EFCD Curriculum for undergraduate students in Integrated Conservative Oral Healthcare (ConsCare)

The majority of dentists after graduation practice within a general oral healthcare setting. As such, most of their clinical care aims to prevent and manage pathological damage to teeth and adjacent tissues [1]. With respect to restorative care, historically, this management fell under the umbrella of “operative dentistry” [2]. This terminology, however, is not used ubiquitously, with some countries retaining the term “operative dentistry” while others have introduced “cariology,” or combinations of these and other terms. With the emergence of distinct branches of dentistry, specifically cariology (the prevention and clinical control or management of dental caries), endodontology (the preservation and treatment of the dental pulp), periodontology (the care of periodontal and associated tissues), and prosthodontics (the replacement of missing teeth and other oral structures), “operative dentistry” became “conservative dentistry” in many countries of the world. It refers to the management of the sequelae of dental caries, tooth wear, trauma, and other disorders of dental hard tissues (e.g., erosion and molar incisor hypomineralization), including the techniques and procedures for the management and replacement of lost and defective dental tissues and restorations in individual teeth. It embraces everything from the prevention of caries and procedures for remineralization of initial caries lesions to extra-coronal restorations, including onlays and full and partial crowns, and the restoration of endodontically treated teeth.

Today, with the increasing emphasis on integrated dental medicine in oral healthcare provision, most of the teaching of conservative dentistry, or its equivalent, prepares students to adopt an integrated, interdisciplinary approach to the care of patients. Hence, the term “Integrated Conservative Oral Healthcare,” which may be shortened to “ConsCare” for convenience, is used in this proposal. “ConsCare” spans (1) core competencies in prevention, cariology, restorative/operative dentistry, endodontology, and dental traumatology (as represented by the EFCD); touches (2) competencies in associated fields including periodontology, pediatric dentistry, and special care dentistry, including gerodontology; and embraces (3) competencies in other disciplines. ConsCare relates to patient-centered, minimum intervention prevention and management of caries, non-carious tooth tissue loss, cracks, splits, fractures, and trauma to the soft and hard tissues of the teeth. ConsCare also includes the management of developmental disorders and defects in the soft and hard tissues of the teeth taking into account esthetic considerations. In other words, ConsCare is about supporting and managing patients to preserve, maintain, and where possible retain teeth, with both good functionality and a pleasing appearance, throughout life, and thereby making a major contribution to establishing and maintaining lifelong oral health and, in turn, general health and wellbeing. The proposed curriculum covers the core competencies of ConsCare.

It is widely accepted that the caries process can be prevented to a large extent. The prevention of caries relies on patients following dietary advice and practicing effective oral hygiene, including the use of fluoride-containing toothpaste, possibly supplemented by the use of mouthwash and other oral hygiene aids [3, 4]. Current curricula and clinical guidelines reflect the increasing emphasis on caries prevention [5, 6], but caries still remains a highly prevalent disease in all age groups [7, 8], with growing concerns for, in particular, the increased prevalence of root caries in older patients [9]. As such, operative intervention to treat carious teeth, and successively repair or replace failing restorations, will continue to be part of the daily routine of general oral healthcare providers (general dental practitioners) across the world for many years to come.

Non-carious tooth tissue loss also known as tooth wear, or tooth surface loss, is the result of abrasion (wear produced by interaction between teeth and other materials), attrition (wear through tooth-to-tooth contact), erosion (chemical softening and dissolution of hard tissue), and erosive tooth wear (wear produced on an already-softened tooth surface). The available evidence is insufficient to establish whether abfraction is an important contributor to tooth wear [10]. Each tooth wear process can operate alone and may result in defects of multifactorial origin. Abrasive forces alone have a limited effect on a sound tooth surface; however, when the surface is softened, abrasive forces will harm it and tooth wear will occur [11].

Early erosive tooth wear, prevalent in young adults, requires early non-invasive management to avoid complex and multidisciplinary treatment, given the relevant functional and esthetic sequels. As life-expectancy increases and individuals retain more teeth throughout life, tooth wear increases in prevalence, with or without loss of vertical face height. Tooth wear, albeit limited to physiological wear, may become problematical, especially in older patients [12], resulting in increased needs and demands for the management of worn teeth in the provision of routine oral healthcare. As such, the graduating dentist must have the relevant competencies to diagnose, investigate, and manage patients presenting with any kind of tooth wear—further, they need to know when to refer patients for advanced or specialist care.

Other non-carious defects of the hard tooth tissues, such as developmental disorders (amelogenesis imperfecta; dentinogenesis imperfecta) or molar incisor hypomineralization (MIH), are also considered to have a considerable influence upon the development of caries and impact upon the patient’s quality of life [13, 14]. Moreover, these lesions may present a challenge to the dentist providing oral healthcare. The graduating dentist must therefore be competent to diagnose and manage patients presenting with all common disorders of the hard tooth tissues and know when to refer them for advanced or specialist care.

With many more individuals retaining teeth longer and remaining physically active long into adult life, the management of dental trauma is anticipated to increase in the provision of general oral healthcare, with an incidence peak in younger patients. The graduating dentist must, therefore, be competent in the management of everyday dental trauma in patients of all ages. This includes referral to a suitable specialist when trauma management falls outside of their scope of practice.

Restoration of function and form of lost tooth tissues remains a major focus in preventatively orientated ConsCare. Driven by the availability of a wide range of materials, techniques, and devices as well as by patients’ demands, there continues a sustained growth in esthetic procedures (tooth color restorations and changes to the appearance of a tooth or teeth involving some change in form and possibly function) including so-called cosmetic procedures that changes the appearance of a tooth or teeth with no change in form and function (e.g., bleaching and whitening of teeth) [15]. Given that many esthetic procedures are already undertaken as part of the everyday provision of general oral healthcare, the relevant competencies should be included in the undergraduate curriculum, making esthetic dentistry, in the same way as cariology, an element of ConsCare.

The Association for Dental Education in Europe (ADEE) published the “Graduating European Dentist: A New Undergraduate Curriculum” in 2017 [16]. This learning outcomes–based curriculum framework encouraged subject matter experts and curriculum leaders to develop discipline-specific curricula. To date, curricula for certain disciplines closely related to “conservative dentistry” have been published (Table 1). The purpose of the present paper is to report the consensus proposals for a curriculum for Integrated Conservative Oral Healthcare (ConsCare), which, in a way, is reminiscent of operative dentistry at the time of GV Black [2], that should be considered central to instruction in general oral healthcare provision and to complement related curricula (Fig. 1).

A task force was established by the European Federation of Conservative Dentistry (EFCD), bringing together individuals representing the Federation (Breschi, Federlin, Lussi, and Doméjean), the European Section of the Academy of Operative Dentistry (AODES (Meyer-Lückel, Opdam and Wilson)), and the ADEE (Field). Four of these individuals (MF, HML, NO, NW) met in April 2017 to plan and undertake preparatory work (e.g., choice of experts from numerous countries) for a curriculum workshop meeting, which was held immediately prior to the 96th General Session of the International Association for Dental Research (IADR) in London in late July 2018.

The Graduating European Dentist framework categorized the curriculum into four domains (Table 2) [16]. The EFCD Taskforce accepted the competencies and learning outcomes approved by ADEE for domains I, II, and IV, leaving the curriculum workshop to focus on domain III—Patient-centered care.

The consensus workshop, held over two days, sought contributions from an expert group drawn from EFCD and AODES and with the help from ADEE in relation to the learning outcomes–based approach. At the outset of the workshop, it was unanimously agreed that proposals for the new curriculum should encourage patient-centered, preventatively orientated, minimum intervention care as proposed by, amongst others [21‐24]. In this way, the proposed curriculum should aim to discourage outdated, episodic, and mechanistic approaches, supporting the concepts of “teeth and oral health for life” through the provision of “patient-engaging, cyclical, longitudinal care.”

With the patient positioned in the center of the care cycle, it was agreed that shared decision-making should be encouraged to best meet the needs and expectations of patients and, in the process, the patient’s perception of the quality of care. Given the multifaceted nature and increasing complexity of diagnosis, risk assessment, and both short- and long-term care planning in the context of lifelong oral healthcare care, these processes were seen to be the responsibility of the general dental practitioner. It was agreed that the efficiency and effectiveness of oral healthcare provision may be enhanced by dental practitioners being supported by other dental healthcare professionals by delegation. It was also agreed that oral healthcare should form part of general healthcare provision, with the general dental care team working collaboratively with dental specialists and other healthcare professionals in the best interests of the patient.

The workshop involved group and collective working, facilitated by Meyer-Lückel, Opdam, and Wilson who acted as group and workshop chairmen. The ADEE major domain III—Patient-centered care (PCC)—was considered under three main areas of competence considered relevant to ConsCare:

After manuscript preparation, appropriate time was given to the boards of the national member associations of EFCD and comments were discussed and adjustments made if suitable.

This section outlines the competencies and learning outcomes of the ConsCare curriculum pertaining to clinical information gathering, diagnosis, and care planning. For this purpose, it is necessary that contemporary diagnostic and risk assessment methodologies are used [25‐28]. The dentist must be able to integrate all aspects of diagnoses and risk assessments into patient-specific, personalized care plan options, including consideration of the options of deferring care, which take account of the patient’s medical and oral healthcare histories.

Selection of the most appropriate care plan must be based on a shared decision-making process [29, 30] in which patients are made aware of their specific oral health risks and can make an informed choice as to what oral healthcare plan option to choose, in the knowledge of the interventions which will be involved, the anticipated clinical outcome, and any problems which may occur during the subsequent maintenance of oral health. In the event of a patient declining care, the graduating dentist must be able to explain the consequences of such a decision.

The relevant competencies are:

This section outlines the competencies and learning outcomes pertaining to establishing and maintaining oral health in ConsCare. The competencies in this area include the:

The consensus at the outset of the workshop on the need to update the term “conservative dentistry” to “integrated conservative oral healthcare” was a historic decision. The proposal that integrated conservative oral healthcare (conservative care/ConsCare) assumes a central position in general oral healthcare provision (Fig. 1) sets the scene for the highly interactive group and collective discussions which occurred during the workshop. Subsequently, the preparation of this paper was a dynamic, interactive process, involving all those who attended the workshop and the organizations they represented as well as the Board of the EFCD. It is acknowledged, as with any curriculum proposal, that domains and learning outcomes should be subject to regular review, especially given the many, different advances in oral and dental sciences which impact on the provision of integrated conservative oral healthcare. Also, it is recognized that it is for individual schools to decide what should be taught.

On behalf of the EFCD, a group of renowned experts has outlined a curriculum for undergraduate students in Integrated Conservative Oral Healthcare (ConsCare), which should be discussed and developed in the context of existing guidelines and frameworks in other disciplines. It is hoped that the suggested curriculum will stimulate debate and actions to revise existing curricula within dental schools across Europe and elsewhere in the world. In addition, it is hoped that the proposed curriculum will be of assistance to practitioners in general oral healthcare settings and their professional bodies in updating their thinking on the provision of oral healthcare.