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Developing Competence in Tooth Extractions during Undergraduate Dental Education -A Qualitative Study

Authors:
  • Islamabad Medical & Dental College, Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad, Pakistan
  • Islamabad Medical and Dental College
Article

Developing Competence in Tooth Extractions during Undergraduate Dental Education -A Qualitative Study

Abstract

Purpose: To gain a deeper understanding of factors which contribute to development of competence in tooth extractions during undergraduate dental education. Methods: A qualitative approach was used to explore the perceptions and experiences of a range of stakeholders. Purposive sampling was used to recruit the participants which included undergraduate dental students, new graduates, dental academic staff, and clinical supervisors. The focus groups were transcribed verbatim, and data were imported into NVivo 12. Data were analyzed thematically using an inductive approach. Results: Two focus groups were conducted. Ten undergraduate students participated in the Student Focus Group while eight dental academics and clinical supervisors participated in the Staff Focus Group. Participants expressed their views on a range of issues related to teaching and training of tooth extractions. The key themes cantered on structured teaching underpinned by patient safety; focus on breadth of clinical experience; and constructive feedback to enhance reflective practice amongst students to enhance the learning experiences of students. Conclusions: This study provides useful insights into how undergraduate dental students develop competence in tooth extractions as perceived by the participants and may help dental educators to reflect of their teaching model.
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South-East Asian Journal of Medical Education
Vol. 15, no. 2, 2021
Original Research Paper
Developing Competence in Tooth Extractions during
Undergraduate Dental Education A Qualitative Study
Ali, K.1, Siddiqi, K.M.2, Qazi, H.S.2
Abstract
Purpose: To gain a deeper understanding of factors which contribute to development of competence in
tooth extractions during undergraduate dental education.
Methods: A qualitative approach was used to explore the perceptions and experiences of a range of
stakeholders. Purposive sampling was used to recruit the participants which included undergraduate
dental students, new graduates, dental academic staff, and clinical supervisors. The focus groups were
transcribed verbatim, and data were imported into NVivo 12. Data were analyzed thematically using an
inductive approach.
Results: Two focus groups were conducted. Ten undergraduate students participated in the Student
Focus Group while eight dental academics and clinical supervisors participated in the Staff Focus
Group. Participants expressed their views on a range of issues related to teaching and training of tooth
extractions. The key themes cantered on structured teaching underpinned by patient safety; focus on
breadth of clinical experience; and constructive feedback to enhance reflective practice amongst
students to enhance the learning experiences of students.
Conclusions: This study provides useful insights into how undergraduate dental students develop
competence in tooth extractions as perceived by the participants and may help dental educators to
reflect of their teaching model.
Keywords: Clinical Skills, Oral and Maxillofacial Surgery, Undergraduate Dental, Competence,
Extractions
Introduction
Competence in tooth extractions is a core skill
in undergraduate dental programs. Students
are expected to be proficient in performing
uncomplicated extractions prior to graduation
(GDC, 2015; Cowpe et al, 2010). Competence
of new dental graduates is defined by abilities
essential to begin independent, unsupervised
dental practice (Chambers & Gerrow, 1994).
1Qatar University College of Dental Medicine, Qatar
2Islamabad Medical and Dental College, Pakistan
Corresponding author: Professor Kamran Ali
ali.kamran@qu.edu.qa
However, competency of a new dental graduate
like their medical peers only represents a point
on a continuum (Harden, 2007; Frank et al.,
2010).
A newly qualified dentist usually develops
through a predictable pattern after experiencing
a variety of challenges in the clinical
environment and it may take several years to
consolidate their knowledge, skills, and
attitudes (Chambers, 1996).
Several studies investigating dental students’
competence in tooth extractions have been
published in recent years (Al-Dajani, 2015;
Macluskey & Durham, 2009; Durham et al.,
2007).
27
DOI: http://doi.org/10.4038/seajme.v15i2.299
Competence in tooth extractions
South-East Asian Journal of Medical Education
Vol. 15, no. 2, 2021
Evidence from the literature underscores the
need to improve students’ training in performing
tooth extractions for a smooth transition into
general dental practice settings (Wilson, 2011).
Dental institutions, especially those in the
developed countries, have adopted a
competency-based framework for imparting
dental education (Prescott et al., 2001).
However, marked differences can be identified
in the structure of teaching, clinical training, and
assessments of tooth extractions in dental
schools globally (Brand et al., 2015). Similarly,
clinical targets in tooth extractions during
undergraduate education vary considerably
ranging from as low as 20 in the United
Kingdom to 200 in some developing countries
(Durham et al., 2007; HEC, 2011).
Controversies also exist regarding the
relationship between the total number of teeth
extracted and the successful completion of the
final assessment (Ali et al., 2020; Al-Dajani,
2015). Therefore, further investigation of
factors, which contribute to development of
students’ competency in tooth extractions, is
warranted.
The aim of the study was to explore the
development of competence in tooth
extractions during undergraduate dental
education and gain a deeper understanding of
factors which facilitate acquisition of
knowledge, as well as psychomotor and
affective skills to help dental students
undertake tooth extractions on patients in a
safe and predictable manner.
The conceptual framework of the study was
underpinned by situated learning theory (Lave
& Wenger, 1991). Situated learning asserts that
learning is a transformative process tied to its
context and to the social relations and
practices. Exposure of learners to authentic
situations and activities facilitates learning
(Herrignton & Oliver, 2000). In the context of
clinical dental education, students and
academics come together in pursuit of a shared
enterprise. Through “legitimate peripheral
participation”, active engagement and
assuming increasing responsibility, the student
in this session acquired the role, skills, and
values of the culture and community (Lave &
Wenger, 1999).
Methods
Ethical approval was obtained for the study
from the Institutional Review Board
(IMDC/DS/IRB/164). This study was
undertaken at the Islamabad Medical and
Dental College, Islamabad Pakistan.
Participants were recruited using purposive
sampling to target undergraduate students,
dental academic staff and clinical supervisors.
Qualitative methods were used for data
collection and two focus groups were
organized: one for students, and the other one
for staff. The participants were invited by email
through the central Faculty office with the
Administration officer as the gatekeeper. The
email invites were accompanied by a
participant information sheet explaining the
purpose and scope of the study and other
relevant details regarding data collection,
storage, and dissemination along with contact
details of the research team. Informed consent
was obtained from all participants to confirm
their agreement to participate in the study. The
participants were offered a choice of dates and
times separately and asked to indicate their
preferences through a doodle poll. Based on
the responses, a date, time, and location were
worked out for each focus group and
communicated to the participants by email.
Participants in the Staff focus group were dental
academics, and clinical supervisors. The
second focus group consisted of final-year
dental students and recent graduates. Both
focus groups were facilitated by the principal
researcher who had no previous direct contact
with the participants. A separate focus group for
students was aimed at allowing them to share
their perceptions and experiences as presence
of staff could be potentially intimidating.
Both focus groups were recorded on a digital
audio device to ensure accuracy of data
collection and allow the research team to revisit
the original data during analyses. The focus
group recordings were transcribed verbatim by
the research team within two weeks of data
collection. The transcripts were anonymized
using pseudonyms to protect the identity of the
participants. The typed transcripts of focus
groups were shared with participants of each
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Ali et al., 2021
South-East Asian Journal of Medical Education
Vol. 15, no. 2, 2021
group to confirm their accuracy. The data were
imported into NVivo 12 (QSR International Pty.
Ltd., Doncaster, Victoria, Australia).
The process of data analysis was started by
listening to the audio recordings repeatedly
along with reading the transcripts. Deep
engagement with the data was essential for
situating competence in tooth extractions within
the narratives of stakeholders emanating from
their understanding, experiences, and
expectations. Data analysis focused on
capturing the context and meanings of the rich
imagery shared by the participants. Systematic
reading through the entire data set was used for
an initial coding. Repetitive revisiting of the data
helped to collapse the nodes into broader
codes. Further analysis and reflection helped to
establish linkages between nodes, which
facilitated development of tree nodes from free
nodes and ultimately helped shape the themes.
An inductive approach was used for thematic
analysis i.e., the themes were data driven
Segments of verbatim quotes from different
participants were incorporated as coded text to
provide the contextual material supporting
different themes. Member checking was used
to validate the data analysis. Two colleagues
who were experienced qualitative researchers
compared analysis to verify the accuracy of the
coding and categorization of themes. Member
checking resulted in minor modifications to
categorization of data under different themes.
The results were shared with two participants
from each of the focus groups to determine the
interpretation of the data was consistent with
their views.
Results
Eighteen participants were involved in this
study. The student focus groups had ten
participants from the final year (six females and
four females). The staff focus group had eight
participants (six males and two females).
Participants shared their perceptions and
experiences regarding a range of issues related
to teaching, clinical training, assessments, and
supervisor feedback on tooth extractions. The
participants also provided recommendations to
enhance the learning experiences of students.
The key themes emanating from data analysis
where there was a broad agreement amongst
the participants are summarized below.
Patient Safety
Participants in both groups unanimously
expressed the need to place patient safety at
the heart of teaching and training in tooth
extractions. They emphasized the need for
comprehensive and meticulous preoperative
evaluation of patients’ medical history, clinical
and radiographic assessment to allow
recognition of potential difficulties and
complications.
“Students often find it difficult to recognize how
patient’s medical conditions and drug
prescriptions can complicate tooth extractions
and we need to focus more on these aspects in
our teaching”. Clinical supervisor 2
Routine use of surgical safety checklists was
recognized as a mandatory step to prevent
extraction of a wrong tooth; this was particularly
highlighted by the participants in the staff focus
group. Most student participants also reported
their concerns regarding patient safety and felt
more comfortable when they were observed
directly by their clinical supervisors.
“I was very nervous and somewhat scared that
I might harm my patient or take out the wrong
tooth and having my clinical supervisor observe
me while performing the extraction was
reassuring”. Dental Student 3.
Regarding operative skills in tooth extractions,
structured training supported by bespoke video
resources followed by practical training and
summative assessments in simulated
environment were also identified as an
essential requirement prior to students being
allowed to undertake tooth extractions on
patients.
“Learning tooth extractions on mannequin can
be very helpful to understand patient /operator
position, tooth movements with forceps and the
use of non-dominant hand, you can focus on
each step, it is more challenging to do so when
working on real patients”. Dental Student 5
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Competence in tooth extractions
South-East Asian Journal of Medical Education
Vol. 15, no. 2, 2021
Student participants unanimously expressed
their desire to start learning tooth extractions in
earlier stages of the program rather than in the
pre-final year as it would allow them more time
to consolidate their clinical skills; also
shadowing specialists undertaking difficult
extractions was considered to be beneficial to
boost their confidence.
Breadth of Clinical Experience
Participants in the staff and students’ groups
felt that the breadth of clinical experience was
more relevant than the numerical clinical
targets. Students felt that the signing off
students purely on the basis of number of
extractions could sometimes be misleading
especially when based on extraction of
periodontally involved teeth and mobile,
retained roots localized to the soft tissues.
Students also mentioned lack of confidence in
undertaking tooth extractions involving
medically compromised patients due to limited
experience.
Variations in difficulty level of individual teeth
could also impact on the competence and
confidence of students and dental trainers
should focus on providing a broad-based
clinical experience in extractions to students.
Four students always extractions of upper first
molars to be challenging due to the complex
root morphology and reiterated the need for
additional opportunities to extract these teeth.
“I find extraction of upper first molars most
difficult and need more experience to feel
confident”. Dental Student 7
Participants in the staff focus group also
acknowledged the importance of breadth of
clinical experience. However, resource
implications for a comprehensive triage of
suitable patients on student clinics were
considered a barrier by staff as it entailed
additional administrative and clinical input.
Individualized and immediate feedback on
student performance in simulated and clinical
settings was identified as a key factor in
enhancing student competence in tooth
extractions and this was endorsed by all
participants uniformly. Student participants
valued timely and constructive feedback and
acknowledged self-reflection was crucial for
developing their skills in tooth extractions
during their university education and beyond.
“I was not confident with my extraction but
feedback and support from my supervisors
helped me identify and reflect at each patient
encounter, now I am more comfortable taking
teeth out Dental Student 1
One student mentioned that they had received
inconsistent feedback and strong comments
from their supervisor which had affected their
confidence adversely.
Participants in the staff group mirrored
students’ comments regarding the importance
of feedback and reflective practice. However,
three supervisors highlighted that feedback
was a two-way process and students who
actively seek feedback are more likely to benefit
from it.
“Students need to engage more actively with
feedback from their tutors, they need to be
receptive to criticism and ask for areas of
improvement, there is always room to do things
better”. Clinical Supervisor 5
It was also reiterated that the feedback should
not be restricted to assessments only and
should be provided for every patient encounter
involving tooth extraction. Recording students’
performance for all patient encounters would
also generate sufficient data point to monitor
and evaluate student skill development
longitudinally facilitating timely remediation.
Discussion
This is perhaps the first study qualitative study
exploring development of tooth extraction
competency in undergraduate dental education
and provides helpful insights into the processes
involved in student training. Patient safety is an
overarching phenomenon, which impacts on all
aspects of clinical education and must be
prioritized throughout. The National Academy
of Medicine in the United States in its report
entitled ‘To err is human’ highlighted the
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Ali et al., 2021
South-East Asian Journal of Medical Education
Vol. 15, no. 2, 2021
importance of human factors, which may
contribute to errors in clinical services (Kohn et
al., 2000). Human errors during tooth
extractions are multifactorial including time
constraints, pre-operative assessment,
managing patient anxiety, identification of
correct teeth, difficulties in accessing the
operative site. Given that tooth extractions are
performed routinely, it is one of the most
common procedure associated with wrong site
surgery (WSS). Like other healthcare
providers, dental schools in Western countries
are increasingly implementing surgical safety
checklists on student clinics to mitigate against
WSS but it is not possible to ascertain if this is
being implemented in underdeveloped
countries consistently (Dargue et al., 2020).
Comprehensive assessment and preparation of
medically compromised patients for invasive
procedures is also essential for safe clinical
practice. However, given the variations in
teaching and training models in dental schools,
dental students may not always be competent
to manage patients with underlying health
conditions (Chávez et al., 2020). Some schools
may address this by filtering medically
compromised patients from student clinics.
However, there is a risk that lack of exposure to
patients with additional healthcare needs may
impact adversely on confidence of students,
which may extend into their clinical careers
after graduation (Holzinger et al., 2020).
Appropriate staff/student ratio for supervision of
tooth extractions is also essential for a number
of reasons including, patient safety, quality of
learning experience, and supervisor feedback.
An staff/student ratio of 1:5 has been reported
in the literature from the United Kingdom, but
recent recommendations suggest that ideally a
ratio of 1:3 is required to ensure patient safety
and student experience (Dargue et al., 2020). It
is acknowledged that this target may be
ambitious for some schools, especially in the
face of faculty shortages in dental schools
(Hamamoto et al., 2013).
Variations in curricular design and teaching
models in dental schools affect the stage at
which tooth extraction teaching is introduced in
the dental programs. Schools following
traditional curricula tend to compartmentalize
basic sciences and clinical disciplines and
students need to wait two to three years before
seeing patients. Early clinical exposure is more
likely to allow dental students more time to
develop their clinical skills in addition to
immense opportunities to their skills in team
working, communication, and professionalism
in clinical environments (Ali et al., 2018). Given
that tooth extraction constitutes an irreversible
procedure, dental schools must endeavor to
provide structured training and standardized
summative assessments in simulated
environments prior to allowing them to
undertake tooth extractions on patients (Brand
et al., 2015). Moreover, teaching should be
supported by high quality video resources
tailored to the stage of student learning, as
reiterated by participants in this study. This may
be particularly relevant to underdeveloped
countries where practical training in simulated
learning may be deficient due to limited
resources (Ali et al., 2020).
Participants in this study emphasized the
importance of the breadth of clinical experience
as numbers alone may not provide an accurate
measure of their skills in performing tooth
extractions. These findings corroborate with
previous studies on factors influencing clinical
competence of dental students (Dawson et al.,
2017; Stelzle et al., 2011). Dental educators
need to ensure that students gain experience in
extracting all types of teeth in both arches to
account for variations in access, root
morphology, bone thickness, relationship to
adjacent anatomical structures (Hupp et al.,
2008).
Clinical assessments of competence in tooth
extractions may be complicated by difficulties in
standardizing patients and therefore,
assessments should be carried out
longitudinally over a sustained period of time,
using multiple data points rather than on a
single assessment occasion. This approach
would also facilitate regular feedback to the
students providing them with opportunities to
reflect on their performance, and seek
remediation, if required. It is recognized that
recording of student performance for each
patient encounter is time-consuming and would
31
Competence in tooth extractions
South-East Asian Journal of Medical Education
Vol. 15, no. 2, 2021
ideally require use of digital platforms, which
may not be possible for all institutions due to
resource constraints.
The main limitation of this study is that the
participants were from a single institution. The
perspectives and experiences of the
participants in this study may be shaped by the
educational environment in a developing
country. Nevertheless, this research has
identified several key areas which may impact
on the development of students’ competency in
tooth extractions. Future collaborative studies
involving multiple institutions from different
geographic locations are recommended to
inform the teaching and assessments of
undergraduate students.
Conclusion
This study provides useful insights into how
undergraduate dental students develop
competence in tooth extractions as perceived
by the stakeholders. Competence development
may be facilitated by structured training in
simulated and clinical settings incorporating
patient safety, providing early clinical exposure
with a focus on breath of clinical experience,
developing a comprehensive patient triage
system, close supervision and feedback by
experienced supervisors, reflective practice,
and periodic assessments to monitor students’
performance longitudinally. The findings of this
study may help dental educators to revisit their
teaching on tooth extractions in undergraduate
dental education programs.
Acknowledgements
The authors would like to thank all the
participants for their contribution to this
research.
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Introduction Patient safety within dental education is paramount. Wrong site surgery (WSS) tooth extraction is not uncommon and is a significant Never Event (NE) in dentistry. This study aims to explore dental schools’ undergraduate experience of NEs, safety interventions implemented and the impact on student experience. Methods All 16 UK Dental Schools were surveyed via e‐mail. Results The response rate was 100%. A modified WHO checklist was used within institutions (94%) including pre‐operative briefings and recording teeth on whiteboards (81% respectively). Students were directly supervised performing extractions (63%) utilising a 1:4 Staff: Student ratio. WSS by students was reported in 69% of schools, with student experience being impacted by an increased patient safety focus. Discussion This study demonstrated an increased utilisation of an adapted WHO checklist. Modification of practices to ensure patient safety was demonstrated at all schools, irrespective of student WSS occurrences. Institutions experiencing student NEs commonly implemented WHO checklists and recording teeth for extraction on whiteboards. Other strategies included direct staff supervision and pre‐operative briefings. Conclusion UK Dental Schools have increased the emphasis on patient safety by the implementation of national healthcare models e.g. WHO checklists and pre‐operative briefings. These strategies both aim to improve communication and teamwork. Increased levels of staff supervision foster greater quality of teaching however, this has resulted in reduced student clinical experience. A proposed minimum standard for undergraduate surgery is suggested to ensure safe and competent dental practitioners of the future.
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The role of the BDJ is to inform its readers of ideas, opinions, developments and key issues in dentistry - clinical, practical and scientific - stimulating interest, debate and discussion amongst dentists of all disciplines.