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- Materials and methods
Background: A national survey was undertaken to establish a baseline of our final year students’ perception of how their undergraduate oral surgery education has equipped them for key areas of general dental practice.
Materials and Methods: Questionnaires were distributed to the 13 UK schools with final year students, towards the end of the academic year in 2009. The questionnaires were completed anonymously and were optically scanned.
Results: In total, 632 questionnaires were returned, which represents 66% of the students of the graduating year. The majority (83%) of the respondents perceived that the teaching in oral surgery had given them sufficient knowledge to undertake independent practise. Most respondents (99%) felt confident to perform forceps exodontia, but confidence in the various aspects of surgical exodontia was lower. A majority (83%) had experience of an outreach scheme performing forceps exodontia (75%) and surgical exodontia (16%) in this environment. Twenty per cent indicated a desire to undertake a career in oral surgery, 6% in oral and maxillofacial surgery and 35% in another speciality.
Conclusion: This survey suggests that the majority of the students perceive that the oral surgery education has prepared them well for key areas of general practice. It also suggests that there is, however, a need to provide further improvement in the delivery of surgical skills and knowledge.
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- Materials and methods
Alongside recent changes in undergraduate curricula, there has also been debate over the dental graduate’s ability to undertake the oral surgery procedures in primary care (1–4). This comes at a time of decreasing academic staff numbers in oral surgery (5) and an increasing desire in the United Kingdom (UK) to have more, of what were traditionally perceived as, ‘specialist’ secondary care treatments provided in the primary care setting either by dentists with a special interest or by registered specialists.
In the UK, the outcomes of the undergraduate oral surgery curriculum are to deliver new graduates with the ability to work independently in primary care as a vocational trainee, under the tutelage of an experienced dentist, for a 1-year period. These outcomes are essentially the same as those outlined in the 2nd edition of ‘Profile and Competencies of the Graduating European Dentist’ (1). Specifically new graduates are expected to be able to carry out forceps extraction of erupted teeth and roots. In the case of a failed forceps extraction, they should be able to raise a mucoperiosteal flap and carry out bone removal, tooth sectioning and elevation of the roots of the tooth prior to wound closure with sutures. In addition, they should be competent in the diagnosis and management of third molar related disease and be cognisant with the referral guidelines (6). They should also be able to recognise and refer potentially malignant and malignant lesions of the oral mucosa and be able to differentiate between pain of odontogenic and non-odontogenic origin.
Against this background, the Association of British Academic Oral Maxillofacial Surgeons (ABAOMS) education committee decided to survey the whole of the graduating year of 2009. The aim of the survey was, for the first time, to establish a baseline of the final year students’ perspective of how their undergraduate oral surgery teaching had equipped them for key areas of general practice. The objective was to highlight the areas of strengths and weaknesses so that these might be further investigated, and lessons from each be reciprocally integrated to help improve undergraduate oral surgery teaching across the UK.
Materials and methods
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- Materials and methods
Members of the Association of British Academic Oral Maxillofacial Surgeons’ (ABAOMS) education committee devised and agreed the structure of the questionnaire over a series of meetings in 2008–2009. The questionnaire was designed to collect: sex and the educational background; experience in core competencies outlined in a previously published curriculum (7); perception of respondents with respect to teaching in oral surgery and applied anatomy; information on their experience of oral surgery in outreach.
Between May and June 2009, a questionnaire was distributed to all final year students at the 13 dental schools in the UK that had students in their final year, excluding The Peninsula, University of Central Lancashire (UCLan) and Aberdeen Dental Schools. The questionnaire was presented on an optically marked double-sided single sheet of A4 that contained statements to be ranked on a Likert scale (8) and three di/trichotomous response questions. The questionnaire was divided into five sections including: (A) general information on the respondent’s sex and previous education, (B) confidence in oral surgery procedures, (C) role of adult outreach, (D) anatomy in relation to oral surgery teaching and (E) career aspirations.
Members of the Association of British Academic Oral Maxillofacial Surgeons’ education committee distributed the questionnaire at their respective schools. Students were first issued with a standardised information sheet explaining the purpose of the study and it was explained that completion was anonymous and voluntary. If they were willing to participate, they gave written consent and were then issued with the questionnaire. They then returned the questionnaire at a time convenient to them and it was wholly reliant on them to return it.
The questionnaires were optically scanned using Speedwell software (Speedwell Survey Software; Speedwell Software Products Ltd, Cambridge, UK). Any responses that could not be scanned, or any multiple responses that were inappropriate to the question type, were examined by hand. If the respondent had clearly indicated that one mark was a mistake then the other response was entered, if not, or if there were more than two marks, the response was omitted from the data analysis. Questions with no response were noted as blanks and omitted from the analysis of the data.
The data were analysed using SPSS version 15 (SPSS; An IBM Company, Chicago, IL, USA). Opinions vary in the scientific community on how to treat Likert type data. We would concur with Jamieson (9) that Likert data are ordinal and therefore have used non-parametric inferential statistics for all Likert data. Questions A and C were treated as categorical variables. Spearman’s Rho correlations were calculated to determine the strength of the correlation (10) for confidence in all aspects of surgical exodontia and confidence in all aspects of forceps exodontia. Correlations were also calculated for all aspects of anatomical teaching and confidence in all aspects of surgical exodontia. A Mann–Whitney test was carried out on all aspects of forceps and surgical exodontia and sex. The significance level was set at P < 0.05.
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- Materials and methods
A total of 632 questionnaires were returned. This represents 66% of the graduating year of dental students in 2009. The return rate for each school ranged from 23% to 95% of their students, however, all but two schools managed >60% response.
Respondents addressed the majority of questions. Excluding question E2 where a blank response could be appropriate, there were 264 blank responses through the whole cohort. This equates to 1%‘failure to respond’ rate across all 23 questions and statements. Few respondents failed to respond to some questions ranging from 0% to 4% with the highest rate for the statement ‘is oral surgery an enjoyable and rewarding discipline’ and the statements related to outreach and anatomy teaching. The Likert response to each statement, by female and male respondents and for the group overall, is shown in Table 1. The data relating to the respondents’ response to the questions on outreach teaching are shown in Table 2.
Table 1. Responses of female (n = 352) and male (n = 273) respondents to statements on their confidence in oral surgery procedures and anatomy teaching presented as percentage of responses of women, men and all respondents
|Statement||Sex||% response by likert scale|
|Strongly agree||Agree||Neither agree or disagree||Disagree||Strongly disagree|
|B1. The teaching that I have received in oral surgery has given me sufficient knowledge to undertake independent practise||Female||10||38||4||3||1|
|B2. I feel confident that I could extract an upper single rooted tooth with an intact crown, in an otherwise intact dentition||Female||40||16||1||0||0|
|B3. I feel confident that I could remove visible retained roots of an upper left first molar with elevators or forceps||Female||20||33||2||1||0|
|B4a. I feel confident to assess and perform the surgical management of a failed extraction (e.g. a lower second molar) necessitating: a) the raising of a mucoperiosteal flap||Female||4||24||13||14||1|
|B4b. Bone removal||Female||4||23||12||15||1|
|B4c. Sectioning the tooth to facilitate elevation of the roots||Female||3||21||13||17||1|
|B4d. Wound closure using appropriate suture materials||Female||11||31||7||5||1|
|B5. I feel confident to diagnose and manage acute pericoronitis||Female||26||28||1||0.5||0|
|B6. I feel confident to manage haemorrhage from a socket||Female||16||33||6||2||0|
|B7. I feel confident to assess an impacted mandibular third molar with respect to guidelines and recognise the need for surgical removal||Female||20||32||4||0||0|
|B8. I feel confident that I can recognise the clinical features of potentially malignant and malignant lesions of the oral cavity||Female||9||32||11||3||1|
|B9. I feel confident that I can write an appropriate referral letter to a specialist in an appropriate time frame dependent on the clinical problem||Female||11||33||7||4||0|
|B10. I feel competent to differentiate between pain of odontogenic and non-odontogenic origin||Female||6||32||14||5||0|
|D1. I believe my teaching in anatomy has been appropriate for my clinical needs in oral surgery||Female||11||34||5||5||1|
|D2. I am more confident about undertaking oral surgery because of my knowledge and understanding of head and neck anatomy||Female||9||30||11||4||1|
|D3. The only anatomical knowledge needed for oral surgery is that of jaw and tooth morphology||Female||2||7||9||26||12|
|E1. Oral surgery is an enjoyable and rewarding discipline||Female||19||27||6||2||0|
Table 2. Responses of female (n = 352) and male (n = 273) respondents to questions on the role of adult outreach teaching presented as percentage of responses of women, men and all respondents
|C1. Where you involved in an outreach scheme?||81||85||83||16||9||14||–|
|C2. Did you carry out any extractions in outreach?||74||76||75||11||11||11||9|
|C3. Did you carry out any surgical extractions in outreach?||15||16||16||69||70||69||9|
Section A – general information
Fifty-six per cent of those responding were women and 44% were men. The 326 students, who did not respond, included 164 women and 162 men. In the sample responding, 12% had a degree qualification other than dentistry and 4% already had a healthcare qualification.
Section B – confidence in oral surgery procedures
On the whole, the response was positive with 83% of the respondents agreeing that the teaching in oral surgery had given them sufficient confidence to undertake the independent practise. The majority (99% and 94%) felt confident to perform simple exodontia (B2 and B3). The questions on various aspects of surgical removal of teeth (B4) provided the highest number of neither agree or disagree responses, however, a small number of students (21%, 22%, 25% and 9%, respectively for sections a, b, c and d, respectively) disagreed with the statements in this section.
The majority of respondents felt confident to diagnose and manage pericoronitis (91%), manage haemorrhage (87%) and assess impacted third molars (91%). Fewer felt confident to recognise potentially malignant lesions (73%), write a referral to a specialist (79%) or differentiate between pain of odontogenic and non-odontogenic origin (64%).
Section C – role of outreach in oral surgery teaching
Eighty-three per cent had been involved in some form of outreach and 75% of these had extracted teeth whilst only 16% had carried out a surgical extraction in this environment.
Section D – anatomy teaching in relation to oral surgery
Three per cent of respondents did not respond to the questions in this section. In total, 78% recorded that the anatomy teaching had been appropriate to their clinical needs and 70% felt more confident as a consequence. When asked whether the only anatomical knowledge, required for oral surgery, was that of the teeth and jaws, 67% disagreed and only 14% agreed.
Section E – career aspirations
The question regarding career aspirations displayed the highest number of multiple responses, with 9% of the respondents marking multiple responses. Of those remaining (n = 574), who gave singular or blank responses, 20% indicated a desire to undertake a career in oral surgery, 5% in oral and maxillofacial surgery, 32% in another speciality and the remaining 34% left their response blank.
Significant correlations were found between all aspects of surgical exodontia and confidence in all aspects of forceps exodontia, as shown in Table 3. There were significant differences between responses of male and female respondents, as males responded more positively than females to all of section B (P < 0.05). Significant direct correlations were found between exodontia/surgical exodontia with anatomy teaching (D1 and D2) and significant indirect correlations were observed with D3, which had questioned the need for a broader knowledge of anatomy beyond the teeth and jaws (Table 4).
Table 3. Spearman’s rho correlation coefficients (r) for questions in section B (forceps and surgical exodontia)
|B2. I feel confident that I could extract an upper single rooted tooth with an intact crown, in an otherwise intact dentition||1.000||–||–||–||–||–|
|B3. I feel confident that I could remove visible retained roots of an upper left first molar with elevators or forceps||0.446**||1.000||–||–||–||–|
|B4. I feel confident to assess and perform the surgical management of a failed extraction necessitating: a) the raising of a mucoperiosteal flap||0.178**||0.304**||1.000||–||–||–|
|B4b. Bone removal||0.202**||0.291**||0.716**||1.000||–||–|
|B4c. Sectioning the tooth to facilitate elevation of the roots||0.243**||0.347**||0.591**||0.718**||1.000||–|
|B4d. Wound closure using appropriate suture materials||0.256**||0.311**||0.504**||0.490**||0.510**||1.000|
Table 4. Spearman rho correlations coefficients (r) for questions in section B (forceps and surgical exodontia) and section D (anatomy teaching)
|Question||D1. I believe my teaching in anatomy has been appropriate for my clinical needs in oral surgery||D2. I am more confident about undertaking oral surgery because of my knowledge and understanding of head and neck anatomy||D3. The only anatomical knowledge needed for oral surgery is that of jaw and tooth morphology|
|B1. The teaching that I have received in oral surgery has given me sufficient knowledge to undertake independent practise||0.372**||0.305**||−0.050|
|B2. I feel confident that I could extract an upper single rooted tooth with an intact crown, in an otherwise intact dentition||0.222**||0.187**||−0.078|
|B3. I feel confident that I could remove visible retained roots of an upper left first molar with elevators or forceps||0.214**||0.227**||−0.104*|
|B4a. I feel confident to assess and perform the surgical management of a failed extraction (e.g. a lower second molar) necessitating the raising of a mucoperiosteal flap||0.243**||0.286**||−0.091*|
|B4b. I feel confident to assess and perform the surgical management of a failed extraction (e.g. a lower second molar) necessitating bone removal||0.204**||0.209**||−0.091*|
|B4c. I feel confident to assess and perform the surgical management of a failed extraction (e.g. a lower second molar) necessitating sectioning the tooth to facilitate elevation of the roots||0.233**||0.238**||−0.087*|
|B4d. I feel confident to assess and perform the surgical management of a failed extraction (e.g. a lower second molar) necessitating wound closure using appropriate suture materials||0.252**||0.300**||−0.192**|
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- Materials and methods
The importance of including student input, through the feedback mechanisms, in education is accepted as a key component of processes used to monitor the quality of academic programmes. Evaluation provides insight into course and teaching effectiveness (11) and can result in a tangible improvement in the delivery of clinical teaching (12). However, students’ perception of their education is an area that has received little attention (11). Previous surveys (4, 13) retrospectively asked vocational trainees their perception of their undergraduate course and therefore are at risk of recall bias. In both previous surveys (4, 13), an apparent lack of confidence in undertaking surgical exodontia was reported. A different survey reported poor self-perceived knowledge of oral surgery amongst 75 dental practitioners (14). The survey reported in this paper sampled 66% of all final year students at the end of their undergraduate studies in 2009 and is therefore the largest such survey within the UK and should be representative of students’ perception. The majority of the respondents were women, which is in keeping with the changing face of the dental workforce (15–18). Although only 4% of respondents had a healthcare qualification, this may increase with the development of dental undergraduate programmes for medical graduates and graduate-only entry programmes for dentistry (19). Because of the anonymous nature of the questionnaire, we could not characterise the group of students not responding with regard to their confidence or ability in oral surgery.
One of our objectives was to examine whether oral surgery teaching in the UK was delivering graduates who felt confident to deliver the core competencies outlined in the First Five Years (2) and other curricula (1, 7). Self-reported confidence does not, however, equate to clinical competence and therefore the findings should be interpreted with this caveat in mind. It was reassuring that the majority of respondents felt confident to undertake the principal activity of forceps exodontia and that they reported that their teaching had given them sufficient confidence for independent practise.
A significant positive correlation was found between the respondents’ confidence in forceps exodontia and surgical exodontia. This should be viewed with caution as generally the responses to surgical exodontia were significantly less confident than for routine forceps exodontia. The reduced confidence to undertake surgical extractions is unsurprising given that a recent survey reported that the average experience of surgical extractions in UK dental schools was low (20). The least confidence in surgical exodontia was recorded in relation to the question on tooth sectioning. This may suggest that students are not usually exposed to the surgical removal of teeth with this level of difficulty. There may be any number of reasons for this, but two could possibly be a lack of suitable cases for undergraduates and staffing difficulties because of the intensive nature of supervision required for the surgical exodontia (21, 22). The latest edition of the First Five Years does not explicitly state that graduates should be competent at the surgical removal of teeth but it does state that they should ‘be competent at undertaking minor soft tissue surgery’ (2). Quite what this statement encompasses is not clear as it could include the ability to perform a biopsy or periodontal surgery. As soft tissue surgery invariably requires suture placement, it is pleasing to see that the respondent response to suturing was favourable.
There appears to be a perceived sex difference within the sample, with men reporting greater confidence in all aspects of exodontia and surgical exodontia. This may reflect that female students are less confident, either as part of their personality makeup (23) or reflect a real reduction in exposure to surgical exodontia. However, it is unlikely that women have less exposure as they are timetabled for the same number of sessions. Alternatively, and more likely, it might reflect over-confidence on the part of the male respondents.
It is reassuring that the majority of respondents reported confidence in a range of oral surgery skills that would be a common part of their practice in the primary care environment, for example: diagnosing acute pericoronitis, haemorrhage control, applying NICE guidelines (6) and referral letters. Two relative worrying findings were highlighted namely: a reduced confidence in the recognition of potentially malignant or frankly malignant lesions and differentiation between pain of odontogenic and non-odontogenic origin. The malignancy recognition finding may be due to the students’ relative lack of exposure to malignancy as the incidence is low. However, both findings do suggest that a more targeted approach to this aspect of the curriculum needs to be addressed. The education committee of the Association of British Academic Oral Maxillofacial Surgeons (ABAOMS) are currently developing virtual education to improve competences in both the areas and that can be used by all UK dental schools.
A large proportion of the respondents (83%) were involved in some form of outreach. There are many reports on the benefits of outreach for dental students (24–27). It would seem from our results that the students perceive to gain experience of forceps exodontia in outreach, and this has been reported elsewhere (24, 28–30). However, there appears to be very little exposure to surgical exodontia in outreach, which seems to correlate with the published literature (31). Reasons for this lack of exposure to surgical exodontia may include the following: where outreach is more paediatric in focus; lack of fractured teeth requiring the need for surgical exodontia; or perhaps low staff confidence (23). Given that 75% of the respondents carried out extractions, it seems unlikely that none of these cases required surgery following a failed attempt.
An important factor in engendering confidence will be through the students’ perception that they have sufficient knowledge and understanding of the relevant basic science necessary to undertake and manage a procedure. An important component of this knowledge is an understanding of the relevant anatomy. To our knowledge, this is the first survey of dental student perceptions of anatomical knowledge. In the majority of UK dental schools, anatomy teaching takes place near the beginning of the course and while there may be some vertically integrated anatomy teaching delivered at later stages of a programme, this will be generally confined to sessions designed to refresh previous teaching. It was encouraging, therefore, that respondents felt that the teaching they had received in anatomy had been appropriate for their later clinical needs. At first sight, it could also be taken as encouraging that respondents expressed confidence about undertaking oral surgical procedures as the result of their knowledge and understanding of head and neck anatomy. However, this result appears to be in conflict with the results of an earlier study undertaken to assess student perceptions of an online anatomy course delivered to final year dental undergraduates (32). Results, from this previous study, indicated that students perceived themselves as lacking in anatomical knowledge. The difference between the results is that in this survey, students were asked to self-report their knowledge, whereas in the previous study, their knowledge of anatomy was being challenged through undertaking pre-tests. Therefore, the question may be asked about the extent to which the confidence expressed by the respondents might have been misplaced in this survey.
The students were asked to state whether the only knowledge relevant to oral surgery was that relating to jaw and tooth morphology. A majority disagreed with this statement. It was pleasing to note that students recognised the importance of having a soundly based anatomical knowledge that was broadly based regionally. The increases in the rise in hospital admissions for the dental abscesses in the UK, over a 10-year period to 2005, illustrate why dental practitioners must continue to have a broadly based knowledge of anatomy (33).
This confidence in anatomical knowledge revealed by this survey, whether soundly based or not, contrasts with the levels of anatomical knowledge said to be possessed by medical students. Prince et al. (34) reported that a majority of Dutch medical students were of the opinion that they had acquired less than half the anatomical knowledge required upon graduation. Similar concerns have been expressed about UK medical graduates (35, 36). Perhaps it is not surprising that the dental students feel more confident about the level of their anatomical knowledge as the amount of anatomical teaching delivered to dental students is greater than their medical counterparts. One-fifth of the respondents expressed a desire to pursue a career in oral surgery. It would suggest that there are insufficient training places to meet the projected demand but also perhaps a lack of need for this number of oral surgeons. This has been highlighted by a recent report (37). If the demand for oral surgery training is so high, it may provide more specialists who might be prepared to offer specialist minor oral surgery in dental practice. This would reduce inappropriate referrals to secondary care and would be acceptable to patients (38, 39).
Previous work reported that vocational trainees had high self-confidence in surgical extractions, particularly in schemes with mandatory assessment (40). Further work is required to investigate whether the self-reporting of confidence in oral surgery continues after vocational or foundation training.