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Application of Basic Science to Clinical Problems: Traditional vs. Hybrid

Problem-Based Learning

Article  in  Journal of Dental Education · October 2010

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Educational Methodologies

Application of Basic Science to Clinical

Problems: Traditional vs. Hybrid Problem-
Based Learning
Amber N. Callis, D.D.S., M.S.; Ann L. McCann, R.D.H., Ph.D.;
Emet D. Schneiderman, Ph.D.; William J. Babler, Ph.D.; Ernestine S. Lacy, D.D.S.;
David Sidney Hale, D.D.S., M.S.D.
Abstract: It is widely acknowledged that clinical problem-solving is a key skill for dental practitioners. The aim of this study was
to determine if students in a hybrid problem-based learning curriculum (h-PBL) were better at integrating basic science knowl-
edge with clinical cases than students in a traditional, lecture-based curriculum (TC). The performance of TC students (n=40) was
compared to that of h-PBL students (n=31). Participants read two clinical scenarios and answered a series of questions regarding
each. To control for differences in ability, Dental Admission Test (DAT) Academic Average scores and predental grade point aver-
ages (GPAs) were compared, and an ANCOVA was used to adjust for the significant differences in DAT (t-test, p=0.002). Results
showed that h-PBL students were better at applying basic science knowledge to a clinical case (ANCOVA, p=0.022) based on
overall scores on one case. TC students’ overall scores were better than h-PBL students on a separate case; however, it was not
statistically significant (p=0.107). The h-PBL students also demonstrated greater skills in the areas of hypothesis generation
(Mann-Whitney U, p=0.016) and communication (p=0.006). Basic science comprehension (p=0.01) and neurology (p<0.001)
were two areas in which the TC students did score significantly higher than h-PBL students.
Dr. Callis is Clinical Assistant Professor of Pediatric Dentistry, University of Texas Health Science Center at Houston Dental
Branch; Dr. McCann is Associate Professor and Director of Planning and Assessment, Baylor College of Dentistry; Dr.
Schneiderman is Associate Professor of Biomedical Sciences, Baylor College of Dentistry; Dr. Babler is Associate Professor
and Acting Chairman, Department of Oral Biology, Indiana University; Dr. Lacy is Associate Professor and Director, Office
of Student Development, Baylor College of Dentistry; and Dr. Hale is Assistant Professor of Pediatric Dentistry, Baylor College
of Dentistry. Direct correspondence and requests for reprints to Dr. Amber N. Callis, University of Texas Health Science Center
at Houston Dental Branch, 6516 M.D. Anderson Blvd., Houston, TX 77030; 832-594-3572 phone; 713-272-7616 fax;
ambercallis@sbcglobal.net.
Keywords: problem-based learning, dental curriculum, basic science, assessment
Submitted for publication 12/8/09; accepted 4/6/10

P
roblem-based learning (PBL) in health care
education originated in the 1970s at McMaster
University School of Medicine in Canada.1
It has since been incorporated into many medical
school curricula and that of a few dental schools.
The typical format of a PBL curriculum involves a
group of usually six to eight students with a trained
faculty mentor or tutor. The students are given a
clinical case with various issues that will need to
be addressed in order to arrive at a solution to the
problem. Students work collaboratively to develop
a problem list and hypotheses for the case, and are
subsequently responsible for independently gather-
ing relevant information to share with the group. The
faculty mentor has the responsibility of guiding the
group throughout the case, not to serve as a source
of information. Usually, a single solution does not
exist for the cases, but the process allows students to
reason and sort through various options and discuss
them with others in the small group.1
PBL allows basic science knowledge to be
made applicable to students’ learning needs by relat-
ing it to a clinical problem. It allows students to be
self-directed in their learning, and the motivation is
no longer placed on memorizing facts for a multiple-
choice exam. Instead, knowledge must be gained and
understood in order to apply it to the clinical scenario
and ultimately better serve the future patient.2
The past decade and a half have seen much
debate on the direction of dental education and the
practice of dentistry. In the Institute of Medicine’s
1995 report on the state of dental education, the need
for change in dental education was clearly outlined.3
Three of the five major themes identified in that re-

October 2010  ■  Journal of Dental Education 1113

 port highlighted the importance of better preparing
students to apply basic science to clinical problems.
Those themes were as follows: 1) dental profession-
als need more comprehensive medical knowledge; 2)
dental educators need to teach and display desirable
models of clinical practice; and 3) dental schools
need to experiment with different models of educa-
tion, practice, and performance assessment.
The practice of evidence-based dentistry (EBD)
has been one of the leading trends in dentistry and
dental education. Evidence-based dentistry is the
application of results from relevant clinical studies
combined with the clinician’s expertise and patient
values.4 If dentistry does not embrace evidence-based
practice as a profession, it risks stagnation. While
dental research has remained on the cutting edge,
EBD serves as an arena in which technical scientific
research is made clinically applicable to practitioners.
When practitioners are not familiar and comfortable
with the practice of EBD, then the potential for stag-
nation in the practicing world of dentistry arises. PBL
often provides a mechanism for students to attain
basic skills in the practice of EBD because students
must critically review research to create hypotheses
and develop solutions to clinical problems. Establish-
ing this habit during dental school might better equip
students to continue this trend after graduation.
The American Dental Education Association’s
Commission on Change and Innovation in Dental
Education (ADEA CCI) has addressed various issues
facing the future of dental education.5-7 Members of
the ADEA CCI have recommended a dental curricu-
lum that promotes lifelong and self-directed learning,
scientific discovery and the integration of knowledge,
and evidence-based oral health care.7 This call for
action also emphasized the need to integrate basic
science with clinical science when considering cur-
riculum decompression and noted that if students are
to practice EBD, it is pivotal that they understand
research, are able to analyze and solve oral health
problems, and can apply basic science principles to
day-to-day clinical scenarios. Another ADEA CCI
article recommended that the new dental curricu-
lum should “enhance the level of inquiry, research
experience, and the applications of relevant science
to clinical problems.”5
While many studies have attempted to inves-
tigate the effects of a problem-based curriculum in
medical and dental education, the focus has usually
been on performance on national board exams. Ver-
non and Blake8 reported that medical students in a
1114
PBL curriculum performed significantly worse than
their traditionally educated counterparts on Part I of
the United States Medical Licensing Examination
(USMLE). This result was based on a meta-analysis
of thirty-five research studies over a twenty-two-year
period. Another study conducted by Blake et al.9
found that medical students in a PBL curriculum per-
formed significantly better on USMLE Step 1. This
study compared the performance of students enrolled
at the University of Missouri–Columbia School of
Medicine over a six-year period, during which the
school transitioned to a PBL format. Statistically
significant scores improved from an average of 199
to an average score of 221.
A retrospective study10 conducted at Harvard
School of Dental Medicine found that students in a
PBL curriculum received superior National Board
Dental Examination (NBDE) Part I scores com-
pared to students in the traditional curriculum. The
NBDE Part I average ranged from 91.3 to 94.6 over
the twenty-year period in which the change to PBL
was implemented. After the University of Southern
California School of Dentistry converted to a PBL
curriculum, its students’ NBDE Part I scores were
also found to have improved.1,11
The performance of students in a PBL curricu-
lum on multiple-choice exams is often questioned by
academicians. A recently published study12 by von
Bergmann et al. found that there was a significant
positive correlation between student performance
on multiple-choice content exams and process skills
examinations such as the triple jump. In this retro-
spective study, data were collected for students at the
University of Southern California Herman Ostrow
School of Dentistry after its complete transition
to a PBL curriculum. The scores for students dur-
ing their first and second years were analyzed and
compared. While the two exams measured different
types of understanding, they showed that students
who genuinely understood the subject matter could be
successful with both types of assessment. The authors
were successful in supporting Butler et al.’s claim that
“true PBL is not skill-oriented—it is understanding-
oriented.”13 This type of research in dental education
is limited, however. Additionally, there were not any
studies available that assessed hybrid problem-based
learning. This further emphasizes the need for ad-
ditional study.
Our study assessed the ability of students to
apply the basic science knowledge acquired during
the first two years of dental school to clinical sce-
Journal of Dental Education ■ Volume 74, Number 10
narios. The performance of students in a traditional
lecture-based curriculum was compared to that of
students in a hybrid PBL curriculum. The aim of the
study was to determine if students in the hybrid PBL
curriculum were better at integrating basic science
knowledge with clinical cases than the students in a
traditional curriculum.
Materials and Methods
Indiana University School of Dentistry
(IUSD) utilizes a hybrid PBL curriculum. A “true”
PBL curriculum would be formatted such that all
learning needs are met with clinical problems in
the small-group scenario. In a hybrid PBL format,
conventional teaching modalities are combined with
PBL settings. At IUSD specifically, some of the basic
science content is introduced to students in lecture
and reinforced with the PBL component, while other
topics are taught solely in the lecture setting or solely
within the clinical problem. Thus, the combination
of traditional and PBL methods makes it a hybrid of
the two. The PBL portion of the curriculum extends
throughout all four years of dental school.
Baylor College of Dentistry (BCD) uses a tra-
ditional curriculum. Courses are divided by subject
matter and taught separately from one another. The
lecture format is the predominant mode of informa-
tion transmission, and there is little student interac-
tion. This type of curriculum is teacher-centered, in
contrast to student-centered PBL. In general, the
basic sciences are introduced and studied during the
first two years, with the focus shifting to the clinical
sciences in the last years of training. The clinical
component of the curriculum is not combined with
the core sciences curriculum. This type of curriculum
is what most students have encountered throughout
their academic lives.
Instrument Design and Sampling
Because essay exams may be the most appropri-
ate assessment tool for PBL,14 an essay examination
format was chosen as the assessment tool for this
investigation. To reduce the effects of known limita-
tions (content specificity and inability to generalize),
several short-answer essays were included, as well as
more than one clinical scenario. Each case booklet
contained two clinical cases followed by a series of
open-ended questions relating to the case. The prin-
cipal investigator developed the clinical scenarios
October 2010  ■  Journal of Dental Education
based on sample scenarios used by other medical
and dental institutions. Biomedical science faculty
at both institutions also aided in the creation of the
scenarios and development of acceptable and ap-
propriate responses. A scoring rubric was developed
to measure student performance. Several established
rubrics were consulted for the creation of the scoring
rubric for this study.15,16 (See Figures 1 and 2 for Case
I and its scoring rubric and Figures 3 and 4 for Case
II and its scoring rubric.)
The instrument was pilot-tested with nineteen
graduate students at BCD before being used in the
study, and the wording of some questions was modi-
fied based on the results. There were no changes to
the scoring rubric.
Third-year dental students at BCD and IUSD
were the population for this study. The BCD students
represented the traditional curriculum group (TC),
and the IUSD students represented the hybrid PBL
group (h-PBL). A power analysis determined that
forty participants in each group would be needed
to detect a 10 percent difference in performance, if
present (where α=.05, β=.20). In an effort to ensure
that each group had forty participants, more students
were invited to participate than necessary.
All ninety-two students in the BCD 2007–08
third-year class were invited to participate in the
study. Students received a letter from the principal
researcher (AC) inviting them to participate, and a
total of forty BCD students participated. Students
in the IUSD 2007–08 third-year class and 2008–09
third-year class were also invited to participate
using the same procedure. Ultimately, thirty-one
IUSD students enrolled in the study: fifteen from
the 2007–08 third-year class and sixteen from the
2008–09 third-year class.
Testing, Scoring, and Analysis
In this type of investigation, there is the risk
that the two groups might have varying academic
abilities that would affect the outcome of the study. To
control for ability, Dental Admission Test Academic
Average (DAT AA) scores and predental grade point
averages (GPAs) were collected to determine if there
were any statistical differences in ability between
the two groups. Students participating in the study
released their DAT AA scores and predental GPAs
to the principal researcher.
All participants were randomly assigned a
number between 1 and 80, and each was instructed
to complete a case booklet with that designated
1115
 John is a 52-year-old African American male who presents to your dental office for a scaling and root planing appointment.

Medical History Medications Allergies

Type 2 Diabetes Insulin lispro No known drug allergies
Metformin (biguanide)
High Cholesterol Lipitor (statin)
High Blood Pressure Atenolol (beta blocker)

John stated at his initial appointment that his blood glucose values are usually 190-300 mg/dL (normal value <180 mg/dL).
His hemoglobin A1C was 10.5 the last time he visited his physician, which he states was an improvement from 3 months before.
John has severe periodontal disease due to prolonged neglect of his oral health. Thirty minutes into the appointment, John
becomes pale, agitated, and confused and begins sweating. John then tells you that he took his medicine as usual this
morning, but did not have time to eat breakfast. He did not want to be late to his cleaning appointment.

Reference Information
Hemoglobin A1C Value
4–8 Normal adult
<7.5 Good control for diabetes
7.6–8.9 Fair control for diabetes
9–20 Poor control for diabetes

What is currently happening to John? DIAGNOSIS

• Hypoglycemic attack or insulin shock
Why has his behavior changed suddenly? PHYSIOLOGY
• John took his insulin this morning without eating.
• His insulin has taken effect, and he does not have an excess of glucose in his blood. With the insulin working, he is
subsequently hypoglycemic due to its effects (uptake of glucose from the blood).
How would you manage John’s current issue? TREATMENT
• Give sugar: juice, frosting, IV dextrose
Compare and contrast Type 1 and Type 2 diabetes. Explain what you know about diabetes on a systems level. Be as
detailed as possible. PHYSIOLOGY
• Type 1: autoimmune disorder, insulin-dependent diabetes mellitus
• Body destroys its own pancreatic beta cells
• Pancreatic beta cells responsible for the production of insulin
• Type 2: non-insulin-dependent diabetes mellitus
• Pancreatic beta cells produce less insulin, or body is resistant to effects of insulin
• Insulin responsible for uptake of glucose from bloodstream; if ineffective, excess amounts are present in blood and urine
• Circulatory effects include atherosclerosis and high blood pressure
• Also affects nerves, retina, and renal glomerulus
John has complained of a burning tongue and tingling sensations. What has led to this symptom? NEUROLOGY
• Diabetic neuropathy
• High blood glucose levels for extended periods of time leading to a chemical change in nerves and impairment of ability
to transmit signals
• Increased uptake of glucose by Schwann cells causing increased water uptake and cellular injury
• Damage to blood vessels carrying oxygen and nutrients to nerves
• Xerostomia
How do John’s medications work? PHARMACOLOGY
• Insulin lispro: causes body to uptake glucose from the bloodstream to be stored
• Metformin: exact mechanism of action unknown
• Associated with decrease in hepatic gluconeogenesis
• Associated with decrease in intestinal glucose absorption
• Improves insulin sensitivity
• Lipitor: inhibits HMG-CoA reductase enzyme leading to reduced cholesterol synthesis
• Atenolol: selective beta one adrenergic antagonist
• Beta one cells play a role in cardiac output and rennin release from juxtaglomerular cells

What does Hemoglobin A1C measure, and why is it an indicator of how well an individual’s diabetes is controlled?
BIOCHEMISTRY
• Glycosylation of hemoglobin A forms Hb A1C in red blood cells
• Hb A1C is present in all individuals and in increased levels of diabetics
• Reflects glucose levels in blood over the 6-12 weeks before the test, therefore good indicator of control
• Not affected by fluctuating levels of blood glucose

Figure 1. Case I in the study with subject area and acceptable answers

1116 Journal of Dental Education ■ Volume 74, Number 10

 0 1 2 3

Basic Science
Component

Basic science Integrates none of the Integrates 1 of the Integrates 2–3 of the Integrates 4 or more
comprehension sciences sciences sciences sciences

Physiology Identifies 0 key points Identifies 1–3 key Identifies 4 –7 key Identifies 8 or more key
points points points

Neurology Identifies 0 key points Identifies 1 key point Identifies 2–4 key Identifies 5 or more key
points points

Pharmacology Identifies 0 key points Identifies 1–2 key Identifies 3–6 key Identifies 7 or more
points points key points

Biochemistry Identifies 0 key points Identifies 1 or fewer Identifies 2–3 key Identifies 4 or more key
key points points points

Clinical
Component

Accuracy of Identifies the Identifies the correct

diagnosis incorrect answer answer

Accuracy of Identifies the Identifies the correct

treatment incorrect answer answer

Thinking

Communication Work is unfocused Organization apparent Organization is clear;

and poorly organized; but inconsistent; some transitions between
lack s logical transitions ideas enhance
connection of ideas presentation

Hypothesis Hypothesis is unclear, Hypothesis is Hypothesis

generation (why is too simplistic, or generally clear, demonstrates
this happening) incomplete although gaps exist integrative thought and
is developed clearly
throughout

Total Points:

Figure 2. Scoring rubric for Case I

number. Study participants were given one hour to
complete the booklet. Participants were asked to
answer each question as thoroughly as possible and
were not allowed to ask any questions of the proctor.
Most students participated during their lunch hour or
after school. A smaller group of students participated
during clinic sessions if they did not have a scheduled
patient. All of the students participated over a five-
month period. Because the participating students did
not complete the case booklet at the same time, they
were asked not to share any information regarding
the cases or the investigation with other students.
The following subject areas were analyzed
with Case I: physiology, neurology, pharmacology,

October 2010  ■  Journal of Dental Education 1117

 Angela is a 21-year-old Caucasian female. She presented to your dental office yesterday for an emergency
appointment. Angela is complaining of pain on the lower right side of her jaw and has minor intraoral swelling.

Medical History Medications Allergies

Healthy Birth control pills No known drug allergies
Advil as needed for pain

The emergency exam yesterday revealed a severely decayed and infected #32 that needs to be extracted.
Radiographically, a large radiolucency was present at the apex of #32. You also noticed that the gingiva around #17
is erythematous. Angela says that it is not bothering her, however. You are concerned that you will be unable to
obtain profound anesthesia, so you prescribe a 7-day course of amoxicillin and tell Angela to return in one week to
have tooth #32 extracted.

Today, Angela has returned with a large facial swelling on the right side. The swelling is fluctuant and extends below
the border of the mandible.

What potential medical emergency concerns you the most about this scenario? How would you manage it?
DIAGNOSIS, TREATMENT
• Ludwig’s angina
• IV antibiotics, maintain airway, remove source of infection, incise and drain, refer to oral surgeon

Describe three of the anatomical spaces potentially involved with this case. ANATOMY
• Submandibular
• Sublingual
• Buccal
• Infratemporal
• Parapharyngeal
• Retropharyngeal

In general terms, describe the process of inflammation. IMMUNOLOGY

• Cardinal signs: redness, swelling, pain, fever, loss of function
• Infiltration of plasma and leukocytes into tissue
• Increase in blood flow to infected or injured area
• Histamine release: arteriole dilation and increased venous permeability
• Pus formation; increase in PMN numbers and C-reactive protein
• Cytokine release
• Pain receptors activated
• Resolution of inflammatory process by tissue growth factor and inhibition of pro-inflammatory molecules

What other structures may be affected by the inflammation, and what are the consequences of that? ANATOMY,
PHYSIOLOGY
• Lingual nerve: paresthesia potentially
• Lymph nodes: lymphadenopathy
• Surrounding bone: destruction due to infectious process

Why did the amoxicillin not work? What makes clindamycin the antibiotic of choice in this scenario?
PHARMACOLOGY, MICROBIOLOGY
• Amoxicillin is a broad spectrum antibiotic, which does not significantly target anaerobic bacteria.
• Clindamycin is very effective against anaerobic bacteria.
• This infection involves more anaerobic bacteria as the infection has spread into deeper tissues.

You did not want to extract the tooth yesterday because you thought you would not achieve profound anesthesia. In
general terms, which pain receptors are involved and what is the purpose of each? NEUROANATOMY
• A delta fibers: fast pain
• Respond to mechanical and thermal stimulation
• C fibers: slow pain
• Respond to chemical stimulation

Figure 3. Case II in the study with subject area and acceptable answers

1118 Journal of Dental Education ■ Volume 74, Number 10

 0 1 2 3

Basic Science
Component

Basic science Integrates none of the Integrates 1 of the Integrates 2–3 of the Integrates 4 or more
comprehension sciences sciences sciences sciences

Anatomy Identifies 0 key Identifies 1–2 key Identifies 3–5 key Identifies 6 or more key
points points points points

Immunology Identifies 0 key Identifies 1–2 key Identifies 3–5 key Identifies 6–8 key
points points points points

Physiology Identifies 0 key Identifies 1 key point Identifies 2 key points Identifies 3 or more key
points points

Pharmacology/ Identifies 0 key Identifies 1 key point Identifies 2 key points Identifies 3 or more key
Microbiology points points

Neuroanatomy Identifies 0 key Identifies 1 key point Identifies 2–3 key Identifies 4 or more key
points points points

Clinical
Component

Accuracy of Identifies the Identifies the correct

diagnosis incorrect answer answer

Accuracy of Identifies the Identifies a partially Identifies the correct

treatment incorrect answer correct answer answer

Thinking

Communication Work is unfocused Organization apparent Organization is clear;

and poorly organized; but inconsistent; some transitions between
lacks logical transitions ideas enhance
connection of ideas presentation

Hypothesis Hypothesis is unclear, Hypothesis is Hypothesis

generation (why is too simplistic, or generally clear, demonstrates
this happening) incomplete although gaps exist integrative thought and
is developed clearly
throughout

Total Points:

Figure 4. Scoring rubric for Case II

and biochemistry. For Case II, the following areas
were addressed: anatomy, immunology, physiology,
microbiology, and neuroanatomy. Overall science
comprehension was evaluated with both cases along
with diagnosis, treatment, communication, and hy-
pothesis generation. Total points were summed for
each individual case. Except for total points, all other
scores were based on a scale of 0 to 3 points.
Data were analyzed with parametric and non-
parametric tests when appropriate using SPSS v.

October 2010  ■  Journal of Dental Education 1119

 15.0 statistical software. Statistical significance was
defined as a p value <0.05. A student’s t-test was used
to determine if the TC and h-PBL groups differed
regarding DAT AA and GPA scores. To control for
differences in ability between the two groups, an anal-
ysis of covariance (ANCOVA) test was performed
using DAT AA values as the covariate, and total
scores for each case were the dependent variables.
The ANCOVA was also used to detect differences in
overall score between the h-PBL D3 and D4 groups.
The paired t-test was used to test for differences in
student performance on each case within each of the
curricular groups. Because the individual subject
data were ordinal, the Mann-Whitney test was used
to assess curricular differences in performance on
individual subject areas within each case. The Mann-
Whitney test was also used in order to determine if
the h-PBL D3 and D4 students performed differently
on individual subjects.
The Institutional Review Boards of Baylor
College of Dentistry and Indiana University-Purdue
University Indianapolis approved the study, and
written informed consent was obtained. Participants
also consented to the release of their DAT AA scores
and predental GPAs from the registrar’s office to the
principal researcher.
Results
Using anticipated values, a power analysis
revealed that 80 percent power would be maintained
with a sample size of forty students per group. The
actual power for Case I was 80.2 percent with Ns of
40 and 31 for the TC and h-PBL groups respectively.
If forty students would have participated in both
groups, the power would have been 83.4 percent.
Thus, there was only a slight diminution in power
based on the smaller sample size.
Table 1 displays mean DAT AA scores and
GPAs and their standard deviations (SD) for both
groups. The t-test showed a significant difference
in DAT AA between TC and h-PBL participants
(p=0.002). There was no difference between the h-
PBL D4 and D3 groups, nor was there a difference
when comparing GPA for all groups. The D3 and D4
class results were therefore combined in subsequent
analyses. Based on the finding of a difference be-
tween the TC and h-PBL groups with regard to DAT,
the total scores for the two cases were adjusted for
DAT using ANCOVA. The lack of significant differ-
ences observed for GPA or between the D3 and D4
classes required no adjustments.
Overall Scores
Participants’ total scores were analyzed using
descriptive statistics. There were 27 total points
available for Case I and 30 points total for Case II.
The means were adjusted for differences in DAT AA
scores using ANCOVA (Table 2). The ANCOVA dem-
onstrated that the h-PBL group performed signifi-
cantly better on Case I than the TC group (p<0.05);
the adjusted scored differed by about 2.5 points. On

Table 1. Participating students’ DAT AA scores and GPAs (mean±SD)

Number of Participants Mean DAT AA Mean GPA

TC 40 19.20±1.224* 3.48±0.23
h-PBL 31 18.10±1.599* 3.47±0.28
D4 15 17.53±1.187 3.45±0.25
D3 16 18.63±1.784 3.49±0.30
*Significant differences between groups as detected with t-tests

Table 2. Mean, SD, and adjusted mean values for Cases I and II total scores
TC TC Adjusted h-PBL h-PBL Adjusted Sig.

Case I 16.53±3.146 16.35 18.71±4.018 18.84 p=0.022*

Case II 19.55±4.126 19.40 17.58±4.185 17.77 p=0.107
Note: ANCOVA used to adjust total scores for DAT AA scores and test for differences between curricula, where * signifies p<0.05.

1120 Journal of Dental Education ■ Volume 74, Number 10

Case II there was no statistically significant differ-
ence in performance of the h-PBL and TC groups
(p=0.107). There was also no statistically significant
difference in performance of the D3 and D4 h-PBL
groups (Case I: p=0.094 and Case II: p=0.138).
A paired t-test was conducted to determine if
there was any statistical difference between Case I
and Case II performance within each group (Table
3). The paired t-test revealed that the TC participants
did significantly better on Case II than on Case I
(p<0.001); the unadjusted difference was about 3
points. The slightly higher mean performance of 2
points by the h-PBL students on Case I versus Case
II did not attain statistical significance (p=0.164).
Subject Scores
Tables 4 and 5 outline mean rank values and
significance for each subject in Cases I and II accord-
ing to the Mann-Whitney analysis. For Case I, h-PBL
students scored significantly higher in the areas of
biochemistry, communication, and hypothesis gen-
eration. For Case II, TC students scored significantly
higher in the areas of science comprehension and
neurology.
The Mann-Whitney test also showed differ-
ences in performance of the h-PBL D3 and D4
groups in the areas of pharmacology (p=0.045) and
biochemistry (p=0.037) on Case I. In both instances,
the D4 group earned higher scores.
Instrument Reliability and Validity
Reliability within each case was analyzed with
Cronbach’s alpha. Case I demonstrated a Cronbach’s
alpha score of 0.754. Case II had a score of 0.716.
Both of these values indicate strong reliability and
indicated the questions were measuring the same
underlying concept. Pearson correlation revealed
a significant correlation (p=0.001) between Case I
total and Case II total scores (0.376). There was no
correlation, however, between case totals and DAT
AA scores or GPAs.

Table 3. Mean and SD values for Cases I and II total scores with paired t-test significance
Case I Case II Sig.

TC 16.53±3.146 19.55±4.126 p<0.001*

h-PBL 18.71±4.018 17.58±4.185 p=0.164
*Significant differences within the group based on paired t-tests

Table 4. Case I: Mann-Whitney mean ranks and significance values

Sci Comp Phys Neuro Pharm Biochem Diagnosis Treatment Comm Hypothesis

TC 33.19 33.31 32.56 33.69 27.98 37.00 37.00 31.41 31.34

h-PBL 39.63 39.47 40.44 38.98 46.35 34.71 34.71 41.92 42.02
Sig. 0.144 0.161 0.087 0.229 <0.001* 0.106 0.106 0.006* 0.016*
*Statistical significance at the p<0.05 level

Table 5. Case II: Mann-Whitney mean ranks and significance values

Sci Comp Anatomy Immun Phys Micro Neuro Diagnosis Treatment Comm Hypothesis

TC 40.95 34.58 35.34 35.78 34.17 47.39 37.49 36.95 36.70 35.53
h-PBL 29.61 37.84 36.85 36.29 38.35 21.31 34.08 34.77 35.10 36.61
Sig. 0.010* 0.450 0.722 0.910 0.370 <0.001* 0.253 0.615 0.656 0.772
*Statistical significance at the p<0.05 level

October 2010  ■  Journal of Dental Education 1121

 There were additional factors that could not
Discussion be controlled for in the design of this investigation.
Those factors include differences in course content at
This investigation found that in some instances
each school and lack of familiarity of the TC students
dental students participating in a hybrid problem-
with the format of the research instrument—the lat-
based learning curriculum were better able than
ter of which may have placed the TC students at a
students educated in a traditional curriculum to ap-
disadvantage. The use of dental students at different
ply the basic science knowledge obtained during the
stages of their dental education in the h-PBL group
first two years of dental school to a clinical scenario.
is a flaw of this investigation. The effects of this have
There was a statistically significant difference in
been addressed earlier in the discussion. Additionally,
overall performance on Case I between the TC and
because the cases were not completed simultane-
h-PBL groups.
ously by participating students, there is a chance
The h-PBL D4 and D3 groups also had dif-
that information regarding the cases was shared or
ferences in performance on Case I in the areas of
that additional learning occurred in the time between
biochemistry and pharmacology. In this case, the
testing. A comparison of scores between early par-
D4 students performed significantly better than the
ticipants and late participants could have added to the
D3 students. Because the D4 students participated in
statistical analysis and strength of this study.
the investigation near the end of their third year, they
Because there was no evidence of a correla-
may have acquired more knowledge in these areas
tion between students’ performance on the clinical
throughout the academic year. The D3 students par-
cases provided and their DAT AA scores and GPAs,
ticipated at the beginning of their third year and may
it can be assumed that the instrument used in this
not have had an opportunity to learn the information
study measures different skills from those measured
addressed in Case I in those subject areas. While this
by the DAT and traditional scoring with GPAs. Two
does not change the final conclusions of the study, an
important ideas came out of this: 1) traditional as-
even greater and more significant difference between
sessment methods may not measure a student’s ability
the h-PBL and TC groups may have appeared if all of
to integrate the biomedical and clinical sciences, and
the h-PBL participants had come from the originally
2) the assessment methods used in this investigation
sampled class (the D4 group).
may be a better way to assess the skills that educators
The results of this study also revealed that h-
value most. This finding has significant implications
PBL students performed significantly better in the
for dental education assessment. Academic dental
areas of hypothesis generation and communication.
institutions, whether employing a traditional cur-
This parallels the findings of Patel et al.17,18 Because
riculum or some form of PBL, need to utilize appro-
of the format used for PBL sessions, it is not surpris-
priate assessment tools. The instrument used in this
ing that the h-PBL students were better in those areas.
investigation may be a good example of a potential
PBL students are expected to develop hypotheses
assessment tool for dental education.
about the provided clinical cases and expound on
The question remains as to the validity and fea-
them to their group. This usually leads to a discussion
sibility of making objective comparisons between two
of which hypotheses are more probable than others
different educational modalities. With the increased
and supporting evidence. Participating in activities
effort required by dental institutions to implement
like these allows PBL students to cultivate both of
a PBL curriculum, a question commonly asked by
these skills.
academicians is whether it is any better than the con-
Theoretically, students who performed well
ventional style of dental education.19 While it may not
on Case I should have similar results with Case II,
be appropriate to directly compare the two curricula,
and the paired t-test would show this. TC students
it is surely acceptable to compare the ability of stu-
performed better on Case II than Case I, while the
dents participating in them. The h-PBL students were
opposite occurred for h-PBL students (although
not always better than the TC students in applying
statistical significance was not attained in the latter).
basic sciences to clinical cases in this study, but they
This may be a consequence of one group being more
were certainly not at a disadvantage either because
familiar with the tested subject matter than the other
the increased performance of TC students on Case
based on curricular differences.
II was not statistically significant. Therefore, dental

1122 Journal of Dental Education ■ Volume 74, Number 10

schools should consider the benefits of h-PBL type
curricula when looking at curricular reform.
The most commonly cited disadvantages of
a PBL curriculum are cost,19,20 case design,21 and
questionable effectiveness of the curriculum as a
whole. The potential need for additional faculty
members could lead to an increase in spending.
Some institutions may also need to address space
issues within their facility to accommodate the small-
group format—which could be costly as well. The
benefits of increased self-directed learning abilities,
increased retention and recall effects,22 and improved
performance on national board examinations1 also
make problem-based learning worth considering.
Ultimately, the benefits may outweigh the potential
obstacles and problems.
It is important to note that this study compared
students in a traditional curriculum and a hybrid PBL
curriculum, not a total PBL curriculum. However, a
hybrid PBL curriculum may prove to be the best of
both worlds. It incorporates all of the benefits of a
PBL format yet provides the structure that most PBL
students find lacking. Many students participating in
true PBL curricula have a desire for some traditional
lectures.23 A hybrid PBL format satisfies this desire.
Additional research in this field should be
conducted to determine the impact of problem-based
learning on the quality of dental education. The use
of the same or a similar instrument from this study
would also further validate this method for assessing
the application of basic science to clinical problems.
Conclusions
As dental educators search for ways to meet
the learning needs of dental students in the new
millennium, curricular innovations become increas-
ingly important. A hybrid problem-based learning
curriculum may provide the innovation needed to
address the Institute of Medicine’s recommendations,
including the need for dental schools to experiment
with different models of education, practice, and
performance assessment while maintaining the stabil-
ity and reliability of the traditional curriculum. The
following conclusions and recommendations can be
made based on this study:
• Students enrolled in a hybrid PBL curriculum dem-
onstrated a greater ability to apply basic science
principles to a clinical scenario when compared to
October 2010  ■  Journal of Dental Education
students in a traditional lecture-based curriculum
based on the attainment of statistically significant
overall scores on one of the two cases presented.
A statistically significant difference in scores was
not found for the second case.
• H-PBL students had increased skills in the areas of
communication and hypothesis generation—which
are necessary as dental professionals interact more
with other health professionals.
• Traditional assessment tools may not be most
appropriate for measuring the ability to integrate
basic science information to clinical cases. While
the instrument used in this study was developed
specifically for this investigation, it proved to be
effective, valid, and reliable. It could thus serve
as a good model for assessing students’ ability to
apply basic science to clinical scenarios.
• Additional research comparing traditional, prob-
lem-based learning, and hybrid problem-based
learning curricula could provide additional useful
data. Long-term studies would serve as a supple-
ment to this data.
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