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 Table of Contents  
Year : 2021  |  Volume : 19  |  Issue : 2  |  Page : 92-99

Assessing dental education environment in India: Foundation for future-A systematic review

1 Department of Prosthodontics, Goa Dental College and Hospital, Bambolim, Goa, India
2 Department of Public Health Dentistry, Goa Dental College and Hospital, Bambolim, Goa, India
3 Department of Public Health Dentistry, Oral Health Sciences, PGIMER, Chandigarh, India

Date of Submission09-Nov-2020
Date of Acceptance20-Jun-2021
Date of Web Publication2-Aug-2021

Correspondence Address:
Kathleen Manuela D'souza
Department of Prosthodontics, Goa Dental College and Hospital, Rajiv Gandhi Complex, Bambolim - 403 201, Goa
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_205_20

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Little information is available on the quality of the learning experience perceived by the dental students in India. The aim of this study was to review the available evidence on the educational environment in Indian dental colleges using Dundee Ready Educational Environment Measure (DREEM). Several electronic databases and reference lists of the included publications were searched according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Quality assessment was performed based on the Joanna Briggs Institute checklist. Eight studies were found to meet the inclusion criteria. DREEM was commonly administered to the undergraduate dental students. The total number of participants included were 1,799. There was clinical heterogeneity in terms of outcome variables and study population. All the included studies reported a total mean score in the range of 101–150. The overall DREEM score indicated positive perceptions among students. Greater number of problem areas were recorded in student's perception of atmosphere and social self-perceptions. Least number of problem areas were recorded in students' perception of learning, teachers, and academic self-perception. Significantly low mean scores for the items “The teaching over emphasizes factual learning” and “The teachers are authoritarian” were also noted. This indicated that these areas of concern in the present educational system need to be addressed with effective intervention strategies.

Keywords: Dental student, dentist, education, India, perception

How to cite this article:
D'souza KM, Rajput S, Kumar A, Aras MA. Assessing dental education environment in India: Foundation for future-A systematic review. J Indian Assoc Public Health Dent 2021;19:92-9

How to cite this URL:
D'souza KM, Rajput S, Kumar A, Aras MA. Assessing dental education environment in India: Foundation for future-A systematic review. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2021 Oct 26];19:92-9. Available from: https://www.jiaphd.org/text.asp?2021/19/2/92/322861

  Introduction Top

The prevailing trends in clinical dentistry demand a “Paradigm shift” in the traditional dental education system, brought about by the emerging interdisciplinary approach to oral health care and evidence-based practice.[1],[2]

The traditional methods in dental education system need to be molded to encompass a dental curriculum that reflects a holistic and socially responsible approach to teaching and learning.[3],[4] Since the educational environment significantly influences the student's well-being, behavior, and academic success,[5] it is pivotal to identify and summarize research on student perceptions of their educational environment to propose an agenda in the future for substantive curriculum changes such as the addition of new technologies, interprofessional collaboration, evidence-based dentistry, and critical thinking.[6]

Although literature reports several survey-based instruments to assess students' perception of dental educational environment,[7],[8],[9] the Dundee Ready Education Environment Measure (DREEM) is frequently used as a survey instrument to diagnose deficiencies in the current educational environment.[5],[10],[11],[12],[13],[14] The DREEM inventory encompasses a closed-question questionnaire with 50 statements relating to five subscales, namely, Students' perception of learning (SPL), Students' perception of teachers (SPT), Students' academic self-perception (SASP), Students' perceptions of atmosphere (SPA) and Students' social self-perception (SSSP). The interpretation of the mean scores is presented in [Table 1].[14]
Table 1: Interpretation of mean Dundee Ready Educational Environment Measure, subscale and individual item scores

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With the application of the DREEM scale in the dental field worldwide, many authors have reported a “more positive than negative” educational environment and have demonstrated a positive association with the academic performance.[15],[16],[17],[18],[19],[20],[21],[22]

Although dentistry in India has seen an exponential boom of dental colleges in the last few years, with 313 operational dental colleges nationwide,[23] there is a woeful lack of knowledge of the students' perception of their educational environment. An amelioration of such knowledge is necessary to identify factors that have an impact on satisfaction of the students with the course of study and thus, enhance the quality of dental education. This review attempts to gather all available research on the students' perception of their educational environment in Indian dental colleges using DREEM to understand the effect of present teaching and learning methodologies on the educational environment encountered by the students.

  Methods Top

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) Statement.[24]

The focus question of the study is as follows: What is effect of the current dental educational system on the perception of the educational environment among Indian dental students?

Following the drafting of the research question, the prestated criteria for the participants, intervention, and outcome were clearly defined.[25] This was done to identify the eligible studies based on undergraduate dental students in Indian colleges (P, population) which recorded the students' perception of their educational environment by administration of the DREEM questionnaire (I, intervention), with the goal to evaluate the quality of students' experience of their learning environment in Indian dental colleges (O, outcome).

Search strategy and eligibility criteria

To identify qualified articles, a comprehensive literature search was carried out using PubMed/MEDLINE, Scopus, Google Scholar, and ResearchGate electronic databases based on MeSH and non-MeSH keywords in various combinations. The literature search strategy is summarized in [Figure 1] and [Table 2]. The literature review was conducted up to October 27, 2019, and manually updated till 30 December 2019 following cross-matching, identification of any gray literature, and relevant data.
Figure 1: Preferred repor ting items for systematic review and meta-analyses flow chart showing the number of publications identified, retrieved, extracted, and included in the final analysis

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Table 2: Search strategy (completed on December 30, 2019)

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Inclusion criteria were as follows: (1) Epidemiological studies with descriptive study design published in scientific databases from 1997 to December 2019, (2) Publications reporting educational environment in dental colleges/institutes in India using Dundee Ready Education Environment Measure (DREEM), (3) Publications reporting translation and/or validation of the DREEM for a different language were included if actual DREEM data was reported, (4) Publications in which target population involved undergraduate dental students and (5) Publications written in English.

Exclusion criteria were as follows: (1) Publications in which target populations were individuals other than undergraduate dental students (dental nurses, postgraduates, or dental technicians) and (2) Publications which used other questionnaires for educational environment evaluation such as Postgraduate Hospital Educational Environment Measure, Medical Education Environment Measure, Dental Clinical Learning Environment Inventory, etc.

Data extraction, quality assessment, and data analysis

Titles and abstracts from the studies obtained by the searches were independently screened by two reviewers (K. D., S. R.) to select studies that potentially met the inclusion criteria. Disagreements concerning the eligibility were resolved by consensus or if disagreement persisted, by arbitration through a third reviewer (AK). Following a thorough screening of the titles and abstracts, the full-text versions of potentially relevant papers were obtained.[25] These full-text articles were screened to identify the final set of full-text articles for inclusion in the study. Further, the reviewers independently scored the individual methodological qualities of the included full-text studies using the Joanna Briggs Institute Critical Appraisal Checklist for studies reporting prevalence data given in the manual for the systematic review of prevalence and incidence data.[26] The data in the articles were evaluated for quality of reporting, methodological rigor, and paradigmatic sufficiency. The acquired data was verified and classified as definitely present (yes), partially or unclearly present (not clear), definitely not present (no) or not applicable according to the questions in the checklist. Based on the overall appraisal, it was decided whether the article was included, excluded, or needed further information. In addition, risk of bias was also assessed to promote a sensitivity analysis of the methodological flaws. Studies that presented a prevalence of “yes” answers (>50%) in the quality assessment were deemed to have a low risk of bias, studies that did not clearly present many of the items assessed were classified to have a moderate risk of bias, while studies that presented a prevalence of “no” answers (>50%) were considered to have a high risk of bias.

The eight eligible full-text articles were thoroughly analyzed, using a heat map as shown in [Figure 2]. The heat map depicts a gradient of quality indicators for each included study. Colors vary from dark green (No), light green (unclear), and red (Yes) representing the three categories used in the quality assessment.
Figure 2: Heat map showing a gradient of quality indicators for each individual study included in the analysis

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After extraction of the outcomes from the included studies and grouping of the relevant findings, data concerning the educational environment in dental colleges in India were tabulated, as shown in [Table 3].
Table 3: Publication characteristics of the surveys included in the analysis

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  Results Top

A total of 823 research papers were found after the initial search. Around 156 papers were gathered following the elimination of the duplicate articles. Further elimination process based on the titles and abstracts resulted in 26 full-text articles that were eligible for screening. Further screening of the full-text articles resulted in eight studies that fulfilled the inclusion criteria. The following results were derived from the analysis of the included articles:

Study characteristics

The total number of individuals participating in selected studies were 1,799. These studies presented a much wider range of participants, varying from as few as 84[27] to as many as 326.[28]

DREEM was most commonly used with all 4 years of undergraduate students.[19],[20],[28] However, it has also been used with other sets of groups, including, only interns[22] and all graduates including interns.[29]

It has been used to explore several issues, which can be classified as follows:


Investigating the perception of the current educational environment and identifying areas of strength and weakness.[19],[20],[21],[22],[27],[28],[29],[30]

Comparison–different groups

Comparing students at different stages of their dental training,[19],[20],[21],[28],[29],[30] comparing different dental education institutions,[22] Comparing gender.[20],[21],[28]

Comparison–same groups

Comparing the actual environment experienced by students with the expected educational environment on commencement and completion of the 1st year of dental course.[27]

Relationship with other measures

Year of study[21],[22],[28],[29] and academic performance.[21],[22]

Reporting and analysis of DREEM data

All the authors have reported the means of subscales and the total score but only in few cases, individual items were reported. None of the articles have presented the percentages of the respondents who agreed, disagreed or were unsure for each item. The articles in which the aim was to diagnose problem areas, several authors have adopted the threshold for the mean approach recommended by the developers of DREEM.[5]

In some cases, where scores from two separate groups of students were compared, reporting was purely descriptive. However, usually either an independent samples t-test or Mann–Whitney U test is used. This choice does not appear to be related to sample size. When three or more groups required comparison, one-way analysis of variance was used, and further in-between group analysis was done using Bonferroni and post hoc test. The DREEM has also been used to investigate the association between perception of the educational environment and other measures such as academic performance using Pearson's correlation or multiple hierarchical regression.

Overall DREEM score in all the studies was “More Positive than Negative” with a total mean score reported in the range of 101–150. Interpretation of the subscale mean scores revealed that the lowest values were significantly recorded in the “perception of atmosphere”[20],[29] followed by social self-perception.”[19],[21],[27],[28],[30] Highest values were significantly recorded in “academic self-perception,”[19],[20],[21],[22],[29] followed by “perception of learning.”[28],[30] Only four out of eight included studies listed all 50 individual items with their mean scores. In most studies, the most positive points were as follows: “The teachers are knowledgeable and come well prepared for class,”[19],[20],[21],[22],[28],[30] “The students are confident about passing the year of study,”[19],[28],[30] “The students felt that much of what they learned seemed relevant to career in health care,”[28] “The students also felt that they have good friends and that governs a good social life and comfort within the classroom,”[20] “The students felt that they are encouraged to participate in class”[20],[27] and “The atmosphere in class is relaxed.”[27] Moreover, “The students felt that the teachers communicate well with the patients”[20] and “The students have developed empathy towards their patients during the course.”[22] Each subscale item indicating the problem area is thoroughly elaborated further in the discussion.

  Discussion Top

An ideal educational environment encompasses positive teaching and learning climate, a healthy balance between the students' social and academic atmosphere, and enhancement of the students' academic capability. This systematic review aims to examine the adoption of DREEM inventory in Indian dental colleges to evaluate the students' perceptions of their dental educational environment.

Numerous studies that have been conducted globally[5],[10],[11],[12],[13],[14] indicate that the DREEM scale is a reliable and valid instrument to quantitatively assess the educational climate in medical and allied health professions. DREEM is considered favorable since it is a culturally nonspecific assessment tool that has been validated by thousands of students across the globe and implemented in more than 20 countries.[5],[10],[11],[12],[13],[14] It has been used to quantitatively evaluate the educational climate of trainee health professionals. It helps to identify the problem areas within a system. Moreover, DREEM is a precursor to curriculum change and it helps to evaluate the effect of a new or revised curriculum on perception of educational climate.[13],[31],[32],[33] In addition, it allows comparative analyses of students' perceptions of the educational climate within and between institutions or between different groups within an institution.[12],[34],[35],[36] It assesses the perceptions of the educational climate and learning styles as related to grade point averages and acts as a predictive tool to identify academic achievers.[12],[21],[37],[38]

Findings from this review indicate that although DREEM has been validated and used for evaluation of educational environment across the globe, very few studies have been conducted in the field of dentistry in India. For this study, the range of inclusion criteria was broad to allow the inclusion of more number of articles to evaluate the general attitude of the students towards their teaching and learning process. Hence, the search terms and dates were expansive. All articles were scrutinized by two investigators to minimize selection bias of included articles and errors during the review process. Despite the expansive search dates, mostly included studies were conducted in the past 5 years indicating that there is an increased awareness among the Indian dental educators for a need to evaluate the students' perspective to draw out a road map for a revised dental education system.

All the eight included observational studies were cross-sectional, which included students attending undergraduate dental courses and followed convenience sampling to acquire the study population. In the future, studies with cohort study design and larger sample sizes need to be undertaken to accurately understand the changing behavior of the same batch of students over time. Marked clinical heterogeneity in terms of outcome variables and study population was noted. This review included studies conducted in private as well as government dental institutes. Furthermore, it included different batches of students within the same institution.

This is the first systematic review of the literature on the adoption of DREEM in the Indian dental setting. Although most PRISMA guidelines are satisfied in this study,[24] a few limitations were encountered. The search included only English language peer-reviewed journals to reduce problems associated with interpretation. Most of the included studies were cross-sectional in nature which makes the adoption of DREEM questionable. In addition, although a comprehensive search strategy was followed, there is a likely hood of not identifying an article pertinent to this systematic review.

Moreover, included studies were judged to present a low risk of bias, since most studies presented the items analyzed. The drawback concerning was the fact that most of the studies were done in private colleges, limiting the generalizing of this matter because of better infrastructure, teacher students fraternization, and less workload compared to government colleges.

The overall DREEM score was used as the main outcome variable, which was used to assess the effectiveness of these studies. Most of these studies reported scores that indicated that the educational environment is perceived to be “more positive than negative” by dental students in India. This was comparable to the DREEM studies conducted in other parts of the world.[16],[17],[18],[39],[40],[41],[42],[43],[44],[45] This can be attributed to a more student-centered curriculum. Moreover, with measures undertaken to identify areas of concern from the students' perceptive in recent years, the dental education system is constantly evolving and various changes have been implemented in the content, structure, and quality of the dental curriculum.

A Cohort study conducted by Farooqi et al.[46] in Saudi Arabia among the 1st year dental students, which reported a difference in the students' expected (114.47) and actual (105.5) perceptions of their educational environment at the commencement and the completion of their academic session respectively. This was attributed to the lack of experience of the students as they transitioned from high school to college. Ahmad et al.[34] and Kang et al.[47] conducted similar studies among dental students in Saudi Arabia and New Zealand respectively. Moreover, in India, Motghare et al.[27] reported a decline in the overall DREEM score from 147.8 among freshman students to 124.6 among 1st-year students after completion of their 1st year of study. Other factors affecting this decline included a shift in teaching and learning patterns in high school and dental institutes and an increased workload.

This review reported that the lowest DREEM score was significantly recorded among the final year Indian dental students as compared to students in another year of study.[19],[20],[29],[30] There is evidence that the final year students experience a highly demanding learning environment owing to a stressful dental curriculum that requires the acquisition of essential clinical and patient management skills.[48],[49] Various sources of stress have been identified, namely, completion of the work quota within the allocated clinical time, academic preparation and procurement of good grades in examination, lack of patient support, the complexity of patient and course work, and fulfillment of the clinical requirements of the course.[50]

The Highest DREEM score was recorded in the 3rd year group which can be attributed to the excitement associated with the shift from a preclinical setting to a controlled and supervised clinical setting with first-time patient interactions.[19],[29] Nevertheless, Highest DREEM scores were also recorded in the 1st year group[28],[30] and the second year group,[20] wherein the students perceived a better learning environment in their preclinical phase of the study as compared to their clinical phase.

The higher mean scores in SASP subscale indicate the students' confidence in their academic skills. This stems from a student-centered curriculum that promotes long-term learning and problem-solving skills.[21] The lower mean scores in SSSP subscale are associated with the stressful and demanding nature of the dental curriculum.[21]

The review also reveals the frequently encountered problem areas in each subscale. Evaluation of the SPL subscale revealed that although students have a positive perception, students felt that the teaching is too teacher-centered and there is over-emphasizes of factual learning.[20],[21],[22],[27],[28],[30] This is attributed to the summative assessment pattern carried out for dental students, which focuses on the outcome of the program.

Evaluation of the SPT subscale identified the following problem areas: “The teachers ridicule the students,” “The teachers are authoritarian,”[21],[22],[27],[28],[30] “Students feel they irritate the teachers,”[19],[21] “The teachers get angry in class,”[28] “Teachers fail to provide constructive criticism,”[27] and “Teachers fail to emphasize patient-centered care during clinical teaching sessions.”[20] This has been attributed to the conventional teaching style employed[20] and the difference in teaching methods in high school and dental institutes.[27]

Evaluation of the SASP revealed the following problem areas: “Students are unable to memorize all that is needed,”[20],[21],[22] which was associated with academic overload and summative assessment methods used for student evaluation.[22]

Evaluation of the SPA revealed the following problem areas: “Cheating is a problem,”[20],[21],[22],[27],[28],[30] “Students find the experience disappointing,”[19],[22],[30] and “The stress outweighs the enjoyment of studying dentistry.”[19],[30] This indicates that the students are concerned about academic dishonesty and the stress is associated with achieving high scores in examinations.[22]

Evaluation of the SSSP revealed the following problem areas: “There is no good support system for students who get stressed,”[19],[20],[21],[22],[28],[30] “Students' get bored;” “feel lonely” and are “too tired to enjoy the course.”[19],[20],[21],[27],[28],[30] This is associated with a lack of leisure time due to tedious academic and clinical workload, poor academic scheduling.[22],[51]

Although the review indicates that the educational environment is “more positive than negative,” the conclusion derived from the interpretation of the problem areas suggested a need for desperate change in the traditional teaching methodologies and course content utilized in the teaching/learning process, a revised assessment protocol employed to evaluate the students and a need for proficient support staff to handle anxiety among students during their dental course.[28] In addition, it is the teacher's responsibility to develop good interpersonal skills with students, to promote a healthy learning environment. Periodic reorientation for teachers should also be made mandatory.[22]

The educational environment is multi-factorial involving a confluence of various elements, such as learning, teaching, academic self-perception, social self-perception, and self-perception of the general atmosphere. DREEM is a valid tool to ascertain the educational environment of an institute or university. The results obtained in one population can be compared to results obtained in another group of people either within the same country or in a different part of the globe. Since very few studies were available for analyses and there was marked clinical heterogeneity and nonuniformity in data reporting and analysis, more studies need to be conducted to analyze the educational environment and the associated strength and weakness of the dental educational system in India, with greater transparency and uniformity of approach in data reporting and analysis.

  Conclusion Top

Within the limitations of the study, the overall DREEM score indicated positive perceptions among students for their educational environment. On the evaluation of the subscales and individual items, it was concluded that more statements associated with problem areas were recorded in SPA and social self-perceptions. The least number of problem areas were recorded in SPL, teachers, and academic self-perception. Although only four out of eight included studies listed all 50 individual items with their mean scores, it was noted that low mean scores in the items “The teaching over emphasizes factual learning” and “The teachers are authoritarian” indicated that these are major points of concern in the present educational system.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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