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1. 1.3 Development of professional competences
Alphons Plasschaert1
Marcia Boyd2
y, Sandra Andrieu3
z, Robin Basker4
z, Roberto J. Beltran5
z,
Giorgio Blasi6
z, Barbara Chadwick7
z, David Chambers8
z, Cecilia Christersson9
z, Fernando
Haddock10
z, Thomas Kerschbaum11
z, Stan Kogon12
z, Gyorgy Kovesi13
z, Fusun Ozer14
z,
Hari Parkash15
z, Juanita E. Villamil10
z, Richard I. Vogel16
z and Anne Wolowski17
z
1
University of Nijmegen, the Netherlands; 2
University of British Columbia, Canada; 3
University of Louisiana, USA; 4
University of Leeds, UK;
5
Universidad Peruana Cayetano, Peru; 6
University of Genoa, Italy; 7
University of Wales Cardiff, UK; 8
University of the Pacific, San Francisco,
USA; 9
University of Malmö, Sweden; 10
University of Puerto Rico, USA; 11
University of Cologne, Germany; 12
University of Western
Ontario, Canada; 13
Semmelweis University Budapest, Hungary; 14
Selcuk University, Konya, Turkey; 15
All India Institute of
Medical Sciences; 16
New York University, USA; 17
University of Munster, Germany
Competency-based education, introduced approximately
10 years ago, has become the preferred method and generally
the accepted norm for delivering and assessing the outcomes of
undergraduate (European) or predoctoral (North America) dental
education in many parts of the world. As a philosophical
approach, the competency statements drive national agencies
in external programme review and at the institutional level in the
definition of curriculum development, student assessment and
programme evaluation. It would be presumptuous of this group to
prescribe competences for various parts of the world; the appli-
cation of this approach on a global basis may define what is the
absolute minimum knowledge base and behavioural standard
expected of a ‘dentist’ in the health care setting, while respecting
local limitations and values. The review of documents and dis-
tillation of recommendations is presented as a reference and
consideration for dental undergraduate programmes and their
administration.
Key words: competency statements; dental competencies.
ßBlackwell Munksgaard, 2002
Introduction
COMPETENCY means the behaviour expected of begin-
ning independent practitioners. This behaviour
incorporates understanding, skills, and values in an inte-
grated response to the full range of circumstances encoun-
tered in general professional practice. This level of
performance requires some degree of speed and accuracy
consistent with patient well-being but not performance at
the highest level possible. It also requires an awareness of
what constitutes acceptable performance under the circum-
stances and desire for self-improvement (1).
The articles and offerings in the bibliography for this
subsection have been reviewed. They represent the
efforts and working documents of various groups from
the European Union, South America, the USA and
Canada. Overall there are more similarities than there
are differences. Competency documents relate directly
to requirements that have been set out by dental educa-
tion institutions or dental professional organizations,
for example, Directives of the European Union, the
General Dental Council or the Commissions on Dental
Accreditation in the USA and Canada. More recently,
these dental professional agencies have adopted a
competency-based approach and these are guiding
documents that outline baseline or reference standards
for dental educational programmes. Programmes
therefore may be subject to self-assessment and/or
be evaluated by the agency against these articulated
standards.
Competency statements describe the knowledge,
skills, attitudes and values that a dental graduate must
have, i.e. the requisite competence to enter into the safe,
independent practice of dentistry. As ‘safe beginner’
standards, the competency statements represent the
‘minimum’ or ‘lowest common denominator’ expected.
However, they are not meant to be so prescriptive as to
stifle further curriculum growth in any area where
Eur J Dent Educ; 6 (Suppl. 3): 33–44
Printed in Denmark. All rights reserved
33
Chairperson.
yRapporteur.
zGroup member.

2. programmes wish to move to higher levels. As out-
comes of the dental educational programmes, they also
make a statement about what is valued by the institu-
tion and makes the programme publicly accountable
for what the degree represents. Additionally the com-
petency document creates the framework for the learn-
ing experiences and the focus for student assessment. It
is a dynamic document that should be fine-tuned based
on feedback from the outcomes of student assessment
and programme evaluation.
The organization of the competency documents
has taken different formats, although all have an intro-
ductory rationale and explanation. Some are a sequen-
tial listing of statements without groupings. The
most common approach, however, is to identify first
broad groupings, general categories or ‘domains’.
Within these domains are ‘major’ competencies. These
statements encompass the integration of basic bio-
medical, clinical and behavioural sciences and are
therefore broad and multidisciplinary in nature. Next
follows the ‘supporting’ competencies, which are more
specific in their description particularly in terms of
foundation knowledge and skills. While not all docu-
ments present three levels, as they are structured, each
level supports the other and underpins the systematic
approach to defining the competency-based approach.
This format is typical of competency documents devel-
oped at the local dental institutional level. The
‘national’ documents such as those developed in the
USA and Canada provide only single sequential state-
ments that were meant to provide a template for insti-
tutions to use to develop their own competency
documents according to their local strengths and cul-
ture. On the other hand, the European Union docu-
ment, as a ‘national’ type document, is more expansive
and has set forth six ‘clinical competences’ that have
supporting statements along with defined prerequisite
knowledge and behaviour. Some areas of competence
are stated as ‘desirable but not mandatory for all Euro-
pean Union countries’.
Compared to earlier standards documents, there
is now an increased emphasis on decision making,
critical thinking, behavioural sciences, professional-
ism, lifelong learning, information management,
comprehensive patient care and understanding limita-
tions in ability to provide quality care. The infrastruc-
ture of cognitive, psychomotor and affective curricular
components and educational methodology that pro-
vide the foundation for the delivery of a dental pro-
gramme that will graduate competent general dentists
is seen to be more similar than dissimilar. Differences
may be only semantic. However, it would be useful
to establish a ‘glossary’ of terms where perceived or
real differences in the interpretation, or use of terms,
exists. For example, ‘examination’, ‘evaluation’, ‘assess-
ment’ are all words that can be applied to and are used
to determine student learning. Some, however, use
each of these words in specific situations and circum-
stances and believe they are used inappropriately in
other circumstances. Another example are the words
‘competences’ and ‘competencies’, which are syno-
nyms.
Regardless of any real differences, competency-based
documents and competency-based education has pro-
vided a common ground for reflection, discussion and
growth. The Prague meeting has provided yet another
opportunity for ‘experts’ and interested others to define
how this philosophy can be translated into useful and
realistic expectations for the members of the global
dental education community.
Parameters within which the section has
decided to work
Using the Chambers definition (1), the working group
decided to divide the knowledge areas into skill group-
ings and subsets in order to address the task. Each
group member worked in a team to consider headings
numbers 4–8 of the index for that grouping of skills. The
groupings were set out as follows:
Clinical skills
Information-gathering
Diagnosis
Treatment planning
Treatment and prevention
Evaluation of treatment
Management skills
Communication
Administration
Team issues
Health and safety
Ethics and jurisprudence
Reflective/critical thinking
The task of each subgroup was to:
Review the existing documents in the bibliography.
Draw from those examples to illustrate important
foundation competences that relate to the various
sections as a basis for further refinement or as a
template or ‘spring board’ for others to use locally
to develop competency statements according to their
own special culture, resources, strengths, etc.
Identify problems; solutions, barriers.
Reference documents as appropriate, if available.
Plasschaert et al.
34

3. Best practices and innovations
In this section the results of the procedure as described
above are presented.
Clinical skills
Information-gathering
The collection of information from the patient and other
sources such as health-care professionals and appro-
priate reference material forms the basis for diagnosis,
risk assessment and subsequent treatment planning.
With respect to ‘information-gathering’ and ‘best
practices’, the competency statement documents of
the European Union Advisory Committee, the
AADS/ADEA and others are very similar with, at
times, greater specificity given in any one area by
one or other documents. The degree of specificity to
be included can be debated. The intent of what follows
is to provide a guideline for best practices that can also
be applied to different regions as well as emerging
countries.
Information-gathering should help the students to:
1. Establish a rapport with and educate the patient so
that he/she understands the rationale for the infor-
mation being asked and the examination that will
be performed.
2. Assess general physical and behavioural status
through observation of and communication with
the patient.
3. Evaluate the need for and, when appropriate and
possible, in consultation with other health care
professionals, obtain results of diagnostic tests to
help evaluate the systemic status of a patient.
4. Obtain the patient’s chief complaint and history of
chief complaint as well as the patient’s expectations
for resolution.
5. Obtain the pertinent medical, family and psycho-
social histories.
6. Obtain a pertinent dental history.
7. Solicit the patient’s concerns about appearance.
8. Perform a head and neck examination.
9. Recognize differences among normal, abnormal
and pathological conditions, as well as aetiological
and/or risk factors that may contribute to disease,
by performing an intraoral examination that
includes the following:
a) oral and oropharyngeal soft tissues;
b) teeth and pulp;
c) supporting periodontal tissues; and
d) occlusion and its muscular-skeletal system.
10. Determine the need for, and when possible, obtain
and evaluate other diagnostic tests such as radio-
graphs, diagnostic casts and other appropriate
diagnostic aids/tests.
The above suggestions for information-gathering
should apply not only to best practices, but also to
differences among regions and emerging countries. It is
recognized that differences in scope of the practice of
dentistry among different regions will determine what
systemic or oral diagnostic procedures are appropriate
to be prescribed, performed or assessed by a dentist.
Similarly, it is recognized that economic barriers may
influence the range of diagnostic tests available to the
practising dentist.
Diagnosis
It is clear that a great deal of thought, effort and
expertise were given the authorship of the competency
statements referenced in the bibliography section of
this report.
Over the past few decades, dentists have been recog-
nized as being primary health-care providers and
integral members of the health professions team
responsible for the overall health of the public. As such,
the responsibility of the dentist goes beyond the diag-
nosing of oral diseases. It should, in addition, include
the recognition of signs and symptoms that may indi-
cate the presence of a systemic disease that the patient is
unaware of, as well as recognition of factors that put the
patient at risk for systemic disease. Although the com-
petency statements of both the AADS/ADEA and the
EuropeanUnionAdvisoryCommitteecanbeinterpreted
to include this philosophy, neither states it explicitly.
The interrelationships of oral disease and its therapy
with systemic health and well-being are multiple. The
European Union statement (subcompetency 2.4.1)
recognizes the importance of the presence of systemic
disease and its treatment in the delivery of dental care.
The AADS/ADEA statement (competency 38) recog-
nizes the importance of diagnosing oral manifestations
of systemic disease. Neither statement, however, states
explicitly that a competent clinician should assess the
affects of oral disease on systemic well-being.
The detection and prevention of oral cancer is among
the most important services that a dentist can offer to a
patient. Although included under competences in most
documents, including the AADS/ADEA and the Eur-
opean Union statements, this disease is not mentioned
explicitly . It should be defined more clearly.
Treatment planning
Most competency documents are given in the refer-
ence list in one way or another. However, there are
substantial differences between some of the documents
in the level of detail to which the competency is defined.
35
Development of professional competences

4. The European Union document states only ‘a long-term
treatment plan has to be formulated’. In contrast the
Canadiandocumentstates,‘developanappropriatecom-
prehensive, prioritized and sequenced treatment plan
based on the evaluation of all relevant diagnostic data’.
As far as treatment planning is concerned, any
national competency document should cover this issue
as a separate and important competency statement for
the graduating student. The level of detail should be
more global on a national level when compared to the
regional or dental school level. The competency docu-
ment of the Cardiff dental school is a good example of
best practice at the local dental school level.
It is recommended as a global standard for any
competency statement regarding treatment planning
that the patient should be involved, in one way or
another, in the decisions to be made in the treatment
planning process.
It is to be noted that some documents have stated
explicitly that written informed consent for the delivery
of the mutually accepted treatment should be obtained
from the patient (Maryland Dental School). This may
become increasingly common practice in the future.
Total patient care or comprehensive patient care should
be addressed in the competency.
Treatment and prevention
Treatment, in the context of this report, is defined as
any action resulting from the treatment plan in order to
put the treatment plan into effect. It may involve pre-
ventive measures by the patient or the dentist/hygie-
nist, treatment procedures or referrals.
It is clear to most dental educators that competences
related to dental treatment form the heart of the matter.
However, if one analyses the available competency
documents, there are differences with respect to:
the level of detail;
the way of formulating and organizing competences;
and
the expected level of competency.
When schools develop a competency document for
their own use, it is recommended that they consider the
level of detail in formulating competency statements.
Another important dimension of clinical skills, which
deserves highlighting, involves prevention. The ability
to prevent oro-dental diseases should be given due
importance in the development and assessment of com-
petency. This particular section aims at analysing exist-
ing documents on development of competences for
dental graduates regarding treatment/preventive skills
with special consideration for emerging countries.
In most of the existing documents listed in the
reference section, the curative aspect has been given
priority. The ability to understand the positive and
negative health behaviour and the ability to generate
awareness in the population for prevention has not
been given adequate importance.
Evaluation of treatment
The intention of the evaluation of clinical skills is to
provide the necessary feedback procedure in order to
analyse the outcome of patient treatment. This can lead
to alternative or future treatment options and lead to a
deeper understanding of the value of:
critical thinking and self assessment;
participation in quality and peer evaluation systems;
and
life-long learning as an integral part of professional
behaviour.
Therefore, ‘best practices’ related to the evaluation of
clinical skills would involve:
1. Use of formative and summative evaluation by tea-
cher/clinicians.
2. Self- and peer-evaluation by students.
Because it is often difficult for students to evaluate the
outcome of the treatment delivered during their rela-
tively short period of predoctoral education, the fol-
lowing solutions are suggested:
1. Learning from a series of well documented case
findings.
2. Learning from the evaluation of ongoing cases per-
formed by other students or faculty members.
The competency statements from the University of
the Pacific School of Dentistry and the University of
Puerto Rico provide a foundation reference for such
competency statements.
Management skills
Communication
Competency statements related to communication are
present in every document—national or school-based.
Communication is seen as central to the effective prac-
tice of dentistry supporting diagnosis, patient education
and motivation, treatment and overall management.
Analysis of the documents available would suggest
that global ‘best practice’ would include the following:
encompasses communication between the clinician
(student or dentist) and patients, peers, staff, other
health-care professionals and the community at
large;
must involve effective verbal and written commu-
nication with all patient groups (e.g. children,
elderly, patients with disabilities, etc.) regarding:
a) medical, dental and psychosocial histories; and
b) patient goals, values and concerns.
36
Plasschaert et al.

5. Administration
From analysis of the European Union and US docu-
ments (national and dental schools) it is possible to
group listed competences under Administration and
Information and Communication Technology (see else-
where in the report for ICT implications).
Best practices should include matters related to:
Personnel
staff management (e.g. receptionist, auxiliaries,
laboratory technicians); and
appropriate utilization of staff.
Patients
scheduling, records, recall system; and
delivery of care for patients with special needs (e.g.
disabled, medically compromised, institutionalized,
etc.).
Legal
medical-legal record, confidentiality;
management of radiation and biomedical wastes,
infection control;
licensure requirements and jurisprudence; and
government and social policies.
Business skills
accounting, insurance, setting up practice/organiza-
tion, equipment and supplies, banking, billing and
payments, contracts.
Personal management
balancing personal and professional life (e.g. stress
management, occupational health and safety, life-
long learning, etc.).
Team issues
In this section ‘team’ implies the clinical team involved
in the provision of dental/oral care. A review of docu-
ments related to the dental team suggests the following
general principles:
The composition of a team will vary from country to
country depending upon legislation, economic cir-
cumstances, the pattern of oral and dental disease,
current attitudes to dental auxiliaries/dental ancil-
laries/professions complementary to dentistry
(whichever terminology is used).
If a team structure exists, the dentist should be leader
of the team and be ultimately responsible for diagno-
sis, treatment planning and the quality of dental care.
A country’s legislation may allow certain dental
auxiliaries to practise independently of the dentist
or dental team.
The ‘best practice’ in the undergraduate dental pro-
gramme should ideally include (1–3):
how to become an effective team leader;
how to prescribe and delegate tasks; and
awareness of professional and legal responsibilities.
Ideally, within the teaching environment there
should be facilities to allow dental students to:
learn assisted operating techniques;
be able to perform the competences that are dele-
gated to the auxiliaries;
receive some instruction from auxiliaries with teach-
ing experience;
work alongside auxiliaries; and
learn how to motivate and manage team members.
Barriers to establishing the teaching and practice of
team dentistry include:
financial restrictions leading to, for example, insuffi-
cient dental nurses for assisted operating to be prac-
tised;
the teaching environment may not provide sufficient
facilitiesfortrainingothermembersofthedentalteam;
insufficient space within the dental school/hospital
to allow the practice of team dentistry;
the national legal framework may not permit the
establishment of some members of the dental team.
For example, the dental hygienist is not recognized in
some countries; and
failure of some groups within the dental profession to
recognize the benefits of team dentistry to the care of
patients.
The following are suggested as possible solutions:
Successful lobbying by groups and even individuals
of, for example, politicians, fund holders, profes-
sional bodies.
Establishing or developing teaching opportunities
outside the dental school/hospital (e.g. use of public
health clinics).
Dealing with illegal practice by the formal establish-
ment of training programmes, schemes of assessment
and formal registration of all auxiliary groups.
Health and safety issues
The practice of clinical dentistry within dental schools,
from the care-giver’s as well as the patient’s perspec-
tive, should exemplify all the principles of ethical
practice under safe, appropriate, hygienic and envir-
onmentally friendly clinical conditions (2).
The education of dental students in this important
area, at the very least, must satisfy the legislative
demands of the country and the dental regulating body
in which the dental school is situated.
Knowledge of the following topics should be
regarded as a minimal requirement (1–5):
standards of personal and professional behaviour;
dealing with cross-infection and transmissible dis-
eases;
radiation protection;
37
Development of professional competences

6. the conditions necessary for the safe provision of
sedation and general anaesthesia;
dealing with medical emergencies; and
employment, training and care of staff.
Health and safety cannot be separated from ethical
issues. The following issues have an important Health
and Safety dimension as well as a strong ethical foun-
dation (5):
problems of alcohol and/or drug dependency;
confidentiality;
informed consent;
indemnity against claims for professional negligence;
and
handling complaints.
While the above lists represent the basic minimum
knowledge, which all new graduates should possess, it
is recognized that there will be variations in the level at
which these standards are set. One way of encouraging
convergence is by establishing education programmes
which raise public awareness and expectations.
An analysis of existing documents from the emerging
countries perspective is as follows.
Both US and European Union documents stress infec-
tion control practices in dentistry but the following
aspects remained untouched:
ethical considerations in treating a patient with com-
municable diseases;
the limitations of a dental professional suffering from
blood-borne infection;
ethical considerations for maintaining confidentiality
about a disease from which the patient or profes-
sional is suffering;
legal considerations of the same conditions; and
the patient’s rights regarding iatrogenic damage
(physical/chemical/infections) inflicted by the pro-
fessional?
Ethics, jurisprudence
Ethics is generally understood to be the choice of right
or wrong behaviour based on principles or beliefs about
how the world should be. Jurisprudence refers to the
laws and regulations that must be obeyed to avoid
penalties. Giving the patient the best care possible
through the aid of an unlicensed auxiliary may be
ethical, but it violates practice regulations. Violating
a patient’s confidentiality is usually unethical, and may
also be a legal violation.
Ethics and jurisprudence are ‘soft’ areas in dentistry.
It is possible to set a test to see if a student ‘knows’
ethical principles or the applicable practice act, but it is
not possible to set a test to see if that same student will
act ethically or consistently with principles of jurispru-
dence. At least in the American experience, licensing
jurisdictions and practice boards claim that more dis-
ciplinary problems are caused by deficiencies in ethics
and jurisprudence than in all technical areas combined.
Reflective/critical thinking
Reflectivethinkingorproblemsolvingreferstorecogniz-
ing that an approach is not ideal, a search for alternatives
and information, choice of new approaches against some
standard, and evaluation of the new outcomes. Critical
thinking is normally understood in a more narrow sense.
Itistheabilitytodetectflawsinthemethodsusedtojustify
claims or in the claims themselves. Students can critique
the research methods of articles in the literature, but may
not be able to select a good product or procedure or even
understand that one is needed.
Reflective thinking and problem solving are critical
competences in a profession where new knowledge is
being generated and where competing claims about
what is best are advanced.
Impact of information and
communications technology
In general, this area will continue to grow and provide
new and exciting opportunities for dental education
with all personnel at all educational levels, including
continuing competence in practice. The potential use
for the technology is huge, ranging from local to distant
collaborative and cooperative education, further
shrinking the global education community.
Some examples would include, but are not limited to,
and are not in hierarchical order:
Access to information and consultation.
Web-based courses and evaluations at all levels and
including all personnel involved in the delivery of
dental care.
Web-based courses can be available worldwide so
that expertise in one place is shared (with the grow-
ing crisis in recruitment of future faculty, this will
become increasingly more important and has the
benefit of cost containment).
Certification and licensure examinations at all levels
(computer-based, real time simulations, case-based
focus, etc.).
Accountability in continuing education courses with
pre- and post-evaluation to demonstrate knowledge
acquired and the ability to utilize distance education.
Electronic records for patients (local and worldwide
capability).
Centralization for pre- or post-doctoral education
serving remote sites with ‘outreach’ in clinical set-
tings.
38
Plasschaert et al.

7. Use by regulatory agencies for ‘diagnostic purposes’
of continuing competence of dental health care per-
sonnel and subsequent remediation—further devel-
opment of ‘real’ simulations for the teaching
environment—the virtual dental school.
Technology supports information management and
the movement toward evidence-based practice.
As a limited example of the effective use and
application of information and communication technol-
ogy in the area of communication, consider the follow-
ing:
Patients can:
communicate with the dental office;
receive information;
receive education; and
evaluate treatment options (e.g. costs, time, bioma-
terials, etc.).
Dentists can:
gather data and transfer of patient information;
consult easily with experts;
access the literature, continuing competency materi-
als; and
develop treatment alternatives and make decisions.
The educational programme can:
test and evaluate student learning;
improve communication between students and
teachers; and
use ICT for patient cases/reports (histories, videos,
etc.).
How to converge towards higher global
standards
Realizing the sensitivity of the global context in
which this is presented, the working group, following
discussion of best practices and analysis of the refer-
enced documents outlining competency for the prac-
tice of dentistry, offers the following list of ‘global
competences’ as a basis for discussion and/or devel-
opment.
Beyond the national competency guidelines that
currently exist, it is both recognized and appreciated
that competences need to be developed by individual
institutions based upon societal needs, customs and
applicable government regulations. Nevertheless, irre-
spective of regional differences, there are indeed core
global competences. These ‘core’ competences are
neither designed to be inclusive of the needs of all
societies nor to represent best practices. They are meant
to represent the general knowledge base, skills and
values expected of a dentist wherever he or she may
practice.
General skills
1. Apply ethical principles in all aspects of practice.
2. Provide empathetic care for all patients.
3. Apply the principles of jurisprudence to the practice
of dentistry.
4. Use scientific knowledge in the management of oral
care.
5. Understand the need for lifelong learning.
Practice management
1. Implement and monitor infection control and health
and safety programmes according to regional stan-
dards and regulations.
2. Establish and maintain patient records.
3. Recognize limitations of expertise.
Public health
1. Understand the pattern of oral disease in society.
2. Understand the needs of society with respect to
prevention and treatment of oral disease.
Communication
1. Establish rapport with the patient.
2. Communicate effectively with patients and collea-
gues.
Diagnosis and treatment planning
1. Assess the patient’s medical and psychosocial status
and use this information in planning and carrying
out treatment.
2. Perform an oral examination.
3. Diagnose hard and soft tissue diseases of the oral
cavity and contributing aetiological factors.
4. Recognize predisposing factors that require inter-
vention to prevent disease.
5. Develop a treatment plan.
6. Obtain the patient’s consent for therapy proposed.
Treatment
1. Provide patient education to maximize oral health.
2. Perform preventive oral health procedures.
3. Manage pain and anxiety.
4. Manage oral diseases.
5. Perform procedures to restore/replace the struc-
tures of the mouth to appropriate form and function.
6. Manage complications that may arise from oral
health care.
Issues and insights in the application of
competences in a global context
1. Each entity writing competency statements should
begin by consulting available resources, both repre-
sentative sets of competences developed by other
39
Development of professional competences

8. groups, and the general literature on competency.
This involves:
a) critical assessment of the environment;
b) more complete identification of problems; and
c) better understanding of the issues and ownership
by participants, analysis of local strengths, weak-
nesses and resources.
2. Competency statements should cover all three
dimensions of performance:
a) knowledge and understanding;
b) skill in application; and
c) supportive values.
A special challenge exists in the areas of ethics and
professionalism and of critical thinking to make
certain that competency statements are written to
cover all three dimensions and that opportunities
exist for the evaluation of students in all three
dimensions of each competency prior to graduation.
3. It is desirable to retain the distinction between com-
petences and teaching objectives. Some of the com-
petences in the areas of ethics and professionalism
and of reinterpretation are discouraged. The benefits
of full participation in the development of critical
thinking may require little ‘teaching’ in the tradi-
tional sense. Opportunities should be made avail-
able for students to demonstrate their competences
in these (and related areas such as communication
and patient management skills) in realistic (clinical)
contexts. Formal teaching separate from clinical
work may be required only in those cases where
students demonstrate deficiencies.
4. The contributions of faculty (or staff) beyond the
formal curriculum is especially important in support
of the competences of ethics and professionalism
and critical thinking. Competency statements should
therefore include ensuring a sound match with the
demands of the organizations and schools and faculty
behaviour within the context of environmental con-
straints and incentives whilst striving to ensure that
these promote the requisite competences.
5. Although there are reasons to divide competency
statements into categories (such as diagnosis, treat-
ment, and professionalism), caution is needed in
applying this practice. Some competences, such as
obtaining informed consent or lifelong learning, cut
across categories. Categories that correspond to exist-
ing disciplines or other models of teaching may lead
to a greater emphasis on teaching than on learning.
6. Not all competences lend themselves to objective
evaluation. ‘Objective’ standards should not be a pre-
requisite for identifying competences in such areas
as ethics and professionalism or critical thinking.
There is evidence in the literature that professional
judgement has high interrater consistency and strong
predictive validity (in fact, the psychometric proper-
ties of evaluation by means of professional judge-
ment may be better than those for ‘objective’ and
discipline-based evaluation). When identifying com-
petences and their evaluation, care should be taken
to ensure that all affected groups are engaged.
7. Defining and evaluating competences should be
undertaken in context. Where the career patterns of
recent graduates are known, this information should
be considered in defining the understanding, skills,
and value (needs) dimensions of practice. Where the
practice patterns of recent graduates are not well
understood, research in this area is indicated.
Important regional and continental
differences
When considering the development of competences for
a specific region, sensitivity must be directed toward
differences related to the following areas, again not
presented in a hierarchical fashion:
language (e.g. interpretation, terminology, vocabu-
lary);
cultural values and differences (e.g. gender, lifestyle,
religious);
legal and governmental regulations;
local norms (e.g. public opinion);
economics (e.g. infrastructure, manpower, facilities);
social policy; and
access to care.
It is acknowledged that given the origin of the group
in attendance there are likely to be many additional
important regional and continental differences not
identified in the above listing.
Considerations not otherwise covered
See caveats stated in the sections ‘How to converge
towards higher global standards’ and ‘Important regio-
nal and continental differences’.
Implications and potential for emerging
countries
As stated elsewhere in this report there are many
considerations, issues and suggestions that face the
development, implementation and evaluation of
competences in the dental education and workforce
environment. It is hoped that this report can be used
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Plasschaert et al.

9. to their best advantage and will provide a basis from
which emerging countries can move toward a compe-
tency base that is appropriate to their culture and
practice.
The following is a personal statement and opinion
provided by Dr Parkash, New Delhi, that deals more
specifically with the implications and limitations in that
part of the world.
The level of oral health in most developing countries
belonging to the South-east Asian Region is highly deplor-
able. The growing incidence of dental caries, periodontal
diseases and malocclusion and a high prevalence rate of oral
cancer have resulted in an alarming situation. The reasons
for this increasing trend are attributed to various factors,
the most significant of which is the inadequacy of training
of dental professionals. The challenge facing the emerging
countries has been therefore to provide quality training
while balancing the obstacles presented from both the
educational system and the external factors, which are
beyond the control of the dental schools. The most impor-
tant limiting factors within the educational system are the
outmoded curriculum, lack of infrastructure, physical
facilities and motivation for providing quality training.
The curriculum at present overemphasizes the curative
aspect at the cost of preventive and health promotion
aspects. There is no clear delineation of the objectives of
training. There is an urgent need for delineating the
objectives and skills required for a basic dental graduate.
The curriculum is largely individual, case orientated rather
than community orientated. The discipline-based format of
curriculum creates disjointed information rather than an
integrated and holistic picture.
The assessment of training is largely subjective consisting
of traditional essays and long cases where the whims and
fancies of the examiners play a major role in deciding their
merit. There is no proper weighting or continuous assess-
ment of the students based on day-to-day performance.
Development and testing of clinical skills takes second
place to the assessment of theoretical knowledge.
Teaching in dental schools is largely didactic, with inade-
quate emphasis on practical training and innovative
approaches to learning. The lecture is still the predominant
mode of conveying knowledge. The teachers are not well
equipped to utilize the modern educational tools and
technology, as a result of inadequate opportunities for
teacher training. The teachers are not motivated to give
their best to the students because of a poor incentive
structure and poor facilities for further learning.
The extra-mural factors which affect the quality of training
are: lack of co-ordinating mechanisms between dental
schools and the health care delivery systems, including
government, private sector and NGOs. What is required
urgently is a partnership between dental schools and other
agencies that are essential to providing comprehensive oral
care to the communities.
Suggested strategies for action
The single most important step in introducing compe-
tency-based learning is to define the goals and objectives
of training, and to delineate, at every level, the essential
skills expected of a dental graduate. The competency state-
ments, prepared by consensus, by both professionals and
consumers would go a long way in streamlining both
teaching and assessment. Attempts toward curricular
changes should be marked by more opportunities for com-
munity-orientated training and problem based learning,
with an integrated approach.
The assessment system largely holds the key for determin-
ing the learning styles of the students. It is therefore
necessary for the assessment system to be objective so as
to include a variety of tools and techniques for a compre-
hensive evaluation of competency.
Necessary facilities should be provided for equipping the
dental schools with modern facilities of Information and
Communication Technology (ICT). This would revolutio-
nize the process of teaching and learning. Modern Infor-
mation and Communication Technology has tremendous
potentiality to offer in terms of multimedia, web-based
training, virtual reality, tele-medicine, all of which should
be fully exploited in the future.
No technology can replace quality teachers and excellence
in instruction. Avenues should be provided to recruit, train
and re-orientate the dental teachers to accept new chal-
lenges. Provision should be made for organizing continu-
ing education programmes utilizing both direct and
distance learning opportunities. Incentives and recogni-
tion for excellence in teaching are obviously necessary for
motivating the teachers to ensure quality instruction.
Issues for emerging countries
Prevention
The emerging countries do require special considera-
tion with respect to prevention because these countries
lack sufficient resources in terms of infrastructure,
manpower, equipment and finances to provide curative
treatment to all.
The prevention of dental diseases requires changes in
the personal behaviour (oral hygiene procedures) and
also social behaviour such as tobacco chewing, etc.
Therefore, the preventive approach requires public
awareness and education to motivate change in perso-
nal and social behaviour. The dental graduate should
be able to:
Identify positive and negative behaviour with
respect to oro-dental health—motivate people
regarding oro-dental health.
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Development of professional competences

10. Generateawareness regardingoro-dentalhealth inthe
community—identify pattern of behaviour change.
Deliver convincing evidence of the role of prevention
at individual, group or community level.
Realize the dentist’s role responsibilities in the local
society.
Be effective in communication skills and interperso-
nal skills.
Use IEC for developing awareness about oro-dental
health.
Mobilize community resources and involve the com-
munity.
Understand psychosocial, cultural and environmen-
tal factors of the community before developing stra-
tegies for prevention.
All of the above-mentioned competences are espe-
cially important for the dental graduates of emerging
countries.
Health and safety: considerations
Because developing countries struggle with various
infectious diseases and the prevalence of iatrogenic
and hospital infection is also high, it becomes extremely
important for dental professionals in such countries to
follow health and safety guidelines strictly. The curri-
culum should contain detailed information on:
Universal work precautions.
Protective barrier techniques.
Use and care of sharp instruments and needles.
Sterilization/disinfection techniques and limitations.
Use and care of hand pieces and other intraoral
devices.
Maintenance of air/water lines of dental units.
Biomedical waste disposal.
Post-exposure guidelines following an accidental
exposure to infection.
Management of patients with communicable diseases.
Prevention of transmission of infections from dental
clinics to the laboratory, etc.
Core values applicable to all
Also see above: ‘How to converge towards higher global
standards’.
In addition to the ‘global standards’ for consideration
the working group has several other core values to
suggest that relate to a broader and ‘higher’ perspec-
tive, rather than from just the working group perspec-
tive. For example:
1. Ethics pervades everything that we do. It should
always be foremost in our minds, actions and deci-
sions in whatever role we are fulfilling.
2. There is always value in reviewing and assessing the
outcomes of education. This is an ongoing process
and must be attended to with vigour and criticism,
hopefully constructive criticism.
3. Integration and ‘wholeness’ is important in educa-
tion and practice. It goes beyond the disciplinary
focus to a higher level of understanding and synth-
esis that should be promoted.
4. Each educational institution should articulate a mis-
sion statement, goals and objectives which provides
a basis and orientation for its statements of compe-
tency for dental graduates.
5. Competency documents should be respected for
their ‘individuality’ rather than for converging
toward one document for everyone. In other words,
each document is respected and valued for it con-
vergence toward the establishment of a competent
dental graduate based on the realization that differ-
ences exist.
6. While competency-based education is emerging as
the norm for dental education, the concept could be
applied across the continuum of dental education.
For example, the development of competency state-
ments could be considered with respect to full-time
faculty, part time faculty, administration, support
staff, etc. This would provide a basis for develop-
ment and evaluation.
7. As an extension of competency on graduation, com-
petency of the dental practitioner should be devel-
oped. It should include, but not be exclusive to,
involvement in organized dentistry, peer assessment
and review, evidence of continuing competence, etc.
Conclusions
As a philosophical and educational approach, compe-
tency-based education appears to have ‘taken hold’ and
to be accepted as a sound method for the design of
instruction and assessment. Many national and local
institutions have adopted this format in respect of
undergraduate dental education.
In reviewing the available documents, of which there
are many and from which our list was not exhaustive
but representative, there is much to be learned from the
scope and extent of the format and presentation.
Although these documents can be used as a basis upon
which to develop other documents, it is acknowledged
that the development of any subsequent document
should be based on local standards, resources,
strengths, weakness and culture coupled with a con-
sensus or ‘buy in’ from those involved. Obviously it
will differ greatly from one local region and continent
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Plasschaert et al.

11. to the next, and it is extremely important that respect
be afforded to each of those areas for their abilities
and limitation as such limitations and extremes may
exist.
The working group has reviewed several baseline
and established documents to provide a reference and
focus for consideration of competency statements in
various areas. It is apparent that much thought and
experience has been given to the production of these
excellent documents, but also that they are ‘living’ and
dynamic documents that must be reviewed and chan-
ged on an ongoing basis to reflect the progress of
science and practice.
The outcome of this effort is to provide a basis upon
which different organizations and institutions might
consider or reconsider their competency statements,
their emphasis and value in the educational process.
It is not meant to be prescriptive in any way, but only as
a guiding tool as it is useful.
It is evident that there is much agreement in the
various documents, although the outcomes may be
stated in slightly different ways. Some are more global
than others. However, they all address the principles of
integration of the basic biomedical, social and clinical
sciences seen as important to the practice of dentistry.
As they are applied in the educational setting they
require further refinement and definition in order to
be implemented and for outcomes behaviours to be
assessed. Regardless of this, they are statements of
institutional and national expectations that drive cur-
riculum and evaluation.
Building and growing a thematic network
See below, ‘Recommendations’.
Recommendations, realistic goals and a
time frame.
1. Expand the working group.
The attendance and representation at this meeting was
incredible. However, there are parts of the global com-
munity that were obvious by their lack of presence. It is
understood that that occurred despite great efforts to
involve those representatives by the organizers. How-
ever, in support of their vision, every effort should be
expended to involve more countries beyond the Eur-
opean and North American representation. Under-
standing the current limitations of finances on both
sides there is hope that continuing insistence on their
presence for this initiative would bring results, e.g.
from South-east Asia and Australia as well as Mexico,
Latin America and particularly South America.
2. Establish a competency database ‘library’ on the
website.
gather all documents and make them available for
others;
one person should manage the group website; and
establish some guides/a person to manage the
development of what is being produced.
3. Face to face
Regardless of the efficiencies that can be attained by
working through the web, there is an inestimable value
in ‘face-to-face’ contact to discuss the issues. Nothing
beats a people-to-people meeting.
Recommendations for DentEdEvolves
1. Keep the discussion going—using e-mail: is easier, at
least at the moment as layout is a problem and
reporting is cumbersome.
2. Do some ‘advertising’ or ‘public relations’, perhaps
through FDI, WHO, ISO (why would ISO not sup-
port standards in education?) at the DentEdEvolves
level.
3. Research base—at the DentEd level objective for the
future.
Will the outcome of the conference result in any
change?
What is the impact of the conference document?
Perhaps a follow-up questionnaire.
Do you know about DentEdEvolves and the docu-
ments (i.e. draw attention to it)?
Has it had any effect in your school?
4. Expand the membership of DentEd level.
What is in it for someone to join? What is the
‘profit’ or benefit? (For example, can it help me in
some way with my school, my job, personally, or
assist with the change process?)
Specific recommendations regarding competences
are embedded within the sections of this report
Itis hopedthat the recommendationsandtemplaterefer-
ences provided will assist those who are interested in the
development of competency-based programmes or per-
haps the review of an existing programme. Members of
the group are available and willing to provide assistance.
It would never be too late to embark on this competency
mission for dental education.
It is important, with the assistance of DentEdEvolves,
that educational research regarding the outcome of the
impact of this conference and its recommendations
relative to the impact of competency development
and assessment be globally investigated. The group
has some connections, interest and resources that could
43
Development of professional competences

12. assist in that endeavour as an educational outcome
assessment.
Additional reading
European Union Advisory Committee on the Training
of Dental Practitioners (XI/ES316/7/93). Clinical pro-
ficiencies required for the practice of dentistry in the
European Union.
References
1. Chambers DW, Gerrow JD. Manual for developing and
formatting competency statements. J Dent Educ 1994: 58:
361–366.
2. American Association of Dental Schools/American
Association of Dental Education (AADS/ADEA). Compe-
tencies for the new dentist. J Dent Educ 1997: 61: 556–
558.
3. General Dental Council. The first five years. The under-
graduate dental curriculum. London: General Dental
Council, 1997.
4. Boyd MA, Gerrow JD, Chambers DW, Henderson BA.
Competencies for dental licensure in Canada. J Dent Educ
1996: 60: 842–846.
5. General Dental Council. Maintaining standards. London:
General Dental Council, 1999.
Address:
Fons Plasschaert
University of Nijmegen
PO Box 9102
6500 HC Nijmegen
the Netherlands
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Plasschaert et al.