ACADEMIA Letters

Using simulation to learn surgical skills in Oral Surgery:

What do students think?
Zarrin Seema Siddiqui, VinUniversity
Michael O’Halloran, St. John of God Health Care
Jeffrey Hamdorf, The University of Western Australia

ABSTRACT
Simulations are increasingly used in surgical teaching across the world. These range from
simple to high fidelity simulated experiences catering to various disciplines among health
professionals at various levels. This study investigated dental students’ perceptions of the use
of animal tissue to enhance oral surgical skills before their first supervised extraction on pa-
tients. Forty-eight students from the second year Doctor of Dental Medicine (DMD) course
participated in one four-hour session. Following preclinical activities, students were divided
into small groups of up to six members in each group. Each group practised the skill of
tooth extraction which is a basic oral surgery procedure on freshly sacrificed pigs’ heads un-
der supervision. Evaluation of the activity included changes in students’ perception observed
through a self-reported instrument using both open ended and closed ended questions. De-
scriptive analysis indicates a positive change with statistically significant results. Open-ended
comments show that students perceive the intervention as an effective learning experience.
The study demonstrated the feasibility of simulation-based environment to maximise the con-
tact time that students have with patients. In regions where resources are limited, academics
can use creative ways and low cost simulations to ensure that students have adequate exposure
and opportunities to learn basic surgical skills.

Academia Letters, October 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Zarrin Seema Siddiqui, zarrin.ss@vinuni.edu.vn

Citation: Siddiqui, Z.S., O’Halloran, M., Hamdorf, J. (2021). Using simulation to learn surgical skills in Oral
Surgery: What do students think? Academia Letters, Article 3677. https://doi.org/10.20935/AL3677.

1
INTRODUCTION
The use of simulation can augment the skills development of health professionals. This is
most important in the case of dentistry where dental students do not have a mandatory in-
ternship requirement and need to be safe dental practitioners for the community at the time
of graduation. The Australian Dental Council recommends using simulation where appro-
priate to support student learning consistent with achieving the best educational outcomes.
As most of the dental curricula in Australian schools are moving to four year postgraduate
programs it is challenging for the students to acquire and practice the hands-on skills required
to be a dentist. The Australian Dental Council expects that dental schools will use simulation
where appropriate to support student learning consistent with achieving the best educational
outcomes.[1]
Online and interactive facilities are used to modernise the way that Dentistry is taught.[2]
Technology is assisting with assessment, feedback, the delivery of theoretical concepts, curric-
ula development and learning support that fosters independent learning. Advances in equip-
ment have even provided dental students with the opportunity to practice a range of skills
using low to high fidelity simulations. However, there is no proven model for gaining sim-
ulated ‘hands-on’ experience in the teaching and learning of Oral Surgery, especially in the
extracting of teeth. This is an integral and mandatory part of the curriculum.
At The University of Western Australia (UWA), the problem of potentially providing in-
adequate training to students was made worse by low number of available patients requiring
dental extractions. Another issue that is regularly faced is a lack of appropriate clinical staff
being available to facilitate students’ learning in the Oral Surgery clinics.
It was therefore more important than ever to optimise the limited clinical time that students
spend at the Oral Surgery extraction clinic.
Oral Surgery teaching commences in year two of the Doctor of Dental Medicine (DMD)
Course. The practical aspect of the Oral Surgery curriculum is taught across the whole year
through lectures, practical sessions and via online interactive facilities. The clinical time al-
lows each student to attend the Oral Surgery clinic four times per year. An intervention was
planned, to provide all students with a ‘hands-on’ simulated experience, using pigs’ heads,
prior to treating patients at clinics. The intervention took place in the latter half of the sec-
ond semester. This allowed students to observed real-life surgery and understand the clinical
environment. As pigs’ heads were used for this intervention, MH (the chief investigator and
Professor of Oral Surgery) e-mailed the class well in advance of the practical session and
invited any students with concerns to come and see him about these concerns, in strict confi-
dence. Alternative male and female contact names were provided if students did not want to

Academia Letters, October 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Zarrin Seema Siddiqui, zarrin.ss@vinuni.edu.vn

Citation: Siddiqui, Z.S., O’Halloran, M., Hamdorf, J. (2021). Using simulation to learn surgical skills in Oral
Surgery: What do students think? Academia Letters, Article 3677. https://doi.org/10.20935/AL3677.

2
contact MH and remain anonymous. It was emphasised that alternative arrangements could
be made and that there would not be any issues generated for any student that came forward.
One student approached MH to discuss her initial concerns and later assured that the student
will had no problem proceeding with the exercises if gloves were worn throughout the session.
It was clarified to the whole class that gloves would of course be mandatory.
Before attending the session, students were required to revise the theoretical teaching sur-
rounding practical Oral Surgery from earlier in the year. A face-to-face session was also
arranged to cover broad concepts from haematology and bone biology. The specific areas
related to this project also included use of anti-coagulant and anti-platelet medications that
are very important in the surgical setting.
During the practical session, all students were given access to instruments, equipment
and hands-on learning after being randomly distributed to the different simulation stations.
All stations were supervised to provide real time feedback on the process.

Evaluation of intervention
To evaluate the intervention, a survey was used with generic statements provided by the Uni-
versity. The short survey comprises eight statements which require a response using Likert
scale (1-5, 1 = Strongly Disagree while 5 = Strongly Agree). In addition, there was an op-
tion to provide comments. The survey was administered online through Qualtrics™ before the
intervention and one week after the intervention. Participation was voluntary and anonymous.

Outcomes
Of forty-eight students enrolled in the class, forty-seven students completed the pre-intervention
evaluation while thirty-six completed the post-intervention evaluation. Table 1 presents the
data from the two sets. Independent t tests were used to compare the differences in Mean
scores for each statement. The significance level was set at 0.05. Where statistically signifi-
cant differences were observed, effect size was calculated to determine the magnitude of the
difference between two groups. The categories defined by Cohen were used to measure the
magnitude of overall effect size i.e. 0.2 – 0.5, small; 0.5 – 0.8, moderate and effect size greater
than 0.8 is considered as large.[3] There is a positive shift among students’ perception in all
the statements. The “encouragement to participate” was one statement that has the largest
effect size (0.83) while the role of teaching team was highly appreciated.

Academia Letters, October 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Zarrin Seema Siddiqui, zarrin.ss@vinuni.edu.vn

Citation: Siddiqui, Z.S., O’Halloran, M., Hamdorf, J. (2021). Using simulation to learn surgical skills in Oral
Surgery: What do students think? Academia Letters, Article 3677. https://doi.org/10.20935/AL3677.

3
 Table 1. Results of student evaluations

Open ended comments.

In all, there were thirty-one comments made by twenty-seven students in the post test. All
comments were positive and can be broadly classified into five themes presented in Table 2.

Academia Letters, October 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Zarrin Seema Siddiqui, zarrin.ss@vinuni.edu.vn

Citation: Siddiqui, Z.S., O’Halloran, M., Hamdorf, J. (2021). Using simulation to learn surgical skills in Oral
Surgery: What do students think? Academia Letters, Article 3677. https://doi.org/10.20935/AL3677.

4
 Table 2. Open-ended comments from the participants

Academia Letters, October 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Zarrin Seema Siddiqui, zarrin.ss@vinuni.edu.vn

Citation: Siddiqui, Z.S., O’Halloran, M., Hamdorf, J. (2021). Using simulation to learn surgical skills in Oral
Surgery: What do students think? Academia Letters, Article 3677. https://doi.org/10.20935/AL3677.

5
DISCUSSION
The incorporation of simulation into dental education continues to grow providing the oppor-
tunity to safely practice and developing procedural skills before performing them on patients.[4-
5] For teaching core skills, simple, cheap, effective, transportable and often reusable simu-
lations are available.[6] Our evaluation shows that students perceive simulation as a positive
learning experience. Reflecting as a team, it is important for us to understand what makes this
simulated experience effective for the dental students. The factors that make this intervention
effective are authenticity, acceptability, feasibility, non-threatening learning environment and
feedback.
Authenticity & transferability: Authentic learning is experiential learning located in
settings that reflect complex real-world problems. In this case, the students were able to ob-
serve and practice an essential skill that they will perform in clinical setting
Acceptability: An experience is acceptable if it is sufficient to serve the purpose for which
it is provided, even if it is far less usable for this purpose than the ideal example. In this case,
the use of animal tissue was more comparable to human tissue than a phantom head.
Feasibility is the state or degree of being easily or conveniently done. Our intervention
was a low fidelity simulation compared to high fidelity computerised simulations and is cost
effective.
Safety & non-threatening: Simulated environments help students to develop psychomo-
tor skills before they perform a clinical procedure for the first time and this should translate
into increases in patient safety. There is evidence that simulated environments facilitate the
transition into clinical settings,[7] and when it is cost effective the institutions should explore
the options available.
Feedback & debriefing:[8] Any experience that provides opportunity for feedback whether
during the session or at the end of session will contribute to the learning process. In this sce-
nario, students were observing each other as well as were provided feedback in real time on
their own performance preparing them for dealing with real patients.
Finally, students have perceived that Pig’s heads can be effectively used to provide a safe
and efficient learning environment to practise surgical skills. In addition to high fidelity sim-
ulations, the institutions should also explore the opportunities using simple and cost effective
simulations.

Academia Letters, October 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Zarrin Seema Siddiqui, zarrin.ss@vinuni.edu.vn

Citation: Siddiqui, Z.S., O’Halloran, M., Hamdorf, J. (2021). Using simulation to learn surgical skills in Oral
Surgery: What do students think? Academia Letters, Article 3677. https://doi.org/10.20935/AL3677.

6
ACKNOWLEDGMENT
The authors wish to acknowledge the support received from Dr. Brendan McQuillan, Dr.
Gareth Davis and students who participated in the study. This project with support from the
University through Improving Student Learning Grant and Clinical Training and Evaluation
Centre (CTEC) has enabled to maximise the contact time that students have with patients and
has provided the academics with an opportunity to lead a successful initiative in the teaching
and learning of Oral Surgery.

ETHICAL APPROVAL
Ethics approval was provided by Human Research Ethics Committee at UWA RA/4/1/7193.

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3. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ, Lawrence
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4. Perry S, Burrow MF, Leung WK, Bridges SM. Simulation and curriculum design: a
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Academia Letters, October 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Zarrin Seema Siddiqui, zarrin.ss@vinuni.edu.vn

Citation: Siddiqui, Z.S., O’Halloran, M., Hamdorf, J. (2021). Using simulation to learn surgical skills in Oral
Surgery: What do students think? Academia Letters, Article 3677. https://doi.org/10.20935/AL3677.