Key points

  • Discusses the issues related to education and training in dentistry, as more education and training is expected to take place in primary care.

  • Assessment in dentistry ought to measure the outcomes of dental treatment and behavioural change as a measure of training and learning.

  • Questions whether personality and learning styles of students should be tested before delivering education and training to dentists in primary care.

Introduction

General dental practitioners are independent contractors who choose to provide NHS dental services and/or dental treatment via the private sector, and as such are entrusted to carry out high quality treatment for their patients.1 There is significant emphasis on distribution of skill-mix and the dentist being supported by a multi-professional team.1,2 With upcoming commissioning guidelines for restorative dentistry for tiered levels of dental provision,3,4,5,6 there will be a need for those with extended skills to be able to provide the treatments that are considered too difficult for general dental practitioners and yet not complicated enough for specialists. Published Department of Health documentation does provide guidance for appointing dentists with enhanced skills for a number of dental disciplines including endodontics, special care dentistry, conscious sedation, orthodontics, periodontics, oral surgery and prison dentistry.3,4,5,6,7,8,9,10,11,12,13,14,15 These guidelines describe the use of a portfolio and curriculum vitae of dentists to validate experienced practitioners. However, the initial vision was to develop 'a framework which is effective in quality assuring and benchmarking the skills of DwSIs' (dentists with special interests).15 Yet there is currently no widely agreed methodology for upskilling general dental practitioners to enable them to achieve the competencies required for validation as outlined in these documents. However, this emphasis on up-skilling and competencies have become a part of dental foundation and dental core training.16 The General Dental Council (GDC) register is the access point for patients to identify qualifications of their dentist and specialists, although additional qualifications have not been published on the GDC register since 2007. The public is therefore unable to easily source information on additional skills of dentists.

Enabling patients to have access to high quality dental care has become increasingly important in healthcare.17,18,19,20,21 Education is a means of improving the quality of healthcare and as a result, rising significance being placed on the quality of teaching and learning.22,23,24,25 This philosophy has continued with the new NHS structure, with NHS England working closely with Public Health England and Health Education England to produce a workforce that is fit for purpose.26,27,28 Ideally, we seek the most efficient use of resources to upskill the existing workforce, without significant reduction in the services that can be provided during training. The key themes described in the NHS Five-year forward view29 were prevention and public health, patients gaining more control over their own care, breaking down barriers on how care is provided with choice of radical new care delivery options such as the introduction of multi-speciality community providers of out-of-hospital care and combining primary and acute care systems. All of these were needed to manage demand, efficiency and funding, particularly as the NHS deficit was estimated to be £30 billion by 2020/21.29 In order to best use resources, the workforce needs to be sufficiently skilled to provide the correct treatment in the right place in the patient pathway, and with suitable education programmes, this can be provided by general dental practitioners, working independently and where necessary seeking training to enhance their skills. When seeking or providing additional skills, an understanding of training within dentistry is necessary to develop and deliver economic and efficacious training.

Training in dentistry

There is a growing view that undergraduate dentists are not graduating with the skills required to provide a variety of dental treatments.30,31,32 Since dental graduates are considered 'safe beginners',33 it is not expected that they will possess all the skills required to be competent at all dental treatment. The lack of suitable patients and an ever-developing undergraduate curriculum with limited number of hours of practical teaching have been cited as barriers to providing adequate knowledge and skills for dental undergraduates.34 Furthermore, there is an opinion that dentists are also starting to de-skill as a result of the dental undergraduate education and NHS arrangements for dental care provision.35,36,37,38 Additional evidence supports the view that the lack of skills and training to complete complex treatments, such root canal treatment, are factors in determining whether or not these complex treatments can be performed in primary care or not.39,40,41 Consequently, there may be an expectation that general dental practitioners involved in vocational training may have a larger role to play in upskilling the graduating dentists of the future.

Training in dentistry is a complex intervention as it is multifaceted and should be assessed in terms of the outcome.42 A three-circle model for specifying learning outcomes in medicine has been adapted to dentistry, and key areas have been identified with regard to what a dentist is able to do:

  • Clinical information gathering (full and relevant patient history)

  • Comprehensive patient examination

  • Arranging and interpreting appropriate investigations

  • Treatment planning (in combination with the patient and recognising when referral is appropriate)

  • Treatment procedures (carrying out the specific treatment interventions required to restore/maintain the patient's oral health).

In addition to this, a number of other domains have been suggested regarding how the dentist approaches their practice:

  • Application of basic clinical sciences

  • Clinical reasoning and judgement, communication

  • Health promotion

  • Attitudes

  • Ethical stance and legal responsibilities

  • Information handling.

The last dimension was described as the dentist's professionalism, in relation to their role within the health system and their personal responsibility towards lifelong learning.42 These domains have already been included in the First five years43 for undergraduate education. However, the assessment is still largely an examination of knowledge and ability to perform a task rather than the outcome of the treatment provided, although in some countries this is now changing.44,45

Theories in education

There are numerous theories in education, which are ever evolving. For example, a classical early theory, behaviourism, was based on animal studies and assumed that learning can be observed and is dictated to by the environmental conditions. Some consider students as learning through behaviourism where reinforcement of particular actions would result in more (with positive reinforcement) or less (with negative reinforcement) willingness to repeat the action.46,47

Later educational theories consider the need for cognitive abilities to process, organise and understand information.48,49 This assumes the need for physical cognitive structures to assimilate new information and to accommodate or make sense of new experiences. Therefore, students test their internally constructed knowledge against what they experience, either discarding, modifying or (re) constructing their understanding to make sense of their own experience.48,49 A 'scaffolding' support structure is often suggested to allow students to access information at a level appropriate to their current understanding.50,51 It is recommended that teaching be organised, structured to allow students to make links between earlier and later periods of learning.50,51 This makes knowledge and understanding unique to the individual, as it is dependent on their own experiences, and therefore it is not assumed that 'teaching' will lead all students to the same knowledge and understanding.

It has been suggested that Bruner's theory can be applied to adult learning and that adults not only have had significant prior learning, which should be built upon, but they also require a 'safe' and collaborative environment to learn effectively. It is also recognised that there needs to be intrinsic motivation and learners need to see the practical relevance of what they are learning.52,53 Experiential learning forms the basis for reflection as an instrument of enhancing self-learning.54,55 Situated learning considers the place where learning occurs and proposes that much of learning takes place in collaboration and social interaction with other practitioners.56

Bloom's taxonomy of cognitive learning domains22 has been revised57,58 in ascending order of difficulty to be remembering (easiest), understanding, application, analysing, evaluating and creating (most difficult). There are also affective domains (such as attitudes and professionalism), which require information to be received, responded to, valued, organised/conceptualised and then internalised or adopted.

In order to achieve the learning objectives described by Bloom,22 Fox developed theories of teaching, which include transferring of theory, shaping of thinking, building on transferring and shaping, travelling through the subject matter with the teacher as a guide and growing or nurturing of the student.24 Transferring and travelling is subject focused, but shaping and growing is student focused.

Practical and 'thinking' skills are considered within the psychomotor domains and require imitation, manipulation, precision, articulation and naturalisation.57,58 Learning objectives, which are now widely accepted as necessary for good teaching use the verbs and nouns from this complex learning, teaching and assessment taxonomy by Anderson et al.,57,58 which is simplified and shown in Table 1.

Table 1 Revised Bloom's Taxonomy of Learning Domains57,58
Full size table

Students learn in diverse ways, partly because of their individual learning styles and partly as a result of the context of the learning.59 Learning styles have been described in terms of 'surface', 'deep' and 'strategic', each causing a different learning outcome.59 'Surface' learning is identification of information considered important by the student and memorising these facts and ideas. In contrast 'deep' learning is described as seeking out meaning, examining evidence, relating the new ideas presented with previous knowledge and personal experience. 'Strategic' learning is the use of deep and surface approaches by some students depending on which approach they felt would produce the most successful results.59 Not surprisingly, deep learning has been found to lead to better understanding and improved recall of facts immediately and several weeks later,60,61 and a tendency towards deep and strategic learning has been demonstrated in postgraduate medical students.62

Learning is also likely to be affected by the motivations to learn.63 The motivation for learning is recognised as being extrinsic or intrinsic.64,65,66 Surface learning may be driven by financial incentives, vocational incentives, or pressures from peers or in this case even from patients. It might also be due to preparation for impending assessments or due to the learning environment.59,60,61,62,63,64,65,66,67 The motivators for deep learning may be intrinsic and due to an inherent desire to gain a sense of mastering, interest and curiosity in the subject, or role models in the subject area.59,60,61,62,63,64,65,66,67 The latter are usually linked with effective, long-term learning, but it is recognised that some external motivators can encourage an intrinsic approach to learning.68 The 'strategic' learners identify what they need to learn before beginning, hence focusing on the product of learning rather than the process. They use whatever means necessary to achieve a successful result as they are motivated by competition and achieving high grades.59,69

Assessment

All assessments are aimed at measuring behavioural change brought about through learning and experience, and should not impede, but rather, promote the development of an intrinsic change in the student.

In order to assess learning, the use of constructive alignment between teaching and assessment was developed by means of a portfolio experiment.70 Following this, portfolio-based assessment was formed in which the students were asked to put together evidence to show that the professional decision making has been improved by the theory that they have been taught. Learning objectives need to be mirrored in the teaching and assessments should compare the student to the intended learning outcomes, so assessments should ideally test a performance or demonstration of understanding. The learning environment needs to be created by the teacher to achieve this goal. The grading system can be qualitative or quantitative but must assess the student against the stated criteria (objectives or learning outcomes) and not against other students.70 Assessments can be formative or summative (formative assessment, which is used to plan and support learning, has been described as 'assessment for learning', whereas summative assessment, which tests the outcomes of learning and may be a gateway to the next stage or graduation, for example, has been identified as 'assessment of learning'.71 Because of this important difference, students need clear guidance on which assessments are formative and which are summative during their learning.70

Interim assessments benefit from being formative, as feedback can be used to promote deeper learning. Summative assessments, however, may actually deter some students from admitting or learning from errors. More importantly, though, they may learn only what they think will be tested in the assessment.

Methods of education and training used in dentistry

Education is at the heart of improving competence and in turn the quality of dentistry. Undergraduate dental education may utilise many teaching and learning methods including didactic teaching, problem based and self-directed learning as well as practical learning in teaching laboratories and clinical environments. Typically, postgraduate education in dentistry tends to use fewer methods such as distance learning courses mainly using printed educational materials, part time courses with or without hands-on components and apprenticeship-style work-based learning.

There are Cochrane reviews72,73,74,75,76 on the effect of various methods of continuing education on professional practice and healthcare outcomes. Printed educational materials were said to make small improvements in professional practice when nine studies were assessed for change in provider behaviour and five studies on patient outcomes. Benefits of printed educational materials varied from -3% to 243.4% for change in provider behaviour and from -16.1% to 175.6% for patient outcomes. None were statistically significant at the 95% level.72 When six studies were used to compare the impact of printed educational materials alone with educational materials combined with a further implementation intervention such as audit and feedback, the findings were mixed.72 When thirty-two randomised controlled and quasi-experimental studies involving between 13 and 441 health professionals were assessed, didactic teaching alone was considered unlikely to change professional practice, whereas interactive workshops could lead to moderately large changes.73 Audit and feedback can also be effective, especially when 'baseline adherence to recommended practice is low and intensity of audit and feedback is high.'74 This Cochrane review included 72 studies comparing any intervention with audit and feedback to no intervention, resulting in compliance with desired practice varying from a 16% absolute decrease in compliance to a 70% increase in compliance.74 Another Cochrane review75 analysed 140 randomised trials, showing that an absolute increase in healthcare professionals' compliance with the desired practice occurred about 4% of the time, and the effectiveness of audit and feedback depends on the baseline performance (better if the baseline is low) and how feedback is provided. Written and verbal feedback together was more effective than either one used separately, and was also more effective when delivered by a supervisor or senior colleague rather than someone unknown to the student. Behaviour change was said to be most likely if feedback is accompanied by comparison with a behavioural target and by action plans.75,76

Simulated learning of technical skills can be as effective in dentistry as bench top learning.77 Newer virtual reality (VR) techniques showed promising results with VR appearing to be as good as traditional training on typodont teeth.78,79 There is also a new trend for continuous learning by reflective thinking, where the individual examines an experience leading to a change in conceptual perspective.80 Portfolios are often used for reflective learning as they record experiences and allow for discussion with trainers and mentors.81,82

There is little conclusive evidence regarding which method of teaching in dentistry improves technical skills, although this may be due to the lack of usable tools to measure technical competence. Unsurprisingly, though, hands-on postgraduate courses are considered to be the most effective method of teaching dentists techniques in restorative dentistry.83

Assessment in dental education and training

Undergraduate and postgraduate dental education assesses learning using traditional tools such as formal, written examinations and work place-based assessments, rather than the outcome of treatment provided by the postgraduate trainee as outlined in the curricula for speciality training in restorative dentistry, paediatric dentistry and endodontics.84,85,86

In Miller's pyramid of assessment of learning, the first step in assessing knowledge and skills is the demonstration that the student 'knows', followed by demonstration of 'knows how', 'shows how' and 'does'.87 For example, the outcome of training in endodontics could be measured using the change in knowledge ('knows'), the adherence to recommended guidelines ('knows how'), development of technical skills ('shows'), adaptation of techniques/instruments/materials ('does'), and the outcome of root canal treatment ('does'). The outcome of root canal treatment could be measured using clinical and radiographic healing as well as patient-related outcomes.

In an article by Darzi & Mackay,23 surgical care was described as having four components: diagnosis, plan of treatment, technical performance, and post-operative care. A surgeon's technical skills were said to be at the centre of surgical practice and technical performance was further segmented to surgeon's judgement which was described as 'decision making that takes place during a surgical (or other) procedure,'23 knowledge, and dexterity. This description of technical skill can also be applied to dentistry. Assessment of technical performance is difficult and 'needs to include a range of competencies necessary for carrying out a procedure effectively.'23 The authors stated that written examinations can be standardised and objective, but can be limiting in scope or depth and mainly focus on factual knowledge; viva voce examinations can be used to explore topics to greater or lesser depth but are a potentially threatening process which may disadvantage some candidates; and objective structured clinical examinations (OSCEs) can be standardised and objective using established objective criteria and marking schemes but the depth of assessment is limited. None of these methods are particularly useful in objectively measuring technical skill. Retrospective reporting from trainers is currently used for technical assessment and this can be subjective, poorly standardised and poorly validated.

Darzi and Mackay23 describe several other methods that have been developed to objectively assess technical skill: the objective structured assessment of technical skill (OSATS) allows the candidate to perform a standardised task while being observed by at least two examiners. The examiners use two marking systems: a checklist (marked yes/no) and a global scoring sheet (marked 1-5, where 1 = poor, 3 = average and 5 = excellent and examples of these marks are given to the examiners as guidelines). The checklists are specific to the task and must be validated. The global score assesses generic aspects and is 'a more effective discriminator between subjects than checklists.'23,88 The OSATS measure knowledge and manual dexterity but not judgement. The OSATS are already being tested for surgical training in medicine.89 The Imperial College surgical assessment device (ICSAD) uses computer software to analyse hand motions. Trackers are attached to the dorsum of the hand and the hands are moved within a magnetic field. This analyses the position of the hands while carrying out standardised tasks, but again judgement is not analysed. The minimally invasive surgical trainer virtual reality (MIST VR) developed in Sweden was the first attempt into using virtual reality for training and assessment. The initial results were said to be disappointing90 but virtual reality is still experimental technology and has potential for objective assessment of technical ability.

As all assessment methods appear to have inherent strengths and weaknesses, it is accepted as good practice that more than one method should be used.23,91 One site of assessment instruments that is becoming used increasingly in postgraduate education is workplace-based assessment. Workplace-based assessment has been developed over the past few years in postgraduate medical education71,92,93 to produce an overall profile of a trainee and should compare their skill, knowledge and behaviour against those identified in the relevant curriculum, which has been approved, originally by the Postgraduate Medical Education and Training Board94 and more recently by the General Medical Council. There are currently moves to introduce a similar system for dentistry.

Rather than assessing knowledge and ability to perform a task, the outcome of the dentistry performed is now being assessed.44,45 The assessment of outcome of treatment is reflective of the quality of dentistry performed and includes the quality of life and patient experience of care.29,95,96

Education leading to behavioural change

There are reports in healthcare that 30-40% of patients in the United States and Netherlands do not receive care that is in accordance with current scientific literature, with 20% or more receiving treatment that is not needed or harmful.97 The levels of compliance with recommendations were associated with the type of health problem, the quality of evidence supporting the recommendations, compatibility of the recommendations with existing values, the description of the desired performance, the complexity of the decision-making required, and the level of new skills and organisational change needed to follow the recommendations. Therefore, even if healthcare professionals are aware of and are willing to embrace changes in clinical practice, there is a need for environments conducive to change in order to achieve it, and it may be more difficult where complex changes in clinical practice are considered.97 It has been suggested that the use of twelve domains for behavioural change processes in implementing evidence-based practice will enhance understanding of behaviour change. These domains are:98

  • Knowledge skills

  • Social/professional role and identity

  • Beliefs about capabilities

  • Beliefs about consequences

  • Motivation and goals

  • Memory, attention and decision processes

  • Environmental context and resources

  • Social influences

  • Emotion regulation

  • Behavioural regulation and nature of the behaviour.

In order to achieve implementation of recommendations Grol & Grimshaw97 suggested interactive and continuous education, involving the discussion of evidence, peer feedback on performance and professional development. These should be built into daily patient care so that decision support tools and real-time patient-specific reminders can be used to allow healthcare workers to make the best decisions for their patients. There was recognition that the patient, the organisation, resources, leadership and the political environment may play a role in adherence to guidelines.97 There is emerging prominence on appraising complex interventions that are aimed at behavioural change in healthcare practitioners and failure to do this may undermine the evaluation of the intervention being tested.99,100,101 It has been recommended that tailored interventions to change behaviour of healthcare practitioners are compared to non-tailored or no intervention.102,103

Conclusion

Dental education and training must be able to change behaviour such that the skills are passed on from generation to generation in a predictable and flexible manner to adapt to the changing needs of the population. Skills need to be assessed in terms of carrying out the treatment rather than knowledge of the procedure alone. Therefore there is a need for accurately and comprehensively assessing technical skills within dentistry. Current methods for training and assessment may be unsuitable for assessing true outcomes in a discipline such as dentistry. It may be more appropriate to consider the use of outcomes related to treatment such as the longevity of restorations, the healing following root canal treatment or long-term complications of surgical procedures as a more appropriate measure of clinical and technical competence. This article has described some of the issues to be considered when delivering dental education/training and measuring its effectiveness.