Implementation and Empirical Evaluation of a Case-based,

Interactive e-Learning Module with X-ray Tooth Prognosis

Thomas Ostermann

, Hedwig Ihlhoff-Goulioumius

, Martin R. Fischer

, Jan P. Ehlers

and Michaela Zupanic

Research Methods and Statistics in Psychology, Faculty of Health, Witten/Herdecke University, Witten, Germany

Didactics and Educational Research in Health Science, Faculty of Health, Witten/Herdecke University, Witten, Germany

Institute for Didactics and Educational Research in Medicine, Clinics of the University of Munich, Munich, Germany

Keywords: e-Learning, CASUS®, Virtual Patients, Case-based Learning, X-ray Pillar Diagnostic, Dental Students.

Abstract: The prognosis estimation of teeth based on radiographs is a subordinate but relevant target in many dental

medicine curricula in Germany. Empirical data on the integration of e-learning material into dental curricula

are rare. We aimed at developing and implementing a radiological pillar diagnostics online-course in the

dental curriculum at the University of Witten/Herdecke. This online course was developed on the CASUS

web-based learning platform and implemented in a blended learning approach. Results showed an easy

creation of learning cases (virtual patients), higher utilization for the intervention group regarding the

number of cases revised, time-on-task, and student acceptance. Dental students experienced improved

learning efficacy, higher long time knowledge retention and significantly better results in case based

assessment. The usability of the CASUS learning Platform therefore can be regarded as high and further

studies using this e-learning approach are recommended.

1 INTRODUCTION

e-Learning and blended learning play an increasing

role in dental education. Recent studies already

showed that the integration of an e-learning course

in the sense of blended learning can be both

effective and efficient (Karamizadeh, 2012;

Kavadella, 2012; Pokieser, 2009). In this

combination, the specific advantages of both forms

(spatial and temporal independence, web-based

communication possibilities, direct exchange of

experience, roll-playing and personal encounters)

are optimally utilized (Wimmer, 2012). This is also

reflected in the usage of computerized virtual

patients to gain clinical competencies and diagnostic

reasoning which is increasing within the last decade

(Cook et al., 2010).

The planning of dentures is an essential

component of the dental prosthesis customer and is

carried out based on various parameters. In addition

to a thorough medical history, clinical examination

and radiographic diagnostics are of crucial

importance. For the prosthetic planning, single tooth

images have the highest value due to their precise

representation (see Figure 1). Using this imaging

technique, the dentist can link and interpret the

clinical picture with the radiological image. Before

manufacturing new dentures, problems can be

detected and corrected if necessary.

Figure 1: Single tooth images from an x-ray.

Ostermann, T., Ihlhoff-Goulioumius, H., Fischer, M., Ehlers, J. and Zupanic, M.

Implementation and Empirical Evaluation of a Case-based, Interactive e-Learning Module with X-ray Tooth Prognosis.

DOI: 10.5220/0006475302770281

In Proceedings of the 6th International Conference on Data Science, Technology and Applications (DATA 2017), pages 277-281

ISBN: 978-989-758-255-4

277

The prosthetic evaluation of the teeth shows

several difficulties, such as the periodontal

(Dannewitz, 2006) or the endodontic situation of the

tooth, but also the coronal situation with possible

fillings or caries. As complex as the findings can be,

the radiological findings and interpretations are not

trivial.

At Witten/Herdecke University radiological

diagnostics is taught to the dental students mainly

during the compulsory course "Radiology" with

theoretical and practical parts in the 4th and 5th

term. The knowledge obtained here will be

examined by a written exam at the end of the 5th

term. Radiological diagnostics is then deepened

during the 7th and 8th semesters during the lectures

"Dentistry Surgery", where the focus is in the area of

surgical teaching contents.

The prognosis estimation of teeth using x-ray

images is a goal of prosthetics, which is

underrepresented in many dental medicine curricula

in Germany but which nevertheless is relevant in

dental practice. Empirical data on the integration of

e-learning courses into dental curricula are rare.

Thus, the aim of this work was to develop an e-

learning course and the integration into the local

dental curriculum. Therefore, in this study the

implementation was performed in dentistry and the

success proved by empirical evaluation.

2 MATERIAL AND METHODS

For the new e-learning course, 55 short case studies

on radiological pillar diagnostics were generated on

the web-based learning platform CASUS® (Fischer,

2000). CASUS contains a platform independent,

web-based authoring tool that allows to create multi-

media, interactive virtual patients without the need

of coding-competencies of the authors. All processes

like authoring, learning and evaluation are done in

the same database to ensure ease of access and high

usability. The cases and media are presented in

html4, all actions (results, time, feedback) are

logged in the database to enable individual and

overall feedback. To prevent cognitive overload the

cases use scaffolding but allow a huge variety of

item formats.

2.1 Implementation

The cases were always divided into three tasks:

anamnesis (judging the medical history), diagnosis

(finding the reason of the problem) and prognosis

assessment (estimating the healing process) using an

X-ray image. This step of a forecasting estimation is

a learning goal which has not yet been taught in the

curriculum in this form beforehand.

The course content was decisively determined by

the dental radiographic findings. Radiological

findings were always assigned to a diagnosis. In the

collection of X-ray images and later in the creation

of the learning cases, the most common dental

diagnoses were integrated into the CASUS program

by at least one case study. Due to the rarity of some

diseases or malformations, it was not yet possible to

insert all X-ray findings as a learning case in

CASUS. However, later completion is possible. All

cases were examined professionally by the senior

physician of the dental prosthesis at the WHU.

Each virtual patient consisted of three learning

cards. The first card started with the anamnesis and

the clinical examination of the patient presented as a

case history in text form (see Figure 2).

Subsequently, the student was asked to examine the

X-ray image and mark the correct answer in the long

menu. The X-ray image can be increased in its size

in CASUS without significant loss of quality. For

reasons of data privacy, the use of panoramic film

recordings was dispensed and only single tooth

recordings were used.

On the second card, the student firstly received

the correct X-ray findings and then was asked to

make a diagnosis. The response possibilities were

selected on card 1 and 2 from a selection list called

"long-menu" which was arranged alphabetically (see

Figure 3) into a drop-down menu and the search for

the terms is arranged via an active field, which

precedes the drop-down menu (Schuwirth, 1996).

Figure 2: Screenshot Card 1 (in german) with selected X-

ray findings and opened long-menu.

In the active field, it was possible to include the

answer itself, restrict the selection by typing the

initial letter with auto-completion, or search for the

correct answer in the list. While on card 1 all

possible X-ray findings were stored in the

DATA 2017 - 6th International Conference on Data Science, Technology and Applications

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corresponding long-menu, on card 2 all possible

dental diagnoses are available. i.e. concrement,

concussion or contusion. Finding of a diagnosis was

not limited to a primary diagnosis, however

individual diagnoses for the virtual patient were

required. As a result, a diagnosis could be assigned

to every X-ray examination.

Figure 3: Screenshot Card 2 (in german) with opened

long-menu.

The third card contained the correct diagnosis

and prognosis assessment with four possible

answers. Here, the student has to make the

estimation of the tooth. The four subdivisions of the

prognosis assessment were designed in accordance

with the four criteria of the California Dental

Association (CDA, 1977). The CDA criteria were

originally used to assess the quality of dentures.

They are divided into "excellent", "acceptable",

"must be corrected" and "must be re-established

immediately". The subdivision used in CASUS in

the estimation of the prognosis was used in "Tooth-

free prosthodontically usable"; “If necessary, extend

prosthetics", "tooth cannot be used prosthetically"

and "tooth must be removed (immediate action)". In

this question, the student could choose only one

answer option. After answering all three cards, a

summary of the learner's success concerning the

anamnesis (Card 1), diagnostic analysis (Card 2),

and prosthetic prognosis (Card 3) shown in percent

is provided (see Figure 4).

Figure 4: Summary of the learning experience (screenshot

of the CASUS learning platform (in german)).

In our study approach, 30 dental students of the

6th semester (intervention group, IG) and 30

students of the 8th semester with more knowledge

and experience in radiological diagnostics.

(historical control, CG) were offered these case

examples. Students of the 6th semester were selected

as IG, because at this point they have acquired a

basic knowledge, but have not yet begun dental

patient treatment. The IG has been successively

opened cases and addressed during the course to the

content (blended learning). The CG could use all

cases for self-controlled learning. Both groups were

able to send questions by email to a clinical tutor.

The case-based knowledge of the volunteers was

recorded formally at the beginning and end of the

summer semester 2011 as well as one year after the

intervention. Indicators for the successful

implementation were the number of case processing,

time-on-task, acceptance and success of the case

processing. Figure 5 shows the flow chart of the

study.

Figure 5: Flow-Chart of the course of the study.

2.2 Empirical Evaluation

It is discussed that some of the subject-specific

knowledge is linked to the success of the study

(Ferguson, 2002; Frischenschlager, 2005). To check

whether there are performance factors such as A

levels, pre-physics, physics, computer use, use of e-

learning for learning, computer safety, and CASUS

usage problems with higher performance Post-test,

these factors were questioned in a questionnaire. In

addition, age was asked as an independent variable.

To test the comparability of both groups, a pre-

test was performed. In the pre-test, consisting of 5

case studies a maximal score value of 15 points (3

points per case) could be archived by the students.

Statistical analysis included univariate between

group comparisons with a significance level of

=0.05. All statistical analyses were performed with

SPSS 23.0.

Implementation and Empirical Evaluation of a Case-based, Interactive e-Learning Module with X-ray Tooth Prognosis

279

3 RESULTS

As a first result, it was found that none of the

performance factors (e.g., physics survey) correlates

with the results of the pre-, post- and sustainability

tests. This result reflects the current scientific

research, which also rarely resulted in significant

results between studies and prior knowledge in

studies with a larger number of participants

(Ferguson, 2002, Frischenschlager, 2005).

In the pre-test, consisting of 5 case studies, the

CG was significantly better (p = 0.015). The CG

reached 6.7 (SD 2.4) while the IG only summed up

to a mean of 5 points (SD 2.1). Despite the

knowledge advancement of the CG, the IG was

significantly superior in the post-test, again

consisting of 5 case studies (p=0.008). In the post-

test the IG achieved 8 (SD 2) out of 15 points and

the CG scored lower with only 6.2 points (SD 2.5).

In the sustainability test, again consisting of 5 case

studies, the IG again was significantly superior with

9.9 points (SD 1.9) compared to the CG with 8.6

points (SD 2) (p = 0.019).

IG moreover shows higher utilization regarding

number of cases revised, time-on-task, and student

acceptance. They experienced improved learning

efficacy, higher long time knowledge retention and

significantly better results in case based assessment.

The usability therefore can be regarded as high.

Figure 6: Score values of the intervention and control

group.

4 DISCUSSION

The course concept developed for this work includes

a curricular gap in dental education for the

integrated mediation of radiological pelvic diag-

nostics. Which students benefit above all from the

described teaching / learning offer? At least in this

examined sample, there was no correlation between

past academic performance (mirrored, for example,

in physics notes, final school grades) and the results

of the knowledge tests. Just as little led to a more

comprehensive pre-education (already completed

studies, vocational training) to a better performance.

This is in line with other studies which, even in

studies with a larger number of participants, were

rarely able to show significant results between

learning success and prior knowledge (Ferguson,

2002, Frischenschlager, 2005). However, it is

described in the literature that it is particularly

powerful students with an appropriate prior

knowledge that benefits more from e-learning than

performance-weaker peers (Grasl, 2012; Issing,

2002). Grassl and colleagues (2012) showed that

students with little prior knowledge of front-end

teaching benefit more than blended learning, while

students with greater prior knowledge benefit more

from blended learning. As the students acquire more

knowledge with each course of learning, those with

an initially low level of prior knowledge of blended

learning will also benefit.

The advantages of integrating an online course

into a compulsory course in the sense of a blended

learning as opposed to the non-moderated, self-

controlled learning reflected the findings of recent

scientific investigations. With the new development

of the course, it was possible to provide the student

with knowledge of the radiological prognosis before

the independent patient treatment in the clinical

study section. Further studies could examine the

transfer to other sites, examine the sustainability of

what has been learned and ultimately examine the

extent to which a positive effect on patient treatment

can be assumed.

With the development of the case-based e-

learning course for radiological pillar diagnostics, an

easy to use and helpful supplement to the regular

dental medical curriculum was created. The

integration of the course into a presence event has

proven itself. A direct and medium-term learning

effect, also in comparison to the CG, could be

shown. It is advisable to locate the course after the

dental radiology course. The teaching course of the

dental prosthesis does not seem to be a prerequisite

and can run parallel to the course. This course can be

integrated into the dental curriculum of other

universities.

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ACKNOWLEDGEMENT

We would like to thank the Instruct AG for their

support of the project.

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