Simulation, coupled with technology, is most

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1 Use of Simulation Technology in Dental Education Judith Ann Buchanan, Ph.D., D.M.D. Abstract: Simulation is becoming very beneficial in the area of health care education. Dentistry has used various types of simulation in preclinical education for some time. This article discusses the impact of the current simulation laboratories on dental education and reviews advanced technology simulation that has recently become available or is in the developmental stage. The abilities of advanced technology simulation, its advantages and disadvantages, and its potential to affect dental education are addressed. Dr. Buchanan is Associate Dean, Academic Affairs, Dental Care Systems, University of Pennsylvania, School of Dental Medicine. Direct correspondence to her at Office of Academic Affairs, University of Pennsylvania, School of Dental Medicine, 4001 Spruce Street, Philadelphia, PA 19104; phone; fax; Key words: simulation, virtual reality, preclinical training, dental education Submitted for publication 7/8/01; accepted 9/19/01 Simulation, coupled with technology, is most identified with the field of aviation 1 but in recent years, simulation using advanced technology has become prominent in the health care field Webster s Dictionary defines a simulator as a training device that duplicates artificially the condition likely to be encountered in some operation. Simulators are most valued when the operation being duplicated is irreversible and hence training is better done in simulation than in real life. Simulators are currently used in the health care field for training responses to cardiovascular emergencies. 5 laparoscopic surgery, 10 emergency room, 12 and operating room emergencies. 13 The role of simulators has been recognized as an important aspect of training in the health field that supports and improves patient safety. 14 Dentistry has also been investigating the extended use of simulation for its training, especially in the area of preclinical training Factors that appear to be driving the interest are a desire to provide a smoother transition for students into the clinic, to support and reinforce ergonomics, to broaden the students preclinical experience by including additional models mimicking real patient conditions, to offer practice for students in the documentation of care, and to improve the delivery of supporting material such as demonstrations, diagrams, manuals, etc. Although simple versions of simulators have been in use in dentistry for many years, what are most commonly referred to now as simulation laboratories incorporate more sophisticated technology and realistic equipment. Although simulation laboratories vary, most consist of a simulated patient or manikin and computer-supported audiovisual systems to aid in the transfer of information from the instructors, manual, or reference material (see Figure 1). The simulation equipment is available in a variety of modular, bench, or chair configurations and can be used in operative, prosthodontic, endodontic, pedodontic, and surgical education, depending on the unit and the type of dentoform used. These simulation laboratories are a vast improvement over older equipment, but the basic educational structure is the same. Students are shown models, didactic information, diagrams, pictures, etc., and are asked to repeatedly perform procedures on plastic teeth. The student s product is then graded by an instructor who usually gives verbal feedback as well. Reports on the impact of these simulation labs on dental student learning are sparse, but some studies indicate that student performance on practical examinations was not altered although student opinion of these simulation laboratories was high Reports from at least one school, 15 which compared an older, traditional laboratory to a new simulation lab over a three-year time period, indicate a reduction in the number of procedures that can be completed by students with the new simulation laboratory. This is perhaps due to increased time for evaluation since faculty must go to each station rather than the students bringing dentoforms to the instructor. Student/faculty ratios improved minimally (from 13/1 to 11/1) in the simulation laboratories, but the percentage of student grades in the A range decreased significantly (22.7 percent to 4.5 percent). Although not documented, it has been hoped that the transition to live patients is eased and students arrive November 2001 Journal of Dental Education 1225

2 in clinic better prepared even if students do not receive grades as high as before. The need for resources such as faculty for evaluation is basically unchanged and, based on what little research is available, simulation laboratories have had little impact on the way schools teach preclinical procedures. The cost of a simulation laboratory is moderately high ($2,000 to $10,000 per unit), but many schools in the United States have been able to afford a more technology-updated simulation preclinical laboratory within the last eight to ten years. The current simulation laboratories do not require a new approach in basic teaching methodology, but they provide students with a more realistic simulated patient, emphasize ergonomics, and provide an active, hands-on learning environment. Virtual Reality-Based Simulation However, these simulation laboratories are losing their position as state of the art due to the emergence, in the last few years, of technology of a higher dimension. Virtual reality-based technology (VRBT) is being used, evaluated, and researched in many areas of health care training and is now being used in dental education as well. Four products deserve discussion because of their potential in dental education: the DentSim simulator manufactured by DenX, Ltd. 18 of Israel; the IGI (Image Guided Implantology) unit, also manufactured by DenX, Ltd.; 18 the VRDTS (Virtual Reality Dental Training System) prototype 19 developed by Novint Technologies of New Mexico; and the IDSS (Iowa Dental Surgical Simulator), 20,21 a product of collaboration between the Colleges of Dentistry and Engineering at the University of Iowa. All of these systems use VRBT. Furthermore, these units have a major advantage over the current simulation technology because, in addition to having most of the benefits of the current simulation lab, VRBT units are designed to provide evaluations of the students performance. This capability of VRBT offers a great potential for significant impact on dental education. DentSim The units by DenX Ltd. are by far the most developed, the most evaluated, and from the author s Figure 1: Simulation laboratory at the University of Louisville, School of Dentistry. Photograph provided by Dr. John Williams, Dean Journal of Dental Education Volume 65, No. 11

3 Figure 2: Virtual reality laboratory at the University of Pennsylvania, School of Dental Medicine. Photograph provided by Dr. Peter Berthold, Associate Dean. Figure 3: View of evaluation screen on DentSim unit. Upper left is the virtual image of student s preparation. Right side of screen is cross-section of optimal preparation (right middle) and student s preparation (lower right). The points deducted for the variance of the student s preparation from the optimal preparation in the floor angulation is three points (bottom center). November 2001 Journal of Dental Education 1227

4 perspective, the most exciting. Although the IGI unit is still in development, the DentSim (Dental Simulator) unit has been available since Research began on the use of the DentSim simulator at the University of Pennsylvania in early 1998 (Figure 2). A detailed description of this unit is available elsewhere, 22 but basically the unit consists of a simulated patient or manikin with head and dentoform, dental handpiece and light, infrared camera, and two computers. The manikin head and handpiece contain infrared emitters that allow the infrared camera to detect their orientation in space. As a student prepares a tooth in the manikin head, the computer can formulate a virtual image of the tooth being prepared in the computer. The virtual tooth can then be compared to the ideal preparation approved by the faculty, and abundant, detailed visual feedback can be given, including a grade (Figure 3). The unit can evaluate the process of the preparation and not just the end product. One of the unique properties of the DentSim unit is the computer s ability to evaluate the students work according to an ideal preparation that can be controlled by end-user faculty. Notification of critical errors is given to the student immediately, and detailed evaluation and grading are available for the student at a click of the mouse. The unit is theoretically available twenty-four hours, seven days a week and evaluates in a standardized, reliable and valid manner according to preset parameters. From my perspective, this is a true breakthrough for dental education as most schools have suffered from a lack of consistency and uniformity among preclinical evaluators. The results of research on the DentSim unit at the University of Pennsylvania indicate that students learn procedures faster on this unit than students in older traditional preclinical laboratories did, but reach the same or higher level of skill as judged by faculty in blinded practicals when compared to control students. 26,27) The efficiency of the learning experience is higher since students using the DentSim prepare 50 percent to twice as many preparations per hour (depending on the type of preparation) as compared to students in a traditional laboratory. 27 In addition, students on the DentSim take advantage of the ease of evaluations by requesting evaluations up to three times more often than in the traditional preclinical laboratory setting. 26,27 At the rate of evaluation seen by students on the DentSim, a traditional laboratory with a class size of 100 would need to evaluate in complete detail one preparation every four to five seconds. With a student/faculty ratio of 10/1, each faculty member would need to evaluate a student s preparation every forty-three seconds to equal the frequency of evaluation available to students on DentSim. The ability of faculty to do this plus providing consistent standardized evaluation is not possible now at even the most well-staffed dental schools. Twenty-one restorative procedures are currently programmed into the DentSim, but the major disadvantage is that the restoration (amalgam, composite or crown) cannot be recorded and faculty must continue to evaluate this part of the procedure. At the present time, DentSim units can be found in twenty dental schools worldwide (nine U.S. schools). One U.S. school is currently installing forty DentSim units, which will allow for all members in a class to have ample access to this technology. Several additional schools, including Columbia University, Case Western Reserve University, the University of Tennessee, and the University of Pennsylvania, have ongoing projects investigating a variety of research questions concerning this technology. Image Guided Implantology (IGI) The IGI (Image Guided Implantology) unit is in the last stage of development by DenX, Ltd. and is specifically directed toward the teaching, diagnosis, treatment planning, and placement of implants. It uses the same technology as the DentSim unit, but a virtual reality composite of an individual patient can be obtained by entering the patient s CAT scan into the unit. Diagnosis, treatment planning, and virtual trial surgery of placing implants can then be done on the virtual patient. The exciting and unique ability of this unit is that the developers have included a registration device that can be used at the time of the surgery and allows the patient and the virtual patient image to be coordinated during the actual surgery. Hence, the surgeon can take advantage of the computer images for better orientation, and the computer will warn the surgeon if he or she is veering from the treatment plan as he or she is actually in the act of the procedure. If the computer recognizes that the surgeon is making a serious deviation from the implant placement treatment plan during surgery, the computer will stop the handpiece and the surgeon will need to override the computer to continue. This greatly enhances patient safety. It is anticipated that simulators with this type of advanced technology will 1228 Journal of Dental Education Volume 65, No. 11

5 encourage easier, more thorough training in the area of implant placement in dental schools and in the private practice arena. The additional support of this technology during implant placement surgery is an added and exciting benefit. Virtual Reality Dental Training System (VRDTS) The VRDTS prototype is being developed by Novint in collaboration with the Harvard School of Dental Medicine. 19 This unit, still very much in the developmental stage, consists of a desktop workstation, a phantom Desktop haptic (referring to sense of touch) interface, and dental simulation software. The software includes simulated dental instruments (low speed drill, an explorer, two carvers, a carrier, and a packer), amalgam material, and a juvenile molar including enamel, dentin, caries, and pulp materials. Visual aids such as zoom magnification and crosssection modes are included. To use the unit, a student holds the PHANTOM interface in the air. The dental instrument, tooth, and decay are displayed as virtual simulated images on the monitor. By moving the interface device, the operator can control the selected dental instrument and prepare or restore the juvenile tooth simulated on the monitor. This unit has two possible advantages. The first is that the tooth in the VRDTS is virtual; hence, there is no need to replace the teeth, which can cost over $2.00 each if using other units such as DentSim. The second advantage is that the VRDTS unit allows for the restoration of the preparation, something that is not possible with the DentSim unit. The unit has one disadvantage, however, in that it does not enforce or support correct positioning or hand finger rests since the student holds the interface in the air. Novint Technologies future plans include adding more aids such as loupe magnification, a selection of thirty dental instruments, simulation of composite material, simulated sound, and actual dental tool handle and foot pedal actuation. Iowa Dental Surgical Simulator (IDSS) The IDSS unit is also still in its early stages of development, but it focuses more on tactile skill development and less on psychomotor skill development. 20,21 Haptic skills, such as the detection of carious lesions, are difficult to teach since the expert cannot feel the force exerted by the student and the response that the student is feeling, thus making feedback difficult. The IDSS consists of three hardware components: the computer, a monitor, and a force feedback device with software. Participants interact with the computer by grasping a joystick or explorer handle attached to the force feedback device. Teeth are displayed on the monitor, and the student can manipulate the joystick or explorer in such a way as to feel enamel, healthy dentin, and carious dentin. Different haptic responses are received when the joystick or explorer is manipulated over the appropriate areas of the tooth. There are obvious benefits of expanding haptic technology to include other tactile sensations important to dentistry such as the sensation of drilling into enamel, healthy dentin, and carious dentin. Discussion Advanced technology simulation is on the verge of dramatically affecting health care education. Specifically, virtual reality-based technology allows for more advanced simulation, thereby setting a new state-of-the-art dental simulation. This new level of simulation, unlike our previous models for simulation labs, has the real potential to influence and modify how we teach. Interest in this advanced (VRBT) technology may be fueled by schools having difficulty in recruiting faculty for preclinical courses, schools looking for ways to reduce costs while maintaining or improving student learning, or schools having difficulty in obtaining sufficient patient pools to address student needs. However, because this simulation technology is involved in the actual evaluation of students, schools with even minimal exposure to this technology are beginning to see a horizon of new ways in which simulation of this type can help improve and change the way dentistry is taught. It must be noted that simulation technology can and must be adapted to the needs of individual schools to reach its potential. For example, the University of Pennsylvania is viewing technology such as DentSim as a way to decrease time in preclinical lab but easily allow for mandatory refreshment on simulators immediately prior to a student s first clinical experience. The University of Pennsylvania will November 2001 Journal of Dental Education 1229

6 evaluate whether this technology will facilitate earlier student entry into the clinic. Other schools may be more interested in using the technology to replace some aspects of actual patient care or reduce the reliance on patients for certain types of procedures. Other schools may see simulation as a way to address problems with faculty staffing of preclinical courses, while others may view this as a method in which to free preclinical faculty from the demanding and burdening constraints of preclinical teaching, allowing more time for scholarly endeavors. It should be noted that the experience to date with advanced simulators supports the continued need for qualified faculty to augment the value of the simulator. 23,24,26,27 Whether the advanced technology simulators decrease the number of faculty needed remains to be evaluated. Many schools perceive the value of virtual reality in competency testing both as part of the curriculum and for regional clinical boards. Preliminary results from Columbia University suggest that this technology may be more helpful with students who are at the lower end of ability in psychomotor skills rather than more gifted students, 28 and the University of Pennsylvania has noted differences in attitude and skill development based on learning styles. 24 Students with learning styles that place a stronger emphasis on learning from individuals appear to have less enthusiasm for this technology. This suggests that the technology may be more beneficial for different student groups and allow for individual teaching programs adapted to a student s ability and learning style. Other areas of potential are in continued competency of practitioners, help with clinical board exams, remediation of impaired practitioners, and continuing education. The cost of this advanced technology simulation is expected to be substantial, but only the DentSim advertises a firm price ($70,000 per unit). The cost for units still in development is not yet available. It is hoped and anticipated that, as more and more companies become involved in the manufacture of this technology, costs associated with it will dramatically decrease. Institutions should be aware of hidden costs, however, and resources must be allocated for on-site staff with technical skills and personnel responsible for maintenance of the units. Additional resources may be necessary for the training of faculty, staff, and students. The economic impact of this technology is certainly an area that needs further evaluation to help schools decide to purchase equipment in this price range. Technology related to the presentation of casebased scenarios and technology authoring programs 29,30 is increasingly available, enabling schools to more easily access and develop electronic case scenarios. The advanced technology simulation may have even greater possibilities if dental education has the vision to couple advanced technology simulators with case-based scenario programs. In summary, advanced technology simulators offer an exciting opportunity for dental educators to review and reconfigure our curricula to meet the needs of our schools and dramatically improve student learning. Further evaluation of currently available systems and new systems arriving in the future is critical to expanding this opportunity. REFERENCES 1. Hilmreich R. Managing human error in aviation. Sci Am May 1997: Issenberg SB et al. Simulation technology for health care professional skills training and assessment. JAMA 1999;282(9): Euliano TY, Good ML. Simulator training in anesthesia growing rapidly: Lorel model born in Florida. J Clin Monit 1997;13: Larsson JE, Hayes-Roth B, Gaba DM, Smith BE. Evaluation of a medical diagnostic system using simulator test scenarios. Artif Intell Med 1997;11(2): Lamkin-Kennard K. Development of a model for simulating cardiopulmonary bypass. Presented at Society for Technology in Anesthesia Conference, Tucson, Arizona, January 14-17, Reinig KD, Spitzer VM, Pelster HL, Johnson TB, Mahalik TJ. More real-time visual and haptic interaction with anatomical data. Studies in Health Technology & Informatics 1997;39: Ota D, Loftin B, Saito T, Lea R, Keller J. Virtual reality in surgical education, Comput Biol Med 1995;25(2): Hoffman H, Irwin A, Ligon R, Murray M, Tohsaku C. Virtual reality-multimedia synthesis: next-generation learning environments for medical education J Biocommun 1995;22(3): Satava R. Virtual reality, telesurgery, and the new world order of medicine. J Image Guided Surg 1995;1(1): Gallagher AG, McClure N, McGuigan J, Crothers I, Browning J. Virtual reality training in laparoscopic surgery: a preliminary assessment of minimally invasive surgical trainer virtual reality. Endoscopy 1993;31(4): University of Washington. Hit lab: human interface technology laboratory at accessed September 4, Journal of Dental Education Volume 65, No. 11

7 12. Small SD, et al. Demonstration of high fidelity simulation team training for emergency medicine. Acad Emerg Med 1999;6: Marsch SCU, Schori C, Scheidegger DH, Harms C. Training complete operating room teams in the simulator enhances team performance in the real operating room. Anesthesiology 1999;91:A The National Institutes of Medicine, Committee on Equality of Health Care in America. To err is human build a safer health care system. Washington, DC: National Academy Press, Chan DC, Pruzler KB, Caughman WF. Simulation with preclinical operative dentistry courses 3 year retrospective results. J Dent Educ 2000;64(3): Green TG, Klausner LH. Clinic simulation and preclinical performance. J Dent Educ 1984;48: Suvinen TL, Messer LB, Franco E. Clinical simulation in teaching preclinical dentistry. Eur J Dent Educ 1998;2: DenX LTD, DenX Advanced Dental Systems, at denx.com, accessed September 4, Novint TM Technologies. Feel the future, at accessed September 4, Thomas G, Johnson L, Dow S, Stanford C. The design and testing of a force feedback dental simulator. Computer Methods Programs Biomed 2001;64: Johnson L, Thomas G, Dow S, Stanford C. An Initial Evaluation of the Iowa Dental Surgical Simulator. J Dent Educ 2000;64(12): Rose JT, Buchanan JA, Sarrett DC. The DentSim system. J Dent Educ 1999;63(5): Stewart D, Gluch J, Hammrick P, Buchanan J. Virtual reality technology versus traditional preclinical lab: perceptions of first-year dental students. J Dent Educ 1998;63(1): Gluch J, Stewart D, Buchanan JA. Virtual reality technology in preclinical laboratory: differential student responses based on learning styles. J Dent Educ 1999;63(1): Mante F, Mante M, Smithgall F, Abu-Hanna A, Weintraub G, Buchanan J. Customization of a virtual reality system for use in dental education. J Dent Educ 1999;63(1): Buchanan J, Gluch J, Stewart D, Abu-Hanna A, Mante M, Mante F, Hammrick P. Use of virtual reality based technology in teaching dental operative procedures. J Dent Educ 2000;64(3): Buchanan J. Overview of three years experience with virtual reality based technology in dental education. J Dent Educ 2001;65(1): Personal communication with Dr. Alice Urbankova, Department of Operative Dentistry, Head of DentSim Research, Columbia University. July 12, Johnson LA, Wohlgemuth B, Cameron CA, Caughman F, Koertge T, Barna J, Schultz J. Dental Interactive Simulations Corporation (DISC): simulations for education, continuing education, and assessment. J Dent Educ 1998;62(11): NewMentor Group.Your dental education destination, at accessed September 4, November 2001 Journal of Dental Education 1231

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