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Dental education in Sweden: cultural perspective, structure, and issues
PERSPECTIVES
The specter of unemploym ent hangs over much of the health care sector in Sweden.
Dental education in Sweden: cultural perspective, structure, and issues Rod Moore, DDS, MA
3 & ental health care needs are per ceived differently by different societies. The cultural, political, and economic tra ditions of any nation affect the evolving roles of dentists, dental researchers, and other dental personnel. These traditions in turn have their influence on dental education. In considering strategic plan ning for the future of the dental profes sion as has the ADA Special Committee on the Future of Dentistry,1 studies of dental issues and educational structure within the context of national cultural modes can provide new perspectives on universal dental education problems and long-range policy formulation. In this ar ticle, the Swedish model is reviewed. Sweden is a country a little larger than California with a population of 8.3 mil lion. Dental services are provided by both private and public dentists. Swedish den tistry and dental research are of high qual ity and are a high public priority.2-4 There are many features and issues unique to Swedish dental education as a result of Swedish cultural and historical tradi tions.
A historical perspective Two noticeable features in Swedish soci ety have had significant impact on dental h e a lth ca re d e liv e ry and d en ta l 692 ■ JADA, Vol. 110, May 1985
education—centralized government and a high degree of belief in authority. The history of the Swedish monarchy, among other related factors, appears to have greatly affected Swedish culture.5 Before Sweden’s declared neutrality in 1814 (unviolated to the present), kings of Sweden led Swedish soldiers in numer ous successful campaigns. Army officers who had fought in the wars were often ceded portions of land by the kings as payment. These landed officers and wealthy nobility dominated provincial administrative offices. The kings of the 16th, 17th, and 18th centuries formed al liances with frustrated commoners and lesser nobility to counterbalance the growing power and feudalistic influences of these provincial aristocrats.5,6 Most of these kings were popular authority fig ures among the gentry and largely un challenged by the aristocracy. Separate governmental boards (for example, the Board of Health and Welfare) were also appointed and directly supervised by the kings to prevent the overconcentration of pow er in govern m en tal m in istrie s headed by the often politically active aris tocrats. This helped the Swedish king maintain his influence on the national administration while engaged in foreign campaigns.5 Constitutional representative govern
ment has replaced the popular monarchy, but respect for a higher central authority is still a part of the Swedish culture. Ves tiges of the monarchal policy-shaping boards remain today as part of a highly centralized form of social democratic government with nationally legislated and municipally administered steering of policy in social welfare, health care, and education. Although central authority has been highly beneficial in organizing a well-coordinated high standard of dental health care available to all Swedish citi zens, the Swedish national boards and politicians with their central policy making authority have contributed to some new problems for dental education.
Educational tradition Educational philosophies and innova tions in Sweden were largely borrowed from other lands and implemented by centralized government until the begin ning of the 20th century.7,8 Swedish dental education began in 1865 when the National Board of Health appointed a committee of dentists to run an apprenticeship teaching clinic in Stockholm. In 1891, an academic dental curriculum was established in Stockholm as a part of the Karolinska Institute of Medicine.9 The 3-year curriculum offered
PERSPECTIVES
courses in chemistry, surgical anatomy, pharmacology, the “art of dental fill ings,” and prosthetics. In 1936, the cur riculum was expanded to 4 years and in cluded no practicum after academ ic studies.
Education before dental school
Table 1 ■ Swedish preclinical dental educa tion (four 18-week semesters). Figures indicate total instructional hours and can vary from school to school. Histology Genetics/embryology General anatomy Biochem istry Nutrition M icrobiology Physiology Oral anatomy/histology General m edicine Ear, nose, and throat General pathology Oral pathology Oral diagnosis Radiology Cariology (operative dentistry) Periodontology Endodontics Pedodontics Orthodontics General and oral surgery Prosthodontics O cclusion (bite physiology) Laboratory technique (dental anatomy) Community dentistry Psychology Pharmacology Ergonomics Electives
120 15 120 150 30 60 180 135 30 15 90 30 15 120 105
Educational training before dental school usually consists of 9 years of “grundskola,” followed by 3 years of “gymnasieskola.” The curricula are very similar to American primary and secondary edu cation, but with a stronger emphasis on foreign language training. The Scandina vian educational system differs from the 105 North American system in that a career 7.5 60 “line” or track is chosen with the help of 60 educational psychologists and coun 120 30 selors in secondary school. 97.5 Swedish dental student selection is confined to a quota system. About 78% of 45 dental students are chosen directly from 60 the gynmasium or from a combined gym 30 nasiu m and accred ited v o ca tio n a l 60 employment program. Another 2% are 7.5 75 selected from various adult junior college educations and 10% are taken from an older group of applicants who are chang Table 2 ■ Swedish clinical dental education ing professions or furthering their educa (five 18-week semesters). Figures indicate total tions. Finally, 10% of dental students are instruction hours and can vary from school to selected from foreign applicants with school. Swedish resident status and adequate technology 465 educational qualifications. There are no Laboratory (in fifth and sixth semesters: interviews of candidates nor tests of dex operative dentistry, crown and bridge, and terity or dental aptitude. It is reasoned removable prosthodontics) that grades on the gymnasium examina Oral 45 diagnosis tions, plus the ready availability and fre Radiology 82.5 330 Cariology (operative quent use of career counseling and test dentistry) ing, are sufficient for student selection. Periodontology 120 Swedish dental school applications have Endodontics 210 165 been declining recently because of in Pedodontics 150 Orthodontics creasingly high dentist unemployment. Oral and m axillofacial 180
Current educational structure Curriculum The Swedish dental colleges at Stock holm, Goteborg, Malmo, and Umea are part of their local university structures. A 9-semester curriculum in the dental schools consists of four preclinical 18week semesters followed by five clinical semesters. The preclinical curriculum consists of histology, embryology, general and den tal anatom y, ph ysiology, g en etics, biochem istry, m icrobiology, general m ed icin e, pathology, in trod u cto ry courses in laboratory technique, and gen eral dentistry and community dentistry (Table 1). There is some variation among the schools in early contact with patients during the preclinical phase—a week of clinical prophylaxis, usually in the first semester, at Goteborg and 5 to 6 weeks in Stockholm during the first three semes-
surgery Prosthodontics Em ergency clin ic O cclusion (bite physiology) Community dentistry Psychology Oncology Ergonomics Cleft palate clin ic Forensic dentistry Electives
405 45 105 45 30 15 15 30 15 75
ters. Laboratory technology coursework begins in preclinical training and con tinues into the fifth and sixth semesters of the clinical phase. The last five semesters provide theoret ical and clinical rotations in the clinical sciences—oral surgery, operative den tistry (“cariology”), periodontology, or thodontics, oral medicine and diagnosis, radiology, pedodontics, prosthodontics, and occlusal studies. Table 2 shows the approximate number of hours in clinical coursework. Theoretical coursework is given mostly in traditional lecture format,
but with increasing numbers of small group se m in a rs and som e se lfinstruction. Textbooks are mostly Scan dinavian but many are American. There are no formal clinical unit requirements beyond completion of clinical rotations. Comprehensive exam inations in any given subject are given at various times of the year and are usually in written form. There may also be midterm examinations and laboratory practical tests at the dis cretion of course leaders. The total of nine semesters in dental school amount to 4V2 years in duration. Until 1979, the curriculum was 10 semes ters (5 years). The current curriculum, which started in September 1979, is sup plemented by a year of general practice residency, “Allman Tjanstgoring” (AT) in the dental p u blic health service (“Folktandvarden”). This residency year concludes with a written examination taken in the field clinic but is evaluated by the faculty of one dental school chosen each year on a rotating basis. Thus, the total dental education of a Swedish den tist before licensure is 5V2 years. The first “new” dentists graduated in December 1983. General practice residency The general practice residency is still in a formative stage and has been a source of controversy in the profession. The dental residency was inspired by its medical counterpart initiated in the late 1960s. The official goals according to Dr. John Hedlin, dental director of the National Board of Health and Welfare, are: —To more fully integrate the students’ theoretical and clinical dental knowledge in the field in a supervised manner ac cording to the specific needs of the stu dent; —To improve the general quality of care in Folktandvarden by improving the knowledge of those educating the student during the residency; —To try to improve the cooperation and inform ation exchange between academic faculties and dentists in the field; —To increase both student and general clinic awareness of the role of dentistry in the context of total health care in the population, emphasizing preventive den tal practices; and —To help redistribute the workforce to areas of high dental care need. The field educators (usually clinic chiefs) who supervise student dentists are trained at government-approved spe cialist and graduate education sites. Their training began in 1977 and consists of 3 weeks of community dentistry, psychol ogy, and education coursework; 3 weeks of prosthodontics, dental materials, and occlusal physiology; and 1 week each of Moore : DENTAL EDUCATION IN SWEDEN • 693
PERSPECTIVES
periodontics, cariology, pedodontics, or thodontics, radiology, diagnosis and oral surgery, and endodontics—a total of 14 weeks. This ambitious project attempts to foster an organized clinical learning envi ronment for dental students as a link to
education, there will be 2,600 by 1990.10 The hygiene education must be pre ceded by a dental assistant education and 2 years of practical experience as a dental assistant. The curriculum includes indi vidual and collective dental hygiene in-
sor), to professor. Only full professors are tenured, and there is only one professor for each department. As a result, a profes sorship is an influential and powerful po sition in Swedish society, a good example of a high degree of belief in a central au thority. Deans and governing structure
In the current re v ise d adm in istrative board structure, the d ea n ’s position is often less influential than the Sw edish professorship.
the concept of lifelong learning. Graduate studies and specialties Swedish dentistry is the most highly spe cialized of all the Scandinavian dental health care systems. A well-organized, regionally coordinated network of spe cialist centers throughout the country provides highly standardized, com prehensive care. Most Swedish graduate dental studies are in the recognized specialties. Ortho dontics requires 3V2 years of study as well as an additional year in pedodontics and 6 months of another selected specialty. Oral and maxillofacial surgery is a 3-year program with examined rotations in otolaryngology and general or plastic surgery and other specialties in dentistry and medicine comprising another year. Endodontics, periodontics, pedodontics, prosthodontics, and oral diagnosisradiology are also 3-year programs with an additional year’s study of at least two other selected specialties. These programs—among others like cariology, oral pathology, and oral microbiology as a research education— culminate in a “ doctor’s degree,” the equivalent of a PhD. There are no master’s programs, only certificated specialties for nondegree dental specialists. Education and certification take place in any of the four dental schools. Some clinical spe cialty training also occurs in some gov ernment accredited postgraduate training centers. Most specialty practitioners practice in Folktandvarden.
struction and motivation, polishing of dental restorations and removal of over hangs, prophylaxis, local anesthetic in jection technique, root planing and scal ing, X-ray technique, making impres sions and study models, use of pit and fissure sealants and fluorides, and pre liminary caries and periodontal disease registration. The curriculum also in cludes an orientation to all phases of clin ical dentistry. Courses in psychology, community dentistry, and educational techniques have also been added re cently, along with the courses in local anesthesia.
Administration organization Faculty members Although officially considered full-time,
Sw edish dental school applications h a ve been declining recen tly because of increasingly high dentist unem ploym ent.
many Swedish dental faculty members are half-time dental practitioners who participate in an academic positionsharing scheme. Full-time academic staff members have various position descrip tions and academic advancement is based Dental hygiene education almost exclusively on research and pub Eleven schools of dental hygiene offer a lication frequency. This promotion pol 1-year program instituted in 1968. As the icy helps explain the large quantity of Swedish government places dental dis high-caliber research generated by the ease prevention and the dental hygienist Swedes as compared with countries of role in high priority, there is an annual greater population size. student capacity of 240 and a current Academic positions progress from as practicing 'd ental hygienist corps of sistant clinical instructor to instructor 1,200. There were only 390 dental hy- “lektor” (assistant professor), to “docent” gienists in 1978, but at the current rate of and research assistant (associate profes 694 ■ JADA, Vol. 110, May 1985
The dean of each dental school is selected by a committee of professors and as sociate professors to preside as the chief central administrator of academic and fi nancial affairs. The Swedish dean can be important in the dental school’s negotia tions with the government, university, and other agencies in obtaining needed resources, and as a public relations per son. However, the administrative author ity of a Swedish dean is small in compari son with North American counterparts. In the current revised administrative board structure, the dean’s position is often less influential than the Swedish professor ship. There are three academic boards within the dental schools: the Faculty Board, headed by the dean, which is responsible for research and postgraduate training; the Curricular and Academic Affairs Board, responsible for the basic dental curriculum and student affairs; and the Dental Care Board, which oversees the practical preclinical and clinical affairs of the dental school. All three of these boards of the dental “Fakultet” are di rectly responsible to a College Governing Board that forwards proposals to the Uni versity and College Authority, an arm of
the Ministry of Education. The Swedish Parliament and Department of the Trea sury then act on new proposals concern ing dental education or exert their own legislative force on the Ministry of Educa tion for changes in funding or dental edu cational priority. A 1977 parliamentary law called for administrative restructuring in all in stitutions of higher education, including dental colleges. It aimed to change the European tradition of professors’ mon opoly in the decision-making process within college academic boards, in an at tempt to democratize the institutions under the leadership of a College Govern-
PERSPECTIVES
ing Board that would consist of a number (John Hedlin, personal communication, mated that, given current market circum of informed business and union leaders, 1983) other than dental school faculty stances and the number of currently en academics, and students. Some say the evaluations of AT written final examina rolled dental students, 1,000 Swedish edict did not go far enough and are calling tions taken in the field. Still, some faculty dentists will not be able to find work in for another reform in which even more members express optimism and a will to Sweden (personal communication, Ste power would be vested in “middle-level” combine academic with dental practice.14 fan Salang, economist, SDA, November The younger members of the SDA have 1983). teachers and researchers in the formation of a representative assembly of academics had three main concerns about the resi For years, the dental association was below the level of professor.11'12 New dency program. Would it be counted as the loudest voice calling for dental school proposals in the Swedish parliament in formal education by other countries? enrollment cutbacks. In 1978, the dentists tend to create a single representative sen Would AT positions be distributed on an at the National Board of Health and Wel atorial body of teachers, researchers, and equitable basis to students desiring a fare also delivered a moderate proposal stu dents in stead of three separate academic boards. The Swedes are appar ently becoming more aware of centralization-decentralization issues and their The Sw edish dental gen eral residen cy program is influence on academic effectiveness and seen as a vital lin k betw een academ ia and the “rea l creativity. Students
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Currently, 380 dental students graduate annually. About half of Swedish dental students are female.10 The average age of graduating students is 25, but it is not uncommon to see students in their 30s and 40s. Dental students receive state guaranteed loans and accrue an average debt the equivalent of $13,000 for their living expenses in their 5 years of study. Dental school tuition is free. A mix of conservative and progressive values and pragmatism and idealism re flects not only the dental students’ values, but Swedish cultural values in general. By one account,13 Swedish dental stu dents have been characterized as being highly motivated to perform tasks well and readily conforming to rules that will help them do so (a high belief in authority), but these values appear to be chang ing rapidly since the time of that report, Almost all the students belong to the Swedish Dental Association (SDA) and membership in their local political Stu dent Union is compulsory. They are di rectly involved in policy-making groups in the dental schools. Issues within the schools, however, have not been as im mediate for the students as the issues of dentist unemployment and controversies surrounding the general practice resi dency (AT).
w o rld ” of dentistry.
choice of location? How would current graduates of the old 5-year curriculum be selected for jobs in competition with AT-graduated dentists? The National Board of Health and Wel fare now speculates that AT will be counted as part of the Swedish formal dental education14 in other countries— but there is no evidence of contacts estab lished with other European national health board ministries to prove this claim. The board believes that the SDA should make these contacts, as Sweden is not a member of the European Common Market. The educational status of AT out side Sweden is still on a “wait and see” basis. In the organizational planning for selection and distribution of dental resi dencies, a federation of Swedish county authorities independently decided to pursue a plan similar to the one in force for AT physicians. The dental association and the students were angry with county officials over the matter and found the county proposal unacceptable. The SDA had spent a year preparing a combined application-lottery scheme, testing it and working with the counties for their ap proval. It was believed that the scheme The AT residency was less complicated and more fair than Most dental students and dental faculty that of the county, which is based com believe that a general practice residency pletely on student merits, both academic is a sound idea. The Swedish dental gen and vocational.15 As AT positions are guaranteed to all eral residency program is seen as a vital link between academia and the “real ninth semester dental students, the al world” of dentistry. Dental faculties have ready unemployed dentists (about 200 as been instrumental in the education of the of January 1984), plus dentists finishing AT field educators, so contacts and coop temporary job placements, are finding the eration have already started. The AT pro- job market even harder than before. gram think-tank at the National Board of Health and Welfare hopes for continued Dentist unemployment cooperation. But according to the board’s dental bureau chief, no formal plans have Dentist unemployment predictions for been made for continuing collaboration Sweden are extremely high. It is esti
for cutbacks to the Swedish govern ment.16 Most observers fault Swedish politicians for their shortsightedness in not acting on these recommendations. Dentists working as county dental direc tors and serving as consultants to the Federation of County Councils have also continuously recommended a high edu cational output of dentists. The National Board of Health and Welfare has been ac cused of not standing together strongly enough with the SDA to convince the politicians about future jobless dentists. The board’s defense is that central politi cians cannot always be convinced of rec om m endations offered from board studies. Of course, younger dentists are the hardest hit, so they are becoming more politically active both in the SDA and in Sweden’s parliament.17 Many younger students are considering switching pro fessions, but other academic and health science professions, including physi cians, are cutting back their enrollments as well. Students’ attitudes range from guarded optimism to near depression over the future employment situation, but they are definitely beginning to question the wisdom of central authority. Many are willing to practice in either Third World projects, especially Africa and the Middle East, or W estern Europe and North America. Even with dental marketing schemes, early retirement ideas, relaxation of Swe den’s private practice “establishment control,”4 and dentist time-sharing plans to improve the prognosis, the Swedish government has recognized the need to make drastic cuts in dental enrollments. In 1983, the dental association offered a proposal to reduce enrollment in all four dental schools equally. The Treasury De partment instead made a dramatic propo Moore : DENTAL EDUCATION IN SWEDEN ■ 695
PE RSPECTIVES
Two noticeable features in Swedish society have had a significant impact on dental health care delivery and dental education— centralized government and a high degree of belief in authority.
sal to close Sweden’s second largest school, Goteborg—a move that would af fect 700 jobs. The shock of this proposal created a wave of protests and demonstra tions by faculty members, students, and staff. Goteborg, internationally known for its research in cariology and periodontol ogy, also received the written support of dental researchers from all over the world in the form of a letter campaign to the Swedish parliament. The threat of closure was dropped by overwhelming political opposition in the parliament and instead a smaller, less active school—Malmo— will be phased out in the next 5 years.
The future With the specter of unemployment hang ing over much of the health care sector in Sweden, some new alternative ideas are beginning to develop. The export of Swedish medical and dental personnel is one of these ideas. The Federation of County Councils has formed a company (SwedeHealth) whose main goal is to con tract and export Sweden’s internationally reputed health care to other countries.18 Swedish dentists are taking an active role in the company’s future—another possi ble solution to help decrease the un employment crunch. There are also some plans for exportation of dental education systems. The decreasing enrollment in under graduate dental programs is changing the role of the dental schools and their societal function. The Swedish dental school faculties plan to expand post graduate and continuing education for practicing dentists in the future. The vi sion is to provide a “learning center” to help retrain clinicians to meet the de mands of a rapidly changing dentist role. For example, now that children’s dental health care in Sweden is excellent and well covered, there is growing emphasis on care for the elderly—part of a larger trend within Swedish society to improve the quality of life for the elderly. Dental school faculties want to prepare the den tal practitioner for the coming shift to gerontology. Some members of academic faculties are also trying to promote a new health policy and dentist image to the public: the dentist as the diagnostic pro fessional who is most easily in the posi tion to provide some simple preventive 696 ■ JADA, Vol. 110, May 1985
medical screening measures such as blood pressure checks and health-history taking. The Swedes tend to see dentistry becom ing more lik e a sp e cia lty of medicine— stomatology. Whatever the future of dentistry in Sweden, the impor tance of the general practice residency as a communication link between academia and the field practitioner could be an ini tial step in a continued and expanding dialogue to create a flexible dental corps capable of meeting social needs.
Conclusions Centralized governmental power and a willingness to believe in authority are culturally rooted in Sweden’s history of popular patriarchal kings. In recent years, however, the government has met the demands of the Swedish people for more decentralization as a continuation of the democratic process. Central authority has created an organized and comprehensive dental healtb care system that makes high-quality dental services available to all Swedish citizens. However, in the cur rent Swedish dental education situation, the shock of possible dental school clos ings caused by increasing dentist un employment points to the need for central government to respond more rapidly to dental workforce estimates provided both by its advisory boards and the Swedish Dental Association. The Swedish professorial monopoly in academic decision-making is also being challenged so that dental and other higher education can become more effi cient and creative. In times of crisis, new ideas and innovations such as Sweden’s general practice residency can provide solutions with far-reaching implications for the future of dentistry.
____________________________ JBCS4 Essays o f opinion on current issues in dentistry are published in this section of ¡ADA. T he opinions ex pressed or im plied are strictly those of the authors and do not necessarily reflect the opinion or official policies or position of the A m erican Dental Associa tion.
The author thanks Drs. Thore Martinsson, John Hedlin, E lof Petterson, Per Odman, Gorel Muller, and colleagues at the Sw edish Dental Association for their assistance in the preparation of this manuscript. Dr. Moore, a former instructor at Ohio State Univer
sity College of Dentistry, spent 2 years in the Sw edish Dental Public Health Service and lived in Denmark for several years since 1976. He researched this article w hile a guest researcher supported by the Royal Den tal College, Aarhus, Denmark, and is now a National Institutes of Health dental behavioral research fellow at the University of W ashington. Address requests for reprints to Dr. Moore, School of Dentistry, depart ment of community dentistry, University of W ashing ton, B -509 Health Scien ce Bldg, SM -35, Seattle, 98195.
1. Dentistry’s blueprint for the future. A report on the strategic plan developed by the A ssociation’s Special Committee on the Future of Dentistry. JADA 1 0 8(l):20-30, 1984. 2. Bawden, J. Dental health care in Sweden, na tional plan covers everyone. Dent Surv 52(9):21-28, 1976. 3. Ahlberg, J.E. Dental care delivery in Sweden. In Ingle, J., and Blair, P., eds. International health care delivery systems: issues in dental health policies. Cambridge, MA, Ballinger Publishing Co, 1978, pp 137-145. 4. Moore, R. T he Swedish national dental insur a n c e a n d d e n t a l h e a l t h c a r e p o l i c y . JA D A 102[5):627-630, 1981. 5. Scott, F.D. Sweden: the nation’s history. M in neapolis, University of M innesota Press, 1977, pp 118-300. 6. A ndersson,I.,and W eibull.J. Sw edish history in brief. Sodertalje, Sweden, W iking Tryckeri A B, 1980, pp 20-23. 7. Boucher, L. Tradition and change in Sw edish education. Exeter, Great Britain, Pergamon Press, A. W heaton and Co, Ltd, 1982, pp 1-20. 8. Ito, H. H ealth p olicy dynam ics and the de velopment of modern democracy: the development of the health care system and modernization in Den mark and Sweden, 1850-1950. Thesis, University of Copenhagen, 1981, pp 94-161. 9. H a n sso n , A. O d o n to lo g isk a F o r e n in g e n s F estskrift T ill M inne av O .F .’s 50-ariga tillvaro. Stockholm , Caslon Press, 1938, pp 7-19. 10. Den langsiktiga tillgangen och efterfragan pa ta n d v a rd sp e rso n a l— re v id e ra d e b e d o m n in g a r. Socialstyrelsen, Stockholm , 1981, pp 17-37. 11. Premfors, R., and Ostergren, B. System s of higher education: Sweden. New York, Interbook, Inc, International Council for Educational Development, 1978, pp 93-119. 12. Ruin, O. Battre sam ordning, overblick och lederskap i hogskolan under omprovning— Fjorton debatt inlagg om hogskolan i den ekonomiska krisen. In Furumark, A., and och W ahlen, S., eds. UHA Skriftserie, 1983. Liber Tryck, Stockholm , 1983, pp 107-118. 13. Bawden, J.W. An experience in dental educa tion in Sweden. J Dent Educ 4 0 ( ll) :7 1 9 - 7 2 3 ,1976. 1 4 . A T p a ta p e t e n . T a n d l a k a r t id n in g e n 75(19) ¡1047-1048, 1983. 1 5 . L a n d s tin g s fo r b u n d e t: R e k r y te rin g o c h anstallning av AT-tanklakare. Tandlakartidningen 75(17):909-911, 1983. 16. Den fram tid ig e efterfrag an pa tan d v ard s p e rso n a l. S o c ia ls ty r e ls e n s T a n d v a rd sp e rso n a l Utredning Rapport no. 3. Stockholm , Ds.S. 9 ,1 9 7 9 . 17 . H u n g rig a ta n d la k a re -fa rlig a ta n d la k a re . Tandlarkartidningen 7 5 (7 ):3 9 4 -3 9 7 ,1983. 18. Salj vard utomlands. Uppsalas Nya Tidningen, 10. Nov, 1983, p 10.
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The specter of unemploym ent hangs over much of the health care sector in Sweden.
Dental education in Sweden: cultural perspective, structure, and issues Rod Moore, DDS, MA
3 & ental health care needs are per ceived differently by different societies. The cultural, political, and economic tra ditions of any nation affect the evolving roles of dentists, dental researchers, and other dental personnel. These traditions in turn have their influence on dental education. In considering strategic plan ning for the future of the dental profes sion as has the ADA Special Committee on the Future of Dentistry,1 studies of dental issues and educational structure within the context of national cultural modes can provide new perspectives on universal dental education problems and long-range policy formulation. In this ar ticle, the Swedish model is reviewed. Sweden is a country a little larger than California with a population of 8.3 mil lion. Dental services are provided by both private and public dentists. Swedish den tistry and dental research are of high qual ity and are a high public priority.2-4 There are many features and issues unique to Swedish dental education as a result of Swedish cultural and historical tradi tions.
A historical perspective Two noticeable features in Swedish soci ety have had significant impact on dental h e a lth ca re d e liv e ry and d en ta l 692 ■ JADA, Vol. 110, May 1985
education—centralized government and a high degree of belief in authority. The history of the Swedish monarchy, among other related factors, appears to have greatly affected Swedish culture.5 Before Sweden’s declared neutrality in 1814 (unviolated to the present), kings of Sweden led Swedish soldiers in numer ous successful campaigns. Army officers who had fought in the wars were often ceded portions of land by the kings as payment. These landed officers and wealthy nobility dominated provincial administrative offices. The kings of the 16th, 17th, and 18th centuries formed al liances with frustrated commoners and lesser nobility to counterbalance the growing power and feudalistic influences of these provincial aristocrats.5,6 Most of these kings were popular authority fig ures among the gentry and largely un challenged by the aristocracy. Separate governmental boards (for example, the Board of Health and Welfare) were also appointed and directly supervised by the kings to prevent the overconcentration of pow er in govern m en tal m in istrie s headed by the often politically active aris tocrats. This helped the Swedish king maintain his influence on the national administration while engaged in foreign campaigns.5 Constitutional representative govern
ment has replaced the popular monarchy, but respect for a higher central authority is still a part of the Swedish culture. Ves tiges of the monarchal policy-shaping boards remain today as part of a highly centralized form of social democratic government with nationally legislated and municipally administered steering of policy in social welfare, health care, and education. Although central authority has been highly beneficial in organizing a well-coordinated high standard of dental health care available to all Swedish citi zens, the Swedish national boards and politicians with their central policy making authority have contributed to some new problems for dental education.
Educational tradition Educational philosophies and innova tions in Sweden were largely borrowed from other lands and implemented by centralized government until the begin ning of the 20th century.7,8 Swedish dental education began in 1865 when the National Board of Health appointed a committee of dentists to run an apprenticeship teaching clinic in Stockholm. In 1891, an academic dental curriculum was established in Stockholm as a part of the Karolinska Institute of Medicine.9 The 3-year curriculum offered
PERSPECTIVES
courses in chemistry, surgical anatomy, pharmacology, the “art of dental fill ings,” and prosthetics. In 1936, the cur riculum was expanded to 4 years and in cluded no practicum after academ ic studies.
Education before dental school
Table 1 ■ Swedish preclinical dental educa tion (four 18-week semesters). Figures indicate total instructional hours and can vary from school to school. Histology Genetics/embryology General anatomy Biochem istry Nutrition M icrobiology Physiology Oral anatomy/histology General m edicine Ear, nose, and throat General pathology Oral pathology Oral diagnosis Radiology Cariology (operative dentistry) Periodontology Endodontics Pedodontics Orthodontics General and oral surgery Prosthodontics O cclusion (bite physiology) Laboratory technique (dental anatomy) Community dentistry Psychology Pharmacology Ergonomics Electives
120 15 120 150 30 60 180 135 30 15 90 30 15 120 105
Educational training before dental school usually consists of 9 years of “grundskola,” followed by 3 years of “gymnasieskola.” The curricula are very similar to American primary and secondary edu cation, but with a stronger emphasis on foreign language training. The Scandina vian educational system differs from the 105 North American system in that a career 7.5 60 “line” or track is chosen with the help of 60 educational psychologists and coun 120 30 selors in secondary school. 97.5 Swedish dental student selection is confined to a quota system. About 78% of 45 dental students are chosen directly from 60 the gynmasium or from a combined gym 30 nasiu m and accred ited v o ca tio n a l 60 employment program. Another 2% are 7.5 75 selected from various adult junior college educations and 10% are taken from an older group of applicants who are chang Table 2 ■ Swedish clinical dental education ing professions or furthering their educa (five 18-week semesters). Figures indicate total tions. Finally, 10% of dental students are instruction hours and can vary from school to selected from foreign applicants with school. Swedish resident status and adequate technology 465 educational qualifications. There are no Laboratory (in fifth and sixth semesters: interviews of candidates nor tests of dex operative dentistry, crown and bridge, and terity or dental aptitude. It is reasoned removable prosthodontics) that grades on the gymnasium examina Oral 45 diagnosis tions, plus the ready availability and fre Radiology 82.5 330 Cariology (operative quent use of career counseling and test dentistry) ing, are sufficient for student selection. Periodontology 120 Swedish dental school applications have Endodontics 210 165 been declining recently because of in Pedodontics 150 Orthodontics creasingly high dentist unemployment. Oral and m axillofacial 180
Current educational structure Curriculum The Swedish dental colleges at Stock holm, Goteborg, Malmo, and Umea are part of their local university structures. A 9-semester curriculum in the dental schools consists of four preclinical 18week semesters followed by five clinical semesters. The preclinical curriculum consists of histology, embryology, general and den tal anatom y, ph ysiology, g en etics, biochem istry, m icrobiology, general m ed icin e, pathology, in trod u cto ry courses in laboratory technique, and gen eral dentistry and community dentistry (Table 1). There is some variation among the schools in early contact with patients during the preclinical phase—a week of clinical prophylaxis, usually in the first semester, at Goteborg and 5 to 6 weeks in Stockholm during the first three semes-
surgery Prosthodontics Em ergency clin ic O cclusion (bite physiology) Community dentistry Psychology Oncology Ergonomics Cleft palate clin ic Forensic dentistry Electives
405 45 105 45 30 15 15 30 15 75
ters. Laboratory technology coursework begins in preclinical training and con tinues into the fifth and sixth semesters of the clinical phase. The last five semesters provide theoret ical and clinical rotations in the clinical sciences—oral surgery, operative den tistry (“cariology”), periodontology, or thodontics, oral medicine and diagnosis, radiology, pedodontics, prosthodontics, and occlusal studies. Table 2 shows the approximate number of hours in clinical coursework. Theoretical coursework is given mostly in traditional lecture format,
but with increasing numbers of small group se m in a rs and som e se lfinstruction. Textbooks are mostly Scan dinavian but many are American. There are no formal clinical unit requirements beyond completion of clinical rotations. Comprehensive exam inations in any given subject are given at various times of the year and are usually in written form. There may also be midterm examinations and laboratory practical tests at the dis cretion of course leaders. The total of nine semesters in dental school amount to 4V2 years in duration. Until 1979, the curriculum was 10 semes ters (5 years). The current curriculum, which started in September 1979, is sup plemented by a year of general practice residency, “Allman Tjanstgoring” (AT) in the dental p u blic health service (“Folktandvarden”). This residency year concludes with a written examination taken in the field clinic but is evaluated by the faculty of one dental school chosen each year on a rotating basis. Thus, the total dental education of a Swedish den tist before licensure is 5V2 years. The first “new” dentists graduated in December 1983. General practice residency The general practice residency is still in a formative stage and has been a source of controversy in the profession. The dental residency was inspired by its medical counterpart initiated in the late 1960s. The official goals according to Dr. John Hedlin, dental director of the National Board of Health and Welfare, are: —To more fully integrate the students’ theoretical and clinical dental knowledge in the field in a supervised manner ac cording to the specific needs of the stu dent; —To improve the general quality of care in Folktandvarden by improving the knowledge of those educating the student during the residency; —To try to improve the cooperation and inform ation exchange between academic faculties and dentists in the field; —To increase both student and general clinic awareness of the role of dentistry in the context of total health care in the population, emphasizing preventive den tal practices; and —To help redistribute the workforce to areas of high dental care need. The field educators (usually clinic chiefs) who supervise student dentists are trained at government-approved spe cialist and graduate education sites. Their training began in 1977 and consists of 3 weeks of community dentistry, psychol ogy, and education coursework; 3 weeks of prosthodontics, dental materials, and occlusal physiology; and 1 week each of Moore : DENTAL EDUCATION IN SWEDEN • 693
PERSPECTIVES
periodontics, cariology, pedodontics, or thodontics, radiology, diagnosis and oral surgery, and endodontics—a total of 14 weeks. This ambitious project attempts to foster an organized clinical learning envi ronment for dental students as a link to
education, there will be 2,600 by 1990.10 The hygiene education must be pre ceded by a dental assistant education and 2 years of practical experience as a dental assistant. The curriculum includes indi vidual and collective dental hygiene in-
sor), to professor. Only full professors are tenured, and there is only one professor for each department. As a result, a profes sorship is an influential and powerful po sition in Swedish society, a good example of a high degree of belief in a central au thority. Deans and governing structure
In the current re v ise d adm in istrative board structure, the d ea n ’s position is often less influential than the Sw edish professorship.
the concept of lifelong learning. Graduate studies and specialties Swedish dentistry is the most highly spe cialized of all the Scandinavian dental health care systems. A well-organized, regionally coordinated network of spe cialist centers throughout the country provides highly standardized, com prehensive care. Most Swedish graduate dental studies are in the recognized specialties. Ortho dontics requires 3V2 years of study as well as an additional year in pedodontics and 6 months of another selected specialty. Oral and maxillofacial surgery is a 3-year program with examined rotations in otolaryngology and general or plastic surgery and other specialties in dentistry and medicine comprising another year. Endodontics, periodontics, pedodontics, prosthodontics, and oral diagnosisradiology are also 3-year programs with an additional year’s study of at least two other selected specialties. These programs—among others like cariology, oral pathology, and oral microbiology as a research education— culminate in a “ doctor’s degree,” the equivalent of a PhD. There are no master’s programs, only certificated specialties for nondegree dental specialists. Education and certification take place in any of the four dental schools. Some clinical spe cialty training also occurs in some gov ernment accredited postgraduate training centers. Most specialty practitioners practice in Folktandvarden.
struction and motivation, polishing of dental restorations and removal of over hangs, prophylaxis, local anesthetic in jection technique, root planing and scal ing, X-ray technique, making impres sions and study models, use of pit and fissure sealants and fluorides, and pre liminary caries and periodontal disease registration. The curriculum also in cludes an orientation to all phases of clin ical dentistry. Courses in psychology, community dentistry, and educational techniques have also been added re cently, along with the courses in local anesthesia.
Administration organization Faculty members Although officially considered full-time,
Sw edish dental school applications h a ve been declining recen tly because of increasingly high dentist unem ploym ent.
many Swedish dental faculty members are half-time dental practitioners who participate in an academic positionsharing scheme. Full-time academic staff members have various position descrip tions and academic advancement is based Dental hygiene education almost exclusively on research and pub Eleven schools of dental hygiene offer a lication frequency. This promotion pol 1-year program instituted in 1968. As the icy helps explain the large quantity of Swedish government places dental dis high-caliber research generated by the ease prevention and the dental hygienist Swedes as compared with countries of role in high priority, there is an annual greater population size. student capacity of 240 and a current Academic positions progress from as practicing 'd ental hygienist corps of sistant clinical instructor to instructor 1,200. There were only 390 dental hy- “lektor” (assistant professor), to “docent” gienists in 1978, but at the current rate of and research assistant (associate profes 694 ■ JADA, Vol. 110, May 1985
The dean of each dental school is selected by a committee of professors and as sociate professors to preside as the chief central administrator of academic and fi nancial affairs. The Swedish dean can be important in the dental school’s negotia tions with the government, university, and other agencies in obtaining needed resources, and as a public relations per son. However, the administrative author ity of a Swedish dean is small in compari son with North American counterparts. In the current revised administrative board structure, the dean’s position is often less influential than the Swedish professor ship. There are three academic boards within the dental schools: the Faculty Board, headed by the dean, which is responsible for research and postgraduate training; the Curricular and Academic Affairs Board, responsible for the basic dental curriculum and student affairs; and the Dental Care Board, which oversees the practical preclinical and clinical affairs of the dental school. All three of these boards of the dental “Fakultet” are di rectly responsible to a College Governing Board that forwards proposals to the Uni versity and College Authority, an arm of
the Ministry of Education. The Swedish Parliament and Department of the Trea sury then act on new proposals concern ing dental education or exert their own legislative force on the Ministry of Educa tion for changes in funding or dental edu cational priority. A 1977 parliamentary law called for administrative restructuring in all in stitutions of higher education, including dental colleges. It aimed to change the European tradition of professors’ mon opoly in the decision-making process within college academic boards, in an at tempt to democratize the institutions under the leadership of a College Govern-
PERSPECTIVES
ing Board that would consist of a number (John Hedlin, personal communication, mated that, given current market circum of informed business and union leaders, 1983) other than dental school faculty stances and the number of currently en academics, and students. Some say the evaluations of AT written final examina rolled dental students, 1,000 Swedish edict did not go far enough and are calling tions taken in the field. Still, some faculty dentists will not be able to find work in for another reform in which even more members express optimism and a will to Sweden (personal communication, Ste power would be vested in “middle-level” combine academic with dental practice.14 fan Salang, economist, SDA, November The younger members of the SDA have 1983). teachers and researchers in the formation of a representative assembly of academics had three main concerns about the resi For years, the dental association was below the level of professor.11'12 New dency program. Would it be counted as the loudest voice calling for dental school proposals in the Swedish parliament in formal education by other countries? enrollment cutbacks. In 1978, the dentists tend to create a single representative sen Would AT positions be distributed on an at the National Board of Health and Wel atorial body of teachers, researchers, and equitable basis to students desiring a fare also delivered a moderate proposal stu dents in stead of three separate academic boards. The Swedes are appar ently becoming more aware of centralization-decentralization issues and their The Sw edish dental gen eral residen cy program is influence on academic effectiveness and seen as a vital lin k betw een academ ia and the “rea l creativity. Students
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Currently, 380 dental students graduate annually. About half of Swedish dental students are female.10 The average age of graduating students is 25, but it is not uncommon to see students in their 30s and 40s. Dental students receive state guaranteed loans and accrue an average debt the equivalent of $13,000 for their living expenses in their 5 years of study. Dental school tuition is free. A mix of conservative and progressive values and pragmatism and idealism re flects not only the dental students’ values, but Swedish cultural values in general. By one account,13 Swedish dental stu dents have been characterized as being highly motivated to perform tasks well and readily conforming to rules that will help them do so (a high belief in authority), but these values appear to be chang ing rapidly since the time of that report, Almost all the students belong to the Swedish Dental Association (SDA) and membership in their local political Stu dent Union is compulsory. They are di rectly involved in policy-making groups in the dental schools. Issues within the schools, however, have not been as im mediate for the students as the issues of dentist unemployment and controversies surrounding the general practice resi dency (AT).
w o rld ” of dentistry.
choice of location? How would current graduates of the old 5-year curriculum be selected for jobs in competition with AT-graduated dentists? The National Board of Health and Wel fare now speculates that AT will be counted as part of the Swedish formal dental education14 in other countries— but there is no evidence of contacts estab lished with other European national health board ministries to prove this claim. The board believes that the SDA should make these contacts, as Sweden is not a member of the European Common Market. The educational status of AT out side Sweden is still on a “wait and see” basis. In the organizational planning for selection and distribution of dental resi dencies, a federation of Swedish county authorities independently decided to pursue a plan similar to the one in force for AT physicians. The dental association and the students were angry with county officials over the matter and found the county proposal unacceptable. The SDA had spent a year preparing a combined application-lottery scheme, testing it and working with the counties for their ap proval. It was believed that the scheme The AT residency was less complicated and more fair than Most dental students and dental faculty that of the county, which is based com believe that a general practice residency pletely on student merits, both academic is a sound idea. The Swedish dental gen and vocational.15 As AT positions are guaranteed to all eral residency program is seen as a vital link between academia and the “real ninth semester dental students, the al world” of dentistry. Dental faculties have ready unemployed dentists (about 200 as been instrumental in the education of the of January 1984), plus dentists finishing AT field educators, so contacts and coop temporary job placements, are finding the eration have already started. The AT pro- job market even harder than before. gram think-tank at the National Board of Health and Welfare hopes for continued Dentist unemployment cooperation. But according to the board’s dental bureau chief, no formal plans have Dentist unemployment predictions for been made for continuing collaboration Sweden are extremely high. It is esti
for cutbacks to the Swedish govern ment.16 Most observers fault Swedish politicians for their shortsightedness in not acting on these recommendations. Dentists working as county dental direc tors and serving as consultants to the Federation of County Councils have also continuously recommended a high edu cational output of dentists. The National Board of Health and Welfare has been ac cused of not standing together strongly enough with the SDA to convince the politicians about future jobless dentists. The board’s defense is that central politi cians cannot always be convinced of rec om m endations offered from board studies. Of course, younger dentists are the hardest hit, so they are becoming more politically active both in the SDA and in Sweden’s parliament.17 Many younger students are considering switching pro fessions, but other academic and health science professions, including physi cians, are cutting back their enrollments as well. Students’ attitudes range from guarded optimism to near depression over the future employment situation, but they are definitely beginning to question the wisdom of central authority. Many are willing to practice in either Third World projects, especially Africa and the Middle East, or W estern Europe and North America. Even with dental marketing schemes, early retirement ideas, relaxation of Swe den’s private practice “establishment control,”4 and dentist time-sharing plans to improve the prognosis, the Swedish government has recognized the need to make drastic cuts in dental enrollments. In 1983, the dental association offered a proposal to reduce enrollment in all four dental schools equally. The Treasury De partment instead made a dramatic propo Moore : DENTAL EDUCATION IN SWEDEN ■ 695
PE RSPECTIVES
Two noticeable features in Swedish society have had a significant impact on dental health care delivery and dental education— centralized government and a high degree of belief in authority.
sal to close Sweden’s second largest school, Goteborg—a move that would af fect 700 jobs. The shock of this proposal created a wave of protests and demonstra tions by faculty members, students, and staff. Goteborg, internationally known for its research in cariology and periodontol ogy, also received the written support of dental researchers from all over the world in the form of a letter campaign to the Swedish parliament. The threat of closure was dropped by overwhelming political opposition in the parliament and instead a smaller, less active school—Malmo— will be phased out in the next 5 years.
The future With the specter of unemployment hang ing over much of the health care sector in Sweden, some new alternative ideas are beginning to develop. The export of Swedish medical and dental personnel is one of these ideas. The Federation of County Councils has formed a company (SwedeHealth) whose main goal is to con tract and export Sweden’s internationally reputed health care to other countries.18 Swedish dentists are taking an active role in the company’s future—another possi ble solution to help decrease the un employment crunch. There are also some plans for exportation of dental education systems. The decreasing enrollment in under graduate dental programs is changing the role of the dental schools and their societal function. The Swedish dental school faculties plan to expand post graduate and continuing education for practicing dentists in the future. The vi sion is to provide a “learning center” to help retrain clinicians to meet the de mands of a rapidly changing dentist role. For example, now that children’s dental health care in Sweden is excellent and well covered, there is growing emphasis on care for the elderly—part of a larger trend within Swedish society to improve the quality of life for the elderly. Dental school faculties want to prepare the den tal practitioner for the coming shift to gerontology. Some members of academic faculties are also trying to promote a new health policy and dentist image to the public: the dentist as the diagnostic pro fessional who is most easily in the posi tion to provide some simple preventive 696 ■ JADA, Vol. 110, May 1985
medical screening measures such as blood pressure checks and health-history taking. The Swedes tend to see dentistry becom ing more lik e a sp e cia lty of medicine— stomatology. Whatever the future of dentistry in Sweden, the impor tance of the general practice residency as a communication link between academia and the field practitioner could be an ini tial step in a continued and expanding dialogue to create a flexible dental corps capable of meeting social needs.
Conclusions Centralized governmental power and a willingness to believe in authority are culturally rooted in Sweden’s history of popular patriarchal kings. In recent years, however, the government has met the demands of the Swedish people for more decentralization as a continuation of the democratic process. Central authority has created an organized and comprehensive dental healtb care system that makes high-quality dental services available to all Swedish citizens. However, in the cur rent Swedish dental education situation, the shock of possible dental school clos ings caused by increasing dentist un employment points to the need for central government to respond more rapidly to dental workforce estimates provided both by its advisory boards and the Swedish Dental Association. The Swedish professorial monopoly in academic decision-making is also being challenged so that dental and other higher education can become more effi cient and creative. In times of crisis, new ideas and innovations such as Sweden’s general practice residency can provide solutions with far-reaching implications for the future of dentistry.
____________________________ JBCS4 Essays o f opinion on current issues in dentistry are published in this section of ¡ADA. T he opinions ex pressed or im plied are strictly those of the authors and do not necessarily reflect the opinion or official policies or position of the A m erican Dental Associa tion.
The author thanks Drs. Thore Martinsson, John Hedlin, E lof Petterson, Per Odman, Gorel Muller, and colleagues at the Sw edish Dental Association for their assistance in the preparation of this manuscript. Dr. Moore, a former instructor at Ohio State Univer
sity College of Dentistry, spent 2 years in the Sw edish Dental Public Health Service and lived in Denmark for several years since 1976. He researched this article w hile a guest researcher supported by the Royal Den tal College, Aarhus, Denmark, and is now a National Institutes of Health dental behavioral research fellow at the University of W ashington. Address requests for reprints to Dr. Moore, School of Dentistry, depart ment of community dentistry, University of W ashing ton, B -509 Health Scien ce Bldg, SM -35, Seattle, 98195.
1. Dentistry’s blueprint for the future. A report on the strategic plan developed by the A ssociation’s Special Committee on the Future of Dentistry. JADA 1 0 8(l):20-30, 1984. 2. Bawden, J. Dental health care in Sweden, na tional plan covers everyone. Dent Surv 52(9):21-28, 1976. 3. Ahlberg, J.E. Dental care delivery in Sweden. In Ingle, J., and Blair, P., eds. International health care delivery systems: issues in dental health policies. Cambridge, MA, Ballinger Publishing Co, 1978, pp 137-145. 4. Moore, R. T he Swedish national dental insur a n c e a n d d e n t a l h e a l t h c a r e p o l i c y . JA D A 102[5):627-630, 1981. 5. Scott, F.D. Sweden: the nation’s history. M in neapolis, University of M innesota Press, 1977, pp 118-300. 6. A ndersson,I.,and W eibull.J. Sw edish history in brief. Sodertalje, Sweden, W iking Tryckeri A B, 1980, pp 20-23. 7. Boucher, L. Tradition and change in Sw edish education. Exeter, Great Britain, Pergamon Press, A. W heaton and Co, Ltd, 1982, pp 1-20. 8. Ito, H. H ealth p olicy dynam ics and the de velopment of modern democracy: the development of the health care system and modernization in Den mark and Sweden, 1850-1950. Thesis, University of Copenhagen, 1981, pp 94-161. 9. H a n sso n , A. O d o n to lo g isk a F o r e n in g e n s F estskrift T ill M inne av O .F .’s 50-ariga tillvaro. Stockholm , Caslon Press, 1938, pp 7-19. 10. Den langsiktiga tillgangen och efterfragan pa ta n d v a rd sp e rso n a l— re v id e ra d e b e d o m n in g a r. Socialstyrelsen, Stockholm , 1981, pp 17-37. 11. Premfors, R., and Ostergren, B. System s of higher education: Sweden. New York, Interbook, Inc, International Council for Educational Development, 1978, pp 93-119. 12. Ruin, O. Battre sam ordning, overblick och lederskap i hogskolan under omprovning— Fjorton debatt inlagg om hogskolan i den ekonomiska krisen. In Furumark, A., and och W ahlen, S., eds. UHA Skriftserie, 1983. Liber Tryck, Stockholm , 1983, pp 107-118. 13. Bawden, J.W. An experience in dental educa tion in Sweden. J Dent Educ 4 0 ( ll) :7 1 9 - 7 2 3 ,1976. 1 4 . A T p a ta p e t e n . T a n d l a k a r t id n in g e n 75(19) ¡1047-1048, 1983. 1 5 . L a n d s tin g s fo r b u n d e t: R e k r y te rin g o c h anstallning av AT-tanklakare. Tandlakartidningen 75(17):909-911, 1983. 16. Den fram tid ig e efterfrag an pa tan d v ard s p e rso n a l. S o c ia ls ty r e ls e n s T a n d v a rd sp e rso n a l Utredning Rapport no. 3. Stockholm , Ds.S. 9 ,1 9 7 9 . 17 . H u n g rig a ta n d la k a re -fa rlig a ta n d la k a re . Tandlarkartidningen 7 5 (7 ):3 9 4 -3 9 7 ,1983. 18. Salj vard utomlands. Uppsalas Nya Tidningen, 10. Nov, 1983, p 10.
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