"Dental Education in South America: Present Situation"

ABSTRACT
South American countries are experiencing the unwarranted proliferation of universities and dental schools. The latter is accompanied by an unlimited number of dental graduates. In addition, there is a shortage of qualified dental teachers, which also creates an ethical predicament. Students' families often question the quality of existing dental education. Eventually, the public may question professional dental services. Accreditation is an important part of the answer to this new problem and its consequences. Accreditation of universities and dental schools is an ongoing, cyclic, and voluntary process. Universities are usually accredited; most private dental schools are not. "Accreditation" is "Official Recognition" and means "Public Guarantee." The situation in Chile is described to explain the present state of dental education in South America.

KEY WORDS: Higher education institutions, globalization, accreditation, official recognition, public guarantee, auto-evaluation, Dentistry, dental school

INTRODUCTION
Since its inception, South American Dentistry has been strongly influenced by Europe and the United States. In the early days, South American professionals generally sought advanced training in those more developed geographic latitudes. England, France, Germany and the United States were the favorite destinations.

It is important to point out that South America is formed by ten different nations. In nine countries, colonized by Spain, Spanish is the official language. Portuguese, which is similar to Spanish, is only spoken in Brazil, which was settled by Portugal. Notwithstanding their virtually common tongue as well as similar origins and historical experiences, these countries comprise very distinct national, political and geographical entities. This can be better appreciated through their respective idiosyncrasies, customs, economies, education, development and linguistic expressions.

A recent phenomenon, "Globalization," has increased the similarities between these nations in certain significant areas. These likenesses are not necessarily for the better. Nor do they always contribute to advancement. It is also questionable as to whether the "new world trend" fosters unity. However, it can be affirmed that it has tremendously facilitated communications and exchanges. Thus, all of a sudden, and despite cultural and national educational differences, in various parts of the globe similar experiences are occurring simultaneously. This is particularly noticeable in South America, even though large geographical distances separate some of its countries. A key area is higher education, and in particular, dental education.

The situation in Chile will be described to illustrate the present status of University Education, and especially Dental Education, in South America. While it can be safely stated that the present dental educational conditions in Chile are similar to those existing in the other South American nations, the reader should be aware that all ten South American countries have different legislations. They also have dissimilar priorities, based on economic, social, cultural and historical experiences.

HISTORICAL BACKGROUND
Chile's first Dental School was founded in Santiago, in 1888. It was called the "School of Dentists" and had a two-year study curriculum. In 1904, Dr. German Valenzuela, the School's Director, obtained approval to develop a three-year dental training program. Dr. Valenzuela was a medical surgeon who received his dental degree in Paris in 1897.

In 1909, Dr. Valenzuela was instrumental in solving a crime committed at the German Diplomatic Legation in Santiago. The Chilean Government rewarded Dr. Valenzuela by fulfilling his request for the construction of a modern dental school. The new dental school building was inaugurated in September 1911.1

In 1916, the above-mentioned Dental School became part of the Faculty of Medicine of the Universidad de Chile (University of Chile), a public university. Thus it became the first university-affiliated Dental School in Chile. In 1928, its curriculum was increased to four years; in 1938, to five years. In 1945, the Universidad de Chile separated the Dental School from the Medical School, thereby creating its School of Dentistry.2

In 1920, the Universidad de Concepcion became legally constituted in the city of Concepcion, located approximately 320 miles south of Santiago. This private university initiated its activities with a Dental School, which was associated with its Science Faculty. The School was created to solve the region's dento-oral problems. In 1927, after the curriculum was homologized with the Universidad de Chile's program, the Universidad de Concepcion separated the School from the Faculty of Sciences, transforming it in a dental faculty. Thus it became the country's first Faculty of Dentistry.1

In 1952, the Universidad de Chile established a Dental School in Valparaiso, a major seaport located 75 miles west of Santiago. In 1955, the new School, under the supervision of the Universidad de Chile's Santiago-based Dental School, started with 15 students. In 1960, it graduated its first class. In 1981, the Universidad de Chile's Valparaiso branch became the Universidad de Valparaiso, an autonomous university. As a result, its Dental School became the Universidad de Valparaiso's Faculty of Dentistry and Chile's third dental school.1

CURRENT SITUATION
In 1990, the Chilean Government approved the Organic Constitutional Education Law, which had a profound impact on the country's Higher Education structure and organization. The law also generated the proliferation of private, higher learning institutions - all with significant financial resources. Once autonomy has been achieved, a university may create, without legal restrictions or impediments, as many colleges and schools as it deems necessary or convenient.3

Around the world, the Higher Education System is seriously concerned about assuring quality in education. This is also true in Chile, as well as in the other South American countries. Such apprehension originates from the new situation described in the previous paragraph.4

Prior to the promulgation of the Organic Constitutional Education Law, most first-year university students were males and recent high school graduates. In addition, most lived in the nation's larger cities and came from similar social-cultural environments. In those years, only a small fraction of the country's secondary school students completed their education.5 Also, universities were very selective and admitted only the best applicants.5

Today, there is a strong demand for Higher Education. Furthermore, the majority of young people finish high school, and have varied social-economic and cultural backgrounds. There are also an ever-growing number of adults interested in pursuing higher education studies. These individuals are being incorporated with the younger group. In this regard, age is no longer a limitation.

Since 1990, with the advent of the Organic Constitutional Education Law, the number of universities in Chile has increased from eight to more than 60. There has been a 400% expansion in the number of undergraduate students. Something similar has occurred with Chilean Dental Education. In 1980, there were three Dental Schools; in 2007, 26. The number of dental students has increased from 1,300 to approximately 7,000. Most are enrolled in private universities. Presently, the private, non-traditional dental schools are absorbing 60% of the country's dental students.

The new dental education scenario has advantages and disadvantages. Among the main advantages are:

• Inclusion of rural and other applicants who previously lacked access to dental schools.
• Incorporation of the private sector, providing new resources and diversified teaching systems.
• Greater availability of human resources (providers) for dental services.
• Major improvements in dental teaching facilities.
• Globalized dental teaching.

Important disadvantages include:

• Educational quality is not uniform or similar among all dental teaching institutions.
• Lack of adequately prepared dental academicians.
• Lack of adequate teaching quality control systems.
• Reduced work opportunities.
• Unusually intense marketing competing for qualified students, capable dental teachers, and resources.

There is a question that needs to be evaluated. How many students, families and employers are being influenced by the diverse higher education offers?4

PROBLEM
The general public in Chile, just like in other countries, is becoming concerned about and beginning to question the quality of the new universities. Various groups of people, including potential students, are starting to have second thoughts about the convenience of investing considerable time, effort and financial resources in studies that apparently cannot deliver adequate results and a promising future. This includes current dental education. F. D. I. President Michele Aerden, during her official visit with Chile's President, Michele Bachelet, voiced the organization's concern regarding the proliferation of dental schools and the possible resulting deterioration of dental education quality and professional standards.6

People require unbiased information. The public has grown increasingly skeptical of advertising claims, and is insisting that human-resource-forming entities, as well as their services, sustain their work and assert excellence through a reliable organization that guarantees quality. The public is demanding assurances that restore credibility and stimulate confidence in the new teaching institutions.

Thus was generated the need for Institutions of Higher Learning to publicly guarantee the quality of their education systems and programs, the fulfillment of their claims, and even more importantly, the delivery of their products according to pre-established and clearly defined criteria and standards. The public is demanding a Public Guarantee of quality and standards; in other words: Accreditation.

SOLUTION
For Accreditation to be valid and credible, it must be conferred by an official and reputable organization. Such an entity must have the authority to demonstrate and prove that a given higher education institution has efficient means and mechanisms to assure the quality of its teaching staff, the ability to organize and direct its actions toward the fulfillment of its declared objectives, and the capacity to conduct efficiently all functions selected as primary tasks.5 International experience has demonstrated that education must be regulated through voluntary accreditation mechanisms. However, this does not exempt the Government from being responsible for guaranteeing the services the public is receiving.4

To satisfy the above-mentioned goal, the Chilean Government, through its Ministry of Education, created in March 1999, the National Undergraduate Accreditation Commission. It remained in operation until November 2006 when Law No. 20129, "Superior Educational Quality Assurance," was promulgated. The latter improved the Accreditation System's capability and authority to accomplish its objectives.

The accreditation of teaching programs is a voluntary process. Only autonomous institutions may request an "official approval." The process consists of three phases:

1. Auto-evaluation
2. External evaluation or external peer visitations
3. Accreditation statement.7

Any teaching program seeking accreditation is solely responsible for its auto-evaluation process. Said procedure requires the gathering, validation, analysis and arrangement of substantial information regarding the program's performance and obligations. The process is based on self-declared objectives, as well as on previously defined and accepted evaluation criteria. It is an ongoing and cyclic process and allows adjustments to meet changes and challenges that may arise during the teaching program's evolution and growth.

An auto-evaluation report must include:

• A description of the course of studies' academic project, institutional context, conditions under which the teaching-learning process is conducted, and the desired graduate profile.
• Evaluation of the extent to which a given course of studies' pre-defined graduate profile and evaluation criteria are fulfilled. Description of detected strengths and weaknesses as related to each of the evaluation criteria.
• Conclusions and an improvement plan. These must prioritize the results of the auto-evaluation process and establish a work plan to meet future growth and development.
• An answer guide for the questionnaires used throughout the entire accreditation process.
• Attachments with support information for opinions, observations and discernments expressed in the auto-evaluation report.

A team of peers performs the external evaluation process. They may be natural or juridical persons, local or foreign, prestigious academicians or prominent professionals who belong to the specialized area or discipline being appraised. They must be listed in the National Accreditation Committee's Public Registry.

External evaluation takes place after the auto-evaluation report has been presented to the National Accreditation Committee. After close examination and careful analysis, the external peers may validate or raise objections to the auto-evaluation process. The procedure includes an assessment of the degree to which the course of studies satisfies the criteria and pre-established parameters, and fulfills its objectives. After their visitation, the peers deliver a report to the National Accreditation Committee.

The Chilean National Accreditation Committee issues a verdict based on pre-defined evaluation criteria, the course of studies' auto-evaluation report, and the external peers' report. It also analyzes the course of studies' response to the latter's observations, as well as the peer committee chairman's opinion regarding any comments offered by the career under review. The pronouncement is a succinct, but substantive public document. It informs the national and international communities about the strength and quality of the course of studies being evaluated.

Professional career accreditations are granted for a minimum of two years and a maximum of seven. The period of time is determined by the nature of the observations and the amount of time deemed necessary to correct any deficiencies. A course of studies will not be accredited unless it adequately fulfills the evaluation criteria and graduate profile standards.

ACCREDITATION
Courses of study already underway have a two-year time limit (July 2009) to complete the accreditation process. Those that are unable to comply due to failure to undergo the process or that are incapable of attaining official approval and recognition will not be eligible to receive grants or guarantees from the Chilean Government, nor financing for projects or assistance for student tuition fees.

As of December 31, 2007, there were 26 dental teaching institutions in Chile. Only six have been accredited by the National Accreditation Committee.8 They are:

1. Universidad de Valparaiso
   Dentistry received a five-year accreditation, until January 20, 2009.
2. Universidad de Concepcion
   Dentistry received a six-year accreditation, until July 26, 2011.
3. Universidad de Talca
   Dentistry received a four-year accreditation, until June 28, 2009.
4. Universidad de Chile
   Dentistry received a six-year accreditation, until November 8, 2012.
5. Universidad La Frontera (Temuco)
   Dentistry received a four-year accreditation, until November 22, 2010.
6. Universidad de Antofagasta
   Dentistry received a two-year accreditation, until November 22, 2008.

STATISTICS
The following information should help to illustrate the situation that has been described:

Brazil9:
Number of Dentists - 217,989
Inhabitants - 181,023,332
Number of Graduates, 2006 - 12,195
Number of Graduates, 2007 - 12,879
Number of Dental Students, 2006 - not available
Number of Dental Students, 2007 - not available
Number of Public Dental Schools - 54
Number of Private Dental Schools - 133
Ratio - 1 dentist per 830 inhabitants (In realistic terms, 1:332).

Chile10:
Number of Dentists - 8,670
Inhabitants - 15,116,435
Number of Graduates, 2006 - 421
Number of Graduates, 2007 - 432
Number of Dental Students, 2006 - not available
Number of Dental Students, 2007 - not available
Number of Public Dental Schools - 6
Number of Private Dental Schools - 20
Ratio -1 dentist per 1,744 inhabitants (In realistic terms, 1:698).

Ecuador11:
Number of Dentists - not available
Inhabitants - 13,000,000
Number of Graduates, 2006 - not available
Number of Graduates, 2007 - not available
Number of Dental Students, 2006 - not available
Number of Dental Students, 2007 - not available
Number of Dental Schools (Public and Private) - 15
Ratio - not available.

Paraguay12:
Number of Dentists - 5,000
Inhabitants - 6,000,000
Number of Graduates, 2006 - 250
Number of Graduates, 2007 - 300
Number of Dental Students, 2006 - 3,000
Number of Dental Students, 2007 - 3,500
Number of Public Dental Schools - 1
Number of Private Dental Schools - 14 (owned by 6 Universities)
Ratio - 1 dentist per 1,200 inhabitants (In realistic terms, 1:480).

Peru13:
Number of Dentists - 20,744
Inhabitants - 27,000,000
Number of Graduates, 2006 - 1,111
Number of Graduates, 2007 - 1,399
Number of Dental Students, 2006 - not available
Number of Dental Students, 2007 - not available
Number of Public Dental Schools - 10
Number of Private Dental Schools - 13
Ratio - 1 dentist per 1,302 inhabitants (In realistic terms, 1:521).

Uruguay14:
Number of Dentists - 3,266
Inhabitants - 3,000,000
Number of Graduates, Public Dental School, 2006 - 153
Number of Graduates, Private Dental School, 2007 - 112
Number of Dental Students, 2006 - not available
Number of Dental Students, 2007 - not available
Number of Public Dental Schools - 1
Number of Private Dental Schools - 1 (established year 2000)
Ratio - 1 dentist per 919 inhabitants (In realistic terms, 1:368).

Venezuela15:
Number of Dentists - 20,000
Inhabitants - 26,000,000
Number of Graduates, 2006 - 1,000
Number of Graduates, 2007 - 1,000
Number of Dental Students, 2006 - 12,500
Number of Dental Students, 2007 - 12,500
Number of Public Dental Schools - 5
Number of Private Dental Schools - 3
Ratio - 1 dentist per 1,300 inhabitants (In realistic terms, 1:520).

No information was available for Argentina, Bolivia, and Colombia.

In Chile, approximately 40% of the population has access to dental care. This figure can also be applied to the other South American countries. At present, the main problem is "accessibility to dental treatment," not the quantity of dentists. Consequently, ways must be established for people to gain access to dental services. The dentist/patients ratio is considerably lower than the statistical figures presented in the previous paragraphs. In realistic terms, the proportion is at least 60% lower.

REFLECTIONS
The unrestrained and unplanned increase in dental schools is also posing a significant ethical challenge to the quality of dental education. An important result has been a shortage of experienced dental educators for pre-clinical and clinical study courses, as well as for the basic sciences. Strict qualification requirements have often been reduced or eliminated. In addition, very few of the new dental schools have earned accreditation. Eventually, the quality of Dentistry and recent dental graduates may be questioned.

The uncontrolled proliferation of dental schools, which is due to a lack of careful planning or of programmed growth according to pre-established needs, is producing an additional problem: the creation of an unrealistic and often unneeded labor force that will not have the opportunity to secure adequate work and earn a comfortable living.

The opportunity for young graduates to establish or enter private dental practices is very remote. This longstanding ambition has turned into an old fashioned and impractical concept, difficult to fulfill. Dentists are seeking employment with private health service providers. The number of dentists looking for employment is so large that employers have established unrealistically low salaries and unsavory working conditions. It is the Law of Supply and Demand applied to university-trained professionals.

The described situation may end up creating unpleasant situations; for instance, large groups of disgruntled professionals. Their bitterness, frustration and inability to improve their reality could result in severe and unnecessary social problems. Such discontent is usually contagious and its outcome, unpredictable.

Effective ways must be established to guarantee the quality of higher dental education, as well as dental graduates' competence. The concepts "Dental Education Standard" and "Dental Care Standard" should become compulsory and practical realities.

CONCLUSIONS
In South America, university and dental school accreditation is an ongoing and cyclic, but voluntary process. Although most universities are accredited, few dental schools are officially recognized. At present, far too many dental schools have been formed, with not nearly enough competent dental academicians to fill all of the teaching positions. There is no uniformity of dental teaching programs or educational quality control. It seems reasonable to infer that, in view of these difficulties, the quality of dental education may decline. The public must receive guarantees concerning the excellence of the academic services provided by each dental school.

The abovementioned state of affairs has led to an over supply of dentists and, perhaps, to inadequately prepared dental graduates. This also means that the possibilities for establishing private dental practices are remote. Therefore, many dentists must seek employment with private health service providers. Lack of professional opportunities and insufficient income usually nourishes dissatisfaction.

A Dental Education Standard and a Dental Care Standard must be established and enforced. Accreditation of Dental Schools must become a widespread global reality. "Accreditation" is "Official Recognition" and means "Public Guarantee."

REFERENCES
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3. Rosselot JE. Acreditacion de la formacion profesional en Ciencias de la
Salud en Chile. Chapter "Calidad en Medicina". Buenos Aires: Talleres Graficos
Pagani. 2002.
4. Matas JJ. Algunas consideraciones sobre calidad de la Educacion
Superior. Revista de la Facultad de Odontologia de la Universidad de Chile.
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Medicina". Buenos Aires: Talleres Graficos Pagani, 2002.
6. Aerden M. Personal communication. Mar del Plata, Argentina. 9 Nov. 2006
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Acreditacion, CNA-Chile. June 2007.
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9. DeFreitas PC. Personal communication. Sao Paulo, Brazil, 20 Dec. 2007.
10. Matas JJ. Personal communication. Santiago, Chile. 23 Jan. 2008.
11. Chavez R. Personal communication. Quito, Ecuador. 25 Jan. 2008.
12. DiTore R. Personal communication. Asuncion, Paraguay. 2 Jan. 2008.
13. Castillo R. Personal communication. Lima, Peru. 18 Jan. 2008.
14. Baranano ME. Personal communication. Montevideo, Uruguay. 9 Dec. 2007.
15. Paez V. Personal communication. Caracas, Venezuela. 11 Feb. 2008.