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Keywords:

  • problem-based learning;
  • dental graduate;
  • competency;
  • dental practice

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Objectives:  To determine how prepared for dental practice graduates from the integrated problem-based learning (PBL) dental undergraduate curriculum at The University of Hong Kong (HKU) perceive themselves to be and to identify factors associated with self-perceived preparedness.

Materials and methods:  A postal questionnaire was sent to five cohorts of dentists who had graduated from HKU’s integrated PBL curriculum between 2004 and 2008. Using a 4-point Likert scale, the questionnaire assessed the self-perceived level of preparedness in 59 competencies grouped in nine domains. Responses were dichotomised into ‘poorly prepared’ and ‘well prepared’.

Results:  The response rate was 66% (159/241). The mean proportion (± standard deviation) of respondents indicating well-preparedness was 72.0 ± 15.1% overall, and for each domain was as follows: general patient management, 93.1 ± 12.1%; practice management, 81.0 ± 22.2%; periodontology and dental public health, 73.5 ± 19.3%; conservative dentistry, 92.5 ± 13.1%; oral rehabilitation, 62.8 ± 24.0%; orthodontics, 23.0 ± 32.9%; managing children and special-needs patients, 64.8 ± 28.9%; oral and maxillofacial surgery, 52.2 ± 25.2%; and drug and emergency management, 84.7 ± 22.6%. The odds of self-perceived well-preparedness were increased for cohorts graduating in 2004 and 2005 and graduates working in a non-solo dental practice.

Conclusions:  Dental graduates of HKU’s integrated PBL curriculum felt well prepared for the most fundamental aspects of dental practice. However, apparent deficiencies of training in orthodontics and oral and maxillofacial surgery will need to be addressed by continuing education, postgraduate training and planning for the new 6-year undergraduate curriculum in 2012.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

The first two Bachelor of Dental Surgery (BDS) programmes at the Faculty of Dentistry, The University of Hong Kong (HKU), followed a traditional lecture-based and teacher-led curriculum that had very limited integration between the different disciplines. Following a faculty review in 1996, the decision was made to change the existing curriculum to a student-centred, fully integrated problem-based learning (PBL) curriculum. The new curriculum allowed both horizontal and vertical integration across the various disciplines to promote collaborative and interactive learning.

The integrated PBL curriculum was first implemented in 1998, with the explicit aims of producing well-rounded, competent and caring dental practitioners who are able to think independently and critically, respond quickly and appropriately to patients with complex problems, adapt to future changes occurring in dentistry and remain contemporary in their skills and knowledge. The new curriculum also encourages students to take responsibility for their own learning so that they become independent, self-directed life-long learners. The first class of students graduated from this programme in 2003. Currently, there are approximately 380 graduates from the integrated PBL curriculum working in dental practice.

When evaluating the success of any dental education programme, it is important to ensure that the goals of the curriculum have been achieved. Several stakeholders at a number of different levels, such as alumni, academic staff, employers and, ultimately, patients, are needed to provide a more global perspective on the entire curriculum (1). Alumni can provide significant information on the strengths and weaknesses of the curriculum that they received (2–10). Teacher-based performance assessment is a useful method to evaluate the overall clinical skills expected of the graduating students (11). Standardised patients have been used to evaluate the communication and clinical skills of the graduates (12). Employers further assess the competency of the graduates in a clinical practice (13–15).

In a previous survey by McGrath and Corbet (7), five cohorts of dental graduates (1997—2001) from the previous curriculum were assessed on how well prepared they perceived themselves to be for dental practice. The results showed that graduates generally felt well prepared for dental practice; however, there were several aspects of dental practice for which they reported feeling ill-prepared. That study provided some important feedback on graduates’ perceptions of preparedness, albeit from the previous curriculum, and has informed the continual development of the BDS curriculum.

In response to the educational reforms approved by the Government of the Hong Kong Special Administrative Region, the new secondary school curriculum across Hong Kong will be shortened from 7 to 6 years and the normative length of the undergraduate university curriculum will be expanded from 3 to 4 years in 2012. For Dentistry, the new curriculum will be extended from 5 to 6 years. Information on the perceived preparedness for practice of BDS graduates from the existing 5-year integrated PBL curriculum is essential during the planning of the new 6-year curriculum. Thus, this study aimed at determining how prepared BDS graduates of HKU’s integrated PBL curriculum (2004—2008) perceived themselves to be for dental practice and to identify factors associated with self-perceived preparedness.

Materials and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Study population

All 241 BDS graduates qualified from the HKU’s Faculty of Dentistry from 2004 to 2008 were invited by mail to participate in this study. Current addresses were obtained from membership records of the HKU Dental Alumni Association or, for non-members, from the List of Registered Dentists in the website of the Hong Kong Dental Council (http://www.dchk.org.hk). Graduates were sent a survey pack containing a cover letter explaining the purpose of the project and assuring the confidentiality of the information collected, an anonymous questionnaire and a stamped addressed return envelope. No financial incentive was offered. Each pack was assigned a number to trace non-respondents. The packs were mailed in July 2009; a second pack and a third pack were mailed to non-respondents in August and September 2009, respectively.

Questionnaire

The self-administered postal questionnaire used in this study contained three sections. The first section included questions about each dentist’s personal characteristics and practice details, and the third provided an opportunity for open-ended feedback about the BDS programme. The second section required respondents to rate self-perceived preparedness for dental practice on a 4-point Likert scale (very well = 4, well = 3, poorly = 2 and very poorly = 1) and was based on an instrument developed by Greenwood et al. (4) to assess self-perceived competency of dental graduates. The section was headed ‘The objective of this section is to evaluate how well prepared you are at performing the following’, followed by a list of 59 items (competencies). This battery of 59 items has been used in previous graduate questionnaires in Australia (3), Canada (4) and Hong Kong (7). Similar to the previous Hong Kong study, items were grouped into nine aspects (domains) of dental practice: ‘general patient management’, ‘practice management’, ‘periodontology and dental public heath’, ‘conservative dentistry’, ‘oral rehabilitation’, ‘orthodontics’, ‘managing children and special-needs patients’, ‘oral and maxillofacial surgery’, and ‘drug and emergency management’.

Data analysis

The data were analysed using the Statistical Package for the Social Sciences (Windows version 16.0, SPSS Inc., Chicago, IL, USA). Internal reliability of the instrument was determined by assessing its Cronbach’s alpha value. The responses to items within the nine domains of dental practice were tabulated as frequency distributions for the 4 ratings. Ratings were then dichotomised into ‘well prepared’ (3 and 4) and ‘poorly prepared’ (1 and 2), and proportions of respondents who were classified as being well prepared were averaged over the number of items in each domain to obtain domain ‘well-preparedness’ levels, following the method of Razak et al. (15). In addition, respondents’ scores were summed for all 59 items to obtain global preparedness scores. Because these scores approximated to a normal distribution, according to the Kolmogorov–Smirnov/Shapiro–Wilk test, the 4-point Likert scale was regraded (very well = 3, well = 2, poorly = 1 and very poorly = 0) and summary statistics of mean and standard deviation (SD) of revised global preparedness scores were determined. Bivariate analysis (analysis of variance; ANOVA) was then undertaken to test the association of the mean global preparedness score with the following independent factors: sex, year of graduation, work in different types of practice since graduation, whether the current practice was solo and whether any postgraduate courses had been pursued. The cut-off level of significance was liberal, at P < 0.10, to identify variables that could be entered into the logistic regression model. For the logistic regression analysis, the dependent variable of self-perceived preparedness was a respondent’s global preparedness score dichotomised as ‘well prepared’ if it was at or above the first quintile and “poorly prepared” if it was below this level. P-values were considered statistically significant at P < 0.05.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Response rate and profile of participants

After the first mailing, two (1%) of the 241 questionnaires were post-returned because of invalid addresses and 60 questionnaires were returned by respondents. After the second and third mailings, 55 and 44 questionnaires, respectively, were returned. Within the project period, a total of 159 sets of replies were received, corresponding to an overall response rate of 66%. The response rate by graduation year was 67% (30/45) for 2008, 70% (33/47) for 2007, 71% (35/49) for 2006, 63% (32/51) for 2005 and 59% (29/49) for 2004.

The mean age of the 159 respondents was 27.3 ± 2.0. There were slightly more men than women (55% vs. 45%), and respondents were most commonly associates in private practice (53%), followed by government dentists (21%) (Table 1). Almost one-third (29%) had changed their working environment since qualification, and about two-fifths (42%) were currently engaged in solo (one-chair) practice. The majority (79%) of graduates had pursued postgraduate study, with more than half (58%) having attended short courses for continuing professional development. The mean domain well-preparedness level was 72.0 ± 15.1%, and the mean global preparedness score (out of 177) was 104.6 ± 18.2. The Cronbach’s alpha value (internal reliability) for the scale was 0.95 and ranged from 0.70 (oral rehabilitation) to 0.89 (orthodontics) amongst the domains. The well-preparedness level for each of the nine domains was as follows: general patient management, 93.1 ± 12.1%; practice management, 81.0 ± 22.2%; periodontology and dental public health, 73.5 ± 19.3%; conservative dentistry, 92.5 ± 13.1%; oral rehabilitation, 62.8 ± 24.0%; orthodontics, 23.0 ± 32.9%; managing children and special-needs patients, 64.8 ± 28.9%; oral and maxillofacial surgery, 52.2 ± 25.2%; and drug and emergency management, 84.7 ± 22.6% (Fig. 1).

Table 1.   Characteristics of HKU dental graduates (2004—2008)
CharacteristicNumber (%)
Sex
 Male87 (55)
 Female72 (45)
Year of graduation
 200429 (18)
 200532 (20)
 200635 (22)
 200733 (21)
 200830 (19)
Type of current dental practice
 Associate86 (53)
 Partnership3 (2)
 Principal8 (5)
 Postgraduate training8 (5)
 University3 (2)
 Public hospital8 (5)
 Private hospital1 (1)
 Government33 (21)
 Other9 (6)
Worked in different types of practice
 No113 (71)
 Yes46 (29)
Nature of current practice
 Non-Solo92 (58)
 Solo67 (42)
Attended postgraduate dental course
 None33 (21)
 Short course for continuing professional development92 (58)
 Other short course5 (3)
 HKU MDS/diploma course20 (13)
 Other Master/diploma course2 (1)
 Royal College Fellowship course5 (3)
 Other2 (1)
image

Figure 1.  Domain well-preparedness levels for HKU dental graduates (2004—2008).

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Perceived preparedness for general patient management

Most graduates (93%, n = 148) felt well prepared in the domain of general patient management (Fig. 1). Nearly all perceived themselves to be well prepared to identify and address a patient’s chief complaint (99%, n = 157), to take and interpret a patient’s medical, social and dental history (98%, n = 156), to discuss treatment plans and obtain informed consent (97%, n = 154), to communicate effectively with patients (96%, n = 153), to interpret test results and patient histories to make a diagnosis (96%, n = 153) and to develop a sequential treatment plan (91%, n = 144). However, almost a quarter (24%, n = 39) of graduates reported that they were poorly prepared to discuss fees and payment options with patients (Table 2).

Table 2.   Self-perceived preparedness for dental practice, by competency, amongst HKU dental graduates (2004—2008)
Domains and competenciesVery wellWellPoorlyVery poorly
  1. Data are expressed as number (%); percentages may not total 100% because of rounding.

General patient management
 Take and interpret medical, social and dental history22 (14)134 (84)2 (1)1 (1)
 Communicate effectively with patients29 (18)124 (78)6 (4)0 (0)
 Discuss treatment plans and get informed consent30 (19)124 (78)5 (3)0 (0)
 Discuss fees and payment options with patients18 (11)102 (64)37 (23)2 (1)
 Develop a sequential treatment plan20 (13)124 (78)15 (9)0 (0)
 Interpret tests and history to make a diagnosis15 (9)138 (87)6 (4)0 (0)
 Identify and address patients’ chief complaints28 (18)129 (81)2 (1)0 (0)
Practice management
 Maintain accurate confidential patient records36 (23)114 (72)9 (6)0 (0)
 Communicate effectively with practice staff23 (14)129 (81)7 (4)0 (0)
 Communicate effectively with colleagues27 (17)127 (80)5 (3)0 (0)
 Manage dental staff11 (7)108 (68)38 (24)2 (1)
 Deal with finances of your clinic2 (1)86 (54)62 (39)9 (6)
 Select and monitor infection control procedures19 (12)104 (65)32 (20)4 (3)
 Prevent dental workplace hazards13 (8)115 (72)29 (18)2 (1)
 Write laboratory prescriptions and evaluate laboratory work23 (14)124 (78)12 (8)0 (0)
 Critically evaluate dental literature to inform dental practice and policy8 (5)105 (66)42 (26)4 (3)
 Apply evidence-based dentistry13 (8)101 (64)39 (25)6 (4)
Periodontology and dental public health
 Treat early periodontal disease45 (28)108 (68)6 (4)0 (0)
 Perform deep scaling and root planing30 (19)118 (74)10 (6)1 (1)
 Perform periodontal surgery for pocket management10 (6)52 (33)70 (44)27 (17)
 Perform periodontal surgery for crown lengthening8 (5)28 (18)87 (55)36 (23)
 Perform oral hygiene instruction and diet analysis46 (29)105 (66)7 (4)1 (1)
 Provide and monitor preventive treatment44 (28)107 (67)8 (5)0 (0)
Conservative dentistry
 Restore teeth with amalgam restorations56 (35)101 (64)2 (1)0 (0)
 Restore teeth with resin composite restorations40 (25)113 (71)6 (4)0 (0)
 Perform root surface restorations41 (26)107 (67)11 (7)0 (0)
 Perform single-root canal treatment56 (35)101 (64)2 (1)0 (0)
 Perform multi-root canal treatment14 (9)101 (64)44 (28)0 (0)
 Restore teeth with single crowns48 (30)109 (69)2 (1)0 (0)
 Restore teeth with post-and-core crowns24 (15)118 (74)16 (10)1 (1)
Oral rehabilitation
 Replace teeth with partial dentures29 (18)125 (79)5 (3)0 (0)
 Replace teeth with complete dentures6 (4)85 (53)53 (33)15 (9)
 Replace teeth with implants (prosthetics)3 (2)46 (29)51 (32)59 (37)
 Replace teeth with conventional bridges16 (10)115 (72)26 (16)2 (1)
 Replace teeth with resin-bonded bridges16 (10)105 (66)33 (21)5 (3)
 Re-establish an occlusal vertical dimension3 (2)50 (31)74 (47)32 (20)
Orthodontics
 Perform orthodontic treatment planning2 (1)36 (23)74 (47)47 (30)
 Perform space maintenance/regaining2 (1)51 (32)66 (42)40 (25)
 Perform minor tooth movement5 (3)31 (19)67 (42)56 (35)
 Perform full-arch alignment3 (2)16 (10)60 (38)80 (50)
Managing children and special-needs patients
 Manage anxious dental patients6 (4)100 (63)48 (30)5 (3)
 Manage child patients13 (8)101 (64)41 (26)4 (3)
 Manage elderly patients11 (7)134 (84)13 (8)1 (1)
 Manage medically compromised patients5 (3)111 (70)37 (23)6 (4)
 Manage mentally or physically disabled patients5 (3)79 (50)61 (38)14 (9)
 Recognise, report and follow up neglect and abuse cases2 (1)51 (32)83 (52)23 (14)
Oral and maxillofacial surgery
 Manage acute pain/infection18 (11)128 (81)12 (8)1 (1)
 Perform simple extraction54 (34)101 (64)4 (3)0 (0)
 Extract impacted third molars12 (8)86 (54)56 (35)5 (3)
 Manage complications of oral surgery5 (3)87 (55)58 (36)9 (6)
 Manage chronic orofacial pain2 (1)49 (31)85 (53)23 (14)
 Identify and manage oral pathology2 (1)55 (35)87 (55)15 (9)
 Perform soft-tissue biopsies3 (2)26 (16)67 (42)63 (40)
 Manage trauma to dentofacial complex2 (1)34 (21)82 (52)41 (26)
Drug and emergency management
 Administer local anaesthetics (LA)62 (39)97 (61)0 (0)0 (0)
 Prescribe drugs30 (19)121 (76)8 (5)0 (0)
 Prevent and manage LA complications20 (13)118 (74)20 (13)1 (1)
 Manage medical emergencies6 (4)93 (58)52 (33)8 (5)
 Prevent and manage dental emergencies10 (6)116 (73)30 (19)3 (2)

Perceived preparedness for practice management

The majority of the respondents (81%, n = 129) felt well prepared in the domain of practice management. Most graduates felt well prepared to communicate effectively with colleagues (97%, n = 154) and practice staff (95%, n = 152), to maintain accurate confidential patient records (95%, n = 150), to write laboratory prescriptions and evaluate laboratory work (92%, n = 147) and to prevent dental workplace hazards (80%, n = 128). A quarter or more felt they were poorly prepared to evaluate dental literature to inform their dental practice and policy (29%, n = 46), to apply evidence-based dentistry (29%, n = 45), to manage dental staff (25%, n = 40) and to select and monitor infection control procedures (23%, n = 36). Forty-five per cent (n = 71) reported that they were poorly prepared to deal with the finances of their clinic.

Perceived preparedness for periodontology and dental public health

About three-quarters of respondents (73%, n = 117) said they were well prepared in the domain of periodontology and dental public health. Nearly all claimed that they were well prepared to treat early periodontal disease (96%, n = 153), to perform oral hygiene instruction and diet analysis (95%, n = 151), to provide and monitor preventive treatment (95%, n = 151) and to perform deep scaling and root planing (93%, n = 148). Nevertheless, sizeable proportions felt that they were poorly prepared in periodontal surgery for pocket management (61%, n = 99) and crown lengthening (78%, n = 123).

Perceived preparedness for conservative dentistry

Most graduates (92%, n = 147) felt well prepared in the domain of conservative dentistry. The majority felt well prepared to restore teeth with amalgam restorations (99%, n = 157), resin composite restorations (96%, n = 153) or root surface restorations (93%, n = 148), to perform single-root canal treatment (99%, n = 157) and to restore teeth with single crowns (99%, n = 157) or post-and-core crowns (89%, n = 142). Nonetheless, 28% (n = 44) felt poorly prepared for multi-root endodontics.

Perceived preparedness for oral rehabilitation

Approximately two-thirds of graduates (63%, n = 100) claimed that they were well prepared in the domain of oral rehabilitation. Although most said they were well prepared to replace teeth with partial dentures (97%, n = 154) and conventional bridges (82%, n = 131), about two-fifths (42%, n = 68) felt poorly prepared to apply complete dentures and about a quarter (24%, n = 38) felt poorly prepared to apply resin-bonded bridges. In addition, roughly two-thirds felt poorly prepared to restore an occlusal vertical dimension (67%, n = 106) and to replace teeth with implants (69%, n = 110).

Perceived preparedness for orthodontics

Only 23% (n = 37) of respondents felt well prepared in the domain of orthodontics. Graduates commonly claimed that they were poorly prepared to perform full-arch alignment (88%, n = 140), orthodontic treatment planning (77%, n = 121) and minor tooth movement (77%, n = 123). Only one-third (33%, n = 53) felt well prepared to perform space maintenance to prevent malocclusion.

Perceived preparedness for managing children and special-needs patients

Nearly two-thirds of graduates (65%, n = 103) felt that they were well prepared to manage children and special-needs patients. Whilst most respondents felt well prepared to deal with elderly patients (91%, n = 145), some did not feel well prepared to treat children (29%, n = 45), medically compromised patients (27%, n = 43) or anxious patients (33%, n = 53). Almost one half (47%, n = 75) said they were poorly prepared to treat mentally or physically disabled patients, and nearly two-thirds (66%, n = 106) said they were poorly prepared to recognise, report and follow up cases of neglect and abuse.

Perceived preparedness for oral and maxillofacial surgery

More than half of the graduates (52%, n = 83) felt well prepared in the domain of oral and maxillofacial surgery. Most graduates felt well prepared to perform simple extractions (98%, n = 155) and manage acute pain or infection (92%, n = 146). About three-fifths felt well prepared to perform surgery on impacted third molars (62%, n = 98) and in managing complications of oral surgery (58%, n = 92). However, about two-thirds of the graduates felt poorly prepared to manage chronic orofacial pain (67%, n = 108) and to identify and manage oral pathology (64%, n = 102). About four-fifths claimed that they were poorly prepared to perform soft-tissue biopsies (82%, n = 130) and to manage trauma to the dentofacial complex (78%, n = 123).

Perceived preparedness for drug and emergency management

Most respondents (85%, n = 135) reported that they were well prepared in the domain of prescribing drugs and treating patients with medical or dental emergencies. All felt well prepared in administering local anaesthetics; however, 14% (n = 21) felt poorly prepared at preventing and managing associated complications. Most graduates felt well prepared to prescribe drugs (95%, n = 151), but nearly two-fifths (38%, n = 60) claimed that they were poorly prepared to manage patients with medical emergencies and about one-fifth (21%, n = 33) said they were poorly prepared to deal with dental emergencies.

Factors associated with preparedness for practice

Bivariate analysis revealed a significant association of overall self-perceived preparedness for dental practice with the year of graduation (P = 0.009) and whether a practice was solo (P = 0.075). No significant association was found with respondents’ sex, nature of practice, work experience in different types of practice and attendance at postgraduate dental courses (Table 3). Logistic regression analysis confirmed that graduation year and nature of practice were independent predictors of self-perceived preparedness (Table 4). The odds of feeling well prepared were lower for dentists in a solo practice than those in non-solo practice (P = 0.015) and higher for the 2004 and 2005 cohorts than those in the 2008 cohort (P = 0.04 and 0.02, respectively).

Table 3.   Association between graduates’ self-perceived preparedness for dental practice and selected characteristics
VariableMean global preparedness scoreSD P value
  1. *P < 0.10, ANOVA.

Sex
 Male104.172.24 
 Female102.172.490.485
Year of graduation
 2004112.563.66 
 2005105.423.57 
 200698.543.23 
 2007102.23.33 
 200897.133.300.009*
Worked in different types of practice
 No103.262.96 
 Yes103.081.910.954
Solo practice
 No105.852.39 
 Yes100.492.430.075*
Attended any postgraduate dental course
 No100.913.24 
 Yes105.431.690.203
Table 4.   Final logistic regression model showing association of feeling well prepared for dental practice with year of graduation and type of practice
VariableOdds ratioSELower 95% CIUpper 95% CI P value
  1. *P < 0.05.

Year of graduation
 20044.562.091.0819.260.04*
 20054.681.941.2817.140.02*
 20063.341.880.9811.470.06
 20072.201.860.667.380.20
 20081 (ref)    
Nature of practice
 Solo0.331.580.140.810.015*
 Non-solo1 (ref)    

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Although the initial response rate was quite low, at 25%, the response rate after second and third mailings increased to 66%, which was comparable to response rates of similar surveys on dental graduates (4, 5, 8, 9, 15). Overall, dentists responding to the survey seemed well prepared in dental practice: the mean domain well-preparedness level of 70% would be classed by Razak et al. (15) as ‘excellent’, and the mean global preparedness score of 104.6 out of 177 is above the first quintile (90/177), which was taken as the cut-off for well-preparedness in the logistic regression analysis. The differing levels of subjectivity of responses must be noted as a limitation, however, together with the assumption that all items and domains were equally weighted and the fact that the questionnaire did not specifically ask respondents to attribute preparedness to the BDS programme or to provide perceptions of preparedness retrospectively as if they had just graduated.

We adopted a survey method that allowed for some work experience after graduation, instead of relying on immediate post-course feedback, which would have been affected by students giving desirable answers, lacking confidence before entering the workforce or securing a job, or awaiting degree results. Still, because we performed a cross-sectional survey across five cohorts for practicality, rather than annual surveys at a fixed time after graduation, responses may have been affected by differing interpretations of the questionnaire owing to time since graduation, length and nature of work experience, and nature of current practice or specialisation. Indeed, the odds of feeling well prepared for practice were increased for dentists in a non-solo practice and for cohorts graduating in 2004 and 2005 (Table 4). Although postgraduate education was not associated with preparedness overall, earlier graduates would be expected to be more experienced than later graduates through clinical practice, postgraduate courses and continuing education such as journal reading; their knowledge and ability, and hence self-confidence, would have thus improved over time. Similarly, graduates from group practices would be able to rely on more experienced dental practitioners or specialists for guidance to enhance clinical and administrative skills, thereby increasing their self-perceived preparedness for practice.

In assessing self-perceived competency for dental practice, an instrument developed by Greenwood et al. (4) was used to facilitate comparison with other studies (3, 4, 7). Graduates from a PBL curriculum are equipped with self-assessment skills that enable them to progress rapidly towards a goal. The capacity to self-assess is essential for reflective practice and is a foundation for providing quality care. However, in a recent systematic review on accuracy of physician self-assessment, the physicians were found to have limited ability to accurately self-assess with little or no associations between physicians’ self-rated assessment with external assessment (16). Peer assessment of surgical skill was shown to be more reliable than self-assessment when compared with assessment by a trainer (17). Surveying the employers, in addition to the graduates, may provide another different perspective in assessing how effective the integrated PBL curriculum has been in preparing the dentist for their dental careers.

General patient management

About a quarter of the graduates felt poorly prepared to discuss fees and payment options with patients. This was also an area of perceived lack of competence amongst Australian (3, 4), Canadian (4) and Trinidad graduates (8). Recent integration of workshops on communication skills and motivational interviewing into the BDS curriculum should improve patient–dentist communication.

Practice management

About a quarter of graduates felt poorly prepared at critically evaluating dental literature to inform dental practice and policy, and 29% were not confident to apply evidence-based dentistry. These figures are disappointing because much emphasis has been placed on these skills in the new curriculum. With the rapid growth in scientific and technological developments pertinent to dental care, it is important for dentists to practise evidence-based dentistry. In fact, the replacement of much of PBL with journal-based learning in the final year of the BDS curriculum in 2009 was designed to improve graduates’ skills in critical appraisal of the literature to respond to clinical problems.

Similar to dental graduates in Australia (3), Canada (4), UK (14), US (18) and France (2), sizeable proportions of HKU graduates feel inadequately prepared in the business side of practice management, such as staff and finance management. Although a multi-session dental practice workshop is given in the final year of the BDS curriculum, students do not have actual hands-on experience with administrative and financial management. Development of postgraduate practice management courses by faculty members and regular opportunities for graduates to share experiences with practitioners who have both business and dental practice backgrounds may enhance preparedness for management aspects.

Periodontology and dental public health

Similar to Canadian graduates, HKU graduates seem to perceive several areas of surgical periodontics as being difficult (3). This is not surprising because advanced periodontal surgery for pocket removal and crown lengthening are mostly undertaken by specialists in periodontology in Hong Kong. Students in the PBL curriculum are not offered first-hand clinical experience in periodontal surgery, although they do practise these procedures in the simulation laboratory on models.

Conservative dentistry

A smaller proportion (72%) of graduates felt confident in performing root canal therapy in multi-rooted teeth. This procedure also seems to be commonly problematic for vocational training practitioners in the UK, with 47% (13) and 69% (14) of UK graduates expressing a lack of preparedness for complex or molar endodontics. Because prevention in general has contributed to a desire to preserve teeth worldwide, reflected by an increased service demand for endodontic treatment, it is important that dentists are well prepared to deal with such demands through continuing professional development.

Oral rehabilitation

Graduates felt more confident in replacing missing teeth with partial removable prostheses (97%) than with conventional bridges (82%) and resin-bonded bridges (76%). These findings are similar to those from the UK, where graduates surveyed said they had insufficient experience in bridgework (5). One explanation for our findings may be that the course on removable partial dentures in our dental school is conducted in the third year of the BDS curriculum, whereas the course in resin-bonded and conventional bridges is conducted in the fourth year; hence, students’ exposure to design and clinical training in dentures is greater than that in resin-bonded and conventional bridges. Moreover, there is increasing difficulty in finding sufficient patients for students to gain experience in conventional bridges, because most clinical rehabilitation cases are now managed by resin-bonded prostheses.

Graduates felt more competent in replacing missing teeth with partial dentures (97%) than with complete dentures (57%). This difference is likely to be mainly attributable to the small number of complete denture cases encountered in the final year of study, when this topic is taught. There has also been a gradual decline in the rate of edentulism amongst 66- to 74-year-olds living in Hong Kong, from 12% in 1991 to 8.6% in 2001 (19). Furthermore, in our experience, the majority of edentulous individuals say they are satisfied with their well-functioning complete dentures and show little interest in implant treatment because of its high cost and the fear of surgical risk. Nevertheless, the teaching of complete denture prosthodontics will need to continue at undergraduate level to maintain the needed level of competency (20).

Restoring an occlusal vertical dimension for partially or totally edentulous patients was the area in which respondents perceived themselves to be least prepared within this domain. Full-mouth rehabilitation for a patient usually requires advanced prosthodontic skills associated with postgraduate study and therefore is often beyond the capability of a general dentist. The teaching of implant dentistry is introduced to fourth- and fifth-year dental students in the PBL curriculum, but with limited hands-on experience in the simulation laboratory on models and with practically no clinical exposure. By comparison, in dental schools in the US and Canada, 86% of students receive clinical experience in implantology (21). Owing to recent advances in implant technology and treatment modalities, there is increasing public interest in implant treatment to rehabilitate partially dentate and edentulous patients. Hence, to prepare new graduates well for the management of patients seeking the provision and maintenance of dental implants, both theoretical and clinical aspects of implant dentistry will need to be included in the 6-year BDS curriculum in 2012.

Orthodontics

Most graduates were not confident at performing full-arch alignment, minor tooth movement and space maintenance or regaining. The corresponding lack of undergraduate experience in orthodontics has been highlighted by previous studies in many countries (5, 6, 13, 14, 22). The current HKU curriculum does not allow for the attainment of such competences. The low level of self-perceived preparedness in orthodontics was probably caused by the change in emphasis in training to enable graduates to diagnose and refer orthodontic problems for specialist care, following the practices of dental schools in other parts of the world such as the USA, the UK, Australia and Scandinavia.

Managing children and special-needs patients

Many special-needs patients have an increased risk of oral disease owing to their compromised oral hygiene, oral manifestations of their medical condition and the side effects of drug regimens. Nearly 50% of graduates felt poorly prepared to treat mentally or physically disabled patients, which is a slightly smaller proportion than that reported in a similar study in Michigan, US, which found that almost 60% of general dentists surveyed did not think their undergraduate dental education had prepared them well to treat special-needs patients (23). A review of the dental curriculum to provide relevant clinical experience to undergraduates would help reduce oral health disparities and increase access of special-needs patients to dental care.

More than 60% of graduates rated themselves as poorly prepared to recognise, report and follow up cases of neglect and abuse. This low perceived preparedness is probably linked to an overall lack of knowledge about signs and symptoms of child abuse and the legal obligations in reporting cases. Because most of the injuries in reported child abuse cases occur in the head and neck region (24), dentists are actually in an excellent position to identify such abuse and to safeguard and promote children’s welfare. Nevertheless, suspected abuse and neglect cases in Hong Kong are usually reported directly by family to the Police or Social Welfare Department. Dental care providers in Hong Kong are thus less likely than those in other countries to encounter cases of abuse and neglect in their professional life.

Oral and maxillofacial surgery

More than 60% of graduates felt confident at extracting impacted third molars, which is a much larger proportion than that of vocational dental practitioners surveyed in the UK, where only 31% (13) and 23% (14) felt confident in performing surgical extractions. Graduates who perform minor oral surgery also need to be able to handle surgical complications; however, only about three in every five HKU graduates said they were well prepared to manage such complications. This observation highlights the need for improved education of undergraduate dental students regarding management of complications of oral surgery.

About three-quarters of graduates perceived themselves to be poorly prepared at performing more complicated oral and maxillofacial surgery such as managing trauma to the dentofacial complex. This large proportion is not surprising because the majority of these trauma cases in Hong Kong are handled by maxillofacial surgeons in general hospitals. Minor soft-tissue surgery such as soft-tissue biopsies are also usually carried out by maxillofacial surgeons in specialist centres. Biopsy taking is not taught in the BDS curriculum because Hong Kong is a geographically small place, so access to specialist centres is not difficult, and because the chance for error, whether diagnostic, logistical or surgical, is high (25).

Drug and emergency management

Roughly one-third of the respondents felt poorly prepared at managing medical emergencies in their dental practice, which is a larger proportion than that reported in New Zealand (26) and the UK (27). Although medical emergencies are not rare in dental practice, most of them are not life-threatening. Further postgraduate training in emergency care should be made available to Hong Kong dentists.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

In general, relatively large proportions of graduates from HKU’s integrated PBL dental curriculum report being well prepared for the common ‘bread and butter’ items of dentistry such as diagnosis, treatment planning, preventive treatment, scaling and root planing, basic restorative dentistry with composites and amalgam, single-root canal treatment, crowns, partial dentures, simple extractions, selection and administration of local anaesthesia, and drug prescriptions. This level of well-preparedness is encouraging and reflects the fact that the PBL curriculum is successful in providing graduates with basic clinical training for general practice. However, substantial proportions of graduates report being poorly prepared for orthodontics and more complex aspects of oral and maxillofacial surgery, which will need to be addressed by postgraduate training to reach clinical competency or the development of referral procedures to readily available specialists. Greater self-perceived preparedness is associated with earlier graduation years and working in a group practice. The findings of this study will provide useful guidelines for the planning of the new 6-year BDS curriculum in 2012 to meet the future needs of the Hong Kong community. Further studies are required to assess employers’ perceptions of the competency of HKU dental graduates in general practice and to conduct in-depth focus groups about the BDS programme amongst alumni and staff.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

The authors thank all the dental practitioners who participated in the study and shared their views. This work was supported by Teaching Development Grant 10100310.14207.8000.304.01, Faculty of Dentistry, The University of Hong Kong. Special thanks go to Carlos Ka-Ho Tam, Paediatric Dentistry and Orthodontics, HKU Faculty of Dentistry, for data processing and statistical analysis, and Dr Trevor Lane, HKU Faculty of Dentistry, for editorial assistance and comments on an earlier draft.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
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