The Art and Science of Swedish Dentistry: From Br?ïnemark Implants to Problem-Based Learning

The Art and Science of Swedish Dentistry:
From Br?ïnemark Implants to Problem-Based
Learning
Submitted for publication 4/7/03; accepted 4/16/03
Ronald H. Hsu
Journal of Dental Education ¨? Volume 67, Number 6
Mr. Hsu is President and the ADEA Representative of the Class of 2003, University of Washington Dental School. Direct
correspondence to him at 15415 SE 44th Place, Bellevue, WA 98006; 206-685-9763 phone; ronhsu@u.washington.edu.
Supported generously by the Alumni Association,
I was one of four students from the University
of Washington (UW) School of Dentistry
who had an opportunity to visit the Malm??
University Center for Oral Health Sciences in Sweden
in September 2002. Dr. Lars Hollender, professor
and director of oral radiology at UW, served as
liaison officer. Fellow dental students Garin Liu,
Lindsay Posner, Megan Shields, and I were treated
to two weeks of presentations, in-class observations,
and a variety of cultural experiences, thanks to the
cooperation of the Malm?? University administration,
faculty, and staff. We returned with renewed excitement
in dental education and a greater appreciation
for the art and science of dentistry.
Swedish dental scientists have long been recognized
for their many important research developments,
especially in cariology and temporomandibular
joint (TMJ) disorders. Perhaps more significant
is the Br?ïnemark dental implant system, which has
reset the standard of care in replacement of missing
teeth. To gain a better perspective on the use of dental
implants, my classmates and I visited the Malm??
Dental Clinic, Br?ïnemarkcenter, beautifully situated
by Malm?? harbor. We observed a full-arch maxillary
alveolar reconstruction surgery using six implant
fixtures. Dr. Jan H?ïkansson, the performing dentist,
gracefully walked us through his forty-five-minute
procedure explaining each step and the rationale behind
it during the surgery. It was an eye-opening experience.
Because of the impressive quantity and
quality of implants placed in the clinic,
Br?ïnemarkcenter recently received credentials to
train graduate students in periodontics and
implantology. It became the first private dental clinic
in Sweden to be so enfranchised.
Within the walls of Malm?? University, we were
introduced to a special presentation on a caries risk
assessment/patient education-oriented computer program
called the Cariogram. Dr. Douglas Bratthall,
professor and chairman of cariology, and his associates
are in the final phase of developing it. This program
uses complex algorithms to compute the caries
risk of an individual based on eleven variables,
such as diet patterns, oral hygiene practices, bacterial
culture counts, and salivary rates. A clinician can
input variables, based on a patientÇƒÙs report and lab
tests, and show the patient his or her risk in developing
decay via a pie chart. By varying the parameters,
a dentist can immediately demonstrate the impact that
simple behavior changes can have on the patientÇƒÙs
oral health. The Cariogram promises to be an excellent
caries assessment and patient motivation tool.
Properly used, it will greatly enhance the practice of
preventive and intervention dentistry.
An important aspect of our trip to Sweden was
seeing problem-based learning (PBL) in action.
Malm?? University began the practice of PBL in the
early 1990s and, after the initial adjustment period,
developed this instructional method into something
the students enjoy and appreciate. Students are given
specific clinical problems and encouraged to seek
out information related to the problem through a variety
of sources. It is an evidence-based style of learning
that finds its roots in cognitive psychology.
The system consists of three basic principles:
1) Learning is a process of restructuring. Therefore,
a student must acquire new knowledge by building
on the principles already present in his or
her memory.
2) Learning is most successful when the information
is stored in a context that is similar to the
one from which a student can retrieve it.
3) Information is better understood and more easily
recalled when the student elaborates on the
information by discussing and explaining concepts
with colleagues and by making schematic
drawings.
The mechanism of PBL practiced at Malm??
includes seven cyclic steps. Students begin the process
by 1) clarifying unknown terms and concepts,
2) defining the problem(s) that the case presents, 3)
brainstorming various solutions to the problem, 4)
developing hypotheses for the solution, 5) formulating
learning goals, 6) collecting information related
to the learning goals, and 7) testing the hypotheses
and consolidating information through group discussion
and information exchange.
Students are introduced to the PBL process at
the beginning of their dental education. Having been
raised under the traditional lecture-based system of
education, the students relied heavily on their tutor
during class discussions in the first weeks of the PBL
program. However, once all the students understand
how PBL works, they prefer that the tutor stays out
of their conversations and intervenes only when necessary.
The role of the tutor diminishes as an instructor,
but he or she becomes a guide who ensures that
the students cover enough material, yet remain focused
on the scope of their research. The students
then go to recommended texts and journals, the
Internet, and other potentially valid sources for information.
Utilizing a variety of sources, the students
not only gain a comprehensive understanding of the
problem at hand, but also learn how to evaluate a
resource for validity. This participation encourages
the process of Çƒ?peer review.Çƒ? Such involvement in
solving problems via research eliminates the fear of
participating in formalized research training and fosters
an environment that encourages the students to
affiliate themselves with academic institutions and
participate in furthering the science of dentistry.
The PBL system is an excellent one for helping
students retain the material they sought. They
take ownership of that knowledge; it becomes a part
of them. In addition to the material learned, they acquire
a tool that will help them Çƒ?ownÇƒ? knowledge
for years to come. They become life-long learners
and researchers.
However, PBL is not without shortcomings.
The students have to be self-motivated and capable
of learning on their own. Students who are accustomed
to having boundaries set for them (criteria,
page numbers, chapters in texts, being told what will
and wonÇƒÙt be on the test) will not enjoy PBL because
evaluation of learning is not done with bubble-sheet
exams. The evaluation process is more intensive, requiring
instructors to comment on each student and
the students to evaluate each other, the tutor(s), and
ultimately themselves. Compared to one or several
bubble-sheets of examinations, this system is much
more intricate and time-consuming. PBL also requires
a tremendous amount of faculty support in
the form of material development and interdepartmental
coordination, particularly in the constant training
and calibration of tutors. A PBL program such
as we observed at Malm?? is difficult to implement
in schools where teachersÇƒÙ workloads are already near
maximum because of faculty shortages. Students
require time to make their research meaningful, and
many schools have heavy curricula and little free time
for independent learning. Such seems to be the situation
in most U.S. dental schools.
In Sweden, the dental school curriculum is
comprised of five years of training. Students pay no
tuition and are admitted typically at age eighteen after
completion of Transition School, which is similar
to the high school system in the United States.
They do not receive a doctoral-level degree upon
graduation, but such is attainable if the student wishes
to take on additional coursework. Although this may
give the impression that Swedish dentistry resembles
a vocation rather than a profession, a careful look at
how dentists are educated at the Malm?? University
Center for Oral Health Sciences reveals that Swedish
dentistry is an ever-learning, ever-progressing
academic profession.
At the University of Washington, we are very
fortunate to have Dr. Hollender as the driving force
behind this visitation program. Our visit was made
possible as a result of his extensive prior involvement
and connections in dental education circles in
Sweden. Four more students from UW will go to
Malm?? in September 2003. Dental faculty members
and administrators who have foreign connections are
a wonderful resource to the dental schools. They can
contribute in many ways other than teaching students
in the classroom. It is my hope that the pioneering
effort of Dr. Hollender will encourage other foreigntrained
faculty members across the nation to actively
develop visitation programs of their own and thus
open additional opportunities of learning for their
students.
This article is the first in this new section, which consists of submissions authored solely by undergraduate dental and allied
dental students. Articles in this section may cover the entire spectrum of academic dentistry from clinical and educational research
to student perceptions of educational methodologies and critical issues in dental education. Submissions should be emailed
to the editor, Dr. Olav Alvares, at Alvares@uthscsa.edu.