Revisiting the Specialty of Operative Dentistry in Pakistan to Suggest a New Educational Model Scheme

INTRODUCTION

Operative Dentistry is one of the five recognized dental specialties offered by the College of Physicians and Surgeons in Pakistan. It deals with the art and science of the diagnosis, treatment and prognosis of the defects of teeth that do not require full coverage restorations for correction.1

However, the author believes the term operative dentistry “as a specialty’s name” is a misnomer leading to incongruity and conflicts with other specialties. In contrast to the definition presented above, the vague term operative dentistry should literally mean, “any operational procedure conducted on dentition”

In fact, if we scrutinize the operative dentistry curriculum set by the College of Physicians and Surgeons, Pakistan, it is noticeable that this field includes a wide range of procedures typically practiced by general dentists or family dentists. Hence, this brings us to our first question: “Should this field be restated as a glorified form of general dentistry?”

Besides Pakistan, only a few US dental schools, and one British College offer postgraduate programs in operative dentistry.

US Dental Schools offering post-graduate programs in Operative Dentistry:

1. University of Florida
2. University of Southern California
3. University of Iowa
4. Nova Southeastern University
5. Tufts University
6. Boston University

A British College offering post-graduate program in Operative Dentistry:

1. Kings College, London

There are several other names that are used to refer operative dentistry such as: conservative dentistry, preventive dentistry, esthetic dentistry and comprehensive dentistry, etc. These names are often used interchangeably to refer to the same field around the world. Even so, the licensing organ for

dental programs in United States known as the Commission on Dental Accreditation (CODA) does not recognize this field.2

The lack of accreditation negatively influences its value, as a specialty in the U.S. Similarly, countries outside U.S. also do not readily identify this field. Due to this nonaccredited status, graduates of this field face several barricades while willing to work abroad or pursuing foreign qualification examinations.

In 2012, Dr. Farhan et al had also expressed concerns in his article refuting the specialty’s name as operative dentistry. Furthermore, he proposed extending the name of specialty to “endodontics and operative dentistry”.3 His publication seems to be the first of its kind expressing concerns regarding the nomenclature of this specialty in Pakistan. Readers can refer to his article for more information.

Steps for acquiring FCPS in Operative Dentistry

The duration of the specialty training has been revised from three-years to distressing four-years in 2010. This adds to the existing list of issues pertaining to this field. The training has a set curriculum outlined by the College of Physicians and Surgeons in Pakistan. Following is a brief review of the steps involved in acquiring FCPS in operative dentistry (Flowchart A):

1. Qualifying the FCPS Part I. (Entrance level Examination)
2. Enrollment into residency program at an accredited institution.
3. Completion of Mandatory Workshops.
4. Completion of Mandatory Rotations (Prosthodontics, Periodontology, Oral Surgery and Orthodontics).
5. Qualifying Intermediate Module (Midway examination after two years of training).
6. Submission of thesis or two articles on prospective studies in lieu.
7. Qualifying the FCPS Part II. (Exit level Examination)
8. Granting FCPS Diploma.

Flow Chart A; showing traditional model of FCPS training in Operative Dentistry. Although the program appears straightforward, it has certain drawbacks.

Plausible Concerns:

Some frequently debated factors within this field are (Flowchart B):

• A need for modification in specialty’s name.
• Restructuring of syllabus and the boundaries of discipline.
• Improving quality of training and its monitoring.
• Reducing the length of training and introduction of new tracks. Postgraduate program in operative dentistry have an excessive training duration of four-years in Pakistan.
• Eliminating periodontics from operative dentistry curriculum and table of specification of the assessment.
• Proposition of documenting and recording at least two treated cases.
• Fixing FCPS examination system i.e. eliminating the rule of re-siting in theory examination after three viva attempts and introduction of two monthly viva cycles to save crucial career time of residents.
• Foreign recognition of the clinical training preferably from royal colleges of surgeons in United Kingdom and Ireland.4,5

In addition, fellows of operative dentistry have their special interests in specific areas and unfortunately, are unable to train at international standards. For example, some fellows wish to focus more on implants, some on endodontics, whereas some prefer cosmetic dentistry and so on. Unluckily, due to a widespread curriculum, the training programs allow limited learning of specialties within operative dentistry and

Flow Chart B; showing certain drawbacks of current operative dentistry program: specialty’s name has long been disputed amongst fraternity, it is a lengthy singular-phase program inclusive of all sub-specialties and leads to one diploma. Furthermore, it lacks a contemporary branched system of subspecialties independent of each other (as available in medical specialties) that makes it an inflexible program. The program also has limited foreign recognition and foreign licensing boards usually have difficulties classifying operative dentistry as either restorative dentistry or endodontics.

hence, a conglomeration of knowledge occurs. As a result, it might be impossible for residents to retain everything memorized during the course of training and exam preparation. Consequently, a wide curriculum may negatively influence the scope of specialty practice and the quality of

specialist care delivered by these fellows.

The solution to this issue is simple yet an overwhelming task. It requires certain reforms in the training program. The initial concurrent steps should be:

1. Reduction of training duration,
2. Tapering of curriculum and,
3. Strengthening of clinical training, as ingredients desired for the evolution of Operative Dentistry.

In addition, special emphasis should be placed on introducing sub-specialty tracks (See flow chart C). These tracks will virtually address the vacuum caused by:

1. Shortened-training period
2. Impart advanced skills and
3. Provide an opportunity for a second fellowship to the clinicians.

Flow Chart C; displaying the suggested contemporary model for Restorative Dentistry Program with its systematic division into sub-specialties. Due to the program’s diversified nature, it would provide flexibility to trainees on-board and allow a faster exit. Whereas, appearing in Foreign Qualifying Exams may be considered optional or until the formulation of a second FCPS examination by CPSP. Another factor should be introduction of a flexible delivery model such as a part-time program.

Another noteworthy factor would be to develop a third party specialty accreditation organ within Pakistan, which administers and certifies programs. An organ similar in function as PMDC or CODA. However, this complex issue is beyond the scope of present article and it requires intervention at a political level.

Recommendations: A complete reform of the training program is being proposed. Following is a numbered list of recommendations:

• Develop a principal specialty and subspecialties under its umbrella.
• Rename principal specialty as Restorative Dentistry.
• Reduce duration of principal specialty training to two years, hence facilitating a faster exit level examination.
• After completion of training, grant eligibility to sit for FCPS Examination in Restorative Dentistry.
• Further subdivide the principal specialty into superspecialties (optional tracks) of two year duration each: (See
• Flow Chart C)

1. Implant Dentistry track (Restorative based)
2. Endodontics track (Microscope based)
3. Pediatric dentistry track (Grant license for sedation, GA etc.)

• Matriculation from each sub-specialty should require completion of a specific number of cases and a case report.
• It should be compulsory to complete and record two treated cases. This will allow candidates to easily sit for international examinations and bring them at par with international standards.
• Optional sub-specialty will offer:

1. A second FCPS.
2. Focused training based on trainee’s interest
3. Higher skillset in specific area, and numerous other advantages.

Furthermore, an essential component of bench practice appears to be missing from the training. At a practical level, it could simply mean practicing couple of hours a week. This should be mandatory for training residents, especially for:

1. Identification of weak areas of residents and molding of training as per specific needs.
2. To train advanced procedures (which require knowledge of applied anatomy, management strategies, and troubleshooting).
3. Additionally, this “Mannequin Phase” will prime residents to enter clinics with a strong skillset, authority and help in development of standardized practices.

Summary: The problem is not just limited to nomenclature of Operative Dentistry, but more importantly, extends to its programming. Due to the wide range of subjects being taught in this field, it becomes difficult if not impossible to master a particular area. This leads to a serious yet invisible void in the skills of prospective clinician. It would be wise if the existing fellows collaborate and bring about major reforms in our specialty of operative dentistry. These reforms should include modification of specialty’s name, structure of training, duration and introduction of sub-specialties into the program. This will provide candidates with a clinical training having core of restorative dentistry with added advantage of choosing a concentration course.

In author’s opinion, this is advantageous since the “Radius-of-Practice” will be significantly improved. It will also be a pivotal step towards modernization of our specialty. I would like to end this article by mentioning a saying, “Quantity is something you count, and quality is something you count on”.

Disclaimer: The views presented in this article are author’s opinions based on observation and discussions with dental fraternity associated with operative dentistry.

CONFLICT OF INTEREST

None declared

REFERENCES

1. Heyman H O, Swift EJ Jr, Ritter AV (eds). Sturdevant’s Art & Science of Operative Dentistry, 6th edition.
2. Accredited Programs, The Commission on Dental Accreditation, United States of America: http://www.ada.org/en/coda
3. Khan FR, Khattak S, Ansari BB. Change in the Specialty’s name, from “Operative Dentistry” to “Endodontics & Operative Dentistry”. J Pak Dent Assoc. 2012;21(4):195- 196.
4. Royal College of Surgeons of England, United Kingdom: https://www.rcseng.ac.uk/education-andexams/exams/search/membership-in-restorative-dentistry/
5. Dental Council of Ireland: http://www.dentalcouncil.ie/exam-details.php