The Influence of Computer-Assisted Instruction on Acquiring Early Skills in Intraoral Radiography

Transcription

1 The Influence of Computer-Assisted Instruction on Acquiring Early Skills in Intraoral Radiography W. Bruce Howerton, Jr., D.D.S., M.S.; Enrique Platin, M.S., Ed.D.; John Ludlow, D.D.S., M.S.; Donald A. Tyndall, D.D.S., Ph.D. Abstract: The purpose of this study was to determine if there was a significant difference in the diagnostic quality of the initial full-mouth series (FMS) exposed by first-year dental students after viewing a Computer Assisted Instruction (CAI) module on radiographic technique as compared to those who did not and to determine if students who used the CAI module expressed a preference to using it and would recommend its use prior to exposure. Fifty-nine first-year dental students were randomly selected and assigned to two groups (students who did not view a CAI CD and students who did) before exposing their initial FMS on a Dental X-ray Training and Teaching Replica (DXTTR ). For each radiographic series, a radiology faculty member determined the total number of error points based on performance criteria. The Wilcoxon Rank Sum Test was used to determine significance between the two groups, p =.05. After exposing the FMS, students in the second group completed a questionnaire to assess their preference for using the CAI CD. The Sign Rank Test was used to determine preference, p =.05. No significant difference in error points were found to exist between the two groups. Dental students who reviewed the CAI preferred using it and would recommend it to others before exposing their FMS. Dr. Howerton is a Fellow in Oral and Maxillofacial Radiology, Dr. Platin is Associate Professor, Dr. Ludlow is Clinical Associate Professor, and Dr. Tyndall is Professor, all in the Department of Diagnostic Sciences and General Dentistry, University of North Carolina School of Dentistry. Direct correspondence to Dr. W. Bruce Howerton, Department of Diagnostic Sciences and General Dentistry, University of North Carolina School of Dentistry, Chapel Hill, NC ; phone; howertob@dentistry.unc.edu. Reprints will not be available. Key words: dental radiography, computer-assisted instruction, dental education Submitted for publication 2/27/02; accepted 8/6/02 An increase in the adoption of computer technology in dental education has allowed the conventional lecture format to be augmented with computer-assisted instruction (CAI). 1-8 With the affordability of robust hardware and authoring software, dental educators have the ability to create teaching modules that allow students to interact with information whenever and as often as desired. It has been demonstrated that CAI is comparable to conventional lecture and preferred by students Most studies dealing with CAI have concentrated on didactic instruction, but little has been reported on the effectiveness of CAI in the clinical setting. Purpose This study had two purposes: to determine if a significant difference existed in the quality of the radiographs produced by first-year dental students after having studied a CAI interactive intraoral radiography module as compared to a group that had not, and to determine whether students who used the CAI module preferred it and would recommend its use. The null hypothesis was that the quality of radiographs produced by first-year dental students was not significantly different whether or not CAI was used and that students had no preference in using CAI when exposing the initial full mouth series (FMS). Methods and Materials Approval of this study was obtained from the Committee on Research Involving Human Subjects (Institutional Review Board for the UNC School of Dentistry). Then we asked sixty-eight first-year dental students, graduating class 2004, enrolled in Fundamentals of Dental Radiology to take part in the study, though they were also given the option not to participate. The course emphasizes the fundamental theory and practice of radiology as it applies to dentistry. In addition, it requires the student to complete a preclinical laboratory exercise to develop practical 1154 Journal of Dental Education Volume 66, No. 10

2 skills in intraoral radiography. Students are required to expose an FMS on a DXTTR in the laboratory using the Extension Cone Paralleling Device (XCP). Students were randomly assigned to a group using computer software that listed the names in random order. No exclusions were based on age, race, or gender. The first thirty-four students listed were assigned to Group 1 (students not exposed to CAI before exposing the initial FMS) and the remaining students were assigned to Group 2 (students who reviewed the CAI guide before exposing the initial FMS). We administered a survey to determine which students had previous experience using the XCP Instrument and excluded from the study the five students who reported this experience. Thus, sixty-three students remained in the study. Prior to the preclinical laboratory session, Group 2 was given an interactive computer-assisted instructional module on CD. No restrictions were placed on the number of times the CD could be viewed, and students were reminded several times by to view the CD. Authoring software (Director 8, Macromedia Inc., San Francisco, CA) was used to create the interactive presentation. The content of the multimedia instruction focused on intraoral radiography featuring use of the XCP Instrument and exposing, developing, and mounting dental radiographs. After an introduction to the advantages of a beam-guiding device for intraoral radiography, the presentation was divided into three sections: instrument armamentarium, technique, and film mounting. Instrument armamentarium covered instrument assembly for posterior, anterior, and bitewing radiographs. Technique was divided into three sections (posterior, anterior, and bitewing radiographs) with each section covering anatomical landmarks, clinical use of the instrument, film processing, and nomenclature. Finally, a film mounting exercise tested the student s ability to correctly place a full series of radiographs into a mount. Video clips were created (QuickTime, Apple Computers Inc., Cupertino, CA) with a digital camcorder (JVC DVL 9500, JVC Co. of America, Wayne, NJ) and video editing software (Adobe Premier 5.1, Adobe Systems Inc., San Jose, CA) to capture, edit, and export digital video. Photographs were taken using a digital camera (Kodak DC 120, Eastman Kodak Co., Rochester, NY) and images were enhanced (Adobe Photoshop 5.5., Adobe Systems Inc., San Jose, CA and LivePix 2.0, Roxio, Inc., Milpitas, CA). The multimedia program was constructed using a workstation or personal computer that met or exceeded the processor speed, RAM, and hard drive storage requirements of the software. The authoring multimedia instruction consisted of twenty-seven separate movies incorporating techniques such as cursor rollover, cast member exchange, sprite tweening, onion skinning, and video clip insertion to allow the student to interact freely with the information. Three instructors from the Oral and Maxillofacial Radiology Section, two graduate Oral and Maxillofacial Radiology residents, and a second-year undergraduate dental student who had completed the course the preceding year reviewed the completed multimedia program. Following the review process, corrections were made, and the multimedia material was placed on CD-ROM discs. Examples of this interactive multimedia may be found at The Computer Assisted Instructional guide was created to differ from traditional teaching style and delivery method. Lecture content was not merely placed on a CD, but was integrated using a variety of authoring tools (animated diagrams, video clips, and full series mounting exercises to name a few). Our goal was to accommodate different learning styles and promote greater learning satisfaction than was attainable with lecture alone. Also, the CAI was produced using hardware and software readily available to the dental educator. During the didactic radiology course, students were instructed on the benefits of using XCP Instruments to produce diagnostic intraoral radiographs. Following the lecture, students were assigned to small groups to expose a full mouth series of radiographs on a DXTTR mannequin. See Figure 1 for the number of images, film sizes, and regions imaged. The UNC radiographic performance was used to evaluate the images. 11 One week after exposing and processing the image receptors, we instructed students to mount their films and write their student number at the top of the mount for anonymity. Subsequently, each mount was scanned at 300 dpi for later evaluation. Eighteen images from each full mouth series were evaluated by a clinical radiology faculty with many years of experience in grading full mouth series. The images were viewed on a twenty-one-inch monitor using Photoshop 5.5 without image enhancement in a dimly lit room. Each radiographic survey was evaluated using the UNC FMS radiographic criteria, and the number of errors (points) for each series was totaled (Table 1). October 2002 Journal of Dental Education 1155

3 Figure 1. Scheme for radiographic full mouth series After the students had exposed a full mouth series, they were surveyed on their opinions about various CAI features and whether or not they would recommend the CAI to others. (See Table 2.) In question 1, the responses were ranked by the amount of time spent reviewing the CD. However, the responses for statements 2-5 were ranked using a Likert scale. The Wilcoxon Rank Sum Test was used to determine significance between the two groups, and the Sign Test was used to determine significance for the evaluation instrument (statements 2-5). The level of significance for the Wilcoxon Rank Sum Test and the Sign Test was.05. Results As a result of data lost during the scanning, saving, and retrieval of the full mouth series of radiographs, four students were eliminated from the study, reducing the number to fifty-nine (thirty students without the CD and twenty-nine with it). Of Table 1. Types of errors and points for each series Abbreviation Error Error Point(s) B Exposed backwards 10 Mt Mounted incorrectly 5 D Density 1 H Horizontal angulation 1 P Packet placement 1 Mv Movement 1 OK Clinically acceptable 0 T Translation 1 Pr Processing error 1 C* Cone cut 1 V Vertical 1 * Cone cut requires one or more modifiers (H, V, T) to indicate vertical and/or horizontal angle error or translation of cone off film center. the four students whose data was lost, two were in the group that did not receive the CD, and two were in the group that did receive it. Because these students represent each group equally, data was lost randomly, and data was measured as median scores, there is no reason to suspect that the results would vary. Table 3 shows the median scores of the entire class: the group that did not view the CD before exposing the radiographs and the group that did. Because the data is non-parametric, exhibited a wide range of scores ( ), and had large standard deviations, significance was determined using median scores in the Wilcoxon Rank Sum Test. The Wilcoxon Rank Sum Test p-value was This suggested there was no difference between the groups using median scores. It should be noted that the CD group had an average median score of 2.5 more total error points than the non-cd group (15.0 vs. 12.5). Question 1 of the evaluation instrument inquired about the amount of time students spent reviewing the CD. Fifty-three percent of the students spent up to two hours and 23 percent of the students spent up to three hours reviewing the CD. Evaluation statements 2 through 5 inquired whether the CD was easy to navigate, helped the student to understand and visualize the radiographic exposure, and helped the student to set up and manipulate the XCP instruments and asked if students would recommend the use of the CD to others. The student responses are listed in numbers, percentages, and cumulative percentages in Table 2. In response to statements 2 through 5, almost all students strongly agreed or agreed with the responses. The Sign Test revealed p- values of < for each question, indicating that opening and navigating the CD was easy; the CD helped students understand and visualize exposure 1156 Journal of Dental Education Volume 66, No. 10

4 Table 2. Students opinions about the CAI Evaluation Instrument Responses 1. Approximately how much time did you spend N % Cum % reviewing the interactive XCP Instrumentation CD? 1. 0 hrs 2. < 1hr < 2 hr < 3 hrs > 3 hrs Opening and navigating the interactive N % Cum % XCP Instrumentation CD was easy. a. strongly agree b. agree The interactive XCP Instrumentation CD helped N % Cum % me to understand and visualize the exposure of a. strongly agree a full series of radiographs. b. agree The interactive XCP instrumentation CD helped me N % Cum % to set up and manipulate the XCP instruments. a. strongly agree b. agree I would recommend the use of this interactive N % Cum % CD for others to introduce the principles of a. strongly agree intraoral radiography. b. agree Table 3. Median scores of the entire class Students Total Error Points Per Full Series All Students Students without CAI CD Students with CAI CD of radiographs; the CD helped students set up and manipulate the XCP instruments; and students would recommend the use of the interactive CD to others. Discussion Dental educators using software (like Microsoft Office) to create electronic presentations, create electronic data spreadsheets, use word processors, and use electronic mailing recall the time required to learn the basic and intermediate fundamentals of the software. Authoring software (like Macromedia) also requires time to learn its capabilities. In the short term, it may be argued whether the extra time required to create the CAI guide that was used in this study was justified because the CD group did not make fewer clerical errors than the non-cd group. Measuring resulting group clinical errors is not the only influential factor of whether to use CAI. For example, many studies have documented that students enjoy CAI and preferred to learn using multimedia There is no consistent evidence in the literature that students trained with CAI retain information longer. The initial extra time to learn October 2002 Journal of Dental Education 1157

5 authoring software should not be a determining factor in deciding whether or not to use CAI. Further study is needed to determine whether students learn more quickly using CAI than traditional forms of teaching. After using Microsoft office and the authoring tools associated with creating the CAI guide, producing CAI educational material becomes more intuitive and less time intensive on the front end. The median error scores for students who used the CD were higher than students who did not. This suggests that dental students performing clinical tasks for the first time will perform differently based on previous eye-hand coordination experiences and natural ability regardless of additional didactic experiences (that is, CAI). In addition, regardless of previous motor skills and natural ability, students preferred using CAI before attempting clinical tasks for the first time. Further research is necessary to substantiate this anecdotal finding. Random informal conversation with students immediately after exposing their full mouth series revealed that those who received the CD felt confident in setting up and understanding how to use the instruments when exposing their first full series of radiographs. Students who did not receive the CD complained they were less prepared and took longer to complete the full series exercise. Their observations were not formally recorded in this study and therefore should be investigated further. Finally, a study using a larger population of subjects is required to substantiate the results of this study. Conclusion Computer technology in dental education is becoming more commonplace. To date, little information has been reported regarding the clinical effectiveness of CAI. Students who received an interactive CAI CD before exposing their initial full series of radiographs made more errors than those students who did not receive the CAI CD. However, those students who received the CAI CD preferred reviewing the CD and recommended the CAI CD to others. REFERENCES 1. Prokhonchukov AA, Milokhov KV, Pelkovskii VI, Kozyr kov SV. A universal computerized training system for the instruction in computer technologies of dentists, students and teachers in dental schools. Stomatologiia 1998;77: Grigg P, Stephens CD. Computer-assisted learning in dentistry: a view from the UK [Review]. J Dent 1998;26: Sellen P, Telford A. The impact of computers in dental education [Review]. Prim Dent Care 1998;l5: Preston JD. Computers in dental education. J Calif Dent Assoc 1997;Oct. 25: van Putten MC. Use of the Internet for educational applications in prosthodontics. J Prosthet Dent 1996;76: Demirjian A. Teaching dentistry in the 21st century. Compendium 1994;15: Deyton GS. Distance learning: an idea that may change the face of dentistry. Missouri Dent J 1993;73: Soh G, Keng SB. Applications of computer technology in dentistry [Review]. Ann Acad Med Singapore 1990;19: Ludlow JB, Platin E. A comparison of Web page and slide/ tape for instruction in periapical and panoramic radiographic anatomy. J Dent Educ 2000;64: Wenzel A, Gotfredsen E. Students attitudes towards and use of computer-assisted learning in oral radiology over a 10-year period. Dento-Max-Fac Rad 1997;26: Radiographic performance criteria. University of North Carolina School of Dentistry, Section of Oral Radiology. Chapel Hill, North Carolina. At: Accessed May 8, Lang WP. Trends in dental students knowledge, opinions, and experience regarding dental informatics in computer applications. JAMIA 1995;2(6): Feldman CA. Dental student experiences and perceptions of computer technology. J Dent Educ 1992;56(3): Journal of Dental Education Volume 66, No. 10