| Abstract|| |
Great advances have been made in the curriculum of dentistry since the start of the first dental college in West Bengal in the early 1900s. Yet the pattern of learning till today has been predominantly lecture oriented. Problem based learning (PBL) is a relatively new pedagogy with a potential to be adopted in the dental curriculum. In PBL, instead of the traditional pattern of teaching, learning is achieved proactively by involving the students. The students learn the many aspects of dentistry by solving problems. The teacher is more of a spectator than an active participant. PBL is very suited to professional education programmes such as dentistry where contextualized learning represents a more accurate reflection of the real-life situation that is presented to practitioners on a daily basis.
Keywords: Dental education, pedagogy, problem based learning
|How to cite this article:|
Jacob P S. Problem based learning in dental education. J Educ Ethics Dent 2011;1:7-11
| Introduction|| |
Enquiry-based Learning (EBL) can be defined as a broad umbrella term used to describe approaches to learning that are driven by a process of enquiry.  Problem-based learning (PBL) comes under the ambit of EBL where the students or the learners pursue their own lines of enquiry, draw on their existing knowledge and identify the consequent learning needs. PBL follows the research of Barrows and Tamblyn, and was first implemented in medical education in McMaster University in Canada in the 60's.  Barrows defines it as: The learning that results from the process of working towards the understanding of a resolution of a problem. The PBL pedagogy (process of teaching) is underpinned by the learning theory principles of constructive, contextualized, collaborative, and self-directed learning.  This pedagogy of dental education has gained sufficient ground in different parts of the world basically due to its philosophy of self enquiry. The paper tries to present an overview on this unique learning method in dental education.
| History|| |
John Dewey,  early in the twentieth century, advocated the use of everyday problems to facilitate learning among students. This student centred learning, where an active rather than passive learning is fostered, is very much in contrast to the traditional lecture format of teaching. In this format of learning, the students explore and learn rather than being as passive listeners to lectures. PBL was officially adopted as a pedagogical approach in 1968 first at McMaster University, a Canadian medical school,  because students were unable to apply their substantial amount of basic scientific knowledge to clinical situations. Among dental schools, Malmö University of Sweden was the first schools introduce PBL as early as 1990 as the method of learning. In North America, the interest was promoted in 1995 by the Institute of Medicine Report, Dental Education at the Crossroads, which strongly urged a reassessment of current dental curricula.  Since then many dental schools have employed some aspects of PBL in their curricula and are found in Europe (Sweden, The Netherlands, Norway, and the United Kingdom); Asia (Hong Kong, Singapore, and Thailand); Australia; New Zealand; United States of America; and, Canada. 
PBL follows the research of Barrows and Tamblyn.  Barrows defines it as: The learning that results from the process of working towards the understanding of a resolution of a problem. The problem is encountered first in the learning process. Emphasis is on learning by introducing the concept of finding a solution to a problem rather than learn all that is required through lectures and books before you encounter with a problem. Traditionally, dental students encounter the 'problem' only during the internship where they face the responsibility of finding an appropriate solution for their patients' problem. PBL tries to introduce this phase early in their education. The role of the teacher is transformed to a person who facilitates, guides, encourages the students to find their solution rather as a traditional teacher who teaches. PBL is part of the shift from the teaching paradigm to the learning paradigm. 
| The Problem Based Learning Pedagogy|| |
The working definition of the PBL can be described as follows. When a problem is presented to a small group of students, they form the PBL tutorial. After defining the presented problem, the students brain storm ideas from previous knowledge, while identifying areas to explore on the problem (learning phase). The students leave the PBL tutorial and go after their resources; be it from library, web, resource persons or peers. They return to the PBL group to work on the problem with their learned information. They find solution/s to the problem. The learning and the process that went into the solution is reviewed and reflected.
Hence, here the learning starts with a problem. Yet to incorporate a PBL pattern of pedagogy few important aspects should be looked into before the conventional curriculum is modified to PBL. They include:
- PBL curriculum design,
- PBL tutorials,
- PBL compatible assessments.
Problem based learning curriculum design
The curriculum is more different from the traditional way of teaching through lectures. Clarifying the learning outcomes for the unit/module of the curriculum is a very important stage of the curriculum design. Problems related to the learning outcomes to stimulate the students' interest to know and learn, is an important step in curriculum development. PBL curriculum should ensure that all learning outcomes will be addressed at least once through presentation of the problems. Problems vary in size; being solved in two sessions or being progressively solved over a period. The format of the problem can include videos, photographs, objects, dialogues, scenarios, progressive disclosures etc. The problems should be designed so that the outcome desired by the learning process through PBL is achieved. Mauffette stated that,  the problem in problem-based learning is the problems; but do they motivate students. Research in PBL found that variety and challenges should be an important aspect perceived by the students when learning through PBL.  Problems should be designed so that it stimulates and encourages the desire of the students to learn.
Problem based learning tutorial
A PBL tutorial consists of a small group of about 5-8 in numbers, who need to work together for a problem. Basically it can be called as a 'group discussion'; however, with a few more extended actions. A tutor is required not for explaining the topic or for a lecture but to facilitate. The tutor will be required to listen attentively, and ask stimulating questions. The whole process of PBL is carried out by the students, with the tutor taking the role of a facilitator or guide, and pitching in only when they face a stumbling block or the group wavers off the course. The PBL group can have a chairperson, scribe, timekeeper, reader and presentation editor as required by the problem. Though many different models are available, yet the underlying theme and the objective remains the same.
Barrows problem based learning tutorial model
Barrows divides the model into four parts: Ideas/hypothesis, Facts, Learning issues and Action Plan. Students using this model may summarise their discussion under these headings on one shared learning environment, which may be a whiteboard or flipchart.
Another PBL tutorial method is the 'seven jump approach' of Schmidt and Moust. ,
Seven jump approach
- Clarify unknown terms or concepts in the problem.
- Define the problem.
- Analyze and brainstorm to get solution or explanation to the problem (Prior Knowledge).
- Criticize the explanations.
- Identify the learning issues.
- Self study.
- Share the findings and integrate the knowledge to get a more acceptable explanation or solution to the problem.
In a PBL tutorial, students collectively elaborate and construct their knowledge together.  Though there are common paths, PBL tutorials are not individual research or a project work. Rather than focusing the whole energy on a single problem, PBL through the tutorials tries to create a flexible scaffold to understand the subject basics in relation to its various problems and the various solutions.
Problem based learning compatible assessments
Traditionally, the assessment strategy was comprised primarily of summative tests during the academic year in both theory and clinical practice, and an examination at the end of the year, where the emphasis was on examining students' knowledge and understanding of principles and concepts. The PBL assessment strategy had to be better integrated into the learning process so that the students would see it as something which would help them learn and develop. Hence, more continuous assessment methods are used and extensive feedback is provided to each student. Each problem would involve the students working together in groups, with and without a tutor present, and then presenting their solution either orally or by a written report. Some methods suggested are oral presentations, written reports, individual contribution to the group process, chairing of the group process, clinical reports, and end-of-year open-book examination. To overcome some of the problems associated with assessing individual contribution when a group has worked on the problem, it is necessary to involve the students in the assessment process through the use of self and peer assessment. This is also important as the tutor is not always present with the group to assess their performance and contributions.
| The Advantage of Problem Based Learning|| |
A critical element of the PBL approach is learning in small groups by pursuing the problems. The literature indicates that group of about six to eight students is optimal to ensure the participation of all members and to eliminate the segregation of the group into smaller subsets.  Apart from the self assessment, each member has expectations about the level of accomplishments of the other members. This small group gives a sense of belonging and a security, providing a "safe" learning environment. Each member can play a different role and support one another with the learning goals in mind. There is a continual self- and peer evaluation, both to enhance the performance of the group and to begin the development of professional behaviours essential to the successful delivery of oral health care. Before a student is introduced into a PBL environment, it is important to realize that most of them will be new to this pedagogy coming from the traditional lecture based teaching methods in their schools. Among the greater strengths of the PBL pedagogy is its innate ability to integrate the learning of the basic and clinical sciences in a way that transcends traditional departmental boundaries.
| Summary of Working of Students on a Problem Through a Problem Based Learning Approach|| |
The PBL group is presented with a problem or case [Table 1].
The facts or data on the case is brought out in points. The group then clarifies the facts of the case. The problem is defined, in simple two or more sentences. Ideas towards understanding or solving the problem are brainstormed based on prior knowledge. This helps them identify the limitations in their knowledge or in other words the areas to be learned are identified (learning issues). An action plan is framed for working on the problem.
A session of independent study is undertaken by the group. The resources could be the library, databases, the web, resource people and observations. This session is undertaken such that the issues presented in the discussion of the group should be substantiated by evidences and should not be unsupported observations.
Back to problem based learning tutorial
With the learning and knowledge acquired, the PBL tutorial joins back to share information, peer teaching and working together on the problem.
The solution to the presented problem case is framed and discussed and presented.
The learning achieved by solving this problem case is reviewed and reflected. All who participated in the process engage in self, peer and tutor review of the PBL process and reflections on each person's contribution to that process.
| Challenges for Problem Based Learning|| |
This pedagogy also has its own share of challenges. The integration of subjects and disciplines could be a major challenge. The challenge in implementing a PBL curriculum is to provide structures that support integration, ensuring relevant content in the curriculum as well as facilitating self-directed learning. Another key issue is the availability of resources. There is an increase of academic staff required in PBL curriculum than traditional teaching method, yet these increases have been found only to be marginal. [15,16] The other major issue on resources is the availability of adequate library and trained librarian for PBL along with e learning facilities. The content of the curriculum is delivered in blocks of problems which follow a theme or topic and can be considered a roadblock in implanting PBL in a dental school. There is a need for an interdisciplinary approach to device and review problems so that PBL component is synchronised with, for example, dental laboratory skills or clinical training or other aspects of the curriculum. 
| Problem Based Learning Experience in Dental Schools|| |
The first dental school to introduce PBL was the Sweden Malmö University when in 1990 the Centre for Oral Health Sciences introduced a full PBL curriculum.  Few other schools which have implemented PBL fully in their undergraduate dental curriculum are the Hong Kong school in China, Dublin school in Ireland, University of South California (USC) in United States of America and Manchester school in United Kingdom.  Many schools have partly replaced the whole curriculum with the PBL model. The International Dental Problem-Based Learning Network (IDPBLN) conducted a survey published in 2002 among 10 Canadian and 55 United States dental schools to determine the extent of PBL in dental education.  22 institutions reported that PBL was being used, and six indicated that they planned to use PBL in the future. For the most part, PBL was used only in certain parts of the curricula, most commonly during the first two to three years while essentially preserving the traditional preclinical/clinical structure of later years, the "horizontal hybrid". Only a few institutions in Canada and the United States used PBL beyond a single subject or course as introducing PBL across an entire curriculum was found difficult.
Many schools wanting this pedagogy are comfortable with a hybrid approach to PBL possibly due to the fear of acceptance from students as well as the outcome of the new curriculum on their graduates' performance. The dental school at Malmö has graduated many classes of students since PBL was first implemented and appears satisfied with the outcomes observed.  A qualitative study in University of Adelaide was done on the observation of the group learning among first year students exposed to PBL pedagogy.  The first year students' approach to work as a PBL group was a complex interplay of individual students' understandings and previous experiences, and shaped by students' responses to their new learning environment. They managed new and unfamiliar learning activities by framing their group work in terms of what was familiar and understandable. Indiana University School of Dentistry (IUSD) implemented a major curriculum revision involving the utilization of problem-based learning in 1997. A study at IUSD showed that library circulation increased since the pedagogical change to PBL.  Students in the new curriculum placed more emphasis on the library as a learning resource; and, thus initiated a desire for life-long learning.
In 1997, the National Taiwan University, School of Dentistry, decided to implement PBL into Oral and Maxillofacial Radiology (OMFR) course within a traditional, discipline-oriented dental curriculum.  More commitment and less disruptive behaviour and improved engagement, interpersonal relationships and self-presentation were found in the PBL course. Implementation of PBL in only Pedodontics in the School of Stomatology at Wuhan University (WHUSS), China, in 2000 led to a positive feedback among students and teachers.  This included the ability of students to more effectively communicate ideas in a group setting, the enhancement of a practical approach in solving dental treatment-related problems, the development of critical thinking and problem-solving skills, and improved enthusiasm for learning. As a result, a multidisciplinary PBL curriculum at WHUSS was established for the clinical education of the seven-year program students with about 80 percent of the lectures kept in the new PBL program. In a study on 5 th year students at the Universidad Europea of Madrid (UEM), Spain, a PBL group was compared with a traditional non PBL group. PBL participants obtained higher grades compared to those receiving lectures only. The two student groups devoted the same amount of time to a subject; however, the PBL students spent more time on group work and analysis of the literature.
In a study on USC dental students, a high level of achievement on United States National Dental Boards Exam (NDBE) (Part I) examinations was attained by PBL students compared to their peers working in a traditional lecture-based curriculum. The "authentic PBL" program of USC has no scheduled lectures and maintains a PBL pedagogy for all four years of the curriculum. In 1994, Harvard School of Dental Medicine (HSDM) incorporated PBL into the first, second, and third (clinical year) year dental courses.  The implementation of PBL here increased NDBE Part I scores, graduation rates, and percentage of graduates entering postgraduate education programs, as well as decreased attrition rates.  In another study on graduates in their postdoctoral training, the PBL training provided HSDM graduates with enhanced abilities in independent learning, communication, and cooperation skills than non HSDM graduates. 
There are no reports where PBL implementation has been stopped or withdrawn from any schools where this pedagogy is employed fully or partly. Though this gives an indirect sense that this method of learning works in dental education, it should not lead us to a state of overconfidence that this system will work in all situations. Customization, acceptance and perseverance can become key words for a successful PBL implementation.
| Conclusion|| |
PBL is very suited to professional education programmes such as dentistry where contextualized learning represents a more accurate reflection of the real-life situation that is presented to practitioners on a daily basis. Skills in self-directed learning are also crucial to health practitioners developing a culture of lifelong learning, which is vital to maintaining competence throughout their practicing careers. PBL introduces a sense of confidence to the learner, and it makes the student an ever learner which is very much needed in this era of evidence based practice. The introduction of real life problems early in the curriculum makes us look through the perspective of the patient expecting a fair deal from his dentist.
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P Shaju Jacob
Department of Periodontology and Oral Implantology, Chhattisgarh Dental College and Research Institute, Sundara, Rajnandgaon, Chhattisgarh
Source of Support: None, Conflict of Interest: None