Littlewood S, Mitchell L An Introduction to Orthodontics.Oxford: Oxford University Press; 2019
Cobourne MT, DiBiase AT Handbook of Orthodontics, 3rd edn. : Elsevier; 2024
Jopson JL, Haworth JA, Atack NE The perceptions of undertaking a higher degree alongside orthodontic speciality training: a cross-sectional survey of British Orthodontic Society members. Br Dent J. 2021; 23:1-8 https://doi.org/10.1038/s41415-021-3617-4
Mintoff JC, Kandiah T, Rogers H What's on your mind? The impact of specialty training on the mental health of trainees in paediatric dentistry. Faculty Dent J. 2024; 15:56-61 https://doi.org/10.1308/rcsfdj.2024.18
This article provides a comprehensive guide for new orthodontic trainees, outlining essential strategies to succeed in specialty training. It emphasizes the importance of building professional relationships with peers, supervisors and staff, cultivating high-quality patient records and ensuring a well-rounded training experience. Key topics include managing training commitments, maintaining accurate case logbooks, understanding assessment requirements, and navigating complex treatment modalities. Additionally, the article discusses the benefits of pursuing a higher degree and the importance of balancing work commitments with personal wellbeing. With practical advice, this guide aims to help trainees approach orthodontic training effectively, and maintain a sustainable work–life balance.
CPD/Clinical Relevance: A comprehensive guide designed for new orthodontic trainees, detailing key strategies for successfully navigating specialty training.
Article
If you are reading this, you have either made or are contemplating making the best decision of your professional life. You have chosen to embark on the journey that is orthodontic speciality training. In 2016, orthodontics was ranked as the number one job in the US for reasons including career satisfaction and overall fulfilment relative to other professions.1 Commencing this journey may invoke feelings of excitement, uncertainty and apprehension, but this article will guide you as you take your first steps in orthodontics.
The first year is arguably one of the most challenging, but efforts made now will pay dividends later in training and for the rest of your career. Below you will find hard-learned lessons and insights that will assist you in making the very most out of your first forays into speciality training.
Professional relationships
Building and maintaining professional relationships is paramount to succeeding in orthodontic training. Key relationships in your orthodontic journey will be those with your speciality trainee peers, clinical and educational supervisors, training programme directors, consultants, dental nurses and administrative staff.
You should aim to begin cultivating these relationships as early as possible. As soon as you have been allocated your training post, show initiative and reach out to the department to arrange a meeting to introduce yourself to your colleagues and supervisors. Ideally, this should be in-person, but a virtual meeting may suffice. It is imperative that you have a frank and open discussion with your educational and clinical supervisors about expectations as early as possible. This way, you are aware of what they expect from you and what in turn you can expect from them. This should be as candid as possible, and topics you may wish to cover include:
Expected speed of response to emails;
How they would like work-based assessments to be completed;
How you can expect to be supervised;
How to manage clinics where supervision may not be available;
When and how to arrange meetings to discuss patients.
Working in collaboration with your fellow ST1 colleagues can reap many benefits. It is important to appreciate that you will be likely to maintain these relationships for the rest of your professional life. Orthodontics is a small world and your propensity and ability to collaborate with others will go far in building your reputation. Conquering training together, and looking out for each other means that you will never miss a deadline, yo will learn from each other's experiences, and have a wider pool of resources upon which to call. You will support each other through clinical and academic challenges, and any difficulties encountered can be more readily tackled through your combined efforts. It is immensely unwise to establish unnecessarily competitive or adversarial relationships with your peers.
When you start your training post, reach out to trainees in the training years above you. They will have vital information and advice on how to make the most of the training in your given unit and will be excellent first points of contact if you require advice before speaking to your consultants. They will, of course, also tell you things your consultants will not. Do not be afraid to ask, and ask often. They were in your shoes not long ago (Figure 1).
Figure 1. Authors' clinical team at the British Orthodontic Conference 2024.
Getting your records right
As you commence your training, you will undoubtedly take records of all the patients you will treat over the coming years. You must endeavour to maximize the quality of these ‘start’ records, as the opportunity to take them correctly is lost as soon as treatment commences (Figure 2). When presenting your work to consultants and colleagues, the quality of your records will be the first thing to be judged, and will say much about your attitude and approach.
Figure 2. High-quality orthodontic records are essential.
Clinical photography is an essential component of the training process. There is no other means of knowing the full effects of what you have done on a visit-by-visit basis. Taking photographs of every patient at every visit and scrutinizing these in close detail allows one to maximize the learning from each clinical encounter. It is is imperative to have the photographs from the last visit viewable at the chairside because they allow a point of reference when discussing mechanics with your clinical supervisors, and are a potent tool in motivating patients and their carers.
The Royal College of Surgeons of Edinburgh has removed the need to present personally treated cases from its Membership in Orthodontics examination (MOrth). Any further iterations of the MOrth are unlikely to contain personally treated cases. If you are going to spend the time meticulously treating your patients to the highest possible standard, it is worth considering submitting your cases to the European Board of Orthodontists (EBO), for provisional membership, at the culmination of your first 3 years of specialty training. This allows you to have your work appraised and provides a means of demonstrating your aspiration for clinical excellence. A good starting point is to familiarize yourself with the EBO requirements.2
Work with your clinical supervisors to identify patients who will positively contribute to your training. It is imperative not to commence orthodontic treatment in the context of suboptimal oral hygiene and dental health, or where there is no intrinsic motivation from the patient to receive treatment. Injudicious attempts at treatment in such instances inevitably lead to more harm than benefit for both the patient and the trainee. Counsel your patients before commencing treatment such that they know what is required of them from a diet, oral hygiene and attendance perspective, and be certain that they are appropriately invested in the treatment journey.
It is important to gain experience in a variety of treatment modalities and to treat similar malocclusions with different techniques so that you can see what works best and why. In order to have a sufficiently broad range of experience, some treatment approaches, techniques and auxiliaries you should aim to gain experience with are:
Protraction facemask;
Rapid maxillary expansion (RME);
Mini-screw assisted RME (MARPE);
Temporary anchorage devices (TADs), placed at all the typical insertion sites;
Sliding appliances, such as mesial- and distal-sliders;
Different bracket prescriptions: Roth; Andrews; MBT;
Fixed functional appliances, such as the Herbst appliance;
Buccal segment intrusion for anterior open bite closure;
Modified Kim mechanics;
Clear aligners;
Lingual appliances;
Finishing and artistic wire bending.
The more treatment modalities you have in your armamentarium, and the greater the effectiveness with which you can deploy them, the better an orthodontist you will be. Work with your consultant supervisors to identify cases where the above interventions may be used and quickly bring to their attention any shortcomings in the cases under your care.
Getting your bearings
There will no doubt be a plethora of systems and associated log-ins with which you will need to familiarize yourself. You must get the relevant access to these as soon as possible, and certainly well before you are due to commence clinics. Use your induction period to complete mandatory training, set up trust accounts, gain remote access, and learn how to manipulate photographic, radiographic and STL software. Do not be afraid to persistently follow up requests with IT departments because delays in setting up your permissions and log-ins inevitably hampers patient care.
You will be assigned an educational supervisor (ES) with whom you will meet regularly to set objectives and to ensure you are meeting the expectations of the training programme. Similar to foundation and dental core training (DCT), there is an online portfolio where you will log elements of your training progression. The system used in orthodontic specialty training is the Intercollegiate Surgical Curriculum Programme (ISCP) (Figure 3). Note that there is a charge per year for the use of this platform. Aim to create your trainee account in advance of your first ES meeting.
Figure 3. ISCP direct observed procedure (DOP) portfolio example.
Progress across the period of specialty training is assessed through the annual review of competence progression (ARCP). Here, a panel reviews your submitted evidence to prove you are making adequate progress and meeting the necessary objectives. It is imperative that you identify what is expected and what requirements are needed for your first ARCP, which will typically be held 6 months into your first year of training. This is likely to be covered in your induction with the deanery and your training programme director, but ensure you are well aware of what evidence needs to be uploaded to the portfolio in advance. An ISCP action list can be found on the Royal College of Surgeons website under higher specialist training documents and curricula.3
Similarly to DCT, you will have a range of workplace-based assessments (WPBAs) that need to be completed to progress at your ARCP. The work-based assessments include:
Direct observation of procedural skills (DOPS);
Clinical evaluation exercise (CEX);
Case-based discussion (CBD);
Assessment of audit;
Evaluation of teaching.
Explicit definitions of these can be found in the ‘Dental Gold Guide’, and there is also useful information on the ISCP platform (Tables 1 and 2).4
HLO
A
B
C
D
E
F
G
H
I
J
Domain 1: Professional knowledge and management
1.1 Demonstrate that they can communicate effectively and respectfully with patients and others, and with colleagues
*
*
*
*
*
*
1
*
1.2 Demonstrate that they can make decisions, while maintaining professional behaviour and judgement
*
*
*
*
*
*
*
1.3 Demonstrate that they can deal with complexity and uncertainty
*
*
*
*
*
*
1.4 Recognize their legal responsibilites and be able to apply in practice any legislative requirements revelant to their jurisdiction of practice
*
*
*
9
1.5 Recognize and work within the context of a health service and healthcare systems, understanding that systems may differ between England, Scotland, Wales and Nothern Ireland
*
*
*
*
*
1.6 Recognize and demonstrate their role in health promotion, disease prevention and dental population health
*
*
*
*
1.7 Recognize the importance of, and demonstrate the ability to practise, person-centred care (PCC), including shared decision making (SDM)
*
*
*
*
*
*
Domain 2: Leadership and teamworking
2.1 Demonstrate understanding of the imporance of personal qualities within leadership (focus on self)
*
*
*
*
*
*
2.2 Demonstrate understanding of the importance of working with others both within their specialty and the wider healthcare system (working with others)
*
*
*
*
*
*
*
2.3 Demonstrate the importance of planning and an understanding of managing dental specialist activities
*
*
*
*
*
*
9
*
Domain 3: Patient safety, quality improvement and governance
3.1 Recognize a professional and statutory duty of candour and act accordingly within established governance, legal and regulatory systems, including equality and diversity
*
*
*
*
*
2
*
3.2 Recognize the impact of human factors on the individual, teams, organizations and systems
*
*
*
2
3.3 Design and employ quality improvement measures that improve clinical effectiveness, patient safety, care or experience
*
*
*
*
*
*
2
3.4 Act to safeguard patients, particularly children, other young people and vulnerable adults in accordance with the requirements of appropriate equality and diversity legislation
*
*
*
*
*
2
3.5 Immediate life support
*
Domain 4: Personal education, training, research and scholarship
4.1 Demonstrate that they can plan and deliver effective education and training activites
*
*
*
*
2–5
*
4.2 Demonstrate that they can critically appraise and interpret scientific/academic literature and keep up to date with current and best practice
*
*
*
*
6–8
*
4.3 Understand what is required to participate in research
*
*
*
*
2,6,7
*
HLO
MSF
CEX
DOPs
CBD
BOS VLE tests
Logbook
Colleague Examination (FOrth)
MRes or equivalent pathways*
ES/research supervisor reports
Published papers
Patient/service user feedback
5.1 Development and growth
*
*
5.2 Orthodontic diagnosis and treatment planning
*
*
*
*
*
*
*
5.3 Delivery of orthodontic care
*
*
*
*
*
*
*
5.4 Multidisciplinary care
*
*
*
*
*
5.5 Research and evidence-based practice in relation to the biological and longitudinal nature of orthodontic care
*
*
*
5.6 Management in primary care
*
*
*
Participation in research and/or evidence-based practice for Orthodontics will be achieved by successful completion of one of the following:
Route 1: Taught Clinical Masters, MRes, doctorate or equivalent university higher degree in orthodontics that involves an original resarch project undertaken within the specialty training programme
Route 2: An authored contribution normally, but not exclusively, within the specialty of orthodontics incorporating several of the above components and undertaken during the specialty training programme, based on original research, systematice review or a quality-improvement project and accepted for publication in a PubMed listed journal; or delivered as an oral presentation by the trainee to a national or international conference
Route 3: Successful completion and approval of an NHS research ethics application undertaken during the specialty training programme with the trainee demonstrating direct involvement in the subsequent research project.
Progress will be assessed through the regional RCP process. The method by which the selected Route would be satisfied will be agreed at the trainee's initial 6-month RCP. Training progression would be dependent on successful demonstration of the above competences. Quality management would be by individual statutory education bodies and quality assurance by the GDC.
At the beginning of your training, you will have numerous patients to treatment plan with your consultant supervisors. Use this time wisely and take the initiative to ask to turn these conversations into CBDs. Arrange to complete DOPS and WPBAs on a regular basis with clinical supervisors. It is useful to plan a DOPS with your clinical supervisor, even if it is the first time you are completing a procedure because this way, you will have direct supervision and can learn how to do things correctly. In addition, it will help to demonstrate your progression because your inevitably low scores from these early attempts will improve in later ones.
An accurate clinical logbook is essential during orthodontic training and getting it right from the beginning will make things much easier. Set your logbook up early and add each patient to it as soon as you have seen them for records. Aim to do this on the clinic immediately after seeing the patient for the first time so that nothing is missed.
After you have seen the patient for records, usually consisting of photos, radiographs and an intra-oral scan, you will need to collate these and meet with your clinical supervisor to discuss a treatment plan. This needs to be done before the patient's next appointment. It is useful to add the date the patient is returning for their treatment planning discussion to your logbook, so that the embarrassing scenario of a patient returning for a discussion of an unmade plan is avoided. The use of a diary, discussed further below, will act as an additional fail-safe.
The clinical logbook will also help keep track of your case mix and facilitate reflection and recording on your ISCP portfolio. In addition, it provides an excellent resource to show your educational supervisor so that you can take action on any shortcomings in the range and diversity of malocclusions under your care. The Specialty Advisory Committee in Orthodontics has made suggestions on what your case mix and numbers should be and has recommended treating a total of 100–140 patients.5 A previous iteration of the curriculum recommended aiming to treat 10–20 cases with functional appliances, and 5–10 cases requiring multidisciplinary care involving paediatric or restorative dentistry.
Figure 4 is a QR code that links to an Excel clinical logbook, which trainees may find useful. Further information, including a useful logbook template, a logbook calculator, and guidance on the ST2 and ST3 case presentations, can be found on the Royal College of Surgeons website under ‘Higher specialist documents and curricula’.3 Orthodontics is unique in that many trainees have little to no direct experience with the specialty prior to commencing training. No amount of background reading is an adequate replacement for first-hand clinical experience, but An Introduction to Orthodontics6 and the Handbook of Orthodontics7 provide excellent starting points for new trainees.
Figure 4. QR code for an Excel clinical logbook
Balancing commitments
You will soon realize that there will be multiple, varied commitments that require your time and attention. One of the greatest pieces of advice the present authors received was to be as organized as possible and to use a diary effectively. Ensure you are aware of all the many tasks expected of you, and the deadlines for them. These will include clinic preparation, journal club presentations, reading for seminars and academic assignments.
The ultimate responsibility for delivering on these expectations is yours. Disorganization inevitably leads to a loss of control and preventable increases in stress. Understand your trust's clinic cancellation policies so that you can adequately rearrange and allocate patients appropriately. Some trusts may require 8 weeks' notice for any clinic cancellations. Study days will not usually be blocked off, so you must apply for any study leave as soon as you know you require it and take a similar approach with other leave. It is likely that you will be given a list of study days soon after starting, so book these clinics off promptly, and inform all relevant people via email.
There have been recent changes to the curriculum for orthodontic specialty training, and the requirement to complete a higher academic degree has been removed. For many years, this requirement has set orthodontics apart from other dental specialties in the UK, and placed UK training on an equal footing with orthodontic programmes worldwide. Hundreds of orthodontic trainees have completed a higher degree alongside their clinical training and the majority would attest to the benefits it brought them.8Figure 5 is an example of a Gant chart showing time allocation and deadlines for specialty training and an MRes, which can help you keep track of commitments. Figure 6 is a QR code for a blank Gant chart to download and use.
Figure 5. Example of a Gant chart showing how to manage ST training and MRes.Figure 6. QR code for a blank Gant chart to download and use
A higher degree will provide additional skills pertinent to your career as an evidence-based orthodontist. One such skill is a greater ability to appraise research as well as appreciate the process through which that research was completed. It would mean you attain parity with international colleagues and those who completed UK orthodontic training before you. We would advise you to speak to your consultants prior to starting for advice on the options available to you.
Work–life balance
The stresses of postgraduate clinical training are well documented.9 The greatest gift you can give yourself during the first few months of training is organization and time management. Do not let work build up, try to use your work hours efficiently, and maximize productivity in your scheduled admin time.
The time span over which one appraises one's work–life balance is an often-neglected consideration. During periods of your specialty training journey, especially the first 6 months, it is easy to feel your life is entirely unbalanced towards work. This is normal and to be expected. You are commencing work in a specialty in which you have no experience, learning to perform certain procedures for the very first time, working under and alongside new colleagues, and potentially all while moving to an entirely new location. It is worth remembering that this is your opportunity to learn your craft and you will get out of the experience what you put in. The balance is inevitably restored as training progresses, with an expected peak in work prior to examinations.
Ensure that while meeting all your targets and deadlines, you take time to look after yourself and your wellbeing. Make time for hobbies and interests, whether they be exercise, holidays or spending time with friends and family. It is essential to plan your annual leave effectively. We recommend planning some breaks well in advance, accounting for any deadlines, so there is always a pause on the horizon.
Orthodontic specialty training has the potential to be a transformative process. Upon completion, you are likely to see the world differently for a myriad of reasons. As you commence this journey, it is worth remembering that you have worked hard to get yourself to this position, you will only gain from this process what you put in, and starting as you mean to go on is essential.
