Predoctoral Dental Education

Comparing Case-Based with Team-Based

Learning: Dental Students’ Satisfaction,
Level of Learning, and Resources Needed
Colin M. Haley, Blase Brown, Anne Koerber, Christina L. Nicholas, Anne Belcher
Abstract: The aims of this study were to compare third-year dental students’ satisfaction and level of learning in case-based
learning (CBL) versus team-based learning (TBL) and the resources required in those two methodologies. Level of learning was
assessed for both knowledge and application, and resources were defined as student and faculty time and rooms. In academic year
2018-19, all 68 third-year dental students in one U.S. dental school were enrolled in two sequential semester-long courses; the
first used CBL, and the second used TBL. After each course, students and faculty facilitators completed surveys, and data from
students’ knowledge and application exams were collected. The student surveys asked students to report their satisfaction with
the learning methodology (CBL or TBL); the faculty surveys asked the faculty facilitators to report the resources used for each
methodology. Forty-five of 68 students (66%) consented to participate; however, a larger number of students completed surveys
in the two semesters (69% for CBL and 87% for TBL). Fourteen of 16 (88%) faculty facilitators completed the CBL survey, and
five of the six (83%) completed the TBL survey. Overall, the results showed that students’ satisfaction was higher with CBL
than TBL (Mann-Whitney U=882.0; p<0.001), and students reported having a better understanding of concepts after CBL than
TBL (U=899.0; p<0.001). The students performed better on knowledge exam items in TBL than CBL (86% vs. 82%) but the
same on application items (both 86%). Resource requirements for both methods were extensive, with TBL requiring fewer
facilitators and rooms than CBL but requiring more time from both students (2.6 vs. 2.3 hours weekly) and faculty members
(2.3 vs. 1.4 hours weekly). In this study, students preferred CBL to TBL but had higher knowledge scores in the TBL course. The
resources needed for both CBL and TBL were said to be extensive, with infrastructure use higher for CBL but time for students
and faculty higher for TBL.
Colin M. Haley, DDS, is Clinical Assistant Professor and Assistant Director of Group Facilitation, Department of Oral Medicine
and Diagnostic Sciences, College of Dentistry, University of Illinois at Chicago; Blase Brown, DDS, MS, is Clinical Associate
Professor and Director of Group Facilitation, Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, University
of Illinois at Chicago; Anne Koerber, DDS, PhD, is Professor and Director of Educational Assessment, Department of Oral Medicine
and Diagnostic Sciences, College of Dentistry, University of Illinois at Chicago; Christina L. Nicholas, PhD, is Research Assistant
Professor, Department of Orthodontics, College of Dentistry, University of Illinois at Chicago; and Anne Belcher, PhD, RN,
is Clinical Associate Professor, School of Education, Johns Hopkins University. Direct correspondence to Dr. Colin M. Haley,
University of Illinois at Chicago College of Dentistry, 801 S. Paulina St., Chicago, IL 60612; 312-413-8317; chaley1@uic.edu.
Keywords: dental education, educational methodology, case-based learning, team-based learning
Submitted for publication 7/29/19; accepted 11/19/19; first published online 12/23/19
doi: 10.21815/JDE.019.190

M
any dental schools face resource limita-
tions in implementing active learning
strategies. Active learning strategies
that support development of critical thinking and
problem-solving skills are encouraged by the Com-
mission on Dental Accreditation (CODA) as a way
to provide a learning environment that fosters critical
thinking and self-directed learning in the context of a
humanistic setting.1 Nadershahi et al. noted that the
1995 Institute of Medicine report on dental education,
which called for the use of more active and integra-
tive learning strategies, encouraged educators to
challenge traditional lecture-based dental education.2
Problem-based learning (PBL) has become
widespread in dental education, with 50 U.S. dental
schools reporting use of some form of PBL in 2009.3
The University of Illinois at Chicago (UIC) Col-
lege of Dentistry has used a mixture of hybrid PBL
and case-based learning (CBL) methods under the
umbrella term of small-group learning (SGL), as all
iterations involve small groups of students working
with a case scenario and a facilitator. Variations
of this approach have been used in all four years
of the UIC DMD curriculum since 2011. Student
satisfaction as evaluated by course evaluations has
been average to above average. However, SGL is

Published online ahead of print 23 Dec. 2019  ■  Journal of Dental Education e1

 resource-intensive since each small group requires
a conference room and faculty facilitator.
Recent research has provided support for the
use of team-based learning (TBL). A review pub-
lished in 2013 found that TBL significantly increased
scores on knowledge-based assessments, but student
satisfaction was not greater for TBL when compared
with other instructional methods.4 Those authors
also noted that the outcomes discovered were likely
not generalizable due to the poor study design of
many of the included studies. Other studies have
compared PBL and TBL, finding that TBL was less
resource-intensive5 and that students preferred TBL
to PBL due to the immediate feedback and learning
in a more time-efficient manner.6 Studies have also
found that TBL improved critical thinking skills and
long-term retention of information7 and that students
in TBL achieved higher levels on Bloom’s taxono-
my.8 Bloom’s taxonomy is a hierarchical ordering
of cognitive skills, with the less complex levels of
learning on the bottom of the pyramid and higher
order thinking skills at the top. The lowest level is
knowledge followed by comprehension, application,
analysis, synthesis, and evaluation.
Few studies have examined TBL use in dental
education curricula. Two studies that compared the
effects of TBL to traditional education (conventional
lecture-based delivery of content) in removable par-
tial denture courses found that TBL increased scores9
and student satisfaction.9,10 Another study conducted
in Japan by Takeuchi et al. found similar results,
with students rating TBL and active group discus-
sion highly.11 In that study, students also performed
better on end-of-term examination items for content
covered in TBL vs. items covered in traditional
lecture sessions. We were unable to find any studies
that compared CBL and TBL methodolo­gies in health
professions education.
Table 1. Comparison of problem-based learning, case-based learning, and team-based learning
Characteristic Problem-Based Learning
Advanced preparation required No
Facilitators 1 per small group
Facilities Conference room
Open or guided inquiry Open
Activities 1. Identify knowledge gaps
2. Research gaps
3. Report findings
IRAT=individual readiness assessment test, TRAT=team readiness assessment test
e2 Journal of Dental Education  ■  Published online ahead of print 23 Dec. 2019
PBL is an open inquiry-based learning method
that incorporates a problem for which a small group
of students, with the help of a tutor or facilitator, must
provide a viable resolution.12 In the learning process,
students identify existing gaps in knowledge, while
investigating learning issues (unknowns) designated
by the PBL team that are critical to comprehension
of the patient problems depicted in the case scenario.
Typically, the PBL process occurs over a number of
days, so that students can identify areas where further
information is needed, with facilitators assisting in
the scaffolding of students’ learning.
While CBL and TBL have factors that dis-
tinguish them from each, commonalities exist.
Each method promotes student-directed learning
in collaborative settings through engagement with
problems while developing self-directed learning
habits (Table 1). CBL is a guided inquiry-based
learning method that uses realistic patient cases
to demonstrate relevance to students and connect
theory to practice.13 A distinguishing factor of CBL
in contrast to PBL is that CBL is most effective
for students who already have strong foundational
knowledge of a topic, while PBL encourages students
to learn foundational knowledge while performing
research on a clinical case.2 CBL also has a facilita-
tor or faculty guide unlike PBL. However, CBL can
occur in a large or small group. CBL uses a more
structured approach than PBL to student discussion,
often with specific questions provided. Faculty
members may use a wide variety of instructional
methods under the umbrella term of CBL, ranging
up to methods that more closely resemble a lecture
but with the addition of patient cases. The lack of
uniformity in approaches to CBL has made it dif-
ficult to quantify the educational outcomes of this
instructional method.
Case-Based Learning Team-Based Learning
Yes Yes
1 per small group (varies 1 or 2 per large room (many
by institution) groups in large room)
Conference room Large room
Guided Guided
Specific prompts or ques- 1. IRAT/TRAT
tions about case scenario 2. Application exercises
(varies by institution)
 TBL (Figure 1) is another form of collabora-
tive learning, which may use a flipped classroom
with students’ coming to sessions having already
addressed preparatory materials. TBL sessions take
place in large rooms with multiple small groups that
meet at the same time. TBL sessions begin with an in-
dividual readiness assessment test (IRAT), followed
by a team readiness assessment test (TRAT), both of
which feature the same fact-based multiple-choice
questions. These assessments are followed by a short
clarifying presentation if needed. The majority of the
time is spent on application exercises: problems that
require groups of students to analyze the content from
the preparatory materials and make a specific choice
based on their analysis as supported by evidence.
Our hybrid model of CBL at UIC uses small
groups of students (each in their own conference
room as opposed to multiple small groups in a large
room) who work with a facilitator. Students are pre-
sented with patient cases that require application of
knowledge learned from previous courses and prepa-
ratory materials. Questions are asked in the context
of cases, in contrast to the open inquiry seen in PBL.
A difference between traditional CBL and the ver-
sion used at UIC is that we also spend time in small
groups reviewing factual information, in addition to
application of knowledge to cases. In this way, we
address the first three levels of Bloom’s taxonomy
(remember, understand, and apply).
The aims of this study were to compare third-
year dental students’ satisfaction and level of learn-
ing in CBL versus TBL and the resources required
in those two methodologies. Level of learning was
assessed for both knowledge and application, and re-
sources were defined as student and faculty time and
rooms. Providing information on our students’ expe-
riences, resource utilization, and level of cognitive
Pre-class
Preparaon study Readiness
Assurance
materials
Figure 1. Typical team-based learning format
IRAT=individual readiness assessment test, TRAT=team readiness assessment test
Published online ahead of print 23 Dec. 2019  ■  Journal of Dental Education
learning achieved may assist other dental schools as
they move towards implementation of sustainable,
cost-effective, and evidence-based active-learning
strategies.
Methods
This study was approved by the Institutional
Review Boards at the University of Illinois at Chi-
cago (protocol #2018-0944) and Johns Hopkins
University (protocol #HIRB00008147). Participants
were third-year students and their faculty facilitators
at UIC who participated in an Oral and Systemic Top-
ics in Dentistry course in two semesters, the first of
which followed a CBL methodology and the second
of which used a TBL methodology.
Course Description
This three-semester course sequence is for
third-year dental students; in 2018-19, the course had
an enrollment of 68 students. This series of courses
includes advanced standing dental students (inter-
nationally degreed dentists), but we did not include
those students in this study as they had prior exposure
to TBL during their previous summer semester, un-
like the other predoctoral students. We also excluded
the advanced standing students because their varied
prior educational experiences in their home countries
constituted a complex and difficult confounding vari-
able, which would have been hard to account for in
the analysis.
The entire course uses a small-group method-
ology, with each group (nine groups with eight or
nine students in each group) requiring a conference
room and faculty facilitator. In fall 2018, the course
used a small-group CBL discussion. Each student
•IRAT
•TRAT
Applicaon •Applicaon
•Queson of Course exercises
appeals
Concepts •Discussion
•Instructor
feedback
e3
 was part of a small group that met once a week in
a conference room to discuss a patient-based case.
Preparatory readings and open book online quizzes
were required prior to attending small-group sessions.
In spring 2019, a TBL format was introduced with
the same students. Three larger rooms were used with
multiple small groups in each room facilitated by one
or two faculty facilitators. This method reduced the
resource need for both rooms and facilitators. TBL
was conducted twice a week in comparison to once
a week for CBL, increasing the in-class time com-
mitment for students. The twice a week commitment
for TBL was needed as the IRAT and TRAT take a
significant portion of class time, and additional time
is needed to adequately cover objectives in the ap-
plication exercises.
While the content of the CBL and TBL semesters
was different, the overall objective was the same for
both: “Given a patient scenario with orofacial and sys-
temic diseases and conditions and/or behavioral issues,
students in this course will apply relevant basic sci-
ences, clinical sciences, and biomedical concepts to
develop a management plan of oral health care using
interprofessional and interdisciplinary approaches
at a general practitioner entry level.” Unfortunately,
we did not have the resources to conduct a study
that used the same content with both CBL and TBL
methodologies. Both courses presented independent
material through a variety of patient cases, so an
understanding of the material presented in the CBL
course was not essential to students’ understanding
of the material in the TBL course. In this way, per-
formance in the TBL course was not dependent on
mastery of concepts presented in the CBL course.
Study Design
We introduced the study to D3 students during
an introductory session to the semester. We collected
three forms of data in both the CBL and TBL courses:
students’ satisfaction measured with a post-course
survey; students’ knowledge and application exam
scores at the end of the course (demonstrating their
level of learning); and required resources (student/
faculty time, rooms) for each methodology as re-
ported by the faculty facilitators.
At the end of the fall semester (CBL), we
forwarded a Qualtrics link to the survey about the
CBL experience to the D3 class listserv, thus avoid-
ing the advanced standing students. We had created
the survey instruments and validated them with
two focus groups of eight third-year students who
e4 Journal of Dental Education  ■  Published online ahead of print 23 Dec. 2019
provided feedback and suggested revisions for survey
items. Additional validation of the instruments was
accomplished through faculty review of suggested
revisions. The survey had 13 Likert scale questions
(response options of 1=strongly agree, 2=agree,
3=neutral, 4=disagree, 5=strongly disagree) that
asked about students’ satisfaction, workload, advance
preparation, facilitator effects, communication, and
group dynamics. In addition, two open-ended ques-
tions asked about students’ perceived strengths and
weaknesses of the small-group, hybrid CBL method.
The faculty facilitators who agreed to participate in
the study completed a faculty survey, which we also
created. This faculty survey was validated in a simi-
lar manner as the student survey by asking faculty
members to review their understanding of the ques-
tions. However, the final faculty survey consisted of
only two questions, asking facilitators about their
time spent preparing for sessions and assessing their
familiarity with content. The student and faculty
surveys are available from the corresponding author.
At the end of the spring semester (TBL), an-
other student survey was sent to the same students as
in the previous survey. Again, respondents reported
their satisfaction, preparation time, and pro/cons on
the same scale. An additional question asked them
which instructional method they preferred and why.
Faculty facilitators in this spring course completed
the same faculty survey as in the fall. However,
fewer facilitators were needed in the spring, so the
group was considerably smaller. The course direc-
tor created an inventory of the number of hours,
facilitators, and rooms needed for preparation and
implementation of each method to further account
for resource utilization.
Since the surveys did not collect identifiers,
we were unable to determine if all respondents had
initially consented to the study as a whole. However,
the survey cover letter specified that response was
voluntary, so completion of surveys (both student and
faculty) implied consent to the survey and allowed us
to use submitted responses in our analysis. All survey
responses from students and faculty were submitted
anonymously via Qualtrics, so all quantitative and
qualitative data from surveys were analyzed without
identifiers being present.
We also evaluated the level of learning achieved
in both the CBL and TBL courses using assessments
of knowledge and application from the course. In
each course, three non-cumulative examinations were
administered, each after four weeks of material were
discussed. There were 30-40 questions per exam, in
a combination of multiple-choice and short-answer
questions (one or two per exam). We used only the
multiple-choice questions in this analysis. Two fac-
ulty raters had examined the multiple-choice ques-
tions and assigned a level of learning rating to each
that aligned with Bloom’s taxonomy. Questions were
either categorized as knowledge-based (testing basic
recall) or application questions that required use of
information in new situations. During the CBL se-
mester, we had several sessions that related to basic
research statistics.
An example of a knowledge question was as
follows: “When a researcher compares groups with
a statistical test, there is a cut-off point in the p-value
that helps the researcher decide whether there is a sig-
nificant difference between groups. Groups are usually
deemed significantly different if the p-value is____.”
Response options were a) less than 0.05, b) more than
0.05, c) less than 0.10, and d) more than 0.10. An
example of an application question was as follows:
“Please refer to the handout (research paper abstract
and pertinent figures) to answer this question: what is
the main outcome variable in this paper?” Response
options were a) the severity of myofascial pain
symptoms, b) the treatment (education vs. splint),
c) patient report of self-care, d) patient knowledge,
and e) splint therapy.
A faculty member unaffiliated with the course
obtained students’ consent to use their exam scores
in the study. This faculty member collated the exam
results, removing those of the students who did not
consent to participation in the study. At the end of
both semesters, we analyzed the assessment data to
determine if there were differences in student perfor-
mance between CBL and TBL groups on items that
addressed knowledge or application. An item analysis
was performed prior to inclusion of questions in the
study in order to remove poorly performing or non-
discriminatory items. We analyzed the quantitative
data using MANOVA and regression analysis using
Excel and SPSS, and we used qualitative analysis
on responses to the open-ended questions. We used
a repeated measures MANOVA to compare the stu-
dents’ performance on knowledge and application
exam questions for each instructional method.
Results
Forty-five of 68 students (66%) consented to
having their scores from both courses used in the
study. One student did not complete the D3 year,
Published online ahead of print 23 Dec. 2019  ■  Journal of Dental Education
making the final number 44/67 students consenting
(66%). A higher than expected number of individu-
als completed the surveys for both courses: 46/67
(69%) students completed the survey for the CBL
method, and 58/67 (87%) completed the survey for
the TBL method. Twenty-four of 44 (54.5%) students
completed the qualitative portion of the CBL survey,
and 29 of 58 students (50%) completed the qualitative
portion of the TBL survey. Fourteen of 16 facilitators
(88%) completed the faculty survey for CBL, and
five of the six (83%) completed the faculty survey
for TBL. We included the added survey responses
in our analysis as completion of the survey implied
consent for the survey portion of our study.
Student Surveys
Overall, the responding students rated their sat-
isfaction higher for CBL than TBL (Mann-Whitney
U=882.0; p<0.001; CBL median was satisfied,
TBL median was neutral) (Figure 2). The students
reported that class sessions contributed more to
their learning in CBL than in TBL (U=746.0; me-
dian CBL=2.0 (agree), TBL=2.5 (agree to neutral);
p<0.001). The students reported that concepts and
principles were better understood in CBL than in
TBL (U=899.0; p<0.001; 87% agreed or strongly
agreed in CBL compared to 58% in TBL). These
students rated higher improvement in their ability
to communicate with others in CBL than in TBL
(U=891.0; p<0.001; CBL median was agree, TBL
median was neutral).
We identified common themes in the qualita-
tive portion of the surveys by reviewing student
responses and pulling out similar comments that
appeared in more than ten and by linking find-
ings from the quantitative portion with student
comments. We then extracted representative com-
ments. In sample comments, one student said CBL
was “easier to participate in,” and another noted
having more opportunities “to learn from peers in
a stress-free environment.” Most students preferred
the small group format of CBL over TBL as they
reported feeling more comfortable participating and
asking questions of their peers. Those who preferred
TBL reported that they liked that they were, as one
said, “held accountable for learning,” and another
noted, “Weekly quizzes made sure we keep on top
of material.” However, many students felt that they
were self-taught with little guidance in TBL and that
there were fewer opportunities for in-depth discus-
sions. Many students expressed dissatisfaction with
e5
 Student Survey Responses
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Sasfacon with learning In class session contributed to Concepts and principles Improved ability to
method my learning related to case objecves communicate with others
were well understood

CBL TBL
Figure 2. Mean student responses on survey items in case-based learning (CBL) and team-based learning (TBL) courses:
CBL N=46, TBL N=58
Note: Response options were 1=strongly agree, 2=agree, 3=neutral, 4=disagree, and 5=strongly disgree. Error bars represent 1 standard
deviation. All differences between CBL and TBL were significant at p<0.05.

the rigid approach to learning in TBL, noting there

was not enough time for discussion or questions
but too much time devoted to quizzes. The larger
group format also caused consternation; in typical
comments, one student reported feeling “lost in the
shuffle,” and another said the rooms “were too noisy
to concentrate.” Interestingly, a common complaint
of both CBL and TBL was that students felt that
they were teaching themselves most of the content
and that most of the learning occurred outside the
classroom.
Students’ Exam Performance
The students’ mean performance on knowledge
items in CBL was 82% (SD=8%) vs. 86% (SD=8%)
in TBL. Their performance on application items
in CBL was 86% (SD=12%) vs. 86% (SD=7%)
in TBL. There was an interaction effect between
the knowledge/applied variable and the TBL/CBL
variable, so that the CBL students showed a greater
difference between knowledge and application than
did the TBL students (F=4.29; df 1 & 44; p=0.044).
Students performed better on application items than
on knowledge items in CBL (F=5.14; 1 & 44 df;
p=0.028). In overall performance, the students had
a mean exam grade in CBL of 83% (SD=8%) vs. a
mean grade in TBL of 86% (SD=7%); the difference
was significant (F=4.22; 1 and 44 df; p=0.046).
Faculty Surveys
Faculty facilitators were asked two questions:
about preparation time and about familiarity with
material. There was a large difference in the number
of facilitators in each semester (due to a reduced need
for facilitators in TBL), leading to a smaller sample
size (N=5) for TBL facilitators. In the Mann-Whitney
U test, the first question on preparation time showed
group differences (U=9.5; p=0.03), with facilitators’
spending more time preparing for TBL (median=two
to three hours) than CBL (median=zero to one hour)
(Figure 3).
The course director for both courses kept a
log of required resources throughout both the CBL
and TBL semesters. That data showed that the CBL
course required five small conference rooms three
days per week while TBL required three larger
rooms two days per week (Figure 4). CBL required
15 facilitators throughout the semester, while TBL
required only five. Facilitator and student prep time as
reported in the facilitator and student surveys showed
a lower number of preparation hours for CBL than
TBL. Faculty facilitators reported 1.4 hours each
week of preparation time for CBL vs. 2.3 hours for
TBL, while students reported an average of 2.3 hours
of preparation time per week for CBL (SD=0.906)
vs. 2.6 hours for TBL (SD=1.1; p=0.1).

e6 Journal of Dental Education  ■  Published online ahead of print 23 Dec. 2019

 Preparaon Time
4
3.5
3
2.5
2
1.5
1
0.5
0
Facilitator Prep (in hours/week) Student Prep (in hours/week)
CBL TBL
Figure 3. Mean preparation time (in hours/week) reported by faculty and students for case-based learning (CBL) and
team-based learning (TBL) courses: CBL faculty N=14, students N=46; TBL faculty N=5, students N=58
Note: Difference between CBL and TBL on faculty responses (p=0.03) was significant at p<0.05; difference for students was not
significant (p=0.1).

Room and faculty facilitator needs
16

14

12

10

0
Room Needs (# of rooms required/week) Facilitator Needs (# of facilitators
required/week)
CBL TBL
Figure 4. Room and faculty facilitator needs in case-based learning (CBL) and team-based learning (TBL) courses
reported by course director

performance overall was better in TBL than CBL. Re-

Discussion source use in both methods was intensive. Although
TBL needed fewer rooms and faculty facilitators than
Hyun et al. found that students preferred active
did CBL, it also required more preparation time for
learning strategies over lecture-based methods.14
students and faculty.
Our search of the literature found a lack of studies
Previous studies found that students preferred
that compared CBL to TBL. Our study found higher
CBL to PBL15 and TBL to PBL6 due to the guided
student satisfaction and perceived understanding of
nature of the instructional methods. While CBL and
the subject matter with CBL than TBL, while student
TBL are both guided inquiry methods, TBL is a

Published online ahead of print 23 Dec. 2019  ■  Journal of Dental Education e7

 more structured approach to learning with multiple
opportunities for formal formative assessment. Both
CBL and TBL use a flipped classroom approach,
making advanced student preparation a centerpiece
prior to applying knowledge. This advanced student
preparation was found to lead to additional work for
students in one study, but also provided the perceived
benefit of enhancing self-directed learning skills.16
In our study, a common complaint in the qualitative
responses for both methods was the additional work
required and students’ feeling they were teaching
themselves the content instead of learning from
faculty.
These characteristics are typical of active
learning strategies and consistent with the concept of
self-directed learning. According to Merriam et al.,
the goals of self-directed learning include develop-
ing lifelong learners who can “plan, carry out, and
evaluate their own learning.”17 Incorporating learn-
ing strategies that use active, self-directed learning
inherently requires more work on the students’ part.
Deslauriers et al. found that, in active learning, there
was a negative correlation between students’ feel-
ings about learning and their actual learning, with
students feeling less positive about active learning
strategies but performing better when compared to
traditional lecture-based instruction.18 This reaction
may require instructors to implement strategies that
prime students for active learning in order to improve
their initial response to these types of instructional
methods.
The students’ comments suggested that their
preference for CBL over TBL occurred for a number
of reasons. Students reported that in CBL they had
more opportunities for discussion and were able to
cover objectives more thoroughly than in TBL. They
commented that the small group format in CBL led to
a lower stress environment that was more conducive
for participation, while they said TBL created a nois-
ier environment, making it difficult to concentrate.
Those who preferred the TBL format commented
that the format was helpful in holding themselves
accountable for their learning and ensuring they
stayed on top of all material. Another possibility for
the preference for CBL may have been simply due to
that fact that there were fewer weekly sessions and
less overall preparation time than in TBL.
However, the students performed better over-
all on assessments in the TBL course than in the
CBL course: the difference on knowledge items
was significantly different, although performance
on application items was not significantly different.
e8 Journal of Dental Education  ■  Published online ahead of print 23 Dec. 2019
The advanced student preparation that is common in
CBL and TBL allows most of the in-class time to be
spent applying material rather than repeating factual
information, helping students reach a higher level
of learning as defined in Bloom’s taxonomy. This
difference may account for the similar performance
on application exam items for CBL and TBL. The
slightly higher (3%) performance for students in the
TBL course than the CBL course was related to their
scores on the knowledge items in the TBL course.
One possible explanation is that the weekly closed-
book, fact-based readiness assurance tests ensured
students stayed on top of the material throughout
the semester, spacing out study sessions instead of
cramming, which may have improved their long-
term retention of factual content, as found in Winer-
men’s study.19 The additional grading opportunities
in TBL also may have led to an increase in overall
mean scores for that course. Overall, the difference
in scores was not large and should encourage educa-
tors that both active learning strategies are valuable
instructional methods.
Any dental school contemplating the incorpo-
ration of active learning strategies must take a close
look at the resources required for implementation.
In our study, TBL required fewer faculty facilitators
and fewer overall rooms, reducing the faculty burden.
However, the rooms required for TBL, while fewer
in number, had to be larger. Depending on overall
class size, multiple large rooms may be required
and could be a limiting factor based on availability
and competing classes. Room configuration is also a
consideration, as traditional lecture-style theater seat-
ing does not work well for TBL. While TBL required
fewer faculty members in our findings, it required
more preparation time for both students and faculty
facilitators. These needs should be a consideration
for implementing TBL as those involved must have
adequate time to commit for session preparation.
This study had some limitations. Consent
was unobtainable for all students who participated
in CBL and TBL, reducing the number of overall
participants and decreasing our sample size. The
52 advanced standing students in both courses had
previous exposure to the TBL method, which may
have influenced the traditional DMD students in some
way. There may have been timing effects since the
CBL course took place first. For example, student
responses to the survey about the TBL course may
have been influenced by their prior experience with
CBL and what they learned in that course. The CBL
and TBL courses contained different content, so a
straight comparison of performance was not pos-
sible, making a clear attribution of separate outcomes
difficult. Further, assessment scores may have dif-
fered due to variations in content difficulty, exam
question difficulty, different learning methods, or
a combination of these factors. Conducting a study
comparing CBL and TBL that used the same content
would provide a better understanding of educational
outcomes. While that was not feasible in our study,
we believe that the small difference in knowledge
vs. application items across methods showed that
one method was not significantly superior to the
other with regards to knowledge acquisition. Another
limitation is that students were required to meet more
frequently and put in more work for TBL than CBL,
which may have accounted for their dissatisfaction
more than the instructional method itself. While TBL
is a very regimented instructional method, there are
many definitions and variations of CBL across health
professions. Our small group CBL represents one
possible iteration of CBL.
Conclusion
Understanding the advantages and disadvantag-
es of active learning methods is important in making
evidence-based decisions on which method to choose
in which setting. In our study, the students preferred
CBL to TBL although they performed better in the
TBL course, both overall and on knowledge items.
Resource needs for both CBL and TBL were exten-
sive, with infrastructure use higher for CBL but time
needed for both students and faculty higher for TBL.
Disclosure
The authors reported no conflicts of interest.
REFERENCES
1. Commission on Dental Accreditation. Accreditation stan-
dards for dental education programs. Chicago: American
Dental Association, 2019.
2. Nadershahi NA, Bender DJ, Beck L, et al. An overview
of case-based and problem-based learning methodologies
for dental education. J Dent Educ 2013;77(10):1300-5.
3. Haden NK, Hendricson WD, Kassebaum DK., et al. Cur-
riculum change in dental education, 2003-09. J Dent Educ
2010;74(5):539-57.
Published online ahead of print 23 Dec. 2019  ■  Journal of Dental Education
4. Fatmi M, Hartling L, Hillier T, et al. The effectiveness
of team-based learning on learning outcomes in health
professions educations. BEME guide no. 30. Med Teach
2013;35(12):e1608-24.
5. Dolmans D, Michaelsen L, Van Merrienboer J, Van Der
Vleuten C. Should we choose between problem-based
learning and team-based learning? No, combine the best
of both worlds! Med Teach 2015;37:354-9.
6. Burgess A, Bleasel J, Haq I, et al. Team-based learning
(TBL) in the medical curriculum: better than PBL? BMC
Med Educ 2017;17(243):1-11.
7. McInerney M, Fink D. Team-based learning enhances
long-term retention and critical thinking in an under-
graduate microbial physiology course. Microbiol Educ
2003;4:3-12.
8. Hawkins D. A team-based learning guide for faculty in
the health professions. Bloomington, IN: AuthorHouse
LLC, 2014.
9. Haj-Ali R, Quran FA. Team-based learning in a preclinical
removable denture prosthesis module in a United Arab
Emirates dental school. J Dent Educ 2013;77(3):351-7.
10. Echeto L, Sposetti V, Childs G, et al. Evaluation of
team-based learning and traditional instruction in teach-
ing removable partial denture concepts. J Dent Educ
2015;79(9):1040-8.
11. Takeuchi H, Omoto K, Okura K, et al. Effects of team-
based learning on fixed prosthodontic education in a Japa-
nese school of dentistry. J Dent Educ 2015;79(4):417-23.
12. Yew E, Goh K. Problem-based learning: an overview
of its process and impact on learning. Health Prof Educ
2016;2(2):75-9.
13. McLean S. Case-based learning and its application in
medical and health care fields: a review of worldwide
literature. J Med Educ Curr Dev 2016;3:39-49.
14. Hyun J, Ediger R, Lee R. Students’ satisfaction on their
learning process in active learning and traditional class-
rooms. Int J Teach Learn Higher Educ 2017;29(1):108-18.
15. Srinivasan M, Wilkes M, Stevenson F, et al. Comparing
problem-based learning with case-based learning: effects
of a major curricular shift at two institutions. Acad Med
2007;82:74-82.
16. Ramnanan C, Pound L. Advances in medical education
and practice: student perceptions of the flipped classroom.
Adv Med Educ Pract 2017;8:63-73.
17. Merriam SB, Caffarella RS, Baumgartner L. Learning in
adulthood: a comprehensive guide. 3rd ed. San Francisco:
Jossey-Bass, 2007.
18. Deslauriers L, McCarty L, Miller K, et al. Measuring
actual learning versus feeling of learning in response to
being actively engaged in the classroom. Proc Natl Acad
Sci U S A 2019;116(39):19251-7.
19. Winermen L. Study smart. American Psychological As-
sociation. 2011. At: www.apa.org/gradpsych/2011/11/
study-smart. Accessed 29 July 2019.
e9