Defining dental operative skills curricula: An ADEE consensus paper

conceptualisation (theorise) In reflecting and discussing the experience, the student may begin to think about how they could remedy or improve on any problems that they encountered. They may also find solutions or reassurance by talking to their peers and tutors. This will lead to the construction of a new approach, or a new "plan" that they should be keen to try. Active experimentation (apply) The student will then have the opportunity to try the exercise again. However, on this occasion, the student is approaching the exercise with a certain amount of direct experience on which they have reflected. They may have developed a new approach, or appreciate the exercise in a different light. The latter may not be immediately obvious to the student. Once the exercise is complete, they will begin the cycle again; reviewing their second attempt.

critical appraisal might be examples of this. It is therefore important for staff and students to understand the expected complexity of each task, at which points essential and straightforward skills are reinforced, and at what points difficult skills will be revisited and developed further. It is critical that expected learning outcomes for the session are pre-published and available to students, and that students are encouraged to raise concerns if they feel that they are failing to meet the expected learning outcomes as they progress through the course.
As a result of these emergent themes and discussions within the group, it was decided that a degree of consensus was required relating to curriculum content, but also levels of operative difficulty for various tasks. This, in turn, will help skills educators to plan their courses and individual sessions in a structured way, that is sensitive to the needs of their learners.
The aims of this paper were therefore to: • report European consensus surrounding the categorisation (level of importance, and difficulty) of basic operative dental clinical skills within the undergraduate curriculum • provide recommendations relating to session structure and timing of curricular elements for basic operative dental clinical skills teaching

| Methods
Developing consensus consisted of two methodological components, in keeping with Kern's model of curriculum development 4 ; a scoping questionnaire (in order to formulate intended learning outcomes) and a panel discussion with pan-European skills educators (to discuss implementation and instruction strategies).
Regarding the questionnaire, a request to complete an online questionnaire, in English, was sent electronically to skills leads at all ADEE member schools across Europe. The following information was collected in relation to basic operative skills: • The level of importance within the curriculum (not important, essential, important or aspirational) • The level of operative difficulty (easy, moderate, difficult) • Whether the skills should be assessed prior to treating patients (yes, no) • Free text about any additional basic operative skills that should be included The questionnaire was piloted by a small working group from across Europe in order to test the face and content validity.
Modifications to clarity of the English and understanding of the format were made after feedback from the initial appraisal. The definitive questionnaire was hosted by onlinesurveys.ac.uk and employed conditional entries, whereby participants were unable to submit without completing the necessary information. The link remained active for three months. The responses were exported as a PDF and used to inform discussion at the ADEE Special Interest Group on 22 August 2019 in Berlin, Germany, where open discussion helped to further develop consensus.

| Result s
The initial survey was completed by 29 institutions, from 9 countries (Table 1). Following discussion of the findings at the Special Interest Group, basic operative skills were divided into: • Essential skills that are classed as easy or moderately difficult ( Table 2) • Difficult and aspirational skills (Table 3) Given the large number of basic operative skills that were discussed, the skills were also categorised within the tables into the following themes: Equipment and environment, Material application, Operative skills, Reflective practice, Communication and Team Working and Professionalism. The Special Interest Group discussion lasted for over 2 hours and it was clear that there were common challenges faced by dental skills educators. Reassuringly, the group was able to come together to suggest some strategies for maximising the learning within each skills session, and longitudinally across a skills course. A significant amount of time was also spent discussing: • Generic session learning outcomes • The need for regular reflection, critical appraisal and peer review • The need for regular progress review and action planning during skills courses (ideally with a progress review scheduled every 4-6 weeks) • The need for bricolage 5 (or purposeful play) with materials and equipment, in order to increase familiarity and develop confidence prior to using them for new operative procedures Following the activities in Berlin, the authors devised a diagram which represents the learning journey longitudinally during a skills course, in an attempt to capture many of the important elements discussed. This is represented in Figure 1. • Practice following shape outlines on the bench whilst holding a handpiece, using a defined finger rest position • Explore a range of operator positions and appropriate finger rest positions in each arch • Discuss and peer monitor the use of a hard tissue finger rest instead of soft tissue support Place and critically assess a fissure sealant (E)

TA B L E 1
• Practice application of the sealant to a range of surfaces, exploring surface adaptation and flow rate • Explore placed sealants with sharp probes and attempt to dislodge or remove (Continues)

Examples of bricolage, purposeful play, or further task deconstruction
Safely administer local infiltration anaesthetic (E) • Explore anatomical landmarks and practice delivering anaesthetic using 3D models or within a virtual environment • Play card game (matching pairs) with anatomical structure and method of LA • Explore the equipment including safe setup and use of anaesthetic needles • Explore the pressure required to administer local anaesthetic (and the associated flow rates) into inanimate objects such as an orange • Practice operator and patient positions and narrate the route of the needle • Practice delivery on peers and discuss the experiences as a group Manage occlusal carious lesions (E) • Narrate the use of radiographic and clinical findings to estimate lesion depth • Discuss how the lesion will be accessed, including handpiece and bur types • Practice planning and then following cavity outlines, ensuring accuracy and consistent depth Remove caries from the ADJ (E) • Explore carious teeth, by sectioning sagittally, and identifying anatomical and pathological features • Discuss access to the ADJ • Narrate the types of instruments available to remove caries at the ADJ • Practice clearing the ADJ on carious natural teeth Remove unsupported tooth tissue and refine preparations (E) • Explore the use and correct application of chisels on natural and typodont teeth on the bench • Explore the impact of stones, discs and burs on the margins of preparations, including pressure and amount of tissue removed Create suitable anterior and posterior approximal preparations (E) • On the bench, explore the emergence position of pear shaped burs when used to remove carious tooth tissue beneath the contact point • Narrate the value of leaving a protective sliver of tooth tissue at the marginal ridge • Practice seating the bur at a defined starting position, using a well-controlled finger rest • Explore the impact of incorrect bur angulation and posture Place effective anterior and posterior approximal restorations (E) • Ask students to narrate the process of restoration from material placement to final finishing • Remove restored teeth from jaws and explore proximal contour and voids or excesses of material • Explore restoring teeth with and without the use of approximal wedges • Explore the effects of bulk placement of composite and the limitations of depth of cure • Explore colour changes in composite after curing • Blinded peer review and critical appraisal of approximal restorations Finish and polish restorations appropriately (E) • Explore the impact of polishing discs, strips and burs on composites and natural tooth tissue both in terms of material removal and heat generation • Explore how discs and strips alter or polish restorations, depending on their grit size • Explore how discs and strips can be revitalised by rinsing debris from their surface Place and critically assess a direct temporary restoration (I) • Explore the working time of temporary restorative materials on the bench • Explore the strength and resilience of temporary restorative materials in thin and thick section Effectively use hand and ultrasonic scalers for supragingival scaling (E) • Play "scaler tip" bingo in order to familiarise students with tip types • Draw large tooth diagrams and indicate which scaler tips should be used on each surface • Explore the sensation and efficacy of various scaler tips when applied at correct and incorrect contact angles • Explore the potential damaging effects of ultrasonic scalers on root dentine on the bench • Remove varnish from the crowns of typodont teeth using an appropriate finger rest • Remove simulated debris sub-gingivally from models, critically appraising the result before and after removal of the gingival mask Obtain accurate upper and lower arch impressions (I) • Explore how trays can be manipulated, adjusted and extended in order to fully support the impression material • Practice inserting the tray whilst maintaining control and retraction of the tissues • Explore different methods for loading and pre-loading material, and for seating the tray Accurately record an intercuspal position (E) • Explore the behaviour and accuracy of registration materials by recording surfaces of detailed object on the bench • Discuss the discrepancy in surface detail between silicone pastes and alginate impressions • Encourage students to take impressions on peers and articulate models themselves-then critically appraise the process, comparing clinically recorded contacts with those noticeable on the articulated models • Explore the border movements of the mandible (Posselt border movements) on peers  • Practice engaging with peer review using non-dental topics that are more familiar-for example students might bake cakes or write a poem and then seek feedback from their colleagues Critically appraise work against set criteria (E) • Practice breaking down tasks into smaller components, which can each receive assessment and feedback • Mediate students grading and offering advice to one another based on set criteria Identify faults with preparations and restorations (E) • Demonstrate and narrate errors when preparing and restoring teeth • Encourage students to make purposeful mistakes with their work and then engage in peer review and peer dialogue.

Communication and team working
Take an effective patient history (E) • Role play with pre-prepared scripts before moving on to unaided history taking • Encourage students to make specific enquiries about defined parts of each other's lives and summarise to the group • Students should practice summarising a history that is told to them, rather than writing things down as the patient is speaking • Explore how closed or open questions can facilitate or hinder history taking • Discuss the impact of social and medical conditions on patients and the way in which this can determine the course of the discussion • Students should be encouraged to watch good and bad history taking examples and highlight important elements such as body language, eye contact, rapport, empathy and question style (these can be peer recordings) Provide tailored oral hygiene, caries prevention, and dietary advice (E) • Students should be encouraged to watch good and bad preventive advice examples and highlight important elements such as body language, eye contact, rapport, and engagement • Students should be encouraged to teach each other novel non-dental skills during a session, in order to develop skills explaining non-familiar concepts-such as playing an instrument or another practical skill Professionalism Demonstrate punctuality and good presentation (E) • Students to take turns to present the first 5 minutes' discussion of a practical skills session (aims, learning outcomes) (taking the tutor's role to start the session) • Encourage students to plan backwards from the session start time, allocating time to various necessary tasks • Encourage late students to share their reasons for being late (voluntarily) to the group, and mediate a discussion around attendance, punctuality and presentation Demonstrate adequate preparation for the sessions (E) • Mediate discussion at the end of each session about the next intended learning outcomes and requirementsthis can be student-led • Mediate discussion at the start of each session that involves the whole group around topics that students should be familiar with Demonstrate care/ maintenance of equipment in the skills laboratory (I) • Encourage students to sign equipment out and maintain an equipment inventory • Give student shared responsibility for equipment (between two students) • Award student professionalism grades based on their level of maintenance of equipment • Award students a mark for "soft tissue management" when working on phantom heads, which reflects the care taken with the cheeks • Encourage students to oil their own handpieces at the end of each session.

TA B L E 2 (Continued)
TA B L E 3 Difficult and aspirational tasks that could be deconstructed, or employ bricolage with materials and equipment (E-essential, Iimportant, A-aspirational)

Topic
Examples of bricolage, purposeful play or further task deconstruction

Operative skills
Undertake operative procedures within a mirror image (E) • Draw simple shapes onto paper whilst working in a mirror image • Escape from a maze or join the dots on paper whilst working in a mirror image • For these tasks, a visual obstacle needs to be set up so that the paper is not visible by direct visionusually this involves a colleague holding a piece of paper over the operator's hand • Consider using a purpose-made training device 19 Establish an ergonomic working position (I) • Demonstrate the lever functions of the operator and nursing chair including an ideal posture • Encourage students to monitor each other's posture and encourage feedback • Consider a formal session with an Alexander Technique (https://www.nhs.uk/condi tions/ alexa ndertechn ique/) • Ensure that students are placing light sources parallel to their line of direct sight • Encourage students to set out any necessary equipment before they begin their operative procedures, and maintain this in an orderly fashion Develop handpiece control and indirect vision (E) • Consider the use of virtual reality simulators to develop handpiece control skills • Consider the use of a "mock" handpiece 20 or home practice blocks 21 Place an effective direct cusp replacement composite restoration (E) • Use of wax to systematically build up cuspal form on study casts • Narration of each critical stage during demonstration of the procedure • Mediating discussion around the challenges and how to overcome these particularly in relation to marginal ridge anatomy, cusp form and occlusal morphology • Practice restoring cuspal form on the bench using the essential lines (or similar) concepts 22 Effectively access and unroof the pulp space (E) • Ask students to map out their anticipated access shape for a range of teeth on paper using outline diagrams • Encourage students to measure bur length in comparison to tooth length and narrate a discussion about the likely position of pulp spaces • Section teeth sagittally and compare bur length and position, highlighting then benefits of unroofing pulp horns in the first instance • Practice long axis orientation of the bur during preparation using blocks of plaster or acrylic-this can also be assessed accurately using VR simulation exercises • Explore use of the briault probe for detecting internal surface features by asking students to explore inside access cavities on the bench Demonstrate effective placement and carving of dental amalgam (I) • Explore the forces required to adequately condense amalgam, using easily dispensable objects such as Polo mints, or using 3-D printed models • Explore the changing handling characteristics of amalgam during the setting time including the optimal time to carve material away and remove matrices • Explore the limit of hand instrumentation in changing amalgam contour once the working time has been reached by working with hand instruments and amalgam on the bench • Encourage students to time their activities from the initial mix, noting the finite working time for amalgam Effectively deliver nerve block anaesthesia (E) • Explore the use of commercial models to demonstrate and narrate anatomy, positioning of self and equipment, aspiration, and delivery • Employ VR haptic systems to visualise the position of the needle in real time relative to other anatomical structures Effectively deliver supplemental local anaesthesia (pdl, intra osseous for example) (A) Effectively prepare occlusal and approximal cavities on primary teeth (I) • Encourage students to draw "caricature" images of primary teeth, narrating their exaggerated features compared to permanent teeth • Carry out approximal preparations without an adjacent tooth in the first instance, so students can explore bur positioning and emergence in relation to the greater bulbosity of primary tooth crown form Undertake operative procedures using magnification (A) • Mediate a discussion with students about the usefulness and application of magnification • Explore the setup and use of magnification on the bench, either with loupes or operating microscopes • Begin setup of focus and magnification, and exploration of settings based on an "x" drawn onto a piece of paper • Explore the impact on restricted focal distance and posture when using magnification (Continues) the Special Interest Group, in categorising the importance and level of difficulty of basic operative dental skills (Tables 2 and 3

| Lesson planning
It was clear from group discussion that colleagues would value guidance on how to develop appropriate lesson plans for operative preclinical skills. Although there are several learning theories that can be applied to the teaching of operative clinical skills, the most appropriate within this context is undoubtedly that of experiential learning, described by Kolb. 6 Kolb's principles build on the previous work of Lewin 7 and Dewey 8 -here the suggestion is that learning is more than just the behavioural model of stimulus and response. There is a suggestion of higher-order thinking-taking into account immediate and past experiences, giving the learning situation context and personal meaning whilst working towards a desired goal. These processes form a "learning cycle" through which the learner transitions on their educational journey. Table 4 outlines how a student might progress through a learning cycle within a pre-clinical skills session.
The learning cycle is a useful concept in that it can accommodate a range of learning styles 9 -self-directed, practical and problem-based. As skills teachers, we are therefore able to plan for the session effectively-and the recommendation is that we ensure that learners pass through each learning stage. 10 Whilst it is often assumed that learners should begin with "active experimentation"-as skills educators, we should be prepared to deliver sessions that start students off in different learning states, in order to maximise their educational experience. This might be by asking students to: • recall theories and knowledge prior to beginning the practical element; • review previous experiences and performance prior to beginning further work; • begin a new practical task with clear goals, but little direct

Topic Examples of bricolage, purposeful play or further task deconstruction
Report accurately on dental radiographs (I) • Encourage students to learn mnemonics to approach radiograph reporting logically and consistently • Discuss with the students about the need to accurately describe the radiograph in written form • Explore with students the concept of reporting visual anomalies (ie radiopacities, radiolucencies) rather than pathologies • Encourage students to identify normal anatomical features on radiographs prior to describing anomalies Undertake minor oral surgery (surgical removal of tooth/tooth roots) (A) • Explore the anatomy of the surgical area using models, 3D prints or within the virtual environment • Explore the surgical kit and trial different instruments to note their effect (for example periosteal elevators) • Discuss the benefits of an aseptic technique • Practice gowning for an aseptic technique and managing a sterile working environment practical instruction.
The latter by its very nature provides an excellent opportunity for problem-based learning (PBL). The way in which this applies to healthcare simulation is eloquently discussed by Russel Jones. 11 It is not appropriate to use this approach for all clinical skills sessions, but it is widely understood that "learners who commence by focussing on a problem before attempting to understand the underlying principles, have equal or greater success than learners using a traditional approach." 11 That said, it is imperative that students undertaking PBL for operative clinical skills have a clear goal in mind, before embarking on their problem-solving journey.

| Cognitive load
Given that these experiential learning processes are based on context and constructivism, we would argue it appropriate that the learning cycle is considered as a learning spiral, which develops over time (and over consecutive sessions). It could be argued that each learning outcome should have an individual and defined learning cycle. However, it is ontologically questionable to try and separate out these experiences; learning experiences will undoubtedly follow on from previous ones and, as such, the cycle becomes more dynamic. As educators, we should also be encouraging students to reflect on their experiences-and in theory, students should be capable of reflecting on and in action. 12 However, the degree to which this is possible will largely depend on the cognitive load 13 of the session, and the number of times a student has been through their experiential cycle. One example is trying an intricate practical skill for the first time-it may be so difficult and have so many elements to consider simultaneously (the intrinsic cognitive load) that the individual undergoes no other conscious thought process than doing; this leaves little or no cognitive capacity for the germane cognitive load necessary for learning. They can later reflect on action. At subsequent attempts, the individual may be able to reflect in action as schemas are constructed and automated for the task 14

| Practical implications
Traditionally operative skills courses begin by teaching the least invasive, least destructive skills first-and by teaching procedures in full; from the start to the intended clinical endpoint. It is also common for programmes to provide both a basic and more advanced

| Conclusions/Recommendations
It became apparent through discussions within the Special Interest Group that simply defining the expected learning outcomes for skills courses was not enough. Educators reported that teaching pre-operative clinical skills was extremely challenging, not just in terms of students acquiring new operative skills-but also by way of ensuring that students were well supported during a particularly stressful and intense period of their programme. As such we, as educators, should be mindful of how we plan our skills sessions, and how our students are expected to develop as curious, independent learners, whilst being able to take risks and make mistakes within a safe learning environment. The Special Interest Group through ADEE has deconstructed a number of operative skills tasks and provided useful examples for bricolage and purposeful play in order to reduce the cognitive load that students may experience. These should act as a very useful basis for skills teachers to develop their own local skills inventories within their own schools or institutions.

TA B L E 4
How a student might progress through a learning cycle within a clinical skills session, based on Schön's reflective cycle 12 Concrete experience (do) The student attempts to carry out the practical exercise. They will be encouraged to critically appraise their work, based on a set of assessment criteria or teaching aids. They will also appraise the work of their colleagues and as a wider group. This process will allow them to objectively assess what they have achieved, or what has actually happened.

Reflective observation (review)
It is likely at this stage that the student has started to think about their own personal experience of the exercise. They may reflect on the outcome and break the experience down into smaller stages. Some things may have gone well; others not. They may have found certain aspects harder than others, or they may have not been able to achieve what they wanted. The student will then discuss the experience with a colleague and the wider group.
Abstract conceptualisation (theorise) In reflecting and discussing the experience, the student may begin to think about how they could remedy or improve on any problems that they encountered. They may also find solutions or reassurance by talking to their peers and tutors. This will lead to the construction of a new approach, or a new "plan" that they should be keen to try.
Active experimentation (apply) The student will then have the opportunity to try the exercise again. However, on this occasion, the student is approaching the exercise with a certain amount of direct experience on which they have reflected. They may have developed a new approach, or appreciate the exercise in a different light. The latter may not be immediately obvious to the student. Once the exercise is complete, they will begin the cycle again; reviewing their second attempt.
The Special Interest Group also makes the following recommendations for consideration when planning or reviewing operative skills courses: • Educators should consider whether to plan skills sessions in relation to deconstructed skills development rather than clinical presentation and complexity.
• Actual and abstract tasks should be planned logically and reinforced longitudinally through the programme.
• Educators should employ and co-create resources with students that break down difficult tasks.
• Longitudinal skills courses that teach students from multiple disciplines should be considered, rather than basic and advanced courses isolated to specific programmes.

ACK N OWLED G EM ENTS
The activity of this Special Interest Group was coordinated through the Association for Dental Education in Europe (ADEE). Special thanks are extended to EDSA, the European Dental Students' Association for their involvement in the consensus workshop and the authorship of this paper.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.