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Dental Education and the British National Health Service
PERSPECTIVE
Dental education and the British National Health Service H. Barry Waldman, DDS, PhD, MPH
n an earlier Perspective, “Dentistry within the British National Health Service,”1 an effort was made to describe dentistry within the Health Ser vice, its effects on the individual practitioner, the delivery of services to the general population, and the accomplishments and problems faced by the sys tem. This paper continues that discussion but nar rows the topic to the educational program for dental students. Dentistry and the dental profession rapidly are becoming the domain of those who grew up during the life of the National Health Service, and fewer and fewer have any idea how it was before and during the early years of the Service. The future of dentistry within Great Britain must be considered in terms of the men and women who currently are attracted to dental education, and how their education affects and is affected by the Service. Applying to dental school “To become qualified in dentistry, one must com plete a university course of between four and six years. After this period of study, which includes much practical work in the treatment of patients, graduates are eligible for full registration in the Den tists Register and to practice the profession.”2 With these opening words, the Careers Research and Ad visory Center, in cooperation with the Dental Educa tion Advisory Council, introduces the young aspir ant to the field of dentistry. There are many differences between the track as piring practitioners in Great Britain must follow as compared with their colleagues in the United States. For example, whereas'many applicants to dental schools in the United States may have informally
considered a dental career throughout their high school and college years, the system of education generally does not direct the choice; that is, the ef fort in the college years is to permit students to ex pand their horizons while completing the necessary prerequisites for admission to dental schools. These prerequisites for admission usually include defined years of study of chemistry, biology, physics, math ematics, English, and various courses in social and behavioral science. In the United States, more than 80% of all current predoctoral dental students have a baccalaureate or advanced degree; only 11% have had fewer than four years of predental college education.3 As a re sult of this added education time, most US students entering dental schools are in the early to middle 20s. Applicants must also compete in the Dental Ad missions Test before consideration by most dental schools. (This requirement may soon be deferred nationwide because new laws may require that ex amination results and test questions be made avail able to the applicant.) Most US schools subscribe to the American Asso ciation of Dental Schools Applicant Service (AADSAS); the applicant files a single application to “as many schools as desired” and pays a nominal fee for each added school beyond the number covered by the initial AADSAS fee. Also, individual schools do not receive notification regarding the applicants’ in terest in other schools. Although the number of applications to indi vidual schools varies greatly (often reflecting the school’s stated or past acceptance policies for in state and out-of-state applicants), the ratio of appli cants to accepted students was a little less than 2:1 JADA, Vol. 100, April 1980 ■ 515
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PERSPECTIVE
for the 1978/1979 academic year throughout the country.3 Unfortunately, comparing US and British systems of dental education is not simple and straight forward. The British system has significant effects on the timing of applicants’ decisions to study den tistry and to tackle hurdles they must overcome to be accepted to a dental school. Aside from the many differences in terminology related to the historic relationship between the church and British educational structure, there are different educational levels that constitute the natu ral breaks in the educational structure. For example, at approximately age 15 to 16, students who have demonstrated sufficient abilities are permitted to complete O-level (ordinary level) standard examina tions that are prepared on a national basis by Oxford, Cambridge, and London universities. Before sitting for the O-level examination, students already may have been “streamed” to the liberal arts and humanities rather than the sciences; this certainly would affect students’ future career decisions. After successfully completing the O-level exami nations (the number of O levels passed, and the par ticular grades often are prerequisites for job oppor tunities in many fields of employment), students are permitted to continue a two-year course of studies for A-level (advanced level) examinations. A-level standard examinations are prepared by the same three universities. To prepare for A-level examina tions, students who have completed O-level exami nations will have concentrated their studies on three or four subjects. Although the students are not at the general level of US baccalaureate degrees, they have received sufficient training in the particular A-level subjects to place them on a par with, or better, in these particular areas of study, than their United States counterparts on their admission to schools of dentistry. Some differences exist between the vari ous schools in Great Britain, but all consider the per formance in the various A-level examinations with some consideration of the performance on O-levels. In general, tbe A-level courses of most concern are those in the physical sciences, biology, chemistry, and physics. The product of their educational system varies in many ways from ours. Two areas of interest are: —Students must decide on a career in the sciences (as compared with the humanities and arts) at an ex tremely early age. Indeed, many students whom I interviewed while visiting British dental schools reported they were required to make their decision for the sciences and dentistry between the ages of 13 and 15. —Students admitted to dental schools are much younger than their American counterparts. Most students enter before their 20th birthday; often they are as young as 18. They usually graduate from den 516 ■ JADA, Vol. 100, April 1980
tal school at about the age that most American stu dents enter dental school training. All applications to the 17 dental schools in Great Britain are made through the Universities Central Council on Admissions (UCCA). Applicants may apply through the UCCA system to a maximum of five schools and generally list their order of prefer ence (though this is not required). Most schools pay strict attention to the preferential ordering and con sider only those applicants who list the particular school in the first three choices. Most schools look for other qualities beyond the required academic achievement. High among these is evidence of potential manual dexterity in the form of practical hobbies and interests. They do not use a counterpart to our Dental Admissions Test (DAT). (It should be noticed that the A- and O-level examina tions are standardized examinations that are compa rable to the DAT or to other state examinations, for example, New York State Regent examinations.) Because of the limited number of schools to which an individual may apply, the number of applica tions considered by each school is far fewer than the numbers considered by most US dental schools. However, on a nationwide basis they have some what more applicants to the available seats than in the United States; the proportion is approximately 3:1. In the United States, most emphasis for admis sions purposes tends to be on the grade point aver age in college and the results on the Dental Admis sions Test; these are followed in importance by the series of letters of reference from academic advisors and instructors. In addition, most American dental schools follow the review of submitted documents by a series of interviews. It should be noticed that some US schools admit some or all of the students without a personal interview. In Great Britain, the primary emphasis is on the performance on the A-level examinations. I often heard admissions officers say that there has been a continued improvement in the quality of applicants to schools of dentistry based on performance on the A-level examinations. Emphasis on A-level exami nations often is used to distinguish between those students who will be accepted to medical or dental schools. I often heard dental students comment that their A-level scores qualified for acceptance to med ical school, but that they preferred dentistry. Appar ently (based on commentary by many students, edu cators, and practitioners), there is less of a “second class” attitude, smaller difference in incomes,1 and little sense of being “almost doctors” than there is in the United States. This final item may be valid be cause both physicians and dentists receive a bac calaureate degree on completion of their studies and are referred to as “Mr., Miss, or Mrs.” The doctoral degree requires advanced training, including the
PERSPECTIVE
writing of a doctoral dissertation. Although some surgeons (physicians) hold doctoral degrees, nevertheless, in accordance with tradition, they are not referred to as Doctor. (I guess they just don’t speak American.) In any event, applications through the UCCA cen tral application system are reviewed before the stu dent’s completion of A-level examinations. Usually, admissions committees for dental schools will interview all applicants who will receive an offer for admission. The deans of several schools remarked that the admissions committees are rather small and that the decision for admission is often made by the dean. In addition, they commented that the inter view tended to be used as a confirmatory review of the all-important letter of reference from the appli cant’s headmaster. Letters of acceptance are sent contingent on successful completion of the A-level examination. Some dental schools attempt to re serve a few seats for students from the Common wealth. The students also must complete the stan dardized A-level examination that is given at dif ferent locations throughout the world and then apply through the UCCA central applicant system. Preference is given to those candidates from coun tries with few or no medical and dental facilities. Although only 17% of the dentists in Great Britain are women, approximately 30% of the current suc cessful applicants for dental school are women. Many dental educators can foresee a time when ap proximately half of the student body and eventually the profession will be women. Finally, in reference to the economics of dental education, many disquieting remarks have been made regarding the cost excesses of US dental edu cation, its effects on the numbers of applicants, and the narrowing of the spectrum of candidates. (As many as 80% of US students in some classes in some dental schools are receiving loans.3) In Great Britain, the cost for most students is borne by the Local Edu cational Council (that is, through taxes). Not only do these grants (not loans) cover the fees for education, but they include maintenance costs (room, board, and even some travel expenses). In addition, the universities maintain hostels and other systems of lodging and board for students. Depending on the economic status of the student’s family, contribu tions to the costs are required, but some financial support is available for all students. Essentially, graduates of British dental schools complete their education with few or no debts and are able to reach the expected average National Health Service in come within a reasonably short time.1 Although specific figures were not made available to me, rep resentatives of the Department of Health and Social Security indicated that only a small number of graduate practitioners were emigrating from Great Britain. There was concern, however, that, with the
entrance of Britain into the European Common Mar ket and with the possible easing of movement be tween nations, more graduates may emigrate.
Dental schools and educational programs Most schools have between approximately 50 and 60 entering students; enrollments range from about 45 to 80 students. Most schools I visited were in rela tively new facilities (1960s era), with reasonably new to quite new equipment and facilities. At one school, the physical plant dated to the turn of the century; therefore, the major advances in architec ture and construction of dental schools are readily appreciated. Faculty and administrators consis tently complained of inadequate staff, space, and re search facilities, particularly since the downturn in the economy during the 1970s. Many faculty mem bers specifically cited that British dental schools did not offer sabbatical leaves, although senior faculty members did secure leaves of absence. In the United States, dental schools are reviewed periodically for accreditation by a Commission on Accreditation which, although associated with the American Dental Association and the American As sociation of Dental Schools, is, in fact, an autono mous organization. The Commission reviews the physical plant and general environment for educa tion, the administration, teaching program, and vir tually every phase of the program to ensure an edu cational regimen that is modern and realistic. A similar system exists in Great Britain; dental schools are reviewed by the General Dental Council. Under the Dentists Act of 1957, the Council is re sponsible for promoting high standards of profes sional education for dentists. The Council requires universities and other bodies in the United King dom and the Republic of Ireland which grant de grees or licenses in dentistry to provide information about the courses of study and examinations for di plomas. The General Dental Council also appoints persons to make site visits. If the Council considers that the course of study and examinations for a de gree of license do not ensure that graduates or licen ciâtes (the Royal Colleges are discussed later) pos sess the requisite knowledge and skill to practice dentistry, the Council may notify the Privy Council, which in turn may order that graduates from these institutions no longer be registered in the Dentists Register and, therefore, not be eligible for practice. Recommendations for improvements in facilities and numbers of personnel must be considered by the University Grants Commission and the Department of Health. Unfortunately, the review by each of these bodies is influenced by the general fiscal state of the government and university, and the Grants Com mission and Department of Health may be unwilling
Waldman: DENTAL EDUCATION AND BRITISH NATIONAL HEALTH SERVICE ■ 517
PERSPECTIVE
to place adequate pressure for improvement in these particular needs. (A following section discusses the potential for improvement of dental personnel and facilities.) The course of studies at all schools is full-time and is divided into two stages, preclinical and clinical. Although the school bulletins and administrators claim that the two components are closely coordi nated, most students complained of a clear separa tion of the two areas of study. (This may resemble the complaints of American dental students.) First year, or predental year, consists of courses in biology (zoology), chemistry, and physics. It is pos sible, and, depending on the institution, obligatory, to gain exemption from these courses by passing ex aminations of A-level standards. Second year, the preclinical year or first dental year, includes courses in anatomy, dental anatomy, physiology, biochemistry, and histology. There is some variation in schools in which there is a combi nation of the first and second years for those stu dents who have not been exempt from the basic sci ences. In these schools, pharmacology, oral biology, pathology, microbiology, and an introductory course in dental technology and materials science are provided. Although dental schools vary, in the third year or first clinical year, students are introduced to the major dental subjects, including conservative den tistry (restorative), child dental health (orthodontics and pedodontics), prosthetic dentistry, dental mate rials, oral surgery (including local and general anes thesia), oral pathology, oral medicine, periodontics, dental epidemiology, and community dentistry. Be cause of my concerns in behavioral science and community dentistry, I particularly was interested to learn that few of the schools had departments of community dentistry; some minimal instruction in these subject areas was provided, however. (At one national conference on the basic sciences, a speaker referred to the behavioral sciences and similar courses as being “woolly.” At least that is different from the statements in the United States, in which the behavioral sciences are referred to as being “fuzzy.”) Fourth and fifth years (some schools require only a third or half of this final year) are used to expand further the student’s experience with the clinical sciences; student involvement with school dental clinics, outside dental practices, retirement homes, community dental clinics, and regional hospitals is included. Much of the nonclinical course material is presented during the clinical years in small group settings. The possibility must be considered that, directly or indirectly, the curriculums of the dental schools are affected by the limitations of treatment available under the National Health Service. For example, the SIS ■ JADA, Vol. 100, April 1980
idea that Health Service dentistry is merely extrac tions and dentures would lead to the belief that den tal schools emphasize these two aspects of care and leave fixed prosthodontics, endodontics, and other fields of study to some “backwater” phases of the educational program. After interviewing the deans of more than half the schools in Great Britain, dis cussing with department chairmen, and reviewing the literature (in particular, the comparison of den tal education in Great Britain and United States by Silversin and others4), the following information was noted. In schools that had specific requirements, the re quired number of crowns and inlays ranged from 17 to 38; the median number was 20. Most dental schools do not have a required number of fixed partial dentures. However, in the schools reviewed in one study, 30% to 90% (median, 75%) of the students did complete at least one fixed partial denture. My discussions with school ad ministrators and students indicated that all students are required to complete varying numbers of fixed partial dentures. Endodontic requirements range from 2 to 23 (me dian, 13) teeth with varying use of rubber dam. In all aspects of dental services, use of rubber dam seems to be an individual department’s, or, in some cases, a teacher’s, decision. When it was apparent that many dental practitioners were performing endodontic services in a single office setting to achieve some fi nancial return from the National Health Service, all instructors emphasized the idea that their role was to teach the proper approach to the service. Thereby, they pressured the National Health Service into needed changes. In terms of department size, teaching hours, and the type and complexity of educational programs, periodontal services receive far less emphasis in Great Britain than in the United States. British students complete far more sets of com plete maxillary and mandibular dentures. They complete three to 20 (median 10) more dentures than American students do (in fewer appointment hours per patient). British students complete a com parable number of chrome cobalt partial dentures, and additionally provide acrylic partial dentures (“flippers”). A dean of one school (an oral pathologist by training) commented that, from a physiologic and community service perspective, he did not see anything wrong with this form of prosthetic replacement. Many administrators emphasized the extensive experience students receive with removable or thodontic appliances. Payment under the National Health Service for orthodontic services is not based on the type of appliance used, but rather, the fee de pends on complexity of the case. Most cases are treated with removable appliances by general dental
PERSPECTIVE
practitioners. Students seem most prepared to provide simple restorative services. Several administrators of dental schools (including chairmen of departments of re storative dentistry) volunteered their negative feel ings about the continued emphasis on gold foil res torations in American schools and state licensing examinations. They believed that the continued teaching of certain techniques in US schools was anachronistic in view of current societal needs and the improvements in available restorative materials. Both students and administrators emphasized the need for increased speed in performing the dental procedures. As most students expected to work under the National Health Service, speed was essen tial to secure a satisfactory income.
Becoming professionally qualified There are two routes to becoming professionally qualified in dentistry. Most students take studies leading to the degree of Bachelor of Dental Surgery (BDS). Another route is to secure a diploma from the Royal College of Surgeons (of England, Edinburgh, or Glasgow) and receive the title of Licentiate of Dental Surgery (LDS). A historical note will show the differences between these two qualifications. Although the LDS was established in 1859 by the Royal College of Surgeons of England and a Register of Dental Licentiates had been established in 1878, it remained possible, until 1921, for a person to prac tice dentistry without examination. By action of Par liament, it became necessary for dentists to have recognized qualifications in dentistry before their names could be placed on the Register of practicing dental surgeons. The Dental Board formed then existed until 1956 when, by an act of Parliament, the General Dental Council was formed. The Council currently main tains the Dentists Register of those legally entitled to practice. With the expansion of university educa tion, degree courses are the main method of study and qualification. The LDS diploma course is simi lar in content to the various degree courses and only in exceptional circumstances will a university allow a student to take the LDS examination without hav ing a university degree. Many dentists consider it a privilege to be a Licentiate of a Royal College of Sur geons in addition to having received a BDS. Final examinations are designed to include an as sessment of the candidate’s practical ability in a va riety of clinical procedures. The examination may include work prepared previously or executed dur ing the actual examination. Candidates are reviewed by at least two external (that is, outside of the indi vidual school) examiners in all written papers and oral and clinical examinations. In grading the can didate, examiners are empowered to consider the
applicant’s performance during the course of study in the subject area of the examinations. The external examiners generally are or have been professors at a university or recognized dental school other than the school at which the candidates were trained. It is suggested that the examiners be appointed or reappointed for at least three consecu tive years.5
General observations Despite a common language (there were times when I was not too sure of this) and supposed aspects of common heritage, no outside observer truly can hope to grasp more than a passing understanding of another culture. The dental education reflects both the cultural heritage and the health care needs of the people served by the National Health Service. My observations are tinged with my American upbring ing and, as such, must reflect particularities which, although important to me and other Americans, need not necessarily be of significant concern to our colleagues in Great Britain. Students
The dental students seem so young—so many are in the late teens. However, during discussions and general school activities, they seem as mature (im mature?) as students in the United States. They complain about not knowing enough about den tistry and express fears regarding the changes in the National Health Service which will have profound effects on the kind of dentistry they want to do. (This sounds all too similar to the comments of American students.) Most significant, many students thought that their choice of dentistry was too early but be lieved that they were better off than medical stu dents because they would have a bigger income (be tween National Health Service and private practice) than their colleagues. They seemed to perceive far less of a second class status to medical students than is heard from American students. As mentioned, dental education is essentially free (including financial support for room and board). This may explain why many students (particularly the more senior students) were far more relaxed about the future than their American counterparts, who so often seem burdened by the need to rid themselves of large debts. British students were aghast when we discussed the expense of dental education in our country. Their comments about community dentistry and behavioral science courses were quite similar to those of US students—questionable value. However, many were interested in more information about the operation of the National Health Service, and few students attended lectures by the department of
W aldm an: DENTAL EDUCATION AND BRITISH NATIONAL HEALTH SERVICE ■ 519
PERSPECTIVE
community dentistry even when the material covered was about the National Health Service. The much higher percentage of women in dental schools (approximately 30%, currently) has had an interesting effect—43% of the female dentists in En gland and Wales are married to dentists. In Great Britain, almost 17% of all dentists are women. Many of the students were surprised that in the United States there were so few female dentists. It seemed natural to them that a dentist could be either a man or woman. Students complained about the excessive amounts of requirements and commented on the relative ease of the curriculum at medical schools. (These comments are similar to those that one hears in the United States.) For the most part, I sensed a close relationship between the students and faculty—possibly as a result of small sized classes and teaching groups. Schools
By American standards, most schools are small with small tutorial arrangements which have a positive effect on the teaching program. Dental students and expanded duty auxiliaries have completely separate educational programs. The student (and later the practitioner) has little or no idea about the potential of these personnel. When the practitioner first meets these auxiliaries in the community health service, difficulties can and do arise.1 Many faculty members practice dentistry part time; there is little movement toward the develop ment of many full-time professorships. Discussions with government economic officers seemed to indi cate that not much more movement in this direction should be expected when the economy improves. Their general feeling is that dental and medical edu cation has been doing well compared with other educational programs. The hospitals, with which many of the schools are associated, often are magnificent examples of late Victorian architecture. Built to endure, they seem too sound to destroy (based on the economy of the country), but they are proving to be inadequate for modern needs. Constant modernization within the cave-like brick building is occurring. Some schools have begun to develop shortages of specific types of treatment services to meet student educational requirements; for example, the dental school in Birmingham, as one of only two cities cur rently with a fluoridation program, is experiencing problems providing adequate pedodontic experi ences for students.
520 ■ JADA, Vol. 100, April 1980
Conclusions A frequently used expression in Great Britain about our two countries is that we are “two nations sepa rated by a common language.” Similarly, the two dental education systems are separated by a com mon profession. Although we speak the same pro fessional language and recognize the same respon sibility to preserve the health of the public, our orientations and methodologies are different. Nevertheless, although differences between our sys tems of education do exist, with each country re flecting its history and culture, both the US and British systems of dental education have continued their long traditions of excellence. After 30 years of the National Health Service, British dental education demonstrates three signs of vitality: large numbers of applicants; continued im provement in the caliber of applicants; a demanding educational program which, while recognizing the realities of the National Health Service, is willing to, and does, challenge the Service to constantly im prove and recognize the dental needs of the public. In addition, the programs in research at schools of dentistry, although hard-pressed because of finan cial limitations, have continued in all phases of the clinical and basic sciences. Dental education in Great Britain certainly re flects the National Health Service and the general cultural attitudes, just as our system reflects the cir cumstances of this country. It should be interesting to see how changes in our system (including adver tising and denturism) significantly affect our educa tional attitudes. The author thanks Dr. Aubrey Sheiham and Mr. John Bulman for assist ance and aid during sabbatical leave at the London Hospital Dental School in the 1978-1979 academic year. Much of their writings and ideas provided the basis for significant components of this and the previous Perspective article on the British National Health Service. Dr. Waldman is professor and chairman, department of dental health, School of Dental Medicine, State University of New York at Stony Brook, Stony Brook, NY 11794. Address requests for reprints to the author. 1. Waldman, H.B. Dentistry within the British National Health Service. JADA 99(3):439-447,1979. 2. The Careers Research and Advisory Center. Dentistry degree course guide, 1978/79. Cambridge, Hobsons Press, 1978. 3. American Association of Dental Schools. Annual report, dental edu cation, 1978-79. Chicago, Division of Education Measurements, American Dental Association. 4. Silversin, J.B., and others. Dental education in Great Britain and the United States. J Dent Educ 38:497-511,1974. 5. General Dental Council. Recommendations concerning the dental curriculum. London, 1975. Essays of opinion on current issues in dentistry are published in this sec tion of The Journal. The opinions expressed or implied are strictly those of the authors and do not necessarily reflect the opinion or official policies or position of the American Dental Association.
Dental education and the British National Health Service H. Barry Waldman, DDS, PhD, MPH
n an earlier Perspective, “Dentistry within the British National Health Service,”1 an effort was made to describe dentistry within the Health Ser vice, its effects on the individual practitioner, the delivery of services to the general population, and the accomplishments and problems faced by the sys tem. This paper continues that discussion but nar rows the topic to the educational program for dental students. Dentistry and the dental profession rapidly are becoming the domain of those who grew up during the life of the National Health Service, and fewer and fewer have any idea how it was before and during the early years of the Service. The future of dentistry within Great Britain must be considered in terms of the men and women who currently are attracted to dental education, and how their education affects and is affected by the Service. Applying to dental school “To become qualified in dentistry, one must com plete a university course of between four and six years. After this period of study, which includes much practical work in the treatment of patients, graduates are eligible for full registration in the Den tists Register and to practice the profession.”2 With these opening words, the Careers Research and Ad visory Center, in cooperation with the Dental Educa tion Advisory Council, introduces the young aspir ant to the field of dentistry. There are many differences between the track as piring practitioners in Great Britain must follow as compared with their colleagues in the United States. For example, whereas'many applicants to dental schools in the United States may have informally
considered a dental career throughout their high school and college years, the system of education generally does not direct the choice; that is, the ef fort in the college years is to permit students to ex pand their horizons while completing the necessary prerequisites for admission to dental schools. These prerequisites for admission usually include defined years of study of chemistry, biology, physics, math ematics, English, and various courses in social and behavioral science. In the United States, more than 80% of all current predoctoral dental students have a baccalaureate or advanced degree; only 11% have had fewer than four years of predental college education.3 As a re sult of this added education time, most US students entering dental schools are in the early to middle 20s. Applicants must also compete in the Dental Ad missions Test before consideration by most dental schools. (This requirement may soon be deferred nationwide because new laws may require that ex amination results and test questions be made avail able to the applicant.) Most US schools subscribe to the American Asso ciation of Dental Schools Applicant Service (AADSAS); the applicant files a single application to “as many schools as desired” and pays a nominal fee for each added school beyond the number covered by the initial AADSAS fee. Also, individual schools do not receive notification regarding the applicants’ in terest in other schools. Although the number of applications to indi vidual schools varies greatly (often reflecting the school’s stated or past acceptance policies for in state and out-of-state applicants), the ratio of appli cants to accepted students was a little less than 2:1 JADA, Vol. 100, April 1980 ■ 515
/
PERSPECTIVE
for the 1978/1979 academic year throughout the country.3 Unfortunately, comparing US and British systems of dental education is not simple and straight forward. The British system has significant effects on the timing of applicants’ decisions to study den tistry and to tackle hurdles they must overcome to be accepted to a dental school. Aside from the many differences in terminology related to the historic relationship between the church and British educational structure, there are different educational levels that constitute the natu ral breaks in the educational structure. For example, at approximately age 15 to 16, students who have demonstrated sufficient abilities are permitted to complete O-level (ordinary level) standard examina tions that are prepared on a national basis by Oxford, Cambridge, and London universities. Before sitting for the O-level examination, students already may have been “streamed” to the liberal arts and humanities rather than the sciences; this certainly would affect students’ future career decisions. After successfully completing the O-level exami nations (the number of O levels passed, and the par ticular grades often are prerequisites for job oppor tunities in many fields of employment), students are permitted to continue a two-year course of studies for A-level (advanced level) examinations. A-level standard examinations are prepared by the same three universities. To prepare for A-level examina tions, students who have completed O-level exami nations will have concentrated their studies on three or four subjects. Although the students are not at the general level of US baccalaureate degrees, they have received sufficient training in the particular A-level subjects to place them on a par with, or better, in these particular areas of study, than their United States counterparts on their admission to schools of dentistry. Some differences exist between the vari ous schools in Great Britain, but all consider the per formance in the various A-level examinations with some consideration of the performance on O-levels. In general, tbe A-level courses of most concern are those in the physical sciences, biology, chemistry, and physics. The product of their educational system varies in many ways from ours. Two areas of interest are: —Students must decide on a career in the sciences (as compared with the humanities and arts) at an ex tremely early age. Indeed, many students whom I interviewed while visiting British dental schools reported they were required to make their decision for the sciences and dentistry between the ages of 13 and 15. —Students admitted to dental schools are much younger than their American counterparts. Most students enter before their 20th birthday; often they are as young as 18. They usually graduate from den 516 ■ JADA, Vol. 100, April 1980
tal school at about the age that most American stu dents enter dental school training. All applications to the 17 dental schools in Great Britain are made through the Universities Central Council on Admissions (UCCA). Applicants may apply through the UCCA system to a maximum of five schools and generally list their order of prefer ence (though this is not required). Most schools pay strict attention to the preferential ordering and con sider only those applicants who list the particular school in the first three choices. Most schools look for other qualities beyond the required academic achievement. High among these is evidence of potential manual dexterity in the form of practical hobbies and interests. They do not use a counterpart to our Dental Admissions Test (DAT). (It should be noticed that the A- and O-level examina tions are standardized examinations that are compa rable to the DAT or to other state examinations, for example, New York State Regent examinations.) Because of the limited number of schools to which an individual may apply, the number of applica tions considered by each school is far fewer than the numbers considered by most US dental schools. However, on a nationwide basis they have some what more applicants to the available seats than in the United States; the proportion is approximately 3:1. In the United States, most emphasis for admis sions purposes tends to be on the grade point aver age in college and the results on the Dental Admis sions Test; these are followed in importance by the series of letters of reference from academic advisors and instructors. In addition, most American dental schools follow the review of submitted documents by a series of interviews. It should be noticed that some US schools admit some or all of the students without a personal interview. In Great Britain, the primary emphasis is on the performance on the A-level examinations. I often heard admissions officers say that there has been a continued improvement in the quality of applicants to schools of dentistry based on performance on the A-level examinations. Emphasis on A-level exami nations often is used to distinguish between those students who will be accepted to medical or dental schools. I often heard dental students comment that their A-level scores qualified for acceptance to med ical school, but that they preferred dentistry. Appar ently (based on commentary by many students, edu cators, and practitioners), there is less of a “second class” attitude, smaller difference in incomes,1 and little sense of being “almost doctors” than there is in the United States. This final item may be valid be cause both physicians and dentists receive a bac calaureate degree on completion of their studies and are referred to as “Mr., Miss, or Mrs.” The doctoral degree requires advanced training, including the
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writing of a doctoral dissertation. Although some surgeons (physicians) hold doctoral degrees, nevertheless, in accordance with tradition, they are not referred to as Doctor. (I guess they just don’t speak American.) In any event, applications through the UCCA cen tral application system are reviewed before the stu dent’s completion of A-level examinations. Usually, admissions committees for dental schools will interview all applicants who will receive an offer for admission. The deans of several schools remarked that the admissions committees are rather small and that the decision for admission is often made by the dean. In addition, they commented that the inter view tended to be used as a confirmatory review of the all-important letter of reference from the appli cant’s headmaster. Letters of acceptance are sent contingent on successful completion of the A-level examination. Some dental schools attempt to re serve a few seats for students from the Common wealth. The students also must complete the stan dardized A-level examination that is given at dif ferent locations throughout the world and then apply through the UCCA central applicant system. Preference is given to those candidates from coun tries with few or no medical and dental facilities. Although only 17% of the dentists in Great Britain are women, approximately 30% of the current suc cessful applicants for dental school are women. Many dental educators can foresee a time when ap proximately half of the student body and eventually the profession will be women. Finally, in reference to the economics of dental education, many disquieting remarks have been made regarding the cost excesses of US dental edu cation, its effects on the numbers of applicants, and the narrowing of the spectrum of candidates. (As many as 80% of US students in some classes in some dental schools are receiving loans.3) In Great Britain, the cost for most students is borne by the Local Edu cational Council (that is, through taxes). Not only do these grants (not loans) cover the fees for education, but they include maintenance costs (room, board, and even some travel expenses). In addition, the universities maintain hostels and other systems of lodging and board for students. Depending on the economic status of the student’s family, contribu tions to the costs are required, but some financial support is available for all students. Essentially, graduates of British dental schools complete their education with few or no debts and are able to reach the expected average National Health Service in come within a reasonably short time.1 Although specific figures were not made available to me, rep resentatives of the Department of Health and Social Security indicated that only a small number of graduate practitioners were emigrating from Great Britain. There was concern, however, that, with the
entrance of Britain into the European Common Mar ket and with the possible easing of movement be tween nations, more graduates may emigrate.
Dental schools and educational programs Most schools have between approximately 50 and 60 entering students; enrollments range from about 45 to 80 students. Most schools I visited were in rela tively new facilities (1960s era), with reasonably new to quite new equipment and facilities. At one school, the physical plant dated to the turn of the century; therefore, the major advances in architec ture and construction of dental schools are readily appreciated. Faculty and administrators consis tently complained of inadequate staff, space, and re search facilities, particularly since the downturn in the economy during the 1970s. Many faculty mem bers specifically cited that British dental schools did not offer sabbatical leaves, although senior faculty members did secure leaves of absence. In the United States, dental schools are reviewed periodically for accreditation by a Commission on Accreditation which, although associated with the American Dental Association and the American As sociation of Dental Schools, is, in fact, an autono mous organization. The Commission reviews the physical plant and general environment for educa tion, the administration, teaching program, and vir tually every phase of the program to ensure an edu cational regimen that is modern and realistic. A similar system exists in Great Britain; dental schools are reviewed by the General Dental Council. Under the Dentists Act of 1957, the Council is re sponsible for promoting high standards of profes sional education for dentists. The Council requires universities and other bodies in the United King dom and the Republic of Ireland which grant de grees or licenses in dentistry to provide information about the courses of study and examinations for di plomas. The General Dental Council also appoints persons to make site visits. If the Council considers that the course of study and examinations for a de gree of license do not ensure that graduates or licen ciâtes (the Royal Colleges are discussed later) pos sess the requisite knowledge and skill to practice dentistry, the Council may notify the Privy Council, which in turn may order that graduates from these institutions no longer be registered in the Dentists Register and, therefore, not be eligible for practice. Recommendations for improvements in facilities and numbers of personnel must be considered by the University Grants Commission and the Department of Health. Unfortunately, the review by each of these bodies is influenced by the general fiscal state of the government and university, and the Grants Com mission and Department of Health may be unwilling
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to place adequate pressure for improvement in these particular needs. (A following section discusses the potential for improvement of dental personnel and facilities.) The course of studies at all schools is full-time and is divided into two stages, preclinical and clinical. Although the school bulletins and administrators claim that the two components are closely coordi nated, most students complained of a clear separa tion of the two areas of study. (This may resemble the complaints of American dental students.) First year, or predental year, consists of courses in biology (zoology), chemistry, and physics. It is pos sible, and, depending on the institution, obligatory, to gain exemption from these courses by passing ex aminations of A-level standards. Second year, the preclinical year or first dental year, includes courses in anatomy, dental anatomy, physiology, biochemistry, and histology. There is some variation in schools in which there is a combi nation of the first and second years for those stu dents who have not been exempt from the basic sci ences. In these schools, pharmacology, oral biology, pathology, microbiology, and an introductory course in dental technology and materials science are provided. Although dental schools vary, in the third year or first clinical year, students are introduced to the major dental subjects, including conservative den tistry (restorative), child dental health (orthodontics and pedodontics), prosthetic dentistry, dental mate rials, oral surgery (including local and general anes thesia), oral pathology, oral medicine, periodontics, dental epidemiology, and community dentistry. Be cause of my concerns in behavioral science and community dentistry, I particularly was interested to learn that few of the schools had departments of community dentistry; some minimal instruction in these subject areas was provided, however. (At one national conference on the basic sciences, a speaker referred to the behavioral sciences and similar courses as being “woolly.” At least that is different from the statements in the United States, in which the behavioral sciences are referred to as being “fuzzy.”) Fourth and fifth years (some schools require only a third or half of this final year) are used to expand further the student’s experience with the clinical sciences; student involvement with school dental clinics, outside dental practices, retirement homes, community dental clinics, and regional hospitals is included. Much of the nonclinical course material is presented during the clinical years in small group settings. The possibility must be considered that, directly or indirectly, the curriculums of the dental schools are affected by the limitations of treatment available under the National Health Service. For example, the SIS ■ JADA, Vol. 100, April 1980
idea that Health Service dentistry is merely extrac tions and dentures would lead to the belief that den tal schools emphasize these two aspects of care and leave fixed prosthodontics, endodontics, and other fields of study to some “backwater” phases of the educational program. After interviewing the deans of more than half the schools in Great Britain, dis cussing with department chairmen, and reviewing the literature (in particular, the comparison of den tal education in Great Britain and United States by Silversin and others4), the following information was noted. In schools that had specific requirements, the re quired number of crowns and inlays ranged from 17 to 38; the median number was 20. Most dental schools do not have a required number of fixed partial dentures. However, in the schools reviewed in one study, 30% to 90% (median, 75%) of the students did complete at least one fixed partial denture. My discussions with school ad ministrators and students indicated that all students are required to complete varying numbers of fixed partial dentures. Endodontic requirements range from 2 to 23 (me dian, 13) teeth with varying use of rubber dam. In all aspects of dental services, use of rubber dam seems to be an individual department’s, or, in some cases, a teacher’s, decision. When it was apparent that many dental practitioners were performing endodontic services in a single office setting to achieve some fi nancial return from the National Health Service, all instructors emphasized the idea that their role was to teach the proper approach to the service. Thereby, they pressured the National Health Service into needed changes. In terms of department size, teaching hours, and the type and complexity of educational programs, periodontal services receive far less emphasis in Great Britain than in the United States. British students complete far more sets of com plete maxillary and mandibular dentures. They complete three to 20 (median 10) more dentures than American students do (in fewer appointment hours per patient). British students complete a com parable number of chrome cobalt partial dentures, and additionally provide acrylic partial dentures (“flippers”). A dean of one school (an oral pathologist by training) commented that, from a physiologic and community service perspective, he did not see anything wrong with this form of prosthetic replacement. Many administrators emphasized the extensive experience students receive with removable or thodontic appliances. Payment under the National Health Service for orthodontic services is not based on the type of appliance used, but rather, the fee de pends on complexity of the case. Most cases are treated with removable appliances by general dental
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practitioners. Students seem most prepared to provide simple restorative services. Several administrators of dental schools (including chairmen of departments of re storative dentistry) volunteered their negative feel ings about the continued emphasis on gold foil res torations in American schools and state licensing examinations. They believed that the continued teaching of certain techniques in US schools was anachronistic in view of current societal needs and the improvements in available restorative materials. Both students and administrators emphasized the need for increased speed in performing the dental procedures. As most students expected to work under the National Health Service, speed was essen tial to secure a satisfactory income.
Becoming professionally qualified There are two routes to becoming professionally qualified in dentistry. Most students take studies leading to the degree of Bachelor of Dental Surgery (BDS). Another route is to secure a diploma from the Royal College of Surgeons (of England, Edinburgh, or Glasgow) and receive the title of Licentiate of Dental Surgery (LDS). A historical note will show the differences between these two qualifications. Although the LDS was established in 1859 by the Royal College of Surgeons of England and a Register of Dental Licentiates had been established in 1878, it remained possible, until 1921, for a person to prac tice dentistry without examination. By action of Par liament, it became necessary for dentists to have recognized qualifications in dentistry before their names could be placed on the Register of practicing dental surgeons. The Dental Board formed then existed until 1956 when, by an act of Parliament, the General Dental Council was formed. The Council currently main tains the Dentists Register of those legally entitled to practice. With the expansion of university educa tion, degree courses are the main method of study and qualification. The LDS diploma course is simi lar in content to the various degree courses and only in exceptional circumstances will a university allow a student to take the LDS examination without hav ing a university degree. Many dentists consider it a privilege to be a Licentiate of a Royal College of Sur geons in addition to having received a BDS. Final examinations are designed to include an as sessment of the candidate’s practical ability in a va riety of clinical procedures. The examination may include work prepared previously or executed dur ing the actual examination. Candidates are reviewed by at least two external (that is, outside of the indi vidual school) examiners in all written papers and oral and clinical examinations. In grading the can didate, examiners are empowered to consider the
applicant’s performance during the course of study in the subject area of the examinations. The external examiners generally are or have been professors at a university or recognized dental school other than the school at which the candidates were trained. It is suggested that the examiners be appointed or reappointed for at least three consecu tive years.5
General observations Despite a common language (there were times when I was not too sure of this) and supposed aspects of common heritage, no outside observer truly can hope to grasp more than a passing understanding of another culture. The dental education reflects both the cultural heritage and the health care needs of the people served by the National Health Service. My observations are tinged with my American upbring ing and, as such, must reflect particularities which, although important to me and other Americans, need not necessarily be of significant concern to our colleagues in Great Britain. Students
The dental students seem so young—so many are in the late teens. However, during discussions and general school activities, they seem as mature (im mature?) as students in the United States. They complain about not knowing enough about den tistry and express fears regarding the changes in the National Health Service which will have profound effects on the kind of dentistry they want to do. (This sounds all too similar to the comments of American students.) Most significant, many students thought that their choice of dentistry was too early but be lieved that they were better off than medical stu dents because they would have a bigger income (be tween National Health Service and private practice) than their colleagues. They seemed to perceive far less of a second class status to medical students than is heard from American students. As mentioned, dental education is essentially free (including financial support for room and board). This may explain why many students (particularly the more senior students) were far more relaxed about the future than their American counterparts, who so often seem burdened by the need to rid themselves of large debts. British students were aghast when we discussed the expense of dental education in our country. Their comments about community dentistry and behavioral science courses were quite similar to those of US students—questionable value. However, many were interested in more information about the operation of the National Health Service, and few students attended lectures by the department of
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community dentistry even when the material covered was about the National Health Service. The much higher percentage of women in dental schools (approximately 30%, currently) has had an interesting effect—43% of the female dentists in En gland and Wales are married to dentists. In Great Britain, almost 17% of all dentists are women. Many of the students were surprised that in the United States there were so few female dentists. It seemed natural to them that a dentist could be either a man or woman. Students complained about the excessive amounts of requirements and commented on the relative ease of the curriculum at medical schools. (These comments are similar to those that one hears in the United States.) For the most part, I sensed a close relationship between the students and faculty—possibly as a result of small sized classes and teaching groups. Schools
By American standards, most schools are small with small tutorial arrangements which have a positive effect on the teaching program. Dental students and expanded duty auxiliaries have completely separate educational programs. The student (and later the practitioner) has little or no idea about the potential of these personnel. When the practitioner first meets these auxiliaries in the community health service, difficulties can and do arise.1 Many faculty members practice dentistry part time; there is little movement toward the develop ment of many full-time professorships. Discussions with government economic officers seemed to indi cate that not much more movement in this direction should be expected when the economy improves. Their general feeling is that dental and medical edu cation has been doing well compared with other educational programs. The hospitals, with which many of the schools are associated, often are magnificent examples of late Victorian architecture. Built to endure, they seem too sound to destroy (based on the economy of the country), but they are proving to be inadequate for modern needs. Constant modernization within the cave-like brick building is occurring. Some schools have begun to develop shortages of specific types of treatment services to meet student educational requirements; for example, the dental school in Birmingham, as one of only two cities cur rently with a fluoridation program, is experiencing problems providing adequate pedodontic experi ences for students.
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Conclusions A frequently used expression in Great Britain about our two countries is that we are “two nations sepa rated by a common language.” Similarly, the two dental education systems are separated by a com mon profession. Although we speak the same pro fessional language and recognize the same respon sibility to preserve the health of the public, our orientations and methodologies are different. Nevertheless, although differences between our sys tems of education do exist, with each country re flecting its history and culture, both the US and British systems of dental education have continued their long traditions of excellence. After 30 years of the National Health Service, British dental education demonstrates three signs of vitality: large numbers of applicants; continued im provement in the caliber of applicants; a demanding educational program which, while recognizing the realities of the National Health Service, is willing to, and does, challenge the Service to constantly im prove and recognize the dental needs of the public. In addition, the programs in research at schools of dentistry, although hard-pressed because of finan cial limitations, have continued in all phases of the clinical and basic sciences. Dental education in Great Britain certainly re flects the National Health Service and the general cultural attitudes, just as our system reflects the cir cumstances of this country. It should be interesting to see how changes in our system (including adver tising and denturism) significantly affect our educa tional attitudes. The author thanks Dr. Aubrey Sheiham and Mr. John Bulman for assist ance and aid during sabbatical leave at the London Hospital Dental School in the 1978-1979 academic year. Much of their writings and ideas provided the basis for significant components of this and the previous Perspective article on the British National Health Service. Dr. Waldman is professor and chairman, department of dental health, School of Dental Medicine, State University of New York at Stony Brook, Stony Brook, NY 11794. Address requests for reprints to the author. 1. Waldman, H.B. Dentistry within the British National Health Service. JADA 99(3):439-447,1979. 2. The Careers Research and Advisory Center. Dentistry degree course guide, 1978/79. Cambridge, Hobsons Press, 1978. 3. American Association of Dental Schools. Annual report, dental edu cation, 1978-79. Chicago, Division of Education Measurements, American Dental Association. 4. Silversin, J.B., and others. Dental education in Great Britain and the United States. J Dent Educ 38:497-511,1974. 5. General Dental Council. Recommendations concerning the dental curriculum. London, 1975. Essays of opinion on current issues in dentistry are published in this sec tion of The Journal. The opinions expressed or implied are strictly those of the authors and do not necessarily reflect the opinion or official policies or position of the American Dental Association.