Self-Directed Study and Carving Tooth Models for Learning ..., Exams of Dentistry

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September 2013 ■ Journal of Dental Education 1147 the prevention of dental diseases, endodontic treat- ment,^4 forensics,^5 anthropological studies,^6 construc- tion of functional fixed and removable prostheses that are compatible with the remaining natural teeth, and even for simple procedures such as placement of rubber dams and matrix bands. The study of tooth morphology has been tradi- tionally delivered through lectures and practical ses- sions involving carving tooth models. Commercially available tooth models, digital atlases,7,8^ and online packages9,10^ are available to aid dental students in the study of this topic. Carving tooth models in wax or soap had been used in the past in many dental schools in the United Kingdom. Unfortunately, due to the in- crease in student numbers and staffing difficulties, this methodology has been dropped. Many schools worldwide, however, still use this method for teach- ing tooth morphology, both in the traditional way and

Self-Directed Study and Carving Tooth

Models for Learning Tooth Morphology:

Perceptions of Students at the University of

Aberdeen, Scotland

Rasha Abu Eid, B.D.S., Ph.D.; Keith Ewan; Jennifer Foley, B.D.S., Ph.D.;

Yara Oweis, B.D.S., M.Sc.; Jaya Jayasinghe, B.D.S., M.Sc., Ph.D., FICCDE

Abstract: Tooth morphology has been taught at the University of Aberdeen Dental School, United Kingdom, through self-directed workshops, using online handouts and tooth models. Tooth carving sessions were recently added to introduce manual skills training through learning tooth morphology at an early stage of the dental course. The aim of this study was to assess students’ perception of both teaching modalities to evaluate their usefulness and to allow further course development. The subjects of this study were first-year dental students. Students’ opinions were sought upon completion of the tooth morphology sessions using a structured questionnaire that investigated their views about the effectiveness of both learning methods. The results suggest that self-directed workshops represent an effective way of learning tooth morphology; however, the students recommended further development of the course to make it more focused. Although students questioned the value of the carving sessions, they agreed that it helped to develop their manual dexterity, which was one of the main objectives of the exercise. Further review and devel- opment of the course is required in addition to follow-up of the students’ performance in clinical skills to further elucidate any advantages of tooth carving to advocate it as a mode of learning. Dr. Abu Eid was Lecturer in Oral Biology, University of Aberdeen Dental School, Aberdeen, Scotland, United Kingdom at the time of this study and is currently Research Fellow, Georgia Regents University Cancer Center, Augusta, Georgia; Mr. Ewan is Dental Laboratory Manager/Technician Tutor, National Health Services (NHS), Grampian, Aberdeen, Scotland, United King- dom; Dr. Foley is Senior Lecturer/Honorary Consultant in Pediatric Dentistry, University of Aberdeen Dental School, Aberdeen, Scotland, United Kingdom; Dr. Oweis is Lecturer in Conservative Dentistry, University of Jordan Faculty of Dentistry, Amman, Jordan; and Prof. Jayasinghe is Chair in Oral Sciences, University of Aberdeen Dental School, Aberdeen, Scotland, United King- dom. Direct correspondence and requests for reprints to Dr. Rasha Abu Eid, Georgia Regents University Cancer Research Center, 1410 Laney Walker Blvd., Augusta, GA 30912; 706-721-9198; [email protected]. Keywords: tooth morphology, tooth anatomy, carving, manual skills, dental education, educational methodology, Scotland Submitted for publication 2/26/12; accepted 10/16/

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ven with the technological advancements in dental education, the fact remains that den- tistry is a profession heavily dependent on manual skills. Excellent technical skills are needed by dentists to perform clinical tasks quickly and safely.^1 To embark on clinical skills training, students have to become familiar with tooth morphology. Dental students are expected to be able to identify different teeth and should be able to recreate tooth morphol- ogy in clinic. This is important to ensure that the end product is not only aesthetically pleasing, but also functionally appropriate for its intended purpose. Tooth morphology is also delivered to dental therapy students, dental technicians, and dental nurses.^2 Accurate tooth anatomy is important to achieve in dental restorations to prevent overloading, help self-cleansing of teeth, promote masticatory efficien- cy, and achieve the required aesthetic results.^3 Proper knowledge of tooth morphology is also important in

1148 Journal of Dental Education ■ Volume 77, Number 9 sion supervisor is available to answer any inquiries and to point out extra information such as the clinical significance of tooth landmarks and some normal variations of the morphology. Students’ understanding of the topic is assessed using the Personalized Response System (PRS) at the end of the session, and at the start of each workshop, a brief exam is conducted to test the students’ knowl- edge on the previous workshop’s topic. The questions are discussed immediately after the test, the test is marked, and the results are returned to students at the end of the session to provide instant feedback. At the end of the course, two workshops are dedicated to the clinical implications of tooth morphology. These sessions also include the identification of natural teeth collected from clinical practice. Natural-sized tooth models are made available for the students to borrow in pairs to give them more time for self-study. Tooth morphology is formally assessed as part of an objec- tive structured practical exam (OSPE), which consists of 1.5-minute stations with two single best answer questions about a specimen, a model, or an image. Students are expected to identify teeth, landmarks, and the clinical implications of tooth morphology. Due to the small number of students, we de- cided to introduce a number of carving sessions as a pilot trial. A small number of teeth in the human den- tal arches were selected for carving four times their natural size to enhance students’ familiarity with the morphology of teeth, and eventually wax was found to be the material of choice. Dedicated sessions for tooth carving were allocated in the timetable. The first session was an introduction to carving in which stu- dents were introduced to the carving instruments and asked to carve basic shapes. They were given detailed step-by-step handouts with the instructions posted on MyBDS prior to the sessions. These included the measurements, figures, and diagrams. The models were assessed anonymously, and the assessment was formative and did not count towards the overall student performance in the course. The marking of the models was against agreed marking criteria that included accuracy of measurements and presence and quality of carving of landmarks. A general feedback session was also scheduled. In this study, we looked at first-year students’ perceptions of the self-directed study approach and the carving sessions in an attempt to assess the course and develop it as required. An anonymous question- naire was used to survey the students’ perception of the course in order to gather large-scale data from which we could make generalizations about the using technological advances for demonstration.^11 Replacement wax carving techniques^12 and carving macro-tooth models to teach occlusion have also been proposed.^13 Due to the importance of clinical skills for dental courses, many new teaching methods are being developed to enhance students’ manual dex- terity prior to clinical practice. Haptic technology is currently state of the art in dental education.14- Manual dexterity exercises are also being introduced in various courses to ensure students’ readiness for clinical tasks.^18 Tooth morphology has been taught at the Uni- versity of Aberdeen Dental School, United Kingdom, through self-directed workshops, using online hand- outs and tooth models. Tooth carving sessions were recently added to introduce manual skills training through learning tooth morphology at an early stage of the dental course. The aim of this study was to assess students’ perception of both teaching modali- ties to evaluate their usefulness and to allow further course development. Materials and Methods The subjects of this study were first-year stu- dents at the University of Aberdeen graduate-entry Dental School, United Kingdom. The 2010-11 class consisted of twenty-three students (nineteen female and four male students). This survey-based study was exempt from Institutional Review Board approval. The tooth morphology course at the University of Aberdeen Dental School was developed to move away from didactic teaching. The course was re- viewed with the aim of making it more hands-on, and currently tooth morphology is taught in workshops using online handouts and plastic tooth models. Carv- ing tooth models is a recent addition to the course. Handouts are posted on the students’ virtual learning environment (MyBDS). These contain infor- mation about each tooth’s morphology, chronology, clinical variations, and images representing different views of each tooth. A list of useful references and online resources is also included. An introductory session is first delivered to familiarize students with tooth nomenclature and landmarks of teeth. The students are encouraged to work in groups (five or six students in each group) using their laptops to access the handouts whilst studying plastic tooth models (both magnified and of the natural size) and to visit the recommended online resources. The ses-

September 2013 ■ Journal of Dental Education 1149 handouts were also assessed. Students’ opinions on the helpfulness of the sessions in developing their manual dexterity were also sought. The suitability of the carving material, the instruments, the labora- tory space, and the supervising staff members were also assessed. Other questions addressed the mark- ing criteria and the usefulness of possible carving demonstrations. The overall view of the sessions was sought by asking students if they thought the sessions were useful or a waste of time. The last section was open for students’ com- ments about the course. Because the rest of the ques- tionnaire had closed questions only, this section was aimed at giving students the opportunity to express their views on the course, especially those aspects not referred to in questions in the first two sections. It was hoped that, through this part of the question- naire, students would raise issues about the course that were not noticed by staff members. The questionnaire was distributed to the stu- dents in a dedicated session at the end of the first semester. This was after they had already finished the main tooth morphology workshops and half the carving sessions. The students were left unsupervised so that they could feel free to express their opin- ions about the course. Descriptive statistics of the questionnaire results were performed using PASW Statistics 18, IBM SPSS Inc. (2010). students’ views and opinions on the course.^19 The questionnaire was in three sections; the first two sections comprised a set of closed questions, whilst the third section was open for students’ comments. Closed questions in the first two sections were de- signed using a psychometric Likert scale to ensure ease of analysis. The questionnaire was anonymous to give the students a sense of freedom to write their opinions without worrying about being identified by staff members. The first section of the questionnaire consisted of fifteen questions dedicated to evaluating the tooth morphology workshops (Table 1). Questions were about the quality and value of the workshop hand- outs, the cooperation of staff members, the sessions’ format, including time provided, group work, and the teaching aids available. There were also questions about the usefulness of the formative tests at the start of each session and the value of taking out the tooth models in pairs. The students’ opinions were also sought regarding their preference for this type of self-directed study or for traditional lectures. The second section consisted of seventeen questions also using the psychometric Likert scale to evaluate the carving sessions (Table 2). In this section, questions asked if the carving sessions were helpful to the students in understanding tooth mor- phology. The quality and usefulness of the carving Table 1. Students’ responses to the first section of the questionnaire addressing the tooth morphology workshops Neither Agree Statement Agree Nor Disagree Disagree The handouts for the workshops posted on MyBDS were of good quality. 72.73% 22.73% 4.54% The handouts were sufficient to understand tooth morphology. 68.18% 22.73% 9.09% The figures in the handouts were clear. 59.09% 22.73% 18.18% The supervising staff members were helpful in the workshops. 81.82% 9.09% 9.09% The time provided for each session was sufficient to cover the material designated 31.82% 13.64% 54.54% for each workshop. I found the magnified tooth models in the workshops helpful in understanding the 71.43% 14.29% 14.29% landmarks of tooth structures. The introductory workshop about landmarks and nomenclature was a good introduction to tooth morphology. 90.91% 4.54% 4.54% Taking out the tooth models gave me a better chance to understand the morphology 95.46% 4.54% 0 by providing the opportunity to study at home. Signing out the tooth model sets in pairs gave me a good opportunity to study with 50.00% 36.36% 13.64% a peer. I would have preferred to sign out the models on my own as I prefer to study by myself. 54.54% 40.91% 4.54% I think that these types of workshops are a good way to learn tooth morphology. 50.00% 22.73% 27.27% These workshops were an excellent opportunity for group work. 54.54% 22.73% 22.73% I would have preferred traditional lectures instead of workshops. 59.09% 22.73% 18.18% The small tests at the start of each session were helpful. 100% 0 0 I found the feedback on the tests useful. 95.46% 4.54% 0 Note: The values represent the percentage of students who agreed (strongly or generally), neither agreed nor disagreed, or disagreed (strongly or generally) with each statement in the questionnaire. Percentages may not total 100% because of rounding.

1150 Journal of Dental Education ■ Volume 77, Number 9 a peer, whilst 14 percent did not find taking out the models in pairs useful. This was further emphasized when 55 percent of the students expressed their pref- erence to sign out the models on their own. Fifty-five percent of the students found the workshops an excellent opportunity for group work, whilst 23 percent disagreed with this. All in all, 50 percent of the students thought that this type of workshop was a good way to learn tooth morphol- ogy, while 27 percent did not. Fifty-nine percent stated they would have preferred traditional lectures instead, and 77 percent said they would have found traditional lectures in addition to the workshops help- ful. The small tests at the start of each session were reported to be helpful by all twenty-two students ( percent), and twenty-one students (96 percent) found the feedback on these tests useful. Carving Sessions Concerning the carving sessions handouts, 73 percent of the students thought the handouts were clear, and 68 percent thought the handouts provided a good guide to recreate tooth morphology (Table 2). Seventy-seven percent of the students thought an online demonstration of the process of carving a tooth would have been helpful. With regards to the setting, materials, and in- struments in the session, 96 percent of the students Results Twenty-two out of the twenty-three possible students (96 percent) completed questionnaires. The twenty-third student was absent that day. Tooth Morphology Workshops Regarding the workshop handouts posted on MyBDS, 73 percent of the students thought they were of good quality, 68 percent thought the handouts were sufficient to understand tooth morphology, and 59 percent believed that the figures in the handouts were clear (Table 1). Eighty-two percent thought the super- vising staff members were helpful in the workshop, whilst only 32 percent found the time provided for each workshop sufficient to cover the material des- ignated for each session. Ninety-one percent agreed that the introductory workshop about landmarks was a good introduction to tooth morphology. Regarding the plastic models used in the work- shops, 71 percent of the students found the magnified tooth models helpful. As for the natural-sized tooth sets, 96 percent of the students thought that taking the models out gave them a better chance to understand tooth morphology by providing the opportunity to study at home. Fifty percent of the students found signing the models out in pairs useful to study with Table 2. Students’ responses to the second section of the questionnaire addressing the carving sessions Neither Agree Statement Agree Nor Disagree Disagree The handouts for the carving sessions were clear. 72.73% 13.64% 13.64% The handouts provided a good guide to recreate the tooth morphology. 68.18% 18.18% 13.64% The carving sessions familiarized me with some of the lab instruments. 95.46% 4.54% 0 The carving sessions helped me understand the proper grip of instruments. 63.64% 31.82% 4.54% The material used (paraffin wax) was easy to handle. 52.38% 23.81% 23.81% The lab space provided was ideal for performing the tasks. 95.46% 4.54% 0 The carving sessions helped develop my manual dexterity. 81.82% 13.64% 4.54% The marking criteria for the tooth models are realistic. 68.18% 22.73% 9.09% The comments that the markers provided were useful. 86.36% 13.64% 0 I think an online demonstration of the process of carving a tooth would have been helpful. 77.27% 18.18% 4.54% The supervising staff members were helpful in the carving sessions. 95.46% 4.54% 0 The carving exercises helped me better understand the tooth morphology. 54.54% 22.73% 22.73% The carving sessions helped me understand the anatomy of the teeth in three dimensions. 63.64% 13.64% 22.73% The carving sessions were complementary to the tooth morphology workshops which 68.18% 13.64% 18.18% involved using models. I do not think the carving sessions added anything to my knowledge of tooth morphology. 31.82% 18.18% 50.00% I found the carving sessions a waste of time. 22.73% 13.64% 63.64% All in all, I found the carving exercises very useful. 59.09% 18.18% 22.73% Note: The values represent the percentage of students who agreed (strongly or generally), neither agreed nor disagreed, or disagreed (strongly or generally) with each statement in the questionnaire. Percentages may not total 100% because of rounding.

September 2013 ■ Journal of Dental Education 1151 taking tooth models out, students’ comments echoed their answers in the questionnaire where they thought that signing teeth out on an individual basis would have been more beneficial as few pairs met up to study together. Students emphasized how helpful the small tests at the start of the workshops were and suggested having tests at the end of each session. As for working in groups during the workshops, the comments suggested the students felt that group work did not help learning and was not productive. This was due to the fact that they are allocated to random groups and have various levels of knowledge, which some saw as a hindrance to their learning. Some students thought that because nobody had prior knowledge of the topic, group work was pointless and that they would have probably learned better on their own as it would have been easier. Revision sessions using natural teeth were said to be helpful, and including more “real” teeth in the course was suggested. Regarding the carving exercises, students commented that the session time was not sufficient to do the tasks justice and achieve the accuracy re- quired and that the tasks were time-consuming. On the other hand, some students commented that the carving task was good for developing their strength and manual dexterity. Discussion The study of tooth morphology has been tra- ditionally delivered through lectures and practical sessions involving carving tooth models. Commer- cially available tooth models have also been used in the study of dental anatomy, and such models can also be used in the study of occlusion and in other dental sciences. Digital atlases7,8^ and online tooth morphology packages9,10^ are also available to aid dental students in the study of this topic. The tooth morphology course at the University of Aberdeen Dental School is delivered through on- line handouts that students discuss during designated self-directed workshops in the presence of a member of the staff. This is done using plastic tooth models both of natural and magnified sizes. Tooth identifica- tion sessions test the students’ knowledge and expose them to natural teeth. Two workshops are dedicated to the clinical implications of tooth morphology to put the students’ acquired knowledge into context. Tooth carving sessions are a recent addition to the course aimed at introducing manual skills training through learning tooth morphology at an early part of the dental course. thought the session familiarized them with some laboratory instruments, and 64 percent thought the sessions helped them understand the proper grip of instruments. Paraffin wax was considered easy to handle by 52 percent of the students, while 23 per- cent found the wax difficult to handle. The majority of the students (96 percent) thought the laboratory space provided was ideal for performing the tasks and found supervising staff members helpful. Eighty-two percent of the students agreed that the carving ses- sions helped develop their manual dexterity (only one student strongly disagreed with this). As for the mark- ing of the carved tooth models, 68 percent thought the marking criteria were realistic, and 86 percent found the markers’ feedback and comments useful. Regarding the students’ perceptions of the usefulness of the carving sessions, 55 percent of the students agreed that the carving exercises helped them better understand tooth morphology, whilst 64 percent found the session helped them understand the anatomy of teeth in three dimensions. Sixty-eight percent of the students agreed that the carving ses- sions were complementary to the workshops, and 32 percent did not think that the carving sessions added anything to their knowledge of tooth morphology. Only five students (23 percent) thought that the carving sessions were of no benefit, and 74 percent disagreed with that. All in all, fifty-nine percent of the students found the carving exercises very useful, 23 percent did not, and the remaining students ( percent) neither agreed nor disagreed. Students’ Comments With regards to workshop handouts, students commented about their length and excessive de- tails; they reported that the volume covered was overwhelming. Some students actually found that the session time was not enough to complete the handout, and others suggested a simplified guide on the main points to help identify a tooth and a comparison between different teeth. The language of the handouts was said to be too complicated for inexperienced students. Many students said they liked the references and resources recommended at the end of each handout, which included videos, websites, and links; some said they learnt better through these resources. Some students expressed their preference for having some form of lecture(s) either to replace or in addition to the workshops, such as having mini-lec- tures prior to workshops to highlight the main points or a short summary at the end of each session. Regarding

1152 Journal of Dental Education ■ Volume 77, Number 9 This study revealed that the students were satisfied with the workshops as a mode of learning although they would prefer the introduction of some sort of didactic teaching in the form of lectures in addition to more time to study the models. These suggestions will certainly be reviewed to assess the possibility of such changes, especially given that most students found the introductory tooth morphol- ogy session very helpful. This session was delivered as a tutorial with some didactic teaching in addition to self-directed study of the models and the use of the personal response system (PRS) at the end of the session to test students’ comprehension of the topic. This format is exactly what the students asked for in the questionnaire. Concerning the students’ views on carving sessions, there was a feeling that, in the four-year graduate dental course, the students’ timetables are overloaded and, therefore, carving sessions would be more appropriate for undergraduate courses, which are not as condensed. This view was expressed by several students. An alternative would be to use other applications of carving to recreate tooth morphol- ogy in part, such as the replacement wax-carving technique, in which tooth models have a component removed and students are tasked with replacing the missing landmark with wax.^12 This is beneficial for manual dexterity and does not consume as much time as carving a whole tooth model and might therefore be useful for our course. In this study, handouts were used as a guide for carving teeth. There are other ways to guide the students in such tasks. In their randomized single blinded study, Nance et al. assessed students’ performance in tooth carving following receiving instructions from staff members in one group and using a DVD with instructions in another and found that a combination of the two techniques might be the best method to enhance students’ performance.^11 Our students expressed similar recommendations, and 77 percent of them commented that an online demonstration would be helpful. Although some students questioned the benefit of carving sessions, they agreed that it helped them develop their manual dexterity, which is an impor- tant outcome of the exercise. The assessment of the carved tooth models was formative and did not count towards the overall performance of the students in the course. Since learning is assessment-driven,^20 this may have influenced the students’ approach and dedication to the task. In fact, it was noticed by the supervising staff members that students behaved dif- ferently during the carving sessions. It is probable In this study and following the delivery of different tooth morphology teaching sessions, a questionnaire asking for the students’ feedback was distributed to the students to complete. The questionnaire probed students’ views about the ef- fectiveness of these teaching methods in learning tooth morphology. As a graduate-level course, self-directed learn- ing makes up an important component of the dental course in Aberdeen. It is thought that “andragogy” or adult learning is more self-directed^20 and that the students’ previous experiences are important sources for learning both for themselves and their colleagues. In our graduate-level course, we have used this to promote peer learning. Mature students are more problem-centered, and this is important in problem- based learning.^20 The mode of delivery of the tooth morphology course emphasized this by providing students with the opportunity for self-directed study at home with the borrowed models. The fact that the tooth morphology workshops allow group work also provides a good opportunity for students who learn better with their peers. However, when their views were sought, many students expressed their feelings of opposition to working in groups, and they expressed their prefer- ence to work on their own. Some of the students felt superior to others and felt that working with students with a lower level of knowledge was a hindrance. This might be related to this being a graduate course and some students feeling more knowledgeable depending on their background. It should be kept in mind that peer teaching/learning is encouraged in our dental school; however, tooth morphology is a topic totally new to the majority of the students. The students’ views against group work also became apparent when the majority declared they would have preferred borrowing the tooth models on an individual basis rather than in pairs. An important part of the course was including small formative tests at the start of each session. These are excellent for providing students with feed- back regarding their progress. Written feedback was provided so that students could see where they went wrong and then keep it as a record for future revi- sion. This is important as it was found that medical students’ performance improved following receiving feedback.^21 Indeed, all of the students in our study agreed that the tests were very useful. Although feed- back is useful for the learning process, some students see it as criticism, and many students consider praise as a satisfactory feedback.^21 It is therefore important to keep the feedback focused.

September 2013 ■ Journal of Dental Education 1153

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19. Cohen L, Manion L, Morrison K. Research methods in education. 6th ed. New York: Routledge, 2007.
20. Fry H, Ketteridge S, Marshall S. Understanding student learning. In: Fry H, Ketteridge S, Marshall S, eds. A handbook for teaching and learning in higher education: enhancing academic practice. 3rd ed. Oxon: Routledge,
21. Boehler M, Rogers D, Schwind C, Mayforth R, Quin J, Williams G, et al. An investigation of medical student reactions to feedback: a randomized controlled trial. Med Educ 2006;40:746-9. that the students would have a better attitude towards these sessions if the assessment counted towards their performance in the course. The students were satisfied with the setting of the carving sessions, the allocated laboratory space, the instruments, and staff support; however, they found the carving material (wax) difficult to work with. Other materials were and still are being assessed to find a good substitute for wax. It is important to emphasize that this was a pilot study involving a small number of students. It is therefore imperative to assimilate data from several cohorts to validate the findings. Involving other dental courses to seek their views on the topic would be beneficial, especially to compare any dif- ferences between students’ attitudes in both graduate and undergraduate courses. Another limitation of the study is that it represents a single point observation; however, the progress of the students included is also being followed through their clinical skills and further into their clinical work. The results of this study suggest that the current format of the tooth morphology course is satisfactory. However, reviewing certain aspects of the program may render it more fit-for-purpose. The course is currently being evaluated to identify potential improvements. Acknowledgments The authors would like to thank Dr. Darren Comber and Dr. Colin Calder, University of Aber- deen, for their help during the design of this study and their advice on developing the course.

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