E-Learning Used in a Training Course on Atraumatic Restorative Treatment (ART) for Brazilian Dentists

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1 E-Learning Used in a Training Course on Atraumatic Restorative Treatment (ART) for Brazilian Dentists Lucila Basto Camargo; Janaina Merli Aldrigui; José Carlos Pettorossi Imparato, Ph.D.; Fausto Medeiros Mendes, Ph.D.; Chao Lung Wen, Ph.D.; Marcelo Bönecker; Daniela Prócida Raggio, Ph.D.; Ana Estela Haddad, Ph.D. Abstract: The purpose of this study was to assess the benefits of using e-learning resources in a dental training course on Atraumatic Restorative Treatment (ART). This e-course was given in a DVD format, which presented the ART technique and philosophy. The participants were twenty-four dentists from the Brazilian public health system. Prior to receiving the DVD, the dentists answered a questionnaire regarding their personal data, previous knowledge about ART, and general interest in training courses. The dentists also participated in an assessment process consisting of a test applied before and after the course. A single researcher corrected the tests, and intraexaminer reproducibility was calculated (kappa=0.89). Paired t-tests were carried out to compare the means between the assessments, showing a significant improvement in the performance of the subjects on the test taken after the course (p<0.05). A linear regression model was used with the difference between the means as the outcome. A greater improvement on the test results was observed among female dentists (p=0.034), dentists working for a shorter period of time in the public health system (p=0.042), and dentists who used the ART technique only for urgent and/or temporary treatment (p=0.010). In conclusion, e-learning has the potential of improving the knowledge that dentists working in the public health system have about ART, especially those with less clinical experience and less knowledge about the subject. Ms. Camargo is a Ph.D. student, Department of Pediatric Dentistry, Faculdade de Odontologia da Universidade de São Paulo, Brazil; Ms. Aldrigui is a Ph.D. student, Department of Pediatric Dentistry, Faculdade de Odontologia da Universidade de São Paulo, Brazil; Dr. Imparato is Associate Professor, Department of Pediatric Dentistry, Faculdade de Odontologia da Universidade de São Paulo, Brazil; Dr. Mendes is Associate Professor, Department of Pediatric Dentistry, Faculdade de Odontologia da Universidade de São Paulo, Brazil; Dr. Wen is Professor, Department of Pathology, Faculdade de Medicina da Universidade de São Paulo, Brazil; Dr. Bönecker is Chair, Department of Pediatric Dentistry, Faculdade de Odontologia da Universidade de São Paulo, Brazil; Dr. Raggio is Associate Professor, Department of Pediatric Dentistry, Faculdade de Odontologia da Universidade de São Paulo, Brazil; and Dr. Haddad is Associate Professor, Department of Pediatric Dentistry, Faculdade de Odontologia da Universidade de São Paulo, Brazil. Direct correspondence and requests for reprints to Ms. Lucila Basto Camargo, Av Lineu Prestes, 2227, São Paulo SP, Brazil; phone; fax; lucilaca@usp.br. Keywords: continuing dental education, e-learning, Atraumatic Restorative Treatment, caries, public health, Brazil Submitted for publication 6/28/10; accepted 2/21/11 Atraumatic Restorative Treatment (ART) was officially adopted by the World Health Organization in the 1990s. 1 It was originally proposed as a caries control system that could be used to treat millions of people in developing countries, who lived in poorer communities with no access to conventional dental treatment and no infrastructure. However, its use has gradually increased in private dental offices, and it is currently also being used in developed countries. According to the systematic review performed by Frencken et al., 2 no significant differences were found between the longevity of single-surface ART and amalgam restorations in permanent teeth after three years. Other studies with a follow-up period of six years have also shown that when using high viscosity glass ionomer cements, ART has better clinical results than conventional amalgam restorations. 3,4 A recent study assessing the longevity of restorations after ten years found that the ART technique has the potential to restore and save permanent molars. 5 Therefore, it is possible to state that ART is an important and effective evidence-based treatment to manage single-surface caries lesions. The ART approach presents many advantages, such as shorter clinical sessions and a reduced cost of treatment. 6 This is important for public health systems, including the one in Brazil where there is high treatment demand, low treatment offer, and limited financial resources. When the advantages of ART are aligned with the characteristics of the Brazilian public health system, it is expected that the use of ART will bring many benefits to the population and reduce inequities in care provision Journal of Dental Education Volume 75, Number 10

2 The first and fundamental step to introduce ART to a health system is the training of oral health professionals, allowing them to understand the philosophy and techniques used in ART. Mickenautsch et al. 7 investigated the barriers encountered when using ART in the public health system in South Africa and found that professionals lack the ability to execute the technique, even after training. The study was based on a relatively short training course, which may explain the participants lack of skills. Since ART is an evidence-based approach with many advantages, 2-4 dentists should have good knowledge and be confident in using this technique in daily clinical practice. In fact, one of the most important barriers of evidence-based medicine lies in persuading professionals to introduce treatments with strong evidence into clinical practice. 8 Well-structured courses using an e-learning approach could offer a means for solving this problem. This form of pedagogy combines communication instruments and the teaching-learning process. E- learning enables educational processes to be carried out with teachers and students who are physically distant. It has high acceptability among students, and it promotes ample autonomy on how, where, and when the student will dedicate himself or herself to the educational process. 9 Therefore, this kind of education can reach remote areas with difficult access. Because of these characteristics, e-learning becomes highly appealing to dentists from the public health system, as they have fixed working hours and usually work far from big cities. A concern about distance education is the possibility that students could face technical difficulties that may hinder the learning process mediated by technology. Also, distance education courses require teaching resources that are specifically developed for this purpose. Furthermore, this teaching method requires significant levels of student motivation and responsibility. Therefore, our study aimed to assess the potential of a training course using e-learning resources to teach ART to dentists from the public health system in Brazil. Materials and Methods This study was approved by our university s Research Ethics Committee. The participating dentists received written information about the study and signed a positive consent form. The DVD training course in ART used in the study had been developed earlier by a research team from the Department of Pediatric Dentistry and Department of Telemedicine of the University of São Paulo. This course combined five resources. First, the Virtual Man project was used to illustrate the development of carious lesions and the clinical sequence of ART restorative procedures. 10 Its purpose was to clarify the clinical characteristics of outer and inner dentin layers to facilitate understanding of the concept of partial caries removal, showing a student-friendly step-by-step technique. The Virtual Man project from the Telemedicine Discipline at the University of São Paulo is based on the concept of learning objects and combines images in movements of high visual quality. Second, a clinical video explained the selection and organization of instruments, the execution of clinical steps, and the dosing and handling of the restorative material (glass ionomer cement). In this video, two children, aged seven and ten years, with occlusal and approximal caries lesions in primary molars, were treated. Third, interviews with ART experts were shown to emphasize the most important aspects of ART: its history and conceptualization, diagnosis, indication and clinical steps, preventive program establishment, and ART use in public health. Fourth, photographs and radiographs were used to support discussion of clinical cases, and, fifth, scientific literature was made available in PDF format. These learning resources were developed by a team of professionals from various areas including digital design, communication studies, information technology, and dentistry. They were edited and organized to create a course of approximately forty minutes. Moreover, the dentists were able to interact with the DVD and choose the topic to be studied. The participants in the study were twenty-six dentists from the public health service in seven cities near São Paulo. This study took place at the University of São Paulo, where the dentists were undergoing monthly attendance meetings as part of a continuing education course. Twenty-four of the twenty-six dentists who participated in the first assessment concluded all stages of the research, yielding a response rate of 92.3 percent. To establish the participants profile, the dentists answered a multiple-choice questionnaire at baseline. This questionnaire gathered information on the dentists initial knowledge of ART, their belief in the treatment technique, and their interest in the e-learning course. October 2011 Journal of Dental Education 1397

3 Data about gender, age, educational background, time elapsed since their graduation, and time they had been working in the public service were also recorded. The educational process was carried out as shown in Figure 1. As depicted in the flow diagram, the dentists participated in the assessment process consisting of multiple-choice questions and written tests that were applied at two distinct moments: before (Assessment 1) and after (Assessment 2) the course. The test contained three sections. Section 1 focused on theoretical/conceptual/cognitive skills, with fifty phrases that were either true or false. The multiple-choice questions addressed various topics of ART. Section 2, a written test, focused on cognitive reasoning-contextualization, with five possible clinical situations illustrated with photographs and radiographs. Section 3, a written test regarding practical observation, consisted of five short films from clinical videos and/or the Virtual Man project. These film sections were exhibited twice for all participants at the same time, with an interval of thirty seconds between each exhibition. The aim of the three sections combined was to assess the dentists theoreticscientific knowledge on the subject, assess their ability to make decisions in different circumstances, and test their ability to identify important aspects in different ART-related situations and procedures. The maximum time allowed for each section was thirty-five minutes. 1 st Attendance Meeting (October 2009) Answering the initial questionnaire Answering before assessment Handout of the DVD Period for the e-learning course (approximately 30 days) 2 nd Attendance Meeting (November 2009) Answering after assessment Figure 1. Flow diagram showing the dynamics of the e-learning process on ART Considering the subjectivity involved when correcting the written answers in sections 2 and 3, the researchers underwent a calibration exercise. For this exercise, two researchers independently answered the test, trying to identify the main points that should be considered from the dentists answers and, therefore, make the correction procedure as objective as possible. Five tests, answered by the dentists, were then randomly selected to be independently corrected by both researchers. The corrections from both researchers were later compared question by question. When diverging grades arose, the researchers discussed the correction methods used and established a consensus. After that, only one calibrated researcher (L.B.C.) corrected all tests (n=68). To determine intraexaminer agreement, this researcher repeated the correction procedure in 10 percent of the sample (seven different tests that were not in the calibration phase) after a three-month interval. The kappa test was used to calculate the intraexaminer agreement, and a paired t-test was used to compare the means between grades from before and after the assessment. A linear regression model was applied, considering the difference between the means from before and after the assessment, to find possible associations between the studied variables. The significance level was set at 5 percent. Results Data from the initial questionnaire are summarized in Tables 1 and 2. The correction of the tests was carried out by a single researcher, and a weighted kappa test was used to calculate the intraexaminer reproducibility (high agreement rate: 0.89). A paired student s t-test showed a significant difference (p<0.05) between the first and second assessments. The median result for the first assessment was 5.8, while for the second the median was 7.4. This means that the course had a positive result on the dentists learning about ART. To establish associations between the studied variables, a linear regression model was used, using the difference between the means from the first and second assessments. The results showed that a better performance in the ART course was significantly associated with the female gender, a shorter time of work in the public health service, and those who used ART only for urgent and/or temporary treatments (Table 3) Journal of Dental Education Volume 75, Number 10

4 Discussion Elementary school teachers in Brazil are specially trained for e-learning skills by the E-learning Secretariat of the Brazilian Ministry of Education. 11 Also, the Ministry of Health has created the Brazilian Telehealth Program, which focuses on the training of health professionals working in the country s public health service. These health professionals usually work in remote areas and do not have the opportunity to attend courses. However, studies on the efficiency of courses directed towards health professionals are still necessary. Our study aimed to assess the potential of an e-learning course to enable dentists who work in the public health service to carry out ART. Dentists trained in the ART approach provide the general population with a treatment that aligns educational and restorative actions and also provides a less painful and quicker treatment. In general, the coverage of dental treatments would increase with more ART treatment. The twenty-six dentists who took part in this study work in the public health service in seven cities near São Paulo. These professionals are involved in a technical-scientific partnership between the municipal Public Health Services and the Department of Pediatric Dentistry at the University of São Paulo. Therefore, they have monthly meetings at the university for training and courses. It was observed that most of them approve of the ART approach (95.8 percent defend the treatment and 91.7 percent recommend it to be used in the general public) and they are in favor of courses directed towards professionals who work in the public health service (58.3 percent alleged lack of training and 100 percent considered that further courses were necessary). One other important response observed in the sample concerned the age of the participants. Since ART was adopted by the World Health Organization during the 1990s and e-learning is a relatively new approach to education, it was hypothesized that younger dentists would be more comfortable with the new techniques and technology, and thus age would be a relevant variable on the professionals performance after the course. Carbonaro et al. 12 found that age differences can cause different initial performance in e-learning courses, yet this tends to decrease once older students get a good grasp of cyberspace. Moreover, for a successful e-learning course, high levels of self-motivation and self-discipline are necessary, and this is usually found in older students. In our study, we could not find any association with age. In this study, a computer technician was available to all participants to ensure that each one could complete the course. Any participant with technical problems could contact this professional as needed. Although some dentists mentioned having difficulties with personal computers, they did not need the technician to resolve the problem. It may be suggested that one difficulty encountered in the study was the assessment of the dentists. Miller 13 argued that, to accomplish the complex task of assessing a professional, it is important to consider the many different levels involved in the learning process, ranging from knows (knowledge) to knowhow (competence) to shows how (performance) to does (action). In addition, Miller states that tests of the knowledge level are important but are incomplete, as there is more to clinical practice than knowledge. Therefore, it is also necessary to assess if individuals have a good grasp of the acquired knowledge, which is the competence level. The other two levels are clearly more difficult to assess, but also need some attention. In our study, assessment was mainly focused on the second level of learning (competence). Assessing a professional s competence goes beyond testing acquired knowledge. New references must be searched to identify, promote, and manage the Table 1. Personal data from the dentists involved in the study Age (years) Median (range) 43 (28 57) Gender Male 5 (20.8%) Female 19 (79.2%) Time since graduation (years) Median (range) 20 (6 34) Time working in the public health system (years) Median (range) 16 (5 22) Higher education background Graduation 11 (45.8%) Specialization 11 (45.8%) Master s degree 1 (4.2%) Did not answer 1 (4.2%) October 2011 Journal of Dental Education 1399

5 knowledge needed for professionals to face situations with initiative and responsibility. The assessment we used was a test in three sectors, thus verifying the professionals theoretical-scientific knowledge, observational capacity, and decision making ability. Table 2. Dentists level of belief in the ART approach and their interest on the course Frequency n (%) Had used ART before 12 (50%) Never used ART 12 (50%) Lack of training 14 (58.3%) Lack of restorative material 0 Negative previous experience 1 (4.2%) Did not answer 9 (37.5%) Defends ART 23 (95.8%) Does not defend ART 1 (4.2%) Uses only as urgent/temporary treatment 7 (29.2%) Uses as definite treatment 17 (70.8%) Had theoretical training 13 (54.2%) Had theoretical and practical training 0 Had no training 11 (45.8%) Feels the need for necessary training on 24 (100%) the public health system Does not feel the need for training on 0 public health system Recommends ART to be used 22 (91.7%) Does not recommend ART to be used 2 (8.3%) Our results demonstrate that a significant improvement in the dentists knowledge occurred after using the e-learning course on ART. This improvement suggests that a well-structured e-learning course can be a good way to introduce new treatment strategies into clinical practice, which is one of the main barriers in evidence-based medicine and dentistry. However, it is still not possible to determine whether these dentists will use this treatment in their daily clinical practice, so longer term studies should be conducted to determine the implementation of new knowledge. Some studies that have assessed e-learning 9,14,15 found that it can enhance the learning experience when used as a support to conventional teaching. However, the aim of our study was to assess the potential of a course using e-learning resources that does not promote teacher-student interaction. Theoretically, although the lack of student interaction with a live educator could limit the learning process, it also presents many advantages, especially for health professionals scattered throughout the country who are not able to attend courses as well as for the populations treated by them. Our course was a simple, low-cost way to prepare dentists to use ART. Moreover, it offers easy access to information as it is only necessary to provide the DVD and a computer to those working in the public health service. Even in the absence of interaction between the course teachers and the dentists, the comparison between Table 3. Linear regression model using the difference between the means from pre and post assessments Variable Category n β SE p Gender Male 5 Female 19 Time since graduation 15 years 7 >15 years 16 Higher education background Graduate 11 Postgraduate 12 Time in public health service Less than 10 years 8 More than 10 years 16 Use of ART Use or have used before 12 Never used 12 Defend ART Yes 23 No 1 Indication for ART Urgent/temporary treatment 7 Restorative treatment 17 Type of training Theoretical 13 Theoretical and practical 10 β=linear regression; SE=standard error Journal of Dental Education Volume 75, Number 10

6 the means from the first and second assessments show that this DVD course represented a significant benefit to the professionals. The associations found in the linear regression model, considering the difference between the means, showed that professionals who had worked for less time in the public health service and those who used ART only as an urgent/temporary treatment showed a better performance in the course. This is relevant information as it is expected that less-prepared students will gain greater benefits when submitted to a well-structured course. The fact that this study was carried out with professionals with some interest in training courses, as they commuted monthly to the university for the meetings, may suggest that these results are overestimated. To assess whether this is the case, another study with the whole population of dental professionals in the public health service from another city near São Paulo is currently in progress. The advantages gained from this type of e- learning course include the ability to reach dentists in remote areas and increase the number who can be educated compared to those participating in traditional courses. We thus conclude that e-learning has the potential to efficiently train and educate oral health professionals. REFERENCES 1. World Health Organization. Atraumatic restorative treatment (ART) for tooth decay. Geneva: World Health Organization, Frencken JE, van t Hof MA, van Amerongen WE, Holmgren CJ. Effectiveness of single surface ART restorations in the permanent dentition: a meta-analysis. J Dent Res 2004;83(2): Frencken JE, Taifour D, van t Hof MA. Survival of ART and amalgam restorations in permanent teeth of children after 6.3 years. J Dent Res 2006;85(7): Frencken JE, van t Hof MA, Taifour D, Al-Zaher I. Effectiveness of ART and traditional amalgam approach in restoring single-surface cavities in posterior teeth of permanent dentitions in school children after 6.3 years. Community Dent Oral Epidemiol 2007;35(3): Zanata RL, Fagundes TC, Freitas MCCA, Lauris JRP, Navarro MFL. Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Invest 2011;15(2): Estupinan-Day S, Milner T, Tellez M. Oral health of lowincome children: procedures for atraumatic restorative treatment. Final report. Washington, DC: Pan American Health Organization, Mickenautsch S, van t Hof MA, Frencken JE. Oral health service systems in Gauteng Province, South Africa. East Afr Med J 2007;84(4): Hofer TP, Zemencuk JK, Hayward RA. When there is too much to do: how practicing physicians prioritize among recommended interventions. J Gen Intern Med 2004;19(8): Reynolds PA, Rice S, Uddin M. Online learning in dentistry: the changes in undergraduate perceptions and attitudes over a four-year period. Br Dent J 2007;203(7): Böhm GM, Wen CL. Virtual man project. At: Accessed: June 28, Moore M, Kearsley G. Educação à distância: Uma visão integrada (E-learning: an integrated point of view). São Paulo: Cengage Learning, Carbonaro M, Dawber T, Arav I. A comparison of students performance under full-time, part-time, and online conditions in an undergraduate nursing microbiology course. J Distance Educ 2006;21(1): Miller GE. The assessment of clinical skills competence/ performance. Acad Med 1990;65(Suppl 9): Boyton JR, Green TG, Johnson LA, Nainar SMH, Straffon LH. The virtual child: evaluation of an Internet-based pediatric behavior management simulation. J Dent Educ 2007;71(9): McCann AL, Schneiderman ED, Hinton RJ. E-teaching and learning preferences of dental and dental hygiene students. J Dent Educ 2010;74(1): October 2011 Journal of Dental Education 1401

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