Exploring the Learned Curriculum at a UK Dental School Through the Lens of Pulp Management

ABSTRACT

Introduction

As part of a wider study investigating the declared, taught and learned curriculum, this paper aims to explore aspects of the learned endodontic curriculum within an undergraduate dental programme in the United Kingdom. This was done through the lens of deep caries management and management of the pulp.

Method

The learned curriculum was identified through a student online questionnaire using case vignettes and subsequently explored further with structured focus group interviews. Two focus groups with a total of 15 participants were undertaken. Following transcription, data were analysed through reflexive thematic analysis.

Results

Valid responses to the questionnaire were received from 39/69 (57%) final year students. Although students largely favoured selective caries removal techniques in deep caries management, their management of a pulp exposure differed significantly from international evidence‐based guidelines in terms of technique and material choice. Following focus group interviews, four themes emerged that influenced the students' answers to the questionnaire and their assumed learning: disconnect between lectures and practical experience; the influence of supervising clinicians; decision‐making regarding treatment; online learning.

Conclusion

This mixed‐methods study identifies variation between current evidence‐based guidelines and the learned curriculum in relation to deep caries and management of the pulp, resulting in student knowledge and practice that do not align with current guidelines. Recommendations include: clear delivery of current guidelines in lectures, use of typodent teeth in the pre‐clinical teaching programme, improved clinical teacher training, a more collaborative and integrative consistent approach, increased availability of materials and creation of more engaging online learning.

1. Introduction

The General Dental Council (GDC) and the Association for Dental Education in Europe (ADEE) both advocate for educators to deliver an evidence‐based curriculum, which is largely outcome based [1, 2, 3]. Outcomes are described, but no details are given relating to how these should be implemented, enabling educational providers some autonomy in determining delivery of outcomes [1, 2].

In accrediting any educational programme, the GDC will need to be assured that the curriculum states where learning outcomes are to be delivered, that is, the declared curriculum. However, as reported previously in relation to the endodontic curriculum at a UK undergraduate dental school [4], there may be disparity between what is declared to be taught and what is formally and/or informally taught. Likewise, it is not safe to assume that what is taught and studied is the same as that which is learned [5]. The concept of the learned curriculum has been described as the changes in knowledge, skills or behaviour that students come away with as a result of their learning experience [6]. The learned curriculum may therefore differ from the declared and taught curriculum (Table 1) [6, 7, 8].

TABLE 1.

Definition of curriculum terms.

Curriculum term	Definition
Declared curriculum	The stated and intended curriculum, which an institution claims is being taught and is described in a course syllabus or guide [7].
Formal taught curriculum	The planned programme of objectives, content, learning experiences, resources and assessment offered by an institution [8].
Informal taught curriculum	The learning that takes place via interactions within the workplace and organisational culture [7].
Learned curriculum	Denotes changes in knowledge, skills or behaviour and is what students come away with as a result of their learning experience [6].

The reasons for disparity between the declared curriculum and the taught curriculum are worth exploring. Endodontic guidelines produced by the International Caries Consensus Collaboration (ICCC), the European Society of Endodontology (ESE) and the American Association of Endodontists in relation to deep caries management and irreversible pulpitis are a helpful model for exploring this further [9, 10, 11]. Challenges exist to ‘delivering’ such guidelines in primary dental care, including access to materials, time constraints and the degree of postgraduate training a dentist has completed [12]. It may therefore be that such challenges influence teaching delivered by part‐time clinical lecturers/supervisors who are also active in primary care delivery. An example of deviation from best practice guidelines was previously identified as different material usage, that is, using calcium hydroxide (CH) instead of calcium silicate cements (CSCs) for direct pulp caps (DPCs) [4]. In this simple example, therefore, we can see that whilst the declared curriculum may reference the above guidelines, teaching on clinical placements (i.e., the taught curriculum) may deviate. However, this may in itself not align with what the students actually learn.

The aim of this study, therefore, is to explore the learned curriculum in relation to the management of deep caries and the pulp through the use of case vignettes and student focus groups and to explore potential differences between the learned curriculum and current guidelines. By understanding what has influenced a student's knowledge of deep caries and pulp management, any deficiencies in the delivery of undergraduate education can be identified and improved upon.

2. Method

This is a mixed‐methods study using qualitative and quantitative methods. Ethical approval was awarded by Newcastle University Research Ethics Committee (REF: 12993/2020).

In order to explore the learned curriculum, a questionnaire aimed at testing students' knowledge of clinical management of deep caries and the pulp was developed (Appendix S1). The questionnaire incorporated clinical vignettes with appropriate images and a series of closed questions. All images were obtained by the authors, which included a radiograph of a deep caries lesion [10], a pulp exposure and a hyperaemic pulp. The questionnaire was modified following a pilot with 10 members of staff. Both the pilot questionnaire and distribution of the final questionnaire were undertaken electronically using JISC Online Survey [13] in June 2021. The questionnaire was emailed to all final year undergraduate students at the School of Dental Sciences, Newcastle University. A reminder email was sent 1 week later. No further reminders were sent due to the proximity of the study to students final examinations. Following the checking and removal of any duplicate responses, data were pseudonymised, cleaned and coded and analysed with IBM SPSS (Version 25, Chicago, IL, USA). Descriptive statistics were used to explore key themes around the management of deep caries and the pulp, including the percentage of participants selecting each answer. No inferential analysis was undertaken because of the limited sample size available.

Final year dental students were invited to participate in focus groups via the questionnaire previously described, with email addresses of volunteers collected prior to pseudonymisation. The focus groups aimed to explore the main drivers in their decision‐making based on answers in the questionnaire through the production of a topic guide (Appendix S2).

Written informed consent was obtained from participants by email before commencing. The semi‐structured focus groups were conducted via Zoom and lasted between 45 and 60 min. The role of the researchers and their professional capacity was made clear to the participants, as well as the aims of the focus group and their anonymity and confidentiality assured. Semi‐structured questioning was used to allow for in‐depth exploration of participants' responses to the previous questionnaire to gain insight into their experiences, perspectives, beliefs and behaviours. Two focus groups consisting of 15 participants in total were conducted, as only one additional subtheme was produced in the second interview; hence, saturation of information was assumed. All focus groups were recorded within Zoom and transcribed verbatim by the authors (D.E./L.B.). No software was used to transcribe the interviews. Participant identities were protected using pseudonyms. Thematic analysis was used to evaluate study data [14]. Two researchers (D.E. and L.B.) coded the transcripts independently, allocating these to emerging themes and findings were compared. Areas of divergence were discussed until an agreement was reached. Debriefing was performed between the moderator and the observer after each focus group to summarise the main findings and prepare the subsequent focus group. No incentive was offered directly to participants, but a revision seminar was provided to all stage 5 BDS students to thank them for their time.

3. Results

3.1. The Learned Curriculum—Student Questionnaire

Valid responses to the questionnaire were received from 39/69 (57%) of students, of which 38.5% (n = 15) were male and 61.5% (n = 24) were female.

Study participants showed deviation from internationally accepted guidelines in several aspects of deep caries management and management of the pulp, including 21/39 (53.8%) would use CH rather than CSC (2/39, 5.1%) for an indirect pulp cap. Similarly, for a direct pulp cap, 21/39 (53.8%) would choose CH and 18/39 (46.2%) CSC. Pulp bleeding was also not controlled appropriately, with 16/39 (41%) participants reporting that they would use ferric sulphate instead of sodium hypochlorite (NaOCl) or chlorhexidine (CHX) (8/39, 20.5%) on a cotton wool pellet to arrest bleeding of an exposed pulp. 30/39 (76.9%) favoured a complete pulpectomy over an ‘emergency’ pulpotomy (9/39, 23.1%) when a patient presents with irreversible pulpitis during an emergency appointment (Table 2).

TABLE 2.

Student responses to questionnaire.

Scenario	Questions	Response options	n (%)
Deep caries management: Participants shown a radiograph with caries present into the inner 1/4 of dentine of UR6 (16), but not penetrating the pulp.	Which caries removal technique would you use?	Non‐selective	4 (10.3)
		Selective in single stage	21 (53.8)
		Stepwise	14 (35.9)
	Which lining material would you use if there was no exposure and a composite restoration was planned?	No lining	10 (25.6)
		Calcium hydroxide	21 (53.8)
		Calcium silicate cement	2 (5.1)
		Resin modified GIC	2 (5.1)
		GIC	3 (7.7)
		IRM/ZOE	1 (2.6)
Direct pulp cap: Following caries removal on an asymptomatic vital tooth the pulp becomes exposed. It is bleeding but not profusely.	How would you control the post exposure haemorrhage?	CW + NaOCl/CHX	8 (20.5)
		CW + ferric sulphate	16 (41.0)
		CW + saline	4 (10.3)
		CW + pressure	10 (25.6)
		Wait	1 (2.6)
	Which material would you apply to the exposed pulp if you could achieve haemorrhage control in < 5‐min?	Calcium hydroxide	21 (53.8)
		Calcium silicate cement	18 (46.2)
		GIC	0 (0)
Irreversible pulpitis: A patient presents with symptoms of irreversible pulpitis during an emergency appointment. After caries removal the pulp is exposed. The patient wishes to save the tooth.	How would you manage this case?	‘Emergency’ pulpotomy	9 (23.1)
		Complete pulpectomy	30 (76.9)
	Following pulp management, and before providing a temporary restoration, would you place a dressing?	No	1 (2.6)
		Antibiotic/corticosteroid dressing	12 (30.8)
		Calcium hydroxide	26 (66.7)

Abbreviations: CHX, chlorhexidine; CW, cotton wool pledget; GIC, glass ionomer cement; IRM/ZOE, intermediate restorative material/zinc oxide eugenol; NaOCl, sodium hypochlorite.

3.2. Focus Groups

Fifteen final‐year dental students were interviewed in the focus groups; nine were male and six were female. Four themes were identified: disconnect between timing of lectures and practical experience; influence of clinical teachers; decision‐making regarding treatment; online learning.

3.3. Disconnect Between Timing of Lectures and Practical Experience

3.3.1. Timing of Dental Materials Lectures

Students felt there was a disconnect between lectures and practical experience. This was apparent specifically in relation to the time gap between dental materials lectures and hands‐on experience. The content at that time did not make sense; hence, the learning was overwhelming.

… we were taught a lot of the dental materials in second year before we have even done KCS [key clinical skills] or had any opportunity to apply it, it was a bit kind of wasted on us because it was so hard to understand all the information that you get in dental materials if you are not using the material straightaway. (DS8)

… when we had the dental materials lectures, I remember trying to learn them for the exams and not having a clue what was going on. (DS6)

…if there is such a large timeframe between getting taught different things, it can be a bit overwhelming. (DS8)

3.3.2. Insufficient Practical Application of Lecture Content

Students also reported with reference to dental materials lectures that they are often not taught the practical application only the science and so lack understanding of the subject.

… the dental materials lectures that we have are just about the material science rather than the applications of it so we miss out a lot on teaching on applications… also miss out on the basic understanding you need to make decisions. (DS5)

3.3.3. Further Practical Experience in Key Clinical Skills Training Required

The students expressed that they needed more practical experience in their key clinical skills section of their training and felt there were insufficient numbers of teeth to adequately practise caries removal techniques. Their concerns were heightened when some did not come across sufficient patients for caries removal in their 3rd year, creating an experience ‘gap’ among their peers. This lack of practical experience of certain situations in clinic reinforced the importance of lecture content.

I remember they picked out about one carious tooth for everyone and said remove this caries, that's all you are getting and then obviously if you didn't come across caries or at least significant caries for most of third year, then you've got a bigger gap than someone who might have just happened to have someone come in who has got lots of caries in their first session. (DS9)

… it's very difficult to do that because they don't have the teeth for the jaws that have the caries to remove really. (DS9)

3.4. Influence of Clinical Teachers

3.4.1. Conflicting Information Given by Supervising Clinicians

From the focus group discussions, it became apparent that confusing messages and conflicting information were sometimes given to students by the supervising clinicians. Students had been advised to use a complete caries removal technique for deep caries management, increasing the risk of pulp exposure, CH for direct and indirect pulp caps and to arrest haemorrhage with dry cotton wool pellets with pressure only. Despite this advice by the supervising clinicians, 35/39 (90%) of students in the questionnaire said they would adopt a selective or stepwise approach to manage deep caries. Although the clinicians told them to remove all the caries, they still picked up that this was not correct.

… the clinicians just tell me to do complete caries removal… they say it's not good to leave like soft caries there, you have to remove everything, and at some point, there was a little bit of pinprick pulp exposure and that's what happened because we had to take all the caries out. (DS11)

… we have been taught to use setting calcium hydroxide to do an indirect pulp cap and that's what I did as well because that was the advice from the clinician. (DS9)

… when I have exposed twice, I have just used calcium hydroxide. No one mentioned calcium silicate or anything. (DS6)

3.4.2. Hospital‐ and Practice‐Based Clinicians

It was also found there was a disconnect between clinicians who are hospital‐based and those based in practice, who seem to have a more pragmatic approach rather than following methods taught to students in lectures.

… clinicians who work one or two days in the hospital have a very different approach to ones based in the hospital, yes they differ from the lectures and I guess that's because the lectures are very much this is how you should do it by the book in the perfect scenario, and they have adapted to do things differently and so they tell you a different method. (DS9)

3.4.3. Not Questioning Supervisors Approach

Another subtheme emerged in which students are heavily influenced by supervising clinicians on how they would manage a clinical situation. They tend to carry out what the clinicians suggest without challenging or questioning their approach.

… it's very clinician dependent and it will be what the clinician says on the day and dictate. (DS2)

I feel like I would just do what I was told. (DS9)

Yes definitely, there has been situations where the opinions of the clinicians will affect how I would have done things, compared to how I would have done it if I didn't have their input. (DS15)

3.5. Decision‐Making Regarding Treatment

3.5.1. Consideration of Clinical Factors

When students were making decisions regarding how they were going to tackle a specific clinical scenario, a number of factors influenced them. Their decisions were generally based on good clinical judgement and they considered factors in caries management such as if the tooth was symptomatic or not and the depth of caries present.

I think it depends whether the tooth has symptoms or not I thought, so if the tooth was like irreversibly damaged you just probably just wanna remove it all but if it has absolutely no symptoms then you probably try and preserve the pulp. (DS6)

3.5.2. Availability of Materials

Another major factor was the availability of materials. CH was readily available, but when they wanted to use materials such as Ledermix or Biodentine, these were not always kept in the clinic.

… a patient presenting with a hot pulp, bleeding quite a lot and clinicians wanting to use Ledermix to dress… but it was not available and so I had to use calcium hydroxide. (DS2)

… Biodentine had to be especially requested… (DS8)

3.5.3. Incorrect Application of Knowledge From Other Dental Disciplines

Students also used their knowledge from other areas of dentistry, which became incorrect when translated to the adult restorative clinical situation. When questioned about their management of symptomatic irreversible pulpitis using a pulpotomy or pulpectomy, most participants considered a pulpotomy could only be performed in a primary tooth. This was taught in their Paediatric course, and hence they opted for a pulpectomy in permanent teeth. Similarly, for haemorrhage control during a direct pulp cap, they were familiar with ferric sulphate as an astringent, which is commonly used in pulpotomies in children, and so chose this material. Their knowledge regarding other methods was lacking.

We've only really spoken about pulpotomies in children, it's never been taught to us as a thing that you would do in an adult. (DS9)

My memory is that a lot of the lectures we've had about pulp caps and pulpotomies are not even part of the restorative course it's all part of the paediatrics course. (DS12)

I feel like the only astringent we have come across is ferric sulphate really and I'm not sure of anything else. (DS13)

3.5.4. Influence of Peers

Students were also influenced by their peers in deciding which material to use, such as the use of CH or Biodentine in a direct pulp cap. As previously discussed, their decisions were also shaped by their supervising clinician.

Calcium hydroxide sounds the most popular that I have heard other students use. (DS3)

Yeah I think I would agree with that I think I have only ever heard of it [biodentine] from like speaking to other people. (DS9)

3.6. Online Learning

3.6.1. Social Media

Among the final‐year dental students, there was a mixed use of social media in their dental education. Some students did not engage in social media at all, although they were aware of the use of YouTube videos and Instagram in dentistry.

…in terms of like YouTube and other social media, I don't use social media that much, and I feel like if I was to use it, it wouldn't be because of dentistry. (DS2)

No, I haven't really engaged in …I have been told there has been some good YouTube videos on pros (prosthodontics) …dental Instagrams I don't really know, I don't get much out of Instagram on dental Instagrams. (DS2)

Those who engaged in social media only used YouTube and that was to view videos showing Prosthodontic procedures and to remind themselves of a technique but not for new learning.

I have watched hours of major imps (impression) videos on YouTube for my competency… at the time it was really really useful and when I went into clinic for the first time and I was doing it, I knew what was going on… so yeah I have used it for pros (prosthodontics) more than anything but everything else not really. (DS4)

Yeah I am the same… for pros (prosthodontics) it is YouTube but not anything else. (DS1)

I think if I wasn't sure on the technique of something but I knew I needed to do it or I wanted a refresher then I would probably watch a YouTube video to help me with that. (DS9)

3.6.2. Trusting Online Resources

The students showed good awareness and were cautious in trusting online resources and their content. One way they evaluated a resource was to consider if the speaker had a valid qualification or not.

I don't really take much off social media as its people doing very off sort of composites… (DS13)

I think there is some good information out there if you believe the source. There's a few consultants that produce YouTube video content and its evidence based. (DS10)

Students also made use of Canvas, the university's interactive web platform where various online learning material is posted. They found the videos on crown preparations particularly useful.

3.6.3. Online vs. Face‐to‐ Face Teaching

During COVID‐19, there was a switch to virtual online learning instead of face‐to‐face lectures. The majority of students preferred face‐to‐face learning as online was more challenging to engage with and be motivated in the session, students felt uncomfortable to ask questions in front of others and missed the social aspect of discussing topics with colleagues.

I definitely prefer face to face. I find it a lot less motivating and harder to engage with them when I'm sat in my house. I'd much rather be in a lecture theatre. I think I'd be more likely to ask questions face to face. (DS9)

… with an (online) lecture with like 70 people, you don't really wanna just start speaking in front of everyone and especially at the end when you have questions, sometimes you feel like you are holding people up. I would rather face to face because it is just so much easier. (DS6)

There is a lack of the social or group aspect that you can ask your colleagues at the time oh what do you think of this and that, which you don't get in the online lectures so it is lacking a little bit. (DS15)

Regarding the university online lectures, there were also a number of comments that the students felt they were very detailed with too much information, making revision from them difficult with time constraints before their final exams.

I think they are quite overloaded and sometimes quite long so like one lecture could have been one hour and a half sometimes and in revision we just want like quick information so we can learn it quick, so we don't have time to just re‐watch them again. (DS11)

4. Discussion

The present study has identified disparities between evidence‐based guidelines and the learned endodontic curriculum, leading to students deviating from current ‘best practice’. In the current literature, no other studies could be found relating to the learned curriculum and current clinical guidelines. In the following discussion, we explore the factors influencing students' knowledge and outline suggested improvements so the learned curriculum can become more aligned with current guidelines, which will ultimately lead to improved patient care. Participants felt there was a disconnect between lectures and gaining practical experience, with time being the main factor. Participants also highlighted a lack of practical experience of the procedures discussed, perhaps identifying a role for using typodont teeth. This was compounded by a disconnect between taught material in lectures and teaching delivered by clinical staff, who students found particularly influential. Participants found the modular delivery of teaching material was disjointed and even conflicting, causing confusion and resulting in an inability to apply theory to practical cases. Again, this was compounded by materials taught in lectures sometimes being unavailable in clinics. Finally, although students engaged in online learning via social media, they preferred face‐to‐face teaching.

4.1. Disconnect Between Lectures and Practical Experience

Students reported a disconnect specifically between the dental materials science course and practical experience. Dental materials science is taught as a stand‐alone course in the second year before the key clinical skills course starts. The timeframe between the two made material science ‘hard’ and ‘overwhelming’ to understand. The lack of practical application also impaired their ability to ‘make decisions’. Teaching both courses concurrently may help students find the content more relatable, improving teaching effectiveness [15] and later this learning can be reinforced with experiential learning in the clinical environment [16].

4.2. Lack of Practical Experience

In the focus groups, students again expressed a need for more practical experience in their Key Clinical Skills course regarding caries removal and were concerned of an experience ‘gap’ across their year group developing as they moved onto clinics. Discussion also highlighted insufficient numbers of plastic teeth to practise on. A plastic tooth model is a common teaching method to develop caries removal skills in students' pre‐clinical years [17]. Limitations include lack of tactile sensation of carious tissue, lack of an enamel dentine junction and cost, which limits the number of teeth distributed to each student [18]. Extracted human teeth can also be used, but good sterilisation that follows infection control guidelines can be difficult, the teeth can be infected with blood borne viruses and finding teeth with a realistic amount of caries is challenging [19]. Virtual reality (VR) simulators are another teaching modality [20] and a number of UK‐based dental schools have integrated this technology into their pre‐clinical teaching programme, although high initial costs are a disadvantage [19, 20, 21].

3D printed teeth overcome many of these issues and are currently used for a number of dental education applications [22, 23, 24, 25]. A recent study using 3D printed teeth containing simulated tactile caries for undergraduate caries removal practice was developed with promising results, finding 64% of students agreed that the 3D printed teeth were a good simulation of tactile clinical caries removal and 71% thought that 3D printed teeth would have prepared them better in caries removal compared to plastic teeth [26].

Recently, the ADEE highlighted the challenges of developing clinical skills, particularly complex tasks [27]. Recommendations to deconstruct and break down difficult tasks, and to develop and reinforce skills throughout the programme of study are highlighted in the findings of the present study. In the United Kingdom there is a shortage of suitable patients for undergraduate treatment teamed with reduced numbers of clinical staff [28]. It may be prudent to consider the use of 3D printed teeth to enhance students' experience, and in the case of pulp management, reinforce this throughout the programme.

4.3. The Influence of Clinical Teachers

Conflicting information was sometimes given to students by the supervising clinicians in reference to current national guidelines. We previously reported that more than half of clinical teachers would advise students to use CH for a direct pulp cap and 16% would advocate non‐selective caries removal to manage deep caries [4]. Recommendations from these findings include formal training of clinical teachers to standardise techniques and protocols to provide uniform teaching. In addition, annual CPD teacher training days with updates on restorative topics are advised.

The most significant challenge supervisors face is the disconnect between academic theory and clinical practice [29]. To improve on this, students need to learn to take ownership of cases by developing critical thinking skills to enable sound clinical decision‐making. This can be achieved by clinicians asking open‐ended questions and making them understand the desired outcomes for a procedure [30, 31]. These techniques are often not used due to time pressures, high student to supervisor ratios and balancing the learning needs of their students with patient safety and quality of care, thus resorting to a teacher‐dominated style of instruction [29].

4.4. Knowledge From Other Areas of Dentistry Translated Incorrectly

From the focus groups conducted, knowledge from the students' paediatric course was being incorrectly translated to the adult restorative clinic which could explain why the majority of students would use ferric sulphate to arrest haemorrhage of an exposed pulp rather than NaOCl/CHX. Nevertheless, we previously reported that the lecture, ‘Managing the Vital Pulp in Operative Dentistry’ specifically states, ‘stop the bleeding and clean the site with NaOCl for a direct pulp cap’ [4]. However, there is no mention to soak a cotton wool pledget in NaOCl to arrest haemorrhage and there is no image to illustrate and make the point clear unlike the use of other images on the slide. Equally, it may be possible to reinforce such approaches using 3D printed models, especially for clinical situations which may be rarely encountered in the undergraduate setting.

In managing symptomatic irreversible pulpitis, most students would perform a pulpectomy rather than an emergency pulpotomy, which aligns with a recent local and national based studies [32, 33]. Students expressed, ‘we've only really spoken about pulpotomies in children and pulpotomies are not even part of the restorative course it's all part of the paediatric course’. We previously identified learning outcomes in the declared curriculum clearly showing the intention of teaching students about pulpotomies in VPT (vital pulp therapy) and when to access the pulp for both permanent and primary teeth [4]. In the same paper, we identified lectures stating a pulpectomy with non‐setting CH paste as the ideal treatment for symptomatic irreversible pulpitis but if there are time or anaesthetic limitations, a pulpotomy can be used, dressing the pulp with moist sterile cotton wool [34]. This shows that students are being taught the relevant information but are remembering the content incorrectly.

Students' knowledge surrounding the management of irreversible pulpitis and gaining haemorrhage control in the exposed pulp is mixed and confused. A more collaborative and integrative approach to teaching between the paediatric and restorative curricula would address this issue. For educators to expand their pedagogic expertise, another suggestion is to adopt Mayer's 12 multimedia principles for effective e‐learning used in the cognitive theory of multimedia learning so key messages are communicated effectively to students (Table 3) [35] and the use of the PeNDVER approach demonstrating operative clinical procedures (Table 4) [36].

TABLE 3.

12 Principles of multimedia learning [35].

Principle	Description
Coherence	People learn better when extraneous words, pictures and sounds are excluded rather than included.
Signalling	People learn better from a computer‐based multimedia lesson when essential parts of text or graphics are highlighted.
Redundancy	People learn better from a computer‐based multimedia lesson that contains graphics and narration rather than graphics, narration and on‐screen text.
Spatial contiguity	People learn better from multimedia lessons when printed words are placed near rather than far from corresponding parts of the graphic in the screen.
Temporal contiguity	People learn better from multimedia lessons when narration and graphics are presented simultaneously rather than successively.
Segmenting	People learn better from multimedia lessons that are broken into self‐paced segments.
Pre‐training	People learn better from computer‐based multimedia lessons when they receive pre‐training in the key elements.
Modality	People learn better from computer‐based multimedia lessons when words are spoken rather than printed.
Multimedia	People learn better from words and pictures than from words alone.
Personalisation	People learn better from computer‐based multimedia lessons when the words are presented in conversational style rather than formal style.
Voice	People learn better from computer‐based multimedia lessons when words are spoken in a human voice rather than a machine‐like voice.
Embodiment	People learn better when an on‐screen agent uses human‐like gestures and movement.

TABLE 4.

PeNDVER approach for practical demonstrations [36].

Recommendations	Details
1. Pre‐emptive	It is important that the episode is planned and steps within the demonstration are verbally introduced prior to being implemented practically.
2. Narrative	A careful narrative is key to a successful demonstration with time built in to allow adequate and clear explanation of the technical stages before they are carried out.
3. Definitive	Actions under the microscope should be definitive and precise so students are not distracted at critical moments, therefore the use of instruments and models to gesture in order to complement the narrative are not recommended.
4. Visible	Students need to effectively see what is being demonstrated so practice by the teacher as well as the use of an output monitor within their field of view, demonstrating a procedure from an angle that is alien to the teacher and ensure the object of interest is always in focus is desirable.
5. Errors	Demonstrations under the microscope should be flawless; however, sometimes it is more useful to demonstrate a mistake or a common problem so students are left to deduce an appropriate way forward.
6. Repeated	The demonstrators should repeat individual stages as many times as possible during the narrative to reinforce the procedure.

4.5. Availability of Materials

The Graduating European Dentist framework by ADEE states, ‘it is critical that teaching institutions develop adequate, dedicated and consistent clinical resources in relation to equipment and staffing’ [3]. Students remarked that the availability of certain materials such as the CSC, Biodentine and Ledermix is variable with Biodentine having to be ‘especially requested’ and resorting to using CH for a ‘hot pulp’ since Ledermix was not available. If students repeatedly use certain materials since others are not readily available, then this may reinforce their use and impact learning, contributing to deviation from the formal taught curriculum.

4.6. Online Learning and Social Media

The COVID‐19 pandemic has accelerated digital transformation in medical education, with face‐to‐face teaching at Newcastle Dental School swapped for a combination of online synchronous and asynchronous lectures [37]. From the focus groups conducted, students overall preferred face‐to‐face teaching, as with online learning they found it more challenging to engage and be motivated, found it uncomfortable to ask questions in front of others and missed the social aspect of their education. This agrees with the opinions of UK medical students who did not find online teaching to be engaging, with limited opportunities to ask questions and overall did not find it as effective as face‐to‐face teaching [38].

Researchers in Germany found dental students had a more positive experience since they had more fun, could better participate and invested less time with online learning; however, 37% of students still preferred face‐to‐face courses instead of online teaching alone [39]. Another study showed that although 54% of students felt less engaged and motivated in following up with distance e‐learning, 79% thought that quarantine actually increased their collaboration with colleagues and 67% of students preferred online lectures compared to face‐to‐face theatre lectures [40].

Moving forward to a post COVID‐19 era, online learning will continue to play a significant part in students' education. A blended approach of online and face‐to‐face learning will likely be implemented. German dental students indicated that they would like on average 53.2% of the theoretical part of their course to be online learning in the future, with lecturers preferring less at 38.6% [39]. Further research involving all stakeholders is warranted to develop evidence‐based information to help educators reform and build a more digitalised face to dental education, with teaching excellence, student satisfaction and student preparedness at its core.

A surprising find from our research was that students' engagement in social media was limited, with YouTube videos mainly being used. Students also showed good awareness and were cautious in trusting online resources, which agrees with another study where medical students did not consider social media as a trusted source of medical information to help with treatment decisions [41]. In the United Kingdom, increasing numbers of dental and medical students use Instagram to learn anatomy. Although Instagram, which focuses on videos and pictures, lends itself to this type of learning, quality control of content is lacking [42]. In creating a more digitalised face to dental education, institutions may need to invest in platforms such as Instagram, providing content that aligns with best practice.

5. Limitations

This study had a reasonable response rate regarding the student questionnaire, but it was not optimal. Students were invited to complete this close to their BDS final examinations, which likely contributed to this. As with all questionnaire surveys, bias and self‐reporting can be problematic. In particular, selection bias may have resulted in the included participants being more engaged students, which could also affect the qualitative research aspects of the present study. Additionally, although the questionnaire was piloted with staff members, additional testing with undergraduate students of a different year group may have improved the accessibility of the questions.

Qualitative research will have several elements of bias, which may be more difficult to manage in the focus group setting. Both social desirability bias and confidentiality bias may result in participants altering and/or aligning their answers with ‘expected’ answers, or those of their peers. All efforts were made to minimise this through strict confidentiality, emphasising the aims of the study and the development of rapport. Unconscious bias and a lack of neutrality from interviewers was managed through the use of a topic guide, an interviewer without a research background in the subject matter (L.B.) and the presence of a moderator (D.E.).

The study provides useful insights into the experiences and views of students; however, the generalisability of the result would be enhanced by extending the study to other dental schools in the United Kingdom and exploring other subjects as clinical vignettes. Given the evidence that UK undergraduate education may deviate from current evidence‐based practice national guidelines [4], such deficiencies are likely to be evident at other institutions.

6. Conclusion

This study identifies and explores reported differences between current evidence‐based guidelines and the learned endodontic curriculum in a UK Dental School. This disparity resulted in student knowledge and practice that do not align with published guidelines. Factors perpetuating the disparity included (i) a varied approach by clinical teachers, (ii) unclear messages being delivered between different areas of the dental programme, (iii) a lack of practical experience in managing the specific clinical scenario and (iv) availability of materials to allow implementation of the recommendations. Based on this and other relevant literature, the authors make the following recommendations:

1. Clear guidance for students, both in written, digital and practical form relating to specific clinical procedures. We recommend Mayer's 12 principals for supporting e‐learning and the PeNDVER approach for practical demonstrations.

2. Replication of clinical scenarios or deconstructed clinical scenarios using 3D printing and use of 3D printed teeth in pre‐clinical teaching programmes.

3. Improved clinical teacher training and benchmarking with specific case‐based exercises to provide context and promote deeper learning.

4. Ensuring coherence between equipment and materials taught in the pre‐clinical skills environment and those available in the patient clinics.

Author Contributions

The authors confirm contribution to the paper as follows: study conception and design: L.B., D.E., J.F., J.E.; data collection: L.B., D.E.; analysis and interpretation of results: L.B., D.E.; draft manuscript preparation: L.B., D.E., J.F. All authors reviewed the results and approved the final version of the manuscript.

Ethics Statement

Ethical approval was awarded by Newcastle University Research Ethics Committee (REF: 12993/2020). All participants consented to participate in the study and for their data to be used as part of the research and published.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix S1: eje70036‐sup‐0001‐AppendixS1.docx.

Appendix S2: eje70036‐sup‐0002‐AppendixS2.docx.

Brooks L., Field J., Ellis J., and Edwards D., “Exploring the Learned Curriculum at a UK Dental School Through the Lens of Pulp Management,” European Journal of Dental Education 30, no. 3 (2026): 896–906, 10.1111/eje.70036.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.