Digital-based Education for Dental Students: A Systematic Review of Randomized

Controlled Trials 
Alfiani Hidayanti, Ayu Rahma Dania, Nurul Ramadhani, Ryan Martin Pratama, Sarah Safira
Azhar, Thalia Ivana Aprillia Manurung
Faculty of Dentistry, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km. 21,
Jatinangor 45363, Indonesia

Abstract
Introduction. The utilization of digital education in dentistry has started to be implemented
globally and its level of achievements depends on locally available resources. The usage of
digital education in dentistry includes numerous aspects such as web-based knowledge transfer,
diagnostic using 3D imaging and digital radiography, dental simulator, virtual reality, and AR for
educational motoric training and clinical testing. The aim of this study was to give an overview
of randomized controlled trials in digital-based education for dental students in covid-19
pandemic situation. Method. The research was conducted using the systematic literature review
method that refers to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-
Analyses). The search for suitable research articles was carried out by doing an online search on
the PubMed database using the keywords and boolean operators, as follows "digital education"
AND "dentistry". Result and Discussion. Search in PubMed database resulting in articles
obtained n = 919 and after applying filter according to the inclusion criteria the results obtained
was n = 27. Twenty-seven articles were screened in detail with inclusion and exclusion criteria
resulting in n = 6. The six RCT studies are then classified into 3 groups according to its use
mainly: operative dentistry, prosthodontics, and oral surgery. We found Quantitative Light-
Induced Fluorescence Technology, ICDAS with E-Learning and Digital Learning, and Dental
Virtual Simulator in operative dentistry; Immersive Virtual Reality for oral surgery; Digital
Impression Techniques and Digital Training System with RDTES and OPRS for prosthodontics.
Conclusion. Digital education and the utilization of various technologies have its own
advantages and disadvantages. ICDAS e-learning and DLT being the most accessible
technologies to be implemented in dental education system, especially in the COVID-19
pandemic because of its accessibility utilizing the internet connection.
Keywords: digital education, dental students, dentistry, e-learning, virtual reality
Introduction
Digital education or also known as e-learning is an approach of how to teach and how to
study that represents every aspects included in the studying process which is based on the
utilization of the electronic devices and media as tools to improve the access for the training,
communication, and interaction to facilitate the implementations of new ways to understand and
develop the studying process1,2. Digital education is a wide ranged term and depicts various
aspects, concepts, methods, and educational technology that keeps improving and developing3.

Digital education covers but is not limited to online or offline computed-based education,
MOOC (Massive Open Online Course), VR (Virtual Reality), AR (Augmented Reality), virtual
simulation, mLearning, and psychomotor skills trainers 1. Digital education can be specifically
categorized into several types which are based on the delivery methods, aim of the course, and
pedagogic approach or the delivery setting4. The utilization of the internet in the digital education
s known as online mode digital education, whereas the usage of application without internet
access is known as offline mode digital education 4. Each of the types of the digital education has
its own advantages and disadvantages, specifications, limitations and challenges 5. The
integration of digital education and traditional education, such as face-to face method, is known
as blended learning1.

Digital education has numerous advantages compared to traditional teaching system,

those advantages are: easier access to learning materials and easier access to the course without
time and geographical constraints4. Through different models, digital education enables different
study experiences with varying forms and different interactivity level, variations of study
duration, intervention, and feedback6. Digital education is also easier to be updated if there are
new evidences discovered and easier to be personalized depending of the users’ needs6. The
efficacy, flexibility, and cost-effectiveness offered by digital education have potentials to provide
more independent, adjustable, and accessible learning4,6. Studies comparing the digital education
methods to traditional education methods in various study fields including health studies and
engineering showed that the utilization of digital education is more effective and efficient in
building knowledge4. Widely used digital technologies alongside with its perpetual
improvements are considered as promising resources for effective and efficient leaning in health
professions education system3,7.
 The utilization of digital education in dentistry has started to be implemented globally
and its level of achievements depends on the locally available resources 8. One of the biggest
challenge in implementing it is the requirement to continuously adapt with the new knowledge
and technologies and integrate it to the dental practices 9. The usage of digital education in
dentistry includes numerous aspects such as web-based knowledge transfer, diagnostic using 3D
imaging and digital radiography, and practically oriented trainings in terms of dental simulator
motor skills including IOS (intra oral scanning) with 3D printing, prototyping, and digital surface
mapping, utilization of VR and AR for educational motoric training and clinical testing8. Since
the methods and the tools used in the learning process keeps improving, therefore the users’
understanding towards the teaching methods is crucial to optimize the learning’s efficacy9.

The digitization in dentistry education has a significant impact. And benefits such as
facilitating accessibility and improving communication and cooperation for both academicians
and staffs.10 The digitization can keep the data on cloud based, automatic assessment, evaluation,
feedback, and easy access to online course.10 Referring to students’ needs, quickly accessible
information is expected and this is the key of developing digital education. 8

The COVID-19 pandemic that occurred at the end of 2019 in Wuhan, China has started a
new challenge in education around the world.11 Several institutions have had to adapt and decide
the alternatives in theoretical and practical learning transfer.8 Research on the digitization is
growing rapidly. However, on previous research of a systematic review of randomized controlled
trial for undergraduate student and resident is not available yet.

The aim of this study was to give an overview of randomized controlled trials in digital
education for dental students in covid-19 pandemic situation.

Method

The research was conducted using the systematic literature review method that refers to
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

Eligibility, Inclusion, and Exclusion Criteria

 The eligibility criteria was determined using the PICO strategy (Population, Intervention,
Comparison, Outcome) as follows P: dental student, I: digital learning system C: conventional
method, O: efficacy (based on outcome and student attitude/perception). Inclusion criteria for
choosing the research articles were 1) accessible online, 2) full text was available, 3) a
randomized controlled trial (RCT) research, 4) published within the range of 2010-2020, 5)
written in English. The exclusion criteria was the research article which did not go to the
accordance with this research’s theme which was digital education methods for dentistry
students.

Information Source and Search Strategies

The search for suitable research articles was done by doing an online search on the
PubMed database using the keywords and boolean operators, as follows "digital education" AND
"dentistry" and the results obtained was n = 919. After searching by applying the keywords and
applying the filter according to the inclusion criteria the results obtained was n = 27.

This systematic review of randomized control trial researched the used of digital based
education for dental students. The literature identified through the search strategy then filtered by
the author based on its title. Irrelevant literature will be excluded. Furthermore, abstract
screening was carried out from the identified literature. Relevant abstracts from identified
literature then included and read by the author for screening of the complete-text feasibility
aspect. The literature that matched selection criteria then continued to data extraction and
analysis, results obtained was n = 6. The data obtained from the literature includes: the authors,
study design, participants, materials and methods, results, and conclusion. The data obtained will
be presented in the table.

Results and Discussions

Articles obtained from the search conducted in PubMed database resulted n = 919 and after
applying filter according to the inclusion criteria the results obtained was n = 27. Twenty-seven
articles were screened in detail with inclusion and exclusion criteria with the result of n = 6. The
PRISMA flow diagram is depicted in Figure 1. Additionally,
present the study characteristics of the studies included in this systematic review.

"digital education" AND "dentistry" in

tifi

tio
en

ca
Id

n
PUBMED database
(n = 919)

Filtered with 1) accessible online, 2) full

Removed duplicates text was available, 3) a randomized
en
Sc

controlled trial (RCT) research, 4)

re

in

(n = 919)
g

published within the range of 2010-2020,

5) written in English.

After filter applied (n = 27)

Records excluded based on

irrelevant title and abstract (n = 21)
gib
ilit
Eli

Full-text articles assessed

for eligibility Full-text articles excluded
(n = 6) (n = 0)
v

Studies included in
ud
ed
In
cl

qualitative synthesis
(n = 6)

Figure 1 PRISMA Flow diagram of literature search

Table 1 List of studies included with study characteristics and main findings

Author Study Country Participants  Type of Main Findings 

(Year) Design Digitalization

Zitzmann, RCT Switzerland 50 undergraduate Digital Most of the participants stated that
et al dental students in impression using IOS is easier and more efficient.
(2017)7 Switzerland

Oh, H. Y. RCT South Korea 92 dental hygiene Quantitative The results showed that the use of
et al. students. light-induced QLF technology can improve
(2017)8 fluorescence competence in students
(QLF)
technology for
dental
restoration

Pulijala, RCT UK 95 novice surgical Immersive There was a significant increase in

Y. et al. residents virtual reality self-confidence after using virtual
(2018) 9
for surgical reality practice for surgical training
training

Liu, et al RCT China 66 fourth-year Digital training Digital participants had significant
(2018) 10
undergraduate system assessment outcome. RDTS + OPRS
dental students (RDTES + could upgrade student’s practical
OPRS) for skills based on the questionnaire
crown taken in digital participants.
preparation

Alves, et RCT Brazil 64 dental students ICDAS E- The study found that students who
al (2018)11 in their fourth year Learning and participated in ICDAS e-learning
Digital and ICDAS e-learning + DLT tended
Learning Tool to be able to detect the healthy and
caries occlusal area precisely
compared to the group that were not
 given training.

Murbay, RCT Hongkong 32 dental Dental Virtual The study found that groups with
S., et al. undergraduate Simulator for virtual reality training performed
(2019) 12
students in their preclinical better in manual and digital method
second year operative assessments and no major
dentistry differences between the two
course assessment methods found whether
the results were satisfactory or
unsatisfactory

1. Operative Dentistry

1.1 Quantitative Light-Induced Fluorescence Technology

Many studies have explained about digital technology that can be used in dentistry, one of
which is Quantitative Light-induced Fluorescence (QLF). In a study by Oh H.Y. et al. (2017)
explained that the use of QLF technology can improve students ability to differentiate between
dental restorations.

Quantitative Light-induced Fluorescence (QLF) is an optical technique used to assess

early carious lesions of enamel. Another definition suggests that QLF is a diagnostic technique
that uses the natural fluorescence of teeth to differentiate between caries and sound enamel and
to measure the severity of lesions. The fluorescence of the carious lesions seen in QLF was lower
than that seen on healthy enamel. QLF measures the percentage change in the fluorescence
emission of demineralized enamel with respect to the surrounding sound enamel, and relates this
directly to the amount of minerals lost during demineralization. The fluorescence difference
between the lesion an healthy enamel when irradiated by blue light at 405 nm was exploited by
QLF technology. The use of QLF technology should be combined with visual clinical
examination. QLF technology makes use of the fluorescence difference between a lesion and
healthly enamel when irradiated by blue light at 405 nm, such as the first one developed by
Inspector Research Systems (Amsterdam, Netherlands) for detection of early caries that is
difficult to identify with conventional methods such as visual inspection and tactile assessment.
The use of QLF technology should be combined with visual clinical examination.12,13,14,15
 Oh H.Y. et al. (2017) make a study to know the usefulness of Quantitative Light-induced
Fluorescence (QLF) technology in detecting dental restorations by comparing students ability to
detect those using only conventional visual inspection and visual inspection combined with QLF
technology. The students were divided into 2 groups consisting of 43 people each in the visual
inspection control group and the experimental group using the combined evaluation visual
inspection with light-induced digital fluorescence-quantitative assessment (QLF-D). Students
will use 43 white light and fluorescence images (QLF-D images) of patients and white light
images for use in the control group, while the experimental group will be taught how to use
QLF-D and evaluated restoration using white light fluorescence images and QLF-D.

QLF been proven to be a sensitive, valid and reproducible detection method. In addition,
it has been reported that this device allows early detection of caries and longitudinal monitoring
of lesion progression or regression. The capabilities of this device are based on dental
autofluorescence. In other literature, Stookey explains that for the detection of caries in cinical
trials the QLF must be a viable methodology. There are 3 things that need to be considered, (1)
further refinement especially related to the prototype instrumentation used in clinical studies, (2).
must be clinically validated to detect and monitor caries, (3). The clinical trial design shall be
identified and validated. However, QLF have the potential to be the technology most likely to be
used in the future of clinical trials. 14,15

In the COVID-19 pandemic situation has resulted in the provision of online education
using various technologies that will support this education. However, there are some
technologies that cannot be used for learning except with the videos sent by lecturers about these
tools and how they work. The use of technology such as QLF will be more effective if it is used
by dentistry students when conducting face-to-face lectures because it can be used immediately.

1.2 ICDAS E-Learning and Digital Learning Tool

Alves. et al. (2018)10 conducted a study that aims to assess dentistry students
performance in detecting occlusal caries lesions in vitro with ICDAS criteria with a variety of
learning tools (e-learning ICDAS and Digital Learning Tool). In this study, the sample used were
64 participants who were 7th semester students majoring in dentistry at the Federal University of
Santa Maria, Brazil, who were able to carry out dental examinations and could detect caries and
non-caries lesions, but had not had any contact with ICDAS criteria.

Initially, all participants performed in-vitro examinations of 80 dental occlusal surface

using ICDAS assessment where participants were given ICDAS score description table during
examination. Two weeks later, the participants was divided into 3 random groups namely G1
(n=21), ICDAS e-learning group; G2 (n=22), ICDAS + DLT e-learning group; and G3 (n=21),
the control group. DLT can be accessed using any browser, there will be brief explanation of
ICDAS and learning tools along with short videos and ended with 60 questions. After training,
the participant performed an examination of the same 80 teeth. The 80 teeth were then validated
by the expert examiners.

The study found that students who participated in ICDAS e-learning (G1) and ICDAS e-
learning + DLT (G2) tended to be able to detect the healthy and caries occlusal area precisely
compared to the parts that were not given training. But only the G2 produces higher sensitivity
and specificity values with significance at the D1 threshold, indicating the need for longer and
more intensive training. At the D2 and D3 threshold, only the G2 produces a significantly higher
AUC score, which is an important calculation in assessing a diagnostic method. This indicates an
increase in ICDAS accuracy after being given a combination of ICDAS e-learning and DLT
training (G2).

One of the limitations of this study is the possibility of longer training time that attribute
to the significance of G2 who has longer contact with ICDAS e-learning method and more
intensive training with 60 questions on DLT. DLT method also provides a detailed explanation
of an answer while ICADS e-learning only shows the correct score. This method also does not
have a significant influence if being tested on experienced dentists. This study is only done in
one dental school so that the results of this study could not be generalized for students on other
campuses.

In the future, researchers could further examine whether time or the methods which has a
bigger impact in the role of improving the results and also conducting research with larger
samples including several dentistry faculties. How the e-learning tools influence caries detection
performance using other caries examination methods such as radiography examinations could be
an interesting topic for future studies. Although this study didn’t state what language is used in
ICDAS and DLT e-learning tools, e-learning tools with more diverse languages will enable
dentistry students from different countries to use this tool.

During the pandemic, where dental students study from their homes, this method can help
students in studying ICDAS assessment in operative dentistry courses. One of the advantages of
this method is that it is easily accessible with only a browser and internet to access the e-learning
and DLT and students can do it from their own home. This method can also be repeated
according to the needs of the student. One of the disadvantages of this method is the possibility
of limited language options so that some dentistry students may not be able to use this tool to the
maximum.

1.3 Dental Virtual Simulator

Virtual Reality Simulator (VR) is one of the most widely used digital technology today.
This system has been used in various fields such as driving simulation training, medical training,
flight simulation training, and the use of robotic patients for medical emergency training and
assessment, as well as applications in the world of dentistry. In the field of dentistry, VR is
expected to be able to improve psychomotor abilities as well as coordination between hands and
eyes.

Murbay. et al. (2019)16 aim to asses preclinical dentistry students’ performance with the
introduction of dental virtual simulators into the direct restoration module of operative dentistry.
Students are instructed to study and practice cavity preparation of SISTA Classification - site 1
caries through the VR system. After the training, students are asked to prepare the phantom and
then evaluated using 2 methods (conventional and digital). The study found that groups with
virtual reality training performed better in manual and digital method assessments and no major
differences between the two assessment methods found whether the results were satisfactory or
unsatisfactory.

The main advantage of VR is being able to provide a more enjoyable learning experience
than conventional methods. Besides, VR has the potential to be applied for pre‐admission
assessments, pre‐clinical training, remedial training for weaker learners, and external
accreditation for licensing. The application into the curriculum of course needs further
confirmation related to the validity, accuracy, and reliability of tasks and assessments to be
carried out.

This VR system allows students to transition more efficiently and quickly from pre-
clinical studies to clinical studies. The system also offers treatment plan features for various
patient cases and dental pathology, the existence of self-assessment evaluations and this system
certainly makes this training cost-effective where students do not need to buy teeth and are safe
because no patients are exposed to treatments that may be dangerous.

One limitation of this study is that it uses a small sample with an inexperienced sample
group (Year 2 students). Therefore, virtual reality cannot be said as the substitute method of
conventional learning methods yet but can be an adjunct in improving conventional learning.

During the pandemic, virtual reality gives an advantage when dentistry students have to
do social distancing. This method can be done without contact with supervisors and can support
learning during the pandemic. Although with its various benefits, VR is not easily accessible,
and not all dentistry faculties have virtual reality facilities in their lab.

2. Oral Surgery

2.1 Immersive Virtual Reality

Virtual Reality surgery is a learning application that provides a close-up operating

experience. The components of virtual reality are Oculus, headset and leap motion controller. In
a study conducted by Pulijala et al (2017), showed the effectiveness of using this virtual reality
application in studying the Le Fort I osteotomy surgery procedure. The way this research worked
was comparing the study group that uses virtual reality applications in the learning process with
the control group who uses conventional teaching with a presentation. As a result, there was a
significant increase in self-confidence in the post-learning study group. This shows the
effectiveness of digital teaching using virtual reality applications.

The use of learning methods through virtual reality applications is very useful, especially
during the pandemic era. The advantage of this training is that it can increase the experience and
knowledge of students in carrying out the Le Fort I osteoctomy surgery procedure and increase
self-confidence. However, there are several drawbacks to this method, namely expensive VR
equipment and the need for a computer with high specifications to achieve the desired target
experience.

3. Prosthodontics
3.1 Digital Impression Techniques
Intra Oral Scanning (IOS) is a method of printing the patient's mouth using a software
application. The component of the IOS that is inserted into the patient's mouth is called an
implant-specific monotype scan body. In a study conducted by Zitzmann et al (2017), showed
the effectiveness of printing with IOS compared to conventional methods. The research was
conducted by asking the participant's choice of printing ptic after trying to print with IOS and
conventional methods. The result, 72% of participants stated that using IOS is easier and more
efficient.

The use of IOS training will be more effective if it is done face-to-face, because students can
practice it directly, given the IOS equipment which is relatively expensive. The advantage of
using this IOS is the fast process and ease of application of IOS equipment.

3.2 Digital Training System with RDTES and OPRS

Liu et al.10 developed a new digital technology system similar to DentSim, based on
RDTES (Real-time Dental Training and Evaluation System). DentSim, an example of a
technology that is often used for preclinical restorative training which has the advantage of
displaying real-time image processing using 3D graphics and VRS so the students can monitor
the illustrations of their preparation results through the monitor. However, the drawback of this
system is that the student's assessment ability on practical assignments does not improve due to
the absence of feedback and peer assessment functions. Therefore, Liu augmented the RDTES
with the OPRS (Online Peer-Review System). Liu’s study was aimed to assess the effectiveness
of using the digital training system (RDTS + OPRS) compared to conventional methods in
improving the ceramic crown preparation practical skills, as well as to assess how the results of
these preparations relate to their attitude towards that system.

Students are assigned to watch the guideline video at the OPRS, which contains ways and
steps in carrying out the practice which consists of intraoral and extraoral part. Then, they were
instructed to make crown preparations on the phantom model under RDTES direction. The video
results of their work will be documented by RDTES both intraorally (through the optical position
sensor system and VRS system) and extraorally (through cameras) until then RDTES will assess
the results of the student’s work based on predetermined criteria. Videos of each student's work
are then uploaded to OPRS. One of the best videos (gold standard) will be chosen by the
instructor and become a reference for other students. OPRS will also randomly select 2-3 videos
for peer-assessment as well as test self-assessments for each student. Each student will receive
input from the peer-assessment results.

In Liu's experimental research, the results of the practice tests of the students from the
intervention group (using RDTES and OPRS) were better than the control group (using
conventional methods through demonstrations by the instructor). Significantly, 5 of the 15
assessment items were better in the group using digital training and the questionnaire results
stated that 96.97% of particapants agreed and strongly agreed that RDTS and OPRES could
upgrade their practical skills. The results of this study are in line with the influence of peer-
assessment system which can improve student's practical skills. On the other hand, because
RDTES has an optical sensor inveterate in the large and heavy handpiece, it can reduce accuracy
during the practical process, so it is necessary to adjust the handpiece to make it more user-
friendly in the future.

This digital training method can be an alternative to conventional methods. The existence
of digital technology such as RDTES and OPRS can be used by dental institutions in various
countries, especially during the implementation of practical activity in the laboratory. Besides
being able to improve students’ abilities in clinical practice, this digital technology will
streamline the performance of instructors because they don't need to provide many interventions
and carry out an intense supervision. However, in this pandemic situation which many students
study at home, there are several considerations. This digital training effectiveness will depend
heavily on the availability of tools (for RDTES) and an internet connection (for OPRS). In
addition, costs are a consideration that must be calculated precisely, especially if we want to
have them for personal use.

Conclusion
 In general, digital education methods can be considered as an alternative in dental
education, but the efficacy of applying various digital technologies will depend on several factors
such as the tools, budget, and users’ understanding towards the system. Those factors should be
considered by the institutions especially amidst the pandemic. Types of digitization that can be
used to support education in dentistry consist of the study field of operative dentistry, namely
Quantitative Light-induced Fluorescence technology (QLF), e-learning ICDAS and DLT, Dental
Virtual Simulator, in the study field of oral surgery, namely Virtual Reality (VR) surgery, in
prosthodontics, namely Digital Impression Techniques (Intra Oral Scanning), Digital Training
System (OPRS and RDTES).

Due to COVID-19 pandemic situation, QLF is more effective when being used during
face-to-face learning. E-learning ICDAS and DLT have the advantage of being able to support
students in detecting occlusal caries lesions in vitro. E-learning ICDAS and DLT can be used
during the COVID-19 pandemic because of its accessibility utilizing the internet connection.
This method can be an alternative to conventional methods and can be done during a pandemic.
In conclusion, digital education and the utilization of various technologies have its own
advantages and disadvantages when being implemented to dental education systems with ICDAS
e-learning and DLT being the most accessible technologies to be implemented.

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