Beruflich Dokumente
Kultur Dokumente
SELF-DIRECTED LEARNING,
Swedish Dental Journal, Supplement 235, 2014
S W E D I S H D E N T A L J O U R N A L , S U P P L E M E N T 2 3 5 , 2 014 . D O C T O R A L D I S S E R T A T I O N I N O D O N T O L O G Y
LEIF LEISNERT SELF -DIRECTED LEARNIN G, TEAMWORK, HOLIS TIC VIEW AND OR AL HEALTH M A L M Ö U N I V E R S I T Y 2 014
MALMÖ UNIVERSITY
205 06 MALMÖ, SWEDEN
WWW.MAH.SE
isbn 978-91-7104-605-5 (print)
isbn 978-91-7104-606-2 (pdf)
issn 0348-6672
SELF -DIRECTED LEARNING, TEAMWORK, HOLISTIC VIEW
AND OR AL HEALTH
Swedish Dental Journal, Supplement 235, 2014
PREFACE.. ...................................................................... 9
ABSTRACT................................................................... 10
POPULÄRVETENSKAPLIG SAMMANFATTNING................... 13
ABBREVIATIONS .......................................................... 19
INTRODUCTION........................................................... 20
AIMS.......................................................................... 24
MATERIALS AND METHODS . . ......................................... 26
RESULTS ..................................................................... 37
DISCUSSION .. ............................................................. 44
CONCLUSIONS . . ......................................................... 60
ACKNOWLEDGEMENTS................................................ 62
REFERENCES................................................................ 63
APPENDIX. . .................................................................. 67
Study I................................................................................. 69
Study II................................................................................. 77
Study III................................................................................ 89
Study IV............................................................................. 101
Questionnaire Study IV......................................................... 131
PREFACE
Study II
Leisnert L, Karlsson M, Franklin I, Lindh L, Wretlind K. Improving
teamwork between students from two professional programs in
dental education. Eur J Dent Educ. 2012 feb;16(1):17-26. doi:
10,1111/j.1600–0579.2011.00702.x. Epub 2011 Sep 27.
Study III
Leisnert L, Hallström H, Knutsson K. What findings do clinicians use
to diagnose chronic periodontitis? Swed Dent J. 2008;32(3):115-23.
Study IV
Leisnert L, Axtelius B, Wennerberg A. A comparison of proposals for
diagnosis and treatment of periodontal conditions by dentists, dental
hygienists and undergraduate students. An analysis based on the
recommendations from the Swedish National Guidelines. Submitted.
9
ABSTRACT
10
cohort of senior dental students, who had gone through an identical
assessment procedure during their second year of studies (4). The
results indicated that self-assessment ability was not directly relevant
to subject knowledge. Upon graduation, there were a number of
students (10%) with significant self-assessment difficulties. Early
detection of students with weak self-assessment abilities appears
possible to achieve.
The aim of the second study, concerning teamwork and holistic view
(5), was to investigate if highlighting teamwork between dental and
dental hygienist students could improve the students’ holistic view on
patients, as well as their knowledge of, and insight into, each other’s
future professions. This project showed that by initiating teamwork
between dental and dental hygienist students, it was possible to
increase students’ knowledge on dental hygienists competence,
develop students’ perceived holistic view on patients, and prepare
students for teamwork.
11
The third study (6) gave valuable information when designing the
fourth study (7). In the fourth study, a questionnaire was distributed
to 2,455 professional clinicians, i.e. dentists and dental hygienists in
public and private activity, and dental students at the Dental School
in Malmö. The results showed that two groups, representing dentists
and dental hygienists delivering basic periodontal care in Sweden,
were to a significant degree not sharing the knowledge basis for
diagnosis and treatment planning. This may result in a less optimal
utilization of resources in Swedish dentistry. The delivery of basic
periodontal care was not in line with the severity of disease and too
much attention was paid to the needs of relatively healthy persons. To
change this pattern, the incentives in, and structure of, the national
assurance system need to be adapted in order to stimulate a better
inter-collegial cooperation between dentists and dental hygienists in
basic periodontal care.
12
POPULÄRVETENSKAPLIG
SAMMANFATTNING
Bakgrund
Tandläkarutbildningen vid Odontologiska fakulteten vid Malmö
Högskola bygger på ”Malmömodellen”, som utgörs av fyra hörn
stenar - självstyrt och livslångt lärande, teamarbete, helhetssyn på
patientomhändertagande och oral hälsa (Fig. 1).
13
Gemensamt för två av de fyra delarbetena är möjligheten att jäm
föra agerandet hos studenter med de verksamma yrkesutövarna.
Möjligheten till återkoppling till såväl utbildning som tandvården
utanför utbildningarna är betydande.
14
med självvärdering och att identifiera nya inlärningsmål. Det är
intressant att 90 % av dessa kunde identifieras redan i början av sin
utbildning. Studien visade på ett svagt samband mellan förmåga till
självvärdering och ämneskunskaper.
15
• Gemensamma patienter planerades tillsammans.
• Vid ett avslutande seminarium fick teamen redovisa vad som
varit bra och vad som kunde bli bättre.
Slutsatserna är att det är nödvändigt och möjligt att dels öka kun
skaperna om tandhygienisternas kompetens, samt att öka helhets
synen i vården av patienterna med ett utökat teamarbete i grund
utbildningen.
16
Frågeställningarna har belysts i avhandlingens tredje samt sista
publikation. Bakgrunden till den tredje studien var att studenter på
Tandvårdshögskolan i Malmö (TVH) använde diagnosen kronisk
parodontit på ett icke konsistent sätt. Det har också genomförts ett
antal internationella konferenser där man försökt definiera olika
former av parodontal sjukdom. I Oslostudien från år 2007 lyfter
man fram inkonsistensen vid registrering av parodontal sjukdom.
17
olika kliniker, om fyndet som användes för att ställa diagnos också
ligger till grund för behandlingen. Detta kan i sin tur leda till en
kostnadsineffektiv behandling.
Avsikten med den fjärde och avslutande studien var att beskriva
hur professionella utövare i den svenska tandvården och
studenter diagnosticerar och behandlar parodontal sjukdom.
Fanns det gemensamma värderingar mellan tandhygienister och
tandläkare om hur en effektiv arbetsfördelning skulle organiseras?
Återspeglades föreslagen behandling i sjukdomens svårighetsgrad?
I vilken utsträckning var behandlingen i överensstämmelse med
Socialstyrelsens nationella riktlinjer?
18
ABBREVIATIONS
19
INTRODUCTION
20
stance as expressed in the Swedish Higher Education Ordinance
(9). In turn, the holistic view provides a basis for oral health to be
maintained, that has been chosen in preference to dentistry seen only
as a practical skill. To achieve this, teamwork is developed through
work in study groups as well as in clinical settings (5).
21
Although the importance of self-assessment seems unquestionable, not
much is known about how to best assist students in their development
of this ability. Furthermore, numerous studies at various levels of
training have shown that healthcare students often possess modest
to poor self-assessment abilities (12). Educational research seems to
point out two critical factors for the development of such skills and
these are continuous practice of self-assessment (1) and constructive
feedback (2). Based on these two elements, several authors have to
various extents described and evaluated methodologies designed
to assist the development and even assessment of students’ self-
assessment ability (3,12,13).
22
and political priorities, calls for an effective and well-developed
cooperation between dentists and dental hygienists in the future of
dentistry.
Hence, the aim of the study concerning teamwork and holistic view
was to investigate if highlighting teamwork during the undergraduate
studies of dental students and dental hygienist students, could
improve the students’ holistic view on patients as well as their
knowledge of each other’s future professions.
Oral health
This work began with the third study entitled “What findings do
clinicians use to diagnose chronic periodontitis?” (6), which in turn
offered valuable information when designing the fourth study entitled
“A comparison of proposals for diagnosis and treatment by dentists,
dental hygienists and undergraduate students. An analysis based on
the recommendations from the Swedish National Guidelines” (7).
The fourth study was distributed to 2,455 professional clinicians,
i.e. dentists and dental hygienists in public and private practice and
dental students at the dental school in Malmö.
It should be mentioned that the third study was the second one in
a time line but, since it related more to the principal of oral health,
it has more connection to the concluding fourth publication. The
results were used when constructing the questionnaire for the fourth
publication.
The third and fourth study were ethically approved by the Regional
Ethical Board in Lund with registration numbers 317/2006 and
593/2010, respectively.
23
AIMS
This was the first study in the thesis on the issue of diagnosing
chronic periodontitis. The aims were to examine:
– What findings dental students, dental hygienist students,
dental teachers, and supervisors in Public Dental Health
used in order to diagnose patients with chronic periodontitis;
– Whether different categories of clinicians used different
findings to diagnose chronic periodontitis. The hypothesis
was that there were differences both between and within the
categories of caregivers;
– Whether irrelevant clinical findings were used in diagnosing
chronic periodontitis.
25
MATERIALS AND METHODS
26
– Students’ reflective skills, as expressed by their ability to point out
weaknesses in their proposed solution, base their choices on sound
arguments, and consequently define relevant future learning needs.
The assessment of this skill was done through a special matrix (see
Table 1, Study I, p. 545) which assessed the student’s comparison
document on a scale ranging from 3-9.
The sample
A whole cohort of final year students (n=48) went through the
Interactive Examination with three clinical cases in the Comprehensive
Care Clinic (CCC) during a period from November 2004 to January
2005. The students of that year had a final theoretical and practical
examination in December, and the successful completion of this
allowed them to start their six month period of vocational training
in public dental clinics. Consequently, the students completed the
first two cases before their final examinations and worked through
the third case right after this examination.
When this stage was completed, the author of the case could
publish the treatment plan he followed together with the outcome
of the treatment. Students then had another week to compare their
treatment plan to the one published and prepare a written comparison
document, according to the previously described principles.
27
The feedback the students received after each case was organised in
two forms:
Evaluation of performance
Each student’s written treatment plan (see Table 2, Study I,
p. 546), was evaluated by use of a specific matrix. The matrix for
each case included a number of key issues representing knowledge
and attitudes a clinician must have, according to the established
standards of the CCC. These key issues were expressed in equivalent
points, the number of which differed slightly in the three cases. The
maximum score for case one, two and three was 18, 21 and 17,
respectively, with the level of acceptance set to 12, 14 and 11 points.
The evaluation framework was designed by the author (LL) of the
three cases, who was also the one to grade students’ performance.
The case in 2001 was assessed on a scale ranging from 1-6.
Evaluation of attitudes
Students’ attitudes were evaluated after the completion of each case
through an anonymous, standardised questionnaire.
Statistical analysis
Grades on the written treatment plan were analysed for the
42 students who participated both in the 2001 and 2004 cohorts.
Differences between male and female student’s scores within each
case were analysed with unpaired t-test. The grades for both the
written treatment plan and the comparison document for each case
in 2004 were compared with performance data of the same students
28
in the year 2001, with a linear regression analysis. The students
who presented unacceptable comparison documents in 2004 were
compared with those unacceptable in 2001, in an attempt to track
weak students’ development.
Project organisation
In the research group for the project, responsible for planning,
directing and carrying out the activities, students and staff from
both the dental hygienist and dental programmes participated.
The project was introduced and started during the spring 2007 by
launching a website within the learning management system of the
Malmö University, acting as a platform for both information and
interactions.
Participants
Beginning from their eighth and second semester, respectively, 34
dental students and 24 dental hygienist students participated in
the study. Teams consisting of one dental student and one dental
hygienist student were formed. As the number of dental students was
larger than dental hygienist students, some dental hygienist students
had two dental students to cooperate with.
29
Activities
A number of activities were carried out during the course of the study
(Fig. 2).
Questionnaire 2
Questionnaire 1
Teamwork
Figure 2. The figure depicts activities carried out during the course
of the study.
Questionnaire
The questionnaire consisted of 23 questions on whether or not dental
hygienists are licensed for the competences described in the different
questions (see Appendix 1 in study II). The same questionnaire was
answered one year later. Between the two tests a number of activities
were performed.
Seminars
Three seminars were held during the course of the study:
Seminar 1: An introduction of the project including a session with a
dentist from the Public Dental Services (PDS), presenting the visions
and experiences of a teamwork model developed and successfully
practised at the PDS.
30
Seminar 3: Presentations given by six chosen teams of students, each
group presenting how they planned and carried out the treatment of
shared patients in the students’ clinic. Discussions on the outcome of
the treatment were also an integral part of this seminar.
Prior to the final session, the students were asked to write down
problems and possibilities that they had encountered during their
team collaborations. These were discussed during the last seminar, as
well as the students´ suggestions for future professional cooperation.
Teamwork
As mentioned earlier, the dental students and the dental hygienist
students were divided into teams. In these teams, they planned and
carried out the treatment of both web-based patients and patients
attending the students´ clinic.
In the folder they also had to document, present and discuss 2-4
shared patients from the student’s clinic. During the students’ clinical
work, they and their clinical instructors could draw on the expertise
of one experienced dentist and one experienced dental hygienist
in order to support them with encouragement and pinpointing
opportunities and advantages of teamwork.
Supervision
To increase the interaction surface between students and to an even
greater extent provide opportunities for developing understanding
and knowledge on how to cooperate as a dental team, the dental
students supervised the dental hygienist students in their clinical
practise on one to two occasions.
31
Students´ opinions on different activities
and parts of the project
Students assessed the different activities and how they valued their
contribution in developing successful teamwork. The questionnaire
used for this purpose was designed with a number of statements
concerning the different activities, where students could mark
whether they agreed or disagreed with the statements on a Visual
Analogue Scale (VAS) from 1 to 10.
Methodological considerations
The first questionnaire was answered by 32 out of 34 dental students
and 23 out of 24 dental hygienist students. On the second occasion,
30 out of 32 dental students and 20 out of 20 dental hygienist
students answered the questionnaire. The missing answers were due
to electives, Erasmus exchange, interrupted studies or illness.
32
Clinicians
Dental students (DS):
Thirty-seven dental students, in their final month of a 5 year-
education at the TVH, were asked to participate. Twenty-two of
the students answered the questionnaires. Thirteen were females and
nine were males. The mean age was 27 years (range 24-36) for the
females and 26 years (range 24-30) for the males. Fifteen students
could not participate due to other commitments; these students were
therefore not obliged to participate.
33
Statistical analysis
If differences existed between the numbers of findings clinicians used
when diagnosing chronic periodontitis, each category of caregiver
was analysed with one way analysis of variance (ANOVA). If
differences existed, Tukey’s test was used to analyse between which
categories these differences existed. Differences between different
categories use of respective findings were analysed using the Chi-
squared test (p=0.05).
34
The completed questionnaires were scanned at the University
of Linköping and transformed into a SPSS file. The scanned
questionnaires were validated through a random sample (n=120) of
all the questionnaires securing that a specific questionnaire with its
number in the SPSS file had the right characteristic concerning age
and gender. No misrepresented data was discovered.
35
Also, there were questions about what clinical findings they used
for the diagnostic classifications, what treatment was proposed, and
which category of caregiver – dentist, dental hygienist or specialist
– they deemed best suited to perform the treatment. There were
choices from a list of alternative treatments possible to combine. All
treatments were chosen from the National Guidelines as presented
by The National Board of Health and Welfare.
Statistical analysis
All data was inserted into the IBM SPSS Statistics version 20. An
analysis of the missing answers, compared to those who answered,
was made with a logistic regression analysis concerning age, gender
and occupation. There were no statistically significant differences
between the groups concerning these factors.
A frequency analysis was made for all groups together for the
different questions and cross tabulation with Pearson Chi-squared
test was used to analyse differences between the participating groups.
36
RESULTS
37
Study II. Guiding principles: teamwork, holistic view
Students’ knowledge on the competences of the dental hygienist
The results of the first questionnaire showed that it was mostly
the dental students who lacked knowledge of the competences of
the dental hygienists. In nine out of 23 questions more than 50%
provided a wrong answer. For instance, between 50 to 70% did not
know that dental hygienists (in Sweden) are allowed to: decide on,
carry out and diagnose x-rays concerning caries and periodontitis;
prescribe alcohol, fluoride and anaesthetics to their place of work;
decide on and carry out bleaching of teeth; glue small pieces of
jewellery on the teeth; and/or decide on and carry out bacterial
analyses of saliva.
38
3. Question to the students: Have the two questionnaires on dental
hygienists competences increased your knowledge on which
competences dental hygienists have?
Dental hygienist students gave a scoring of 6.6 and the dental
students 7.2.
4. Dental students supervising dental hygienist students.
This part scored high especially among the dental hygienist
students (7.1), who claimed that the teamwork had increased,
the holistic approach on patients had been strengthened, and
that they had gained valuable experiences for future cooperation.
Concerning the holistic view on patients, there was a significant
lower score from the dental students (4.8). Both groups found
it valuable to make this part permanent (DHS=8.2; DS=7.0)
(see Figure 4, Study II, p. 4).
5. Team-work with shared patient.
Both groups of students felt that treating shared patients should
become a permanent part of the education (DHS=9.1; DS=7.0)
and start earlier (DHS=8.7; DS=6.3, a significant difference). In
addition, the students experienced sharing patients to increase
the knowledge – interplay concerning teamwork (DHS=8.4;
DS=7.5, a significant difference) and the knowledge on the
team members’ competences (DHS=8.3; DS=7.9). Furthermore,
it gave valuable experiences for future cooperation (DHS=8.0;
DS=7.4) and a more holistic view on patients (DHS=8.5; DS=6.3,
a significant difference).
The dental hygienist students display the same pattern of giving
higher scores on questions (see Figure 5, Study II, p. 4).
39
together. For example, bleeding on probing and bleeding index were
registered as bleeding. Further, subgingival and supragingival calculus
were registered as calculus, and plaque and plaque index were
registered as plaque. In a third step, findings registered by less than
three participants, were excluded. Such findings were age, halitosis,
genetics, and diabetes. After these steps, 13 findings remained and
were further analysed.
Findings
The 13 findings were divided into three subgroups showing: soft
tissue inflammation, loss of supporting tissue, and irrelevant findings,
i.e. findings that were considered not to be relevant for diagnosing the
disease per se. (see Table 1, Study III, p. 118) presents the subgroups
of these findings.
40
used irrelevant findings is presented in Table 3. With the exception
of the dental teachers, the majority of clinicians within each category
used irrelevant findings.
In table 2 (see study IV, p. 11), the results from the question whether
the practitioners regarded the different patients to have a disease
or not, are depicted. No significant differences were found between
caregiver groups in case 1, 2 and 3. In case 1, almost 94% considered
that the patient had disease, while 6% considered that the patient
had no disease. For case 2 and 3, almost 100% had the opinion that
patients had periodontal disease.
In table 3 (see study IV, p. 12), the clinicians were asked to describe
what risks they forecasted for developing gingival or/and periodontal
disease. The different groups scored between 86 to 97%, with 86%
saying the risk is low and 97% saying the risk is none or low.
No significant differences were found between the groups. The 2.6%
of the students saying there was no risk of developing disease in any
of the cases, represent one student.
41
was needed, i.e. 17% in comparison to the other groups who scored
about 8%. However, there were no significant differences between
the caregiver groups. Still, about 91% of the professional clinicians
wanted to give preventive care in this case.
In table 5 (see study IV, p. 14), the opinion is depicted about what
category of dental caregiver should examine the patient. In case 1,
there were significant differences between the groups: 74% of the
private practitioners, 49% of the dentists in the public dental services
and 59% of the students wanted the dentist to examine the patients,
while only 21% of the dental hygienists considered a dentist should
examine the patient (p=0.000).
Table 6 (see study IV, p. 16), depicts to what extent treatment was
suggested and what category of dental caregiver should perform
instruction for effective self-care. Relative agreement could be
found between the groups that dental hygienist should perform
this treatment. Dental students and private practitioners had lower
scores, i.e. less support for leaving this to dental hygienists. The
respondents had a possibility to choose more than one option. There
were significant differences between categories of caregivers in all 3
cases, with the exception of specialists.
42
In Table 7 (see study IV, p. 17), the respondents were asked to describe
what findings they used for diagnoses with regard to presence of
plaque and calculus.
Table 8 (see study IV, p. 19), depicts what category of dental caregiver
should perform professional cleaning of the teeth, according to the
respondents. A significant difference appeared. In case 1, 15% of
the PP wanted to give professional cleaning, while 0.3% of the DH
wanted the dentist to perform this procedure. The corresponding
figures for PDS were 7% and DS 0%, respectively (p=0.000). The
PP was more inclined (25%) to let the dental nurse perform this
treatment (p=0.000).
43
DISCUSSION
44
the first year of dental education, it was found that students’ self–
assessment ability increased during the course of three consecutive
semesters.
45
actual subject knowledge was. Consequently, the improvement of
the self-assessment skills should be a parallel and independent aim
in every healthcare curriculum.
46
It is more uncertain if there is any connection between self-assessment
ability and subject knowledge. In the future, prospective intervention
studies are needed to further verify the findings of this single,
relatively small study. Special care should be taken to address if and
how remedial interventions can help weak students to develop an
acceptable level of self-assessment ability before graduation.
47
of what a dental hygienist license includes. If the dentist do not know
what the hygienists are allowed and have education for to perform,
it would be troublesome for the dentist to leave parts of the dental
care to the hygienists.
48
more complex approaches towards treatment planning and actual
treatment when working together with dental students, than vice
versa. This is also illustrated by the fact that the comments from the
dental hygienist students were more numerous and overall positive,
while the dental students offered very few comments. Another
explanation could be that the dental students already had a developed
holistic view and therefore felt that they were less likely to increase
it to a significant extent. However, the overall impression is that
dental students, acting as supervisors for dental hygienist students,
contributed to develop dental hygienist students’ ability to acquire
a more holistic view on patient care. The fact that both student
groups recommended this activity to become a permanent part of
the education also indicates that dental students valued it highly.
49
As mentioned earlier, there were 34 dental students and 24 dental
hygienist students participating in the study. This resulted in some
dental hygienist students cooperating with two dental students instead
of one. Since the questionnaires were answered anonymously, we can
not separate results from dental hygienist students that worked with
one or two dental students. It would be relevant to see if this could
have had any impact on the results.
Methodological considerations
One open question was “What findings, or combination of findings,
do you use when you diagnose chronic periodontitis?” The reason
for including this question was to have the clinicians report in their
own words all the findings they used, and whether they used these
findings solitarily or in combinations in order to diagnose chronic
periodontitis. This open structure of the question might be the reason
that very few, only 18 of the 76 participants, stressed that they used
the findings in combinations. In studies where the participants are
50
asked to describe their judgment strategies, it is vital that they are not
directed (26). If we had given alternatives beforehand, the answers
would probably have been limited to these. Further, the situation in
which the clinicians were presented to the questionnaire was almost
identical for the different categories.
The dental and hygienist students were soon to be licensed. They had
finished their work in their tutorial groups and their clinical work
and must therefore be regarded as highly knowledgeable theoretically
in the different subject areas included in the dental curriculum.
Overall, one would expect the variation in findings they used when
they diagnosed chronic periodontitis to be smaller than amongst a
randomized selection of clinicians (28).
51
sex, and type of clinical specialty. However, the author (LL) that was
present when the dental teachers answered the questionnaire received
negative feed-back from some of the colleagues. They felt as if it was
a test and as if they were controlled. This might be one explanation
for the relatively low response frequency.
52
tissue over time (32). Until date, no exact definition exists and very
few of the clinicians in this study commented that there should be a
loss of supporting tissue over time.
53
periodontal illness in the CCC. They often presented very different
diagnoses and findings when asked to describe chronic periodontitis.
They seldom combined findings. The study confirmed the clinical
observations that inspired the on-taking of the study. How valid the
results and conclusions are must be considered in the light of quite a
small number of participants, with implications of an uncertainty of
the results. It should be mentioned that in this study, dental hygienist
students to a significant degree used more irrelevant findings than the
other groups. This was not the case in the fourth publication with
2,455 participants, where clinicians outside the dental school, both
dentists and dental hygienists, used irrelevant findings three times
more often than the dental students.
54
students. It is difficult to explain, but the numbers for the students
are in line with the results from the findings in Leisnert et al. (6). The
situation in the present study is almost the same concerning calculus.
55
Also, with regard to less complicated treatment such as professional
cleaning, only about 60% of PP and PDS thought this should be left
to DH. The PP was also more inclined to use dental nurses for this
treatment.
When asked if they could see a risk for developing gingival and/
or periodontal disease for case 1, 97% of clinicians judged this
risk as none or low and this is most probably a correct judgment.
Therefore it is surprising that 91% of professional clinicians said it
was necessary to give preventive care to these patients. In a national
economic perspective, it seems like a waste of money and resources.
When we look at case 2 and case 3, it seems relevant both to judge
that they have disease and are in need of dental care to somewhat
different extents. Case 3 belongs to the group where no improvement
has occurred, i.e. the number of patients with serious periodontal
disease has not been reduced in the same way as in the other groups.
To once again come back to the opinion of Baelum & Lopez (34)
that there is no natural base for a sharp distinction between health
and disease or between different forms of periodontitis, the question
arises whether it could be that it is easier to give treatment to healthy
persons than to persons with severe illness? Could it be that there are
56
no substantial financial incentives in the national assurance system
to take care of the latter group?
To sum up, the answer to the question “Are the methods of treatment
used in accordance with the degree of severity of the disease?”, is
negative.
The question arises: Why use both one treatment with no effect and
one treatment highly recommended by the National Guidelines? The
guidelines were presented in the beginning of 2011 but discussed
and presented in a preliminary version 2010. The questionnaire
in this study was presented and sent out around autumn 2011, so
reasonably, the respondents should be aware of the content of the
guidelines.
57
Thus, the knowledge of evidence and effect on the treatment options
described above was low and treatment performed seems to be based
a lot on treatment tradition within the traditional care professions.
58
Summary
In summary, this thesis highlights in four publications the four linked
principles of the Malmö Model: self-directed learning, teamwork, a
holistic view of patient care, and oral health.
The third study, studying the principle of oral health, found that
the majority of clinicians (dental students, dental hygienist students,
dental teachers, and clinical supervisors in PDS) did not combine
findings from both the hard and soft tissues to assess chronic
periodontitis. Further, irrelevant findings were also used to diagnose
the condition.
The fourth study, building on the findings of the third study and also
addressing the principle of oral health, found that practicing clinicians
also used irrelevant findings to diagnose chronic periodontitis.
Further, practicing dentists were generally unwilling to let a dental
hygienist diagnose all three types of clinical scenarios. However, they
were willing to let the hygienist perform self-care instructions. In all,
the study points to the value of including teamwork between dental
hygienist and dental students during their education, to enhance
knowledge on each other’s competences and future cooperation.
Thus, by ensuring efficient teamwork, resources could be more
efficiently allocated in order to achieve oral health.
59
CONCLUSIONS
Study I
Results indicated that self-assessment ability is not directly related
to subject knowledge. Upon graduation, there are students (10% in
our case) with significant self-assessment difficulties. Early detection
of students with weak self-assessment abilities appears possible to
achieve.
Study II
The dental hygienist students in general valued the different parts of
the project higher than the dental students. However, there was also
consensus in both student groups that the activities should become
permanent parts of the curricula and for the future it could be kept
in mind to start treating shared patients earlier in order to achieve
greater impact.
60
Study III
Variations were found between what findings different categories of
clinicians used when they diagnose chronic periodontitis.
Study IV
The two groups representing dentists and dental hygienist delivering
basic periodontal care in Sweden, were to a significant degree not
sharing the knowledge basis for diagnosis and treatment planning.
This may result in a less than optimal utilization of resources in
Swedish dentistry.
The delivery of basic periodontal care was not in line with the severity
of disease and too much attention was paid to the needs of relatively
healthy persons.
61
ACKNOWLEDGEMENTS
I also want to thank Alborz Soltani and my youngest son Viktor who
both spent a lot of hours dealing with 2,455 questionnaires. A lot of
philosophical talks accompanied that work.
Last but not least I want to thank my wonderful wife Carina and my
three children Paul, Ulrika and Viktor for all support.
62
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63
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65
APPENDIX
Medical Teacher, Vol. 28, No. 6, 2006, pp. 544–548
Table 1. Criteria for grading students’ comparison documents on a scale from 3 to 9 points.
Comparison of The student has The student has identified The student has only identified
content identified most/all the half of the major differences very few or irrelevant differences
important differences
Analysis of explanation The student is able to The student can only partly The student does not attempt
of the differences analyse/attribute differences analyse/attribute differences to analyse the differences
Defining learning The student reaches the The student provides learning The student does not reach learning
objectives learning objectives deriving objectives only partly relevant to objectives, or they are irrelevant to
from the analysis of differences his/her analysis of differences his/her analysis of differences
further applied and developed in different institutions Forty-two of the students had been assessed using the
ever since. A number of studies have evaluated different Interactive Examination methodology in autumn 2001,
applications of the Interactive Examination, including during the third semester of their studies. Six students
Web-based (Mattheos et al., 2004b and teleconference- from the 2004 cohort who had not attended the
based ones (Mattheos et al., 2003). Interactive Examination in 2001 were excluded from the
The principally important element for the assessment of comparative part of the study, but their opinions and
reflective skills appears to be the so called ‘comparison attitudes were registered through the three evaluation
document’. In this procedure, the students receive a task in questionnaires.
the form of a clinical problem and are expected to provide
a written account of their solution, usually a diagnosis and
treatment plan. Thereafter, they receive a solution proposed Clinical cases
by a qualified physician. This solution is not the only or the A special project site was created in ‘Webzone’, the Internet
best treatment possibility but it represents a grounded Learning Content Management System of Malmö
opinion of a qualified colleague, reflecting his or her priorities University. All students and resource persons were registered
and reasoning. Then the students have to come up within members of the project and had access to public functions, as
a week with a ‘comparison document’ where in written form well as a private folder.
they compare their own answer with that of the qualified Each case was presented at a given time through an
physician. In their comparison students are expected to interactive PowerPoint slideshow. Under the appropriate
identify differences and similarities between the two essays, hyperlinks, each case provided the student with general and
investigate and elaborate on the reasons why these differences dental history, current status, major complaints, the patient’s
exist and consequently define learning objectives for the wishes, extra-oral, intra-oral and X-ray images. After each
future. case was published, students had about two weeks to come
The assessment is based on two elements: up with a written full treatment plan, which they then had to
. Students’ subject-related competence, as this is expressed upload into their private folder.
through their proposed solution to the clinical case. The When this stage was completed, the author of the case
assessment of students’ performance is based on a matrix could publish the treatment plan he/she followed and the
reflecting the specific learning objectives of each case. outcome of his/her treatment. Students then had another
. Students’ reflective skills, as expressed by their ability to week to compare their treatment plan with the one published
point out weaknesses in their essay, base their choices on and prepare a written comparison document, according to
sound arguments and consequently define relevant future the previously described principles.
learning needs. The assessment of this skill is made The feedback the students received after each case was
through a special matrix (Table 1), which assesses each organized in two forms:
student’s comparison document in a scale from 3 to 9. (1) a written commentary, presenting the key issues of
each case and discussing the most common character-
istics of students’ treatment choices;
Sample (2) a group discussion where each case and the treatment
plan, as well as students’ common choices, were
A whole cohort of final-year students (n ¼ 48) went through thoroughly discussed with the case author and
the Interactive Examination with three clinical cases in respective expert resource persons.
Comprehensive Oral Care Clinic (COCC) during the
period from November 2004 to January 2005. The students
of that year have a final theoretical and practical examination
Evaluation of performance
in December, successful completion of which allows them to
start their 15-week period of vocational training in public Each student’s written treatment plan was evaluated through
dental clinics. Consequently, the students completed the first a specific matrix. The matrix for each case included a number
two cases before their final examinations and went through of key issues representing knowledge and attitudes a
the third case immediately thereafter. clinician must have according to the established standards
545
L. Leisnert & N. Mattheos
Table 2. Results of students’ performance on the written task and the comparison document for each of the three cases,
as compared with the results of the same students in year 2001a.
Notes: aThe number in parentheses represents the maximum score possible in each case and the percentage is the percentage of
success in relation to the maximum possible score. *p ¼ 0.0005; **p ¼ 0.0019; ***p ¼ 0.02; yp < 0.0001; yyp ¼ 0.003;
yyyp ¼ 0.03.
546
The interactive examination in a comprehensive oral care clinic
characteristics (Murray-Garcia et al., 2005). It would be of stages in their studies, there exist students (five out of
great interest in future studies to investigate how the general 48—10% in our case) who have significant difficulties in
self-reflection ability is connected with profession or task- assessing their own actions and defining learning objectives.
related self-assessment skills. An interesting observation was that 90% of these students
Very few studies are available in this field with a were already identified in 2001. The sensitivity of the 2001
longitudinal perspective. Fitzgerald et al. (2003) followed examination in predicting the weak students in 2004,
medical students’ self-assessment at four intervals over the based on these figures, is therefore 80% and the specificity
course of their first three years. They concluded that 86%. Therein lies one of the most important benefits of
self-assessment accuracy measures were relatively stable longitudinal observation, which is to enable validation of the
over the first two years. In another study conducted during predictability of earlier measurements of self-assessment
the first year of dental education, Zijlstra-Shaw et al. (2004) ability.
found that students’ self-assessment ability increased during The present interventions were conducted within
the course of three consecutive terms. a fully PBL curriculum, which is expected to place great
The students in this study had an assessment rather emphasis on self-directed learning principles. Similar studies
early in their studies in which their profession-related comparing the impact of the curriculum (PBL or not) on the
self-assessment ability was evaluated. In the three years that development of self-assessment ability would be of great
followed, the students did not go through any structured interest. In the future, prospective intervention studies are
intervention of the same magnitude. However, as their PBL needed to further verify the findings of this single, relatively
curriculum includes many instances of self-assessment and small study. Special care should be taken to address if and
constructive feedback, one should expect that by the end of how remedial interventions can help weak students to
their studies students will present a more mature and develop an acceptable level of self-assessment ability before
complete ability to assess their competence. This is in fact graduation.
one of the critical functions of a healthcare curriculum,
although is rarely evaluated (Shumway & Harden, 2003).
Students’ task in 2004 to present a written treatment Acknowledgements
plan is not comparable to the written task they had in The authors would like to thank Prof. Emeritus Rolf
2001, therefore no attempt was made to compare students’ Attström for his constructive feedback and guidance
performance in this field. However, correlation of their throughout the project. They would also like to thank
grades between 2001 and 2004 was investigated, to see if Dr Martin Janda Schittek for his significant help with the
the pattern of students’ achievement was repeated. The development of the electronic material and his assistance
correlation between the written treatment plan grades in throughout the study.
2001–04 was in general poor and there was a moderate
positive correlation in one of the three cases.
In contrast to the written task, the comparison document Notes on contributors
was used in the same way in both 2001 and 2004 and is LEIF LEISNERT, DDS, is the head of the COCC, Faculty of Odontology,
the main focus of the study, as it attempts to evaluate not Malmö University, Sweden. He has vast experience in clinical teaching
subject-related knowledge but reflective skills. Interestingly, and supervision and his main interest is in instructional approaches for
the grades on self-assessment ability in 2004 present a higher holistic professional development.
correlation with those of 2001 than actual subject-related NIKOS MATTHEOS, DDS PhD, is currently a research associate in the
knowledge does. In addition, as seen in case 3, self- Centre for Educational Research and Technology in Oral Health
assessment ability remains quite stable even when the written (CERT), Faculty of Odontology, Malmö University, Sweden. His
performance is low. research includes studies on interaction in virtual learning environments
These observations indicate that self-assessment ability and development of innovative assessment methodologies.
is not directly tied to subject knowledge. Although
students seemed to have developed their knowledge and
understanding in different ways in the years that followed References
2001, their self-assessment ability was correlated to that BROWN, G., BULL, J. & PENDLEBURY, M. (1997) Peer and self-assessment,
measured in 2001, much more than their actual subject in: Assessing Student Learning in Higher Education, pp. 170–184
knowledge was. Consequently, the improvement in self- (London, Routledge).
assessment skills must be a parallel and independent aim in FITZGERALD, J.T., WHITE, C.S. & GRUPPEN, L.D. (2003) A longitudinal
study of self assessment accuracy, Medical Education, 37, pp. 645–649.
every healthcare curriculum.
HAYS, R.B., JOLLY, B.C., CALDON, L.J., et al. (2002) Is insight important?
It still remains unclear whether self-assessment skills have
Measuring capacity to change performance, Medical Education, 36,
improved overall during these three years. Grades indicate pp. 965–971.
a moderate improvement, but the possible inter-assessor HENDERSON, P. & JOHNSON, M. (2002) An innovative approach to
variation does not allow for safe conclusions. However, the developing the reflective skills of medical students, BMC Medical
fact that the number of comparisons below the level of Education, 2, pp. 1–4.
acceptable was much smaller in 2004 might be indicative. LEISNERT, L. & MATTHEOS, N. (2006). A longitudinal investigation of self-
assessment ability of dental students, 84th Congress of the International
Half of those judged unacceptable in 2001 were found to be
Association of Dental Research, Brisbane June 2006, submitted for
at an acceptable level in three consecutive tests in 2004, publication.
although still remaining below the average scores of their MACDONALD, J., WILLIAMS, R.G. & ROGERS, D.A. (2003) Self-assessment
fellow students. However, the other half remained at an in simulation-based surgical skills training, American Journal of Surgery,
unacceptable level. This fact suggests that, even at the latest 185(4), pp. 319–322.
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MATTHEOS, N., NATTESTAD, A. & ATTSTRÖM, R. (2003) Feasibility SHUMWAY, J.M. & HARDEN, R.M. (2003) AMEE Guide No.25: the
and satisfaction with the use of teleconference for examination of assessment of learning outcomes for the competent and reflective
undergraduate dental students: a comparative study, Journal of physician, Medical Teacher, 25, pp. 569–584.
Telemedicine and Telecare, 9, pp. 278–281. TOUSIGNANT, M. & DESMARCHAIS, J.E. (2002) Accuracy of student self-
MATTHEOS, N., NATTESTAD, A., ATTSTRÖM, R. & FALK NILSSON, E. assessment ability compared to their own performance in a problem-
(2004a) The interactive examination: assessing students’ based learning medical program: a correlation study, Advances in Health
self-assessment ability, Medical Education, 38, pp. 378–389. Sciences Education, Theory and Practice, 7(1), pp. 19–27.
MATTHEOS, N., NATTESTAD, A., CHRISTERSSON, C., JANSSON, H. & WEINBERG, A.D., ULLIAN, L.L., CHRISTIANSEN, C.H. & RAIZNER, A.
ATTSTROM, R. (2004b) The effects of an interactive software (1977) Perceived ability versus actual ability: a problem for continuing
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MURRAY-GARCIA, J.L., HARRELL, S., GARCIA, J.A., GIZZI, E. & ZELLER, A., BATTEGAY, M., GYR, N. & BATTEGAY, E. (2003)
SIMMS-MACKEY, P. (2005) Self-reflection in multicultural training: be Evaluation of unstructured medical school examinations:
careful what you ask for, Academic Medicine, 80, pp. 694–701. prospective observational study, Swiss Medical Weekly, 133(11–12),
REES, C. & SHEPHERD, M. (2005) Students’ and assessors’ attitudes pp. 184–187.
towards students’ self-assessment of their personal and professional ZIJLSTRA-SHAW, S., KROPMANS, T.J.B. & TAMS, J. (2004) Assessment of
behaviours, Medical Education, 39, pp. 30–39. professional behaviour: a comparison of self-assessment by first year
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548
European Journal of Dental Education ISSN 1396-5883
Keywords Abstract
teamwork; undergraduate dental education;
intervention. In Sweden, the National Board of Health and Welfare forecasts a decrease in dentists
with 26% and an increase in dental hygienists with 47% until the year of 2023. This,
Correspondence together with changes in both epidemiology, especially of dental caries, and political
Leif Leisnert priorities, calls for an effective and well-developed cooperation between dentists and
Faculty of Odontology dental hygienists in future dentistry. Hence, the aim of this project was to investigate
20506, Malmo University whether highlighting teamwork during the undergraduate studies of dental students
Malmo and dental hygiene students could improve the students’ holistic view on patients as
Sweden well as their knowledge of and insight into each other’s future professions. Thirty-four
Tel: 46709655415 dental students and 24 dental hygiene students participated in the study. At the begin-
Fax: 46406658503 ning of their final year in undergraduate education, a questionnaire testing the level of
e-mail: Leif.Leisnert@gmail.com knowledge of the dental hygienists’ clinical competences was completed by both groups
of students. In addition, activities intending to improve teamwork quality included the
Accepted: 20 July 2011
following: (i) a seminar with a dentist representing the Public Dental Health Services
in Sweden, (ii) dental students as supervisors for dental hygiene students, (iii) planning
doi:10.1111/j.1600-0579.2011.00702.x
and treatment for shared patients and (iv) students’ presentations of the treatments
and their outcomes at a final seminar. The project was ended by the students answer-
Re-use of this article is permitted in accordance
ing the above-mentioned questionnaire for the second time, followed by an evaluation
with the Terms and Conditions set out at
http://wileyonlinelibrary.com/onlineopen#
of the different activities included in the study. The knowledge of dental hygienists’
OnlineOpen_Terms. competences showed higher scores in almost all questions. Both groups of students
considered the following aspects important: seminars with external participants, dental
students acting as supervisors and planning and treating shared patients. By initiating
and encouraging teamwork between dental students and dental hygiene students, it is
possible to increase knowledge on dental hygienists’ competence and also to develop
and strengthen a holistic view on patients and dental work, thereby preparing both
groups of students for their professional life.
Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S 1
Improving teamwork between students from two professional programmes Leisnert et al.
Traditionally, the education of dentists and dental hygienists their last semester – for dental students their tenth and for
has taken place as uniprofessional educations where students dental hygiene students their fourth. Students have a gradually
learn in isolation from each other (6), but growing evidence increasing responsibility for the oral health care of their
supporting the idea that interprofessional education (IPE) will patients, who require oral health needs of increasing complex-
improve abilities both to work as a team and to communicate ity. From the onset, an environment is created in which provi-
more effectively with colleagues and patients (7) must also be sion of care is related to (i) a fundamental understanding of
taken into account. However, most of the research regarding the needs of the individual patient, (ii) an evidence-based
IPE within the medical field concerns the relationship between approach for the outcome of clinical interventions and (iii) an
doctors and nurses, and only a few papers are concerned with interdisciplinary approach to oral health care. Both groups of
dentistry (8). In a survey of IPE, including seven academic students experience an increase in intensity and opportunities
health centres (8) that have schools of dentistry associated with for a mixed and varied care of more and more complex
them, a review was made and completed with interviews. One patients during their final semesters, and dental students
conclusion was that dental schools were isolated from other assisted by dental nurses, experience comprehensive care in
schools and not interested in IPE. Another conclusion pointed cooperation with dental hygiene students (12). Both dental stu-
to the importance of dental schools becoming an active partici- dents and dental hygiene students practise in the Public Dental
pant in future interprofessional educational initiative. Further- Health Services (PDHS) (13).
more, in a study examining how teamwork influences resource The project was designed as an intervention study with dif-
planning in acute hospitals, it was concluded that effective ferent activities, including seminars, treating patients together
teamwork is one of the important factors to the success of dis- and presentations of the outcomes of the treatments, framed by
charge planning. (9). pre- and post-test. As a pre-test, we used a questionnaire map-
Thus, a general agreement has emerged that improving team- ping the students’ knowledge on a sample of the dental hygien-
work is important for achieving both better and more cost- ists competencies. Post-test included answering the same
effective treatment for patients (3, 7, 8). questionnaire once more, with questions relating to how the
different activities were experienced and to what extent they
were deemed useful by the students.
Objectives
This study had the objective of examining whether placing a
Project organisation
stronger emphasis on teamwork during the undergraduate
studies of dental students and dental hygiene students could: In the research group for the project, responsible for planning,
l Increase knowledge of and insight into the respective future directing and carrying out the activities, students and staff from
professions with special emphasis on the dental hygienists both the dental hygiene and dental programmes participated.
field of competence. The project was introduced and started during the spring 2007
l Develop the holistic view and approach towards patients, as by launching a website within the learning management system
experienced by the students. of the university, acting as a platform for both information and
interactions.
Material and methods
Participants
Students from two dental programmes, dental hygiene students
and dental students, participated in the study. Beginning from their eighth and second semester respectively, 34
dental students and 24 dental hygiene students participated in the
study. The number of students corresponded to the size of the
Educational context of the dental programmes
courses. Teams consisting of one dental student and one dental
in Malmö
hygiene student were formed. As the number of dental students
The dental and the dental hygiene programmes are taught at was greater than that of dental hygiene students, some dental
the Faculty of Odontology at Malmö University, and they are hygiene students had two dental students to cooperate with.
guided by four linked principles: (i) Self-directed learning, (ii)
Holistic view of patient care, (iii) Oral health and (iv) Team-
Activities
work. Self-directed learning is implemented as problem-based
learning throughout the programmes (10). The holistic view is The timetable for included activities is shown in Fig. 1.
interpreted as caring for the individual rather than as produc-
ing quantities of items of dental treatment. Such an approach Seminar 1 + Seminar 2 Seminar 3 +
towards the patient should encourage students to use their Questionnaire Questionnaire
oped through work in study groups and clinical settings. Teamwork (web-based + actual patients)
In the clinical setting, students from both programmes
respectively care for their own patients from their second to Fig. 1. Timetable for performed activities.
2 Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S
Leisnert et al. Improving teamwork between students from two professional programmes
Teamwork
0
As mentioned earlier, the dental students and the dental 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
hygiene students were divided into teams. In these teams, they Question number
planned and carried out the treatment for both web-based Percentage of correct answers before Percentage of correct answers after
intervention. intervention.
patients and actual patients attending the students¢ clinic. The
web-based cases were presented and made available on the
B 100
website of the project, where electronic folders for each team
Percentage of correct answers
Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S 3
Improving teamwork between students from two professional programmes Leisnert et al.
10
formed using a Sign test, Figs 2a,b. Independent samples t-test
was used in the comparisons of the two student groups in the
9 evaluation of activities shown in Figs 3–5. The significance level
8
in all tests was a = 5%. The program used was PASW/SPSS for
Windows, release 18.0.0 2009 (SPSS Inc., Chicago, IL, USA).
7 The significance level is marked besides respectively statements
in Figs 3–5. *0.01 > P < 0.05, **0.001 £ P < 0.01, ***P <
6
0.001.
Mean
4 Results
3
Students’ knowledge on the competences of the
2 dental hygienist
1 The results of the first questionnaire showed that it was mostly
the dental student who lacked knowledge on the competences
0
Dental hygiene students Dental students of the dental hygienist. In nine of 23 questions more than 50%
provided a wrong answer. For instance, between 50% and 70%
Error bars: 95 % CI
did not know that dental hygienists (in Sweden) are allowed to
… was valuable **
decide on, carry out and diagnose X rays concerning caries and
… initiated interesting discussions**
periodontitis; prescribe alcohol, fluoride and anaesthetics to
… gave knowledge on cooperation
their place of work; decide on and carry out bleaching of teeth;
… gave a holistic view on patient treatment glue small pieces of jewellery on the teeth; and/or decide on
… presentation gave experiences on teamwork and carry out bacterial analyses of saliva. Concerning dental
… should be a permanent part of education hygiene students more than 50% answered wrongly in five of
the 23 questions. Their gaps of knowledge were on the follow-
Fig. 3. Students’ ratings of six statements regarding the fictional web-
based clinical cases. **0.001 £ P < 0.01.
… was valuable for future cooperation … was valuable for future cooperation
… contributed to more knowledge on teammate’s competence … contributed to more knowledge on teammate’s competence
… gave increased knowledge on interplay … gave increased knowledge on interplay*
… increased a holistic view on patients** … increased a holistic view on patients**
… gave more focus on preventive care … gave more focus on preventive care
… developed a rational view on dental care … developed a rational view on dental care
… has developed my knowledge on therapy planning * … has developed my knowledge on therapy planning*
… should be a part of future education … should be a part of future education*
… should start earlier in our education** … should start earlier in our education**
… presentation on seminar gave insight on how to work together
Fig. 4. Students’ ratings of nine statements regarding dental students
supervising dental hygiene students in the clinical setting. Fig. 5. Students’ ratings of ten statements regarding teamwork with
*0.01 > P < 0.05, **0.001 £ P < 0.01. shared patients. *0.01 > P < 0.05, **0.001 £ P < 0.01.
4 Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S
Leisnert et al. Improving teamwork between students from two professional programmes
ing: not aware of being allowed to possess X-ray equipment (SD) DHS 9.1 (0.9) and DS = 7.9 (1.5). There were significant
when practising on their own; not being allowed to diagnose differences between the two groups in five of the questions. It
diseases in mucous membrane; being allowed to carry out fis- concerned the questions whether this moment gave increased
sure blocking; decide on and carry out bleaching of teeth; and/ knowledge on interplay, increased holistic view on patients, has
or to manufacture a bleaching tray. At the concluding seminar, developed knowledge on therapy planning and should be a part
the students’ knowledge had improved in almost all matters of of future education, and that the presentations on the seminar
the questionnaire. For the dental students group, there were gave insight into how to work together. The questions display
significant changes concerning questions 2, 3, 4, 5, 8, 12, 13, 16 the same pattern of DHS giving higher scores. (Fig. 5).
and 17, and for the dental hygiene students, there were signifi-
cant changes concerning questions 17 and 23. (Fig. 2a,b).
Discussion
Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S 5
Improving teamwork between students from two professional programmes Leisnert et al.
6 Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S
Leisnert et al. Improving teamwork between students from two professional programmes
Yes No Do not
know
1. Seminar on team-work – Dr Eva Åberg from Ängelholm, DPHS Region of Skåne, presented a model for team-work: dentist – dental
hygienist – dental nurse
What did you gain from this seminar (e.g. inspiration, insight, got goose bumps, got bored, reflection, commitment, reluctance)?
......................................................................................................... . .
......................................................................................................... . .
......................................................................................................... . .
......................................................................................................... . .
This moment belongs to those that should be permanent in the education! Mark on the line to what extent this statement
in your opinion is correct
Not at al correct Totally correct
If not correct – how do you suggest it to be improved?
........... ...... ... .......................................................................................
........... ...... ... .......................................................................................
........... ...... ... .......................................................................................
....
Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S 7
Improving teamwork between students from two professional programmes Leisnert et al.
2. Patient cases presented on webzone – co-written treatment plans on the web followed by seminar with presentations from selected
teams
The moment with team-work on patient cases on Webzone: Mark on the lines to what extent this state-
ment in your opinion is correct
Not at all correct Totally correct
The selected presentations of shared patients was of substantial value ———————————————————
Comment: Why/ why not? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.............................................................
The selected presentations of shared patients gave rise to valuable discussions ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
...
The selected presentations of shared patients gave insight in what collaboration means ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
...
The selected presentations of shared patients gave rise to a holistic view on the patient ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.............................................................
The selected presentations of shared patients in a seminar gave ———————————————————
an insight in what a collaboration might imply
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
...
What did you gain from this seminar (e.g. inspiration, insight, got goose
bumps, got bored, reflection, commitment, reluctance)?
.
.
.
.
This moment belongs to those that should be permanently Not at all correct Totally correct
included in the education! ———————————————————
If not correct – how do you suggest it to be improved?
.
.
.
.
8 Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S
Leisnert et al. Improving teamwork between students from two professional programmes
Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S 9
Improving teamwork between students from two professional programmes Leisnert et al.
Has created a base for more focus on prevention and causal treatment ——————————-
—————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................
Has contributed to the development of my opinion on rational dental work ——————————-
—————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................
Has in combination with the treatment planning from these patients developed my knowledge? ——————————-
—————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................
Should in the future be mandatory part of the education ——————————-
—————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................
Should start earlier ——————————-
—————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................
The presentation of some shared patients in a seminar gave an insight in what collaboration can imply ——————————-
—————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................
What did you gain from this last seminar (e.g. inspiration, insight, got goose
bumps, got bored, reflection, commitment, reluctance)?
10 Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S
swed dent j 2008; 32: 115–123 leisnert, hallström, knutsson
Abstract
The prevalence of chronic periodontitis is around 40% in the adult population and most
patients visiting a dental clinic experience an intervention related to this disease, either as
prophylaxis, e.g. disease information, oral hygiene instruction and polishing, or as treatment
of the disease, per se. Hence, chronic periodontitis is a diagnosis that initiates time and costs
consuming interventions. The findings clinicians use to diagnose chronic periodontitis are
probably also the base for their choice of treatment. The aim of this study was to examine:
• What findings dental students, dental hygienist students, dental teachers, and supervisors in
Public Dental Health use to diagnose patients with chronic periodontitis.
• If different categories of clinicians use different findings to diagnose chronic periodontitis.
A questionnaire was distributed. Seventy-six clinicians representing the four categories
answered the question: “What findings, or combinations of findings, do you use when you diag-
nose chronic periodontitis?”
Twenty-five different findings were identified as findings the clinicians use when they diag-
nosed chronic periodontitis. The most frequently reported findings were bleeding, deepened
pockets and loss of marginal bone tissue. Variations between different categories of clinicians
were identified. For example, dental hygienist students used more findings (P<0.05), and were
also more inclined to use irrelevant findings like calculus, plaque, smoking, compared to the
other categories of clinicians (P<0.05). The majority of clinicians used only one finding at a time
to diagnose chronic periodontitis, and more seldom combined findings. Only 12 out of 76 clini-
cians used a finding that provided soft tissue inflammation, e.g. bleeding, in combination with
a finding that provided loss of supporting tissue, e.g. marginal bone loss. Few clinicians com-
mented that there should be a progressive loss of supporting tissue over time. Further research
is needed to investigate if these variations in findings used to diagnose chronic periodontitis
indicate variations in treatment of these patients.
Key words
Periodontitis, diagnosis, chronic disease, decision-making
1
Department of Comprehensive Care, Faculty of Odontology, Malmö University, Malmö, Sweden
2
Maxillofacial unit, Halmstad Hospital, Halmstad, Sweden
3
Department of Oral Radiology, Faculty of Odontology, Malmö University, Malmö, Sweden
Sammanfattning
Kronisk sjukdom har ett eller flera av följande karakteristika: sjukdomen är varaktig,
lämnar kvarvarande invaliditet, orsakar irreversibla patologiska förändringar och fordrar
återkommande stöd i form av någon slags intervention eller instruktion. Detta innebär
att diagnosen kronisk parodontit med stor sannolikhet medför personella och ekono-
miska insatser från patient och tandvård. Majoriteten av alla patienter med parodontit
har kronisk parodontit. Vilka fynd som används för att diagnostisera sjukdomen kan vara
av central betydelse för val av behandling. Tidigare forskningsresultat visar att det finns
stora variationer inom hälso- och sjukvård avseende vilka fynd som används för att ställa
diagnos och hur man omhändertar patienter med likartade diagnoser/symptom.
Målet med studien var att undersöka vilka fynd olika kategorier av kliniker använder
för att ställa diagnosen kronisk parodontit och om det finns skillnader mellan de olika
kategorierna.
En enkät distribuerades som innehöll frågan: ”Vilka fynd eller kombinationer av fynd
använder du för att ställa diagnosen kronisk parodontit?”. De undersökta kategorierna av
kliniker utgjordes av sista terminens tandläkarstuderande och tandhygieniststuderande,
kliniska lärare på Tandvårdshögskolan i Malmö och VFU (verksamhetsförlagd utbildning)
-handledare i folktandvården dvs. tandläkare som är ansvariga för tandläkarstuderande
när de fullgör sin obligatoriska tjänstgöring i folktandvården. Sjuttiosex kliniker, som
representerade de olika kategorierna, angav tjugofem olika fynd för att ställa diagnosen
kronisk parodontit. De fynd som angavs mest frekvent av samtliga kategorier var blöd-
ning, fördjupad tandköttsficka och förlust av marginal benvävnad. Tandhygieniststude-
rande angav signifikant fler fynd (P<0.05) än övriga kategorier och var mer benägna att
använda irrelevanta fynd, dvs. fynd som inte per definition beskriver själva sjukdomen,
t.ex. tandsten, plack och rökning, jämfört med övriga kategorier (P<0.05). Stor variation
inom en och samma kategori av kliniker sågs också avseende vilka fynd som användes
för att ställa diagnosen kronisk parodontit, dvs. om man angav fynd som påvisar inflam-
mation i tandens stödjevävnad, förlust av tandens stödjevävnad eller om fynden var
irrelevanta. Anmärkningsvärt var att de flesta deltagarna använde fynden solitärt, dvs.
de angav antingen ett fynd som påvisade inflammation i tandens stödjevävnad eller
ett fynd som påvisade förlust av tandens stödjevävnad eller ett fynd som var irrelevant.
Endast 12 av de 76 deltagarna angav att de kombinerade fynden för att ställa diagnosen,
dvs. en kombination av fynd som beskrev både förlust och inflammation av tandens
stödjevävnad. Variationerna i vilka fynd man använde för att ställa diagnosen kronisk
parodontit medför kanske att patienter med samma diagnos och sjukdomsbild får olika
behandling av olika kliniker, om fyndet som användes för att ställa diagnos också ligger
till grund för behandlingen. Detta kan i sin tur leda till icke kostnadseffektiv behandling.
Vi avser att belysa detta i framtida studier.
Table 1. The most frequently used findings (N=13) by four different categories of clinicians when they diagnose chronic
periodontitis. The findings are divided into three subgroups.
Soft tissue inflammation findings Loss of supporting tissue findings Irrelevant findings
-bleeding -marginal bone loss -plaque
-pus -marginal bone loss changed over time -calculus
-marginal bone loss on >1/3 of root length -smoking
-vertical bone pocket -mobility
-attachment loss
-furcation involvement
-deepened pocket
Figure 1. Dental students, dental hygienist students, supervisors, and dental teachers use of 13 findings when they diagnose
chronic periodontitis. The bars represent the percentage of clinicians within each category that used respectively finding.
% of clinicans
100
Dental teachers
0
100
Supervisors
0
100
Dental hygienist students
0
100
Dental students
0
pus
dee
mo
pla
cal
sm
ble
att
fur
bon
boner tim
bon/3 o
ver
ov
>1
oki
c
bil
que
kat
ach
edi
tica
pen
ulu
e lo
e lo e
e lo f roo
ity
ng
ion
n
s
l bo
d
ss o
ss o
ss o t le
g
ent
poc
inv
ne
nx
nx
n x ngt
l
oss
ket
olv
poc
-ra
-ra
-ra h
me
ket
nt
Figure 2. Mean number of findings (N=13) used by four different categories of clinicians to diagnose chronic periodontitis
in patients. The bar within each column represents the 95% confidence interval. Dental hygienists students used more findings
compared to the other categories (P<0.05).
6
Mean number of criteria
0
Dental students Dental hygienist students Supervisors Dental teachers
Categories
Table 2. Distribution of number of clinicians within each category that used findings that provide soft tissue inflammation
(1), loss of supporting tissue (2). The majority used the findings solitarily to diagnose chronic periodontitis. Only 12 of 76 used findings
in subgroups 1 and 2 as combinations.
Table 3. Number of clinicians within each category that used irrelevant findings to diagnose chronic periodontitis.
Irrelevant findings Dental students Dental hygienist students Supervisors Dental teachers
N=22 N=15 N=27 N=12
n % n % n % n %
Calculus 1 5 10 67 7 26 0 0
Plaque 6 27 10 67 6 22 2 16
Smoking 0 0 2 13 5 19 0 0
Mobility 7 32 6 40 7 26 1 8
TOTAL 13 59 13 87 17 63 3 25
the treatment includes surgery and in some cases censed: they had finished their work in their tutorial
antibiotics even though evidence is lacking for any groups and their clinical work and must therefore
long-time effects of this treatment (12). Chronic pe- be seen as highly knowledgeable theoretically in the
riodontitis is a diagnosis that probably initiates time different subjects included in the dental curriculum.
consuming interventions. The findings used to di- Overall, one would expect the variation in findings
agnose this condition could be the base for choice they use when they diagnose chronic periodontitis
of treatment option. This is why we intended to to be smaller than amongst a randomised selection
examine what findings different clinicians use when of clinicians (17).
they diagnose the disease per se. Except for the dental teachers the response fre-
quencies were satisfying. Even after receiving a re-
Methodological considerations minder only 12 out of 18 dental teachers responded.
Our overall aim, of which this study is a part, is to The responding teachers were representative for the
examine how different categories of clinicians reach whole group of dental teachers according to age,
their treatment plans for patients with chronic pe- sex, and kind of speciality. However, the author that
riodontitis. One question was ”What findings, or was present, LL, when the dental teachers answered
combination of findings, do you use when you di- the questionnaire received negative feed-back from
agnose chronic periodontitis?”. The aim was to have some of the colleagues. They felt as if it was a test and
the clinicians to report in their own words all the as if they were controlled. This might be one expla-
findings they used, and whether they used these fin- nation for the relatively low response frequency.
dings solitarily or in combinations to diagnose ch-
ronic periodontitis. This open structure of the ques- Reflection on the answers
tion might be the reason that very few, only 18 of the The MESH-term “Chronic Disease”, in Pub Med,
76 participants, stressed that they used the findings is defined as “Diseases which have one or more of
in combinations. In studies where the participants the following characteristics: they are permanent,
are asked to describe their judgement strategies it is leave residual disability, are caused by irreversible
vital that they are not steered (5). If we had given pathological alteration, require special training of
alternatives the answers would probably have been the patient for rehabilitation, or may be expected to
limited to these. Further, the situation in which the require a long period of supervision, monitoring, or
clinicians were presented to the questionnaire was care”. Translated to a health care perspective this, in
almost identical for the different categories. The our opinion means, that when patients receive the
dentists were informed and had a choice whether or diagnosis chronic periodontitis, personal and eco-
not to participate, in opposite to the students, who nomic resources are consumed and the patients of-
were obliged to participate. The dental teachers re- ten become lifelong dependents on dental care. The
turned the questionnaires by post or handed it back diagnosis and probably the findings that constitute
on a later occasion. They might have obtained infor- the diagnosis are therefore crucial.
mation that the other categories were unable to get, In concordance with other studies in decision
since they answered the questionnaire and returned making our results underpin existing evidence that
it back on that same occasion.The clinicians in this variations in medical practice exist (6, 17, 26). In this
study are neither a randomised selection nor a re- study, we recorded all 25 different findings used by
presentative group of dental clinicians in Sweden. the clinicians to diagnose chronic periodontitis. The
They could rather be regarded as a highly know- most frequently used findings were deepened pock-
ledgeable group. Dental teachers are supposed to ets, bleeding on probing, and loss of bone level on
be informed about the evidence base for the clinical x-ray. This is in concordance with other studies on
methods used at the CCC, and thus expected to have how to define the disease chronic periodontitis (4).
the knowledge on which findings should be used to The listed findings correspond well to findings
diagnose patients with chronic periodontits. Super- that are in concordance with soft tissue inflamma-
visors in the Public Dental Health continuously par- tion and loss of supporting tissue. However, it was
ticipate in postgraduate education and are recruited surprising that only 12 out of 76 clinicians combined
from dentists with experience and interest in clinical the findings belonging to these two subgroups. To
questions, educational matters and supporting the be in concordance with the definitions of chronic
students’ professional development (18). periodontitis “An infectious disease resulting in in-
The dental and hygienist students were almost li- flammation within the supporting tissues of the te-
eth and progressive attachment and bone loss”(21), higher number of findings (P<0.05), and were
at least one finding providing soft tissue inflamma- also more inclined to use irrelevant findings like
tion, and one providing loss of supporting tissue calculus, plaque, and smoking compared to the
should be used, for example bleeding and bone loss. other categories (P<0.05).
Furthermore to be chronic there should be a loss of • Within each category of clinicians wide variations
supporting tissue over time (20). Until date, no exact were found in which findings they used to diag-
definition exists and very few of the clinicians in this nose chronic periodontitis. The majority only used
study comments that there should be a loss of sup- the findings solitarily and they did not combine
porting tissue over time. one finding that provided soft tissue inflamma-
In all categories there were clinicians that used tion with a finding that provided loss of sup-
irrelevant findings, i.e. findings not mentioned in porting tissue. Only 12 of 76 clinicians used two
any study or classification to be a finding used to relevant findings in combination.
diagnose chronic periodontitis. Such findings were • The wide variations when clinicians diagnose
for example plaque and calculus. These findings chronic periodontitis might indicate variations in
are considered to be irrelevant since they do not, treatment plans and treatment options. Further
per se, describe the disease. Plaque and calculus are research is planned to investigate the extent to
findings that could be present both in patients with which the used findings influence the treatment
and without periodontitis (3). Even though the den- options.
tal hygienist students were in the majority when it
comes to the use of irrelevant findings, both dental Acknowledgements
students and supervisors used such findings. The The study was approved by the Ethics Committee
teachers used few irrelevant findings and were found at Lund University, Lund, Sweden (LU- 317/2006).
to be more evidence-based but the students were not We thank Per-Erik Isberg, B.Sc., for statistical advice
in compliance with their teachers. Only one dental and the participants in this study: dental students,
teacher used tooth mobility as an irrelevant finding. dental hygienists, and dental teachers at the faculty
None of the supervisors in the Dental Public Health of Odontology, Malmö University, Malmö. We also
used attachment loss as a finding when they diagno- thank the supervisors in the Public Dental Health in
sed chronic periodontitis. This was expected since the region of Skåne, Sweden.
attachment loss as a measurement of loss of sup-
porting tissue is hard to perform in daily praxis and
is also time-consuming, and hence, more often used
in research projects. The supervisors in contrast to
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