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TEAMWORK, HOLISTIC VIEW

SELF-DIRECTED LEARNING,
Swedish Dental Journal, Supplement 235, 2014

AND ORAL HEALTH


LEIF LEISNERT

S W E D I S H D E N T A L J O U R N A L , S U P P L E M E N T 2 3 5 , 2 014 . D O C T O R A L D I S S E R T A T I O N I N O D O N T O L O G Y
LEIF LEISNERT SELF -DIRECTED LEARNIN G, TEAMWORK, HOLIS TIC VIEW AND OR AL HEALTH M A L M Ö U N I V E R S I T Y 2 014

MALMÖ UNIVERSITY
205 06 MALMÖ, SWEDEN
WWW.MAH.SE
isbn 978-91-7104-605-5 (print)
isbn 978-91-7104-606-2 (pdf)
issn 0348-6672
SELF -DIRECTED LEARNING, TEAMWORK, HOLISTIC VIEW
AND OR AL HEALTH
Swedish Dental Journal, Supplement 235, 2014

© Leif Leisnert 2014


ISBN 978-91-7104-605-5 (print)
ISBN 978-91-7104-606-2 (pdf)
ISSN 0348-6672
Holmbergs, Malmö 2014
LEIF LEISNERT
SELF -DIRECTED LEARNING,
TEAMWORK, HOLISTIC
VIEW AND OR AL HEALTH

Malmö University, 2014


Faculty of Odontology
Institution of Oral Public Health
This publication is also available at:
http://dspace.mah.se/handle/2043/17710
TABLE OF CONTENTS

PREFACE.. ...................................................................... 9
ABSTRACT................................................................... 10
POPULÄRVETENSKAPLIG SAMMANFATTNING................... 13
ABBREVIATIONS .......................................................... 19
INTRODUCTION........................................................... 20
AIMS.......................................................................... 24
MATERIALS AND METHODS . . ......................................... 26
RESULTS ..................................................................... 37
DISCUSSION .. ............................................................. 44
CONCLUSIONS . . ......................................................... 60
ACKNOWLEDGEMENTS................................................ 62
REFERENCES................................................................ 63
APPENDIX. . .................................................................. 67
Study I................................................................................. 69
Study II................................................................................. 77
Study III................................................................................ 89
Study IV............................................................................. 101
Questionnaire Study IV......................................................... 131
PREFACE

This thesis is based on the following papers:



Study I
Leisnert L, Mattheos N. The interactive examination in a compre­
hensive oral care clinic: a three-year follow up of students’ self-
assessment ability. Med Teach. 2006 Sep;28(6):544-8.

Study II
Leisnert L, Karlsson M, Franklin I, Lindh L, Wretlind K. Improving
teamwork between students from two professional programs in
dental education. Eur J Dent Educ. 2012 feb;16(1):17-26. doi:
10,1111/j.1600–0579.2011.00702.x. Epub 2011 Sep 27.

Study III
Leisnert L, Hallström H, Knutsson K. What findings do clinicians use
to diagnose chronic periodontitis? Swed Dent J. 2008;32(3):115-23.

Study IV
Leisnert L, Axtelius B, Wennerberg A. A comparison of proposals for
diagnosis and treatment of periodontal conditions by dentists, dental
hygienists and undergraduate students. An analysis based on the
recommendations from the Swedish National Guidelines. Submitted.

9
ABSTRACT

The dental program at the Malmö Dental School, the so called


Malmö-model, is guided by four linked principles: self-directed
learning, teamwork, a holistic view of patient care, and oral health
(Fig.1).

Figure 1. The four guiding principles of problem based learning at


Malmö Dental School, Malmö.

Self-assessment ability is a critical competence for healthcare


professionals, necessary for the successful adaptation to the modern
life-long learning environment. Educational research seems to
point out two critical factors for the development of such skills,
continuous practice of self-assessment (1) and constructive feedback
(2). The first study (3) presented in this thesis assessed students’
self-assessment ability by means of the Interactive Examination in a

10
cohort of senior dental students, who had gone through an identical
assessment procedure during their second year of studies (4). The
results indicated that self-assessment ability was not directly relevant
to subject knowledge. Upon graduation, there were a number of
students (10%) with significant self-assessment difficulties. Early
detection of students with weak self-assessment abilities appears
possible to achieve.

The aim of the second study, concerning teamwork and holistic view
(5), was to investigate if highlighting teamwork between dental and
dental hygienist students could improve the students’ holistic view on
patients, as well as their knowledge of, and insight into, each other’s
future professions. This project showed that by initiating teamwork
between dental and dental hygienist students, it was possible to
increase students’ knowledge on dental hygienists competence,
develop students’ perceived holistic view on patients, and prepare
students for teamwork.

The third study explored findings clinicians used when diagnosing


chronic periodontitis. A questionnaire was distributed to students,
dental teachers and clinical supervisors in the Public Dental Services.

Within all categories of clinicians, the majority of the clinicians used


deepened pocket, bone loss on x-rays, and bleeding as findings.
There were differences in the use of findings between the categories
of clinicians. None of the supervisors used attachment loss as a
finding, while 13% to 27% of the other categories of clinicians used
this finding. A higher frequency of dental hygienist students used
plaque, calculus and pus, compared to the other categories.

Dental hygienist students used more findings for diagnosing as


compared to the other categories of clinicians. Fifty-eight of the
76 clinicians used each finding solitarily, i.e. one at a time, and
not in combination to diagnose chronic periodontitis. However,
about a third of the dental students and the supervisors only used
findings either from the soft tissue inflammation subgroup or
the loss of supporting tissue subgroup. With the exception of the
dental teachers, the majority of clinicians within each category used
irrelevant findings.

11
The third study (6) gave valuable information when designing the
fourth study (7). In the fourth study, a questionnaire was distributed
to 2,455 professional clinicians, i.e. dentists and dental hygienists in
public and private activity, and dental students at the Dental School
in Malmö. The results showed that two groups, representing dentists
and dental hygienists delivering basic periodontal care in Sweden,
were to a significant degree not sharing the knowledge basis for
diagnosis and treatment planning. This may result in a less optimal
utilization of resources in Swedish dentistry. The delivery of basic
periodontal care was not in line with the severity of disease and too
much attention was paid to the needs of relatively healthy persons. To
change this pattern, the incentives in, and structure of, the national
assurance system need to be adapted in order to stimulate a better
inter-collegial cooperation between dentists and dental hygienists in
basic periodontal care.

12
POPULÄRVETENSKAPLIG
SAMMANFATTNING

Bakgrund
Tandläkarutbildningen vid Odontologiska fakulteten vid Malmö
Högskola bygger på ”Malmömodellen”, som utgörs av fyra hörn­
stenar - självstyrt och livslångt lärande, teamarbete, helhetssyn på
patientomhändertagande och oral hälsa (Fig. 1).

Figur 1. De fyra styrande principerna för problembaserad inlärnings­


metodik vid Odontologiska fakulteten, Malmö Högskola.

Det övergripande målet med detta forskningsprojekt är att ur olika


perspektiv belysa dessa grundprinciper samt att jämföra diagnostik
och behandling av oral hälsa och sjukdom för olika kategorier av
vårdaktörer inom grundutbildning och den kliniska professionen.

13
Gemensamt för två av de fyra delarbetena är möjligheten att jäm­
föra agerandet hos studenter med de verksamma yrkesutövarna.
Möjligheten till återkoppling till såväl utbildning som tandvården
utanför utbildningarna är betydande.

Studie 1. Förmåga till självstyrt lärande


Denna studie syftade till att undersöka om förmågan till självvärdering
är relaterat till ämneskunskap och om det förekom en kontinuerlig
förbättring av denna förmåga under den 5-åriga utbildningen.

Självvärdering är en avgörande kompetens för den professionelle


utövarens förmåga att ta ett eget ansvar för självstyrt lärande. Det
är också uppenbart från flera publikationer att alla yrkesutövare
inte har denna förmåga. Även om förmåga till självvärderingen
inte ifrågasätts vet vi lite om hur man bäst stödjer studenterna i
utvecklingen av denna förmåga. Forskning indikerar att två
faktorer är viktiga - kontinuerlig användning av självvärdering
och konstruktiv återkoppling till studenten. Flera tvärsnittsstudier
har beskrivit metoder för att stimulera och utvärdera studenters
förmåga till självvärdering. Det saknas dock longitudinella data
som visar förändringar i studentens förmåga över tid avseende
deras självvärderingsförmåga under utbildningen och hur detta kan
kopplas till effekten av olika utbildningsinsatser.

I den första studien användes en metod - ”Interaktiv examination”


- där 42 studenter på termin 4 (år 2001) och senare på termin 9-10
(år 2004-2005) fick bedöma 1 respektive 3 kliniska fall och föreslå
en behandling som värderades mot den behandling som utförts på
patienten av en lärare. Samtliga studenter fick skriftligen identifiera
skillnader och likheter mellan föreslagen och utförd behandling,
samt definiera nya inlärningsmål. Den skrivna behandlingsplanen
betygsattes liksom förmågan att identifiera nya inlärningsmål.

Kvinnliga studenter redovisade signifikant bättre resultat avseende


behandlingsplanen än de manliga studenterna. Hälften av
studenterna som underkändes 2001 var godkända 2004 medan
hälften av studenterna fortfarande var underkända. Detta innebar
att även i slutet av utbildningen fanns 10 % som hade svårigheter

14
med självvärdering och att identifiera nya inlärningsmål. Det är
intressant att 90 % av dessa kunde identifieras redan i början av sin
utbildning. Studien visade på ett svagt samband mellan förmåga till
självvärdering och ämneskunskaper.

Studie 2. Teamtandvård och helhetssyn


Avsikten med denna studie var att undersöka om ett bättre utvecklat
samarbete mellan de båda studentgrupperna under utbildningen
förbättrade helhetssynen på patienterna, teamarbetet mellan
grupperna samt kunskaperna om varandras kompetenser.

Flera studier visar på epidemiologiska förändringar i Sverige i före­


komsten av tandsjukdomar. Dessutom är finansieringen av tandvård
föremål för kontinuerlig översyn och omprioritering. I Sverige
kommer också antalet tandläkare och tandhygienister att förändras.
Prognosen från Socialstyrelsen för år 2023 är att antalet tandläkare
minskar med 26 % till 5400 och antalet tandhygienister ökar med
47 % till 4700. Sammantaget förutsätter dessa förändringar en
god kooperation mellan tandläkare och tandhygienister i syfte att
optimera resursutnyttjandet och med en helhetssyn på vården med
goda kunskaper om varandras kompetenser. Av tradition sker dock
utbildningen av tandläkare och tandhygienister i utbildningar där
samarbetet mellan studenterna är begränsat.

Deltagare i studien var 34 tandläkarstudenter och 24 tandhygienist­


studenter som gick sitt sista utbildningsår. I början av den näst sista
terminen besvarade de ett frågeformulär som testade deras kunskaper
om varandras kompetenser. Frågeformuläret byggde på ett tidigare
publicerat formulär i Tandläkartidningen med frågeställningen
”Vilken tandvård har tandhygienisterna behörighet att utföra?”.

Samtidigt med den ovan beskrivna undersökningen genomfördes


projekt ägnade åt att förbättra och underlätta teamsamarbetet:

• Företrädare för Folktandvården föreläste om teamprojekt


i sin verksamhet.
• Tandläkarstudenterna fungerade som handledare på
tandhygienistutbildningen.

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• Gemensamma patienter planerades tillsammans.
• Vid ett avslutande seminarium fick teamen redovisa vad som
varit bra och vad som kunde bli bättre.

Projektet avslutades med att studenterna fick besvara ovan nämnda


frågeformulär en andra gång, nu inkluderande en utvärdering av de
ingående projekten.

Kunskaperna om tandhygienisternas kompetens hade ökat i nästan


alla frågor. Avseende de genomförda projekten fick planering och
genomförd vård på gemensamma patienter, samt tandläkarstudenternas
arbete som handledare på tandhygienistutbildningen, högst betyg.

Slutsatserna är att det är nödvändigt och möjligt att dels öka kun­
skaperna om tandhygienisternas kompetens, samt att öka helhets­
synen i vården av patienterna med ett utökat teamarbete i grund­
utbildningen.

Studie 3 och 4. Bedömning och behandling av


olika tillstånd av oral hälsa
De två avslutande studierna behandlar hur tandläkare, tandhygienister
och studenter bedömer och behandlar olika tillstånd av oral sjukdom.

Det finns betydande variationer inom tandvården för hur man


diagnostiserar och behandlar sjukdom. Detta behöver relateras till de
evidensbaserade medicinska insatserna som Socialstyrelsen fastställt
i nationella riktlinjer. En central fråga är om det finns samma
variation hos blivande yrkesutövare, såsom tandläkarstudenter
och tandhygieniststudenter, som det finns bland redan etablerade
kliniska utövare? Hur bedömer och behandlar studenter sjukdom
av olika svårighetsgrad i jämförelse med erfarna tandläkare? Finns
det variation mellan och inom grupperna av studenter och erfarna
tandläkare? En naturlig följdfråga blir vilken betydelse variation i
bedömning av olika grader av sjukdom har för den behandling som
patienten får och om behandlingen är anpassad till sjukdomsbilden?
Hur ser samarbetsformerna mellan aktörerna i teamet ut?

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Frågeställningarna har belysts i avhandlingens tredje samt sista
publikation. Bakgrunden till den tredje studien var att studenter på
Tandvårdshögskolan i Malmö (TVH) använde diagnosen kronisk
parodontit på ett icke konsistent sätt. Det har också genomförts ett
antal internationella konferenser där man försökt definiera olika
former av parodontal sjukdom. I Oslostudien från år 2007 lyfter
man fram inkonsistensen vid registrering av parodontal sjukdom.

I det tredje delarbetet var målet således att undersöka vilka


fynd olika kategorier av kliniska utövare använde för att ställa
diagnosen kronisk parodontit och om det fanns skillnader mellan
och inom de olika kategorierna. En enkät med den öppna frågan:
”Vilka fynd eller kombinationer av fynd använder du för att ställa
diagnosen kronisk parodontit?” distribuerades till sista terminens
tandläkarstuderande och tandhygieniststuderande, kliniska lärare på
TVH och handledare i Folktandvården i Region Skåne. Sjuttiosex
kliniska utövare, som representerade de olika kategorierna, angav
tjugofem olika fynd för att ställa diagnosen kronisk parodontit. De
fynd som angavs mest frekvent av samtliga kategorier var blödning,
fördjupad tandköttsficka och förlust av marginal benvävnad.
Tandhygieniststuderande angav signifikant fler fynd än övriga
kategorier och var mer benägna att använda irrelevanta fynd, dvs.
fynd som inte beskriver själva sjukdomen, t.ex. tandsten, plack och
rökning, jämfört med övriga kategorier. Stor variation inom en och
samma kategori av kliniska utövare sågs också avseende vilka fynd
som användes för att ställa diagnosen kronisk parodontit, dvs. om
man angav fynd som påvisar inflammation i tandens stödjevävnad,
förlust av tandens stödjevävnad eller om fynden var irrelevanta.

Anmärkningsvärt var att de flesta deltagare använde fynden solitärt,


dvs. de angav antingen ett fynd som påvisade inflammation i tandens
stödjevävnad, ett fynd som påvisade förlust av tandens stödjevävnad,
eller ett fynd som var irrelevant. Endast 12 av de 76 deltagarna
angav att de kombinerade fynden för att ställa diagnos, dvs. en
kombination av fynd som beskrev både förlust och inflammation av
tandens stödjevävnad. Variationerna i vilka fynd man använde för
att ställa diagnosen kronisk parodontit medför en risk att patienter
med samma diagnos och sjukdomsbild får olika behandling av

17
olika kliniker, om fyndet som användes för att ställa diagnos också
ligger till grund för behandlingen. Detta kan i sin tur leda till en
kostnadsineffektiv behandling.

Avsikten med den fjärde och avslutande studien var att beskriva
hur professionella utövare i den svenska tandvården och
studenter diagnosticerar och behandlar parodontal sjukdom.
Fanns det gemensamma värderingar mellan tandhygienister och
tandläkare om hur en effektiv arbetsfördelning skulle organiseras?
Återspeglades föreslagen behandling i sjukdomens svårighetsgrad?
I vilken utsträckning var behandlingen i överensstämmelse med
Socialstyrelsens nationella riktlinjer?

En enkät med tre olika fall av parodontal sjukdom sändes ut


till 804 privatpraktiker, 809 tandläkare i Folktandvården, 802
tandhygienister, samt 40 tandläkarstudenter på sista terminen
vid TVH. Fallen beskrevs med olika grad av parodontal sjukdom
inklusive röntgenbilder. Deltagarna ombads bedöma diagnos och
vilken behandling som var indicerad.

En majoritet, 94 %, av de som besvarade enkäten ansåg att en


relativt frisk patient hade sjukdom och 97 % ansåg att risken för
att utveckla fortsatt sjukdom var obefintlig till låg. Trots detta ansåg
man att patienten behövde förebyggande vård. En majoritet föreslog
relativt sett mer tandvård till friska patienter jämfört med patienter
med svår parodontal sjukdom.

De två grupperna, tandläkare och tandhygienister, hade olika


uppfattningar om hur man optimerar resursanvändningen inom
tandvården. Föreslagna insatser bedömdes i hög grad inte vara i
överensstämmelse med sjukdomens svårighetsgrad och för mycket
uppmärksamhet riktades mot behoven hos relativt friska patienter.
För att förändra detta bör strukturen i det nationella tandvårdsstödet
förändras och de nationella riktlinjerna implementeras på ett
effektivare sätt.

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ABBREVIATIONS

PBL Problem Based Learning


CCC Comprehensive Care Clinic
DS Dental Students
DH Dental Hygienists
PP Private Practitioner
PDS Public Dental Service
TVH Tandvårdshögskolan (The Faculty of Odontology)
MAH Malmö University
DHS Dental Hygienist Students
DT Dental Teachers

19
INTRODUCTION

The dental program at the Malmö Dental School (TVH), the so


called Malmö-model, is guided by four linked principles: self-directed
learning, teamwork, a holistic view of patient care, and oral health
(Fig.1).

Figure1. The four guiding principles of problem based learning at


Malmö Dental School, Malmö.

Self-directed learning is implemented as problem-based learning


throughout the whole dental program (8). The holistic view is
interpreted as caring for the individual rather than providing
quantities of items of dental treatment. Furthermore, such a holistic
view towards the patient should encourage students to approach
their knowledge and understanding, skills and ability, judgment and

20
stance as expressed in the Swedish Higher Education Ordinance
(9). In turn, the holistic view provides a basis for oral health to be
maintained, that has been chosen in preference to dentistry seen only
as a practical skill. To achieve this, teamwork is developed through
work in study groups as well as in clinical settings (5).

In the clinical setting, students take care of their own patients


from their second to their final semester. Students have a gradually
increasing responsibility for the oral health care of their patients,
who present oral health needs of increasing complexity. From the
onset, an environment is created in which provision of care is related
to: (i) a fundamental understanding of the needs and demands of the
individual patient, (ii) evidence-based clinical interventions, and (iii)
an inter-disciplinary approach to oral health care. This is enhanced
during the 8th to the 10th semesters when students, assisted by
dental nurses, experience comprehensive care in teamwork with
dental hygienist students and dental technicians. The prescription
of dental laboratory work is another important inherent part of the
program - especially during this comprehensive care period. This is
essential because teamwork contributes to a developed holistic view.

This thesis contains four publications trying to highlight these four


linked principles. Thus, each principle will be linked to the studies
in the thesis.

Publications 3 and 4 specifically compare students to dentists and


dental hygienists outside educational programs.

Ability to self-directed learning


Self-assessment ability is a critical competence for healthcare
professionals, necessary for the successful adaptation to the essential
and imperative life-long learning in a modern healthcare context.
Educational researchers seem to agree that self-assessment ability,
especially in a professional context, is a skill which can be learned,
developed and excelled (10). It is also evident that not all professionals
possess this ability to a satisfactory degree, thus jeopardizing the
implementation of lifelong learning attitudes (11).

21
Although the importance of self-assessment seems unquestionable, not
much is known about how to best assist students in their development
of this ability. Furthermore, numerous studies at various levels of
training have shown that healthcare students often possess modest
to poor self-assessment abilities (12). Educational research seems to
point out two critical factors for the development of such skills and
these are continuous practice of self-assessment (1) and constructive
feedback (2). Based on these two elements, several authors have to
various extents described and evaluated methodologies designed
to assist the development and even assessment of students’ self-
assessment ability (3,12,13).

However, the majority of available research consists of one-shot


cross-sectional studies. Such studies offer important insights, but lack
the ability to investigate development and change over time. There
is a current lack of longitudinal data in the field of self-assessment
ability. Longitudinal data could allow educators to better register and
follow how students’ self-assessment abilities develop throughout
the curriculum and would also provide the urgently needed
documentation for the effectiveness of educational interventions.

The Interactive Examination is a structured examination scheme


aiming to assess not only students’ knowledge and skills, but also
their ability to accurately assess their own competence (4). The
first study presented in this thesis “The interactive examination in
a comprehensive oral care clinic: a three-year follow up of students’
self-assessment ability”, assesses students’ self-assessment ability by
means of the Interactive Examination in a cohort of senior dental
students. These had gone through an identical assessment procedure
during their second year of studies. The study aimed to assess
students´ self-assessment ability, in parallel with their knowledge and
competences.

Teamwork and holistic view


In Sweden, the National Board of Health and Welfare forecasts a
decrease of the number of dentists with 26% and an increase of
dental hygienists with 47% until the year of 2023 (14). This, together
with changes in both epidemiology, especially of dental caries,

22
and political priorities, calls for an effective and well-developed
cooperation between dentists and dental hygienists in the future of
dentistry.

Hence, the aim of the study concerning teamwork and holistic view
was to investigate if highlighting teamwork during the undergraduate
studies of dental students and dental hygienist students, could
improve the students’ holistic view on patients as well as their
knowledge of each other’s future professions.

Oral health
This work began with the third study entitled “What findings do
clinicians use to diagnose chronic periodontitis?” (6), which in turn
offered valuable information when designing the fourth study entitled
“A comparison of proposals for diagnosis and treatment by dentists,
dental hygienists and undergraduate students. An analysis based on
the recommendations from the Swedish National Guidelines” (7).
The fourth study was distributed to 2,455 professional clinicians,
i.e. dentists and dental hygienists in public and private practice and
dental students at the dental school in Malmö.

It should be mentioned that the third study was the second one in
a time line but, since it related more to the principal of oral health,
it has more connection to the concluding fourth publication. The
results were used when constructing the questionnaire for the fourth
publication.

The third and fourth study were ethically approved by the Regional
Ethical Board in Lund with registration numbers 317/2006 and
593/2010, respectively.

23
AIMS

The aims of this thesis were to highlight, from different perspectives,


the basic principles guiding the education at TVH. The thesis consists
of four publications.

• Study I: The interactive examination in a comprehensive oral


care clinic: a three-year follow up of students’ self-assessment
ability.
Leisnert L, Mattheos N. Med Teach. 2006 Sep;28(6):544-8.

This study aimed to find out whether self-assessment ability is relevant


to subject knowledge and if there was continuous improvement in
this regard in the 5-year educational program.

Since there was a lack of longitudinal data showing how students’


self-assessment abilities develop throughout the curriculum, this
study tried to assess students’ self-assessment ability at two points in
their studies (2nd and 5th year).

• Study II: Improving teamwork between students from two


professional programs in dental education.
Leisnert L, Karlsson M, Franklin I, Lindh L, Wretlind K. Eur
J Dent Educ. 2012 feb;16(1):17-26. doi: 10,1111/j.1600–
0579.2011.00702.x. Epub 2011 Sep 27.

This study had the objectives of examining whether placing a stronger


emphasis on teamwork during the undergraduate studies of dental
and dental hygienist students could:
– Increase the students´ knowledge of future professional
collaborations with special emphasis on the dental hygienists´
field of competence;
24
– Develop a holistic view and approach towards patients, as
experienced by the students;
– Prepare the students for teamwork in their future professional
life.

• Study III: What findings do clinicians use to diagnose chronic


periodontitis?
Leisnert L, Hallström H, Knutsson K. Swed Dent J.
2008;32(3):115-23.

This was the first study in the thesis on the issue of diagnosing
chronic periodontitis. The aims were to examine:
– What findings dental students, dental hygienist students,
dental teachers, and supervisors in Public Dental Health
used in order to diagnose patients with chronic periodontitis;
– Whether different categories of clinicians used different
findings to diagnose chronic periodontitis. The hypothesis
was that there were differences both between and within the
categories of caregivers;
– Whether irrelevant clinical findings were used in diagnosing
chronic periodontitis.

• Study IV: A comparison of proposals for diagnosis and treat­


ment of periodontal conditions by dentists, dental hygienists
and undergraduate students. An analysis based on the recom­
mendations from the Swedish National Guidelines.
Leisnert L, Axtelius B, Wennerberg A. Submitted.

The aims of this study were to explore:


– How professional clinicians in dentistry performed diagnostic
procedures in general;
– If there was a common ground between dentists and dental
hygienists concerning sharing different job assignments in an
effective way;
– If the methods of treatment used was in accordance with the
degree of severity of the disease;
– To what extent the proposed treatment was in accordance
with the National Guidelines.

25
MATERIALS AND METHODS

Study I. Guiding principle: self-directed learning


The Interactive Examination Method
The interactive Examination was introduced in 1998 at the faculty
of Odontology, Malmö University (4). A number of studies have
evaluated different applications of the Interactive Examination,
including web-based (4) and teleconference-based ones (15). The
important element for the assessment of reflective skills appears to
be the so called “comparison document” (4) . In this procedure, the
students received a task in the form of a clinical problem and were
expected to provide a written account of their solution, usually a
diagnosis and treatment plan. Thereafter, they received a solution
proposed by a qualified dentist. This solution was not the only or
the best treatment possible, but represented a grounded opinion of
a qualified colleague, reflecting his or her priorities and reasoning.
The students then had to come up with a “comparison document”
within a week, where they compared their own answer to that of the
qualified dentist. In their comparison, the students were expected
to identify differences and similarities between the two solutions,
investigate and elaborate on the reasons why these differences
existed, and consequently define learning objectives for the future.

The assessment was based on two elements:


– Students’ subject related competence, as this was expressed through
their proposed solution to the clinical case. The assessment of
student’s performance was based on a matrix reflecting the specific
learning objectives of each case.

26
– Students’ reflective skills, as expressed by their ability to point out
weaknesses in their proposed solution, base their choices on sound
arguments, and consequently define relevant future learning needs.
The assessment of this skill was done through a special matrix (see
Table 1, Study I, p. 545) which assessed the student’s comparison
document on a scale ranging from 3-9.

The sample
A whole cohort of final year students (n=48) went through the
Interactive Examination with three clinical cases in the Comprehensive
Care Clinic (CCC) during a period from November 2004 to January
2005. The students of that year had a final theoretical and practical
examination in December, and the successful completion of this
allowed them to start their six month period of vocational training
in public dental clinics. Consequently, the students completed the
first two cases before their final examinations and worked through
the third case right after this examination.

The clinical cases


A special project site was created in “Web zone”, the Internet learning
content management system, used at Malmö University at that time.
All students and resource persons were registered members of the
project and had access to public functions, as well as a private folder.

Each case was presented at a given time through an interactive


PowerPoint slideshow. Below the appropriate hyperlinks, each case
provided the student with general and dental history, current status,
major complaints, patient’s wishes, extraoral, intraoral and x-ray
images. After each case was published, students had about two
weeks to come up with a written complete treatment plan, which
they should then upload in their private folder.

When this stage was completed, the author of the case could
publish the treatment plan he followed together with the outcome
of the treatment. Students then had another week to compare their
treatment plan to the one published and prepare a written comparison
document, according to the previously described principles.

27
The feedback the students received after each case was organised in
two forms:

• A written commentary, presenting the key issues of each case


and discussing the most common characteristics of students’
treatment choices.
• A group discussion where each case and the treatment plan, as
well as students’ common choices, were thoroughly discussed
with the case author and expert resource persons, respectively.

Evaluation of performance
Each student’s written treatment plan (see Table 2, Study I,
p. 546), was evaluated by use of a specific matrix. The matrix for
each case included a number of key issues representing knowledge
and attitudes a clinician must have, according to the established
standards of the CCC. These key issues were expressed in equivalent
points, the number of which differed slightly in the three cases. The
maximum score for case one, two and three was 18, 21 and 17,
respectively, with the level of acceptance set to 12, 14 and 11 points.
The evaluation framework was designed by the author (LL) of the
three cases, who was also the one to grade students’ performance.
The case in 2001 was assessed on a scale ranging from 1-6.

Students’ comparison documents were evaluated through the


previously designed matrix (see Table 1, Study I, p. 545). This matrix
was used for all three cases and it was also used in 2001 for the same
purpose.

Evaluation of attitudes
Students’ attitudes were evaluated after the completion of each case
through an anonymous, standardised questionnaire.

Statistical analysis
Grades on the written treatment plan were analysed for the
42 students who participated both in the 2001 and 2004 cohorts.
Differences between male and female student’s scores within each
case were analysed with unpaired t-test. The grades for both the
written treatment plan and the comparison document for each case
in 2004 were compared with performance data of the same students

28
in the year 2001, with a linear regression analysis. The students
who presented unacceptable comparison documents in 2004 were
compared with those unacceptable in 2001, in an attempt to track
weak students’ development.

Individual student differences between grades in the comparison


document of each of the cases in 2004 and the same in 2001 were
analysed with a paired t-test.

Study II. Guiding principles: teamwork, holistic view


Students from two dental programmes, dental hygienist and dental
students participated in the study.

The project was designed as an intervention study with different


activities including seminars, treating patients together, and with
presentations of the outcomes of the treatments, framed by pre-
and post-test. As a pre-test a questionnaire was used (16), mapping
the students’ knowledge on a sample of the dental hygienists´
competences. Post-test included answering the same questionnaire
once more, with questions relating to how the different activities
were experienced and to what extent they were deemed useful by
the students.

Project organisation
In the research group for the project, responsible for planning,
directing and carrying out the activities, students and staff from
both the dental hygienist and dental programmes participated.
The project was introduced and started during the spring 2007 by
launching a website within the learning management system of the
Malmö University, acting as a platform for both information and
interactions.

Participants
Beginning from their eighth and second semester, respectively, 34
dental students and 24 dental hygienist students participated in
the study. Teams consisting of one dental student and one dental
hygienist student were formed. As the number of dental students was
larger than dental hygienist students, some dental hygienist students
had two dental students to cooperate with.

29
Activities
A number of activities were carried out during the course of the study
(Fig. 2).

Questionnaire 2
Questionnaire 1

Seminar 1 Seminar 2 Seminar 3

Mar Jun Sep Dec Mar


-08 -08 -08 -08 -09

Teamwork

Dental students supervising

Figure 2. The figure depicts activities carried out during the course
of the study.

Questionnaire
The questionnaire consisted of 23 questions on whether or not dental
hygienists are licensed for the competences described in the different
questions (see Appendix 1 in study II). The same questionnaire was
answered one year later. Between the two tests a number of activities
were performed.

Seminars
Three seminars were held during the course of the study:
Seminar 1: An introduction of the project including a session with a
dentist from the Public Dental Services (PDS), presenting the visions
and experiences of a teamwork model developed and successfully
practised at the PDS.

Seminar 2: Presentations held by ten chosen teams of students, each


group presenting different aspects of how to plan and carry out the
treatment of two web-based patients. All students attended this
seminar together with supervisors from different fields of dentistry.

30
Seminar 3: Presentations given by six chosen teams of students, each
group presenting how they planned and carried out the treatment of
shared patients in the students’ clinic. Discussions on the outcome of
the treatment were also an integral part of this seminar.

Prior to the final session, the students were asked to write down
problems and possibilities that they had encountered during their
team collaborations. These were discussed during the last seminar, as
well as the students´ suggestions for future professional cooperation.

Teamwork
As mentioned earlier, the dental students and the dental hygienist
students were divided into teams. In these teams, they planned and
carried out the treatment of both web-based patients and patients
attending the students´ clinic.

The web-based cases were presented and made available on the


website of the project, where electronic folders for each team were
created as well. In the folders the teams documented their discussions
and agreements regarding the web-based cases on the following
items: diagnosis, treatment planning and prognosis.

In the folder they also had to document, present and discuss 2-4
shared patients from the student’s clinic. During the students’ clinical
work, they and their clinical instructors could draw on the expertise
of one experienced dentist and one experienced dental hygienist
in order to support them with encouragement and pinpointing
opportunities and advantages of teamwork.

Supervision
To increase the interaction surface between students and to an even
greater extent provide opportunities for developing understanding
and knowledge on how to cooperate as a dental team, the dental
students supervised the dental hygienist students in their clinical
practise on one to two occasions.

31
Students´ opinions on different activities
and parts of the project
Students assessed the different activities and how they valued their
contribution in developing successful teamwork. The questionnaire
used for this purpose was designed with a number of statements
concerning the different activities, where students could mark
whether they agreed or disagreed with the statements on a Visual
Analogue Scale (VAS) from 1 to 10.

Methodological considerations
The first questionnaire was answered by 32 out of 34 dental students
and 23 out of 24 dental hygienist students. On the second occasion,
30 out of 32 dental students and 20 out of 20 dental hygienist
students answered the questionnaire. The missing answers were due
to electives, Erasmus exchange, interrupted studies or illness.

Study III. Guiding principle: Oral health


Study design
The questionnaire explored findings clinicians used when diagnosing
chronic periodontitis, where one open question was: “What findings,
or combination of findings, do you use when you diagnose chronic
periodontitis?”

The questionnaires with included information were distributed to


dental teachers at the faculty by one of the researchers (LL) in a
personal meeting. Supervisors in the PDS were informed via e-mail
and after a general meeting at the faculty the questionnaires were
distributed and answered directly after the meeting. The students
filled out the questionnaire at the school in conjunction with their
clinical work. The participation of the dentists was voluntary and
anonymous, while it was regarded as a part of the education for
the students. The licensed dentists stated their age, gender, years of
experience as dentist, and specialists noted type of speciality. Teachers
at the dental hygienist education did not participate because they
were too few to form a group that could be statistically analysed and
compared with the other categories of clinicians.

32
Clinicians
Dental students (DS):
Thirty-seven dental students, in their final month of a 5 year-
education at the TVH, were asked to participate. Twenty-two of
the students answered the questionnaires. Thirteen were females and
nine were males. The mean age was 27 years (range 24-36) for the
females and 26 years (range 24-30) for the males. Fifteen students
could not participate due to other commitments; these students were
therefore not obliged to participate.

Dental hygienist students (DHS):


Sixteen dental hygienist students in their final month of a 2 year-
education at TVH, were invited to participate. Fourteen females and
one male of a total of 16 students participated. The mean age was
31 years (range 21-45 years). One student did not participate due
to illness.

Dental teachers (DT):


Eighteen dental teachers in the CCC at TVH were invited to
participate. The teachers worked at the CCC four to 16 hours per
week. Twelve teachers participated, four of these were specialists in
prosthodontics, two in periodontology and six were general dental
practitioners. Six teachers were females and six were males. The
mean age was 47 years (range 34-67), for the males 53 years and for
the females 41 years. The mean age of the 18 teachers that worked
at the CCC were 45 years (range 34-67). The questionnaires were
returned anonymously in such a way that no drop-out analyses could
be performed without unmasking the anonymity. The reason for this
being that drop-outs could easily have been identified since they were
all known by the authors according to age, gender and speciality.

Supervisors in the PDS:


Thirty dentists in PDS, who also had a role as supervisors for dental
students in their period of outreach training, were invited via e-mail
for participation. Twenty-seven supervisors, 15 females and 12 males,
participated in the study. The mean age was 52 years (range 36-65)
for the females and 49 years (range 30-64) for the males. Three of the
30 dentists did not participate due to other commitments.

33
Statistical analysis
If differences existed between the numbers of findings clinicians used
when diagnosing chronic periodontitis, each category of caregiver
was analysed with one way analysis of variance (ANOVA). If
differences existed, Tukey’s test was used to analyse between which
categories these differences existed. Differences between different
categories use of respective findings were analysed using the Chi-
squared test (p=0.05).

Study IV. Guiding principle: Oral health


Respondents
From each professional organization of dentists in the PDS, private
practitioners (PP) and dental hygienists (DH), some 800 names were
randomly selected for a questionnaire study. Of the respondents, 346
were PP, 349 from the PDS, 369 DH and 39 DS on their tenth and
last semester of their five year dental education.

A questionnaire was constructed consisting of three typical patient


cases showing different degrees of periodontal disease. The case
construction was made in accordance with the grouping in the first
Jönköping study (17) and used throughout their following studies
up to 2008.

The questionnaires were distributed in the beginning of October


2011 and it was followed by two reminders, four and seven weeks
after the original distribution, to those who did not answer the
first mail. In total, 2,455 questionnaires were sent out and the
participation was voluntary and anonymous. The questionnaire was
completed by 1,103 respondents (47%), while 1,226 did not return
the questionnaire and 126 were returned by the Postal Service, i.e.
it was not possible to deliver or the respondents mailed back and
informed us that they for different reasons did not want to answer
the questionnaire. The reasons for this were e.g. weakened health,
no present activity in their profession or the questionnaire was too
extensive and time consuming. The DS answered the questionnaire
in conjunction with one of their clinical session. Of the students, 40
received the questionnaire and 39 answered it (98%). Four students
were absent due to illness and other commitments. The students also
participated voluntarily.

34
The completed questionnaires were scanned at the University
of Linköping and transformed into a SPSS file. The scanned
questionnaires were validated through a random sample (n=120) of
all the questionnaires securing that a specific questionnaire with its
number in the SPSS file had the right characteristic concerning age
and gender. No misrepresented data was discovered.

Description of the clinical cases in the questionnaire:


Case 1- healthy individual
Female, 45 years old, healthy and no medicines. Yearly check-ups.
Plaque index 28% , bleeding when probing 22%. Small amount of
calculus in the front of the lower jaw. No horizontal bone loss.

Case 2- localized mild periodontitis


Male, 55 years old, healthy and no medicines. No check-up for the
last 3 years. Has the feeling that it is bleeding when he brushes his
teeth. Plaque index 40%, bleeding when probing 31%. Subgingival
calculus and pus 17m, 16d and 26d. Deepened pocket >4 mm at 24
surfaces. Marginal bone loss ≤1/5 of the root. Vertical bone pockets
17md, 16d, 46d, 26d and 27m. Furcation involvement 17, 16 and 26.

Case 3- generalized advanced periodontitis


Male 45, years old. Medical treatment of high blood pressure. In
other aspects healthy. Smokes 20 cigarettes/day. New patient, no
check-up for the last 5 years. Has the feeling that it is bleeding when
he brushes his teeth. Plaque index 50%. Bleeding when probing 41%.
Subgingival calculus lingually in lower jaw. In general, deepened
pockets >4mm. Generalized marginal bone loss 1/3-1/2 of the length
of the root. Bone pockets 36m and 46m. Furcation involvement 16,
26, 37, 36, 46 and 47.

In the questionnaire to the clinicians, there were questions concerning


gender, age, whether they worked in private or public dental service,
whether they worked in big or small towns and where they were
educated. In each case, there was a question if the patient was
considered to have periodontal disease or not and whether treatment
was suggested or not.

35
Also, there were questions about what clinical findings they used
for the diagnostic classifications, what treatment was proposed, and
which category of caregiver – dentist, dental hygienist or specialist
– they deemed best suited to perform the treatment. There were
choices from a list of alternative treatments possible to combine. All
treatments were chosen from the National Guidelines as presented
by The National Board of Health and Welfare.

Statistical analysis
All data was inserted into the IBM SPSS Statistics version 20. An
analysis of the missing answers, compared to those who answered,
was made with a logistic regression analysis concerning age, gender
and occupation. There were no statistically significant differences
between the groups concerning these factors.

A frequency analysis was made for all groups together for the
different questions and cross tabulation with Pearson Chi-squared
test was used to analyse differences between the participating groups.

36
RESULTS

Study I. Guiding principle: self-directed learning


The average scores of students’ written treatment plans and
comparison documents in the three cases mentioned above can be
seen in Table 2, Study I, p. 546. Only the grades of written treatment
plans in case 2 in 2004 were positively correlated with the respective
grades in 2001 (p=0.02, r= 0.34). Female students performed
significantly better than males in two out of three cases in the written
treatment plan in 2004.

Regarding the comparison documents, the grades on case 1 (p=0.001,


r = 0.48) and case 2 (p = 0.0002, r = 0.55) presented a strong positive
correlation with the respective grades in year 2001. Comparing
document grades in the year 2004, these were in all three cases higher
than those of 2001, but the difference was statistically significant
only for case 1 (p < 0.0001). Female students received significantly
higher grades than males in all three cases.

A total of eight comparison documents were judged unacceptable


throughout the three cases. All eight documents originated from five
students, four of which were also among the nine students who were
judged unacceptable in the year 2001 in the same field. The average
score in the 2004 comparison document for these nine students
(unacceptable in 2001) was 6.1 for the first case, 4.5 for the second,
and 5.1 for the third. This was in all cases lower than the average
score of the cohort and this difference was statistically significant for
cases 1 and 2 (p = 0.01 and 0.001), respectively.

37
Study II. Guiding principles: teamwork, holistic view
Students’ knowledge on the competences of the dental hygienist
The results of the first questionnaire showed that it was mostly
the dental students who lacked knowledge of the competences of
the dental hygienists. In nine out of 23 questions more than 50%
provided a wrong answer. For instance, between 50 to 70% did not
know that dental hygienists (in Sweden) are allowed to: decide on,
carry out and diagnose x-rays concerning caries and periodontitis;
prescribe alcohol, fluoride and anaesthetics to their place of work;
decide on and carry out bleaching of teeth; glue small pieces of
jewellery on the teeth; and/or decide on and carry out bacterial
analyses of saliva.

Concerning dental hygienist students, more than 50% answered


wrongly in five out of the 23 questions. Their gaps of knowledge
were on: not being aware of allowance to possess x-ray equipment
when practicing on their own; not being allowed to diagnose diseases
in mucous membrane; being allowed to carry out fissure blocking;
decide on and carry out bleaching of teeth; and/or to manufacture a
bleaching tray.

At the concluding seminar, the students’ knowledge had improved


on about almost all matters in the questionnaire (see Figures 2a and
2b, in Study II, p. 3).

Evaluation of activities carried out during the project

1. Seminar on teamwork with adentist from the Public Dental


Health Services.
Dental hygienist students (DHS) rated this seminar to 6.9, while
dental students (DS) rated it 5.3.
2. The fictional web-based clinical cases, with treatment planning
in teams followed by a seminar with a presentation of the sug­
gested treatment.
We noted a significant difference between the dental hygienist
students who scored 4.5 and the dental students who scored
6.7, whether to what degree this activity was valuable or not
(see Figure 3, Study II, p. 4).

38
3. Question to the students: Have the two questionnaires on dental
hygienists competences increased your knowledge on which
competences dental hygienists have?
Dental hygienist students gave a scoring of 6.6 and the dental
students 7.2.
4. Dental students supervising dental hygienist students.
This part scored high especially among the dental hygienist
students (7.1), who claimed that the teamwork had increased,
the holistic approach on patients had been strengthened, and
that they had gained valuable experiences for future cooperation.
Concerning the holistic view on patients, there was a significant
lower score from the dental students (4.8). Both groups found
it valuable to make this part permanent (DHS=8.2; DS=7.0)
(see Figure 4, Study II, p. 4).
5. Team-work with shared patient.
Both groups of students felt that treating shared patients should
become a permanent part of the education (DHS=9.1; DS=7.0)
and start earlier (DHS=8.7; DS=6.3, a significant difference). In
addition, the students experienced sharing patients to increase
the knowledge – interplay concerning teamwork (DHS=8.4;
DS=7.5, a significant difference) and the knowledge on the
team members’ competences (DHS=8.3; DS=7.9). Furthermore,
it gave valuable experiences for future cooperation (DHS=8.0;
DS=7.4) and a more holistic view on patients (DHS=8.5; DS=6.3,
a significant difference).
The dental hygienist students display the same pattern of giving
higher scores on questions (see Figure 5, Study II, p. 4).

Study III: Guiding principle: Oral health


After the data had been collected, the questionnaires were read by
all the authors. Analyses of the answers were performed stepwise. In
a first step, the questionnaires were scrutinized to find content-word
or concepts that could be coded as a finding. Twenty-five different
findings were identified as findings the clinicians used to diagnose
chronic periodontitis. In a second step, different content-words or
concepts that could be interpreted as the same finding were brought

39
together. For example, bleeding on probing and bleeding index were
registered as bleeding. Further, subgingival and supragingival calculus
were registered as calculus, and plaque and plaque index were
registered as plaque. In a third step, findings registered by less than
three participants, were excluded. Such findings were age, halitosis,
genetics, and diabetes. After these steps, 13 findings remained and
were further analysed.

Findings
The 13 findings were divided into three subgroups showing: soft
tissue inflammation, loss of supporting tissue, and irrelevant findings,
i.e. findings that were considered not to be relevant for diagnosing the
disease per se. (see Table 1, Study III, p. 118) presents the subgroups
of these findings.

Figure 1, Study III, page 119, presents the number of clinicians


that used each of the 13 findings to diagnose chronic periodontitis.
Within all categories of clinicians, the majority of the clinicians used
deepened pocket, bone loss on x-rays, and bleeding. There were
differences in the use of findings between the categories of clinicians.
None of the supervisors used attachment loss as a finding, while 13%
to 27% of the other categories of clinicians used this finding (p<0.05).
A higher frequency of dental hygienist students used plaque, calculus
and pus, compared to the other categories (p<0.05).

Dental hygienist students used more findings as compared to the


other categories of clinicians (p<0.05) (see Figure 2, Study III,
p. 119). They registered in average six findings that provided soft
tissue inflammation or loss of supporting tissue. All the other
categories used in average four findings. The different categories
usage of the 13 findings is presented in Table 2 and 3 Study 3, page
120. There was a difference in the number of findings that each
category of the clinicians used, as presented in Table 2. Fifty-eight
of the 76 clinicians used each finding solitarily, i.e. one at a time,
and not in combination to diagnose chronic periodontitis. However,
about a third of the dental students and the supervisors only used
findings either from the soft tissue inflammation subgroup or the
loss of supporting tissue subgroup. The distribution of clinicians that

40
used irrelevant findings is presented in Table 3. With the exception
of the dental teachers, the majority of clinicians within each category
used irrelevant findings.

Eighteen clinicians, four dental students, two dental hygienist


students, seven dental teachers and five supervisors, out of totally
76 participants, reported that they combined two findings to reach
the diagnosis. However, of these 18 clinicians only 12 combined one
finding that provided soft tissue inflammation with a finding that
provided loss of supporting tissue. The other four only combined
findings that all provided loss of supporting tissue.

Study IV: Guiding principle: Oral health


In table 1 (see study IV, p. 10), market demand for clinicians in
different dental care sectors are depicted. PP had the lowest number
of dentists with patients waiting for dental care (17%), while the
same figure for PDS was 52%. Lacks of patients were evident from
18% of the PP, 8% of the dentists in PDS and 8% of DH.

In table 2 (see study IV, p. 11), the results from the question whether
the practitioners regarded the different patients to have a disease
or not, are depicted. No significant differences were found between
caregiver groups in case 1, 2 and 3. In case 1, almost 94% considered
that the patient had disease, while 6% considered that the patient
had no disease. For case 2 and 3, almost 100% had the opinion that
patients had periodontal disease.

In table 3 (see study IV, p. 12), the clinicians were asked to describe
what risks they forecasted for developing gingival or/and periodontal
disease. The different groups scored between 86 to 97%, with 86%
saying the risk is low and 97% saying the risk is none or low.
No significant differences were found between the groups. The 2.6%
of the students saying there was no risk of developing disease in any
of the cases, represent one student.

Table 4 (see study IV, p. 13), depicts whether the respondents


regarded that the patients needed preventive care or not. In case 1,
the students to a greater extent rejected that preventive dental care

41
was needed, i.e. 17% in comparison to the other groups who scored
about 8%. However, there were no significant differences between
the caregiver groups. Still, about 91% of the professional clinicians
wanted to give preventive care in this case.

In table 5 (see study IV, p. 14), the opinion is depicted about what
category of dental caregiver should examine the patient. In case 1,
there were significant differences between the groups: 74% of the
private practitioners, 49% of the dentists in the public dental services
and 59% of the students wanted the dentist to examine the patients,
while only 21% of the dental hygienists considered a dentist should
examine the patient (p=0.000).

In case 2, the corresponding figures for caregiver groups were 88%,


80%, 72% and 67%, respectively. A significant majority of dental
hygienists considered that they should examine the patients, while
a majority of the dentists thought that a dentist should examine the
patients (p=0.000).

In case 3, the corresponding figures for caregiver groups were 85%,


50%, 92% and 70%, respectively. In this case, a majority of all
caregiver categories considered that the dentist should perform the
examination, although 45% of the hygienists felt prepared to do
so. In general, private practitioners to a significantly higher degree
wanted to perform the examination of the patients (p=0.000).

Table 6 (see study IV, p. 16), depicts to what extent treatment was
suggested and what category of dental caregiver should perform
instruction for effective self-care. Relative agreement could be
found between the groups that dental hygienist should perform
this treatment. Dental students and private practitioners had lower
scores, i.e. less support for leaving this to dental hygienists. The
respondents had a possibility to choose more than one option. There
were significant differences between categories of caregivers in all 3
cases, with the exception of specialists.

42
In Table 7 (see study IV, p. 17), the respondents were asked to describe
what findings they used for diagnoses with regard to presence of
plaque and calculus.

Table 8 (see study IV, p. 19), depicts what category of dental caregiver
should perform professional cleaning of the teeth, according to the
respondents. A significant difference appeared. In case 1, 15% of
the PP wanted to give professional cleaning, while 0.3% of the DH
wanted the dentist to perform this procedure. The corresponding
figures for PDS were 7% and DS 0%, respectively (p=0.000). The
PP was more inclined (25%) to let the dental nurse perform this
treatment (p=0.000).

43
DISCUSSION

In the book “Qualitative methods” by Malterud (18), the author


claims three fundamental conditions for scientific knowledge –
relevance, validity and reflexivity. Relevance tells us what the new
knowledge could be used for. Validity is about if the new knowledge
is true and can be transferable to other situations and conditions.
Reflexivity is about the researcher’s ability to raise questions and
doubts around the results from the research results. During this
discussion these aspects will be highlighted related to the different
publications.

Study I: Guiding principle: self-directed learning


The main focus of the first study was the reflective process, which is
initiated through comparing your own work with that of someone
else. This process is well founded in students’ self-assessment ability,
which is a necessary professional skill. In this study, self-assessment
ability is addressed as it applies on profession-related activities. The
general skill of self-reflection, however, appears to be more of an
element of personality, often associated with personal and cultural
characteristics (19). It would be of great interest in future studies to
investigate how the general self-reflection ability is connected with
professional or task-related self-assessment skills.

Very few studies with a longitudinal perspective are available in this


field. One study (20) followed medical students’ self-assessment
ability at four intervals over the course of their first three years. They
concluded that self-assessment accuracy measures were relatively
stable over the first two years. In another study (21) conducted during

44
the first year of dental education, it was found that students’ self–
assessment ability increased during the course of three consecutive
semesters.

The students in this study had an opportunity early in their studies


for self-assessment, i.e. in 2001, when their profession-related self-
assessment ability was evaluated. In the three years that followed,
the students did not go through any structured intervention of the
same magnitude. However, as their PBL curriculum included many
instances of self-assessment and constructive feedback, one should
expect that by the end of their studies these students would present
a more mature and complete ability to assess their competence. This
is actually one of the critical functions of the healthcare curriculum,
although rarely evaluated (22).

The students’ task in 2004 to present a written treatment plan is


not comparable to the written task they had in 2001. Therefore no
attempt was made to compare students’ performance in this respect.
However, correlations of their grades between 2001 and 2004 were
investigated in order to see if the patterns of students’ achievements
were repeated. The correlations between the written treatment plans
with grades between 2001-2004 were in general poor, while there
was a moderate positive correlation in one of the three cases.

In contrast to the written task, the comparison of documents was


used in the same way both in 2001 and 2004 and is the main focus
of the study, as it attempts to evaluate not subject related knowledge
but reflective skills. Interestingly, the grades of the self-assessment
ability in 2004 presented a higher correlation with those of 2001,
than the actual subject related knowledge did. In addition, as seen in
case 3, self-assessment ability remained rather stable even when the
written performance was low.

These observations indicate that the self-assessment ability was


not directly tied to subject knowledge. Although students seemed
to have developed their knowledge and understanding in different
ways in the years that followed 2001, their self-assessment ability
was correlated to the one measured in 2001 much more than their

45
actual subject knowledge was. Consequently, the improvement of
the self-assessment skills should be a parallel and independent aim
in every healthcare curriculum.

Still, it remains unclear whether the self-assessment skills had


in general improved during these three years. Grades indicated a
moderate improvement, but the possible inter-assessor variation
did not allow for firm conclusions. However, the fact that the
number of comparisons below the level of the acceptable was much
smaller in 2004, might be indicative. Half of the students judged as
unacceptable in 2001 were found to have an acceptable level in three
consecutive tests in 2004, although still remaining below the average
scores of their fellow students. However, the other half remained
on an unacceptable level. This fact suggests that even at the latest
stages in their studies, there were students (5 out of 48 – i.e. 10%
in our case) who had significant difficulties in assessing their own
actions and defining learning objectives. An interesting observation
was that 90% of these students were identified already in 2001. The
sensitivity of the 2001 examination in predicting the weak students in
2004, based on these figures, was therefore 80% and the specificity
86%. Herein lays one of the most important benefits of longitudinal
observation, which is to enable validation of the predictability of the
earlier measurements of self-assessment ability.

Strengths and weaknesses


There is a lack of studies showing how progress concerning self-
assessment develops during the students dental studies. This study
assessed students’ self-assessment ability at two points during their
studies, making it possible to register if there is any progress during
their five year education. Could it be that this differs between
different educational concepts? The present interventions were
conducted within a full PBL curriculum, which is expected to
place a large emphasis on self-directed learning principles. Similar
studies comparing the impact of the curriculum (PBL or not) on the
development of self-assessment ability would be of great interest.
The study is valid with respect to the possibility to early detection
of students with weak self-assessment – in this study 10% of the
respondents.

46
It is more uncertain if there is any connection between self-assessment
ability and subject knowledge. In the future, prospective intervention
studies are needed to further verify the findings of this single,
relatively small study. Special care should be taken to address if and
how remedial interventions can help weak students to develop an
acceptable level of self-assessment ability before graduation.

Study II: Guiding principles: teamwork, holistic view.


Knowledge on competence
This study had the aim to investigate whether it was possible to
increase a holistic view and improve teamwork in patient care between
dental students and dental hygienist students in an undergraduate
education context.

Both dental hygienist students and dental students in this project


demonstrated an increased knowledge regarding the competences of
dental hygienists, as well as a perceived increased understanding and
appreciation of some of the common principles of the programmes.
Moreover, according to what the students expressed in the evaluation
comments, merely sharing patients, planning and performing
treatment together, contributed to a more holistic view of the
patient and gave valuable experiences for cooperation in their future
professional roles. Thus, without this cooperation, especially the
dental students would have graduated with considerable knowledge
gaps of the dental hygienists competences and it would presumably
have proven to be an obstacle for them in developing a fruitful and
effective teamwork in the future.

The reasons for testing the students’ knowledge on only competences


of the dental hygienists were several. First, one publication (16)
found that dentists’ knowledge on this issue was low. Further, they
suggested that undergraduate dental students should be better
prepared within this field in order to be able to lead and develop
a successful teamwork. Third, the competences of dentists are not
limited like those of the dental hygienist and are therefore more clear-
cut and known - therefore, there was no need to ask for them. Fourth,
the development of teamwork between dental hygienist students and
dental students depends to a large degree on the students’ knowledge

47
of what a dental hygienist license includes. If the dentist do not know
what the hygienists are allowed and have education for to perform,
it would be troublesome for the dentist to leave parts of the dental
care to the hygienists.

Seminar with dentist from Public Dental Health Services


The relatively low ratings on the seminar with a dentist from the
PDS could be an effect of a poor performance on the part of the
lecturer. On the other hand the comments on the event revealed that
it was valued positively in terms of initiating reflections and that
the seminar was stated as a good start for the project. The seminars
with participants from dental care external to the faculty were
recommended to be a permanent part of the curriculum and that
it could stimulate students´ knowledge’s and reflections on how to
perform good dentistry.

Web-based clinical cases


In general, the dental students were more positive to this activity.
Judging from the written comments, the reason behind this probably
was because the cases consisted of complicated prosthetic cases
which the dental students were more familiar with, compared to
the dental hygienist students. Comments suggested that the dental
hygienist students found it too difficult to participate in the debate
as the case was too “dentist” focused.

The two questionnaires


When asked if the two questionnaires contributed to increased
knowledge, the dental students gave higher scores, indicating they
felt their knowledge had increased more. It is likely that this was
due to their large initial knowledge gaps, and thus they had more
to learn.

Dental students supervising dental hygienist students and


cooperation with shared patients
It is harder to grasp why dental hygienist students to a higher degree
than dental students claimed that they received a more holistic
view on patients, when treating shared patients and/or when dental
students acted as supervisors. One explanation could be that the
dental hygienist students experienced broader perspectives and

48
more complex approaches towards treatment planning and actual
treatment when working together with dental students, than vice
versa. This is also illustrated by the fact that the comments from the
dental hygienist students were more numerous and overall positive,
while the dental students offered very few comments. Another
explanation could be that the dental students already had a developed
holistic view and therefore felt that they were less likely to increase
it to a significant extent. However, the overall impression is that
dental students, acting as supervisors for dental hygienist students,
contributed to develop dental hygienist students’ ability to acquire
a more holistic view on patient care. The fact that both student
groups recommended this activity to become a permanent part of
the education also indicates that dental students valued it highly.

Strengths and weaknesses


One study (16) found that dentists’ knowledge on the competence of
dental hygienists was low. Further, they suggested that undergraduate
dental students should be better prepared within this field in order to
be able to lead and develop a successful teamwork.

This study is in this matter relevant, showing that dental students’


knowledge on what dental hygienists were allowed to do in the
clinical care of patients was low but that it was possible to increase
with different projects. This is important for their future cooperation
outside school. We know that most of the students experienced a
more holistic view towards the patients. To validate this, we must
in a future study ask the patients how they in this aspect experience
the dental care.

This collaboration between dental and dental hygienist students is


still on-going in the PBL programme, but it is very dependent on
the engagement of involved supervisors in the dental and dental
hygienist programs. After the project had ended, the collaboration
has been moved from dental students semesters 9-10 to semesters 7-8
due to lack of time for seminars in the curriculum during semesters
9-10. The effect of this has not yet been evaluated. The fact that the
different programs were located in the 4th and 6th floor, respectively,
did not facilitate the cooperation. This will probably be possible to
change when a new school is built.

49
As mentioned earlier, there were 34 dental students and 24 dental
hygienist students participating in the study. This resulted in some
dental hygienist students cooperating with two dental students instead
of one. Since the questionnaires were answered anonymously, we can
not separate results from dental hygienist students that worked with
one or two dental students. It would be relevant to see if this could
have had any impact on the results.

Study III: Guiding principle: Oral Health


The overall aim of this study was to examine how different categories
of clinicians decided on their treatment plans for patients with
chronic periodontitis.

Chronic periodontitis is a common disease that affects about 40%


of the adult population, depending on how the disease is defined
and selection of age group (23,24). Most patients visiting a dental
clinic experience an intervention related to the disease of chronic
periodontitis, either as prophylaxis, e.g. disease information, oral
hygienist instruction and polishing, or as treatment of the disease
per se. The latter group is treated with scaling and root planning,
often performed by a dental hygienist. In more severe cases the
treatment includes surgery and in some cases the use of antibiotics,
even though evidence is lacking for any long-time effects of this
treatment (25). Chronic periodontitis is a diagnosis that probably
initiates time consuming interventions. The findings used to diagnose
this condition could be the basis for choice of treatment option. This
is why we decided to examine what findings different clinicians used
when they diagnosed the disease.

Methodological considerations
One open question was “What findings, or combination of findings,
do you use when you diagnose chronic periodontitis?” The reason
for including this question was to have the clinicians report in their
own words all the findings they used, and whether they used these
findings solitarily or in combinations in order to diagnose chronic
periodontitis. This open structure of the question might be the reason
that very few, only 18 of the 76 participants, stressed that they used
the findings in combinations. In studies where the participants are

50
asked to describe their judgment strategies, it is vital that they are not
directed (26). If we had given alternatives beforehand, the answers
would probably have been limited to these. Further, the situation in
which the clinicians were presented to the questionnaire was almost
identical for the different categories.

However, several features of the study presented different


preconditions for the participants. First, the dentists were informed
and had a choice whether or not to participate, in contrast to the
students whose participation was part of the educational programme.
Second, the dental teachers returned the questionnaires by post or
handed it back on a later occasion. In this procedure, they might
have obtained information that the other categories were unable
to get, since they all, i.e. students and supervisors, answered the
questionnaire and returned it back on that same occasion. Thus,
the clinicians in this study were neither a randomized selection nor
a representative group of dental clinicians in Sweden. They could
rather be regarded as a highly knowledgeable group. Dental teachers
are supposed to be informed about the evidence base for the clinical
methods used at the CCC, and thus expected to have the knowledge
on which findings should be used to diagnose patients with chronic
periodontitis. Supervisors in the PDS continuously participate in
postgraduate education and are traditionally recruited from dentists
with experience and interest in clinical questions, educational matters
and supporting the students’ professional development (27).

The dental and hygienist students were soon to be licensed. They had
finished their work in their tutorial groups and their clinical work
and must therefore be regarded as highly knowledgeable theoretically
in the different subject areas included in the dental curriculum.
Overall, one would expect the variation in findings they used when
they diagnosed chronic periodontitis to be smaller than amongst a
randomized selection of clinicians (28).

Except for the dental teachers, the response frequencies were


satisfying. Even after receiving a reminder, only 12 out of 18 dental
teachers responded. The responding teachers were representative of
the whole group of dental teachers at the faculty according to age,

51
sex, and type of clinical specialty. However, the author (LL) that was
present when the dental teachers answered the questionnaire received
negative feed-back from some of the colleagues. They felt as if it was
a test and as if they were controlled. This might be one explanation
for the relatively low response frequency.

Reflection on the answers


The MESH-term “Chronic Disease” in Pub Med is defined as
“Diseases which have one or more of the following characteristics:
they are permanent, leave residual disability, are caused by
irreversible pathological alteration, require special training of the
patient for rehabilitation, or may be expected to require a long
period of supervision, monitoring, or care”. Translated to a health
care perspective, this means that when patients receive the diagnosis
chronic periodontitis, personal and economic resources are consumed
and the patients often become lifelong dependents on dental care. The
diagnosis, and probably the findings that constitute the diagnosis, are
therefore crucial for the patients’ wellbeing also in a socio-economic
perspective (29).

In accordance with other studies on decision making, our results


underpin existing evidence that variations in medical practice exist
(28). In this study, in all, 25 different findings were found to be
used by the clinicians to diagnose chronic periodontitis. The most
frequently used findings were deepened pockets, bleeding on probing,
and loss of bone level on x-ray. This is in accordance with other
studies on how to define chronic periodontitis (30).

The listed findings correspond well to findings that are in accordance


with soft tissue inflammation and loss of supporting tissue. However,
it was surprising that only 12 out of 76 clinicians combined the
findings belonging to these two subgroups. To be in accordance
with the definitions of chronic periodontitis, i.e. an infectious
disease resulting in inflammation within the supporting tissues of
the teeth and progressive attachment and bone loss (31), at least one
finding providing soft tissue inflammation and one providing loss
of supporting tissue should be used, for example bleeding and bone
loss. Furthermore, to be chronic there should be a loss of supporting

52
tissue over time (32). Until date, no exact definition exists and very
few of the clinicians in this study commented that there should be a
loss of supporting tissue over time.

In every category, there were clinicians using irrelevant findings, i.e.


findings not mentioned in a classification scheme to be a finding
used in diagnosing chronic periodontitis. Such findings were for
example the presence of plaque and calculus. These findings are
considered to be irrelevant since they do not, per se, describe the
disease. Plaque and calculus are findings that could be present both in
patients with and without periodontitis (33). Even though the dental
hygienist students were in the majority when it comes to the use of
irrelevant findings, both dental students and supervisors used such
findings. The teachers used few irrelevant findings and were found
to be more evidence-based, but the students were not in agreement
with their teachers. Only one dental teacher used tooth mobility as
an irrelevant finding. None of the supervisors in the Dental Public
Services used attachment loss as a finding when they diagnosed
chronic periodontitis. This was expected since attachment loss as a
measurement of loss of supporting tissue is hard to perform in daily
praxis and is also time-consuming, and hence, more often used in
research projects. The clinical supervisors, in contrast to the dental
teachers, have in general sparse experience of performing research.

The reasons why dental hygienist students differed could depend on


their educational training and the traditional image of their future
work, which mainly consists of prophylactic treatment, supporting
treatment and treatment of the disease, including removal of the
biofilm with bacteria and calculus. The clinical experience and
knowledge of the teachers could also be an explanation as to why
there are differences between students. The majority of the teachers
at the dental hygienist education were dental hygienists, while they
were all dentists at the dentist education.

Strengths and weaknesses


The main reason for performing this study was the experience that the
students often used the diagnosis “chronic periodontitis”, when they
discussed and planned treatment for patients with different forms of

53
periodontal illness in the CCC. They often presented very different
diagnoses and findings when asked to describe chronic periodontitis.
They seldom combined findings. The study confirmed the clinical
observations that inspired the on-taking of the study. How valid the
results and conclusions are must be considered in the light of quite a
small number of participants, with implications of an uncertainty of
the results. It should be mentioned that in this study, dental hygienist
students to a significant degree used more irrelevant findings than the
other groups. This was not the case in the fourth publication with
2,455 participants, where clinicians outside the dental school, both
dentists and dental hygienists, used irrelevant findings three times
more often than the dental students.

Study IV: Guiding principle: Oral health


Diagnostic procedures in general
The wide variations within and between groups found in study 3,
inspired the fourth study. In this publication was studied how larger
number of dentists, dental hygienists and students diagnose and
treat patients with respect to the National Guidelines for dentistry.
In a recent publication (6), it was concluded that beyond the
traditional findings describing chronic periodontitis, i.e. soft tissue
inflammation and loss of supporting tissue, all the participating
dentists and students used irrelevant findings such as calculus and
plaque as a basis for treatment planning. The dentists in the Public
Dental Services and teachers at the dental school scored somewhat
lower than the students, but also used irrelevant findings to diagnose
periodontitis. With this in mind, we wanted to see if any change
had occurred regarding these aspects, i.e. using irrelevant findings
diagnosing chronic periodontitis, but also the participant’s attitudes
concerning diagnosing disease, proposals of treatment and the
structure of collaboration between dentists and dental hygienists.
Thus, the participants were asked to describe the findings they used
in relation to the study (6), as the basis for the different diagnoses.

About 75% of respondents used plaque as a finding for diagnosing


periodontal disease. It is interesting to see that students differed
to a greater extent from the other groups, where the professional
clinicians used this irrelevant finding three times more often than the

54
students. It is difficult to explain, but the numbers for the students
are in line with the results from the findings in Leisnert et al. (6). The
situation in the present study is almost the same concerning calculus.

It is difficult to draw any conclusions on whether the use of irrelevant


findings in any way influenced the quality of periodontal care. It could
contribute to confusion that, for example, plaque is an indicator used
for intervention. The statement there is no sharp distinction between
disease and no disease (34) could, in combination with the extensive
use of irrelevant findings, influence the delivery of dental care not
needed.

Is there a common ground between dentists and dental hygienists


concerning sharing different job assignments in an effective way? This
is an interesting question concerning a background of an increasing
number of dental hygienists and decreasing number of dentists. In
parallel to the discussions on the dimensionality of education for
dentists and dental hygienists to meet epidemiological changes in the
population, the discussion of the formal and informal competence
of dental hygienists and, in extension, their role within dentistry,
has been going on for decades. The debate has taken place in most
European countries in which dental hygienists have become a part
of the oral health care system (16, 35, 36).

Is there a consensus in Sweden for dental practitioners concerning


different job assignments? When we look at the examination
procedure of the clinicians where the dentists still want to examine
the patients, the answer to this question is no. In both case 1 and
2, a majority of the dentists thought that they should examine the
patients, while the dental hygienists had the opposite opinion. In case
3, there was a majority for dentists to examine the patient, but on the
other hand almost 50% of the hygienists felt prepared to examine
the patients. Obviously, there is no agreement on this matter, which
may cause problems when the patients will show less disease in the
future and more dental hygienists are expected to get educated. It is
surprising that not even in case 1 the dentists were inclined to leave
this examination to the hygienists.

55
Also, with regard to less complicated treatment such as professional
cleaning, only about 60% of PP and PDS thought this should be left
to DH. The PP was also more inclined to use dental nurses for this
treatment.

Instruction for effective self-care being left to DH had a greater


support, and this can depend on the fact that DH perhaps had a better
education and interest for this procedure. In spite of this, the PP was
the least inclined to leave this to DH. Perhaps the lack of patients,
18% in private sector and 5% in the Public Dental Service, could
have had an influence on the willingness to leave the assignment to
someone else in the team.

Are the methods of treatment proposed in accordance with the


degree of severity of the disease? Almost 94% of the respondents
had the opinion that a 45 year old healthy woman, with no bone
loss and a bleeding index of 22% and a plaque index of 28%, had
a periodontal disease. Is this condition a basis for reimbursement
of care from the community? Where is the delineation towards the
natural course of ageing?

When asked if they could see a risk for developing gingival and/
or periodontal disease for case 1, 97% of clinicians judged this
risk as none or low and this is most probably a correct judgment.
Therefore it is surprising that 91% of professional clinicians said it
was necessary to give preventive care to these patients. In a national
economic perspective, it seems like a waste of money and resources.
When we look at case 2 and case 3, it seems relevant both to judge
that they have disease and are in need of dental care to somewhat
different extents. Case 3 belongs to the group where no improvement
has occurred, i.e. the number of patients with serious periodontal
disease has not been reduced in the same way as in the other groups.
To once again come back to the opinion of Baelum & Lopez (34)
that there is no natural base for a sharp distinction between health
and disease or between different forms of periodontitis, the question
arises whether it could be that it is easier to give treatment to healthy
persons than to persons with severe illness? Could it be that there are

56
no substantial financial incentives in the national assurance system
to take care of the latter group?

To sum up, the answer to the question “Are the methods of treatment
used in accordance with the degree of severity of the disease?”, is
negative.

To what extent are treatment proposals in accordance


with National Guidelines?
Professional cleaning of the teeth was proposed by 90 to 100%
of the respondents, bearing in mind that the respondents had
the possibility to choose more than one option concerning what
caregiver category should perform the treatment. Thus, the numbers
could be too high reflecting to what extent they wanted to perform
the treatment. However, the numbers, when excluding the effect
described above, are between 66-84%. This treatment option has
been described as the least recommended to perform by the National
Guidelines (37) and studied by Hugoson et al. (38), giving no effect
at all on the patient’s oral health, and there is good evidence for this
statement. A conclusion to be drawn is that the dental care suggested
to be performed to a limited degree is in line with the guidelines
or in agreement with evidence based care. It is also important to
underline that this treatment is not reimbursed in The Dental and
Pharmaceutical Benefits Agency (TLV) (39), which decides on the
reimbursement for different treatments in dentistry.

When considering instruction for effective self-care, this was proposed


by 84-89% of the clinicians and is also highly recommended in the
National Guidelines. This treatment is also reimbursed by the TLV.

The question arises: Why use both one treatment with no effect and
one treatment highly recommended by the National Guidelines? The
guidelines were presented in the beginning of 2011 but discussed
and presented in a preliminary version 2010. The questionnaire
in this study was presented and sent out around autumn 2011, so
reasonably, the respondents should be aware of the content of the
guidelines.

57
Thus, the knowledge of evidence and effect on the treatment options
described above was low and treatment performed seems to be based
a lot on treatment tradition within the traditional care professions.

Strengths and weaknesses


This study seeks the answers to some vital questions in dental care
that has importance for the quality of care which we give our patients:

• How do professionals perform diagnostic procedures in gene­


ral?

• Is there a common ground between dentists and dental hy­


gienists concerning sharing different job assignments in an
effective way?

• And perhaps the most important question - is the decisions on


treatment choice and performed treatment in accordance with
the severity of the disease and in accordance with our National
Guidelines in dentistry?

In summary: too much attention seemed to be paid to healthy


individuals, the human resources were not used in an optimal way
and the treatment choices were in some aspects not in line with the
National Guidelines in dentistry. This is especially pertinent in relation
to the choice between “professional cleaning” and “instruction for
effective self-care”. One of the results from the third publication was
from a question “What treatment do you suggest?”, where the dental
hygienists to a greater extent proposed instruction for effective self-
care. The other groups were more inclined to use surgical procedures.

When discussing the validity of the results, the response rate is


important to consider. Many professional clinicians outside school
did not feel comfortable answering the questionnaire due to many
reasons: lack of integrity and questionnaires being too time
consuming, were some reasons given.

58
Summary
In summary, this thesis highlights in four publications the four linked
principles of the Malmö Model: self-directed learning, teamwork, a
holistic view of patient care, and oral health.

The first study, studying the principle of self-directed learning, found


that self-assessment skills were not necessarily dependent on subject
knowledge and that students weak in the former aspect could be
detected early in their education. This point to the importance of
developing self-assessments skills as an independent aim in the
curriculum.

The second study addressing the principle of holistic view and


teamwork, found that increased teamwork between dental hygienist
and dental students improved both teamwork, the dental students’
knowledge about the dental hygienists’ competences, and a holistic
view of the patient. In light of the expected changes in the dental work
force, epidemiology and political priorities, the findings reveal the
value of increased teamwork in the clinical setting of the education.

The third study, studying the principle of oral health, found that
the majority of clinicians (dental students, dental hygienist students,
dental teachers, and clinical supervisors in PDS) did not combine
findings from both the hard and soft tissues to assess chronic
periodontitis. Further, irrelevant findings were also used to diagnose
the condition.

The fourth study, building on the findings of the third study and also
addressing the principle of oral health, found that practicing clinicians
also used irrelevant findings to diagnose chronic periodontitis.
Further, practicing dentists were generally unwilling to let a dental
hygienist diagnose all three types of clinical scenarios. However, they
were willing to let the hygienist perform self-care instructions. In all,
the study points to the value of including teamwork between dental
hygienist and dental students during their education, to enhance
knowledge on each other’s competences and future cooperation.
Thus, by ensuring efficient teamwork, resources could be more
efficiently allocated in order to achieve oral health.

59
CONCLUSIONS

Study I
Results indicated that self-assessment ability is not directly related
to subject knowledge. Upon graduation, there are students (10% in
our case) with significant self-assessment difficulties. Early detection
of students with weak self-assessment abilities appears possible to
achieve.

Study II
The dental hygienist students in general valued the different parts of
the project higher than the dental students. However, there was also
consensus in both student groups that the activities should become
permanent parts of the curricula and for the future it could be kept
in mind to start treating shared patients earlier in order to achieve
greater impact.

Thus, by initiating teamwork between dental students and dental


hygienist students during their undergraduate education it was
possible to:

• Increase students’ knowledge on dental hygienists´ competences


• Develop students’ perceived holistic view on patients.
• Prepare students for teamwork

60
Study III
Variations were found between what findings different categories of
clinicians used when they diagnose chronic periodontitis.

Dental hygienist students used a significantly higher number of


findings, and were also more inclined to use irrelevant findings like
calculus, plaque and smoking, compared to the other categories of
clinicians.

Within each category of clinicians, wide variations were found in


which findings they used to diagnose chronic periodontitis. The
majority only used the findings solitarily and they did not combine
one finding that provided soft tissue inflammation with a finding that
provided loss of supporting tissue.

The wide variations when clinicians diagnose chronic periodontitis


might indicate variations in treatment plans and treatment options.
Further research is planned to investigate the extent to which the
used findings influence the treatment options.

Study IV
The two groups representing dentists and dental hygienist delivering
basic periodontal care in Sweden, were to a significant degree not
sharing the knowledge basis for diagnosis and treatment planning.
This may result in a less than optimal utilization of resources in
Swedish dentistry.

The delivery of basic periodontal care was not in line with the severity
of disease and too much attention was paid to the needs of relatively
healthy persons.

To change this pattern, the incentives and structure of the national


assurance system have to be adapted in order to stimulate a better
inter-collegial cooperation in basic periodontal care.

61
ACKNOWLEDGEMENTS

First of all I want to express my deepest gratitude to my main


supervisor professor Björn Axtelius and my assistant supervisor
professor Ann Wennerberg. Without your support in a critical
situation I would not have been registered as a PhD-student 2010
getting the possibility to fulfil my research.

I also want to express my gratitude to the co-authors in the


different publications which has given me the opportunity to learn
different ways to approach research and since this paper deals with
fundamental principles in our education learn how we in different
ways implement those principles.

I also want to thank Alborz Soltani and my youngest son Viktor who
both spent a lot of hours dealing with 2,455 questionnaires. A lot of
philosophical talks accompanied that work.

To all my wonderful friends in CCC and Oral Prosthetics- tanks for


your understanding and positive attitude especially when I have been
absent to a greater extent the last time.

Last but not least I want to thank my wonderful wife Carina and my
three children Paul, Ulrika and Viktor for all support.

I also want to express my gratitude to the organisations for the


dentists in private and public health and dental hygienists. It was
very generous of you to provide me with the 800 names each from
your members registry.

Thank you all!

62
REFERENCES

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65
APPENDIX
Medical Teacher, Vol. 28, No. 6, 2006, pp. 544–548

The interactive examination in a comprehensive


oral care clinic: a three-year follow up of students’
self-assessment ability

L. LEISNERT1 & N. MATTHEOS1,2


1
Malmo¨ University, Sweden; 2University of Berne, Switzerland

ABSTRACT Little is known of how students’ self-assessment ability


evolves throughout the curriculum. The Interactive Examination Practice points
aims to assess students’ self-assessment ability, in parallel with their
knowledge and competences. The method utilizes a written task and . There is a lack of longitudinal data showing how
subsequent comparison of own performance with that of a qualified students’ self-assessment abilities develop throughout
clinician. One cohort of dental students (n ¼ 48) underwent the curriculum.
assessment through Interactive Examination at three instances in . This study assesses students’ self-assessment ability at
2004, during their final year of studies. Forty-two of them were two points in their studies (2nd year–5th year).
assessed with the same methodology in 2001. Students’ individual . Results indicate that self-assessment ability is not
performance, self-assessment ability scores and attitudes in 2004 directly relevant to subject knowledge.
were correlated with their respective data from 2001. Students’ . On graduation, there exist students (10% in our case)
acceptance of the methodology was high. The written performance with significant self-assessment difficulties.
in 2004 was positively correlated with this of 2001 in one of the . Early detection of students with weak self-assessment
three cases, while the comparison document scores in two out of three abilities appears possible.
cases. Five students presented unacceptable self-assessment ability
in 2004, four of whom were also unacceptable in 2001 in the same
field. Unacceptable students of 2001 (n ¼ 9) presented significantly
However, the majority of available research consists of one-
lower results than their colleagues in 2004. These observations
shot cross-sectional studies. Such studies offer important
indicate that the self-assessment ability is not directly relevant to
insight but lack the ability to investigate development and
subject knowledge. On graduation, there exist students with
change over time. There is a current lack of longitudinal data
significant self-assessment difficulties, the majority of whom could
in the field of self-assessment ability. Longitudinal data could
be detected earlier in their studies.
allow educators to better register and follow how students’
self-assessment abilities develop throughout the curriculum
Introduction and would also provide urgently needed documentation on
the effectiveness of educational interventions.
Self-assessment ability is a critical competence for healthcare The Interactive Examination is a structured
professionals, necessary for successful adaptation to the examination scheme aiming to assess not only students’
modern lifelong learning environment. Educational research- knowledge and skills but also their ability to assess their own
ers seem to agree that self-assessment ability, especially in competence accurately (Mattheos et al., 2004a). The present
a professional context, is a skill that can be learned, developed study assesses students’ self-assessment ability by means of the
and excelled at (Brown et al., 1997). It is also evident that not Interactive Examination in a cohort of senior dental students
all professionals possess this ability to a satisfactory degree, who had gone through an identical assessment procedure
thus jeopardizing the implementation of lifelong learning during their second year of studies (Mattheos et al., 2004a).
attitudes (Weinberg et al., 1977; Hays et al., 2002). The study aims to investigate correlations indicative of the
Although the importance of self-assessment seems unques- progress of students’ self-assessment ability, while changes in
tionable, not much is known about how to best assist students student attitudes and priorities will be the focus of a separate
in the development of this ability. Furthermore, numerous publication (Leisnert & Mattheos, 2006).
studies at various levels have shown that healthcare students
often possess modest to poor self-assessment abilities (Reisine,
1996; Tousignant & DesMarchais, 2002). Educational Material and method
research seems to point to two critical factors for the
The Interactive Examination method
development of such skills and these are continuous practice
of self-assessment (MacDonald et al., 2003) and constructive The Interactive Examination was introduced in 1998 in the
feedback (Rees & Shepherd, 2005). Based on these two faculty of Odontology (Mattheos et al., 2004a) and has been
elements, several authors have to various extents described
and evaluated methodologies designed to assist the develop-
Correspondence: Nikos Mattheos, Centre for Oral Health Sciences, Malmö
ment and even assessment of students’ self-assessment ability University, 205 06 Malmö, Sweden. Tel: þ46 40 66 58 364; fax: þ46 40 88
(Henderson & Johnson 2002; Zeller et al., 2003). 44 1; email: nikolaos.mattheos@od.mah.se

544 ISSN 0142–159X print/ISSN 1466–187X online/06/060544–5 ß 2006 Informa UK Ltd.


DOI: 10.1080/01421590600878184
The interactive examination in a comprehensive oral care clinic

Table 1. Criteria for grading students’ comparison documents on a scale from 3 to 9 points.

Evaluation Excellent (3 pts) Acceptable (2 pts) Not acceptable (1 pt)

Comparison of The student has The student has identified The student has only identified
content identified most/all the half of the major differences very few or irrelevant differences
important differences
Analysis of explanation The student is able to The student can only partly The student does not attempt
of the differences analyse/attribute differences analyse/attribute differences to analyse the differences
Defining learning The student reaches the The student provides learning The student does not reach learning
objectives learning objectives deriving objectives only partly relevant to objectives, or they are irrelevant to
from the analysis of differences his/her analysis of differences his/her analysis of differences

further applied and developed in different institutions Forty-two of the students had been assessed using the
ever since. A number of studies have evaluated different Interactive Examination methodology in autumn 2001,
applications of the Interactive Examination, including during the third semester of their studies. Six students
Web-based (Mattheos et al., 2004b and teleconference- from the 2004 cohort who had not attended the
based ones (Mattheos et al., 2003). Interactive Examination in 2001 were excluded from the
The principally important element for the assessment of comparative part of the study, but their opinions and
reflective skills appears to be the so called ‘comparison attitudes were registered through the three evaluation
document’. In this procedure, the students receive a task in questionnaires.
the form of a clinical problem and are expected to provide
a written account of their solution, usually a diagnosis and
treatment plan. Thereafter, they receive a solution proposed Clinical cases
by a qualified physician. This solution is not the only or the A special project site was created in ‘Webzone’, the Internet
best treatment possibility but it represents a grounded Learning Content Management System of Malmö
opinion of a qualified colleague, reflecting his or her priorities University. All students and resource persons were registered
and reasoning. Then the students have to come up within members of the project and had access to public functions, as
a week with a ‘comparison document’ where in written form well as a private folder.
they compare their own answer with that of the qualified Each case was presented at a given time through an
physician. In their comparison students are expected to interactive PowerPoint slideshow. Under the appropriate
identify differences and similarities between the two essays, hyperlinks, each case provided the student with general and
investigate and elaborate on the reasons why these differences dental history, current status, major complaints, the patient’s
exist and consequently define learning objectives for the wishes, extra-oral, intra-oral and X-ray images. After each
future. case was published, students had about two weeks to come
The assessment is based on two elements: up with a written full treatment plan, which they then had to
. Students’ subject-related competence, as this is expressed upload into their private folder.
through their proposed solution to the clinical case. The When this stage was completed, the author of the case
assessment of students’ performance is based on a matrix could publish the treatment plan he/she followed and the
reflecting the specific learning objectives of each case. outcome of his/her treatment. Students then had another
. Students’ reflective skills, as expressed by their ability to week to compare their treatment plan with the one published
point out weaknesses in their essay, base their choices on and prepare a written comparison document, according to
sound arguments and consequently define relevant future the previously described principles.
learning needs. The assessment of this skill is made The feedback the students received after each case was
through a special matrix (Table 1), which assesses each organized in two forms:
student’s comparison document in a scale from 3 to 9. (1) a written commentary, presenting the key issues of
each case and discussing the most common character-
istics of students’ treatment choices;
Sample (2) a group discussion where each case and the treatment
plan, as well as students’ common choices, were
A whole cohort of final-year students (n ¼ 48) went through thoroughly discussed with the case author and
the Interactive Examination with three clinical cases in respective expert resource persons.
Comprehensive Oral Care Clinic (COCC) during the
period from November 2004 to January 2005. The students
of that year have a final theoretical and practical examination
Evaluation of performance
in December, successful completion of which allows them to
start their 15-week period of vocational training in public Each student’s written treatment plan was evaluated through
dental clinics. Consequently, the students completed the first a specific matrix. The matrix for each case included a number
two cases before their final examinations and went through of key issues representing knowledge and attitudes a
the third case immediately thereafter. clinician must have according to the established standards

545
L. Leisnert & N. Mattheos

Table 2. Results of students’ performance on the written task and the comparison document for each of the three cases,
as compared with the results of the same students in year 2001a.

(a) Written treatment plan


Case 1 (18) Case 2 (21) Case 3 (17) 2001 (6)

n Score % n Score % n Score % n Score %

Average 42 13.8 77 42 15.8 75 41 5.8 34 42 2.95 49


Male 12 11.8* 65 12 13.6** 65 11 5.1 30 12 2.6 43
Female 30 14.8* 82 30 16.8** 80 30 6.1 36 30 3 50

(b) Comparison document


Case 1 (9) Case 2 (9) Case 3 (9) 2001 (9)

n Score % n Score % n Score % n Score %

Average 40 7.3y 81 39 6.2 68 39 6.0 67 41 5.8y 64


Male 12 5*** 55 5yy 55 5.2*** 58 5yyy 55
Female 28 7.7*** 85 6.6yy 73 6.3*** 70 6.2yyy 68

Notes: aThe number in parentheses represents the maximum score possible in each case and the percentage is the percentage of
success in relation to the maximum possible score. *p ¼ 0.0005; **p ¼ 0.0019; ***p ¼ 0.02; yp < 0.0001; yyp ¼ 0.003;
yyyp ¼ 0.03.

of the COCC. These key issues were expressed in equivalent Results


points, the number of which differed slightly in the three
The average scores of students’ written treatment plan and
cases. The maximum score for cases one, two and three was
comparison document in the three cases can be seen in
18, 21 and 17 respectively, with the level of acceptance set to
Table 2. Only the grades of the written treatment plan in case
12, 14 and 11 points. The evaluation framework was
2 in 2004 were positively correlated with the respective grades
designed by the author of the three cases, who was also the
in 2001 (p ¼ 0.02, r ¼ 0.34). Female students performed
one to grade students’ performance. The case in 2001 was
significantly better than males in two out of three cases in the
assessed through a scale of 1–6.
written treatment plan in 2004.
The students’ comparison document was evaluated
Regarding the comparison document, the grades on case 1
through the previously designed matrix (see Table 1). This
(p ¼ 0.001, r ¼ 0.48) and case two 2 (p ¼ 0.0002, r ¼ 0.55)
matrix was used for all three cases and it was also used in
presented a strong positive correlation with the respective
2001 for the same purpose.
grades in year 2001. Comparison document grades in year
2004 were in all three cases higher than those of 2001, but the
difference was statistically significant only for case 1
Evaluation of attitudes
(p < 0.0001). Female students received significantly higher
Students’ attitudes were evaluated after the completion grades than males in all three cases.
of each case through an anonymous, standardized A total of eight comparison documents were judged
questionnaire. Results on students’ attitudes towards the unacceptable throughout the three cases. All eight documents
methodology will be discussed in a separate publication originated from five students, four of whom were also among
(Leisnert & Mattheos, 2006). the nine students who were judged unacceptable in 2001 in
the same field. The average score in the 2004 comparison
document for these nine students (unacceptable in 2001) was
Statistical analysis 6.1 for the first case, 4.5 for the second and 5.1 for the third.
Grades on the written treatment plan were analysed for the This was in all cases lower than the average score of the
42 students who participated in both the 2001 and 2004 cohort and this difference was statistically significant for cases
cohorts. The difference between male and female student 1 and 2 (p ¼ 0.01 and 0.001 respectively).
scores within each case was analysed with an unpaired t-test.
The grades for both the written treatment plan and the
Discussion
comparison document for each case in 2004 were compared
with performance data of the same students in 2001 with a The main focus of this study was the reflective process that is
simple linear regression analysis. The students who presented initiated through comparing one’s own work with that of
unacceptable comparison documents in 2004 were compared someone else. This process is well rooted in students’ self-
with those unacceptable in 2001, in an attempt to track weak assessment ability, a necessary professional skill. In this
students’ development. study, self-assessment ability is addressed as it applies to
Individual student differences between grades in the profession-related activities. The general skill of self-
comparison document of each of the cases in 2004 and the reflection, however, appears to be a wider element of
same in 2001 were analysed with a paired t-test. personality, often connected with personal and cultural

546
The interactive examination in a comprehensive oral care clinic

characteristics (Murray-Garcia et al., 2005). It would be of stages in their studies, there exist students (five out of
great interest in future studies to investigate how the general 48—10% in our case) who have significant difficulties in
self-reflection ability is connected with profession or task- assessing their own actions and defining learning objectives.
related self-assessment skills. An interesting observation was that 90% of these students
Very few studies are available in this field with a were already identified in 2001. The sensitivity of the 2001
longitudinal perspective. Fitzgerald et al. (2003) followed examination in predicting the weak students in 2004,
medical students’ self-assessment at four intervals over the based on these figures, is therefore 80% and the specificity
course of their first three years. They concluded that 86%. Therein lies one of the most important benefits of
self-assessment accuracy measures were relatively stable longitudinal observation, which is to enable validation of the
over the first two years. In another study conducted during predictability of earlier measurements of self-assessment
the first year of dental education, Zijlstra-Shaw et al. (2004) ability.
found that students’ self-assessment ability increased during The present interventions were conducted within
the course of three consecutive terms. a fully PBL curriculum, which is expected to place great
The students in this study had an assessment rather emphasis on self-directed learning principles. Similar studies
early in their studies in which their profession-related comparing the impact of the curriculum (PBL or not) on the
self-assessment ability was evaluated. In the three years that development of self-assessment ability would be of great
followed, the students did not go through any structured interest. In the future, prospective intervention studies are
intervention of the same magnitude. However, as their PBL needed to further verify the findings of this single, relatively
curriculum includes many instances of self-assessment and small study. Special care should be taken to address if and
constructive feedback, one should expect that by the end of how remedial interventions can help weak students to
their studies students will present a more mature and develop an acceptable level of self-assessment ability before
complete ability to assess their competence. This is in fact graduation.
one of the critical functions of a healthcare curriculum,
although is rarely evaluated (Shumway & Harden, 2003).
Students’ task in 2004 to present a written treatment Acknowledgements
plan is not comparable to the written task they had in The authors would like to thank Prof. Emeritus Rolf
2001, therefore no attempt was made to compare students’ Attström for his constructive feedback and guidance
performance in this field. However, correlation of their throughout the project. They would also like to thank
grades between 2001 and 2004 was investigated, to see if Dr Martin Janda Schittek for his significant help with the
the pattern of students’ achievement was repeated. The development of the electronic material and his assistance
correlation between the written treatment plan grades in throughout the study.
2001–04 was in general poor and there was a moderate
positive correlation in one of the three cases.
In contrast to the written task, the comparison document Notes on contributors
was used in the same way in both 2001 and 2004 and is LEIF LEISNERT, DDS, is the head of the COCC, Faculty of Odontology,
the main focus of the study, as it attempts to evaluate not Malmö University, Sweden. He has vast experience in clinical teaching
subject-related knowledge but reflective skills. Interestingly, and supervision and his main interest is in instructional approaches for
the grades on self-assessment ability in 2004 present a higher holistic professional development.
correlation with those of 2001 than actual subject-related NIKOS MATTHEOS, DDS PhD, is currently a research associate in the
knowledge does. In addition, as seen in case 3, self- Centre for Educational Research and Technology in Oral Health
assessment ability remains quite stable even when the written (CERT), Faculty of Odontology, Malmö University, Sweden. His
performance is low. research includes studies on interaction in virtual learning environments
These observations indicate that self-assessment ability and development of innovative assessment methodologies.
is not directly tied to subject knowledge. Although
students seemed to have developed their knowledge and
understanding in different ways in the years that followed References
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548
European Journal of Dental Education ISSN 1396-5883

Improving teamwork between students from two


professional programmes in dental education
L. Leisnert, M. Karlsson, I. Franklin, L. Lindh and K. Wretlind
Faculty of Odontology, Malmo University, Malmo, Sweden

Keywords Abstract
teamwork; undergraduate dental education;
intervention. In Sweden, the National Board of Health and Welfare forecasts a decrease in dentists
with 26% and an increase in dental hygienists with 47% until the year of 2023. This,
Correspondence together with changes in both epidemiology, especially of dental caries, and political
Leif Leisnert priorities, calls for an effective and well-developed cooperation between dentists and
Faculty of Odontology dental hygienists in future dentistry. Hence, the aim of this project was to investigate
20506, Malmo University whether highlighting teamwork during the undergraduate studies of dental students
Malmo and dental hygiene students could improve the students’ holistic view on patients as
Sweden well as their knowledge of and insight into each other’s future professions. Thirty-four
Tel: 46709655415 dental students and 24 dental hygiene students participated in the study. At the begin-
Fax: 46406658503 ning of their final year in undergraduate education, a questionnaire testing the level of
e-mail: Leif.Leisnert@gmail.com knowledge of the dental hygienists’ clinical competences was completed by both groups
of students. In addition, activities intending to improve teamwork quality included the
Accepted: 20 July 2011
following: (i) a seminar with a dentist representing the Public Dental Health Services
in Sweden, (ii) dental students as supervisors for dental hygiene students, (iii) planning
doi:10.1111/j.1600-0579.2011.00702.x
and treatment for shared patients and (iv) students’ presentations of the treatments
and their outcomes at a final seminar. The project was ended by the students answer-
Re-use of this article is permitted in accordance
ing the above-mentioned questionnaire for the second time, followed by an evaluation
with the Terms and Conditions set out at
http://wileyonlinelibrary.com/onlineopen#
of the different activities included in the study. The knowledge of dental hygienists’
OnlineOpen_Terms. competences showed higher scores in almost all questions. Both groups of students
considered the following aspects important: seminars with external participants, dental
students acting as supervisors and planning and treating shared patients. By initiating
and encouraging teamwork between dental students and dental hygiene students, it is
possible to increase knowledge on dental hygienists’ competence and also to develop
and strengthen a holistic view on patients and dental work, thereby preparing both
groups of students for their professional life.

Parallell to these changes, the discussion of the formal and


Introduction informal competences of dental hygienists, and in extension
Epidemiological changes in dental diseases, ageing populations their role within dentistry, has been going on for decades. Still,
with an increasing need of complex dental treatment and the after more than 30 years of cooperation between the groups,
changed political priority to funding in dentistry underline the articles such as ‘Who does what and why’? (3) are published in
needs of improved cooperation between the different members dental magazines, this one in 2008. Four years prior to this, the
of the dental team. Furthermore, the ratio of dentists to dental same magazine ran ‘Cost effective teamwork’ (4) as the editorial,
hygienists is forecasted to change in some countries. In Sweden, in which it was stated that ‘until recently many dentists were still
the number of dentists is forecasted to decrease with 26%, slightly uncomfortable about other people actually treating their
landing on around 5400 dentists in 2023 (1), while dental patients’. This debate has taken place in most European coun-
hygienists are expected to increase by 47% to 4700 (1). tries in which dental hygienists have become a part of the oral
Although the dental teams vary in structure and composition health system. Klefbom et al. (5) conclude that dentists’ knowl-
between different countries, general changes in the surrounding edge on the competences of dental hygienists ought to be
society demand flexibility and proper knowledge on competen- improved to facilitate teamwork. They also suggest that coopera-
cies for each professional group (2) to rise to these mounting tion and integration in undergraduate education could be a way
challenges. to enhance knowledge on respective professions’ competencies.

Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S 1
Improving teamwork between students from two professional programmes Leisnert et al.

Traditionally, the education of dentists and dental hygienists their last semester – for dental students their tenth and for
has taken place as uniprofessional educations where students dental hygiene students their fourth. Students have a gradually
learn in isolation from each other (6), but growing evidence increasing responsibility for the oral health care of their
supporting the idea that interprofessional education (IPE) will patients, who require oral health needs of increasing complex-
improve abilities both to work as a team and to communicate ity. From the onset, an environment is created in which provi-
more effectively with colleagues and patients (7) must also be sion of care is related to (i) a fundamental understanding of
taken into account. However, most of the research regarding the needs of the individual patient, (ii) an evidence-based
IPE within the medical field concerns the relationship between approach for the outcome of clinical interventions and (iii) an
doctors and nurses, and only a few papers are concerned with interdisciplinary approach to oral health care. Both groups of
dentistry (8). In a survey of IPE, including seven academic students experience an increase in intensity and opportunities
health centres (8) that have schools of dentistry associated with for a mixed and varied care of more and more complex
them, a review was made and completed with interviews. One patients during their final semesters, and dental students
conclusion was that dental schools were isolated from other assisted by dental nurses, experience comprehensive care in
schools and not interested in IPE. Another conclusion pointed cooperation with dental hygiene students (12). Both dental stu-
to the importance of dental schools becoming an active partici- dents and dental hygiene students practise in the Public Dental
pant in future interprofessional educational initiative. Further- Health Services (PDHS) (13).
more, in a study examining how teamwork influences resource The project was designed as an intervention study with dif-
planning in acute hospitals, it was concluded that effective ferent activities, including seminars, treating patients together
teamwork is one of the important factors to the success of dis- and presentations of the outcomes of the treatments, framed by
charge planning. (9). pre- and post-test. As a pre-test, we used a questionnaire map-
Thus, a general agreement has emerged that improving team- ping the students’ knowledge on a sample of the dental hygien-
work is important for achieving both better and more cost- ists competencies. Post-test included answering the same
effective treatment for patients (3, 7, 8). questionnaire once more, with questions relating to how the
different activities were experienced and to what extent they
were deemed useful by the students.
Objectives
This study had the objective of examining whether placing a
Project organisation
stronger emphasis on teamwork during the undergraduate
studies of dental students and dental hygiene students could: In the research group for the project, responsible for planning,
l Increase knowledge of and insight into the respective future directing and carrying out the activities, students and staff from
professions with special emphasis on the dental hygienists both the dental hygiene and dental programmes participated.
field of competence. The project was introduced and started during the spring 2007
l Develop the holistic view and approach towards patients, as by launching a website within the learning management system
experienced by the students. of the university, acting as a platform for both information and
interactions.
Material and methods
Participants
Students from two dental programmes, dental hygiene students
and dental students, participated in the study. Beginning from their eighth and second semester respectively, 34
dental students and 24 dental hygiene students participated in the
study. The number of students corresponded to the size of the
Educational context of the dental programmes
courses. Teams consisting of one dental student and one dental
in Malmö
hygiene student were formed. As the number of dental students
The dental and the dental hygiene programmes are taught at was greater than that of dental hygiene students, some dental
the Faculty of Odontology at Malmö University, and they are hygiene students had two dental students to cooperate with.
guided by four linked principles: (i) Self-directed learning, (ii)
Holistic view of patient care, (iii) Oral health and (iv) Team-
Activities
work. Self-directed learning is implemented as problem-based
learning throughout the programmes (10). The holistic view is The timetable for included activities is shown in Fig. 1.
interpreted as caring for the individual rather than as produc-
ing quantities of items of dental treatment. Such an approach Seminar 1 + Seminar 2 Seminar 3 +
towards the patient should encourage students to use their Questionnaire Questionnaire

knowledge and understanding, skills and ability, judgement and


stance as expressed in the Swedish Higher Education Ordinance March-2008 June-2008 September-2008 December-2008 March-2009
(11). In turn, the holistic view provides a platform for oral
health that has been chosen over dentistry. Teamwork is devel- Dental students supervising

oped through work in study groups and clinical settings. Teamwork (web-based + actual patients)
In the clinical setting, students from both programmes
respectively care for their own patients from their second to Fig. 1. Timetable for performed activities.

2 Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S
Leisnert et al. Improving teamwork between students from two professional programmes

Questionnaires. Students’ opinions on different activities and


parts of the project
At the start of the project, 23 dental hygiene students (N = 24)
and 32 dental students (N = 34) answered a questionnaire (7), Students assessed the different activities and how they valued
Appendix 1, at the same occasion. The questionnaire consisted their contribution in developing successful teamwork. The
of 23 questions on whether or not dental hygienists are licensed questionnaire, Appendix 2, used for this purpose was designed
for the competences described in the different questions. The with a number of statements, concerning the different activities,
same questionnaire was answered 1 year later. Between the two where students could mark on a visual analogue scale from 1
tests a number of activities were performed. to 10 whether they agreed or disagreed on the statements.

Seminars Methodological considerations


Three seminars were held during the course of the study: The first questionnaire was answered by 32 of 34 dental stu-
Seminar 1: An introduction of the project including a session dents and 23 of 24 dental hygiene students. On the second
with a dentist from the PDHS, presenting the visions and expe- occasion, 30 of 32 dental students and 20 of 20 dental hygiene
riences of a teamwork model developed and successfully prac- students answered. The missing answers were attributable to
tised at the PDHS. electives, Erasmus exchange, interrupted studies or illness.
Seminar 2: Presentations held by ten chosen teams of students,
each group presenting different aspects of how to plan and
Statistical methods
carry out the treatment for two web-based patients. All stu-
dents attended this seminar together with supervisors from dif- Statistical comparisons of the percentage of correct answers
ferent fields of Odontology. before and after intervention, within each group, were per-
Seminar 3: Presentations given by six chosen teams of students,
each group presenting how they planned and carried out the
A 100
treatment for shared patients in the students’ clinic. Discussions
Percentage of correct answers

on the outcome of said treatment were also an integral part of


80
this seminar.
Prior to the final session, the students were asked to write
down problems and possibilities that they had encountered 60

during their team collaborations. These were discussed during


the last seminar, as well as the students’ suggestions for future 40
professional cooperation.
20

Teamwork
0
As mentioned earlier, the dental students and the dental 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
hygiene students were divided into teams. In these teams, they Question number
planned and carried out the treatment for both web-based Percentage of correct answers before Percentage of correct answers after
intervention. intervention.
patients and actual patients attending the students¢ clinic. The
web-based cases were presented and made available on the
B 100
website of the project, where electronic folders for each team
Percentage of correct answers

were created as well. In the folders, the teams documented


80
their discussions and agreements regarding the web-based
cases on following items: diagnosis, treatment planning and
prognosis. In the folder, they also had to document, present 60

and discuss 2—4 shared patients from the student’s clinic.


During the students’ clinical work, they and their clinical 40
instructors could draw on one experienced dentist and on one
experienced dental hygienist to support them with encourage- 20
ment and pinpointing opportunities and advantages of team-
work. 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Question number
Supervising Percentage of correct answers Percentage of correct answers after
before intervention. intervention.
To increase the interaction surface between students and to an
even greater extent provide opportunities for developing under- Fig. 2. (a) Percentage of correct answers on each of the 23 questions in
standing and knowledge on how to cooperate as a dental team, the questionnaire, before and after intervention. Dental students. (b) Per-
the dental students supervised the dental hygiene students in centage of correct answers on each of the 23 questions in the question-
their clinical practice in one to two occasions. naire, before and after intervention. Dental hygiene students.

Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S 3
Improving teamwork between students from two professional programmes Leisnert et al.

10
formed using a Sign test, Figs 2a,b. Independent samples t-test
was used in the comparisons of the two student groups in the
9 evaluation of activities shown in Figs 3–5. The significance level
8
in all tests was a = 5%. The program used was PASW/SPSS for
Windows, release 18.0.0 2009 (SPSS Inc., Chicago, IL, USA).
7 The significance level is marked besides respectively statements
in Figs 3–5. *0.01 > P < 0.05, **0.001 £ P < 0.01, ***P <
6
0.001.
Mean

4 Results
3
Students’ knowledge on the competences of the
2 dental hygienist
1 The results of the first questionnaire showed that it was mostly
the dental student who lacked knowledge on the competences
0
Dental hygiene students Dental students of the dental hygienist. In nine of 23 questions more than 50%
provided a wrong answer. For instance, between 50% and 70%
Error bars: 95 % CI
did not know that dental hygienists (in Sweden) are allowed to
… was valuable **
decide on, carry out and diagnose X rays concerning caries and
… initiated interesting discussions**
periodontitis; prescribe alcohol, fluoride and anaesthetics to
… gave knowledge on cooperation
their place of work; decide on and carry out bleaching of teeth;
… gave a holistic view on patient treatment glue small pieces of jewellery on the teeth; and/or decide on
… presentation gave experiences on teamwork and carry out bacterial analyses of saliva. Concerning dental
… should be a permanent part of education hygiene students more than 50% answered wrongly in five of
the 23 questions. Their gaps of knowledge were on the follow-
Fig. 3. Students’ ratings of six statements regarding the fictional web-
based clinical cases. **0.001 £ P < 0.01.

Error bars: 95 % CI Error bars: 95 % CI

… was valuable for future cooperation … was valuable for future cooperation
… contributed to more knowledge on teammate’s competence … contributed to more knowledge on teammate’s competence
… gave increased knowledge on interplay … gave increased knowledge on interplay*
… increased a holistic view on patients** … increased a holistic view on patients**
… gave more focus on preventive care … gave more focus on preventive care
… developed a rational view on dental care … developed a rational view on dental care
… has developed my knowledge on therapy planning * … has developed my knowledge on therapy planning*
… should be a part of future education … should be a part of future education*
… should start earlier in our education** … should start earlier in our education**
… presentation on seminar gave insight on how to work together
Fig. 4. Students’ ratings of nine statements regarding dental students
supervising dental hygiene students in the clinical setting. Fig. 5. Students’ ratings of ten statements regarding teamwork with
*0.01 > P < 0.05, **0.001 £ P < 0.01. shared patients. *0.01 > P < 0.05, **0.001 £ P < 0.01.

4 Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S
Leisnert et al. Improving teamwork between students from two professional programmes

ing: not aware of being allowed to possess X-ray equipment (SD) DHS 9.1 (0.9) and DS = 7.9 (1.5). There were significant
when practising on their own; not being allowed to diagnose differences between the two groups in five of the questions. It
diseases in mucous membrane; being allowed to carry out fis- concerned the questions whether this moment gave increased
sure blocking; decide on and carry out bleaching of teeth; and/ knowledge on interplay, increased holistic view on patients, has
or to manufacture a bleaching tray. At the concluding seminar, developed knowledge on therapy planning and should be a part
the students’ knowledge had improved in almost all matters of of future education, and that the presentations on the seminar
the questionnaire. For the dental students group, there were gave insight into how to work together. The questions display
significant changes concerning questions 2, 3, 4, 5, 8, 12, 13, 16 the same pattern of DHS giving higher scores. (Fig. 5).
and 17, and for the dental hygiene students, there were signifi-
cant changes concerning questions 17 and 23. (Fig. 2a,b).
Discussion

Evaluation of activities carried out during the Knowledge on competence


project
Both DHS and dental students in this project demonstrate an
increase in knowledge regarding the competences of dental
Seminar on teamwork with dentist from PDHS.
hygienists as well as a perceived increased understanding and
Dental hygiene students (DHS) rated this seminar with mean appreciation of some of the common principles of the pro-
score (SD) of 6.9 (2, 7), while dental students’ (DS) mean score grammes. Moreover, according to what the students expressed
(SD) was 5.3 (2, 3). in the evaluation comments, merely sharing patients, planning
and performing treatment together, contributed to a more
holistic view of the patient and gave valuable experiences for
The fictional web-based clinical cases: treatment plan-
cooperation in their future professional roles. Thus, without
ning in teams followed by a seminar with a presenta-
this cooperation, especially the dental students would have
tion of the suggested treatment.
graduated with considerable knowledge gaps of the dental
A significant difference between the DHS and the dental stu- hygienists’ competences and it would presumably have proven
dents, on to which degree this activity was valuable or not and to be an obstacle in developing a fruitful and effective team-
to what extent the seminar initiated interesting discussions, was work.
noted. The reasons behind testing only the students’ knowledge on
Dental students rated this activity lower in regard to its con- competences of the dental hygienist were several. First, Klef-
tribution to improve teamwork as well as to increase the bom et al. (5) found that dentists’ knowledge on this issue
knowledge on cooperation. Nevertheless, both groups found it was low; further, they suggested that undergraduate dental
valuable to make this part of education permanent with mean students should be better prepared within this field to be able
scores (SD) for DHS 6.7 (2.9) and DS 7.7 (1, 6) (Fig. 3). to lead and develop a successful teamwork. Second, the com-
petences of dentists are not limited like those of the dental
hygienist and are therefore more clear cut and known – we
Have the two questionnaires on the competences of
felt no need to ask for them. Third, the development of team-
dental hygienists increased your knowledge on which
work between DHS and dental students depends to a large
competences dental hygienists have?
degree on the students’ knowledge of what a dental hygienist
Dental hygiene students gave mean score (SD) 6.6 (2.7) and license includes.
dental students 7.2 (2.4).
Seminar with dentist from PDHS
Dental students supervising DHS.
The relatively low ratings on the seminar with a dentist from
This part scored high especially among the DHS who claimed the PDHS could be an effect of a poor performance of the
that the teamwork had increased, that the holistic approach on lecturer because the comments on the event reveal that it was
patients had been strengthened with mean score (SD) of 7.1 (2, valued positive in terms of initiating reflections and that the
7) and that they had gained valuable experiences for future seminar was stated as a good start for the project. The seminars
cooperation. Concerning the holistic view on patients, there with participants from dental care external to the faculty were
was a significant lower mean score (SD) from the dental stu- recommended to be a permanent part of the curriculum in that
dents 4.8 (2.9). Other significant differences were that DHS felt it could stimulate students’ knowledge and reflections on how
that this moment should start earlier in education and that it to perform good dentistry.
should develop their knowledge on therapy planning. Both
groups found it valuable to make this part permanent with
Web-based clinical cases
mean scores (SD) DHS 8.2 (2.7) and DS 7.0 (2.5) (Fig. 4).
In general, the dental students were more positive to this activ-
ity. Judging from the written comments, the reason behind this
Teamwork with shared patient.
is that the cases consisted of complicated prosthetic cases where
Both groups of students felt that treating shared patients should the dental students were more familiar with compared to the
become a permanent part of the education with mean scores dental hygienist students. Comments suggest that the DHS

Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S 5
Improving teamwork between students from two professional programmes Leisnert et al.

found it too difficult to participate in the debate as the case Conclusions


was too ‘dentist’ orientated.
By initiating teamwork between dental students and DHS dur-
ing their undergraduate education, it was possible to:
The two questionnaires l increase students’ knowledge on dental hygienists competence

l develop students’ perceived holistic view on patients


When asked if the two questionnaires contributed to increased
knowledge, the dental students gave higher scores, indicating
that they felt their knowledge had increased more. It is likely References
that this is because of their initial great gaps and thus had
1 Report from the Swedish Board of Health and Welfare: en analys
more to learn.
av barnmorskors, sjuksköterskors, läkares, tandhygienisters och
tandläkares arbetsmarknad. 2009. http://www.socialstyrelsen.se/
Dental students supervising DHS and coopera- publikationer2009/2009-126-28 (Accessed 21 January 2011).
tion with shared patients 2 General Dental Council. Standards for dental professionals. 2009.
http://www.gdc-uk.org/NR/rdonlyres/1B66D814-A197-4253-B331-
It is harder to grasp why DHS to a higher degree than dental A2DB7F3254DC/0/StandardsforDentalProfessionals.pdf. (Accessed
students claimed that they received a more holistic view on 21 January 2011).
patients when treating shared patients and/or when dental 3 Hancocks S. Who does what and why? Br Dent J 2008: 204: 221.
students acted as supervisors. One explanation could be that 4 Grace M. Cost effective teamwork. Br Dent J 2004: 197: 447.
the DHS experienced broader perspectives and more complex 5 Klefbom C, Wenestam CG, Wikström M. What dental care are the
dental hygienists allowed to perform? J Swedish Dent Assoc 2005:
approaches towards treatment planning and actual treatment
10: 66–73. http://www.tandlakartidningen.se/media/1578/Klef-
when working together with dental students than vice versa. bom10_2005.pdf (Accessed 21 January 2011).
This is perhaps also illustrated by the fact that the comments 6 Reeves S, Zwarenstein M, Goldman J, et al. Interprofessional educa-
from the DHS were more numerous and overall positive, tion: effects on professional practice and health care outcomes.
while the dental students offered very few. Another explana- Cochrane Database Syst Rev 2008, (1). Art. No: CD002213. doi:
tion could be that the dental students already had a devel- 10.1002/14651858.CD002213.pub2.
oped holistic view and therefore felt that they were less likely 7 Hoffman S. Del Harnish The merit of mandatory interprofession-
to increase it to a significant extent. However, our overall al education for pre-health. Med Teach 2007: 29(8): e235–e242.
impression is that dental students acting as supervisors for 8 Rafter ME, Pesun IJ, Herren M, et al. A preliminary survey of inter-
DHS contribute to developing DHS’ ability to acquire a more professional education. J Dent Educ 2006: 70: 417–427.
9 Pethybridge J. How team working influences discharge planning
holistic view on patient care, and the fact that both student
from hospital: a study of four multi-disciplinary teams in an acute
groups recommended this activity to become a permanent hospital in England. J Interprof Care 2004: 18: 29–41.
part of the education also indicates that dental students 10 Rohlin M, Petersson K, Svensäter G. The Malmo model: a prob-
valued it. lem-based learning curriculum in undergraduate dental education.
Eur J Dent Educ 1998: 2: 103–114.
11 Translation of Högskoleförordningen, 1993:100, issued 4 February
Possible errors of the study 1993. The translation includes amendments up to Swedish Code of
As mentioned earlier, there were 34 dental students and 24 Statutes (SFS) No 2006:1054 issued 18 July 2006.
12 Leisnert L, Carlsson M, Franklin I, Lindh L, Wretlind K. Improving
DHS participating in the study, which resulted in that some
teamwork in dental education. Abstract and Oral presentation.
dental students cooperated with two DHS instead of one. As
Association for Dental Education in Europe, Zagreb. 2008. Eur J
the questionnaires were answered anonymously, we cannot Dent Educ 2009: 13: 110–126.
separate results from DHS that worked with one or two 13 Leisnert L, Ericson D, Nilner K, Rohlin M. Outreach training in the
dental students. It would have been relevant to see whether Malmö-model: students’ and supervisors’ views on some qualitative
this could have any impact on the results, but it is not aspects. Abstract. Association for Dental Education in Europe, Dub-
possible. lin. 2007. Abstract Book.

6 Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S
Leisnert et al. Improving teamwork between students from two professional programmes

Appendix 1 Questionnaire regarding the competences of the dental hygienist

Yes No Do not
know

A licensed dental hygienist is entitled to…. h h h


1. Offer and give care in an office of her/his own h h h
2. Possess a radiography equipment in her/his office h h h
3. Decide on and perform radiological examination h h h
4. Radio graphically diagnose carious lesions h h h
5. Clinically diagnose carious lesions (by aid of mirror and explorer) h h h
6. Radio graphically diagnose periodontitis h h h
7. Clinically diagnose periodontitis by aid of mirror and pocket probe h h h
8. Assess risks for the reoccurrence of caries and plan for preventive measures h h h
9. Assess risks for the reoccurrence of periodontitis and plan for preventive measures h h h
10. Inject local anaesthetics h h h
11. Independently procure local anaesthetics h h h
12. Prescribe fluorides for treatment of carious lesions h h h
13. Seal fissures (apply resins on teeth without preparation, to avoid carious lesions) h h h
14. Block fissures (apply resins on teeth after minimal preparation, (to avoid carious lesions) h h h
15. Plan for and perform tooth bleaching h h h
16. Plan for and stick ‘tooth jewellery’ on teeth h h h
17. Take impression for and produce appliances for local application of fluoride and/or tooth bleaching h h h
18. Place restorations after tooth preparations made by a dentist h h h
19. Decide whether cervical tooth substance losses (due to too heavy tooth brushing) h h h
should be treated and subsequently place the restoration
20. Plan for and perform preventive measures in outreach activities among patients in special need of care h h h
21. Plan for and perform information on oral health measures in schools and nurseries h h h
22. Decide on and perform intra oral bacterial sampling h h h
23. Examine and diagnose diseases in the oral mucosa h h h

Appendix 2 Evaluation of team-work between dental students and dental hygiene


students spring 2007—spring 2008
I am h a dental student h dental hygienist student.

1. Seminar on team-work – Dr Eva Åberg from Ängelholm, DPHS Region of Skåne, presented a model for team-work: dentist – dental
hygienist – dental nurse
What did you gain from this seminar (e.g. inspiration, insight, got goose bumps, got bored, reflection, commitment, reluctance)?
......................................................................................................... . .
......................................................................................................... . .
......................................................................................................... . .
......................................................................................................... . .

This moment belongs to those that should be permanent in the education! Mark on the line to what extent this statement
in your opinion is correct
Not at al correct Totally correct
If not correct – how do you suggest it to be improved?
........... ...... ... .......................................................................................
........... ...... ... .......................................................................................
........... ...... ... .......................................................................................
....

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Improving teamwork between students from two professional programmes Leisnert et al.

2. Patient cases presented on webzone – co-written treatment plans on the web followed by seminar with presentations from selected
teams
The moment with team-work on patient cases on Webzone: Mark on the lines to what extent this state-
ment in your opinion is correct
Not at all correct Totally correct
The selected presentations of shared patients was of substantial value ———————————————————
Comment: Why/ why not? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.............................................................
The selected presentations of shared patients gave rise to valuable discussions ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
...
The selected presentations of shared patients gave insight in what collaboration means ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
...
The selected presentations of shared patients gave rise to a holistic view on the patient ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.............................................................
The selected presentations of shared patients in a seminar gave ———————————————————
an insight in what a collaboration might imply
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
...
What did you gain from this seminar (e.g. inspiration, insight, got goose
bumps, got bored, reflection, commitment, reluctance)?
.
.
.
.
This moment belongs to those that should be permanently Not at all correct Totally correct
included in the education! ———————————————————
If not correct – how do you suggest it to be improved?
.
.
.
.

3. Questionnaires Mark on the line to what extent this statement in


your opinion is correct
The questionnaires on the competences of a dental hygienist have Not at all correct Totally correct
improved my knowledge on dental hygienist/dentist competence ———————————————————

8 Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S
Leisnert et al. Improving teamwork between students from two professional programmes

4. The supervision by the dental students in the clinic


Mark on the line to what extent the
statement in your opinion is correct
Not at all correct Totally correct
———————————————————
Has provided a base for future collaboration ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
....
Has contributed to a better understanding of the team-member competence ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.................................................................
Has contributed to a better understanding of how the team-work between ———————————————————
a dentist and a dental hygienist might work
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.................................................................
Has contributed to an improved holistic view on the patient ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.................................................................
Has created a base for more focus on prevention and causal treatment ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.................................................................
Has contributed to the development of my opinion on rational dental work ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.................................................................
Has in combination with the treatment planning for these patients developed my knowledge ———————————————————
Should in the future be a mandatory part of the education ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.................................................................
Should start earlier ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.................................................................
For dental students:
The instruction for the supervision was relevant and sufficient ———————————————————
The instruction facilitated the supervision! ———————————————————

5.Collaboration with shared patients from spring 2007—spring 2008


Mark on the line etc…
The moment with shared patients: Not at all correct Totally correct
Has provided a base for future team-work ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.......................................................
Has contributed to a better understanding of the team-member’s competence ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.......................................................
has contributed to a better understanding of how the collaboration between ———————————————————
a dentist and a dental hygienist works
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.......................................................
Has contributed to an improved holistic view on the patient ———————————————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.......................................................

Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S 9
Improving teamwork between students from two professional programmes Leisnert et al.

Has created a base for more focus on prevention and causal treatment ——————————-
—————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................
Has contributed to the development of my opinion on rational dental work ——————————-
—————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................
Has in combination with the treatment planning from these patients developed my knowledge? ——————————-
—————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................
Should in the future be mandatory part of the education ——————————-
—————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................
Should start earlier ——————————-
—————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................
The presentation of some shared patients in a seminar gave an insight in what collaboration can imply ——————————-
—————————
Comment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................
What did you gain from this last seminar (e.g. inspiration, insight, got goose
bumps, got bored, reflection, commitment, reluctance)?

10 Eur J Dent Educ 15 (2011) 1–10 ª 2011 John Wiley & Sons A/S
swed dent j 2008; 32: 115–123  leisnert, hallström, knutsson

What findings do clinicians use


to diagnose chronic periodontitis?
Leif Leisnert1, Hadar Hallström2, Kerstin Knutsson3

Abstract
 The prevalence of chronic periodontitis is around 40% in the adult population and most
patients visiting a dental clinic experience an intervention related to this disease, either as
prophylaxis, e.g. disease information, oral hygiene instruction and polishing, or as treatment
of the disease, per se. Hence, chronic periodontitis is a diagnosis that initiates time and costs
consuming interventions. The findings clinicians use to diagnose chronic periodontitis are
probably also the base for their choice of treatment. The aim of this study was to examine:
• What findings dental students, dental hygienist students, dental teachers, and supervisors in
Public Dental Health use to diagnose patients with chronic periodontitis.
• If different categories of clinicians use different findings to diagnose chronic periodontitis.
A questionnaire was distributed. Seventy-six clinicians representing the four categories
answered the question: “What findings, or combinations of findings, do you use when you diag-
nose chronic periodontitis?”
Twenty-five different findings were identified as findings the clinicians use when they diag-
nosed chronic periodontitis. The most frequently reported findings were bleeding, deepened
pockets and loss of marginal bone tissue. Variations between different categories of clinicians
were identified. For example, dental hygienist students used more findings (P<0.05), and were
also more inclined to use irrelevant findings like calculus, plaque, smoking, compared to the
other categories of clinicians (P<0.05). The majority of clinicians used only one finding at a time
to diagnose chronic periodontitis, and more seldom combined findings. Only 12 out of 76 clini-
cians used a finding that provided soft tissue inflammation, e.g. bleeding, in combination with
a finding that provided loss of supporting tissue, e.g. marginal bone loss. Few clinicians com-
mented that there should be a progressive loss of supporting tissue over time. Further research
is needed to investigate if these variations in findings used to diagnose chronic periodontitis
indicate variations in treatment of these patients.

Key words
Periodontitis, diagnosis, chronic disease, decision-making

1
Department of Comprehensive Care, Faculty of Odontology, Malmö University, Malmö, Sweden
2
Maxillofacial unit, Halmstad Hospital, Halmstad, Sweden
3
Department of Oral Radiology, Faculty of Odontology, Malmö University, Malmö, Sweden

swedish dental journal vol. 32 issue 3 2008 115


swed dent j 2008; 32: 115–123  leisnert, hallström, knutsson

Vilka fynd använder kliniker vid


diagnostik av kronisk parodontit?
Leif Leisnert, Hadar Hallström, Kerstin Knutsson

Sammanfattning

 Kronisk sjukdom har ett eller flera av följande karakteristika: sjukdomen är varaktig,
lämnar kvarvarande invaliditet, orsakar irreversibla patologiska förändringar och fordrar
återkommande stöd i form av någon slags intervention eller instruktion. Detta innebär
att diagnosen kronisk parodontit med stor sannolikhet medför personella och ekono-
miska insatser från patient och tandvård. Majoriteten av alla patienter med parodontit
har kronisk parodontit. Vilka fynd som används för att diagnostisera sjukdomen kan vara
av central betydelse för val av behandling. Tidigare forskningsresultat visar att det finns
stora variationer inom hälso- och sjukvård avseende vilka fynd som används för att ställa
diagnos och hur man omhändertar patienter med likartade diagnoser/symptom.
Målet med studien var att undersöka vilka fynd olika kategorier av kliniker använder
för att ställa diagnosen kronisk parodontit och om det finns skillnader mellan de olika
kategorierna.
En enkät distribuerades som innehöll frågan: ”Vilka fynd eller kombinationer av fynd
använder du för att ställa diagnosen kronisk parodontit?”. De undersökta kategorierna av
kliniker utgjordes av sista terminens tandläkarstuderande och tandhygieniststuderande,
kliniska lärare på Tandvårdshögskolan i Malmö och VFU (verksamhetsförlagd utbildning)
-handledare i folktandvården dvs. tandläkare som är ansvariga för tandläkarstuderande
när de fullgör sin obligatoriska tjänstgöring i folktandvården. Sjuttiosex kliniker, som
representerade de olika kategorierna, angav tjugofem olika fynd för att ställa diagnosen
kronisk parodontit. De fynd som angavs mest frekvent av samtliga kategorier var blöd-
ning, fördjupad tandköttsficka och förlust av marginal benvävnad. Tandhygieniststude-
rande angav signifikant fler fynd (P<0.05) än övriga kategorier och var mer benägna att
använda irrelevanta fynd, dvs. fynd som inte per definition beskriver själva sjukdomen,
t.ex. tandsten, plack och rökning, jämfört med övriga kategorier (P<0.05). Stor variation
inom en och samma kategori av kliniker sågs också avseende vilka fynd som användes
för att ställa diagnosen kronisk parodontit, dvs. om man angav fynd som påvisar inflam-
mation i tandens stödjevävnad, förlust av tandens stödjevävnad eller om fynden var
irrelevanta. Anmärkningsvärt var att de flesta deltagarna använde fynden solitärt, dvs.
de angav antingen ett fynd som påvisade inflammation i tandens stödjevävnad eller
ett fynd som påvisade förlust av tandens stödjevävnad eller ett fynd som var irrelevant.
Endast 12 av de 76 deltagarna angav att de kombinerade fynden för att ställa diagnosen,
dvs. en kombination av fynd som beskrev både förlust och inflammation av tandens
stödjevävnad. Variationerna i vilka fynd man använde för att ställa diagnosen kronisk
parodontit medför kanske att patienter med samma diagnos och sjukdomsbild får olika
behandling av olika kliniker, om fyndet som användes för att ställa diagnos också ligger
till grund för behandlingen. Detta kan i sin tur leda till icke kostnadseffektiv behandling.
Vi avser att belysa detta i framtida studier.

116 swedish dental journal vol. 32 issue 3 2008


what findings do clinicians use to diagnose periodontitis?

Introduction tist, first use findings pertinent to diagnosis to make


Within health care there are wide variations in how a diagnostic judgment, and subsequently, based on
clinicians’ diagnose and manage patients with the that diagnostic judgement and another information
same symptoms (14-17, 19). These variations are seen relevant for treatment, he or she chooses a treatment
within different disciplines among both experts and option, i.e. the clinician judges the probability of a
novices (5). In spite of this, clinicians generally be- particular diagnosis and then chooses an action, e.g.
lieve that the treatment decisions made by their col- further testing, treatment, wait-and-see (24). Cont-
leagues would be similar to their own. Hence, they rary to ”the sequential processing view” we believe
assume that there is a broad consensus in medical that clinicians use the ”independent processing view”.
practice (17, 26). Considering the increasing flow of In this model the dentist makes the diagnostic judge-
information and new technologies that are develo- ment and the treatment choice by means of a largely
ped or improved it is also reasonable to assume that independent, often simultaneous processing of both
the diversity in diagnoses and management will in- the diagnostic findings and treatment information,
crease. when diagnosing and treating patients. In this model
Periodontitis is an infectious disease characteri- the same information and findings that constitute the
zed by inflammation and loss of supportive tissues base for the diagnosis also constitute the base for the
around teeth. Based on the character and etiology treatment option and the diagnosis itself has no direct
of the disease it is classified into eight groups where impact on the treatment option (28).
the group chronic periodontitis represents the ab- To study the decision-making strategies in pa-
solute majority of subjects with periodontitis (1, 2). tients with periodontitis several research questions
The prevalence of chronic periodontitis is up to 40% have been raised. This is the first study on this issue
in the adult population while severe attachment loss and our aim was to examine:
occurs in 7-20%, but the reported prevalence varies • What findings dental students, dental hygienist
depending on the selected population and definition students, dental teachers, and supervisors in Public
of the disease (1, 2, 11, 23, 29). Chronic periodontitis Dental Health use to diagnose patients with chro-
is mainly treated by general dentists and dental hy- nic periodontitis.
gienists. • If different categories of clinicians use different
The method used to prevent and treat chronic findings to diagnose chronic periodontitis.
periodontitis is to reduce the dental biofilm accu-
mulation and its ability to induce tissue destruction, Material and methods
and thus, the goal is to prevent tooth loss. The Swe- Study design
dish Council on Technology Assessment in Health In a questionnaire on findings clinicians use when
Care (SBU) has in a theoretical model, based on five diagnosing chronic periodontitis one question was:
original studies on economic analyses of preventive “What findings, or combination of findings, do you
diagnostic and treatment methods (8, 9, 13, 22, 25), use when you diagnose chronic periodontitis?” The
calculated the annual costs for examination and questionnaires with included information were dist-
treatment of chronic periodontitis in 55-59 years ributed to dental teachers at the faculty by one of the
old individuals in Sweden to 175 million SEK. The authors (LL) in a personal meeting. Supervisors in
theoretical model included both direct costs, such the Public Dental Health were informed via e-mail
as salaries for dentists and nurses, material, x-rays, and after a general meeting at the faculty the ques-
localities, equipment, and indirect costs such as loss tionnaires were distributed and answered directly
of production and salary due to absence from work after the meeting. The students filled in the ques-
(27). tionnaire at the school in connection to their clinical
Diagnosis is an essential fundament for making work. The participation of the dentists were volun-
treatment decisions. In medical decision-making, tarily and anonymous while it was regarded as a part
several findings are used to diagnose chronic pe- of the education for the students. The licensed den-
riodontitis, e.g. bleeding on probing providing tists stated their age, sex, years of experience as den-
soft tissue inflammation, deepened pocket, and tist, and specialists noted type of speciality. Teachers
bone loss measured in radiographs providing loss in the dental hygienist education did not participate
of supporting tissue over time (30). In the classic because they were too few to form a group that could
paradigm, ”the sequential processing view”, on de- be statistically analysed, and thus, compared with
cision-making strategies, the clinician, e.g. the den- the other categories of clinicians.

swedish dental journal vol. 32 issue 3 2008 117


leisnert, hallström, knutsson

Clinicians Supervisors in the Public Dental Health Service (S):


Dental students (DS): Thirty dentists in the Public Dental Health service,
Thirty-seven dental students, in their final month of a who also have a role as supervisors for dental stu-
5 year-education, at the Faculty of Odontology, Mal- dents in their period of outreach training (18), were
mö University were asked to participate. Twenty-two asked via e-mail if they would participate. Twenty-
of the students answered the questionnaires. Thirteen seven supervisors, 15 females and 12 males, partici-
were females and nine were males. The mean age was pated in the study. The mean age was 52 years (range
27 years (range 24-36) for the females and 26 years 36-45) for the females and 49 years (range 30-64) for
(range 24-30) for the males. Fifteen students could the males. Three of the 30 dentists did not partici-
not participate due to other commitments; these stu- pate due to other commitments.
dents were therefore not obliged to participate.
Analysis
Dental hygienists students (DHS): If differences existed between the numbers of fin-
Sixteen dental hygienist students in their final dings each category used was analysed with one way
month of a 2 year-education at the Faculty of analysis of variance (ANOVA). If differences existed,
Odontology, Malmö University were asked to par- Turkey’s test was used to analyse between which cate-
ticipate. Fourteen females and one male of a to- gories these differences existed. Differences between
tal of 16 students participated. The mean age was different categories use of respectively findings were
31 years (range 21-45 years). One student did not analysed using chi-square test (P=0.05).
participate due to illness.
Results
Dental teachers (DT): Analysis of the answers
Eighteen dental teachers in the Comprehensive After the data had been collected the questionnaires
Care Clinic (CCC) at the Faculty of Odontology, were read by all the authors. Analyses of the answers
Malmö University, were asked to participate. The were performed stepwise. In a first step, the ques-
teachers worked at the CCC four to sixteen hours tionnaires were scrutinised to find content-word or
per week. Twelve teachers participated, four of concepts that could be coded as a finding. Twenty-
these were specialists in prosthodontic, two in five different findings were identified as findings the
periodontology and six were general dental prac- clinicians used to diagnose chronic periodontitis. In
titioners. Six teachers were females and 6 were a second step different content-words or concepts
males. The mean age was 47 years (range 34-67); that could be interpreted as the same finding were
for the males 53 years and for the females 41 years. brought together. For example bleeding on pro-
The mean age of the 18 teachers that worked at the bing and bleeding index were registered as bleeding.
CCC were 45 years (range 34-67). The questionn- Further, subgingival and supragingival calculus was
aires were returned anonymously in such a way registered as calculus, and plaque and plaque index
that no drop-out analyses could be performed were registered as plaque. In a third step, findings
without unmasking the anonymity. The drop- registered by less than three participants, were exclu-
outs could easily have been identified since they ded. Such findings were age, halitosis, genetics, and
were all known by the authors according to age, diabetes. After these steps, 13 findings remained and
gender and speciality. were further analysed.

 Table 1. The most frequently used findings (N=13) by four different categories of clinicians when they diagnose chronic
periodontitis. The findings are divided into three subgroups.

Soft tissue inflammation findings Loss of supporting tissue findings Irrelevant findings
-bleeding -marginal bone loss -plaque
-pus -marginal bone loss changed over time -calculus
-marginal bone loss on >1/3 of root length -smoking
-vertical bone pocket -mobility
-attachment loss
-furcation involvement
-deepened pocket

118 swedish dental journal vol. 32 issue 3 2008


what findings do clinicians use to diagnose periodontitis?

 Figure 1. Dental students, dental hygienist students, supervisors, and dental teachers use of 13 findings when they diagnose
chronic periodontitis. The bars represent the percentage of clinicians within each category that used respectively finding.

% of clinicans
100
Dental teachers

0
100
Supervisors

0
100
Dental hygienist students

0
100
Dental students

0
pus

dee

mo

pla

cal

sm
ble

att

fur

bon

boner tim

bon/3 o

ver
ov

>1

oki
c
bil

que
kat
ach
edi

tica
pen

ulu
e lo

e lo e

e lo f roo

ity

ng
ion
n

s
l bo
d

ss o

ss o

ss o t le
g

ent
poc

inv

ne
nx

nx

n x ngt
l
oss
ket

olv

poc
-ra

-ra

-ra h
me

ket
nt

 Figure 2. Mean number of findings (N=13) used by four different categories of clinicians to diagnose chronic periodontitis
in patients. The bar within each column represents the 95% confidence interval. Dental hygienists students used more findings
compared to the other categories (P<0.05).

6
Mean number of criteria

0
Dental students Dental hygienist students Supervisors Dental teachers

Categories

swedish dental journal vol. 32 issue 3 2008 119


leisnert, hallström, knutsson

 Table 2. Distribution of number of clinicians within each category that used findings that provide soft tissue inflammation
(1), loss of supporting tissue (2). The majority used the findings solitarily to diagnose chronic periodontitis. Only 12 of 76 used findings
in subgroups 1 and 2 as combinations.

Category of clinicians Findings 1 and 2 Findings 1 or 2


n % n %
Dental students, N=22 15 68 7 32
Dental hygienist students, N=15 15 100 0 0
Supervisors, N=27 18 67 9 33
Dental teachers, N=12 11 92 1 8

 Table 3. Number of clinicians within each category that used irrelevant findings to diagnose chronic periodontitis.
Irrelevant findings Dental students Dental hygienist students Supervisors Dental teachers
N=22 N=15 N=27 N=12
n % n % n % n %

Calculus 1 5 10 67 7 26 0 0
Plaque 6 27 10 67 6 22 2 16
Smoking 0 0 2 13 5 19 0 0
Mobility 7 32 6 40 7 26 1 8
TOTAL 13 59 13 87 17 63 3 25

Findings nic periodontitis. However, about a third of the den-


The 13 findings were divided into three subgroups tal students and the supervisors only used findings
showing: soft tissue inflammation, loss of sup- either from the soft tissue inflammation subgroup
porting tissue, and irrelevant findings, i.e. findings or the loss of supporting tissue subgroup. The dist-
that were considered not being relevant to diagnose ribution of clinicians that used irrelevant findings is
the disease, per se. Table 1 presents the subgroups of presented in Table 3. With the exception of the den-
these findings. tal teachers, the majority of clinicians within each
Figure 1 presents the number of clinicians that category used irrelevant findings.
used each of the 13 findings to diagnose chronic Eighteen clinicians, 4 dental students, 2 dental hy-
periodontitis. Within all categories the majority of gienist students, 7 dental teachers and 5 supervisors,
the clinicians used deepened pocket, bone loss on x- of totally 76 participants, reported that they combi-
rays, and bleeding. Differences between the catego- ned two findings to reach the diagnosis. However, of
ries use of findings existed. None of the supervisors these 18 clinicians only 12 combined one finding that
used attachment loss as a finding, while 13% to 27% provided soft tissue inflammation with a finding
of the other categories of clinicians used this finding that provided loss of supporting tissue. The other
(P<0.05). A higher frequency of dental hygienist stu- 4 only combined findings that all provided loss of
dents used plaque, calculus, and pus compared to supporting tissue.
the other categories (P<0.05).
Dental hygienist students used more findings as Discussion
compared to the other categories (P<0.05) (Figure Chronic periodontitis is a common disease that af-
2). They registered 6 findings as a mean that provi- fects about 40% of the adult population depending
ded soft tissue inflammation or loss of supporting on how the disease is defined and selection of age
tissue. All the other categories used as a mean 4 fin- group (7, 10). Most patients visiting a dental clinic
dings. The different categories use of the 13 findings experience an intervention related to the disease ch-
are presented in Table 2 and 3. There was a difference ronic periodontitis, either as prophylaxis, e.g. disease
in the number of findings that each category of the information, oral hygiene instruction and polishing,
clinicians used, as presented in Table 2. Fifty-eight of or as treatment of the disease, per se. The latter group
the 76 clinicians used each finding solitarily, i.e. one is treated with scaling and root planning, often per-
at a time, and not in combination to diagnose chro- formed by a dental hygienist. In more severe cases

120 swedish dental journal vol. 32 issue 3 2008


what findings do clinicians use to diagnose periodontitis?

the treatment includes surgery and in some cases censed: they had finished their work in their tutorial
antibiotics even though evidence is lacking for any groups and their clinical work and must therefore
long-time effects of this treatment (12). Chronic pe- be seen as highly knowledgeable theoretically in the
riodontitis is a diagnosis that probably initiates time different subjects included in the dental curriculum.
consuming interventions. The findings used to di- Overall, one would expect the variation in findings
agnose this condition could be the base for choice they use when they diagnose chronic periodontitis
of treatment option. This is why we intended to to be smaller than amongst a randomised selection
examine what findings different clinicians use when of clinicians (17).
they diagnose the disease per se. Except for the dental teachers the response fre-
quencies were satisfying. Even after receiving a re-
Methodological considerations minder only 12 out of 18 dental teachers responded.
Our overall aim, of which this study is a part, is to The responding teachers were representative for the
examine how different categories of clinicians reach whole group of dental teachers according to age,
their treatment plans for patients with chronic pe- sex, and kind of speciality. However, the author that
riodontitis. One question was ”What findings, or was present, LL, when the dental teachers answered
combination of findings, do you use when you di- the questionnaire received negative feed-back from
agnose chronic periodontitis?”. The aim was to have some of the colleagues. They felt as if it was a test and
the clinicians to report in their own words all the as if they were controlled. This might be one expla-
findings they used, and whether they used these fin- nation for the relatively low response frequency.
dings solitarily or in combinations to diagnose ch-
ronic periodontitis. This open structure of the ques- Reflection on the answers
tion might be the reason that very few, only 18 of the The MESH-term “Chronic Disease”, in Pub Med,
76 participants, stressed that they used the findings is defined as “Diseases which have one or more of
in combinations. In studies where the participants the following characteristics: they are permanent,
are asked to describe their judgement strategies it is leave residual disability, are caused by irreversible
vital that they are not steered (5). If we had given pathological alteration, require special training of
alternatives the answers would probably have been the patient for rehabilitation, or may be expected to
limited to these. Further, the situation in which the require a long period of supervision, monitoring, or
clinicians were presented to the questionnaire was care”. Translated to a health care perspective this, in
almost identical for the different categories. The our opinion means, that when patients receive the
dentists were informed and had a choice whether or diagnosis chronic periodontitis, personal and eco-
not to participate, in opposite to the students, who nomic resources are consumed and the patients of-
were obliged to participate. The dental teachers re- ten become lifelong dependents on dental care. The
turned the questionnaires by post or handed it back diagnosis and probably the findings that constitute
on a later occasion. They might have obtained infor- the diagnosis are therefore crucial.
mation that the other categories were unable to get, In concordance with other studies in decision
since they answered the questionnaire and returned making our results underpin existing evidence that
it back on that same occasion.The clinicians in this variations in medical practice exist (6, 17, 26). In this
study are neither a randomised selection nor a re- study, we recorded all 25 different findings used by
presentative group of dental clinicians in Sweden. the clinicians to diagnose chronic periodontitis. The
They could rather be regarded as a highly know- most frequently used findings were deepened pock-
ledgeable group. Dental teachers are supposed to ets, bleeding on probing, and loss of bone level on
be informed about the evidence base for the clinical x-ray. This is in concordance with other studies on
methods used at the CCC, and thus expected to have how to define the disease chronic periodontitis (4).
the knowledge on which findings should be used to The listed findings correspond well to findings
diagnose patients with chronic periodontits. Super- that are in concordance with soft tissue inflamma-
visors in the Public Dental Health continuously par- tion and loss of supporting tissue. However, it was
ticipate in postgraduate education and are recruited surprising that only 12 out of 76 clinicians combined
from dentists with experience and interest in clinical the findings belonging to these two subgroups. To
questions, educational matters and supporting the be in concordance with the definitions of chronic
students’ professional development (18). periodontitis “An infectious disease resulting in in-
The dental and hygienist students were almost li- flammation within the supporting tissues of the te-

swedish dental journal vol. 32 issue 3 2008 121


leisnert, hallström, knutsson

eth and progressive attachment and bone loss”(21), higher number of findings (P<0.05), and were
at least one finding providing soft tissue inflamma- also more inclined to use irrelevant findings like
tion, and one providing loss of supporting tissue calculus, plaque, and smoking compared to the
should be used, for example bleeding and bone loss. other categories (P<0.05).
Furthermore to be chronic there should be a loss of • Within each category of clinicians wide variations
supporting tissue over time (20). Until date, no exact were found in which findings they used to diag-
definition exists and very few of the clinicians in this nose chronic periodontitis. The majority only used
study comments that there should be a loss of sup- the findings solitarily and they did not combine
porting tissue over time. one finding that provided soft tissue inflamma-
In all categories there were clinicians that used tion with a finding that provided loss of sup-
irrelevant findings, i.e. findings not mentioned in porting tissue. Only 12 of 76 clinicians used two
any study or classification to be a finding used to relevant findings in combination.
diagnose chronic periodontitis. Such findings were • The wide variations when clinicians diagnose
for example plaque and calculus. These findings chronic periodontitis might indicate variations in
are considered to be irrelevant since they do not, treatment plans and treatment options. Further
per se, describe the disease. Plaque and calculus are research is planned to investigate the extent to
findings that could be present both in patients with which the used findings influence the treatment
and without periodontitis (3). Even though the den- options.
tal hygienist students were in the majority when it
comes to the use of irrelevant findings, both dental Acknowledgements
students and supervisors used such findings. The The study was approved by the Ethics Committee
teachers used few irrelevant findings and were found at Lund University, Lund, Sweden (LU- 317/2006).
to be more evidence-based but the students were not We thank Per-Erik Isberg, B.Sc., for statistical advice
in compliance with their teachers. Only one dental and the participants in this study: dental students,
teacher used tooth mobility as an irrelevant finding. dental hygienists, and dental teachers at the faculty
None of the supervisors in the Dental Public Health of Odontology, Malmö University, Malmö. We also
used attachment loss as a finding when they diagno- thank the supervisors in the Public Dental Health in
sed chronic periodontitis. This was expected since the region of Skåne, Sweden.
attachment loss as a measurement of loss of sup-
porting tissue is hard to perform in daily praxis and
is also time-consuming, and hence, more often used
in research projects. The supervisors in contrast to
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