Education in Periodontology: The Past, the Present, and the Future

The harmonization of dental education in Europe occurred alongside the broader process of European convergence in higher education initiated by the La Sorbonne Declaration in 1998 and the signing of the Bologna Declaration in 1999. This declaration emphasized the importance of achieving coherence within the European higher education area while maintaining diversity. It established a two-tier structure consisting of undergraduate and postgraduate cycles [1]. Additionally, it introduced a common credit system known as the European Credit Transfer and Accumulation System or ECTS. It promoted curricular development, inter-institutional collaboration, and the integration of studies, training, and research to enhance mobility and ensure comparable criteria and methodologies. With this aim, the Association for Dental Education in Europe (ADEE) and the “DentEd” thematic network secured funding from the European Commission for a third Network Project, “DentEd III” (2004–2007), to create a curricular model in dentistry that fully complies with the principles of the Bologna Declaration [2]. The first step in this challenge was to agree on a professional profile with a defined set of general and specific competencies. Despite the need for graduates equipped to undertake independent dental practice safely, the educational and training programs varied significantly, with each school and country adopting different approaches shaped by their structures, cultures, and resources. Nevertheless, there was a common aspiration to achieve the highest possible standards in educational outcomes and relevant clinical competencies, enabling graduates to move freely and practice anywhere in Europe [3]. The profile of the dentist was defined in the European Union by a directive on the recognition of professional qualifications, which stated: “All Member States must recognize the profession of dental practitioner, equipped with the skills needed for the prevention, diagnosis, and treatment of diseases related to the teeth, mouth, jaws, and associated tissues.” It was further emphasized that dental training should consist of at least five years of full-time theoretical and practical training. Based on these legal provisions, the proposed ADEE Dental Curricular structure was organized into modules according to the ECTS and aligned with the profile, domains, and competencies approved by ADEE. This framework defines competencies as a combination of knowledge, skills, and attitudes relevant to the dental education process, with a minimum acceptable level of performance for graduating dentists, emphasizing speed and accuracy that is consistent with patient well-being rather than performance at the highest possible level. Competencies were organized into seven domains representing the broad categories of professional activity and dimensions that occur in the general practice of dentistry: (I) professionalism, (II) communication and interpersonal skills, (III) knowledge base, (IV) information handling and critical thinking, (V) clinical information gathering, (VI) diagnosis and treatment planning, and (VII) the establishment and maintenance of oral health. While domains I, II, and IV pertain to all dental disciplines and thus represent horizontal competencies, those related to domains III, V, and VI concern the content, learning outcomes, and specific competencies of the different classical dental disciplines (cariology, periodontology, orthodontics, endodontics, restorative dentistry, prosthetics, etc.) [2]. These well-established disciplines have defined the specific supporting competencies relevant to their respective fields, outlining the attitudes, skills, and learning outcomes expected of dental graduates. This framework provides a benchmark for reviewing, refining, and reshaping the undergraduate curriculum, enhancing student evaluation processes, and implementing outcome measures to assess the effectiveness of the educational process. Among these disciplines, Periodontology is one of the major oral health sciences that studies the biology of periodontal and peri-implant tissues and the diagnosis, prevention, and treatment of their associated conditions and diseases. In the last 25 years, formal education and training in Periodontology have been redefined as part of the harmonization process of higher education in Europe, defined by the Bologna Declaration and, specifically for dentistry, by the DENTED project. This perspective article aims to examine this process by focusing on past, present, and future perspectives in Education in Periodontology. The European Federation of Periodontology (EFP) was founded in 1991 as a nonprofit organization structured as a federation that includes national societies of Periodontology. Its aim is to promote Periodontology and oral health in Europe and beyond. To achieve these goals, the EFP established an Education Committee focused on maintaining high and equitable standards in undergraduate and postgraduate periodontal education and training across member societies. In 2009, the EFP organized a workshop on periodontal education [4], which brought together experts from all European countries in academia and representatives from the ADEE. The specific objectives of this workshop were to review trends in the epidemiology of periodontal diseases and the treatment needs in Europe; to make recommendations on the scope and limits of periodontal education at the undergraduate, postgraduate, and continuing education levels; and to define the competencies, learning outcomes, teaching methods, and evaluation systems suitable for undergraduate, postgraduate, and continuing education in Periodontology. At undergraduate training level, the EFP's objective was to prepare modern dentists to meet the periodontal health needs and public demands for most patients. This implied the necessary training to enable dentists to implement both population-based and individual preventive strategies for improved periodontal health, including the diagnosis and treatment of the most common oral periodontal diseases and conditions. Considering the epidemiological trends in Europe, there was a need to address the demands of an increasingly aged and medically compromised population, which requires enhanced and increasingly sophisticated education in both clinical medicine and modern restorative therapy. In this context, the results from the EFP Workshop on Dental Education [4] defined a set of recommended supporting competencies in Periodontology, within the ADEE competence-based curriculum, organized into domains, major competencies, and the referred supporting competencies. While the major ADEE competencies were fully adopted from the ADDE's document, the supporting competencies for Periodontology were defined as a specific set of competencies and learning outcomes aimed at unifying periodontal education and training in Europe to serve as a model for universities framing periodontal education within the dental curriculum. Within the major competencies of professionalism, ethics, communication, and interpersonal skills, the workshop proceedings highlighted the dentist's leading role in the oral health team, specifically in providing periodontal services. It emphasized the need to develop competencies in communication and behavior change to facilitate effective oral hygiene practices and manage risk factors, such as smoking cessation interventions, which are crucial for optimal periodontal treatment outcomes. It also stressed the importance of recognizing one's own limitations, as the complexity of certain periodontal conditions may exceed the competencies acquired during dental graduation, underscoring the necessity of referring patients to specialists or professionals with advanced postgraduate training in Periodontology. Within the supporting competencies for establishing the knowledge base of Periodontology, the workshop outlined the levels of understanding in fundamental biological, medical, and technical subjects, as well as clinical sciences, to equip graduates with the ability to differentiate between normal and pathological conditions or disorders of the periodontium pertinent to clinical dental practice [5]. In the domain of gathering clinical information, diagnosing and treatment planning in Periodontology, the Workshop outlined the competencies necessary to obtain all the patient's medical, oral, and periodontal information relevant for diagnosing periodontal and peri-implant diseases and conditions within the framework of a comprehensive oral diagnosis. This included biological, medical, clinical, radiological, psychological, and social information pertinent to evaluating the patients' periodontal and peri-implant condition. After acquiring these competencies, the graduating dentist must demonstrate a degree of decision-making, clinical reasoning, and judgment to develop a diagnosis and treatment plan that meets the needs and demands of patients while recognizing treatments that are beyond their skills and necessitate referral for specialist opinions and treatment. For the establishment and maintenance of periodontal and peri-implant health, the workshop defined the competencies of the graduating dentists for managing plaque-induced gingivitis, peri-implant mucositis, acute periodontal conditions, mild to moderate periodontitis, and peri-implantitis, as well as mild oral mucosal diseases. When addressing the most advanced periodontal and peri-implant issues, the workshop acknowledged the necessity for graduates to gain skills in performing basic periodontal and peri-implant surgery, while also recognizing the limitations of the university environment in providing the infrastructure, faculty, and patient supply needed for training in these surgical interventions. Nevertheless, the workshop proceedings stressed the importance of graduates understanding the principles of tissue reconstruction and being familiar with current surgical approaches and technologies used in periodontal regeneration and the surgical treatment of peri-implant conditions. While the guarantee of a minimum duration of studies and the fulfillment of the minimum standards in undergraduate education mentioned above have ensured some degree of uniformity, this does not guarantee that the graduating dentist is competent to treat every periodontal health issue for every patient. Therefore, while the community can be assured that dental graduates can take responsibility for treating the most common periodontal health problems, the undergraduate dental curriculum cannot be expected to provide enough knowledge and experience to address all periodontal/peri-implant pathologies. This is particularly relevant given that European epidemiological data indicate that most of the population has mild to moderate forms of periodontal diseases. However, a significant percentage of the population is affected by severe forms of periodontal diseases, complex interdisciplinary restorative needs, and increased patient expectations that require advanced periodontal therapy. Furthermore, these advanced periodontal treatments are also necessary to address the less common diseases or conditions that may require extended competencies. Therefore, there is a need for a healthcare provider with specialized training as a periodontist [6]. In 2005, the European Union published a new European Directive, Article XXIV, which clearly specifies the requirements for specialist dental training. According to this directive, specialist dental training should be provided for at least three years full-time. It must include theoretical and practical instruction at a university center or in a health establishment approved for that purpose by the relevant authorities or bodies. As part of the of the EFP Education one of objectives is to promote the of postgraduate education by a formal postgraduate in Periodontology. 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