An Integrated Model for the Iranian General Dentistry Curriculum

Introduction

 In today's complex and changing world, in order to meet the needs and expectations of dentists and society in a comprehensive way, dynamic training in various sciences, including dentistry is required. However, many dental students still receive a discontinuous education; in such a way that even after obtaining official certificates, they have no understanding of the association of some of the learned basic sciences or they lack the knowledge of the link between research and practice. For this reason, the general dentistry curriculum must have content that meets the needs of the new world (1). The experience of teaching in the twentieth century and scientific confrontation with the real issues of practice at the beginning of the 21st century, led to the achievement that an "Integrated Dental Education Curriculum" is one of the practical and tested ways to deal with these issues. Integrating curricula means connecting and integrating curriculum content to the coherence of student learning experiences (2). An integrated curriculum model includes the points of views and guidance provided by an expert (medical education and curriculum planning) for the optimal and successful organization of the content of the curriculum (3).

 The general dentistry’s curriculum which is currently practiced in dentistry faculties of the country was approved at the 126th meeting of the Supreme Planning Council dated June 17, 1988. In the current dentistry curriculum, courses were divided into three groups of general, basic and specialized courses. In this curriculum, the courses are divided into thematic units and each subject is individually planned. Although in vertical organization, courses are planned in such a way thatthe relevance of each course is preserved as “prerequisite”, and basic sciences have been proposed as a prerequisite for clinical sciences, the horizontal relationship between courses belonging to different scientific disciplines has been pursued in the least possible way. From the perspective of the subject of this study, two features of the present curriculum of dentistry in Iran are: the separation between theoretical and practical training and one (practical) being based on another (theoretical); and the separation between theoretical and practical courses based on disciplines and branches of science. These two features are based on the decision of the dentistry curriculum planners on how to apply two types of “communication” between the content components of the curriculum, which are referred to as the “vertical relation” and “horizontal relation”, respectively (4).

 By investigating the current pattern of dentistry curriculum in Iran and other features governing it, such as the separation of basic sciences from each other and from the clinical sciences and being subject-oriented and neglecting horizontal and vertical relations of the topics, it can be said that the principles of integrated curriculum is not included in this program. Therefore, due to the effects and consequences of applying integration into the dental curriculum (5), updating dentistry curriculum in Iran requires the use of appropriate integration approaches in the dental curriculum suitable for the country. Hence, the proposed model is the result of studying and reviewing the literature and the history of integrating and reviewing the curriculum of dental faculties of the world’s accredited universities which seeks to provide a comprehensive image of the discussed topics in integrating the dental curriculum for implementation in Iran's ecosystem.

 Methods

The present study is a mixed research (qualitative and quantitative). In the qualitative section, using the available sources and documentation, the integration of the dental curriculum with an analytical perspective was examined. At this stage, the data gathering tool was note taking. For this purpose, the literature on the integrated curriculum and documents related to the general dental curriculum in Iran and 40 validated dental faculties such as Marquette and Connecticut dental schools (6,7) were investigated. In addition to referring to accredited medical universities in Iran (Faculty of Dentistry of Shahid Beheshti University of Medical Sciences, Faculty of Dentistry of Tehran University of Medical Sciences, Faculty of Dentistry of Islamic Azad University, Shahed University, Kerman, Isfahan and Tabriz Universities of Medical Sciences), the scientific documents and research were also studied using the “Spider’s Web” method. In this method, each source could provide clues from other sources and lead the research to new information. To achieve a wide range of scientific texts, the purposeful search was conducted through Google Scholar and AltaVista search engines. PubMed and MEDLINE databases were also used, and to access bibliographies, the ERIC and RDRB databases were used and keywords such as integration, integrative curriculum, dentistry faculty, dental curriculum, higher education, the basics and elements of dentistry curriculum and types of integration were used to search for theoretical literature and research backgrounds from the year 2000.

 In order to increase credit in qualitative research, a semi-structured interview was used in addition to reviewing the documentation. For this purpose, using focal groups, attempts have been made to obtain the opinion of dental specialists regarding the pattern of dental curriculum. In this regard, the current status of general dentistry curriculum, the characteristics of courses and integrated programs, the principles and foundations for designing an integrated syllabus model in higher education and dentistry and methods to move towards integration in this area were questioned. Therefore, 15 experts related to the subject, who are the head, deputy, manager, dentistry board members and other faculty members in two areas of dentistry and curriculum planning, as well as dental residents were identified by purposeful sampling method and were interviewed. Due to the theoretical saturation, this number was considered as adequate. Based on the studies, an integrated model of dental curriculum was designed. The validity of the designed model was evaluated through a questionnaire and an interview with the experts in the field of dentistry and curriculum planning in Delphi method (in three stages). In order to select experts, expertise, knowledge, experience in the field of dentistry and curriculum planning, teaching years and having papers and compilations on related topics were considered. Through judgment sampling, 21 experts, 15 members of the board of dentistry of the country and 6 faculty members of Allameh Tabataba'i University, Tehran University and Farhangian University were included. After selecting the members of the experts’ group, the three rounds of the Delphi method were conducted from October 2010 to January 2011. In the first round, a list of integration factors in the dental curriculum that had been extracted from earlier studies was provided to members to determine their importance. In addition, they were asked to submit their comments on factors which were not included in this list. In the second round, factors suggested in the first round by the Delphi panel, were given to determine their significance. In the third round, regarding factors that were identified as important and very important in the first and second rounds, the members' opinions were asked again. The Delphi method ended after the third round and a favorable consensus was reached. In the quantitative part of the study, descriptive statistics (frequency percentage) were used to validate the proposed model. In examining the content validity of the curriculum, opinions of 15 experts in dentistry who were members of the board of dentistry in the country were used, and regarding the structural dimension of the model, the opinions of 6 faculty members were used to judge the proposed curriculum. Three criteria have been introduced in this validation: being logical (defensibility based on curriculum knowledge), coherence (internal consistency of the elements and the proper relationship between them) and applicability (adaptation to social policy conditions and real conditions of the curriculum).

  Results

Findings of the library study showed that the current dental curriculum only focuses on the purpose and content, and no integration was conducted, and the courses are taught separately. If a student does not complete the first two years of basic sciences, he would not be able to enter the pre-clinics and the clinics which follows the pre-clinics. Practically, dental courses are provided in three separate periods, and in each period, courses are taught in a completely separate form. In addition, studying the native needs of changing dental curriculum, referring to the oral health department of the Ministry of Health, revealed that the necessities of dental health include the status of dental schools of the country, the Epidemiology of oral and dental diseases in the area regarding ​​geography, and cultural and social status of various regions of Iran. Therefore, proper and practical integration of dentistry courses into educational packages is crucial for solving this issue and improving oral and dental health. In order to achieve the proper method for integration of the dentistry curriculum, international experiences have been reviewed and localized. Global experiences in dental curriculum reform show that integration in dentistry education is divided into horizontal and vertical types. Horizontal integration has been used quantitatively in curriculum (for example, integration of basic sciences, behavioral sciences and clinical sciences in all four years of dentistry education), but vertical integration is commonly seen in curriculum (for example, integration of basic sciences in clinical sciences and vice versa, the integration of computer sciences and research methods in dentistry).

 Generally, in order to plan a desirable integrated curriculum for dental education in Iranian universities, based on the experience of modeling in the curriculum (8,9), modeling for curriculum in Iran (10-12) and in other countries (since 2000) and based on the requirements of dental education in Iran and the experiences of dental curriculum in prestigious universities of the world (13), three essential components of the integrated dentistry curriculum model were identified as follows:

1) The basics of the integrated dental curriculum; 2) Principles of the integrated dental curriculum; 3) Components of the integrated dental curriculum. There is a “cyclic” relationship between these three parts of the integrated dental curriculum; the basics propose the information infrastructure to the principles, and principles propose requirements for any measure in relation to the component, and any kind of measure in the components can help develop the basic information (14).

Each component has its own dimensions. When determining the “connection” between “components” and between “dimensions and parts of components” in the dentistry curriculum, considering the quality and the method in which the components of the curriculum are linked, results in “integrated dental curriculum” to emerge (15). The facts about dentistry curriculum in Iran and other countries (13) show that the following four categories of principles in the curriculum in the field of practical and theoretical education are important: 1) knowledge of the human’s nature “philosophical foundations” 2) knowledge of the community "social foundations" 3) personal knowledge "psychological foundations". 4) Knowledge of the tools and means that can be used to teach "technological foundations" (16).

Also, the basis for change and reform is based on principles that can be described as “the principles of the integration of dental curriculum.” These principles have been introduced in the context of curriculum studies and applied to the conditions of the universities of Iran:

Principle 1: simultaneous integration at micro and macro levels: Based on this principle, both interdisciplinary and multidisciplinary integrations must be considered (17,18).

Principle 2: Variety of methods and multi-dimensionality: the pattern of curriculum integration should not be treated dogmatically and fanatically (19).

Principle 3: Balance between content and process-orientation of the integration: The curriculum integration model should lead to a balanced mix of content-based and process-based curricula (13, 20, 21).

Principle 4: Complementary nature of internal and external integration: The integration model should focus on both general types of “internal integration” and “external integration”. External integration means the design of a curriculum and the organization of content in a form that is integrated with the curriculum. The internal integration is related to learning activity and is an action taken by students (4, 22, 23).

 In order to observe the principles of the integrated planning of dentistry courses and based on the global experiences of dental curriculum planning, a framework for integrating the dental curriculum based on three levels (23) and four elements (4) was arranged. Accordingly, by combining these two dimensions, the curriculum components were identified and determined. The curriculum is considered at three levels of scientific, field of study, and subject (17, 22). The four curriculum elements are: objectives, content, methodology, and evaluation (19). At each level and for each element of the curriculum, it is necessary to make decisions which result in the achievement that can be called “curriculum pillar”. Table 1 lists the components of the curriculum for applying in dentistry education that are derived from cross-linking of curriculum levels and elements.

In a deeper search for the integrated curriculum model used at the studied universities (6, 7, 24-51), 40 cases of dental curriculum integration were identified which were the basis of the design of the first phase of the Delphi questionnaire. At the end of the first phase of the Delphi questionnaire, a question was asked to obtain expert opinions regarding other integration factors in this syllabus. The first round’s results indicate that 37 factors are effective in integrating the dental curriculum. In the second round, the opinion of the members was evaluated about the extent of the impact of the integration factors introduced in the first phase. The results of the second phase of Delphi show that 35 factors are effective in integrating into the dental curriculum. In the third step, the comments of each member of the panel in the preceding periods were sent to them and they were asked to correct their previous opinions, if necessary. The results of this phase showed that 33 integrations were accepted as presented in table 2.

Based on the explanation given, the proposed model framework for an integrated dental curriculum is presented in figure 1. With regard to the proposed model framework of the integrated curriculum, the expanded model of this program can be presented in figure 2.

The findings of this study showed that 15 dental specialists believe that all mentioned items should be applied unconditionally to the curriculum. In total, 89% of dental specialists approved the proposed integration for general dentistry curriculum, and only 5% explicitly opposed this kind of “integration”. This agreement and the type of position adopted ultimately resulted in a credibility of 93.3% for the model. This agreement showed that if the predicted integration items (33 titles) listed in table 2 are applied in the current dental curriculum, the combined dental education curriculum would be resulted. To validate the structural value of the designed model, the opinions of six experts were used to judge the curriculum. The results of this validation show that what is called the integrated dental curriculum model is adequately valid (88.9%), but this overall agreement was accompanied by some corrective suggestions, while at the same time have shown different validities in each of the examined criteria.

Figure 1. Proposed Model’s Framework of the Integrated Dental Curriculum

Figure 2. Expanded model for the proposed integrated curriculum of dentistry

Discussion

By examining global experiences, it has been concluded that most dental schools in the world have integrated their dental sciences into their curricula (6, 7, 24-51), and it seems that the favorable situation of Iranian dental curriculum is due to the fact that the current curriculum which is run by a separated approach, moves toward an integrated curriculum. Therefore, by examining indigenous needs and international experiences, it was concluded that the optimum condition of Iranian dental curriculum is also achieved through the use of an integrated curriculum.

By studying Iranian models, especially the Shahisd Beheshti University’s model (20) and numerous foreign models, especially the American Marquette and Connecticut universities (6, 7) regarding the dentistry curriculum integration, it was concluded that the of change and modification of the dental curriculum was based on the introduction of three approaches into the curriculum: "The approach of education al
ong with research in dentistry", "Evidence-based dental approach" and "The approach of introducing new knowledge to dentistry." Nevertheless, the focus of these three approaches has not prevented a variety of measures taken regarding specific reforms in curriculum; although these were not general, but among the three approaches mentioned above, achieving the ways in which new sciences enter into dental topics were more emphasized. It has also been increasingly focused on research over the past years. The following modifications have been introduced in the reform programs of the universities: (1) The integration of basic sciences, biomedical, behavioral sciences and clinical sciences throughout the course of dentistry; (2) the establishment and introduction of a unit of case-based dental rounds 3) Creating early clinical experiences and learning opportunities for community-based experiences; 4) integrating biomedical sciences with clinical sciences; 5) introducing informatics and information resources into the curricula; 6) predicting scientific writing of papers and evaluating and criticizing scientific papers; 7) designing curriculum for education and research design and critical statistics; 8) curriculum and education based on evidence-based dentistry.

These studies showed that different types of vertical and horizontal integrations were proposed based on internal and external integration methods for dental education curricula of different universities of the world. Accordingly, a total of 33 corrective measures have been taken in the process of dental curriculum reform, most of which are considered “vertical integration”.

Theoretical validation of the proposed model considering the content and structure showed that the issues raised were not sufficiently considered in the current dentistry curriculum. Dental specialists also stated that almost all of the items in the proposed general Iranian dentistry curriculum should be unconditional applied, and a number of them should be applied in the current curriculum under some conditions. The main concern of experts was the issue of "being native" or "imitation". They emphasized that the adaptation of these achievements to the conditions of the Iranian universities should be considered, and the model produced should be implemented "experimentally and with the participation of dentists". The judgments made showed that the credibility of the proposed model was 93.3%. At the same time, the structural aspect of the integrated dental curriculum model was judged by curriculum experts on the basis of three criteria (coherence, feasibility, and logic), which confirmed the structure of the designed model to about 88.9%.

Finally, the proposed model has focused on the subject beyond the domestic and foreign models, and has been able to focus on both aspects of the curriculum modeling approach (which focuses on theoretical aspects) and the desired dental curriculum (which clearly focuses on practical aspects and diverges from the theoretical ones), and presents a pattern of "equilibrium" between “theoretical” and “practical” aspects. In the foreign models of dental programs, the theoretical topics and the basics of the curriculum are not "obvious" and do not seem to be taken into account (13). The reason for this is probably the highlighted aspect of "practicality" in the field of dentistry. Also, in most Iranian models that are designed for higher education curricula, attention is paid to the macro level of curriculum and policy, and the moderate and micro level of the curriculum are neglected and practically the levels that lead to the implementation of the curriculum are more or less ignored (10, 52, 53). In the dental reform model of Shahid Beheshti University of Medical Sciences (20), most of the practical topics of the curriculum have been considered and based on this curriculum development. Therefore, in this model, the basics and theoretical subjects of the curriculum have not been raised, since principally the "production of the curriculum" has been raised and not the production of a curriculum guide. However, in the proposed model in this study, both theoretical and the basis of the curriculum were considered, and both theoretical and practical aspects were "simultaneously" considered. Another feature of the innovative suggested model is that the four principles of this model are not considered in any of the fields of the curriculum. These principles are, in fact, a compilation of all disciplines in the field of integration in the curriculum. If the two aspects of the proposed model are related to the main two aspects of the curriculum (theoretical) and the dentistry (practical), then given that the curriculum is a theoretical discipline and dentistry is a practical field, the resulting model is practically an “interdisciplinary” model linking both theoretical and practical domains. Although this is a conceptual model, it is a good guide for action so that it provides the basis for designing dental curricula.

 Based on the studies carried out in the current Iranian dentistry curriculum and the study of the types of integrations available in the curriculum of the accredited universities of the world, and using the specialized views, three integration approaches in the present Iranian dental curriculum have been presented: 1) Integrating the items currently available in the curriculum (courses need to be integrated into the current curriculum); 2) courses need to be revised in the current curriculum; 3) integration in the form of adding new and required courses to complete the current curriculum. The results of this study showed that two major policies should govern the production of Iran's general dental curriculum: first, horizontal integration by reducing the number of courses, and second, vertical integration through early onset of clinical activities.

In general, it can be concluded that the designed model of the integrated dental general curriculum has a strong and well-founded theoretical basis and extensive research background that is well known for the general dentistry field in Iran.

Interdisciplinary research with "disorientation" and "distrust" problems are addressed by the custodians of each of the disciplines involved in interdisciplinary research, which was actually experienced in the present study; what dental professionals said in order to regulate current curriculum was hardly accepted by curriculum specialists. Though researchers have tried to overcome this disorientation and distrust, it is suggested that this model be disseminated in dental groups, and this can be done by holding workshops.

Acknowledgments

The authors would like to thank all dentistry curriculum planning experts who helped researchers to accomplish this study.

Conflict of interest

The authors state that there is no conflict of interest