Eur] Dent Educ 1997; 1: 13-17 Printed in Denmark. All rights reserved

Copyrigkt 0 Munksgaad 1997

E U K O P E A Y J O l l R h A L O r

Dental Education ISSN 1396-5883

Acceptance of psychology teaching in paediatric dentistry by undergraduate dental students

Matthias Kalwitzki Department of Conservative Dentistry, Faculty of Dentistry, University of Tiibingen, Tabingen, Germany

By means of a questionnaire, 4 cohorts of undergraduate stu- dents (n=144) were asked before and after the clinical course in paediatric dentistry about their acceptance of the teaching of psychological aspects in dentistry. A generally very high interest was found for psychology as well as for child-related psychology. The teaching of this topic by means of lectures was thought to be useful, but other didactic means were demanded to supplement teaching. For many of the aspects taught, more information was requested. Moreover, teaching of aspects not taught in the lec- tures was also requested. The more obvious the practical rel- evance of each topic appeared, the greater was the students’ interest. Psychology was thought to be useful as an aid to paedi-

atric treatment. However, interest dropped after the completion of the paediatric dentistry course. It is concluded that undergrad- uate dental students have no particular inclination towards the treatment of children but rather a need for guidelines to avoid potential problems in dealing with this demanding group of pa- tients.

Key words: psychological teaching: dental students; paediatric dentistry.

0 Munksgaard, 7997 Accepted for publication 27 March 1997

It has been well-established by numerous studies that the successful dental treatment of children requires a sound knowledge of clinical psychology. Numerous ideas and methods have been discussed and recom- mended for the cooperative and the non-cooperative paedodontic patient (1-5). In order to be successful, the practitioner has to be able to cooperate with the most diverse stages of development, reactions and situations, taking into consideration that children are subject to a continuous personal development. Fur- thermore, dental treatment in the early stages of life is of fundamental significance for the later adult attitude towards dental treatment (6-8).

Thus, psychological training has been included in the dental curriculum in many countries (9, lo), de- spite a common belief among many dentists that den- tistry is a profession requiring mainly mechanical skills. In Germany, there is still no generalised pro- gramme in psychology in the dental curriculum; how- ever, different programmes were created in some uni- versities with a growing tendency for exchange and standardisation. Thus, the inclusion of psychology is a fairly new addition to the German dental curricu- lum and the purpose of this study was therefore to evaluate the acceptance of this subject by the 5th year dental students at the University of Tiibingen, who had not been exposed to any previous training.

Aim of study Clarification of the following questions was sought:

1. Is the teaching of psychological aspects in dentistry thought to be a necessary part of the curriculum?

2. Is the teaching of particularly child-related psycho- logical aspects thought to be a necessary part of the curriculum?

3. Is teaching by means of lecturing thought to be useful? If not, what alternatives are desired?

4. Which aspects presented in the lectures are of greater, which of lesser, interest?

5. Is there a shift between the topics perceived as most important by the students before and after the completion of the clinical course?

6. Is there a desire to learn about further psycho- logical aspects not presented within the lectures? If yes, which ones are desired?

Material and methods Over a period of 2 years 4 classes with a total of 144 students attending the clinical course for paediatric dentistry (10th semester, final semester before gradu- ation) participated in this study. Within this course,

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Kalwitzki

students initially receive a theoretical introduction and are subsequently required to treat paediatric pa- tients under the supervision of experienced clinicians. Patient age in this course varies between 2 and 16 years, including also mentally and physically handi- capped children.

During the theoretical introduction to paediatric dentistry and before the start of the clinical course, all students were asked to answer a questionnaire. The same questionnaire had to be answered again after the completion of the clinical course at the end of the semester with an additional question about the practi- cal use of the given information.

Practical study design 3 lectures (1 hour each) were compiled in consul- tation with the Department of Psychology of the University of Tubingen. These comprised the most important issues and aspects derived from the pae- dodontic literature (2,4,6,7,9) and our own clinical experience. A concise summary of these issues was given to the students before the lectures were held, in order to assure a smooth introducion to this matter.

The following nine topics were presented: As an introduction, the necessity of psychology in

dentistry, and in particular, the necessity of child-re- lated psychological aspects were stressed. Subse- quently, the students were introduced to different the- ories of child development. Part 4 dealt with the vari- ous influences by family, friends, former experiences with medical or dental treatment, etc., on child behav- iour. Part 5 explained aspects of child behaviour within dental surroundings according to the different stages of development. Part 6 was dedicated to the problem of fear and its causes. The 7th part explained aspects of interactions between the dentist and the paediatric patient, e.g., significance of voice, speech, physical contact. In part 8 methods to increase the compliance of the paediatric patient were presented. In part 9, a (successful) example demonstrated the practical use of one of these methods in a case report taken from our clinical course (systematic desensitis- a tion).

Personal codes were used for both questionnaires so as to preserve anonymity.

Questionnaire After a pilot test (one class), the questionnaire was designed under the supervision of the Department of Psychology of the University of Tubingen. For reasons of standardisation, the method of answering consisted in offering different options for each question from

which the student could choose only one (except for “Other didactic means’’ (Table 1)).

The questionnaire basically addressed 3 topics with a total of 23 questions before the clinical course and 24 questions after the clinical course: (i) Accept- ance and didactics of the lecture series (6 questions). (ii) Acceptance of contents and extent of the lectures and the specific aspects presented (10 questions). (iii) Desire to learn about psychological aspects not presented in the lectures (7 questions). (iv) Evalu- ating the practical use of the given information was answered only in the 2nd questionnaire after the completion of the clinical course (1 question).

Analysis of the questionnaires was carried out by logical evaluation. Therefore, .if the teaching of psy- chology in paediatric dentistry was deemed to be use- less, only this information and the data about the teaching of psychological aspects .in dentistry were taken into consideration. The question concerning the extent of a specific aspect was of no further relevance if the question about the contents of this specific as- pect had been answered with “not necessary”. The responses from students repeating the course were re- corded only once.

Results The response rate was 100%. However, 5 students had to be ruled out for filling out their questionnaires in- correctly. The remainder comprised a total of 144 stu- dents. The analysis was done separately for each class.

TABLE 1. Results concerning the acceptance of teaching psychology and didactic means

Beginning End YO YO

psychology in dentistry necessary 98.6 95.8 not necessary 1.4 4.2

psychology In paediatric necessary 98.7 96.4

3.6

lecturing as a didactic useful 93.6 90.2

not useful 6.4 9.8 other didactic means’ r61e plays 14.3 22.6

film 47.1 57.1 47.1 47.4 seminar

concise summary useful 97.1 98.5 not useful 2.9 1.5

Other didactic means were only marked where students found lee- turing to be not sufficient. However, Percentages were taken from

dentistry not necessary 1.3

means

100 Yo (n=144).

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Acceptance of psychological teaching in paediatric dentistry

As the differences between the 4 classes included in this study could not be verified statistically, all infor- mation shown in the following represents the pooled data from all 4 classes.

General acceptance and didactics of the lecture The teaching of psychological aspects in dentistry was thought to be necessary by 98.6% (n=142) in the beginning and 95.8% (n=138) at the end of the semester. The teaching of psychological aspects in paediatric dentistry was thought to be necessary by 98.7% (n=140) in the beginning and 96.4% (n=133) at the end of the semester. Lecturing was an accept- able didactic means for the teaching of this matter for 93.6% (n=131); later the figure dropped to 90.2% (n=120). In descending order other didactic means mentioned were: film, seminar, rdle plays. The printed abridged lecture content given to the stu- dents before the lecture was found to be helpful by 97.1% (n=136) in the beginning, and 98.5% (n=131) at the end (Table 1).

Contents and extent of the lecture An acceptance of close to 100% was found for almost all the presented topics. Results significantly under 100% were limited to “Different theories of child de- velopment” (78.6% (n=110) before and 77.3% (n=102) afterwards) and to the case report at the end of the semester (95.7% (n=134) and 92.4% (n=122)). The ex- tent of the different aspects mentioned was generally considered to be sufficient. About a $ of the students expressed their desire for additional information on most of these aspects. About of the students ex- pressed their desire for additional information on the following aspects: “Aspects of interaction between dentist and the paediatric patient” (45.3% (n=63) be- fore and 39.4% (n=52) afterwards) and ”Methods to increase the compliance of the paediatric patient” (63.6% (n=89) before and 64.6% (n=84) afterwards). Only a scant interest for additional information could be observed for “Different theories of child develop- ment” (15.5% (n=17) and 17.6% (n=l8)). At the same time, this topic scored relatively high in the category “too extensive” (14.5% (n=16) before and 11.8% ( n = 12) afterwards). Surprisingly, the interest for case re- ports dropped from 48.5% (n=65) in the beginning to 40.2% ( n 4 9 ) at the end (Table 2).

Psychological aspects not mentioned in the lecture From the list of paediatric aspects not mentioned in the lecture but arising as a subsequent interest in the students, “Specific cases” (67.1% (n=94) before and 71.4% (n=95) afterwards) was ahead of “How to in-

TABLE 2. Results concerning the acceptance of dflereitt aspects taught

Beginning End Y O YO

~

Child development content necessary

extent sufficient not necessary

not sufficient too extensive

Interaction dentist-patient content necessary

extent sufficient not necessary

not sufficient too extensive

Methods to improve compliance content necessary

extent sufficient not necessary

not sufficient too extensive

Case reports content necessary

extent sufficient not necessary

not sufficient too extensive

78.6 21.4

70 15.5 14.5

99.3 0.7

54.7 45.3 0

100 0

35.7 63.6 0.7

95.7 4.3

50.7 48.5 0.8

77.3 22.7

70.6 17.6 11.8

100 0

60.6 39.4 0

98.5 1.5

35.4 64.6 0

92.4 7.6

40.2 1.6

58.2

TABLE 3. Results concernhlg the iitterest for diflererlf aspects not tariglit in the lectures

Beginning End % YO

incorporation into private practice 58.6 45.9 specific paedodontic cases 67.1 71.4 more theory on child development 17.9 14.3 oral cavity 19.7 15.9 fear and pain 40.8 55.8 interaction patient-dentist 69.7 49.3 students’ fear and stress 37.3 38.4

corporate this matter into private practice” (58.6% (n=82) before and 45.9% (tz=61) afterwards.

The possibility of “More examples for the theories of child development (Freud, Erikson, Piaget)” how- ever, aroused much less interest at both times (17.9”/0 (1z=25) and 14.3% (1z=l9)).

The topic “Aspects of fear and pain” was found to be of higher interest at the end (55.8% (n=77)) than initially (40.8% (12 =58)), whereas the “Interaction be- tween patient and dentist” was found to be of less interest at the end (49.3% (n=68)) than initially (69.7% (12=99)). The scarce interest for “The oral cavity seen from a psychological view” did not increase (19.7% (n=28) and 15.9% (n=22)), just as the topic “Students’

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Kalwi tzki

fear and stress while treating patients within the den- tal curriculum” kept its higher estimation (37.3% (n= 53) and 38.4% (n=53)) (Table 3).

Practical use of the given information For 87.9% (n=116) of the students, favouring the teaching of psychological aspects in paediatric den- tistry, the given information proved to be of practical value.

Discussion The data show that the acceptance of psychological aspects in dentistry and particularly the teaching of psychology in paediatric dentistry is very high amongst undergraduate dental students, confirming the results of other authors. Korn (11) found that 75.4% of undergraduate dental students in Hannover and Kiel were in favour of involving psychology in the dental curriculum. A general interest for an al- ready established psychologcal teaching in paedo- dontics is stated by Friis-Hasche & Kirkegaard (9); however, teaching of psychology and psychology-re- lated subjects are introduced much earlier and cover a much wider time-span (4 semesters) than our pro- gramme does.

The fact that the general interest was higher in the beginning than at the end of the semester could be explained by expectations being too high or by failure when trying to transpose the given information into practical use. Students could see reasons for a failure in the fact that a lecture requires too much abstract thinking in order to convert the theoretical advice into practical success. This could also explain the decrease of the data concerning the lecture as a useful didactic means for teaching psychology and an increase in the desire for more practically oriented didactic means like films or seminars. Schneller & Magri (12) sug- gested a specific video-training for dentists and dental students. Friis-Haschk & Kirkegaard (9) report the use of videotapes in Denmark, as well as audiotapes and seminars. Moreover dialogue, discussion, conver- sation and problem-solving are preferred educational methods. Possibly, the need for practically-oriented didactic means is related to a specific mechanical way of thinking that has been acquired from the beginning of the curriculum and produces the need for proven recipes and mechanisms, which hardly exist in this field. Korn (11) criticises a lack of social and psycho- logical teaching in a technical and natural-science oriented curriculum. The abridged version found very high acceptance, while the desire for a more complete

version persisted. This can be interpreted as further proof of interest in this matter.

For most of the aspects taught, a desire for more information was expressed. Of highest interest were: “Aspects of the interaction between the dentist and the paediatric patient” and “Methods to increase the compliance of the paediatric patient”, both topics which deal with the practical side of the matter. Kuhn & Allen (13) stress the teaching of compliance techniques as most important for later treatments in practice. This complements the fact that the interest for ’Theories of child development” (a more theoreti- cal aspect) proved to be comparatively low, which corresponds with the results of Kom (ll), who found that the teaching of basic psychological knowledge was of moderate interest whereas interactive aspects were highly appreciated. Szewczyk (14) also stated a high interest for communicatively-oriented psycho- logical education. The interest for case reports dropped, possibly under the impression of the treat- ments performed.

The interest for ”How to incorporate this matter into private practice”,, the future place of work for most students, dropped over the period of the course. The treatment of paediatric patients may thus be not one of the fields of work preferred by future dentists. By contrast, a generally high and ultimately increased interest for “Specific cases” was found. This can be explained by difficulties not satisfactorily overcome and open questions about the treatment of non-coop- erative children. Taking into account the results from above, the conclusion is that children were not pre- ferred patients for the future dentists, and that by more knowledge, only a reduction of difficult or un- pleasant interferences of the practice routine is attempted. The interest in ”More examples for the the- ories of child development’’ stayed low. There were no other references found here.

Of the general psychological aspects “The oral cav- ity seen from a psychological view” gained little inter- est, whereas the knowledge about “Interaction be- tween patient and dentist” was considered to be help- ful, which was also stated by Korn (11).

After the practical part of the course, a high percen- tage of students thought that teaching psychology by lecturing was a helpful means to perform paediatric dentistry. Thus, it seems justified to conclude that a lecture sufficiently meets the practical demands of the students. It may be sensible however to complete teaching by other didactic means, like seminars, films etc.

The results of all 4 classes corresponded very well. The tendencies found in class no. 1 could be con-

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Acceptance of psychological teaching in paediatric dentistry

firmed in class nos. 2, 3 amd 4. In conclusion, it can be stated that students are very much in favour of the teaching of psychological aspects. When looking at the underlying reasons, however, it seems that there is no particular inclination towards the treatment of children, as the interest for child-related aspects dropped. Rather there is a quest for guidelines to avoid potential probIems in deaIing with this de- manding group of patients, which was expressed by a higher interest for specific treatment-related aspects.

Acknowledgements The author wishes to thank Dr. I.M. Zalaman, Depart- ment of Psychology of the University of Tiibingen, Dr. D. Axmann-Krecmar, Institute of Medical Information Processing of the University of Tubingen, Dr. Thomas Schneller, Department of Clinical Psychology of the University of Hannover and Dr. U. Schlagenhauf, De- partment of Conservative Dentistry of the University of Tubingen, for their advice and assistance.

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Address: Matthias Kalwitzki Dcpartment of Conservative Dentistry Faculty of Dentisfry University of Tilbingen Osinnderstrasse 2-8 72076 Tiibingen Germany