key: cord-0776594-e7orc9hm
authors: Kerkstra, Robin L.; Rustagi, Khyati A.; Grimshaw, Alyssa A.; Minges, Karl E.
title: Dental education practices during COVID‐19: A scoping review
date: 2022-01-03
journal: J Dent Educ
DOI: 10.1002/jdd.12849
sha: a8de716b48fbc5f13f18932e44ae27419660c6cb
doc_id: 776594
cord_uid: e7orc9hm

INTRODUCTION: Dental education was brought to a halt with the emergence of coronavirus disease (COVID‐19). Traditional dental education comprised students working closely with instructors in a clinical laboratory setting; however, public health precautions necessitated a shift to a virtual learning platform. A scoping review of dental education practices since the start of the pandemic will help to understand approaches instructors have taken to provide dental education during this unprecedented time and suggest future applications of virtual learning in dental education. METHODS: We performed an exhaustive scoping literature search of primary peer‐reviewed intervention articles published between December 2019 and April 2021 using the following databases: Academic Search Premier, Cochrane Library, Embase, ERIC, LitCovid, MedEdPortal, MedRxiv, Medline, Scopus, and Web of Science. The selection process included two independent reviewers through each phase of review. Articles were categorized and analyzed by domain. RESULTS: A total of 629 articles were identified; after titles and abstracts were reviewed, 66 articles were selected for full‐text review. Following full‐text review, 41 articles met eligibility criteria and comprised our study sample. Articles were arranged within domains of assessment, instruction, instructional technology, and software. The advantages to online dental education included improved accessibility, willingness to accept new assessment techniques, and lower anxiety levels. Barriers included problems with technology, classroom time management, lack of student interaction, and absence of hands‐on training. CONCLUSION: Evidence suggests emerging best practices in dental education during COVID‐19, and recommendations for the future of virtual and distance learning in dental education.

The emergence of the COVID-19 pandemic changed how dental education was delivered in early 2020. 1 Quarantine and lockdown regulations required many dental and dental hygiene programs and schools to close with only hours' notice to minimize the spread of COVID-19. The inability to social distance in lecture classrooms, as well as the clinic laboratory classrooms, required dental instructors and students to leave campuses for an indefinite amount of time, necessitating a shift to completely virtual education. The rate of COVID-19 transmission rose quickly, producing student and community concerns of safety in dentistry forcing dental education to immediately shift from an in-person education to an online format. Dental and dental hygiene education involves both didactic and clinical skills training. Students work in close proximity to instructors to observe step-by-step procedures, and then students demonstrate the procedure on patients. 2 Questions about the health risks for instructors and students performing clinical work, as well as concern over the transmission of COVID-19 through aerosols, forced direct contact clinical instruction to cease in most cases until updated guidelines for personal protective equipment (PPE) in dentistry were established, and the rate of infection decreased. 3, 4 Thus, most training aspects of dental and dental hygiene education were shifted to a virtual learning platform. 5 Virtual clinical skill training was more problematic, as it was difficult to mimic the in-person clinical environment. Student preparedness is linked to an adequate amount of hands-on practical experience in order to graduate dentist and dental hygienist who are capable and confident in their ability to safely treat patients. 6 COVID-19 initiated shifts in dental and dental hygiene education that is still ongoing and presenting challenges, especially given the delta variant and slow progress of global vaccination efforts. 7 It is essential to understand and education practices in the virtual era, so practices can be integrated when returning to in-person learning or in place where COVID-19 still exists. To date, only one systematic review on this topic has been published; however, it was limited by strict inclusion and exclusion criteria, a short period of observation, and a relatively small sample size. 8 The scoping review approach was chosen to answer the research question using multiple types of resources. The objective of our scoping review was to sample a large body of research over a broader period of time to understand approaches instructors have taken to provide dental education during COVID-19 and suggest future applications of virtual learning in dental education.

A total of 629 articles were identified from the literature search. In all 522 articles, titles and abstracts were deemed irrelevant to the topic of study. After full-text review of 107 articles, 20 duplicates and 66 full-text reviews were eliminated primarily due to wrong study design (Online Appendix C). Overall, 41 articles met the eligibility criteria and informed our study sample ( Figure 1 ). 12 

Twenty-five of the selected studies were conducted in North America, and eight, seven, and one studies were conducted in Asia, Europe, and South America, respectively. Almost three-quarters of eligible studies were published in the Journal of Dental Education, a journal focused on peer-reviewed scholarly work in dental education.

After extracting the data, we identified four domains for the studies: assessment (n = 9), instruction (n = 13), instructional technology (n = 10), and software (n = 9). In terms of time frame of journal submission, two studies were sent for review between December 2019 and March 2020, 17 studies between April and July 2020, 15 between August and November 2020, and seven between December 2020 and April 2021. Table 1 summarizes the study characteristics by domain.

Four of five studies included dental students as the subjects as well as seven additional studies included instructors, administrative staff, and dentists. Of all, Zoom, as a virtual platform, was used in 15 of the studies. The other platforms used included Canvas (n = 3), Moodle (n = 3), Microsoft Teams (n = 6), Blackboard (n = 1), Big Blue Button (n = 1), FlipGrid (n = 1), Webex/Cisco (n = 1), DenTeach (n = 1), Kobra simulator (n = 1), Echo60 (n = 1), Learning Management Space (n = 1), and Humanoid robots (n = 1).

Assessment is operationalized as summative techniques used to understand students' knowledge acquisition. Nine articles were categorized in this domain, with each study assessing students virtually. [12] [13] [14] [15] [16] [17] [18] [19] [20] Three of the studies were related to objective structured clinical examination (OSCE), a case-based summative examination used for clinical assessment. 12, 17, 18 The remaining six articles focused on general online assessment, excluding the OSCE. [13] [14] [15] [16] 19, 20 The OSCE assessment shifted to an online format due to COVID-19 using Canvas, Moodle, and Zoom as the virtual platforms to deliver assessments to dental students. 12, 17, 18 Overall, the OSCEs were implemented successfully by determining competency through demonstration of knowledge. 12, 18 Additionally, students had an overall positive attitude toward the new assessment modality. 17 Drawbacks included technical issues, lack of "hands-on" activities, and image quality issues. 12, 17, 18 In terms of general online assessment, studies employed oral health interviewing, treatment planning, recorded lectures, laboratory for anatomy assessment, case studies for a periodontal senior clinical case challenge, instrumentation assessment with video, and program exit exams. [13] [14] [15] [16] 19, 20 Zoom was primarily used as the virtual platform to deliver the general online assessments along with Microsoft Teams, Blackboard, Big Blue Button, and Flipgrid. Largely, the general online assessments had positive outcomes, and instructors felt students were given the opportunity to demonstrate their knowledge. 13, 14, 20 Nevertheless, challenges consisted of poor student attire and professionalism during exams, lack of in-person activities to increase retention of material, multiple skill sets were hard to assess, and Flipgrid was found to not be suitable for video management. [14] [15] [16] 20 Records identified from:

Databases (n = 1326) Registers (n = 2) Preprint Servers (n = 9)

Records removed before screening: Duplicate records removed (n = 708) Records marked as ineligible by automation tools (n = 0) Records removed for other reasons (n = 0)

Records screened (n = 629)

Records excluded (n = 522)

Reports sought for retrieval (n = 107)

Reports not retrieved (n = 0)

Reports assessed for eligibility (n = 107) Reports excluded: (n = 66) Wrong Study Design (n = 38) Conference Abstracts (n = 11) Duplicate (n = 6) Wrong Outcomes (n = 6) Wrong Intervention (n = 2) Wrong Indication (n = 1) No Original Data (n = 1) Wrong Patient Population (n = 1)

Studies included in review (n = 41)

Included F I G U R E 1 PRISMA 2020 flow diagram for new systematic reviews, which included searches of databases and registers only. 12 For more information, visit: http://www.prisma-statement.org/

For our study, instruction was defined as changes made to the course design to facilitate new learning environments. Thirteen of the 41 articles were primarily related to instruction. [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] Four articles were dedicated to the flipped classroom approach [22] [23] [24] 31 ; five articles were generally grouped for multi-faceted online instruction formatting and delivery; 21, 25, 27, 28, 33 and four articles focused on the return to in-person clinical and general dental education. 26, 29, 30, 32 Flipped classrooms replaced traditional in-class lecture with individual or group discussion-based activities to support online prerecorded lectures. 34 The flipped classroom approach in dental education was facilitated through Zoom breakout rooms, virtual polls, Kahoot, Canvas, Webex, and the Moodle skills laboratory. Individual or group discussion-based activities were held online with instructors after prerecorded lectures were viewed by students. Course topics included caries risk assessment, community health, periodontal recall visit, and a peer-based teaching skills laboratory. Investigators reported that moving courses to a flipped classroom design was received well by instructors and students due to the ease of use with online modules and the pace of learning. [22] [23] [24] 31 For example, according to Banava et al., 95% of students who used Kahoot found it to be an interactive online teaching strategy. 22 However, many studies addressed barriers to online instruction including Wi-Fi connectivity and a lack of adequate online class time for reflection discussions. 24 Regarding multifaceted online instruction formatting and delivery, online modules were created to deliver public health courses in rapid oral health deterioration and early childhood oral health training. 21 Positive: Students scored well on the stay-at-home anatomy practical for 2020.

The average class score for the practical was above the previous 3-year average by 9.71 percentage points. Modification of the "hit list" to represent the actual laboratory requirements was recommended to help students understand the written material. Negative: A negative aspect of this virtual lecture and laboratory assessment included students concern information would not be retained due to the lack of in-person, active dissections. Interested students could be invited back with the 2021 class to relearn material in person. Second-year dental students recorded themselves delivering oral healthcare counseling and pediatric dental treatment plans using a Zoom platform. An asynchronous teledentistry format was used as a replacement for in-person interviews.

Students responded to standardized patient questions and delivered a prioritized list of treatment options.

They had 24 h to prepare and submit a 5-10-min video for grading. Examiners used rubric with a four-point Likert scale to assess students' performance.

Positive: This modification was successful in providing students an opportunity to demonstrate oral health counseling and treatment planning. Additionally, peer-to-peer reflection helped students understand important concepts. Negative: The virtual standardized patient experience included poor attire and professionalism during the recorded patient encounter. This can be remedied with more guidance regarding assessment expectations.

Aguilar-Galvez et al.

August 18, 2020 Peru 10 expert pediatric dentists and 25 dental students with the diagnosis of dental caries Virtual/unspecified VLO was created to learn the diagnosis for dental caries. The VLO included flexibility, personalization of teaching, modularity, adaptability, reuse in other contexts, durability, and gamification. The complete process of construction of the VLO to be used in managing learning in dentistry included four main stages: (1) construction of the VLO, (2) validation by 10 specialists, (3) assessment of learning, and (4) assessment of the VLO by students. Positive: The 13 dental students exposed to the VLO group correctly answered 90% of the questions evaluated, in relation to the 12 students exposed to the virtual synchronous class group who correctly answered 40% of the same questions evaluated. The students tended to have higher amounts of removal in the parameters, except the parameter of infected tissue, where dentists had a higher amount of removal.

• Simulation of wisdom tooth extraction (group 2 vs. control group).

The differences between group 2 and the control group showed no significance according to the Mann-Whitney U Positive: Results from the Google Form questionnaires showed none of the students believed the Zoom education meetings were better than their standard dental education. Additionally, a small minority of the 40 students did not attend the remote educational meetings, and the pattern of absence is consistent with some individuals. Ninety percent of the allocated dental students have stated they find the remote educational meetings beneficial academically and report to enjoy them. This demonstrates a high satisfaction among the respondents. Surprisingly, almost half of the responding students reported that the remote educational meetings have been beneficial clinically, despite the lack of face-to-face contact or the ability to learn physically with their dental instructor.

Over half of the allocated dental students revealed they found the remote educational meetings "better" than the normal delivery of their academic dental education. Negative: None were noted. Zoom Students in a 3-week intensive course for tooth morphology were provided with the instrumentation and materials required to complete five waxing projects at home using the 3D Tooth Atlas app. At the same time, the didactic content was presented via 11 webinar sessions. A postcourse survey provided student perspectives regarding this new experience.

Positive: Students were able to effectively complete high-quality waxing projects at home by using step-by-step images and videos, but the survey indicated an overwhelming preference for in-person instructors' feedback. Webinars based on the students having studied the 3D Tooth Atlas and an instructor reviewing content in the Atlas was effective in teaching the didactic aspect of tooth morphology as evidenced by the student grades and survey results. Negative: None were noted.

(Continues) Multiple items could be displayed simultaneously in addition to the main teaching slides. The instructors could also stand anywhere in the Spatial workspace, for example, beside the slides or away from them. A postlecture discussion was conducted in another environment in Spatial.

Positive: Ability to take a closer look at the slides/images in various directions by attendees, which cannot be achieved with other virtual teaching methods. The use of VR technology with a live communication tool could be an alternative teaching method.

Limited data can be uploaded in Spatial.

In Spatial, only limited types of 3D formatted data are available. It would be challenging to use 3D anatomy data with precise anatomical features in Spatial. Positive: One hundred percent of students responded showing that 92% of the students agreed that "students benefited" from Whiteboard sessions, followed by 8% for the video and Kahoot.

None were noted.

Abbreviations: CCD, charged couple device sensor; CODA, commission on dental accreditation; DXTTR, dental X-ray teaching shifted instruction and demonstration of oral hygiene instruction with dental hygiene students to a fully virtual platform using manikin heads with real-time feedback from instructors. 33 A statistically significant positive correlation was established between the online course design for problem-solving and guided reflection with the most important factor to students being feedback and reflection. 33 Moore et al. polled student satisfaction at 77% and identified Zoom as a preferred platform for virtual learning. 25 Yet, technical challenges were encountered such as difficulty interacting with students who did not have their cameras on. 28 The third area in this domain focused on returning to in-person clinical and general dental education. 26, 29, 30, 32 In one study, radiology course material was front-loaded online to lighten the in-person clinic requirements and assist with completing the course requirements within the semester. 26 In another, curriculum committees met using a think-pair-share activity to evaluate long-term changes to the curriculum based on what had transpired during the pandemic. 30 Advantages included identifying that fundamental topic knowledge can be successfully delivered online, and videos can be used to help enable online discussions. 30 Lastly, a nontraditional addition to the dental clinic coursework was diaphragmatic breathing to help calm pandemic-related anxiety. 29 The breathwork was led in huddles by instructors before patient treatment. Instructors and students expressed benefits from the calming effects and a more relaxed clinical environment for patient care. 29 One disadvantage was some instructors were not as comfortable leading the breathwork due to lack of confidence in the technique, but were willing to learn. 29 

We operationalized instructional technology as the virtual platforms used for collaboration. In total, 10 studies met these criteria. [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] Epidemix 2, robot-SIMROID, Kobra Surgery simulator, and asynchronous e-learning tools like Google Classroom, Microsoft Teams, YouTube, and WhatsApp were used to deliver the interventions. Elearning tools allowed students and instructors to engage in "beyond the classroom" learning during the pandemic. In Malaysia, free online resources, quizzes, discussion forums, and assessments related to clinical and nonclinical procedures were posted on YouTube for a better student understanding. 35 In a study by Lee et al., before-duringafter strategies which included signing a test ethics pledge before the exam, automated face tracking on Zoom, and listing cheating behaviors along with their consequences were implemented. These strategies helped to avoid cheat-ing when using remote assessments. 37 Postassessment student surveys indicated that the face tracking technology, Zoom monitoring, and random question sequencing were perceived as effective ways to control cheating by 32%, 95%, and 67% of students, respectively. 36 In another study, Microsoft Teams helped facilitate the monthly oral and maxillofacial surgery journal club, rotations in a simulation clinic, and problem-based learning. 43 In another study by Mansoor, enquiry-based learning was implemented using Zoom. 44 Ninety percent of the dental students stated they found the remote educational meetings beneficial. 44 Over half of the dental students agreed that distant education is better than the regular delivery of their academic dental education, despite the lack of face-to-face contact. A few barrier arose including difficulty accessing the course material, navigating the system, submitting assignments, and poor internet connection. 44 Buchbender et al. 42 devised a pioneering method for oral surgery simulation using a Kobra Surgery Simulator. Overall, students showed less precise surgical skills than dentists, especially the younger group. The observations show that computer surgical simulation cannot replace handson training, but the Kobra simulator may provide more clinical experience for students and may offer new opportunities for practical examination, offering benefits for the instructors as well. 42 In another study by Nishioka et al., a humanoid robot-SIMROID simulated as a patient was utilized for the international students. 41 This robot could interact with students through movements, provide pain feedback, and help students build communication skills with patients. Overall, 97.7% of students revealed that SIM-ROID was "effective in dental training" because of the robot's ability to mimic the patient response, open the mouth realistically, and respond to any uncomfortable procedure. However, barriers include expense, lack of space, maintenance, and only a few students were able to practice at one time.

The domain software was operationalized as the digital programs and tools used to facilitate learning in new virtual environments. [45] [46] [47] [48] [49] [50] [51] [52] [53] In studies by Gali and Rath et al., Microsoft Paint, Pocket Paint, and Whiteboard were used for teaching preclinical prosthodontics and periodontal surgeries. 46, 49 In both studies, most of the students benefited from this type of instruction using the noted software platforms. However, instructors found it difficult to assess the nonverbal responses of the nonparticipating students, and the technical issues involved with creating and submitting quizzes and assignments. 46, 49 First, Omar et al. used CAE Learning Space to link each encounter of participants with patients and enable the instructors to observe these encounters and provide feedback. 45 Using the online platform, they created opportunities for all students to complete the planned standardized patient encounters. The feedback by students (n = 81) was positive for the activity. 45 In another study, students in Serbia used a mobile dental simulator from their home to simulate the procedure of maxillary infiltration and inferior alveolar nerve block in a 3D environment, with feedback. 47 All respondents (100%) believed that the application helped them understand the techniques of local anesthesia. 47 Next, the 3D Tooth Atlas app was used for at-home waxing projects. 48 A postsurvey revealed an overwhelming preference for in-person instructors feedback for waxing projects. 49 In a study by Iwanaga et al., the online virtual reality (VR) required a VR headset for lectures to show the dental surgical procedures and related anatomy in a VR Spatial workspace. 51 Authors found VR with a live communication tool could be an alternative teaching method. However, data storage is limited, and access to precise anatomical features posed challenges. 51 Lastly, in a study by Patterson et al., a cloud-based package, Mentimeter allowed presenters and recipients to interact in real-time during a presentation by incorporating various formats of quiz questions and polling queries. 50 Knowledge attainment was high, and participating pediatric dentistry residents reported a positive learning experience. 50 

This is among the first scoping reviews of its kind to examine dental education practices during COVID-19. We sought to identify benefits and barriers to techniques as well as determine best practices that can be incorporated in dental education. This information can be used for countries still under the constraints of pandemic protocols, in addition to determining which virtual practices can be incorporated once traditional educational practices continue.

Although COVID-19 emergency guidelines required dental education programs to shift to a virtual education format, dental instructors rose to the challenge with creativity and new pedagogical planning and delivery. Instructors incorporated lectures, videos, and group discussions to engage critical thinking based on the patient treatment being mindful of complying with guidelines established by the American Dental Education Association for remote learning during the pandemic. 54 Many dental and dental hygiene programs included workshops and webinars incorporating formative and summative assessments. 55 The shift to online education was met by using a platform like Zoom to hold synchronous and asynchronous didactic coursework. 2 Assessments were viewed positively due to the ability to assess student competence using adapted course objectives. Instructors modified online instruction to include flipped classroom pedagogy and recorded lectures to facilitate new learning environments during COVID-19. Providing students with prerecorded lectures in the flipped classroom format allowed for more time for synchronous discussions with instructors. One unconventional instructional delivery included diaphragmatic breathing to help decrease student's anxiety returning to clinic work during a pandemic which served as a springboard to enrich relationships between community, students, and instructors. 29 The most successful virtual platforms used for instruction collaboration included Google Classroom, Microsoft Teams, and Zoom. Specific software programs, such as CAE Learning Space, Microsoft Paint, Mentimeter, and VR, were used to facilitate learning in new virtual environments.

Transitioning to fully online education using virtual platforms was not without issues, as noted in another review. 8 First, studies found a general lack of the essential hands-on training for the dental professional, which cannot be replicated in a virtual setting. Second, technical difficulties made online education especially challenging for instructors and students, and Wi-Fi connections were consistently lost or interrupted. Third, time management during synchronous online coursework was difficult to manage, and instructors found it difficult to fully engage students in discussion or reflection. Last, there was a lack of perceived interaction between instructors and students when students did not turn on video cameras.

Finally, several best practice recommendations are provided for dental schools and programs to consider if interested in pursuing virtual and distance learning. First, the OSCE could be used for clinical exercises and "real-life" clinical cases, and online assessment. Second, student presentations and simulation demonstrations held virtually can be effective tools for evaluation and reflection. Third, consider implementing the flipped classroom approach for courses with lecture heavy material, which will allow for more peer-to-peer interaction to foster critical thinking through group work. Fourth, continue training instructors to establish best online practices and ensure engaging educational experiences for students. Fifth, incorporate online platforms for practical patient encounters to enhance dental students' communication skills. Sixth, create and implement interactive learning approaches to overcome student passivity. Seventh, mobile applications can successfully be used with conventional learning to teach specific dental techniques. Finally, for online learning, create pre-, mid-, and postcourse evaluations to rate Limited data can be uploaded student learning and engagement, especially given the known challenges of knowledge attainment in a virtual setting. These have also been outlined in Table 2 .

Our findings must be interpreted in the context of the following limitations. First, although exhaustive search methods were used to eliminate any potential bias, it is possible that not all quantitative studies were identified. Second, the primary articles used a variety of experimental and quasi-experimental designs, and reported numerous outcomes, limiting the potential for a meta-analysis. Furthermore, the sample characteristics were omitted from several of the reviewed studies, potentially influencing the generalizability of the findings to other contexts. Despite an extensive search, a publication bias could also be possible due to the omission of nontraditional or unpublished literature. Many studies focused more on proof of concept than employing a rigorous experimental design given the fast-changing nature of the pandemic and need for virtual education platform. For this reason, important study details were missing from primary articles, limiting our ability to perform a formal assessment of bias.

Furthermore, as only one study took place in a dental hygiene program, more evidence is needed in areas of dental hygiene and dental assisting. Finally, studies lacked important comparative outcomes, such as grades, pertinent to student academic performance.

Dental education halted with the emergence of COVID-19, and instructors across the world transitioned from traditional way of students working in clinical laboratories to fully online education. A review of dental education practices since the start of pandemic will help to understand nontraditional approaches instructors have taken to provide dental education during this unprecedented time to establish recommendations for best practices going forward. Future work should be done to validate novel teaching methods in online dental education with virtual platforms using a more robust design. It is advisable to consider publications outside of dental such as medical and nursing to enhance future discussion. Studies should also seek to compare traditional versus virtual education by student grades. In addition, increased representation from dental hygiene and dental assisting programs is needed to broaden the scope of virtual dental education. In summary, the COVID-19 pandemic was a challenging period in dental education for instructors and students. Despite the challenges, our scoping review illuminated emerging best practices in dental education during COVID-19 and recommendations for the future of virtual and distance learning in dental education in postpandemic times.

The authors declare no conflict of interest.

O R C I D Alyssa A. Grimshaw MSLIS, IPI, PMC https://orcid.org/ 0000-0003-3985-0056

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