Critical Issues in Dental Education

Clinical Reasoning in Dentistry: A

Conceptual Framework for Dental Education
Shiva Khatami, D.D.S., Cert. Ortho., Ph.D.; Michael I. MacEntee, L.D.S.(I), Dip. Prosth.,
F.R.C.D.(C), Ph.D.; Daniel D. Pratt, Ph.D.; John B. Collins, Ph.D.
Abstract: This study presents a conceptual framework for clinical reasoning by dental students. Using a think-aloud method with
six vignettes, the researchers interviewed eighteen dental students from two stages of training about oral health-related problems
influenced by biopsychosocial factors. Verbatim transcripts of the interviews were analyzed to identify the processes and strate-
gies of clinical reasoning used by the students to produce treatment plans. The process included 1) rituals to collect information;
2) forward and backward reasoning to generate and test clinical hypotheses; 3) pattern recognition from integrated scripts of
knowledge and experience; and 4) decision trees to assess options and outcomes. The process was supplemented by scientific,
conditional, collaborative, narrative, ethical, pragmatic, and part-whole reasoning strategies. Senior students showed a keen
awareness of the contextual determinants of care and emphasized patients’ motivations for treatment. In contrast, junior students
focused more on problems associated with individual teeth as they struggled to integrate the information within each vignette. In
this article, the processes and strategies for reasoning used by both groups of dental students are abstracted and then illustrated by
a model of clinical reasoning that accommodates the complicated contexts in which clinical problems usually arise.
Dr. Khatami is Assistant Professor, Department of Orthodontics, College of Dental Medicine, Nova Southeastern University;
this study was conducted at the University of British Columbia while he was a Ph.D. student there; Dr. MacEntee is Professor
of Prosthodontics and Dental Geriatrics, Oral Health Sciences, University of British Columbia; Dr. Pratt is Professor, Educational
Studies, University of British Columbia; and Dr. Collins is Adjunct Professor, Educational Studies, University of British
Columbia. Direct correspondence and requests for reprints to Dr. Shiva Khatami, Department of Orthodontics, College of
Dental Medicine, Nova Southeastern University, 3200 South University Drive, Fort Lauderdale, FL 33328; 954-262-1896;
shiva.khatami@nova.edu.
Keywords: dental education, dental students, clinical reasoning
Submitted for publication 4/27/11; accepted 11/9/11

D
ental professionals’ competence in clinical
reasoning is essential for the delivery of oral
health care. Such competence requires that
the dentist utilize integrated networks of knowledge
to identify and solve clinical problems. Interacting
with patients demands competent communications,
critical thinking, professionalism, ethics, and aware-
ness of the social and cultural context of practice; yet
we know very little about when or how these skills
evolve, develop, or become integrated for dental stu-
dents during their education. Consequently, dentistry
lacks a robust and comprehensive model of clinical
reasoning to explain the complicated cognitive and
interactive processes that guide dental clinicians
when identifying, framing, and solving the wide
range of oral health problems. Existing models of
clinical reasoning in dentistry, as in medicine, con-
centrate predominantly on the process of diagnos-
ing diseases, but they offer no accommodation for
the more complicated decisions associated with the
psychosocial determinants of health. Consequently,
they contribute little to the effectiveness of curricular
models and assessment methods in dental education.1
Existing definitions and models of clinical
reasoning tend to be specific to the individual health
professions and reflect a diversity of clinical profes-
sions.2-5 Medicine, for example, has focused mainly
on the process of diagnosis and for the most part falls
short of describing how physicians plan treatment.5-7
In contrast, physiotherapy and occupational therapy
have explored the complicated and interactive pro-
cess those clinicians employ when negotiating and
implementing plans.8,9 Higgs and Jones9 recently
portrayed this reasoning process as a contextual
and interactive phenomenon within a multilayered
context involving patients, clinicians, and clinical
problems surrounded by an even larger social, cul-
tural, and global environment.
Studies of clinical reasoning were originally
based to a large extent on the observational methods
and psychometric theories of cognitive psychol-
ogy.7,10 The focus initially was on observable clinical

1116 Journal of Dental Education  ■  Volume 76, Number 9

performance but broadened later to include the cogni-
tive processes underlying clinical performance.10,11
This change coincided with the early investigations
in medical education of problem-solving skills
and an emphasis on the “primacy of process over
content”3 by exploring and modelling the reasoning
process used by experts. Elstein et al.,3 for example,
introduced the hypothetico-deductive (H-D) model
of solving medical problems whereby the clinician
acquires cues, generates hypotheses, interprets the
cues, and evaluates the hypotheses. Later, more elab-
orate versions of the H-D model were introduced,2,12
although with little success in explaining differences
between the reasoning processes of novice and expert
clinicians.
Groen and Patel13 sought an alternative ex-
planation for those differences and suggested that
experts apply “forward or data-driven” reasoning
to arrive at a diagnostic hypothesis, while novices
apply “backward or hypothesis-driven” reasoning to
find data that confirm or reject a list of hypotheses
about the problem. However, it is unclear how the
novices construct the hypothesis in the first place and
whether or not experts are influenced by a dominant
hypothesis while they collect and interpret clinical
information. About the same time, pattern recognition
emerged as an explanation for the rapid and efficient
problem-solving skills of experts, particularly in
highly visual material.7,14-16 This idea led further to
studies of the structure and application of knowledge
in medical problem-solving across levels of expertise,
which led to introductions of schemas,17 prototypes,18
exemplars,19 and illness scripts20 as explanations of
the differences between diagnostic reasoning of nov-
ice and expert physicians.13 Boshuizen and Schmidt21
proposed a theory of medical expertise, suggesting
three stages of development for organizing and in-
tegrating biomedical knowledge for a diagnosis. Ini-
tially, the novice builds a “propositional network” to
explain the pathophysiological mechanisms underly-
ing a disease and then gives the network a diagnostic
label following further exposure to patients. During
the intermediate stage when exposed to additional
clinical experience, the biomedical knowledge be-
comes “encapsulated” within illness scripts, and
repeated clinical encounters refine the scripts as the
clinician evolves from novice to expert.
Elstein and Schwartz,22 in their review of the
cognitive literature, drew attention to the heuristics
and biases influencing the diagnostic decisions of
physicians. They were encouraged by an interest
September 2012  ■  Journal of Dental Education
in evidence-based medicine and medical informat-
ics to assist rational and evidence-based decisions
in clinical practice.11 Recently, medical educators
have favored a conceptual model for the diagnostic
process by incorporating a “dual processing” theory
of reasoning.7,23-25 Process 1 resembles pattern rec-
ognition and forward reasoning that unconsciously
compares the situation at hand with previous expe-
riences. Process 2, in contrast, is highly analytical
and resembles H-D reasoning. The dual processing
theory explains how illness scripts are triggered and
processed through a non-analytical approach when
clinicians encounter a typical presentation of a dis-
ease and how they adopt an analytical approach when
they encounter an atypical presentation of a disease
for which they cannot find a matching script.23
Starting in the 1980s, there was growing inter-
est especially among nurses, occupational therapists,
and physiotherapists to “interpret” clinical reasoning
with an emphasis on the contextual issues influencing
diagnostic and treatment decisions.26,27 Interpretive
inquiry, for example, was used to explore the nature
of expertise and the role of intuition when clini-
cians encounter clinical problems and the reasoning
strategies they use to deal with the biopsychosocial
determinants of health.8,9,28,29
Research in clinical reasoning in dentistry has
largely focused on decision theory, particularly to
develop computerized decision support systems.30,31
Also, H-D models32 and pattern recognition through
use of a “caries script”33 have offered descriptions of
the diagnostic process in dentistry. Results to date
suggest that dental experts use “forward reasoning”
to produce diagnostic hypotheses from clinical data,
whereas novices produce the hypotheses before mov-
ing “backward” to confirm or reject the hypotheses
from their interpretation of the clinical data.34 How-
ever, the diversity in focus and approach to clinical
reasoning research within and across health care dis-
ciplines poses a challenge to integrate their findings.
We do not know that a universal or generic model of
clinical reasoning can serve other disciplines, such
as dentistry.9,35 This article reports on a study to ad-
dress 1) the reasoning strategies used by a group of
junior and senior dental students at the University
of British Columbia to address the biopsychosocial
determinants of oral health and 2) the similarities and
differences in clinical reasoning between the junior
and senior dental students. The results provide a basis
for a conceptual framework for the clinical reasoning
of dental students.
1117

Methods
With approval from the University of British
Columbia’s Ethical Review Board, we selected as
participants nine full-time members of the dental fac-
ulty from various dental specialties along with eight
dental students at the beginning and ten at the end
of their final year of the predoctoral dental program.
We constructed six situational vignettes2,21 about two
hypothetical patients to represent a realistic simula-
tion of student encounters with clinical problems
(Figure 1). The vignettes offered information about
the two patients to challenge the student participants
with a range of biopsychosocial and ethical problems.
The nine faculty members were interviewed
individually for their opinions on the appropriateness
of the vignettes as reflections of the clinical problems
typically encountered by dental students. They were
asked if the vignettes were likely to prompt responses
to reveal a student’s knowledge and awareness of
the psychosocial and ethical factors influencing the
problems, treatment options, prognosis, and context
of clinical practice. We incorporated these faculty
members’ suggestions into the vignettes.
The eighteen students were selected purpose-
fully36 with assistance from the associate dean for
academic affairs to provide a similar distribution of
participants with below-average, average, and above-
average academic standings. Semistructured, tape-
recorded individual interviews lasting about one hour
were conducted by one of the authors (SK) in private
with each student. At the beginning of the interview,
instructions were given on the “think-aloud” method37
before introducing the first vignette and a request for
thoughts on each scenario from diagnosis to treatment
plan. The students were told at the beginning of the
interview that diagnostic casts, photographs, and
radiographs for each vignette were available to them
for inspection at any time during the interview, but

VIGNETTE 1
A 42-year-old woman attends the university dental clinic. She says, “I want to have new dentures.
My old plate is not stable and is broken. I want to fix my teeth and take care of them.”
PATIENT 1

VIGNETTE 2
After you present a treatment plan, the 42-year-old woman shows concerns about the cost of
treatment. She asks you if you could extract all her teeth and make a set of dentures.
VIGNETTE 3
You are at the end of fourth year, and you need two more crowns to complete your requirements.
The patient is reluctant to pay for the caries-management program and is wondering if you can
just make the removable partial denture without the crowns.
VIGNETTE 4
A 35-year-old man comes to the clinic complaining of pain from broken anterior teeth. He says, “My
front teeth are broken and they are hurting me, but the pain comes and goes. Also, my molar tooth
is broken and I am not able to chew on both sides.”
VIGNETTE 5
You consult your clinical instructor about a white lesion in a patient’s mouth. The instructor believes
PATIENT 2

that the lesion is leukoplakia and it should be monitored for change. You consult a periodontist
about this patient on a different matter, and he notices the white lesion in the patient’s mouth. He
believes that the lesion needs to be biopsied immediately. He rebukes you as a senior student for
ignoring such an important issue and is upset when you tell him in your defense that your clinical
instructor doesn’t agree that a biopsy is needed yet.
VIGNETTE 6
As soon as you tell your instructor about the patient’s smoking habit, he tells the patient to quit
smoking right away because, otherwise, the white lesion in the mouth could become cancerous
and kill him. The patient is quite upset about the way he is treated by your instructor and tells you
that such an attitude would not help him to stop smoking. He asks you to schedule his
appointments on the days when that instructor is not around.

Figure 1. Situational vignettes about two hypothetical patients

1118 Journal of Dental Education  ■  Volume 76, Number 9

only on request. They were prompted, if necessary,
to elaborate or clarify explanations, and all explana-
tions were accepted without comment or judgment.
Each interview was transcribed verbatim and
the texts analyzed by two investigators (SK and MM).
Our content analyses identified and coded the spe-
cific steps in the process of discovering, interpreting,
and solving problems as explained by each student
participant. With guidance from descriptions by
Higgs and Jones,9 codes were assigned deductively
to relevant segments of each transcript. The codes
were later clustered as broader categories, and themes
emerged describing the processes and strategies of
reasoning used by the participants. We also used a
bottom-up inductive approach36 to search for new
reasoning processes and strategies. Subsequently,
we summarized the processes and strategies to com-
pare the junior and senior students. In reporting the
results, we will identify students by the following
letters: “JS” is a junior student in the beginning of the
fourth year, while “SS” is a senior student at the end
of fourth year. The letters “A,” “B,” “C,” etc. were
assigned to students based on the order in which they
were interviewed, so that, for example, “JSG” is the
seventh junior student interviewed.
Results
Processes of Clinical Reasoning
The student participants reasoned their way
through the vignettes by 1) collecting and evalu-
ating information, 2) identifying and interpreting
problems, 3) evaluating options, and 4) diagnos-
ing diseases and planning treatment. The passage
was not always linear or in need of all four stages.
However, the students were usually guided by ritual;
forward or backward reasoning or a combination of
the two; pattern recognition and scripts; and deci-
sion analysis.
Ritual. All participants followed the clinical
protocol of the dental school in a ritual of obtain-
ing medical, dental, and social histories; exploring
the chief complaint; and assessing clinical data and
diagnostic aids, such as standard odontograms,
radiographs, and study models, all of which were
available only on request. Subsequently, they planned
a sequence of treatment, usually starting with man-
agement of disease followed by rehabilitation and
maintenance of health. There were participants who
seemed to follow each step of the ritual without
September 2012  ■  Journal of Dental Education
understanding its implications. For example, some
were unsure about the reasons for classifying peri-
odontal status when “treatment [seems to be] always
the same” (JSG), while others reported that the ritual
was time-consuming and delayed treatment.
Backward (deductive) and forward (induc-
tive) reasoning. The students used both backward
and forward reasoning to diagnose clinical problems.
When they observed a white lesion in the mouth, for
example, some started with a diagnostic hypothesis
and worked backwards to accept or reject it, as in
this comment:
[The lesion can be] a hyperkeratosis caused
by trauma . . . [or] lichen planus [which]
sometimes has diffuse pattern of light
patches. . . . You might be thinking about any
kind of viral [causes]; however, this doesn’t
look too much like that. . . . [It could be] a
known drug reaction. [So I try to] find out
if they’re taking any drugs and see if there’s
anything that’s causing trauma. . . . Candida
[Albicans] is sometimes white. . . . See if it
rubs off and then leaves erythema behind.
. . . [I am] concerned about malignancy, like
a squamous cell carcinoma. (JSC)
Alternatively, other students collected informa-
tion and moved forward to a diagnostic hypothesis,
although they occasionally reasoned backward from
an initial diagnosis to form an alternative hypothesis,
as in this example:
First thing would be to ask the patient about
medicine, drugs, smoking, alcohol use. I’d
check the other side [of the mouth] to see if
[the lesion] is bilateral. . . . If you could rub
it off . . . it is a Candida infection. . . . I’d
look for anything in the mouth that could be
irritating those areas. . . . There is always a
concern that it could be a dysplasia or can-
cer. . . . [If] it has a cobblestone appearance,
you consider things like Crohn’s disease or
inflammatory bowel disease. (SSD)
A combination of forward and backward reasoning
seemed to compensate for a student’s limited expe-
rience and was used when dealing with signs and
symptoms common to several problems.
Pattern recognition through scripts. Visual
and historical cues helped the students to recognize
the patterns of specific diseases, like caries, peri-
odontal diseases, and other mucosal abnormalities.
A pattern helped to bypass the process of making
1119
 and testing hypotheses and was followed often by
requests for additional clinical information to expand
the differential diagnosis.
Most of the students diagnosed caries from the
color and appearance of lesions and often requested
additional information about the tactile feel of the
lesion. Assessing the etiology and risk of caries and
tooth loss required a more elaborate exploration mov-
ing from physical to psychosocial considerations.
Generally, the scripts relating to caries consisted of
a network of information about the saliva and oral
bacteria along with details on the patient’s diet, hy-
giene, and socioeconomic status, all of which guided
a student to a therapeutic decision.
Scripts for periodontal diseases were trig-
gered mainly by visual cues about the normal versus
abnormal appearance of the gingiva around teeth.
Measurements of gingival recession, periodontal
pockets, and other numerical data supplemented the
visual cues in the scripts to help classify the severity
of the disease. The classification was used then to
determine the course of treatment.
Visual cues helped to diagnose mucosal lesions.
Malignant lesions, for example, were triggered by a
script that included information about the location of
the lesion and cues from the patient’s psychosocial
background, which influenced prognosis and treat-
ment. However, in general, all the students struggled
with diagnosing mucosal lesions and did not seem
to have developed a reliable diagnostic script for
oral lesions.
Decision analysis. Decisions to treat problems
usually involved a process of 1) interpreting the prob-
lem, 2) developing options, and 3) evaluating options.
A senior student, for example, evaluating options for
restoring a patient’s mutilated dentition stated:
She doesn’t have any posterior occlusal sup-
port and room for her denture. . . . [I would]
determine if these teeth are restorable or not
and whether we’re going to be using them as
overdenture abutments or whether we’re just
going to be doing a complete upper denture.
. . . [I would] determine whether we can
place any artificial teeth there or not and, if
we do, can we open up more space by doing
an enameloplasty or orthodontics. But that’s
pretty hard. . . . You have to present her with
options of bridges, implants. . . . A bridge
. . . would be a long span [and] compromise
the natural dentition. . . . It might look easy
now but it could haunt you later. . . . This
1120
is something that I would prefer to refer to
somebody who is more experienced. (SSG)
None of the students suggested numbers to
quantify the probability or utility value of the options.
Decision analysis seemed to be an interpretive activ-
ity by which the students integrated their knowledge
and experience to assess the problem and options for
intervention and to ensure a reasonable and practical
outcome.
Reasoning Strategies
The students used seven reasoning strategies to
interpret and address the problems: scientific, con-
ditional, collaborative, narrative, ethical, pragmatic,
and part-whole reasoning.
Scientific reasoning. The students applied the
H-D process of reasoning, which emulates a scientific
method to analyze clinical data and test the diag-
nostic hypotheses. However, this method was often
supplemented by nonanalytical approaches such as
pattern recognition. We found that the students based
their knowledge on theory and experience derived
from textbooks and manuals of didactic and clinical
courses supplemented by the opinions of instructors
and other students. They were aware of the limitation
and uncertainty of scientific evidence to support their
decisions because, according to SSG, “[Scientific
evidence] gives me an indication of what sort of
treatment has been done on teeth like this [but] has
it been successful or is it just a five-year recall or has
it been a ten-year recall? . . . Another thing is: every
patient is different, oral hygiene is different, their
habits are different. . . . You have to look into more
parameters: how was the study done, what type of
patients . . . what was their guideline for success?”
Conditional reasoning. Conditional reasoning
involved a historical analysis of the biological, psy-
chological, and socioeconomic factors that contribute
to the initiation and progression of problems. This
analysis helped the students to explore the source
of problems, envision the problems that could arise
in the future, and evaluate the possible outcomes
of their selected intervention. Uncertainty about
therapeutic outcomes dominated clinical decisions.
Biological, psychological, and socioeconomic fac-
tors were considered routinely by most students. As
SSJ commented, “You can’t skip caries management
altogether because . . . if you crown that tooth before
getting rid of the caries, the caries might spread
around. . . . There’s just too many problems down
the road.” Another student explained that achiev-
Journal of Dental Education  ■  Volume 76, Number 9
ing the objectives of treatment depended on the
condition of a patient’s motivation because “it can’t
just be me trying to fix the problems” (SSB). Other
students considered financial implications of future
problems: for example, “To save these teeth for as
long as possible would be financially a benefit to her.
. . . By 80 [years] she is going to have no bone. . . .
So there could be a whole new set of problems and
financial burdens” (SSB).
Collaborative reasoning. All the students re-
ferred to the significance of interacting with patients
and seeking their opinions about treatment decisions
in an effort to reach a shared understanding of the
most desirable and feasible treatment outcome, share
the responsibility of making decisions, and educate
the patient to facilitate decision making or promote
a change in behavior. In most situations, the students
seemed to accept that patients collaborate in the
decision and usually have further collaboration with
instructors because there are “just so many things that
can happen” and “so many options” (SSI).
Narrative reasoning. This strategy helped the
students understand from the patient’s perspective the
meaning of problems and expectations from treat-
ment. Some participants reflected on the assumptions
that they bring to this interpretive process and on a
comparison of values and beliefs between themselves
and their patients. Sometimes, they drew attention to
a problem that they had encountered previously to
help interpret the vignette and to justify a diagnostic
decision.
Ethical reasoning. The students tended to
tackle ethical problems either by starting from an
ethical principle and then analyzing the specific case
by using that principle or by reasoning their way
through a case toward a principle-based decision.
The former might be called deductive ethical reason-
ing and the latter inductive ethical reasoning. When
refusing to extract healthy teeth, for example, one
student asserted an ethical stance by saying, “I’m at
the point in my life where I’m not going to compro-
mise my morals and my values for another person”
(JSC). Patient autonomy guided other decisions, such
as “if that’s what she wants after she knows all her
options . . . you do what [she] wants” (JSH).
Ethical decisions typically were made rela-
tively quickly and confidently unless competing
ethical principles were evident, such as patient
autonomy versus practitioner maleficence when a
patient wanted healthy teeth extracted, which caused
students much discomfort. Inductive approaches
predominated when the ethical problem contained
September 2012  ■  Journal of Dental Education
a contextual mix of social, cultural, and economic
factors, as illustrated in this lament by JSB: “I know
it’s expensive . . . but the reality is that sometimes
you just can’t afford anything but clearance [of teeth]
and a new denture. . . . It’s really sad that the money
would dictate what kind of treatment you would get,
but that’s the way the world is I guess. . . . If she re-
ally, really can’t afford [restorations], the alternative
is walking around with no teeth . . . that’s a worse
alternative. So, I probably would end up [extracting
the teeth].” Another student, SSG, addressed a similar
dilemma but with a more inductive approach as he
reasoned his way to a final decision: “Do you just
ignore the patient and say go next door or do you clue
this patient . . . like autonomy, this is what they want,
[but] can you do it? I consider both sides. . . . I would
probably [extract the teeth] because she’s probably
going to go next door and receive the [extractions]
and might not have [received the] informed consent
as maybe I would have provided. So I feel comfort-
able. . . . I would not refuse treatment as long as I
know it’s an informed decision.”
Pragmatic reasoning. Although the students
tended to follow the rules and requirements of the
clinic, some clinical problems raised issues relating to
the social, economic, or political environment of the
health care system. This process called for pragmatic
reasoning to help their patients and themselves. To
help patients with financial problems, for example,
some students were disposed to “bending the rules”
of the clinic. SSA commented, “If the patient [is]
really, really tight on money . . . I’ll still [provide
treatment] for free . . . [and] write on the chart that it
is done . . . but I wouldn’t enter it under a computer
code. . . . It is an educational facility and we are
helping poor people.”
When problems included interpersonal conflict
between students and their instructors, the students
felt vulnerable, clinically inexperienced, politically
powerless, and fearful of becoming “a target for un-
fair assessments” (JSB). Students in general believed
that “you just don’t argue with anyone” in the clinic
(JSB), even if an instructor seems unreasonable or
wrong. The key to pragmatic reasoning for survival
by many students was to “fly below the radar” and
“keep quiet on a lot of things and just let it be” (SSD).
Part-whole reasoning. Students used several
reasoning strategies to refocus on various aspects of
a clinical problem and from one problem to another.
Often, interpreting problems and evaluating options
for treatment involved integrating several reasoning
strategies and moving away from a specific problem
1121
 to consider the larger context within which the prob-
lem occurred. This was most evident when consid-
ering how the needs of an individual tooth relate to
the dentition as a whole or more generally, in order
to “treat the whole patient, not just the chief com-
plaint” (SSI). One student summarized this strategy
as “you’ve got to remember there’s a person around
that mouth as well” (SSE).
Generally, clinical reasoning of the students
followed a combination of analytical and nonanalyti-
cal reasoning processes. The students adopted and
integrated the identified reasoning strategies to ad-
dress the contextual issues influencing their approach
to problems. In the following section, we describe
the contextual aspects of clinical reasoning and the
interactions of the contexts.
Contexts of Clinical Reasoning
The students’ clinical reasoning occurred in a
multilayered context including their own and their
patients’ personal frames of reference. These were
influenced by a larger array of social, cultural, politi-
cal, and economic contexts.
Personal frame of reference. Combinations
of knowledge, values, beliefs, and past experiences
shaped the personal frames of reference for the stu-
dents as explained by SSD: “to solve the problem,
you have to address why it happened. If you continue
just to patch the holes, you never address why, and
the patient continues to go down a road where the
disease progresses or continues.”
Some clinical experiences had negative impacts
on students, usually associated procedures with large
psychosocial characteristics. JSD explained with
frustration how
[making a denture] would be opening up a
can of worms that I wouldn’t want to deal
with. . . . Patients are very finicky when it
comes to their dentures: they expect them to
be [like] their natural dentition. . . . They get
dentures and they need to get them relined or
remade in five years [and] they think you’ve
done something wrong; when in reality, their
mouth is changing . . . and even though I try
ad nauseam to explain things to patients,
they don’t want to hear it, and they only get
frustrated with you, and then you’re carrying
that frustration.
Patient’s frame of reference. The approach to
some problems differed depending on the personal
1122
frame of reference that dominated the problem. If
the students interpreted the problem based solely
on their personal frame of reference, the problem
could be perceived differently from when they tried
to look at the problem from the patient’s perspective.
For example, some students believed that it is justifi-
able to scare a patient about the risk of cancer if the
patient has a precancerous lesion in the mouth and
smokes. However, some students looked at smoking
as a habit that is difficult to break; therefore, “it’s the
responsibility of a dentist to inform their patients and
give them advice on stopping smoking and health
advice . . . but it’s not our place to judge or accuse
patients” (SSE).
The students referred to the challenge of deal-
ing with patients’ misconceptions about health and
diseases and the need to educate patients about the
benefits of certain treatment options to “convince”
patients that the treatment is in their best interest.
For example, some students recognized that the
preventive approach “doesn’t click-in all that often”
for people who believe that cavities can be simply
drilled and filled (SSD). Therefore, presenting caries
management as “part of the general protocol of dental
treatment” rather than as an “add-on” or “money
grab” achieved a positive response and acceptance
from patients (SSD).
Nature of the problem. The specific nature
of some problems influenced the care offered by the
students. For example, most students considered pain,
bleeding, swelling, or infection to be urgent problems
to address before anything else. The impact of each
problem on general health and quality of life also
influenced the approach to care.
The health care environment. All of the
students reflected on the environment of the dental
clinic. Some commented how they will approach
care differently when they graduate. They acknowl-
edged that the context of clinical reasoning extends
beyond the teaching clinic to the larger health care
environment. As JSB commented, “It depends on
what your neighborhood is like; if you practice [in a
poor neighbourhood], you’re not going to be doing
crowns and bridges and implants. . . . A lot of patients
come here, [and] they end up going for suboptimal
treatment because they can’t afford anything else.”
Similarities and Differences in
Reasoning
The students’ clinical reasoning differed at
several levels within and between groups of students.
Journal of Dental Education  ■  Volume 76, Number 9
The major difference appeared to be the impact of
their personal frame of reference for identifying
and interpreting problems. This interpretive process
determined how the students appraised alternative
treatments within their own preferences. Past expe-
riences helped to recognize the pattern of problems
or diagnostic and management scripts although most
students acknowledged their limited experience.
Limitations of knowledge and experience influenced
their abilities to integrate information into a coher-
ent plan, especially among the junior students. JSA
explained that “It’s hard to put everything together.
. . . I know bits and pieces here and there, but it’s just
integrating everything, which hopefully I’ll get better
at it this year. . . . There’s so much . . . I need to be able
to integrate everything together. . . . What’s the best
option for this patient? At which stage would you do
what? In what sequence? . . . Integrating everything
into a logical, sequential plan as well as evidence or
experience for why you’d want to do that—that’s
what I don’t have at this stage.”
Generally, the students used rituals to collect
information and plan treatment. The junior students
Figure 2. Conceptual model of clinical reasoning in dentistry
September 2012  ■  Journal of Dental Education
tended towards standard rituals, such as the written
protocol of the clinic, whereas more experienced
students were more flexible with their own routines.
The juniors moved slowly from the biological to the
psychosocial characteristics of a patient’s problem,
but the seniors could prioritize by exploring patients’
expectations and motivations and personal context.
It seemed also that the senior students were
more aware of their personal frame of reference, their
individual view or philosophy of care, and how that
influenced their interpretation of problems and their
approach to care. They reflected on their professional
responsibilities as dentists and believed that at the end
of their predoctoral education they were “almost at
the same level as instructor[s]” (SSF) although with
some limitations.
A Conceptual Framework
Figure 2 portrays a conceptual model of clinical
reasoning in dentistry developed from the findings
of this study. The multilayered context of clinical
reasoning is shown as overlapping ovals to denote
1123
 the personal frame of reference of the dentist, the
frame of reference of the patient, the problem(s), and
the larger health care environment. The dentist uses
a nonlinear cyclical process to diagnose problems
and plan treatment within the broader context of the
health care environment and under the influence of
separate reasoning strategies that are integrated by
the part-whole strategy.
Discussion
Our research question was based on the premise
that clinical reasoning in dentistry is an integrated
process of diagnosis and treatment planning. There-
fore, we paid equal attention to exploring both activi-
ties. Our findings suggest that dental students rarely
follow a linear process as they unravel and address
clinical problems (i.e., starting with diagnosis and
ending with a treatment plan). As the students evalu-
ate information, nonanalytical approaches such as
pattern recognition through illness scripts help those
with more experience to arrive quickly at a diagno-
sis. The diagnostic ritual ensured a comprehensive
collection and appraisal of information. We left the
collection of information entirely to the student par-
ticipants without offering information unless it was
requested, which encouraged them to explain the
rituals they use. Diagnostic rituals were often supple-
mented by a linear process of listing and prioritizing
the problems before planning treatment. However,
when evaluating alternative treatment options, most
of the students needed to reevaluate clinical infor-
mation, reassess the accuracy of their diagnosis, and
revisit their treatment plans accordingly.
The student participants used a mixture of
analytical and nonanalytical approaches for diagno-
ses. This process necessitated a backward reasoning
to identify specific problems although most of the
students combined forward and backward reasoning
strategies as they unravelled the problems before
them. Likewise, Crespo et al.34 found that dentists
across all levels of expertise used a combination of
forward and backward reasoning in diagnosis. Den-
tists use scripts to confirm the presence of caries as
described previously.32,33 Dental students also identi-
fied pattern recognition and scripts as nonanalytical
reasoning processes for diagnosing caries. Caries
scripts help to reveal “upstream contributing” fac-
tors such as psychosocial issues that initiate and
sustain caries as described by Baelum et al.,38 so it
appears that the students were beginning to adopt a
1124
more comprehensive biopsychosocial approach to
clinical reasoning for the complex chronic diseases
managed by dentistry.
Overall, we found that almost all the students
combined both analytical and nonanalytical reason-
ing, depending on the nature of the problems and
their personal experiences. This combination is
consistent with the dual processing model of medical
problem-solving as described by Norman25 and with
the recommendation by medical educators favoring
a combination to improve the accuracy of diagnostic
decisions.24,39,40 Further studies using standardized
vignettes, more diverse groups of students, and
dentists with a wide range of expertise are needed
to consider further the process of clinical reasoning
used in dentistry.
Descriptions of scientific reasoning such as the
H-D reasoning refer mostly to the analytical process
of diagnosis.27,41 We used this term to denote the
strategies used by students to support their reasoning
with any kind of evidence. The limitation of scien-
tific evidence was identified by students as a barrier
prompting the need for either personal experiences
or the argument of authority to arrive at a decision.
Nonetheless, despite the growing interest in evidence-
based dentistry and promoting “rational” decision
making of dentists,30 not everyone uses the available
scientific evidence routinely. Dental students and
experienced dentists do not follow Bayesian formu-
las even when instructed to do so with appropriate
evidence.42 Apparently, they believe that it is difficult
to estimate a probability for the presence or prognosis
of a disease based on epidemiological data alone.
Clearly, reasoning in dentistry extends well beyond a
purely scientific and biomedical discipline to involve
a range of sophisticated practical and experience-
based sociocultural and historical phenomena.43-45
We found that uncertainty when addressing
complex problems leads to conditional reasoning.
For example, evaluating prognosis requires an un-
derstanding of many factors involved in the initiation
and progression of the condition. The same strategy is
used by occupational therapists and physiotherapists
as they anticipate the impact of their interventions.41
Furthermore, one of the dominant applications of
conditional reasoning by the dental students was the
condition set by the financial status of their patients
on the selection of treatment. These students read-
ily modified the treatment plan so that it would be
financially beneficial to the patient.
Collaborative reasoning has been found to help
clinicians to arrive at a shared understanding of prob-
Journal of Dental Education  ■  Volume 76, Number 9
lems and treatment objectives.9 Communicating with
patients and exploring their perceptions of problems
also involves narrative reasoning.8 Since our study
did not involve real patients or role-playing with sim-
ulated patients, our descriptions of collaborative and
narrative reasoning reflect the comments made about
the use of those strategies only when a hypothetical
situation demanded such communications. Loftus46
has stated that communication and use of language
are the essential aspects of clinical reasoning. Our
model illustrates the interaction among clinicians,
patients, and others (e.g., consultant specialists).
Interactive and interpretive activities are impossible
without language; however, the think-aloud method
does not replicate the complexity of the “real world”
in which clinicians typically interact with problems,
patients, and others.
Consequently, the value of our model will be
confirmed only when tested during real communi-
cations between clinicians and their patients. This
might be achieved by observational studies using
video or other surveillance, although research in
clinical settings is challenging to avoid jeopardizing
the privacy of the patient-clinician relationship and
the Hawthorne effect.
In our study, the dental students’ ethical reason-
ing followed the top-down, bottom-up, and combined
approaches described by Edwards and Delany47 as the
students struggled with the ethical dilemmas posed
by the vignettes. We found that a deductive approach
to ethical problems resulted in a faster decision, and
students who used this approach seemed more cer-
tain and confident. However, a deductive approach
involving two or more ethical principles caused un-
certainty and confusion. Alternatively, the students
who moved back and forth between inductive and
deductive ethical reasoning could more easily justify
their decisions on treatments.
These dental students used pragmatic reasoning
to address the problems inherent in the larger social,
cultural, political, and economic context of practice.
Again, financial issues dominated the discourse about
access to care for some patients. The dental students
worried about their personal relationships and teach-
ers, which hindered their opportunities to engage in
critical thinking or act on their beliefs about social
responsibility to disadvantaged patients. Henzi et al.48
discovered similar issues among students in other
North American dental schools where relationships
with faculty, bureaucracy, and pressures to become
clinically competent occasionally compromised their
ethical approach to care. The influence of these issues
September 2012  ■  Journal of Dental Education
on students needs further exploration as they develop
their professional identity and socialize into their
professional roles.
We noticed that part-whole reasoning was the
core strategy dominating the reasoning of all the par-
ticipants. With it, the students were able to integrate
problems as they moved in and out of a comfortable
frame of reference for patients and others involved
in care. The students evaluated problems individually
and in relation to other problems in the larger social,
cultural, political, and financial contexts. Part-whole
reasoning helped the participants integrate other strat-
egies of clinical reasoning and supported a compre-
hensive plan to address the biopsychosocial factors
that influence problems across different contexts.
The most recent model of clinical reasoning,
introduced by Higgs and Jones,9 highlights the inter-
active and contextual nature of this thought process.
Higgs and Loftus35 emphasize the need to develop
discipline-specific models of clinical reasoning for
research, practice, and education. The model of
clinical reasoning that we have constructed from our
study illustrates the dynamic interaction of these con-
texts, largely through the application of part-whole
reasoning, and reflects the biopsychosocial nature
of problems and approach to care in dentistry. We
showed how application of conditional and pragmatic
reasoning requires a conceptual and pedagogical
shift from the biology of disease to a larger context
of patients within society’s health care system. We
believe that dental educators and students benefit
from diverse clinical environments in which students
are exposed to a wide range of psychosocial issues
influencing oral health.
Problem-based learning (PBL) is the most
dominant educational method in dentistry with
claims to improving the problem-solving skills of
dental students by focusing on the development of
an H-D reasoning process.49-51 A systematic review
by Rochmawati and Wiechula52 found inconclusive
evidence regarding the effectiveness of PBL in
improving clinical reasoning. They acknowledged
the diversity of PBL in various educational settings
and called for further studies to explore the impact
of PBL on how health professions students reason.
Charlin et al.53 compared the PBL practices within
three Canadian medical programs and suggested that
problems be used as media for applying and relating
theoretical knowledge to practice. Others7,24,54 have
recommended that clinical problems be selected
according to specific educational objectives. We
recommend that dental educators select problems that
1125
 integrate reasoning strategies to address the multitude
of biopsychosocial determinants of oral health.
Dental students could benefit from the concept
of “deliberate practice”55 to develop the networks
of knowledge and experience required for clinical
reasoning. This process requires continuous exposure
to problems and aims involving repetition, reflection,
and feedback. Mylopoulos and Regehr56 argue that
the pedagogical objective of “deliberate practices”
should emphasize adaptive expertise rather than
routine or ritualistic approaches to clinical prob-
lems. This objective requires a greater emphasis on
reflection and feedback to ensure that the contextual
aspects of problems are recognized and that the stu-
dents have opportunities to reflect on their reasoning
and compare it with the reasoning of their peers and
more experienced clinicians.57 Perhaps reflection on
clinical reasoning could be a routine exercise given
to students following encounters with new clinical
problems, possibly in the context of group discus-
sions of real or fictitious patients. Reflections can be
used as a topic for discussion in group seminars for
students to compare their reasoning to their peers
and mentors and be exposed to alternative frames of
reference and interpretation of problems.
Currently, there are several computer programs
available to develop virtual patients in medicine and
dentistry.58,59 They offer templates that could be used
by instructors to incorporate clinical and diagnostic
information about real patients into a virtual environ-
ment. Virtual patients do not offer the opportunity of
interacting with peers and mentors in face-to-face
seminars, but they provide a cost-effective alternative
for small-group seminars.60 They seem to be at least
as effective as PBL seminars in achieving educational
objectives.59 Further studies are needed to evaluate
their effectiveness in simulating clinical scenarios.
Conclusions
Our study found that the clinical reasoning
of dental students involves a nonlinear process of
diagnosis and treatment planning. The diagnostic
process involves both analytical and nonanalytical
approaches depending on the nature of the problem
at hand and on the previous experience of the clini-
cian confronting the problem. A combination of
knowledge, experiences, values, and beliefs of the
clinician forms a personal frame of reference that
guides an interpretive activity whereby problems are
identified and prioritized. This frame also directs the
1126
treatment-planning process to identify and evaluate
alternative approaches that can address the problem.
These interpretive activities are also influenced by the
interactions of the clinician with patients and others
involved with the problem. Often, these interactions
aim to arrive at a shared understanding of the mean-
ing of the problems and their impact on the patient’s
quality of life and to determine the objectives of care.
We also found that the clinical reasoning of
dental students involves an integration of several
reasoning strategies (scientific, conditional, collab-
orative, narrative, ethical, pragmatic, and part-whole
reasoning) to address problems as they surface within
the larger cultural, social, political, and financial
contexts. Using part-whole reasoning strategy helps
a dentist to zoom in and out of problems from a local
or specific anatomical level to the larger psychoso-
cial context. This strategy requires moving back and
forth between the problems and alternative treatment
options to arrive at a treatment plan that optimizes
interventions, foresees future problems, and is flex-
ible in relation to addressing changes in situation if
new problems arise.
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Journal of Dental Education  ■  Volume 76, Number 9