Eur J Dent Educ 2005; 9: 26–31
All rights reserved
Copyright ª Blackwell Munksgaard 2005
european journal of
Dental Education
Vertical and horizontal integration of knowledge and
skills – a working model
W. D. Snyman1 and J. Kroon2
1
Faculty of Health Sciences, School of Dentistry, University of Pretoria, 2Department of Community Dentistry, Faculty of Dentistry, Medical University of
Southern Africa, Pretoria, South Africa
The new integrated outcomes-based curriculum for dentistry was
introduced at the University of Pretoria in 1997. The first
participants graduated at the end of 2001. Educational principles
that underpin the new innovative dental curriculum include
vertical and horizontal integration, problem-oriented learning,
student-centred learning, a holistic attitude to patient care and
the promotion of oral health. The aim of this research project was
to develop and assay a model to facilitate vertical integration of
knowledge and skills thereby justifying the abovementioned
action. The learning methodology proposed for the specific
outcome of the Odontology module, namely the diagnosis of
dental caries and the design of a primary preventive programme,
included problem-solving as the driving force for the facilitation of
vertical and horizontal integration, and an instructional design for
V
ertical integration in the context of medical
and dental curricula can be defined as the
integration of basic knowledge and skills, such as
biology, in the clinical context. Horizontal integration
can be defined as the integration of knowledge and
skills between the clinical subjects that relates to
comprehensive and holistic patient care. Both these
ideals are difficult to accomplish in the traditional
discipline-based curriculum. Although the School of
Dentistry, University of Pretoria, decided to move
away from a discipline-based curriculum, the teaching
and learning of the clinical component takes place in
discipline-based clinics due to the traditional design of
the building. Integration of clinical learning is accommodated in the module ‘Comprehensive Patient Care’,
with the objective of facilitating holistic patient care in
a real-world situation.
In order to facilitate vertical and horizontal integration, the curriculum and the learning programme
should be integrated. Furthermore, it is essential that
assessment must follow the same integrated pattern.
This was accomplished in the new Pretoria model
by developing an integrated outcomes-based curriculum, utilising problem driven learning as a vehicle
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the integration of the basic knowledge and clinical skills into a
single learning programme. The paper describes the methodology of problem-oriented learning as applied in this study together
with the detail of the programme. The consensus of those
teachers who represent the basic and clinical sciences and who
participate in this learning programme is that this model is
practical and can assist vertical as well as horizontal integration
of knowledge.
Key words: dental education; integrated curriculum; problemoriented learning; vertical and horizontal integration.
ª Blackwell Munksgaard, 2005
Accepted for publication, 14 June 2004
to drive the integration process, and to design the
learning and assessment programme in order to
facilitate and implement the integration process. In
this paper the authors briefly discuss the application
of problem-solving as the driving force to facilitate
vertical and horizontal integration. The methodology
applied to the instructional design of the learning
and assessment programme in order to facilitate
vertical and horizontal integration will also be
discussed (1).
Problem-solving: the driving force
behind integration
As stated earlier, problem-solving as a process enhances horizontal and vertical integration between the
basic and clinical sciences, a deficiency characterised
by the traditional discipline-based curriculum.
Through the development of self-directed problemsolving, students acquire the ability to investigate
unfamiliar patient problems, which they are likely to
encounter in their professional careers. In this way
they become life-long learners and are motivated by
Integration of knowledge and skills
the need to solve authentic patient problems, the
relevance of which becomes immediately apparent (2).
Contact sessions are based on problem-solving during which learning is facilitated while the learner is
engaged in problem-solving. The session commences
by first stating the problem. This is followed by a brief
overview of the embedded knowledge. Students are
then supplied with relevant notes on the subject to
support their learning. Learning is then facilitated by
the utilisation of this knowledge to solve the problem,
which is consistent with the learning objective. The
tutor involved in solving the problem continuously asks
appropriate leading questions, which assists in guiding
the learners. The learner is further required to reflect,
discuss and defend the application of his or her
knowledge or skills.
Differentiation is made between problem-oriented
learning and problem-based learning (3). Both
problem-based and problem-oriented learning will
facilitate the integration of knowledge and skill. Problem-oriented learning has been defined in various
ways, e.g. it is a system of instruction in which the
student uses a stimulatory problem to define both the
learning needs and learning objectives (4). In both
problem-based and problem-oriented learning, the
learner is confronted with a case study or a real patient
problem to determine what he/she needs to know in
order to solve the problem. A problem is defined as a
puzzling phenomenon (3); it can also be seen as
discovering a better way to do something. As problems
are the driving force behind learning, the authors prefer
to refer to this process as problem-driven learning.
Problems presented to the learning groups are
related to clinical situations and are selected on the
basis of scenarios, which a new graduate in contemporary oral health practice will encounter, must
recognise and be able to manage. The learners
encounter an application of basic biology, medical
sciences and behavioural sciences as they work their
way through clinical oral health problems (5).
The integrated curriculum
The first cohort of final year learners in the new
integrated outcomes-based curriculum at the School of
Dentistry, University of Pretoria, qualified at the end
of 2001. The new curriculum was developed to
facilitate vertical and horizontal integration of knowledge and skills. This was accomplished in the new
Pretoria model as follows.
The ICD-DA Application of the International
Classification of Diseases to Dentistry and Stomatol-
ogy (6) was utilised to identify diseases and conditions to be managed by the dentist in his/her
practice. The selection of diseases is based on oral
conditions prevalent in the community and directs
the context in which learning takes place. The
activities in the learning sessions are so planned as
to enable students to develop a clinical competence
for managing the health of patients in terms of
disease and conditions pertaining to dentistry. The
management level of appropriate diseases and conditions was determined according to the Nijmegen
model e.g. recognition or diagnosis of a disease and
referral of the patient only, or diagnosis, treatment
planning and final implementation of the treatment
plan (1).
The next logical step in the development process of
the integrated curriculum was to classify or to group
the diseases and disorders. The method followed in
identifying the majority of modules in the patient
component was to classify diseases according to
anatomical structures, e.g. Odontology, i.e. diseases
pertaining to the teeth (2).
The purpose of the Odontology module, which acts
as a frame of reference for the development of the
specific outcome as mentioned below, can be defined
as follows.
In order to enable the newly qualified dentist to be
competent in assessing the oral health status of the
child, adolescent, adult and geriatric patient in terms
of diseases and conditions related to the hard tissues
of the oral cavity, including those of the pulp and periapical tissues, the learner should be able to manage the
oral health of the patient according to the following
protocol (B. Monkeith, personal communication):
• The diagnosis of the disease.
• The diagnosis of a patient’s risk profiles.
• Design an appropriate treatment plan.
• Instructing the patient to be capable of exercising
self-protective practices.
• Patient motivation aimed at changing his/her
behavioural pattern.
• Creating resistant and optimally maintainable dental hard tissues, including the pulp.
• Reversing early lesions where possible.
• Successfully managing advanced lesions of the hard
dental tissues, including the pulp.
• Morphologically and functionally restoring lesions
(rehabilitation) of the relevant tissues.
• Evaluating the outcome of the relevant treatment.
Learners are supplied with a description of the
outcomes for the particular module as well as detailed
references regarding the available material for each of
the specific or sub-outcomes.
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Snyman & Kroon
The Odontology module was selected to test and
describe this concept for the accomplishment of
vertical and horizontal integration.
The learning and teaching methodology
to accomplish integration
This section describes the method that was followed in
order to apply vertical integration in a specific
outcome of Odontology, namely the diagnosis, design
and implementation of a preventive programme for
dental caries targeting the following outcomes:
• The diagnosis of caries
• The diagnosis of patients’ risk profiles for caries
• Design an appropriate preventive treatment plan
that will include the following outcomes.
Instructing patients to be capable of exercising selfprotective practices, patient motivation aimed at
changing his/her behavioural pattern, creating resistant and optimally maintainable dental hard tissues,
and reversing early carious lesions.
The instructional design of the
integrated learning programme for the
specified outcome
Integrated learning can only be accomplished if the
learning programme is totally vertical integrated.
The following instructional design was used to
develop the learning programme.
• The natural history of dental caries.
• The biological aspects of enamel, dentine, cementum and saliva.
• The microbiological aspect of caries.
• The pathogenesis of caries.
• The natural history of dental caries in relation to its
prevention.
• Health promotion measures with regard to dental
caries.
• Specific protection methods with regard to dental
caries.
• Caries risk assessment.
• Case studies.
Each of the above elements of the learning programme will be discussed briefly.
The natural history of dental caries
The natural history (Fig. 1) of a disease as a concept
can be defined as the events that take place during
the onset, progression and final outcome of the
disease process without any prevention, intervention
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or treatment (B. Monteith, personal communication).
Disease or health is a dynamic process characterised
by a constant pattern of change; an everlasting battle
of man (host) to maintain a positive balance amongst
biological, physical, psychological and social forces.
The combination of the process in the environment (patient still healthy) and the process in man
(pathogenesis and post-pathogenesis phases) may be
termed, for preventive purposes, the natural history
of a disease (7). It comprises all the interrelations of
the agent, host and environmental forces, which
create the disease stimulus leading to defect, disability, recovery or death. The three phases of the
natural history of a disease namely the pre-pathogenesis (healthy phase), pathogenesis and postpathogenesis phases correspond, respectively with
the three levels of prevention namely primary,
secondary (intervention) and tertiary prevention
(rehabilitation) (Fig. 1).
This model is ideally suited to the integration of
all the aspects of the learning outcomes of Odontology and places it in context. It explains to the
student the necessity to be able to recognise healthy
(biology) and abnormal tissues (pathology) for the
purpose of early detection of a disease. The importance of aetiological factors and the pathogenesis of a
disease in the determination of risk factors and the
correct diagnosis of a disease is also highlighted.
The necessity of taking aetiological factors into
consideration in the planning process of the preventive programme can also be defended, in this
case the need to know, understand and apply health
promotion and specific protection measures with
regard to dental caries. Learners will therefore be
able to understand the relationship and interdependence of the discussion topics and the relevancy
thereof. Learners are constantly reminded during
discussion sessions of the final outcome, namely the
design of a preventive programme for a specific
patient. This concept is also mastered by means of a
problem that is briefly explained to the learners after
which they are confronted with the natural history
and prevention of an African endemic disease, such
as malaria, for the application of this concept.
Although learners had no formal lecture on the
topic, they were required to determine, during
group sessions, the aetiological factors of the disease,
the disease process and the necessary preventive
measures. The knowledge utilised by the student is
derived from their personal experience of having
visited a high-risk malaria area, the lay press and
other media as well as discussions with their
pharmacist on the prevention of malaria before
Integration of knowledge and skills
The Natural History of a Disease as it
relates to the Prevention of a Disease
(Adapted from Leavell & Clark (1965) & Monteith (1996)
Pathogenic Phase
Healthy Phase
Host
End Result
Irreversible
condition
Environment
Reversible
phase
Advanced
lesion
Agent
Death or loss
of tissue
Early lesion
Interaction of the aetiological
factors triggering the disease
The Clinical Horizon
Latent/Prodromal period
Intervention
Secondary Prevention
Primary Prevention
Health
promotion
Specific
Protection
Early diagnosis & Risk
Assessment
Therapeutic
treatment
Curative
treatment
Tertiary Prevention
Rehabilitation
Fig. 1. The natural history of a disease as it relates to the prevention of a disease [adapted from 7 & B. Monteith (personal communication)].
entering an endemic area. Utilising this model in a
practical way helps the learner to understand and
apply this concept in the real-world situation.
The biological aspects of enamel, dentine,
cementum and saliva
The biological aspect of enamel, dentine, cementum
and saliva as it relates to dental caries are discussed in
detail during discussion sessions pertaining to these
topics. The importance of the biological aspects of
these tissues in terms of clinical application (i.e.
recognition of healthy tissue) is also highlighted.
The microbiological aspect of caries
The microbiological aspect of caries such as the role of
the cariogenic bacteria as the agent factor in its
pathogenesis, the role of environmental factors such
as diet, saliva, etc. and the importance of host factors
including host resistance, forms part of this topic. The
clinical application of these, namely the role of
aetiological factors in the planning of a primary
preventive programme, is highlighted during small
group discussions.
The pathogenesis of caries
Pathogenesis is defined as ‘the preliminary interaction
of potential agent, host and the environmental factors
in disease production’ (7). In terms of dental caries the
topic is mastered by way of small group discussions where groups must establish a definition of
pathogenesis, types of carious lesions, aetiology of
caries, basic structure of enamel and dentine, the
process of de- and re-mineralisation and the phases of
caries development. Learners are required to read a
chapter in the prescribed handbook in preparation for
this discussion.
The natural history of dental caries in relation
to its prevention
By applying the concept of the natural history of a
disease as it relates to its prevention to dental caries,
the previous three learning topics, namely the
biological aspects of enamel, dentine, cementum
and saliva, the microbiological aspect of caries and
the pathogenesis of caries, are vertically integrated
into the clinical situation in a condensed form. The
aim is for learners to understand the importance of
the knowledge base related to the basic components
and be able to recognise healthy enamel, to make a
diagnosis and to determine the risk profile of a
patient for caries. The same applies to the knowledge base with regard to specific protection measures, e.g. topical fluoride as well as to health
promotion measures that form part of the preventive
programme for a specific patient.
Health promotion measures with regard to
dental caries
Health promotion involves much more than health
education and is the process of enabling individuals
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Snyman & Kroon
TABLE 1. Example of a case study and assignment
Case information
Demographic information
Female
Age 30
Married with two toddler daughters
Resident of Rustenburg in the North West Province since birth
Qualified computer software programmer
Present occupation: housewife
Dental history
Has only received a professional fluoride application once in her lifetime
Visits her dentist irregularly
No history of systemic fluoride supplement intake
Chief complaint
Gingival bleeding and swelling since falling pregnant
Complains of a clicking TM joint during mastication
Some of her teeth are sensitive to cold, sweetened foods and beverages
Other clinical findings
Plaque index of 50%
Majority of plaque present on the gingival aspects of the teeth
Stimulated salivary flow ¼ 0.7 ml/min
Deviation of the mandible coupled with a clicking sound of the right TM joint when she opens her mouth
Medical history
3 months pregnant, expecting twin babies
Developed high blood pressure since becoming pregnant
Has a kidney problem
Complains of a high frequency of stress headaches and morning sickness
Diet
Craving for sticky sugar products such as Nougat during the last 2 months
Consumes sweetened lemon juice regularly
Clinical findings of hard tissue
16 and 46 were removed due to caries at age 10
17 and 47 inclined mesially
Extensive amalgam and gold restorations on remaining molars
12, 11, 21 and 22 are restored with porcelain jacket crowns
11 and 21 are non-vital and root filled
Gingival recessions with dentine exposure on premolar teeth
Facets are present on the incisal edges of all anterior teeth and canines
Visible demineralisation on the gingival third of the labial/buccal aspects of most teeth
Secondary caries on 26 and 36
Assignment
In terms of the above case information determine the oral health status (diagnose diseases and conditions, problems and risks),
susceptibility towards caries and periodontal diseases and motivation level. Motivate and defend your decisions. Prescribe an ideal
primary preventive treatment programme
Structure your answer according to the following protocol:
1. Diagnosis of diseases and conditions
1.1 Motivation level of the patient
1.2 Systemic diseases that require a modification of the treatment plan
1.3 Risk level of oral diseases
1.3.1 Dental tissues (enamel and dentine)
1.3.2 Periodontal tissues
2. Primary preventive treatment plan targeting the aetiological factors
2.1 Health promotion
2.2 Specific protection
2.3 Therapeutic treatment
and communities to exercise increased control over
the determinants of disease in an effort to improve
their health (8). Three elements are involved in
health promotion, namely health education, prevention and health protection. Health promotion as a
topic is dealt with extensively as part of the module
‘The Community as Patient’. Elements of health
promotion, namely nutrition guidance and diet
planning and the application of psychological prin-
30
ciples of patient motivation are addressed as part of
the module ‘Odontology’ by way of small group
discussion and simulation.
Specific protection methods with regard
to dental caries
Specific protection involves measures applicable to a
particular disease in order to intercept its causes
before it affects man (7). When applied to dental
Integration of knowledge and skills
caries, topics such as mechanical and chemical plaque
control, cariostatic mechanisms of fluoride, topical
fluoride (both professional and home care products),
systemic fluoride and toxicology of fluoride are
addressed. Small group discussions are used to master
all topics related to specific protection measures.
Learners must solve problems within their groups
related to each topic. Each group is presented with a
case study for which relevant clinical and other
information about the patient is presented to them.
They are then requested to develop a treatment plan
emphasising specific protection measures. Knowledge
of aetiology and pathogenesis of dental caries is
integrated with knowledge of preventive measures
and products in solving these problems.
Caries risk assessment
Learners are supplied with all the indicators in order
to determine a patient’s caries risk profile. This is
classified as low, moderate or high. Knowledge of
these factors is then applied by allowing the students
the opportunity to determine the caries risk profiles of
several clinical cases.
Case studies
In order to prepare learners for group discussions on
case studies, additional information with regard to the
clinical reasoning process is given. Application of this
concept is reinforced in the design of a primary
preventive programme for the patient. Learners are
briefed with regard to group discussion techniques/
theories and group dynamics. Heterogeneous groups
are selected according to their learning preferences.
Well-structured clinical cases providing all relevant
information with regard to the condition of the
patient’s oral health are available to learners with the
request that they analyse the data and provide a
diagnosis and risk assessment with regard to all oral
diseases. Table 1 provides an example of a case study
presented to students. Although this module concentrates on diseases of the hard tissues, diagnosis of
diseases of the periodontium, soft tissues, tongue,
temporomandibular joint, etc. are included in these
exercises. The latter facilitates the integration of
knowledge between the different clinical modules
(horizontal integration). It is not expected of students
to design a detailed primary preventive treatment
plan for diseases other than those of the hard tissues. It
is, however, expected of students to outline a detailed
primary preventive programme for the caries problem. A tutor facilitates these discussion sessions and
groups are encouraged to discover the answers within
the group. Such sessions are concluded by feedback
and evaluation of the diagnosis and treatment plans of
the various groups.
Conclusion
A long-term goal of dental education has been the
successful integration of basic sciences into the clinical
curriculum. Such integration should make learning
more relevant and ultimately more available for use in
a clinical context (9). The authors are convinced that
this model can be adapted to suit other modules or
parts of modules within the new Pretoria curriculum.
The consensus of those teachers who represent the
basic and clinical sciences and who participate in this
learning programme is that this model is practical and
can assist vertical as well as horizontal integration of
knowledge.
References
1. Snyman WD, Ligthelm AJ. The new Pretoria curriculum.
J DASA 2000: 55: 642–647.
2. Seeliger JE, Snyman WD. A new approach to undergraduate dental education and training. J DASA 1996: 51
(special edition): 746–749.
3. Barrows HS. The essentials of problem-based learning.
J Dent Educ 1998: 62: 630–633.
4. Branda LA. Implementing problem-based learning.
J Dent Educ 1990: 54: 548–549.
5. Rohlin M, Petersson K, Svensater G. The Malmo model:
a problem-based curriculum in undergraduate dental
education. European J Dent Educ 1998: 2: 103–114.
6. World Health Organization. Application of the International Classification of Diseases to dentistry and
stomatology. Geneva: World Health Organization, 1995.
7. Leavell HR, Clark EG. Preventive medicine for the doctor
in his community, 2nd edn. NY: McGraw Hill Book
Company, 1965: 1–38.
8. Ashley FP, Allen CD. Oral health promotion. In: Murray
JJ, ed. Prevention of oral diseases, Chapter 9, 3rd edn.
New York: Oxford University Press, 1996: 139–146.
9. Forrest AS, Walsh LJ, Isaacs G, Williams LM. PBL as a
tool for integrating anatomy into the dental curriculum.
J Dent Educ 1998: 62: 634–639.
Address:
Prof. Willem D. Snyman
PO Box 1226
Pretoria 0001
South Africa
Tel: +27 12 319 2552
Fax: +27 12 323 7616
e-mail: [email protected]
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