This was a qualitative study based on phenomenology using FGDs to understand the phenomenon (challenges in learning preclinical prosthodontics).

Two FGDs were conducted with two different groups of students and one FGD was conducted with the faculty members of Department of Prosthodontics at their workplace between June 2015 to August, 2015. The study was approved by the Institutional Review Board of Bharati Vidyapeeth Institute, Sangli.

The moderator (KS) and the assistant moderator (BS) had Masters Degree in Prosthodontics while authors (J) and (UW) had Masters Degree in Public Health Dentistry. Author J received training in qualitative research methods, contributed towards development of FGD guide and identified key strategy to be adopted for conducting the discussion thus contributing towards strengthening of qualitative research methods.

The presence of four researchers in the present study, with varying teaching experience and type of expertise, helped in better understanding of the research related issues from varying perspectives, thus helping in increasing the validity of the study. Author KS conducted the FGDs. The study subjects knew the principal investigator. Informed consent was taken from the participants.

Theoretical framework: The investigators wanted to probe into the difficulties faced by the students and faculty in learning and teaching preclinical prosthodontics. On identifying the difficulties, suitable remedial measures could be recommended and if feasible tested.

Participant selection: The sample for the FGD was a purposive sample. Students who had completed preclinical prosthodontics examination were eligible to participate in the study. Both of the student FGDs comprised of 10 participants each (five interns, three final years and two third years). The faculty involved in preclinical teaching and the head of the department were requested to participate in the discussion. The faculty FGD had 11 participants. This was conducted in a different institute by the same moderator (KS). The moderator was from the Department of Prosthodontics and the assistant moderator was from the Department of Public Health Dentistry.

A FGD guide consisting of a series of six guiding questions with probes, each for the student and faculty FGD discussion was developed by the investigators to initiate and conduct the discussion [Table/Fig-1]. The guide was reviewed by the experts in the field. The first question in the FGD for students probed the opinion of the students regarding the subjects. The second and third question probed the difficulties faced in understanding the subjects and the rest of the questions pertained to the ways of overcoming these difficulties.

The first question in the FGD for faculty probed the difficulties faced by the faculty while teaching the students. The second and third question explored the faculty perception of difficulties faced by the students in understanding the subject. The remaining questions addressed ways of overcoming these difficulties. The FGDs explored the students’ and faculty perception on the topics which were difficult for the students to correlate theory with clinical aspects and their suggestions on ways to make topics easier for them [Table/Fig-2].

Student focus group discussion: The moderator adopted a neutral approach and stressed that there was no correct or wrong answers but only opinions and the purpose of the focus group was to understand students’ experiences and views. The participants were assured of anonymity that the information collected from them would not be used in anyway against them. An average time planned for the focus groups was 60-90 minutes, which would be modified if required. The first few minutes were spent to break the ice and build rapport, provide orientation to the subjects and to make them feel comfortable. The moderator motivated the participants to share their experiences and put across views freely and ensured the discussion was not dominated by any particular member. Respondent validation was done during the FGD wherein the information collected from the subject was summarized to the subject and checked for accuracy.

Faculty focus group discussion: Data saturation was discussed with the faculty members analysing the comments. The discussions were audio taped. The written and audio taped records were reviewed and transcribed in order to capture all the words and phrases.

The audio taped records were heard twice by the researchers to facilitate accurate interpretation of the recording and to ensure that minor details were not missed. Analyst triangulation was also done with three faculty members who analysed the comments of the FGD so that data could be interpreted in multiple aspects. Inductive content analysis of the data was done. Initially the data was coded; which included generating descriptive codes that summarized the quotes. The codes were then organized as code families. Later, the themes were derived from the code families. The themes and the comments were discussed by the three faculty members and 100% consensus was reached.

A total of 20 students (12 females and 8 males) and 11 staff members (two females and nine males) participated in the study. The mean age of the students was 22±1.37 years. The mean age of the staff members was 35.5±6.83 years. Among them, three staff members had a teaching experience of more than nine years, three staff members had a teaching experience exceeding four years and remaining five staff members had a teaching experience of up to four years.

The themes that emerged from the FGDs were:

The subthemes from which the themes emerged were: ‘teaching is more theoretical’, ‘lack of interest during classes’, ‘lack of exposure to actual clinical situation’, ‘demonstration of clinical procedures’, ‘early clinical exposure to preclinical students’ and ‘modification of syllabus’.

This theme highlights the need for vertical integration of preclinical subjects. The aim of imparting information to the student is for him/ her to understand the logic behind information being imparted and not just to pass tests. Vertical integration helps the student to understand the link between the theoretical aspects and how it has an impact on the management of real time patients. Teaming up the junior students with the senior students will assist in enhancing the learning experience.

Subtheme 1: Teaching is more theoretical: The respondents were asked how well they understood the topics which were taught to them during their second year of BDS course. The study subjects responded that they found it “difficult to grasp the clinical topics that were taught” to them. They were of the opinion that it was “not easy to understand by only listening to the lectures”. They were “not able to visualize all the things that were going on”. ‘Impression techniques, jaw relations, anatomical landmarks, dental ceramics, casting procedures, arrangement of teeth, components of removable and fixed partial denture emerged as challenging topics for the students.

Similarly, the faculty members also reported that it is “difficult to correlate with clinical aspects as they teach all ideal things and not what happens in real clinical settings”. They also expressed that “students are more confused”.

The faculty perceived jaw relation, facebow, occlusion, articulators, dental ceramics and casting defects to pose challenge to students.

Subtheme 2: Lack of interest during classes: Students reported that “the traditional method of chalk and talk lectures was not very interesting”. As half of the “lectures were scheduled during the afternoon sessions”, the students felt drowsy. At times “audibility of some teachers” was reported as a hindrance.

The faculty expressed that they were “giving half knowledge as students are not exposed to patients”.

Subtheme 3: Lack of Exposure to actual clinical situations: Students opined that as they were “not exposed to clinics” they found it “difficult to imagine” what was taught.

The faculty felt that “lack of clinical exposure” was a major impediment in training students. They reported that the students might find it “difficult to correlate as they cannot understand what actually happens”.

This section emphasized student and faculty opinion on the means to be employed to improve teaching and enhance learning. Traditional instruction methods should change with time and should be supplemented with recent technology.

Subtheme 1: Demonstration of procedures: Respondents felt that “demonstration of preclinical procedures” might help them in understanding the subject better. “Videos to supplement the traditional chalk-and-talk method” might be a critical component in understanding the subject better. “Video sharing and documenting” of interesting cases in the department. They also suggested that “Interactive session: student presentations and group discussions should be encouraged”.

The faculty also suggested the use of “video demonstrations” to augment the learning process. One of the respondents also suggested that “a dental chair be kept in the preclinical setting and the procedures can be demonstrated on patients, which was said to be similar to the practices followed by dental schools in the USA”.

Subtheme 2: Early Clinical Exposure (ECE) to preclinical students: Students expressed “some exposure to clinics at least in the second half of second year” might help them in correlating theory with clinical aspects very well.

Faculty felt that students require “clinical exposure at preclinical level”. They suggested that the “students should be exposed to clinic once in a week” to facilitate student learning. According to the faculty “the entire procedure for a complete denture should be shown to the students”.

Subtheme 3: Syllabus modification to include relevant topics: Students perceived prosthodontics to be a “vast subject with more of practical work”.

Staff members in the present study opined that the “syllabus is vast”, “reduce syllabus” to render the teaching process more effective. The respondents also suggested that the “syllabus for the second years might be restricted only to complete dentures”. Faculty members observed that the “second year syllabus was difficult to be complete” within the stipulated time as it was very vast. They also expressed that it was “difficult to accommodate revision class”.

They also observed that the “syllabus in preclinical training was vast” in comparison with the other departments.

This study reveals challenges faced by the faculty and the students in teaching and learning of preclinical prosthodontics and includes their recommendations for improvement. The students and faculty have expressed a “felt need” for ECE to enhance the learner’s understanding of the preclinical aspects of the subject. The results of our study are similar to those of Haralur SB and Al-Malki AE according to whom students are not trained to cope up with commonly found clinical variations [3]. Henzi D et al., and Manakil J and George R reported that there is a need for more patient interaction and community outreach opportunities to reinforce classroom learning [5,6]. It has also been reported that dental school graduates rank, ECE as an important factor which helps them in preparing for clinical practice [2].

It has been observed that when the students enter the clinical fields they are unable to recall important basic scientific concepts. Approaches have been introduced to find means of instruction to improve teaching and make it more practical [7]. Early exposure to clinical scenario may help to bridge the gap between preclinical and clinical setting and strengthen students’ learning.

It has been suggested that the earlier the contact with patients, the easier it is for the students to put in context the information acquired from basic sciences [8]. Early patient contact can be realized by observing and assisting in senior student clinics, participating in community clinics, or by actually performing simple non-invasive procedures, even in the first year of studies [8]. It has been reported that the opportunity to observe and assist senior students in the clinic was a valuable experience for the junior students that helped them to ease their transition from lab to clinic [9]. Gerzina TM et al., reported that students value seeing the “expert” completing the task that they would be expected to complete [10].

Some authors have proposed that providing students with denture patient contact during the first or second year could increase student interest and enthusiasm toward complete denture prosthodontics [11,12]. The College of Dentistry at the University of Illinois at Chicago has introduced an active learning environment for second-year students based on significant clinical exposure with patients [2]. Early clinical exposure has been tried and found better than traditional teaching for medical students [13] but we did not come across any Indian studies related to ECE in dental students. In our study, the recommendation for improving teaching learning of preclinical prosthodontics has been for early clinical exposure.

The results of our study are similar to those of Sukotjo C et al., and Aragon CE and Zibrowski EM where the majority of students felt that they did not gain enough from conventional didactic methods which tend to make skill acquisition difficult [14,15]. Elangovan S et al., suggested that engaging students in case discussions and seminars rather than lectures would aid in development of analytical skills [16]. Clinical seminars and active group discussions are generally preferred by students compared with traditional didactic lectures [9,17]. It is stated that most of the learning occurs outside the classroom, when information has been retrieved, revised, applied and mainly associated with other existing information or experiences [9].

Similar results were found to those of Rosenberg H et al., Lechner SK et al., and Fayaz A et al., where Computer-Aided Learning (CAL) was proven effective [18-20].

According to Goset J and Espinoza P, students considered educational videos (especially the demonstrative type) as a useful tool being complementary to the role of the teacher [21]. Nikzad S et al., Packer ME et al., and Kon H et al., concluded that students perceived clinical videos as not preferable to live demonstrations but they were good supplementary materials for self-study due to revision convenience and effectiveness for clinical session preparation [22-24]. A study by Bennadi D et al., assessed the learning preferences of dental students and concluded that most students prefer multimodal type of learning [25].

Parolia A et al., have found that their students preferred early morning classes, because students are able to concentrate better at this time of the day [26]. Clinical demonstration after theory class was preferred to enable the students to correlate the procedure to the lecture.

Dentistry has used various types of simulation in preclinical education for some time [27]. Suvinen TI et al., found positive student response to teaching and learning in the simulator over a three-year evaluation period and preferred it over traditional preclinical laboratory instruction [28].

The strength of the study exists in the conduction of a qualitative study using FGDs involving the important stakeholders like students and faculty. Unlike use of closed-ended questionnaires, this modality helps us obtain and explore rich data which can be analysed in depth.

The results of this study cannot be generalized. FGDs were conducted by the faculty members from the Department of Prosthodontics. There are chances of “acquiescence bias during the FGD. In order to overcome it, the students were put at ease, confidentiality was assured. They were told that there are no right or wrong answers to the queries being put across and each one can share their experience/opinion without fear. The group was reassured that contradictory opinions were welcome too.

Future Implications: The present study paves the way for further research on various issues related to training in preclinical prosthodontics of dental students. A yearly feedback of students and faculty of their perceptions of the curriculum is necessary to improve the system. The present study sheds light on the problems that students face during their undergraduate dental training. It brings to focus the need for changes in dental curriculum that might pave the way for enhanced learning experiences of undergraduate students. It also underscores the need for policy changes in dental education in developing nations like India.

The students and the faculty expressed felt need to supplement traditional teaching with early clinical exposure. Early clinical exposure might be a critical step in paving the way for enhanced learning among the undergraduate dental students. We recommend early clinical exposure and active teaching learning methods for teaching learning of preclinical prosthodontics.