J Dent Educ. 71(11): 1457-1466 2007
© 2007 American Dental Education Association
International Dental Education |
Cross-Cultural Comparison of the Attitudes of Dental Students in Three Countries
Hiroyuki Karibe, D.D.S., Ph.D.;
Atsuko Suzuki, D.D.S., Ph.D.;
Tsuneo Sekimoto, D.D.S., Ph.D.;
M.L. Theerathavaj Srithavaj, B.S., M.S., D.D.S.;
Anak Iamaroon, D.D.S., M.S., Ph.D.;
Sachie Warita, D.D.S., Ph.D.;
Tomomi Kawakami, D.D.S., Ph.D.;
Kiyokazu Ogata, D.D.S., Ph.D.;
Toshiomi Shirase, D.D.S., Ph.D.;
Sen Nakahara, D.D.S., Ph.D.
Key words: students, attitude, education, curriculum, career choice
Submitted for publication 01/22/07;
accepted 08/15/07
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Abstract
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The aim of this study was to identify and compare the attitudes of dental students toward their career choice and dental education in three different countries. Three hundred thirty-six dental students from the University of British Columbia, Canada; Mahidol University and Chiang Mai University, Thailand; and Nippon Dental University, Japan, participated in this study. Information was derived from a questionnaire consisting of career choice items and dental education items. Significant differences in the responses of the participants from each of the three countries were detected for each of the questionnaire items (P<0.001). Regarding factors that may have served as motivations for career choice, the majority of dental students from each country indicated positive reasons such as interpersonal motives, caring for other people, and academic interest. For future career options, the majority of Japanese and Canadian students planned to work as general dentists. Thai students were more likely than Japanese or Canadian to prefer specialization than practicing general dentistry. Nearly three-quarters of the Canadian and Thai students were satisfied with the teaching faculty of their schools, while only a quarter of the Japanese students indicated satisfaction. The findings from this study enhance our understanding of differences and/or similarities among dental students in three nations; this information may help to define strategies to improve the quality of international student exchange programs.
The motivation of dental students to choose their career has been studied extensively.1–9 A number of studies have also investigated the sources of stress in dental students and examined the students’ perspectives about dental education.10–15 However, few cross-cultural comparisons have been made of dental students’ perceptions about their educational experience in Western and Eastern countries.16 Large differences may exist in attitudes about educational issues and career choice among dental students who live in diverse societies. Kuusela et al.17 compared the career choice and future plans of dental students in Tanzania and Finland. They reported that the observed difference in the preferred career options was most probably due to differing practical opportunities for a graduating dentist in the two countries. Mayya et al.18 stated that cultural specificity should be considered when investigating the students’ approaches to learning. Therefore, it would be informative for dental educators to investigate the attitudes of dental students in different nations about their career choice and dental education and explore whether these perceptions are influenced by cultural and social background.
Nippon Dental University, Tokyo and Niigata, Japan, has sixteen sister dental schools all over the world, and international student exchange programs have been conducted among these affiliated schools since 1987. For dental students participating in these exchange programs, the information and insights derived from a study that compared the perceptions of students from different nations would help develop understanding of the dental education system and environment in different nations. The purpose of this study was to identify and compare the career decisions, perceptions of dental education, and study circumstances of students in five dental schools located in Canada, Thailand, and Japan.
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Methods
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Students at five dental schools in three countries were invited to participate in this study. Participation was voluntary and anonymous. The following categories of students served as subjects: fourth-year students from the University of British Columbia (UBC), Canada; fifth- and sixth-year students from Mahidol University (MU) and fourth-year students from Chiang Mai University (CMU), Thailand; and fifth-year students from Nippon Dental University (NDU), Tokyo and Niigata, Japan. Even though the curriculum was different among these dental schools, all participants were exposed to clinical practice at the time of the study. Anonymous questionnaires were administered during the 2004–05 academic year at all five dental schools.
Information was derived from a questionnaire consisting of two parts: five questions for career choice and six questions for dental education (Table 1
). There were eight multiple choice questions and three descriptive questions. The questionnaire was originally developed by the authors in Japanese. As English is the common language for international scientific and cultural exchange,19 we translated the questionnaire into English with the assistance of native-speaking colleagues who had experience with the questionnaire and survey research. To confirm that the questionnaires had the same contents, the initial translation in English was back-translated into Japanese by five bilingual faculty members whose mother tongue was Japanese and who had not participated in the previous phase. The questionnaires were back-translated for the purpose of checking for discrepancies between content and meaning of the original and translated versions. All versions were analyzed and compared by the authors, and a final version was obtained. To assess the equivalency of the language, the test-retest method was used.20 According to this method, the questionnaire was given to five bilingual dental students, twice under similar conditions. Each subject received two versions (English and Japanese) of the questionnaire, and they were instructed to answer the first version (English or Japanese) on the same day the questionnaire was handed in and the second version (Japanese or English) on the next day, at the same time and under similar conditions, without referring to the previous questionnaire. The Kappa coefficient was used for evaluation of equivalency of the language. Accordingly, nine of the eleven items that comprised the questionnaire obtained an average Kappa value of 0.88, with six items obtaining a score equal to 1. The other three items reached a Kappa value between 0.55 and 0.71. For two of the eleven items, it was not possible to calculate the Kappa coefficient, but four of the five bilingual students responded with the same answers regarding these two items in both versions. These results indicated good equivalency between the two versions of the questionnaire. The Japanese version was used for Japanese dental students, and the English version was used for Canadian and Thai dental students. In Thailand, bilingual authors helped students to understand the questionnaire.
Simple frequency tables for group comparison were developed, and for analysis of the results, chi-square statistics were applied. Statistical significance was based on probability values of less than 0.05. Data were analyzed by the SPSS 14.0J (SPSS Japan Inc., Tokyo, Japan).
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Results
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A total of three hundred and thirty-six questionnaires were returned (Canada n=31; Thailand n=122; Japan n=183). The response rates of the Canadian, Thai, and Japanese students were 60.8 (31/51), 53.0 (122/230), and 81.7 percent (183/224), respectively.
Table 2 presents the responses from dental students of each country to the questions regarding career choice (Items 1, 2, 8, 8a, 10, and 11) and results of the chi-square tests. Significant differences were detected in the responses of the participants from the three countries to each item (Item 1, 2, 8, 10, and 11, P<0.001 in each item), except future career as a specialist (Item 8a, P=0.339).
The dental students were asked to describe the reason why they chose to become a dentist in Item 1. The responses were categorized into four reasons based on motive factors; 1) "positive" reasons included interpersonal motives, caring for and helping other people, desire to have a health care occupation, academic interest, and interesting career; 2) "family" reasons included family expectations and encouragement from other people; 3) "economic/social" reasons included financial and job security aspects, self-employment, status and prestige, control of time, and working with hands; 4) "uncertain" reasons included no reason, destiny, etc. Additionally, if no reasons were specified, we categorized it as "no answer." Regarding factors that may have served as motivations for choosing dentistry as an occupation, the majority of the Canadian dental school students indicated positive reasons (83.9 percent), while 39.3 percent of Japanese students and 36.9 percent of Thai students indicated positive reasons. Also, Canadian students more frequently indicated economic/social reasons (74.2 percent), compared to Thai (32.8 percent) and Japanese students (12.0 percent) (Item 1).
Regarding the difficulty in entering a dental school, approximately 70 percent of Thai dental students felt that they had a difficult time gaining admission to dental school, whereas more than 50 percent of Japanese students thought entering dental school was not so difficult (Item 2). As for future career options, the majority of the Japanese (61.2 percent) and Canadian (51.6 percent) students planned to work as general dentists. Thai students preferred to specialize in a field (39.3 percent), rather than practicing general dentistry (24.6 percent) (Item 8). When the students who had chosen "specialist as a future career" were examined, 22.2 to 35.3 percent of students had not selected a specific specialization yet. On the other hand, 14.6 to 44.4 percent of students hoped to be an orthodontist. No significant differences were found among the three countries in the selection of specialization in the future (Item 8a, P=0.339). Most of the Japanese dental students (73.2 percent) believed that the examination to obtain a dental license—the national examination for dentists—would be difficult, while 45.2 percent of Canadian and 34.4 percent of Thai students felt the same (Item 10). As for future plans to work abroad, the majority of the Japanese students (53.0 percent) planned to work in Japan. Thai students preferred working abroad (44.2 percent) than working in Thailand (36.1 percent). More Canadian students also preferred working abroad (35.5 percent) than working in Canada (29.0 percent) (Item 11).
Table 3 shows the responses of students in each country regarding attitudes toward dental education and results of the chi-square tests. Significant differences were detected in the responses of the participants from the three countries to each of the questionnaire items (Items 3–7 and 9, P<0.001 in each item). More than 60 percent of students in Canada and Thailand were content with their dental school life. However, only 30 percent of Japanese students were content with it (Item 3). The most frequent reason for discontent with dental school life in the three countries was "Curriculum" (Item 4). Thai students indicated more contentment with the curriculum; 59.0 percent of the Thai students indicated that they were content, compared to 26.2 percent of the Japanese and 16.1 percent of the Canadian students (Item 5). The most frequent reasons for discontent with the curriculum were lack of clinical training for Canadian students, workload for Thai students, and a frequent change in the curriculum for Japanese students (Item 6). Regarding the quality of the teaching faculty in their dental schools, around three-quarters of the Canadian and Thai students were satisfied with instructors in their schools, while only 23.5 percent of the Japanese students felt so (Item 7). As for the duration of the dental school curriculum, most of the Canadian dental students (83.9 percent) felt that their dental curriculum was too short, while 70.5 percent of Thai students and 32.2 percent of Japanese students felt it was reasonable (Item 9).
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Discussion
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In our study, fourth-, fifth-, and sixth-year dental students were included as subjects because the commencement of clinical practice and duration of the Doctor of Dental Surgery (D.D.S.) or Doctor of Dental Medicine (D.M.D.) program varied in each country. The D.M.D. program in Canada is a four-year program, and students attend four years of predental courses before entering dental school. At the UBC, third- and fourth-year students develop clinical and patient management skills through participation in integrated group practices managed by a faculty member.21 The duration of the D.D.S. program in Thailand and Japan is six years. Thai students in the MU and the CMU start clinical practice during the fourth academic year and acquire advanced skills during the fifth and sixth years.22 At the NDU in Japan, clinical and practice sessions start from the first term of the fifth year, and the duration of these sessions is one year. Since all the dental students were already exposed to clinical practice, it was expected that dental students could identify their future plans, even though the time of exposure to clinical practice varied among the schools.
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Positive Reasons for Choosing Dentistry
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Previous studies have reported dental students’ motivation for pursuing dentistry as a career.1–6 Scarbecz and Ross1 identified eight motive items: 1) financial aspect, 2) interpersonal motives, 3) flexibility in scheduling, 4) self-employment, 5) encouragement from families, 6) career talks in school, 7) dentists among relatives, and 8) non-death cases. Crossley and Mubarik2 summarized seventeen items into six areas of motivation: 1) status and security, 2) nature of the occupation, 3) career opportunities, 4) patient care and working with people, 5) use of personal skills, and 6) interest in science. In the present study, we did not specify any motive items in the questionnaire, and the students entered their own responses. We then categorized the different answers recorded by the students into the following five reasons: 1) positive, 2) family, 3) economic/social, 4) uncertain, and 5) no answer.
We noted that the students from all three countries mentioned many positive reasons (interpersonal motives, helping people, health care-related occupation, and academic interest). This result is consistent with findings of previous studies conducted in the United States, the United Kingdom, and Scandinavia. A survey of fourth-year U.S. dental students found "service to others" as the most important reason for pursuing dentistry as a career.3 Final-year dental students in Scandinavia responded that a combination of theory and practice and a wish to work with people were their main reasons for choosing dentistry.4 In a postal survey involving all first-year U.K. dental students, Morris5 reported that working with people and serving the community were the most popular reasons for students choosing dentistry as a career.
Morris5 also noted that nearly 70 percent of the 202 students for whom dentistry was not the first choice had first considered a career in medicine. Interestingly, this observation was also found in our study in Japanese and Thai students. Sugiura et al.6 reported that one-third of the students who entered national dental schools in Japan had not succeeded in the entrance examination for other professional disciplines and entered dental school as a second choice and 30 percent of the students had first considered becoming a medical doctor. This response was categorized as a health care-related factor under positive reasons; however, this reason seemed to be related to the difficulty of entering medical school in each country. In most countries, admission to medical school is highly competitive, and medicine is usually reserved for the students who gain high scores; students with lower scores tend to enter dentistry.6
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Family Reasons for Choosing Dentistry
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Approximately 30 percent of the Japanese and 20 percent of the Thai students reported "family" reasons (family expectations, encouragement from other people) for choosing dentistry as a career. The Canadian students did not indicate any "family" reasons. In Japan, children of dentists mostly follow their parents in occupational choice, meaning that they would gain the benefits of the parent’s business. Considering the financial advantages, this response could be interpreted as an economic reason. A recent study7 reported that the trend of university selection in Japanese dental students was strongly affected by family recommendation. In Thailand, especially in the capital city, most students lived with their families, and their parents still played an important role in making decisions in the students’ lives.10 Marino et al.8 presented data on the persons who influenced the selection of dentistry as a career by students belonging to different ethnic groups in Australia and New Zealand. It was reported that parents—in particular, the mother—were more influential among Asian students than among Anglo-Australian or New Zealander students. In another report in the United Kingdom, friends and relatives in the profession had an important influence on the students to choose this career.5 A survey in the United States also demonstrated that almost half of the fourth-year dental students responded that "family member or friend who is a dentist" was a high influencing factor in their career choice.3 Regardless of following the family business or ethnic factors, the career choice is very likely to be influenced by the occupation of familiar persons.
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Economic/Social Reasons for Choosing Dentistry
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Many previous studies reported that dental students rated economic and/or social reasons such as high position or status along with positive reasons for their career choice. This indicates that a dentist’s status is socially recognized in many countries. A previous study that investigated first-year dental students’ motivation to attend dental school in the United States reported that male students rated self-employment and business-related motives as more important, while female students rated people- oriented motives more highly, and both students rated financial and flexibility motives equally.1 Surveys involving dental students in the U.K. and Israel revealed a primary interest in professional status, financial rewards, and security.2,9 In our study, 74.2 percent of Canadian and 32.8 percent of Thai students indicated economic/social reasons; this result is consistent with previous studies. However, Japanese students less frequently indicated economic/social reasons (12.0 percent). These findings may suggest the differences in responsibility for the educational expenses among countries. The educational costs for Canadian dental students are largely financed by private loans or other forms of debt,23 whereas most Japanese students depend on their parents for financial support during their dental education.
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Entering Dental School
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In Thailand, medical doctors and dentists are highly respected in the society.10 Currently, there are nine dental schools in Thailand. Eight of them, including the MU and the CMU, are government-based universities. There is only one private dental school. All candidates applying to national dental schools in Thailand appear for a common examination after graduation from high school. Candidates rank the names of the dental schools that they hope to enter. Based on the results of this examination, the candidates gain admission to dental school in order of their preference. The admission process is extremely competitive, a statement corroborated by our study in which approximately 70 percent of Thai dental students said they felt they had a difficult time gaining admission to their school.
There are ten dental schools in Canada, all of which are managed by governmental funds. Admission to the dental program is primarily based on academic ability and personal qualities as evidenced by predental scholastic records, aptitude tests, letters of recommendation, personal essays, and personal interviews.24 In terms of the difficulty in entering dental school, Canadian students’ responses were varied. Only half of them felt it was difficult to enter dental school.
More than 50 percent of Japanese students thought entering dental school was not particularly difficult. In Japan, there are twenty-nine dental schools in three categories: eleven national, one public, and seventeen private schools. The entrance examination system also differs in these schools. In this study, all Japanese dental students attended private schools. For admission to private schools, candidates take examinations conducted by the individual dental schools, and there are several types of entrance examinations conducted by private schools. There is also a nationwide multiple-choice examination, a school-based written examination, a personal essay and a personal interview, and an entrance examination upon official recommendation by a high school principal, which includes a candidate essay and an interview process. Some of these examinations not only apply to private schools but also to public and national schools. The diversity of entrance examinations may affect Japanese students’ responses.
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Future Career Plans
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Regarding future career options, approximately 20 to 30 percent of students in each nation had not yet made decisions about their future career. A majority of Japanese (61.2 percent) and Canadian (51.6 percent) students had decided to work as general dentists. As mentioned above, in Japan, many students are expected to take over their parents’ dental office, and this may affect Japanese students’ future career options. On the other hand, debt among Canadian university graduates is increasing, and dental students have absorbed increased tuition fees at both the undergraduate and postgraduate levels.23 In the United States, 22 percent of students indicated that debt was a major factor influencing their career plans following graduation, and as the levels of debt increased, an increasing percentage of the fourth-year students with higher levels of debt planned to immediately enter private practice.3 Existing debt and high tuition fees may have adversely influenced the future career decision for Canadian students. In contrast to Canadian and Japanese students, Thai students more likely preferred specialization than general dentistry. This is based on the belief that a specialist can obtain more financial stability than a general dentist. Furthermore, urban areas in Thailand are overpopulated with general practitioners.
In most countries, dentists can obtain a certificate, degree, or diploma in many areas of specialization by training in various types of postgraduate programs.25 Of the students who hoped to become specialists in this study, 44.4 percent of Canadian students, 14.6 percent of Thai students, and 23.5 percent of Japanese students hoped to be orthodontists. Weaver et al.3 reported that orthodontics continues to be the dental specialty most pursued by graduating dental students in the United States, and 29.4 percent of the students applied to this specialty program in 2004. This preference was consistent with our finding that pursuing training in orthodontics was Canadian and Japanese students’ first preference among those planning to pursue a specialty.
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Dental License Exam
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The licensure examination is regarded as a qualifying examination in most countries. However, recently in Japan, the nationwide examination to obtain a dental license has come to be considered as a highly selective examination. Therefore, we hypothesized that the students’ perceptions regarding the difficulty of the examination would be different among countries.
From the results, we found that most Japanese students (73.2 percent) felt that the nationwide examination to obtain a dental license would be difficult. Sixth-year dental students in Japan are eligible to take the examination to obtain a dental license. This examination is a multiple-choice written test based on knowledge of and techniques concerning basic science, dental health, and clinical dentistry and does not include additional restorative or clinical tests or interviews.26 The average pass rates on the examination were 74.6, 80.8, and 74.2 percent in 2005, 2006, and 2007, respectively. It is possible that, because of the governmental policy of supply-demand balance to control the surplus of dentists in Japan, Japanese students may find it difficult to obtain a dental license.
In Thailand, dental students who pass the final examination at the end of the sixth year receive a dental license. Fourth-, fifth-, and sixth-year students who were receiving clinical education participated in this study. It may not be easy for students with less clinical experience to determine the difficulty of the final examination at the sixth year. As a result, approximately 60 percent of students responded "undecided" or "no answer" to the question concerning difficulty in obtaining a license. However, one-third of the students in Thailand still responded that the examination to obtain a dental license would be difficult.
In Canada, students are required to pass a national qualifying examination in order to obtain a dental license. Forty-five percent of Canadian students responded that the examination can be difficult, suggesting that the students also felt it was difficult to pass the national examination in Canada.
Even though statistical analysis showed significant differences in students’ responses among nations, the most frequent responses in all three countries indicated that students perceived it was difficult to pass the licensure examination. Our hypothesis was that the students’ perceptions regarding difficulty of the examination would be different among countries. The results did not support our hypothesis. We found that the students’ perceptions of the difficulty of the examination might not affect their career selection, but it might affect their selection of dental school, i.e., they would generally opt for a dental school that has a high pass rate on the licensure examination.
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Working Abroad
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Fifty-three percent of Japanese students planned to work in Japan, indicating that the majority of the Japanese students (61.2 percent) would work as general dentists and those who possibly would eventually take over their parents’ dental practice. In contrast, 35.5 percent of students in Canada and 44.2 percent of students in Thailand preferred working abroad. Various opportunities are available for dentists abroad: participation in a specific postgraduate program at an overseas university or hospital, working as a researcher in an overseas laboratory, working at a clinic or managing their own clinic after obtaining an overseas dental license, international volunteer activity, and others. In Thailand, many faculty members have received their dental education from various overseas countries; this could also be a factor that influences the decision of Thai students to go abroad.
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Content with Dental School Life and Curriculum
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In all three countries, 20 to 40 percent of students were not content with their dental school life. Sanders and Lushington11 indicated eight principle stress factors in Australian dental students: 1) self-efficacy beliefs, 2) faculty and administration, 3) workload, 4) attitudes to female students, 5) peer pressure, 6) performance pressure, 7) financial constraints, and 8) clinical training. In our study, the frequent reasons for discontent with dental school life in the three countries were 1) curriculum, 2) economic issues, 3) personal issues, 4) facilities, 5) faculty, and 6) location. These findings are generally consistent with the abovementioned stress factors.
Approximately 65 percent of Canadian students were content with their school life; this percentage was the highest among the three countries. While 12.9 percent of Canadian students were not content with their school life due to economic issues, 1.1 percent of Japanese students and no students in Thailand mentioned this as a reason. The results of our study are in agreement with the findings of Yap et al.,16 who compared sources of stress in American and Singapore students and found that the most common reason for stress in American students was financial responsibilities and, for Singapore students, it was completing graduation requirements. Increasing debt among Canadian students23 may impact the contentment in dental school life as noted in our study.
Approximately 60 percent of the Thai students, 26 percent of students in Japan, and 16 percent of students in Canada were content with their curriculum. These results indicate that a substantial percentage of students in each nation were not content.
The reason for discontent varied among countries. Frequent change in the curriculum was the most common reason for discontent among Japanese students, who were more dissatisfied with the structure or schedule of the curriculum than its content. This may suggest that Japanese students tend to seek how to complete their workload efficiently and obtain their technical knowledge and skills effectively in the dental school. The most frequent reason for discontent in Canadian students was lack of clinical education. This may be explained by the duration of the D.M.D. program in Canada, which is a four-year program and thus shorter than the six-year D.D.S. program in Thailand and Japan. The most frequent reason for discontent with the curriculum in Thai students was the difficulty of academic requirements (workload) in their curriculum. Although this aspect was not reported by Canadian and Japanese students, past studies conducted in Australia, the U.K., and India support this finding. Sanders and Lushington11 reported that Australian dental students perceive workload as a stressful factor. Another study reported that 83 percent of the U.K. dental students found that the dental curriculum required harder work than they had expected before joining the program.5 Acharya12 reported that the main sources of stress among dental students in a private dental school in India were heavy workload and fear of facing parents after failure. Regardless of the difference in curriculum among schools, heavy workload could be one cause of students’ stress.
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Satisfaction with Teaching Faculty and Duration of Curriculum
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Nearly three-quarters of the Canadian and Thai students were satisfied with the teaching faculty in their schools. In Japan, 54.1 percent of students did not respond as to whether they were satisfied with their faculty; 23.5 percent of them were satisfied; and 20.2 percent were not. In Denmark, Finland, Norway, and Sweden, there was general dissatisfaction with the teachers’ pedagogic skills, and there was a feeling that teaching was regarded as secondary to research.4 Dental students in North America rated their interaction with clinical instructors favorably, but analysis of more than 1,000 written comments provided by these students indicated inconsistent and sometimes insensitive feedback from faculty.13 In this study, students did not provide any comments regarding dissatisfaction with their teachers. Most of the dental faculty members have not received training in pedagogy; therefore, additional pedagogical programs may be useful to help the faculty members improve their skills in dental education.
Regarding the duration of the dental school curriculum, most of the Canadian students (83.9 percent) felt that the length of the curriculum (four years) was too short. This was also indicated as one of the reasons for discontent with the curriculum, namely, lack of clinical education. Approximately 70 percent of Thai students felt that the duration of the six-year D.D.S. program was reasonable. Farge et al.14 reported that, in France, an additional year has been included in the dental curriculum since 1994, when the traditional five-year program was extended to a six-year curriculum. Observations regarding the influence of the duration of dental school in France revealed that 77.8 percent of students in the new curriculum believed that the six-year program was sufficient. This report was consistent with our result among Thai students. However, the responses of Japanese students varied with respect to the six-year duration of the program, which was the same as in Thailand: 36.1 percent of Japanese students felt it was too long, 32.2 percent felt it was reasonable, and 18.0 percent answered it was too short. We could not analyze which part of the course was too long or short because no descriptive question concerning this matter was included in the questionnaire. The opinion that the six-year duration was too long may reflect one of the reasons for discontent with the curriculum, indicating that distribution of time for each subject was inefficient. These findings from our study indicated that dental students believed that the duration of five or six years would be sufficient for the program.
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Conclusions
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The attitudes of dental students toward their career choice and dental education were very different among the three countries that were included in this study. Our results might enhance our understanding of differences and/or similarities among dental students in the three nations, and this information might help to define strategies to improve the quality of student exchange programs among different countries.
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Acknowledgments
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We would like to express our appreciation to Professor Hideo Ogura, Secretary of International Union of Schools of Oral Health, School of Life Dentistry at Niigata, Nippon Dental University, Japan; Dr. Jurai Nakaparksin, former Dean, Faculty of Dentistry, Mahidol University; and Professor Edwin H.K. Yen, former Dean, Faculty of Dentistry, University of British Columbia, for their valuable support. The authors also would like to acknowledge the cooperation of students and their participating dental schools in the conduct of this study.
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Footnotes
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Dr. Karibe is Professor, Dr. Ogata is Associate Professor, and Drs. Warita and Kawakami are Assistant Professors, Department of Pediatric Dentistry, School of Life Dentistry at Tokyo, Nippon Dental University; Drs. Suzuki and Shirase are Assistant Professors, Department of Orthodontics and Pediatric Dentistry, Nippon Dental University Hospital; Dr. Sekimoto is Professor and Director, Nippon Dental University, Niigata Hospital; Dr. Srithavaj is Associate Dean for International Relations, Faculty of Dentistry, Mahidol University; Dr. Iamaroon is Professor, Department of Odontology and Oral Pathology, Faculty of Dentistry, Chiang Mai University; and Dr. Nakahara is President, Nippon Dental University, School of Life Dentistry at Tokyo and Niigata. Direct correspondence and requests for reprints to Dr. Hiroyuki Karibe, Nippon Dental University, Department of Pediatric Dentistry, 1-9-20 Fujimi Chiyoda-ku, Tokyo, 102-8159, Japan; 81-3-3261-6524 phone; 81-3-5216-3720 fax; h-karibe{at}tky.ndu.ac.jp.
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