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Received: 7 February 2020 Revised: 9 August 2020 Accepted: 12 August 2020

DOI: 10.1002/jdd.12385

ORIGINAL ARTICLE

Attitudes and perceptions of dental students towards


artificial intelligence

Emir Yüzbaşıoğlu DDS, PhD1,2


1 Department of Prosthodontics, School of Dental Medicine, Bahçeşehir University, Istanbul, Turkey
2 Department of Dentistry, Faculty of Medicine, BAU International University, Batumi, Georgia

Correspondence
Dr. Emir Yüzbaşıoğlu, DDS, PhD, Depart- Abstract
ment of Prosthodontics, School of Dental Introduction: Artificial Intelligence (AI) is a burning topic and use of AI
Medicine, Bahçeşehir University, Çırağan
Caddesi, Osmanpaşa Mektebi Sokak, No: in our day-to-day life has increased exponentially. The purpose of this study
4–6 Beşiktaş, 34353 Istanbul/TURKEY. was to evaluate the attitudes and perceptions of Turkish dental students
Email: emiryuzbasioglu@icloud.com
towards AI and to provide information about their opinions to use of AI in
dentistry.
Methods: A 22-question survey was distributed through Google Forms to all
dental students at 9 Turkish dental schools in March 2019. It consisted of var-
ious sections aiming to evaluate the dental students’ knowledge and attitudes
toward AI and possible applications in dentistry. Respondents’ anonymity was
ensured.
Results: A total of 1103 students (650 female, 453 male; mean age was 21.36 ±
1.93 years) responded to the questionnaire for a 21.69% response rate. Of these,
about 48.40% had basic knowledge about AI technologies and 10.6% stated that
they had no information sources about AI. 85.70% agreed that dentistry would
be revolutionized by AI but 28.60% did not agree that AI could replace them-
selves in the near future. In addition, 74.60% and 79.80% of agreed on topics
about AI to be included in undergraduate and postgraduate dental education,
respectively.
Conclusions: Although participants have insufficient knowledge of AI, they are
willing to improve their knowledge in this field. Participants shared an optimistic
views and thought that AI will have a positive impact on dental future prac-
tice. Follow-up surveys and multinational studies should be conducted to further
explore these issues.

KEYWORDS
artificial intelligence, attitudes, awareness, dental student

1 INTRODUCTION affect health services.2 AI is defined as “a field of science


and engineering concerned with the computational under-
Artificial Intelligence (AI) is a popular issue. It is at standing of what is commonly called intelligent behav-
the center of current high-tech breakthroughs1 and could ior, and with the creation of artifacts that exhibit such

J Dent Educ. 2020;1–9. wileyonlinelibrary.com/journal/jdd © 2020 American Dental Education Association 1


2 YÜZBAŞIOĞLU et al.

behaviour.”3 The usage of AI has grown exponentially in 2 METHODS


our daily lives: we use Google’s intelligent search, iPhone
personal assistant voice recognition and management of The study carried out as a descriptive observational study
knowledge and tools like Citymapper to help us travel effi- among dental students from 9 different dental schools in
ciently in cities. Turkey. The research project was approved by Bahçeşehir
Advances in computer and informatics technolo- University Committee of Research and Publication Ethics
gies have enabled the use of AI technology such as (Document Date & Number: 15/10/2019-E.2454). A web-
machine learning and deep learning in health information based electronic survey using Google Forms was designed
systems.4,5 In data-intensive specialties such as radiol- to obtain information about dental students’ knowledge
ogy, pathology, and ophthalmology, AI has been widely and attitudes toward AI and possible applications in den-
integrated into decision support systems (DSSs).6 tistry. A survey comprised of 3 sections, and 22 questions
Deep learning systems, one of the methods of AI for was developed according literature which was assessed
various clinical tasks, has been introduced in recent medical students’ attitudes towards AI.35 For the clarity of
years.7 They were used effectively in various fields for the questions, the survey was evaluated with AI experts
image-based automated diagnosis, including lung cancer,8 before it was distributed. The survey contents consisted of
colorectal polyps,9 prostate cancer,10 hip osteoarthritis,11 a questionnaire on demographics and educational infor-
bone age assessment,12 caries diagnosis,13 color selection,14 mation about dental students, knowledge of and attitudes
removable partial denture design,15,16 temporomandibu- towards AI, future application areas of AI in dentistry, and
lar disorders,17,18 orthognathic treatment,19 maxillary topics of AI in dental education. The first part of the survey
sinusitis,20 root morphology,21 periodontal diseases,22 required data (4 questions) on sociodemographic charac-
oral cancer, 23 periapical lesions, 24 radiolucent lesions,25 teristics such as age, gender, attending dental school, and
cystic lesions,26 cephalometric analysis,27 and debonding grade of dental education. In the second part, the partici-
of computer-aided design/computer-aided manufacturing pants were asked 3 questions about (1) “information source
(CAD/CAM) crowns.28 Future systems are expected of recent AI applications using in daily life,” (2) “having
to be increasingly autonomous, going beyond recom- a basic knowledge about the working principles of AI,”
mending possible clinical actions to perform certain and (3) “being aware of the usage of AI in dentistry.” In
tasks independently, such as patient trial and screening the third section, the participants were presented with 15
references.29,30 statements and asked to indicate their level of agreement
Many experts have stated their views on the future of (disagree entirely, rather disagree, rather agree, or agree
radiology following the emergence of AI,31,32 and white entirely). For ensuring anonymity, no tracking system was
papers published by radiological societies and promot- used. The survey was pretested and refined using similar
ing views on this.33,34 Studies have shown that medical group of dental students within 2 weeks. After analyzing
students are not concerned and afraid of being replaced the data, the Cronbach’s was calculated to assess the inter-
by AI,35 but the anxiety associated with the “displace- nal consistency of survey (= 0.83).
ment” demotivated some students from taking a specialty The survey was sent out via e-mail and advertised on
into account.36 There are both good and pessimistic per- social media to dental students at 9 Turkish universi-
spectives on how AI will affect daily human life. A pes- ties. All dental students of participating dental schools
simistic view of AI is that in many sectors, AI will replace were invited to complete the survey: Istanbul Medipol
humans. Besides, optimistic views that people with AI sup- University (N = 843), Selçuk University (N = 675),
port will have more opportunities to take advantage of Ondokuz Mayıs University (N = 664), Çukurova Univer-
future advances. 37 sity (N = 594), Karadeniz Technical University (N = 548),
To the best of author’s knowledge, there is no study Bolu Abant Izzet Baysal University (N = 494), Zonguldak
about Turkish dental students’ views and attitudes regard- Bulent Ecevit University (N = 479), Bezmialem Founda-
ing the application of AI in dental practice. Current den- tion University (N = 437), and Van Yuzuncuyil Univer-
tal students and young dentists will suffer from AI before sity (N = 351). Recruitment was conducted between March
retirement. Therefore, dentists need to be prepared to 1, 2019 and May 30, 2019 via emailed/posted invitations
use AI effectively as a resource for these changes. To with anonymous survey links. Outreach efforts were in
address this issue, a national multicenter survey among accordance with regulations and guidelines specific to
undergraduate dental students was conducted to assess each dental school and comprised the use of class lists,
their thoughts about AI in dentistry. This study aimed to social networking sites (class Facebook pages, etc.), and
evaluate the attitudes and perceptions of Turkish dental in-person recruitment.
students towards AI and to provide information about their The data were analyzed with IBM SPSS V23. The suit-
opinions to use of AI in dentistry. ability of quantitative data to normal distribution was
YÜZBAŞIOĞLU et al. 3

T A B L E 1 Comparison of information sources between "having a basic knowledge about the working principle of AI” and “being aware
of the usage of AI in dentistry”
Having a basic knowledge about the Being aware of the usage of AI in
Information sources about AI working principle of AI dentistry
applications using in daly life Yes No P Yes No P
Friends, family, etc 188 (54.2)ab 159 (45.8) <0.001 298 (85.9)a 49 (14.1) <0.001
Neewspaper, magazines, etc 292 (62)a 179 (38) 402 (85.4)a 69 (14.6)
Lectures in university 114 (54.5)ab 95 (45.5) 184 (88)a 25 (12)
Social Media (Facebook, Instagram, etc.) 413 (49.2)b 426 (50.8) 670 (79.9)b 169 (20.1)
a-b: There is no difference between information sources with the same letter. Multiple response question.

T A B L E 2 Comparison "having a basic knowledge about the working principle of AI” and “being aware of the usage of AI in dentistry”
between respondents sex and grade
Having a basic knowledge about the working
principle of AI Being aware of the usage of AI in dentistry
Yes No P Yes No P
Sex
Male 260 (57.4) 193 (42.6) <0.001 355 (78.4) 98 (21.6) 0.729
Female 274 (42.2) 376 (57.8) 515 (79.2) 135 (20.8)
Grade
1st 157 (51.6) 147 (48.4) 0.125 247 (81.3) 57 (18.8) 0.074
2nd 206 (50.6) 201 (49.4) 329 (80.8) 78 (19.2)
3rd 73 (45.3) 88 (54.7) 118 (73.3) 43 (26.7)
4th 61 (45.5) 73 (54.5) 107 (79.9) 27 (20.1)
5th 37 (38.1) 60 (61.9) 69 (71.1) 28 (28.9)

examined with the Kolmogorov-Smirnov test. One-way When participants are asked where they have access to
analysis of variance and independent samples t test were information about AI, they stated that they had heard from
used to compare normally distributed data. Multiple com- the social media such as Facebook/Instagram (76.10%,
parisons were compared to Tukey HSD. Categorical data n = 839; yes), newspapers/magazines (42.70%, n = 470;
were analyzed with chi-square test. The results of the yes). During university lectures, only a smaller number
analysis were presented as mean ± standard deviation for of participants (18.90%, n = 208; yes) had heard of AI and
quantitative data and categorical data as frequency (per- from friends/family (31.50% n = 341; yes). However, 10.6%
cent). The significance level was taken as P < 0.05. (n = 117) of the participants reported that they had no
information sources about AI.
There are statistical differences between the informa-
3 RESULTS tion sources of participants who have basic knowledge
about the working principle of AI (P < 0.001). The
During study period 1103 dental students completed the median scores of “newspapers/magazines” were higher
survey, for a 21.69% response rate. 58.9% of the participants than “social media such as facebook/instagram.” And also
(n = 650) were women; 41.10% were men (n = 453). The there are statistical differences between the information
mean age of dental students was 21.36 ± 1.93 years old. sources of participants who are being aware of the usage
27.6% of the participants were first grade (n = 304), 36.90% of AI in dentistry (P < 0.001). The median scores of “social
were second grade (n = 407), 14.60% were third grade (n = media such as Facebook/Instagram” were lower than
161), 12.10%) were fourth grade (n = 134), and 8.80% were other information sources. The comparison of information
fifth grade dental students (n = 97). 78.9% of respondents sources, sex and grades between "having a basic knowledge
(n = 870) have heard about AI in dentistry and health sci- about the working principle of AI” and “being aware of the
ences. However, 48.40% of participants (n = 534) have had usage of AI in dentistry” are shown in Tables 1 and 2.
basic knowledge of about AI technologies (48.40% yes vs. While the majority of the participants agreed that den-
51.60% no). tistry would be revolutionized by AI (85.70% agreement),
4 YÜZBAŞIOĞLU et al.

TA B L E 3 Responses to questions about feelings and attitudes towards AI in dentistry


Statistical significance according to
Being
Having aware of
basic the usage
Strongly Strongly knowledge of AI in
disagree Disagree No idea Agree agree Sex Class about AI dentistry
I think artificial 11 (1) 26 (2.4) 121 (11) 513 (46.5) 432 (39.2) <0.001 0.881 <0.001 <0.001
intelligence will lead to
major advances in
dentistry and medicine.
Artificial intelligence can 147 (13.3) 433 (39.3) 208 (18.9) 237 (21.5) 78 (7.1) <0.001 0.504 <0.001 0.279
replace
dentists/physicians in
the future
I find the use of artificial 34 (3.1) 79 (7.2) 156 (14.1) 562 (51) 272 (24.7) 0.002 0.626 <0.001 <0.001
intelligence in dentistry
and medicine exciting.
Artificial intelligence can 112 (10.2) 398 (36.1) 262 (23.8) 258 (23.4) 73 (6.6) 0.001 0.037 0.004 0.269
be used as a “definitive
diagnostic tool” in the
diagnosis of diseases.
Artificial intelligence can 15 (1.4) 105 (9.5) 241 (21.9) 597 (54.2) 144 (13.1) <0.001 0.104 <0.001 0.040
be used as a “prognostic
tool” to predict the
course of a disease and
determine whether
there is a chance of
recovery.
Artificial intelligence can 8 (0.7) 32 (2.9) 134 (12.1) 681 (61.7) 248 (22.5) 0.003 0.75 0.002 <0.001
be used for radiographic
diagnosis of tooth caries
Artificial intelligence can 10 (0.9) 67 (6.1) 203 (18.4) 625 (56.7) 198 (18) 0.006 0.002 0.005 <0.001
be used in the
radiographic diagnosis
of periodontal diseases.
Artificial intelligence can 15 (1.4) 100 (9.1) 225 (20.4) 603 (54.7) 160 (14.5) 0.004 0.052 0.076 <0.001
be used in the diagnosis
of soft tissue lesions of
the mouth
Artificial intelligence can 11 (1) 40 (3.6) 111 (10.1) 626 (56.8) 315 (28.6) <0.001 0.917 <0.001 <0.001
be used in
3-dimensional implant
positioning and
planning
Artificial intelligence can 18 (1.6) 98 (8.9) 165 (15) 631 (57.2) 191 (17.3) <0.001 0.7 <0.001 <0.001
be used as a “treatment
planning tool” in
diagnosis and treatment
planning in dentistry
Artificial intelligence can 20 (1.8) 78 (7.1) 171 (15.5) 652 (59.1) 182 (16.5) <0.001 0.786 <0.001 <0.001
be used as a “quality
control tool” to assess
the success of
treatments.
(Continues)
YÜZBAŞIOĞLU et al. 5

TA B L E 3 (Continued)
Statistical significance according to
Being
Having aware of
basic the usage
Strongly Strongly knowledge of AI in
disagree Disagree No idea Agree agree Sex Class about AI dentistry
Artificial intelligence can 12 (1.1) 55 (5) 180 (16.3) 656 (59.5) 200 (18.1) 0.001 0.049 <0.001 0.001
be used in the
radiographic diagnosis
of pathologies in the
jaws.
Artificial intelligence can 16 (1.5) 75 (6.8) 266 (24.1) 575 (52.1) 171 (15.5) <0.001 0.038 0.006 <0.001
be used in forensic
dentistry
Artificial intelligence 28 (2.5) 69 (6.3) 183 (16.6) 473 (42.9) 350 (31.7) 0.009 0.446 <0.001 <0.001
applications should be
part of undergraduate
dental training
Artificial intelligence 16 (1.5) 48 (4.4) 159 (14.4) 495 (44.9) 385 (34.9) <0.001 0.335 <0.001 <0.001
applications should be
part of postgraduate
dental training

half of the participants did not agree that AI could replace dentistry” and with several statements which indicates
themselves in the near future and only a few parts of par- the level of agreement about attitudes towards AI in den-
ticipants agreed (28.60% agreement). Three-fourths of par- tistry. Responses to questions about feelings and attitudes
ticipants were somewhat excited by use of AI in dentistry towards AI in dentistry are shown in Table 3.
(75.70% agreement). It was widely agreed that AI could be When comparing the mean scores of statements about
used as a “prognostic tool” to predict the course of a dis- attitudes towards AI in dentistry, except for the sec-
ease and determine whether there is a chance of recovery ond statement (AI can replace dentists/physicians in the
(67.30% agreement vs. 10.90% disagreement), radiographic future), there was no statistically significant gender dif-
diagnosis of tooth caries (84.20% agreement vs. 3.60% dis- ference. Besides, there was statistically significant differ-
agreement), radiographic diagnosis of periodontal diseases ences between grades and various statements about feel-
(74.70% agreement vs. 7.00% disagreement), diagnosis of ings and attitudes towards AI such as using AI for “prog-
soft tissue lesions of the mouth (69.20% agreement vs. nostic tool,” “radiographic diagnosis of periodontal dis-
10.50% disagreement), 3D implant positioning and plan- eases,” and “diagnosis of soft tissue lesions of the mouth.”
ning (85.40% agreement vs. 4.60% disagreement), “treat- The mean score of the questions about feelings and atti-
ment planning tool” in diagnosis and treatment planning tudes towards AI in dentistry according to grades and sex
(75.40% agreement vs. 10.50% disagreement), “quality con- are shown in Table 4.
trol tool” to assess the success of treatments (75.60% agree-
ment vs. 8.90% disagreement), and radiographic diagnosis
of pathologies in the jaws (77.60% agreement vs. 6.10% dis- 4 DISCUSSION
agreement) and in forensic dentistry (67.60% agreement vs.
8.30% disagreement). But there was a certain disagreement AI inevitably will have a major impact on the next gener-
that AI could be used as a “definitive diagnostic tool" in ation of medicine and diagnostic radiology.39,40 After con-
the diagnosis of diseases (46.30% disagreement vs. 30.00% cerns about the development and future of AI began to be
agreement). In addition, 74.60% and 79.80% of participants talked about at various scientific meetings, radiologists, in
agreed on topics about AI to be included in undergraduate particular, began to worry about their professional career
and postgraduate dental education, respectively. in the future. However, apart from these claims that have
Questions were asked about attitudes towards AI in no scientific basis, no survey has been conducted among
dentistry. There was a statistically significant difference undergraduate dental students on their attitudes towards
between gender and “being aware of the usage of AI in AI in dentistry.
6

TA B L E 4 Mean score of the questions about feelings and attitudes towards AI in dentistry according to the grades and sex
Grades Sex
1st grade 2nd grade 3rd grade 4th grade 5th grade P Male Female P
I think artificial intelligence will lead to major 4.17 ± 0.87 4.23 ± 0.77 4.22 ± 0.78 4.15 ± 0.84 4.26 ± 0.71 0.759 4.25 ± 0.89 4.17 ± 0.74 0.091
advances in dentistry and medicine.
Artificial intelligence can replace dentists/physicians 2.71 ± 1.2 2.75 ± 1.14 2.61 ± 1.18 2.7 ± 1.09 2.57 ± 1.13 0.580 2.61 ± 1.23 2.76 ± 1.1 0.044
in the future
I find the use of artificial intelligence in dentistry and 3.78 ± 1.07 3.88 ± 0.94 3.98 ± 0.91 3.87 ± 0.93 3.94 ± 0.88 0.301 3.87 ± 1.06 3.87 ± 0.9 .895
medicine exciting.
Artificial intelligence can be used as a “definitive 2.88 ± 1.11ab 2.89 ± 1.13a 2.66 ± 1.1ab 2.67 ± 1.04b 2.6 ± 1.05b 0.016 2.8 ± 1.19 2.8 ± 1.05 0.980
diagnostic tool” in the diagnosis of diseases.
Artificial intelligence can be used as a “prognostic tool” 3.57 ± 0.9 3.67 ± 0.85 3.78 ± 0.89 3.78 ± 0.81 3.76 ± 0.85 0.047 3.64 ± 0.98 3.71 ± 0.78 0.190
to predict the course of a disease and determine
whether there is a chance of recovery.
Artificial intelligence can be used for radiographic 4.03 ± 0.77 4.04 ± 0.68 4.04 ± 0.77 3.98 ± 0.73 3.97 ± 0.7 0.832 4.05 ± 0.8 4.01 ± 0.67 0.355
diagnosis of tooth caries
Artificial intelligence can be used in the radiographic 3.89 ± 0.83a 3.94 ± 0.7ab 3.78 ± 0.87ab 3.66 ± 0.91b 3.66 ± 0.92ab 0.001 3.89 ± 0.87 3.82 ± 0.77 0.192
diagnosis of periodontal diseases.
Artificial intelligence can be used in the diagnosis of 3.81 ± 0.87ab 3.77 ± 0.81a 3.65 ± 0.92ab 3.53 ± 0.93ab 3.58 ± 0.89b 0.005 3.75 ± 0.93 3.7 ± 0.82 0.325
soft tissue lesions of the mouth
Artificial intelligence can be used in 3-dimensional 4.03 ± 0.87 4.09 ± 0.74 4.1 ± 0.78 4.15 ± 0.73 4.1 ± 0.76 0.606 4.13 ± 0.87 4.05 ± 0.71 0.089
implant positioning and planning
Artificial intelligence can be used as a “treatment 3.81 ± 0.91 3.81 ± 0.9 3.75 ± 0.87 3.8 ± 0.84 3.77 ± 0.84 0.956 3.83 ± 0.97 3.78 ± 0.82 0.348
planning tool” in diagnosis and treatment planning
in dentistry
Artificial intelligence can be used as a “quality control 3.85 ± 0.86 3.86 ± 0.81 3.78 ± 0.86 3.7 ± 0.89 3.71 ± 0.93 0.217 3.85 ± 0.94 3.79 ± 0.79 0.233
tool” to assess the success of treatments.
Artificial intelligence can be used in the radiographic 3.89 ± 0.84 3.95 ± 0.72 3.87 ± 0.78 3.83 ± 0.85 3.71 ± 0.85 0.084 3.89 ± 0.87 3.88 ± 0.74 0.779
diagnosis of pathologies in the jaws.
Artificial intelligence can be used in forensic dentistry 3.72 ± 0.91 3.8 ± 0.81 3.68 ± 0.83 3.67 ± 0.82 3.67 ± 0.93 0.354 3.7 ± 0.96 3.76 ± 0.78 0.345
Artificial intelligence applications should be part of 3.92 ± 1.07 4 ± 0.91 3.84 ± 1 4.01 ± 0.96 3.93 ± 0.97 0.469 3.96 ± 1.06 3.94 ± 0.92 0.733
undergraduate dental training
Artificial intelligence applications should be part of 4.05 ± 0.95 4.04 ± 0.87 4.11 ± 0.86 4.11 ± 0.92 4.2 ± 0.77 0.543 4.05 ± 0.99 4.09 ± 0.81 0.521
postgraduate dental training
a-b: There is no difference between grades/sex with the same letter.
YÜZBAŞIOĞLU et al.
YÜZBAŞIOĞLU et al. 7

This is the first report on attitudes and perceptions of ish universities. Therefore different educational curricu-
Turkish dental students towards AI. The results indicate lum and teaching strategies in different countries should
that most of the dental students are aware of AI but the effect the results. Additionally, the selected participants
basic knowledge about working principles are low. The may not have generally been a good representation of den-
dental student believe that AI will revolutionize the future tal students. Moreover, as we examined only the attitude of
of dentistry. Although they are excited by the use of AI in undergraduate dental students, it could be stated that doc-
dentistry, respondents did not agree that AI could replace torate student and residency students or even more senior
themselves in the near future as in a Korean study.41 dentists do not share the students’ rather optimistic views.
28.6% of the participants believed that dentists would Participants were not asked background questions about
be substituted by AI, according to the results of this study how technically they understood AI technology. Each par-
which are not consistent with previous studies. In a sur- ticipant might have had different AI conceptualizations.
vey conducted with 4135 participants, it was found that Lastly, instead of AI experts, the survey was created by a
the public is about twice as likely to express worry (72%) dentist with their supports.
than enthusiasm (33%) about a future in which robots
and computers can do many human jobs.35 Unlike other
professions, it is obvious that AI technology will have 5 CONCLUSION
difficulties in replacing physicians or dentists. There are
some challenges, such as AI cannot engage in high-level This survey found that Turkish students felt it would be
discussions with patients to gain trust, reassure them, useful to apply the AI to dentistry. Respondents decided
express empathy43 and although sensors that gather valu- that diagnosis and treatment planning were the fields
able information to assist with diagnosis, physicians will of dentistry where AI would be most useful. To order
still be required for interpretation in ambiguous situations to explore these problems further, follow-up surveys and
to incorporate medical history, perform physical examina- multicenter research should be carried out. On the basis of
tions and encourage further discussion.44 these results, the lectures and seminars must be organized
Although scientific studies have been increasing, the to ensure that dental students gain a better understanding
results of this study demonstrate clearly that Turkish den- of AI and ultimately help them play a fully conscious and
tal students continue to lack education and knowledge of active role in the development, implementation and use of
AI. These results show once again the interest of dental stu- AI tools in dentistry.
dents in new technologies such as AI and their willingness
to learn. Participants emphasized that the basic working AC K N OW L E D G M E N T S
principles of AI should be taught in dentistry, as indicated The author declare that there is no conflict of interest
in other studies in the literature.35,45 regarding the publication of this article.
Participants also noted that their information was pro-
vided more by social media than by academics. However, ORCID
most educated students were also the least afraid of this Emir Yüzbaşıoğlu DDS, PhD https://orcid.org/0000-
new technology. It suggests that there is a lot of room for 0001-5348-6954
undergraduate students to teach the fundamental princi-
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