The transition from an undergraduate to a graduate/professional program – such as the transition to dental school – can be a challenging time for incoming students [1]. Students often have pre-conceived notions regarding their upcoming dental school experience and these may be influenced by several sources, including information from current and former dental students and their own experiences in previous programs. One longitudinal study comparing dental students’ expectations to their lived experiences revealed an overall negative shift, suggesting that students initially expected more from their educational environment than what they experienced [2]. This kind of mismatch between expectations and reality can be frustrating, potentially leading to academic and personal struggles, and even mental health issues [3]. This is particularly true for dental students. Several studies report that stress is very prominent among dental students and its sources are mainly related to academic and clinical aspects of dental training [3–5]. If stress levels remain high, they may significantly impact students’ academic performance, physical health, and psychological well-being [4]. An important long-term consequence of stress is burnout. A cross-sectional study showed an alarming figure of 40% of dental students suffering from burnout at an American dental school and reported that prolonged burnout is not sustainable and can lead to depression, self-isolation, and in severe cases, suicidal ideation [6].

Because dental education is inherently challenging and potentially stressful to students, we believe that if incoming students can set realistic expectations, they may be better prepared for the challenges they will face in their education. That preparation may, in turn, reduce potential negative impacts on their education, mental health, and overall wellbeing. For this reason, it is important to evaluate the degree to which incoming dental students’ expectations about dental school match their reality. Thus, the goal of this study was to compare students’ perceptions of their experiences in undergraduate education to expectations and experiences in dental school. To this end, we conducted observational cross-sectional and longitudinal studies comparing expectations and experiences from students in a US-based dental program. By focusing on student-centered insights, we hope to better understand the specific aspects involved in these challenges, help shape preventative strategies, and inform the kinds of resources needed in dental schools to address these issues.

The main purpose of this study was to investigate pre-doctoral students’ expectations and experiences throughout the dental program in comparison to their undergraduate experiences. The cross-sectional cohort was intended to give a snapshot of expectations and experiences across the classes for a given year, whereas the longitudinal cohort was intended to allow observation of the same group of students over time. Both cohorts had similar differences between what incoming students expected and what was experienced in later years during their education. Of note, D1 students based their expectations solely on what they had heard about dental school, as they hadn’t had any dental curricular experience at the time when questionnaires were distributed.

Open-ended question results for both cohorts showed that D1 students expected increased workload, paralleling their more senior peers’ reports. Another study also found that dental students reported a heavier workload when compared to their undergraduate experience [9]. However, in our study, other D1 expectations regarding classes were reported in lower proportions by D2, D3, and D4 students, including more depth and more difficulty, faster pace, relevance to dentistry, and more difficulty in managing time. The decrease in these proportions is possibly due to students’ ability to adjust during their education and could also be attributed to the fact that clinic time increases throughout the curriculum and students have significantly fewer (or no) didactic classes by the time they reach their fourth year. As a result, they report encountering fewer class-related issues in these final years. The decrease may also be related to the culture of dental education being known as inherently challenging [4]. In other words, students may have an expectation that their education will be difficult, but once they are enrolled, they face fewer challenges than initially expected.

The cross-sectional open-ended responses also showed that incoming students expected more attention, support, and access to faculty than they received as undergraduates, whereas their senior peers mentioned these themes in smaller proportions. The longitudinal data showed similar overall trends, though the disparity was less evident. Previous studies indicate comparable trends, with dental students perceiving that faculty were less helpful and supportive than anticipated, with antiquated teaching methodologies and rigid hierarchical relationships offered as a possible explanation [10,11]. Even today, traditional teaching methods are still widely prevalent in dental education; however, students’ prior educational experience may have changed to include more up-to-date instructional strategies, priming them for potential disappointment when entering dental education. Additionally, students’ rationale for expecting more attention may be due to the apprenticeship model characteristic of health professional education. Moreover, depending on their undergraduate experience (possibly at a larger institution), students may expect increased faculty attention due to a more favorable student-faculty ratio. Conversely, from the faculty’s perspective, dental students may be viewed as adults, and more mature than undergraduate students, therefore not requiring as much attention.

Another noteworthy finding from our qualitative data is that D1 students’ expectations regarding having more professionalism and dental-related experiences outside the classroom had a higher percentage of responses compared to their senior peers’. A possible explanation for this discrepancy could be that D2, D3, and D4 students have an implicit understanding that opportunities for profession-related exposures as dental students will take place outside of the curriculum, and therefore, do not consider including this aspect in their responses when asked about their non-classroom-related experiences.

Students’ responses mentioning being closer to classmates showed different patterns in the cross-sectional and longitudinal studies. In our cross-sectional data, student’s initial expectations were higher compared to the reported experiences of D2-D4 classes. This could be due to intrinsic difference among the different classes, and we do not know how the experience of any single class might have changed over time. We can glean some additional insights, however, from our longitudinal data. Here we saw a similar pattern in higher expectations for the incoming D1 class compared to their experiences in their D2 and D3 years, but this changed dramatically in their D4 year, rising even higher than their initial expectations at the start of dental school. A possible explanation could be that the initial camaraderie expected in D1 was negatively impacted due to stressors and the high degree of competitiveness characterizing their D2 and D3 years. In contrast, the D4 year represents a new stage of their dental education marked by less competition as most students have fulfilled the majority of their requirements and placed into a residency program or secured their first job. Another recent study from the University of Hong Kong reported overall high rates of dental students having “a positive relationship with their classmates” [12], but it is difficult to compare our results due to cultural and curricular differences and the fact that their study did not present these data broken down by class year or assess attitudes longitudinally.

For open-ended questions, most students also reported more stress than anticipated, although the high stress level aligns with the expectation reported in the Likert scale-type questions. Though far from ideal, this is expected and has been previously reported as an inherent component of dental or health profession educations [3,4,13,14].

As for Likert scale-type questions, both cohorts reported having more difficulty managing time than expected when compared to their undergraduate experiences. However, for the longitudinal group, the effect was attenuated when factoring in academic performance confounders. Considering that the longitudinal group is more uniform, it could be interpreted that more adept students would be able to manage their time more efficiently and would therefore have more realistic expectations. On the other hand, it could also be that this result was impacted by sample size, which was limited to students who were present in all four time points, and model complexity, rather than the impact of confounders. Regardless, a good management of time is desirable not only because the workload requires it, but also because it has been shown to help with coping with stress [14] and maintaining adequate work-life balance [13].

Importantly, recurring responses in both cohorts indicated that students expected to have a stronger academic support system than they did as undergraduates, but that D2-D4 experiences fall below these expectations. The lack of academic support was also pointed out by dental students in other studies, including a recent cross-sectional investigation [10]. It should, however, be pointed out that this study was conducted prior to the COVID-19 pandemic. During and after the pandemic, many institutions, including the UPSDM, implemented a number of measures to improve students’ experience, with special focus on support and mental health [15,16].

Several such measures can be taken to address the results discussed above, foster a better learning environment, and improve students’ overall experience in a dental school [12,14]. Dental schools may use the data collected to better curate their curriculum, extra-curricular offerings, and faculty training (which would address some of the recurring responses by students) to create a more supportive environment [11,13]. To prevent frustration, stress (which was also mentioned in students’ responses), and burnout, dental schools may consider offering early detection/prevention programs and interventions to foster psychological safety amongst students [17–19]. In this regard, one study found that medical and dental students thought early psychological assessment and counseling to be very important for students [20]. With the popularity of social media, virtual group therapy may provide students with an alternative source of help [6]. Examples of such measures have already been implemented or enhanced at the UPSDM after this study was conducted, and include peer tutoring programs, hiring of a full-time Licensed Professional Counselor, identifying an ombudsperson, a meditation room, earlier extended onboarding, student focus groups, among many others. Finally, to avoid overwhelming students, it is key to properly curate all resources and communicate to students their availability, and to clarify how they can properly be used to their best advantage [12].

As a future direction, it may be worthwhile to redistribute questionnaires to students to measure effects of implemented actions, gauge future changes, and assess whether the discrepancy between expectations and experiences will be significantly reduced. Similar to other health professions, transitions at other time points in dental education, e.g., from predoctoral to residency education, may also be worth investigating [21].

Our study only included responses from a single institution, which poses a limitation, because it might have introduced possible biases pertaining to geographical location, philosophical aspects of the university, and cultural background of students. However, it should be noted that our students have a similar profile when compared to the national data of the same period, so it is reasonable to assume that our findings are generalizable [22]. Nonetheless, single classes may have individual characteristics that set them apart from other classes, which might also have introduced bias to the cross-sectional study. We were also limited by sample size, as there is a restricted number of students enrolled in each year, as well as uncontrollable issues, such as absences and duplicate unique identifiers. Repeating similar studies in other institutions could potentially provide more reliable conclusions and more broadly applicable recommendations. Another limitation was the fact that our questionnaires were not validated prior to distribution. However, we considered them robust, as they were based on the literature [7] and were revised by a panel of experts. Furthermore, while open-ended questions were intentionally included because they offer rich data and allow the participants to include any relevant experience, they limit conclusions, because students were not specifically prompted to report their experiences in specific themes, such as those mentioned in D1 responses.

This study provides student-centered insights to better understand specific challenges when transitioning from undergraduate to dental education by documenting dental students’ expectations and experiences in a professional health education environment. We found that some of the students’ initial expectations at the start of their first year differed from the experiences of students in later years. Some of these discrepancies were in key areas, related to managing workloads or the degree of academic support available. Dental schools should consider implementing measures to address these issues and help pave a smoother path from admission to graduation.