Sles in Dentistry Oral Health Curricula 201108

HWA/ RFQ/2010/17
Use of Simulated Learning Environments

in Dentistry and Oral Health Curricula
Submitted to:
Katie L. Walker, Health Workforce Australia
22 November 2010
Katie.l.walker@dhs.vic.gov.au
Prepared by:
Professor Laurence J Walsh
With contributions from Dr Lei Chai,
A/Prof Camile Farah, Prof Hien Ngo, and Mr Gary Eves
for the consortium of the
Universities of Queensland, Adelaide and Melbourne
SLE in Dentistry and Oral Health: Final Report
1.0 Executive Summary

Dental educators must create learning environments that promote critical thinking,
decision making and transfer of knowledge from didactic to clinical settings in order to
enhance the knowledge, skills and performance of their students. In addition, due to a
rapidly changing health care environment, dental education has been plagued with
increasing quantities of complex information with waning numbers of academics. Adding
to the challenge, the expectations of new graduates in dentistry and oral health differ
from those in other health professions because students must be fully prepared for clinical
practice at the time of graduation. Because there is no mandatory internship, the full
complement of skills and competencies must be acquired during university education.
The Australian dental Council (ADC) has mapped out the competencies required for
newly graduated dentists and oral health therapists (Appendices 1 A and 1 B), and this
forms a well articulated regulatory framework from which to define simulation-supported
activities.
Recommendation 1. The ADC framework be used as a basis for embedding novel
simulation methods into dental and oral health curricula.
Apart from a requirement to acquire academic knowledge, during their training, dental
and oral health students need to acquire a full range of highly precise manual and
technical skills, including excellent hand/eye coordination, to enable them to visualize
and understand how to undertake complex tasks such as placing restorations and scaling
teeth. Furthermore, unlike students in medicine, dental and oral health students are in the
position of administering treatment to patients very early in their training. This
requirement brings with it a range of challenges.
All dental schools make extensive use of clinical material, particularly case studies (with
treatment records, photographs, study models, and radiographs), for sensitizing students
to the diagnostic, therapeutic, and patient management challenges of the dental clinical
environment. Dental education is visually driven and image intensive, yet the visual
information must be aligned with high fidelity hand skills.
Because of the need for well developed procedural skills prior to students working
directly with their own patients, all dental schools have preclinical simulation laboratories,
and these complex and expensive facilities form a major part of the first and second year
of both dentistry and oral health programs (Appendix 2). The use of these facilities for
skills development in restorative dentistry currently occupies large amounts of curriculum
time, as was mapped in Stage 1 of the project. All dental schools have simulator
laboratories with phantom heads and typodonts (removable artificial teeth and jaws)
which are used for preclinical skills development in restorative and periodontal
procedures as a core part of existing dental and oral health programs, occupying several
hundred hours across first and second year. Use of these facilities was greater in schools
who had less access to clinical facilities, where it served as a partial substitute for
chairside time.
In all the dental existing programs, the progression in dental education through
psychomotor skills development for first and second year students moved from simple
instrument handling tasks to a high fidelity phantom head simulator in one step. Analysis
of this approach identified that it was not optimal because it did not permit any scaled
learning and was time- and cost-intensive because junior students were not ready to make
full use of the more complex environment of the phantom head.
A significant gap was identified in the area of simulation prior to commencing preclinical
work. Here a number of opportunities present:
Use of accelerometer devices including games to build hand-eye coordination and
fine motor skills
Training devices for hand-eye and mirror vision skills
Use of haptics to develop and refine manual dexterity
Virtual clinic and virtual lab environments for familiarization before classes.
Stage 2 of the project identified that in order to more efficiently prepare trainees for the
higher cost and supervision intensive lab simulation, a new class of intermediary
simulation device is required. This class of device sits between simple proxy devices for
hand-eye coordination and the high fidelity haptic and virtual reality simulators which are
commercially available. Such a device would follow the approach already used for
surgical skills training, with visual feedback to develop hand-eye, finger rest, instrument
positioning, mirror vision, and other skills, presented to the trainee through a reverse
image window initially and then through smaller dental mirrors as skills develop. The
trainees would use dental instruments to work on artificial or mounted natural teeth
placed in the training box. Such training boxes could include additional features such as
synthetic tongues and saliva to introduce additional task complexity and realism.
Current VR technology to support dental education (DentSim and EPED) does not
provide a complete solution to the challenges of skills acquisition, thus the preferred
technology platform for high end dental simulation appears to be haptic technology
combined with visualization, using existing surgical simulators (such as VOXEL-MAN)
for some procedures, and custom built dental haptic simulators (Simodont) for refinement
of skills across a range of dental procedures. At the resent time there is only limited
research investigating the effectiveness of haptic technology for dental education. Such
technology can augment but not replace instruction from tutors.
There appears to be considerable scope for enhancing the efficiency of learning prior to
reaching clinical environments by using specific skills-development boxes for
enhancing fine motor control and learning mirror vision prior to students commencing
work on typodont teeth in phantom heads. The curriculum impacts of this change would
be
accelerated learning prior to commencing phantom head work
reduced wastage of synthetic teeth, student time and instructor effort during
preclinical instruction
greater benefit educationally from hours spent with phantom head simulators
greater readiness for more complex procedures when reaching the clinics
a greater skill base when reaching the clinical placement phase of the course.
Recommendation 2. Future HWA support be provided to develop and implement

skills development boxes which can be deployed at scale to all dental schools to
bridge the skill gap for junior students in dentistry and oral health before they
commence phantom head work, particularly in restorative dental procedures.
The information literacy and computer literacy of dental and oral health students is very
high, making them very receptive to a range of simulation activities which can enrich and
accelerate their learning experiences. The opportunity this presents has yet to be
exploited fully, and the emerging evidence for curricula elements such as virtual
microscopy is very positive. A virtual slide box for dental education had been
developed and evaluated comprehensively at UQ over recent years to enrich teaching in
oral biology, oral histology and oral pathology, and the medical education literature
relating to this innovation provided direct evidence of the value of this approach.
Recommendation 3. The following measures be deployed as standard parts of
curricula, to increase the depth of learning and provide a platform for professional
development during the dental course and beyond.
(a) Opportunities to interact with other students in dentistry locally and globally,
and with other students in health professional courses using virtual worlds.
(b) Virtual microscopy to augment or replace traditional microscopy with light
microscopes for oral biology, oral histology and oral pathology.
(c) Three dimensional software for appreciating both dental anatomy and dental
radiology.
(d) In-person interprofessional interactions with other students in health science
programs, to build relationships, establish professional identity, develop
teamwork skills, and appreciate the need for coordination between
healthcare professionals for gaining optimal patient care.
In addition to the conventional phantom heads, several dental schools were exploring
more complex simulation systems which included virtual reality or haptics, with single
trial units either recently obtained or under negotiation. This very promising technology
is ideally suited for a wide range of procedures, unlike the narrow range of phantom head
systems. There is evidence of effectiveness for training in oral surgical procedures. The
richer simulation experience of depth and tactile feedback ideally suited for most clinical
procedures in dentistry,
Recommendation 4. Haptic simulation units be deployed in dental schools to enrich
clinical skills, particularly in the area of training in more complex procedures where
they can accelerate skills progression and help avoid surgical misadventure. Such
simulators can enhance the level of preparedness of students prior to clinical
placements. Given the limited scope of the existing literature on simulation in
dentistry, such deployment should be accompanied by multi-centre research on the
educational benefits of such technology.
Recommendation 5. Deployment of haptic simulators to large placement clinics

where many students are located is recommended to allow students to enrich their
skills outside of rostered clinic time. Such simulation units could also be considered
for skills assessments undertaken by the ADC of those re-entering clinical practice
or joining the profession from overseas training programs, as an alternative to live
patient treatments.
Stage 3 of the project identified that various types of simulation are already used
extensively in the curricula for dentistry and oral health. A number of activities are well
suited to class activities prior to clinical contact, including case studies, role plays, and
students working in small groups rotating between the roles of clinician and patient.
Aspects of patient communication such as establishing rapport, dealing with medical
history, and discussing treatment options are generic to many health professions, and thus
present opportunities for interprofessional and multiprofessional learning activities.
Recommendation 6. Dental schools collaborate with other health professions to
maximise opportunities for interprofessional learning.
Each of the dental schools has already provided input into the development of the ADC
competency maps for dentistry and for oral health. These ADC documents will be used
for accreditation of programs from 2011 onwards. The accreditation function for dental
programs in Australia has been designated to the ADC from the Dental Board of
Australia.
The use of simulation (such as haptics and virtual reality) can augment the skills
development of dental and oral health students, making them more productive when on
placements in providing patient care to the Australian community. There is no current
evidence that using high end simulators can completely replace input from instructors in
the simulation laboratory, nor replace authentic clinical experience in patient care. This is
in part because effective, high quality clinical dentistry requires the application of skills
across the domains of communication, pattern recognition, hand-eye coordination, and
tactile sensation which cannot be provided by existing simulation technologies.
The project was discussed with the Australian Council of Dental Schools in September
2010, and after circulating the draft report and recommendations in late October a special
teleconference of ACODS was held on 14 November. At this meeting, the heads/deans of
all nine Australian university dental schools which offer professional entry programs in
dentistry and/or oral health (the Universities of Queensland, Adelaide, Melbourne,
Newcastle, Western Australia, James Cook, Sydney, Griffith, Labtrobe) gave their
unanymous endorsement of the report, and all of its six recommendations. The report has
been transmitted to the Australian Dental Council as the accreditation body for these
programs, and to the Dental Board of Australia as the national regulatory authority.
2. Background to the Project

This project forms one of a series of projects in simulated learning environments (SLEs)
initiated by HWA in mid 2010. The project occurred during a time when the Australian
Dental Council (ADC) was undertaking a competency mapping exercise for dentistry and
oral health. Fortuitously, the ADC committee for this major exercise included two senior
members of the HWA project team (Professors Walsh and DeVries). This unique overlap
of the two work agendas allowed an alignment between the HWA project work and the
matrix of competencies for new graduates in dentistry and oral health, documents which
had been developed, refined after extensive stakeholder input, and endorsed by the ADC
(Appendices 1A and 1B).
In 2006, as part of the health workforce reform package, the Council of Australian
Governments (COAG) announced that capital and recurrent funding would be available
to build and operate new or enhance current SLEs. A consortium led by The
University of Queensland (UQ), with the University of Adelaide (UA) and the University
of Melbourne (UM) was established to undertake the project. The project team worked
with the Australasian Council of Dental Schools as the key body for academic dentistry,
and communicated with the Australian dental schools offering profession-level entry
programs in dentistry and in oral health to establish the extent of existing activity using
SLEs. Oral health programs combine dental hygiene practice and dental therapy practice
into a three year degree, the Bachelor of Oral Health (BOH). Programs in dentistry and
oral health share a significant number of learning activities which are undertaken using
SLEs, as a prelude to students commencing in clinics with patient treatment.
2.1 Context of the project: Existing simulation in dental education
Over the past decade, rapid growth has occurred in higher education in the areas of
distance learning, interactive telecommunications, computer-assisted instruction, and
computer simulations. While the use of simulation has been proposed as the next major
step in the evolution of health science education, dentistry has been using various types
of simulation for many years as a standard part of the curriculum.
The use of SLEs in dentistry and oral health differs from other areas in health because
simulation has been used for many years and is a normal part of existing curricula,
ensuring that students are both competent and safe at a range of clinical procedures
before they enter teaching clinics in their second or third year as clinical operators. Most
schools with dental programs use educational models in which students, particularly in
their final year, work at placements outside the central location or hub.
All dental schools have purpose-built pre-clinical simulation laboratories (PCSLs), where
activities are run as part of the core curricula in dentistry and oral health. These PCSLs
have multiple stations, each with a simulated patient head and torso, removable jaws and
teeth, dental handpieces, air/water syringe, and a dental light. (Examples of traditional
PCSLs are shown in Figures 1-6 in Appendix 2).
Phantom head simulators for restorative, prosthodontic and periodontal procedures are
found in large numbers in existing dental schools, with PCSLs containing between 30 and
60 phantom head simulation stations (according to the size of the school) being quite
common. PCSLs represent a major capital and recurrent cost for the dental schools, with
a lab of 30 simulators costing in excess of $ 6 million to fit out, since phantom head units
and their associated dental equipment cost up to $ 70,000 for each station.
Commercial systems for high end simulation (using virtual reality or haptics) have
become available in recent years, with current costs of $100-150,000 per station. This
high cost has been a major barrier in the adoption of high end simulation internationally,
but less so than problems with accuracy, realism and software performance which have
plagued earlier systems of such types.
Because of the high cost and complexity of these PCSLs, it is not particularly cost
effective to consider replicating these to all the placement locations across regional and
rural centres. The later parts of this document extend the current concepts of simulation
in dental education to include skills acquisition prior to students entering PCSLs, and
identifies activities which could support students during a placement semester or year in
enhancing their skills.
2.2 Survey
The schools surveyed for this HWA project included the five established Go8 dental
schools:
The University of Queensland (dentistry 5 year program and BOH)
The University of Sydney (dentistry 4 year program and BOH)
The University of Melbourne (dentistry 5 year program and BOH)
The University of Adelaide (dentistry 5 year program and BOH), and
The University of Western Australia (dentistry 5 year only),
and the five newer university dental schools, the majority of which are located in regional
centres:
University of Newcastle - Ourimbah Campus: BOH (dental hygiene only)
Griffith University Gold Coast campus: Dentistry (3+2 program) and BOH
Latrobe University- Bendigo campus: Dentistry (3+2 program) and BOH
Charles Sturt University Wogga Wogga campus: Dentistry 5 year program
James Cook University Smithfield campus: Dentistry 5 year program.
The inclusion of all the dental schools adds to the significant experience of the three
consortium partners, all of whom have students in rural and remote placements.
2.3 Project Methodology
The consortium developed an approach and a project plan which involved activities by
staff from UQ, UA and UM.
Support staff
To support the work of the project, UQ employed three staff in a fractional capacity an
associate lecturer with experience in systematic reviews (Dr Lei Chai), an experienced
general dental practitioner who had been involved in student clinical education (Dr Bruce
Kidd), and a consultant (Mr Gary Eves) with considerable experience in developing
simulation technology and using this in both health and non-health related contexts.
Engagement
The project team engaged ACODS, with a presentation by Professor Walsh and
discussion of the project at the September ACODS meeting held in Kiama, NSW. The
senior project members then met with the President of the ADC as part of the subsequent
ACODS meeting in Canberra, and in a broad discussion of current matters discussed the
project and its progress to date. To ensure benchmarking of the work with international
best practice, Professor DeVries provided information from the Association of Dental
Education for Europe (ADEE) from their July meeting. UQ staff involved in the project
attended the Universitas-21 dental educators meeting in August, and a major dental
educators meeting in the United States in October, and as part of their normal university
work also visited manufacturers and suppliers of conventional and virtual reality dental
simulators. Professor Walsh as the project lead also collaborated with UQ colleagues in
veterinary science who were working on deploying haptic simulation into their
curriculum for procedural tasks.
The draft report and recommendations from the project were circulated to all ACODS
members in late October. A special teleconference of ACODS members was held on 14
November to discuss the outcomes of the project, seek additional comments, and obtain
endorsement of the report as a whole, and of its six individual recommendations. The
report was transmitted to the Australian Dental Council as the accreditation body for
these programs, and to the Dental Board of Australia as the national regulatory authority.
3. Existing simulation activities
3.1 Inclusions for the survey
A survey tool for dentistry was sent to all Australian dental schools offering entry level
programs (BDent, BDS, BDSc, and comparable 3+2 programs recognized by the
Australian Dental Council (ADC) in August 2010 (Appendix 3A), as listed in Table 1
overleaf. In a like manner, a survey tool for oral health programs was sent to all schools
which currently offer degree programs in oral health (BOH) (Appendix 3B).
The survey tool did not include case studies, electronic patient records, role plays and
other lecture class-type activities which are themselves forms of simulation, but rather
focused on laboratory-based simulation activities.
Table 1. Ten Australian education programs in dentistry and oral health (2010)
In early October 2010, information came to hand that Griffith University was closing its
BOH program, with no further intakes of students, and would see through the existing
students to completion. This information was confirmed by checking with the
Queensland Tertiary Admissions Centre (QTAC) who advised that both program code
233822 Bachelor of Oral Health in Oral Health Therapy (Griffith University - Gold
Coast) and the related program 233872 Bachelor of Oral Health in Oral Health Therapy
Studies were not available for commencing students from February 2011. The data from
Griffith regarding their BOH program was thought to be useful and so was retained for
the project.
3.2 Exclusions for the survey
Late in October 2010, further information came to hand to the project team that Central
Queensland University (CQU) was planning to commence BOH programs at some point
in the future, on the basis of their having sought HWA funding for growth places for
clinical training. This intention was flagged in the Interim Agreement for Mission-Based
Compacts between CQU and the Australian Government for the period 1 January 2010 31 December 2010, however not details of timing were provided in this compact for a
BOH program. No information regarding the CQU program could be sourced from that
universitys website and there was no program on offer through QTAC for
commencement in 2011. The team members thus believe that the intended commencing
date will be 2012 or later.
Given the timing of the information about CQU coming to light, and the fact that CQU
had yet lodged formal notification to either ACODS or the ADC regarding this new
programs, it was considered that their stage of development would not have permitted
them to make a detailed response to the survey tool, and thus they were not included.
In mid October 2010, the team became aware that Curtin University was planning to
introduce a new 3-year Bachelor of Science (Oral Health Therapy) program from 2011
that would incorporate elements of both dental hygiene and therapy into an integrated
program. Curtin University currently provides an Associate Degree in Dental Hygiene

and a parallel but separate Associate Degree in School Dental Therapy. A requirement
from HWA for the project was that only accredited university based programs in
dentistry and oral health were to be included. To the teams knowledge, no such
accreditation had yet been undertaken for this new combined program. The decision was
therefore made not to include Curtin in the survey.
3.3 Map of Simulated Learning currently being delivered in dental schools
The mapping of current simulation is presented in Appendix 4A for Dentistry and
Appendix 4B for Oral Health, with a mapping by year of the relevant programs in
Appendix 5A.
Across Australia, both dentistry and oral health programs are large users of simulation,
with dentistry being the larger of the two. In dentistry programs, upwards of 460 hours
was devoted to simulation activities, with the single biggest component being restorative
dentistry (cavity preparation and restoration of teeth) and the related area of
prosthodontics (crown and bridgework), followed by removable prosthodontics (denture
fabrication), endodontics (root canal work) and orthodontics. This pattern is typical of
dental schools internationally, and explains why all dental schools have large simulation
laboratories (PCSLs) with multiple workstations with phantom heads for undertaking
such work (Appendix 2). Most of these simulation laboratories are located at the Schools
home base (Appendix 5A).
Variation between schools was noted in terms of total simulation hours. Part of this was
due to how the various activities were classified by the respondents and aligned to the
questionnaires. Dental schools used upwards of 550 hours for simulation activities in the
existing dental curricula. This was much less than the number of hours devoted to clinical
patient care, which was approximately twice this benchmark (2000 plus hours). Similarly,
simulation in oral health was upwards of 300 hours, compared with over 1000 hours of
clinical practice.
Simulation was used in each Australian dental school to ensure competence and safety as
a barrier before proceeding to undertake patient care in later parts of the course. Because
of the strong proceduralist emphasis in dental and oral health clinical education, the hours
devoted to clinical education were multiples of the simulation hours. In other words, all
schools used the simulation work as a prelude to much longer patient contact within the
program. Across the discussions held regarding the project, no school supported
replacing or substituting clinical patient contact with increased periods of simulation,
however it was agreed that existing simulation activities could usefully be expanded and
their efficiency improved. In particular, schools believed that the existing clinical contact
intra-murally and extra-murally during the program was critical for producing dental
graduates who were fit for purpose and who could meet the requirements articulated by
the profession at large and by the ADC in particular.
10
All schools felt that existing clinical training days should be preserved and in some cases
expanded to provide the full breadth and depth of clinical experience. Most schools were
involved intensively with projects to expand clinical placement opportunities for their
existing and future students, and saw this as a major focus for their immediate future.
Different models of clinical care were used across the sector, as shown in Table 2 below.
At one extreme, two dental schools operated large private clinics (Griffith and UQ) as
well as a network which extended interstate. At the other, four older dental schools (WA,
Adelaide, Melbourne, Sydney) relied on the state dental hospital(s) for the bulk of their
clinical teaching.
Table 2. Models of dental education
4. Literature review
4.1 Methodology for the literature review
A literature review on simulation in dentistry was undertaken, drawing on national and
international published literature. The search strategy included all levels of research
evidence, and a database was created. From abstracts, filtering of the papers was
undertaken, followed by further filtering based on a review of the full paper. This was
undertaken by two separate assessors using established evidence-based frameworks as
applied in systematic reviews. In addition, information was sourced from relevant
manufacturers for current and future projects involving simulation. The US patent
database was searched to obtain information regarding prior art in dental simulation and
to establish the status of current technology for dental simulation, including both virtual
reality and haptics.
11
4.2 Outcomes of the Literature Review.

The published literature was searched using the PUBMED keyword search:
(Dental) AND (Education OR Learning OR Teaching OR Instruction) AND (Simulation
OR Computer-assisted OR Computer-Aided).
This retrieved 370 papers, which were then screened by title and abstract by two team
members. Articles were excluded if they were not research articles (such as editorials,
letters, communications, interviews, news and features), or on an irrelevant topic. This
reduced the data set to 229, as shown in Table 3 below.
Table 3. Full publications on simulation in dental education
The following MeSH searches were also undertaken:

(Education, Dental) AND (Patient Simulation OR Computer Simulation)
(Dentistry) AND (Learning OR Teaching OR Computer-Assisted Instruction OR
Programmed Instruction as Topic) AND (Patient Simulation OR Computer Simulation)
This search retrieved 145 papers, which were then cross-matched to the primary search
results so that there were no double entries into the database.
To explore image guided surgical training in dentistry, a search using the following
MeSH terms was undertaken: (Dental implants OR Surgery, Oral) AND (Surgery,
Computer-Assisted OR Video-Assisted Surgery) AND (Education OR Teaching OR
Learning OR Instruction). In addition, several journals in implantology were searched
manually. A total of 18 articles and 2 conference abstracts were retrieved after systemic
searching. Out of the 18 articles, 3 were written in Dutch and 1 in Hebrew. In terms of
the type of study, of the 18 articles and 2 conference abstracts, there were 4 literature
reviews, 1 symposium note, 2 surveys, 12 simulation system validations or evaluations
and only one cohort study. The searching result is summarized in Table 4 below.
Table 4. Supporting literature on image-guided surgery in dental education
With the development of computer-assisted 3D image technology such as 3D computed

tomography and cone beam volumetric tomography, computer-assisted or image-guided
12
implant placement and oral surgery have attracted recent attention. To maximize the
outcome of implant placement, the use of advanced radiographic procedures such as
computerized tomography, along with fabrication of surgical guides, has been advocated
to inform surgeons of ideal implant location. More recently, simulation computer
software has been introduced to view radiographic images and test potential implant
locations. Surgical guides are processed based on ideal tooth position, with little
consideration for underlying anatomical limitations, which creates a disconnection
between diagnostic planning and surgical restrictions. In response to this "missing link,"
computer-assisted design and computer-assisted manufacturing, as well as real-time
surgical navigation have recently been developed to obtain fully integrated surgical and
prosthetic planning. Today, there are several technologies available, but no systematic
assessment of surgical guidance has yet been performed. For this project, we undertook
MeSH searching using (Dental implants OR Surgery, Oral) AND (Surgery, ComputerAssisted OR Video-Assisted Surgery) retrieved a total of 354 articles, of which only 18
were related to oral surgery and implantology training. Only one cohort study was found.
From the combination of all of the above measures, the full-text versions of the papers
were retrieved, and screened by two team members before allocation to additional team
members to complete focused reviews on issues of relevance to the project.
To supplement the search, relevant journals according to different categories such as
endodontics, prosthodontics, paediatric dentistry, oral radiology, oral surgery and
implantology were hand searched respectively.
Refereed abstracts from the International Association for Dental Research
(http://www.iadr.com ) were searched using the keywords (Education OR Learning OR
Teaching OR Instruction) AND (Simulation OR Computer-assisted OR Computer-Aided).
This retrieved 321 abstracts, which were then screened using the same approach as for
the full papers above, resulting in 30 relevant abstracts, as shown in Table 5 below
Table 5. Refereed abstracts on simulation in dental education
4.3 Virtual reality

Considered semantically, the term virtual reality is an oxymoron; that is, its meaning is
essentially contradictory. On the one hand a virtual construction, on the other, real one,
however both ideas occur simultaneously. Because virtual reality is the key component in
simulated learning, this contradictory essence is embedded in the latters practices,
leading one observer to say that it is an uncanny or a threshold concept (Bayne 2008).
Simulated learning entails several contradictions: embodied and disembodied; digital and
13
analogue; single mode and multimodal; subjective and objective; sensorial and cognitive,
abstract and vocationally orientated; mental and physical labour; and a virtual and real
interaction. An associated contradiction identified by simulated learning researchers, both
in the health-care field and elsewhere, has centred on a simulations fidelity
(Dieckmann, et al. 2007), or affordance (Dalgarno & Lee 2010), or physical
verisimilitude (Herrington et al. 2007), to the real action it depicts. In all these
mentioned sources though the stress is put on the learning capacities of simulated
environments and not on their truthful rendition of one or another procedure that it is
attempting to depict.
If a virtual world (VW) like Second Life is used in dentistry (Phillips & Berge 2009),
then what is achieved educationally is engaging three-dimensional environments that
mimic real life. The same applies when attempting to simulate the dental profession for
potential students in order to give them a realistic picture of this choice of career (Hawley
et al. 2009).
The virtual world approach has recently been developed for the education of health
professionals, with a local example being PIER VIRTUAL (based in Brisbane)
(http://www.pieronline.org ) which has been involved in the development of learning
worlds in both Second Life (http://secondlife.com/ ) and Open Sim
(http://opensimulator.org/ ). OpenSimulator is an open source multi-platform, multi-user
3D application server which can be used to create a virtual environment (or world) which
can be accessed through a variety of clients, on multiple protocols. OpenSimulator allows
virtual world developers to customize their worlds, and simulate virtual environments
similar to Second Life.
VW technologies such as Second Life and OpenSim have potential use as a medium for
total virtual patient simulation, particularly as an adjunct to preclinical teaching methods
in virtual problem-solving and communication prior to student clinicians' treating patients
in the clinical setting. Activities in VW could provide a way to combine new simulation
technologies with role-plays to enhance instruction in diagnosis and treatment planning.
Case studies and role-plays have been used as effective evaluation mechanisms to foster
decision-making and problem-solving strategies in the delivery of patient care. As the use
of VW in dental education is in its infancy, there is limited research to prove its merits;
14
however, the literature suggests that existing educational practices may be enhanced by
its use (Phillips & Berge, 2009).
Preclinical teaching and learning take up a majority of classroom and laboratory time in
the first half of the dental curriculum as students prepare for entering clinical treatment
areas. Using VW, students can be assessed on recording and analyzing medical histories,
chief complaints, and assessments of present oral diseases in a standardized manner.
Likewise, the ability of students to teach their patients how to modify or establish new
oral health behaviors can also be evaluated using virtual patients in virtual worlds.
Student clinician/patient role-play, which is normally conducted in class between
students, can be done in virtual worlds with audio and video.
Dental students need to deliver care to populations that are not only living longer, but
doing so with a host of chronic diseases. Students have, at times, limited access to treat
diverse populations while in the dental school intra-mural environment. VW offer ways
to virtually encounter clinical scenarios, a point of particular relevance for teaching how
to problem-solve for patients with complex medical conditions and uncommon health
ailments, if the opportunity for real interactions with such patients is not available.
Patients with physical or developmental disabilities, language barriers, psychosocial
behaviours, and geriatric patients with age-related issues are all suited to a virtual world
setting to help prepare students for such challenges.
A virtual world which is used at the University of Southern California School of
Dentistry exposes students to exercises in diagnosing complicated problems, which in
turn eliminates the use of live patients in a risky environment. Such VW are especially
useful during the first half of the curriculum when students are inexperienced in patient
care. Other examples of VW include the Case School of Dental Medicine which uses VW
to assess students abilities to communicate with their patients on issues such as tobacco
cessation. The International Virtual Dental School (IVIDENT) created by Kings College
London Dental Institute to become a repository for globally distributed online dental
education has engaged in VW and is using Second Life collaboratively for educational
research between IVIDENT and the University of Michigan School of Dentistry.
A detailed review of the use of virtual worlds in health science education has been
provided by Hansen (2008), who points out that despite the educational and research
potential of virtual worlds, the evidence base in terms of quality educational research
involving the use and effectiveness of these innovative technologies is still in its infancy.
Reported advantages to having students engage in virtual worlds include:
interacting with diverse content;
risk-free role plays of scenarios including medical emergencies;
opportunities to interact with others through their avatars (e.g., patients, staff
members, and other healthcare professionals) in a safe, simulated environment;
familiarization with the health care setting leading to a decrease in student anxiety;
encouragement to cooperate and collaborate, and resolve conflicts; and
enhanced self-reflection and knowledge.
15
Hansen found that the use of VW improved cooperation and collaboration, and supported
conflict resolution when students interact with patients and other health care
professionals avatars.
For educators, the advantages of virtual worlds are the ability to design and construct
unique environments and then share them with others in a collaborative fashion.
Educators may write specific learning goals for students to complete while learners
actively build and interact in environments that promote creativity and social networking.
Hansen in her critical review of VW in health education concludes that empirical
research is needed for future use of virtual worlds in healthcare training and general
education, and that educational research regarding 3-D virtual worlds and the effects on
learning outcomes is lacking. Nevertheless, current evidence indicates that participating
or playing in a virtual world is enjoyable for the learner, encourages creative expression,
and broadens socialization skills. It may also promote independent problem solving,
provide opportunities for self-teaching, and help set the stage for group work.
The University of Marylands virtual dental school (http://dspub.umaryland.edu/vi/) has
three floors that mimic the actual building design, including a lecture hall to
accommodate seventy avatars, and multiple clinical dental chairs. Plans are being made
for an anatomy practicum using virtual skulls, and dental faculty members developed
nervous and hostile virtual patients to challenge students problem-solving skills.
Perhaps one of the greatest advantages of VW technology is in terms of collaboration.

Guest lecturers can present classes, and students can collaborate with other dental
students or students studying in other health disciplines from within their own
universities or from around the globe. Virtual worlds may help encourage the deployment
of standardized methods of evaluation and testing, and grant wider access to educational
materials. Nevertheless, the major barriers to the use of VW in dental education are the
lack of instructional design expertise by dental academics and the challenges in its
integration into the appropriate parts of the dental curriculum.
16
4.4 Computer literacy in dentistry

Computer-based self-instructional media may be able to increase the range of learning
experiences for students and thereby supplement the dental curriculum at relatively low
total cost (Wotman, 1989). Dental students are typically fluent with information
technology and are eager to use sophisticated tools for learning, particularly when this
gains them freedom from a fixed classroom structure. The development of computer
literacy amongst dental students and their familiarity with information technology have
been identified as attributes of the new graduate from dental school (Zimmerman et al.,
1986; Abbey 1987). In contrast, academic staff members have varying levels of computer
literacy, and emphasize the quality of learning which occurs with computer-based
approaches - while making learning attractive (Lang et al., 1992).
4.5 Simulation to enhance decision making
Several randomized controlled trials have demonstrated that computer-based media offer
a range of advantages over self-teaching booklets in terms of skills needed for clinical
decision making in dentistry:
a consistency in the information presented,
an interactive learning experience which may be more effective than lectures, and
close approximation to the clinical situation (Tira 1986, Graig 1986; Puskas,
1991).
Self-instructional computer programs appear to be as effective as the lecture format for
instruction in decision making principles. Over the past three decades, self instructional
programs in dentistry have been developed to teach methods of diagnosis in a range of
areas, including:
oral medicine (Finklestein et al., 1988; Siegel et al., 1990),
orthodontics (Luffingham 1984; Irvine & Moore 1986),
jaw joint dysfunction (Bagnall et al., 1988; Clark et al., 1993),
orofacial pain (Clark et al. 1993),
endodontics (Mullaley et al., 1976; McKedry, 1989),
prosthodontics (Tira 1977),
removal partial denture design (Lefebvre et al., 1990) and
geriatric dentistry Mulligan & Wood 1993).
Software also has been used to assist with the analysis of both panoramic and periapical
radiographs (Webber et al., 1982; Jeffcoat et al., 1984), including automated diagnosis
programs (Sloan, 1980; Hyman & Doblecki 1983).
Students using computer based instruction performed either as well or better than
students who received instruction via lectures or printed self-study materials. An
evaluation of different computer-based simulations of patients with orofacial disorders
revealed dramatic improvement and reduced variability in students knowledge as they
reviewed more of the simulated cases (Clark et al., 1993). A uniform message is that
simulations of diagnostic challenges offer dental students an appealing medium to
17
promote the development of critical thinking and clinical problem-solving skills (Graig et
al., 1989; Clancy et al., 1990). This is important because dental students achieve varying
levels of competency in this area by the time they complete their clinical training (Clancy
et al., 1990).
Overall, while the literature regarding whether these simulation programs improves the
quality and economy of instruction is very positive, the depth of the education
evaluations which have been undertaken of these self-instruction packages is variable.
Many of these studies did not include a strict randomized controlled trial design. Having
said that, there is also evidence that the content of the message is more important than the
means by which it is presented (Sandoval et al., 1987).
4.6 Software for improved visual diagnosis
With the rising standards and increasing complexity of modern dental care, there is a
need to introduce dental and oral health students to a variety of difficult or unusual cases
to enhance their problem-solving abilities. These skills develop with practice and
individualized feedback in clinical settings. Because of time pressures in the clinic, the
conceptual aspects of treatment decisions may not be emphasized in the clinic. In
addition, each students clinical experiences are limited and not standardized.
Self-instructional programs offer dental students an appealing medium to promote critical
thinking and clinical problem-solving (Graig et al., 1989;Clancy et al., 1990). Computerbased instructional packages based on clinical cases and simulations have the potential
for providing additional experiences in clinical problem-solving for dental students.
Compared to other self-instructional technologies, computer-based simulations can
provide a degree of interactivity which allows for the needs of the individual student.
Computer-based packages can allow high levels of flexibility, so that students can review
material in a personalized sequence to meet individual learning needs. Computer-based
packages can provide image material at a quality greater than possible through print
media, and these can be linked with text, audio, and video. Finally, once developed,
computer-based simulation packages can be reproduced at low cost and be made
available both to libraries and to individual students.
Computer-based and other self-instructional technologies have gained considerable
popularity in dental education since their initial implementation in the early 1980's
(Williams 1981). However, in relation to using simulation to improve visual diagnosis, a
definitive analysis of the existing studies is difficult because of factors such as
confounding, potentially small effect sizes, contamination effects, and ethics. Two
distinct approaches to evaluation have been used, objectivist and subjectivist. These two
complement each other in describing the whole range of effects a new educational
approach can have. Ideally, objectivist demonstration studies should be preceded by
measurement studies that assess the reliability and validity of the evaluation instrument(s)
used. Many evaluation studies compare the performance of learners who are exposed to
either a new software program or a more traditional approach. However, this method is
problematic because test or exam performance is often a weak indicator of competence,
18
and may fail to capture important nuances in outcomes. Subjectivist studies may provide
insights complementary to those gained with objectivist studies, but these are few in
number.
4.7 Simulation to enhance dental radiology
Effective patient simulations can assist learning because they are highly interactive,
reinforce concepts and theories, and place the patient at the center of learning (Barnett
1987; Shugars et al., 1991). In line with this, utilization of computer assisted instruction
for mixed dentition analysis (Irvine & Moore 1986) and in intra-oral radiography
(Wenzel & Gotfredsen 1988) has been shown to result in higher test scores and greater
retention than traditional teaching.
A 3 year study conducted at UQ (Mubarak 2000) assessed the impact of a prototype CDROM
interactive tutor package on student learning. The cohort used was second year
dental students across three years (1997, 1998 and 1999) who had no prior exposure to
radiology. The CD-ROM was created to both instruct and to allow self-testing (via image
mapping). The 1997 cohort served as the control group, while the 1998 and 1999 cohorts
had identical class experiences but were also provided with access to multiple copies of
the CD-ROM (one shared between 5 students in 1998, and one CD-ROM per student in
1999), to permit use outside of scheduled class hours. A panel of discrete radiological
skills relating to bitewing and periapical radiographs were assessed using an objective
structural clinical examination (OSCE). The OSCE assessment instrument was identical
in the three years of the study. The OSCE incorporated sub-scales to assess separately
each of 8 defined skills included on the CD-ROM package, as well as control skills
which were not included in the instructional package. Differences between the three
groups were compared using Chi-square analysis for categorical variables and nonparametric
statistical methods for continuous variables.
The global performance of the second and third cohorts on the panel of defined skills
included on the CD-ROM package increased by 28%, while there was no significant
change in terms of the internal controls. The skills showing the greatest improvement
were the diagnosis of small enamel lesions and the diagnosis of lesions at the dentoenamel
junction (DEJ). Across all examination components, the 1997 cohort detected
27.2% of the total number of lesions, while the 1998 and 1999 cohorts detected on
average more lesions in total than the 1997 cohort, 62.5% and 66.4%, respectively. These
results indicate that significant educational benefits were achieved through the adoption
of a flexible learning approach using the simulation combined with improved access to
tutor-type feedback.
4.8 Virtual Microscopy
Virtual microscopy (VM) is a major area where simulation has been successfully
introduced into the foundation sciences for dental education. The intention is to for
students to gain a greater appreciation of structure of normal and pathological oral tissues,
so that the learning goal predominates. VM does set out to simulate the action or feel of
using a microscope, but rather focuses on the visual information which is created as the
endpoint. The same point applies when this type of approach is used for radiology
19
education the outcome is the image and its use, rather than replicating how that image
was produced (Hatcher 2006).
Across a broad range of medical disciplines, learning how to use an optical or light
microscope has been a mandatory inclusion in the undergraduate curriculum. Dental
programs routinely include the use of light microscopy in the teaching of oral biology,
oral histology, general pathology and oral pathology. The development of VM
technology during the past 10 years has called into question the use of the optical
microscope in educational contexts, not only in dentistry but in human and veterinary
medicine.
In VM, slide specimens are digitized at high resolution, which, in turn, allows the
computer to mimic the workings of the light microscope, with the student moving across
the virtual specimen and the enlarging selected areas in exactly the same manner as is
used with Google Earth and similar mapping programs which combine aerial imaging
into databases which can be moved through in virtual space.
This move from analogue technology (the light microscope) to digital technology (the
computer as microscope) parallels the broader move from print-literate traditions of
knowledge (requiring literacy) to an electronics-literate, or "electrate," mode (requiring
"electracy"). The transition is accompanied by a move from teacher-directed learning to
student-centered learning, or "user-led education," which points to a redefinition of
"pedagogy" as "andragogy." The use of VM by dental and oral health students builds
their level of electracy, which enhances their ability to engage more strongly with
computer simulation and telemedicine (Maybury & Farah 2009).
Both microscopic and radiographic forms of information sit at the interface of the real
perceivable world and the cellular/histological world, being equally real but for the
most part beyond the understanding of novice dental students. It is here in the simulation
of the cellular/molecular world that cognitive realism (Herrington et al., 2007) is far
more important than the physical verisimilitude of many simulations focused on
developing psychomotor skills. This is an especially important point in terms of visualspatial
ability in radiology, that is, spatial cognition (Nilsson et al., 2004; Nilsson et al.,
20
2007; Nilsson et al., 2007b). Here the aim is for students to discover anatomical truth
(Harrell et al., 2002). It takes some time for students to develop expertise in reading
three-dimensional microscopic and radiographic information because of this more
abstract question of spatial cognition when interpreting the anatomical matrix. Effective
use of VM and its parallels in radiology depends on the development of educational
affordances (or competencies) in simulated learning as a necessary first step.
Digital VM technology was first used intensively in dental education at the University of
Queensland. Several evaluations of the benefits of this approach, as deployed at UQ, have
been published in the educational literature. A cohort of 60 dental students studying a
course in pathology in 2005 were introduced to virtual microscopy technology alongside
the traditional light microscope, and then asked to evaluate their own learning outcomes
from this technology. A wide variety of questions dealing the pedagogic implications of
the introduction of virtual microscopy into pathology were asked of students. There was
strong evidence that VM enhanced their learning of pathology (Farah & Maybury 2009b).
The move to virtual microscopy and computer-assisted, student-centered learning of
pathology enhanced the learning experience by helping students engage and interact with
the course material.
A follow-up study by the same authors (Farah & Maybury 2009a) using the same cohort
of students in two separate courses in 2006 and 2008, produced responses from students
which were overwhelmingly in favor of VM. Interestingly, when it came to completely
replacing the light microscope with virtual microscopy, the students were much more
ambivalent about such a wholesale change, although this was less of an issue in the senior
year. One explanation for this is that traditional microscopic skills for histopathological
examination of materials are not used in the routine clinical practice of dentistry, but
surgical operating microscopes are used in clinical dental practice for procedures
requiring high magnification. The physical interaction with a binocular light microscope
may benefit students by providing some skills to supporting a later adoption of surgical
operating microscopes.
21
4.9 Haptic simulation

PerioSim is an example of a haptic technology system which uses a periodontal probe. It
was developed at the University of Illinois at Chicago College of Dentistry. The system
offers 3D, VR graphics and tactile sensation (haptics) allowing the user to feel a variety
of dental instruments, such as a Shepherd's hook explorer for training in visualizing and
detecting the feel of an caries active white spot lesion or use a VR periodontal probe to
probe and evaluate the disease status of a periodontal pocket. A realistic 3-D human
mouth is shown in real-time, and the user can adjust the model position, viewpoint and
transparency level. The haptic device allows the student to feel the sensations in the
virtual mouth, and a control panel lets the user choose different procedures to practice
and instruments to use. The instrument pressure (in grams of force being applied to the
gingival area) can also be viewed on a gauge and recorded. A control panel is available
for fine control of a variety of parameters such as instrument and model selection, degree
of model transparency, navigation, haptic fidelity of tissues and tremor modulation.
Students access PerioSim via the Internet. The system allows instructors to create short
scenarios of periodontal procedures, which can be saved and replayed at any time. The 3D component permits students to replay from any angle, so the user can observe different
views of the placement of the instrument and gingival relationships during a procedure.
The recorded file can be viewed on any personal computer, and while not in 3-D, it is an
actual representation of the original scenario, which offers great training potential.
The program also allows for a second playback mode, where an instructor leads the
trainee through the program. By simply holding onto the haptic stylus, the trainee
receives the same sensations felt by the instructor. Trainees can also be tested and
evaluated on their ability to mimic the instructor's periodontal procedures. An overview
of Periosim is provided at http://www.cvrl.cs.uic.edu/~stein/PeriosimUpdate08.htm.
In a study by Steinberg et al., (2007), only minimal training time was necessary, and
neither staff age nor computer skills were barriers to use of the instrument SL has the
potential to greatly enhance current methodologies, eliminating some of the need for new
design.
The system offers 3D, VR graphics and tactile sensation allowing the user to feel a
variety of dental instruments, such as a Shepherd's hook sickle probe or explorer for
22
training in visualizing and detecting the feel of an carious lesion. A VR periodontal probe
can be used to probe and evaluate the disease status of a periodontal pocket. The grams of
force being applied to the gingival area is displayed and recorded.
The Moog Simodont system (Appendix 2) uses force sensors for a high fidelity feel.
Instruments can be replicated using a range of movement and realistic force feedback,
from very delicate forces up to very strong forces. Simodont courseware was developed
by the Academic Center for Dentistry, Amsterdam, The Netherlands (ACTA). The
software gives high quality video and audio to accompany the selected procedure.
The Simodont system was launched at the Association for Dental Education in Europe
(ADEE) Meeting (25-28 August 2010) in Amsterdam. The theme of the ADEE meeting
was Digital dentistry, with an emphasis on digital techniques in dental education and
particularly haptic simulation and virtual reality. This meeting was attended by HWA
team member Prof Johann DeVries.
Current capabilities of the Simodont system include
Manual dexterity exercises with software evaluation of psychometric skills
Cavity preparation and other restorative exercises, in which students drill and
manipulate rotary drills and hand instruments in a realistic manner
Diagnosis and treatment planning exercises, by including simulations of
pathologically altered tissues
Suitability to either left or right handed students.
Current software allows
standard drilling exercises with software grading of outcomes
spatial orientation exercises for dental mirror use, and
manual dexterity training
while future software updates will allow periodontal procedures and crown and
bridgework.
4.10 Virtual reality for surgical training using medical simulators (Voxel-Man)
Crucially, in various forms of dental surgery the dexterity of the hands is a critical
attribute of student success in the field (Rucker 2007). Simulating the coordination of this
critical hand/brain focussed psychomotor skill via virtual surgery (Pohlenz et al., 2010) is
essential to developing both preclinical and para-clinical expertise in the dental student.
Work in Hamburg, Germany has explored how technology developed for training in
surgery can be used for dentistry. The virtual environment of the Voxel-Man simulator
that was originally designed for virtual surgical procedures of the middle ear was adapted
to intraoral procedures, specifically the surgical procedure of apicectomy, which involves
resecting the end from a root after tunneling through the supporting bone a difficult and
complex procedure in which selective reduction of bone without collateral damage
(nerves, teeth) is essential. In the Hamburg study (Pohlenz et al., 2010), a group of 53
dental students undertook this virtual surgery in the Voxel-Man simulator, and of these
23
51 were positive regarding such virtual simulation as an additional modality in dental

education. The students indicated that the integrated force feedback (e.g. simulation of
haptic pressure), spatial 3D perception, and image resolution of the simulator were
sufficient for virtual training of dental surgical procedures.
In a related study (von Sternberg et al., 2007), the same group assessed whether skills
acquired when undertaking a virtual apicectomy on the VOXEL-MAN system with
integrated force-feedback) were transferable from the virtual world to physical reality.
The study compared two groups of trainees. The first group received computer-based
virtual surgical training before performing an apicectomy in pig cadavers, while the
second group did not. The probability of preserving vital neighboring structures was
improved six-fold after virtual surgical training. The average volume of the bony defects
created by the VR trainees was only half that of the controls. This study shows that dental
surgical skills training with a haptic simulator are transferable to physical reality.
Moreover, the ability to objectively self-assess performance was significantly improved
after virtual training.
4.11 High end dental simulators for restorative dentistry
A significant proportion of dental education is dedicated to teaching psychomotor clinical
skills. A unit designed for the instruction of dental procedures using virtual reality-based
technology was introduced into the dental education marketplace in 1998. This unit, the
DentSim, was the world's first virtual reality (VR) unit designed to teach the manual
skills that dental students must master before they are ready to treat patients (Appendix 2).
The system was developed by DenX, an Israel-based hi-tech company specializing in 3D
graphics and real-time image processing (Hayka & Eytan 1997). The unit is a simulation
system which can (i) simulate the real process of drilling a tooth during a dental treatment,
(ii) imitate a real process of drilling a tooth during training while drilling an artificial
tooth and, in both cases, (iii) display the process in an enlarged scale on a display. The
system was designed for training dental students but could also be used to monitor in
real-time an actual dental treatment performed by a clinician.
24
The original patent for this system describes the intent for the system to be used for a
broad range of procedures, in two groups:
cavity preparation and crown preparation (implemented)
root canal preparations, other tasks carried out using dental handpieces, and other
tasks using hand instruments (e.g., chisels, enamel hatchets) (not implemented in the
commercial version of the DentSim).
For operative dentistry training, the user selects a tooth to practice on, the extent of caries,
and the type, depth and shape of cavity to be prepared. The actual work with the system
is preferably performed in the phantom head and is displayed and observed by the trainee
on the screen (as can be seen in Appendix 2). Many parameters of cavity preparation can
be monitored, analyzed and displayed in real time, thus, leading the trainee to improve
their techniques, through instant feedback as well as by review of all previous stages of
work. The intent of the inventors was that the system could be used by drilling into
artificial teeth or could be used as a fully virtual environment. The lack of any haptic
components prevented the latter from ever being achieved.
As shown in Appendix 2, the commercial DentSim unit combines a patient manikin
(phantom head), a set of dental instruments, infrared sensors and an overhead infrared
camera with a monitor and two computers. Readings from sensors on the manikin and
instruments are processed by one of the computers to interpret the spatial orientation of
the manikin, the teeth and the instruments and produce a three-dimensional image of the
patient's mouth. The second computer runs instructional software to provide students
with a comprehensive learning experience.
Using the unit, a student can prepare typodont/dentoform teeth in much the same manner
as with the standard dental simulators. However, the unique property of this unit is its
ability to construct a real-time virtual image of the students preparation in the computer.
The software evaluates the tooth preparation both immediately and at the students
request. Real-time evaluation for critical, non-correctable errors is given as immediate
feedback. A more detailed evaluation of a restorative preparation is given when requested
by the student. The extensive evaluative feedback given when requested is presented in
visual and written forms and includes a numerical grade. Hence, the DentSim offers
objective, consistent evaluation of preparations easily obtained at any time during the
25
process of preparing the tooth. This evaluation includes both formative (corrective)
feedback and helps to generate a final (summative) evaluation. This is in contrast to an
evaluation given by teaching staff faculty that consists, for the most part, of evaluation of
an end product (such as a cavity shape).
Features of the DentSim unit include:
Simultaneous viewing via the monitor of the cut being made into a tooth and the ideal
preparation.
Real-time audio signaling when a student makes a critical error. At that point, a
student can replay the procedure and see how the mistake was made.
Performance feedback at any time. At any point, students can stop working and have
their preparation evaluated against the ideal preparation. The system runs a list of
errors and provides cross sections and diagrams of how the outlines match up.
The acquisition of knowledge takes place in a multimedia learning environment with a
high audio-visual content and degree of interaction and complexity, and problem-oriented
learning takes place through clinically relevant work. Individual students can work to
personalized programs through the digital tutor function, in which three-dimensional
preparations can be analyzed by two-dimensional error analysis. All tooth preparation
exercises are recorded for error and effectiveness analysis.
The realism of the virtual environment is enhanced by complete patient records that
accompany each case, including medical and dental history, x-rays, examination notes
and the reason for diagnosis. Links within the patient record give students access to more
information on specific topics.
In terms of the student learning experience, it was hoped by the developers that such a 3D
VR system would offer the following advantages and benefits:
(i) less space required for training
(ii) fewer instructors
(iii) a move to self teaching rather than using instructors
(iv) an unlimited ability to repeat exercises without increasing costs
(v) greater standardization of procedures
(vi) better alignment with curriculum needs
(vii) flexible learning with self teaching not limited to formal teaching hours
(viii) greater evaluation of student performance in real time
(ix) more consistency in assessment of student work
(x) improved manual dexterity before commencing with patients
(xi) lower overall cost and duration of student training
(xii) trainees will attain a higher standard of performance and knowledge in
comparison with trainees practicing using conventional methods.
The University of Pennsylvania School of Dental Medicine (UPSDM) was the exclusive
United States test site for DentSim, which was introduced there in 1998. UPSDM started
with one (beta) version unit in 1998, which was later updated and expanded first to four units
and then in 2003 to fifteen units. First-year students from 2003 onwards received
most of their preparative training in operative dentistry on these VR units.
26
A total of 11 papers have been published on DentSim, including a comprehensive evaluation

by UPSDM (Buchanan 2004). UPSDM's experience consisted of several years of research
using control and experimental groups, employing students to participate in an
investigative project, and using the units for remediation and a supplement to their
traditional preclinical laboratory.
The first study at UPSDM began soon after they had acquired the beta DentSim unit.
Being one of the very first units, it was much more prone to technical problems than later
units. A sample of 16 students was selected from the 94 students enrolled in the first-year
class, and were matched in pairs (for controls) for computer skills, gender, aptitude test
scores, and academic performance. For each of the eight pairs, one student of the pair was
randomly chosen for the experimental group and the other assigned to the control group.
The experimental students were assigned to the DentSim unit in two-hour time blocks
over a three-week block, while students in the control group were instructed in the
UPSDM traditional laboratory. The experimental group was instructed to practice Class I
amalgam procedures on the simulation unit and to receive no other instruction on this
procedure from staff or other students. The control group prepared teeth in the traditional
lab and requested evaluation from academic staff. Although the control group had access
to faculty only during course hours, they were allowed to practice during the hours the
laboratory was open (nights and weekends). In both groups, the criteria for assessment
were determined by the restorative teaching staff involved in the preclinical operative
course and were consistent between the two groups. Both groups were instructed to keep
detailed time logs in which they recorded 1) time used to practice preparations, 2) the
number of teeth used for practice, and 3) number of times they requested expert
evaluation. The number of times students asked for expert evaluation represents the
number of times an experimental student asked the computer for a complete evaluation of
their preparation or when a control student asked a faculty member for evaluation. At a
scheduled time, a practical examination (Class I preparation) was given to both control
and experimental groups. The teeth were collected from both groups, and one staff
member graded all teeth from both groups in a blinded manner.
Experimental students spent less time preparing Class I preparations (6.71 vs 3.69 hours),
and asked for evaluation more times per hour (6.52 vs 3.21, p=0.08). The experimental
students prepared significantly more teeth per hour (3.8 vs 1.6) and not surprisingly used
more teeth in total (average 11.71 versus 6.57, p=0.02). The results of the Class I
practical examination were only slightly higher for the experimental group (72.6% vs
61.9%) and this was not statistically significant.
In a second study at UPSDM, the format from the first study was repeated except that 28
students were chosen and paired. Students learned the procedures of Class I and Class II
amalgam restorations, but this time limited staff input was allowed for each student one
hour a week while they were assigned to the VR laboratory. Staff only responded to
procedural questions such as what burs to use, how to correct errors, etc. As before,
student performance was measured by a practical examination of a Class I and Class II
preparation, which was graded by one staff member in a blinded manner. Experimental
students scored lower for Class I (72.0 vs 79.3%) but similar for the more difficult Class
II (79.7 vs 80.9%). The two groups had very similar final overall grades in the course.
27
The UPSDM results, while based on low numbers of students, suggest that students learn
faster, to arrive at the same level of performance. Students using VR accomplish more
practice procedures per hour, and request more evaluations per procedure or per hour
than those using traditional laboratories.
Students' attitudes, as measured by surveys, group interviews, and private interviews, to VR
were mixed. The overall evaluation of their experience with this technology was positive, and
this led to the purchase of additional units in 2003, its full incorporation into the curriculum,
and curriculum revision to maximize its potential. Buchanans conclusion is that this
technology offers significant potential in the field of dental education and that further use and
investigation are both desired and justified.
UPSDM staff believed that a significant advantage over the traditional methodology used
for the instruction of restorative preparative procedures was the ability of the unit to give
immediate, consistent, unbiased feedback based on evaluation of the preparation in terms
of tenths of millimeters.
Focus group discussions completed by all students involved with the DentSim over 5
years at UPSDM were summarized by Buchanan (2004) into several key observations:
1) students want staff to play some part in their skills training even though students
dislike the considerable variability between instructors and are frustrated by waiting for
staff to check their work;
2) students view VR technology as having a positive role in preclinical training;
3) students feel that they learn faster with VR; and
4) students feel more confident with a high-speed hand-piece after training on VR.
Although several other schools have similar positive experiences (LeBlanc et al. 2004;
Imber at al. 2003) there are some who have had experience with VR dental simulation
and have drawn different conclusions about its potential. Quinn et al. 2003 a and b)
reported on the Dublin Dental School and Hospitals experience with VR. To evaluate
possible benefits, in the first study junior undergraduate dental students were randomly
assigned to one of three groups: group 1 as taught by conventional means only; group 2
as trained by conventional means combined with VR repetition and reinforcement (with
access to a human instructor for operative advice); and group 3 as trained by conventional
means combined with VR repetition and reinforcement, but without instructor
evaluation/advice, which was only supplied via the VR-associated software. At the end of
the research period, all groups executed two class 1 preparations that were evaluated
blindly by 'expert' trainers, under traditional criteria (outline, retention, smoothness, depth,
wall angulation and cavity margin index). There were no significant differences between
the three groups except for scores for the category of 'outline form', for group 2, which
produced significantly lower (i.e. better) scores than the conventionally trained group. A
statistical comparison between scores from two 'expert' examiners indicated lack of
agreement, despite identical written and visual criteria being used for evaluation by both.
Both examiners, however, generally showed similar trends in evaluation.
28
An anonymous questionnaire of the Dublin students suggested that they recognized the
benefits of VR training (e.g. ready access to assessment, error identification and how they
can be corrected), but the majority felt that it would not replace conventional training
methods (95%). The most common reasons cited for the preference of conventional
training were excessive critical feedback (55%), lack of personal contact (50%) and
technical hardware difficulties (20%) associated with VR-based training.
In the second study at Dublin, two groups of dental students, with no experience in
operative dentistry, were trained solely by either VR or conventional training in the
preparation of conventional Class 1 cavities. The subjects all used the same operative
armamentarium and phantom heads, and were allocated the same duration of practice
periods. At the completion of these training periods, both groups produced two Class 1
cavities on the lower left first molar, which were subsequently coded and blindly scored
for the traditional assessment criteria of outline form, retention form, smoothness, cavity
depth and cavity margin angulation. An ordinal score of 0-3 or 0-4 was assigned for each
assessment criterion: the higher the score, the worse the evaluation. After initial
independent scoring, the two examiners discussed any notable differences until an agreed
score was reached. Non-parametric analyses of the semi-quantitative scores indicated
worse scores for VR training groups for outline form, depth and smoothness, but an
identical scores for retention and a borderline worse score for cavity margin angulation.
The Dublin staff concluded that VR-based skills acquisition is unsuitable for use as the
sole method of feedback and evaluation for novice dental students.
Some limitations of the Dublin studies are that they used very early generations of
simulators, measured student performance after only four hours of exposure to VR plus
16 hours of traditional teaching (in the first study) and 5 hours in the second study
which rather than using the evaluation capabilities of the unit, relied on staff feedback.
A study in Belgium (Wierinck et al., 2005) also questioned the value of the DentSim.
Novice dental students at Leuven were randomly assigned to one of three groups and
given the task of drilling a geometrical class 1 cavity. The VR group trained under
augmented visual feedback conditions using the DentSim). The no-VR group practised
under normal vision conditions, and a control group performed the test sessions without
participating in any training. All preparations were evaluated by the VR grading system
according to four traditional criteria (outline shape, floor depth, floor smoothness and
wall inclination), and two critical, clinical criteria (pulp exposure and damage to adjacent
teeth). The DentSim group obtained the highest score for floor depth (P < 0.001), whilst
the no-VR group was best for floor smoothness (P < 0.005). However, at the retention
test, the VR group demonstrated inferior performance compared with the no-VR group. It
was concluded that drilling experience on a VR system with frequently provided
feedback and a lack of any tutor input was not beneficial to learning.
The University of Tennessee Health Science Center College of Dentistry deployed 40
DentSim simulators, in conjunction with an 80-unit traditional simulation laboratory.
They described both the positive and negative aspects as they impacted on the students,
staff and school over one year. Issues included the high cost, frustration with the time
taken for calibration, and the limited rang of learning programs available. Positive aspects
were greater feedback for students on their work (Lackey 2004).
29
An evaluation of the DentSim was conducted at the Tokyo Medical and Dental
University, the largest dental school in Japan, to determine whether enhanced feedback
assisted novice but highly computer-literate dental students when learning cavity
preparation. A total of 39 dental students were randomly divided into two groups, and
the students then performed a Class II cavity preparation on the lower left first molar
tooth four times every week without any instructor feedback. At the last session, all
preparations were assessed using the DentSim (Yasukawa 2009). The DentSim users
obtained significantly higher scores than the conventional controls, for outline shape,
outline centralization, outline smoothness, wall incline, wall smoothness, proximal
clearance, and box width. The DentSim students tended to spend a longer preparation
time each week than the controls, so the effectiveness of cavity preparation with feedback
would have been influenced by that greater time for practice makes perfect. The
finding of positive student views on computer technology enhancing their engagement
with the technology to give better learning outcomes was also shown in a more recent
study in Taiwan (Chen et al., 2010).
A rather more rigorous user assessment was undertaken using students in the UK (Rees et
al. 2007). A total of 16 second year undergraduate dental students spent 6 hours cutting
an unlimited number of Class I cavities and Class II cavities. The final mark awarded by
the VR software together with the overall preparation time and number of evaluations for
each cavity were recorded. For the Class I cavity the mean mark obtained was 66.8, the
mean preparation time was 12.5 mins and the mean number of evaluations was 6.7. For
the Class II cavity the mean mark was 26.5, the mean preparation time was 18 mins and
the mean number of evaluations was 7.0. Final marks were also stratified into quartiles
(0-24, 25-49, 50- 74, 75-100). For the Class II cavity the time taken to complete the
cavity and the number of evaluations made were greater for those cavities that gained a
mark of 50 or more. There was also a trend towards higher marks being associated with
longer preparation times and more evaluations during the preparation, demonstrating the
impact of feedback. The same trend was seen in a similar study conducted at the same
time in Belgium (Wierinck et al., 2006).
The Ernst-Moritz-Arndt-University in Greifswald, Germany assessed student responses
to the DentSim system when done as an optional elective (Welk et al., 2008). With a self
selected group the response bias was high, and thus strong scores for acceptance of, and
response to, additional elective training time in the computer-assisted simulation lab were
high as expected. Overall, some 87.3% rated the experience of using a DentSim as
interesting. There were trends for better knowledge retention and incidental learning
regarding anatomy, preparation procedures, and cavity design, although not reaching
statistical significance. A major factor identified in the study was the wide range in the
number of prepared teeth needed to acquire the necessary skills, which demonstrated the
varied individual learning curves of the students.
The same group from Greifswald also assessed awareness of high dental simulation by
their academic peers by surveying the Departments of Conservative Dentistry and
Prosthetic Dentistry of all 32 dental schools in Germany. Besides investigating the
usefulness of, familiarity with and level of current usage of computer simulation systems,
the questionnaire also contained questions regarding each respondent's gender, age,
academic rank, experience in academia and computer skills, all of which correlated with
the responses. From a very good response rate of 90% (112 out of 125 academics), the
30
majority believed that computer assisted simulation was either 'partly' or 'very' useful for
evaluating the acquisition of knowledge (83.9%), qualitative issues (73.2%) and
processes (72.3%) of dental preparation exercises and complex treatment strategies.
However, only about half the respondents reported that they knew of, and even fewer
used, any such systems (Welk et al., 2006a).
A further study by the same authors (Wierinck et al., 2006b) explored the effect of
reducing the frequency of augmented feedback on manual dexterity skills using the
DentSim, for a cavity preparation on a molar tooth undertaken by novice dental students.
A total of 36 dental students were assigned to one of two training groups or a control
group. The task consisted of a geometrical cross preparation on the lower left first molar
tooth. After a baseline skill assessment, the two training groups received simulation
feedback, enriched with tutorial information, one with continuous augmented feedback,
and the other with intermittent feedback (66% of the time). After 1 day and 4 months, all
students were examined by requiring them to prepare the adjacent lower second molar
tooth. All tests were performed in the absence of feedback, and were graded by the
DentSim software. Both the two training groups performed similarly and improved with
practice. After 1 day and 4 months of no practice, both outperformed the control group on
the skills retention test, indicating no effect from reduced feedback within the range
tested. The authors suggested that in future training sessions on a simulation unit could be
alternated with training sessions in the traditional phantom head laboratory.
A major issue found in all studies of the DentSim across the globe was calibration, which
admitted improved in each upgrade of the software. There was frustration in all studies
among students when technical problems interfered with their ability to complete a task
that was part of their course grade. Recent information received from Hong Kong
University is that their fleet of some 20 DentSim units will soon be decommissioned
because of ongoing technical issues (the units are no longer available commercially).
A summary of the literature regarding DentSim and the original expectations of benefit as
proposed by its developers is presented in Table 6 below. This shows that more rapid
training is the single benefit of the system, which infers that for maximum cost/benefit
this system may be much better used not with every student but deployed to those few
students who are struggling to gain the required skills. Such students will gain the most
benefit from the intense and detailed feedback.
31
Table 6. Overall assessment of the DentSim 3D VR system
4.12 EPED system

Released in early 2010, the CDS-100 system by Eped (Taiwan) (Appendix 2) is based on
exactly the same approach as the DentSim, and comprised (a) a dental handpiece with a
drill for drilling a cavity in a synthetic tooth; (b) a three-dimensional sensor with six
degrees of freedom attached to the dental handpiece, which provides the system with the
position and orientation in space of the handpiece and the drill; and (c) a data processing
and display unit for displaying the procedure.
The three-dimensional sensors provide
information regarding the position (e.g., in X, Y and Z terms of a Cartesian coordinates
system) and the orientation (e.g., in alpha, beta and gamma angles of the Cartesian
coordinates system or as also known the azimuth, elevation and roll) of the handpiece in
space.
32
The system uses as a reference point artificial teeth inside a phantom head artificial tooth,
with an additional three-dimensional sensor attached to the head to provide the system
with the position and orientation in space of the head and all the teeth. There are no
published studies with the CDS-100, however a 6 month trial of this system in 2010 at
The University of Queensland gave similar results to that shown above for DentSim,
which is to be expected as it is essentially the same approach, albeit with more modern
hardware and software.
5. Industrial best practice in simulation the lessons for dental education
A dedicated high fidelity training environment is offered in a number of industries, with
perhaps the best example being the airline industry with full motion flight simulation.
The airline industry quickly realized that to improve the utilization from a cost and
training benefit standpoint, supportive training devices were needed. For some 20 years
the airline industry has specifically mapped the numbers and types of training device
needed for their fleets, not just by aircraft type, but how they are used dependant on
operational requirements and staffing ratios.
To support this training optimization, multiple devices of tiered fidelity, function and number
are used to lead the crew up to the point of maximum benefit from the training hours in the
hugely expensive full flight simulators.
33
In same way, dental education could benefit from an approach that uses many pervasive
and economical training tools to progress trainees, as and only when, skills evolve to the
point where the next level of fidelity, complexity and cost are required and beneficial.
This approach aligns with a barrier/hurdle model for competency development and skill
assessment which is already used in dental education.
5.1 Future use of SLEs using a stepwise approach
The project work mapped the future use of simulation in dentistry and oral health
according to the typology of simulations proposed, as follows:
a. High Fidelity Simulation: devices that replicate whole systems and provide realistic
response of the system to user input.
b. Part Task Trainers: devices that provide high fidelity for a sub-system or part of a more
complex task.
c. Computer Based Training: software packages that provide blended material of text,
video, animation and audio to supplement didactic learning.
d. E-Learning: blended learning material delivered over the web or in a thin client format.
e. Virtual Environments: Interactive real time 3D worlds depicting training environments
and providing appropriate fidelity for interaction and system performance
f. Games technology: the user of commercial entertainment consoles to provide
interactive experiences with virtual environments.
For future use of simulation, a model is proposed in which trainees graduate upwards
through a scaled structure of devices, which provide increasing realism and fidelity of the
complete dental practice. This model would provide larger numbers of more affordable
simulators, catering for decomposed tasks, preparing trainees for exposure to more
sophisticated and expensive simulators only when their competence is such that they can
derive economical benefit from the more advanced simulation.
There are several key areas of training where a scalable approach to the use of simulators
and technology can be beneficial to dental education. This industrial experience supports
the model proposed for the development of the scaled use of large numbers of low cost
low fidelity devices, rising through more sophisticated devices to the high fidelity
simulators found in skills laboratories currently used in medical education. This
approach can be illustrated by examples from other industries.
g. High Fidelity dental skills trainers are akin to the medical human mannequins are
common and used in skills labs, but much like the flight environment, require mastery of
fundamental skills and decision making processes before they are utilized to their full
potential.
34
Fig. 9. The role of computer-based simulation
h. Skills training, part task training devices of scaled fidelity provide progressive training,
in: pilot, engineering and maintenance training with sub-system devices with which
trainees can only progress from one to the other once acceptable standards are reached. A
example of the range of such devices can be seen at
http://www.flightglobal.com/staticpages/milsimacronyms.html.
i. Non-technical skills, computer based training and simulation are now commonly used
to provide learning experiences in the development of decision making skills, situational
awareness and cultural sensitivity. Examples of recent developments are:
the Virtual Dental Implant Training System from Breakaway Games and the
University of Georgia;
Project Canary from the Mining Industry Skills Centre for safety training; and
Tactical Language Trainer providing cultural sensitivity training for service personnel
in Afghanistan.
j. Team training, the use of simulations based on computer game style technology has
been extensively used by defence forces all over the world to provide teams with
coordination and decision making skills e.g Americas Army, VBS2. Recently, this
crew resource management approach has been applied to dentistry (Michigan 2010).
35
5.2 Task decomposition for technical skill development

In order to either develop new or adapt existing training technology, some degree of task
decomposition will be required, with trainee competence end states defined. This will
leave possible one of two choices for the system(s) development. Firstly, the task is
decomposed into objectives, to the point where end states can be matched against device
or technology end state capabilities. An example might be where motor skill control of a
dental instrument (such as an air turbine handpiece or scaler) for X,Y,Z displacement of
N mm, with an accuracy of 0.001mm.
Alternatively, taking a systems design approach, one could define the design constraints
of the system. Typically these constraints might start with: a cost low enough to allow
each student to have unrestricted access; mobility such that classroom space is not taken
up; an approach which is engaging for the student; and an ability to show learning
progression. The following sections and concepts assume some degree of task
decomposition.
5.3 Simulation prior to commencing preclinical work
If the pyramid model for the number, fidelity and cost of simulation device is followed
along with the task decomposition approach, the use of simulation based training could
begin with what is commonly and easily available. If tasks are decomposed to the level of
for example hand/eye coordination, the instruments or tools selected could address this.
Whilst not task specific, this would develop overall dexterity, accuracy of movement and
decision making, with good effect as shown by Kahol.
5.4 Simulation based training devices
To fully realize the economic, layered skill development and potential for easing clinical
supervision load benefits of synthetic learning environments, a range of simulation
technologies need to be adopted. These should follow general guidelines in their
development:
1. Extensibility, to include multiple modules, avoiding unnecessary repetition of the same
content
2. Measurability, to provide reportable metrics of trainee performance
3. Scalability, to allow for skill acquisition and motivational challenge
4. They should promote engagement with the trainee, such that they complete the
curriculum.
5.5 The use of proxy devices
To make best use of the technology and exploit the creativity of the simulation (and
serious game) industry, the key attributes of software flexibility and mobile computing
should be exploited.
36
At the fundamentals level of simulation use, the development should begin by avoiding
hardware adaptation, and instead should focus on what is easier, namely software and 3D
modeling. The focus should be on cheaper and more extensible software engineering, as
opposed to creating custom engineered hardware interfaces. Custom engineered
simulation devices can and should be used, but in lesser numbers and only when the
training need and trainee capability can warrant the expense, as shown in the pyramid
model proposed.
The intention for the selection and software design would be to create proxy devices
that provide some relevant skill or competency to an acceptable degree for their
introductory level in the training hierarchy.
The programs adapted or engineered for simulation must provide controllable; repeatable;
and measurable simulated learning environments.
The use of proxy devices should be considered in 3 levels:
1. Out of the box consumer and professional grade devices that could, with clear
understanding of task decomposition, provide a training benefit, e.g computer
games that enhance manual dexterity or hand-eye coordination.
2. Software modified consumer products. Here specifically adapted software, virtual
environment or programs provide the user with tasks that require the next level of
skill development, e.g. the practice of manual dexterity when working with a
mirrored image.
3. Hardware and software modified devices. The intention would be to provide an
adapted hardware user interface to the training that more closely simulates some
element of clinical procedure, e.g. integrating a spatially tracked dental instrument
to the task.
These proxy devices would follow the same pyramid approach, where Level 1 would be
the cheapest and most widely proliferated; Level 2, slightly more expensive; and Level 3
more so and used in lesser numbers and only when levels 1 and 2 have been successfully
completed.
A recent example can be found at The University of Glasgow Dental School
(http://www.physorg.com/news157134004.html ) where consumer entertainment
products were used to create dental task training simulations.
The next level of proxy device could make use of commercially available tools, mainly
the hardware interface, to provide the next level of progression to real physical motor
skills. Here one would use haptic devices such as joysticks or phantoms with dental
instrument additions, or computer drawing tablets to allow trainee development of small
but precise x, y and z motor control over the tool.
37
5.6 Technical skills development

Technical skill development can be broken down into several building blocks of
capability that act as gates, through which students must pass in sequence. By having
stepped barriers to progress, only when the student successfully completes a stage of skill
development do they progress to more sophisticated training devices. There are
fundamentals skills which must be developed before entry to any clinical setting which
justify greater attention and access to more advanced simulators and supervisor time.
These skills can be developed in a non-clinical setting with supervision and assessment
provided submission of electronic performance data: score; playbacks or virtual data.
When these systems are being considered for use, some fundamental capabilities need to
be considered:
1. Provide visual representation of suitable tasks, a 2D and 3D template along with
drilling of artificial (synthetic) teeth to pre-determined outlines.
2. Provide sufficient and appropriate visual fidelity of the computer generated images
3. Mimic a suitable hand held instrument
4. Replicate the reverse image as seen in a hand held dental mirror
5. Track the movement of the instrument in X, Y and Z coordinates. The displacement (in
mm) and accuracy must be confirmed through calibration.
6. Provide visual feedback to the trainee of accurate versus inaccurate progression in the
allocated task
7. Provide a well designed interface so that the trainee is encouraged to sit upright in
correct operating posture, with the hands at the correct level and the head aligned so as
not to induce a stoop over the patients head.
8. Allow multiple Start, Stop, Replay and Save as best scenarios
9. Be low cost and deployable into existing dental training laboratories
10. Allow clinician educators the ability to create or define levels of complexity
5.7 Proxy Device Level 1
At the entry level, training solutions could begin with simple use of existing simulation
technology, using the experience as a warm up to more realistic scenarios. This
approach has been shown to be success for medical simulation, if the warm up periods
are of sufficient length and close to further training (Kahol et al. 2009). This study
showed how out of the box consumer products can be used to provide elementary
practice with fundamental motor skills.
At the second proxy level, consumer devices such as digital drawing tablets could be
used to develop skills in forming 2D shapes, and then by using the pressure
sensitive versions, an approximation to depth or 3D control can be introduced.
38
Fig. 10. Pressure-sensitive drawing tablet (left) and haptic controller (right)
Similarly at this second level, software engineering can create virtual environments for
use with these devices that assist in skills development. The software and virtual
environments used can operate at many levels of fidelity, providing abstract to fully
realistic environments designed to offer skills development.
At the higher end of Level 2, inexpensive adaptation of consumer electronics and games
consoles can provide innovate solutions for training. Of particular interest for physical
skill development in the dental situation and linking low cost proxy devices can be
illustrated by the work of Lee and the adaptations of that work by Kahol.
The image below shows schematics developed by Kahol, based on work by Johnny Lee
(now Microsoft). The URL http://www.youtube.com/user/jcl5m#p/u/2/0awjPUkBXOU
shows how Wii motion trackers can detect user hands and fingers with reflective material
attached. The proposed concept here would be to have either gloves or finger sock with
reflectors to register position. The trainee can then hold any device and have their
movements tracked in 3D space, overlade on suitable 3D models and combined to create
dexterity building tasks.
39
There would be value in creating simple dexterity developing simulations using the
modified Wii device.
At the third level of the proxy device the introduction of customized hardware
interfaces can link actual procedural tools and technologies such force feedback, or
haptics to provide the next level in fidelity.
Phantom devices can provide a force feedback to the user for certain physical tasks and
have been used in surgical and dental simulation. Here the instrument or tool is attached
or mimicked at the end effector of the phantom device. The phantom device provides a
calibrated resistance or force feedback to the user, dependant on the tissue type being
virtually touch by the trainee in the simulation.
Examples of this approach used in dental education are the Periosim and the Simodont.
40
5.10 Simodont
As shown in the figures below and also in Figures 21-24 in Appendix 2, a commercially
available dental haptic system (the Simodont by Moog) has recently become available for
use in dental education, and is currently under trial in several Australian dental schools.
The Simodont system currently offers simple restorative and periodontal procedures,
however it is anticipated that a greater range of skills-based exercises will be added to
repertoire over time.
As well as simple cavity preparations and crown preparations, the haptic simulation
devices and technologies discussed so far can be applied to a number of typodont-based
simulation activities:
1. Dental prophylaxis and stain removal
2. Dental local anaesthesia
3. Intramuscular injection
4. Splinting of mobile or avulsed teeth
5. Bonding of tooth fragments
6. Multi-layer composite resin veneers
7. Sealing of endodontic perforations
8. Precision and magnetic attachments
9. Removal of posts
10. Removal of broken endodontic instruments
Similarly, improved virtual reality haptic dental simulators can be created with the
approaches discussed to address:
1. Administration of local anaesthesia by infiltration
2. Administration of local anaesthesia by block injection
3. Intra-osseous anaesthesia
4. Biopsy techniques
5. Gingivectomy and gingivectomy
6. Crown lengthening surgery
7. Guided tissue and guided bone regeneration
8. Alveolectomy, ostectomy and osteotomy
9. Use of lasers for hard tissue procedures
41
10. Use of lasers for soft tissue procedures

11. Use of electrosurgery for soft tissue procedures
12. Periodontal flap surgery
13. Use of piezosurgery for bone surgery
14. Technique work for bone chip harvesting and block bone grafts
15. Surgical tooth removal guided by virtual reality
16. Third molar surgery guided by virtual reality
17. Implant placement surgery guided by virtual reality
18. Endodontic apical surgery guided by virtual reality
The existing simulation systems used in dental education have been designed primarily
for skills development in restorative (operative) dental procedures, particularly for cavity
preparation using rotary instruments. It would be possible to adapt such systems to
increase their versatility, for example of the current VR systems (Dent-Sim by DenX and
CDS-100 by Eped, shown below and in Appendix 2) can be adapted to include
Implant placement surgery guided by virtual reality (DentSim)
Administration of local anaesthesia (CDS100).
5.11 The current gap in technical skills training
The current progression in dental education through psychomotor skills development
moves from a simple 2D block drilling task on a low cost consumable learner block to
a high fidelity phantom head simulator in one step. The progression required in skill
development and application is much like moving a pilot from desktop joystick to a full
flight simulator. This approach, even though used internationally for many years, does
not permit any scaled learning and assessment stages to monitor progression.
Moreover, from the perspective of managing the learning process, the students move
from a largely low cost unsupervised environment to a very high cost supervisorintensive
laboratory in one step. The current experience shows that from a skills
development and supervisory point of view, the students are not ready to make use of the
more complex environment of the phantom head, and as a result many months are
potentially wasted in the laboratory whilst skills evolve slowly to the point when they are
truly ready to make use of the phantom head simulation and the input of the clinicians
who serve as instructors.
In order to more efficiently prepare trainees for the higher cost and supervision intensive
lab simulation, a new class of intermediary simulation device is required. This device sits
above the proxy devices described previously and below the high fidelity simulators
such as the Moog and EPED units shown above. Such a device would clearly fit within
the pyramid model proposed .This approach has been successfully adopted in Surgical
Skills training with the use of the Box FLS system, by G.M Fied.
42
Fig 15. FLS Training Box

The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills
(MISTELS) is a series of five tasks with an objective scoring system using a simple
simulation of motor control for picking, placing and suturing of proxy objects.
http://www.flsprogram.org/
The dental equivalent of the FLS Box Trainer would follow the same principle of being
low cost, and driven by curriculum and skill development rather than absolute fidelity
and visual realism. The units would be easy to install and they require no calibration
since no absolute measurements and tracking are required. All the end effecter/tool
position feedback would be visual, presented to the trainee through a reverse image
window initially, and then through smaller dental mirrors as skills develop. The trainees
would be able to use actual dental instruments, and be seated in the correct posture thus
developing transferable motor control skills. The simulator exercises would use either
mounted natural or artificial teeth placed in the box. This box could even be modified to
include additional features such as synthetic tongues and saliva to introduce additional
task complexity.
5.12 Non-technical skills development Simulation to support clinical work, undertaken
extramurally
The following examples of simulation application developed to meet Dental curricula
should be developed from the outset with the following operational concepts:
Provide standalone installations for individual PCs
Offer web based solutions with thin clients
Exploit the availability of cloud computing for application and data hosting
Offer versions for hand held devices, such I Phones and other Android and
Windows Mobile operating system devices
Patient history taking practice can be provided in a scaled sequence of interactive
scenarios presented in a web based format:
a. The student watches multi-media presentations of patient history taking conversations
and reports via multiple choice questions on the effectives of the process. Here the
student is guided through the process critically appraising the history taking.
43
b. The next level requires the student to watch similar presentations of a history taking,
but responds in free text form to questions posed by the tutor on the effectiveness of the
process.
c. The final stage of the web based tool would see the student reviewing history taking
conversations and reporting without staged questions on the effectiveness.
2. Patient history taking can also be presented in a interactive computer simulation
where the student engages in a conversation with a virtual patient. This conversation is
enabled by text entry by the student of their questions or by selection of presented
questions. In both instances the virtual patient responds from a structured logic
conversation (commonly used in chat bots).
The virtual environments and patient scenarios used to create all the presentations and
tools can be from the same source, making maximum use of the technology and ensuring
ease of updating and maintenance of technical concurrency.
3. Patient scenarios for diagnosis and treatment planning.
The outcome of the history taking, would be a treatment plan, which similarly can be
presented in a virtual environment where the student can plan follow through with the
aim of visualizing and observing the outcomes of their decision making processes.
4. Digital tutor tools for oral medicine, oral pathology and radiology.
Virtual pedagogical agents can be embedded into virtual environments providing guided
assistance on request by the student or when the students decision making or interaction
has resulted in some error in process being recorded by the simulation logic.
5. Electronic portfolios for self reflection and peer review. All simulations and exercises
undertaken can be stored and reviewed for self assessment and submission at any time.
44
6. Decision making exercises with the explicit intention of developing naturalistic

decision making skills, supported by expert and novice thinking algorithm, embedded in
the problem solving exercise.
7. Emergency management scenarios that involve one or more trainees. Single and
multiple user simulations can be constructed from the same virtual environments as used
in previous applications to role play out the management of clinical events where
emergency intervention is required. The simulations focus on the decision making skill
and enable the trainee to observe the implication of choices played out in safe
controllable and repeatable simulated scenarios.
8. Simulation using students working in pairs/groups:
Handling the wheelchair bound patient (transfers & hoists)
Fabrication and fitting of mandibular advancement splints
Electromyographic recording and analysis
Improving teamwork and communication. The application or crew resource
anagement techniques to the dental surgery as seen at The University Of Michigan
and reported in the Journal of the American Dental Association 2010.
9. Whole of patient / medical procedure simulators
Intravenous drug administration
Management of the collapsed patient
Treatment of patients under sedation (virtual operating room),
Treatment of patients under general anaesthesia (virtual operating room)
10. Virtual clinic and virtual lab environments for familiarization before classes.
Many of these non-technical skills development uses of synthetic learning environments
can be applied to the other clinical areas under evaluation by Health Workforce Australia
and would benefit from a coordinated development approach.
6. Outcome of stakeholder consultation
At the ACODS meetings there was unanimous agreement from the Heads/Deans that
preclinical simulation activities should remain a formal part of curricula in dental and
oral health programs, and should be extended where there is evidence that the new SLEs
address shortcomings in the existing programs and improve the quality of graduates.
The Heads/Deans were unified in their view that clinical contact with patients by students
must not be replaced or diminished by simulation but rather must remain a core part of
university training programs because of the need to produce graduates who possessed a
broad range of competencies, including the ability to work safety and effectively with
patients in a range of settings.
45
There was a formal requirement from ADC and an expectation from the community that
graduates from dentistry and oral health programs would display cultural and social
sensitivity, show respect for patients differences and autonomy, be able to relieve pain
and suffering in an empathic and kind manner, coordinate continuous care, advocate
disease prevention, and promote a healthy lifestyle in a holistic approach to the
individual patient as well as the community.
Each of the 10 Australian dental schools has given their unanimous endorsement of this
report, and all of its six recommendations. This report has been transmitted to the
Australian Dental Council as the accreditation body for these programs, and to the Dental
Board of Australia as the national regulatory authority.
The ADC competency framework (2010) provides the basis for a national approach to
dentistry and oral health education programs. The ADC expects that dental schools will
use simulation where appropriate to support student learning, consistent with achieving
the best educational outcomes.
6.1 Mapping to professional competencies
Two of the senior members of the project team (Professors DeVries and Walsh) served
on the ADC committee which developed such listings for both dentists and oral health
therapists during 2010. This latter work occurred in parallel with the HWA project, and
this alignment of work was to the benefit of the HWA project.
A number of publications from Australian and international dental and accreditation
organizations were drawn on in preparing these competency maps, including material from
Canada, Europe, New Zealand, South Africa United Kingdom and USA, and particularly
work from the Association for Dental Education in Europe (ADEE) and the American Dental
Education Association (ADEA).
Competencies of new graduates that can be assisted by the use of SLEs are shown in
Appendix 1, which maps the 2010 ADC listing of competencies by current and future
SLEs. Note that when referring to this document, the majority of activities use some form
of simulation and that new simulation technologies have application in a range of
learning areas.
6.2 Discussion with stakeholders
As already outlined, interim findings from the project were fed back to a special meeting
of the Heads/Deans of dental schools (ACODS) in September, which was held in parallel
with the IADR ANZ division research meeting at Kiama, NSW.
The recommendations from the project were discussed at a special teleconference of
ACODS held on 14 November. At this meeting, the heads/deans of all nine Australian
university dental schools which offer professional entry programs in dentistry and/or oral
health supported the recommendations regarding specific curricular elements identified
for simulation which could be added into the existing simulation activities.
46
These specific elements include:

(a) Virtual worlds for students to interact with others both locally and globally;
(b) Virtual microscopy to augment or replace traditional light microscopy;
(c) 3D software for dental anatomy and dental radiology
(d) Skills development boxes to bridge the identified gap before students use phantom
head simulators, targeted to manual dexterity, hand-eye coordination, and mirror vision.
Such units, yet to be developed, would enhance greatly the efficiency of existing
curriculum time devoted to using phantom heads.
(e) Haptic simulation units to accelerate skills progression and to enhance training so as
to reduce surgical misadventure.
6.3 Analysis of issues relating to deployment of these technologies.
(a) Virtual worlds for students to interact with others both locally and globally
A number of web-based platforms already exist (e.g. Second Life). The specific
educational objectives relating to this activity are as follows:
Be able to engage effectively and appropriately with information and communication

technologies;
Appreciate the philosophical and social contexts of the dental profession;
Appreciate cultural diversity;
Appreciate the diversity of systems for and approaches to clinical care both nationally
and globally;
Understanding how other health disciplines relate to dentistry and oral health;
Be able to select and use the appropriate level, style and means of communication for
the situation at hand;
Be able to interact effectively with others in order to work towards the common
outcome of improved rapport, consent and clinical care;
Gain greater understanding of the range of medical and psychological factors which
impact patient care; and
Develop skills in establishing rapport with patients and with handling situations
where establishing communication and gaining consent for treatment are more
difficult.
(b) Virtual microscopy to augment or replace traditional light microscopy

A range of freeware viewers for VM databases already exist. Both the Universities of
Queensland and Melbourne have recent experience at using and deploying VM. The UQ
virtual slidebox could be used under licence by other dental schools. The specific
47
Appreciate the fine structure of oral and peri-oral tissues;

Be able to delineate abnormalities in tissue structure from normal;
Understand the interactions between microscopic processes and clinical
appearances of hard and soft oral tissues;
Understand the cellular and molecular basis of oral disease, and demonstrate this
understanding by analysing relevant clinical problems and explaining a patients
response to infectious agents, and other immunological diseases and
abnormalities;
Appreciate common pathological conditions relevant to clinical practice;
Gain greater understanding of key processes including inflammation,
degeneration, necrosis and neoplasia;
Understand the pathology of primary and secondary diseases of the oral and paraoral
structures; and
Communicate with medical and dental colleagues on morbidity and terminal
pathology, from a basic understanding of the more common general systemic
diseases and their histopathology, and be able to relate this to normal histology.
(c) 3D software for dental anatomy and dental radiology
A range of commercial products exist which can be used to support the areas of anatomy
and radiology which are relevant to dental and oral health students. These could be
provided through university libraries under site licensing arrangements as a cost-effective
means for their deployment at scale so that all students have identical opportunities to
access these resources. The specific educational objectives relating to this activity are as
follows:
Understand the principles of tomography, particularly rotational tomography and
volumetric tomography in imaging the head, jaws and teeth;
Appreciate the gross structure of oral and peri-oral soft and hard tissues;
Be able to delineate abnormalities in tissue structure from normal;
Identify common abnormalities in the development of the teeth and jaws;
Identify common disease processes including dental caries, periodontitis, pulpa
and endodontic pathology;
Identify critical structures within and immediately adjacent to the oral cavity; and
the potential for misadventure during administration of local anaesthesia and
during surgical procedures such as tooth extraction.
(d) Skills development boxes to bridge the identified gap before students use phantom
head simulators, targeted to manual dexterity, hand-eye coordination, and mirror vision.
Such units are already used for training surgeons in endoscopic procedures, and a parallel
logic could be applied to dental education, following a progression of skills. The cost of
such units would be low, and they would be deployed at scale one for each PCSL
station so that all students would use these as part of their normal skills development. The
development of such skills trainers would be a major focus of future HWA supported
work in enriching and expanding simulation in dentistry and oral health. The specific
48
Develop fine control of pressure using direct vision;

Apply control of position and pressure to machine defined shapes in trainer
blocks;
Understand the principles of positioning instruments and devices with contraangle
designs;
Develop skills in instrument grasps and in using finger rests to stabilize the fine
motor control of instruments;
To develop competence in basic clinical skills relevant to oral health and dentistry
Develop hand-eye coordination for applying instruments and materials to teeth
under direct vision to achieve clinically relevant outcomes;
Develop skills in using mirror vision for topical, reversible procedures;
Develop skills in undertaking irreversible procedures such as tooth cutting using
mirror vision.
Develop the technical ability to place simple intracoronal restorations in
permanent teeth; and
Be able to use and apply a limited range of direct dental restorative materials.
(e) Haptic simulation units to accelerate skills progression and to enhance training so as
to reduce surgical misadventure.
At the present time, one commercial unit is available for haptic dental simulation
(Simodont). It is anticipated that each school would have one or two such units located
within or nearby to their existing PCSL to support their existing simulation curriculum
for specific activities involving the controlled application of force, particularly
periodontal probing and the use of dental explorers to diagnose common oral diseases.
These would be used by student cohorts on a rotational basis to extend and enrich their
skills. The high cost of these units would be prohibitive for a wider deployment.
The specific educational objectives relating to this activity are as follows
develop fine control of tactile pressure using both direct and indirect (mirror)
vision for diagnostic procedures in the management of dental caries, periodontal
diseases and other disorders;
enrich existing skills for applying fine control of position and pressure; and
develop skills in undertaking irreversible procedures in endodontics and oral
surgery.
6.4 Impact on dental education
Likely impacts of these extensions of existing simulation activities in dentistry and oral
health curricula are summarized in Table 7.
6.5 Implementation
No major barriers to these activities, other than their direct costs, were recognized by the
universities for clinical training purposes. In other words, all schools saw these types of
activities as being well suited to incorporate into existing curricular frameworks.
Implementation of these 5 simulation initiatives would require the actions shown in Table
8.
49
50
51
7. New horizons for simulation

Information regarding the feasibility, barriers, and deployment of novel SLEs was
developed by the project officers and consultant working with team members, to explore
opportunities for:
skills enhancement to commencing preclinical work
new approaches for typodont-based simulation activities
simulation work to support and enhance clinical work, undertaken extramurally,
including patient assessment, and
building focus on communication skills and professionalism.
This work was supported and refined by verbal and other communications amongst team
members. These areas have been mapped onto the ADC competencies in Appendices 1A
and 1B.
As shown in Appendices 1A and 1B, the project identified a number of additional areas
beyond the above five where simulation could be potentially be used in education in
dentistry and oral health. The first cluster of these was rated as medium in terms of
feasibility. Comments on these are provided in Table 9 below.
52
Identification of additional future possibilities for simulation by the Schools, beyond the
areas already mentioned above is presented in Appendix 5B. At the postgraduate level
and for continuing professional education there was considerable interest in surgical
aspects of dentistry, particularly oral and maxillofacial surgery, periodontal surgery, and
implant insertion surgery. A more detailed mapping of possible areas is presented in
Table 10 below.
Current haptic dental simulators (such as the Simodont) could be adapted for oral surgical
procedures including:
Use of piezosurgery for bone surgery
Technique work for bone chip harvesting and block bone grafts
Surgical tooth removal guided by virtual reality
Third molar surgery guided by virtual reality
Implant placement surgery guided by virtual reality, and
Endodontic apical surgery guided by virtual reality.
An emerging area is that of image-guided oral surgery. This topic has an emerging
literature which is summarized in Appendix 6. This type of surgery is typically more
complex than would be considered within the scope of the new dental graduate.
53
11. Recommendations from the project

Recommendation 1. The ADC framework be used as a basis for embedding novel
simulation methods into dental and oral health curricula.
Recommendation 2. Future HWA support be provided to develop and implement
skills development boxes which can be deployed at scale to all dental schools to
bridge the skill gap for junior students in dentistry and oral health before they
commence phantom head work, particularly in restorative dental procedures.
Recommendation 3. The following measures be deployed as standard parts of
curricula, to increase the depth of learning and provide a platform for professional
development during the dental course and beyond.
(a) Opportunities to interact with other students in dentistry locally and globally,
and with other students in health professional courses using virtual worlds.
(b) Virtual microscopy to augment or replace traditional microscopy with light
microscopes for oral biology, oral histology and oral pathology.
(c) Three dimensional software for appreciating both dental anatomy and dental
radiology.
(d) In-person interprofessional interactions with other students in health science
programs, to build relationships, establish professional identity, develop
teamwork skills, and appreciate the need for coordination between
healthcare professionals for gaining optimal patient care.
Recommendation 4. Haptic simulation units be deployed in dental schools to enrich
clinical skills, particularly in the area of training in more complex procedures where
they can accelerate skills progression and help avoid surgical misadventure. Such
simulators can enhance the level of preparedness of students prior to clinical
placements. Given the limited scope of the existing literature on simulation in
dentistry, such deployment should be accompanied by multi-centre research on the
educational benefits of such technology.
Recommendation 5. Deployment of haptic simulators to large placement clinics
where many students are located is recommended to allow students to enrich their
skills outside of rostered clinic time. Such simulation units could also be considered
for skills assessments undertaken by the ADC of those re-entering clinical practice
or joining the profession from overseas training programs, as an alternative to live
patient treatments.
Recommendation 6. Dental schools collaborate with other health professions to
maximise opportunities for interprofessional learning.
54
Bibliography
Abbey LM. An expert system for oral diagnosis. J Dent Educ 1987;51:475-480.
Bagnal RD, Geissler PR. Computerized teaching of temperomandibular joint dysfunction.
Br Dent J 1988;164:98-102.
Barnett O. Information technology and undergraduate medical education. Acad Med
1987;64:187-190.
Bayne, S. Uncanny Spaces for Higher Education: Teaching and Learning in Virtual
Worlds. ALT-J Res Learn Technol. 2008; 16(3):197205.
Brody HA, Lucaccini LF, Lamp M. Computer-based education for evaluation of oral
lesions. Spec Care Dentist 1993;12:146-150.
Buchanan JA. Use of simulation technology in dental education. J Dent Educ 2001; 65:
1225-31.
Buchanan JA. Experience with virtual reality-based technology in teaching restorative
dental procedures. J Dent Educ. 2004;68(12):1258-65.
Chen ML, Su ZY, Wu TY, Shieh TY, Chiang CH. Influence of dentistry students' elearning satisfaction: a questionnaire survey. J Med Syst. 2010 Feb 12. [Epub ahead of
print]
Clancy MS, Johnson L, Finkelstein MW, Lilly GE. Diagnosis and treatment (DDx & Tx):
interactive videodisc simulations for dental education. Comp Methods Prog Biom
1990;33:21-26.
Correa L, de Campos AC, Souza SC, Novelli MD. Teaching oral surgery to
undergraduate students: a pilot study using a Web-based practical course. Eur J Dent
Educ 2003; 7: 111-5.
Dalgarno B, Lee MJW. What are the learning affordances of 3-D virtual environments?
Brit J Educ Technol. 2010;41:1032.
Dieckmann P, Gaba D, Rall M. Deepening the theoretical foundations of patient
simulation as social practice. Simulat Healthcare 2007;2:183193.
Farah CS, Maybury TS. The e-evolution of microscopy in dental education. J Dent Educ.
2009a;73(8):942-9.
Farah CS, Maybury TS. The e-evolution of microscopy in dental education. J Dent Educ.
2009a;73:942-949.
55
Farah CS, Maybury T. Implementing digital technology to enhance student learning of

pathology. Eur J Dent Educ. 2009b;13(3):172-8.
Feuerstein O, Houri-Haddad Y, Lipovetsky M, Perez-Davidi M, Weiss EI. Hi-tech trends
in future dentistry - part A: computerized technologies. Refuat Hapeh Vehashinayim
2006; 24: 71-8, 95.
Finklestein MW, Johnson LA, Lilly GE. Interactive videodisc patient simulations of oral
diseases. J Dent Educ 1988;52:217-220.
Graig JF. Potential for computer and optical video-disc techology in dental education.
Dent Clin North Am 1986;30:713-720.
Grigg P, Stephens CD. Computer-assisted learning in dentistry. A view from the UK. J
Dent 1998; 26: 387-95.
Hansen MM. Versatile, immersive, creative and dynamic virtual 3-D healthcare learning
environments: a review of the literature. J Med Internet Res 2008; 10(3):e26
Harrell WE, Hatcher DC, Bolt RL. In Search of Anatomic Truth: 3-Dimensional Digital
Modeling and the Future of Orthodontics. Am J Orthod Dentofac Orthoped.
2002;122:325330.
Hatcher DC. Three-dimensional Digital Imaging. In: McNamara JA & Kapila S (Eds.),
Digital Radiography and Three-Dimensional Imaging. Ann Arbor, Michigan: Needham
Press, pp. 122.
Hawley N, Dye J, Ditmyer M. Knowledge, attitudes, and perceptions of participants and
instructors taking part in a dental school simulation course for potential dental students. J
Dent Educ. 2009;73:483489.
Hayka A, Eytan L. Image sound and feeling simulation system for dentistry. US patent
5,688,188. Issued 1997.
Herrington J, Reeves TC, Oliver R. Immersive learning technologies: realism and online
authentic learning. J Comput Higher Educ. 2007;19:8099.
Hsieh M-S, Tsai M-D, Chang W-C. Virtual reality simulator for osteotomy and fusion
involving the musculoskeletal system. Comput Med Imag Graph 2002; 26: 91-101.
Hyman JJ, Doblecki W. Computerized endodontic diagnosis. J Am Dent Assoc
1983;107:755-758.
Imber S, Shapira G, Gordon M, Judes H, Metzger Z. A virtual reality dental simulator

predicts performance in an operative dentistry manikin course. Eur J Dent Educ
2003;7:1603.
56
Irvine NP, Moore RN. Computer-assisted instruction in mixed dentition analysis. J Dent
Educ 1986;50:312-315.
Jeffcoat MK, Williams RC. Relationship between linear and area measurements of
radiographic bone levels utilizing simple computerized techniques. J Periodont Res
1984;19:191-198.
Kahol K, Satava RM, Ferrara J, Smith ML. Effect of short-term pretrial practice on
surgical proficiency in simulated environments: a randomized trial of the "preoperative
warm-up" effect. J Am Coll Surg. 2009;208(2):255-68.
Kusumoto N, Sohmura T, Yamada S, Wakabayashi K, Nakamura T, Yatani H.
Application of virtual reality force feedback haptic device for oral implant surgery. Clin
Oral Implants Res 2006; 17(6): 708-13.
Lackey MA. One year's experience with virtual reality preclinical laboratory simulation
at the University of Tennessee. Int J Comput Dent. 2004;7(2):131-41.
Lang WP, Green TG, Jacobson JJ. Students knowledge opinions, and behaviors
concerning dental informatics and computer applications. J Dent Educ 1992;56:195-204.
LeBlanc VR, Urbankova A, Hadavi F, Lichtenthal RM. A preliminary study in using

virtual reality to train dental students. J Dent Educ 2004;68(3):37883.
Lefebvre CA, Richardson GB, Taylor RL. Computer-assisted removable partial denture
design. J Dent Educ 1990;54:46-49.
Luffingham JK. An assessment of computer-assisted learning in orthodontics. Br J
Orthod 1984;11:205-208.
Maybury T, Farah CS. Electronic systems of knowledge in the world of virtual

microscopy. Acad Med. 2009;84(9):1244-9.
McKedry D, Krell KV. An interactive computerized textbook for endodontics. J Dent
Educ 1989;53:76-79.
Mubarak S. Design, implementation and assessment of a CD-ROM tutor in dental
radiology. MDSc thesis, the University of Queensland, 2000.
Mullaley TP, Smith TA, Duell RC. Four phase study of computer-assisted and slide-tape
methods of simulating clinical endodontic problems. J Dent Educ 1976;40: 681-687.
Mulligan R, Wood GJ. A controlled evaluation of computer assisted training simulations
in geriatric dentistry. J Dent Educ 1993;57:16-24.
57
Nilsson T, Ahlqvist J, Johansson M, Isberg A. Virtual reality for simulation of

radiographic projections: validation of projection geometry. Dentomaxillofac Radiol.
2004:33:4450.
Nilsson TA, Hedman LR, Ahlqvist JB. A randomized trial of simulation-based versus
conventional training of dental student skill at interpreting spatial information in
radiographs. Simulat Healthcare 2007:2:164169.
Phillips J, Berge ZL. Second Life for dental education. J Dent Educ. 2009:73:12601264.
Pohlenz P, Grbe A, Petersik A, von Sternberg N, Pflesser B, Pommert A, Hhne KH,
Tiede U, Springer I, Heiland M. Virtual dental surgery as a new educational tool in dental
school. J Craniomaxillofac Surg. 2010 Mar 17. [Epub ahead of print]
Puskas JC. Comparison of self-instructional methods for teaching diagnostic testing. J
Dent Educ 1991;55:316-312.
Quinn F, Keogh P, McDonald A, Hussey D. A study comparing the effectiveness of

conventional training and virtual reality simulation in the skills acquisition of junior
dental students. Eur J Dent Educ 2003;7:1649.
Quinn F, Keogh P, McDonald A, Hussey D. A pilot study comparing the effectiveness of
conventional training and virtual reality simulation in the skills acquisition of junior
dental students. Eur J Dent Educ 2003;7:139.
Rees JS, Jenkins SM, James T, Dummer PM, Bryant S, Hayes SJ, Oliver S, Stone D,
Fenton C. An initial evaluation of virtual reality simulation in teaching pre-clinical
operative dentistry in a UK setting. Eur J Prosthodont Restor Dent. 2007;15(2):89-92.
Rucker LM. DentistryA show of hands, please! J Am Coll Dent. 2007;74:410.
Sandoval VA, Dale RA, Hendricson WD. A comparison of four simulation and
instructional methods for endodontic review. J Dent Educ 1987;51:532-538.
Shugars DA, ONeil EH, Bader JD, eds. Healthy America: practitioners for 2005, an
agenda for action for U.S. health professional schools. Durham, N.C. The Pew Health
Professions Commission, 1991.
Siegel MA, Graig JF. Evaluation of oral diagnostic and management skills using
interactive patient simulations. J Dent Educ 1990;54:49-53.
Sloan RF. Computer applications in orthodontics. Int Dent J 1980;30:189-200.
Sohmura T, Hojo H, Nakajima M, Wakabayashi K, Nagao M, Iida S. et al. Prototype of

simulation of orthognathic surgery using a virtual reality haptic device. Int J Oral
Maxillofac Surg 2004; 33: 740-50.
58
Steinberg AD, Bashook PG, Drummond J, Ashrafi S, Zefran M. Assessment of faculty

perception of content validity of PerioSim, a haptic-3D virtual reality dental training
simulator. J Dent Educ 2007; 71(12):157482.
Tan CK, Rajendran K, Voon FC. Hypertext-based enhancement of medical and dental
undergraduate learning. Ann Acad Med Singapore 1990; 19: 761-7.
Tira DE, Tharp LBK, Lipson LF. Computers in dental education. Dent Clin North Am
1986; 30:681-694.
Tira DE. Rationale for an evaluation of a CAI tutorial in a removable partial
prosthodontics classification system. J Comp-based Instr 1977;4:34-42.
Vikal S, U-Thainual P, Carrino JA, Iordachita I, Fischer GS, Fichtinger G. Perk Station-Percutaneous surgery training and performance measurement platform. Comput Med
Imag Graph 2010; 34: 19-32.
von Sternberg N, Bartsch MS, Petersik A, Wiltfang J, Sibbersen W, Grindel T, Tiede U,
Warnke PH, Heiland M, Russo PA, Terheyden H, Pohlenz P, Springer IN. Learning by
doing virtually. Int J Oral Maxillofac Surg. 2007;36(5):386-90.
von Sternberg-Gospos N, Heiland M, Pohlenz M, Schmelzle R, Petersik A, Tiede U.
Learning by doing virtual surgical training. J Craniofac Surg 2006; 34: 64.
Webber RL, Ruttimann UE, Grondhal HG. X-ray image subtraction as a basis for
assessment of periodontal changes. J Periodont Res 1982;17:509-511.
Welk A, Splieth Ch, Seyer D, Rosin M, Siemer M, Meyer G. German dental faculty
attitudes towards computer-assisted simulation systems correlated with personal and
professional profiles. Eur J Dent Educ. 2006;10(2):87-95.
Welk A, Maggio MP, Simon JF, Scarbecz M, Harrison JA, Wicks RA, Gilpatrick RO.
Computer-assisted learning and simulation lab with 40 DentSim units.
Int J Comput Dent. 2008;11(1):17-40.
Wenzel A, Gotfredsen E. Retention after computer-assisted instruction in intraoral
radiography. J Dent Educ 1987;51:244-245.
Widmann G, Stoffner R, Keiler M, Zangerl A, Widmann R, Puelacher W. A laboratory

training and evaluation technique for computer-aided oral implant surgery. Int J Med
Robot 2009; 5: 276-83.
Wierinck E, Puttemans V, Swinnen S, van Steenberghe D. Effect of augmented visual
feedback from a virtual reality simulation system on manual dexterity training. Eur J
Dent Educ. 2005 Feb;9(1):10-6.
59
Wierinck E, Puttemans V, van Steenberghe D.Effect of tutorial input in addition to

augmented feedback on manual dexterity training and its retention. Eur J Dent Educ.
2006a;10(1):24-31.
Wierinck E, Puttemans V, van Steenberghe D. Effect of reducing frequency of
augmented feedback on manual dexterity training and its retention. J Dent.
2006b;34(9):641-7.
Williams RE. Self-instruction in dental education, 1960-1980. J Dent Educ 1981;44:290299.
Wotman S. How are we adapting to change? J Dent Educ 1989;53:697-703.
Yasukawa Y. The effectiveness of cavity preparation training using a virtual reality

simulation system with or without feedback. Kokubyo Gakkai Zasshi. 2009;76(2):73-80.
Yoshida Y, Yamaguchi S, Wakabayashi S, Nagashima T, Takeshige F, Kawamato Y.
Virtual reality simulation training for dental surgery. Stud Health Technol Inform 2009;
142: 435-7.
Zimmerman JL, Ball MJ, Petroski SP. Computers in dentistry. Dent Clin North Am
1986;30:
739-743.
60
Appendix 1A.
A. Purpose of the document

This document describes the type of dentist needed in Australia viz
a scientifically oriented, technically skilled, socially sensitive, professionally minded practitioner who adheres to high standards of
professional conduct and ethics and who can function safely and effectively as a member of the health care system on graduation and
throughout their professional career.
The document is oriented to the newly qualified dentist.
B. Terminology
The concepts described in section C below refer to the achievement of complex capabilities; the term competency has been used in this
document as a shorthand way to refer to these concepts.
The term competency has traditionally been associated with technical training. It is important therefore to clarify how it is being used in this
document and to caution against reducing the framework to a checklist of competencies, each of which is dealt with in isolation from the others as
this does not do justice to the holistic interactions required between knowledge, skills, attitudes and experience in the hands of a practising oral
health clinician. Problem-solving skills, professionalism, ethics and other higher order attributes are just as important to professional clinical
practice as technical abilities. These cannot be measured as discrete competencies but are a vital component of current university health
curricula.
Consequently, for the purposes of this document the following definitions of key concepts are assumed:
Competency
is a complex behaviour or ability essential for the dental practitioner to begin independent, unsupervised dental
practice. Competency includes knowledge, experience, critical thinking and problem-solving skills,
professionalism, ethical values, and technical and procedural skills. These components become an integrated
61
whole during the delivery of patient care by the competent practitioner. Competency assumes that all behaviours
are performed with a degree of quality consistent with patient well-being and that the practitioner self-evaluates
treatment effectiveness. The term covers the complex combination of knowledge and understanding, skills and
attitudes needed by the graduate. Competencies are outcomes of clinical training and experience;
Competent
the behaviour expected of the beginning practitioner. This behaviour incorporates understanding, skill, and
values in an integrated response to the full range of requirements presented in practice.
The following terms which appear in the domain descriptions, embody complex ideas and also need to be defined:
Evidence-based dentistry
an approach to oral health care that requires judicious integration of systematic assessments of clinically
relevant scientific evidence relating to the patients oral and medical condition and history integrated with the
practitioners clinical expertise and the patients treatment needs and preferences;
Patient-centred care
to display cultural and social sensitivity, respect for patients differences and autonomy, relieve pain and
suffering in an empathic and kind manner, coordinate continuous care, advocate disease prevention and promote
a healthy lifestyle in a holistic approach to the individual patient as well as the community;
Critical thinking
the process of assimilating and analysing information, encompassing an interest in finding new solutions, a
professional curiosity with an ability to admit to any lack of understanding, a willingness to examine beliefs and
assumptions and to search for evidence to support those beliefs and assumptions, and the ability to distinguish
between fact and opinion;
Problem solving
the process of finding answers and obtaining outcomes in the absence of the obvious by following an acceptable
heuristic approach;
Health promotion
the process of enabling individuals and communities to increase control over the determinants of health and
thereby improve their health; includes education of patients and the public to prevent chronic oral disease, public
health actions to protect or improve oral health and promote oral well-being through behavioural, educational
and enabling socioeconomic, legal, fiscal, environmental and social measures;
Manage
to manage the oral health care needs of a patient includes all actions performed by a practitioner that are
designed to alter the course of a patients condition. Such actions may include providing education, advice,
treatment by the practitioner, treatment by the practitioner after consultation with another health care
professional, referral of a patient to another health care professional, monitoring treatment provided; it may also
include observation or providing no treatment. Manage assumes the use of the least invasive therapy necessary
to gain a successful outcome in accordance with patient wishes.
62
The structure of the Statements

The range of personal qualities, cognitive abilities and applied skills expected of the newly qualified practitioner have been clustered into the
following six domains:
Professionalism
Communication and Social Skills
Critical Thinking
Health Promotion
Scientific and Clinical Knowledge
Patient Care (which has sub-domains of Clinical Information Gathering, Diagnosis and Treatment Planning, Clinical Treatment and
Evaluation).
The domains represent the broad categories of professional activity and concerns that occur in the general practice of dentistry. As indicated
above, there is a degree of artificiality in the classification, as effective professional performance requires the integration of multiple competencies.
The Competencies Statements below must be read in the context of the matters outlined above and the definitions provided.
C. The Competencies Statements
The goal of dental education in Australia is to develop dentists, dental hygienists and dental therapists who are competent to practise safely and
effectively and who have an appropriate foundation for professional growth and development so that they can respond to changing health needs
throughout their professional lives.1 Dentists, dental hygienists and dental therapists must have an understanding of, and be responsive to, the
oral health needs of Australian communities and individual citizens and apply dental knowledge, clinical and technical skills and professional
attitudes to provide safe and effective patient-centred care.
It is acknowledged that this may change if an internship year is introduced as is proposed in A Healthier Future For All Australians Final Report of the
National Health and Hospitals Reform Commission June 2009. Currently there is no intern system for Australian dental graduates and practitioners must be
competent to practise on the day they graduate.
63
C1 Competencies of the newly qualified dentist

Domain
Description
1.
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to SLEs
Professionalism
On graduation a dentist must:
covers personal
values, attitudes
and behaviours
a. display appropriate caring behaviour towards

patients
a. Role Plays
b. provide patient-centred care, respect patients dignity

and choices; acknowledge that all interactions,
including diagnosis, treatment planning and
treatment, must focus on the patients best interests
b. Case studies, role plays and standardized patients
c. recognise and respect patients rights, particularly

with regard to confidentiality, privacy, informed
consent
c. Case studies and role plays
d. practise evidence-based dentistry

e. recognise personal limitations and know when to
refer appropriately
f.
employ a critically reflective approach to practice

which involves acknowledging and learning from
mistakes and participating in and contributing to
peer review
g. have an ethos of life long professional growth and

development and support continuing education for
all members of the dental team
h. have a thorough understanding of the ethical
principles and legal responsibilities involved in the
provision of dental care to individual patients, to
populations and communities, practising with
personal and professional integrity, honesty and
trustworthiness
d. Assignments and projects

e. Case studies, hypotheticals and role plays.
f.
Reflective journals
g. N/A
h. Case studies, hypotheticals, role plays, and
interprofessional learning activities.
64
Domain
Description
i.
understand and apply Commonwealth, State and

Territory legislation relevant to practise as a dentist
j.
use contemporary information technology for

documentation, continuing education,
communication, management of information and
applications related to health care
i.
Assignments, case studies and role plays
j.
N/A
k. Case studies and role plays
k. have a desire to achieve the optimal patient care with

an awareness of the need for cost-effectiveness to
allow maximum benefit from the available resources
l.
manage and maintain a safe working environment;

have an appreciation of the systems approach to
health care safety, and the need to adopt and practise
health care that maximises patient safety, including
cultural safety
l.
Virtual clinic environments, case studies,

hypotheticals and role plays
m. understand systems of health care provision in a

culturally diverse society including their advantages
and limitations, the principles of efficient and
equitable allocation and use of finite resources, and
recognition of local and national needs in health
care and service delivery
m. Case studies, hypotheticals, role plays, and

interprofessional learning activities
n. understand how to manage a dental practice

including planning, organising and leading the
practice team
n.
o. apply basic principles of practice administration,

financial and personnel management to a dental
practice
Case studies and role plays
o. N/A
p. N/A
p. appreciate personal responsibility to contribute to the

generation of knowledge, to mentor young
65
Domain
Description
professionals and to build the image of the

profession to ensure continuing public respect for it
2.
Communication
and Social
Skills
covers
interpersonal
skills, ability to
work
cooperatively and
to communicate
effectively with a
range of people

a. communicate effectively, interactively and
reflectively with patients, their families, relatives and
carers in a manner that takes into account their age,
intellectual development, social and cultural
background
a.
Case studies, hypotheticals, role plays, and

b. provide open, complete and timely communication

throughout the period of care
b.
N/A
c. establish a patient/family-practitioner relationship

that allows the effective delivery of dental treatment
c.
N.A
d. identify patients expectations, desires and attitudes

when planning and delivering treatment
d.
Case studies, hypotheticals, role plays, and

e.
Role plays
g. provide information in a manner that ensures

patients and families can be fully informed when
consenting to any procedure and encourage them to
make fully informed decisions by discussing
treatment options and expected outcomes
f.
Role plays
g.
Role plays, writing referral letters
h. communicate effectively with other health

professionals involved in patients care and convey
written and spoken information clearly
h.
Case studies, role plays, and interprofessional learning

activities
e. apply psychosocial and behavioural principles in

patient-centred health care in
f.
provide care in a way that is respectful of a persons

culture and beliefs and that is free of discrimination
66
Domain
Description
i.
j.
ensure the health information of patients and

consumers is shared only with relevant health care
providers
work productively with other members of the dental
team and display appropriate professional behaviour
towards them
k. understand their role as part of a team of health care

practitioners delivering health care in a cooperative,
collaborative, integrative manner to ensure care is
continuous and reliable
3.
Critical
Thinking
covers matters
relating to the
acquisition of
knowledge and its
application to
identify and solve
real-life problems
i.
Case studies
j.
Interprofessional learning activities
k.

a. utilise critical thinking and problem-solving skills
a. Case studies
b. apply decision-making, clinical reasoning and

judgment to develop a differential, provisional or
definitive diagnosis by interpreting and correlating
findings from the history, clinical and radiographic
examination and other diagnostic tests, taking into
account the social and cultural background of the
patient
b. Case studies
c. evaluate and integrate emerging trends in health

care as appropriate
c. N/A
d. evaluate and integrate research outcomes with

clinical expertise and patient values for evidencebased practice
d. Case studies
67
Domain
Description
e. evaluate the validity of claims related to the

risks/benefits of products and techniques
f.
have a level of information literacy that allows the

acquisition and use of relevant information in a
critical, scientific and effective manner
g. interpret dental evidence in a critical and scientific

manner and use information technology
appropriately as an essential resource for modern
dental practice
4.
Health
Promotion
covers educating
about oral health,
its relationship to
general health and
empowering
individuals to
assume
responsibility for
their oral health
e. Case studies, Assignments in evidence-based practice

f.
Assignments in evidence-based practice
g. Assignments in evidence-based practice

a. in serving the community in private or public
practice settings, promote health and prevent disease
through: educating individuals and groups;
interacting with others to promote activities that
protect, restore and improve oral health and the
quality of life; organised community efforts
b. promote and improve the oral health of individuals
and the community by understanding and applying
the principles of health promotion and disease
prevention
c. recognise and appreciate the need to contribute to
the improvement of oral health beyond those served
in traditional practice settings
d. understand the complex interactions between oral
health, nutrition, general health, drugs and diseases
that can have an impact on oral health care and oral
a. N/A
b. Role plays
c. N/A
d. Case studies
68
Domain
Description
diseases
e. have awareness of the importance of their own
health in relation to occupational hazards and its
impact on the ability to practise as a dentist
f.
promote health maintenance of patients and

colleagues and look after their own health
g. encourage patients to take interest in, and

responsibility for, the management of their health
and support them in this
5.
Scientific and
Clinical
Knowledge
covers knowledge,
clinical and
technical skills
used in dentistry
e. N/A
f.
N/A
h. educate patients at all stages in their life, or patients

family, carers or guardians, about the aetiology and
prevention of oral disease
g. N/A
i.
h. Role plays
develop strategies to predict, prevent and correct

deficiencies in patients oral hygiene regimens and
provide patients with strategies to control
undesirable oral habits
i.
Role plays

a.
apply knowledge and understanding of the basic

biological, medical, technical and clinical sciences in
order to recognise the difference between normal
and pathological conditions relevant to clinical
dental practice
b.
understand the scientific basis of dentistry, including

the relevant biomedical sciences, the mechanisms of
knowledge acquisition, scientific method and
evaluation of evidence
a. Case studies , objective structured clinical

examinations (OSCE)
b. Student research projects and laboratory exercises
69
Domain
Description
c.
understand how to prevent, diagnose and treat

anomalies and illnesses of the teeth, mouth, jaws and
associated tissues
d.
select treatment options based on the best available

information
e.
select the least invasive therapy necessary to gain a

successful outcome for the patient
f.
apply the scientific principles of sterilisation,

disinfection and antisepsis, and infection control
g.
understand the hazards of ionising radiations and

their effects on biological tissues, together with the
regulations relating to their use, including radiation
protection and dose reduction
h.
6.
understand pharmacology and therapeutics relevant

to clinical dental practice and be familiar with
pharmacology in general medicine
c. Case studies
d. Case studies
e. Case studies
f.
Case studies, laboratory practicals on sterilization
g. Case studies
h. Case studies, software for quality use of medicines
Patient Care
6.1 Clinical
Information
Gathering
On graduation a dentist must be able to:

a.
obtain and record a complete history of the patients

medical, oral and dental state
a. Typodont and preclinical simulations
b.
perform an appropriate physical examination;

interpreting the findings and organising further
investigations when necessary in order to arrive at
an appropriate diagnosis
b. Physical examination of other students, Standardized

patients/manikins/medical simulators
70
Domain
Description
c.
d.
6.2 Diagnosis and

Treatment
Planning
be aware of his or her limitations and know when

and how to refer a patient for an appropriate opinion
and/or treatment, where treatments are beyond skills
or to confirm prescribed treatment
c. Case studies
select appropriate clinical laboratory and other

diagnostic procedures and tests, understand their
diagnostic reliability and validity, and interpret their
results
d. Case studies
e.
maintain an accurate, consistent and legible record

of patient treatment
e. Patient notes and paper cases
f.
obtain informed consent for all forms of treatment
f.
Role plays

a. perform an extraoral and intraoral examination
appropriate to the patient, including assessment of
vital signs, and the recording of those findings
a.
b. complete and chart a comprehensive examination of

oral hard and soft tissue
b. Charting exercises with models and typodonts, use of

haptics for periodontal probing, digital tutor
software for radiographs
c. formulate and record a comprehensive diagnosis,

treatment and/or referral plan which meets the needs
of patients
d. select and prioritise treatment options that are
sensitive to each patients individual needs, goals
and values, compatible with contemporary methods
of treatment, and congruent with an appropriate oral
health care philosophy
Physical examination of other students, Standardized

c. Case studies including electronic patient records

d. Case studies including electronic patient records
71
Domain
Description
e. understand the aetiological factors determining
dental disease or disorder
f.
recognise the clinical features of oral mucosal

diseases and disorders
g. examine the dentition for dental caries, wear,

including attrition, abrasion and erosion, and other
damage to the hard tissues of the teeth
h. identify the location, extent and degree of activity of
dental caries, tooth wear and other structural or
traumatic anomalies and the reason for their
occurrence
i.
take radiographs of relevance to dental practice and

interpret the images
j.
recognise the presence of systemic disease and know

how the disease and its treatment, including present
medication, affect the delivery of dental care
k. diagnose, explain and manage the deterioration and

failure of restorations in clinical service
l.
conduct, explain and discuss planning of restorative

and prosthetic treatment as part of comprehensive
oral rehabilitation
e. Case studies
f.
Case studies, tele-dentistry for oral medicine
g. Charting exercises with models and typodonts

h. Charting exercises with models and typodonts
i.
Simulators (manikins with human skulls) for taking

radiographs
j.
Case studies
k. Case studies
l.
Case studies
m. understand the common impairments of function

consequent on tooth loss
n. understand the properties and risks and benefits of
commonly used dental materials and related tissue
responses
m. Case studies
n. Assignments and case studies
o. diagnose abnormalities in dental or periodontal

anatomical form that compromise periodontal
72
Domain
Description
health, function or aesthetics and identify conditions
which require management
p. distinguish between periodontal health and
periodontal disease and identify conditions that
require management
6.3 Clinical
Treatment and
Evaluation
o. Case studies, typodont exercises, use of haptics for
periodontal probing
p. Case studies, typodont exercises, use of haptics for
periodontal probing

a. employ appropriate techniques to manage oro-facial
pain, including TMJ disorders, discomfort and
psychological distress
b. manage periodontal disease
a. Role plays
b. Typodonts, haptics for using periodontal scalers
c. manage caries and other hard tissue tooth loss
c. Typodonts, virtual reality and haptics for restorative

dentistry
d. manage pulpal and peri-radicular disease and

disorders
d. Typodonts for endodontic procedures
e. restore defective, non-defective and/or missing teeth

to acceptable form, function and aesthetics
f.
plan and perform all common prosthetic procedures,

including tooth preparation and impression taking
g. understand and apply the biomechanical principles

of fixed and removable prostheses commonly used to
replace missing teeth
h. treat and manage conditions requiring minor
surgical procedures of the hard and soft tissues, and
apply and /or prescribe appropriate pharmaceutical
agents to support treatment
i.
manage common oral mucosal diseases and
e. Typodonts, virtual reality and haptics for restorative

dentistry , VR for administration of local anaesthesia
f.
Preclinical simulations of clinical procedures in

prosthetic dentistry, such as models mounted on
articulators and manikins for impression taking
g. Case studies
h. Preclinical exercises in design of partial dentures;
virtual reality and haptics for restorative dentistry
i.
Surgical procedures on pig jaws, suturing exercises,

prescribing exercises, case studies
73
Domain
Description
disorders
j.
j.
manage minor developmental or acquired

dentoalveolar, growth-related and functional
abnormalities of the primary, mixed and permanent
dentition
k. produce diagnostic casts, mounted with interocclusal records

l.
prevent and manage where necessary medical and

dental emergency situations encountered in clinical
dental practice
m. evaluate systematically all treatment outcomes,

including information on a patients and/or patients
family/carers satisfaction/dissatisfaction with
treatment and providing and/or recommending
additional action and planning for the maintenance
of oral health
Case studies using image libraries, teledentistry
k. Case studies, typodont exercises with space

maintainers, tooth jaw size predictions, cephalometric
analyses of radiographs
l.
Impressions and records from manikins and fellow

students
m. Case scenarios, role plays, resuscitation manikins,

interprofessional learning, simulated environments for
emergency patient care
n. Case audits and reviews, case studies
74
D. Bibliography
American Dental Education Association. (2008). Competences for the New General Dentist as approved by the American Dental Education Association
(ADEA) House of Delegates on April 2, 2008. Used with permission of ADEA, www.adea.org.
Australian Dental Council. (2007). Accreditation Assessment Guidelines for Programs offered in Dental Therapy and Dental Hygiene
Australian Dental Council. (2007). Accreditation Assessment Guidelines for Programs offered in Dentistry
Australian Medical Council. (2009). Assessment and Accreditation of Medical Schools: Standards and Procedures. Retrieved from
http://www.amc.org.au/index.php/accreditation
Cowpe J., Plasschaert A., Harzer W., Vinkka-Puhkka H. and Walmsley A.D. (2008). Profile and Competences for the Graduating European Dentist
Association for Dental Education in Europe (ADEE). Used with permission of the ADEE. Retrieved from
http://www.adee.org/cms/uploads/adee/ProfileCompetencesGraduatingEuropeanDentist1.pdf)
Dental Council of New Zealand. (n.d.). Competencies required for the BDS degree at the University of Otago. Retrieved 3 April 2009, from
http://www.dentalcouncil.org.nz/dcExaminationsWritten
Dental Council of New Zealand. (n.d.). Core competencies of an oral health practitioner
General Dental Council. (2008}. The First Five Years (3rd edition interim). Retrieved from http://www.gdc-uk.org/
Gerrow J.D., Murphy H.J., Boyd M.A. (March 2007). Review and revision of the competencies for a beginning dental practitioner in Canada. Journal of the
Canadian Dental Association, 73 (2). Retrieved from http://www.cda-adc.ca/jcda
Health Professions Council of South Africa Medical and Dental Professions Board. (April 2001). The Undergraduate Dental Curriculum Pretoria
Royal Australasian College of Surgeons. (n.d.) Definition of Surgical Competence. Retrieved 23 April 2009, from
http://www.surgeons.org/Content/NavigationMenu/EducationandTraining/Training/Standardsandprotocols/Competencies1.htm
Royal College of Physicians and Surgeons of Canada. (2005). CanMEDS 2005 Framework. Retrieved 23 April 2009, from:
http://rcpsc.medical.org/canmeds/bestpractices/framework_e.pdf
75
The National Dental Examining Board of Canada. (n.d.). Competencies for a beginning practitioner in Canada. Retrieved 27 March 2009, from
http://www.ndeb.ca/en/accredited/competencies.htm
The University of British Columbia. (n.d.). Competencies for the new practitioner 2008-2009 Retrieved 23 April 2009, from
http://www.dentistry.ubc.ca/Education/DMD/CompetencyDocument.asp
76
Appendix 1B.
C1 Competencies of the newly qualified oral health therapist

Domain
Description
7.
Underline = new activities; N/A = not applicable to
SLEs
Professionalism
On graduation an oral health therapist must:
covers personal
values, attitudes
and behaviours
a. display appropriate caring behaviour towards

patients
a. Role Plays
b. provide patient-centred care, respect patients dignity

and choices; acknowledge that all interactions,
including diagnosis, treatment planning and
treatment, must focus on the patients best interests
b. Case studies, role plays and standardized patients
c. recognise and respect patients rights, particularly

with regard to confidentiality, privacy, informed
consent
c. Case studies and role plays
d. practise evidence-based dentistry

e. recognise personal limitations and know when to
refer or seek advice appropriately
f.
employ a critically reflective approach to practice

which involves acknowledging and learning from
mistakes and participating in and contributing to
d. Assignments and projects

e. Case studies, hypotheticals and role plays.
f.
Reflective journals
77
Domain
Description
SLEs
peer review
g. have an ethos of life long professional growth and
development and support continuing education for
all members of the dental team
h. have a thorough understanding of the ethical
principles and legal responsibilities involved in the
provision of dental care to individual patients, to
populations and communities, practising with
personal and professional integrity, honesty and
trustworthiness
i.
understand and apply Commonwealth, State and

Territory legislation relevant to practise as an OHT
j.
use contemporary information technology for

documentation, continuing education,
communication, management of information and
applications related to health care
k. have a desire to achieve the optimal patient care with

an awareness of the need for cost-effectiveness to
allow maximum benefit from the available resources
l.
manage and maintain a safe working environment;

have an appreciation of the systems approach to
health care safety, and the need to adopt and practise
health care that maximises patient safety, including
cultural safety
m. understand systems of health care provision in a

culturally diverse society including their advantages
and limitations, the principles of efficient and
g. N/A
h. Case studies, hypotheticals, role plays, and
interprofessional learning activities.
i.
Assignments, case studies and role plays
j.
N/A
k. Case studies and role plays
l.
Virtual clinic environments, case studies,

hypotheticals and role plays
m. Case studies, hypotheticals, role plays, and

78
Domain
Description
SLEs
equitable allocation and use of finite resources, and

recognition of local and national needs in health
care and service delivery
n. understand how to manage a dental practice
including planning, organising and delivering oral
health care in public or private practice
o. demonstrate effective organization skills including
time management and personal organization for
effective practice
p. appreciate personal responsibility to contribute to the
generation of knowledge, to mentor young
professionals and to build the image of the
profession to ensure continuing public respect for it
8.
Communication
and Social
Skills
covers
interpersonal
skills, ability to
work
cooperatively and
to communicate
effectively with a
range of people
n.
Case studies and role plays
o. N/A
p. N/A

a. communicate effectively, interactively and
reflectively with patients, their families, relatives and
carers in a manner that takes into account their age,
intellectual development, social and cultural
background
a. Case studies, hypotheticals, role plays, and

b. provide open, complete and timely communication

throughout the period of care
b. N/A
c. establish a patient/family-practitioner relationship

that allows the effective delivery of dental treatment
c. N.A
d. identify patients expectations, desires and attitudes
79
Domain
Description
when planning and delivering treatment
e. apply psychosocial and behavioural principles in
patient-centred health care in
f.
provide care in a way that is respectful of a persons

culture and beliefs and that is free of discrimination
g. provide information in a manner that ensures

patients and families can be fully informed when
consenting to any procedure and encourage them to
make fully informed decisions by discussing
treatment options and expected outcomes
h. communicate effectively with other health
professionals involved in patients care and convey
written and spoken information clearly
i.
ensure the health information of patients and

consumers is shared only with relevant health care
providers
j.
work productively with other members of the dental

team and display appropriate professional behaviour
towards them
k. understand their role as part of a team of health care

practitioners delivering health care in a cooperative,
collaborative, integrative manner to ensure care is
continuous and reliable
SLEs
d. Case studies, hypotheticals, role plays, and
e. Role plays
f.
Role plays
g. Role plays, writing referral letters

h. Case studies, role plays, and interprofessional learning
activities
i.
Case studies
j.
k. Interprofessional learning activities
80
Domain
9.
Critical
Thinking
covers matters
relating to the
acquisition of
knowledge and its
application to
identify and solve
real-life problems
Description
SLEs

a. utilise critical thinking and problem-solving skills
a. Case studies
b. apply decision-making, clinical reasoning and

judgment to develop a differential, provisional or
definitive diagnosis within their scope of practice by
interpreting and correlating findings from the
history, clinical and radiographic examination and
other diagnostic tests, taking into account the social
and cultural background of the patient
b. Case studies
c. evaluate and integrate emerging trends in health

care as appropriate
c. N/A
d. evaluate and integrate research outcomes with

clinical expertise and patient values for evidencebased practice
d. Case studies
e. evaluate the validity of claims related to the

risks/benefits of products and techniques
f.
have a level of information literacy that allows the

acquisition and use of relevant information in a
critical, scientific and effective manner
g. interpret dental evidence in a critical and scientific

manner and use information technology
appropriately as an essential resource for modern
practice
e. Case studies, Assignments in evidence-based practice

f.
Assignments in evidence-based practice
g. Assignments in evidence-based practice
81
Domain
10. Health
Promotion
covers educating
about oral health,
its relationship to
general health and
empowering
individuals to
assume
responsibility for
their oral health
Description
SLEs

a. promote health and prevent disease through:
implementing effective consultation and education
strategies with individuals, groups and communities;
developing and contributing to strategies to promote,
protect, restore and improve oral health and the
quality of life; supporting and participating in
organised community efforts to promote oral health
a. N/A
b. understand and apply the theories and evidence for

inducing behavioural changes which benefit oral
health and/or general health
b. Role plays
c. educate patients at all stages in their life, or patients

family, carers or guardians, about the aetiology and
prevention of oral disease using effective and
evidence based education and communication
strategies
c. Role plays
d. advocate appropriately for oral and general health in

public policy
e. promote and improve the oral health of individuals
and the community by understanding and applying
the principles of primary health care, health
promotion and disease prevention
f.
select and implement appropriate health promotion

strategies and interventions for individuals and
communities
d. N/A
e. N/A
f.
Case studies
g. contribute to the improvement of the oral health of
82
Domain
Description
people beyond those served in traditional practice
settings to advance the oral health of the community
h. identify the impact of environmental and lifestyle
factors and the determinants of health on oral health
and implement strategies to positively influence these
interactions
i.
apply knowledge of common health risks to inform

public policy, and educate practitioners and the
public
j.
maintain their own health and understand its

importance in relation to occupational hazards and
its impact on the ability to practise as an oral health
therapist
SLEs
g. N/A
h. Case studies
i.
N/A
j.
N/A
k. promote health maintenance of colleagues

k. N/A
11. Scientific and
Clinical
Knowledge

a.
understand and apply knowledge of the scientific

basis of dentistry, including the relevant biomedical
and psychosocial sciences, the mechanisms of
knowledge acquisition, scientific method and
evaluation of evidence
b.
apply knowledge and understanding of the basic

biological, medical, technical and clinical sciences in
order to recognise the difference between normal
and pathological conditions relevant to clinical
covers knowledge,
clinical and
technical skills
used in dentistry
a. Case studies , objective structured clinical examinations

(OSCE)
b. Student research projects and laboratory exercises
83
Domain
Description
SLEs
dental practice
c.
d.
understand how to prevent, diagnose and treat

anomalies and illnesses of the teeth, mouth, jaws and
associated tissues, within their scope of practice and
to refer conditions that are beyond it
c. Case studies
select treatment options based on the best available

information and the least invasive therapy necessary
to achieve the appropriate and favourable outcome
for the patient
d. Case studies
e.
apply the scientific principles of sterilisation,

disinfection and antisepsis, and infection control
f.
work safely with ionising radiations with

consideration for their effects on biological tissues
and understand and apply the regulations relating to
their use, including radiation protection and dose
reduction
g.
identify the impact of pharmacology and

therapeutics relevant to clinical oral health practice
h.
appreciate medical conditions and medications

which can impact on oral health or make the
provision of dental treatment unsafe
e. Case studies and demonstrations

f.
Case studies
g. Case studies
h. Case studies
12. Patient Care

6.1 Clinical
Information
On graduation an oral health therapist must be able to:

a.
obtain and record a complete history of the patients
a. Preclinical simulations and case studies
84
Domain
Description
Gathering
6.2 Diagnosis and

Treatment
Planning
SLEs
medical, oral and dental state

b.
assess individual and social determinants of health,

to identify risk and protective factors in order to
inform holistic oral health care planning
b. Case studies
c.
perform an appropriate physical examination;

interpreting the findings and organising further
investigations when necessary in order to arrive at
an appropriate diagnosis
c. Physical examination of other students, Standardized

d.
be aware of his or her limitations and know when

and how to refer a patient for an appropriate opinion
and/or treatment, where treatments are beyond skills
or to confirm prescribed treatment
e.
select appropriate clinical laboratory and other

diagnostic procedures and tests, understand their
diagnostic reliability and validity, and interpret their
results
e. Case studies
f.
maintain an accurate, consistent and legible record

of patient treatment including referral or handover
f.
g.
appreciate the importance of identifying both the

patient and the intended site for a procedure before
undertaking irreversible treatment
g. N/A
d. Case studies
Patient notes and paper cases

a. perform an extraoral and intraoral examination
appropriate to the patient, including assessment of
a.
Physical examination of other students, Standardized

85
Domain
Description
SLEs
vital signs, and the recording of those findings

b. complete and record a comprehensive examination
of oral hard and soft tissues
c. formulate and record a comprehensive diagnosis,
treatment and/or referral plan which meets the needs
of patients and which is within their scope of
practice
d. develop strategies to evaluate the risk factors for oral
disease and to encourage and support patients
efforts to control their own oral health
e. propose, discuss and agree treatment options,
including a preventive care plan, that are sensitive to
each patients individual needs, goals and values,
compatible with contemporary methods of treatment,
and congruent with an appropriate oral health care
philosophy
f.
understand the causes and factors that lead to

common dental diseases or disorders to assist
preventive action by patients
b.
Charting exercises with models and typodonts, use of

haptics for periodontal probing, digital tutor software
for radiographs
c.
Case studies including electronic patient records
d.
Case studies
e. Case studies including electronic patient records
f.
Case studies
g. Case studies
g. recognise the factors affecting discomfort and

psychological distress and their likely impact on the
provision of oral health care
h. recognise the clinical features of common oral
mucosal conditions, diseases and disorders, orofacial
pain, including TMJ disorders and make appropriate
referral for their management
h. Case studies
i.
Charting exercises with models and typodonts
86
Domain
Description
i.
identify the location, extent and degree of activity of

dental caries, tooth wear, including attrition,
abrasion and erosion and other structural or
traumatic anomalies and integrate into planning
oral health care
j.
take radiographs of relevance to the diagnostic

process
k. interpret radiographic and other diagnostic tests

relevant to clinical practice and apply this to
treatment planning
l.
recognise the presence of systemic disease,

disabilities and mental illness, and know how these
and their treatments, including present medication,
affect the delivery of care and vice versa
SLEs
j.
Simulators (manikins with human skulls) for taking

radiographs
k. Image libraries of dental radiographs

l.
Case studies
m. integrate knowledge of comorbidities and

polypharmacies into planning oral health care
m. Case studies
n. diagnose abnormalities in dental or periodontal

anatomical form that compromise periodontal
health, function or aesthetics and identify conditions
that require management
n. Case studies and laboratory exercises with extracted

teeth
o. distinguish between periodontal health and

periodontal disease and identify conditions that
require management
o. Case studies, typodont exercises, use of haptics for

periodontal probing
p. diagnose and explain the deterioration and

breakdown of existing restorations and integrate this
knowledge into treatment planning
p. Case studies
87
Domain
Description
q. conduct, explain and discuss the planning of
restorative dental treatment
q. Case studies
r. explain simple prosthetic treatment and assist in the

maintenance care of such prostheses
r. N/A
s. understand and communicate to patients the

common impairments of function as a consequence
of tooth loss
s. N/A
t.
recognise the properties and risks and benefits of

dental materials and related tissue responses in order
to make recommendations to patients about their
oral health care
u. obtain and record informed consent for all forms of

treatment
v. know when to refer patients to the appropriate health
professional for consultation or treatment, where
treatments are outside professional scope of practice
or require collaborative care
6.3 Clinical
Treatment and
Evaluation
SLEs
t.
Assignments and case studies
u. Role palys
v. Case studies and interprofessional learning activities

a. manage common periodontal disease and advise
patients on home management and prevention and
refer and seek advice where appropriate
a. Case studies, typodonts, haptics for using periodontal

scalers
b. manage dental caries and other hard tissue tooth

loss
b. Typodonts, virtual reality and haptics for restorative

dentistry
c. identify pulp and periradicular disease and disorders

and treat or refer such conditions according to their
c. Case studies
88
Domain
Description
SLEs
scope of practice
d. restore teeth and the dentition to acceptable form,
function and aesthetics using direct procedures
e. extract deciduous or permanent teeth where this does
not involve either surgical techniques or incisions
f.
provide preventive management for patients with

prosthodontic needs and refer where necessary
d. Typodonts, virtual reality and haptics for restorative

dentistry , VR for administration of local anaesthesia
e. Manikins for extraction technique
g. perform orthodontic procedures according to their

scope of practice
f.
h. take impressions and produce study models
g. Preclinical typodonts exercises for band or bracket

placement and removal
i.
j.
prevent and manage where necessary medical and

dental emergency situations encountered in clinical
dental practice, consulting and seeking advice from
peers and other dental and health practitioners if
and when required
evaluate systematically all treatment outcomes,
including information on a patients and/or patients
family/carers satisfaction/dissatisfaction with
treatment and providing and/or recommending
additional action and planning for the maintenance
of oral health
N/A
h. Preclinical simulations such as models mounted on

articulators and manikins for impression taking
i.
Case scenarios, role plays, resuscitation manikins,

interprofessional learning, simulated environments for
emergency patient care
j.
Case audits and reviews, case studies
k. utilise pain management techniques, psychosocial

and behavioural principles to optimise patient
management and compliance
k. N/A
l.
l.
provide advice to patients for the prevention of oral

diseases including self care strategies and home
Case studies
89
Domain
Description
SLEs
management
m. use appropriate preventative pharmaceutical agents
to support oral health treatment and care and
educate patients in the use of these agents
m. Case studies
n. apply behaviour management techniques

appropriate to the patients level of development,
understanding and compliance to support effective
delivery of care
n. N/A
90
D. Bibliography for Appendix 1

American Dental Education Association. (2008). Competences for the New General Dentist
as approved by the American Dental Education Association (ADEA) House of Delegates
on April 2, 2008. Used with permission of ADEA, www.adea.org.
Australian Dental Council. (2007). Accreditation Assessment Guidelines for Programs
offered in Dental Therapy and Dental Hygiene
Australian Dental Council. (2007). Accreditation Assessment Guidelines for Programs
offered in Dentistry
Australian Medical Council. (2009). Assessment and Accreditation of Medical Schools:
Standards and Procedures. Retrieved from http://www.amc.org.au/index.php/accreditation
Cowpe J., Plasschaert A., Harzer W., Vinkka-Puhkka H. and Walmsley A.D. (2008). Profile
and Competences for the Graduating European Dentist Association for Dental Education
in Europe (ADEE). Used with permission of the ADEE. Retrieved from
http://www.adee.org/cms/uploads/adee/ProfileCompetencesGraduatingEuropeanDentist1
.pdf)
Dental Council of New Zealand. (n.d.). Competencies required for the BDS degree at the
University of Otago. Retrieved 3 April 2009, from
http://www.dentalcouncil.org.nz/dcExaminationsWritten
Dental Council of New Zealand. (n.d.). Core competencies of an oral health practitioner
General Dental Council. (2008}. The First Five Years (3rd edition interim). Retrieved from
http://www.gdc-uk.org/
Gerrow J.D., Murphy H.J., Boyd M.A. (March 2007). Review and revision of the
competencies for a beginning dental practitioner in Canada. Journal of the Canadian
Dental Association, 73 (2). Retrieved from http://www.cda-adc.ca/jcda
Health Professions Council of South Africa Medical and Dental Professions Board. (April
2001). The Undergraduate Dental Curriculum Pretoria
Royal Australasian College of Surgeons. (n.d.) Definition of Surgical Competence. Retrieved
23 April 2009, from
http://www.surgeons.org/Content/NavigationMenu/EducationandTraining/Training/S
tandardsandprotocols/Competencies1.htm
Royal College of Physicians and Surgeons of Canada. (2005). CanMEDS 2005 Framework.
Retrieved 23 April 2009, from:
http://rcpsc.medical.org/canmeds/bestpractices/framework_e.pdf
The National Dental Examining Board of Canada. (n.d.). Competencies for a beginning
practitioner in Canada. Retrieved 27 March 2009, from
http://www.ndeb.ca/en/accredited/competencies.htm
The University of British Columbia. (n.d.). Competencies for the new practitioner 2008-2009
Retrieved 23 April 2009, from
http://www.dentistry.ubc.ca/Education/DMD/CompetencyDocument.asp
91
Appendix 2. State of the Art in dental simulation
Figures 1 and 2 above show conventional simulation laboratories with phantom

heads/manikins fitted with removable jaws with plastic teeth (typodonts) which are
used for a range of exercises in restorative dentistry. The phantom heads hinge from
or slide under the benches to the appropriate working position.
Figures 3 and 4 above show a close up view of a phantom head with artificial teeth (in
this case 32 adult teeth). Each tooth can be easily removed and replaced. The phantom
head hinges so that it can be used in a realistic position resembling a supine (reclined)
patient, or as a patient in the seated forward position. Standard phantom heads do not
have stimulant tissue for the human tongue or for the flow of saliva.
92
Figures 5 and 6 above show the typodont model removed from the phantom head.
Such models can also be made to incorporate natural (extracted) teeth and a wide
range of synthetic teeth and synthetic gingival (gum) tissues are available for
replicating common clinical situations (crowded teeth, missing teeth, primary teeth)
and the major dental diseases. Such models can also be used in advanced 3D VR
simulators.
Figures 7 and 8 above show that the preclinical simulation laboratory is typically the
site for a range of bench-based simulation exercises using synthetic teeth or natural
teeth (which after being sterilized can be mounted anatomically in plaster or resin).
93
Figure 9 (left) above shows examples of various types of problems which can be
replicated in synthetic teeth that are then placed into typodonts. Figure 10 (right)
shows an example of an exercise performed on a plaster model in this case an
exercise in carving and shaping dental materials teeth to appreciate to dimensional
anatomy and build up hand skills that are needed for handling restorative dental
materials in the clinic.
Figure 11 (left) above shows a laboratory exercise designed to copy a clinical

situation, in this case using plaster and resin models to attach a bridge to two implants.
The example in Figure 12 (right) is a situation where students, after gaining the
required skills in the simulation laboratory, have now progressed to the clinic and are
practicing a reversible procedure on fellow students working in threes with one
student serving as operator, one as assistant and one as the patient, and then rotating.
This approach is used widely with junior students to familiarize them with the clinical
environment before they see patients. Some brands of phantom heads attach to the end
of dental chairs which allows students to work in the clinic doing procedures on a
manikin rather than on a dental patient or fellow student.
94
Examples of current 3D Virtual reality systems are shown on the following pages.
Figures 13-17 above are the DentSim system by DenX (Israel) which uses 3d virtual
reality to provide feedback to students whilst they are doing one of a number of preselected restorative dentistry procedures. This system uses cameras to track the
movement of the handpiece and then displays the situation on a computer monitor.
The system is particularly useful for remediation of students whose progress is slow
because of the detail of feedback which can be provided.
95
Figures 18-20. CDS100 unit by EPED (Taiwan) is very similar to the DentSim but
uses 2010 3d VR technology rather than the 1998 platform which underpins DentSim.
96
Appendix 3A. Survey instrument for Dentistry
97
98
99
100
Appendix 3B. Survey instrument for Oral Health
101
102
Appendix 4.
Part A. Summary of existing simulation activities in Dentistry
UQ
UWA
Adelaid
e
LaTrobe
Griffith
Sydney
CSU
Melb
Foundation clinical
sciences for dentistry
Anatomy
Examination/treatment
planning
Radiology
Prescribing
Restorative dentistry
Fixed prosthodontics
Removable prosthodontics
Endodontics
Orthodontics
Periodontology
Oral surgery
Implant dentistry
3.5
71
9.5
6
12
94.5
26.5
55
7
106
3
120
452
182
13
6
111
36
4
209
44
57
48
84
6
18
3
26
3
0
355
0
0
39
26
0
0
0
45
34
0
176
66
20
39
45
6
6
6
74
36.5
0
182.5
37
54.5
38
24
32
11
18
77
18
0
519
105
48
84
9
36
8
9
92
26
2
123.5
77
57
96
16
6
9
17
110
18
12
312
24
0
105
0
12
0
0
36
37
0
717
93
36
69
37
15
12
18
Total simulation hours
694.5
464.5
549.5
589
1026
644.5
1227
1089
Table 1. Summary data.
Figure 1. Distribution by discipline area.
103
Figure 2. Total simulation hours.
Figure 3. Distribution of simulation activities within each university program.
104
Appendix 4. Part B. Existing simulation activities in Oral Health

Total simulation hours
Foundation clinical
sciences
Anatomy
Examination/treatment
planning
Radiology
Dental therapy practice
Orthodontics
Dental hygiene practice
Newcas
tle
Adelaid
e
Latrobe
4
32
8
24
3
73
24
38
20
9
16
13
4
28
27
15
178
0
34
32
20
58
8
53
51
22
174
3
5
76
42
196
8
36
75
0
534
12
36
0
54
566
0
36
123
48
144
48
48
290
203
331
420
686
685
443
UQ
Sydney
Table 2. Summary data.
Figure 4. Distribution by discipline area.
Melb
Griffith
105
Figure 5. Total simulation hours.
Figure 6. Distribution of simulation activities within each university program.
106
Appendix 5A. Detailed mapping for Dentistry
107
108
109
Appendix 5B. Future simulation activities
110
111
Appendix 6. Image-guided surgery

Types of article/study
Literature Review
Symposium note
Survey
Validation
Authors and publication years

Bachunan, 2001.
Feuerstein et al., 2006.
Grigg and Stephens, 1998.
Verdonschot, 1994.
Walls et al., 1999.
Gth et al., 2009
Verdonschot et al., 1998
Hsieh et al., 2002.
Kobayashi et al., 2006.
Park et al., 2010.
Tan et al., 1990.
Vikal et al., 2010.
Yoshida et al., 2009.
Evaluation
Correa et al., 2003.

Kusumoto et al., 2006.
Meijer et al., 2004.
Pohlenz et al., 2010.
Sohmura et al., 2004.
Widmann et al., 2009.
Cohort study
von Sternberg-Gospos et al., 2006.
112

Sles in Dentistry Oral Health Curricula 201108

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Sles in Dentistry Oral Health Curricula 201108

Caricato da

Copyright:

Formati disponibili

HWA/ RFQ/2010/17

Use of Simulated Learning Environments

SLE in Dentistry and Oral Health: Final Report

1.0 Executive Summary

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

Recommendation 2. Future HWA support be provided to develop and implement

SLE in Dentistry and Oral Health: Final Report

Recommendation 5. Deployment of haptic simulators to large placement clinics

SLE in Dentistry and Oral Health: Final Report

2. Background to the Project

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

program. Curtin University currently provides an Associate Degree in Dental Hygiene

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

4.2 Outcomes of the Literature Review.

The following MeSH searches were also undertaken:

With the development of computer-assisted 3D image technology such as 3D computed

SLE in Dentistry and Oral Health: Final Report

4.3 Virtual reality

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

Perhaps one of the greatest advantages of VW technology is in terms of collaboration.

SLE in Dentistry and Oral Health: Final Report

4.4 Computer literacy in dentistry

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

4.9 Haptic simulation

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

51 were positive regarding such virtual simulation as an additional modality in dental

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

A total of 11 papers have been published on DentSim, including a comprehensive evaluation

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

Table 6. Overall assessment of the DentSim 3D VR system

4.12 EPED system

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

Fig. 9. The role of computer-based simulation

SLE in Dentistry and Oral Health: Final Report

5.2 Task decomposition for technical skill development

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

5.6 Technical skills development

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

SLE in Dentistry and Oral Health: Final Report

10. Use of lasers for soft tissue procedures

SLE in Dentistry and Oral Health: Final Report

Fig 15. FLS Training Box

SLE in Dentistry and Oral Health: Final Report