Special oral care in educational systems from four European countries

Abstract

Aim. To compare under- and postgraduate training programs for special oral care (SOC) from the 4 European countries taking part in OSCAR Erasmus+ 2019-1-RO01-KA202-063820 Project: France, Italy, Turkey and Romania.

Methods. Data on the under- and postgraduate training programs for SOC were extracted from the websites of dental faculties from the four analyzed countries and compared in order to find elements in common and/or differences.

Results. a) Training curricula in SOC vary widely in partner countries, with regard to both theoretical and clinical aspects; b) In France, pediatric dentistry (PD) is not recognized as specialty, but there are four postgraduate programs for SOC/sedation; c) Italy has a 3-years residency in PD and a master of science degree in sedation; d) Turkey has a residency in PD and also a postgraduate program for master of science degree “Oral Health Care in Special Needs-Medically Compromised Children” for foreign dentists only; e) In Romania, PD has been recognized as a specialty since 2015, with a 3 years residency lasting 3 years.

Conclusions. A standardization of training programs on SOC for dental students and dentists in all countries in accordance with European standards to improve access of special needs patients to quality oral care services is needed.

Introduction

Pediatric Dentistry (PD) traditionally covers a relatively wide range of subjects and topics related to all fields of dentistry that refer to specialized treatment of children and adolescents, including Special Oral Care (SOC).

Under- and postgraduate teaching systems in various countries in Europe vary widely and so does the organization of the medical systems, including provision of dental treatment to children and adults with general pathologies with impact on oral health.

Young et al. (2005) consider that there are three main strands to improving oral health in people with special needs: improving oral hygiene, defining specific training for dental professionals, and allocating funds to cover dental care access and service utilization [1].

In 2019, Erasmus+ 2019-1-RO01-KA202-063820 Oral Special Care Academic Resources (OSCAR) project was initiated. The project promotes recognition of professional qualification of dentists on SOC across 4 different countries.

A pilot study carried out within the OSCAR project, aiming to assess dentists’ level of confidence in providing treatment to children with SHCN and their felt need for more information on SOC, revealed differences in SOC training, perception and confidence between participants in Romania, Turkey and Italy. A total number of 163 dentists (29 PD specialists, 100 PD residents, 34 GPs interested in working with children) took an on-line survey regarding their own experience and self-perception in providing SOC. While 97.6% of all respondents confirmed the need for more information and training on SOC, significant differences in SOC training, experience and attitude were found. Romanian dentists were less likely to have treated patients with SOCN than colleagues from the other countries, with statistically significant (ss) differences (p=0.007). Turkish dentists were ss more likely to have treated children with SOCN (p=0.000) and also ss more confident than the others in treating children with SOCN without the help of pharmacologic means (p=0.001). Of all the respondents, 27% had never treated SOCN patients, 17% would rather refer all patients in this category, 59.5% would refer all patients needing GA and 43.5% would refer all patients needing various types of sedation. All of these findings are explicable given that 72% of the responding PD residents had never treated patients under any kind of sedation/ GA [2].

The conclusion to the above-mentioned findings is that there is still a lot of reluctance among dental professionals in dealing with disabled patients, due to lack of knowledge and skills. In response to this situation, Erasmus+ OSCAR (Oral Special Care Academic Resources) project aims to raise awareness among Pediatric Dentistry residents regarding the oral health of children with special health care needs and improve knowledge and skills of dental practitioners in the field of SOC in order to enable them to provide adequate dental treatment for this category of patients. For this purpose, an online platform http://oscarpd.eu/ with useful practical information regarding professional and home oral care for children with general pathologies and special healthcare needs was created.

The aim of this paper was to compare under- and postgraduate training programs for SOC from the 4 European countries taking part in the OSCAR Erasmus+ 2019-1-RO01-KA202-063820 Program: France, Italy, Turkey and Romania.

Material and methods

Data on the under- and postgraduate training programs for SOC were extracted from the websites of the dental faculties from the four analyzed countries. Details were obtained from academics directly involved in the teaching process.

Data were compared in order to find elements in common and/or differences.

Results

1. France          

In France PD is not a certified specialty; however, several postgraduate programs in the field of SOC are available.

There is a postgraduate program about “Care pathway for patients with rare oral/dental diseases” comprising 4 hours of theoretical teaching and 32 hours of clinical stages. Topics covered are rare diseases, the rare diseases reference centers (CRMR), health sectors rare diseases, European Reference Network (ERN) device, databases, genetic tests, the analysis of clinical situations and bibliographic research to discuss the diagnosis, indications of care and treatment plan, patient financial support through the ALD (Allocation de Longue Durée) system, training and therapeutic education  (ETP) etc. As personal work(12h), students must prepare a 5-6 pages paper on the clinical pathway of a patient (from first visit), including presentation of a rare disease.

Another post graduate program is “Interuniversity diploma for oral health care for disabled patients” (“Diplôme Interuniversitaire de prise en charge de la santé orale des patients handicapés“). This program comprises 72.3 hours of theoretical courses and 30 hours of clinical stages. The main topics are: interdisciplinarity; multiple educational skills, determinants of psychological and aesthetic disability, mental retardation, autism spectrum disorders, old age, oral manifestations of the major genetic syndromes with orofacial manifestations and their consequences on the limitation of good oral health; improvement of oral health as public health matter. The objectives of this program are:

• to ensure better organization of prevention;
• to facilitate access to healthcare;
• to smoothen the flow of care;
• to guarantee quality of care;
• multi-professional work with exchanges of practices
• sharing experience and innovative actions in supporting methods.

A postgraduate program is “Dental care using inhalation-sedation” (“Soins dentaires sous sédation par inhalation de MEOPA”). Topics covered are:

• patient evaluation; pain; anxiety; disability; sedation;
• nitrous protoxide in dentistry; pharmacology and pharmacodynamics; indications and limits;
• physiology of breathing;
• conscious sedation for SN children / for anxious/phobic adults;
• drug associations;
• legal aspects;
• patient evaluation.

Another post graduate continuing education program containing SOC topics is “Pediatric dentistry and prevention”. This 1-year training program touches to important aspects, such as:

– the acquisition of fundamental knowledge about the development and growth of the child;

– specific care of the disabled child and the various aspects of oral and dental prevention;

– physiology and pathologies of normal deciduous and immature permanent teeth, as well as trauma.

Figures 1 and 2 give views from the digital learning center for under- and postgraduate students in the Dental Faculty, Hôpitaux Universitaires de Strasbourg.

No information on undergraduate SOC curricula in France was available.

2. Italy

For undergraduate students, “Special needs patients” subject is taught in one section of a course on oral health.

 Postgraduate students can choose a 3 years residency in Pedodontics. Courses, clinical stages and requirements are different depending on the faculty. Thus, at the Faculty of Dentistry in Naples, any postgraduate student must perform 10 treatments on disabled patients during the 3 years of training, with or without sedation. At the Faculty of Dentistry in Trieste, there is half a day of theoretical education on special needs patients per year of specialization.

Residents in Paediatric Dentistry and Orthodontics respectively can (but do not have to) choose to go, for their clinical stages, in hospitals hosting dedicated SOC services and to learn from highly experienced professionals in this field. For example, Ospedale Pediatrico Bambino Gesù offers to young residents, by convention with Università degli Studi dell’Aquila, the opportunity to take part in 9 sessions of SOC.

The Faculty of Dentistry in Padua hosts a master’s degree in sedation and master students can choose to assist a senior colleague once a week in special needs patients treatment with sedation.

3. Turkey

In Turkey, Pediatric Dentistry specialty has been recognized since 2009 [3].

There is also a postgraduate program for a master of science degree “Oral Health Care in Special Needs-Medically Compromised Children” at the Department of Pediatric Dentistry. It comprises 4 semesters (16 credits), with 28 hours of theoretical courses and 32 hours of clinical stages. The courses are in English only, available exclusively for foreign postgraduate students, and the following topics are detailed:

• childhood disability and oral health;
• diagnosis and treatment of children with special needs;
• prevention of serious dental problems in SN children;
• behavior management;
• legislation, ethics;
• advanced dental sciences to SC dentistry;
• research in SOC.

No data on undergraduate teaching were available for Turkey.

4. Romania

The 5^th year students from the Faculty of Dentistry – Carol Davila University, Bucharest have a two-hours theoretical course on SOC in undergraduate pedodontics curricula.

An optional course was introduced in the 4^th year undergraduate curricula of the same faculty: “Dental management of children and adolescents with various general diseases”. Theoretical sessions (14 hours in total) provide information on general diseases most frequently found during childhood and adolescence, particularities of dental diagnosis, behavior management methods, preventive and curative treatment methods for children/adolescents with general diseases. Fourteen hours of clinical practice were recently added to this optional course in order to better familiarize undergraduate students with practical aspects of providing SOC and help them overcome the anxiety that interaction with patients with complex pathologies could induce.

Dental students of Gr T Popa University of Medicine and Pharmacy, Iași, can choose during their 6th year an optional course on SOC : « Dental management of the child with general pathologies » (14 hours theoretical course), while for those in Iuliu Hațieganu University of Medicine and Pharmacy from Cluj-Napoca the SOC course (2 hours) is part of the mandatory undergraduate curriculum for the 6th year. However, in George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu-Mureș, an optional course on SOC was removed from the curriculum due to students’  lack of interest in the field.

Since 2016, pedodontics has been recognized as a self-standing dental specialty in Romania, with a 3-years residency (Order of Health Ministry no 1109/6.10.2016, Published MO 786 / 6 Oct. 2016). During the 3^rd year of residency, there are 12 hours of courses and 28 hours of clinical stages dedicated to SOC. The following topics are studied :

– terminology and classifications of patients with special needs according to their disabilities (physic, intellectual, sensitive, medical);

– comprehensive and interdisciplinary therapeutic management of patients with special needs;

– specific aspects of pedodontic treatment of special and medically compromised patients.

Clinical activities comprise performing therapeutic tasks in patients with disabilities and reviews of the scientific literature in order to submit reports.

Not solely linked to the special needs patient, but with obvious applicability in the field, the oro-maxilo-facial surgery department of Carol Davila University hosts a 3-month postgraduate program on ‘Inhalation sedation using nitrous protoxide and oxygen in dentistry”.

Discussion

Many studies have shown that children with disabilities have poorer oral health than healthy children [4-8]. For example, Dorin et al. performed a study on a sample of 8,401 children and teenagers with disability from France and they found that only 3.4% had no oral health disease [9]. Dental caries and chronic gingivitis are the most common oral pathologies in children with different types of disabilities [10]. These results are explained by the fact that people with disability do not always have the neuromotor abilities required to perform oral hygiene independently and effectively [8, 11].

Even detected, many oral diseases in these patients remain unresolved [12-15]. In fact, the 2001 National Survey of Children with Special Health Care Needs conducted in the USA showed that dental care was the most commonly reported unmet service need [16].

Consequences of unmet oral health care needs include infection of the oral tissues, negative behavior and aggravation of concomitant medical conditions [17].

Oral conditions of special needs patients remain unsolved due to a variety of factors. Limited access of this category of population to dental treatment is partly due to their reduced ability to cooperate with the medical staff, which may induce reluctance or even refusal of treatment by the inexperienced, untrained practitioner. Parents’ low level of literacy regarding the importance of oral health and regular check-ups is another contributing factor. In countries where dentistry is mainly private, financial reasons may also induce limitation of dental treatments in people with disabilities, especially in case of late presentation, with already complex pathologies, needing treatments with a higher level of difficulty and therefore more expensive. Dental treatment in people with disabilities may require 2-5 times more time, more materials and resources to provide treatment under special circumstances like sedation or general anesthesia (GA) [6,18].

Regarding the professional training of the practitioners in the four analyzed countries, we can notice that the training curricula in SOC varies widely, with regard to both theoretical and clinical aspects.

According to the European Academy of Pediatric Dentistry (EAPD) and Association of Dental Education in Europe (ADEE), pediatric dentists must get extensive training in all areas of dentistry regarding the dental management of patients aged 0 to 18 years, affected or not by general diseases/disabilities, must know the behavioral management techniques and all techniques of conscious sedation used exclusively in a hospital setting or/and in dental offices and must be trained in providing oral care under GA [19,20].

In 17 European countries (Bulgaria, Croatia, Great Britain, Finland, Hungary, Italy, Lithuania, Norway, Poland, Portugal, Romania, Russia, Serbia, Slovenia, Sweden, Turkey, Ukraine) PD is recognized as a self-standing dental specialty, with a dedicated residency training program [21]. Thus, in Italy, Romania and Turkey there is a 3-year residency in Pedodontics and during this postgraduate program all residents receive theoretical and practical information on providing oral care to patients with special needs.

Other countries (like France) train and recognize specialists in SOC, without having a certified PD specialty. In these countries, dentists may choose a residency or master of science program in SOC.

On the other hand, Turkey has both residency in Pedodontics and a postgraduate program for master of science degree regarding oral health care in special needs children. The residency in Pedodontics is available for Turkish dentists, but the master of science program for SOC is  available exclusively for foreign postgraduate students.

In some countries, like Italy and Romania, undergraduate students receive some information about special needs patients in oral health or pedodontics courses. These courses are either optional or part of the undergraduate curricula. In Romania, 4th grade dental students from Carol Davila University can take an extensive optional course (14 hours theoretical teaching + 14 hours clinical training) regarding the dental management of children and adolescents with various general diseases. Well received by students, these courses raise awareness of young dental professionals with regard to SOC.

Despite various educational systems’ preoccupation regarding special oral care – even with obvious differences in the curriculum – in many countries children with disabilities reportedly have poorer oral health than healthy children and this situation worsens with age [4]. 

Given that over 1 billion people, corresponding to about 15% of the world’s population, are estimated to experience disability during their lifetime [20] and people with special needs currently have unmet oral health care needs, it is important for the future that theoretical and practical training of dentists focuses more on SOC. Training of hygienists and addressing special care issues during dental education could help improve oral hygiene and care standards for people with disabilities [23].

Conclusions

Many differences in SOC curricula not only between countries but also between training programs within the same country induce different attitudes and perceptions among dental practitioners with regard to providing oral care to people with special healthcare needs. Need is felt for a leveling of training programs on SOC for dental students and dentists in all countries in accordance with European and international standards in order to improve access of special needs patients to quality oral care services.

Standardized under- and postgraduate curricula in SOC would also represent a step towards the recognition of SOC training across borders.

The authors declare they have no conflict of interest.

This research is part of Erasmus + project 2019-1-RO01-KA202-063820  “Oral Special Care Academic Resources” (OSCAR)

References

1. Young NL, Steele C, Fehlings D, Jutai J, Olmsted N, et al. Use of health care among adults with chronic and complex physical disabilities of childhood. Disabil Rehabil2005; 27:1455–1460.
2. Didilescu A, Vinereanu A, Tanase M, Vacaru RP, Ilinca R, Munteanu A. Romanian paediatric dentistry residents’ self-perceived training needs towards treating patients with special oral care needs. ADEE Strasbourg on-line  annual meeting 2021. https://adee.org/tour-poster-showcase-session-1.
3. Kargul B, Bakkal M. Systems for the previsions of oral health care in the Black Sea Countries. Part 6: Turkey. OHDMBSC 9.3 (2010): 115-21.
4. Hennequin M, Moysan V, Jourdan D, Dorin M, Nicolas E. Inequalities in oral health for children with disabilities: a French national survey in special schools. PLoS One. 2008; 25;3(6):e2564. doi: 10.1371/journal.pone.0002564. PMID: 18575600; PMCID: PMC2432497.
5. Gurbuz T, Tan H. Oral health status in epileptic children. Pediatr Int 2010; 52(2):279-83. doi: 10.1111/j.1442-200X.2009.02965.x. Epub 2009 Sep 15. PMID: 19793211.
6. Oliveira JS, Prado Júnior RR, de Sousa Lima KR, de Oliveira Amaral H, Moita Neto JM, Mendes RF. Intellectual disability and impact on oral health: a paired study. Spec Care Dentist 2013;33(6):262-8. doi: 10.1111/scd.12015. Epub 2013 Mar 11. PMID: 24164223.
7. Dziwak M, Heinrich-Weltzien R, Limberger K, Ifland S, Gottstein I, Lehmann T, Schüler IM. Dental health and odontogenic infections among 6-to 16-year-old German students with special health care needs (SHCN). Clin Oral Investig 2017;21(6):1997–2006. https://doi.org/10.1007/s00784-016-1988-8.
8. Zhou N, Wong HM, Wen YF, Mcgrath C. Oral health status of children and adolescents with intellectual disabilities: a systematic review and meta-analysis. Dev Med Child Neurol 2017;59:1019-26. doi: 10.1111/dmcn.13486.
9. Dorin M, Moysan V, Cohen C, Collet C, Hennequin M. Evaluation des besoins de santé bucco-dentaire des enfants et adolescents fréquentant un institut médico-éducatif ou un établissement pour enfants et adolescents polyhandicapés, en France. Prat Organ Soins 2006; 37: 14.
10. Chi DL – Oral Health for US Children with Special Care Needs. Pediatr Clin North 2018; 65: 981-93.
11. Faulks D, Collado V, de Fréminville B, Newton TJ, Hennequin M. A controlled national survey of difficulty encountered by persons with Down syndrome during hygiene and health care. Nursing Outlook2006;54:345–352.
12. Stanfield M, Stanfield M, Scully C, Davison MF, Porter S.  Oral healthcare of clients with learning disability: changes following relocation from hospital to community. Br Dent J2003; 194: 271-277. 
13. Turner S, Sweeney M, Kennedy C, Macpherson L. The oral health of people with intellectual disability participating in the UK Special Olympics. J Intellect Disabil Res 2007; 52: 29-36.
14. Petrovic BB, Peric TO, Markovic DLJ, Bajkin BB, Petrovic D, et al. Unmet oral health needs among persons with intellectual disability. Res Dev Disabil2016; 59: 370-377.
15. Kassebaum NJ, Smith AGC, Bernabé E, Fleming TD, Reynolds AE, et al. Global, regional, and national prevalence, incidence, and disability-adjusted life years for 195 countries, 1990–2015: A systematic analysis for the global burden of diseases, injuries, and risk factors. J Dent Res 2017; 96: 380-387. 
16. Waldman HB, Perlman SP. Children with special health care needs: results of a national survey. J Dent Child2006; 73:57–62.
17. Edelstein BL. Dental care considerations for young children. Spec Care Dentist 2002; (22):11s-25s.
18. Spinei A, Spinei I, Burlacu V., Dizabilitatea copiilor-factor de risc privind accesul la serviciile stomatologice. Revista Română de Medicină Dentară 2019; XXII (3): 427-452
19. http://eapd.eu/ Curriculum Guidelines for Education and Training in Paediatric Dentistry 1996
20. Cowpe J, Plasschaert A, Harzer W, Vinkka-Puhakka H, Walmsley AD. Profile and competences for the graduating European dentist – update 2009. Eur J Dent Educ. 2010 Nov;14(4):193-202.
21. https://www.eapd.eu/index.php/post/european-countries-with-paediatric-dentistry-specialty-recognition.
22. World Health Organization. Disabilities. [Online] Available from: http://www.who.int/topics/disabilities/en/ [Accessed 23rd December 2021]
23. Allison PJ, Hennequin M, Faulks D. Dental care access among individuals with Down syndrome in France. Spec Care Dentist2000; 20:28–34.