Escolar Documentos
Profissional Documentos
Cultura Documentos
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
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.
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
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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.
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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
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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;
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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.
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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.
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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,
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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
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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.,
SLE in Dentistry and Oral Health: Final Report
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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.
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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
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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
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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
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
SLE in Dentistry and Oral Health: Final Report
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.
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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
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).
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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
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.
5.9 Proxy Device Level 3
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
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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
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.
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47
48
49
50
51
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.
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59
60
Appendix 1A.
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
Professionalism
Critical Thinking
Health Promotion
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
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to SLEs
Professionalism
covers personal
values, attitudes
and behaviours
a. Role Plays
Reflective journals
g. N/A
h. Case studies, hypotheticals, role plays, and
interprofessional learning activities.
64
Domain
Description
i.
j.
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to SLEs
i.
j.
N/A
l.
n.
o. N/A
p. N/A
65
Domain
Description
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to SLEs
2.
Communication
and Social
Skills
covers
interpersonal
skills, ability to
work
cooperatively and
to communicate
effectively with a
range of people
a.
b.
N/A
c.
N.A
d.
e.
Role plays
f.
Role plays
g.
h.
66
Domain
Description
i.
j.
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to SLEs
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.
k.
a. Case studies
b. Case studies
c. N/A
d. Case studies
67
Domain
Description
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to SLEs
4.
Health
Promotion
covers educating
about oral health,
its relationship to
general health and
empowering
individuals to
assume
responsibility for
their oral health
a. N/A
b. Role plays
c. N/A
d. Case studies
68
Domain
Description
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to SLEs
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.
5.
Scientific and
Clinical
Knowledge
covers knowledge,
clinical and
technical skills
used in dentistry
e. N/A
f.
N/A
g. N/A
i.
h. Role plays
i.
Role plays
b.
69
Domain
Description
c.
d.
e.
f.
g.
h.
6.
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to SLEs
c. Case studies
d. Case studies
e. Case studies
f.
g. Case studies
Patient Care
6.1 Clinical
Information
Gathering
b.
70
Domain
Description
c.
d.
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to SLEs
c. Case studies
d. Case studies
e.
f.
f.
Role plays
a.
71
Domain
Description
e. understand the aetiological factors determining
dental disease or disorder
f.
j.
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to SLEs
e. Case studies
f.
i.
j.
Case studies
k. Case studies
l.
Case studies
m. Case studies
n. Assignments and case studies
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
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to SLEs
o. Case studies, typodont exercises, use of haptics for
periodontal probing
p. Case studies, typodont exercises, use of haptics for
periodontal probing
a. Role plays
b. Typodonts, haptics for using periodontal scalers
g. Case studies
h. Preclinical exercises in design of partial dentures;
virtual reality and haptics for restorative dentistry
i.
73
Domain
Description
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to SLEs
disorders
j.
j.
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.
7.
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to
SLEs
Professionalism
covers personal
values, attitudes
and behaviours
a. Role Plays
Reflective journals
77
Domain
Description
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to
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.
j.
g. N/A
h. Case studies, hypotheticals, role plays, and
interprofessional learning activities.
i.
j.
N/A
l.
78
Domain
Description
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to
SLEs
8.
Communication
and Social
Skills
covers
interpersonal
skills, ability to
work
cooperatively and
to communicate
effectively with a
range of people
n.
o. N/A
p. N/A
b. N/A
c. N.A
79
Domain
Description
when planning and delivering treatment
e. apply psychosocial and behavioural principles in
patient-centred health care in
f.
j.
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to
SLEs
d. Case studies, hypotheticals, role plays, and
interprofessional learning activities
e. Role plays
f.
Role plays
i.
Case studies
j.
80
Domain
9.
Critical
Thinking
covers matters
relating to the
acquisition of
knowledge and its
application to
identify and solve
real-life problems
Description
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to
SLEs
a. Case studies
b. Case studies
c. N/A
d. Case studies
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
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to
SLEs
a. N/A
b. Role plays
c. Role plays
d. N/A
e. N/A
f.
Case studies
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.
j.
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to
SLEs
g. N/A
h. Case studies
i.
N/A
j.
N/A
b.
covers knowledge,
clinical and
technical skills
used in dentistry
83
Domain
Description
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to
SLEs
dental practice
c.
d.
c. Case studies
d. Case studies
e.
f.
g.
h.
Case studies
g. Case studies
h. Case studies
84
Domain
Description
Gathering
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to
SLEs
b. Case studies
c.
d.
e.
e. Case studies
f.
f.
g.
g. N/A
d. Case studies
a.
85
Domain
Description
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to
SLEs
b.
c.
d.
Case studies
f.
Case studies
g. Case studies
h. Case studies
i.
86
Domain
Description
i.
j.
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to
SLEs
j.
Case studies
m. Case studies
p. Case studies
87
Domain
Description
q. conduct, explain and discuss the planning of
restorative dental treatment
q. Case studies
r. N/A
s. N/A
t.
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to
SLEs
t.
u. Role palys
v. Case studies and interprofessional learning activities
c. Case studies
88
Domain
Description
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to
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.
f.
i.
j.
N/A
j.
k. N/A
l.
l.
Case studies
89
Domain
Description
SIMULATION ACTIVITIES
Underline = new activities; N/A = not applicable to
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. N/A
90
91
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.
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
97
98
99
100
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
694.5
464.5
549.5
589
1026
644.5
1227
1089
103
104
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
Melb
Griffith
105
106
107
108
109
110
111
Symposium note
Survey
Validation
Evaluation
Cohort study
112