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INTRODUCTION

When you ask dentists, anywhere in the world, about their memories from Dental School (DS) training, you will end up with a pool of stories about different experiences: the doctor in front of a classroom, the strong smells from laboratory, practice drilling on extracted teeth, mixing acrylics, and the anxiety before administering their first anesthetic injection in a patient. The last experience is the most relatable, since starting clinical practice is considered as the most stressful year because of the fear and apprehension about patient contact (1). Unlike many other careers, dentistry is an amalgamation of three fundamental components: theory, laboratory, and clinical practice; under this triage, a vast number of social programs, research projects, and interdisciplinary learning experiences are intricated (Figure 1). These interactions mostly take place in DS where teachers, students, and patients share more than just the school’s infrastructure. Now, try to imagine an uncommon scenario where this learning process has been interrupted because of a natural catastrophe, political crisis, or the threat of an unknown virus.

For many careers, the migration from a face-to-face setting to a virtual/remote communication started as soon as the worldwide web and the emerging collateral technologies were accessible (2,3). The number of available online academic programs, especially postgraduate programs, is on the rise in different modalities (4). Many disciplines understood that replacing the old classroom for a virtual scenario was not betraying the “classic pedagogic pathway,” but an opportunity to innovate, facilitate learning, improve access to education, and optimize the available resources. Unfortunately, the traditional triage in dental education limits the implementation of e-learning strategies. In the last decade, technologies such as virtual reality simulators, augmented reality, and computer aided design/computer aided manufacturing (CAD/CAM) systems have facilitated the introduction of these strategies in some DSs, especially for clinical and pre-clinical disciplines (5-7).

A recent publication in the Journal of Dental Research discussed some challenges that dentists and dental education will face due to the COVID-19 pandemic (8). The authors analyzed the educative process developed during the COVID-19 outbreak in the Stomatology School at the University of Wuhan, China, emphasizing on the measures taken to ensure the protection of the students’ health by reinforcing infection control protocols in the clinical setting. They also recommend using e-learning activities like online lectures, virtual case studies, and problem-based learning tutorials as measures to avoid unnecessary crowding exposure.

Understanding the positive impact and some challenges of virtualizing the dental education makes us consider the present and future of e-learning in DS in developing countries. Are these regions prepared to digitalize and to integrate e-learning experiences into their curricula? Do they have to deal with the same challenges richer countries have dealt with? Is it possible to use the experiences generated by the pioneer countries/institutions to enhance these processes in the poorer countries? This article aims to explore some of these issues and to offer potential answers with the available information. We hope that the discussion generated here will help DS worldwide into a new urgent educational realm, forced by this viral pandemic.

E-LEARNING IN DENTISTRY: A PANORAMIC VIEW

With the social dissemination of information and communication technologies (ICT), the growth of Internet users, and the fast evolution of a wide variety of mobile electronic devices (e.g., smartphones, tablets, and laptop computers), the concept of e-learning has gained substantial recognition in dentistry, even though it has been around since the early 1990s (9). It has been discussed that the traditional e-learning platforms, despite their large diffusion and consolidation, need to widen the range of possibilities required by the users, and be comprised of a complex electronic ecosystem focused on the teaching/learning symbiosis and knowledge management, both, at an institutional and a personal level (10).

E-learning includes a variety of modalities and terms such as online learning, mobile learning, blended learning, computer assisted instruction, distance learning, e-teaching, mediated learning, simulation-based learning, and virtual learning, each one of these having their own operative differences but all part of the digital learning ecosystem (11). However, independent of the modalities, e-learning is built on three key elements: the various pedagogical models, the instructional and learning strategies, and the pedagogical tools or online learning technologies (12).

According to a recent systematic review (13), some barriers or challenges reported for implementing e-learning strategies in health sciences education are (i) poor motivation and/or expectation: from the learners caused by internal factors (e.g., poor engagement, high levels of anxiety and stress, lack of student’s self-discipline) and external factors (course structure, poor pedagogical design, management policy, limited use of technology in education, lack of support); (ii) resource-intensive: time-, cost- and labor-intensive approach of e-learning programs; (iii) no suitability for all disciplines/contents: for contents with the need for practical or demonstrative activities, where e-learning is hard or nearly impossible to implement; (iv) lack of IT skills: especially untrained persons in computer skills. Dental education faces all the listed challenges for the complexity and variety of courses that are required. However, the biggest unresolved challenge is to analyze and commonly agree on the ideal evaluation tools necessary for each discipline and teaching method. A thorough cultural transformation in the education system, following standardization, validation, and equivalence testing, is necessary to ensure an appropriate blended curriculum of traditional face-to-face teaching and e-learning (14).

Literature points out some enablers for implementing e-learning strategies in DS courses, such as (i) facilitate learning: a more integrated and contextualized learning may develop an optimal interaction between students and teachers; (ii) learning in practice: an effective approach for transferring clinical skills and knowledge using virtual clinical case studies, adopting a mixed learning approach, and combining distinct styles and modalities; (iii) systematic approach to learning: moving from simple to complex concepts, logically interconnecting knowledge and ideas for more consolidated learning; and (iv) integration of e-learning into curricula: combining face-to-face classroom experiences with online learning to stimulate independent, interactive, and collaborative learning with a flexible and technologically rich format (13).

DSs have successfully integrated e-learning into curricula for some specific contents, as the use of virtual teaching in dental education is gaining acceptance as a complementary method to traditional learning. Integrating virtual patients (VP), a computer simulation of real-life clinical scenarios (15), as part of a student’s clinical training is one example on how dental education could benefit from e-learning strategies. VPs have been used to develop patient interviewing skills, analysis of ethical cases, and clinical decision making in many specialties. VPs offer advantages such as efficiency, interactivity, a broader range of exposure to rare but critical cases, and more significantly, the student improves his/her clinical skills in a non-threatening setting. In a 2012 survey of the U.S. and Canadian DSs, 63% of the respondents confirmed the usage of VPs for preclinical or clinical exercises (16). The authors of this 8-year old survey had concluded that the use of VP in dental education was on the rise, and thus we can infer that more DSs have integrated this virtual tool in their courses. The study noted some advantages like, the reinforcement of basic sciences during clinical treatment considerations, the uniformity of student experiences, and the immediate feedback and self-assessment.

Virtual reality (VR) technology has been defined as a method by which a three-dimensional environment is simulated, giving the user a sense of being inside this environment, controlling, and interacting with it (17). It has been used for patient education, medical students’ training, instruction of surgical procedures (18), and recently in dental training (19,20). Augmented reality (AR) is a superimposition of computer-generated graphics over a real-life scene, and unlike VR, the actual situation is not entirely suppressed (21). In dentistry, it has been used in the training for dental implants, maxillofacial surgery, temporomandibular joint motion analysis, and prosthetic surgery, permitting the student/dentist to envision deep masked structures, allowing for a 3D planning of the surgical procedure, and even designing virtual surgical guides (19,22). The applications of CAD/CAM technologies in dental laboratories and as dental chairside tools have been rapidly increasing over the last decade. The CAD/CAM process comprises of a digitization tool, a data processing software, and a manufacturing technology (either subtractive like milling or additive like 3D printing). The use of CAD/CAM can be inculcated in teaching prosthodontics, maxillofacial surgery, orthodontics, periodontics, endodontics, and restorative dentistry (6).

A qualitative study employing focus groups for data collection evaluated the learning experience of dental students who used Internet Visual Resources (IVRs), defined as, visual materials (videos, animations, photos) that were freely available on public websites. They found that the most commonly used IVRs were videos of clinical demonstrations performed on real-life patients. This tool was especially helpful for the beginners. This form of visual aid was more attractive to students than reading the procedure from a textbook (23). A recent survey confirmed these findings on 3rd, 4th, and 5th year dental students at the University of Montpellier where researchers aimed to identify the pedagogical support the students preferred according to their discipline. They concluded all students requested videos for clinical subjects like endodontics, and 95.7% of students reported online classes and e-learning as useful (1). Dental students reported, in another survey, to accept e-learning during their clinical training, which was most likely due to the favorable accessibility to the hardware and Internet. Although, it is important to highlight that they obtained these results from a sample of dental students in their second and third clinical semester at the University of Mainz, Germany; and all the participants had access to at least one hardware type suitable for e-learning (24).

By analyzing the currently available pedagogical tools and the role of mobile technology (especially via smartphones) with its rapidly changing approach to learning and teaching in clinical dental education, a warning flag must be raised. Several IVRs of clinical procedures are abundantly available on varied Internet portals. Globally, dental students widely use these mobile tools to access information. However, how little do we know about their ability to discern and recognize between evidence-based information and unsupported materials? Academic institutions should be aware of this imminent challenge and prepare the teachers and clinical instructors to provide proper guidance to their students about using mobile technology and searching for online information (25).

Continuing dental education programs have benefited from webinars, online courses, and web-based learning tools as an attractive and lucrative option because of the capacity to deliver constant training, increased learner convenience, flexibility of the process, personalized learning options with lower costs, and the ease of delivery (26).

E-LEARNING VERSATILITY: OPPORTUNITIES FOR THE STUDENTS AND FACULTY

As discussed previously, several reports support the use of virtual educative aids in dentistry. Although the academic institutions can implement few modalities easily, most of them require trained personnel and a sound budget to support the necessary infrastructure and equipment. Using these academic tools may vary among the disciplines, as well as their acceptance by the students and teachers. Tables 1, 2, and 3 briefly summarize a literature review on the application of e-learning modalities in dentistry (Tables 1, 2, and 3).

Several approaches have been reported in pedagogical dental literature. Most of the review papers concurred with four focal points. First, e-learning is a reality in many DSs, with an increasing popularity in the last few years (41,44,48,38). Second, the alumni accepted e-learning strategies as part of their curricula, and many reports identified several benefits after its implementation (27,28,30,32-37,39-43,45-47,52-57). Third, e-learning represents a point of debate within academics since some disciplines consider its application as valuable as the traditional teaching methods, while others considered it only as a good complement (29,42,44,50,53,58). Finally, despite the data available about e-learning in dentistry, many authors considered that more evidence is needed to understand the real impact and the best alternatives for its implementation (31,38,43,44,49,51). All these facts must be analyzed carefully when considering a particular discipline, examining their individual strengths and limitations.

INDIVIDUALIZING THE PROCESS: EXAMPLE OF THE UNIVERSITY OF COSTA RICA DURING THE COVID-19 PANDEMIC

Costa Rica epidemiologic behavior during the COVID-19 pandemic was particularly interesting, with a low death rate and an apparent contention of the disease (Figure 2).

By May 7, Costa Rica confirmed 765 cases, ranking 102 in the 187 countries with COVID-19 cases. The demographic situation of Costa Rica within the Central America region is notably interesting, it being in the middle of the countries with lower and higher prevalence (Nicaragua and Panamá, respectively). The government policies included closure of the borders, transit restrictions, closure of commercial sites, and the cancellation of private and public schools, including the universities. The University of Costa Rica (UCR) is the only local public university that offers Dentistry. Since 2016, the Faculty of Dentistry implemented partial virtual aids in some offered courses, categorized as low virtual (25% virtualization of the course, mainly used for materials and information sharing), bimodal modality (50% virtual interaction), high virtual (75% virtual interaction), or virtual (100% virtualization) (59). However, when the country was struck by the COVID-19 pandemic, the academic curriculum consisted of courses classified as low virtual or those that completely lacked a virtual component. The university’s academic authorities urged an immediate virtual modality adaptation for the active courses offered during the first semester of 2020. However, it was also recognized that this quick transformation would affect some courses with a practical or clinical component. The DS Dean and the Faculty Board implemented an emergency academic plan to fulfil this task, which was strategically designed in four stages. Figure 3 briefly explains each stage.

Stage A-Curricula classification and analysis

The complete 6-year dental study plan was carefully analyzed to determine the feasibility of virtualizing the active courses during the first semester of 2020 (Figure 3).

From the 49 courses offered in the first semester, 14 qualified as service courses, i.e., they are provided by other schools within the university with their own resources and thus have external jurisdiction. This is beneficial in terms of budget optimization and an interdisciplinary student approach; however, its virtualization strategy is not controlled by the DS. Some of these courses include Humanities, Repertoires, Macroscopic Anatomy, Head and Neck Anatomy, Physiology, Pharmacology, Histology, Biostatistics, and Chemistry, among others. The rest of the courses are coordinated directly by the DS, and sub-classified as theoretical (12 courses), theoretical-practical (7 courses, involving laboratory and face-to-face guided practices), theoretical-preclinical (4 courses, including introductory guided patient care), and clinical (12 courses). According to its virtualization feasibility, four categories were created: Feasible virtualization (theoretical courses), highly virtualizable courses (Courses with a limited practical component), partially virtualizable courses (Courses with high practical component), and unfeasible virtualization (mainly clinical courses). As seen in Figure 4, after excluding the service courses, only 26% of the courses could be totally virtualized with no content changes, while 32% were unfeasible. The variety of the courses required individual intervention plans to fulfil the academic objectives of each course.

Stage B-Evaluation of the students’ conditions and needs

To analyze the possibility of the students to access virtual platforms, an online survey was carried out involving all active students of the Faculty of Dentistry, using the institutional email address of each student. A 70% response rate was obtained, 450/647 students completed the questionnaire. In terms of demographics, respondents represented the seven provinces of Costa Rica (San Jose (40.9%), Alajuela (23.15%), Cartago (13.03%), Heredia (12.13%), Guanacaste (4.27%), Puntarenas (3.82%), and Limón (2.7%)). Seventy-five percent of the respondents were females and an average age of 22 years (range:17-37). According to the academic year of enrollment, 13% of respondents were first-year students, 23% second-year, 19% third-year, 14% fourth-year, 21% fifth-year, and 10% were sixth-year students. All respondents confirmed access to the internet, however, the quality and stability of the connection deferred according to the respective devices. All of the students had access to a virtual environment using either a laptop (84%), a cell phone (64%), a tablet (39%), or a desk computer (8%) (Figure 6).

Most of the students (80%) reported to have personal devices, while 20% shared them with other family members. It is important to emphasize that 4% could access the devices asynchronously, because the access priority to the device was reserved for other persons who needed to be connected for remote work or other activities. Hence, despite the accessibility to a virtual environment, the e-learning process is unequal, and university authorities must implement further improvising strategies.

Stage C-Continuing education for the faculty

During the adaptation process and the imminent suspension of the regular academic activities, DS authorities organized several online seminars for the faculty. Along with general continuing dental education, the seminars familiarized the faculty to the various e-learning modalities available on the university’s platforms. These seminars were not compulsory, but provided regular assistance to maintain virtual communication (Figure 7).

Specific training in topics like online evaluation, assertive ways for communication in the virtual environment, and access and management of the institutional virtual desktop were requested, and experts provided fundamental knowledge to cover these subjects. The seminars maintained a direct communication, and enhanced teamwork among the faculty members. Further research will evaluate the impact of these seminars and virtual meetings and identify any specific needs required to create new training strategies.

Stage D-Activation of the virtual platforms

After initial weeks of research and planning, the faculty could continue with the theoretical courses, using the institutional virtual platform Metics (https://metics.ucr.ac.cr ), complementing their classes with didactic activities like clinical case discussions, diagnosis and treatment plans of VPs, and interdisciplinary seminars with national and international speakers. However, as novel activities were successfully applied for some courses, others had to be suspended. As an example, a partially virtualizable course like dental anatomy included video demonstrations to familiarize the students with the activities that will be done after the COVID-19 restrictions (https://youtu.be/DBx1w5cKxJk). For the clinical courses, all the students participated in synchronous and asynchronous meetings with their instructors and classmates, to review the VP and new protocols to be implemented in the clinical activities. Additional strategies and changes will need to be analyzed for reinsertion of students and instructors to the clinical activities as the pandemic slowly starts to evolve. In this phase, feedback from the users (the students) and the guides (the teachers) is essential.

FINAL CONSIDERATIONS

A key aspect in implementing e-learning strategies in DSs is that virtualization is not a choice, but a process, and all the involved sections need to take action and make decisions to transform the established paradigms and move forward. As seen recently, many DSs began this virtualization process without the necessary preparation. The abrupt closure of the universities worldwide for the COVID-19 emergency, although undesirable, represents an enormous opportunity to some DSs to start this process and to expand the virtualization environment as a teaching/learning experience.

ACKNOWLEDGEMENTS

The authors thank the Dean, the Faculty Board, the teachers, the administrative staff, and the students from the Faculty of Dentistry of the University of Costa Rica for the hard work during the planning and implementation of the virtualization process during the COVID-19 emergency, and for all the information provided for the elaboration of this manuscript. The authors also thank Dr. Mariela Padilla from the University of Southern California for her academic advices during this process.

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