Entrustable professional activities (EPAs) in postgraduate periodontics programs in Saudi Arabia: A modified Delphi study

Abstract

Purpose

The purpose of this study was to obtain a validated consensus among expert periodontists in Saudi Arabia regarding end‐of‐periodontics‐residency‐training entrustable professional activities (EPAs) using a modified Delphi method.

Methods

The study consisted of two phases. A preliminary phase in which experts met and proposed an initial list of EPAs following an extensive literature review. The second phase consisted of two rounds of the modified Delphi method in which expert periodontists in Saudi Arabia determined the content validity of each EPA. This was determined with a 5‐point scale ranging from 1 (not important/relevant) to 5 (very important/relevant), and the mean score for each EPA was calculated. EPAs with a mean value of ≤ 4 or agreement rate among experts of less than 80% were excluded.

Results

An initial list of 40 EPAs was proposed. A total of 30 expert periodontists participated in the first round, and 24 participated in the second round of the modified Delphi method ratings. Most of the participants were program directors and represented different programs and cities in Saudi Arabia. Five EPAs were removed, and a final list of EPAs was produced based on the defined criteria. The Cronbach's alpha was 0.920, indicating high reliability.

Conclusions

A final list of 35 end‐of‐periodontics‐training EPAs was produced. The findings of this study can serve as a valuable resource for curriculum development, assessments, and evaluation of periodontics training programs in Saudi Arabia.

1. INTRODUCTION

Entrustable professional activities (EPAs) are defined as the units of professional practices (tasks or responsibilities) to be entrusted to unsupervised execution by trainees once they have attained sufficient specific competency. ¹ The concept was introduced in 2005, and it helped translate competency into clinical practices. ² While competency usually describes the general characteristics of individuals and consists of knowledge, skills, and attitudes, EPAs are the core activities of the profession. ³ Each EPA may require multiple competencies. Therefore, assessments of EPAs are considered a more holistic assessments of competency. ⁴ EPAs have been embraced in many postgraduate medical and health professions worldwide, ⁵ , ⁶ , ⁷ and several predoctoral and postgraduate dental programs have recently begun to adopt them. ⁸ , ⁹ , ¹⁰

In Saudi Arabia (SA), the accreditation standards for the Saudi Counsel for Health Specialty (SCFHS) adopted the CanMED competency framework. ¹¹ There are gaps in the implementation process of these competencies. While the SCFHS curriculum for periodontics residency describes the core knowledge, skills, and attitudes periodontics residents need, each training program is left alone to determine how levels of competence are achieved and assessed. In contrast to EPAs, the SCFHS curriculum does not provide a unifying framework that stipulates what tasks and responsibilities a graduating periodontist should be capable of performing independently. Adopting the concept of EPAs allows training programs to develop milestones and training stages. It ensures a safe and monitored transition of trainees from lower to higher levels of competency with varying degrees of supervision from one year to the next.

Many dental programs rely on the repetition of procedures ¹² (e.g., performing 50 dental implants) without establishing priorities or milestones for residents in Year 1 compared to Year 4. Direct observation of procedure performance is also the main assessment method. ¹³ Although it provides immediate feedback on performance, it is strict, inflexible and does not allow for the development of independent practice, particularly for residents in the final year of training. In addition, the quantity and quality of clinical training and experiences may vary between programs. All the abovementioned factors do not align with the concept of competency‐based education. EPAs on the other hand, add a great value as they define the tasks and responsibilities of the graduate at the time of graduation.

Creating end‐of‐training EPAs for periodontics training programs in SA will precisely define the shape of the graduates of the program by identifying the tasks and responsibilities that must be entrusted to them to be performed independently. In addition, EPAs impact the design and composition of comprehensive assessment approaches. Including specific entrustment decisions in each EPA takes into account the learner's ability to cope with risks, ask for help, and adapt to unexpected situations ⁴ which not only beneficial to the learner but also ensure patient safety.

There is a lack of published EPAs in the field of dentistry. Orofacial pain and pediatric dentistry are the only two dental specialties with published EPAs. ⁹ , ¹⁰ It is crucial to acknowledge that EPAs reflect the local culture in which they were developed, its healthcare system and regulations, and patients’ specific values and needs. ⁵ Contextualized curriculum development is an established principle in medical education. ¹⁴ Since there are no EPAs currently available for periodontics residency programs, the objective of this study was to develop and validate the core EPAs for this specialty.

2. METHODS

The study design was approved by the institutional review board at Umm Al‐Qura University, Makkah, SA (Approval # HAPO‐02‐K‐012‐2024‐05‐2168). The study implemented a modified Delphi method to develop a consensus among experts on end‐of‐training EPAs for periodontics training programs. The data collection methods and procedure are shown in Figure 1.

FIGURE 1.

Schematic representation of the data collection methods and procedure. EPA, entrustable professional activities.

The study consisted of two phases: In the preliminary phase, three periodontists with over 5 years of experience in periodontal training programs reviewed the literature on EPAs, the Commission on Dental Accreditation (CODA) standards for Advanced Dental Education Programs in Periodontics, ¹⁵ and the SCFHS competency training framework for periodontics training programs in SA. ¹¹ They then identified a broad range of possible EPAs in the profession. They held several meetings and openly discussed all the available resources for EPAs. They proposed an initial list of EPAs that was also reviewed by two medical educationalists.

The second phase consisted of two‐rounds modified Delphi method, which required rating the relevance of the initial EPAs by expert periodontists. Expert periodontists were defined as individuals with at least 5 years of experience in the field of periodontics and who were participating in a postgraduate periodontics training program in SA. The panel member size for the Delphi method varies in the literature, it is generally recommended to have at least 20 members. Considering a response rate of approximately 80% based on previous studies, the minimum recruitment number was determined to be 25. ¹⁶ The nominated experts were identified using purposive and snowball sampling methods and were invited to rate the relevance and importance of the initial list of EPAs. Each expert was sent an e‐mail that included the objectives and description of the study, the stages of the Delphi rounds, and an invitation to participate in the study. In addition, a definition and short summary of the implications of EPAs in dental education, as well as selected reading materials, were included. ¹ Written informed consent was obtained from all participants in the study. The first survey was distributed in March 2024 and remained open for responses for 4 weeks. The second round was distributed in May 2024 and remained open for the same duration.

Participants were sent an electronic survey and asked to determine the content representativeness and relevance (i.e., content validity) of each EPA in the initial list based on a 5‐point scale ranging from 1 (not important/relevant) to 5 (very important/relevant). Participants also had an opportunity to comment on the proposed EPAs and request modifications to and additions of EPAs. The survey also included items about participants’ sociodemographic information, and clinical and academic experience. The mean score for each EPA was calculated; a value of > 4 was considered the cutoff point, ⁶ and EPAs with a mean score of ≤ 4 or less than 80% agreement rate were eliminated from the second round of the Delphi method. By the end of this phase, a modified list of EPAs was produced based on the participants’ initial ratings.

In the second round of the modified Delphi method—the same participants rated the relevance and representativeness of the modified list of EPAs. The modified list of EPAs was sent to the same panel to verify their decisions based on the consensus obtained in the first round. We followed the same procedure as in the second phase of the study. The completion of this phase yielded our final list of end‐of‐training EPAs for periodontics training programs in SA.

Descriptive statistics were used to describe participants’ demographic characteristics and to group responses to each statement. Means, standard deviations, and the percentage of strongly agree/agree responses for each survey item were calculated. The internal consistency of the survey was measured using Cronbach's alpha.

3. RESULTS

A total of 30 periodontists agreed to participate in the study, the majority of which were male (53.3%). Fifty‐seven percent were program directors, and 50% of the participants had 10 years of experience as periodontists. Participants represented a wide variety of programs in different regions in SA (Table 1). The initial list of proposed EPAs consisted of 40 statements organized into three domains: 21 in the disease management domain, 11 in the clinical assessment domain, and 8 in the transferable skills domain.

TABLE 1.

Demographic data of the participants.

	N (%)
Gender
Male	16 (53.3)
Female	14 (46.7)
Nationality
Saudi	29 (96.7)
Non‐Saudi	1 (3.3)
Age
25–34	1 (3.3)
35–44	22 (73.3)
45–54	5 (16.7)
>55	2 (6.7)
Years of experience as a periodontist
<5	0
5–10	15 (50)
>10	15 (50)
Years of experience in training programs
<2	2 (6.7)
2–5	11 (36.7)
6–10	12 (40)
>10	5 (16.7)
Status in graduate training
Program director	17 (57)
Former program director	3 (10)
Trainer	10 (33.3)
City of Practice
Jeddah	11 (36.66)
Makkah	4 (13.33)
Riyadh	11 (36.66)
Dharan	2 (6.66)
Hail	1 (3.3)
Buraidah	1 (3.3)
Abha	1 (3.3)
Affiliations
University (Academic–governmental sector)	14 (46.6)
University (Academic–private sector)	3 (10)
Health cluster (Ministry of Health)	8 (26.66)
Others (Military Hospital, National Gard, etc.)	5 (16.66)

The first round of the modified Delphi method included all 30 participants and had a 100% response rate. Thirty‐four of the 40 EPAs met the criteria, as they were rated as very important / important by more than 80% of the participants (Table 2). Three EPAs received 100% strongly agree response (EPAs 4, 12, and 17). All the EPAs in the clinical assessment domain were accepted. In the disease management domain, four EPAs were rejected, and in the transferable skills domain, two EPAs were rejected.

TABLE 2.

Final list of end of residency periodontics training entrustable professional activities (EPAs).

				Second Delphi
EPA # A	Clinical assessment	First Delphi Mean ± SD	% of agree / strongly agree	Mean ± SD	% of agree / strongly agree
1	Obtaining medical and dental histories and performing periodontal examinations in patients with periodontal disease.	4.97 ± 0.18	100	5 ± 0	100
2	Diagnosing emergency periodontal conditions and providing appropriate management and follow‐up.	4.93 ± 0.25	100	4.95 ± 0.2	100
3	Assessing the clinical presentations of periodontal diseases, constructing a diagnostic approach (including differential diagnosis), and providing treatment plans.	4.97 ± 0.18	100	4.95 ± 0.2	100
4	Providing initial clinical assessments, diagnoses, and management for patients with a range of acute and chronic periodontal presentations.	5 ± 0	100	4.91 ± 0.28	100
5	Detecting periodontal abnormalities through proper examination and radiographic interpretation.	4.83 ± 0.38	100	4.91 ± 0.28	100
6	Assessing and managing patients with gingival soft tissue defects.	4.77 ± 0.50	96.7	4.82 ± 0.38	100
7	Providing initial clinical assessments and investigations and developing a management plan for patients in need of dental implants.	4.73 ± 0.45	100	4.95 ± 0.2	100
8	Providing initial clinical assessments and investigations and developing a management plan for patients with peri‐implant diseases.	4.7 ± 0.53	96.7	4.8 ± 0.38	100
9	Assessing and managing patients with hard and soft tissue defects in preparation for prosthetic treatment.	4.76 ± 0.43	100	4.8 ± 0.33	100
10	Providing initial clinical assessments and investigations and coordinating a management plan for oral soft tissue lesions (oral mucosa disease) with other specialties.	4.3 ± 0.75	83.3	4.4 ± 0.77	83.3
11	Assessing and managing patients with traumatic occlusion and parafunctional habits and planning appropriate referrals.	4.46 ± 0.78	83.3	4.7 ± 0.62	91.7
12	Assessing the clinical presentations of periodontal diseases, developing management plans, and providing periodontal/implant treatment to medically compromised patients.	N/A	N/A	4.8 ± 0.38	100
B	Disease management
13	Performing nonsurgical management of periodontal disease.	5 ± 0	100	5 ± 0	100
14	Performing nonsurgical management of peri‐implant disease.	4.8 ± 0.6	90	4.95 ± 0.2	100
15	Demonstrating the fundamental aspects of periodontal and implant surgical procedures.	4.9 ± 0.30	100	4.95 ± 0.2	100
16	Demonstrating understanding and knowledge of different indications of biomaterials used in periodontal/implant practices.	4.56 ± 0.62	93.3	4.7 ± 0.46	100
17	Performing surgical management of periodontal disease, including open flap debridement, osseous resective surgeries, and regenerative therapy.	5 ± 0	100	5 ± 0	100
18	Providing surgical management for patients with gingival recession.	4.87 ± 0.34	100	4.83 ± 0.38	100
19	Performing periodontal plastic surgery to address esthetic needs.	4.66 ± 0.48	100	4.83 ± 0.38	100
20	Performing autogenous and other soft tissue grafts.	4.8 ± 0.48	96.7	4.9 ± 0.2	100
21	Performing autogenous and other bone grafts for reconstructive surgeries.	4.5 ± 0.73	86.7	4.75 ± 0.5	95.8
22	Placing dental implants in simple and complicated cases.	4.37 ± 0.45	100	4.78 ± 0.5	95.8
23	Performing internal sinus augmentation procedures.	4.8 ± 0.48	96.7	4.73 ± 0.61	91.7
24	Performing external sinus augmentation procedures.	4.5 ± 0.68	90	4.54 ± 0.7	87.5
25	Providing surgical management for patients with preimplant disease.	4.6 ± 0.62	93.3	4.66 ± 0.6	91.7
26	Performing pre‐prosthetic surgery.	4.56 ± 0.68	90	4.7 ± 0.8	95.8
27	Performing atraumatic extractions and socket preservation techniques.	4.76 ± 0.57	93.3	4.7 ± 0.5	95.8
28	Managing postoperative complications in periodontal/implant patients.	4.38 ± 0.378	100	4.79 ± 0.5	95.8
29	Designing and implementing maintenance programs for patients with periodontal disease and dental implants.	4.86 ± 0.34	100	4.9 ± 0.28	100
C	Transferable skills
30	Documenting clinical encounters in an accurate, complete, and timely manner.	4.93 ± 0.25	100	4.8 ± 0.38	100
31	Providing patient education and informed consent in preparation for surgical care.	4.9 ± 0.30	100	4.9 ± 0.28	100
32	Working with an interprofessional team to coordinate care for patients with periodontal disease or in need of dental implants.	4.83 ± 0.37	100	4.75 ± 0.5	95.8
33	Integrating the periodontal scientific literature with clinical practice.	4.7 ± 0.47	100	4.79 ± 0.5	95.8
34	Developing a personal learning plan for future practice and ongoing professional development.	4.6 ± 0.49	100	4.54 ± 0.65	91.7
35	Implementing the principles of quality improvement and patient safety.	4.8 ± 0.40	100	4.7 ± 0.55	95.8

All comments from the expert periodontists were reviewed by the study investigators and incorporated into the second round of the modified Delphi method, which led to the addition of two new EPAs: one in the clinical assessment domain and one in the disease management domain.

The second round was completed by 24 of the original expert panel (80% response rate). The modified list of EPAs achieved a high degree of agreement, with most of the suggested 36 EPAs being approved. All the EPAs, except one, had a mean score of 4.7 ± 0.41 (Table 2). Only one (performing guided implant surgery) did not meet the proposed criteria, with a mean of 4 ± 0.77, and as six respondents rated it 3 or less, it was eliminated. The final list of end‐of‐training EPAs for periodontics training programs in SA is shown in Table 2.

The consistency of the survey was measured using Cronbach's alpha (α = 0.920), which indicates high reliability.

4. DISCUSSION

The study developed and validated a list of end‐of‐training EPAs for periodontics training programs in Saudi Arabia using a modified Delphi method. This approach is widely recognized in the literature. ⁵ , ⁹ , ¹⁰ We categorized the EPAs into three domains that reflect daily periodontal practice, ranging from obtaining medical histories and performing examinations to collaborating with interprofessional teams to enhance patient care.

Following conducting an extensive literature review and discussions among periodontists, we created an initial list of 40 EPAs. We then carried out two rounds of the modified Delphi method with Saudi experts, all of whom had significant experience in periodontal practice—half with at least 5 years and half with over 10 years. The average years of practice among experts in several studies conducted in the literature ranged from 5 to 10 years and up to 26 years. ⁵ Several studies have also included experts with training or community‐based experience. ⁶ , ¹⁷ Our experts came from diverse affiliations and cities in Saudi Arabia, with the majority (57%) serving as current program directors, enhancing the reliability of our results. To maximize the success of the Delphi method, it is essential for participants to understand the definition of EPAs and their implications. Each participant received an email outlining the project's aim, the definition of EPA, the study phases, their required contributions, and the timeframe for each phase, along with selected reading materials on EPA development. The Delphi method yielded a high reliability index and a strong consensus on the 35 end‐of‐training EPAs, which aligns with the recommended number for postgraduate programs. ¹⁸ This indicates that the selected EPAs are highly relevant and represent the profession of periodontics in Saudi Arabia.

Dentistry in general and periodontics in particular are procedure‐based specialties and daily observation of practices is the main assessment method used to determine the competency level of residents and their ability to move on to more complex procedures. ¹² , ¹³ However, a standard criteria determining when competency has been achieved is lacking. ¹² EPAs help determine when competency is achieved by breaking down clinical practice into specific, measurable tasks that a practitioner must be able to perform independently. Each EPA defines a concrete, observable activity that reflects the level of skill and responsibility expected from a competent professional.

The results of this study define the units of practices or the core tasks that a graduating periodontist must be able to perform independently. It provides a standardized guide that can be expanded to define different milestones and to determine the timeline—as well as concomitant assessment methods—needed to achieve an “entrustable level.” EPAs in general require the simultaneous mastering of multiple competencies. ¹⁸ However, the identification of EPA statements is the first step in workplace‐based curriculum (WBC) development. Several factors need to be fulfilled for the successful application of EPA‐WBC. These include determining the specifications and limitations of each EPA, mapping EPA‐competency milestones across years of training, determining the level of supervision needed at each stage, and identifying the knowledge, skills, and attitudes needed for summative assessments and entrustment decisions. ⁴

Entrustment decisions indicate that a given resident is able and competent enough to perform the task in question unsupervised. Providing a detailed framework of EPAs for periodontics training, such as the one outlined in this study, should help define the appropriate assessment tools, such as using portfolios and other measures. EPA‐based assessment would link educational objectives directly to health care and patient safety objectives. In addition, having clear units of practices—EPAs—would support the faculty in providing more effective feedback and empower the residents to take an independent approach to their learning journey and gradually increase their autonomy.

We considered all the comments of the expert panel and took action. Following the first Delphi round, several experts requested that examination and management of medically compromised patients be a separate EPA because periodontists are often asked to provide consultations and treatment plans to medically compromised patients in need of dental treatment. This was also frequently emphasized in the literature. ¹⁹ , ²⁰ Accordingly, EPA 12 was added in the second round of the Delphi method. This EPA had a 100% expert agreement in the second round of Delphi method.

After the first Delphi round, some experts requested the addition of a specific EPA for the periodontal management of orthodontic patients. However, after extensive discussion, we decided that the tasks involved in the periodontal management of orthodontic patients are not separable from the general EPAs that concern the examination of periodontal tissue (EPAs 3 and 5) and surgical and nonsurgical treatment of periodontal patients and therefore should not be considered a stand‐alone EPA. According to Ten Cate et al., EPAs that are inseparable from other EPAs should be combined. ¹⁸

One recommendation in designing EPA titles is to ensure that they are broad and vague. ²¹ From this perspective, the EPA list includes broad titles that focus on the tasks to be performed and avoided, including specific surgical techniques (e.g., tunnel procedures, piezoelectric surgery, osseodensification techniques, etc.). Periodontology is a fast‐growing specialty, and new techniques and instruments are frequently introduced. We tried to incorporate this essential aspect of periodontal practice into the EPA list. Our final list of EPAs includes items related to ongoing professional development and the integration of scientific literature into clinical practice.

We came across a significant, controversial discussion in this research. The initial proposed list included items related to performing digital‐guided implant surgery. Most experts commented that residents should be exposed to such cases but not necessarily be able to “perform it completely independently before graduation.” Similar comments were made related to “performing full arch implant reconstructions.” The experts discussed the degree of complexity involved in those procedures and that proficiency level require a steep learning curve that is gained by continues practices. ²² Neither statement reached consensus, with less than 80% of experts agreeing in the first round of the Delphi method; therefore, they were removed.

Based on our experts’ recommendations following the first Delphi round, we added “performing digital‐guided periodontal surgery” in the second Delphi round. Again, less than 80% of experts agreed that this EPA should be considered an end‐of‐training EPA; therefore, it was excluded from the final list. While we believe that digital technology is becoming an integral part of dentistry, many barriers to the adoption of computer‐assisted surgeries persist. ²²

Addressing the desires of patients in need of dental implants, peri‐implant soft and hard tissue reconstruction, peri‐implant disease prevention, and management have become part of periodontal practices. ¹⁹ The final list of EPAs includes nine EPAs that exclusively address dental implant management. This study identifies the core tasks related to dental implant procedures that a periodontist must master. Placing and restoring dental implants can also be performed by oral surgeons and prosthodontists. EPAs allow for a discussion of cross boundaries between specialties that manage dental implant patients. ¹⁸ For example, external maxillary sinus augmentation (EPA 24) can also be performed by oral surgeons, and atraumatic extractions (EPA 27) can be performed by other dental specialties.

The final EPA list does not include the use of conscious sedation techniques in periodontics. The Saudi periodontology residency curriculum does not refer to any competency related to performing sedation. ¹¹ By contrast, CODA statements 4–11 mandate institutions to provide clinical training to a level of competency in adult minimal eternal and moderate parental sedation. ¹⁵ However, periodontists in SA have a limited privilege to use sedation techniques. ²³ Although EPAs aim at transferable credentialing, specific limitations can be identified, and EPAs should adapt to local health regulations. ²¹

The key difference between EPAs and CODA lies in their focus and approach to competency. CODA sets accreditation standards that stress on ensuring programs cover essential “topics” within a curriculum, but it leaves the definition and assessment of “competence” to individual programs. It addresses broader program effectiveness, curriculum content, and institutional quality and ensures the accredited training programs are in compliance with the accepted standards. ¹⁵ In contrast, EPAs focus on specific clinical tasks that a periodontist must be competent to perform independently. By identifying these tasks, EPAs provide a framework in dental education that helps ensure a trusted level of safe and effective practice by graduates of periodontics programs. It also serves as a strategic approach to improve and address gaps in Competency‐Based Medical Education (CBME). EPAs complement accreditation standards and assist training programs to meet the standards.

While implementing and operationalizing EPAs can be challenging, having a well‐defined EPA, stakeholder collaboration, along with ongoing monitoring and adaptation strategies, can effectively help navigate and overcome these challenges. ²⁴

This study has several limitations. It is specific to SA, so its findings may not apply to other countries. Although the findings are a great tool for developing a WBC, they are not definitive, and further specification and competency mapping are needed. In addition, periodontal clinical practice is changing rapidly, with new management techniques, procedures, and instruments being introduced frequently. This necessitates regular assessment of EPAs and appropriate adjustments or modifications to match current trends in healthcare practices.

5. CONCLUSIONS

This study adopted a strict methodology to develop and validate a core set of EPAs for periodontics training programs in SA. The final list consisted of 35 end‐of‐periodontics‐training EPAs that covers clinical assessment, disease management and transferable skills domains. The findings of this study will facilitate improvements to training and assessments in periodontics residency programs. Further specifications of each EPA with adequate competency mapping and milestone development are essential for proper EPA‐WBC development.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Aldahlawi SA, Zaini RG, Almoallim HM. Entrustable professional activities (EPAs) in postgraduate periodontics programs in Saudi Arabia: A modified Delphi study. J Dent Educ. 2025;89:1042–1050. 10.1002/jdd.13791