Students at Saarland University dental school—A survey on their background and curriculum perception

Introduction: With the aim of optimising dental education without overburden-ing students, new legislation restructuring the undergraduate dental curriculum in German is under way. The goal of this study was to survey the current situation of dental students at one specific university with respect to their socio-economic background, admission to dental school, curriculum perception and work-life balance. Materials and methods: An online questionnaire was presented to all undergraduate students enrolled at Saarland University who had at least completed the first preclinical practical course in dentistry. Results: A response rate of 85% was reached with two-thirds of the student body being females. The profession of 40% of students' parents either was physicians or dentist. Students reported a slight reduction in time spent for leisure activities during their studies, however, with sports activities hardly being affected. With respect to a proper work-life balance, almost 50% of respondents considered their clinical workload as being too high. Students did not express a clear opinion regarding curriculum structure, whilst the content mostly satisfied their expectations (59%). The majority (71%) of students considered their preclinical training as being demanding whilst less than 3% fully agreed that preclinical

posture during treatment, 23 students also have to deal with anxiety resulting from patient treatment 24 and immature multitasking skills. 9,25 In Germany, the curriculum is currently structured in a preclinical part of five semesters focusing on basic disciplines such as anatomy, biochemistry and physiology. In addition, three major practical dental courses are being taught on phantom heads and in a dental laboratory setting. After passing two state examinations, students are admitted to clinical training for five semesters with a strong focus on patient treatment predominantly in operative dentistry and prosthodontics.
Passing of a final state examination comprising oral tests as well as patient treatment forms the basis for getting a dental license in Germany.
In the light of these circumstances and with the aim of generating reference values for future comparisons, it was the goal of this study to survey the current situation of undergraduate dental students at Saarland University in Germany with respect to their socio-economic background, admission to dental school, curriculum structure and work-life balance.

| MATERIAL S AND ME THODS
Saarland University dental school is amongst the smallest dental schools in Germany annually accepting 24 students. In fall 2019, a questionnaire was designed combining input from administrators, educators and students. A pretest was performed by one student attending the preclinical phase and one student attending the clinical phase which led to further adaptation of the questionnaire. All preclinical and clinical students enrolled at Saarland University dental school during the winter term 2019/ 2020 who had at least completed the first preclinical practical course in dentistry were then asked to complete the questionnaire in a blinded online format (Please see Appendix providing an overview of the items included in the questionnaire). The students were invited through the dean's office of student affairs and were reminded after 1 week with the survey being closed after a total of 2 weeks.
The survey was organised in different subsections dealing with the students' background and admission to dental school as well as the students' personal learning strategies. The students were also asked whether or not the sequence of learning modules experienced so far made sense and how they perceived the transition between preclinical and clinical education. Further items were related to their personal situation with respect to work-life balance as reflected by the time spent on personal hobbies and their future plans. The survey consisted of both, multiple choice and free-text questions, and the students were allowed to provide multiple answers to specific questions.

| RE SULTS
Out of 83 students being asked to participate, a total of 71 students completed the online questionnaire (86% response rate). The student body was composed of 66% females and 31% males with two students either not disclosing their gender or classifying themselves as divers.
Regarding their family background, 30% of the students indicated that their fathers were dentists or physicians whilst only 11% of mothers fell into that category. On the contrary, 15% of mothers worked as auxiliary personnel in the dental or medical field. Out of those parents who did not work in the medical or dental field, 14% had an academic background.
During their childhood, students obviously spent more time for a wide range of hobbies with the vast majority of students having several hobbies in parallel. The greatest reduction in comparison with their current situation was seen in the fields of handcrafting (62%) and music/ computers/ gaming (51%) followed by reading/ science/ nature (32%) and spending time with friends (21%). Sports activities (8%) were hardly reduced and students spent a mean of 10.49 hours (SD 7.94) per week for leisure activities.
The most important motivation for studying dentistry was the students' interest in the subject (76%) or a general interest in medical and natural sciences (73%). Adequate salary (63%) and social recognition (54%) were further motivational aspects mentioned. Internet resources, their social networks as well as voluntary internships were the primary sources of information prior to enrolment in dental school.
The vast majority of students (92%) directly obtained their university entrance qualification from school whilst 8% of students used second chance education opportunities. If the students had the chance to pick focus subjects in school, biology, chemistry and physics were frequently chosen. The final grades achieved (German school system Best grade: 1; Worst grade: 6) ranged from 1.0 to 3.1 with a mean of 1.69. The mean waiting period prior to admission to dental school was 2.7 semesters (SD 5.14) with the vast majority having no waiting time whilst the maximum waiting time was 17 semesters in one case. Prior to studying dentistry, 25% of students had started and successfully completed an apprenticeship; predominantly in the medical or dental field. Six students had started studying a different subject at a university, and three students had completed university studies prior to attending dental school.
Students did not express a clear opinion regarding the general structure of their curriculum whilst the content satisfied or fully satisfied their expectations (59%). Asking where additional learning content is required, neither of the four classic disciplines (operative dentistry, prosthodontics, orthodontics, oral and maxillofacial surgery) was clearly identified whilst several students explicitly asked for more information about economic aspects of dentistry.
The first preclinical, practical course was considered as being demanding or very demanding by 49% of students with 28% of all respondents stating that the practical work requirements created problems whilst only 5% had problems with the theoretical course content. The complexity of the course content was considered as being adequate. A total of 72% of students considered their preclinical training as being demanding or very demanding whilst less than 3% of students fully agreed that preclinical training provided an optimal background for patient treatment. When asking for suggestions to improve preclinical training, respondents made no clear indications with respect to balancing practical and theoretical learning content, as well as with respect to dental vs. basic medical (anatomy, biochemistry, physiology) learning modules. The clinical course in prosthetic dentistry, for which the foundation is being laid during preclinical training, was considered as being adequate by 64% of respondents. Similarly, the complexity of the learning modules in the first clinical semester was considered as being adequate by 56% of students. Examinations during courses were considered as properly reflecting the students' knowledge by 79% of students and 85% of respondents considered the number of examinations as being adequate. Following completion of dental school, students predominantly intended working as general dentists (63%). The most frequently named specialisation was implant dentistry (41%).
The weekly workload for self-directed studies reached a mean of 11.05 hours (SD 9.07) when students attended the first practical preclinical course and a mean of 8.74 hours (SD 7.13) when they attended the clinical course in prosthetic dentistry. In this context, students indicated that they had more difficulty in memorising and reproducing factual knowledge as compared to learning and applying basic knowledge for solving unknown problems. Also, workflows were unproblematic to be memorised and applied. The clinical workload was considered as being too high by 48% of students whilst 31% considered their workload as being optimal.

| D ISCUSS I ON
Admission to dental school remains being controversial with a wide variety of processes being implemented. 3 In the German system, the grade achieved in the university entrance qualification is the most important selection criterion, whilst the completion of an apprenticeship in the dental or medical field may result in a bonus for admission. In the current system, one's grade can be improved by waiting terms which consequently can be seen as an indicator for students' performance. The mean value of 2.7 semesters obtained in the current survey may be considered as being misleading due to one outlier accumulating 17 waiting semesters. However, three students had started university studies in natural sciences prior to switching to dental school, which may also be regarded as accumulating waiting semesters. The problem associated with this strategy is crowding of other programs in addition to artificially increasing failure rates in these disciplines. Whilst admission to dental school certainly has to be controlled, it should also be ensured that not too many waiting semesters can be accumulated by applicants. Besides these specifics and supporting current literature, two-thirds of the current student body were females, 4,5 which is in contrast to the situation indicated for the parent generation with the male partners working as physicians or dentists whilst females were rather working as auxiliary staff.
Preclinical students consider their training as being stressful 8,9 whilst in the clinical part of their studies, retrospective judgment changes to adequate. This change in response may be seen as a hint that the current sequence of modules provided as well as their contents facilitate the transition from preclinical to clinical education. [20][21][22] However, more robust assessments also involving recent graduates would be required to confirm whether the curriculum is properly aligned and facilitates the transition mentioned above.
Given the complexity of Germany's social and medical system, specific economic aspects of dentistry are currently presented on a rudimentary level which is often criticised by students and professional dental organisations as well. Whilst the need for basic economic knowledge for successfully practicing dentistry is undoubted, this must not constitute a major goal of undergraduate training which is supposed to focus on teaching state of the art dentistry as a scientific discipline.
Students indicated to spend a mean of 10.49 hours per week for leisure activities but wide variation was seen in the response received. Both, the workload at dental school as well as the time required for self-directed learning were considered as being high.
Potentially even worsening this situation, the updated curriculum coming into effect in fall 2020 may even increase the workload for students. With sports activities obviously not diminishing as a result of attending dental school, students try to maintain a healthy worklife balance 11 and to counteract their risk for mental disorders. 8,9 How to cite this article: