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Educational Methodologies |
Key words: Delphi technique, consensual curriculum, periodontics
Submitted for publication 10/23/06; accepted 06/27/07
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Abstract |
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Faculties are constantly determining what adjustments should be made in curricula and instruction to keep up with the tremendous explosion of knowledge and evolution experienced by the health care delivery system. In line with this, relevant and progressive dental curricula should be designed to allow future dentists to meet the challenges of contemporary and future oral health needs of our changing society. Accomplishing this task, however, requires a thorough grasp of present and future health problems, as well as a clear perception of health care trends.
As with other oral health disciplines, periodontics is in a continuous process of change, with new concepts and therapeutic approaches3 being established. As such, there is a growing need for a dynamic curriculum for that discipline. For instance, chronic diseases such as obesity and diabetes are increasing not only in developed countries but in developing nations as well. As a result, quality of life related to general health may deteriorate. Similar associations could also be established in relation to oral health. Given that oral and other chronic diseases have determinants in common, more emphasis should then be placed on the common risk factor approach.4 Furthermore, the world population is getting older, and the number of older individuals retaining their teeth is increasing. Greater demands are therefore being placed on general dental practitioners for periodontal therapy. Many factors, including the aging process itself, impact directly or indirectly on periodontal health.5 Moreover, future advances in science, such as the human genome sequence, will dramatically alter how we define, treat, and prevent disease. In this context, the development and implementation of innovative dental therapies will require the intensive education of current practitioners. Coupled with this, considerable restructuring of dental school curricula will have to take place.6
A curriculum planning process that incorporates recommendations from several periodontics experts is likely to result in an educational program that reflects multiple perspectives for this discipline. Such a program will be more likely to simultaneously accommodate current and future training needs for dental practitioners.
We used the Delphi technique in an attempt to design a curriculum that represents an expert consensus opinion and is, most importantly, capable of producing periodontics instruction that is forward-looking. In doing so, we aim at producing dental school graduates prepared to meet the patient care challenges that will emerge throughout their careers.
The Delphi technique is a widely accepted method for obtaining group consensus in education, research, health, business, economics, and the social sciences.7,8 The Rand Corporation developed the technique, which was originally used for technological forecasting.9 It is intended to survey the "expert" opinion of individuals knowledgeable in a particular field of study. Delphi technique methodology uses sequential questionnaires sent to those involved in the experiment. Respondents should anonymously answer the questionnaires, indicating the desirability and/or the likeliness of possible future events occurring in the topic under investigation. Anonymity allows respondents to freely express their views, minimizing the possibility of any given individual influencing the opinion of others.10 Following every questionnaire dispatching and receiving round, participants are given feedback in the form of peer consensus. This feedback stimulates participants to consider factors they might have previously missed. Likewise, it also helps to elicit and continually re-fine their opinions. Every new survey reflects the consensus opinion reached by the experts at the previous stage. Typically, after three to four rounds, respondents tend to reach agreement on key issues, and the process should then be stopped. This process of eliciting the opinions and recommendations of experts, without incurring the interpersonal dynamics introduced by face-to-face contacts, tends to produce group consensus for evolving trends. Furthermore, while preventing psychological peer pressure, anonymity allows equal voice for all participants. For our particular application, consensus opinion reached at the end of the experiment could be used to examine projected curricular goals.11
In the dental field, several studies have used this methodology. Investigations involving the identification of competencies in geriatric dentistry, tendencies in restorative dentistry, and the determination of the success or failure of periodontal treatment, among others, have been conducted using the Delphi technique.8,11–13 The goal of this study was to use the Delphi technique to identify a consensus about what topics should be included in a periodontics curriculum for undergraduate dental students. Nine periodontics faculties at dental schools in two Brazilian cities participated in this curriculum planning process.
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Methods |
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For the first phase of the experiment, lecturers were asked to list, in writing, items that should be included in a periodontics curriculum for dental students. Suggested items were split into two groups. The first group involved theory-related items associated with foundational concepts and basic principles of periodontics. The second group of items, related to dental practice, was associated with laboratory training and clinical experience with patients. For the second phase of the experiment, previously obtained responses were scrutinized and collated into items. Then, a comprehensive Likert-scale questionnaire was compiled for submission to the panel. The questionnaire offered the following options for rating the importance of proposed curriculum items: "indispensable"; "important"; "relatively important"; "of little importance"; and "should not be included."
The Likert-scale questionnaire was sent to all forty respondents, and the returned answers were evaluated as follows. An item was "kept" if it reached a "50 percent plus one" consensus classification as "essential/important." It was eliminated if it reached a "50 percent plus one" consensus classification as "of little importance/should not be included." Whenever an item did not reach a "50 percent plus one" consensus agreement or a "50 percent plus one" consensus rejection, it was selected to be included in the next round of the questionnaire. For example, if an item attained an "important" rating of 30 percent, a "relatively important" rating of 45 percent, and a "little importance" rating of 25 percent, it was included in that questionnaire.
During stage three, the only participants were individuals who provided the most extreme positive ratings (indispensable) or most negative ratings (should not be included) during the previous stage for items where no clear consensus was reached.
For the fourth and last stage, for each non-consensual item singled out in the third stage, the positive and negative justifications required from third-stage participants were transcribed into a new questionnaire. The resulting instrument was then mailed to all original participants to vote for inclusion ("yes") or exclusion ("no") of each pending item. The format used for the fourth stage questionnaire was that of a sequence of items, each of them carrying its associated positive and negative justifications, followed by corresponding "yes" and "no" answering options. Frequencies for the answers thus obtained were calculated with the SPSS statistical package.
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Results |
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Out of the thirty-four lecturers who participated in each of the four Delphi technique stages, thirteen (38 percent) were females, and twenty-one (62 percent) were males. They had an average of ten years (±8.19) teaching experience.
From responses obtained at the first stage, twenty-three theoretical items, involving 249 sub-items, and twenty-five dental practice items, involving ninety sub-items, were compiled and included in a questionnaire. For the second stage of the experiment, the theory-related section of the questionnaire involved items and sub-items spanning concepts associated with a historical review of periodontics, anatomy, periodontal disease, prevention, periodontal treatment, epidemiology, and implantology. The dental practice section of the questionnaire involved laboratory training and clinical treatment items. At the end of the second stage, seven theoretical items were left pending. For two of these items, all sub-items involved were left pending. For the other five items, some but not all sub-items were left in that same situation. All of the remaining sixteen theoretical items were voted for inclusion (Table 1
). For the dental practice section of the questionnaire, item "periodontal surgery performed by the student," involving thirteen sub-items, had two of its sub-items excluded ("extended periodontal surgeries"), four sub-items included ("uncomplicated surgeries"), and seven sub-items pending ("different surgery techniques"). Six additional items were left pending. All other dental practice items were voted for inclusion (Table 2). For the third stage of the experiment, every participant who offered extreme positive or extreme negative support for any item in the second stage questionnaire was asked to justify his or her views on these items. Finally, for the fourth stage, out of the initially suggested items, ten theoretical and eighteen dental practice items ended up being excluded (following the same inclusion/exclusion conditions).
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Discussion |
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Throughout the four stages of the consensus-building Delphi technique approach used in this study, participants identified various up-to-date scientific research trends within periodontics. However, in spite of that, items associated with some recent technological advances were not included in the final set of "indispensable" items. Furthermore, from our perspective, it is important to note that only a few of the aspects regarding professional periodontal training that received high (indispensable) ratings were directly related to the health needs of our society.
Several items related to medical periodontics ended up being selected for the curriculum. This is in accordance with the high prevalence of chronic diseases in elder populations,4 who are an increasing proportion of the overall population. Accommodating older people’s needs requires the dentist to have a basic knowledge of heart disease, diabetes, high blood pressure, and the interaction between these diseases and the oral cavity. The interrelation between periodontics and other disciplines also reinforces the concept that curricula for health care providers should be interdisciplinary in nature. This is necessary to reflect the merging patterns identified for disease and the increasing need for interdisciplinary therapeutic strategies.17
The literature also stresses the need to acquaint students with modern techniques.18 Items related to technological advances in odontology, such as human molecular genetics and DNA probing, were initially listed as important to a periodontics curriculum. However, half way through our study, they were excluded from the final list of selected items.
Out of all general periodontics concepts addressed in the study, either theoretical or practical, only one theoretical sub-item related to public health made it to the final list of selected items. Not a single item related to public health/prevention appears in the dental practice section of the inventory. This result corroborates criticism that undue emphasis is still being given to the "private practice dentistry service model." More specifically, emphasis is still being placed on teaching technical treatment procedures to the detriment of educating students about health promotion and disease risk prevention. This point becomes even more evident if one observes that, out of the forty-one items eventually selected to be included in a periodontics curriculum, only one presents a clear social focus. This fact indicates that the currently used periodontics teaching approach is far from training the student to be a modifying health agent, i.e., someone with a critical conscience capable of addressing a social reality.19
The results of our study indicate that some issues involved in the discussion above, such as a public health-oriented vision, were not addressed by the panel. This suggests that the majority of the individuals involved are focused on the treatment model rather than on health promotion. However, such a drawback may also be credited to limitations of the Delphi technique, which does not allow an interpersonal discussion of topics.
Overall, however, the Delphi technique proved functional in allowing periodontics lecturers from dental schools in two Brazilian cities to participate in the design of a periodontics curriculum. This happened in spite of some practical limitations that would otherwise occur in such an experiment. These relate to difficulties associated with scheduling meetings involving all participants, implementing associated transportation arrangements, and providing convenient physical locations for these meetings. Such limitations made it, right from the start, very difficult for us to contemplate the organization of multiple meetings involving the forty participants in our study. Overall, use of the Delphi process allowed accomplishment of the primary goal of the study, which was to identify a consensus about what items should be included in the periodontics curriculum for undergraduate dental students based on the perspectives of a panel of faculty who teach periodontics at several different institutions.
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Footnotes |
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REFERENCES |
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