Teaching oral surgery to undergraduate students: a pilot

study using a Web-based practical course

Luciana Correa1, Antonio Carlos de Campos2, Suzana C. O. M. Souza1 andMoacyr Domingos Novelli1

1Pathology Department, 2Oral Surgery Department, School of Dentistry, University of Sao Paulo, Sao Paulo, Brazil

The Internet has been used in oral surgery teaching mainly todeliver learning material across the World Wide Web and to makeuse of online interactivity resources in everyday surgical prac-tice, such as by e-mails, discussion groups, and chats. The aim ofthis paper is to describe and evaluate a Web-based practicalcourse on oral surgery principles, which was applied to under-graduate students. This course was investigated as a distancelearning simulation in which the student would be performingsurgical activities at home, and the teacher and the schoolenvironment would be absent. A Web site was created containingthe course material. For this study, the students participatedin the Web-based course in a multimedia lab equipped withcomputers and Internet, internal sound system and TV circuits.In the event of significant mistakes by students, the TV circuitcould be used to show the correct procedure for all the partici-

pants at the same time. Microcameras were used to monitor thestudent’s actions during the Internet use. Students’ impressionswere determined by a questionnaire. Computer manipulationwith ease and antiergonomic postures were observed. We con-cluded that distance learning courses with practical modulesmust be considered as a special type of educational modality,with reference to the relationship between the student and thecomputer.

Key words: oral surgery and computer-assisted education; oralsurgery and distance learning by the Internet; dental educationand the Internet.

� Blackwell Munksgaard, 2003Accepted for publication 31 August 2002

INTERNET resources have been used as tools for teach-

ing and learning, especially in the medical sciences

(1, 2). High potential for information diffusion, includ-

ing texts, images, videos and animations are some of

the advantages of this new way of communication in

the educational system. Recent researches on education

and the Internet have been focused on distance learning

or distance education, where students and teachers

have no physical contact. Many authors report the

expanding role of distance learning in higher education

(3–5).

Particularly in oral surgery teaching, computers have

been applied mainly to virtual reality and simulators

(6–8) in order to obtain interactive three-dimensional

educational tools in surgical training. Some projects use

the Internet to deliver the didactic material across the

World Wide Web (9, 10), and others use online inter-

active resources in everyday surgical practice, such as

by e-mails, discussion groups, and chats (11–14).

Most of these projects focus on continuing education

for general dental practitioners. In 1996, we created a

‘Principles of Surgical Technique’ course at the Dentis-

try School, University of Sao Paulo, dedicated to teach-

ing oral surgery principles to undergraduate students

enrolled in the second and third semesters. This train-

ing course is part of the undergraduation complemen-

tary curriculum. Students learn some topics of surgical

technique that will be used and developed in other

disciplines of the dental curriculum, i.e. surgical instru-

ment nomenclature, types of dental anaesthesia, and

basic incisions and sutures. The aim of this course is to

develop manual abilities, in order to prepare students

for all disciplines that involve manual skills (laboratory

and clinical activities). At the same time, the course focu-

ses on the introduction of an interdisciplinary situation

represented by the surgical context. Therefore, anat-

omy, physiology, pathology and radiology are review-

ed and applied to surgical situations. All the surgical

procedures are performed on a chicken’s leg, which is

very helpful to learn the different head and neck tissues

(skin, bone, cartilage, connective tissues, and muscles).

The use of chicken legs was derived from comparative

Eur J Dent Educ 2003; 7: 111–115Printed in Denmark. All rights reserved

111

anatomy studies (15) that show similarities and differ-

ences between humans and birds. In the course, analo-

gies between human and bird anatomy are frequently

carried out, especially for muscle and bone structures.

For example, masticatory muscles can be compared to

the elevator muscles present in the chicken legs.

A Web version of this course was created in order to

analyse the impact of distance learning on dental

undergraduate students in a surgical context. The aim

of this paper is to describe this application, focusing on

student behaviour and the relationship between surgi-

cal practice and computer manipulation. Some aspects

of the impact of this experience, which involves distant

instructors, are also reported.

Methods

Web-based course developmentA Web site was created (http://www.usp.br/fo/lido/

acs) at the Dental Computing Laboratory, School of

Dentistry, University of Sao Paulo (USP), Brazil. This

site was based on the ‘Principles of Surgical Technique’

course. The Web site content is divided into three basic

modules: (i) material and theoretical basis – students

access the nomenclature and function of surgical instru-

ments and review some topics of pathology, anatomy,

physiology and radiology; (ii) first class – the principles

of surgical environment organization are presented, as

well as health and safety rules; (iii) second class –

anaesthesia, incision and suture techniques are

described; in this module, the student is orientated to

perform all the surgical procedures on a chicken’s leg

using surgical instruments. Texts, figures, graphic ani-

mations and digital videos make up this material.

Course evaluationTwenty-two dental undergraduate students (enrolled

in the second and third semester of the dental under-

graduate course) took part in the course. These students

participated in the Web-based course in a multimedia

lab equipped with computers, internal sound system

and TV circuits. During the course, all participants

individually accessed the site through personal com-

puters connected to the Internet. Data management and

report issues were obtained using distance learning

software (TopClass1, WBT Systems). The teacher and

instructors were absent most of the time, intervening

only in the case of difficulties presented by the students.

In these situations, the correct action was shown using

the TV circuit and cameras. TV circuit was the only com-

munication channel between teacher and student. It

was employed to broadcast images indicating common

mistakes and correct actions to all the students at the

same time. Students’ difficulties were detected by

means of microcameras installed in the work-field of

each student, and controlled by the teacher from a

distance. This strategy was adopted in order to simulate

a context in which the student performs the surgical

activity in isolation (for example, at home), without the

presence of the teacher/instructors, and outside school

environment.

All the activities were recorded in a SVHS format

tape. Instructors observed and registered some student

behaviours, such as the time gap between Internet

access and course beginning, the interaction between

the surgical activity and keyboard/mouse manipula-

tion, ergonomics, and utilization levels of the multi-

media lab and site interactivity.

At the end of the course, a questionnaire was dis-

tributed containing four ‘open’ questions as follows:

(1) Is it easy to handle the computer and to perform the

surgical activity at the same time? Why?

(2) Assign values (0¼minimum to 10¼maximum) to

the information transmission resources used during

the course: by the television; by the computer; by

the teacher.

(3) Describe the importance of the following resources in

the course: (i) television; (ii) computer; (iii) teacher.

(4) Point out three positive and three negative aspects

of the course.

Data collected from this questionnaire and registered

by the micro-cameras, SVHS tape, distance learning

software, and instructors were compiled and analysed.

Results

Characteristics of the participantsThe age range of the students was 18–35 years, with an

average age of 21 years, and 59% were female. All the

participants declared regular computing experience

and frequent access to the Internet. This information

was confirmed by the time interval between accessing

the online material and beginning the course activities,

which was an average of 30 s. All students finished all

course steps, devoting about 4 h to this. During the

course, various access strategies (different navigations

in the hypertext) and execution times between the three

modules were observed, which demonstrated different

tendencies of handling abilities and learning habits.

Moreover, we observed that all students were able to

conclude the surgery, but sometimes the quality of

incisions and sutures was inadequate (about 30% of

the students performed sutures and incisions inade-

quately).

Correa et al.

112

As a general behaviour, the work sequence adop-

ted by the student in each module was: to read all the

texts on the surgical procedure; to observe carefully

all the images; to confirm the presence of the surgi-

cal instruments in the work field and then to begin

the surgical activity. In addition, the students fre-

quently interrupted the surgical procedure in order

to manipulate the keyboard and the mouse. During

these actions, frequent antiergonomic postures were

observed.

Questionnaire dataAll the students answered all the questions. In question

1, 77% of the answers were positive. The most frequent

comments on the positive responses were ‘well-estab-

lished course sequence’ and ‘presence of figures’. ‘Diffi-

culty to understand the texts’, and ‘no surgical abilities’

were the most frequent comments on the negative

responses (23%). In question 2, the average of attribu-

ted values were 8.7, 9.5 and 10.0, to the TV system,

computer, and teacher, respectively. In answering

question 3, many students said that the internal TV

system was crucial to uniform information access; for

most of the participants, the computer was essential

in all course steps, since it was the main information

resource; and for the greatest number of the students,

the teacher was important to eliminate the practical

doubts, especially in surgical instrument manipula-

tion. The most frequent positive aspects of the course

(question 4) were the learning of surgical techniques,

the manipulation of surgical instruments, and the

technological resources. About 50% of the students

mentioned negative aspects, which were mainly the

absence of the teacher during the course, and problems

with the Web site content, especially the video visua-

lization.

Tables 1–4 show the most frequent comments for all

questions. Answers with only one respondent were

omitted.

TABLE 1. Main responses to question 1�

Question 1 – Ease of using the computer and performing thesurgical activity at the same time

Positive responses (17) Negative responses (5)

Well-established coursesequence (8)

Difficulty to understand thetexts (3)

Presence of figures (8) No surgical abilities (3)Interactivity using the

hypertext (2)Teacher absence (2)

Good content division (2) Anxiety (2)Good Web site layout (2)Personal learning (2)

�The number of respondents is in parenthesis.

TABLE 2. Responses to question 2

Question 2 – Assigned values (0¼minimum to 10¼maximum)to the information transmission resources

Student Television Computer Teacher

1 8.5 9 102 7.5 10 103 8.5 9 104 9.5 9.5 9.55 8 10 106 9 9 107 8.5 10 108 8 10 109 8.5 8.5 10

10 8 10 1011 9 9 1012 9.5 9.5 1013 9.5 10 9.514 7.5 9.5 1015 9.5 9.5 1016 8.5 9 1017 9.5 10 1018 9.5 9.5 1019 8 9 1020 9.5 10 1021 9 10 1022 8 10 10

Average 8.7 9.5 10

TABLE 3. Main responses to question 3

Question 3 – Importance of following resources in the course

Resources No. ofrespondents

Television 18Uniform access to the information 3To observe other students 2To visualize the surgical technique pattern 2No response 4

Computer 21To explain all course steps 9To understand the surgical technique 4To eliminate doubts 4To record basic surgical procedures 2

Teacher 22To explain surgical instruments manipulation 8To individually eliminate doubts 6To correct the surgical manual practice 5To verify the individual action 2

TABLE 4. Main responses to question 4�

Question 4 – Positive and negative aspects of the course

Positive (22) Negative (11)

Technological resources (12) Inadequate videovisualization (8)

Learning of surgicaltechniques (9)

Absence of teacher (2)

Surgical instrumentsmanipulation (5)

Absence of surgicaltechnique details (2)

Adequate number ofinstructors (3)

Inadequate contentsequence (2)

Adequate number ofstudents (2)

Chicken’s leg withoutbleeding (2)

Adequate didactic material (2) No response (11)

�The number of respondents is in parenthesis.

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Teaching oral surgery to undergraduate students

Discussion

This course has been applied to undergraduate stu-

dents since 1996. Before this distance learning experi-

ence, the course was carried out without computers or

the Internet, i.e. by means of traditional classes with the

presence of a teacher and instructors to demonstrate the

surgical technique directly to the student. This period

allowed us to detect some basic problems involved in

surgical teaching to students of the first and second

semesters of the dentistry course, such as physical

injuries occurring during surgical instrument manip-

ulation, inexperience with basic anatomy, physiology

and pathology nomenclature, and the absence of dental

practice experience. The detection of these problems led

us to correct and review some elements (texts, images,

content division) before developing a distance learning

programme, in order to minimize future faults during

the test.

In actual practice, the course is only delivered in the

multimedia lab in the presence of the teacher/instruc-

tors. This study therefore presents a distance learning

simulation by which the student would be performing

by himself the surgical activities at home, i.e. without

the school environment. In this simulation, it was clear

that distance teaching and learning projects involving

manual activities must be considered as a special mod-

ality of distance learning. Results indicate some find-

ings that are directly related to the usefulness of

distance learning media. Since this course was based

on manual practice, mouse and keyboard were obsta-

cles to learning, revealed by antiergonomic postures of

the students and also the many interruptions during the

surgical process. Foot control, voice control, or other

media controls that do not use the hands may be more

appropriate. However, the most commonly commer-

cialized distance learning software products are based

on mouse and keyboard control (including Top Class).

Thus, the use of these tools must be reconsidered in

future projects, especially those involving undergrad-

uate students.

For undergraduate students of the second and third

semesters, training deficiencies are only to be expected,

especially in surgical instrument manipulation. Never-

theless, all students finished all course steps in the

expected time. We believe that the use of hypertexts

and personal computers was essential to this result

because such resources facilitate self-learning. Indivi-

dual performance and personal interactivity increase

learning abilities and improve the potential of problem

solving. But against this, we did observe inadequate

incisions and sutures. This fact directs us to apply this

distance learning modality only to the student who has

already participated in a conventional course, where

the correct principles of sutures and incisions are

directly transmitted by the teacher.

The questionnaire was composed of ‘open’ questions

in order to detect impressions of individual users. A

multiple choice questionnaire or ‘closed’ questions

were not applied because our intention was to compare

spontaneous statements to behavioural actions during

the course. The first question is an example of point of

view discrepancies between the student and the tea-

cher/instructors: 77% of the students considered the

manipulation of the computer and the surgical activity

at the same time ‘easy’; as mentioned above, several

situations of antiergonomic positions and inadequate

instrument manipulation caused by computer use (for

example, use of the mouse with the same hand that

holds surgical scissors) were observed. Because of these

discrepancies, we believe that it is very important to

apply a direct observation of students submitted to this

distance learning modality.

The answers to questions 2 and 3 revealed that the

teacher was not an information and knowledge source,

as occurs in conventional classes. The computer takes

up this function. In this class modality, the teacher was

important to eliminate doubts raised when reading and

interpreting computerized texts and images. This new

teacher–student relationship must be carefully consid-

ered, especially when designing the course. Principles

of interactivity, navigation and legibility must be

applied to support this new relationship.

The questionnaire answers also revealed that TV had

a secondary importance in the course context. Consid-

ering this, we believe that the computer (with periph-

eral controls that do not need hand use), the Internet

and a distance control by the teacher were sufficient to

support the course. However, an ergonomic study is

essential, as well as exhaustive tests and simulations, in

order to optimize the design and educational princi-

ples. Together, these drawbacks limit the application of

this course in a wholly distance learning setting.

Acknowledgements

The authors wish to thank MicroPower Ltd and Livio

Yoshinaga, for the technical support and TopClass1

free-educational licenses.

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Address:

Luciana CorreaUniversidade de Sao PauloFaculdade de Odontologia, Disciplina de Patologia GeralAv. Prof. Lineu Prestes, 2227, Cidade UniversitariaCEP 05508-900, Sao Paulo SPBrazil

Tel: þ55 11 3091 7884

Fax: þ55 11 3091 7831

e-mail: luciana.correa@br.inter.net

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Teaching oral surgery to undergraduate students