Background: Virtual reality technology can expose students to realistic simulated procedural training. This paper discusses the benefits and drawbacks of these technologies for use in dental education and identifies future development directions.
Methods: A literature review was conducted using PUBMED with the key search terms (Dental) AND (Education OR Learning OR Teaching OR Instruction) AND (Virtual OR Computer-assisted OR Computer-Aided) AND (Simulation OR Training). The reference lists of relevant journals and “similar articles” search function were also used. An additional search of journals, reports and book material was made via the World Wide Web using the same key words.
Results: Virtual reality based simulation technology has demonstrated clear direct benefits for student learning experiences. These benefits are currently balanced by technical limitations, costs and faculty adaptation challenges.
Conclusion: Specific technical improvements in virtual reality technology and research supporting sustained clinical impacts may serve to mandate this promising tool for future use in dental education.
Many undergraduate dentistry courses offer intensive delivery of biomedical sciences for the first two years of study, followed by a further two or more years of intensive clinical education. A challenge currently exists for dental educators to bridge the gap between theory, reasoning and clinical practice (Murphy et al., 2004).
Dentistry has a unique educational context within the health sciences due to the need for development of high precision manual dexterity at an early stage during the degree. Treatment of patients typically begins during the second or third year of the course meaning that students are commonly completing irreversible, high-risk procedures at a novice stage. Dental degrees in Australia do not mandate an internship period prior to completion. This structure dictates that students graduating from dentistry must have full clinical competency and exposure to the spectrum of conditions that will be encountered in clinical practice by the time of graduation. Virtual reality based simulation (VRBS) technologies have been proposed as one possible solution to these challenges (Walsh et al., 2010).
Although applications of VRBS technology have been proposed throughout different fields of dentistry such as anaesthetics and implantology (Walsh et al., 2010), this paper will primarily consider the use of VRBS in teaching restorative dentistry – a subject present in all undergraduate dental courses. This paper does not seek to provide a comprehensive literature review of the body of work that surrounds this topic. Instead, it will explore the major factors presently underlying adoption and resistance of VRBS integration. A commercially available VRBS system will be used to illustrate these points and identify specific challenges for research and development in this field.
A search for papers published between 1990 and 2011 was conducted using PUBMED. The key search terms (Dental) AND (Education OR Learning OR Teaching OR Instruction) AND (Virtual OR Computer-assisted OR Computer-Aided) AND (Simulation OR Training) were used. From this search, results were manually screened for relevancy to the topic. The reference lists of useful journals were used to identify further resources and the “similar articles” search function within PUBMED was also used to link to other relevant resources. An additional search of journals, reports and book materials was made via the World Wide Web using the same key words. These resources were manually reviewed by the author to determine research quality and relevancy to this discussion paper.
All dental schools in Australia currently have purpose-built pre-clinical simulation laboratories (PCSLs). Commonly these PCSLs contain 30-60 phantom head simulation stations complete with removable synthetic jaws and teeth, dental hand pieces, air/water syringes and a dental light. Students typically move from bench top tooth preparation activities to more complex tasks inside the phantom head (Walsh et al, 2010). Supervision ratios for such PCSLs are typically around 1:10 at best (Buchanan, 2001). Students usually watch a demonstration of a procedure by a supervisor then move back to their own station to attempt to mimic this procedure using plastic teeth with or without a ‘phantom head’ mannequin. There are several critical flaws in this system.
Direct visualization of the procedure being demonstrated can be difficult due to the intricacy of work being performed. While audiovisual aides are available in some schools to magnify demonstrations, these add considerable expense to preclinical teaching. Due to restrictions in available supervision time and preclinical resources, there is little opportunity for repetition of demonstrations or divergence from linear technique protocols in order to demonstrate a point or provide remediation for students having difficulty with the procedural concepts.
Students often waste significant time waiting as supervisors attempt to evaluate the work of each member of the group. Once work has been assessed, opportunities for remediation may be scarce (Buchanan, 2001). An additional concern is that teaching and assessment in PCSLs are impacted upon significantly by variations in supervisor skill and subjective student evaluations (Buchanan, 2001). Duta et al. (2011) propose that compromises such as those outlined above render traditional PCSLs “…costly, time consuming and inexact.”
Commonly, preclinical training is undertaken without distinct integration of biomedical theory or patient management skills. This leads to a concern that “on completion of such preclinical training, the student inevitably faces the patient without the proper development of his /her skills” (Duta et al., 2011). These shortcomings of traditional preclinical training may lead to discomfort, higher risk of adverse outcomes, prolonged treatment times and substandard care for patients (Duta et al., 2011).
A virtual solution?
Virtual reality based simulation may be defined as training activities that include technologically synthesised features that mimic real situations (Walsh et al., 2010). VRBS has its most recognizable origins in the world of aviation (Hilmreich, 1997), but has more recently been applied in medical education.
The potential ability of VRBS systems to control content, and time pressures allows progressive exposure of students to increasingly difficult scenarios. It also allows the student to make mistakes, try different approaches and engage in formative self-assessment without detriment to patients (Walsh et al., 2010). One area in which these features have proven very beneficial is in the teaching of medical emergency management for war injuries. Such environments expose trainees to the unique conditions, ‘patient factors,’ unpredictability and time pressures encountered by military medics in battle-zone medical emergencies. This exposure allows trainees to organise their thought processes and hone their decision-making skills before having to apply these in a high stake real-world context (Freeman et al., 2001.)
There is evidence of virtual reality based simulation (VRBS) technology being developed for dental education environments since the nineteen nineties. DentSim (DenX Ltd.) units were first used in a University teaching setting in 1998 and are the most well researched VRBS system currently being used. The DentSim unit includes an anatomically accurate mannequin with replaceable teeth to represent the patient. An infrared camera detects the orientation of the infrared emitters in the dental hand piece and mannequin to provide real-time data to a computer program as the student operates. This then provides dynamic feedback to the student including a digital representation of their preparation and comparison to an ideal standard throughout the procedure (Buchanan, 2001, 2004; Walsh et al., 2010).
A student may be provided with supporting information by the computer program including patient history, health information, previous records and links to further reading. An instructional module that teaches the stages and application of the procedure is also included, allowing progression through activities independently by the student. Performance of clinical procedures by students can be objectively compared with standards set by teaching staff to generate an instantaneous assessment (Buchanan, 2001; Walsh et al., 2010).
Such a system has several advantages, but the most prominent in the author’s opinion relate to the quality and quantity of feedback that can be generated. Unlike traditional preclinical assessment methods, the program can objectively assess the process of preparation as well as the final result. This allows errors to be identified as soon as possible so that remediation is timely and the specific problem causing the error can be addressed. Study of DentSim use within the University of Pennsylvania reveals several key assessment trends. Not only were students up to three times more likely to seek assessment feedback, but such was the speed of feedback gained, that teachers would have to evaluate a preparation every four to five seconds to match the DentSim’s efficacy (Buchanan, 2004).
Major positive prospects of VRBS include improved student engagement, accelerated learning and the opportunity to encourage self-directed learning in accordance with strong general preferences of adult learners (Murphy et al., 2004, Buchanan, 2001; Walsh et al., 2010). Administrative benefits such as reduced costs associated with preclinical staffing and resources, avoidance of adverse impacts of dental academic shortages, addressing insufficient patient pools for broad patient experiences and earlier introduction to the clinical environment are also proposed but require additional substantiation (Jasinevicius et al., 2004; Buchanan, 2001, 2004; Duta et al., 2011; Hanson & Shelton, 2008; Walsh et al., 2010).
Despite these possible advantages of VRBS use, shortcomings of existing technology remain apparent. The most outstanding of these in the author’s opinion is the inability to simulate and assess an entire patient interaction, from meeting the patient and assessing their problem to giving treatment options, gaining consent, preparing the tooth and restoring the tooth. While communication factors alluded to in this statement demand improvements in integration of intelligent tutoring into dental simulation, the latter procedural point presents a distinct physical challenge. Although VRBS systems are beginning to master the teaching and tracking of tooth preparation, none has accurately replicated the process of restoring tooth structure- a procedural skill that contributes at least equally to treatment prognosis (Walsh et al., 2010).
A further challenge posed by existing circumstances is that a VRBS unit such as the DentSim typically cost around $100 000-$150 000 compared with a traditional simulation unit with an upper limit of approximately $70 000 (Walsh et al., 2010). Although it is suggested that savings associated with improved laboratory efficiency and less staff demand may serve to offset this cost discrepancy (Jasinevicius et al., 2004; Buchanan, 2001; Duta et al., 2011), the expense of initial set-up and staff training are likely to deter some potential users. Ongoing costs associated with maintenance and supplies must also be considered. Despite original intentions of DentSim to offer a completely virtual platform, the unit still depends on the use of synthetic teeth that typically cost around $2.00 each for practicing preparations (Walsh et al., 2010; Buchanan, 2001). This introduces a steady ongoing cost, especially since students perform up to twice as many procedures using this system compared with a traditional PCSL (Buchanan, 2004). The learning advantages gained through increased opportunity to practice must be balanced with the associated expense. For some schools, the 24/7 accessibility of VRBS units cited as a distinct advantage (Buchanan 2001; Duta, 2011), may not be a practical reality.
Eventually, total immersion virtual reality systems in co-ordination with haptic technology may eliminate such ongoing costs. To date however, only one system (Novint Virtual Reality Training System) is capable of distinguishing between the tactile sensations of enamel, dentine, pulp and caries, yet perception of this distinction has a critical part to play in clinical practice. Unfortunately, this system requires students to hold a haptic device in mid-air to perform procedures on a virtual tooth projected on a computer screen (Walsh et al., 2010), which disregards the skills of indirect vision, overcoming anatomical barriers, and use of stable finger positioning during preclinical learning (Buchanan, 2001).
A VRBS system that uses realistic, variable anatomical features combined with accurate haptic device feedback, virtual patient interactivity and intelligent tutoring technology to steadily progress the student through increasingly difficult scenarios may represent the ideal preclinical training tool. This is not an unrealistic expectation when one considers that each of these separate entities is now being developed and refined independently (Walsh et al., 2010).
Critically, staff must be trained in the application, administration and optimal use of these technologies. From the large body of literature that now exists in this field, it is clear that students see this technology as novel, stimulating and helpful for their learning, but commonly identify a wish to maintain staff accessibility whilst using these tools. (Quinn et al., 2003; Buchanan, 2004) It seems logical that any time saved in avoiding the need to assess students would increase the quantity and potentially the quality of teaching time available, however this is only the case when the tutor is competent in the use of VRBS technology. A present concern is that the curriculum must adapt to accommodate VRBS systems (Walsh et al., 2010). Developments in coming years should seek to reverse this trend and allow teachers to readily customize the technology to meet their own teaching needs. This opportunity will also present a challenge to faculty to adapt and innovate.
While it is difficult to deny the potential of VRBS technologies to improve dental education, particularly in a preclinical context, it remains to be demonstrated whether integration of this approach creates significant and sustained improvements in clinical competency, safety and patient satisfaction relative to traditional preclinical training (Walsh et al., 2010). Quality research focused on these parameters will serve to validate the position of VRBS technology within the teaching armamentarium of dental educators. Given the staggered uptake of VRBS systems, multi-centre research may offer a better insight into any broad educational benefits to be gained.
Dental education lends itself to the application of VRBS technology due to the need for development of high precision manual dexterity at an early stage during the degree, the irreversible, high risk nature of procedures, and the need for clinical proficiency across a full spectrum of possible clinical encounters. Improved student engagement, preclinical efficiency, assessment objectivity and self-directed learning are attractive prospects of VRBS for innovative dental educators. Technical barriers, cost considerations, challenges in staff training and lack of quality evidence of broadly sustained impacts remain as deterrents to adoption of VRBS teaching tools in the short term.
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