To have clinically competent dental practitioners,

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1 Patient Demonstration Videos in Predoctoral Endodontic Education: Aspects Perceived as Beneficial by Students Hadeel Y. Edrees, BDS, MSc; Johan Ohlin, DDS, MSc; Michael Ahlquist, PhD; Mesfin K. Tessma, PhD; Nabil Zary, PhD Abstract: The aim of this study was to assess the perceived benefits of video-mediated demonstrations in learning endodontics. Participants in the study were 75 third-year students enrolled in the undergraduate dentistry program at Karolinska Institute, Stockholm, Sweden. After the endodontic preclinical course, the students were introduced to the treatment protocol in the clinic by watching two live patient-demonstrated videos. The first video demonstrated how to communicate with the patient and perform diagnosis and root canal instrumentation. The second video illustrated how to perform bacterial sampling and root canal filling. After the students watched each video, a questionnaire was used to evaluate their opinions about various steps of the endodontic treatment protocol and the benefit of such educational material for their practice. Of the total 75 students, 72 completed the first questionnaire (96% response rate), and 65 completed the second questionnaire (87% response rate). The results showed that the students perceived high value in the video demonstrations related to treatment procedure. A statistically significant difference was observed between the perceived benefits of the first and second sessions in communication and treatment procedure (p<0.001). Further studies are needed to assess improvement in the design and delivery format for video demonstrations to enhance their effectiveness as a teaching modality for endodontics. Dr. Edrees is Assistant Professor, Department of Endodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia; Dr. Ohlin is Lecturer and Assistant Senior Dentist, Division of Endodontics, Department of Dental Medicine, Karolinska Institute, Stockholm, Sweden; Dr. Ahlquist is Associate Professor and Head of Endodontic Division, Department of Dental Medicine, Karolinska Institute, Stockholm, Sweden; Dr. Tessma is Lecturer, Department of Learning, Informatics, Management, and Ethics, Karolinska Institute, Stockholm, Sweden; and Dr. Zary is Associate Professor and Director of the Centre for Learning and Knowledge, Karolinska Institute, Stockholm, Sweden. Direct correspondence to Dr. Hadeel Y. Edrees, Department of Endodontics, Faculty of Dentistry, King Abdulaziz University, P.O. Box 50737, Jeddah, Saudi Arabia; ; hedrees@ kau.edu.sa. Keywords: dental education, endodontics, clinical skills, teaching method, educational technology, video-mediated demonstration Submitted for publication 3/25/14; accepted 10/2/14 To have clinically competent dental practitioners, students need to develop sound clinical judgment and technical skills through their education, including lectures, seminars, and reading assignments. These teaching methods provide important fundamental information in dental education. However, they may not be as effective in teaching the technical aspects of clinical procedures. 1 Video-based learning in dentistry has been documented for teaching technical skills and simulating clinical situations. 2,3 The introduction of videobased learning has overcome many limitations in dental teaching: for example, the limited operating space, the small size of an oral cavity, and the detailed nature of most dental procedures. Students often find it difficult to get a clear view of the operating field during a live clinical demonstration. 1,4 With the decline in patient numbers, coupled with a shortage of instructors, an increase in student numbers, and heightened treatment complexities, it became difficult for instructors to meet the educational needs of dental students. 5,6 Video learning can assist instructors in their teaching efforts, especially for a large audience. These videos can also be used to promote self-directed learning since students can view prerecorded clinical procedures prior to performing on live patients. 7 Video-based learning has been shown to be effective in various aspects of dentistry. One study found that the use of video-based teaching enhanced application of a number of behavior-modifying techniques in pediatric dentistry, 8 while others showed that instructional videos aided in the teaching of fixed prosthodontics and removable partial dentures In the field of endodontics, the value of new technology is generally accepted, including the surgical operating microscope and the use of videos for teaching postgraduate students. 12 Students have varying learning curves for the steps of endodontic treatment, including patient communication, diagnostic reasoning, and the procedure for filling root canals. In 928 Journal of Dental Education Volume 79, Number 8

2 a study comparing four simulation and instructional methods for endodontic review (slide tape, latentimage simulation, computer text simulation, and computer-assisted video-interactive simulation), the results showed that students in the simulation group made fewer diagnostic errors compared with those in the control group. 13 However, the error reduction in clinical treatment was not significantly reduced between the two groups. A systematic review of the use of computerassisted learning (CAL) in endodontic education concluded that CAL is useful to support traditional learning methods but not to replace them. 14 Video patient demonstrations in endodontics could be beneficial as well. However, little is known about the impact of video-based demonstrations on endodontic students learning, including efficiency compared to lectures, optimal content and design, and tangible student benefits. The aim of this study was to assess students perceived benefits of video-mediated learning in endodontics in four major areas: patient communication, diagnosis, bacterial sampling, and treatment procedure. Methods The study was conducted at the Department of Odontology, Karolinska Institute (KI) in Stockholm, Sweden, using videos to teach the steps of endodontic treatment when third-year students were taking the endodontic preclinical course. The eight-week course was mainly comprised of lectures and laboratory work. The KI review board exempted the study from a formal comprehensive review. A cohort of a class of 75 third-year undergraduate dental students was enrolled in the study. The project had two video-mediated demonstrations. The first video was 90 minutes in length and addressed three parts of endodontic treatment: patient communication, diagnosis of pulp, and periapical disease and root canal instrumentation. The second video, which lasted 30 minutes, was also divided into three segments: patient communication during the second visit, bacterial sampling, and root canal filling. The demonstration, recorded on videotape, was custom-made and contained the necessary information to enable the students to carry out and check each procedure. The participants watched the videos in two consecutive sessions with a one-week break in between. The commentary for the procedures was recorded simultaneously. Questionnaires were developed for each video to assess the perceived benefits of the two videomediated demonstrations. The questionnaire for the first video consisted of 17 items, while the questionnaire for the second video consisted of 16 items. Each item had a general question followed by a statement. The general question was How much benefit was the video to you for the following? Each item had four response options: very little benefit, little benefit, large benefit, and very large benefit (see Table 1 for examples). Descriptive statistics were presented as percentages. A four-point scale was used, which is an ordinal variable. This ordinal variable was dichotomized as yes and no. Response categories of very little and little were classified as no, and response categories of large and very large were classified as yes. The internal consistency of the items was esti- Table 1. Examples of survey items for rating benefit of an area after watching the video demonstration 1. Communication How much benefit was the video to you for the following: A. Telling the patient about the procedure 1. Very little benefit 2. Little benefit 3. Large benefit 4. Very large benefit 2. Diagnosis How much benefit was the video to you for the following: A. Performing a sensibility test for the tooth 1. Very little benefit 2. Little benefit 3. Large benefit 4. Very large benefit 3. Treatment How much benefit was the video to you for the following: A. Determining the working length for the tooth you re treating 1. Very little benefit 2. Little benefit 3. Large benefit 4. Very large benefit August 2015 Journal of Dental Education 929

3 mated by the Cronbach s alpha coefficient. A sign test was performed to examine differences between the first and second video demonstrations. Results Of the total 75 students, 72 completed the questionnaire after the first video (96% response rate), and 65 completed the questionnaire after the second video (87% response rate). The Cronbach s alpha was 0.86 for the first questionnaire and 0.77 for the second questionnaire. The students rated the video demonstrations related to treatment procedure as having high value. A statistically significant difference between the perceived benefits of the first and second sessions in communication and treatment procedure was observed (p<0.001). For the first video, 80% of the respondents perceived its benefit as high (combination of large and very large benefit) for teaching them about greeting (in the communication category) (Table 2). In the diagnosis category, 62% of the respondents perceived that video s benefit as high for teaching them about the sensibility test. In the root canal instrumentation category, 86% of the respondents perceived that video s benefit as high for teaching them about sterility. For the second video, only 22% of the respondents perceived its benefit as high (combination of large and very large benefit) for teaching them about greeting (in the communication category) (Table 3). In bacterial sampling, 48% of the respondents perceived this video s benefit as high for teaching them about effect of air on irrigation, in contrast with 80% who perceived its benefit as high for teaching them about sample fluid. In the category of root canal obturation, the area for which students perceived that the video provided the greatest benefit was removal of intracanal medication, with 88% of respondents reporting it was of large or very large benefit. Discussion The findings from this study support the results of previous studies on the benefits of these videos in demonstrating clinical skills. 2,9 However, other studies have shown that videotaped and live demonstrations produce little difference in student learning of dental procedures 10 and that it is just one factor in how students develop competence. 15 The following paragraphs address the relevant findings of this study for each area in endodontic treatment. Teaching Communication Skills When students evaluated the communication area for the first video, the percentage of benefit was 80%, while for the second video it decreased to 22%, a significant difference (p<0.001). Although the benefit of the second video in communication was not as high as the first, it should be noted that repeating a procedure could help students gain more knowledge in areas they missed from the first video. This observation is in agreement with a study by Kalwitzki et al. related to pediatric dentistry, which showed the use of video could be recommended for teaching communication patterns although it may not provide additional benefits over a traditional lecture. 16 This could be because what was transmitted in the course was not the actual communication pattern but the idea of making use of video in a clinical situation in this field of study. Teaching How to Perform a Diagnosis Diagnosis and clinical reasoning are complex skills and cannot be covered by only one video or one scenario. Some current educational trends make the assumption that students will learn to reason merely by listening to and/or observing an expert, reinforcing the theory of learning clinical reasoning by osmosis/ diffusion. 17 But another study found that useful strategies to facilitate the development of clinical reasoning abilities include providing guidance that extends learners beyond their independent ability, featuring observation and modeling, and creating open discussion with feedback. 18 Those findings indicate that learning to reason accelerates when courses blend an explicit socializing process rather than relying on passive and incidental learning. Since diagnosis cannot be covered in patient video demonstrations, other means of reinforcements should be used to promote effective learning, like virtual patient education (VPE) and multimedia patient simulation. A study of the use of VPE in periodontology found that students who practice with a virtual patient prior to their first patient encounter behave more knowledgeably and professionally compared with students who undergo only routine teaching concerning the history of dental patients. 19 Another study concluded that using a multimedia patient simulation 930 Journal of Dental Education Volume 79, Number 8

4 Table 2. Evaluation of the first video in patient communication, diagnosis, and root canal instrumentation, by degree to which respondents reported the video was a benefit (n=72) Total Large and Question Very Little Little Large Very Large Very Large Communication Greeting 17% 4% 31% 49% 80% Information on procedure 31% 22% 35% 12% 47% Use of anesthesia 10% 26% 33% 31% 64% Diagnosis Sensibility test 11% 25% 40% 22% 62% Other test 31% 35% 19% 15% 34% Treatment: root canal instrumentation Sterility 8% 6% 25% 61% 86% Working length 8% 21% 40% 31% 71% Verifying working length 8% 32% 38% 22% 60% Instruments and files 17% 26% 38% 19% 57% Cleaning and shaping 15% 32% 26% 27% 53% Canal irrigation 12% 38% 29% 21% 50% Irrigation material 12% 28% 31% 29% 60% Use of lentulo 18% 11% 32% 39% 71% Preparation for intracanal medication 26% 18% 25% 31% 56% Design for lentulo 21% 14% 37% 28% 65% Preparation for temporization 17% 18% 35% 31% 66% Temporization 22% 22% 25% 31% 56% Note: Percentages may not total 100% because of rounding. Table 3. Evaluation of the second video in patient communication, bacterial sampling, and root canal obturation, by degree to which respondents reported the video was a benefit (n=65) Total Large and Question Very Little Little Large Very Large Very Large Communication Greeting 65% 14% 5% 17% 22% Bacterial test Rubber damp sealing 21% 22% 28% 29% 57% Adding sample fluid 9% 11% 35% 45% 80% Collecting sample fluid 32% 9% 39% 20% 59% Effect of air on irrigation 40% 12% 25% 23% 48% Labeling 21% 19% 38% 22% 60% Treatment: root canal obturation Temporization removal 9% 11% 35% 45% 80% Removal of intracanal medication 6% 7% 28% 60% 88% Sealing material 29% 8% 15% 48% 63% Technique for instrumentation 23% 15% 25% 37% 62% Working with assistant 34% 12% 14% 40% 54% Final irrigation 8% 6% 25% 61% 86% Alcohol irrigation 23% 26% 22% 29% 51% Drying canals 14% 15% 31% 40% 71% Mixing sealer 17% 18% 26% 39% 65% Cutting gutta percha 15% 14% 28% 43% 71% Note: Percentages may not total 100% because of rounding. August 2015 Journal of Dental Education 931

5 for teaching endodontic diagnosis offers a promising alternative for teaching and assessing student diagnostic skills. 20 Such a multimedia patient simulation demonstrates a well-defined diagnostic task, then supplies informative feedback and opportunities for repetition and correction of errors. Teaching the Treatment Procedure Previous knowledge of the subject could have an effect on the outcome of this study. 13 The students found great benefits in observing the treatment procedure. This could be because they were shown how to perform the root canal cleaning, shaping, and root filling from their laboratory course before they were introduced to the videos, while in the diagnostic and communication phases, this was their first exposure to the subject following lectures. However, some elements in the technical treatment procedures did not score high percentages, such as temporization and irrigation materials in the first video. This would indicate that the students might not benefit from repeating easy tasks. It has frequently been discussed how much repetition is required for students to acquire sufficient knowledge and skills to adequately and independently resolve dental problems. In one of those discussions, Plasschaert et al. concluded that the individual characteristics of a student and the level of difficulty of the skill are the main determinants. 21 The difference in predoctoral endodontic teaching across schools worldwide has been established. 22 Many dental schools do not teach bacterial sampling because the value in teaching it could be questioned, as well as the deficiencies the technique suffers from. 23 However, the reason the Karolinska Institute teaches this technique to its students is to give them the chance to learn how to perform the skill and be trained in self-assessing their cleaning and shaping procedures. 24 One of the limitations of this study was the relatively small number of participants from only one school. Another point to consider in future design of video-mediated patient demonstrations is the timing of the video. The difference in the proportion of timing for each video could have affected the results of our study. The first video was given in 90 minutes and the second in 30 minutes. These two videos are considered long and could have been completed in short, segmented patterns. This possibility aligns with one study addressing sequential and segmented videos, which seem to provide a better learning outcome and are watched longer. 25 Taking into consideration an appropriate number of participants and helpful areas to include in the video demonstration, further studies are needed to assess improvement in the design and delivery format for video demonstrations to enhance their effectiveness as a teaching modality for endodontics. Conclusion Our study found that video demonstrations with a focus on technical clinical skills rendered the most perceived learning benefits to students in a preclinical endodontic course. Teaching communication skills using video demonstrations was also perceived by the students as valuable but to a lesser extent. REFERENCES 1. Fakhry A, Cooper S, Slach N, Krenz S. Video-assisted clinical instruction in dentistry: overview and applications. Eur J Dent Educ 2007;11(4): Robinson PB, Lee JW. The use of real time video magnification for the preclinical teaching of crown preparations. Br Dent J 2001;190(9): Suvinen TI, Messer LB, Franco E. Clinical simulation in teaching preclinical dentistry. Eur J Dent Educ 1998;2(1): Fakhry A, Dehkordi-Vakil FH. Video-assisted clinical instruction in dentistry (VACID) enhances real-time visualization of clinical procedures. Eur J Dent Educ 2007;11(4): Froeschle ML, Sinkford JC. Full-time dental faculty perceptions of satisfaction with the academic work environment. J Dent Educ 2009;73(10): Walker MP, Duley SI, Beach MM, et al. Dental education economics: challenges and innovative strategies. J Dent Educ 2008;72(12): Amer RS, Denehy GE, Cobb DS, et al. Development and evaluation of an interactive dental video game to teach dentin bonding. J Dent Educ 2011;75(6): Kalwitzki M, Beyer C, Meller C. Differences in the perception of seven behavior-modifying techniques in pediatric dentistry by undergraduate students using lecturing and video sequences for teaching. Eur J Dent Educ 2010;14(4): Aragon CE, Zibrowski EM. Does exposure to a procedural video enhance preclinical dental student performance in fixed prosthodontics? J Dent Educ 2008;72(1): Packer ME, Rogers JO, Coward TJ, et al. A comparison between videotaped and live demonstrations for the teaching of removable partial denture procedures. Eur J Dent Educ 2001;5(1): Ingebrigtsen J, Roynstrand E, Berge ME. An evaluation of preclinical prosthodontic training at the Faculty of Dentistry, University of Bergen, Norway. Eur J Dent Educ 2008;12(2): Journal of Dental Education Volume 79, Number 8

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