Sles in Dentistry Oral Health Curricula 201108

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SLE in Dentistry and Oral Health: Final Report 1

HWA/RFQ/2010/17

Use of Simulated Learning Environments

in Dentistry and Oral Health Curricula

Submitted to:Katie L. Walker, Health Workforce Australia

22 November 2010

[email protected]

Prepared by:Professor Laurence J Walsh

With contributions from Dr Lei Chai,A/Prof Camile Farah, Prof Hien Ngo, and Mr Gary Eves

for the consortium of theUniversities of Queensland, Adelaide and Melbourne


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1.0 Executive Summary

Dental educators must create learning environments that promote critical thinking,decision making and transfer of knowledge from didactic to clinical settings in order toenhance the knowledge, skills and performance of their students. In addition, due to a

rapidly changing health care environment, dental education has been plagued withincreasing quantities of complex information with waning numbers of academics. Addingto the challenge, the expectations of new graduates in dentistry and oral health differfrom those in other health professions because students must be fully prepared for clinicalpractice at the time of graduation. Because there is no mandatory internship, the fullcomplement of skills and competencies must be acquired during university education.The Australian dental Council (ADC) has mapped out the competencies required fornewly graduated dentists and oral health therapists (Appendices 1 A and 1 B), and thisforms a well articulated regulatory framework from which to define simulation-supportedactivities.

Recommendation 1. The ADC framework be used as a basis for embedding novelsimulation methods into dental and oral health curricula.

Apart from a requirement to acquire academic knowledge, during their training, dentaland oral health students need to acquire a full range of highly precise manual andtechnical skills, including excellent hand/eye coordination, to enable them to visualizeand understand how to undertake complex tasks such as placing restorations and scalingteeth. Furthermore, unlike students in medicine, dental and oral health students are in theposition of administering treatment to patients very early in their training. Thisrequirement brings with it a range of challenges.

All dental schools make extensive use of clinical material, particularly case studies (withtreatment records, photographs, study models, and radiographs), for sensitizing studentsto the diagnostic, therapeutic, and patient management challenges of the dental clinicalenvironment. Dental education is visually driven and image intensive, yet the visualinformation must be aligned with high fidelity hand skills.

Because of the need for well developed procedural skills prior to students workingdirectly with their own patients, all dental schools have preclinical simulation laboratories,and these complex and expensive facilities form a major part of the first and second yearof both dentistry and oral health programs (Appendix 2). The use of these facilities forskills development in restorative dentistry currently occupies large amounts of curriculumtime, as was mapped in Stage 1 of the project. All dental schools have simulatorlaboratories with phantom heads and typodonts (removable artificial teeth and jaws)which are used for preclinical skills development in restorative and periodontalprocedures as a core part of existing dental and oral health programs, occupying severalhundred hours across first and second year. Use of these facilities was greater in schoolswho had less access to clinical facilities, where it served as a partial substitute forchairside time.


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In all the dental existing programs, the progression in dental education throughpsychomotor skills development for first and second year students moved from simpleinstrument handling tasks to a high fidelity phantom head simulator in one step. Analysisof this approach identified that it was not optimal because it did not permit any scaledlearning and was time- and cost-intensive because junior students were not ready to make

full use of the more complex environment of the phantom head.A significant gap was identified in the area of simulation prior to commencing preclinicalwork. Here a number of opportunities present:

Use of accelerometer devices including games to build hand-eye coordination andfine motor skills

Training devices for hand-eye and mirror vision skills

Use of haptics to develop and refine manual dexterity

Virtual clinic and virtual lab environments for familiarization before classes.

Stage 2 of the project identified that in order to more efficiently prepare trainees for thehigher cost and supervision intensive lab simulation, a new class of intermediary

simulation device is required. This class of device sits between simple proxy devices forhand-eye coordination and the high fidelity haptic and virtual reality simulators which arecommercially available. Such a device would follow the approach already used forsurgical skills training, with visual feedback to develop hand-eye, finger rest, instrumentpositioning, mirror vision, and other skills, presented to the trainee through a reverseimage window initially and then through smaller dental mirrors as skills develop. Thetrainees would use dental instruments to work on artificial or mounted natural teethplaced in the training box. Such training boxes could include additional features such assynthetic tongues and saliva to introduce additional task complexity and realism.

Current VR technology to support dental education (DentSim and EPED) does not

provide a complete solution to the challenges of skills acquisition, thus the preferredtechnology platform for high end dental simulation appears to be haptic technologycombined with visualization, using existing surgical simulators (such as VOXEL-MAN)for some procedures, and custom built dental haptic simulators (Simodont) for refinementof skills across a range of dental procedures. At the resent time there is only limitedresearch investigating the effectiveness of haptic technology for dental education. Suchtechnology can augment but not replace instruction from tutors.

There appears to be considerable scope for enhancing the efficiency of learning prior toreaching clinical environments by using specific skills-development boxes forenhancing fine motor control and learning mirror vision prior to students commencing

work on typodont teeth in phantom heads. The curriculum impacts of this change wouldbe

accelerated learning prior to commencing phantom head work

reduced wastage of synthetic teeth, student time and instructor effort duringpreclinical instruction

greater benefit educationally from hours spent with phantom head simulators

greater readiness for more complex procedures when reaching the clinics

a greater skill base when reaching the clinical placement phase of the course.


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Recommendation 2. Future HWA support be provided to develop and implement

skills development boxes which can be deployed at scale to all dental schools to

bridge the skill gap for junior students in dentistry and oral health before they

commence phantom head work, particularly in restorative dental procedures.

The information literacy and computer literacy of dental and oral health students is veryhigh, making them very receptive to a range of simulation activities which can enrich andaccelerate their learning experiences. The opportunity this presents has yet to beexploited fully, and the emerging evidence for curricula elements such as virtualmicroscopy is very positive. A virtual slide box for dental education had beendeveloped and evaluated comprehensively at UQ over recent years to enrich teaching inoral biology, oral histology and oral pathology, and the medical education literaturerelating to this innovation provided direct evidence of the value of this approach.

Recommendation 3. The following measures be deployed as standard parts of

curricula, to increase the depth of learning and provide a platform for professionaldevelopment during the dental course and beyond.

(a)Opportunities to interact with other students in dentistry locally and globally,and with other students in health professional courses using virtual worlds.

(b)Virtual microscopy to augment or replace traditional microscopy with lightmicroscopes for oral biology, oral histology and oral pathology.

(c)Three dimensional software for appreciating both dental anatomy and dentalradiology.

(d)In-person interprofessional interactions with other students in health scienceprograms, to build relationships, establish professional identity, develop

teamwork skills, and appreciate the need for coordination between

healthcare professionals for gaining optimal patient care.

In addition to the conventional phantom heads, several dental schools were exploringmore complex simulation systems which included virtual reality or haptics, with singletrial units either recently obtained or under negotiation. This very promising technologyis ideally suited for a wide range of procedures, unlike the narrow range of phantom headsystems. There is evidence of effectiveness for training in oral surgical procedures. Thericher simulation experience of depth and tactile feedback ideally suited for most clinicalprocedures in dentistry,

Recommendation 4. Haptic simulation units be deployed in dental schools to enrich

clinical skills, particularly in the area of training in more complex procedures where

they can accelerate skills progression and help avoid surgical misadventure. Such

simulators can enhance the level of preparedness of students prior to clinical

placements. Given the limited scope of the existing literature on simulation in

dentistry, such deployment should be accompanied by multi-centre research on the

educational benefits of such technology.


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Recommendation 5. Deployment of haptic simulators to large placement clinics

where many students are located is recommended to allow students to enrich their

skills outside of rostered clinic time. Such simulation units could also be considered

for skills assessments undertaken by the ADC of those re-entering clinical practice

or joining the profession from overseas training programs, as an alternative to live

patient treatments.

Stage 3 of the project identified that various types of simulation are already usedextensively in the curricula for dentistry and oral health. A number of activities are wellsuited to class activities prior to clinical contact, including case studies, role plays, andstudents working in small groups rotating between the roles of clinician and patient.Aspects of patient communication such as establishing rapport, dealing with medicalhistory, and discussing treatment options are generic to many health professions, and thuspresent opportunities for interprofessional and multiprofessional learning activities.

Recommendation 6. Dental schools collaborate with other health professions to

maximise opportunities for interprofessional learning.

Each of the dental schools has already provided input into the development of the ADCcompetency maps for dentistry and for oral health. These ADC documents will be usedfor accreditation of programs from 2011 onwards. The accreditation function for dentalprograms in Australia has been designated to the ADC from the Dental Board ofAustralia.

The use of simulation (such as haptics and virtual reality) can augment the skillsdevelopment of dental and oral health students, making them more productive when onplacements in providing patient care to the Australian community. There is no currentevidence that using high end simulators can completely replace input from instructors inthe simulation laboratory, nor replace authentic clinical experience in patient care. This isin part because effective, high quality clinical dentistry requires the application of skillsacross the domains of communication, pattern recognition, hand-eye coordination, andtactile sensation which cannot be provided by existing simulation technologies.

The project was discussed with the Australian Council of Dental Schools in September2010, and after circulating the draft report and recommendations in late October a specialteleconference of ACODS was held on 14 November. At this meeting, the heads/deans ofall nine Australian university dental schools which offer professional entry programs indentistry and/or oral health (the Universities of Queensland, Adelaide, Melbourne,Newcastle, Western Australia, James Cook, Sydney, Griffith, Labtrobe) gave theirunanymous endorsement of the report, and all of its six recommendations. The report hasbeen transmitted to the Australian Dental Council as the accreditation body for theseprograms, and to the Dental Board of Australia as the national regulatory authority.


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2. Background to the Project

This project forms one of a series of projects in simulated learning environments (SLEs)initiated by HWA in mid 2010. The project occurred during a time when the AustralianDental Council (ADC) was undertaking a competency mapping exercise for dentistry and

oral health. Fortuitously, the ADC committee for this major exercise included two seniormembers of the HWA project team (Professors Walsh and DeVries). This unique overlapof the two work agendas allowed an alignment between the HWA project work and thematrix of competencies for new graduates in dentistry and oral health, documents whichhad been developed, refined after extensive stakeholder input, and endorsed by the ADC(Appendices 1A and 1B).

In 2006, as part of the health workforce reform package, the Council of AustralianGovernments (COAG) announced that capital and recurrent funding would be availableto build and operate new or enhance current SLEs. A consortium led by TheUniversity of Queensland (UQ), with the University of Adelaide (UA) and the University

of Melbourne (UM) was established to undertake the project. The project team workedwith the Australasian Council of Dental Schools as the key body for academic dentistry,and communicated with the Australian dental schools offering profession-level entryprograms in dentistry and in oral health to establish the extent of existing activity usingSLEs. Oral health programs combine dental hygiene practice and dental therapy practiceinto a three year degree, the Bachelor of Oral Health (BOH). Programs in dentistry andoral health share a significant number of learning activities which are undertaken usingSLEs, as a prelude to students commencing in clinics with patient treatment.

2.1 Context of the project: Existing simulation in dental education

Over the past decade, rapid growth has occurred in higher education in the areas ofdistance learning, interactive telecommunications, computer-assisted instruction, andcomputer simulations. While the use of simulation has been proposed as the next majorstep in the evolution of health science education, dentistry has been using various typesof simulation for many years as a standard part of the curriculum.

The use of SLEs in dentistry and oral health differs from other areas in health becausesimulation has been used for many years and is a normal part of existing curricula,ensuring that students are both competent and safe at a range of clinical proceduresbefore they enter teaching clinics in their second or third year as clinical operators. Mostschools with dental programs use educational models in which students, particularly intheir final year, work at placements outside the central location or hub.

All dental schools have purpose-built pre-clinical simulation laboratories (PCSLs), whereactivities are run as part of the core curricula in dentistry and oral health. These PCSLshave multiple stations, each with a simulated patient head and torso, removable jaws andteeth, dental handpieces, air/water syringe, and a dental light. (Examples of traditionalPCSLs are shown in Figures 1-6 in Appendix 2).


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Phantom head simulators for restorative, prosthodontic and periodontal procedures arefound in large numbers in existing dental schools, with PCSLs containing between 30 and60 phantom head simulation stations (according to the size of the school) being quitecommon. PCSLs represent a major capital and recurrent cost for the dental schools, witha lab of 30 simulators costing in excess of $ 6 million to fit out, since phantom head units

and their associated dental equipment cost up to $ 70,000 for each station.

Commercial systems for high end simulation (using virtual reality or haptics) havebecome available in recent years, with current costs of $100-150,000 per station. Thishigh cost has been a major barrier in the adoption of high end simulation internationally,but less so than problems with accuracy, realism and software performance which haveplagued earlier systems of such types.

Because of the high cost and complexity of these PCSLs, it is not particularly costeffective to consider replicating these to all the placement locations across regional andrural centres. The later parts of this document extend the current concepts of simulation

in dental education to include skills acquisition prior to students entering PCSLs, andidentifies activities which could support students during a placement semester or year inenhancing their skills.

2.2 Survey

The schools surveyed for this HWA project included the five established Go8 dentalschools: The University of Queensland (dentistry 5 year program and BOH) The University of Sydney (dentistry 4 year program and BOH) The University of Melbourne (dentistry 5 year program and BOH) The University of Adelaide (dentistry 5 year program and BOH), and The University of Western Australia (dentistry 5 year only),and the five newer university dental schools, the majority of which are located in regionalcentres: University of Newcastle - Ourimbah Campus: BOH (dental hygiene only) Griffith University Gold Coast campus: Dentistry (3+2 program) and BOH Latrobe University- Bendigo campus: Dentistry (3+2 program) and BOH Charles Sturt University Wogga Wogga campus: Dentistry 5 year program James Cook University Smithfield campus: Dentistry 5 year program.

The inclusion of all the dental schools adds to the significant experience of the threeconsortium partners, all of whom have students in rural and remote placements.

2.3 Project Methodology

The consortium developed an approach and a project plan which involved activities bystaff from UQ, UA and UM.


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Support staff

To support the work of the project, UQ employed three staff in a fractional capacity anassociate lecturer with experience in systematic reviews (Dr Lei Chai), an experiencedgeneral dental practitioner who had been involved in student clinical education (Dr Bruce

Kidd), and a consultant (Mr Gary Eves) with considerable experience in developingsimulation technology and using this in both health and non-health related contexts.

Engagement

The project team engaged ACODS, with a presentation by Professor Walsh anddiscussion of the project at the September ACODS meeting held in Kiama, NSW. Thesenior project members then met with the President of the ADC as part of the subsequentACODS meeting in Canberra, and in a broad discussion of current matters discussed theproject and its progress to date. To ensure benchmarking of the work with internationalbest practice, Professor DeVries provided information from the Association of Dental

Education for Europe (ADEE) from their July meeting. UQ staff involved in the projectattended the Universitas-21 dental educators meeting in August, and a major dentaleducators meeting in the United States in October, and as part of their normal universitywork also visited manufacturers and suppliers of conventional and virtual reality dentalsimulators. Professor Walsh as the project lead also collaborated with UQ colleagues inveterinary science who were working on deploying haptic simulation into theircurriculum for procedural tasks.

The draft report and recommendations from the project were circulated to all ACODSmembers in late October. A special teleconference of ACODS members was held on 14November to discuss the outcomes of the project, seek additional comments, and obtainendorsement of the report as a whole, and of its six individual recommendations. Thereport was transmitted to the Australian Dental Council as the accreditation body forthese programs, and to the Dental Board of Australia as the national regulatory authority.

3. Existing simulation activities

3.1 Inclusions for the survey

A survey tool for dentistry was sent to all Australian dental schools offering entry levelprograms (BDent, BDS, BDSc, and comparable 3+2 programs recognized by theAustralian Dental Council (ADC) in August 2010 (Appendix 3A), as listed in Table 1overleaf. In a like manner, a survey tool for oral health programs was sent to all schools

which currently offer degree programs in oral health (BOH) (Appendix 3B).

The survey tool did not include case studies, electronic patient records, role plays andother lecture class-type activities which are themselves forms of simulation, but ratherfocused on laboratory-based simulation activities.


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Table 1. Ten Australian education programs in dentistry and oral health (2010)

In early October 2010, information came to hand that Griffith University was closing itsBOH program, with no further intakes of students, and would see through the existingstudents to completion. This information was confirmed by checking with theQueensland Tertiary Admissions Centre (QTAC) who advised that both program code233822 Bachelor of Oral Health in Oral Health Therapy (Griffith University - GoldCoast) and the related program 233872 Bachelor of Oral Health in Oral Health TherapyStudies were not available for commencing students from February 2011. The data fromGriffith regarding their BOH program was thought to be useful and so was retained forthe project.

3.2 Exclusions for the survey

Late in October 2010, further information came to hand to the project team that CentralQueensland University (CQU) was planning to commence BOH programs at some pointin the future, on the basis of their having sought HWA funding for growth places forclinical training. This intention was flagged in the Interim Agreement for Mission-BasedCompacts between CQU and the Australian Government for the period 1 January 2010 -31 December 2010, however not details of timing were provided in this compact for aBOH program. No information regarding the CQU program could be sourced from thatuniversitys website and there was no program on offer through QTAC forcommencement in 2011. The team members thus believe that the intended commencingdate will be 2012 or later.

Given the timing of the information about CQU coming to light, and the fact that CQUhad yet lodged formal notification to either ACODS or the ADC regarding this newprograms, it was considered that their stage of development would not have permittedthem to make a detailed response to the survey tool, and thus they were not included.

In mid October 2010, the team became aware that Curtin University was planning tointroduce a new 3-year Bachelor of Science (Oral Health Therapy) program from 2011that would incorporate elements of both dental hygiene and therapy into an integrated


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program. Curtin University currently provides an Associate Degree in Dental Hygieneand a parallel but separate Associate Degree in School Dental Therapy. A requirementfrom HWA for the project was that only accredited university based programs indentistry and oral health were to be included. To the teams knowledge, no suchaccreditation had yet been undertaken for this new combined program. The decision was

therefore made not to include Curtin in the survey.

3.3 Map of Simulated Learning currently being delivered in dental schools

The mapping of current simulation is presented in Appendix 4A for Dentistry andAppendix 4B for Oral Health, with a mapping by year of the relevant programs inAppendix 5A.

Across Australia, both dentistry and oral health programs are large users of simulation,with dentistry being the larger of the two. In dentistry programs, upwards of 460 hourswas devoted to simulation activities, with the single biggest component being restorativedentistry (cavity preparation and restoration of teeth) and the related area ofprosthodontics (crown and bridgework), followed by removable prosthodontics (denture

fabrication), endodontics (root canal work) and orthodontics. This pattern is typical ofdental schools internationally, and explains why all dental schools have large simulationlaboratories (PCSLs) with multiple workstations with phantom heads for undertakingsuch work (Appendix 2). Most of these simulation laboratories are located at the Schoolshome base (Appendix 5A).

Variation between schools was noted in terms of total simulation hours. Part of this wasdue to how the various activities were classified by the respondents and aligned to thequestionnaires. Dental schools used upwards of 550 hours for simulation activities in theexisting dental curricula. This was much less than the number of hours devoted to clinicalpatient care, which was approximately twice this benchmark (2000 plus hours). Similarly,

simulation in oral health was upwards of 300 hours, compared with over 1000 hours ofclinical practice.

Simulation was used in each Australian dental school to ensure competence and safety asa barrier before proceeding to undertake patient care in later parts of the course. Becauseof the strong proceduralist emphasis in dental and oral health clinical education, the hoursdevoted to clinical education were multiples of the simulation hours. In other words, allschools used the simulation work as a prelude to much longer patient contact within theprogram. Across the discussions held regarding the project, no school supportedreplacing or substituting clinical patient contact with increased periods of simulation,however it was agreed that existing simulation activities could usefully be expanded andtheir efficiency improved. In particular, schools believed that the existing clinical contact

intra-murally and extra-murally during the program was critical for producing dentalgraduates who were fit for purpose and who could meet the requirements articulated bythe profession at large and by the ADC in particular.


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All schools felt that existing clinical training days should be preserved and in some casesexpanded to provide the full breadth and depth of clinical experience. Most schools wereinvolved intensively with projects to expand clinical placement opportunities for theirexisting and future students, and saw this as a major focus for their immediate future.

Different models of clinical care were used across the sector, as shown in Table 2 below.At one extreme, two dental schools operated large private clinics (Griffith and UQ) aswell as a network which extended interstate. At the other, four older dental schools (WA,Adelaide, Melbourne, Sydney) relied on the state dental hospital(s) for the bulk of theirclinical teaching.

Table 2. Models of dental education

4. Literature review

4.1 Methodology for the literature review

A literature review on simulation in dentistry was undertaken, drawing on national andinternational published literature. The search strategy included all levels of researchevidence, and a database was created. From abstracts, filtering of the papers wasundertaken, followed by further filtering based on a review of the full paper. This was

undertaken by two separate assessors using established evidence-based frameworks asapplied in systematic reviews. In addition, information was sourced from relevantmanufacturers for current and future projects involving simulation. The US patentdatabase was searched to obtain information regarding prior art in dental simulation andto establish the status of current technology for dental simulation, including both virtualreality and haptics.


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4.2 Outcomes of the Literature Review.

The published literature was searched using the PUBMED keyword search:(Dental) AND (Education OR Learning OR Teaching OR Instruction) AND (SimulationOR Computer-assisted OR Computer-Aided).

This retrieved 370 papers, which were then screened by title and abstract by two teammembers. Articles were excluded if they were not research articles (such as editorials,letters, communications, interviews, news and features), or on an irrelevant topic. Thisreduced the data set to 229, as shown in Table 3 below.

Table 3. Full publications on simulation in dental education

The following MeSH searches were also undertaken:(Education, Dental) AND (Patient Simulation OR Computer Simulation)(Dentistry) AND (Learning OR Teaching OR Computer-Assisted Instruction ORProgrammed Instruction as Topic) AND (Patient Simulation OR Computer Simulation)This search retrieved 145 papers, which were then cross-matched to the primary searchresults so that there were no double entries into the database.

To explore image guided surgical training in dentistry, a search using the following

MeSH terms was undertaken: (Dental implants OR Surgery, Oral) AND (Surgery,Computer-Assisted OR Video-Assisted Surgery) AND (Education OR Teaching ORLearning OR Instruction). In addition, several journals in implantology were searchedmanually. A total of 18 articles and 2 conference abstracts were retrieved after systemicsearching. Out of the 18 articles, 3 were written in Dutch and 1 in Hebrew. In terms ofthe type of study, of the 18 articles and 2 conference abstracts, there were 4 literaturereviews, 1 symposium note, 2 surveys, 12 simulation system validations or evaluationsand only one cohort study. The searching result is summarized in Table 4 below.

Table 4. Supporting literature on image-guided surgery in dental education

With the development of computer-assisted 3D image technology such as 3D computedtomography and cone beam volumetric tomography, computer-assisted or image-guided


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implant placement and oral surgery have attracted recent attention. To maximize theoutcome of implant placement, the use of advanced radiographic procedures such ascomputerized tomography, along with fabrication of surgical guides, has been advocatedto inform surgeons of ideal implant location. More recently, simulation computersoftware has been introduced to view radiographic images and test potential implantlocations. Surgical guides are processed based on ideal tooth position, with littleconsideration for underlying anatomical limitations, which creates a disconnectionbetween diagnostic planning and surgical restrictions. In response to this "missing link,"computer-assisted design and computer-assisted manufacturing, as well as real-timesurgical navigation have recently been developed to obtain fully integrated surgical andprosthetic planning. Today, there are several technologies available, but no systematicassessment of surgical guidance has yet been performed. For this project, we undertookMeSH searching using (Dental implants OR Surgery, Oral) AND (Surgery, Computer-Assisted OR Video-Assisted Surgery) retrieved a total of 354 articles, of which only 18were related to oral surgery and implantology training. Only one cohort study was found.

From the combination of all of the above measures, the full-text versions of the papers

were retrieved, and screened by two team members before allocation to additional teammembers to complete focused reviews on issues of relevance to the project.

To supplement the search, relevant journals according to different categories such asendodontics, prosthodontics, paediatric dentistry, oral radiology, oral surgery andimplantology were hand searched respectively.

Refereed abstracts from the International Association for Dental Research(http://www.iadr.com ) were searched using the keywords (Education OR Learning ORTeaching OR Instruction) AND (Simulation OR Computer-assisted OR Computer-Aided).This retrieved 321 abstracts, which were then screened using the same approach as forthe full papers above, resulting in 30 relevant abstracts, as shown in Table 5 below

Table 5. Refereed abstracts on simulation in dental education

4.3 Virtual reality

Considered semantically, the term virtual reality is an oxymoron; that is, its meaning isessentially contradictory. On the one hand a virtual construction, on the other, real one,however both ideas occur simultaneously. Because virtual reality is the key component insimulated learning, this contradictory essence is embedded in the latters practices,leading one observer to say that it is an uncanny or a threshold concept (Bayne 2008).Simulated learning entails several contradictions: embodied and disembodied; digital and


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analogue; single mode and multimodal; subjective and objective; sensorial and cognitive,abstract and vocationally orientated; mental and physical labour; and a virtual and realinteraction. An associated contradiction identified by simulated learning researchers, bothin the health-care field and elsewhere, has centred on a simulations fidelity(Dieckmann, et al. 2007), or affordance (Dalgarno & Lee 2010), or physicalverisimilitude (Herrington et al. 2007), to the real action it depicts. In all thesementioned sources though the stress is put on the learning capacities of simulatedenvironments and not on their truthful rendition of one or another procedure that it isattempting to depict.

If a virtual world (VW) like Second Life is used in dentistry (Phillips & Berge 2009),then what is achieved educationally is engaging three-dimensional environments thatmimic real life. The same applies when attempting to simulate the dental profession forpotential students in order to give them a realistic picture of this choice of career (Hawleyet al. 2009).

The virtual world approach has recently been developed for the education of health

professionals, with a local example being PIER VIRTUAL (based in Brisbane)(http://www.pieronline.org ) which has been involved in the development of learningworlds in both Second Life (http://secondlife.com/ ) and Open Sim(http://opensimulator.org/ ). OpenSimulator is an open source multi-platform, multi-user3D application server which can be used to create a virtual environment (or world) whichcan be accessed through a variety of clients, on multiple protocols. OpenSimulator allowsvirtual world developers to customize their worlds, and simulate virtual environmentssimilar to Second Life.

VW technologies such as Second Life and OpenSim have potential use as a medium for

total virtual patient simulation, particularly as an adjunct to preclinical teaching methodsin virtual problem-solving and communication prior to student clinicians' treating patientsin the clinical setting. Activities in VW could provide a way to combine new simulationtechnologies with role-plays to enhance instruction in diagnosis and treatment planning.Case studies and role-plays have been used as effective evaluation mechanisms to fosterdecision-making and problem-solving strategies in the delivery of patient care. As the useof VW in dental education is in its infancy, there is limited research to prove its merits;


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however, the literature suggests that existing educational practices may be enhanced byits use (Phillips & Berge, 2009).

Preclinical teaching and learning take up a majority of classroom and laboratory time inthe first half of the dental curriculum as students prepare for entering clinical treatmentareas. Using VW, students can be assessed on recording and analyzing medical histories,chief complaints, and assessments of present oral diseases in a standardized manner.Likewise, the ability of students to teach their patients how to modify or establish neworal health behaviors can also be evaluated using virtual patients in virtual worlds.Student clinician/patient role-play, which is normally conducted in class betweenstudents, can be done in virtual worlds with audio and video.

Dental students need to deliver care to populations that are not only living longer, butdoing so with a host of chronic diseases. Students have, at times, limited access to treatdiverse populations while in the dental school intra-mural environment. VW offer waysto virtually encounter clinical scenarios, a point of particular relevance for teaching howto problem-solve for patients with complex medical conditions and uncommon health

ailments, if the opportunity for real interactions with such patients is not available.Patients with physical or developmental disabilities, language barriers, psychosocialbehaviours, and geriatric patients with age-related issues are all suited to a virtual worldsetting to help prepare students for such challenges.

A virtual world which is used at the University of Southern California School ofDentistry exposes students to exercises in diagnosing complicated problems, which inturn eliminates the use of live patients in a risky environment. Such VW are especiallyuseful during the first half of the curriculum when students are inexperienced in patientcare. Other examples of VW include the Case School of Dental Medicine which uses VWto assess students abilities to communicate with their patients on issues such as tobaccocessation. The International Virtual Dental School (IVIDENT) created by Kings CollegeLondon Dental Institute to become a repository for globally distributed online dentaleducation has engaged in VW and is using Second Life collaboratively for educationalresearch between IVIDENT and the University of Michigan School of Dentistry.

A detailed review of the use of virtual worlds in health science education has beenprovided by Hansen (2008), who points out that despite the educational and researchpotential of virtual worlds, the evidence base in terms of quality educational researchinvolving the use and effectiveness of these innovative technologies is still in its infancy.Reported advantages to having students engage in virtual worlds include:

interacting with diverse content;

risk-free role plays of scenarios including medical emergencies;

opportunities to interact with others through their avatars (e.g., patients, staffmembers, and other healthcare professionals) in a safe, simulated environment;

familiarization with the health care setting leading to a decrease in student anxiety;

encouragement to cooperate and collaborate, and resolve conflicts; and

enhanced self-reflection and knowledge.


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Hansen found that the use of VW improved cooperation and collaboration, and supportedconflict resolution when students interact with patients and other health careprofessionals avatars.

For educators, the advantages of virtual worlds are the ability to design and constructunique environments and then share them with others in a collaborative fashion.Educators may write specific learning goals for students to complete while learnersactively build and interact in environments that promote creativity and social networking.

Hansen in her critical review of VW in health education concludes that empiricalresearch is needed for future use of virtual worlds in healthcare training and generaleducation, and that educational research regarding 3-D virtual worlds and the effects onlearning outcomes is lacking. Nevertheless, current evidence indicates that participatingor playing in a virtual world is enjoyable for the learner, encourages creative expression,and broadens socialization skills. It may also promote independent problem solving,provide opportunities for self-teaching, and help set the stage for group work.

The University of Marylands virtual dental school (http://dspub.umaryland.edu/vi/) hasthree floors that mimic the actual building design, including a lecture hall toaccommodate seventy avatars, and multiple clinical dental chairs. Plans are being madefor an anatomy practicum using virtual skulls, and dental faculty members developednervous and hostile virtual patients to challenge students problem-solving skills.

Perhaps one of the greatest advantages of VW technology is in terms of collaboration.Guest lecturers can present classes, and students can collaborate with other dentalstudents or students studying in other health disciplines from within their ownuniversities or from around the globe. Virtual worlds may help encourage the deploymentof standardized methods of evaluation and testing, and grant wider access to educationalmaterials. Nevertheless, the major barriers to the use of VW in dental education are thelack of instructional design expertise by dental academics and the challenges in itsintegration into the appropriate parts of the dental curriculum.


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4.4 Computer literacy in dentistry

Computer-based self-instructional media may be able to increase the range of learningexperiences for students and thereby supplement the dental curriculum at relatively lowtotal cost (Wotman, 1989). Dental students are typically fluent with informationtechnology and are eager to use sophisticated tools for learning, particularly when thisgains them freedom from a fixed classroom structure. The development of computerliteracy amongst dental students and their familiarity with information technology havebeen identified as attributes of the new graduate from dental school (Zimmerman et al.,1986; Abbey 1987). In contrast, academic staff members have varying levels of computerliteracy, and emphasize the quality of learning which occurs with computer-basedapproaches - while making learning attractive (Lang et al., 1992).

4.5 Simulation to enhance decision making

Several randomized controlled trials have demonstrated that computer-based media offera range of advantages over self-teaching booklets in terms of skills needed for clinical

decision making in dentistry: a consistency in the information presented,

an interactive learning experience which may be more effective than lectures, and

close approximation to the clinical situation (Tira 1986, Graig 1986; Puskas,1991).

Self-instructional computer programs appear to be as effective as the lecture format forinstruction in decision making principles. Over the past three decades, self instructionalprograms in dentistry have been developed to teach methods of diagnosis in a range ofareas, including:

oral medicine (Finklestein et al., 1988; Siegel et al., 1990), orthodontics (Luffingham 1984; Irvine & Moore 1986),

jaw joint dysfunction (Bagnall et al., 1988; Clark et al., 1993),

orofacial pain (Clark et al. 1993),

endodontics (Mullaley et al., 1976; McKedry, 1989),

prosthodontics (Tira 1977),

removal partial denture design (Lefebvre et al., 1990) and

geriatric dentistry Mulligan & Wood 1993).

Software also has been used to assist with the analysis of both panoramic and periapicalradiographs (Webber et al., 1982; Jeffcoat et al., 1984), including automated diagnosisprograms (Sloan, 1980; Hyman & Doblecki 1983).Students using computer based instruction performed either as well or better thanstudents who received instruction via lectures or printed self-study materials. Anevaluation of different computer-based simulations of patients with orofacial disordersrevealed dramatic improvement and reduced variability in students knowledge as theyreviewed more of the simulated cases (Clark et al., 1993). A uniform message is thatsimulations of diagnostic challenges offer dental students an appealing medium to


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promote the development of critical thinking and clinical problem-solving skills (Graig etal., 1989; Clancy et al., 1990). This is important because dental students achieve varyinglevels of competency in this area by the time they complete their clinical training (Clancyet al., 1990).

Overall, while the literature regarding whether these simulation programs improves thequality and economy of instruction is very positive, the depth of the educationevaluations which have been undertaken of these self-instruction packages is variable.Many of these studies did not include a strict randomized controlled trial design. Havingsaid that, there is also evidence that the content of the message is more important than themeans by which it is presented (Sandoval et al., 1987).

4.6 Software for improved visual diagnosis

With the rising standards and increasing complexity of modern dental care, there is aneed to introduce dental and oral health students to a variety of difficult or unusual casesto enhance their problem-solving abilities. These skills develop with practice and

individualized feedback in clinical settings. Because of time pressures in the clinic, theconceptual aspects of treatment decisions may not be emphasized in the clinic. Inaddition, each students clinical experiences are limited and not standardized.

Self-instructional programs offer dental students an appealing medium to promote criticalthinking and clinical problem-solving (Graig et al., 1989;Clancy et al., 1990). Computer-based instructional packages based on clinical cases and simulations have the potentialfor providing additional experiences in clinical problem-solving for dental students.Compared to other self-instructional technologies, computer-based simulations canprovide a degree of interactivity which allows for the needs of the individual student.Computer-based packages can allow high levels of flexibility, so that students can reviewmaterial in a personalized sequence to meet individual learning needs. Computer-basedpackages can provide image material at a quality greater than possible through printmedia, and these can be linked with text, audio, and video. Finally, once developed,computer-based simulation packages can be reproduced at low cost and be madeavailable both to libraries and to individual students.

Computer-based and other self-instructional technologies have gained considerablepopularity in dental education since their initial implementation in the early 1980's(Williams 1981). However, in relation to using simulation to improve visual diagnosis, adefinitive analysis of the existing studies is difficult because of factors such asconfounding, potentially small effect sizes, contamination effects, and ethics. Twodistinct approaches to evaluation have been used, objectivist and subjectivist. These two

complement each other in describing the whole range of effects a new educationalapproach can have. Ideally, objectivist demonstration studies should be preceded bymeasurement studies that assess the reliability and validity of the evaluation instrument(s)used. Many evaluation studies compare the performance of learners who are exposed toeither a new software program or a more traditional approach. However, this method isproblematic because test or exam performance is often a weak indicator of competence,


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and may fail to capture important nuances in outcomes. Subjectivist studies may provideinsights complementary to those gained with objectivist studies, but these are few innumber.

4.7 Simulation to enhance dental radiology

Effective patient simulations can assist learning because they are highly interactive,reinforce concepts and theories, and place the patient at the center of learning (Barnett1987; Shugars et al., 1991). In line with this, utilization of computer assisted instructionfor mixed dentition analysis (Irvine & Moore 1986) and in intra-oral radiography(Wenzel & Gotfredsen 1988) has been shown to result in higher test scores and greaterretention than traditional teaching.

A 3 year study conducted at UQ (Mubarak 2000) assessed the impact of a prototype CDROMinteractive tutor package on student learning. The cohort used was second yeardental students across three years (1997, 1998 and 1999) who had no prior exposure toradiology. The CD-ROM was created to both instruct and to allow self-testing (via image

mapping). The 1997 cohort served as the control group, while the 1998 and 1999 cohortshad identical class experiences but were also provided with access to multiple copies ofthe CD-ROM (one shared between 5 students in 1998, and one CD-ROM per student in1999), to permit use outside of scheduled class hours. A panel of discrete radiologicalskills relating to bitewing and periapical radiographs were assessed using an objectivestructural clinical examination (OSCE). The OSCE assessment instrument was identicalin the three years of the study. The OSCE incorporated sub-scales to assess separatelyeach of 8 defined skills included on the CD-ROM package, as well as control skillswhich were not included in the instructional package. Differences between the threegroups were compared using Chi-square analysis for categorical variables and nonparametricstatistical methods for continuous variables.

The global performance of the second and third cohorts on the panel of defined skillsincluded on the CD-ROM package increased by 28%, while there was no significantchange in terms of the internal controls. The skills showing the greatest improvementwere the diagnosis of small enamel lesions and the diagnosis of lesions at the dentoenameljunction (DEJ). Across all examination components, the 1997 cohort detected27.2% of the total number of lesions, while the 1998 and 1999 cohorts detected onaverage more lesions in total than the 1997 cohort, 62.5% and 66.4%, respectively. Theseresults indicate that significant educational benefits were achieved through the adoptionof a flexible learning approach using the simulation combined with improved access totutor-type feedback.

4.8 Virtual Microscopy

Virtual microscopy (VM) is a major area where simulation has been successfullyintroduced into the foundation sciences for dental education. The intention is to forstudents to gain a greater appreciation of structure of normal and pathological oral tissues,so that the learning goal predominates. VM does set out to simulate the action or feel ofusing a microscope, but rather focuses on the visual information which is created as theendpoint. The same point applies when this type of approach is used for radiology


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education the outcome is the image and its use, rather than replicating how that imagewas produced (Hatcher 2006).

Across a broad range of medical disciplines, learning how to use an optical or lightmicroscope has been a mandatory inclusion in the undergraduate curriculum. Dentalprograms routinely include the use of light microscopy in the teaching of oral biology,oral histology, general pathology and oral pathology. The development of VMtechnology during the past 10 years has called into question the use of the opticalmicroscope in educational contexts, not only in dentistry but in human and veterinarymedicine.

In VM, slide specimens are digitized at high resolution, which, in turn, allows thecomputer to mimic the workings of the light microscope, with the student moving acrossthe virtual specimen and the enlarging selected areas in exactly the same manner as isused with Google Earth and similar mapping programs which combine aerial imaginginto databases which can be moved through in virtual space.

This move from analogue technology (the light microscope) to digital technology (thecomputer as microscope) parallels the broader move from print-literate traditions ofknowledge (requiring literacy) to an electronics-literate, or "electrate," mode (requiring"electracy"). The transition is accompanied by a move from teacher-directed learning tostudent-centered learning, or "user-led education," which points to a redefinition of"pedagogy" as "andragogy." The use of VM by dental and oral health students buildstheir level of electracy, which enhances their ability to engage more strongly with

computer simulation and telemedicine (Maybury & Farah 2009).

Both microscopic and radiographic forms of information sit at the interface of the realperceivable world and the cellular/histological world, being equally real but for themost part beyond the understanding of novice dental students. It is here in the simulationof the cellular/molecular world that cognitive realism (Herrington et al., 2007) is farmore important than the physical verisimilitude of many simulations focused ondeveloping psychomotor skills. This is an especially important point in terms of visualspatialability in radiology, that is, spatial cognition (Nilsson et al., 2004; Nilsson et al.,


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2007; Nilsson et al., 2007b). Here the aim is for students to discover anatomical truth(Harrell et al., 2002). It takes some time for students to develop expertise in readingthree-dimensional microscopic and radiographic information because of this moreabstract question of spatial cognition when interpreting the anatomical matrix. Effectiveuse of VM and its parallels in radiology depends on the development of educationalaffordances (or competencies) in simulated learning as a necessary first step.

Digital VM technology was first used intensively in dental education at the University ofQueensland. Several evaluations of the benefits of this approach, as deployed at UQ, havebeen published in the educational literature. A cohort of 60 dental students studying acourse in pathology in 2005 were introduced to virtual microscopy technology alongsidethe traditional light microscope, and then asked to evaluate their own learning outcomesfrom this technology. A wide variety of questions dealing the pedagogic implications ofthe introduction of virtual microscopy into pathology were asked of students. There wasstrong evidence that VM enhanced their learning of pathology (Farah & Maybury 2009b).The move to virtual microscopy and computer-assisted, student-centered learning ofpathology enhanced the learning experience by helping students engage and interact with

the course material.

A follow-up study by the same authors (Farah & Maybury 2009a) using the same cohortof students in two separate courses in 2006 and 2008, produced responses from studentswhich were overwhelmingly in favor of VM. Interestingly, when it came to completelyreplacing the light microscope with virtual microscopy, the students were much moreambivalent about such a wholesale change, although this was less of an issue in the senioryear. One explanation for this is that traditional microscopic skills for histopathologicalexamination of materials are not used in the routine clinical practice of dentistry, butsurgical operating microscopes are used in clinical dental practice for proceduresrequiring high magnification. The physical interaction with a binocular light microscopemay benefit students by providing some skills to supporting a later adoption of surgicaloperating microscopes.


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4.9 Haptic simulation

PerioSim is an example of a haptic technology system which uses a periodontal probe. Itwas developed at the University of Illinois at Chicago College of Dentistry. The systemoffers 3D, VR graphics and tactile sensation (haptics) allowing the user to feel a varietyof dental instruments, such as a Shepherd's hook explorer for training in visualizing anddetecting the feel of an caries active white spot lesion or use a VR periodontal probe toprobe and evaluate the disease status of a periodontal pocket. A realistic 3-D humanmouth is shown in real-time, and the user can adjust the model position, viewpoint andtransparency level. The haptic device allows the student to feel the sensations in thevirtual mouth, and a control panel lets the user choose different procedures to practiceand instruments to use. The instrument pressure (in grams of force being applied to thegingival area) can also be viewed on a gauge and recorded. A control panel is availablefor fine control of a variety of parameters such as instrument and model selection, degreeof model transparency, navigation, haptic fidelity of tissues and tremor modulation.

Students access PerioSim via the Internet. The system allows instructors to create short

scenarios of periodontal procedures, which can be saved and replayed at any time. The 3-D component permits students to replay from any angle, so the user can observe differentviews of the placement of the instrument and gingival relationships during a procedure.The recorded file can be viewed on any personal computer, and while not in 3-D, it is anactual representation of the original scenario, which offers great training potential.

The program also allows for a second playback mode, where an instructor leads thetrainee through the program. By simply holding onto the haptic stylus, the traineereceives the same sensations felt by the instructor. Trainees can also be tested andevaluated on their ability to mimic the instructor's periodontal procedures. An overviewof Periosim is provided at http://www.cvrl.cs.uic.edu/~stein/PeriosimUpdate08.htm.

In a study by Steinberg et al., (2007), only minimal training time was necessary, andneither staff age nor computer skills were barriers to use of the instrument SL has thepotential to greatly enhance current methodologies, eliminating some of the need for newdesign.

The system offers 3D, VR graphics and tactile sensation allowing the user to feel avariety of dental instruments, such as a Shepherd's hook sickle probe or explorer for


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training in visualizing and detecting the feel of an carious lesion. A VR periodontal probecan be used to probe and evaluate the disease status of a periodontal pocket. The grams offorce being applied to the gingival area is displayed and recorded.

The Moog Simodont system (Appendix 2) uses force sensors for a high fidelity feel.Instruments can be replicated using a range of movement and realistic force feedback,from very delicate forces up to very strong forces. Simodont courseware was developedby the Academic Center for Dentistry, Amsterdam, The Netherlands (ACTA). Thesoftware gives high quality video and audio to accompany the selected procedure.

The Simodont system was launched at the Association for Dental Education in Europe(ADEE) Meeting (25-28 August 2010) in Amsterdam. The theme of the ADEE meetingwas Digital dentistry, with an emphasis on digital techniques in dental education andparticularly haptic simulation and virtual reality. This meeting was attended by HWAteam member Prof Johann DeVries.

Current capabilities of the Simodont system include

Manual dexterity exercises with software evaluation of psychometric skills Cavity preparation and other restorative exercises, in which students drill and

manipulate rotary drills and hand instruments in a realistic manner

Diagnosis and treatment planning exercises, by including simulations ofpathologically altered tissues

Suitability to either left or right handed students.

Current software allows

standard drilling exercises with software grading of outcomes

spatial orientation exercises for dental mirror use, and

manual dexterity training

while future software updates will allow periodontal procedures and crown andbridgework.

4.10 Virtual reality for surgical training using medical simulators (Voxel-Man)

Crucially, in various forms of dental surgery the dexterity of the hands is a criticalattribute of student success in the field (Rucker 2007). Simulating the coordination of thiscritical hand/brain focussed psychomotor skill via virtual surgery (Pohlenz et al., 2010) isessential to developing both preclinical and para-clinical expertise in the dental student.Work in Hamburg, Germany has explored how technology developed for training insurgery can be used for dentistry. The virtual environment of the Voxel-Man simulator

that was originally designed for virtual surgical procedures of the middle ear was adaptedto intraoral procedures, specifically the surgical procedure of apicectomy, which involvesresecting the end from a root after tunneling through the supporting bone a difficult andcomplex procedure in which selective reduction of bone without collateral damage(nerves, teeth) is essential. In the Hamburg study (Pohlenz et al., 2010), a group of 53dental students undertook this virtual surgery in the Voxel-Man simulator, and of these


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51 were positive regarding such virtual simulation as an additional modality in dentaleducation. The students indicated that the integrated force feedback (e.g. simulation ofhaptic pressure), spatial 3D perception, and image resolution of the simulator weresufficient for virtual training of dental surgical procedures.

In a related study (von Sternberg et al., 2007), the same group assessed whether skillsacquired when undertaking a virtual apicectomy on the VOXEL-MAN system withintegrated force-feedback) were transferable from the virtual world to physical reality.The study compared two groups of trainees. The first group received computer-basedvirtual surgical training before performing an apicectomy in pig cadavers, while thesecond group did not. The probability of preserving vital neighboring structures wasimproved six-fold after virtual surgical training. The average volume of the bony defects

created by the VR trainees was only half that of the controls. This study shows that dentalsurgical skills training with a haptic simulator are transferable to physical reality.Moreover, the ability to objectively self-assess performance was significantly improvedafter virtual training.

4.11 High end dental simulators for restorative dentistry

A significant proportion of dental education is dedicated to teaching psychomotor clinicalskills. A unit designed for the instruction of dental procedures using virtual reality-basedtechnology was introduced into the dental education marketplace in 1998. This unit, theDentSim, was the world's first virtual reality (VR) unit designed to teach the manual

skills that dental students must master before they are ready to treat patients (Appendix 2).The system was developed by DenX, an Israel-based hi-tech company specializing in 3Dgraphics and real-time image processing (Hayka & Eytan 1997). The unit is a simulationsystem which can (i) simulate the real process of drilling a tooth during a dental treatment,(ii) imitate a real process of drilling a tooth during training while drilling an artificialtooth and, in both cases, (iii) display the process in an enlarged scale on a display. Thesystem was designed for training dental students but could also be used to monitor inreal-time an actual dental treatment performed by a clinician.


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The original patent for this system describes the intent for the system to be used for abroad range of procedures, in two groups:

cavity preparation and crown preparation (implemented)

root canal preparations, other tasks carried out using dental handpieces, and othertasks using hand instruments (e.g., chisels, enamel hatchets) (not implemented in thecommercial version of the DentSim).

For operative dentistry training, the user selects a tooth to practice on, the extent of caries,and the type, depth and shape of cavity to be prepared. The actual work with the systemis preferably performed in the phantom head and is displayed and observed by the traineeon the screen (as can be seen in Appendix 2). Many parameters of cavity preparation canbe monitored, analyzed and displayed in real time, thus, leading the trainee to improvetheir techniques, through instant feedback as well as by review of all previous stages ofwork. The intent of the inventors was that the system could be used by drilling into

artificial teeth or could be used as a fully virtual environment. The lack of any hapticcomponents prevented the latter from ever being achieved.

As shown in Appendix 2, the commercial DentSim unit combines a patient manikin(phantom head), a set of dental instruments, infrared sensors and an overhead infraredcamera with a monitor and two computers. Readings from sensors on the manikin andinstruments are processed by one of the computers to interpret the spatial orientation ofthe manikin, the teeth and the instruments and produce a three-dimensional image of thepatient's mouth. The second computer runs instructional software to provide studentswith a comprehensive learning experience.

Using the unit, a student can prepare typodont/dentoform teeth in much the same manneras with the standard dental simulators. However, the unique property of this unit is itsability to construct a real-time virtual image of the students preparation in the computer.The software evaluates the tooth preparation both immediately and at the studentsrequest. Real-time evaluation for critical, non-correctable errors is given as immediatefeedback. A more detailed evaluation of a restorative preparation is given when requestedby the student. The extensive evaluative feedback given when requested is presented invisual and written forms and includes a numerical grade. Hence, the DentSim offersobjective, consistent evaluation of preparations easily obtained at any time during the


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process of preparing the tooth. This evaluation includes both formative (corrective)feedback and helps to generate a final (summative) evaluation. This is in contrast to anevaluation given by teaching staff faculty that consists, for the most part, of evaluation ofan end product (such as a cavity shape).

Features of the DentSim unit include:

Simultaneous viewing via the monitor of the cut being made into a tooth and the idealpreparation.

Real-time audio signaling when a student makes a critical error. At that point, astudent can replay the procedure and see how the mistake was made.

Performance feedback at any time. At any point, students can stop working and havetheir preparation evaluated against the ideal preparation. The system runs a list oferrors and provides cross sections and diagrams of how the outlines match up.

The acquisition of knowledge takes place in a multimedia learning environment with ahigh audio-visual content and degree of interaction and complexity, and problem-orientedlearning takes place through clinically relevant work. Individual students can work to

personalized programs through the digital tutor function, in which three-dimensionalpreparations can be analyzed by two-dimensional error analysis. All tooth preparationexercises are recorded for error and effectiveness analysis.

The realism of the virtual environment is enhanced by complete patient records thataccompany each case, including medical and dental history, x-rays, examination notesand the reason for diagnosis. Links within the patient record give students access to moreinformation on specific topics.

In terms of the student learning experience, it was hoped by the developers that such a 3DVR system would offer the following advantages and benefits:(i) less space required for training(ii) fewer instructors(iii) a move to self teaching rather than using instructors(iv) an unlimited ability to repeat exercises without increasing costs(v) greater standardization of procedures(vi) better alignment with curriculum needs(vii) flexible learning with self teaching not limited to formal teaching hours(viii) greater evaluation of student performance in real time(ix) more consistency in assessment of student work(x) improved manual dexterity before commencing with patients(xi) lower overall cost and duration of student training(xii) trainees will attain a higher standard of performance and knowledge in

comparison with trainees practicing using conventional methods.

The University of Pennsylvania School of Dental Medicine (UPSDM) was the exclusiveUnited States test site for DentSim, which was introduced there in 1998. UPSDM startedwith one (beta) version unit in 1998, which was later updated and expanded first to four unitsand then in 2003 to fifteen units. First-year students from 2003 onwards receivedmost of their preparative training in operative dentistry on these VR units.


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A total of 11 papers have been published on DentSim, including a comprehensive evaluationby UPSDM (Buchanan 2004). UPSDM's experience consisted of several years of researchusing control and experimental groups, employing students to participate in aninvestigative project, and using the units for remediation and a supplement to theirtraditional preclinical laboratory.

The first study at UPSDM began soon after they had acquired the beta DentSim unit.Being one of the very first units, it was much more prone to technical problems than laterunits. A sample of 16 students was selected from the 94 students enrolled in the first-yearclass, and were matched in pairs (for controls) for computer skills, gender, aptitude testscores, and academic performance. For each of the eight pairs, one student of the pair wasrandomly chosen for the experimental group and the other assigned to the control group.The experimental students were assigned to the DentSim unit in two-hour time blocksover a three-week block, while students in the control group were instructed in theUPSDM traditional laboratory. The experimental group was instructed to practice Class Iamalgam procedures on the simulation unit and to receive no other instruction on thisprocedure from staff or other students. The control group prepared teeth in the traditional

lab and requested evaluation from academic staff. Although the control group had accessto faculty only during course hours, they were allowed to practice during the hours thelaboratory was open (nights and weekends). In both groups, the criteria for assessmentwere determined by the restorative teaching staff involved in the preclinical operativecourse and were consistent between the two groups. Both groups were instructed to keepdetailed time logs in which they recorded 1) time used to practice preparations, 2) thenumber of teeth used for practice, and 3) number of times they requested expertevaluation. The number of times students asked for expert evaluation represents thenumber of times an experimental student asked the computer for a complete evaluation oftheir preparation or when a control student asked a faculty member for evaluation. At ascheduled time, a practical examination (Class I preparation) was given to both controland experimental groups. The teeth were collected from both groups, and one staffmember graded all teeth from both groups in a blinded manner.

Experimental students spent less time preparing Class I preparations (6.71 vs 3.69 hours),and asked for evaluation more times per hour (6.52 vs 3.21, p=0.08). The experimentalstudents prepared significantly more teeth per hour (3.8 vs 1.6) and not surprisingly usedmore teeth in total (average 11.71 versus 6.57, p=0.02). The results of the Class Ipractical examination were only slightly higher for the experimental group (72.6% vs61.9%) and this was not statistically significant.

In a second study at UPSDM, the format from the first study was repeated except that 28students were chosen and paired. Students learned the procedures of Class I and Class II

amalgam restorations, but this time limited staff input was allowed for each student onehour a week while they were assigned to the VR laboratory. Staff only responded toprocedural questions such as what burs to use, how to correct errors, etc. As before,student performance was measured by a practical examination of a Class I and Class IIpreparation, which was graded by one staff member in a blinded manner. Experimentalstudents scored lower for Class I (72.0 vs 79.3%) but similar for the more difficult ClassII (79.7 vs 80.9%). The two groups had very similar final overall grades in the course.


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The UPSDM results, while based on low numbers of students, suggest that students learnfaster, to arrive at the same level of performance. Students using VR accomplish morepractice procedures per hour, and request more evaluations per procedure or per hourthan those using traditional laboratories.

Students' attitudes, as measured by surveys, group interviews, and private interviews, to VRwere mixed. The overall evaluation of their experience with this technology was positive, andthis led to the purchase of additional units in 2003, its full incorporation into the curriculum,and curriculum revision to maximize its potential. Buchanans conclusion is that thistechnology offers significant potential in the field of dental education and that further use andinvestigation are both desired and justified.

UPSDM staff believed that a significant advantage over the traditional methodology usedfor the instruction of restorative preparative procedures was the ability of the unit to giveimmediate, consistent, unbiased feedback based on evaluation of the preparation in termsof tenths of millimeters.

Focus group discussions completed by all students involved with the DentSim over 5years at UPSDM were summarized by Buchanan (2004) into several key observations:1) students want staff to play some part in their skills training even though studentsdislike the considerable variability between instructors and are frustrated by waiting forstaff to check their work;2) students view VR technology as having a positive role in preclinical training;3) students feel that they learn faster with VR; and4) students feel more confident with a high-speed hand-piece after training on VR.

Although several other schools have similar positive experiences (LeBlanc et al. 2004;Imber at al. 2003) there are some who have had experience with VR dental simulationand have drawn different conclusions about its potential. Quinn et al. 2003 a and b)reported on the Dublin Dental School and Hospitals experience with VR. To evaluatepossible benefits, in the first study junior undergraduate dental students were randomlyassigned to one of three groups: group 1 as taught by conventional means only; group 2as trained by conventional means combined with VR repetition and reinforcement (withaccess to a human instructor for operative advice); and group 3 as trained by conventionalmeans combined with VR repetition and reinforcement, but without instructorevaluation/advice, which was only supplied via the VR-associated software. At the end ofthe research period, all groups executed two class 1 preparations that were evaluatedblindly by 'expert' trainers, under traditional criteria (outline, retention, smoothness, depth,wall angulation and cavity margin index). There were no significant differences betweenthe three groups except for scores for the category of 'outline form', for group 2, which

produced significantly lower (i.e. better) scores than the conventionally trained group. Astatistical comparison between scores from two 'expert' examiners indicated lack ofagreement, despite identical written and visual criteria being used for evaluation by both.Both examiners, however, generally showed similar trends in evaluation.


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An anonymous questionnaire of the Dublin students suggested that they recognized thebenefits of VR training (e.g. ready access to assessment, error identification and how theycan be corrected), but the majority felt that it would not replace conventional trainingmethods (95%). The most common reasons cited for the preference of conventionaltraining were excessive critical feedback (55%), lack of personal contact (50%) andtechnical hardware difficulties (20%) associated with VR-based training.

In the second study at Dublin, two groups of dental students, with no experience inoperative dentistry, were trained solely by either VR or conventional training in thepreparation of conventional Class 1 cavities. The subjects all used the same operativearmamentarium and phantom heads, and were allocated the same duration of practiceperiods. At the completion of these training periods, both groups produced two Class 1cavities on the lower left first molar, which were subsequently coded and blindly scoredfor the traditional assessment criteria of outline form, retention form, smoothness, cavitydepth and cavity margin angulation. An ordinal score of 0-3 or 0-4 was assigned for eachassessment criterion: the higher the score, the worse the evaluation. After initialindependent scoring, the two examiners discussed any notable differences until an agreed

score was reached. Non-parametric analyses of the semi-quantitative scores indicatedworse scores for VR training groups for outline form, depth and smoothness, but anidentical scores for retention and a borderline worse score for cavity margin angulation.The Dublin staff concluded that VR-based skills acquisition is unsuitable for use as thesole method of feedback and evaluation for novice dental students.

Some limitations of the Dublin studies are that they used very early generations ofsimulators, measured student performance after only four hours of exposure to VR plus16 hours of traditional teaching (in the first study) and 5 hours in the second study which rather than using the evaluation capabilities of the unit, relied on staff feedback.A study in Belgium (Wierinck et al., 2005) also questioned the value of the DentSim.Novice dental students at Leuven were randomly assigned to one of three groups and

given the task of drilling a geometrical class 1 cavity. The VR group trained underaugmented visual feedback conditions using the DentSim). The no-VR group practisedunder normal vision conditions, and a control group performed the test sessions withoutparticipating in any training. All preparations were evaluated by the VR grading systemaccording to four traditional criteria (outline shape, floor depth, floor smoothness andwall inclination), and two critical, clinical criteria (pulp exposure and damage to adjacentteeth). The DentSim group obtained the highest score for floor depth (P < 0.001), whilstthe no-VR group was best for floor smoothness (P < 0.005). However, at the retentiontest, the VR group demonstrated inferior performance compared with the no-VR group. Itwas concluded that drilling experience on a VR system with frequently providedfeedback and a lack of any tutor input was not beneficial to learning.

The University of Tennessee Health Science Center College of Dentistry deployed 40DentSim simulators, in conjunction with an 80-unit traditional simulation laboratory.They described both the positive and negative aspects as they impacted on the students,staff and school over one year. Issues included the high cost, frustration with the timetaken for calibration, and the limited rang of learning programs available. Positive aspectswere greater feedback for students on their work (Lackey 2004).


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An evaluation of the DentSim was conducted at the Tokyo Medical and DentalUniversity, the largest dental school in Japan, to determine whether enhanced feedbackassisted novice but highly computer-literate dental students when learning cavitypreparation. A total of 39 dental students were randomly divided into two groups, andthe students then performed a Class II cavity preparation on the lower left first molartooth four times every week without any instructor feedback. At the last session, allpreparations were assessed using the DentSim (Yasukawa 2009). The DentSim usersobtained significantly higher scores than the conventional controls, for outline shape,outline centralization, outline smoothness, wall incline, wall smoothness, proximalclearance, and box width. The DentSim students tended to spend a longer preparationtime each week than the controls, so the effectiveness of cavity preparation with feedbackwould have been influenced by that greater time for practice makes perfect. Thefinding of positive student views on computer technology enhancing their engagementwith the technology to give better learning outcomes was also shown in a more recentstudy in Taiwan (Chen et al., 2010).

A rather more rigorous user assessment was undertaken using students in the UK (Rees et

al. 2007). A total of 16 second year undergraduate dental students spent 6 hours cuttingan unlimited number of Class I cavities and Class II cavities. The final mark awarded bythe VR software together with the overall preparation time and number of evaluations foreach cavity were recorded. For the Class I cavity the mean mark obtained was 66.8, themean preparation time was 12.5 mins and the mean number of evaluations was 6.7. Forthe Class II cavity the mean mark was 26.5, the mean preparation time was 18 mins andthe mean number of evaluations was 7.0. Final marks were also stratified into quartiles(0-24, 25-49, 50- 74, 75-100). For the Class II cavity the time taken to complete thecavity and the number of evaluations made were greater for those cavities that gained amark of 50 or more. There was also a trend towards higher marks being associated withlonger preparation times and more evaluations during the preparation, demonstrating theimpact of feedback. The same trend was seen in a similar study conducted at the same

time in Belgium (Wierinck et al., 2006).

The Ernst-Moritz-Arndt-University in Greifswald, Germany assessed student responsesto the DentSim system when done as an optional elective (Welk et al., 2008). With a selfselected group the response bias was high, and thus strong scores for acceptance of, andresponse to, additional elective training time in the computer-assisted simulation lab werehigh as expected. Overall, some 87.3% rated the experience of using a DentSim asinteresting. There were trends for better knowledge retention and incidental learningregarding anatomy, preparation procedures, and cavity design, although not reachingstatistical significance. A major factor identified in the study was the wide range in thenumber of prepared teeth needed to acquire the necessary skills, which demonstrated the

varied individual learning curves of the students.

The same group from Greifswald also assessed awareness of high dental simulation bytheir academic peers by surveying the Departments of Conservative Dentistry andProsthetic Dentistry of all 32 dental schools in Germany. Besides investigating theusefulness of, familiarity with and level of current usage of computer simulation systems,the questionnaire also contained questions regarding each respondent's gender, age,academic rank, experience in academia and computer skills, all of which correlated withthe responses. From a very good response rate of 90% (112 out of 125 academics), the


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majority believed that computer assisted simulation was either 'partly' or 'very' useful forevaluating the acquisition of knowledge (83.9%), qualitative issues (73.2%) andprocesses (72.3%) of dental preparation exercises and complex treatment strategies.However, only about half the respondents reported that they knew of, and even fewerused, any such systems (Welk et al., 2006a).

A further study by the same authors (Wierinck et al., 2006b) explored the effect ofreducing the frequency of augmented feedback on manual dexterity skills using theDentSim, for a cavity preparation on a molar tooth undertaken by novice dental students.A total of 36 dental students were assigned to one of two training groups or a controlgroup. The task consisted of a geometrical cross preparation on the lower left first molartooth. After a baseline skill assessment, the two training groups received simulationfeedback, enriched with tutorial information, one with continuous augmented feedback,and the other with intermittent feedback (66% of the time). After 1 day and 4 months, allstudents were examined by requiring them to prepare the adjacent lower second molartooth. All tests were performed in the absence of feedback, and were graded by theDentSim software. Both the two training groups performed similarly and improved with

practice. After 1 day and 4 months of no practice, both outperformed the control group onthe skills retention test, indicating no effect from reduced feedback within the rangetested. The authors suggested that in future training sessions on a simulation unit could bealternated with training sessions in the traditional phantom head laboratory.

A major issue found in all studies of the DentSim across the globe was calibration, whichadmitted improved in each upgrade of the software. There was frustration in all studiesamong students when technical problems interfered with their ability to complete a taskthat was part of their course grade. Recent information received from Hong KongUniversity is that their fleet of some 20 D

Sles in Dentistry Oral Health Curricula 201108

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