Preliminary Assessment of Critical Thinking Among Fifth-Year Dental Students Using Temporomandibular Disorder Questions: A Cross-Sectional Study

Abstract

Background

Educational stress in clinical environments can negatively influence students’ academic performance. This might also hamper students’ critical clinical reasoning. A stressful environment can impair one’s ability to reflect and make sound judgments. Some authors believe that clinical reasoning requires greater educational and clinical exposure. Problem-based learning (PBL) and case-based learning (CBL) through realistic clinical cases help students to engage in higher-order thinking.

Methods

Fifth-year dental students in a single dental school were asked at the end of an oral surgery lecture on temporomandibular disorder (TMD) to write and answer their own question(s) on any topic within the lecture. After receiving the answers, the questions were categorized according to the following categories: 1) number of questions; 2) type of question (enumeration vs short answer); and 3) relevance of the provided questions. The relevance of the questions was assessed and agreed upon by the 1^st and 3^rd authors. Topic relevance was considered based on the diagnostic, clinical, radiographic, and surgical values of the given question.

Results

Out of seventy-nine students who agreed to participate in this study, the majority were female (60, 75.9%). There were 19 (24.1%) male participants. No significant relationship (P = 0.509) was found between sex and the importance of the question (Chi-Square Test). In addition, the Chi-Square Test did not show a significant relationship (P = 0.678) between the number of questions and the importance of the questions. The chi-square Test showed a highly significant relationship (P < 0.001) between the importance of the question and the type of answer.

Conclusion

Associations were observed between the judged relevance of student-generated questions and their question and answer characteristics. These findings may provide preliminary insight into how students prioritize clinically relevant information. However, student-generated questions should be considered an exploratory proxy rather than a direct measure of critical thinking.

Introduction

Dental education is a challenging multi-dimensional learning endeavor¹ that involves the integration of theoretical knowledge, cognitive thinking, and clinical skill development.² This multi-task process puts dental students under considerable stress as they treat patients in their 4^th and 5^th academic year.³

Educational stress in a clinical environment can negatively influence students’ academic performance.⁴ This might also hamper students’ critical clinical reasoning. Critical thinking is a reflective process that encompasses clinical judgement and problem-solving processes.⁵ A stressful environment can affect the ability to reflect and judge. Some authors believe that clinical analytical reasoning requires more educational clinical exposure.⁶ Problem-based learning (PBL) and case-based learning (CBL) are adopted using realistic clinical cases.^7,8

However, we believe that clinical dental education needs to transcend theoretical knowledge in educational dental clinics. Clinical education needs to encourage analytical thinking among dental students. This not only helps them reflect on their knowledge but also creates a positive learning environment. Clinical education mandates analytical thinking and the ability to establish relationships between various diagnostic and treatment elements. Acquiring and recalling knowledge using analytical cognitive processing is as important as recalling/memorizing.⁶ This study aimed to explore patterns in student-generated questions as a preliminary proxy for aspects of critical thinking among fifth-year dental students.

The null hypothesis was that there would be no association between the question characteristics (number, type, and answer format) and the perceived importance of the selected topic.

Materials and Methods

This preliminary cross-sectional study examined student-generated question characteristics as an exploratory proxy for aspects of critical thinking among fifth-year dental students attending a theoretical lecture on TMD. All available fifth-year dental students attending the lecture during the study period were invited to participate, and 79 agreed to participate.

The study used a single stimulus: a standard 60-minute didactic lecture on TMD diagnosis and management. Immediately following the TMJ disorders lecture, the participants were given 15 minutes to write and answer their own question(s) with full freedom regarding format and topic choice.

Analysis

After receiving the answers, the questions were categorized according to the following categories: 1) number of questions; 2) type of question (enumeration vs short answer); and 3) relevance of the provided questions. Relevance was evaluated using a predefined 5-point scale (1= Of Little Use, 2 = Useful, 3 = Important, 4 = Very Important, 5 = Essential). The question relevance criteria are based on the scale provided in Table 1.

Table 1.

Relevance Criteria for Students’ Questions

Category	Example
Essential	Diagnostic criteria of TMD
Very Important	Treatment planning
Important	Radiographic indications
Useful	Epidemiological information
Of little use	Historical facts

Seventy-nine students agreed to participate in the study. Some students generated more than one question, resulting in 87 questions available for analysis. The analyses of question characteristics were performed at the question level. Descriptive and inferential analyses of question format and answer detail were therefore based on 87 observations.

The first and third authors evaluated all responses. They reviewed and evaluated the relevance of each question and reached a consensus regarding the degree of importance for all provided questions. The fifth Author reviewed the level of relevance and approved their evaluation.

The answer type was also considered in the evaluation criteria. The answers were divided into “simple” answers or “detailed” answers. A simple answer is a one-sentence answer, without further explanation or enumeration. A detailed answer refers to a multiple-sentence answer with an explanation, specification, or enumeration.

Statistical analyses were performed using SPSS Ver. 23. Descriptive and inferential statistics were used in this study. The primary unit of analysis was the individual question (n=87). To account for sparse cell counts (n<5) in cross-tabulations, Fisher’s exact test was performed alongside Chi-square analyses, and Cramer’s V was computed to report effect sizes. Statistical significance was set at P <0.05.

Results

A total of 79 students participated, of whom 60 (75.9%) were females, and 19 (24.1%) were males. No significant relationship (P = 0.509) was found between sex and the judged importance of the question (Chi-Square Test). In addition, the Chi-Square Test did not show a significant relationship (P = 0.678) between the number of questions (87 questions) and questions’ relevance.

Further analysis of question importance in relation to question format and answer type is presented in Table 2. Among point-format questions, the majority (76.4%) were classified within the “Of Little Use” or “Useful” categories, compared with 21.9% of short-sentence questions. A similar pattern was observed for answer detail: simple answers were predominantly associated with the “Of Little Use” or “Useful” categories (79.7%), whereas detailed answers were predominantly associated with the “Important” or “Very Important” categories (92.9%).

Table 2.

Importance of Students’ Questions by the Question’s Choice (Format) and Answer Type (N=87)

Variable	Of Little Use	Useful n (%)	Important n (%)	Very Important n (%)	Essential n (%)	Total	df	P value	Cramer’s V
	n (%)					n (%)
Question format
Questions requiring answers in points	26 (47.3)	16 (29.1)	9 (16.4)	2 (3.6)	2 (3.6)	55 (100.0)	4	<0.001	0.586
Questions requiring short-sentence answers	4 (12.5)	3 (9.4)	15 (46.9)	10 (31.3)	0 (0.0)	32 (100.0)
Answer detail
Simple answer	29 (49.2)	18 (30.5)	9 (15.3)	1 (1.7)	2 (3.4)	59 (100.0)	4	<0.001	0.745
Detailed answer	1 (3.6)	1 (3.6)	15 (53.6)	11 (39.3)	0 (0.0)	28 (100.0)

Most students preferred simple answers, with a nearly 2/1 ratio (Table 2). The chi-square tests showed highly significant associations between question importance and both question format and answer detail (P < 0.001). The association between question format and importance showed a moderate-to-strong effect (Cramer’s V = 0.586), whereas the association between answer detail and importance showed a strong effect (Cramer’s V = 0.745).

Further analysis of the importance of the question in relation to question choice and answer type is presented in Table 2. Students who chose the questions to be answered on points showed different levels of importance. The highest, however, was found within the “of little use category, which is by itself higher than the number of students who chose the “short sentence” question. Questions written by students in the latter group fell predominantly within the lower categories of importance. Most participants overall preferred simple answers, which correlated mainly with the “of little use” and “useful” categories. This contrasted sharply with the group providing detailed answers, where questions were significantly associated with higher levels of importance (“Important” or “Very important”).

Discussion

Critical thinking can be defined as a hierarchy of cognitive processes that involves information gathering and conceptualization. Critical thinking evolves when dental students become familiar with questions that encourage them to reflect on and conceptualize their thinking by establishing relationships between different information.^9,10 Students with critical thinking are more likely to be better equipped to comprehend the importance of the different aspects of the topic under study.¹¹ Memorization, however, remains an important element of education. It is the foundation that enables students to build arguments or reflect on their findings.¹² This means that both enumeration and short-answer questions must be implemented.

This study aimed to provide initial insights on senior dental students’ critical thinking through an exam simulation following a lecture on temporomandibular disorders. Temporomandibular disorders occupy a unique position in the educational experience of fifth-year dental students, shaped by the convergence of academic timing and psychological pressure. Under the Iraqi Dental Schools’ Curriculum, TMJ disorders are typically introduced during the final year of academic study. This coincides with the significant clinical and educational burden of the fourth and fifth years.^3,13 Stress has also been discussed in relation to temporomandibular disorders in previous studies.^14,15

As a well-known demographic fact, Iraqi dental schools have been dominated by female students.^16–18 This fact has remained unchanged over the last three decades. However, gender did not significantly influence the perceived importance of clinical topics in this study, suggesting that gender does not dictate how students prioritize inquiry significance.¹⁹

Preference for short-answer questions indicates an inclination toward conceptual thinking with a tendency for analysis and justification.²⁰ Such questions offer students an opportunity to express their thoughts coherently and reflect on relationships between different concepts. The study showed that almost all students who favored detailed answers chose either important or very important questions. This association may suggest that questions accompanied by detailed answers involve greater elaboration and reflection among students.

On the other hand, preference toward point-based tasks might suggest, among other things, their preference for more structured tasks with distinctive concrete facts.²¹ It might also suggest a cognitive attitude, which relies on memorization rather than synthesis.²² It might also reflect less pressure on thought organization. Such a preference may be associated with less emphasis on deeper conceptual processing.²³ This, in turn, emphasizes the important role of question design with deeper cognitive awareness, echoing other research findings.²⁴

Almost two-thirds of respondents preferred questions with simple answers. This suggests that students favor a straightforward method of scientific communication.²⁵ It might also suggest that participants approached the task partly from an examination-oriented perspective. However, this interpretation should be considered cautiously because the present exercise was limited to a single post-lecture setting.

A notable finding was that a substantial number of point-based questions were classified within the lower relevance categories. This pattern may reflect differences between the clinical importance assigned by the evaluators and the aspects of the lecture prioritized by students, highlighting the potential importance of active learning in supporting meaningful knowledge acquisition.²⁶ However, an alternative explanation should also be considered: students may prioritize demonstrating mastery of the material as presented rather than independently identifying its clinical importance, a pattern noted in other studies.^27,28

The patterns observed in this preliminary study may reflect aspects of how fifth-year dental students prioritize and organize information within this specific educational context. Clinical learning may also be influenced by contextual factors such as anxiety and perceived difficulty in the dental clinical environment.²⁹ These findings should not be interpreted as evidence of a general weakness in critical thinking. Structured problem- and case-based exercises, concept maps, and analytical assessment strategies may provide useful approaches for encouraging reflective and higher-order thinking in dental education.

This study has several limitations. It was conducted in a single educational setting and evaluated only one educational topic (TMD) and relied on a single lecture snapshot. Given the environmental variability of theoretical lectures, it is difficult to reproduce the exact environment in different lecture settings. The study results need to be interpreted with caution. The study relied on student-generated questions (a proxy measure), which has not been validated as a direct assessment of critical thinking. The observed associations can only provide preliminary evidence and should not be interpreted as establishing a direct measure of critical thinking.

Conclusion

In this preliminary single-institution, single-lecture study, associations were observed between the judged relevance of student-generated questions and their question and answer characteristics. These patterns may provide preliminary insight into how students prioritize clinically relevant information. However, student-generated questions represent an unvalidated proxy and should not be interpreted as a direct measure of critical thinking. Further studies using validated measures across multiple topics and institutions are required to confirm these findings.

Funding Statement

No external funding was received for this study.

Ethical Approval

This study was reviewed and approved by the Ethical Committee at Ibn Sina University of Medical and Pharmaceutical Sciences, Baghdad, Iraq (ISU.16.1.24) on 29/10/2024.

Informed Consent Statement

Participants were asked if they agreed to participate in this study. Students who agreed to participate were provided with a consent form to sign. This form explains the purpose of the study and the participant’s role. The form stated that they have the right to withdraw from the study at any time, and their personal information will be kept confidential.

Disclosure

The authors declare no conflicts of interest.