Introduction

The lag and dropout in university studies are complex and multifactorial phenomena that can be due to scarce economic resources, social and family issues, the student’s dilemma between studying and working, lack of interest and sense of belonging, institutional problems, and high failure rates, among others (1,2,3).

A common concern in all higher education institutions is the high failure rates, especially during the first cycles, which are directly related to university dropout rates (1). Course failure affects student dropout rates and terminal efficiency, as it prolongs the time required for graduation, impacting teaching and the use of financial resources. Combating course failure would expedite students’ educational trajectory and time to graduation. This would have significant social consequences for those in the educational process, as it reduces failure and enables them to enter the job market more rapidly. Additionally, it enhances resource utilization efficiency by freeing up spaces for new students to use. Moreover, it contributes to the country by producing the professionals it needs in a timely manner (4).

Regarding student dropout at the Faculty of Dentistry (FOd by its acronym in Spanish) of the University of Costa Rica (UCR), a study conducted with cohorts from 2007 to 2014 indicates that 32% of students dropped out of their studies. The academic cycles with the highest percentage of dropouts were the first and second (56%), while the average terminal efficiency was 6%, with 46% of students graduating with delays (5).

The current curriculum of the Dentistry degree program at UCR has a duration of 12 academic cycles, consisting of 198 credits distributed among 61 core courses and 24 service courses. A course is considered “core” when an academic unit offers it for one or several of its study programs.

On the other hand, a course is categorized as “service” when an academic unit offers it solely for study programs from other academic units, and these courses are taught by faculty members from other faculties (6). During the first six academic cycles of the Dentistry program at UCR, there are both core courses and service courses. However, starting from the seventh academic cycle, only core courses are available for students.

The organization of courses within a program like the Dentistry degree at UCR allows students to gradually develop knowledge, skills, and attitudes to graduate as competent general dentists (7). As students progress through the curriculum, knowledge is acquired progressively, starting with basic sciences and humanities courses, leading to the development of manual skills. Initially, these skills are practiced through preclinical laboratory procedures and then progress to simulation exercises using mannequins before students begin treating patients under the supervision of an instructor (7,8). Subsequently, students work in specialized clinics organized by dental fields and, later, in comprehensive clinics during their final year (9). This sequential approach to education ensures that students build a solid foundation of theoretical knowledge and practical skills, gradually transitioning from simulated practice to real-life patient care under proper guidance and supervision.

A study published in 2009 indicates that, on average, dentistry students at UCR take two years longer to graduate than the established duration of the curriculum, mainly due to high failure rates, especially in some service courses. Among these service courses, the ones with the highest failure rates are General Chemistry with 41%, Medical Physics with 39%, and Dental Biochemistry with 43%. As for the core courses of the program, from 2004 to 2007, the Dental Anatomy course had a failure rate of 13%, and from 2005 to 2007, the Pediatric Dentistry Clinic had a failure rate of 25% (10). Since that publication, no further studies have been conducted to determine whether the mentioned courses continue to generate high failure rates or if other courses are currently facing this situation. As a result, the objective of this research was to identify the failure rates of the courses in the Dentistry curriculum at UCR from the cohorts of 2007 to 2014.

Methodology

Participants

This study is a descriptive, longitudinal, and retrospective follow-up of the cohorts of dentistry students at FOd UCR who entered the program from the year 2007 until 2014. The follow-up of the cohorts was conducted until December of the year 2021. The inclusion criteria were based on the records of students who enrolled in the Dentistry program at UCR from the years 2007 to 2014, either through admission exam scores or by transferring from other university programs, and whose information was available in the Student Application System (SAE, by its acronym in Spanish). The exclusion criterion was the presence of incomplete information in the records.

Data collection

The information concerning the following variables was collected using the SAE: sex (male or female), age at the time of enrollment in FOd UCR (age in completed years); nationality (Costa Rican or foreign); domicile (within the Greater Metropolitan Area (GAM by its acronym in Spanish) or outside the GAM); previous high school atten- ded (public, private, subsidized, by maturity, or abroad); admission exam score to UCR; approved and failed courses; the number of course repetitions; and academic cycle in which students dropped out of their studies.

Some records were not accessible for review because SAE does not allow access to the records of individuals who obtained a qualifying score for admission to the program but did not complete their enrollment or students who are currently pursuing postgraduate studies at UCR.

To obtain data related to marital status (single or married at the time of enrollment) and having children (yes or no during all years of study), the digital documents of the Supreme Electoral Tribunal of Costa Rica were consulted, which contain data from the Civil Registry.

Statistic analysis

The data were entered into an Excel database (Microsoft, Inc., Redmond, WA, USA) and reviewed, and inconsistencies were corrected for analysis. Descriptive statistics were performed to establish the absolute and relative frequency of the variables. All analyses were conducted using Stata version 14.

To obtain the overall success rate of the courses in the results, the number of students who passed the course was divided by the sum of the times they enrolled.

A Poisson regression was used to analyze the relationship between students’ success or failure and the variables domicile (GAM or outside GAM) and previous high school for courses with less than a 90% success rate. The exposure varia- ble was the number of attempts.

Ethical considerations

The research was approved by the Scientific Ethics Committee of the UCR (CEC-84-2022).

Results

A total of 778 records from the eight years of the study were reviewed, of which 733 with complete data were obtained. Of the students, 97.8% were Costa Rican, with a higher percen- tage of females (68%). Regarding the admission method, 79% entered through the admission exam grade. In terms of age, 68% enrolled at the age of 18 or younger, and 50% came from a public school. Regarding residence, 76.7% were from the GAM. In terms of marital status, 95% were single and remained childless throughout their entire Dentistry program (Table 1).

Out of the 12 cycles of the study program of the Degree in Dentistry at the UCR, it is evident that 85% of the dropouts occurred in the first four cycles of the Dentistry program (Table 2).

The courses in the curriculum that achieved the lowest overall success rates were General Chemistry (52%) and Organic Chemistry (52%).

Among all the courses in the curriculum, the one that students enrolled in the most times was Biochemistry, with a total of 16 enrollments, followed by Organic Chemistry with 12 enrollments, and General Chemistry and General Mathematics, each with eight enrollments (Table 3).

When conducting a correlation analysis for courses failed, a statistically significant difference was found only in the failure rate of the Fundamentals of Physics course and the school of origin. The lowest success rate was observed among students who completed their studies in public schools, followed by students from private schools, and finally, those from subsidized schools.

Regarding the courses offered by the Faculty of Dentistry, the clinical courses in the fifth year (cycles 9 and 10) of the program were among the 10 courses with the lowest overall success rates. The two clinics with the lowest percentage of overall success were as follows: in second place was the Endodontics Clinic (68%), and in the first place was the Pediatric Dentistry and Orthodontics Clinic (64%), which was the course most frequently enrolled in by a student, totaling eight times, followed by the Anesthesia course and the Endodontics Clinic, which a student enrolled in up to five times (Table 4).

Table 1

Distribution of sociodemographic variables (N=733).

Table 2

Cycles of the Dentistry degree curriculum with the highest dropout rates.

Table 3

Courses in the entire curriculum with the lowest overall success rate and cycle where the course is teach.

Table 4

Courses in the entire curriculum with the lowest overall success rate and cycle where the course is teach.

Discussion

This research highlights that during the first two years of the degree in Dentistry at the UCR, there is the highest rate of course failure and, consequently, student dropout, posing a complex challenge frequently encountered in many higher education institutions.

In this research, the subjects with high failure rates that posed the greatest challenges for the advancement of dentistry students in the curriculum were the service courses, with General Chemistry leading the list, followed by Organic Chemistry and General Mathematics. This is in line with the study by Garcia and Román (2021) who pointed out that service courses have higher failure rates and that this failure rate decreases as students progress in their program. At UCR, there is a 10-point difference between the failure rates in in-service courses (21%) and career courses (11%). This difference could be attributed to the design of these courses or to their classification as “service courses,” which may lead students to underestimate their importance in favor of dedicating more time to specialized courses (11).

The failure in courses during the first cycles may be due to the students’ adjustment from high school to university, as they adapt to university life, teaching style, and the need for social support from their peers, which can also influence their regular attendance and academic performance (12). According to the Academic and Student Regime Regulations of the UCR, attendance in courses is not mandatory (13); however, numerous studies suggest that attending classes in traditional face-to-face courses can be one of the key factors influencing students’ performance (14). Students who miss classes not only miss out on participating in classroom activities, such as group discussions and problem-solving, but attendance also reflects students’ efforts and academic motivation, which are also related to their overall course performance (15,16,17). Additionally, students may believe they can skip lectures because they can obtain academic information by discussing with their peers, reading the textbook, or reviewing someone else’s notes (15).

The failure of these service courses is not observed in all dental faculties since, in many cases, these courses are not part of the curriculum. For example, at the University of Michigan or New York University, the Doctor of Dental Surgery program lasts for four years. Students applying for admission must have completed an undergraduate degree from an accredited institution that includes courses in biochemistry, microbiology, psychology, sociology, English composition, biology, general chemistry, organic chemistry, and physics, all with their respective laboratories. Additionally, they must complete 100 hours of direct observation of a dentist in a patient-care setting and submit at least two letters of recommendation from science professors the student had during their university level (18, 19). However, even though the basic courses are not part of the curriculum, it does not imply that the failure rate is low. An investigation into the characterization of prerequisite courses for dental schools and admission recommendations in the United States indicates that general chemistry, physics, organic chemistry, general biology, and biochemistry were the most failed courses (20).

The courses of General Chemistry and Organic Chemistry had the lowest overall success rates, which could be attributed to a crucial study in Costa Rica demonstrating the inadequate quality of education of high school students in this area (21). This is particularly important because the introductory chemistry course is a part of scientific-oriented university programs (22). Internationally, there are studies indicating that poor performance in chemistry courses was one of the factors influencing students to drop out of their studies (23,24,25).

The Elemental Mathematics course presents the third worst success rate, and this high failure rate in this subject has also been reported at the Universidad Tecnológica de Pereira, where it is indicated that this problem cannot be resolved until the psychological differences and the prior knowledge with which students enter the university are considered (26). Similarly, at the National University of Colombia, the failure rates in the Elementary Mathematics course are very high, leading to the creation of a voluntary leveling course. However, the results were not as desired, with 35% of enrollees abandoning the course and 30% failing it (27, 28).

In Costa Rica, the National University reports a 35% failure rate in the basic mathematics course, prompting research into anxiety levels and their correlation with course failure. The results showed that if a student’s anxiety toward mathematics is high, their academic performance will be significantly lower (29). Similarly, in the year 2023, UCR called upon first-year students to take a diagnostic mathematics test, but only 38% of them enrolled in it. Among those who participated, only 5% obtained a grade higher than 70, which was the minimum passing grade (30).

The UCR does not have a limit on the number of times a student can retake a failed course, and no special permission is required to enroll in a course again. This policy explains why, in this research, some students had taken the Biochemistry Dental course 18 times and others had taken Organic Chemistry 12 times before successfully passing them.

Within the core courses of the Dentistry program, the Pediatric Dentistry and Orthodontics Clinic shows the lowest academic performance. This could be attributed to the complexity of dealing with children’s behavior as well as the clinical treatments performed on primary teeth, such as pulp therapy, stainless steel crowns, and extractions, compared to similar treatments in adults, which can lead to higher stress levels among students (31). Another factor that can affect performance is the reported fear among many students in health-related fields, even those with excellent academic performance when it comes to executing procedures that could impact the physical integrity of patients under their care. This fear can lead to treatment delays, increased patient appointments, and in some cases, failure in the course (32). Considering that this clinic handles pediatric patients, these fears and treatment delays might be even more significant, leading to the inability of the students to meet the required competencies during the academic period.

Regarding the low success rate of the Endodontics Clinic, it has been evidenced that it can be considered difficult and stressful due to the complex anatomy of the root canal system, the responsibility toward patients, and low self- confidence (33). These factors can lead to a higher failure rate among students in this course. Another reason that can affect the approval of this clinic is the difficulty in finding patients for endodontic treatments. Two-thirds of the population experience a fear of the dentist, which can be associated with this difficulty.

Furthermore, research indicates that 77% of patients treated at the Faculty of Stomatology of the University of Medical Sciences of Havana attended the dental clinic late due to the presence of fear (34). Additionally, the literature indicates that 90% of patients seeking pulp treatment experience pain (35); therefore, the fear of the dentist associated with the pain of receiving a pulp treatment can impact the number of patients seeking treatment in this clinic.

Higher failure rates in clinical courses compared to other core courses in the dentistry program may be due to stress. During their professional training, dental students experience different levels of stress and anxiety, which can be caused by various factors, including fear of the unknown, fear of competing with their peers in the clinical setting, interpersonal problems, difficulty in making appropriate decisions while caring for patients, a noisy environment, a sense of helplessness within the system, lack of free time, delays, conflicts in achieving goals, lack of proficiency in clinical procedures, the distress of some patients, which can be sensed and absor- bed by the student, patient no-shows, and challen- ges in finding patients to fulfill academic requirements (36).

The failure rates in all courses of the curriculum did not show any correlation with gender, age, admission exam score, marital status, parenthood, or student’s place of origin. However, a statistically significant difference was observed in the course of Fundamentals of Physics, where there was a higher failure rate among students coming from public high schools. This finding aligns with a study conducted at UCR, which evaluated the academic performance of first-year students and found that students from private schools performed better than those from public schools (37). Similarly, a study involving first-year students at the Costa Rican Institute of Technology in the General Mathematics course also indicates that the student’s high school background can influence course approval rates. The approval percentage was higher for graduates of semi-private educational institutions (76.4%) compared to those who completed their secondary education in private (54%) or public (45.5%) schools (38). Furthermore, a research study at the National University in Costa Rica reports that students coming from private schools have a higher approval rate in Elementary Mathematics courses (28).

One of the strengths of this research is that it confirms that service courses continue to have the highest failure rates. The data obtained will enable the Academic Unit to analyze the situation and take appropriate measures to address the issue. However, one of the limitations of this study is that it did not establish correlations between course failure and certain personal variables such as priorities, work obligations, and family responsibi- lities, among others. As a result, future research is planned to explore this area further and contribute to understanding the complex problem of course failure, especially in the early cycles of the dentistry program.

Conclusion

The failure rate of courses in the Dentistry degree program at University of Costa Rica is higher in the first four cycles, which is when service courses are predominantly offered. Among the service courses with the lowest success rates are General Chemistry, Organic Chemistry, and Mathematics. On the other hand, among the core courses of the program, the Pediatric Dentistry and Orthodontics Clinic show the highest failure rate, followed by the Endodontics Clinic. These results underscore the importance of analyzing and addressing the challenges that students face in these courses to improve their academic performance and promote successful development in their dental professional education.

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Author Contribution Statement