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REPORT FROM COMMITTEE ON EDUCATION STANDARDS, IAMDMFR. JUNE ...

  1. 1. REPORT FROM COMMITTEE ON EDUCATION STANDARDS, IAMDMFR. JUNE 1997 Members of committee Laetia M Brocklebank, UK Hans-Goran Grongahl, Sweden Agnar Halse, Norway Kanji Kishi, Japan Stephen Matteson, USA Tae Won Park, Korea Irmela Reuter, Germany Madeleine Rohlin, Sweden Keiji Tanimoto, Japan Xandra L Velders, The Netherlands Ann Wenzel, Denmark Stuart C. White, USA
  2. 2. Contents Preface 1 General Issues 2 Undergraduate Education 3 Postgraduate Education 4 Proposal for Future Tasks of the Committee Enclosures 1. Ad hoc curriculum committee report to draft guidelines for the teaching of undergraduate dento-maxillo-facial radiology. Issued 1988. 2. Address list of members of the committee. 3. Article “Global trends in oral and maxillofacial radiology education”. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:517-26 by Rohlin M, Hirschmann PN and Matteson S. 4. Curriculum of undergraduate education in oral radiology from the Royal Dental College, University of Aarhuss, Denmark, by Professor A Wenzel. 5. Article “Manual for developing and formatting competency statements”. J Dent Educ 1994;58:361-6 by Chambers DW and Gerrow JD. 6. Article “The rationale behind problem-based learning” by Schmidt HG. 7. Regulations for the Diploma in Dental Radiology, The Royal College of Radiologists. 8. ABOMR Application Information for Diplomate Status, USA. 9. Abstract of the curriculum for specialist training in maxillo-facial radiology, Sweden.
  3. 3. PREFACE The Committee on Education Standards was established at the General Assembly of the 10th Congress of the International Association of Dento-Maxillo-Facial Radiology (IADMFR) in Seoul Korea, 1994. As President of the IADMFR, Professor Allan Farman of University Louisville (Kentucky, USA) took the responsibilities of ensuring the progress of the committees appointed. Professor Madeleine Rohlin, Lund University (Malmo, Sweden) was appointed chairperson of the Committee on Education Standards. Prior to the Committee on Education Standards, an ad hoc committee consisting of A Ruprecht (chairperson), LM Brocklebank, C-O Henrikson, N Serman and NJD Smith prepared a report on undergraduate education in dento-maxillo-facial radiology. This report (Enclosure 1) was published in the IADMFR-1994-Seoul, Korea. A workshop on undergraduate education was held on the 9th Congress of IADMFR in Budapest, Hungary, 1991. There was a vivid discussion, which was summarized and published in the IADMFR Newsletter Winter 1991-1992. The Committee on Education Standards is conscious of its responsibility to promote dental education. Member’s experience in dental education may be different, as academic learning in different countries appeals to different intellectual abilities. However, we are united on a common belief that education at all levels leads to improved oral health. Better-educated students make better practitioners, better able to deliver an enhanced quality of oral health care. Dental education experiences an exciting phase of development worldwide. Innovations of dental education occur at the level of dental school, department, or the individual course and range from computer-assisted learning to attitude development and student assessment. As a radiologist I want to phrase it in this way: “Learning is in focus”. Learning is a philosophy and should be looked upon as a process. Teaching is intended to support the student’s learning and to stimulate the active curiosity and alertness needed for the complex tasks of clinical practice. If life-long learning is accepted by all practitioners this will generate a need for educators to promote and evaluate the effectiveness of programmes, both for continuing professional development and postgraduate training for specialization. Thus, our aim is to stimulate our future colleagues and our colleagues in striving to develop their professional competence. As a Swedish proverb says: “It is a question of whetting the appetite rather than spoon- feeding it.” (Det galler att vacka aotiten, inte att mata). Malmo in June 1997 Madeline Rohlin 1 General Issues 1.1 Members of the Committee
  4. 4. Laetia M Brocklebank, UK Hans-Goran Grongahl, Sweden Agnar Halse, Norway Kanji Kishi, Japan Stephen Matteson, USA Tae Won Park, Korea Irmela Reuter, Germany Madeleine Rohlin, Sweden Keiji Tanimoto, Japan Xandra L Velders, The Netherlands Ann Wenzel, Denmark Stuart C. White, USA The intention is not to make this Committee exclusive but to increase the number of members gradually. It is the mention to invite those who are interested in educational issues. We hope that you feel free to contact any of the members of the Committee. Addresses are presented in Enclosure 2. 1.2 Communications Letter 1 was sent on December 29, 1994 to ask colleagues to join the Committee. The “IADMFR-objectives of undergraduate education”, an example of EC-objectives of undergraduate education prepared by Ann Wenzel in Aarhus, Denmark, and the Swedish curriculum of specialist training were enclosed. Almost all colleagues who received the letter were positive were to join the Committee. However, representatives from some countries, even continents, are still missing. Letter 2 was sent on March 30, 1995. Two subgroups were formed: - the group on postgraduate education and the group on undergraduate education The members were asked to answer two questions on the specialty in oral and maxillofacial radiology. They were also asked to send short descriptions on examinations of the undergraduate education. A glossary for the definition of objectives, a paper on problem-based learning (PBL), the Regulations for the Diploma in Dental Radiology for UK and Application Information for Diplomate Status for USA were enclosed in letter 2. Excellent examples on examinations/assessments were received. Furthermore, suggestions on postgraduate as well a undergraduate education were included. Interim meeting on November 8, 1995 in Cologne, Germany. The main topic of this meeting was specialist training. There were diversities among the members whether the specialist should serve as a clinician or as a researcher. It was concluded that a strategic plan presenting visions, goals, and action plans was needed for the Committee. Article “Global trends in oral and maxillofacial radiology education”. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:517-26 written by Rohlin M, Hirschmann P N and Matteson S (Enclosure 3).
  5. 5. 2. UNDERGRADUATE EDUCATION 2.1 Members of the subgroup are: Laetitia Brocklebank, Agnar Halse, Tae Won Park, Irmela Reuter, Madeleine Rohlin, Xandra Velders, Ann Wenzel and Stuart White. 2.2 Objectives As mentioned above a curriculum with guidelines for the teaching of undergraduate dento-maxillo-facial radiology was presented 1988. During the last 10 years several innovative changes in educational thinking have occurred. In Europe sectoral directives were issued in respect to dentistry, Medicine, Veterinary Medicine Architecture, Pharmacy, Nursing and Midwifery to promote convergence towards acceptability high standards of education and training within the European Union. Directive 78/687/EEC provides a list of subjects to be studied in dentistry. Professor Ann Wenzel from Aarhus (Aarhus University, Denmark) has prepared a curriculum in Oral Radiology (Enclosure 4) that has been formally accepted according to the directives. Another major contribution to dental education was the study by the Institute of Medicine (IOM) in the United States. The study carried out was “to assess dental education in the United State sand make recommendations regarding the future”. The report was summarized as “Dental Education at the Crossroads – Summary”. The report and eight background papers developed to assist the report were published in the January background papers developed to assist the report were published in the January 1995 issue of the Journal of Dental Education. Overall there is an increasing stress on the staff of dental and medical schools to identify the core competencies of their graduates. An integrated approach to competence is one way to capture the complexity of practice. This defines competence as a complex combination of knowledge, attitudes, values, and skills necessary for performance in different situations. There is some confusion on how to phrase this approach. IN the article “Manual for Developing and Formatting Competency Statements” which was sent to the members of the Committee, several key terms are discussed. (Enclosure 5) Based on the presented changes the members of our Committee were asked if we should modify existing objectives which are presented in Enclosure 1. The majority answered NO. A few members suggested that we should discuss the objectives orally when together. Objectives on digital radiography should, however, be added. 2.3 Educational process The numerous names such as action learning, case-based education, competency- based education, contextual learning, problem-based learning and self-directed learning reflect an interest for the educational process. There is an increasing stress on learning and on human competence to cope with change and the unknown. In problem-based learning (PBL) which is one way to meet these demands, the control of the learning process is transferred from the teacher to the students. As the members f the Committee expressed an interest to know more about PBL a short description of PBL was sent to them (Enclosure 6)
  6. 6. 2.4 Information on Computer Aided Instructions (CAI)-programs *ACTA has several in Dutch; “Anatomic landmarks” available also in English/Swedish in September, 1995 *Aarhus, Denmark, has approximately 15 programs running. Some of them are in English. *UCLA: ORAD (Oral Radiographic Diagnosis) described by White SC. Computer-aided differential diagnosis of oral radiographic lesions. Dentomaxillofac Radiol 1989;18:53-4. *NorDig, a group chaired y Professor Hans-Goran Grondahl, consisting of the departments of oral radiology in all Scandinavian dental schools, works on the development of several programs. 2.5 Examinations/assessments The members enclosed excellent examples of different types of examinations. There are multiple-choice questions, short essay questions and modified essay questions, which evaluate knowledge. There are also examples on how to evaluate skills. This topic will be discussed during the 11th Congress of IADMFR in Louisville, USA, 1997.
  7. 7. 3 POSTGRADUATE EDUCATION. 3.1 Members of the subgroup Hans-Goran Grondahl, Kanji Kishi, Stephen Matteson and Keiji Tanimoto 3.2 Specialist training in oral and maxillofacial radiology in different countries Country Length of Education Certified by Brazil 2 University Board Federal Council of Dentistry Canada 2-3 Canadian Dental Association Royal College of Dentists of Canada Chile 1.5 University Board and Chilean Society of Dental Radiology Finland 3 University Board Japan 3 Sweden 3-4 Board of Health and Welfare United Kingdom 4 The Royal College of Radiologists United States 2-3 American Board of Oral and Maxillofacial Radiology 3.3 Motives for the specialty In letter 2 we formulated based on our individual experience from our own country the ideas on the specialty in oral and maxillofacial radiology. The following two questions were posed: - For what purpose are specialists in oral and maxillofacial radiology needed? - Why should be any specialists in oral and maxillofacial radiology? The answers varied and were mainly influenced on which country the member was from. Some statements are cited: “Whether a specific country should accept a specialty in oral and maxillofacial radiology is a function of tradition, economic situation, skill levels, public health needs and social fabric.” “Specialists in oral and maxillofacial radiology are needed to provide patients with the best care regarding socialized examinations fro imaging and diagnosis of diseases and abnormalities of the maxillofacial complex.” “Specialists in oral and maxillofacial radiology are needed to promote good practice in the use of ionizing radiations through research and education.” 3.4 Curriculum for specialist training Three curricula were distributed among the members. Those are:
  8. 8. * Regulations for The Diploma in Dental Radiology published by The Royal College of Radiologists in the UK, 1993. *Application Information for Diplomate Status published by The American Board of Oral and Maxillofacial Radiology, 1993. (Enclosure) *Abstract of the Curriculum for Specialist Training in Maxillo-Facial Radiology published by The Swedish Board for Health and Welfare, 1993. (Enclosure 9).
  9. 9. 4. PROPOSAL FOR FUTURE TASKS OF THE COMMITTEE There are several tasks for the Committee on Education Standards. A strategic plan presenting visions, goals and action plans is needed. Such a plan will facilitate the development of education programs which help students to become competent in solving health problems of individuals as well as of communities. Specific considerations may be different for undergraduate education as compared to postgraduate education. Below some of these specific considerations are listed: 4.1 Tasks in undergraduate education • To improve the definitions of competencies of graduates such as relevant skills, including skills in problem-solving, independence learning, critical appraisal of evidence. • To develop learning tools such as CAI_-programs in English and stimulate exchange of these programs • To improve the design of procedures and tools fro assessing student and graduate performance. • To disseminate information on improvements in undergraduate education 4.2 Tasks in postgraduate education The need to disseminate results if clinical research and to promote concepts of evidence-based best practice is rapidly increasing in dento-maxillo-facial radiology. Therefore we should play an important role as facilitators of the continuity of dental education. When it comes to the specialty in oral and maxillofacial radiology we could discuss considerations such as which are the minimal standards for specialty competence, definition of the specialty and should there be an international diploma?
  10. 10. AD HOC CURRICULUM COMMITTEE REPORT Axel Ruprecht Report of the Ad Hoc Committee to Draft Guidelines for the Teaching of Undergraduate Dento-Maxillo-Facial Radiology The study of Dento-Maxillo-Facial Radiology by undergraduate dental students is of importance, not only to the members of this organization, who devote a great deal of time and effort to the advancement of this science, but to the dental profession at large. The study of diagnosis is part of a sound education in dental sciences, because without proper diagnosis all else that is performed can at best be only empirical. Radiology forms an integral part of the diagnosis process and, thus, its study id of equal importance to other aspects of diagnosis. Since radiology employs ionizing radiation and electrical and chemical variables in the production of images, it follows that the dentist must have a solid grasp of the principles that underlie the Physics of Radiology, if he is to produce images of the dentist must have a solid grasp of the principles that underlie the Physics of Radiology, if he is to produce images of tissue injury, however slight that possibility might be in individual cases, the dentist must understand how such injury may occur, how best to minimize the risk and how to make judgments concerning the potential risk relative to the potential benefits of making a radiograph. This requires an understanding of radiation biology and radiation hygiene linked to the physics that underlies these sciences. Even when these principles are properly understood and utilized the dentist will be able to produce a technically correct radiograph only if he is familiar with the techniques involved in producing specific views of areas of concern, so that radiographs which depict clearly the area of interest can be consistently produced. This requires not only didactic teaching but also clinical and darkroom experience which can be gained only in a controlled supervised environment. Once the student dentist has mastered all of this he should be able to make those radiographs hat are required in the day-to-day practice of dentistry. This, however, is only half the battle. Since the dentist is his own radiologist for most of his radiographic requirements, he must be able to interpret competently the radiographs produced with the above knowledge and skill. This requires a thorough knowledge of disciplines outside the narrowly defined field of radiology. It requires that the student dentist have a thorough knowledge of head and neck anatomy, physiology, and pathology, since all radiographs will depict images of anatomy of the area under investigation, its variants (based not only on developmental variation, but on function in its broadest sense) and changes due to pathological processes. It is assumed that students will have acquired this requisite knowledge for various parts of the radiology course. What is required, however, is that the prerequisite knowledge for carious parts of the course be learned prior to the study the specific area of radiology. For example, it is not necessary to have mastered anatomy when the student is studying the physics of x- ray production, but it is necessary when he starts to learn about the various areas under investigation. No attempt is made here, nor is any implication intended, as to how these vital prerequisite subjects should be taught and by whom. What is important to us is that they be taught adequately and at the proper time. We present a curriculum outline that should be seen as a guideline of what to teach, with suggestions as to how and when appropriate. We do not suggest that the outline need
  11. 11. be followed to the letter. Indeed, we should be disappointed if all institutions were to attempt to implement the outline without question. This would rob the field of Dento- Maxillo-Facial Radiology of a rich diversity from which come experimentation and change which ultimately lead to advances. Also, what works well in one area, given the resources and expertise available could well be a disaster elsewhere. We present this as a guide of what should be included in a course in radiology to assist those who are setting up courses, revising older courses, or who wish to have a comparison to see if their own courses are deficient in any area. It is our hope that this document will not just be filed away, but used and updated frequently. It is written on a word processor to allow for easy change, not carved into tablets of stone, to be preserved, immutable, for all ages. A. Ruprecht (Chairperson) June 3, 1998 L.M Brocklebank C. O Henrikson N. Serman N.J.D. Smith
  12. 12. I. RADIATION PHYSICS I.A. Production of X-Rays The material to be presented should include the atomic interactions that lead to the production of x rays, the circuitry that is required to produce these interactions, and the effect of various electrical factors (kVp, mA and time). Wavelength and the mechanism by which scattering of the primary beam occurs should be explained. The construction of the unit housing, including collimation, filtration and position – indicating devices should be explained. The material presented in this section will provide the student with sufficient knowledge to make decisions regarding techniques that are based on a proper consideration of the consequences of these decisions, not on rote memory that does not allow modification when required. I.B. Interaction of X-rays The material presented will enable the student to base his decisions about radiation protection, as well as interpretation; on a clear understating of how x rays interact with matter, and the effect of material within the path of the beam. I.I. RADIATION BIOLOGY AND RADIATION PROTECTION II.A. Radiation Biology The interaction between ionizing radiation and biological tissue constitutes the base for radiology. This interaction will inevitably produce physical, chemical, and biologic effects as a consequence of ionization with the tissue. In order to understand the processes following ionization it is necessary to have some fundamental knowledge of the effect of radiation, and the reactions of specific tissues, somatic and genetic, to it. II. B. Radiation Protection The use of radiation in DMF radiology is necessary to provide ssential information of diagnostic value for the individual. To ensure that radiation is used wisely, it is necessary to acquire knowledge about the connection between dose and risk, so that the individual, as well as the collective, dose can be kept to acceptable levels by means of adequate radiation protection. The risk for the individual, as well as for the population, will then be so low that most indicated examinations may be performed. The level of indication is influenced by the knowledge of the diagnostic efficacy of the examination, its technical standard and the ability of the examiner to make a proper interpretation. II. B. 1 One fundamental base for radiation protection is the technical design of the x-ray machine, the image receptors and the darkroom. II. B. 2
  13. 13. Another fundamental base for radiation protection is a proper handling of the x- ray equipment, adequate shielding for adequate examination, proper equipment alignment, and processing techniques. II. C. Quality Control Quality Control and record keeping in DMK radiography should be described in sufficient detail to allow the operator to meet all government regulations and professional standards. III. PRODUCTION OF THE RADIOGRAPH: TECHNIQUES AND DARKROOM III.A. Techniques The course on production of the radiograph should be designed to provide the student with an understanding of the theoretical aspect s of producing a radiograph and adequate experience of putting this theory into practice, as demonstrated by competence at executing oral radiographic techniques. It is strongly recommended that all techniques are first practiced on manikins and/or dry skulls and that competence is demonstrated in each technique before the student is allowed to carry out radiographic examination of patients. III.A.1 Theoretical knowledge and practical experience in this section is designed to enable the student to decide on the appropriate radiographic technique to be used to produce a radiograph of a given area, to expose the film using the proper technique, process the film, evaluate the radiograph for diagnostic acceptability and correct any faults that have occurred in the production of the radiograph. III.A. 2 Projection geometry in intraoral radiographic techniques, and its effect on image production should be described. Specific geometry as it relates to specific views will be considered in detail. III.A. 3 Image receptor systems (film and film-screen combinations) should be described. Screen-films and non-screen films will be compared, especially how each is affected by x-rays to produce the latent image. Exposure factors and their influence on radiographic density and contrast should be explained. III.A. 4 The production of extraoral radiographs should be dealt with, at least to the extent that the more commonly used views are explained to the student. This area will be the most variable, depending on geographic location and types of patients to be seen, but an
  14. 14. introduction to the major types of extraoral radiographic examinations should be included. III. B. The processing of a film to produce the finished radiograph should be considered. The effect of the various chemicals on the emulsion will be discussed. Common technique and processing errors will be taught, both from the point of view of how and why they occur, and how to determine what the causes of specific errors are when they are first seen. III.C. The proper orientation for mounting, viewing and labeling of radiographs should be stresses, showing what diagnostic problems can arise if not properly carried out. The proper viewing conditions are described here, showing why various factors are important. These will be reinforced in the interpretation section of the course. III.E. Practical (tutor) demonstrations may be given fro various aspects of radiography. These are listed in Appendix A. III. F. Practical experience should be gained in all intraoral techniques, and in those extraoral techniques that are emphasized regionally, and are within the remit of locally practicing dentists e.g. panoramic radiography, oblique lateral jaw radiography. The student should at the end of his training be able to demonstrate competence in all techniques and procedures in which he has received instruction; adequate experience may be obtained through the use of clock hours or number of procedures. It is strongly recommended that all techniques are first practiced on manikins and/or dry skulls and that competence is demonstrated in each technique before the student is allowed to carry out radiographic examination of patients. Appendix B lists those areas in which the student become competent by supervised practical experience. Appendix B lists those areas in which the student should become competent by supervised practical experience. IV RADIOLOGIC INTERPRETATION IV. A. Radiologic interpretation represents the goal of all else that has been done in radiography prior to this step. Before this phase can be undertaken, the student must have a thorough knowledge of all steps that have gone before, inasmuch as each one affects the image produced and must be taken into consideration in the interpretation. As with the previous section the tenets of radiologic interpretation require a didactic (lecture/seminar) and a practical (clinical) component. It is not necessary that all aspects be taught by the members of the radiology department, but it is important that there be consistency in terminology presented to the student. This terminology varies from area to area, and thus no attempt will be made here to present a list that should be universally used. Although this might be a valid goal in itself, it is beyond the mandate of the committee. The teaching of interpretation can be divided into sections that deal with
  15. 15. normal and abnormal, and then in many subsections. The exact content in each section will be influenced by the techniques and equipment used in each institution. IV. B Normal radiographic anatomy must be well understood, both in its classis form and with its many variations. The material presented should be relevant to the population(s) that the student will encounter, in the dental school and in practice, but should include examples from other groups so that an appreciation of variability is fostered. The normal appearance, together with common variations, of all dental and skeletal structures in the dento-maxillo-facial region, as demonstrated by intraoral and common extraoral views should be taught in depth. IV C. Pathological processes that manifest on radiographs cause changes in the appearances of normal anatomical structures. The lesions and processes that should be included in a didactic radiology course include IV.C.1. developmental anomalies and disturbances of the teeth, the jaws and the face IV.C.2 pathological processes in dental hard tissues IC.C.3 infection/inflammation of the jaws IV.C.4 periodontal diseases IV.C.5 cysts and tumors of the jaws of odontogenic origin IV.C.6 cysts and tumors of the jaws of non-odontogenic origin IV.C.7 diseases of bone manifested in the jaws IV.C.8 systemic disease manifested in the jaws IV.C.9 pathological calcification and ossification of the soft tissues IV.C.10 dysplastic/fibro-osseous lesions IV.C.11 injuries to DMF region IV.C.12 diseases of the TMJ IV.C.13 disease of the paranasal sinuses IV.C.14 diseases of the salivary glands IV.C.15 effects of irradiation upon teeth and the jaw bone Each of these broad areas can be expanded to include those lesions prevalent in a given geographical location. For example, if fluorosis is common in an are it would be covered under developmental anomalies. The great interest in so-called TMJ problems
  16. 16. requires that students/practitioners learn what can and what cannot be seen on views of the joint. In all such lectures it is assumes that indications, lack of indication, contra- indications for radiographic investigation of certain problems will be included. Students must also have the opportunity to use the knowledge acquired in lectures, to organize it in a useful format so that for example they know (in simplified form) not only that a cyst has a hydraulic appearance, but also, conversely, that a radiolucent lesion with a hydraulic appearance might be a cyst. There are two possible methods, which are complimentary, not mutually exclusive. One is the controlled method, such as clinical radiologic conferences when the instructor can determine which types of lesions will be reviewed, ensuring that the student see those that are necessary. The other is the random method, which occurs when students interpret radiographs of patients in the clinic as they occur. This does not assume that all lesions are presented, but does give realism to the learning. In this second exercise students learn how to write proper radiology reports that can be clearly understood by other practitioners. Both should be under close supervision and review of a trained instructor.
  17. 17. Appendix A PRACTICAL (TUTOR) DEMONSTRATIONS FOR VARIOUS ASPECTS OF RADIOGRAPHY A.1 image receptors A.2a. film packets i. construction ii. handling iii. orientation A.2.b cassettes i. construction ii. handling iii. mode of function A.2.c films i. construction ii. handling iii. differences in size and speed iv. proper storage before use A.2 darkroom use i. elimination of white, use of safe-lights and testing of blackout efficiency ii. care of equipment iii. chemical storage iv. general organization v. film identification methods A.3 processing i. correct use of chemicals and containers ii. use of manual and automated systems iii. trouble shooting iv. quality control A.4 film holders i. construction and specific uses ii. sterilization iii. relation between film holders and collimators A.5 the x-ray machine i. exposure variables and their selection ii. avoidance of unnecessary irradiation iii. filtration of the beam iv. collimation of the beam v. warning devices A.6 protection measures i. for the patient ii. for the operator
  18. 18. iii. for the public A.7 intraoral radiography techniques on manikins and dry skulls with radiation exposure, and on individuals for positioning demonstration only without radiation exposure except in those cases where films are required for diagnostic evaluation. Film packet immobilization should be carried out by non-manual means. Modification of techniques to suit individual situations, e.g. endodontic radiography, should be demonstrated. A.8 correct use of extraoral and intraoral landmarks and of film holders in order to minimize repeats due to technical errors such as cone cutting, incorrect horizontal angulation, incorrect vertical angulation. A.9 assessment of patient (type, condition) for modification of exposure factors. A.10 film identification and viewing i. use of anatomical landmarks ii. purpose of raised dot iii. correct arrangement iv. mounting and labeling v. records vi. storage A.11 extra-oral radiographic techniques i. patient positioning ii. film position iii. tube angle and centering iv. exposure values v. identification A.12 duplication of radiographs A.13 quality control i. processor/chemical ii. darkroom, including white light and safelight leaks iii. unit output iv. storage of films and chemicals in main stores v. storage of films in x-ray rooms A.14 decontamination i. disinfection of the x-ray room ii. disinfection of the darkroom iii. sterilization of film holders and other instruments Appendix B AREAS IN WHICH THE STUDENT SHOULD BECOME COMPETENT THROUGH SUPERVISED PRACTICAL EXPERIENCE
  19. 19. B.1 film packets and cassettes i. handling of both in the operatory and the darkroom B.2 processing i. manual methods emphasizing time/temperature control ii. automated methods iii. error recognition and correction B.3 film holders i. assembly ii. use iii. sterilization and maintenance B.4 intraoral radiographic techniques i. relevant exposure settings ii. radiation protection and hygiene measures iii. bitewing technique iv. paralleling technique for periapical radiographs v. occlusal techniques B.5 intraoral radiographic techniques i. patient positioning ii. film position iii. tube angle and centering iv. exposure values v. identification Enclosure 2 Address Phone Fax Laetitia M. Brocklebank 44-41-2119640 44-41-2119800 Dept of Oral Radiology Glasgow Dental Hospital and School 378 Sauchiedal Street Glasgow, G2 3JZ, Scotland, UK Hans-Goran Grondhal 46-31-7733000 46-31-827351 Dept. of Oral Radiology Faculty of Odontology Medicinaregatan S-413 90 Goteborg, Sweden Agnar Halse 47-55-206598 47-55-206494 Dept of Oral Radiology School of Dentistry Arstadveien 17 N-5009 Bergen, Norway
  20. 20. Keith Horner 44-61-2756690 44-61-2756840 Dept of Dental and Maxillofacial Radiology Turner Dental School University Dental Hospital Higher Cambridge Street Manchester M15 6FH, England Kanji Kishi 81-862-237151 81-862-224572 Dept of Oral Radiology Okayama University Dental School 5-1, Shikata-cho, 2 chome Okayama City, Japan Stephen Matteson 1-210-5673334 1-210-5673334 Dept of Dental Diagnostic Science UTHSCSA 7703 Floyd Curl Drive San Antonio, Texas 78284-7919, USA Tae-Won Park 82-2-7602620 82-2-7408742 Department of Oral and Maxillofacial Radiology College of Dentistry Seoul National University 28 Yeun Gun-Dong Chong Ro-Ku Seoul 110-744, Korea Address Phone Fax Irmela Reuter 49-251-837168 49-251-87184 Institut fur Zahnarztliche Roentgenologi Zentrum fur Zahn-, Mund- und Keiferheilkunde Waldeyerstrasse 30 48129 Munster, Germany Madeleine Rohlin 46-40-322013 46-40-322023 Dept of Oral Radiology Centre for Oral Health Sciences Carl Gustafs vag 34 S-214 21 Malmo, Sweden Keiji Tanimoto 81-82-2575691 81-82-2575692 Dept of Oral and Maxillofacial Radiology Hiroshima University School of Dentistry 1-2-3 Kasumi, Minami-ku Hiorshima, 734, Japan Xandra L. Velders 31-20-5188398 31-20-5188480 Dept of Oral Radiology ACTA Louwesweg 1
  21. 21. 1066 EA Amsterdam, The Netherlands Ann Wenzel 45-86-132533 45-86-196029 Dept of Oral Radiology Royal Dental College Aarhus University Vennelyst Boulevard DK-8000 Aarhus C, Denmark Stuart C. White 1-310-8255711 1-310-2065539 Section of Oral Radiology Section of Oral Radiology School of Dentistry UCLA 10833 Le Conte Avenue Los Angeles, CA 90024-1668
  22. 22. Enclosure 4 CURRICULUM OF UNDERGRADUATE EDUCATION IN ORAL RADIOLOGY ROYAL DENTAL COLLEGE, UNIVERSITY OF AARHUS, DENMARK Dr. Anne Wenzel ORAL RADIOLOGY ORAD4-1 RADIOLOGY (techniques + anatomy) lec sem lab pcl cli additional CAL – course (techniques) 9 4 4 ORAD4-2 CLINICAL ORAL RADIOGRAPHY (intraoral) 5 ORAD5-1 PATHOLOGY OF THETEETH AND JAW BONE 10 (develop, anomalies, caries, resumptions, cysts, infections, trauma) ORAD5-2 CLINCIAL ORAL RADIOGRAPHY (intra-+extraoral) 10 ORAD6-1 RADIOLOGY (instruments, radiophysics, and digital 6 radiology, x-ray hygiene and riscs) additional CAL-courses 5 ORAD6-2 PATHOLOGY OF THE SKULL AND TMJ 8 (tumor, TMJ, and salivary, differentials) ORAD6-3 CLINCIAL ORAL RADIOGRAPHY 10 (extraoral – spec. TMJ) TOTAL 33 9 4 25
  23. 23. GENERAL OBJECTIVES Having attended the course in oral radiology, the student must be capable of 1.Using his radiographic equipment optimally in due consideration of the radiation risks. 2.Performing intraoral radiographic and the most common extraoral radiographic examinations on patients in dental practice. 3.Interpreting radiographs and, by comparing the images with the clinical findings, attain to a diagnosis in due consideration of differential-diagnostic problems. Literature Recommended: Goaz PW, White SC: “Oral Radiology – Principles and Interpretation”. CV Mosby Comp., St. Louis, 1987 Sewerin I (Ed): “Radiation biology and protection”. Danish Dental Association, Copenhagen, 1990 (in Danish) Sundhedsstyrelsen: “Bekendtgorelser om dental rontgenanlaeg- nr. 217 af 29. April 1977” (in Danish). Additional: Computer Assisted Learning Programs (approx. 20 programs in English and Danish). Evaluation Course certificate and a written 4-hour examination after 6th semester. CREDIT VALUE FOR RADIOLOGY 8 points
  24. 24. Teaching objectives in Oral Radiology, Royal Dental College, University of Aarhus. AIM Having attended the course in oral radiology, the student must be capable of 5.1 Using his radiographic equipment optimally in due consideration of the radiation risks. Performing intraoral and the most common extraoral radiographic examinations on patients in dental practice. Interpreting radiographs and, by comparing the images with the clinical findings, attain to a diagnosis in due consideration of differential – diagnostic problems. 5.2 Physics and radiation biology The student must be capable of 1.1 defining x-rays 1.2 explaining how they are produced 1.3 describing their characteristics 1.4 defining how they are applied 1.5 providing protection against their harmful consequences 1.6 surveying radiation protection of any operator, patient or persons who are casually present within the x-ray monitored area. Thus, the student has to attain a positive attitude to active radiation protection of these three categories, specifically by continuously monitoring passive radiation protection combined with an optimal active radiation hygiene in each case. The definition of passive radiation protection is: the protection provided by an appropriate set-up as well as installment and use of radiographic units. The definition of active radiation protection is: the correct procedure at radiographic examination. 2. Projection geometry, exposure, film, and darkroom techniques 2.1 Basic projection geometry. The student must be capable of describing. 2.1.1 the rules for how 3-dimensional radiolucent and radiopaque structures are transformed into a 2-dimensioanl radiograph, 2.1.2 the image distortion due to form and size of the focal spot, 2.1.3 the image distortion due to the diverging x-ray beam. 2.2 Intraoral technique. The student must be capable of describing 2.2.1 the theory of the bisecting angle technique, and of performing radiographs by use of this technique, 2.2.2. the theory of the paralleling technique using long cone and filmholder, and of performing radiographs by use of this technique; in addition, of performing 2.2.3 standard radiographs of the dentition, e.g. a 14-film survey, 2.2.4 bitewings of premolars and molars, 2.2.5 occlusal plane radiographs: semiaxials, symmetric and asymmetric, of the mandibular and maxillary regions, and axials of the mandible,
  25. 25. 2.2.6 eccentric exposures, 2.2.7 exposures ad modum Le Master 2.3 Extraoral techniques. The student must be capable of performing radiographs of: 2.3.1 The TMJ: in the oblique lateral, transphrayngeal, transmaxillary, and postero- anterior projections 2.3.2 the maxillary sinus: in the lateral and postero-anterior projections, 2.3.3 the skull and jaw bones, and axial projections 2.4 Extraoral technique. The student must be capable of defining the orthopantomographic, the cephalographic, and the cranial table techniques; and to account for the theoretical background behind the equipments. 2.5 Extraoral technique. The student must be capable of describing the principle of tomography. 2.6 Film and image display. The student must be capable of describing the basis for conventional silver-halde-based film imaging and for digital imaging. 2.7 Photograph technique. The student must be capable of describing the processing technique form the phase of exposure to the finished radiograph, and of performing the developing process of standard radiographs. 3. Indication for and interpretation of radiographs 3.1 The student must be capable of defining the most relevant radiographs 3.2 The student must be capable of describing the principles of contrast injection in the salivary gland – and TMJ region 3.3 The student must be capable of detecting unsuccessful radiographs and of identifying errors in exposure, film handling, and processing. 3.4 The student must be capable of identifying normal anatomic structures, and of detecting deviations from normal structures on the below types of radiographs: 3.4.1 all intraoral radiographs, 3.4.2 orthopantomograms, cephalograms, and TMJ radiographs. 3.5 The student must be capable of stating a radiographic diagnosis of disease in the teeth and jaw bones: 3.5.1 anomalies in the tooth structure, development, position, and number. 3.5.2 deviations in tooth eruption, 3.5.3 dental caries and subsequent conditions 3.5.4 the marginal and apical periodontal bone, 3.5.5 conditions caused by traumas of the teeth and jaws. 3.5.6 foreign bodies 3.5.7 resorptive processes of teeth and adjacent regions, 3.5.8 infection processes, degeneration processes, benign tissue formations, cysts, and tumors in the jaw bones, 3.5.9 TMJ diseases, 3.5.10 diseases of the maxillary sinus, 3.5.11 diseases of the salivary glands 5.3 the total course in oral radiology, i.e. the theoretical as well as the clinical teaching, is mandatory. Seminar attendance is checked by student signature, and clinical attendance by the supervisors in the radiography clinic. Having completed the clinical course and received the course certificate, the student enrolls for the final exam. This is a 4-hour written examination consisting of 15 multiple-choice questions and 10 patient cases described by clinical information and radiographs. The student is to answer questions regarding radiographic
  26. 26. techniques, normal anatomy, and tooth and bone pathology based on these cases. An external censor (head of the Oral Radiology Department at Copenhagen University) together with the head of Oral Radiology Department at this Institute evaluate students’ answers resulting in a grade (scale from 0 to 13). Approximately 60% correct answers imply the grade “6” which is the minimum for passing the exam.
  27. 27. THE ROYAL OF RADIOLOGISTS Tel: 071-636-4432 38 PORTLAND Place Fax: 071-323-3100 LONDON W1N 3DG Regulations for the Diploma in Dental Radiology To be eligible to commence training candidates are required: (a) to have had two years of clinical experience after qualification; (b) to have Registration with the General Dental Council (either Full or Temporary) if training is to be undertaken in the United Kingdom. All trainees must enroll with Royal College of Radiologists at the commencement of training. Heads of Training Departments should ensure that trainees are aware of this requirement and that they comply with regulations concerning clinical experience. Training The minimum full time training is two years, which must be spent in departments fully recognized by the Royal College of Radiologists. During this time, the trainee should obtain experience of IV injections, CT scanning, ultrasound, and MRI. An academic year of training is required for the Part I examination, not less than half time receiving instruction in general and dental radiology and the remainder preferably in other relevant general dental hospital work. There must also be a period of secondment, equivalent to a minimum of six weeks full time, to a General Radiology Department. It is recommended that the initial three weeks of this period should be spent as a block allocation. One further year of full time, or two years’ half time, training is required for the Part II examination. This must include a period of secondment, equivalent to a minimum of eight weeks full time, to a General Radiology Department, for which there must be a defined programme. Examinations Part I The DDR Part I examination comprises the following subjects: (1) Physics, apparatus, photography and film faults. (2) Radiological anatomy and radiography (3) Principles of modern imaging techniques and procedures, and the use of contrast media and drugs. Candidates are allowed only four attempts that the Part I examination. The examination is held twice each year in June and September. The examination consists of: (a) multiple choice question paper (b) A written paper in subjects (1) and (2) above (c) A film viewing session (d) Two oral examinations
  28. 28. Part II the examination is held in October of each year and consists of: (a) Two three hour written papers pertaining to dental radiology, maxillo-facial imaging and general radiology. Oral pathology and clinical aspects will be included in these papers. (b) An oral examination. In order to pass the examination as a whole, it is essential for a candidate to obtain a pass standard in the oral part. A candidate can compensate to some extent for a slightly weak performances in the written part by performing particularly well in the oral examination. An essential requirement for taking the examinations is certification by the Head of Department concerned that the course of instruction has been completed satisfactorily. No exemption is granted from any part of the examination. Candidates who withdraw from part of any examination will be deemed to have failed the examination as a whole. Syllabus A syllabus is available free of charge from the Examinations Secretary of the Royal College of Radiologists. Examination Fees Details of examination fees may be obtained form the Examination Secretary. If a candidate withdraws after the closing date for an examination, the whole of the examination fee is forfeit. The college may make exceptions to this rule in special circumstances. Cheques for examination fees should be made payable to “The Royal College of Radiologists”. Diploma Each successful candidate will receive a diploma. Accreditation Application for a certificate of Accreditation may be made by holders of the DDR on completion of the equivalent of three years full time recognized training. Full time research, experience in related clinical fields, or time spent gaining specialist experience is encouraged but may not be counted wholly towards the accreditation period. Approval by the Royal College of Radiologists should be obtained prospectively if accreditation is to be sought for such experience. Each candidate approved for accreditation will receive a certificate on payment of the required accreditation fee. March 1993. THE ROYAL COLLEGE OF RADIOLOGISTS DIPLOMA IN DENTAL RADIOLOGY: PART I
  29. 29. Objectives On completion of training for the Diploma in Dental Radiology Part I examination, the trainee should: 1 Have a detailed knowledge of anatomy and normal variants relevant to radiological examinations. In addition, the candidate should have a clear knowledge of anatomy as displayed by modern imaging techniques including ultrasound, CT and MRI. 2 Know the special “core of knowledge” of the current (1988) Ionising Radiation (Protection of Persons Undergoing Medical Examination or Treatment) Regulations, or its subsequent revisions. 3 Have a knowledge of radiation protection sufficient to: (a) Understand current official radiation protection guidelines and regulations, and to be able to explain those guidelines and regulations to medical and radiographic staff as well as to patients, both for clinical practice and research purpose. (b) Comprehend those practical measures which should be in place in a department of Clinical Radiology © Understand the relative risks of medical radiation 4 Have sufficient knowledge of X-radiation and diagnostic X-ray equipment to be able to understand the interaction of X-rays on tissues and the factors that affect image quality, in order to be able to discuss these subjects with radiographers and clinicians, to recognize artifacts and to be able to use equipment correctly. 5 Have sufficient knowledge of the basic principles of ultrasound, CT, MRI and radionuclide imaging to be able to understand the nature of the radiation/sound waves used in these techniques and to understand, in outline, the performance of imaging equipment as well as the means by which the relevant images are created. 6 Know sufficient basic radiography to demonstrate an understanding of the standard radiographic projections relating to the regions outlined in the radiological anatomy syllabus, and to be able to give practical advice on improving the quality of the image obtained. 7 Have a knowledge of the techniques, including the materials (e.g. contrast agents, drugs) and equipment (e.g. catheters, needles) used in those techniques which a candidate is expected to have carried out personally and on his/her own during the first nine months of training in Radiology. These techniques are listed in the syllabus under section 1.2.
  30. 30. The syllabus is based on these objectives. It has been constructed so that all lectures and formal tutorials for Part I DDR training can be accomplished in the equivalent of two sessions per week, with the physics portion designed so that it can be covered in 40 hours of formal teaching. This will allow training departments to arrange for each trainee to spend at least five sessions per week in radiological environment. The college strongly supports the principle that trainees should participate in the work of their departments as far as practically possible and as early as possible in their training. The general comments, which introduce each of the following sections, are intended to help define the level of knowledge, which will be tested in the examination. Although the syllabus for the physics section is set out in greater detail, trainees and teachers should realize that this section would contribute only on third of the marks of the whole examination.
  31. 31. THE SYLLABUS 1.0 RADIOLOGICAL ANATOMY AND TECHNIQUES 1.1 Radiological Anatomy General comments: The candidate should be familiar not only with the basic anatomy relevant to all the common radiological examinations but should also be familiar with cross-sectional anatomy in the axial, coronal, sagittal and, where appropriate, oblique planes. A knowledge of normal anatomical variations will be expected. It is expected that the formal teaching course will build on the anatomical knowledge already expected of a radiological trainee, in much the same way as the interpretation of radiological abnormalities is built on a sound knowledge of basic pathology. Candidates should know the normal dental development of the growing child. Detailed knowledge of the normal radiological anatomy of: (a) The skull and facial bones; including the teeth and their development, the temporo-mandibular joints, the paranasal sinuses, the orbits and salivary glands. (b) Pharynx, larynx major blood vessels and lymph nodes in the neck. A broad knowledge of the radiological anatomy of: (a) Cervical spine, brain (b) The respiratory system and cardiovascular system (c) The abdomen 1.2 Radiological Techniques 1.2.1 The candidate will be expected to show familiarity with, and experience of, everyday investigations. A detailed knowledge is required for those techniques which a candidate is expected to have carried out personally and on his/her own during the first nine months of training in radiology. 1.2.2 A broad knowledge of the basic principles underlying the techniques used in arteriography, interventional radiology, nuclear medicine, ultrasound, CT and MRI will also be expected. For these investigations, the candidate should know, in outline only, the following: Patient preparation. Radiographic apparatus used. Contrast media (see 1.3 below) Outline of technique with main variations. Principal complications and their treatment. 1.3 Contrast Media, Radiopharmaceuticals and Drugs
  32. 32. 1.3.1 Contrast Media: The contrast media to be studied are those which relate to the practical procedures mentioned in 1.2 above. They include the contrast media in current clinical use for radiography, computed tomography and magnetic resonance imaging. For each contrast agent the following are expected: Official name. Doses, including doses for children. Constitution (not the detailed formula). Modes of administration and the clinical uses. Routes of elimination. Relative advantages of the different types of media. Side effects and treatment of reactions. Contra-indications to use. 1.3.2 Radiopharmaceuticals: The choice of radiopharmaceuticals. 1.3.3 Drugs: Some knowledge is expected of those drugs – commonly used in radiological practice, including their dosage. These can be considered under the following headings: Sedation before radiological procedures. Prophylaxis and treatment of reactions to contrast media. 1.4 Radiography General comments: Candidates will be expected to demonstrate a knowledge of the staff the standard radiographic projections relating to the regions outlined in the radiological anatomy syllabus (section 1.1 above). Candidates should, therefore, be able to comment on the positioning and tube angulation used to obtain the image and should be able to give practical advice on improving the quality of the film. A knowledge of infrequently used projections will not be expected. 1.4.1 Knowledge of, and practical familiarity with, the following will be expected: Positioning of patients. The use of immobilizing devices and protective devices. Standard radiographic projections and angles. Correction of errors in centering an exposure. 2.0 PHYSICS General comments: A basic knowledge of physics is assumed. On the assumption that the whole of the physics syllabus can be covered in approximately 40 hours of formal teaching, the hours indicated in brackets are a guide
  33. 33. as to how these 40 hours might be divided. The suggested time for each section is an indication of the approximate proportion of questions devoted to each topic in the MCQ part of the examination and the depth of knowledge expected in the topic. The changes in content and recommended time contained in this revision of the syllabus are designed to reflect the introduction of the newer imaging modalities. Equipment design and construction details will not be examined, but an understanding of the function of the equipment components relevant to image formation may be tested. A mathematical approach to the physics in inappropriate; the emphasis should be placed on a clear understanding of the physical basis of radiological practice in a qualitative sense. However, the knowledge of the approximate magnitude of quantities encountered in daily practice will be expected, e.g. percentage transmission of X-radiation through a patient; the activity of a radionuclide used for bone scanning. Basic electricity, magnetism and mathematics are not included in the syllabus and questions on these subjects will not be included in the examination. During formal teaching, all physics demonstration/practicals should have a direct relevance to everyday radiology. Knowledge of the principles of quality assurance, contrast resolution, spatial resolution and noise is excepted for all the sections listed below. 2.1 Ionising radiation (5 hours) Structure of the atom. Radioactivity and radionuclides: basic definition of alpha, beta and gamma radiation; principles of exponential decay, half-life, specific activity and units of activity. Electromagnetic spectrum. General properties of X and rays with matter: coherent, Compton and photoelectric interactions; concepts of attenuation, absorption and scatter – and their practical consequences. 2.2 Radiation Protection (7 hours) Statutory responsibilities: an appreciation of relevant legislation and Codes of Practice. The content of the “core of knowledge” as specified by the Ionising Radiation (POPUMET) Regulations (1988) or subsequent revisions. Genetic and somatic effects of ionizing radiations. Relative risks of ionizing radiations.
  34. 34. The principles of dose limitation, the various practical means of dose reduction to staff and patient with special consideration of females and children. Staff and patient doses: magnitude and measurement. 2.3 Production of X-rays (3 hours) The basic principles of a rotating anode X-ray Basic factors which influence X-ray output from differing types of X-ray machinery; anode material kV, mA, focal spot size, tube rating, filtration. Design and construction details will not be examined) 2.4 Geometric factors and magnification, effect of focal spot size, geometric movement and unsharpness. Convention film/screen systems: basic structure: characteristic curve; latitude; density; speed; contrast and how to influence or manipulate it. Basic principles and effects of film processing. Basic principles of image intensification. Operator-controlled variables. Principles of tomography, particularly CT, with emphasis on operator-controlled variables, e.g. slice thickness, partial volume effect, field size and effect on resolution, data storage and display, pixel/voxel, window width and level, and gray scale. Basic principles of digital imaging and picture archiving and communications systems (PACS). 2.5 Principles of diagnostic ultrasound (5 hours) The basic components of ultrasound system. Types of transducer and the production of ultrasound with emphasis on operator- controlled variables. The frequencies of medical ultrasound. The interaction of ultrasound with tissue, including biological effects. The basic principles of A, B, M, real-time and duplex scanning. The basic principles of pulsed, continuous wave and colour Doppler ultrasound. Recognition and explanation of common artifacts. 2.6 Magnetic resonance imaging (5 hours) Basic principles and origin of the signal.
  35. 35. Principles of basic sequences in clinical use. Concept of T1, T2, proton density and effect of motion on signal. Magnetic field hazards to patients, staff and passers by. 2.7 Radionuclide imaging (5 hours) The function of a gamma camera. Properties of radiopharmaceuticals. Static and dynamic imaging. Handling of radionuclides. Introduction to single photon emission computed tomography (SPECT) and positron emission tomography (PET).
  36. 36. MAXILLO-FACIAL RADIOLOGY. I. DEFINITION AND OBJECTIVES IN GENERAL The specialty of maxillo-facial radiology comprises knowledge and skills concerning the diagnostic utilization of ionizing radiations. The focus of the specialty should be on interpretation of information on the teeth, jaws, facial skeleton, oral cavity, nasal sinuses, temporomandibular joints, salivary glands and pharynx with surrounding tissues and functions. The scope of the specialty shall include diagnosis of pathological lesions, traumatic and post-surgical changes and other craniofacial deviations in individuals of all ages. Education in maxillo-facial radiology shall result in specific knowledge and skills in radiological examination techniques that have odontological applications and also in knowledge of other techniques. Knowledge of the biological, physical and technical basis underlying different diagnostic methods, equipment and different imaging processes is also required. In addition to the above mentioned, the education shall provide knowledge in stomatognathic physiology, oral surgery, oral pathology, medical radiology and ear, nose, and throat diseases (ENT). II. DIAGNOSIS IN ORAL HEALTH A. Independently and in an experienced manner be able to perform: - examination and diagnostics diseases and anatomical deviations of the teeth, jaws, and facial skeleton with the aid of optimal radiological techniques. - examination and diagnosis of the salivary glands and of the soft tissues, of the temporomandibular joints, and the nasal sinuses - cephalometric examinations and analyses B. Having good knowledge and come experience of: - existing imaging techniques for the examination and diagnostics of the functions of the oral cavity, jaws, salivary glands and pharynx C. Have theoretical examinations on and have attended the handling/examination of: - ultrasound examinations and radiological examinations of the neurocranium and the neck III. PREVENTIVE DUTIES The specialist with her/his specific knowledge shall be able to inform and advise on:
  37. 37. - radiation protection - radiation dosages and measurement of dosages - evaluation of radiation risks and diagnostic methods IV. COOPERATION WITHIN AND OUTSIDE THE ORAL HEALTH SYSTEM The specialist in maxillo-facial radiology gets into contact with many individuals in general dentistry, in other health specialists, in medical radiology and in other medical specialties in particular in ENT but also in oncology and rheumatology. Therefore the specialist shall be able to cooperate with representatives of all these disciplines. CURRICULUM FOR SPECIALIST TRAINING IN ORAL HEALTH decided by the Swedish Board Health and Welfare, 1993 In the general description the following issues are defined for specialist training in general: -directions -objectives -knowledge and skills common to all the specialties -time-limits (the education should be minimum 3 years. The supervisor should decide if the described objectives of knowledge, skills, and attitudes are accomplished after 3 years. If not, the education should be extended or discontinued). - certification (accreditation) of educational programs of a clinic - certification on completion of education - certificate on specialist competence that is given by the Board fro Health and Welfare - general advice on o the aims and structure of the objectives o supplementary education o supervision o quality assurance of specialist education Then there is a description for each of the eight specialties: Pedodontics, orthodontics, periodontics, oral surgery, prosthodontics, maxillo-facial radiology, and stomatognathic physiology.

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