317J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 317–322 Original Development of Dental Specialties in Iran: A Qualitative Study Tayebe Rojhanian1, Mohammad Pooyan Jadidfard1, Shahram Yazdani2* 1Department of Community Oral Health, Shahid Beheshti University of Medical Sciences, Tehran, IR-Iran. 2Department of Medical Education, Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Science, Tehran, IR-Iran. *Correspondence to: Shahram Yazdani (E-mail: yazdani.shahram01@gmail.com) (Submitted: 07 May 2022 – Revised version received: 29 June 2022 – Accepted: 08 July 2022 – Published Online: 26 October 2022) Abstract Objectives: Dental specialties in Iran were first established in 1970s, and developed over time. Considering that information is essential for health policymaking, and lack of it is the main problem; therefore, policymakers require adequate knowledge about development and alterations of healthcare providers to recognize the influential factors on them. Regarding the information gap on development of dental specialties in Iran, this qualitative study aimed to assess it. Methods: This qualitative case study was conducted through 12 semi-structured interviews with the experts and pioneers of the oral healthcare system in Iran who were selected by purposive and snowball sampling. Data were analyzed by content analysis method, which included transcribing, identifying the meaning units, abstracting the content, sorting codes, and formulating themes using Atlas.ti software. Results: After data analysis, three main themes were extracted regarding development of dental specialties in Iran according to the interviewees: (A) trend of development, (B) challenges of development, and (C) necessities of development. Trend of development of dental specialties included two comprehensive phases, and one phase focusing on quantity and inadequate attention to quality. The challenges of development of dental specialties included management and policy-making problems, interactions outside the system, popularity of specialization, and process of admission to specialty programs. The necessity of need assessment, paying attention to the costs of healthcare interventions, defining the range of specialization, and revision of dental specialty programs are among the necessities of development of dental specialties. Conclusion: Dental specialties in Iran were developed at a time with inadequate attention to shortage of infrastructure based on political interactions. The popularity of specialization in dentistry and the associated high costs in a free educational system highlight the significance of need assessment regarding the number of specialists required in academic and therapeutic fields, and setting some criteria for development of specialty programs. Keywords: Higher education, dental education, postgraduate, professional training, health care provider ISSN 2413-0516 Introduction Dental specialists receive education and training beyond gen- eral dentists, and acquire a higher level of expertise and com- petence in a field of specialty. The number of specialists and fields of specialties in a country are related to the oral health- care provision system and socioeconomic factors.1 There is variation in the number of dental specialties, especially in European countries. Austria, Luxemburg, and Spain have no officially recognized dental specialty. In the United Kingdom and Iceland, there is a high number of officially recognized dental specialties. Dental specialties in countries like Iceland, Poland, Sweden, and United Kingdom have developed in response to public pressure with the aim of protection of public health.2 Advances in dental technology, the need for complex procedures, demographic changes, population aging, improved level of wealth, and changed lifestyle are among the reasons proposed for increased number of dental specialties.1 Financial considerations and economic factors play a funda- mental role in development of specialties in medical field.3 Several studies have assessed the variations, number, reasons for development, and trend of changes of dental specialties, mainly in developed and high-income (HI) countries. Little information is available regarding dental specialties in devel- oping and low-middle income countries (LMICs). Since the influential factors on the development and number of medical specialties are different in HI and LMICs,4 case studies of LMICs can be valuable to obtain comprehensive information in this regard.5 Iran is a developing and LMIC.6 Establishment and devel- opment of dental specialties in Iran dates back to 1970s. Tehran University was the pioneer in this process, and over time, dental specialties were also established in other universi- ties. Higher education in Iran is provided to Iranian citizens free of charge and by financial support from the government. Currently, there are 190 dental specialty fields-locations in 19 public and private dental schools in Iran. Approximately 360 postgraduate students are accepted and admitted annually in 12 specialty fields in Iran. Since the pattern and severity of oral and dental diseases have a significant impact on dental educa- tion strategy planning, type of service provider, and service provider system,7 it appears that the number of trained dental specialists in Iran does not match the high rate of unmet needs,8 and the high share of out of pocket expenses of patients for dental services.9 The reason is that the need for specialized services is lower and such services are more expensive than other levels of care.10 To date, no study has been conducted on dental specialties in Iran, and no information is available regarding their trend of development. Conduction of a qualitative study on a topic regarding which, scarce information is available, can help better scrutinize the topic.5 Thus, this qualitative case study was designed aiming to assess the trend of development of dental specialties in Iran. Information obtained from such studies can be used by policymakers since lack of information is the main problem in health policymaking, and adequate information can play an influential role in healthcare policymaking.11 mailto:yazdani.shahram01@gmail.com 318 J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 317–322 Development of Dental Specialties in Iran: A Qualitative Study Original T. Rojhanian et al. Methods The case study design was selected for this qualitative study due to its applicability to enhance the understanding and per- ception of complex contemporary phenomena in different fields of life, such as medical and social domains.5 The partici- pants were selected by purposive and snowball sampling. Data collection was continued until data saturation. In 2020, 12 semi-structured interviews were conducted with experts of the healthcare system. The participants of the present study comprised of experts, policymakers, and pioneers of oral healthcare system in Iran who were well aware of the history of establishment and development of dental specialties in Iran (Table 1). The objectives of the study and its ethical guidelines were explained to the participants prior to the interview, and written informed consent was obtained from them at the onset of interview. The location and time of interview were sched- uled according to the preferences of the participants. The interviews were audio-recorded. The information provided by the participants was reported anonymously. One researcher conducted face-to-face interviews. The main question of this study was that “how was the development of dental specialties in Iran?” (Box 1). Each interview took approximately 30 min- utes. After each interview, its contents were transcribed ver- batim. The interviewee was then provided with the transcript to confirm the data’s accuracy and make the necessary revi- sions, if required. Data were analyzed using Atlas.ti software (version 7.57).12 Data analysis was conducted by the content analysis method.13 Since one researcher (TR) performed the interviews and prepared the transcripts, and was completely familiar with the data, she also performed data analysis. The contents of the interviews were reviewed several times, the meaning units were identified, and the primary codes were extracted from the meaning units. After defining the meaning units, the con- tents of each interview were divided into meaning units. The related meaning units were further abstracted to obtain the research codes. After assessing the differences and similar- ities of the existing codes, subcategories were formed, and finally, the themes were extracted. Peer debriefing and member- checking were used to ensure the correct extraction of themes. All ethical guidelines were followed in this study, which included obtaining written informed consent for participation in the study, confidentiality of information, avoiding bias, the right to quit the study at any time, and anonymity of the participants. Results After data analysis, three main themes including (A) trend of development of dental specialties, (B) challenges of development of dental specialties, and (C) the necessities of development of dental specialties were extracted (Table 2). Trend of Development of Dental Specialties According to the participants’ opinion, the trend of develop- ment of dental specialties in Iran can be divided into three phases, influenced by the number of dental schools in Iran. It included an initiation phase with establishment of specialty programs in 5 primary dental schools in 1970s. The second phase included increasing the number of dental schools from 5 to 18 in year 2000, and the third phase included increasing the number of dental schools from 18 to 66 in the next years (of 66 permits given for establishment of dental schools, 44 schools are now active). The first phase (in 1970s) was part of the development process, which was pioneered by foreign-graduate experts (mainly graduated from the United States and United Kingdom universities). The majority of such experts had received full scholarship from the government for their education abroad, and were obliged to work for the government and service their country after graduation. These graduates later became the instructors of the newly established dental schools in the second phase in undergraduate and residency programs. One respondent stated: “They [foreign graduates] were the pio- neers of development of dental specialties in the country.” For some years (1980s), dental auxiliaries trained to increase dental care access for underserved people. In the Table 1. Number and composition of participants in semi- structured interviews Organizational ranking Number of respondents Former heads of the dental education and spe- cialty council secretariat, Ministry of Health and Medical Education 3 Former managers or members of the committee for educational programming in the Ministry of Health and Medical Education 4 Experts in different dental specialties 5 Total 12 Table 2. Contents and subcategories related to development of dental specialties in Iran Theme Subcategories Trend of devel- opment of dental specialties - First and second phases: Comprehensive, with optimal quality and quantity - Third phase: Non-comprehensive, with special focus on quantity and inadequate attention to quality and elimination of infrastructural shortcomings Challenges of development of dental specialties - Management and policymaking problems - Interactions out of the system - Popularity of specialization - Process of admission to specialty programs Necessities of development of dental specialties - Necessity of need assessment - Significance of paying attention to the costs of healthcare interventions - Defining the extent of development of dental specialties and their revision Box 1: Main questions of the interviews -What do you know about the development of dental specialties in Iran? -How was the trend of development of dental specialties in Iran? And what modifications they have undergone so far? -What are the main challenges in the process of development of dental specialties in Iran? -Do you have any suggestions to improve the current status of dental specialties in Iran? 319J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 317–322 T. Rojhanian et al. Original Development of Dental Specialties in Iran: A Qualitative Study given for establishment of numerous dental specialty programs in different universities. One participant added: “Their goal was to do something to be recognized by it later.” 2. Effect of interactions outside of the system on decision- making was another challenge. According to the partici- pants, these interactions affected the decisions made in the Ministry of Health and Medical Education regarding dental specialties. The majority of participants pointed to the sig- nificant role of lobbying in budget allocation and provision, and role and influence of some certain people out of the Ministry of Health on development of new dental schools and establishment of dental specialties in Iran. According to one participant: “Well, there was quite a competition at that time! All provinces somehow acquired a permit that all province capitals can have a dental school. Some provinces such as [X] even established several dental schools! They wanted to do something big, and later brag about it that this particular dental school or specialty program was devel- oped under my management and gain people’s support as such.” 3. According to the participants’ opinion, popularity of specialization is another problem that led to offering spe- cialty programs by some service providers, and they focused their activities on a specific field of specialty. One participant said: “The majority of dental require- ments of our people can be provided by general dentists, and there is actually no need to train such a high number of specialists.” 4. According to the participants, the process of admission to specialty programs is another challenge. The test score acquired in the national residency examination is currently the only criterion for admission to a residency program in Iran, and there is no other assessment. One participant explained that: “test score is a necessity; but now, it is the only requirement.” Necessities of Development of Dental Specialties According to the participants, development of dental spe- cialties in Iran requires attention to some necessities. Need assessment is imperative for development of dental spe- cialties. The goal and purpose of specialty programs should be defined as well. The number of specialists required for aca- demic educational purposes differs from the number required for therapeutic purposes; also, such needs vary depending on the time and distribution patterns. Therefore, the needs should be identified and periodically updated. One partici- pant explained: “when making a decision, we should see what we need.” In healthcare interventions, especially in the field of spe- cialization, the costs need to be taken into account as well. In addition to the possible achievements, the costs should be also considered in decision making, and decisions should be made to minimize the costs inside and outside of the health domain. One participant added: “dental education is costly; so, you should watch for the costs and see what decision is better.” According to the participants’ opinion, considering the necessity of specialty programs, the need for specialists should be quantified. Type of healthcare system and its priorities, model of service provision, and technique of management of the market of specialty services can all affect this decision. The second phase, schools for the training of dental auxiliaries were converted to dental schools. In this phase, the physical infrastructure was available, and the number of specialty pro- grams increased to train instructors required for general den- tistry programs in the increasing number of dental schools. Development of specialty programs in this phase was compre- hensive, had optimal quality and quantity, and was based on precise programming. The graduates of this phase had the required competencies in their field of specialty, and became successful clinicians and academic instructors. According to one participant: “They were very well-trained, because of the quality of training.” In the third phase, according to the interviewees, increasing the number of admitted students for specialty pro- grams became competitive among dental schools, such that the quality of instruction in postgraduate residency programs was seriously compromised. Increasing the number of dental schools, establishment of several dental schools in some prov- inces, establishing specialty programs in universities that did not have the required infrastructure, and immethodical increase in admission capacity of universities without taking into account the actual requirements of the country all indi- cated absence of a strategic plan with respect to training of dental specialists. One participant said: “At first, quantitative development was proportionate to qualitative development, but later, we had quantitative development but quality was no longer important.” Challenges of Development of Dental Specialties 1. Management and policymaking problems: According to the opinion of the interviewees, development of dental spe- cialties in Iran, especially in the third phase, had several problems and challenges, one of which, was management and policymaking problems in the healthcare system. These problems included: (A) non-responsiveness of the authorities, (B) impaired problem solving, (C) political influence over appointments, and (D) implementing pro- grams only to leave a mark from management period of managers. A. In the healthcare system of Iran, monitoring and evaluation of managers has been rarely conducted, resulting in their poor responsiveness regarding the consequences of their actions and decisions. In other words, no difference exists between the managers that improve the healthcare system status and those who intensify the problems. One partici- pant stated: “They are not responsive and have no worries in this regard either.” B. Absence of a mechanism for corrections in the system results in continuation of old problems and development of new problems. According to one participant: “The system has not been defined for corrections and revisions; thus, old problems continue to exist and new problems emerge.” C. Managers in the healthcare system are often appointed based on their political party. One participant stated: “when your political party wins, you get a position, depending on your level of cooperation with them.” D. Another management challenge is the interest of the newly appointed healthcare authorities and managers in changing the existing system, and implementing pro- grams only to leave a mark from their management period. One example of such activities is the permit 320 J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 317–322 Development of Dental Specialties in Iran: A Qualitative Study Original T. Rojhanian et al. criteria for development and expansion of specialty programs should be clear, and the existing programs should be revised accordingly. One participant added: “We have to set some- thing straight; for example, we don’t yet know how many spe- cialists we need.” Another participant stated: “We should know how to manage specialty services, and what are the criteria for development of a specialty program.” Discussion The present results revealed that development of dental spe- cialties in Iran had three phases. The first and second phases were based on the current needs and logic; however, the third phase had drawbacks such as immethodical increase in the number of specialty programs and ignoring the shortcomings of infrastructures. Mohammadpour et al.14 evaluated the chal- lenging in oral health policymaking in Iran and mentioned that insufficient and inadequate infrastructure for dental edu- cation was one of the existing challenges. Isiekwe et al.15 evalu- ated the perception of Nigerian dental students regarding their educational curricula, and concluded that insufficient infra- structure affected dental education. They added that the chal- lenges of dental education are different in developing and developed countries with adequate infrastructure. Bailit16 dis- cussed that financial problems of publicly-supported dental schools were one reason for inadequate infrastructure. Jawaid17 in his study entitled “plight of dentistry in Pakistan” pointed to the shortage of infrastructures in dental education institutes in Pakistan. Specialization of dental education in Iran has been asso- ciated with some challenges. Many challenges, such as man- agement and policymaking problems, and interactions outside of the system, are not exclusive to development of specialties, but affect it. The ministers of the next govern- ment that takes over are rarely interested in interacting with the previous ministers. Personal capture is another problem, which is also considered as a healthcare system problem by the World Health Organization. It leads to instability in implementation of programs, and results in no commitment to implementation of programs after the ministers and man- agers are changed. By changing of the managers and minis- ters of the political party that loses the election, their policies are also canceled before implementation and assessment, because the new ministers and managers are reluctant to continue implementation of programs designed by the pre- vious team. Proper stewardship can decrease the risk of policy orientation.18 The effect of interactions out of the system on health policies is another challenge, which is also a threat to the healthcare system. Decision-making by indi- viduals who may not even be healthcare experts, consider the healthcare market to be similar to any other market, and intentionally or unintentionally aim to attract public support without recognizing the consequences of their actions and decisions can further complicate the problems in a system that already has a high volume of unmet needs. Shadpour,19 in his study, aimed to criticize the activities for correction of healthcare system in Iran and highlighted the impact of political decisions made outside of the healthcare system on health policies. Presence of legislative and regulatory bodies in the system can be helpful, given that they are not used for political goals of parties and individuals; however, unfortunately, political and factional tendencies often domi- nate the national goals.20 According to the interviewees, the process of admission to specialty programs is another challenge in development of dental specialties in Iran. In the current model of student admission for residency programs in Iran, a national entrance exam is held, and the students select a specialty program based on their test score. In a study on challenges of dental education in India, holding one entrance exam for all students was men- tioned as an existing challenge. The authors suggested holding a separate standard examination for each program accompa- nied by personal interviews to determine the level of interest of the candidates in a particular fields.21 To train adequate human resources, the admission fre- quency increased in many countries worldwide as recom- mended by the World Health Organization.22 In Iran, the number of dental schools increased aiming to serve justice in provision of services. Over time, the number of dental schools offering specialty programs, and the number of admitted stu- dents for such programs also increased. Although such edu- cational developments can enhance accessibility of services, they have regulatory challenges as well.23 The Australian Research Centre for Population Oral Health stated that estab- lishing new dental schools would be effective for enhance- ment of geographical distribution of dental specialists, but there is no evidence in this respect.24 Maia et al.25 evaluated the characteristics of expanding private dental education, and discussed that increasing the number of dental schools can affect the dental job market but cannot guarantee better and fair distribution of dentists and dental services. Moreover, increasing the number of dental schools not only does not improve oral health status of the public, but also creates some concerns with respect to the quality of instructions.14 Jawaid17 pointed to the decreased quality of education due to absence of the required infrastructure. Social status and earning more income are among the factors that contribute to acquiring a specialty degree.4 It is possible that by training higher number of specialists and lack of supervision on their distribution, competitions form between them to attract more patients and make more money, which would lead to an increase in certain treatments. Also, specialists may compete with general dentists to make more money.26 In Iran, higher education is mainly public and free, aiming to serve justice in accessing higher education and minimize injustice in this respect. However, informal estimates reveal that in the recent years, the share of benefitting from higher education has been positively correlated with the socioeco- nomic status of the families. Increasing the number of univer- sities and expansion of higher education were performed in some countries for the purpose of privatization and commod- itization of higher education, which has an economic justifica- tion.27 Jawaid17 reported uncontrolled increase in the number of dental schools in Pakistan; he added that making more money was the main goal behind establishment of new dental schools. Cumulative increase in number of dental specialists in Iran occurred with the aim of provision of human resources following population growth and increased public demands; however, considering the type and quality of instructions, it does not have economic justification. Expansion of higher education especially in countries with free public education 321J Contemp Med Sci | Vol. 8, No. 5, September-October 2022: 317–322 T. Rojhanian et al. Original Development of Dental Specialties in Iran: A Qualitative Study would be associated with a considerable rise in costs.23 More- over, considering the limited financial resources and high cost of undergraduate and postgraduate dental educations,28 it is imperative to estimate the number and type of oral health ser- vice providers according to precise need assessment. Eklund and Bailit29 believed that high number of dental graduates in the United States had little scientific justification, and dis- cussed that study of supply and demand should be prioritized to establishing a new dental school. Not performing need assessment and no access to adequate information are among other challenges of the healthcare system, and it has been demonstrated that many decisions related to human resources in oral health domain are made in absence of precise local data, and only based on models implemented in other coun- tries.30 Therefore, further attention should be directed to acquire and use precise data. Also, it is imperative to devise policies to maintain the specialists in the country; otherwise, the outcome of training of specialized forces would be the human capital flight.31 This study focused on the less addressed topic of dental specialties in Iran. Uncertainty about the commitment of the reviewers regarding the accuracy of the provided information was a limitation of this study. To prevent its confounding effect, data were interpreted with caution. Peer debriefing and member-checking methods were also applied to ensure data verifiability. Considering the wide reference of the inter- viewees to the role of political interactions in health decisions, further studies are recommended to comprehensively assess the effect of political interactions and develop strategies to control them. According to the opinion of the interviewees, process of admission to specialty programs was one of the challenges in development of dental specialties in Iran. Since addressing this topic was out of the scope of this study, further studies are required to address this topic. Conclusion The trend of development of dental specialties in Iran included two phases with optimal quality and quantity, and one phase of focusing on quantity with less attention to quality of educa- tions and elimination of the shortcomings of infrastructures. Although the challenges in the process of development of dental specialty programs in Iran are not exclusive to this field, they impacted it. A suitable stewardship can decrease the con- sequences of some challenges such as policy orientation. Polit- ical interactions and decisions have also affected the development of dental specialization in Iran. Popularity of specialization in dentistry and high costs of education in a free educational system highlight the significance of need assess- ment for human resources. According to the perspectives of the reviewers, determining the required number of dental spe- cialists in academic and therapeutic fields, and setting some criteria for development of specialty programs are among the necessities for development and expansion of dental spe- cialties in Iran. Acknowledgment This research has been extracted from a Ph.D. dissertation in Community Oral Health. All study methods were car- ried out following the relevant regulation of The Research Ethics Committees of Research Institute of Dental Scienc- es-Shahid Beheshti University of Medical Sciences that approved this study (Ethical code: IR.SBMU.DRC. REC.1398.178). Conflict of Interest The authors declare that they have no conflict of interest.  References 1. Widström E, Eaton KA. Factors guiding the number of dental specialists in the European Union and Economic Area. Den Norske tannlegeforenings tidende. 2006;116:718–21. 2. Owall B, Welfare R, Garefis P, Hedzelek W, Hobkirk J, Isidor F, et al. Specialisation and specialist education in prosthetic dentistry in Europe. European Journal of Prosthodontics and Restorative Dentistry. 2006;14(3):105. 3. Chukwuma Sr C. Information-base and determinants of medical specialization and primary care: A view point. JBAH. 4. Sriram V, Hyder AA, Bennett S. 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