Student perceptions toward virtual reality training in dental implant education

Introduction

The professional training of dentists is quite complex since a qualified dentist must possess knowledge of a variety of clinical competencies (Polychronopoulou & Divaris, 2009), which is acquired through the accumulation of theoretical knowledge, clinical skills, and unique problem-solving abilities (Botelho, Gao & Bhuyan, 2018; Dutã et al., 2011). To meet the requirements of a quickly developing society, dental education has continuously changed in every aspect to prepare competency-based dentists. These changes include areas such as the ability to think critically, apply lifelong learning, scientific research, and knowledge integration, adapt to healthcare needs and a more humanistic environment, and the development of faculty (Change et al., 2006). In addition, patient safety and a focus on quality of care and education are increasingly important, which requires more pre-clinical operational training to acquire the necessary skills.

Major advancements in the sciences, technology, and public health have dramatically impacted dental education (Field, 1995). One such example is the application of medical simulation in dental education (Perry, Bridges & Burrow, 2015). Although the application of simulations in dental education is not new, it has been greatly facilitated when combined with virtual reality (VR) technology, a computer-based simulation of 3-dimensional (3D) images. Consequently, VR technology has been actively incorporated into a variety of dental educational events, teaching, and educational environments in multiple application domains (Correa et al., 2017; Zhang et al., 2020). Especially during the COVID-19 pandemic, dentists are classified as under the very-high-risk category because of the potential of exposure to coronavirus through aerosol-generating procedures, VR works as an effective educational strategy to bridge emergency and ensuring continuity of dental education (Iyer, Aziz & Ojcius, 2020).

VR is a powerful, emerging technology that allows users to experience a high degree of immersion within a 3D environment (Radianti et al., 2020). Because of the significant improvement in affordability and processing power, VR is increasingly used in various educational settings, including remote classroom settings, inorganic and organic chemistry, nanoscience, and biology (Baggio, 2019; Dai et al., 2020; Doutreligne et al., 2014; Lv et al., 2013; Pérez et al., 2015), which has been shown to improve students’ learning outcome via an immersive 3D experience. In the scenarios of medical education, VR could supply the optimal conditions to transform a traditional simulation model to a more realistic clinical setting (Levine et al., 2013; Perry, Bridges & Burrow, 2015; Scott et al., 2000; Wilson et al., 1997). The various combinations of VR technologies and dental education have also been employed in preclinical teaching and training for dental students (Buchanan, 2001). For instance, VR techniques combined with haptic device were verified to be satisfactory for the training of needle insertion during dental anesthesia training, including the correct insertion point and depth, as well as the perception of tissues resistances during the insertion (Correa et al., 2017). Virtual simulation education with a jaw simulation model could improve students’ implantology achievements and training (Zhang et al., 2020).

However, there is still some doubtees on the VR applications. For example, in a study which evaluated the students’ acceptance of four different kinds of digital learning technologies (classroom response system, classroom chat, e-lectures and mobile VR), the students evaluated the first three tools favorably before and after usage, except for mobile VR, which saw a substantial drop in perceived usefulness and behavioral intention after 3 months of use (Sprenger & Schwaninger, 2021). They attributed that VR usage in their course did not have a clear link to the exam. Another study about teaching basic surgical tasks with VR headsets showed VR added value to teaching, but only together with high quality traditional teaching methods, the usefulness and usability of VR was experienced more positively (Ojala et al., 2022). It is important to determine the differences between VR and traditional teaching methods and incorporate these methods perfectly in the future. Still more protocols, ideas and users’ experiences and comments should be considered to improve the new techniques widely.

Dental implantation refers to the installation of an endosseous implant via a surgical fixture, in which a metal post replaces the root portion of a missing tooth in the jawbone. Although implant dentistry is still a relatively new scientific discipline, it has dramatically expanded and is now practiced all over the world (Dragan et al., 2019). Initially, dental implant education was rooted in clinical training in the form of continuing education courses provided by dentists experienced in implantology (Payant, Williams & Zwemer, 1994). Gradually, this technique has been integrated into the undergraduate dental curriculum system for implant dentistry. At Jinan University College of Stomatology, implant dentistry was separated from prosthetic dentistry and was provided as an optional course in 2017. The course consisted of 36 total teaching credit hours, including 24 credit hours for the theoretical section, and 12 for the practical portion, provided for the fourth-year dental students. The most recently revised education plan of dental students, which will be executed in 2023, has listed implant dentistry as a compulsory course. However, there is still intense debate about whether this technique should be regularly taught and applied among undergraduate dental students (Schweyen et al., 2020). It is commonly thought that more quality-controlled and practice-directed dental implant training is required for improving the education of implant dentistry, especially for novice dentists who are going to work in implant dentistry (Dragan et al., 2019).

VR technology may provide novice dental students and practitioners with effective and repetitive training on dental implants. This training may resolve the practical deficiency that many dentists have when it comes to dental implants, which has been caused by the small size of many dentistry programs or a lack of mentorship. However, the success of technology based learning depends on the attitudes and interactive teaching styles of the faculty, as well as on the experience and attitudes of students with regard to the technology. Therefore, whether the dental students are satisfied with the replacement of VR at their training, and how they perceive the new techniques in learning need more proof to verify. In this study, we developed a novel VR program with immersive head-mounted displays (HMDs) for dental implants, including the crucial steps required for placing a dental implant, as illustrated in Appendix S1. This training was implemented with current undergraduate students at the Jinan University School of Stomatology, Guangzhou, China. Subsequently, we collected feedback regarding the use of the VR application on dental implant training through a follow-up questionnaire survey to the attendees. The aim of this study was to evaluate the usability of VR application in dental implantation and investigate how this technique was perceived and accepted by the dental students in gaining core knowledge and skills in implant dentistry at the phase of preclinical studies.

Material and Methods

VR setup

The VR system was set up as previously described (Huang et al., 2022). Specifically, the VR system used in this study (Shanghai VR-Sens Intelligent Technology Co. Ltd., Shanghai, China) consisted of a VR interface, a VR headset, two controllers, and two cameras (Fig. 2). The VR system was linked to a conventional gaming computer (CPU: Intel i7-7700 and GPU: NVIDIA GTX1060). The VR interface offered scenarios in virtual reality. Two tracking cameras were used to precisely determine the location of the VR headset. The two controllers were employed to interact with VR objects. As a data visualization tool, custom software (VR-SENS VR Implant Tutorial Software) was utilized. The VR-compatible files were previously generated computationally.

VR dental implant training and procedures

Students’ dental implant training using VR systems was designed and developed by the first author as a senior dentist and the technical staff of Shanghai VR-Sens Intelligent Technology Co., Ltd., on the basis of a previous report (Payant, Williams & Zwemer, 1994). In this pilot project, we used the “An introduction to dental implant” module as an example to begin the VR application in dentistry. Training sessions lasted approximately half an hour for each participant and were fully supervised by one of the authors to reduce errors. During the operation, the participants were asked to perform the dental implant procedure using a standardized two-handed method. The operating procedure was video recorded. The basic principles of the training included a one-on-one teaching method to provide a VR learning experience. The objectives of the VR session were to make the dental students familiar with the dental implant operating procedure. The VR display of the procedure was shown to the participants using HMDs (Fig. 2).

Figure 3 showed the main steps of dental implant VR training. Briefly, the student participant wearing the VR-HMD entered the virtual dental implant classroom, according to the developer’s instructions provided, watched a movie to understand the dental implant protocol, and prepared for the implant surgery based on the prompts given (Fig. 3A); the gingival tissue was incised according to the operation tips (Fig. 3B); an implant bore was drilled in the alveolar bone (Fig. 3C); a dental implant was implanted into the hole (Fig. 3D); the wound was stitched after implant surgery (Fig. 3E); and the dental implant training using VR was ended (Fig. 3F).

Results

Discussion

In recent decades, the landscape of Chinese dental education system has undergone continuous reforms, in order to cultivate dentists who are qualified to meet the care requirements of the 1.4 billion citizens (Wang, Zhao & Tan, 2017; Wu et al., 2010). However, some problems in the dental education system of China have impeded these efforts; for example, the regional discrepancies in the distribution of dental resources is inconsistent nationwide, the financial and technical support to improve dental students’ practical skills is deficient (Fu et al., 2006). Dental implant is such an example. Regional heterogeneity in implant education is existed not only in China but worldwide.

The application of VR in dental medicine provides solutions to these problems. Using a VR approach, dental students could study theoretical knowledge and simultaneously obtain hands-on experiences that can be used later in clinical work (Joda et al., 2019). By VR-based technology in teaching and learning, dental students or young residents enjoy the advantage of repetitive exercises to master the skills, instead of practicing on patients in a clinic. Assuming no simulation in a virtual environment, our dental students have to observe their instructors’ operations at clinics with very little opportunity to practice themselves. The expectation of having plentiful and superior VR systems to train dental trainees should be met to allow these students to practice until their clinical skills or proficiency satisfy the work requirements at clinics. The application of VR technology may also tremendously abridge teaching costs in dental school and save experienced dentists’ teaching time as well. This type of training allows for the development of a standardized procedure that dental students should be objectively trained in before being allowed to actualize the surgical operation of dental implant on a patient. Therefore, it would be helpful to improve the unequal distribution of educational and academic resources due to the regional economic disparity in China (Wang & Fan, 2004).

VR was first used in healthcare in early 1990s to visualize complex medical structures during surgeries and preoperatively in planning surgeries (Kyaw et al., 2019). The most studied VR application is screen-based display, also known as simulation. In China, the simulation laboratory model is considered common in dental implant education (Zhang et al., 2020; Zhou et al., 2021). However, in this pilot study implemented at the Jinan University School of Stomatology, VR system with HMDs was focused, which is a less-studied form of VR in medical teaching. Compared with regular simulators, the VR system with HMDs is characterized by reliably imitating the sensation of touch so that the operator may experience the objects without having actual physical contact with them, which increasing the feeling of realistic haptics. Except for focusing on the simulated training on psychomotor skills, a clinical scenario has been designed in our dental implantation VR module, to enhance the 3D visualization and to supply the students a more engaging and immersing learning environment, that may foster the teaching and learning of complex medical contents. The VR system is also conducive to developing other basic abilities (e.g., distinguishing anatomical structure, decision-making, accurate diagnosis, etc.), which are also necessary for a qualified dentist in addition to their practical clinical skills.

Although the VR-based approach has been used in the field of endodontics, dental surgery and dental prostheses in some countries (Cayo, Cervantes & Agramonte, 2020; Miki et al., 2016), it has not yet been widely adopted in dental education in mainland China, as it can be expensive and difficult to incorporate into the dental school curriculum (Yeweng, Huang & Ren, 2002; Zhou et al., 2013). Our VR application in dental implants can provide some reference for later design and improvement of such program. The VR system with HMDs was first evaluated using the SUS questionnaire before carrying on the formal survey among the participants on training dental implant. This is a recognized evaluative approach for the usability of a product or service (Bangor, Kortum & Miller, 2009). Our results verified that the VR system was generally well-perceived by the participants in terms of usability, with an average SUS score of 82.00 ± 10.79, suggesting that the score was high enough to accurately rank the VR apparatus among the top tenth percentage based on the above mentioned rules (Brooke, 1996). This SUS score is quite close to another VR-HMD facility developed and reported by Portugal dental educators, IMMPLANT (IMMersive Implant PLANning using a Mobile Touchscreen), with a usability score of 83.91, which revealing the good usability and high learnability of IMMPLANT (Zorzal et al., 2021). Our participants provided positive feedback for their VR experiences, which implies that the traditional teaching methods in a dental laboratory may be replaced by a VR system in the future. Most of the participants acknowledged that “I am able to study and master VR training program even without the support of technical person”, and “I repeatedly experienced this operation just now”. The playfulness of VR exercises is a natural learning approach for this new generation, many of whom have played various games ever since childhood. Nevertheless, this study showed that past VR experience did not affect the participants’ evaluation of the VR application on dental implantation. Meanwhile, female participants showed stronger interest in this new facility than the male without any barrier during usage.

It was worth noting that the results of the questionnaire which collected user feedback on the VR application to dental implants, showed that the students were not overly enthusiastic about this VR-based dental implants training. Some students seemed not to strongly agree that VR could be more efficient and provide sufficient learning. Their acceptance toward the VR training on dental implantation was not so high as the attitudes toward another training module we did almost the same period, the VR training module of orthodontic bracket bonding (Huang et al., 2022). We analyzed the reason might be the different natures of these two modules. The VR-based dental implant training we selected in this study is a general introduction to this technique, but not focusing on any specific implant operational step such as implant placement, so it is more theoretical than the orthodontic bracket bonding module, which is focusing on the training of intraoperative performance. That is, VR is highly conducive to clinical operating skills and surgical procedures-focused training. This phenomenon reminds us that the operational training programs are more suitable to be set up using VR-based techniques, and should be considered first with a limited budget, after all, the VR facilities require specialized equipment and are costly. The drawbacks in the VR application, as identified by the study participants, were valuable contributions that can be used to evaluate the hardware and software of future VR systems. Providing educational services, including excellent facilities to meet students’ learning needs, has always been a challenge for dental schools worldwide. The single application of VR in a dental education would never be sufficient, as the ideal software and corresponding mentoring in each dental specialty requires further improvement.

Conclusion

In this study we revealed the feasibility and usability of VR applications on training dental implant among undergraduate dental students. This pilot study showed that the participants benefited from the dental implant VR training. With the help of VR controllers, dental students were able to interact with a virtual patient and perform a dental implant procedure in the VR system. This program mimicked the real scenarios encountered in clinics. Furthermore, the feedback from student participants affirmed the usability and advantages of the VR application in dental education.

This research has following practical significance for future VR-based dental implant teaching:

1. The repeated preoperative rehearsal and self-assess the work by interactive feedback on a VR system could help students identify the quality of their work and determine skills to improve.

2. Although the VR facilities are costly for hardware and software, HMD can often be easily realized as a headset or glasses, seem to be advantageous to limited budget based on their low-price and mobile nature.

3. When developing VR based education, clinical operational procedures-focused training program should be considered first.

Supplemental Information