The Experience of Integration in the Dental Curriculum of the World’s Accredited Universities and How to Apply it in Iran

Introduction
Dentistry is one of the branches of medical sciences that should be in the context of up-to-date educational changes in the world and in responding to the needs of society in the third millennium. In its 80th session in the Comprehensive Care Unit, the United States Dental Education Association has suggested that dental clinical curriculum in the 21st century should be patient-oriented and based on ability. The need to pay attention to the modern methods of information transfer with emphasis on the progress of electronic tools, being student-oriented, clinical stimuli, and the double emphasis on the combination of medicine and pathology, behavioral and social sciences in dentistry education is necessary in today's world. These scientific-social foundations have led to a clear focus on the need to integrate theoretical and practical aspects of social issues into account in recent advances in dentistry education and curriculum planning (1).

There are different approaches to integrating curricula. The initial idea is that in the integration approach, theoretical and practical courses are combined, while this type of integration is the minimum outcome of an integrated approach (2). In spite of the tradition governing dentistry curriculum that has been divided into "basic sciences" and "clinical sciences" separately, the realities of the new scientific and social world indicate that in order to have a successful curriculum in teaching practical sciences, such as dentistry, theoretical and practical education need to be coordinated and integrated (3). Integration means the mixing of content or topics that are separately included in the curriculum of educational centers in the traditional educational systems (4-5). Integrating curriculum isassociating and integrating content and curriculum processes to achieve the goal of the coherence of learning experiences in learners (6). Integration of medical education is divided into horizontal and vertical categories: the purpose of horizontal integration is to integrate courses that are taught in one stage. The integration of basic sciences with each other falls into this category (e.g. embryology, histology, pathology,...), or the integration of clinical courses with one another (e.g. preventive medicine, psychiatry, geriatrics, ...) . So, this integration involves a series of courses that are presented at one stage, and the time they are presented as a program is considered a "unit." (7-8). The goal of vertical integration is to integrate courses that areconsecutively placed after one another. Integrating basic sciences with clinical sciences can be mentioned here. Vertical integration between basic sciences and clinical sciences with problem-based learning method deepens learning. In fact, vertical integration involves early student contact with patients in the first semester in basic sciences as well as basic science education in clinical curriculum, which has been given particular attention by the Ministry of Health and Medical Education in recent years. In this regard, the purpose of this study is to investigate the experiences of the general dentistry curriculum in the twenty first century at prestigious universities of the world and to use it to revise the curriculum in Iran.

Methods
This is a historical research which is considereda qualitative research. In its implementation, it has been tried to study the integration of the dental curriculum with an analytical perspective using available resources and documents. Historical research examines certain issues at a specified time, and the researcher evaluates the integrity of the material to interpret and analyze the information (10). Given the theoretical nature of the research, the data gathering tool was taking notes through the study of documents. For this purpose, the literature on the integrated curriculum was studied and the documents were used to collect information about the general dental curriculum in Iran and other reputable universities in the world. This review has been limited to a specific time frame: it was limited to examining the status of Iran during the period covering the current program and foreign universities from 2000, which are among the newest examples. In order to access resources, in addition to referring to prestigious 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 study of scientific and research documents was also carried out using the "Spider’s Web" method. In this method, each source can provide clues from other sources and lead the research to new information. This method was especially used to obtain information about sources outside of Iran. To collect information, a targeted, organized search was used. To access a wide range of scientific texts, Google Scholar and Alta Vista search engines were used. Also, medical databases such as PubMed and MEDLINE were used, and to access bibliographies, databases such as ERIC and RDRB were used. In these databases, keywords such as integration, integrativecurriculum, dental school, dental curriculum, higher education, the basics and elements of dentistry syllabus, types of integration, and other related terms were used to search for theoretical literature and research backgrounds since 2000.Therefore, methods such as document analysis, comparative study, and review of documentation were used during the study. In general, in this method, the initial plan of information is compiled based on the main questions and is being sought in the resources. To analyze the data, the method of theoretical analysis focused on the questionnaire was used. In this method, the dataare combined to form a comprehensive and logical answer, and their defensible organization is the basis for determining the validity of the method.

Findings
(A) Revising the curriculum for general dentistry in prestigious universities in the world
In this review, the experience of revising in forty dental faculties in the world was reviews and were summarized using the basic concepts of curriculum. The two main types of integration with the themes of "horizontal integration" and "vertical integration" were the basis for organizing and combining data. Totally, after reviewing the curriculum of the world's leading universities, it was concluded thatsince 2000, the degree of vertical integration was larger than the horizontal integration. In this study, it was found that common types of horizontal integration in two cases and common types of vertical integration were used in forty cases as presented in Table 1.

Horizontal integration in dentistry curriculum: This type of integration becomes necessary when new sciences emerge. In dental field, this was also evident due to scientific developments in other fields. New advances in computer sciences, information and communication sciences, behavioral sciences, basic sciences and management sciences have led to the integration of this progress with dentistry with more success in this field. Accordingly, two methods of horizontal integration in dental programs were pursued:

1) Integration of basic sciences, behavioral sciences and clinical sciences in all four years of dentistry education; and 2) Integration of basic sciences with dental topics (basic sciences of dentistry).

Vertical integration in the dentistry curriculum: Vertical integration generally takes place in the topics of a discipline or field. Although it has a history, this type of integrationwas not as close to horizontal integration as was noticed in the last decade of the twentieth century and early twenty first century. By integrating basic sciences in clinical practice and vice versa, students' motivation to learn both sciences improves. Also, integration education rationalizes the educational resources, so that all faculty members come together in each discipline and subject at a college and are given the right person to take the responsibility of teaching each part and learning resources can be shared. Based on this, in the last ten years, vertical integration has been undertaken in various forms.

Since it is not possible discuss all types of integrations in detail in this article, a few cases are mentioned based on the practice of the universities and the results are reported.

University of Marquette: This University has launched the Comprehensive Patient Care Program in 2010-2011. In this plan, the clinical curriculum of the Faculty of Dentistry is based on the General Practice Model. The philosophy of this model is that a qualified comprehensive program, without dividing it into disciplines or individual specialties in dental care, is more successful (11). The program is patient-oriented and managed by general dentists. This allows the integration of behavioral sciences, basic sciences and clinical sciences into patient care and treatment (12).

University of Connecticut: This University has presented a unique program on Biodontics in the form of the introduction of new biologic sciences and research in dentistry. The main goal of the new curriculum is the use of new discoveries such as molecular biology, biotechnology and informatics that utilize these sciences in teaching dentists to serve more to patients. Part of this program includes translational research training and clinical trial programs designed to integrate basic sciences in clinical applications and new technologies such as Probiotic, Dental Laser and Electronic Patient Record System. The highest level of Biodontontics education has been documented in a formal admission of assistants leading to formal education certificate after two years (11, 13).

University of Texas: The curriculum was reviewed at the university to revise the program in terms of its use of the new sciences at all levels, and the critical evaluation approach was used in this direction. The main achievement of the review of the dental curriculum of this university can be described in three main approaches: 1) Students and professors should experience evidence-based practice; 2) Students and professors should be able to evaluate critically in all educational and therapeutic areas; 3) Clinical teaching strategies should be followed when teaching to students. In this curriculum, known as CAT, new information is integrated into the dental curriculum and private practice setting, giving students an opportunity to actually get acquainted with the form of dentistry that is fundamentally mixed with new sciences and technology (14-16).

Considering that vertical integration is widely seen in dentistry curricula, Table 2 refers to global experiences in integrating different dental curricula. It should be noted that the detailed report for each of the 40 commonly used vertical integrations in the dental colleges of the studied universities is not included in this article, and only a few examples have been mentioned.

B)The experience of reviewing the dentistry curriculum in Iran: The first dentistrycurriculum after the Islamic Revolution and the Cultural Revolution, was established on the basis of the statute of the dental schools approved on March1, 1983 by the headquarters of the Cultural RevolutionAdministration. According to the regulations approved by the Cultural Revolution Administration, the total units of this course were 213 theoretical units and 20 units of internship at the medical centers and the provincial capital. The second training program from the second review, approved by the Supreme Planning Council dated June 17, 1988, was based on the constitution of the Islamic Republic of Iran and the goals of the World Health Organization - which the Government of the Islamic Republic of Iran was bound to assume - with the aim of restoring wellness for the people of Iran, changes were made to the courses. The program consists of 202-205 courses and a period of 6 years. After two years of teaching 68 units of general and basic science courses, students enter the clinical course (pre-clinic and clinic) and continue their education with the presence of patients. At the end of the six-year period, studentspresent their thesis and graduate. The third review was carried out in 1999 by the Dental Education Review Committee of Shahid Beheshti University of Medical Sciences. After the approval of the Secretariat of the Council for Dentistry and Specialized Medicine, the Board of the Medical Sciences Planning Council was approved by the Supreme Council on May 20, 2000. One of the key points in this review and in the direction of its correction was the importance that the training of human resources in the dentistry sector should lead to the goal of providing, maintaining and promoting oral and dental health in the community, which unfortunately has not yet been achieved. And on the other hand, in the past few years, disagreementsregarding the contents of the curriculum of dentistry has begun and increased. According to the above, the review of the program, which is an essential component of the development of education, was accepted as a definite necessity and implemented (17).

Table 3. Revisions of dental education curriculum at Shahid Beheshti University of Medical Sciences (18)
Stages	Title	Features
1st stage	Basic Medical Sciences	At this stage, basic sciences and general courses will be presented during three semesters with the following modifications: 1. Adding courses to build self-centered learning capabilities by adding information technology courses, studying and finding dental evidence. 2. The horizontal integration of the content of basic medical sciences in the form of body systems. 3. Vertical integration of the theoretical content of traditional courses of "internal diseases" and pathology in the content of courses of the body. In this section, most common or important diseases will be considered from the perspective of a dentist. 4. Adding Basic CPR Course. 5. Adding general communication skills. 6. Addingearly patient contact.
2nd stage	Basic Dental Sciences	This phase, which is intended as a one-semester course, contains courses that provide students with specific topics in basic dental sciences with the following changes: 1. Vertical integration of histology and pathology in the form of oral histology-pathology. 2. Vertical integration of embryology with congenital oral diseases as a course of Dentofacial growth and development 3. Presentation of Pharmacology in the Integration of Oral Microbialogy and Oral Antimicrobial Pharmacology 4. Vertical integration of oral diseases in the above courses 5. The presentation of new courses: Physics of radiology and protection, occlusion and and masticatorysystem, and Local Anesthesia and Nerve Blocks 6. Continuing communication skills training in clinical communication skills training. 7. Continuing to organize the topic of community-based dentistry during this phase during the course of the "Foundations of Oral Health". 8. The new organization of English in the curriculum in this phase has been seen in such a way that by changing the content, students at the end of this phase will be able to study dentistry references. 9. The new organization of the topic of research in the curriculum that begins with the presentation of the research methodology course at this stage.
3rd Stage	Preclinical  Dental science	The duration of this phase is 2 years. The purpose of this phase of student preparation is to assume the responsibility of the patient's administration as a general dentist with the following modifications: 1. Theoretical and practical integration (pre-clinic and clinic) of clinical courses in specialized departments. 2. Integration of dental materials courses in clinical departments. 3. Continuing the training of evidence-based dental positions in this phase during the two periods of critical appraisal of dental literature and "Evidence-Based Dentistry". 4. Continuing education of emergency medical units in this phase by providing a new course of advanced CPR and medical emergencies. 5. Continuing education of community dentistry in the curriculum by providing a new course "PreventiveDentistry 1 & 2" and finally "Promoting Individual Oral Health". 6. Promoting student responsibility at the patient's administration (the role of dental assistant for students at this stage). 7. Continuing teaching English at the level of achieving the goals of speaking English as a dentist. 8. Continuing the teaching of ethics and professional behavior as "Ethical vignette case discussion". 9. Starting offering selective courses for dental students.
4th stage	Dental clerkship	The duration of this phase is 18 months. The purpose of this phase is to gain experience, develop skills, strengthen decision-making power, increase self-esteem and complete the development of thought through direct confrontation of trainee with oral and dental health issues and assign responsibility for oral healt References 1. American Dental Education Association.Allied dental education programs. [cited 2003 July 9]. Available from:https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwj4sJLc46PKAhWC7RQKHcrqACQQFgghMAA&url=http%3A%2F%2Fwww.adea.org%2FDocuments%2FCompendiumofCurriculumGuidelinesforAlliedDentalEducationPrograms.pdf&usg=AFQjCNH52t5UQb0pDfJxAhk3alq1G580eg 2. Yazdani Sh, Hosseini F. The Dentistry Curriculum Revision Plan; 2008. [In Persian]. 3. Bazargan A. An introduction to qualitative research methods and common approaches in behavioral sciences. 6th ed. Tehran: Didaar; 2016. 4. 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Scott J. Dental education in Europe: The challenges of variety. J Dent Educ 2003; 67(1):69-78.   Volume 8, Issue 1 - Serial Number 1 June 2018 Files XML PDF 409.34 K Share How to cite RIS EndNote Mendeley BibTeX APA MLA HARVARD VANCOUVER Statistics Article View: 1,928 PDF Download: 389 × APA Safarnavadeh, M., Ebrahimpour Koumleh, S., & Mousapur, N. (1999). The Experience of Integration in the Dental Curriculum of the World’s Accredited Universities and How to Apply it in Iran. Future of Medical Education Journal, 8(1), -. doi: 10.22038/fmej.2018.30484.1192 × MLA Maryam Safarnavadeh; Samira Ebrahimpour Koumleh; Nematollah Mousapur. "The Experience of Integration in the Dental Curriculum of the World’s Accredited Universities and How to Apply it in Iran", Future of Medical Education Journal, 8, 1, 1999, -. doi: 10.22038/fmej.2018.30484.1192 × HARVARD Safarnavadeh, M., Ebrahimpour Koumleh, S., Mousapur, N. (1999). 'The Experience of Integration in the Dental Curriculum of the World’s Accredited Universities and How to Apply it in Iran', Future of Medical Education Journal, 8(1), pp. -. doi: 10.22038/fmej.2018.30484.1192 × VANCOUVER Safarnavadeh, M., Ebrahimpour Koumleh, S., Mousapur, N. The Experience of Integration in the Dental Curriculum of the World’s Accredited Universities and How to Apply it in Iran. Future of Medical Education Journal, 1999; 8(1): -. doi: 10.22038/fmej.2018.30484.1192 ×