Conscious sedation in Spanish dental schools: Current situation

Abstract The current Spanish curricula for degrees in dentistry include conscious sedation (CS) as a basic training competency. However, is the CS training delivered by Spanish dental schools a consensus‐based educational framework enabling students to use this anesthetic technique after graduation? To answer this research question, a study was designed aiming to identify the strategies used to teach this competency in Spanish dental schools and the characteristics of teaching. The authors reviewed legislation concerning officially established requirements for a degree in dentistry as well as curricula currently taught in Spain. Our analysis identified clear discrepancies among the schools of dentistry studied. The only overlap was observed in reference to the level of proficiency imparted, which prevents Spanish dentistry students from using this anesthetic technique after graduation. Specific features of the normative framework and of the Spanish legislative system underlying the design of the present curricula of degrees in dentistry would explain the discrepancies in CS competencies taught at our schools of dentistry. Almost 10 years since its implementation and in light of the new demands of the complex society in which we live, Spanish universities must unify their educational criteria regarding CS training to ensure the appropriate qualification of our new dentists in this technique.

promoted a new training profile in which the acquisition of this skill is highly important for new Spanish dental graduates.
As published studies clearly show, these are international factors compromising the oral health of the world population that are also shared by Spain; thus, there is a need to develop educational training programs to meet the needs of society (Abdulwahab et al., 2010;Chanpong, Haas, & Locker, 2005;Facco & Zanette, 2017).
Indeed, despite advances in dental techniques and technologies, the latest Spanish national survey on oral and dental health (2015; Consejo General de Colegios de Dentistas de España, 2016b) reported that fear is the third leading reason why Spaniards avoid visiting the dentist. This figure has increased by 3% since the 2010 survey. Furthermore, studies evaluated by the General Dental Council of Spain (Consejo General de Dentistas de España-CGDE) highlight that 65% of dental patients suffer from severe dental phobia (CGDE, 2015). From the dentist's point of view, the management of elderly patients is a considerable challenge because the members of this demographic group age differently. The healthy elderly ask to be treated with the latest surgical and restorative techniques to recover their image and oral function, but their decreased functional reserve, which is typical of aging, lowers their ability to adapt to stressful situations, including the use of these techniques (Caballero & Caballero, 1998). Elderly patients with physical and cognitive deterioration, who show increased vulnerability and decreased ability to control their environment, require individualized treatment plans with health interventions under conscious sedation (CS; Bermejo, 2015).
In summary, Spain shares a series of international factors that seriously affect the oral health of its population and require consensusbased training in CS to enable recent graduates to use this technique safely, a task not exempt from difficulties according to the universities of different European and non-European countries who share our concerns, including the United Kingdom and Ireland (Leitch & Jauhar, 2006), the United States (Boynes, Lemak, & Close, 2006), Australia (Moore, Boynes, Cuddy, Giovannitti, & Zovko, 2009), Japan (Morse, Sano, Fujii, & Kanri, 2004), and Jordan (Al-Shayyab, Ryalat, Dar-odeh, & Alsoleihat, 2013).
The following question emerges from the abovementioned research findings: Is the CS training delivered by Spanish dental schools a consensus-based educational framework enabling students to use this anesthetic technique after graduation?
To answer this question, in October 2015 at the School of Dentistry at International University of Catalonia (Facultad de Odontología de la Universidad Internacional de Cataluña, Barcelona), we started to identify different strategies adopted at Spanish schools of dentistry to analyze CS competency in new curricula currently in use for degrees in dentistry.

| MATERIALS AND METHODS
This study was divided into two phases.

| First phase
We reviewed the Libro Blanco del Título de Grado en Odontología [White paper on the degree in dentistry] (ANECA, 2004) (Orden CIN/2136/2008, 2008 issued by the Ministry of Science and Innovation (Ministerio de Ciencia e Innovación), which regulate the minimum teaching requirements of the degree in dentistry because they are the main sources on which the schools of dentistry base the design of their current curricula. Our objective was to gather information regarding the description of CS competency in both documents.
The first document we reviewed, the Libro Blanco ANECA (ANECA, 2004), defines the common mandatory contents of the degrees in dentistry into seven training modules. In three, CS is included in the specific basic and professional training competencies.
They define proficiency in CS as "having knowledge on conscious sedation techniques applied to dental treatments" and only explain the content as "conscious sedation in dentistry," with no additional information (Estructura general de la titulación.   (Table 1).

| Second phase
We were able to access the curricula and teaching guides of 20 schools of dentistry from their webpages. Therefore, the two schools with no information available online were excluded from the study, as was our own.

| RESULTS
All curricula of the 20 schools of dentistry analyzed include CS competency, albeit using different strategies.
We use the term "strategy" considering its meaning of "technique and set of activities aimed at achieving an objective," as recognized by the Spanish Royal Academy of Language.
On the basis of this definition, we will divide the presentation of the results of our study into two sections: • The "technique" used: In our study, this would correspond to the way in which competence in CS is introduced.
• Achievement of the objective: in our case, training and enabling students to use CS.

| Strategy: The technique used
In the 2017-2018 academic year, the schools introduced the competence through 23 subjects that, according to the educational legislation, should belong to the General Medical and Surgical Pathology and Therapeutics [Patología y Terapéutica Médica y Quirúrgica General] module (Orden CIN/2136/2008, 2008. However, only 52% related to this module (Table 2).
We found that each school allocates a different number of subjects: Most schools use two (45%) subjects, with some using one (30%) or three (25%) subjects (Table 3 and Figure 1).
If we relate this fact with the academic year in which the subjects are taught, approximately 60% of the 23 subjects the schools allocate to introduce competence in CS correspond to the second year of pursuing the degree; when the centers teach only one subject, it is always part of the second-year curriculum. In cases where two or three subjects are used to deliver the content, the percentage of second-year subjects is higher than that of the other courses of the degree (Table 3 and Figure 1).
Importantly, in presenting the curricula analysis results, we replaced the names of the schools of dentistry included in the present study with uppercase letters for confidentiality purposes in several of the tables prepared.

| Strategy: Achievement of an objective
To examine student training and whether it enables students to use CS, we analyzed the subjects from various perspectives:  1. Title of the subject. Several schools share the same subject titles, although the topics addressed vary on the basis of the center in which they are taught. Therefore, they are considered different subjects.

European Credit Transfer System (ECTS) credits assigned.
The ECTS is the system adopted by all universities of the EHEA to standardize their studies. Each ECTS credit requires 25 to 30 hr of education, including lecture time, study time, tutoring, seminars, assignments, rotations or projects, and time required to prepare and to perform examinations and evaluations.
The data obtained reflect that most subjects-almost 60%-that include CS among their competencies assign six ECTS credits (from 150 to 180 hr). However, the syllabus only allocates one topic for CS training, presented as a lecture (from 1 to 2 hr). The level of proficiency is not uniformly described. Several formats (Table 4) (Table 5).
The results suggest that although the curricula of the dental degree include the general objectives and the learning content to train students in pain control, the schools have not yet introduced a formal training program in CS enabling students to use this anesthetic technique after graduation.

| DISCUSSION
This study aims to review the strategies used in our schools of dentistry to introduce competence in CS and was conducted to answer a specific research question: Is the CS training delivered by Spanish Knowing pharmacological principles, applied anatomy, and different clinical techniques for local, regional, and general oral anesthesia 1 4 Knowing the basics of local or general anesthesia and sedation in the dental patient 1 5 Knowing the sedation techniques used in dentistry, understanding the principles of sedation in dentistry and knowing the techniques used in the dental clinic, and knowing and understanding conscious sedation 1 6 Assessing techniques of sedation and general anesthesia in dentistry, as well as underlying risk factors 1 7 Being competent in the indication, planning and prevention, and resolution of risks of an anesthetic or sedative procedure and knowing the medicines, doses, and side effects 1 8 Knowing special dental treatment techniques: general anesthesia and sedation 1 9 Being able to describe and explain the anesthetic techniques used in oral surgery 1 dental schools a consensus-based educational framework enabling students to use this anesthetic technique after graduation?
The ambiguity of state requirements (Real Decreto 970/1986, 1986-not detailing the level of sedation in which future dentists are to be trained-and the imprecision of the educational framework (ANECA, 2004) created a dilemma within the dental curriculum regarding the adequate amount and content of CS training for the dental student. Considering the flexibility provided by the Spanish legal system to universities, it is not surprising that the defining characteristic of the results of our study is disagreement among schools.  Module IV: sedation 6. Sedation in dentistry and complications Outpatient anesthesia 10. Outpatient anesthesia, preanesthetic evaluation, anesthetic considerations, appropriate procedures for outpatient anesthesia, immediate postoperative period, and outpatient pediatric anesthesia level of competence Spanish dental schools consider a mandatory requirement, the only common ground among them.
Therefore, answering the second part of our research question, the degree of dentistry in Spain is limited to providing a pharmacological basis for CS and knowledge of its effects on patients, not enabling dentists to use CS techniques.

| CONCLUSIONS
Our degrees in dentistry should meet the guidelines of the "Profile and Competencies for the European Dentist" (Plasschaert, Holbrook, Delap, Martinez, & Walmsley, 2007), which establish that dentists must competently identify, evaluate, and treat anxiety with both pharmacological and behavioral techniques.
CS is a basic pharmacological technique to manage dental fear and anxiety. Similar to other European countries, the challenges posed by the increase in dental phobia and population aging create an urgent need to allow students to master this competence.
The results of our study show there is no regulated CS teaching, and thus, the degree in dentistry does not enable our dentists to use this technique (Consejo General de Colegios de Dentistas de España, 2016a).
As Botelho, Oancea, Thomas, Paganelli, and Ferrillo (2017) state, "a shared problem is a problem reduced by half." Therefore, future studies could complement the data we have collected with a strengths, weaknesses, opportunities, and threats survey sent to each Spanish dental school regarding CS training and their proposals to develop a training program.
Universities, similar to any organization, can improve their processes and results by incorporating new techniques to meet social needs and demands.
To advance in this area, one possibility would be to design new academic training programs on the subject of competence in CS, mainly involving stakeholders such as professional associations, dentists, and anesthesiologists. This cooperation would provide an educational response to current demands, helping to eliminate the reluctance of other groups to the use of sedation techniques by dentists (Consejo General de Colegios de Dentistas de España, 2016a), a circumstance not unique to our country (Costa, Valadao, & Costa, 2010;Shearer, Wilson, & Girdler, 2004).
However, given our membership in the EHEA, another possibility would be for universities to develop their own programs by consensus, taking as reference the European countries that have included CS in the degree in dentistry since the end of the last century (Leitch & Girdler, 2000).