This position paper has been peer-reviewed by the participants of Group B: “Postgraduate University Programmes in Implant Dentistry”
Group B consisted of the following: Chair Chair Reviewer Reviewer
Professor Professor Professor Professor Dr. Mr. Mr. Professor Dr. Dr. Professor Dr. Professor Professor Dr. Professor
Niklaus P. Mariano Lior Nikos Owen Graham Stuart Nikos Kay Martin Joerg Sven Marc Stefan Anselm Daniel
Lang Sanz Shapira Mattheos Addison Blackbeard Conway Donos Horsch Janda Meyle Muhleman Quirynen Renvert Wiskott Wismeijer
European Journal of Dental Education ISSN 1396-5883
Implant dentistry in postgraduate university education. Present conditions, potential, limitations and future trends N. Mattheos1, D. Wismeijer2 and L. Shapira3 1 2 3
Faculty of Dentistry, The University of Hong Kong, Hong Kong, China, Academic Centre for Dentistry, ACTA, Amsterdam, The Netherlands, Hadassah Faculty of Dental Medicine, Hebrew University, Jerusalem, Israel
keywords implant dentistry; postgraduate dental education; dental specialist education. Correspondence Nikos Mattheos Department of Oral Rehabilitation, Implant Dentistry Faculty of Dentistry The University of Hong Kong Prince Philip Dental Hospital 34 Hospital Road, Sai Ying Pun Hong Kong, SAR – China Tel: +852 2859 0310 Fax: +852 2858 6114 e-mail: [email protected] Accepted: 30 October 2013 doi: 10.1111/eje.12074
Abstract Introduction: In recent years, opportunities for postgraduate university education in implant dentistry have increased significantly, with an increase in both the number but also the complexity of available postgraduate programmes. However, there appears to be a lack of standards directing the learning outcomes of such programmes. Methods: A scientific literature search was conducted for publications reporting on university programmes within implant dentistry, including description of programmes and evaluation of learning outcomes. A separate Internet search was conducted to collect information on existing university programmes as presented on university websites. Results: Implant dentistry has reached a critical mass of an independent, multidisciplinary and vibrant domain of science, which combines knowledge and discovery from many clinical and basic sciences. Many university programmes conclude with a master’s or equivalent degree, but there appears to be a great diversity with regard to duration and learning objectives, as well as targeted skills and competences. The importance of implant dentistry has also increased within established specialist training programmes. There was little indication, however, that the comprehensive aspects of implant dentistry are present in all specialist training programmes where implants are being covered. Conclusions: Although universities should maintain the options of designing academic programmes as they best see fit, it is imperative for them to introduce some form of transparent and comparable criteria, which will allow the profession and the public to relate the degree and academic credentials to the actual skills and competences of the degree holder. With regard to established specialist training programmes, the interdisciplinary and comprehensive nature of implant dentistry needs to be emphasised, covering both surgical and restorative aspects. Finally, implant dentistry is not, at present, a dental specialty. The profession has not reached a consensus as to whether the introduction of a new recognised specialist field is either necessary or desired.
Introduction Postgraduate university education in implant dentistry has been a field of rapid development in the years that followed the European consensus workshop in 2008 (1). In their position paper, Donos et al. (2) described a model that could facilitate different educational pathways for the practicing dentist, from ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 24–32
a continuing education certificate to a full specialist training. A dentist would be able to acquire the level of skills and competence desired within implant dentistry, advancing accordingly through an educational pathway of increasing complexity. Such a pathway was made possible by relying on a competence-based model of education, that is, targeting specific skills and competences with each educational activity or programme. 25
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In the years that followed the publication of this model for post-graduation training in implant dentistry, a great number of courses were developed by universities but also non-university institutions such as professional societies and private institutions. The increase was not only in the number of the available courses and education providers, but also in the complexity of the courses, as many universities introduced longer and more complex degrees in implant dentistry. At present, the spectrum of implant dentistry education includes courses extending from a few days to 3 years, full-time attendance. It is evident that those who wish to acquire competence within implant dentistry have a wide diversity of choices. Arguably, all these choices fall within the overall framework of continuing professional development (CPD). However, for the purpose of this study, a distinction is being made between university degree programmes, which lead to an advanced diploma, a master’s degree or equivalent, and the other available educational pathways. This paper will discuss the first type of programmes, whilst the latter educational pathways will be dealt with in a separate paper, as these two different types of education address different educational objectives and present different educational and organisational challenges.
Aims The aim of this study is to review the current status in the postgraduate university programmes leading to advanced degrees in implant dentistry as well as identify current challenges, trends and directions for future development. In particular this study aims to investigate: How is implant dentistry being taught at present in dedicated university degree and established specialist training programmes? What is the position of implant dentistry in relation to the established dental specialist structures and is ‘oral implantology’ an emerging dental specialisation? Which are the main directions for improvement in university teaching of implant dentistry at a postgraduate level?
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Methods A literature review was undertaken in PubMed for papers published after the year 2000 reporting or discussing aspects of postgraduate education in implant dentistry. The keywords used for the search included ‘Postgraduate’ OR ‘Post Doctoral’ AND ‘Dental Education’ AND ‘Implantology’ OR ‘implant dentistry’. Furthermore, an Internet search was conducted using similar keywords to identify websites of university postgraduate programmes in implant dentistry. The search was supplemented with a manual search of specific Internet resources originating from professional and scientific associations related to implant dentistry.
Working definitions University degree (award) programmes refer to university programmes of different durations and delivery modes, the completion of which leads to the award of a degree such as advanced studies diploma or master’s. 26
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Implant dentistry dedicated degree (award) programmes refer to university programmes of different durations and delivery modes, which aim specifically at developing competences of different levels for the practice of implant dentistry. Established specialist training programmes refer to university programmes leading to an accredited specialist status, according to European and national legislations. Such programmes are typically 3 years and full-time in duration and lead to specialist recognition in periodontology, oral surgery, endodontics, prosthodontics, etc.
A. University degree programmes dedicated to implant dentistry The number of postgraduate degree programmes dedicated to implant dentistry has rapidly increased in the years since Prague, and such programmes are now available in almost every European country. The follow-up survey of the 2nd European consensus workshop identified that such programmes range from 1 to 3 years in duration, offering from 12 to 180 European Credit Transfer System (ECTS) credits. Little can be found in scientific literature evaluating the learning effectiveness or other educational aspects of such postgraduate programmes. Lang et al. (3) found that dentists trained in a comprehensive postgraduate programme in implant dentistry were three times more likely to maintain a periodontally compromised molar than those without such training. Few curriculum descriptions have been published (4), but no papers appear to report any scientific evaluation of educational or other outcomes. Most of the available publications focus mainly on success and survival outcomes of implants placed by residents in specialist training, which in all cases are reported to be of standards comparable to that reported in current research (5–9). It is consequently very difficult to identify best practices within the postgraduate university degrees in implant dentistry, on the basis of the current scientific literature. Although many programmes dedicated to implant dentistry conclude with a master’s or equivalent degree, there appears to be a great diversity with regard to duration and learning objectives, as well as targeted skills and competences. For the purpose of this study, an attempt has been made to group such courses according to their duration and main objectives, through information presented on the respective university sites.
1. Three-year full-time programmes At present, there appear to be three full-time 3-year residency implant dentistry programmes worldwide. The ACTA in the Netherlands (10), The University of Hong Kong (11) and the University of Loma Linda (12) in the USA offer such programmes dedicated to implant dentistry. All three programmes include theoretical education, pre-clinical and clinical training, as well as completion and dissemination of an individual research project. The ACTA and Hong Kong programmes lead to the award of a master’s degree, whilst the pathway to a master’s is optional in Loma Linda University. Both the ACTA and Hong Kong programmes mention in their descriptions the ‘training of specialists’ in implantology, but completion of the programme does not award a specialist status. ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 24–32
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The programme in Amsterdam (ACTA) was initiated in 2007. It is a Master of Science in Oral Implantology and Implant Prosthodontics and goes beyond the standards set by NVOI (Dutch Association for Oral Implantology) for registration as a dentist specialised in oral implantology (tandartsimplantoloog) in the Netherlands. Application for registration is, however, the responsibility of the candidate and will be judged individually by the NVOI. In the Netherlands, oral implantology is not recognised as a specialisation in dentistry. The only recognised specialisations are orthodontics and oral and maxillofacial surgery. According to the information available online, at the end of the course the graduate student will: Have a detailed knowledge of the biological foundations of oral implantology and implant prosthodontics and have learned how to apply this knowledge clinically. Be able to diagnose and treat a wide variety of implantand prosthodontic-related problems to a high standard. Be able to critically evaluate current research literature and determine any potential application to the principles or procedures of oral implantology and implant prosthodontics. Have completed a research report containing the results of an investigation related to oral implantology and/or implant prosthodontics. Have further developed the acquired attitudes and skills essential for independent and life-long learning. Be able to run his/her own practice specialised in oral implantology. The course fees for 2013 have been set at 18,500 Euros per year. The programme in Hong Kong was initiated in 2008 and leads to the degree of Master of Dental Surgery in Implant Dentistry. The programme is accredited by the dental board of Hong Kong. There is at present no structure for recognition of a specialist status. The aims of the programme as presented in the school’s website are the following: To be competent in evidence-based, comprehensive treatment planning of partially and fully edentulous patients. To be competent in implant installation, in prosthetic reconstruction and in maintenance of the implant patient. To be competent in the diagnosis, prevention and management of biological and technical complications. To be familiar with dental and medical disciplines as well as the biomedical sciences relevant to implant dentistry. To have knowledge of the scientific literature relevant to implant dentistry and related fields such as biology, periodontology, prosthodontics and occlusion. To be competent in the basic scientific skills, and conduct and disseminate an individual research project. The course fees in 2012 were set at 350,000 HKD per year. The University of Hong Kong offers also a 2-year part-time degree in implant dentistry leading to a Master of Science degree. In Loma Linda University, the Advanced Education Program in implant dentistry is a 3-year programme leading to the award of a specialty certificate and an optional Master of Science (MS) or Master of Science in Dentistry (MSD) degree. Individuals who successfully complete the programme are awarded a professional certificate, but not a recognised specialist status. A lengthy dis-
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claimer on the website explains that specialist practice in the State of California and USA must fulfil requirements of specialist boards of the American Dental Association (ADA), where implant dentistry is at present not represented. The goals of the programme as found on the website are as follows: To educate graduate students of the Advanced Education Program in implant dentistry to the proficiency level and capability to deliver implant dentistry treatment. To provide in-depth didactic and clinical instruction in problem-based patient situations that require implant prosthodontic and surgical solutions. To train graduate students of the Advanced Education Program in implant dentistry to develop a clinical practice. To achieve highest levels of patient treatment satisfaction. To educate graduate students of the Advanced Education Program in implant dentistry to perform research and practise teaching. Completion of the programme costs $161,924, with some additional costs for books and supplies of about $15,000. The University of Loma Linda offers an array of postgraduate programmes in implant dentistry, including a 2-year practicum, internships and externships. All three programmes present some brief overriding aims at the university website, which however do not reveal much detail as to how the aims are achieved in practice and which are the components of the programmes in basic, clinical and biological sciences, or the dental disciplines necessary for comprehensive care such as periodontology and restorative dentistry. The programme at ACTA in addition to the overriding aims offers a detailed description of the programme in a pdf format.
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2. Two-year full-time programmes A more common education pathway in implant dentistry is through a 2-year full-time programme, leading most commonly to a Master of Science, a Master of Clinical Dentistry or an equivalent degree. Such programmes can be found in the majority of European countries and typically combine theoretical with clinical training whilst covering surgical and restorative aspects of implant dentistry.
3. Part-time or less than equivalent of 2-year full-time programmes Not surprisingly, this is the category of programmes with the wider diversity and where the border between university degree programmes and continuing professional development becomes more obscure. In the most simple form, it is possible to attain a Master of Science in Implant Dentistry degree through 1 year of part-time study, which does not involve clinical practice. Furthermore, different combinations exist, where part-time programmes of duration from 1 to 4 years can lead to a diversity of learning outcomes and often to a master’s degree of some form.
4. Online, distance/flexible/blended learning programmes Several universities have set up flexible blended learning postgraduate programmes, which can enrol both regional and 27
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remote/overseas students. This is commonly made possible by combining a modular blended learning structure of theoretical courses, with clinical training offered in collaboration with regional training centres/clinics or accredited mentors. The University of Warwick in the UK and Goethe Universit€at in Frankfurt am Main at present offer such programmes leading to a master’s degree. The University of M€ unster in Germany, through a consortium named International Medical College is also offering a ‘Master of Oral Medicine in Implantology’. The programme extends over 15 months and is credited with 60 ECTS. An interesting dimension is that many of the courses that are currently presented as online/flexible master’s are actually not university courses. Such courses are typically marketed with a variation of the word ‘master’s’ (clinical master’s, master clinicians, online master’s, etc.), they are directed by a private course provider or institute and evolve around the attendance of specific educational events in different regions of the world combined with online/distance learning. Whether the term ‘master’s’ should be used in that concept and who is accredited or appropriate to award a master’s degree is a worthy debate.
Postgraduate degrees in Europe – a master confusion There appears to be a wide diversity in the available university degree programmes. Diversity is not necessarily a disadvantage, as it could lead to the development of parallel models and evaluation of best practices. This could promote the progress of the discipline in the long term. However, although uniformity is not desired, standardisation and transparency are necessary, in a free market of 400 million people such as the European Union. Although many universities might offer diverse programmes, the end points of these programmes must be transparent and comparable. This is especially important for master’s programmes, which aim to the achievement of clinical competences, as the graduates of such programmes will be most likely performing clinical procedures at a high level of complexity. Unfortunately, the awarded academic title offers at present very little understanding of the nature and extent of training in implant dentistry which the recipient has received, or if clinical training has been received at all. The terms ‘master’s’ or ‘Master of Science’ with different variations, when currently used by universities, describe courses that extend from 1-year part-time attendance without clinical practice to 3-year full-time clinical programmes. If to these legitimate university master’s degrees, we add the numbers of graduates of the numerous ‘clinical master’s’ and ‘master clinicians’, one can immediately see this ‘master confusion’ constitutes maybe the most prominent danger at present within implant dentistry. Traditionally, the title ‘Master of Science’ has described a university postgraduate degree of a significant duration, but it says nothing about the actual skills and competencies the dentist has acquired, the level of complexity he/she is competent to deal with or even if he/she has received clinical training at all. Although the universities should maintain the options of designing academic programmes as they best see fit, it is an imperative need for them to introduce some form of transparent and comparable criteria, which will allow the 28
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profession and the public to relate the degree and academic credentials to the actual skills and competences of the degree holder. In particular, the academic title of ‘Master’ is today ill-defined and could certainly benefit from the introduction of some uniform minimum requirements or criteria. In certain cases, an attempt has been made to separate at least the master’s degrees that include a significant clinical training by introducing the title of ‘Master of Clinical Dentistry’ (13) as opposed to ‘Master of Philosophy’ or ‘Master of Science’, which can imply research-based or purely theoretical programmes. This pathway has been however rejected by other institutions. However, the name of the degree is not the only way to illustrate the qualifications acquired. The competencebased education, which is increasingly adopted by universities in Europe, could be a good starting point to at least identify the end products of each programme. The levels introduced by ADEE to describe the learning outcomes of a programme (be familiar with, have knowledge of, be competent in) can actually say much more than the title of the award and the duration of the programme and should be a necessary supplement to any programme description. Furthermore, the description of clinical competences with the levels of straightforward, advanced and complex, as introduced by ITI (14), can further assist the expression of learning objectives in a standardised and objective manner. Finally, the diploma supplement template as recommended by EU (15) offers a good understanding of the studied programme. Making available certain standardised information for every programme would help improve transparency and minimise confusion. Such information could include the learning outcomes expressed in the three levels proposed by ADEE, clinical skills and competences expressed in the SAC (Straightforward, Advanced, Complex) classification and also the most current version of the diploma supplement (e.g. that of the most recent graduating cohort). This could in time lead to a further organisation of the degrees as well, hopefully with names more indicative of the actual content of the studies.
B. Implant dentistry within existing specialist education programmes 1. Overview Historically, since the 1980s, clinical training in implant dentistry has been an integral part of specialty programmes in periodontology, oral surgery and prosthodontics. Oral surgery and periodontology programmes were focused on surgical aspects of osseointegration, and prosthodontics programmes on restoring implants. With the advancement of implant dentistry and the move from the initially fully edentulous patient to partial edentulous and aesthetic restorations, it became clear that implants should be placed in a prosthetically driven manner. The communication between the surgeon and the restoring clinician became tighter, particularly during treatment planning and directing of implant positioning during surgery. The introduction of computer-assisted planning and placement of implants has facilitated early visualisation of treatment outcomes with increased accuracy and promoted further interdisciplinary collaboration. Oral radiology programmes have a large ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 24–32
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component of their curriculum being devoted to radiography and diagnostics related to implant dentistry, although this training does not include clinical components. Some orthodontics programmes offer training in implants used for retentive anchorage. Recently, specialist training programmes in endodontics have introduced the theoretical but also clinical teaching of implant dentistry.
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of the American Dental Association for advanced education programmes in prosthodontics (18). A recent retrospective analysis of dental implants placed by prosthodontics residents had a success rate comparable to previously published studies for other specialties, and the year of prosthodontics residency training had no influence on the rate of failure (19).
4. Oral surgery 2. Periodontology The European Federation of Periodontology (EFP) expects all graduates of approved specialist training programmes in Europe (12 programmes in 2013) to be competent in the surgical placement of implants in simple to complex cases and implant site development, including guided bone regeneration and sinus floor augmentation, as well as patient maintenance and treatment for implant-related pathology. The competences described by EFP aim to prepare the graduate to practise the surgical aspects of implant dentistry in his/her periodontal practice at a high level of complexity, in collaboration with the restorative team. These guidelines extend to include the restorative aspects of implant dentistry, with the explicit reference that the periodontist is expected to have ‘comprehensive knowledge of the inter-relationships of orthodontic, restorative therapies and periodontal treatment (including implant therapy)’. The periodontal graduates need to prove their knowledge and skills in periodontology and implant dentistry by presenting five treated cases (some of them should include implant therapy) to the examining committee of the EFP.
3. Prosthodontics Restoring implants has been an integral part of prosthodontics specialty training. Although at present, many prosthodontists are surgically placing implants as well, surgical training within prosthodontist specialist education varies widely. Already in 2004, 43% of the advanced prosthodontics programmes in the USA either required residents to place or offered the option to have residents place implants. At the same time, 40% of programme directors were not trained in the placement of dental implants, and if they were, the majority (82%) stated that the nature of their training was 1- to 3-day course(s) (16). A more recent survey of residents of prosthodontics in the USA (17) found that the majority of the programmes in prosthodontics allow residents to place implants in their own patients, but it is an option, not a requirement. The volume of the didactic education also varies between 30 and 90 h. Fifty per cent of the residents received training in implant dentistry using models, but approximately half of them were trained during industry-driven courses and not by a university. According to the majority of the responders, computer-guided implant planning and surgery training were offered in their programmes. An interesting point is that a third of prosthodontics residents stated that their residency training did not adequately prepare them for implant surgery. The survey revealed that most advanced education programmes in prosthodontics in the USA at least encouraged their residents to perform the surgical part of implant dentistry for their own patient, although placement of implants is a part of the accreditation guideline ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 24–32
Oral surgeons were amongst the pioneers and leaders of the surgical part of implant dentistry. A 2007 survey between residents in oral and maxillofacial surgery in the USA (20) found that 30% of the residents estimated that they would place between 51 and 100 implants and 32% estimated that they would place more than 100 implants during their residency. Interestingly, 98% of the residents felt that implant dentistry would be an important part of their practice, but 28% felt that their residency did not adequately prepare them for implant surgery.
5. Endodontics According to the Commission on Dental Accreditation (21) of the ADA in the USA, advanced specialty programmes in endodontics ‘must provide instruction at the level of understanding and clinical training to the level of exposure in implant dentistry’. It is reasonable that an endodontist, when treating a questionable tooth, will be familiar with clinical and scientific aspects of dental implants as an alternative to root canal therapy or apical surgery. A survey in 2009 showed that 57% of the responding endodontists believed that placing implants was within their scope of practice, whilst only approximately 6% of them were placing implants (22). A later survey of the specialty programmes in endodontics in the USA revealed that most of the programmes have didactic courses in implant dentistry, whilst a third of the programmes offer clinical training as well in placing implants, and the training is given mostly by periodontists. However, there are no formal recommendations for training in placing implants into the endodontics curriculum (23). As the introduction of implant dentistry to the curriculum of endodontics is still at an early stage, many aspects of this training are still not addressed, unclear or under debate. The level of complexity of implant dentistry training for an endodontist is not addressed. Furthermore, it is unclear whether the theoretical and clinical training, when offered, extends to the restoration of implants as well, or is limited only to placement.
Established specialties and implant dentistry As today implant dentistry has become a widely applicable treatment modality, it is reasonable to expect its significance to rise within the existing specialist training programmes. It is also not surprising to see the rise of implant dentistry in the training of specialties previously not directly related to implants, such as endodontics. However, success with implant dentistry requires a comprehensive treatment plan, rather than possession of surgical and/or restorative skills. There is a great synergy between placing and restoring implants, whilst biology 29
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and technical components interact in critical ways determining the long-term success of implant treatments. Many of the complications and failures we see today are not attributed to lack of competence with procedures, but rather to inadequate treatment planning or poor communication between the specialists involved (24). In addition, there is growing evidence indicating that biological and technical complications are often interrelated (25). Procedural training is essential for a specialist to master clinical treatments, but there is a danger if this happens without developing the comprehensive understanding of implant dentistry as a restorative-driven discipline. A specialist (periodontist, surgeon) placing dental implants should have a profound understanding and certain level of clinical competence with the restorative procedures as well, whilst a restorative specialist must also have a good background in the surgical procedures, regardless if he chooses to place implants or not (26, 27). In the case of the endodontist, if clinical training in implant dentistry is desired, this should adequately include both surgical and restorative aspects. The emphasis in the comprehensive aspect of implant dentistry should be present in all specialist training programmes where implants are being taught, and this is at present not always reflected in available guidelines.
C. Is ‘implantology’ an emerging dental specialty? Since the 1980s, many authors from different parts of the world have initiated calls for the recognition of ‘oral implantology’ as a new dental specialty (28–37). The debate appears much more relevant today, as implant dentistry has expanded to the extent that the term ‘oral implantologist’ has been introduced and is used by some individuals, associations or journals as referring to a de facto dental specialist. There is no doubt at present that implant dentistry has reached the critical mass of an independent, multidisciplinary and vibrant domain of science, which combines knowledge and discoveries from many clinical and basic sciences. Implant dentistry has matured to be not only a widespread treatment modality, but also one of the most active fields of education and research and development in health care (38). There is a growing body of research dedicated to implant dentistry, which is reflected in the thousands of scientific publications of all kinds that are being produced annually. The ISI Web of Science includes at least seven peer-reviewed journals with impact factors dedicated to implant dentistry, whilst PubMed includes 25 such journals and periodicals. That excludes the journals from the fields of periodontology, prosthodontics, oral surgery and clinical dentistry, a large volume of whose content also evolves around implant dentistry. Furthermore, several scientific and professional associations related to implant dentistry have been created at national (39, 40), European (41) and international levels, numbering thousands of members. At a European level, several educational and scientific events within implant dentistry are attracting thousands of participants every year, such as the European Academy of Osseointegration annual congress, the Osteology congress and many more. In that sense, implant dentistry already presents a higher level of activity both in scientific and professional domain than many of the established dental specialties. 30
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At the same time, the knowledge and competences required for the practice of implant dentistry are not being taught in the undergraduate dental curriculum, and this has generated the need for postgraduate education in this field. But is all this sufficient to proclaim ‘implantology’ or ‘oral implantology’ as a new dental specialty? Even if we accept that oral implantology has grown into an independent scientific discipline, there are still some critical missing links, before the status of an independent dental specialty can be considered. One very important factor is education. The training pathway towards acquisition of implantology as a specialist competence, including the learning outcomes, knowledge and competences of a potential specialist, remain largely diverse and unclear. The ability to place an implant into an edentulous alveolus does not qualify someone to be ‘implantologist’ and the clinician who engages with implant treatment must possess a thorough understanding of every phase of dentistry required before and after placement of a titanium screw (26). Consequently, the challenge is not only whether ‘implantology’ is a specialty, but also how could we define the ‘implantologist’ as a dental specialist. The established dental specialties, even if not always recognised at the government level, have long since established educational pathways through regulated 3-year full-time specialist training programmes. Such programmes have well-defined learning outcomes, which have been developed through consensus in most cases at a European level and are supervised and accredited by European professional and scientific bodies. Even if oral implantology today can be perceived as a well-defined and established scientific domain, the term ‘implantologist’ has been used to describe a very diverse mass of practitioners, with a wide range of skills and competencies, acquired in many different ways, at different levels and under greatly varying standards. Consequently, the term ‘implantologist’ or ‘implant specialist’ is at present ill-defined and often misleading. Unfortunately, this confusion is not unique to implant dentistry, although it is there that it is at present most pronounced. As long ago as 1984, the American College of Oral Implantology submitted an application for specialty recognition to the ADA, followed by a similar one by the American Academy of implant dentistry (30, 31). The ADA rejected several repeated applications (33), and the specialty status remains largely inconclusive as of today. The ADA has set six clear criteria that must be fulfilled for a discipline to be recognised as a dental specialty (33). According to these, a candidate discipline for specialty recognition must be: Represented by an organisation whose membership is reflective of the special area of practice and recognised by the profession at large for its contribution to the art and science of the discipline. A distinct and well-defined field that requires unique knowledge and skills beyond those commonly possessed by general dental practitioners. The scope of the discipline must not be coincident with or readily subsumed within the scope of other recognised specialties. Substantial public need and demand for services, which cannot be adequately met by general practitioners or specialists in other areas must be documented.
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The discipline must incorporate some aspects of clinical practice. Adequate formal advance education programmes must exist to provide the special knowledge and skills. Whether implantology fulfils the above criteria has been repeatedly debated, but the decision of ADA has been negative so far, although not excluding specialty status in the future. One of the most debated criteria was about the need and demand for services, which cannot be adequately met by general practitioners or existing specialists. In addition, one can argue that such a new specialist would serve no purpose, because all possible procedures within implant dentistry can be accommodated by the qualified general practitioners in collaboration with existing specialists, including the comprehensive treatment planning and maintenance of patients. On the other hand, one should not overlook the arguments presented in support of a dental specialty devoted to oral implants. The introduction of an accredited specialism in implant dentistry might improve service to the public, by introducing some necessary standards and clearing the current confusion caused by the overflow of diverse ‘implantologists’. Practice of implant dentistry after fragmented, substandard or inadequate training is an increasing reality and poses a real risk to the public but also to the profession itself (24, 42). This can pose a serious risk to how implants are perceived by the public. For example, a recent wave of negative publicity in Japan has raised suspicion and caused an alarming decrease in the acceptance of implant treatments by the public (43). It is true that the field of work of a specialist in implant dentistry would overlap with parts of the areas of a periodontist, prosthodontist or oral surgeon, but in reality this is what happens today with everyone practicing implant dentistry, regardless of the level and quality of education they have received. A concern has been often expressed by clinicians that introduction of an ‘implantologist’ would automatically imply that this person is better qualified than other practitioners to do implants (44). Advocates of implant dentistry as a specialty, however, claim that the introduction of specialty recognition in implant dentistry will not aim to replace the established specialties, nor to prevent general practitioners from placing and restoring implants (33). The aim of such a specialty would be to ensure quality of comprehensive practice at the highest level within the discipline. At the core of a specialist, training is not the competence with procedures, but rather the synthetic ability to manage complex patient treatments, identify risks, deal with expected or unexpected complications as well as contribute to the development and progress of the scientific discipline. A practitioner who has an overview of the whole scientific area and who is able to treat complications whether they are of a biological, mechanical or prosthetic nature has become desirable, when considering the explosive growth in this field. However, this could also be at least partly addressed by enriching the education of current specialists in such a way that the periodontist, prosthodontist and oral surgeon will have a significant understanding of each others’ fields. The development of recognised specialist training programmes in implant dentistry is expected by some to have positive academic implications for the whole scientific domain. Such pro-
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grammes foster further interdisciplinary collaboration under one comprehensive teaching programme and could promote the development of multidisciplinary centres of excellence, which can significantly promote the scientific domain of implant dentistry. In Europe, at present, we lack a definition from the respective authorities of what is ‘sufficient’ to manifest a new dental specialty. The situation with the dental specialties in Europe remains very complex and confusing, even without the discussion on implant dentistry. As of today, the only two dental specialties that under EU Directive are recognised throughout the European Union remain maxillofacial surgery and orthodontics. Although an increasing number of countries have recognised a further number of dental specialties, there is still no uniformity in this issue and consequently no definition as to what are the prerequisites to recognise a clinical domain as a ‘specialty’. In some cases, a move has been made to introduce some uniformity through initiatives taken by scientific bodies such as the European Federation of Periodontology specialist education accreditation, which accredits programmes educating specialists in periodontology at a European level. This offers a standardisation and quality assurance for programmes and graduates, even if periodontology is not formally recognised as a specialty in all respective countries. Conclusively, although oral implantology can be described as a well-defined and vibrant interdisciplinary scientific field, significant challenges need to be addressed before a dental specialty status is seriously discussed. First, the profession should reach a consensus whether the introduction of a new recognised specialist is necessary or desired. Second and most important, the skills and competences and the training pathway for the new specialist should be defined and agreed upon. Such a specialist training should adhere to the same educational, quality assessment and accreditation standards, which other established specialties follow at a European level.
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Conflicts of interest The authors declared no conflicts of interest.
References 1 Mattheos N, Albrektsson T, Buser D, et al. Teaching and assessment of implant dentistry in undergraduate and postgraduate education: a European consensus. Eur J Dent Educ 2009: 13 (Suppl. 1): 11–17. 2 Donos N, Mardas N, Buser D. An outline of competencies and the appropriate postgraduate educational pathways in implant dentistry. Eur J Dent Educ 2009: 13 (Suppl. 1): 45–54. 3 Lang-Hua BH, McGrath CP, Lo EC, Lang NP. Factors influencing treatment decision-making for maintaining or extracting compromised teeth. Clin Oral Implants Res 2013 doi: 10.1111/clr. 12142 [Epub ahead of print]. 4 Gallucci GO, Weber HP, Kalenderian E. Implementation of a new advanced graduate education program in oral implantology. J Dent Educ 2012: 76: 1347–1357. 5 Farino M, Branscum A, Robinson FG, et al. Programmatic effectiveness of a university-based implant training program: longterm, patient-centered outcomes. J Long Term Eff Med Implants 2010: 20: 343–351.
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6 Melo MD, Shafie H, Obeid G. Implant survival rates for oral and maxillofacial surgery residents: a retrospective clinical review with analysis of resident level of training on implant survival. J Oral Maxillofac Surg 2006: 64: 1185–1189. 7 Starr CB, Maksoud MA. Implant treatment in an urban general dentistry residency program: a 7-year retrospective study. J Oral Implantol 2006: 32: 142–147. 8 Chung WE, Rubenstein JE, Phillips KM, Raigrodski AJ. Outcomes assessment of patients treated with osseointegrated dental implants at the University of Washington Graduate Prosthodontic Program, 1988 to 2000. Int J Oral Maxillofac Implants 2009: 24: 927–935. 9 Smith LP, Ng M, Grubor D, Chandu A. Outcomes of dental implants placed in a surgical training programme. Aust Dent J 2009: 54: 361–367. 10 Amsterdam AACT. Master of science in oral implantology and implant prosthodontics Available at: http://www.acta.nl/en/Images/ Opleiding%202011-2012_tcm82-203915.pdf (Last accessed December 2013). 11 The University of Hong Kong. Master of dental surgery in implant dentistry. Available at: http://www.asa.hku.hk/admissions/tpg/ prospectus/2012/faculties_dentistry_taught_mdsid.html (Last accessed October 2013). 12 Loma Linda University. Advanced education program in implant dentistry. Available at: http://www.llu.edu/dentistry/implant/ graduateprogram.page (Last accessed October 2013). 13 Mattheos N, Ivanovski S, Heitz-Mayfield L, Klineberg I, Sambrook P, Scholz S. University teaching of implant dentistry: guidelines for education of dental undergraduate students and general dental practitioners. An Australian consensus document. Aust Dent J 2010: 55: 329–332. 14 Dawson A, Chen S (eds). The SAC classification in implant dentistry. Berlin: Quintessence Publishing Co, 2009. 15 European Commission. E. T., Lifelong learning policy. The diploma supplement. Available at: http://europass.cedefop.europa.eu/en/ documents/european-skills-passport/certificate-supplement. 16 Sukotjo C, Arbree NS. Prosthodontic program directors’ perceptions regarding implant placement by prosthodontic residents: a 2004 survey conducted by the Educational Policy Subcommittee of the American College of Prosthodontists. J Prosthodont 2008: 17: 662–668. 17 Yuan JC, Lee DJ, Knoernschild KL, Campbell SD, Sukotjo C. Residents’ perceptions of implant surgical training in advanced education in prosthodontic programs. J Prosthodont 2010: 19: 557–564. 18 Commission on Dental Accreditation, A. D. A. Accreditation standards for advanced specialty education programs in prosthodontics. Available at: http://www.ada.org/sections/ educationAndCareers/pdfs/prostho.pdf 19 Barias PA, Lee DJ, Yuan JC, Sukotjo C, Campbell SD, Knoernschild KL. Retrospective analysis of dental implants placed and restored by advanced prosthodontic residents. J Prosthodont 2013: 22: 157–163. 20 Melo MD, McGann G, Obeid G. Survey of implant training in oral and maxillofacial surgery residency programs in the United States. J Oral Maxillofac Surg 2007: 65: 2554–2558. 21 Commission on Dental Accreditation, American Dental Association. Accreditation standards for advanced specialty programs in endodontics. Available at: http://www.ada.org/ sections/educationAndCareers/pdfs/endo.pdf (Last accessed October 2013).
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22 Potter KS, McQuistan MR, Williamson AE, Qian F, Damiano P. Should endodontists place implants? A survey of U.S. endodontists. J Endod 2009: 35: 966–970. 23 Aminoshariae A, Montagnese TA, Solanki PD, Mickel AK. Introduction of implants into postdoctoral endodontic residency programs. J Dent Educ 2011: 75: 1244–1248. 24 Wheeler S, Bollinger CM. Complication or substandard care? Risks of inadequate implant training. J Calif Dent Assoc 2009: 37: 647–651. 25 Kim P, Ivanovski S, Latcham N, Mattheos N. The impact of cantilevers on biological and technical success outcomes of implant-supported fixed partial dentures. A retrospective cohort study. Clin Oral Implant Res 2013. doi: 10.1111/clr.12102 [Epub ahead of print]. 26 Chiarenza A. The elevation of dental implantology to the height of incompetence. J Oral Implantol 1987: 13: 316–319. 27 Gottesman E. Periodontal-restorative collaboration: the basis for interdisciplinary success in partially edentulous patients. Compend Contin Educ Dent 2012: 33: 478–482. 28 Judy KW, Misch CE. An imperative context for recognition of oral implantology as a dental specialty. N Y J Dent 1985: 55: 33–35. 29 Misch CE. Oral implantology–specialty or subspecialty–that is the question. Implantologist 1985: 3: 3–5. 30 Misch CE, Judy KW. Oral implantology: specialty status. Mo Dent J 1985: 65: 23–24. 31 Judy KW. Implantology as a dental specialty: a moral and an educational focus. Implantologist 1986: 4: 15–19. 32 Lentrodt J. Development of dental implantology–seriousness and medical justification of a young profession. ZWR 1048: 1986: 1053– 1055. 33 McCann D. Implantology. Does it merit specialty status? J Am Dent Assoc 1990: 121: 322–323, 325, 328. 34 Palmer JD. Regulations needed for implantology. Dent Econ 1993: 83: 19–20. 35 Misch CE. The specialty of oral implantology. J Mich Dent Assoc 1994: 76: 42–44. 36 Meijer HJ, Raghoebar GM, Wismeijer D, ten Bruggenkate CM. [Recommendations in oral implantology]. Ned Tijdschr Tandheelkd 2008: 115: 481–488. 37 Bhagania M. Implantology: is it the end of the road for dental specialties? J Oral Maxillofac Surg 2009: 67: 1575. 38 Levine RA, Gallucci GO. Implantology: an evolving dental discipline. Compend Contin Educ Dent 2011: 32: 70–71. 39 Terheyden H, Kopp I. Proceedings of the 1st consensus conference of the german association of oral implantology, Aerzen, Germany, 29th and 30th September. Eur J Oral Implantol 2010: 4: 5–10. 40 Kawazoe T. Introduction of Japanese Society of Oral Implantology. Int J Oral Sci 2009: 1: 13–15. 41 EAO. European Association for Osseointegration. Available at: http://www.eao.org/ (Last accessed October 2013). 42 Solaiman T. Implant failure: attempting procedures beyond skill level. J Calif Dent Assoc 2009: 37: 850–852. 43 Dental Tribune Asia Pacific. Implant woes high among Japanese dental patients. 2012: Available at: http://www.dental-tribune.com/ articles/news/asiapacific/9025_implant_woes_high_among_japanese_ dental_patients.html (Last accessed: October 2013). 44 Clepper DP. Implantology. J Am Dent Assoc 1991: 122: 16–17.
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Group B consisted of the following: Chair Chair Reviewer Reviewer
Professor Professor Professor Professor Dr. Mr. Mr. Professor Dr. Dr. Professor Dr. Professor Professor Dr. Professor
Niklaus P. Mariano Lior Nikos Owen Graham Stuart Nikos Kay Martin Joerg Sven Marc Stefan Anselm Daniel
Lang Sanz Shapira Mattheos Addison Blackbeard Conway Donos Horsch Janda Meyle Muhleman Quirynen Renvert Wiskott Wismeijer
European Journal of Dental Education ISSN 1396-5883
Implant dentistry in postgraduate university education. Present conditions, potential, limitations and future trends N. Mattheos1, D. Wismeijer2 and L. Shapira3 1 2 3
Faculty of Dentistry, The University of Hong Kong, Hong Kong, China, Academic Centre for Dentistry, ACTA, Amsterdam, The Netherlands, Hadassah Faculty of Dental Medicine, Hebrew University, Jerusalem, Israel
keywords implant dentistry; postgraduate dental education; dental specialist education. Correspondence Nikos Mattheos Department of Oral Rehabilitation, Implant Dentistry Faculty of Dentistry The University of Hong Kong Prince Philip Dental Hospital 34 Hospital Road, Sai Ying Pun Hong Kong, SAR – China Tel: +852 2859 0310 Fax: +852 2858 6114 e-mail: [email protected] Accepted: 30 October 2013 doi: 10.1111/eje.12074
Abstract Introduction: In recent years, opportunities for postgraduate university education in implant dentistry have increased significantly, with an increase in both the number but also the complexity of available postgraduate programmes. However, there appears to be a lack of standards directing the learning outcomes of such programmes. Methods: A scientific literature search was conducted for publications reporting on university programmes within implant dentistry, including description of programmes and evaluation of learning outcomes. A separate Internet search was conducted to collect information on existing university programmes as presented on university websites. Results: Implant dentistry has reached a critical mass of an independent, multidisciplinary and vibrant domain of science, which combines knowledge and discovery from many clinical and basic sciences. Many university programmes conclude with a master’s or equivalent degree, but there appears to be a great diversity with regard to duration and learning objectives, as well as targeted skills and competences. The importance of implant dentistry has also increased within established specialist training programmes. There was little indication, however, that the comprehensive aspects of implant dentistry are present in all specialist training programmes where implants are being covered. Conclusions: Although universities should maintain the options of designing academic programmes as they best see fit, it is imperative for them to introduce some form of transparent and comparable criteria, which will allow the profession and the public to relate the degree and academic credentials to the actual skills and competences of the degree holder. With regard to established specialist training programmes, the interdisciplinary and comprehensive nature of implant dentistry needs to be emphasised, covering both surgical and restorative aspects. Finally, implant dentistry is not, at present, a dental specialty. The profession has not reached a consensus as to whether the introduction of a new recognised specialist field is either necessary or desired.
Introduction Postgraduate university education in implant dentistry has been a field of rapid development in the years that followed the European consensus workshop in 2008 (1). In their position paper, Donos et al. (2) described a model that could facilitate different educational pathways for the practicing dentist, from ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 24–32
a continuing education certificate to a full specialist training. A dentist would be able to acquire the level of skills and competence desired within implant dentistry, advancing accordingly through an educational pathway of increasing complexity. Such a pathway was made possible by relying on a competence-based model of education, that is, targeting specific skills and competences with each educational activity or programme. 25
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In the years that followed the publication of this model for post-graduation training in implant dentistry, a great number of courses were developed by universities but also non-university institutions such as professional societies and private institutions. The increase was not only in the number of the available courses and education providers, but also in the complexity of the courses, as many universities introduced longer and more complex degrees in implant dentistry. At present, the spectrum of implant dentistry education includes courses extending from a few days to 3 years, full-time attendance. It is evident that those who wish to acquire competence within implant dentistry have a wide diversity of choices. Arguably, all these choices fall within the overall framework of continuing professional development (CPD). However, for the purpose of this study, a distinction is being made between university degree programmes, which lead to an advanced diploma, a master’s degree or equivalent, and the other available educational pathways. This paper will discuss the first type of programmes, whilst the latter educational pathways will be dealt with in a separate paper, as these two different types of education address different educational objectives and present different educational and organisational challenges.
Aims The aim of this study is to review the current status in the postgraduate university programmes leading to advanced degrees in implant dentistry as well as identify current challenges, trends and directions for future development. In particular this study aims to investigate: How is implant dentistry being taught at present in dedicated university degree and established specialist training programmes? What is the position of implant dentistry in relation to the established dental specialist structures and is ‘oral implantology’ an emerging dental specialisation? Which are the main directions for improvement in university teaching of implant dentistry at a postgraduate level?
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Methods A literature review was undertaken in PubMed for papers published after the year 2000 reporting or discussing aspects of postgraduate education in implant dentistry. The keywords used for the search included ‘Postgraduate’ OR ‘Post Doctoral’ AND ‘Dental Education’ AND ‘Implantology’ OR ‘implant dentistry’. Furthermore, an Internet search was conducted using similar keywords to identify websites of university postgraduate programmes in implant dentistry. The search was supplemented with a manual search of specific Internet resources originating from professional and scientific associations related to implant dentistry.
Working definitions University degree (award) programmes refer to university programmes of different durations and delivery modes, the completion of which leads to the award of a degree such as advanced studies diploma or master’s. 26
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Implant dentistry dedicated degree (award) programmes refer to university programmes of different durations and delivery modes, which aim specifically at developing competences of different levels for the practice of implant dentistry. Established specialist training programmes refer to university programmes leading to an accredited specialist status, according to European and national legislations. Such programmes are typically 3 years and full-time in duration and lead to specialist recognition in periodontology, oral surgery, endodontics, prosthodontics, etc.
A. University degree programmes dedicated to implant dentistry The number of postgraduate degree programmes dedicated to implant dentistry has rapidly increased in the years since Prague, and such programmes are now available in almost every European country. The follow-up survey of the 2nd European consensus workshop identified that such programmes range from 1 to 3 years in duration, offering from 12 to 180 European Credit Transfer System (ECTS) credits. Little can be found in scientific literature evaluating the learning effectiveness or other educational aspects of such postgraduate programmes. Lang et al. (3) found that dentists trained in a comprehensive postgraduate programme in implant dentistry were three times more likely to maintain a periodontally compromised molar than those without such training. Few curriculum descriptions have been published (4), but no papers appear to report any scientific evaluation of educational or other outcomes. Most of the available publications focus mainly on success and survival outcomes of implants placed by residents in specialist training, which in all cases are reported to be of standards comparable to that reported in current research (5–9). It is consequently very difficult to identify best practices within the postgraduate university degrees in implant dentistry, on the basis of the current scientific literature. Although many programmes dedicated to implant dentistry conclude with a master’s or equivalent degree, there appears to be a great diversity with regard to duration and learning objectives, as well as targeted skills and competences. For the purpose of this study, an attempt has been made to group such courses according to their duration and main objectives, through information presented on the respective university sites.
1. Three-year full-time programmes At present, there appear to be three full-time 3-year residency implant dentistry programmes worldwide. The ACTA in the Netherlands (10), The University of Hong Kong (11) and the University of Loma Linda (12) in the USA offer such programmes dedicated to implant dentistry. All three programmes include theoretical education, pre-clinical and clinical training, as well as completion and dissemination of an individual research project. The ACTA and Hong Kong programmes lead to the award of a master’s degree, whilst the pathway to a master’s is optional in Loma Linda University. Both the ACTA and Hong Kong programmes mention in their descriptions the ‘training of specialists’ in implantology, but completion of the programme does not award a specialist status. ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 24–32
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The programme in Amsterdam (ACTA) was initiated in 2007. It is a Master of Science in Oral Implantology and Implant Prosthodontics and goes beyond the standards set by NVOI (Dutch Association for Oral Implantology) for registration as a dentist specialised in oral implantology (tandartsimplantoloog) in the Netherlands. Application for registration is, however, the responsibility of the candidate and will be judged individually by the NVOI. In the Netherlands, oral implantology is not recognised as a specialisation in dentistry. The only recognised specialisations are orthodontics and oral and maxillofacial surgery. According to the information available online, at the end of the course the graduate student will: Have a detailed knowledge of the biological foundations of oral implantology and implant prosthodontics and have learned how to apply this knowledge clinically. Be able to diagnose and treat a wide variety of implantand prosthodontic-related problems to a high standard. Be able to critically evaluate current research literature and determine any potential application to the principles or procedures of oral implantology and implant prosthodontics. Have completed a research report containing the results of an investigation related to oral implantology and/or implant prosthodontics. Have further developed the acquired attitudes and skills essential for independent and life-long learning. Be able to run his/her own practice specialised in oral implantology. The course fees for 2013 have been set at 18,500 Euros per year. The programme in Hong Kong was initiated in 2008 and leads to the degree of Master of Dental Surgery in Implant Dentistry. The programme is accredited by the dental board of Hong Kong. There is at present no structure for recognition of a specialist status. The aims of the programme as presented in the school’s website are the following: To be competent in evidence-based, comprehensive treatment planning of partially and fully edentulous patients. To be competent in implant installation, in prosthetic reconstruction and in maintenance of the implant patient. To be competent in the diagnosis, prevention and management of biological and technical complications. To be familiar with dental and medical disciplines as well as the biomedical sciences relevant to implant dentistry. To have knowledge of the scientific literature relevant to implant dentistry and related fields such as biology, periodontology, prosthodontics and occlusion. To be competent in the basic scientific skills, and conduct and disseminate an individual research project. The course fees in 2012 were set at 350,000 HKD per year. The University of Hong Kong offers also a 2-year part-time degree in implant dentistry leading to a Master of Science degree. In Loma Linda University, the Advanced Education Program in implant dentistry is a 3-year programme leading to the award of a specialty certificate and an optional Master of Science (MS) or Master of Science in Dentistry (MSD) degree. Individuals who successfully complete the programme are awarded a professional certificate, but not a recognised specialist status. A lengthy dis-
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claimer on the website explains that specialist practice in the State of California and USA must fulfil requirements of specialist boards of the American Dental Association (ADA), where implant dentistry is at present not represented. The goals of the programme as found on the website are as follows: To educate graduate students of the Advanced Education Program in implant dentistry to the proficiency level and capability to deliver implant dentistry treatment. To provide in-depth didactic and clinical instruction in problem-based patient situations that require implant prosthodontic and surgical solutions. To train graduate students of the Advanced Education Program in implant dentistry to develop a clinical practice. To achieve highest levels of patient treatment satisfaction. To educate graduate students of the Advanced Education Program in implant dentistry to perform research and practise teaching. Completion of the programme costs $161,924, with some additional costs for books and supplies of about $15,000. The University of Loma Linda offers an array of postgraduate programmes in implant dentistry, including a 2-year practicum, internships and externships. All three programmes present some brief overriding aims at the university website, which however do not reveal much detail as to how the aims are achieved in practice and which are the components of the programmes in basic, clinical and biological sciences, or the dental disciplines necessary for comprehensive care such as periodontology and restorative dentistry. The programme at ACTA in addition to the overriding aims offers a detailed description of the programme in a pdf format.
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2. Two-year full-time programmes A more common education pathway in implant dentistry is through a 2-year full-time programme, leading most commonly to a Master of Science, a Master of Clinical Dentistry or an equivalent degree. Such programmes can be found in the majority of European countries and typically combine theoretical with clinical training whilst covering surgical and restorative aspects of implant dentistry.
3. Part-time or less than equivalent of 2-year full-time programmes Not surprisingly, this is the category of programmes with the wider diversity and where the border between university degree programmes and continuing professional development becomes more obscure. In the most simple form, it is possible to attain a Master of Science in Implant Dentistry degree through 1 year of part-time study, which does not involve clinical practice. Furthermore, different combinations exist, where part-time programmes of duration from 1 to 4 years can lead to a diversity of learning outcomes and often to a master’s degree of some form.
4. Online, distance/flexible/blended learning programmes Several universities have set up flexible blended learning postgraduate programmes, which can enrol both regional and 27
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remote/overseas students. This is commonly made possible by combining a modular blended learning structure of theoretical courses, with clinical training offered in collaboration with regional training centres/clinics or accredited mentors. The University of Warwick in the UK and Goethe Universit€at in Frankfurt am Main at present offer such programmes leading to a master’s degree. The University of M€ unster in Germany, through a consortium named International Medical College is also offering a ‘Master of Oral Medicine in Implantology’. The programme extends over 15 months and is credited with 60 ECTS. An interesting dimension is that many of the courses that are currently presented as online/flexible master’s are actually not university courses. Such courses are typically marketed with a variation of the word ‘master’s’ (clinical master’s, master clinicians, online master’s, etc.), they are directed by a private course provider or institute and evolve around the attendance of specific educational events in different regions of the world combined with online/distance learning. Whether the term ‘master’s’ should be used in that concept and who is accredited or appropriate to award a master’s degree is a worthy debate.
Postgraduate degrees in Europe – a master confusion There appears to be a wide diversity in the available university degree programmes. Diversity is not necessarily a disadvantage, as it could lead to the development of parallel models and evaluation of best practices. This could promote the progress of the discipline in the long term. However, although uniformity is not desired, standardisation and transparency are necessary, in a free market of 400 million people such as the European Union. Although many universities might offer diverse programmes, the end points of these programmes must be transparent and comparable. This is especially important for master’s programmes, which aim to the achievement of clinical competences, as the graduates of such programmes will be most likely performing clinical procedures at a high level of complexity. Unfortunately, the awarded academic title offers at present very little understanding of the nature and extent of training in implant dentistry which the recipient has received, or if clinical training has been received at all. The terms ‘master’s’ or ‘Master of Science’ with different variations, when currently used by universities, describe courses that extend from 1-year part-time attendance without clinical practice to 3-year full-time clinical programmes. If to these legitimate university master’s degrees, we add the numbers of graduates of the numerous ‘clinical master’s’ and ‘master clinicians’, one can immediately see this ‘master confusion’ constitutes maybe the most prominent danger at present within implant dentistry. Traditionally, the title ‘Master of Science’ has described a university postgraduate degree of a significant duration, but it says nothing about the actual skills and competencies the dentist has acquired, the level of complexity he/she is competent to deal with or even if he/she has received clinical training at all. Although the universities should maintain the options of designing academic programmes as they best see fit, it is an imperative need for them to introduce some form of transparent and comparable criteria, which will allow the 28
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profession and the public to relate the degree and academic credentials to the actual skills and competences of the degree holder. In particular, the academic title of ‘Master’ is today ill-defined and could certainly benefit from the introduction of some uniform minimum requirements or criteria. In certain cases, an attempt has been made to separate at least the master’s degrees that include a significant clinical training by introducing the title of ‘Master of Clinical Dentistry’ (13) as opposed to ‘Master of Philosophy’ or ‘Master of Science’, which can imply research-based or purely theoretical programmes. This pathway has been however rejected by other institutions. However, the name of the degree is not the only way to illustrate the qualifications acquired. The competencebased education, which is increasingly adopted by universities in Europe, could be a good starting point to at least identify the end products of each programme. The levels introduced by ADEE to describe the learning outcomes of a programme (be familiar with, have knowledge of, be competent in) can actually say much more than the title of the award and the duration of the programme and should be a necessary supplement to any programme description. Furthermore, the description of clinical competences with the levels of straightforward, advanced and complex, as introduced by ITI (14), can further assist the expression of learning objectives in a standardised and objective manner. Finally, the diploma supplement template as recommended by EU (15) offers a good understanding of the studied programme. Making available certain standardised information for every programme would help improve transparency and minimise confusion. Such information could include the learning outcomes expressed in the three levels proposed by ADEE, clinical skills and competences expressed in the SAC (Straightforward, Advanced, Complex) classification and also the most current version of the diploma supplement (e.g. that of the most recent graduating cohort). This could in time lead to a further organisation of the degrees as well, hopefully with names more indicative of the actual content of the studies.
B. Implant dentistry within existing specialist education programmes 1. Overview Historically, since the 1980s, clinical training in implant dentistry has been an integral part of specialty programmes in periodontology, oral surgery and prosthodontics. Oral surgery and periodontology programmes were focused on surgical aspects of osseointegration, and prosthodontics programmes on restoring implants. With the advancement of implant dentistry and the move from the initially fully edentulous patient to partial edentulous and aesthetic restorations, it became clear that implants should be placed in a prosthetically driven manner. The communication between the surgeon and the restoring clinician became tighter, particularly during treatment planning and directing of implant positioning during surgery. The introduction of computer-assisted planning and placement of implants has facilitated early visualisation of treatment outcomes with increased accuracy and promoted further interdisciplinary collaboration. Oral radiology programmes have a large ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 24–32
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component of their curriculum being devoted to radiography and diagnostics related to implant dentistry, although this training does not include clinical components. Some orthodontics programmes offer training in implants used for retentive anchorage. Recently, specialist training programmes in endodontics have introduced the theoretical but also clinical teaching of implant dentistry.
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of the American Dental Association for advanced education programmes in prosthodontics (18). A recent retrospective analysis of dental implants placed by prosthodontics residents had a success rate comparable to previously published studies for other specialties, and the year of prosthodontics residency training had no influence on the rate of failure (19).
4. Oral surgery 2. Periodontology The European Federation of Periodontology (EFP) expects all graduates of approved specialist training programmes in Europe (12 programmes in 2013) to be competent in the surgical placement of implants in simple to complex cases and implant site development, including guided bone regeneration and sinus floor augmentation, as well as patient maintenance and treatment for implant-related pathology. The competences described by EFP aim to prepare the graduate to practise the surgical aspects of implant dentistry in his/her periodontal practice at a high level of complexity, in collaboration with the restorative team. These guidelines extend to include the restorative aspects of implant dentistry, with the explicit reference that the periodontist is expected to have ‘comprehensive knowledge of the inter-relationships of orthodontic, restorative therapies and periodontal treatment (including implant therapy)’. The periodontal graduates need to prove their knowledge and skills in periodontology and implant dentistry by presenting five treated cases (some of them should include implant therapy) to the examining committee of the EFP.
3. Prosthodontics Restoring implants has been an integral part of prosthodontics specialty training. Although at present, many prosthodontists are surgically placing implants as well, surgical training within prosthodontist specialist education varies widely. Already in 2004, 43% of the advanced prosthodontics programmes in the USA either required residents to place or offered the option to have residents place implants. At the same time, 40% of programme directors were not trained in the placement of dental implants, and if they were, the majority (82%) stated that the nature of their training was 1- to 3-day course(s) (16). A more recent survey of residents of prosthodontics in the USA (17) found that the majority of the programmes in prosthodontics allow residents to place implants in their own patients, but it is an option, not a requirement. The volume of the didactic education also varies between 30 and 90 h. Fifty per cent of the residents received training in implant dentistry using models, but approximately half of them were trained during industry-driven courses and not by a university. According to the majority of the responders, computer-guided implant planning and surgery training were offered in their programmes. An interesting point is that a third of prosthodontics residents stated that their residency training did not adequately prepare them for implant surgery. The survey revealed that most advanced education programmes in prosthodontics in the USA at least encouraged their residents to perform the surgical part of implant dentistry for their own patient, although placement of implants is a part of the accreditation guideline ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 18 (Suppl. 1) (2014) 24–32
Oral surgeons were amongst the pioneers and leaders of the surgical part of implant dentistry. A 2007 survey between residents in oral and maxillofacial surgery in the USA (20) found that 30% of the residents estimated that they would place between 51 and 100 implants and 32% estimated that they would place more than 100 implants during their residency. Interestingly, 98% of the residents felt that implant dentistry would be an important part of their practice, but 28% felt that their residency did not adequately prepare them for implant surgery.
5. Endodontics According to the Commission on Dental Accreditation (21) of the ADA in the USA, advanced specialty programmes in endodontics ‘must provide instruction at the level of understanding and clinical training to the level of exposure in implant dentistry’. It is reasonable that an endodontist, when treating a questionable tooth, will be familiar with clinical and scientific aspects of dental implants as an alternative to root canal therapy or apical surgery. A survey in 2009 showed that 57% of the responding endodontists believed that placing implants was within their scope of practice, whilst only approximately 6% of them were placing implants (22). A later survey of the specialty programmes in endodontics in the USA revealed that most of the programmes have didactic courses in implant dentistry, whilst a third of the programmes offer clinical training as well in placing implants, and the training is given mostly by periodontists. However, there are no formal recommendations for training in placing implants into the endodontics curriculum (23). As the introduction of implant dentistry to the curriculum of endodontics is still at an early stage, many aspects of this training are still not addressed, unclear or under debate. The level of complexity of implant dentistry training for an endodontist is not addressed. Furthermore, it is unclear whether the theoretical and clinical training, when offered, extends to the restoration of implants as well, or is limited only to placement.
Established specialties and implant dentistry As today implant dentistry has become a widely applicable treatment modality, it is reasonable to expect its significance to rise within the existing specialist training programmes. It is also not surprising to see the rise of implant dentistry in the training of specialties previously not directly related to implants, such as endodontics. However, success with implant dentistry requires a comprehensive treatment plan, rather than possession of surgical and/or restorative skills. There is a great synergy between placing and restoring implants, whilst biology 29
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and technical components interact in critical ways determining the long-term success of implant treatments. Many of the complications and failures we see today are not attributed to lack of competence with procedures, but rather to inadequate treatment planning or poor communication between the specialists involved (24). In addition, there is growing evidence indicating that biological and technical complications are often interrelated (25). Procedural training is essential for a specialist to master clinical treatments, but there is a danger if this happens without developing the comprehensive understanding of implant dentistry as a restorative-driven discipline. A specialist (periodontist, surgeon) placing dental implants should have a profound understanding and certain level of clinical competence with the restorative procedures as well, whilst a restorative specialist must also have a good background in the surgical procedures, regardless if he chooses to place implants or not (26, 27). In the case of the endodontist, if clinical training in implant dentistry is desired, this should adequately include both surgical and restorative aspects. The emphasis in the comprehensive aspect of implant dentistry should be present in all specialist training programmes where implants are being taught, and this is at present not always reflected in available guidelines.
C. Is ‘implantology’ an emerging dental specialty? Since the 1980s, many authors from different parts of the world have initiated calls for the recognition of ‘oral implantology’ as a new dental specialty (28–37). The debate appears much more relevant today, as implant dentistry has expanded to the extent that the term ‘oral implantologist’ has been introduced and is used by some individuals, associations or journals as referring to a de facto dental specialist. There is no doubt at present that implant dentistry has reached the critical mass of an independent, multidisciplinary and vibrant domain of science, which combines knowledge and discoveries from many clinical and basic sciences. Implant dentistry has matured to be not only a widespread treatment modality, but also one of the most active fields of education and research and development in health care (38). There is a growing body of research dedicated to implant dentistry, which is reflected in the thousands of scientific publications of all kinds that are being produced annually. The ISI Web of Science includes at least seven peer-reviewed journals with impact factors dedicated to implant dentistry, whilst PubMed includes 25 such journals and periodicals. That excludes the journals from the fields of periodontology, prosthodontics, oral surgery and clinical dentistry, a large volume of whose content also evolves around implant dentistry. Furthermore, several scientific and professional associations related to implant dentistry have been created at national (39, 40), European (41) and international levels, numbering thousands of members. At a European level, several educational and scientific events within implant dentistry are attracting thousands of participants every year, such as the European Academy of Osseointegration annual congress, the Osteology congress and many more. In that sense, implant dentistry already presents a higher level of activity both in scientific and professional domain than many of the established dental specialties. 30
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At the same time, the knowledge and competences required for the practice of implant dentistry are not being taught in the undergraduate dental curriculum, and this has generated the need for postgraduate education in this field. But is all this sufficient to proclaim ‘implantology’ or ‘oral implantology’ as a new dental specialty? Even if we accept that oral implantology has grown into an independent scientific discipline, there are still some critical missing links, before the status of an independent dental specialty can be considered. One very important factor is education. The training pathway towards acquisition of implantology as a specialist competence, including the learning outcomes, knowledge and competences of a potential specialist, remain largely diverse and unclear. The ability to place an implant into an edentulous alveolus does not qualify someone to be ‘implantologist’ and the clinician who engages with implant treatment must possess a thorough understanding of every phase of dentistry required before and after placement of a titanium screw (26). Consequently, the challenge is not only whether ‘implantology’ is a specialty, but also how could we define the ‘implantologist’ as a dental specialist. The established dental specialties, even if not always recognised at the government level, have long since established educational pathways through regulated 3-year full-time specialist training programmes. Such programmes have well-defined learning outcomes, which have been developed through consensus in most cases at a European level and are supervised and accredited by European professional and scientific bodies. Even if oral implantology today can be perceived as a well-defined and established scientific domain, the term ‘implantologist’ has been used to describe a very diverse mass of practitioners, with a wide range of skills and competencies, acquired in many different ways, at different levels and under greatly varying standards. Consequently, the term ‘implantologist’ or ‘implant specialist’ is at present ill-defined and often misleading. Unfortunately, this confusion is not unique to implant dentistry, although it is there that it is at present most pronounced. As long ago as 1984, the American College of Oral Implantology submitted an application for specialty recognition to the ADA, followed by a similar one by the American Academy of implant dentistry (30, 31). The ADA rejected several repeated applications (33), and the specialty status remains largely inconclusive as of today. The ADA has set six clear criteria that must be fulfilled for a discipline to be recognised as a dental specialty (33). According to these, a candidate discipline for specialty recognition must be: Represented by an organisation whose membership is reflective of the special area of practice and recognised by the profession at large for its contribution to the art and science of the discipline. A distinct and well-defined field that requires unique knowledge and skills beyond those commonly possessed by general dental practitioners. The scope of the discipline must not be coincident with or readily subsumed within the scope of other recognised specialties. Substantial public need and demand for services, which cannot be adequately met by general practitioners or specialists in other areas must be documented.
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The discipline must incorporate some aspects of clinical practice. Adequate formal advance education programmes must exist to provide the special knowledge and skills. Whether implantology fulfils the above criteria has been repeatedly debated, but the decision of ADA has been negative so far, although not excluding specialty status in the future. One of the most debated criteria was about the need and demand for services, which cannot be adequately met by general practitioners or existing specialists. In addition, one can argue that such a new specialist would serve no purpose, because all possible procedures within implant dentistry can be accommodated by the qualified general practitioners in collaboration with existing specialists, including the comprehensive treatment planning and maintenance of patients. On the other hand, one should not overlook the arguments presented in support of a dental specialty devoted to oral implants. The introduction of an accredited specialism in implant dentistry might improve service to the public, by introducing some necessary standards and clearing the current confusion caused by the overflow of diverse ‘implantologists’. Practice of implant dentistry after fragmented, substandard or inadequate training is an increasing reality and poses a real risk to the public but also to the profession itself (24, 42). This can pose a serious risk to how implants are perceived by the public. For example, a recent wave of negative publicity in Japan has raised suspicion and caused an alarming decrease in the acceptance of implant treatments by the public (43). It is true that the field of work of a specialist in implant dentistry would overlap with parts of the areas of a periodontist, prosthodontist or oral surgeon, but in reality this is what happens today with everyone practicing implant dentistry, regardless of the level and quality of education they have received. A concern has been often expressed by clinicians that introduction of an ‘implantologist’ would automatically imply that this person is better qualified than other practitioners to do implants (44). Advocates of implant dentistry as a specialty, however, claim that the introduction of specialty recognition in implant dentistry will not aim to replace the established specialties, nor to prevent general practitioners from placing and restoring implants (33). The aim of such a specialty would be to ensure quality of comprehensive practice at the highest level within the discipline. At the core of a specialist, training is not the competence with procedures, but rather the synthetic ability to manage complex patient treatments, identify risks, deal with expected or unexpected complications as well as contribute to the development and progress of the scientific discipline. A practitioner who has an overview of the whole scientific area and who is able to treat complications whether they are of a biological, mechanical or prosthetic nature has become desirable, when considering the explosive growth in this field. However, this could also be at least partly addressed by enriching the education of current specialists in such a way that the periodontist, prosthodontist and oral surgeon will have a significant understanding of each others’ fields. The development of recognised specialist training programmes in implant dentistry is expected by some to have positive academic implications for the whole scientific domain. Such pro-
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grammes foster further interdisciplinary collaboration under one comprehensive teaching programme and could promote the development of multidisciplinary centres of excellence, which can significantly promote the scientific domain of implant dentistry. In Europe, at present, we lack a definition from the respective authorities of what is ‘sufficient’ to manifest a new dental specialty. The situation with the dental specialties in Europe remains very complex and confusing, even without the discussion on implant dentistry. As of today, the only two dental specialties that under EU Directive are recognised throughout the European Union remain maxillofacial surgery and orthodontics. Although an increasing number of countries have recognised a further number of dental specialties, there is still no uniformity in this issue and consequently no definition as to what are the prerequisites to recognise a clinical domain as a ‘specialty’. In some cases, a move has been made to introduce some uniformity through initiatives taken by scientific bodies such as the European Federation of Periodontology specialist education accreditation, which accredits programmes educating specialists in periodontology at a European level. This offers a standardisation and quality assurance for programmes and graduates, even if periodontology is not formally recognised as a specialty in all respective countries. Conclusively, although oral implantology can be described as a well-defined and vibrant interdisciplinary scientific field, significant challenges need to be addressed before a dental specialty status is seriously discussed. First, the profession should reach a consensus whether the introduction of a new recognised specialist is necessary or desired. Second and most important, the skills and competences and the training pathway for the new specialist should be defined and agreed upon. Such a specialist training should adhere to the same educational, quality assessment and accreditation standards, which other established specialties follow at a European level.
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Conflicts of interest The authors declared no conflicts of interest.
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