Critical aspects of educating clinical management and clinical reasoning in primary teeth pulpotomy: A qualitative study based on the perspectives of experts and novices

Abstract Introduction In dental education, students must learn to integrate and coordinate complex knowledge, skills and attitudes and to transfer this learning to clinical practice. One major issue of concern in education in general and dental education, in particular, is to fill the gap between knowledge and practice. Methods The purpose of this study was to explore the problems that dental students have in transferring knowledge from the classroom to the real clinical setting. More specifically, we investigated the factors that complicate clinical management and clinical reasoning for these novices, including their common errors, in order to design an educational simulation programme in primary teeth pulpotomy. To this end, we conducted 16 semi‐structured interviews with experts and novices, performing a thematic analysis of the data obtained. All interviews were audio recorded and transcribed verbatim. Results For each major skill—clinical management and clinical reasoning—we identified complicating factors and common errors that related to the child (the patient), parents and dental student (the three main themes). For each theme, we identified further sub‐themes. Conclusion The data obtained provided valuable insights into the factors that affect dental students' performance on clinical management and clinical reasoning in primary teeth pulpotomy.


| Design of the interview
This qualitative study is based on the Phenomenological approach, to illuminate a phenomenon through how it is perceived by the participants in a situation. 16 We aimed to identify the factors that complicate clinical management and clinical reasoning including the errors that are common amongst dental students. As a first step, following the advice of two paediatric dentists, we decided to focus on pulp treatment as our object of study. The dentists were unanimous that the incidence of errors in this field was relatively high and that it was more difficult for most students than other treatments. Next, with their help, we designed a semi-structured interview. Moreover, we reviewed the research literature and scientific documents from the American Pediatric Dental Association, 17 the educational curriculum in paediatric dentistry, prerequisite and passed courses and required prior knowledge. Based on this scrutiny, we formulated the steps in clinical management and clinical reasoning that students should follow when writing the treatment plan.
In the second round, the two paediatric dentists reviewed the relevant steps and sub-steps and confirmed the structure of the interview. The interview consisted of three sections: (1)  -What factors or characteristics (individual and dental) can complicate the diagnostic process?
-What errors can occur in the process?
-How do students receive feedback from their supervisors? -Do students and experts believe it is feasible to train the process in a simulation programme?

| Participants
Given the intention of this research, that is to gather data regarding the phenomenon of learning and working towards becoming a dentist, we decided to investigate not only the students' but also the experts' perspective. This is to ensure the validity 16 of our findings since the students we focus on have limited practical experience.
For both groups, we used purposive sampling. 18 The inclusion criteria for experts were as follows: be paediatric dentists; have at least 5 years of experience in paediatric dentistry; and be doing the primary tooth pulp treatment on a regular basis. The inclusion criteria for students were as follows: be an undergraduate dental student (of a continuous 6-year programme) and have passed theoretical and practical paediatric courses.
Following this, we selected eight paediatric dentists in three different cities (Tehran-Isfahan-Yazd), four of them with an academic teaching background. For the novices group, we selected eight students from three dental schools in the same cities.
The first researcher conducted one-to-one interviews with each of the experts and students via Skype. We sought ethical approval from the Kharazmi University Ethics Committee. Before the start of the interview, each interviewee agreed to participate in the study by signing a consent form. All interviews were audio recorded. Each interview lasted approximately 45 min.

| Analysis
We performed a thematic analysis of the data following the six phases outlined by Braun and Clarke 19 : 1. familiarising with the data; 2. generating initial codes; 3. searching for themes; 4. Rrviewing themes; 5. defining and naming themes; and 6. producing the report.
All interviews were first transcribed verbatim, reviewed and checked to confirm their accuracy by the first author. Next, two authors extracted initial codes and searched for potential themes, defining and naming them independently and solving any disagreements through discussion. The last author consequently reviewed and analysed all the extracted codes and themes.

| RE SULTS
The demographic information showed that the average age of participants in the expert group was 40, and for the novice group, it was 23. On average, the experts had 7 years of work experience and regularly performed pulp therapy for primary tooth with an average number of 50 procedures per year. Moreover, all students had passed the theoretical and practical paediatric courses, five students were in their sixth year and three of them were at the end of their fifth year; on average, they had five cases in primary pulp treatment during clinical practice.

| Clinical management
We identified three overarching themes for all data: a child-related, parent-related and student-related theme. Table 1 presents the themes and the factors and errors for each theme that complicate clinical management.

| Child
All participants (students and experts) unanimously considered the level of child collaboration as a factor that effectively mediated the complexity of clinical management. The non-cooperative child included a continuum of different factors and characteristics such as individual differences, age, special cases (mental and physical disability or disorder), the child's pain or anxiety and the child's previous negative experiences. Sluggish action on the part of the dental student could sometimes also affect the child's cooperation. The second child-related factor was the child's characteristics, including his or her developmental features, psychological aspects such as shyness, introversion, being unpredictable or aggressive and gag reflex.
With respect to typical errors, we identified specifically "poor communication." Although this error could also be ascribed to the dental student, the child's characteristics and cooperation could complicate this situation, making dental students more prone to errors.

| Parent
The first factor was the parents' presence: According to most participants, the parents had stress and transferred this to their child. Also, in some cases parents were overprotective, they interfered with the dental student's work, complicating his/her interactions with the patient. Doubts about parental presence or absence arose in cases where the dental student needed further information or assistance  With respect to typical errors related to the dental student, participants first mentioned a lack of theoretical and practical knowledge. For instance, some students did not know which developmental characteristics of the child were typical of each age, nor did they know the essential differences between child and adult characteristics. The second error, unsuccessful application of behavioural management techniques, was as discussed above due to a lack of practice. The third error was their insistence on treatment, even in complex cases, such as a non-cooperative child, where referral to a paediatric dental specialist would be preferred. The last error was low self-confidence in interacting with the child and parent, in using the behavioural management techniques and in writing a treatment plan.

| Child
The first two factors related to the child's condition and included the correct diagnosis of painful teeth, especially in young children or in cases where several decayed teeth were adjacent. The third and fourth factors concerned anatomical and physiological differences between children and adults and the child's age and tooth development. The last three factors involved the child's willingness to cooperate, special cases and oral hygiene. More specifically, the child's level of collaboration affected the treatment plan; in some cases, for instance, when the child was not willing to undergo radiography, it could lead to a mistake in clinical examination and diagnosis. In cases with special dental and individual needs, moreover, it could be more difficult to write the treatment plan. The last complicating factor related to the child was a lack of oral hygiene. In some cases, where a lack of hygiene or genetic factors had caused high decay or lesions, the decision to treat was difficult because it seemed useless in the absence of care.
As mentioned before, the above-listed child-related complicating factors made novices more prone to typical errors in clinical reasoning and in writing the treatment plan.
In some cases, three adjacent teeth need to be treated with a pulpotomy, but determining which of the teeth is the cause of pain and should be treated first is very important. [This can be done] by checking the radiography and [by doing] clinical tests such as precaution and heat and cold tests.

(EXP-P02)
The patient's misinformation may lead to an error, for example, which teeth have pain or is it a referral pain or not? (STU-P04)

| Parent
Then, there were also factors affecting the treatment plan that was related to the different demands/expectations of the parent. More specifically, the social and cultural state of the family could influence the treatment plan of each individual patient, including the parents' occupation and education, the quality of the patient-family relationship, siblings and parenting style.

| Student
The overarching factor was the lack of clinical practice before their first encounter with patients, again pointing to a gap between theory and practice. This was detailed in clinical judgement in general and more in particular how to deal with all (or what) patient aspects when writing an individual treatment plan and how to account for in the treatment plan for indications and contraindications. A specific case was how to deal with inadequate radiography information. In some cases, radiographs that were of low quality did not reflect radiolucency around the root, which could lead to a wrong decision or to misinterpretations of radiographic images.
Finally, the errors related to the dental student included unfamiliarity with tooth morphology and anatomy, inaccurate clinical judgements, misinterpretation of radiographs and, lastly, inadequate clinical experience because of the aforementioned gap between theory and practice.
In the first encounter, most students have problems,

| General findings
In the final part of the interview, we asked participants how students received feedback from their supervisors in each stage of clinical management and clinical reasoning during their training courses. The results showed that the theory-based courses did include a theoretical evaluation. However, students did not apply the theory in a training setting, and their first practice took place with real patients in the clinic, and here, they received feedback from their supervisors.
Moreover, we asked all participants for their opinion about the feasibility of using simulation to teach students clinical management and clinical reasoning skills. All participants were unanimously in favour of using simulation in the pre-clinical phase. They stated that this could be very effective in behavioural management training, especially in teaching students how to communicate and interact with patients in paediatric dentistry. Participants acknowledged that the use of simulation in dental education could offer students a novel educational experience introducing students to a variegated range of cases in anatomy and physiology, including emergency and complicated situations, systematic disease, age and tooth development, radiographic images and different interpretations. Also, by offering students training and the opportunity to practise in conditions quite similar to the real environment, simulation would improve selfconfidence, group discussion, writing of the treatment plan for inexperienced students and give the opportunity to receive systematic feedback on "where am I going?", "how am I going?" and "where to next?". 20

| DISCUSS ION
Transition of theoretical knowledge and skills to actual clinical practice is a complex part of dental and medical training. Due to teaching methods, that focus mainly on theoretical knowledge most graduate students do not have enough self-confidence and communication skills when interacting with patients. 21 As our findings demonstrated, most dental students have many problems in clinical management and clinical reasoning TA B L E 2 The themes and their complicating factors and typical errors in clinical reasoning

Factors/ errors per themes:
Complicating factors Typical errors