1st Place: Manuela Milos

Dental treatment challenges in special care dentistry services

 

Author: Manuela Milos

Dental School: School of Dental Medicine, University of Zagreb, Croatia (Gundulićeva 5, 10 000 Zagreb, Croatia)

Year of study: 5th

Contact details: manuela.milos123@gmail.com 

 

Introduction

Special care dentistry (SCD) is described as providing oral care for people with an impairment or disability, where this terminology is defined as: „The improvement of oral health of individuals and groups in society who have a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability or, more often, a combination of a number of these factors“ (1). Since this group includes different patients whose disease etiology is diverse, an individual approach to patients is extremely important, as it varies greatly from person to person. Thus, for example, patients whose problem is of a physical nature will require unhindered access to the dental facility, aids for transfer to the dental chair, and a toilet suitable for people with disabilities. On the other hand, patients with mental disabilities will require special attention regarding communication and planning of the procedure. It is important to emphasize that not everyone with a disability requires SCD. This is because not all disabilities limit oral health. Those who can easily access dental services and who can express their needs, despite their disability, do not need the SCD approach. Contrary, those people who are unable to do so because of their disability (due to sensory impairments, mobility impairments, fear, inability to co-operate, etc.) require SCD (1). Patients with disabilities, same as the healthy population, want to keep their teeth to look good, be socially accepted, and consume their favorite foods unhindered. Although this group of people deserves equal access to dental care as other people, this is often not the case. 

​

Literature Review

According to the European disability forum, over 100 million people with disabilities live in the European Union. In other words, every fifth resident of the European Union is disabled.

Although it could be assumed that a large number of people with disabilities determines the frequency of such patients in dental practice, this is not necessarily the case. According to research by D'Addazio et al. (2), 49.1% of people with disabilities report that they rarely or never go to the dental office and when they do, it is mainly for emergencies. This can be explained by the low position of dental health on their list of priorities, that is, on the list of priorities of their caregivers in cases when patients are not able to take care of themselves. In that case, caregivers are responsible for the oral health of the person they care for, and their knowledge, attitude, and actions are often unsatisfactory (3,4). The literature clearly states that the oral health of people with disabilities is significantly worse than that of the healthy population (5-7). The high level of plaque documented in disabled patients is a predisposition to the development of periodontal diseases and tooth decay. The cause of such conditions can be attributed to the lack of manual dexterity required for good plaque removal which is present in the majority of individuals with mental retardation (4). Deterioration of oral hygiene can also occur in cases of improper functions of the oral musculature, in which the natural cleaning ability is impaired (8). Research related to the prevalence of caries among people with disabilities shows that caries rates are lower or the same as in the general population (7). Such data can potentially be explained by the balanced diet that patients receive in many institutional and group settings, with the controlled intake of refined carbohydrates (9,10). Several studies report more decayed and missing teeth, but fewer restored teeth in individuals with intellectual disabilities (11-14). A potential reason for this is the frequent use of radical methods in treating dental problems in patients with disabilities, which often results in tooth extractions. This therapeutic approach can be explained by non-cooperativity in patients with mental disabilities. Patients who are cooperative during dental procedures lose fewer teeth than those who cannot cooperate (9). Prosthetic restorations, such as crowns, bridges, and implants, are scarce among this population (15).

The problem of access to the dental office is often reported in the literature (5,16-18). In addition to in-office architectural barriers that often make it difficult for patients to access dental services, the problem is the distance from the office, transportation, difficulty in lying position, and inappropriate dental equipment (dental chair). Research shows that less than one third of dental practices have full physical access to disabled patients (19).

One of the major problems of patients with cognitive disabilities is communication with the dental team. Patients face the challenges of transmitting information about their difficulties, and if there is a lack of attention and skillful approach to the patient by the doctor of dental medicine, misunderstandings can easily occur.

It is also important to mention the problem related to insufficient education of dentists for working with special care patients (20-22). Research indicates that one of the reasons why patients do not visit dental offices is the difficulty in finding a specialized dentist who can treat them (2). According to research by D'Addazio et al. (2), 54% of dentists do not treat people with cognitive impairment and poor ability to collaborate during treatment. In addition, over 50% of dentists who treat non-collaborating patients do not intend to include them in follow- up programs (2). These data are devastating considering that the follow-up program of special care patients is essential for the prevention and maintenance of good oral health in this group of patients.

​

Innovative Section

Although adequate education of dentists in the field of SCD is necessary for the satisfactory treatment of this group of patients, the question arises of the sufficiency of a specialist study in the field of SCD. The establishment of this specialist branch with the education of a certain number of future specialists will not meet the needs for the treatment of millions of patients with special needs. This is comparable to the fact that most oral health services for children are carried out by general practice dentists, despite a pediatric dentistry specialty. In cases where there is a need for a specialist, the complexity lies mainly in the management of the patient, not the dental procedure. For this reason, it is important to conduct education at a general level, including students of dental medicine, but also more experienced practitioners who lack knowledge in this field. The introduction of a mandatory course in study programs of dental medicine is of crucial importance precisely because of the necessary competence of future doctors of dental medicine for the treatment of disabled patients. Ensuring contact with such patients in the working environment during studies will ensure not only the necessary knowledge but also the self-confidence of future doctors of dental medicine when working with such patients. The implementation of face-to-face contact with disabled patients, at least those whose disability is of a physical nature, can be of great benefit in raising awareness of the needs and difficulties that this group of people faces. On the other hand, it is often not enough to simply offer education to doctors of dental medicine, because due to the wide availability of various educations in the field of dental medicine, SCD can easily remain unnoticed, or perceived as unattractive. One of the ways in which it is possible to ensure the attendance of education in SCD by older practitioners is to set this education as a prerequisite for exercising the right to a relicense.

Ease of access to the dental office can be achieved by installing stairlifts, wheelchair lifts, providing accessible parking spaces, suitable toilets, widening the entrance, providing space for a wheelchair in the waiting room, leveling thresholds, and clear signage. Since the dental chair is often a source of difficulty in the treatment of special care patients, it is necessary to consider the option of purchasing a chair with a "break-leg" option (1). It is desirable to provide space for setting up a wheelchair next to the dental chair, which facilitates the transfer of the patient to the dental chair. If transferring the patient to the dental chair is difficult, it is good to have "transfers" (1). These are curved boards that are placed between the wheelchair and the dental chair to make it easier for the patient to move in both directions.

Good communication is fundamental in dental practice. Unfortunately, it is particularly damaged in the field of SCD and therefore requires special attention. This is caused by cognitive and sensory disorders. Improving communication with patients who exhibit cognitive and emotional impairments can be achieved by providing written instructions that the patient can study at home, independently or with the help of a caregiver. It is necessary to ensure enough time, use simple sentences, speak more slowly and use gestures. In the case of hearing impairment, it is important to get information from the patient about his preferred method of communication. In the case of elderly patients who wear hearing aids, the therapist should check whether the device is switched on. If the patient prefers lip-reading, it is necessary to speak clearly, not too slowly, and without exaggerating lip movements. Due to the possibility of a preference for the use of sign language, it would be practical for the therapist to know sign language. If this is not the case, the therapist should provide an interpreter that will facilitate communication. It is important to always address the patient face to face, not to communicate with the interpreter. For patients with visual impairment, it can be helpful to guide them through the practice by allowing them to take hold of your elbow rather than taking them by the arm, and warning them if they are coming near the steps and saying how many are there. Informing them in detail about all stages of the procedure, especially before painful sensations is helpful to avoid surprises. It would be of great benefit to provide such patients with information in the form of audio recordings or tactile formats such as Braille.

Performing oral hygiene is challenging for patients with mental disabilities. Although this task is often performed by caregivers, whenever possible, oral hygiene should be performed independently by patients. In this way, patients gain a sense of autonomy and reduce their dependence on the caregiver's potentially unfavorable positioning of oral hygiene on the list of priorities. The use of toothbrushes with a stable grip, electric toothbrushes, the use of an alarm, or listening to a song of a certain duration while brushing teeth can be helpful in the implementation of oral hygiene in disabled patients.

Potentially the most important matter in the treatment of patients with disabilities is prevention. In addition to preserving the patient's health, proper prevention eliminates the need for invasive procedures that are particularly challenging to perform among this group of patients. The first step in prevention is the use of fluoride through toothpaste or fluoride mouthwashes. The application of fluoride varnishes is also an effective method due to their simple use and long- term effectiveness, while fluoride gels should be avoided due to the possibility of ingestion. Proper nutrition is imperative in the fight against dental diseases, which is why special attention needs to be focused on educating patients and caregivers about the importance of healthy eating habits in preserving oral health.

Since the oral health of patients depends to a large extent on the attitude, knowledge, and actions of caregivers, it is necessary to focus special attention on education and awareness of caregivers on their responsibility and role in the oral health of the patient. Education can take place during a visit to the dental office in the form of a demonstration of the correct brushing technique and with the help of information leaflets that can serve as reminders.

Since patients with disabilities tend to visit the dentist only in emergency cases, it is necessary to include these patients in the follow-up program. In this way, periodic control of patients, the possibility of timely intervention, and the implementation of prophylactic procedures are ensured.

Educating wider groups (such as associations of patients with special needs or people placed in institutional settings) about the importance of oral health care can be useful for raising general awareness of this issue. Information leaflets or educational visits to these associations can bring benefits to the overall preservation of oral health.

It was previously stated that the most common method of solving dental problems of patients of this group involves tooth extractions. The reason for this is the uncooperativeness of patients, but also insufficient knowledge of dentists and incorrect attitude when treating disabled patients. This problem can be solved by providing a multidisciplinary approach that provides patients with a wide range of specialists, who can, with the proper education, provide a variety of necessary treatments to disabled patients. In this way, the patient can be provided with prosthetic restorations, endodontic procedures, orthodontic therapies, and others. Although every doctor must know the methods necessary to work with patients with special needs and can provide a quality basic dental service, the establishment of larger specialist institutions that will ensure the coverage of all specialist branches trained to work with this specific group of patients can be of great benefit when treating complex cases.

​

Conclusion

While it is undeniable that all people deserve the same quality dental care, this is often not the case. One of the deprived groups in this respect is certainly patients with special needs. Physical barriers, lack of trained dental staff, and dependence on the caregiver's attitude towards oral health are just some of the difficulties faced by this group of patients. As a result, the oral health of patients with special needs is deficient compared to the healthy population. Preventing health inequalities should be of primary importance. To avoid existing discrimination, SCD was established. The task of SCD is to provide adequate care to patients with special needs by ensuring the competence of dentists to work with this challenging group of patients. In addition to the education of the dental staff, it is extremely important to carry out appropriate education among caregivers, since in a significant number of cases they are directly responsible for the patient's oral health. Forming the right attitude and prioritizing oral hygiene in everyday life provides a good foundation for achieving the oral health of patients. Whenever possible, it is necessary to carry out corrections of the dental clinic to achieve barrier-free access and a pleasant environment for the patient. For the provision of comprehensive dental services, the establishment of larger specialist institutions can be a good solution. Nevertheless, it is important to emphasize the need for education of general dentists to work with patients with disabilities due to the large scope of this group of patients and the necessary ability to provide adequate basic dental services.

 

References

1. Dougall A, Fiske J. Access to special care dentistry, part 1. Access. Br Dent J. 2008 Jun 14;204(11):605-16. doi: 10.1038/sj.bdj.2008.457. PMID: 18552796.

2. D'Addazio G, Santilli M, Sinjari B, Xhajanka E, Rexhepi I, Mangifesta R, Caputi S. Access to Dental Care-A Survey from Dentists, People with Disabilities and Caregivers. Int J Environ Res Public Health. 2021 Feb 6;18(4):1556. doi: 10.3390/ijerph18041556. PMID: 33562099; PMCID: PMC7915372.

3. Cumella S, Ransford N, Lyons J, Burnham H. Needs for oral care among people with intellectual disability not in contact with Community Dental Services. J Intellect Disabil Res. 2000 Feb;44 ( Pt 1):45-52. doi: 10.1046/j.1365-2788.2000.00252.x. PMID: 10711649.

4. Thornton JB, al-Zahid S, Campbell VA, Marchetti A, Bradley EL Jr. Oral hygiene levels and periodontal disease prevalence among residents with mental retardation at various residential settings. Spec Care Dentist. 1989 Nov-Dec;9(6):186-90. doi: 10.1111/j.1754-4505.1989.tb01185.x. PMID: 2533727.

5. Gerreth K, Borysewicz-Lewicka M. Access Barriers to Dental Health Care in Children with Disability. A Questionnaire Study of Parents. J Appl Res Intellect Disabil. 2016 Mar;29(2):139-45. doi: 10.1111/jar.12164. Epub 2015 Mar 5. PMID: 25754132.

6. Gizani S, Declerck D, Vinckier F, Martens L, Marks L, Goffin G. Oral health condition of 12-year-old handicapped children in Flanders (Belgium). Community Dent Oral Epidemiol. 1997 Oct;25(5):352-7. doi: 10.1111/j.1600- 0528.1997.tb00954.x. PMID: 9355771.

7. Anders PL, Davis EL. Oral health of patients with intellectual disabilities: a systematic review. Spec Care Dentist. 2010 May-Jun;30(3):110-7. doi: 10.1111/j.1754- 4505.2010.00136.x. PMID: 20500706.

8. Shaw L, Shaw MJ, Foster TD. Correlation of manual dexterity and comprehension with oral hygiene and periodontal status in mentally handicapped adults. Community Dent Oral Epidemiol. 1989 Aug;17(4):187-9. doi: 10.1111/j.1600- 0528.1989.tb00608.x. PMID: 2758792.

9. Gabre P, Martinsson T, Gahnberg L. Incidence of, and reasons for, tooth mortality among mentally retarded adults during a 10-year period. Acta Odontol Scand. 1999 Feb;57(1):55-61. doi: 10.1080/000163599429110. PMID: 10207537.

10. Steinberg AD, Zimmerman S. The Lincoln dental caries study: a three-year evaluation of dental caries in persons with various mental disorders. J Am Dent Assoc. 1978 Dec;97(6):981-4. doi: 10.14219/jada.archive.1978.0421. PMID: 152772.

11. Tiller S, Wilson KI, Gallagher JE. Oral health status and dental service use of adults with learning disabilities living in residential institutions and in the community. Community Dent Health. 2001 Sep;18(3):167-71. PMID: 11580093.

12. Whyman RA, Treasure ET, Brown RH, MacFadyen EE. The oral health of long-term residents of a hospital for the intellectually handicapped and psychiatrically ill. N Z Dent J. 1995 Jun;91(404):49-56. PMID: 7675347.

13. Shaw MJ, Shaw L, Foster TD. The oral health in different groups of adults with mental handicaps attending Birmingham (UK) adult training centres. Community Dent Health. 1990 Jun;7(2):135-41. PMID: 2379087.

14. Cheng RH, Leung WK, Corbet EF, King NM. Oral health status of adults with Down syndrome in Hong Kong. Spec Care Dentist. 2007 Jul-Aug;27(4):134-8. doi: 10.1111/j.1754-4505.2007.tb00335.x. PMID: 17972443.

15. Fauroux MA, Germa A, Tramini P, Nabet C. Prosthetic treatment in the adult French population: Prevalence and relation with demographic, socioeconomic and medical characteristics. Rev Epidemiol Sante Publique. 2019 Jul;67(4):223-231. doi: 10.1016/j.respe.2019.04.055. Epub 2019 Jun 14. PMID: 31204147.

16. Smith JM, Sheiham A. Dental treatment needs and demands of an elderly population in England. Community Dent Oral Epidemiol. 1980 Oct;8(7):360-4. doi: 10.1111/j.1600-0528.1980.tb01308.x. PMID: 7009039.

17. Pool D. Dental care for the handicapped. Br Dent J. 1981 Oct 20;151(8):267-70. doi: 10.1038/sj.bdj.4804678. PMID: 6456751.

18. Finger ST, Jedrychowski JR. Parents' perception of access to dental care for children with handicapping conditions. Spec Care Dentist. 1989 Nov-Dec;9(6):195-9. doi: 10.1111/j.1754-4505.1989.tb01187.x. PMID: 2533729.

19. Edwards DM, Merry AJ. Disability part 2: access to dental services for disabled people. A questionnaire survey of dental practices in Merseyside. Br Dent J. 2002 Sep 14;193(5):253-5. doi: 10.1038/sj.bdj.4801538. PMID: 12353044.

20. Gizani S, Kandilorou H, Kavvadia K, Tzoutzas J. Oral health care provided by Greek dentists to persons with physical and/or intellectual impairment. Spec Care Dentist. 2014 Mar-Apr;34(2):70-6. doi: 10.1111/scd.12011. Epub 2013 Jan 16. PMID: 24588491.

21. Hennequin M, Moysan V, Jourdan D, Dorin M, Nicolas E. Inequalities in oral health for children with disabilities: a French national survey in special schools. PLoS One. 2008 Jun 25;3(6):e2564. doi: 10.1371/journal.pone.0002564. PMID: 18575600; PMCID: PMC2432497.

22. Gondlach C, Catteau C, Hennequin M, Faulks D. Evaluation of a Care Coordination Initiative in Improving Access to Dental Care for Persons with Disability. Int J Environ Res Public Health. 2019 Aug 1;16(15):2753. doi: 10.3390/ijerph16152753. PMID: 31374964; PMCID: PMC6696062.

 

2nd Place: Maria Ioana Onicas

Next Stop in Digitalisation: Periodontology

 

Name: Maria Ioana Onicaș

Dental school: University of Medicine and Pharmacy “Iuliu Hațieganu” Cluj-Napoca, Romania (Address: 8 Victor Babes Street, Cluj-Napoca)

Year of study: 6th

Contact details: ioana_onicas@yahoo.com

 

Introduction

In this day and age, technology is developing at a fast pace, bringing a tremendous breakthrough in the medical field in terms of diagnosis, treatment, and medical education. The impact of technological innovation has left its mark in numerous fields of dentistry, changing the game in the current dental workflows. Indisputable, in prosthodontics significant improvements have been made in the last few years, starting from intraoral scanning and CAD-CAM technology to jaw movement digital registration. Not to mention implantology, where digitalization has increased the accuracy of data collection and treatment planning. Also, in orthodontics technological approaches have brought ground-breaking changes to the traditional methods of designing and production of clear aligners for teeth straightening therapy. The complicated anatomy of the root canal system can be elucidated currently using 3D images along with performing the measurement of the length of the root canals directly on CBCT. In periodontology, three-dimensional surgical guides for the procedure of crown lengthening can be designed on the computer and printed. In terms of periodontal measurements, a few methods have been tested in the past few years, but the conventional periodontal probe is still the gold standard. Periodontology is a field with true potential of digitalization, and it may be rising in the coming years in terms of technology.

​

Literature Review

Periodontal disease is characterized as an inflammatory disease that affects the supporting tissue of the teeth.(1) Left untreated it leads to tooth loss, which affects the masticatory function, esthetic function along with individuals’ self-confidence (2) and moreover, his quality of life. (3) In a study carried by Global Burden of Disease in 2016, the 11th place of the most prevalent condition in the world was occupied by severe periodontitis. (4) Due to the high prevalence of periodontal disease and duet o its implications regarding oral and general health, an accurate diagnosis and an efficient treatment are needed.

The most used instrument in the current dental practice for diagnosing and monitoring periodontal disease is the periodontal probe. The measurement should be accurate and reproductible, but some errors can interfere. For instance, variation of pressure when inserting the probe, inconstancy of gingival inflammation, failure of recongnizing the cemento-enamel junction are factors that contribute to the variations in values obtained by examinators. (5)

The disadvantages of the classic periodontal probe have led to the invention of a series of new periodontal probes, that can be classified into second (constant force), third (automated constant force  and fourth (ultrasonographic periodontal) generation probes. (6) When comparing a William probe to a Floride probe, which is an automated constant force probe, Gupta el al (5) concluded that more precise and reproductible results were obtained when Florida probe was used.

In the study conducted by Fagehh et al (7), a comparison between clinical and digital measurements of gingival recession was done. The sites evaluated were 97. Four examinators had to evaluate the gingival recession using the following four methods: intraorally, using William’s probe, on a model, using a calliper, and digitally, on virtual models obtained from intraoral optical impressions using a software or from optical impressions of models. The results obtained emphasised that all examinators obtained similar results only when using the digital method. Therefore the variations obtained in measurements can be reduced this way.

In another study done in 2020, Lee et al (8) compared the measurement of the keratinized tissue width using three methods: clinical with a periodontal probe, digital using a scanner and histologic measurements. They came to the conclusion that digital and histologic measurements were similar and the classic method using a periodontal probe overestimated the values by 1 mm. The importance of this measurement is to evaluate if the procedure of soft tissue augmentation had a favorable result or not.

In a study conducted by Chung et al (9), the supra-alveolar gingival dimension was measured using CBCT images, which were superimposed with the images obtained with an oral scanner and the probing depth was measured clinically using UNC-15 probe. The findings of the study were that due to the correlation between clinical probing depth and digitally supra-alveolar gingival dimension measured, digital measurements can be used when the probing depth data is missing. Also, similar to a finding in the study mentioned before(8), when measuring probing depth clinically, there was a tendency of value overestimation.

Tooth mobility caused by periodontal disease is often treated using a dental splint. Zhang et al (10)  documented a case where a titanium splint for the anterior mandibular teeth was made using a digital method. The mandibular teeth were scanned and the files were imported into a software programme where the splint was designed. Next, the file was sent to a 3D printer, then after printing, the spling was finished, polished and prepared for cementation.

An often performed procedure nowaday that can be done digitally is represented by crown lenghtening. It assures the pink and white aesthetics and it uses a three dimensional surgical guide that is designed using a special software and based on the 3D image obtained after intraoral scanning.  A great number of studies have concluded that three dimensional printed guides are predictable and reliable in crown lengthening procedures .(11–13)

​

Innovative Section

In today’s society, the physical appearance plays an important role, having a direct impact on the life experiences and opportunities an individual has during his life. Dental esthetics have gained significant importance in the last decade and patients are starting to have more and more expectations nowadays in their aspiration for a perfect smile. When it comes to esthetics, periodontology is one of the fields of dentistry that is of crucial importance in assuring an ideal smile due to its direct influence on the aspect of dental implants and prosthetic restorations. Considering that prosthodontics and dental implantology have progressed considerably in the past few years with the aid of digital technology, the next promising field of dentistry that should benefit from a technological rise must be periodontology.

Recent literature has shown that digital technology has started to be implemented in periodontal procedures. For instance, the invention of second, third and fourth generations of periodontal probes were the first steps taken into the digitalization of periodontological workflows. In the past years research has been done in the direction of periodontal measurements done on tridimensional images obtained after an intraoral scan. Gingival recession, keratinized tissue width and supra-alveolar gingival dimensions were measured using this method and the results were favorable. More research and technical work needs to be done in this direction, as the gold standard now is still the manual periodontal probe. Variations in the values obtained after a periodontal examination should be reduced with the help of technology. Accurate measurements lead to a more precise diagnosis and to a more predictable outcome of the periodontal treatment, which is for the benefit of both the doctor and the patient.

After finding a 100% accurate digital solution for measuring periodontal parameters, advancements should be made in the direction of treatment. For the moment, the only procedure done digitally in this field is crown lengthening using three-dimensional surgical guides designed on the computer. In one study (10), a dentist did a titanium splint in order to immobilise the anterior inferior teeth affected by periodontal disease, although this is not a standard procedure like the treatment of the gummy smile mentioned before.

The most important step after discovering a device for precise periodontal measurements and digital dental workflows that improve the predictability of periodontal treatments is teaching the dental community how to implement these discoveries into their day-to-day practice. This could start with sending a digital brochure to every dental practice with an explanation of these new digital concepts in periodontology. Then, at every congress a sample of these products that digitalize the classic procedures should be present, in order for dentists to test the appliances themselves. Now the appetite for knowledge has increased, a series of workshops should be done in as many locations as possible, so every dentist has the opportunity to learn how to use the new technology. After workshops with more participants, trainings 1 on 1 should be done for the doctors who buy the technology. In order to stimulate more dentists to adopt a digital workflow in their practice, regional competitions could be organized for the best cases resolved using digital methods. Additionally, approaching dental universities to offer a mandatory course about digital dentistry, not only in the field periodontology, but in all fields of dentistry could be the biggest step taken into changing classical dentistry into digital dentistry.

​

Conclusion

It is clear to say that the cutting-edge technology available now on the market has led to the digitalization of dentistry and benefits both the provider of medical services and the patient receiving the treatment, in terms of time, comfort, treatment precision and predictable results. On this account, digitalising the fields that have not been digitalised yet or that have just started to take part of the digital process is a must that will lead to raised standards in dentistry. Periodontology has unveiled a potential for digitalization when it comes to periodontal measurements and existing treatment methods.

 

Reference Page

1. Carranza; Newman; Carranza’s Clinical periodontology 12thEd. Oral Surgery, Oral Medicine, Oral Pathology. 2015.

2. Tonetti MS, Jepsen S, Jin L, Otomo-Corgel J. Impact of the global burden of periodontal diseases on health, nutrition and wellbeing of mankind: A call for global action. Journal of Clinical Periodontology. 2017;44(5).

3. Reynolds I, Duane B. Periodontal disease has an impact on patients’ quality of life. Vol. 19, Evidence-Based Dentistry. 2018.

4. Vos T, Abajobir AA, Abbafati C, Abbas KM, Abate KH, Abd-Allah F, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. The Lancet. 2017;390(10100).

5. Gupta N, Rath SK, Lohra P. Comparative evaluation of accuracy of periodontal probing depth and attachment levels using a florida probe versus traditional probes. Medical Journal Armed Forces India. 2015;71(4).

6. Elashiry M, Meghil MM, Arce RM, Cutler CW. From manual periodontal probing to digital 3-D imaging to endoscopic capillaroscopy: Recent advances in periodontal disease diagnosis. Vol. 54, Journal of Periodontal Research. 2019.

7. Fageeh HN, Meshni AA, Jamal HA, Preethanath RS, Helboub E. The accuracy and reliability of digital measurements of gingival recession versus conventional methods. BMC Oral Health. 2019;19(1).

8. Lee JS, Jeon YS, Strauss FJ, Jung HI, Gruber R. Digital scanning is more accurate than using a periodontal probe to measure the keratinized tissue width. Scientific Reports. 2020;10(1).

9. Chung HM, Park JY, Ko KA, Kim CS, Choi SH, Lee JS. Periodontal probing on digital images compared to clinical measurements in periodontitis patients. Scientific Reports. 2022;12(1).

10. Zhang C, Liu Q, Yang J, Hou J. A digital technique for splinting periodontally compromised mobile teeth in the mandibular anterior region. Journal of Prosthetic Dentistry. 2021;125(4).

11. Mendoza-Azpur G, Cornejo H, Villanueva M, Alva R, Barbisan de Souza A. Periodontal plastic surgery for esthetic crown lengthening by using data merging and a CAD-CAM surgical guide. Journal of Prosthetic Dentistry. 2022;127(4).

12. Alazmi SO. Three Dimensional Digitally Designed Surgical Guides in Esthetic Crown Lengthening: A Clinical Case Report with 12 Months Follow Up. Clinical, Cosmetic and Investigational Dentistry. 2022;14.

13. Passos L, Soares FP, Choi IGG, Cortes ARG. Full digital workflow for crown lengthening by using a single surgical guide. Journal of Prosthetic Dentistry. 2020;124(3).

 

 3rd Place: Ataberk Kayhan

Dentistry in Another World

​

Name of Author: Ataberk Kayhan

University: Marmara University, Faculty of Dentistry, Maltepe, Istanbul, Turkey.

Grade: 5th

Contact Details: ataberk-319@hotmail.com

 

Introduction

Dentistry is a profession that cannot be considered without practical training. With the

Covid-19 pandemic, the practical education of dentistry students began to be insufficient. This has become a concern for many students. So what are the changes in educational area for this problem?

Traditional teaching has been used in education systems for centuries. Traditional teaching puts the teacher at the center of education. It is the teacher who is active and decides the content, gives lectures, exams, assignments and is responsible for them. The student, on the other hand, is more passive; listens, takes notes and saves the questions for later. In traditional teaching, time and duration are determined in a classroom, and a limited number of students can be active in the learning process. One limitation with traditional teaching is that all students need to be in the same place simultaneously with certain materials. (1)

Distance education is a method that has its origins in communication by post, and it has found a wider application area in our lives with the COVID-19 epidemic. Basically, distance education can be defined as a learning experience where the teacher and the learner are physically separated. Distance learning can be pre-recorded and given to students by the instructor, this is called asynchronous teaching. Also, distance learning can be given by the instructor on a platform where he/she connects with his/her students at the same time. This is called sychronous teaching. The need for online education, especially during the COVID-19 pandemic, has led to the re-evaluation of traditional education systems and processes. A carefully designed and well-executed online education can help students access more information faster. Additionally, the use of diverse media environments can appeal to different modes of learning. (1)

Hybrid education can be defined as the use of in-person and online learning environments together. In hybrid education cognitive and applied content is generally accessed online, while hands-on activities, assessment and evaluation are carried out in-person. (1)

The first cases of new coronavirus disease (COVID-19), which is brought on by SARS- CoV-2, were reported in Wuhan, China, in December 2019.(17) The COVID-19 flare-up rapidly spread not just in China but also globally, and the World Health Organization (WHO) declared the COVID-19 virus, also known as the SARS-CoV-2 virus, to become a pandemic on March 11, 2020. (2)

Millions of people have died as a result of the epidemic, contributing to the global health catastrophe, but it has also had an influence on higher education around the world, forcing institutions to postpone or cancel their activities or switch to alternate teaching and learning strategies. (3)

​

Literature Review

COVID-19 pandemic impacted dental students and postgraduate residents world-wide, forcing them to rapidly adapt to new forms of teaching and learning. (4) Today’s dental students and residents are members of Gen Z. People who were born in the middle of the 1990s and grew up in the early 2000s are referred to as members of Generation Z. Their addiction to computers and other technologies in general describes them. The Internet, mobile phones, computers, iPads, tablets, and other electronic gadgets have become a part of the everyday life of today's dentistry school students, who are members of the Z generation. (5) This probably helped students adapt quickly in the transition to online education.

Students should be made aware of the expectations for distance learning during this process, and those expectations should be specified in the course description with additional credit given for participation in online seminars, journal clubs, and case-based discussions. In choosing the type of educational methodology to be utilized for distance learning, it is important to understand the differences between synchronous and asynchronous teaching.

When peer contact would be advantageous and when critical thinking abilities are being taught at the beginner level, synchronous teaching is recommended. Asynchronous instruction might be used to promote group learning, but it might need to be supervised by knowledgeable professors. For teaching integrated knowledge and its application in clinical circumstances, such as dental emergencies, hybrid learning that combines both synchronous and asynchronous components may be beneficial. (6) Numerous essays about the transformation of the educational system during the Covid-19 epidemic period are found in the present literature. (1-17) These articles allow readers to gain insight into the recommendations and opinions of professionals and students regarding the modification of the educational foundation.

In a survey of dentistry and postgraduate students from across Europe which held in autumn of 2020, there were significant difference in the level of the satisfaction with the education given: %44 (n = 382) said they were satisfied or very satisfied with how the teaching had been carried out, compared to 31 % (n = 279) who have said they are either unsatisfied or very unsatisfied. The percentage of those reporting satisfaction with the online platform was higher at 61% (n = 532), with only 17% (n = 147) reporting being unsatisfied or very unsatisfied. When asked how much time they spent on their education, 50% of the participants (n = 435) said less time, while 30% (n = 265) said more. In the survey study, students were most concerned with their clinical experience and skills. (4)

According to a different study, even the students have adjusted well to the new hybrid teaching methods and are aware of the fact that dental education requires practice and clinical experiences that cannot be delivered online. Also, the study indicated that the students felt uncomfortable about this situation. (3)

Sapienza University of Rome in Italy switched to online education with the pandemic and evaluated the period by preparing a questionnaire for the students after the semester. As a result of this evaluation, when students were asked the question 'What is the best aspect of online lessons?', most common answers; more comfortable and reduction of travel. When students are asked the question 'What is the worst aspect of online lessons?', they mostly answer; Spending a lot of time in front of the computer and more distraction. When the students were asked the question 'What would you change to improve your online lessons?', the common answers were; more interaction and more problem solving, and receiving didactical materials before lessons. (7)

A survey study was prepared to evaluate students’ perceptions of online education during the Covid19 pandemic in Turkey, and 1600 dentistry students participated in this study. Most students (59.1 %, n=949) considered that traditional face-to-face education was more successful than distance learning in dental courses. When the students were asked for suggestions to strengthen distance education, the answers were:

-        make lectures interactive and synchronous,

-        restrict lectures to 30 minutes,

-        use videos or live demonstrations rather than PowerPoint slides.

When students were asked about their positive opinions about distance education:

-        I can concentrate much better since listening to lessons in the home environment is more comfortable than in the classroom,

-        Less waste of time and less tired,

-        Thanks to the course contents and videos uploaded to the system, I can open the lessons and listen again if something is unclear.

When students' negative experiences of the educational process are questioned:

-        If the lesson duration is longer than 30 minutes, my concentration deteriorates because I constantly look at the computer screen

-        Only theoretical training can be done with online training. Our clinical training is incomplete. (8)

In a study conducted with students in Pakistan, The advantages included remote learning; comfort, accessibility, while the limitations involved inefficiency and difficulty in maintaining academic integrity. The recommendations were to train faculty on using online modalities and developing lesson plan with reduced cognitive load and increased interactivities. Students ask, after lockdown when the university will open, there should be a revision session and practical work. (9)

In one article, it has been tried to increase the students' interactivity by using different applications in addition to the online and hybrid systems. Preclinical didactic and case-based exercises could be delivered as videos with embedded quiz questions using a platform such as EDpuzzle. EDpuzzle is an innovative tool that converts video watching into a student- centered activity by increasing student engagement. It allows faculty to embed timestamped questions with instant feedback in a clinical video for students to answer while watching the video (10, 11)

To summarize, based on the literature review, what has been done for the education system with the pandemic all over the world and the ideas of the students about the changing system have been collected. As a result, students mostly think that they experience distraction due to long-term use of computers, long duration of online courses, and that the courses should be more interactive. In separate studies, almost all of the students state that their clinical training is incomplete and they are concerned about this issue.

​

Innovative Section

Dentistry is a profession that cannot be considered without practical training. For this reason, many universities preferred hybrid systems where theoretical education is provided over the internet and clinical education is continued with physical participation.

The treatment of patients other than emergency in hospitals was limited, and students were allowed to observe only in certain groups, in order to minimize physical interaction between students and patients. This enabled dental students to acquire some practical competencies necessary for dental education and was important for their satisfaction. So, was that enough? (12, 13)

What can we do in the Covid-19 pandemic to improve education? Although hybrid systems have been tried, as it was clear from the previous section, majority of students believe that their clinically based knowledge is limited, and most of them are concerned about this situation. First of all, the Covid-19 pandemic has been a good opportunity for us to realize what we do not know and what we lack about traditional, present and hybrid education systems. We do not know whether such a pandemic situation will occur again in the next 10 years, but we can make preparations for it and strengthen our education systems.

Dentistry, unlike many other branches, requires intense practical work and experience. Students might be able to get practical experience through Augmented Reality (AR) and Virtual Reality (VR) systems, which have developed with the rapid progress of technology in the last period, into dentistry education systems. VR systems, completely immerse a user inside a synthetic environment. AR systems allow the user to see the real world with virtual objects superimposed upon or composited with the real world. It combines real and interactive in real time. Also these systems allow for experimental simulations.

These techniques allow students to watch live surgical or dental treatments being performed by the teachers and better understand of the operations. In addition, with these systems, students can perform these procedures in virtual environments and learn from through trial and error. Many software developed in accordance with this application method are currently being developed. Simodont Dental Trainer, DentSim, PerioSim can be given as examples.

With such technologies, students will not be missing out from their practical training, and they will have the opportunity to apply the procedure online whenever they want, and they will be more prepared for real-life applications. Thanks to the training modules carried out with AR and VR systems, physical interactions between people are minimized. (14, 15)

In addition, newly developed AI-Enhanced Virtual Standardized Patient (VSP) programs are used to improve dental student's communication proficiencies. This program allows Room- Scale AR experience, AI enhanced seamless conversation, adaptive storytelling. (16)

​

Conclusion

Covid-19 has shown us that the world can face such a pandemic at any time that can bring the world to a breaking point. Online systems have ingrained themselves more into our life as a result of the Covid-19 pandemic, making it hard to live independently from them. We should organize and design our educational systems and methods to be ready for these kind of situations.

The advancement of VR and AR is a valuable tool for our civilization. Not only applied to the education, but also developed in the clinical treatment. These systems can spread and apply to all departments of dentistry, enabling dental students to train in their own time. The development of dental systems in the fields of VR and AR for education should continue and the necessary deficiencies should be completed. Dental schools’ faculty members could be involved in the design and development process so that these technologies are conducive to effective learning. In the future, it can be predicted that education processes will be a process dominated by such stimulating programs and devices.

 

Reference Page

1. Ministry of National Education of Turkey. Open Education Courses 2022, Types of Education.

2. WHO/Europe. WHO Announces COVID-19 Outbreak a Pandemic. Available online at: https://www.euro.who.int/en/health-topics/healthemergencies/coronavirus-covid- 19/news/news/2020/3/who-announcescovid-19-outbreak-a-pandemic (accessed December 25, 2020)

3. Adam M, Urbančič-Rak T, Crnić T. Dental Students' Discomfort and Anxiety During the First and the Second Lockdown Due to COVID-19 Pandemic at the School of Dental Medicine, University of Zagreb. Acta Stomatol Croat. 2021 Jun;55(2):186-197. doi: 10.15644/asc55/2/8. PMID: 34248152; PMCID: PMC8255037.

4. James Coughlan; Daniela Timuş; Tin Crnic; Dora Srdoč; Ciara Halton; Irina F. Dragan. Impact of COVID‐19 on dental education in Europe: The students' perspective. European Journal of Dental Education 2021, 26, 599 -607.

5. Constantinescu-Dobra A, Maier V. Generation Z and Online Dentistry. An Exploratory Survey on the Romanian Market 2017. p. 291-6.

6. Iyer P, Aziz K, Ojcius DM. Impact of COVID-19 on dental education in the United States. J Dent Educ. 2020 Jun;84(6):718-722. doi: 10.1002/jdd.12163. Epub 2020 Apr 27. PMID: 32342516.

7. Di Giacomo P, Di Paolo C. COVID-19 AND DENTAL DISTANCE-BASED EDUCATION: students' perceptions in an Italian University. BMC Med Educ. 2021 Aug 2;21(1):414. doi: 10.1186/s12909-021-02840-3. Erratum in: BMC Med Educ. 2021 Oct 12;21(1):528. PMID: 34340662; PMCID: PMC8327040.

8. Sarialioglu Gungor A, Sesen Uslu Y, Donmez N. Perceptions of dental students towards online education during the COVID-19 pandemic. Eur Oral Res. 2021 Sep 1;55(3):124-132. doi: 10.26650/eor.2021869185. PMID: 34746783; PMCID: PMC8547755.

9. Mukhtar K, Javed K, Arooj M, Sethi A. Advantages, Limitations and Recommendations for online learning during COVID-19 pandemic era. Pak J Med Sci. 2020 May;36(COVID19-S4):S27-S31. doi: 10.12669/pjms.36.COVID19-S4.2785. PMID: 32582310; PMCID: PMC7306967.

10. Sahu P. Closure of Universities Due to Coronavirus Disease 2019 (COVID-19): impact on education and mental health of students and academic staff. Cureus. 2020;12(4):e7541.

11. EDpuzzle. https://edpuzzle.com/. Accessed April 18, 2020.

12. Hassan MG, Amer H. Dental Education in the Time of COVID-19 Pandemic: Challenges and Recommendations. Front Med (Lausanne). 2021 May 31;8:648899. doi: 10.3389/fmed.2021.648899. PMID: 34136499; PMCID: PMC8200815.

13. Sukumar S, Dracopoulos SA, Martin FE. Dental education in the time of SARS-CoV- 2. Eur J Dent Educ. (2020) 25:325–31. doi: 10.1111/eje.12608

14. Ta-Ko Huang, Chi-Hsun Yang, Yu-Hsin Hsieh, Jen-Chyan Wang, Chun-Cheng Hung, Augmented reality (AR) and virtual reality (VR) applied in dentistry, The Kaohsiung Journal of Medical Sciences, Volume 34, Issue 4, 2018, Pages 243-248, ISSN 1607-551X, https://doi.org/10.1016/j.kjms.2018.01.009.

15. Li Y, Ye H, Ye F, Liu Y, Lv L, Zhang P, Zhang X, Zhou Y The Current Situation and Future Prospects of Simulators in Dental Education J Med Internet Res 2021;23(4):e23635 doi: 10.2196/23635

16. Cortino Sukotjo. Updates on the use of AR and VR in Dentistry/Dental Education. ADEA Prosthodontics Section Presentation 2021.

17. Wiersinga WJ, Rhodes A, Cheng AC, Peacock SJ, Prescott HC. Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review. JAMA. 2020;324(8):782.