USC Moves to Problem-Based Learning

Six years after the University of Southern California’s problem-based-learning pilot program was initiated, people are still saying "Huh?"

The USC School of Dentistry transitioned to the innovative problem-based-learning approach to encourage students to become engaged in their learning and develop critical thinking skills essential for success in dental practice. Traditionally, the first few years of dental school involve sitting through disconnected lectures presented in multiple courses on different themes. Lectures introduce curricular content that students are to memorize and master for subsequent application to patient care, however actual clinical application may not occur for months to years. Unfortunately, the delay from passive learning to active implementation challenges retention in even the brightest students.

In the problem-based-learning changeover, USC joins the ranks of Harvard Medical School, Harvard School of Dental Medicine and Indiana University, which make problem-based learning a significant component of their education programs. USC’s Medical School is currently transitioning to the format as well.

"The traditional approach involves lectures often unrelated to one another, and few other overarching themes exist that allow the students to relate physiology to biochemistry to other disciplines," said Malcolm Snead, DDS, PhD, professor of USC School of Dentistry, Center for Craniofacial Molecular Biology. Dr. Snead is one of the faculty actively involved in problem-based-learning program development and student facilitation.

Instead of waiting until the last two years of dental school to give students real-world problems to solve, problem-based learning is done throughout all of dental school for all courses and involves no scheduled lectures. The problems serve as the vehicle for learning for all curricular content, including both the basic and clinical sciences.

During freshman year, the application of content learned through the cases is applied as the student progresses from simulator to the clinic. The student provides care and completes clinical procedures that are at his or her level of competency, such as examinations, data collection, and initial periodontal therapy. Right from the beginning, this approach to learning serves as an engaging means of learning "the basics" and how these pieces of knowledge fit into the puzzle of a case scenario. The problem cases naturally lead to the delivery of dental care, and the sequence of learning is established so that the students progress to more-complicated therapies in the later years of dental school. For example, a senior would do complicated restorative, prosthodontic, and periodontal procedures.

This problem-based-learning approach is often likened to the process that a clinician follows when working up a patient.

The typical steps of problem-based learning include:

* The facilitator provides a small group of students with a case scenario that includes a series of signs and symptoms exhibited by a patient.

* The students first establish the facts of the case and then brainstorm hypotheses in analyzing the facts, thereby determining a course of investigation. This course of investigation involves the students formulating their learning needs so they further understand the facts, their hypotheses, and the mechanisms behind the signs and symptoms. In doing so, they go to the literature and acquire the knowledge needed to understand the patient’s presentation (a skill development critical for lifelong learning);

* The students meet and review the facts based on their newly amassed knowledge, revising and rejecting ideas and establishing new lines of investigation to further expand their knowledge base.

* The cycle of learning continues when the facilitator provides the group with an additional page of information about the case scenario, from which the students begin to triage their ideas, link facts, and identify new learning needs. The cycles of critical thinking, mastery of new material and application to the problem occur continually.

This process of learning integrates all the content mastered by the student and provides a high degree of relevance through the application to a patient’s condition. One result of the problem-based-learning process can be summed up by the "high-fives" students sometimes give each other when they discover that they have successfully diagnosed and identified treatment for solving the patient’s problem.

The problem-based-learning students begin clinical experiences in the first trimester and continue to increase the number of clinical experiences per week throughout the four years of the curriculum. Compared with students in the traditional DDS program at USC, the problem-based-learning students have more than 50 percent more clinical sessions during their four years in school. All clinical experiences occur at the student’s level of clinical competency since they enter the clinic to perform a procedure once they have demonstrated preclinical competency. Early clinical experience is a valuable incentive for students and helps them to appreciate the rationale for the content of the curriculum and the application of the basic and clinical sciences they have mastered.

The problem-based-learning students meet the same set of clinical competencies as all other graduates of the school. Currently, there are 24 competencies established by the faculty that define the abilities of a new dental graduate. These competencies require both breadth and quality of clinical experience as important criteria to establish student ability. There is little difference between the criteria used to establish graduation competency for either the traditional or problem-based-learning programs.

According to Charles Shuler, DMD, PhD, associate dean of student and academic affairs, the problem-based-learning format is breeding a new crop of critical thinkers who investigate the evidence presented to them.

"Analyzing the student achievements, it has been shown that the students performed at a much higher level on standardized tests and had a much greater interest in learning," Shuler said.

Traditional naysayers resisting the changeover to problem-based learning at other dental schools claim its flaw is the potential for "gaps in knowledge" because students may not address some issues in a case. Countered Snead: "For that reason, we employ cases that overlap learning themes," which he claims results in reinforcement in detail and refined knowledge, correcting misunderstandings.

The case scenarios chosen are in fact carefully selected to, at minimum, equate learning imparted through a traditional lecture, but minus the yawning, bobbing heads.

In fact, more than 20 U.S. dental schools, and several international dental schools, have contacted USC for more information on problem-based learning. According to Shuler, whose office has played a central role in the transition, several visiting faculty have sat in to observe the process and learn the teaching skills of being a problem-based-learning facilitator.

Snead said practicing dentists who have observed the problem-based-learning process say it is identical to the process they use in their practices every day.

NIDCR Gives UCSF $11 Million Grant

The University of California at San Francisco School of Dentistry has received an $11 million grant from the National Institute of Dental and Craniofaial Research to study eliminating painful, difficult, and expensive treatments for tooth decay in children as young as 1 year old. Aimed at children from environments with a high incidence of dental problems, the project aims to eventually find results that will help all young people maintain healthy teeth and mouths.

Jane A. Weintraub, DDS, MPH, Lee Hysan Professor of Oral Epidemiology and Dental Public Health, will assume additional duties as director of the new Center to Address Disparities in Children’s Oral Health, based in San Francisco. The center will collaborate on a seven-year program with the San Francisco Department of Public Health and the San Ysidro Community Center, located at the Mexican border south of San Diego. An additional 12 institutions along the West Coast will participate in the work of the center.

"This is the first time that the NIDCR has funded a project so closely networked with community organizations," Weintraub said.

A California survey of children showed that 33 of every 100 children in Head Start programs had dental caries, with even higher rates among children of Asian heritage (44 of every 100) and Latino children (39 of every 100).

"The prevalence of early childhood caries is particularly high among some racial and ethnic minorities and low socioeconomic groups," Weintraub said. "The primary goals of the center are to understand, prevent, and reduce oral health disparities among young children, with a primary focus on preventing early childhood caries."

A secondary focus of the center is to understand the interactions between the oral health and medical delivery systems that an affect children’s oral health, Weintraub explained.

Life Expectancy Hits New High in 2000

Life expectancy for the U.S. population reached a record high of 76.9 years in 2000 as mortality declined for several leading causes of death, according to preliminary figures from a report released by the U.S. Centers for Disease Control and Prevention.

"Americans on average are living longer than ever before, and much of this is due to the progress we’ve made in fighting diseases that account for a majority of deaths in the country," Health and Human Services Secretary Tommy G. Thompson said.

"But we can do even more by eating right, exercising regularly, and taking other simple steps to promote good health and prevent serious illness and disease."

The estimates are featured in a new CDC report, "Deaths: Preliminary Data for 2000," an analysis of more than 85 percent of the death certificates recorded in the United States for 2000.

The report shows that age-adjusted death rates continued to fall for heart disease and cancer, the two leading causes of death in the United States, which account for more than half of all deaths in the country each year. Mortality from heart disease has declined steadily since 1950, while cancer mortality has been on the decline since 1990.

In addition, the preliminary infant mortality rate in the United States fell to its lowest level ever in 2000 -- 6.9 infant deaths per 1,000 live births, down from a rate of 7.1 in 1999.

* The report can be found online at the CDC Web site: www.cdc.gov/nchs.

New Material Can Reduce Caries

Researchers at the National Institute of Standards and Technology are developing a material using amorphous calcium phosphate that can prevents dental caries from forming.

Amorphous calcium phosphate has been shown to cause new mineral growth in cow dentition, according to Joe Antonucci, a polymer chemist at the institute. He said the new material can regenerate small areas but not large ones.

"We don’t think it’s going to work with a large cavity," he said, "because it only repairs small holes and isn’t as strong or hard as conventional filling materials such as ceramic and glass."

But the material may be used as a liner or base for another filling material. That could help to prevent secondary caries from forming around fillings. Also, amorphous calcium phosphate may find a role in the use of orthodontics to keep caries from forming where appliances touch teeth.

Beyond dentistry, Antonucci said, the material may be useful for delicate bone repair such as facial reconstruction. "Long term," he explained, "we envision our material in tissue-engineering applications where you want to remineralize defects in bone with injectable, biodegradable, polymer-based composites."

Study Shows Fee-for-Service Preference

Patients enrolled in fee-for-service dental plans are better satisfied with their dental care than patients in capitation plans, a new report shows.

These findings are consistent with the American Dental Association’s long-held policies about the advantages of private-practice-based, fee-for-service dentistry.

Although managed care had already gained prominence within the U.S. health care system by the early 1990s, increased concentration within dentistry prompted ADA to seek information about the impact it would have on dental care for patients.

Surveyed adults enrolled in capitation plans expressed less satisfaction with their plans than adults enrolled in fee-for-service plans and were less likely to give an "excellent" rating to their oral health.

Such are some of the conclusions of the ADA-funded RAND study, "Self-Reported Behavior and Attitudes of Enrollees in Capitated and Fee-for-Service Dental Benefit Plans." The 1995 ADA House of Delegates authorized the study because the implications of managed care in dentistry were largely unknown.

Dental Pulp Cells May Have Therapeutic Use

Researchers at the University of Michigan School of Dentistry, Ann Arbor, and the Karolinska Institute in Stockholm say research they are conducting on dental pulp cells may one day help improve the lives of patients with spinal cord injuries.

The research focuses on determining if dental pulp cells might have purposes other than making and maintaining teeth, said Dr. Christopher Nosrat, assistant professor at the UM School of Dentistry.

In a laboratory setting, the researchers will grow dental pulp cells and closely monitor the growth and development of nerves within those cells that eventually lead to the formation of proper nerve connections in teeth. The process of dental pulp cell innervation and spinal cord cell regeneration after injury may be similar, Nosrat said. The research seeks to determine if similar mechanisms and molecules may be involved in both processes and how these similarities could be exploited in new treatment strategies for patients with nerve injuries.

"Conceivably, it one day may be possible to extract a tooth, grow dental pulp cells, and implant those cells into a patient suffering from neuro-degenerative disease such as Parkinson's disease," Nosrat said. "While that is the ultimate goal, it still is a long way off. We need to conduct experiments over a long period of time."

JAMA Articles Available on Biological Weapons

In response to the recent concern about biological terrorism, the Journal of the American Medical Association has made the full text of articles on this subject available free to the public.

Beginning in May 1999, JAMA published a series of articles that outlined recommendations for medical and public health professionals following the use of five kinds of biological weapons against a civilian population -- smallpox, anthrax, plague, botulinum toxin, and tularemia. These articles are by the Working Group on Civilian Biodefense and can be found on the JAMA Web site (www.jama.com):

* Anthrax as a biological weapon. J Am Dent Assoc 281:1735-45, 1999.

* Smallpox as a biological weapon. J Am Dent Assoc 281:2127-37, 1999.

* Plague as a biological weapon. J Am Dent Assoc 283:2281-90, 2000.

* Botulinum toxin as a biological weapon. J Am Dent Assoc 285:1059-70, 2001.

* Tularemia as a biological weapon. J Am Dent Assoc 285:2763-73, 2001.

Honors

Gordon L. Douglass, DDS, is the new president-elect of the American Academy of Periodontology. He maintains a full-time private periodontal practice in Sacramento and Folsom, Calif.

Michael G. Newman, DDS, has received the Fellowship Award from the American Academy of Periodontology. Newman is an adjunct professor of periodontics at the University of California at Los Angeles School of Dentistry and a private practitioner in Los Angeles.

Gary C. Armitage, DDS, MS, has received a Special Citation in recognition of outstanding contributions to the American Academy of Periodontology. Armitage is the chair of the Division of Periodontology, professor of periodontics and practitioner at the University of California at San Francisco School of Dentistry.

Upcoming Meetings

2002

Jan. 31-Feb. 3 Yankee Dental Congress, Boston, (508) 480-9797, www.yankeedental.com

March 13-16 Academy of Laser Dentistry Annual Conference & Exhibition, San Diego, (954) 346-3776, www.laserdentistry.org

April 4-7 CDA Scientific Session, Anaheim, (916) 443-3382, Ext. 4470

April 12-14 International Dental Exhibition and Meeting, Singapore, 212 -974-8835, www.idem2002.com

May 7-12 American Academy of Cosmetic Dentistry Annual Session, Honolulu, (800) 543-9220, www.aacdhawaii.com

May 16-19 Organization for Safety and Asepsis Procedures Symposium, Nashville, (800) 298-OSAP, www.osap.org

Sept. 27-29 CDA Scientific Session, San Francisco, (916) 443-3382, Ext. 4470.

Oct. 19-23 ADA Annual Session, New Orleans, (312) 440-2500.

To have a meeting included on this list, please send the information to Upcoming Meetings, CDA Journal, P.O. Box 13749, Sacramento, CA 95853 or fax the information to (916) 443-2943.