Undergraduate Curriculum Guidelines for Endodontology

Earlier editions of the ESE undergraduate curriculum guidelines for Endodontology were published in 1992 and 2001 (International Endodontic Journal 25, 169–72; 34, 574–80) and formed a benchmarking reference for dental schools and regulatory bodies. Despite much technological advance and the publication of quality guidelines for endodontic treatment (European Society of Endodontology 2006), studies published during the last decade have continued to show disappointing technical standards of root canal treatment in European populations (Eriksen et al. 2002, Segura-Egea et al. 2004, Tavares et al. 2009, Gencoglu et al. 2010, Peters et al. 2011). Longitudinal observational studies have also reinforced the relationship between treatment quality and persistent disease (Eckerbom et al. 2007, Kirkevang et al. 2007). Although a limited number of European countries have recognized endodontics as a speciality, there is no doubt that the vast proportion of endodontic procedures will continue to be undertaken by general dental practitioners. Evidence suggests that many general practitioners lack sufficient knowledge of the factors important in determining the outcome of root canal treatment (Bjørndal et al. 2007) and that basic principles are often disregarded (Peciuliene et al. 2009). Some of this may reflect the acquisition of foundational knowledge and skills during undergraduate training, where standards remain highly variable (Eleftheriadis the acquisition of basic skills in a suitably equipped pre-clinical environment, and the integration of knowledge and skills through clinical observation and supported clinical practice. It is acknowledged that the time and resource devoted by schools to endodontic education varies widely, and it has not been possible to define a minimum level of knowledge or skills-based input. Nor is it possible or desirable to provide definitive directions to schools on the manner in which they plan and deliver their courses (Sonntag et al. 2008). Innovation and the implementation of contemporary learning resources are encouraged, and the sharing of good practice with the ESE Education and Scholarship Committee is welcomed. Endodontic procedures should be undertaken within the context of comprehensive patient care. Whilst it was agreed that undergraduate students may benefit from teaching and clinical supervision by specialists, it is acknowledged that this is unrealistic in many schools. The breadth of endodontic procedures is reflected by their integration with aspects of cariology, conservative dentistry, restorative dentistry, surgical dentistry, paediatric dentistry, traumatology and periodontology. Whilst some schools may have dedicated endodontic clinics, it is recognized that many do not, and that the conduct of endodontic procedures in mixed clinics may in fact encourage holistic care. It was, however, agreed that teaching staff should ideally have a special interest in Endodontology, and be able to integrate knowledge and skills in the clinical setting. Recommendations are not made on the appropriate number of procedures such as pulp caps, pulpotomies and root canal treatments required for a student to reach a threshold of competence. Indeed, a competency-based approach to training implies that the quality and consistency of student performance are more important than simply the quantity of clinical exposure, but levels of expertise are intimated by the descriptors (Be competent at, Have knowledge of, Be familiar with) assigned to each competency. For root canal treatment, students should be competent to undertake the treatment of uncomplicated molar teeth, and it was the view of the committee that all students should gain adequate experience in the treatment of anterior, premolar and molar teeth in both the pre-clinical and clinical environment. It is essential within an endodontic curriculum that students should gain the assigned level of competence not just in root canal treatment but in vital pulp therapies, the management of endodontic emergencies, the management of dental trauma and in surgical procedures. It is recognized that much of this may occur in clinics other than dedicated endodontic or conservation clinics. It is important that students are not simply trained as technicians or ‘root canal therapists’. Students should be encouraged to consider all options for the management of compromised teeth and justify the case for tooth preservation by vital pulp therapy, root canal treatment or nonsurgical/surgical retreatment, followed by adequate coronal restoration, and balance this against tooth loss and prosthetic/implant-supported replacement. The foundational nature of endodontic procedures, the importance of assessing the restorability of teeth preoperatively and of planning the restorative strategy before embarking on treatment should be emphasized. Against this background, students should gain the assigned level of competence in assessing endodontic treatment complexity. They should be aware of the factors associated with treatment success and tooth survival, and implement these within their decision-making. They should equally be encouraged to reflect on their own skills and knowledge in case assessment and recognize when referral would be in the best interests of their patients. Assessment ensures that the knowledge and skills learned are reinforced and a standard of competence is achieved by the end of training. The demonstration of competence should involve both formative and summative assessment. Assessment manuals can be developed, corresponding to the competencies included in this guideline document. Direct observation has been shown to be a good method of assessing clinical skills. This method can be difficult to standardize, but precise criteria (checklists) can improve consistency and reliability. Formative assessment can only work if there is effective and structured feedback. Quality feedback on performance has been shown to have a positive influence on feelings of competence. Feedback should encourage self-assessment or reflection and is relevant when set against specified criteria. It has been shown (Dunnington et al. 1994) that when clinical skills are practised without feedback or evaluation, errors are reinforced rather than corrected. Constructive feedback should wherever possible be provided immediately. Suitable methods for formative assessment of clinical skills include the objective structured clinical examination (OSCE), structured clinical operative test (SCOT) and procedural observation tests such as direct observation of procedure skill (DOPS) and mini-clinical evaluation exercise (mini-CEX) tests (Fromme et al. 2009, Kogan et al. 2009). These can involve the assessment of complete clinical procedures or for lengthy procedures such as root canal treatment can be separated into smaller, defined elements. Students can be encouraged to undertake these when they wish to present themselves as competent. Typically, students are observed during the procedure and also assess themselves using the same criteria as the supervising clinician. When the procedure is completed, the patient is dismissed and the student and staff member meet to discuss the exercise, provide feedback and agree on grading. It is acknowledged that such methods of assessment and feedback are resource intensive and may be aspirational. It is important that not only theoretical and technical competence is tested, but also the professional attitude of the student. This may form part of a broader assessment of generic skills and professional development, and include compliance with local regulations on matters such as cross-infection control, radiation protection and record keeping, in addition to aspects of patient management and communication skills. Summative assessment by formal examination provides another important means of assessing competence. This may take the form of standard-set written, online, practical or oral examinations, or the objective assessment of completed clinical work. Consideration should be given to providing examinations specifically in Endodontology, and students should be given the opportunity to demonstrate their integration of endodontic knowledge and skills within broader summative assessments. The following pages present a list of competencies that the European Society of Endodontology considers essential for a graduating dentist in Europe. Competencies are presented in three domains: Domain 1: Scientific foundations of endodontic practice. Domain 2: Nonsurgical endodontic treatment. Domain 3: Surgical endodontic treatment. Each domain includes a list of major competencies which is followed by a list of supporting competencies – the elements of the curriculum that will allow students to achieve the desired level of competence. All undergraduates should be adequately grounded in basic and applied science for the safe practice of clinical dentistry (including endodontics). For the safe practice of clinical endodontics, undergraduates should have knowledge of: In order to meet these competencies, the dental curriculum should provide didactic teaching, in addition to a range of open and experiential learning opportunities for students to be able to: The undergraduate should be competent at: The undergraduate should have knowledge of: In order to meet these competencies, the curriculum should provide didactic teaching and clinical experience for students to be able to: The undergraduate should be competent at: The undergraduate should have knowledge of: In order to meet these competencies, the curriculum should provide didactic teaching and clinical experience for students to be able to: