An Integrated Curriculum: Evolution,

Evaluation, and Future Direction

Katherine M. Howard, Ph.D.; Tanis Stewart, Ph.D.; Wendy Woodall, D.D.S.;
Karl Kingsley, Ph.D.; Marcia Ditmyer, Ph.D.
Abstract: The topic of curriculum reform has received an enormous amount of attention in the field of dental education. While re-
cently established dental schools benefit from the evolution of curriculum change and innovation in constructing their new curri-
cula, these advantages can become lost if the curriculum is not assessed to ascertain the degree to which the curriculum accurate-
ly reflects the initial intended goals. The purpose of this educational research project was to evaluate a dental school curriculum
to determine the extent of vertical and horizontal integration originally intended. After a faculty retreat that presented a historical
perspective and prevalent concepts of the definitions of an integrated curriculum, a survey instrument was distributed to all course
directors asking them to assign each of their courses to one of ten established models of integration. Analysis of the survey results
allowed the mapping of each of the eighty-four courses to four themes of integration. Chi-square analysis demonstrated courses
were distributed in a classic bell-shaped curve along the integration continuum. Dental school year 4 courses mapped to the high-
est levels of integration, while no courses were assigned to the lowest level (fragment or silo model). All courses were found to
have at least some level of integration. More than half (n=43) were found to be both horizontally and vertically integrated.
Dr. Howard is Assistant Professor of Biomedical Sciences; Dr. Stewart is Director of Information Technology; Dr. Woodall is
Assistant Professor of Clinical Sciences; Dr. Kingsley is Assistant Professor of Biomedical Sciences; and Dr. Ditmyer is Assistant
Professor of Professional Studies—all at the University of Nevada, Las Vegas, School of Dental Medicine. Direct correspondence
and requests for reprints to Dr. Katherine M. Howard, School of Dental Medicine, University of Nevada, Las Vegas, 1001 Shadow
Lane, MS 7410, Las Vegas, NV 89106-4124; 702-774-2630 phone; 702-774-2721 fax; katherine.howard@unlv.edu.
Key words: integration, curriculum reform, dental education, curriculum evaluation
Submitted for publication 1/16/09; accepted 4/3/09

I
n 1995, the Institute of Medicine (IOM) docu-
mented numerous challenges to dental education,
citing curricula that are often fragmented, out-
dated, crowded with redundant material, and delivered
in “disciplinary silos.”1 In addition, most traditional
dental curricula were found to be bound to conven-
tional pedagogical methods. In response to this report,
various calls for curriculum and pedagogical change in
dental education have been made, with the momentum
for change accelerating over the past several years. The
theme of the 85th American Dental Education Associa-
tion (ADEA) Annual Session in 2008, for example,
was “Curricular Change: It’s Time,” which included
a focus on curriculum reform to meet the educational
needs of the new millennial learner.
Attention to curriculum reform has been
a cumulative result of a number of issues facing
dental education, and, in 2005, the ADEA Board of
Directors appointed an oversight committee—the
Commission on Change and Innovation in Dental
Education (ADEA CCI)—to foster discussion and
provide leadership for implementing changes in den-
tal education.2 The establishment of the commission
was intended to provide a means for collaboration
on innovative change in dental education so that
dentists entering the profession are competent to
meet the oral health needs of the public throughout
the twenty-first century.
Under the auspices of the ADEA CCI, the
former Competencies for the New Dentist were
updated, now under the name “Competencies for
the New General Dentist.”3 The new competencies,
in turn, are leading to the development of founda-
tion knowledge guidelines to be used, among other
things, to play a part in test construction of Part I of
the National Board Dental Examination (NBDE);
initiation by the Commission on Dental Accreditation
of its Standards for Predoctoral Dental Education;
and introduction of interdisciplinary questions into
Part II of the NBDE.
Curriculum reform includes, but is not limited
to, topics such as revising competencies, implement-
ing problem- or case-based learning, and exploring
alternative methods for delivering education mate-
rial across generations—from the Silent Generation
(born in 1922–41) to the baby boomers (1942–61) to
Generation X (1962–81) to the Millennials (1982 to
the present).2 As a component of curriculum reform,
curriculum integration enables learners to recognize
how diverse concepts and/or processes are inter-
related.4 This concept has received much attention
across the health sciences.5-9

962 Journal of Dental Education ■ Volume 73, Number 8

 Many researchers concur that curriculum
integration through use of problem- or case-based
approaches increases the quality of instruction, im-
proves cohesiveness in sequencing of four-year pro-
grams, enhances communication of faculty by work-
ing together on new curricula, and invigorates the
learning process by developing critical thinking skills
in students.8,10 This evidence has been one of the pri-
mary motivations for using technology in education
that supports and enhances learning by facilitating
integration within and across the disciplines. These
methods of integration provide new and improved
tools for students, which may promote critical think-
ing and foster a deeper understanding of the material.
One additional effect of these newer methods may be
their synergistic effects, allowing curricula to be more
easily adapted to changing technology and newer or
evolving methods of instruction.
The evidence base for integrated curricula first
appeared in small, progressive medical colleges,11,12
which helped to direct modernization and improve-
ment efforts towards more interdisciplinary and in-
tegrated courses that became widely adopted within
medical and health science centers.13-15 Integrated
curricula then began to appear in combination with
problem-based learning (PBL),16 and frameworks
for specific types of integration, such as vertical and
horizontal integration, evolved further.17,18 These
frameworks for vertical and horizontal integration
and integrated multi- and interdisciplinary teaching
have been further developed within the dental school
setting.5,9,19 Although standardization of these con-
cepts and frameworks has been called for,8 a working
definition has not yet been standardized.
Many proposed frameworks of integration
focus on creating general categories that include a
combination of approaches for connecting topics
or disciplines. For instance, Fogarty defined three
categories of courses: 1) courses that fall within a
single discipline, 2) courses that fall within mul-
tiple disciplines, and 3) courses in which the learner
is immersed in the learning.20-22 Courses within a
single discipline are, fundamentally, the more tra-
ditional method of individual class instruction, in
which there is little or no relationship with other
courses. Courses incorporating multiple disciplines
integrate several different topics or subjects that have
some commonality or relevant connections. Courses
with an immersed theme involve a learning process
internal to the student, gained from learning prob-
lem-solving skills and also critical thinking. Within
these three general categories, Fogarty defined ten
August 2009 ■ Journal of Dental Education
individual models that portray various fundamental
aspects of integration. The ten are fragmented, con-
nected, nested, sequenced, shared, threaded, webbed,
integrated, networked, and immersed models. The
operational definition for each of these models ap-
pears in Table 1.
It is hoped that dental school curricula inher-
ently incorporate a multiple-discipline theme leading
to one common goal: to graduate knowledgeable and
competent dentists. This natural or innate level of
integration, however, can be greatly improved upon.
Once clearly understood, utilizing these themes
and corresponding models or methods to their best
possible fit within a particular school or program
may help administrators and educators create ver-
satile, dynamic, and comprehensive curricula. The
University of Nevada, Las Vegas (UNLV) School
of Dental Medicine (SDM), founded in 2002, estab-
lished a curriculum that implements both vertical
and horizontal integration of the three disciplines of
biomedical, behavioral, and clinical sciences.7,19,23
The original intent of the UNLV-SDM’s mission was
to offer foundation subject matter concurrently with
clinical instruction to complement the clinical setting
and ensure achievement of clinical competence. The
purpose of this educational research project was to
evaluate the SDM curriculum and determine the
extent of integration of the current curriculum as
it relates to the ten models of integration outlined
above. This comprehensive evaluation will aid in
developing future strategies aimed towards enhanc-
ing the SDM curriculum model in the future and may
serve as a useful example for other schools with the
same goals.
Methods
All current UNLV-SDM course directors (CDs)
(n=38) were asked to evaluate each of their courses
(n=84) using a brief survey instrument. From a list of
the ten models of integration, the CDs were asked to
select the model they perceived best illustrated their
course framework and design. Although the course
may potentially fall within more than one model
based on their design, each CD was instructed to se-
lect only one model from the list that best represented
his or her course.
The survey instrument included a visual display
and definition of each of the ten models of integra-
tion, as defined by Fogarty.20,21 Prior to the adminis-
tration of the survey instrument, all faculty members
963
 Table 1. Operational definitions of models of integration
Model Operational Definition

Single Discipline
Fragmented Focuses on a traditional pedagogical approach in which subject matter and/or courses are disconnected.
Subject matter is linked only by coincidence.
Connected Subject matter within a single discipline is connected from course to course. Key concepts taught in a
course lead to concepts within a subsequent course.
Nested Multiple skills are taught within a single course.

Multiple Discipline
Sequenced Topics within a single department/discipline are arranged to coincide with one another.
Shared Faculty within a single department/discipline do team planning and/or teaching in which overlapping
concepts emerge.
Threaded Skills are taught in a specific order as they feed into the next topic or skill within and across departments/
disciplines.
Webbed A common theme serves as a basis for instruction within and across departments/disciplines.
Integrated Interdisciplinary approach in which faculty do team planning and/or teaching both within disciplines and
across departments.

Learner Models
Networked Courses are taught so that students are required to integrate content that leads to external networks in the
field of dentistry.
Immersed Courses are student-centered so that the learner filters the content and becomes immersed/absorbed in his
or her learning experience.

Sources: Based on Fogarty R. Ten ways to integrate curriculum. Educational Leadership 1991;49:2; and Fogarty R, Stoehr J. Integrating
curricula with multiple intelligences: teams, themes, and threads. 2nd ed. Thousand Oaks, CA: Sage Publications, 2007.

and CDs were presented with a brief review of the
history of curriculum integration during a UNLV-
SDM faculty retreat. This review of curriculum
integration included more prevalent theories found in
the literature involving integrated curriculum models,
including the ten models of integration described
above. Faculty members were encouraged to engage
in discussions of this framework and these models
as they relate to the current curriculum at SDM and
to ask questions specific to their courses.
The total number of courses was tallied for each
of the ten models, and course numbers were cross-
referenced to create several independent matrices
depicting the current level of integration as perceived
by faculty members. The majority of courses were
assigned as, or belonging, to two basic themes: 1)
across departments/disciplines, and 2) within and
across departments/disciplines. Differences between
the themes were found among all the UNLV-SDM
courses using chi-square distribution. Chi-square
analysis was determined to be the most appropriate
test, as it is most commonly used to make infer-
ences about a single population variance, although
it may be useful in many other applications.24 Once
the data were gathered, courses were matched to the
models to create a representation of the current level
of integration and determine the number of courses
within each model.
Approval for administration of the survey and
the administration protocol were received from the
UNLV Institutional Research Board (IRB), as an
exemption to human subjects research under the
Basic HHS Policy for Protection of Human Research
Subjects (OPRS#0801-2599).
Results
The UNLV-SDM is comprised of three depart-
ments: Biomedical Sciences, Professional Stud-
ies, and Clinical Sciences. Figure 1 outlines the
relationship within the school regarding curriculum
development and feedback. The three departments
jointly coordinate the curriculum, which is then
presented to the curriculum committee for approval.
The curriculum committee is comprised of faculty
representatives from each department and two dental
student representatives. The curriculum committee

964 Journal of Dental Education ■ Volume 73, Number 8

 Executive Committee
Student Focus
BIOMEDICAL
Groups
SCIENCES

CURRICULUM
COMMITTEE

CLINICAL PROFESSIONAL
SCIENCES STUDIES

Figure 1. UNLV-SDM departmental relationships regarding curriculum development

also receives input from student focus groups and
the executive committee in making final curriculum
determinations.
Course survey results were obtained from
thirty-eight faculty members encompassing eighty-
four courses, which represented 100 percent of the
courses offered in the SDM curriculum. Course
numbers were cross-referenced to create several
matrixes depicting faculty members’ perceptions of
the current level of integration. After reviewing the
information, four specific themes emerged: 1) courses
in which integration primarily occurred within a
single discipline, 2) courses in which integration
occurred primarily across disciplines, 3) courses
in which integration primarily occurred within and
across disciplines, and 4) courses in which integra-
tion primarily occurred within and across learners.
The ten models of integration were then organized
within these four themes (Figure 2).
Once the four themes were established, courses
were mapped to match the theme and model. Figure 3
depicts the total number of courses tallied for each of
the ten models. In order to ascertain any patterns of
integration with respect to the integration theme, indi-
vidual department, or dental student school year, the
courses were also segregated and analyzed by these
criteria (Figures 4 and 5). The results of the survey
revealed that no course at SDM fell within the frag-
mented or traditional silo model. The majority of the
courses fell within two themes: across departments/
disciplines, and within and across disciplines/depart-
ments (fifty-four out of eighty-four, Figure 4). The
“within and across disciplines” themes were found
to have the most number of courses (twenty-eight);
however, the individual model “shared,” which falls
into the “across disciplines” theme, was the model
selected most by faculty members as representing
the level of integration (twenty courses). With the
chi-square analysis, significant differences between
the themes were found. There were significant dif-
ferences in the curriculum between the number of
courses “within a single discipline” (n=16) and the
number of courses “across disciplines” (n=26) and
“within and across disciplines” (n=29) (χ2=4.65,
p=0.003). Significant differences were also found
in the curriculum between the number of courses
“within and across learners” (n=14) and the number
of courses “across disciplines” (n=26) and “within

August 2009 ■ Journal of Dental Education 965

 WITHIN A SINGLE
DISCIPLINE

FRAGMENTED

CONNECTED
NESTED
ACROSS DISCIPLINES

SEQUENCED

SHARED

WITHIN AND ACROSS

DISCIPLINES

THREADED

INTEGRATED

WEBBED
WITHIN AND ACROSS
LEARNERS

IMMERSED

NETWORKED

Figure 2. Mapping of UNLV-SDM curriculum themes and models

and across disciplines” (n=29) (χ2=6.31, p=0.001).
However, no significant differences were found
between the number of courses “within a single dis-
cipline” (n=16) and the number of courses “within
and across learners” (n=14) (p=0.42) or between the
number of courses “across disciplines” (n=26) and
the number of courses “within and across disciplines”
(n=29) (p=0.623). Figure 4 depicts the graphical
representation of the number of courses mapped to
the four identified themes. In addition, the identified
themes were grouped by dental school year and by
department (Figure 5). Dental school year 4 (DS4)
courses mapped entirely to the themes “within and
across disciplines” and “within and across learners,”
whereas DS1 courses were biased toward the lower
levels of integration (Figure 5A). With respect to
departments responsible for the courses taught, there
was a fairly even distribution among the four themes,
with the exception of a relatively large number of
clinical sciences courses falling within the single
discipline theme (Figure 5B).
Discussion
In the IOM report that documented challenges
facing dental education, one concern expressed was
that the current dental school curriculum is crowded
with redundant material, which is often taught in
disciplinary silos.1 The UNLV-SDM was in a unique
position to establish a curriculum that crossed tra-

966 Journal of Dental Education ■ Volume 73, Number 8

Figure 3. Course mapping of UNLV-SDM courses to themes and models of integration
ditional disciplinary silos. This new dental school
established a curriculum that implements both a
vertical and horizontal integration of the biomedi-
cal, behavioral, and clinical sciences,23 and a unique
departmental organization was created.
In order to promote curriculum innovation dis-
cussions, share strategies, provide leadership, and as-
sist with the dissemination of information, the ADEA
CCI enlisted the help of representatives or liaisons
from participating dental schools. The liaisons attend
special conferences twice yearly; attendance has
included representatives from over forty-six dental
schools and upwards of 140 participants. The liaisons
were charged with identifying a curriculum reform
project for their individual dental schools. In consul-
tation with the dean of the UNLV-SDM, the school’s
liaisons identified a project to evaluate the integrated
curriculum to determine if the original goals had been
met and to determine future directions for change
in the curriculum. As a first step in the UNLV-SDM
curriculum evaluation, the liaisons participated in a
faculty retreat and conducted a survey to ascertain the
August 2009 ■ Journal of Dental Education
level of integration in the entire curriculum. Although
definitions of integration vary widely and the SDM
departmental organization already encompassed
integration of multiple disciplines, the ten models of
integration as proposed by Fogarty were used as an
initial reference point for this evaluation.20-22
An analysis of the course survey resulted in the
categorization of the ten models into four themes.
This organization into themes aided in the evaluation
of the level of integration of the SDM curriculum
as a whole. Although definitions of integration vary
widely throughout the literature, one prevailing con-
cept included in all integration models is that integra-
tion represents a continuum, along which learners
are taught subject matter ranging from lower levels
of integration such as fragmented and nested models
to higher levels of integration in which the learner is
immersed in the subject material and makes decisions
based upon knowledge and experience. The SDM
curriculum was organized into four themes.
The first theme—within a single discipline
models—included the fragmented, connected, and
967
 Total SDM Courses Mapped to Themes
30 * **
*
25
20
Number of Courses
15
10
0
Single Discipline Across
Disciplines
*p=0.003 **p=0.001
Figure 4. Distribution of UNLV-SDM courses across integration themes
nested models. The fragmented model is the more
traditional pedagogical approach, in which a course
is taught as a separate and distinct unit. The con-
nected model views subject matter within a single
discipline as connected from course to course. Key
concepts taught in a course lead to concepts within
a subsequent course. The nested model uses a three-
dimensional approach in which multiple skills are
taught within a single course.25 None of the SDM
courses mapped to the fragmented model, which
likely reflects the integrated nature of the SDM
departmental structure. Only one biomedical sci-
ence and two behavioral science courses mapped to
this theme of integration. Fourteen clinical science
courses were identified as “nested” within the single
discipline theme. This relatively large number of
clinical courses likely reflects the basic clinical motor
968
**
Within and Within and
Across Across Learners
Disciplines
skills taught to DS1 and DS2 students prior to entry
into the clinic. While DS1, DS2, and DS3 courses
were mapped to “within a single discipline,” no DS4
courses were mapped to this theme. While this result
could be anticipated, it was reassuring to confirm that
DS4 courses were being offered at the highest levels
of integration.
The second theme—across discipline mod-
els—includes the sequenced and shared models. The
sequenced model views the course matter as separate
information connected by a common theme. Units
are taught separately, but rearranged or sequenced
in such a manner as to create a framework to relate
the concepts. The shared model brings different
subject matter together into a single theme using
overlapping concepts to organize the framework. The
shared model was the single model selected most by
Journal of Dental Education ■ Volume 73, Number 8
 SDM Courses Mapped to Themes by Dental School
A. Year
Course Percentage to Total Course

80
70
60
Offered in Year

DS1
50
DS2
40
DS3
30
DS4
20
10
0
Single Across Within and Within and
Discipline Disciplines Across Across
Disciplines Learners

SDM Courses Mapped to Themes by Department

B.
Course Percentage to Total Course

50
45
Offered by Departments

40
35
30 Biomedical Science
25 Behavior Sciences
20 Clinical Sciences
15
10
5
0
Single Across Within and Within and
Discipline Disciplines Across Across
Disciplines Learners

Figure 5. Distribution of UNLV-SDM courses in integration themes

the course directors. The majority of courses falling
within this theme were DS1 and DS2 courses; again
there was a lack of DS4 courses. All three depart-
ments mapped courses within this theme with no
remarkable differences.
The third theme—within and across discipline
models—included the webbed, threaded, and inte-
grated models. The webbed model uses a common
theme to integrate subject matter. The threaded model
develops several ideas and then threads them together

August 2009 ■ Journal of Dental Education 969

 using a common theme. The integrated model rear-
ranges subject matter around overlapping concepts,
patterns, and designs, blending them together. The
“within and across discipline” theme was the most
commonly identified theme for SDM courses. Cours-
es from all dental school years were represented in
this theme as well as from each department.
The fourth theme—within and across learner
models—included the immersed and networked
models. The immersed model allows the learner to
take information previously gathered and look more
deeply into its meaning and uses. The learner begins
to integrate all data with little or no outside interven-
tion. The networked model takes the learner beyond
the immersed level. Learners are able to target re-
sources within and across their areas of study through
the use of experts. This is where the learner works
independently with minimal oversight. Seventy-five
percent of the DS4 courses mapped to this level of
integration. In contrast, relatively few DS1, DS2, and
DS3 courses were assigned to this theme.
There are some limitations to drawing conclu-
sions from this study. SDM courses were assigned to
one level of integration by the course directors after
a faculty retreat that introduced each of the ten mod-
els of integration. The survey instrument contained
a visual guide and definitions of the ten models of
integration to assist faculty members in assigning
their courses to one level of integration. Although
the course directors are the most knowledgeable
persons concerning course content and design, each
faculty member could conceivably have interpreted
the defined levels of integration differently. A more
unbiased approach could utilize a panel of calibrated
faculty to assign each course to a level of integration
based upon a thorough review of course content and
design. However, this labor-intensive process seemed
unjustified for this initial evaluation of the SDM
curricula. In addition to the possibility of some am-
biguity concerning the models of integration, some
courses could genuinely encompass more than one
level of integration. For instance, the first portion
of the course could present basic concepts, while
the second half utilizes a more integrated approach.
Because the study limitations were encountered by all
the CDs, the statistical differences identified in this
study likely reflect the overall level of integration of
the SDM curriculum.
970
Conclusions
All courses in the SDM curriculum were found
to have at least some level of integration. More than
half (n=43) were found to be both horizontally and
vertically integrated. The number of courses falling
within each theme represented a bell-shaped curve,
with fewer courses at both the lowest and high-
est level of integration. This distribution reflects a
continuum of integration that parallels the needs of
dental students as they progress through their dental
education. The majority of DS4 courses mapped
to the highest level of integration, reflecting the
expectation that DS4 students are capable of using
their acquired foundational knowledge to approach
subject matter with critical thinking skills. Because
the assessment of level of course integration was
based on self-reported perceptions of faculty mem-
bers, future studies should look at whether the level
selected actually reflects course content and whether
the model chosen is the most appropriate for teach-
ing the course content. Future studies will address
these issues in our continuing efforts to evaluate the
SDM curriculum.
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