key: cord-0900637-bltdwkz0
authors: Crome, Marius; Adam, Knut; Flohr, Marco; Rahman, Alexander; Staufenbiel, Ingmar
title: Application of the inverted classroom model in the teaching module “new classification of periodontal and peri-implant diseases and conditions” during the COVID-19 pandemic
date: 2021-06-15
journal: GMS J Med Educ
DOI: 10.3205/zma001485
sha: 9b7fe23f8bbeda6763799054e04602fe66c37886
doc_id: 900637
cord_uid: bltdwkz0

Background: Due to the need for patient-free dental education during the COVID-19 pandemic, Hannover Medical School (MHH) implemented a new periodontology module. Its didactic structure was based on the “inverted classroom model” (ICM) in combination with elements of case-based learning. The educational objective was to increase the diagnostic confidence of dental students in the classification of periodontal patients (staging & grading), based on 33 digitized patient cases. To assess the suitability of the module for future dental curricula, this study aimed to evaluate student satisfaction and skills acquisition. Methods: The periodontology module, which was attended by final year dental students of MHH (n=55, mean age: 26.5±3.9 years, male/female ratio: 24.1%/75.9%) was evaluated in a two-tiered way. Student satisfaction was recorded using a questionnaire. Learning success was assessed by comparing error rates in patient case classifications before (T(0)) and after (T(1)) participation in the periodontology module. Results: The study found a high level of student satisfaction with the ICM format and a significant reduction in error rates (T(0) error rate=28.3%; MV±SD=3.12±1.67 vs. T(1) error rate=18.7%; MV±SD=2.06±1.81; Δ=9.6%). However, of the 11 diagnostic decisions required, only four parameters (extent, grading, percentage of bone loss per age, phenotype) showed significant improvements, with effect sizes ranging from small to medium. Conclusions: The ICM-based teaching concept is definitely not an alternative to patient-based learning. However, in regard to student satisfaction and learning success, it might be superior to conventional classroom-based lectures, especially when complex topics are covered. In summary, the newly developed periodontology module may be a useful addition to traditional dental education in future curricula, even for the time after the COVID-19 pandemic.

This article describes the integration of a new teaching format into dental education during the COVID-19 pandemic. The objective was to increase the confidence of 10 th -semester students in the use of the new, recently published classification of periodontal diseases. The results showed very high student satisfaction and a significant increase in learning success.

The COVID-19 pandemic poses an immense challenge to society in terms of solidarity and socioeconomics and is therefore negatively connoted. Conventional teaching methods and work processes cannot simply be maintained, but need to be adapted to the new situation. Both business and education are identifying ways and means to benefit from the pandemic-related adaptations in the long term [4] , [19] , [25] , [35] . Against the background of infection control measures in the form of contact bans and social distancing, faster digitization in workplaces and educational institutions is definitely most important. As a result, the attendance culture prevalent in German businesses is increasingly being questioned in the light of the opportunities and synergies offered by telework or work from home, for instance [20] . This also applies to traditional, classroom-based dental and medical teaching, which is evidently not efficient enough. The German Council of Science and Humanities (Wissenschaftsrat) , an advisory body to the Federal Government and State Governments, and Hochschulforum Digitalisierung, a think tank orchestrating the discourse on higher education in the digital age, have urged for restructuring measures, including the implementation of didactically valuable digital elements, since 2016 [10] , [11] , [18] , [23] , [34] , [36] . And although Germany's institutions of higher education considered themselves digitally wellequipped for the COVID-19 summer semester, according to a survey conducted by the Donors' Association for the Promotion of Humanities and Sciences (Stifterverband), many of them were only able to perform distance teaching based on mere information transfer without any underlying didactic concept, for reasons of infrastructure, staffing and time [21] , [30] . In daily clinical routine, dental practitioners need to make numerous diagnostic and therapeutic decisions that substantially influence the course and success of a treatment. However, skills like "critical thinking" and "decision-making ability" have so far been taught only insufficiently in lecture-based education. Student-centered, didactically sound teaching formats would be necessary to properly prepare dental students for practice [3] . This is why the Hannover Medical School (MHH) Department of Conservative Dentistry, Periodontology and Preventive Dentistry developed a case-based teaching module, guided by the "inverted classroom model" (ICM). It was designed to compensate for the fact that students did not have the chance to improve their clinical decision-making skills by treating real patients [14] . The module aimed to ensure a deeper understanding and reliable clinical application of the new classification of periodontal diseases, published in 2018. This classification allows clinicians to combine a wide variety of diagnostic parameters in therapeutically and prognostically relevant categories and to develop treatment concepts tailored to patients' individual needs [15] , [29] , [33] . As almost every second adult in Germany is affected by periodontitis and prevalence increases with age, profound knowledge of periodontology is a must for prospective dental practitioners [13] . The ICM, first used 20 years ago, is highly popular in the literature and considered one of the most important teaching concepts for higher education [2] , [32] . Against the backdrop of new digital challenges, continuously growing scientific knowledge and lifelong learning needs, information processing is becoming more and more important to teaching than mere information transfer [34] . This is why the inverse principle was synergistically combined with "case-based learning" (CBL) for didactic reasons in this periodontology module (see figure 1 ). Since this dental teaching concept was used for the first time at the MHH, our educational study aimed to assess student satisfaction and learning success. To evaluate the latter objective, the following hypothesis was formulated: Participation in the periodontology module reduces students' error rates in the classification of periodontal patients.

The participants in the periodontology module were MHH 10 th -semester dental students, who acquired their knowledge of the new classification of periodontal diseases in a hybrid approach due to the pandemic. This approach included a conventional, classroom-based lecture course given in the 2019/2020 winter semester and an individualized and digitalized phase completed shortly before participation in the periodontology module. The classroom-based part consisted of five lectures of 45 minutes each, given on five days. The slides of the lectures and suggestions for further, in-depth reading for self-study were made available to the students via an elearning platform (ILIAS; Integrated Learning, Information and Collaboration System; Peter L. Reichertz Institute). The students had already gained some practical experience in the treatment of periodontal patients in two clinical treatment courses (Conservative Dentistry Course I, 2018/2019 winter semester, Integrated Course I, 2019/2020 winter semester). In the 2020 summer semester, there were no clinical treatment courses due to the COVID-19 pandemic. To evaluate student satisfaction with the periodontology module, a 17-item questionnaire was prepared. Due to the short lead time, this tool could not be checked for reliability, so the data recorded were only analyzed descriptively. In addition to general questions (age, gender, time invested in self-study), the evaluation questionnaire included 13 Likert-type items with a 5-point scale ("strongly disagree"=1, "rather disagree"=2, "undecided"=3, "rather agree"=4, "strongly agree"=5, "cannot judge"=X, cf. figure 2) . Furthermore, the students rated the periodontology module using the German upper secondary education grading system (0: failed, 1-3: insufficient, 4-6: sufficient, 7-9: satisfactory, 10-12: good, 13-15: very good).

The periodontology module comprised two teaching units of four hours each. At the start, each student received a comprehensive documentation of findings (dental findings, photo status, periodontal status, panoramic radiograph and/or x-ray status) in a real patient case for classification in accordance with the case definitions published in 2018 [33] . Most patient cases were generated on the basis of case presentations used in previous clinical treatment courses. It was taken into consideration that both dental findings and periodontal status might include mistakes or measuring errors. Correct classifications of the 33 patient cases included in the module were determined beforehand by three experienced periodontists. The students were expressly instructed to base their decisions on the radiographic images in case there were any inconsistencies in the documentations. The classification of periodontitis consists of "staging" and "grading". Staging (Stage 1, 2, 3, 4) aims to determine the severity and complexity of the disease and comprises five diagnostic aspects: 1. Interdental clinical attachment level in the region with the largest bone loss; 2. Radiographic bone loss in the region with the largest loss; 3. Tooth loss due to periodontitis, 4. Local complexity factors; and 5. Extent/distribution. Grading (Grade A, B, C) aims to determine the progression rate of the disease and estimate the treatment result achievable on the basis of patient-specific factors. By definition, it comprises five subparameters:

1. Longitudinal comparison of radiographic bone loss; 2. Percentage of bone loss in the region with the largest loss divided by patient age; 3. Phenotype (periodontal destruction in relation to the presence of microbial biofilm); 4. Nicotine abuse; and 5. Glycohemoglobin concentration in the patient's blood.

Since a longitudinal comparison of radiographic bone loss could not be reconstructed in all patient cases, this parameter was not included in the classification. So the 55 students used nine subparameters and the two main categories (staging & grading) to make a total of 11 diagnostic decisions per patient case. Subsequently, the students developed patient-specific treatment concepts, based on their diagnoses, and presented and discussed their concepts in small groups to comply with the pandemic-related hygiene rules. The lecturers (K.A. and I.S.) acted rather as mediators than as instructors, drawing the students' attention to the critical points of the new classification. At the end of the case discussion phase, the students classified their patient cases again.

The data collected were statistically analyzed using the IBM SPSS Statistics 26 software (IBM Corporation, Armonk, New York, USA), both in a descriptive way and with the aid of test methods based on inductive statistics. The Wilcoxon signed-rank test was used to investigate the total error rates of the students in the classification of patient cases before (T 0 ) and after (T 1 ) participation in the periodontology module. Besides, the chi-square test was used to analyze the stochastic independence of individual aspects of the new classification of periodontal diseases with regard to learning success.

From June 11 th to July 1 st , 2020, a total of 55 MHH 10 th -semester dental students participated in the periodontology module. Of these students, 76.4% (42/55) were female, 23.6% (13/55) male, and 0% diverse. The average age was 26.5±3.9 years.

Basically, the periodontology module was rated "very good" by the students, with an average score of 13.66±1.04 out of 15 points. Moreover, they all agreed that this teaching concept should be permanently integrated into the dental curriculum (Questionnaire Item 13: "strongly agree", n=52; "rather agree", n=2). Although 81.5% of the students stated they were able to classify the patient cases by themselves without any problems (Item 6), 88.9% (n=48) said at the end of the periodontology module that they now felt more confident in the use of the new classification of periodontal diseases on patients (Item 8). The reasons they gave for this optimistic view were both the comprehensive case discussions, which had substantially contributed to a better understanding of the matter (Item 7: "strongly agree", n=45; "rather agree", n=9), and the lecturers' fully satisfactory answers to questions arising from the discussions (Item 12: "strongly agree", n=50; "rather agree", n=3). As regards teaching and learning without the periodontology module, 42.6% of the participants stated that the classroom-based lectures alone would not have been sufficient for them to understand the new classification (Item 4). Besides, 79.6% of the students (n=43) answered that they had invested more than one day in self-study to prepare for the periodontology module. Still, 77.7% (n=42) indicated that they had not fully understood "staging and grading" until they took part in the subsequent attendance phase, i.e. the case discussions in small groups (Item 5).

In comparison with the ideal classifications defined by periodontal specialists, the students' 605 diagnostic decisions included 168 errors in the first classification of their patient cases [T 0 error rate: 27.8%; mean value (MV) ± standard deviation (SD): 3.07±1.56; parameters not specified: 19 (3.1%); n=55], and 106 errors [T 1 error rate: 17.5%; MV±SD: 2.03±1.72; parameters not specified: 44 (7.2%); n=55] in the second classification (Δ=10.2%). Since an inductive statistical approach was used, the results of students who had not specified all parameters were eliminated; this reduced the sample size by 21 participants (n=34, T 0 error rate: 28.3%; MV±SD: 3.12±1.67 vs. T 1 error rate: 18.7%; MV±SD: 2.06±1.81; Δ=9.6%). The error rate proved to be significantly lower after participation in the periodontology module (asymptotic Wilcoxon test: z=-3.066; p=.002; n=34). Based on Cohen's guidelines, the effect size may be considered medium (r=.52) [6] . Furthermore, detailed analysis of the individual diagnostic parameters using the chi-square test showed statistically significant correlations between participation in the periodontology module und reduced error rates only for three grading parameters and extent assessment (cf. Regarding effect size, however, it should be mentioned that only small to medium effects were achieved and seven diagnostic parameters did not show any significant changes at all.

This educational study aimed to assess an ICM-based periodontology module integrated into the dental curriculum on a short-term basis due to the COVID-19 pandemic in terms of student satisfaction and learning success. Statistical analysis showed that the participating students were satisfied with this teaching concept and supported its future use. Comparison of the students' total error rates before and after participation in the periodontology module proved a significant learning effect. Basically, the positive results of this study are in line with other studies on comparable topics from the fields of medical and non-medical education [5] , [9] , [16] , [22] , [24] , [31] . So it may be concluded that students prefer student-centered learning scenarios designed to improve higher cognitive skills (application of knowledge, analysis, synthesis and evaluation) to lecture-based knowledge transfer [1] , [9] , [27] . However, it should be ensured that the teaching materials made available beforehand are not too complex to be understood by the students on their own and that redundancies between the contents of selfstudy and classroom phases are avoided for reasons of efficiency [24] . If students cannot acquire the necessary declarative knowledge on their own in the self-study phase, due to motivation deficits or because the teaching materials are too complex or time-consuming, the use of the ICM will not make much sense. In this case, factual knowledge needs to be acquired in the classroom phase, even though certain skills that are important to professional life and lifelong learning (critical thinking, decisionmaking ability) are not improved in this way [8] , [26] , [32] . Considering these insights, the didactic structure of the periodontology module seems promising, since it allows students to efficiently work toward achieving their learning objective. It should be noted, however, that 79.6% of the students (n=43) stated they had invested more than one day in self-study. This substantial time investment suggests that the matter and the teaching materials may still be too extensive or complex, although the lecturers did their best to condense the contents of the primary literature used as much as possible. This assumption is confirmed by the students' self-perception. Despite the distinct self-study phase, 77.7% said that they had not fully understood "staging and grading" until taking part in the case discussions of the periodontology module. This result is alarming, especially against the backdrop that the ICM project was integrated into the curriculum only as a substitute due to the COVID-19 pandemic and almost half the students did not consider the lectures, once the only teaching method used, sufficiently effective. While assessments of student satisfaction with the ICM are relatively consistent in the literature, there is much less agreement on learning success. Researchers do agree that hybrid teaching concepts combining online and classroom elements have the potential to enhance learning success, as compared to traditional, single-phase concepts. To date, however, there has not been any strong evidence of the effectiveness of ICM concepts [5] , [17] . In a systematic review from the field of dental education, only three of the five selected studies showed significant differences in learning effectiveness [9] . The results of a review by Hu et al. on the use of the ICM in nursing education, by contrast, were much more positive. The authors found the ICM to be superior to traditional teaching methods in eight out of nine studies [12] . The results of our study are similarly ambivalent with regard to learning success. The students made significantly fewer mistakes in the classification of patient cases after participating in the periodontology module (Δ=9.6%), but this does not prove an all-embracing learning effect, because only four of the 11 clinical/diagnostic parameters contributed to this reduction in the total error rate. Besides, the effect size was only small to medium, despite the considerable time and effort invested in learning. Detailed analysis of the error structure showed that espe- cially for the parameters requiring transfer of knowledge and clinical experience (complexity, tooth loss) no improvement had been achieved. Parameters that are relatively easy to understand (extent, phenotype), by contrast, showed much better results. It is also interesting to see that the error rate for identifying the interdental space with the largest clinical attachment loss or radiographic bone loss remained unchanged. The case presentations revealed that it was difficult for the students to identify the outline of the crestal bone and, consequently, the interdental space with the largest radiographic bone loss in panoramic radiographs or x-ray statuses. This suggests that three-dimensional interpretation of radiographs is a skill that cannot be imparted by a single teaching unit but is acquired procedurally, as professional experience increases. Erroneous assessment of clinical attachment levels might also be explained by the fact that, in cases of inconsistencies in their documentations, the students did not base their decisions on the panoramic radiograph or x-ray status, but on the periodontal status, which had been determined in previous clinical treatment courses. Research has shown that clinicians' experience substantially influences the accuracy of periodontal recordings and that measurements performed by students are significantly less accurate [7] , [28] . In summary, the results of this educational study indicate that correct classification of periodontal patients requires a degree of clinical experience and procedural knowledge acquisition that the ICM format cannot adequately compensate for. When assessing the learning effect described in this study, it should be taken into account that the study design only followed a "before-after" approach, although a direct comparison of different didactic methods in a "cross-over" design would definitely have been more valuable. However, such a design could not be developed due to the short lead time and almost spontaneous implementation of the new teaching approach. It should also be considered that the questionnaire used to evaluate student satisfaction with the periodontology module has its limitations in terms of reliability and validity and can thus only show tendencies. The highly positive rating of the periodontology module (13.66 out of 15 points) is surely also attributable to the fact that the students welcomed it as a substitute for the clinical treatment of periodontal patients during the COVID-19 pandemic.

This educational study evaluated the implementation of an ICM-based periodontology module in dental teaching during the COVID-19 pandemic. The data collected are largely congruent with related literature on the "inverted classroom model". Accordingly, high student satisfaction and a significant learning success were achieved. The question as to whether this concept is fundamentally superior to traditional teaching methods cannot be unequivocally answered. However, the results of our study suggest that the classification of periodontal patients (staging & grading) cannot be adequately taught in classroom-based lectures but requires innovative teaching methods, such as the ICM or case-based learning, which support procedural skills acquisition. Although the 2020 summer semester was a rather negative experience due to the COVID-19 pandemic, we gained a few positive insights. Probably, the pandemic has accelerated digitization in dental and medical education, and innovative teaching concepts like the ICM will have a formative influence on future curricula.

Equal first authors: Marius Crome and Knut Adam.

The authors declare that they have no competing interests. 33 Da der röntgenologische Knochenabbau im longitudinalen Vergleich nicht für jeden Patientenfall rekonstruierbar war, wurde dieser Parameter nicht in die Auswertung einbezogen. Die 55 Studierenden hatten folglich mit den neun Subparametern und den beiden Hauptkategorien (Staging & Grading) in Summe 11 diagnostische Entscheidungen pro Patientenfall zu treffen. Im weiteren Verlauf entwickelten die Studierenden basierend auf ihrer gestellten Diagnose ein patientenindividuelles Therapiekonzept, welches Pandemie-bedingt in hygienekonformen Kleingruppen vorgestellt und diskutiert wurde. Die Dozenten (K.A. und I.S.) fungierten dabei vornehmlich als Mediatoren und weniger als Instruktoren und lenkten die Aufmerksamkeit der Studierenden auf die neuralgischen Punkte der neuen Klassifikation. Nach Abschluss der Fall-basierten Diskussionsrunden klassifizierten die Studierenden ihren Patientenfall erneut.

Die statistische Auswertung der erhobenen Daten erfolgte mit dem Statistikprogramm IBM SPSS Statistics 26 (IBM Corporation, Armonk, New York, USA) sowohl deskriptiv, als auch mithilfe schließend-induktiver Testverfahren. So wurde unter Verwendung des Wilcoxon-Vorzeichen-Rang-Tests die Gesamtfehlerquote der Studierenden bei der Klassifizierung von Patientenfällen vor (T 0 ) und nach (T 1 ) der Teilnahme am Parodontologie-Modul untersucht.

Darüber hinaus wurde der Chi-Quadrat-Test angewandt, um die stochastische Unabhängigkeit einzelner Aspekte der neuen Klassifikation parodontaler Erkrankungen hinsichtlich des Lernerfolges zu analysieren.

Im Zeitraum vom 11.06.2020 bis zum 01.07.2020 nahmen 55 Studierende der Zahnmedizin aus dem 10. Semester der MHH am Parodontologie-Modul teil. Insgesamt waren 76,4% (42/55) der Teilnehmer weiblich, 23,6% (13/55) männlich und 0% divers. Das durchschnittliche Alter betrug 26,5±3,9 Jahre.

Insgesamt haben die Studierenden das Parodontologie-Modul sehr gut bewertet und vergaben im Mittel 13,66±1,04 von 15 möglichen Punkten. Ferner waren sich alle einig, dass die dauerhafte Integration dieses Lehrkonzepts in die zahnmedizinische Lehre zu befürworten sei (Punkt 13 des Evaluationsbogens: "stimme voll zu"; n=52, "stimme eher zu"; n=2). Obwohl 81,5% der Studierenden die eigenständige Klassifizierung der Patientenfälle als unproblematisch einstuften (Punkt 6), gaben am Ende des Parodontologie-Moduls 88,9% (n=48) von ihnen an, dass sie sich nun sicherer in der Patientenbezogenen Anwendung der neuen Klassifikation parodon-taler Erkrankungen fühlten (Punkt 8). Als Beweggründe für diese optimistische Einstellung führten sie sowohl die umfangreichen Fallbesprechungen an, die maßgeblich zu einem verbesserten Verständnis der Materie beigetragen hätten (Punkt7: "stimme voll zu"; n=45, "stimme eher zu"; n=9), als auch die vollumfänglich zufriedenstellenden Antworten der Dozenten auf die sich aus der Diskussion heraus ergebenden Fragen (Punkt 12: "stimme voll zu"; n=50, "stimme eher zu"; n=3). Hinsichtlich der Modul-unabhängigen Lehre und Wissensaneignung waren 42,6% der Teilnehmer der Meinung, dass die Präsenzbasierte Vorlesung allein nicht ausreichend gewesen sei, um die neue Klassifikation verstehen zu können (Punkt 4). Überdies gaben 79,6% der Studierenden (n=43) an, als Vorbereitung auf das Parodontologie-Modul mehr als einen ganzen Tag in das Selbststudium investiert zu haben. Dennoch brachten 77,7% der Studierenden (n=42) zum Ausdruck, dass sie das "Staging and Grading" erst vollends in der anschließenden Präsenzphase, ergo den fallbezogenen Diskussionen in Kleingruppen verstanden hätten (Punkt 5). 

Das Ziel dieser Lehrstudie war es, die Integration eines aufgrund der COVID-19-Pandemie kurzfristig in den zahnmedizinischen Lehrplan integrierten Parodontologie-Moduls hinsichtlich Zufriedenheit der Studierenden und Lerneffekt zu überprüfen. Dabei konnte durch die statistische Auswertung gezeigt werden, dass die Studierenden mit dieser Lehrmethode zufrieden waren und ihren Einsatz auch weiterhin wünschten. Überdies konnte ein signifikanter Lerneffekt durch den Vergleich der Gesamtfehlerquote vor und nach der Teilnahme am Parodontologie-Modul festgestellt werden. Grundsätzlich stehen die positiven Ergebnisse dieser Lehrstudie im Einklang mit anderen, thematisch vergleichbaren Arbeiten aus der medizinischen und nicht-medizinischen Hochschullehre [5] , [9] , [16] , [22] , [24] , [31] . Insofern kann gefolgert werden, dass Studenten-zentrierte Lernszenarien, die auf die Verbesserung höhergradiger, kognitiver Fähigkeiten (Anwendung von Wissen, Analyse, Synthese und Evaluation) abzielen, gegenüber dem Vorlesungsbasierten Wissenstransfer von den Studierenden präferiert werden [1] , [9] , [27] . Dabei gilt es aber zu beachten, dass die im Vorfeld zur Verfügung gestellten Lehrmittel von ihrer Komplexität her selbstgesteuert von den Studierenden durchdrungen werden können und dass inhaltliche Redundanzen mit der Präsenzphase aus Effizienzgründen vermieden werden [24] . Kann aufgrund von Motivationsdefiziten, zu hoher Komplexität oder Zeitintensität der Lehrmittel die Selbstlernphase zum deklarativen Wissenserwerb nicht durch die Studierenden allein geleistet werden, ist die Anwendung des ICM wenig sinnvoll. In einem solchen Fall muss der Erwerb von Faktenwissen in der Präsenzphase sichergestellt werden, auch wenn die für den Beruf und das lebenslange Lernen wichtigen Lernkompetenzen (kritisches Denken, Entscheidungsfindung) dadurch nicht gefördert werden [8] , [26] , [32] . Unter Berücksichtigung dieser Erkenntnisse scheint der didaktische Aufbau des Parodontologie-Moduls geglückt zu sein, da effizient auf das Lernziel hingearbeitet werden konnte. Allerdings sollte beachtet werden, dass 79,6% der Studierenden (n=43) angaben, mehr als einen Tag in das Selbststudium investiert zu haben. Dieses ausgeprägte Zeitinvestment gibt einen Anhalt dafür, dass die Materie wie auch die Lehrmittel unabhängig von den Bemühungen der Dozenten, die Primärliteraturinhalte so kompakt wie möglich aufzubereiten, immer noch zu umfangreich oder grenzwertig komplex sein könnten. Bestätigung findet diese Vermutung in der Selbstwahrnehmung der Studierenden. So gaben 77,7% von ihnen an, trotz der ausgeprägten Selbstlernphase erst nach der Teilnahme am Parodontologie-Modul zum vollen Verständnis des "Staging and Grading" gelangt zu sein. Diese Ansicht ist gerade vor dem Hintergrund alarmierend, dass das ICM-Projekt nur aufgrund der COVID-19-Pandemie ersatzweise [5] , [17] . So konnte in einer systematischen Übersichtsarbeit aus dem Bereich der zahnmedizinischen Lehre lediglich in drei von fünf ausgewählten Arbeiten ein signifikanter Unterschied hinsichtlich der Lerneffektivität nachgewiesen werden [9] . Deutlich positiver fiel dagegen das Review von Hu et al. aus, das den Einsatz von ICM in der Ausbildung von Pflegefachkräften beleuchtete. Die Autoren stellten fest, dass das ICM in acht von neun Studien besser abschnitt als traditionelle Lehrmethoden [12] . Auch die Ergebnisse der vorliegenden Studie sind mit Blick auf den Lerneffekt ähnlich ambivalent. Denn obwohl die Studierenden nach der Teilnahme am Parodontologie-Modul signifikant weniger Fehler (Δ=9,6%) bei der Klassifizierung ihres Patientenfalls machten, kann nicht auf einen vollumfassenden Lerneffekt geschlossen werden, da lediglich vier der 11 klinisch-diagnostischen Parameter einen Anteil an der Gesamtfehlerreduktion hatten. Darüber hinaus ist die Effektstärke vor dem Hintergrund der zeitlich wie inhaltlich intensiven Beschäftigung mit der Thematik eher als gering-bis mittelgradig einzuschätzen. Eine detaillierte Analyse der Fehlerstruktur zeigte, dass vor allem bei Parametern, die Transferwissen und klinische Erfahrung erfordern (Komplexität, Zahnverlust), keine Verbesserung erreicht wurde. Parameter, die vergleichsweise einfach erfasst werden können (Ausdehnung, Phänotyp), schnitten hingegen deutlich besser ab. Interessant ist auch die unveränderte Fehlerquote bei der Bestimmung des Interdentalraums mit dem größten klinischen Attachmentverlust bzw. dem größten röntgenologischen Knochenabbau. Bei den Fallpräsentationen fiel hierbei auf, dass es den Studierenden schwerfiel, auf dem Orthopantomogramm bzw. Röntgenstatus den Verlauf des krestalen Knochens und folglich den Interdentalraum mit dem größten röntgenologischen Knochenabbau zu identifizieren. Dies spricht dafür, dass es sich bei der dreidimensionalen Interpretation von Röntgenbildern um eine Kompetenz handelt, die nicht durch eine einmalige Lehrveranstaltung vermittelt werden kann, sondern prozedural mit steigender Berufserfahrung erworben wird. Eine fehlerhafte Beurteilung des klinischen Attachmentlevels könnte zudem damit erklärt werden, dass die Studierenden bei Diskrepanzen in den Befundunterlagen ihre Entscheidung nicht anhand des Orthopanthogramms bzw. Röntgenstatus trafen, sondern auf Basis des Parodontalstatus, der im Rahmen früherer studentischer Behandlungskurse erstellt worden war. Für die Aufnahme eines Parodontalstatus haben Untersuchungen gezeigt, dass die Erfahrung des Untersuchers einen wesentlichen Einfluss auf die Genauigkeit der Messungen von Sondierungs-und Rezessionstiefe hat und dass die Messungen bei Studierenden eine signifikant geringere Genauigkeit aufweisen [7] , [28] . Zusammenfassend lassen die Ergebnisse darauf schließen, dass eine korrekte Klassifikation von parodontal erkrankten Patienten klinische Erfahrung und einen prozeduralen Wissenserwerb voraussetzt, der nicht in ausreichender Form mit dem ICM-Format kompensiert werden kann. Bei der Einordnung des in dieser Lehrstudie beschriebenen Lehreffekts sollte berücksichtigt werden, dass das Studiendesign lediglich einen "vorher-nachher"-Ansatz verfolgte, obwohl ein direkter Vergleich unterschiedlicher didaktischer Methoden im "cross-over"-Design sicherlich einen größeren Mehrwert geboten hätte. Dieser Umstand war aber angesichts der kurzen Vorlaufzeit und der nahezu spontanen Einführung des neuen Lehransatzes nicht zu realisieren. Weiterhin muss berücksichtig werden, dass der Evaluationsbogen zur Erhebung der studentischen Zufriedenheit mit dem Parodontologie-Modul hinsichtlich Reliabilität und Validität nur eingeschränkt gültig ist und daher lediglich Tendenzen aufzeigen kann. Die Tatsache, dass die Lehrveranstaltung durchweg positiv bewertet wurde (13,66 von 15 Punkten), ist sicherlich auch darauf zurückzuführen, dass sie den Studierenden während der COVID-19-Pandemie als Ersatzprogramm für die klinische Behandlung parodontal erkrankter Patienten angeboten wurde.

Die vorliegende Lehrstudie evaluierte die Einführung eines Parodontologie-Moduls in die zahnmedizinische Hochschullehre zur Zeit der COVID-19-Pandemie. Die erhobenen Daten sind weitestgehend kongruent mit verwandter Literatur zum Thema "Inverted Classroom Model". Entsprechend konnte eine hohe studentische Zufriedenheit und ein signifikanter Lernerfolgt erreicht werden. Ob eine grundsätzliche Überlegenheit gegenüber der traditionellen Lehre besteht, kann nicht eindeutig beantwortet werden. Die Ergebnisse unserer Studie legen jedoch nahe, dass die Klassifizierung parodontal erkrankter Patienten (Staging & Grading) nicht in ausreichender Form mit frontal ausgerichteten Vorlesungen vermittelt werden kann, sondern dass hierfür innovative Lehrmethoden wie das ICM oder Fall-basierte Lernen erforderlich sind, die den prozeduralen Kompetenzerwerb fördern. Auch wenn das Sommersemester 2020 überwiegend negativ durch die Pandemie beeinflusst wurde, konnten dennoch positive Erkenntnisse gewonnen werden. Es ist wahrscheinlich, dass die COVID-19-Pandemie die Digitalisierung der zahnmedizinisch-medizinischen Hochschullehre beschleunigt hat und dass innovative Lehrkonzepte wie das ICM die Gestaltung zukünftiger Curricula nachhaltig prägen werden.

Gleichberechtigte Autoren: Marius Crome und Knut Adam.

Die Autoren erklären, dass sie keinen Interessenkonflikt im Zusammenhang mit diesem Artikel haben.

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