Features of an effective operative dentistry learning environment: students' perceptions and relationship with performance.

OBJECTIVE: Students' perceptions of their learning environment influence the quality of outcomes they achieve. Learning dental operative techniques in a simulated clinic environment is characterised by reciprocal interactions between skills training, staff- and student-related factors. However, few studies have examined how students perceive their operative learning environments and whether there is a relationship between their perceptions and subsequent performance. Therefore, this study aimed to clarify which learning activities and interactions students perceived as supporting their operative skills learning and to examine relationships with their outcomes. METHODS: Longitudinal data about examples of operative laboratory sessions that were perceived as effective or ineffective for learning were collected twice a semester, using written critical incidents and interviews. Emergent themes from these data were identified using thematic analysis. Associations between perceptions of learning effectiveness and performance were analysed using chi-square tests. RESULTS: Students indicated that an effective learning environment involved interactions with tutors and peers. This included tutors arranging group discussions to clarify processes and outcomes, providing demonstrations and constructive feedback. Feedback focused on mistakes, and not improvement, was reported as being ineffective for learning. However, there was no significant association between students' perceptions of the effectiveness of their learning experiences and subsequent performance. CONCLUSIONS: It was clear that learning in an operative technique setting involved various factors related not only to social interactions and observational aspects of learning but also to cognitive, motivational and affective processes. Consistent with studies that have demonstrated complex interactions between students, their learning environment and outcomes, other factors need investigation.

Validity of scores from communication skills instruments for patients and their dental student-clinicians.

The development of appropriate communication skills by healthcare providers is central to providing quality patient-centred care. Patients can provide valuable feedback to practitioners about their clinical communication. However, in oral health care, their involvement is uncommon and instruments specific for communication in oral health care have not been available. Recently, two complementary instruments have been developed by the Faculty of Dentistry, University of Manitoba for evaluating student-clinicians' clinical communication: one for patient evaluation and one for student self-evaluation. The aim of the current study was to provide validity evidence for the scores related to the internal structure of the revised 2007 versions of these instruments in two dental clinical/education contexts, namely the Universities of Manitoba, Canada (UM) and Adelaide, Australia (UA). The proposed factor structure and loadings, and their stability across contexts were assessed using confirmatory factor analysis, and the adequacy of the internal consistency reliability of the scores was analysed using Cronbach's alpha. The factor structure of the current 2007 versions of the patient and student instruments, derived from the previously developed longer versions of these instruments, was confirmed and was consistent across the two clinical/educational contexts. A model of partial invariance provided the best fit for these data due to variations in the magnitude of the factor loadings between sites. The internal consistency reliability of scores was high with a range of 0.88-0.97. In conclusion, the current study provides preliminary evidence regarding the validity of the scores of the current 2007 instruments, in terms of the internal structure, as measuring the five factors well. Replication of the factor structure of these instrument scores with more participants at both UA and other institutions is required.

Acquiring psychomotor skills in operative dentistry: do innate ability and motivation matter?

OBJECTIVE: The acquisition of psychomotor skills is a key competence in the practice of dentistry, and innate abilities and motivation have been shown to influence motor performance. However, the explicit integration of these factors into the design of research projects about skill acquisition in dentistry has been limited. Therefore, the purpose of this study was to provide a comprehensive analysis of how dental students' abilities and motivation affected their performance in an operative task. METHODS: A longitudinal study with two cohorts of dental students was conducted in laboratory classes forming part of an operative technique course. A range of standardised psychometric tests was used to assess different abilities before completing a cavity preparation on Frasaco teeth. This was followed immediately by completion of an Intrinsic Motivation Inventory. RESULTS: Low but statistically significant correlations (P<0.05) were found between dental performance and psychomotor ability (r=0.22), and also dental performance and motivation (r=0.19). A significant difference (P<0.05) was found in the grades obtained for the cavity preparation exercise in one cohort between students with higher levels of psychomotor ability compared with those with lower levels (Tracing scores) (P<0.05). No significant differences in grades obtained for the cavity preparation exercise were found between students with higher and lower levels of motivation. CONCLUSION: Both innate psychomotor ability and motivation showed only weak positive associations with dental performance on cavity preparation exercises. Our study suggests that student-related factors only provide limited information to explain differences in performance or to be useful as specific predictors of future performance by individuals.

Improving clinical assessment: evaluating students' ability to identify and apply clinical criteria.

AIM: There is ongoing concern by health educators over the inability of professionals to accurately self-assess their clinical behaviour and standards, resulting in doubts over a key expectation of effective self-regulation in the health professions. Participation by students in the assessment process has been shown to increase the understanding of assessment criteria in written assessment tasks. How this might transfer to the clinical setting is the focus of this study. This paper is part of an ongoing investigation of the impact on learning of a series of activities that provides students with opportunities to discuss and apply criteria and standards associated with self-assessment in clinical dentistry. Our aim was to evaluate whether participation in these assessment activities improved the ability of first-year dental students to recognise behaviours demonstrated by 'peers' in videos of clinical scenarios and to relate these to the assessment criteria. MATERIALS AND METHODS: A series of three workshops in conjunction with weekly clinical assessment activities in Semesters 1 and 2 were use to support first-year students' learning of clinical assessment criteria. The design of the workshops was based on the principles of social constructivist theories of learning and the concept of tacit knowledge. Accordingly workshop activities were planned around videos that were specifically constructed to illustrate procedures and behaviours typical of those observed by staff and tutors in the first year of the dental course at The University of Adelaide, Australia. First-year students viewed the videos prior to and after the workshops and recorded observed behaviours that related to the assessment criteria that were used in their clinical practice course. Student learning outcomes were assessed 10-14 weeks after the initial workshop and again up to 42 weeks later. To check whether learning resulted from repeated viewing of the videos without formal discussion, a reference group of third-year students who did not attend the workshops also viewed the videos two times, separated by 12 weeks, and recorded observations in the same way. RESULTS: There was no consistent evidence that repeat viewing of the videos in isolation resulted in improved recognition of 'peer' behaviours by third-year dental students. Results for the first-year students indicated that the workshops and clinical assessment activities had a significantly positive effect on the ability of students to identify 'peer' behaviours related to the criteria used for clinical assessment. In particular, students' recognition in others of knowledge and professional behaviours improved significantly. This improvement was retained over the year and students were able to recognise these behaviours in other scenarios relevant to their year level. CONCLUSIONS: This early exposure to the process of clinical assessment, coupled with ongoing self-assessment and tutor feedback throughout first year, improved the ability of first-year students to identify and apply some key assessment criteria to observed 'peer' behaviour, and this ability was retained over time.

Problem-based learning in dental education: what's the evidence for and against...and is it worth the effort?

All Australian dental schools have introduced problem-based learning (PBL) approaches to their programmes over the past decade, although the nature of the innovations has varied from school to school. Before one can ask whether PBL is better than the conventional style of education, one needs to consider three key issues. Firstly, we need to agree on what is meant by the term PBL; secondly, we need to decide what "better" means when comparing educational approaches; and thirdly, we must look carefully at how PBL is implemented in given situations. It is argued that PBL fulfils, at least in theory, some important principles relating to the development of new knowledge. It also represents a change in focus from teachers and teaching in conventional programmes to learners and learning. Generally, students enjoy PBL programmes more than conventional programmes and feel they are more nurturing. There is also some evidence of an improvement in clinical and diagnostic reasoning ability associated with PBL curricula. The main negative points raised about PBL are the costs involved and mixed reports of insufficient grounding of students in the basic sciences. Financial restraints will probably preclude the introduction of pure or fully integrated PBL programmes in Australian dental schools. However, our research and experience, as well as other published literature, indicate that well-planned hybrid PBL programmes, with matching methods of assessment, can foster development of the types of knowledge, skills and attributes that oral health professionals will need in the future.

Cytokine profiles of lesional and splenic T cells in Porphyromonas gingivalis infection in a murine model.

T cell cytokine profiles in the spleens and Porphyromonas gingivalis-induced lesions of P. gingivalis-immunized mice were examined. BALB/c mice were immunized with P. gingivalis outer membrane (OM) antigens/mouse weekly for 3 weeks followed by challenge with live organisms 2 weeks after the final immunization. Control mice were immunized with PBS. Spleens were excised at 0 and 4 days and lesions at 1, 4, and 7 days after challenge. Splenic and lesional CD4 and CD8 cells were stained for intracytoplasmic interleukin (IL)-4, interferon (IFN)-gamma, and IL-10. More than 50% of the T cells in the spleens of immunized mice were IFN-gamma positive at day 0 which was significantly higher than for IL-4 or IL-10, these levels decreasing significantly 4 days after challenge. Less than 6% of the T cells in sham immunized mice were cytokine positive at day 0, although at day 4, there was a significant increase in the percent IL-10 positive CD4 cells and IL-4 and IL-10 positive CD8 cells. There were no differences in the percent IL-4, IFN-gamma, or IL-10 positive T cells in the lesions of immunized mice, but there was a dramatic decrease at day 7 to very low levels in control mice. In conclusion, the results of the present study show a predominant Th1 response in the spleens of BALB/c mice after immunization with P. gingivalis OM antigens, suggesting that a protective immune response to P. gingivalis may involve a strong IFN-gamma response.

The influence of genetic variation on the splenic T cell cytokine and specific serum antibody responses to Porphyromonas gingivalis in mice.

BACKGROUND: T cell cytokine profiles in the spleens and anti-Porphyromonas gingivalis antibodies in the sera of P. gingivalis-immunized BALB/c (H-2d), CBA/CaH (H-2k), C57BL6 (H-2b), and DBA/2J (H-2d, C5 deficient) mice were examined. METHODS: Mice were immunized either by intraperitoneal injections of P. gingivalis outer membrane antigens and Freund's incomplete adjuvant weekly for 3 weeks or sham-immunized with PBS and adjuvant, followed by subcutaneous challenge with live organisms 1 week after the final immunization. Spleens were excised and blood samples collected by heart puncture at 0 and 7 days after challenge. Splenic CD4 and CD8 cells were stained for intracytoplasmic interleukin (IL)-4, interferon (IF)-gamma, and IL-10 and levels of anti-P. gingivalis antibodies in the serum samples determined by ELISA. RESULTS: Lesion sizes in immunized BALB/c mice remained stable for the 7-day experimental period. Immunized CBA/CaH and C57BL6 mice exhibited large lesions at day 1 reducing by day 7 particularly in the latter strain. Lesions in immunized DBA/2J mice were still larger than the other strains at day 7. With the exception of DBA/2J mice, sham-immunized mice demonstrated lesions which did not show signs of healing by day 7. T cell cytokine responses in sham-immunized mice at day 0 were low, increasing to a variable degree by day 7 after challenge in the 4 strains. Immunized BALB/c mice demonstrated intermediate T cell responses while generally exhibiting a stronger IFN-gamma response than IL-4 or IL-10. Immunized CBA/CaH and C57BL6 mice showed weak T cell cytokine responses while immunized DBA/2J displayed the strongest T cell responses particularly in regard to IL-4 positive cells. Sham-immunized mice had low levels of serum anti-P. gingivalis antibody levels at day 0 with levels increasing significantly by day 7 after challenge. Antibody levels in immunized mice seemed to correlate with lesion sizes. Immunized C57BL6 mice had the highest antibody levels followed by CBA/CaH, BALB/c with DBA/2J exhibiting low levels. The T cell and B cell antibody responses in each strain appeared to exhibit an inverse relationship. CONCLUSIONS: This study has shown that genetic differences at the level of H-2 haplotype induce variations in the local and T and B cell responses to P. gingivalis antigens. The responses of DBA/2J mice which have the same haplotype as BALB/c mice suggest that factors other than H-2 haplotype such as the C5 deficiency may influence this immune response. The significance of the specific antibody and T cell responses and of their inverse relationship to susceptibility to periodontal disease remains to be determined.

Induction of the CD1a Langerhans cell marker on human monocytes.

Monocytes have recently been recognized as a precursor of Langerhans cells. This study examined the regulatory influence of the epithelial environment on the putative first step of the transition towards a Langerhans cell phenotype--the induction of CD1a antigen. The keratinocyte-derived cytokines granulocyte-macrophage-colony-stimulating factor, tumour necrosis factor-alpha, interleukin-6, and interleukin-1 beta induced CD1a expression, as did supernatants of keratinocytes extracted from inflammatory sites (periodontitis). Induction was abrogated by transforming growth factor-beta and a keratinocyte-derived interleukin-1 inhibitor. The optimal temperature for induction was 34 degrees C, not 37 degrees C. These results demonstrate that the components of the epithelial environment (cytokines and lower temperature) exert important influences, which may be part of local regulation of Langerhans cell development.

A comparison of postoperative pain relief techniques in orchidopexy.

Fifty consecutive patients admitted to the Western General Hospital for orchidopexy, were randomly allocated to receive either a caudal bupivacaine block or peroperative wound instillation with bupivacaine, to provide postoperative analgesia. Bupivacaine wound instillation reduced the total operating time, gave more efficient postoperative pain relief in hospital and proved both inexpensive and simple in its application.

First-year responses to a new problem-based curriculum in dentistry.

The first year of a new Bachelor of Dental Surgery curriculum was introduced at the University of Adelaide in 1993. Four integrated streams replaced the previous large number of separate subjects, with an overall reduction in formal contact hours, more exposure to clinical practise, and an emphasis on problem-based learning and student self-directed learning. This report compares students attitudes to the new programme with their attitudes to the previous course. Evaluation forms were completed by 30 of 53 first-year students in 1992 and 38 of 47 first-year students in 1993. Comparisons between years, made using the Student's that, indicated significant differences for several questions. For example, the workload in the previous course was considered to be significantly heavier, with too much theory and too many topics. It was felt that the aims and objectives of the new course were significantly clearer; there was more time to understand material; more opportunities to choose areas to study; students were encouraged more to think for themselves; and staff were more understanding and supportive. The authors conclude that the new problem-based Adelaide dental curriculum has facilitated a more contextual and better-balanced learning environment for students.

The effect of vitamin A on the proliferation of oral epithelium in the rat.

This study assessed the effect of topical and systemic 13-cis-retinoic acid on rat palatal epithelial proliferation with bromodeoxyuridine labelling and silver stained nucleolar organizer regions. Sixty male Wistar rats were assigned randomly to a control group or treatment groups of topical orabase, RA in orabase, 5 times/week or twice weekly systemic doses of 12 mg RA in coconut oil. The rats were treated for 1, 2, 4 or 8 weeks and killed 1 h post-injection of 40 mg/kg BrdUrd. The palatal mucosae were processed, using immunoperoxidase staining or silver stain to visualize BrdUrd utilization or AgNORs, respectively. The number of BrdUrd positive nuclei/mm overlying epithelium and number and area of AgNORs in the basal cells were assessed using image analysis. ANOVA indicated there was no significant effect of treatment on LN/mm or the numbers or areas of AgNORs. The LN/mm for the 8 w group (29.5) was significantly lower than the other groups. RA did not influence rat palatal epithelial proliferation, but across all groups increased age was associated with decreased proliferation. It would appear that the proliferation of normal oral mucosa may not be subject to altered proliferation when treated with therapeutic doses of topical or systemic RA.

Association of frontal sinus development with somatic and skeletal maturation in Aboriginal Australians: a longitudinal study.

There have been very few studies of frontal sinus development and its association with other growth parameters in humans. The aim of this study was to investigate the relationship of frontal sinus development with somatic and skeletal maturation in a sample of Aboriginal Australians. The sample comprised 31 individuals, of whom 17 were males and 14 females. For the selected subjects the following records were available: lateral head radiographs, hand-wrist radiographs and stature recordings, generally covering the age range from 7 to 18 years. Descriptive statistics for frontal sinus size, skeletal ossification and body height were calculated at yearly intervals and comparisons made between the sexes. Growth velocities in frontal sinus height, frontal sinus depth and stature were also calculated for both sexes. The frontal sinus was found to display a well-defined adolescent growth spurt, with its peak velocity occurring after the peak velocity in body height. Females were found to attain peak velocity in sinus height earlier, on average, than males but they attained peak velocity in sinus depth at a similar age to males. The sequence of hand-wrist ossification events followed a similar pattern in both sexes, with events in females occurring approximately one year earlier than those in males. These results indicate that an adolescent spurt is present in frontal sinus growth and that the spurt tends to occur after statural velocity has peaked. Hand-wrist ossification events also tend to have a close relationship to peak statural and frontal sinus velocity and these relationships may be useful in clinical situations for predictive purposes.

Intrinsic rewards experienced by a group of dentists working with underserved populations.

BACKGROUND: The aim of this study was to explore, using qualitative methods, the intrinsic reasons why dentists work with underserved groups. Minority and marginalized groups of Australians suffer a greater burden of dental disease than the general population due to disparities in accessing care. Recruitment and retention of dentists to care for underserved groups is problematic due to personal, professional and structural reasons. What drives dentists to work with underserved groups is not widely known. METHODS: Sixteen dentists were recruited using 'snowball' purposeful sampling. Semi-structured in-depth interviews were conducted. Thematic analysis was conducted on the transcriptions to identify themes. RESULTS: Five key themes emerged: (1) 'tapped on the shoulder', being personally approached or invited; (2) 'dental school experience', the challenges faced as a student; (3) 'empathic concern', the non-judgemental expressions of care toward others; (4) 'resilience', the ability to bounce back after setbacks; (5) 'intrinsic reward', the personal gain and satisfaction received. This study focuses on the intrinsic rewards which were found to be simple, unexpected, and associated with relieving pain, community engagement and making a difference. CONCLUSIONS: Emphasizing personal fulfilment and intrinsic reward could be useful when promoting dentistry as a career and when encouraging graduates to consider working with disadvantaged groups.

Reorientating dental curricula to reflect a minimally invasive dentistry approach for patient-centred management.

Minimally invasive dentistry (MID), together with patient-centred care (PCC), can be considered central to patient management. These approaches have been incorporated in the structure of various dental curricula and indeed formally assessed. However, there is limited evidence that students have an integrated skill-set and are able to apply these skills when providing direct patient care within the clinical setting. Assessment of students' application of core clinical skills has identified numerous deficiencies that need to be addressed. The revised Bachelor of Dental Surgery curriculum at the School of Dentistry, The University of Adelaide, provides an example of how MID, underpinned by PCC, can be presented throughout a dental curriculum. Essentially, MID and PCC are not considered as separate subjects but as a patient management approach that is 'woven into the whole fabric' of the curriculum. The programme relies on the development of empathic communication skills that enable students to obtain key patient information, including their patients' values, beliefs, needs, preferences and expectations, thereby allowing management to be tailor-made. As a result, patients are empowered to be a part of the oral health care team. The Adelaide undergraduate dental curriculum consists of one clinical stream called Dental Science and Practice (DSP), that promotes the application of student knowledge, skills and behaviours in the clinical setting. Vertical and horizontal integration, aligned with an integrated approach to assessment, drives the learning throughout the programme. Clearly-defined outcomes are introduced by Integrated Learning Activities (ILAs) that provide a focus for associated learning activities (e.g. class meetings, tutorials, simulation laboratories, etc). The aim of this approach to learning and teaching is to ensure the required learning outcomes are achieved. It also requires coordinated teaching teams including trained external tutors who clearly understand all aspects of MID and PCC within the curriculum structure.

The missing link: self-assessment and continuing professional development.

The purpose of this paper is to review current understanding of the role of self-assessment in continuing education, particularly in the health professions, and to examine how this knowledge can assist in more effective continuing education. The ongoing debate over compulsory continuing professional development (CPD) has seen a variety of approaches proposed. CPD programmes are expected to foster self-assessing and self-directed practitioners, but the common structure is reported to be largely ineffectual in modifying behaviour. If dentistry is to maintain the rights and privileges of a self-regulating profession, then it must ensure that the development and judgement of ongoing competence is meaningful. Improving practitioners' knowledge of the how and why of effective self-assessment should improve participation in, and outcomes of, CPD. An oft-repeated observation is that the least competent are the most confident. If this is the case, then the idea that dentists should be able, or entitled, to choose the path of their continuing professional development must be open to question. We propose that development of the ability of practitioners to self-assess their ongoing requirements for CPD is essential if all stakeholders are to get the maximum return for effort.