European Journal of Dental Education ISSN 1396-5883
Dental student perception and assessment of their clinical knowledge in educating patients about preventive dentistry M. J. Metz1, C. J. Miller2, W. S. Lin3, T. Abdel-Azim3, A. Zandinejad3 and G. A. Crim1 1 2 3
Department of General Dentistry and Oral Medicine, University of Louisville School of Dentistry, Louisville, KY, USA, Department of Physiology and Biophysics, University of Louisville School of Medicine, Louisville, KY, USA, Department of Oral Health and Rehabilitation, University of Louisville School of Dentistry, Louisville, KY, USA
keywords preventive dentistry; student opinion; disease prevention; self-assessment; interactive learning and patient education. Correspondence Michael J. Metz University of Louisville School of Dentistry Office no. 0107. 501 S. Preston Street Louisville, KY 40202, USA Tel: +502 852 6168 Fax: +502 852 6239 e-mail: [email protected] Accepted: 29 April 2014 doi: 10.1111/eje.12107
Abstract In today’s dental school curricula, an increasing amount of time is dedicated to technological advances, and preventive dentistry topics may not be adequately addressed. Freshman (D1) students participated in a new Introduction to Preventive Dentistry course, which consisted of didactic lectures, active learning breakout sessions and casebased studies. The goal of this study was to determine if D1 dental students completing the course had a better knowledge and comfort level with basic preventive dentistry concepts and caries risk assessment than the upcoming graduating senior dental students. Following the completion of the course, D1 students were administered a survey that assessed their comfort level describing preventive dentistry topics to patients. This was immediately followed by an unannounced examination over the same topics. Senior (D4) students, who had not taken a formal course, reported statistically significant higher comfort levels than D1 students. However, the D4s scored significantly lower in all of the examination areas than the D1 students. Higher scores in D1s may have been due to recent exposure to the course material. However, the basic nature of the content-specific questions should be easily answered by novice practitioners educating their patients on oral disease prevention. As the current data shows lower contentspecific scores of basic preventive dentistry knowledge amongst graduating D4 students, this may indicate a need for more guidance and education of students during the patient care. This study showed that implementation of a formalised course for D1 students can successfully ameliorate deficiencies in knowledge of preventive dentistry topics.
Introduction In today’s dental school curricula, the task of keeping up with the advancement of the digital world is a daunting goal. The growing demand to fill the curriculum with advanced restorative concepts like digital imaging, digital scanning and implantology to prepare students for these advancements is extraordinary (1). The importance of educating students on these techniques is paramount; however, the basic foundation for teaching disease prevention has fallen to the wayside. This is especially important for fledgling dentists returning to rural areas of Kentucky where prevention education is drastically needed and affordable (2). Dental students must be able to educate their patients to the basic principles of dental caries prevention, biofilm formation and plaque removal (2). Students themselves must be able to collect and evaluate salivary flow and composition, past caries experience, current
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 81–86
caries experience, dietary factors and environmental factors in assessing individual risk for future caries (2). The students must then use this caries risk assessment to formulate a treatment therapy individualised for each patient (2). In a general dentistry practice, the number of elderly dentate patients is rising and poses other preventive issues to fledgling dental practitioners. Their opinions and basic knowledge of root caries and medication induced hyposalivation need to be guided in terms of risk assessment and prevention treatment planning (3, 4). The lack of emphasis on evidencebased prevention in the current technological curricula can negatively influence student perception and opinions to the importance of incorporation into everyday dental practice (5–8). Additionally, the lack of emphasis on caries prevention in the curriculum can lead to the student’s underappreciation of the importance of this topic to patients’ overall health (5, 7). 81
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Risk assessment and prevention treatment planning from data collection is a complex tool that could use more attention in all curricula (8). Population-specific prevention is still needed in rural areas where oral diseases disproportionately exist at the highest rates (9). The process of merely repairing the carious disease process and not adequately teaching prevention directly to our students and indirectly to our patients is falling short of educational obligations (9). Of importance is student knowledge and opinions about their educational experience in terms of disease prevention (10–12). The current published literature does not contain a study in which basic preventive dentistry concept retention is evaluated and compared to self-reported student comfort levels. Therefore, the novel design and purpose of this study was to evaluate and compare the retention and knowledge gained from the implementation of a new freshman course titled “Introduction to Preventive Dentistry” to the basic preventive dentistry knowledge of upcoming graduating senior dental students who did not receive a formal preventive dentistry course. Of interest was the implementation of problem-based learning in the new preventive course through patient-based case studies in an interactive classroom environment. The primary hypothesis of this study was that the freshman dental students will have a better knowledge of basic preventive dentistry concepts and caries risk assessment immediately following the course compared with the upcoming graduating senior dental students. Furthermore, it was hypothesised that senior dental students may report higher comfort levels with preventive dentistry topics than the D1 students.
Materials and methods Participants and course design This study was completed at the University of Louisville School of Dentistry in Louisville, KY. Introduction to Preventive Dentistry was a newly implemented general dentistry course for 1st year dental students, with an enrolment of 120 students. The course was one credit hour, with 16 contact hours. The course followed a progression from basic preventive dentistry concepts to collecting patient data for caries risk assessment and preventive treatment planning.
Instructional methodology The Introduction to Preventive Dentistry lectures consisted of 10–15 min of formal instruction, followed by an activity that allowed students to actively apply the content to which they had just been exposed. These activities included problems or prompts that required students to brainstorm outcomes, classify components, compare/contrast pathologies, match terminology and definitions, solve fluoride dosing equations, complete Venn diagrams, watch professor-designed video clips and complete worksheets, do “think-pair-share” activities and write one-minute papers, etc. All of the activities were developed exclusively by the PI of the study, using guidelines and
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suggestions from the large body of literature on active learning techniques (13–16). The activities ranged in duration from 1 min to 60 min. In almost all of the activities, students were encouraged to work in small groups of four to five students. Each activity was followed by a class debriefing, in which students were called upon to share their findings with the class. Rather than call on specific students, random characteristics were used to determine which students would respond. These included: student with the longest hair, student with the most writing instruments on their desk, student with the brightest piece of clothing and student who arrived last to class, etc. This ensured that over the course of the semester, all of the members of the large class had an opportunity to share their results. The course concluded with varying case-based studies where students were provided with both a radiographic and photographic series. The students were also provided a medical history of the patient where key points needed to be addressed in terms of oral health. Due to the D1 student’s lack of clinical experience, they were informed of any clinical dental caries activity and depth of progression. Explained to the D1 students were the existence of white spot demineralization, enamel cavitation and dentin cavitation. Additionally, the students were introduced to basic radiographic interpretation of enamel cavitation, dentin cavitation and existing repair of the disease process (direct restorations, indirect prosthesis and root canal therapy). These concepts were important to determine the patient’s current and past caries experience. Students were given both stimulated and unstimulated salivary flow rates, salivary pH and buffering capacity as associated with varying medical conditions. Also, the students were given a week-long dietary assessment of the patient’s eating, drinking habits and plaque index. From the available collected data, the student groups (5 students) worked together to form a caries risk assessment and individualised preventive treatment plan. The students were then asked to present their findings in terms of past caries experience, current caries experience, salivary flow/composition and dietary choices formulating a caries risk determination to the entire class. Following that, the students provided a detailed preventive treatment plan to eliminate active cavitated carious lesions, educate oral hygiene, recommend remineralization therapy, restore or replace salivary flow, recommend sealants, prescribe fluoride therapy and establish effective recall time frames.
Research design At the conclusion of the Introduction to Preventive Dentistry Course, volunteer freshman, referred to as D1 students (n = 120) were administered a 10-question Likert scale survey to gauge their comfort level in discussing and educating specific preventive dentistry content areas with their patients. Senior students (n = 117), referred to as D4 students, who had not taken the course were also administered the survey. Following the completion of the survey, all students were given an immediate unannounced corresponding 30 content question
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 81–86
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examination to provide justification for their reported comfort level. The Likert survey and examination required approximately 30 min of student time to complete.
Instrument design The 10-question Likert scale survey consisted of the following comfort levels in discussing content area specific preventive topics with their patients (for content areas see Table 1): 1 = Very Uncomfortable, 2 = Uncomfortable, 3 = Neutral, 4 = Comfortable and 5 = Very Comfortable. The unannounced 30-question examination consisted of three different types of questions for each of ten content areas addressed on the Likert scale questions (Table 1): one multiple choice, one fill-in-the-blank and one single sentence written response. Each multiple choice question had only one correct answer, the fill-in-the-blank had only one correct written term and the single sentence written response required two predetermined key words to be correct. All questions were peer-reviewed within the authorship of this manuscript using evidence-based literature and answers agreed upon with 100% agreement. All single sentence written response and fill-in-the-blank terms were evaluated by the primary author for consistency and key word verification due to the subjective nature of grading. The first set of three questions on the 30-question examination corresponded to content area one (question 1) on the Likert scale survey. Please see Table 1 for all content areas. An example of the instrument implementation was as follows for content area two: Content Area Two Likert Scale Survey Question: How comfortable do you feel discussing the role of saliva in overall patient oral health? TABLE 1. Preventive Dentistry Content Areas (10). It consists of 10 specific preventive dentistry content areas used to form the 10-question Likert scale survey. Each content area sought the students comfort level in discussing specific preventive dentistry topics with their patients Content Area 1 2 3 4 5 6 7 8 9 10
How comfortable do you feel. . .. . ... Discussing the role of preventive dentistry in overall patient oral health? Discussing the role of saliva in overall patient oral health? Discussing demineralization and remineralization at the tooth/saliva interface? Discussing the formation and importance of acquired pellicle to tooth integrity? Discussing the formation and role of plaque biofilm on tooth integrity? Discussing the causality of dental caries? Discussing the dental caries process and appropriate detection techniques? Discussing the available forms of fluoride and its mechanisms of action? Discussing caries diagnosis in respects to sensitivity and specificity? Discussing caries risk assessment and the importance of data collection?
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 81–86
Very Uncomfortable 1______
Uncomfortable
Neutral
Comfortable
2______
3______
4______
Very Comfortable 5______
Content Area Two Corresponding Examination Questions: Which of the following would be considered a normal stimulated salivary flow rate for an adult dentate patient? a) 0.015 mL/min b) 0.15 mL/min c) 1.50 mL/min d) 150 mL/min The primary buffering capacity of unstimulated saliva required in managing plaque pH is predominantly under the control of the ___________________________buffering system. In one sentence, please explain what parasympathomimetic oral medication you would prescribe for your xerostomic patient with viable salivary tissue. The only acceptable correct answer for the multiple choice question was answer c and therefore all other responses would be incorrect. The only acceptable answer for the fill-in-theblank question was phosphate buffering system, and therefore, carbonic acid/bicarbonate and protein buffering system were incorrect. The two key words for the short-answer question were ‘Pilocarpine (Salagen) or Cevimeline (Evoxac)’ and ‘patient produced.’ Biotene, fluoride, chlorahexadine gluconate, xytitol and amorphous calcium phosphate were all incorrect.
• • •
Rationale for study design The data collected was used to compare the reported comfort level of freshman dental students with graduating senior dental students in discussing content-specific preventive concepts with their patients. Additionally, the data collected was used to compare the content-specific examination performance of freshman dental students with graduating senior dental students. Students were administered both a survey and an examination, with the premise being that if the student reported a high comfort level of ‘very comfortable’, the student should be able to answer all three questions correctly about the specific content at hand. If students self-report feeling very comfortable discussing content and do not relay accurate information to their patient, resolution of the disease process is difficult. Initially, student identifiers (student university numbers) were used to marry the Likert surveys with the appropriate unannounced examinations because they were not distributed at the same time. It was emphasised to students that the student identifiers were used solely to determine that all students had completed the survey, and the results would be held confidential. All the likert surveys were distributed, completed and collected before the immediate unannounced examination was distributed, completed and collected. The integrity of the Likert survey could have been altered if the students knew they had to justify their self-reported comfort level with question verification. No identifiers were maintained after marrying the information to protect student privacy, and the results had no bearing on their course grades or proposed graduation requirements. 83
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Data analysis and IRB approval
Discussion
Statistical analyses were performed using Origin software version 8.1 (OriginLab, Northampton, MA, USA), as shown in the figure legends, with statistical significance defined as P < 0.05. This study was determined to be IRB exempt by the University of Louisville (Tracking #: 13.0274, 6/17/2013).
As dental digital technology advances, the need to incorporate these principles into dental curricula is crucial (1). However, this must be reconciled with the need for the students to be formally exposed to the basics of disease prevention for all age groups in various populations (2–5). Placing prevention within the confines of larger courses can cause students to dismiss the importance of risk assessment and prevention (6–9). The lack in emphasis of prevention in current dental school curricula may negatively influence student perceptions and opinions to the importance of incorporation into everyday dental practice (10–12). Additionally, the lack of emphasis on caries prevention in curricula can lead to the student’s underappreciation of this topic to the patients’ overall health (5, 7–9). This underappreciation may lead to inadequate knowledge to educate patients on basic disease prevention and future risk assessment, especially in high risk populations (2, 5, 7, 8). In order to address these issues, a formal course titled, “Introduction to Preventive Dentistry” was implemented for the entering D1 dental students. In this course, students were engaged in regular breakout sessions that allowed them to actively apply the content to clinical scenarios. Previous studies completed by our research group showed a significant positive effect of the active learning strategies on student performance, retention of knowledge and confidence with the material (17). The concepts of risk assessment and prevention treatment planning from data collection were presented in clinical case presentations through problem-based learning by the students to their colleagues. Data collected for risk assessment came from understanding salivary flow/composition, demineralization/remineralization, enamel pellicle/biofilm formation, dental caries process, fluoride therapy, dental sealant placement and dental caries detection.
Results As shown in Figure 1, both the D1 students, who recently completed the Introduction to Preventive Dentistry course, and the D4 students, who never received formal interactive instruction in preventive dentistry, reported very high levels of comfort regarding the material. The mean Likert scale responses all ranged between 4 (comfortable) and 5 (very comfortable). However, D4 students reported statistically significant higher comfort levels than D1 students in eight of the ten content areas (n = 117–120 students, * P < 0.05, Mann–Whitney U-test used for ordinal, Likert scale data). Across the entire survey, the D4 students reported an average comfort level of 4.8 (SD 0.1), whilst the D1 students indicated a comfort level of 4.3 (SD 0.4). This suggests that, despite not receiving a formalised course in preventive dentistry, the D4 students felt more comfortable discussing these content-specific concepts to patients than the D1 students. Figure 2 compares the examination scores of the D1 students, who had recently completed the Introduction to Preventive Dentistry course, compared to the D4 students. The D4 students scored significantly lower in all of the preventive dentistry content areas than the D1 students (n = 117–120 students, * P < 0.0001, One-way ANOVA and Tukey post hoc test). The overall exam average for D1 students was a 94% (SD 4), whilst the D4 exam average was a 46% (SD 13).
Fig. 1. Comparison of Survey Results for D1 and D4 Students. Students completed a Likert scale survey regarding their comfort level discussing specific-content area topics in preventive dentistry with their patients. (n = 117–120 students, data presented as means SD, * P < 0.05 D1 students vs. D4 students, Mann–Whitney U-test used for ordinal, Likert scale data).
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ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 81–86
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Fig. 2. Comparison of Exam Results for D1 and D4 Students. Students completed a 30-question exam covering ten different topics in preventive dentistry. Each content area was assessed through one multiple choice, one fill-in-the-blank and one short-response question. (n = 117–120 students, data presented as means SD, *P < 0.0001 D1 students vs. D4 students, One-way ANOVA and Tukey post hoc test).
The results of this study revealed that the D4 students reported statistically significant higher comfort levels than D1 students in eight of the ten content-specific areas. This indicates that, despite not receiving a formalised course in preventive dentistry, the D4 students felt more comfortable discussing content-specific preventive concepts with patients than did the D1 students. The higher self-reported D4 confidence levels could have been reported due to the D4s eagerness of their upcoming graduation and essentially 24 months of clinical interactions with patients. Additionally, one weakness of the study design was that the students had to disclose their student university numbers on the survey. This was necessary to marry the survey results with the subsequent, unannounced examination. Whilst it was emphasised to participants that the results of the study were confidential, D4 students may have felt less comfortable reporting any weaknesses in their knowledge of preventive dentistry. It has been shown that students are more likely to report sensitive or damaging information when their anonymity is guaranteed (18). Alternatively, the lower comfort levels reported by the D1s may be due to a lack of experience interacting with actual patients in a clinical setting. Therefore, future studies should analyse the clinical outcomes of the preventive course and the effectiveness of the course in preparing students for actual patient interactions. It will be necessary to determine whether factual knowledge of preventive dentistry correlates with an improved ability to communicate the information to patients. Unfortunately, the D4 students scored significantly lower in all of the content-specific areas than did the D1 students. The overall exam average for D1 students was a 94%, whilst the D4 exam average was a 46%. Higher scores in D1s may have been due to recent exposure to the course material. However, the ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 81–86
basic nature of the content-specific questions should be easily answered by novice practitioners educating their patients on disease prevention. Therefore, a repeated study in 3 years will be necessary to determine if the current D1 students retain this content knowledge over the course of their dental education. Whilst D4 students self-reported a higher comfort level with the majority of topics, their knowledge of basic preventive dentistry concepts may be insufficient. However, the D4s higher confidence levels reported and lower scores on content-specific questions do not imply insufficient clinical presentation during patient education. Exposed is a limitation in study design methodology and to internal validity, lack of clinical assessment of student’s education of patients on disease prevention. As the current data shows lower content-specific scores of basic preventive dentistry knowledge amongst graduating D4 students, this may indicate a need for more guidance and education of students during the patient care. It is imperative that students be provided a positive clinical learning experience under guided instruction in the basics of prevention to mould student opinions and perceptions to its value on overall patient health.
Conclusion The results of this study demonstrated that D4 students may lack basic content knowledge in preventive dentistry, despite high self-reported comfort levels with the topics. A new Introduction to Preventive Dentistry course, which utilised active learning techniques, resulted in greater alignment between D1 student perceptions of their preventive dentistry expertise and actual student performance on examinations. Future studies will investigate the ability of dental students to retain their knowledge of preventive dentistry topics over the progression 85
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of their educational careers and effectively implement this knowledge during clinical patient interactions.
References 1 Fasbinder DJ. Computerized technology for restorative dentistry. Am J Dent 2013: 26: 115–120. 2 Brown JP. The future of prevention in dental schools. J Am Coll Dent 1992: 59: 18–24. 3 Issrani R, Ammanagi R, Keluskar V. Geriatric dentistry–meet the need. Gerodontology 2012: 29: e1–e5. 4 Dounis G, Ditmyer MM, McClain MA, Cappelli DP, Mobley CC. Preparing the dental workforce for oral disease prevention in an aging population. J Dent Educ 2010: 74: 1086–1094. 5 Polverini PJ. A curriculum for the new dental practitioner: preparing dentists for a prospective oral health care environment. Am J Public Health 2012: 102: e1–e3. 6 Morgan MZ, Verkroost S, Hunter L. Evidence-based prevention: a comparison of oral hygiene advice given by dental and dental care professional students. Int J Dent Hyg 2013: 11: 121–125. 7 Allen F. Embedding a population oral health perspective in the dental curriculum. Community Dent Oral Epidemiol 2012: 2: 127– 133. 8 Brown JP. A new curriculum framework for clinical prevention and population health, with a review of clinical caries prevention teaching in U.S. and Canadian dental schools. J Dent Educ 2007: 71: 572–578.
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9 Garcia RI, Sohn W. The paradigm shift to prevention and its relationship to dental education. J Dent Educ 2012: 76: 36–45. 10 Autio-Gold JT, Tomar SL. Dental students’ opinions and knowledge about caries management and prevention. J Dent Educ 2008: 72: 26–32. 11 Pakdaman A, Evans RW, Howe E. Dental students’ knowledge and perceptions of non-invasive dental caries management. Aust Dent J 2010: 55: 28–36. 12 Calder on SH, Gilbert P, Zeff RN, et al. Dental students’ knowledge, attitudes, and intended behaviors regarding caries risk assessment: impact of years of education and patient age. J Dent Educ 2007: 71: 1420–1427. 13 Angelo TA, Cross KP. Classroom assessment techniques: a handbook for college teachers. 2nd Ed. San Francisco, CA: JosseyBass, Inc., 1993. 14 Barkley EF, Cross KP, Major CH. Collaborative learning techniques: a handbook for college faculty. San Francisco, CA: Jossey-Bass, Inc., 2005. 15 Barkley EF. Student engagement techniques: a handbook for college faculty. San Francisco, CA: Jossey-Bass, Inc., 2009. 16 Silberman M. Active learning: 101 strategies to teach any subject. Des Moines, IA: Pearson, 1996. 17 Miller CJ, McNear J, Metz MJ. A comparison of traditional and engaging lecture methods in a large, professional-level course. Adv Physiol Edu 2013: 37: 347–355. 18 Ong AD, Weiss DJ. The impact of anonymity on responses to sensitive questions. J Applied Social Psych 2000: 30: 1691–1708.
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Dental student perception and assessment of their clinical knowledge in educating patients about preventive dentistry M. J. Metz1, C. J. Miller2, W. S. Lin3, T. Abdel-Azim3, A. Zandinejad3 and G. A. Crim1 1 2 3
Department of General Dentistry and Oral Medicine, University of Louisville School of Dentistry, Louisville, KY, USA, Department of Physiology and Biophysics, University of Louisville School of Medicine, Louisville, KY, USA, Department of Oral Health and Rehabilitation, University of Louisville School of Dentistry, Louisville, KY, USA
keywords preventive dentistry; student opinion; disease prevention; self-assessment; interactive learning and patient education. Correspondence Michael J. Metz University of Louisville School of Dentistry Office no. 0107. 501 S. Preston Street Louisville, KY 40202, USA Tel: +502 852 6168 Fax: +502 852 6239 e-mail: [email protected] Accepted: 29 April 2014 doi: 10.1111/eje.12107
Abstract In today’s dental school curricula, an increasing amount of time is dedicated to technological advances, and preventive dentistry topics may not be adequately addressed. Freshman (D1) students participated in a new Introduction to Preventive Dentistry course, which consisted of didactic lectures, active learning breakout sessions and casebased studies. The goal of this study was to determine if D1 dental students completing the course had a better knowledge and comfort level with basic preventive dentistry concepts and caries risk assessment than the upcoming graduating senior dental students. Following the completion of the course, D1 students were administered a survey that assessed their comfort level describing preventive dentistry topics to patients. This was immediately followed by an unannounced examination over the same topics. Senior (D4) students, who had not taken a formal course, reported statistically significant higher comfort levels than D1 students. However, the D4s scored significantly lower in all of the examination areas than the D1 students. Higher scores in D1s may have been due to recent exposure to the course material. However, the basic nature of the content-specific questions should be easily answered by novice practitioners educating their patients on oral disease prevention. As the current data shows lower contentspecific scores of basic preventive dentistry knowledge amongst graduating D4 students, this may indicate a need for more guidance and education of students during the patient care. This study showed that implementation of a formalised course for D1 students can successfully ameliorate deficiencies in knowledge of preventive dentistry topics.
Introduction In today’s dental school curricula, the task of keeping up with the advancement of the digital world is a daunting goal. The growing demand to fill the curriculum with advanced restorative concepts like digital imaging, digital scanning and implantology to prepare students for these advancements is extraordinary (1). The importance of educating students on these techniques is paramount; however, the basic foundation for teaching disease prevention has fallen to the wayside. This is especially important for fledgling dentists returning to rural areas of Kentucky where prevention education is drastically needed and affordable (2). Dental students must be able to educate their patients to the basic principles of dental caries prevention, biofilm formation and plaque removal (2). Students themselves must be able to collect and evaluate salivary flow and composition, past caries experience, current
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 81–86
caries experience, dietary factors and environmental factors in assessing individual risk for future caries (2). The students must then use this caries risk assessment to formulate a treatment therapy individualised for each patient (2). In a general dentistry practice, the number of elderly dentate patients is rising and poses other preventive issues to fledgling dental practitioners. Their opinions and basic knowledge of root caries and medication induced hyposalivation need to be guided in terms of risk assessment and prevention treatment planning (3, 4). The lack of emphasis on evidencebased prevention in the current technological curricula can negatively influence student perception and opinions to the importance of incorporation into everyday dental practice (5–8). Additionally, the lack of emphasis on caries prevention in the curriculum can lead to the student’s underappreciation of the importance of this topic to patients’ overall health (5, 7). 81
D.M.D. student knowledge of preventive dentistry
Risk assessment and prevention treatment planning from data collection is a complex tool that could use more attention in all curricula (8). Population-specific prevention is still needed in rural areas where oral diseases disproportionately exist at the highest rates (9). The process of merely repairing the carious disease process and not adequately teaching prevention directly to our students and indirectly to our patients is falling short of educational obligations (9). Of importance is student knowledge and opinions about their educational experience in terms of disease prevention (10–12). The current published literature does not contain a study in which basic preventive dentistry concept retention is evaluated and compared to self-reported student comfort levels. Therefore, the novel design and purpose of this study was to evaluate and compare the retention and knowledge gained from the implementation of a new freshman course titled “Introduction to Preventive Dentistry” to the basic preventive dentistry knowledge of upcoming graduating senior dental students who did not receive a formal preventive dentistry course. Of interest was the implementation of problem-based learning in the new preventive course through patient-based case studies in an interactive classroom environment. The primary hypothesis of this study was that the freshman dental students will have a better knowledge of basic preventive dentistry concepts and caries risk assessment immediately following the course compared with the upcoming graduating senior dental students. Furthermore, it was hypothesised that senior dental students may report higher comfort levels with preventive dentistry topics than the D1 students.
Materials and methods Participants and course design This study was completed at the University of Louisville School of Dentistry in Louisville, KY. Introduction to Preventive Dentistry was a newly implemented general dentistry course for 1st year dental students, with an enrolment of 120 students. The course was one credit hour, with 16 contact hours. The course followed a progression from basic preventive dentistry concepts to collecting patient data for caries risk assessment and preventive treatment planning.
Instructional methodology The Introduction to Preventive Dentistry lectures consisted of 10–15 min of formal instruction, followed by an activity that allowed students to actively apply the content to which they had just been exposed. These activities included problems or prompts that required students to brainstorm outcomes, classify components, compare/contrast pathologies, match terminology and definitions, solve fluoride dosing equations, complete Venn diagrams, watch professor-designed video clips and complete worksheets, do “think-pair-share” activities and write one-minute papers, etc. All of the activities were developed exclusively by the PI of the study, using guidelines and
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suggestions from the large body of literature on active learning techniques (13–16). The activities ranged in duration from 1 min to 60 min. In almost all of the activities, students were encouraged to work in small groups of four to five students. Each activity was followed by a class debriefing, in which students were called upon to share their findings with the class. Rather than call on specific students, random characteristics were used to determine which students would respond. These included: student with the longest hair, student with the most writing instruments on their desk, student with the brightest piece of clothing and student who arrived last to class, etc. This ensured that over the course of the semester, all of the members of the large class had an opportunity to share their results. The course concluded with varying case-based studies where students were provided with both a radiographic and photographic series. The students were also provided a medical history of the patient where key points needed to be addressed in terms of oral health. Due to the D1 student’s lack of clinical experience, they were informed of any clinical dental caries activity and depth of progression. Explained to the D1 students were the existence of white spot demineralization, enamel cavitation and dentin cavitation. Additionally, the students were introduced to basic radiographic interpretation of enamel cavitation, dentin cavitation and existing repair of the disease process (direct restorations, indirect prosthesis and root canal therapy). These concepts were important to determine the patient’s current and past caries experience. Students were given both stimulated and unstimulated salivary flow rates, salivary pH and buffering capacity as associated with varying medical conditions. Also, the students were given a week-long dietary assessment of the patient’s eating, drinking habits and plaque index. From the available collected data, the student groups (5 students) worked together to form a caries risk assessment and individualised preventive treatment plan. The students were then asked to present their findings in terms of past caries experience, current caries experience, salivary flow/composition and dietary choices formulating a caries risk determination to the entire class. Following that, the students provided a detailed preventive treatment plan to eliminate active cavitated carious lesions, educate oral hygiene, recommend remineralization therapy, restore or replace salivary flow, recommend sealants, prescribe fluoride therapy and establish effective recall time frames.
Research design At the conclusion of the Introduction to Preventive Dentistry Course, volunteer freshman, referred to as D1 students (n = 120) were administered a 10-question Likert scale survey to gauge their comfort level in discussing and educating specific preventive dentistry content areas with their patients. Senior students (n = 117), referred to as D4 students, who had not taken the course were also administered the survey. Following the completion of the survey, all students were given an immediate unannounced corresponding 30 content question
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 81–86
Metz et al.
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examination to provide justification for their reported comfort level. The Likert survey and examination required approximately 30 min of student time to complete.
Instrument design The 10-question Likert scale survey consisted of the following comfort levels in discussing content area specific preventive topics with their patients (for content areas see Table 1): 1 = Very Uncomfortable, 2 = Uncomfortable, 3 = Neutral, 4 = Comfortable and 5 = Very Comfortable. The unannounced 30-question examination consisted of three different types of questions for each of ten content areas addressed on the Likert scale questions (Table 1): one multiple choice, one fill-in-the-blank and one single sentence written response. Each multiple choice question had only one correct answer, the fill-in-the-blank had only one correct written term and the single sentence written response required two predetermined key words to be correct. All questions were peer-reviewed within the authorship of this manuscript using evidence-based literature and answers agreed upon with 100% agreement. All single sentence written response and fill-in-the-blank terms were evaluated by the primary author for consistency and key word verification due to the subjective nature of grading. The first set of three questions on the 30-question examination corresponded to content area one (question 1) on the Likert scale survey. Please see Table 1 for all content areas. An example of the instrument implementation was as follows for content area two: Content Area Two Likert Scale Survey Question: How comfortable do you feel discussing the role of saliva in overall patient oral health? TABLE 1. Preventive Dentistry Content Areas (10). It consists of 10 specific preventive dentistry content areas used to form the 10-question Likert scale survey. Each content area sought the students comfort level in discussing specific preventive dentistry topics with their patients Content Area 1 2 3 4 5 6 7 8 9 10
How comfortable do you feel. . .. . ... Discussing the role of preventive dentistry in overall patient oral health? Discussing the role of saliva in overall patient oral health? Discussing demineralization and remineralization at the tooth/saliva interface? Discussing the formation and importance of acquired pellicle to tooth integrity? Discussing the formation and role of plaque biofilm on tooth integrity? Discussing the causality of dental caries? Discussing the dental caries process and appropriate detection techniques? Discussing the available forms of fluoride and its mechanisms of action? Discussing caries diagnosis in respects to sensitivity and specificity? Discussing caries risk assessment and the importance of data collection?
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 81–86
Very Uncomfortable 1______
Uncomfortable
Neutral
Comfortable
2______
3______
4______
Very Comfortable 5______
Content Area Two Corresponding Examination Questions: Which of the following would be considered a normal stimulated salivary flow rate for an adult dentate patient? a) 0.015 mL/min b) 0.15 mL/min c) 1.50 mL/min d) 150 mL/min The primary buffering capacity of unstimulated saliva required in managing plaque pH is predominantly under the control of the ___________________________buffering system. In one sentence, please explain what parasympathomimetic oral medication you would prescribe for your xerostomic patient with viable salivary tissue. The only acceptable correct answer for the multiple choice question was answer c and therefore all other responses would be incorrect. The only acceptable answer for the fill-in-theblank question was phosphate buffering system, and therefore, carbonic acid/bicarbonate and protein buffering system were incorrect. The two key words for the short-answer question were ‘Pilocarpine (Salagen) or Cevimeline (Evoxac)’ and ‘patient produced.’ Biotene, fluoride, chlorahexadine gluconate, xytitol and amorphous calcium phosphate were all incorrect.
• • •
Rationale for study design The data collected was used to compare the reported comfort level of freshman dental students with graduating senior dental students in discussing content-specific preventive concepts with their patients. Additionally, the data collected was used to compare the content-specific examination performance of freshman dental students with graduating senior dental students. Students were administered both a survey and an examination, with the premise being that if the student reported a high comfort level of ‘very comfortable’, the student should be able to answer all three questions correctly about the specific content at hand. If students self-report feeling very comfortable discussing content and do not relay accurate information to their patient, resolution of the disease process is difficult. Initially, student identifiers (student university numbers) were used to marry the Likert surveys with the appropriate unannounced examinations because they were not distributed at the same time. It was emphasised to students that the student identifiers were used solely to determine that all students had completed the survey, and the results would be held confidential. All the likert surveys were distributed, completed and collected before the immediate unannounced examination was distributed, completed and collected. The integrity of the Likert survey could have been altered if the students knew they had to justify their self-reported comfort level with question verification. No identifiers were maintained after marrying the information to protect student privacy, and the results had no bearing on their course grades or proposed graduation requirements. 83
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Data analysis and IRB approval
Discussion
Statistical analyses were performed using Origin software version 8.1 (OriginLab, Northampton, MA, USA), as shown in the figure legends, with statistical significance defined as P < 0.05. This study was determined to be IRB exempt by the University of Louisville (Tracking #: 13.0274, 6/17/2013).
As dental digital technology advances, the need to incorporate these principles into dental curricula is crucial (1). However, this must be reconciled with the need for the students to be formally exposed to the basics of disease prevention for all age groups in various populations (2–5). Placing prevention within the confines of larger courses can cause students to dismiss the importance of risk assessment and prevention (6–9). The lack in emphasis of prevention in current dental school curricula may negatively influence student perceptions and opinions to the importance of incorporation into everyday dental practice (10–12). Additionally, the lack of emphasis on caries prevention in curricula can lead to the student’s underappreciation of this topic to the patients’ overall health (5, 7–9). This underappreciation may lead to inadequate knowledge to educate patients on basic disease prevention and future risk assessment, especially in high risk populations (2, 5, 7, 8). In order to address these issues, a formal course titled, “Introduction to Preventive Dentistry” was implemented for the entering D1 dental students. In this course, students were engaged in regular breakout sessions that allowed them to actively apply the content to clinical scenarios. Previous studies completed by our research group showed a significant positive effect of the active learning strategies on student performance, retention of knowledge and confidence with the material (17). The concepts of risk assessment and prevention treatment planning from data collection were presented in clinical case presentations through problem-based learning by the students to their colleagues. Data collected for risk assessment came from understanding salivary flow/composition, demineralization/remineralization, enamel pellicle/biofilm formation, dental caries process, fluoride therapy, dental sealant placement and dental caries detection.
Results As shown in Figure 1, both the D1 students, who recently completed the Introduction to Preventive Dentistry course, and the D4 students, who never received formal interactive instruction in preventive dentistry, reported very high levels of comfort regarding the material. The mean Likert scale responses all ranged between 4 (comfortable) and 5 (very comfortable). However, D4 students reported statistically significant higher comfort levels than D1 students in eight of the ten content areas (n = 117–120 students, * P < 0.05, Mann–Whitney U-test used for ordinal, Likert scale data). Across the entire survey, the D4 students reported an average comfort level of 4.8 (SD 0.1), whilst the D1 students indicated a comfort level of 4.3 (SD 0.4). This suggests that, despite not receiving a formalised course in preventive dentistry, the D4 students felt more comfortable discussing these content-specific concepts to patients than the D1 students. Figure 2 compares the examination scores of the D1 students, who had recently completed the Introduction to Preventive Dentistry course, compared to the D4 students. The D4 students scored significantly lower in all of the preventive dentistry content areas than the D1 students (n = 117–120 students, * P < 0.0001, One-way ANOVA and Tukey post hoc test). The overall exam average for D1 students was a 94% (SD 4), whilst the D4 exam average was a 46% (SD 13).
Fig. 1. Comparison of Survey Results for D1 and D4 Students. Students completed a Likert scale survey regarding their comfort level discussing specific-content area topics in preventive dentistry with their patients. (n = 117–120 students, data presented as means SD, * P < 0.05 D1 students vs. D4 students, Mann–Whitney U-test used for ordinal, Likert scale data).
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Fig. 2. Comparison of Exam Results for D1 and D4 Students. Students completed a 30-question exam covering ten different topics in preventive dentistry. Each content area was assessed through one multiple choice, one fill-in-the-blank and one short-response question. (n = 117–120 students, data presented as means SD, *P < 0.0001 D1 students vs. D4 students, One-way ANOVA and Tukey post hoc test).
The results of this study revealed that the D4 students reported statistically significant higher comfort levels than D1 students in eight of the ten content-specific areas. This indicates that, despite not receiving a formalised course in preventive dentistry, the D4 students felt more comfortable discussing content-specific preventive concepts with patients than did the D1 students. The higher self-reported D4 confidence levels could have been reported due to the D4s eagerness of their upcoming graduation and essentially 24 months of clinical interactions with patients. Additionally, one weakness of the study design was that the students had to disclose their student university numbers on the survey. This was necessary to marry the survey results with the subsequent, unannounced examination. Whilst it was emphasised to participants that the results of the study were confidential, D4 students may have felt less comfortable reporting any weaknesses in their knowledge of preventive dentistry. It has been shown that students are more likely to report sensitive or damaging information when their anonymity is guaranteed (18). Alternatively, the lower comfort levels reported by the D1s may be due to a lack of experience interacting with actual patients in a clinical setting. Therefore, future studies should analyse the clinical outcomes of the preventive course and the effectiveness of the course in preparing students for actual patient interactions. It will be necessary to determine whether factual knowledge of preventive dentistry correlates with an improved ability to communicate the information to patients. Unfortunately, the D4 students scored significantly lower in all of the content-specific areas than did the D1 students. The overall exam average for D1 students was a 94%, whilst the D4 exam average was a 46%. Higher scores in D1s may have been due to recent exposure to the course material. However, the ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 19 (2015) 81–86
basic nature of the content-specific questions should be easily answered by novice practitioners educating their patients on disease prevention. Therefore, a repeated study in 3 years will be necessary to determine if the current D1 students retain this content knowledge over the course of their dental education. Whilst D4 students self-reported a higher comfort level with the majority of topics, their knowledge of basic preventive dentistry concepts may be insufficient. However, the D4s higher confidence levels reported and lower scores on content-specific questions do not imply insufficient clinical presentation during patient education. Exposed is a limitation in study design methodology and to internal validity, lack of clinical assessment of student’s education of patients on disease prevention. As the current data shows lower content-specific scores of basic preventive dentistry knowledge amongst graduating D4 students, this may indicate a need for more guidance and education of students during the patient care. It is imperative that students be provided a positive clinical learning experience under guided instruction in the basics of prevention to mould student opinions and perceptions to its value on overall patient health.
Conclusion The results of this study demonstrated that D4 students may lack basic content knowledge in preventive dentistry, despite high self-reported comfort levels with the topics. A new Introduction to Preventive Dentistry course, which utilised active learning techniques, resulted in greater alignment between D1 student perceptions of their preventive dentistry expertise and actual student performance on examinations. Future studies will investigate the ability of dental students to retain their knowledge of preventive dentistry topics over the progression 85
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of their educational careers and effectively implement this knowledge during clinical patient interactions.
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