The need to teach dental students how to develop and use critical thinking skills has been a dominant theme in dental education for more than a decade. However, the notion of how faculty teach these skills, as well as how well students demonstrate these skills in didactic basic science courses and the pre-doctoral dental learning environments is less understood. A lack of expertise or knowledge may also compound this issue as those who teach in higher education rarely have had instruction in teaching.[i] Further, the quality of teaching in the classrooms and clinics has been infrequently studied. How faculty develop opportunities for students to demonstrate critical thinking, suggests that dental educators and researchers have a unique opportunity to change the course of their own academic history. Clearly, teaching students how to use critical thinking skills will respond in part to Hansten and Washburn’s concern about the quality of health care by (a) reducing errors and sentinel events, (b) encouraging cost savings[ii] and (c) increasing worker and patient satisfaction.

Teaching students critical thinking skills also has implications for patient care. As students increasingly take ownership for diagnosis and treatment planning and articulate the thinking that supports their decision-making, they are poised to become better teachers. That is, they will be able to teach patients about their diseases, self-care, what symptoms to look for, and the role of compliance to promote self-care. Patients that take primary roles, rather than healthcare professionals, are likely to have less dental and other healthcare visits. Aside from helping students transform learning so that they can become competent practitioners, teaching students CTS has implications for the quality of oral healthcare, costs, and well-being.

Those who are skeptical of the association’s mission to ensure that students are critical thinkers because they believe that they are already teaching CTS may wish to ask themselves the following questions in Table 1.

Table 1. Checklist of Teaching Basic Critical Thinking Skills

  1. In what ways do I encourage students to explain or demonstrate what they know? How often?
  2. How much of my teaching in the classroom and/or clinic is dominated by teacher-talk? Teacher-student talk?
  3. What percentage of my teaching time in the classroom and/or clinic is devoted to having students provide a rationale for “what” they think and to explain “how” and “why” they know?
  4. How often do I ask questions that check for student understanding?
  5. How often do I ask students to identify the cues that indicate or contraindicate treatment and to explain why these cues are relevant to prospective treatment outcomes?
  6.  What percentage of the time do I ask students to describe how their understanding of body systems, like the cardiovascular system and related diseases impact oral health?
  7. How often do I ask students to rephrase what I have just told them?
  8. How often do I help a student by asking questions to identify why a patient is not responding to treatment in ways that are anticipated?
  9. How often do I explain explicitly to students how they will be evaluated on their clinical skills?
  10. How often do I ask students explain to me the differences between a poor and an excellent tooth preparation?

If you find that you are talking for 50% or more of your instructional time in responses to questions 1-3, and/or that your responses to questions 4-10 is equal or less than 50% of the time, then are likely to benefit from exploring the contents of this portal.

In addition, Distler has observed, patients are now being treated by a multitude of highly specialized healthcare professional.[iii]  A recent Institute for Medicine’s report emphasizes interprofessional collaboration.4 If dentistry becomes more involved in systemic health and with other healthcare professionals, the problems with which dentists deal are likely to become more complicated and ambiguous. Technology is becoming more sophisticated and methods of diagnosis and treatment continue to expand. The implications of these changes is that dental educators are likely to see more patients who are acutely ill and it is more likely that they will need to coordinate care with a variety of other healthcare providers. The information explosion is yet another reason why it is important that dental students can use critical thinking skills.5 The sheer amount of knowledge that is available at a fingertip and within a matter of minutes means that faculty must teach students to how to decide what information is credible and what to do with the deluge of data.5

Recognizing the need to make substantial changes in the dental education curriculum, the American Dental Educational Association (2004) established the Commission on Change and Innovation (CCI). This group is where dental educators, administrators, representatives from dental organizations, the dental licensure community, the Commission on Dental Accreditation, the ADA Council on Dental Education and Licensure and the Joint Commission on National Dental Examinations meet and coordinate efforts to improve dental education and the oral health of the nation.

This portal was originally developed in 2008 to assist dental educators across the US and Canada in making necessary curricular changes, ADEA agreed to jointly sponsor the creation of a critical thinking skills (CTS) toolkit. This version has been modified to reflect advances in research. Through this portal, the reader is introduced to the use and assessment of critical thinking skills in the classroom and clinical learning environments.

In June 2007, dental schools across the nation sent representatives to the first annual ADEA CCI Liaisons’ conference. At this meeting dental school representatives discussed critical thinking, learned about instructional strategies that promote the development of critical thinking and discussed assessment tools that could be used to measure critical thinking skills. Because traditional dental education has a long-standing history of explaining and demonstrating to students what they need to know, students may not receive the type of instruction that allows them to transform learning and make it their own.6 Learning how to teach students to use critical thinking skills (CTS) will require fundamental shifts in beliefs about and planning for teaching. At this ADEA CCI meeting, some dental educators asked, “What does critical thinking look like in the clinic? In the classroom? How do I get students to use critical thinking skills when they don’t even read before class or attend class?”

An overview of the dental educational literature shows how dental hygienists have effectively used instructional strategies to promote critical thinking skills.7 Moore used a mnemonic (that denoted a series of steps) to help lower students’ initial cognitive load and better remember how to transfer the steps to new problem-solving settings. The mnemonic, INFORMED was:

I- Issues and Information known;

N- Need to know;

F- Find information;

O- teach and learn from Others;

R- Recycle, Reflect, identify Real problems;

M- Make a list of solutions; E- Evaluate solutions;

D- Decide, Deliver, and Debrief.

However, because this study occurred in a highly structured, contextualized program, it is difficult to tell if the study results were due to PBL, teacher expertise, group dynamics, student expertise, or prior experience. Thamasitboon et al. found that there was a significant difference between students who took problem-based learning experiences and those who had traditional learning experiences in their development of several skill sets including critical thinking skills.8 While these and other studies hold promise for acculturating the teaching of critical thinking into dental school curriculum, they are limited by small sample sizes and the use of single outcome measures. In addition, Thamasitboon et al.’s study was limited by the low response rate and the disadvantages inherent to using a questionnaire with a rating scale.7,8

Overall, there is little practice-based evidence to suggest how to implement CT changes in dental education. Some studies with small samples of undergraduate students have showed that a moderate infusion of critical thinking skills during instruction can enhance critical thinking skills — without the instructor having made considerable changes to the course (See Teaching Students to Use CTS during Instruction. Yet similar studies have not been conducted in dental education. Perhaps without social demand and funding opportunities faculty may be reluctant to take on these types of studies. Nonetheless, the importance of teaching dental students how to develop and use critical thinking skills is not a question.

The shift to teaching critical thinking will require an organizational commitment to understanding what critical thinking is, identifying what strategies can be used to effectively teach critical thinking, testing changes in students’ critical thinking skills, providing continuous faculty development opportunities and places to discuss, implement, and examine the scholarship of teaching.2 As Hansten and Washurn point out, the organization can support and foster critical thinking or hinder it by creating faculty who are apathetic and feel powerless to make the changes that will be needed.2 Behar-Horenstein, et al. describes how faculty development initiatives brought about changes in instructional practices.9 Behar-Horenstein, et al. (2005), and Behar-Horenstein, et al. (2000) also described the role of assessment to study how teaching critical thinking skills effects student thinking and practice in the classroom and pre-doctoral clinical learning environments respectively.10,11As dental educators seek to transform the nature of teaching from telling and showing, to holding students accountable for telling and showing their understanding and thinking, dental educators will need to develop more robust research studies to build an evidence-based collective of studies that reflect how efforts directed at teaching critical thinking skills matter to the new dental professional, the dental school and society.

[i] Irby D, DeMers J, Scher M, Matthews D. A model for the improvement of medical faculty lecturing. Journal of Medical Education 1976; 51:403-9.

[ii] Hansten RJ, Washburn M. Facilitating critical thinking.  Journal of Nurses in Staff Development 2000; 16(1): 23-30.

[iii] Distler JW. Critical thinking and clinical competence: results of the implementation of student-centered teaching strategies in an advanced practice new curriculum. Nurse Educ in Practice 2007; 7: 53-9.

4 Institute of Medicine, Committee on Quality of health Care in America. Crossing the quality chasm: a new health care system for the 21st century. Washington, DC: National Academy Press, 2001.

5 Halpern DF. Teaching critical thinking for transfer across domains. Am Psychologist 1998; 53(4): 449-455.

6 Zull JE. The art of changing the brain Sterling, VA: Stylus; 2002.

7 Moore TS. Implementation of problem-based learning in a baccalaureate dental hygiene program. J of Dent Educ 2007; 71(8):1058-69.

8 Thammasitboon K, Sukotjo C, Howell H, Karimbux N. Problem-based learning at the Harvard school of dental medicine: self-assessment of performance in postdoctoral training. J of Dent Educ 2007; 71: 1080-1089.




9 Behar-Horenstein LS, Mitchell GS, Graff R. Faculty perceptions of a professional development seminar.  J of Dent Educ 2008; 72(4): 472-483.

10 Behar-Horenstein LS, Mitchell GS, Dolan T. A case study examining instructional practices at a U.S. dental school. J of Dent Educ 2005; 69(6): 639-648.

11 Behar-Horenstein LS, Mitchell GS, Dolan T. A case study examining instructional practices at a U.S. dental school. J of Dent Educ 2000; 64(8): 610-615.

12 Facione P. critical thinking: a statement of expert consensus for purposes of educational assessment and instruction. 1990: 2.

13 Simpson E, Courtneay M. Critical thinking in nursing education: literature review. Intern J of Nursing Practice 2002; 8: 89-98.

14 Banning M. Measures that can be used to instill critical thinking in nurse prescribers. Nurse Educ in Practice 2006; 6: 98-105.

15 Brookfield S. Developing critical thinkers: Challenging adults to explore alternative ways of thinking and acting. San Francisco: Jossey-Bass; 1987.

16 Ornstein AC, Hunkins, FP. Curriculum: foundations, principles and issues. 4th ed. Boston, MA: Allyn & bacon; 2004.

17 Sternberg RJ. Thinking styles: Keys to understanding performance. Phi Delta Kappan 1990: 366-371.

18 Sternberg RJ, Torff B, Grigorenko E. Teaching triachically improves student achievement. J of Educ Psych 1998: 90(3): 364-384.

19 Lipman M. Critical thinking: What can it be? Educ Leadership 1988: 38-43.