- Email: [email protected]
Effect of CBCT Training Sessions in Detecting Apical Bone Defects
OOOO Volume 117, Number 5
ABSTRACTS Abstracts e417
Tufts University School of Dental Medicine
Team-Based Learning: a new Oral and Maxillofacial Radiology Curriculum Design in Advanced Dental Education Section Heading
Presentation # 20
Aruna Ramesh, Rumpa Ganguly, Donna Qualters
This article describes the transition of an oral and maxillofacial radiology course from a traditional lecture format to a new interactive case-based, team-based, inter-disciplinary, and intra-professional learning model in advanced dental education. Over the past decade, health care professionals have been urged to improve collaboration among their practitioners with the objective of improving the quality of care they provide, especially the complex care needed for an aging population and patients with chronic disease. 1 This philosophy holds true within the field of dentistry as well. The Institute of Medicine in 2003 set as its farreaching goal “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.” 2. Intra-professional education describes collaborative learning within a field, such as dentistry, which has multiple recognized specialties. Dentists enrolled in post-graduate specialty programs are typically exposed to education and patient care training in isolated disciplinary settings. As oral health is inter-disciplinary and intra-disciplinary in nature, it is best served by education programs and clinical training that mimic this nature. General dentists refer patients needing advanced or complex care to dental specialists for management. The reasons for these referrals could range from endodontic or dental implant therapy to management of a pathology that might require surgical intervention. Many of these instances may necessitate the involvement of more than one dental specialist. This would constitute intra-professional collaboration that is essential for the restoration and maintenance of oral health of the patient. Historically challenges associated with clinical training methods include siloed disciplinary training and treatment planning which translates to fragmented disciplinary patient care. This prevalent model is contradictory to the philosophy of providing comprehensive patient care. A class room would be a logical place to start interdisciplinary collaboration. The areas that are most conducive to such inter and intra-disciplinary educational models conceptually, are those that are over-arching the dental specialties, one such being oral and maxillofacial radiology(OMFR). In our experience, most OMFR courses in post-graduate dental curriculum involve students enrolled in different dental specialty programs. This provides a ready-made intra-professional environment that can support a transition to an interactive, team-based, and case-based educational model. American Dental Education Association Commission on Change and Innovation points out that students require more than memorization skills; they need to acquire skills such as team performance, the ability to listen and communicate, the willingness and ability to learn throughout life, and the capacity to think critically, evaluate situations and solve problems. 3 This article presents a curricular innovation along these lines,that embraces key aspects of team- based, case-based inter-disciplinary and intra-professional educational models. All of the above mentioned educational models already exist, although mostly independently. Team-based learning (TBL) is an educational strategy adopted since early 1990s, first implemented by business school environments. TBL is an active learning method that is learner centered but instructor led 4. It fosters individual and group accountability as small groups (teams) of five to seven students each work together to solve clinical problems. The primary goal of this strategy is to reap the benefits of small team learning in larger classes. It differs from problem-based learning and other small team learning models as it does not require an increase in the number of class rooms or faculty. This model necessitates individual advance student preparation and the majority of in-class time devoted to decision-based application assignments done in teams. Parmelee et al 5 described TBL as an active learning and small team instructional strategy that provides students with opportunities to apply conceptual knowledge through a sequence of activities that include individual work, teamwork and immediate feedback. It uses a learner-centered educational model with critical faculty input, grading, peer evaluation and immediate feedback. Case-Based learning (CBL) refers to a model that is used to stimulate and underpin the acquisition of knowledge, skills and attitudes via clinical cases. 6, 7, 8 CBL links theory and practice through learning activities based on real, simulated, virtual or text-based clinical patients. student learning is therefore associated with real-life situations. Inter-professional education (IPE) and practice describe a recent movement to break down professional barriers that can inhibit the easy flow of prevention and management of disease for individual patients and population teams. 1 A preamble to IPE would be intra-professional education that implies educational and patient care collaborations among the various disciplines within a health field. Dentistry with its multiple specialties and subspecialties would greatly benefit from this practice and would set the stage for IPE. Thompson noted that there is favorable evidence for IPE within PBL(Problem Based Learning) settings improving attitudes towards other professional teams. Collaboration between IPE and PBL appears to be most appropriate for areas of the curriculum that will have relevance for all in their professional lives.9 As mentioned above, radiology constitutes one such common thread and radiographic interpretation and diagnostic skill are critical components of patient evaluation and treatment planning in all clinical specialties of dentistry. The authors’ personal experiences as former dental post-graduate students and now as faculty members, show that the “lectures followed by final exam” format of these courses do not encourage active engagement of the learners in class or between various specialties. The learners in the course typically view the traditional instructive course as a peripheral requirement of their core curriculum that does not necessitate interaction with their peers in class. The students generally seat themselves within their department teams and the interaction between the teams is rare at best. This perceived general attitude necessitated a curriculum revision that would correct the inherent weaknesses of the current ‘sage on the stage’ model. In accordance with the best educational practices like TBL, CBL, etc, described above and the conviction of the need for a curriculum innovation, we developed a new case-based, team-based, inter-disciplinary, intra-professional educational model in post-graduate oral and maxillofacial radiology curriculum. The aim of this paper is to describe a new interactive case-based, team-based, interdisciplinary, and intra-professional learning model in advanced dental education and to evaluate initial perceptions of students on TBL. .
Methods There were 44 post-graduate dental students enrolled in the Oral and maxillofacial radiology course over a 12- week period in the Fall of 2012. The class consisted of American and Foreign-trained dentists enrolled in the certificate or masters advanced education program in one of the following nine dental disciplines: Endodontics, Orthodontics, Pediatric Dentistry, Periodontology, Prosthodontics, Craniomandibular Disorders and Orofacial Pain, Implant dentistry fellowship and Esthetic dentistry. The class met once a week for an hour for 12 weeks. The course faculty pre-assigned interdisciplinary teams with 4-5 members in each. No team had two members from the same advanced education program. The objective was to have maximal diversity within the teams and relative uniformity between the teams. The teams were seated and worked together for the entire length of this course. Information about team assignments and format of the course was provided to the class prior to the start of the course. The format of each lecture slot was designed as follows: The first two of the 12 sessions were faculty lectures, devoted to reviewing general concepts and terminology of radiographic interpretation. The goal of these lectures was to serve as revision of concepts learned in undergraduate dental curriculum. The format of each of the following 10 sessions was: Team presentation(10 min presentation + 5 min class discussion moderated by the presenting team), individual quiz(10min), Team Quiz(10min), and Case Discussion(10min). The course schedule included the topics that would be addressed each week. The teams selected their topics at the beginning of the course. Each session started with a team presentation on the topic of the day. The team presentation requirement included a case- based discussion facilitated by the presenting team on the pre-selected topic. An additional case was presented by a faculty member to summarize the main concepts. This was followed by a case-based quiz, with 3 multiple-choice questions on the presented topic. The same quiz was completed by each student individually (Individual Quiz) and then as a team (team Quiz). The individual quizzes were collected before the team set to do the quiz as a team. This allowed for comparison of individual performance with team performance. The last activity during the hour was discussion of the case presented in the quiz by the faculty member who facilitated class participation and interaction. Each member of a team received an individual grade and a team grade for the weekly quizzes that contributed to their final course grade. A description of requirements, expectations and breakdown of assessment for the team presentations was given to the class. The team presentation grade constituted 30% of the final course grade. Two faculty members graded the team presentations on the following criteria and the average was calculated: Peer evaluation was completed by each member of a team for each of the other team members during weeks 6 and 12 of the course. This peer evaluation scale consisted of 3 categories, (below expectation, meets expectation, above expectation), to evaluate team members for their participation and contribution to both the presentation and team quizzes. A numerical score was assigned to the evaluation and accounted for 10% of the final course grade. Anonymous written feedback about ‘what was’ and ‘what wasn’t’ working was collected during weeks 5 and 10 of the course. Assessment in the course occurred on a continuous basis through individual ( 30%)and team quiz ( 30%)grades and team presentation grades. There was no final exam. Results The participants in the course were 44 advanced dental education students enrolled in the fall semester OMFR course. The final course grade was calculated as a composite of individual and team quiz grade, team presentation and peer evaluation grades. The overall class average was 90.43 with 82.5 and 100 being the lowest and the highest class grades, respectively. 37/44 students had total team grades higher than total individual quiz grades. This majority performed better as a team than as individuals in the quizzes. 5/44 received a total individual quiz grade equal to the total team quiz grades. 2/44 received total individual quiz grades higher than the total team quiz grades. Written anonymous feedback was requested three times during the course as this was a new course format the students were introduced to. On-Going modifications were made as needed based on the feedback. The third feedback was very favorable and the strengths identified by the students were the absence of a final exam, continuous evolution of the course to address their concerns, motivation to think and work as an interdisciplinary team, open discussions, and enhanced learning both from peers and faculty. The weaknesses identified were the need for additional resources to prepare for the weekly quizzes and the perceived mismatch between expected and actual baseline knowledge level of the class in general. The overall course was well-received by the students and this was noted subjectively through students’ feedback during the course and objectively through the formal course evaluation report. The course was evaluated by students using a 5 point scale with 1= strongly Agree, 2 = Agree, 3= Mixed Feelings, 4= Disagree, 5= Strongly Disagree. Table 1 indicates the mean scores with standard deviation received for each of the questions included in the course evaluation report. This was a generic evaluation form completed by the students for many courses taught at the school and hence does not specifically address the new format of this course. 36/44(81%) students completed the evaluation form. Table 1 presents the course evaluation questions with the mean class rating and standard deviations. For the 5-point rating scale used, the standard deviations ranged from 0.66 to 1.12, indicating relatively good agreement among the student ratings for the individual questions. Course Evaluation Question
Rating
Standard Deviation
1.
This course effectively promoted learning.
2.15
1.03
2.
Learning objectives and goals were appropriate and clearly stated.
2.00
1.03
3.
The lectures were sequenced in a logical way.
2.24
1.09
4.
The lectures were well organized and comprehensible.
2.45
1.12
5.
The course material presented was current.
2.00
0.98
6.
The course material was at the appropriate level of complexity and enhanced previous learning.
2.18
1.10
7.
I would like to see different/additional topics covered in this course.
2.43
1.10
8.
The course material was relevant to my area of specialization.
1.96
0.98
9.
To understand and apply the course material, class attendance was necessary.
1.96
0.98
10.
The exam was based on the stated course objectives.
2.00
0.76
11.
The exam reflected the material covered in the course.
2.04
0.78
12.
The difficulty level of the exam was appropriate for the material taught.
2.40
1.05
13.
The course instructor(s) made the course interesting.
1.93
0.91
14.
The course instructor(s) demonstrated thorough knowledge and understanding of the subject matter.
1.68
0.78
15.
The course instructor(s) encouraged student participation and questions.
1.51
0.66
16.
The course instructor(s) was/were sensitive to the students' needs and gave appropriate attention to all students.
1.87
1.08
17.
Sufficient opportunity was provided to ask questions and/or obtain help when I had difficulty comprehending the course material.
1.66
0.88
Albert Einstein said, “I never teach my pupils. I only attempt to provide the conditions in which they can learn”. Dental faculty members strive to achieve balance in the educational process between knowledge enhancement and student engagement in class. The traditional didactic model centered on the teacher was losing its purpose with the post graduate OMFR course, as the students, who were dentists, were losing interest with just receiving unidirectional information. There was a need to better engage and involve the students in their own education. The application of any new teaching method to an individual program can be influenced by several factors such as engagement of students and faculty, time constraints and other curricular demands. Within a dental post-graduate curriculum, a certain level of basic knowledge of interpretation of diseases on radiographs can be assumed since the students are dentists; hence curricular innovation is generally easier than in the undergraduate curriculum. Furthermore oral and maxillofacial radiology, an integral component of any dental specialty education, lends itself to innovative educational models in the classroom. Analysis of quantitative and qualitative data demonstrated that this case-based, team-based, inter-disciplinary, and intra-professional learning model was well-received by the enrolled students. The grades reflected that, learning was indeed achieved. These grades could not be compared to grades in the course from previous years as both the course format and the assessment criteria were very different. The students seemed to enjoy the challenge of interpreting radiographic pathology both individually and in teams. Although they appeared skeptical initially, they soon adapted to it and were completely engaged. The on-going modifications guided by student feedback could have played a role in this change in student perspective. There was an apparent improvement in the level of active engagement of the class during the sessions observed through increased student-initiated discussions, questions addressed to faculty and other students to clarify their reasoning, etc. Although this format required students to come prepared to class, their lively involvement in class discussions indicated that the preparation was deemed meaningful and worth the pre-class self-effort. The pre-assigned inter-disciplinary teams fostered interaction among students that may not have occurred otherwise. The teams had to identify time outside of class to work on their team presentations and work in class on the team quizzes. The anonymous written feedback from the students indicated that this interaction with peers from different specialties was perceived as one of the strengths of the course. This is supported by the fact that 42/44 of the students received higher or equal team quiz grades than individual quiz grades. There were just 2 individuals who received a higher individual quiz grade. This reflects the general understanding that in any class of students, there will be a distribution of low, average and high performing individuals. These 2 individuals, despite obtaining lower grades in team quiz compared to individual quiz, can be expected to have gained some experience with team-based learning that has the potential to translate to patient care. After each case-based quiz, there was immediate clarification and feedback provided by the faculty, who also promoted discussion among the students. The interactive nature of the course encouraged students to readily present their perspectives and the reasoning for their choices to the class. The overall course evaluation by the students indicated that it was well received. The two week refresher lectures was not considered as adequate by the students. This was indicated in the first feedback received from the class. To address this, pre-recorded lectures on radiographic interpretation were made available through the school’s multimedia knowledge management system (TUSK) to the class participants, as a supplemental resource to prescribed text books. This course necessitated pre-class preparation, which resulted in additional time commitment in an already packed curriculum. This could not be avoided as, ‘learner accountability’ is one of the basic principles of TBL 5 and is essential its success. TBL provides opportunities to hold each student accountable for their own performance and their individual contributions to the team. 5 Peer evaluation was introduced as an important component of this education model. Each student in a group was evaluated by every other member in their group which translated to a numerical value contributing to the final grade. This allowed the students to practice giving and receiving feedback on their ability to work in a team, as health care professionals are often evaluated by their patients, colleagues and employers. The written anonymous feedback from students obtained on three different occasions during the course, was identified as one of the strengths of this course. This allowed for continuous monitoring and correcting of the challenges faced by the learners. In addition to improving the students’ attitude toward the new course format, it helped the faculty in streamlining the course and planning improvements. One such example of modification based on feedback was the inclusion of pre-recorded lectures in the school’s multimedia knowledge management system (TUSK) that could be used in preparing for the class. In conclusion, the authors’ objective of creating a new case-based, team-based, inter-disciplinary, intra-professional interactive learning model in advanced dental education was achieved. The students’ perspective was favorable to this new course format. Anecdotally, some of the course participants conveyed that they have utilized the expertise of their team members to enhance patient care, well after completion of the OMFR course. This leads us to believe that team-based and case-based educational models can have a positive impact on student class participation and learning.
References: 1. Formicola AJ et al. Interprofessional education in U.S. and Canadian dental schools: An ADEA team study team report. Journal of Dental Education; vol 76(9) 2. Greiner Ann C., Knebel E. Health professions education: A bridge to quality. The national academies press, 2003. 3. Hendricson et al. Educational strategies associated with development of problem-solving, critical thinking and self-directed learning. J Dent Educ 2006; 70 (9): 925-36 4. Koles P, Nelson S, Stolfi A, Parmelee D, Destephen D. Active learning in a Year 2 pathology curriculum. Med Educ. 2005 Oct;39(10):1045-55.
Table 1: Item Number
Discussion
5. Parmelee D et al. Team-based learning: A practical guide: AMEE guide no.65 Med Teach 34 (5): e275-e287 6. Cao X et al. The application of case-based learning in English in teaching of clinical stomatological courses. Shanghai Kou Qiang Yi Xue. 2009;18(2):207–210 7. Fincham AG, Shuler CF. The changing face of dental education: the impact of PBL. J Dent Educ. 2001;65(5):406–4218. 8. Hobson R. The competent graduate. Br Dent J. 1998;184(4):156 9. Thompson C. Do interprofessional education and problem-based learning work together? The clinical teacher. 7(3):197-201, 2010 Sep
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Effect of CBCT Training Sessions in Detecting Apical Bone Defects Rice D, Luikham V, Christensen H, Torabinejad M, Oyoyo U
Loma Linda University School of Dentistry, Loma Linda, CA
Introduction
Methods
The aim of this study was to determine the degree to which a multisession CBCT software training course could improve the accuracy of detecting artificial bone defects in cadaver mandibles.
All images and volumes were presented in a randomized manner for each viewing session. Detection of the various sizes of apical lesions where recorded in a PowerPoint format.
Methods
Figure 1 Specimen prepared for scanning. A custom jig was made to stabilize and orient for scan.
Hemi-mandible prosections were scanned with CBCT and then rescanned after successive holes were created at the base of an alveolar socket with round burs of sizes # ¼ to # 6.
Figure 4. Results quantified and recorded in PowerPoint format by readers (5= definitely present)
Results Reading
Before Training After Training
Following training the readers did a final reading session recording their findings as before.
P-Value
Asymptotic 95% Confidence Interval Lower Bound
Upper Bound
.586
.021
<.001
.546
.627
.667
.020
<.001
.629
.706
Basic training ROC - 0.586 (95% confidence at 0.546 - 0.627) Advanced training ROC - 0.667 (95% confidence of 0.629 - 0.706) There is a statistically significant difference between first and last reads (p <0.013)
Impression
Figure 2. Round burrs were used to create PA lesions of known dimensions that were then categorized and CBCT scanned for interpretation
Figure 3. CBCT slices showing defects increasing in round bur sizes. From left to right the defects are: no defect, 0.5mm dia. defect, 0.6mm dia defect, 0.8mm dia defect, 1.0mm dia defect, 1.4mm in dia. defect.
Std. Error
Figure 6 ROC curves and table of reader results. Graph on left are results of the first read before training, (AUC) of 0.586 Graph on right is after the training sessions, (AUC) of 0.667 There is a statistically significant difference, (p <0.013).
The dental students then received ~8 hours of additional CBCT training. The training included information on CBCT core principles, image acquisition, and interpretation, practical instructions and hands on training with the imaging software.
Twelve senior dental students were initially given a half- hour tutorial on how to view and manipulate CBCT data. They were then asked to identify the bur-created defects in the mandible prosection scans
CBCT volumes were acquired using the Morita Veraviewepocs 3De at 80 kV, 7 mA, FOV 40 X 40 mm and a voxel size of 125 µm.
Area (AUC)
Before training, detecting bone defects was only slightly better than chance. After training, detection rates more accurately predicted the presence of lesions.
Conclusion Basic initial training has little effect on clinician identification competency. Specific diagnostic training sessions positively affect CBCT diagnostic competency.
Figure 5. Actual recorded results from one of the readers sessions. They recorded their level of certainty that the defect was present , copied image slice from the CBCT volume and placed a marker arrow to the defect.
ROC Statistical Analysis Sensitivity and specificity at variable decision thresholds were calculated using 2971 scores. The receiver operating characteristic (ROC) analysis was carried out stratifying for true state and reader. The area under the curve (AUC) was calculated along with its 95% confidence interval to represent a point estimate of diagnostic accuracy. The AUC serves as a numerical estimate and summary measure of the diagnostic accuracy, ranging from 0 to 1. An AUC of 1.0 represents a modality that perfectly predicts whether a lesion is present or absent. An AUC of 0.5 represents a modality that accurately predicts the presence or absence of a lesion 50% of the time.
References 1.
Tsai P, Torabinejad M, Rice D, Azevedo B. Accuracy of cone-beam computed tomography and periapical radiography in detecting small periapical lesions. J Endod2012 Jul;38(7):965-70. 2. Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T. Detection of periapical bone defects in human jaws using cone beam computed tomography and intraoral radiography. Int Endod J2009 Jun;42(6):507-15. 3. Affairs TADACoS. The use of cone-beam computed tomography in dentistry: An advisory statement from the American Dental Association Council on Scientific Affairs. JADA. [Association report]. 2012 August 2012;143(8):899-902. 4. Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis. J Endod2008 Mar;34(3):273-9.
Acknowledgements This study was approved by the Loma Linda University Institutional Review Board. For more information please contact Dr. Rice at [email protected]
ABSTRACTS Abstracts e417
Tufts University School of Dental Medicine
Team-Based Learning: a new Oral and Maxillofacial Radiology Curriculum Design in Advanced Dental Education Section Heading
Presentation # 20
Aruna Ramesh, Rumpa Ganguly, Donna Qualters
This article describes the transition of an oral and maxillofacial radiology course from a traditional lecture format to a new interactive case-based, team-based, inter-disciplinary, and intra-professional learning model in advanced dental education. Over the past decade, health care professionals have been urged to improve collaboration among their practitioners with the objective of improving the quality of care they provide, especially the complex care needed for an aging population and patients with chronic disease. 1 This philosophy holds true within the field of dentistry as well. The Institute of Medicine in 2003 set as its farreaching goal “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.” 2. Intra-professional education describes collaborative learning within a field, such as dentistry, which has multiple recognized specialties. Dentists enrolled in post-graduate specialty programs are typically exposed to education and patient care training in isolated disciplinary settings. As oral health is inter-disciplinary and intra-disciplinary in nature, it is best served by education programs and clinical training that mimic this nature. General dentists refer patients needing advanced or complex care to dental specialists for management. The reasons for these referrals could range from endodontic or dental implant therapy to management of a pathology that might require surgical intervention. Many of these instances may necessitate the involvement of more than one dental specialist. This would constitute intra-professional collaboration that is essential for the restoration and maintenance of oral health of the patient. Historically challenges associated with clinical training methods include siloed disciplinary training and treatment planning which translates to fragmented disciplinary patient care. This prevalent model is contradictory to the philosophy of providing comprehensive patient care. A class room would be a logical place to start interdisciplinary collaboration. The areas that are most conducive to such inter and intra-disciplinary educational models conceptually, are those that are over-arching the dental specialties, one such being oral and maxillofacial radiology(OMFR). In our experience, most OMFR courses in post-graduate dental curriculum involve students enrolled in different dental specialty programs. This provides a ready-made intra-professional environment that can support a transition to an interactive, team-based, and case-based educational model. American Dental Education Association Commission on Change and Innovation points out that students require more than memorization skills; they need to acquire skills such as team performance, the ability to listen and communicate, the willingness and ability to learn throughout life, and the capacity to think critically, evaluate situations and solve problems. 3 This article presents a curricular innovation along these lines,that embraces key aspects of team- based, case-based inter-disciplinary and intra-professional educational models. All of the above mentioned educational models already exist, although mostly independently. Team-based learning (TBL) is an educational strategy adopted since early 1990s, first implemented by business school environments. TBL is an active learning method that is learner centered but instructor led 4. It fosters individual and group accountability as small groups (teams) of five to seven students each work together to solve clinical problems. The primary goal of this strategy is to reap the benefits of small team learning in larger classes. It differs from problem-based learning and other small team learning models as it does not require an increase in the number of class rooms or faculty. This model necessitates individual advance student preparation and the majority of in-class time devoted to decision-based application assignments done in teams. Parmelee et al 5 described TBL as an active learning and small team instructional strategy that provides students with opportunities to apply conceptual knowledge through a sequence of activities that include individual work, teamwork and immediate feedback. It uses a learner-centered educational model with critical faculty input, grading, peer evaluation and immediate feedback. Case-Based learning (CBL) refers to a model that is used to stimulate and underpin the acquisition of knowledge, skills and attitudes via clinical cases. 6, 7, 8 CBL links theory and practice through learning activities based on real, simulated, virtual or text-based clinical patients. student learning is therefore associated with real-life situations. Inter-professional education (IPE) and practice describe a recent movement to break down professional barriers that can inhibit the easy flow of prevention and management of disease for individual patients and population teams. 1 A preamble to IPE would be intra-professional education that implies educational and patient care collaborations among the various disciplines within a health field. Dentistry with its multiple specialties and subspecialties would greatly benefit from this practice and would set the stage for IPE. Thompson noted that there is favorable evidence for IPE within PBL(Problem Based Learning) settings improving attitudes towards other professional teams. Collaboration between IPE and PBL appears to be most appropriate for areas of the curriculum that will have relevance for all in their professional lives.9 As mentioned above, radiology constitutes one such common thread and radiographic interpretation and diagnostic skill are critical components of patient evaluation and treatment planning in all clinical specialties of dentistry. The authors’ personal experiences as former dental post-graduate students and now as faculty members, show that the “lectures followed by final exam” format of these courses do not encourage active engagement of the learners in class or between various specialties. The learners in the course typically view the traditional instructive course as a peripheral requirement of their core curriculum that does not necessitate interaction with their peers in class. The students generally seat themselves within their department teams and the interaction between the teams is rare at best. This perceived general attitude necessitated a curriculum revision that would correct the inherent weaknesses of the current ‘sage on the stage’ model. In accordance with the best educational practices like TBL, CBL, etc, described above and the conviction of the need for a curriculum innovation, we developed a new case-based, team-based, inter-disciplinary, intra-professional educational model in post-graduate oral and maxillofacial radiology curriculum. The aim of this paper is to describe a new interactive case-based, team-based, interdisciplinary, and intra-professional learning model in advanced dental education and to evaluate initial perceptions of students on TBL. .
Methods There were 44 post-graduate dental students enrolled in the Oral and maxillofacial radiology course over a 12- week period in the Fall of 2012. The class consisted of American and Foreign-trained dentists enrolled in the certificate or masters advanced education program in one of the following nine dental disciplines: Endodontics, Orthodontics, Pediatric Dentistry, Periodontology, Prosthodontics, Craniomandibular Disorders and Orofacial Pain, Implant dentistry fellowship and Esthetic dentistry. The class met once a week for an hour for 12 weeks. The course faculty pre-assigned interdisciplinary teams with 4-5 members in each. No team had two members from the same advanced education program. The objective was to have maximal diversity within the teams and relative uniformity between the teams. The teams were seated and worked together for the entire length of this course. Information about team assignments and format of the course was provided to the class prior to the start of the course. The format of each lecture slot was designed as follows: The first two of the 12 sessions were faculty lectures, devoted to reviewing general concepts and terminology of radiographic interpretation. The goal of these lectures was to serve as revision of concepts learned in undergraduate dental curriculum. The format of each of the following 10 sessions was: Team presentation(10 min presentation + 5 min class discussion moderated by the presenting team), individual quiz(10min), Team Quiz(10min), and Case Discussion(10min). The course schedule included the topics that would be addressed each week. The teams selected their topics at the beginning of the course. Each session started with a team presentation on the topic of the day. The team presentation requirement included a case- based discussion facilitated by the presenting team on the pre-selected topic. An additional case was presented by a faculty member to summarize the main concepts. This was followed by a case-based quiz, with 3 multiple-choice questions on the presented topic. The same quiz was completed by each student individually (Individual Quiz) and then as a team (team Quiz). The individual quizzes were collected before the team set to do the quiz as a team. This allowed for comparison of individual performance with team performance. The last activity during the hour was discussion of the case presented in the quiz by the faculty member who facilitated class participation and interaction. Each member of a team received an individual grade and a team grade for the weekly quizzes that contributed to their final course grade. A description of requirements, expectations and breakdown of assessment for the team presentations was given to the class. The team presentation grade constituted 30% of the final course grade. Two faculty members graded the team presentations on the following criteria and the average was calculated: Peer evaluation was completed by each member of a team for each of the other team members during weeks 6 and 12 of the course. This peer evaluation scale consisted of 3 categories, (below expectation, meets expectation, above expectation), to evaluate team members for their participation and contribution to both the presentation and team quizzes. A numerical score was assigned to the evaluation and accounted for 10% of the final course grade. Anonymous written feedback about ‘what was’ and ‘what wasn’t’ working was collected during weeks 5 and 10 of the course. Assessment in the course occurred on a continuous basis through individual ( 30%)and team quiz ( 30%)grades and team presentation grades. There was no final exam. Results The participants in the course were 44 advanced dental education students enrolled in the fall semester OMFR course. The final course grade was calculated as a composite of individual and team quiz grade, team presentation and peer evaluation grades. The overall class average was 90.43 with 82.5 and 100 being the lowest and the highest class grades, respectively. 37/44 students had total team grades higher than total individual quiz grades. This majority performed better as a team than as individuals in the quizzes. 5/44 received a total individual quiz grade equal to the total team quiz grades. 2/44 received total individual quiz grades higher than the total team quiz grades. Written anonymous feedback was requested three times during the course as this was a new course format the students were introduced to. On-Going modifications were made as needed based on the feedback. The third feedback was very favorable and the strengths identified by the students were the absence of a final exam, continuous evolution of the course to address their concerns, motivation to think and work as an interdisciplinary team, open discussions, and enhanced learning both from peers and faculty. The weaknesses identified were the need for additional resources to prepare for the weekly quizzes and the perceived mismatch between expected and actual baseline knowledge level of the class in general. The overall course was well-received by the students and this was noted subjectively through students’ feedback during the course and objectively through the formal course evaluation report. The course was evaluated by students using a 5 point scale with 1= strongly Agree, 2 = Agree, 3= Mixed Feelings, 4= Disagree, 5= Strongly Disagree. Table 1 indicates the mean scores with standard deviation received for each of the questions included in the course evaluation report. This was a generic evaluation form completed by the students for many courses taught at the school and hence does not specifically address the new format of this course. 36/44(81%) students completed the evaluation form. Table 1 presents the course evaluation questions with the mean class rating and standard deviations. For the 5-point rating scale used, the standard deviations ranged from 0.66 to 1.12, indicating relatively good agreement among the student ratings for the individual questions. Course Evaluation Question
Rating
Standard Deviation
1.
This course effectively promoted learning.
2.15
1.03
2.
Learning objectives and goals were appropriate and clearly stated.
2.00
1.03
3.
The lectures were sequenced in a logical way.
2.24
1.09
4.
The lectures were well organized and comprehensible.
2.45
1.12
5.
The course material presented was current.
2.00
0.98
6.
The course material was at the appropriate level of complexity and enhanced previous learning.
2.18
1.10
7.
I would like to see different/additional topics covered in this course.
2.43
1.10
8.
The course material was relevant to my area of specialization.
1.96
0.98
9.
To understand and apply the course material, class attendance was necessary.
1.96
0.98
10.
The exam was based on the stated course objectives.
2.00
0.76
11.
The exam reflected the material covered in the course.
2.04
0.78
12.
The difficulty level of the exam was appropriate for the material taught.
2.40
1.05
13.
The course instructor(s) made the course interesting.
1.93
0.91
14.
The course instructor(s) demonstrated thorough knowledge and understanding of the subject matter.
1.68
0.78
15.
The course instructor(s) encouraged student participation and questions.
1.51
0.66
16.
The course instructor(s) was/were sensitive to the students' needs and gave appropriate attention to all students.
1.87
1.08
17.
Sufficient opportunity was provided to ask questions and/or obtain help when I had difficulty comprehending the course material.
1.66
0.88
Albert Einstein said, “I never teach my pupils. I only attempt to provide the conditions in which they can learn”. Dental faculty members strive to achieve balance in the educational process between knowledge enhancement and student engagement in class. The traditional didactic model centered on the teacher was losing its purpose with the post graduate OMFR course, as the students, who were dentists, were losing interest with just receiving unidirectional information. There was a need to better engage and involve the students in their own education. The application of any new teaching method to an individual program can be influenced by several factors such as engagement of students and faculty, time constraints and other curricular demands. Within a dental post-graduate curriculum, a certain level of basic knowledge of interpretation of diseases on radiographs can be assumed since the students are dentists; hence curricular innovation is generally easier than in the undergraduate curriculum. Furthermore oral and maxillofacial radiology, an integral component of any dental specialty education, lends itself to innovative educational models in the classroom. Analysis of quantitative and qualitative data demonstrated that this case-based, team-based, inter-disciplinary, and intra-professional learning model was well-received by the enrolled students. The grades reflected that, learning was indeed achieved. These grades could not be compared to grades in the course from previous years as both the course format and the assessment criteria were very different. The students seemed to enjoy the challenge of interpreting radiographic pathology both individually and in teams. Although they appeared skeptical initially, they soon adapted to it and were completely engaged. The on-going modifications guided by student feedback could have played a role in this change in student perspective. There was an apparent improvement in the level of active engagement of the class during the sessions observed through increased student-initiated discussions, questions addressed to faculty and other students to clarify their reasoning, etc. Although this format required students to come prepared to class, their lively involvement in class discussions indicated that the preparation was deemed meaningful and worth the pre-class self-effort. The pre-assigned inter-disciplinary teams fostered interaction among students that may not have occurred otherwise. The teams had to identify time outside of class to work on their team presentations and work in class on the team quizzes. The anonymous written feedback from the students indicated that this interaction with peers from different specialties was perceived as one of the strengths of the course. This is supported by the fact that 42/44 of the students received higher or equal team quiz grades than individual quiz grades. There were just 2 individuals who received a higher individual quiz grade. This reflects the general understanding that in any class of students, there will be a distribution of low, average and high performing individuals. These 2 individuals, despite obtaining lower grades in team quiz compared to individual quiz, can be expected to have gained some experience with team-based learning that has the potential to translate to patient care. After each case-based quiz, there was immediate clarification and feedback provided by the faculty, who also promoted discussion among the students. The interactive nature of the course encouraged students to readily present their perspectives and the reasoning for their choices to the class. The overall course evaluation by the students indicated that it was well received. The two week refresher lectures was not considered as adequate by the students. This was indicated in the first feedback received from the class. To address this, pre-recorded lectures on radiographic interpretation were made available through the school’s multimedia knowledge management system (TUSK) to the class participants, as a supplemental resource to prescribed text books. This course necessitated pre-class preparation, which resulted in additional time commitment in an already packed curriculum. This could not be avoided as, ‘learner accountability’ is one of the basic principles of TBL 5 and is essential its success. TBL provides opportunities to hold each student accountable for their own performance and their individual contributions to the team. 5 Peer evaluation was introduced as an important component of this education model. Each student in a group was evaluated by every other member in their group which translated to a numerical value contributing to the final grade. This allowed the students to practice giving and receiving feedback on their ability to work in a team, as health care professionals are often evaluated by their patients, colleagues and employers. The written anonymous feedback from students obtained on three different occasions during the course, was identified as one of the strengths of this course. This allowed for continuous monitoring and correcting of the challenges faced by the learners. In addition to improving the students’ attitude toward the new course format, it helped the faculty in streamlining the course and planning improvements. One such example of modification based on feedback was the inclusion of pre-recorded lectures in the school’s multimedia knowledge management system (TUSK) that could be used in preparing for the class. In conclusion, the authors’ objective of creating a new case-based, team-based, inter-disciplinary, intra-professional interactive learning model in advanced dental education was achieved. The students’ perspective was favorable to this new course format. Anecdotally, some of the course participants conveyed that they have utilized the expertise of their team members to enhance patient care, well after completion of the OMFR course. This leads us to believe that team-based and case-based educational models can have a positive impact on student class participation and learning.
References: 1. Formicola AJ et al. Interprofessional education in U.S. and Canadian dental schools: An ADEA team study team report. Journal of Dental Education; vol 76(9) 2. Greiner Ann C., Knebel E. Health professions education: A bridge to quality. The national academies press, 2003. 3. Hendricson et al. Educational strategies associated with development of problem-solving, critical thinking and self-directed learning. J Dent Educ 2006; 70 (9): 925-36 4. Koles P, Nelson S, Stolfi A, Parmelee D, Destephen D. Active learning in a Year 2 pathology curriculum. Med Educ. 2005 Oct;39(10):1045-55.
Table 1: Item Number
Discussion
5. Parmelee D et al. Team-based learning: A practical guide: AMEE guide no.65 Med Teach 34 (5): e275-e287 6. Cao X et al. The application of case-based learning in English in teaching of clinical stomatological courses. Shanghai Kou Qiang Yi Xue. 2009;18(2):207–210 7. Fincham AG, Shuler CF. The changing face of dental education: the impact of PBL. J Dent Educ. 2001;65(5):406–4218. 8. Hobson R. The competent graduate. Br Dent J. 1998;184(4):156 9. Thompson C. Do interprofessional education and problem-based learning work together? The clinical teacher. 7(3):197-201, 2010 Sep
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Effect of CBCT Training Sessions in Detecting Apical Bone Defects Rice D, Luikham V, Christensen H, Torabinejad M, Oyoyo U
Loma Linda University School of Dentistry, Loma Linda, CA
Introduction
Methods
The aim of this study was to determine the degree to which a multisession CBCT software training course could improve the accuracy of detecting artificial bone defects in cadaver mandibles.
All images and volumes were presented in a randomized manner for each viewing session. Detection of the various sizes of apical lesions where recorded in a PowerPoint format.
Methods
Figure 1 Specimen prepared for scanning. A custom jig was made to stabilize and orient for scan.
Hemi-mandible prosections were scanned with CBCT and then rescanned after successive holes were created at the base of an alveolar socket with round burs of sizes # ¼ to # 6.
Figure 4. Results quantified and recorded in PowerPoint format by readers (5= definitely present)
Results Reading
Before Training After Training
Following training the readers did a final reading session recording their findings as before.
P-Value
Asymptotic 95% Confidence Interval Lower Bound
Upper Bound
.586
.021
<.001
.546
.627
.667
.020
<.001
.629
.706
Basic training ROC - 0.586 (95% confidence at 0.546 - 0.627) Advanced training ROC - 0.667 (95% confidence of 0.629 - 0.706) There is a statistically significant difference between first and last reads (p <0.013)
Impression
Figure 2. Round burrs were used to create PA lesions of known dimensions that were then categorized and CBCT scanned for interpretation
Figure 3. CBCT slices showing defects increasing in round bur sizes. From left to right the defects are: no defect, 0.5mm dia. defect, 0.6mm dia defect, 0.8mm dia defect, 1.0mm dia defect, 1.4mm in dia. defect.
Std. Error
Figure 6 ROC curves and table of reader results. Graph on left are results of the first read before training, (AUC) of 0.586 Graph on right is after the training sessions, (AUC) of 0.667 There is a statistically significant difference, (p <0.013).
The dental students then received ~8 hours of additional CBCT training. The training included information on CBCT core principles, image acquisition, and interpretation, practical instructions and hands on training with the imaging software.
Twelve senior dental students were initially given a half- hour tutorial on how to view and manipulate CBCT data. They were then asked to identify the bur-created defects in the mandible prosection scans
CBCT volumes were acquired using the Morita Veraviewepocs 3De at 80 kV, 7 mA, FOV 40 X 40 mm and a voxel size of 125 µm.
Area (AUC)
Before training, detecting bone defects was only slightly better than chance. After training, detection rates more accurately predicted the presence of lesions.
Conclusion Basic initial training has little effect on clinician identification competency. Specific diagnostic training sessions positively affect CBCT diagnostic competency.
Figure 5. Actual recorded results from one of the readers sessions. They recorded their level of certainty that the defect was present , copied image slice from the CBCT volume and placed a marker arrow to the defect.
ROC Statistical Analysis Sensitivity and specificity at variable decision thresholds were calculated using 2971 scores. The receiver operating characteristic (ROC) analysis was carried out stratifying for true state and reader. The area under the curve (AUC) was calculated along with its 95% confidence interval to represent a point estimate of diagnostic accuracy. The AUC serves as a numerical estimate and summary measure of the diagnostic accuracy, ranging from 0 to 1. An AUC of 1.0 represents a modality that perfectly predicts whether a lesion is present or absent. An AUC of 0.5 represents a modality that accurately predicts the presence or absence of a lesion 50% of the time.
References 1.
Tsai P, Torabinejad M, Rice D, Azevedo B. Accuracy of cone-beam computed tomography and periapical radiography in detecting small periapical lesions. J Endod2012 Jul;38(7):965-70. 2. Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T. Detection of periapical bone defects in human jaws using cone beam computed tomography and intraoral radiography. Int Endod J2009 Jun;42(6):507-15. 3. Affairs TADACoS. The use of cone-beam computed tomography in dentistry: An advisory statement from the American Dental Association Council on Scientific Affairs. JADA. [Association report]. 2012 August 2012;143(8):899-902. 4. Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis. J Endod2008 Mar;34(3):273-9.
Acknowledgements This study was approved by the Loma Linda University Institutional Review Board. For more information please contact Dr. Rice at [email protected]