, is not present. A CBD allows discussion and and knowledge of limiting factors and alter- exploration of the trainee’s understanding native treatment options. of the treatment provided, and the trainee receives feedback at the end. CEXs are used to assess the skills 5.3.5 Objective Structured required in clinical encounters. Trainees are often assessed during new patient clin - Clinical Examinations ics and while discussing treatment plans and options with a patient. The clinical This style of assessm ent generally involves encounter is observed, and in-depth for- a series of short (usually lasting 10 minutes) mative feedback is provided at the end of stations, in which the trainee is required to the treatment episode. undertake certain clinically based tasks. MSF is a way of assessing a trainee in OSCEs test competence in speci c clinical the workplace by asking trainers, peers, co- skills—for example, communication and workers, and patients to complete surveys the ability to interpret radiographs and/or about the trainee and his or her clinical prac- other clinical records. tice. The person being assessed then receives feedback w ith a sum m ary of the ratings. 5.3.6 Workplace-Based Assessments 5.3.7 Presentation of Workplace-based assessments (WBAs) are a Research Thesis or formative assessments, which means that Dissertation they do not contribute to nal marks in a training program but are designed to help Research is a key component of the orth- trainees identify their own strengths and odontic curriculum, and the ndings of the weaknesses and target areas that require research are usually presented as a thesis 38 Orthodontic Postgraduate Education: A Global Perspective

or dissertation. According to the GDC cur- the individual universities when apply- riculum, it is also acceptable to provide ing. There are also additional costs, such evidence of competency in the research as the purchase of computer and photogra- module by having two papers in appro- phy equipment, travel costs, and the costs priately peer-reviewed journals submitted of printing and photocopying, and these on work undertaken during the training should be borne in m ind. period. However, the submission of a thesis/dissertation is by far the most common w ay of sat isfyin g t h is cr iter ion . Th e requ ire- ments for the thesis/dissertation vary, and 5.5 Applying for the details can be obtained from individual Programs universities. 5.5.1 Entry to Salaried 5.3.8 Membership in Specialty Training Orthodontics 5.5.1.1 Application Process Membership in Orthodontics (MOrth) of for Salaried Specialty Registrar one of the Royal Colleges sets a national Training standard within the United Kingdom and is held both in the United Kingdom and The application for entry to one of the sala- internationally; this quali cation is now ried specialty registrar (StR) training pro- accepted in many countries as a benchmark grams is a competitive process that takes for specialty level training. Written assess- place nationally once a year. Applicants ments, diagnostic tests/structured clinical must check their eligibility by referring to reasoning tests, case presentations, OSCEs, the Person Speci cation at the time they communication scenarios, and general are applying. vivas are used in the MOrth examination. All salaried StR training programs in the Further details of the assessment methods United Kingdom are joint programs shared used can be found on the Royal College Web by hospital orthodontic departments, sites (addresses are included at the end of which employ the trainee, and university this chapter). dental schools, which provide the academic Candidates who are able to provide teaching. The training programs are a li- evidence of successful completion of the ated with the universities listed earlier in written examination papers leading to an the chapter, and the num ber of posts varies approved university quali cation in ortho- from year to year. dontics at a center recognized by the Royal Posts are advertised early in the year, College of Surgeons of England, Glasgow, with interviews scheduled for May or June or Edinburgh are exempt from the written each year. Applications are submitted online, component of the MOrth examination. and several resources are available about each program to help inform candidates and assist them in their choice of posts. The programs available through national recruit- 5.4 Costs of Training ment all follow the GDC curriculum, and if the trainee successfully completes the pro- Trainees are required to pay fees to the gram , he or she is recom m ended to the GDC university for the academic component of as eligible for entry to the specialist list in their training, and these fees vary among orthodontics held by the GDC. universities and among United Kingdom/ In 2014, the essential and desirable crite- European Union and non–United Kingdom/ ria for those applying for StR posts included European Union trainees. It is important those detailed in the following paragraph. It for a candidate to check fee levels with is important to note that these are subject 5 Specialty Level Education in Orthodontics in the United Kingdom 39 to change, and applicants must check care- Web sites listed at the end of this fully to determ ine whether they ful ll the chapter criteria detailed in the Person Speci cation • Broad clinical experience at the tim e of their application. • Vocational training certi cate or Essential criteria in 2014 included the equivalent following: • Completion of dental foundation training/general professional train- • Eligibility for registration with the ing (or the equivalent) United Kingdom GDC • Experience in teaching and enthusi- • Bachelor of dental surgery (BDS) asm for teaching degree or the equivalent • Experience in research (includ- • Eligibility to work in the United ing publications, posters, and Kingdom (https://www.gov. presentations) uk/government/organisations/ uk-visas-and-immigration) The interview process involves several • At least 24 m onths of full-tim e post “stations,” at which the applicant’s essen- primary quali cation clinical expe- tial and desirable criteria are assessed, as rience (or the part-time equivalent) detailed in the Person Speci cation. The at the tim e of application applicants are then ranked according to • Demonstrable skills in written and their perform ance during the interviews, spoken English adequate to en- and they are subsequently asked to indicate able e ective communication with which of the posts they would be willing patients and colleagues (supporting to accept. Applicants are able to visit any evidence may be required) of the posts in which they are interested • Ability to practice safely and apply after the interviews. Posts are then o ered sound clinical judgment in early or mid-July and start at the end of • Understanding of clinical gover- September or beginning of October, when nance and evidence of active par- the university term commences. ticipation in audit If an applicant accepts a post, he or she

• Good communication skills, empa- is allocated a unique national training num- thy, and sensitivity ber; this allows training to be monitored • Good organizational skills and the as described under Section 5.5.1.2, “Qual- ability to work under pressure ity Management of the Salaried Specialty • Flexibility and willingness to work Training Programs,” and as detailed in the as part of a team Dental Gold Guide, which is available on • Understanding of the principles of the UK Committee of Postgraduate Dental research Deans and Directors (COPDEND) Web site • Commitment to orthodontics (http://www.copdend.org). • Professional integrity Desirable criteria in 2014 included the 5.5.1.2 Quality Management of following: the Salaried Specialty Training • Possession of the FDS (Fellow ship Programs in Dental Surgery), FFD (Fellowship of the Faculty of Dentistry), MFDS The quality of salaried StR training pro- (Membership of the Faculty of gram s is m an aged by Health Edu cat ion Eng- Dental Surgery), or MJDF (Mem ber- land and by deaneries in Scotland, Wales, ship of the Joint Dental Faculties) and Northern Ireland. The Specialty Advi- of the Royal Colleges of Surgeons, sory Committee for Orthodontics of the or equivalent quali cation; fur- Royal College of Surgeons also plays a role ther details can be found on the in this process by providing expert advice. 40 Orthodontic Postgraduate Education: A Global Perspective

During the training program, progress career in a primary care setting, a second- is monitored through a process called the ary care hospital setting, or a combination annual review of competence progression of the two. (ARCP), which is managed by postgraduate For a specialist to work in a hospital dental deans as employees of Health Edu- orthodontic service as a consultant, a fur- cation England or deaneries. The trainee ther two years of training is required at a m ust have a satisfactory ARCP at the end of post-specialty level. This training includes years 1 and 2 to be allowed to progress to the management of more complex interdis- the next year of training. ciplinary orthodontic cases, experience in At the end of year 3, trainees are hospital management, and teaching expe- required to have a satisfactory ARCP, to rience. The intercollegiate specialty fellow- have passed the summative examination ship examination (ISFE), run by the dental (the MOrth examination), and to have com- facu lt ies of t h e Royal Colleges of Su rgeon s in pleted all components of the GDC curricu- the United Kingdom and Ireland, marks the lum (including satisfactory completion of end of this training and incorporates three the research component) in order that the major sections: clinical, management, and postgraduate dental dean can recommend research/critical appraisal. To become an the award of a Certi cate of Completion of academic consultant based within a univer- Specialty Training (CCST). At that stage, the sity, there is also the requirem ent to under- trainee can apply to be accepted onto the take research toward the award of a higher GDC specialist list in orthodontics; accep- university degree, such as a PhD. tance allows one to practice as a specialist in orthodontics in the United Kingdom. 5.5.2 Entry for Those Who Do Not Meet the Essential 5.5.1.3 Electronic Training Record and Workplace-Based Assessments Criteria for Salaried Specialty Training The ARCP process is informed by an electronic training record, which is held on the Trainees who do not meet the essential intercollegiate specialty curriculum pro- requirements in the Person Speci cation for gram (ISCP). The ISCP stores information salaried StR training apply directly to a uni- regarding personal development plans, versity. Each university has its own applica- global objectives for the training program, tion process, requirements, and deadlines, appraisals, and assessments. Additional so applicants need to investigate each indi- information, such as publications, audits, vidual program carefully. Programs start in and presentations, can also be stored. All late September or early October, and the salaried StRs are required to be registered curriculum followed is the GDC curricu- on the ISCP as part of their training. lum detailed previously. Admission is also W BAs are a m an dator y part of th e ARCP through competitive entry, and short-listed process, and a speci ed number of WBAs applicants m ay be interviewed in person or must be completed at the appropriate level via electronic link. each year to have a satisfactory ARCP. Three-year programs incorporate a master’s or taught doctorate level degree alongside the clinical training, and upon suc- 5.5.1.4 Career Progression cessful completion of the program, trainees are eligible to take the MOrth examination Once accepted onto the GDC specialist list of t h e Royal College of Su rgeon s. Train ees d o in orthodontics, orthodontic specialists not, however, undergo the same ARCP/ISCP can choose whether they wish to pursue a processes as salaried StRs. 5 Specialty Level Education in Orthodontics in the United Kingdom 41

As mentioned earlier in this chap- • UK Com m ittee of Postgraduate ter, some universities o er a two-year (or Dental Deans and Directors (http:// part-time equivalent) master’s level pro- w w w.copdend.org) gram without an additional third year of • Individual university Web sites training; it is important to note that this • Royal College of Surgeons of England does not give eligibility to take the MOrth (https://w w w.rcseng.ac.uk) examination. • Royal College of Surgeons of Edin- Those trainees who have not been burgh appointed through the national process (http://www.rcsed.ac.uk) for salaried StRs, who do not have a unique • Royal College of Physicians and Sur- national training number, and who are geons of Glasgow therefore not on a recognized StR train- (http://w w w.rcpsg.ac.uk) ing program are not automatically enti- • Royal College of Surgeons in Ireland tled to specialist recognition in the United (http://www.rcsi.ie) Kingdom or in their home country, even • UK Visas and Im m igra- if they have been successful in the MOrth tion (https://www.gov.uk/ examination. To apply for registration in government/organisations/ the United Kingdom, a trainee would have uk-visas-and-immigration) to apply for entry to the United Kingdom GDC specialist list in orthodontics through To the best of the author’s knowledge the process of equivalence. To do this, the this information was correct at the time of trainee must have full registration with the writing the chapter: December 2014. GDC and be able to demonstrate that the training undertaken was the same as that undertaken by those trainees who success- References fully completed an approved StR training 1. Huggare J, Derringer KA, Eliades T, et al. program as evidenced by the award of a The Erasmus programme for postgradu- CCST. There is no guarantee of acceptance ate education in orthodontics in Europe: onto the specialist list via this route. an update of the guidelines. Eur J Orthod 2014;36(3):340–349 2. Advisory Comm ittee on the training of dental practitioners report on the eld of activ- 5.6 Sources of Further ity and training programmes for the dental specialists. 1986 European Commission Di- Information rective number III/D/1374/5/84-EN 3. Ath an asiou AE, Daren d eliler MA, Eliades T, et al; Further sources of information that poten- World Federation of Orthodontists. The World tial applicants may nd useful are listed Federation of Orthodontists (WFO) guidelines below: for postgraduate orthodontic education. World J Orthod 2009;10(2):153–166 • British Orthodontic Society (http:// w w w.bos.org.uk) • General Dental Council (w w w.gdc-uk.org) Postgraduate Orthodontic 6 Education in the United States

Peter Ngan and Christina DeBiase

Orthodontics and dentofacial orthopedics changes in institutional accreditation; or are de ned as the dental specialties that interruption of an educational program include the diagnosis, prevention, intercep- because of unforeseen circumstances that tion, and correction of malocclusion, as well take faculty, administrators, or students as neuromuscular and skeletal abnormali- away from the program . ties of the developing or mature orofacial Programs that are not fully operational structures (adopted by the American Asso- are those that have not enrolled or gradu- ciation of Orthodontists [AAO], April 2003).1 ated at least one class of students/residents There are currently 66 accredited orth- and do not have students/residents enrolled odontic programs in the United States and in each year of the program. The accredita- ve in Canada. Each year, approximately tion classi cation granted by the Commis- 350 orthodontists graduate from these pro- sion on Dental Accreditation to programs gram s. The Com m ission on Dental Accredi- that are not fully operational is termed tation advocates for the oral health care initial accreditation. When initial accredi- needs of the public through the develop- tation status is granted to a developing ment and administration of standards that education program, it is in e ect through foster the continuous quality improvement the projected enrollment date. However,

of dental and dental-related educational if enrollment of the rst class is delayed programs. Programs that earn approval and for two consecutive years following the are fully operational achieve or exceed the projected enrollment date, the program’s basic requirem ents for accreditation. Pro- accreditation will be discontinued, and the grams that receive approval with reporting institution must reapply for initial accredi- requirem ents have speci c de ciencies or tation and update pertinent information on weaknesses in one or m ore areas. Evidence program development. Following this, the of compliance with the cited standards commission will reconsider granting initial must be demonstrated within 18 months accreditation status. This accreditation clas- if the program is two years or longer in si cation provides evidence to educational le n gt h , or w it h in t w o ye a r s if t h e p r ogr a m is institutions, licensing bodies, and govern- up to t w o years in length. If the de ciencies m ent or other granting agencies that, at the are not corrected within the speci ed time time of initial evaluation(s), the develop- period, accreditation will be withdrawn, ing education program had the potential unless the commission extends the period for meeting the standards set forth in the for achieving compliance for good cause. requirements for an accredited educational Circumstances under which an extension program for the speci c occupational area. for good cause would be granted include, The classi cation of initial accreditation is but are not limited to, sudden changes in granted based upon one or m ore site evalu- institutional commitment; natural disaster ation visit(s). A developing program can- that a ects a liated agreements between not enroll students/residents until initial institutions; faculty support; facilities; accreditation has been achieved. 42 6 Postgraduate Orthodontic Education in the United States 43

Maintaining and improving the qual- 6.1 Commission on ity of advanced education in the nationally recognized specialty areas of dentistry is Dental Accreditation a primary aim of the Commission on Den- Standards tal Accreditation. The com mission is recognized by the public, the profession, and The Commission on Dental Accreditation the U.S. Department of Education as the establishes general standards that are com- specialized accrediting agency in dentistry. m on to all dental specialties, institutions, and Accreditation of advanced specialty edu- programs regardless of specialty. Each spe- cation programs is a voluntary e ort of all cialty develops specialty-speci c standards parties involved. The process of accredita- for educational program s in its specialty. The tion assures students/residents, specialty general and specialty-speci c standards, sub- boards, and the public that accredited train- sequent to approval by the Commission on ing program s are in compliance w ith pub- Dental Accreditation, set forth the standards lished standards. Accreditation is extended for the educational content, instructional to institutions o ering acceptable programs activities, patient care responsibilities, super- in orthodontics and dentofacial orthopedics. vision, and facilities that should be provided Program accreditation will be withdrawn by programs in that particular specialty.2 when the training program no longer con- forms to the standards as speci ed in this document, when all rst-year positions remain vacant for a period of two years, or 6.2 Standard 1: when a program fails to respond to requests for program information. Exceptions for Institutional Commitment/ non-enrollment may be made by the com- Program E ectiveness mission for programs with “approval without reporting requirements” status upon The program must develop clearly stated receipt of a formal request from an institu- go a ls a n d o bje ct ive s a p p r o p r iat e t o a d va n ce d tion stating reasons why the status of the specialty education that address education, program should not be w ithdraw n. patient care, research, and service. Plan- Advanced education in a recognized ning for, evaluation of, and improvement in specialty area of dentistry may be o ered educational quality for the program must be on either a certi cate-only or a certi - broad-based, systematic, continuous, and cate- and degree-granting basis. Accredita- designed to promote the achievement of tion actions by the Commission on Dental program goals related to education, patient Accreditation are based upon inform ation care, research, and service. gained through written submissions by program directors, and evaluations made on site by assigned consultants. The com- 6.2.1 West Virg inia Unive rsity mission has established review commit- Goals and Objectives tees in each of the recognized specialties to review site visit and progress reports Graduates must receive instruction in the and make recommendations to the com- application of the principles of ethical rea- mission. Review committees are composed soning, ethical decision making, and profes- of representatives selected by the special- sional responsibility as they pertain to the ties and their certifying boards. The com- academic environment, research, patient mission has the ultimate responsibility care, and practice management. for determining a program’s accreditation At West Virginia University (WVU), a status. The commission is also responsible full-day seminar is given to students annu- for the adjudication of appeals of adverse ally addressing a range of resources, such decisions and has established policies and as professional codes, regulatory law, and procedures for appeal.2 ethical theories, to guide their judgment 44 Orthodontic Postgraduate Education: A Global Perspective

and actions regarding issues that are com- their professional employm ent settings. plex, novel, ethically arguable, divisive, or of The program encourages graduates to public concern. complete the last clinical phase of the ABO The program must document its e ec- examination. The numbers of alumni who tiveness by using a formal and ongoing continue to pursue the clinical portion of outcomes assessment process that includes the ABO exam ination are tabulated. measures of advanced education student/ The outcomes of the program are also resident achievement. assessed each year to monitor the achieve- At WVU, the following program goals m ent of the program ’s goals and objectives. and objectives for postgraduate orthodon- We w ill kn ow t h at w e are produ cing gradu - tic education exist: ates who demonstrate outstanding clinical skills based on the following: • To provide educational experiences that produce graduates who • Faculty assessm ent of the quality of demonstrate outstanding clinical student clinical performance yielded skills patient outcomes of outstanding • To provide a program that produces quality 100% of the tim e. graduates who demonstrate • A chart review conducted at the e ective patient management skills end of the second sem ester of the • To provide a program w ith a high third year revealed no seriously level of ethics and professional mismanaged cases and that at responsibility least 95% of cases were m anaged • To provide adequate orthodontic successfully. practitioners for the state of West • All graduates passed the ABO phase Virginia and the profession II written examination successfully • To encourage and assist in before graduation. increasing the supply of orthodontic • All graduates passed the ABO m ock educators clinical examination given by the • To promote and enhance research in three board-certi ed orthodontists

the specialty of orthodontics in the state of West Virginia. Students are required to prepare To achieve these goals and objectives, three cases in ABO style and take graduate students are evaluated every year the oral exam ination as part of the by all faculty on their progress in didactic examination. and clinical work. Graduates are required to take the m ock Am erican Board of Ortho- We will know we are producing gradu- dontics (ABO) examination conducted ates who demonstrate e ective manage- by three board-certi ed orthodontists in ment skills if: the state of West Virginia. In addition, the • Tracking records do not show results of the written ABO exam ination are excessive numbers of emergency evaluated to check if there are de ciencies phone calls, canceled appointments, in the didactic or clinical portion of the and appliance breakage. WVU curriculum. • The entire faculty agrees and Program e ectiveness is evaluated by certi es that 100% of the students both faculty and residents. Faculty and resi- completing the program each year dents are given evaluation form s to indicate have e ective management skills. their perceived e ectiveness of courses, clinical administration, and faculty teach- We will know we are producing gradu- ing. At the tim e of graduat ion, graduates are ates who demonstrate a high level of ethics also asked to participate in an exit interview. and professional responsibility if: Every seven years, the program conducts an alumni survey to gather informa- • Our records show no breaches of tion on how graduates are performing in ethics or professionalism during school year by any student. 6 Postgraduate Orthodontic Education in the United States 45

• Faculty evaluations show no breach program directors appointed after January of ethics or serious professional 1, 1997, who have not previously served as infractions during the year. program directors must be board-certi ed). At W VU, the program director is board- We w ill kn ow th at w e provide adequate certi ed in orthodontics and dentofacial orthodontic practitioners for the state of orthopedics. The program director has West Virginia if: su cient authority and time to achieve • There is no drastic increase the educational goals of the program and or decrease in the num ber of assess the program’s e ectiveness in meet- orthodontists practicing in the ing its goals. The program director spends state of West Virginia. The program 70% of his or her tim e on the graduate pro- m onitors the total num ber of gram to complete his or her educational orthodontists practicing in the and administrative responsibilities. The state. If a drastic reduction occurs, program director has su cient training the program will urge students to and experience in teaching orthodontics practice in the state. and dentofacial orthopedics at both the predoctoral and graduate levels. Periodic We w ill know that the program encour- faculty meetings are held for the proper ages and assists in increasing the supply of function and improvement of an advanced orthodontic faculty if: specialty education program in orthodon- • The survey of alum ni identi es that tics and dentofacial orthopedics. graduates are actively involved in Most of the specialty instruction and teaching in a full-time or part-time supervision is conducted by individuals capacity. who are educationally quali ed in ortho- • The program can maintain a dontics and dentofacial orthopedics. The minimum of three full-time faculty clinical instruction and supervision in and six part-time faculty for the orthodontics and dentofacial orthopedics graduate program. are provided by individuals who have com- • The entire faculty is board-certi ed pleted an advanced specialty education or board-eligible. program in orthodontics and dentofacial orthopedics approved by the Commission We will know that the program is on Dental Accreditation, or by individuals successful in promoting and enhancing who have equivalent education in ortho- research in the specialty of orthodontics if: dontics and dentofacial orthopedics. Full- • At least 50% the completed master’s time faculty members have adequate time theses are published in refereed for their own professional development. orthodontic journals. The number and time commitment of fac- • Every year, graduate students are ulty are su cient to provide full supervi- encouraged to participate and sion of the clinical portion of the program. attend professional meetings and Faculty evaluations are conducted and doc- present their research ndings. umented at least annually. The quality of treatment provided by residents/students in the program is evaluated by: • All faculty for each patient seen 6.3 Standard 2: each semester Prog ram Dire ctor and • Review of all charts by the clinic Teaching Sta director each semester • Preparation of completed cases in ABO st yle The program must be administered by • Survey of patient satisfaction one director who is board-certi ed in the before the removal of orthodontic respective specialty of the program. (All appliances for all patients 46 Orthodontic Postgraduate Education: A Global Perspective

6.4 Standard 3: • Equipment that is subjected to periodic state inspection to ensure Facilities and Resources compliance w ith safety standards • Monitoring of the departm ent of Institutional facilities and resources must radiology by the oral radiology be adequate to provide the educational quality assurance program experiences and opportunities required to ful ll the needs of the educational program as speci ed in these Standards. Equipment 6.4.1 Policies and Procedures and supplies for use in managing medical on the Management of emergencies must be readily accessible and functional. Hazardous Materials and The advanced specialty program needs Blood-Borne and Infectious to document that its facilities and resources Diseases for Patients, are adequate to provide the educational experiences and opportunities required Advanced Education to ful ll the needs of the educational pro- Students/Residents, and Sta gram . At W VU, the equipm ent and supplies for use in managing medical emergencies At WVU, the School of Dentistry maintains are readily accessible. Emergency carts an infectious disease control and biohaz- are ready and functional on demand. The ards committee. Inspections are completed program docum ents its compliance w ith on a regular basis by Occupational Safety the institution’s policy and the applicable and Health Adm inistration (OSHA) compli- regulations of local, state, and federal agen- ance faculty to provide notice of incidents cies, including but not limited to radiation of noncompliance. Correctional measures hygiene and protection, ionizing radiation, are instituted immediately. The faculty hazardous materials, and blood-borne and and sta are required to pass a mandatory infectious diseases. The above policies are annual online course on infection control provided to all students/residents, faculty, and blood-borne pathogens. The infectious

and appropriate support sta and continu- disease control and biohazards com mit- ously monitored for compliance. tee monitors satisfactory compliance with At WVU, the facility o ers compre- infection control, universal precautions, hensive radiologic assessment capability and regulatory waste disposal. Such safety that includes conventional peri-apical and measures include the following: panoramic machines, as well as cephalo- • The provision of sterile instrum ent metric and cone beam computed tomogra- cassettes for all clinical procedures phy units. All residents are trained to take by central sterilization and full-mouth series, panoramic radiographs, dispensing and cephalometric radiographs for their • Mandated full-length, long-sleeve patients. Radiologic protection is ensured clinical disposable cover gowns that by the following: exceed OSHA recommendations/ • Lead aprons and shields for patients requirements • Machines that are triggered from • Continuous printouts that monitor behind lead-lined walls the proper functioning of central • The use of ultra-speed lm to lessen sterilization equipment exposure time • Microban disposable infectious • Automated lm processors with waste containers that are collected fresh solutions to minimize retakes by a special crew each evening and resulting from processing errors incinerated on site • Radiology personnel wearing • Annual mandated blood-borne exposure badges pathogen training/retraining seminar 6 Postgraduate Orthodontic Education in the United States 47

• An infection control manual that is 6.4.3 Instrument Sterilization updated as required • Departmental exposure control and Dispensing of Clinical plans in the case of needlesticks, etc. Supplies • Weekly biological reports that monitor all sterilization equipment At WVU, all instruments are stored as sets • Universal precautions for all patient in marked cassettes and are decontami- treatm ent by all faculty, residents, nated and sterilized at the Suncrest Towne and sta Center Clinic, Morgantown, West Virginia. Students, faculty, and sta obtain wrapped sterile cassettes and clinical supplies from the dispensing window of the “clean” sec- 6.4.2 Handling of Hazardous tion of central processing. Contaminated Waste, Disposal of Hazardous instruments in cassettes are returned to Waste and Hazardous Waste the receiving window of the “contaminated” section of central processing. In the Spills, and Enforcement of contaminated area of central processing is the Dental Hazardous Waste a large washer/decontaminator, through Policy which all instruments in cassettes are pro- cessed. After cleaning, the instruments Once a year, or sooner if noncompliance is within the cassettes are wrapped in the reported, the Health Sciences Center health clean area and then sterilized in either an and safety director inspects each laboratory autoclave or a dry heat sterilizer. for compliance. Noncompliance with any Biological monitoring is conducted in directive is forwarded to the chair or direc- central processing three times each week tor of the speci c department involved. (Monday, Wednesday, and Friday) for the Individuals may be required to attend edu- autoclaves and two times a week (Tuesday cational sessions on the particular noncom- and Thursday) for the dry heat sterilizer. pliance issue, and/or the department may Spores tested for are Bacillus stearother- be ned. mophilus and Bacillus subtilis var. niger. The Annually, all dental school faculty, stu- records of all biological monitoring results dents, and clinical sta are required to take are kept on le for ve years in central an online course in blood-borne pathogens processing. and infection control speci c to the WVU The persons who process all instru- School of Dentistry. This includes informa- ments in central processing work only in tion on blood-borne pathogens; preclini- that area and include the supervisor and cal, clinical, and laboratory asepsis; and seven st a m em bers w h o are t rain ed by t h e infection and biohazard control. Part-time supervisor of central processing and clini- faculty are given a packet containing the cal dispensing. above information, which they must read; they then sign and return a veri cation form to the director of clinical education 6.4.4 Enforcement of the and patient care. In addition, rst-year den- School’s Policy on Preclinical, tal students are presented with a one-hour Clinical, and Laboratory overview of blood-borne pathogens and infection control during orientation week Asepsis and Infection Control in July, as well as a two-hour detailed lecture during the m iddle of the fall sem ester. At WVU, the chair of the infection disease control and biohazards committee of the School of Dentistry coordinates regular inspections of all clinics and laboratories 48 Orthodontic Postgraduate Education: A Global Perspective

in the School of Dentistry. When possible, 6.4.6 Private O ce Facilities these inspections are conducted two times a month by members of the infectious dis- Used as a Means of Providing ease control and biohazards committee. Clinical Experiences in Using the “Infection Control and Safety Advanced Specialty Education Guidelines for the School of Dentistry,” the inspection team visits each clinic and labo- The advanced specialty program should ratory on a designated day and observes all be able to demonstrate that the space faculty, sta , and students. Any violations designated speci cally for the program of these guidelines are recorded on “OSHA is adequate, and that facilities permit the violations” sheets, along with the name students/residents to work e ectively with of the violator. This record of violations is trained allied dental personnel. returned to the o ce of the director of clinical education and patient care. 6.4.7 Radiographic, Biometric, and Data- 6.4.5 Infection Control Collecting Facilities Readily Policies Provided to All Available to Document Both Students, Residents, Faculty, Clinical and Research Data and Appropriate Support Sta and Continuously The advanced specialty program should be Monitore d fo r Compliance able to demonstrate that imaging equipment is available for collecting radiographic and The program should be able to demonstrate biometric data, and that students/residents that all students, faculty, and sta interfac- in the orthodontic program have access to ing with patients are apprised of the proto- adequate space, equipment, and physical col and periodic upgrades. All orthodontic facilities to do research. At WVU, adequate

instruments are centrally sterilized. The secretarial, clerical, dental auxiliary, and infectious disease control and biohazards technical personnel are provided to enable committee performs periodic inspections students/residents to achieve the educa- of the clinic to make sure that all stu- tional goals of the program. Su cient space dents, sta , and faculty comply with OSHA is provided for the storage of patient records, requirements. All new graduate students models, and other related diagnostic mate- are required to take the OSHA course, and rials. These records and materials should all sta , students, and faculty are required be readily available to e ectively document to take the OSHA update each year. active treatment progress and immediate as Policies on blood-borne and infectious well as long-term results of treatment. diseases are m ade available to applicants for admission, and patients. Students/residents, faculty, and appropriate support sta encouraged to be immunized against and/ 6.5 Standard 4: or tested for infectious diseases, such as Curriculum and mumps, measles, rubella, and hepatitis B, Program Duration before contact with patients and/or infectious objects or materials, in an e ort to m in im ize t h e r isk to p at ie n t s an d d en t al p e r- 6.5.1 Curriculum Approach: sonnel. All students/residents, faculty, and Evidence-Based Dentistry support sta involved in the direct provision of patient care are continuously recognized/ Evidence-based dentistry is an approach to certi ed in basic life support procedures, oral health care that requires the judicious including cardiopulmonary resuscitation. integration of systematic assessments of 6 Postgraduate Orthodontic Education in the United States 49 clinically relevant scienti c evidence, relat- tion and culm inates in the award of a m as- ing to the patient’s oral and medical condi- ter of science degree and a certi cate in tion and history, with the dentist’s clinical orthodontics. expertise and the patient’s treatment needs and preferences (adopted by the American 6.5.3 Biomedical Sciences Association of Orthodontists House of Del- egates, May 24, 2005).3 Curriculum The advanced orthodontic education program should provide special knowl- Advanced specialty programs must be able edge and skills beyond training for the to show that their graduates are competent DDS or DMD degree and orientation to the to: accepted standards of specialty practice. a. Develop treatm ent plans and The program should include instruction diagnoses based on information about and learning experiences in evidence- normal and abnormal growth and based practice. This inform ation allows development graduates to judiciously integrate clinically b. Use the concepts gained in em bryology relevant judgments based on scienti c evi- and genetics in planning treatment dence with the patient’s treatment needs and preferences in mind. At WVU, these c. Include knowledge of anatomy and instructions include: histology in planning and carrying out treatment • Formal instruction (a module/ d. Apply knowledge about the diagnosis, lecture m aterials) on evidence- prevention, and treatment of diseases based practice of the oral tissues • Case presentations that integrate aspects of evidence-based practice At WVU, biom edical science m odules • Literature review seminars in anatomy, microbiology, and pharmacol- • Projects/portfolios that include ogy are provided to ensure that the stu- critical reviews of the literature dents gain advanced knowledge in these disciplines and can apply this know ledge to according to evidence-based practice principles (“search of direct patient care. publication databases and appraisal of the evidence”) • Assignments that include 6.5.4 Clinical Sciences publication database searches and Curriculum literature appraisal for best evidence to answer patient-focused clinical Advanced specialty programs must be able questions to show that their clinical sciences curriculum is evidence-based. At WVU, the 6.5.2 Program Duration: curriculum is designed to ensure that the literature reviewed is applied to clinical Advanced Specialty Education treatment decisions, current systematic lit- Programs in Orthodontics erature reviews are integrated with treat- and Dentofacial Orthopedics ment conferences, and ethics are applied to Must Be a Minimum of 24 patient management. The clinical training in orthodontics Months and 3,700 Scheduled should be extensive, with comprehensive Hours in Duration clinical experience that is representative of the character of orthodontic problems All advanced specialty education programs encountered in private practice. Students/ must adhere to the program duration set residents should be able to acquire experi- forth by the accreditation guidelines. At ence in the treatment of all types of mal- WVU, the program is 34 months in dura- occlusion, whether in the permanent or 50 Orthodontic Postgraduate Education: A Global Perspective

transitional dentition, and their experience m. Practice orthodontics in full should include treatment of the primary compliance w ith accepted standards of dentition, when appropriate. At WVU, ethical behavior graduates are competent to: n. Manage and motivate patients to a. Coordinate and document detailed participate fully with orthodontic interdisciplinary treatment plans that treatment procedures m ay include care from other providers, o. Study and critically evaluate the such as restorative dentists, oral and literature and other information m axillofacial surgeons, or other dental pertaining to this eld specialists Other than clinical training, gradu- b. Treat and manage developing ates must have an understanding of the dentofacial problems that can be following areas as part of the supporting minimized by appropriate and timely curriculum: intervention c. Use dentofacial orthopedics in a. Biostatistics the treatment of patients when b. History of orthodontics and dentofacial appropriate orthopedics d. Treat and m anage m ajor dentofacial c. Ethics and jurisprudence abnormalities and coordinate care with d. Oral physiology oral and m axillofacial surgeons and e. Pain and anxiety control other health care providers f. Pediatrics e. Provide all phases of orthodontic g. Periodontics treatment, including initiation, h. Pharmacology completion, and retention i. Preventive dentistry f. Treat patients w ith at least one contemporary orthodontic technique j. Psychological aspects of orthodontic and dentofacial orthopedic treatment g. Manage patients with functional k. Public health aspects of orthodontics occlusal and temporomandibular disorders and dentofacial orthopedics h. Treat or manage the orthodontic l. Speech pathology and therapy aspects of patients w ith m oderate or m. Practice management advanced periodontal problems n. Various recognized techniques used in i. Develop and document treatment contemporary orthodontic practice plans w ith the use of sound principles of appliance design and biom echanics j. Obtain and create long-term les of quality im ages of patients by 6.6 Standard 5: using techniques of photography, Eligibility and Selection radiology, and cephalometrics, including computer techniques, when of Advanced Education appropriate Students and Residents k. Use dental m aterials knowledgeably in the fabrication and placem ent of xed Eligible applicants to advanced specialty and rem ovable appliances education programs accredited by the Commission on Dental Accreditation must l. Develop and m aintain a system of long- be graduates of: term treatment records as a foundation for understanding and planning a. Predoctoral dental programs in treatment and retention procedures the United States accredited by the Commission on Dental Accreditation, or 6 Postgraduate Orthodontic Education in the United States 51 b. Predoctoral dental programs in Canada nature of their assignments to other depart- accredited by the Commission on ments or institutions and teaching com- Dental Accreditation of Canada, or mitments. Teaching commitments cannot c. International dental schools that exceed 10% of the curriculum. Additionally, provide equivalent educational all advanced specialty education students/ background and standing as residents should be provided with written determined by the program information that a rms their obligations and responsibilities to the institution, the The admission of students/residents program , and the program faculty. with advanced standing must be based on the same standards of achievement required of students/residents regularly enrolled in the program. Transfer students/ 6.9 Standard 6: Research residents with advanced standing m ust receive an appropriate curriculum that Advanced specialty education students/ results in the same standards of compe- residents m ust engage in scholarly activity. tence required of students/residents regu- At WVU, students/residents are larly enrolled in the program . A committee required to initiate and complete a research of orthodontic faculty members must be project that includes a critical review of responsible for the selection of students/ the literature, development of a hypoth- residents for postdoctoral training unless esis, statistical analysis, and interpretation the program is sponsored by a federal ser- of data, culminating in an original written vice utilizing a centralized student/resident thesis. They are also required to defend selection process. At WVU, the selection their theses orally in front of a committee and interview process is included in the of faculty and peers. A draft of the manu- program policies and is documented on the script is required to be subm itted and pub- sch ool’s w ebsite an d in t h e m in u tes of com - lished in peer-reviewed journals following mittee meetings. program graduation.

References 6.7 Due Process 1. Accreditation standards for advanced spe- The institution or program should have cialty education program s in Orthodontics and Dentofacial Orthopedics. Commission speci c written due process policies and on Dental Accreditation, www.ada.org procedures for the adjudication of aca- 2. Comm ission on Dental Accreditation. Ac- demic and disciplinary complaints that creditation standards for advanced spe- parallel those established by the sponsor- cialty education program s in orthodontics ing institution. and dentofacial orthopedics. http://www. ada.org/~/media/CODA/Files/ortho.ashx. Accessed January 25, 2015 3. American Association of Orthodontists 6.8 Rights and House of Delegates, May 24, 2005. http:// Responsibilities uthscsa.edu/vpaa/accreditation/docs/coda_ standard_4_1_orthodontics.pdf. Accessed May 27, 2015 At the time of enrollment, advanced specialty education students/residents should be apprised in writing of the educational experiences to be provided, including the Orthodontic Specialty 7 Education in Canada

William A. Wiltshire

Canada, the second largest country in the equating to approximately 7 million Cana- world, has an area of 9,984,670 square kilo- dians in total.3 meters; it ranks 37th in population density, with 35,427,524 inhabitants.1,2 The report of the Canadian Dental Association, “Den- 7.1 Regulatory tal Health Services in Canada,” estimates that there were 19,563 licensed dentists in Organizations Governing Canada in January 2010, of whom 11% were Orthodontic Education specialists. Orthodontists accounted for the and Practice in Canada highest number of specialists in Canada, with a total of 735.3 By June 30, 2013, the numbers had increased to 20,616 dentists 7.1.1 Commission on Dental and 790 orthodontists. Accreditation of Canada There are 10 dental schools across Canada graduating approximately 512 The CDAC head o ce, situated in Ottawa, dentists per year, and six have orthodontic Ontario, establishes the minimum national programs: the University of Toronto, Uni- guidelines for orthodontic education in

versity of Western Ontario, and University Canada. It establishes site visits to Canadian of Montreal (the French language univer- programs every seven years. The reviewer sity o ering an orthodontic program) in has the opportunity to make recommen- the provinces of Ontario and Quebec; the dations to the program in areas where University of Manitoba and University of weakness or de ciency exists. When a rec- Alberta in the prairie provinces; and the ommendation is made, it is expected that University of British Columbia in the west. the program will address the issue. When All dental schools and orthodontic pro- issues are identi ed that may improve or grams are in publicly funded universities.3 enhance a program, the reviewer may make The University of Toronto orthodontic pro- suggestions that are meant to be helpful to gram is the oldest in Canada, established in the program. The accreditation require- 1945, followed by the University of Mon- ments for orthodontics were last updated treal (1947), University of Manitoba (1966), on November 30, 2013.5 In 2014, all six University of Alberta (1969), University of Canadian programs were accredited. Western Ontario (1973),4 and University of British Columbia (2010). Dental Health Services Canada states 7.1.2 Commission on Dental that 4.1% of Canadians were receiving orth- Accreditation odontic treatment in 2010; 18% of these were adolescents and 6.2% were children. The CODA is the o cial accreditation body It was estimated that by 2010, almost 20% in the United States. Its o ces are located of Canadians had received or were in the in Chicago, Illinois. By reciprocal agreement, orthodontic programs in Canada that 52 process of receiving orthodontic treatment, 7 Orthodontic Specialty Education in Canada 53 are recognized by the CDAC are also rec- Applications to challenge the exam inations ognized by the CODA in the United States, are due by mid-September of the previous and vice versa.6 This reciprocal agreement year. Candidates failing Component II three allows orthodontic graduates of accred- times are required to retake Component I ited program s in North Am erica (CDAC and within a ve-year window before attempt- CODA) to be able to challenge the American ing to retake Com ponent II.7 Board of Orthodontics examination, which Orthodontists who graduated from is regarded as an excellence examination, as non-accredited programs may opt to write w ell as the Royal College of Dentists of Can - the dental specialty core knowledge exami- ada (RCDC) national dental specialty man- nation (DSCKE), which is a general den- datory licensing examinations in Canada. In tistry examination administered by the Canada, all orthodontic graduates of pro- National Dental Examining Board of Can- grams in the United States and Canada are ada (NDEB); if su ccessfu l, th ey m ay ap p ly to required to pass the RCDC examinations to one of the Canadian orthodontic programs be licensed to practice as specialist ortho- that o er dental specialty assessment and dontists anywhere in Canada, subject to training programs (DSATP). An alternative immigration or work permit requirements. pathway is an academic pathway. In this pathway, an applicant is required to have a full-time academic appointment at the 7.1.3 Royal College of rank of assistant professor or higher and Dentists of Canada to have been in that position for at least 12 months. The applicant also needs to have The RCDC was established by an act of the taken the DSCKE and must obtain a letter federal government of Canada in 1965 to from the program director and the dental maintain high standards of specialty prac- regulatory authority supporting his or her 8 tice in Canada. Applicants for fellowship in application to take the RCDC examination. the RCDC may challenge the examinations The fees levied to challenge the RCDC via d irect ap p licat ion on ly if t h ey h ave com - examinations in August 2014 were as fol- 9 pleted their specialty training at an accred- lows : application fee: C$500; Component ited North American program in Canada or I: C$1,000; Component II: C$4,500; total: the United States. Successful candidates are C$6,000. then admitted as fellows of the RCDC and may use the FRCD(C) designation if they are successful in both components of the 7.1.4 National Dental examination. Examining Board of Canada The RCDC examination is a mandatory credential of all the dental regulatory The NDEB was established in 1952 by authorities in the 13 Canadian provinces an act of the Canadian Parliament and is and territories. To obtain fellowship in responsible for establishing qualifying con- the RCDC, the dental specialty program is ditions for a national standard of dental required to provide proof to the RCDC that competence.10 the applicant has graduated from an The NDEB adm inisters the DSCKE, w hich accredited program, and in addition, a let- is a requirement for all applicants for entry ter is required from the registrar of the to the DSATP and the RCDC examinations relevant dental regulatory authority con- for orthodontists from non-accredited pro- rming that the candidate has the relevant grams. This nine-hour examination consists moral and ethical standing in the profes- of four components taken over two days. sion. RCDC examinations are o ered once Applicants may retake the examination only annually, Component I in March each year once. and Component II in June. Candidates who Spaces for the DSATP are presently lim- fail the examination may apply to retake it ited to one applicant for those of the six following payment of the examination fees. programs annually accepting DSATP stu- 54 Orthodontic Postgraduate Education: A Global Perspective

dents. The results of the DSCKE are used to its role as being the o cial voice of gradu- evaluate and select, among others, success- ate orthodontic education in Canada. ful applicants for the DSATP. The CCGOPD meets twice a year, at the Application fees for the DSCKE are as annual CAO meeting in September and at follows11: application fee: C$1,500; exami- the annual American Association of Ortho- nation fee: C$3,000; total fees: C$4,500. dontists (AAO) meeting in April/May. Edu- The total estimated fees for an ortho- cational issues at the provincial, national, dontist from a non-accredited program to North American, and international levels go through the pathway process for fellow- a ecting orthodontic education are dis- ship in the RCDC, provided that the appli- cussed, as well as strategies formulated cant passes all the examinations the rst to aid in the recruitment and retention of time around and depending on the indi- academ ic sta . It also puts system s in place vidual assessment and training fees at the each year regarding the “Canadian match” di erent universities o ering the DSATP, for applicants to Canadian programs, ensur- can be on th e order of th e follow ing: DSCKE ing that dates do not clash nationally or process: C$4,500; RCDC process: C$6,000; with the U.S. match program. The CCGOPD DSATP process: C$65,000; total: C$75,500. also meets with representatives of exter- These estimated fees do not include living nal organizations, such as the CAO, dental expenses and the costs of transportation, regulatory authorities, RCDC, and CDAC, on instruments, textbooks, and conference an as-needed basis to discuss matters of attendance, among others. mutual interest and concern.

7.2 Canadian Council of 7.3 Graduate Orthodontic Graduate Orthodontic Programs in Canada Prog ram Dire ctors There are some 72 accredited graduate orthodontic programs in North America, The Canadian Council of Graduate Orth- odontic Program Directors (CCGOPD) was six of which are in Canada. Although all established in Toronto in 2002 at a joint Canadian programs and many American meeting of the educational executives of programs now have a minimum length the Canadian Association of Orthodontists of 35 to 36 months, there remain several (CAO: Drs. Gerry Solom on, Richard Marcus, American programs that are 24 months and Donald Robertson) and the orthodon- in length. The lengths of the programs do tic program directors of the ve programs not a ect accreditation or the reciprocal at the time. The inaugural members of agreement between Canada and the United the CCGOPD were Drs. Antonios Maman- States.12 The CCGOPD strongly supports 35- dras (Western Ontario), Bryan Tompson or 36-month minimum program lengths, (Toronto), Claude Remise (Montreal), Wil- which represent the “Canadian standard,” liam Wiltshire (Manitoba), and Paul Major and are of the opinion that the RCDC should (Alberta); Dr. Claude Remise was elected limit its access to licensing exam inations the inaugural chair. The CCGOPD added the to graduates from accredited programs in University of British Columbia to its ranks the United States and Canada, which are a in 2010 after the commencement of its new m inim um of 35 to 36 m onths in length. The program , w ith Dr. Edw in Yen serving as the programs in Alberta and Montreal are 35 program director. Dr. Carlos Flores-Mir has months in length, and the other four pro- replaced Dr. Paul Major as the program grams are 36 months long. director at Alberta. Dr. William Wiltshire In most European countries, programs currently chairs the CCGOPD. The CCGOPD also have a m inimum length of 36 m onths, is an independent council of Canadian edu- which appears to be the “international stan- cators who are program directors and sees dard.”13 The Canadian programs all require 7 Orthodontic Specialty Education in Canada 55 a master’s degree research project and a 7.4.1 The Accreditation thesis defense. The United States also has accredited hospital-based programs that Document are not necessarily associated with dental The accreditation document is divided into faculties/schools or colleges. However, all nine sections: Canadian orthodontic programs are university-based, and all are also attached to 1. Program information medical schools. 2. Institutional structure In Canada, the deadlines for applica- 3. Educational program tions for admittance to the rst-year programs vary between July 1 and October 4. Administration, faculty, and faculty 1. The Canadian rst-year residents start development their programs from June to August each 5. Educational support and services year.12 Tuition fees across Canada vary from 6. Clinic administration C$3,300 to C$48,000 for Canadians and 7. Research and scholarly activities permanent residents. International stu- 8. Program relationships dents’ fees vary from C$22,000 to C$68,000. 9. Appendix A: dental specialty Some U.S. programs charge as much as assessment and training program US$80,000 to US$111,000, whereas others charge no tuition and in addition pay a stipend to their residents. The Canadian programs do not pay stipends, other than that 7.4.2 Curriculum Content some programs assist their residents with travel stipends to attend scienti c confer- The curriculum content consists of basic ences. The CAO also provides some travel sciences and clinical sciences. The didac- assistance to residents who are presenting tic program list does not represent course research papers at the annual CAO confer- content, but rather the necessary knowl- ence in Canada.12 edge, skills, and behaviors within the scope In total, Canadian programs graduate and depth required for a specialt y program . 14 approximately 21 orthodontists per year. This must include the following : An estimated 50 applicants challenged the • Anatomy of the head and neck RCDC e xa m in a t io n s in 2 0 1 4 , s u gge st in g t h at • Biology of orthodontics and there are more graduates of non-Canadian dentofacial orthopedics program s taking the RCDC exam inations. It • Biostatistics is clear t h at t h e largest grou p in creasing t h e • Cephalometrics potentially eligible orthodontic workforce • Craniofacial growth and in Canada are the graduates of accredited development United States–based programs. • Design, fabrication, and manipulation of removable, functional, and xed appliances • Diagnostic techniques and analyses 7.4 The Commission • Ethics on Dental Accreditation • Etiology of dentofacial malrelations • Evidence-based clinical decision of Canada Graduate making Orthodontic Curriculum • History of orthodontics and dentofacial orthopedics The curricula of the six Canadian graduate • Literature review and scienti c orthodontic programs are governed by the writing CDAC.14 • Management and orthodontic correction of malocclusions in: – Medically compromised patients 56 Orthodontic Postgraduate Education: A Global Perspective

– Patients w ith clefts palate and they had received the appropriate number other facial deform ities of formal didactic teaching sessions and – Patients w ith amount of dedicated and protected aca- temporomandibular disorders demic time. All residents indicated that – Patients requiring their programs o ered training in numer- interdisciplinary treatment plans ous treatment philosophies: 93.18% said • Neurophysiology they had su cient clinically based training, • Occlusion and 72.73% indicated that their research- • Pathology of oral system s based training was su cient. All respond- • Orthodontic materials ing residents indicated that they would • Orthognathic surgery complete more than 30 patients from start • Physiology to nish, and 25% estimated completion of • Practice management more than 70 patients by graduation. Resi- • Psychological aspects of orthodontic dents said they would complete on average and dentofacial orthopedic treatment 5 orthognathic surgeries, 24 extractions, 31 • Radiology non-extractions, 8 adults, and 13 patients • Rationale for orthodontic with mixed dentition. Only 50% said that treatment14 their programs contained care for disabled or underserved patients. Most (86.36%) Regarding the clinical requirem ents of said they felt they would be adequately pre- the Canadian programs, the CDAC accredi- pared to provide unsupervised orthodontic tation requirements state that14: care after graduation. These orthodontic A graduate of an advanced specialty residents indicated that they collaborated education program in orthodontics and most with the disciplines of oral surgery, dentofacial orthopedics must be com- periodontics, and prosthodontics. However, petent to provide all active phases of only 52.27% indicated that they had a for- treatment and retention, diagnose and mal interdisciplinary program for treating treatment plan, malocclusion, manage patients. In conclusion, Canadian orthodon- developing problems, patients requiring tic residents are satis ed with the didactic, orthognathic surgery and exposure and clinical, and research aspects of their pro- orthodontic eruption of impacted teeth. grams. They receive comprehensive instruc- Radiographic interpretation and systemic tion with the opportunity to complete a condition recognition is also required. signi cant number of patients, employing a There must be opportunities to provide variety of treatment approaches.15 treatment for patients who are medically com- In another study, Noble et al16 investigated promised or who have craniofacial di erences the motivation of orthodontic residents in or temporomandibular joint disorders.14 In Canada and the United States to treat patients general, students in Canadian programs start with craniofacial anomalies, cleft lip and pal- bet w een 50 an d 70 n ew patien ts an d com plete ate, and special needs. Residents who indicated approximately 75% of their patient starts. that they would not treat these patients cited limited experience and inadequate expertise as the reasons. Fewer than 30% indicated a willingness to pursue a fellowship program.16 7.5 Residents’ Evaluation of Orthodontic Programs in Canada 7.6 Challenges Facing

Noble et al15 explored residents’ evaluations Orthodontic Graduate of orthodontic programs in Canada. A total Education in Canada of 44 residents responded, for a participation rate of 81.48%. Overall, 86.36% of the Undergraduate orthodontic programs across responding residents were satis ed with Canada teach varying amounts of clinical their program. Respondents said they felt orthodontic techniques, from removable 7 Orthodontic Specialty Education in Canada 57 appliances limited to interceptive ortho- ments have mandated that an orthodontist dontics to full xed braces. General dentists have ABO eligibility in the United States or also attend orthodontic continuing educa- the FRCD(C) designation in Canada to be tion courses across Canada and the United appointed as a program director. Exten- States, many of which emphasize full xed sive experience as a clinician and exten- procedures. The introduction of clear aligner sive research credentials are not part of therapy has also found favor among many the stated requirements. This could well general dentists, who are attending training be a re ection of the continued di culty courses and providing increasing numbers of recruiting academics with many years of orthodontic patient starts, from basic to of experience in the clinical, research, and advanced orthodontic care, with braces and administration areas. clear aligners. Whether dentists are also Another challenge is the lure of “quick and being schooled in the more advanced diag- easy orthodontics” o ered to general dentists. nostic and treatment-planning skills and Orthodontic treatment is being advertised as biomechanics to mirror and complement possibly being completed in as short a time as the complexity of their orthodontic treat- t h ree or six m on t h s, often w it h t h e u se of on ly ment starts is unknown. A recent survey one arch w ire and often w ith a focus on align - indicated that 15.4% of Canadian dentists ment of the “social six” as the only treatment provide full xed orthodontic treatment, goal. This comes at a time when the num- while the cohort of dentists with 5 to 24 ber of new orthodontic specialists in Canada years of experience treat up to 19% of full increased by 55 in the two and one-half xed cases themselves, which include orth- years between the end of 2010 and June of odontic–orthognathic surgical cases.17 201317 (deaths and retirements not taken into The increase in the numbers of ortho- account). Of further note is the potential m ar- dontists graduating from the increased keting of a “do-it-yourself orthodontic kit” numbers of new orthodontic programs containing a do-it-yourself impression and starting across North America is also note- advertised as requiring no professional ser- worthy, particularly because patient starts vices by either a dentist or an orthodontist.18 are often related to socioeconomic factors. Thus, the future challenges facing the De sp it e t h e in cr e a s e d p r o d u c t io n o f o r t h o - orthodontic profession in Canada are many dontists, there remains a very real concern and varied. Indeed, an ever-changing land- regarding the shortage of full-time academic scape demands that leaders in orthodontics orthodontists. It is becoming increasingly dif- continually step forward, be willing and cult to nd orthodontic program directors able to face these challenges head on, and with eight or more years of clinical experi- be prepared to lead Canadian orthodontists ence and a signi cant body of research and to m eet th ose ch allenges as a u n i ed grou p, peer-reviewed publications in journals of always with the best interests of the Cana- high standing to m anage our program s. dian public in mind. New graduates with high levels of debt May the noble Hippocratic Oath always and the threat of tenure denial if they fall be forem ost in our m inds as we continue to short of research production requirements endeavor to serve the Canadian public to and expectations of research funding are the best of our abilities: I w ill prescribe reg- reluctant to enter academia, particularly im en s for t h e good of m y p at ie n t s accord in g with non–market-related salaries on o er. to my ability and my judgment and never While the quantity of orthodontic pro- do harm to anyone.19 grams is undoubtedly on the rise, there is a concern regarding the lim ited number of orthodontic educators who have earned References higher degrees, such as master’s and doc- 1. List of countries by population. http:// toral (PhD/DSc) credentials, and who have en.wikipedia.org/wiki/List_of_countries_ acquired signi cant research and clinical by_population. Published 2014. Accessed experience before being appointed as pro- July 18, 2014 gram directors in North America. From 2. List of countries and dependencies by area. January 1997, CODA and CDAC require- http://en.wikipedia.org/wiki/List_of_coun- 58 Orthodontic Postgraduate Education: A Global Perspective

tries_and_dependencies_by_area. Accessed 12. Graduate Orthodontic Programs. https:// July 18, 2014 www.aaoinfo.org/system/ les/media/docu- 3. Dental health services in Canada. http:// ments/Graduate%20Orthodontic%20Pro- www.med.uottawa.ca/sim/data/Den- grams%20Form%20-%20Aug%202014.pdf. tal/Dental_Health_Services_in_Canada_ Published 2014. Accessed August 20, 2014 June_2010.pdf. Published 2010. Accessed 13. Athanasiou AE, Darendeliler MA, Eliades T, July 18, 2014 et al; World Federation of Orthodontists. 4. Haryett RD. A history of orthodontics in World Federation of Orthodontists (WFO) Canada. Toronto, Ontario: Canadian Asso- guidelines for postgraduate orthodontic ciation of Orthodontists; 2008 education. World J Orthod 2009;10(2): 153–166 5. Com mission on Dental Accreditation of Canada (CDAC). https://www.cda-adc.ca/ 14. Accreditation requirements for orthodon- cdacweb/en/. Published 2013. Accessed Au- tics and dentofacial orthopedics programs. gust 9, 2014 https://www.cda-adc.ca/cdacweb/_files/ OrthodonticsRequirements.doc. Updated 6. Com mission on Dental Accreditation (CODA). http://www.ada.org/en/coda/ac- November 30, 2013. Accessed August 30, creditation/about-us/. Published 2014. Ac- 2014 cessed August 9, 2014 15. Noble J, Hechter FJ, Karaiskos NE, Wilt- shire WA. Resident evaluation of orth- 7. The Royal College of Dentists of Canada. http://www.rcdc.ca/en?CFID=14817192& odontic programs in Canada. J Dent Educ CFTOKEN=1ca1af0dd6507912-591AF326- 2009;73(2):192–198 B3E4-5485-8DCB1E6E3803DFD4. Pub- 16. Noble J, Schroth RJ, Hechter FJ, Huminicki A, lished 2014. Accessed August 6, 2014 Wiltshire WA. Motivations of orthodontic residents in Canada and the United States to 8. The Royal College of Dentists of Canada. International candidates. http://www.rcdc. treat patients with craniofacial anomalies, ca/en/international-candidate. Published cleft lip/palate, and special needs. Cleft Pal- 2014. Accessed August 9, 2014 ate Craniofac J 2012;49(5):596–600 17. Aucoin M, Wiltshire WA, Hechter FJ, Torchia 9. The Royal College of Dentists of Canada. Fees structure. http://www.rcdc.ca/en/ex- M. Provision of orthodontic care by den- amination/fees. Published 2014. Accessed tists in Canada and certi ed orthodontists’ perspectives. Presented at: 66th Annual

August 9, 2014 Scienti c Session - Canadian Association of 10. National Dental Examining Board of Canada Orthodontists; September 4–6, 2014; Mon- (NDEB). ht tp://w w w.ndeb.ca/about. Pub- treal, Quebec, Canada lished 2014. Accessed August 9, 2014 18. Do-it-yourself orthodontic kit and method. US 11. National Dental Examining Board of Canada. Patent and Trademark O ce patent applica- Graduates of eligible non-accredited dental tion 20060105287. http://www.freshpatents. specialty programs. Fees. http://www.ndeb. com/Do-it-yourself-orthodontic-kit-and- ca/non-accredited-specialty/fees. Published method-dt20060518ptan20060105287.php. 2014. Accessed August 9, 2014 Patent led 2004. Accessed August 30, 2014 19. The Hippocratic Oath. http://en.wikipedia. org/wiki/Hippocratic_Oath. Published 2014. Accessed January 26, 2015 Orthodontic Specialty 8 Education in Latin America

Julia F. de Harf n

La t in Am e r ic a is t h e s u b r e g io n o f t h e Am e r ic a s need for speci c studies and training led to that includes the countries where Romance the formation of schools that specialized in languages are spoken—mostly Spanish and dentistry. Portuguese. There are 22 countries in Latin America; they start at the southern border of the United States, include the Caribbean region, and extend across South America 8.2 The Role of (Ta b l e 8 . 1 ). Lat in Am erica h as a w ealth of cu l- Orthodontic Societies ture. The countries of this region share many in Latin America features, but they also di er greatly from one another in numerous aspects. Orthodontic societies are of singular importance in every country in Latin America. Their mission is to develop and ensure the quality of orthodontic practice. They aim 8.1 Brief History of to make signi cant contributions to oral Dentistry in Latin America health, foster research, and maintain the

highest standards in education and spe- The practice of dentistry is almost as cialized training. Thanks to the guidelines ancient as the history of humanity and that the World Federation of Orthodontists civilization. In regard to the history of (WFO) has provided,1 it is now m uch easier dentistry, in most of the countries of Latin to evaluate the functioning of postgraduate America, the beginnings were similar. Den- programs. The real di erences are related tal problems and needs have existed since to how health and education laws within ancient times. A diversity of dental treat- each country and/or region are applied ments and remedies has been present in and implem ented. In som e countries, orth- Latin America since before colonial tim es. odontic societies are invited to assist the In many countries, there are chronicles Ministry of Education or Ministry of Health that provide information about the di er- in determining the best way to recognize ent kinds of dental treatment that Native orthodontic specialists. Americans performed before the arrival of the rst colonials. After the start of Euro- pean colonization, dental treatment began to evolve. It was provided by monks, mili- 8.3 Orthodontic tary o cers, and later barbers. Ultimately, medical doctors became responsible for Postgraduate Programs dental treatment. Most of these doctors in Latin America came from North America and from France, among other European countries. In the In general terms, the programs include late 1700s and early 1800s, as universi- theoretical and clinical hours, although ties started to appear in Latin America, the the number of hours varies greatly from 59 60 Orthodontic Postgraduate Education: A Global Perspective

Table 8.1 Subregions of Latin America in North America, Central America, and South Am e ric a

Country Population Area, km 2

North America

Mexico 103,460,000 1,958,000

Central America

Costa Rica 4,667,096 51,100

El Salvador 6,108,590 21,040

Guatemala 15,438,384 108,890

Honduras 8,555,072 112,090

Nicaragua 5,788,531 130,373

Panama 3,661,868 78,200

South America

Argentina 41,660,417 2,766,890

Bolivia 10,461,053 1,098,580

Brazil 201,032,714 8,514,877

Chile 17,556,815 756,950

Colombia 47,387,109 1,138,910

Ecuador 15,439,429 283,560

Guyana 772,298 214,999

Paraguay 6,800,284 406,750

Peru 30,475,144 1,285,220

Suriname 472,000 16,327

Uruguay 3,324,460 17,622

Venezuela 31,648,930 91,645 8 Orthodontic Specialty Education in Latin America 61 one country to another, and each program 8.3.1 Postgraduate has some unique characteristics. Some require that residents begin and complete Orthodontic Curriculum a certain number of cases, whereas oth- Although the curricula in postgraduate ers do not. The program requirements also programs in orthodontics vary from coun- di er in regard to the number of patients try to country, m any have a lot in com m on. each resident must treat. Orthodontic A typical curriculum in most current pro- societies, in conjunction with universities, grams is the following: should encourage and motivate colleagues to become actual specialists in orthodontics. In regard to the number of residents, the number of those accepted into each Firs t ye a r program varies widely. Some universities • Prenatal growth and development admit ve residents into an entire two- or • Biology of tooth m ovem ent three-year program, whereas others admit • Research fundamentals I and II ve to seven new students per year into a • Basic orthodontic diagnosis three-year program (total of 15 to 21 resi- • Development of dentition and dents at the same time). The criteria for the occlusion I and II selection of residents vary not only among • Biophysics and biomechanics countries but also within each country. • Preclinical orthodontics I Some countries require that the future resi- • Basic clinical orthodontics I and II dent have two to three years of practice in • Seminars in surgical orthodontic general dentistry before acceptance in the cases I and II orthodontic program. Others require ve • Techniques in orthodontics years of experience as a general practitio- • Dentofacial anomalies I ner. This requirement has advantages and • Assessm ent and m onitoring of cases disadvantages. Some programs have fewer I and II requirements and prefer that residents • Bioethics begin the program as soon as they n-

• Basic biomechanics ish their undergraduate dental program. • Research in orthodontics I Another signi cant di erence is related to • Growth and postnatal development residents’ participation in research proj- • Biology of craniofacial development ects. Some postgraduate programs require • Orthodontic clinic in adults I the completion of a research project to • Relations of orthodontics with other m eet the program objectives, whereas oth- specialties I ers do not. In most cases, a research paper, • Basic corrective orthodontic clinic I monograph, or nal paper is required for each resident to complete the program. Second year

• Relations of orthodontics with other specialties II • Intermediate biomechanics • Basic and advanced applied biomechanics • Orthodontic management I • Orthodontic clinic in adults II and III • Orthodontic diagnosis intermediate and advanced • Intermediate corrective orthodontic clinic 62 Orthodontic Postgraduate Education: A Global Perspective

• Seminars in surgical orthodontic 8.3.1.3 Orthodontic Postgraduate cases III and IV Programs in the Dominican Republic • Early treatm ent clinic I and II • Interdisciplinary clinical cases The only recognized full-time program • Dentofacial anomalies II available is three years long and includes • Research in orthodontics II and III approximately 4,380 hours. Each group has • Assessm ent and m onitoring of cases four to ve students. III and IV • Advanced biomechanics 8.3.1.4 Orthodontic Postgraduate • Intermediate corrective orthodontic Programs in Colombia clinic II • Dentofacial anomalies III For the Colombian Society of Orthodontics • Occlusion and temporomandibular to recognize a postgraduate program, it joint disorders (TMD) basic must be at least 3,000 hours long, interns • Retention I must be in attendance ve days a week, each day must be six to eight hours long, and nally the program must belong to Third year a dental school that has previously been approved. • Cleft lip and palate I and II • Early treatm ent clinic III and IV 8.3.1.5 Orthodontic Postgraduate • Assessment and monitoring of early Programs in Venezuela treatm ent cases I and II • Orthodontic clinic in adults IV and V Two programs that specialize in orthodon- • Advanced orthodontic clinic I and II tics are recognized by the Society of Ortho- • Orthodontic management II dontics of Venezuela. Both follow WFO • Dentofacial anomalies IV and V guidelines and are full-tim e two-year pro- • Orthodontic research IV gram s w ith an average of nine students per • Seminars in surgical orthodontic course. cases V and VI • Retention II and III 8.3.1.6 Orthodontic Postgraduate • Assessm ent and m onitoring of cases Programs in Ecuador V • Occlusion and TMD intermediate Four programs that specialize in orthodon- and advanced tics are recognized. All of them are full- • Orthodontic management III time, two and one-half-year programs with • Assessm ent and m onitoring of cases an average of seven to eight students per V and VI course.

8.3.1.1 Orthodontic Postgraduate 8.3.1.7 Orthodontic Postgraduate Programs in Guatemala Programs in Brazil

Tw o p r ogr a m s a re re cogn ize d in Gu at e m a la . Although m ore than 200 program s are currently available in Brazil, only 23 meet WFO 8.3.1.2 Orthodontic Postgraduate guidelines. The programs have a duration of Programs in Panama two to three years.

Two programs are recognized in Panama. Both last two and one-half to three and one-half years. One program allows 8 students per course and the other 20. 8 Orthodontic Specialty Education in Latin America 63

8.3.1.8 Orthodontic Postgraduate of Orthodontics and have the option of Programs in Argentina attaining certi cation.

In Argentina, 10 programs are recognized. They are t wo- to three-year program s, and the number of students per course ranges from 8.4 Goals for the Future 12 to 50, although managing 50 postgraduate students at the same time is very di cult. Be cau se e d u cat ion is key t o a ch ievin g excellence in professional life, we all need to keep 8.3.1.9 Orthodontic Postgraduate in m in d w h ere w e are h eaded an d w h at ou r vision is—in ot h er w ord s, w h ere w e w an t to Programs in Chile be. Many countries in Latin America are in the process of considering som e if not all of The 10 recognized programs in Chile are th e follow ing goals to raise the standards of two and one-half- to three-year programs their postgraduate programs. with approximately 10 to 22 students per course. Regarding the number of hours, although these are part-time programs, all of them include the number of hours 8.4.1 Training in English required by the WFO guidelines. English as a second language is essential for 8.3.1.10 Orthodontic Postgraduate professional life, no matter what the profession. Providing part of the program in Programs in Bolivia English would be helpful for future orthodontists because they could access and The programs are three years long and consult all the information available at an include a total of 3,000 hours. Residents international level. Panama is one of the attend three days a week, seven hours a countries that is doing this now. Additional day. There are approximately 20 students training in English would allow us to open per course. doors for postgraduate students. 8.3.1.11 Orthodontic Postgraduate Programs in Peru 8.4.2 Academic Research Four program s are recognized in Peru. Everyone knows that conducting accurate, 8.3.1.12 Orthodontic Postgraduate valid, and tim ely research is critical to success. Academic research is used to establish Programs in Mexico or con rm facts, rea rm the results of previous work, and solve new or existing prob- There are approximately 75 postgraduate lems. Although academic research is part programs in Mexico, which are available of most programs, postgraduate students in public and private universities as well should perform more academic research, as private institutions and schools. Univer- which will help them improve their ana- sities and institutions recognized by the lytical skills and motivate them to become Mexican government are given Recogni- involved in basic sciences. tion of O cial Validity of Studies (Recono- cimiento de Validez O cial de Estudios, or RVOE). To obtain this recognition, the schools m ust present their program s to the 8.4.3 Interdisciplinary secretary of public education. Programs Te a m w o r k last two to three years, and the number of students per course ranges from 10 to 15. Learning to work as a team is important in After nishing their studies, students may most jobs today. It is essential that future become a liates of the Mexican Academy orthodontists learn to work in interdisci- 64 Orthodontic Postgraduate Education: A Global Perspective

plinary teams because doing so provides specialists but do not have the means to them with multiple approaches to the study do so. Naturally, di erent types of scholar- of health care, encourages an appreciation ships would be o ered, and each speci c and understanding of other disciplines, and case would be evaluated independently. helps them understand strategies for future practice. Through interdisciplinary teamwork, they learn to seek opinions about 8.4.7 Faculty problems from appropriate team members, each of whom contributes his or her own To ensure academic success, it is essential unique professional perspective. Together, that appropriately quali ed academic sta the team develops and evaluates poten- be available. Ideally, the program director tial solutions or management plans and should have a PhD degree with an ade- chooses the best ones for each speci c case. quate teaching and research background, and the director should also be an experienced orthodontic specialist. Lower-rank 8.4.4 Curriculum faculty (e.g., assistant professors) should be orthodontic specialists w ith experience. It is of the utmost importance for residents It would be also advisable to use external to gain practical experience in a variety examiners/evaluators for each program. of settings, so that they can put the skills they have learned into practice with real patients. It is also of great importance that 8.4.8 Recerti cation dental students receive increased levels of practical experience during their prepara- To encourage further study and ensure that tion for dental practice. Each postgraduate orthodontic specialists are well acquainted student must complete 25 to 30 cases, and with new developments in the eld, recer- these should represent a variety of prob- ti cation of the postgraduate degree would lems, including patients w ith cleft palate, be an interesting option. Recerti cation patients undergoing orthognathic surgery, is an excellent way to guarantee stan- and medically compromised patients, dards of excellence among the orthodontic among others. community.

8.4.5 Research Facilities 8.4.9 Exchange Programs

It is highly recommended that radiology Spending t wo or three m onths before grad- and dental laboratories be located within uation as an exchange student in another the same facility. This eliminates the need program within the same or a di erent to send patients elsewhere and allows orth- country is also a worthy goal. The advan- odontic residents to have closer contact tage is that residents have an opportu- with these activities. nity to increase their experience at other institutions. 8.4.6 Scholarships 8.4.10 Congresses and As w e all kn ow , it is d i cu lt or eve n im p os- Me e ting s sible for some students to further their studies. Everyone should have the same In the past few years, m ost congresses held opportunity to become a specialist in his in Latin America have included a special or her chosen eld. Providing more schol- chapter for postgraduate residents from arships is an important step toward help- di erent universities. The residents are ing those who wish to become orthodontic invited to give presentations on clinical or 8 Orthodontic Specialty Education in Latin America 65 research topics. It is very important to pro- is important to keep in mind that not all mote this practice because it stimulates of these programs have been approved by teaching among young orthodontists, and the local relevant authorities. In fact, m any teaching improves not only knowledge but are not. It is essential that all recognized also clinical skills. It adds to residents’ expe- (validated/certi ed) program s maintain a rience and better prepares them to treat all full-time schedule with a duration of 30 to types of malocclusion. O ering awards and 36 months. Orthodontic societies in con- honors for the best presentations is a good junction with universities should encour- way to motivate young colleagues, and age and motivate dentists to become actual some countries currently do o er awards orthodontic specialists. Unfortunately, one for excellent scienti c contributions pre- of the biggest problem s is that m any young sented at meetings. colleagues are tempted to take brief courses provided by orthodontic commercial companies. Each national orthodontic society 8.4.11 Information and has an important role to play in controlling Orientation these programs to ensure that all patients receive top-quality treatment. Orthodontic societies can help future residents by providing vital information to the Reference dental community, and by o ering objective orientation and speci c information 1. Athanasiou AE, Darendeliler MA, Eliades T, et about all the programs that are available. al; World Federation of Orthodontists. World During the past years, a huge number of Federation of Orthodontists (WFO) guide- private universities have opened their lines for postgraduate orthodontic education. doors, many of which have created and World J Orthod 2009;10(2):153–166 are now o ering postgraduate courses. It

Orthodontic Specialty 9 Education in East and Southeast Asia, with a Particular Focus on China

Jiu-Xiang Lin, Yan-Heng Zhou, Tian-Min Xu, and Xue-Dong Wang

Orthodontics, an important branch of oral specialty education in East and Southeast medicine, is part of the postgraduate edu- Asia has evolved rapidly, and that a series cation system globally, and professional of necessary steps has been implemented. postgraduate education is one of the most The content and duration of specialist important and standardized methods of training in orthodontics are generally simi- cultivating orthodontic specialists. lar in East and Southeast Asia but do vary The quality of orthodontic treatment slightly. In these countries, orthodontic and oral health care is based on the quality specialty education and training are under- of the education and training that the doc- taken essentially at the postgraduate level, tors who provide such care receive at the following the completion of an undergrad- initial practicing stage. Generally speaking, uate degree. In the undergraduate learning the objective of orthodontic specialty edu- phase, the content of orthodontics learning cation is to (1) provide education in ortho- is mainly basic theory and simple orthodon- dontics at higher levels, (2) create a solid tic techniques, such as sim ple w ire bending foundation for diagnosis and treatment, and brackets bonding. After undergradu- and (3) promote active “orthodontic” in u- ate dental studies graduation, the student ences in the science world. learns more speci c treatment technology This chapter introduces the concepts and diagnostic methods as part of a com- and characteristics of orthodontic specialty plete graduate course in orthodontics, or education in East and Southeast Asia. Pro- as part of short-term studies in orthodon- viding information mainly on the current tics. In general, all of the well-structured status of orthodontic education in China, educational systems involve a mix of for- we introduce the various educational sys- mal lectures, practical skills training, and tems at the university level. The content of supervised clinical practice. educational courses, nature of m edical conditions, and aspects of scienti c research are also summarized. 9.2 Orthodontic Specialty Programs in 9.1 Status of Orthodontic Dental Schools Specialty Education The goal of orthodontic specialty education is to produce graduates who have East Asia and Southeast Asia comprise obtained a solid background in diagnosis many countries, including China, Japan, and treatment and will become specialists South Korea, Thailand, Singapore, and in orthodontics; a diversity of educational Malaysia. It is gratifying that orthodontic 66 forms exists. In China, several orthodontic 9 Orthodontic Specialty Education in East and Southeast Asia, with a Particular Focus on China 67 specialty program s are available in den- 9.4 Characteristics of tal schools, including three-year m aster’s degree and ve-year doctoral degree educa- Orthodontic Specialty tion. Each program has two training objec- Programs tives: one is training in scienti c research, including fundam ental and clinical research Enrollment in postgraduate education is in orthodontics; the other is training in uniform throughout China. After graduat- clinical orthodontic treatment. Students are ing from ve-year colleges, graduates who awarded an associate degree in science for are recommended by their colleges and the PhD degree or in a clinical specialty for trainees who ranked top in the entrance the SMD (stomatologic MD) degree. There examinations for postgraduate schools is also an eight-year program and an eight- have the opportunity to enter a three- or plus three-year double doctoral degree prove-year postgraduate training course in gram, the latter of which was speci cally, orthodontics. and rst successfully, completed at Peking University in China. In this program, the students are trained in orthodontics in the 9.4.1 Thre e -Year Maste r’s last one or two of the eight years and are Degree Education awarded a doctoral degree in stomatologic medicine; they then receive another three The students in the three-year educational years of training in both orthodontic clini- program focus on clinical education and, in cal practice and scienti c research and are part, clinical research. They take multiple awarded a PhD degree. Unlike the medical basic and thematic orthodontic courses in eld in China, the medical eld in Japan the rst year, including lectures on orth- (including dentistry) has available only a odontic principles and current clinical doctoral degree with a duration of four to techniques, the preparation of study casts, ve years. Another educational program is photography, and so on. They begin to for specialized students who focus on clini- consult with and treat patients under the cal practice and prepare for the opening of supervision of a tutor after the rst win- future dental clinics; the duration of this is ter vacation. Some clinical research is also generally at least three years. Overall, orth- performed. At the end of the three years, odontic specialty training comes in various the students are required to undergo the forms, including academic courses, clinical assessment mentioned previously and to training, and basic research. have completed 20 orthodontic cases.

9.4.2 Five -Year Structure d 9.3 Quali cation of Education for the PhD and Applicants and Selection SMD De g re e s Crit e ria In the ve-year structured educational pro- Graduates of oral medicine who apply for gram, students are trained for the PhD and further studies are considered as candidates SMD degrees, the highest quali cations that for postgraduate education in orthodontics. a physician or scientist can achieve. How- This stage usually includes two degrees: a ever, these two degrees are characterized three-year master’s degree and a ve-year by distinct training models. PhD students, doctoral degree. Applicants must pass the who are required to focus mainly on basic uniform entrance examinations, including science training, must take several courses those in English and orthodontics. They related to basic science and experimental are interviewed by ve professors. Only the skills, produce an integrated dissertation, students who perform outstandingly are and publish a high-level scienti c paper accepted. upon graduation. Although these individu- 68 Orthodontic Postgraduate Education: A Global Perspective

als are not required to complete clinical dontics at PKUSS. To cultivate versatile doc- cases, they can treat patients and practice tors with both clinical and scienti c skills, orthodontic specialty thinking and skills the program requires students to com- under the supervision of senior tutors, plete another three years of study after the just like the clinical students. For this rea- eight-year program to compete for the PhD son, increasing numbers of undergraduates degree, similar to the ve-year PhD training choose to strive and compete for the ve- previously described. Graduates who dem- year PhD programs. onstrate outstanding and comprehensive In contrast, the ve-year SMD degree is ability and who have passed the entrance available to medically quali ed individuals, examinations for doctoral degrees are per- who are required to complete 30 orthodon- mitted to proceed to this second stage. tic patient cases by the time of graduation. They must complete 30 cases and a scien- The degree involves part-time research, ti c research dissertation at a high level. related to clinical topics or basic science, After 11 years of comprehensive education, undertaken by the trainees. Before achiev- these students become excellent doctors ing the SMD degree, students are expected with both clinical and scienti c skills. To to produce and defend successfully a disser- date, PKUSS has graduated two cohorts of tation, as well as to publish the ndings of students with double doctoral degrees. their dissertation in core journals. Ultimately, after receiving their professional orthodontic education, students have acquired comprehensive abilities, including 9.4.3 Eight-Year Program clinical skills in the specialty of orthodontics, academ ic communication skills, skills Peking University School of Stomatology in scienti c thinking, and practical ability. (PKUSS) was the rst top school in China They can not only expertly treat orthodon- to develop the eight-year program sys- tic patients but also system atically conduct tem. Only the students who are ranked scienti c research in accordance with the top in the school entrance examination are aims of the com bined program in clinical accepted into the program at PKUSS. There and academ ic work. Such professionals will is only one class with 40 to 50 students in be the backbone of future orthodontics. each year of the eight-year system. During the rst ve years, students must take multiple courses relevant to basic science, such as physiology and pharmacology; to clini- 9.5 Orthodontic Courses cal topics, such as internal m edicine, sur- and Academic Research gery, and medical ethics; and to research methods, such as animal experimentation We have mentioned repeatedly the training and molecular biology. Clinical practice is in orthodontic clinical practice and scien- also required at this stage. Three or four of ti c research included in the diverse edu- the top students then begin specialty educational systems because it constitutes the cation for orthodontics during the last one most important educational content. or two years of the eight-year program . These orthodontic courses lay the foun- dations for education in the specialty. They 9.4.4 Eight- plus Three-Year can be divided into basic and advanced courses. Speci c textbooks are used for Double Doctoral Degree both, which are written by specialty pro- Prog ram fessors in China. The basic courses cover mainly entry level knowledge, including We would like to emphasize the eight- the following topics: exam ination and diag- plus three-year double doctoral degree nosis; etiology; classi cation and common program, which was rst implemented types of malocclusion; craniofacial growth successfully by the department of ortho- and development; a general introduction to 9 Orthodontic Specialty Education in East and Southeast Asia, with a Particular Focus on China 69 orthodontic appliances; the biomechanical ment for patients with malocclusion. This principles of treatment, orthodontic appli- clinical research has an irreplaceable role in ances, and techniques; orthodontic early orthodontic specialty education. treatment; retention; oral health care; and However, basic research is also a crucial education in orthodontic treatment. These aspect of any educational system, especially general courses are oriented to students in one that trains candidates for scienti c the fth year of their eight-year course and degrees. Scienti c research is increasingly those in the rst year of their postgraduate popular in Asia because it not only helps education. discover and further solve clinical questions The enhanced courses also play an but also provides an objective criterion for important role in orthodontic education. assessing the strength and potential of a They are taught by specialty professors teaching hospital, which should be com- as lessons of un xed form, lectures, and petent in both clinical practice and aca- forums concentrating on specialized and demic research. Scienti c research has a detailed topics, such as anchorage protec- broad range, with many branches. Teach- tion during orthodontic treatment, inter- ing hospitals and departments of ortho- disciplinary cases, asymmetric extraction dontics attempt to encourage applied choice, timing for skeletal Class III maloc- basic research, interdisciplinary research, clusion, etc. These advanced courses help translational medicine research, and so on. the orthodontic trainees improve their spe- They also encourage extensive exploration cialty knowledge and assist them in clinical and reporting of all elds of science, aim - diagnosis and treatm ent. ing for breakthroughs in orthodontic bond- Clinical courses involve typodont training materials, the genetic mechanisms and ing, archwire bending, and orthodontic diagnosis of congenital m issing teeth, the techniques. Case reporting is another indis- arti cial mineralization or regeneration pensable part of practice; it is required of tooth enamel and dentin, translational daily and is performed regularly in small medicine research in bone tissue engineer- groups and also weekly with the whole ing and bone defect repair, temporoman- department, with a focus on special, di - dibular joint disorders and m alocclusion, cult, and complicated cases. the evaluation of orthodontic treatment It is generally agreed that academic mechanics and new materials, and com- courses should not be the only element puter-based oral medicine research. This in orthodontic specialty education. As a research is performed by various teams hospital-based academic medical center, that have constantly prom oted its clinical PKUSS is com m itted to both basic and clini- application. cal research. Based on its abundant clinical resources, the department has long devoted itself to developing clinical research. It covers the predominant research directions 9.6 Quali cations of the of orthodontic digital diagnosis and treat- Teaching Team ment systems, interdisciplinary treatment, novel orthodontic ideas, and the explora- A key element of education is teaching, the tion of new types of orthodontic appli- quality of which directly in uences the ances. For instance, the use of computed learning and practice of every student or tomography, digital imaging, and three- trainee. The quality of the teaching team dimensional m odeling illustrates how in schools or institutes that carry out orth- orthodontists have increased their ability to odontic specialty education should be of a provide each patient with a full diagnosis. very h igh level and adhere to rigorous stan- The development-related studies, clinical dards. A teacher should be a doctor and a technique-related mechanism studies, and scientist who takes responsibility for teach- orthodontic biology-related basic research ing basic courses and clinical techniques facilitate faster and more e ective treat- and for supervising scienti c research. 70 Orthodontic Postgraduate Education: A Global Perspective

In most academic schools in China, the other oral disciplines. Three to ve orth- teachers are at least associate professors. As odontic professors are present to assess an example, more than 20 of the 40 doc- each student’s performance, including tors at the department of orthodontics of his or her clinical knowledge, thinking, PKUSS are involved in teaching. They are and reasoning. Each professor completes assigned various teaching tasks and are a standardized checklist according to the required to prepare extensively before for- student’s performance. The average score mally presenting their courses. In the clinic, of the three steps of the examination is the professors monitor the students treating student’s nal result. orthodontic patients daily, aiding them in Besides the general examinations, planning treatments and the details of the all graduating students are required to treatment procedures. The quality of the produce a dissertation related to their teaching and quali cations of the teach- research subject and publish articles in ers are monitored by established systems, in uential journals before being awarded a ensuring that the teaching progresses master’s or doctoral degree. There is also smoothly. a China-speci c professional degree, for which students must exhibit 20 to 30 completed orthodontic cases upon graduation. This degree aims mainly to produce stu- 9.7 Assessment of dents with professional clinical skills and Graduating Classes experience.

At the end of orthodontic training, the quality of specialty education is assessed with examinations. Such examinations are 9.8 Orthodontic deemed to evaluate the quality of care that Specialty Requirements an orthodontist can provide. The principal bene t of the assessment and evaluation Orthodontic residents must pass vocational of the graduating class is the provision of quali cation examinations before they can

a uniform and objective standard regard- enter the professional stage of training. As ing students’ knowledge. The examina- an orthodontic professional doctor, the res- tions also motivate the students to learn ident must be equipped with comprehen- and make progress. At present in East and sive intellectual and physical skills as well Southeast Asia, examination methods vary as innovative and rigorous scienti c skills. widely, from externally audited tests of Not only solid medical expertise in orth- orthodontic ability to closed discussions odontic basic theories and knowledge but between students and their own orthodon- also clinical orthodontic skills in diagnosis tic tutors. and treatment are needed. In addition, to To assess the e cacy of the three- and obtain a professional degree, orthodon- ve-year courses, nal examinations are tists should have engaged in oral medicine taken. These examinations involve a series research and be able to combine theory of steps to ensure an objective result and with practice. The ability to engage in inde- cover all required areas of learning. Knowl- pendent scienti c research or be indepen- edge related to the orthodontic specialty dently responsible for specialized technical is rst assessed. Then, wire-bending skills work is another necessity. Orthodontists are evaluated by having the student nish must also possess good academic com- ordered bends, loops, or arch forms, which munication skills and attend regional or are commonly used in clinical orthodon- national conferences related to oral medi- tics. Finally, each student must analyze cine. Students can report their research one of two complicated orthodontic cases, results as oral reports or poster boards, or which may incorporate many problems of they may use other methods. 9 Orthodontic Specialty Education in East and Southeast Asia, with a Particular Focus on China 71

9.9 Departments’ technique, transmission straight wire technique, micro-implant anchorage system, Facilities lingual appliances, Invisalign, treatment of obstructive sleep apnea syndrome, and In the preceding sections, we described so on. The duration varies from two days the basics of orthodontic specialty educa- to one month. Besides these short-term tion in China. In addition, the facilities of classes, many dental schools or hospitals an orthodontic department are crucial for provide a one-year further study program realizing the stated objectives. The gen- in which students take orthodontic courses eral organization and structure of teaching and receive training in clinical skills. They hospitals do not di er much. In China, for may also treat the patients of supervisors example, more than 100 universities and in the independent clinic. This program is medical colleges have established orth- very popular throughout the country. odontic departments, and there are more than 3,000 full-time orthodontists and more than 2,000 part-time orthodontists nationwide. The department of ortho- 9.11 Conclusion dontics of PKUSS, for example, which was the rst established in China, has a well- In this chapter, we introduced orthodon- structured sta comprising 58 clinicians, tic specialty education in East and South- 48 nurses, and 10 technicians. The distinct east Asia, with a particular focus on China; levels of experience of the clinicians ful ll the topics described included the status of the requirements for clinical, teaching, and orthodontic specialty education, orthodon- scienti c work. In addition, there are 51 tic specialty program s in dental schools, dental units and 9 independent outpatient quali cations of applicants and selection clinic rooms. These clinical facilities and criteria, orthodontic specialty program sta contribute to the successful imple- characteristics, assessment of graduat- mentation of orthodontic specialty educa- ing classes, and orthodontic specialty tion and allow it to proceed steadily and requirements. The objective of postgradu- develop continually. ate orthodontic education in this region is to produce graduates who will complete their clinical education in an advanced educational institution, obtain a solid 9.10 Continuing background in diagnosis and treatment, Ed u c a t i o n and become specialists in orthodontics. Strongly motivated, intelligent graduates Because of rapid progress in science and who have passed the entrance examina- technology, specialist orthodontists must tions are welcomed to study orthodontics. update their existing scienti c knowledge They receive systematic clinical training and continue their education by attending in orthodontics and conduct related scien- refresher courses, as well as acquire further ti c research during the three- to ve-year clinical experience. Thus, visiting scholar program s. At the end of their training, they programs and continuing education have are required to subm it a typical m aster’s or become global trends and increasingly pop- doctoral thesis and complete m ultiple orth- u lar in recen t years. As an im p or t an t p ar t of odontic cases before they are awarded their orthodontic specialty education, continu- degree. In addition, institutions of higher ing education has developed rapidly. In education provide continuing orthodontic China, continuing education in orthodon- education for residents or orthodontists. tics takes the form of annual short-term Considering the present state of orth- courses on various “hot topics,” such as the odontic specialty education worldwide, we Tweed–Merri eld technique, straight wire realize that many aspects can and must be 72 Orthodontic Postgraduate Education: A Global Perspective

improved, and that many issues need to be have taken place during recent years. Let us resolved. Orthodontic specialty education unite to contribute to worldwide orthodon- in East and Southeast Asia has a long way tic education and support the continued to go. However, we should recognize the e ort toward achieving the goals of ortho- signi cant achievements and progress that dontics globally.

Orthodontic Specialty 10 Education in Oceania

Alexandra K. Papadopoulou, Oyku Dalci, and M. Ali Darendeliler

In the early 20th century, as orthodontic p ract ice in all st ates or territories of Au st ra- training was not provided in Oceania, som e lia and New Zealand.2–4 general dentists went overseas rst to the The Australian Dental Council (ADC) United States, to study under the famous has been appointed by the Dental Board Dr. E. H. Angle, and later to the United King- of Australia, under the Health Practitioner dom. Those rst specialists in orthodontics Regulation National Law Act 2009 (National founded the Australian Society of Ortho- Law ), a s t h e a ccre d it at ion a u t h or it y re sp on - dontists (ASO) in 1927. The rst full-time, sible for accrediting education providers 18-month course that had the scope of pre- and programs of study for the dental pro- paring students for specialist orthodontic fession, including general dentistry and all practice was established at the University dental specialties, including orthodontics. of Sydney in 1962. Later, in 1964, this was The ADC and the Dental Council of New changed into a two-year master’s degree Zealand (DCNZ) have adopted a joint con- course. The University of Adelaide started tact for an Australasian accreditation pro- the rst equivalent course ve years later, cess w ith th e con st it u t ion of th e ADC/DCNZ and very quickly courses providing specialist Accreditation Com mittee. Accreditation of a program signi es that the program o ered

education were begun at the Universities of Melbourne, Queensland, and Western Aus- by the education provider has been found tralia, as well as at the University of Otago to meet ADC/DCNZ accreditation standards in New Zealand. These courses have become and provides graduating students with the well-known over the years as they have knowledge, skills, and professional attri- admitted and graduated many national and butes necessary to practice the profession international applicants. in Australia and New Zealand. Currently, dental graduates wishing to Accredited orthodontic courses in Aus- practice as specialized orthodontists are tralia and New Zealand are o ered by the required to undertake a three-year pro- following universities5–9: gram leading to a doctor in clinical den- • The University of Adelaide School of tistry or equivalent degree at an Australian Dentistry or New Zealand accredited university. • The University of Melbourne These programs involve three years of full- Melbourne Dental School time supervised practice and instruction • University of Otago Faculty of in a university environment. The process Dentistry consistently concludes with a nal exami- • The University of Sydney Faculty of nation that assesses knowledge, compe- Dentistry tency, and pro ciency in a wide range of • The University of Western Australia procedures within the scope of practice of School of Dentistry a specialist orthodontist.1 Registrants may

73 74 Orthodontic Postgraduate Education: A Global Perspective

10.1 Australian Dental Evidence requirements are overview of Council/Dental Council the following: • The philosophy of postgraduate of New Zealand education Accreditation Standards: • The objectives of postgraduate Education Programs for education • The common template across 2 Dental Specialists individual dental specialty programs • The balance of basic science, The ADC/DCNZ Accreditation Standards: statistics, and the specialist Education Programs for Dental Specialties discipline are the criteria against which dental spe- • The balance of research and course cialty education and training programs are work assessed for accreditation purposes. These standards are regularly monitored based on experience and feedback from partici- 10.1.2 Standard 2: pants, and they are periodically reviewed Responses to Conditions, and updated with wide consultation and appropriate external assistance. The stan- Recommendations, and dards are organized around the following Suggestions from the Previous broad structure: Accreditation Process • Context/overview of the program • Actions taken since the last review The school must address the recommenda- • Administration and educational tions and suggestions made in the report resources of the previous accreditation visit and in • Students any other reports since that time. This is • St a an important determinant of the accredi- • Peer evaluation tation status awarded because it demon-

• Curriculum and assessment strates the school’s awareness of the need • Delivery of the program for continual improvement. The school pro- • Research vides a detailed report on how each condi- • External relationships tion, recommendation, and suggestion of • Program evaluation the previous accreditation report has been For each accreditation standard, evi- addressed. dence requirem ents are listed to assist schools in their self-assessment and preparation of their accreditation submission 10.1.3 Standard 3: responses. Peer Evaluation

Evidence must be provided of peer evalu- 10.1.1 Standard 1: Overview ation of the content of each of the dental of the Program specialty programs being accredited and of measures taken to implement any recom- The school must have a clearly de ned mendations of such evaluations. The evalu- educational philosophy for each of its ating body or person must be representative dental specialty programs. Dental spe- of the contemporary specialty and be rec- cialty education should be a core activity ognized by the ADC/DCNZ as appropriate to and be governed by bodies such as a post- undertake the peer evaluation. The review graduate studies committee and a research reports are to be included in the submis- com m ittee. sions for individual dental specialties. 10 Orthodontic Specialty Education in Oceania 75

In the accreditation of dental specialty • Level of support provided by any programs, peer review takes on an added other interested parties dimension with the contribution of the relevant specialty academy or society. The specialty program must provide evidence 10.1.5 Standard 5: of peer evaluation of the content of the program and of measures taken to implement Relationship between Dental any recommendations of such evaluations. Specialty Students and This is a considerable responsibility, and Education Provider/University the assistance of specialist societies and academies is acknowledged in the lead-up Dental specialty students must have the to the accreditation process for dental spe- same rights and privileges as other post- cialty programs. graduate students. Programs and services Information and recommendations are are provided that are speci c to dental spe- provided concerning the following: cialty studies/students, and representation on the central com m ittees of the education • An overview of the peer review provider/university is established. process • Guidelines provided to reviewers • Peer review reports • Response of the school to the 10.1.6 Standard 6: School recommendations of peer review Administration and Budget reports • The current peer review status The continuing nancial resources, management structure, and administrative and support sta of the education provider 10.1.4 Standard 4: must be adequate to enable the objectives of its dental specialty programs to be Relationship between School achieved. The education provider has to supply detailed evidence of the follow ing: and the Education Provider/ University • Governance of dental specialty education The dental school must exist as a distinct • Adequacy of nancial support entity within the education provider/uni- • Adm inistration and support of the versity, with administrative responsibility dental specialty students within the and status similar to those of compara- school ble units, such as schools of other health • Areas requiring further professions. development and constraint An overview is provided of the • “Outsourcing” of students to other following: departments for speci c training/ • Postgraduate structure within the subjects education provider/university • Position of the education provider/ university within this structure 10.1.7 Standard 7: • Degree of control and independence Teaching Facilities of postgraduate studies w ithin the school School facilities, including seminar rooms, • Level of support and any laboratories, clinics, hospitals, and general infrastructure given by the education provider facilities, and their rele- education provider vant equipment must be adequate to allow • Level of support provided by the the dental school to achieve its dental spe- faculty (where relevant) cialty educational objectives. 76 Orthodontic Postgraduate Education: A Global Perspective

The follow ing details m ust be m et: ence of the sta m ust be appropriate for the specialist disciplines seeking accreditation. • School teaching facilities for dental There must be a director for each specialty specialty programs program with de ned responsibilities. The • Sharing arrangements with current sta status m ust be provided. undergraduate and other programs • Time allocations and constraints of shared facilities 10.1.10 Standard 10: • Access to electronic teaching materials Admissions Policies and • E-mail and Internet access Procedures • Student o ces Admission into a dental specialty program Any outplacement facilities used in must be based on published selection cri- the dental specialty program (including teria that are applied equitably during the the number of chairs in each clinic) must selection process. These must be continu- be listed, as well as any formal relation- ally evaluated to assess their e ectiveness. ships/agreements between the education The education provider must have estab- provider responsible for dental specialty lished, clear processes and provide details education and the agency engaged in the on the following: teaching and supervision of students in these outplacement settings. • Information provided to all students • Quotas and num ber of individual streams in each discipline 10.1.8 Standard 8: Education • Current selection procedures Provider/University Library • Reference of current processes • Special conditions applying to Students must have access to library international students resources, services and facilities, and sta to • Options for integration with support both learning and research. Infor- concurrent doctoral or other higher

mation retrieval, analysis, and organization degree programs sh ou ld be an in t egral p ar t of t h e e d u cat ion al • Policy on blood-borne viruses and process. These include the following: immunizations for new students • Dental specialty course guide for • Library as a postgraduate resource new students • Adequacy of acquisitions • Introduction program for new • Educational programs by library postgraduate students sta for dental specialty students • Inclusion of adequate library tim e within individual programs 10.1.11 Standard 11: • Plans for future developm ent Interface with Community • Borrowing rights • Access to general, health sciences, Dental specialty students should be under- and biological sciences libraries standing of, and be responsive to, the oral health needs of the Australian/New Zealand community and of overseas communities, 10.1.9 Standard 9: as well as those of the individual patients. Specialist Sta As a result, an epidemiologic component is included in all or some programs. The sta -to-student ratios must be adequate The program develops an understanding of for the school to achieve its dental specialty disease as a public health issue, and dental educational objectives. The specialty quali- specialty students are educated in the man- cations, time commitment, and experi- agem ent of ethical issues. 10 Orthodontic Specialty Education in Oceania 77

10.1.12 Standard 12: • Provide details of the m anagem ent of poor performance and mentoring Principles of Mana Māori and/or supervision programs and the Treaty of Waitangi; • Describe the input to program s from National Strategic Framework relevant specialist bodies for Aborig inal and Torre s • Detail the involvem ent of students in continuing education courses, as Strait Islander Health participants or presenters

New Zealand education providers must demonstrate that the principles of mana 10.1.14 Standard 14: Māori and of the Treaty of Waitany are upheld throughout the programs. Australian Student Assessment education providers should demonstrate that the nine principles in the National A clearly stated, valid, and reliable system Strategic Framework for Aboriginal and of formative and summative assessment Torres Strait Islander Health are promoted must be used to determine the progression throughout the program, and that there is and graduation of students. This includes a commitment to contributing to the devel- the following: opment of an Aboriginal and Torres Strait • Assessment methods as related to Islander (ATSI) dental specialty workforce. educational objectives E ect is given in the recruitment of • The school’s assessment procedures, Māori and ATSI students and in scholar- including portfolio/logbook ship, teaching, and research. For New Zea- requirements land education providers, the school has • Selection of examiners to describe its relationship with local iwi • Policy of supplem entary and hapū in ways that illustrate plans to examinations increase Māori participation within the • Involvem ent of specialist bodies in profession and ways to ensure cross-cul- assessm ent of students tural understanding. In addition, strategies have to be outlined to ensure the retention of Māori and ATSI students and for achiev- 10.1.15 Standard 15: ing Māori and ATSI treatment objectives. Student Representation

The school m ust have m echanism s in place 10.1.13 Standard 13: for the representation of its dental specialty Scholarship and Expertise students on relevant committees or boards responsible for postgraduate matters. Graduates of dental specialty programs must be capable of competent independent specialty practice immediately upon gradu- 10.1.16 Standard 16: ation and must be committed to continue Student Well-being professional development. They must be provided with suitable patients and facili- Counseling and health services should be ties during their training program to enable available to all dental specialty students. them to develop this level of competence. The health services must: To sat isfy t h e above st an d ard t h e ed u cation provider must: • Be available to both local and international students • Describe the progression of students • Include requirements for and access through specialty training to routine vaccinations • Detail the use of assessm ent as a • Comply with occupational health determinant of progression and safety protocols 78 Orthodontic Postgraduate Education: A Global Perspective

• Ensure the presence of protocols so • List of publications in each that students are provided with a discipline over the past ve years safe working environment identifying papers authored or co- authored by specialist students 10.1.17 Standard 17: Interface with Government, Hospitals, 10.1.19 Standard 19: and Professional Bodies Undergraduate Teaching

The education provider must have functional Dental specialty students should be encour- relationships with the following bodies: aged to participate in undergraduate teach - ing throughout their program. In detail, this • The dental authority includes: • A general hospital • A dental hospital • School policy on undergraduate • Institutional health care facilities teaching by specialist students • Specialist societies • Individual program requirements • Other education provider for participation of specialty departments students in undergraduate teaching • The dental profession, the Australian • Perceived value of undergraduate and New Zealand dental associations, teaching in dental specialty and specialist academies/societies programs • Specialty areas at interstate • Student payment for teaching institutions • Dental specialty student appointments to teaching positions Depending upon the particular specialty, dental specialty students should gain experience in the management of patients 10.1.20 Standard 20: in the general hospital setting and in other Evaluation of Outcomes extramural facilities. Ongoing evaluation of the outcomes of dental specialty program s m ust be undertaken 10.1.18 Standard 18: to determine whether the speci c objec- Research tives are being met. Results must be used to improve the program. The evaluation There must be a demonstrated commit- requirements must have a description of ment to research activity by the dental the following: school. Research must represent an identi able and substantial component in all • How dental specialty program specialty programs. Students must receive outcomes are evaluated formal instruction in scienti c method, • School processes for subsequent research methodology, biometrics, and review and implem entation of the ethical conduct. evaluation recommendations The education provider must have a • The frequency of evaluations detailed: • Research philosophy 10.1.21 Standard 21: • Research requirement Strategies for Improvement • Form al and program tim e commitment to research Each school must formulate strategies and a • Requirement for preparation and timetable for the improvement of its dental presentation of a thesis/research specialty program based on the self-assess- report ment process undertaken for accreditation. 10 Orthodontic Specialty Education in Oceania 79

10.1.22 Standard 22: educationally quali ed and appropriately registered in orthodontics by an equivalent SWOT Analysis teaching program. This list should include a brief curriculum vitae and details of the The school must identify its own strengths, period of service to the departm ent. weaknesses, opportunities for improvement, and threats to the quality (SWOT) of its dental specialty program s. 10.2.3 Visiting Specialists/ Le c t u r e r s 10.2 Australian Society of A list of visiting specialist/lecturers with a Orthodontist Education brief curriculum vitae is required. Committee Guidelines 1 10.2.4 Other Specialist The ASO participates in the peer review Student Support Mechanisms assessment of specialty programs and maintains an active role in the prom otion of high- Clinical assistants, technicians, and a quality education within these programs. departmental secretary are required. Throughout the period from its establish- m en t to cu rren t years, th e ASO h as su p p or ted orthodontic research and education, either by 10.2.5 Course Objectives sponsoring overseas competent academics or by funding research projects of specialty Th ese a re a s st at e d in St a n d a rd 1 of t h e ADC. students and of doctoral or postdoctoral students with the rationale of furthering the development of the specialty. The ASO, in its 10.2.6 Prerequisites for comm itment to the high standards of education maintained by Australasian university Application to the Specialty specialty programs, provides guidelines addi- Pro g rams (Primary tional to the ADC/DCNZ accreditation stan- Examinations, Research/ dards through the ASO education com m ittee. Teaching Experience)

Each school must clearly state the speci c 10.2.1 Course Director criteria and policy of selection, as well as the process and m echanism of selection. A course director must have evidence of a Individually, further details are provided registration certi cate with the Australian on the Web site of each school.5–10 Health Practitioner Regulation Agency con- Compliance with the following guide- rming registration as a specialist in ortho- lines is necessary, and dentists with the dontics. In addition, documentation of st ated qu ali cat ion s an d experien ce are eli- certi cation by the Australasian Orthodon- gible for consideration to enter a graduate t ic Bo a r d o r e v id e n ce o f p r o g r e s s in g t h r o u gh training programs in orthodontics: the certi cation process is required, as well as documentation con rming experience • Graduates of institutions m ust have in teaching orthodontics in an academic com pleted a bachelor’s degree or the departm ent for a m inim um of two years. equivalent and must have satis ed the requirements for general registration as a dentist w ith the 10.2.2 Acade m ic Sta Dental Board of Australia. • Graduates of international dental A list must be included of the registered schools who possess equivalent quali cations of the full-tim e and frac- educational background and tional sta to demonstrate that they are standing as determined by the 80 Orthodontic Postgraduate Education: A Global Perspective

institution and the program are 10.2.10 Clinical and Practical eligible. Graduates m ust have satis ed the requirem ents of lim ited Training registration with the Dental Board A case log for a typical graduate student is of Australia before entry into the submitted to demonstrate exposure and program. involvement in the treatment of all types • Prospective candidates must have of malocclusion, including experience and completed a m inim um of two years instruction in the interdisciplinary man- in general dental practice before agement of complex dentofacial problems. being admitted to graduate dental The scope of cases should represent the training. General dental practice range of problems encountered in private m ay include practice in an academ ic practice. or government institution or in the military service. 10.2.11 Average Number 10.2.7 Number of Students of New Cases Started by Accepted per Year and Overall Each Candidate under Direct Number of Students Enrolled Supervision as Opposed to Cases Treated for Paid Service The number of students accepted per year and Transfer Cases is 3 or 4, and the total number of students is 9 to 12. At least 50 and no m ore than 90 active new cases in comprehensive appliance therapy 10.2.8 Course Structure are advised for each graduate student.

The chronological progression, year of the 10.2.12 Teaching

course, and subject codes with credit ratings for which the candidates are form ally Commitments of Each enrolled at the university level must be Candidate listed in detail for each semester and year of study. An academic timetable to dem- Specialty students must contribute to onstrate that the number of sta and their undergraduate teaching in any area of the time commitment are su cient for full dental school. supervision of the clinical component of the course is also advised. 10.2.13 Patient Management

10.2.9 Course Content Patients are seen in the screening clinic, and when they are allocated for treatment, the The content of each formal subject as pre- student obtains records (photos, impressions, viously described and the number of hours radiographs). The student then prepares all devoted to each area with a detailed descrip- the diagnostic records, and before treatment tion of the courses are required. Copies of begins, the cases are presented to the dele- course outlines have to be submitted, and gated faculty member or to the department at speci c courses in biom edical sciences w ith case presentation sessions during which the application to the diagnosis, prevention, n d in gs are d iscu ssed an d a t reat m en t p lan is and treatment of disease of the oral tissues decided, so that all individuals involved bene- should be included. Graduate specialty pro- t from the experience. Surgical or interdisci- grams must be a minimum of three full- plinary cases are presented to a joint sem inar time academic years or the equivalent. before any treatment commences. 10 Orthodontic Specialty Education in Oceania 81

10.2.14 Facilities • Written and oral examinations • Assessm ent of the clinical cases The follow ing issues m ust be satis ed: previously unseen by the student • Submission of a research report • The clinical facilities must operate based on original work conducted w ithin the um brella of a tertiary by the candidate during the course institution, either a university or a hospital, su cient to ful ll the educational needs of the program . 10.2.16 Internal Course • The clinical facilities must have Evaluation access to radiographic and diagnostic data collection facilities Internal procedures to evaluate course and must maintain an adequate content should be applied, and students storage and retrieval process. must be provided with an assessment of • The clinical facilities must permit their performance and progress at least students to work e ectively w ith each semester as part of a regular feedback allied dental health professionals. session with the course director. Depart- • This environment must have in mental meetings must be scheduled on a place policies consistent with regular basis to ensure adequate function- government regulations related ing of the teaching unit. A m echanism m ust to health care delivery at an be in place for the ongoing and systematic institution. review of the quality of treatment provided • The use of private o ces as a m eans in the program. of providing clinical experience is not supported. 10.2.17 Is s u e s Identi ed in 10.2.15 Examinations Previous Review and Action Ta k e n

Details of assessments and examination protocols and the names of the examiners The education provider must prepare a for the various stages over the past three detailed description of the actions taken years have to be provided. for improvement, according to the recom- Documents that demonstrate regu- mendations of the previous peer review lar (at least each semester) reviews of the evaluation. knowledge, skills, ethical conduct, and professional growth of the students by means of written, oral, and/or practical examina- 10.3.18 Issues That Have tions have to be submitted. In addition, completion of a comprehensive nal exam- Changed Since the Last ination process is required; this includes a Review review by at least one individual external to the institution, who must be education- Signi cant changes in funding, administra- ally quali ed in orthodontics and from tion, curriculum, clinical, laboratory, and an equivalent teaching program. In more research facilities may have an impact on detail, the examination process should the ability of a program to comply w ith the include the following: ADC/DCNZ accreditation standards. If such circumstances arise after the review, an • Presentation of 15 to 20 treated extraordinary peer review may be neces- cases demonstrating various types sary to ensure that the program meets the of m alocclusion that re ect the equivalent national standards. range of problem s encountered in the Australian clinical setting 82 Orthodontic Postgraduate Education: A Global Perspective

Acknowledgments 5. The University of Adelaide School of Den- tistry. https://health.adelaide.edu.au/den- Material published with the permission of tistry. Accessed January 28, 2015 the Australian Dental Council. 6. The University of Melbourne Melbourne Dental School. http://www.dent.unimelb. edu.au. Accessed January 28, 2015 References 7. University of Otago Faculty of Dentistry. http://dentistry.otago.ac.nz. Accessed Janu- 1. Australian Society of Orthodontists. http:// ary 28, 2015 www.aso.org.au. Accessed January 28, 2015 8. The Universit y of Sydney Facult y of Dentist- 2. Australian Dental Council. http://www.adc. ry. http://sydney.edu.au/dentistry. Accessed org.au. Accessed January 28, 2015 January 28, 2015 3. Dental Board of Australia. http://www.dental- 9. The University of Western Australia School board.gov.au. Accessed January 28, 2015 of Dentistry. http://www.dentistry.uwa. 4. Australian Health Practitioner Regulation edu.au. Accessed January 28, 2015 Agency. http://ahpra.gov.au. Accessed Janu- ary 28, 2015

Orthodontic Specialty 11 Education in the Middle East and Africa

Abbas R. Zaher and Hassan Kassem

A questionnaire was sent to the author’s The didactic part of the program personal com munications in the Middle includes lectures, seminars on selected East and Africa. Additional inform ation was topics, journal clubs, and workshops. At acquired through university Web sites. A the outset of the program, the resident is de nition of the Middle East region is the assigned a minimum of 50 new cases, in one adopted by the World Federation of addition to a variable number of transfer Orthodontists. Furthermore, the data col- cases. The candidate receives on average lected represent the received responses 25 hours of supervised clinical training per from the main geographic areas that con- week. Diverse clinical techniques are taught stitute the regions of the Middle East and in the program, including conventional and Afr ica . modi ed edgewise appliances, straight wire appliances, functional appliances, and conventional and skeletal anchorage modalities. The candidates see pediatric 11.1 North African patients requiring space supervision or Countries orthopedic treatment, typical adolescent patients requiring orthodontic treatment,

adults with malocclusion and interdisci- 11.1.1 Egypt plinary problems, patients with orofacial clefts or other craniofacial anomalies, and In Egypt, seven government-funded uni- patients undergoing orthognathic surgery. versities o er specialty orthodontic train- A weekly case presentation sem inar is con- ing ending in the award of either a master ducted at which residents are required to of science or a doctor of philosophy degree. present their assigned cases and discuss The typical duration of a master’s degree treatment planning options with the fac- program is three years, whereas it is four ulty and other residents. Each resident has to ve years for a doctoral degree program, to complete 20 cases of various malocclu- with a special emphasis on a research proj- sion problems by the end of the program. ect in the latter. A previous master of sci- Periodic forms of evaluation include writ- ence degree is a prerequisite for adm ission ten papers, seminars, and clinical and oral to a PhD program. The number of teaching examinations. At the end of the program, sta in every program is 10 on average. The the resident must pass a written examina- master of science degree programs accept tion, a case-based oral examination, and from three to ve applicants every year. a practical test. The candidate is awarded Doctoral candidates are accepted on an the degree upon the successful defense of a individual basis. research dissertation.

83 84 Orthodontic Postgraduate Education: A Global Perspective

11.1.2 Morocco 11.2.2 South Africa

Mo h a m m e d V Un ive r s it y a t So u is s i in Ra b a t , The government of South Africa registered Morocco, o ers a certi cate of orthodontics orthodontics as a specialist dental practice and master’s and doctor’s degrees. All pro- in 1948. Currently, an orthodontist has to grams are conducted in French. The pro- complete a four-year full-time postgradu- gram accepts an average of 20 candidates ate p rogram after ear n in g t h e d en t al d egree every year. Each candidate has to complete to specialize in the eld. The longest-run- four hours of supervised clinical training ning orthodontic program is the one at the per week. The candidates are assigned 40 University of the Witwatersrand, Johan- new and 10 transferred patients, and they nesburg, which started in 1953. At present, are expected to nish a minimum of 10 three more universities o er specialized cases by the end of the program. The nal training: the University of Pretoria; the assessment includes a written test, an oral University of the Western Cape, Cape Town; presentation, and a presentation of nished and the University of Limpopo. cases. The program research plan focuses on the topics of biocorrosion, arch length discrepancy, and dental caries. 11.2.3 Sudan

Advanced orthodontic training at the Uni- versity of Khartoum includes both a mas- 11.2 Central and South ter’s degree and a doctor’s degree. On African Countries average, six candidates are accepted every year. There as 23 full-time sta members 11.2.1 Nigeria participating in the program , which lasts for an average of three years. Candidates attend In Nigeria, seven institutions o er train- eight hours of lectures per week and are ing for orthodontic residents; the largest is required to complete 20 hours of supervised clinical training per week; they are assigned Lagos University Teaching Hospital in Lagos, w hich accepts two to four candidates every 60 new and 20 transferred patients. Tech- year. The orthodontic resident is awarded a niques taught in the program include both fellowship diploma of either the West Afri- xed and removable appliances. Candidates can College of Surgeons or the Faculty of for the master’s and doctor’s degrees are Dental Surgery of the National Postgradu- required to complete two and three hours ate Medical College of Nigeria, which in of research work per week, respectively. The Nigeria is considered superior to a PhD. The candidate submits ve nished cases at the average duration of the program, which completion of the program. is conducted in English, is four and a half years. The candidate receives two didactic. Each resident is assigned 50 patients at the outset of the program, in addition to a vari- 11.3 Asian Countries able number of transfer patients. The candidate completes 30 hours of supervised 11.3.1 Iraq patient management per week, with train- in g in t h e u s e o f st r a igh t w ir e a n d fu n ct io n a l Three universities have postdoctoral orth- appliances. To graduate, the candidate is odontic education programs. The MSci and required to complete 25 xed appliance PhD degrees are o ered. Full-time sta is cases, 5 removable appliance cases, and 1 involved in conducting these programs. interdisciplinary case. The nal assessment Each university accepts three to ve can- includes the defense of a dissertation on didates every year. Both programs are con- research performed by the resident and an ducted in English. The average duration of oral examination. the master’s degree program is two years, 11 Orthodontic Specialty Education in the Middle East and Africa 85 and it is three years for the doctoral degree 36-month international specialty program, program. Upon entry, each candidate is conducted in English, that leads to a mas- assigned from 20 to 40 new patients and ter’s degree in dental sciences. The pro- from 10 to 20 transferred patients. The gram meets the academic guidelines of the candidate has 15 to 20 hours of supervised European Erasmus program. There are 26 clinical training per week. Candidates are faculty members involved in the program. trained in edgewise and straight wire tech- The curriculum consist of core courses, niques, in addition to the use of functional seminars on diverse topics, workshops, and appliances and skeletal anchorage devices. a supervised research project. At the end To graduate, each candidate must complete of the program, the candidates take a nal at least 20 cases. The nal assessment of written examination, which is followed by the residents takes the form of a compre- an oral examination if they pass the former. hensive oral and written examination. All students are concurrently enrolled in a Periodic evaluation includes practical and two-year master of science program in the written tests, in addition to oral presenta- biomedical sciences and are awarded the tions. A research thesis is required for the MSci degree from the Hebrew University completion of both degrees. upon the completion of a research project. Research activities in the department focus on craniofacial development and develop- 11.3.2 Israel ment of the dentition; biological aspects of tooth movement; orthodontic treatment The Goldschleger School of Dental Medi- for children with special needs, clefts, and cine at Tel Aviv University, where the Eras- craniofacial anomalies; and orthodontic mus program curriculum of the European materials. Union was rst implemented, conducts an The School of Graduate Dentistry at international orthodontic training program Rambam Health Care Campus o ers an in English. The program o ers a certi cate orthodontic residency program three and a in orthodontics and either a master’s or a half years in duration. The faculty includes doctor’s degree. The program is conducted 14 sta members and a unit director. The by 22 faculty members, who include 4 pro- program emphasizes the interdisciplinary fessors, 2 lecturers, and clinical instruc- training, combining pediatric and adult tors. The duration of the program is three surgical orthodontic techniques for the and a half years, with an additional two to treatment of acquired and congenital cra- three years of research for those on th e PhD niofacial anomalies. track. Various treatment philosophies are taught in the program, including modi ed edgewise, straight wire, lingual, and remov- 11.3.3 Lebanon able and xed functional appliances; clear aligners; and temporary anchorage devices. Saint Joseph University, in Beirut, o ers Each candidate is assigned 40 new and 30 several postgraduate degrees in both Eng- transfer and retention cases. The candidate lish and French, including a certi cate of must complete 10 new cases of di erent orthodontics and a master’s and a doctoral categories to graduate; the cases are evalu- degree. The master’s degree program is on ated according to the American Board of average three years long. Other programs Orthodontists requirements. The program are customizable to each candidate. The concludes with clinical oral exam inations academic sta is mainly part-time. Two and a thesis defense. The research con- to three residents are accepted every year. ducted in the department covers a wide The prime focus of the program is on the scope of topics featuring root resorption clinical skills of the residents. Each resident and functional appliances. is assigned 50 new patients and 30 trans- The Hebrew University Hadas- ferred patients. Residents undergo 15 hours sah School of Dental Medicine o ers a of supervised clinical training every week, 86 Orthodontic Postgraduate Education: A Global Perspective

which is focused mainly on xed appliance evaluated periodically and at the end of the therapy in addition to the implementation program with oral, written, and practical of skeletal anchorage techniques. Periodic tests. At the end of the program, a typical evaluation includes written examinations, candidate has nished a minimum of 30 presentations, and practical tests. The pro- cases and defends a research thesis. Cur- gram does n ot in clu de a form al n al assess- rently, the program does not endorse a par- ment of the residents. The main research ticular area of research. domain is clinical. In 2001, the American University of Beirut started a combined specialty train- 11.3.5 United Arab Emirates ing and master of science degree program in orthodontics in the newly founded divi- The United Arab Emirates (UAE) features sion of orthodontics and dentofacial ortho- two postgraduate orthodontic programs pedics of the department of otolaryngology in Dubai. The rst is a master of science and head and neck surgery. The program in orthodontics program o ered by the is conducted by four academic sta , 13 Hamdan Bin Mohammed College of Dental clinical associates from di erent dental and Medicine, an institution of the Moham- medical elds, and a research consultant. med Bin Rashid University of Medicine Three to four candidates are accepted every and Health Sciences. The duration of the year. The course spans 36 months and program is 36 months and incorporates includes didactic and clinical modules. The clinical training at the level of specialist program is not restricted to certain treat- trainee and appropriate preparation for ment modalities. Residents are exposed to the Membership Examination of The Royal the various philosophies used to treat dif- College of Surgeons of Edinburgh (UK). ferent types of orthodontic patients in dif- The program is conducted in English and ferent age groups. Residents graduate upon accepts six residents every academ ic year. the completion of clinical requirements Four full-time academic sta members run and the defense of a thesis. the orthodontic curriculum of the program Postdoctoral orthodontic training is and 10 other academic faculty members

also o ered by Beirut Arab University and are involved in educational aspects related the Lebanese University. to basic sciences, radiology and im aging, biostatistcs, research methodology, ethics and legislation, and multidisciplinary 11.3.4 Jordan management. Each resident is assigned 35 to 40 new patients and is expected to nish The Jordan University of Science and Tech- a minimum of 25 cases by the end of the nology, near Irbid, o ers a master of science program. The candidates must complete d e g r e e . Th e p r o g r a m is co n d u c t e d in En g lis h . 25 hours of supervised patient manage- Five full-time academic sta members are ment per week, which includes preventive, involved in the three-year program. Three interceptive, and corrective orthodontics candidates on average are accepted every of children, adolescents, and adults. The year. The program comprises six didactic majority of the knowledge base of the hours of lectures and seminars every week, curriculum is delivered through a blend two hours of treatment planning sessions, of learning styles including lectures and and 15 hours of practical work, in addi- small group enquiry-based learning. Resi- tion to three hours of research work. Each dents are expected to prepare in advance resident is assigned a minimum of 50 new for small group teaching that will then be patients and 30 transferred patients. The used to put knowledge into context of the candidates are trained mainly in the straight clinical experience of teachers and learners wire technique and functional appliance and current research evidence. The resi- therapy. Skeletal anchorage is also included dents are required to complete four hours in the training program. Each candidate is of research work every week leading to the 11 Orthodontic Specialty Education in the Middle East and Africa 87 presentation and defense of a dissertation Swedish National Board of Health and Wel- by the end of the program. Final candidate fare. The faculty includes four full-time and evaluation includes a written examination eight part-time sta . Both programs are and a case presentation, in addition to the conducted in English. The master’s degree successful completion of the research the- program consists of three years of full-tim e sis. At the end of the program, the candi- study, whereas the certi cate of orthodon- date takes a nal examination, which can tics program is o ered on a part-time basis also take place as a conjoint exam ination an d can t ake u p to ve years. Th e can d idates w ith the Royal College of Surgeons of Edin- are trained in all modern xed appliances burgh for the Membership in Orthodontics. techniques, including the use of edge- Diverse periodic evaluations comprise oral wise, straight wire, functional, and lingual and written evaluations, research reviews, appliances, in addition to skeletal anchor- case presentations, seminars on selected age methods. Each candidate is assigned a topics, and practical tests. Current areas of total of 50 patients and receives supervised research comprise epidemiology of mal- clinical training for 26 hours per week. occlusion in UAE, orthodontic treatment The candidate has to complete 30 cases to outcomes, orthodontic materials, e-models graduate. Final assessment of the residents technology as well as system atic reviews includes an external exam ination by Malm ö and/or meta-analysis. University faculty. Master’s degree candi- The European University College (for- dates are required to complete two hours of merly Nicolas & Asp University College) is research per week ending in the com pletion a private dental institution in Dubai that and defense of a research thesis. Areas of o ers both a specialty certi cate in ortho- research include the epidem iology of m al- dontics and a master’s degree in ortho- occlusion, oral hygiene in UAE and expatri- dontics. The training programs are o ered ate sam ples, and outcom es and e ciency of in collaboration with Malmö University, di erent treatments, with a special empha- in Sweden, following the regulation of the sis on corticotomy-facilitated orthodontics.

Orthodontic Specialty 12 Education in the Indian Subcontinent

Om P. Kharbanda

The Indian subcontinent, a region of south college started with a one-year License in Asia, com prises th e coun t ries of In dia, Paki- Dental Surgery (LDS) diploma. In 1922, the stan, Bangladesh, the Himalayan states of duration of the course was increased to two Nepal and Bhutan, and Sri Lanka, an island years, and further increased to four years in o the southeastern tip of the Indian pen- 1936–1937. A chronology of the signi cant insula.1 Before 1947, the three nations of events on the development of dental edu- India, Pakistan, and Bangladesh were his- cation in India is given in Table 12.1. The torically combined and comprised British rst dental faculty of independent India India. “The seven countries of South Asia was formed in Bombay (now Mumbai) in constitute geographically a compact region 1957, o ering a bachelor of dental surgery around the Indian subcontinent.”2 To foster (BDS) degree.7 At present, India has more regional political and economic coopera- than 300 dental colleges recognized by the tion, the governments of the seven coun- Dental Council of India (DCI) that o er BDS tries created the South Asian Association quali cation.8 for Regional Cooperation (SAARC) in 1980. It w as in 1933 t h at a series of lect u res in The rst summit was held in December the subject of orthodontics were delivered for the rst time in a teaching institution, at

1985. The countries included Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, Nair Hospital Dental College by H.D. Mer- and Sri Lanka.3 Since then, the organiza- chant. In 1937, orthodontics was accepted tion has expanded by accepting one new as a separate subject.9 full member, Afghanistan, and several observer members.4 “The Indian subcontinent is home to a vast diversity of peoples, 12.1.2 Postgraduate Dental most of whom speak languages from the Indo-Aryan subgroup of the Indo-Euro- Ed u c a t i o n pean family.”5 Nearly 25% of the world’s population (22% in 2010) lives in the Indian Before the 1950s, facilities for postgraduate subcontinent.6 dental education hardly existed in India. In the 1940s, a master’s degree in dentistry (MDS) was awarded by the one and only college of dentistry, De’Montmorency College of 12.1 History of Dental Dentistry at Lahore, and the graduates of this college formed the nucleus for the advance- Education in India ment of dental education during the time of British India. After independence from Brit- 12.1.1 The Beginning ish rule (1947), India was partitioned into India and Pakistan (East and West). Lahore Dr. Ra udin Ahmed established the rst being in Pakistan, India had no institution formal dental college in India in 1920 at granting postgraduate quali cation in den- Calcutta (now Kolkata), West Bengal. The 88 12 Orthodontic Specialty Education in the Indian Subcontinent 89

Table 12.1 Chronology of signi cant events related to the dental profession and dental education in India

1920 Dr. R. Ahmed establishes rst formal dental college in India at Calcutta, West Bengal. The college starts with a one-year LDS diploma. In 1922, the duration of the course is increased to two years.

1923 First dental and optical college established – namely, Punjab Dental College, Lahore. However, it cannot be sustained and eventually closes.

1926 American Dental College, Karachi established; however, it closes in 1947.

1928 Andhra Dental College and Hospital Bezwada founded. Renamed American Dental College and Hospital, Madras. Functions until 1947.

1932 City Dental College, Calcutta founded; closes in 1940.

1933 Bai Yamunabai L. Nair Hospital Dental College started in Bombay. In 1946, taken over by the municipal corporation of Bombay. In 1954, becomes a liated with Bombay University.

1933 De’Montmorency Dental College and Hospital, Lahore. Regular BDS course started with Punjab University in 1936. First postgraduate course in dentistry started in 1945. Dr. K. L. Shourie among the rst recipients of MDS degree, who eventually heads the Dental Council of India as president.

1938 Delhi Dental College and Hospital established but does not survive.

1940 Sir C.E.M. Dental College, Bombay. In 1945 becomes a liated with Bombay University. In 1960 becomes Government Dental College, Bombay.

1943 Health Survey and Development Committee established by the government of India. Chairman Sir Joseph Bhore. Recommendations pave the way for enact- ment of the Dentists Act 1948 and the formation of Dental Council of India.

March 29, Dentists Act (XVI of 1948) reviewed; assent of the president of India. 1948

Ap ril 1 2 , Dental Council of India formed by the government of India by a special 1949 noti cation.

1953 First Indian Dentists Register prepared and placed before the council.

1957 Formation of the rst dental facult y in India, at the Universit y of Bombay.

1959 Dental Council of India establishes regulations and syllabus for master’s degree courses. Universities encouraged to establish postgraduate courses in the following: Prosthetic dentistry Oral surgery Operative dentistry Orthodontia Periodontia Oral diagnosis and dental radiology Dental pathology and bacteriology

(Continued on page 112) 90 Orthodontic Postgraduate Education: A Global Perspective

Table 12.1 (Continued) Chronology of signi cant events related to the dental profession and dental education in India

1960 Approval of government of India for a minimum basic quali cation for appointment of teaching sta for master’s degree courses (MDS).

1963 Government of Uttar Pradesh sanctions start of postgraduate courses at Luc- know Dental College.

1963 Dental Council of India lays down syllabus for master’s degree in pedodontia and preventive dentistry.

1964 Dentists Act 1948 extended to Union Territories of Goa, Daman, and Diu.

1965 Government approves MDS courses in periodontia.

1971 Dental Council of India lays down syllabus for master’s degree in periodontics.

1983 Dental Council of India course regulations for master’s degree program.

1986 All India Institute of Medical Sciences, New Delhi starts rst full-time three-year residency program for master’s degree in orthodontics.

1993 Indian Orthodontic Society conducts National Workshop on Postgraduate Orth- odontic Education. Recommends higher case load.

1993 Dental Council of India passes a resolution (DE-1[SC]-93/2064 28.10.1993) for MDS course duration of three years.

1998 Dental Council of India regulations for master’s degree courses (unpublished).

2000 National Board of Medical Examinations established. Orthodontics included in 2002.

2006 National workshop at All India Institute of Medical Sciences to update curriculum in all nine specialties of dentistry.

2006 Dental Council of India course regulations.

2007 and Dental Council of India course regulations and amendments. later

Abbreviations: BDS, bachelor of dental surgery; LDS, license in dental surgery; MDS, master of dental surgery. Source: History of Dental Council of India. Souvenir released on the occasion of the Silver Jubilee of the Dental Council of India. New Delhi, India: Dental Council of India; 1973:59–67, 70–73.7 12 Orthodontic Specialty Education in the Indian Subcontinent 91 tistry in 1947. Then, East Pakistan in 1971 ing the 1990s, with private entrepreneurs separated from Pakistan to form Bangladesh. taking the lead. The number of postgradu- The foundation of higher dental edu- ate departments grew to 48 in 2005 and cation in British India was laid by the rec- reached the enormous number of 186 by ommendations of a committee chaired by 2014.8 The complete list of institutions Sir Joseph Bhore. In 1943, the Bhore com- updated up to 2014 is given in Table 12.2. mittee recommended that all graduates in In addition, many Indian dental graduates dentistry be encouraged to pursue a post- pursue higher dental education in ortho- graduate degree and that provisions be dontics in Russia, China, and the Philip- made in all universities to establish MDS pines, as well as the United Kingdom and courses because these measures could the United States. Their exact number can- ensure the gradual growth of a cadre of not be ascertained. well-trained teachers in dentistry. The Dental Council of India (DCI) was incorporated under the Dentists Act 1948 to 12.1.2.2 Evolution of Orthodontics regulate dental education and the dental Syllabus and Curriculum in India profession throughout India. In 1959, the DCI laid down regulations and a syllabus The MDS course regulations 1965 listed for the master’s degree courses. The DCI rather a brief syllabus in the subject of recommended the following specialties orthodontia.13 There was no mention of for postgraduate education in dentistry: the quantum of the clinical workload to prosthetic dentistry, oral surgery, operative be undertaken and the outcome to be dentistry, orthodontia, periodontia, oral assessed. It mentioned only techniques and diagnosis and dental radiology, and dental laboratory work, clinical orthodontia, and pathology and bacteriology. Pedodontia, lectures and seminars. preventive dentistry, and public health The subjects of the seminars were dentistry were established in 1963 and listed as orthodontics, art, applied oral and 1971 respectively.7,10 maxillofacial surgery, otolaryngology, and speech. The examination pattern consisted of two parts. The prerequisite for taking 12.1.2.1 First Master of Dental the Part II nal examination included sub- Surgery Orthodontic Course in mission of a thesis, in addition to passing In d ia the Part I examination. The duration of the course was two years. MDS courses in India, including orthodon- The rst formal DCI regulations contain- tia, were established in 1959 simultane- ing a syllabus on master’s degree courses ously at Nair Hospital Dental College and were published in 1965. 13 The subsequent Government Dental College and Hospital, detailed revision of the course regulations both in Bombay and both a liated with by the DCI in 1983 contained exhaustive the University of Bom bay.7,10,11 This was fol- guidelines for all nine specialties of den- lowed by MDS in orthodontia at Lucknow tistry. 14 1964, Bangalore 1966, Trivandrum 1969, The revision included a detailed list of Ahmadabad 1970, Manipal 1972, Madras the preclinical work to be undertaken by 1975, Hyderabad 1978, Nagpur 1985, All students. Clinical training was based on India Institute of Medical Sciences, New the preparation of case records, the use of Delhi 1986, and so on.10,12 By the 1970s, appliances, and the treatment of di erent seven dental schools o ered MDS courses types of malocclusion with di erent tech- in orthodontics, with 31 admissions per niques. It categorically mentioned that a year. Half of these belonged to the t w o den - student was expected to submit ve n- tal colleges in Bombay. The dental profes- ished cases treated with any technique. A sion and education showed steady growth case presentation and discussion of the until the 1980s and incredible grow th dur- same were to constitute an important part

(Text continued on page 99) 92 Orthodontic Postgraduate Education: A Global Perspective

Table 12.2 Institutions granting master of dental surgery (MDS) quali cation in India No. of Institutions granting MDS quali cation admissions in India (approved/recognized by Dental for State Council of India as of August 27, 2014) Type 2013–2014 1 DL All India Institute of Medical Sciences, Centre Federal 4 for Dental Education and Research, New Delhi govt. 2 KA A.B. Shetty Memorial Institute of Dental Private 9 Sciences, Mangalore 3 KA A.J. Institute of Dental Sciences, Mangalore Private 6 4 GJ Ahmedabad Dental College & Hospital, Private 5 Gandhinagar 5 KA Al Am een Dent al College & Hospit al, Bijarpur Private 2 6 KA Al-Badar Rural Dental College & Hospital, Private 5 Gulbarga 7 KA AME’s Dental College & Hospital, Raichur Private 2 8 KL Amrita School of Dentistry, Kochi Private 3 9 MH Annasaheb Chudaman Patil Memorial Dental Private 3 College, Dhule 10 MH Armed Forces Medical College, Pune Govt. 2 11 AP Army College of Dental Sciences, Secunderabad Private 2 12 DL Army Hospital (Research and Referral), Cantt, Govt . 2 Delhi 13 JH Awadh Dental College & Hospital, Jamshedpur Private 2 14 KL Azeezia College of Dental Sciences & Research, Private 3 Ko lla m

15 UP Babu Banarasi Das College of Dental Sciences, Private 6 Lu c k n o w 16 KA Bangalore Institute of Dental Sciences & Private 3 Hospital, Bangalore 17 KA Bapuji Dental College & Hospital, Davangere Private 6 18 MH Bharati Vidyapeeth Dental College & Hospital, Private 6 Pune 19 MH Bharati Vidyapeeth Dental College & Hospital, Private 3 Navi Mum bai 20 HP Bhojia Dental College & Hospital, Nalagarh Private 3 21 BR Buddha Institute of Dental Sciences & Hospital, Private 3 Patna 22 AP C.K.S. Teja Institute of Dental Sciences & Private 6 Research, Renugunda, Tirupati 23 UP Career Institute of Dental Sciences & Hospital, Private 2 Lu c k n o w 24 UP Chandra Dental College & Hospital, Safedabad, Private 2 Barabanki 25 MH Chatrapati Shahu Maharaj Shikshan Sanstha’s Private 3 Dental College & Hospital, Aurangabad 26 CG Chattisgarh Dental College & Research Private 2 Institute, Rajnandgaon 12 Orthodontic Specialty Education in the Indian Subcontinent 93

No. of Institutions granting MDS quali cation admissions in India (approved/recognized by Dental for State Council of India as of August 27, 2014) Type 2013–2014 27 GJ College of Dental Sciences and Research Private 3 Centre, Ahmedabad 28 KA College of Dental Sciences, Davangere Private 6 29 MP College of Dentistry, Indore Govt. 2 30 KA Coorg Institute of Dental Sciences, Verajpet, Private 6 Co o rg 31 KA D.A. Pandu Memorial R.V. Dental College, Private 5 Bangalore 32 HR D.A.V. Centenary Dental College, Yamuna Private 3 Nagar 33 UP D.J. College of Dental Sciences & Research, Private 6 Modi Nagar 34 RJ Darshan Dental College & Hospital, Udaipur Private 4 35 PB Dasmesh Institute of Research & Dental Private 3 Sciences, Faridkot 36 KA Dayanand Sagar College of Dental Sciences, Private 5 Bangalore 37 KL Dent al College, Medical College Cam pus, Govt . 2 Ko z h i k o d e 38 OR Dental Wing, S.C.B. Medical College, Cuttack Govt. 2 39 GJ Dharmsinh Desai University, Faculty of Dental Private 3 Science, Nadiad 40 BR Dr. B.R. Ambedkar Institute of Dental Sciences Private 2 & Hospital, Patna 41 MH Dr. D.Y. Patil Dental College & Hospital, Pune Private 6 42 WB Dr. R. Ahmed Dental College & Hospital, Govt . 4 Calcut t a 43 KA Dr. Syamala Reddy Dental College, Hospital & Private 2 Research Centre, Bangalore 44 UP Dr. Ziauddin Ahmad Dental College, Aligarh Govt. 2 45 AP Drs. Sudha & Nageswara Rao Siddhartha Private 3 Institute of Dental Sciences, Krishna District 46 UP Faculty of Dental Sciences, Lucknow Govt. 4 47 KA Farooqia Dental College & Hospital, Mysore Private 3 48 AP G. Pulla Reddy Dental College & Hospital, Private 3 Kurnool 49 PB Genesis Institute of Dental Sciences & Research, Private 2 Ferozepur 50 AP Git am Dent al College & Hospit al, Private 5 Visakhapatnam 51 Goa Goa Dental College & Hospital, Bambolin Govt. 2

(Continued on page 94) 94 Orthodontic Postgraduate Education: A Global Perspective

Table 12.2 (Continued) Institutions granting master of dental surgery (MDS) quali cation in India

No. of Institutions granting MDS quali cation admissions in India (approved/recognized by Dental for State Council of India as of August 27, 2014) Type 2013–2014 52 MH Govt. Dental College & Hospital, Mumbai Govt. 5 53 AP Govt . Dent al College & Hospit al, Afzalganj Govt . 2 54 RJ Govt. Dental College & Hospital, Near T.B. Govt . 2 Hospital, Jaipur 55 GJ Govt. Dental College & Hospital, Ahmadabad Govt. 4 56 MH Govt. Dental College & Hospital, Nagpur Govt. 2 57 KA Govt. Dental College & Research Institute, Govt . 3 Bangalore 58 HR Govt. Dental College, Medical Campus, Rohtak Govt. 3 59 KL Govt. Dental College, Medical Campus, Govt . 3 Trivandram 60 J & K Govt. Dental College, Srinagar Govt. 2 61 KL Govt. Dental College, Gandhinagar Govt. 3 62 PB Guru Nanak Dev Dental College & Research Private 2 Institute, Bhatinda Road, Sunam 63 WB Gurunanak Institute of Dental Science & Private 5 Research, Kolkatta 64 KA H.K.E. Society’s S. Nijalingappa Institute of Private 3 Dental Sciences & Research, Gulbarga

65 HP H.P. Govt. Dental College & Hospital, Shimla Govt. 2 66 HP Him achal Dental College, Mandi Private 5 67 HP Himachal Institute of Dental Sciences, Sirmour Private 3 68 MP Hitkarini Dental College & Hospit al, Jabalpur Private 3 69 UP I.T.S. Centre for Dental Studies & Research, Private 5 Ghaziabad 70 UP I.T.S. Dental College, Hospital & Research Private 3 Centre, Greater Noida 71 TN Indira Gandhi Institute of Dental Sciences, Private 3 Pondicherry 72 OR Institute of Dental Sciences, Bhubaneswar Private 3 73 UP Institute of Dental Sciences, Bareilly Private 3 74 UP Institute of Dental Studies & Technology, Private 3 Modinagar 75 UP Institute of Medical Sciences, Banaras Hindu Govt . 3 University, Varanasi 76 RJ Jaipur Dental College, Jaipur Private 5 77 TN J.K.K. Natarajah Dental College & Hospital, Private 2 Namakkal 78 KA J.S.S. Dental College & Hospital, Mysore Private 4 79 UP K.D. Dental College, Mathura Private 6 12 Orthodontic Specialty Education in the Indian Subcontinent 95

No. of Institutions granting MDS quali cation admissions in India (approved/recognized by Dental for State Council of India as of August 27, 2014) Type 2013–2014 80 GJ K.M. Shah Dental College & Hospital, Vadodara Private 4 81 TN K.S.R. Institute of Dental Science & Research, Private 3 Namakkal 82 KA K.V.G. Dental College & Hospital, Kannada Private 5 83 AP Kamineni Institute of Dental Sciences, Private 3 Nalgonda 84 KL Kannur Dental College, Kannur Private 2 85 GJ Karnavati School of Dentistry, Gandhinagar Private 3 86 KA KLE Society’s Institute of Dental Sciences, Private 3 Bangalore 87 KA KLE Vishwanath Katti Institute of Dental Private 7 Sciences, Belgaum 88 KL KMCT Dental College, Kozhikode Private 3 89 UP Kothiwal Dental College & Research Centre, Private 6 Kanth Road, Moradabad 90 KA Krishnadevaraya College of Dental Sciences & Private 5 Hospital, Bangalore 91 MH Late Shri Yashwantrao Chavan Memorial Private 3 Medical & Rural Development Foundation’s Dental College & Hospital, Ahmednagar

92 MH M.A. Rangoonwala College of Dental Sciences & Private 6 Research Centre, Pune 93 KA M.R.A. Dental College & Hospital, Bangalore Private 4 94 KA M.S. Ramaiah Dental College, Bangalore Private 3 95 KA Maaruti College of Dental Sciences & Research Private 6 Centre, Bangalore 96 MP Maharana Pratap College of Dentistry & Private 3 Research Centre, Gwalior 97 HR Maharishi Markandeshwar College of Dental Private 6 Sciences & Research, Ambala 98 RJ Mahatma Gandhi Dental College & Hospital, Private 2 Sitapura, Jaipur 99 MH Mahatma Gandhi Missions Dental College & Private 3 Hospital, Mumbai 100 MH Mahatma Gandhi Vidya Mandir’s Dental Private 3 College & Hospit al, Nasik 101 CG Maitri College of Dentistry and Research Private 0 (3) Centre, Anjora, Durg 102 AP Mamata Dental College, Khamamam Private 3 103 HR Manav Rachana Dental College, Faridabad Private 3

(Continued on page 96) 96 Orthodontic Postgraduate Education: A Global Perspective

Table 12.2 (Continued) Institutions granting master of dental surgery (MDS) quali cation in India

No. of Institutions granting MDS quali cation admissions in India (approved/recognized by Dental for State Council of India as of August 27, 2014) Type 2013–2014 104 KA Manipal College of Dental Sciences, Mangalore, Private 5 Mangalore 105 KA Manipal College of Dental Sciences, Manipal Private 3 106 GJ Manubhai Patel Dental College & Dental Private 3 Hospit al & SSR General Hospit al, Vadodara 107 KL Mar Baselios Dental College, Ernakulam Private 3 108 KA Maratha Mandal’s Dental College & Research Private 3 Centre, Belgaum 109 DL Maulana Azad Dental College & Hospital, New Govt . 2 Delhi 110 TN Meenakshi Ammal Dental College & Hospital, Private 7 Chennai 111 AP Meghna Institute of Dental Sciences, Nizambad Private 3 112 AP M.N.R. Dental College, Sangareddy Private 3 113 MP Modern Dental College & Research Centre, Private 5 In d o re 114 MH Nair Hospital Dental College, Mumbai Govt. 2 (10) 115 AP Narayana Dental College & Hospital, Nellore Private 5 116 GJ Narsinhbhai Patel Dental College & Hospital, Private 3

Visn a g a r 117 KA Navodaya Dental College, Raichur Private 3 118 CG New Horizon Dental College & Research Private 3 Institute, Bilaspur 119 RJ NIMS Dental College, Jaipur Private 3 120 KA P.M.N.M. Dental College & Hospital, Bagalkot, Private 2 Bija p u r 121 RJ Paci c Dent al College & Hospit al, Udaipur Private 5 122 MH Padm ashree Dr. D.Y. Patil Dental College & Private 6 Hospital, Navi Mumbai 123 MH Pandit Dindayal Upadhyay Dental College, Private 2 Solapur 124 AP Panineeya Mahavidyalaya Institute of Dental Private 5 Sciences & Research Centre, Hyderabad 125 HR P.D.M. Dental College & Research Institute, Private 3 Jhajjar 126 MP People’s Dental Academy, Bhopal Private 3 127 MP People’s College of Dental Sciences & Research Private 5 Centre, Bhopal 128 KL PMS College of Dental Science & Research, Private 3 Tiruvananthapuram 12 Orthodontic Specialty Education in the Indian Subcontinent 97

No. of Institutions granting MDS quali cation admissions in India (approved/recognized by Dental for State Council of India as of August 27, 2014) Type 2013–2014 129 CH Postgraduate Institute of Medical Education & Govt . 2 Research, Chandigarh 130 TN Ragas Dental College & Hospital, Chennai Private 8 131 TN Rajah Muthiah Dental College &Hospital, Private 6 Annamalai University, Chidambaram 132 KA Rajarajeswari Dental College & Hospital, Private 6 Bangalore 133 RJ RJ Dent al College & Hospit al, Jaipur Private 3 134 UP Rama Dental College, Hospital & Research Private 5 Centre, Kanpu 135 AS Regional Dental College, Kamrum Govt. 2 136 MP Rishiraj College of Dental Sciences & Research Private 2 Centre, Bhopal 137 KL Royal Dent al College, Palakkad Private 3 138 CG Rungta College of Dental Sciences & Research, Private 3 Bh ila i 139 MH Rural Dental College, Ahmednagar Private 4 140 MH S.M.B.T. Dental College & Hospital, Private 3 Ahmednagar

141 TN S.R.M. Dental College, Chennai Private 9 142 MH S.R.M.M.M.T.’s Sharad Pawar Dental College & Private 6 Hospital, Wardha 143 UP Santosh Dental College & Hospital, Ghaziabad Private 2 144 MH Saraswati Danwantri Dental College & Hospital, Private 2 Parbhani 145 UP Saraswati Dental College, Lucknow Private 6 146 UP Sardar Patel Post Graduate Institute of Dental & Private 4 Medical Sciences, Lucknow 147 TN Saveetha Dental College & Hospital, Chennai Private 7 148 UP School of Dental Sciences, Greater Noida Private 3 149 KA SDM College of Dental Sciences & Hospital, Private 6 Dharwad 150 UK Seema Dental College & Hospital, Rishikesh Private 3 151 UP Shree Bankey Bihari Dental College & Research Private 3 Centre, Ghaziabad 152 AP Sibar Institute of Dental Sciences, Guntur Private 5 153 MH Sinhgad Dental College & Hospital, Pune Private 3 154 TN Sree Balaji Dental College & Hospital, Chennai Private 4 155 MP Sri Aurobindo College of Dentistry, Indore Private 3

(Continued on page 98) 98 Orthodontic Postgraduate Education: A Global Perspective

Table 12.2 (Continued) Institutions granting master of dental surgery (MDS) quali cation in India

No. of Institutions granting MDS quali cation admissions in India (approved/recognized by Dental for State Council of India as of August 27, 2014) Type 2013–2014 156 HR Sri Govind Tricentenary Dental College, Private 6 Hospital & Research Institute, Gurgaon 157 PB Sri Guru Ram Das Institute of Dental Sciences & Private 3 Research, Amritsar 158 KA Sri Hasanamba Dental College & Hospital, Private 2 Hassan 159 TN Sri Mookambika Institute of Dental Sciences, Private 2 Kulasekharam, K.K. District 160 KA Sri Rajiv Gandhi College of Dental Sciences & Private 3 Hospital, Bangalore 161 TN Sri Ramachandra Dental College & Hospital, Private 4 Chennai 162 TN Sri Ramakrishna Dental College & Hospital, Private 2 Coimbatore 163 AP Sri Sai College of Dental Surgery, Vikarabad Private 5 164 KL Sri Sankara Dental College, Private 2 Thiruvananthapuram 165 KA Sri Siddhartha Dental College, Tumkur Private 2 166 AP Sri Venkata Sai Institute of Dental Sciences, Private 5 Mahabubnagar 167 AP St. Joseph Dental College, West Godavari Private 3 168 UP Subharati Dental College, Meerut Private 6 169 HR Sudha Rustagi College of Dental Sciences & Private 3 Research, Faridabad 170 RJ Surendra Dental College & Research Institute, Private 3 Ganganagar 171 HR Swam i Devi Dyal Hospital & Dental College, Private 0 (3) Panchkula 172 MH Swargiya Dadasaheb Kalmegh Smruti Dental Private 3 College & Hospital, Nagpur 173 TN TN Government Dental College & Hospital, Govt . 6 Chennai 174 MH Tatyasaheb Kore Dental College & Research Private 2 Centre, Kolhapur 175 UP Teerthanker Mahaveer Dental College & Private 3 Research Centre, Moradabad 176 TN Thai Moogambigai Dental College & Hospital, Private 6 Chennai 177 KA The Oxford Dental College, Bangalore Private 8 178 KA V.S. Dental College, Bangalore Private 4 12 Orthodontic Specialty Education in the Indian Subcontinent 99

No. of Institutions granting MDS quali cation admissions in India (approved/recognized by Dental for State Council of India as of August 27, 2014) Type 2013–2014 179 MH Vasantdada Patil Dental College and Hospital, Private 5 Sangli 180 MH Vidya Shikshan Prasarak Mandal’s Dental Private 3 College & Research Centre, Nagpur 181 TN Vinayaka Mission’s Sankarachariyar Dental Private 2 College, Salem 182 AP Vishnu Dental College, West Godavari Private 6 183 RJ Vyas Dental College & Hospital, Jodhpur Private 3 184 KA Vydehi Institute of Dental Sciences & Research, Private 2 Bangalore 185 KA Yenepoya Dental College & Hospital, Mangalore Private 8 186 MH Yerala Medical Trust & Research Centre’s Dental Private 5 College & Hospital, Mumbai Abbreviations: AP, Andhra Pradesh; AS, Assam; BR, Bihar; CG, Chhattisgarh; CH, Chandigarh; DL, Delhi; GJ, Gujarat; HP, Himachal Pradesh; HR, Haryana; JH, Jharkhand; J & K, Jammu & Kashmir; KA, Karnataka; KL, Kerala; MH, Maharashtra; MP, Madhya Pradesh; OR, Orissa; PB, Punjab; RJ, Rajast- han; TN, Tamil Nadu; UK, Uttrakhand; UP, Uttar Pradesh; WB, West Bengal. Source: www.dciindia.org.in.13

of the practical examination. The revision progress from rst-year junior resident to also gave details on the curriculum and the third-year junior resident. A residency pro- number of papers required for the Part I gram entails an obligation to provide hos- examination, which applied to all nine spe- pital services similar to that expected from cialties of dentistry. Requirements for the residents in m edical disciplines and for that thesis w ere also given as w ere details of the a substantial salary is paid. This obliged a Part II examination (both theory and prac- resident to be a part of hospital service pro- tical). The duration of the course remained vider and treat a variety of cases in much two years. greater numbers than other postgraduate An MDS orthodontics program at All non-residency programs. AIIMS, being a ter- India In st it ute of Medical Sciences (AIIMS), tiary care hospital and referral center for the New Delhi, began in 1986 as a full-time cleft lip and palate orthodontics, provided three-year residency program based on ample opportunities of interdisciplinary regulations similar to those for the Master cleft care training in orthodontics. AIIMS in Surgery/Doctor of Medicine (MS/MD) of also introduced a requirement for more than medical disciplines.12 This was the rst paid ve cases to be presented in the nal exam i- residency program in orthodontics in India nation, including preparation of a myofunc- whereby each postgraduate student would tional appliance for a provided case. 100 Orthodontic Postgraduate Education: A Global Perspective

12.1.2.3 Technique-Oriented and e ciency of this appliance soon perco- Approach to Orthodontic lated throughout India. Teaching institutions Education in India in India started using functional appliances more often than before; Twin Blok is the Traditionally, orthodontic training in India most widely accepted and used functional has been largely in uenced by teachers appliance. The construction of a functional who were trained in North America.9 Dr. appliance was also introduced at AIIMS as a Prem Prakash rst introduced Edgewise major component of the clinical examination Technique at Sir CEM Dental College in at the end of the MDS course, rst at AIIMS Bo m b ay.9 In the 1960s, orthodontic equip- and soon followed by others, and so the DCI ment and materials were imported mainly guidelines were modi ed as well. from the United States. Economic develop- The DCI made some e orts to change ment of India has been slow after indepen- the curriculum in all nine postgraduate dence, with constraints and a heavy duty on specialties of dentistry through workshops imports contributing to di culties in teach- held in 1998 and 2001. ing and patient services. Although the initial MDS courses that were started at Mumbai and later at Lucknow and Nair Hospital Den- 12.1.3 National Board of tal College were headed by teachers trained Examinations mainly at North American universities in edgewise techniques, the scarce availability In 2000, the Ministry of Health and the gov- of materials and high import cost led them ernment of India initiated board certi ca- to choose other options, including the Begg tion and examination in three disciplines of appliance. While the dental school at Luc- dentistry, in addition to the existing post- know with Professor Ram Nanda as its rst graduate board certi cations in the medical chair continued to teach the Tweed edge- disciplines.15 The purpose of the National w ise technique, there was a drift toward use Board of Examinations (NBE) was to proof the Begg appliance in other institutions vide more opportunities for postgradu- and in private services. In the 1970s, Begg ate quali cation to dentists across India

tubes and brackets were manufactured in and to have uniform national standards of India. The low cost and the ease of availabil- education. Orthodontics was included as a ity of these materials further popularized new specialty, and a new curriculum was the Begg technique in India. designed in 2002. At rst, those who had During the 1980s, with the advent completed an MDS program in the spe- and popularization of preadjusted appli- cialty subject were eligible to take an NBE ances, there has been a gradual drift by the examination. Eventually, the examinations Begg practitioners to adopt preadjusted w ere opened to dent ists w ith three years of appliance systems. Some moved to the tip training at NBE-certi ed centers across the edge technique, a combination of the Begg country. appliance with the control of the edgewise The NBE curriculum was a fair and system, whereas others moved on to the recent update that addressed recent devel- so-called straight wire appliances. opments in orthodontic materials and the During the 1980s and 1990s, many ref- competencies expected of an orthodontist. erences to functional appliances and their The objectives of interdisciplinary ortho- proven clinical e cacy in growth modi ca- dontics were also included. The syllabus tion in uenced thinking across the United speci ed a variety and a minimum number States and among the Indian orthodontic fra- o f c a s e s t h a t t h e s t u d e n t s h o u ld h a ve t r e a t e d ternity. In the year 1990, the author had the before taking a summative examination. opportunity to visit William Clark, the inven- The minimum caseload was 20; however, tor of the Twin Blok appliance, and received the student was expected to present ve rst-hand clinical exposure; it was then nished cases in the examination, and this introduced in AIIMS. Treatment outcome presentation would comprise a signi cant 12 Orthodontic Specialty Education in the Indian Subcontinent 101 component of the practical examination. 12.1.5 Postgraduate Dental There was no deviation from the norm of ve nished cases speci ed in the DCI Education Reforms by Dental guidelines of 1965, although the current Council 2006 duration of the course had been extended to three years. The only change in clinical To review the existing guidelines and competencies mentioned was the availabil- update the postgraduate curriculum, a ity of 10 nished cases before the exami- national workshop on postgraduate den- nation, of which ve would be selected for tal education was organized by the DCI in the examination. A minimal detail on a collaboration with the Centre for Dental research component was included—men- Education and Research and KL Wig Cen- tion of completion of a dissertation. tre for Medical Education and Technology at AIIMS.18 In this national workshop, faculty from postgraduate departments in all 12.1.4 National Workshop nine specialties in dentistry from across the country debated, revised, and sub- on Postgraduate Orthodontic mitted an updated curriculum to the DCI Education in India (1993) for consideration. With respect to orthodontics, a national survey on the status The Indian Orthodontic Society (IOS) in of orthodontic education and curriculum, 1993 convened a National Workshop, conducted by the author, laid the founda- “Postgraduate Orthodontic Education in tion for change. The ndings were inter- India—Its Future Directions” at Bombay. esting in several respects, particularly in The workshop recommendations included terms of caseload and the number and three years of full-time instruction for variety of cases to be treated by an orth- the MDS course. In addition, a two-year odontic student, and the number of cases diploma in orthodontics (DOrth) was rec- to be presented in summative examina- ommended to encourage quality orthodon- tions. Consequently, an appropriate casel- tic practice, while MDS candidates were oad was considered a vital part of training also expected to be trained as teachers and for all other dental specialties. The work- researchers as well as good clinicians. A shop recommendations eventually evolved need to encourage students to obtain a PhD as DCI guidelines for MDS courses 2007.19 in orthodontics and the related sciences Subsequently, the updated guidelines on was strongly felt. the syllabus and curriculum were estab- The prescribed syllabus consisted of an lished in 2007. These guidelines have been exhaustive list of topics, including digital am ended from tim e to tim e.20,21 cephalometry and modern dental materials. The assessment modality outlined internal formative assessments based on 12.1.5.1 Extending Course Duration a six-month semester. Only one summative examination had been recommended Admission to a postgraduate course in at the end of three years. Perhaps the most medicine and dentistry usually required signi cant workshop recommendation was one year of housemanship following grad- an increase in the number of nished cases uation (i.e., attainment of a bachelor of to be presented in the examination, from medicine, bachelor of surgery [MBBS]/BDS ve to ten.16,17 degree) but was not mandatory. To main- The recommendations of IOS could tain uniformity in course duration with be routed only through the DCI for imple- medical sciences, i.e., MS/MS, DCI sug- mentation. The DCI made some e orts to gested that housemanship of one year be change the curriculum in all nine postgrad- merged with the postgraduate course of uate specialties of dentistry through their two years to m aintain uniformity of course revisions and the organization of dental duration, three years postgraduate courses education workshops.18,19 to three years duration.22,23 102 Orthodontic Postgraduate Education: A Global Perspective

AIIMS, New Delhi, which had a three- ducted by DCI nominees to ensure that the year duration for its master’s degree pro- guidelines are followed to ensure quality gram in medical sciences, maintained the control of education. Exceptions to the above same pattern of in-house, full-time, three- are two institutions in India: All India Insti- year residency for its MDS in orthodontics tute of Medical Sciences (AIIMS), New Delhi, program, started in 1986. It is worth men- and Post Graduate Institute of Medical Edu- tioning that AIIMS, having been created by cation and Research (PGIMER), Chandigarh, a special act of parliament, enjoys immu- that enjoy immunity from the Medical and nity to the Medical Council of India (MCI) Dental Council of India, as a special status and the DCI. In the rest of the country, a granted by acts of Parliament. These institu- few dental colleges followed DCI directions are expected to provide a leadership tives for a three-year course, while oth- role in medical and dental education in India ers were reluctant to increase the course and are autonomously enabled to issue a duration. A directive issued by the DCI on degree w ithout the a liation of a university. October 27, 1994, reiterated, “The council decided to reiterate its circular sent earlier for a three-years MDS Programme in all the 12.1.6 Indian Orthodontic Dental specialties from the academic year Society and Its Role in 1993–94.”23 Education and Faculty Development 12.1.5.2 Three-Year Curriculum The IOS started as a study group in Bom- E orts were made to modify or extend the bay (now Mumbai) way back in 1963.24 It duration of the curriculum to three years. was formally established as the Indian The unpublished DCI guidelines of 1998 Orthodontic Society on October 5, 1965, provided a much more elaborate curricu- by seven orthodontists. The late Dr. H.D. lum for the duration of three years. They Merchant was the founding president, and outlined the objectives of the course, details Dr. Naishadh Parikh was the founding sec-

of preclinical and laboratory work, clini- retary and treasurer. Other founding mem- cal caseload, types of cases to be treated, bers included Drs. A.B. Modi, Prem Prakash, mechano-therapy to be used, details of H.S. Shaikh, Keki Mistry, and Mohan Das the topics to be covered, and examination Bhat t. IOS is the rst den tal specialist’s pro- schedule to be maintained for the period fessional society in India. of three years. This curriculum was further IOS held its rst conference in 1967 in debated and discussed in 2001 and 2006. New Delhi. This was followed by regular The dental colleges that o er MDS pro- annual conferences, which are attended grams must follow and adhere to the DCI by a large number of orthodontists from guidelines. The guidelines include speci - within the country and abroad. IOS will cel- cations for buildings, physical space, equip- ebrate its golden jubilee in 2016 at Hyder- ment, laboratory and clinical requirements, abad. IOS has also established regional minimum number of teachers (faculty) and study groups to encourage the exchange of their teaching and professional experience, scienti c knowledge among its members. and the teacher-to-student ratio. The num- IOS and study groups organize continuing ber of students admitted per year in each education programs (CDE) and hands-on department is regulated by the DCI based courses for the bene t of the m em bers, fac- on the number of teachers and their quali- ulty, and graduate students. National con- cations and experience. The courses can- ferences and regional workshops are aimed not start without the prior approval and at and have contributed to advancements permission of the DCI and the Ministry of in contemporary diagnostic methods, Health, government of India. Any course to and appliances/techniques and treatment be accredited by the DCI must abide by the approach for better quality of orthodontic guidelines. Planned inspections are con- treatment outcome and research. 12 Orthodontic Specialty Education in the Indian Subcontinent 103

IOS has published a quarterly scienti c graduate quali cations in the United States journal named Journal of Indian Orthodon- and Turkey.26 tic Society (JIOS) since 1968 and an IOS newsletter since 2009. Since 1996, the IOS has held a convention for postgraduate stu- 12.2.1 College of Physicians dents every year. This event is m uch sought and Surgeons of Pakistan after, where postgraduate students have the opportunity to listen to and interact Lt. Gen. Wajid Ali Burki founded the Col- with faculty and other students from across lege of Physicians and Surgeons Pakistan the country. IOS established a library and (CPSP) in 1962 with the objective of pro- the rst dental m useum in India in 1998. moting postgraduate education in general In 1999, the IOS established the Indian surgery, m edicine, and other subjects. CPSP Board of Orthodontics, the rst such board o ers admission to fellowship of the Col- in the eld of dentistry in India and the lege of Physicians and Surgeons (FCPS) in third in the world. The board was estab- 70 specialties/subspecialties and to mem- lished to examine IOS members with ve bership (MCPS) in 21 specialties. In 1999, years of experience after the MDS degree CPSP started postgraduate fellowship and for clinical excellence in the practice of membership quali cations in all the dis- orthodontics. Board certi cation encour- ciplines of dentistry. Presently, 21 institu- ages the m em bers to practice and strive for tions in Pakistan are accredited by CPSP for 26 clinical excellence and quality treatment. the four-year training program leading to a With the signing of the charter of the fellowship in orthodontics.27 In addition to World Federation of Orthodontics in San the CPSP postgraduate programs, several Francisco, California, United States, in 1995, universities o er four-year master’s degree the IOS becam e a part of the World Federa- programs in orthodontics. Whereas there tion of Orthodontics. were only four overseas-quali ed ortho- The rst SAARC orthodontic conference dontists in Pakistan in 1996, currently was held in Delhi in 2009, and the Eighth there are more than 100 orthodontists. Asian Paci c Orthodontic Conference was Approximately similar numbers of orth- held in Delhi in 2012. IOS in collabora- odontic residents are currently enrolled tion with the World Implant Orthodontic in postgraduate programs in the country Society is ready to host the Eighth World (Table 12.3).27,28 Implant Orthodontic Society Conference in 2016. 12.2.2 Pakistan Association of Orthodontists

12.2 Orthodontic The Pakistan Association of Orthodontists Education in Pakistan (PAO) was established in 2006 with the objective of organizing and promoting the Pakistan has a long histor y in dental educa- specialty of orthodontics in Pakistan. PAO is tion since establishment of the rst dental the sole representative of the orthodontists teaching institution in Undivided India, the in Pakistan and continuously plays a vital de’Montmorency College of Dentistry in role in the development of the specialty of 1929 by the then Governor of the Punjab, orthodontics in the country. In addition, Sir Geo rey Fritz Harvey de’Montmorency. PAO has developed close ties with inter- Currently, there are 40 recognized dental national orthodontic societies around the schools in Pakistan (11 public and 29 pri- world to facilitate the sharing of knowledge vate).25 General dentists in Pakistan have and expertise among professionals. PAO is always been keen on learning the art and a member of the Asian Paci c Orthodontic science of orthodontics. Some of the early Society and the World Federation of Ortho- orthodontists there acquired their post- dontists.29 The members elect the executive 104 Orthodontic Postgraduate Education: A Global Perspective

Table 12.3 Postgraduate programs in India and the subcontinent as of 2014

Ye a r Current Quali cation/degree of course Full-time/ Country awarded start duration part-time

1 India MDS (Mast e r of De nt al 1959 3 y Full-time Surgery) 1986 Fu ll-t im e residency program

Total

2 Bangladesh FCPS (Fellow of the College 2002 4 y Fu ll-t im e of Physicians and Surgeons) MS 2006 5 y Fu ll-t im e residency

3 Nepal MDS (Master of Dental 2008 3 y Full-time Surgery) 2010

2012

2014

4 Pakist an FCPS (Fellow College of Phy- 1999 4 y Fu ll-t im e sicians and Surgeons Paki- 1985 2 y Fu ll-t im e stan) Orthodontics 4 y Fu ll-t im e MCPS (Member College of 2 y Fu ll-t im e Physicians and Surgeons Pakistan) MDS in Orthodontics MSc in Orthodontics 12 Orthodontic Specialty Education in the Indian Subcontinent 105

Number of institutions Number of admissions Certifying or University a liation/ GPT per year regulatory body curriculum

25 159 184 692 Dental Council of DCI regulations 2007 for MDS In d ia (DCI) examination 2 159 2 8 Institute Body l of All India Institute of All India Institute of Medical Medical Sciences, Sciences New Delhi 27 186 700 Post Graduate In- stitute of Medical Post Graduate Institute of Education and Re- Medical Education and Re- search, Chandigarh search, Chandigarh

2 2 24 Bangladesh Medical Bangladesh College of Physi- and Dental Council cians and Surgeons Part I, Part (BMDC) II, and Dissertation Bangabandhu Sheikh Mujib Me dical Unive rsit y (BSMMU), Dhaka

1 0 1 5–10 Nepal Medical National Academy of Medical Council (NMC) Sciences, Kathmandu 1 2 3 Tribhuvan University, Kathmandu 1 0 1 B.P. Koirala Institute of Health Sciences, Dharan 0 1 1 Kathmandu University – Dhu- likhel, Kathmandu

12 9 21 8 trainees Pakistan Medical College of Physicians and Sur- 12 9 21 per supervi- and Dental Council geons Pakistan 1 4 5 sor per year (PMDC) College of Physicians and Sur- 2 2 Sam e as Pakistan (CPSP) geons Pakistan above Pakistan Medical Relevant universit y to which 12 and Dental Council the college is a liated (same 6 (PMDC) for both MDS and MSc) Pakistan (CPSP) Pakistan Medical and Dental Council (PMDC) and relevant university (same for both MDS and MSc)

(Continued on page 106) 106 Orthodontic Postgraduate Education: A Global Perspective

Table 12.3 (Continued) Postgraduate programs in India and the subcontinent as of 2014

Ye a r Current Quali cation/degree of course Full-time/ Country awarded start duration part-time

5 Sri Lanka MS in Orthodontics, changed 1989 4 y Full-tim e to MD since 2010

MD in Orthodontics 2010 4 y

MD in Orthodontics 2014 5½ y

6 Bhutan* – – – –

7 Maldives No – – –

8 Afghanistan No – – –

* Only one orthodontist with MDS quali cation from India.

council for a one-year tenure. PAO has more 12.3.1 Bangladesh College than 75 active and 150 student members.30 Pakistan Orthodontic Journal, started in of Physicians and Surgeons

2009, is an o cial publication of the PAO A draft postgraduate curriculum in ortho- (Table 12.3).31 dontics and dentofacial orthopedics at the Bangladesh College of Physicians and Surgeons was prepared in 1996. The rst 12.3 Orthodontic group of FCPS Part II in orthodontics candi- Education in Bangladesh dates enrolled at Dhaka Dental College and Hospital (DDCH) in 2002. Between 2002 Formal dental education in Bangladesh and 2014, 24 dental surgeons received started with the opening of Dhaka Den- FCPS status in orthodontics and dentofa- tal College and Hospital in 1961. Professor cial orthopedics. With the expansion of a Emadul Haq, the rst quali ed orthodon- large faculty, 32 trainees are registered for tist, obtained a DOrth from the Royal Col- FCPS training at DDCH. There are two lev- lege of Surgeons of England in 1973 and els of examination. The Part I examination joined as an assistant professor in 1976. Dr. is focused on basic sciences. During their Zakir Hossain joined as an assistant profes- clinical tenure, fellows undergo training in sor after completion of a PhD degree from contemporary orthodontic techniques, as Hiroshima University, Japan, in 1989 and well as a mandatory rotation in oral and contributed signi cantly to higher orth- maxillofacial surgery for three months and odontic education and the Bangladesh in plastic surgery for three months. A full- Orthodontic Society (BOS).32,33 time MS residency program was initiated 12 Orthodontic Specialty Education in the Indian Subcontinent 107

Number of institutions Number of admissions Certifying or University a liation/ GPT per year regulatory body curriculum

1 2–8 Sri Lanka Medical Postgraduate Institute of Med- Council (SLMC) icine, University of Colombo

Sri Lanka Medical Postgraduate Institute of Med- Council (SLMC) icine, University of Colombo

–––– – –

at Bangabandhu Sheikh Mujib Medical Uni- sentatives to the Asian Paci c orthodontic versity (BSMMU) in 2009. The course dura- meeting every year, and representatives tion is ve years.33,34 attended the World President Orthodon-

tic Sum mit Meeting in Taipei, Taiwan, in December 2010 and appealed for coopera- 12.3.2 Bangladesh tion in orthodontic education in developing Orthodontic Society countries. Bangladesh Journal of Orthodon- tics and Dentofacial Orthopedics has been 35,36,37 The Bangladesh Orthodontic Society (BOS) published since 2010 (Ta b l e 1 2 . 3 ). was founded in 1993. The BOS joined the World Federation of Orthodontists in 1995 by signing the charter. Secretary General Dr. Zakir Hossain and Joint Secretary Dr. 12.4 Orthodontic Mostaque Hasan Sattar were representa- Education in Nepal tives at this historic event. At present, there are 70 full members and 50 student mem- Dental education in Nepal started in 1998. bers. The BOS conducts a national confer- Presently, there are 12 dental colleges ence and continuing medical education. o ering BDS programs and six institutions It organized the rst international orth- o ering MDS programs in various dental odontic conference in 2012. The BOS is a specialties. The specialty practice of ortho- member of the Asian Paci c Orthodontic dontics is relatively new in Nepal. During Society and represented Bangladesh during the 1970s and 1980s, orthodontic service the rst SAARC orthodontic conference in was provided by general dentists, who New Delhi in 2009. The BOS sends repre- used removable appliances. During those 108 Orthodontic Postgraduate Education: A Global Perspective

decades, a few foreign dentists visited gov- 12.4.2 Orthodontic and ernment hospitals as part of m issionary programs, and a few orthodontists from Dentofacial Orthopedic India visited private clinics in Kathmandu Association of Nepal to provide specialist service. Members of elite Nepalese fam ilies visited neighbor- Pioneer orthodontists established the ing cities in India to obtain orthodontic Orthodontic and Dentofacial Orthopedic treatment. Association of Nepal (ODOAN) in 2007, The rst Nepalese orthodontic special- with the objective of improving orthodon- ist was Dr. Shambhu Man Singh, who com- tic fraternity in Nepal. ODOAN is the rst pleted a DOrth from the Royal College of registered dental specialty organization Surgeons of Edinburgh in 1989 and started in Nepal. It acquired membership in the orthodontic practice in 1990. In 1996, Dr. World Federation of Orthodontics and the Praveen Mishra started an exclusive orth- Asian Paci c Orthodontic Society in 2008. odontic practice in Nepal after completing ODOAN organized the rst orthodontic an MDS (Orthodontics) degree in India. conference of Nepal in May 2008 in Kath- Then, after 2002, a number of orthodon- mandu. Subsequently, ODOAN organized tists graduated every year from institu- an international orthodontic conference tions in India, China, the Philippines, and in November 2011 in Dhulikhel and again Russia. At present, there are approximately in September 2013 in Kathmandu. ODOAN 50 quali ed orthodontists among 1,500 published Orthodontic Journal of Nepal in registered dentists in Nepal. It is estimated November 2011 as the rst specialty dental that about another 50 postgraduate stu- journal of Nepal. Since then, Orthodontic dents are studying orthodontics in Nepal or Journal of Nepal has been published regu- abroad.38,39,40,41 larly as a half-yearly, open-access, indexed scienti c journal (Ta b l e 1 2 . 3 ).42 12.4.1 Master of Dental Surgery in Orthodontics 12.5 Structured Dental Postgraduate orthodontic education con- Education in Sri Lanka sists of a three-year residency program, and successful candidates are awarded an Formal dental training in Sri Lanka started MDS (Orthodontics) degree. The core cur- as early as 1943 with the training of ve riculum comprises applied basic sciences, dental surgeons. Now, the University of Per- specialized subjects, and recent advances. adeniya Faculty of Dental Sciences o ers A special licentiate exam ination is provided an undergraduate dental program, with 75 by the Nepal Medical Council for the gradu- local and ve foreign students graduating ates. National Academy of Medical Sciences annually. The Sri Lanka Dental Association Bir Hospital was the pioneer, starting a post- is the national and parent body of the dental graduate orthodontic program in Nepal in profession in Sri Lan ka. Sin ce its form ation in 2008. Later, Tribhuvan University started 1932, the Sri Lanka Dental Association has an MDS (Orthodontics) program in 2010, contributed immensely to the development and B.P. Koirala Institute of Health Sciences, of the profession, as well as to the welfare of Dharan, in 2012. Kathmandu University the public in Sri Lanka.43,44,45,46,47 started an MDS (Orthodontics) program in The orthodontic profession in Sri Lanka 2014. To date, 10 orthodontic graduates have is relatively young, although the demand received MDS degrees from Nepal, and 18 for orthodontic care is huge. A total of 39 students are studying orthodontics in vari- orthodontists practice in Sri Lanka, most ous postgraduate colleges in Nepal.38,39,40,41 of them in government hospitals, the Uni- 12 Orthodontic Specialty Education in the Indian Subcontinent 109 versity of Peradeniya Faculty of Dental Sci- References ences, and health services of the armed forces. Orthodontic services in the private 1. The Columbia Electronic Encyclopedia. sector are available in di erent parts of the 6th ed. New York, NY: Columbia Univer- country. There are currently more than 15 sity Press; 2003. https://www.questia.com/ read/1E1-Indiansu/indian-subcontinent. trainees at di erent levels of training.48,49,50 Accessed September 14, 2014 2. Vanhanen T. Prospects of Democracy: A Study of 172 Countries. New York, NY: Rout- 12.5.1 MD/MS Degree in ledge; 144. Cited from http://en.wikipedia. Orthodontics org/wiki/Indian_subcontinent. Accessed September 14, 2014 Postgraduate quali cation in Sri Lanka is 3. Dhaka declaration. First SAARC summit. called MS/MD in Orthodontics and requires http://www.saarc-sec.org/user les/01-Dha- fellowship certi cation. The MD in Orthodon- ka-1stSummit1985.pdf. Accessed February tics program is o ered at the Postgraduate 11, 2015 Institute of Medicine University of Colombo, 4. Declaration of the fourteenth SAARC summit. Sri Lanka. The total duration of the train- http://www.saarc-sec.org/user les/Summit ing program is long: ve and a half years. %20Declarations/14%20-%20New%20Del- hi,%2014th%20Summit%203-4%20April%20 The training is split: four and a half years in 2007.pdf. Accessed February 11, 2015 approved centers in Sri Lanka and one year at 5. Encyclopædia Britannica Online 2009. Cited a recognized center overseas. Several ortho- from http://en.wikipedia.org/wiki/Indian_ dontists in Sri Lanka have undergone train- subcontinent. Accessed September 14, 2014 ing in the department of orthodontics at the 6. Encyclopedia of Modern Asia 2006. Cited dental school of The University of Western from http://en.wikipedia.org/wiki/Indian_ Australia, Perth, and at several centers in the subcontinent. Accessed September 14, 2014 United Kingdom. This is followed by board 7. History of Dental Council of India. Souvenir 48,50 certi cation as a consultant orthodontist. released on the occasion of the Silver Jubilee of Dental Council of India. New Delhi, India: Dental Council of India; 1973:59–67, 70–73

12.5.2 Sri Lanka Orthodontic 8. www.dciindia.org.in. Accessed November 5, Society 2014 9. Parikh NH, Modi AB. Fifty Years of Orth- Th e Sr i La n k a Or t h o d o n t ic So cie t y (SLOS) w a s odontic Education in Proceedings of the formed in January 1999. SLOS is a specialty 22nd Indian Orthodontic Conference and organization whose members are quali ed Golden Jubilee of Orthodontic Education in India. Indore, India; 1987 orthodontists with board certi cation. The SLOS is a member of the Asian Paci c Orth- 10. Jayna P, Chauhan DN. Development of the orthodontic specialty in India. In: Proceed- odontic Society and the World Federation of ings of the 23rd Indian Orthodontic Confer- Orthodontics. The SLOS was represented at ence; 1988 the SAARC orthodontic conference in New 11. Joshi MR. How I became an orthodontist: Delhi in 2009 (Table 12.3). history, mystery and my story. “Genesis” souvenir released on the occasion of the 39th Indian Orthodontic Conference; 2004; Davangere, India 12.6 Bhutan, Maldives, 12. All India Institute of Medical Sciences. Cur- and Afghanistan riculum. New Delhi, India; 2004 13. Dental Council of India master’s degree It was not possible to obtain information on courses regulations 1965 orthodontic education in Bhutan, Maldives, 14. Dental Council of India MDS course regu- or Afghanistan, although mention of orth- lations 1983. http://www.mohfw.nic.in/ odontic services in these countries can be WriteReadData/l892s/2975521555943086 8860dciregulations.pdf. Accessed February found on the internet (Table 12.2). 11, 2015 110 Orthodontic Postgraduate Education: A Global Perspective

15. National Board of Exam inations guidelines 29. Pakistan Association of Orthodontists. Di- o f co m p e t e n cy b a s e d t r a in in g p r o gr a m m e in rector y. ht tp://w w w.pao.org.pk/index.php/ orthodontics 2000; Orthodontics: 438–441 directory. Accessed February 22, 2015 16. Mistry KK. Report of the National Workshop 30. Pakistan Association of Orthodontists. Of- on Postgraduate Orthodontic Education in cial Website. http://w w w.pao.org.pk. Ac- India—Its Future Directions. Chennai, India: cessed February 11, 2015 Indian Orthodontic Society; 1993 31. Pakistan Orthodontic Journal. http://poj. 17. Kumar J. Orthodontic education in India: the org.pk. Accessed February 11, 2015 challenge of change. Som e suggestions from 32. Dr. Zakir Hossain, head of the department Trivandrum. Base paper for the National of orthodontics, Dhaka Dental College and Workshop on Postgraduate Orthodontic Hospital, Dhaka, Bangladesh (personal Education in India—Its Future Directions, communication) October 1993 33. Orthodontics Bangladesh. http://en.wikipedia. 18. Dental Council of India master’s degree org/wiki/Orthodontics#Bangladesh. courses regulations 1988 (unpublished) Accessed February 11, 2015 19. Dental Council of India. Master’s degree 34. Bangladesh College of Physicians & Sur- course revised regulations 2007. http:// geons. http://www.bcpsbd.org. Accessed www.dciindia.org.in/Rule_Regulation/ February 11, 2015 MDS_Course_Regulations_2007_along- 35. World Federation of Orthodontists. http://www. with_Amendments.pdf wfo.org/links. Accessed February 11, 2015 20. Government of India Dental Gazette Extra 36. http://www.banglajol.info/index.php/ ordinary No. 139 dated August 20, 2008. BJODFO/. Accessed May 28, 2015 First am endm ent for MDS curriculum 2007. http://www.dciindia.org.in/Rule_Regu- 37. Hossain MZ. Short comm unication-2: role lation/MDS_Course_Regulations_2007_ of Bangladesh Orthodontic Society in World alongwith_Amendments.pdf President Orthodontic Summit in Taipei. Bangladesh J Orthod and Dentofacial Or- 21. Government of India Dental Gazette Extra thop 2012;2(1):209–238 ordinary No. 140 dated May 21, 2012. Sec- ond amendment for MDS curriculum 2007. 38. Shrestha RM. History of Nepal Dental Asso- http://www.dciindia.org.in/Rule_Regu- ciation. Bites 2006;2(2):8–9 lation/MDS_Course_Regulations_2007_ 39. Shrestha RM. Nepalese history of orthodon-

alongwith_Amendments.pdf tics. Orthod J Nepal 2011;1(1):10 22. Dental Council of India letter No: DE- 40. Shrestha RM. Orthodontic scenario of Ne- 1(SC)-93/2064, October 28, 1993 pal. Orthod J Nepal 2013;3(1):5–6 23. Dental Council of India letter No: DE- 41. Shrestha RM. Orthodontic research in Ne- 1(SC)-94/2695, October 27, 1994 pal. Orthod J Nepal 2012;2(1):1–3 24. Directory of the Indian Orthodontic Society. 42. Orthodontic & Dentofacial Orthopedic As- Mysore, India: Roy ET, ed; 2003:i–iv. Pub - sociation of Nepal. www.odoan.org.np. Ac- lished by Editor Roy ET, Doctors Corner, My- cessed February 11, 2015 sore, India 43. Dental Services, Ministry of Health, Sri Lanka. 25. Eduvision. http://www.eduvision.edu.pk/ Histor y. http://w w w.dental.health.gov.lk/ institutionSearch.php?disciplineType=Medi about-us/History. Accessed February 11, 2015 cal+Sciences&subLevel=MAJOR+TRAINING+ 44. Faculty of Dental Sciences, University of %5BMEDICAL%5D&pageNo=1&discipline=O Peradeniya. http://www.pdn.ac.lk/dental/ RTHODONTICS&cit y=&Submit=Search. Ac- dental/about/deans_massage.html. Ac- cessed February 11, 2015 cessed February 11, 2015 26. Professor Sheraz Burki, past president of 45. Sri Lanka Dental Association. http://www. the Pakistan Association of Ortho (personal slda.lk/about. Accessed February 11, 2015 communication, August 30, 2014) 46. Siriyani Basanayake, orthodontic specialist, 27. College of Physicians and Surgeons Paki- Colombo, Sri Lanka (com munication) stan. http://cpsp.edu.pk. Accessed February 47. Dental Services, Ministry of Health, Sri 11, 2015 Lanka. Orthodontics. http://www.dental. 28. Dr. Amjad Mehm ood, im m ediate past presi- health.gov.lk/services/orthodontics. Ac- dent of the Pakistan Association of Ortho- cessed February 11, 2015 dontists (personal com munication) 12 Orthodontic Specialty Education in the Indian Subcontinent 111

48. University Grants Commission, Sri Lanka. dontics. http://pgim.cmb.ac.lk/wp-content/ Postgraduate courses. http://www.ugc. uploads/2014/04/Pros-Orthodontics.pdf. ac.lk/en/universities-and-institutes/de- Accessed March 17, 2015 gree-courses/postgraduate-courses.html. 50. University Grants Commission—Sri Lanka. Accessed March 17, 2015 http://www.ugc.ac.lk/en/universities-and- 49. Postgraduate Institute of Medicine, Uni- institutes/degree-courses/postgraduate- versity of Colombo, Sri Lanka. Doctor of courses.htm l. Accessed on March 17, 2015 medicine and board certi cation in ortho-

The Educational Role of 13 Orthodontic Boards around the World

Mauro Cozzani and Frank Weiland

Its certi cate has no legal standing, theoretical knowledge. The World Federa- but it is a powerful psychological fac- tion of Orthodontists (WFO) emphasizes tor in stimulating specialists to acquire that board certi cation is of critical impor- increased knowledge and skill in their tance to improve the level of orthodontic respective branches. treatment that the public receives. It is also –Albert H. Ketcham , Founder, felt that board certi cation encourages self- American Board of Orthodontics improvement among colleagues who are recognized specialists in orthodontics and Th e n u m b e r o f o r t h o d o n t ist s a n d t h e a m o u n t indicates that an orthodontist has demon- of orthodontic treatment provided grew strated a clinical standard of excellence. im m ensely during the second part of the last The American Board of Orthodon- century. However, standards of orthodontic tics (ABO), the oldest certifying board, postgraduate education di er among coun- has existed since 1929 as an independent tries and even within countries. Therefore, peer review institution, supported by the controlling and improving the quality of American Association of Orthodontists. clinical care in daily practice has become an James Vaden, past president of the ABO, issue of growing importance for the general has listed some reasons for sitting a board

public, health care policy, and regulatory examination: bodies. Certi cation by board examination is one method to secure high standards of • To experience personal grow th as a clinical care, with the assessment of treat- practicing clinician ment quality by peer review. The aim of this • To increase one’s self-con dence chapter is to describe the e ect of the board • To undergo an invaluable learning certi cation process on the quality of post- experience graduate education, and vice versa. • To be able to o er better clinical care to patients Large di erences still exist among various countries in regard to postgraduate 13.1 The Goal of Board education and public health systems. These Certi cation di erences have had a major impact on the way orthodontic care is provided and prac- Board certi cation is a voluntary process ticed, and on what portion of the population that comprises an extensive review of an has access to service. Board examination may orthodontist’s basic education, as well as enhance the quality of orthodontic treatment an intense assessment of his or her exper- by providing a standard against w hich ortho- tise. The goal is to improve the professional dontists who so desire can be judged. The performance of the individual clinician by board certi cation process, however, di ers means of a careful and extensive evalua- among countries. Still, a major goal of estab- tion of all aspects of actual patient treat- lishing an orthodontic board is to develop 112 ment—both clinical performance and standards and parameters for the profession. 13 The Educational Role of Orthodontic Boards around the World 113

13.2 Setting of Standards required for certi cation. According to data supplied by the WFO, this policy raised the percentage of board-certi ed orthodontists The WFO established an Orthodontic Board among members of the American Associa- Committee to coordinate the guidelines and tion of Orthodontists from 28 to 52%. The standards of various existing as well as new Australasian Orthodontic Board started a certifying boards around the world. Topics “student pathway” toward membership by that were discussed comprised, among oth- having students submit a list of ve cases; ers, the eligibility of candidates, exam ina- two of these are assessed after treatment. tion process, selection of examiners, and Full certi cation is granted after success- recerti cation. fully completing the orthodontic course Orthodontics is a clinical specialty w ith and after successful assessment of the post- a sound theoretical basis. Therefore, the treatment records of the two Board cases. certi cation process consists of the com- Within two years the Australasian Orth- bination of a theoretical examination and odontic Board re-certi cation process must a presentation of treated and documented be started. The European Board of Ortho- cases. Th e w ay t h ese t w o p ar t s of t h e exam - dontists uses a similar method. Recently ination are handled di ers among boards. graduated orthodontists may sit the rst This issue is discussed in greater depth in part of the certi cation examination. This the next section. consists of the presentation of two cases The basis of board certi cation is clini- treated during the postgraduate intern- cal excellence. This should be re ected in ship and an oral examination comprising the quality of the treated cases. There is the diagnosis and treatment planning of general agreement that it is mandatory to two new cases. The successful candidate display various t ypes of cases for the m odel becom es a p rovision al m em ber of t h e Eu ro - display, treated to the highest clinical stan- pean Board of Orthodontists. The remain- dards. Th e n u m ber of requ ested cases is n ot ing requirements for full membership must uniform and m ay vary between 5 and 10. be ful lled within six years. It is generally felt that the board certi - The idea behind opening membership

cation process should be open only to edu- to recently graduated orthodontists is to cationally quali ed orthodontists who have get young, enthusiastic orthodontists on graduated from recognized postgraduate board, in the hope that they will want to orthodontic programs. A general problem, remain members in good standing for per- however, is that in the majority of existing sonal and professional reasons. Experience organizations throughout the world that in the United States, Europe, and Australia have formed an orthodontic board, only a indicates that this seems to be an e cient small proportion of their m embers have way of increasing the percentage of board- become certi ed. This makes it di cult certi ed orthodontists. for a board to set standards in clinical care that are widely accepted. Several reasons for choosing not to pursue board certi cation have been discussed. Some orthodon- 13.3 Di erent Bo ards— tists feel that too much time and e ort are required to prepare for the examination Di erent Certi cation successfully. Others feel that a direct mon- Processes etary advantage is lacking, so that the cost e ciency of the process is lim ited. The oldest board of orthodontics, the ABO, To overcome this reluctance to becom- has amended the guidelines for certi ca- ing board-certi ed, the ABO recently tion several times. Nowadays, the process established an alternative pathway to cer- consists of a written examination and the ti cation in which recent graduates (within presentation of case reports. Central to the 24 months after graduation) are given the examinations of all the boards founded in opportunity to present some of the cases the following decades is the presentation 114 Orthodontic Postgraduate Education: A Global Perspective

of clinical cases. The numbers vary from Regional Orthodontic Boards. It is antici- 5 to 10 cases. Some boards require cases pated that these guidelines will encour- from several de ned types of malocclu- age the establishment of new certifying sion, whereas others use the severity of boards in orthodontics. Existing certifying the original m alocclusion as a criterion. All boards may wish to compare their current boards require the submission of pre- and guidelines and procedures with those rec- post-treatment records, but not all require ommended by the WFO and modify them retention records. accordingly, if they nd that doing so will Several boards require that the candi- improve their standards. The WFO should date take a theoretical examination as part act as an umbrella organization to which of the certi cation procedure. The ABO, boards can turn for help, cooperation, and Indian Board of Orthodontics, Philippine sharing ideas. In this way, a board standard Board of Orthodontics, and Taiwan Asso- is available against which any other board ciation of Orthodontists all have a written can be m easured. examination. Only after successful completion of this part is the candidate allowed to present cases. Phase I of the Brazilian Board of Orthodontics and Facial Orthope- 13.4 The Interaction dics examination consists of an evaluation between Postgraduate of the diagnosis and treatment planning of cases presented by the board. The Euro- Education and Board pean Board of Orthodontists does not have Ce rt i c a t io n a written examination. Unlike in the Bra- zilian Board of Orthodontics examination, Board certi cation requires a considerable the required cases are examined in Phase amount of knowledge and high-quality I. Phase II, which is an oral examination, clinical skills. The basis is laid during the follows immediately. In addition, the cases postgraduate residency, with the addition that the candidate presents can be dis- of clinical experience and continuing edu- cussed if deemed necessary by the examin- cation. The immediate e ect of the qual- ers. The French Board of Orthodontics also ity of postgraduate education increased includes an oral interview. The advantage in recent years after several orthodontic of an oral interview following the examina- boards changed their certi cation proce- tion of the presented cases is that the can- dures to accept recently graduated ortho- d idate can receive feed back abou t h is or h er dontists. The theoretical examination is presented cases. The examiners may point usually the rst step toward certi cation, out inaccuracies in the diagnosis, treatment and the knowledge acquired during post- plan, or treatment result. This approach graduate education is essential to pass this m ay in crease t h e learn in g exp er ien ce of t h e examination. During the residency, the can- participant during the examination. didate diagnoses and plans the treatment of Before being eligible to sit the examina- the required cases, and treats them under tion of the German Board of Orthodontics supervision. The guiding hand of a sta and present documented cases, the candi- orthodontist is of major importance dur- date must have attended a fair number of ing this phase. As a consequence, successful continuing education classes and partici- board certi cation implies not only that the pated in scienti c work, if possible. candidate has shown a high level of compe- The WFO is aware of the di erences tence but also that the postgraduate educa- in the requirements of the various boards. tion program is competitive. Con se qu e n t ly, it in it iat e d t h e W FO Com m it - As stated on its Web site, the primary tee on National and Regional Orthodontic purpose of the ABO is to elevate the level Boards. Since its formation, this commit- of orthodontic care provided to the public tee has developed the WFO Guidelines for by encouraging excellence in clinical prac- the Establishment of New National and tice and specialty education. This state- 13 The Educational Role of Orthodontic Boards around the World 115 ment clearly indicates that excellence of orthodontic knowledge implies that practi- specialty education is one of the goals of tioners m ust make a lifelong com mitment board certi cation. The Taiwan Association to the improvement of skills, acquisition of of Orthodontists sets guidelines regarding knowledge, and modi cation of practice. the quali cations of the institutes where This is not possible without continuing candidates are trained and their instructors education. The Australasian Orthodontic for candidates to become diplomates of the Board and the German Board of Orthodon- board. One of the objectives of the Philip- tics and Orofacial Orthopedics, among oth- pine Board of Orthodontics is to accredit ers, see contin uing educat ion as on e of th eir and approve the various orthodontic pro- responsibilities. The German board orga- grams and review the examinations admin- nizes a yearly congress at which attendance istered. The Indian Board of Orthodontics by diplom ates is m andatory. clearly states that orthodontic training is Lifetime certi cation seems less appro- intensively reviewed. priate nowadays than it m ay have been in the Some postgraduate programs in Europe past because of the rapid increase in orth- (e.g., Department of Orthodontics, Medical odontic knowledge. Several certifying boards University Vienna, Austria) require that the have changed their certi cation procedure by t w o ca ses t h at m u st b e d isp laye d t o fu l ll p ar t implementing a recerti cation process. Recer- of the criteria for provisional membership of ti cation for members of the German Board the European Board of Orthodontists be pre- of Orthodontics includes mandatory par- sented at the nal postgraduate examination. ticipation in continuing education organized Board certi cation enables an indirect or recognized by the board. In addition, ve assessment of the quality of postgraduate years after the status of diplomate has been education. If a high percentage of candi- achieved, an active contribution (case pre- dates educated in a certain department are sentation, poster presentation, or lecture) is su cce ssfu l, t h at fa ct m ay b e u se d t o p r o m ot e required. The German Board of Orthodontics the educational quality of the departm ent. de nes board certi cation as the voluntary The board certi cation process is gener- comm itment to lifelong continuing education ally open only to orthodontists who have at a high professional level. The Taiwan Asso- graduated from recognized postgraduate ciation of Orthodontists has implemented a orthodontic programs. Some countries, similar recerti cation procedure that involves however, do not o cially recognize the spe- lecturing, publishing, participating in con- cialty of orthodontics. For board-certi ed tinuing education, and the like. Recerti ca- orthodontists in these countries, the dispar- tion is obligatory every six years. ity between board certi cation and the lack The recerti cation procedure for the of a legally recognized status as an ortho- ABO takes place every 10 years. The proto- dontist may pressure health care authori- col depends on the time when the renewal ties to recognize the specialty. This, again, is undertaken. At the rst certi cation m ay h elp t o im p rove t h e level o f or t h od on t ic renewal, two cases with a discrepancy treatment received by the public. The WFO index of 20 or higher must be submitted. In has initiated a discussion on accreditation addition, an online m ultiple-choice exam i- standards and the criteria used to recognize nation assesses the candidate’s theoreti- bona de orthodontic programs. cal knowledge. Subsequent recerti cation examinations include the submission of one case and a theoretical examination, as described previously. 13.5 Clinical Excellence Certi cation by the Australasian Orth- and How to Maintain It odontic Board is for ve years, after which the board member must undergo recerti - Achieving clinical excellence is one thing; cation, including the submission of cases. maintaining excellence during practice as a The presentation of one new case every professional is another. The rapid increase in six years is mandatory to remain a member 116 Orthodontic Postgraduate Education: A Global Perspective

of the Brazilian Board of Orthodontics and Further Reading Facial Orthopedics. Members of the Italian Board of Ortho- American Board of Orthodontics. www.ameri- dontics must present a case every second canboardortho.com. Accessed March 30, year at the national meeting of the organi- 2015 zation. The case, however, is not evaluated. Australasian Society of Orthdontists, Austral- In summary, the recerti cation pro- asian Orthodontic Board. www.aso.org.au/ australasian-orthodontic-board. Accessed cess aims to keep the quality of treatment March 30, 2015 at a high level by re-evaluating the clini- Brazilian Board of Orthodontics and Facial Or- cal knowledge and skills of practitioners thopedics. www.bbo.org.br. Accessed March throughout their professional careers. This 30, 2015 may be done by the periodic presentation European Orthodontic Society, European Board of treated cases, successful completion of a of Orthodontists. www.eoseurope.org/ebo. theoretical examination, and/or mandatory Accessed March 30, 2015 participation in continuing education. French Board of Orthodontics. www.ceortho.fr/ en/french-board-orthodontics. Accessed March 30, 2015 German Board of Orthodontics and Orofacial 13.6 Conclusion Orthopedics. www.german-board.de. Ac- cessed March 30, 2015 Board certi cation, postgraduate educa- Indian Orthodontic Society, Indian Board of Or- tion, and continuing education are inex- thodontics. http://www.iosweb.net/ibo. tricably related in securing and enhancing htm . Accessed March 30, 2015 the standards of clinical orthodontic care. Italian Society of Orthodontics, Italian Board Only well-educated orthodontists are able of Orthodontics. www.sido.it/ibo.asp. Ac- to become board certi ed. Board certi ca- cessed March 30, 2015 tion requires that clinicians have achieved Philippine Board of Orthodontics. www.pbo.ph. a high level of postgraduate education and Accessed March 30, 2015 are committed to clinical excellence based Taiwan Association of Orthodontists. www.tao.

on sound theoretical knowledge that is kept org.tw. Accessed March 30, 2015 up to date by means of continuing educa- World Federation of Orthodontists. Accessed tion. Furthermore, the examinations pro- March 30, 2015 www.wfo.org vide a unique opportunity for candidates to review their practices and to re ect on the importance of high-quality records, mechanical control during treatment, and careful attention to the nal phase of treatment. Structure and Org anizatio n 14 of Dental Specialty Education in the United Kingdom

Fraser McDonald, G. Howard Moody, and Dirk Bister

This chapter is aim ed at giving the reader an ized academic element associated with a overview of the structure of postgraduate university during training. dental specialty education and its regulatory The academ ic component itself is split bodies in the United Kingdom. More spe- into two parts: form alized teaching (lec- ci cally, it highlights the standardization of tures, seminars, tutorials, practical exer- postgraduate specialty education and exam- cises) and a research-based thesis at either ination in dentistry throughout the three the master’s or doctoral degree level (MSc/ countries plus Northern Ireland that make DDS). The academic component is run by up the United Kingdom, and the responsibil- the university with which the training pro- ities and tasks that are undertaken by vari- gram is a liated. The clinical component is ous bodies. It emphasizes the importance of organized by local education and training the independence of the Royal Colleges in boards (LETBs), formerly known as post- setting standards and organizing examina- graduate deaneries (please see below). tions at the postgraduate level. Following specialization and entry into the General Dental Council’s specialist list, a trainee m ay undergo two years of further education as a higher trainee (formerly

14.1 Overview known as a senior registrar). This training is intended to facilitate clinical pro ciency Clinical dental education in the United King- at a higher level and is assessed via a higher dom is divided into three distinctive levels: quali cation (currently an intercollegiate undergraduate ( ve years), dental founda- fellowship) suitable for a hospital post at tion (DF; two years), and postgraduate spe- the consultant level. This additional train- cialty training (three years plus an optional ing is unique to dentistry in the United additional two years). Higher degrees Kingdom and Ireland and is not discussed leading to university careers in specialties further. In m edicine, successful specialty involve intercalated PhD/DDS degrees, and training and assessm ent alone allow access the clinical specialist training will still be a to consultant level posts. three-year full-time equivalent. At the postgraduate level (DF and spe- Postgraduate specialty training for cialty training), the organization of train- dentistry has two components: clinical ing is principally national; this ranges from training and an academic element. The recruitment, to the setting of curricula and two components are parallel and comple- syllabuses, to the provision of training and ment each other. Postgraduate courses are examinations. However, recruitment to DF therefore usually advertised as combined training is national for England, Wales, and membership and MSc/DDS programs (e.g., Northern Ireland; for a variety of reasons, MOrth/MSc for orthodontics). Postgradu- Scotland recruits separately. ate training in dentistry is di erent from Recruitment to core training posts is the equivalent specialty training in medi- arranged locally, although there is an aspi- cine, in which there is no distinct formal- ration to develop national recruitment. It is 117 118 Orthodontic Postgraduate Education: A Global Perspective

currently hampered by the lack of a curricu- A major area of con ict exists between lum. Recruitment for specialty training posts the Department of Health, whose workforce is national (throughout the United Kingdom ) is trained and delivered at the undergradu- for orthodontics (specialist trainees) and ate level, an d t h e Dep ar t m en t of Ed u cat ion . pediatric dentistry. For post-specialty edu- The interface of the two departments when cation ( xed-term training of an additional the training of students is taken into clinical two years leading to a consultant job) posts areas with direct access to patients has for in orthodontics, Wales is currently excluded. many years been without issue. However, There are plans to extend national recruit- the increase in student numbers, together ment to other dental specialties in the future. with the expectations of patients and the increase in administrative regulation, has made it necessary for more formal links to be put in place. These include the recogni- 14.2 Department of tion that students in training are covered by He alth the appropriate clinical indem nity.

Currently, the Department of Health (Edu- cation and Welfare) is ultimately respon- 14.3 Professional sible for health care regulation in the United Kingdom through the Professional Standards Standards Authority Authority (PSA). This includes dentistry. The aims of the Department of Health As previously m entioned, the PSA regulates are to help people lead “healthier lives, and advises health care bodies at a higher recover well from illness, and live better for level. The PSA is responsible for overseeing longer.” Its role is to implement policies to the nine health care professional regula- achieve those aims. The department is one tory bodies in the United Kingdom. These of the numerous (24) ministerial depart- include the General Chiropractic Council, ments, which report directly to the o ces the General Dental Council (GDC), the Gen - eral Medical Council, the General Optical of the prim e m inister and the deput y prim e minister, and it works with other depart- Council, the General Osteopathic Council, ments. Their far-reaching responsibilities the General Pharmaceutical Council, the are divided into executive agencies, execu- Health and Care Professions Council, the tive nondepartmental bodies, and advisory Nursing & Midwifery Council, and the Phar- nondepartmental public bodies. The di er- maceutical Society of Northern Ireland. It ent departmental roles are wide-ranging comprises three teams assigned to (1) scru- and include social care, the National Health tiny and quality, (2) standards and policy, Se r v ice (NHS), a n d p u b lic s a fe t y. He a lt h e d u - and (3) governance and operations, a per- cation is delivered though NHS Education formance review body that makes sure that for Scotland, the Workforce Education and the nine regulatory bodies are performing Development Services Wales, the Northern according to the standards set. Ireland Medical and Dental Training Agency, and Health Education England. The NHS is a publicly funded body that aims to provide health care that is free to the public at point 14.4 General Dental of delivery; dentistry is partially funded. Council The Department of Health issues guidance on how heath care, including dental The GDC is an independently funded services, should be delivered. The Depart- organization whose aim is to “protect the ment of Health guidance speci es working patients and regulate the dental team.” All conditions and contractual arrangements dental professionals legally working within for the NHS, as well as referral arrange- the United Kingdom must be on one of the ments within the health care system. GDC registers, including dentists, dental 14 Structure and Organization of Dental Specialty Education in the United Kingdom 119 nurses, dental technicians, clinical dental Scotland, Workforce Education and Devel- technicians, dental hygienists, dental ther- opment Services Wales, Northern Ireland apists, and orthodontic therapists. The GDC Medical and Dental Training Agency, and regulates the dental profession by setting Health Education England. standards, including standards to ensure the quality of dental education at all levels. One of the responsibilities of the GDC is 14.5.1 Co m m it t e e f o r to take actions against those who work out- Postgraduate Dental Deans side the legal framework, and as the main regulatory body of dental professionals, its and Directors objective is to enhance patient con dence and safety as well as improve the quality of These training boards are themselves over- care. The GDC is made up of 12 members: seen by the Committee for Postgraduate six appointed registrants (dental profes- Dental Deans and Directors (COPDEND). sionals) and six appointed lay members. It COPDEND and the four agencies deliver and set s u p st an d in g com m it tees to look at p oli- manage postgraduate dental education for cies and processes, and statutory commit- the dental team. Local organization is with tees, de ned by the Dentists Act 1984, to the four agencies, and national organization carry out delegated regulatory work. is m ainly at the COPDEND level. Som e COP- The GDC is funded solely by annual DEND-linked com mittees are the standing retention fees paid by dental profession- advisory com mittees, which advise on mat- als, including dental nurses and therapists, ters a ecting the various dental specialties. dental technicians, and dentists. In con- Postgraduate training in dentistry contrast to the European Union regulations, sists mainly of two parts: (1) DF for up to which recognize only two dental special- two years and (2) postgraduate specialty ties (orthodontics and oral surgery) across training (three years plus an optional addi- all states, the GDC recognizes a total of 13 tional two years, the latter for consultant dental specialties for the United Kingdom, training). and it speci es the tasks of each specialty. One year of DF training is compulsory The GDC is responsible for overseeing for all graduates qualifying from a United dental education at all levels: undergradu- Kingdom dental school. This was previ- ate education, DF training, and postgradu- ously also known as vocational training. ate specialty training. However, a large Successful completion of training allows number of its educational responsibili- the dentist to apply for an NHS performer ties are devolved to universities and their number, which is necessary to hold a con- respective supervisory bodies for under- tract with the NHS. graduate education, and to postgradu- A trainee in the second year (DF2) was ate deaneries for foundation training and formerly known as a senior house o cer. postgraduate specialty education. Lately, The second year is not compulsory but the postgraduate deaneries have been sub- allows the dentist to prepare for the MFDS sumed by LETBs; some of these work at a (Membership of the Faculty of Dental Sur- local and others at a national level. geons)/MJDF (Membership of the Joint Dental Faculties) examinations of one of the Royal Colleges. Obtaining one of these diplomas puts a dentist in a good position 14.5 Postgraduate Dental to apply for specialist training. COPDEND also organizes national Training in the United recruitment to specialist training and hence Kingdom is involved in specialist workforce planning as well as in quality assurance of training. Four educational agencies oversee post- National recruitment takes place once a graduate medical and dental education in year, and the interviews for all candidates the United Kingdom: NHS Education for are held in one center over two days. The 120 Orthodontic Postgraduate Education: A Global Perspective

interviews are structured and standard- Th e d e n t a l co u n cil o f t h e Roya l Co lle ge o f ized and are more like examinations than Surgeons of Edinburgh was created in 1954, interviews. The interviews cover several set and it achieved faculty status in 1982.1 The items (e.g., audit and research), and marks other dental faculties were also established are allocated for each section. The cumula- in the 1980s, and they hold examinations t ive m a rk is u se d fo r r a n k in g t h e ca n d id at e s. for all of the recognized specialties in the Postgraduate dental trainees undergo United Kingdom and m any overseas. a large number of quality assurance pro- The membership and fellowship exami- cesses. These include regular appraisals, nations function as specialist examinations. which incorporate information gained from To be accredited as a specialist dentist with workplace-based assessments and other the GDC, applicants must prove that they formalized information about the trainee have the appropriate amount and level of (e.g., number of patients in treatment and specialist training (con rm ed by universi- case mix). COPDEND and the four agen- ties and LETBs) and must prove that they cies are responsible for organizing these have successfully passed the specialty exam- appraisals, which are mainly, but not exclu- ination as determ ined by one of the colleges. sively, form ative. All specialt y training posts All this must be set against a backdrop are subject to inspection, and a speci c of how we have arrived at the current level training number is issued after recognition. of regulation (Ta b l e 1 4 . 1 ). Neither the four agencies nor COPDEND examine or set up nal specialty examinations, however. Specialty examinations are set up by the Royal Colleges. COPDEND has 14.7 Role of the Dental a lead dean, w ho relates to the dental facul- Faculties of the Royal ties of the Royal Colleges and the standing advisory committees. Surgical Colleges of the United Kingdom in Dental Health Regulation

14.6 The Royal Colleges The dental faculties of the Royal Colleges of Surgeons o er postgraduate career guid- Examinations at the postgraduate dental ance, as do postgraduate deans (LETBs). The specialty level are supervised by the Royal co lle ge s m ay e xt o l t h e at t r a ct io n a n d vir t u e s Colleges. The principal colleges involved of certain subspecialist disciplines, but they in postgraduate dental education are the do not, as colleges, train anyone in these Royal College of Physicians and Surgeons disciplines. College councils may comment of Glasgow, the Royal College of Surgeons on NHS or governm ent “discussion papers,” in Ireland, the Royal College of Surgeons and while this is a useful function, it is of Edinburgh, and the Royal College of hardly unique. Specialist associations, uni- Surgeons of England. The Royal College of versities, postgraduate and undergraduate Pathologists and the Royal College of Radi- deans, and patient representative groups ologists are also involved where appropri- make equally valid contributions to such ate. Originally, the Royal Colleges were debates. Colleges also provide educational medical and/or surgical in nature, but they events, but so do other health care bodies, now all have dental faculties. such as NHS Education for Scotland, Health The Royal Colleges are funded indepen- Education England, and LETBs, with the dently of government by annual member- bene t of much larger budgets. The Royal ship subscriptions, examination and course Colleges are well placed as independent fees, and some generous legacies. The den- evaluators of clinical competence, while the tal faculties of the four Royal Colleges of universities evaluate academic knowledge. Surgeons, although entirely independent, The colleges are, however, uniquely quali ed collaborate closely to their mutual bene t. through experience, training, and logistical 14 Structure and Organization of Dental Specialty Education in the United Kingdom 121 support to provide relevant and a ordable Table 14.1 Dates of importance in the Postgraduate Independent External Quality formation of the current regulations Assurance (PIEQA). Speci c event/body Year James Rae2 lectures to the Royal 1776 14.7.1 Postgraduate College of Surgeons of Edinburgh Independent External Quality William Rae 2 lectures at John 1785 Assurance Hunter’s house in London

Postgraduate independent external qual- Universit y College London 1826 ity assurance (PIEQA) is the third side of (London University) the medical–dental triangle (Fig. 14.1). The King’s College 1829 rst side comprises all that is encompassed by the word education—from the rst year University of London 1836 of undergraduate studies to the completion Royal Dental Hospital 1858 of continuing professional development (also known as continuing professional General Medical Council 1858 education) at retirement. The second side is delivery—delivery of every conceivable License of Dental Surgery 1860 form of health care in the widest possible First Dental Act 1878 interpretation of care. (an Act of Parliament) Scottish Dental Education 1878 14.7.2 Postgraduate Co m m it t e e Education and Quality Dental teaching linked with 1911 Control universities (10 years of negotiations) The quality of undergraduate medical and Royal College of Edinburgh 1919 dental education in the United Kingdom higher dental diploma3 is controlled as previously detailed. With the advent of the NHS, the historical role Interdepartmental Committee 1943 of the colleges in undergraduate education on Dentistry ended; all undergraduate education nally National Health Service 1948 p a sse d t o t h e u n ive r sit ie s. Th is r elat e s t o t h e area of unease between the Department of General Dental Council 1956 Health and the Departm ent of Education. A (another Dentists Act) speci c example of this strategic di culty

Fig. 14.1 The medical–dental triangle. 122 Orthodontic Postgraduate Education: A Global Perspective

is that employed trainees are managed and soon specialist membership diplomas within the framework of employment law closely allied to training programs emerged. rather than educational need. Furthermore, thoroughly reputable fellow- The Royal College of Surgeons of Edin- ship and membership diplomas emerged burgh pioneered the development of higher from sister colleges in Glasgow and Ireland, clinical diplomas in dentistry when in 1919 and a Faculty of General Dental Practice it introduced the higher dental diploma. (UK), based at th e Royal College of Su rgeon s This diploma assessed the entire range of of England, also cam e into being. dental disciplines. When the Royal College Meanwhile, cash-strapped universi- of Surgeons of England in 1948 introduced ties created and taught clinically oriented the fellowship in dental surgery (FDS), master’s degree programs, inadvertently with its medical and surgical emphasis, the adding to the confusion that a plethora of Royal College of Surgeons of Edinburgh in postgraduate clinical degrees caused. 1949 revised and upgraded the higher den- However, there were positive aspects to t al diplom a to create its ow n FDS. Th e Edin - all these slightly confusing developm ents. burgh FDS examined dentistry across the Th e r ivalr y am on g t h e colleges h as resu lted in board, thus providing an FDS more suited, diplomas that are continually revised in the at that time, for those pursuing a career in light of modern educational and assessment the nonsurgical aspects of dentistry. theory, with the result that the colleges are It was felt that in a tim e of post-war aus- now experts in this eld, with the support terity,4 and with the proven ability of den- of educationalists and psychometricians to tists “in the eld” to do much more than advise on assessment practice. This has been restorative dentistry, it should be possible to the great bene t of examination candi- to construct a diploma that would re ect dates and indirectly of their patients. further training in oral surgery, dental surgery, and the associated skills in m edicine, surgery, and pathology and would render unnecessary the time-consuming and 14.8 Standard Setting expensive acquisition of a medical degree or of Examinations a fellowship of the Royal College of Surgeons (FRCS). General dental practitioners in the All current specialist dental examinations United Kingdom were frequently considered are aimed at delivering a valid, standard- to belong to a “reserved occupation,” and ized, reproducible, and fair examination during the Second World War, in addition process. The examinations follow a set to providing dental services, they admin- protocol and aspire to test the breadth and istered general anesthesia at several hos- depth of the knowledge and clinical skills pitals, including Sta ord General Hospital acquired during specialty training. Stan- (personal com munication, H. Moody).4 This dard setting of the examination is by peer was not unique but clearly demonstrated review and is competency and criterion the acceptance by hospitals and doctors at based. Questions as well as clinical scenar- that time that dentists could perform roles ios are standardized throughout one diet of beyond dental surgery per se provided that the examination. As a result, sophisticated they had appropriate and relevant training. and elaborate m ethods are required, which This fortuitous arrangement worked are time-consuming. Results are scruti- well. With full reciprocity between the nized by independent assessors, and feed- colleges for a Part 1 FDS, the successful back is provided for candidates who have candidate could choose between a Part 2 not passed the examination. FDS particularly suited for those wishing However, all this comes at a cost, and to become oral surgeons and a Part 2 FDS the fees for candidates undergoing specialty better suited for those pursuing a career assessments have increased threefold. This in orthodontics and restorative dentistry. in crease is m ade even m ore acu te by th e fact However, specialization moved apace, that the exam ination fees are not eligible for 14 Structure and Organization of Dental Specialty Education in the United Kingdom 123 taxation allowances in the United Kingdom , re ected by the funding exercises of the adding further pressure to professionals Department of Education (i.e., the research who will in turn have to pass the costs onto assessment exercise, now evolved into the their patients, especially when it is consid- research excellence framework). Clinical ered that neither the government nor the practice and teaching are no longer the only public funds the GDC or the Royal Colleges. focus of universities, and for this reason, it Protection of the public is the rst duty is important that a trainee come under the of the GDC, and success in earning higher in uence of several consultants and prefer- college diplomas provides strong, transpar- ably acquires the experience of working in ent evidence of competence at the special- more than one university or hospital. ist level. When it comes to assessment, the colleges can draw upon experienced examiners from a great variety of institutions, including, if they so wish, fellows from 14.9 Independent and overseas. If the consensus view of such a External Colleges panel of examiners at the end of an assessment procedure is that a candidate has The colleges are independent of both the reached the required level, the public will government and the GDC. It would be irre- have considerable con dence in that deci- sponsible and arrogant to interpret this as sion. It is also a well-recognized aspect of meaning that there should not be coopera- assessment practice that the more varied tion with these bodies, but the agenda of the pairs of examiners, the less possibility a future government or a lay-dominated of any bias w ithin the system . GDC is uncertain. The colleges, by retaining It is believed that all the Royal Colleges their independence, examine and assess would agree that ultimately they exist for on purely clinical grounds in the best inter- t h e ben e t of th e pu blic, an d to th is en d, th e est of patients, not primarily to satisfy the concept of PIEQA is not only a worthy and requirements of the government or any of important one, but also a vital one, and one its bodies. This examining and assessment w it h w h ich t h e lay m em bers of t h e GDC w ill role is undertaken in the closest possible resonate if it is clearly placed before them. collaboration with the specialist associa- With expectations of further interna- tions. However, the overarching governing tionalization (already existing w ithin the body of the profession is the GDC. If the European Union, allowing the free move- GDC intended to establish a marker of suc- ment of professionals), the public must be cessful completion of two years of general aware that it may not be treated by prac- professional training or specialist training titioners of United Kingdom origin and/or or any other speci ed objective, the colleges training. Evidence shows that there was a would be able to deliver the appropriate period of several years when the United assessment. To retain the trust of the pub- Kin gd om w as a n et im p or t er of d e n t al grad - lic and health employers, there is nothing uates. Having a college quali cation of high to prevent the colleges from making their international repute (membership or fel- highest diplomas, the fellowships, aspira- lowship), and therefore a “passport” prov- tional and totally independent of any gov- ing to regulators overseas and their public ernm ent or GDC “specialist” requirem ent. the level of education and training attained, Thus, college membership and fel- will allow easier access for professionals lowship examinations are independent seeking employment and reduce the costs assessments, and there are good reasons of regulators who must oversee individu- why universities may not be best suited als applying for entry to their country. The to deliver these assessments. University Royal Colleges are able to play an important departments are small and are becoming part in this process while at the same time smaller because of nancial constraints. upholding and enhancing dental standards The focus on research is intensifying, as in many countries. 124 Orthodontic Postgraduate Education: A Global Perspective

References Further Reading

1. Dingwall HM. The dental council and fac- Department of Health. https://www.gov.uk/ ulty. In: A Famous and Flourishing Society: government/organisations/department-of- Th e Histor y of th e Royal College of Surgeons health. Accessed January 29, 2015 of Edinburgh, 1505-2005. Edinburgh, Unit- General Dental Council. http://www.gdc-uk.org. ed Kingdom: Edinburgh University Press; Accessed January 29, 2015 2005:247 Health Education England. http://hee.nhs.uk/ 2. Macintyre I, MacLaren I, eds. Surgeons tag/letb. Accessed January 29, 2015/ Lives. Edinburgh, United Kingdom: The NHS. http://www.nhs.uk/Pages/HomePage.aspx. Royal College of Surgeons of Edinburgh; Accessed January 29, 2015 2005:50 NHS Education for Scotland. http://www.nes. 3. Dingwall HM. The dental council and fac- scot.nhs.uk/education-and-training. Ac- ulty. In: A Famous and Flourishing Society: cessed January 29, 2015 Th e Histor y of th e Royal College of Surgeons of Edinburgh, 1505-2005. Edinburgh, Unit- Northern Ireland Medical and Dental Training ed Kingdom: Edinburgh University Press; Agency. ht tp://w w w.nim dta.gov.uk. Ac- 2005:196 cessed January 29, 2015 Royal College of Surgeons of Edinburgh. http:// 4. Personal communication to Dr. Moody from the late Professor J. Boyes, who regularly www.rcsed.ac.uk. Accessed January 29, com municated with the late Sir Robert Bra- 2015 dlaw, a driving force behind the Royal Col- Royal College of Surgeons of England. https:// lege of Surgeons of England in the creation www.rcseng.ac.uk. Accessed January 29, of the FDS RCSEng, 1969 2015 Royal College of Physicians and Surgeons of Glasgow. http://www.rcpsg.ac.uk. Accessed January 29, 2015 Royal College of Surgeons in Ireland. http://www. rcsi.ie. Accessed January 29, 2015 Professional Standards Authority. http://www. professionalstandards.org.uk. Accessed Jan- uary 29, 2015 UK Committee of Postgraduate Dental Deans and Directors. http://www.copdend.org. Ac- cessed January 29, 2015 Workforce Education and Development Services Wales). http://www.wales.nhs.uk/sitesp- lus/955/page/65980. Accessed January 29, 2015 International Guidelines 15 of the Erasmus Project and the World Federation of Orthodontists

Athanasios E. Athanasiou and Theodore Eliades

At the national level, accreditation bodies very valid model of orthodontic postgradu- and guidelines regarding orthodontic post- ate education. graduate education and the recognition of For two decades, this report contrib- the dental specialty of orthodontics have uted signi cantly to strengthening the been in function for many years in many level of postgraduate training in ortho- countries.1,2 In countries with strict and dontics in Europe and fueled the debate advanced regulatory policies, these accred- about quality enhancem ent and quality itation standards for advanced orthodontic control. Many programs in Europe used the specialty education are regularly updated guidelines outlined in the report as their by the responsible authorities to follow “gold standard” for the education of future recent developments and evolutions in the orthodontists. Since the original publica- scienti c and professional environment.3 In tion, however, the eld of orthodontics has addition, during the past 25 years, the exis- changed substantially in regard to diagnos- tence of multistate political entities within tic tools, treatment techniques, interactions certain geographical borders and the large- with other dental specialties, and methods scale movement of orthodontic special- and technologies of teaching. ists to countries other than the ones in In July 2006, the European Orthodon- which they were educated have led to the tic Society initiated an attempt to critically need for regional and international guide- assess various aspects of the implemen- lines regarding orthodontic postgraduate tation of the Erasmus project, but it was education. the Network of Erasmus-Based European In 1992, “Three Years Postgraduate Pro- Orthodontic Programmes (NEBEOP), newly gramme in Orthodontics: the Final Report established in 2008, that nally updated of the Erasmus Project” was published, the 1992 guidelines. In 2010, a task force providing relevant guidelines for European was formed to come up with proposals for institutions.4 These guidelines aimed to an update. In 2012, after several rounds reduce the diversity in length, intensity, and of amendments, the nal revision was content of existing programs, and to develop approved by the NEBEOP assembly. The guidelines for countries about to embark nal report about the updated guidelines on postgraduate education in orthodontics. was published in 2014.5 The project was nanced by grants of the The objectives, general and speci c European Union (EU), was implemented by conditions, and distribution of hours of prominent professors from European coun- the orthodontic postgraduate program tries, and took into consideration the exist- remained largely the same as in the guide- ing characteristics of dental education and lines of 1992. The theoretical contents were the provision of dental services in Europe. divided into eight themes, which were Many programs in Europe and other parts rede ned and modernized. Furthermore, in of the world adopted, fully or in part, this the 2014 guidelines, essential levels were 125 126 Orthodontic Postgraduate Education: A Global Perspective

de ned for the skills and competencies that and sin ce th en h ave been used by academ ic residents should have acquired at the end of institutions and orthodontic organizations their postgraduate education. The revision in m any parts of the world. of the Erasmus program should be used as The recommendations aim to assist a guideline to assist in the development and countries, associations, and educational maintenance of high-quality postgraduate institutions in need to develop or improve education in orthodontics. The Erasmus orthodontic postgraduate programs. The program is not part of EU legislation, and WFO guidelines may be also used by post- NEBEOP, w hich took the initiative to update graduate program directors worldwide, at all the guidelines, is not a legal authority that levels of sophistication, to measure their cur- can override the EU directives or national ricula against a worldwide standard.7 (The laws and regulations. Nevertheless, the articles “World Federation of Orthodontists guidelines serve as a useful model for good- Guidelines for Postgraduate Orthodontic quality postgraduate training in orthodon- Education”5 and “The Erasmus Programme tics and have had a proven impact in m any for Postgraduate Education in Orthodontics countries in Europe and around the world. in Europe: an Update of the Guidelines”7 Because many countries around the appear in the Appendix of this book.) world have similar needs but may present The provision of high-standard health di erent characteristics in regard to dental services, including orthodontics, requires education, the practice of dentistry, and the competent personnel. The nal and cen- provision of dental services, the World Fed- tral goal of any postgraduate program is to eration of Orthodontists (WFO) in July 2003 improve the services provided to the popu- adopted minimum orthodontic specialty lation seeking orthodontic treatment. It is guidelines, which were proposed by a sub- the responsibility of the orthodontic com- committee of the WFO Executive Commit- munity (e.g., universities, scienti c soci- tee.6 In 2006, the WFO Executive Committee eties, professional groups, specialists) to established a task force on guidelines for convince the political bodies that in uence postgraduate orthodontic education. This or regulate orthodontic specialization that task force consisted of 10 prominent indi- only educationally quali ed and properly viduals who were recognized orthodontic trained orthodontists can guarantee high educators and represented regions with a standards of delivery of orthodontic treat- high level of educational and practice stan- ment. In many countries, the orthodontic dards regarding our specialty. The objective community experienced di culty in nally of the task force was to provide the WFO convincing politicians or even colleagues Executive Committee with detailed rec- within dentistry of the need for establish- ommendations concerning guidelines for ing high standards of orthodontic educa- postgraduate orthodontic education. Since tion and specialty recognition. If politicians its formation, the WFO has increasingly wish to secure the provision of high-quality placed emphasis on support, through its orthodontic treatment, they have to realize a liated national organizations, for recog- that general dentists or poorly educated nized training programs in every region of orthodontists cannot accomplish this mis- the world, while at the same time providing sion. The wheel must not be reinvented in encouragement and expertise to develop- any country or university in which spe- ing orthodontic graduate programs in areas cialty education is initiated. Excellent stan- where orthodontic training previously did dards, accumulated experience, and rich not exist. These guidelines for postgradu- knowledge of postgraduate education are ate orthodontic education were approved available from di erent parts of the world, by the WFO Executive Committee in 20096 and these must be utilized. 15 International Guidelines of the Erasmus Project and the WFO 127

References 4. van d er Lin d en FPGM. Th re e years p ostgrad- uate programme in orthodontics: the nal 1. DeKock WH, Athanasiou AE, Kuroda T. A report of the Erasmus Project. Eur J Orthod WFO-com missioned study provides data on 1992;14(2):85–94 the specialty’s current characteristics and 5. Huggare J, Derringer KA, Eliades T, et al. standards throughout the world. WFO Ga- The Erasmus programme for postgradu- zette 2000;1:4 ate education in orthodontics in Europe: 2. Kessel NC, DeKock WH, Phillips CL, Hershey an update of the guidelines. Eur J Orthod HG. A survey of the status of orthodontics 2014;36(3):340–349 among organizations within the World Fed- 6. WFO Executive Committee approves orth- eration of Orthodontists. J World Fed Or- odontic specialty education guidelines to thod 2014;3(4):146–154 assist academic institutions. WFO Gazette 3. American Dental Association Com mis- 2003;8(2):1–2 sion on Dental Accreditation. Accreditation 7. Athanasiou AE, Darendeliler MA, Eliades T, Standards for Advanced Specialty Education et al; World Federation of Orthodontists. Programs in Orthodontics and Dentofacial World Federation of Orthodontists (WFO) Orthopedics. Chicago, IL: American Dental guidelines for postgraduate orthodontic Association; 2013 education. World J Orthod 2009;10(2): 153–166

The Role of New 16 Technologies in Orthodontic Specialty Education

Shazia Naser-Ud-Din

The rst education revolution occurred in retention of information? New studies are Mainz, Germany, in 1450 with the invention certainly reinforcing the e ectiveness of of the printing press, credited to Johannes virtual learning in comparison with tradi- Gutenberg. This device propagated the tional teaching.1 written word faster than had previously The e ectiveness of e-learning has been possible. However, to be fair, there is been demonstrated by randomized con- historical evidence that type printing was trolled trials, considered the highest level developed nearly 500 years earlier in China. of evidence in contemporary literature. A The huge time lag is, of course, due to the recent study evaluated face-to-face learn- lack of sharing and communication that we ing, e-learning, and blended learning styles currently take so much for granted. Now, for orthodontics.2 The results indicated thanks to the e orts of Sir Tim Berners-Lee that face-to-face learning and e-learning (am ong m any others), we are at the cusp of complement each other, and that blended yet another big revolution with the World learning is the way to go. Di erent media Wide Web, where the transfer and exchange address student di erences in learning of information are occurring faster than styles, as alluded to by Kolb.3 ever before. In fact, what is so interesting Another dimension to learning is being

is that a dichotomy—between the “immi- explored. There is no doubt that emotions grants” and the “natives” of the Internet play a major role in the retention of infor- and arti cial intelligence—is emerging as a mation. Information learned in a pleasur- result of the widespread use of technology able, nonthreatening environment, with and information sharing by the members of rewards and grati cation, is de nitely a generation (the “millennials”) who have stored in long-term memory.4 So, how do used the Internet during their formative, we introduce entertainment and educa- developmental years. tion sim ultaneously? Of course, work has As our toddlers spend more and more already begun, and many resources online time with tablets and computers, they w ill discuss the concepts of “gami cation” and be even more in sync than the generation “edutainment.” The concept of “edutain- before them. Therefore, further initia- ment” was proposed by Demirijian and tives are being made to develop online David5,6; essentially, it is an important teaching tools because they are interac- self-motivating tool (what we enjoy we tive and captivating, not static and two- continue for a longer time), particularly dimensional like print. However, the big for competing Web-based portals. Online question remains: What will technology learning management systems are com- do for higher education, where most of mon in most universities and have been the learning is self-directed and internally well established since the early part of the motivated? Can the various learning styles twenty- rst century.7 be addressed, and can tailor-made educa- The younger generation is not happy tional packages improve cognition and the with bland paper text. It may just be that 128 16 The Role of New Technologies in Orthodontic Specialty Education 129

Thomas Edison’s prediction that “books will ning and conducting educational research soon be obsolete in the school”) has come are challenges in themselves.16 to pass. This will de nitely be the case in Both formative and summative assess- future decades and will also be environments can be administered online. The mentally sustainable. An interesting read advantages are e cient use of time, ease is the second-order meta-analysis of the of administration, structure, and a lack of 40-year impact of technology on learn- bias toward candidates (e.g., language bar- ing.8 The study compares technology-rich riers). However, it is a challenge to ensure with technology-impoverished educational secure student output remotely. Moreover, environments and work extending from predictive validity over a period of time can 1985 onward. It was really in the 1980s that be easily evaluated with data collected over m any schools in developed countries began a series of assessments.17 The nature of the to provide computers in learning environ- specialty of orthodontics, requiring com- ments. However, a surge occurred after the plex treatment planning in four dimensions millennium and the “Y2K” (year 2000) fears. and variations in treatment methodologies, Electronic learning, Web-based instruction, makes it challenging to design a single sum - and integrated learning systems are now mative assessment. Hence, algorithms with commonplace. The major role for technol- multiple ows to a particular case must be ogy in education is to support the didactic designed and credited equally. Overall, this process and to provide a platform avail- adds to the complexity of online assess- able 24 hours a day, seven days a week that ments for orthodontics. learners can access at their convenience. Perhaps the most pressing reason to look seriously into e-learning is the sharp decline in the numbers of teaching faculty world- 16.2 Advanced wide, particularly in orthodontics.9 This E-Learning Tools shortage of teachers is projected to become worse as nancial cuts are imposed on many In other disciplines of dentistry, work is in universities. progress to develop virtual surgical train-

ing in collaboration with industrial partners o ering sophisticated software (SimPlant).18 In summary, nonroutine complex proce- 16.1 Interactive Medium dures may be simulated for hands-on training in which the trainer uses stereoscopic Historically, self-instruction in dentistry glasses, digital gloves, and real-patient surgi- with computers was rst discussed by cal scenarios. Such simulations are not easy Guild.10 In the mid-1980s, the University to develop because complex algorithms and of Bristol, United Kingdom , followed with huge computations are required. However, its rst interactive orthodontic modules.11 it is possible that such sim ulated learning Blended learning in dentistry has been well modules will become more accessible in the accepted and was documented in a study future as access to technological advances from Europe,12 enhancing competencies increases. and core knowledge and supplementing Another market leader is Japan, o er- traditional pedagogy.13 ing sophisticated typodonts and man- Interactive modules14 essentially nikins that can mimic patients in pain, increase student focus and enhance atten- with tears emerging from their eyes (e.g., tion, leading to retention in long-term the life-like dental training robot Sim uloid memory. Immediate assessment and feed- [2007]).19 Special materials are developed, back with open- and closed-ended ques- n ot so m uch for e-learn ing but for a greater tions further reinforce learning, as has been appreciation of tactile sensations.20 The documented in the literature.15 However, as rate of acceptance by learners and their many educationists will appreciate, plan- instructors of such nonthreatening envi- 130 Orthodontic Postgraduate Education: A Global Perspective

ronm ents is high, nearly 60%, because they Perl, XML (extensible markup language), can learn new skills without fear of causing PHP (hypertext preprocessor), and MySQL irreversible errors that a ect a real patient. (structure query language). Open sources However, such projects are expensive com- reduce the cost of the m odules developed.22 pared with e-learning modules, which have a h igh in it ial cost bu t low er lon g-t e r m cost s for software maintenance and upgrade. Many of us in orthodontics are familiar 16.4 Medical with water bath typodonts—to accelerate Educationists and Health changes and visualize a treatment lasting an average of 18 to 24 months dur- Professional Education ing a week of simulated learning. A more sophisticated version, now introduced, There is ample evidence to indicate that is the electrotypodont (Savaria Dent Kft, online modules need to be developed on Szombathely, Hungary),21 which uses cop- sound educational principles and grounded per conducting wires at the roots of each in psychological theories of education, par- 23 tooth and brings about movement with ticularly andragogy (described by Terrell ), 24 heat melting the wax—and in direct view for anatomy (Yeung et al ). of the observer rather than immersed in a It is well established that a virtual learn- warm water bath. Finite element analysis ing environment provides a strong platform (FEA) does the same; however, the electro- for learning clinical skills and supplements typodont provides the learner with tactile traditional teaching in orthodontics and 25 sensations and skills acquired in real time. dentistry. Simulation e-learning assists the novice in gaining skills in patient management, diagnosis, and clinical assessment. Dent Sim (Dent Sim Lab NYC, New York, New 16.3 Literature Review: York), one such simulation program, had a high satisfaction rate in Taiwan.26 Moreover, Computer Science and a virtual learning environm ent tracks life-

Health Sciences long learning with progress les, continuing education logs, and updates of career A multiprofessional approach with infor- achievements as part of a comprehensive mation technology (IT) specialist input is e-learning portal. A pilot program run by the needed to generate high-quality teaching University of London27 in the United King- modules for medicine, dentistry, and par- dom shows that such progress les are well ticularly orthodontics. These programs are accepted by the profession. written with HTML (hypertext markup It is documented that viewing vid- language), JavaScript, and VRML (virtual eos of clinical procedures before manag- reality modeling language), to name just a ing patients provides greater con dence, few. Coordination and collaboration with improves clinical performance, and specialist animators can enhance the qual- enhances the self-esteem of the novice cli- ity of the teaching programs. There is no nician.28,29 Moreover, with advancing tech- doubt that many in the medical eld may nology, three-dimensional viewing can have neither the time nor the IT expertise improve visual spatial ability. Dual coding to develop online programs on their own, theory30,31 st ates th at m ult isen sor y im ager y and teaching institutions will need to pro- enhances learning concepts. It was used to vide faculty support for that purpose. assess education with videos, as opposed to A new generation of online educa- paper-based learning, and the results were tors will need to be not only pedagogically evident; signi cantly higher overall e ec- sound but also technologically trained tiveness was noted in the group exposed to in the use of computers. E-modules can videos for education.32 Videos can be used be programmed with open-source code- successfully to assist in problem -solving based languages like HTML, Java, JavaScript, strategies, critical reasoning, communica- 16 The Role of New Technologies in Orthodontic Specialty Education 131 tion, and collaboration—all essential com - 16.7 E-learning—the ponents of higher-level cognitive behavior. United Arab Emirates Perspective

16.5 Medical Education It is indeed gratifying to see that a young Online Learning country like the United Arab Emirates (UAE) has a futuristic vision and has placed For anatomy and physiology instruction e-learning in the forefront of its national particularly,33 a head in virtual reality was development. Most of the electronic pro- an endeavor to provide a three-dimensional cesses are e cient and environmentally rollercoaster learning experience with dif- sustainable. The UAE Advanced Network ferent depth cues and interactive control for Research and Education, w ith the m ajor features. Innovation with polarized glasses project EduRoam in collaboration with for depth perception was also envisaged in An ka b u t , AUS (Am e r ica n Un ive r sit y of Sh a r - this project. Interestingly, the study docu- jah), MIST (Masdar Institute), and KUSTAR mented that there was no advantage over (Khalifa University of Science & Technology “learner-controlled wiggle conditions,” but and Research), is actively involved in deliv- an argument can be made that perhaps there ering and evaluating e-learning programs were issues w ith the learning curve; also, the across education platforms. UAE has rec- nesse of the system might not yet have been ognized the impact of sm art learning for quite there—technological advances may future generations. The goal is to provide change this in the future. The same authors the highest quality of education through in a m ore recent publication do acknowledge a knowledge-based and highly productive that technology will improve the quality of economy. The e-education vision for UAE modules produced in the future. is to develop instructional designs, inter- Technology will perhaps never replace active content/skills training, collaborative real tactile sensory input, but visual appeal curricula, and state-of-the-art educational is perhaps possible. The use of magnetic technology and to set up an educational resonance images and frozen cadaver over- cloud—Ankabut—which is a global project lays can certainly enhance learning and the linking leading universities and UAE educa- understanding of key concepts.34 tional institutions.36 The e-education collaboration with the UAE Ministry of Education is creating a national repository of educational content, 16.6 Where Is Education supporting smart learning initiatives and in General with national licenses for software. An ongoing evaluation of the educational metadata will Technology? enhance the future development of online programs. HBMeU (Hamdan Bin Moham- Phenomenal work on the implications of mad e-University) was short-listed for tailoring teaching to individual needs has the prestigious HoTEL (Holistic Approach been documented in the recent literature. to Technology Enhanced Learning) by the Several articles have recently appeared in European Union (EU). The conceptual Computers & Education. The use of multi- framework is based on critical re ection 35 media for basic subjects like physics has and innovative creativity. An important elucidated the fact that concept clearing is aspect of the project is building personal linked to right and left hemispheric pref- learning networks in the context of courses. erences, and this can assist in developing The International Council for Open and Dis- education that is not “one style ts all,” tance Education (ICDE) awarded a blended but with prelearning assessment provid- learning project to UAE in 2013.37,38 ing speci c modules for the learning to be The standards for both health and edu- highly e cient in practice. cation are very high in UAE, where the 132 Orthodontic Postgraduate Education: A Global Perspective

Commission for Academic Accreditation with better technology and algorithms— (CAA) has established e-learning stan- LEAP adaptive learning on D2L.43 It is the dards. CAA encourages higher educational opinion of the author that this has poten- institutions to enhance learning with syn- tial for the orthodontic specialty because chronous (video conferencing) and asyn- postgraduates can gauge their learning and chronous (discussion boards, blogs, etc.) improve their skills through LEAP guidance. methods, e-assessments with feedback, and the secure delivery of examination and assessment policies. The aim is to provide a strong blended learning platform for edu- 16.9 Patient Education cational institutions in UAE.39 with Technology

Huge interest has been shown in having 16.8 Are We Ready patients look up information regarding their probable treatment by health pro- for Technology fessionals. Moreover, live updates of treat- in Postgraduate ment experiences are available on various Orthodontic Education? social media. In the rst study of its kind, conducted in New Zealand,44 a qualitative In the world of education in general so far, analysis was done of orthodontic-related many opportunities are available for online posts on Twitter and concluded that there users that are not currently available for the is indeed interest in posting both positive specialty of orthodontics. Some of these are and negative experiences. Our postgradu- brie y mentioned here. Massive open online ates not only can learn from this interactive courses (MOOCs)40 are con sidered t h e fu t u re medium but also can acquire an under- of online education, with interactive forums standing of the perceptions and expecta- for discussion. However, even though tions of patients in regard to the profession. MOOCs have a great deal of potential, one However, not all information can be taken at face value,45 and expectations should be needs to assess their future. Major leading universities in the United States are o ering clari ed during patient consultations. online courses in certain disciplines free of charge to provide opportunity to all through MOOCs. Another commonly used acro- nym is MOODLE (m odular object-oriented 16.10 Use of Technology dynamic learning environm ent),41 a free in Orthodontics software e-learning platform where users can register and assist in a global collabora- An excellent recent meta-analysis46 has tion to develop teaching modules. Also gain- addressed blended learning and tech- ing momentum is LEAP (learning algorithm nology in higher education. The study path),42 which is a personalized learning compared traditional classroom instruc- pathway for individual learners. A pretest tion with online teaching, and although is conducted to establish a baseline for the interaction and discussion are the forte of learner’s existing level of understanding. traditional classroom instruction, if com- Once this has been established, algorithms munication via discussion boards and are used to generate and adapt a personal- blogs is included in online teaching, the ized learning pathway for individual stu- learning process is certainly enhanced. dents. A student can then learn through the Blended learning, which consists of nearly resources prescribed, and reassessment can 50% of online instruction combined with be used to determine if the new learning traditional instruction, is considered the pathway has improved the student’s level of best of both worlds. Currently, research is understanding of the subject matter. Further showing a modest increase in achievement improvement in this dom ain will take place with blended learning (13%),46 and this 16 The Role of New Technologies in Orthodontic Specialty Education 133 will certainly continue in the future with bene tting equally as “Internet natives” the millennial generation.15 nd the medium to be second nature and A decade ago, Marquis47 noted that are very com fortable using it to access nearly 90% of instructors in higher educa- information and learn. tion rated blended learning as more e ec- Certainly the orthodontic modality, in tive than learning with no technological relation to industry, has taken full advan- input. Of course, this distinction is going to tage of technological and IT advances50 in blur as technological advances and ease of enhancing the treatment planning process access make online education m ore acces- with customized treatment modalities, sible. However, blended learning is e ec- such as Invisalign (Align Technology, San tive over a period of time and needs to be Jose, California), Insignia (Ormco, Orange, made an essential component of the cur- California), Incognito (3M, St. Paul, Min- riculum to be successful. nesota), and Harmony (Harmony Ortho- The four patterns of blended learning, dontics, Logansport, Indiana), to name just as described by Driscoll and Carliner,48 are a few. Industry, with its complex three- the following: dimensional sim ulated treatm ent plans, is an excellent portal for teaching and can be 1. Mix of Web-based technologies included in collaborative e orts to develop 2. Mix of pedagogical approaches e-learning clinical modules. (constructivism, behaviorism, and Other applications of technology in cognitivism) orthodontics are the following: 3. Face-to-face instructor-led teaching 1. Diagnostic records and computer-aided 4. E ective learning strategies analysis Th e qu est ion is n o longer w h eth er tech - 2. Three-dimensional models, imaging, nology is e ective or not, but what mode and warping images of technological information transfer is best 3. Scanners for a particular content, skill acquisition, a. Intra-oral and behavior modi cation. Moreover, what b. Soft tissues will engage and keep the learner motivated—in an essentially isolated m edium 4. Wire sim ulations and FEA for research of instruction? This has been the challenge, particularly for andragogy. Di erent technological aspects are not only the tools but also the approach based on sound andra- 16.11 Scenario-Based gogic principles to bene t the learner. With Learning Interactive t h e daw n of t h e m illen n iu m , t h ere h as been an exponential increase in both the design The author was fortunate to work on a proj- of online learning and the research evaluat- ect at the University of Queensland, Bris- ing its e ects and success. It is now docu- bane, Australia, in which nine interactive mented that online orthodontics teaching modules for teaching orthodontics were materials should be developed according developed and qualitatively evaluated.29 Th e to the principles of hierarchical sequenc- generic software Scenario-Based Learning ing (HS) for the e ective delivery of new Interactive (SBLi) for online teaching was content.49 There is a need to further inves- tailored to orthodontic skills, knowledge, tigate the various delivery modes for their and syllabus content, targeting postgradu- e ectiveness, such as elaboration sequenc- ate training, and there were also three ing (ES) and macro-sequencing (MS), which introductory modules for dental under- place emphasis on the practical application graduates. Four of the clinical applied mod- of knowledge.49 ules were based on clinical cases included There is no doubt that technology has in the membership examinations of the a positive impact on learning, particularly form at of Royal Colleges of the United King- higher education, although pedagogy is dom, selected for complexity and rarity of 134 Orthodontic Postgraduate Education: A Global Perspective

conditions (Fig. 16.1). Five modules were a nonjudgmental learning forum and pre- based on orthodontic procedures and clini- vent discouragement from active learning. cal skills orientation; examples include There was a high rate of acceptance orthognathic case VTO (virtual treatment of SBLi for orthodontics, albeit in a small objectives) as video presentation embed- group. The strength of SBLi lay in the intro- ded—speci c to the style adopted at the duction of rare clinical conditions—for University of Queensland orthodontic example, cerebral palsy, transpositions, teaching program, indirect bonding, space geminations, and temporomandibular dis- analysis, etc. Up-to-date evidence in the lit- orders—that are not easily presented dur- erature, along with open- and closed-ended ing postgraduate training and can be taught questions requiring critical thinking, were more reliably through e-learning. posted for the postgraduates to evaluate The major advantage of e-learning is their own learning. Immediate feedback the incorporation of video content. This with pre-answers clari ed the key concepts. has been a driving force to encourage No score was allocated purposely to provide the development of computer-assisted

Fig. 16.1 Rare clinical case of a patient with cerebral palsy seeking orthodontic treatment. Previous treatment with a functional orthopedic appliance did not correct the malocclusion. Interactive windows allow the learner to collect clinical information and formulate a treatment plan. 16 The Role of New Technologies in Orthodontic Specialty Education 135 learning packages. Open sources of video (https://www.youtube.com/watch? content, such as YouTube, and videos devel- v=PUIanIl5CFc), were developed. Each mod- oped by marketing companies are already ule had an interactive window (Figs. 16.1 being used by postgraduates. Well-known and 16.2) with current and contemporary presenters of international caliber have literature (pdf), videos of procedures, and produced Web sites dedicated to online from YouTube the armam entarium available teaching that are resources for online learn- for current orthodontic use. Each segment ing. Attempts have been made at the Uni- was followed by a formative assessment versity of Queensland to introduce these and immediate feedback. Combinations of modules from leading names, such as Dr. open-ended and radio button items were Gerry Sampson for the (G)nathos Web site placed throughout the modules to enhance at http://gnathosce.com/gnathos.html and the learner’s engagement and alertness. Dr. Jason Cope for CopestheticCE at http:// Each module was a stand-alone entity, so www.copestheticce.com.51,52 t h e m od u les d id n ot h ave to be view ed in any The gist of the qualitative evaluation particular order. was that postgraduate students in particular are very time-constrained and want e-learning to be made as “to the point” as 16.12.2 (G)nathos Webinars possible so they can obtain information e ciently. Moreover, when the module The style adopted was that of the much-loved provides an overall view comprehensively, and enthusiastic speaker Dr. Gerry Sam- students can spend less time sur ng the son. The topics were enhanced with well- Web. Hence, the feedback from the con- illustrated PowerPoint slides placed side by 51 temporary approach to e-learning showed side with the presenter. The humor, lively the high demand, particularly in current style, anecdotes, and pdf illustrations (“Loco postgraduate programs in orthodontics and Motion Mechanics Series,” “The Lineup,” allied health sciences. “Deep Bite Corrections”), which could be downloaded, added an enriching experience to the much-dreaded biomechani-

cal aspect of orthodontics. The day-to-day 16.12 Evaluating Di erent examples, with a tennis racket and lively music added, and the amusing titles (“Trou- Styles of E-Learning in ble in Torque Town”) were intended to Orthodontics keep the learner interested at all times, along with the essential cues (http://www This second project that the author under- .gnathosCE.com). Perhaps the most unique took at the University of Queensland was to aspect was the introduction of hands-on look at di erent e-learning delivery styles participation, which allowed the learner to and how they a ect learner motivation appreciate three-dimensional changes with and engagement. Therefore, four di erent an overlay of Perspex drawings. e-learning packages were introduced to the postgraduate program of orthodontics at the University of Queensland.29 A brief overview 16.12.3 CopestheticCE of the four e-learning packages follows. Mo dule

16.12.1 Scenario-Based This online e-module was developed by Dr. Jason Cope and provides PowerPoint Learning Interactive for presentations clarifying aspects of tem- Orthodontics porary anchorage devices along with contemporary literature.52 Immediate online SBLi software was developed for ortho- evaluation with feedback is provided. The dontics. Nine di erent topics, sepa- postgraduate students accessed the Copes- rated into clinical and procedural parts theticCE e-m odule in the second sem ester. 136 Orthodontic Postgraduate Education: A Global Perspective

Fig. 16.2 Past dental and orthodontic history from the patient and prompts in the upper left window for the learner to acquire the process of history taking in a clinical setup. The upper Clark twin block does not have a midline palatal screw, hence the developing posterior cross bite observed in the intraoral photo in the upper right window.

16.12.4 American minutes. The seminars covered growth and development, biomechanics, treatment Association of Orthodontists– planning, and cephalometric radiography. University of North Carolina The discussions and PowerPoint slides Web Program 53 allowed the learner to feel like a part of the session and to glean information from the This program was kindly donated to all references and papers discussed during the the dental schools in Australia by the Aus- seminar. tralian Society of Orthodontists. The mod- The four e-learning modules were eval- ules were mostly based on seminars on a uated by nine orthodontic postgraduate variety of topics presented by prominent students at the University of Queensland orthodontists and videotaped for 60-plus for the academic year 2012. A Likert ve- 16 The Role of New Technologies in Orthodontic Specialty Education 137 item scale (strongly agree, agree, unsure, 16.13 Technology disagree, and strongly disagree) was used to ensure ease/e ciency of lling in the paper in Orthodontic form s for each e-m odule package. Anonym- Postgraduate Education— ity was ensured. Di erences in means and standard deviations across the four groups the Future! were apparent (Fig. 16.3). Interestingly, in Assessment is an essential part of all learn- this study the group means were signi - ing and teaching. It is also perhaps a very cantly di erent from one another, with (G) resource-intensive aspect of education, nathos clearly favored and highly accepted. necessitating the generation of a questions The standard deviations for SBLi and (G) data bank, the randomization of questions, nathos were slightly greater than those of the administration and evaluation of grades, the other modules and may re ect the dif- and feedback. Online learning management ferent tastes and styles in learning. systems include evaluation as part of the Although the number of e-modules learning objectives. The one used at the available in orthodontics is limited, the Ham dan bin Mohamm ed College of Dental SBLi was the rst interactive module to Medicine, Desire 2Learn (Brightspace 10.3, be developed in Australia. The aim was available at http://www.atom iclearning. to promote independent self-learning, com/desire-2-learn-10.3-student-training) which is essential if health professionals is certainly tim e-e cient once set up for the are to attain the rst two goals of Miller’s subject matter. Additionally, LEAP can assist assessment pyramid: “knows” and “knows in the process of self-evaluation. how.”54 Moreover, it would be an im portant Continuing professional developm ent resource for procedures shown on embed- (CPD) is mandatory, and many professional ded videos for clinical applications. Hence bodies have legislation in place requiring the signi cance of developing e-modules successful completion of a de ned num ber on sound andragogy principles. of hours for professional license renewal.

Fig . 1 6 . 3 Acceptability of the various e-programs in orthodontics on a 5-point Likert opinion scale (x-axis). Greater overall accept abilit y of the (G)nathos st yle in com parison with the others during the academ ic year 2012. 138 Orthodontic Postgraduate Education: A Global Perspective

On line CPD courses are a convenient opt ion literature, formative/ for busy practitioners, and recent Euro- summ ative assessm ent, preferably pean recomm endations22 have once again w ith imm ediate feedback generated stressed the need for sound pedagogi- by algorithm s) cal principles in the design of online CPD courses. Webinars o er the synchronous It has been recognized that the cur- online delivery of information; however, rent generation lives at a time of instant with global time di erences, participation grati cation, which includes instant mes- can sometimes be challenging. Question saging and the instant acquisition of infor- and answer sessions in real time are the mation via the Internet. The University of forte of webinars, but once again, because Queensland study29 raised the issue of the of limited time, not all participants can need for instant feedback, and perhaps a have their queries answered, which is frus- Skype interface for online webinars would trating after they have lost out on sleep. work for such a purpose. A similar attempt Therefore, asynchronous online learning is by the 3M Web site,56 with synchronous considered more user-friendly. real-time webinars presented by reputable Nothing is more satisfying than deep, international speakers, has gained huge meaningful learning with the clari cation popularity. The greatest advantage of this of key concepts. Biomechanics has always program is the interaction at the end of the been a challenging concept, particularly PowerPoint presentations, with question- when explained with two-dimensional dia- and-answer sessions. Face-to-face discus- grams, and e-learning modules for this sub- sion clears concepts and provides a “not ject were rst developed in 1992.55 Online alone in the World Wide Web” feeling, to version 4, available since 2013, is a very quote one of the participants. One needs creative and engaging software that allows to be mindful that this method of instruc- di cult concepts to be clari ed. Nearly 50 tion too would increase constraints on dental and orthodontic programs have sub- time and would be resource-intensive for scribed, and more than 1,000 e-copies of instructors/academics. the software have been purchased. The higher cognitive functions of analy- Essential guidelines have been pre- sis and synthesis can be encouraged with sented for developing online teaching, and e-modules. Moreover, structured e-mod- the use of windows for in-depth learning ules increase the e ciency of learning has been advocated. Videos, animations, because time is not wasted during tangent and sounds, when used appropriately, fur- Web sur ng.57 In teract ive m odules enhance ther enhance learning and engagement. learner interest.58 Built-in quizzes are often New standardizations, m ethodologies, used as self-tests before the examination and techniques can be covered by distance period. Furthermore, critical thinking and e-learning provided that there is no cogni- problem solving are often easily observed tive overload. in experts who acquire these skills over several years following graduation.59 E-mod- • Co n ce p t s (a n im ations, videos, ules provide learners with problem-based interactive) learning to acquire such expertise early in • Procedures (videos, clinical footage, their careers. Ideally, it would be preferable and three-dimensional animations, to evaluate critical thinking following deep m any prepared by orthodontic learning, but this can be rather challeng- providers) ing,60 along with the lim ited sample size of • New techniques (text, videos, learners in specialist programs. clinical footage, three-dimensional Subjective evaluation of the e-learning animations, many prepared by style preference captured in this small orthodontic providers) study indicates that future e-modules need • Self-assessments (open- and closed- to address the “edutainment” factor of ended questions, critical thinking, online learning. Moreover, the style of pre- linking with evidence-based 16 The Role of New Technologies in Orthodontic Specialty Education 139 sentation of didactic materials is essential three-dimensional learning packages for not only for acceptability and engagement t h e fu t u re, h ow can w e b r idge t h e gap ? Th at but also for long-term memory retention is t h e big qu est ion for t h e n ext d ecad e or so. because pleasing episodes are recalled for a At the level of tertiary education, particu- longer time. Ideally, such a variety of styles larly in the health sciences, a large compo- w it h lon g- t e r m follow - u p , b ot h for p e r son a l nent consists of hands-on training and skill preference and subject matter evaluation, learning, along with the acquisition of vital could guide academicians in producing information that can be retrieved imm edi- modules that would have an impact on ately in case of emergency. CPD, webinars, metacognition. Outcome evaluations in skill laboratories, and sim ulations are all the future will require greater sample sizes technological IT advances that have become as national audits of the higher education available in the past two decades and are delivery process.60 continually being re ned for better reso- Syst e m ic reviews and meta-analysis, lution, speed of access, and versatility to considered a hierarchy of evidence, rein- enhance online learning. force that learning is e ective with e-mod- The ideal online learning of the future ules.15,61 The major bene ts are exibility would be: a n d a cce ss 2 4 h o u r s p e r d a y, 7 d a ys p e r w e e k , • Simple (software with a m inimal 365 days per year with no global boundar- learning curve to conserve the user’s ies—providing unlimited academic freedom time) that is not available with other modes of • As close to real scenarios as possible traditional learning. A group study from • Engaging/interactive the United Kingdom stresses that e-m odule • Entertaining and fun to use quality and design are paramount to engage • In addition, self-evaluation would the interest and involvem ent of the learner. be included to gauge w hether A recent sm all-scale study has certainly val- learning goals have been achieved, idated that.29 A review of e-learning could and critical thinking would be not reach clear conclusions regarding the encouraged. e ectiveness of this medium.62 A relevant orthodontic study by Komolpis and John- son63 did not nd a signi cant di erence. Ru iz e t a l 64 stated that there is a higher acceptance of e-learning with greater 16.14 Conclusion and learner satisfaction, and that there is some Recommendations evidence to suggest increased retention of information following e-learning, albeit not The development of e-modules is a resource- statistically signi cant. intensive exercise with large economic and Academicians in most leading univer- time implications for creators and Web sities are now required to have a diploma designers. Therefore, it would be better “not in higher education (tertiary) so as to be to reinvent the wheel” remaking the same able to provide information on sound subject modules and to amalgamate inter- cognitive principles and encourage the nationally available e-modules for a global process of deep learning rather than a orthodontic learning portal. Doing so would super cial or strategic examination-based signi cantly add to blended learning and outcome.65 The e-modules are therefore enhance traditional teaching. required to be produced on sound tertiary As aptly described by Luckin and col- education principles. There is continued leagues,68 “e-learning is the capability interest in exploring the ever-important required of learners/users in order that relationship of online learning for medical they can manage their own learning in the professionals.66,67 twenty- rst century using technology as Until our toddlers with their tablets appropriate to context and task.” Interest- undertake to put together sophisticated ingly, the results of popular polls indicate 140 Orthodontic Postgraduate Education: A Global Perspective

apprehension on the part of the general a s p a r t of t h e Un ive r sit y of Qu e e n sla n d New public toward online stand-alone courses Sta research start fund. The cost of the because they might not be worth the project exceeded and was supplemented by cost and time invested, particularly if not the author’s consultation fee fund. accredited.69 For example, learning foreign languages on an e-learning platform scored highest, and learning science scored much Acknowledgments lower.70 Perhaps instruction in subjects requiring skills and application is still best I would like to thank all those involved in delivered with a blended learning model. preparing this chapter: Professor Athana- National and international collabora- siou for providing a unique opportunity—it tion in developing online learning is the is indeed a privilege and an honor to work way to go. It certainly is proceeding at a under his guidance and encouragement— brisk pace with some didactics. Orthodon- and Avril Reid and Mohamed Rafeeq at the tics will need to catch up and provide an library of Moham m ed Bin Rashid Academic international forum for such e orts. Ongo- Medical Center for promptly providing lit- ing research and consumer evaluation of erature access, and Dr. Shaima Al-Naqbi for higher education will provide feedback for proofreading in depth. the continuing development of live online The original research projects on SBLi documents by subject experts. One needs and the various orthodontic teaching mod- to be mindful in orthodontics of patient ules were also presented at the following con dentiality, and that the material international congresses: used in e-learning must be appropriately • 1st E-Lernen vielversprechend de-identi ed. für die kieferorthopädische With e-education, it is rather chal- Fachzahnarztausbildung? lenging to evaluate outcomes and process Wissenschaftliche Jahrestagung measures with a limited sample of post- der Deutsche Gesellschaft für graduate student intake each year. A recent Kieferorthopädie (DGKFO); study29 explored what creates interest

September 10–13, 2014; Munich, for postgraduate students, who are often Germ any struggling with time management. Perhaps • Evaluating di erent e-learning it is important to view the bigger picture styles in orthodontics. 28th British with lateral thinking; second-order meta- Orthodontic Society Congress; analyses are a better way to evaluate the September 18–20, 2014; Edinburgh, ever-evolving e-learning landscape. Mate- United Kingdom rial used less than ve years ago would be either obsolete or outdated technologically and could not provide evidence with References a large meta-analysis. Hence, the challenge is to obtain concrete evidence with online 1. Moazami F, Bahram pour E, Azar MR, Jahedi F, learning methodologies. On the other hand, Moattari M. Comparing two methods of edu- this is a very exciting and liberating forum cation (virtual versus traditional) on learning to explore and build. Therefore, the direc- of Iranian dental students: a post-test only tion of future learning is to provide means design study. BMC Med Educ 2014;14:45. http://www.biomedcentral.com/1472- for sustainable self-learning.71 6920/14/45. Accessed February 13, 2015 2. Bains M, Reynolds PA, McDonald F, Sherri M. E e ct ive n ess an d acce p t ab ilit y of face - to - Co n i c t of In t e re s t face, blended and e-learning: a randomised trial of orthodontic undergraduates. Eur J There is no con ict of interest to report. Dent Educ 2011;15(2):110–117 This project was funded by UQN- 3. Kolb A. The Kolb learning style inventory – SRSF–2010000763 (NASER-UD-DIN Shazia) version 3.1 2005 technical speci cations. 16 The Role of New Technologies in Orthodontic Specialty Education 141

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Athanasios E. Athanasiou

Orthodontic postgraduate education aims cation and the disproportionally high num- to produce graduates who (1) have com- ber of quali ed applicants are taken into pleted their didactic and clinical education consideration, it is natural that postgradu- at an institution of higher learning, (2) have ate programs accept as residents those received a broad-based advanced education with extremely good quali cations and in orthodontics and relevant biomedical outstanding academic records. As a result, sciences, (3) have obtained a solid back- postgraduate orthodontic classes consist ground in orthodontic diagnosis and treat- of very competitive, strongly motivated, ment modalities, and (4) are fully quali ed and sharp-minded students who welcome to become specialists in this discipline. the opportunity to study orthodontics, do Postgraduate orthodontic programs research that usually leads to publication in around the world usually have a duration refereed scienti c journals, and are greatly that ranges from 24 to 48 m onths, with the appreciative of their clinical training. Criti- majority of them being 36-month full-time cal thinking is an important part of their courses. Nowadays, residents are required daily educational routine. to attend a goodly number of supervised Follow ing graduation, orthodontic specialists must continue their education

clinical sessions to establish pro ciency in clinical orthodontics. In addition, a signi - and update their existing scienti c knowl- cant amount of course work is dedicated to edge by reading scienti c publications and research and additional, clinically related attending refresher courses, as well as by tasks (e.g., treatment planning, preparation acquiring further technical training in new of tutorials, case presentations). The num- clinical and laboratory techniques. Material ber of new patients assigned to each resi- is easily accessible and may be provided at dent may vary among schools but is usually home or abroad. The orthodontic specialist not less than 30, and an equal number of may choose to attend courses, lectures, or transferred cases are also included during seminars from a variety of available types the course of study. The programs expose to satisfy theoretical, clinical, and techni- the residents to a variety of contempo- cal needs and priorities. In many countries, rary treatment modalities, techniques, this type of continuous professional devel- and appliances, while written and/or oral opment is also mandatory for maintaining evaluations are conducted to assess post- the validity of both the dental license and graduate students’ performance. Most of specialty quali cations. the programs require the submission of a In t h e p ast , on ly scie n t i c societ ies, p ro - dissertation, which reports original data fessional groups, and institutions of higher derived from research activities in various learning provided continuing orthodon- elds, and/or the preparation of a paper in tic education. Nowadays, the orthodontic a publishable format.1,2 industry, indirectly or directly, is heav- When the limited number of places ily involved in these activities. The goal is available for orthodontic postgraduate edu- obvious—namely, the marketing of their 144 17 The Role of Continuous Professional Development in Orthodontic Education 145 products. Marketing is de ned as “the the- results identical to the corresponding inter- ory and practice of (large-scale) selling” or pretations and claims of th e in du st r y? Have “the various activities by which goods are the con icts of interest or the comm ercial supplied, advertised, and sold.” “Theory” interests of the speakers and authors been and “advertisement” are the two essential clearly identi ed? Does evidence-based components of marketing, which are also mean randomized prospective clinical trial, an integral part of the continuing education systematic review, and/or meta-analysis activities provided by industry. Although of the evidence? What makes these col- marketing is useful for informing consum - leagues hope that by attending such meet- ers of existing products and innovations, ings, which are organized by orthodontic it is also highly biased and clearly involves companies and whose speakers are usually con icts of interest. on the companies’ direct or indirect pay- Although new orthodontic appliances roll, they w ill incorporate into their clinical and techniques should o er some superior- practices “predictable treatment, greater it y to com peting products, existing m arket- patient comfort, consistent and reliable n- ing strategies require that, to be attractive, ishing” or “excellent results in fewer visits”? they also look exclusive, custom-made, and Is it a mentality and/or a con dence special. In this way, the customers will feel problem that causes one to shift intellec- that they belong to a special VIP group. It tually from the complex, sophisticated, is no surprise that the most aggressive and and unpredictable clinical reality of orth- e ective marketing of orthodontic tech- odontic practice to the simpli ed cookbook niques, materials, and appliances is pro- approach? Or it is an attempt to “compete” m oted as a “total treatm ent ph ilosophy and with colleagues and clinics using the same appliance system,” so that clinicians must “exclusive, modern, and special tech- completely integrate the whole “package” niques,” which nowadays in many countries of products into their clinical practice. are openly promoted to the general pub- At present, continuing education activi- lic with all available means of publicity? ties concerning orthodontic techniques and What happens to the critical thinking and appliances directly organized or indirectly the evidence-based scienti c background sponsored by the orthodontic industry are acquired and developed during postgradu- outnumbering those organized by scienti c ate education? or professional organizations based solely Existing scienti c evidence does not on noncomm ercial criteria. Postgraduate support claims that certain orthodontic students and young orthodontic specialists techniques, materials, and appliances pos- constitute a signi cant component of the sess extraordinary biological and biome- “clientele” of these meetings organized by chanical properties and characteristics, so the industry. that the nal treatment outcome will be When an enormous amount of clinical bet ter, faster, and m ore risk-free with their information is unilaterally given to orth- use and application than w ith others.4–7 odontic practitioners without validation Orthodontics remains a dental disci- or veri cation,3 professionals need to scru- pline whose practice involves both art and tinize and re ne it. Intelligent colleagues, science, and regrettably, scienti c docu- with their scienti c background acquired mentation and evidence are not available during postgraduate studies, and with their in many areas. However, the trend is clear. com m on sense, should not unquestioningly Our specialty closely follows the path of all accept claims of “faster treatments associ- other biomedical sciences and disciplines, ated with less extractions, without root in which scienti c evidence must support resorption, and with minimal periodon- diagnosis and treatment.8 tal problems, no relapse, and superb den- For the near future, we should expect tal and facial aesthetics.” They should ask that the involvement of technology in clini- some questions: Which clinical studies? cal management will continue to increase, Where have they been published? Are their especially with regard to the diagnostic and 146 Orthodontic Postgraduate Education: A Global Perspective

biomechanical therapeutic aspects. Prog- References ress should be anticipated in understanding the etiology of various craniofacial anoma- 1. Athanasiou AE, Darendeliler MA, Eliades T, et lies, so that their clinical m anagement will al; World Federation of Orthodontists. World be enhanced. Standards of orthodontic Federation of Orthodontists (WFO) guidelines for postgraduate orthodontic education. education will continue to rise, and ortho- World J Orthod 2009;10(2):153–166 dontics will be m ore politically involved 2. Huggare J, Derringer KA, Eliades T, et al. within its social environment, thus facili- Th e Erasm us programm e for postgradu- tating the improvement of conditions for ate education in orthodontics in Europe: the provision of orthodontic services to the an update of the guidelines. Eur J Orthod population. In many parts of the world, a 2014;36(3):340–349 large proportion of the population, which 3. Kau CH. Orthodontics in the 21st centu- at present is excluded, will obtain access ry: a view from across the pond. J Orthod to orthodontic services. This progress 2012;39(2):75–76 requires the contribution of well-educated, 4. Mavreas D, Athanasiou AE. Factors af- modern orthodontic specialists trained in fecting the duration of orthodontic treat- well-structured postgraduate orthodon- ment: a systematic review. Eur J Orthod tic programs; it also requires the involve- 2008;30(4):386–395 ment of dedicated, quali ed, and ambitious 5. Flem ing PS, Johal A. Self-ligating brackets teachers who will act as role models for in orthodontics. A systematic review. Angle academic excellence, clinical competence, Orthod 2010;80(3):575–584 and professional attitude. 6. Weltman B, Vig KW, Fields HW, Shanker S, Critical thinking, as related to scienti c Kaizar EE. Root resorption associated with documentation and cost–bene t judgment, orthodontic tooth movement: a system- must characterize all human resources atic review. Am J Orthod Dentofacial Orthop 2010;137(4):462–476, discussion 12A involved in the systems of orthodontic education and practice. The role of continuous 7. Nim eri G, Kau CH, Abou-Kheir NS, Corona R. Acceleration of tooth movement during professional development in orthodontic orthodontic treatment—a frontier in ortho- education is of great importance. How- dontics. Prog Orthod 2013;14:42–50 ever, the issues of competing and con ict- 8. Turpin DL. Improve care with clinical prac- ing interests must be clearly identi ed, tice guidelines. Am J Orthod Dentofacial Or- addressed, and taken into consideration thop 2009;136(4):475–476 w hen the objectivity, substance, and evidence-based characteristics of presented information are judged. Th e Ro l e of Scienti c 18 Journals in Orthodontic Specialty Education

David L. Turpin

Before 1900, dental publications often today are likely to be amazed at the bitter, included historical articles consisting of uncompromising tone of so-called scien- rather crude descriptions of clinical pro- ti c discussions. Yet, that was the character cedures used to move teeth, often called of the era; intemperate remarks and per- orthodontia. Evidence found in human sonal villi cation were the order of the day, skulls indicates that crooked teeth have all in the nam e of science.3,4 been around since the time of Neanderthal Norman W. Kingsley (1825–1896) was man (circa 50,000 bc), but it was not until the rst of those dental pioneers who made 3,000 years ago that we had the rst writ- the last half of the 19th century a period ten record of attempts to correct crowded of great advancement. He became widely or protruding teeth.1 Beginning in the 18th known after publishing his Treatise on Oral century, the leading country in the eld of Deform ities as a Branch of Mechanical Sur- dentistry was France. This was the result gery.5 Later on, the emergence of orthodon- of the e orts of one man, Pierre Fauchard tics as a true specialty was largely the result (1678–1761), who has been called the of the e orts of one man, Edward Hartley father of orthodontia. As such, he was the Angle (1855–1930), regarded as the father of modern orthodontics.6 Sheldon Peck

rst to remove dentistry from the bonds of empiricism and put it on a scienti c foun- studied the career of Dr. Angle for nearly a dation. In 1728, he published the rst gen- lifetim e, and after reading hundreds of his eral work on dentistry, a two-volume opus personal letters, he concluded, “Edward entitled The Surgeon Dentist: A Treatise on Hartley Angle’s dream in 1900 was to make the Teeth.2 In the early 19th century, before orthodontia a self-standing division of medi- the time of Edward H. Angle, the treatment cine. He sought to do this in three ways: by of malocclusions was taught with little creating a specialty school of orthodontia, understanding of normal occlusion and by organizing a society of orthodontic spe- even less about the development of den- cialists, and nally, by initiating a scienti c tal and skeletal problems. Appliances were journal exclusively for the new specialty.” primitive, and there was no rational basis After Dr. Angle started the American Soci- for diagn osis an d case an alysis. It w as m uch ety of Orthodontists in 1901, the world’s later that Calvin Case showed remarkable rst orthodontic specialty association and foresight in di erentiating between “dental forerunner of the American Association of malposition” and “dentofacial imperfec- Orthodontists (AAO), he started the Angle tions,” comparable with today’s terms for School of Orthodontia in St. Louis, Missouri. dentoalveolar and skeletal problems. Later, Then, in 1906, he was responsible for initi- he became known for advocating extraction ating the rst scienti c journal dedicated to correct facial deformities. Case’s 1911 to orthodontics, The American Orthodontist. paper provoked an acrimonious debate that Material to publish in the rst four issues, came to be known as the great extraction released in 1907, was gathered by the newly debate. According to Norm Wahl, dentists appointed editor, Martin Dewey, one of 147 148 Orthodontic Postgraduate Education: A Global Perspective

An gle ’s m ost accomplished graduates. The recognized the need to standardize his appli- rst issue contained papers read at the Angle ance, thus creating the Angle system, w hich School alumni meeting, held that year in St. could be purchased in various combinations Louis. After a year of publication, it became of prefabricated parts. Through his in uence, more and more di cult to nd submissions orthodontics emerged from a speculative of high quality for the new specialty journal. state and became an exacting science.9 Much to the dismay of Angle, Dewey then Today, the specialty of orthodontics is resigned as editor. Determined not to let the looked upon by the public with respect, concept of a specialty journal die, Milo Hell- even admiration. There are at least 30 man, another distinguished graduate of the English language journals whose primary Angle School, agreed to take on the editor- focus is orthodontics; many more could ship in 1910. Despite continued support by be listed if we included journals in related the Alumni Society of the Angle School and areas, such as oral surgery and periodon- great e ort, as evidenced by the publication tics. Most professionals still know little of eight more issues, the journal closed in about the struggles that took place initially, October of 1912.7,8 when the teaching of orthodontics was not The cost of publications was high, and yet welcom e in the dental school curricu- there was little of merit to publish in those lum. Orthodontics was new as a specialty, days. Despite these ongoing problems, Ber- second only to ophthalmology. Angle even nhard W. Weinberger found support for speculated that orthodontics was destined other new journals of the day and peri- to become a specialty of m edicine. odically submitted articles on the history Years passed, and in looking back at the of dentistry as ller material. After a few early developments rightfully claimed dur- years of this experience, considered suc- ing the 20th century by those dedicated cessful, Weinberger was hooked on his- to the specialty of orthodontics, one has tory. He proceeded to publish 250 books, to be impressed. The perfection of xed monographs, and articles in a landmark appliances was far ahead of the many con- bibliography entitled An Introduction to the tributions made in later years to assist in History of Dentistry (1948).8 Other popular diagnosis and treatment planning. More orthodontic journals that have taken root than 50 years later, the use of adhesives to since those early days include The Angle replace metal bands and the application of Orthodontist (1930), Journal of Clinical orthognathic surgery, not to m ention a bet- Orthodontics (1967), and the World Journal ter understanding of the biology of tooth of Orthodontics (2000), recently renamed movement and the response of growing under ownership of the World Federation sutures to a variety of forces, have all had a of Orthodontists as the Journal of the World great impact on the ability of orthodontists Federation of Orthodontists (2010). to treat malocclusion of the teeth and jaws. During the early years of the 20th cen- One has to believe that the publication of tury, popular appliances included Angle’s scien t i c jou r n als for t h e p ast 100 years h as ribbon arch, the Crozat and Mershon lingual also played a major role in helping to bring appliances, and the McCoy open tube. Dr. m any of these ideas to fruition.9 Edward Angle completed work on his rst complete edgewise appliance in 1925, and four years later, Spencer Atkinson came out with the universal appliance. For the fabri- 18.1 Role of the Journal cation of bands and arch wires, the material Ed i t o r most frequently chosen was gold. Bands were pinched and soldered. There were no orth- Several years ago, the American College of odontic supply houses, only dental suppliers Dentists devoted an entire issue of its journal such as S. S. White and the gold m anufactur- to “advice for a young editor.”10,11 That advice ers. Before 1887, it was necessary to design is well worth considering if you believe that and fabricate an appliance for each patient involvement in scienti c journalism adds individually, which could take hours. Angle value to the academic curriculum. 18 Th e Ro le of Scienti c Journals in Orthodontic Specialt y Education 149

The rst responsibility of an editor manuscript preparation. Excellent journal- is to the readers. The editor should work ism can help merge scienti c ndings with to ensure that the content is from repu- patient needs, in uencing treatment plans table sources, factually accurate, balanced, and improving outcomes. A specialty whose and unbiased. Personal opinion should be members can express themselves via the labeled as such, with potential con icts of publication of properly conducted clinical interest disclosed. The publication should research can enrich untold numbers of peo- be readable and based on a standardized ple throughout the world—both colleagues style, with careful editing for gram m ar and and the public at large. clarity. Opportunity should be provided for alternative opinions when possible. The second responsibility of the editor, representing the professional comm unity, 18.2 Authorship is to the authors. The editor should promote the dignity of the specialty, regularly Authorship credit should be based on (1) publishing the standards for the selection of substantial contributions to conception content and the format for the submission of and design, acquisition of data, or analysis material. All material should be reviewed by and interpretation of data; (2) drafting of competent experts in the eld, in a fashion the article or critical revision for important that is timely, con dential, and constructive. intellectual content; and (3) nal approval Standards should be set for reviewers and of the version to be published. Authors the rules according to which they operate should meet all three of these conditions. enforced for all peer-reviewed articles. The acquisition of funding, collection of The third responsibility of the editor is data, or general supervision of the research to the organization publishing the journal. group alone does not constitute author- The editor should diligently avoid placing ship. When a large, multicenter group has the sponsoring organization in a legally conducted the work, the group should questionable position. He or she should identify the individuals who accept direct respect the terms of employment, fully responsibility for the manuscript.12 These understanding what is expected as both an individuals should fully m eet the criteria editor and a participant in various comm it- for authorship/contributorship previously tees, task forces, annual meetings, and so de ned, and editors will ask them to com - on . Th e e d it or sh ou ld e n su re t h at t h e a d ve r- plete journal-speci c author and con ict- tising is in good taste and does not violate of-interest disclosure forms. the association’s advertising guidelines. All co n t r ib u t o r s w h o d o n ot m e e t t h e cr it e r ia The fourth responsibility of the editor for authorship should be listed in an acknowl- is to the comm unity of editors. This means edgments section of the respective journal. that the editor should regularly seek advice Exam ples of those w ho m ight be acknowledged and be open to guidance from peers. The include a person who provided purely techni- editor should endorse policy covering re- cal help or writing assistance, or a department publication and other use of published chair who provided only general support. material, and be open to incorporating new form s of comm unication, such as videos and blogs. In all formats used, the editor should have the nal say regarding the con- 18.3 Institutional Review tent of the publication, not the organization Board Approval or its sponsoring advertisers. Writing and editing are privileges of A university’s institutional review board self-expression and entail ethical respon- (IRB) has the responsibility of developing sibilities to readers. Sound advice to any and approving all research studies involving editor of a scienti c journal is to build and human beings before the initiation of such maintain trust by knowing the process. This research. Determining whether or not the also applies to the student in the middle of design of a project m eets the federal de ni- 150 Orthodontic Postgraduate Education: A Global Perspective

tion of human subject research is a two-step 18.5 Protection of process. The investigator must determine if the project meets the federal de nition of Human Subjects and research and, if so, determine if the project Animals in Research includes human subjects. Additional information can be found on the following Web When reporting experiments on human site to help you determine whether or not subjects, authors should indicate whether IRB review is required for a speci c study13: the procedures followed were in accor- http://www.fda.gov/regulatoryinforma- dance with the ethical standards of the tion/guidances/ucm 126420.htm responsible comm ittee on human experi- The purpose of IRB review is to ensure, mentation (institutional and national) and both in advance and by periodic review, with the Helsinki Declaration of 1975, as that appropriate steps are being taken to revised in 2000.5 When reporting experi- protect the rights and welfare of humans ments on animals, authors should indicate participating as subjects in the research. whether the institutional and national To accomplish this purpose, the IRB uses a gu id e for t h e care an d u se of laborator y an i- group process to review research protocols m als was followed. and related materials.

18.6 Copyright 18.4 Obligation to Ownership Register Clinical Trials With the increase in the size and num- The International Comm ittee of Medical ber of journals designed to publish scien- Journal Editors (ICMJE) believes that it ti c ndings, controlling the ownership of is important to foster a comprehensive, articles becom es increasingly important publicly available database of clinical tri- to many authors. That leads us to an age- als. The ICMJE de nes a clinical trial as old question: Who owns the copyright to any research project that prospectively your words, and how can you protect that assigns human subjects to intervention ownership? or to concurrent comparison in a control The author of an article or other w ritten group to study the cause-and-e ect rela- material owns the copyright to that mate- tionship between a medical intervention rial, even if the copyright has not been reg- and a health outcome. The ICMJE mem- istered, until such tim e as he or she assigns ber journals may require, as a condition ownership to another entity. Most publica- of consideration for publication in their tions have a standard copyright form that journals, registration in a public trials the author is asked to sign before a writ- registry. There are additional bene ts to ten work is published. This form de nes the registration of clinical trials. It may who retains ownership of the work as well prevent redundancy in certain research as other issues, such as the right to reprint topics and assist in allowing subsequent the work. Editors and authors alike should investigators to gather data similarly, so ensure that all copyright issues are settled that pooling or comparison of the results in writing, to the satisfaction of both par- can be more easily accomplished. In gen- ties, before publication. The copyright eral, the purpose of a clinical trial registry transfer gives a publisher or the owner of is to promote the public good by ensur- the publication the exclusive right to pub- ing that everyone can nd key informa- lish the article. This right m ay also grant tion about every clinical trial in the world authors certain rights to their own work, whose principal aim is to shape medical including the right to post it on their own and dental decision making.14 Web sites for their students and those who 18 Th e Ro le of Scienti c Journals in Orthodontic Specialt y Education 151 listen to their scienti c presentations. If an the ownership of intellectual output, author wants to reuse a gure that has been an author should understand the published previously, most publishers make consequences and options. it easy w ith an online permissions process. The issues of access to research ndings But what if an author wants to retain and the rights of authors will continue to more rights than the publisher allows? be of concern to authors and publishers as For example, what if the author’s funding they seek to nd the proper balance. There requires “open source” distribution of his is every reason to believe that this balance or her article? In the United States, this may can be achieved when both sides comm u- mean that the article should be sent to the nicate their deepest concerns and listen National Institutes of Health w ithin 6 to 12 to one another as changes continue in the months after the original publication date publishing industry. so that it can be posted on the National In a related issue involving copyright, Institutes of Health Web site and be made authors should guard against their work freely available to all readers. Doing this being used im properly. This includes words could require a change in the original copy- and graphics, such as charts and photo- right agreement. Is that possible? If so, how graphs. The term plagiarize is de ned as can the author ensure that it will happen? to “appropriate and pass o as one’s own Most publishers are now very aware of the the writings and ideas of another.” Legal desire for “open access” to published nd- resources, including books, articles, and ings and have o cially agreed to work with other materials, should be consulted to their authors to provide greater access. explore this topic more fully. All of this The Scholarly Publishing and Academic means that credit should be given to, and Resources Coalition (SPARC) is one entity permission obtained from, appropriate that was formed with this purpose in m ind. sources when needed. SPARC, an international alliance of more than 800 academic and research libraries, works toward a more open system of scholarly comm unication.15 It believes 18.7 Co n i c t s of In t e re s t that to achieve a more balanced approach to copyright management, authors should A renewed focus on the potential for con- consider the following steps: icts of interest in scienti c writing is evident in many of our periodicals, educa- • Reading the publication’s copyright tional institutions, and research comm uni- agreement with great care. It m ay ties. In scienti c authorship, the term refers capture more of an author’s rights to situations in which nancial or other than is necessary to publish the personal considerations might compromise work. Ensuring that the agreement the integrity of professional judgm ent dur- is balanced and clearly states the ing the conduct or reporting of research. author’s rights is up to the author. Historically, the key stages in the evolution • Negotiating for the agreem ent that of requirements for disclosure of interest is wanted. Publishing agreements began in 1984, when Arnold Relman, edi- are negotiable, and publishers may tor of The New England Journal of Medicine, require only permission to publish proposed that all medical journals require an article, not w holesale transfer of authors submitting scienti c m anuscripts copyright. to identify any relevant nancial connec- • The author should value the tions with industry. In 1990, the same jour- copyright in his or her intellectual nal implemented a policy to forbid authors property. A journal article is often of reviews or editorials to have nancial ties the culmination of years of study, with companies whose products gured research, and hard work. The more prominently in the article, although this the article is read and cited, the rule was often violated.16,17 greater its value. Before transferring 152 Orthodontic Postgraduate Education: A Global Perspective

18.7.1 Pote ntial Co n i c t s : In 2001, the editors of 13 leading medical journals published a joint editorial not- Authors’ Commitments ing the impact of the comm ercialization of medical research on researchers’ behavior. • Con ict of interest exists w hen That was the predecessor of the Uniform an author (or the author’s Re qu ir e m ents for Manuscripts Submitted institution), reviewer, or editor has to Biomedical Journals, formulated by the nancial or personal relationships ICMJE. The ICMJE con ict-of-interest form that inappropriately in uence is now used by many journals. It can be (bias) his or her actions. Such implemented simply by downloading it to a relationships are also known as dual computer (http://ww w.icmje.org/con icts- comm itments, competing interests, of-interest/),18 completing and saving it, or competing loyalties. and submitting it directly to the journal to • When authors submit a m anuscript, w hich the manuscript has been sent. w hether an article or a letter, they Because we have entered into a world are responsible for disclosing all with complex interactions of industry and nancial and personal relationships science, which are the subject of critical that might bias their work. Authors interest because of the potential nan- should do so in the m anuscript on a cial exploitation of research ndings, the con ict-of-interest noti cation page disclosure of any potential ties of authors that follows the title page, providing to third parties becomes necessary. The additional detail, if necessary, in a reader has the right to know whether an cover letter that accompanies the author has an underlying a liation with manuscript. t h e in du st r y. It is a righ t to exercise at h is or To remain in good standing with any her discretion, and hiding this information journal selected for a publication, authors can only damage t h e valid it y of t h e p u blica- should always disclose a con ict of interest t ion and the trust of th e public in the scien- involving them or any of their co-authors. ti c endeavor. Potential con icts of interest The following might be considered grounds related to the comm itments of editors and for such a con ict: journal sta , or even reviewers, are most often detected by other reviewers. How- • Possession of shares of stock tied in ever, in this age of electronic journalism, any way to the subject of the article companies have developed software like • Receipt of direct or indirect funding CrossCheck, which is a system for detect- or reimbursement from a corporate ing plagiarism. CrossCheck com pares a new body, including m oneys as a gift submission against a database of more than for a lecture or a presentation 30 million articles from 200 publishers. A on a m aterial/appliance or a “sim ilarity report” speci es the percentage pharmacological agent and of th e text of th e n ew su bm ission that over- funds to cover travel expenses, laps with the text of one or more published accomm odations, and registration articles. As convenient as they sound, these for a m eeting and similar programs have shortcomings. • Receipt of gifts in the form of That said, reviewers are still our best line bulk amounts of free m aterials or of defense. To summ arize this issue, edi- appliances for personal use, not tors should avoid selecting external peer intended for research purposes reviewers with obvious potential con icts • Participation in networks that are of interest—for example, those who work supported by the industry or the in the same department or institution as private sector, regardless of their any of the authors. Editors who make nal objective or scope of formation decisions about manuscripts must have no personal, professional, or nancial involve- m ent in any of the issues they m ight judge. 18 Th e Ro le of Scienti c Journals in Orthodontic Specialt y Education 153

18.8 Peer Review of that peer review not only fails to prevent the publication of awed research but also Scienti c Articles permits the publication of research that is fraudulent. Some have described peer Peer review is described as the evaluation review as arbitrary, subjective, and secre- of work by one or more people with com - tive. In addition, many critics maintain petence similar to that of the producers of that it is simply unnecessary and slows the the work (peers). It constitutes a form of comm unication of information. According self-regulation by quali ed m embers of a to the most comprehensive survey of active profession within the relevant eld. Peer reviewers throughout the scienti c world, review methods are employed to maintain such is not the case. standards of quality, improve performance, One of the largest-ever international and provide credibility. In academia, peer surveys of authors and reviewers, the Peer review is often used to determine the suit- Review Survey 2009, was conducted by ability of an academic paper for publication. Sen se About Scien ce. Preliminary ndings One m ight wonder what would motivate were presented at the British Science Fes- anyon e to agree to ser ve in such capacit y … tival at the University of Surrey, Guildford, that of agreeing to critically review the United Kingdom , on September 8, 2009. work of another (Fig. 18.1). Som e 40,000 researchers were randomly As glam orous as it sounds on the sur- selected from the Institute for Scienti c face, peer review as practiced today is far Inform ation author database, which con- from perfect. Critics often make the point tains the names of researchers with work

Fig . 1 8 . 1 The reasons volunteers most frequently give for agreeing to review scienti c articles before revision and subsequent publication. 154 Orthodontic Postgraduate Education: A Global Perspective

published in more than 10,000 journals. for AJO-DO audience (27%). Manuscripts Altogether 4,037 researchers completed the rejected for poor study design had the least survey.19 success in achieving subsequent publica- The authors of this comprehensive tion, whereas those rejected as inappro- study concluded that most (69%) research- priate for AJO-DO had the highest rate of ers are satis ed with the current system of subsequent publication elsewhere. Area of peer review, but only a third (32%) think origin was found to be signi cantly asso- that the current system is the best that ciated with acceptance by AJO-DO, with can be achieved. Most (84%) believe that articles from the United States and Canada without peer review there would be no m ost likely to be accepted (p < 0.01). Mean - control in scienti c comm unication, and while, it was found that countries with the only one in ve researchers (19%) believe lowest publication rate in AJO-DO had the that peer review is unsustainable because highest publication rate elsewhere. The there are too few willing reviewers. Almost inclusion of statistically signi cant nd- all researchers (91%) believe that their last ings was shown to be signi cantly asso- paper was improved as a result of peer ciated with acceptance by AJO-DO (p = review, with the biggest area of improve- 0.013), but not with publication elsewhere. ment in the discussion, and 73% of review- The authors concluded that rejection by ers (a subgroup in the study) believe that AJO-DO did not preclude publication else- technologic advances have made it easier to where. Geographic origin was a predictor do a thorough job of reviewing now than it of acceptance by AJO-DO as well as by sub- w as ve years ago. Alt h ough t h e m ajor it y of sequent journals. Authors aiming to maxi- respondents enjoy reviewing and will con- mize their chance of article acceptance tinue to review (86%), many think that more should submit to an appropriate journal, could be done to support reviewers; 56% use a well-designed and described study believe there is a lack of guidance on how with adequate sample sizes, and empha- to review, and 68% agree that formal train- size the novelty and relevance of their ing would improve the quality of reviews. work (Figs. 18.2 and 18.3). Based on an analysis of the data in this survey, researchers agree that peer review is well understood by the scienti c community. However, this level of understanding is 18.9 Obligation to in sharp contrast to the research comm u- Publish Negative Studies nity’s perception of the public’s awareness of peer review; just 30% believe the public For som e time, journal editors have shown understands the term peer review. a tendency to prefer accepting manuscripts Of the 440 original articles submitted for publication when the study has a sig- to the Am erican Journal of Orthodontics ni cant outcome. This tendency was veri- and Dentofacial Orthopedics (AJO-DO) in ed in 2009 when a study of three of the 2008, 116 (26%) were accepted for pub- top orthodontic publications by Koletsi et lication and 324 (74%) were rejected.20 al was published.21 The percentage of arti- All accepted articles underwent revision cles in the journals included in the study before acceptance and publication. Of the that showed signi cant results was higher rejected articles, 137 were subsequently than the percentage of articles without sig- published in 58 di erent journals, with an ni cant associations (on average, 88% vs average time to publication of 22 months 12%). Overall, the three journals published after rejection by AJO-DO. Among articles more studies with signi cant results, rang- not accepted by AJO-DO, the top three rea- ing from 75% to 90%. The ndings indicated sons for rejection were the following: (1) that journals seem to prefer reporting sig- poor study design/small sample size (59% ni cant results; this may persist because of of rejected papers), (2) outdated/unorigi- authors’ perceptions of the importance of nal topic (42%), and (3) inappropriateness their ndings and editors’ and reviewers’ 18 Th e Ro le of Scienti c Journals in Orthodontic Specialt y Education 155

Fig. 18.2 Acceptance rates according to country of origin of authors of articles published by the American Journal of Orthodontics and Dentofacial Orthopedics in 2008. (From Farjo N, Turpin DL, Coley RY, Feng J. Char- acteristics and fate of orthodontic articles submitted for publication: An exploratory study of the American Journal of Orthodontics and Dentofacial Orthopedics. Am J Orthod Dentofac Orthop 2015;147:680–690.)

preferences for signi cant results. Based on heavily involved in applying for patents this study, editors should: and manufacturing the components of new appliances, while at the same time starting • Seriously consider for publication new schools and publishing textbooks—all any careful study of an important com m ercial activities for which he received question that is relevant for their substantial remuneration. He lived in the readers, whether or not the results age of the “expert,” and the push to suc- for the prim ary or any additional ceed nancially was strong throughout the outcome are statistically signi cant. early part of the 20th century. However, • Realize that failure to subm it or questionable historical practices are no publish ndings because of a lack reason to turn a blind eye to the injurious of statistical signi cance is an e ects that comm ercialism can have on im portant cause of publication bias. our delivery of patient care today.22 Stan- dards for continuing education provided by universities, professional associations, and comm ercial entities continue to walk 18.10 Advertising and a ne line w hile balancing the prom otional Commercialism “sales pitch” against the current ndings of clinical trials. When the education of Financial con icts of interest played a our membership is concerned, responsi- major role in the formative years of orga- bility for evaluating content resides w ith nized orthodontics. Edward H. Angle was each individual. If someone is lecturing on 156 Orthodontic Postgraduate Education: A Global Perspective

Fig. 18.3 Six reasons for the rejection of articles submitted to the American Journal of Orthodontics and Dentofacial Orthopedics in 2008. The most common reasons for rejection included (1) inappropriateness of topics, (2) poor design with small sample sizes, and (3) outdated or uninteresting topics. (From Farjo N, Turpin DL, Coley RY, Feng J. Characteristics and fate of orthodontic articles submitted for publication: An exploratory study of the American Journal of Orthodontics and Dentofacial Orthopedics. Am J Orthod Dentofac Orthop 2015;147:680–690.)

something that has been used for years, the and electronic versions; Web site advertis- appropriate evidence can be located in the ing policy should parallel that for the print literature and referred to. If the level of evi- version to the greatest extent possible. dence is not strong, that can also be made Ed itors m ust have full and nal author- known by the speaker. But if the topic is ity for approving advertisements. A well- directly related to a new product or tech- conceived advertising policy may require nique that has not been on the market long the citation of published articles in support enough to be tested, then the lecturer has of questionable wording used in an adver- an even greater responsibility to disclose tisement for a product or service being any con icts of interest. When it comes promoted. It may be necessary to change to a relationship between the speaker and words used in the advertisement if such the company that produces the product, proof is not found in the published litera- this con ict of interest m ust be made very ture. Review articles, guest editorials, and clear to the audience, whether the presen- letters to the editor have not always been tation is to a large audience of experienced held to this same standard. A change in this clinicians or a small class of residents at a policy was made in 2002 by The New Eng- university. land Journal of Medicine, w hich states, “… Most medical and dental journals carry the authors of such articles will not have advertising, which generates income for any signi cant nancial interest in a com- their publishers, but advertising must not pany that m akes a product discussed in the be allowed to in uence editorial decisions. article.”23 Many ot h er jou r n als follow ed su it Journals should have formal, explicit, writ- by making this a part of their advertising ten policies for advertising in both print policy.24 18 Th e Ro le of Scienti c Journals in Orthodontic Specialt y Education 157

18.11 Guidelines for 18.11.2 Guidelines for the Manuscript Pre paratio n Preparation of Orthodontic Case Reports Uniform Requirem ents for Manuscripts Su bm itted to Biomedical Journals are a set Case reports are published on a regular of guidelines produced by the ICMJE for basis in many orthodontic publications. standardizing the ethics, preparation, and These short clinical comm unications not form atting of manuscripts submitted to only are of interest to clinicians in private biomedical journals for publication. Com - practice but also provide a unique and pliance with the ICMJE recomm endations important forum for the presentation and is required by most leading biom edical discussion of unusual and perplexing treat- journals. As of 2014, thousands of journals ment situations. Authors are encouraged as listed worldwide follow the Uniform to consider using the following guidelines Requirements25: http://www.icmje.org/rec- in preparing or editing their manuscripts omm endations/browse/manuscript-prepa- of case reports that describe the rationale ration/preparing-for-submission.htm l. for the treatment of dental malocclusion This Web site is continually updated to (revised guidelines for the publication of re ect the wishes of scienti c journal edi- case reports as implemented by Vincent G. tors regarding articles submitted for publi- Kokich, June 2000, after being appointed cation in their medical and dental journals. Editor of Case Reports for the American The following sections are included and Journal of Orthodontics and Dentofacial should be carefully studied during the prep- Orthopedics). aration of a new manuscript: General Prin- ciples, Reporting Guidelines, Manuscript Sections (Title Page, Abstract, Introduction, 18.11.2.1 Introduction Methods, Results, Discussion, References, Tables, Illustrations [Figures], Units of Mea- In this section, the author must introduce surement, Abbreviations and Symbols). The the reader to the general topic or problem follow ing form s are also included with the that is illustrated by the case report. The ICMJE recom m endations: model release and introduction should brie y refer to speci c permission forms; photographic consent literature that has discussed the topic of the statement. case report. It should end with a sentence that leads the reader into a speci c description of the patient’s records. 18.11.1 Photo Release (Example) 18.11.2.2 Diagnosis and Etiology

I, the undersigned, do hereby relinquish In this section, the author summ arizes any and all rights to photographs, trans- the patient’s skeletal and dental diagnos- parencies, negatives, prints, or other pho- tic ndings. It is important to focus on tographic reproductions captured for use abnormal factors and not dwell on norby the (journal name). It is my/our under- mal ndings. The section should include standing that my scienti c illustrations or the patient’s age, classi cation of the mal- photos of our son/daughter may be pub- occlusion, speci c unusual dental prob- lished periodically on the Web site of the lems, hereditary factors, periodontal or (organization name) as an example of restorative complications, etiology of the (research outcomes or related reasons). malocclusion, and other criteria that will (Subject’s name, address and signature. in uence the treatment plan. The author If under 18 years of age, parent or guardian should refer to speci c cephalometric data m ust also sign.) if necessary and should refer the reader to speci c gures containing pretreatment 158 Orthodontic Postgraduate Education: A Global Perspective

cephalometric and intraoral radiographs, 18.11.2.7 Discussion intraoral and facial photographs, and photographs of the dental casts. This is perhaps the most important section of the entire case report. The speci c problem that makes the case report unique is discussed, 18.11.2.3 Treatment Objectives how it relates to the decisions made by the author, and nally how the treatment relates to The list of problem s itemized in the section the published literature on the topic. The dis- on diagnosis and etiology should naturally cussion must contain references to the litera- lead the author and reader to a list of spe- ture. It should focus on four or ve points that ci c treatments designed to solve each one. made the treatment outcome unique. Each The treatment objectives should include point is discussed in a separate paragraph, references to the m axilla, m andible, m axil- with reference to the patient’s treatment and lary dentition, mandibular dentition, occlu- the appropriate literature. sion, and facial aesthetics. The objectives should include the correction of problems in the transverse, vertical, and anterior and 18.11.2.8 Summary and posterior planes of space if appropriate. Conclusions

This should be the shortest section of the 18.11.2.4 Treatment Alternatives case report. It should consist of one paragraph that summ arizes the most important The next logical step in the treatment plan- points learned from the patient’s treat- ning process is for the author to articulate ment. And of course, all references should the various treatment alternatives that can be listed in a form at similar to that used for be used to accomplish the listed objectives. any scienti c article published in the sam e The author must be complete and refer to journal. all possible treatment plans, and the advan- In 2000, Vincent G. Kokich designed tages and disadvantages of each treatment a standardized method of evaluating the

alternative should be described brie y. quality of orthodontic case reports submitted for publication, making it easier for peers to review them (revised guidelines 18.11.2.5 Treatment Progress for the publication of case reports as implemented by Vincent G. Kokich, June 2000, In this section, the author must describe the a ft e r b e in g a p p o in t e d Ed it o r o f Ca se Re p o r t s step-by-step process of treatment, focus- for the American Journal of Orthodontics ing on the important details of treating the and Dentofacial Orthopedics). Each case patient’s unique set of problems. The type report being considered for publication is of appliances used, length of treatment, objectively assessed and scored based on interaction with other aspects of dentistry, ve areas, each one weighted according to and special decisions made during treat- its relative importance. The ve areas are m ent should be included. the following: • Uniqueness of the case: A high 18.11.2.6 Treatment Results priority is given to a case that exhibits unique skeletal, dental, or In this section, the author should describe the occlusal problems. results of orthodontic treatment. The results • Co m pleteness of the records: Case sh o u ld p a r a llel t h e o bje ct ive s o f t r e at m e n t a n d reports are seldom published therefore be presented in the same sequence. w ithout complete records, including The author should be careful to identify both excellent photographs, intraoral expected and unexpected outcomes, and how and cephalometric radiographs, they a ected the overall treatment outcome. and photos of dental casts. Progress 18 Th e Ro le of Scienti c Journals in Orthodontic Specialt y Education 159

photographs illustrating speci c 18.12 Advances Possible and unique treatment aspects are encouraged. w ith Electronic Publication • Quality of the records: The quality of all records is given high priority. When it became possible to submit and • Quality of the treatm ent: Again, the m anage manuscripts electronically, only a quality of the treatm ent re ects few of the many bene ts were recognized on the clinician/author. Although at rst. Of course, there was a dramatic ideal results are not m andatory, the increase in the ow of material, not to men- quality of treatment has the second- tion a reduction in mailing costs. Articles in highest weighting. which a plethora of charts and graphs is • Quality of the m anuscript: Written needed to describe the data thoroughly can guidelines for case reports are now be published online with little added available to all authors and provide cost. Once reviewed, revised, and accepted, a framework for creating a well- articles can be placed online until space is w ritten manuscript to accompany available to publish them in print, if that is the patient’s records. t h e goal. As a resu lt , t h e volu m e of scienti c • The following form provides the articles published yearly continues to soar reviewer with a m ethod that can be beyond imagination. Over time, other, m ore used for the objective assessm ent dramatic innovations have become possible of all case reports being considered as the creative juices ow in the minds of for publication. Each area is scored b o t h a u t h o r s a n d e d it o r s . M o s t jo u r n a ls n o w as unsatisfactory or incomplete have apps that allow readers to download (0), satisfactory (1), or exceptional articles conveniently on their sm artphones (2), and the score is m ultiplied or tablets. Authors are able to upload mul- by the weighting for that area to timedia les along with their subm ission— achieve the score. The scores for including movies and three-dimensional the individual areas are added to images. Many journals now encourage the determine the total score. publication of videos by authors, allowing a timely description of the research study 160 Orthodontic Postgraduate Education: A Global Perspective

and why it was undertaken. Blogs are also scienti c ndings has continued to thrive. a frequent feature of most online publica- Num erous orthodontic publications now tions and encourage increased interaction exist throughout the world, and another between readers and the authors of cur- 40% of the specialty’s research ndings are rent articles. Letters to the editor can be published in other scienti c journals with published almost imm ediately on blogs, h igh im pact factors. Th is is a t im e when the eliminating the typical three-m onth delay value of evidence-based dental research is in normal response tim e. In addition, som e reaching new heights, allowing clinicians to publishers have developed software to have greater exposure to a higher qualit y of allow the publication of three-dimensional published research ndings. It is my hope images when they facilitate the under- that the next hundred years of dentistry standing of research outcomes. will be as productive as the rst hundred, leading to ever better outcomes of orthodontic treatment. 18.13 Conclusion References It is my hope that this chapter has provided a broad un derst an ding of th e role played by 1. Weinberger BW. Historical resume of the a variety of publications in the process of evolution and growth of orthodontia. J Am educating the orthodontic resident. Early Dent Assoc 1934;21:2001–2021 publications in the eld of dentistry were 2. Wahl N. Orthodontics in 3 millennia. descriptive in design, relating the experi- Chapter 1: Antiquity to the mid-19th cen- ences of early dentists who dabbled in a tury. Am J Orthod Dentofacial Orthop variety of ways to move teeth. Diagnos- 2005;127(2):255–259 tic procedures leading to treatm ent plans 3. Dewel BF. The Case-Dewey-Cryer extraction designed to accomplish speci c objectives debate. Am J Orthod 1964;50:862–865 were rare and often ill de ned. The study 4. Wahl N. Orthodontics in 3 millennia. of long-term outcomes was unheard of in Chapter 2: entering the modern era. Am J clinical circles. Orthod Dentofacial Orthop 2005;127(4):

During the last century, the specialty 510–515 of orthodontics has come full circle as it 5. Pro t WR, Fields HW, eds. Contemporary is now practiced worldwide. The identi- Orthodontics. 3rd ed. St. Louis, MO: Mosby; 2000 cation of the specialty of orthodontics has led to a plethora of publications tout- 6. Ch ap m an H. Orthodontics: fty years in retrospect. Am J Orthod 1955;41:421–442 ing a multitude of di erent ways to move teeth with increasing e ciency. Educa- 7. Peck S, ed. Correpondence with Dr. Mar- tin Dewey. In: The World of Edward Hart- tion has been formalized in schools that ley Angle, MD, DDS: His Letters, Accounts place emphasis on the value of scienti c and Patents. Vol 3. Boston, MA: The E. H. study as well as clinical excellence. The Angle Education and Research Foundation; application of cephalometric analysis has 2007:320–322 now been expanded by the use of three- 8. Weinberger BW. Dr. Edward Hartley Angle, dimensional technology where indicated, his in uence on orthodontics. Am J Orthod further enhancing the diagnostic skills of 1950;36(8):596–607 the specialist. The expansion of bonding 9. Wahl N. Orthodontics in 3 millennia. Chap- adhesives to the eventual obsolescence of ter 4: the professionalization of orthodon- m etal bands placed around every tooth has tics (concluded). Am J Orthod Dentofacial been revolutionary. But of even greater sig- Orthop 2005;128(2):252–257 ni cance is the continued development and 10. Ch am bers DW, Curtis EK, Fratzke JP, Mark use of new biomaterials in several phases HI, Rosen R, Seward MH. Code for dental of tooth movement. Throughout this entire editors. J Am Coll Dent 2005;72:5–8 period of change in the way orthodontists 11. Turpin DL. The search for a new editor- practice, the publication of clinical and in-chief. Am J Orthod Dentofacial Orthop 2013;144:635 18 Th e Ro le of Scienti c Journals in Orthodontic Specialt y Education 161

12. International Comm ittee of Medical Journal 19. Sense About Science. Peer review survey Editors. De ning the role of authors and con- 2009: full report. http://ww w.sensea- tributors. http://www.icmje.org/recomm en- boutscience.org/data/files/Peer_Review/ dations/browse/roles-and-responsibilities/ Peer_Review_Survey_Final_3.pdf. Accessed de ning-the-role-of-authors-and-contribu- March 23, 2015 tors.html. Accessed March 23, 2015 20. Farjo N, Turpin DL. Characteristics and fate 13. U.S. Food and Drug Administration. Regu- of orthodontic articles submitted for publi- latory information. Institutional review cation: an exploratory study of the Ameri- boards frequently asked questions – infor- can Journal of Orthodontics and Dentofacial mation sheet. http://www.fda.gov/regulato- Orthopedics. Am J Orthod Dentofacial Or- ryinformation/guidances/ucm126420.htm. thop. In press Accessed March 23, 2015 21. Koletsi D, Karagianni A, Pandis N, Makou M, 14. Turpin DL. The need to register clinical tri- Polychronopoulou A, Eliades T. Are studies als in orthodontics. Am J Orthod Dentofacial reporting signi cant results m ore likely to Orthop 2006;130(4):429–430 be published? Am J Orthod Dentofacial Or- 15. Turpin DL. Your copyright and the SPARC thop 2009;136(5):632.e1–632.e5, discus- author addendum. Am J Orthod Dentofacial sion 632–633 Orthop 2010;137(1):1 22. Tu r p i n D L. Co m m ercialism on the rise, 16. Eliades T, Turpin DL. Con ict of inter- again. Am J Orthod Dentofacial Orthop est: always report it, and if in doubt, ask. 2007;132(1):1–2 Am J Orthod Dentofacial Orthop 2008; 23. Drazen JM, Curfman GD. Financial as- 134(3):327–328 sociations of authors. N Engl J Med 17. Goozner M. Unrevealed: non-disclosure of 2002;346(24):1901–1902 con icts of interest in four leading medical 24. Turpin DL. Authors and their nancial and scienti c journals. http://cspinet.org/ ties. Am J Orthod Dentofacial Orthop new/pdf/unrevealed_ nal.pdf. Published 2002;122(5):449 July 12, 2004. Accessed March 23, 2015 25. International Comm ittee of Medical Journal 18. International Comm ittee of Medical Journal Editors. Preparing for submission. http:// Editors. Con icts of interest. http://ww w. www.icmje.org/recommendations/browse/ icmje.org/con icts-of-interest/. Acce ss e d manuscript-preparation/preparing-for- March 23, 2015 submission.html. Accessed March 23, 2015

The Role of Research in 19 Orthodontic Specialty Ed u c a t i o n

Kee-Joon Lee and Young-Chel Park

19.1 The Rationale short-term stability to substantiate their protocol.3 However, neither of these two of Evidence-Based groups showed scienti cally acceptable evi- Orthodontics dence regarding post-treatment stability. Apart from this debate, in the 1980s, The concept of evidence-based orthodon- numerous clinical studies from the Uni- tics, although the majority of orthodon- versity of Washington School of Dentistry, tists still nd it di cult to accept,1 has Seattle, were published about the e ects been around since 2000.2 Residents in orth- of various treatment modalities on the odontic specialty programs are trained to stability of treatment outcomes, leaving acquire technical pro ciency in diagnosing rather vague answers to the major ques- and treating patients with various types of tions. For instance, orthodontic treatment m alocclusion and/or craniofacial deformity. with premolar extraction, which was pro- In this context, so-called cookbook train- posed to eliminate possible relapse after ing, in which the instructors designate the non-extraction treatment, was not stable treatment plans, types of appliances, and through a 10-year post-retention period.4,5 Furthermore, serial extraction, which had sequence of overall treatment, tends to be comm onplace because the protocols were been presumed to be more stable than the practiced by numerous predecessors based extraction of premolars after full eruption, on individual experience and possibly trial was not shown to be superior to its coun- and error. terpart over 10 years of post-retention.6 A sim ilar nding was reported regarding the timing of second premolar extraction.7 19.1.1 Controversies in Overall, apparently the question of whether Orthodontic Diagnosis and the extraction of premolars improves stability still remains unanswered. Treatment Planning

The pattern of education in orthodontic programs may be associated with the long- 19.1.2 Th e Va lu e of Ev i d e n c e - standing history of orthodontics, which Based Education dates back to the era of Dr. E. H. Angle, when non-extraction treatme n t w a s b e lie ve d t o b e The preceding examples imply two dif- the main and only goal of orthodontic prac- ferent but not necessarily contradictory tice. Later, this conviction was opposed by aspects—the possible consequences of Dr. C.H. Tweed’s group, whose members expert opinion not supported by sound evi- doubted the feasibility and stability of pre- dence, and the notion that even “evidence- vious non-extraction treatments and dem- based orthodontics” may not be able to onstrated numerous extraction cases with provide clinically valuable answers. 162 19 The Role of Research in Orthodontic Specialty Education 163

Ironically, when the term evidence- or veri cation.12 The debate on the e ects based medicine was coined, clinicians of self-ligating brackets may be one of the were worried that it would lead to “cook- latest examples. Certainly the profession- book” medicine.8 So far, in the eld of als, not the manufacturers, need to re ne orthodontics, debates are still ongoing in the clinical information so that patients can regard to various treatment modalities, have a better idea of w hat is being done. such as stability related to extraction or An additional notion to support the non-extraction, early treatment and the validity of research in the clinical eld is the e ect of growth modi cation, and so on. fact that many of the fundamental questions For instance, despite ample evidence that are raised not by academicians but by the growth modi cation does not “enhance” patients who will be a ected by the clinical the patient’s growth potential,9,10 conven- techniques. Lay people want to know if a tional appliances such as headgear and/ speci c treatment modality is the best one or functional appliances are still in use,11 possible when they visit the clinic, if there indicating that orthodontists do not aban- is any alternative available, and if they will don treatment strategies that have not been face irreversible consequences if they do supported by scienti c evidence. not undergo the recomm ended treatment Based on the short history of evidence- at the appropriate time; this applies to such based orthodontics, one may raise a radical choices in treatment modalities as extrac- question: Has evidence-based orthodon- tion or non-extraction, one-phase or two- tics been valid in our daily practice? If not, phase treatment, orthognathic surgery or the evidence to support orthodontic prac- camou age, and so forth. tice would no longer have to be sought. Presumably, one may acquire most of However, it must be understood that the the previous information through a lit- evidence-based approach does not provide erature review rather than by conducting imm ediate answers to questions. Instead, research oneself. However, self-ful llment the attitude is necessary for the clinicians cannot be gained solely through a lit- to better understand the clinical e ects of erature review. For instance, one may not each approach or appliance. Attached to acquire certain clinical competencies only the study of McReynolds and Little, Boese’s by reviewing the literature; various types comm entary suggested the multifacto- of hands-on practice in clinical subjects rial nature of post-treatment stability.7 In are a must. Similarly, conducting research fact, a random ized clinical trial of subjects is intended not only to gain scienti c infor- matched for age, degree of crowding, and mation but also to help students enhance other factors might be a solution. Unfor- their critical thinking and produce cre- tunately, appropriately designed studies ative solutions.13 It is therefore better for of human subjects tend to be unethical clinically oriented research to be conducted in essence, which is why evidence-based mainly by postgraduate students than for medicine is often di cult to achieve. In clinical education and research activity to regard to the use of functional appliances, be separate. Huang claim ed that anteroposterior correc- In sum m ary, to answer clinical and tion should be reassessed before having its practical questions, research activities are advocates stop using it.1 indispensable, and it is the academician’s responsibility to nd the best environment 19.1.3 The Main Body of in which to perform such activities. The role of research and the evidence-based Research approach in the orthodontic eld can be summ arized as follows: The current clinical environm ent inevitably includes overwhelming comm ercialism, in 1. Evidence-based medicine or evidence- which an enormous amount of clinical based orthodontics does not readily information is unilaterally given to orth- provide practical answers to clinical odontic practitioners without validation questions. Instead, more adequate 164 Orthodontic Postgraduate Education: A Global Perspective

questioning and reasoning can be achieved through critical appraisal or systematic reviews to nd a clinically valuable answer over time (Fig. 19.1). Over the short history of evidence- based orthodontics, it is even natural that “cookbook” orthodontics has not yet been realized in the clinical eld. Ongoing academic activities are encouraged to nd a better structure for answering clinical questions. 2. The institutions and dental schools o ering professional orthodontic Fig. 19.1 Hierarchy of evidence-based m edicine. training programs can be a good environment for research activities for evidence-based orthodontics. Because some of the best subjects for clinical studies are the patients, bined master’s/PhD degrees,16 in addition orthodontic training programs need to to providing clinical education. Currently, provide a combination of research and there are a total of 31 orthodontic programs, clinical hands-on activities. Currently, including 11 university-based departments, the majority of research outcomes in Korea, producing approximately 45 to 50 are produced in these program s, and specialists every year. To m eet the require- orthodontic residents are involved both ments for the specialty examination, it is in treating patients and in conducting mandatory for students to earn academic various types of research. credit based on presentations at orthodontic conferences or the publication of articles in academic journals. Most of the programs in Korea encourage residents to conduct vari-

19.2 Assessment ous clinical and/or experim ental research to of Dental Education earn their academic degrees. These policies show how much importance each program Programs: Current Status director/organizer ascribes to the orthodontic training course, and indicate that clinical 19.2.1 Research in Dental education to some degree must be com- and Orthodontic Programs bined with research activities.

Although dentistry is regarded as an applied rather than a basic science, some dental 19.2.2 Motivational Factors schools have a mandatory research require- versus Future Plans ment,14 with highly positive attitudes toward the research experience noted among stu- In contrast, the orthodontic residents dents. In another survey, a “passion for considered clinical education, location, orthodontics” was identi ed as the single reputation, length of training, and cost as m ost in uential factor leading to a choice the most important reasons for selecting of orthodontics as a life career, followed by a program, and only 4.6% chose research “intellectual stim ulation and challenge.”15 opportunities as the most important fac- Interestingly, “earning potential” was the tor.17 Moreover, few orthodontic residents least important factor. Related to this, the actually wanted to stay in academia as majority (80%) of the orthodontic programs part of their plan for the future (1.76% in the United States lead to m aster’s or com- opted for full-time research and a teach- 19 The Role of Research in Orthodontic Specialty Education 165 ing career, and 1.76% for further graduate in an orthodontic training course is to be of degree or work in research, in the United value, like the following. States; 4.4% opted for full-time research From bench to clinic: and a teaching career in Canada).11,15 In – Conducting clinically relevant North America, the length of orthodontic research (either clinical or residency programs is gradually extend- experimental) ing from 24 to 36 months, but this trend – Soundly interpreting the outcome of is related to the increased clinical case research load, while the amount of time available – Applying the known rules to for research is decreasing.17 Financial bur- individual cases den was presumed to be another limiting – Verifying the clinical validity of factor keeping residents from wanting a ndings, making suggestions for full-tim e faculty position.15 It may be that further research orthodontic residents were not interested – Proposing / establishing new and/or in research in the rst place, or that some creative treatment protocols based clinical aspects during training a ected on the research outcome them more than the research activity did From clinic to bench: in regard to their choice of a lifetime plan. – Analyzing diagnostic data and A gr ow ing concern is that this overall pat- identifying problems tern may cause an academic crisis after all. – Asking the necessary questions for The discrepancy between motivational appropriate treatment planning factors and future plans needs to be over- – Finding evidence, searching the com e at some point. Noble et al proposed literature, and thinking critically that orthodontic programs must change – Applying known solutions and/ their selection policy to accept candidates or trying creative solutions in with a true passion for research in ortho- individual cases dontics.15 In fact, it is impossible to force – Monitoring carefully, comparing residents to stay in academia if they are not clinical ndings with the evidence w illing to do so. Moreover, it is very hard to

found in the literature anticipate whether a particular candidate – Suggesting new treatment protocols will eventually remain in an academic track and verifying them through research after the completion of a program .

19.3 Role of Research in 19.4 Clinical Application the Clinical Program and Translation

To facilitate research activity and better One of the relevant elds in which the pre- understand the role of research in the orth- ceding system can be applied is orthodontic odontic eld, a smooth transition “from biomechanics. The selection of a treatment bench to clinic” and “from clinic to bench” protocol and appliances presumably depends is essential. Because orthodontics is an on relevant research outcomes. The follow- applied science, conducting clinically rel- ing clinical example may be illustrative. evant research may help clinicians better understand the rationale of clinical trials, better interpret the outcomes, and be bet- 19.4.1 Clinical Application: ter prepared to propose alternative solu- Creative Troubleshooting tions in case of trouble.2 Instructors then must be ready to accept and apply new A description or demonstration of the sig- ndings in individual cases. This mutual ni cance of research activity during an orth- process is essential if a research program odontic training program is beyond the scope 166 Orthodontic Postgraduate Education: A Global Perspective

of this chapter. However, some clinical exam- The initial panoramic radiograph did not ples of the application of creative solutions show any pathological ndings (Fig. 19.4). based on the literature and on evidence may Ce p h a lo m etric analysis revealed a be illustratative. hyperdivergent face and related retrusive The vertical–anteroposterior relation- pro le (Fig. 19.5). To improve the facial ship is well described in the orthodon- pro le and relieve the crowding, e ec- tic literature, but little evidence has been tive growth modi cation com bined with shown so far. In particular, regarding m olar extraction of premolars was necessary. intrusion for vertical correction, it appears Based on the analysis, extraction of that true molar intrusion has not been sub- the four rst premolars was performed, in stantiated because of the lack of soundness combination with the use of a vertical chin in the study.18 Although it is admitted that cup. Interradicular miniscrews were also high-pull headgear provides some verti- used to secure anchorage during retraction cal control during grow th, whether this of the incisors. Intraoral views revealed clinical application gives rise to a clinically some bowing of the arch wire near the end e ective outcome may be another issue. A of the space closure (Fig . 1 9 .6 ). clinical example is hereby presented. What was striking was the lateral pro- le, which still showed severe lip protrusion (Fig. 19.7). According to the cephalometric 19.4.2 Clinical Example superimposition, grow th modi cation with the vertical chin cup did not appear e ec- A 10-year-old girl visited the orthodon- tive, partly because of the backward rota- tic department with lip protrusion and tional grow th of the mandible. This nding, crowding as the chief problems. The initial according to the literature, was not surpris- photographs showed a dolichofacial pat- ing; a review article suggested very little tern, retrusive chin, and lip protrusion with evidence of vertical control during growth signi cant lip incompetency (Fig. 19.2). with the use of conventional appliances.18 The patient was prepubertal and had not Because of the clearly uncertain growth reached menarche. pattern, the treatment was provisionally The initial intraoral views showed m od- discon t in u ed at age 12 (18 m onths of active erate to severe crowding (Fig. 19.3). Based treatment). Growth observation followed on the lateral pro le, extraction of premo- the treatment. The patient and her mother lars was considered unavoidable. wanted further improvement of the pro-

Fig . 1 9 . 2 Initial extraoral views. 19 The Role of Research in Orthodontic Specialty Education 167

Fig. 19.3 Initial intraoral views.

Fig . 1 9 . 4 Initial panoram ic view. 168 Orthodontic Postgraduate Education: A Global Perspective

Fig. 19.5 Cephalom etric analysis at initial visit.

le, which was considered very challenging nated, growth modi cation with ortho- because of the lack of extraction space. pedic appliances was no longer practical.

The patient underwent reassessment Instead of unreliable growth modi ca- at age 15. Interestingly, she had not yet tion, it is noteworthy that miniscrews may reached menarche. The lateral pro le still induce predictable movement of the over- showed protrusive lips (Fig. 19.8). Intraoral all arch within the given alveolar bone. views showed minor anterior crowding and The latest experimental study suggested lack of space, with fair Class I molar rela- a center of resistance of the whole arch tion (Fig. 19.9). A panoramic view showed around the premolar area (Fig. 19.12).19 no signi cant change in the condylar posi- In addition, simultaneous movement of tion and shape (Fig. 19.10). Cephalometric the entire arch was shown to be realistic.20 analysis revealed a constant increase in Based on these ndings, it was presumed the anterior facial height and convex pro- that it would be e ective to combine the le (Fig. 19.11). The situation was nearly normal residual growth with arbitrary the same as at the end of the rst treat- movement of the whole arch, to improve ment. However, it was noteworthy that her pro le. In other words, the maxillary she showed constant growth during her and mandibular arches were restricted active growth phase (between T1 and T2; against the normal forward and downward Table 19.1) without further opening of the growth of the m andible. sella–nasion plane/mandibular plane angle Follow ing leveling and alignm ent, mini- (SNMP) angle (Ta b l e 1 9 . 1 ). screws were inserted in the interradicular The question then was how to improve area, between the second premolar and her pro le further. Obviously, without rst molar. To produce a backward intru- additional extraction of premolars, there sive force vector approximating the cen- were very few solutions. Because it was ter of resistance of the entire arch, a short known that her growth was not termi- occlusal crimpable hook was attached to 19 The Role of Research in Orthodontic Specialty Education 169

Fig. 19.6 Intraoral views at 13 months of treatment.

Fig. 19.7 Extraoral view at 18 months of treatment with cephalometrogram. 170 Orthodontic Postgraduate Education: A Global Perspective

Fig. 19.8 Extraoral views at age 15.

the main arch wire at the distal side of the e ect of backward and upward displace- canine (Fig. 19.13). On the right side, the m ent of the m axillary arch against forward miniscrew was loosened after 3 months, and downward maxillary alveolar grow th,

and the reinsertion was done on the infra- and vice versa in the mandible, lead- zygomatic crest to produce an equivalent ing to pure forward growth of mandible force vector (Fig. 19.13). while the dentition was restricted in place Intrusive retraction was done in both (Fig. 19.20). This can be called four-dimen- the maxillary and the mandibular arches sional total arch movement because the (Fig. 19.14). arbitrary arch displacement was conducted The brackets were removed after w hile grow th took place. 18 months of the second treatment. The occlusion and pro le were main- An appropriate occlusal relationship tained during the next 5 years (Figs. 19.21 and midline coincidence were gained and 19.22). (Fig. 19.15, Fig. 19.16). This case demonstrates how research Co m parison of the pro le views in outcomes can be e ectively integrated and the initial and nal photographs showed reinterpreted to produce a creative solu- remarkable attening of the lateral pro- tion in a challenging situation. A rather new le after treatment. A remarkable change concept, four-dimensional total arch move- was found in the pro le (Fig. 19.17). m ent, was proposed; however, this was just The post-treatment panoramic and a modi cation of known rules and regu- cephalometric views showed accept- lations. This kind of translation between able root parallelism and incisor axes bench and clinic can encourage interest in (Fig. 19.18, Fig. 19.19). various research activities in orthodontic In the cephalometric superimposition, practice. Therefore, it can be concluded that signi cant forward mandibular displace- research in orthodontic programs is indis- m ent was noteworthy. In essence, this was pensable, particularly research in clinically presumed to be the result of the combined relevant areas. 19 The Role of Research in Orthodontic Specialty Education 171

Fig . 1 9 . 9 Intraoral views at age 15.

Fig. 19.10 Panoramic view after observation period (at the beginning of the second treatment). 172 Orthodontic Postgraduate Education: A Global Perspective

Fig. 19.11 Cephalometric analysis at the beginning of the second treatment.

Table 19.1 Cephalometric measurements

T0 T1 T2 T3

(10 y: (12 y: (15 y: (16 y: initial) end of 1st beginning end of 2nd treatment) of 2nd treatment) treatment)

SNA, o 80.9 78.8 77.4 77.2

SNB, o 72.1 72.0 72.1 73.5

ANB, o 8.8 6.8 5.3 3.8

SNMP, o 46.0 47.6 47.7 43.6

Anterior facial height, mm 113.5 124.3 132.9 133.9

U1 to SN, o 102.7 103.0 102.2 104.2

L1 t o MP, o 93.0 91.0 89.7 93.2

ANB, A point–nasion–B point angle; L1, lower incisor; MP, mandibular plane; SNMP, sella–nasion plane/mandibular plane angle; U1, upper incisor; SNA, sella–nasion–A point angle; SNB, sella– nasion–B point angle. 19 The Role of Research in Orthodontic Specialty Education 173

Fig. 19.12 Center of resistance of the entire arch.19

Fig. 19.13 Intraoral views at 6 months during the second treatment. 174 Orthodontic Postgraduate Education: A Global Perspective

Fig. 19.14 Intraoral views at 12 months during the second treatment.

19 The Role of Research in Orthodontic Specialty Education 175

Fig. 19.15 Final intraoral views after the second treatment.

176 Orthodontic Postgraduate Education: A Global Perspective

Fig. 19.16 Final extraoral views after the second treatment.

19 The Role of Research in Orthodontic Specialty Education 177

Fig. 19.17 Comparison of initial and nal lateral pro les (second treatment). 178 Orthodontic Postgraduate Education: A Global Perspective

Fig. 19.18 Panoramic view after the second treatment.

Fig. 19.19 Cephalometric analysis after the second treatment. 19 The Role of Research in Orthodontic Specialty Education 179

Fig. 19.20 Cephalometric superimposition before and after the second treatment.

180 Orthodontic Postgraduate Education: A Global Perspective

Fig. 19.21 Follow-up intraoral views at 5 years after treatment.

Fig. 19.22 Follow-up extraoral views at 5 years after treatment. 19 The Role of Research in Orthodontic Specialty Education 181

References 11. Noble J, Hechter FJ, Karaiskos NE, Lekic N, Wiltshire WA. Future practice plans of 1. Huang GJ. Making the case for evidence- orthodontic residents in the United States. based orthodontics. Am J Orthod Dentofa- Am J Orthod Dentofacial Orthop 2009; cial Orthop 2004;125(4):405–406 135(3):357–360 2. Harrison JE. Evidence-based orthodontics: 12. Kau CH. Orthodontics in the 21st centu- where do I nd the evidence? J Orthod ry: a view from across the pond. J Orthod 2000;27(1):71–78 2012;39(2):75–76 3. Br a m ante MA. Controversies in ortho- 13. Kharbanda OP. Global issues with orth- dontics. Dent Clin North Am 1990;34(1): odontic education: a personal viewpoint. J 91–102 Orthod 2006;33(4):237–240 4. Little RM, Riedel RA, Artun J. An evalu- 14. Nalliah RP, Lee MK, Da Silva JD, Allareddy ation of changes in mandibular anterior V. Impact of a research requirement in alignment from 10 to 20 years postreten- a dental school curriculum. J Dent Educ tion. Am J Orthod Dentofacial Orthop 2014;78(10):1364–1371 1988;93(5):423–428 15. Noble J, Hechter FJ, Karaiskos N, Wiltshire 5. Little RM, Wallen TR, Riedel RA. Stability WA. Motivational factors and future life and relapse of mandibular anterior align- plans of orthodontic residents in the Unit- ment- rst premolar extraction cases treated States. Am J Orthod Dentofacial Orthop ed by traditional edgewise orthodontics. 2010;137(5):623–630 Am J Orthod 1981;80(4):349–365 16. Burk T, Orellana M. Assessment of graduate 6. Lit tle RM, Ried el RA, Engst ED. Serial ext rac- orthodontic programs in North America. J tion of rst premolars—postretention eval- Dent Educ 2013;77(4):463–475 uation of stability and relapse. Angle Orthod 17. Bruner MK, Hilgers KK, Silveira AM, Butters 1990;60(4):255–262 JM. Graduate orthodontic education: the 7. McReynolds DC, Little RM. Mandibular sec- residents’ perspective. Am J Orthod Dento- ond premolar extraction—postretention facial Orthop 2005;128(3):277–282 evaluation of stability and relapse. Angle 18. Ng J, Major PW, Flores-Mir C. True molar in- Orthod 1991;61(2):133–144 trusion attained during orthodontic treat- 8. Harrison JE. Evidence-based orthodon- ment: a systematic review. Am J Orthod

tics—how do I assess the evidence? J Orthod Dentofacial Orthop 2006;130(6):709–714 2000;27(2):189–197 19. Jeong GM, Sung SJ, Lee KJ, Chun YS, Mo SS. 9. Pro t WR, Tulloch JF. Preadolescent Class Finite-elem ent investigation of the center II problem s: treat now or wait? Am J Or- of resistance of the maxillary dentition. Ko- thod Dentofacial Orthop 2002;121(6): rean J Orthod 2009;39(2):83–94 560–562 20. Bechtold TE, Kim JW, Choi TH, Park YC, 10. Tulloch JF, Phillips C, Koch G, Pro t WR. Lee KJ. Distalization pattern of the max- The e ect of early intervention on skeletal illary arch depending on the number of pattern in Class II malocclusion: a random- orthodontic miniscrews. Angle Orthod ized clinical trial. Am J Orthod Dentofacial 2013;83(2):266–273 Orthop 1997;111(4):391–400 Advanced Orthodontic 20 Education: Evolution of Assessment Criteria and Me tho ds to Me e t Future Challenges*

Theodore Eliades and Athanasios E. Athanasiou

In recent years, the achievements of aca- Apart from nancial and educational demic and research institutions, con- purposes, other practical issues may give troversial as it may seem, have been rise to the necessit y for program assessm ent. subjected to ran king by in depen den t orga- For example, the shortage of orthodontic nizations and various electronic m edia. faculty in the United States is expected to This trend has received wide acclam ation reach unprecedented gures during the and evolved to include undergraduate and next decade.3–5 Between the early and late graduate sciences, as well as research insti- 1990s, the number of vacant orthodontic tutes, professional programs, and medical positions tripled,5 and high-ranked spots, specialties. which require academic experience, su er Th e assessm ent of programs directly from understa ng. A recent survey showed

impacts the reputation and academic pro- that the annual incom e of faculty is less than le of schools rated at the top of the list, half that of private practitioners. Faculty thus in uencing their nancial growth.1 also reported working on average 25% more The economic implications of such assess- hours per week, whereas income p e r h ou r for ment may be twofold. First, reputable full-t im e facu lt y is less th an on e-th ird th at of institutions attract more applicants and their colleagues in private practice. In addi- are able to choose from a large pool of stu- tion, faculty perceive that they experience dents. In addition, private and public uni- more stress, encounter more bureaucracy, versities seek to secure funds from many and receive less respect.6 The implication of sources, a signi cant component of which program assessment in regard to the short- is the m oney donated by organizations, the age of faculty is that in the future, reputable public, and industry. These endowm ents programs may become more appealing to may be positively or negatively a ected academically oriented professionals. by the perception of the reputation of an In addition, the establishment of a institution.2 reliable method of assessing orthodontic On a di erent level, the assessment educational institutions may nd applica- process responds to the need to de ne the tion in potential future projects of relevant “gold standard” of education, and to facili- organizations, so that stricter criteria for tate the educational role model in various professional recognition and educational disciplines. equivalency are proposed on a global scale.

182 * This chapter is based on the previously published article “Eliades T, Athanasiou AE. Advanced orthodontic education: Evolution of assessment criteria and methods to meet future challenges. Angle Orthodontist 2005;75:147–154.” 20 Advanced Orthodontic Education 183

20.1 Assessment Bodies 20.2 Professional and Clinical Program In addition to governmental organizations, such as the National Research Council, Assessment rankings in the United States are frequently done by various private sources, several In the health sciences, professional educa- professional societies, and the press.7 One tion is assessed by peer surveys addressed of the best-known rating sources is U.S. to medical school deans, heads of residency News & World Report, which frequently programs, and directors of admissions. publishes rankings for a wide array of insti- These academic and professional experts tutions. The assessment is based on demo- are asked to rate the quality of a specialty graphic data, the reputation of the school, program on a scale of 1 (“marginal”) to 5 and its academic and social environment, (“outstanding”), indicating the quality of presumably to facilitate an inform ed choice both research and primary care programs for prospective applicants. However, the on a single survey instrum ent. incorporation of an ambiguous “reputa- Speci cally, medical school deans and tion” factor in ranking academic institu- senior faculty are asked to identify the 10 tions most often results in the same group schools o ering the best programs in each of established élites dom inating the top specialty area. The 10 programs receiving ranks. Newly established universities have the highest cumulative number of nomi- been underestimated as a result of the rat- nations are included in the report. Input ing of universities based on prestige rather variables of academic quality are m easures than research achievements.2,8 that re ect the quality of factors brought The global trend toward educational to the graduate education process, includ- program assessment and ranking is clearly ing academic preparation of the entering evidenced by the ranking of the top 500 class, faculty-to-student ratio, and level of academic institutions chosen from a pool of research funding. The deans, directors, and 2,000 universities from all over the world. “experts” who are chosen to assess these areas are individuals in academ ia and prac-

These universities were assessed based on the following criteria (http://www.shanghai- titioners in each profession.2 ranking.com/aboutarwu.html): number of The method described is not objective Nobel laureates in physics, chemistry, medi- and incorporates a high degree of error for cine, and economics (weight 20%); num- the following reasons: ber of highly cited researchers in 21 broad 1. The selection of the responders is subject categories (weight 20%); number biased, and with the exception of of articles published in the journals Nature academic faculties, the experts and and Science (weight 20%); number of arti- practicing professionals are chosen cles in the Science Citation Index Expanded based on a subjectively de ned and Social Sciences Citation Index (weight “reputation” factor. Also, the criteria 20%); and academic performance per faculty that the experts use in nominating a (weight 20%). program may vary according to the On a di erent level, the European Acad- general economic climate, degree emy of Pediatric Dentistry has formulated of nancial stability, and the rater’s accreditation guidelines and requirements personality, social status, and personal that include academic, clinical, and research wealth. components of specialty education (http:// 2. The rates of response to the research www.eapd.gr/E06C0EEF.en.aspx). survey in the form of questionnaire range from 35% for faculty to 25% for 184 Orthodontic Postgraduate Education: A Global Perspective

primary care centers and 56% for deans 20.3 Development of (ww w.usnews.com). Such low response rates preclude the extrapolation of data Crite ria fo r the Asse ssme nt to achieve a reliable consensus on the of Orthodontic ranking of programs. Actually, if this survey were to be reviewed as a clinical Postgraduate Programs study, the project would be rejected The delirious pace of technologic advance- because of the low response rates. ments, coupled with the highly competitive 3. The responders’ subjectivity in and demanding environment in which the proposing centers of excellence may orthodontists of the next decade will prac- distort the reliability of the ranking tice, necessitates a continuous evolution outcomes. The output of the raters is of advanced educational programs. The temporary and may be valid only for authors of this article propose a criteria- the speci c period of questionnaire driven assessment method that incorpo- submission. A person’s impression rates six parameters and assigns a weight of a speci c educational program factor to each of these basic components largely depends on various factual of orthodontic education, thus providing and personality-related variables. a template for clarifying the standing of Th ese m ay include temporal variations programs. or occasional “bursts” of reputation The components of orthodontic educa- associated w ith the publication of tion, along with the potential weight factor an impressive study or a discovery for each one, are presented in Table 20.1. of signi cant m erit. Recent personal Although the actual importance of each acquaintance of the responder with component may be judged subjectively, it a prominent faculty member or can be postulated that academic education attendance at an impressive lecture or conference may also in uence output. 4. The fact that the responders are persons at the top of the academ ic hierarchy

does not necessarily imply that they Table 20.1 Components of advanced are knowledgeable about the standing orthodontic education and their of each specialty departm ent. If one potential importance in determining the considers the enormous expansion in the number of graduate programs and educational pro le of a program the strictly administrative role of deans, Component Weight* it follows that these people have little or no exposure to developments in Facilities 0.05 research. Thus, their opinions should be viewed with caution. Clinical training 0.30 5. The use of weight or signi cance Academic education and 0.30 factors in various ranking reports organization is arbitrary and can be m isleading because schools that have a strong Re s e a rc h 0.25 ranking in components with a low weight factor m ay on average score Teaching 0.05 less than institutions that have a m edium ranking in com ponents w ith a General 0.05 high weight factor. The assignm ent of * The weight factor illustrates the relative speci c weight factors to the various signi cance of each component included in components is subjective, with no the assessment as viewed by the authors of criteria supporting the range of high- this chapter. Thus, the assignment of weight and low-impact parameters. variances is subjective. 20 Advanced Orthodontic Education 185 and clinical training m ay be of high impact 20.3.2 Clinical Training relative to the other components. It can also be argued that the arbitrary assign- The constituents of the “clinical training” ment of values to the various components component of advanced orthodontic edu- of the appraisal will elicit some di erences cation are the following: of opinion among educators and clinicians. However, it was felt that the need • Hours devoted to clinic and to start from somewhere might prevail clinical seminars weekly; variety over the necessity for objectivity in de n- of m alocclusions, treatment ing the exact weight of each component. m odalities, and dental ages of The components may include the facilities patients; quality of treatment of the program, the exposure of students outcome (American Board of to teaching, and general data pertinent to Orthodontics discrepancy index) the clinical and scienti c recognition of its • Variety of treatment techniques graduates. In the following sections, the (inclusion of various appliances, educational components of the orthodontic utilities, and treatment auxiliaries) programs are analyzed. • Ratio of full-/part-time clinical faculty per resident • Variety of m alocclusions treated 20.3.1 Facilities • Adjunctive treatment (temporomandibular joint disorders, The constituents of the “facilities” compo- orthognathic surgery, clefts, and nent of advanced orthodontic education craniofacial anomalies) are the following: • Multidisciplinary therapy (pedodontics, periodontics, • Library, computers, and journals prosthodontics, impants) (hard copies and electronic) • Incorporation of new developments • Clinic setup (open bay chair (materials, techniques) arrangement), availability of The clinical training component is ana- photographic and X-ray facilities • Num ber of chair-side assistants per lyzed to its constituents in the preceding resident list. This section is the most controversial • Secretarial support because a quantitative assessment does not • Access to computers and patients’ alw ays corresp on d to th e qu alit y of t rain ing records in the clinic provided. In the assessment of this component, the number and variety of malocclu- Analysis of the facilities component sions treated, the number of hours devoted implies that a high degree of importance to clinic and clinical sem inars, and the vari- is attributed to the clinic arrangement and ety of malocclusions, treatment modalities, access to photographic and X-ray facilities, and dental ages of patients are considered as well as the number of chair-side assis- the key parameters in the program assess- tants per resident. If time-consuming and ment. On the other hand, extensive patient trivial procedures (e.g., cement mixing, assignment may serve institutional nan- preparation of brackets for bonding) are cial needs, and thus a ratio of the time avoided, a more e cient management of spen t in th e clin ic to th at devoted to clin ical patients’ needs may be achieved. Although seminars may more reliably represent the the hiring of auxiliary personnel requires clinical direction of the program. that funds be directed to a non-academi- Em phasis should be placed on the qual- cally related area, the long-term bene ts of ity of the results of orthodontic treatment e ciently organizing the clinical training by implementing the use of appropriate of residents and their clinical experience, indices (e.g., peer assessment rating [PAR]; potentially generating a higher earning index of complexity, outcome, and need capacity, may outweigh this cost. [ICON]; American Board of Orthodontics 186 Orthodontic Postgraduate Education: A Global Perspective

objective grading system). The qualita- Emphasis is placed on the organiza- tive assessment of occlusal improvements tion of seminars on current literature and as a result of orthodontic treatment may topics (including subjects in the associated constitute a feedback for students and elds of biomedicine and statistics, which instructors. A model proposed to familiar- are essential for a solid background in the ize residents with the actual conditions sciences) and on the format of assessm ents and environment of practice, including (e.g., exam inations, term papers).11 Con- managerial and nancial components, was temporary orthodontic research involves originally introduced by Dr. Robert Isaac- the extensive use of advanced instrumental son at the University of Minnesota in the analyses (biomaterials, biomechanics) and mid-1960s.9,10 This plan involved exten- requires the design of epidemiologic stud- sive auxiliary help, in the form of a model ies (clinical research) and complex assays group practice consisting of a junior resi- (biological research). Therefore, an acquain- dent, a senior resident, and an assistant. tance of students with the fundamentals of At the time of its introduction, this scheme research techniques in various disciplines consistently generated the highest income is critical for their understanding of the relative to that of orthodontic programs literature, which has long since undergone operating under conventional rules. Gradu- transformation from the standard and sim- ally, th e in creased role of assist an ts becam e plistic essays of the case report type. a recognized necessity, and in a way, the principles of the training philosophy of this program have spread throughout the cur- 20.3.4 Research rent structure of graduate training in the United States. Apart from the exchange of The research component of advanced orth- clinical experiences, this concept exposes odontic education is analyzed as follows: future clinicians to aspects of practice that • Requirement for a research paper are not usually taught on a practical level. or thesis (some programs may These include the e ective handling of not enroll students in graduate organizational aspects of practice, such as

school but require the submission logistics of materials and utilities, but most of a paper that can be published; importantly, the system provides expo- m ost lead to a certi cate/m aster of sure to the fundamentals of managing the science (MS) degree; som e include a nances of clinical orthodontics. specialty/doctoral (PhD) direction) • Research facilities (school or 20.3.3 Academic Education campus) • Laboratory rotations, courses on and Organization research techniques • Public (i.e., federal or state) and The important aspects of academic educa- private (corporate) funding to tion and organization are summ arized as facult y follows: • Index of annual publications • Syllabuses, handouts, and relevant per faculty member, number of structured materials citations, faculty impact factor index • Adjunctive courses (biomedical and In the assessment of the research com- engineering sciences, statistics) ponent of programs, the main emphasis is • Organization of specialty sem inars placed on the research activity and creden- (structure, topics, examinations) t ia ls o f t h e fa cu lt y, a s t h e s e a r e in st r u m ental • Literature readings: seminars and in providing the appropriate environment journal club for fruitful research. • Continuing education, invited Traditionally, advanced dental pro- lectures grams have been structured around a diar- 20 Advanced Orthodontic Education 187 chic rule, specifying a research or a clinical has not yet experienced a striking change character. However, it must be noted that from this almost decade-long program. It separating specialty education from a has been proposed that the discrepancy research constituent may be detrimen- m ay be associated w it h t h e st r u ct u re of t h e tal to the e ciency of education. This is academic system.13 Because faculty activ- because the absence of any research com- ity is assessed by criteria used in the asso- ponent from advanced dental curricula ciated biomedical elds, researchers strive leads to a situation in which the graduate to have their work published in periodicals is unaware of the limitations of methodo- with a high impact factor. However, this logic approaches to research, and so accepts preference excludes all orthodontic jour- the results of studies indiscriminately and nals, which are characterized by either a endorses unsubstantiated claims inertly. In low impact factor14 or no impact factor the era of evidence-based health science at all. Therefore, papers on orthodontic practice, this may have devastating conse- topics increasingly appear in the Journal quences for both treatment providers and of Biomechanics, the Journal of Biomedi- patients. cal Materials Research, Im m unology, the Research in orthodontics possesses Journal of Anatomy, Bone, and The Journal some distinctive characteristics. A large of Biological Chemistry, am ong others,15 number of the research articles that appear and the orthodontic comm unity does not in orthodontic journals correspond to stu- bene t from the knowledge published in dents’ projects submitted in ful llment of the broader biomedical literature. To over- the requirement for graduation. Although come this discrepancy, it is proposed that a this may increase the productivity of group of quali ed orthodontic researchers departments and contribute to the distri- review the articles of orthodontic interest bution of information to the profession, published in associated disciplines and list the fact that residents usually use applied the issues of interest in a special column in protocols, coupled with a lack of training in orthodontic periodicals. research techniques, may adversely a ect An additional explanation for the afore- the caliber of the research perform ed.12 mentioned lack of in uence of research in To deal with this de ciency, the the orthodontic comm unity may be that National Institute of Dental and Craniofa- during the early stages of the DSA program , cial Research (formerly the National Insti- fellows most frequently were supervised t u t e of Den t al Research ) in it iate d a p rogram by non-orthodontic faculty. This occurred to encourage basic research in the dental because by the late 1980s, most orthodon- sciences. Thus, the dentist scientist award tic programs in the United States were (DSA) program was implemented with the sta ed by MS-level or recently graduated, objective of attracting individuals seeking junior PhD faculty, who could not obtain combined specialty/PhD training. Research the required status from graduate schools e orts by junior faculty were also assisted to serve as advisors to doctoral candi- by the new ly introduced young invest igator dates. (It may be worth noting that only award. Along with federal funding, institu- recently has the requirement for prospec- tional and organizational grants, such as tive faculty to possess a terminal academic the American Association of Orthodontists degree become frequent in advertisements Foundation faculty development award, for vacant orthodontic faculty positions.) were designed to provide support to junior Therefore, students enrolled in a specialty/ orthodontic researchers. Ph D p rogr a m w e re a ssign e d t o b a sic scie n ce Nonetheless, concern has been or senior dental faculty who ran their own expressed regarding the impact of these research programs in the broader biom edi- projects on contemporary practice.13 cal eld. This tactic did not always ensure Alth ough it is t ru e th at w ide-scale research that the candidate’s thesis would focus on programs may not directly generate clini- an orthodontic topic. As a result, a large cally applicable evidence, the specialty portion of doctoral research performed by 188 Orthodontic Postgraduate Education: A Global Perspective

orthodontists did not directly contribute high ratio of applicants to residents and a to the advancement of the research status high percentage of graduates succeeding of the specialty. Considering that the topic in examinations (certi cation, orthodon- of doctoral research usually determines tic boards, specialty, fellowships, etc.) or the area of a future scientist’s interest, it is entering academics. The constituents of clear why the specialty has not witnessed the “general” component of advanced orth- the fruits of the funded e orts of some odontic education are listed below: of its members during past years. This is • Percentage of graduates succeeding expected to change drastically in the next in Board examinations decade as more orthodontists enter doc- • Num ber of graduates entering toral degree curricula. academics The foregoing issues have provoked a • Ratio of the num ber of applicants to swing of the pendulum too far to the other class size side and led to the proposition that orthodontic education, to avoid the academic implications, should return to preceptor programs, which were comm o n at t h e d aw n 20.4 Implementation of of our specialty.13 It should be stressed that this arrangement would be disastrous for Crite ria: Accre ditatio n the advancement of the clinical and aca- and Self-assessment demic status of orthodontics. The components of the educational programs, discussed in the preceding sections, 20.3.5 Teaching generate a requirement for the formation of bodies of experts to design, direct, and Many programs assign undergraduate assess the implementation of criteria; nat- teaching and clinical supervision to resi- urally, these will correspond to the char- dents, and some also include sem inars con- acteristics, requirements, and priorities of ducted by senior students for the entering speci c countries or regions. This process

class. The constituents of the “teaching” should also re ect the di erent concepts component of advanced orthodontic edu- of orthodontic education. Nonetheless, the cation are listed below: accreditation processes followed in m any • Undergraduate teaching and countries present some fundamental simi- supervision of pre-doctoral clinic larities, which involve review of curricula, • Postgraduate teaching (seminars to visits to facilities, and interviews with fac- entering class) ulty, other sta , and graduate students. Therefore, the experience of this body of The experience gained from this activ- experts in clinical education and research ity may be of value later on for both aca- is of critical importance to reveal the actual demically and clinically oriented graduates. st a n d in g of e a ch p rogr a m , eva lu at e t h e e d u - The latter group may bene t because apart cation provided, and highlight the compo- from the presentations to peers, experience nents requiring improvement or revision. in teaching may assist them in e ciently Th e m ain methods followed for program structuring future lectures to comm unity assessment are described schematically in or professional organizations. Fig. 20.1. In the United States and Canada, a “central” approach is followed, in the sense that a comm ittee reviews the implem enta- 20.3.6 General Considerations tion of a set of criteria widely recognized to be representative of the education pro- Lastly, the overall reputation of a program vided. This method relies on the assump- and its role in educating leaders for the tion that if the individual components (e.g., future may be empirically assessed by a program design, facilities) are present in 20 Advanced Orthodontic Education 189

Fig. 20.1 Schematic description of the assessment of orthodontic programs used by various accreditation bodies and licensure agent s in di erent countries. The central approach assum es that strict adherence to a set of criteria ensures the level of education provided, whereas an alternative method ensures that the product of the educational program is equipped to function as a treatm ent provider on an individual basis. A merge of these two approaches may substantially enhance the assessment of programs and graduates and serve as a guide to keep specialty programs abreast of the challenges in contemporary orthodontics.

the right proportions, the product will be on a larger scale, it may serve as an indian e cient program that will “produce” a rect means of revealing the e ectiveness of competent graduate. Alternatively, many speci c curricula in advanced orthodontic licensing bodies in Europe apply a com - programs. bined approach. In addition to compliance In conclusion, the evolution of assess- with criteria for curricula (e.g., Erasmus ment criteria and methods for advanced program guidelines11), an examination of orthodontic education may be an absolute the graduate is integrated as a direct means necessity in the coming years. Such assess- to assess the competency of the treatment ment may be required to recognize the provider, regardless of the reputation and components of excellent academic perfor- overall standing of the program in which mance and clinical training, as well as to he or she has received advanced train- implement strict criteria for professional ing. Although this method was not imple- recognition and educational equivalency m en ted to assess t h e ed u cat ion p rovid ed by among countries and individuals. The pur- programs, instead being intended to evalu- pose of this chapter has been to provide a ate the competency of individuals, it pres- stimulus for relevant discussion within the ents two main advantages. First, it ensures orthodontic comm unity, as many coun- a minimum standard in the provision of tries and organizations are in the process orthodontic services by directly examin- of establishing, improving, or coordinating ing the quali cations of graduates. Second, their standards of orthodontic education. 190 Orthodontic Postgraduate Education: A Global Perspective

Additional steps, such as the incorporation 7. National Research Council. Research Doc- of elements of both approaches (i.e., pro- torate Programs in the United States: Con- gram assessment and individual examina- tinuity and Change. Washington, DC: The tion) may contribute to the achievement of National Academ ies Press; 1995 this objective.16 8. Graham DH, Diamond N. The Rise of Am erican Research Universities. Baltimore, MD: Johns Hopkins University Press; 1997 References 9. Isaacson RJ. Orthodontic faculty—a modest proposal. Angle Orthod 2000;70:4 1. Cr a ig DD. TheCenter top American research 10. Isaacson RJ. Ethics and economics. Angle universities: an overview. TheCenter Re- Orthod 2002;72(3):iv ports, January 2002. mup.asu.edu/TA- 11. van der Linden FP. Three years postgradu- RUChina.pdf. Accessed March 24, 2015 ate programm e in orthodontics: the nal 2. Graham DH. Should we abolish ranking uni- report of the Erasmus Project. Eur J Orthod versities by their reputations? http://ww w. 1992;14(2):85–94 vanderbilt.edu/News/register/Jun5_00/sto- 12. Burstone CJ. Interview. Hel Orthod Rev ry12.html. Accessed March 24, 2015 1998;2:99–117 3. Tuncay OC. The American perspective: or- 13. White L. A historic timeline. http://orthocj. thodontics - the rst specialty of dentistry com/2001/06/an-historical-time-line is at risk to be the rst to disappear. Clin Or- thod Res 2002;4:3 14. Eliades T, Athanasiou AE. Impact factor. A review with speci c relevance to orthodon- 4. Tuncay OC. American perspective - part II. tic journals. J Orofac Orthop 2001;62(1): Strategies for the survival of the species. 74–83 Clin Orthod Res 2001;4(2):63–64 15. Mavropoulos A, Kiliaridis S. Orthodontic 5. Am erican Dental Education Association literature: an overview of the last 2 de- Council. 2002 Section Annual Report. cades. Am J Orthod Dentofacial Orthop http://www.adea.org/sections/Orthodon- 2003;124(1):30–40 tics/Report. Accessed 2004 16. DeKock WH, Athanasiou AE, Kuroda T. A 6. Lindauer SJ, Peck SL, Tufekci E, Co ey T, Best WFO-commisioned study provides data on AM. The crisis in orthodontic education: the specialty’s current characteristics and

goals and perceptions. Am J Orthod Dento- standards throughout the world. WFO Ga- facial Orthop 2003;124(5):480–487 zette 2000;1:4 Appendix

The Erasmus Programme for Postgraduate Education in Orthodontics in Europe: An Update of the Guidelines*

J. Huggare R. Martina Departm ent of Dental Medicine, Scienze Odontostomatologiche Karolinska Institutet, Huddinge, Sweden Università di Napoli Federico II, Italy

K.A. Derringer P. Pirttiniem i Departm ent of Orthodontics, Oral Development and Orthodontics, King’s College London Dental Institute, UK Institute of Dentistry, University of Oulu, Fin la n d T. Eliades

Orthodontic and Paediatric Dentistry Clinics, S. Ruf University of Zurich, Switzerland Orthodontics, Justus-Liebig University, Giessen, Germ any M.P. Filleul Departm ent of Orthodontics, R. Schwestka-Polly University Henri Poincaré of Nancy, France Departm ent of Orthodontics, Hannover Medical School, Germany S. Kiliaridis Departm ent of Orthodontics, University of Correspondence to: Geneva Dental School, Switzerland Jan Huggare P.O. Box 4064 A. Kuijpers-Jagtm an Alfred Nobels Allé 8 Orthodontics and Craniofacial Biology, SE-14104 Huddinge, Sweden Radboud University Nijmegen Medical Centre, The Netherlands

*This article was originally published in The European Journal of Orthodontics by Oxford Univer- 191 sity Press. Eur J Orthod (2014) 36 (3): 340–349. © The Author 2013. 192 Orthodontic Postgraduate Education: A Global Perspective

‘Three year Postgraduate Programm e in Summary Orthodontics: the Final Report of the Erasmus Project’ (van der Linden, 1992). In 1989, th e ERASMUS Bureau of th e European The next two decades the orthodontic Cultural Foundation of the Comm ission of the profession has undergone substantial changes European Comm unities funded the develop- with regard to education. New diagnostic ment of a new 3-year curriculum for post- tools, materials, and clinical advancements as graduate education in orthodontics. The new well as broadened interdisciplinary dem ands curriculum was created by directors for orth- should be re ected in new recomm enda- odontic education representing 15 European tions for the specialty training. Therefore, countries. The curriculum entitled ‘Three years at the general meeting of NEBEOP 2010 in Postgraduate Programm e in Orthodontics: the Portorož, Slovenia, a Task Force was installed Final Report of the Erasmus Project’ was pub- with Professor JH (Sweden) as the coordina- lished 1992. In 2012, the ‘Network of Erasm us tor to make proposals for an update of the Based European Orthodontic Programm es’ Erasm us programm e. The comm ission was to developed and approved an updated version of update ‘Objectives of compulsory elements of the guidelines. The core programm e co n sist s o f theoretical education of orthodontists’, deal- eight sections: general biological and medical ing with obligatory courses for education of subjects; basic orthodontic subjects; general orthodontists. After presenting the proposal to orthodontic subjects; orthodontic techniques; the Council of NEBEOP where further amend- interdisciplinary subjects; m anagement of m ents were m ade, the revision was presented health and safety; practice management, to the general assembly of NEBEOP 2011 in administration, and ethics; extramural edu- Istanbul (Turkey) and was nally approved by cational activities. The programm e goals and NEBEOP assembly 2012 at the m eeting held in objectives are described and the competen- Santiago de Compostela (Spain). cies to be reached are outlined. These guide- It should be noted that the revision should lines m ay serve as a baseline for programm e be considered as guidelines, not as rules, as development and quality assessment for post- NEBEOP is n ot a le gal au t h or it y, w h ich can ove r- graduate programm e directors, national asso- ride the regulations and recomm endations of ciations, and governmental bodies and could the national boards in each country. The main assist future residents when selecting a post-

objectives of the programm e, general and spe- graduate programm e. ci c conditions, and the distribution of hours remain largely unchanged as compared with the 1992 version of the programm e (van der Introduction Linden, 1992) and have only been adapted to be in agreement with the updated and revised The ‘Network of Erasmus Based European content of 2012. A new section has been added Orthodontic Programm es’ (NEBEOP) was about com petency levels to be reached. The full fou n ded in 2009. It com prises a group of orth - guidelines for postgraduate education in ortho- odontic postgraduate training programm es in dontics in Europe are presented below. Europe represented by programm e directors or orthodontists assigned by institutes, which deliver a structured programm e in orthodon- Programme objectives tics. The primary concern of the Network is education, speci c to the specialty of ortho- The general objective of the programm e is dontics, and the main purpose is the advance- to educate dentists to become specialists in ment of orthodontic postgraduate training in orthodontics with a solid and broad academic Europe. In 1989, the ERASMUS Bureau of the background and adequate clinical experience European Cultural Foundation of the Comm is- in di erent treatment methods. Upon com- sion of th e Eu rop ean Com m unities funded the pletion of the programm e, the graduate must development of a new 3-year curriculum for be able to: postgraduate education in orthodontics. The curriculum was created by directors for orth- 1. Diagnose anomalies of the dentition, odontic education representing 15 European facial structures, and functional countries. It was published in 1992, entitled conditions Appendix The Erasmus Programme for Postgraduate Education in Orthodontics 193

2. Detect deviations of the developm ent 6. Speci cation of the minim al number of the dentition, facial grow th, and of hours is provided for the obligatory functional conditions courses, but is not indicated in detail for 3. For m ulate a treatment plan and predict the preclinical and clinical activities its course 7. The core programm e requires 75 4. Evaluate psychological aspects relevant percent of the available time and to orthodontics must be supplemented by additional 5. Conduct interceptive orthodontic activities (electives) procedure 8. Th e m inimal number of clinical 6. Execu te t reat m ent for all t ypes of treatment hours is 16 hours per week malocclusions (not including clinical seminars and 7. Collaborate in the interdisciplinary discussion of treatment plans). The treatment of m edically and dentally minimal number of hours over the compromised patients, patients with 3-year period devoted to clinical syndromes and craniofacial anomalies, practice (including preclinical course including orthognathic surgery care and works) is 2000 craniomandibular disorders (CMDs) 9. Each resident must start a minim um of 8. Assess the need for orthodontic 50 well-documented patient cases treatment on individual and societal 10. Residents must treat patients under levels continuous supervision of quali ed 9. Practice orthodontics according to orthodontists professional and ethical standards 11. The clinical sta –student ratio in 10. Comprehensively review, understand, supervising treatment must be a and evaluate the literature pertinent m axim um of eight residents per to orthodontics in a wide array of supervisor disciplines relevant to the specialty 12. Dental laboratory work should be 11. For m ulate a research hypothesis, design limited to learning experiences a methodological study, conduct the 13. Teaching of undergraduate students can research, and present the ndings be part of the program m e, but not for 12. Use available opportunities for m ore than 10 percent of the tim e

improving professional skills and 14. Residents must conduct a research lifelong learning project leading to a publication or a congress presentation 15. Results of research and other activities undertaken in the postgraduate General conditions programm e can be used without limitation as partial ful lment of 1. The education of orthodontists must requirements for an advance degree take place within universities or 16. All theoretical courses m ust be institutions with academic a liation concluded with an assessment of the under responsibility of appointed acquired understanding and knowledge academic teachers in orthodontics 17. At the end of the program m e, there 2. The basic objective of the programm e m ust be a nal exam ination by a is to educate clinicians; additional comm ittee including at least one education is needed for those who external examiner also want to become a teacher and/or 18. Part of the nal exam ination is the researcher presentation of 10 fully documented 3. Can d id at es m ust be registered as a cases, representing di erent dentist in the country where the degree malocclusions and treatment was obtained or in which the candidate procedures, started and completed by is presently practicing the resident 4. The programm e requires fulltim e attendance of the residents 5. Residents should receive a stipend for living expenses 194 Orthodontic Postgraduate Education: A Global Perspective

7. Research opportunities, methodological Speci c conditions support, and statistical guidance must be available 1. The director of the programm e must be: • Registered as a specialist in orthodontics for at least 5 years • Actively practicing the specialt y • Appointed for at least 80 percent of Distribution of hours the working week 2. Besides the director, the equivalent The academic programm e is based on a m ini- of one fulltime position for an m um of 40 weeks a year and 40 hours a week, orthodontist must be present. When w h ich tot als 4800 sch e d u led h ou rs for 3 years. more than a total of four residents are In ad d it ion , st u d e n t s are requ ire d to p u t in present, additional orthodontic sta are a considerable number of hours of their own required tim e for studying. For exam ple, for every class 3. Adequate library, laboratory, clinical, hour on academic subjects, on an average of 2 research, and administrative facilities must hours studying time are required. be available 4. Su cient non-academic sta must be available to realize an e cient conduct of the program m e and patient care Objectives of compulsory 5. An established connection with centres elements of theoretical for oral and maxillofacial surgery, periodontology, and restorative education of orthodontists dentistry is required 6. Su cient expertise must be available to The hours indicated in parentheses in the fol- realize the objectives of the theoretical lowing sections are the minimum number of courses hours necessary for the average student to devote to the subject in order to achieve the

Assignment of the 4800 scheduled hours

St a f /student contact activities Clinical (and preclinical) practical work 2000 h Pretreatment clinical conferences 230 h Seminars on treatment evaluation 100 h Lectures, seminars, workshops on obligatory academic courses 455 h Lectures, seminars, workshops on elective theoretical subjects 150 h Sta /student contact time outside regular classes for individual 115 h consultations, research guidance, manuscript preparation, etc. 3050 h

Non sta f /student contact activities Analysis of records of patients to be treated 120 h Undergraduate teaching, including preparation time 480 h Re s e a r c h 100 h Elective act ivit ies (including addit ional t im e for research) 1050 h 1750 h Appendix The Erasmus Programme for Postgraduate Education in Orthodontics 195 required level of knowledge equivalent to ‘be 4. Concept of biological age, skeletal fam iliar wit h’ an d ‘h ave kn ow ledge of’ accord- age, dental age, and stages of sexual ing to the Association for Dental Education development in Europe (Cowpe et al., 2009). The number 5. Endocrine-related problems in growth of hours devoted to each of the subjects are and development shown in Ta b l e 1 . In addition, the students 6. Allergies related to orthodontics are required to achieve a level of competency 7. Eating and weight issues in children and in the subjects indicated in ‘Essential com - adolescents petency levels for postgraduate education in 8. Blood diseases including leukaemia orthodontics’. The term ‘competent to’ means 9. Diabetes that students should have a sound theoretical 10. De cits in attention, motor control, and knowledge and understanding of the subject perception together with adequate clinical experience to 11. Non-accidental injury in children be able to independently resolve clinical challenges encountered. The number of hours to Anatom y and em bryology of craniofacial struc- reach these competencies is not prede ned. tures (40 hours). Knowledge of embryology of At least one-third of the theoretical edu- craniofacial structures for understanding of: cation hours must be spent in sta –student 1. Norm al growth and developm ent of the contact activities (lectures, seminars, work- face, jaws, and teeth shops, etc.). 2. Teratogenesis 3. Developm ent of clefts and other facial congenital malformations General biological and medical 4. Grow th of the craniofacial skeleton subjects (310 hours) 5. Developm ent of skeletal deform ities 6. Orthognathic surgical correction Paediatrics (20 hours). Knowledge of the of facial dysm orphologies and implications of the following to orthodontics: malocclusions 1. Som atic growth and its variations 2. Ad o le s ce n t g r ow th spurt and Genetics (25 hours). Knowledge of genetic its relationship to grow th of the principles essential for comprehension of: craniofacial complex 1. Norm al development of the craniofacial 3. Genetic and environmental factors that complex in uence somatic growth 2. Craniofacial malformations

Ta b l e 1 Subjects and number of hours in ‘Objectives of compulsory elements of theoretical education of orthodontists’.

Part Name Number of hours A General biological and m edical subject s 310 B Basic orthodontic subjects 325 C General orthodontic subjects 340 D Orthodontic techniques 195 E Interdisciplinary treatment procedures 125 F Management of health and safety 25 G Practice management, administration, and ethics 45 H Extramural educational activities Elective Total theoretical hours 1365 The contents of the programme can be restructured to large modules for which each university may approve European Credit Transfer (ECT) credits. 196 Orthodontic Postgraduate Education: A Global Perspective

3. Pre- and postnatal diagnosis of ENT and speech (20 hours). Knowledge of basic craniofacial anomalies principles of normal function and ENT-patho- 4. Genetic counselling physiology related to orthodontics and/or cra- 5. Molecular genetic methods niofacial grow th: 1. Of the nose and para-nasal sinuses Cell a n d m olecular biology, imm unology, and 2. Of the pharynx, epipharynx, and larynx microbiology (30 hours). Knowledge of cyto- 3. Exter n al, m iddle, and inner ear logical, histochem ical, and m icrobiological 4. Norm al and compromised nasal principles essential for the understanding of: breathing 1. Cell metabolism under normal and 5. Sleep disorders, particularly snoring abnormal conditions and obstructive sleep apnoea (OSA) 2. Tissu e for m ation and proliferation 6. Diagnostic tools for sleep disorders and 3. Developm ent of bone, cartilage, teeth, how to interpret the results and muscle 7. Norm al and abnormal speech 4. Bo n e gr ow th 8. Velopharyngeal function 5. Tooth eruption, movements and reactions in tooth supporting tissues Craniofacial syndrom es (20 hours). Know l- 6. Soft tissue changes related to edge of the most comm on types of orofacial orthodontics clefts, craniofacial anomalies, and syndromes 7. Mechanisms of root resorption in which the head is involved with respect to: 8. Bio lms 1. Aetiology 2. Classi cation Oral pathology and medicine (20 hours). 3. E ect on craniofacial grow th Knowledge of the most comm on oral patho- 4. Psychosocial development logic conditions and their im pact on the orthodontic treatment: Psychology of the child, adolescent, and adult 1. Oral cancer and pre-cancer (35 hours). Knowledge of concepts and prin- 2. Oral m anifestations in ciples of developm ental psychology essential imm unocompromised patients for the understanding of: 3. Oral m anifestation of diseases 1. Patient m otivation and assessment of 4. Oral ulceration co-operation 5. Oral candidosis 2. Psychological aspects of puberty and 6. Periodontal manifestations of systemic adolescence diseases 3. Psychosocial impact of dental and facial 7. Salivary gland diseases appearance 8. Facial trauma 4. Psychological aspects of orthognathic 9. Head and neck tumour treatment 5. Developm ent of cognition, language and Ph arm acology (10 hours). Knowledge of phar- comm unication macological agents with relevance to orthodontic treatment: Knowledge of concepts of psychopathol- 1. Antibiotics, antiviral and antifungal ogy and mental disorders essential for the agents understanding of their impact on orthodontic 2. Prostaglandin inhibitors treatment: 3. Non-steroidal anti-in am m atory drugs 1. Delayed learning, dyslexia 4. Calcium regulators (parathyroid 2. Eating disorders, anorexia nervosa, hormone, thyroid hormones, estrogens, psychiatric disorders bisphosphonates) 3. Attention-de cit/hyperactivity and 5. Anti-epileptics other behavioural disorders 6. Im m unosuppressive agents 4. Autistic spectrum disorders 7. Grow th hormone substitutes 5. Conduct disorders, oppositional de ant 8. Psychiatric drugs and tranquillizers disorders, self-harming behavior 9. Agents a ecting salivation 6. Suicidal thoughts and attempts Appendix The Erasmus Programme for Postgraduate Education in Orthodontics 197

Research m ethodology and biostatistics (90 3. Norm al and abnormal behavior of soft hours). Knowledge of general principles, tissue structures theory and practice or research designs, and 4. Norm al and abnormal function of the com m only used statistical methods in: temporomandibular joint 1. Diagnostic studies 2. Intervention and experimental studies Aspects of tooth movements and dentofacial 3. Aetiological research orthopaedics (35 hours). Knowledge of: 4. Epidemiologic surveys 1. The process of tooth eruption and 5. Sys t e m atic reviews and meta-analyses spontaneous tooth movement 2. Biological response to di erent types of Knowledge of: force application 1. Philosophy of science 3. In uence of force systems and force 2. Ethical and legal aspects in research magnitude involving animals and humans 4. Post-treatment changes 3. Scienti c integrity 4. Scienti c misconduct 5. Evidence-based decision making Oral and maxillofacial radiology and other im aging techniques (30 hours). Knowledge of: 1. Ab n or m alities and pathological Basic orthodontic subjects (325 hours) conditions that can be diagnosed on radiographs 2. Health and safety guidelines with Developm ent of the dentition (normal and respect to oral and maxillofacial abnormal; 70 hours). Knowledge of: radiology 1. Norm al and abnormal development of 3. Digital oral and m axillofacial the dentition from birth to adulthood radiographic and other imaging 2. Ab n o r m alities in number, size, form , techniques and position of the teeth 4. 3D imaging (computed 3. Genetic and environmental factors tomography, cone beam computed relevant to the development of the tomography, magnetic resonance, dentition stereophotogramm etry) and their 4. Orthodontic consequences of indications. abnormalities of the dentition 5. The impact of interceptive orthodontic measures Cephalometric radiography (45 hours). Know l- edge of: 1. Head and neck anatomy as applied to Facial growth (normal and abnormal: 50 radiology hours). Knowledge of: 2. Ce p h a lo m etric analyses 1. Grow th sites in the craniofacial skeleton 3. Lim itations of cephalogram s and their 2. Postnatal grow th changes in the analyses craniofacial region, including soft tissues 3. Va r ia t i o n s w ithin the craniofacial region Orthodontic materials (25 hours). Knowledge relevant to facial growth of: 4. In uence of genetic and environm ental 1. Properties, composition, and uses of factors on facial growth orthodontic materials

Physiology and pathophysiology of the sto- Orthodontic biomechanics (35 hours). Know l- matognathic system (35 hours). Knowledge of: edge of: 1. Norm al and abnormal mastication and 1. Force syst e m s produced by di erent swallowing orthodontic appliances 2. Norm al and abnormal functional dental 2. Force syst e m s produced by dentofacial occlusion orthopaedic devices 198 Orthodontic Postgraduate Education: A Global Perspective

General orthodontic subjects (340 Long-term e ect of orthodontic treatment (30 hours) hours). Knowledge of: 1. The long-term e ect of orthodontic Aetiology and epidem iology of malocclusions treatment in individual patients, also in (25 hours). Knowledge of: relation to ageing e ects on the face and 1. Genetic and environmental factors that dentition in uence postnatal development of the dentition and facial complex Iatrogenic e ects of orthodontic treatment (30 2. Unfavourable environmental in uences hours). Knowledge of: and their interception 1. Th e develop m ent of demineralization, 3. Prevalence of m alocclusions and ethnic pulp necrosis, root resorption, variations recession, and periodontal disease during orthodontic treatment Need and demand for orthodontic treatment 2. Caries risk evaluation and preventative (15 hours). Knowledge of: measures during orthodontic treatment 1. Validity of indices in estimating need 3. Pain and discomfort related to for t reat m ent orthodontic treatment 2. Models to determine the demand for 4. The possible in uence of treatment of treatment dentofacial aesthetics 3. In uence of society on demand for 5. The possible in uence or orthodontic treatment treatment to CMDs 4. Aspects involved in subjective need for treatment Orthodontic literature (120 hours). Knowledge 5. Role played by orthodontists in of: establishing demand for treatment 1. Methods to evaluate the m ethodological 6. Factors involved in estimating objective quality of scienti c publications need Orthodontic techniques (195 hours) Diagnostic procedures (15 hours). Knowledge A level of competency is required for the top- of: ics D1–D8. The requirem ents are described in

1. Taking a patient history and perform ing detail in ‘Essential competency levels for post- a clinical examination graduate education in orthodontics’. 2. Prerequisites for high quality D1. Rem ovable appliances (30 hours) diagnostic records (impression of the D2. Functional appliances (20 hours) dentition, photographs, and necessary D3. Extra-oral appliances (20 hours) radiographic images) D4. Partial xed appliances (20 hours) D5. Fixed labial and lingual appliances Orthodontic diagnostic assessm ent, treatment (60 hours) objectives, and treatment planning (60 hours). D6. Retention appliances (15 hours) Knowledge of: D7. Skeletal anchorage devices (20 hours) 1. Principles of orthodontic diagnostic D8. Oral devices for OSA treatm ent (10 assessment, treatment objectives, and hours) systematic treatment planning

Grow th and treatment analysis (45 hours). Interdisciplinary treatment Knowledge of: procedures (125 hours) 1. In dices to m easure occlusal and aesthetic outcomes of orthodontic Adult orthodontics (20 hours). Knowledge of: treatment 1. Indications and speci c aspects of 2. Grow th analyses based on serial orthodontic treatment in adults radiographic images 3. Lim itations of analyses of growth and treatment changes (including computerized prediction) Appendix The Erasmus Programme for Postgraduate Education in Orthodontics 199

Trea t m ent of patients w ith orofacial clefts and Health and safety in orthodontic practice (10 craniofacial anomalies (25 hours). Knowledge hours). Knowledge of: of: 1. Guidelines and recom m endations for 1. Interdisciplinary aspects of treatment preventing and controlling infectious 2. Indication, timing, and process of diseases in orthodontic settings and interdisciplinary treatment complying with these guidelines 3. Orthodontic treatment in cleft lip and palate patients Multicultural health and health care behavior (5 hours). Knowledge of: Orthodontic-surgical treatment (20 hours). 1. Cultural di erences in patient Knowledge of: expectations 1. Minor surgical procedures in relation to 2. Cultural di erences in comm unication orthodontic treatment skills in a patient–care provider 2. Indication and application of di erent relationship types of orthognathic procedures

3. 2D and/or 3D treatment planning Practice management, Orthodontic-periodontal treatment (20 hours). administration, and ethics (45 hours) Knowledge of: 1. The e ect of orthodontic treatment on O ce m anagement (15 hours). Knowledge of: the periodontium 1. Design of an orthodontic practice 2. Speci c aspects of orthodontic 2. Equipment and instruments needed in treatment in periodontally an orthodontic practice compromised dentitions 3. Re cr u it m ent and selection of auxiliary personnel Orthodontic-restorative treatment (20 hours). 4. Personal and professional development of Knowledge of: auxiliary personnel 1. Principles of combined orthodontic- 5. Financing and administration of an restorative treatment orthodontic practice 2. Orthodontic implications of implants 6. Public relationships 7. Quality management certi cation Cra n iom andibular disorders (20 hours). Knowledge of: Co m m unication (10 hours). Knowledge of: 1. Aetiology of CMDs 1. Principles of e ective comm unication 2. Methods for clinical assessm ent of the with patients, parents, sta , and third temporomandibular joint parties 3. General m easures to improve CMDs Ergonomics (5 hours). Knowledge of: 1. Principles of ergonom ic positioning Management of health and safety of patient, orthodontist, chairside (25 hours) assistant, instruments

Management of oral health (10 hours). Know l- Legislation (10 hours.) Knowledge of: edge of: 1. Laws and regulations that apply to 1. Procedures to detect a high risk of orthodontic practice developing periodontal problem s, 2. Aspects of litigation in orthodontic enamel demineralization, and dental practice caries in orthodontic patients Professional ethics (5 hours). Knowledge of: A m ajor part of this subject is incorporated in 1. Behaviour and conduct expected of an ‘Iatrogenic e ects of orthodontic treatment’. orthodontist as a health-care provider 200 Orthodontic Postgraduate Education: A Global Perspective

2. Ethical standards that apply to 2. Assess the quality of evidence and relationships with personnel, patients, validity of conclusions and colleagues 3. Use electronic databases e ciently to obtain the evidence to answer a clinical or research question Extramural educational activities 4. Understand and evaluate statistical methods and interpretation of ndings It is highly recom m ended to: in current literature 1. Participate in European Orthodontic 5. Perform an analytical review of research Society (EOC) Distinguished Teacher’s papers Le c t u r e s w here possible 6. Write a protocol for a research project 2. Participate in meetings and congresses 7. Apply data processing procedures arranged by national and international 8. Interpret ow n research ndings orthodontic societies 9. Present research ndings in oral and written form

Essential competency Basic orthodontic subjects levels for postgraduate Development of the dentition (normal and abnormal). Competent to recognize and education in orthodontics identify: 1. Norm ality or abnormality of grow th In addition to the theoretical knowledge of and development levels indicated in ‘Objectives of compulsory 2. Developm ental stage attained elements of theoretical education of ortho- 3. Potential future developm ent dontists’, the students are required to achieve 4. Possibilities for interceptive m easures a level of com p et e n cy in t h e b elow -m entioned to improve the current and future subjects. The term ‘competent to’ means that situation students should have a sound theoretical knowledge and understanding of the subject Competent to: together with an adequate clinical experience 1. Plan and undertake interceptive to be able to independently resolve clinical orthodontic treatment challenges encountered. Th e m inimal number of hours necessary for the average student to devote to the sub- Facial growth (normal and abnormal). Com pe- ject in order to achieve the required level of tent to recognize and identify: comprehension (= a sound knowledge of and 1. Postnatal growth changes in the understanding of all subjects) are indicated craniofacial region, including soft tissues in ‘Objectives of compulsory elements of 2. Variation in the function of components theoretical education of orthodontists’. The with the craniofacial region relevant to competency level ‘competent to’ should be facial growth achieved throughout the education without 3. Individual variation in facial speci ed hours. morphology 4. In uence of genetic and environm ental factors on facial grow th General biological and medical subjects Aspects on tooth movements and dentofacial orthopaedics. Competent to recognize and identify: Research m ethodology and biostatistics. Com - 1. The process of tooth eruption and petent to: spontaneous tooth movement 1. Apply the principles of evidence-based 2. Biological response to di erent types of medicine force application 3. In uence of force systems and force magnitude 4. Post-treatment changes Appendix The Erasmus Programme for Postgraduate Education in Orthodontics 201

Oral and maxillofacial radiology and other 4. Evaluate in uence of functional im aging techniques. Competent to: components of soft tissues on 1. Recognize and identify abnormalities dentofacial morphology and pathological conditions that can be 5. Take high quality im pressions of the diagnosed on radiographs dentition 2. Apply the As Low As Reasonable 6. Take high quality photographs Achievable principles for radiation 7. Take high quality radiographic im ages protection 3. Judge and improve the quality of Orthodontic diagnostic assessment, treatment radiographs for orthodontic purposes objectives, and treatment planning. Competent 4. Apply health and safety guidelines to: with respect to oral and maxillofacial 1. Arrive at a tentative diagnosis and radiology classi cation based on the initial clinical Ce p h a lo m etric radiography. Competent to: examination of a patient 1. Describe the radiographic anatomy of 2. Provide advice after an examination the head concerning feasibility of treatment, 2. Identify relevant anatomical structures need for a m ore detailed analysis on cephalograms and treatment planning, or further 3. Undertake digital or manual tracings of consultation with other specialists lateral and AP cephalograms 3. Arrive at a proper diagnosis on the 4. Undertake cephalometric diagnostic basis of anamnestic data, patient analyses and draw appropriate examination, dental casts, photographs, conclusions radiographs, and other relevant data 4. Predict the likely e ect if no therapy is Orthodontic materials. Com petent to: implemented 1. Select appropriate materials for 5. De ne objectives of treatment with due orthodontic procedures consideration of the alternatives 2. Handle and use orthodontic materials 6. De ne a treatment plan for various appropriately types of orthodontic and dentofacial abnormalities, including treatment

Orthodontic biomechanics. Com petent to: and retention strategies, therapeutic 1. Apply principles of m echanics to clinical measures, timing and sequence of their problems application, prognosis, and estimated 2. Calculate force systems produced by treatment and retention time di erent orthodontic appliance 7. Undertake a cost/bene t assessment 3. Est im ate force systems produced by for di erent treatm ent and retention dentofacial orthopaedic devices procedures 8. Asses scope, limitations, and stability or orthodontic treatment General orthodontic subjects 9. Co m m unicate the treatment plan to patients (and their parents if the patient Aetiology and epidemiology of malocclusions. is under the age of consent) Co m p e t e n t t o : 1. Assess orthodontic treatment need and Grow th and treatment analysis. Com petent to: perform screening procedures 1. Use indices to measure occlusal and aesthetic outcomes or orthodontic Diagnostic procedures. Competent to: treatment 1. Obtain a relevant patient history 2. Undertake growth analyses based on 2. Perform a thorough clinical radiographic images examination 3. Describe treatment changes by analysis 3. Determ ine habitual occlusion, evaluate of before and near end of treatm ent functional occlusion, and di erent jaw records relationships 202 Orthodontic Postgraduate Education: A Global Perspective

4. Understand the bene ts and limitations 3. Design appliances and describe and of analyses of grow th and treatment evaluate their construction changes 4. Undertake limited repairs

Long-term e ect of orthodontic treatment. Functional appliances. Competent to: Competent to: 1. Describe the use and the lim itations 1. Describe the potential long-term e ect of removable and xed functional of orthodontic treatment in individual appliances patients, also in relation to ageing 2. Identify indications and e ects of the face and dentition contraindications 2. Inform the patients about potential 3. Design appliances and describe and post-treatment changes associated evaluate their construction with di erent anomalies and treatment 4. Undertake limited repairs procedures Extra-oral appliances. Competent to: Iatrogenic e ects of orthodontic treatment. 1. Describe the use and the lim itations of Competent to: various types of headgears, face masks, 1. Identify factors involved in development chin cups, and combined extra-oral/ of demineralization, pulp necrosis, functional appliances root resorption, gingival recession, and 2. Identify indications and periodontal disease during orthodontic contraindications treatment 3. Design appliances and describe and 2. Prevent or m anage intra- and extra-oral evaluate their construction lesions due to orthodontic treatment 4. Identify safety aspects of extra-oral 3. Make a caries risk evaluation and appliances apply preventative measures during orthodontic treatment A m ajor part of the section is covered in 4. Advise patients how to m anage pain ‘Aspects of tooth movements and dentofacial and discomfort related to orthodontic orthopaedics’. treatment

5. Describe the possible in uence of Partial xed appliances. Competent to: treatment on dentofacial appearances 1. Describe the use of partial xed and and aesthetics semi-removable appliances 6. Evaluate the in uence of treatment on 2. Identify indications and CMDs contraindications, and design appliances Orthodontic literature. Competent to: 3. Describe the di erent concepts and 1. Detect essential publications in the treatment approaches in partial xed current literature (taught in speci c appliance therapy literature review sessions) 2. Evaluate the methodological quality of Fixed labial and lingual appliances. Competent scienti c publications to: 3. Develop and present a critical appraised 1. Describe the use of labial and lingual topic xed appliances, including their limitations 2. Identify indications and Orthodontic techniques contraindications 3. Describe di erent concepts and Rem ovable appliances. Com petent to: treatment approaches in design and 1. Describe the use of removable biomechanical principles appliances, including advantages and 4. Use at least one xed appliance system lim itations 2. Identify indications and contraindications for rem ovable appliance use Appendix The Erasmus Programme for Postgraduate Education in Orthodontics 203

Retention appliances. Com petent to: 2. Describe aspects of orthodontic 1. Describe the uses and limitations of treatment speci c for periodontally retention appliances compromised dentitions 2. Identify indications and 3. Evaluate indications and contraindications contraindications for orthodontic 3. Design the appliance and describe and treatment in periodontally evaluate its construction compromised dentitions 4. Describe the most appropriate duration 4. Collaborate in the diagnosis and of retention treatment planning of periodontally 5. Undertake limited repairs compromised dentitions

Skeletal anchorage devices. Competent to: Orthodontic-restorative treatment. Co m p e t e n t 1. Recognise when temporary anchorage to: devices or skeletal anchorage devices 1. Identify indications and should be considered as part of the contraindications for combined management of a malocclusion orthodontic-restorative treatment 2. Describe orthodontic implications of Oral devices for OSA treatm ent. implants 1. The achievement of a competency level 3. Describe aspects of orthodontic is encouraged, but is not obligatory treatment speci c for combined orthodontic-restorative patient care 4. Collaborate in the diagnosis and Interdisciplinary treatment treatment planning of patients procedures requiring orthodontic-restorative treatment Adult orthodontics. Com petent to: 1. Describe indications and speci c Cra n iom andibular disorders. Competent to: aspects of orthodontic treatm ent for 1. Describe indications and adults contraindications for orthodontic 2. Collaborate in the diagnosis and treatment in patients with CMDs

treatment planning of adult patients 2. Identify possible implications of with general dental practitioners and orthodontic treatment in the presence other specialists of CMD 3. Collaborate in the diagnosis and Tre a t m ent of patients with orofacial clefts and treatment planning of patients with craniofacial anomalies. CMD by a team of specialists 1. The achievement of a competency level is encouraged, but is not obligatory Management of health and safety Orthodontic-surgical treatment. Competent to: 1. Describe aspects of orthodontic Management of oral health. Competent to: treatment speci c for patients requiring 1. Instruct patients to m aintain optical orthognathic surgery oral hygiene as a preventative measure 2. Collaborate in the diagnosis and for gingival and dental lesions treatment planning or patients who require minor surgical procedures or Health and safety conditions in an orthodontic orthognathic surgery practice. Competent to: 1. Implement guidelines and Orthodontic-periodontal treatment. Competent recommendations for preventing and to: controlling infectious diseases in an 1. Describe how orthodontic treatment orthodontic setting and comply with them may bene t patients who have a history 2. Im plem ent guidelines and of periodontal disease recomm endations for managing personnel health and safety concerns 204 Orthodontic Postgraduate Education: A Global Perspective

related to infection control in an Acknowledgements orthodontic practice and comply with them The authors would like to express their 3. Evaluate systematically the practice gratitude to the members of the Network or infection-control programm e to ensure Erasm us Based European Orthodontic Pro- procedures are followed accurately gramm es (NEBEOP) for their valuable input to 4. Control exposure to substances this document. Furthermore, they are grateful hazardous to health for patients and to the European Orthodontic Society for pro- personnel viding support to the m eetings.

Practice management, References administration, and ethics 1. Cow p e J, Pla ssch a e r t A, Ha r ze r W, Vin kka - O ce m anagement. Competent to: Puhakka H, Walmsley AD. 2009. Pro le 1. Implement a quality management and competences for the graduating Eu- system in an orthodontic practice ropean dentist—update 2009. European Journal of Dental Education 14:193–202 Co m m unication. Competent to: 2. van der Linden FPGM. 1992. Three years 1. Co m m unicate e ectively with patients, Postgraduate Programm e in Orthodon- parents, sta , other medical personnel, t ics: th e Fin al Report of t h e Erasm us Proj- and third parties ect. European Journal of Orthodontics 2. Utilize e ective comm unications tools 14: 85–94 and di erent presentation modes

Ergonomics. Competent to: 1. Position patient, orthodontist, chairside assistant, and instruments in an ergonomic optimal manner 2. To perform speci c clinical procedures

in the most e cient sequence World Federation of Orthodontists (WFO) Guidelines for Postgraduate Orthodontic Education*

Athanasios E. Athanasiou, DDS, MSD, Dr Dent Stephen Richmond, BDS, DOrth Professor and Head, Department of RCS(London), MScD, PhD Orthodontics, School of Dentistry, Aristotle Professor of Orthodontics, Dental Health and University of Thessaloniki, Thessaloniki, Biological Sciences, Dental School, Cardi Greece. University, Cardi , Wales, United Kingdom.

M. Ali Darendeliler, BDS, PhD, Dip Orth, Ku n i m ichi Soma, DDS, PhD Certif Orth, Priv Doc Professor and Chair, Orthodontic Science, Professor and Chair, Discipline of Graduate School, Tokyo Medical and Dental Orthodontics, Faculty of Dentistry, University University, Tokyo, Japan. of Sydney; Head, Departm ent of Orthodontics, Sydney Dental Hospital, Sydney South West Alexander Vardimon, DMD Area Health Services, Sydney, Australia. Professor and Head, Departm ent of Orthodontics, School of Dental Medicine, Theodore Eliades, DDS, MS, Dr Med, PhD Tel Aviv University, Tel Aviv, Israel. Associate Professor, Department of Orthodontics, School of Dentistry, Aristotle William Wiltshire, BChD(HONS), MDent, University of Thessaloniki, Thessaloniki, Greece. MChD(Orth), DSc Professor and Head, Department of Urban Hägg, DDS, Odont Dr Orthodontics, Faculty of Dentistry, University

Professor and Chair, Departm ent of of Manitoba, Winnipeg, Manitoba, Canada. Orthodontics, Faculty of Dentistry, University of Hong Kong, Prince Philip Dental Hospital, Correspondence Hong Kong, Hong Kong SAR, PR China. Dr. Athanasios E. Athanasiou Departm ent of Orthodontics Brent E. Larson, DDS, MS School of Dentistry Director, Division or Orthodontics, School Aristotle University of Thessaloniki of Dentistry, University of Minnesota, GR-54124 Thessaloniki Minneapolis, Minnesota, USA. Greece

Pertti Pirttiniemi, DDS, PhD Professor and Head, Department of Orthodontics and Oral Development, Institute of Dentistry, University of Oulu, Oulu, Finland.

* This article was originally published in the World Journal of Orthodontics by Quintessence 205 Publishing Co, Inc. World J Orthod 2009; 10:153-166. © 2009 Quintessence Publishing Co, Inc. Used w ith permission. 206 Orthodontic Postgraduate Education: A Global Perspective

In July 2006, the Executive Comm ittee of the specialists worldw ide, who have credentials World Federation of Orthodontists (WFO) that satisfy the standards set by the WFO. accepted the president’s proposal for estab- According to the currently described lishing a WFO task force on Guidelines for guidelines, the objective of orthodontic post- Postgraduate Orthodontic Education. graduate educational programs is to produce This task force was chaired by WFO Presi- graduates who have completed their didactic dent Professor Athanasios E. Athanasiou and and clinical education under the auspices and had as m embers Professor M. Ali Darendeliler, direction of an advanced education institution. Associate Professor Theodore Eliades, Profes- Graduates of an orthodontic program—b a s e d sor Urban Hägg, Professor Brent E. Larson, in or a liated with an advanced education Professor Pertti Pirttiniemi, Professor Stephen institution—are provided with a broad-based Rich m ond, Professor Kunimichi Soma, Profes- higher level of education in orthodontics sor Alexander Vardimon, and Professor Wil- and its allied biomedical sciences and clini- liam Wiltshire. cal disciplines. Graduates are trained in the The objective of this task force was to discipline of orthodontics and dentofacial provide the WFO Executive Comm ittee with orthopedics so they will become specialists detailed recomm endations concerning guide- in this area with a solid background in orth- lines for postgraduate orthodontic education, odontic diagnosis and orthodontic treatments which may assist countries, associations, and modalities. educational institutions to develop or improve Upon completing the academic, clinical, such programs. and research requirements of the program, Over the past several years, the WFO has the graduate must be able to: placed increased emphasis on support for the • Diagnose and characterize anomalies of recognized training programs in every region the dentition, growth of the craniofacial of the world through its a liate national orga- skeleton, and functional abnormalities nizations. At the sam e time, the WFO intends • For m ulate and exercise a controlled and to continue to provide, when requested, predictable treatment plan encouragement and expertise to developing • Conduct interceptive and preventive orthodontic graduate programs in areas w here orthodontic procedures orthodontic education did not previously exist. • Treat all types of malocclusion

It is anticipated that these guidelines will • Evaluate psychological aspects of be used by postgraduate program directors relevance to orthodontics all over the world and by related educational, • Collaborate in the interdisciplinary scienti c, and administrative institutions at all treatment of medically compromised levels of sophistication to m easure their respec- patients, syndromes, and craniofacial tive curriculum against a worldw ide standard. anomalies, including orthognathic surgery The following detailed recomm endations care of the task force on Guidelines for Postgradu- • Assess the need for orthodontic treatment ate Orthodontic Education are herewith pre- on individual and societal levels sented, and they are accompanied by two • Practice orthodontics according to the appendices: (1) Clinical Care, Study, and standards of ethics Research Facilities and (2) Educational Topics. • Comprehensively review, understand, and evaluate the literature pertinent to orthodontics in a wide array of disciplines relevant to the specialty, including 1. Program Goals and m olecular biology, biomaterials, and Obje ctive s biomechanics • For m ulate a research hypothesis and The goal of the program is, inter alia, to be in design and conducts and experiment to accordance with the requireme n t s of t h e p res- test its validity ent and past WFO docum ents on Orthodontic • E ciently organize, present, and publish Specialty Education Guidelines to identify and research ndings, as well as present recognize appropriately trained orthodontic clinical cases in a com prehensive m anner Appendix World Federation of Orthodontists (WFO) Guidelines 207

• Be registered as an orthodontic specialist 2. Program Duration for at least 10 years • Actively practice the specialty at least Postgraduate orthodontic programs should 1 day a week be a minimum of full-time, 24-month dura- • Dem onstrate excellence in clinical tion. However, it is strongly recomm ended to experience with completion of a su cient have a least 36 months of full-time specialist number of cases per year education, speci cally to allow residents su - • Be m ember in good standing of the cient time to complete their research projects, country’s orthodontic specialists’ the majority of orthodontic and interdisci- association plinary cases assigned to them, as well as to • Be appointed for at least 60% of the plan and monitor retention for at least a few working week months prior to graduation. • Dem onstrate administrative ability to coordinate a graduate clinical program • Present research ability and a proven track record in supervising research studies for 3. Residents higher degrees

To be admitted to the postgraduate program, In addition to the director, a full-time the candidate should have undertaken and position for an orthodontist (clinical aca- passed a full-time course in dentistry of at demic) must be present. When more than six least 4 years. The candidate must provide residents are enrolled, additional clinical aca- proof of registration as a dentist in a county demic sta is required. in which the degree was obtained or in w hich It is recomm ended that the clinical aca- the candidate is presently practicing. demic should: It is recomm ended that the candidate should have com pleted at least 2 years of gen - • Possess a PhD and/or MDSc in eral dentistry practice experience in a private, orthodontics or equivalents government, or university-clinic environm ent • Be registered as an orthodontic specialist before being accepted in the postgraduate for at least 5 years orthodontic program. • Actively practice the specialty

Ad m ission criteria should include pre- • Complete a su cient num ber of cases per vious academic performance, clinical and year to maintain clinical skills research experience, foreign language famil- • Be a m ember in good standing for iarit y as needed, as well as evaluation of goals the country’s orthodontic specialists’ and motivation for orthodontics. association

When more than one clinical academic is appointed, the appointment may be also on a 4. Faculty part-time basis. Nonorthodontic clinicians, such as a An appropriately quali ed academic sta and research academic and/or biostatistician, may program director are essential for academic occupy other faculty positions. success. The faculty may be composed of per- The research academic must: manent, a liate/adjunct, and full- or part- • Possess a PhD w ith experience in time academic sta . graduate-level teaching and graduate The clinical sta –resident ratio in super- student research supervision vising treatm ent must be at least 1:4–6. • Possess research ability with an important It is recomm ended that the program publication record in refereed journals director should: and proven experience in supervising • Possess a PhD and/or MDSc (or research of Masters and Doctoral students. equivalents) in orthodontics and present a strong research and publication record, as External collaborators (orthodontic spe- well as teaching experience cialists or other dental specialists) may be 208 Orthodontic Postgraduate Education: A Global Perspective

appointed to conduct lectures in basic and dental laboratory technician for each six interdisciplinary subjects. These lecturers do residents is required. Local conditions, appli- not have to be enrolled permanently as fac- ances’ characteristics, and available resources ulty sta . should be considered regarding the place in Orthodontic experts with a high degree of which the technical work will take place. clinical experience and dedication in teaching not enrolled in the faculty may be invited to conduct lectures or seminars. VI. Re s e a rc h facilities/support

Clinical and laboratory facilities and support are required based on research interest and 5. Clinical Care, Study, specialization elds of the institution. and Research Facilities See Section 11 for details on these areas.

A specialist course in orthodontics needs to provide adequate clinical, building, adm inistrative, information technology (IT), and 6. Required Curriculum research facilities. I. Pro g ram curriculum I. Clinic Residents must be enrolled full-time and are required to at tend an adequate am ount of fac- Clinics should include waiting room, reception ulty-supervised clinical sessions to establish area, consultation/disabled/special-care room , pro ciency in clinical orthodontics. Twenty- operatory (main clinic) rooms, oral hygiene fou r (2 4 ) h ou rs p e r w e ek of su p e r vise d p at ie n t room/cubicle/corner, sterilizing room/area, mix- management is recommended. The trainee ing area, and a photography area. may spend more time in preparatory work in the form of individual studies, research, or II. Ra d io lo g y a re a other speci c assignments. However, all clini-

cal training and taught courses mu st t w ithin a n 8 - h o u r d a ily w o r k sch e d u le . Te n t o 1 2 h o u r s Should be in the same department or building. per week, 25% to 30% of the program, should be dedicated for research and administration (treatment planning, preparation of tutorials, III. O ce s assignments, and case presentations). The number of new patients assigned to Departm ent’s head and program director each resident should not be fewer than 30, o ces, lecturers’ o ce(s), administrative sta and equal or more transferred patients will be o ce, residents’ o ce/study area, and lec- assigned during the course of the study. Clini- ture/tutorial room. cal responsibilities of the residents should also include supervision of retention patients and recall for observation of former patients with IV. Sto rag e special clinical interest. A m inimum of 2 hours per week should be devoted to case presenta- Storage is required to store teaching, research, tion and another 1 hour for review of the cur- and clinical materials, as well as o ce rent literature in the form of a journal club. stationery. Tr e a t m ent modalities and appliances should include removable and xed appliances, growth modi cation and orthognathic surgery, V. Te c h n i c a l laboratory guided eruption of im pacted teeth, craniofacial anomalies, interdisciplinary management, and Technical work can be performed in-house preventive and interceptive case management. and/or in cooperation with external orth- Written and/or oral examinations must be odontic laboratories. If technical work is conducted in all courses. In addition, program s performed exclusively in-house, a full-time may electively impose a nal examination Appendix World Federation of Orthodontists (WFO) Guidelines 209 upon completion of the program. The latter is C. Special orthodontic subjects necessary, especially in countries where ortho- • Biom echanics and tooth movement dontics is not an o cial dental specialt y recog- • Obstructive sleep apnea and orthodontics nized by the local education, health, and other • Interdisciplinary treatment (e.g., professional authorities, which usually orga- prosthodontics-periodontics) nize independent assessments of competence. • TMD and orthodontics As a requirement for successful comple- • Orthognathic surgery joint clinics and tion of the program, residents must submit a seminars thesis in the form of a typical Master’s docu- • Face asymm etries ment, which reports original data derived • Cla ss I m alocclusion from research activities in various elds, and/ • Class II m alocclusion or prepare a paper in publishable format. • Class III m alocclusion • Vertical problem s • Maxillary constriction II. Speci c conditions • Orthodontic diagnosis in 3 dimensions of space Orthodontic curriculum must be assessed • Orthodontic techniques independently. However, active interaction • Cleft lip and/or palate treatm ent with adjunct dental disciplines, including • Adult orthodontics restorative dentistry, oral and maxillofacial • Noncompliance treatment surgery, pediatric dentistry, and periodontol- • Temporary anchorage device (TAD) ogy, is essential in providing a thorough per- • Practice m anagement spective on treatment planning.

III. Course work/topics to be 7. Sponsoring Institution covered and Institutional Commitments A. Biomedical sciences with Advance orthodontic specialty education pro- emphasis on biological and medical subjects grams must be sponsored by institutions (university/ school/hospital), which are properly • Grow th and development chartered and licensed to operate and o er • Anatomy of the head and neck instruction leading to degrees, diplomas, or • Genetics certi cates with recognized education valid- • Em bryology of the head ity. It is recomm ended that hospitals that • Cell and m olecular biology sponsor advanced orthodontic specialty edu- • Oral imm unology and microbiology cation programs should be university-a li- • Oral physiology ated. All educational institutions that sponsor • Biostatistics advanced orthodontic specialty education • Research methodology programs must be accredited by an agency recognized by the national or regional governmental education and/or health authorities. B. Basic orthodontic subjects • Developm ent of the dentition • Physiology of the stomatognathic system I. Academic and quality • Orthodontics as it relates to grow th assurance • Bio m echanics • Dental radiography A. Compatibility of standards, e.g., • Introductory orthodontic seminars/ with subject benchmarking diagnosis and treatment planning statements and meeting the • Ce p h a lo m etric radiography requirements of the professional • Orthodontic materials and statutory bodies • Occlusion and TMJ • Iatrogenic e ects from orthodontics • The sponsoring institution must provide a comm ittee structure to oversee the 210 Orthodontic Postgraduate Education: A Global Perspective

course taught in orthodontics to ensure II. Regulations and program that it delivers what it is supposed to and provides a high standard of teaching administration and learning compatible with the course provided at the university and other A. Program regulations universities national and internationally. • The orthodontic regulations should be • The sponsoring institution must facilitate incorporated with university/school/ visitations from other professional hospital documentation and be consistent and statutory bodies nationally and with national and international guidelines. internationally to ensure that course standards are being m aintained and that resources (e.g., sta , environment, and B. Program management and nancial) are above the accepted m inimum. re po rting structures • There should be a robust managerial structure that integrates fully w ith the B. The communication of those university/school/hospital structure so standards to sta and re side nts that minutes of m eetings are reported/ • The sponsoring institution must provide referred to the appropriate university/ documentation of structures that set school/hospital comm ittees. out standards of teaching and learning consistent with national and international standards, ensuring that these are clearly C. The contribution of residents to stated and comm unicated to both sta the program-management process and residents. • The residents should be encouraged to provide feedback and develop suggestions on all aspects of the course, resources, C. An account of the school’s management, and sponsoring institution. quality-assurance arrangement applicable to the program, including school quality manual. III. Su p p o rt fo r re s id e n t s

• The sponsoring institution must provide a protocol of how the orthodontic A. Academic support for residents program is managed and integrated in the • The university/school/hospital should university/school/hospital quality manual. provide the infrastructure to support teaching and learning with state-of-the- art facilities: clinical, laboratory, personal D. Monitoring and review workspace, and information technology. arrangements in accordance There should be excellent library support with institutional requirements with Internet access to relevant academic and opportunities to ensure journals. continuous enhancement (accreditation) B. Mechanisms to be employed • The sponsoring institution must provide a for monitoring the academic m echanism of review of the provision of the pro g re ss o f re side nts orthodontic course (every 3 to 6 months) and facilitate a period of self-assessm ent • Monitoring should be undertaken on and external assessment (1 to 3 years). a frequent basis w ith regular formal documented meetings with the residents every 3 to 6 m onths. E. The involvement of residents in the quality-assurance process C. Pastoral support for residents • Residents should be formally invited to contribute to the review and development • The university/school/hospital should of the orthodontic program and quality- provide formalized system s for personal assurance initiatives. support for the resident. This support can be provided by m embers of the Appendix World Federation of Orthodontists (WFO) Guidelines 211

orthodontic sta , but it may be m ore orthodontic course, although the provision of appropriate if the support is provided by the course should not cause a nancial strain sta not associated with the orthodontic on university/school/hospital resources. teaching (essential in cases where there is potential orthodontic sta /resident con ict). The university/school/hospital B. Sta reso urce s to support the should provide occupational health and program safety facilities to ensure total well-being • There should be su cient administrative, throughout the education period. clinical, and technical sta support to cover the postgraduate program. D. Personal tutor system • Residents should be allocated personal C. Resources to support learning tutors to mentor them throughout their and teaching, including library, training period. The tutors should follow IT, and other resident support the role of tutor guidelines set out by the mechanisms institution. • There should be adequate resources to support teaching and learning. E. Personal development planning for residents D. Recruitment • A detailed personal-development plan • The university/school/hospital should (PDP) must be provided for each resident. provide support for the recruitment It m ay be either paper- or electronically process for orthodontic postgraduates. based. Financial support should be allocated to attend conferences and other continuing professional educational courses. E. Ful lment of legal responsibilities • The university/school/hospital should F. Support for residents studying ful ll and ensure that national and away from the institution, international legal responsibilities are m et. including placement settings • The university/school/hospital should F. Tr a i n i n g of sta support travel expenses for work • The university/school/hospital should undertaken outside the host institutions. provide the training of sta to keep Facilities similar to the host institution them up-to-date with legal m atters should be available. and international and national policies pertinent to the training of residents. G. Support for overseas residents • Overseas residents often need extra support G. Health and safety to ease the transition into the postgraduate • The university/school/hospital should course (e.g., language and cultural), and the comply with appropriate international university/school/hospital should provide and national law and policies. In addition, these supporting mechanisms. the orthodontic program must comply with local rules and regulations. IV. Co rp o ra t e governance ( nancial, physical, and V. Re s e a rc h governance human resources) A. Research ethics A. Financial and resource plan for • Any research undertaken in the the orthodontic program university/school/hospital should follow • The university/school/hospital should and com ply w ith international/national/ provide and support facilities for the regional rules and regulations on ethics. 212 Orthodontic Postgraduate Education: A Global Perspective

B. Research management this area. This will result in a continual process of program evaluation and improvement • The university/school/hospital should as diagramm ed in Fig. 1. monitor and manage research and ensure This program evaluation could be insti- that research follows stringent guidelines tuted on several levels. set out by the appropriate international Internal. All programs are expected to and national bodies. e n gage in t h is t yp e o f o n goin g a sse ssm ent with data collection and evaluation at least annually. Documentation of the process should minimally include evidence of data collected, 8. Program Evaluation evidence of discussion by faculty, recomm endations for program changes (as indicated), Each program is expected to maintain an and timetable for repeated data collection. ongoing assessment of its e ectiveness based Country or region. In areas where formal on the program’s de ned goals and objec- accreditation exists, site visitors could review this tives. The goals and objectives must mini- program evaluation. Speci c em phasis should be mally address the areas of didactic education placed on identi cation of program weaknesses, (including biomedical and clinical sciences), institution of suggested changes, and follow-up patient-care experience, and research experi- data collection to evaluate the changes. ence. The objectives should be measurable by Worldw ide/WFO. The program evalua- one or more indicators. tion materials could be submitted on a peri- The degree to which the program objec- odic basis to a WFO review comm ittee to tives are met should be assessed on a regular demonstrate compliance with the program basis (at least annually), and de ciencies that evaluation process. This could be of value are noted should lead directly to program especially in countries/regions that do not changes designed to improve performance in have accreditation processes in place.

Fig . 1 Appendix World Federation of Orthodontists (WFO) Guidelines 213

The process relies heavily on program- Examinations/evaluations speci c goals and objectives. The goals and objectives must be complete and well-de ned During the program for the process to be e ective. After completing a subject/module/course, and depending on the subject/module/course, this assessment should include theoretical exami- 9. Resident Evaluation nation (e.g., written essay or multiple-choice test), practical evaluation of residents’ capabili- By evaluating the program, it m ay be assumed ties (e.g., wire bending, typodont exercises), or that if the individual components (e.g., pro- assignment of independent review paper writ- gram curriculum, facilities, and sta ) are ing or presen tation . Other in form al assessm en ts present in the right proportions, the product for resident feedback will be based on direct will be an e cient program that will pro- observation of clinical performance, as well as duce competent graduates. However, exist- on performance at problem-based seminars. ing international practices suggest that apart from curricula compliance examination of the graduate, there should be a direct approach to Final examination assess the competency of the treatment provider, regardless of the reputation and overall After completing the program, residents standing of the program from which he/she should participate in the nal exam ination(s), has received advanced education. This method which will involve assessm ent of their over- secures a minimum standard in the provision all knowledge regarding orthodontics and of orthodontic services by directly examining related clinical disciplines. the quali cation of the graduate. In addition, If external examiners are used in the nal taken in large scale, a resident’s evaluation examination (recomm ended) a viva-voce may serve as an indirect means of revealing examination with an internal and an external the e ective ness of speci c advanced orth- examiner using set questions may be utilized. odontic program curricula. Final examination(s) should include an Evaluation of residents should take place initial examination, diagnosis, and treatment- on a regular and prescheduled basis through- planning exercise on a set of patient records out the program, a s w ell a s on com p let ion . Th e that are not known to the residents. The residents, teachers, and internal and external examiner(s) will have previously examined examiners should undertake this evalua- the record(s) and agreed on questions and tion. The program should enable continuous solutions. The residents will examine these assessment of residents’ performance, thus records for a speci c period (e.g., 45 to 60 recognizing individuals’ strengths and identi- minutes) and then be examined by the exam- fyin g areas of im p rovem ent through personal- iners on their diagnosis and treatment plan. development plans. If a National Orthodontic Board exists in There should be a process of appraisal the country, it is recommended that this Board for all residents, consisting of an informal should be involved in the nal examination; discussion between residents and their aca- if the resident passes the exam, he/she should demic sta at least in every semester, dur- receive the Board’s certi cation and become eli- ing which they are encouraged to re ect on gible for re-certi cation every certain num ber of their progress and set goals for the remain- years in order to maintain a high standard of care. der of the course. The residents are encour- Should unsatisfactory outcomes charac- aged to review their progress in achieving terize the performance of a resident, a resit these goals. The appraisal process provides evaluation should be held w ithin a reasonable an opportunity to identify potential prob- tim e period. In case of another failure, repeti- lem s early and provide appropriate support tion of the subject/module/course at the next and guidance. With su cient sta support, academic semester or year should be consid- the problems may be discussed and resolved ered. In cases of serious and repeated unsat- expeditiously. isfactory performance by the resident, the Evaluation of residents m ay take place situation should be discussed within the fac- at the end of each semester, year, or speci c ulty and the resident may be advised that his/ module. her registration be suspended or terminated. 214 Orthodontic Postgraduate Education: A Global Perspective

Practical requirements to come within the eld, as well as through interaction with other dental and medical Residents are expected to attend all scheduled disciplines. This implies that postgraduate sessions punctually. Attendance and active par- orthodontic education providers and gradu- ticipation by the residents in all seminars orga- ate orthodontic specialists should be com m it- n ized by t h e p ostgrad u ate p rogram is m an d ator y. ted to the continuing process of expanding To acquire su cient knowledge and orthodontic knowledge. This comm itment capabilities regarding orthodontic laboratory may be facilitated by WFO-sponsored actions, work, each resident should fabricate a spe- activities, and programs that aim to expand ci c number of study models, diagnostic set- academic sta knowledge (e.g., education ups, retainers, and removable and functional exchange programs), acknowledge students appliances assigned by the program. and academic sta research (i.e., awards), and Each residen t sh ould be ready to presen t a recognize continuously updated educators minimum number of nished and fully docu- (e.g., certi cation). m en ted cases (5 to 10 cases) th at w ere t reated entirely by the resident during the course of the program. Docum entation should be made 11. Clinical Care, Study, according to the guidelines of the country governing authority (e.g., American Board of and Research Facilities Orthodontics). Clinic

Dissertation or Master’s thesis Clinics should consist of a waiting room, reception area, consultation/disabled/special Each resident should undertake a research proj- care room, operatory (main clinics) rooms, ect for which its methodology, as well as the oral hygiene room/cubicle/corner, sterilizing results, should be presented in the form of a dis- room/area, mixing area, and a photography sertation. The resident should produce a bound area. The details are highlighted below. dissertation of 20,000 to 50,000 words by the required submission date an d be able to discu ss Waiting room

and defend the research in an oral exam ination. Space Residents are expected to publicize the ndings High capacity (chairs and tables, etc.) of their research in a variety of ways, including Relat ive co m fort (a) presentation at research seminars, (b) pre- Toilets/accomm odations for disabled* sentation at national/international meetings, and (c) publication in a refereed journal. Reception area Subject to achieving a satisfactory perfor- Visible / rst contact* mance in all elements of the program, he/she Provide record access w ill be awarded w ith the degree. Ad m inistrative tasks* With regard to the level of educational Scheduling* award and assessments (e.g., MSc, profes- Clinical coordination sional doctorate, PhD—merit and distinction), Center for deliveries* local rules in universities/institutions/coun- Media center (screens in reception and tries should apply. waiting room) IT equipment

Consultation room(s) 10. Outcome Assessment Dental chair* Parent/patient discussion desk with light box Orthodontics, like any medical discipline, is a incorporated dynamic eld. Orthodontic specialists and sci- Multim edia facilities entists working in this eld are com m itted to Interactive and educative software improving treatment results and stability, and Display cabinet minim izing the side e ects. The motivation Acce ss fo r d is a b le d * and initiative for these advancements have Appendix World Federation of Orthodontists (WFO) Guidelines 215

Ope rato ry Safety features Dental chairs* (at least one chair per two Lead linings* residents) in a cubicle, clinical room, or Blinds* open set-up Glasses* Utility/storage* Warning labels/lights* Working drawers Hygienic ooring* Sharp disposal* O ce s Bin s* Head of department’s o ce*, lecturers’ o ce Co m p r e ss e d a ir * (can be open set-up)*, administrative sta o ce (can be open set-up)*, residents’ study Oral hygiene area o ce (can be open set-up)* Sin k* Mirror* Lecture/tutorial room* St orage Meeting-sized table/seating* Bin * Multim edia/IT equipment* Display cabinet Hygienic ooring* Computer/server room Workstations* Sterilizing area Server and IT hardware* Clean/dirty area* Peripherals (printers, scanners)* Bin s* Back-up disks/drives* Sharp disposal* Co m m unications: network stations* Sin k/ t a p * Cold sterilizer* So ftw are Packing area* Practice m anagement Sterilizer* Im age analysis (radiographic and Dying area* photographic) Clean instruments storage* Internet* Co n s u m ables storage Em ail* Hygienic ooring* Word processor* Lig h t in g * Database management (Microsoft Excel, SRL, IT equipment SPSS)* Re m ote access Mixing area Secu rit y* Algin at e m ixer Financial PVS m ixer Patient database Tray storage* Co n s u m ables Sin k/ t a p * Storag e Bin s* Hygienic ooring* Co n s u m ables* and study models

Photography area Technical Laboratory Im age background* Controlled lighting Plaster-mixing equipment* Mirrors and accessories* Plaster storage* 2D or 3D digital photography unit ( xed or Sin k s w ith plaster trap* removable)* Working benches w ith necessary technical IT equipment accessories* Model trim m ers* Bench tops* Radiology Area Laboratory jobs in/out storage* In the same department or building: orthop- Steam source* antomograph, cephalometric, and/or 3D diag- Wax removal* nostic radiographic imaging machines*; chair; Sand blaster IT equipment; storage/accessories. Fu m e cupboard* 216 Orthodontic Postgraduate Education: A Global Perspective

Curing light box Genetics Vacuum curing (for thermoplastic materials)* The genetic basis of diseases Dust extraction* Genetic diseases – syndromes Laboratory materials* Cancer genetics Compressed air lines* Gene therapy and bioethics Bin s* Developm ent of m alformations Welding equipment (laser and gas) Genetic and epigenetic control of grow th 3D laser scanner for 3D digital m odels Em bryology of the head Sto rage Developm ent of jaws, teeth, and face IT equipment Teratogenesis and syndromes Job booking and follow-up software Developm ent of clefts Lighting assorted w ith m agnifying glass Hygienic and nonslip ooring* Cell and molecular biology Ad m inistrative desk Cell metabolism To o t h m ovement and reaction to force Bioch e m ical pathways of force transduction Research Facilities/Support to cell Clinic* Biological m echanism s of root resorption Biological events accompany force Laboratory with equipment application to cartilage, bone and Orthodontic periodontal ligament IT Bio m aterials Oral im m unology and microbiology Histology Oral imm unology Molecular Saliva and the formation of acquired pellicle Microscopy Oral m icrobiology An im al facilities Bio lms

Support Oral physiology University* Physiology of speech, swallow ing and gestation Governm ent/hospital Physiology of TMJ Professional Physiology of breathing and swallowing Private/corporate Norm al and abnormal breathing and Experienced manpower obstructive sleep apnea Ad m inistrative General and oral pathology Item s marked with an asterisk (*) constitute Syst e m ic diseases (growth and sex hormone minimum requirements. imbalances, hepatitis, HIV, leukemia, osteoporosis, and endocarditis) Oral m anifestations of diseases (radiation, 12. Educational Topics cysts, herpes, and aphtha) Biostatistics Basic Medical Subjects Regression and correlation Param etric and nonparam etric analyses Gro w th and development Analysis of variance Som atic growth and variation Meta analysis Developm ent of the craniofacial complex Applications in orthodontics Genetic/environmental factors and growth Biostatistic-epidemiologic surveys Determ ination of skeletal and biological age Clinical research in orthodontics Stages of sexual development Re s e arch m ethodology Anatomy of the head and neck Ethics and integrity in research Craniofacial structures Design of a study Skelet al deform ities Subm ission of a protocol Craniofacial malformations Statistical analysis of ndings Appendix World Federation of Orthodontists (WFO) Guidelines 217

Basic Orthodontic Subjects Measurements Noninvasive techniques Developm ent of the dentition Analyses (Steiner, Wits, Dow ns, Hasund, Developm ent of normal occlusion Coben, Bjork, Sassouni, Tweed, Ricketts, To o t h e r u p t i o n McNamara, and Pancherz) Developm ent of abnormal occlusion Superimpositions (overall, regional) Local and genetic factors 3D imaging Deviation from normality Agenesis and supernumerary teeth Orthodontic materials Alloys Physiology of the stomatognatic system Polym ers Constituent muscles, bone, and cartilage Ce r a m ics Ab n o r m al function Bonding to enamel TMJ physiology and function in health and Bonding to restorative m aterials disease En am el side e ects Diagnostic procedures Therapeutic protocols Occlusion and temporomandibular disorders (TMD) Orthodontics as it relates to grow th Anatomy and function Types of growth in bone, condyle, and sutures General TMJ concepts Adaptation of tissues to stimuli Norm al occlusion and function Mechanical stim ulation Di erential diagnosis of TMD Dentofacial orthopedics TMD in children, adolescents and adults Management philosophies Bio m echanics Equilibrium of bodies Iatrogenic e ect from orthodontics Mechanics of solids Classi cation of undesirable tissue, organ, Viscoelasticity and system e ects En am el e ects during bonding; debonding Oral and m axillofacial radiography and treatment with xed appliances

Periapical radiographs [intra- and extraoral Root resorption technique] Dam age to tooth-supporting tissues Variables a ecting the quality of radiographs Risk-m anagement principles An at om ical landmarks in intra- and extraoral radiographs Caries diagnosis through radiographs Special Orthodontic Subjects Periodontal diagnosis and radiographs Bio m echanics and tooth movement Oral and maxillofacial applications Methods of study Orthodontic applications Applications to clinical practice Digital imaging Cone beam computed tom ography Obstructive sleep apnea and orthodontics Radiation safety Interdisciplinary treatment Introductory orthodontic seminars/ (prosthodontics, periodontics, etc.) diagnosis and treatment-planning Medical/dental history TMD and orthodontics Re co r d s Extra- and intraoral examination Orthognathic surgery joint clinics and Diagnostic sequelae seminars Photographic assessment Model analysis (crowding/space assessment, Fa c e a s y m m etries Bolton analysis, set-up) Classi cation Etiology Cephalometric radiography Diagnosis La t e r a l Tr e a t m ent options Posterior - anterior La n d m ark identi cation 218 Orthodontic Postgraduate Education: A Global Perspective

Cl a s s I m alocclusion patient Adult orthodontics Diagnosis Est h et ics Etiology Em ergence pro le Tr e a t m ent planning Periodontal considerations Tr e a t m ent planning complex cases Class II m alocclusion patient Lim itations of reconstructive techniques Diagnosis Etiology Noncompliance treatment Tr e a t m ent planning Headgear TAD Functional appliances Accelerated osteogenic orthodontics (e.g., Class III m alocclusion patient Wilckodontics) Diagnosis Etiology Practice management Tr e a t m ent planning Sterilization and disinfection protocols Fa ce m ask, chin cup Orthodontic practice: setting up/the design process Vertical problems Orthodontic practice: engaging with the Open bite team/the building process Deep bite Medical and legal aspects of orthodontic care Diagnosis Practice visits and discussion with private Etiology practitioners Tr e a t m ent planning Professional ethics

Maxillary constriction Rapid maxillary expansion Diagnosis Acknowledgements Appliances (Quad-helix, Haas and Hyrax expanders) The authors of this document express their

E ects on periodontium appreciation to the members of the WFO E ect s on air w ay Exe cu t ive Com m ittee: Professor Athanasios E. Athanasiou, president, Thessaloniki, Greece; Orthodontic diagnosis in 3 dimensions of Professor Abbas R. Zaher, vice president, space Alexandria, Egypt; Dr. William H. DeKock, Sagit t al secretary-general, Cedar Rapids, Iowa, USA; Transverse Dr. Jam es E. Gjerset, Georgetown, Texas, USA; Ve r t i c a l Professor Julia F. Har n, Buenos Aires, Argen- Ap p lia n ces tina; Professor Roberto Justus, Mexico City, Mexico; Dr. Larson R. Keso, Oklahoma City, Orthodontic techniques Oklahom a, USA; Dr. Jung Kook Kim, Seoul, St ra igh t -w ire South Korea; Professor Francesca A. Miotti, Tw e e d Padova, Italy; Dr. Richard J. Olive, Brisbane, Ricket t s Australia; Dr. Somchai Satravaha, Bangkok, Standard edgewise Thailand; Dr. Allan R. Thom, London, Englan d, Tip - e dge United Kingdom; and Dr. B. Ian Watson, Gle- Self-ligating techniques nelg, South Australia, Australia for appointing Clear sequential appliances them to the WFO Task Force on Guidelines for Postgraduate Orthodontic Education, for Cleft lip and/or palate treatm ent providing valuable editorial comm ents and Indications, timing, protocols accepting on March 29, 2009, these guidelines Interdisciplinary approach as WFO policy. Speech therapy Psychological involvement Index

A All India Institute of Medical Sciences – Begg appliance, 100 (AIIMS), 99–102, 105 – in Canadian curriculum, 55 AAO. See American Association of Am erican Association of Orthodontists – comm ercialism and, 145 Orthodontists (AAO) – con icts of interest and, 152 ABO (Am erican Board of Orthodontics), – board certi cation and, 112, 113 – in early 20th century, 148 44, 112–115 – CCGOPD and, 54 – Erasmus program on, 29 Aboriginal and Torres Strait Islander – Council on Orthodontic Education, 11 – in Middle East/African curricula, (ATSI) dental specialty workforce, 77 – forerunner of, 147 83–87 academic education and organization, – founding of, 3 – in Nepal, 107 assessment criteria and m ethods – preceptorship program, 6–8, 10 – research and, 163 for, 186 – precursor to, 9 – Twin Blok appliance, 100 academic institutions, ranking of, – standardization of m embership in, 3–5 – undergraduate knowledge of, 17, 18 182–190 – Web program, 136–137 ARCP (annual review of competence academic research. See research Am erican Board of Orthodontics (ABO), progression), 40 accreditation, 37, 73, 74–79, 188–190. 44, 112–115 area of origin, for journal articles, 154, See also Comm ission on Dental Am erican College of Dentists, on young 155 Accreditation (CODA); Comm ission editors, 148–149 Argentina, postgraduate programs on Dental Accreditation of Canada; Am erican Dental Association (ADA), 7, in, 63 regulatory organizations 11. See also Comm ission on Dental asepsis and infection control, U.S. ADA. See American Dental Association Accreditation (CODA) standards on, 47–48

ADC (Australian Dental Council), 73 Am erican Journal of Orthodontics and Asian Paci c Orthodontic Conferences, ADC/DCNZ (Australian Dental Council/ Dentofacial Orthopedics (AJO-DO), 103 Dental Council of New Zealand), acceptance rate for, 154 Asian Paci c Orthodontic Society, 103, 74–79 The Am erican Orthodontist (journal), 107, 108, 109 ADC/DCNZ Accreditation Com m ittee, 73 establishment of, 147–148 ASO (Australian Society of ADC/DCNZ Accreditation Standards: Am erican Society of Dental Surgeons, 1 Orthodontists), 73, 79–81, 136–137 Education Programs for Dental Am erican Society of Orthodontists, assessment(s) Specialties, 74–79 2, 147 – assessment bodies, 183 ADEE (Association of Dental Education Am erican University of Beirut, 86 – by colleges, UK, 123 in Europe), 18 Am erican University of Sharjah (AUS), – of dental education programs, current Adelaide, University of, 73 131 status of, 164–165 admissions policies and procedures, andragogy, 130, 133 – external, of postgraduate programs, ADC/DCNZ Accreditation Standards anesthesiologists in turf wars, 14 31–32 on, 76 Angle, Edward Hartley, 1–2, 9, 73, 147, – of graduating classes, in East and advanced e-learning tools, 129–130 148, 155 Southeast Asia, 70 Advanced Network for Research and The Angle Orthodontist (journal), – of learning methods, 19–20 Ed u cat ion (UAE), 131 establishment of, 148 – Miller assessment pyramid, 137 advertising and comm ercialism, in Angle School (later College) of – in online learning management scienti c journals, 155–156 Orthodontia, 2, 3, 9, 147 systems, 137 Afghanistan “The Angle System of Regulating Teeth” – self-assessment process, ADC/DCNZ – lack of information on, 106, 109 (Angle), 1 Accreditation Standards on, 78 – as SAARC member, 88 animals, protection of, in research, 150 – standard setting of exam inations, UK, Africa, 83–84 Ankabut (educational cloud), 131 122–123 Ah m ed, Ra udin, 88 annual review of competence – of students, ADC/DCNZ Accreditation AJO-DO (Am erican Journal of progression (ARCP), 40 Standards on, 77 Orthodontics and Dentofacial appliances (dental) – in UK, 36–37 Orthopedics), acceptance rate for, 154 – Angle’s knowledge of, 3 – at W VU, 44–45 Alberta, University of, 52 219 220 Orthodontic Postgraduate Education: A Global Perspective

assessment criteria and methods, Be r n e r s- Le e, Tim , 128 CDAC (Co m m ission on Dental evolution of, 182–190 Bhore, Joseph, 91 Accreditation of Canada), 52–53, – academic education and organization, Bh u t a n 55–56 186 – lack of inform ation on, 106, 109 Centre for Dental Education and – accreditation and self-assessment, – as SAARC m ember, 88 Research (India), 101 188–190 biomechanics, e-learning of, 138 Certi cate of Completion of Specialty – assessment bodies, 183 Biom ed 2 Project (EURO-QUAL II), 26, 32 Training (CCST), 40 – clinical training, assessm ent of, biomedical sciences curriculum, U.S. certi cation, by orthodontic boards, 185–186 standards on, 49 112–116 – facilities, assessment of, 185 blended learning, 19, 129, 132–133 certi ed registered nurse anesthetists, 14 – general considerations, 188 blogs, electronic journal publishing CEX (clinical evaluation exercises), 37 – overview, 182 and, 159 Chile, postgraduate programs in, 63 – postgraduate programs, assessment board certi cation, 112–116 Ch in a . See East Asia, Southeast Asia, of, 184–185 Bolivia, postgraduate programs in, 63 and China – professional and clinical program BOS (Bangladesh Orthodontic Society), Clark, William , 100 assessment, problems of, 183–184 106, 107 clear aligner therapy, 57 – research, assessment of, 186–188 B.P. Koirala Institute of Health Sciences clinical and research data, U.S. standards – teaching, assessment of, 188 (Nepal), 108 on imaging equipment for, 48 Association of Dental Education in Brazil, postgraduate programs in, 62 clinical application and translation, of Eu rop e (ADEE), 1 8 Brazilian Board of Orthodontics and research, 165–166 asynchronous online learning, 138 Facial Orthopedics, 114, 116 clinical evaluation exercises (CEX), 37 Atkinson, Spencer R., 3, 148 Bristol, University of, 129 clinical example, for research, 166–180 ATSI (Aboriginal and Torres Strait Br it a in . See England; United Kingdom clinical excellence, maintaining, Islander) dental specialty workforce, British Columbia, University of, 52, 54 115–116 77 British India, 88, 91 clinical facilities, guidelines on, 81 AUS (Am erican University of Sharjah), 131 British Orthodontic Society (BOS), clinical inform ation, sources of, 145 Australasian Orthodontic Board, 113, 115 36, 40 clinical sciences curriculum , U.S. Australian Dental Council (ADC), 73 British Science Festival, 153 standards on, 49–50 Australian Dental Council/Dental Brod ie , Allan G., 3, 23 clinical supplies, U.S. standards on, 47 Council of New Zealand (ADC/DCNZ), BSMMU (Bangabandhu Sheikh Mujib clinical training, 35, 80, 165, 185–186 74–79 Medical University, Bangladesh), 107 clinical trials, obligation to register, 150 Australian Societ y of Orthodontists Burki, Wajid Ali, 103 CODA. See Comm ission on Dental (ASO), 73, 79–81, 136–137 Accreditation authorship credit, for scienti c journal C College of Dentistry (University of articles, 149 CAL (computer-assisted learning), 19 Illinois Chicago), 3

California San Francisco, University College of Physicians and Surgeons B of (UCSF) School of Dentistry, Pakistan (CPSP), 103, 105 Baker, Charles R., 3 “Curriculum II,” 10 colleges, independent and external Ba lt im ore College of Dental Surgery, 1 Canada, 52–58 (UK), 123 Bangabandhu Sheikh Mujib Medical – graduate curriculum, 55–56 Colo m bia, postgraduate programs in, 62 University (BSMMU, Bangladesh), 107 – graduate education, challenges facing, Colo m bian Society of Orthodontics, 62 Bangladesh 56–57 Colo m bo, University of, Postgraduate – education in, 104, 106–107 – graduate programs, 54–55 Institute of Medicine (Sri Lanka), 109 – formation of, 91 – match system, 54 Colu m bia University, 1, 2, 9 – as SAARC member, 88 – regulatory organizations, 52–54 com m ercialism, 145, 155–156, 163 Bangladesh College of Physicians and – residents’ program evaluations, 56 Com m ission for Academ ic Accreditation Surgeons, 106 Canadian Association of Orthodontists (CAA, UAE), 13 2 Bangladesh Journal of Orthodontics (CAO), 54, 55 Com m ission of the European and Dentofacial Orthopedics, Canadian Council of Graduate Com m unities, European Cultural establishment of, 107 Orthodontic Program Directors Foundation, Erasmus Bureau, 26 Bangladesh Orthodontic Society (BOS), (CCGOPD), 54 Com m ission on Dental Accreditation 106, 107 Canadian Dental Association, 52 (CODA), 11, 12, 42–43, 52–53. See also Barts and the London School of Case, Calvin, 147 United States, CODA standards Medicine and Dentistry (Queen Mary cases Com m ission on Dental Accreditation of Un iversit y), 35 – case-based discussions (CBD), as Canada (CDAC), 52–53, 55–56 “Basic Principles of Orthodontics” assessment method, 37 Com m ittee of Postgraduate Dental (Johnson), 2 – case logs, guidelines on, 80 Deans and Directors (COPDEND, UK), Begg appliances, 100 – case presentations, in UK, 37 39, 119–120 Beirut Arab University, 86 – case reports, 69, 157–159 Com m ittee on National and Regional Belgiu m – numbers of, guidelines on, 80 Orthodontic Boards (WFO), 114 – education in, 27 CCGOPD (Canadian Council of Graduate com m unity interface, ADC/DCNZ – EFOSA and, 27 Orthodontic Program Directors), 54 Accreditation Standards on, 76 Index221 competencies, assessment of, 20 – in Iraq, 84 – and treatment planning, controversies computer-assisted learning (CAL), 19 – in Middle East, 83–87 in, 162 computer languages, for e-learning, 130 – in Nepal, 108 diagnostic tests assessment, in UK, 37 Co m puters & Education (journal), on – research papers for, 186 diplom a in orthodontics (DOrth, India), multimedia learning, 131 – in Sri Lanka, 109 101 con icts of interest, 13, 151–152, 155 – in UK, 34, 35, 40, 117, 122 directives, of European Union, 24–26 continuing education (continuing – in U.S., 49, 164 direct observation of procedural skills professional development, CPD), 71, – in U.S., for faculty, 187 (DOPS), 37 115–116, 137–138, 144–146 De’Montm orency, Geo rey Fritz Harvey, directors. See program directors continuous improvements, ADC/DCNZ 103 discussion, in case reports, 158 Accreditation Standards on, 74 De’Montm orency College of Dentistry dissertation/research theses, 37–38, 70 “cookbook training,” 162, 163 (Lahore, India), 88, 103 do-it-yourself orthodontic kits, 57 COPDEND (Com m ittee of Postgraduate Denm ark, EFOSA and, 27 Dom inican Republic, postgraduate Dental Deans and Directors, UK), 39, Dental Board of Australia, 73 programs in, 62 119–120 Dental Council of India (DCI), 88, 91, 99, DOPS (direct observation of procedural CopestheticCE Web site, 135–136, 137 100, 101, 102 skills), 37 copyright ownership, for journal Dental Council of New Zealand (DCNZ), DOrth (diplom a in orthodontics, India), articles, 150–151 73 101 corporations, program support and dental education programs, current double doctoral degree program con icts of interest, 13 status of assessments of, 164–165 (China), 67, 68 Council on Dental Education, 7–8 dental foundation (DF), 117, 119 DSA (dentist scientist award) program , courses. See programs of education Dental Gold Guide (UK), 39 187 CPD (continuing professional dental health regulation (UK), role of DSATP (dental specialty assessment and development, continuing education), dental faculties in, 120–121 training programs), 53–54 71, 115–116, 137–138, 144–146 “Dental Health Services in Canada” DSCKE (dental specialty core knowledge CPSP (College of Physicians and (Canadian Dental Association), 52 examination), 53–54 Surgeons Pakistan), 103, 105 dental schools dual coding theory, 130 critical thinking, 145–146 – in East Asia, 66–67 due process, U.S. standards on, 51 CrossCheck (plagiarism detection – relationship w ith education provider, software), 152 ADC/DCNZ Accreditation Standards E curricula. See also programs of on, 75 early predoctoral and specialty education dental specialty assessment and education, 9–11 – in Canada, 55–56 training programs (DSATP), 53–54 East Asia, Southeast Asia, and China, – in China, 67–69 dental specialty core knowledge 66–72 – historical aspects of postgraduate, examination (DSCKE), 53–54 – applicants, quali cation of, and

1–8 dental specialty students, relationship selection criteria, 67 – in India, 91, 99 w ith education provider, ADC/DCNZ – conclusions on, 71–72 – intercollegiate specialty curriculum Accreditation Standards on, 75 – continuing education, 71 program, 40 dental training robot (Sim uloid), 129 – dental school programs, 66–67 – in Latin Am erica, 61–63, 64 DentEd project (European Union), 21 – department facilities, 71 – in UK, 34–35 dentistry – double doctoral degree program, 67, 68 – U.S. standards on, 48–50 – history of, in Latin Am erica, 59 – eight-year programs, 68 “Curriculum II” (University of California, – turf wars and, 14 – graduating classes, assessment of, 70 San Francisco (UCSF) School of – workforce issues, 13 – orthodontic courses, 68–69 Dentistry), 10 Dentists Act (India, 1948), 91 – orthodontic residents, requirements Cyprus, education in, 27 Dentists Act (UK, 1984), 119 for, 70 dentist scientist award (DSA) program , – PhD and SMD degrees, 67–68 D 187 – research, 69 DCI (Dental Council of India), 88, 91, 99, dentofacial orthopedics, 42 – status of education in, 66 100, 101, 102 DentSim (e-learning program), 130 – teaching teams, quali cations of, DCNZ (Dental Council of New Zealand), Department of Health, Education and 69–70 73 Welfare (UK), 118, 121, 123 – three-year master’s degrees, 67 DDCH (Dhaka Dental College and Desire 2Learn (online learning East Pakistan, 91 Hospital, Bangladesh), 106 management system), 137 Ecuador, postgraduate programs in, 62 degrees Dewey, Martin, 2, 147–148 Edgew ise Technique, 100 – in Australia and New Zealand, 73 Dewey School of Orthodontia, 2 Edison, Thomas, 129 – in East Asia, Southeast Asia, and DF (dental foundation), 117, 119 editors, of journals, role of, 148–149 China, 67–68, 70 Dhaka Dental College and Hospital education. See also continuing – higher, lim ited num ber of educators (DDCH, Bangladesh), 106 education; curricula; programs of with, 57 diagnosis education – in Indian subcontinent, 88, 91, 101–104, – etiology and, in case reports, 157–158 – assessment criteria and methods, 106, 108, 109 – theory vs., in education, 20 evolution of, 182–190 222 Orthodontic Postgraduate Education: A Global Perspective

education (continued) Erasm us program (European evidence-based orthodontics – in Canada, 52–58 Co m m unity Action Scheme for the – education, value in, 162–163 – continuous professional development, Mobility of University Students) – importance of methods for, 12 role of, 144–146 – about, 26–27 – marketing vs., 145 – in East Asia, Southeast Asia, and – on aim s of postgraduate education, – rationale for, 162 China, 66–72 17–18 examinations, 81, 122–123 – Erasmus Project and World Federation – Erasmus-based European programs, examiners (for CODA guidelines), 12–13 of Orthodontists, 125–127 external assessment of, 31–32 exchange programs, in Latin Am erica, – in Europe, 23–33 – guidelines on education, summary of, 30 64 – general aims of, 17–18 – guidelines on theoretical contents of external assessments, of postgraduate – historical aspects of, 1–8 postgraduate education, 28–29 programs, 31–32 – in the Indian subcontinent, 88–111 – initiation of, 21 – in Latin Am erica, 59–65 – international guidelines on, 125–126 F – in the Middle East and Africa, 83–87 – origins of, 26 facilities – objectives of, 66 – purpose of, 23 – assessment of, 185 – in Oceania, 73–82 – on research in education, 21 – guidelines on, 81 – orthodontic boards, educational role ES (elaboration sequencing), 133 – for orthodontic departments, in of, 112–116 ethics, 149, 163 Ch in a , 7 1 – postgraduate programs, 9–22 Europe, 23–33. See also Erasmus – U.S. standards on, 46–48 – research, role of, 162–181 program; European Union facult y. See also sta – scienti c journals, role of, 147–161 – conclusions on education in, 32–33 – in China, quali cations of, 69–70 – technologies, role of new, 128–143 – European Federation of Orthodontic – DSA program and, 187 – in the UK, 34–41, 117–124 Specialists Associations, 27, 31 – income, vs. practitioners, 182 – in the U.S., 42–51 – European Union directives, 24–26 – institutional assessm ents by, 183 Education Department (U.S.), – overview of education in, 23 – in Latin Am erica, 64 recognition of CODA, 43 – program quality and consistency, – shortage of, 21, 129, 182 education providers, ADC/DCNZ approach to, 14–15 – U.S. standards on, 45 Accreditation Standards on interface – undergraduate hours on orthodontics, Faculty of Dental Surgery of the with, 78 17 National Postgraduate Medical Ed u Roam , 131 European Academy of Pediatric College of Nigeria, 84 edutainment, 128, 138–139 Dentistry, 183 Faculty of General Dental Practice EEA (European Economic Area), 24 European Board of Orthodontists, 113, (UK), 122 EFOSA (European Federation of 114, 115 father of orthodontia (Pierre Fauchard), Orthodontic Specialists Associations), European Comm unity Action Scheme 147 23, 27, 31 for the Mobility of University Fauchard, Pierre, 147

Egypt, education in, 83 Students. See Erasmus program FEA ( nite elem ent analysis), 130 eight-year program (China), 68 European Cultural Foundation, Erasmus Federal Drug Administration (FDA), IRB elaboration sequencing (ES), 133 Bureau, 14, 26 review guidelines, 150 e-learning European Economic Area (EEA), 24 Federal Trade Comm ission, 13 – advanced, tools for, 129–130 European Federation of Orthodontic fees – bene ts of, 139 Specialists Associations (EFOSA), 23, – for Canadian graduate programs, 55 – e ectiveness of, 128 27, 31 – for DSCKE, 54 – evaluations of styles of, 135–137 European Orthodontic Society, 31, 125 – for orthodontists from non-accredited – interactive m odules, 138 European Orthodontic Teachers’ programs for RCDC fellowship, 54 – popularity of, 19 For u m s, 31 – for RCDC exam inations, 53 – in UAE, 131–132 European Union. See also Erasmus – for specialty assessm ents in UK, 122 electronic publication, of scienti c program – for training in UK, 38 journals, 159–160 – dentistry, recognition of specialties – for U.S. graduate program s, 55 electrotypodont, 130 in, 20 fellowship in dental surgery (FDS, UK), eligibility and selection of students and – directives, 24–26 122 residents, U.S. standards on, 50–51 – HoTEL, 131 Fellowship of the College of Physicians emotions, learning and, 128 – on standards for undergraduate and Surgeons (FCPS, Pakistan), 103, endodontists in turf wars, 14 education, 21 104, 106 England. See also United Kingdom European University College (formerly fellowship of the Royal College of – DF recruitment in, 117 Nicolas & Asp University College, Surgeon s (FRCS), 122 – EFOSA and, 27 UAE), 87 nal examinations, 27, 31, 70 – Health Education England, 118, 119 EURO-QUAL II (Biom ed 2 Project), 26, nancial resources, ADC/DCNZ English language training, in Latin 32 Accreditation Standards on, 75 Am erica, 63 evaluation. See assessment(s) nite element analysis (FEA), 130 Erasm us Bureau (European Cultural evidence-based dentistry, 48–49 four-dim ensional total arch movement, Foundation), 14, 26 evidence-based medicine, 163 170 Index223

Fr a n ce hazardous materials management, U.S. – National Workshop, “Postgraduate – education in, 27 standards on, 46–47 Orthodontic Education in India,” 101 – EFOSA and, 27 Health and Care Professions Council – postgraduate dental education, 88, – as leader in early dentistry, 147 (UK), 118 91, 99–100 FRCD(C) designation, 53 Health Education England, 39, 40, 118, – as SAARC member, 88 French Board of Orthodontics, 114 119 Indian Board of Orthodontics, 103, full xed orthodontic treatm ent, Health Practitioner Regulation National 114, 115 providers of, in Canada, 57 Law Act (National Law, Australia, Indian subcontinent, 88–111 future goals, in Latin America, 63 2009), 73 – Bangladesh, 106–107 health services, for dental specialty – Bhutan, Maldives, and Afghanistan, G students, 77–78 109 gami cation, 128 Hebrew University Hadassah School of – Dental Council reform s, 101–102 GDC (General Dental Council, UK), Dental Medicine, 85 – India, 88–103 34–35, 38, 40, 118–119, 123 Hellman, Milo, 148 – Nepal, 107–108 General Chiropractic Council (UK), Helsinki Declaration (1975, 2000), 150 – Pakistan, 103, 106 118, 123 hierarchical sequencing (HS), 133 – postgraduate programs in, 104–106 General Dental Council (GDC, UK), high-impact scienti c journals, – Sri Lanka, 108–109 34–35, 38, 40, 118–119, 123 orthodontic topics in, 187 individualized learning, new technology General Medical Council (UK), 118 high-pull headgear, 166 and, 131 General Optical Council (UK), 118 history infection control, U.S. standards on, General Osteopathic Council (UK), 118 – of dental education in Indian 47–48 General Pharmaceutical Council (UK), subcontinent, 88–91, 99–100 infectious disease control and biohazards 118 – of dentistry in Latin Am erica, 59 comm ittee (WVU), 46, 47–48 geographic origin, for journal articles, – of postgraduate curriculum inform ation transfer, speed of, 128 154, 155 form ulation, 1–8 initial accreditation status (U.S.), 42 Germ an Board of Orthodontics and Holistic Approach to Technology Insignia (treatment modality), 133 Orofacial Orthopedics, 114, 115 Enhanced Learning (HoTEL), 131 In st it ute for Scien t i c In form ation, Germ any Hossain, Zakir, 106, 107 author database, 153–154 – education in, 27 HoTEL (Holistic Approach to Technology institutional comm itm ent/program – EFOSA and, 27 Enhanced Learning), 131 e ectiveness, U.S. standards on, (G)nathos Web site, 135, 137 HS (hierarchical sequencing), 133 43–45 Goldschleger School of Dental Medicine human subjects and animals, protection institutional review boards (IRBs), (Tel Aviv), 85 of, 150 149–150 Governm ent Dental College and institutions, ranking of, 182 Hospital (India), 91 instructors. See sta ; teaching I graduate education. See also entries ICDE (International Council for Open instrum ent sterilization, U.S. standards beginning “postgraduate” and Distance Education), 131 on, 47 – in Canada, 54–57 Icelan d interactive media, 129 great extraction debate, 147, 162 – education in, 27 intercollegiate specialty curriculum Great Lakes Society of Orthodontists, – in EEA, 24 program (ISCP), 40 3–4 ICMJE (International Comm ittee of intercollegiate specialty fellowship growth modi cation, 163, 168 Medical Journal Editors), 150, 152, examination (ISFE), 40 Guatem ala, postgraduate programs 157 interdisciplinary teamwork, in Latin in, 62 Illinois at Chicago, University of, College Am erica, 63–64 Guidelines for the Establishm ent of New of Dentistry, 3, 23 internal program evaluations, National and Regional Orthodontic im aging equipment for clinical and guidelines on, 81 Boards (WFO), 114 research data, U.S. standards on, 48 International Association of Dental Guilford, Sim eon H., 1 Incognito (treatment modality), 133 Research, 2 Gutenberg, Johannes, 128 independent and external colleges International Comm ittee of Medical (UK), 123 Journal Editors (ICMJE), 150, 152, 157 H India, 88–103 International Council for Open and Ham dan Bin Mohamm ad e-University – chronology of signi cant dental- Distance Education (ICDE), 131 (HBMeU), 131 related events, 89–90 international m ovements, contents of Ham dan Bin Mohamm ed College of – Dental Council of India, education undergraduate education and, 20–21 Dental Medicine (UAE), 86, 137 reforms by, 101–102 International School of Orthodontia, 2 hapū, 77 – Indian Orthodontic Society, 101, introduction, in case reports, 157 Haq, Em adul, 106 102–103 An Introduction to the History of Harm ony (treatment modality), 133 – institutions granting MDS Dentistry (Weinberger), 148 Harris, Chapin A., 1 quali cation, 92–99 Invisalign, 133 Harvard-Forsyth, graduate program in – National Board of Exam inations, IOS (Indian Orthodontic Society), 101, orthodontics, 9 100–101 102–103 224 Orthodontic Postgraduate Education: A Global Perspective

Iraq, education in, 84–85 – future goals, 63–65 Membership of the Faculty of Dental IRBs (institutional review boards), – history of dentistry in, 59 Surgeons (MFDS)/MJDF (Membership 149–150 – orthodontic societies, 59 of the Joint Dental Faculties), 119 Irelan d – postgraduate programs, 59, 61–63 Merchant, H.D., 102 – EFOSA and, 27 – subregions, 60 Mershon, John V., 2–3 – examinations in, 31 learning algorithm path (LEAP), 132, Mexican Academy of Orthodontics, 63 – Northern Ireland Medical and Dental 137 Mexico, postgraduate programs in, 63 Training Agency, 118 learning management systems, 128 Michigan, University of, 2 “Irregularities of the Teeth” (Angle), 1 learning methods, evaluation of, 19–20. Middle East and Africa, 83–87 Irregularities of the Teeth and Their See also e-learning; virtual learning millennials, 128, 131 Trea t m ent (Talbot), 1 Lebanese University, 86 Miller assessment pyramid, 137 Isaacson, Robert, 186 Lebanon, education in, 85–86 Ministry of Education (UAE), 131 ISCP (intercollegiate specialty lectures. as UK teaching m ethod, 36 Ministry of Health (India), 102 curriculum program), 40 LETBs (local education and training Mishra, Praveen, 108 ISFE (intercollegiate specialty fellowship boards, formerly postgraduate MIST (Masdar Institute), 131 examination), 40 deaneries), 117, 119, 120 mobility, undergraduate education and, Israel letters to the editor, electronic 20–21 – education in, 85 publication of, 159 model group practices, 186 – EFOSA and, 27 library resources, ADC/DCNZ modular object-oriented dynamic issues (quality issues), 81 Accreditation Standards on, 76 learning environment (MOODLE), 132 Italian Board of Orthodontics, 116 Liechtenstein, in EEA, 24 Mohamm ed Bin Rashid University of Italy, EFOSA and, 27 lifetim e certi cation, 115 Medicine and Health Sciences, 86 iw i, 77 Lim popo, University of, 84 Mohamm ed V University (Morocco), 84 local education and training boards molar intrusion for vertical correction, 166 J (LETBs, form erly postgraduate Montreal, University of, 52 Ja p a n deaneries), 117, 119, 120 MOOCs (m assive open online courses), – advanced e-learning tools in, 129–130 log books, use in assessment, 20 132 – medical degrees in, 67 London, University of, 130 Morocco, education in, 84 JIOS (Journal of Indian Orthodontic Lu x e m bourg, education in, 27 MOrth (Mem bership in Orthodontics), Society), publication of, 103 34, 38 Johnson, A. LeRoy, 2 M MS (macro-sequencing), 133 Jordan University of Science and macro-sequencing (MS), 133 multimedia tasks, use in learning, 19 Technology, 86 Maldives multiple-source feedback (MSF), 37 Jordan, education in, 86 – lack of inform ation on, 106, 109 Journal of Clinical Orthodontics, – as SAARC m ember, 88 N establishment of, 148 Malmö University (Sweden), 87 Nair Hospital Dental College (India), 91 Journal of Indian Orthodontic Society Malocclusion of the Teeth (Angle), 1 Nanda, Ram, 100 (JIOS), publication of, 103 m anagem ent structure, ADC/DCNZ National Academy of Medical Sciences Journal of the World Federation of Accreditation Standards on, 75 Bir Hospital (Nepal), 108 Orthodontists (formerly World Journal mana Māori principles, ADC/DCNZ National Board of Examinations (NBE, of Orthodontics), establishment of, 148 Accreditation Standards on, 77 India), 100–101 journals. See scienti c journals, role of; Manitoba, University of, 52 National Dental Exam ining Board of titles of individual journals manual skills, as part of undergraduate Canada (NDEB), 53–54 education, 18–19 National Institute of Dental and K manuscript preparation, for scienti c Craniofacial Research (U.S.), 187 Ka t h m andu University, 108 journals, guidelines for, 157 National Institutes of Health (U.S.), 151 Ke t ch a m , Albert H., 112 marketing, de nition of, 145 National Law (Health Practitioner key ridge, origin of term, 3 Masdar Institute (MIST), 131 Regulation National Law Act, Khalifa University of Science & Technology massive open online courses (MOOCs), Australia, 2009), 73 and Research (KUSTAR), 131 132 National Strategic Fram ework for Kh a r t o u m , University of, 84 Master of Dental Surgery (MDS) courses Aboriginal and Torres Strait Islander Kingsley, Norman, 1, 147 (India), 91 Health, 77 KL Wig Centre for Medical Education match systems, 13, 54 National Workshop (“Postgraduate and Technology (India), 101 McCoy, James D., 3 Orthodontic Education in India”), 101 Korea, academic research in, 164 McCoy, John, 3 NBE (National Board of Examinations, KUSTAR (Khalifa University of Science & Medical Council of India (MCI), 101 India), 100–101 Technology and Research), 131 medical-dental triangle, 121 NDEB (Nat ion al Den t al Exam ining medical educationists, new technology Board of Canada), 53–54 L and, 130–131 NEBEOP (Network of Erasmus-Based Lagos University Teaching Hospital, 84 Melbourne, University of, 73 European Orthodontic Postgraduate La t in Am erica, 59–65 Membership in Orthodontics (MOrth), Programm es), 14–15, 23, 26–27, – description of, 59 34, 38 31–33, 125–126 Index225 negative studies, obligation to publish, optometrists in turf wars, 14 PGIMER (Post Graduate Institute of 154–155 oral and maxillofacial surgery, 11, 12, 14 Medical Education and Research, Nepal Orthodontic and Dentofacial India), 102, 105 – education in, 104, 107–108 Orthopedic Association of Nepal Pharm aceutical Society of Northern – as SAARC m ember, 88 (ODOAN), 108 Ireland (UK), 118 Nepal Medical Council, 108 orthodontic biomechanics, examples of Philadelphia Dental College, 1 Netherlands research on, 165–180 Philippine Board of Orthodontics, 114, – education in, 27 Orthodontic Journal of Nepal, 115 – EFOSA and, 27 publication of, 108 photo releases, for journal articles, 157 – postgraduate programs in, 23 orthodontics (orthodontia). See also PIEQA (Postgraduate Independent Network of Erasmus-Based European education; names of individual External Quality Assurance), 121, 123 Orthodontic Postgraduate countries PKUSS (Peking University School of Programm es (NEBEOP), 14–15, 23, – de nition of, 42 St om atology), 68–71 26–27, 31–33, 125–126 – early history of, 147 plagiarism, journal articles and, 151 neurosurgery in turf wars, 14 – rst textbook on, 1 plastic surgery in turf wars, 14 The New England Journal of Medicine – setting for, 11 Poland, education in, 27 – con ict of interest policy, 156 – turf wars and, 14 postgraduate deaneries (later local – editor of, 151 – use of new technologies in, 132–133 education and training boards, new technologies. See technologies, orthodontic societies. See names of LETBs), 117, 119, 120 role of new individual societies, e.g., Pakistan Postgraduate Independent External New York University, 2, 9 Association of Orthodontists Quality Assurance (PIEQA), 121, 123 New Zealand. See also Oceania orthodontic specialty education. See Post Graduate Institute of Medical – patient education study, 132 education Ed u cat ion an d Research (PGIMER, NHS Education for Scotland, 118, 119 orthognathic surgery, 11 India), 102, 105 Nicolas & Asp University College orthopedics in turf wars, 14 Postgraduate Institute of Medicine (later European University College, OSCE (objective structured clinical University of Colombo (Sri Lanka), 109 UAE), 87 examinations), 37 “Postgraduate Orthodontic Education Nigeria, education in, 84 osteopathy in turf wars, 14 in India” (National Workshop, India), Noble, Henry Bliss, 1 Otago, University of, 73 101 North Am erica, academic research in, otolaryngology in turf wars, 14 postgraduate programs, 9–22 165. See also Canada; United States – assessment criteria for, 184–185 North Carolina, University of, Web P – comparison with other selected areas program, 136–137 Paci c, University of the, School of of dental specialty education, 11–12 Northern Ireland Dentistry, 3 – conclusions on, 15 – DF recruitm ent in, 117 Pakistan – curriculum for, in Latin Am erica,

– Pharmaceutical Society of Northern – education in, 103–106 61–63 Ireland, 118 – as SAARC member, 88 – early predoctoral and specialty Northern Ireland Medical and Dental Pakistan Association of Orthodontists education, 9–11 Training Agency, 118, 119 (PAO), 103, 106 – in Indian subcontinent, 88, 91–100, Northwestern University, 3 Pakistan Orthodontic Journal, 104–106 Norway, in EEA, 24 publication of, 106 – in Latin Am erica, 59, 61 Noyes, Frederick B., 3 Panam a – learning, evaluation of, 19–20 Nursing & Midw ifery Council (UK), 118 – English-language training in, 63 – orthodontic education, general aims – postgraduate programs in, 62 of, 17–18 O Papadopoulou, Alexandra K., 66 – orthodontic specialty programs, objective structured clinical Parikh, Naishadh, 102 challenges to, 12–13 examinations (OSCE), 37 patient education, new technology – program quality and consistency, Oceania, 73–82 and, 132 European approach to, 14–15 – Australian Dental Council/Dental patient management, guidelines on, 80 – teaching, developments and trends Council of New Zealand accreditation PBL (problem-based learning), 19, 35 in, 19 standards, 74–79 pediatric dentistry, 11–12 – turf wars and, 14 – Australian Society of Orthodontist peer review, 74–75, 153–154, 155 – in UK, 119–122 education comm ittee guidelines, Peer Review Survey (2009), 153–154 – undergraduate education and, 17–21 79–81 Peking University, 67 practical and technique courses, as UK – overview, 73 Peking University School of Stomatology teaching method, 36 ODOAN (Orthodontic and Dentofacial (PKUSS), 68–71 practical assessments, in UK, 36 Orthopedic Association of Nepal), 108 Pennsylvania, University of, 2 practitioners, recognition of, in EU, 24 online learning, 36, 128, 130–131, 140. Peradeniya, University of, Faculty of preceptorships, 3–8, 10, 27, 188 See also e-learning Dental Sciences (Sri Lanka), 108 premolars, extraction of, 162, 166 open source distribution, of journal periodontics, 11–12, 14 prerequisites for application to specialty articles, 151 personalized learning, 132 programs, guidelines on, 79–80 ophthalmologists in turf wars, 14 Peru, postgraduate programs in, 63 Pretoria, University of, 84 226 Orthodontic Postgraduate Education: A Global Perspective

printing press, 128 – in Asia, 69 Sattar, Mostaque Hasan, 107 private o ce facilities, U.S. standards – assessment of, 186–188 SBLi (Scenario-Based Learning on, 48 – in China, 68, 69 Interactive), 133–135, 137 problem-based learning (PBL), 19, 35 – comm ercialization of, 152 Scandinavia, postgraduate programs professional and clinical program – environments for, 164 in, 23 assessment, 183–184 – lack of in uence of, 187–188 Scenario-Based Learning Interactive professional development. See – in Latin Am erica, 61, 63, 64 (SBLi), 133–135, 137 continuing education – as part of education, 21 Scholarly Publishing and Academic Professional Standards Authority (PSA, – in specialty areas, 12 Resources Coalition (SPARC), 151 UK), 118 – student acquaintance with, 186 scholarship and expertise, ADC/DCNZ program directors, 11, 45, 57, 64, 79 – in UK, 34–35, 37–38, 117 Accreditation Standards on, 77 programs of education. See also – U.S. standards on, 48, 51 scholarships, in Latin America, 64 curricula; degrees; program research, role of, 162–181 School of Graduate Dentistry at Ram bam directors; sta ; students; teaching; – clinical application and translation, Health Care Campus (Israel), 85 names of individual countries 165–166 science, in orthodontics, 10, 12. See also – content, guidelines on, 80 – clinical example for, 166–180 entries beginning “evidence-based” – course objectives, guidelines on, 79 – clinical program s and, 165 scienti c journals, role of, 147–161 – duration of, U.S. standards on, 49 – dental education programs, current – advertising and comm ercialism, – e ectiveness/institutional status of assessments of, 164–165 155–156 comm itment, U.S. standards on, – evidence-based education, value of, – authorship credit, 149 43–45 162–163 – clinical trials, obligation to register, – evaluations of, by Canadian residents, – main body of research, 163–164 150 56 – orthodontic diagnosis and treatm ent – conclusions on, 159–160 – outcomes evaluation, ADC/DCNZ planning, controversies in, 162 – con icts of interest, 151–152 Accreditation Standards on, 78 residents (medical graduates) – copyright ow nership, 150–151 – quality and consistency of, European – board certi cation and, 114 – electronic publication of, 159–160 approach to, 14–15 – in China, 70 – human subjects and animals, – structure of, guidelines on, 80 – at congresses and m eetings in Latin protection of, 150 – in UK, applying for, 38–41 Am erica, 64–65 – institutional review boards, 149–150 prosthodontists in turf wars, 14 – evaluation of Canadian programs, 56 – journal editor, role of, 148–149 PSA (Professional Standards Authority, – in India, 99 – manuscript preparation, guidelines UK), 118 – in Latin Am erica, 61 for, 157 psychiatrists and psychologists in turf – match system for, 13 – negative studies, obligation to publish, wars, 14 – U.S. standards on, 50–51 154–155 resources and facilities, U.S. standards – orthodontic case reports, guidelines

Q on, 46–48 for, 157–159 Queensland, University of, 73, 133–137, retainers, vulcanite plates as, 1 – overview, 147–148 138 Royal College of Dentists of Canada – peer review and, 153–154 (RCDC), 5 3 , 5 4 – photo releases, 157 R Royal College of Pathologists, 120 Scotlan d radiology, at WVU, 46 Royal College of Physicians and – DF recruitm ent in, 117 RCDC (Roya l Co lle ge o f De n t ist s o f Surgeons of Glasgow, 120 – NHS Education for Scotland, 118, 119 Canada), 53, 54 Royal College of Radiologists, 120 selection of students and residents, U.S. recerti cation, 64, 115 Royal College of Surgeons, 34, 38, 39, standards on, 50–51 Re co n o cim iento de Validez O cial 40, 120–121 self-assessment guide (NEBEOP), 37 de Estudios (RVOE, Recognition of Royal College of Surgeons in Ireland, 120 self-ligating brackets, debate over, 163 O cial Validity of Studies), 63 Royal College of Surgeons of Edinburgh, seminars and problem-solving sessions, regulations on education (UK), 121 86, 87, 108, 120, 122 as UK teaching m ethod, 36 regulatory organizations. See also Royal College of Surgeons of England, Sense About Science (charitable trust), Co m m ission on Dental Accreditation 120, 122 153–154 – Australian Dental Council/Dental Royal Colleges, 23, 31, 120, 123 settings, for specialties, 11 Council of New Zealand accreditation RVOE (Reconocimiento de Validez Sim Plant, 129 standards, 74–79 O cial de Estudios, Recognition of Sim uloid (dental training robot), 129 – in Canada, 52–54 O cial Validity of Studies), 63 Sin gh , Sh a m bhu Man, 108 – Professional Standards Authority Sir CEM Dental College (Bom bay), 100 (UK), 118 S Skype, 138 rejection, of journal articles, 154, 155, 156 SAARC (South Asian Association for SLOS (Sri Lanka Orthodontic Society), 109 relapse phenomenon, 2–3 Regional Cooperation), 88, 103, 107, SMD (stom atologic MD) degree, 67, 68 Relm an, Arnold, 151 109 social workers in turf wars, 14 research Saint Joseph University, 85 Society of Orthodontics (U.S.), 9 – ADC/DCNZ Accreditation Standards salaried specialty registrar (StR) Society of Orthodontics of Venezuela, 62 on, 78 training, 38–41 South Africa, education in, 84 Index227

South Asian Association for Regional – methods of, in UK, 35 – demands on, from current Cooperation (SAARC), 88, 103, 107, 109 – by specialty students, guidelines on, 80 postgraduate education, 20 Southeast Asia. See East Asia, Southeast teaching facilities, ADC/DCNZ – in East and Southeast Asia, 66 Asia, and China Accreditation Standards on, 75–76 – future perspectives on, 21 Southern California School of Dentistry, teamwork, interdisciplinary, in Latin – international movements and University of, 3 Am erica, 63–64 contents of, 20–21 SPARC (Scholarly Publishing and technique courses, as UK teaching – postgraduate programs and, 17–21 Aca d e m ic Resources Coalition), 151 method, 36 – by specialty students, standards and specialist associations, in Europe, 27 technologies, role of new, 128–143 guidelines on, 78, 80 specialist dental training. See education – advanced e-learning tools, 129–130 – in UK, 121 Specialty Advisory Comm ittee for – computer languages for teaching Un iform Requ irem ents for Manuscripts Orthodontics, Royal College of modules, 130 Su bm itted to Biom edical Journals, Surgeon s, 39 – conclusions and recom m endations 152, 157 Sri Lan ka on, 139–140 United Arab Emirates (UAE) – education in, 106, 108–109 – e-learning, evaluations of styles of, – education in, 86–87 – as SAARC m ember, 88 135–137 – e-learning in, 131–132 Sri Lanka Dental Association, 108 – e-learning, in UAE, 131–132 United Kingdom, 34–41. See also United Sri Lanka Orthodontic Society (SLOS), 109 – future of, 137–139, 145–146 Kin gd o m , structure and organization S. S. White (dental supplier), 148 – individualized learning and, 131 of education in sta . See also faculty – interactive m edia, 129 – additional information, sources of, 41 – academic, guidelines on, 79 – online learning, 130–131 – assessments and examinations, 36–37 – ADC/DCNZ Accreditation Standards – overview, 128–129 – clinical practice, 35 on, 75, 76 – patient education and, 132 – examinations in, 31 statistics, in specialty areas, 12 – possible additional technologies, 132 – General Dental Council curriculum, stomatologic MD (SMD) degree, 67, 68 – scenario-based interactive learning, 34–35 straight wire appliances, use in India, 100 133–135 – learning types, study of, 19 structured clinical reasoning, – simulation e-learning, 130–131 – Membership in Orthodontics, 38 assessment of, in UK, 37 – use in orthodontics, 132–133 – program applications, 38–41 students. See also residents (medical – virtual reality, 131 – research thesis/dissertation, graduates); undergraduate education theory, diagnosis vs., in education, 20 presentation of, 37–38 – ADC/DCNZ Accreditation Standards thesis presentation, in UK, 37–38 – teaching methods, 35–36 on, 77–78 3M Web site, 138 – training, costs of, 38 – numbers of, guidelines on, 80 three-year master’s degrees, 67 – treatment planning assessments, 37 – support m echanisms for, guidelines “Three Years Postgraduate Programm e – UK Com m ittee of Postgraduate Dental on, 79 in Orthodontics: The Final Report Deans and Directors, 40

– U.S. standards on, 50–51 of the Erasmus Project” (NEBEOP), – UK Visas and Im m igration, 40 subregions, of Latin America, 60 14–15, 26, 125 – undergraduate education in, 18 Sudan, education in, 84 tip edge technique, 100 United Kingdom , structure and summ ary and conclusions, in case Toronto, University of, 52 organization of education in, 117–124. reports, 158–159 training, information and orientation See also entries beginning “Royal support mechanisms, for specialt y on, in Latin America, 65 College” students, guidelines on, 79 Treatise on Oral Deformities as a Branch – dental health regulation, role of The Surgeon Dentist: A Treatise on the of Mechanical Surgery (Kingsley), 147 dental faculties in, 120–121 Teeth (Fauchard), 147 treatment details, in case reports, 158 – Department of Health, 118 Swedish National Board of Health and treatment planning, 37, 162 – examinations, standard setting for, Welfare, 87 Treaty of Waitany, 77 122–123 Sw itzerland Tribhuvan University (Nepal), 108 – General Dental Council, 118–119 – education in, 27 turf wars among specialties, 14 – independent and external colleges, 123 – postgraduate programs in, 23 Turkey, EFOSA and, 27 – overview, 117–118 SWOT analysis, ADC/DCNZ Tweed, C.H., 162 – postgraduate independent external Accreditation Standards on, 79 Tweed edgewise technique, 100 quality assurance, 121 Sydney, University of, 73 Tw in Blok appliance, 100 – postgraduate training, 119–120 Tw itter, 132 – Professional Standards Authority, 118 T typodont courses, 36, 69 – quality control in postgraduate Taiwan, DentSim in, 130 typodonts, use of, 7, 129, 130 education, 121–122 Taiwan Association of Orthodontists, United States, 42–51 114, 115 U – Commission on Dental Accreditation, 43. Talbot, Eugene S., 1 UCSF (University of California San See also United States, CODA standards teachers. See faculty Francisco) School of Dentistry, – eligibility and selection of students teaching. See also faculty “Curriculum II,” 10 and residents, 50–51 – assessment of, 188 undergraduate education – evidence-based dentistry, 48–49 – developments and trends in, 19 – contents of, 18–19 – overview of education in, 42–43 228 Orthodontic Postgraduate Education: A Global Perspective

United States, CODA standards virtual learning, 36, 128, 130, 131. See WFO. See World Federation of – asepsis and infection control, 47–48 also e-learning Orthodontists – biomedical sciences curriculum , 49 visiting specialists/lecturers, guidelines wire-bending skills, assessment of, 36 – clinical sciences curriculum , 49–50 on, 79 Witwatersrand, University of, 84 – curriculum and program duration, vulcanite plates, as retainers, 1 workforce, supply and demand issues 48–50 of, 13 – due process, 51 W Workforce Education and Development – facilities and resources, 46–48 Waitany, Treaty of, 77 Services Wales, 118, 119 – hazardous materials management, Wales workplace-based assessments (WBAs), 46–47 – recruitment in, 117, 118 37, 40 – hazardous wastes, 47 – Workforce Education and World Federation of Orthodontists (WFO) – imaging equipment for clinical and Development Services Wales, 118, 119 – on aim s of postgraduate education, 17 research data, 48 Washington, University of, School of – on board certi cation, 112 – infection control policies, 48 Dentistry, 162 – Comm ittee on National and Regional – institutional comm itment/program water bath typodonts, 130 Orthodontic Boards, 114 e ectiveness, 43–45 Waugh, Leuman M., 2 – guidelines for postgraduate – instrument sterilization, 47 WBAs (workplace-based assessments), orthodontic education, 126 – private o ce facilities, 48 37, 40 – members of, 103, 107, 108, 109 – program director and teaching sta , 45 webinars, 135, 138, 139 – Middle East, de nition of, 83 – program duration, 49 Weinberger, Bernhard W., 148 – minimum orthodontic specialty – research, 51 West African College of Surgeons, 84 guidelines, 126 – student rights and responsibilities, 51 Western Australia, University of, 73, 109 – Orthodontic Board Comm ittee, 113 universities. See name of speci c Western Cape, University of the, 84 – program guidelines, 17, 34, 59, 115 location (e.g., “Toronto, University of”) Western Ontario, University of, 52 World Implant Orthodontic Society, 103 U.S. New s & World Report, institutional West Virginia University (W VU), 43–51 World Journal of Orthodontics (later rankings by, 183 – curriculum and program duration, Journal of the World Federation of 48–50 Orthodontists), publication of, 148 V – facilities and resources, 45–48 World President Orthodontic Summ it Venezuela, postgraduate programs – goals and objectives, 43–45 Meeting, 107 in, 62 – program director and teaching sta , World Wide Web, 128 vertical-anteroposterior relationship, 45 w ritten assessm ents, in UK, 36 166–180 – student/resident research, 51 Wuerpel, Edmund, 2 videos, 130–131, 134–135, 158–159 – student selection, 51 W VU. See West Virginia University