Changing Dental PBL

406 Journal of Dental Education ■ Volume 65, No. 5

The Changing Face of Dental Education:The Impact of PBLAlan G. Fincham, Ph.D.; Charles F. Shuler, D.M.D., Ph.D.Abstract: The past decade has seen increasing demands for reform of dental education that would produce a graduate betterequipped to work in the rapidly changing world of the twenty-first century. Among the most notable curriculum changesimplemented in dental schools is a move toward Problem-Based Learning (PBL). PBL, in some form, has been a feature ofmedical education for several decades, but has only recently been introduced into dental schools. This paper discusses therationale for the introduction of a PBL pedagogy into dental education, the modalities of PBL being introduced, and the implica-tions of the introduction of PBL into dental schools. Matters related to implementation, faculty development, admissions, andassessment are addressed. Observations derived from a parallel-track dental PBL curriculum at the University of SouthernCalifornia (USC) are presented and discussed. This program conforms to the Barrows (1998) concept of “authentic PBL” in thatthe program has no scheduled lectures and maintains a PBL pedagogy for all four years of the curriculum. The USC dentalstudents working in the PBL curriculum have attained a high level of achievement on U.S. National Dental Boards (Part I)examinations, significantly superior to their peers working in a traditional lecture-based curriculum.

Dr. Fincham is Research Professor (Biochemistry) and Dr. Shuler is Associate Dean, Academic Affairs, both at the Center forCraniofacial Molecular Biology, School of Dentistry, University of Southern California. Direct correspondence and requests forreprints to Dr. Fincham at the School of Dentistry, University of Southern California, 2250 Alcazar Street, Los Angeles, CA90033; 323-442-3177 phone; 323-442-2981 fax; [email protected] e-mail.

Key words: problem-based learning, PBL, dental education, curriculum

Submitted for publication 2/8/01, accepted for publication 4/9/01

Educational Methodologies

This paper seeks to provide the reader with anoverview of the problem-based learning(PBL) process, the present status of PBL in

dental education, the modalities of PBL being used,the problems likely to be met in implementing suchinnovative programs, the human and physical re-sources required, and some limited data on outcomesfrom the authors’ experience at the University ofSouthern California (USC) School of Dentistry.1,2

PBL DefinedThe term “problem-based learning” has been

variously interpreted. Many educational programsthat profess to employ a PBL pedagogy have doubt-ful claims in that these programs fail to meet the cri-teria for authentic PBL programs.3,4 Barrows,4 aleader in the field of medical PBL education, refersto “authentic PBL” as addressing three critical edu-cational objectives:

1. The acquisition of a rich body of deeplyunderstood knowledge that is integratedfrom a wide variety of disciplines, structured

in ways that will facilitate recall and appli-cation to other Problems, and enmeshed withthe Problem-solving, required to analyze andsolve patient Problems. 2. The developmentof effective clinical Problem-solving, self-directed learning, and team and interper-sonal skills. 3. The development of aninsatiable curiosity and a desire to continu-ally learn.”

Such a definition appears to be equally appli-cable to dental as well as to medical education. Inany consideration of PBL, it is critical to clarify thedifference between “problem-solving exercises,”which are frequently and incorrectly reported as be-ing PBL and true (authentic) PBL in the Barrowssense. The difference has been succinctly stated byInman: “One (problem-solving) leads to a solutionbut not necessarily to understanding; while the other(PBL) leads to understanding but not necessarily asolution.” He continues: “Profound Problem-basedLearning may arise from a Problem which has amultiplicity of solutions, or from one which has nosolution at all.”5

May 2001 ■ Journal of Dental Education 407

Problem-based learning has its origins in healthcare education in the 1960s at McMaster Universityin Canada where it was applied in the Medical Sci-ences curriculum.6-7 Since that time, PBL has beenextensively implemented in medical curricula (andother professional training programs) worldwide, butto only a limited extent in dental education.

In 1984, the dental school at Malmö in Swe-den was closed as being in excess of the Swedishnational need for dental education. Following the clo-sure of the school, a cohort of the faculty set to workto prepare a completely new curriculum that wouldbe based on the principles of problem-based learn-ing. The faculty were assisted in this endeavor byexperts in cognitive learning psychology from Euro-pean medical schools such as Maastricht Universityin the Netherlands, which were already using a PBL-based curriculum. In 1990, the Malmö Dental Schoolwas reopened with a completely revised dental edu-cation curriculum employing a student-centered PBLpedagogy.8 This development stands as a significantmilestone in dental education since, up to that time,problem-based learning had not been significantlyemployed in dental education. Since that time therehas been increasing interest in PBL-based dentalcurriculum development worldwide. In NorthAmerica this interest was further promoted by the1995 Institute of Medicine Report, Dental Educa-tion at the Crossroads, which strongly urged a reas-sessment of current dental curricula.9

Dental schools currently employing some as-pects of PBL in their curricula are found in Europe(Sweden, The Netherlands, Norway, and the UnitedKingdom); Asia (Hong Kong, Singapore, and Thai-land); Australia and New Zealand; and the UnitedStates and Canada.

Why PBL in Dentistry?

According to Schmidt, as quoted in Kelly etal.,10 three conditions that facilitate learning are:1. Learning has a restructuring character. Earlier

knowledge is used in understanding new infor-mation.

2. Retrieval cues reactivate information. The closerthe resemblance between the situation in whichsomething is learnt and the situation in which it isto be applied, the better the performance and theeasier it is in respect of recall and application.

3. Elaboration of knowledge. Information is betterunderstood, processed, and retrieved if students

have an opportunity to elaborate on that infor-mation. Students can elaborate by answeringquestions about the matter, by taking notes, byteaching peers what they have already learntthemselves, by summarizing, and by formulat-ing and criticizing hypotheses about a givenproblem. A teaching-dominated approach failsto accommodate these conditions for learning.

A PBL curriculum, employing student-centeredlearning, clearly provides conditions that will pro-mote learning based on these three postulates.11

Among a range of other reasons to convert to a PBLcurriculum, we might select:• Traditional curricula tend to be directed towards

memorizing facts and gaining technical skills with-out sufficient concern for understanding or clini-cal reasoning.

• Traditional curricula tend to be “dense-packed,”allowing insufficient time for reflection and self-directed learning.

• The traditional “pre-clinical/clinical” division ofthe curriculum inhibits integration and causes stu-dents to view the preclinical phase as simply a“hurdle to be overcome.”

• In traditional dental curricula, the clinical experi-ence is delayed as a result of the non-integratedcourse content.

• The scheduling of the subject matter frequentlyobscures its relevance to clinical situations.

• There may be insufficient emphasis on attributessuch as patient/practitioner interactions, commu-nication, and interpersonal and management skills.

• The traditional departmental structure inhibits con-tent integration.

• Traditional curricula fail to emphasize student re-sponsibility for learning. Rather the focus is onfaculty responsibility to teach the students.

• Students have historically enjoyed the PBL expe-rience.12-14

Modalities of PBL

While PBL has been introduced into the cur-riculum of a number of dental schools, the mode anddegree of the implementation have varied. These dif-ferent modalities range from the introduction of asingle PBL-format course or module to the completetransformation of the curriculum to PBL. Examplesof the complete transformation of the curriculum toPBL include the USC parallel track program and the,more recent, University of Hong Kong curriculum.15


Perhaps most commonly, PBL dental curricula havebeen developed as a “horizontal hybrid,” essentiallypreserving the traditional “preclinical/clinical” struc-ture and limiting the PBL component to the first twoto three years. While this approach preserves the tra-ditional structure, it suffers from the inability toreadily link basic science learning with clinical ap-plication, so a degree of vertical integration is lost(see also Houlden16). For a fuller discussion of mo-dalities of PBL, see Barrows.17 In a number of uni-versities, dental schools that are linked with PBLmedical schools have chosen to initially place thedental students in the PBL medical curriculum.18-22

Examples of linkage between medical school PBLand dental education include Harvard, Connecticut,and the University of British Columbia. While thisapproach has the certain merit of providing the den-tal student with a firm foundation in medicine, theintegration of dentally related case materials may belogistically problematic since the medical faculty di-recting the sequence and content of the problems mayfail to recognize opportunities for linkage to oral signsand symptoms. Finally, in other cases (partial hy-brids), PBL implementation has been limited to singlecourses or curricular “blocks.”23-25 This approach suf-fers from the drawbacks that integration of curricu-lar content is limited and students are faced with theconfusion of drastically contrasted pedagogies (stu-dent-centered vs. teacher-centered) within the sametime frame. Under such conditions it is likely thatstudents’ attention will have a greater focus on thetraditional (comfortable) pedagogy, rather than theinnovative.26 (See Table 1 for examples of the differ-ent modalities of PBL currently being employed.

PBL vs. “Case-Based” Learning

While PBL employs problem-cases as the fo-cus for promoting student learning, PBL is not thesame as “case-based” learning, as is frequently sug-

gested by clinicians: “Oh yes! Of course we use‘cases’ in our program.” The difference is essentiallythat outlined by Inman.5 In case-based learning ex-ercises, the student is usually expected to “solve” thecase (i.e., arrive at an acceptable differential diagno-sis and treatment plan), applying his or her existingknowledge. In PBL, however, a “case” is employedto prompt the students (as a group) to identify anddevelop new areas of learning, whether the case is“solved” or not. There is little doubt that PBL devel-ops problem-solving skills in the students, and thereis certainly value in providing clinical cases for stu-dents to “solve” as a part of formative assessments.At USC, such problem-solving of clinical case datais employed as objective assessment instruments inthe third and fourth years of the program. The pro-cess of learning in a PBL-based curriculum providesstudents with the tools to become effective problemsolvers, and methods of student assessment shouldinclude means to measure this outcome.

PBL: The Process and Effectson Curriculum Change

A PBL pedagogy has three essential compo-nents that must be integrated to permit the fosteringof an inquiry-driven learning environment. Thosecomponents—the problems, the small group learn-ing, and the student-centered environment—must allbe present to achieve a successful result (Figure 1).Each of these three components has specific elementsthat need to be addressed during the implementationof a PBL dental education program. The importanceof these three components of PBL can be establishedin ground rules for the operation of the groups thatreinforce the commitment of students, faculty, andcurriculum to the PBL ideals (Figure 1).

Table 1. Examples of modalities of PBL currently in use at a selection of dental schools

Modality Country School Class size Reference

Full implementation China Hong Kong 50 15Full implementation Ireland Dublin ~40 10Full implementation Sweden Malmö 40 8Full implementation USA USC 24(140*) 1, 2, 42Hybrid with Medicine Canada UBC 40 20-21Hybrid with Medicine USA Harvard ~40 18-19, 22Course based hybrid Australia Queensland ~50 54Full implementation UK Manchester 65 74PBL/traditional hybrid USA Indiana 100 72*Scheduled intake for 2001


The Problems

A key requirement of a PBL curriculum is that“the problem always comes first.” This requirementmay be presented as one of the ground rules for theprogram and has an important meaning for the struc-ture of the curriculum. This ground rule means thatall students first encounter a learning objectivethrough the process of discovery in a problem devel-oped by the curriculum organizers and facilitated bya faculty member. This order of introduction requiresthe student/student group to critically analyze theproblem, identify the content needed to understandit, and complete the research necessary to learn thematerial (Figure 2). It is important that the content is

never presented prior to the engagement of the stu-dent/student group in the critical thinking requiredto analyze the problem. Frequently, both students andfaculty identify this process as “inefficient” since theperception is that a lecture can more quickly and ef-fectively transmit the material; however, if the stu-dents are unprepared intellectually to understand thetopic and apply it to a clinical situation, the resultwill be ineffective transmittal of knowledge. Effi-ciency in education is an interesting concept that isoften perceived to be synonymous with the fewestnumber of contact hours between faculty and stu-dents; yet high efficiency could also be identified asthe ability of the student to effectively understandthe material and apply it to a clinical situation. Learn-

Figure 1. PBL has three essential components. The area of overlap of all three equals effective PBL. The establish-ment of specific ground rules for the group is an important demonstration of commitment of students, faculty, andcurriculum to the PBL ideals.

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ing in context through the use of problems to intro-duce the learning objectives inherently provides forearly appreciation of the applicability of the contentto patient care. Thus, to have efficient application ofmaterial, it is critical that “the problem always comefirst” and that students understand the importanceof the content at the beginning of the learning pro-cess.

The use of problems to convey the content ofthe curriculum through PBL pedagogy requires thatthe curriculum organizing group first identify theintended outcomes of the program and then estab-lish a sequence of problems that provide the contentnecessary to achieve the stated objectives. In this re-gard, the development and sequencing of the prob-lems are critical to provide a comprehensive set oflearning outcomes and an orderly progression of thedevelopment of competence. In dental education theneed to identify graduation competencies and specifythe progression during the curriculum towards thesecompetencies provides an important framework fordeveloping and sequencing the problems from whichstudents will learn. Problems must be tested and re-fined based on the achievement of students. In theevent that a problem fails to meet a learning objec-tive intended by the faculty, future problems need tobe developed/modified to ensure coverage. Whilemany students and faculty may feel that the PBL cur-riculum is particularly “unstructured,” a large amountof organization is required to structure the sequenceof learning and develop a catalog of problems thatengage the students’ learning in the critical topic ar-eas. Students will “discover” the topics and achievethe desired endpoints, yet frequently remain unawarethat their educational progress has been directed bythe curricular structure. Student inquiry, inherent ina PBL-based pedagogy, into the nature of the prob-lems will lead them to the underlying structure ofthe curriculum.

Typical “good” PBL problems have been de-scribed as being “real and ill-structured.”27 By this itis meant that the situation/patient case presented bythe problem approximates reality and that a full un-derstanding of the problem cannot be achieved with-out substantial research and learning by the students.The problem should be seen by the students as beingrelevant to their chosen profession and the real world,thus engaging their interest.

It is essential that each problem be carefullyanalyzed to define the expected (major and minor)learning objectives it would generate. This factual

material is then assembled to from the basis of thecurriculum, and the problems can be sequenced ap-propriately to link with other curricular activities. Forexample, a problem case dealing with a “patient” whoreports with gingival bleeding will generate learn-ing related to gingival histology and aspects of clini-cal periodontology and an understanding of the fun-damental processes of blood clotting. In theexperience of the authors, it has proven important tomaintain detailed records of all student-generated“learning needs” arising from each problem case. Atthe completion of each case, the group facilitatorsare asked to complete a document listing both the“major” and “minor” learning needs identified bythe students. These data are entered into a computerdatabase of “Problem Outcomes.” Such records sup-port the organization of the curricular content—thatis, what material the students will learn and in whatsequence that underlies a PBL curriculum.

Case Materials—Sources and Development.While there now exists a substantial pool of devel-oped PBL “cases” for medical education, the samecannot be said for dentistry. In our experience, start-ing in 1995, no significant body of dentally relevantPBL case materials could be located, beyond theSwedish material and some limited sources in Aus-tralia. While modification of existing case materialscan generally address the basic biomedical needs ofthe curriculum, the biodental and clinical case re-quirements will usually require the creation and test-ing of new case materials, although a body of dentallyrelated PBL cases is now beginning to emerge (seethe International Dental PBL Network, IDPN, andANZdental web sites which provide links to, andexamples of, dentally related PBL case documents37-38).Interactions among dental educators throughout theworld have begun to develop a significant body ofproblem material with applicability to dental cur-ricula. These materials have been readily shared,tested in other institutions, and compared as to learn-ing outcomes. As additional institutions move togreater incorporation of PBL, the body of problemsavailable to structure the curriculum is certain togrow.

Among the recommendations of the 1995 In-stitute of Medicine Report9 was the recognition thatthe training of a dental practitioner for the twenty-first century will require that the student initially ac-quires a substantial body of basic medical knowl-edge. Noting this requirement, we have found thatmany existing medical PBL cases that generate learn-


ing needs related to basic biomedical systems canreadily be modified to provide a “dental slant” to thecase.1 For example, a medical trauma case, designedto address learning aspects of hematology (hemo-philia, clotting cascade, etc.) can easily be modifiedto make the initial case presentation dental traumawith a problem of prolonged bleeding. Such modifi-cations serve to stimulate dental student interest in amanner that would not usually occur in the“mouthless” medical school environment. A studyof the effectiveness of problems has been providedby Dolmans et al.36

Small Group Learning

The function of small groups of students to-gether pursuing the problem is a critical element of aPBL curriculum. The literature indicates that groupsof about six to eight students is optimal34, to ensurethe participation of all members and to eliminate thesegregation of the group into smaller subsets. Thefunction of the group as a learning organization willchange over time. In the first semester of a PBL cur-riculum, it may take as long as two months for a groupof students to become highly effective in this type ofpedagogy. The change in style of learning, the re-sponsibility to other students in the group, the selfand peer evaluations included in the process, and therequirement for student-directed learning will all benew to nearly every entering dental student. The fa-cilitator plays a key role with the new groups to helpdevelop the PBL process of learning and reassurethe group that the process is working (Figure 2). Thegroup also provides a critical element of normaliz-ing the learning process, since each member has ex-pectations about the level of accomplishments of theother members. This provides a critical real-timemeasure of student achievement and prevents mem-bers of the group from falling considerably behind.The small group also provides a “safe” learning en-vironment in which students can admit a lack of un-derstanding and receive support and encouragementfrom their peers, which ultimately leads to the growthof the entire group. A key question often asked ofPBL programs regards the nature of remediation ofstudents who fall behind their peers in educationalaccomplishment. Commonly, remediation occursthrough the support of the group, and students arerarely able to fall more than one to two days behindtheir group without the group intervening to bring allmembers to a similar level of educational achievement.

A by-product of the small group learning en-vironment is the understanding of functional groupdynamics. Most entering dental students have neverhad to rely on a well-organized group to accomplishan identified goal. Yet in dental practice the functionof the group of individuals involved in patient careis essential to ensure the highest quality of oral healthcare delivery. The skills required to become a well-integrated member of a small group learning envi-ronment are critical to the future success of the oralhealth care professional. The organization of the cur-riculum again provides a learning objective neces-sary for the students yet not completely obvious tothem as an expected outcome. Each group continu-ally engages in self- and peer evaluation, both to en-hance the performance of the group and to begin thedevelopment of professional behaviors essential tothe successful delivery of oral health care. The for-mat for these self- and peer evaluations has been for-malized to assist students in the process and providefacilitators with a reproducible mechanism (Figure 3).

An important aspect of a small group learningenvironment is student acceptance of this style ofpedagogy. Some students may be more comfortablein a traditional learning curriculum, so an elementnecessary to the implementation of a PBL dentaleducation program is the consideration of the admis-sions process. We have shown that, by using a lessconventional method of dental student admissions,we are able to identify students with a greater poten-tial to excel in a PBL environment.42

Admissions in a PBL Curriculum. The PBLprocess relies heavily on the ability of students tofunction effectively in a group. A dysfunctional PBLgroup39 will result in the failure of some or all of itsmembers to learn. Recognition of this fact requires areconsideration of the procedures used in admittingstudents to a PBL program. While the traditional re-quirement of academic achievement cannot be over-looked, greater emphasis needs to be placed on theselection of individuals who will function effectivelyin the PBL group. To achieve this, an emphasis mayneed to be placed on the interview and on identify-ing individuals who show evidence of working suc-cessfully in group situations. An additional factor inselecting students is the recognition that most appli-cants will have had no prior experience with the PBLprocess and will need information on the style ofthis pedagogy. In our experience, much can be gainedby organizing applicants into groups and running ashort PBL case. Participation of dental school appli-


cants in a real session of PBL learning serves a dualpurpose, in that it allows the applicant to experiencePBL first hand and it permits faculty to observe ap-plicants in a group situation. Faculty facilitators andobservers record subjective assessments for eachapplicant under the headings of attention, ideas, em-pathy, comprehension, and language. A further as-pect considered important in the application/admis-sions process is arranging for applicants to observePBL student groups in session and to discuss the pro-gram with current PBL students. The opportunity ofthe applicants to both participate in an actual PBLlearning session and observe the process with cur-rent dental students provides all applicants with de-tailed information concerning this style of learning.Although this process is labor-intensive and time-consuming we believe it greatly assists with the se-lection of students who will function effectively in aPBL program. These, and related admissions issueshave been discussed by Martinez-Burrola et al.40,Greenwood et al.41, and by Pereira.42

The Student Centered Environment

It should be clear that in any educational pro-gram the students are truly the focal point, and alllearning methods are thus student-centered. But fre-quently, this fact is obscured by the delivery of edu-cational content in very traditional ways that are inlarge part structured to benefit the faculty rather thanthe student. When classes are designed to tell stu-dents at the beginning all the material they must learnand the order in which they must learn it, yet providelittle information on the relevance of the material tofuture career objectives, it becomes difficult to ap-preciate the “student-centeredness” of the program.Students quickly identify the lowest common de-nominator for learning, strive to master only thematerial relevant to exams, and fail to develop highlevels of sustainable knowledge. In a truly student-centered environment, faculty recognize the impor-tance of the students in the learning process and un-derstand that the content must be appreciated by thestudents before they will become motivated to mas-ter the material.

The PBL structure inherently recognizes theimportance of the student in the process of learning(see Figure 3). The faculty facilitator and the stu-dents in the group all develop a level of respect forthe thoughts and ideas of others and work to refineand reinforce these thinking processes for their mu-

tual benefit. Importantly, in PBL it is recognized thatstudent research and mastery of material will occuroutside the classroom either individually or in sub-sets of the group. This necessary component of PBLrequires that the time in the curriculum reflect thiscommitment to learning. Thus, sufficient “studytime” is required in the weekly schedule, and everyeffort is needed to prevent erosion of this scheduledtime by other activities. Time to learn is a key com-mitment to a student-centered environment, as wellas recognition by both students and faculty that tomaster the material time is needed. Time is thus anessential structural component of a PBL curriculum.

Structuring the Time Schedule in a PBLCurriculum. Experience with traditional dental ormedical curricula suggests that scheduled activitieswill always expand to fill the time available. Com-monly, department chairs will seek additional timein which to teach their “discipline” and will strenu-ously defend their time against any attrition of theirallocations. This condition has been described byAbrahamson as “Curriculomegaly.”35 Among thegreater strengths of the PBL pedagogy is its innateability to integrate the learning of the basic and clini-cal sciences in a way that transcends traditional de-partmental boundaries. Thus in a fully implementedPBL curriculum, time is no longer scheduled to de-partments, but only to “problems.” Typically, in theearly years, a PBL case may consist of several “parts”provided successively to the student groups; thesemay occupy student time over a one to two week pe-riod. To allow students time for self-motivated inde-pendent research and study, it becomes essential toallocate scheduled study time within the weeklyschedules. Typically, two to three hours of “sched-uled study” time needs to be allotted for each PBLgroup session.1 This issue is vitally important for suc-cessful PBL outcomes. In curricular structures thatemploy a hybrid between traditional lecture/lab-basedinstruction and PBL, scheduled study time is fre-quently overlooked or negated by pressures from thetraditional courses.

PBL in Dental ClinicalEducation

One comment frequently heard in reviews ofPBL for dental education is “PBL works fine for thebasic sciences but wouldn’t work for the clinical el-


Figure 2. The PBL process: 1) the problem is described; 2) students will identify the relevant “facts”; 3) based onthese facts, they will generate a list of “ideas” about the problem; 4) consideration of these ideas will lead to theidentification of a list of “learning needs.” The lower flow-chart illustrates the iterative nature of the PBL process. Asadditional data are obtained and facts learned, the ideas are refined and the learning needs revisited.


Figure 3. Group Self and Peer Assessments

This document is used to assist the facilitator and the group in making an assessment of its work. In practice, at the endof each case, the facilitator asks each student to complete this form. The individual subjective assessments and com-ments are then tabulated and are discussed with the group. This has been found helpful in prompting the group toconsider its collective work and the contributions of each individual. In addition, we have found this process helpful inrevealing any interpersonal problems that might be inhibiting the group dynamics.

PBL Process Evaluation – How did I do?

On a scale of a 1-5 score (1 = Very poor; 5 = Magnificent!) how do you feel that you haveperformed in this problem case? (Be objective!)

A. Group skills. I actively participated in the work of the group showing a sensitivity to groupneeds as well as self needs and demonstrating respect for the aspirations of all members of thegroup.

B. Learning skills. I effectively identified group and individual learning needs and identifiedthe appropriate learning resources.

C. Reasoning skills. I demonstrated an ability to critically evaluate information, to synthesizeand to critically appraise data.

D. Feedback skills. I demonstrated an ability to provide constructive feedback to the group,promoting the group’s ability to learn.

AND (One sentence only)

E. I could do better in the following:

F. I feel I did a good job in the following:

G. Overall I would rate our group performance in this case as:

H. In terms of “Interest” I would rate this case as:(1-5. 1 = Very dull; 5 = Highly interesting)

USC Dental PBL Program 2/8/01


ements.” This type of bias reflects the comments re-ported by Abrahamson that medical school facultyfrequently made that “PBL will work for your stu-dents but not for ours.” The underlying premise isthat the learning of dental clinical procedures is some-how different from other learning, yet there is clearlya cognitive element common to mastering any typeof learning content. If the rule that “the problem al-ways comes first” is accepted, then incorporatinglearning objectives with clinical outcomes would alsoneed to adhere to this rule. Is that possible?

The answer is yes, it is very possible. Prob-lems can be readily developed that introduce any typeof clinical learning objective. A simulated patient sce-nario can be developed that includes the signs andsymptoms for any dental patient presentation. Thestudents will direct their learning to understand thepathogenesis of the problem first, and then extendthe learning process through the stages of diagnosis,therapy, and prevention as directly linked to a par-ticular pathology. Once the pathology is accuratelydiagnosed by understanding the nature of the signsand symptoms, the basic sciences contributing to thesigns and symptoms mastered, and the long-termoutcomes of untreated disease understood, the ratio-nale for a particular therapy follows naturally. Theproblems can easily lead the student to determinethe appropriate type of therapy required to eliminatethe pathology and restore form and function. Stu-dents can explore the principles underlying a par-ticular therapeutic strategy, the materials required,and the steps needed to complete the technique. Thus,the basic learning of the clinical sciences in dentistrycan easily be incorporated into a PBL format andstudent inquiry can be used to lead the process, fol-lowing the identical pedagogical model used for allother elements of the PBL curriculum. In fact, thistype of learning will lead students to develop an evi-dence base for the methods to diagnose and treat oraldisease and allow them to investigate the most re-cently reported literature—a benefit not often foundin clinically related dental courses. Yet, the problemremains that the actual hand skills required to com-plete the technical procedures, while identifiedthrough the PBL format, still need to be practicedand mastered by the student. Again, the commentfrequently heard is that these can not be learned in aPBL setting, but is that premise really correct? Is thelearning of the hand skills an inherently differentcognitive activity that would not be amenable to PBL?Does psychomotor skill development require criti-cal thinking and evaluation?

The development of competency in the proce-dural skills in dentistry is a requirement for each in-dividual. Similarly the mastery of the cognitive con-tent in the curriculum is the responsibility of eachindividual student. In PBL, research on learning ob-jectives, mastery of the material, and contact withexperts for additional advice are all individual ac-tivities that support the objectives of the group. Theseare similarly supported by members of group pro-viding feedback and reinforcement related to theachievements of the individual. The group evalua-tion of individual accomplishment provides an im-portant resource for the advancement of both thespecific student and the group as a whole. This typeof group activity can be similarly applied to the de-velopment of competency in procedural skills. Theachievement in clinical/preclinical techniques can beviewed as equivalent to the research related to a learn-ing objective and thus a topic for discussion by allmembers of the group. Self- and peer evaluation ofclinical achievements provides a means to integrateprocedural skills into a PBL approach using the groupas a resource for individual accomplishment. In theseways, the design of the learning environment can bedeveloped to enable a PBL approach to the develop-ment of clinical skills.

The organization of PBL for preclinical andclinical technical learning requires that the groupstructure and learning environment be maintained.At USC, this is accomplished by a small-group, fac-ulty-facilitated “Pre-Session” prior to any preclini-cal laboratory or clinical activity. In the presessions,students discuss their intended clinical objectives, re-view the procedures and patients, and establish theirreadiness to proceed to the “Research Phase” inves-tigating the actual completion of a clinical procedure.The pre-session reviews the delivery of care to ei-ther a simulated patient who was the focus for learn-ing in a PBL scenario or a real patient who will beseen in the clinic. In both cases, the completion ofspecific technical procedures is the focus for discus-sion and precedes the individual learning experience.The situation is the same both preclinically and clini-cally, in that all students review their learning objec-tives and then proceed to the research phase in eitherthe simulator lab or the clinic. In either place, thestudent-faculty-patient relationship is identical withthe current methods of teaching in these environ-ments. Faculty serve as expert resources, mentoringstudent accomplishment and providing expertise tohelp students advance their state of knowledge. The


program maintains a database of all student-patientexperiences and monitors the accomplishment ofeach student to ensure the breadth and depth of ex-perience necessary to achieve the curricular compe-tencies. Analysis of the clinical experiences of thefirst 2 classes to complete the PBL pilot project atUSC has shown that the students have a clinical ex-perience level that is within the range for their peersin the traditional track.

The “Research Phase” of PBL in the clinictherefore has a cumulative outcome comparable tothat of the traditional track; however, the events be-fore and after the clinical experience are critical toenhance learning. In the research phase, facultyshould provide expert information and function as aresource to assist student achievement, exactly as afaculty member would provide expertise when a stu-dent researched a problem-generated learning need.In this way, the individual experiences in both thesimulator lab and clinic are equivalent to the indi-vidual research conducted by students pursuing aPBL problem. The difference is that the outcome is aprocedure. However, this procedure represents theoutcome of individual research that can be broughtto a group for discussion and used to advance thelearning of all members of the group. To achieve thisend, the research phase is followed by another facili-tated small-group “Post-Session” in which the stu-dent group discusses the outcomes, identifies defi-ciencies, and establishes additional didactic learningand technical practice needed to advance their levelof accomplishment. This cycle of learning is exactlythe PBL model and provides the students with criti-cal peer support for the learning and application pro-cess and a method of self- and peer evaluation. In allof these instances, every student in the group learnsfrom all the other students and consequently expandshis or her range of experience far beyond individualactivity. The small groups provide an excellent op-portunity to reinforce clinical guidelines and stan-dards and to normalize the accomplishment of thegroups.

A key element in the use of PBL in the clinicalareas is to establish the sequential clinical achieve-ments for the student groups. As in a medical resi-dency, the group of students can be linked to par-ticular levels of clinical competency, and the learningobjectives in the problems can be established toachieve this competency (Table 2). At USC, we haveestablished a sequence of clinical skill sets that gradu-ally introduces the student to patient care. The de-

velopment of clinical skills has been sequenced sothat students in all four years of the curriculum canbe involved in the comprehensive care of patients.Verticalized treatment teams are organized with onestudent from each of the first-, second-, third-, andfourth-year classes. Each of the teams has a practicewith patients whose comprehensive care is their re-sponsibility. All of these students in the vertical teamparticipate in evaluating patient needs and develop-ing a comprehensive treatment plan. The fourth-yearstudent has the role similar to a senior resident in amedical residency, with the supervising faculty serv-ing as the attending doctor. Once a treatment plan isestablished for a patient, individual students providecare at the level of their clinical competency withfrequent interaction and collaboration with all stu-dent members of the team. This situation models themethods used in medical residency because it in-volves all levels of experience in the care of patientsand allows each member of the team to provide careat the level of their competence. The structure alsoprovides a means for all students to reach their even-tual educational goal and to benefit from an increasednumber of patient care experiences. The integrationof all levels of student skill into the treatment of pa-tients provides both high-quality comprehensive careand the opportunity for all students to participate ina greater number of clinical experiences to broadenthe educational experience. The inclusion of a pre-session and post-session format permits the PBLpedagogy to be perpetuated in the clinical situationand reinforces the commitment of the dental educa-tion program to a consistent method to enhance stu-dent learning.

Introducing PBL into theDental School

In the introduction, we referred to the MalmöUniversity Dental School, where a PBL curriculumwas introduced when the school was reopened. Thissituation is reminiscent of the original introductionof PBL in 1965 at McMaster University Health Sci-

Table 2. Clinical skill progression in a PBL curriculum

Year Skill Set

1 Dental Hygiene2 Single tooth, single tissue therapies3 Multiple teeth, multiple tissue therapies4 Comprehensive care using all clinical abilities


ences, where PBL was adopted as the pedagogy foran entirely new medical education program.6 In bothof these cases, one dental and the other medical, aninnovative PBL-based curriculum was developed andimplemented in a new school, allowing the innova-tors a free rein unlikely to occur when the traditionalcurriculum of an existent school is being convertedto PBL.

The process of changing a traditional dental/medical curriculum to PBL cannot be taken lightly,28-30

since the changes involved are not a simple “tweak-ing” of existing courses or blocks. Rather, the con-version involves the total transformation of the so-cial and academic structure of the school in a mannerlikely to engender both skepticism and hostilityamong some faculty. These problems have been ad-dressed by Abrahamson.31 Experiences at Harvardand at the University of Hawaii have been recordedby Moore22 and Anderson.32 One approach to the in-troduction of a PBL curriculum is the initial intro-duction of a “pilot” program,33 or “parallel track”program, as was initiated at University of SouthernCalifornia1-2 in 1995. The introduction of a PBL peda-gogy requires the completion of several essentialevents to prepare both the dental faculty and theschool facility for the optimal environment for thepedagogy.

Faculty Development

Among the many changes required to converta traditional dental education curriculum to PBL,none is more important than that of faculty develop-ment. In a PBL curriculum, the role of the facultymember is changed so radically that a high degree ofdiscomfort, if not direct opposition, must be expected.It becomes critical for the innovators to work togetherwith “traditional” faculty to develop a collective un-derstanding of the philosophy of the PBL pedagogyand its relationship to cognitive psychology prin-ciples. Further, faculty have to be helped to adaptfrom their traditional roles of “teacher/instructor” tothat of a “facilitator” of learning for student groups.For some, such a change in professional role andbehavior may prove to be unacceptable; but manywill come to find their involvement in the moreclosely personal role of group facilitator rewarding.In a PBL curriculum, the faculty facilitator worksdirectly with the group to explore the problem, ex-tract the relevant facts, generate hypotheses and, fi-nally, identify the learning needs the students willneed to research in order to better evaluate their hy-

potheses. In all of this, the facilitator does not act asa teacher or as a “content expert,” but seeks to helpthe group work with the problem (“case”) to gainmaximum benefit from their learning. This is a de-manding new role for many faculty and will requireboth prior learning, sensitization, and practice be-fore the satisfaction of proficiency will be achieved.A variety of published guides, courses, and on-line re-sources exist to assist in this development process, 43-48

but hands-on guidance from local experienced fa-cilitators and educators is likely to be needed.

The training and development of a cadre of ef-fective PBL facilitators (called “Tutors”) is a criticalstep in any implementation of PBL. Generally, onlya few faculty are likely to have well-developed fa-cilitator skills and experience. Our experience at USChas shown that initially the majority of novice facili-tators will adopt one of two patterns: either becom-ing essentially mute, having a minimal involvementin the activities of the group beyond supplying thenecessary problem documents, or adopting a highlydirective role in which they seek to control all as-pects of the groups’ work and push the student grouptowards specific learning objectives. This latter be-havior pattern is especially prevalent in faculty whomay have content expertise in an aspect of the sub-ject matter of the problem.49-54 It is, however, usefulto reflect that, in a fully implemented PBL curricu-lum, the scope of the student-generated learning aris-ing from any particular “case,” will often exceed the“expert knowledge” of the facilitator. Observationof sessions with experienced facilitators and subse-quent discussion is a critical learning experience thatneeds to be followed by peer mentoring when newfacilitators begin their first case. Systems can bedeveloped to videotape and observe small group ses-sions and provide data that can be used to improveboth facilitation skills and group dynamics.

Faculty academic and professional expertisealso becomes a critical resource for student accom-plishment. The ability of faculty experts to bring to-gether lines of thought and integrate critical infor-mation is a vital resource for any PBL curriculum,which emphasizes a future role for current expertfaculty.

Physical Resources—Space

A further and potentially costly issue in con-version to PBL is the need to modify existing spaceto meet the needs of PBL student groups. Effective


PBL groups comprise from five to eight studentsworking with a faculty facilitator. Thus, a PBL cur-riculum requires that a suitable number of smallerrooms are available to accommodate these groupsthat are at the heart of the PBL process. While tradi-tional dental and medical school buildings usuallyhave available a selection of “seminar” rooms, it islikely that these alone will be inadequate to meet theneeds of a fully integrated PBL curriculum. Mostschools have large lecture theaters that are appropri-ate for large group presentations but not of great util-ity for most aspects of a PBL curriculum. Structuralmodifications are likely to be required, probably atthe expense of lecture theatre space. The small roomsIalso need internet connections and equipment to sup-port the activities both of the group process and thestudent learning needs completion.

Learning Resources—Libraries

A critical item in an effective transition to adental PBL curriculum, is the availability of “learn-ing resources” appropriate for the student researcharising from PBL cases. As noted above, in the ear-lier stages of the curriculum there is likely to be anemphasis on learning biomedical sciences; depend-ing on class size, this may put stress on the moretraditional dental school library resources. If studentshave ready access to a medical school library, thenthis difficulty can be, at least partially, ameliorated.However, it is a general observation that PBL stu-dents will make far greater demands on library re-sources than their traditional peers, so it becomesimportant to involve the librarians in the conversionto the PBL curriculum.55-57 Beyond the library re-sources, thought needs to be given to the accessibil-ity to computer (Internet) resources, clinical simula-tors, etc., for the demands on those resources maychange with curricular conversion.

Assessment in a Dental PBLProgram

In a problem-based learning curriculum, assess-ments are used in two ways. One is to inform stu-dents of their progress, so that they can practice self-directed learning more effectively. The other is to testthe students’ progress in the acquisition and assimi-lation of knowledge and skills. However, in the earlystages of the program it is useful to also assess thestudents’ abilities in the PBL process. The methods

of assessment are critical for the reinforcement ofprogram objectives. If the methods of student assess-ment do not mirror stated program objectives, thestudents will eventually make “strategic” learningdecisions that address the assessment methods theyencounter. In PBL, it becomes critical to developassessment methods that measure student achieve-ment in the process of problem dissection, identifi-cation of learning objectives, and development ofcritical thinking skills. As students achieve theseoutcomes, the assessment methods need to reflectthe application of these skills in problem-solving situ-ations, so that the development of the desired educa-tional objectives can be measured. Subjective as-sessments can be made on a continuous basis byfaculty group facilitators and through self- and peerassessments at the end of each case. A further sub-jective assessment instrument is the “Triple Jump”exercise,58 in which students are required to workthrough a problem case individully, and assessmentis based on their self-directed learning skills. Boththe group evaluations and the triple jumps measurethe development of students’ critical thinking skillsand application of the learning process. Beyond theseassessments of the PBL process, more traditionalobjective outcome-oriented assessments may includeproblem-solving exercises, multiple-choice tests toassess levels of factual recall, objective structuredclinical examinations (OSCE), and clinical compe-tency assessments. Reviews of assessment methodsin a PBL curriculum have been provided by O’Neill,59

Swanson et al.,60 Sullivan,61 and Chaves et al.62 Allof the assessment methods used need to be integrated,so that all of the educational objectives are achievedby specific outcome measures.

Outcomes and the WayForward

Outcomes data for educational programs maybe thought of under several headings, such as clini-cal competency, performance in national or local pro-fessional examinations, and long-range behavioralcharacteristics of the graduates. Blake et al.,63 pro-vide a discussion of the twenty-five-year experiencein student evaluation methods at McMaster HealthSciences, and while concluding that “Problem-basedlearning in small groups have (sic) stood the test oftime,” they also acknowledge that “We have not yetarrived at a perfect system.”


In an earlier study of PBL outcomes at nine-teen institutions, Vernon and Blake64 conclude that“results support the superiority of the PBL approachover more traditional methods.” These reports relateto medical education, but when we turn to dentaleducation the record is mostly too new to derive broaddata on outcomes, comparable to those from medi-cine. The dental school at Malmö has graduated fiveclasses of students (200 graduates) and appears sat-isfied with the outcomes observed.8 Others65-70 havereported and discussed outcomes from PBL programsand courses. Greenwood et al.,71 compared the per-ceptions of competency of dental graduates from atraditional curriculum to those graduating from aPBL curriculum and concluded that the self-per-ceived levels of competence were comparable. Seek-ing an independent objective external assessmentinstrument, we reported2 on the results obtained bythe first class of USCSD PBL-track students (n=12)on the Part I National Dental Board Examination anddemonstrated a significantly superior performanceof the PBL students, at all subject levels, as com-pared both with their peers in the USCSD traditionaltrack and with national means. It is noteworthy thatthis was achieved by dental students working in afully implemented “authentic”4 PBL program inwhich learning occurred almost solely through themedium of scheduled biomedical/biodental casesimulations. Some preparation for the board exami-nations is undoubtedly obtained through the ongo-ing (twice per semester) objective multiple choicequestion (MCQ) assessments that examine recall ofmaterial related to the PBL cases. At USC, these as-sessments usually employ “board-type” questions.Further, as noted previously2,42 a demographic com-parison of the USC PBL-track students and theirpeers in the traditional track showed no significantdifferences between the two groups.2

At USC, forty-eight students in the PBL track(Classes of 1999 to 2002) have now sat the NationalDental Boards Part I examination. An analysis of thescores obtained by these students, as compared withthose obtained by their peers in the USC traditionaltrack (481 students), shows that the mean averagescore of PBL students is 88.7 as compared to a meanaverage of 83.4 for the traditional students. An inde-pendent t-test shows that the mean difference betweenthese two groups of students is statistically signifi-cant (t=-6.5, p=.000). Further, this significant dif-ference is also shown in all the mean scores for allfour of the sub-tests of the Part I board examination

(Anatomical Sciences, Biochemistry/Physiology, Mi-crobiology/Pathology, and Dental Anatomy). Basedupon this experience, we conclude that dental stu-dents working in an authentic PBL program, in whichthere are no scheduled lecture presentations, exhib-ited a high level of achievement in a standardizedexternal assessment (National Dental Boards, PartI) that was equal, if not superior to the majority ofU.S. dental school students working in a traditionallecture-based didactic curriculum.2,75

In conclusion, we summarize our findings asfollows:• PBL has been implemented in dental schools

worldwide over the past decade, and this trend ap-pears to be increasing.

• Dental schools considering moving to PBL shouldbe mindful of the changes required in physicalplant and infrastructure and of the implicationsfor faculty development, new curriculum materi-als, and student admissions procedures.

• Experience with the USC parallel-track PBL pro-gram has demonstrated the feasibility of imple-menting a PBL pedagogy across all years of thecurriculum, fully integrating basic and clinical sci-ence learning.

• Student achievement at the level of scores in theU.S. National Dental Boards (Part I) has beenfound to be significantly higher for USC PBL stu-dents as compared to either their peers in a tradi-tional curriculum or to national means.

AcknowledgmentsWe are grateful to all of our many colleagues

at the USC School of Dentistry, both faculty and staff,who have supported and worked to make the PBLtrack program a success, and to all of the studentswithout whom the program would not exist. We alsothank the past deans, Dr. H.M. Landesman and Dr.G. Vale, and Dean H.C. Slavkin for their enthusias-tic support throughout the six formative years of theprogram.

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Changing Dental PBL