Clinical Reasoning in Dentistry: A Conceptual Framework for Dental Education

Objectives. To describe the process and strategies of clinical reasoning used by dental clinicians across different levels of expertise to develop a conceptual framework for curricular design and assessment of competency. Methods. Using “think-aloud” method, we interviewed 18 dental students about biopsychosocial issues influencing oral health identified in 6 vignettes; and 8 orthodontic residents plus 11 orthodontists about problems of craniofacial growth and malocclusion presented in 2 vignettes. The interview transcripts were analyzed to explore the process and strategies of clinical reasoning used. Results. The reasoning process in both groups included: 1) a ritualistic approach to collect information for a treatment plan; 2) forward and backward reasoning to make and test hypotheses from clinical information; 3) pattern recognition and an integrated script of knowledge and experience triggered by related attributes of the script leading to a clinical diagnosis and plan; and 4) decision trees to evaluate treatment options and maximize the probability and utility of outcomes. Seven reasoning strategies (scientific, conditional, collaborative, narrative, ethical, pragmatic and “part-whole”) were used by both groups. However, experienced clinicians were more confident in their appraisal of uncertain situations and dilemmas as they integrated several reasoning strategies in the process; used refined scripts of knowledge and experience in familiar situations; and were able to reflect on the impact on their reasoning of the larger social, cultural and political context. Conclusions. Clinical reasoning in dentistry is a contextual and interactive phenomenon that requires integration of specific reasoning strategies to address the biopsychosocial factors influencing oral health. Grants. This study was supported by the Institute for the Scholarship of Teaching and Learning at University of British Columbia, Vancouver, Canada