The Royal College of Dentists of Canada: History, Misconceptions and Recent Developments

History

In the 1960s, the CDA recognized the importance of creating an independent organization to establish standards for dental specialists in Canada. This function of setting and enforcing standards for dental specialists would be similar to the regulation of general dental practitioners through the National Dental Examining Board and the provincial licensing bodies. On March 18, 1965, the Act of Incorporation for the Royal College of Dentists of Canada was passed in Parliament. The goals of the RCDC, as stated in the Act of Incorporation, are as follows:

• To promote high standards of specialization in the dental profession.

• To set up qualifications for and provide for the recog ni tion and designation of properly trained dental specialists.

• To encourage the establishment of training programs in the dental specialties in Canadian schools; and

• To provide for the recognition and designation of dentists who possess special qualifications in areas not recognized as specialties.

Through this legislation, the RCDC became the only group with parliamentary authority to examine dental specialists on a national basis.

The structural organization of the RCDC is comparable to that of the Royal College of Physicians and Surgeons of Canada (RCPSC), and its rules and regulations were drawn up with substantial assistance from the RCPSC registrar. While the RCDC was in its infancy, a so-called provisional council was required to carry out the functions that would eventually be assumed by the RCDC. The members of this council, nominated by the CDA, consisted of 2 outstanding senior specialists from each of the specialties recognized by the CDA.

Initially, interim examinations were offered to practitioners who were already registered as specialists, to help establish a membership base for the RCDC. It must be remembered that in the mid-1960s not all dental specialists had undergone formal training, although many had done so. For example, some had been practising as specialists for many years, even though formal training in their specialty did not exist in the 1940s and 1950s, when they were establishing their practices. Successful completion of the interim examination allowed the candidate to use the designation Fellow in the Royal College of Dentists of Canada (FRCD(C)).

Later, the examination took the form of a 2-part test: part 1 covered the basic science associated with the individual specialty, and part 2 was clinically oriented; for part 2, the candidate was often required to bring histories of treated cases with long-term follow-up. The part 1 examination could be taken immediately upon graduation from a specialty program or residency, but part 2 could not be taken until a minimum of 3 years had elapsed after graduation from a specialty program. In the 1970s and 1980s, the FRCD(C) designation paralleled in many ways the diplomate status conferred by the American dental specialty boards. As a result, it was frequently recognized as equivalent, but reciprocity was not granted. The most significant structural difference is the fact that the RCDC, a single national body, examines all dental specialties recognized by the CDA, whereas in the United States, each specialty has its own examining board.

In 1981, the part 1 examination was modified to include a clinical component and was designated as the entry-level, “Membership” evaluation of competence (MRCD(C)). The previous part 2 examination was designated the expert, “Fellowship” level (FRCD(C)). In retrospect, the MRCD(C) category served a useful purpose in that certain DRAs used this designation as one criterion for specialty licensure. Unfortunately, many candidates who took the Membership examination did not proceed to the Fellowship level, which led to the potential perception of 2 levels of dental specialists. The Membership examination was eventually re-designated the part 1 examination to eliminate this confusion.

Obtaining Fellowship status has become critical for specialists who practise in a hospital setting, because this achievement is often essential for obtaining hospital privileges in such dental specialties as oral and maxillofacial surgery, oral pathology, pediatric dentistry, oral radiology and now oral medicine. The dental Fellowship qualifications parallel those of the medical equivalent and provide a national standard for specialists regardless of where they obtained their training.

Recent Developments

Over the past few years there has been a rapid escalation of change in the RCDC’s activities, precipitated chiefly by the proposed Agreement on Internal Trade. One of the principles underlying this agreement is ease of portability of qualifications. Therefore, under the agreement, the DRAs, which grant licences to practise, will not be allowed to prevent dentists recognized as specialists in one province or territory from practising in a different province or territory. The DRAs were theoretically required to sign a Mutual Recognition Agreement (MRA) by July 2001 to ensure compliance with the Agreement on Internal Trade. At the time of writing, 7 of 10 DRAs have signed the MRA.

Most DRAs currently require incoming specialists to have undergone graduate training or residency in programs certified by either the CDA or the American Dental Association (ADA). Most also require graduate specialists to have undergone some form of examination. The purpose is to evaluate the individual’s capabilities, rather than the content of the various programs. For the past several years and up until 2000, the Membership or part 1 RCDC examination has been chosen by many DRAs as one of the licensing requirements for incoming specialists. In addition, for many hospital-based specialists, a Fellowship designation has been required to obtain hospital privileges. This situation represented a potential conflict, in that trained, competent specialists might be denied hospital privileges because they lacked a Fellowship. For this reason, in the mid-1990s, the examinations for oral and maxillofacial surgery and other hospital-based specialties such as oral radiology, oral pathology and oral medicine, were converted to a one-step Fellowship, which was available on completion of the residency or graduate program. In 1997 the examinations for pediatric dentistry were also converted to a one-step Fellowship. These changes created a disparity between the specialties with a one-step Fellowship and the other specialties, specifically orthodontics, prosthodontics, endodontics, dental public health and periodontics, which continued to have a 2-step Fellowship (part 1 obtained at graduation and Fellowship some years later).

The Task Force on Provincial Specialty Relations, consisting of representatives from the various DRAs and the RCDC, was formed in the late 1990s to review these conflicts. As a result of this highly cooperative effort, the RCDC has required that all specialties have a one-step, entry-level Fellowship examination for 2001 and beyond. In addition, to satisfy the unique requirements of each provincial DRA, the RCDC was asked to administer the NDSE beginning in January 2001. Candidates who pass the NDSE can obtain a licence as a specialist in their chosen province. They can also apply for Fellowship designation, according to the credentialing requirements of the RCDC. It can therefore be expected that, as of 2001, most incoming dental specialists who pass the NDSE run by the RCDC will, on application to the RCDC, be given the FRCD(C) designation. This process is similar to the fellowship process for their medical counterparts.

Provincially registered dental specialists who have passed the RCDC part 1 examinations, who hold the designation MRCD(C) or who have no previous experience with the RCDC examination may be concerned that they do not have the FRCD(C) designation, whereas most incoming dental specialists will obtain this designation through a single examination process. To address these concerns, the RCDC will offer, for a limited time, the opportunity for provincially registered specialists to obtain the FRCD(C) designation by successfully completing an interim examination. The interim examinations will be clinically oriented, and the exact format of each will be specific to the individual dental specialty. Interim examinations will be available as of 2002.

The Examination Process

To fulfill their role of protecting the public, the DRAs must ensure that specialists meet the level of competence required for licensure. The RCDC cooperates with the DRAs in developing improved evaluation methods that are acceptable to both parties. Given that successful completion of the RCDC-administered NDSE will soon be the main criterion for obtaining a specialty registration in most provinces and territories, the examination process is now a high-stakes entry-level competency examination. The RCDC has periodically conducted examiner workshops, and a psychometrician has recently been employed to help the examiners develop examination techniques that are suitable for the entry level in a specialty and that also satisfy the requirements of the DRAs. An examiner workshop was held in 2000 in cooperation with and with the financial support of the British Columbia, Alberta, Ontario and Quebec licensing authorities. In 2001, the oral and maxillofacial surgery examiners held a workshop to refine their examination process.

Successful completion of the NDSE may add portability to a specialist’s credentials. However, this portability is subject to the signing of the Mutual Recognition Agreement by the DRAs. Therefore, successful completion of the NDSE will be considered equivalent to the National Dental Examining Board examinations for general practitioners.

The RCDC also offers a mechanism for assessing foreign dental graduates. Given the challenges of recruiting faculty across North America, the deans of Canadian dental schools have often turned to foreign graduates to fill their senior academic positions. To assist in assessing the qualifications of these teachers, who may be recruited to be heads of departments, the RCDC offers a process involving examination of credentials and approval to write the Fellowship examination. The approval is subject to the applicant’s ability to prove that he or she has received training in a program assessed as equivalent to programs accredited by the Commission on Dental Accreditation of Canada (CDAC) or the ADA Commission on Dental Accreditation (CODA). Because many of these academics have strong research backgrounds, an alternative method of achieving the Fellowship has been established. The examination is every bit as rigorous as the conventional one but takes into account their research and teaching background. The RCDC examination process ensures that the candidates meet standards consistent with current teaching and dental practices in North America.

The RCDC examination process and questions are designed to reflect the content required by the CDAC and the CODA, and the RCDC has a representative on the Canadian body, to facilitate exchange of information. As the knowledge base changes, so does the need to ensure that candidates and their training programs remain up-to-date. This is achieved not only through revision of the examinations but also through contact with directors of graduate programs accredited by the CDAC or the CODA. There is now increasing cooperation between the RCDC and the heads of the graduate programs and with the national specialty groups. It is hoped that eventually the heads of all graduate programs in Canada will be required to hold a Fellowship or American board certification, a requirement that is already in place in the United States. To further enhance the examination process, the RCDC consults with the various dental specialty boards of the United States, with the RCPSC and with other appropriate groups.

Conflicts of interest are avoided through strict examiner guidelines on conduct and confidentiality. Because the DRAs have a stake in the quality of the examination process, they may send observers to the examinations. However, observers who have not yet attained Fellowship status may not present themselves as RCDC examination candidates for a period of 5 years after the date of observation. Observers are expected to follow the same strict code of conduct and confidentiality expected of RCDC examiners. The DRAs also have representation on the RCDC Council, particularly for matters pertaining directly to examinations.

The RCDC offers examinations in all dental specialties, including the dental sciences. Specific information can be obtained from the RCDC at the following address: Royal College of Dentists of Canada, 405 – 5075 Yonge St., Toronto, ON, M2N 6C5. Telephone: 416-512-6571; fax: 416-512-6468; e-mail: director@rcdc.ca; Web site: www.rcdc.ca. 

Summary

The standards of practice that dental specialists uphold are of paramount importance to the public and to other dentists. The DRAs will soon require a national standard for dental specialists entering practice, regardless of where they trained or their practice location. The RCDC is serving an important role in ensuring that these standards are met by offering the NDSE, which can also lead to the designation of Fellow in the Royal College of Dentists of Canada. 

Acknowledgments: The author would like to thank his colleagues from the Royal College of Dentists of Canada, Drs. Allen Wainberg, James Shosenberg, John Fraser, Keith Titley and John McComb, as well as the executive director, Mr. David McDonald, and the registrar emeritus, Dr. John Speck, for their valuable input.

Dr. Kennedy is vice-president, Royal College of Dentists of Canada.

Correspondence to: Dr. David B. Kennedy, 200-650 W 41st Ave., Vancouver, BC V5Z 2M9. E-mail: kennedys@direct.ca.