Introduction

Experiential learning is defined as students’ construction of knowledge and meaning through active participation in a “real-life” experience [1]. Yardley described that in the context of medical/dental education, the term is applied to experiences which have been included in the curriculum to bring the student into contact with others in a particular role and context [1]. In the context of dentistry, it would mean bringing dental students out of the classroom and allowing them to participate in direct patient care. This concept is not foreign to most dental schools since dental students are typically allowed to manage and treat patients under staff supervision [2, 3].

The objective of the dental school curriculum is to equip graduates with the necessary skills and knowledge to embark on their careers. In a span of a few years, students are required to acquire a significant amount of information and to learn a variety of dental procedures [4]. Due to limited time, the school must select what is necessary for graduates to practice dentistry safely. As such, certain skills or knowledge that are deemed too advanced at the undergraduate level may not be prioritized [5].

An example would be the management of medically compromised patients and acute medical emergencies [5–7]. Compared to the typical patient, a medically compromised patient often requires special considerations in terms of patient care and treatment planning. For example, a patient on anti-coagulant is at high risk of excessive bleeding and precautions must be taken to prevent this. When treating medically compromised patients, the dentist must be able to cater their treatment according to the patient’s health state and provide first-line care for medical emergencies in the dental clinic setting [8]. Some examples of acute medical emergencies that may occur during dental treatment include cardiac arrest, asthma attack and seizures. Unfortunately, there are no existing data in Singapore that reports on the incidence of acute medical emergencies in dental clinics, and we can only rely on inaccurate anecdotal experience and recounting of incidences among colleagues. Inadequate assessment of a patient’s susceptibility to such emergencies and mishandling of these emergencies can lead to dire consequences [9, 10]. Having considered a patient’s medical and dental conditions, a dentist must then determine the urgency and necessity of a dental treatment based on a risk-benefit analysis. If necessary, the dentist must defer the appointment until the patient’s medical condition is better optimized for dental procedures [11]. For instance, patients who had a recent acute myocardial infarction should have a non-urgent elective dental treatment postponed until a few weeks later.

Medically compromised patients require more than routine delivery of care, so it is not surprising that many dental schools omit clinical training for this subgroup of patients [12]. This would mean that dental graduates may only have a theoretical understanding of the management of these patients, without any experiential learning. While global health has improved over the years, a large fraction of the burden of diseases comes from non-communicable or chronic diseases such as cardiovascular disorders and stroke [13]. Thus, dental professionals can anticipate a greater proportion of medically compromised patients in their clinical practice. However, with solely theoretical education, graduates may not be adequately prepared to treat medically compromised patients [14, 15], or to handle acute medical emergencies in a dental setting [16–20]. This may not be ideal for patient safety.

Among all the subjects taught in dental schools, dental graduates from Hong Kong felt the least prepared in the management of patients with medically compromised conditions and acute medical emergencies [6]. The majority of dental students from the United States were not comfortable managing medically compromised geriatric patients [21]. Similar responses were provided by dental graduates [15]. Only 30% of general dental practitioners based in the United Kingdom felt adequately prepared to manage acute medical emergencies upon graduation [22]. More than half of the general dental practitioners surveyed in New Zealand responded that the training for acute medical emergencies during dental school were not satisfactory and 14.1% felt inadequate to manage these patients [16]. Similarly, more than half of the dentists surveyed in Germany were not confident in providing basic life support in a dental setting [23]. This was corroborated by similar studies conducted in Latin America [7].

This problem was also identified in Singapore. Regardless of dental needs, patients under the care of dental students are usually screened based on their medical history before even being considered suitable for undergraduate dental treatment. Medically compromised patients (for example, those on dual-anti platelet therapy, ongoing cancer treatment, etc.) would be referred instead to the hospital dental specialists or dental officers for dental management.

The objective of the present study was to evaluate whether experiential learning affects the confidence and competence of dental undergraduates (UG), Junior Dental Officers (JDO) and Senior Dental Officers (SDO) in the management of medically compromised patients and acute medical emergencies in a dental setting.

Materials and methods

A descriptive cross-sectional study was conducted electronically via an online survey platform from April to June 2021. This study was approved by the National University of Singapore Institutional Review Board prior to commencement (Reference no. 2021–390). The need for consent was waived by the ethics committee because there was no personal data or identifiers collected.

Recent dental graduates (Graduated in the academic year 2017–2020) and undergraduates in their clinical years (3^rd and 4^th(Final) year of program) from Singapore were recruited. The electronic survey was distributed via the respective cohort representatives. The respondents were stratified into three groups according to their experience level: UG–Respondents who were in the 3^rd or final year of dental school (cohort size = 107), JDO–Respondents who graduated in 2019 or 2020 (cohort size = 103) and SDO–Respondents who graduated in 2017 or 2018 (cohort size = 117). Based on the sample size calculations, 90, 82 and 84 respondents were required for the UG, JDO and SDO groups respectively (95% confidence interval, 5% margin of error).

The survey consisted of four sections. The first section collected the following demographic details from the respondents: Gender, Year of Graduation (2017, 2018, 2019 or 2020) or Year of study (3^rd Year or 4^th/Final Year), Work experiences, and Exposure to medically compromised patients (Table 1).

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Table 1. Demographic profile of respondents.

https://doi.org/10.1371/journal.pone.0281801.t001

The second and third section sought to assess the respondents’ confidence and competence in the management of medically compromised patients. It consisted of six domains: cardiovascular disorders, respiratory disorders, neurological disorders, hematological disorders, endocrine disorders and malignancy. The six chosen domains were important to clinical dentistry as these conditions are more likely to affect treatment decision and are relatively more prevalent [24].

For the second section, the respondents were required to indicate their level of confidence in managing the patients and also, in providing management for acute medical emergencies of each domain. This was assessed on a 5-point Likert scale whereby the respondents were to rate their confidence level from 1 to 5 (1- Not confident 2- Slightly confident, 3- Somewhat confident, 4- Fairly Confident and 5- Very confident). The total scores within each domain and across all the domains were calculated.

For the third section, respondents were asked to answer five multiple-choice questions (MCQs) in each of the six medical domains to assess their knowledge (Table 2). For each MCQ, only 1 out of the 4 options was the correct answer. MCQ was selected as an assessment tool due to its objectivity and reliability [25]. Compared to direct workplace observation or clinical simulations, MCQs were also a more feasible and standardized form of assessment in the context of our study. Lastly, MCQs served as a valid measurement of clinical competence, namely that of basic facts and applied knowledge [25, 26]. The MCQs were vetted by our co-author RCW who was the NUS undergraduate oral and maxillofacial surgery (OMS) module coordinator for management of medical emergencies and medically compromised patients from 2013 to 2021. Similarly, the total scores within each domain and across all the domains were calculated.

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Table 2. Questionnaire on the six domains and respondents’ answers.

https://doi.org/10.1371/journal.pone.0281801.t002

In the fourth section, the respondents were asked whether they perceived the theory-only training provided by dental school to be sufficient and if experiential learning from clinical practice was necessary to prepare them for the management of medically compromised patients. The theory-training that the respondents received included four hours of lectures and tutorials for managing acute medical emergencies and medically compromised patients. This didactic content was supplemented with content which covered oral medicine and internal medicine knowledge. The learning objectives for these two topics are listed in Table 3.

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Table 3. Learning objectives by topics in the course.

https://doi.org/10.1371/journal.pone.0281801.t003

Results

Section 2: Confidence of the respondents

In contrast to both the JDO and SDO, the UG were less confident in the management of dental patients with stable medical conditions (Confidence scores of 15.76, 21.02 and 22.12, respectively), or in the management of unexpected acute medical emergency (Confidence scores of 12.27, 13.94. 15.00, respectively, Table 4). The mean score was determined by dividing the total score by six. Based on this, the mean score across the six domains would be 2.62, 3.50, 3.69, respectively. The average total score for the self-rated confidence in the management of acute medical emergencies in a dental setting for the UG, JDO, and SDO were 12.27, 13.94 and 15.00, respectively (mean of 2.05, 2.33, 2.50, respectively, across the six domains).

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Table 4. Self-rated perceived confidence and MCQ score.

https://doi.org/10.1371/journal.pone.0281801.t004

Statistical analysis indicated that the UG had statistically significant lower confidence in the management of medically compromised patients (t-tests, UG vs JDO: p<0.00001, UG vs SDO: p<0.00001) and lower confidence in the management of an acute medical emergency in a dental setting (t-tests, UG vs JDO: p = 0.005, UG vs SDO: p = 0.0001)

When JDO and SDO were compared, no statistical differences were observed between their confidence and competence in the acute management of medical emergencies in a dental setting (t-tests, p = 0.51 and p = 0.10, respectively). However, the SDO were more confident in the management of medically compromised patients (t-test, p = 0.02).

Section 4: Perception of training

More than half of the respondents (61.7%) reported that a theory-only training provided by the dental school did not adequately prepare them for the management of medically compromised patients. These sentiments were shared across all three groups (Chi-square test, p<0.025). A statistically significant greater proportion of SDO (80.6%) felt that their dental officer postings prepared them to manage these patients compared to JDO (54.2%) (Chi-square, p<0.0001). Respondents who felt that their dental officer posting adequately prepared them to manage medical compromised patients had greater confidence in managing these patients and acute management of medical emergencies in dental setting. They also scored better for the MCQs (t-tests, p = 0.009, p<0.00001, p<0.002, respectively). The responses were summarised and can be found in Table 5.

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Table 5. Perspective on dental school and post-graduation workplaces.

https://doi.org/10.1371/journal.pone.0281801.t005

Discussion

This study aimed to determine whether experiential learning is an important component of preparing dentists to manage medically compromised patients and acute medical emergencies in a dental setting. The results of this study suggested that theoretical training must be supplemented by experiential learning.

In general, the graduated dentists (JDO and SDO) were found to have greater confidence and competence when compared to the UG. With respect to the teaching of medically complex patients and medical emergencies, all three groups would have undergone similar theoretical training during dental school as there were no changes to the curriculum during their education period. The differences were that the JDO and SDO had an additional 1–2 and 3–4 years of clinical practice upon graduation, respectively. During this time period, both the JDO and SDO were more frequently exposed to medically compromised patients as compared to that of UG. This allowed the JDO and SDO to apply the theoretical knowledge into an “actual” clinical setting [1]. With each patient, the graduate can also reflect upon the experience, contextualize theoretical knowledge into the actual clinical scenarios and further improve their clinical practice [27, 28]. In a study by Watters et al, students were surveyed before and after a clinical rotation in the management of medically complex patients. The authors reported statistically significant increase in the comfort and interest in management of these patients after the clinical rotation. This highlights the importance of supplementing clinical training to theory lessons [29].

The results from the study also suggested that SDO were more confident than the JDO in the management of medically complex patients. This is not only attributed to the difference in the years of clinical practice but also, the type of patients seen in their practices and the access to consultation with various on-site or in-house dental specialists. Among the dental officers, 17.7% and 84.9% of the JDO and SDO, respectively, had experience working in a specialist outpatient clinic (SOC) or a multi-specialist service (MSS) (Table 1). The SOC and MSS are typically hospital-based practices or national centers which receive a greater clinical caseload and complexity of medically compromised patients. This is concurred by a significant amount of SDOs reporting that their dental officer postings have prepared them for the management of medically complex patients.

In contrast, there were no differences between the JDO and SDO in their confidence in the management of acute medical emergencies. This was despite the differences in experience as mentioned previously. This may be attributed to a generally low incidence of acute medical emergencies in a dental setting and thus less familiarity towards the necessary management. This is consistent with many prior studies examining the confidence of dental students or new graduates in the management of acute medical emergencies [15, 30–32]. For instance, Atherton et al reported that 97% of the dental staff from an UK hospital expressed the need for further training in the management of acute medical emergencies in a dental setting and this may be due to the low incidence of most acute medical emergencies at 1.8 events per years [22].

About 62% of the respondents agreed that theoretical training alone was not adequate preparation for the management of medically compromised patients and acute medical emergencies. This concern is not unique to our respondents [6, 15, 16, 21–23, 33, 34]. With limited time in the dental curriculum, some schools may prefer to focus more on other aspects of dentistry and place less emphasis on this module. However, the results of this study have already elicited the implications of forgoing clinical training in the management of these patients. Furthermore, with an increased burden of diseases that come from non-communicable, or chronic disease such as cardiovascular disorders and stroke, dental professionals can anticipate a greater proportion of medically compromised patients in their practice [13]. In addition, the public expects dentists to understand their medical conditions and handle acute medical emergencies in the dental setting [35]. Thus, it is imperative that a dental professional has sufficient knowledge to manage these patients and be adequately prepared to handle medical emergencies.

Most of the respondents of this study are currently working in the public service. Dental graduates are bonded to the public service for 4–5 years following the completion of a subsidized dental school education in Singapore. To our best knowledge, this scenario is unique to Singapore. In most nations, there is no mandatory public service of such extended duration for dental graduates. Other exceptions include a short 1-year internship at public dental services for fresh graduates in China, Japan, Belgium, Croatia and Slovenia [5–7, 36–38]. Thus, most dentists around the world have the liberty to enter private practice immediately after graduation, or at least much earlier in their career compared to Singapore-trained dentists. During the 4-year bond, Singapore dental graduates work under the supervision of senior colleagues who provide guidance and are available for case consultations. This serves as an opportunity for experiential learning in the management of medically compromised patients. Nonetheless, the presence of this extended bond and “training” should not discourage educators from improving the undergraduate education.

This study is not without limitations. Firstly, the ideal sample size for the UG group should be 84. However, we have failed to recruit sufficient dental students in the UG group. Although the number of respondents still made up more than 80% of the expected population, the results related to the UG group should still be interpreted with caution. Secondly, the male to female respondent ratio was not equal. The female gender made up 60% of the respondents. Although it was more likely for females to participate in an online survey, the skew in gender ratio reflects the actual gender ratio in the dental school in Singapore [39]. In the recent years, there are generally more female than male students. Thirdly, this is a cross-sectional study that reflected on the ability of students and graduates at a time point. The confidence and competence of the students and graduates may change over time. Lastly, the competence of the respondents was based solely on their MCQ score. While MCQs can assess their ability to apply their knowledge, it may not always translate to their actual performance in a clinical setting [25, 26].

Despite the limitations, the unique mandatory bond period of Singapore dental graduates allowed for cohorts of students to be compared, before and after clinical experiences in managing medically complex patients or acute medical emergencies. All 3 groups had similar theoretical training and thus the UG group served as a good control for the study. Most importantly, the findings of this study serve as a reminder for dental educators and administrators to assess on the adequacy of training of dental students in this aspect. With only theoretical education and no experiential training, young dental graduates may feel inadequate and unconfident to see medically compromised patients in their practice [14, 15, 40]. This can result in a barrier to oral healthcare for these patients [32, 41]. Therefore, there is a need to relook at the importance of dedicated clinical training, or specialist consultation clinics for the undergraduates to improve their exposure in this aspect [42]. This perspective is also shared by the United States Commission on Dental Accreditation [43].

Conclusion

Experiential learning from “real-life” clinical experiences is an essential component in developing graduates’ confidence and competence in the management of medically compromised patients and acute medical emergencies. Most of the respondents indicated that a theory-only education provided by their dental school was insufficient in preparing them for the management of these patients. Instead, clinical exposure via actual work experience may have played a greater role in developing their confidence and competence in this aspect. Therefore, the authors recommend incorporating specialized clinical sessions in which dental students are allowed to treat and manage medically compromised patients. Future studies may develop these dental undergraduate modules and determine the effectiveness of experiential learning in increasing the confidence and competency of dentists.

Supporting information