A Review of Continuing Professional Development For Dentists in Europe

European Journal of Dental Education ISSN 1396-5883
A review of continuing professional development for dentists

in Europe*
E. Barnes1, A. D. Bullock2, S. E. R. Bailey1, J. G. Cowpe1 and T. Karaharju-Suvanto3
1
2
School of Postgraduate Medical and Dental Education, Cardiff University, University Dental Hospital and School, Heath Park, Cardiff, UK,
Cardiff Unit for Research and Evaluation in Medical and Dental Education (CUREMeDE), School of Social Science, Cardiff University, Glamorgan Building, Cardiff, UK,
Institute of Dentistry, University of Helsinki, Helsinki, Finland
Keywords
continuing professional development;
continuing education; dentistry.
Correspondence
Jonathan G. Cowpe
Dental Postgraduate Section,
Wales Deanery - School of Postgraduate
Medical and Dental Education
Neuadd Meirionnydd
Heath Park
Cardiff CF14 4YS, UK
Tel: +44 (0)29 2074 4317
Fax: +44 (0)29 2074 3960
e-mail: cowpeJG@cardiff.ac.uk
Accepted: 5 January 2012

doi:10.1111/j.1600-0579.2012.00737.x
Abstract
Aim: To summarise findings from a literature review of dentists engagement in
continuing professional development (CPD) and its effects on improving oral health
care for patients.
Method: The search strategy used key terms in a range of databases and an academic
literature search engine, complemented by hand searching and citation follow-up.
Results: One hundred and fourteen papers were reviewed. The majority of dentists
engaged in CPD. Factors affecting participation included time since graduation, costs,
work and home commitments, postgraduate qualification, interest and convenience.
Learning needs identification and reflection on practice were rarely evidenced. Common modes of CPD were courses and journal reading; no one delivery method proved
more effective. Few papers directly explored recommendations for topics although
suggestions related to common areas of error and gaps in knowledge or skill. Studies
of CPD effectiveness and impact-on-practice suggested that courses can result in widespread new learning and considerable self-reported change in practice. However, significant barriers to implementing change in workplace practice were noted and included
availability of materials, resources and support from colleagues.
Conclusion: To ensure high standards of care, alongside recommending core or mandatory topics, more attention should be given to reflection on learning needs, the learners readiness to engage with education and training and the influence of the
workplace environment.
Introduction
Key competences required of the new dental graduate and a
European perspective on the quality assurance of undergraduate
education have been established (1). In the context of changing
patterns of oral health needs (2), an increasingly wide range of
health issues (3) and higher patient expectations (46), practitioners need to develop a wider knowledge base than that
which can be provided by undergraduate training alone (610).
Continuing professional development (CPD) is the mechanism
by which dental practitioners develop their skills and knowl*Article reproduced from Eur J Dent Educ 16 (2012) 166178
2013 John Wiley & Sons A/S
Eur J Dent Educ 17 (Suppl. 1) (2013) 517
edge and maintain up-to-date practice. Definitions of CPD

(1114) draw attention to the career-long importance of CPD
and its value for patient care.
Although rules about the required amount and content of
CPD vary across the European Union (EU) (1517), there is
evidence of a worldwide trend towards mandatory CPD (5, 9,
1821). The need to update clinical skills and integrate new
developments into patient care is an accepted part of professional practice and increasingly related to continued registration (22, 23). However, differences in CPD requirements mean
that patients are likely to be subject to different standards of
oral health care depending on where they live, or travel to,
within the EU (24). This paper presents a summary of the findings
5
Review of CPD for dentists
Barnes et al.
of a review of the literature undertaken as part of a wider study

(DentCPD part funded by the European Commission
(#509961-LLP-1-2010-1-UK-ERASMUS-EMHE). The review
aimed to report dentists engagement in CPD, focused on Europe, and its effects on the oral health care for patients. This
involved reviewing:
l the volume of CPD undertaken, factors associated with
uptake and barriers to participation;
l the range of CPD delivery methods;
l CPD topic preferences and
l what is known about CPD effectiveness and impact-onpractice.
Method
As well as searching for papers in the scientific, medical and
nursing databases (Web of Science; OVID Medline; EMBASE;
CINAHL; SCOPUS Life Sciences, Health Sciences, Physical Sciences and Social Sciences & Humanities), others were included
to capture educational (ERIC after 1996; British Education
Index) or social sciences and psychology aspects (ISI Web of
Knowledge; ASSIA after 1987; PsychInfo). Unless otherwise
indicated, there was no date limit initially, although papers
published prior to 1990 were later excluded. An academic literature search engine (Google Scholar) was also utilised. This
search was conducted in the UK and complemented by one
undertaken by colleagues in Finland who searched four databases (OVID Medline; EBM Reviews ACP Journal Club 1991
to December 2010; EBM Reviews Cochrane Database of

Systematic Reviews 2005 to December 2010, EBM Reviews
Database of Abstracts of Reviews of Effects 1st Quarter 2011).
All searches were conducted during February 2011.
The UK team employed the following search terms:
dent* AND CPD
dent* AND CPD AND Europe
dental AND education
dental AND education AND continuing
dental AND education AND Europe
dental AND education AND continuing AND Europe
The terms employed by the Finland team were:
dent* AND continuing education
education, dental, continuing/legislation & jurisprudence,
standards
Additional papers were identified by the DentCPD research
team through reviewing the reference lists of retrieved articles
and hand searching the European Journal of Dental Education
and the British Dental Journal.
Titles and abstracts, if available, of each reference were
scanned for relevance or further investigation. Only papers
focusing on CPD for general dentists were included. This
excluded papers focusing on dental care professionals (DCPs),
undergraduate education, vocational training or assessment
rather than continuing education. Papers published before 1990
and those advertising courses or events were also excluded.
Papers including empirical evidence, reviews, summaries or
opinion articles were included. Papers were first categorised by
EB (UK) and TKS (FI). Uncertain cases were cross-checked
with AB (UK).
Databases
searched
Results
4310 papers
retrieved
2546 duplicates
removed
1764
titles/abstracts
screened
118
papers
relevant
1646
papers
excluded
32 could not
access
26 from
other
sources
103 full
papers
9
abstracts
only
114
sources
included
Fig. 1. Literature selection process.
Comprising:
83 empirical papers
8 reports
7 literature reviews
4 opinion pieces
12 topic summaries
Initial database searches identified 1764 potentially relevant

papers of which 119 were judged to be relevant. An additional
27 were included from reference lists and hand searches. Of
these, 105 were read in full, abstracts were only available for
nine, and 32 could not be accessed. Eighty-three of these were
empirical, and 31 were summary papers, reports, literature
reviews or opinion pieces (see Figure 1). A full list of papers
included and excluded are available upon request.
Continuing professional development uptake

A number of studies have reviewed the amount of CPD undertaken by dental practitioners. Table 1 provides a summary.
Most typically, information on the amount of CPD undertaken
has focused on course attendance and has been gathered by
questionnaire survey.
These studies show that uptake varies considerably and
several report a small proportion of dentists not participating
in any courses (4, 31, 33, 39). However, it is difficult to make
comparisons because studies report a variety of modes of CPD
delivery and even where courses alone are considered, the type
(e.g. lecture, hands-on) and duration (e.g. half-day, full-day)
differ or are not specified. Furthermore, although the majority
of these studies looked at courses undertaken in the previous
year (4, 25, 31, 33, 34, 3941, 43), some looked over a 2-year
period (28, 29, 35, 36) and one considered intentions (10).
Country
UK
Ireland
Worldwide
UK
USA
UK
Ireland
UK
UK
USA
Saudi Arabia
Northern Ireland
Switzerland
Authors
Walmsley and Frame (25)
Buckley and Crowley (26)
Allen et al. (27)
Johnson, Johnson et al. (28)
Kuthy, Bean et al. (29)
Baldwin et al. (31)
Buckley and Gloster (32)
Mercer, Long et al. (33)
Ireland et al. (34)
Kuthy et al. (35)
Al Fouzan (36)
McGimpsey et al. (37)
Wiskott, Borgis et al. (38)
Audit of records, questionnaire

(unclear 40-60% of 1300)
Questionnaire, no n given
Questionnaire 298 returns
Audit 507 returns
Questionnaire, 90 responses
Questionnaire 183 responses
Audit 507 returns
Audit, 146 dentists
Audit, 1700 GDPs
Main method, numbers
Geneva
GDPs in eight urban cities within Kingdom of Saudi

Arabia
Sample of Northern Ireland GDPs
Dentists on Ohio register
Dentists on Health Authority lists in two regions
2 cohorts 1 qualified just before mandatory DVT

and 1 qualifying just after its introduction from the
Scottish Dental School in 1991 and 1994
Sample of dentists on the Irish Dental Council
register in the South West region
GDPs taking part in clinical audit in Yorkshire
Practitioners attending day courses
Sample of dentists participating in CDE in the South

and Mid-West regions of Ireland
26 selected national dental associations
Data collected from records held by West Midlands

Regional Postgraduate Dental Education Committee
on attendance at courses
Context, subjects
TABLE 1. Studies reporting amount of continuing professional development (CPD) undertaken by dental practitioners
10 countries reported hands-on courses were taken

by <10% of dentists, four countries reported
20-40%.
74% attended at least five courses over the
preceding 2 years.
Mean of 10 courses (56 CPD hours), mode 6, max
37. This related to a mean of 56 CPD hours over
the previous 2 years.
98% attended a mean of 5.6 sessions in the previous
year. 15% attended none. No differences by year of
graduation or gender.
92% attended at least one course and more than
65% had attended more than three courses.
In previous year, 82% attended 1 State funded
course; 50% 1 private course. 13% attended
zero. 20% involved in study groups.
In the previous year: 99% attended one
postgraduate session, 89% attended 2, 53%
attended 4.
Mean of 10 courses taken over the previous 2 years.
42% took at least one course provided by a dental
school and 67% took at least one from a local
dental society.
Within the previous 2 years 46% attended only one
or two courses.
90% of respondents fulfilled contractual requirement
by attending at least two courses annually. 60%
attend 5+ events a year.
Only 20% of the required course hours were
undertaken.
41% attended at least one course during previous

academic year.
Age variation, reduced uptake amongst older
practitioners.
Low level of involvement in some modes of CPD.
Key findings
Barnes et al.
8
Country
Australia
Ireland
Mongolia
UK
UK
Hong Kong
Greece
Italy
Australia
Authors
Best and Messer (39)
Buck and Newton (40)
Tseveenjav, Vehkalahti et al. (12)

Firmstone, Bullock et al. (41)
Burke, Wilson et al. (4)
Chang, Ng et al. (10)
Kossioni, Tzoutzas et al. (42)
Nieri and Mauro (43)
Hopcraft et al. (44)
TABLE 1. Continued
123 telephone interviews

Questionnaire 396 returns.

Review of records
Dentists on register
Dental practitioners in Prato
Greek Dental Associations (DAs)
Dentists attending 26th Asia Pacific Dental Congress
GDPs in Scotland and North West England
Dentists in the capital city

GDPs in three English deaneries
Dentists on general dental council (GDC) register
Dental practitioners in Victoria
Context, subjects
52% belonged to a study group; 67% subscribed to

journal; 89% regularly discussed work with
colleagues; 99% assessed their own work but 13%
did not attend CPD courses and 18% did not
complete any courses within the previous year.
50% attended 5+ days in the previous year. 87%
read journals once per month.
In last 2 years 38% undertook some form of CPD.
97% one 2.5 h course; 43% 15+ hours in the
previous year.
In previous year: 41% 5+ courses; 27% 3-4; 27%
1-2; 5% zero.
96% intended to attend CPD courses within next
5 years.
18 DAs had organised CPD courses in previous
3 years. Attendance was 21-50% (11 DAs), 70%
(three DAs).
In previous year: mean two courses, consulted 31
books, 53 journal papers (mainly national), accessed
internet information 16 times, 44 consultations with
colleagues.
During 2007 more than half of respondents attended
20+ hours of CPD. 93% attended a course, 85%
read journals, 68% discussed practice with
colleagues and 68% attended a conference. Only
5% took part in distance learning, 8% clinical audit
and self-assessment (16%).
Key findings

Barnes et al.
Barnes et al.
To understand more about the reasons for the variation in

engagement with CPD, studies that reported factors relating to
CPD uptake were scrutinised. Table 2 provides a summary of
the findings.
A number of these studies report a curvilinear relationship
between age/experience and CPD: less CPD seemed to be
undertaken by both younger or more recently qualified practitioners as well as older or more experienced practitioners. Leggate and Russell (51) suggest that more recent graduates may
not participate beyond the minimum requirements because
they have recently qualified and may be reluctant to pay for
CPD because of the financial demands of building a clinical
practice whilst managing educational debts. Provision, costs
and the professionals time may restrict the practitioners willingness to participate in CPD (41, 46, 50, 54). Older dentists
may only seek out activities which fulfil a perceived clinical
need, such as new techniques or materials, or ones that provide
an opportunity for an increased income (29). Other factors
affecting uptake include domestic commitments, gender and
whether the practitioner holds a postgraduate qualification (12,
46, 52, 55, 57).
Some studies have looked at reasons for attending courses or
engaging in other forms of CPD (Table 3).
A key dimension is whether choice of CPD activity is needsdriven or convenience- and/or interest-led. Although these
studies provide evidence of dentists selecting CPD on the basis
of the content and a desire to improve skills or knowledge
(which may or not be linked with an analysis of learning need),
the literature also provides evidence of dentists selecting CPD
on the basis of factors such as location, the speakers or need to
fulfil CPD requirements.
In summary, a number of empirical studies have explored
CPD uptake and factors that recur include: the age of the practitioner and time since graduation, the costs of taking part,
work and home commitments, whether the practitioner holds a
postgraduate qualification, the practitioners desire to improve
their practice as well as their interest and convenience-related
factors.
Continuing professional development modes of

delivery
Several papers focused on how CPD is delivered. The modes
commonly reported include: courses (including hands-on, seminars and lectures); reading journals or books; e-learning/internet usage; distance learning; and audit (8, 38, 54). The General
Dental Council (GDC) surveyed dentists opinions shortly after
the introduction of mandatory CPD in the UK and found that
commonly respondents thought that effective methods of verifiable CPD included reading journals (93%) lectures (89%), and
hands-on courses (88%). They were observed to undertake peer
review (62%), audit (54%) and use dental education websites
(39%) less often (63). This finding echoed an earlier survey
reported by Bullock et al. (52) who observed that the most frequently undertaken forms of CPD within their UK sample were
journal reading (98%) and courses (97%) whilst the least frequently undertaken were clinical audit (11%) and distance
learning (9%). Chan et al. (10) discovered that respondents at
the Asia Pacific conference preferred formal lectures (82%),
with self-learning approaches such as distance learning (29%)

and Internet courses (29%) also mentioned. Regular discussion
with colleagues was also reported as a common form of continued learning. Abbott et al. (56) found that half of the courses
taken by their Australian participants were lecture courses or
seminars with the remainder incorporating practical and clinical components. However, when Woolfolk et al. (64) presented
participants with a choice of CPD formats, 42% selected distance learning methods whilst only 17% chose traditional formal lecture courses.
Lectures are acknowledged as a useful method for disseminating information as well as providing an opportunity to meet
up with colleagues (28, 51). Seminars require the dentist to
take a more active part in the session. Interaction between
tutors and the audience, and amongst the group itself, can aid
learning but relies on the skills of the facilitator (53). Bullock
et al. (65) found that hands-on courses were well received by
participants.
Professional dental journals are a source of information with
high potential value to practitioners (53). The array of journals
available, the range of topics covered within them and a lack of
interest in, or relevance to their practice of some topics means
that their impact can be lessened without careful review (53).
Tredwin et al. (66) observed that this is rarely the dentists only
form of CPD.
Self-assessment and clinical audit are not only mechanisms
for identifying gaps in knowledge but, as Redwood et al. (62)
argue, should involve monitoring and reflection on clinical
practice. This was also found as an important factor in the
recent view of CPD impact untaken by the GDC (67).
The internet is now a well-accepted source of information
for both practitioners and patients (6870), and e-learning is
a common and well-received method of distance learning
(71, 72). In 2000, Kuthy et al. (73) found that at least 25%
of the dentists they audited had taken part in distance learning courses and just over 5% achieved all their required
CPD hours via this method. In some studies, participants
have requested greater access to IT-based courses (52), particularly younger dentists (51). In 2003, Clark (74) found more
than 300 courses for dentists available online and concluded
that use of e-learning would continue to rise. However,
Schleyer and Pham (75) reported that online courses could
be hard to search as there was no consistency in the terms
used by the sites, and most web pages did not state which
dental boards would accept accreditation of this form of
CPD. Websites can also remain online, unchanged, for many
years resulting in out-of-date information (53, 75). Another
disadvantage is the limited opportunity for human interaction
(7678). Eaton and Hammick (71) made recommendations
for distance learning programmes. A noted potential limitation of e-learning is the limited potential for teaching clinical
skills (79).
Overall, lectures are reported as cost-efficient, acceptable and
effective but their passive nature may hinder learning. Handson activity is good for learning skills and journal reading can
be a valuable adjunct if the reader knows how to filter information. Peer review and self-assessment are recommended components for CPD (15, 62), not just for identifying gaps in
knowledge but also reflecting on own practice. In addition,
9
10
USA
UK
UK
UK
UK
Australia
UK
Ireland
UK
UK
Kuthy et al. (29)

Baldwin et al. (31)
Ireland et al. (34)
Newton et al. (48)

Ralph et al. (49)
Belfield et al. (50)
Buck and Newton (40)
Leggate and Russell (51)
Bullock, Firmstone et al. (52)
UK
Ireland
Buckley and Crowley (26)
UK
USA
Mouatt et al. (46)

Young and Rudney (47)
Mongolia
USA
Bean (45)
Tseveenjav, Vehkalahti et al. (12)
Country
Authors
Questionnaire
Questionnaire 396 returns,

review of records
Discussion paper

Questionnaires 154 returns
Audit 507 returns

Audit 146 dentists

Audit of 507 GDPs and data

from American Dental Directory
All GDPs in three English Deaneries
Dentists practising in the capital city
GDPs in three English Deaneries
General dental practices in Scotland
Dentists on GDC register
n/a
Dentists on GDC register

Dental graduates of University of Leeds

2 cohorts 1 qualified just before mandatory DVT
and 1 qualifying just after its introduction from the
Scottish Dental School in 1991 and 1994
Dentists on English register

Sample of practising dentists within a six state
regions of the upper Midwest
Sample of dentists participating in CDE in the South
and Mid-West regions of Ireland
Context, subjects
TABLE 2. Studies reporting factors relating to continuing professional development (CPD) uptake
Travelling up to 30 miles for a one-off session was

acceptable to 27%.
Least likely to attend courses: female.
Completing a postgraduate vocational year had little
impact on later amount of CPD activity.
Most likely to attend courses: Association members
and mid-career dentists.
Two main types of costs of CPD: (a) provision costs
and (b) opportunity cost of professionals time.
Reading journals: those qualified longest were least
likely to read professional journals.
Views on CPD benefits: skill enhancement (those with
further qualification); career prospects
(those <30 years of age).
More likely to complete recommended amount of
CPD: postgraduate qualification; part-time related
work (e.g. tutor). Least likely: longer in practice;
single-handed.
Perceived need for CPD: less clinical experience,
working in general practice, having a postgraduate
degree and other CPD attendance during the time
period.
Four main constraints on participation: cost; personal
and staff issues; time and restraints owing to
regulating body.
Mean age of those undertaking CPD was 46.9 years,

graduating 20.2 years ago. 73% claimed to work
more than 30 h a week.
Least likely to attend courses: age < 30 and >50.
Cost and distance were less important factors than the
quality of the courses.
Dentists belonging to a number of organisations and
subscribing to various journals also tended to be the
most frequent attendees at relevant courses,
conferences and meetings.
With some exceptions, specialists and hospital-based
dentists were more likely to be involved in CPD
activities.
Curvilinear relationship between age and CPD.
The number of sessions attended was significantly
associated with feelings of competence.
Key findings

Barnes et al.
Less CPD undertaken by those with child(ren).

More CPD: working full-time. General practitioners
less likely to attend conferences than specialists.
Those in rural areas found accessing CPD harder.
Greece
Australia
Ireland
Kossioni, Tzoutzas et al. (42)

Abbot, Burgess et al. (55)
Polyzois, Claffey et al. (56)
Greek Dental Associations (DAs)

Data collected from University Continuing Dental
Education Committee (UCDEC)
12 cohorts of dentists who had qualified in Dublin
Australia
John and Parashos (54)
Audit
Australia
Best et al. (16)
Members of key dental organisations in 17 countries.
USA
Christensen (53)
Questionnaire, n undisclosed
Country
Opinion article
Effectiveness of different forms of CPD
Dentists tend not to attend CPD courses for the first

few years after education.
Costs of CPD involve not only the direct cost of
courses and other activities but also indirect costs
such as travelling and accommodation expenses and
loss of earnings.
Only dentists without a postgraduate qualification
tend not to attend CPD courses for the first few
years after education.
More likely to attend courses: <40 year of age.
Curvilinear relationship between age and CPD.
Authors
TABLE 2. Continued
Context, subjects
Key findings
Barnes et al.

e-learning has potential and is becoming a common aspect of

blended techniques.
Continuing professional development preferences

Many countries have no regulation about the content of CPD
and currently allow their dentists the freedom to make their
own choice of CPD topics: selection of CPD activity is left to
an individuals professional judgement. Other European countries mandate that certain core topics are studied.
There is a relative dearth of information on the essential subject areas for dentists CPD. Some studies report on what topics
dentists want to study rather that what might be judged essential. Vaughan (80) found that respondents wanted courses to
focus on, in order, theory, clinical demonstration, practical
work and the laboratory work. Mouatt et al. (46) found that
their participants wanted more information on practice management, hands-on training, computer use, restorative techniques, preventative treatment and oral surgery. Wiskott et al.
(38) reported that their participants requested more courses on
risk assessment in medically compromised patients, communication with attending physicians, medical emergencies and formal courses on topics such as otolaryngology, pharmacology,
haemostasis and antibiotics. Chan et al. (10) found that participants requested CPD in oral implantology, cosmetic dentistry
and root canal therapy. Similarly, Hopcraft et al. (20), in a survey of Australian dentists, asked what areas they required more
CPD which elicited the response implantology (39%), endodontics (39%) and aesthetic/cosmetic dentistry (37%).
In terms of what may be required, Shanley et al. (24) claimed
that most dental mistakes are made because of inadequate
cross-infection control, incorrect use of ionising radiation, failure to recognise the early signs of serious diseases such as cancer and incorrect management of a medically compromised
patient. They suggested CPD should focus on reinforcing these
topics. When Wright and Franklin (81) conducted a significant
event analysis workshop, they found that incidents fell into
three main themes: those involving clinical treatment, incidents
involving the running of the practice, and those related to the
relationships between members of the team and members of
the team and patients. Walker et al. (82) found their respondents identified gaps in their specialised clinical skill knowledge
but relatively few reported gaps in general clinical skills, communicating with patients, acute care of dental patients or
continuing care of dental patients. Christensen (8) based his
discussion of core topics on content that he considered insufficiently addressed in undergraduate training. He concluded that
practice management, practical occlusion concepts, aesthetic
dentistry, implant prosthodontics and implant surgery, orthodontics, diagnosis and treatment planning should be core topics.
The movement of dentists around Europe would be facilitated by a recognised core education available to all European
dentists, although as Blinkhorn et al. (19) highlight, harmonisation of CPD should accommodate diversity and innovation.
Promoting consistency in approach to training programmes,
argues Scott (83), should ultimately lead to a convergence of
high standards of the delivery of patient care. However, mandatory
11
12
Ireland
UK
USA
Australia
UK
UK
UK
Australia
Australia
Renehan (58)
Ireland et al. (34)
Johnson (59)
Leggate and Russell (51)
Sutton et al. (60)
John and Parashos (54)

Hopcraft, Marks et al. (20)
Australia
UK
Vlitos et al. (30)
Redwood, Winning et al. (61)
UK
Johnson, Johnson et al. (28)
Australia
Canada
Patterson and Thompson (57)
Hopcraft et al. (44)
Country
Authors
Summary paper

Questionnaire 396 returns,
review of records
Questionnaire
The role of self-assessment in CPD
Dentists on Victoria, Australia Register

Dentists on Victoria, Australia register
GDPs working in Merseyside area,
GDPs in three English Deaneries
General dental practices in Scotland
Practitioners attending alumni day

Dentists on Irish register
Pre-, post- and 6 months post-programme

assessment of dentists attending a year-long
restorative techniques course.
Dentists practising in Alberta and Atlantic Canada
Context, subjects
TABLE 3. Studies reporting reasons for choosing continuing professional development (CPD) activity
Most important factors in decision making: course content

(91%), identity of the speaker (72%) and location/travel
time of venue (39%).
Influenced by, title and content of the courses as
advertised, personal recommendation of a colleague,
geographic location.
Choice influenced by desire to improve skills (100%), to
learn new skills (94%), build confidence (100%) and
work under expert supervision (88%). Also break from
routine (63%) and contact with other GPs (75%) were
important.
Choice related to improving skills and knowledge
associated with work.
The cost was not as important a factor as the quality of
the course.
Delivery method least important factor in decision making.
Topics of the course and the identity of the tutor were
most important factors.
Views on CPD benefits: skill enhancement (those with
further qualification); career prospects (those <30 years of
age)
Selection of CPD on basis of a review of learning need
was rare. More commonly choice was convenience-led
plus consideration of other factors (e.g. new
developments, colleagues suggestions and views on
quality).
99% attended CPD courses out of interest in a particular
dental discipline and only one because of a personal
learning need.
Choice influenced by course presenters.
54% chose courses to improve knowledge; 27% to fulfil
CPD requirements; 11% to learn new skills; 3% for
personal satisfaction; 2% to mix with colleagues; 1% to
increase patient numbers.
Selection factors included: the topic (94%), the identity of
the speaker (66%), the day of the week it was held
(57%) and travel time (54%).
Choice influenced by who are course presenters.
Key findings

Barnes et al.
Barnes et al.
CPD creates challenges, not least for the quality assurance of

courses and programmes (19, 20) as well as the need for international recognition of activities (16). Over-prescription
beyond the inclusion of core topics risks de-motivating practitioners (84). Prior to any Europe-wide agreement on CPD,
targeted CPD for migrating dentists, rather than a system based
on free choice, may be a useful interim mechanism for achieving harmonisation (54, 85).
Continuing professional development effectiveness and impact-on-practice

As well as maintaining regular CPD activities, it is important,
perhaps more so in mandatory systems, that CPD is effective
(54, 66, 86, 87). Effective CPD is that which enables the participants to gain new knowledge and/or skills. CPD can be said to
have had an impact where an improvement in practice results
from the application of new knowledge or skills (20). The value
of CPD confirming that current practice is up-to-date has also
been noted (41).
The effectiveness and impact of CPD are difficult to evaluate.
Many CPD programmes do not assess learning gain, for example, through pre- and post-testing (3), and changes may not
occur immediately post-learning but emerge some time after
participation, after reflection, or emerge in a way that is difficult to quantify (18). It is unsurprising that there is relatively
little literature on CPD effectiveness or the impact of CPD on
practice. Absi et al. (88, 89) published two studies exploring
the pre- and post-course scores achieved over a series of 1-day
radiation protection courses. Participants showed a improvement (88, 89) although the authors noted that improvement in
scores is not evidence of improved clinical performance.
OFlynn et al. (90) asked attendants of courses Will you apply
what you learned to your practice? and found that the majority would at least apply it a little. However, this is an indication
of intention rather than behaviour. Cohen et al. (91) measured
changes in clinical performance immediately and 6 months
after taking part in a 1-day AIDS awareness course in the USA.
At 6 months, they found an increase in use of gloves, masks
and protective eyewear.
As reported above, dentists may select CPD on a convenience-led or interest basis (20). However, it has been observed
that the impact-on-practice is greater when CPD targets a dentists learning needs (52, 67). Bullock et al. (92) investigated the
use of personal development plans (PDPs) with UK dentists
and found that those who were supported in the process had a
clearer view of their learning needs and that learning from a
CPD activity was more likely to be applied in the workplace.
Courses have been found to be effective in improving knowledge and understanding (93, 94). Based on a survey of dentists
in Scotland, Maidment (94) reported that courses and reading
journals were both thought to be better for enhancing knowledge whilst other modes of CPD were better at changing practice. Mercer et al. (33) asked GDPs about CPD activities that
had impacted on the way they practised. Eighty per cent
claimed that participation in courses had led to change, followed by journals (9%) and peer review activity (7%). Over
three quarters of respondents reported a change in techniques,
use of materials and/or methods of treatment. Tredwin et al.
(66) observed that as well as increasing knowledge, more than

two-thirds of their respondents felt that an element of their
clinical practice had changed as a result of taking part in a British Dental Journal CPD initiative which entailed the self-completion of quizzes related to papers in every edition. Paterson
et al. (95) reported that between 28% and 44% of participants
identified a change in their practice after using Trends, an
illustrated guidebook. In 1994, Holt et al. (96) found that dentists reported a change in practice in providing detailed
descriptions to dental technicians, using a surveyor and tooth
preparation and choice of design after viewing a video on partial denture design.
John and Parashos (55) surveyed the effectiveness of CPD
programmes in endodontics and implant dentistry, using questionnaires on three occasions, pre-, post-course and delayed
(3 months later). Participation in these courses was voluntary
and the courses self-selected. Significant numbers of participants felt that their practice had changed (90% of the 60
respondents who had attended endodontic courses and 53% of
the 19 implant course participants).
Vlitos et al. (30) evaluated participants pre-course, immediately post-course and 6 months after completing a course. They
found that the topics that were rated to have the least impacton-practice were also those which were seen to have the lowest
relevance to their practice. Facilitators of change included perceived financial benefit, regular patient attendance, particularly
a compliant core patient group, staff loyalty, open communication and access to peer support (97).
Collado et al. (98) studied the effectiveness of a year-long
training course on conscious sedation in France. Forty-five dentists, with five or more years of clinical experience, attended
four 23 day long sessions which comprised both theory and
practical learning. Both trainees and trainers reported on each
treatment session via standardised forms. Post-course there was
no significant difference between the trainers and trainees
ability to successfully complete treatment under conscious sedation; however, there was a higher number of minor adverse
effects reported by trainees.
Such studies, largely based on self-report, suggest that
courses in particular have led to widespread new learning and
in some cases considerable changes in practice have been
claimed. However, significant barriers to implementing change
in everyday practice have also been noted and include issues
such as the availability of materials and resources or support
from colleagues in their practice (84). As for the value of particular CPD delivery modes, Best et al. (54) comment that in
general, evidence shows that no approach for transferring evidence to practice is superior to all changes in all situations.
Discussion
In the context of movement of graduate dentists across countries within the EU, there is a clear need to review education
and training provided through CPD, so that patients can be
assured of high quality care as a result of dentists undertaking
additional education and training. That review of undergraduate education has been undertaken by the DentEd programme
(99101). Following that, the DentCPD project has focused on
CPD and this review is part of that project.
13
Although care was taken to provide comprehensive coverage

of the topic, it is feasible that areas of the literature will have
been missed and the review should not be considered exhaustive or systematic in the formal sense. However, we can report
with confidence that a variety of learning modes are open to
graduate dentists in their pursuit of continuing education,
including both formal and informal activity and that there
appears to be a role for different CPD types, the most common
of which include courses and reading journals. How much
CPD is undertaken by different dental practitioners varies but
comparisons across studies are difficult because of the different
measures employed and this makes it hard to draw summary
conclusions. We have learned, however, that common factors
affecting updating relate to age or years experience and that the
relationship is not linear. We know that reasons for selecting
CPD activity also vary and that some activities are selected on
the basis of interest or convenience rather than led by some
reflection on learning need. This has been shown to have an
effect on the difference that CPD can make to practice. The literature reported here has drawn attention to some of the factors that may enable or impede the implementation of new
learning and our findings generally concur with those in the
recent review of CPD impact undertaken by the GDC (67).
The introduction of a mandatory system of CPD is based on
the argument that CPD will ensure that dental practitioners
knowledge and skills are up-to-date and by implication that
CPD contributes to high-quality dental care. In considering
what methods or modes of delivery might enhance the development of knowledge and skills, in this review, we have chosen to
take a limited focus on the dental education literature and so
have not included the wealth of literature from the medical
educational field that we know is extensive in terms of providing evidence on factors affecting CPD impact-on-practice
(102). Touching on this wider literature here, we know that
more effective CPD is undertaken over a period of time, when
it is interactive, and includes on-the-job opportunities to reinforce learning in practice. Multi-method and multi-phased
(more than a one-off) events are more likely to bring about
change (103105). On-the-job opportunities to practise can
result in improvements, and the workplace has been recognised
as a key site for professional learning (106108). Didactic, traditional lecture sessions on their own have been shown to have
little impact (109) although more generally, mode of delivery
or type of activity (e.g. lecture, web-based, reading, discussion
with colleagues, audit) is less critical than the match between
the CPD and the learning need (110112).
Harmonisation of dental CPD is needed to ensure that
patient care across Europe is provided at similar high standards
regardless of where that care is received. But it is not simply
sufficient to know what is up-to-date best practice. The practitioner needs to engage in a process of reflection so that that
new learning may be applied and the CPD used to improve the
standards of patient care for all. What is evident from our dentistry focused review is that to make a difference to clinical
care, it is necessary that the learner, the dental practitioner,
engages in a process of reflection on the new learning or skills
acquisition that might arise from an educational input.
In a system of harmonisation, we need to attend to what
CPD (content) must be undertaken and this should be largely
14
Barnes et al.
driven by patient safety concerns. We need also to address how

CPD is delivered and what methods or modes may be more
and less effective. We know something about more and less
valuable approaches to CPD from medical education literature,
as noted above. A drive towards harmonisation also needs to
be informed by an understanding of learning processes, how
they occur and how they may be best supported. Looking to
the healthcare management literature can provide information
on effective processes and systems of knowledge transfer (113).
Phillips and Phillips (84) have reviewed factors that promote
change and stage-of-change models have been suggested which
recognise the importance of the context in which change is
expected to occur, including the support of others, which in
our case would include other members of the dental team
(114). Key to models of change is the notion that the learning
programme or intervention needs to fit with the participants
readiness-to-change level. Here, there is value in reviewing
what may be learned from the work of psychologists and others
in studies of inventions designed to address addictive behaviours. Prochaska et al. (115), for example, describe a five stage
model from precontemplative, through contemplative, preparation, action and maintenance. They concluded that probably
the most obvious and direct implication of our research is the
need to assess the stage of a clients readiness for change and to
tailor interventions accordingly (p1108). In studies of learning
effectiveness, what is often overlooked is the importance of
what the learner in this case the dental practitioner brings
to the learning situation and their readiness to engage with the
educational input.
Parent et al. (113) write about a knowledge transfer capacity
model which includes what they label as an absorptive capacity
which brings together a number of elements relevant to this
discussion. They describe this capacity as the ability to do three
key things in relation to new knowledge, namely recognise its
value, assimilate it and then apply it. They identify that this
capacity is typically found in certain environments, those possessing prior related knowledge, a readiness to change, trust
between partners, flexible and adaptable work organisations
and management support (p87). Clearly, in addition to attending to CPD content, delivery method and what the learner
brings, a fourth element that requires consideration is the
workplace context. The workplace environment is an important
variable affecting the application of learning and a workplace
climate that promotes learning (including the informal learning
from self-reflection and problem-solving with colleagues) can
support the application of that learning to practice, to the benefit of all, including patients (102, 116).
Conclusion
Our review has described the range of factors that have been
found to affect participation in CPD. We have noted that a
variety of modes of CPD delivery are available and that the
level of learner engagement and the match with learning need
can make a difference to the effectiveness of the CPD. It can be
hard for dentists to implement change in practice but they can
be helped by supportive colleagues. The discussion draws on
the medical education literature in better understanding how
dental CPD may lead to improved patient care. We conclude
Barnes et al.
that more attention should be given to the importance of practitioner reflection, the state of the learners readiness to engage
with education and training and the influence of the workplace
environment.
Acknowledgements
This review was undertaken as part of the DentCPD project,
supported by colleagues in the University of Helsinki (Kimmo
Suomalanien), National and Kapodistrian University of Athens
(Argyro Kavadella, Anastassia Kosioni), Academic Centre for
Dentistry, Amsterdam (Henk Kersten, Eva Povel), Association
for Dental Education in Europe (Majella Giles, Damien Walmsley) and Riga Stradins University (Una Soboleva, Ilze Akota,
Andra Liepa) and part funded by the European Commission
(#509961-LLP-1-2010-1-UK-ERASMUS-EMHE). The authors
would like to thank Wendy Hardyman (CUREMeDE) for her
critical comment.
Conflicts of interest (added after original publication)

The authors have no conflicts of interest to declare.
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A Review of Continuing Professional Development For Dentists in Europe

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A Review of Continuing Professional Development For Dentists in Europe

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European Journal of Dental Education ISSN 1396-5883

A review of continuing professional development for dentists

Accepted: 5 January 2012

edge and maintain up-to-date practice. Definitions of CPD

Review of CPD for dentists

of a review of the literature undertaken as part of a wider study

to December 2010; EBM Reviews Cochrane Database of

Fig. 1. Literature selection process.

Initial database searches identified 1764 potentially relevant

Continuing professional development uptake

Walmsley and Frame (25)

Buckley and Crowley (26)

Allen et al. (27)

2013 John Wiley & Sons A/S

Eur J Dent Educ 17 (Suppl. 1) (2013) 517

Johnson, Johnson et al. (28)

Kuthy, Bean et al. (29)

Baldwin et al. (31)

Buckley and Gloster (32)

Mercer, Long et al. (33)

Ireland et al. (34)

Kuthy et al. (35)

McGimpsey et al. (37)

Wiskott, Borgis et al. (38)

Audit of records, questionnaire

Questionnaire 298 returns

Audit 507 returns

Questionnaire 514 returns

Questionnaire 307 returns

Questionnaire 183 responses

Audit 507 returns

Questionnaire 200 returns

Audit, 146 dentists

Audit, 1700 GDPs

Main method, numbers

GDPs in eight urban cities within Kingdom of Saudi

Dentists on Ohio register

Dentists on Health Authority lists in two regions

2 cohorts 1 qualified just before mandatory DVT

Dentists on Ohio register

Practitioners attending day courses

Sample of dentists participating in CDE in the South

Data collected from records held by West Midlands

10 countries reported hands-on courses were taken

41% attended at least one course during previous

Best and Messer (39)

Buck and Newton (40)

Tseveenjav, Vehkalahti et al. (12)

Burke, Wilson et al. (4)

Chang, Ng et al. (10)

Kossioni, Tzoutzas et al. (42)

Nieri and Mauro (43)

Hopcraft et al. (44)

Questionnaire 552 returns

123 telephone interviews

Questionnaire 514 returns

Questionnaire 701 returns

Questionnaire 245 returns

Questionnaire 379 returns

Questionnaire 396 returns.

Main method, numbers

Dental practitioners in Prato

Greek Dental Associations (DAs)