As a hands-on clinical educational programme undergraduate dentistry is an anomaly in Higher Education

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An evaluation of the perceptions of teaching and learning by members of the dental team at the chairside in one UK Dental School


As a hands-on clinical educational programme undergraduate dentistry is an anomaly in Higher Education. This study aimed to evaluate the perceptions of chairside teaching of dental team stakeholders, including dental nurses, dental students, and dental tutors at a single UK dental school. From this sample the penetration of current learning and teaching innovations within Higher Education into the specialist filed of clinical dentistry could be evaluated. This article is the first of a series of three, which investigates the perceptions of stakeholders of chairside teaching at a single dental school. The second evaluates chairside teaching on a UK wide scale. The third provides a scaffold for a scenario and questions to encourage collaboration in sharing and evolving good chairside teaching practice.


There have been a remarkable number of innovations in teaching and understanding of student learning in recent years in Higher Education that may have contributed to a better learning experience for students. Much of the groundwork was in cognitive1 and experiential learning2, and use of reflection3-4. Attention has been given to the need for alignment of assessment with teaching5. Current views are that learning is not only based on activation of past knowledge6, but is socially based and culturally determined7-8. Deeper approaches to learning that can lead to new relevant understandings are to be encouraged9 in a student centred approach10 that can lead to students becoming more directly involved in tutoring each other11, in assessment12 and research13. There is also a literature ready to challenge concepts as soon as they become the status quo such as going beyond "communities of practice"14, considering variation, going beyond competences approach15. In fact, Barnett16 says that the changing milieu of Higher Education and the wider world is "supercomplex" and demands that lecturers should continually challenge students with examples of uncertainty to get them used and capable of dealing with it.

However, it is uncertain how much of this innovation and progress in education has been translated into the teaching and learning situation that occurs in clinical dentistry, where dental students have to care for patients much in the same way as they will have to in practice once they are qualified. This ‘hands-on’ training treating patients differentiates dental from medical education, which is more observational at the undergraduate stage. Much clinical teaching in dentistry currently occurs in one-to-one situations where good practice cannot be easily identified and shared.

For the dental student the learning situation is far more complex than most. Acceptable practice in dentistry is a well defined spectrum of activity delimited by the need for patient safety and to abide by current guidelines in using specialized techniques, equipment and materials. There is little literature on how students from diverse backgrounds adapt and conform to this specific culture of assumed and expected standards. A brief review is carried out in the second paper in this series.

Dental chairside teaching is unique because the student takes responsibility for the restoration and preservation of a patient's oral health under guidance from a tutor. Not only is communication with patients of vital importance to inform and encourage them to engage with disease prevention measures but some treatment options involve making irreparable changes to structures in the mouth. Successful dental care should therefore include a sensitivity to the wishes of patients as well as technical ability and most important an understanding of risk, what to do, when to intervene, and to critically appraise treatment outcomes.

The purpose of this study was to widen the field of investigation to include the perceptions of multiple stakeholders in dental chairside teaching, which has not been reported in the literature so far. As a way forward, a detailed study of a sample of dental students, dental nurses, and dental tutors was carried out in one dental school. Different survey methods were selected using the most appropriate for any specific dental team group. These multiple methods had the advantage of providing 'triangulation' as multiple measures ensure that the variance reflected is that of the subject of the research and not that associated with the measures17.


A UK Dental School (Cardiff) was selected as a Case Study for the project and stakeholders sampled to give as wide a representation as possible for their group. 10 dental tutors (out of a possible 35 academic clinical staff) were invited to take part using maximum variety sampling18 to represent a range of age and experience, seniority, gender and full or part-time employment. One to one, semi structured qualitative interviews were utilised19, to allow for in depth accounts to be obtained from the teachers.

[Table 1 about here]

Focus groups were conducted with 24 fourth-year dental students out of a cohort of 54 and 12 qualified dental nurses out of cohort of 24, all of whom volunteered in response to an e-mail request from the non-dental author. Fourth year dental students were chosen because they had experienced a full year of clinical chairside teaching and were therefore experienced enough to critically appraise what they were experiencing. Fully trained dental nurses were chosen because they were conversant with the training of dental students.

The focus group was chosen as the qualitative research tool since it has the advantage that multiple views could be elicited on the same interview occasion, allowing for the group dynamic to confirm or refute opinions20. Each group consisted of between six and eight participants with the moderator using a schedule designed to allow the participants to explore their attitudes and understanding of dental student learning in the clinic and their response to the teaching they receive.20-21 The questioning became progressively more focused in order to stimulate discussions about the topic.

Since in chairside teaching the patient is the teaching model, providing the student with an opportunity to learn practical skills, the patient plays an integral part in the teaching and learning process. A questionnaire was developed and administered to patients following their dental treatment seeking their opinions on teaching and learning. 150 questionnaires were distributed to patients, however only 11 (<14%) were returned. With such a poor return no meaningful results or conclusions could be drawn. It is possible that patients felt unable to comment on the educational experience, or that they were not interested in it, merely attending to receive dental treatment.

Data analysis

The data were collected and, where necessary, transcribed into text and analysed using Atlas.ti software22. As an overview, perceptions were matched against Pratt's23 perceptions of teaching model which describes five major approaches (in brief: transmission, apprenticeship, nurturing, developmental and social reform). Detailed analysis of perceptions was then made, point by point, assessing to what degree they appeared "teacher-centered" or "student-centered"10

Case Study Results

Three of the stakeholder groups, the students, the dental nurses and the tutors, engaged enthusiastically with the study. Most dental tutors looked on their teaching very much from their own position as teacher. They appeared to consider themselves most clearly as subject specialists or experienced practitioners and thus have transmission or apprenticeship perceptions of teaching23. In essence students need to know what to do and how to do it. In this there was recognition of the value of briefing and debriefing as good practice, for this laid out opportunity to do things well the first time, and how things could be done better still on a future occasion. There was recognition that some students were more adept practically and at linking theory with practice, but differences in learning styles were not considered.

Perceptions as Teacher-centered or Student-centered

The perceptions of chairside teaching of all stakeholders appeared to center around two major themes of "student learning" and "provision of teaching and clinical organisation". The origin of these perceptions could be subdivided into those taking a "student centered" or "teacher centered" approach. This is illustrated with examples in Tables 2 and 3. The focus groups revealed that the students had a very clear idea of what good chairside teaching could be and whilst they had no academic education theoretical background their responses and views could be aligned to learning theorists (see Table 2).

Cognitive Learning

For example, one student talking about chairside teaching says:

"Each case is different, you may be thinking at first, well it's a filling. But each one is different, each patient is different. So it's really important to have a chance to think about what we have been taught and draw on it, learn from it. You need to think about what you know and how you are going to use that knowledge."

This is clearly looking at things from a student centered view. Prior thinking and placing experience into concept maps indicates having a cognitivist approach where organisation and structure of knowledge is critical for understanding1. Dental tutors also did not refer to learning theorists, but were clearly interested in what they see is the cognitive role for chairside teaching: "you develop a way of talking to a patient and describing to a patient what you are trying to achieve so logically you can use that skill to talk to the students and describe to them what they need to achieve, what the patient requires and so on" which places this at the transmission, teacher centered end of encouraging cognitive student learning.

Experiential Learning

Other students’ perceptions of chairside teaching were that:

"It's really a way for allowing us to learn by doing. You know, all the stuff that we are told about in lectures and we read about and the phantom head practices, they all come together in these sessions.”

“I learn best when I make mistakes. That way I'm able to see what's what."

These comments are aligned to experiential learning concepts of learning by doing2. Amongst the dental tutors "learning by doing" was one of the strongest perceptions of chairside teaching. But it was also conceived as something haphazard and perhaps its success relied on mistakes. As one tutor noted:

"I think they have no idea of what they're doing; pretty inadequate. I think it happens by accident that they learn. Generally I think they learn by making mistakes".

It was generally considered that they need "lots of practice", but how much was difficult to decipher. However one tutor made the point that:

"experience does not make one competent; competence must always be linked with the capability of explaining why".

Collaborative Learning

Another student perception was to do with working with peer groups:

"It's really good when we have the House Officers in clinic. They are just above us and so know what we need to know. They are more of an equal".

"I like learning from other students, you can listen and learn in pairs and that's really good, really helpful, you feel comfortable with them."

These views follow the thinking of Vygotsky24 who proposed the concept of zones of proximal development, where peer tutoring is encouraged as an aid to learning. In contrast a number of the dental tutors opposed the idea of different years working together and the one year teaching another.

Interprofessional Learning

The students reported that:

"The senior dental nurses can give very useful little tips, these are really helpful, we can learn a lot from them and hopefully they learn too in these sessions."

"I wish the nurses did more of the teaching, the experienced ones are brilliant and a lot of them do supervise us in the one clinic at Bayside and that's invaluable."

This follows concepts of the value of interprofessional education and the effectiveness of learning and working together25. However, many tutors held negative views about integrated learning with Dental Care Professionals (DCPs) thinking that teaching should be by dentally qualified tutors.

Novice / Expert Learning

A concept alluded to by dental tutors but not students was that students start as novices and work their way up through beginner, competent and proficient practitioners - finally to expert, a sequence proposed by Dreyfuss and Dreyfuss26. One tutor working at an intuitive level of expert said:

"...inherently my own organised mind is the crucial thing in trying to identify how to structure a course... some people have got a natural talent for organising, quantifying and structuring and communicating and you can't teach it."

Some tutors were disparaging of reflective practice, clearly perceiving this as neither required for themselves as intuitive experts, nor for students who as beginners:

"have nothing to reflect upon".

Learning Psychomotor Skills

Psychomotor skill theory was hinted at by a dental tutor with:

"It's quite important to show them the finished product so they know what a cavity should really look like and this has to be in a variety of situations."

However, despite the mention of the view of the finished product no mention was made of visualisation of sequential steps or a knowledge of the expected range of common errors related to a skill as important for learning27.

Teaching and Clinic Organisation

Both dental tutors and students were most articulate about issues concerning the provision of teaching and clinical organization, with some problems identified as clearly related to individual teacher differences:

"The problem is, it depends who is supervising the clinic. There is so much variation in the teaching."

Educational training in teaching for dental tutors

Students were extremely vocal about how they thought clinical tutors should be prepared to teach and how teacher training may be of value:

"The GDP tutors and academics chose to teach and so they should have training. It's very obvious that many of them are not trained to teach and then the sessions are often a waste of time."

"You can tell Mrs. Best has been on a teaching course, she is brill.[sic] She explains things, asks what you think and lets you ask questions."

"Sometimes the feedback is good, they'll ask what you're doing and why, but some tutors they jump in and tell you what to do and that's no help."

One tutor thought that:

"There can be something to be said for the teacher that they are terrified of!"

Continuity of dental tutor allocation

Some problems were perceived by students as defects in clinic organisation:

"The treatment plans vary week by week depending on who is in charge. Often there is a mismatch of specialty with the teaching and the teacher".

Dental tutors were also concerned that clinical chairside teaching needs:

"Organisation- doing the right thing at the right time".


Some students noted:

"These can be really useful, when they happen - which is not that often. You have the opportunity to get a breakdown on the clinic and information on the cases. You can consolidate your knowledge if you can prepare for stuff coming up."

"Having an opportunity to debrief after a clinic is really useful, you can talk through what you have learned, what went well or what was rubbish."

"I loved the debriefs, but the tutors are often in a rush to leave at the end of clinic."

Dental tutors were generally in favour of debriefs, but they have been a fairly recent introduction and have not been fully embedded yet. One said:

"At the end of the session it is important to go over what they've done wrong, to debrief things and that should go on throughout the session and on all the time. Important thing is to realise that you've messed up and what you are going to do about it in future, what are you going to do to remedy the situation."

Student Centred Practice

Some students reported some dental tutor behaviour that obstructed their learning:

"Mr Hyde spends all his time avoiding us, he's in the office drinking coffee."

"Some tutors disappear before they sign off our lists and we need the signatures for the records. When this happens I either hide the list and pretend it's been misfiled or keep it in my locker and try and catch them the next week, once I did forge the handwriting, I know I shouldn't have done, but I'm the one who'll be in trouble for not signing off. They should stay 'til the end of the session and do the teaching properly."

But that is not to say there were no good examples of a student centred approach:

"Everyone is different and if you're doing a practical procedure you get good at it if you do lots of it - you'll find some that don't find it too difficult to do and I can recognise those straight away - and then there's those that need more nurturing and finally those who find it difficult to relate to a practical situation -and it is those who need more teaching, the others just need guidance".

"I like to encourage more self-created learning and find the evidence base for clinical methods and use of materials -- and importance of writing something down at the time about the clinical work for later reflection".


Despite various curricula modifications and changes, chairside teaching itself appears to have changed very little over the years, relying on dental tutor/dental student relationship with dental nurses having an assumed supportive but rarely formalised role. Dental tutors appeared to be enthusiastic subject specialists or practitioners who were keen to transfer their skills to the students. However, generally they were not particularly student-centered, nor was the need for educational training in how to teach widely expressed. Dental tutors reported that there was scope for improving the chairside learning experience through organising one-to-one relationship master-classes and attention to the use of technology to improve demonstration visibility, so that students "can see what you're doing”. Part-time dental practitioner lecturers perceived that they helped the students see an all important general practice side to things but despite that they were happy to follow "a party line" on detail of clinical procedures that are taught. Without educational training, eight of the tutors had very wide ranging views on the degree of "supervision" that students required and how much they should let the student do and when to "take over" to demonstrate how it should be done. The idea that intimidation would have a positive learning outcome does not seem to fit with any current educational theory.

Media (other than standard radiographs and photographs) were not widely used to illustrate clinical issues or provide resources for debriefing. Students and dental nurses recognised the value of peer and interprofessional education, a view not shared by the majority of tutors. Only the two tutors with formal training in education favoured peer learning and collaborative teaching. This appeared to be based on how they valued the time spent on their postgraduate education courses, where they reported that networking with other colleagues on the course and across disciplines, was as equally important for their development as the taught elements. Obviously there is some confusion in taking the use of novice to expert skills sequence model beyond consideration of simples skills issues into complex ones of clinical practice. A counter intuitive position is arrived at where novices and experts alike appear to gain little from reflection. The problem lies with taking the original driving skills development sequence26 and enlarging it inappropriately into a model for competence and professional development28. Some creative ideas were found for gaining continuity from pre-clinical training: bringing students through from the phantom head into the clinic with the same dental tutors -- but this was seen as a problem for some teachers not willing to “risk getting away from the safety of phantom head into the clinic". Good patient selection for improving the resource of types of patients suitable for teaching is seen as a massive organisational problem of critical importance. Also the importance of debriefing alluded to positively by students and tutors follows a pattern in the education literature29.

Resources may be drawn together more fruitfully by reorganising dental curricula so that interdisciplinary students such as undergraduate dental, hygienist and therapist from a number of years work together in collaborative practices, a process which can be summed up as "vertical podding". This may be of particular value in overcoming some of the drawbacks of traditional clinic organisation as suggested by Lawton30. By providing a team of student clinicians with differing skills and learning needs, the treatment requirements of patients can be matched more easily. "Vertical podding" also provides a favourable collaborative learning situation for peer support and positive interdependence31 where a reliance on other members of a group for learning underpins successful learning.


Only a few of the innovations sweeping through Higher Education have reached dental chairside teaching investigated here. In part, it is the complexity of the clinical teaching situation that has kept teaching traditionally as a dental tutor/dental student one-to-one relationship. However, in keeping with understandings of social and technological change there are many possibilities for chairside teaching to change too. Some of these were reported as early as 197630 and some exemplar schools such as Adelaide32 have implemented programmes that include comprehensive educational teacher training. What was evident from this study was the enthusiasm for chairside teaching of most dental tutors but also the complexity of carrying it out. This paper provides a starting point (much as Frank Lawton's in 1976) to draw attention to the current status of chairside teaching. The next stage will be to investigate chairside teaching more widely across the UK in the second article in this series and to develop educational materials to encourage and to share good chairside teaching practice in the third article.


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  2. Kolb DA. Experiential learning experience as the source of learning and development. Englewood Cliffs: Prentice-Hall, 1984.

  3. Boud D, Keogh R, Walker D. Reflection: Turning Experience into Learning. London: Kogan Page, 1985.

  4. Cowan J. On Becoming an Innovative University Teacher. Buckingham: Open University Press, 1998.

  5. Biggs J. Teaching for quality learning at university: What the student does. Buckingham: SRHE and OUP, 1999.

  6. Schmidt HG. Foundations of problem-based learning: some explanatory notes. Medical Education 1993;27:422-432.

  7. Jaques D. Learning in Groups: A handbook for improving group work. London: Kogan Page, 2000.

  8. Bruffee KA. Collaborative Learning: Higher Education, Interdependence, and the Authority of Knowledge. paperbacks edition 1995 ed. Baltimore and London: The John Hopkins University Press, 1993.

  9. Marton F, Booth S. Learning and Awareness. Mahwah, New Jersey: Lawrence Erlbaum Associates, 1997.

  10. Prosser M, Trigwell K. Understanding Learning and Teaching: The Experience in Higher Education. Buckingham: Open University Press, 1998.

  11. Falchikov N. Learning Together: Peer tutoring in higher education. London: Routledge Falmer, 2001.

  12. Falchikov N. Improving Assessment through student involvement: Practical solutions for aiding learning in higher and further education. London: Routledge, 2005.

  13. Jenkins A, Breen R, Lindsay R. Reshaping Teaching in Higher Education. London: Kogan Page, 2003.

  14. Barton D, Tusting K, editors. Beyond Communities of Practice: Language, Power and Social Context. Cambridge: Cambridge University Press, 2005.

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  22. ATLAS.ti: ATLAS.ti knowledge workbench [software]: accessed 19 Jan 2005.

  23. Pratt DD. Five Perspectives on Teaching in Adult and Higher Education. Malabar, Florida: Krieger Publishing, 1998.

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  25. Barr H. Interprofessional Education: Today, yesterday and tomorrow. London: LTSN- Centre for Health Sciences and Practice, 2000.

  26. Dreyfus H, Dreyfus S. Mind Over Machine: The power of human intuition and expertise in the era of the computer. Oxford: Basil Blackwell, 1986.

  27. Mayberry WE, Requa-Clark B, Feil PH, et al. An Introduction to Problem-Based Learning. Kansas: University of Missouri-Kansas City, 1993.

  28. Chambers DW, Gerrow JD. Manual for Developing and Formatting Competency Statements. Journal of Dental Education 1994;58:559–564.

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  30. Lawton FE. What can be dome to correct deficiencies in the undergraduate course. International Dental Journal 1976;26:67–72.

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  32. Mullins G, Wetherell J, Townsend G, Winning T, Greenwood F. Problem-Based Learning in Dentistry: The Adelaide Experience. Adelaide: University of Adelaide, 2001.


Dental School Study Sample


Total sample size



































Learning issues seen as teacher or student centred










Talking lecturing at

Teacher liistens and



structures student








By demonstration

By doing it themselves










Teaching by tutor

Learning with peers


no learning together









Teaching by tutor

Interaction and learning


no learning with DCPs

with DCPs








Expert intuits knowledge

Reflection essential for an


novice knows very little

understanding of skills


little need for reflection



for novice or expert





Show vision of best outcome

Locate example of best


Tell student when wrong



make and celebrate a


range of errors in







Clinic organisation seen as teacher or student centred










Staff student ratio

opportunity to gain a


range of experience








tend to take over

Understanding learning


and demonstrate

"explain, let think, ask"








get to know students

Continuity of treatment


less adjustment to new




more patient centred






Talk through issues as

Allows student to talk and


the teacher sees it

express feelings and thoughts


about the session






Educational terms textbox

Cognitive development

How thinking patterns change over time1

Experiential learning

The complex phenomenon of learning from experience2

Collaborative learning

…may be defined as a learner-centered instructional process in which small, intentionally selected groups of 3-5 students work interdependently on a well-defined learning task; individual students are held accountable for their own performance and the instructor serves as a facilitator/consultant in the group-learning process.3

Zone of proximal development

understanding that lies just beyond current knowledge and ability: what we cannot learn on our own at the moment, but can learn with a little help from our friends. As a result, I may be ready to understand a good deal more as a member of a working group than I would be ready to understand by myself alone.4

Novice, beginner, competent, proficient and expert skills training

A careful study of the skill acquisition process shows that the person usually passes through at least five stages of qualitatively different perceptions of his task and or mode of decision-making as his skill improves.5

Psychomotor skills

The characteristics of a psychomotor skill are ...mental planning and calculating combined with accurately executing (muscular actions).6

Positive interdependence

When positive interdependence is clearly understood...

each group member's efforts are required and indispensible for group success

each group member has a unique contribution to make to the joint effort because of his or her resources for role and task responsibilities.7


1. Merriam SB, Caffarella RS. Learning in Adulthood: A Comprehensive Guide. San Francisco: Jossey-Bass Wiley imprint, 1999. pp 139.

2. Merriam SB, Caffarella RS. Learning in Adulthood: A Comprehensive Guide. San Francisco: Jossey-Bass Wiley imprint, 1999. pp 225.

3.  Cuseo J. Cooperative Learning Vs. Small-Group Discussions and Group Projects: The Critical Differences. Cooperative Learning and College Teaching 1992;2.3: pp 5.

4.  Bruffee KA. Collaborative Learning: Higher Education, Interdependence, and the Authority of Knowledge. paperbacks edition 1995 ed. Baltimore and London: The JohnHopkins University Press, 1993. pp 39.

5.  Dreyfus H, Dreyfus S. Mind Over Machine: The power of human intuition and expertise in the era of the computer. Oxford: Basil Blackwell, 1986. pp 19.

  1. Dick W, Carey L. The Systematic Design of Instruction. 3rd ed. : Harper Collins, 1990. pp 36.

  2. Johnson DW, Johnson RT. Learning Together and Alone. 5th ed. Boston: Allyn and Bacon, 1999.

Addendum on “teaching and learning innovations”

There have been a remarkable number of innovations in teaching and understanding of student learning in recent years in Higher Education that may have contributed to a better learning experience for students. Much of the groundwork was in cognitive (Ausubel, 1978) and experiential learning (Kolb, 1983) and use of reflection (Boud, Keogh and Walker, 1985; Cowan, 1998). It was considered important to maximise learning for students to know why and how they were learning, that learning can be achieved by doing things. Learning could be enhanced further by returning to the thoughts and feelings of the experience and placing these into the context of the course and possibly overall life goals as well. Current views are that learning is not only based on activation of past knowledge (Schmidt, 1993) but is socially based and culturally determined. Hence the added value of small group working in co-operation and collaboration (Jaques, 2000; Bruffee, 1993), in "intermediary cultures" that allow students to ease into a completely new culture of discipline or profession. Also there are exceptional opportunities for students in interprofessional education to learn and practice together, creating a community of practice, mimicking the working situation (Barr, 2000). There has also been the move to encourage lifelong learning, recognising that with the rapid spread of "technological" and "cultural" change, lecturers are unable to teach all that students need to know in their work and life skills. At the same time these two factors can make positive contributions to learning. The use of media (Dutton and Loader, 2002) can create opportunities to make visualisation easier and transmission of information wider, once the technology and consequences of using it are mastered. A change from traditional views allows for the recognition and acceptance that students can become directly involved not only in tutoring each other (Falchikov, 2001) but in assessment (Falchikov, 2005) and even research (Jenkins et al., 2003). Critical appraisal of available information encourages deeper approaches to learning that can lead to new relevant understandings as opposed to a surface approach, where students just attempt to memorise everything (Marton and Booth, 1997). There is also the recognition of the benefit of student centred approaches to teaching, where there is a focus on what can help student learning rather than teacher centred teaching, where the teacher focuses mainly on the delivery and content of their discipline (Prosser and Trigwell, 1998). In addition, more successful encouragement of learning has been recorded when attention has been given to alignment of assessment with teaching (Biggs, 1999) and students are emancipated, playing a part in determining the content and objectives of the course (Mezirow, 1990). There is also a literature ready to challenge concepts as soon as they become the status quo such as going beyond "communities of practice" (Barton and Tusting, 2005), considering variation, going beyond competences approach (Bowden and Marton, 1998). In fact, Barnett (2005) says that the changing milieu of Higher Education and the wider world is "supercomplex" and demands that lecturers should continually challenge students with examples of uncertainty to get them used and capable of dealing with it.

Addendum refs to follow if necessary

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