Guidance for the core content of a Curriculum in Special Care Dentistry at the undergraduate level

Authors


Abstract

Given the rapidly changing demography of populations worldwide, dental professionals of the future need to be able to meet the challenge posed by the evolving landscape in health care needs. Leading institutions are now embedding teaching and learning in special care dentistry (SCD) within their curricula, to provide students with the knowledge, skills and attitudes to meet the oral health needs of vulnerable groups within their communities. The International Association for Disability and Oral Health (iADH) has initiated the development of undergraduate curriculum guidance in SCD through a consensus process. The curriculum in SCD is defined in statements of learning outcomes with many of the skills being transferable across the undergraduate course. This curriculum includes examples of teaching and assessment, designed to enhance critical thinking in relation to SCD and to promote positive attitudes towards disability and diversity. The learning outcomes are designed to be readily adapted to conform to the generic profiles and competencies, already identified in undergraduate frameworks by global educational associations, as well as meeting the requirements of professional regulatory bodies worldwide. Suggestions for teaching and learning are not intended to be prescriptive; rather, they act as a signpost to possible routes to student learning. Ideally, this will require that students have a sufficiently diverse patient case mix during their undergraduate studies, to achieve the required levels of confidence and competence by the time they graduate. Clinical care competencies in SCD emphasise the need for learners to broaden their theoretical knowledge and understanding through practical experience in providing care for people with special health care needs. It is crucial to the development of equitable dental services for all members of a community, that these learning outcomes are embedded into evolving curricula but most importantly, that they are evaluated and refined in a dynamic way with shared learning for all teachers.

Background

Graduates of dentistry are, potentially, likely to see a significant number of patients with special health care needs in the course of their practising lives [1]. Their confidence and willingness to provide care for this diverse group of patients correlates with the quality and content of special care dentistry (SCD) in their undergraduate education [2]. Health care providers have been reported as lacking the skills set to provide care for people with disabilities, leading to inequalities in health [3] and in 2004, Nunn et al. [4] stated that ‘It was no longer tenable, within the framework of the Disability Discrimination Act, the Human Rights Act as well as the rapidly changing demographic trends in the population, that new graduates can qualify in ignorance of the impact of these for the wider community they serve'. Given the rapidly changing demography of populations worldwide [3], dental professionals of the future need to be able to meet the challenge posed by the evolving landscape in health care needs.

Leading institutions internationally are now embedding teaching and learning in special care dentistry (SCD) within their curricula, to imbue in their students the knowledge, skills and attitudes to meet the oral health needs of people with disabilities and marginalised groups within their communities. It is the responsibility of higher education institutions to ensure that, on qualification, the dental team is competent and confident to respond in a dynamic way to these challenges. There remains, however, evidence of variation of availability of education across the world in this emerging area of dentistry, with little guidance on benchmarking the core content of an undergraduate curriculum [4, 5].

Methodology of development of curriculum guidance

In response to requests from educators worldwide, the International Association for Disability and Oral Health (iADH) initiated the development of guidance on an undergraduate curriculum in SCD [6]. Full details of the rigorous methodology used to produce the evidence base for the curriculum guidance are described in an earlier publication [1]. The authors detail the three-round Delphi process, followed by a face-to-face meeting, which established consensus on what constituted the essential core knowledge, skills and attitudes required by a newly qualified dentist, so that they are able to deliver patient care to diverse populations following graduation [1]. A high level of agreement was established amongst the international panel of experts in SCD from 30 countries who took part in the consensus process [1]. The resulting curriculum document, outlined in this article, is defined in statements of learning outcomes, derived from the items identified and agreed during the consensus process. Included are examples of teaching and assessment, designed to provide undergraduates with theoretical knowledge and clinical experience to build the required skills, attitudes and behaviours in SCD [6].

It was acknowledged that this approach focused on dental students and that there was a need to develop similar learning outcomes for other members of the oral health care team.

Undergraduate curriculum

The evidence-based learning outcomes are designed to be student-centred, with the flexibility to be easily imported into contemporary dental curricula [7]. Domains normally associated with dental education have been used to group the learning outcomes namely knowledge (cognitive), skills (psychomotor), attitudes and behaviours (affective) across six areas of competency (Table 1). Educators in individual countries should use the learning outcomes to design the content of their own programmes according to local needs, and/or curriculum guidelines within their institutions, with many of the skills being transferable across the entire undergraduate curriculum [7-10].

Table 1. Undergraduate learning outcomes in Special Care Dentistry from the iADH undergraduate curriculum in SCD [6]. Each of the learning outcomes should be prefaced with ‘Students who have successfully completed this component will be able to….'
Learning outcomes in SCDKnowledge (cognitive)Skills (psychomotor)Behaviours (affective)
1. Scope of SCD

1a

Describe the cultural, legal and social context of people with disability and other marginalised groups.

1b

Discuss epidemiology, terminology, concepts & classifications of human function, disability and health.

1c

Demonstrate positive attitudes in relation to human difference and diversity.

2. Access & barriers to oral health for marginalised groups & people with disabilities

2a

Identify the social determinants of health in relation to health inequalities in people with disability and other marginalised groups.

2b

Recognise barriers and facilitators to oral health for people with disability and other marginalised groups.

2c

Use social and environmental facilitators to oral health and oral health promotion within service structure.

3. Consent for patients requiring SCD

3a

Outline the appropriate consent process when providing care for people with communication, cognitive or sensory impairments.

3b

Obtain valid consent or assent for oral health procedures appropriately.

3c

Demonstrate respect for patient autonomy and the role of the family and caregivers in supported decision making.

4. Communication skills in SCD

4a

Describe appropriate methods of communication for people with cognitive, sensory and/or other communication impairments.

4b

Use appropriate methods of communication for people with cognitive, sensory and/or other communication impairments.

4c

Demonstrate culturally sensitive and inclusive language with patients, colleagues and care givers.

5. Impact of impairments, systemic conditions & disabilities on oral health & oral function

5a

Describe common impairments, disabilities and systemic conditions in relation to their impact on oral health and oral function.

5b

Identify the key elements of impairments, disabilities and systemic conditions that may impact on oral health or oral function for individual patients.

5c

Consider the need for and benefits of inter-professional liaison in patient assessment.

6. Clinical management of patients requiring SCD

6a

Describe the factors (medical, social, psychological and environmental) that impact on risk assessment and treatment planning for individual patients requiring special care.

6d

Discuss behavioural and pharmacological approaches that facilitate dental treatment for individual patients requiring special care dentistry (according to local guidelines and protocols)

6b

Design oral health education for individual patients and their caregivers.

6e Provide simple clinical treatment using appropriate facilitation techniques for patients requiring special care, likely to present to a primary care service.

6c

Recognise the value of teamwork in the management for patients requiring special care.

6f Take responsibility for referring or arranging care for patients with more complex needs.

The learning outcomes specifically relate to people requiring special care dentistry defined as ‘those people with a disability or activity restriction that directly or indirectly affects their oral health, within the personal and environmental context of the individual' [11]. This approach supports the incorporation into curricula of the International Classification of Functioning, Disability and Health (ICF) [12]; it also directs the focus of teaching and learning towards holistic, patient-centred care across the entire curriculum and away from solely the medical condition. Depending on local service structure and individual patient factors, people requiring special care may, therefore, include patients across all age groups, medically compromised patients, patients with intellectual or physical disabilities, prison populations, recent immigrants or refugees, homeless persons and persons with dental fear or phobia. It is recognised that the majority of these patients will receive their care in the primary health care sector, and a minority with more complex needs will most likely require referral for specialist care [11].

Profiles and competencies

Recognising the pressures associated with providing additional teaching in already overcrowded curricula, the learning outcomes in SCD are designed to be readily adapted to conform to the generic profiles and competencies identified in undergraduate frameworks of global educational associations, as well as meeting the requirements of professional regulatory bodies worldwide. As an exemplar, Table 2 demonstrates the SCD competencies from the iADH undergraduate curriculum document mapped to the seven major competences in the Profile and Competences for the Graduating European Dentist Document [8], published in 2009 by the Association of Dental Education in Europe (ADEE).

Table 2. Learning outcomes in SCD mapped to the seven major competencies in the 2009 ADEE profiles and competencies document [8]
Special Care Dentistry competencies from the undergraduate curriculum in SCD [6]Exemplar of mapping to corresponding major domains and supporting competencies of the profile and competences for the Graduating European Dentist [8]

Scope of Special Care Dentistry

Learning outcomes 1a, 1b, 1c (Table 1)

Domain I: Professionalism (with supporting competencies 1.1, 1.5, 1.8, 1.11)

Domain VII: Improving Oral Health of Individuals, Families and Groups in the Community (with supporting competencies 7.5, 7.6, 7.7)

Access & barriers to oral health for people with disability & other marginalized groups

Learning outcomes 2a, 2b, 2c (Table 1)

Domain 1: Professionalism (with supporting competencies 1.10,1.11,1.19,1.20, 1.21)

Domain II: Communication and Interpersonal Skills (with supporting competencies 2.2, 2.3, 2.4)

Domain VII: Improving Oral Health of Individuals, Families and Groups in the Community (with supporting competencies 7.1, 7.4, 7.6, 7.7, 7.8)

Consent for people requiring special care

Learning outcomes 3a, 3b, 3c (Table 1)

Domain I: Professionalism (with supporting competencies 1.7, 1.18, 1.19)

Domain II: Communication and Interpersonal Skills (with supporting competencies (2.1, 2.2, 2.7)

Domain IV: Clinical Information Gathering (with supporting competencies 4.17)

Domain V: Diagnosis and Treatment Planning (with supporting competency 5.1)

Communication skills for people requiring special care

Learning outcomes 4a, 4b, 4c (Table 1)

Domain I: Professionalism (with supporting (competencies 1.1, 1.2, 1.3)

Domain II: Communication and Interpersonal Skills (with supporting competencies 2.1, 2.2, 2.4, 2.6, 2.7)

Domain III: Knowledge Base, Information and Information Literacy (with supporting competency 3.13)

Domain V: Diagnosis and Treatment Planning (with supporting competencies 5.19, 5.20, 5.21)

Impact of impairments, disabilities & systemic conditions on oral health & oral function

Learning outcomes 5a, 5b, 5c (Table 1)

Domain II: Communication and Interpersonal skills (with supporting competencies 2.3, 2.4,2.6)

Domain III: Knowledge Base, Information Handling and Critical Thinking (with supporting competencies 3.7, 3.8, 3.9, 3.10, 3.11, 3.12, 3.14)

Domain V: Diagnosis and Treatment Planning (with supporting competencies 5.5, 5.13, 5.21)

Domain VII: Improving Oral Health of Individuals, Families and Groups in the Community (with supporting competency 7.2)

Clinical management of patients requiring SCD

Learning outcomes 6a–6f (Table 1)

Domain I: Professionalism (with supporting competencies 1.1, 1.5, 1.7, 1.8, 1.9, 1.10, 1.11, 1.12, 1.14, 1.18, 1.20)

Domain II: Communication and Interpersonal Skills (with supporting competencies 2.1, 2.2, 2.3, 2.6, 2.7, 2.8, 2.9)

Domain III: Knowledge Base, Information Handling and Critical Thinking (with supporting competencies 3.12, 3.16, 3.18, 3.19, 3.21)

Domain IV: Clinical Information (with supporting competencies 4.3, 4.4, 4.9)

Domain V: Diagnosis and Treatment Planning (with supporting competencies 5.2,5.18, 5.19, 5.20, 5.21, 5.22)

Domain VI: Establishment and Maintenance of Oral Health (with supporting competencies 6.1, 6.2, 6.15, 6.16, 6.19, 6.21, 6.25, 6.32, 6.64, 6.70)

Domain VII: Improving Oral Health of Individuals, Families and Groups in the Community (with supporting competencies 7.1, 7.6, 7.7)

Learning and teaching methodologies

Undergraduate students will be expected to acquire the requisite knowledge, skills, attitude and behaviours through a variety of learning environments [13], to enhance their critical thinking in relation to SCD and promote positive attitudes towards disability and diversity [1].

The curriculum document contains specific examples of SCD teaching methodologies and assessments including lectures, seminars, blended learning, problem based learning, case based learning, role play, observation and simulation [7]. Importantly, the SCD curriculum aims to ensure experiential learning by recommending provision of hands-on, simple clinical care for diverse groups of patients, including people with disability, encouraging workplace-based learning with guided, chair side teaching and mentoring. The document emphasises the need for learners to broaden their knowledge base by applying theories and constructs in a workplace setting. This is required to enhance their skills development and to make sense of more complex situations through practical experience. Ideally, this will require that students have a sufficiently diverse patient case mix, across the dental disciplines, during undergraduate studies. By those means they will, on graduation, have achieved the required level of confidence and competence to provide care for people with special health care needs in a primary care setting [2].

Assessment

Assessment and feedback are crucial in the development of those skills, attitudes and behaviours that will encourage lifelong learning in SCD. A variety of assessments can be used to assess the desired learning outcomes in SCD and will be expected to form part of the overall assessment strategy for undergraduate dental education, mapped within an assessment blueprint.

The curriculum is designed to encourage skills acquisition through reflective clinical practice [14], whilst appreciating the need for summative assessment to satisfy stakeholders. Examples of summative assessments such as clinical scenarios in examination papers, objective structured clinical assessments (OSCE) and workplace-based assessments may be mapped to multiple learning outcomes from the SCD curriculum, allowing knowledge, skills and behaviours to be assessed at key stages of student progression. An emphasis on student-centred formative assessment and multisource feedback is encouraged, to enhance the learning experience through a clinical portfolio, including a reflective log–diary to assess student attitudes and skills related to facilitation of oral health care for people with disabilities.

Evaluation and feedback

The iADH undergraduate curriculum document has been developed to assist educators to further develop teaching and learning in SCD in their own schools and faculties. It is envisaged that the learning outcomes and assessments will be adopted through an incremental approach, to enhance a dynamic, evolving curriculum over a period of time. The curriculum will be subject to continuous quality enhancement based on ongoing evaluation and continuing feedback from key stakeholders including educators and academics, students, regulatory bodies and patients.

The undergraduate curriculum was launched at the IADH Congress in Melbourne 2012. It was evident that the curriculum would be easily adapted and used for training of nurses, hygienists and therapists at the undergraduate level, thereby harmonising the basis for lifelong learning in SCD for the whole dental team.

In 2012, a SCD Special Interest Group (SIG) was established within the Association for Dental Education in Europe (ADEE). It is envisaged that further groups and networks will be set-up within similar education organizations worldwide, aiming to develop an evidence base to inform and support teaching and learning in this important, emerging subject area as it becomes established globally.

Conclusion

Graduates of dental programmes are increasingly being confronted by clinical and other challenges, posed by patients with special health care needs, for which they have little or no undergraduate education or training.

The needs of this special patient group can be met through the delivery of educational material as a part of a curriculum that embrace what are often generic skills relevant to many patient groups, not just those with disabilities. This document sets out to familiarise the reader with the learning outcomes that should be incorporated into an undergraduate curriculum. Suggestions for teaching and learning are included but are not intended to be prescriptive; rather, they act as a signpost to possible routes for student learning. It is crucial to the development of equitable dental services for all members of a community, that these learning outcomes are embedded into evolving curricula but most importantly, evaluated and refined in a dynamic way with shared learning for all teachers.

Contact

The curriculum document can be freely downloaded from the iADH website www.iadh.org and may be adapted for education and training purposes according to local need via a Creative Commons attribution non-commercial share alike license which credits the original source (www.creativecommons.org).

For more information regarding the curriculum and other iADH education activities please contact scipe@iadh.org or visit www.iadh.org. The iADH education committee will value your feedback or experiences regarding local implementation of the curriculum.

Acknowledgements

The authors and the iADH education committee would like to thank and acknowledge the work, time and commitment of the Delphi Expert Panel during the consensus process and to thank the members of the iADH Council and all of the stakeholders and organisations who have been involved during the consultation process. They would also like to thank ADEE for their ongoing commitment to teaching and learning in SCD and for their support in facilitating and hosting the International iADH-Scipe task force during the development of this curriculum.

Ancillary