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Review Article

A Review of the Use of Simulation in Dental Education

Perry, Suzanne BDS, MFDS RCPS(Glas) MOrth(HK) MOrthRCS(Edin); Bridges, Susan Margaret BA (Qld), DipEd (Qld), GradCertTESOL MAAppLing, EdD (Griffith); Burrow, Michael Francis BDS MDS, DDSc (Adel), PhD (Tokyo Med & Dent U), MEd (Melb)

Author Information
Simulation in Healthcare: Journal of the Society for Simulation in Healthcare: February 2015 - Volume 10 - Issue 1 - p 31-37
doi: 10.1097/SIH.0000000000000059
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Abstract

In the current economic climate, clinical education providers are increasingly aware of both the tightening of government funding and accountability issues.1 In modern health care, patient safety is of utmost concern. Standards of care need to be adhered to, and breaching such not only results in patient neglect but also opens the door to litigation. Time-restricted curricula and more demanding surgical techniques are adding pressure for educators to assist students to achieve the requisite high psychomotor skill levels in a short time frame. It has been argued that decreasing operative time in overcrowded curricula of health care professionals may be restricting opportunities for the surgical trainee.2 Updating simulation techniques and modalities may act as a way to enhance efficiency in the delivery of surgical training. The most recent efforts have been in the area of virtual reality (VR), which in this context is defined as a computer-generated medical simulation of a 3-dimensional (3D) image or environment with which a learner interacts in a seemingly real or physical way. Simulation in health care has evolved since the late 1960s when mannequins were first introduced for anesthetic training.2 In the 1990s, with expanding interest in minimally invasive surgery, the first simple laparoscopic simulators were developed.3 Ensuing studies indicated that this technology was useful, with evidence that motor skills gained on a VR simulator could be transferred into the real setting.4 Major benefits of VR, therefore, include skill acquisition before patient exposure, the ability to repeatedly practice identical procedures to establish skill levels, and the ability to provide standardized feedback with independence from direct supervision.

As with all health care professions, dentistry is constantly evolving. For dentistry, the irreversible nature of most operative procedures means students must have the skills for safe delivery at the point of patient treatment and care. Past clinical techniques reflected a more surgical, aggressive approach to dental caries (decay) removal and tooth restoration—the mainstay of general dentistry. Current philosophies have moved toward a focus on prevention and conservation of tooth structures, even when operative intervention is necessary. Differing from the medical profession, where only a particular subset of specialties routinely require a defined set of surgical psychomotor skills, dentistry encompasses a wide range of procedures, each requiring a task-specific skill base. As a field, VR simulations in dental education, including haptic simulations, have not as yet provided the full gamut of possible case scenarios for student practice.5–8

As a practical vocation, dentistry has always drawn on simulation as an essential part of student clinician education. In the early days of dental training, real teeth were used in a bench-top setting before the introduction of the phantom head. These phantom heads or mannequins enable removal and insertion of a complete artificial dentition that use individual plastic teeth, or, to a lesser extent given the scarcity of resources, real, extracted teeth. Relatively realistic simulation was evident, and so current dental programs routinely incorporate phantom head instruction in both undergraduate and postgraduate skills training. Less widely but increasingly apparent is the incorporation of virtual environments and VR clinical simulators into dental training, the most recent innovation being in the form of haptic VR simulators providing sensory feedback. The word haptic is derived from the late 19th century Greek word Haptikos (able to touch or grasp), with modern haptics being the science of interacting with the external environment through the manipulation of objects using the senses of touch and proprioception.9 Haptic simulators may improve the realism of simulation and, as such, be increasingly used in health care skill training. Ideally, VR simulation should be available to all dentists, allowing them to develop the required skills for new techniques or simply to update current practice safely through continuing education for further professional development.

This article reviews the historical development of simulation in dental education as well as the current applications and recent developments, including the latest field of VR simulation with haptic feedback. Finally, future needs and directions for the implementation of supportive simulation technologies for student learning are identified. The literature review was performed using the search terms dental education, simulation, virtual reality, dentistry, haptics, and healthcare using the PubMed database and Google Scholar.

CONVENTIONAL DENTAL EDUCATION SIMULATIONS

The first college of dental surgery was founded in 1840 in Baltimore, Ohio, United States, which served as the foundation for the formation of other dental schools worldwide.10 Restorative techniques at that time were practiced using extracted teeth and bench-top simulation. A major problem in the 1800s was the lack of availability of natural human teeth for practicing on the simulators, mainly because of the demand of such teeth for use in dentures. Denture teeth had been previously carved from ivory, but human teeth were much more desired because of their realistic appearance. Supplies of teeth had come from war victims such as those of Waterloo, giving rise to the name of the Waterloo denture.11 The use of “resin-based” teeth became much more commonplace in the late 20th century when dental education was developing rapidly and the supply of real teeth was limited. The first phantom head simulators were used in 1894 in an effort to improve realism. These were assembled with 1 metal rod with 2 brass jaws as can be seen in Figure 1, a sketch of the first phantom head simulator created by Oswald Fergus in 1894.12 Natural teeth are now used only when readily available and often for more complicated training where true anatomic features are necessary, such as root canal therapy (endodontics).

FIGURE 1
FIGURE 1:
A sketch of the first phantom head designed by Oswald Fergus in 1894.

The combination of bench-top and phantom head training for the acquisition of dental surgical skills seems to have been the norm from the early 1900s and still exists in an updated form in dental schools today. Figure 2 shows the relationship of important key events in the development of clinical dental education.

FIGURE 2
FIGURE 2:
Timeline of simulations in dental education.

The phantom head simulator has been the iconic and mainstay simulation device for dental education since its creation. There are many benefits of such a device; it is ergonomically correct and allows proper handling of both the dental mirror and handpiece. It also allows the possibility of a finger rest to maintain stability when performing instrumentation, an essential, foundational concept that a novice must acquire before developing more complex skills. Modern phantom head simulators (Fig. 3) also include a water spray to add realism, and natural teeth can be inserted, if available. Unfortunately, the opportunity for students to practice on natural, extracted teeth is diminishing. Plastic teeth may provide an adequate substitute, but it would be a challenge to create synthetic teeth to be equal to that of natural teeth for learning the fine motor skills required in restorative dentistry.

FIGURE 3
FIGURE 3:
A modern phantom head simulator.

Concerns when using phantom heads may include possible water line contamination and infection control. In addition, the cost of handpiece maintenance and disposable items such as dental burs may also increase expenses. Supervision is required for phantom head exercises for safety because of the use of air or electrically driven dental handpieces (drills) with real burs and also to provide feedback during training exercises.

Evidence for the use of the traditional bench top or phantom heads is limited. One study13 compared the bench-top technique with a phantom head simulator to assess which produced the best motor skills in students. The phantom head simulator was found to be preferable as the students who had trained on the bench top found difficulty in the transfer of skills to the phantom head but not vice versa. Another study14 examined the effects on the clinical environment by assessing the results of student preparations of tooth cavities performed on mannequins in a clinic and mannequins in a simulation laboratory. Contrary to the study mentioned earlier, no difference was apparent.

TECHNOLOGICAL TRENDS IN DENTAL EDUCATION

Computer-Supported and VR Simulators

The introduction of computer-supported and VR simulators began to enter dental schools of North America and Europe in the early 2000s, creating a new avenue for motor skill learning in dentistry. Computer-generated virtual teeth were used in combination with a variety of devices to simulate control of the dental handpiece, such as joysticks and pen devices. One of the first systems that allowed for a wide variety of restorative procedures to be performed was DentSim. The advantage of this system was that it blended mannequin-based learning with 3D visuals. This improved realism because of the prospect of a finger rest, water spray, and a dental handpiece while incorporating infrared technology to project an image of the students’ preparation on a computer screen for real-time evaluation and feedback, a known asset in complex motor skill learning.15 An increasing number of computer-supported and virtual reality simulators have been introduced worldwide.5 Models of the dentition can now be scanned and simulated in a 3D form, allowing for improved access and accuracy of measurements.16 Across the dental specialties, simulation software has increasingly provided support for orthognathic surgical planning and implant treatment as well as the diagnosis and treatment of periodontal (gum) disease. In dental education, simulations are available for the extraction of teeth5 and practicing dental injections.17 Robotic simulated patients with the ability to move independently, secrete saliva, and have a limited conversation with the trainee have also been recently introduced, mainly in Japan.18,19 Advanced software has also been used to create an immersive virtual dental school as a supportive learning environment.19 Such technological advances may be a useful addition to the education of dental students, adding experience and patient management skills earlier in the curriculum and before the provision of direct patient care.

With the introduction of computer-generated simulations, dental students were, for the first time, able to repeatedly practice the same tooth preparation without the need for supervision and with synchronous computer feedback. For the most effective motor skill development, awareness of when and how an error was made (knowledge of performance) is more important than the final result itself (knowledge of result).20 Real-time, process-based recordings of a preparation allow students and their tutors to review errors at the exact time point they occurred for detailed feedback and correction. Inconsistent feedback on surgical preparations due to tutor subjectivity has been a topic of controversy in dental education.21 The provision of objective, standardized computer-generated feedback able to be reviewed may be one way to overcome this concern. Virtual-reality simulators also increase the possibility of students being able to practice in their own time. Although initial VR simulator installation costs are substantial with time-consuming staff training and software updates, the savings in terms of handpiece replacements and disposables such as plastic teeth make the VR simulator not only a viable teaching tool but also possibly more cost-effective over the long term. Simulators also avoid the need for water pipes and suction, and so the threat of water-borne diseases such as Legionella is eliminated.

Simulations may, however, lack some of the realism found to be beneficial with phantom heads. Systems only relying on the use of joysticks with computer-generated images lose critical psychomotor skills such as correct handpiece grip, posture, and associated finger rest. Some systems also do not have foot pedals or require control of soft tissues, and so the transferability of skills from computerized simulation to clinical settings may be questionable. The limited number of programmed cases results in restricted exposure to the range of procedures available on mannequins, and some may allow cutting of teeth but not restoration and vice versa. Performative aspects of the procedures themselves may be unrealistic because of time lag between input device and image display, in some cases with voxelization occurring or unrealistic outcomes (“floating” section in Fig. 4).

FIGURE 4
FIGURE 4:
Unrealistic simulation where a “floating” piece of tooth remains on the image.

The study of Quinn et al22 in 2003 investigating possible differences in skill level found that undergraduate students trained with DentSim were actually worse at some aspects of cavity preparation than those trained on a traditional phantom head and recommended that novices should not use “virtual representations” for training exclusively. However, other small-scale studies have emerged with more encouraging results, suggesting that students may learn fine motor skills more quickly with VR simulation (DentSim) when compared with traditional phantom head simulation.7,23,24 The most likely reason for this positive effect may be in the ability to practice a greater number of preparations using VR simulators than in the same practice time as with mannequins. This may indicate the improved efficiency of motor skill learning when VR simulators are used and so make the process potentially more cost-effective. This increase in time efficiency does not seem to affect quality.

A 2004 study found that although computer simulators seem to reduce the number of staff-student interactions, the quality of resultant preparations showed no difference to the control group using noncomputer simulations.25 Another study showed that dental students using computerized simulation were also found to learn procedures faster than those using “older, traditional, preclinical” laboratory equipment yet still maintain or have superior skill levels.7 On the contrary, not only was the study of Quinn et al22 negative with regard to performance outcomes, but also a questionnaire with the same study group was less than positive with 95% of the students preferring conventional techniques because of “excessive critical feedback,” “lack of personal contact,” and “technical hardware difficulties” experienced with the computer-supported simulators. This suggests that not all students will embrace new technologies and the need for further refinements of simulators for user-friendliness and effectiveness in student learning.

A retrospective study26 also compared staff perceptions of 2 groups of students, one with experience using a VR simulator and one with traditional bench-top and phantom head learning. The staff perceived the abilities of the VR students to be higher than those who had traditional learning. However, staff perceptions of the VR students’ abilities were much higher than their actual final overall ability. So, in some way, the staff may have overestimated the strength of the VR training. Interestingly, a strong point of VR training was the observation that the students had correct hand and body posture, something this particular simulator (DentSim) alerted students to during training. They also felt that students with the VR training were more apt at self-assessment, a concept which may be associated with continual feedback from the simulator. Other studies7,8 have indicated further positive outcomes from students using a variety of simulators over differing periods, suggesting that overall perceptions of VR in dental education seem to be positive.

Surveys demonstrate that students are relatively comfortable with simulator technology, even when not completely computer literate.24 Virtual-reality simulators may be used as a predictive tool to screen for students who may struggle to gain motor skill competency within a restricted curriculum.27 Virtual-reality simulation also provides identical clinical simulations for all students, allowing standardization for grading if used for assessment purposes. Students are able to replicate procedures they may find difficult, allowing more individualized learning, and as such, the provision of reproducible, unbiased criticism can occur.

Haptic-Enhanced VR Simulation

The trend toward haptic-enhanced VR simulation came in the late 1970s from the areas of flight simulation28 and computer gaming as a result of a desire to improve realism via heightened sensory feedback. Cross-disciplinary applied research has indicated the importance of haptics for speed29 and accuracy30 in psychomotor skill development and for practice in perilous conditions.31 It is in the field of surgery, however, that the use of haptics has gained a niche foothold to replicate surgical conditions for skills training. Because surgical techniques have become more intricate and less invasive, patient demands for less radical and intrusive procedures have also increased. A greater number of surgical procedures are being performed laparoscopically, which is heavily dependent on sensory perception rather than a direct line of sight; hence, appropriate training is essential before attempting such complex procedures.

Studies of haptics in surgery have been generally encouraging. The review of Van Der Meijden et al32 found that haptics were of benefit in robotic-assisted surgery but not when used with VR simulators. It seemed that there was a lack of evidence to substantiate the claim that haptic simulators were superior to nonhaptic but the addition of haptics was seen to reduce surgical errors and could be deemed as important in the early phase of psychomotor skill acquisition and development.32 Sewell et al33 suggested that haptic training allows a student to start further along the learning curve when brought into reality. Bethea et al34 noted that practice using a haptic knot-tying simulator increased the number of successful sutures. Strom et al35 found that haptic-trained residents were able to perform diathermy tasks significantly better than non–haptic-trained practitioners. Panait et al36 observed superior precision, speed of task completion, and fewer technical errors with haptic-based simulators and concluded that their extra expense was justified.

Haptic-Enhanced VR in Dentistry

The restoration of teeth is an extremely tactile process with differences in sensation between drilling enamel and dentine. Heightened sensitivity is also required to perceive when dental pulpal (nerve) tissue has been involved. With the use of the technology from the aeronautical industry and surgical fields, prototype dental haptic simulators began to be constructed, leading to the implementation of the first dental haptic simulator in dental schools in the early 2000s.5,6 This recent development has excited many dental educators who see potential applications for a device that not only aims to realistically replicate the clinical situation but also can identify and pinpoint errors in skill learning.

Dental haptic-enhanced VR simulators are now being used to assess periodontal disease, prepare for implant and maxillofacial surgery, and restore 3D simulated teeth. The Simodont (MOOG, the Netherlands) was developed partially using technology from the aircraft simulation industry and has the ability to simulate removal of caries (dental decay) and the finishing of restorations. Figure 5 shows the Simodont simulator units in use at the University of Hong Kong, with Figure 6 illustrating a tooth preparation exercise. Another system, PerioSim (University of Illinois at Chicago, Collage of Dentistry, Chicago, IL), allows students to experience differences in tactile sensation when treating periodontal (gum) disease and removing dental calculus (tartar). A staff perception survey indicated positive opinions of the device and its potential in evaluating student performance.37 In 2011, a team from Osaka University, Japan, developed the Bone Navi,38 a haptic simulator with sound and virtual vibration when drilling bone for improved realism. The Bone Navi can use the patient computed tomographic images for individualized treatment planning and practice before the actual clinical procedure.

FIGURE 5
FIGURE 5:
Simodont VR haptic units in use at the University of Hong Kong.
FIGURE 6
FIGURE 6:
A haptic tooth preparation exercise.

Within dentistry, limited evidence-based practical research has been performed to validate the use of haptic-enhanced VR simulators for clinical education. One small-scale study performed by Bakker et al39 took 3 groups of students, trained one group on a haptic simulator, one group using traditional phantom head, and a third control group. Those who were trained on either haptic or phantom head (compared with the control group) had better final skills, as expected, but there was no increased skill level for those who had trained on the haptic units. Overall, the numbers in this study were low, and replication of such a study with a larger sample size would be of value.

Gal et al40 found that both staff and students believed that haptic simulators would be a useful addition to the teaching facilities, with students more positively disposed than staff; however, both groups suggested improvements to make the sensation more convincing. Students noted that it would allow them to perform tasks in their own time rather than being dictated to by dental school timetables, whereas staff saw the potential for evaluating the entire process of the preparation rather than just the outcome. Other studies of undergraduate dental student perceptions of haptic simulators have also been positive.40,41

FUTURE NEEDS AND DIRECTION

Global Trends

Education systems and trends are constantly changing with new concepts and technology. Distance learning is commonplace and has influenced the medical field with staff members or specialists able to analyze preparations performed by students and provide an expert opinion from remote locations. In supporting face-to-face delivery of undergraduate clinical surgical skill development, the notion of blended learning is not uncommon.42 Programs on some units not only are able to provide skill-based exercises but also can simulate virtual patients to support more holistic approaches to patient treatment planning. In an era of globally competitive staffing for dental facilities, recruitment of academic staff is increasingly difficult.43–45 Virtual-reality simulation may be beneficial in this work force context, especially if the simulators themselves are able to provide timely and useful feedback.

More broadly, in terms of the relationship between academia and industry, the OECD1 [Organization for Economic Co-operation and Development] has suggested increased integration to support and enable collaborations. This concept is already being embraced in dental education, and it is such developments that can provide innovative knowledge and equipment. One example is the knowledge transfer between the flight simulator company, MOOG, in collaboration with a Dutch dental school, ACTA, to create a haptic simulator for dentistry, Simodont. Education in general has to evolve as we are living in an era of continuous technological development. Publications1,46 suggest global changes in the future of higher education with greater global migration of students for educational purposes; more cross-continental collaborations; increased urbanization placing more stress on tertiary establishments; increased demands on educational standards by stakeholders, including parents; and continued rapid technological development. Additional to these forces of change are the increasing calls for accountability by governments and professional bodies for maintaining and advancing educational and professional standards. In responding to these forces of change, the education sector has recognized the need to become more flexible, efficient, and evidence based. Virtual-reality simulation technologies and haptic simulation, in particular, are providing one avenue of opportunity where such demands can be met.

The use of VR simulation in licensing and examination has been considered by a number of health care professions but has not been extensively applied to date because of a perceived lack of technical sophistication.47 The aim of simulation for examination or licensing differs from training in that the aim is not to improve skill level but for gatekeeping, ensuring a candidate has achieved a certain level of competency so they can be deemed “safe” to treat the general public.12 In dentistry, like general surgery, VR simulation for licensing or examination is not currently applied in the United States, United Kingdom, or Asia.

Future Research in VR Simulations in Dental Education

Virtual-reality and haptic-enhanced VR simulations in dentistry are still in its infancy, but increasing interest in its future direction and development is apparent. In terms of technological advancements, further development of haptic units with improvements in sensory feedback, real-time simulation, ergonomics, and recording of the procedure would be beneficial. Expansion of software to increase the number of dental procedures available would also be advantageous. Many research questions have yet to be answered both to direct these technological developments and to establish a wider acceptance of simulation in dental education. An evidence base is lacking as to the effectiveness of VR or haptic simulations compared with the traditional phantom head techniques. Studies to date show some promise, indicating that the introduction of haptic units may assist in improving realism to a level where the transfer of skills can occur from the simulation laboratory to the dental clinic; however, these are mainly small-scale studies, and the benefits have yet to be proven. Further studies need to be conducted comparing the effectiveness of skill acquisition between various VR simulation units with that of traditional techniques. Larger-scale studies in dental education may be problematic given the curriculum constraints and generally small size of cohorts.

Research questions that should to be considered might be how many hours of simulation training is sufficient for the majority of students to reach the required competency? Would fewer training hours be acceptable on a simulator if it were more efficient? Where do simulators fit in in a dental curriculum—is it best for them to be used extensively at the start or to be used as the first step when learning a new procedure? Do some particular students respond better to simulation training than others? Further research is required into these areas before the majority of the dental teaching population will embrace VR simulation training.

CONCLUSIONS

Simulation in dentistry is an evolving and exciting sphere. For further integration into dental curricula and use as a potential examination and licensing tool, additional development of hardware and software is required. If this is possible, the opportunities are extensive and varied, allowing dental schools to be able to encourage learning of a variety of procedures not just to a limited level of preclinical competency but closer to in vivo proficiency. Such advancements would be beneficial to the general public in improving the boundaries for standards of care. Crossover of information between the dental sphere and other health care disciplines in the development of simulations has been limited. Dentistry can learn from advances in surgical research in this area and vice versa, as both fields encompass fine motor skill development and clinical decision making. If further efforts can be made to advance simulation technologies through research collaborations across specialties, there is no reason why VR simulation cannot become an integral and beneficial part of modern dental curricula.

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Keywords:

Dental education; Simulation; Virtual reality; Dentistry; Haptics

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