European Federation of Periodontology Survey of Postgraduate and Specialist Training in Europe in 2020

Abstract Aims The survey's aim was to establish which universities and other educational organisations deliver postgraduate and specialist training in Periodontology in the 31 countries who are members of the European Federation of Periodontology (EFP) and to obtain details of how these programmes are organised, funded, regulated and evaluated. Methods A questionnaire and covering letter were emailed to all national periodontal societies. The questions were on the name of country, official recognition, training programmes, entry to specialist training, specialist training assessment and recognition after completion of training. Results Twenty‐nine (93%) of national periodontal societies responded. Key findings included the following: Periodontology was reported as being recognised at a national level in 17 countries, there was a three‐year full‐time programme in 12 countries, no fees were charged for specialist training in 10 countries, in 14 countries trainees received annual salaries, end of training (summative) assessments varied from country to country, 12 countries reported that they had a requirement for specialists in Periodontology to complete continuing education to maintain registration as specialists. Conclusions This survey has established which universities and other educational organisations deliver postgraduate and specialist training in Periodontology and how these programmes are organised, funded, regulated and evaluated. To provide uniformly high‐quality periodontal care for patients in all European countries, further harmonisation of postgraduate and specialty training in Periodontology would be advantageous.


| ME THODS
In April 2020, the EFP office co-ordinator emailed the presidents and secretaries of all 31 national periodontal societies/associations who are members of the EFP with a questionnaire and a covering letter from the EFP Secretary General. The questionnaire contained 28 questions, which were grouped under the headings: • Name of country and name of specialty The questionnaire was based on the questionnaire used in a survey of orthodontic specialist training. 6 In 2019, additional questions were added. The resulting version was piloted and then used in an internal survey of all dental specialties in Europe to advise Health Education England (HEE), as part of Phase II of the Advancing Dental Care Review. 7 As such, it was decided that there was no need to pilot the questionnaire for a second time, prior to its distribution.
All the questions in the questionnaire appear in the results section of this paper.
A covering letter explained the purpose of the survey and reassured respondents that they would not be named in any paper or presentation which reported the results of the survey. Respondents indicated their written consent to taking part in the survey by ticking a box at the top of the first page of the questionnaire.
Reminders were sent to non-responders by email in May and June 2020. After an analysis of the responses, respondents were sent a copy of the results in June 2020 with a covering email asking them to check that the results for their country had been reported accurately.
The survey was approved by the EFP's Executive, who had consent from the national societies. In view of this and the facts that it was an internal survey and that respondents were not personally identified in publications arising from the survey, ethics approval was deemed not to be required.

| RE SULTS
4.1 | Name of country and name of specialty 1

| Official recognition
3. Is Periodontology an officially recognised specialty in your country?
Respondents from all 29 countries answered this question. Seventeen replied yes and 11 no. In Germany, the specialty is recognised only in one Lande (Federal State), which is Nordrhein-Westfalen. 4. Who keeps a list of officially recognised specialists in your country?
Respondents from 17 countries plus Germany reported that the organisation(s) keeping the list were as follows: The Ministry of Health in nine countries, The Dental Chamber (Association) and/or Periodontology Society in association with Ministry of Health in three countries, The Dental Chamber (Association) and/or Periodontology Society in three countries, a Government Agency in two countries, An Independent national regulator for dentistry in one country. 1 In the other 11 countries, it was reported that the specialty was not officially recognised but periodontal societies keep lists of those who have completed formal (three years) training in the specialty in two and that there was no list as the specialty was not recognised in the other nine countries. 5. Are there Masters or other postgraduate training programmes in dental specialties (such as Periodontology), in your country, which do not lead to official recognition as a specialist?

| Training programmes
Respondents from 17 countries replied "yes" and gave details in answer to question 6.
Eleven countries replied "no." There was no reply to this question from one country.
6. If "yes," please list the Masters programmes.
Respondents reported that 52 universities in the 17 countries ran Masters or Masters/Doctoral programmes in periodontology.
Sixteen universities in 12 of these countries ran the three-year EFPapproved Periodontal course. 7. Is a period of postgraduate training and/or experience in general dentistry required before starting training in your specialty (Periodontology)?

| Entry to specialist training
8. If "yes," how many years since initial qualification as a dentist? Respondents from 24 countries described the entry process to specialist training in their country. Twelve countries require a period of postgraduate training and/or experience in general dentistry before starting training in periodontology, and this is not required in the other 12. Where the requirements are present, they range from one to three years, with two years the most frequently reported figure. 9. How many years full-time does specialist training in your specialty (Periodontology) take?

| Specialist training
Respondents from 22 countries answered this question. In twenty-one countries, the answer was answered three-year fulltime and in one, three and a half years full-time. 14. If they have to, how much do they pay per year?
In the countries, where trainees were reported as having to pay for their training, the annual fees ranged from €1400 to €47 000 for trainees from non-EU countries.

During training do trainees receive a salary?
Respondents from 23 countries responded to this question with the answer yes from 14 countries and no from nine. 16. If "yes" who pays the salary to university/hospital/government/other organisation?
Of the 14 countries which reported that trainees were paid, only two countries answered university only. In others, payment was usually from more than one source which frequently included a hospital in combination with a university or the government or the Health Ministry.
Apart from the organisations mentioned in the answers to question 16, payments were reported as coming from public clinics in one country and private dental practices/offices in three. Respondents from two countries reported that, if trainees are in the military, they are paid salaries by the military whilst they train.
18. How much salary per year are trainees paid?

Are trainees assessed during training?
Respondents from four countries did not answer this question.
In all the other 25 countries, it was reported that trainees were assessed during training. 20. If "yes," who is responsible for assessment examinations?
In 24 of the 25 countries, it was reported that assessment was by a university, in the following countries in collaboration with other organisations as follows: With hospitals in four countries. Universities and government bodies in two countries.
Universities and hospitals in two countries, followed by approval from the National Board for Health and Welfare.
Universities and the EFP in three countries.
Universities and the specialist society in two counties. In one country, it was reported that there is often a short wait, for administrative reasons, between completing specialist training and obtaining confirmation from the national registration body.
In the seventeenth country, those who have completed a threeyear full-time training in Periodontology also have to pass an examination set by a Royal Colleges of Surgeons before they can apply to register as specialists.
25. If there is a wait between successfully completing specialist training and being able to work as Periodontal specialists, how long is it?
Respondents from only two countries reported that there was a wait. In one, there is no official specialist list for Periodontology. 13, the answer was yes, and from nine, it was no.
In two countries, specialists must renew their registration every 6 years by providing evidence of attending at least five periodontal congresses or seminars in Periodontology over the previous 6 years.
In ten, there is a requirement to attend approved oral health continuing education regularly and prove this to registering organisations at five yearly (seven yearly in two countries) intervals. The requirement in terms of /points credits/hours varies from country to country and it appears that in none of the countries, is it less than 100 h every five years or 140 h every 7 years.
In one, where the specialty is not officially recognised, the Periodontal society maintains a list of periodontal specialists and requires dentists to complete a wide range of tasks including completing at least 180 h of continuing dental education every five years and treating referred patients on at least 2 days per week.
27. In your country are those registered as dental specialists permitted to continue to work as general dentists?
There were responses to this question from 25 countries with the answer yes from 23 countries and no from two.

Additional Comments
Respondents from seven countries provided additional comments, which together with the full results can be viewed at www. efp.org.

| DISCUSS ION
Overall, the findings of the present survey indicated that there was considerable variation between European counties in postgraduate training in Periodontology, the mechanisms for funding such training, its assessment and the official recognition of the specialty. This mirrors the situation reported 20 years ago for orthodontic postgraduate and specialist training in Europe. 6 With any survey, there may be doubts that the respondents fully understand the questions or interpret them differently. In order to address this potential problem, the questionnaire which was selected had been piloted and used in a recent survey of dental specialist training in Europe 7 and the full set of results were sent to all respondents to ask them to check them and confirm that they were correct. The response rate of over 90% (29 countries out of 31) was considered to be excellent, with the findings therefore providing an clear picture of existing arrangements. The first inter-country variation was in the name of the specialty. Although in 26 of the 29 countries, it was Periodontology or Periodontics, in three the specialty was included in, or grouped with other specialties. For example, currently, in Serbia, the specialty is Periodontology and Oral Medicine. However, the respondent from Serbia explained that the two specialties are likely to be recognised as individual specialties in the near future.
On the topic of recognition, the responses indicated that Periodontology was recognised nationally as a specialty in 17 EFP member countries, not all of whom are EU Member States.
Essentially, three types of organisation, referred to in EU law as competent authorities, 1 were reported as keeping lists of recognised specialists in Periodontology. In some countries, the competent authority was the Ministry of Health or, in Finland and Sweden, a "satellite" government agency. In others, it was the Dental Chamber (Dental Association), and in the UK, an independent, regulatory body (the General Dental Council). In some countries, the Society of Periodontology also maintained lists of periodontists. Within the EU, independent national recognition and regulation in at least twofifths of Member States are important for Periodontology to satisfy the key criterion for eligibility for specialty recognition by the European Commission. 3 The EFP have been campaigning for this to happen for some years, and although eligibility has been confirmed, the goal has not yet been achieved, despite the many different ways in which the EU and its population would benefit from this development in professional freedom of movement. The responses to the questions on entry to specialist training indicated that equal numbers of countries required or did not require experience in providing general dentistry prior to starting specialist training in Periodontology. In eight of the countries, which did require such experience, two years or more was required. As specialists in Periodontology, as in other specialties, require to understand the constraints under which many general dentists work or the general dentists' ability to manage clinical problems, it was disappointing to see that experience of general dental practice, prior to entering specialist training, was reported as not being required in 12 countries. Again, this begs the question of why, especially when many aspects of general dentistry underpin the provision of specialist services.
In 16 of the countries, specialist training in Periodontology had to be undertaken through a three-year full-time programme. However, in a further seven counties it could be completed by means of equivalent part-time training. If trainees must pay for their training, this option makes it easier for trainees to fund as they have the opportunity to maintain an income on the days that they are not undertaking specialist training-"earn and learn." Also, part-time training provides the opportunity to remain in practice and acquire experience which typically compliments the experience gained in training. It was reported that no fees were charged for specialist training in 10 countries, and in a further 14, where fees were charged, the annual cost ranged from €1400 to €30 000 for trainees from EU Members States and up to € during their training in 14 countries, and their annual salary ranged from €2500 to €45 000. The pay came from universities, hospitals, health ministries, and in one country, the specialist practice where they worked. Remuneration of specialty trainees is believed to be linked to local arrangements for funding specialist services. In all 25 countries, more than one method was used for summative assessment. A previous study found even greater differences in end of training assessment for Orthodontic specialty training. 6 Although the EFP has endeavoured to standardise the summative assessment of periodontal specialty trainees across Europe, specifically in relation to competences, the results of the current survey indicate that further work is required. To date, there is no evidence of any significant differences in the competences of newly qualified specialty trainees in Periodontology across Europe; however, confirmation of this assertion would be advantageous.
Answers to the questions on the topics of registration after successful completion of training and commencing work as a periodontal specialist indicated that there was usually minimal delay in registering as a specialist with the relevant national body (competent authority), in countries where the specialty is recognised nationally.
However, in two countries there were some limitations on the freedom to practice immediately as a specialist in Periodontology. In the Netherlands, where Periodontology is not officially recognised as a specialty, as reported in the results section of this paper, those who have successfully completed a three-year postgraduate programme in Periodontology have to build up a portfolio of treated cases and have them successfully evaluated by the Dutch Society of Periodontology before this Society recognises them as periodontists.
In Slovenia, individuals who successfully complete specialty training in Periodontology can only work as specialists in Periodontology in the public dental service and must wait five years before they can practice as specialists in private clinics. In two countries (Belgium and France), dental specialists (including periodontists) are not permitted to work as general dentists. This restriction can and does cause inconvenience to patients and considerably limits the scope of the dentists concerned. Such arrangements may be difficult to sustain with the international shift to the integrated, holistic care of patients, with high-quality general dentistry underpinning the provision of specialist services.
As far as a requirement for trained periodontists to complete a minimum number of hours of continuing education (CE) in Periodontology was concerned, this was found to be obligatory in 12 countries. In most of these countries, the requirement was for at least 100 hours of CE within a five-year period. However, in the Netherlands, the Dutch Society of Periodontology has stringent requirements, for individuals to remain on the Society's list of specialists. Other countries have continuing professional development requirements to ensure high-quality standards are maintained.
Two previous studies have identified the need for common standards in postgraduate and specialist training in Periodontology in Europe. 2,10 It is therefore disappointing that the EFP-accredited Postgraduate Programme is available in only a minority of European countries whose national periodontal societies are members of the EFP. Harmonisation of at least core specialty training across Europe would have greatly aided the EFP's campaign for EU specialty recognition, let alone reinforce the assertion that specialists in Periodontology across Europe share the same competences.

ACK N OWLED G EM ENTS
The authors would like to thank the European Federation of Periodontology for their support, Xavier Struillou (President of the EFP at the time the survey took place) for approving it and Mónica Guinea for distributing the questionnaire to national periodontal associations, monitoring the return of the questionnaires and administering the survey and the respondents for completing the questionnaires.

CO N FLI C T O F I NTE R E S T
The authors do not have any conflicts of interests.

AUTH O R CO NTR I B UTI O N S
KAE designed the survey, drafted the covering letter, analysed the results, drafted the paper and approved its final version. NXC obtained approval for the survey, reviewed the progress of the project at all stages, revised drafts and approved the final version of the paper. NHFW contributed to the preparation of the report and approved the final version of the paper. MS contributed to the preparation of the report and approved the final version of the paper.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request, and a more detailed results section of the report of the survey can be accessed from the Publications and Education section of the EFP's website www.efp.org.