Effect of digital virtual reality simulator on pre-clinical dental surgical skill training: a retrospective study

Abstract

Aim

Dental surgical skills training assumes critical importance for aspiring dentists. Our present study aimed to investigate the effectiveness of innovative DVRS approach in assessing competency and improving skill in preclinical dental surgical skill training.

Methods

A total of 142 students participated in this study. Within this cohort, 70 students from the 2017 intake were trained using traditional manikins (Group TM), while 72 students from the 2018 were trained using a Digital Virtual Reality Simulator for Dental Surgical Skills (Group DVRS). The scores of the training course between two groups were compared. Additionally, the experiences of students from Group DVRS were collected through a questionnaire survey regarding the use of DVRS in their preclinical training.

Results

Pedagogical outcome revealed that the average scores for Group DVRS were slightly higher than Group TM (P < 0.05). The feedback collected via questionnaires from Group DVRS participants reflected their satisfaction with the DVRS, praising its user-friendliness, clarity, training efficacy, and the resultant enhancement in their operational skills.

Conclusions

These findings suggest that DVRS is an effective and beneficial tool for preclinical dental surgical skill training.

Introduction

Dentistry, as a remarkably hands-on discipline, necessitates dentists to conduct an array of procedures within the confines of a patient’s mouth [1, 2]. Most of these are marked by their irreproducibility and irreversibility, particularly in surgical dentistry. Key structures like the mandibular canal, lingual nerve, and maxillary sinus are involved in dental surgeries, obliging surgeons to hone both theoretical proficiency and practical dexterity. Consequently, dental surgical skills training assumes critical importance for aspiring dentists [3, 4].

However, traditional training methodologies are apparently lacking in effectiveness. As students practice, they often remain unsure about the correctness of their procedures, and immediate feedback on their operative outcomes is mostly absent [5, 6]. Over time, this can diminish their enthusiasm for learning. The traditional manikins do not adequately simulate real-life oral clinical conditions, leading to students experiencing a transition hurdle from lab practice to actual clinical work [7]. This precipitates a lack of confidence and under preparedness, often resulting in overlooked preoperative doctor-patient communication and insufficient patient empathy.

Granted, advancements in digital technology, particularly Virtual Reality (VR), have brought about substantial improvements. Offering a virtually interactive milieu for operations, VR serves phenomenally in realizing practical teaching [8, 9]. Privy to this study is a training system, China’s maiden multifunctional VR platform, known as the Digital Virtual Reality Simulator (DVRS) for Dental Surgical Skill Training. This unique system creates a complete 3D patient oral model, enabling full-fledged surgical training for students. The complete 3D models of the real patients and the clinical environment are built in to allow students to practice the whole process of clinical treatment from inquiry to operations. It can truly restore the patient’s oral lesions and general health status and enable students to practice the whole process and key links of diagnosis and treatment in a virtual environment. The system can provide real-time feedback on students’ learning results, through repeated practice can enhance students’ self-confidence in clinical practice. The underlying purpose of this study was to juxtapose the traditional manikin-based pedagogy against the innovative DVRS approach and to scrutinize the upsides and drawbacks of the latter. We further endeavored to compile a comprehensive evaluation of the students’ experience with preclinical training supported by DVRS-based multimedia.

Methods

This study was approved by the Ethics Committee of Hospital of Stomatology, Wuhan University, the Clinical Trial Number is WDKQ2023-B61. The selection criteria for participation targeted fourth-year undergraduates majoring in stomatology who had completed theoretical coursework in dental and alveolar surgery. We enlisted all qualifying students admitted in the years 2017 and 2018 for our study, with cohorts categorized based on their year of admission. Specifically, 70 students who were admitted in 2017 participated in the study in 2021, and 72 students admitted in 2018 engaged in the study in 2022. Within this cohort, the students from 2017 underwent preclinical training using the traditional manikin (TM) teaching approach (designated as Group TM), whereas the students from 2018 employed a DVRS teaching methodology from Beijing Unidraw VR Technology Research Institute Co Ltd (labeled as Group DVRS). In this study, the students of 2017 participated in a traditional study. A comparative analysis was conducted on the performance scores between the two groups (Fig. 1).

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Preclinical training using TM

The traditional manikin (TM) used head model. The TM-based preclinical training sequence began with the instructor detailing and demonstrating crucial steps, ensuring that students gain familiarity with pertinent anatomical sites and the procedures required for the experiment. Given that visibility can be a challenge for many students, instructors may need to perform multiple demonstrations and explanations. Following this, students practiced on traditional manikins under the guidance of the instructor. To conclude, three separate instructors individually evaluated and scored each student’s practical skills.

Preclinical training using DVRS

All the instructors received dedicated training in the use of this technology before commencing with their preclinical sessions to ensure the effectiveness of the teaching process. In the initial phase of the preclinical training courses, instructors diligently introduced the utilization of DVRS to students and performed an in-depth theoretical explanation on operational procedures through PowerPoint slides or illustrative videos. Subsequently, students were afforded the opportunity to independently carry out operations, following the guided demonstration by the instructor. Our system consists of two parts: the Oral Virtual PC-based Teaching Platform (Unidraw Stomatology Digital Virtual Training System) and the Oral Surgery Simulator (Unidraw Virtual Classic Edition). The Oral Virtual PC-based Teaching Platform uses 3D virtual models to display the various anatomical structures of the oral cavity. Students can perform complete case diagnosis and treatment operations online via computers or mobile devices. During the operation, the platform monitors their actions in real-time and provides precise feedback and scores. In addition to the online simulation, the system also includes the Oral Surgery Simulator, which creates a realistic oral clinical operation environment using computer graphics technology. Through high-definition displays and stereoscopic reflection technology, the images are spatially registered with hand-force feedback. The dual-hand force feedback technology allows for precise tactile perception, providing a more “sensory” operation feedback. During the operation, students directly feel feedback such as tooth hardness, bone structure, and surgical instruments. For example, the left-hand device simulates the mouth mirror, while the right-hand device simulates surgical instruments to complete examination or surgical steps. The evaluation system inherent in DVRS provides real-time scoring and generates feedback of each student’s operation, supporting replay for review (Fig. 2).

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Assessment of pedagogical outcomes: TM vs. DVRS

All the students in both TM and DVRS groups experienced 48-hour theoretical and preclinical training courses such as local anesthesia, tooth extraction, abscess incision drainage, suture and so on. Subsequently, the students received a final theoretical written exam. The pedagogical outcome included both pre-clinical training score and final theoretical written exam score.

Questionnaire survey

Our questionnaire was designed based on previous study in dental education [10]. Additionally, before its official use, a pilot test was conducted with a small sample (n = 20) to gather feedback. The questionnaire (supplementary material), designed to capture the evaluations of 72 students in DVRS group on their preclinical practice experiences, contained eight focused items. These items were grouped into three main aspects: the authenticity of the simulation experience, the subjective feelings of the students, and the level of student confidence. Specifically, items 1 through 3 pertained to the authenticity of the simulation, items 4 to 7 addressed subjective feelings, and item 8 evaluated student confidence. Anonymity was maintained as all students completed the questionnaire, which employed a five-point Likert scale (1 = Strongly Disagree to 5 = Strongly Agree, with ratings also translating from 1 = Poor to 5 = Excellent) for the quantifiable items, supplemented by an open-ended question soliciting candid feedback on the pros and cons of DVRS. Upon collection, the survey responses underwent rigorous analysis to ascertain the reliability and validity of the instrument.

Statistical analysis

Version 24.0 of the SPSS statistical software was employed for the analysis of anonymized data sets. Prior to conducting inferential statistics, data distribution was examined to ensure appropriateness for subsequent analyses. Comparative evaluation between the scores was facilitated by the student t-test. The questionnaire’s reliability was analyzed via a Cronbach’s Alpha value. The validity of the instrument was analyzed by the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy. Data were presented as Mean ± SD, and statistical significance was established at P < 0.05.

Results

Students’ scores in DVRS group were significantly higher than those in TM group

In the dental surgery courses, students’ scores encompassed both theoretical knowledge and preclinical training based on the benchmarks for attending physicians. For the TM group, which consisted of 70 students, scores varied between 69 and 95. In contrast, the DVRS group, comprising 72 students, saw scores ranging from 80 to 100. A comparative analysis revealed that the average scores of the DVRS group (88.41 ± 4.75) were significantly higher than those of the TM group (86.10 ± 6.21) (P < 0.05) (Table 1).

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Students regarded DVRS as an effective pedagogical mode according to questionnaire data

To guarantee the extraction of credible data from the questionnaire, we conducted a thorough analysis of its reliability, validity and communality. The questionnaire’s reliability was confirmed via a Cronbach’s Alpha value of 0.952, indicating a high level of internal consistency. The validity was verified via the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy with a score of 0.710, pointing to the satisfactory construct validity of the questionnaire. All the communality value of eight items exceeded the 0.5 benchmark, affirming the absence of any incongruent items within the questionnaire (Table 2). The response rate of the questionnaire was 84.72% (61/72). The students’ responses, as presented in Table 3, underlined the constructive impact of DVRS on dental surgery courses. Unanimity was observed as all students concurred that the virtual reality technology was user-friendly and straightforward to operate (61/61, 100%). An overwhelming majority opined that the virtual simulation system’s automatic scoring was clear, with feedback that was both timely and beneficial (60/61, 98.36%). Nearly all participants agreed on the technology’s proficiency in replicating patient oral conditions realistically (59/61, 96.72%). A significant number also noted that virtual reality technology helped alleviate anxiety during procedures (59/61, 96.72%) and honed their clinical operational skills (57/61, 93.44%). Most students believed that the technology enhanced their comprehensive analytical and judgement abilities pertaining to patient conditions (57/61, 93.44%). There was a consensus that it heightened their attention to patient details (59/61, 96.72%). Additionally, the technology was credited for boosting their enthusiasm for learning and confidence in clinical practice (58/61, 95.08%). Taken questionnaire data revealed that students regarded DVRS as an effective pedagogical mode.

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Discussion

Medical students primarily gain essential clinical skills through experiential learning or preclinical training, a domain where traditional pedagogies increasingly fall short. The traditional manikin approach is fraught with limitations, most notably, its divergence from authentic clinical contexts and its inefficiency in providing real-time corrective feedback [11]. Further, it neglects the fundamental aspect of early doctor-patient interaction, thereby undermining the development of empathetic patient care. Our present study showed that the superiority of the VR was apparent, evidenced by significantly enhancing not only theoretical knowledge but also practical skills [12, 13].

Empirical research endorses the integration of theory and practice as a means to refine clinical acumen and augment practical skills within medical education [14, 15]. Recent advancements in simulation technologies have greatly enhanced dental education, particularly in areas such as digital simulators, virtual reality (VR), haptic feedback, simulated and virtual patients, role-play, and simulation-based serious games [16,17,18,19,20,21,22,23,24,25]. VR in preclinical training has gained considerable attention and holds great promise in various fields, including healthcare [26, 27]. VR technology provides a simulated environment that allows trainees to experience realistic scenarios without any physical risks or constraints [28, 29]. VR-based simulators allow dental students to practice procedures in a risk-free environment [16,17,18]. Recent studies show that VR enhances procedural skills and confidence by enabling repeated practice in a controlled setting [16,17,18]. Haptic technology integrates tactile sensations into VR simulations, helping students develop manual dexterity by simulating the feeling of resistance during dental procedures [19, 20]. Virtual patients provide students with realistic clinical scenarios for diagnosis and treatment planning without real patients [21]. Role-playing improves communication and patient interaction skills [22]. By simulating real-world dental situations, students gain confidence in managing patient relationships [23]. Serious games engage students through interactive, game-like environments that mimic dental procedures and these games enhance both technical skills and motivation [24, 25].

DVRS encompasses an inclusive array of interfaces: a receiving interface, an operating interface, an explanatory interface, and a scoring interface-each integral to the span of diagnosis and treatment procedures [30]. The clinical receiving interface emulates the scenario of a dental department, simulating both the oral treatment environment and patient information. Within this virtual context, students independently conduct examinations and receptions, honing their clinical competencies in patient communication, medical history documentation, and treatment planning, as well as interaction with virtual patients in realistically simulated scenarios. The operating interface provides immediate feedback on any procedural deviations or errors, presenting operation details and key steps with clarity. Lastly, the scoring interface rigorously evaluates the students’ performance against established operational standards, offering prompt assessments. Through high-definition displays and stereoscopic reflection technology, the images are spatially registered with hand-force feedback. The dual-hand force feedback technology allows for precise tactile perception, providing a more “sensory” operation feedback. Taken together, the format of DVRS provides greater alignment with actual clinical practice, and the detailed explanations in DVRS complement hands-on activities, reinforcing theoretical knowledge concurrently with practical application. This integration underscores the importance of merging cognitive understanding with tangible experience, resulting in marked improvements in both conceptual understanding and technical proficiency among DVRS trainees.

DVRS provides realistic operational experiences and sensations, deepening students’ grasp of pertinent knowledge, in line with educational objectives. Additionally, DVRS offers several advantages, such as safe failure, standardization and repeatability. While introducing an innovative edge to medical education, DVRS do come with their share of limitations, notably the requirement of specialized equipment, smooth computer operation, and a higher investment cost. The small sample size of our study may limit the generalizability of the findings. Moreover, as a retrospective study rather than a randomized controlled trial (RCT), it lacks the rigor of prospective research designs. Future research should track students’ clinical acumen, real patient outcomes, complication rates, and skill development. Furthermore, conducting multi-center studies with larger sample sizes would enhance the robustness of the research and provide more comprehensive insights.

In conclusion, we had a positive experience with the DVRS pedagogical mode in dental surgery course. DVRS led to improvements in students’ theoretical knowledge and preclinical dental surgical skills. Also, students expressed satisfaction with DVRS, highlighting its high operability, true-to-life scenarios and timely feedback.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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